STATE OF CALIFORNIA Provider Name: NEW VISTA NURSING & REHABILITATION CENTER 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-1 Page 2 Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period: ZZT06031H 1386631885 206190236 JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 10 11 12 13 14 15 16 17 RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT 4,477 7,650 4,652 2,060 55,635 469,722 (525,071) (4,477) (4,652) (2,060) (55,635) (469,722) 525,071 000000000000 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: NEW VISTA NURSING & REHABILITATION CENTER ZZT06031H 1386631885 206190236 JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Pages 1 & 2) 18 19 20 21 22 23 24 25 26 5.00 Plant Operations and Maintenance 0 5.01 Plant Operations and Maintenance - Salaries and Wages 0 5.02 Plant Operations and Maintenance - Fringe Benefits 0 5.03 Plant Operations and Maintenance - Agency Staff 0 5.04 Plant Operations and Maintenance - Other - Nonlabor 0 10.00 Housekeeping 0 10.01 Housekeeping - Salaries and Wages 0 10.02 Housekeeping - Fringe Benefits 0 10.03 Housekeeping - Agency Staff 0 10.04 Housekeeping - Other - Nonlabor (475) (475) 15.00 Depreciation: Bldgs and Improvements 0 20.00 Depreciation: Leasehold Improvements 0 25.00 Depreciation: Equipment 0 30.00 Depreciation and Amortization - Other 0 35.00 Leases and Rentals (515,777) 1,754 4,469 (522,000) 40.00 Property Taxes 65,154 65,154 45.00 Property Insurance 20,240 20,240 50.00 Interest-Property, Plant, and Equipment 166,994 166,994 55.00 Interest-Other 0 60.00 Laundry and Linen 0 60.01 Laundry and Linen - Salaries and Wages 0 60.02 Laundry and Linen - Fringe Benefits 0 60.03 Laundry and Linen - Agency Staff 0 60.04 Laundry and Linen - Other - Nonlabor 0 65.00 Dietary 0 65.01 Dietary - Salaries and Wages 0 65.02 Dietary - Fringe Benefits 0 65.03 Dietary - Agency Staff 0 65.04 Dietary - Other - Nonlabor 0 70.00 Provision for Bad Debts 0 75.00 Patient Supplies 0 75.01 Patient Supplies - Salaries and Wages 0 75.02 Patient Supplies - Fringe Benefits 0 75.03 Patient Supplies - Agency Staff 0 75.04 Patient Supplies - Other - Nonlabor 0 77.00 Specialized Support Surfaces 0 80.00 Physical Therapy 0 80.01 Physical Therapy - Salaries and Wages 0 80.02 Physical Therapy - Fringe Benefits 0 80.03 Physical Therapy - Agency Staff 0 80.04 Physical Therapy - Other - Nonlabor 0 81.00 Respiratory Therapy 0 81.01 Respiratory Therapy - Salaries and Wages 0 81.02 Respiratory Therapy - Fringe Benefits 0 81.03 Respiratory Therapy - Agency Staff 0 81.04 Respiratory Therapy - Other - Nonlabor 0 82.00 Occupational Therapy 0 82.01 Occupational Therapy - Salaries and Wages 0 ADJUSTMENTS TO REPORTED COSTS 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: NEW VISTA NURSING & REHABILITATION CENTER ZZT06031H 1386631885 206190236 JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Pages 1 & 2) 18 19 20 21 22 23 24 25 26 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 0 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 0 105.02 Skilled Nursing Care - Fringe Benefits 0 105.03 Skilled Nursing Care - Agency Staff 0 105.04 Skilled Nursing Care - Other - Nonlabor 924 110.00 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: NEW VISTA NURSING & REHABILITATION CENTER ZZT06031H 1386631885 206190236 JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Pages 1 & 2) 18 19 20 21 22 23 24 25 26 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 0 145.00 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 0 165.00 Administration 0 165.01 Administration - Salaries and Wages (61,420) (61,420) 165.02 Administration - Fringe Benefits (10,278) (10,278) 165.03 Administration - Medical Records - Salaries and Wages 0 165.04 Administration - Medical Records - Fringe Benefits 0 165.05 Administration - Medical