REPORT ON THE RATE SETTING AUDIT COUNTRY VILLA … filench/Audits Sec Suite 280, MS 6-4757/FAX:...
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REPORT ON THE RATE SETTING AUDIT COUNTRY VILLA LAGUNA HILLS HEALTHCARE CENTER LAGUNA HILLS, CALIFORNIA NATIONAL PROVIDER IDENTIFIER: 1720072374 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: Deborah Lee Auditor: Sunita Parmar
Transcript of REPORT ON THE RATE SETTING AUDIT COUNTRY VILLA … filench/Audits Sec Suite 280, MS 6-4757/FAX:...
REPORT ON THE
RATE SETTING AUDIT
COUNTRY VILLA LAGUNA HILLS HEALTHCARE CENTER
LAGUNA HILLS, CALIFORNIA NATIONAL PROVIDER IDENTIFIER: 1720072374
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: Deborah Lee Auditor: Sunita Parmar
TO
OBY DOUGLAS DIRECTOR
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Chief Department of Health Care Services Office of Administrative Hearings and Appeals 1029 J Street, Suite 200 Sacramento, CA 95814 (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 Enclosure cc: Ruth Mendoza Director of Reimbursement Country Villa Health Services 5120 Goldleaf Circle, Suite 400 Los Angeles, CA 90056
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:COUNTRY VILLA LAGUNA HILLS HEALTHCARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility No.:1720072374 206301115
LineNo.
SKILLED NURSING CARE1 Cost of Direct Care - Labor (Sch. 2, Ln. 105) $ N/A $ 6,737,510 $ 107.292 Cost of Indirect Care - Labor (Sch. 3, Ln. 105) $ N/A $ 1,548,120 $ 24.653 Cost of Direct and Indirect Nonlabor - Other (Sch. 4, Ln. 105) $ N/A $ 1,613,826 $ 25.704 Cost of Capital Related (Sch. 5, Ln. 105) $ N/A $ 675,510 $ 10.765 Property Taxes (Sch. 5, Ln. 105) $ N/A $ 67,320 $ 1.076 CDPH Licensing Fees (Sch. 6, Ln. 105) $ N/A $ 43,777 $ 0.707 Professional Liability Insurance (Sch. 6, Ln. 105) $ N/A $ 212,665 $ 3.398 Caregiver Training (Sch. 6, Ln. 105) $ N/A $ 0 $ 0.009 Quality Assurance Fees (Sch. 6, Ln. 105) $ N/A $ 570,069 $ 9.0810 Cost of Administration (Sch. 6, Ln. 105) $ N/A $ 1,666,638 $ 26.5411 Cost of Routine Service/Audited Total Costs $ 13,247,505.00 $ 13,135,435.25 $ 209.1812 Total Patient Days (Adj ) 62,795 62,79513 Cost Per Patient Day (Cost Divided by Days) $ 210.96 $ 209.18 14 Overpayments (Adj ) $ $ 015 Medi-Cal Days (Adj 28 ) 36,112 22216 Medi-Cal Managed Care Days (Adj 29) 35,965
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
SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY
COST PERAUDITED
PROGRAM DESCRIPTIONAS REPORTED AS AUDITED PATIENT DAY
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:COUNTRY VILLA LAGUNA HILLS HEALTHCARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility No.:1720072374 206301115
LineNo.
SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY
COST PERAUDITED
PROGRAM DESCRIPTIONAS REPORTED AS AUDITED PATIENT DAY
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
STATE OF CALIFORNIA SCHEDULE 2
Provider Name: Fiscal Period:COUNTRY VILLA LAGUNA HILLS HEALTHCARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility No.:1720072374 206301115
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 168,096$ 168,096$ 160 Activities 158,763 158,763$ 165 Administration166 Medical Records170 Inservice Education - Nursing
ANCILLARY SERVICES075 Patient Supplies 4,993 0 0 4,993077 Specialized Support Surfaces N/A 0 0 0080 Physical Therapy 1,175,548 0 0 1,175,548081 Respiratory Therapy 0 0 0 0082 Occupational Therapy 759,166 0 0 759,166083 Speech Pathology 230,702 0 0 230,702085 Pharmacy 0 0 0 0090 Laboratory 2,467 0 0 2,467095 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 6,410,651 168,096 158,763 6,737,510 *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 8,910,386$ 168,096$ 158,763$ 8,910,386$ * (To Schedule 1)
ALLOCATION OF GENERAL SERVICES DIRECT CARE LABOR
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STATE OF CALIFORNIA SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Provider Name: Fiscal Period:COUNTRY VILLA LAGUNA HILLS HEALTHCARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1720072374 206301115
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) 736,599$ 91%Property Tax (line 40) 73,408 9% 810,007$
005 Plant Operations and Maintenance 11,286 11,286$ 010 Housekeeping 6,460 91 6,552$ 060 Laundry and Linen 13,613 192 113 13,918$ 065 Dietary 110,595 1,563 915 0 113,073$ 155 Social Services 4,615 65 38 0 0 4,718$ 160 Activities 9,325 132 77 0 0 0 9,534$ 165 Administration 33,282 470 275 0 0 0 0166 Medical Records 6,806 96 56 0 0 0 0170 Inservice Education - Nursing 15,382 217 127 0 0 0 0
ANCILLARY SERVICES075 Patient Supplies 4,480 63 37 0 0 0 0077 Specialized Support Surfaces 0 0 0 0 0 0 0080 Physical Therapy 16,439 232 136 0 0 0 0081 Respiratory Therapy 0 0 0 0 0 0 0082 Occupational Therapy 20,381 288 169 0 0 0 0083 Speech Pathology 5,191 73 43 0 0 0 0085 Pharmacy 3,499 49 29 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 542,594 7,667 4,487 13,918 113,073 4,718 9,534110 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 6,057 86 50 0 0 0 0145 Other Nonreimbursable 0 0 0 0 0 0 0
TOTAL 810,007$ 100% 810,007$ 11,286$ 6,552$ 13,918$ 113,073$ 4,718$ 9,534$ * (To Schedule 1)
STATE OF CALIFORNIA
Provider Name:COUNTRY VILLA LAGUNA HILLS HEALTHCARE CENTER
Provider NPI:1720072374
Net Exp ForLine DESCRIPTION Cost AllocNo. (From Sch 8) Ratio
GENERAL SERVICESCapital Related (excluding lines 40 & 45) 736,599$ 91%Property Tax (line 40) 73,408 9%
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 810,007$ 100%* (To Schedule 1)
SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Fiscal Period:JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
OSHPD Facility Number:206301115
Inserv. Ed Admin Medical Capital PropertyRecords Related Tax
Accumulated 91% 9%170 Costs 165 166 Total Of Total Of Total
34,028$ 34,028$ 6,959 6,959$
15,726$
0 4,580 162 33 4,775$ 4,342$ 433$ 0 0 36 7 43 39 40 16,808 2,998 613 20,419 18,569 1,8510 0 95 19 115 104 100 20,837 1,986 406 23,230 21,125 2,1050 5,308 598 122 6,028 5,482 5460 3,578 1,640 335 5,553 5,050 5030 0 470 96 567 515 510 0 0 0 0 0 00 0 143 29 172 157 160 0 0 0 0 0 00 0 0 0 0 0 0
15,726 711,717 25,830 5,282 742,830 675,510 67,320 *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 6,192 70 14 6,276 5,707 5690 0 0 0 0 0 0
15,726$ 769,020$ 34,028$ 6,959$ 810,007$ 736,599$ 73,408$
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90
.02
24
16
69
0.6
07
06
58
50
.00
06
96
36
0.0
01
40
72
40
.00
23
21
21
0.0
02
47
19
60
.00
05
05
53
ST
AT
IST
ICS
FO
R C
OS
T A
LL
OC
AT
ION
CO
UN
TR
Y V
ILL
A L
AG
UN
A H
ILL
S H
EA
LT
HC
AR
E C
EN
TE
R
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:COUNTRY VILLA LAGUNA HILLS HEALTHCARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1720072374 206301115
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER005 Plant Operations and Maintenance005 .01-.19 Salaries and Wages 6200 $ 110,558 $ 0 $ 110,558 (Sch 3)005 .20-.39 Fringe Benefits 6200 27,424 (527) 26,897 (Sch 3)005 .79 Agency Staff 6200 0 0 (Sch 3)005 .40-.99 Other - Nonlabor 6200 447,734 50 447,784 (Sch 4)005 Plant Operations and Maintenance - Total 6200 $ 585,716 $ (477) $ 585,239
010 Housekeeping010 .01-.19 Salaries and Wages 6300 $ 0 $ 0 $ 0 (Sch 3)010 .20-.39 Fringe Benefits 6300 0 0 0 (Sch 3)010 .79 Agency Staff 6300 236,167 0 236,167 (Sch 3)010 .40-.99 Other - Nonlabor 6300 72,532 0 72,532 (Sch 4)010 Housekeeping - Total 6300 $ 308,699 $ 0 $ 308,699
