House of Sakhi - Hospital License Application

Joint Commission International
Accreditation
Survey Application
for
HOSPITALS
Effective: January 2010

Revised: 10 February 2010
HOSPITAL ACCREDITATION SURVEY APPLICATION
PART 1
Check the type of survey you are applying for:
INITIAL ACCREDITATION TRIENNIAL ACCREDITATION
FOR INITIAL SURVEY APPLICANTS: If you have provided clinical services for less than a year,
please provide the date that your organization began providing clinical services.
04/23/2010
dd / mm / yyyy
I. APPLICANT INFORMATION
A. Demographics
1. Organization Name: (The entry text below, as entered, will be used for your certificates. Only a maximum
length of 60-characters is allowed.)
RACHEL SAKHI ATTORNEY
2. Facility Address:
5225 FIGUEROA MOUNTAIN ROAD
[street number and name]
[P.O. Box]
LOS OLIVOS, CALIFORNIA

[city/province and/or state]
93441
[postal/zip code]
UNITED STATES OF AMERICA

[country]
www.p4style.us
[website address]
3. Main Telephone Number:

805 294 32
[country code] [city code] [number]
Hospital Survey Application Page 2 of 26

4. Ownership:
HJTT % RACHEL SAKHI
[Owner Name/Parent Company]
Choose applicable Ownership Type from the list below.

private / non-government
public / governmental
public / private mix
governmental / military
Other
Mailing Address: (if different from above)

5225 FIGUEROA MOUNTAIN ROAD
[street number and name]
[P.O. Box]
LOS OLIVOS, CA
[city/province and/or state]
93441
[postal/zip code]
USA
[country]
5. Ownership Primary Contact:

Name: Dr. Rachel Lynne-Sakhi
[Mr./Mrs./Miss/Ms./Dr.]
Title: Registered Agent
E-mail: ywma@hawaii.usa.com
Tel: 805 294 32

Fax:

B. Organization Contacts
6. Staff Information: Fill in the names, titles, telephone numbers and email addresses for the individuals listed below
Chief Executive Officer: (or equivalent)

Title: Chairwoman & President
E-mail: neverland@engineer.com
Tel: 805 294 32

Fax:
Individual responsible for Medical services (or equivalent)

Tel: 805 294 32

Fax:
Individual responsible for Nursing services (or equivalent)

Tel: 805 294 32

Fax:

Accreditation Survey Coordinator: (provide contact information)
Tel: 805 294 32

Fax:
7. Individual responsible for completing this application

If this individual is the same as an individual listed above, add only their name
Tel: 805 294 32

Fax:
8. Individual responsible for processing invoices and payments:

Title: Medical Director
Tel: 805 294 0032

Fax:

C. General Information
9. Are there laws or regulations requiring your organization to have a current operating permit
or license?
Yes* No
a) * If yes, please submit a copy of the permit or license along with this application. The
application cannot be accepted until a copy of the license is received.
b) If no, please name the government agency that grants your organization the authority to
operate and provide services
10. Are you applying as a hospital that is located within another hospital?
Yes No
If yes, what is the name of the hospital in which you are located?
11. Please provide your usual hours of operation, and provide information on any daily
religious observances, staff functions, etc. that will need to be part of the survey agenda and
activities of the survey team.
Regular Business Hours
12. In the box below check any changes that you anticipate will happen within the next 12
months related to the applicant organization and give a brief description of what will
change.
Check Type of Change Description

Ownership Change of Ownership of Property
Clinical Medical Services (new services or expansion of Establishment of Clinical Medical Services
services)
Organization Management Integration of Organization Management
Patient Care Buildings (new or renovations planned) Establishment & Infrastructure Installation of Patient
Care Building (Renovations & New Construction)

13. In what language is the medical record documentation written?
English & Spanish
14. In what language are the policies, procedures, and committee minutes written?
English & Spanish
15. In what language is patient care conducted?

English or the Primary Language.

