STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS _part1 ppt

STATE OF CALIFORNIA Schedule 8A-2 Page 1 Provider Name: Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period: HOLLENBECK PALMS ZZT05115F 1831186345 206190378 JULY 1, 2007 THROUGH JUNE 30, 2008 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Pages 1, 2, & 3) 12 13 14 15 16 17 18 19 20 ADJUSTMENTS TO REPORTED COSTS 82.02 Occupational Therapy - Fringe Benefits 0 82.03 Occupational Therapy - Agency Staff 0 82.04 Occupational Therapy - Other - Nonlabor 0 83.00 Speech Pathology 0 83.01 Speech Pathology - Salaries and Wages 0 83.02 Speech Pathology - Fringe Benefits 0 83.03 Speech Pathology - Agency Staff 0 83.04 Speech Pathology - Other - Nonlabor 0 85.00 Pharmacy 0 85.01 Pharmacy - Salaries and Wages 0 85.02 Pharmacy - Fringe Benefits 0 85.03 Pharmacy - Agency Staff 0 85.04 Pharmacy - Other - Nonlabor 0 90.00 Laboratory 553 90.01 Laboratory - Salaries and Wages 0 90.02 Laboratory - Fringe Benefits 0 90.03 Laboratory - Agency Staff 0 90.04 Laboratory - Other - Nonlabor 0 95.00 Home Health Services 0 95.01 Home Health Services - Salaries and Wages 0 95.02 Home Health Services - Fringe Benefits 0 95.03 Home Health Services - Agency Staff 0 95.04 Home Health Services - Other - Nonlabor 0 100.00 Other Ancillary Services 0 100.01 Other Ancillary Services - Salaries and Wages 0 100.02 Other Ancillary Services - Fringe Benefits 0 100.03 Other Ancillary Services - Agency Staff 0 100.04 Other Ancillary Services - Other - Nonlabor 0 100.06 Subacute Ancillary Services 0 100.07 Subacute Ancillary Services - Salaries and Wages 0 100.08 Subacute Ancillary Services - Fringe Benefits 0 100.09 Subacute Ancillary Services - Agency Staff 0 100.10 Subacute Ancillary Services - Other - Nonlabor 0 100.12 Subacute Pediatrics Ancillary Services 0 105.00 Skilled Nursing Care 0 105.01 Skilled Nursing Care - Salaries and Wages (18,948) 105.02 Skilled Nursing Care - Fringe Benefits 0 105.03 Skilled Nursing Care - Agency Staff 49,552 49,552 105.04 Skilled Nursing Care - Other - Nonlabor (108,231) (8,989) (3,195) (49,552) 110.00 Intermediate Care 0 115.00 Mentally Disordered 0 120.00 Developmentally Disabled 0 125.00 Subacute Care 0 125.01 Subacute Care - Salaries and Wages 0 125.02 Subacute Care - Fringe Benefits 0 125.03 Subacute Care - Agency Staff 0 125.04 Subacute Care - Other - Nonlabor 0 126.00 Subacute Care - Pediatrics 0 This is trial version www.adultpdf.com STATE OF CALIFORNIA Schedule 8A-2 Page 1 Provider Name: Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period: HOLLENBECK PALMS ZZT05115F 1831186345 206190378 JULY 1, 2007 THROUGH JUNE 30, 2008 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Pages 1, 2, & 3) 12 13 14 15 16 17 18 19 20 ADJUSTMENTS TO REPORTED COSTS 130.00 Hospice Inpatient Care 0 135.00 Other Routine Services 0 136.00 Residential Care 0 140.00 Beauty and Barber 160,272 145.00 Other Nonreimbursable 0 155.00 Social Services 0 155.01 Social Services - Salaries and Wages 0 155.02 Social Services - Fringe Benefits 0 155.03 Social Services - Agency Staff 0 155.04 Social Services - Other - Nonlabor 0 160.00 Activities 0 160.01 Activities - Salaries and Wages 0 160.02 Activities - Fringe Benefits 0 160.03 Activities - Agency Staff 0 160.04 Activities - Other - Nonlabor (143) (143) 165.00 Administration 0 165.01 Administration - Salaries and Wages (149,669) (85,183) 165.02 Administration - Fringe Benefits (48,090) (28,935) 165.03 Administration - Medical Records - Salaries and Wages 85,183 85,183 165.04 Administration - Medical Records - Fringe Benefits 