37.00 38.00 39.00 40.00 41.00 41.01 41.02 41.03 42.00 43.00 44.00 44.01 46.00 47.00 49.00 50.00 51.00 52.00 53.00 53.01 53.02 54.00 55.00 56.00 57.00 59.00 59.01 59.02 60.00 60.01 61.00 62.00 71.00 82.00 83.00 84.00 85.00 86.00 96.00 97.00 98.00 99.00 99.01 99.02 99.03 99.04 99.05 100.00 100.01 100.02 100.03 100.07 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH Unoccupied Space Cent Transport Public Relations Mob I NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic CAT Scan Ultra Sound Magnetic Resonance Imaging (MRI) Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Cardiology Cardiac Rehab Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis Lithotripsy Pain Management Rehab Nuero Clinic Other Clinic Services Emergency Observation Beds Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 0 0.000000 0 0.000000 29,445 887 2,507 520 244 360 1,694 10,532 6,494 4,338 11,381 5,769 1,371 887 2,507 520 244 360 1,694 10,532 6,494 4,338 11,381 315,284 8,936,596 28.344591 11,446 315,284 4,845,922 15.370022 11,446 283 5,769 1,371 5,490 229 10,230 1,288 2,116 756 1,216 283 5,490 229 10,230 1,288 2,116 756 1,216 29,445 OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE & FIXTURES EQUIP & FIXTURES EQUIP (SQ FT) (SQ FT) (SQ FT) (SQ FT) 1.00 2.00 3.00 4.00 STAT 0 0.000000 4.01 0 0.000000 4.02 STAT STATISTICS FOR COST ALLOCATION (W/S B-1) 0 0.000000 4.03 STAT 0 0.000000 4.04 STAT 0 0.000000 4.05 STAT 0 0.000000 4.06 STAT 0 0.000000 4.07 STAT 0 0.000000 4.08 STAT Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00 28.00 29.00 30.00 31.00 32.00 33.00 34.00 35.00 36.00 36.01 36.02 Nursery Medicare Certified Nursing Facility Distinct Part Nursing Facility Adult Subacute Care Unit Subacute Care Unit II Transitional Care Unit Surgical Intensive Care Neonatal Intensive Care Unit Subprovider II Nursing School Intern & Res Service-Salary & Fringes Intern & Res Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS Adults & Pediatrics (Gen Routine) Intensive Care Unit Coronary Care Unit Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services & Supply Pharmacy Medical Records and Library Social Service Employee Benefits Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office GENERAL SERVICE COST CENTERS Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipment New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipment Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 429,008 2,147,077 28,191,916 9,396,442 1,140,249 470,716 3,860,870 2,114,247 111,387 97,350 44,133 5,126,375 1,625,031 EMP BENE (GROSS SALARIES) 5.00 STAT 6.02 STAT 6.01 6.03 STAT 6.04 STAT 6.05 STAT STATISTICS FOR COST ALLOCATION (W/S B-1) 6.06 STAT 6.07 STAT 6.08 STAT 42,790,753 13,586,416 0 3,084,437 0 832,689 0 0 7,225,862 4,885,054 1,255,759 4,160,641 1,596,092 51,889 1,557,979 386,719 4,985,422 4,471,318 68,815 0 0 0 0 ADM & GEN (ACCUM COST) 2,151 706 93,316 11,990 8,080 1,529 856 43,835 2,158 1,425 5,966 1,187 MAINT & REPAIRS (SQ FT) 7.00 Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE 9.1 37.00 38.00 39.00 40.00 41.00 41.01 41.02 41.03 42.00 43.00 44.00 44.01 46.00 47.00 49.00 50.00 51.00 52.00 53.00 53.01 53.02 54.00 55.00 56.00 57.00 59.00 59.01 59.02 60.00 60.01 61.00 62.00 71.00 82.00 83.00 84.00 85.00 86.00 96.00 97.00 98.00 99.00 99.01 99.02 99.03 99.04 99.05 100.00 100.01 100.02 100.03 100.07 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH Unoccupied Space Cent Transport Public Relations Mob I NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic CAT Scan Ultra Sound Magnetic Resonance Imaging (MRI) Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Cardiology Cardiac Rehab Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis Lithotripsy Pain Management Rehab Nuero Clinic Other Clinic Services Emergency Observation Beds Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 77,132,292 976,185 0.012656 33,362 47,587 47,301 3,959,314 1,337,025 502,099 198,145 785,494 755,247 102,367 123,370 4,107,269 167,368 2,002,652 46,969 2,312,311 653,818 635,254 334,367 358,985 3,867,187 EMP BENE (GROSS SALARIES) 5.00 STAT 0 0.000000 6.01 0 0.000000 6.02 STAT 0 0.000000 6.03 STAT 0 0.000000 6.04 STAT 0 0.000000 6.05 STAT STATISTICS FOR COST ALLOCATION (W/S B-1) 0 0.000000 6.06 STAT 0 0.000000 6.07 STAT 0 0.000000 6.08 STAT 169,138,089 29,099,733 0.172047 0 0 0 0 54,601 1,298,826 1,040,893 500,357 13,482,643 3,536,622 234,930 4,737,187 1,014,411 1,025,657 792,284 896,717 8,089,270 522,426 2,251,518 6,039,937 1,528,339 532,606 246,606 1,504,101 7,093,014 126,585 212,066 606,125 7,668,867 1,817,433 14,000 54,224 51,611 0 11,224,388 0 0 0 ADM & GEN (ACCUM COST) 281,795 8,469,051 30.053944 11,446 283 11,381 6,494 4,338 887 2,507 520 244 360 1,694 10,532 5,769 1,371 5,490 229 10,230 1,288 2,116 756 1,216 29,445 MAINT & REPAIRS (SQ FT) 7.00 Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE 9.1 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00 28.00 29.00 30.00 31.00 32.00 33.00 34.00 35.00 36.00 36.01 36.02 Nursery Medicare Certified Nursing Facility Distinct Part Nursing Facility Adult Subacute Care Unit Subacute Care Unit II Transitional Care Unit Surgical Intensive Care Neonatal Intensive Care Unit Subprovider II Nursing School Intern & Res Service-Salary & Fringes Intern & Res Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS Adults & Pediatrics (Gen Routine) Intensive Care Unit Coronary Care Unit Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services & Supply Pharmacy Medical Records and Library Social Service Employee Benefits Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office GENERAL SERVICE COST CENTERS Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipment New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipment Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 2,151 706 93,316 11,990 8,080 1,529 22,968 1,031,738 168,816 2,151 706 93,316 11,990 8,080 1,529 856 856 16,603 HOUSEKEEPING (SQ FT) 10.00 5,966 1,187 LAUNDRY & LINEN (LB LNDRY) 9.00 2,158 1,425 5,966 1,187 OPER PLANT (SQ FT) 8.00 139,848 9,113 DIETARY (MEALS SERVED) 11.00 49 12 11 26 405 106 (FTE's) 12.00 CAFETERIA MAINT OF PERSONNEL (# HOUSED) 13.00 STATISTICS FOR COST ALLOCATION (W/S B-1) 10,209 41,122 589,743 153,098 423 1,077 NURSING ADMIN (NURSE HR) 14.00 1,509 110,246 852,220 345,099 39,856 432 CENT SERV & SUPPLY (CST REQ) 15.00 10,837 162,605 47,784 PHARMACY (COSTS REQUIS) 16.00 7,904,800 21,643,100 301,430,200 67,981,100 MED REC (TIME SPENT) 17.00 4,391 2,789 62,121 9,258 SOC SERV (TIME SPENT) 18.00 19.00 STAT Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE 9.2 37.00 38.00 39.00 40.00 41.00 41.01 41.02 41.03 42.00 43.00 44.00 44.01 46.00 47.00 49.00 50.00 51.00 52.00 53.00 53.01 53.02 54.00 55.00 56.00 57.00 59.00 59.01 59.02 60.00 60.01 61.00 62.00 71.00 82.00 83.00 84.00 85.00 86.00 96.00 97.00 98.00 99.00 99.01 99.02 99.03 99.04 99.05 100.00 100.01 100.02 100.03 100.07 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH Unoccupied Space Cent Transport Public Relations Mob I NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic CAT Scan Ultra Sound Magnetic Resonance Imaging (MRI) Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Cardiology Cardiac Rehab Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis Lithotripsy Pain Management Rehab Nuero Clinic Other Clinic Services Emergency Observation Beds Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 102,366 LAUNDRY & LINEN (LB LNDRY) 9.00 5,490 229 10,230 1,288 2,116 756 1,216 887 2,507 520 244 360 1,694 10,532 887 2,507 520 244 360 1,694 10,532 237,960 7,042,929 29.597111 234,377 4,961,471 21.168761 11,446 11,446 1,808,250 1,600,536 0.885130 283 283 11,381 11,381 306,915 6,494 4,338 6,494 4,338 25,874 5,769 1,371 5,490 229 10,230 1,288 2,116 756 1,216 29,445 HOUSEKEEPING (SQ FT) 10.00 5,769 1,371 10 1,169 1,575 77,579 52,637 29,445 OPER PLANT (SQ FT) 8.00 153,556 2,352,866 15.322528 3,136 1,459 DIETARY (MEALS SERVED) 11.00 98 46 59 12 10 1 69 34 31 10 4 50 1,074 156,750 145.949503 (FTE's) 12.00 CAFETERIA 0 0.000000 MAINT OF PERSONNEL (# HOUSED) 13.00 STATISTICS FOR COST ALLOCATION (W/S B-1) 1,030,017 1,896,958 1.841676 109,435 5,272 4,584 82 41 2,162 176 73 21,833 37,196 942 6,494 177 41 45,837 NURSING ADMIN (NURSE HR) 14.00 17,487,255 471,538 0.026965 2,037 424,207 833 583 8,886 203,066 2,198,858 423,034 797 1,388 30 274,194 3,256,096 2,204,880 188,877 230,198 110,340 1,044,056 14,728 38,791 4,583 129,007 5,378,424 CENT SERV & SUPPLY (CST REQ) 15.00 8,039,931 5,844,225 0.726900 69,329 198 29 889 7,483,334 8,772 7,477 16,317 6,228 667 181,708 14,012 6,347 913 586 517 21,382 PHARMACY (COSTS REQUIS) 16.00 1,547,839,937 5,901,562 0.003813 86,098,626 2,563,444 53,903,767 4,641,624 1,594,903 406,182 40,462,624 19,886,733 9,388,483 1,579,673 234,412,470 241,708,950 17,837,132 190,845 541,722 610 162,889,960 1,211,146 8,964,037 22,301,238 32,512,124 57,470,248 16,361,285 13,178,801 11,432,966 107,341,144 MED REC (TIME SPENT) 17.00 78,559 204,228 2.599670 SOC SERV (TIME SPENT) 18.00 0 0.000000 19.00 STAT Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE 9.2 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00 28.00 29.00 30.00 31.00 32.00 33.00 34.00 35.00 36.00 Nursery Medicare Certified Nursing Facility Distinct Part Nursing Facility Adult Subacute Care Unit Surgical Intensive Care Neonatal Intensive Care Unit Subprovider II Nursing School Intern & Res Service-Salary & Fringes Intern & Res Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS Adults & Pediatrics (Gen Routine) Intensive Care Unit Coronary Care Unit Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services & Supply Pharmacy Medical Records and Library Social Service Employee Benefits Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office GENERAL SERVICE COST CENTERS Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipment New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipment Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com STAT 19.03 (Adj ) (Adj ) STAT 19.02 (Adj ) (Adj ) NONPHY ANESTH (ASG TIME) 20.00 (Adj ) (Adj ) NURSE SCHOOL (ASG TIME) 21.00 (Adj ) (Adj ) I&R-SAL & FRINGES (ASG TIME) 22.00 (Adj ) (Adj ) I&R-PRG COST (ASG TIME) 23.00 (Adj ) (Adj ) STATISTICS FOR COST ALLOCATION (W/S B-1) PARAMED EDUCAT (ASG TIME) 24.00 (Adj ) (Adj ) Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE 9.3 37.00 38.00 39.00 40.00 41.00 41.01 41.02 41.03 42.00 43.00 44.00 44.01 46.00 47.00 