Annual Utilization Report of Specialty Clinics
Facility Name:COFFEE ROAD SURGERY CENTER, INC.
OSHPD ID:306504050Report Status:Revised
License Category:SurgicalReport 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 - Patients and Encounters
Section 4 - Income Statement
Section 5 - Major Capital Expenditures
Errors and Warnings
Section 1 - General Information

1.Facility Name:COFFEE ROAD SURGERY CENTER, INC.
2.OSHPD ID Number:306504050
3.Street Address:1335 COFFEE ROAD
2ND FLOOR
4.City:MODESTO
5.Zip:95355
6.Facility Phone No.:( 209) 492 - 0483 ext.
7.Administrator Name:Michael Lipomi, CEO
8.Administrator E-mail Address:
9.Was this clinic in operation at any time during the year?No
10.Operation Open From:6/7/2005
11.Operation Open To:12/31/2005
12.Name of Parent Corporation:Stanislaus Surgical Hospital, Inc.
13.Corporate Business Address:1421 Oakdale Road
14.City:Modesto
15.State:CA
16.Zip:95355 -
17.Person Completing Report:Cynthia Jeremica
18.Report Preparer's Phone No.:916-683-9222
19.Fax No.:916-244-2625
20.E-mail Address:STATMED2000@aol.com
30.Submitted by:coffeersjg
31.Submitted Date and Time:2/9/2006 11:24:23 AM


Section 2 - Facility Description
LICENSE CATEGORY (TYPE)
Line
No.		(1)
1.License CategorySurgical
LICENSEE TYPE OF CONTROL
Line
No.		(1)
5.Select the category that best describes the licensee type of control of your clinic from drop down list:Unselected Type of Control


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.)00
SURGICAL CLINICS ONLY
Line
No.		(1)
Number
5.Number of surgical operating rooms on December 310
6.Total number of surgical operations performed during the calendar year0
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


Section 4 - Income Statement
INCOME STATEMENT
Line
No.		(1)
Total
1.Gross Patient Revenue0
WRITE-OFFS AND ADJUSTMENTS:
2.Charity0
3.Contractual Adjustments0
4.Bad Debts0
8.Other Adjustments0
9.Total Write-Offs and Adjustments (line 2-8)0
10.Net Patient Revenue (line 1 minus 9)0
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)0
Operating Expenses:
30.Salaries, Wages and Employee Benefits0
31.Contract Services - Professional0
32.Supplies0
33.Rent / Depreciation / Mortgage Interest0
34.Utilities0
35.Professional Liability Insurance0
36.Other Insurances0
44.All Other Expenses0
45.Total Operating Expenses (sum lines 30 - 44)0
50.Net From Operations (line 25 minus Line 45)0

The Clinic's License Fee Will Be Based Upon The Completion Of This Income Statement And Will Be Calculated Accordingly.

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
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.)Undecided

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)."
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.)Undecided

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