STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS _part2 pptx

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
RECLASSIFICATIONS OF REPORTED COSTS
12 10.1(4) 55 14 8A-2 55.00 Interest - Other $1,307,709 ($533,869) $773,840 *
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * (30,981) 533,869 502,888 *
To reclassify the provider's adjustment of members' interest expense
to the appropriate cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
13 Not Reported 8A-2 5.04 Plant Operations and Maintenance - Other - Nonlabor * $291,014 ($4,199) $286,815 *
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 502,888 (6,553) 496,335 *
10.1(4) 35 14 8A-2 35.00 Leases and Rentals 0 10,752 10,752
To reclassify lease and rental expenses to the appropriate cost
center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
14 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * $289,559 ($8,989) $280,570 *
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 496,335 8,989 505,324 *
To reclassify telephone expenses to the appropriate cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8

15 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * $280,570 ($3,195) $277,375 *
Not Reported 8A-2 160.04 Activities - Other - Nonlabor * 16,327 (143) 16,184
Not Reported 8A-2 170.04 Inservice Education - Nursing - Other - Nonlabor * 2,011 (77) 1,934
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 505,324 3,415 508,739 *
To reclassify dues and subscriptions expenses to the appropriate
cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
*Balance carried forward from prior/to subsequent adjustments Page 4
This is trial version
www.adultpdf.com
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
RECLASSIFICATIONS OF REPORTED COSTS
16 Not Reported 8A-2 165.07 Administration - Facility License Fees $0 $49,495 $49,495 *
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 508,739 (49,495) 459,244 *
To reclassify facility license fees to the appropriate cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
17 Not Reported 8A-2 165.08 Administration - Liability Insurance $0 $68,446 $68,446

Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 459,244 (68,446) 390,798 *
To reclassify liability insurance expenses to the appropriate cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
18 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $638,978 ($85,183) $553,795 *
Not Reported 8A-2 165.02 Administration - Fringe Benefits * 219,185 (28,935) 190,250 *
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 390,798 (1,929) 388,869 *
Not Reported 8A-2 165.03 Administration - Medical Records - Salaries and Wages 0 85,183 85,183
Not Reported 8A-2 165.04 Administration - Medical Records - Fringe Benefits 0 28,935 28,935
Not Reported 8A-2 165.06 Administration - Medical Records - Other - Nonlabor 0 1,929 1,929
To reclassify medical records expenses to the appropriate cost centers.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
19 Not Reported 8A-2 105.03 Skilled Nursing Care - Agency Staff $0 $49,552 $49,552
Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 277,375 (49,552) 227,823 *
To reclassify nurse registry expenses to the appropriate cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
20 Not Reported 8A-2 165.07 Administration - Facility License Fees * $49,495 ($27,559) $21,936
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 388,869 27,559 416,428 *
To reclassify non-facility license fees to the appropriate cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
*Balance carried forward from prior/to subsequent adjustments Page 5
This is trial version
www.adultpdf.com
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
RECLASSIFICATIONS OF REPORTED COSTS
21 Not Reported 8A-2 10.03 Housekeeping - Agency Staff $0 $72,286 $72,286
Not Reported 8A-2 10.04 Housekeeping - Other - Nonlabor * 98,896 (72,286) 26,610 *
To reclassify housekeeping agency costs to the appropriate cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
Medi-Cal Bulletin 375
22 Not Reported 8A-2 65.03 Dietary - Agency Staff $0 $93,569 $93,569
Not Reported 8A-2 65.04 Dietary - Other - Nonlabor * 390,853 (93,569) 297,284 *
To reclassify dietary agency costs to the appropriate cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
23 Not Reported 8A-2 10.04 Housekeeping - Other - Nonlabor * $26,610 $416 $27,026
Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 227,823 (416) 227,407 *
To reclassify housekeeping supply expenses to the appropriate cost
center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
24 Not Reported 8A-2 90.00 Laboratory $27,151 $553 $27,704
Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 227,407 (553) 226,854 *
To reclassify laboratory supply expenses to the appropriate cost center.
42 CFR 413.20 and 413.24

CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
25 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * $226,854 ($15,000) $211,854 *
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 416,428 15,000 431,428 *
To reclassify the administrative portion of medical directors fees to the
appropriate cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
*Balance carried forward from prior/to subsequent adjustments Page 6
This is trial version
www.adultpdf.com
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
ADJUSTMENTS TO REPORTED COSTS
10.1(4) 55 14 8A-2 55.00 Interest - Other * $773,840
26 To adjust interest expense for the provider's elimination of members' $23,012
interest from the cost report, that would create a credit balance, to
net a zero balance in conjunction with adjustment 12.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
27 To eliminate bond interest expense for Magnolia Court building not (795,803)
related to patient care. ($772,791) $1,049

42 CFR 413.9(c)(3) / CMS Pub. 15-1, Sections 202.2 and 2102
28 Not Reported 8A-2 60.01 Laundry and Linen - Salaries and Wages * $117,318 ($65,365) $51,953
Not Reported 8A-2 60.02 Laundry and Linen - Fringe Benefits * 39,850 (22,203) 17,647
Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * 22,737 (12,668) 10,069
Not Reported 8A-2 65.01 Dietary - Salaries and Wages * 275,534 (8,420) 267,114
Not Reported 8A-2 65.02 Dietary - Fringe Benefits * 114,847 (3,510) 111,337
Not Reported 8A-2 65.04 Dietary - Other - Nonlabor * 297,284 (11,945) 285,339 *
To eliminate the residential care portion of expenses, based on the
appropriate apportionment factor of patient days, for proper
allocation of costs.
42 CFR 413.24 / CMS Pub. 15-1, Section 2302.8
29 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $553,795 ($38,583) $515,212 *
Not Reported 8A-2 165.02 Administration - Fringe Benefits * 190,250 (13,106) 177,144 *
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 431,428 (37,161) 394,267 *
To eliminate the residential care portion of expenses, based on the
appropriate apportionment factor of accumulated costs, for proper
allocation of costs.
42 CFR 413.24 / CMS Pub. 15-1, Section 2302.8
*Balance carried forward from prior/to subsequent adjustments Page 7
This is trial version
www.adultpdf.com
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
ADJUSTMENTS TO REPORTED COSTS
30 Not Reported 8A-2 5.04 Plant Operations and Maintenance - Other - Nonlabor * $286,815 ($5,121) $281,694 *
Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 211,854 (5,520) 206,334 *
To abate guest rooms and rental revenues against the appropriate cost
centers.
42 CFR 413.5 and 413.9 / CMS Pub. 15-1, Section 2328
Not Reported 8A-2 65.04 Dietary - Other - Nonlabor * $285,339
31 To abate guest meals against the appropriate cost center. ($8,523)
42 CFR 413.5 and 413.9 / CMS Pub. 15-1, Section 2328
32 To abate bazaar revenue against related costs. (6,080)
42 CFR 413.5 and 413.9 / CMS Pub. 15-1, Section 2328
33 To eliminate general supplies expenses due to lack of (1,585)
documentation. ($16,188) $269,151
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
10.1(4) 140 14 8A-2 140.00 Beauty and Barber ($107,094)
34 To reverse the provider's abatement of beauty and barber revenue $53,916
against a nonreimbursable cost center.
42 CFR 413.9, 413.20 and 413.24 / CMS Pub. 15-1, Section 2328
35 To reverse the provider's elimination of beauty and barber expenses. 53,178
42 CFR 413.9, 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2304 and 2328
36 To include the cost of beauty and barber in a nonreimbursable cost center. 53,178
42 CFR 413.53(a) and 413.9(b)(1) $160,272 $53,178
CMS Pub. 15-1, Sections 2102.1, 2200.1, 2304 and 2328
CCR, Title 22, Section 51511(d)
*Balance carried forward from prior/to subsequent adjustments Page 8
This is trial version

