State of California Fiscal Period JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 _part2 pot

State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 77 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 TOPANGA TERRACE CONVALESCENT CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06092G ADJUSTMENTS TO REPORTED STATISTICS 67 Not Reported 5.00 Plant Operations and Maintenance (Square Feet) 0 461 461 Not Reported 10.00 Housekeeping 0 168 168 Not Reported 65.00 Dietary 0 1,207 1,207 11.1 (1 of 3) 40 2 7 105.00 Skilled Nursing Care 7,203 198 7,401 11.1 (1 of 3) 60 2 7 125.00 Subacute Care 6,234 229 6,463 Not Reported 155.00 Social Services 08787 Not Reported 160.00 Activities 0 838 838 Not Reported 165.00 Administration 0 620 620 Not Reported 165.00 Medical Records 0 232 232 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 14,503 4,040 18,543 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 14,503 3,579 18,082 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 14,503 3,411 17,914 To establish the correct square footage in order to properly allocate indirect costs. 42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306 68 11.1(1 of 3) 60 4 7 125.00 Subacute Care (Clean, Dry Pounds) 161,920 (20) 161,900 11.1(1 of 3) 40 4 7 105.00 Skilled Nursing Care 213,760 20 213,780 To reclassify the reported laundry and linen statistics in order to properly allocate indirect costs 42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306 69 11.1(2 of 3) 40 6 7 105.00 Skilled Nursing Care (Patient Meals) 64,128 6 64,134 11.1(2 of 3) 60 6 7 125.00 Subacute Care 48,576 (20,343) 28,233 11.1(2 of 3) 85 6 7 N/A Total Statistics - Patient Meals 112,704 (20,337) 92,367 To adjust the reported patient meals statistics in order to properly allocate indirect costs. 42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306 Page 14 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 77 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 TOPANGA TERRACE CONVALESCENT CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06092G ADJUSTMENTS TO REPORTED PATIENT DAYS 70 4.1 05 6 1 12.00 Skilled Nursing Patient Days - Total 21,616 2 21,618 4.1 25 6 ASA1 36.00 Subacute Care Patient Days - Total 16,670 (2) 16,668 To reclassify the reported patient days to agree with the provider's patient census reports for proper cost determination. 42 CFR 413.20 and 413.50 CMS Pub. 15-1, Sections 2205 and 2304 71 4.3 (1) 100 1 ASA1 48.00 Subacute Patient Days - Ventilator 6,676 404 7,080 4.3 (1) 115 1 ASA1 49.00 Subacute Patient Days - Non Ventilator 9,994 (406) 9,588 To adjust the reported Subacute 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 15 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 77 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 TOPANGA TERRACE CONVALESCENT CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06092G ADJUSTMENTS TO REPORTED TOTAL CHARGES 72 13.1 10 2 ASA2 11.00 Patient Supplies $688,286 ($199,761) $488,525 13.1 20 2 ASA2 77.00 Pharmacy 1,428,741 (691,783) 736,958 13.1 25 2 ASA2 88.00 Laboratory 144,663 (14,746) 129,917 13.1 35 2 ASA2 99.00 Other Ancillary Services 172,454 9,664 182,118 To adjust the total ancillary charges to agree with the provider's general ledger and to account for the items included in the daily Medi-Cal rate. 42 CFR 413.20 and 413.50 CMS Pub. 15-1, Sections 2206, 2206.1 and 2304 CCR, Title 22, Sections 51511(c) and 51511.5 (d) 73 13.1 10 5 ASA2 11.00 Patient Supplies $409,433 ($67,203) $342,230 13.1 20 5 ASA2 77.00 Pharmacy 466,658 (225,951) 240,707 To adjust the total Subacute ancillary charges to agree with the provider's general ledger and to account for the items included in the daily Medi-Cal rate. 42 CFR 413.20 and 413.50 CMS Pub. 15-1, Sections 2206, 2206.1 and 2304 CCR, Title 22, Sections 51511(c) and 51511.5 (d) Page 16 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 77 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 TOPANGA TERRACE CONVALESCENT CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06092G ADJUSTMENT TO REPORTED MEDI-CAL SETTLEMENT DATA - SUBACUTE CARE 74 4.3 (1) 120 2 ASA1 44.00 Medi-Cal Subacute Patient Days - Total 15,670 (121) 15,549 4.3 (1) 100 2 ASA1 48.00 Medi-Cal Subacute Patient Days - Ventilator 6,504 (127) 6,377 To adjust Medi-Cal Settlement Data to agree with the following EDS Paid Claims Summary: Report Date: September 29, 2009 Payment Period: January 1, 2008 through August 31, 2009 Service Period: January 1, 2008 through December 31, 2008 42 CFR 413.20, 413.50, 413.53, 413.60 and 413.64 CMS Pub. 15-1, Sections 2304 and 2408 Page 17 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 77 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 TOPANGA TERRACE CONVALESCENT CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06092G ADJUSTMENTS TO OTHER MATTERS 75 Not Reported 1 14.00 Overpayments $0 $4,350 $4,350 To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed. 42 CFR 413.5 and 413.20 / CMS Pub. 15-1, Section 2409 76 Not Reported ASA1 41.00 Contracted Number of Adult Subacute Beds 0 48 48 To include the contracted Subacute beds in the audit report. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 77 Not Reported ASA1 48.00 Ventilator Equipment $0 $180,186 $180,186 To include ventilator equipment expense. 42 CFR 413.24 / CMS Pub. 15-1, Section 2304 Page 18 This is trial version www.adultpdf.com . 2009 Payment Period: January 1, 2008 through August 31, 2009 Service Period: January 1, 2008 through December 31, 2008 42 CFR 413.20, 413.50, 413.53, 413.60 and 413.64 CMS Pub. 15 -1, Sections. References Cost Report Audit Report Explanation of Audit Adjustments Adjustments TOPANGA TERRACE CONVALESCENT CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06092G ADJUSTMENTS TO REPORTED PATIENT. References Cost Report Audit Report Explanation of Audit Adjustments Adjustments TOPANGA TERRACE CONVALESCENT CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06092G ADJUSTMENTS TO REPORTED TOTAL