STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS _part1 ppt

STATE OF CALIFORNIA Schedule 8A-2
Page 1
Provider Name: Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period:
HOLLENBECK PALMS ZZT05115F 1831186345 206190378 JULY 1, 2007 THROUGH JUNE 30, 2008
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
(Pages 1, 2, & 3) 12 13 14 15 16 17 18 19 20
ADJUSTMENTS TO REPORTED COSTS
82.02 Occupational Therapy - Fringe Benefits 0
82.03 Occupational Therapy - Agency Staff 0
82.04 Occupational Therapy - Other - Nonlabor 0
83.00 Speech Pathology 0
83.01 Speech Pathology - Salaries and Wages 0
83.02 Speech Pathology - Fringe Benefits 0
83.03 Speech Pathology - Agency Staff 0
83.04 Speech Pathology - Other - Nonlabor 0
85.00 Pharmacy 0
85.01 Pharmacy - Salaries and Wages 0
85.02 Pharmacy - Fringe Benefits 0
85.03 Pharmacy - Agency Staff 0
85.04 Pharmacy - Other - Nonlabor 0
90.00 Laboratory 553
90.01 Laboratory - Salaries and Wages 0
90.02 Laboratory - Fringe Benefits 0
90.03 Laboratory - Agency Staff 0
90.04 Laboratory - Other - Nonlabor 0
95.00 Home Health Services 0
95.01 Home Health Services - Salaries and Wages 0
95.02 Home Health Services - Fringe Benefits 0
95.03 Home Health Services - Agency Staff 0
95.04 Home Health Services - Other - Nonlabor 0
100.00 Other Ancillary Services 0

100.01 Other Ancillary Services - Salaries and Wages 0
100.02 Other Ancillary Services - Fringe Benefits 0
100.03 Other Ancillary Services - Agency Staff 0
100.04 Other Ancillary Services - Other - Nonlabor 0
100.06 Subacute Ancillary Services 0
100.07 Subacute Ancillary Services - Salaries and Wages 0
100.08 Subacute Ancillary Services - Fringe Benefits 0
100.09 Subacute Ancillary Services - Agency Staff 0
100.10 Subacute Ancillary Services - Other - Nonlabor 0
100.12 Subacute Pediatrics Ancillary Services 0
105.00 Skilled Nursing Care 0
105.01 Skilled Nursing Care - Salaries and Wages (18,948)
105.02 Skilled Nursing Care - Fringe Benefits 0
105.03 Skilled Nursing Care - Agency Staff 49,552 49,552
105.04 Skilled Nursing Care - Other - Nonlabor (108,231) (8,989) (3,195) (49,552)
110.00 Intermediate Care 0
115.00 Mentally Disordered 0
120.00 Developmentally Disabled 0
125.00 Subacute Care 0
125.01 Subacute Care - Salaries and Wages 0
125.02 Subacute Care - Fringe Benefits 0
125.03 Subacute Care - Agency Staff 0
125.04 Subacute Care - Other - Nonlabor 0
126.00 Subacute Care - Pediatrics 0
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STATE OF CALIFORNIA Schedule 8A-2
Page 1
Provider Name: Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period:
HOLLENBECK PALMS ZZT05115F 1831186345 206190378 JULY 1, 2007 THROUGH JUNE 30, 2008

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
(Pages 1, 2, & 3) 12 13 14 15 16 17 18 19 20
ADJUSTMENTS TO REPORTED COSTS
130.00 Hospice Inpatient Care 0
135.00 Other Routine Services 0
136.00 Residential Care 0
140.00 Beauty and Barber 160,272
145.00 Other Nonreimbursable 0
155.00 Social Services 0
155.01 Social Services - Salaries and Wages 0
155.02 Social Services - Fringe Benefits 0
155.03 Social Services - Agency Staff 0
155.04 Social Services - Other - Nonlabor 0
160.00 Activities 0
160.01 Activities - Salaries and Wages 0
160.02 Activities - Fringe Benefits 0
160.03 Activities - Agency Staff 0
160.04 Activities - Other - Nonlabor (143) (143)
165.00 Administration 0
165.01 Administration - Salaries and Wages (149,669) (85,183)
165.02 Administration - Fringe Benefits (48,090) (28,935)
165.03 Administration - Medical Records - Salaries and Wages 85,183 85,183
165.04 Administration - Medical Records - Fringe Benefits 28,935 28,935
165.05 Administration - Medical Records - Agency Staff 0
165.06 Administration - Medical Records - Other - Nonlabor 1,929 1,929
165.07 Administration - Facility License Fees 21,936 49,495 (27,559)
165.08 Administration - Liability Insurance 68,446 68,446
165.09 Administration - Caregiver Training 0
165.10 Administration - Quality Assurance Fees 0
165.11 Administration - Other - Nonlabor 413,887 533,869 (6,553) 8,989 3,415 (49,495) (68,446) (1,929) 27,559

