Annual Utilization Report of Specialty Clinics
Facility Name:SHRINERS FOR CHILDREN AMBULATORY SURGICAL CENTER
OSHPD ID:306197915Report 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:SHRINERS FOR CHILDREN AMBULATORY SURGICAL CENTER
2.OSHPD ID Number:306197915
3.Street Address:909 S. FAIR OAKS AVE.
STE 200
4.City:PASADENA
5.Zip:91105
6.Facility Phone No.:( 626) 389 - 9500 ext.
7.Administrator Name:Phillip Grady
8.Administrator E-mail Address:pgrady@shrinenet.org
9.Was this clinic in operation at any time during the year?Yes
10.Operation Open From:10/12/2017
11.Operation Open To:12/31/2017
12.Name of Parent Corporation:Shriners Hospitals for Children
13.Corporate Business Address:2900 Rocky Point Dr
14.City:Tampa
15.State:FL
16.Zip:33607 -
17.Person Completing Report:Nicole Johnson
18.Report Preparer's Phone No.:626-389-9562
19.Fax No.:626-389-9337
20.E-mail Address:nicjohnson@shrinenet.org
30.Submitted by:nicjohnson
31.Submitted Date and Time:2/15/2018 5:11:56 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:Non-profit 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.)6868
SURGICAL CLINICS ONLY
Line
No.		(1)
Number
5.Number of surgical operating rooms on December 312
6.Total number of surgical operations performed during the calendar year68
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)No
Section 4 - Income Statement
INCOME STATEMENT
Line
No.		(1)
Total
1.Gross Patient Revenue$383,545
WRITE-OFFS AND ADJUSTMENTS:
2.Charity0
3.Contractual Adjustments0
4.Bad Debts0
8.Other Adjustments$322,178
9.Total Write-Offs and Adjustments (lines 2-8)$322,178
10.Net Patient Revenue (line 1 minus line 9)$61,367
Other Operating Revenue:
11.Grants - Public0
12.Grants - Private0
13.Donations / Contributions0
19.Other0
20.Total Other Operating Revenue (sum lines 11 - 19)$0
25.Total Operating Revenue (line 10 + line 20)$61,367
Operating Expenses:
30.Salaries, Wages and Employee Benefits$613,104
31.Contract Services - Professional$70,655
32.Supplies$106,881
33.Rent / Depreciation / Mortgage Interest0
34.Utilities0
35.Professional Liability Insurance0
36.Other Insurances0
44.All Other Expenses$13,622
45.Total Operating Expenses (sum lines 30 - 44)$804,262
50.Net From Operations (line 25 minus line 45)-$742,895

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