16. Site Demographics and Building Codes: Specific information is required in order to assist in
the development of the on-site survey agenda. The information needed includes the location(s),
distance(s), and occupied areas (square meters) of the organization's physical layout (both on the
main campus and/or off campus locations) where the health care services are provided. Also
needed are the local or national codes under which the buildings were designed and are being
maintained, and the approximate age of each site. Please fill in the information on this form. List
each building separately: See Addendum on page 19for additional form(s).
Building Name Address: Is this building located If an additional site:

Include number, street, on the Main campus or include Kilometers
and city is it an additional site? from main campus
(check box)
Parcel # TBD; Zone TBD Main campus N/A
Additional site
Building Code(s) followed:
None
Age of building:
Area - square meters:
Additional site
None
Age of building:
Additional site
None
Age of building:

D. Finance
17. Does your organization have any special billing or invoice requirements?
Yes No
If yes, please explain.
To Be Determined
18. Does your organization require an itemized statement of charges to be included in the
standard invoice?
Yes
No
19. Does your organization require receipts for the survey team’s travel and maintenance
expenses?
Yes
No
20. All invoices are sent to the billing contact by email. Does your organization require an
original copy sent by mail/courier?
Yes
No
WHEN YOU RECEIVE THE CONTRACT: Included in the contract will be a wire transfer form
with the detailed information to transfer funds to our bank.
VERY IMPORTANT - Please complete and submit the wire transfer form to the fax number or
email address listed on the form so we can properly credit your account once the payment is
received. All invoices are due upon receipt. Payments should be made by wire transfer.

PART 2
I. ORGANIZATIONAL DESCRIPTION
A. In-patient Services
21. Total number of beds: As Needed
22. Total number of holding or observing beds: As Needed
23. Average daily in-patient census: To Be Determined
24. Emergency room annual visits: On Demand
25. Does the organization conduct or participate in any research or clinical trials?
Yes No
If yes, please list the research or clinical trials currently underway.
To Be Determined/As per Schedule
26. Does the organization serve as a site for training health care students or residents?
Yes No
If yes, please check the type of students who are on-site and list the number of students on-
site annually.
Type of Student Number on-site

Annually
Medical students
Dental students
Medical Residents
Nursing students
Allied health students (PT, OT, RT, dietitian)
Other To Be Determined
27. List the top five primary patient discharge diagnosis and the top five surgical procedures
performed. Enter the information in the table provided below.
Top Five Primary Discharge Top Five Surgical

Diagnoses Procedures
To Be Determined To Be Determined

28. Check all applicable Clinical Medical Services or Units currently provided by the
Organization: (Please add at the bottom under “Other”, any services provided that do not appear on this list)
Check all that apply

Ambulatory ICU Medical Otolaryngology
Anesthesiology ICU Neonatal Pediatrics
Blood bank ICU Neurosurgical Pharmacy-Outpatient
Cardiac catheterization ICU Pediatric Pharmacy-Inpatient
Cardiac Surgery ICU Surgical Physical Therapy/Physiology
Cardiology Infectious Diseases Plastic Surgery
Day hospital Interventional Radiology Podiatry
Day surgery In vitro Fertilization (IVF) Pulmonary Medicine
Dental Surgery Immunology Psychiatry
Dentistry Labor and Delivery Psychology
Dermatology Laboratory Radiology
Dialysis – Inpatient Maxillofacial surgery Radiation Therapy
Dialysis - Outpatient Medical - General Rehabilitation Medicine
Emergency Medicine Nephrology Renal medicine
Endocrinology Neurology Renal surgery
Endoscopy Neurosurgery Research
Family & Community Medicine Nuclear Medicine Respiratory Medicine
Gastroenterology Nursery Respiratory Therapy
Geriatric Medicine Obstetrical Rheumatology
Gynecology Occupational Therapy Surgical – General
Hematology Oncology Thoracic surgery
Histopathology Ophthalmology Urology
ICU Burn Unit Organ Transplant Vascular surgery
ICU Cardiology Orthopedics
Others not included on this list:

To Be Determined

29. In-Patient Care Units/Wards: Using the table below please list each Inpatient Care Unit/Ward
including the additional information requested. See the example in the first two lines.
NOTE: List each patient unit/ward separately. The survey team needs to know each area that
houses patients in order to select those areas that will be visited during tracer methodology sessions.
Include patient care units located at the main site as well as any areas that are separate from the
hospital. If you need an additional form please click on this link to down load an additional form.
Download and complete as many forms as necessary and submit all completed forms with your
application. See Addendum on page 19for additional form(s).
Please check the last column only if anesthesia/sedation is administered in the location listed. If
you need the Joint Commission International Accreditation’s definition of Anesthesia and
Sedation1.
Name of Average Type of Floor Building Name Check here if

Unit/Ward Daily Care Given Anesthesia /
Census Sedation
Administered
Example: Ward A 32 Surgical Intensive Care 3 Main site
Example: Ward B7 10 Mental Health 2 Building C
1
The administration to an individual, in any setting, for any purpose, by any route, medication to induce a partial or total loss of sensation for the
purpose of conducting an operative or other procedure.

