Annual Utilization Report of Specialty Clinics
Facility Name:DSI BERKELEY DIALYSIS
OSHPD ID:306014004Report Status:Submitted
License Category:DialysisReport Year:2013
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:DSI BERKELEY DIALYSIS
2.OSHPD ID Number:306014004
3.Street Address:2895 SEVENTH STREET
4.City:BERKELEY
5.Zip:94710
6.Facility Phone No.:( 510) 644 - 1489 ext.
7.Administrator Name:Abraham Fanco
8.Administrator E-mail Address:afanco@dsi-corp.com
9.Was this clinic in operation at any time during the year?No
10.Operation Open From:1/1/2013
11.Operation Open To:12/31/2013
12.Name of Parent Corporation:
13.Corporate Business Address:
14.City:
15.State:
16.Zip:-
17.Person Completing Report:Abraham Fanco
18.Report Preparer's Phone No.:510-843-0627
19.Fax No.:510-644-3792
20.E-mail Address:afanco@dsi-corp.com
30.Submitted by:abrahamfanco
31.Submitted Date and Time:5/29/2014 3:19:36 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: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
DIALYSIS CLINICS ONLY
Line
No.		(1)
Number
21.No. of Dialysis Stations24
22.Approved for In-Home Training(CAPD, CCPD)Undecided
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 (lines 2-8)0
10.Net Patient Revenue (line 1 minus line 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

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.)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)."
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.)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