Annual Utilization Report of Specialty Clinics
Facility Name:SAN JOSE DENTAL SURGERY CENTER
OSHPD ID:306434201Report Status:Submitted
License Category:SurgicalReport Year:2017
Table of Contents
Click on any of the links listed below to view the corresponding section.
Section 1 - General Information
Section 2 - Clinic Description
Section 3 - Patients and Encounters
Section 4 - Income Statement
Section 5 - Major Capital Expenditures
Errors and Warnings
Section 1 - General Information
1.Facility Name:SAN JOSE DENTAL SURGERY CENTER
2.OSHPD ID Number:306434201
3.Street Address:1998 ALUM ROCK AVE
4.City:SAN JOSE
5.Zip:95116
6.Facility Phone No.:( 408) 240 - 9000 ext.
7.Administrator Name:KHAM NGUYEN
8.Administrator E-mail Address:sanjosedentalsurgerycenter@hotmail.com
9.Was this clinic in operation at any time during the year?Yes
10.Operation Open From:1/1/2017
11.Operation Open To:12/31/2017
12.Name of Parent Corporation:SAN JOSE DENTAL SURGERY CENTER
13.Corporate Business Address:1998 ALUM ROCK AVE
14.City:SAN JOSE
15.State:CA
16.Zip:95116 -
17.Person Completing Report:Kham Nguyen
18.Report Preparer's Phone No.:408-240-9000
19.Fax No.:408-240-9090
20.E-mail Address:sleepdentistry@sanjosedentalsurgerycenter.com
30.Submitted by:sanjosez3r
31.Submitted Date and Time:1/20/2018 3:12:16 PM
Section 2 - Clinic Description
LICENSE CATEGORY (TYPE) (Completed by OSHPD.)
Line
No.		(1)
1.License CategorySurgical
LICENSEE TYPE OF CONTROL
Line
No.		(1)
5.Select the category that best describes the licensee type of ownership of your clinic from drop down list:Investor - Corporation
Section 3 - Patients and Encounters
PATIENTS AND ENCOUNTERS IN THE CALENDAR YEAR (ALL CLINICS)
Please report the total number of individual, unduplicated patients served and the total number of encounters for these patients. Please refer to the instructions for further details.
Line
No.		(1)
Unduplicated Patients
(2)

Encounters
1.Total, all locations under this license (Main, Mobile, Satellite, etc.)950970
SURGICAL CLINICS ONLY
Line
No.		(1)
Number
5.Number of surgical operating rooms on December 311
6.Total number of surgical operations performed during the calendar year970
PSYCHOLOGY CLINICS ONLY
Line
No.		Service Type(1)
Encounters
11.General Medical0
12.Substance Abuse (alcohol and drug)0
13.Mental Health Counseling0
14.All Other0
15.Total0
DIALYSIS CLINICS ONLY
Line
No.		(1)
Number
21.No. of Dialysis Stations0
22.Approved for In-Home Training(CAPD, CCPD)Undecided
Section 4 - Income Statement
INCOME STATEMENT
Line
No.		(1)
Total
1.Gross Patient Revenue$1,857,659
WRITE-OFFS AND ADJUSTMENTS:
2.Charity$0
3.Contractual Adjustments$0
4.Bad Debts$0
8.Other Adjustments$0
9.Total Write-Offs and Adjustments (lines 2-8)$0
10.Net Patient Revenue (line 1 minus line 9)$1,857,659
Other Operating Revenue:
11.Grants - Public$0
12.Grants - Private$0
13.Donations / Contributions$0
19.Other$0
20.Total Other Operating Revenue (sum lines 11 - 19)$0
25.Total Operating Revenue (line 10 + line 20)$1,857,659
Operating Expenses:
30.Salaries, Wages and Employee Benefits$692,775
31.Contract Services - Professional$161,245
32.Supplies$107,000
33.Rent / Depreciation / Mortgage Interest$237,565
34.Utilities$15,430
35.Professional Liability Insurance$5,616
36.Other Insurances$6,522
44.All Other Expenses$371,169
45.Total Operating Expenses (sum lines 30 - 44)$1,597,322
50.Net From Operations (line 25 minus line 45)$260,337

Section 5 - Major Capital Expenditures

Section 127285(3) of the Health and Safety Code requires each clinic to report "acquisitions of diagnostic or therapeutic equipment during the reporting period with a value in excess of five hundred thousand dollars ($500,000)."

Diagnostic and Therapeutic Equipment Acquired During The Report Period
Line
No.		(1)
1.Did your clinic acquire any diagnostic or therapeutic equipment that had a value in excess of $500,000? (If 'Yes', fill out lines 2 through 11, as necessary, below.)No

Diagnostic and Therapeutic Equipment Detail
Line
No.
(1)


Description of Equipment
(2)


Value		(3)
Date of Aquisition
MM/DD/YYYY
(4)


Means of Acquisition
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Building Projects Commenced During Report Period Costing Over $1,000,000

Section 127285(4) of the Health and Safety Code requires each clinic to report the "commencement of projects during the reporting period that require a capital expenditure for the facility or clinic in excess of one million dollars ($1,000,000)."
Line
No.		(1)
25.Did your clinic commence any building projects during the report period which will require an aggregate capital expenditure exceeding $1,000,000? (If 'Yes', fill out lines 26 through 30, as necessary, below.)No

Detail of Capital Expenditures
Line
No.
(1)


Description of Project
(2)

Projected Total Capital Expenditure		(3)
OSHPD Project No.
(if applicable)
26.
27.
28.
29.
30.

General Comments:
Errors and Warnings