30. List the type of surgical/operating room theaters, the number you have, and the building in
which they are located.
(Include all locations and buildings where surgery is provided, such as obstetrics operating theater, general operating theater,
cardiac operating theater, pediatric operating theater, outpatient operating theater, and so on.)
Operating Theater Number Building Name
31. List Non-clinical Hospital Departments or Services. (non-clinical services that support the hospital such as
human resources, housekeeping, dietary, information systems, finance)
32. List any contracted services.

Contracted services are defined as services provided through a written agreement with another organization, agency, or individual,
the agreement specifies the services or personnel to be provided on behalf of the applicant organization. For example, a hospital
may contract with another organization for services such as pathologists, physical therapists, reading x-rays, dietary emergency
room physicians, medical specialists.
Name of contracted organization Services provided

B. Out Patient Services
33. List Outpatient Units, the number of annual visits, and the type of service provided.
(Example: Surgical clinic, 150 visits per month, pre and post operative procedure evaluation and treatment).
NOTE: See Addendum on page 19 for additional form(s).
Name of Outpatient Number Type of Floor Building Name Anesthesia /

Unit or Clinic of Annual Care Given Sedation
Visits Administered
Sample: Surgery Clinic 5 Pre and post operative 1 Building G
procedure evaluation
and treatment
Sample: Behavioral 10 Mental Health 1 Main Site
Health Outpatient Clinic
Total Number of 0
Annual Visits

PART 3
I. ADDITIONAL SERVICES
A. Medical Transport
34. Do you own and operate a medical transport service that provides Emergency Medical
Transport Services to the community?
Yes If you answered “Yes”, continue to #35 and # 36 below.
No If you answered “No”, please skip to section B
35. Number of medical transports per year. ON DEMAND
36. Does the medical transport service use advanced life support/paramedics?
Yes
No
B. Home Care Services

37. Does your organization provide services in an individual’s home?
Yes If you answered ‘yes’, please complete # 38 through # 40
No If you answered “no”, go to Part IV
38. Average number of individuals visited in the home per day. ON DEMAND
39. Total number of home visits made per year. ON DEMAND
40. Please indicate the type of care provided in the patient’s home:
(check all that apply)
Home Health (nursing service)
Personal Care and support
Home Medical Equipment
Home Pharmacy
Hospice Service/Palliative Care in the home
Other (please specify) TBD

PART 4
I. SCHEDULING AND TRAVEL (Section Must Be Completed In Full)
A. Scheduling
41. Please indicate three months in which the organization could have the survey scheduled.
Month Year
05 2010
06 2010
07 2010
42. Please indicate up to a MAXIMUM of five other weeks during the year to avoid scheduling
a survey, if preferred months cannot be accommodated.
From To
DD/MM/YY DD/MM/YY
08/01/10 08/30/10
09/01/10 09/27/10
10/01/10 10/31/10
11/01/10 11/31/10
12/01/10 12/31/10
B. Traveling Instructions
43. Air Transportation: Please indicate the airport(s) nearest to your organization that the surveyors
should fly into.
Sycamore Valley Airfield
44. Ground Transportation: Please provide travel directions from airport to hotel.
Please provide the following to assist the surveyors in making their ground transportation
arrangements.
From Airport to Hotel: Recommended method of transport (taxi, car service, etc)
From Hotel to Airport: Recommended method of transport (taxi, car service, etc)

From Hotel to Organization: Recommended method of transport (taxi, car service, etc)
Please provide travel direction from hotel to organization.
Surveyor Assembly: Location to which surveyors should go. (building name and/or number and
door entrance, if applicable)
Assembly Point at organization when surveyors arrive.
45. Recommended Hotel Accommodations: (high-speed internet access is required)

Please recommend two to three business hotels near your organization that have high-speed internet access.
High-speed internet access is required for the surveyors to complete the survey report each evening. If
possible, please include the Marriott, Hilton or Intercontinental hotel nearest to your organization, as these
hotels provide preferred rates for the surveyors. If your organization has a preferred rate with business hotels
near your organizations, please include the specific information and directions for obtaining the preferred
rates for surveyors.
Hotel Name Address/Web site Distance to hospital Telephone/Fax

(please include country
and city code)
Kilometers Phone:
Travel time Fax:
Kilometers Phone:
Travel time Fax:
Kilometers Phone:
Travel time Fax:
Kilometers Phone:
Travel time Fax:
Kilometers Phone:
Travel time Fax:
NOTE: For insurance/security purposes the survey team is required to make travel
reservations through JCI's travel agent.

