Annual Utilization Report of Primary Care Clinic
Facility Name:COMPREHENSIVE COMMUNITY HEALTH CENTERS, INC. - SUNLAND
OSHPD ID:306191327Report Status:Submitted
License Category:Community ClinicReport 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 Services
Section 3 - Patient Demographics
Section 4 - Encounters by Principal Diagnosis
Section 5 - Encounters by Principal Service
Section 6 - Revenue and Utilization by Payer
Section 7 - Income Statement
Section 8 - Capital Projects and Funds
General Comments
View Errors and Warnings
Section 1 - General Information
1.Facility Name:COMPREHENSIVE COMMUNITY HEALTH CENTERS, INC. - SUNLAND
2.OSHPD ID Number:306191327
3.Street Address:8316 FOOTHILL BLVD
4.City:SUNLAND
5.Zip:91040
6.Facility Phone No.:(818) 273 - 8800 ext.
7.Administrator Name:Flora Poladyan
8.Administrator E-mail Address:florap@cchccenters.org
9.Was this clinic in operation at any time during the year?:Yes
10.Operation Open From:4/10/2017
11.Operation Open To:12/31/2017
12.Name of Parent Corporation:Comprehensive Community Health Centers, Inc
13.Corporate Business Address:801 S. Chevy Chase Dr., Suite 20
14.City:Glendale
15.State:CA
16.Zip:91205 -
17.Person Completing Report:Shameen Cooper
18.Phone No.:818-630-6104
19.Fax No.:818-552-2621
20.E-mail Address:shameenc@cchccenters.org
30.Submitted by:shameencooper
31.Submitted Date and Time:5/30/2018 5:28:15 PM
Section 2 - Clinic Services
LICENSE CATEGORY (TYPE) (Completed by OSHPD.)
Line
No.		(1)
1.License Category:Community Clinic
Federally Qualified Health Clinic (FQHC)
Line
No.		Federally Qualified Health Clinics(1)
2.Indicate clinic type, if applicable:FQHC
Rural Health Clinic
Line
No.		Rural Health Clinic(1)
3.Is this a 95-210 Rural Health Clinic?No
Table 2.1 - Community Services
Check one or more boxes for each service provided.
Line
No.		Community Services(1)
Offered
10.Adult Day CareNo
11.Child CareNo
12.Community EducationYes
13.Community NutritionNo
14.Disaster ReliefNo
15.Environmental HealthNo
16.HomelessNo
17.LegalNo
18.OutreachYes
19.Social ServicesNo
20.Substance AbuseNo
21.TransportationYes
22.Vocational Training PlacementNo
23.OtherNo
HEALTH SERVICES
Check one or more boxes for each service provided.
Line
No.		(1)
Offered
100.MedicalYes
101.DentalYes
102.VisionYes
103.Mental Health (Psychology / Psychiatry / Behavioral health)Yes
104.Substance Abuse (Alcohol / Drug Services)
105.Domestic Violence
106.Basic LabYes
107.Radiological Services
108.Urgent CareYes
109.Pharmacy
110.Women's Health (Ob-Gyn/Family Planning/Midwives)Yes
Table 2.2 - Languages Spoken By Staff and Patients
Check the staff box if one or more of your staff members speak a listed language. Check the patients box if 100 patients (or more than 1% of your patient population) are best served in a listed language. Estimates are acceptable if exact counts are not available.
Line
No.		Language Spoken By(1)
Staff		(2)
Patients
30.ArabicNoNo