015 Depreciation: Buildings and Improvements 7110 - 7120 $ 231,404 $ 0 $ 231,404 (Sch 5)020 Depreciation: Leasehold Improvements 7130 48,259 0 48,259 (Sch 5)025 Depreciation: Equipment 7140 19,185 0 19,185 (Sch 5)030 Depreciation and Amortization - Other 7150 - 7160 0 0 (Sch 5)035 Leases and Rentals 7200 183,732 0 183,732 (Sch 5)040 Property Taxes 7300 73,408 0 73,408 (Sch 5)045 Property Insurance 7400 40,764 0 40,764 (Sch 6)050 Interest - Property, Plant, and Equipment 7500 254,019 0 254,019 (Sch 5)055 Interest - Other 7600 $ 32,028 $ 0 $ 32,028 (Sch 6)
057 Subtotal 005 - 055 $ 1,777,214 $ (477) $ 1,776,737
060 Laundry and Linen060 .01-.19 Salaries and Wages 6400 $ 0 $ 0 $ 0 (Sch 3)060 .20-.39 Fringe Benefits 6400 0 0 0 (Sch 3)060 .79 Agency Staff 6400 152,333 0 152,333 (Sch 3)060 .40-.99 Other - Nonlabor 6400 54,091 0 54,091 (Sch 4)060 Laundry and Linen - Total 6400 $ 206,424 $ 0 $ 206,424
065 Dietary065 .01-.19 Salaries and Wages 6500 $ 673,608 $ 0 $ 673,608 (Sch 3)065 .20-.39 Fringe Benefits 6500 178,531 (3,912) 174,619 (Sch 3)065 .79 Agency Staff 6500 0 0 0 (Sch 3)065 .40-.99 Other - Nonlabor 6500 667,510 1,005 668,515 (Sch 4)065 Dietary - Total 6500 $ 1,519,649 $ (2,907) $ 1,516,742
070 Provision for Bad Debts 7700 $ 0 0 $ 0
Ancillary Services 075 Patient Supplies075 .01-.19 Salaries and Wages 8100 $ 4,109 $ 0 $ 4,109 (Sch 2)075 .20-.39 Fringe Benefits 8100 1,132 (248) 884 (Sch 2)075 .79 Agency Staff 8100 0 0 0 (Sch 2)075 .40-.99 Other - Nonlabor 8100 60,128 (9,399) 50,729 (Sch 4)075 Patient Supplies - Total 8100 $ 65,369 $ (9,647) $ 55,722
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 14,395 0 14,395 (Sch 4)077 Specialized Support Surfaces - Total 8150 $ 14,395 $ 0 $ 14,395
REPORTEDAS AS
AUDITEDADJUSTMENTS
8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:COUNTRY VILLA LAGUNA HILLS HEALTHCARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1720072374 206301115
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER REPORTED
AS ASAUDITED
ADJUSTMENTS8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
080 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 1,168,146 7,402 1,175,548 (Sch 2)080 .40-.99 Other - Nonlabor 8200 2,048 0 2,048 (Sch 4)080 Physical Therapy - Total 8200 $ 1,170,194 $ 7,402 $ 1,177,596
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 38,456 0 38,456 (Sch 4)081 Respiratory Therapy - Total 8220 $ 38,456 $ 0 $ 38,456
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 754,386 4,780 759,166 (Sch 2)082 .40-.99 Other - Nonlabor 8250 562 0 562 (Sch 4)082 Occupational Therapy - Total 8250 $ 754,948 $ 4,780 $ 759,728
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 229,250 1,452 230,702 (Sch 2)083 .40-.99 Other - Nonlabor 8280 0 0 (Sch 4)083 Speech Pathology - Total 8280 $ 229,250 $ 1,452 $ 230,702
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 653,365 2,453 655,818 (Sch 4)085 Pharmacy - Total 8300 $ 653,365 $ 2,453 $ 655,818
090 Laboratory090 .01-.19 Salaries and Wages 8400 $ 1,934 $ 0 $ 1,934 (Sch 2)090 .20-.39 Fringe Benefits 8400 533 0 533 (Sch 2)090 .79 Agency Staff 8400 0 0 (Sch 2)090 .40-.99 Other - Nonlabor 8400 187,854 0 187,854 (Sch 4)090 Laboratory - Total 8400 $ 190,321 $ 0 $ 190,321
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 57,444 385 57,829 (Sch 4)100 Other Ancillary Services - Total 8900 $ 57,444 $ 385 $ 57,829
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:COUNTRY VILLA LAGUNA HILLS HEALTHCARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1720072374 206301115
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER REPORTED
AS ASAUDITED
ADJUSTMENTS8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
101 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 $ 3,173,742 $ 6,825 $ 3,180,567
Routine Services105 Skilled Nursing Care105 .01-.19 Salaries and Wages 6110 $ 5,080,424 $ (35,478) $ 5,044,946 (Sch 2)105 .20-.39 Fringe Benefits 6110 1,400,197 (34,492) 1,365,705 (Sch 2)105 .49 Agency Staff 6110 0 0 (Sch 2)105 .40-.99 Other - Nonlabor 6110 353,858 10,563 364,421 (Sch 4)105 Skilled Nursing Care - Total 6110 $ 6,834,479 $ (59,407) $ 6,775,072
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
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:COUNTRY VILLA LAGUNA HILLS HEALTHCARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1720072374 206301115
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER REPORTED
AS ASAUDITED
ADJUSTMENTS8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
128 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 15,102 0 15,102 (Sch 4)140 Beauty and Barber - Total 8900 $ 15,102 $ 0 $ 15,102
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 $ 6,849,581 $ (59,407) $ 6,790,174
155 Social Services155 .01-.19 Salaries and Wages 6600 $ 132,148 $ 0 $ 132,148 (Sch 2)155 .20-.39 Fringe Benefits 6600 36,583 (635) 35,948 (Sch 2)155 .49 Agency Staff 6600 0 0 (Sch 2)155 .40-.99 Other - Nonlabor 6600 7,858 (5,551) 2,307 (Sch 4)155 Social Services - Total 6600 $ 176,589 $ (6,186) $ 170,403
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:COUNTRY VILLA LAGUNA HILLS HEALTHCARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1720072374 206301115
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER REPORTED
AS ASAUDITED
ADJUSTMENTS8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
160 Activities160 .01-.19 Salaries and Wages 6700 $ 126,513 $ 0 $ 126,513 (Sch 2)160 .20-.39 Fringe Benefits 6700 32,296 (46) 32,250 (Sch 2)160 .49 Agency Staff 6700 0 0 (Sch 2)160 .40-.99 Other - Nonlabor 6700 11,627 (350) 11,277 (Sch 4)160 Activities - Total 6700 $ 170,436 $ (396) $ 170,040
165 Administration165 .01-.19 Salaries and Wages 6900 $ 681,184 $ 35,478 $ 716,662 (Sch 6)165 .20-.39 Fringe Benefits 6900 203,927 355 204,282 (Sch 6)165 .49 Agency Staff 6900 0 0 (Sch 6)165 .40-.99 Other - Nonlabor 6900 1,264,106 (62,279) 1,201,827 (Sch 6)165 Administration - Total 6900 $ 2,149,217 $ (26,446) $ 2,122,771
166 Medical Records166 .01-.19 Salaries and Wages 6900 $ 109,543 $ 0 $ 109,543 (Sch 3)166 .20-.39 Fringe Benefits 6900 30,219 (473) 29,746 (Sch 3)166 .49 Agency Staff 6900 0 0 (Sch 3)166 .40-.99 Other - Nonlabor 6900 28,642 0 28,642 (Sch 4)166 Medical Records - Total 6900 $ 168,404 $ (473) $ 167,931
167 CDPH Licensing Fees 6900 $ 57,670 $ 0 $ 57,670 (Sch 6)168 Professional Liability Insurance 6900 $ 314,292 $ (34,136) $ 280,156 (Sch 6)169 Quality Assurance Fees 6900 $ 750,986 $ 0 $ 750,986 (Sch 6)
170 Inservice Education - Nursing170 .01-.19 Salaries and Wages 6800 $ 78,708 $ 0 $ 78,708 (Sch 3)170 .20-.39 Fringe Benefits 6800 20,823 (340) 20,483 (Sch 3)170 .49 Agency Staff 6800 0 0 (Sch 3)170 .40-.99 Other - Nonlabor 6800 14,309 0 14,309 (Sch 4)170 Inservice Education - Nursing - Total 6800 $ 113,840 $ (340) $ 113,500
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 $ 3,901,434 $ (67,977) $ 3,833,457
200 Total $ 17,428,044 $ (123,943) $ 17,304,101
STA
TE O
F C
ALI
FOR
NIA
Sche
dule
8A
-1Pa
ge 1
Prov
ider
Nam
e:Pr
ovid
er N
PI:
OSH
PD F
acili
ty N
umbe
r:Fi
scal
Per
iod:
CO
UN
TRY
VIL
LA L
AG
UN
A H
ILLS
HE
ALT
HC
AR
E C
EN
TER
1720
0723
7420
6301
115
JAN
UA
RY
1, 2
010
THR
OU
GH
DE
CE
MB
ER
31,
201
0
TOTA
L A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
Line
Sub
(Pag
es 1
,2,3
&4)
12
34
56
78
No.
