23 24 AUDIT ADJ 25 AUDIT ADJ 26 AUDIT ADJ 41,189 85.02 Pharmacy - Fringe Benefits 85.01 Pharmacy - Salaries and Wages 85.00 Pharmacy 83.04 Speech Pathology - Other - Nonlabor 83.03 Speech Pathology - Agency Staff 83.02 Speech Pathology - Fringe Benefits 83.01 Speech Pathology - Salaries and Wages AUDIT ADJ 22 (11,342) 105.01 Skilled Nursing Care - Salaries and Wages 105.02 Skilled Nursing Care - Fringe Benefits 155.01 Social Services - Salaries and Wages 155.00 Social Services 125.04 Subacute Care - Other - Nonlabor 125.03 Subacute Care - Agency Staff 125.02 Subacute Care - Fringe Benefits 125.01 Subacute Care - Salaries and Wages 125.00 Subacute Care 105.04 Skilled Nursing Care - Other - Nonlabor 105.03 Skilled Nursing Care - Agency Staff (29,847) 105.00 Skilled Nursing Care 100.10 Subacute Ancillary Services - Other - Nonlabor 100.09 Subacute Ancillary Services - Agency Staff 100.08 Subacute Ancillary Services - Fringe Benefits 100.07 Subacute Ancillary Services - Salaries and Wages 100.06 Subacute Ancillary Services 100.04 Other Ancillary Services - Other - Nonlabor 100.03 Other Ancillary Services - Agency Staff 100.02 Other Ancillary Services - Fringe Benefits 100.01 Other Ancillary Services - Salaries and Wages 100.00 Other Ancillary Services 95.04 Home Health Services - Other - Nonlabor 95.03 Home Health Services - Agency Staff 95.02 Home Health Services - Fringe Benefits 95.01 Home Health Services - Salaries and Wages 95.00 Home Health Services 90.04 Laboratory - Other - Nonlabor 90.03 Laboratory - Agency Staff 90.02 Laboratory - Fringe Benefits 90.01 Laboratory - Salaries and Wages 90.00 Laboratory 85.04 Pharmacy - Other - Nonlabor 85.03 Pharmacy - Agency Staff 27 AUDIT ADJ 28 AUDIT ADJ AUDIT ADJ 206190124 ZZT05900F GRANCELL VILLAGE AUDIT ADJ OSHPD Facility Number: Provider No.: RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT Provider Name: STATE OF CALIFORNIA This is trial version www.adultpdf.com AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 Fiscal Period: Page Schedule 8A-1 23 0 26 AUDIT ADJ (34,063) 21,626 (3,751) 21,626 (21,626) 28 AUDIT ADJ 175.00 Total 170.04 Inservice Education - Nursing - Other - Nonlabor (7,196) 170.02 Inservice Education - Nursing - Fringe Benefits (5,027) (1,603) (6,719) 170.01 Inservice Education - Nursing - Salaries and Wages 170.03 Inservice Education - Nursing - Agency Staff (12,827) (18,016) 170.00 Inservice Education - Nursing 165.11 Administration - Other - Nonlabor 165.10 Administration - Quality Assurance Fees 165.09 Administration - Caregiver Training 165.08 Administration - Liability Insurance 165.07 Administration - DHS Licensing Fees 165.06 Administration - Medical Records - Other - Nonlabor 165.05 Administration - Medical Records - Agency Staff 165.04 Administration - Medical Records - Fringe Benefits (2,249) (10,625) 165.03 Administration - Medical Records - Salaries and Wages 165.02 Administration - Fringe Benefits 84,463 27 AUDIT ADJ (39,775) 3,751 25 AUDIT ADJ 165.01 Administration - Salaries and Wages 165.00 Administration 160.04 Activities - Other - Nonlabor 2,249 24 AUDIT ADJ 29,762 160.03 Activities - Agency Staff 160.02 Activities - Fringe Benefits 160.01 Activities - Salaries and Wages 160.00 Activities 155.04 