REPORT ON THE RATE SETTING AUDIT COUNTRY …€¦ · · 2017-08-22Laverne Bailey Page 2...

REPORT ON THE

RATE SETTING AUDIT

COUNTRY VILLA NORTH HC LOS ANGELES, CALIFORNIA

NATIONAL PROVIDER IDENTIFIER: 1033103205

FISCAL PERIOD ENDED DECEMBER 31, 2010

Audits Section - Gardena Financial Audits Branch

Audits and Investigations Department of Health Care Services

Section Chief: Maria Delgado Audit Supervisor: Cyrus C. Lam Auditor: Derek Bradley

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Laverne Bailey Page 2

Notwithstanding this audit report, overpayments to the provider are subject to recovery pursuant to Section 51458.1, Article 6 of Division 3, Title 22, California Code of Regulations. If you disagree with the decision of the Department, you may appeal by writing to: Chief Office of Administrative Appeals and Hearings 1029 J Street, Suite 200 Sacramento, CA 95814-2825 (916) 322-5603 The written notice of disagreement must be received by the Department within 60 calendar days from the day you receive this letter. A copy of this notice should be sent to: United States Postal Service (USPS) Courier (UPS, FedEx, etc.) Assistant Chief Counsel Assistant Chief Counsel Department of Health Care Services Department of Health Care Services Office of Legal Services Office of Legal Services MS 0010 MS 0010 PO Box 997413 1501 Capitol Avenue, Suite 71.5001 Sacramento, CA 95899 Sacramento, CA 95814 (916) 440-7700 The procedures that govern an appeal are contained in Welfare and Institutions Code, Section 14171, and California Code of Regulations, Title 22, Section 51016, et seq. If you have questions regarding this report, you may call the Audits Section—Gardena at (310) 516- 4757. Original Signed By: Maria Delgado, Chief Audits Section—Gardena Financial Audits Branch Certified

Laverne Bailey Page 3

cc: Ruth Santo Domingo Mendoza Director of Reimbursement Country Villa Health Services 5120 West Goldleaf Circle, Suite 400 Los Angeles, CA 90056

STATE OF CALIFORNIA SCHEDULE 1

Provider Name: Fiscal Period:COUNTRY VILLA NORTH HC JANUARY 1, 2010 THROUGH DECEMBER 31, 2010

Provider NPI: OSHPD Facility No.:1033103205 206190774

LineNo.

SKILLED NURSING CARE1 Cost of Direct Care - Labor (Sch. 2, Ln. 105) $ N/A $ 3,041,186 $ 88.602 Cost of Indirect Care - Labor (Sch. 3, Ln. 105) $ N/A $ 752,070 $ 21.913 Cost of Direct and Indirect Nonlabor - Other (Sch. 4, Ln. 105) $ N/A $ 623,934 $ 18.184 Cost of Capital Related (Sch. 5, Ln. 105) $ N/A $ 262,922 $ 7.665 Property Taxes (Sch. 5, Ln. 105) $ N/A $ 31,472 $ 0.926 CDPH Licensing Fees (Sch. 6, Ln. 105) $ N/A $ 24,089 $ 0.707 Professional Liability Insurance (Sch. 6, Ln. 105) $ N/A $ 66,221 $ 1.938 Caregiver Training (Sch. 6, Ln. 105) $ N/A $ 0 $ 0.009 Quality Assurance Fees (Sch. 6, Ln. 105) $ N/A $ 348,291 $ 10.1510 Cost of Administration (Sch. 6, Ln. 105) $ N/A $ 676,734 $ 19.7211 Cost of Routine Service/Audited Total Costs $ 5,848,056.00 $ 5,826,918.01 $ 169.7612 Total Patient Days (Adj ) 34,325 34,32513 Cost Per Patient Day (Cost Divided by Days) $ 170.37 $ 169.76 14 Overpayments (Adj ) $ $ 015 Medi-Cal Days (Adj 7) 29,491 29,65516 Medi-Cal Managed Care Days (Adj ) 0