31.ArmenianYesYes
32.CambodianNoNo
33.ChineseNoNo
34.HindustaniNoNo
35.HmongNoNo
36.JapaneseNoNo
37.KoreanNoNo
38.LaotianNoNo
39.PortugueseNoNo
40.PunjabiNoNo
41.RussianNoNo
42.Sign LanguageNoNo
43.SpanishYesYes
44.TagalogNoNo
45.VietnameseNoNo
Language Summary
Line
No.		Language Summary(1)
55.Percentage (%) of patient population best served in a non-English language (round to nearest WHOLE percent):43%
56.Primary non-English language spoken by patients (from list above):Spanish
FTE's and Encounters by Primary Care Provider
Line
No.		Primary Care Provider(1)
Salaried
FTE's		(2)
Contract
FTE's		(3)
Volunteer
FTE's		(4)
Total
FTE's
(5)
No. of
Encounters
60.Physicians0.420.030.451,372
61.Physician Assistants0.500.501,103
62.Family Nurse Practitioners0.000
63.Certified Nurse Midwives0.000
64.Visiting Nurses0.000
65.Dentists0.600.601,475
66.Registered Dental Hygienists (Alternative Practice)0.000
67.Psychiatrists0.010.0120
68.Clinical Psychologists0.000
69.Licensed Clinical Social Workers (LCSW)0.020.0275
70.Other Providers billable to Medi-Cal**0.400.40493
74.Other Certified CPSP providers not listed above***0.000
75.Subtotal1.940.040.001.984,538
** Other Providers billable to Medi-Cal - Included here are Chiropractors, Physical Therapists, Optometrists and any other professionals who are able to be reimbursed through the Medi-Cal program.
*** Comprehensive Perinatal Services Program - List all other professional not listed above that are certified by the CPSP program to render services and can be reimbursed.
FTE's and Contacts by Clinical Support Staff
Line
No.		Clinical Support Staff(1)
Salaried
FTE's		(2)
Contract
FTE's		(3)
Volunteer
FTE's		(4)
Total
FTE's
(5)
No. of
Contacts
80.Registered Dental Hygienists (not Alternative Practice)0.000
81.Registered Dental Assistants0.000
82.Dental Assistants - Not licensed0.800.800
83.Marriage and Family Therapists (MFT)0.000
84.Registered Nurses0.000
85.Licensed Vocational Nurses0.710.710
86.Medical Assistants - Not licensed (1)1.111.110
87.Non-Licensed Patient Education Staff0.310.570.880
88.Substance Abuse Counselors (2)0.000
89.Billing Staff (3)0.220.22
90.Other Administrative Staff (4)3.070.063.13
94.Other Providers not listed above0.00
95.Subtotal6.220.630.006.850
(1) Also includes Certified Medical Assistants
(2) Does not include substance abuse counseling performed by providers listed elsewhere
(3) Staff must spend 80% of time on billing
(4) Includes Executive Directors, CFO's, Medical & Dental Records staff, Medical & Dental Receptionists & other management staff
Section 3 - Patient Demographics
Race
Line
No.		Race(1)
# of
Patients
1.White (include Hispanic)2,026
2.Black50
3.Native American / Alaskan Native4
4.Asian / Pacific Islander91
5.More than one race5
9.Other / Unknown66
10.Total Patients *2,242
Ethnicity
Line
No.		Ethnicity(1)
# of
Patients
11.Hispanic1,219
12.Non-Hispanic955
13.Unknown68
15.Total Patients *2,242

