Facility Number: Hospital Owner/Licensee: City: Address: Facility Name: Year of Reporting: Contact 1 e-mail Address: Contact 2 e-mail Address: Contact 3 e-mail Address:: Name of Submitter: Submission Date: 10301 Mendocino Coast District Hospital 700 River Drive Fort Bragg Mendocino Coast Health Care District 2011 David Killion 1/29/2012 3:00:00 PM Provide the Hospital Owner and Year of Report per Section 130061(e) Report Status: 1/30/2012 12:45 PM Data Last Update: 01/12/2012 Submission Date: 01/29/2012 Print Date: 10301 2011 Mendocino Coast District Hospital Fort Bragg Page:1 of 27 Report Year:
Transcript
Facility Number:
Hospital Owner/Licensee:
City:
Address:
Facility Name:
Year of Reporting:
Contact 1 e-mail Address:
Contact 2 e-mail Address:
Contact 3 e-mail Address::
Name of Submitter:
Submission Date:
10301
Mendocino Coast District Hospital
700 River Drive
Fort Bragg
Mendocino Coast Health Care District
2011
David Killion
1/29/2012 3:00:00 PM
Provide the Hospital Owner and Year of Report per Section 130061(e)
103012011 Mendocino Coast District Hospital Fort Bragg Page:1 of 27Report Year:
For buildings which are planned for retrofit or replacement the report shall identify: Whether the hospital owner intends to retrofit or replace the building to SPC 2 or SPC 5 per section 130061(c)(1)(A). The deadline, as described in Section 130060 or 130061.5, for retrofit or replacement of the bulding that the hospital owner intends to meet, and the applicable extension for which the hospital owner has been approved per Section 130061(c)(1)(B)
Bldg.No. Building Name Alternate Building Address
Building Resolution
Final SPC RatingIf Required
Extension Date
Anticipated Completion Date
06/01/201201/01/2013SPC2RetrofitCentral Plant02 700 River Drive
103012011 Mendocino Coast District Hospital Fort Bragg Page:2 of 27Report Year:
Central PlantBuilding No: 02 Yes-SubmittedRetrofit/Replacement Project:
10301 HS021153 0 SPC 1 CENTRAL PLANT PARTIAL RENOVATION
05/15/2002 08/12/2003 09/12/2003 10/01/2011 OPEN No
Facility Project Sub Scope Date Plan Approved Proj. Start Proj. Completed Status CEQANumber Number Num in Date Date Date Review_
For each building which is planned for retrofitting or replacement, provide the project numbers, per Section 130061(c)(1)(C). The projected construction start date or dates and projected Completion date or dates per Section 130061(c)(1)(D) and the most recent project status and approvals per Section 130061(c)(1)(E).
103012011 Mendocino Coast District Hospital Fort Bragg Page:7 of 27Report Year:
Building Number: Building Name:
Nursing
IntensiveCare
Pediatric/Adolescent
PsychiatricNursing
ObstetricalAnte/Postprtum
IntermediateCare
Skilled Nursing
02 Central Plant
Type of Service Provided
Surgical
Anesthesia
Support Services
Administration
Dietetic
Pharmaceutical
Clinical Lab
Radiological/Imaging
OutpatientSurgery
Central Plant
RehabilitationTherapy
Renal Dialysis
X
X
Obstetrical Cesarean/Deliv
ObstetricalRecovery
Newborn/WellBaby
Emergency
Nuclear Medicine
Report any general acute care hospital inpatient service that is provided in any genaral acute care hospital building that is rated SPC-1 per Section 130061(c)(4)
103012011 Mendocino Coast District Hospital Fort Bragg Page:8 of 27Report Year:
Nursing
IntensiveCare
Pediatric/Adolescent
PsychiatricNursing
ObstetricalAnte/Postprtum
IntermediateCare
Skilled Nursing
Support Services
Administration
Dietetic
Pharmaceutical
Radiological/Imaging
Clinical Lab
Anesthesia
Surgical
ObstetricalRecovery
Newborn/WellBaby
Emergency
Nuclear Medicine
RehabilitationTherapy
Renal Dialysis
OutpatientSurgery
Central Plant
Obstetrical Cesarean/Deliv
Building Number:
Type of Service Provided
Building Name:
X
X
X
01 Main Hospital
Retrofit Non-Conforming building to SPC 5 and NPC 4 or NPC 5Configuration:
X
XX
X
X
X
X
X
X
X
