REPORT ON THE
RATE SETTING AUDIT
DOWNEY CARE CENTER DOWNEY, CALIFORNIA
PROVIDER NUMBER: ZZT05519J NATIONAL PROVIDER IDENTIFIER: 1942335062
FISCAL PERIOD ENDED DECEMBER 31, 2009
Audits Section – Santa Ana Financial Audits Branch
Audits and Investigations Department of Health Care Services
Section Chief: Margaret A. Varho Audit Supervisor: Stan Van Arsdale Auditor: Teri Hung
State of California—Health and Human Services Agency Department of Health Care Services
TOBY DOUGLAS EDMUND G. BROWN JR. DIRECTOR GOVERNOR
605 West Santa Ana Blvd., Building 28, Room 830, Santa Ana, CA 92701 (714) 558-4434 / (714) 558-4179 fax Internet Address: www.dhcs.ca.gov
Date: June 24, 2011 Carol Sparks Director of Reimbursement Covenant Care, LLC 27071 Aliso Creek Road, Suite 100 Aliso Viejo, CA 92656 PROVIDER: DOWNEY CARE CENTER PROVIDER NO. ZZT05519J NATIONAL PROVIDER IDENTIFIER: 1942335062 FISCAL PERIOD ENDED DECEMBER 31, 2009 We have examined the facility's Integrated Disclosure and Medi-Cal Cost Report for the above-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 the cost report and accompanying financial statements, Medi-Cal Paid Claims Summary Report, 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 Schedule 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 Rate Development Branch. 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.
Carol Sparks Page 2
If you disagree with the decision of the Department, you may appeal by writing to: Chief Office of Administrative Appeals and Hearings 1029 J Street, Suite 200 Sacramento, CA 95814-2825 (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 95899-7413 Sacramento, CA 95814-5005 (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—Santa Ana at (714) 558-4434. (Original signed by Margaret Varho) Margaret A. Varho, Chief Audits Section—Santa Ana Financial Audits Branch Certified
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:DOWNEY CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009
Provider Number: NPI: OSHPD Facility No.:ZZT05519J 1942335062 206190874
LineNo.
SKILLED NURSING CARE1 Cost of Direct Care - Labor (Sch. 2, Ln. 105) $ N/A $ 2,874,557 $ 86.072 Cost of Indirect Care - Labor (Sch. 3, Ln. 105) $ N/A $ 674,933 $ 20.213 Cost of Direct and Indirect NonLabor - Other (Sch. 4, Ln. 105) $ N/A $ 455,584 $ 13.644 Cost of Capital Related (Sch. 5, Ln. 105) $ N/A $ 436,871 $ 13.085 Property Taxes (Sch. 5, Ln. 105) $ N/A $ 35,072 $ 1.056 DPH Licensing Fees (Sch. 6, Ln. 105) $ N/A $ 20,498 $ 0.617 Liability Insurance (Sch. 6, Ln. 105) $ N/A $ 160,636 $ 4.818 Caregiver Training (Sch. 6, Ln. 105) $ N/A $ 0 $ 0.009 Quality Assurance Fees (Sch. 6, Ln. 105) $ N/A $ 252,924 $ 7.57
10 Cost of Administration (Sch. 6, Ln. 105) $ N/A $ 739,495 $ 22.1411 Cost of Routine Service/Audited Total Costs $ 5,638,937 $ 5,650,569 $ 169.2012 Total Patient Days (Adj ) 33,396 33,39613 Cost Per Patient Day (Cost Divided by Days) $ 168.85 $ 169.20 14 Overpayments (Adj ) $ 0 $ 015
INTERMEDIATE CARE16 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 017 Total Patient Days (Adj ) 018 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0019 Overpayments (Adj ) $ $ 0
MENTALLY DISORDERED CARE20 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 021 Total Patient Days (Adj ) 022 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0023 Overpayments (Adj ) $ $ 0
DEVELOPMENTALLY DISABLED24 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 025 Total Patient Days (Adj ) 026 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0027 Overpayments (Adj ) $ $ 0
SUBACUTE CARE28 Cost of Direct Care - Labor (Adult Subacute Sch. 1, Ln. 25) $ N/A $ 0 $ 0.0029 Cost of Indirect Care - Labor (Adult Subacute Sch. 1, Ln. 26) $ N/A $ 0 $ 0.0030 Cost of Direct and Indirect NonLabor - Other (Adult SA Sch. 1, Ln. 27) $ N/A $ 0 $ 0.0031 Cost of Capital Related (Adult Subacute Sch. 1, Ln. 28) $ N/A $ 0 $ 0.0032 Property Taxes (Adult Subacute Sch. 1, Ln. 29) $ N/A $ 0 $ 0.0033 DPH Licensing Fees (Adult Subacute Sch. 1, Ln. 30) $ N/A $ 0 $ 0.0034 Liability Insurance (Adult Subacute Sch. 1, Ln. 31) $ N/A $ 0 $ 0.0035 Quality Assurance Fees (Adult Subacute Sch. 1, Ln. 32) $ N/A $ 0 $ 0.0036 Caregiver Training (Adult Subacute Sch. 1, Ln. 33) $ N/A $ 0 $ 0.0037 Cost of Administration (Adult Subacute Sch., Ln. 34) $ N/A $ 0 $ 0.0038 Total Cost of Subacute Service (Adult Subacute Sch. 1, Ln. 35) $ 0 $ 0 $ 0.0039 Total Patient Days (Adult Subacute Sch. 1, Ln. 36) 0 040 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0041 Overpayments (Adult Subacute Sch. 1, Ln. 38 + Ln. 39) $ 0 $ 0
SUMMARY OF AUDITED FACILITY COST PER PATIENT DAY
COST PERAUDITED
AS REPORTED AS AUDITED PATIENT DAYPROGRAM DESCRIPTION
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:DOWNEY CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009
Provider Number: NPI: OSHPD Facility No.:ZZT05519J 1942335062 206190874
LineNo.
SUMMARY OF AUDITED FACILITY COST PER PATIENT DAY
COST PERAUDITED
AS REPORTED AS AUDITED PATIENT DAYPROGRAM DESCRIPTION
SUBACUTE - PEDIATRIC SUBACUTE42 Cost of Routine Service (Ped-SA, Sch. 1, Ln 3) $ 0 $ 043 Cost of Ancillary Service (Ped-SA, Sch. 1, Ln. 1 + Ln. 2) $ 0 $ 044 Total Cost of Pediatric Subacute Service (Ln. 42 + Ln. 43) $ 0 $ 045 Total Patient Days (Ped-SA, Sch. 1, Ln. 5) 0 046 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0047 Overpayments (Ped-SA, Sch. 1, Ln. 7 + Ln. 8) $ 0 $ 0
TRANSITIONAL INPATIENT CARE48 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 049 Total Patient Days (Adj ) 050 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0051 Overpayments (Adj ) $ $ 0
HOSPICE INPATIENT CARE52 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 053 Total Patient Days (Adj ) 054 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0055 Overpayments (Adj ) $ $ 0
OTHER ROUTINE SERVICES56 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 057 Total Patient Days (Adj ) 058 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0059 Overpayments (Adj ) $ $ 0
STATE OF CALIFORNIA SCHEDULE 2
Provider Name: Fiscal Period:DOWNEY CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009
Provider Number: NPI: OSHPD Facility No.:ZZT05519J 1942335062 206190874
Soc Srvs ActivitiesNet Exp For
Line DESCRIPTION Cost AllocNo. (From Sch 8) 155 160 Total
GENERAL SERVICES005 Plant Operations and Maintenance010 Housekeeping060 Laundry and Linen065 Dietary155 Social Services (Salaries, Fringe Benefits, & Agency Labor) 111,749$ 111,749$ 160 Activities (Salaries, Fringe Benefits, & Agency Labor) 94,785 94,785$ 165 Administration166 Medical Records170 Inservice Education - Nursing
ANCILLARY SERVICES075 Patient Supplies 30,678 0 0 30,678 ***077 Specialized Support Surfaces N/A 0 0 0 ***080 Physical Therapy 385,993 0 0 385,993 ***081 Respiratory Therapy 0 0 0 0 ***082 Occupational Therapy 343,986 0 0 343,986 ***083 Speech Pathology 118,434 0 0 118,434 ***085 Pharmacy 335,351 0 0 335,351 ***090 Laboratory 39,057 0 0 39,057 ***095 Home Health Services 0 0 0 0100 Other Ancillary Services 26,054 0 0 26,054101 Subacute Ancillary Services 0 0 0 0102 Subacute Pediatrics Ancillary Services 0 0 0 0 **
ROUTINE SERVICES105 Skilled Nursing Care 2,668,023 111,749 94,785 2,874,557 *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 - Pediatrics 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 0140 Beauty and Barber 3,659 0 0 3,659145 Other Nonreimbursable 0 0 0 0
TOTAL 4,157,769$ 111,749$ 94,785$ 4,157,769$
* (To Schedule 1)** (To Pediatric Subacute Schedule 1)*** (To Pediatric Subacute Schedule 2)
ALLOCATION OF GENERAL SERVICES - LABOR (DIRECT CARE)
ST
AT
E O
F C
AL
IFO
RN
IAS
CH
ED
UL
E 3
Pro
vid
er N
ame:
Pro
vid
er N
um
ber
:N
PI:
OS
HP
D F
acili
ty N
um
ber
:F
isca
l Per
iod
:D
OW
NE
Y C
AR
E C
EN
TE
RZ
ZT
0551
9J19
4233
5062
2061
9087
4JA
NU
AR
Y 1
, 200
9 T
HR
OU
GH
DE
CE
MB
ER
31,
200
9
Pla
nt
Op
sH
skp
ng
Lau
nd
ryD
ieta
ryS
oc
Srv
sA
ctiv
itie
sIn
-ser
v. E
dA
dm
inM
edic
alN
et E
xp F
or
Rec
ord
sL
ine
DE
SC
RIP
TIO
NC
ost
Allo
cA
ccu
mu
late
dN
o.
