Annual Utilization Report of Long Term Care Facilities
Facility Name:	SAMARKAND SKILLED NURSING FACILITY
OSHPD ID:	206420510	Report Status:	Submitted
License Category:	Skilled Nursing Facility	Report Year:	2005

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:	SAMARKAND SKILLED NURSING FACILITY
2.	OSHPD ID Number:	206420510
3.	Street Address:	2566 TREASURE DRIVE
4.	City:	SANTA BARBARA
5.	Zip:	93105
6.	Facility Phone No.:	(805) 687 - 0701 ext.
7.	Administrator Name:	Ann B. Cox
8.	Administrator E-mail Addr:	abcox@covenenatretirement.org
9.	Was this facility in operation at any time during the year?	Yes
10.	Operation Open From:	1/1/2005
11.	Operation Open To:	12/31/2005
12.	Name of Parent Corporation:	Covenant Retirment Communities
13.	Corporate Business Address:	5115 N. Francisco Ave
14.	City:	Chicago
15.	State:	IL
16.	Zip:	60625 - 3611
17.	Person Completing Report:	Ann Cox
18.	Report Preparer's Phone No.:	805-569-8588
19.	Fax No.:	805-898-0379
20.	E-mail Address:	abcox@covenantretirement.org
30.	Submitted by:	206420510
31.	Submitted Date and Time:	2/3/2006 9:41:16 AM

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: Non-profit 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

Section 3 - Census and Utilization

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, 2004 Census 57 0 0 0 0 57 2. + Admissions 119 0 0 0 0 119 3. - Discharges 115 0 0 0 0 115 4. Dec. 31, 2005 Census (Total) 61 0 0 0 0 61 5. Patient Days for 2005 21,428 0 0 0 0 21,428 7. Licensed Beds 63 0 0 0 0 63 8. Licensed Bed Days 22,995 0 0 0 0 22,995

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 3 12 12. Hospital 53 12 13. State Hospital 0 0 14. Other LTC 20 7 15. Residential Board & Care 14 30 16. Other 29 13 17. AWOL 0 18. Death 41 20. Total 119 115

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 11 23. Managed Care* 0 24. Private Insurance 4 25. Self-Pay 43 29. All Other 0 30. Total 61

* 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 24 32. 2 weeks to less than 1 month 27 33. 1 month to less than 3 months 34 34. 3 months to less than 7 months 12 35. 7 months to less than 1 year 4 36. 1 year to less than 2 years 7 37. 2 years to less than 3 years 4 38. 3 years to less than 5 years 2 39. 5 years to less than 7 years 1 40. 7 years to less than 10 years 0 41. 10 years or longer 0 45. Total 115

Hospice Program

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

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? No

Line No. (1) Patients 54. Number of patients who had a primary or secondary diagnosis of Alzheimer's Disease. 22

Section 4 - Patient Demographics

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 0 0 0 1 2 8 0 11 2. Black 0 0 0 0 0 0 0 0 3. Asian / Pac. Islander 0 0 0 0 0 0 0 0 4. Native American 0 0 0 0 0 0 0 0 5. Other / Unknown 0 0 0 0 0 1 0 1 6. Total Males 0 0 0 1 2 9 0 12

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 0 0 0 1 13 22 9 45 12. Black 0 0 0 0 0 0 0 0 13. Asian / Pac. Islander 0 0 0 0 0 0 0 0 14. Native American 0 0 0 0 0 0 0 0 15. Other / Unknown 0 0 0 1 1 2 0 4 16. Total Females 0 0 0 2 14 24 9 49

Ethnicity of Patients on December 31.

Line No. (1) Male* (2) Female** (3) Total 21. Hispanic 0 1 1 22. Non-Hispanic 11 45 56 23. Unknown 1 3 4 25. Total Patients 12 49 61

*  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.

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 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 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. 27. 28. 29. 30.

General Comments:

Errors and Warnings