49.00 50.00 51.00 52.00 53.00 53.01 53.02 54.00 55.00 56.00 57.00 59.00 59.01 59.02 60.00 60.01 61.00 62.00 71.00 82.00 83.00 84.00 85.00 86.00 36.01 36.02 96.00 97.00 98.00 99.00 99.01 99.02 99.03 99.04 99.05 100.00 100.01 100.02 100.03 100.07 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH Unoccupied Space Cent Transport Public Relations Mob I NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers Subacute Care Unit II Transitional Care Unit ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic CAT Scan Ultra Sound Magnetic Resonance Imaging (MRI) Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Cardiology Cardiac Rehab Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis Lithotripsy Pain Management Rehab Nuero Clinic Other Clinic Services Emergency Observation Beds Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com STAT 0 0.000000 19.02 0 0.000000 19.03 STAT 0 0.000000 NONPHY ANESTH (ASG TIME) 20.00 0 0.000000 NURSE SCHOOL (ASG TIME) 21.00 0 0.000000 I&R-SAL & FRINGES (ASG TIME) 22.00 0 0.000000 I&R-PRG COST (ASG TIME) 23.00 0 0.000000 PARAMED EDUCAT (ASG TIME) 24.00 STATISTICS FOR COST ALLOCATION (W/S B-1) Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE 9.3 STATE OF CALIFORNIA SCHEDULE 10 TRIAL BALANCE OF EXPENSES Provider Name: CENTINELA HOSPITAL MEDICAL CENTER Fiscal Period Ended: DECEMBER 31, 2008 REPORTED 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 GENERAL SERVICE COST CENTERS Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipment New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipment Employee Benefits Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services & Supply Pharmacy Medical Records and Library Social Service Nursing School Intern & Res Service-Salary & Fringes Intern & Res Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 29.00 Surgical Intensive Care 30.00 Neonatal Intensive Care Unit 31.00 Subprovider II 32.00 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 Adult Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit $ ADJUSTMENTS (From Sch 10A) $ 8,936,596 4,845,922 874,680 28,104,432 6,773,264 2,968,824 1,160,013 4,097,116 1,334,732 1,506,128 380,762 4,936,559 4,091,346 1,975 38,354,684 12,943,357 3,026,401 733,229 This is trial version www.adultpdf.com 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 AUDITED $ 0 8,936,596 4,845,922 0 0 0 0 874,680 0 0 0 0 28,104,432 6,773,264 2,968,824 1,160,013 4,097,116 1,334,732 0 1,506,128 380,762 4,936,559 4,091,346 1,975 0 0 0 0 38,354,684 12,943,357 0 3,026,401 0 733,229 0 0 STATE OF CALIFORNIA SCHEDULE 10 TRIAL BALANCE OF EXPENSES Provider Name: CENTINELA HOSPITAL MEDICAL CENTER Fiscal Period Ended: DECEMBER 31, 2008 REPORTED 37.00 38.00 39.00 40.00 41.00 41.01 41.02 41.03 42.00 43.00 44.00 44.01 46.00 47.00 49.00 50.00 51.00 52.00 53.00 53.01 53.02 54.00 55.00 56.00 57.00 59.00 59.01 59.02 60.00 60.01 61.00 62.00 71.00 82.00 83.00 84.00 85.00 86.00 96.00 97.00 98.00 99.00 99.01 99.02 99.03 99.04 99.05 100.00 100.01 100.02 100.03 100.07 100.99 101 GENERAL SERVICE COST CENTERS ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic CAT Scan Ultra Sound Magnetic Resonance Imaging (MRI) Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Cardiology Cardiac Rehab Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis Lithotripsy Pain Management Rehab Nuero Clinic Other Clinic Services Emergency Observation Beds SUBTOTAL NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers $ ADJUSTMENTS (From Sch 10A) 12,146,523 $ 3,271,283 224,325 4,260,722 949,832 925,117 755,004 839,017 7,785,099 460,375 2,212,743 5,880,235 1,488,686 515,585 228,361 1,420,107 6,623,053 125,289 210,505 322,242 7,479,233 1,817,433 14,000 53,622 51,012 (1,539,659) $ Cent Transport Public Relations Mob I 183,589,764 $ 54,179 1,286,455 1,040,893 Unoccupied Space SUBTOTAL TOTAL $ $ 2,381,527 $ 185,971,291 $ $ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12,266,531 0 0 0 12,266,531 $ AUDITED 12,146,523 3,271,283 224,325 4,260,722 949,832 925,117 755,004 839,017 7,785,099 460,375 2,212,743 5,880,235 1,488,686 515,585 228,361 1,420,107 6,623,053 125,289 210,505 322,242 7,479,233 1,817,433 14,000 53,622 51,012 0 10,726,872 0 0 0 195,856,295 0 0 0 0 0 0 0 0 0 54,179 1,286,455 1,040,893 0 0 $ 2,381,527 12,266,531 $ 198,237,822 (To Schedule 8) This is trial version www.adultpdf.com 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 Nursing School Intern & Res Service-Salary & Fringes Intern & Res Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 29.00 Surgical Intensive Care 30.00 Neonatal Intensive Care Unit 31.00 Subprovider II 32.00 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 Adult Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services & Supply Pharmacy Medical Records and Library Social Service Employee Benefits Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office GENERAL SERVICE COST CENTER Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipment New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipment Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com SCHEDULE 10A Page Fiscal Period Ended: DECEMBER 31, 2008 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 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page & 2) ADJUSTMENTS TO REPORTED COSTS Unoccupied Space Cent Transport Public Relations Mob I NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic CAT Scan Ultra Sound Magnetic Resonance Imaging (MRI) Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Cardiology Cardiac Rehab Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis Lithotripsy Pain Management Rehab Nuero Clinic Other Clinic Services Emergency Observation Beds 101.00 TOTAL 96.00 97.00 98.00 99.00 99.01 99.02 99.03 99.04 99.05 100.00 100.01 100.02 100.03 100.07 37.00 38.00 39.00 40.00 41.00 41.01 41.02 41.03 42.00 43.00 44.00 44.01 46.00 47.00 49.00 50.00 51.00 52.00 53.00 53.01 53.02 54.00 55.00 56.00 57.00 59.00 59.01 59.02 60.00 60.01 61.00 62.00 71.00 82.00 83.00 84.00 85.00 86.00 Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com (To Sch 10) $12,266,531 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12,266,531 0 0 0 TOTAL ADJ (Page & 2) 12,266,531 12,266,531 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ ADJUSTMENTS TO REPORTED COSTS AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ SCHEDULE 10A Page Fiscal Period Ended: DECEMBER 31, 2008 ... SERVICE COST CENTERS Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipment New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipment Provider Name: CENTINELA HOSPITAL MEDICAL. .. SERVICE COST CENTERS Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipment New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipment Provider Name: CENTINELA HOSPITAL MEDICAL. .. CENTERS Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipment New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipment Provider Name: CENTINELA HOSPITAL MEDICAL CENTER