State of California Department of Health Care Services Provider Name Fiscal Period Provider Number CASTRO VALLEY HEALTHCARE AND REHABILITATION CENTER MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted MEMORANDUM ADJUSTMENT 1 10.7 075 2, 3 7 075 Patient Supplies (Square Feet) 0 108 108 10.7 080 2, 3 7 080 Physical Therapy 0 200 200 10.7 082 2, 3 7 082 Occupational Therapy 0 200 200 10.7 083 2, 3 7 083 Speech Pathology 0 133 133 10.7 085 2, 3 7 085 Pharmacy 0 134 134 10.7 105 2, 3 7 105 Skilled Nursing Care 0 8,505 8,505 * 10.7 175 2, 3 7 N/A Total - Square Feet 0 9,280 9,280 * To reconcile provider's reported statistics on page 10.7 to provider's reported statistics on page 11.1. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 1 Adjustments JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05239J Cost Report Explanation of Audit Adjustments Report References Audit Report 17 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number CASTRO VALLEY HEALTHCARE AND REHABILITATION CENTER MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05239J Cost Report Explanation of Audit Adjustments Report References Audit Report 17 RECLASSIFICATIONS OF REPORTED COSTS 2 10.5 065 3 8A-2 065 3 Dietary - Agency Staff $17,148 ($17,148) $0 10.5 065 4 8A-2 065 4 Dietary - Other - Nonlabor 131,085 17,148 148,233 * To reclassify dietary consultant expenses for proper cost determination. 41 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 3 10.5 105 3 8A-2 105 3 Skilled Nursing Care - Agency Staff $22,420 ($22,420) $0 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor 131,134 2,643 133,777 * 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor 587,880 19,777 607,657 * To reclassify reported SNF agency staff expenses for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 4 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * $133,777 ($3,931) $129,846 * 10.5 035 4 8A-2 035 4 Leases and Rentals 412,050 2,256 414,306 * 10.5 090 4 8A-2 090 4 Laboratory - Other - Nonlabor 70,347 142 70,489 10.5 100 4 8A-2 100 4 Other Ancillary Services - Other - Nonlabor 7,579 1,011 8,590 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * 607,657 522 608,179 * To reclassify reported non- SNF expenses for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 5 10.5 105 1 8A-2 105 1 Skilled Nursing Care - Salaries and Wages $1,557,282 ($5,609) $1,551,673 10.5 105 2 8A-2 105 2 Skilled Nursing Care - Fringe Benefits 307,186 (1,602) 305,584 10.5 075 1 8A-2 075 1 Patient Supplies - Salaries and Wages 0 2,622 2,622 10.5 075 2 8A-2 075 2 Patient Supplies - Fringe Benefits 0 749 749 10.5 165 1 8A-2 165 1 Administration - Salaries and Wages 192,109 2,987 195,096 10.5 165 2 8A-2 165 2 Administration - Fringe Benefits 49,998 853 50,851 To reclassify payroll expenses of central supply 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 State of California Department of Health Care Services Provider Name Fiscal Period Provider Number CASTRO VALLEY HEALTHCARE AND REHABILITATION CENTER MC530 Adj. 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Line Sub No Reported (Decrease) Adjusted Adjustments JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05239J Cost Report Explanation of Audit Adjustments Report References Audit Report 17 RECLASSIFICATIONS OF REPORTED COSTS 6 10.5 075 4 8A-2 075 4 Patient Supplies - Other - Nonlabor $21,438 ($11,417) $10,021 * 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * 129,846 11,417 141,263 * To reclassify enteral expenses for proper cost determination. 41 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 7 10.5 085 4 8A-2 085 4 Pharmacy - Other - Nonlabor $141,838 $2,871 $144,709 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * 141,263 (2,871) 138,392 * To reclassify prescription drug expenses for proper cost determination. 41 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 8 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $608,179 ($1,099) $607,080 * 10.5 167 4 8A-2 167 4 Administration - DPH Licensing Fees 25,018 1,099 26,117 To reclassify DPH licensing fees for proper cost determination. 41 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 9 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $607,080 $2,527 $609,607 * 10.5 168 4 8A-2 168 4 Administration - Liability Insurance 51,718 (2,527) 49,191 * To reclassify liability insurance expenses other than premiums for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 10 10.5 005 4 8A-2 005 4 Plant Operations and Maintenance - Other - Nonlabor $145,914 ($176) $145,738 10.5 060 4 8A-2 060 4 Laundry and Linen - Other - Nonlabor 18,699 (487) 18,212 10.5 065 4 8A-2 065 4 Dietary - Other - Nonlabor * 148,233 (383) 147,850 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * 138,392 (10,191) 128,201 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * 609,607 (2,825) 606,782 * 10.5 035 4 8A-2 035 4 Leases and Rentals * 414,306 14,062 428,368 To reclassify equipment rental expenses for proper cost determination. 