Records - Agency Staff 0 165.06 Administration - Medical Records - Other - Nonlabor 0 165.07 Administration - Facility License Fees 0 165.08 Administration - Liability Insurance 0 165.09 Administration - Caregiver Training 0 165.10 Administration - Quality Assurance Fees 0 165.11 Administration - Other - Nonlabor 5,921 (1,754) (4,469) 15,831 (682) (1,945) (1,060) 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 0 175.00 Total ($328,717) 0 0 (71,698) (522,000) 268,219 (682) (1,945) (1,060) (475) (To Sch 8) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: NEW VISTA NURSING & REHABILITATION CENTER 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: ZZT06031H 1386631885 206190236 JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 27 ADJUSTMENTS TO REPORTED COSTS This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: NEW VISTA NURSING & REHABILITATION CENTER 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: ZZT06031H 1386631885 206190236 JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 27 ADJUSTMENTS TO REPORTED COSTS 924 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: NEW VISTA NURSING & REHABILITATION CENTER 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: ZZT06031H 1386631885 206190236 JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 27 ADJUSTMENTS TO REPORTED COSTS 924000000000 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 28 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 $716,944 ($729,871) ($12,927) * Not Reported 8A-1 5.01 Plant Operations and Maintenance - Salaries and Wages 0 239,859 239,859 Not Reported 8A-1 5.02 Plant Operations and Maintenance - Fringe Benefits 0 74,635 74,635 Not Reported 8A-1 5.04 Plant Operations and Maintenance - Other - Nonlabor 0 415,377 415,377 * 2 10.1(4) 10 14 8A-1 10.00 Housekeeping $218,595 ($218,595) $0 Not Reported 8A-1 10.01 Housekeeping - Salaries and Wages 0 91,052 91,052 Not Reported 8A-1 10.02 Housekeeping - Fringe Benefits 0 28,681 28,681 Not Reported 8A-1 10.04 Housekeeping - Other - Nonlabor 0 98,862 98,862 * 3 10.1(4) 60 14 8A-1 60.00 Laundry and Linen $237,688 ($237,688) $0 Not Reported 8A-1 60.01 Laundry and Linen - Salaries and Wages 0 111,295 111,295 Not Reported 8A-1 60.02 Laundry and Linen - Fringe Benefits 0 38,796 38,796 Not Reported 8A-1 60.04 Laundry and Linen - Other - Nonlabor 0 87,597 87,597 4 10.1(4) 65 14 8A-1 65.00 Dietary $530,508 ($530,508) $0 Not Reported 8A-1 65.01 Dietary - Salaries and Wages 0 223,097 223,097 Not Reported 8A-1 65.02 Dietary - Fringe Benefits 0 73,362 73,362 Not Reported 8A-1 65.04 Dietary - Other - Nonlabor 0 234,049 234,049 5 10.1(4) 105 14 8A-1 105.00 Skilled Nursing Care $3,904,464 ($3,904,464) $0 Not Reported 8A-1 105.01 Skilled Nursing Care - Salaries and Wages 0 2,636,321 2,636,321 Not Reported 8A-1 105.02 Skilled Nursing Care - Fringe Benefits 0 873,156 873,156 Not Reported 8A-1 105.04 Skilled Nursing Care - Other - Nonlabor 0 394,987 394,987 * 6 10.1(4) 155 14 8A-1 155.00 Social Services $128,382 ($128,382) $0 Not Reported 8A-1 155.01 Social Services - Salaries and Wages 0 96,897 96,897 Not Reported 8A-1 155.02 Social Services - Fringe Benefits 0 22,647 22,647 Not Reported 8A-1 155.04 Social Services - Other - Nonlabor 0 8,838 8,838 -Continued on next page- *Balance carried forward from prior/to subsequent adjustments Page 1 Adjustments NEW VISTA NURSING & REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06031H Report References Cost Report Audit Report Explanation of Audit Adjustments This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 28 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments NEW VISTA NURSING & REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06031H Report References Cost Report Audit Report Explanation of Audit Adjustments 