28,935 28,935 165.05 Administration - Medical Records - Agency Staff 0 165.06 Administration - Medical Records - Other - Nonlabor 1,929 1,929 165.07 Administration - Facility License Fees 21,936 49,495 (27,559) 165.08 Administration - Liability Insurance 68,446 68,446 165.09 Administration - Caregiver Training 0 165.10 Administration - Quality Assurance Fees 0 165.11 Administration - Other - Nonlabor 413,887 533,869 (6,553) 8,989 3,415 (49,495) (68,446) (1,929) 27,559 170.00 Inservice Education - Nursing 0 170.01 Inservice Education - Nursing - Salaries and Wages 0 170.02 Inservice Education - Nursing - Fringe Benefits 0 170.03 Inservice Education - Nursing - Agency Staff 0 170.04 Inservice Education - Nursing - Other - Nonlabor (77) (77) 175.00 Total ($941,034) 000000000 (To Sch 8) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: HOLLENBECK PALMS 5.00 Plant Operations and Maintenance 5.01 Plant Operations and Maintenance - Salaries and Wages 5.02 Plant Operations and Maintenance - Fringe Benefits 5.03 Plant Operations and Maintenance - Agency Staff 5.04 Plant Operations and Maintenance - Other - Nonlabor 10.00 Housekeeping 10.01 Housekeeping - Salaries and Wages 10.02 Housekeeping - Fringe Benefits 10.03 Housekeeping - Agency Staff 10.04 Housekeeping - Other - Nonlabor 15.00 Depreciation: Bldgs and Improvements 20.00 Depreciation: Leasehold Improvements 25.00 Depreciation: Equipment 30.00 Depreciation and Amortization - Other 35.00 Leases and Rentals 40.00 Property Taxes 45.00 Property Insurance 50.00 Interest-Property, Plant, and Equipment 55.00 Interest-Other 60.00 Laundry and Linen 60.01 Laundry and Linen - Salaries and Wages 60.02 Laundry and Linen - Fringe Benefits 60.03 Laundry and Linen - Agency Staff 60.04 Laundry and Linen - Other - Nonlabor 65.00 Dietary 65.01 Dietary - Salaries and Wages 65.02 Dietary - Fringe Benefits 65.03 Dietary - Agency Staff 65.04 Dietary - Other - Nonlabor 70.00 Provision for Bad Debts 75.00 Patient Supplies 75.01 Patient Supplies - Salaries and Wages 75.02 Patient Supplies - Fringe Benefits 75.03 Patient Supplies - Agency Staff 75.04 Patient Supplies - Other - Nonlabor 77.00 Specialized Support Surfaces 80.00 Physical Therapy 80.01 Physical Therapy - Salaries and Wages 80.02 Physical Therapy - Fringe Benefits 80.03 Physical Therapy - Agency Staff 80.04 Physical Therapy - Other - Nonlabor 81.00 Respiratory Therapy 81.01 Respiratory Therapy - Salaries and Wages 81.02 Respiratory Therapy - Fringe Benefits 81.03 Respiratory Therapy - Agency Staff 81.04 Respiratory Therapy - Other - Nonlabor 82.00 Occupational Therapy 82.01 Occupational Therapy - Salaries and Wages Schedule 8A-2 Page 2 Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period: ZZT05115F 1831186345 206190378 JULY 1, 2007 THROUGH JUNE 30, 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 21 22 23 24 25 26,27 28 29 30 31-33 (5,121) 72,286 (72,286) 416 (772,791) (65,365) (22,203) (12,668) (8,420) (3,510) 93,569 (93,569) (11,945) (16,188) ADJUSTMENTS TO REPORTED COSTS This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: HOLLENBECK PALMS 82.02 Occupational Therapy - Fringe Benefits 82.03 Occupational Therapy - Agency Staff 82.04 Occupational Therapy - Other - Nonlabor 83.00 Speech Pathology 83.01 Speech Pathology - Salaries and Wages 83.02 Speech Pathology - Fringe Benefits 83.03 Speech Pathology - Agency Staff 83.04 Speech Pathology - Other - Nonlabor 85.00 Pharmacy 85.01 Pharmacy - Salaries and Wages 85.02 Pharmacy - Fringe Benefits 85.03 Pharmacy - Agency Staff 85.04 Pharmacy - Other - Nonlabor 90.00 Laboratory 