(Fro
m S
ch 8
)00
501
006
006
515
516
017
0C
ost
s16
516
6T
ota
l
GE
NE
RA
L S
ER
VIC
ES
005
Pla
nt O
pera
tions
and
Mai
nten
ance
68,2
25$
68,2
25$
01
0H
ouse
keep
ing
145,
858
1,13
5
146,
993
$
06
0La
undr
y an
d Li
nen
77,2
683,
690
8,08
589
,044
$
065
Die
tary
272,
668
8,56
318
,761
029
9,99
2$
155
Soc
ial S
ervi
ces
N/A
16
736
60
053
4$
16
0A
ctiv
ities
N/A
34
275
00
00
1,09
2$
165
Adm
inis
trat
ion
N/A
9,
184
20,1
220
00
029
,306
$
29
,306
$
166
Med
ical
Rec
ords
72,1
782,
886
6,32
30
00
081
,388
81,3
88$
17
0In
serv
ice
Edu
catio
n -
Nur
sing
80,0
7744
296
80
00
081
,487
$
AN
CIL
LA
RY
SE
RV
ICE
S07
5P
atie
nt S
uppl
ies
287
628
00
00
091
517
949
71,
591
$
**
*07
7S
peci
aliz
ed S
uppo
rt S
urfa
ces
00
00
00
00
00
0**
*08
0P
hysi
cal T
hera
py1,
477
3,23
60
00
00
4,71
32,
107
5,85
212
,673
***
081
Res
pira
tory
The
rapy
00
00
00
00
00
0**
*08
2O
ccup
atio
nal T
hera
py1,
091
2,39
00
00
00
3,48
11,
862
5,17
210
,516
***
083
Spe
ech
Pat
holo
gy1,
246
2,73
00
00
00
3,97
670
11,
947
6,62
4**
*08
5P
harm
acy
00
00
00
00
1,74
34,
839
6,58
2**
*09
0La
bora
tory
00
00
00
00
203
564
767
***
095
Hom
e H
ealth
Ser
vice
s0
00
00
00
00
00
100
Oth
er A
ncill
ary
Ser
vice
s0
00
00
00
013
537
651
110
1S
ubac
ute
Anc
illar
y S
ervi
ces
00
00
00
00
00
010
2S
ubac
ute
Ped
iatr
ics
Anc
illar
y S
ervi
ces
00
00
00
00
00
0**
RO
UT
INE
SE
RV
ICE
S10
5S
kille
d N
ursi
ng C
are
37,1
3481
,359
89,0
4429
9,99
253
41,
092
81,4
8759
0,64
222
,316
61,9
7567
4,93
3*
110
Inte
rmed
iate
Car
e0
00
00
00
00
00
*11
5M
enta
lly D
isor
dere
d C
are
00
00
00
00
00
0*
120
Dev
elop
men
tally
Dis
able
d C
are
00
00
00
00
00
0*
125
Sub
acut
e C
are
00
00
00
00
00
0*
126
Sub
acut
e C
are
- P
edia
tric
s0
00
00
00
00
00
**12
8T
rans
ition
al In
patie
nt C
are
00
00
00
00
00
0*
130
Hos
pice
Inpa
tient
Car
e0
00
00
00
00
00
*13
5O
ther
Rou
tine
Ser
vice
s0
00
00
00
00
00
*N
ON
RE
IMB
UR
SA
BL
E
139
Res
iden
tial C
are
00
00
00
00
00
014
0B
eaut
y an
d B
arbe
r58
11,
273
00
00
01,
855
5916
42,
077
145
Oth
er N
onre
imbu
rsab
le0
00
00
00
00
00
TO
TA
L71
6,27
4$
68
,225
$
146,
993
$
89
,044
$
299,
992
$
53
4$
1,
092
$
81
,487
$
605,
581
$
29,3
06$
81
,388
$
716,
274
$
*(T
o S
ched
ule
1)**
(To
Ped
iatr
ic S
ubac
ute
Sch
edul
e 1)
***
(To
Ped
iatr
ic S
ubac
ute
Sch
edul
e 2)
AL
LO
CA
TIO
N O
F G
EN
ER
AL
SE
RV
ICE
S -
LA
BO
R(I
ND
IRE
CT
CA
RE
)
ST
AT
E O
F C
AL
IFO
RN
IAS
CH
ED
UL
E 4
Pro
vid
er N
ame:
Pro
vid
er N
um
ber
:N
PI:
OS
HP
D F
acili
ty N
um
ber
:F
isca
l Per
iod
:D
OW
NE
Y C
AR
E C
EN
TE
RZ
ZT
0551
9J19
4233
5062
2061
9087
4JA
NU
AR
Y 1
, 200
9 T
HR
OU
GH
DE
CE
MB
ER
31,
200
9
Pla
nt
Op
sH
skp
ng
Lau
nd
ryD
ieta
ryS
oc
Srv
sA
ctiv
itie
sIn
-ser
v. E
dA
dm
inM
edic
alN
et E
xp F
or
Rec
ord
sL
ine
DE
SC
RIP
TIO
NC
ost
Allo
cA
ccu
mu
late
dN
o.
(Fro
m S
ch 8
)5
1060
6515
516
017
0C
ost
s16
516
6T
ota
l
GE
NE
RA
L S
ER
VIC
ES
005
Pla
nt O
pera
tions
and
Mai
nten
ance
104,
040
$
104,
040
$
01
0H
ouse
keep
ing
38,1
631,
730
39,8
93$
06
0La
undr
y an
d Li
nen
21,1
065,
628
2,19
428
,928
$
065
Die
tary
174,
230
13,0
585,
092
019
2,38
0$
155
Soc
ial S
ervi
ces
5,38
325
599
00
5,73
7$
160
Act
iviti
es8,
246
522
204
00
08,
972
$
16
5A
dmin
istr
atio
nN
/A
14,0
055,
461
00
00
19,4
66$
19,4
66$
16
6M
edic
al R
ecor
ds7,
640
4,40
11,
716
00
00
13,7
5713
,757
$
170
Inse
rvic
e E
duca
tion
- N
ursi
ng58
567
426
30
00
01,
522
$
A
NC
ILL
AR
Y S
ER
VIC
ES
075
Pat
ient
Sup
plie
s0
437
170
00
00
060
811
984
811
$
***
077
Spe
cial
ized
Sup
port
Sur
face
s0
00
00
00
00
00
0**
*08
0P
hysi
cal T
hera
py0
2,25
287
80
00
00
3,13
01,
400
989
5,51
9**
*08
1R
espi
rato
ry T
hera
py0
00
00
00
00
00
0**
*08
2O
ccup
atio
nal T
hera
py0
1,66
364
90
00
00
2,31
21,
237
874
4,42
3**
*08
3S
peec
h P
atho
logy
01,
900
741
00
00
02,
641
466
329
3,43
6**
*08
5P
harm
acy
00
00
00
00
01,
157
818
1,97
6**
*09
0La
bora
tory
00
00
00
00
013
595
230
***
095
Hom
e H
ealth
Ser
vice
s0
00
00
00
00
00
010
0O
ther
Anc
illar
y S
ervi
ces
00
00
00
00
090
6415
310
1S
ubac
ute
Anc
illar
y S
ervi
ces
00
00
00
00
00
00
102
Sub
acut
e P
edia
tric
s A
ncill
ary
Ser
vice
s0
00
00
00
00
00
**R
OU
TIN
E S
ER
VIC
ES
105
Ski
lled
Nur
sing
Car
e11
4,03
856
,628
22,0
8128
,928
192,
380
5,73
78,
972
1,52
243
0,28
514
,823
10,4
7645
5,58
4*
110
Inte
rmed
iate
Car
e0
00
00
00
00
00
*11
5M
enta
lly D
isor
dere
d C
are
00
00
00
00
00
0*
120
Dev
elop
men
tally
Dis
able
d C
are
00
00
00
00
00
0*
125
Sub
acut
e C
are
00
00
00
00
00
00
*12
6S
ubac
ute
Car
e -
Ped
iatr
ics
00
00
00
00
00
0**
128
Tra
nsiti
onal
Inpa
tient
Car
e0
00
00
00
00
00
*13
0H
ospi
ce In
patie
nt C
are
00
00
00
00
00
0*
135
Oth
er R
outin
e S
ervi
ces
00
00
00
00
00
0*
NO
NR
EIM
BU
RS
AB
LE
13
9R
esid
entia
l Car
e0
00
00
00
00
00
140
Bea
uty
and
Bar
ber
886
346
00
00
01,
232
3928
1,29
914
5O
ther
Non
reim
burs
able
00
00
00
00
00
0
TO
TA
L47
3,43
1$
10
4,04
0$
39,8
93$
28
,928
$
192,
380
$
5,
737
$
8,
972
$
1,
522
$
44
0,20
7$
19
,466
$
13,7
57$
47
3,43
1$
*(T
o S
ched
ule
1)**
(To
Ped
iatr
ic S
ubac
ute
Sch
edul
e 1)
***
(To
Ped
iatr
ic S
ubac
ute
Sch
edul
e 2)
AL
LO
CA
TIO
N O
F G
EN
ER
AL
SE
RV
ICE
S -
OT
HE
R N
ON
LA
BO
R(D
IRE
CT
AN
D IN
DIR
EC
T C
AR
E)
STATE OF CALIFORNIA SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Provider Name: Fiscal Period:DOWNEY CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009
Provider Number: NPI: OSHPD Facility Number:ZZT05519J 1942335062 206190874
Capital Plant Ops Hskpng Laundry Dietary Soc Srvs ActivitiesNet Exp For
Line DESCRIPTION Cost AllocNo. (From Sch 8) Ratio Various 5 10 60 65 155 160
GENERAL SERVICESCapital Related (excluding lines 40 & 45) 492,355$ 93%Property Tax (line 40) 39,526 7% 531,881$
005 Plant Operations and Maintenance 15,166 15,166$ 010 Housekeeping 8,593 252 8,845$ 060 Laundry and Linen 27,949 820 487 29,256$ 065 Dietary 64,853 1,903 1,129 0 67,886$ 155 Social Services 1,266 37 22 0 0 1,326$ 160 Activities 2,593 76 45 0 0 0 2,714$ 165 Administration 69,557 2,041 1,211 0 0 0 0166 Medical Records 21,859 642 381 0 0 0 0170 Inservice Education - Nursing 3,347 98 58 0 0 0 0
ANCILLARY SERVICES075 Patient Supplies 2,171 64 38 0 0 0 0077 Specialized Support Surfaces 0 0 0 0 0 0 0080 Physical Therapy 11,186 328 195 0 0 0 0081 Respiratory Therapy 0 0 0 0 0 0 0082 Occupational Therapy 8,261 242 144 0 0 0 0083 Speech Pathology 9,437 277 164 0 0 0 0085 Pharmacy 0 0 0 0 0 0 0090 Laboratory 0 0 0 0 0 0 0095 Home Health Services 0 0 0 0 0 0 0100 Other Ancillary Services 0 0 0 0 0 0 0101 Subacute Ancillary Services 0 0 0 0 0 0 0102 Subacute Pediatrics Ancillary Services 0 0 0 0 0 0 0
ROUTINE SERVICES105 Skilled Nursing Care 281,242 8,254 4,896 29,256 67,886 1,326 2,714110 Intermediate Care 0 0 0 0 0 0 0115 Mentally Disordered Care 0 0 0 0 0 0 0120 Developmentally Disabled Care 0 0 0 0 0 0 0125 Subacute Care 0 0 0 0 0 0 0126 Subacute Care - Pediatrics 0 0 0 0 0 0 0128 Transitional Inpatient Care 0 0 0 0 0 0 0130 Hospice Inpatient Care 0 0 0 0 0 0 0135 Other Routine Services 0 0 0 0 0 0 0
NONREIMBURSABLE 139 Residential Care 0 0 0 0 0 0 0140 Beauty and Barber 4,402 129 77 0 0 0 0145 Other Nonreimbursable 0 0 0 0 0 0 0
TOTAL 531,881$ 100% 531,881$ 15,166$ 8,845$ 29,256$ 67,886$ 1,326$ 2,714$
* (To Schedule 1)** (To Pediatric Subacute Schedule 1)*** (To Pediatric Subacute Schedule 2)
STATE OF CALIFORNIA
Provider Name:
DOWNEY CARE CENTER
Provider Number: NPI:
ZZT05519J 1942335062
Net Exp For
Line DESCRIPTION Cost AllocNo. (From Sch 8) Ratio
GENERAL SERVICES
Capital Related (excluding lines 40 & 45) 492,355$ 93%
Property Tax (line 40) 39,526 7%
005 Plant Operations and Maintenance
010 Housekeeping
060 Laundry and Linen
065 Dietary
155 Social Services
160 Activities
165 Administration
166 Medical Records
170 Inservice Education - Nursing
ANCILLARY SERVICES
075 Patient Supplies
077 Specialized Support Surfaces
080 Physical Therapy
081 Respiratory Therapy
082 Occupational Therapy
083 Speech Pathology
085 Pharmacy
090 Laboratory
095 Home Health Services
100 Other Ancillary Services
101 Subacute Ancillary Services
102 Subacute Pediatrics Ancillary Services
ROUTINE SERVICES
105 Skilled Nursing Care
110 Intermediate Care
115 Mentally Disordered Care
120 Developmentally Disabled Care
125 Subacute Care
126 Subacute Care - Pediatrics
128 Transitional Inpatient Care
130 Hospice Inpatient Care
135 Other Routine Services
NONREIMBURSABLE
139 Residential Care
140 Beauty and Barber
145 Other Nonreimbursable
TOTAL 531,881$ 100%
* (To Schedule 1)
** (To Pediatric Subacute Schedule 1)
*** (To Pediatric Subacute Schedule 2)
SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Fiscal Period:
JANUARY 1, 2009 THROUGH DECEMBER 31, 2009
OSHPD Facility Number:
206190874
In-serv. Ed Admin Medical Capital Property
Records Related Tax
Accumulated 93% 7%170 Costs 165 166 Total Of Total Of Total
72,809$ 72,809$
22,881 22,881$
3,503$
0 2,272 445 140 2,857$ 2,645$ 212$ ***
0 0 0 0 0 0 0 ***
0 11,709 5,236 1,645 18,590 17,208 1,381 ***
0 0 0 0 0 0 0 ***
0 8,647 4,627 1,454 14,729 13,634 1,095 ***
0 9,878 1,742 547 12,168 11,263 904 ***
0 0 4,329 1,361 5,690 5,267 423 ***
0 0 504 158 663 613 49 ***
0 0 0 0 0 0 0
0 0 336 106 442 409 33
0 0 0 0 0 0 0
0 0 0 0 0 0 0 **
3,503 399,076 55,443 17,423 471,943 436,871 35,072 *
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 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 0 0 *
0 0 0 0 0 0 0
0 4,608 147 46 4,800 4,444 357
0 0 0 0 0 0 0
3,503$ 436,191$ 72,809$ 22,881$ 531,881$ 492,355$ 39,526$
ST
AT
E O
F C
AL
IFO
RN
IAS
CH
ED
UL
E 6
Pro
vid
er N
ame:
Pro
vid
er N
um
ber
:N
PI:
OS
HP
D F
acili
ty N
um
ber
:F
isca
l Per
iod
:D
OW
NE
Y C
AR
E C
EN
TE
RZ
ZT
0551
9J19
4233
5062
2061
9087
4JA
NU
AR
Y 1
, 200
9 T
HR
OU
GH
DE
CE
MB
ER
31,
200
9
Ad
min
.D
PH
Lia
bili
tyQ
ual
ity
Ass
ur.
Car
egiv
erN
et E
xp F
or
Acc
um
Acc
um
Acc
um
Acc
um
To
tal
Allo
cate
dL
icen
se F
ees
Insu
ran
ceF
ees
Tra
inin
gL
ine
DE
SC
RIP
TIO
NC
ost
Allo
cC
ost
sC
ost
sC
ost
sC
ost
sA
ccu
mA
dm
in.
63%
2%14
%22
%0%
No
.(F
rom
Sch
8)
Rat
io(F
rom
Sch
2)
(Fro
m S
ch 3
)(F
rom
Sch
4)
(Fro
m S
ch 5
)C
ost
sC
ost
so
f T
ota
lo
f T
ota
lo
f T
ota
lo
f T
ota
lo
f T
ota
l
GE
NE
RA
L S
ER
VIC
ES
045
Pro
pert
y In
sura
nce
10,8
89$
05
5In
tere
st-O
ther
016
5A
dmin
istr
atio
n (S
alar
ies
& W
ages
, Frin
ge B
enef
its,
Age
ncy
Sta
ff an
d O
ther
- N
onla
bor)
960,
239
Tot
al C
osts
Allo
cabl
e as
Adm
inis
trat
ion
971,
128
63%
167
DP
H L
icen
sing
Fee
s26
,919
2%16
8Li
abili
ty In
sura
nce
210,
952
14%
169
Qua
lity
Ass
uran
ce F
ees
332,
147
22%
174
Car
egiv
er T
rain
ing
00%
Tot
al
1,54
1,14
610
0%1,
541,
146
$
A
NC
ILL
AR
Y S
ER
VIC
ES
075
Pat
ient
Sup
plie
s30
,678
$
915
$
608
$
2,27
2$
34,4
72$
9,42
05,
936
$
165
$
1,
289
$
2,03
0$
-
$
**
*07
7S
peci
aliz
ed S
uppo
rt S
urfa
ces
00
00
00
00
00
0**
*08
0P
hysi
cal T
hera
py38
5,99
34,
713
3,13
011
,709
405,
545
110,
821
69,8
321,
936
15,1
6923
,884
0**
*08
1R
espi
rato
ry T
hera
py0
00
00
00
00
00
***
082
Occ
upat
iona
l The
rapy
343,
986
3,48
12,
312
8,64
735
8,42
697
,945
61,7
191,
711
13,4
0721
,109
0**
*08
3S
peec
h P
atho
logy
118,
434
3,97
62,
641
9,87
813
4,92
936
,871
23,2
3464
45,
047
7,94
70
***
085
Pha
rmac
y33
5,35
10
00
335,
351
91,6
4057
,745
1,60
112
,544
19,7
500
***
090
Labo
rato
ry39
,057
00
039
,057
10,6
736,
725
186
1,46
12,
300
0**
*09
5H
ome
Hea
lth S
ervi
ces
00
00
00
00
00
010
0O
ther
Anc
illar
y S
ervi
ces
26,0
540
00
26,0
547,
120
4,48
612
497
51,
534
010
1S
ubac
ute
Anc
illar
y S
ervi
ces
00
00
00
00
00
010
2S
ubac
ute
Ped
iatr
ics
Anc
illar
y S
ervi
ces
00
00
00
00
00
0**
RO
UT
INE
SE
RV
ICE
S10
5S
kille
d N
ursi
ng C
are
2,87
4,55
759
0,64
243
0,28
539
9,07
64,
294,
560
1,17
3,55
373
9,49
520
,498
160,
636
252,
924
0*
110
Inte
rmed
iate
Car
e0
00
00
00
00
00
*11
5M
enta
lly D
isor
dere
d C
are
00
00
00
00
00
0*
120
Dev
elop
men
tally
Dis
able
d C
are
00
00
00
00
00
0*
125
Sub
acut
e C
are
00
00
00
00
00
0*
126
Sub
acut
e C
are
- P
edia
tric
s0
00
00
00
00
00
**12
8T
rans
ition
al In
patie
nt C
are
00
00
00
00
00
0*
130
Hos
pice
Inpa
tient
Car
e0
00
00
00
00
00
*13
5O
ther
Rou
tine
Ser
vice
s0
00
00
00
00
00
*N
ON
RE
IMB
UR
SA
BL
E
139
Res
iden
tial C
are
00
00
00
00
00
014
0B
eaut
y an
d B
arbe
r3,
659
1,85
51,
232
4,60
811
,353
3,10
21,
955
5442
566
90
145
Oth
er N
onre
imbu
rsab
le0
00
00
00
00
00
SU
BT
OT
AL
1,54
1,14
6$
4,15
7,76
9$
605,
581
$
440,
207
$
436,
191
$
5,63
9,74
8$
1,54
1,14
6$
Tot
al A
dmin
istr
ativ
e C
osts
1,54
1,14
6$
971,
128
$
26,9
19$
210,
952
$
332,
147
$
-
$
U
nit C
ost M
ultip
lier
0.27
3265
04
A
ccum
ulat
ed A
dmin
istr
atio
n C
osts
(S
ch 2
thru
5)
110,
693
$
33,2
24$
72
,809
$
216,
726
$
TO
TA
L F
AC
ILIT
Y C
OS
TS
7,39
7,62
0$
*(T
o S
ched
ule
1)**
(To
Ped
iatr
ic S
ubac
ute
Sch
edul
e 1)
***
(To
Ped
iatr
ic S
ubac
ute
Sch
edul
e 2)
AL
LO
CA
TIO
N O
F A
DM
INIS
TR
AT
ION
AN
D O
TH
ER
DIR
EC
T P
AS
S-T
HR
OU
GH
CO
ST
S
ST
AT
E O
F C
AL
IFO
RN
IAS
CH
ED
UL
E 7
Pro
vid
er
Na
me
:
Pro
vid
er
Nu
mb
er:
NP
I:O
SH
PD
Fa
cili
ty N
um
be
r:F
isca
l Pe
rio
d:
ZZ
T0
55
19
J1
94
23
35
06
22
06
19
08
74
JAN
UA
RY
1, 2
00
9 T
HR
OU
GH
DE
CE
MB
ER
31
, 20
09
Ca
pit
al
Pla
nt
Op
sH
skp
ng
Lau
nd
ryD
ieta
ryS
oc
Srv
sA
cti
viti
esIn
-ser
v. E
dA
dm
in.
Med
Rec
ord
s(T
OT
AL
(TO
TA
LL
ine
DE
SC
RIP
TIO
N(S
Q F
T)
(SQ
FT
)(S
Q F
T)
(LB
S)
(ME
AL
S)
(DIR
EC
T E
XP
)(D
IRE
CT
EX
P)
(DIR
EC
T E
XP
)A
CC
UM
(AC
CU
MN
o.
VA
RIO
US
51
06
06
51
55
16
01
70
CO
ST
)C
OS
T)
(Ad
j
)(A
dj
)
(Ad
j
)(A
dj
)
(Ad
j
)(A
dj
)
(Ad
j
)(A
dj
)
GE
NE
RA
L S
ER
VIC
ES
00
5P
lan
t Op
era
tion
s a
nd
Ma
inte
na
nce
50
30
10
Ho
use
kee
pin
g2
85
28
50
60
La
un
dry
an
d L
ine
n9
27
92
79
27
06
5D
ieta
ry2
,15
12
,15
12
,15
11
55
So
cia
l Se
rvic
es
42
42
42
16
0A
ctiv
itie
s8
68
68
61
65
Ad
min
istr
atio
n2
,30
72
,30
72
,30
71
66
Me
dic
al R
eco
rds
72
57
25
72
51
70
Inse
rvic
e E
du
catio
n -
Nu
rsin
g1
11
11
11
11
AN
CIL
LA
RY
SE
RV
ICE
S0
75
Pa
tien
t Su
pp
lies
72
72
72
34
,47
23
4,4
72
07
7S
pe
cia
lize
d S
up
po
rt S
urf
ace
s0
00
80
Ph
ysic
al T
he
rap
y3
71
37
13
71
40
5,5
45
40
5,5
45
08
1R
esp
ira
tory
Th
era
py
00
08
2O
ccu
pa
tion
al T
he
rap
y2
74
27
42
74
35
8,4
26
35
8,4
26
08
3S
pe
ech
Pa
tho
log
y3
13
31
33
13
13
4,9
29
13
4,9
29
08
5P
ha
rma
cy3
35
,35
13
35
,35
10
90
La
bo
rato
ry3
9,0
57
39
,05
70
95
Ho
me
He
alth
Se
rvic
es
00
10
0O
the
r A
nci
llary
Se
rvic
es
26
,05
42
6,0
54
101
Sub
acut
e A
nci
llary
Se
rvic
es0
010
2S
ubac
ute
Ped
iatr
ics
An
cilla
ry S
erv
ices
00
RO
UT
INE
SE
RV
ICE
S1
05
Ski
lled
Nu
rsin
g C
are
9,3
28
9,3
28
9,3
28
66
,79
29
8,8
80
2,7
82
,06
12
,78
2,0
61
2,7
82
,06
14
,29
4,5
60
4,2
94
,56
01
10
Inte
rme
dia
te C
are
00
00
01
15
Me
nta
lly D
iso
rde
red
Ca
re0
00
00
12
0D
eve
lop
me
nta
lly D
isa
ble
d C
are
00
00
01
25
Su
ba
cute
Ca
re0
00
00
12
6S
ub
acu
te C
are
- P
ed
iatr
ics
00
00
01
28
Tra
nsi
tion
al I
np
atie
nt C
are
00
00
01
30
Ho
spic
e In
pa
tien
t Ca
re0
00
00
13
5O
the
r R
ou
tine
Se
rvic
es
00
00
0N
ON
RE
IMB
UR
SA
BL
E
13
9R
esi
de
ntia
l Ca
re0
01
40
Be
au
ty a
nd
Ba
rbe
r1
46
14
61
46
11
,35
31
1,3
53
14
5O
the
r N
on
reim
bu
rsa
ble
00
TO
TA
L S
TA
TIS
TIC
S1
7,6
41
17
,13
81
6,8
53
66
,79
29
8,8
80
2,7
82
,06
12
,78
2,0
61
2,7
82
,06
15
,63
9,7
48
5,6
39
,74
8T
OT
AL
DIR
EC
T S
AL
AR
IES
CO
ST
S -
SC
H. 2
11
1,7
49
$
94
,78
5$
UN
IT C
OS
T M
UL
TIP
LIE
R (
DIR
EC
T S
AL
AR
IES
)0
.04
01
67
70
30
.03
40
70
06
5T
OT
AL
IND
IRE
CT
SA
LA
RIE
S C
OS
TS
- S
CH
. 36
8,2
25
$
1
46
,99
3$
8
9,0
44
$
29
9,9
92
$
5
34
$
1
,09
2$
8
1,4
87
$
2
9,3
06
$
8
1,3
88
$
U
NIT
CO
ST
MU
LT
IPL
IER
(IN
DIR
EC
T S
AL
AR
IES
)3
.98
09
19
59
8.7
22
04
13
01
.33
31
48
35
3.0
33
90
03
70
.00
01
91
77
0.0
00
39
26
80
.02
92
90
17
0.0
05
19
62
80
.01
44
31
08
TO
TA
L IN
DIR
EC
T O
TH
ER
CO
ST
S -
SC
H. 4
10
4,0
40
$
39
,89
3$
28
,92
8$
1
92
,38
0$
5,7
37
$
8,9
72
$
1,5
22
$
19
,46
6$
13
,75
7$
UN
IT C
OS
T M
UL
TIP
LIE
R (
IND
IRE
CT
OT
HE
R)
6.0
70
72
00
42
.36
71
24
86
0.4
33
10
40
01
.94
55
88
64
0.0
02
06
22
80
.00
32
24
82
0.0
00
54
69
30
.00
34
51
59
0.0
02
43
93
7T
OT
AL
CA
PIT
AL
CO
ST
S -
SC
H. 5
53
1,8
81
$
15
,16
6$
8,8
45
$
29
,25
6$
6
7,8
86
$
1,3
26
$
2,7
14
$
3,5
03
$
72
,80
9$
22
,88
1$
UN
IT C
OS
T M
UL
TIP
LIE
R (
CA
PIT
AL
CO
ST
S)
30
.15
02
74
93
0.8
84
91
00
40
.52
48
34
02
0.4
38
01
85
90
.68
65
45
32
0.0
00
47
64
50
.00
09
75
59
0.0
01
25
92
00
.01
29
09
97
0.0
04
05
71
0
ST
AT
IST
ICS
FO
R C
OS
T A
LL
OC
AT
ION
DO
WN
EY
CA
RE
CE
NT
ER
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:DOWNEY CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009
Provider Number: NPI: OSHPD Facility Number:ZZT05519J 1942335062 206190874
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER
005 Plant Operations and Maintenance005 .01-.19 Salaries and Wages 6200 $ 50,339 $ 0 $ 50,339 (Sch 3)005 .20-.39 Fringe Benefits 6200 17,886 0 17,886 (Sch 3)005 .79 Agency Staff 6200 0 0 0 (Sch 3)005 .40-.99 Other - Nonlabor 6200 104,040 0 104,040 (Sch 4)005 Plant Operations and Maintenance - Total 6200 $ 172,265 $ 0 $ 172,265
010 Housekeeping010 .01-.19 Salaries and Wages 6300 $ 110,545 $ 0 $ 110,545 (Sch 3)010 .20-.39 Fringe Benefits 6300 35,313 0 35,313 (Sch 3)010 .79 Agency Staff 6300 0 0 0 (Sch 3)010 .40-.99 Other - Nonlabor 6300 38,163 0 38,163 (Sch 4)010 Housekeeping - Total 6300 $ 184,021 $ 0 $ 184,021
015 Depreciation: Buildings and Improvements 7110 - 7120 $ 0 0 $ 0 (Sch 5)020 Depreciation: Leasehold Improvements 7130 15,025 0 15,025 (Sch 5)025 Depreciation: Equipment 7140 45,852 0 45,852 (Sch 5)030 Depreciation and Amortization - Other 7150 - 7160 0 0 0 (Sch 5)035 Leases and Rentals 7200 427,381 0 427,381 (Sch 5)040 Property Taxes 7300 39,526 0 39,526 (Sch 5)045 Property Insurance 7400 10,889 0 10,889 (Sch 6)050 Interest-Property, Plant, and Equipment 7500 0 4,097 4,097 (Sch 5)055 Interest-Other 7600 4,097 (4,097) 0 (Sch 6)
057 Subtotal 005 - 055 $ 899,056 $ 0 $ 899,056
060 Laundry and Linen060 .01-.19 Salaries and Wages 6400 $ 56,677 $ 0 $ 56,677 (Sch 3)060 .20-.39 Fringe Benefits 6400 20,591 0 20,591 (Sch 3)060 .79 Agency Staff 6400 0 0 0 (Sch 3)060 .40-.99 Other - Nonlabor 6400 21,106 0 21,106 (Sch 4)060 Laundry and Linen - Total 6400 $ 98,374 $ 0 $ 98,374
065 Dietary065 .01-.19 Salaries and Wages 6500 $ 203,155 $ 0 $ 203,155 (Sch 3)065 .20-.39 Fringe Benefits 6500 69,513 0 69,513 (Sch 3)065 .79 Agency Staff 6500 0 0 0 (Sch 3)065 .40-.99 Other - Nonlabor 6500 174,230 0 174,230 (Sch 4)065 Dietary - Total 6500 $ 446,898 $ 0 $ 446,898
070 Provision for Bad Debts 7700 $ 0 0 $ 0
Ancillary Services (Note 1)075 Patient Supplies075 .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 22,942 7,736 30,678075 Patient Supplies - Total 8100 $ 22,942 $ 7,736 $ 30,678 (Sch 2)
077 Specialized Support Surfaces077 .01-.19 Salaries and Wages 8150 $ 0 $ 0 $ 0 N/A077 .20-.39 Fringe Benefits 8150 0 0 0 N/A077 .79 Agency Staff 8150 0 0 0 N/A077 .40-.99 Other - Nonlabor 8150 0 0 0 (Sch 4)077 Specialized Support Surfaces - Total 8150 $ 0 $ 0 $ 0
8A-1 8A-2ADJUSTED ASADJUSTMENTS
SUMMARY OF AUDITED PROGRAM EXPENSES
AS AUDIT
AUDITED
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:DOWNEY CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009
Provider Number: NPI: OSHPD Facility Number:ZZT05519J 1942335062 206190874
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER 8A-1 8A-2
ADJUSTED ASADJUSTMENTS
SUMMARY OF AUDITED PROGRAM EXPENSES
AS AUDIT
AUDITED
080 Physical Therapy080 .01-.19 Salaries and Wages 8200 $ 0 $ 0 $ 0 (Sch 2)080 .20-.39 Fringe Benefits 8200 0 0 0 (Sch 2)080 .79 Agency Staff 8200 0 0 0 (Sch 2)080 .40-.99 Other - Nonlabor 8200 385,993 0 385,993080 Physical Therapy - Total 8200 $ 385,993 $ 0 $ 385,993 (Sch 2)
081 Respiratory Therapy081 .01-.19 Salaries and Wages 8220 $ 0 $ 0 $ 0 (Sch 2)081 .20-.39 Fringe Benefits 8220 0 0 0 (Sch 2)081 .79 Agency Staff 8220 0 0 0 (Sch 2)081 .40-.99 Other - Nonlabor 8220 0 0 0081 Respiratory Therapy - Total 8220 $ 0 $ 0 $ 0 (Sch 2)
082 Occupational Therapy082 .01-.19 Salaries and Wages 8250 0 0 0 (Sch 2)082 .20-.39 Fringe Benefits 8250 0 0 0 (Sch 2)082 .79 Agency Staff 8250 0 0 0 (Sch 2)082 .40-.99 Other - Nonlabor 8250 343,986 0 343,986082 Occupational Therapy - Total 8250 $ 343,986 $ 0 $ 343,986 (Sch 2)
083 Speech Pathology083 .01-.19 Salaries and Wages 8280 $ 0 $ 0 $ 0 (Sch 2)083 .20-.39 Fringe Benefits 8280 0 0 0 (Sch 2)083 .79 Agency Staff 8280 0 0 0 (Sch 2)083 .40-.99 Other - Nonlabor 8280 118,434 0 118,434083 Speech Pathology - Total 8280 $ 118,434 $ 0 $ 118,434 (Sch 2)
085 Pharmacy085 .01-.19 Salaries and Wages 8300 $ 0 $ 0 $ 0 (Sch 2)085 .20-.39 Fringe Benefits 8300 0 0 0 (Sch 2)085 .79 Agency Staff 8300 0 0 0 (Sch 2)085 .40-.99 Other - Nonlabor 8300 335,351 0 335,351085 Pharmacy - Total 8300 $ 335,351 $ 0 $ 335,351 (Sch 2)
090 Laboratory090 .01-.19 Salaries and Wages 8400 $ 0 $ 0 $ 0 (Sch 2)090 .20-.39 Fringe Benefits 8400 0 0 0 (Sch 2)090 .79 Agency Staff 8400 0 0 0 (Sch 2)090 .40-.99 Other - Nonlabor 8400 35,600 3,457 39,057090 Laboratory - Total 8400 $ 35,600 $ 3,457 $ 39,057 (Sch 2)
095 Home Health Services095 .01-.19 Salaries and Wages 8800 $ 0 $ 0 $ 0 (Sch 2)095 .20-.39 Fringe Benefits 8800 0 0 0 (Sch 2)095 .79 Agency Staff 8800 0 0 0 (Sch 2)095 .40-.99 Other - Nonlabor 8800 0 0 0095 Home Health Services - Total 8800 $ 0 $ 0 $ 0 (Sch 2)
100 Other Ancillary Services100 .01-.19 Salaries and Wages 8900 $ 0 $ 0 $ 0 (Sch 2)100 .20-.39 Fringe Benefits 8900 0 0 0 (Sch 2)100 .79 Agency Staff 8900 0 0 0 (Sch 2)100 .40-.99 Other - Nonlabor 8900 26,054 0 26,054100 Other Ancillary Services - Total 8900 $ 26,054 $ 0 $ 26,054 (Sch 2)
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:
DOWNEY CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009
Provider Number: NPI: OSHPD Facility Number:
ZZT05519J 1942335062 206190874
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER 8A-1 8A-2
ADJUSTED ASADJUSTMENTS
SUMMARY OF AUDITED PROGRAM EXPENSES
AS AUDIT
AUDITED
101 Subacute Ancillary Services
101 .01-.19 Salaries and Wages 8100-8900 $ 0 $ 0 $ 0 (Sch 2)
101 .20-.39 Fringe Benefits 8100-8900 0 0 0 (Sch 2)
101 .79 Agency Staff 8100-8900 0 0 0 (Sch 2)
101 .40-.99 Other - Nonlabor 8100-8900 0 0 0
101 Subacute Ancillary Services - Total 8100-8900 $ 0 $ 0 $ 0 (Sch 2)
102 Subacute Pediatrics Ancillary Services
102 .01-.19 Salaries and Wages 8100-8900 $ 0 $ 0 $ 0 (Sch 2)
102 .20-.39 Fringe Benefits 8100-8900 0 0 0 (Sch 2)
102 .79 Agency Staff 8100-8900 0 0 0 (Sch 2)
102 .40-.99 Other - Nonlabor 8100-8900 0 0 0
102 Subacute Pediatrics Ancillary Services - Total 8100-8900 $ 0 $ 0 $ 0 (Sch 2)
104 Subtotal 075 - 102 $ 1,268,360 $ 11,193 $ 1,279,553
Routine Services
105 Skilled Nursing Care
105 .01-.19 Salaries and Wages 6110 $ 2,009,405 $ (2,037) $ 2,007,368 (Sch 2)
105 .20-.39 Fringe Benefits 6110 661,268 (613) 660,655 (Sch 2)
105 .49 Agency Staff 6110 0 0 0 (Sch 2)
105 .40-.99 Other - Nonlabor 6110 161,816 (47,778) 114,038 (Sch 4)
105 Skilled Nursing Care - Total 6110 $ 2,832,489 $ (50,428) $ 2,782,061
110 Intermediate Care
110 .01-.19 Salaries and Wages 6120 $ 0 $ 0 $ 0
110 .20-.39 Fringe Benefits 6120 0 0 0
110 .49 Agency Staff 6120 0 0 0
110 .40-.99 Other - Nonlabor 6120 0 0 0
110 Intermediate Care - Total 6120 $ 0 $ 0 $ 0 (Sch 2)
115 Mentally Disordered Care
115 .01-.19 Salaries and Wages 6130 $ 0 $ 0 $ 0
115 .20-.39 Fringe Benefits 6130 0 0 0
115 .49 Agency Staff 6130 0 0 0
115 .40-.99 Other - Nonlabor 6130 0 0 0
115 Mentally Disordered Care- Total 6130 $ 0 $ 0 $ 0 (Sch 2)
120 Developmentally Disabled Care
120 .01-.19 Salaries and Wages 6140 $ 0 $ 0 $ 0
120 .20-.39 Fringe Benefits 6140 0 0 0
120 .49 Agency Staff 6140 0 0 0
120 .40-.99 Other - Nonlabor 6140 0 0 0
120 Developmentally Disabled Care- Total 6140 $ 0 $ 0 $ 0 (Sch 2)
125 Subacute Care
125 .01-.19 Salaries and Wages 6150 $ 0 $ 0 $ 0 (Sch 2)
125 .20-.39 Fringe Benefits 6150 0 0 0 (Sch 2)
125 .49 Agency Staff 6150 0 0 0 (Sch 2)
125 .40-.99 Other - Nonlabor 6150 0 0 0 (Sch 4)
125 Subacute Care - Total 6150 $ 0 $ 0 $ 0
126 Subacute Care - Pediatrics
126 .01-.19 Salaries and Wages 6160 $ 0 $ 0 $ 0 (Sch 2)
126 .20-.39 Fringe Benefits 6160 0 0 0 (Sch 2)
126 .49 Agency Staff 6160 0 0 0 (Sch 2)
126 .40-.99 Other - Nonlabor 6160 0 0 0126 Subacute Care - Pediatrics - Total 6160 $ 0 $ 0 $ 0
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:DOWNEY CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009
Provider Number: NPI: OSHPD Facility Number:ZZT05519J 1942335062 206190874
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER 8A-1 8A-2
ADJUSTED ASADJUSTMENTS
SUMMARY OF AUDITED PROGRAM EXPENSES
AS AUDIT
AUDITED
128 Transitional Inpatient Care128 .01-.19 Salaries and Wages 6170 $ 0 $ 0 $ 0128 .20-.39 Fringe Benefits 6170 0 0 0128 .49 Agency Staff 6170 0 0 0128 .40-.99 Other - Nonlabor 6170 0 0 0128 Transitional Inpatient Care - Total 6170 $ 0 $ 0 $ 0 (Sch 2)
130 Hospice Inpatient Care130 .01-.19 Salaries and Wages 6180 $ 0 $ 0 $ 0130 .20-.39 Fringe Benefits 6180 0 0 0130 .49 Agency Staff 6180 0 0 0130 .40-.99 Other - Nonlabor 6180 0 0 0130 Hospice Inpatient Care - Total 6180 $ 0 $ 0 $ 0 (Sch 2)
135 Other Routine Services135 .01-.19 Salaries and Wages 6190 $ 0 $ 0 $ 0135 .20-.39 Fringe Benefits 6190 0 0 0135 .49 Agency Staff 6190 0 0 0135 .40-.99 Other - Nonlabor 6190 0 0 0135 Other Routine Services - Total 6190 $ 0 $ 0 $ 0 (Sch 2)
Other Nonreimbursable139 Residential Care139 .01-.19 Salaries and Wages 9100 $ 0 $ 0 $ 0139 .20-.39 Fringe Benefits 9100 0 0 0139 .49 Agency Staff 9100 0 0 0139 .40-.99 Other - Nonlabor 9100 0 0 0139 Residential Care - Total 9100 $ 0 $ 0 $ 0 (Sch 2)
140 Beauty and Barber140 .01-.19 Salaries and Wages 8900 $ 0 $ 0 $ 0140 .20-.39 Fringe Benefits 8900 0 0 0140 .49 Agency Staff 8900 0 0 0140 .40-.99 Other - Nonlabor 8900 3,659 0 3,659140 Beauty and Barber - Total 8900 $ 3,659 $ 0 $ 3,659 (Sch 2)
145 Other Nonreimbursable145 .01-.19 Salaries and Wages 9100 $ 0 $ 0 $ 0145 .20-.39 Fringe Benefits 9100 0 0 0145 .49 Agency Staff 9100 0 0 0145 .40-.99 Other - Nonlabor 9100 0 0 0145 Other Nonreimbursable - Total 9100 $ 0 $ 0 $ 0 (Sch 2)
146 Subtotal 105 - 145 $ 2,836,148 $ (50,428) $ 2,785,720
155 Social Services155 .01-.19 Salaries and Wages 6600 $ 84,770 $ 0 $ 84,770 (Sch 2)155 .20-.39 Fringe Benefits 6600 26,979 0 26,979 (Sch 2)155 .49 Agency Staff 6600 0 0 0 (Sch 2)155 .40-.99 Other - Nonlabor 6600 5,383 0 5,383 (Sch 4)155 Social Services - Total 6600 $ 117,132 $ 0 $ 117,132
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:DOWNEY CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009
Provider Number: NPI: OSHPD Facility Number:ZZT05519J 1942335062 206190874
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER 8A-1 8A-2
ADJUSTED ASADJUSTMENTS
SUMMARY OF AUDITED PROGRAM EXPENSES
AS AUDIT
AUDITED
160 Activities160 .01-.19 Salaries and Wages 6700 $ 70,681 $ 0 $ 70,681 (Sch 2)160 .20-.39 Fringe Benefits 6700 24,104 0 24,104 (Sch 2)160 .49 Agency Staff 6700 0 0 0 (Sch 2)160 .40-.99 Other - Nonlabor 6700 8,246 0 8,246 (Sch 4)160 Activities - Total 6700 $ 103,031 $ 0 $ 103,031
165 Administration165 .01-.19 Salaries and Wages 6900 $ 349,616 $ 0 $ 349,616 (Sch 6)165 .20-.39 Fringe Benefits 6900 120,929 0 120,929 (Sch 6)165 .49 Agency Staff 6900 0 0 0 (Sch 6)165 .40-.99 Other - Nonlabor 6900 502,318 (12,624) 489,694 (Sch 6)165 Administration - Total 6900 $ 972,863 $ (12,624) $ 960,239
166 Medical Records166 .01-.19 Medical Records - Salaries and Wages 6900 $ 54,276 $ 0 $ 54,276 (Sch 3)166 .20-.39 Medical Records - Fringe Benefits 6900 17,902 0 17,902 (Sch 3)166 .49 Medical Records - Agency Staff 6900 0 0 0 (Sch 3)166 .40-.99 Medical Records - Other - Nonlabor 6900 7,640 0 7,640 (Sch 4)166 Medical Records - Total 6900 $ 79,818 $ 0 $ 79,818
167 DPH Licensing Fees 6900 $ 26,919 $ 0 $ 26,919 (Sch 6)168 Liability Insurance 6900 $ 110,952 $ 100,000 $ 210,952 (Sch 6)169 Quality Assurance Fees 6900 $ 332,147 $ 0 $ 332,147 (Sch 6)
170 Inservice Education - Nursing170 .01-.19 Salaries and Wages 6800 $ 58,171 $ 2,037 $ 60,208 (Sch 3)170 .20-.39 Fringe Benefits 6800 19,256 613 19,869 (Sch 3)170 .49 Agency Staff 6800 0 0 0 (Sch 3)170 .40-.99 Other - Nonlabor 6800 0 585 585 (Sch 4)170 Inservice Education - Nursing - Total 6800 $ 77,427 $ 3,235 $ 80,662
174 Caregiver Training 174 .01-.19 Salaries and Wages 6900 $ 0 $ 0 $ 0 (Sch 6)174 .20-.39 Fringe Benefits 6900 0 0 0 (Sch 6)174 .49 Agency Staff 6900 0 0 0 (Sch 6)174 .40-.99 Other - Nonlabor 6900 0 0 0 (Sch 6)174 Caregiver Training - Total 6900 $ 0 $ 0 $ 0
Subtotal 155 - 174 $ 1,820,289 $ 90,611 $ 1,910,900
200 Total $ 7,369,125 $ 51,376 $ 7,420,501
NOTE 1: Ancillary service costs are reclassified only if the facility has an Adult Subacute unit.
STATE OF CALIFORNIA SCHEDULE 8A-1
Provider Name: Fiscal Period:DOWNEY CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009
Provider Number: NPI: OSHPD Facility Number:ZZT05519J 1942335062 206190874
Line Sub ACCOUNT TITLE ADJ MEMONo. No. NO. ADJUSTMENT
005 Plant Operations and Maintenance005 1 Salaries and Wages $ 50,339 $ $ 50,339005 2 Fringe Benefits 17,886 17,886005 3 Agency Staff 0005 4 Other - Nonlabor 104,040 104,040005 5 Plant Operations and Maintenance - Total $ 172,265 $ 0 $ 172,265
010 Housekeeping010 1 Salaries and Wages $ 110,545 $ $ 110,545010 2 Fringe Benefits 35,313 35,313010 3 Agency Staff 0010 4 Other - Nonlabor 38,163 38,163010 5 Housekeeping - Total $ 184,021 $ 0 $ 184,021
015 4 Depreciation: Buildings and Improvements $ $ $ 0020 4 Depreciation: Leasehold Improvements 15,025 15,025025 4 Depreciation: Equipment 45,852 45,852030 4 Depreciation and Amortization - Other 0035 4 Leases and Rentals 427,381 427,381040 4 Property Taxes 39,526 39,526045 4 Property Insurance 10,889 10,889050 4 Interest-Property, Plant, and Equipment 0055 4 Interest-Other 4,097 4,097
Subtotal 005 - 055 899,056 0 899,056
060 Laundry and Linen060 1 Salaries and Wages $ 56,677 $ $ 56,677060 2 Fringe Benefits 20,591 20,591060 3 Agency Staff 0060 4 Other - Nonlabor 21,106 21,106060 5 Laundry and Linen - Total $ 98,374 $ 0 $ 98,374
065 Dietary065 1 Salaries and Wages $ 203,155 $ $ 203,155065 2 Fringe Benefits 69,513 69,513065 3 Agency Staff 0065 4 Other - Nonlabor 174,230 174,230065 5 Dietary - Total $ 446,898 $ 0 $ 446,898
070 4 Provision for Bad Debts $ $ $ 0
Ancillary Services (Note 1)075 Patient Supplies075 1 Salaries and Wages $ $ $ 0075 2 Fringe Benefits 0075 3 Agency Staff 0075 4 Other - Nonlabor 22,942 22,942075 5 Patient Supplies - Total $ 22,942 $ 0 $ 22,942
077 Specialized Support Surfaces077 1 Salaries and Wages $ $ $ 0077 2 Fringe Benefits 0077 3 Agency Staff 0077 4 Other - Nonlabor 0077 5 Specialized Support Surfaces - Total $ 0 $ 0 $ 0
SUMMARY OF AUDITED PROGRAM EXPENSES
REPORTEDASAS
ADJUSTED
STATE OF CALIFORNIA SCHEDULE 8A-1
Provider Name: Fiscal Period:DOWNEY CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009
Provider Number: NPI: OSHPD Facility Number:ZZT05519J 1942335062 206190874
Line Sub ACCOUNT TITLE ADJ MEMONo. No. NO. ADJUSTMENT
SUMMARY OF AUDITED PROGRAM EXPENSES
REPORTEDASAS
ADJUSTED
080 Physical Therapy080 1 Salaries and Wages $ $ $ 0080 2 Fringe Benefits 0080 3 Agency Staff 0080 4 Other - Nonlabor 385,993 385,993080 5 Physical Therapy - Total $ 385,993 $ 0 $ 385,993
081 Respiratory Therapy081 1 Salaries and Wages $ $ $ 0081 2 Fringe Benefits 0081 3 Agency Staff 0081 4 Other - Nonlabor 0081 5 Respiratory Therapy - Total $ 0 $ 0 $ 0
082 Occupational Therapy082 1 Salaries and Wages $ $ $ 0082 2 Fringe Benefits 0082 3 Agency Staff 0082 4 Other - Nonlabor 343,986 343,986082 5 Occupational Therapy - Total $ 343,986 $ 0 $ 343,986
083 Speech Pathology083 1 Salaries and Wages $ $ $ 0083 2 Fringe Benefits 0083 3 Agency Staff 0083 4 Other - Nonlabor 118,434 118,434083 5 Speech Pathology - Total $ 118,434 $ 0 $ 118,434
085 Pharmacy085 1 Salaries and Wages $ $ $ 0085 2 Fringe Benefits 0085 3 Agency Staff 0085 4 Other - Nonlabor 335,351 335,351085 5 Pharmacy - Total $ 335,351 $ 0 $ 335,351
090 Laboratory090 1 Salaries and Wages $ $ $ 0090 2 Fringe Benefits 0090 3 Agency Staff 0090 4 Other - Nonlabor 35,600 35,600090 5 Laboratory - Total $ 35,600 $ 0 $ 35,600
095 Home Health Services095 1 Salaries and Wages $ $ $ 0095 2 Fringe Benefits 0095 3 Agency Staff 0095 4 Other - Nonlabor 0095 5 Home Health Services - Total $ 0 $ 0 $ 0
100 Other Ancillary Services100 1 Salaries and Wages $ $ $ 0100 2 Fringe Benefits 0100 3 Agency Staff 0100 4 Other - Nonlabor 26,054 26,054100 5 Other Ancillary Services - Total $ 26,054 $ 0 $ 26,054
STATE OF CALIFORNIA SCHEDULE 8A-1
Provider Name: Fiscal Period:
DOWNEY CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009
Provider Number: NPI: OSHPD Facility Number:
ZZT05519J 1942335062 206190874
Line Sub ACCOUNT TITLE ADJ MEMONo. No. NO. ADJUSTMENT
SUMMARY OF AUDITED PROGRAM EXPENSES
REPORTEDASAS
ADJUSTED
101 Subacute Ancillary Services
101 1 Salaries and Wages $ $ $ 0
101 2 Fringe Benefits 0
101 3 Agency Staff 0
101 4 Other - Nonlabor 0
101 5 Subacute Ancillary Services - Total $ 0 $ 0 $ 0
102 Subacute Pediatrics Ancillary Services
102 1 Salaries and Wages $ $ $ 0
102 2 Fringe Benefits 0
102 3 Agency Staff 0
102 4 Other - Nonlabor 0
102 5 Subacute Pediatrics Ancillary Services - Total $ 0 $ 0 $ 0
104 Subtotal 075 - 102 $ 1,268,360 $ 0 $ 1,268,360
Routine Services
105 Skilled Nursing Care
105 1 Salaries and Wages $ 2,009,405 $ $ 2,009,405
105 2 Fringe Benefits 661,268 661,268
105 3 Agency Staff 0
105 4 Other - Nonlabor 161,816 161,816
105 5 Skilled Nursing Care - Total $ 2,832,489 $ 0 $ 2,832,489
110 Intermediate Care
110 1 Salaries and Wages $ $ $ 0
110 2 Fringe Benefits 0
110 3 Agency Staff 0
110 4 Other - Nonlabor 0
110 5 Intermediate Care - Total $ 0 $ 0 $ 0
115 Mentally Disordered
115 1 Salaries and Wages $ $ $ 0
115 2 Fringe Benefits 0
115 3 Agency Staff 0
115 4 Other - Nonlabor 0
115 5 Mentally Disordered - Total $ 0 $ 0 $ 0
120 Developmentally Disabled
120 1 Salaries and Wages $ $ $ 0
120 2 Fringe Benefits 0
120 3 Agency Staff 0
120 4 Other - Nonlabor 0
120 5 Developmentally Disabled - Total $ 0 $ 0 $ 0
125 Subacute Care
125 1 Salaries and Wages $ $ $ 0
125 2 Fringe Benefits 0
125 3 Agency Staff 0
125 4 Other - Nonlabor 0
125 5 Subacute Care - Total $ 0 $ 0 $ 0
126 Subacute Care - Pediatrics
126 1 Salaries and Wages $ $ $ 0
126 2 Fringe Benefits 0
126 3 Agency Staff 0
126 4 Other - Nonlabor 0126 5 Subacute Care - Pediatrics - Total $ 0 $ 0 $ 0
STATE OF CALIFORNIA SCHEDULE 8A-1
Provider Name: Fiscal Period:
DOWNEY CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009
Provider Number: NPI: OSHPD Facility Number:
ZZT05519J 1942335062 206190874
Line Sub ACCOUNT TITLE ADJ MEMONo. No. NO. ADJUSTMENT
SUMMARY OF AUDITED PROGRAM EXPENSES
REPORTEDASAS
ADJUSTED
128 Transitional Inpatient Care
128 1 Salaries and Wages $ $ $ 0
128 2 Fringe Benefits 0
128 3 Agency Staff 0
128 4 Other - Nonlabor 0
128 5 Transitional Inpatient Care - Total $ 0 $ 0 $ 0
130 Hospice Inpatient Care
130 1 Salaries and Wages $ $ $ 0
130 2 Fringe Benefits 0
130 3 Agency Staff 0
130 4 Other - Nonlabor 0
130 5 Hospice Inpatient Care - Total $ 0 $ 0 $ 0
135 Other Routine Services
135 1 Salaries and Wages $ $ $ 0
135 2 Fringe Benefits 0
135 3 Agency Staff 0
135 4 Other - Nonlabor 0
135 5 Other Routine Services - Total $ 0 $ 0 $ 0
Other Nonreimbursable
139 Residential Care **
139 1 Salaries and Wages $ $ $ 0
139 2 Fringe Benefits 0
139 3 Agency Staff 0
139 4 Other - Nonlabor 0
139 5 Residential Care - Total $ 0 $ 0 $ 0
140 Beauty and Barber
140 1 Salaries and Wages $ $ $ 0
140 2 Fringe Benefits 0
140 3 Agency Staff 0
140 4 Other - Nonlabor 3,659 3,659
140 5 Beauty and Barber - Total $ 3,659 $ 0 $ 3,659
145 Other Nonreimbursable
145 1 Salaries and Wages $ $ $ 0
145 2 Fringe Benefits 0
145 3 Agency Staff 0
145 4 Other - Nonlabor 0
145 5 Other Nonreimbursable - Total $ 0 $ 0 $ 0
146 Subtotal 105 - 145 $ 2,836,148 $ 0 $ 2,836,148
155 Social Services
155 1 Salaries and Wages $ 84,770 $ $ 84,770
155 2 Fringe Benefits 26,979 26,979
155 3 Agency Staff 0
155 4 Other - Nonlabor 5,383 5,383
155 5 Social Services - Total $ 117,132 $ 0 $ 117,132
160 Activities
160 1 Salaries and Wages $ 70,681 $ $ 70,681
160 2 Fringe Benefits 24,104 24,104
160 3 Agency Staff 0
160 4 Other - Nonlabor 8,246 8,246160 5 Activities - Total $ 103,031 $ 0 $ 103,031
STATE OF CALIFORNIA SCHEDULE 8A-1
Provider Name: Fiscal Period:DOWNEY CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009
Provider Number: NPI: OSHPD Facility Number:ZZT05519J 1942335062 206190874
Line Sub ACCOUNT TITLE ADJ MEMONo. No. NO. ADJUSTMENT
SUMMARY OF AUDITED PROGRAM EXPENSES
REPORTEDASAS
ADJUSTED
165 Administration165 1 Salaries and Wages $ 349,616 $ $ 349,616165 2 Fringe Benefits 120,929 120,929165 3 Agency Staff 0165 4 Other - Nonlabor 502,318 502,318165 5 Administration - Total $ 972,863 $ 0 $ 972,863
166 Medical Records166 1 Medical Records - Salaries and Wages $ 54,276 $ $ 54,276166 2 Medical Records - Fringe Benefits 17,902 17,902166 3 Medical Records - Agency Staff 0166 4 Medical Records - Other - Nonlabor 7,640 7,640166 5 Medical Records - Total $ 79,818 $ 0 $ 79,818
167 4 DPH Licensing Fees *** $ 26,919 $ $ 26,919168 4 Liability Insurance *** $ 110,952 $ $ 110,952169 4 Quality Assurance Fees *** $ 332,147 $ $ 332,147
170 Inservice Education - Nursing170 1 Salaries and Wages $ 58,171 $ $ 58,171170 2 Fringe Benefits 19,256 19,256170 3 Agency Staff 0170 4 Other - Nonlabor 0 0170 5 Inservice Education - Nursing - Total $ 77,427 $ 0 $ 77,427
174 Caregiver Training ***174 1 Salaries and Wages $ $ $ 0174 2 Fringe Benefits 0174 3 Agency Staff 0174 4 Other - Nonlabor 0174 5 Caregiver Training - Total $ 0 $ 0 $ 0
Subtotal 155 - 174 $ 1,820,289 $ 0 $ 1,820,289
200 Total $ 7,369,125 $ -$ $ 7,369,125
NOTE 1: Ancillary service costs are reclassified only if the facility has an Adult Subacute unit.* Amounts reclassified from ancillary service type accounts (lines 75 through 100)** Complete with Direct Residential Care Costs*** Amounts reclassified from Administration (line 165)**** Totals in column 5 must match page 10.1, column 14, for each respective cost center (except reclasses)
ST
AT
E O
F C
ALI
FO
RN
IAS
ched
ule
8A
-2
Pag
e 1
Pro
vid
er N
ame:
Pro
vid
er N
um
ber
:N
PI:
OS
HP
D F
acili
ty N
um
ber
:F
isca
l Per
iod
:
DO
WN
EY
CA
RE
CE
NT
ER
ZZ
T05
519J
1942
3350
6220
6190
874
JAN
UA
RY
1, 2
009
TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
009
TO
TA
L A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
J
Lin
eS
ub
(Pag
es 1
& 2
)1
23
45
67
No
.N
o.
005
1P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Sal
arie
s an
d W
ages
0
005
2P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Frin
ge B
enef
its0
005
3P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Age
ncy
Sta
ff0
005
4P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Oth
er -
Non
labo
r0
010
1H
ouse
keep
ing
- S
alar
ies
and
Wag
es0
010
2H
ouse
keep
ing
- F
ringe
Ben
efits
0
010
3H
ouse
keep
ing
- A
genc
y S
taff
0
010
4H
ouse
keep
ing
- O
ther
- N
onla
bor
0
015
4D
epre
ciat
ion:
Bui
ldin
gs a
nd Im
prov
emen
ts0
020
4D
epre
ciat
ion:
Lea
seho
ld Im
prov
emen
ts0
025
4D
epre
ciat
ion:
Equ
ipm
ent
0
030
4D
epre
ciat
ion
and
Am
ortiz
atio
n -
Oth
er0
035
4Le
ases
and
Ren
tals
0
040
4P
rope
rty
Tax
es0
045
4P
rope
rty
Insu
ranc
e0
050
4In
tere
st-P
rope
rty,
Pla
nt, a
nd E
quip
men
t4,
097
4,09
7
055
4In
tere
st-O
ther
(4,0
97)
(4,0
97)
060
1La
undr
y an
d Li
nen
- S
alar
ies
and
Wag
es0
060
2La
undr
y an
d Li
nen
- F
ringe
Ben
efits
0
060
3La
undr
y an
d Li
nen
- A
genc
y S
taff
0
060
4La
undr
y an
d Li
nen
- O
ther
- N
onla
bor
0
065
1D
ieta
ry -
Sal
arie
s an
d W
ages
0
065
2D
ieta
ry -
Frin
ge B
enef
its0
065
3D
ieta
ry -
Age
ncy
Sta
ff0
065
4D
ieta
ry -
Oth
er -
Non
labo
r0
070
4P
rovi
sion
for
Bad
Deb
ts0
075
1P
atie
nt S
uppl
ies
- S
alar
ies
and
Wag
es0
075
2P
atie
nt S
uppl
ies
- F
ringe
Ben
efits
0
075
3P
atie
nt S
uppl
ies
- A
genc
y S
taff
0
075
4P
atie
nt S
uppl
ies
- O
ther
- N
onla
bor
7,73
67,
736
077
1S
peci
aliz
ed S
uppo
rt S
urfa
ces
- S
alar
ies
and
Wag
es0
077
2S
peci
aliz
ed S
uppo
rt S
urfa
ces
- F
ringe
Ben
efits
0
077
3S
peci
aliz
ed S
uppo
rt S
urfa
ces
- A
genc
y S
taff
0
077
4S
peci
aliz
ed S
uppo
rt S
urfa
ces
- O
ther
- N
onla
bor
0
080
1P
hysi
cal T
hera
py -
Sal
arie
s an
d W
ages
0
080
2P
hysi
cal T
hera
py -
Frin
ge B
enef
its0
080
3P
hysi
cal T
hera
py -
Age
ncy
Sta
ff0
080
4P
hysi
cal T
hera
py -
Oth
er -
Non
labo
r0
081
1R
espi
rato
ry T
hera
py -
Sal
arie
s an
d W
ages
0
081
2R
espi
rato
ry T
hera
py -
Frin
ge B
enef
its0
081
3R
espi
rato
ry T
hera
py -
Age
ncy
Sta
ff0
081
4R
espi
rato
ry T
hera
py -
Oth
er -
Non
labo
r0
082
1O
ccup
atio
nal T
hera
py -
Sal
arie
s an
d W
ages
0
082
2O
ccup
atio
nal T
hera
py -
Frin
ge B
enef
its0
082
3O
ccup
atio
nal T
hera
py -
Age
ncy
Sta
ff0
082
4O
ccup
atio
nal T
hera
py -
Oth
er -
Non
labo
r0
083
1S
peec
h P
atho
logy
- S
alar
ies
and
Wag
es0
083
2S
peec
h P
atho
logy
- F
ringe
Ben
efits
0
083
3S
peec
h P
atho
logy
- A
genc
y S
taff
0
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
ST
AT
E O
F C
ALI
FO
RN
IAS
ched
ule
8A
-2
Pag
e 1
Pro
vid
er N
ame:
Pro
vid
er N
um
ber
:N
PI:
OS
HP
D F
acili
ty N
um
ber
:F
isca
l Per
iod
:
DO
WN
EY
CA
RE
CE
NT
ER
ZZ
T05
519J
1942
3350
6220
6190
874
JAN
UA
RY
1, 2
009
TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
009
TO
TA
L A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
J
Lin
eS
ub
(Pag
es 1
& 2
)1
23
45
67
No
.N
o.
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
083
4S
peec
h P
atho
logy
- O
ther
- N
onla
bor
0
085
1P
harm
acy
- S
alar
ies
and
Wag
es0
085
2P
harm
acy
- F
ringe
Ben
efits
0
085
3P
harm
acy
- A
genc
y S
taff
0
085
4P
harm
acy
- O
ther
- N
onla
bor
0
090
1La
bora
tory
- S
alar
ies
and
Wag
es0
090
2La
bora
tory
- F
ringe
Ben
efits
0
090
3La
bora
tory
- A
genc
y S
taff
0
090
4La
bora
tory
- O
ther
- N
onla
bor
3,45
73,
457
095
1H
ome
Hea
lth S
ervi
ces
- S
alar
ies
and
Wag
es0
095
2H
ome
Hea
lth S
ervi
ces
- F
ringe
Ben
efits
0
095
3H
ome
Hea
lth S
ervi
ces
- A
genc
y S
taff
0
095
4H
ome
Hea
lth S
ervi
ces
- O
ther
- N
onla
bor
0
100
1O
ther
Anc
illar
y S
ervi
ces
- S
alar
ies
and
Wag
es0
100
2O
ther
Anc
illar
y S
ervi
ces
- F
ringe
Ben
efits
0
100
3O
ther
Anc
illar
y S
ervi
ces
- A
genc
y S
taff
0
100
4O
ther
Anc
illar
y S
ervi
ces
- O
ther
- N
onla
bor
0
101
1S
ubac
ute
Anc
illar
y S
ervi
ces
- S
alar
ies
and
Wag
es0
101
2S
ubac
ute
Anc
illar
y S
ervi
ces
- F
ringe
Ben
efits
0
101
3S
ubac
ute
Anc
illar
y S
ervi
ces
- A
genc
y S
taff
0
101
4S
ubac
ute
Anc
illar
y S
ervi
ces
- O
ther
- N
onla
bor
0
102
1S
ubac
ute
Ped
iatr
ics
Anc
illar
y S
ervi
ces
- S
alar
ies
and
Wag
es0
102
2S
ubac
ute
Ped
iatr
ics
Anc
illar
y S
ervi
ces
- F
ringe
Ben
efits
0
102
3S
ubac
ute
Ped
iatr
ics
Anc
illar
y S
ervi
ces
- A
genc
y S
taff
0
102
4S
ubac
ute
Ped
iatr
ics
Anc
illar
y S
ervi
ces
- O
ther
- N
onla
bor
0
105
1S
kille
d N
ursi
ng C
are
- S
alar
ies
and
Wag
es(2
,037
)(2
,037
)
105
2S
kille
d N
ursi
ng C
are
- F
ringe
Ben
efits
(613
)(6
13)
105
3S
kille
d N
ursi
ng C
are
- A
genc
y S
taff
0
105
4S
kille
d N
ursi
ng C
are
- O
ther
- N
onla
bor
(47,
778)
(36,
000)
(585
)(3
,457
)(7
,736
)
110
1In
term
edia
te C
are
- S
alar
ies
and
Wag
es0
110
2In
term
edia
te C
are
- F
ringe
Ben
efits
0
110
3In
term
edia
te C
are
- A
genc
y S
taff
0
110
4In
term
edia
te C
are
- O
ther
- N
onla
bor
0
115
1M
enta
lly D
isor
dere
d -
Sal
arie
s an
d W
ages
0
115
2M
enta
lly D
isor
dere
d -
Frin
ge B
enef
its0
115
3M
enta
lly D
isor
dere
d -
Age
ncy
Sta
ff0
115
4M
enta
lly D
isor
dere
d -
Oth
er -
Non
labo
r0
120
1D
evel
opm
enta
lly D
isab
led
- S
alar
ies
and
Wag
es0
120
2D
evel
opm
enta
lly D
isab
led
- F
ringe
Ben
efits
0
120
3D
evel
opm
enta
lly D
isab
led
- A
genc
y S
taff
0
120
4D
evel
opm
enta
lly D
isab
led
- O
ther
- N
onla
bor
0
125
1S
ubac
ute
Car
e -
Sal
arie
s an
d W
ages
0
125
2S
ubac
ute
Car
e -
Frin
ge B
enef
its0
125
3S
ubac
ute
Car
e -
Age
ncy
Sta
ff0
125
4S
ubac
ute
Car
e -
Oth
er -
Non
labo
r0
126
1S
ubac
ute
Car
e -
Ped
iatr
ics
- S
alar
ies
and
Wag
es0
126
2S
ubac
ute
Car
e -
Ped
iatr
ics
- F
ringe
Ben
efits
0
126
3S
ubac
ute
Car
e -
Ped
iatr
ics
- A
genc
y S
taff
0
126
4S
ubac
ute
Car
e -
Ped
iatr
ics
- O
ther
- N
onla
bor
0
ST
AT
E O
F C
ALI
FO
RN
IAS
ched
ule
8A
-2
Pag
e 1
Pro
vid
er N
ame:
Pro
vid
er N
um
ber
:N
PI:
OS
HP
D F
acili
ty N
um
ber
:F
isca
l Per
iod
:
DO
WN
EY
CA
RE
CE
NT
ER
ZZ
T05
519J
1942
3350
6220
6190
874
JAN
UA
RY
1, 2
009
TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
009
TO
TA
L A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
J
Lin
eS
ub
(Pag
es 1
& 2
)1
23
45
67
No
.N
o.
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
128
1T
rans
ition
al In
patie
nt C
are
- S
alar
ies
and
Wag
es0
128
2T
rans
ition
al In
patie
nt C
are
- F
ringe
Ben
efits
0
128
3T
rans
ition
al In
patie
nt C
are
- A
genc
y S
taff
0
128
4T
rans
ition
al In
patie
nt C
are
- O
ther
- N
onla
bor
0
130
1H
ospi
ce In
patie
nt C
are
- S
alar
ies
and
Wag
es0
130
2H
ospi
ce In
patie
nt C
are
- F
ringe
Ben
efits
0
130
3H
ospi
ce In
patie
nt C
are
- A
genc
y S
taff
0
130
4H
ospi
ce In
patie
nt C
are
- O
ther
- N
onla
bor
0
135
1O
ther
Rou
tine
Ser
vice
s -
Sal
arie
s an
d W
ages
0
135
2O
ther
Rou
tine
Ser
vice
s -
Frin
ge B
enef
its0
135
3O
ther
Rou
tine
Ser
vice
s -
Age
ncy
Sta
ff0
135
4O
ther
Rou
tine
Ser
vice
s -
Oth
er -
Non
labo
r0
139
1R
esid
entia
l Car
e -
Sal
arie
s an
d W
ages
0
139
2R
esid
entia
l Car
e -
Frin
ge B
enef
its0
139
3R
esid
entia
l Car
e -
Age
ncy
Sta
ff0
139
4R
esid
entia
l Car
e -
Oth
er -
Non
labo
r0
140
1B
eaut
y an
d B
arbe
r -
Sal
arie
s an
d W
ages
0
140
2B
eaut
y an
d B
arbe
r -
Frin
ge B
enef
its0
140
3B
eaut
y an
d B
arbe
r -
Age
ncy
Sta
ff0
140
4B
eaut
y an
d B
arbe
r -
Oth
er -
Non
labo
r0
145
1O
ther
Non
reim
burs
able
- S
alar
ies
and
Wag
es0
145
2O
ther
Non
reim
burs
able
- F
ringe
Ben
efits
0
145
3O
ther
Non
reim
burs
able
- A
genc
y S
taff
0
145
4O
ther
Non
reim
burs
able
- O
ther
- N
onla
bor
0
155
1S
ocia
l Ser
vice
s -
Sal
arie
s an
d W
ages
0
155
2S
ocia
l Ser
vice
s -
Frin
ge B
enef
its0
155
3S
ocia
l Ser
vice
s -
Age
ncy
Sta
ff0
155
4S
ocia
l Ser
vice
s -
Oth
er -
Non
labo
r0
160
1A
ctiv
ities
- S
alar
ies
and
Wag
es0
160
2A
ctiv
ities
- F
ringe
Ben
efits
0
160
3A
ctiv
ities
- A
genc
y S
taff
0
160
4A
ctiv
ities
- O
ther
- N
onla
bor
0
165
1A
dmin
istr
atio
n -
Sal
arie
s an
d W
ages
0
165
2A
dmin
istr
atio
n -
Frin
ge B
enef
its0
165
3A
dmin
istr
atio
n -
Age
ncy
Sta
ff0
165
4A
dmin
istr
atio
n -
Oth
er -
Non
labo
r(1
2,62
4)36
,000
(48,
624)
166
1M
edic
al R
ecor
ds -
Sal
arie
s an
d W
ages
0
166
2M
edic
al R
ecor
ds -
Frin
ge B
enef
its0
166
3M
edic
al R
ecor
ds -
Age
ncy
Sta
ff0
166
4M
edic
al R
ecor
ds -
Oth
er -
Non
labo
r0
167
4D
PH
Lic
ensi
ng F
ees
0
168
4Li
abili
ty In
sura
nce
100,
000
100,
000
169
4Q
ualit
y A
ssur
ance
Fee
s0
170
1In
serv
ice
Edu
catio
n -
Nur
sing
- S
alar
ies
and
Wag
es2,
037
2,03
7
170
2In
serv
ice
Edu
catio
n -
Nur
sing
- F
ringe
Ben
efits
613
613
170
3In
serv
ice
Edu
catio
n -
Nur
sing
- A
genc
y S
taff
0
170
4In
serv
ice
Edu
catio
n -
Nur
sing
- O
ther
- N
onla
bor
585
585
174
1C
areg
iver
Tra
inin
g -
Sal
arie
s an
d W
ages
0
174
2C
areg
iver
Tra
inin
g -
Frin
ge B
enef
its0
ST
AT
E O
F C
ALI
FO
RN
IAS
ched
ule
8A
-2
Pag
e 1
Pro
vid
er N
ame:
Pro
vid
er N
um
ber
:N
PI:
OS
HP
D F
acili
ty N
um
ber
:F
isca
l Per
iod
:
DO
WN
EY
CA
RE
CE
NT
ER
ZZ
T05
519J
1942
3350
6220
6190
874
JAN
UA
RY
1, 2
009
TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
009
TO
TA
L A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
J
Lin
eS
ub
(Pag
es 1
& 2
)1
23
45
67
No
.N
o.
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
174
3C
areg
iver
Tra
inin
g -
Age
ncy
Sta
ff0
174
4C
areg
iver
Tra
inin
g -
Oth
er -
Non
labo
r0 0 0 0 0 0 0 0 0
200
T
otal
$5
1,37
60
00
00
(48,
624)
100,
000
(To
Sch
8)
Sta
te o
f C
alif
orn
iaD
epar
tmen
t o
f H
ealt
h C
are
Ser
vice
s
Pro
vid
er N
ame
Fis
cal P
erio
dP
rovi
der
Nu
mb
er7
MC
530
Adj
.P
age
orA
sIn
crea
seA
sN
o.E
xhib
itLi
neC
ol.
Sch
. L
ine
Sub
No
Rep
orte
d(D
ecre
ase)
Adj
uste
d
RE
CLA
SS
IFIC
AT
ION
S O
F R
EP
OR
TE
D C
OS
TS
110
.510
54
8A-2
105
4S
kille
d N
ursi
ng C
are
- O
ther
- N
onla
bor
$161
,816
($36
,000
)$1
25,8
16*
10.5
165
48A
-216
54
Adm
inis
trat
ion
- O
ther
- N
onla
bo50
2,31
836
,000
538,
318
*T
o re
clas
sify
med
ical
dire
ctor
cos
ts to
the
appr
opria
te c
ost c
ente
42 C
FR
413
.20
and
413.
24 /
CM
S P
ub. 1
5-1,
Sec
tions
230
0 an
d 23
04
CC
R, T
itle
22, S
ectio
n 52
000
210
.510
5
18A
-210
5
1S
kille
d N
ursi
ng C
are
- S
alar
ies
and
Wag
es$2
,009
,405
($2,
037)
$2,0
07,3
6810
.510
5
28A
-210
5
2S
kille
d N
ursi
ng C
are
- F
ringe
Ben
efits
661,
268
(613
)66
0,65
510
.510
5
48A
-210
5
4S
kille
d N
ursi
ng C
are
- O
ther
- N
onla
bor
*12
5,81
6(5
85)
125,
231
*10
.517
0
18A
-217
0
1In
serv
ice
Edu
catio
n -
Nur
sing
- S
alar
ies
and
Wag
es58
,171
2,03
760
,208
10.5
170
2
8A-2
170
2
Inse
rvic
e E
duca
tion
- N
ursi
ng -
Frin
ge B
enef
its19
,256
613
19,8
6910
.517
0
48A
-217
0
4In
serv
ice
Edu
catio
n -
Nur
sing
- O
ther
- N
onla
bor
058
558
5T
o re
clas
sify
hom
e of
fice
expe
nses
to th
e ap
prop
riate
cos
t cen
ter.
42 C
FR
413
.20
and
413.
24C
MS
Pub
. 15-
1, S
ectio
ns 2
300,
230
2.4
and
2302
.8
310
.509
04
8A-2
090
4La
bora
tory
- O
ther
- N
onla
bor
$35,
600
$3,4
57$3
9,05
710
.510
54
8A-2
105
4S
kille
d N
ursi
ng C
are
- O
ther
- N
onla
bor
*12
5,23
1(3
,457
)12
1,77
4*
To
recl
assi
fy s
tat c
harg
e ex
pens
e to
an
anci
llary
cos
t cen
ter.
42 C
FR
413
.20
and
413.
24 /
CM
S P
ub. 1
5-1,
Sec
tion
2203
.2C
CR
, Titl
e 22
, Sec
tion
5112
3
410
.507
54
8A-2
075
4P
atie
nt S
uppl
ies
- O
ther
- N
onla
bor
$22,
942
$7,7
36$3
0,67
810
.510
54
8A-2
105
4S
kille
d N
ursi
ng C
are
- O
ther
- N
onla
bor
*12
1,77
4(7
,736
)11
4,03
8T
o re
clas
sify
oxy
gen
expe
nse
to a
n an
cilla
ry c
ost c
ente
r.42
CF
R 4
13.2
0 an
d 41
3.24
/ C
MS
Pub
. 15-
1, S
ectio
n 22
03.2
CC
R, T
itle
22, S
ectio
n 51
123
*Bal
ance
car
ried
forw
ard
from
prio
r/to
sub
sequ
ent a
djus
tmen
tsP
age
1
Ad
just
men
tsD
OW
NE
Y C
AR
E C
EN
TE
RJA
NU
AR
Y 1
, 200
9 T
HR
OU
GH
DE
CE
MB
ER
31,
200
9Z
ZT
0551
9J
Cos
t Rep
ort
Exp
lana
tion
of A
udit
Adj
ustm
ents
Rep
ort R
efer
ence
sA
udit
Rep
ort
Sta
te o
f C
alif
orn
iaD
epar
tmen
t o
f H
ealt
h C
are
Ser
vice
s
Pro
vid
er N
ame
Fis
cal P
erio
dP
rovi
der
Nu
mb
er7
MC
530
Adj
.P
age
orA
sIn
crea
seA
sN
o.E
xhib
itLi
neC
ol.
Sch
. L
ine
Sub
No
Rep
orte
d(D
ecre
ase)
Adj
uste
d
Ad
just
men
tsD
OW
NE
Y C
AR
E C
EN
TE
RJA
NU
AR
Y 1
, 200
9 T
HR
OU
GH
DE
CE
MB
ER
31,
200
9Z
ZT
0551
9J
Cos
t Rep
ort
Exp
lana
tion
of A
udit
Adj
ustm
ents
Rep
ort R
efer
ence
sA
udit
Rep
ort
RE
CLA
SS
IFIC
AT
ION
S O
F R
EP
OR
TE
D C
OS
TS
510
.505
04
8A-2
050
4In
tere
st -
Pro
pert
y, P
lant
, and
Equ
ipm
ent
$0$4
,097
$4,0
9710
.505
54
8A-2
055
4In
tere
st -
Oth
er4,
097
(4,0
97)
0T
o re
clas
sify
leas
ehol
d in
tere
st e
xpen
se to
the
appr
opria
te c
ost c
ente
r.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
e2
Sta
te o
f C
alif
orn
iaD
epar
tmen
t o
f H
ealt
h C
are
Ser
vice
s
Pro
vid
er N
ame
Fis
cal P
erio
dP
rovi
der
Nu
mb
er7
MC
530
Adj
.P
age
orA
sIn
crea
seA
sN
o.E
xhib
itLi
neC
ol.
Sch
. L
ine
Sub
No
Rep
orte
d(D
ecre
ase)
Adj
uste
d
Ad
just
men
tsD
OW
NE
Y C
AR
E C
EN
TE
RJA
NU
AR
Y 1
, 200
9 T
HR
OU
GH
DE
CE
MB
ER
31,
200
9Z
ZT
0551
9J
Cos
t Rep
ort
Exp
lana
tion
of A
udit
Adj
ustm
ents
Rep
ort R
efer
ence
sA
udit
Rep
ort
AD
JUS
TM
EN
TS
TO
RE
PO
RT
ED
CO
ST
S
610
.516
54
8A-2
165
4A
dmin
istr
atio
n -
Oth
er -
Non
labo
r*
$538
,318
($48
,624
)$4
89,6
94T
o ad
just
rep
orte
d ho
me
offic
e co
sts
to a
gree
with
the
Cov
enan
t C
are,
LLC
Hom
e O
ffice
Aud
it R
epor
t for
fisc
al p
erio
d en
ded
Dec
embe
r 31
, 200
9.42
CF
R 4
13.1
7 / C
MS
Pub
. 15-
1, S
ectio
ns 2
150.
2 an
d 23
04
710
.516
84
8A-2
168
4Li
abili
ty In
sura
nce
$110
,952
$100
,000
$210
,952
To
adju
st th
e lia
bilit
y in
sura
nce
expe
nse
to a
llow
the
limita
tion
of$1
00,0
00 in
lieu
of a
ctua
l los
ses
and
the
exce
ss li
abili
ty p
rem
ium
expe
nse.
CM
S P
ub. 1
5-1,
Sec
tions
216
2.4,
216
2.5,
216
2.7,
230
0 an
d 24
00
*Bal
ance
car
ried
forw
ard
from
prio
r/to
sub
sequ
ent a
djus
tmen
tsP
age
3