www.adultpdf.com
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
ADJUSTMENTS TO REPORTED COSTS
37 Not Reported 8A-2 5.04 Plant Operations and Maintenance - Other - Nonlabor * $281,694 ($57) $281,637
To abate vending machine revenue against related costs.
42 CFR 413.5 and 413.9 / CMS Pub. 15-1, Section 2328
Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * $206,334
38 To eliminate the remaining utilization review expense due to the fact ($1,500)
that the State performs its own utilization review.
CMS Pub. 15-1, Section 2126
CCR, Title 22, Sections 50009.1 and 51159
39 To abate other private ancillary revenue against related costs. (23,137)
42 CFR 413.5 and 413.9 / CMS Pub. 15-1, Section 2328
40 To eliminate personal care items not included in the rate. (369)
CCR, Title 22, Section 51511 ($25,006) $181,328
41 Not Reported 8A-2 105.01 Skilled Nursing Care - Salaries and Wages * $1,986,884 ($18,948) $1,967,936
To abate private duty nurse revenue against related costs.
42 CFR 413.5 and 413.9 / CMS Pub. 15-1, Sections 2104.2 and 2328
42 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $515,212 ($25,903) $489,309

Not Reported 8A-2 165.02 Administration - Fringe Benefits * 177,144 (6,049) 171,095
To adjust owner's/administrator's compensation based on the State
guidelines.
SPA, Section (III)(J) / W&I Code, Section 14126.023(f)
Medi-Cal Bulletin 371 / 42 CFR 413.102
CMS Pub. 15-1, Sections 901, 902.3, 904, and 1005
43 10.1(4) 40 14 8A-2 40.00 Property Taxes $6,174 ($1,401) $4,773
To eliminate property tax expense not related to patient care.
42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3
*Balance carried forward from prior/to subsequent adjustments Page 9
This is trial version
www.adultpdf.com
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
ADJUSTMENTS TO REPORTED COSTS
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $394,267
44 To abate miscellaneous revenue against related costs. ($6,741)
42 CFR 413.5 and 413.9 / CMS Pub. 15-1, Section 2328
45 To eliminate patient television costs. (1,442)
42 CFR 413.5 and 413.9(c)(3) / CMS Pub. 15-1, Section 2106.1

46 To reflect the proper accrual of other insurance applicable to the (1,036)
audit period.
42 CFR 413.5 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2302.1
47 To reconcile the reported expense to agree with the provider's trial (2,142)
balance. ($11,361) $382,906
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
*Balance carried forward from prior/to subsequent adjustments Page 10
This is trial version
www.adultpdf.com
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
ADJUSTMENT TO REPORTED STATISTICS
48 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 695 695
Not Reported 7 10.00 Housekeeping 0 165 165
Not Reported 7 60.00 Laundry and Linen 0 152 152
Not Reported 7 65.00 Dietary 0 1,630 1,630
11.1 (1 of 3) 10 2 7 75.00 Patient Supplies 0 100 100
11.1 (1 of 3) 40 2 7 105.00 Skilled Nursing Care 11,282 112 11,394
Not Reported 7 155.00 Social Services 04949
Not Reported 7 160.00 Activities 0 400 400

Not Reported 7 165.00 Administration 0 1,018 1,018
Not Reported 7 165.00 Medical Records 0 232 232
Not Reported 7 170.00 Inservice Education - Nursing 0 136 136
11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 11,670 4,689 16,359
11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 11,670 3,994 15,664
11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 11,670 3,829 15,499
To adjust square footage statistics to agree with prior year's audited
amounts.
42 CFR 413.24 and 413.50 / CMS Pub. 15-1, Sections 2304 and 2306
Page 11
This is trial version
www.adultpdf.com