Social Services - Other - Nonlabor 155.03 Social Services - Agency Staff 155.02 Social Services - Fringe Benefits AUDIT ADJ 22 AUDIT ADJ 206190124 ZZT05900F GRANCELL VILLAGE AUDIT ADJ OSHPD Facility Number: Provider No.: RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT Provider Name: STATE OF CALIFORNIA This is trial version www.adultpdf.com AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 Fiscal Period: Page Schedule 8A-1 0 10.01 Housekeeping - Salaries and Wages 0 10.00 Housekeeping (79,591) 5.04 Plant Operations and Maintenance - Other - Nonlabor 37,150 5.02 Plant Operations and Maintenance - Fringe Benefits 5.03 Plant Operations and Maintenance - Agency Staff 5.01 Plant Operations and Maintenance - Salaries and Wages 40.00 Property Taxes 0 0 82.00 Occupational Therapy 82.01 Occupational Therapy - Salaries and Wages 81.02 Respiratory Therapy - Fringe Benefits 81.04 Respiratory Therapy - Other - Nonlabor 81.01 Respiratory Therapy - Salaries and Wages 81.03 Respiratory Therapy - Agency Staff 0 80.03 Physical Therapy - Agency Staff 81.00 Respiratory Therapy 80.02 Physical Therapy - Fringe Benefits 80.04 Physical Therapy - Other - Nonlabor 0 80.01 Physical Therapy - Salaries and Wages 77.00 Specialized Support Surfaces 80.00 Physical Therapy 0 75.04 Patient Supplies - Other - Nonlabor 75.02 Patient Supplies - Fringe Benefits 75.03 Patient Supplies - Agency Staff 0 75.01 Patient Supplies - Salaries and Wages 70.00 Provision for Bad Debts 75.00 Patient Supplies 0 65.02 Dietary - Fringe Benefits 65.04 Dietary - Other - Nonlabor 65.01 Dietary - Salaries and Wages 65.03 Dietary - Agency Staff 0 65.00 Dietary (149,685) 60.04 Laundry and Linen - Other - Nonlabor 60.02 Laundry and Linen - Fringe Benefits 149,685 60.01 Laundry and Linen - Salaries and Wages 60.03 Laundry and Linen - Agency Staff 0 60.00 Laundry and Linen 55.00 Interest-Other 50.00 Interest-Property, Plant, and Equipment (2,960) 35.00 Leases and Rentals 45.00 Property Insurance 30.00 Depreciation and Amortization - Other (26,613) 25.00 Depreciation: Equipment (13,501) 10.04 Housekeeping - Other - Nonlabor 20.00 Depreciation: Leasehold Improvements 10.03 Housekeeping - Agency Staff 15.00 Depreciation: Bldgs and Improvements 0 10.02 Housekeeping - Fringe Benefits (149,685) 149,685 29 5.00 Plant Operations and Maintenance AUDIT ADJ (Pages & 2) ZZT05900F GRANCELL VILLAGE TOTAL ADJ Provider No.: Provider Name: STATE OF CALIFORNIA This is trial version www.adultpdf.com (37,150) 37,150 30 AUDIT ADJ 31 AUDIT ADJ ADJUSTMENTS TO REPORTED COSTS 32 AUDIT ADJ 33 AUDIT ADJ 206190124 (26,613) (13,501) 34 AUDIT ADJ OSHPD Facility Number: (42,441) 35 AUDIT ADJ 36 AUDIT ADJ 37 AUDIT ADJ SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 Fiscal Period: Page Schedule 8A-2 0 0 83.00 Speech Pathology 83.01 Speech Pathology - Salaries and Wages 83.02 Speech Pathology - Fringe Benefits 83.03 Speech Pathology - Agency Staff 0 82.04 Occupational Therapy - Other - Nonlabor 82.03 Occupational Therapy - Agency Staff 29 82.02 Occupational Therapy - Fringe Benefits AUDIT ADJ (Pages & 2) ZZT05900F GRANCELL VILLAGE TOTAL ADJ Provider No.: Provider Name: STATE OF CALIFORNIA 95.04 Home Health Services - Other - Nonlabor 0 0 125.03 Subacute Care - Agency