Annual Utilization Report of Specialty Clinics
Facility Name:COFFEE ROAD SURGERY CENTER, INC.
OSHPD ID:306504050Report Status:Submitted
License Category:SurgicalReport Year:2004
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) 524 - 4649 ext.
7.Administrator Name:Michael B. Purnell, M.D.
8.Administrator E-mail Address:orthogold@aol.com
9.Was this clinic in operation at any time during the year?Yes
10.Operation Open From:11/19/2004
11.Operation Open To:12/31/2004
12.Name of Parent Corporation:Coffee Road Surgery Center, Inc.
13.Corporate Business Address:1335 Coffee Road
2nd Floor
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:2/7/2005 12:51:21 PM


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: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.)66
SURGICAL CLINICS ONLY
Line
No.		(1)
Number
5.Number of surgical operating rooms on December 312
6.Total number of surgical operations performed during the calendar year6
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 Revenue$29,970
WRITE-OFFS AND ADJUSTMENTS:
2.Charity0
3.Contractual Adjustments$11,584
4.Bad Debts0
8.Other Adjustments0
9.Total Write-Offs and Adjustments (line 2-8)$11,584
10.Net Patient Revenue (line 1 minus 9)$18,386
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)$18,386
Operating Expenses:
30.Salaries, Wages and Employee Benefits$6,808
31.Contract Services - Professional$3,005
32.Supplies$2,000
33.Rent / Depreciation / Mortgage Interest$7,431
34.Utilities$1
35.Professional Liability Insurance$665
36.Other Insurances$305
44.All Other Expenses$1,000
45.Total Operating Expenses (sum lines 30 - 44)$21,215
50.Net From Operations (line 25 minus Line 45)-$2,829

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.)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)."
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