Federal Poverty Level
Line
No.		Federal Poverty Level(1)
# of
Patients
20.Under 100%1,586
21.100 - 138%310
22.139 - 200%173
23.201 - 400%91
24.Above 400%81
25.Unknown1
26.Total Patients by Federal Poverty Level *2,242
Seasonal Agricultural And Migratory Workers
Line
No.		Seasonal Agricultural and Migratory Workers(1)
Number
30.Total Patients0
31.Total Encounters0
Age Category
Line
No.		Age Category(1)
Males		(2)
Females
40.Under 1 year2730
41.1 - 4 years6888
42.5 - 12 years160150
43.13 - 14 years3026
44.15 - 19 years6577
45.20 - 34 years130361
46.35 - 44 years98223
47.45 - 64 years211368
48.65 and over5575
55.Total Patients *8441,398
Patient Coverage
Line
No.		Patient Coverage(1)
# of
Patients
60.Medicare52
61.Medicare - Managed Care22
62.Medi-Cal565
63.Medi-Cal - Managed Care1,017
64.County Indigent / CMSP / MISP0
65.Private Insurance140
66.Covered California32
67.Alameda Alliance for Health0
68.My Health LA (MHLA)150
69.PACE Program0
70.Self-Pay / Sliding Fee264
71.Free0
74.All Other Payers0
75.Total Patients *2,242
Episodic Programs
Line
No.		Episodic Programs(1)
# of
Patients
80.BCCTP0
81.CHDP69
82.
83.Family PACT96
84.Other County Programs0
85.Childrens Treatment Program0
89.Other Payer - covered by a grant0
90.Total Episodic Patients (duplicated)165
Child Health And Disability Prevention (CHDP)
Line
No.		Child Health And Disability Prevention (CHDP)(1)
# of
Assessments
95.CHDP Assessments80
* Totals for these tables must agree.
Section 4 - Encounters By Principal Diagnosis
Encounters by Principal Diagnosis
Report the diagnosis (or symptom, condition, problem or complaint) as the main reason for the encounter. Do not report the secondary diagnosis(es). There should be only one principal diagnosis for each encounter.
Line
No.		Classification of Diseases and/or Injuries
for each Principal Diagnosis
ICD - 10-CM Codes
(1)
# of Encounters
1.Infectious and Parasitic DiseasesA00-B99100
2.NeoplasmsC00-D4937
3.Endocrine, Nutritional, and Metabolic Diseases; and Immunity DisordersE00-E89345
4.Blood and Blood Forming DisordersD50-D8922
5.Mental, Behavioral, and Neurodevelopment DisordersF01-F99152
6.Nervous System and Sense Organs DiseasesG00-H95559
7.Circulatory System DiseasesI00-I99118
8.Respiratory System DiseasesJ00-J99185
9.Digestive System Diseases, excluding dental diagnosisK20-K9560
10.Genitourinary System DiseasesN00-N99111
11.Pregnancy, Childbirth & the PuerperiumO00-O9A1
12.Skin and Subcutaneous Tissue DiseasesL00-L9964
13.Musculoskeletal System and Connective Tissue DiseasesM00-M99162
14.Congenital AnomaliesQ00-Q993
15.Certain Conditions Originating in the Perinatal PeriodP00-P960
16.Symptoms, Signs, and Ill-defined ConditionsR00-R99213
17.Injury and PoisoningS00-T8861
18.Factors Influencing Health Status and Contact with Health ServicesZ00 – Z29, Z40 – Z991,265
19.Dental DiagnosisK00-K14849
20.Family Planning "Z" CodesZ30 – Z39231
21.OtherAll other codes not in lines 1-200
25.Total4,538
Section 5 - Encounters By Principal Service
Encounters by Principal Service