46. Please enter any comments or other information you feel may be pertinent for surveyors
traveling to your survey.
47. Date application completed: 04/23/2010

dd / mm / yyyy

PART 5
I. AUTHORIZATION
The undersigned makes request to Joint Commission International for an accreditation survey of the
Applicant Organization named below. By signing this document we hereby provide accurate and truthful
information within this application. Also, by signing this document, we hereby authorize JCI to obtain any
records and reports about this organization that may be available from other agencies and/or organizations
that may be pertinent to the survey.
I am authorized to make this agreement on behalf of:
Name of Applicant Organization: RACHEL SAKHI ATTORNEY
Name: Rachel Sakhi
Title: Authorized Representative
Signature:
Date: April 23, 2010
I have also included a copy of the organization’s license (Part I Section C)
Signature
Return Completed Application long with any Additional Forms Used

by FAX or EMAIL to:
Joint Commission International Accreditation
Fax: +1 630 268 2996
OR
E-mail: jciaccreditation@jcrinc.com

ADDENDUM(S)
SEE FOLLOWING PAGES

Additional Form(s): #16
(check box)
Main campus N/A
Additional site
None
Age of building:
Main campus N/A
Additional site
None
Age of building:
Main campus N/A
Additional site
None
Age of building:
Main campus N/A
Additional site
None
Age of building:

Additional Form(s): #16
(check box)
Main campus N/A
Additional site
None
Age of building:
Main campus N/A
Additional site
None
Age of building:
Main campus N/A
Additional site
None
Age of building:
Main campus N/A
Additional site
None
Age of building:

Additional Form(s): #29 In-Patient Care Units/Wards
Census Sedation
Administered

Additional Form(s): #29 In-Patient Care Units/Wards
Census Sedation
Administered

Additional Form(s): #33 Out-Patient Services
Visits Administered
and treatment
Total Number of 0
Annual Visits

Additional Form(s): #33 Out-Patient Services
Visits Administered
and treatment
Total Number of 0
Annual Visits

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Joint Commission International

Effective: January 2010

INITIAL ACCREDITATION TRIENNIAL ACCREDITATION

LOS OLIVOS, CALIFORNIA

UNITED STATES OF AMERICA

3. Main Telephone Number:

Hospital Survey Application Page 2 of 26

Choose applicable Ownership Type from the list below.

Mailing Address: (if different from above)

5. Ownership Primary Contact:

Title: Registered Agent

Tel: 805 294 32

Hospital Survey Application Page 3 of 26

Chief Executive Officer: (or equivalent)

Title: Chairwoman & President

Tel: 805 294 32

Individual responsible for Medical services (or equivalent)

Title: Chairwoman & President

Tel: 805 294 32

Individual responsible for Nursing services (or equivalent)

Title: Chairwoman & President

Tel: 805 294 32

Hospital Survey Application Page 4 of 26

Title: Chairwoman & President

Tel: 805 294 32

7. Individual responsible for completing this application

Title: Chairwoman & President

Tel: 805 294 32

8. Individual responsible for processing invoices and payments:

Title: Medical Director

Tel: 805 294 0032

Hospital Survey Application Page 5 of 26

Check Type of Change Description

Organization Management Integration of Organization Management

Hospital Survey Application Page 6 of 26

15. In what language is patient care conducted?

Hospital Survey Application Page 7 of 26

Building Name Address: Is this building located If an additional site:

Parcel # TBD; Zone TBD Main campus N/A

Parcel # TBD; Zone TBD Main campus N/A

Hospital Survey Application Page 8 of 26

Hospital Survey Application Page 9 of 26

22. Total number of holding or observing beds: As Needed

23. Average daily in-patient census: To Be Determined

24. Emergency room annual visits: On Demand

Type of Student Number on-site

Top Five Primary Discharge Top Five Surgical

Hospital Survey Application Page 10 of 26

Check all that apply

Others not included on this list:

Hospital Survey Application Page 11 of 26

Name of Average Type of Floor Building Name Check here if

Hospital Survey Application Page 12 of 26

Operating Theater Number Building Name

32. List any contracted services.

Name of contracted organization Services provided

Hospital Survey Application Page 13 of 26

Name of Outpatient Number Type of Floor Building Name Anesthesia /

Hospital Survey Application Page 14 of 26

35. Number of medical transports per year. ON DEMAND

B. Home Care Services

39. Total number of home visits made per year. ON DEMAND

Hospital Survey Application Page 15 of 26