170.00 Inservice Education - Nursing 0
170.01 Inservice Education - Nursing - Salaries and Wages 0
170.02 Inservice Education - Nursing - Fringe Benefits 0
170.03 Inservice Education - Nursing - Agency Staff 0
170.04 Inservice Education - Nursing - Other - Nonlabor (77) (77)
175.00 Total ($941,034) 000000000
(To Sch 8)
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STATE OF CALIFORNIA
Provider Name:
HOLLENBECK PALMS
5.00 Plant Operations and Maintenance
5.01 Plant Operations and Maintenance - Salaries and Wages
5.02 Plant Operations and Maintenance - Fringe Benefits
5.03 Plant Operations and Maintenance - Agency Staff
5.04 Plant Operations and Maintenance - Other - Nonlabor
10.00 Housekeeping
10.01 Housekeeping - Salaries and Wages
10.02 Housekeeping - Fringe Benefits
10.03 Housekeeping - Agency Staff
10.04 Housekeeping - Other - Nonlabor
15.00 Depreciation: Bldgs and Improvements
20.00 Depreciation: Leasehold Improvements
25.00 Depreciation: Equipment
30.00 Depreciation and Amortization - Other
35.00 Leases and Rentals
40.00 Property Taxes
45.00 Property Insurance
50.00 Interest-Property, Plant, and Equipment

55.00 Interest-Other
60.00 Laundry and Linen
60.01 Laundry and Linen - Salaries and Wages
60.02 Laundry and Linen - Fringe Benefits
60.03 Laundry and Linen - Agency Staff
60.04 Laundry and Linen - Other - Nonlabor
65.00 Dietary
65.01 Dietary - Salaries and Wages
65.02 Dietary - Fringe Benefits
65.03 Dietary - Agency Staff
65.04 Dietary - Other - Nonlabor
70.00 Provision for Bad Debts
75.00 Patient Supplies
75.01 Patient Supplies - Salaries and Wages
75.02 Patient Supplies - Fringe Benefits
75.03 Patient Supplies - Agency Staff
75.04 Patient Supplies - Other - Nonlabor
77.00 Specialized Support Surfaces
80.00 Physical Therapy
80.01 Physical Therapy - Salaries and Wages
80.02 Physical Therapy - Fringe Benefits
80.03 Physical Therapy - Agency Staff
80.04 Physical Therapy - Other - Nonlabor
81.00 Respiratory Therapy
81.01 Respiratory Therapy - Salaries and Wages
81.02 Respiratory Therapy - Fringe Benefits
81.03 Respiratory Therapy - Agency Staff
81.04 Respiratory Therapy - Other - Nonlabor
82.00 Occupational Therapy
82.01 Occupational Therapy - Salaries and Wages

Schedule 8A-2
Page 2
Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period:
ZZT05115F 1831186345 206190378 JULY 1, 2007 THROUGH JUNE 30, 2008
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
21 22 23 24 25 26,27 28 29 30 31-33
(5,121)
72,286
(72,286) 416
(772,791)
(65,365)
(22,203)
(12,668)
(8,420)
(3,510)
93,569
(93,569) (11,945) (16,188)
ADJUSTMENTS TO REPORTED COSTS
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STATE OF CALIFORNIA
Provider Name:
HOLLENBECK PALMS
82.02 Occupational Therapy - Fringe Benefits
82.03 Occupational Therapy - Agency Staff
82.04 Occupational Therapy - Other - Nonlabor
83.00 Speech Pathology
83.01 Speech Pathology - Salaries and Wages
83.02 Speech Pathology - Fringe Benefits
83.03 Speech Pathology - Agency Staff