No.
005
1P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Sal
arie
s an
d W
ages
000
52
Pla
nt O
pera
tions
and
Mai
nten
ance
- Fr
inge
Ben
efits
(527
)(5
0)(4
77)
005
3P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Age
ncy
Sta
ff0
005
4P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Oth
er -
Non
labo
r50
5001
01
Hou
seke
epin
g - S
alar
ies
and
Wag
es0
010
2H
ouse
keep
ing
- Frin
ge B
enef
its0
010
3H
ouse
keep
ing
- Age
ncy
Sta
ff0
010
4H
ouse
keep
ing
- Oth
er -
Non
labo
r0
015
4D
epre
ciat
ion:
Bui
ldin
gs a
nd Im
prov
emen
ts0
020
4D
epre
ciat
ion:
Lea
seho
ld Im
prov
emen
ts0
025
4D
epre
ciat
ion:
Equ
ipm
ent
003
04
Dep
reci
atio
n an
d A
mor
tizat
ion
- Oth
er0
035
4Le
ases
and
Ren
tals
004
04
Pro
perty
Tax
es0
045
4P
rope
rty In
sura
nce
005
04
Inte
rest
- P
rope
rty, P
lant
, and
Equ
ipm
ent
005
54
Inte
rest
- O
ther
006
01
Laun
dry
and
Line
n - S
alar
ies
and
Wag
es0
060
2La
undr
y an
d Li
nen
- Frin
ge B
enef
its0
060
3La
undr
y an
d Li
nen
- Age
ncy
Sta
ff0
060
4La
undr
y an
d Li
nen
- Oth
er -
Non
labo
r0
065
1D
ieta
ry -
Sal
arie
s an
d W
ages
006
52
Die
tary
- Fr
inge
Ben
efits
(3,9
12)
(1,0
05)
(2,9
07)
065
3D
ieta
ry -
Age
ncy
Sta
ff0
065
4D
ieta
ry -
Oth
er -
Non
labo
r1,
005
1,00
507
04
Pro
visi
on fo
r Bad
Deb
ts0
075
1P
atie
nt S
uppl
ies
- Sal
arie
s an
d W
ages
007
52
Pat
ient
Sup
plie
s - F
ringe
Ben
efits
(248
)(1
20)
(128
)07
53
Pat
ient
Sup
plie
s - A
genc
y S
taff
007
54
Pat
ient
Sup
plie
s - O
ther
- N
onla
bor
(9,3
99)
(8,3
53)
120
077
1S
peci
aliz
ed S
uppo
rt S
urfa
ces
- Sal
arie
s an
d W
ages
007
72
Spe
cial
ized
Sup
port
Sur
face
s - F
ringe
Ben
efits
007
73
Spe
cial
ized
Sup
port
Sur
face
s - A
genc
y S
taff
007
74
Spe
cial
ized
Sup
port
Sur
face
s - O
ther
- N
onla
bor
008
01
Phy
sica
l The
rapy
- S
alar
ies
and
Wag
es0
080
2P
hysi
cal T
hera
py -
Frin
ge B
enef
its0
080
3P
hysi
cal T
hera
py -
Age
ncy
Sta
ff7,
402
7,40
208
04
Phy
sica
l The
rapy
- O
ther
- N
onla
bor
008
11
Res
pira
tory
The
rapy
- S
alar
ies
and
Wag
es0
081
2R
espi
rato
ry T
hera
py -
Frin
ge B
enef
its0
081
3R
espi
rato
ry T
hera
py -
Age
ncy
Sta
ff0
081
4R
espi
rato
ry T
hera
py -
Oth
er -
Non
labo
r0
082
1O
ccup
atio
nal T
hera
py -
Sal
arie
s an
d W
ages
008
22
Occ
upat
iona
l The
rapy
- Fr
inge
Ben
efits
008
23
Occ
upat
iona
l The
rapy
- A
genc
y S
taff
4,78
04,
780
082
4O
ccup
atio
nal T
hera
py -
Oth
er -
Non
labo
r0
083
1S
peec
h P
atho
logy
- S
alar
ies
and
Wag
es0
083
2S
peec
h P
atho
logy
- Fr
inge
Ben
efits
008
33
Spe
ech
Pat
holo
gy -
Age
ncy
Sta
ff1,
452
1,45
2
REC
LASS
IFIC
ATI
ON
S A
ND
/OR
AD
JUST
MEN
TS T
O R
EPO
RTE
D C
OST
S
STA
TE O
F C
ALI
FOR
NIA
Sche
dule
8A
-1Pa
ge 1
Prov
ider
Nam
e:Pr
ovid
er N
PI:
OSH
PD F
acili
ty N
umbe
r:Fi
scal
Per
iod:
CO
UN
TRY
VIL
LA L
AG
UN
A H
ILLS
HE
ALT
HC
AR
E C
EN
TER
1720
0723
7420
6301
115
JAN
UA
RY
1, 2
010
THR
OU
GH
DE
CE
MB
ER
31,
201
0
TOTA
L A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
Line
Sub
(Pag
es 1
,2,3
&4)
12
34
56
78
No.
No.
