Annual Utilization Report of Specialty Clinics
Facility Name:CARQUINEZ DIALYSIS
OSHPD ID:306484050Report Status:Submitted
License Category:DialysisReport Year:2011
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:CARQUINEZ DIALYSIS
2.OSHPD ID Number:306484050
3.Street Address:125 CORPORATE PLACE, STE. C
4.City:VALLEJO
5.Zip:94590
6.Facility Phone No.:( 253) 280 - 9425 ext.
7.Administrator Name:Vicki Kertzman
8.Administrator E-mail Address:vicki.kertzman@davita.com
9.Was this clinic in operation at any time during the year?Yes
10.Operation Open From:1/1/2011
11.Operation Open To:12/31/2011
12.Name of Parent Corporation:DaVita Inc
13.Corporate Business Address:1423 Pacific Ave
14.City:Tacoma
15.State:WA
16.Zip:98402 -
17.Person Completing Report:Lynn Webster
18.Report Preparer's Phone No.:253-280-9437
19.Fax No.:253-552-2390
20.E-mail Address:lynn.webster@davita.com
30.Submitted by:lynnwebster
31.Submitted Date and Time:2/2/2012 1:12:25 PM
Section 2 - Clinic Description
LICENSE CATEGORY (TYPE) (Completed by OSHPD.)
Line
No.		(1)
1.License CategoryDialysis
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:Investor - 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.)1710
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
DIALYSIS CLINICS ONLY
Line
No.		(1)
Number
21.No. of Dialysis Stations21
22.Approved for In-Home Training(CAPD, CCPD)No
Section 4 - Income Statement
INCOME STATEMENT
Line
No.		(1)
Total
1.Gross Patient Revenue$65,450,102
WRITE-OFFS AND ADJUSTMENTS:
2.Charity$56,015
3.Contractual Adjustments$59,755,606
4.Bad Debts$30,369
8.Other Adjustments0
9.Total Write-Offs and Adjustments (lines 2-8)$59,841,990
10.Net Patient Revenue (line 1 minus line 9)$5,608,112
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)$5,608,112
Operating Expenses:
30.Salaries, Wages and Employee Benefits$1,743,311
31.Contract Services - Professional0
32.Supplies$1,073,323
33.Rent / Depreciation / Mortgage Interest$443,844
34.Utilities$83,987
35.Professional Liability Insurance$13,958
36.Other Insurances$7,322
44.All Other Expenses$1,303,889
45.Total Operating Expenses (sum lines 30 - 44)$4,669,634
50.Net From Operations (line 25 minus line 45)$938,478

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