Report the final configuration of all buildings on the hospital campus showing how each building will comply with the SPC-5/NPC-4 or 5 requirements whether by retrofit or by replacement and the type of service that will be provided in each general actue care hospital building per Section 130061(c)(5)
103012011 Mendocino Coast District Hospital Fort Bragg Page:9 of 27Report Year:
Nursing
IntensiveCare
Pediatric/Adolescent
PsychiatricNursing
ObstetricalAnte/Postprtum
IntermediateCare
Skilled Nursing
Support Services
Administration
Dietetic
Pharmaceutical
Radiological/Imaging
Clinical Lab
Anesthesia
Surgical
ObstetricalRecovery
Newborn/WellBaby
Emergency
Nuclear Medicine
RehabilitationTherapy
Renal Dialysis
OutpatientSurgery
Central Plant
Obstetrical Cesarean/Deliv
Building Number:
Type of Service Provided
Building Name:
02 Central Plant
Retrofit Non-Conforming building to SPC 5 and NPC 4 or NPC 5Configuration:
X
X
Report the final configuration of all buildings on the hospital campus showing how each building will comply with the SPC-5/NPC-4 or 5 requirements whether by retrofit or by replacement and the type of service that will be provided in each general actue care hospital building per Section 130061(c)(5)
103012011 Mendocino Coast District Hospital Fort Bragg Page:10 of 27Report Year:
Nursing
IntensiveCare
Pediatric/Adolescent
PsychiatricNursing
ObstetricalAnte/Postprtum
IntermediateCare
Skilled Nursing
Support Services
Administration
Dietetic
Pharmaceutical
Radiological/Imaging
Clinical Lab
Anesthesia
Surgical
ObstetricalRecovery
Newborn/WellBaby
Emergency
Nuclear Medicine
RehabilitationTherapy
Renal Dialysis
OutpatientSurgery
Central Plant
Obstetrical Cesarean/Deliv
Building Number:
Type of Service Provided
Building Name:
X
03 Respiratory Neurophysiology Lab
Retrofit Conforming building to NPC 4 or NPC 5Configuration:
Report the final configuration of all buildings on the hospital campus showing how each building will comply with the SPC-5/NPC-4 or 5 requirements whether by retrofit or by replacement and the type of service that will be provided in each general actue care hospital building per Section 130061(c)(5)
103012011 Mendocino Coast District Hospital Fort Bragg Page:11 of 27Report Year:
Nursing
IntensiveCare
Pediatric/Adolescent
PsychiatricNursing
ObstetricalAnte/Postprtum
IntermediateCare
Skilled Nursing
Support Services
Administration
Dietetic
Pharmaceutical
Radiological/Imaging
Clinical Lab
Anesthesia
Surgical
ObstetricalRecovery
Newborn/WellBaby
Emergency
Nuclear Medicine
RehabilitationTherapy
Renal Dialysis
OutpatientSurgery
Central Plant
Obstetrical Cesarean/Deliv
Building Number:
Type of Service Provided
Building Name:
X
X
X
04A Emergency Addition - East
Retrofit Conforming building to NPC 4 or NPC 5Configuration:
X
Report the final configuration of all buildings on the hospital campus showing how each building will comply with the SPC-5/NPC-4 or 5 requirements whether by retrofit or by replacement and the type of service that will be provided in each general actue care hospital building per Section 130061(c)(5)
103012011 Mendocino Coast District Hospital Fort Bragg Page:12 of 27Report Year:
Nursing
IntensiveCare
Pediatric/Adolescent
PsychiatricNursing
ObstetricalAnte/Postprtum
IntermediateCare
Skilled Nursing
Support Services
Administration
Dietetic
Pharmaceutical
Radiological/Imaging
Clinical Lab
Anesthesia
Surgical
ObstetricalRecovery
Newborn/WellBaby
Emergency
Nuclear Medicine
RehabilitationTherapy
Renal Dialysis
OutpatientSurgery
Central Plant
Obstetrical Cesarean/Deliv
Building Number:
Type of Service Provided
Building Name:
04B Emergency Addition - West
Retrofit Conforming building to NPC 4 or NPC 5Configuration:
X
Report the final configuration of all buildings on the hospital campus showing how each building will comply with the SPC-5/NPC-4 or 5 requirements whether by retrofit or by replacement and the type of service that will be provided in each general actue care hospital building per Section 130061(c)(5)