INTERMEDIATE CARE17 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 018 Total Patient Days (Adj ) 019 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0020 Overpayments (Adj ) $ $ 0

MENTALLY DISORDERED CARE21 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 022 Total Patient Days (Adj ) 023 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0024 Overpayments (Adj ) $ $ 0

DEVELOPMENTALLY DISABLED CARE25 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 026 Total Patient Days (Adj ) 027 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0028 Overpayments (Adj ) $ $ 0

SUBACUTE CARE29 Cost of Direct Care - Labor (Subacute Care Sch. 1, Ln. 25) $ N/A $ 0 $ 0.0030 Cost of Indirect Care - Labor (Subacute Care Sch. 1, Ln. 26) $ N/A $ 0 $ 0.0031 Cost of Direct and Indirect Nonlabor - Other (Subacute Care Sch. 1, Ln. 27) $ N/A $ 0 $ 0.0032 Cost of Capital Related (Subacute Care Sch. 1, Ln. 28) $ N/A $ 0 $ 0.0033 Property Taxes (Subacute Care Sch. 1, Ln. 29) $ N/A $ 0 $ 0.0034 CDPH Licensing Fees (Subacute Care Sch. 1, Ln. 30) $ N/A $ 0 $ 0.0035 Professional Liability Insurance (Subacute Care Sch. 1, Ln. 31) $ N/A $ 0 $ 0.0036 Quality Assurance Fees (Subacute Care Sch. 1, Ln. 32) $ N/A $ 0 $ 0.0037 Caregiver Training (Subacute Care Sch. 1, Ln. 33) $ N/A $ 0 $ 0.0038 Cost of Administration (Subacute Care Sch.1, Ln. 34) $ N/A $ 0 $ 0.0039 Total Cost of Subacute Service (Subacute Care Sch. 1, Ln. 35) $ 0 $ 0 $ 0.0040 Total Patient Days (Subacute Care Sch. 1, Ln. 36) 0 041 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0042 Amount Due Provider (State) (Subacute Care Sch. 1, Ln. 40) $ 0 $ 0

AS REPORTED AS AUDITED PATIENT DAY

SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY

COST PERAUDITED

PROGRAM DESCRIPTION




LineNo. AS REPORTED AS AUDITED PATIENT DAY

SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY

COST PERAUDITED

PROGRAM DESCRIPTION

SUBACUTE CARE - PEDIATRIC43 Cost of Routine Service (Subacute Care - Pediatric, Sch. 1, Ln 3) $ 0 $ 044 Cost of Ancillary Service (Subacute Care - Pediatric, Sch. 1, Ln. 1 + Ln. 2) $ 0 $ 045 Total Cost of Subacute Care - Pediatric Service (Ln. 42 + Ln. 43) $ 0 $ 046 Total Patient Days (Subacute Care - Pediatric, Sch. 1, Ln. 5) 0 047 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0048 Amount Due Provider (State) (Subacute Care - Pediatric, Sch. 1, Ln. 9) $ 0 $ 0

TRANSITIONAL INPATIENT CARE49 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 050 Total Patient Days (Adj ) 051 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0052 Overpayments (Adj ) $ $ 0

HOSPICE INPATIENT CARE53 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 054 Total Patient Days (Adj ) 055 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0056 Overpayments (Adj ) $ $ 0

OTHER ROUTINE SERVICES57 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 058 Total Patient Days (Adj ) 059 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0060 Overpayments (Adj ) $ $ 0




Soc Srvs ActivitiesNet Exp For

Line DESCRIPTION Cost AllocNo. (From Sch 8) 155 160 Total

GENERAL SERVICES005 Plant Operations and Maintenance010 Housekeeping060 Laundry and Linen065 Dietary155 Social Services 62,552$ 62,552$ 160 Activities 89,014 89,014$ 165 Administration166 Medical Records170 Inservice Education - Nursing