83.04 Speech Pathology - Other - Nonlabor
85.00 Pharmacy
85.01 Pharmacy - Salaries and Wages
85.02 Pharmacy - Fringe Benefits
85.03 Pharmacy - Agency Staff
85.04 Pharmacy - Other - Nonlabor
90.00 Laboratory
90.01 Laboratory - Salaries and Wages
90.02 Laboratory - Fringe Benefits
90.03 Laboratory - Agency Staff
90.04 Laboratory - Other - Nonlabor
95.00 Home Health Services
95.01 Home Health Services - Salaries and Wages
95.02 Home Health Services - Fringe Benefits
95.03 Home Health Services - Agency Staff
95.04 Home Health Services - Other - Nonlabor
100.00 Other Ancillary Services
100.01 Other Ancillary Services - Salaries and Wages
100.02 Other Ancillary Services - Fringe Benefits
100.03 Other Ancillary Services - Agency Staff
100.04 Other Ancillary Services - Other - Nonlabor
100.06 Subacute Ancillary Services
100.07 Subacute Ancillary Services - Salaries and Wages
100.08 Subacute Ancillary Services - Fringe Benefits
100.09 Subacute Ancillary Services - Agency Staff
100.10 Subacute Ancillary Services - Other - Nonlabor
100.12 Subacute Pediatrics Ancillary Services
105.00 Skilled Nursing Care
105.01 Skilled Nursing Care - Salaries and Wages
105.02 Skilled Nursing Care - Fringe Benefits

105.03 Skilled Nursing Care - Agency Staff
105.04 Skilled Nursing Care - Other - Nonlabor
110.00 Intermediate Care
115.00 Mentally Disordered
120.00 Developmentally Disabled
125.00 Subacute Care
125.01 Subacute Care - Salaries and Wages
125.02 Subacute Care - Fringe Benefits
125.03 Subacute Care - Agency Staff
125.04 Subacute Care - Other - Nonlabor
126.00 Subacute Care - Pediatrics
Schedule 8A-2
Page 2
Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period:
ZZT05115F 1831186345 206190378 JULY 1, 2007 THROUGH JUNE 30, 2008
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
21 22 23 24 25 26,27 28 29 30 31-33
ADJUSTMENTS TO REPORTED COSTS
553
(416) (553) (15,000) (5,520)
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STATE OF CALIFORNIA
Provider Name:
HOLLENBECK PALMS
130.00 Hospice Inpatient Care
135.00 Other Routine Services
136.00 Residential Care
140.00 Beauty and Barber
145.00 Other Nonreimbursable

155.00 Social Services
155.01 Social Services - Salaries and Wages
155.02 Social Services - Fringe Benefits
155.03 Social Services - Agency Staff
155.04 Social Services - Other - Nonlabor
160.00 Activities
160.01 Activities - Salaries and Wages
160.02 Activities - Fringe Benefits
160.03 Activities - Agency Staff
160.04 Activities - Other - Nonlabor
165.00 Administration
165.01 Administration - Salaries and Wages
165.02 Administration - Fringe Benefits
165.03 Administration - Medical Records - Salaries and Wages
165.04 Administration - Medical Records - Fringe Benefits
165.05 Administration - Medical Records - Agency Staff
165.06 Administration - Medical Records - Other - Nonlabor
165.07 Administration - Facility License Fees
165.08 Administration - Liability Insurance
165.09 Administration - Caregiver Training
165.10 Administration - Quality Assurance Fees
165.11 Administration - Other - Nonlabor
170.00 Inservice Education - Nursing
170.01 Inservice Education - Nursing - Salaries and Wages
170.02 Inservice Education - Nursing - Fringe Benefits
170.03 Inservice Education - Nursing - Agency Staff
170.04 Inservice Education - Nursing - Other - Nonlabor
175.00 Total
Schedule 8A-2
Page 2

Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period:
ZZT05115F 1831186345 206190378 JULY 1, 2007 THROUGH JUNE 30, 2008
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
21 22 23 24 25 26,27 28 29 30 31-33
ADJUSTMENTS TO REPORTED COSTS
(38,583)
(13,106)
15,000 (37,161)
00000(772,791) (124,111) (88,850) (10,641) (16,188)
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STATE OF CALIFORNIA
Provider Name:
HOLLENBECK PALMS
5.00 Plant Operations and Maintenance
5.01 Plant Operations and Maintenance - Salaries and Wages
5.02 Plant Operations and Maintenance - Fringe Benefits
5.03 Plant Operations and Maintenance - Agency Staff
5.04 Plant Operations and Maintenance - Other - Nonlabor
10.00 Housekeeping
10.01 Housekeeping - Salaries and Wages
10.02 Housekeeping - Fringe Benefits
10.03 Housekeeping - Agency Staff
10.04 Housekeeping - Other - Nonlabor
15.00 Depreciation: Bldgs and Improvements
20.00 Depreciation: Leasehold Improvements
25.00 Depreciation: Equipment
30.00 Depreciation and Amortization - Other
35.00 Leases and Rentals
40.00 Property Taxes

45.00 Property Insurance
50.00 Interest-Property, Plant, and Equipment
55.00 Interest-Other
60.00 Laundry and Linen
60.01 Laundry and Linen - Salaries and Wages
60.02 Laundry and Linen - Fringe Benefits
60.03 Laundry and Linen - Agency Staff
60.04 Laundry and Linen - Other - Nonlabor
65.00 Dietary
65.01 Dietary - Salaries and Wages
65.02 Dietary - Fringe Benefits
65.03 Dietary - Agency Staff
65.04 Dietary - Other - Nonlabor
70.00 Provision for Bad Debts
75.00 Patient Supplies
75.01 Patient Supplies - Salaries and Wages
75.02 Patient Supplies - Fringe Benefits
75.03 Patient Supplies - Agency Staff
75.04 Patient Supplies - Other - Nonlabor
77.00 Specialized Support Surfaces
80.00 Physical Therapy
80.01 Physical Therapy - Salaries and Wages
80.02 Physical Therapy - Fringe Benefits
80.03 Physical Therapy - Agency Staff
80.04 Physical Therapy - Other - Nonlabor
81.00 Respiratory Therapy
81.01 Respiratory Therapy - Salaries and Wages
81.02 Respiratory Therapy - Fringe Benefits
81.03 Respiratory Therapy - Agency Staff
81.04 Respiratory Therapy - Other - Nonlabor

82.00 Occupational Therapy
82.01 Occupational Therapy - Salaries and Wages
Schedule 8A-2
Page 3
Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period:
ZZT05115F 1831186345 206190378 JULY 1, 2007 THROUGH JUNE 30, 2008
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
34-36 37 38-40 41 42 43 44-47
(57)
(1,401)
ADJUSTMENTS TO REPORTED COSTS
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STATE OF CALIFORNIA
Provider Name:
HOLLENBECK PALMS
82.02 Occupational Therapy - Fringe Benefits
82.03 Occupational Therapy - Agency Staff
82.04 Occupational Therapy - Other - Nonlabor
83.00 Speech Pathology
83.01 Speech Pathology - Salaries and Wages
83.02 Speech Pathology - Fringe Benefits
83.03 Speech Pathology - Agency Staff
83.04 Speech Pathology - Other - Nonlabor
85.00 Pharmacy
85.01 Pharmacy - Salaries and Wages
85.02 Pharmacy - Fringe Benefits
85.03 Pharmacy - Agency Staff
85.04 Pharmacy - Other - Nonlabor
90.00 Laboratory

