alden terrace convalescent hospital
TRANSCRIPT
REPORT ON THE
RATE SETTING AUDIT
ALDEN TERRACE CONVALESCENT HOSPITAL LOS ANGELES, CALIFORNIA
NATIONAL PROVIDER IDENTIFIER: 1568544781
FISCAL PERIOD ENDED MAY 31, 2011
Audits Section—Gardena Financial Audits Branch
Audits and Investigations Department of Health Care Services
Section Chief: Maria Delgado Audit Supervisor: Deborah Lee Auditor: Angela Guan
State of California—Health and Human Services Agency
Department of Health Care Services
EDMUN
GD G. BROWN JR.
OVERNOR
February 13, 2013 Renita Chan, Administrator Alden Terrace Convalescent Hospital 1240 South Hoover Street Los Angeles, CA 90006 ALDEN TERRACE CONVALESCENT HOSPITAL NATIONAL PROVIDER IDENTIFIER (NPI): 1568544781 FISCAL PERIOD ENDED: MAY 31, 2011 We have examined the facility's Integrated Disclosure and Medi-Cal Cost Report for tabove-referenced fiscal period. Our examination was made under the authority of Section 14170 of the Welfare and Institutions Code and was limited to a review of thecost report and accompanying financial statements, Medi-Cal payment data reports, prior fiscal period's Medi-Cal program audit report, and Medicare audit report for the current fiscal period, if applicable and available. In our opinion, the data presented in the accompanying Summary of Audited Facility Cost per Patient Day represents a proper determination of the allowable costs and patient days for the above fiscal period in accordance with Medi-Cal reimbursement principles. This audit report includes the: 1. Summary of Audited Facility Cost per Patient Day and supporting schedules 2. Audit adjustments that include a summary of the total due the State in the
amount of $35,298 which resulted from Medi-Cal overpayments 3. Audited Allocation of Home Office Cost
he
The audit settlement will be incorporated into a Statement(s) of Account Status, which provider, f
ry. t Status.
may reflect tentative retroactive adjustment determinations, payments from the and other financial transactions initiated by the Department. The Statement(s) oAccount Status will be forwarded to the provider by the State’s fiscal intermediaInstructions regarding payment will be included with the Statement(s) of Accoun
Financial Audits Branch/Audits Section—Gardena
19300 South Hamilton Avenue, Suite 280, MS 2103, Gardena, CA 90248 Telephone: (310) 516-4757 FAX: (310) 217-6918
Internet Address: www.dhcs.ca.gov
TOBY DOUGLAS DIRECTOR
Renita Chan Page 2 Future Medi-Cal long-term care prospective rates may be affected by this examination. The extent to which the rates change will be determined by the Department's Fee-For-Service Rates Development Division.
Notwithstanding this audit report, overpayments to the provider are subject to recovery pursuant to Section 51458.1, Article 6 of Division 3, Title 22, California Code of Regulations. If you disagree with the decision of the Department, you may appeal by writing to: Chief Department of Health Care Services Office of Administrative Hearings and Appeals 1029 J Street, Suite 200 Sacramento, CA 95814 (916) 322-5603 The written notice of disagreement must be received by the Department within 60 calendar days from the day you receive this letter. A copy of this notice should be sent to: United States Postal Service (USPS) Courier (UPS, FedEx, etc.) Assistant Chief Counsel Assistant Chief Counsel Department of Health Care Services Department of Health Care Services Office of Legal Services Office of Legal Services MS 0010 MS 0010 PO Box 997413 1501 Capitol Avenue, Suite 71.5001 Sacramento, CA 95899 Sacramento, CA 95814 (916) 440-7700 The procedures that govern an appeal are contained in Welfare and Institutions Code, Section 14171, and California Code of Regulations, Title 22, Section 51016, et seq. If you have questions regarding this report, you may call the Audits Section—Gardena at (310) 516-4757. Original Signed By: Maria Delgado, Chief Audits Section—Gardena Financial Audits Branch
Renita Chan Page 3 Certified cc: Zaid Pervaiz Corporate Controller Longwood Management Corporation 4032 Wilshire Boulevard, Suite 600 Los Angeles, CA 90010
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STATE OF CALIFORNIA SCHEDULE 1
SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY
Provider Name: Fiscal Period:
ALDEN TERRACE CONVALESCENT HOSPITAL JUNE 1, 2010 THROUGH MAY 31, 2011
Provider NPI: OSHPD Facility No.:
1568544781 206190013
Line No.
PROGRAM DESCRIPTION AS REPORTED AS AUDITED
COST PER
AUDITED
PATIENT DAY
SKILLED NURSING CARE
1 Cost of Direct Care - Labor (Sch. 2, Ln. 105) $ N/A $ 4,579,043 $ 62.58
2 Cost of Indirect Care - Labor (Sch. 3, Ln. 105) $ N/A $ 1,256,910 $ 17.18
3 Cost of Direct and Indirect Nonlabor - Other (Sch. 4, Ln. 105) $ N/A $ 1,092,426 $ 14.93
4 Cost of Capital Related (Sch. 5, Ln. 105) $ N/A $ 190,889 $ 2.61
5 Property Taxes (Sch. 5, Ln. 105) $ N/A $ 77,021 $ 1.05
6 CDPH Licensing Fees (Sch. 6, Ln. 105) $ N/A $ 41,964 $ 0.57
7 Professional Liability Insurance (Sch. 6, Ln. 105) $ N/A $ 125,954 $ 1.72
8 Caregiver Training (Sch. 6, Ln. 105) $ N/A $ 0 $ 0.00
9 Quality Assurance Fees (Sch. 6, Ln. 105) $ N/A $ 716,371 $ 9.79
10 Cost of Administration (Sch. 6, Ln. 105) $ N/A $ 925,138 $ 12.64
11 Cost of Routine Service/Audited Total Costs $ 9,663,471.00 $ 9,005,716 $ 123.08
12 Total Patient Days (Adj 9) 73,156 73,167
13 Cost Per Patient Day (Cost Divided by Days) $ 132.09 $ 123.08
14 Overpayments (Adj 11) $ 0 $ 35,298
15 Medi-Cal Days (Adj 10) 57,067 57,201
16 Medi-Cal Managed Care Days (Adj ) 0
INTERMEDIATE CARE
$ $ 0
1
17 Cost of Routine Service (Sch. 2, 3, 4, 5, 6)
8 Total Patient Days (Adj ) 0
19 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
20 Overpayments (Adj ) $ $ 0
MENTALLY DISORDERED CARE
21 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0
22 Total Patient Days (Adj ) 0
23 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
24 Overpayments (Adj ) $ $ 0
DEVELOPMENTALLY DISABLED CARE
25 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0
26 Total Patient Days (Adj ) 0
27 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
28 Overpayments (Adj ) $ $ 0
SUBACUTE CARE
29 Cost of Direct Care - Labor (Subacute Care Sch. 1, Ln. 25) $ N/A $ 0 $ 0.00
30 Cost of Indirect Care - Labor (Subacute Care Sch. 1, Ln. 26) $ N/A $ 0 $ 0.00
31 Cost of Direct and Indirect Nonlabor - Other (Subacute Care Sch. 1, Ln. 27) $ N/A $ 0 $ 0.00
32 Cost of Capital Related (Subacute Care Sch. 1, Ln. 28) $
33 Property Taxes (Subacute Care Sch. 1, Ln. 29) $
34 CDPH Licensing Fees (Subacute Care Sch. 1, Ln. 30) $
35 Professional Liability Insurance (Subacute Care Sch. 1, Ln. 31) $
36 Quality Assurance Fees (Subacute Care Sch. 1, Ln. 32) $
37 Caregiver Training (Subacute Care Sch. 1, Ln. 33) $
38 Cost of Administration (Subacute Care Sch.1, Ln. 34) $
39 Total Cost of Subacute Service (Subacute Care Sch. 1, Ln. 35) $
40 Total Patient Days (Subacute Care Sch. 1, Ln. 36)
41 Cost Per Patient Day (Cost Divided by Days) $
42 Amount Due Provider (State) (Subacute Care Sch. 1, Ln. 40) $
STATE OF CALIFORNIA SCHEDULE 1
SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY
Provider Name: Fiscal Period:
ALDEN TERRACE CONVALESCENT HOSPITAL JUNE 1, 2010 THROUGH MAY 31, 2011
Provider NPI: OSHPD Facility No.:
1568544781 206190013
Line No.
PROGRAM DESCRIPTION AS REPORTED AS AUDITED
COST PER
AUDITED
PATIENT DAY
SUBACUTE CARE - PEDIATRIC
43 Cost of Routine Service (Subacute Care - Pediatric, Sch. 1, Ln 3) $ 0 $ 0
44 Cost of Ancillary Service (Subacute Care - Pediatric, Sch. 1, Ln. 1 + Ln. 2) $ 0 $ 0
45 Total Cost of Subacute Care - Pediatric Service (Ln. 43 + Ln. 44) $ 0 $ 0
46 Total Patient Days (Subacute Care - Pediatric, Sch. 1, Ln. 5) 0 0
47 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
48 Amount Due Provider (State) (Subacute Care - Pediatric, Sch. 1, Ln. 9) $ 0 $ 0
TRANSITIONAL INPATIENT CARE
49 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0
50 Total Patient Days (Adj ) 0
51 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
52 Overpayments (Adj ) $ $ 0
HOSPICE INPATIENT CARE
53 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0
54 Total Patient Days (Adj ) 0
55 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
56 Overpayments (Adj ) $ $ 0
OTHER ROUTINE SERVICES
57 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0
58 Total Patient Days (Adj ) 0
59 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
60 Overpayments (Adj ) $ $ 0
STATE OF CALIFORNIA SCHEDULE 2
ALLOCATION OF GENERAL SERVICES
DIRECT CARE LABOR
Provider Name: Fiscal Period:
ALDEN TERRACE CONVALESCENT HOSPITAL JUNE 1, 2010 THROUGH MAY 31, 2011
Provider NPI: OSHPD Facility No.:
1568544781 206190013
Line No.
DESCRIPTION
Net Exp For
Cost Alloc (From Sch 8)
Soc Srvs
155
Activities
160 Total
GENERAL SERVICES
005 Plant Operations and Maintenance
010 Housekeeping
060 Laundry and Linen
065 Dietary
155 Social Services 87,912$ 87,912$
160 Activities 151,258 151,258$
165 Administration
166 Medical Records
170 Inservice Education - Nursing
ANCILLARY SERVICES
075 Patient Supplies 0 0 0 0
077 Specialized Support Surfaces N/A 0 0 0
080 Physical Therapy 756,046 0 0 756,046
081 Respiratory Therapy 0 0 0 0
082 Occupational Therapy 782,962 0 0 782,962
083 Speech Pathology 130,203 0 0 130,203
085 Pharmacy 0 0 0 0
090 Laboratory 0 0 0 0
095 Home Health Services 0 0 0 0
100 Other Ancillary Services 0 0 0 0
101 Subacute Care Ancillary Services 0 0 0 0
102 Subacute Care - Pediatric Ancillary Services 0 0 0 0
ROUTINE SERVICES
105 Skilled Nursing Care 4,339,873 87,912 151,258 4,579,043
110 Intermediate Care 0 0 0 0
115 Mentally Disordered Care 0 0 0 0
120 Developmentally Disabled Care 0 0 0 0
125 Subacute Care 0 0 0 0
126 Subacute Care - Pediatric 0 0 0 0
128 Transitional Inpatient Care 0 0 0 0
130 Hospice Inpatient Care 0 0 0 0
135 Other Routine Services 0 0 0 0
NONREIMBURSABLE
139 Residential Care 0 0 0 0
140 Beauty and Barber 0 0 0 0
145 Other Nonreimbursable 0 0 0 0
TOTAL 6,248,254$ 87,912$ 151,258$ $ 6,248,254
*
*
*
*
*
*
*
*
*
* (To Schedule 1)
ST
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:
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Net
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r
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st A
lloc
(Fro
m S
ch 8
)
Pla
nt
Op
s
005
Hsk
pn
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010
Lau
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060
Die
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So
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155
Act
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160
Inse
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170
Acc
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ted
C
ost
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Ad
min
165
Med
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166
To
tal
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L S
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Pla
nt O
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15
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158,
198
$
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Hou
seke
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5,83
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$
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Laun
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2,63
4 4,
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7,56
7 17
4,39
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Die
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44
2,26
6 13
,175
23
,805
0
479,
246
$
155
Soc
ial S
ervi
ces
N/A
86
4 1,
562
0 0
2,42
6$
160
Act
iviti
es
N/A
0
0 0
0 0
-$
165
Adm
inis
trat
ion
N/A
5,
343
9,65
3 0
0 0
0 14
,996
$ 14
,996
$
166
Med
ical
Rec
ords
13
3,92
5 1,
378
2,49
0 0
0 0
0 13
7,79
3 13
7,79
3$
170
Inse
rvic
e E
duca
tion
- N
ursi
ng
121,
424
0 0
0 0
0 0
121,
424
$
AN
CIL
LA
RY
SE
RV
ICE
S
075
Pat
ient
Sup
plie
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2,42
4 0
0 0
0 0
3,76
6 45
41
1 4,
222
$
077
Spe
cial
ized
Sup
port
Sur
face
s 0
0 0
0 0
0 0
0 0
0 0
080
Phy
sica
l The
rapy
1,
523
2,75
2 0
0 0
0 0
4,27
5 1,
242
11,4
13
16,9
30
081
Res
pira
tory
The
rapy
0
0 0
0 0
0 0
0 0
0 0
082
Occ
upat
iona
l The
rapy
66
5 1,
201
0 0
0 0
0 1,
866
1,27
5 11
,713
14
,853
083
Spe
ech
Pat
holo
gy
0 0
0 0
0 0
0
0
211
1,
935
2,14
5
085
Pha
rmac
y 0
0 0
0 0
0 0
0
70
5
6,48
1 7,
187
090
Labo
rato
ry
0 0
0 0
0 0
0
0 59
53
9
598
095
Hom
e H
ealth
Ser
vice
s 0
0 0
0 0
0 0
0 0
0 0
100
Oth
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Ser
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0 0
0 0
0 0
0
52
479
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1
101
Sub
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Anc
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0 0
0 0
0 0
0 0
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102
Sub
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RV
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S
105
Ski
lled
Nur
sing
Car
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0 12
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4 1,
140,
772
11,3
98
104,
739
1,25
6,91
0
110
Inte
rmed
iate
Car
e 0
0 0
0 0
0 0
0 0
0 0
115
Men
tally
Dis
orde
red
Car
e 0
0 0
0 0
0 0
0 0
0 0
120
Dev
elop
men
tally
Dis
able
d C
are
0 0
0 0
0 0
0 0
0 0
0
125
Sub
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are
0 0
0 0
0 0
0 0
0 0
0
126
Sub
acut
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are
- P
edia
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0
0 0
0 0
0 0
0 0
0 0
128
Tra
nsiti
onal
Inpa
tient
Car
e 0
0 0
0 0
0 0
0 0
0 0
130
Hos
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Inpa
tient
Car
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0 0
0 0
0 0
0 0
0 0
135
Oth
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0 0
0 0
0 0
0 0
0 0
0
NO
NR
EIM
BU
RS
AB
LE
139
Res
iden
tial C
are
0 0
0 0
0 0
0 0
0 0
0
140
Bea
uty
and
Bar
ber
290
524
0 0
0 0
0 81
4 9
81
904
145
Oth
er N
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le
0 0
0 0
0 0
0 0
0 0
0
TO
TA
L 1,
304,
281
$ 15
8,19
8$
285,
834
$ 17
4,39
0$
479,
246
$ 2,
426
$ -
$ 12
1,42
4$
1,15
1,49
3$
14,9
96$
137,
793
$ 1,
304,
281
$
* * * * * * * * *
* (T
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ule
1)
ST
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NO
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Pro
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P
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: F
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JUN
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)
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Lau
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Act
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160
Inse
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170
Acc
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C
ost
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Ad
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165
Med
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s
166
To
tal
GE
NE
RA
L S
ER
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Pla
nt O
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$
010
Hou
seke
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0
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060
Laun
dry
and
Line
n 18
,726
11
,622
2,
315
32,6
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065
Die
tary
35
8,29
9 36
,559
7,
282
0 40
2,14
0$
155
Soc
ial S
ervi
ces
0 2,
398
478
0 0
2,87
6$
160
Act
iviti
es
268
0 0
0 0
0
268
$
165
Adm
inis
trat
ion
N/A
14
,825
2,
953
0 0
0 0
17,7
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17,7
78$
166
Med
ical
Rec
ords
7,
636
3,82
4 76
2 0
0 0
0 12
,221
12
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$
170
Inse
rvic
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duca
tion
- N
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ng
0 0
0 0
0 0
0 -
$
AN
CIL
LA
RY
SE
RV
ICE
S
075
Pat
ient
Sup
plie
s 17
,106
3,
723
742
0 0
0 0
0 21
,570
53
36
21
,660
$
077
Spe
cial
ized
Sup
port
Sur
face
s 0
0 0
0 0
0 0
0 0
0 0
0
080
Phy
sica
l The
rapy
0
4,22
6 84
2 0
0 0
0 0
5,06
8 1,
473
1,01
2 7,
553
081
Res
pira
tory
The
rapy
0
0 0
0 0
0 0
0 0
0 0
0
082
Occ
upat
iona
l The
rapy
0
1,84
5 36
7 0
0 0
0 0
2,21
2 1,
511
1,03
9 4,
762
083
Spe
ech
Pat
holo
gy
0 0
0 0
0 0
0 0
0
25
0
172
42
1
085
Pha
rmac
y 43
6,16
1 0
0 0
0 0
0 0
436,
161
836
575
437,
572
090
Labo
rato
ry
36,2
85
0 0
0 0
0 0
0 36
,285
70
48
36
,402
095
Hom
e H
ealth
Ser
vice
s 0
0 0
0 0
0 0
0 0
0 0
0
100
Oth
er A
ncill
ary
Ser
vice
s 32
,254
0
0 0
0 0
0 0
32,2
54
62
43
32,3
58
101
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
0 0
0 0
0 0
0 0
0 0
0 0
102
Sub
acut
e C
are
- P
edia
tric
Anc
illar
y S
ervi
ces
0 0
0 0
0 0
0 0
0 0
0 0
RO
UT
INE
SE
RV
ICE
S
105
Ski
lled
Nur
sing
Car
e 20
0,99
5 35
9,14
8 71
,535
32
,662
40
2,14
0 2,
876
268
0 1,
069,
624
13,5
13
9,29
0 1,
092,
426
110
Inte
rmed
iate
Car
e 0
0 0
0 0
0 0
0 0
0 0
115
Men
tally
Dis
orde
red
Car
e 0
0 0
0 0
0 0
0 0
0 0
120
Dev
elop
men
tally
Dis
able
d C
are
0 0
0 0
0 0
0 0
0 0
0
125
Sub
acut
e C
are
0 0
0 0
0 0
0 0
0 0
0 0
126
Sub
acut
e C
are
- P
edia
tric
0
0 0
0 0
0 0
0 0
0 0
0
128
Tra
nsiti
onal
Inpa
tient
Car
e 0
0 0
0 0
0 0
0 0
0 0
130
Hos
pice
Inpa
tient
Car
e 0
0 0
0 0
0 0
0 0
0 0
135
Oth
er R
outin
e S
ervi
ces
0 0
0 0
0 0
0 0
0 0
0
NO
NR
EIM
BU
RS
AB
LE
139
Res
iden
tial C
are
0 0
0 0
0 0
0 0
0 0
0 0
140
Bea
uty
and
Bar
ber
3,16
5 80
5 16
0 0
0 0
0 0
4,13
0 10
7
4,14
8
145
Oth
er N
onre
imbu
rsab
le
0 0
0 0
0 0
0 0
0 0
0 0
TO
TA
L 1,
637,
303
$ 43
8,97
3$
87,4
35$
32,6
62$
402,
140
$ 2,
876
$ 26
8$
-$
1,60
7,30
4$
17,7
78$
12,2
21$
1,63
7,30
3$
* * * * * * * * *
* (T
o S
ched
ule
1)
STATE OF CALIFORNIA SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Provider Name: Fiscal Period:
ALDEN TERRACE CONVALESCENT HOSPITAL JUNE 1, 2010 THROUGH MAY 31, 2011
Provider NPI: OSHPD Facility Number:
1568544781 206190013
Line No.
DESCRIPTION
Net Exp For
Cost Alloc (From Sch 8) Ratio
Capital
Various
Plant Ops
5
Hskpng
10
Laundry
60
Dietary
65
Soc Srvs
155
Activities
160
GENERAL SERVICES
Capital Related (excluding lines 40 & 45) 197,676$ 71%
Property Tax (line 40) 79,760 29% 277,436$
005 Plant Operations and Maintenance 7,788 7,788$
010 Housekeeping 0 0 -$
060 Laundry and Linen 7,139 206 0 7,345$
065 Dietary 22,457 649 0 0 23,106$
155 Social Services 1,473 43 0 0 0 1,516$
160 Activities 0 0 0 0 0 0 -$
165 Administration 9,106 263 0 0 0 0 0
166 Medical Records 2,349 68 0 0 0 0 0
170 Inservice Education - Nursing 0 0 0 0 0 0 0
ANCILLARY SERVICES
075 Patient Supplies 2,287 66 0 0 0 0 0
077 Specialized Support Surfaces 0 0 0 0 0 0 0
080 Physical Therapy 2,596 75 0 0 0 0 0
081 Respiratory Therapy 0 0 0 0 0 0 0
082 Occupational Therapy 1,133 33 0 0 0 0 0
083 Speech Pathology 0 0 0 0 0 0 0
085 Pharmacy 0 0 0 0 0 0 0
090 Laboratory 0 0 0 0 0 0 0
095 Home Health Services 0 0 0 0 0 0 0
100 Other Ancillary Services 0 0 0 0 0 0 0
101 Subacute Care Ancillary Services 0 0 0 0 0 0 0
102 Subacute Care - Pediatric Ancillary Services 0 0 0 0 0 0 0
ROUTINE SERVICES
105 Skilled Nursing Care 220,614 6,372 0 7,345 23,106 1,516 0
110 Intermediate Care 0 0 0 0 0 0 0
115 Mentally Disordered Care 0 0 0 0 0 0 0
120 Developmentally Disabled Care 0 0 0 0 0 0 0
125 Subacute Care 0 0 0 0 0 0 0
126 Subacute Care - Pediatric 0 0 0 0 0 0 0
128 Transitional Inpatient Care 0 0 0 0 0 0 0
130 Hospice Inpatient Care 0 0 0 0 0 0 0
135 Other Routine Services 0 0 0 0 0 0 0
NONREIMBURSABLE
139 Residential Care 0 0 0 0 0 0 0
140 Beauty and Barber 494 14 0 0 0 0 0
145 Other Nonreimbursable 0 0 0 0 0 0 0
TOTAL 277,436$ 100% 277,436$ 7,788$ -$ 7,345$ 23,106$ 1,516$ -$
* (To Schedule 1)
STATE OF CALIFORNIA SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Provider Name:
ALDEN TERRACE CONVALESCENT HOSPITAL
Provider NPI:
1568544781
Fiscal Period:
JUNE 1, 2010 THROUGH MAY 31, 2011
OSHPD Facility Number:
206190013
Line No.
DESCRIPTION
Net Exp For
Cost Alloc (From Sch 8) Ratio
Inserv. Ed
170 Accumulated
Costs
Admin
165
Medical
Records
166 Total
Capital
Related
71% Of Total
Property
Tax
29% Of Total
GENERAL SERVICES
Capital Related (excluding lines 40 & 45) $ 197,676 71%
005 Plant Operations and Maintenance
Property Tax (line 40) 79,760 29%
010 Housekeeping
060 Laundry and Linen
065 Dietary
155 Social Services
160 Activities
165 Administration $ 9,369 $ 9,369
2,417 $ 2,417
2,353 28 7 $ 2,388 $ 1,702 $ 687
0 0
2,599 1,049
0 0
1,545 623
118 48
395 159
33 13
0 0
29 12
0 0
0 0
0
7
0
8
5
4
6
0
1
0
0
0
0
0
0
0
0
0
0
0
0
6
0
6
190,889 77,021 *
0 0 *
0 0 *
0 0 *
0 0 *
0 0 *
0 0 *
0 0 *
0 0 *
0 0
367 148
0 0
$ 197,676 $ 79,760
0 0 0
2,671 776 200 3,64
0 0 0
1,166 796 205 2,16
0 132 34 16
0 441 114 55
0 37 9 4
0 0 0
0 33 8 4
0 0 0
0 0 0
8,952 7,122 1,837 267,91
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
509 6 1 51
0 0 0
5,650 $ 9,369 $ 2,417 $ 277,43
166 Medical Records
170 Inservice Education - Nursing $ -
ANCILLARY SERVICES
075 Patient Supplies 0
077 Specialized Support Surfaces 0
080 Physical Therapy 0
081 Respiratory Therapy 0
082 Occupational Therapy 0
083 Speech Pathology 0
085 Pharmacy 0
090 Laboratory 0
095 Home Health Services 0
100 Other Ancillary Services 0
101 Subacute Care Ancillary Services 0
102 Subacute Care - Pediatric Ancillary Services 0
ROUTINE SERVICES
105 Skilled Nursing Care 0 25
110 Intermediate Care 0
115 Mentally Disordered Care 0
120 Developmentally Disabled Care 0
125 Subacute Care 0
126 Subacute Care - Pediatric 0
128 Transitional Inpatient Care 0
130 Hospice Inpatient Care 0
135 Other Routine Services 0
NONREIMBURSABLE
139 Residential Care 0
140 Beauty and Barber 0
145 Other Nonreimbursable 0
TOTAL $ 277,436 100% $ - $ 26
* (To Schedule 1)
ST
AT
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F C
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RN
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SC
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3,68
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554 0
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2,32
7
7,79
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97 0
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$
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2,59
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192 0 0
41,9
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716 0
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111,
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194,
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11,8
47,7
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0 0 0 0 0 0
258,
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509 0
265,
650
11,7
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$ $
436,
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36,2
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32,2
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29,
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$ $
3,76
6 0
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6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
814 0
152,
788
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(Fro
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Rat
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(To
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080
081
082
090
095
100
101
102
105
110
115
120
126
128
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ALD
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* * * * * * * * *
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5
Ho
me
He
alth
Se
rvic
es
10
0
Oth
er
An
cilla
ry S
erv
ice
s
10
1
Su
ba
cute
Ca
re A
nci
llary
Se
rvic
es
10
2
RO
UT
INE
SE
RV
ICE
S
Su
ba
cute
Ca
re -
Pe
dia
tric
An
cilla
ry S
erv
ice
s
STATE OF CALIFORNIA SCHEDULE 8
SUMMARY OF AUDITED PROGRAM EXPENSES
Provider Name: Fiscal Period:
ALDEN TERRACE CONVALESCENT HOSPITAL JUNE 1, 2010 THROUGH MAY 31, 2011
Provider NPI: OSHPD Facility Number:
1568544781 206190013
AUDIT
Line Natural ACCOUNT AS ADJUSTMENTS ASNo. Class ACCOUNT TITLE NUMBER REPORTED 8A-1 AUDITED
005 Plant Operations and Maintenance
005 .01-.19 Salaries and Wages 6200 $ 360,412 $ (231,804) $ 128,608 (Sch 3)
005 .20-.39 Fringe Benefits 6200 29,590 0 29,590 (Sch 3)
005 .79 Agency Staff 6200 0 0 0 (Sch 3)
005 .40-.99 Other - Nonlabor 6200 438,973 0 438,973 (Sch 4)
005 Plant Operations and Maintenance - Total 6200 $ 828,975 $ (231,804) $ 597,171
010 Housekeeping
010 .01-.19 Salaries and Wages 6300 $ 232,370 $ 0 $ 232,370 (Sch 3)
010 .20-.39 Fringe Benefits 6300 53,464 0 53,464 (Sch 3)
010 .79 Agency Staff 6300 0 0 0 (Sch 3)
010 .40-.99 Other - Nonlabor 6300 87,435 0 87,435 (Sch 4)
010 Housekeeping - Total 6300 $ 373,269 $ 0 $ 373,269
015 Depreciation: Buildings and Improvements 7110 - 7120 $ 70,379 $ 0 $ 70,379 (Sch 5)
020 Depreciation: Leasehold Improvements 7130 8,072 0 8,072 (Sch 5)
025 Depreciation: Equipment 7140 52,915 0 52,915 (Sch 5)
030 Depreciation and Amortization - Other 7150 - 7160 0 0 0 (Sch 5)
035 Leases and Rentals 7200 0 0 0 (Sch 5)
040 Property Taxes 7300 82,000 (2,240) 79,760 (Sch 5)
045 Property Insurance 7400 9,832 0 9,832 (Sch 6)
050 Interest - Property, Plant, and Equipment 7500 88,705 (22,395) 66,310 (Sch 5)
055 Interest - Other 7600 $ 0 $ 0 $ 0 (Sch 6)
057 Subtotal 005 - 055 $ 1,514,147 $ (256,439) $ 1,257,708
060 Laundry and Linen
060 .01-.19 Salaries and Wages 6400 $ 132,214 $ 0 $ 132,214 (Sch 3)
060 .20-.39 Fringe Benefits 6400 30,420 0 30,420 (Sch 3)
060 .79 Agency Staff 6400 0 0 0 (Sch 3)
060 .40-.99 Other - Nonlabor 6400 18,726 0 18,726 (Sch 4)
060 Laundry and Linen - Total 6400 $ 181,360 $ 0 $ 181,360
065 Dietary
065 .01-.19 Salaries and Wages 6500 $ 380,937 $ (21,395) $ 359,542 (Sch 3)
065 .20-.39 Fringe Benefits 6500 82,724 0 82,724 (Sch 3)
065 .79 Agency Staff 6500 0 0 0 (Sch 3)
065 .40-.99 Other - Nonlabor 6500 358,299 0 358,299 (Sch 4)
065 Dietary - Total 6500 $ 821,960 $ (21,395) $ 800,565
070 Provision for Bad Debts 7700 $ 0 0 $ 0
Ancillary Services
075 Patient Supplies
075 .01-.19 Salaries and Wages 8100 $ 0 $ 0 $ 0 (Sch 2)
075 .20-.39 Fringe Benefits 8100 0 0 0 (Sch 2)
075 .79 Agency Staff 8100 0 0 0 (Sch 2)
075 .40-.99 Other - Nonlabor 8100 17,106 0 17,106 (Sch 4)
075 Patient Supplies - Total 8100 $ 17,106 $ 0 $ 17,106
077 Specialized Support Surfaces
077 .01-.19 Salaries and Wages 8150 $ 0 $ 0 $ 0 N/A
077 .20-.39 Fringe Benefits 8150 0 0 0 N/A
077 .79 Agency Staff 8150 0 0 0 N/A
077 .40-.99 Other - Nonlabor 8150 0 0 0 (Sch 4)
077 Specialized Support Surfaces - Total 8150 $ 0 $ 0 $ 0
STATE OF CALIFORNIA SCHEDULE 8
SUMMARY OF AUDITED PROGRAM EXPENSES
Provider Name: Fiscal Period:
ALDEN TERRACE CONVALESCENT HOSPITAL JUNE 1, 2010 THROUGH MAY 31, 2011
Provider NPI: OSHPD Facility Number: 1568544781 206190013
Line No.
Natural Class ACCOUNT TITLE
ACCOUNT NUMBER REPORTED
AS ADJUSTMENTS 8A-1
AUDIT
AS AUDITED
080 Physical Therapy
080 .01-.19 Salaries and Wages 8200 $ 0 $ 0 $ 0
080 .20-.39 Fringe Benefits 8200 0 0 0
080 .79 Agency Staff 8200 756,046 0 756,046
080 .40-.99 Other - Nonlabor
080
8200
Physical Therapy - Total 8200 $ 756,046 $ 0 $ 756,046
081
$ 0 $ 0 $ 0 (Sch 2)
0 0 0 (Sch 2)
0 0 0 (Sch 2)
0 0 0 (Sch 4)
$ 0 $ 0 $ 0
$ 0 $ 0 $ 0 (Sch 2)
0 0 0 (Sch 2)
782,962 0 782,962 (Sch 2)
0 0 0 (Sch 4)
$ 782,962 $ 0 $ 782,962
$ 0 $ 0 $ 0 (Sch 2)
0 0 0 (Sch 2)
130,203 0 130,203 (Sch 2)
0 0 0 (Sch 4)
$ 130,203 $ 0 $ 130,203
$ 0 $ 0 $ 0 (Sch 2)
0 0 0 (Sch 2)
0 0 0 (Sch 2)
436,161 0 436,161 (Sch 4)
$ 436,161 $ 0 $ 436,161
$ 0 $ 0 $ 0 (Sch 2)
0 0 0 (Sch 2)
0 0 0 (Sch 2)
36,285 0 36,285 (Sch 4)
$ 36,285 $ 0 $ 36,285
$ 0 $ 0 $ 0 (Sch 2)
0 0 0 (Sch 2)
0 0 0 (Sch 2)
0 0 0 (Sch 4)
$ 0 $ 0 $ 0
$ 0 $ 0 $ 0 (Sch 2)
0 0 0 (Sch 2)
0 0 0 (Sch 2)
32,254 0 32,254 (Sch 4)
$ 32,254 $ 0 $ 32,254
Respiratory Therapy
081 .01-.19 Salaries and Wages 8220
081 .20-.39 Fringe Benefits 8220
081 .79 Agency Staff 8220
081 .40-.99 Other - Nonlabor 8220
081 Respiratory Therapy - Total 8220
082 Occupational Therapy
082 .01-.19 Salaries and Wages
082 .20-.39 Fringe Benefits
8250
8250
082 .79 Agency Staff 8250
082 .40-.99 Other - Nonlabor 8250
082 Occupational Therapy - Total 8250
083 Speech Pathology
083 .01-.19 Salaries and Wages 8280
083 .20-.39 Fringe Benefits 8280
083 .79 Agency Staff 8280
083 .40-.99 Other - Nonlabor 8280
083 Speech Pathology - Total 8280
085 Pharmacy
085 .01-.19 Salaries and Wages 8300
085 .20-.39 Fringe Benefits 8300
085 .79 Agency Staff 8300
085 .40-.99 Other - Nonlabor 8300
085 Pharmacy - Total 8300
090 Laboratory
090 .01-.19 Salaries and Wages 8400
090 .20-.39 Fringe Benefits 8400
090 .79 Agency Staff 8400
090 .40-.99 Other - Nonlabor 8400
090 Laboratory - Total 8400
095 Home Health Services
095 .01-.19 Salaries and Wages 8800
095 .20-.39 Fringe Benefits 8800
095 .79 Agency Staff 8800
095 .40-.99 Other - Nonlabor 8800
095 Home Health Services - Total 8800
100 Other Ancillary Services
100 .01-.19 Salaries and Wages 8900
100 .20-.39 Fringe Benefits 8900
100 .79 Agency Staff 8900
100 .40-.99 Other - Nonlabor 8900
100 her Ancillary Services - Total Ot 8900
0 0 0
(Sch 2)
(Sch 2)
(Sch 2)
(Sch 4)
STATE OF CALIFORNIA SCHEDULE 8
SUMMARY OF AUDITED PROGRAM EXPENSES
Provider Name: Fiscal Period:
ALDEN TERRACE CONVALESCENT HOSPITAL JUNE 1, 2010 THROUGH MAY 31, 2011
Provider NPI: OSHPD Facility Number: 1568544781 206190013
Line No.
Natural Class ACCOUNT TITLE
ACCOUNT NUMBER REPORTED
AS ADJUSTMENTS 8A-1
AUDIT
AS AUDITED
101 Subacute Care Ancillary Services
101 .01-.19 Salaries and Wages 8100-8900 $ 0 $ 0 $ 0
101 .20-.39 Fringe Benefits 8100-8900 0 0 0
101 .79 Agency Staff 8100-8900 0 0 0
101 .40-.99 Other - Nonlabor 8100-8900 0 0 0
101
102
Subacute Care Ancillary Services - Total
Subacute Care - Pediatric Ancillary Services
8100-8900 $ 0 $ 0 $ 0
102 .01-.19 Salaries and Wages 8100-8900 $ 0 $ 0 $ 0
102 .20-.39 Fringe Benefits 8100-8900 0 0 0
102 .79 Agency Staff 8100-8900 0 0 0
102 .40-.99 Other - Nonlabor 8100-8900 0 0 0
102
104 Subtotal 075 - 102 $ 2,191,017 $
Routine Services
105 Skilled Nursing Care
105 .01-.19 Salaries and Wages 6110 $ 3,626,288 $
105 .20-.39 Fringe Benefits 6110 820,812 (8,936) 811,876 (Sch 2)
0 0 0 (Sch 2)
025 (12,030) 200,995 (Sch 4)
125 $ (119,257) $ 4,540,868
105 .49 Agency Staff
0 $ 0 $ 0
0 0 0
0 0 0
0 0 0
0 $ 0 $ 0 (Sch 2)
0 $ 0 $ 0
0 0 0
0 0 0
0 0 0
0 $ 0 $ 0 (Sch 2)
0 $ 0 $ 0
0 0 0
0 0 0
0 0 0
0 $ 0 $ 0 (Sch 2)
0 $ 0 $ 0 (Sch 2)
0 0 0 (Sch 2)
0 0 0 (Sch 2)
0 0 0 (Sch 4)
0 $ 0 $ 0
0 $ 0 $ 0 (Sch 2)
0 0 0 (Sch 2)
0 0 0 (Sch 2)
0 0 0 (Sch 4)
0 $ 0 $ 0
6110
105 .40-.99 Other - Nonlabor 6110 213,
105 Skilled Nursing Care - Total 6110 $ 4,660,
110 Intermediate Care
110 .01-.19 Salaries and Wages 6120 $
110 .20-.39 Fringe Benefits 6120
110 .49 Agency Staff 6120
110 .40-.99 Other - Nonlabor 6120
110 Intermediate Care - Total 6120 $
115 Mentally Disordered Care
Salaries and Wages 115 .01-.19 6130 $
115 .20-.39 Fringe Benefits 6130
115 .49 Agency Staff 6130
115 .40-.99 Other - Nonlabor 6130
115 Mentally Disordered Care - Total 6130 $
120 Developmentally Disabled Care
120 .01-.19 Salaries and Wages 6140 $
120 .20-.39 Fringe Benefits 6140
120 .49 Agency Staff 6140
120 .40-.99 Other - Nonlabor 6140
120 Developmentally Disabled Care - Total 6140 $
125 Subacute Care
125 .01-.19 Salaries and Wages 6150 $
125 .20-.39 Fringe Benefits 6150
125 .49 Agency Staff 6150
125 .40-.99 Other - Nonlabor 6150
125 Subacute Care - Total 6150 $
126 Subacute Care - Pediatric
126 .01-.19 Salaries and Wages 6160 $
126 .20-.39 Fringe Benefits 6160
126 .49 Agency Staff 6160
126 .40-.99 Other - Nonlabor 6160
126 Subacute Care - Pediatric - Total 6160 $
Subacute Care - Pediatric Ancillary Services - Total 8100-8900 $ 0 $ 0
0
$
$
0
2,191,017
(98,291) $ 3,527,997
(Sch 2)
(Sch 2)
(Sch 2)
(Sch 4)
(Sch 2)
(Sch 2)
(Sch 2)
(Sch 4)
(Sch 2)
STATE OF CALIFORNIA SCHEDULE 8
SUMMARY OF AUDITED PROGRAM EXPENSES
Provider Name: Fiscal Period:
ALDEN TERRACE CONVALESCENT HOSPITAL JUNE 1, 2010 THROUGH MAY 31, 2011
Provider NPI: OSHPD Facility Number:
1568544781 206190013
AUDIT
Line Natural ACCOUNT AS ADJUSTMENTS ASNo. Class ACCOUNT TITLE NUMBER REPORTED 8A-1 AUDITED
128 Transitional Inpatient Care
128 .01-.19 Salaries and Wages 6170 $ 0 $ 0 $
128 .20-.39 Fringe Benefits 6170 0 0
128 .49 Agency Staff 6170 0 0
128 .40-.99 Other - Nonlabor 6170 0 0
128 Transitional Inpatient Care - Total 6170 $ 0 $ 0 $
130 Hospice Inpatient Care
130 .01-.19 Salaries and Wages 6180 $ 0 $ 0 $
130 .20-.39 Fringe Benefits 6180 0 0
130 .49 Agency Staff 6180 0 0
130 .40-.99 Other - Nonlabor 6180 0 0
130 Hospice Inpatient Care - Total 6180 $ 0 $ 0 $
135 Other Routine Services
135 .01-.19 Salaries and Wages 6190 $ 0 $ 0 $
135 .20-.39 Fringe Benefits 6190 0 0
135 .49 Agency Staff 6190 0 0
135 .40-.99 Other - Nonlabor 6190 0 0
135 Other Routine Services - Total 6190 $ 0 $ 0 $
Other Nonreimbursable
139 Residential Care
139 .01-.19 Salaries and Wages 9100 $ 0 $ 0 $
139 .20-.39 Fringe Benefits 9100 0 0 0 (Sch 2)
139 .49 Agency Staff 9100 0 0 0 (Sch 2)
139 .40-.99 Other - Nonlabor 9100 0 0 0 (Sch 4)
139 Residential Care - Total 9100 $ 0 $ 0 $
140 Beauty and Barber
140 .01-.19 Salaries and Wages 8900 $ 0 $ 0 $
140 .20-.39 Fringe Benefits 8900 0 0 0 (Sch 2)
140 .49 Agency Staff 8900 0 0 0 (Sch 2)
140 .40-.99 Other - Nonlabor 8900 3,165 0 3,165 (Sch 4)
140 Beauty and Barber - Total 8900 $ 3,165 $ 0 $ 3,165
145 Other Nonreimbursable
145 .01-.19 Salaries and Wages 9100 $ 0 $ 0 $
145 .20-.39 Fringe Benefits 9100 0 0 0 (Sch 2)
145 .49 Agency Staff 9100 0 0 0 (Sch 2)
145 .40-.99 Other - Nonlabor 9100 0 0 0 (Sch 4)
145 Other Nonreimbursable - Total 9100 $ 0 $ 0 $
146 Subtotal 105 - 145 $ 4,663,290 $ (119,257) $ 4,544,033
155 Social Services
155 .01-.19 Salaries and Wages 6600 $ 71,468 $ 0 $ 71,468 (Sch 2)
155 .20-.39 Fringe Benefits 6600 16,444 0 16,444 (Sch 2)
155 .49 Agency Staff 6600 0 0 0 (Sch 2)
155 .40-.99 Other - Nonlabor 6600 0 0 0 (Sch 4)
155 Social Services - Total 6600 $ 87,912 $ 0 $ 87,912
0
0
0
0
0 (Sch 2)
0
0
0
0
0 (Sch 2)
0
0
0
0
0 (Sch 2)
0 (Sch 2)
0
0 (Sch 2)
0 (
0
Sch 2)
STATE OF CALIFORNIA SCHEDULE 8
SUMMARY OF AUDITED PROGRAM EXPENSES
Provider Name: Fiscal Period:
ALDEN TERRACE CONVALESCENT HOSPITAL JUNE 1, 2010 THROUGH MAY 31, 2011
Provider NPI: OSHPD Facility Number:
1568544781 206190013
AUDIT
Line Natural ACCOUNT AS ADJUSTMENTS ASNo. Class ACCOUNT TITLE NUMBER REPORTED 8A-1 AUDITED
160 Activities
160 .01-.19 Salaries and Wages 6700 $ 122,966 $ 0 $ 122,966 (Sch 2)
160 .20-.39 Fringe Benefits 6700 28,292 0 28,292 (Sch 2)
160 .49 Agency Staff 6700 0 0 0 (Sch 2)
160 .40-.99 Other - Nonlabor 6700 268 0 268 (Sch 4)160 Activities - Total 6700 $ 151,526 $ 0 $ 151,526
165 Administration
165 .01-.19 Salaries and Wages 6900 $ 571,429 $ (244,099) $ 327,330 (Sch 6)
165 .20-.39 Fringe Benefits 6900 66,229 8,936 75,165 (Sch 6)
165 .49 Agency Staff 6900 0 0 0 (Sch 6)
165 .40-.99 Other - Nonlabor 6900 895,485 (90,722) 804,763 (Sch 6)
165 Administration - Total 6900 $ 1,533,143 $ (325,885) $ 1,207,258
166 Medical Records
166 .01-.19 Salaries and Wages 6900 $ 108,875 $ 0 $ 108,875 (Sch 3)
166 .20-.39 Fringe Benefits 6900 25,050 0 25,050 (Sch 3)
166 .49 Agency Staff 6900 0 0 0 (Sch 3)
166 .40-.99 Other - Nonlabor 6900 7,636 0 7,636 (Sch 4)
166 Medical Records - Total 6900 $ 141,561 $ 0 $ 141,561
167 CDPH Licensing Fees 6900 $ 55,207 $ 0 $ 55,207 (Sch 6)
168 Professional Liability Insurance 6900 $ 143,649 $ 22,053 $ 165,702 (Sch 6)
169 Quality Assurance Fees 6900 $ 942,441 $ 0 $ 942,441 (Sch 6)
170 Inservice Education - Nursing
170 .01-.19 Salaries and Wages 6800 $ 98,712 $ 0 $ 98,712 (Sch 3)
170 .20-.39 Fringe Benefits 6800 22,712 0 22,712 (Sch 3)
170 .49 Agency Staff 6800 0 0 0 (Sch 3)
170 .40-.99 Other - Nonlabor 6800 0 0 0 (Sch 4)
170 Inservice Education - Nursing - Total 6800 $ 121,424 $ 0 $ 121,424
174 Caregiver Training
174 .01-.19 Salaries and Wages 6900 $ 0 $ 0 $ 0 (Sc
0 (Sch 6)
0 (Sch 6)
0 (Sch 6)
0
31
14
56
174 .20-.39 Fringe Benefits 6900 0 0
174 .49 Agency Staff 6900 0 0
h
Other - Nonlabor 6900 0 0
Caregiver Training - Total 6900 $ 0 $ 0 $
Subtotal 155 - 174 $ 3,176,863 $ (303,832) $ 2,873,0
Total $ 12,548,637 $ (700,923) $ 11,847,7
Total Facility Group Health Insurance * (Adj 1) 6900 $ 112,3
purposes only, this amount is included in various cost centers above. .
174 .40-.99
174
200
210 0.24
* For informational
6)
ST
AT
E O
F C
AL
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RN
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SIF
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ST
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S T
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S
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8A
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Pag
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Pro
vid
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P
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NP
I:
OS
HP
D F
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um
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: F
isca
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:
ALD
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RR
AC
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VA
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HO
SP
ITA
L 15
6854
4781
20
6190
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JUN
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, 201
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1, 2
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Lin
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(P
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2 3
4 5
6 7
8
No
. N
o.
005
1 P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Sal
arie
s an
d W
ages
(2
31,8
04)
(231
,804
)
005
2 P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Frin
ge B
enef
its
0
005
3 P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Age
ncy
Sta
ff 0
005
4 P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Oth
er -
Non
labo
r 0
010
1 H
ouse
keep
ing
- S
alar
ies
and
Wag
es
0
010
2 H
ouse
keep
ing
- F
ringe
Ben
efits
0
010
3 H
ouse
keep
ing
- A
genc
y S
taff
0
010
4 H
ouse
keep
ing
- O
ther
- N
onla
bor
0
015
4 D
epre
ciat
ion:
Bui
ldin
gs a
nd Im
prov
emen
ts
0
020
4 D
epre
ciat
ion:
Lea
seho
ld Im
prov
emen
ts
0
025
4 D
epre
ciat
ion:
Equ
ipm
ent
0
030
4 D
epre
ciat
ion
and
Am
ortiz
atio
n -
Oth
er
0
035
4 Le
ases
and
Ren
tals
0
040
4 P
rope
rty
Tax
es
(2,2
40)
(2,2
40)
045
4 P
rope
rty
Insu
ranc
e 0
050
4 In
tere
st -
Pro
pert
y, P
lant
, and
Equ
ipm
ent
(22,
395)
(2
2,39
5)
055
4 In
tere
st -
Oth
er
0
060
1 La
undr
y an
d Li
nen
- S
alar
ies
and
Wag
es
0
060
2 La
undr
y an
d Li
nen
- F
ringe
Ben
efits
0
060
3 La
undr
y an
d Li
nen
- A
genc
y S
taff
0
060
4 La
undr
y an
d Li
nen
- O
ther
- N
onla
bor
0
065
1 D
ieta
ry -
Sal
arie
s an
d W
ages
(2
1,39
5)
(21,
395)
065
2 D
ieta
ry -
Frin
ge B
enef
its
0
065
3 D
ieta
ry -
Age
ncy
Sta
ff 0
065
4 D
ieta
ry -
Oth
er -
Non
labo
r 0
070
4 P
rovi
sion
for
Bad
Deb
ts
0
075
1 P
atie
nt S
uppl
ies
- S
alar
ies
and
Wag
es
0
075
2 P
atie
nt S
uppl
ies
- F
ringe
Ben
efits
0
075
3 P
atie
nt S
uppl
ies
- A
genc
y S
taff
0
075
4 P
atie
nt S
uppl
ies
- O
ther
- N
onla
bor
0
077
1 S
peci
aliz
ed S
uppo
rt S
urfa
ces
- S
alar
ies
and
Wag
es
0
077
2 S
peci
aliz
ed S
uppo
rt S
urfa
ces
- F
ringe
Ben
efits
0
077
3 S
peci
aliz
ed S
uppo
rt S
urfa
ces
- A
genc
y S
taff
0
077
4 S
peci
aliz
ed S
uppo
rt S
urfa
ces
- O
ther
- N
onla
bor
0
080
1 P
hysi
cal T
hera
py -
Sal
arie
s an
d W
ages
0
080
2 P
hysi
cal T
hera
py -
Frin
ge B
enef
its
0
080
3 P
hysi
cal T
hera
py -
Age
ncy
Sta
ff 0
080
4 P
hysi
cal T
hera
py -
Oth
er -
Non
labo
r 0
081
1 R
espi
rato
ry T
hera
py -
Sal
arie
s an
d W
ages
0
081
2 R
espi
rato
ry T
hera
py -
Frin
ge B
enef
its
0
081
3 R
espi
rato
ry T
hera
py -
Age
ncy
Sta
ff 0
081
4 R
espi
rato
ry T
hera
py -
Oth
er -
Non
labo
r 0
082
1 O
ccup
atio
nal T
hera
py -
Sal
arie
s an
d W
ages
0
082
2 O
ccup
atio
nal T
hera
py -
Frin
ge B
enef
its
0
082
3 O
ccup
atio
nal T
hera
py -
Age
ncy
Sta
ff 0
082
4 O
ccup
atio
nal T
hera
py -
Oth
er -
Non
labo
r 0
083
1 S
peec
h P
atho
logy
- S
alar
ies
and
Wag
es
0
083
2 S
peec
h P
atho
logy
- F
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Ben
efits
0
083
3 S
peec
h P
atho
logy
- A
genc
y S
taff
0
ST
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S
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8A
-1
Pag
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Pro
vid
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P
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NP
I:
OS
HP
D F
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um
ber
: F
isca
l Per
iod
:
ALD
EN
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RR
AC
E C
ON
VA
LES
CE
NT
HO
SP
ITA
L 15
6854
4781
20
6190
013
JUN
E 1
, 201
0 T
HR
OU
GH
MA
Y 3
1, 2
011
TO
TA
L A
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DJ
AU
DIT
AD
J A
UD
IT A
DJ
Lin
e S
ub
(P
age
1)
2 3
4 5
6 7
8
No
. N
o.
083
4 S
peec
h P
atho
logy
- O
ther
- N
onla
bor
0
085
1 P
harm
acy
- S
alar
ies
and
Wag
es
0
085
2 P
harm
acy
- F
ringe
Ben
efits
0
085
3 P
harm
acy
- A
genc
y S
taff
0
085
4 P
harm
acy
- O
ther
- N
onla
bor
0
090
1 La
bora
tory
- S
alar
ies
and
Wag
es
0
090
2 La
bora
tory
- F
ringe
Ben
efits
0
090
3 La
bora
tory
- A
genc
y S
taff
0
090
4 La
bora
tory
- O
ther
- N
onla
bor
0
095
1 H
ome
Hea
lth S
ervi
ces
- S
alar
ies
and
Wag
es
0
095
2 H
ome
Hea
lth S
ervi
ces
- F
ringe
Ben
efits
0
095
3 H
ome
Hea
lth S
ervi
ces
- A
genc
y S
taff
0
095
4 H
ome
Hea
lth S
ervi
ces
- O
ther
- N
onla
bor
0
100
1 O
ther
Anc
illar
y S
ervi
ces
- S
alar
ies
and
Wag
es
0
100
2 O
ther
Anc
illar
y S
ervi
ces
- F
ringe
Ben
efits
0
100
3 O
ther
Anc
illar
y S
ervi
ces
- A
genc
y S
taff
0
100
4 O
ther
Anc
illar
y S
ervi
ces
- O
ther
- N
onla
bor
0
101
1 S
ubac
ute
Car
e A
ncill
ary
Ser
vice
s -
Sal
arie
s an
d W
ages
0
101
2 S
ubac
ute
Car
e A
ncill
ary
Ser
vice
s -
Frin
ge B
enef
its
0
101
3 S
ubac
ute
Car
e A
ncill
ary
Ser
vice
s -
Age
ncy
Sta
ff 0
101
4 S
ubac
ute
Car
e A
ncill
ary
Ser
vice
s -
Oth
er -
Non
labo
r 0
102
1 S
ubac
ute
Ped
iatr
ic A
ncill
ary
Ser
vice
s -
Sal
arie
s an
d W
ages
0
102
2 S
ubac
ute
Ped
iatr
ic A
ncill
ary
Ser
vice
s -
Frin
ge B
enef
its
0
102
3 S
ubac
ute
Ped
iatr
ic A
ncill
ary
Ser
vice
s -
Age
ncy
Sta
ff 0
102
4 S
ubac
ute
Ped
iatr
ic A
ncill
ary
Ser
vice
s -
Oth
er -
Non
labo
r 0
105
1 S
kille
d N
ursi
ng C
are
- S
alar
ies
and
Wag
es
(98,
291)
(3
9,48
1)
(58,
810)
105
2 S
kille
d N
ursi
ng C
are
- F
ringe
Ben
efits
(8
,936
) (8
,936
)
105
3 S
kille
d N
ursi
ng C
are
- A
genc
y S
taff
0
105
4 S
kille
d N
ursi
ng C
are
- O
ther
- N
onla
bor
(12,
030)
(1
2,03
0)
110
1 In
term
edia
te C
are
- S
alar
ies
and
Wag
es
0
110
2 In
term
edia
te C
are
- F
ringe
Ben
efits
0
110
3 In
term
edia
te C
are
- A
genc
y S
taff
0
110
4 In
term
edia
te C
are
- O
ther
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onla
bor
0
115
1 M
enta
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isor
dere
d C
are
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alar
ies
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Wag
es
0
115
2 M
enta
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are
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ringe
Ben
efits
0
115
3 M
enta
lly D
isor
dere
d C
are
- A
genc
y S
taff
0
115
4 M
enta
lly D
isor
dere
d C
are
- O
ther
- N
onla
bor
0
120
1 D
evel
opm
enta
lly D
isab
led
Car
e -
Sal
arie
s an
d W
ages
0
120
2 D
evel
opm
enta
lly D
isab
led
Car
e -
Frin
ge B
enef
its
0
120
3 D
evel
opm
enta
lly D
isab
led
Car
e -
Age
ncy
Sta
ff 0
120
4 D
evel
opm
enta
lly D
isab
led
Car
e -
Oth
er -
Non
labo
r 0
125
1 S
ubac
ute
Car
e -
Sal
arie
s an
d W
ages
0
125
2 S
ubac
ute
Car
e -
Frin
ge B
enef
its
0
125
3 S
ubac
ute
Car
e -
Age
ncy
Sta
ff 0
125
4 S
ubac
ute
Car
e -
Oth
er -
Non
labo
r 0
126
1 S
ubac
ute
Car
e -
Ped
iatr
ic -
Sal
arie
s an
d W
ages
0
126
2 S
ubac
ute
Car
e -
Ped
iatr
ic -
Frin
ge B
enef
its
0
126
3 S
ubac
ute
Car
e -
Ped
iatr
ic -
Age
ncy
Sta
ff 0
126
4 S
ubac
ute
Car
e -
Ped
iatr
ic -
Oth
er -
Non
labo
r 0
ST
AT
E O
F C
AL
IFO
RN
IA
RE
CL
AS
SIF
ICA
TIO
NS
AN
D/O
R A
DJU
ST
ME
NT
S T
O R
EP
OR
TE
D C
OS
TS
S
ched
ule
8A
-1
Pag
e 1
Pro
vid
er N
ame:
P
rovi
der
NP
I:
OS
HP
D F
acili
ty N
um
ber
: F
isca
l Per
iod
:
ALD
EN
TE
RR
AC
E C
ON
VA
LES
CE
NT
HO
SP
ITA
L 15
6854
4781
20
6190
013
JUN
E 1
, 201
0 T
HR
OU
GH
MA
Y 3
1, 2
011
TO
TA
L A
DJ
AU
DIT
AD
J A
UD
IT A
DJ
AU
DIT
AD
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AU
DIT
AD
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IT A
DJ
AU
DIT
AD
J A
UD
IT A
DJ
Lin
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ub
(P
age
1)
2 3
4 5
6 7
8
No
. N
o.
128
1 T
rans
ition
al In
patie
nt C
are
- S
alar
ies
and
Wag
es
0
128
2 T
rans
ition
al In
patie
nt C
are
- F
ringe
Ben
efits
0
128
3 T
rans
ition
al In
patie
nt C
are
- A
genc
y S
taff
0
128
4 T
rans
ition
al In
patie
nt C
are
- O
ther
- N
onla
bor
0
130
1 H
ospi
ce In
patie
nt C
are
- S
alar
ies
and
Wag
es
0
130
2 H
ospi
ce In
patie
nt C
are
- F
ringe
Ben
efits
0
130
3 H
ospi
ce In
patie
nt C
are
- A
genc
y S
taff
0
130
4 H
ospi
ce In
patie
nt C
are
- O
ther
- N
onla
bor
0
135
1 O
ther
Rou
tine
Ser
vice
s -
Sal
arie
s an
d W
ages
0
135
2 O
ther
Rou
tine
Ser
vice
s -
Frin
ge B
enef
its
0
135
3 O
ther
Rou
tine
Ser
vice
s -
Age
ncy
Sta
ff 0
135
4 O
ther
Rou
tine
Ser
vice
s -
Oth
er -
Non
labo
r 0
139
1 R
esid
entia
l Car
e -
Sal
arie
s an
d W
ages
0
139
2 R
esid
entia
l Car
e -
Frin
ge B
enef
its
0
139
3 R
esid
entia
l Car
e -
Age
ncy
Sta
ff 0
139
4 R
esid
entia
l Car
e -
Oth
er -
Non
labo
r 0
140
1 B
eaut
y an
d B
arbe
r -
Sal
arie
s an
d W
ages
0
140
2 B
eaut
y an
d B
arbe
r -
Frin
ge B
enef
its
0
140
3 B
eaut
y an
d B
arbe
r -
Age
ncy
Sta
ff 0
140
4 B
eaut
y an
d B
arbe
r -
Oth
er -
Non
labo
r 0
145
1 O
ther
Non
reim
burs
able
- S
alar
ies
and
Wag
es
0
145
2 O
ther
Non
reim
burs
able
- F
ringe
Ben
efits
0
145
3 O
ther
Non
reim
burs
able
- A
genc
y S
taff
0
145
4 O
ther
Non
reim
burs
able
-O
ther
- N
onla
bor
0
155
1 S
ocia
l Ser
vice
s -
Sal
arie
s an
d W
ages
0
155
2 S
ocia
l Ser
vice
s -
Frin
ge B
enef
its
0
155
3 S
ocia
l Ser
vice
s -
Age
ncy
Sta
ff 0
155
4 S
ocia
l Ser
vice
s -
Oth
er -
Non
labo
r 0
160
1 A
ctiv
ities
- S
alar
ies
and
Wag
es
0
160
2 A
ctiv
ities
- F
ringe
Ben
efits
0
160
3 A
ctiv
ities
- A
genc
y S
taff
0
160
4 A
ctiv
ities
- O
ther
- N
onla
bor
0
165
1 A
dmin
istr
atio
n -
Sal
arie
s an
d W
ages
(2
44,0
99)
39,4
81
(283
,580
)
165
2 A
dmin
istr
atio
n -
Frin
ge B
enef
its
8,93
6 8,
936
165
3 A
dmin
istr
atio
n -
Age
ncy
Sta
ff 0
165
4 A
dmin
istr
atio
n -
Oth
er -
Non
labo
r (9
0,72
2)
12,0
30
2,24
0 2,
584
(107
,576
)
166
1 M
edic
al R
ecor
ds -
Sal
arie
s an
d W
ages
0
166
2 M
edic
al R
ecor
ds -
Frin
ge B
enef
its
0
166
3 M
edic
al R
ecor
ds -
Age
ncy
Sta
ff 0
166
4 M
edic
al R
ecor
ds -
Oth
er -
Non
labo
r 0
167
4 C
DP
H L
icen
sing
Fee
s 0
168
4 P
rofe
ssio
nal L
iabi
lity
Insu
ranc
e 22
,053
(2
,584
) 24
,637
169
4 Q
ualit
y A
ssur
ance
Fee
s 0
170
1 In
serv
ice
Edu
catio
n -
Nur
sing
- S
alar
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and
Wag
es
0
170
2 In
serv
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catio
n -
Nur
sing
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ringe
Ben
efits
0
170
3 In
serv
ice
Edu
catio
n -
Nur
sing
- A
genc
y S
taff
0
170
4 In
serv
ice
Edu
catio
n -
Nur
sing
- O
ther
- N
onla
bor
0
174
1 C
areg
iver
Tra
inin
g -
Sal
arie
s an
d W
ages
0
174
2 C
areg
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Tra
inin
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Frin
ge B
enef
its
0
ST
AT
E O
F C
AL
IFO
RN
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LA
SS
IFIC
AT
ION
S A
ND
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AD
JUS
TM
EN
TS
TO
RE
PO
RT
ED
CO
ST
S
Sch
edu
le 8
A-1
Pag
e 1
Pro
vid
er N
ame:
P
rovi
der
NP
I:
OS
HP
D F
acili
ty N
um
ber
: F
isca
l Per
iod
:
ALD
EN
TE
RR
AC
E C
ON
VA
LES
CE
NT
HO
SP
ITA
L 15
6854
4781
20
6190
013
JUN
E 1
, 201
0 T
HR
OU
GH
MA
Y 3
1, 2
011
TO
TA
L A
DJ
AU
DIT
AD
J A
UD
IT A
DJ
AU
DIT
AD
J A
UD
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DJ
AU
DIT
AD
J A
UD
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DJ
AU
DIT
AD
J A
UD
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DJ
Lin
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ub
(P
age
1)
2 3
4 5
6 7
8
No
. N
o.
174
3 C
areg
iver
Tra
inin
g -
Age
ncy
Sta
ff 0
174
4 C
areg
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Tra
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Oth
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200
Tot
al
($70
0,92
3)
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0 0
(22,
395)
24
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(To
Sch
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Sta
te o
f C
alif
orn
ia
Dep
artm
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of
Hea
lth
Car
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ervi
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Pro
vid
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ame
ALD
EN
TE
RR
AC
E C
ON
VA
LES
CE
NT
HO
SP
ITA
L
Fis
cal P
erio
d
JUN
E 1
, 201
0 T
HR
OU
GH
MA
Y 3
1, 2
011
Pro
vid
er N
PI
1568
5447
81
11
Ad
just
men
ts
Rep
ort R
efer
ence
s
Exp
lana
tion
of A
udit
Adj
ustm
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A
s R
epor
ted
Incr
ease
(D
ecre
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A
s A
djus
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Adj
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Cos
t Rep
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Aud
it R
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C53
0 P
age
or
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C
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Sch
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ine
Sub
No
ME
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TM
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0 T
otal
Fac
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up H
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Insu
ranc
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56
$112
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T
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entif
y gr
oup
heal
th in
sura
nce
in th
e au
d fo
r in
form
atio
nal p
urpo
ses
only
42
CF
R 4
13.2
0 an
d 41
3.24
C
MS
Pub
15-
1, S
ectio
ns 2
300
and
2304
Pag
e 1
Sta
te o
f C
alif
orn
ia
Dep
artm
ent
of
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lth
Car
e S
ervi
ces
Pro
vid
er N
ame
ALD
EN
TE
RR
AC
E C
ON
VA
LES
CE
NT
HO
SP
ITA
L
Fis
cal P
erio
d
JUN
E 1
, 201
0 T
HR
OU
GH
MA
Y 3
1, 2
011
Pro
vid
er N
PI
1568
5447
81
11
Ad
just
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ts
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efer
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s
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of A
udit
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ents
A
s R
epor
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A
s A
djus
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F R
EP
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2 10
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105
4 8A
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are
- O
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bor
$213
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($
12,0
30)
$200
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10
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165
4 8A
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165
4 A
dmin
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n -
Oth
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5,48
5 12
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90
7,51
5 *
To
recl
assi
fy p
harm
acy
cons
ulta
nts
expe
nse
to th
e ad
min
istr
atio
n co
st c
ente
r.
42 C
FR
413
.20
and
413.
24
CM
S P
ub. 1
5-1,
Sec
tions
230
0, 2
302.
4 an
d 23
02.8
3 10
.5
040
4 8A
-1
040
4 P
rope
rty
Tax
es
$82,
000
($2,
240)
$7
9,76
0 10
.5
165
4 8A
-1
165
4 A
dmin
istr
atio
n -
Oth
er -
Non
labo
r *
907,
515
2,24
0 90
9,75
5 *
To
recl
assi
fy F
ranc
hise
Tax
and
City
of L
os A
ngel
es B
usin
ese
Tax
ex
pens
es to
the
appr
opria
te c
ost c
ente
r fo
r pr
oper
cos
t det
erm
inat
ion.
42
CF
R 4
13.2
0 an
d 41
3.24
C
MS
Pub
. 15-
1, S
ectio
ns 2
300,
230
2.4
and
2302
.8
4 10
.5
165
4 8A
-1
165
4 A
dmin
istr
atio
n -
Oth
er -
Non
labo
r *
$909
,755
$2
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$9
12,3
39
* 10
.5
168
4 8A
-1
168
4 A
dmin
istr
atio
n -
Pro
fess
iona
l Lia
bilit
y In
sura
nce
143,
649
(2,5
84)
141,
065
* T
o re
clas
sify
fina
nce
fees
, tax
es a
nd o
ther
fees
ass
ocia
ted
with
liab
ility
in
sura
nce
to th
e A
dmin
istr
atio
n co
st c
ente
r.
42 C
FR
413
.24
/ CM
S P
ub. 1
5-1,
Sec
tion
2162
C
CR
, Titl
e 22
, Sec
tions
520
00(b
) an
d 52
501
5 10
.5
105
1 8A
-1
105
1 S
kille
d N
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are
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alar
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and
Wag
es
$3,6
26,2
88
($39
,481
) $3
,586
,807
*
10.5
10
5 2
8A-1
10
5 2
Ski
lled
Nur
sing
Car
e -
Frin
ge B
enef
its
820,
812
(8,9
36)
811,
876
10.5
16
5 1
8A-1
16
5 1
Adm
inis
trat
ion
- S
alar
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and
Wag
es
571,
429
39,4
81
610,
910
* 10
.5
165
2 8A
-1
165
2 A
dmin
istr
atio
n -
Frin
ge B
enef
its
66,2
29
8,93
6 75
,165
T
o re
clas
sify
cen
tral
sup
ply
cler
k w
ages
and
ben
efits
to
the
Adm
inis
trat
ion
cost
cen
ter.
42
CF
R 4
13.2
0 an
d 41
3.24
C
MS
Pub
. 15-
1, S
ectio
ns 2
300
and
2304
, C
CR
, Titl
e 22
, Sec
tions
520
00(b
) an
d 52
501
*Bal
ance
car
ried
forw
ard
from
prio
r/to
sub
sequ
ent a
djus
tmen
ts
Pag
e 2
Sta
te o
f C
alif
orn
ia
Dep
artm
ent
of
Hea
lth
Car
e S
ervi
ces
Pro
vid
er N
ame
ALD
EN
TE
RR
AC
E C
ON
VA
LES
CE
NT
HO
SP
ITA
L
Fis
cal P
erio
d
JUN
E 1
, 201
0 T
HR
OU
GH
MA
Y 3
1, 2
011
Pro
vid
er N
PI
1568
5447
81
11
Ad
just
men
ts
Rep
ort R
efer
ence
s
Exp
lana
tion
of A
udit
Adj
ustm
ents
A
s R
epor
ted
Incr
ease
(D
ecre
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s A
djus
ted
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. N
o.
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it R
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ine
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JUS
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RT
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CO
ST
S
6 10
.5
050
4 8A
-1
050
4 In
tere
st -
Pro
pert
y, P
lant
, and
Equ
ipm
ent
$88,
705
($22
,395
) $6
6,31
0 T
o ab
ate
inte
rest
inco
me
agai
nst i
nter
est e
xpen
se.
42 C
FR
413
.153
(b)(
2)(ii
i) / C
MS
Pub
. 15-
1, S
ectio
n 20
2.2
CM
S P
ub. 1
5-2,
Sec
tion
3613
7 10
.5
168
4 8A
-1
168
4 A
dmin
istr
atio
n -
Pro
fess
iona
l Lia
bilit
y In
sura
nce
* $1
41,0
65
$24,
637
$165
,702
T
o ad
just
the
repo
rted
liab
ility
insu
ranc
e ex
pens
e to
ag
ree
with
pro
vide
r's in
voic
es.
42 C
FR
413
.20
and
413.
24
CM
S P
ub. 1
5-1,
Sec
tions
230
0 an
d 23
04
8 10
.5
005
1 8A
-1
005
1 P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Sal
arie
s an
d W
ages
$3
60,4
12
($23
1,80
4)
$128
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10
.5
065
1 8A
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065
1 D
ieta
ry -
Sal
arie
s an
d W
ages
38
0,93
7 (2
1,39
5)
359,
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10.5
10
5 1
8A-1
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5 1
Ski
lled
Nur
sing
Car
e -
Sal
arie
s an
d W
ages
*
3,58
6,80
7 (5
8,81
0)
3,52
7,99
7 10
.5
165
1 8A
-1
165
1 A
dmin
istr
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n -
Sal
arie
s an
d W
ages
*
610,
910
(283
,580
) 32
7,33
0 10
.5
165
4 8A
-1
165
4 A
dmin
istr
atio
n -
Oth
er -
Non
labo
r *
912,
339
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,576
) 80
4,76
3 T
o ad
just
rep
orte
d ho
me
offic
e co
sts
to a
gree
with
the
Long
woo
d M
anag
emen
t Cor
pora
tion
Hom
e O
ffice
A
udit
Rep
orts
for
fisca
l per
iods
end
ed F
ebru
ary
28, 2
011
and
Feb
ruar
y 29
, 201
2.
42 C
FR
413
.17
and
413.
24
CM
S P
ub. 1
5-1,
Sec
tions
215
0.2
and
2304
*Bal
ance
car
ried
forw
ard
from
prio
r/to
sub
sequ
ent a
djus
tmen
ts
Pag
e 3
Sta
te o
f C
alif
orn
ia
Dep
artm
ent
of
Hea
lth
Car
e S
ervi
ces
Pro
vid
er N
ame
ALD
EN
TE
RR
AC
E C
ON
VA
LES
CE
NT
HO
SP
ITA
L
Fis
cal P
erio
d
JUN
E 1
, 201
0 T
HR
OU
GH
MA
Y 3
1, 2
011
Pro
vid
er N
PI
1568
5447
81
11
Ad
just
men
ts
Rep
ort R
efer
ence
s
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lana
tion
of A
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A
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epor
ted
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ease
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ecre
ase)
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s A
djus
ted
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. N
o.
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t Rep
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it R
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t M
C53
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age
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ibi t
Line
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ol.
Sch
. L
ine
Sub
No
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JUS
TM
EN
TS
TO
RE
PO
RT
ED
PA
TIE
NT
DA
YS
9 4.
1 5
6 1
12
Tot
al P
atie
nt D
ays
73,1
56
11
73,1
67
To
adju
st to
tal p
atie
nt d
ays
to a
gree
with
the
prov
ider
's
patie
nt c
ensu
s re
port
s.
42 C
FR
413
.20,
413
.24
and
413.
50
CM
S P
ub. 1
5-1,
Sec
tions
220
5, 2
300
and
2304
10
4.1
5 2
1 15
M
edi-C
al P
atie
nt D
ays
57,0
67
134
57,2
01
To
adju
st r
epor
ted
Med
i-Cal
Nur
sing
Fac
ility
day
s ba
sed
on
the
follo
win
g F
isca
l Int
erm
edia
ry P
aym
ent D
ata:
Ser
vice
Per
iod:
Ju
ne 1
, 201
0 th
roug
h M
ay 3
1, 2
011
Pay
men
t Per
iod:
Ju
ne 1
, 201
0 th
roug
h S
epte
mbe
r 30
, 201
2 R
epor
t Dat
e:
Oct
ober
8, 2
012
42 C
FR
413
.20,
413
.24,
413
.50,
413
.53,
413
.60,
413
.64,
and
433
.139
C
MS
Pub
. 15-
1, S
ectio
ns 2
300,
230
4, 2
404,
and
240
8 C
CR
, Titl
e 22
, Sec
tion
5154
1
Pag
e 4
Sta
te o
f C
alif
orn
ia
Dep
artm
ent
of
Hea
lth
Car
e S
ervi
ces
Pro
vid
er N
ame
ALD
EN
TE
RR
AC
E C
ON
VA
LES
CE
NT
HO
SP
ITA
L
Fis
cal P
erio
d
JUN
E 1
, 201
0 T
HR
OU
GH
MA
Y 3
1, 2
011
Pro
vid
er N
PI
1568
5447
81
11
Ad
just
men
ts
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ort R
efer
ence
s
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lana
tion
of A
udit
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s R
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ted
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ease
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s A
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t Rep
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it R
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11
Not
Rep
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rpay
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ts
$0
$35,
298
$35,
298
To
reco
ver
outs
tand
ing
Med
i-Cal
Cre
dit B
alan
ces.
42
CF
R 4
13.2
0 an
d 41
3.24
C
MS
Pub
. 15-
1, S
ectio
n 23
00 a
nd 2
304
CC
R, T
itle
22, S
ectio
ns 5
0761
and
514
58.1
Pag
e 5