ANCILLARY SERVICES075 Patient Supplies 5,326 0 0 5,326077 Specialized Support Surfaces N/A 0 0 0080 Physical Therapy 235,132 0 0 235,132081 Respiratory Therapy 0 0 0 0082 Occupational Therapy 191,988 0 0 191,988083 Speech Pathology 79,645 0 0 79,645085 Pharmacy 0 0 0 0090 Laboratory 2,009 0 0 2,009095 Home Health Services 0 0 0 0100 Other Ancillary Services 0 0 0 0101 Subacute Care Ancillary Services 0 0 0 0102 Subacute Care - Pediatric Ancillary Services 0 0 0 0

ROUTINE SERVICES105 Skilled Nursing Care 2,889,620 62,552 89,014 3,041,186 *110 Intermediate Care 0 0 0 0 *115 Mentally Disordered Care 0 0 0 0 *120 Developmentally Disabled Care 0 0 0 0 *125 Subacute Care 0 0 0 0 *126 Subacute Care - Pediatric 0 0 0 0 *128 Transitional Inpatient Care 0 0 0 0 *130 Hospice Inpatient Care 0 0 0 0 *135 Other Routine Services 0 0 0 0 *

NONREIMBURSABLE 139 Residential Care 0 0 0 0140 Beauty and Barber 0 0 0 0145 Other Nonreimbursable 0 0 0 0

TOTAL 3,555,286$ 62,552$ 89,014$ 3,555,286$ * (To Schedule 1)

ALLOCATION OF GENERAL SERVICES DIRECT CARE LABOR

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ALLOCATION OF CAPITAL COSTS


Provider NPI: OSHPD Facility Number:1033103205 206190774

Capital Plant Ops Hskpng Laundry Dietary Soc Srvs ActivitiesNet Exp For

Line DESCRIPTION Cost AllocNo. (From Sch 8) Ratio Various 5 10 60 65 155 160

GENERAL SERVICESCapital Related (excluding lines 40 & 45) 295,323$ 89%Property Tax (line 40) 35,350 11% 330,673$

005 Plant Operations and Maintenance 13,164 13,164$ 010 Housekeeping 4,208 174 4,383$ 060 Laundry and Linen 10,830 449 152 11,431$ 065 Dietary 31,035 1,287 434 0 32,756$ 155 Social Services 1,556 65 22 0 0 1,642$ 160 Activities 20,244 839 283 0 0 0 21,367$ 165 Administration 19,746 819 276 0 0 0 0166 Medical Records 4,428 184 62 0 0 0 0170 Inservice Education - Nursing 1,775 74 25 0 0 0 0

ANCILLARY SERVICES075 Patient Supplies 3,470 144 49 0 0 0 0077 Specialized Support Surfaces 0 0 0 0 0 0 0080 Physical Therapy 14,660 608 205 0 0 0 0081 Respiratory Therapy 0 0 0 0 0 0 0082 Occupational Therapy 8,576 356 120 0 0 0 0083 Speech Pathology 1,675 69 23 0 0 0 0085 Pharmacy 1,815 75 25 0 0 0 0090 Laboratory 0 0 0 0 0 0 0095 Home Health Services 0 0 0 0 0 0 0100 Other Ancillary Services 0 0 0 0 0 0 0101 Subacute Care Ancillary Services 0 0 0 0 0 0 0102 Subacute Care - Pediatric Ancillary Services 0 0 0 0 0 0 0

ROUTINE SERVICES105 Skilled Nursing Care 192,991 8,001 2,700 11,431 32,756 1,642 21,367110 Intermediate Care 0 0 0 0 0 0 0115 Mentally Disordered Care 0 0 0 0 0 0 0120 Developmentally Disabled Care 0 0 0 0 0 0 0125 Subacute Care 0 0 0 0 0 0 0126 Subacute Care - Pediatric 0 0 0 0 0 0 0128 Transitional Inpatient Care 0 0 0 0 0 0 0130 Hospice Inpatient Care 0 0 0 0 0 0 0135 Other Routine Services 0 0 0 0 0 0 0

NONREIMBURSABLE 139 Residential Care 0 0 0 0 0 0 0140 Beauty and Barber 499 21 7 0 0 0 0145 Other Nonreimbursable 0 0 0 0 0 0 0