90.01 Laboratory - Salaries and Wages 90.02 Laboratory - Fringe Benefits 90.03 Laboratory - Agency Staff 90.04 Laboratory - Other - Nonlabor 95.00 Home Health Services 95.01 Home Health Services - Salaries and Wages 95.02 Home Health Services - Fringe Benefits 95.03 Home Health Services - Agency Staff 95.04 Home Health Services - Other - Nonlabor 100.00 Other Ancillary Services 100.01 Other Ancillary Services - Salaries and Wages 100.02 Other Ancillary Services - Fringe Benefits 100.03 Other Ancillary Services - Agency Staff 100.04 Other Ancillary Services - Other - Nonlabor 100.06 Subacute Ancillary Services 100.07 Subacute Ancillary Services - Salaries and Wages 100.08 Subacute Ancillary Services - Fringe Benefits 100.09 Subacute Ancillary Services - Agency Staff 100.10 Subacute Ancillary Services - Other - Nonlabor 100.12 Subacute Pediatrics Ancillary Services 105.00 Skilled Nursing Care 105.01 Skilled Nursing Care - Salaries and Wages 105.02 Skilled Nursing Care - Fringe Benefits 105.03 Skilled Nursing Care - Agency Staff 105.04 Skilled Nursing Care - Other - Nonlabor 110.00 Intermediate Care 115.00 Mentally Disordered 120.00 Developmentally Disabled 125.00 Subacute Care 125.01 Subacute Care - Salaries and Wages 125.02 Subacute Care - Fringe Benefits 125.03 Subacute Care - Agency Staff 125.04 Subacute Care - Other - Nonlabor 126.00 Subacute Care - Pediatrics Schedule 8A-2 Page 2 Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period: ZZT05115F 1831186345 206190378 JULY 1, 2007 THROUGH JUNE 30, 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 21 22 23 24 25 26,27 28 29 30 31-33 ADJUSTMENTS TO REPORTED COSTS 553 (416) (553) (15,000) (5,520) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: HOLLENBECK PALMS 130.00 Hospice Inpatient Care 135.00 Other Routine Services 136.00 Residential Care 140.00 Beauty and Barber 145.00 Other Nonreimbursable 155.00 Social Services 155.01 Social Services - Salaries and Wages 155.02 Social Services - Fringe Benefits 155.03 Social Services - Agency Staff 155.04 Social Services - Other - Nonlabor 160.00 Activities 160.01 Activities - Salaries and Wages 160.02 Activities - Fringe Benefits 160.03 Activities - Agency Staff 160.04 Activities - Other - Nonlabor 165.00 Administration 165.01 Administration - Salaries and Wages 165.02 Administration - Fringe Benefits 165.03 Administration - Medical Records - Salaries and Wages 165.04 Administration - Medical Records - Fringe Benefits 165.05 Administration - Medical Records - Agency Staff 165.06 Administration - Medical Records - Other - Nonlabor 165.07 Administration - Facility License Fees 165.08 Administration - Liability Insurance 165.09 Administration - Caregiver Training 165.10 Administration - Quality Assurance Fees 165.11 Administration - Other - Nonlabor 170.00 Inservice Education - Nursing 170.01 Inservice Education - Nursing - Salaries and Wages 170.02 Inservice Education - Nursing - Fringe Benefits 170.03 Inservice Education - Nursing - Agency Staff 170.04 Inservice Education - Nursing - Other - Nonlabor 175.00 Total Schedule 8A-2 Page 2 Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period: ZZT05115F 1831186345 206190378 JULY 1, 2007 THROUGH JUNE 30, 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 21 22 23 24 25 26,27 28 29 30 31-33 ADJUSTMENTS TO REPORTED COSTS (38,583) (13,106) 15,000 (37,161) 00000(772,791) (124,111) (88,850) (10,641) (16,188) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: HOLLENBECK PALMS 5.00 Plant Operations and Maintenance 5.01 Plant Operations and Maintenance - Salaries and Wages 5.02 Plant Operations and Maintenance - Fringe Benefits 5.03 Plant Operations and Maintenance - Agency Staff 5.04 Plant Operations and Maintenance - Other - Nonlabor 10.00 Housekeeping 10.01 Housekeeping - Salaries and Wages 10.02 Housekeeping - Fringe Benefits 10.03 Housekeeping - Agency Staff 10.04 Housekeeping - Other - Nonlabor 15.00 Depreciation: Bldgs and Improvements 20.00 Depreciation: Leasehold Improvements 25.00 Depreciation: Equipment 30.00 Depreciation and Amortization - Other 35.00 Leases and Rentals 40.00 Property Taxes 45.00 Property Insurance 50.00 Interest-Property, Plant, and Equipment 55.00 Interest-Other 60.00 Laundry and Linen 60.01 Laundry and Linen - Salaries and Wages 60.02 Laundry and Linen - Fringe Benefits 60.03 Laundry and Linen - Agency Staff 60.04 Laundry and Linen - Other - Nonlabor 65.00 Dietary 65.01 Dietary - Salaries and Wages 65.02 Dietary - Fringe Benefits 65.03 Dietary - Agency Staff 65.04 Dietary - Other - Nonlabor 70.00 Provision for Bad Debts 75.00 Patient Supplies 75.01 Patient Supplies - Salaries and Wages 75.02 Patient Supplies - Fringe Benefits 75.03 Patient Supplies - Agency Staff 75.04 Patient Supplies - Other - Nonlabor 77.00 Specialized Support Surfaces 80.00 Physical Therapy 80.01 Physical Therapy - Salaries and Wages 80.02 Physical Therapy - Fringe Benefits 80.03 Physical Therapy - Agency Staff 80.04 Physical Therapy - Other - Nonlabor 81.00 Respiratory Therapy 81.01 Respiratory Therapy - Salaries and Wages 81.02 Respiratory Therapy - Fringe Benefits 81.03 Respiratory Therapy - Agency Staff 81.04 Respiratory Therapy - Other - Nonlabor 82.00 Occupational Therapy 82.01 Occupational Therapy - Salaries and Wages Schedule 8A-2 Page 3 Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period: ZZT05115F 1831186345 206190378 JULY 1, 2007 THROUGH JUNE 30, 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 34-36 37 38-40 41 42 43 44-47 (57) (1,401) ADJUSTMENTS TO REPORTED COSTS This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: HOLLENBECK PALMS 82.02 Occupational Therapy - Fringe Benefits 82.03 Occupational Therapy - Agency Staff 82.04 Occupational Therapy - Other - Nonlabor 83.00 Speech Pathology 83.01 Speech Pathology - Salaries and Wages 83.02 Speech Pathology - Fringe Benefits 83.03 Speech Pathology - Agency Staff 83.04 Speech Pathology - Other - Nonlabor 85.00 Pharmacy 85.01 Pharmacy - Salaries and Wages 85.02 Pharmacy - Fringe Benefits 85.03 Pharmacy - Agency Staff 85.04 Pharmacy - Other - Nonlabor 90.00 Laboratory 90.01 Laboratory - Salaries and Wages 90.02 Laboratory - Fringe Benefits 90.03 Laboratory - Agency Staff 90.04 Laboratory - Other - Nonlabor 95.00 Home Health Services 95.01 Home Health Services - Salaries and Wages 95.02 Home Health Services - Fringe Benefits 95.03 Home Health Services - Agency Staff 95.04 Home Health Services - Other - Nonlabor 100.00 Other Ancillary Services 100.01 Other Ancillary Services - Salaries and Wages 100.02 Other Ancillary Services - Fringe Benefits 100.03 Other Ancillary Services - Agency Staff 100.04 Other Ancillary Services - Other - Nonlabor 100.06 Subacute Ancillary Services 100.07 Subacute Ancillary Services - Salaries and Wages 100.08 Subacute Ancillary Services - Fringe Benefits 100.09 Subacute Ancillary Services - Agency Staff 100.10 Subacute Ancillary Services - Other - Nonlabor 100.12 Subacute Pediatrics Ancillary Services 105.00 Skilled Nursing Care 105.01 Skilled Nursing Care - Salaries and Wages 105.02 Skilled Nursing Care - Fringe Benefits 105.03 Skilled Nursing Care - Agency Staff 105.04 Skilled Nursing Care - Other - Nonlabor 110.00 Intermediate Care 115.00 Mentally Disordered 120.00 Developmentally Disabled 125.00 Subacute Care 125.01 Subacute Care - Salaries and Wages 125.02 Subacute Care - Fringe Benefits 125.03 Subacute Care - Agency Staff 125.04 Subacute Care - Other - Nonlabor 126.00 Subacute Care - Pediatrics Schedule 8A-2 Page 3 Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period: ZZT05115F 1831186345 206190378 JULY 1, 2007 THROUGH JUNE 30, 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 34-36 37 38-40 41 42 43 44-47 ADJUSTMENTS TO REPORTED COSTS (18,948) (25,006) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: HOLLENBECK PALMS 130.00 Hospice Inpatient Care 135.00 Other Routine Services 136.00 Residential Care 140.00 Beauty and Barber 145.00 Other Nonreimbursable 155.00 Social Services 155.01 Social Services - Salaries and Wages 155.02 Social Services - Fringe Benefits 155.03 Social Services - Agency Staff 155.04 Social Services - Other - Nonlabor 160.00 Activities 160.01 Activities - Salaries and Wages 160.02 Activities - Fringe Benefits 160.03 Activities - Agency Staff 160.04 Activities - Other - Nonlabor 165.00 Administration 165.01 Administration - Salaries and Wages 165.02 Administration - Fringe Benefits 165.03 Administration - Medical Records - Salaries and Wages 165.04 Administration - Medical Records - Fringe Benefits 165.05 Administration - Medical Records - Agency Staff 165.06 Administration - Medical Records - Other - Nonlabor 165.07 Administration - Facility License Fees 165.08 Administration - Liability Insurance 165.09 Administration - Caregiver Training 165.10 Administration - Quality Assurance Fees 165.11 Administration - Other - Nonlabor 170.00 Inservice Education - Nursing 170.01 Inservice Education - Nursing - Salaries and Wages 170.02 Inservice Education - Nursing - Fringe Benefits 170.03 Inservice Education - Nursing - Agency Staff 170.04 Inservice Education - Nursing - Other - Nonlabor 175.00 Total Schedule 8A-2 Page 3 Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period: ZZT05115F 1831186345 206190378 JULY 1, 2007 THROUGH JUNE 30, 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 34-36 37 38-40 41 42 43 44-47 ADJUSTMENTS TO REPORTED COSTS 160,272 (25,903) (6,049) (11,361) 160,272 (57) (25,006) (18,948) (31,952) (1,401) (11,361) 0 0 0 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 48 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT 1 10.1(4) 5 14 8A-1 5.00 Plant Operations and Maintenance $452,271 ($452,271) $0 Not Reported 8A-1 5.01 Plant Operations and Maintenance - Salaries and Wages 0 120,370 120,370 Not Reported 8A-1 5.02 Plant Operations and Maintenance - Fringe Benefits 0 40,887 40,887 Not Reported 8A-1 5.04 Plant Operations and Maintenance - Other - Nonlabor 0 291,014 291,014 * 2 10.1(4) 10 14 8A-1 10.00 Housekeeping $127,207 ($127,207) $0 Not Reported 8A-1 10.01 Housekeeping - Salaries and Wages 0 21,133 21,133 Not Reported 8A-1 10.02 Housekeeping - Fringe Benefits 0 7,178 7,178 Not Reported 8A-1 10.04 Housekeeping - Other - Nonlabor 0 98,896 98,896 * 3 10.1(4) 60 14 8A-1 60.00 Laundry and Linen $179,905 ($179,905) $0 Not Reported 8A-1 60.01 Laundry and Linen - Salaries and Wages 0 117,318 117,318 * Not Reported 8A-1 60.02 Laundry and Linen - Fringe Benefits 0 39,850 39,850 * Not Reported 8A-1 60.04 Laundry and Linen - Other - Nonlabor 0 22,737 22,737 * 4 10.1(4) 65 14 8A-1 65.00 Dietary $781,234 ($781,234) $0 Not Reported 8A-1 65.01 Dietary - Salaries and Wages 0 275,534 275,534 * Not Reported 8A-1 65.02 Dietary - Fringe Benefits 0 114,847 