REC
LASS
IFIC
ATI
ON
S A
ND
/OR
AD
JUST
MEN
TS T
O R
EPO
RTE
D C
OST
S
083
4S
peec
h P
atho
logy
- O
ther
- N
onla
bor
008
51
Pha
rmac
y - S
alar
ies
and
Wag
es0
085
2P
harm
acy
- Frin
ge B
enef
its0
085
3P
harm
acy
- Age
ncy
Sta
ff0
085
4P
harm
acy
- Oth
er -
Non
labo
r2,
453
2,45
309
01
Labo
rato
ry -
Sal
arie
s an
d W
ages
009
02
Labo
rato
ry -
Frin
ge B
enef
its0
090
3La
bora
tory
- A
genc
y S
taff
009
04
Labo
rato
ry -
Oth
er -
Non
labo
r0
095
1H
ome
Hea
lth S
ervi
ces
- Sal
arie
s an
d W
ages
009
52
Hom
e H
ealth
Ser
vice
s - F
ringe
Ben
efits
009
53
Hom
e H
ealth
Ser
vice
s - A
genc
y S
taff
009
54
Hom
e H
ealth
Ser
vice
s - O
ther
- N
onla
bor
010
01
Oth
er A
ncill
ary
Ser
vice
s - S
alar
ies
and
Wag
es0
100
2O
ther
Anc
illar
y S
ervi
ces
- Frin
ge B
enef
its0
100
3O
ther
Anc
illar
y S
ervi
ces
- Age
ncy
Sta
ff0
100
4O
ther
Anc
illar
y S
ervi
ces
- Oth
er -
Non
labo
r38
538
510
11
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Sal
arie
s an
d W
ages
010
12
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Frin
ge B
enef
its0
101
3S
ubac
ute
Car
e A
ncill
ary
Ser
vice
s - A
genc
y S
taff
010
14
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Oth
er -
Non
labo
r0
102
1S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - S
alar
ies
and
Wag
es0
102
2S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - F
ringe
Ben
efits
010
23
Sub
acut
e P
edia
tric
Anc
illar
y S
ervi
ces
- Age
ncy
Sta
ff0
102
4S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - O
ther
- N
onla
bor
010
51
Ski
lled
Nur
sing
Car
e - S
alar
ies
and
Wag
es(3
5,47
8)10
52
Ski
lled
Nur
sing
Car
e - F
ringe
Ben
efits
(34,
492)
(5,6
08)
(21,
823)
105
3S
kille
d N
ursi
ng C
are
- Age
ncy
Sta
ff0
105
4S
kille
d N
ursi
ng C
are
- Oth
er -
Non
labo
r10
,563
8,35
3(3
85)
(2,4
53)
5,60
811
01
Inte
rmed
iate
Car
e - S
alar
ies
and
Wag
es0
110
2In
term
edia
te C
are
- Frin
ge B
enef
its0
110
3In
term
edia
te C
are
- Age
ncy
Sta
ff0
110
4In
term
edia
te C
are
- Oth
er -
Non
labo
r0
115
1M
enta
lly D
isor
dere
d C
are
- Sal
arie
s an
d W
ages
011
52
Men
tally
Dis
orde
red
Car
e - F
ringe
Ben
efits
011
53
Men
tally
Dis
orde
red
Car
e - A
genc
y S
taff
011
54
Men
tally
Dis
orde
red
Car
e - O
ther
- N
onla
bor
012
01
Dev
elop
men
tally
Dis
able
d C
are
- Sal
arie
s an
d W
ages
012
02
Dev
elop
men
tally
Dis
able
d C
are
- Frin
ge B
enef
its0
120
3D
evel
opm
enta
lly D
isab
led
Car
e - A
genc
y S
taff
012
04
Dev
elop
men
tally
Dis
able
d C
are
- Oth
er -
Non
labo
r0
125
1S
ubac
ute
Car
e - S
alar
ies
and
Wag
es0
125
2S
ubac
ute
Car
e - F
ringe
Ben
efits
012
53
Sub
acut
e C
are
- Age
ncy
Sta
ff0
125
4S
ubac
ute
Car
e - O
ther
- N
onla
bor
012
61
Sub
acut
e C
are
- Ped
iatri
c - S
alar
ies
and
Wag
es0
126
2S
ubac
ute
Car
e - P
edia
tric
- Frin
ge B
enef
its0
126
3S
ubac
ute
Car
e - P
edia
tric
- Age
ncy
Sta
ff0
126
4S
ubac
ute
Car
e - P
edia
tric
- Oth
er -
Non
labo
r0
STA
TE O
F C
ALI
FOR
NIA
Sche
dule
8A
-1Pa
ge 1
Prov
ider
Nam
e:Pr
ovid
er N
PI:
OSH
PD F
acili
ty N
umbe
r:Fi
scal
Per
iod:
CO
UN
TRY
VIL
LA L
AG
UN
A H
ILLS
HE
ALT
HC
AR
E C
EN
TER
1720
0723
7420
6301
115
JAN
UA
RY
1, 2
010
THR
OU
GH
DE
CE
MB
ER
31,
201
0
TOTA
L A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
Line
Sub
(Pag
es 1
,2,3
&4)
12
34
56
78
No.
No.
REC
LASS
IFIC
ATI
ON
S A
ND
/OR
AD
JUST
MEN
TS T
O R
EPO
RTE
D C
OST
S
128
1Tr
ansi
tiona
l Inp
atie
nt C
are
- Sal
arie
s an
d W
ages
012
82
Tran
sitio
nal I
npat
ient
Car
e - F
ringe
Ben
efits
012
83
Tran
sitio
nal I
npat
ient
Car
e - A
genc
y S
taff
012
84
Tran
sitio
nal I
npat
ient
Car
e - O
ther
- N
onla
bor
013
01
Hos
pice
Inpa
tient
Car
e - S
alar
ies
and
Wag
es0
130
2H
ospi
ce In
patie
nt C
are
- Frin
ge B
enef
its0
130
3H
ospi
ce In
patie
nt C
are
- Age
ncy
Sta
ff0
130
4H
ospi
ce In
patie
nt C
are
- Oth
er -
Non
labo
r0
135
1O
ther
Rou
tine
Ser
vice
s - S
alar
ies
and
Wag
es0
135
2O
ther
Rou
tine
Ser
vice
s - F
ringe
Ben
efits
013
53
Oth
er R
outin
e S
ervi
ces
- Age
ncy
Sta
ff0
135
4O
ther
Rou
tine
Ser
vice
s - O
ther
- N
onla
bor
013
91
Res
iden
tial C
are
- Sal
arie
s an
d W
ages
013
92
Res
iden
tial C
are
- Frin
ge B
enef
its0
139
3R
esid
entia
l Car
e - A
genc
y S
taff
013
94
Res
iden
tial C
are
- Oth
er -
Non
labo
r0
140
1B
eaut
y an
d B
arbe
r - S
alar
ies
and
Wag
es0
140
2B
eaut
y an
d B
arbe
r - F
ringe
Ben
efits
014
03
Bea
uty
and
Bar
ber -
Age
ncy
Sta
ff0
140
4B
eaut
y an
d B
arbe
r - O
ther
- N
onla
bor
014
51
Oth
er N
onre
imbu
rsab
le -
Sal
arie
s an
d W
ages
014
52
Oth
er N
onre
imbu
rsab
le -
Frin
ge B
enef
its0
145
3O
ther
Non
reim
burs
able
- A
genc
y S
taff
014
54
Oth
er N
onre
imbu
rsab
le -
Oth
er -
Non
labo
r0
155
1S
ocia
l Ser
vice
s - S
alar
ies
and
Wag
es0
155
2S
ocia
l Ser
vice
s - F
ringe
Ben
efits
(635
)(6
5)(5
70)
155
3S
ocia
l Ser
vice
s - A
genc
y S
taff
015
54
Soc
ial S
ervi
ces
- Oth
er -
Non
labo
r(5
,551
)65
(1,5
00)
160
1A
ctiv
ities
- S
alar
ies
and
Wag
es0
160
2A
ctiv
ities
- Fr
inge
Ben
efits
(46)
(46)
160
3A
ctiv
ities
- A
genc
y S
taff
016
04
Act
iviti
es -
Oth
er -
Non
labo
r(3
50)
165
1A
dmin
istra
tion
- Sal
arie
s an
d W
ages
35,4
7816
52
Adm
inis
tratio
n - F
ringe
Ben
efits
355
(445
)(2
,940
)16
53
Adm
inis
tratio
n - A
genc
y S
taff
016
54
Adm
inis
tratio
n - O
ther
- N
onla
bor
(62,
279)
445
1,50
084
,136
29,7
04(1
3,63
4)16
61
Med
ical
Rec
ords
- S
alar
ies
and
Wag
es0
166
2M
edic
al R
ecor
ds -
Frin
ge B
enef
its(4
73)
(473
)16
63
Med
ical
Rec
ords
- A
genc
y S
taff
016
64
Med
ical
Rec
ords
- O
ther
- N
onla
bor
016
74
CD
PH
Lic
ensi
ng F
ees
016
84
Pro
fess
iona
l Lia
bilit
y In
sura
nce
(34,
136)
(84,
136)
169
4Q
ualit
y A
ssur
ance
Fee
s0
170
1In
serv
ice
Edu
catio
n - N
ursi
ng -
Sal
arie
s an
d W
ages
017
02
Inse
rvic
e E
duca
tion
- Nur
sing
- Fr
inge
Ben
efits
(340
)(3
40)
170
3In
serv
ice
Edu
catio
n - N
ursi
ng -
Age
ncy
Sta
ff0
170
4In
serv
ice
Edu
catio
n - N
ursi
ng -
Oth
er -
Non
labo
r0
174
1C
areg
iver
Tra
inin
g - S
alar
ies
and
Wag
es0
174
2C
areg
iver
Tra
inin
g - F
ringe
Ben
efits
0
STA
TE O
F C
ALI
FOR
NIA
Sche
dule
8A
-1Pa
ge 1
Prov
ider
Nam
e:Pr
ovid
er N
PI:
OSH
PD F
acili
ty N
umbe
r:Fi
scal
Per
iod:
CO
UN
TRY
VIL
LA L
AG
UN
A H
ILLS
HE
ALT
HC
AR
E C
EN
TER
1720
0723
7420
6301
115
JAN
UA
RY
1, 2
010
THR
OU
GH
DE
CE
MB
ER
31,
201
0
TOTA
L A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
Line
Sub
(Pag
es 1
,2,3
&4)
12
34
56
78
No.