Staff 125.04 Subacute Care - Other - Nonlabor 126.00 Subacute Care - Pediatrics 125.01 Subacute Care - Salaries and Wages 125.02 Subacute Care - Fringe Benefits 0 125.00 Subacute Care 0 120.00 Developmentally Disabled 110.00 Intermediate Care 115.00 Mentally Disordered 105.02 Skilled Nursing Care - Fringe Benefits 0 105.01 Skilled Nursing Care - Salaries and Wages 105.04 Skilled Nursing Care - Other - Nonlabor 105.00 Skilled Nursing Care 105.03 Skilled Nursing Care - Agency Staff 0 100.12 Subacute Pediatrics Ancillary Services 0 100.10 Subacute Ancillary Services - Other - Nonlabor 100.08 Subacute Ancillary Services - Fringe Benefits 100.09 Subacute Ancillary Services - Agency Staff 0 100.04 Other Ancillary Services - Other - Nonlabor 100.07 Subacute Ancillary Services - Salaries and Wages 100.03 Other Ancillary Services - Agency Staff 100.06 Subacute Ancillary Services 0 100.02 Other Ancillary Services - Fringe Benefits 95.03 Home Health Services - Agency Staff 0 95.02 Home Health Services - Fringe Benefits 100.01 Other Ancillary Services - Salaries and Wages 95.01 Home Health Services - Salaries and Wages 100.00 Other Ancillary Services 0 95.00 Home Health Services 0 90.02 Laboratory - Fringe Benefits 90.04 Laboratory - Other - Nonlabor 90.01 Laboratory - Salaries and Wages 90.03 Laboratory - Agency Staff 0 90.00 Laboratory 0 85.02 Pharmacy - Fringe Benefits 85.04 Pharmacy - Other - Nonlabor 85.01 Pharmacy - Salaries and Wages 85.03 Pharmacy - Agency Staff 0 85.00 Pharmacy 83.04 Speech Pathology - Other - Nonlabor This is trial version www.adultpdf.com 30 AUDIT ADJ 31 AUDIT ADJ ADJUSTMENTS TO REPORTED COSTS 32 AUDIT ADJ 33 AUDIT ADJ 206190124 34 AUDIT ADJ OSHPD Facility Number: 35 AUDIT ADJ 36 AUDIT ADJ 37 AUDIT ADJ SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 Fiscal Period: Page Schedule 8A-2 0 155.00 Social Services 155.01 Social Services - Salaries and Wages 0 145.00 Other Nonreimbursable 136.00 Residential Care 140.00 Beauty and Barber 135.00 Other Routine Services 29 130.00 Hospice Inpatient Care AUDIT ADJ (Pages & 2) ZZT05900F GRANCELL VILLAGE TOTAL ADJ Provider No.: Provider Name: STATE OF CALIFORNIA 29,230 165.04 Administration - Medical Records - Fringe Benefits 165.10 Administration - Quality Assurance Fees 0 170.03 Inservice Education - Nursing - Agency Staff 170.04 Inservice Education - Nursing - Other - Nonlabor (To Sch 8) ($224,934) 170.02 Inservice Education - Nursing - Fringe Benefits Total 170.01 Inservice Education - Nursing - Salaries and Wages 175.00 170.00 Inservice Education - Nursing (179,430) 165.11 Administration - Other - Nonlabor 131,400 165.08 Administration - Liability Insurance 165.07 Administration - DHS Licensing Fees 165.09 Administration - Caregiver Training 35,876 21,960 165.06 Administration - Medical Records - Other - Nonlabor 81,814 165.03 Administration - Medical Records - Salaries and Wages 165.05 Administration - Medical Records - Agency Staff (77,093) 165.02 Administration - Fringe Benefits (183,176) 165.00 Administration 165.01 Administration - Salaries and Wages 0 160.04 Activities - Other - Nonlabor 160.02 Activities - Fringe Benefits 160.03 Activities - Agency Staff 0 160.01 Activities - Salaries and Wages 155.04 Social Services - Other - Nonlabor 160.00 Activities 0 155.03 Social Services - Agency Staff 155.02 Social Services - Fringe Benefits This is trial version www.adultpdf.com 30 AUDIT ADJ (50,527) 50,527 41,166 115,223 (41,166) (115,223) 31 AUDIT ADJ ADJUSTMENTS TO REPORTED COSTS (131,400) 131,400 32 AUDIT ADJ (21,960) 21,960 33 AUDIT ADJ 206190124 40,114 34 AUDIT ADJ OSHPD Facility Number: (42,441) 35 AUDIT ADJ (15,657) (15,657) 36 AUDIT ADJ (59,996) (14,651) (11,936) (33,409) 37 AUDIT ADJ SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 Fiscal Period: Page Schedule 8A-2 10.01 Housekeeping - Salaries and Wages 10.00 Housekeeping 5.04 Plant Operations and Maintenance - Other - Nonlabor 5.03 Plant Operations and Maintenance - Agency Staff 5.02 Plant Operations and Maintenance - Fringe Benefits 5.01 Plant Operations and Maintenance - Salaries and Wages 5.00 Plant Operations and Maintenance 82.01 Occupational Therapy - Salaries and Wages 82.00 Occupational Therapy 81.04 Respiratory Therapy - Other - Nonlabor 81.03 Respiratory Therapy - Agency Staff 81.02 Respiratory Therapy - Fringe Benefits 81.01 Respiratory Therapy - Salaries and Wages 81.00 Respiratory Therapy 80.04 Physical Therapy - Other - Nonlabor 80.03 Physical Therapy - Agency Staff 80.02 Physical Therapy - Fringe Benefits 80.01 Physical Therapy - Salaries and Wages 80.00 Physical Therapy 77.00 Specialized Support Surfaces 75.04 Patient Supplies - Other - Nonlabor 75.03 Patient Supplies - Agency Staff 75.02 Patient Supplies - Fringe Benefits 75.01 Patient Supplies - Salaries and Wages 75.00 Patient Supplies 70.00 Provision for Bad Debts 65.04 Dietary - Other - Nonlabor 65.03 Dietary - Agency Staff 65.02 Dietary - Fringe Benefits 65.01 Dietary - Salaries and Wages 65.00 Dietary 60.04 Laundry and Linen - Other - Nonlabor 60.03 Laundry and Linen - Agency Staff 60.02 Laundry and Linen - Fringe Benefits 60.01 Laundry and Linen - Salaries and Wages 60.00 Laundry and Linen 55.00 Interest-Other 50.00 Interest-Property, Plant, and Equipment 45.00 Property Insurance 40.00 Property Taxes 35.00 Leases and Rentals 30.00 Depreciation and Amortization - Other 25.00 Depreciation: Equipment 20.00 Depreciation: Leasehold Improvements 15.00 Depreciation: Bldgs and Improvements 10.04 Housekeeping - Other - Nonlabor 10.03 Housekeeping - Agency Staff 10.02 Housekeeping - Fringe Benefits 39 (2,960) AUDIT ADJ 38 ZZT05900F GRANCELL VILLAGE AUDIT ADJ Provider No.: Provider Name: STATE OF CALIFORNIA This is trial version www.adultpdf.com AUDIT ADJ AUDIT ADJ ADJUSTMENTS TO REPORTED COSTS AUDIT ADJ AUDIT ADJ 206190124 OSHPD Facility Number: AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 Fiscal Period: Page Schedule 8A-2 83.03 Speech Pathology - Agency Staff 83.02 Speech Pathology - Fringe Benefits 83.01 Speech Pathology - Salaries and Wages 83.00 Speech Pathology 82.04 Occupational Therapy - Other - Nonlabor 82.03 Occupational Therapy - Agency Staff 82.02 Occupational Therapy - Fringe Benefits 126.00 Subacute Care - Pediatrics 125.04 Subacute Care - Other - Nonlabor 125.03 Subacute Care - Agency Staff 125.02 Subacute Care - Fringe Benefits 125.01 Subacute Care - Salaries and Wages 125.00 Subacute Care 120.00 Developmentally Disabled 115.00 Mentally Disordered 110.00 