Menlo Park Surgery Center, LLC 10 Parsonage Road, Suite 204

CHRIS CHRISTIE DEPARTMENT OF HEALTH
Governor
PO BOX 367
KIM GUADAGNO TRENTON, N.J. 08625-0360
Lt. Governor
www.nj.gov/health

MARY E. O'DOWD, M.P.H.
Commissioner

May 2, 2014

Agnes Romulo, R.N.
Administrator
Menlo Park Surgery Center, LLC
10 Parsonage Road, Suite 204
Edison, NJ 08837

Dear Ms. Romulo:

Thank you for the courtesy and cooperation extended during the Approval Survey
conducted April 25, 2014 by surveyors from the Department of Health.

Enclosed is a copy of the State deficiency form indicating that no deficiencies were
found during the survey. Please sign the first page of the State deficiency form and
return the original copy to my attention. It is important to return the form promptly to
this office.

If you have questions concerning this letter, please do not hesitate to contact me,
at (609) 292-9900.

Sincerely,

Crescenza Zizza, RN
Health Care Services Evaluator
Assessment and Survey

Encl.

PRINTED: 05/19/2014 Statement of Deficiencies
Citation Summary Sheet

For: MENLO PARK SURGERY CENTER, LLC ( 24828 / NJ24828 )
Survey Event: 1H5311, Exit Date 04/25/2014

Citations Cited This Visit

Regulation Regulation Regulation Building Tag Tag Title Scope/
Number INITIAL COMMENTS Severity
Type ID Version Number
0000
State Z7BQ 8.00 00

New Jersey Department of Health PRINTED: 05/19/2014
FORM APPROVED
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: ______________________ (X3) DATE SURVEY
COMPLETED

24828 B. WING _____________________________ 04/25/2014

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MENLO PARK SURGERY CENTER, LLC 10 PARSONAGE ROAD, SUITE 204
EDISON, NJ 08837

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE
TAG TAG DATE
DEFICIENCY)

A 000 8:43A INITIAL COMMENTS A 000

Licensure approval of a new ambulatory surgical
center with 2 OR's and support areas.

There were no deficiencies noted during this
approval.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
If continuation sheet 1 of 1
STATE FORM 6899 1H5311