TOTAL 330,673$ 100% 330,673$ 13,164$ 4,383$ 11,431$ 32,756$ 1,642$ 21,367$ * (To Schedule 1)

STATE OF CALIFORNIA

Provider Name:COUNTRY VILLA NORTH HC

Provider NPI:1033103205

Net Exp ForLine DESCRIPTION Cost AllocNo. (From Sch 8) Ratio

GENERAL SERVICESCapital Related (excluding lines 40 & 45) 295,323$ 89%Property Tax (line 40) 35,350 11%

005 Plant Operations and Maintenance010 Housekeeping060 Laundry and Linen065 Dietary155 Social Services160 Activities165 Administration166 Medical Records170 Inservice Education - Nursing

ANCILLARY SERVICES075 Patient Supplies077 Specialized Support Surfaces080 Physical Therapy081 Respiratory Therapy082 Occupational Therapy083 Speech Pathology085 Pharmacy090 Laboratory095 Home Health Services100 Other Ancillary Services101 Subacute Care Ancillary Services102 Subacute Care - Pediatric Ancillary Services

ROUTINE SERVICES105 Skilled Nursing Care110 Intermediate Care115 Mentally Disordered Care120 Developmentally Disabled Care125 Subacute Care126 Subacute Care - Pediatric128 Transitional Inpatient Care130 Hospice Inpatient Care135 Other Routine Services

NONREIMBURSABLE 139 Residential Care140 Beauty and Barber145 Other Nonreimbursable

TOTAL 330,673$ 100%* (To Schedule 1)

SCHEDULE 5

ALLOCATION OF CAPITAL COSTS

Fiscal Period:JANUARY 1, 2010 THROUGH DECEMBER 31, 2010

OSHPD Facility Number:206190774

Inserv. Ed Admin Medical Capital PropertyRecords Related Tax

Accumulated 89% 11%170 Costs 165 166 Total Of Total Of Total

20,841$ 20,841$ 4,673 4,673$

1,874$

0 3,663 114 26 3,803$ 3,396$ 407$ 0 0 90 20 110 99 120 15,473 1,044 234 16,751 14,960 1,7910 0 1 0 1 1 00 9,052 821 184 10,057 8,982 1,0750 1,768 323 72 2,163 1,932 2310 1,916 653 146 2,715 2,425 2900 0 86 19 106 94 110 0 0 0 0 0 00 0 33 7 41 37 40 0 0 0 0 0 00 0 0 0 0 0 0

1,874 272,761 17,670 3,962 294,393 262,922 31,472 *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 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 0 0 00 526 5 1 532 475 570 0 0 0 0 0 0

1,874$ 305,159$ 20,841$ 4,673$ 330,673$ 295,323$ 35,350$

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Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER005 Plant Operations and Maintenance005 .01-.19 Salaries and Wages 6200 $ 50,330 $ 0 $ 50,330 (Sch 3)005 .20-.39 Fringe Benefits 6200 14,539 0 14,539 (Sch 3)005 .79 Agency Staff 6200 0 0 (Sch 3)005 .40-.99 Other - Nonlabor 6200 178,484 0 178,484 (Sch 4)005 Plant Operations and Maintenance - Total 6200 $ 243,353 $ 0 $ 243,353

010 Housekeeping010 .01-.19 Salaries and Wages 6300 $ 121,966 $ 0 $ 121,966 (Sch 3)010 .20-.39 Fringe Benefits 6300 37,245 0 37,245 (Sch 3)010 .79 Agency Staff 6300 0 0 (Sch 3)010 .40-.99 Other - Nonlabor 6300 30,379 0 30,379 (Sch 4)010 Housekeeping - Total 6300 $ 189,590 $ 0 $ 189,590