No.
REC
LASS
IFIC
ATI
ON
S A
ND
/OR
AD
JUST
MEN
TS T
O R
EPO
RTE
D C
OST
S
174
3C
areg
iver
Tra
inin
g - A
genc
y S
taff
017
44
Car
egiv
er T
rain
ing
- Oth
er -
Non
labo
r0
200
T
otal
($
123,
943)
00
00
00
00
(To
Sch
8)
STA
TE O
F C
ALI
FOR
NIA
Prov
ider
Nam
e:C
OU
NTR
Y V
ILLA
LA
GU
NA
HIL
LS H
EA
LTH
CA
RE
CE
NTE
R
Line
Sub
No.
No.
005
1P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Sal
arie
s an
d W
ages
005
2P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Frin
ge B
enef
its00
53
Pla
nt O
pera
tions
and
Mai
nten
ance
- A
genc
y S
taff
005
4P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Oth
er -
Non
labo
r01
01
Hou
seke
epin
g - S
alar
ies
and
Wag
es01
02
Hou
seke
epin
g - F
ringe
Ben
efits
010
3H
ouse
keep
ing
- Age
ncy
Sta
ff01
04
Hou
seke
epin
g - O
ther
- N
onla
bor
015
4D
epre
ciat
ion:
Bui
ldin
gs a
nd Im
prov
emen
ts02
04
Dep
reci
atio
n: L
ease
hold
Impr
ovem
ents
025
4D
epre
ciat
ion:
Equ
ipm
ent
030
4D
epre
ciat
ion
and
Am
ortiz
atio
n - O
ther
035
4Le
ases
and
Ren
tals
040
4P
rope
rty T
axes
045
4P
rope
rty In
sura
nce
050
4In
tere
st -
Pro
perty
, Pla
nt, a
nd E
quip
men
t05
54
Inte
rest
- O
ther
060
1La
undr
y an
d Li
nen
- Sal
arie
s an
d W
ages
060
2La
undr
y an
d Li
nen
- Frin
ge B
enef
its06
03
Laun
dry
and
Line
n - A
genc
y S
taff
060
4La
undr
y an
d Li
nen
- Oth
er -
Non
labo
r06
51
Die
tary
- S
alar
ies
and
Wag
es06
52
Die
tary
- Fr
inge
Ben
efits
065
3D
ieta
ry -
Age
ncy
Sta
ff06
54
Die
tary
- O
ther
- N
onla
bor
070
4P
rovi
sion
for B
ad D
ebts
075
1P
atie
nt S
uppl
ies
- Sal
arie
s an
d W
ages
075
2P
atie
nt S
uppl
ies
- Frin
ge B
enef
its07
53
Pat
ient
Sup
plie
s - A
genc
y S
taff
075
4P
atie
nt S
uppl
ies
- Oth
er -
Non
labo
r07
71
Spe
cial
ized
Sup
port
Sur
face
s - S
alar
ies
and
Wag
es07
72
Spe
cial
ized
Sup
port
Sur
face
s - F
ringe
Ben
efits
077
3S
peci
aliz
ed S
uppo
rt S
urfa
ces
- Age
ncy
Sta
ff07
74
Spe
cial
ized
Sup
port
Sur
face
s - O
ther
- N
onla
bor
080
1P
hysi
cal T
hera
py -
Sal
arie
s an
d W
ages
080
2P
hysi
cal T
hera
py -
Frin
ge B
enef
its08
03
Phy
sica
l The
rapy
- A
genc
y S
taff
080
4P
hysi
cal T
hera
py -
Oth
er -
Non
labo
r08
11
Res
pira
tory
The
rapy
- S
alar
ies
and
Wag
es08
12
Res
pira
tory
The
rapy
- Fr
inge
Ben
efits
081
3R
espi
rato
ry T
hera
py -
Age
ncy
Sta
ff08
14
Res
pira
tory
The
rapy
- O
ther
- N
onla
bor
082
1O
ccup
atio
nal T
hera
py -
Sal
arie
s an
d W
ages
082
2O
ccup
atio
nal T
hera
py -
Frin
ge B
enef
its08
23
Occ
upat
iona
l The
rapy
- A
genc
y S
taff
082
4O
ccup
atio
nal T
hera
py -
Oth
er -
Non
labo
r08
31
Spe
ech
Pat
holo
gy -
Sal
arie
s an
d W
ages
083
2S
peec
h P
atho
logy
- Fr
inge
Ben
efits
083
3S
peec
h P
atho
logy
- A
genc
y S
taff
Sche
dule
8A
-1Pa
ge 2
Prov
ider
NPI
:O
SHPD
Fac
ility
Num
ber:
Fisc
al P
erio
d:17
2007
2374
2063
0111
5JA
NU
AR
Y 1
, 201
0 TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
010
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
J9
1011
1213
1415
1617
(1,1
66)
REC
LASS
IFIC
ATI
ON
S A
ND
/OR
AD
JUST
MEN
TS T
O R
EPO
RTE
D C
OST
S
STA
TE O
F C
ALI
FOR
NIA
Prov
ider
Nam
e:C
OU
NTR
Y V
ILLA
LA
GU
NA
HIL
LS H
EA
LTH
CA
RE
CE
NTE
R
Line
Sub
No.
No.