103012011 Mendocino Coast District Hospital Fort Bragg Page:13 of 27Report Year:
Nursing
IntensiveCare
Pediatric/Adolescent
PsychiatricNursing
ObstetricalAnte/Postprtum
IntermediateCare
Skilled Nursing
Support Services
Administration
Dietetic
Pharmaceutical
Radiological/Imaging
Clinical Lab
Anesthesia
Surgical
ObstetricalRecovery
Newborn/WellBaby
Emergency
Nuclear Medicine
RehabilitationTherapy
Renal Dialysis
OutpatientSurgery
Central Plant
Obstetrical Cesarean/Deliv
Building Number:
Type of Service Provided
Building Name:
05 Emergency Generator Shelter
Retrofit Conforming building to NPC 4 or NPC 5Configuration:
X
Report the final configuration of all buildings on the hospital campus showing how each building will comply with the SPC-5/NPC-4 or 5 requirements whether by retrofit or by replacement and the type of service that will be provided in each general actue care hospital building per Section 130061(c)(5)
103012011 Mendocino Coast District Hospital Fort Bragg Page:14 of 27Report Year:
Nursing
IntensiveCare
Pediatric/Adolescent
PsychiatricNursing
ObstetricalAnte/Postprtum
IntermediateCare
Skilled Nursing
Support Services
Administration
Dietetic
Pharmaceutical
Radiological/Imaging
Clinical Lab
Anesthesia
Surgical
ObstetricalRecovery
Newborn/WellBaby
Emergency
Nuclear Medicine
RehabilitationTherapy
Renal Dialysis
OutpatientSurgery
Central Plant
Obstetrical Cesarean/Deliv
Building Number:
Type of Service Provided
Building Name:
06 X-Ray File Storage
N/AConfiguration:
X
Report the final configuration of all buildings on the hospital campus showing how each building will comply with the SPC-5/NPC-4 or 5 requirements whether by retrofit or by replacement and the type of service that will be provided in each general actue care hospital building per Section 130061(c)(5)
103012011 Mendocino Coast District Hospital Fort Bragg Page:15 of 27Report Year:
01 Main Hospital
X
X
Nursing
Building Number: Building Name:
IntensiveCare
X
Pediatric/Adolescent
PsychiatricNursing
ObstetricalAnte/Postprtum
IntermediateCare
Skilled Nursing
X
X
X
X
X
X
X
X
X
49
42
Type of Service Provided
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
4
0
0
3
0
0
Total Beds this Building
Surgical
X
Anesthesia
Support Services
Administration
Dietetic
Pharmaceutical
Clinical Lab
Radiological/Imaging
OutpatientSurgery
Central Plant
RehabilitationTherapy
Renal Dialysis
Obstetrical Cesarean/Deliv
ObstetricalRecovery
Newborn/WellBaby
Emergency
Nuclear Medicine
Include information on the number of inpatient beds by type of Service provided by buildings that are classified as SPC-2, SPC-3, SPC-4, and SPC-5 per Section 130061(e)
103012011 Mendocino Coast District Hospital Fort Bragg Page:16 of 27Report Year:
03 Respiratory Neurophysiology Lab
X
Nursing
Building Number: Building Name:
IntensiveCare
Pediatric/Adolescent
PsychiatricNursing
ObstetricalAnte/Postprtum
IntermediateCare
Skilled Nursing
0
0
Type of Service Provided
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
0
0
0
0
0
0
Total Beds this Building
Surgical
Anesthesia
Support Services
Administration
Dietetic
Pharmaceutical
Clinical Lab
Radiological/Imaging
OutpatientSurgery
Central Plant
RehabilitationTherapy
Renal Dialysis
Obstetrical Cesarean/Deliv
ObstetricalRecovery
Newborn/WellBaby
Emergency
Nuclear Medicine
Include information on the number of inpatient beds by type of Service provided by buildings that are classified as SPC-2, SPC-3, SPC-4, and SPC-5 per Section 130061(e)
103012011 Mendocino Coast District Hospital Fort Bragg Page:17 of 27Report Year:
04A Emergency Addition - East
X
X
Nursing
Building Number: Building Name:
IntensiveCare
X
Pediatric/Adolescent
PsychiatricNursing
ObstetricalAnte/Postprtum
IntermediateCare
Skilled Nursing
X
0
0
Type of Service Provided
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
0
0
0
0
0
0
Total Beds this Building
Surgical
Anesthesia
Support Services