Classify each encounter by the principal CPT code that was reported on the billing document for this encounter. Do not report secondary procedures. There should be one and only one procedure code reported for each encounter.
Line
No.		Principal ServicesCPT Codes - 2012(1)
# of
Encounters
1.Evaluation and Management (new patient)99201 - 99205396
2.Evaluation and Management (established patient)99211 - 992151,527
3.Hospital Related Services99217 – 99226,
99231 - 99239,
99477		0
4.Consultations99241 - 99245,
99441 - 99444		2
5.Other Evaluation and Management Services99291 - 99292,
99354 - 99360,
99450, 99455 - 99456, 99499		0
6.Nursing Facility Related Services99304 - 993180
7.Case Management Services99363 - 99364,
99366 - 99368		0
8.Preventive Medicine (infant, child, adolescent)99381 - 99384,
99391 - 99394,
99461		259
9.Preventive Medicine (adult)99385 - 99387,
99395 - 99397		266
10.Counseling99401 - 99404,
99406 – 99409,
99411 – 99412,
99420 – 99429,
99605 – 99607		0
All Other Services
11.Anesthesia00100 – 01999,
99100,
99116,
99135,
99140,
99151-99153		0
12.Integumentary System10021 - 194990
13.Musculoskeletal System20005 - 299990
14.Respiratory System30000 - 329990
15.Cardiovascular System33010 - 377990
16.Hemic and Lymphatic System38100 - 389990
17.Mediastinum and Diaphragm System39000 - 395990
18.Digestive System40490 - 499990
19.Urinary System50010 - 538990
20.Male Genital System54000 - 559200
21.Intersex Surgery55970, 559800
22.Female Genital System56405 - 589990
23.Maternal Care and Delivery59000 - 5989945
24.Endocrine System60000 - 606990
25.Nervous System61000 - 649990
26.Eye and Ocular Adnexa System65091 - 68899493
27.Auditory System69000 - 699790
28.Radiology70010 - 799990
29.Pathology / Laboratory80047 – 89356, 893980
30.Medicine - Special Services90281 – 99091,
99170 – 99199		75
31.Family Planning "Z" Codes"Z" codes0
32.Dental Encounters (CDT codes)D0100-D09991,475
33.CPT Category III Codes0042T - 0463T0
44.OtherAll other codes not in lines 1-330
45.Total4,538
Selected Procedure Code
Report the number of procedures for each code (or range of codes) regardless of whether it is the principal or secondary procedure code.
Line
No.		Evaluation and Management ServicesCPT Codes - 2012(1)
# of
Procedures
50.Mammogram77053-770670
51.HIV Testing86689,
86701 - 86703,
87390 - 87391		0
52.Pap Smear88141 - 88155,
88164 - 88167,
88174 - 88175		119
53.Contraceptive Management11976, 55250,
55300, 55400, 55450, 57170,
58300 - 58301, 58600
58605, 58611, 58615, 58670 - 58671		4
Vaccinations
60.DTap, DTP, Diphtheria and Tetanus90389, 90696-90698, 90700 -90702, 90714 - 90715, 9072388
61.Hemophilus Influenza B (Hib)90647, 90645 - 9064829
62.Hepatitis A90632 – 90634,
90636		41
63.Hepatitis B90740, 90743 - 90744, 90746 - 9074722
64.HepB and Hib907480
65.Influenza Virus Vaccine90630, 90654-90658, 90660-90662, 90664, 90666-90668, 90685-90688176
66.Measles, Mumps and Rubella (MMR) and Varicella (MMRV)90705-90708, 90710, 9071634
67.Pneumococcal90669 - 90670, 9073245
68.Poliovirus9071325
69.Varicella90396, 9071630
Section 6 - Revenue and Utilization by Payer
Revenue and Utilization by Payment Source
(Do not put any "$" signs, commas or decimals, round up to whole dollar)
Line
No.
(1)