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 $121,605 ($121,605) $0 Not Reported 8A-1 160.01 Activities - Salaries and Wages 0 79,547 79,547 Not Reported 8A-1 160.02 Activities - Fringe Benefits 0 30,011 30,011 Not Reported 8A-1 160.04 Activities - Other - Nonlabor 0 12,047 12,047 8 10.1(4) 165 14 8A-1 165.00 Administration $1,640,410 ($1,659,535) ($19,125) * Not Reported 8A-1 165.01 Administration - Salaries and Wages 0 288,407 288,407 * Not Reported 8A-1 165.02 Administration - Fringe Benefits 0 62,829 62,829 * Not Reported 8A-1 165.03 Administration - Medical Records - Salaries and Wages 0 87,388 87,388 Not Reported 8A-1 165.04 Administration - Medical Records - Fringe Benefits 0 16,517 16,517 Not Reported 8A-1 165.06 Administration - Medical Records - Other - Nonlabor 0 21,493 21,493 Not Reported 8A-1 165.07 Administration - Facility License Fees 0 29,455 29,455 Not Reported 8A-1 165.08 Administration - Liability Insurance 0 115,399 115,399 Not Reported 8A-1 165.10 Administration - Quality Assurance Fees 0 360,546 360,546 Not Reported 8A-1 165.11 Administration - Other - Nonlabor 0 677,501 677,501 * 9 10.1(4) 170 14 8A-1 170.00 In-Service Education - Nursing $126,073 ($126,073) $0 Not Reported 8A-1 170.01 In-Service Education - Nursing - Salaries and Wages 0 93,249 93,249 Not Reported 8A-1 170.02 In-Service Education - Nursing - Fringe Benefits 0 31,599 31,599 Not Reported 8A-1 170.04 Inservice Education - Nursing - Other - Nonlabor 0 1,225 1,225 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 State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 28 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments NEW VISTA NURSING & REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06031H Report References Cost Report Audit Report Explanation of Audit Adjustments RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT 10 10.1(4) 5 14 8A-1 5.00 Plant Operations and Maintenance * ($12,927) $12,927 $0 Not Reported 8A-1 5.04 Plant Operations and Maintenance - Other - Nonlabor * 415,377 (12,927) 402,450 To reclassify the provider's elimination of radio and television service expense for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 11 10.1(4) 165 14 8A-1 165.00 Administration * ($19,125) $4,477 ($14,648) * Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 677,501 (4,477) 673,024 * To reclassify the provider's revenue abatement on other operating revenue for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 12 10.1(4) 165 14 8A-1 165.00 Administration * ($14,648) $7,650 ($6,998) * Not Reported 8A-1 105.04 Skilled Nursing Care - Other - Nonlabor * 394,987 (7,650) 387,337 * To reclassify the provider's elimination of inpatient utilization expense for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 13 10.1(4) 165 14 8A-1 165.00 Administration * ($6,998) $4,652 ($2,346) * Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 673,024 (4,652) 668,372 * To reclassify the provider's elimination of advertising promotions expense for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 14 10.1(4) 165 14 8A-1 165.00 Administration * ($2,346) $2,060 ($286) * Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 668,372 (2,060) 666,312 * To reclassify the provider's elimination of dues and subscriptions (CAHF Lobbying) 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 3 This is trial version www.adultpdf.com . 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 10 11 12 13 14 15 16 17 RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS. 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 27 ADJUSTMENTS TO REPORTED COSTS This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider. 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 27 ADJUSTMENTS TO REPORTED COSTS 924 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider