State of California Fiscal PeriodLTC55165JDepartment of Health Care Services Provider Number potx

State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 30 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 $144,206 ($143,867) $339 * Not Reported 8A-1 5.01 Plant Operations and Maintenance - Salaries and Wages 0 34,345 34,345 Not Reported 8A-1 5.02 Plant Operations and Maintenance - Fringe Benefits 0 9,472 9,472 Not Reported 8A-1 5.04 Plant Operations and Maintenance - Other - Nonlabor 0 100,050 100,050 * 2 10.1(4) 10 14 8A-1 10.00 Housekeeping $79,366 ($79,366) $0 Not Reported 8A-1 10.04 Housekeeping - Other - Nonlabor 0 79,366 79,366 * 3 10.1(4) 60 14 8A-1 60.00 Laundry and Linen $24,120 ($22,762) $1,358 * Not Reported 8A-1 60.04 Laundry and Linen - Other - Nonlabor 0 22,762 22,762 * 4 10.1(4) 65 14 8A-1 65.00 Dietary $298,312 ($296,887) $1,425 * Not Reported 8A-1 65.01 Dietary - Salaries and Wages 0 144,221 144,221 Not Reported 8A-1 65.02 Dietary - Fringe Benefits 0 41,862 41,862 Not Reported 8A-1 65.04 Dietary - Other - Nonlabor 0 110,804 110,804 * 5 10.1(4) 105 14 8A-1 105.00 Skilled Nursing Care $1,411,013 ($1,400,497) $10,516 * Not Reported 8A-1 105.01 Skilled Nursing Care - Salaries and Wages 0 1,060,651 1,060,651 Not Reported 8A-1 105.02 Skilled Nursing Care - Fringe Benefits 0 289,847 289,847 Not Reported 8A-1 105.04 Skilled Nursing Care - Other - Nonlabor 0 49,999 49,999 * 6 10.1(4) 155 14 8A-1 155.00 Social Services $37,156 ($37,156) $0 Not Reported 8A-1 155.01 Social Services - Salaries and Wages 0 27,840 27,840 Not Reported 8A-1 155.02 Social Services - Fringe Benefits 0 7,835 7,835 Not Reported 8A-1 155.04 Social Services - Other - Nonlabor 0 1,481 1,481 -Continued on next page- *Balance carried forward from prior/to subsequent adjustments Page 1 Adjustments HIGHLAND PARK SKILLED NURSING & WELLNESS CTR. FEBRUARY 15, 2008 THROUGH DECEMBER 31, 2008 LTC55165J 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 30 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments HIGHLAND PARK SKILLED NURSING & WELLNESS CTR. FEBRUARY 15, 2008 THROUGH DECEMBER 31, 2008 LTC55165J 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 $44,948 ($44,948) $0 Not Reported 8A-1 160.01 Activities - Salaries and Wages 0 35,046 35,046 Not Reported 8A-1 160.02 Activities - Fringe Benefits 0 9,135 9,135 Not Reported 8A-1 160.04 Activities - Other - Nonlabor 0 767 767 8 10.1(4) 165 14 8A-1 165.00 Administration $620,143 ($680,103) ($59,960) * Not Reported 8A-1 165.01 Administration - Salaries and Wages 0 166,609 166,609 * Not Reported 8A-1 165.02 Administration - Fringe Benefits 0 39,671 39,671 * Not Reported 8A-1 165.11 Administration - Other - Nonlabor 0 473,823 473,823 * 9 10.1(4) 170 14 8A-1 170.00 Inservice Education - Nursing $9,711 ($9,711) $0 Not Reported 8A-1 170.01 Inservice Education - Nursing - Salaries and Wages 0 7,465 7,465 Not Reported 8A-1 170.02 Inservice Education - Nursing - Fringe Benefits 0 2,246 2,246 To reclassify the 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 30 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments HIGHLAND PARK SKILLED NURSING & WELLNESS CTR. FEBRUARY 15, 2008 THROUGH DECEMBER 31, 2008 LTC55165J 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 * $339 ($339) $0 Not Reported 8A-1 5.04 Plant Operations and Maintenance - Other - Nonlabor * 100,050 339 100,389 11 10.1(4) 60 14 8A-1 60.00 Laundry and Linen * $1,358 ($1,358) $0 Not Reported 8A-1 60.04 Laundry and Linen - Other - Nonlabor * 22,762 1,358 24,120 * 12 10.1(4) 65 14 8A-1 65.00 Dietary * $1,425 ($1,425) $0 Not Reported 8A-1 65.04 Dietary - Other - Nonlabor * 110,804 1,425 112,229 * 13 10.1(4) 105 14 8A-1 105.00 Skilled Nursing Care * $10,516 ($10,516) $0 Not Reported 8A-1 105.04 Skilled Nursing Care - Other - Nonlabor * 49,999 10,516 60,515 * 14 10.1(4) 165 14 8A-1 165.00 Administration * ($59,960) ($1,054) ($61,014) * Not Reported 8A-1 165.06 Administration - Medical Records - Other - Nonlabor 0 1,054 1,054 * 15 10.1(4) 165 14 8A-1 165.00 Administration * ($61,014) $61,014 $0 Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 473,823 (61,014) 412,809 * To reclassify the provider's adjustments 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 State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 30 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments HIGHLAND PARK SKILLED NURSING & WELLNESS CTR. FEBRUARY 15, 2008 THROUGH DECEMBER 31, 2008 LTC55165J Report References Cost Report Audit Report Explanation of Audit Adjustments RECLASSIFICATIONS OF REPORTED COSTS 16 10.1(4) 35 14 8A-2 35.00 Leases and Rentals $231,784 $25,495 $257,279 * Not Reported 8A-2 65.04 Dietary - Other - Nonlabor * 112,229 (1,754) 110,475 10.1(4) 77 14 8A-2 77.00 Specialized Support Surfaces 15,023 (12,040) 2,983 10.1(4) 80 14 8A-2 80.00 Physical Therapy 112,314 (3,800) 108,514 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 60,515 (7,901) 52,614 To reclassify equipment rental expenses for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 17 Not Reported 8A-2 10.03 Housekeeping - Agency Staff $0 $74,441 $74,441 Not Reported 8A-2 10.04 Housekeeping - Other - Nonlabor * 79,366 (74,441) 4,925 18 Not Reported 8A-2 60.03 Laundry and Linen - Agency Staff $0 $48,997 $48,997 Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * 24,120 (48,997) (24,877) * To reclassify the labor portion of purchase services expenses to the Agency Staff line for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 19 Not Reported 8A-2 165.07 Administration - DHS Licensing Fees $0 $13,288 $13,288 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 412,809 (13,288) 399,521 * To reclassify DHS Licensing Fees to the appropriate audit report line number. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 20 Not Reported 8A-2 165.08 Administration - Liability Insurance $0 $48,914 $48,914 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 399,521 (48,914) 350,607 * To reclassify 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 4 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 30 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments HIGHLAND PARK SKILLED NURSING & WELLNESS CTR. FEBRUARY 15, 2008 THROUGH DECEMBER 31, 2008 LTC55165J Report References Cost Report Audit Report Explanation of Audit Adjustments RECLASSIFICATIONS OF REPORTED COSTS 21 Not Reported 8A-2 165.10 Administration - Quality Assurance Fees $0 $134,405 $134,405 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 350,607 (134,405) 216,202 * To reclassify Quality Assurance Fees to the appropriate audit report line number. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 22 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $166,609 ($28,930) $137,679 Not Reported 8A-2 165.03 Administration - Medical Records - Salaries and Wages 0 28,930 28,930 23 Not Reported 8A-2 165.02 Administration - Fringe Benefits * $39,671 ($5,693) $33,978 Not Reported 8A-2 165.04 Administration - Medical Records - Fringe Benefits 0 5,693 5,693 24 Not Reported 8A-2 165.06 Administration - Medical Records - Other - Nonlabor * $1,054 $9,716 $10,770 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 216,202 (9,716) 206,486 To reclassify medical records expense for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 25 Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * ($24,877) ($749) ($25,626) * 10.1(4) 145 14 8A-2 145.00 Other Nonreimbursable 0 749 749 To reclassify laundry expenses done for an unrelated facility to a nonreimbursable cost center. 42 CFR 413.9, 413.20 and 413.24 CMS Pub. 15-1, Section 2328 26 10.1(4) 35 14 8A-2 35.00 Leases and Rentals * $257,279 $16,315 $273,594 Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * (25,626) (16,315) (41,941) * To reclassify equipment rental 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 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 30 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments HIGHLAND PARK SKILLED NURSING & WELLNESS CTR. FEBRUARY 15, 2008 THROUGH DECEMBER 31, 2008 LTC55165J Report References Cost Report Audit Report Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED COSTS 27 Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * ($41,941) $124 ($41,817) * To adjust the reported expense to agree with the provider's invoices. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 28 10.1(4) 40 14 8A-2 40.00 Property Taxes $23,518 ($3,725) $19,793 To eliminate property tax penalties and fines not related to patient care and to agree with provider's invoices. 42 CFR 413.9(c)(3), 413.20 and 413.24 CMS Pub. 15-1, Sections 2102.3, 2122.1, 2300 and 2304 29 Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * ($41,817) $52,500 $10,683 To reverse the abatement of laundry revenue received from an unrelated facility since a nonreimbursable cost center is established by adjustment 25. 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 30 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments HIGHLAND PARK SKILLED NURSING & WELLNESS CTR. FEBRUARY 15, 2008 THROUGH DECEMBER 31, 2008 LTC55165J Report References Cost Report Audit Report Explanation of Audit Adjustments ADJUSTMENT TO REPORTED STATISTICS 30 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 221 221 Not Reported 7 10.00 Housekeeping 0 118 118 Not Reported 7 60.00 Laundry and Linen 0 521 521 Not Reported 7 65.00 Dietary 0 432 432 11.1 10 2 7 75.00 Patient Supplies 21 215 236 11.1 12 2 7 77.00 Specialized Support Surfaces 0 36 36 11.1 15 2 7 80.00 Physical Therapy 251 (83) 168 11.1 16 2 7 81.00 Respiratory Therapy 0 36 36 11.1 17 2 7 82.00 Occupational Therapy 0 108 108 11.1 20 2 7 85.00 Pharmacy 01515 11.1 40 2 7 105.00 Skilled Nursing Care 4,857 1,810 6,667 11.1 75 2 7 140.00 Beauty and Barber 01010 11.1 80 2 7 145.00 Other Nonreimbursable 0 521 521 Not Reported 7 155.00 Social Services 07272 Not Reported 7 160.00 Activities 0 1,723 1,723 Not Reported 7 165.00 Administration 0 316 316 Not Reported 7 165.00 Medical Records 08181 Not Reported 7 170.00 Inservice Education - Nursing 0 91 91 11.1 85 2 7 N/A Total - Square Feet 5,129 6,243 11,372 11.1 85 2 7 N/A Total - Square Feet 5,129 6,022 11,151 11.1 85 2 7 N/A Total - Square Feet 5,129 5,904 11,033 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 7 This is trial version www.adultpdf.com . 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 30 MC530 Adj State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 30 MC530 Adj. Page or As Increase As No. Exhibit. adjustments Page 2 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 30 MC530 Adj. Page or As Increase As No. Exhibit