083
4S
peec
h P
atho
logy
- O
ther
- N
onla
bor
085
1P
harm
acy
- Sal
arie
s an
d W
ages
085
2P
harm
acy
- Frin
ge B
enef
its08
53
Pha
rmac
y - A
genc
y S
taff
085
4P
harm
acy
- Oth
er -
Non
labo
r09
01
Labo
rato
ry -
Sal
arie
s an
d W
ages
090
2La
bora
tory
- Fr
inge
Ben
efits
090
3La
bora
tory
- A
genc
y S
taff
090
4La
bora
tory
- O
ther
- N
onla
bor
095
1H
ome
Hea
lth S
ervi
ces
- Sal
arie
s an
d W
ages
095
2H
ome
Hea
lth S
ervi
ces
- Frin
ge B
enef
its09
53
Hom
e H
ealth
Ser
vice
s - A
genc
y S
taff
095
4H
ome
Hea
lth S
ervi
ces
- Oth
er -
Non
labo
r10
01
Oth
er A
ncill
ary
Ser
vice
s - S
alar
ies
and
Wag
es10
02
Oth
er A
ncill
ary
Ser
vice
s - F
ringe
Ben
efits
100
3O
ther
Anc
illar
y S
ervi
ces
- Age
ncy
Sta
ff10
04
Oth
er A
ncill
ary
Ser
vice
s - O
ther
- N
onla
bor
101
1S
ubac
ute
Car
e A
ncill
ary
Ser
vice
s - S
alar
ies
and
Wag
es10
12
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Frin
ge B
enef
its10
13
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Age
ncy
Sta
ff10
14
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Oth
er -
Non
labo
r10
21
Sub
acut
e P
edia
tric
Anc
illar
y S
ervi
ces
- Sal
arie
s an
d W
ages
102
2S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - F
ringe
Ben
efits
102
3S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - A
genc
y S
taff
102
4S
ubac
ute
Ped
iatri
c A
ncill
ary
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105
1S
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105
2S
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53
Ski
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Nur
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Car
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105
4S
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Inte
rmed
iate
Car
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02
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Ben
efits
110
3In
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Inte
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Car
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115
1M
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115
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120
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126
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SHPD
Fac
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Num
ber:
Fisc
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d:17
2007
2374
2063
0111
5JA
NU
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139
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139
3R
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139
4R
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ther
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140
1B
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51
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Sal
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145
2O
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Ben
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145
3O
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able
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taff
145
4O
ther
Non
reim
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ther
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bor
155
1S
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l Ser
vice
s - S
alar
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Wag
es15
52
Soc
ial S
ervi
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53
Soc
ial S
ervi
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Sta
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54
Soc
ial S
ervi
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Non
labo
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01
Act
iviti
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Sal
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s an
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160
2A
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Ben
efits
160
3A
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ities
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genc
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taff
160
4A
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165
1A
dmin
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165
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53
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165
4A
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61
Med
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Rec
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alar
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62
Med
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Rec
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Ben
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166
3M
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Sta
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64
Med
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Rec
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- O
ther
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onla
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167
4C
DP
H L
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Fee
s16
84
Pro
fess
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l Lia
bilit
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sura
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169
4Q
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Inse
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02
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Ben
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170
3In
serv
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Age
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04
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174
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8A
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Prov
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NPI
:O
SHPD
Fac
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Num
ber:
Fisc
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d:17
2007
2374
2063
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5JA
NU
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:O
SHPD
Fac
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Num
ber:
Fisc
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d:17
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2374
2063
0111
5JA
NU
AR
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Sub
No.
No.
005
1P
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025
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035
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52
Die
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065
3D
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Age
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Sta
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54
Die
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070
4P
rovi
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075
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atie
nt S
uppl
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d W
ages
075
2P
atie
nt S
uppl
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ge B
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53
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075
4P
atie
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uppl
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71
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s - S
alar
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72
Spe
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Sup
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Sur
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s - F
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Ben
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077
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74
Spe
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Sup
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s - O
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080
1P
hysi
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Sal
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s an
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ages
080
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hysi
cal T
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Frin
ge B
enef
its08
03
Phy
sica
l The
rapy
- A
genc
y S
taff
080
4P
hysi
cal T
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py -
Oth
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labo
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11
Res
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The
rapy
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alar
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12
Res
pira
tory
The
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081
3R
espi
rato
ry T
hera
py -
Age
ncy
Sta
ff08
14
Res
pira
tory
The
rapy
- O
ther
- N
onla
bor
082
1O
ccup
atio
nal T
hera
py -
Sal
arie
s an
d W
ages
082
2O
ccup
atio
nal T
hera
py -
Frin
ge B
enef
its08
23
Occ
upat
iona
l The
rapy
- A
genc
y S
taff
082
4O
ccup
atio
nal T
hera
py -
Oth
er -
Non
labo
r08
31
Spe
ech
Pat
holo
gy -
Sal
arie
s an
d W
ages
083
2S
peec
h P
atho
logy
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inge
Ben
efits
083
3S
peec
h P
atho
logy
- A
genc
y S
taff
Sche
dule
8A
-1Pa
ge 3
Prov
ider
NPI
:O
SHPD
Fac
ility
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ber:
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2374
2063
0111
5JA
NU
AR
Y 1
, 201
0 TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
010
AU
DIT
AD
JA
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IT A
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AD
JA
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DIT
AD
JA
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IT A
DJ
AU
DIT
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2526
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LASS
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ON
S A
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D C
OST
S
STA
TE O
F C
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Prov
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Nam
e:C
OU
NTR
Y V
ILLA
LA
GU
NA
HIL
LS H
EA
LTH
CA
RE
CE
NTE
R
Line
Sub
No.
No.
083
4S
peec
h P
atho
logy
- O
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- N
onla
bor
085
1P
harm
acy
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s an
d W
ages
085
2P
harm
acy
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53
Pha
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taff
085
4P
harm
acy
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labo
r09
01
Labo
rato
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Sal
arie
s an
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ages
090
2La
bora
tory
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Ben
efits
090
3La
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genc
y S
taff
090
4La
bora
tory
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onla
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095
1H
ome
Hea
lth S
ervi
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s an
d W
ages
095
2H
ome
Hea
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enef
its09
53
Hom
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Ser
vice
s - A
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095
4H
ome
Hea
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Non
labo
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Oth
er A
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Ser
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s - S
alar
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Wag
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02
Oth
er A
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Ser
vice
s - F
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Ben
efits
100
3O
ther
Anc
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Sta
ff10
04
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Ser
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ther
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101
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ute
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vice
s - S
alar
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and
Wag
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12
Sub
acut
e C
are
Anc
illar
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its10
13
Sub
acut
e C
are
Anc
illar
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ervi
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ncy
Sta
ff10
14
Sub
acut
e C
are
Anc
illar
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ervi
ces
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er -
Non
labo
r10
21
Sub
acut
e P
edia
tric
Anc
illar
y S
ervi
ces
- Sal
arie
s an
d W
ages
102
2S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - F
ringe
Ben
efits
102
3S
ubac
ute
Ped
iatri
c A
ncill
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Ser
vice
s - A
genc
y S
taff
102
4S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - O
ther
- N
onla
bor
105
1S
kille
d N
ursi
ng C
are
- Sal
arie
s an
d W
ages
105
2S
kille
d N
ursi
ng C
are
- Frin
ge B
enef
its10
53
Ski
lled
Nur
sing
Car
e - A
genc
y S
taff
105
4S
kille
d N
ursi
ng C
are
- Oth
er -
Non
labo
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01
Inte
rmed
iate
Car
e - S
alar
ies
and
Wag
es11
02
Inte
rmed
iate
Car
e - F
ringe
Ben
efits
110
3In
term
edia
te C
are
- Age
ncy
Sta
ff11
04
Inte
rmed
iate
Car
e - O
ther
- N
onla
bor
115
1M
enta
lly D
isor
dere
d C
are
- Sal
arie
s an
d W
ages
115
2M
enta
lly D
isor
dere
d C
are
- Frin
ge B
enef
its11
53
Men
tally
Dis
orde
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Car
e - A
genc
y S
taff
115
4M
enta
lly D
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Non
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01
Dev
elop
men
tally
Dis
able
d C
are
- Sal
arie
s an
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ages
120
2D
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Ben
efits
120
3D
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Car
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120
4D
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Car
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ther
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125
1S
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52
Sub
acut
e C
are
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ge B
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53
Sub
acut
e C
are
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ncy
Sta
ff12
54
Sub
acut
e C
are
- Oth
er -
Non
labo
r12
61
Sub
acut
e C
are
- Ped
iatri
c - S
alar
ies
and
Wag
es12
62
Sub
acut
e C
are
- Ped
iatri
c - F
ringe
Ben
efits
126
3S
ubac
ute
Car
e - P
edia
tric
- Age
ncy
Sta
ff12
64
Sub
acut
e C
are
- Ped
iatri
c - O
ther
- N
onla
bor
Sche
dule
8A
-1Pa
ge 3
Prov
ider
NPI
:O
SHPD
Fac
ility
Num
ber:
Fisc
al P
erio
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2007
2374
2063
0111
5JA
NU
AR
Y 1
, 201
0 TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
010
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DIT
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AU
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1920
2122
2324
2526
REC
LASS
IFIC
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ON
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MEN
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S
STA
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Prov
ider
Nam
e:C
OU
NTR
Y V
ILLA
LA
GU
NA
HIL
LS H
EA
LTH
CA
RE
CE
NTE
R
Line
Sub
No.
No.