015 Depreciation: Buildings and Improvements 7110 - 7120 $ 40,165 $ 0 $ 40,165 (Sch 5)020 Depreciation: Leasehold Improvements 7130 14,606 0 14,606 (Sch 5)025 Depreciation: Equipment 7140 21,782 0 21,782 (Sch 5)030 Depreciation and Amortization - Other 7150 - 7160 0 0 (Sch 5)035 Leases and Rentals 7200 27,803 0 27,803 (Sch 5)040 Property Taxes 7300 35,350 0 35,350 (Sch 5)045 Property Insurance 7400 3,328 0 3,328 (Sch 6)050 Interest - Property, Plant, and Equipment 7500 190,967 0 190,967 (Sch 5)055 Interest - Other 7600 $ 1,224 $ 0 $ 1,224 (Sch 6)

057 Subtotal 005 - 055 $ 768,168 $ 0 $ 768,168

060 Laundry and Linen060 .01-.19 Salaries and Wages 6400 $ 74,300 $ 0 $ 74,300 (Sch 3)060 .20-.39 Fringe Benefits 6400 16,542 0 16,542 (Sch 3)060 .79 Agency Staff 6400 0 0 (Sch 3)060 .40-.99 Other - Nonlabor 6400 23,289 0 23,289 (Sch 4)060 Laundry and Linen - Total 6400 $ 114,131 $ 0 $ 114,131

065 Dietary065 .01-.19 Salaries and Wages 6500 $ 303,607 $ 0 $ 303,607 (Sch 3)065 .20-.39 Fringe Benefits 6500 84,944 0 84,944 (Sch 3)065 .79 Agency Staff 6500 0 0 (Sch 3)065 .40-.99 Other - Nonlabor 6500 223,924 0 223,924 (Sch 4)065 Dietary - Total 6500 $ 612,475 $ 0 $ 612,475

070 Provision for Bad Debts 7700 $ 0 0 $ 0

Ancillary Services 075 Patient Supplies075 .01-.19 Salaries and Wages 8100 $ 4,304 $ 0 $ 4,304 (Sch 2)075 .20-.39 Fringe Benefits 8100 1,022 0 1,022 (Sch 2)075 .79 Agency Staff 8100 0 0 (Sch 2)075 .40-.99 Other - Nonlabor 8100 18,026 (2,129) 15,897 (Sch 4)075 Patient Supplies - Total 8100 $ 23,352 $ (2,129) $ 21,223

077 Specialized Support Surfaces077 .01-.19 Salaries and Wages 8150 $ $ 0 $ 0 N/A077 .20-.39 Fringe Benefits 8150 0 0 N/A077 .79 Agency Staff 8150 0 0 N/A077 .40-.99 Other - Nonlabor 8150 23,415 0 23,415 (Sch 4)077 Specialized Support Surfaces - Total 8150 $ 23,415 $ 0 $ 23,415

SUMMARY OF AUDITED PROGRAM EXPENSES

AUDIT

REPORTEDAS AS

AUDITEDADJUSTMENTS

8A-1




Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER


AUDIT

REPORTEDAS AS

AUDITEDADJUSTMENTS

8A-1080 Physical Therapy080 .01-.19 Salaries and Wages 8200 $ $ 0 $ 0 (Sch 2)080 .20-.39 Fringe Benefits 8200 0 0 (Sch 2)080 .79 Agency Staff 8200 235,132 0 235,132 (Sch 2)080 .40-.99 Other - Nonlabor 8200 188 0 188 (Sch 4)080 Physical Therapy - Total 8200 $ 235,320 $ 0 $ 235,320

081 Respiratory Therapy081 .01-.19 Salaries and Wages 8220 $ $ 0 $ 0 (Sch 2)081 .20-.39 Fringe Benefits 8220 0 0 (Sch 2)081 .79 Agency Staff 8220 0 0 (Sch 2)081 .40-.99 Other - Nonlabor 8220 317 0 317 (Sch 4)081 Respiratory Therapy - Total 8220 $ 317 $ 0 $ 317

082 Occupational Therapy082 .01-.19 Salaries and Wages 8250 $ $ 0 $ 0 (Sch 2)082 .20-.39 Fringe Benefits 8250 0 0 (Sch 2)082 .79 Agency Staff 8250 191,988 0 191,988 (Sch 2)082 .40-.99 Other - Nonlabor 8250 315 0 315 (Sch 4)082 Occupational Therapy - Total 8250 $ 192,303 $ 0 $ 192,303

