State of California Fiscal Period JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 _part3 pdf

State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 15 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted MEMORANDUM ADJUSTMENTS 1 10.7 075 1, 2, 3 7 075 Patient Supplies (Square Feet) 0 71 71 * 10.7 080 1, 2, 3 7 080 Physical Therapy 0 404 404 * 10.7 105 1, 2, 3 7 105 Skilled Nursing Care 0 5,474 5,474 * 10.7 140 1, 2, 3 7 140 Beauty and Barber 0 48 48 10.7 175 1, 2, 3 7 N/A Total - Square Feet 0 5,997 5,997 * 2 10.7 105 4 7 105 Skilled Nursing Care (Pounds of Laundry) 0 116,313 116,313 10.7 175 4 7 N/A Total - Pounds of Laundry 3 10.7 105 5 7 105 Skilled Nursing Care (Meals Served) 0 55,791 55,791 10.7 175 5 7 N/A Total - Meals Served To reconcile the provider’s reported statistics on page 10.7 to the 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 SANTA MARIA CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05563G Cost Report Explanation of Audit Adjustments Report References Audit Report This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 15 MC530 Adj. 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Line Sub No Reported (Decrease) Adjusted Adjustments SANTA MARIA CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05563G Cost Report Explanation of Audit Adjustments Report References Audit Report RECLASSIFICATIONS OF REPORTED COSTS 4 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other Nonlabor $86,681 ($12,559) $74,122 10.5 165 4 8A-2 165 4 Administration - Other Nonlabor 134,644 12,559 147,203 * To reclassify Medical Director salaries to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 5 10.5 167 4 8A-2 167 4 DPH Licensing Fees $22,905 ($8,781) $14,124 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * 147,203 8,781 155,984 * To reclassify DPH Licensing fees to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 6 10.5 168 4 8A-2 168 4 Liability Insurance $46,523 ($4,522) $42,001 * 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * 155,984 4,522 160,506 * To reclassify other than premium expenses to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 7 10.5 5 4 8A-2 5 4 Plant Operation and Maintenance - Other - Nonlabor $117,390 ($170) $117,220 10.5 35 4 8A-2 35 4 Leases and Rental 313,241 170 313,411 To reclassify leases and rental expenses to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 8 10.5 140 4 8A-2 140 4 Beauty and Barber $0 $1,836 $1,836 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * 160,506 (1,836) 158,670 * To reclassify beauty and barber expenses to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 *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 15 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments SANTA MARIA CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05563G Cost Report Explanation of Audit Adjustments Report References Audit Report RECLASSIFICATIONS OF REPORTED COSTS 9 10.5 65 3 8A-2 65 3 Dietary - Agency Staff $9,434 ($9,434) $0 10.5 65 4 8A-2 65 4 Dietary - Other - Nonlabor 116,391 9,434 125,825 To reclassify dietary consultant expenses to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 10 10.5 166 3 8A-2 166 3 Medical Records - Agency Staff $1,524 ($1,524) $0 10.5 166 4 8A-2 166 4 Medical Records - Other - Nonlabor 0 1,524 1,524 To reclassify medical record consultant expenses to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 *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 15 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments SANTA MARIA CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05563G Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENTS TO REPORTED COSTS 11 10.5 40 4 8A-2 40 4 Property Tax $13,577 ($6,190) $7,387 To eliminate property tax expenses due to lack of documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 12 10.5 168 4 8A-2 168 4 Liability Insurance * $42,001 $2,144 $44,145 To reconcile the reported liability insurance expenses to agree with the provider's general ledger. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 13 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $158,670 ($12,659) $146,011 To adjust home office costs to agree with the filed Eagleeye Management Home Office Cost Report for the fiscal period ended December 31, 2009. 42 CFR 413.17 / CMS Pub. 15-1, Sections 2150.2 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 15 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments SANTA MARIA CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05563G Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENT TO REPORTED STATISTICS 14 10.7 005 1, 2, 3 7 005 Plant Operation and Maintenance (Square Feet) 0 360 360 10.7 010 1, 2, 3 7 010 Housekeeping 04444 10.7 060 1, 2, 3 7 060 Laundry and Linen 0 444 444 10.7 065 1, 2, 3 7 065 Dietary 0 699 699 10.7 075 1, 2, 3 7 075 Patient Supplies * 71 23 94 10.7 080 1, 2, 3 7 080 Physical Therapy * 404 (53) 351 10.7 081 1, 2, 3 7 081 Respiratory Therapy 0 24 24 10.7 082 1, 2, 3 7 082 Occupational Therapy 0 50 50 10.7 083 1, 2, 3 7 105 Skilled Nursing Care * 5,474 (776) 4,698 10.7 160 1, 2, 3 7 160 Activities 0 292 292 10.7 165 1, 2, 3 7 165 Administration 0 664 664 10.7 166 1, 2, 3 7 166 Medical Records 0 174 174 10.7 175 1 7 N/A Total - Square Feet * 5,997 1,945 7,942 10.7 175 2 7 N/A Total - Square Feet * 5,997 1,585 7,582 10.7 175 3 7 N/A Total - Square Feet * 5,997 1,541 7,538 To adjust the correct square footage in order to properly allocate indirect costs. 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 15 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments SANTA MARIA CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05563G Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENT TO REPORTED PATIENT DAYS 15 4.1 70 6 1 12 N/A Total Patient Days 18,705 (1) 18,704 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 SANTA MARIA CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05563G Cost Report Explanation of Audit Adjustments Report References Audit Report RECLASSIFICATIONS OF REPORTED COSTS 4 10.5. CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05563G Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENT TO REPORTED STATISTICS 14 10.7 005 1, 2, 3 7. 413.24/CMS Pub. 15 -1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 1 Adjustments SANTA MARIA CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05563G Cost