90.01 Laboratory - Salaries and Wages
90.02 Laboratory - Fringe Benefits
90.03 Laboratory - Agency Staff
90.04 Laboratory - Other - Nonlabor
95.00 Home Health Services
95.01 Home Health Services - Salaries and Wages
95.02 Home Health Services - Fringe Benefits
95.03 Home Health Services - Agency Staff
95.04 Home Health Services - Other - Nonlabor
100.00 Other Ancillary Services
100.01 Other Ancillary Services - Salaries and Wages
100.02 Other Ancillary Services - Fringe Benefits
100.03 Other Ancillary Services - Agency Staff
100.04 Other Ancillary Services - Other - Nonlabor
100.06 Subacute Ancillary Services
100.07 Subacute Ancillary Services - Salaries and Wages
100.08 Subacute Ancillary Services - Fringe Benefits
100.09 Subacute Ancillary Services - Agency Staff
100.10 Subacute Ancillary Services - Other - Nonlabor
100.12 Subacute Pediatrics Ancillary Services
105.00 Skilled Nursing Care
105.01 Skilled Nursing Care - Salaries and Wages
105.02 Skilled Nursing Care - Fringe Benefits
105.03 Skilled Nursing Care - Agency Staff
105.04 Skilled Nursing Care - Other - Nonlabor
110.00 Intermediate Care
115.00 Mentally Disordered
120.00 Developmentally Disabled
125.00 Subacute Care
125.01 Subacute Care - Salaries and Wages

125.02 Subacute Care - Fringe Benefits
125.03 Subacute Care - Agency Staff
125.04 Subacute Care - Other - Nonlabor
126.00 Subacute Care - Pediatrics
Schedule 8A-2
Page 3
Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period:
ZZT05115F 1831186345 206190378 JULY 1, 2007 THROUGH JUNE 30, 2008
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
34-36 37 38-40 41 42 43 44-47
ADJUSTMENTS TO REPORTED COSTS
(18,948)
(25,006)
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STATE OF CALIFORNIA
Provider Name:
HOLLENBECK PALMS
130.00 Hospice Inpatient Care
135.00 Other Routine Services
136.00 Residential Care
140.00 Beauty and Barber
145.00 Other Nonreimbursable
155.00 Social Services
155.01 Social Services - Salaries and Wages
155.02 Social Services - Fringe Benefits
155.03 Social Services - Agency Staff
155.04 Social Services - Other - Nonlabor
160.00 Activities
160.01 Activities - Salaries and Wages

160.02 Activities - Fringe Benefits
160.03 Activities - Agency Staff
160.04 Activities - Other - Nonlabor
165.00 Administration
165.01 Administration - Salaries and Wages
165.02 Administration - Fringe Benefits
165.03 Administration - Medical Records - Salaries and Wages
165.04 Administration - Medical Records - Fringe Benefits
165.05 Administration - Medical Records - Agency Staff
165.06 Administration - Medical Records - Other - Nonlabor
165.07 Administration - Facility License Fees
165.08 Administration - Liability Insurance
165.09 Administration - Caregiver Training
165.10 Administration - Quality Assurance Fees
165.11 Administration - Other - Nonlabor
170.00 Inservice Education - Nursing
170.01 Inservice Education - Nursing - Salaries and Wages
170.02 Inservice Education - Nursing - Fringe Benefits
170.03 Inservice Education - Nursing - Agency Staff
170.04 Inservice Education - Nursing - Other - Nonlabor
175.00 Total
Schedule 8A-2
Page 3
Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period:
ZZT05115F 1831186345 206190378 JULY 1, 2007 THROUGH JUNE 30, 2008
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
34-36 37 38-40 41 42 43 44-47
ADJUSTMENTS TO REPORTED COSTS
160,272
(25,903)

(6,049)
(11,361)
160,272 (57) (25,006) (18,948) (31,952) (1,401) (11,361) 0 0 0
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
48
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT
1 10.1(4) 5 14 8A-1 5.00 Plant Operations and Maintenance $452,271 ($452,271) $0
Not Reported 8A-1 5.01 Plant Operations and Maintenance - Salaries and Wages 0 120,370 120,370
Not Reported 8A-1 5.02 Plant Operations and Maintenance - Fringe Benefits 0 40,887 40,887
Not Reported 8A-1 5.04 Plant Operations and Maintenance - Other - Nonlabor 0 291,014 291,014 *
2 10.1(4) 10 14 8A-1 10.00 Housekeeping $127,207 ($127,207) $0
Not Reported 8A-1 10.01 Housekeeping - Salaries and Wages 0 21,133 21,133
Not Reported 8A-1 10.02 Housekeeping - Fringe Benefits 0 7,178 7,178
Not Reported 8A-1 10.04 Housekeeping - Other - Nonlabor 0 98,896 98,896 *
3 10.1(4) 60 14 8A-1 60.00 Laundry and Linen $179,905 ($179,905) $0
Not Reported 8A-1 60.01 Laundry and Linen - Salaries and Wages 0 117,318 117,318 *
Not Reported 8A-1 60.02 Laundry and Linen - Fringe Benefits 0 39,850 39,850 *
Not Reported 8A-1 60.04 Laundry and Linen - Other - Nonlabor 0 22,737 22,737 *
4 10.1(4) 65 14 8A-1 65.00 Dietary $781,234 ($781,234) $0
Not Reported 8A-1 65.01 Dietary - Salaries and Wages 0 275,534 275,534 *
Not Reported 8A-1 65.02 Dietary - Fringe Benefits 0 114,847 114,847 *
Not Reported 8A-1 65.04 Dietary - Other - Nonlabor 0 390,853 390,853 *
5 10.1(4) 105 14 8A-1 105.00 Skilled Nursing Care $2,951,335 ($2,952,535) ($1,200) *
Not Reported 8A-1 105.01 Skilled Nursing Care - Salaries and Wages 0 1,986,884 1,986,884 *

Not Reported 8A-1 105.02 Skilled Nursing Care - Fringe Benefits 0 674,892 674,892
Not Reported 8A-1 105.04 Skilled Nursing Care - Other - Nonlabor 0 290,759 290,759 *
6 10.1(4) 155 14 8A-1 155.00 Social Services $73,142 ($73,142) $0
Not Reported 8A-1 155.01 Social Services - Salaries and Wages 0 46,549 46,549
Not Reported 8A-1 155.02 Social Services - Fringe Benefits 0 15,811 15,811
Not Reported 8A-1 155.04 Social Services - Other - Nonlabor 0 10,782 10,782
-Continued on next page-
*Balance carried forward from prior/to subsequent adjustments Page 1
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
Adjustments
HOLLENBECK PALMS JULY 1, 2007 THROUGH JUNE 30, 2008 ZZT05115F
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
48
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
Adjustments
HOLLENBECK PALMS JULY 1, 2007 THROUGH JUNE 30, 2008 ZZT05115F
RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT
-Continued from previous page-

7 10.1(4) 160 14 8A-1 160.00 Activities $98,142 ($98,142) $0
Not Reported 8A-1 160.01 Activities - Salaries and Wages 0 61,071 61,071
Not Reported 8A-1 160.02 Activities - Fringe Benefits 0 20,744 20,744
Not Reported 8A-1 160.04 Activities - Other - Nonlabor 0 16,327 16,327 *
8 10.1(4) 165 14 8A-1 165.00 Administration $827,182 ($1,473,604) ($646,422) *
Not Reported 8A-1 165.01 Administration - Salaries and Wages 0 638,978 638,978 *
Not Reported 8A-1 165.02 Administration - Fringe Benefits 0 219,185 219,185 *
Not Reported 8A-1 165.11 Administration - Other - Nonlabor 0 615,441 615,441 *
9 10.1(4) 170 14 8A-1 170.00 Inservice Education - Nursing $90,642 ($90,642) $0
Not Reported 8A-1 170.01 Inservice Education - Nursing - Salaries and Wages 0 66,159 66,159
Not Reported 8A-1 170.02 Inservice Education - Nursing - Fringe Benefits 0 22,472 22,472
Not Reported 8A-1 170.04 Inservice Education - Nursing - Other - Nonlabor 0 2,011 2,011 *
To reclassify reported expenses for proper cost determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
*Balance carried forward from prior/to subsequent adjustments Page 2
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
48
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
Adjustments
HOLLENBECK PALMS JULY 1, 2007 THROUGH JUNE 30, 2008 ZZT05115F
RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT

10 10.1(4) 105 14 8A-1 105.00 Skilled Nursing Care * ($1,200) $1,200 $0
Not Reported 8A-1 105.04 Skilled Nursing Care - Other - Nonlabor * 290,759 (1,200) 289,559 *
11 10.1(4) 165 14 8A-1 165.00 Administration * ($646,422) $646,422 $0
Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 615,441 (646,422) (30,981) *
To include the provider's adjustments for proper cost determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
*Balance carried forward from prior/to subsequent adjustments Page 3
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