083 Speech Pathology083 .01-.19 Salaries and Wages 8280 $ $ 0 $ 0 (Sch 2)083 .20-.39 Fringe Benefits 8280 0 0 (Sch 2)083 .79 Agency Staff 8280 79,645 0 79,645 (Sch 2)083 .40-.99 Other - Nonlabor 8280 0 0 (Sch 4)083 Speech Pathology - Total 8280 $ 79,645 $ 0 $ 79,645

085 Pharmacy085 .01-.19 Salaries and Wages 8300 $ $ 0 $ 0 (Sch 2)085 .20-.39 Fringe Benefits 8300 0 0 (Sch 2)085 .79 Agency Staff 8300 0 0 (Sch 2)085 .40-.99 Other - Nonlabor 8300 165,024 0 165,024 (Sch 4)085 Pharmacy - Total 8300 $ 165,024 $ 0 $ 165,024

090 Laboratory090 .01-.19 Salaries and Wages 8400 $ 1,620 $ 0 $ 1,620 (Sch 2)090 .20-.39 Fringe Benefits 8400 389 0 389 (Sch 2)090 .79 Agency Staff 8400 0 0 (Sch 2)090 .40-.99 Other - Nonlabor 8400 20,396 0 20,396 (Sch 4)090 Laboratory - Total 8400 $ 22,405 $ 0 $ 22,405

095 Home Health Services095 .01-.19 Salaries and Wages 8800 $ $ 0 $ 0 (Sch 2)095 .20-.39 Fringe Benefits 8800 0 0 (Sch 2)095 .79 Agency Staff 8800 0 0 (Sch 2)095 .40-.99 Other - Nonlabor 8800 0 0 (Sch 4)095 Home Health Services - Total 8800 $ 0 $ 0 $ 0

100 Other Ancillary Services100 .01-.19 Salaries and Wages 8900 $ $ 0 $ 0 (Sch 2)100 .20-.39 Fringe Benefits 8900 0 0 (Sch 2)100 .79 Agency Staff 8900 0 0 (Sch 2)100 .40-.99 Other - Nonlabor 8900 8,668 0 8,668 (Sch 4)100 Other Ancillary Services - Total 8900 $ 8,668 $ 0 $ 8,668






AUDIT

REPORTEDAS AS

AUDITEDADJUSTMENTS

8A-1101 Subacute Care Ancillary Services101 .01-.19 Salaries and Wages 8100-8900 $ $ 0 $ 0 (Sch 2)101 .20-.39 Fringe Benefits 8100-8900 0 0 (Sch 2)101 .79 Agency Staff 8100-8900 0 0 (Sch 2)101 .40-.99 Other - Nonlabor 8100-8900 0 0 (Sch 4)101 Subacute Care Ancillary Services - Total 8100-8900 $ 0 $ 0 $ 0

102 Subacute Care - Pediatric Ancillary Services102 .01-.19 Salaries and Wages 8100-8900 $ $ 0 $ 0 (Sch 2)102 .20-.39 Fringe Benefits 8100-8900 0 0 (Sch 2)102 .79 Agency Staff 8100-8900 0 0 (Sch 2)102 .40-.99 Other - Nonlabor 8100-8900 0 0 (Sch 4)102 Subacute Care - Pediatric Ancillary Services - Total 8100-8900 $ 0 $ 0 $ 0

104 Subtotal 075 - 102 $ 750,449 $ (2,129) $ 748,320

Routine Services105 Skilled Nursing Care105 .01-.19 Salaries and Wages 6110 $ 2,255,009 $ 0 $ 2,255,009 (Sch 2)105 .20-.39 Fringe Benefits 6110 634,611 0 634,611 (Sch 2)105 .49 Agency Staff 6110 0 0 (Sch 2)105 .40-.99 Other - Nonlabor 6110 158,396 2,129 160,525 (Sch 4)105 Skilled Nursing Care - Total 6110 $ 3,048,016 $ 2,129 $ 3,050,145