Intermediate Care 105.04 Skilled Nursing Care - Other - Nonlabor 105.03 Skilled Nursing Care - Agency Staff 105.02 Skilled Nursing Care - Fringe Benefits 105.01 Skilled Nursing Care - Salaries and Wages 105.00 Skilled Nursing Care 100.12 Subacute Pediatrics Ancillary Services 100.10 Subacute Ancillary Services - Other - Nonlabor 100.09 Subacute Ancillary Services - Agency Staff 100.08 Subacute Ancillary Services - Fringe Benefits 100.07 Subacute Ancillary Services - Salaries and Wages 100.06 Subacute Ancillary Services 100.04 Other Ancillary Services - Other - Nonlabor 100.03 Other Ancillary Services - Agency Staff 100.02 Other Ancillary Services - Fringe Benefits 100.01 Other Ancillary Services - Salaries and Wages 100.00 Other Ancillary Services 95.04 Home Health Services - Other - Nonlabor 95.03 Home Health Services - Agency Staff 95.02 Home Health Services - Fringe Benefits 95.01 Home Health Services - Salaries and Wages 95.00 Home Health Services 90.04 Laboratory - Other - Nonlabor 90.03 Laboratory - Agency Staff 90.02 Laboratory - Fringe Benefits 90.01 Laboratory - Salaries and Wages 90.00 Laboratory 85.04 Pharmacy - Other - Nonlabor 85.03 Pharmacy - Agency Staff 85.02 Pharmacy - Fringe Benefits 85.01 Pharmacy - Salaries and Wages 85.00 Pharmacy 83.04 Speech Pathology - Other - Nonlabor AUDIT ADJ 39 38 ZZT05900F GRANCELL VILLAGE AUDIT ADJ Provider No.: Provider Name: STATE OF CALIFORNIA This is trial version www.adultpdf.com AUDIT ADJ AUDIT ADJ ADJUSTMENTS TO REPORTED COSTS AUDIT ADJ AUDIT ADJ 206190124 OSHPD Facility Number: AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 Fiscal Period: Page Schedule 8A-2 175.00 Total 170.04 Inservice Education - Nursing - Other - Nonlabor 170.03 Inservice Education - Nursing - Agency Staff 170.02 Inservice Education - Nursing - Fringe Benefits 170.01 Inservice Education - Nursing - Salaries and Wages 170.00 Inservice Education - Nursing 165.11 Administration - Other - Nonlabor 165.10 Administration - Quality Assurance Fees 165.09 Administration - Caregiver Training 165.08 Administration - Liability Insurance 165.07 Administration - DHS Licensing Fees 165.06 Administration - Medical Records - Other - Nonlabor 165.05 Administration - Medical Records - Agency Staff 165.04 Administration - Medical Records - Fringe Benefits (103,880) (35,927) 165.02 Administration - Fringe Benefits 165.03 Administration - Medical Records - Salaries and Wages 165.01 Administration - Salaries and Wages 165.00 Administration 160.04 Activities - Other - Nonlabor 160.03 Activities - Agency Staff 160.02 Activities - Fringe Benefits 160.01 Activities - Salaries and Wages 160.00 Activities 155.04 Social Services - Other - Nonlabor 155.03 Social Services - Agency Staff 155.02 Social Services - Fringe Benefits (2,960) 39 (67,953) 155.01 Social Services - Salaries and Wages 155.00 Social Services 145.00 Other Nonreimbursable 140.00 Beauty and Barber 136.00 Residential Care 135.00 Other Routine Services 130.00 Hospice Inpatient Care AUDIT ADJ 38 ZZT05900F GRANCELL VILLAGE AUDIT ADJ Provider No.: Provider Name: STATE OF CALIFORNIA This is trial version www.adultpdf.com AUDIT ADJ AUDIT ADJ ADJUSTMENTS TO REPORTED COSTS AUDIT ADJ AUDIT ADJ 206190124 OSHPD Facility Number: AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 Fiscal Period: Page Schedule 8A-2 Adj No 10.1(4) Not Reported Not Reported Not Reported 10.1(4) Not Reported Not Reported Not Reported 10.1(4) Not Reported Not Reported Not Reported 10.1(4) Not Reported 10.1(4) Not Reported Not Reported Not Reported 10.1(4) Not Reported Not Reported Not Reported 155 105 65 60 10 05 14 14 14 14 14 14 Report References Cost Report MC530 Page or Exhibit Line Col 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 Sch As ZZT05900F Housekeeping Housekeeping - Salaries and Wages Housekeeping - Fringe Benefits Housekeeping - Other - Nonlabor Plant Operations and Maintenance Plant Operations and Maintenance - Salaries and Wages Plant Operations and Maintenance - Fringe Benefits Plant Operations and Maintenance - Other - Nonlabor 155.00 155.01 155.02 155.04 105.00 105.01 105.02 105.04 65.00 65.01 65.02 65.04 *Balance carried forward from prior/to subsequent adjustments -Continued on next page- Social Services Social Services - Salaries and Wages Social Services - Fringe Benefits Social Services - Other - Nonlabor Skilled Nursing Care Skilled Nursing Care - Salaries and Wages Skilled Nursing Care - Fringe Benefits Skilled Nursing Care - Other - Nonlabor Dietary Dietary - Salaries and Wages Dietary - Fringe Benefits Dietary - Other - Nonlabor 60.00 Laundry and Linen 60.04 Laundry and Linen - Other - Nonlabor 10.00 10.01 10.02 10.04 5.00 5.01 5.02 5.04 $157,626 0 $4,604,531 0 $910,472 0 $198,534 $316,838 0 $430,640 0 As Adjusted 43 * * * * ($95,230) * 293,764 * ($604,815) 562,060 218,287 141,306 ($221,994) 157,866 60,504 3,624 ($4,691,862) 3,428,147 1,242,805 20,910 Page ($64,368) 157,866 60,504 3,624 * * * * ($87,331) * 3,428,147 * 1,242,805 * 20,910 ($1,925,684) ($1,015,212) * 873,753 873,753 * 290,802 290,802 * 761,129 761,129 * ($293,764) 293,764 ($921,653) 562,060 218,287 141,306 Adjustments ($1,598,199) ($1,167,559) * 240,004 240,004 * 88,405 88,405 * 1,269,790 1,269,790 * Increase (Decrease) Provider Number Department of Health Care Services Reported Explanation of Audit Adjustments RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT Line GRANCELL VILLAGE Audit Report Fiscal Period SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 Provider Name State of California This is trial version www.adultpdf.com 10.1(4) Not Reported Not Reported Not Reported 10.1(4) Not Reported Not Reported Not Reported 170 165 -Continued from previous page7 10.1(4) 160 Not Reported Not Reported Not Reported Adj No 14 14 14 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 Sch As ZZT05900F 170.00 170.01 170.02 170.04 165.00 165.01 165.02 165.11 160.00 160.01 160.02 160.04 *Balance carried forward from prior/to subsequent adjustments To reclassify reported expenses for proper cost determination 42 CFR 413.20 and 413.24 / CMS Pub 15-1, Sections 2300 and 2304 Inservice Education - Nursing Inservice Education - Nursing - Salaries and Wages Inservice Education - Nursing - Fringe Benefits Inservice Education - Nursing - Other - Nonlabor Administration Administration - Salaries and Wages Administration - Fringe Benefits Administration - Other - Nonlabor Activities Activities - Salaries and Wages Activities - Fringe Benefits