41 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 3 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number CASTRO VALLEY HEALTHCARE AND REHABILITATION CENTER MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05239J Cost Report Explanation of Audit Adjustments Report References Audit Report 17 ADJUSTMENTS TO REPORTED COSTS 11 10.5 040 4 8A-2 040 4 Property Taxes $35,358 $16,619 $51,977 To adjust property taxes expenses to agree with the provider's documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 12 10.5 075 4 8A-2 075 4 Patient Supplies - Other - Nonlabor * $10,021 ($1,194) $8,827 To eliminate enteral expenses due to insufficient documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 13 10.5 168 4 8A-2 168 4 Administration - Liability Insurance * $49,191 ($1,505) $47,686 To adjust liability insurance expense to agree with the provider's documentation. 43 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 14 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $606,782 $2,264 $609,046 To adjust taxes and finance charges related to liability insurance expense for proper cost determination. 43 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 4 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number CASTRO VALLEY HEALTHCARE AND REHABILITATION CENTER MC530 Adj. 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Line Sub No Reported (Decrease) Adjusted Adjustments JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05239J Cost Report Explanation of Audit Adjustments Report References Audit Report 17 ADJUSTMENTS TO REPORTED STATISTICS 15 10.7 010 2, 3 7 010 Housekeeping (Square Feet) 0 576 576 10.7 060 2, 3 7 060 Laundry and Linen 0 314 314 10.7 065 2, 3 7 065 Dietary 0 1,833 1,833 10.7 105 2, 3 7 105 Skilled Nursing Care * 8,505 (152) 8,353 * 10.7 155 2, 3 7 155 Social Services 0 565 565 10.7 165 2, 3 7 165 Administration 0 1,546 1,546 10.7 175 2 7 N/A Total - Square Feet * 9,280 4,682 13,962 * 10.7 175 3 7 N/A Total - Square Feet * 9,280 4,106 13,386 * To reconcile provider's reported statistics on page 10.7, Column 2 and Column 3 to Column 1. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 16 10.7 005 1, 2, 3 7 005 Plant Operations and Maintenance (Square Feet) 1,078 30 1,108 10.7 010 1, 2, 3 7 010 Housekeeping 576 (456) 120 10.7 060 1, 2, 3 7 060 Laundry and Linen 314 (62) 252 10.7 065 1, 2, 3 7 065 Dietary 1,833 (803) 1,030 10.7 075 1, 2, 3 7 075 Patient Supplies 108 76 184 10.7 080 1, 2, 3 7 080 Physical Therapy 200 430 630 10.7 082 1, 2, 3 7 082 Occupational Therapy 200 (200) 0 10.7 083 1, 2, 3 7 083 Speech Pathology 133 (133) 0 10.7 085 1, 2, 3 7 085 Pharmacy 134 (134) 0 10.7 105 1, 2, 3 7 105 Skilled Nursing Care * 8,353 (731) 7,622 10.7 140 1, 2, 3 7 140 Beauty and Barber 0 144 144 10.7 145 1, 2, 3 7 145 Other Nonreimbursable 0 90 90 10.7 155 1, 2, 3 7 155 Social Services 565 (405) 160 10.7 165 1, 2, 3 7 165 Administration 1,546 (878) 668 10.7 166 1, 2, 3 7 166 Medical Records 0 900 900 10.7 170 1, 2, 3 7 170 Inservice Education - Nursing 0 196 196 10.7 175 1 7 N/A Total - Square Feet 15,040 (1,936) 13,104 10.7 175 2 7 N/A Total - Square Feet * 13,962 (1,966) 11,996 10.7 175 3 7 N/A Total - Square Feet * 13,386 (1,510) 11,876 To adjust square footage statistics to agree with the provider's documentation. 42 CFR 413.24 and 413.50 / CMS Pub. 15-1, Sections 2304 and 2306 *Balance carried forward from prior/to subsequent adjustments Page 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number CASTRO VALLEY HEALTHCARE AND REHABILITATION CENTER MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05239J Cost Report Explanation of Audit Adjustments Report References Audit Report 17 ADJUSTMENT TO REPORTED PATIENT DAYS 17 4.1 70 6 1 12 Total Patient Days 22,845 1 22,846 To adjust total patient days to agree with the provider's patient census reports. 42 CFR 413.20 and 413.50 CMS Pub. 15-1, Sections 2205 and 2304 Page 6 This is trial version www.adultpdf.com . Adjusted Adjustments JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05239J Cost Report Explanation of Audit Adjustments Report References Audit Report 17 RECLASSIFICATIONS OF REPORTED COSTS 2. Adjusted Adjustments JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05239J Cost Report Explanation of Audit Adjustments Report References Audit Report 17 RECLASSIFICATIONS OF REPORTED COSTS 6. 413.24 / CMS Pub. 15 -1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 1 Adjustments JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05239J Cost