110 Intermediate Care110 .01-.19 Salaries and Wages 6120 $ $ 0 $ 0110 .20-.39 Fringe Benefits 6120 0 0110 .49 Agency Staff 6120 0 0110 .40-.99 Other - Nonlabor 6120 0 0110 Intermediate Care - Total 6120 $ 0 $ 0 $ 0 (Sch 2)

115 Mentally Disordered Care115 .01-.19 Salaries and Wages 6130 $ $ 0 $ 0115 .20-.39 Fringe Benefits 6130 0 0115 .49 Agency Staff 6130 0 0115 .40-.99 Other - Nonlabor 6130 0 0115 Mentally Disordered Care - Total 6130 $ 0 $ 0 $ 0 (Sch 2)

120 Developmentally Disabled Care120 .01-.19 Salaries and Wages 6140 $ $ 0 $ 0120 .20-.39 Fringe Benefits 6140 0 0120 .49 Agency Staff 6140 0 0120 .40-.99 Other - Nonlabor 6140 0 0120 Developmentally Disabled Care - Total 6140 $ 0 $ 0 $ 0 (Sch 2)

125 Subacute Care125 .01-.19 Salaries and Wages 6150 $ $ 0 $ 0 (Sch 2)125 .20-.39 Fringe Benefits 6150 0 0 (Sch 2)125 .49 Agency Staff 6150 0 0 (Sch 2)125 .40-.99 Other - Nonlabor 6150 0 0 (Sch 4)125 Subacute Care - Total 6150 $ 0 $ 0 $ 0

126 Subacute Care - Pediatric126 .01-.19 Salaries and Wages 6160 $ $ 0 $ 0 (Sch 2)126 .20-.39 Fringe Benefits 6160 0 0 (Sch 2)126 .49 Agency Staff 6160 0 0 (Sch 2)126 .40-.99 Other - Nonlabor 6160 0 0 (Sch 4)126 Subacute Care - Pediatric - Total 6160 $ 0 $ 0 $ 0






AUDIT

REPORTEDAS AS

AUDITEDADJUSTMENTS

8A-1128 Transitional Inpatient Care128 .01-.19 Salaries and Wages 6170 $ $ 0 $ 0128 .20-.39 Fringe Benefits 6170 0 0128 .49 Agency Staff 6170 0 0128 .40-.99 Other - Nonlabor 6170 0 0128 Transitional Inpatient Care - Total 6170 $ 0 $ 0 $ 0 (Sch 2)

130 Hospice Inpatient Care130 .01-.19 Salaries and Wages 6180 $ $ 0 $ 0130 .20-.39 Fringe Benefits 6180 0 0130 .49 Agency Staff 6180 0 0130 .40-.99 Other - Nonlabor 6180 0 0130 Hospice Inpatient Care - Total 6180 $ 0 $ 0 $ 0 (Sch 2)

135 Other Routine Services135 .01-.19 Salaries and Wages 6190 $ $ 0 $ 0135 .20-.39 Fringe Benefits 6190 0 0135 .49 Agency Staff 6190 0 0135 .40-.99 Other - Nonlabor 6190 0 0135 Other Routine Services - Total 6190 $ 0 $ 0 $ 0 (Sch 2)

Other Nonreimbursable139 Residential Care139 .01-.19 Salaries and Wages 9100 $ $ 0 $ 0 (Sch 2)139 .20-.39 Fringe Benefits 9100 0 0 (Sch 2)139 .49 Agency Staff 9100 0 0 (Sch 2)139 .40-.99 Other - Nonlabor 9100 0 0 (Sch 4)139 Residential Care - Total 9100 $ 0 $ 0 $ 0

140 Beauty and Barber140 .01-.19 Salaries and Wages 8900 $ $ 0 $ 0 (Sch 2)140 .20-.39 Fringe Benefits 8900 0 0 (Sch 2)140 .49 Agency Staff 8900 0 0 (Sch 2)140 .40-.99 Other - Nonlabor 8900 0 0 (Sch 4)140 Beauty and Barber - Total 8900 $ 0 $ 0 $ 0