Administration
Dietetic
Pharmaceutical
Clinical Lab
Radiological/Imaging
OutpatientSurgery
Central Plant
RehabilitationTherapy
Renal Dialysis
Obstetrical Cesarean/Deliv
ObstetricalRecovery
Newborn/WellBaby
Emergency
Nuclear Medicine
Include information on the number of inpatient beds by type of Service provided by buildings that are classified as SPC-2, SPC-3, SPC-4, and SPC-5 per Section 130061(e)
103012011 Mendocino Coast District Hospital Fort Bragg Page:18 of 27Report Year:
04B Emergency Addition - West
Nursing
Building Number: Building Name:
IntensiveCare
Pediatric/Adolescent
PsychiatricNursing
ObstetricalAnte/Postprtum
IntermediateCare
Skilled Nursing
X
0
0
Type of Service Provided
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
0
0
0
0
0
0
Total Beds this Building
Surgical
Anesthesia
Support Services
Administration
Dietetic
Pharmaceutical
Clinical Lab
Radiological/Imaging
OutpatientSurgery
Central Plant
RehabilitationTherapy
Renal Dialysis
Obstetrical Cesarean/Deliv
ObstetricalRecovery
Newborn/WellBaby
Emergency
Nuclear Medicine
Include information on the number of inpatient beds by type of Service provided by buildings that are classified as SPC-2, SPC-3, SPC-4, and SPC-5 per Section 130061(e)
103012011 Mendocino Coast District Hospital Fort Bragg Page:19 of 27Report Year:
05 Emergency Generator Shelter
Nursing
Building Number: Building Name:
IntensiveCare
Pediatric/Adolescent
PsychiatricNursing
ObstetricalAnte/Postprtum
IntermediateCare
Skilled Nursing
X
0
0
Type of Service Provided
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
0
0
0
0
0
0
Total Beds this Building
Surgical
Anesthesia
Support Services
Administration
Dietetic
Pharmaceutical
Clinical Lab
Radiological/Imaging
OutpatientSurgery
Central Plant
RehabilitationTherapy
Renal Dialysis
Obstetrical Cesarean/Deliv
ObstetricalRecovery
Newborn/WellBaby
Emergency
Nuclear Medicine
Include information on the number of inpatient beds by type of Service provided by buildings that are classified as SPC-2, SPC-3, SPC-4, and SPC-5 per Section 130061(e)
103012011 Mendocino Coast District Hospital Fort Bragg Page:20 of 27Report Year:
06 X-Ray File Storage
Nursing
Building Number: Building Name:
IntensiveCare
Pediatric/Adolescent
PsychiatricNursing
ObstetricalAnte/Postprtum
IntermediateCare
Skilled Nursing
X
0
0
Type of Service Provided
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
Inpatient Beds
0
0
0
0
0
0
Total Beds this Building
Surgical
Anesthesia
Support Services
Administration
Dietetic
Pharmaceutical
Clinical Lab
Radiological/Imaging
OutpatientSurgery
Central Plant
RehabilitationTherapy
Renal Dialysis
Obstetrical Cesarean/Deliv
ObstetricalRecovery
Newborn/WellBaby
Emergency
Nuclear Medicine
Include information on the number of inpatient beds by type of Service provided by buildings that are classified as SPC-2, SPC-3, SPC-4, and SPC-5 per Section 130061(e)
103012011 Mendocino Coast District Hospital Fort Bragg Page:21 of 27Report Year:
Building Number: Building Name:
Pediatric
Perinatal (excluse Newborn / GYN)
Medical / Surgical (Include GYN)
Intermediate Card
Coronary Care
Intensive Care Rehabilitation Center
Chemical Dependency
Acute Respiratory Care
Skilled Nursing Burn
intensive Care Newborn Nursery
Acute Psychiatric
Int. Care / development Disabled
Total Beds this Building Per Unit
Total Beds this Building Per Service
InpatientBed
InpatientDays
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
01 Main Hospital
38 3444
7 0
0 0
4 688
0 0
0 0
0 0
0 0
0 0
0 0 49 49
0 0
0 0
0 0
0 0
Include information on the number of inpatient beds by type of unit provided by buildings that are classified as SPC-2, SPC-3, SPC-4, and SPC-5 per Section 130061(e)
103012011 Mendocino Coast District Hospital Fort Bragg Page:22 of 27Report Year:
Building Number: Building Name:
Pediatric
Perinatal (excluse Newborn / GYN)
Medical / Surgical (Include GYN)
Intermediate Card
Coronary Care
