Annual Utilization Report of Long Term Care Facilities
Facility Name:	PLOTT NURSING HOME
OSHPD ID:	206361299	Report Status:	Submitted
License Category:	Skilled Nursing Facility	Report Year:	2002

Table of Contents

Click on any of the links listed below to view the corresponding section.

Section 1 - General Information

Section 2 - Facility Description

Section 3 - Census and Utilization

Section 4 - Patient Demographics

Section 5 - Major Capital Expenditures

Errors and Warnings

Section 1 - General Information
1.	Facility Name:	PLOTT NURSING HOME
2.	OSHPD ID Number:	206361299
3.	Street Address:	800 EAST 5TH STREET
4.	City:	ONTARIO
5.	Zip:	91764
6.	Facility Phone No.:	(909) 984 - 8629 ext.
7.	Administrator Name:	Tony Scarpelli
8.	Administrator E-mail Address:	n/a
9.	Was this facility in operation at any time during the year?	Yes
10.	Operation Open From:	01/01/2002
11.	Operation Open To:	12/31/2002
12.	Name of Parent Corporation:	Waterman Convalescent Hospital, Inc.
13.	Corporate Business Address:	1850 N. Waterman Ave
14.	City:	San Bernardino
15.	State:	CA
16.	Zip:	92404 -
17.	Person Completing Report:	Ryann Skyllingstad
18.	Report Preparer's Phone No.:	323-655-7180
19.	Fax No.:	323-655-7122
20.	E-mail Address:	rls@tyler-law.com
30.	Submitted by:	206361299
31.	Submitted Date and Time:	10/17/2003 5:30:14 PM
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Section 2 - Facility Description

LICENSE CATEGORY (TYPE)

Line No. (1) 1. License Category Skilled Nursing Facility

LICENSE TYPE OF CONTROL

Line No. (1) 5. Select the category that best describes the licensee type of control of your Long Term Care facility from drop down list: Investor- Corporation

Facility Certifications

From the certification categories below, check those categories for which your facility was certified or contracted during the year (Check all that apply.)

Line No. (1) 21. Medicare Skilled Nursing Yes 22. Medi-Cal Skilled Nursing Yes 23. Medi-Cal Skilled Nursing/Mentally Disordered (Special Treatment Program) No 24. Medi-Cal Intermediate Care (General) No 25. Medi-Cal Intermediate Care / Developmentally Disabled No 26. Medi-Cal Subacute or Subacute - Pediatric No

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Section 3 - Census and Utilization Instructions

Census and Patient Days

For each licensed bed category (columns 1 through 5), enter prior year ending census (line 1), admissions (line 2), discharges (line 3), current year ending census, and patient days (line5).

Line No. (1) Skilled Nursing (2) Skilled Nursing Mentally Disordered (3) Intermediate Care (4) Intermediate Care Develop- mentally Disabled (5) Congregate Living Health Facility (6) Total 1. Dec 31, 2001 Census 174 0 0 0 0 174 2. + Admissions 420 0 0 0 0 420 3. - Discharges 423 0 0 0 0 423 4. Dec. 31, 2002 Census (Total) 171 0 0 0 0 171 5. Patient Days for 2002 73,498 0 0 0 0 73,498 7. Licensed Beds 216 0 0 0 0 216 8. Licensed Bed Days 78,840 0 0 0 0 78,840

Patients Admitted From and Discharged To

LTC Patients admitted from and discharged to each place shown.

Line No. (1) Admitted From (2) Discharged To 11. Home 63 140 12. Hospital 329 167 13. State Hospital 0 0 14. Other LTC 21 18 15. Residential Board & Care 7 7 16. Other 0 0 17. AWOL 0 18. Death 91 20. Total 420 423

Patients By Payment Source On December 31

Number of patients in the facility on December 31, whose principal source of payment was from the sources shown.

Line No. (1) Patients 21. Medicare 3 22. Medi-Cal 139 23. Managed Care* 6 24. Private Insurance 0 25. Self-Pay 7 29. All Other 16 30. Total 171

* Include patients enrolled in Medicare and Medi-Cal managed care health plans.

Discharges By Length Of Stay

Number of discharges for each of the ranges of length of stay below.

Line No. Time in Facility (1) Patients 31. Less than 2 weeks 136 32. 2 weeks to less than 1 month 83 33. 1 month to less than 3 months 65 34. 3 months to less than 7 months 49 35. 7 months to less than 1 year 22 36. 1 year to less than 2 years 23 37. 2 years to less than 3 years 17 38. 3 years to less than 5 years 12 39. 5 years to less than 7 years 9 40. 7 years to less than 10 years 4 41. 10 years or longer 3 45. Total 423

Hospice Program

Line No. (1) 51. Did your facility offer a hospice program during the report period? No

Special Programs

Line No. (1) Patients 52. Number of patients diagnosed as having AIDS, ARC, prodromal AIDS or HIV-related diseases and illness (HTLV-III / LAV). 0

Line No. (1) 53. Does your facility offer a specialized program for Alzheimer's patients? Yes

Line No. (1) Patients 54. Number of patients who had a primary or secondary diagnosis of Alzheimer's Disease. 11

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Section 4 - Patient Demographics Instructions

Males - Race and Age of Male LTC Patients on December 31.

Line No. (1) < 45 (2) 45-54 (3) 55-64 (4) 65-74 (5) 75-84 (6) 85-94 (7) 95+ (8) Total 1. White 1 5 6 7 8 6 0 33 2. Black 0 1 2 1 2 1 0 7 3. Asian / Pac. Islander 0 0 0 1 0 0 0 1 4. Native American 0 0 0 0 1 0 0 1 5. Other / Unknown 0 2 3 4 5 0 0 14 6. Total Males 1 8 11 13 16 7 0 56

Females - Race and Age of Female LTC Patients on December 31.

Line No. (1) < 45 (2) 45-54 (3) 55-64 (4) 65-74 (5) 75-84 (6) 85-94 (7) 95+ (8) Total 11. White 1 4 9 10 27 31 3 85 12. Black 0 0 1 2 0 1 0 4 13. Asian / Pac. Islander 0 0 0 1 0 0 1 2 14. Native American 0 0 0 0 1 0 0 1 15. Other / Unknown 0 0 1 3 10 9 0 23 16. Total Females 1 4 11 16 38 41 4 115

Ethnicity of Patients on December 31.

Line No. (1) Male* (2) Female** (3) Total 21. Hispanic 14 25 39 22. Non-Hispanic 42 90 132 23. Unknown 0 0 0 25. Total Patients 56 115 171

*  Total male patients in column 1, line 25 must agree with column 8, line 6.

**  Total female patients in column 2, line 25 must agree with column 8, line 16.

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Section 5 - Major Capital Expenditures

Section 127285(3) of the Health and Safety Code requires each facility 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

1. Did your facility acquire any diagnostic or therapeutic equipment that had a value of $500,000 or more? (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. 0 3. 0 4. 0 5. 0 6. 0 7. 0 8. 0 9. 0 10. 0 11. 0

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

Section 127285(4) of the Health and Safety Code requires each facility 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)."

25. Did your facility 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. 0 27. 0 28. 0 39 0 30. 0

General Comments: Instructions Glossary

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Errors and Warnings	Instructions
	Glossary