Medicare		(2)
Medicare
Managed
(3)

Medi-Cal		(4)
Medi-Cal
Managed		(5)
County/
CMSP/MISP		(6)
Private
Insurance
1.Encounters95411,0992,0290227
2.Gross Revenue
(Charges at 100% Rate)		$45,074$10,087$319,219$726,145$0$59,567
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$32,432$8,862$48,098$334,405$0$43,802
6.Bad Debts
7.Grants (see Section 7)
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$32,432$8,862$48,098$334,405$0$43,802
15.Net Patient Revenue (collected)
(line 2 – line 10)		$12,642$1,225$271,121$391,740$0$15,765
*Include LIHP encounters under County Indigent/CMSP/MISP
Line
No.
(7)

Covered
California		(8)
Self-Pay/
Sliding Fee
(9)


Free
(10)

Breast
Cancer*
(11)


CHDP
(12)


EAPC
1.Encounters713740080
2.Gross Revenue
(Charges at 100% Rate)		$16,676$117,439$0$0$23,060
3.Sliding Fee Scale
Write-offs		$99,212
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$13,237$0$4,378
6.Bad Debts
7.Grants (see Section 7)
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$13,237$99,212$0$0$4,378
15.Net Patient Revenue (collected)
(line 2 – line 10)		$3,439$18,227$0$0$18,682
*  These include the following:
Breast Cancer Early Detection Program
Breast Cancer & Cervical Cancer Control Program
Line
No.
(13)

Family
PACT		(14)
PACE
Program**
(15)

My Health
LA
(MHLA)
(16)

Alameda
Alliance
(17)

Other
County
(18)

All Other
Payers
1.Encounters1400382000
2.Gross Revenue
(Charges at 100% Rate)		$40,882$0$95,441$0$0$0
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$26,073$95,400$0$0$0
6.Bad Debts
7.Grants (see Section 7)
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$26,073$0$95,400$0$0$0
15.Net Patient Revenue (collected)
(line 2 – line 10)		$14,809$0$41$0$0$0
**  Report number of patients on Line 1 for the PACE Program
Line
No.		(19)
Grand Totals
1.Encounters4,538
2.Gross Revenue
(Charges at 100% Rate)		$1,453,590
3.Sliding Fee Scale Write-offs$99,212
4.Free/Complimentary Write-offs$0
5.Contractual Adjustments$606,687
6.Bad Debts$0
7.Grants (see Section 7)
8.Other Adjustments$0
9.Reconciliation$0
10.Total Write-offs & Adjustments
(sum lines 3 through 9)		$705,899
15.Net Patient Revenue (collected)
(line 2 – line 10)		$747,691
Section 7 - Income Statement
Income Statement
(Do not input any "$" signs, commas or decimals, round up to whole dollar.)
Line
No.		Revenue(1)
1.Gross Patient Revenue (from Sec 6, line 2, column 19)$1,453,590
2.Total Write-offs and Adjustments (from Sec 6, line 10, column 19)$705,899
3.Net Patient Revenue (from Sec 6, line 15, column 19)$747,691
Other Operating Revenue
4.Federal Funds - Grants - all others (e.g. 330 funds)$95,652
400.Federal Stimulus Grants - American Recovery and Reinvestment Act (ARRA)
401.Federal Funds - New Access Point (NAP)
402.Federal Funds - Increased Demand for Services (IDS)
403.Federal Funds - Capital Improvement Project (CIP)
State Funds
6.Other
County Funds
10.Other County Grant Programs
11.Local (City or District) Funds
12.Private$15,930
13.Donations/Contributions$246,554
19.Other$56,101
20.Total Other Operating Revenue (Sum lines 4 through 19)$414,237
25.Total Operating Revenue (line 3 + line 20)$1,161,928
Operating Expenses
30.Salaries, Wages, and Emplyee Benefits$378,549
31.Contract Services - Professional
32.Supplies - Medical and Dental$189,206
33.Supplies - Office$26,135
34.Outside Patient Care Services$5,480
35.Rent / Depreciation / Mortgage Interest$848,764
36.Utilities$19,350
37.Professional Liability Insurance$1,680
38.Other Insurance$136
39.Continuing Education$8
40.Information Technology (including EHR)$54,024
44.All Other Expenses$508,048
45.Total Operating Expenses (Sum lines 30 through 44)$2,031,380
50.Net from Operations (line 25 - line 45)-$869,452
Section 8 - 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.)		Yes
Detail of Capital Expenditures
Line
No.
(1)


Description of Project		(2)
Projected Total Capital Expenditure
(3)

OSHPD Project No. (if applicable)
26.Leasehold improvement for the new clinic location$3,751,201n/a
27.
28.
29.
30.
Capital Fund
Line
No.		Capital Fund(1)
40.Beginning Fund Balance
41.Current Year Contribution
42.Current Year Interest Earnings
43.Current Year Expenditures
44.Ending Fund Balance
(line 40 + line 41 + line 42 - line 43)		$0
General Comments:
Errors and Warnings