Intensive Care Rehabilitation Center
Chemical Dependency
Acute Respiratory Care
Skilled Nursing Burn
intensive Care Newborn Nursery
Acute Psychiatric
Int. Care / development Disabled
Total Beds this Building Per Unit
Total Beds this Building Per Service
InpatientBed
InpatientDays
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
03 Respiratory Neurophysiology Lab
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
0 0
0 0
0 0
0 0
Include information on the number of inpatient beds by type of unit provided by buildings that are classified as SPC-2, SPC-3, SPC-4, and SPC-5 per Section 130061(e)
103012011 Mendocino Coast District Hospital Fort Bragg Page:23 of 27Report Year:
Building Number: Building Name:
Pediatric
Perinatal (excluse Newborn / GYN)
Medical / Surgical (Include GYN)
Intermediate Card
Coronary Care
Intensive Care Rehabilitation Center
Chemical Dependency
Acute Respiratory Care
Skilled Nursing Burn
intensive Care Newborn Nursery
Acute Psychiatric
Int. Care / development Disabled
Total Beds this Building Per Unit
Total Beds this Building Per Service
InpatientBed
InpatientDays
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
04A Emergency Addition - East
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
0 0
0 0
0 0
0 0
Include information on the number of inpatient beds by type of unit provided by buildings that are classified as SPC-2, SPC-3, SPC-4, and SPC-5 per Section 130061(e)
103012011 Mendocino Coast District Hospital Fort Bragg Page:24 of 27Report Year:
Building Number: Building Name:
Pediatric
Perinatal (excluse Newborn / GYN)
Medical / Surgical (Include GYN)
Intermediate Card
Coronary Care
Intensive Care Rehabilitation Center
Chemical Dependency
Acute Respiratory Care
Skilled Nursing Burn
intensive Care Newborn Nursery
Acute Psychiatric
Int. Care / development Disabled
Total Beds this Building Per Unit
Total Beds this Building Per Service
InpatientBed
InpatientDays
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
04B Emergency Addition - West
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
0 0
0 0
0 0
0 0
Include information on the number of inpatient beds by type of unit provided by buildings that are classified as SPC-2, SPC-3, SPC-4, and SPC-5 per Section 130061(e)
103012011 Mendocino Coast District Hospital Fort Bragg Page:25 of 27Report Year:
Building Number: Building Name:
Pediatric
Perinatal (excluse Newborn / GYN)
Medical / Surgical (Include GYN)
Intermediate Card
Coronary Care
Intensive Care Rehabilitation Center
Chemical Dependency
Acute Respiratory Care
Skilled Nursing Burn
intensive Care Newborn Nursery
Acute Psychiatric
Int. Care / development Disabled
Total Beds this Building Per Unit
Total Beds this Building Per Service
InpatientBed
InpatientDays
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
05 Emergency Generator Shelter
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
0 0
0 0
0 0
0 0
Include information on the number of inpatient beds by type of unit provided by buildings that are classified as SPC-2, SPC-3, SPC-4, and SPC-5 per Section 130061(e)
103012011 Mendocino Coast District Hospital Fort Bragg Page:26 of 27Report Year:
Building Number: Building Name:
Pediatric
Perinatal (excluse Newborn / GYN)
Medical / Surgical (Include GYN)
Intermediate Card
Coronary Care
Intensive Care Rehabilitation Center
Chemical Dependency
Acute Respiratory Care
Skilled Nursing Burn
intensive Care Newborn Nursery
Acute Psychiatric
Int. Care / development Disabled
Total Beds this Building Per Unit
Total Beds this Building Per Service
InpatientBed
InpatientDays
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
InpatientDays
InpatientBed
06 X-Ray File Storage
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
0 0
0 0
0 0
0 0
Include information on the number of inpatient beds by type of unit provided by buildings that are classified as SPC-2, SPC-3, SPC-4, and SPC-5 per Section 130061(e)