128
1Tr
ansi
tiona
l Inp
atie
nt C
are
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s an
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128
2Tr
ansi
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l Inp
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are
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enef
its12
83
Tran
sitio
nal I
npat
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Car
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128
4Tr
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labo
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Hos
pice
Inpa
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Car
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alar
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Inpa
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Ben
efits
130
3H
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are
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04
Hos
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Inpa
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Car
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ther
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135
1O
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Rou
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Ser
vice
s - S
alar
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52
Oth
er R
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ces
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ge B
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53
Oth
er R
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e S
ervi
ces
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Sta
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54
Oth
er R
outin
e S
ervi
ces
- Oth
er -
Non
labo
r13
91
Res
iden
tial C
are
- Sal
arie
s an
d W
ages
139
2R
esid
entia
l Car
e - F
ringe
Ben
efits
139
3R
esid
entia
l Car
e - A
genc
y S
taff
139
4R
esid
entia
l Car
e - O
ther
- N
onla
bor
140
1B
eaut
y an
d B
arbe
r - S
alar
ies
and
Wag
es14
02
Bea
uty
and
Bar
ber -
Frin
ge B
enef
its14
03
Bea
uty
and
Bar
ber -
Age
ncy
Sta
ff14
04
Bea
uty
and
Bar
ber -
Oth
er -
Non
labo
r14
51
Oth
er N
onre
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rsab
le -
Sal
arie
s an
d W
ages
145
2O
ther
Non
reim
burs
able
- Fr
inge
Ben
efits
145
3O
ther
Non
reim
burs
able
- A
genc
y S
taff
145
4O
ther
Non
reim
burs
able
- O
ther
- N
onla
bor
155
1S
ocia
l Ser
vice
s - S
alar
ies
and
Wag
es15
52
Soc
ial S
ervi
ces
- Frin
ge B
enef
its15
53
Soc
ial S
ervi
ces
- Age
ncy
Sta
ff15
54
Soc
ial S
ervi
ces
- Oth
er -
Non
labo
r16
01
Act
iviti
es -
Sal
arie
s an
d W
ages
160
2A
ctiv
ities
- Fr
inge
Ben
efits
160
3A
ctiv
ities
- A
genc
y S
taff
160
4A
ctiv
ities
- O
ther
- N
onla
bor
165
1A
dmin
istra
tion
- Sal
arie
s an
d W
ages
165
2A
dmin
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tion
- Frin
ge B
enef
its16
53
Adm
inis
tratio
n - A
genc
y S
taff
165
4A
dmin
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tion
- Oth
er -
Non
labo
r16
61
Med
ical
Rec
ords
- S
alar
ies
and
Wag
es16
62
Med
ical
Rec
ords
- Fr
inge
Ben
efits
166
3M
edic
al R
ecor
ds -
Age
ncy
Sta
ff16
64
Med
ical
Rec
ords
- O
ther
- N
onla
bor
167
4C
DP
H L
icen
sing
Fee
s16
84
Pro
fess
iona
l Lia
bilit
y In
sura
nce
169
4Q
ualit
y A
ssur
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Fee
s17
01
Inse
rvic
e E
duca
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sing
- S
alar
ies
and
Wag
es17
02
Inse
rvic
e E
duca
tion
- Nur
sing
- Fr
inge
Ben
efits
170
3In
serv
ice
Edu
catio
n - N
ursi
ng -
Age
ncy
Sta
ff17
04
Inse
rvic
e E
duca
tion
- Nur
sing
- O
ther
- N
onla
bor
174
1C
areg
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Tra
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g - S
alar
ies
and
Wag
es17
42
Car
egiv
er T
rain
ing
- Frin
ge B
enef
its
Sche
dule
8A
-1Pa
ge 3
Prov
ider
NPI
:O
SHPD
Fac
ility
Num
ber:
Fisc
al P
erio
d:17
2007
2374
2063
0111
5JA
NU
AR
Y 1
, 201
0 TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
010
AU
DIT
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AD
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DJ
AU
DIT
AD
JA
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AU
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2122
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IFIC
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ON
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TS T
O R
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D C
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S
(350
)
(9,4
13)
(4,6
19)
(1,6
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(9,3
31)
(369
)(1
2,57
1)
STA
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Prov
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Nam
e:C
OU
NTR
Y V
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LA
GU
NA
HIL
LS H
EA
LTH
CA
RE
CE
NTE
R
Line
Sub
No.
No.
174
3C
areg
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Tra
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genc
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taff
174
4C
areg
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Tra
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g - O
ther
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onla
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200
T
otal
Sche
dule
8A
-1Pa
ge 3
Prov
ider
NPI
:O
SHPD
Fac
ility
Num
ber:
Fisc
al P
erio
d:17
2007
2374
2063
0111
5JA
NU
AR
Y 1
, 201
0 TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
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OST
S
(350
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,413
)(4
,619
)(1
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)(4
0,80
0)(1
,620
)(9
,331
)(3
69)
(12,
571)
STA
TE O
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ALI
FOR
NIA
Prov
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e:C
OU
NTR
Y V
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LA
GU
NA
HIL
LS H
EA
LTH
CA
RE
CE
NTE
R
Line
Sub
No.
No.
005
1P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Sal
arie
s an
d W
ages
005
2P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Frin
ge B
enef
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53
Pla
nt O
pera
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and
Mai
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genc
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taff
005
4P
lant
Ope
ratio
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nd M
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Oth
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Non
labo
r01
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Hou
seke
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g - S
alar
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and
Wag
es01
02
Hou
seke
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g - F
ringe
Ben
efits
010
3H
ouse
keep
ing
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ncy
Sta
ff01
04
Hou
seke
epin
g - O
ther
- N
onla
bor
015
4D
epre
ciat
ion:
Bui
ldin
gs a
nd Im
prov
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ts02
04
Dep
reci
atio
n: L
ease
hold
Impr
ovem
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025
4D
epre
ciat
ion:
Equ
ipm
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030
4D
epre
ciat
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and
Am
ortiz
atio
n - O
ther
035
4Le
ases
and
Ren
tals
040
4P
rope
rty T
axes
045
4P
rope
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sura
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050
4In
tere
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Pro
perty
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nd E
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men
t05
54
Inte
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ther
060
1La
undr
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d Li
nen
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arie
s an
d W
ages
060
2La
undr
y an
d Li
nen
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ge B
enef
its06
03
Laun
dry
and
Line
n - A
genc
y S
taff
060
4La
undr
y an
d Li
nen
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er -
Non
labo
r06
51
Die
tary
- S
alar
ies
and
Wag
es06
52
Die
tary
- Fr
inge
Ben
efits
065
3D
ieta
ry -
Age
ncy
Sta
ff06
54
Die
tary
- O
ther
- N
onla
bor
070
4P
rovi
sion
for B
ad D
ebts
075
1P
atie
nt S
uppl
ies
- Sal
arie
s an
d W
ages
075
2P
atie
nt S
uppl
ies
- Frin
ge B
enef
its07
53
Pat
ient
Sup
plie
s - A
genc
y S
taff
075
4P
atie
nt S
uppl
ies
- Oth
er -
Non
labo
r07
71
Spe
cial
ized
Sup
port
Sur
face
s - S
alar
ies
and
Wag
es07
72
Spe
cial
ized
Sup
port
Sur
face
s - F
ringe
Ben
efits
077
3S
peci
aliz
ed S
uppo
rt S
urfa
ces
- Age
ncy
Sta
ff07
74
Spe
cial
ized
Sup
port
Sur
face
s - O
ther
- N
onla
bor
080
1P
hysi
cal T
hera
py -
Sal
arie
s an
d W
ages
080
2P
hysi
cal T
hera
py -
Frin
ge B
enef
its08
03
Phy
sica
l The
rapy
- A
genc
y S
taff
080
4P
hysi
cal T
hera
py -
Oth
er -
Non
labo
r08
11
Res
pira
tory
The
rapy
- S
alar
ies
and
Wag
es08
12
Res
pira
tory
The
rapy
- Fr
inge
Ben
efits
081
3R
espi
rato
ry T
hera
py -
Age
ncy
Sta
ff08
14
Res
pira
tory
The
rapy
- O
ther
- N
onla
bor
082
1O
ccup
atio
nal T
hera
py -
Sal
arie
s an
d W
ages
082
2O
ccup
atio
nal T
hera
py -
Frin
ge B
enef
its08
23
Occ
upat
iona
l The
rapy
- A
genc
y S
taff
082
4O
ccup
atio
nal T
hera
py -
Oth
er -
Non
labo
r08
31
Spe
ech
Pat
holo
gy -
Sal
arie
s an
d W
ages
083
2S
peec
h P
atho
logy
- Fr
inge
Ben
efits
083
3S
peec
h P
atho
logy
- A
genc
y S
taff
Sche
dule
8A
-1Pa
ge 4
Prov
ider
NPI
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SHPD
Fac
ility
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ber:
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2374
2063
0111
5JA
NU
AR
Y 1
, 201
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UG
H D
EC
EM
BE
R 3
1, 2
010
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
J27
REC
LASS
IFIC
ATI
ON
S A
ND
/OR
AD
JUST
MEN
TS T
O R
EPO
RTE
D C
OST
S
STA
TE O
F C
ALI
FOR
NIA
Prov
ider
Nam
e:C
OU
NTR
Y V
ILLA
LA
GU
NA
HIL
LS H
EA
LTH
CA
RE
CE
NTE
R
Line
Sub
No.
No.
083
4S
peec
h P
atho
logy
- O
ther
- N
onla
bor
085
1P
harm
acy
- Sal
arie
s an
d W
ages
085
2P
harm
acy
- Frin
ge B
enef
its08
53
Pha
rmac
y - A
genc
y S
taff
085
4P
harm
acy
- Oth
er -
Non
labo
r09
01
Labo
rato
ry -
Sal
arie
s an
d W
ages
090
2La
bora
tory
- Fr
inge
Ben
efits
090
3La
bora
tory
- A
genc
y S
taff
090
4La
bora
tory
- O
ther
- N
onla
bor
095
1H
ome
Hea
lth S
ervi
ces
- Sal
arie
s an
d W
ages
095
2H
ome
Hea
lth S
ervi
ces
- Frin
ge B
enef
its09
53
Hom
e H
ealth
Ser
vice
s - A
genc
y S
taff
095
4H
ome
Hea
lth S
ervi
ces
- Oth
er -
Non
labo
r10
01
Oth
er A
ncill
ary
Ser
vice
s - S
alar
ies
and
Wag
es10
02
Oth
er A
ncill
ary
Ser
vice
s - F
ringe
Ben
efits
100
3O
ther
Anc
illar
y S
ervi
ces
- Age
ncy
Sta
ff10
04
Oth
er A
ncill
ary
Ser
vice
s - O
ther
- N
onla
bor
101
1S
ubac
ute
Car
e A
ncill
ary
Ser
vice
s - S
alar
ies
and
Wag
es10
12
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Frin
ge B
enef
its10
13
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Age
ncy
Sta
ff10
14
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Oth
er -
Non
labo
r10
21
Sub
acut
e P
edia
tric
Anc
illar
y S
ervi
ces
- Sal
arie
s an
d W
ages
102
2S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - F
ringe
Ben
efits
102
3S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - A
genc
y S
taff
102
4S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - O
ther
- N
onla
bor
105
1S
kille
d N
ursi
ng C
are
- Sal
arie
s an
d W
ages
105
2S
kille
d N
ursi
ng C
are
- Frin
ge B
enef
its10
53
Ski
lled
Nur
sing
Car
e - A
genc
y S
taff
105
4S
kille
d N
ursi
ng C
are
- Oth
er -
Non
labo
r11
01
Inte
rmed
iate
Car
e - S
alar
ies
and
Wag
es11
02
Inte
rmed
iate
Car
e - F
ringe
Ben
efits
110
3In
term
edia
te C
are
- Age
ncy
Sta
ff11
04
Inte
rmed
iate
Car
e - O
ther
- N
onla
bor
115
1M
enta
lly D
isor
dere
d C
are
- Sal
arie
s an
d W
ages
115
2M
enta
lly D
isor
dere
d C
are
- Frin
ge B
enef
its11
53
Men
tally
Dis
orde
red
Car
e - A
genc
y S
taff
115
4M
enta
lly D
isor
dere
d C
are
- Oth
er -
Non
labo
r12
01
Dev
elop
men
tally
Dis
able
d C
are
- Sal
arie
s an
d W
ages
120
2D
evel
opm
enta
lly D
isab
led
Car
e - F
ringe
Ben
efits
120
3D
evel
opm
enta
lly D
isab
led
Car
e - A
genc
y S
taff
120
4D
evel
opm
enta
lly D
isab
led
Car
e - O
ther
- N
onla
bor
125
1S
ubac
ute
Car
e - S
alar
ies
and
Wag
es12
52
Sub
acut
e C
are
- Frin
ge B
enef
its12
53
Sub
acut
e C
are
- Age
ncy
Sta
ff12
54
Sub
acut
e C
are
- Oth
er -
Non
labo
r12
61
Sub
acut
e C
are
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iatri
c - S
alar
ies
and
Wag
es12
62
Sub
acut
e C
are
- Ped
iatri
c - F
ringe
Ben
efits
126
3S
ubac
ute
Car
e - P
edia
tric
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ncy
Sta
ff12
64
Sub
acut
e C
are
- Ped
iatri
c - O
ther
- N
onla
bor
Sche
dule
8A
-1Pa
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Prov
ider
NPI
:O
SHPD
Fac
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Num
ber:
Fisc
al P
erio
d:17
2007
2374
2063
0111
5JA
NU
AR
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, 201
0 TH
RO
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R 3
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No.
128
1Tr
ansi
tiona
l Inp
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nt C
are
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128
2Tr
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are
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enef
its12
83
Tran
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Car
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128
4Tr
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Ben
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130
3H
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are
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Car
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135
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53
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54
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91
Res
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are
- Sal
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s an
d W
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139
2R
esid
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l Car
e - F
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Ben
efits
139
3R
esid
entia
l Car
e - A
genc
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taff
139
4R
esid
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ther
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onla
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140
1B
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d B
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alar
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02
Bea
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and
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Frin
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03
Bea
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and
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Age
ncy
Sta
ff14
04
Bea
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and
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Oth
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Non
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51
Oth
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onre
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Sal
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s an
d W
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145
2O
ther
Non
reim
burs
able
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Ben
efits
145
3O
ther
Non
reim
burs
able
- A
genc
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taff
145
4O
ther
Non
reim
burs
able
- O
ther
- N
onla
bor
155
1S
ocia
l Ser
vice
s - S
alar
ies
and
Wag
es15
52
Soc
ial S
ervi
ces
- Frin
ge B
enef
its15
53
Soc
ial S
ervi
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- Age
ncy
Sta
ff15
54
Soc
ial S
ervi
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- Oth
er -
Non
labo
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01
Act
iviti
es -
Sal
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s an
d W
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160
2A
ctiv
ities
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Ben
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160
3A
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ities
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genc
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taff
160
4A
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ther
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onla
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165
1A
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istra
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s an
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165
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enef
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53
Adm
inis
tratio
n - A
genc
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taff
165
4A
dmin
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- Oth
er -
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labo
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61
Med
ical
Rec
ords
- S
alar
ies
and
Wag
es16
62
Med
ical
Rec
ords
- Fr
inge
Ben
efits
166
3M
edic
al R
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ds -
Age
ncy
Sta
ff16
64
Med
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Rec
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- O
ther
- N
onla
bor
167
4C
DP
H L
icen
sing
Fee
s16
84
Pro
fess
iona
l Lia
bilit
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sura
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169
4Q
ualit
y A
ssur
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Fee
s17
01
Inse
rvic
e E
duca
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sing
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alar
ies
and
Wag
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02
Inse
rvic
e E
duca
tion
- Nur
sing
- Fr
inge
Ben
efits
170
3In
serv
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Edu
catio
n - N
ursi
ng -
Age
ncy
Sta
ff17
04
Inse
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duca
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sing
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onla
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174
1C
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42
Car
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- Frin
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its
Sche
dule
8A
-1Pa
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Prov
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NPI
:O
SHPD
Fac
ility
Num
ber:
Fisc
al P
erio
d:17
2007
2374
2063
0111
5JA
NU
AR
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1, 2
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174
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174
4C
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200
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Num
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Fisc
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d:17
2007
2374
2063
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5JA
NU
AR
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