145 Other Nonreimbursable145 .01-.19 Salaries and Wages 9100 $ $ 0 $ 0 (Sch 2)145 .20-.39 Fringe Benefits 9100 0 0 (Sch 2)145 .49 Agency Staff 9100 0 0 (Sch 2)145 .40-.99 Other - Nonlabor 9100 0 0 (Sch 4)145 Other Nonreimbursable - Total 9100 $ 0 $ 0 $ 0

146 Subtotal 105 - 145 $ 3,048,016 $ 2,129 $ 3,050,145

155 Social Services155 .01-.19 Salaries and Wages 6600 $ 49,756 $ 0 $ 49,756 (Sch 2)155 .20-.39 Fringe Benefits 6600 12,796 0 12,796 (Sch 2)155 .49 Agency Staff 6600 0 0 (Sch 2)155 .40-.99 Other - Nonlabor 6600 7,954 0 7,954 (Sch 4)155 Social Services - Total 6600 $ 70,506 $ 0 $ 70,506






AUDIT

REPORTEDAS AS

AUDITEDADJUSTMENTS

8A-1160 Activities160 .01-.19 Salaries and Wages 6700 $ 69,932 $ 0 $ 69,932 (Sch 2)160 .20-.39 Fringe Benefits 6700 19,082 0 19,082 (Sch 2)160 .49 Agency Staff 6700 0 0 (Sch 2)160 .40-.99 Other - Nonlabor 6700 6,527 0 6,527 (Sch 4)160 Activities - Total 6700 $ 95,541 $ 0 $ 95,541

165 Administration165 .01-.19 Salaries and Wages 6900 $ 231,993 $ 0 $ 231,993 (Sch 6)165 .20-.39 Fringe Benefits 6900 71,109 0 71,109 (Sch 6)165 .49 Agency Staff 6900 0 0 (Sch 6)165 .40-.99 Other - Nonlabor 6900 481,239 9,277 490,516 (Sch 6)165 Administration - Total 6900 $ 784,341 $ 9,277 $ 793,618

166 Medical Records166 .01-.19 Salaries and Wages 6900 $ 55,758 $ 0 $ 55,758 (Sch 3)166 .20-.39 Fringe Benefits 6900 13,522 0 13,522 (Sch 3)166 .49 Agency Staff 6900 0 0 (Sch 3)166 .40-.99 Other - Nonlabor 6900 18,597 0 18,597 (Sch 4)166 Medical Records - Total 6900 $ 87,877 $ 0 $ 87,877

167 CDPH Licensing Fees 6900 $ 28,412 $ 0 $ 28,412 (Sch 6)168 Professional Liability Insurance 6900 $ 146,771 $ (68,667) $ 78,104 (Sch 6)169 Quality Assurance Fees 6900 $ 410,790 $ 0 $ 410,790 (Sch 6)

170 Inservice Education - Nursing170 .01-.19 Salaries and Wages 6800 $ 10,570 $ 0 $ 10,570 (Sch 3)170 .20-.39 Fringe Benefits 6800 3,872 0 3,872 (Sch 3)170 .49 Agency Staff 6800 0 0 (Sch 3)170 .40-.99 Other - Nonlabor 6800 0 0 (Sch 4)170 Inservice Education - Nursing - Total 6800 $ 14,442 $ 0 $ 14,442

174 Caregiver Training 174 .01-.19 Salaries and Wages 6900 $ $ 0 $ 0 (Sch 6)174 .20-.39 Fringe Benefits 6900 0 0 (Sch 6)174 .49 Agency Staff 6900 0 0 (Sch 6)174 .40-.99 Other - Nonlabor 6900 0 0 (Sch 6)174 Caregiver Training - Total 6900 $ 0 $ 0 $ 0

Subtotal 155 - 174 $ 1,638,680 $ (59,390) $ 1,579,290

200 Total $ 6,931,919 $ (59,390) $ 6,872,529

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