Activities - Other - Nonlabor $51,256 0 $2,243,289 0 $328,263 0 ($102,644) 62,133 23,173 17,338 ($1,433,045) 492,312 170,265 770,468 ($462,313) 295,200 99,023 68,090 Increase (Decrease) Provider Number Page ($51,388) 62,133 23,173 17,338 $810,244 492,312 170,265 770,468 ($134,050) 295,200 99,023 68,090 As Adjusted 43 * * * * * * * * * * * * Adjustments Department of Health Care Services Reported Explanation of Audit Adjustments RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT Line SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 Report References Cost Report MC530 Page or Exhibit Line Col GRANCELL VILLAGE Audit Report Fiscal Period Provider Name State of California This is trial version www.adultpdf.com Not Reported 10.1(4) Not Reported Not Reported 10.1(4) Not Reported 10.1(4) 10.1(4) Not Reported Not Reported 10.1(4) 10 11 12 13 14 Adj No 165 165 165 105 65 14 14 14 14 14 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 8A-1 Sch As ZZT05900F *Balance carried forward from prior/to subsequent adjustments 165.11 Administration - Other - Nonlabor 165.00 Administration To reclassify the provider's adjustment of lobbying activity expenses for proper cost determination 42 CFR 413.20 and 413.24 CMS Pub 15-1, Sections 2300, 2302.4 and 2302.8 165.00 Administration 165.11 Administration - Other - Nonlabor To reclassify home office adjustment for proper cost determination 42 CFR 413.20 and 413.24 CMS Pub 15-1, Sections 2300, 2302.4 and 2302.8 To reclassify the reported revenue abatements for proper cost determination 42 CFR 413.20 and 413.24 CMS Pub 15-1, Sections 2300, 2302.4 and 2302.8 165.11 Administration - Other - Nonlabor 165.00 Administration 105.01 Skilled Nursing Care - Salaries and Wages 105.02 Skilled Nursing Care - Fringe Benefits 105.00 Skilled Nursing Care 65.04 Dietary - Other - Nonlabor 65.00 Dietary * * * * * * * * * * * $2,060,677 (479,965) $812,290 768,422 $770,468 810,244 $3,428,147 1,242,805 (87,331) $761,129 (1,015,212) ($1,977) 1,977 ($1,292,255) 1,292,255 ($2,046) 2,046 ($33,436) (12,706) 46,142 ($3,396) 3,396 Increase (Decrease) Provider Number Page $2,058,700 * (477,988) * ($479,965) * 2,060,677 * $768,422 * 812,290 * $3,394,711 * 1,230,099 * (41,189) * $757,733 * (1,011,816) * As Adjusted 43 Adjustments Department of Health Care Services Reported Explanation of Audit Adjustments RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT Line SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 Report References Cost Report MC530 Page or Exhibit Line Col GRANCELL VILLAGE Audit Report Fiscal Period Provider Name State of California This is trial version www.adultpdf.com ... (1,011,816) * As Adjusted 43 Adjustments Department of Health Care Services Reported Explanation of Audit Adjustments RECONCILIATION OF THE PROVIDER''S ADJUSTMENTS TO THE AUDIT REPORT Line SEPTEMBER... Not Reported Not Reported Not Reported 10.1(4) Not Reported Not Reported Not Reported 10.1(4) Not Reported Not Reported Not Reported 10.1(4) Not Reported 10.1(4) Not Reported Not Reported Not Reported... * * * * * * * * * * * * Adjustments Department of Health Care Services Reported Explanation of Audit Adjustments RECONCILIATION OF THE PROVIDER''S RECORDS TO THE AUDIT REPORT Line SEPTEMBER 1,