State of California Fiscal Period JANUARY 1, 2008 THROUGH DECEMBER 31, 2008_part4 doc

State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 26 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 COUNTRY VILLA REDLANDS HEALTHCARE JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT05650J RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT 14 10.1(4) 65 14 8A-1 65.00 Dietary * $125 ($125) $0 Not Reported 8A-1 65.04 Dietary - Other - Nonlabor * 172,014 125 172,139 To reclassify the provider's adjustment of dietary expense 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 4 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 26 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 COUNTRY VILLA REDLANDS HEALTHCARE JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT05650J RECLASSIFICATIONS OF REPORTED COSTS 15 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $244,040 ($36,738) $207,302 Not Reported 8A-2 165.02 Administration - Fringe Benefits * 79,436 (12,275) 67,161 Not Reported 8A-2 165.03 Administration - Medical Records - Salaries and Wages 0 36,738 36,738 Not Reported 8A-2 165.04 Administration - Medical Records - Fringe Benefits 0 12,275 12,275 * Not Reported 8A-2 165.06 Administration - Medical Records - Other - Nonlabor 0 5,344 5,344 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 714,349 (5,344) 709,005 * To reclassify medical records salaries, fringe benefits and other non labor expenses for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 16 Not Reported 8A-2 105.03 Skilled Nursing Care - Agency Staff $0 $883 $883 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 103,975 (883) 103,092 * To reclassify wound care expense to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 17 Not Reported 8A-2 65.02 Dietary - Fringe Benefits * $46,006 $4 $46,010 10.1(4) 85 14 8A-2 85.00 Pharmacy 93,207 1,668 94,875 Not Reported 8A-2 105.02 Skilled Nursing Care - Fringe Benefits * 502,570 43 502,613 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 103,092 (1,727) 101,365 * Not Reported 8A-2 155.02 Social Services - Fringe Benefits * 12,384 8 12,392 Not Reported 8A-2 165.04 Administration - Medical Records - Fringe Benefits * 12,275 4 12,279 To reclassify the reported expenses to the appropriate cost centers. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *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 26 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments COUNTRY VILLA REDLANDS HEALTHCARE JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT05650J RECLASSIFICATIONS OF REPORTED COSTS 18 10.1(4) 100 14 8A-2 100.00 Other Ancillary Services $5,242 $1,561 $6,803 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 101,365 (1,561) 99,804 To reclassify transportation expense to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 19 Not Reported 8A-2 10.03 Housekeeping - Agency Staff $0 $95,566 $95,566 Not Reported 8A-2 10.04 Housekeeping - Other - Nonlabor * 107,534 (95,566) 11,968 * To reclassify agency staff expenses to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 20 Not Reported 8A-2 60.03 Laundry and Linen - Agency Staff $0 $58,951 $58,951 Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * 73,987 (58,951) 15,036 * To reclassify agency staff expenses to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 21 Not Reported 8A-2 10.04 Housekeeping - Other - Nonlabor * $11,968 $1,477 $13,445 Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * 15,036 (1,477) 13,559 To reconcile the reported housekeeping expense to agree with the provider's invoices. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 6 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 26 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 COUNTRY VILLA REDLANDS HEALTHCARE JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT05650J RECLASSIFICATIONS OF REPORTED COSTS 22 Not Reported 8A-2 165.07 Administration - Facility Licensing Fees $0 $21,938 $21,938 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 709,005 (21,938) 687,067 * To reclassify the facility licensing fees for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 23 Not Reported 8A-2 165.10 Administration - Quality Assurance Fees $0 $237,241 $237,241 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 687,067 (237,241) 449,826 * To reclassify the Quality Assurance Fees for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 24 Not Reported 8A-2 165.08 Administration - Liability Insurance $0 $22,009 $22,009 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 449,826 (22,009) 427,817 * To reclassify the liability insurance expense 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 7 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 26 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 COUNTRY VILLA REDLANDS HEALTHCARE JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT05650J ADJUSTMENT TO REPORTED COSTS 25 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $427,817 ($246) $427,571 To reconcile the reported liability insurance expense to agree with the provider's invoices. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 8 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 26 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 COUNTRY VILLA REDLANDS HEALTHCARE JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT05650J ADJUSTMENT TO REPORTED STATISTICS 26 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 544 544 Not Reported 7 10.00 Housekeeping 05353 Not Reported 7 60.00 Laundry and Linen 0 426 426 Not Reported 7 65.00 Dietary 0 1,304 1,304 Not Reported 7 155.00 Social Services 0 158 158 Not Reported 7 160.00 Activities 0 1,184 1,184 Not Reported 7 165.00 Administration 0 738 738 Not Reported 7 165.00 Medical Records 0 150 150 Not Reported 7 170.00 Inservice Education - Nursing 0 184 184 11.1(1 of 3) 85 2 7 N/A Total - Square Feet 9,658 4,741 14,399 11.1(1 of 3) 85 2 7 N/A Total - Square Feet 9,658 4,197 13,855 11.1(1 of 3) 85 2 7 N/A Total - Square Feet 9,658 4,144 13,802 To adjust the square footage statistics to agree with the provider's records. 42 CFR 413.24 and 413.50 / CMS Pub. 15-1, Sections 2304 and 2306 Page 9 This is trial version www.adultpdf.com . Report Audit Report Explanation of Audit Adjustments Adjustments COUNTRY VILLA REDLANDS HEALTHCARE JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT05650J RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS. Report Audit Report Explanation of Audit Adjustments Adjustments COUNTRY VILLA REDLANDS HEALTHCARE JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT05650J RECLASSIFICATIONS OF REPORTED COSTS 15 Not Reported. REDLANDS HEALTHCARE JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT05650J RECLASSIFICATIONS OF REPORTED COSTS 18 10.1(4) 100 14 8A-2 100.00 Other Ancillary Services $5,242 $1,5 61 $6,803 Not Reported