114,847 * Not Reported 8A-1 65.04 Dietary - Other - Nonlabor 0 390,853 390,853 * 5 10.1(4) 105 14 8A-1 105.00 Skilled Nursing Care $2,951,335 ($2,952,535) ($1,200) * Not Reported 8A-1 105.01 Skilled Nursing Care - Salaries and Wages 0 1,986,884 1,986,884 * Not Reported 8A-1 105.02 Skilled Nursing Care - Fringe Benefits 0 674,892 674,892 Not Reported 8A-1 105.04 Skilled Nursing Care - Other - Nonlabor 0 290,759 290,759 * 6 10.1(4) 155 14 8A-1 155.00 Social Services $73,142 ($73,142) $0 Not Reported 8A-1 155.01 Social Services - Salaries and Wages 0 46,549 46,549 Not Reported 8A-1 155.02 Social Services - Fringe Benefits 0 15,811 15,811 Not Reported 8A-1 155.04 Social Services - Other - Nonlabor 0 10,782 10,782 -Continued on next page- *Balance carried forward from prior/to subsequent adjustments Page 1 Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments HOLLENBECK PALMS JULY 1, 2007 THROUGH JUNE 30, 2008 ZZT05115F This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 48 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments HOLLENBECK PALMS JULY 1, 2007 THROUGH JUNE 30, 2008 ZZT05115F RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT -Continued from previous page- 7 10.1(4) 160 14 8A-1 160.00 Activities $98,142 ($98,142) $0 Not Reported 8A-1 160.01 Activities - Salaries and Wages 0 61,071 61,071 Not Reported 8A-1 160.02 Activities - Fringe Benefits 0 20,744 20,744 Not Reported 8A-1 160.04 Activities - Other - Nonlabor 0 16,327 16,327 * 8 10.1(4) 165 14 8A-1 165.00 Administration $827,182 ($1,473,604) ($646,422) * Not Reported 8A-1 165.01 Administration - Salaries and Wages 0 638,978 638,978 * Not Reported 8A-1 165.02 Administration - Fringe Benefits 0 219,185 219,185 * Not Reported 8A-1 165.11 Administration - Other - Nonlabor 0 615,441 615,441 * 9 10.1(4) 170 14 8A-1 170.00 Inservice Education - Nursing $90,642 ($90,642) $0 Not Reported 8A-1 170.01 Inservice Education - Nursing - Salaries and Wages 0 66,159 66,159 Not Reported 8A-1 170.02 Inservice Education - Nursing - Fringe Benefits 0 22,472 22,472 Not Reported 8A-1 170.04 Inservice Education - Nursing - Other - Nonlabor 0 2,011 2,011 * To reclassify reported expenses for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 2 This is trial version www.adultpdf.com [...]... (30,981) * $0 289,559 * As Adjusted 48 3 Adjustments Department of Health Care Services Reported Explanation of Audit Adjustments RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT Line JULY 1, 2007 THROUGH JUNE 30, 2008 Report References Cost Report MC530 Page or Exhibit Line Col HOLLENBECK PALMS Audit Report Fiscal Period Provider Name State of California This is trial version www.adultpdf.com...10.1(4) Not Reported 10.1(4) Not Reported 10 11 Adj No 165 105 14 14 8A-1 8A-1 8A-1 8A-1 Sch As ZZT05115F *Balance carried forward from prior /to subsequent adjustments To include the provider's adjustments for proper cost determination 42 CFR 413.20 and 413.24 / CMS Pub 15-1, Sections 2300 and 2304 165.00 . 416 (772,791) (65,365) (22,203) (12,668) (8,420) (3,510) 93,569 (93,569) (11,945) (16,188) ADJUSTMENTS TO REPORTED COSTS This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: HOLLENBECK PALMS 82.02 Occupational. ADJ 21 22 23 24 25 26,27 28 29 30 31-33 ADJUSTMENTS TO REPORTED COSTS 553 (416) (553) (15,000) (5,520) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: HOLLENBECK PALMS 130.00. 28 29 30 31-33 ADJUSTMENTS TO REPORTED COSTS (38,583) (13,106) 15,000 (37,161) 00000(772,791) (124,111) (88,850) (10,641) (16,188) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider