RECONCILIATION OF THE PROVIDER''''S ADJUSTMENTS TO THE AUDIT REPORT _part1 docx

23

24

AUDIT ADJ
25

AUDIT ADJ
26

AUDIT ADJ

41,189

85.02 Pharmacy - Fringe Benefits

85.01 Pharmacy - Salaries and Wages

85.00 Pharmacy

83.04 Speech Pathology - Other - Nonlabor

83.03 Speech Pathology - Agency Staff

83.02 Speech Pathology - Fringe Benefits

83.01 Speech Pathology - Salaries and Wages

AUDIT ADJ

22

(11,342)

105.01 Skilled Nursing Care - Salaries and Wages

105.02 Skilled Nursing Care - Fringe Benefits

155.01 Social Services - Salaries and Wages

155.00 Social Services

125.04 Subacute Care - Other - Nonlabor

125.03 Subacute Care - Agency Staff

125.02 Subacute Care - Fringe Benefits

125.01 Subacute Care - Salaries and Wages

125.00 Subacute Care

105.04 Skilled Nursing Care - Other - Nonlabor

105.03 Skilled Nursing Care - Agency Staff

(29,847)

105.00 Skilled Nursing Care

100.10 Subacute Ancillary Services - Other - Nonlabor

100.09 Subacute Ancillary Services - Agency Staff

100.08 Subacute Ancillary Services - Fringe Benefits

100.07 Subacute Ancillary Services - Salaries and Wages

100.06 Subacute Ancillary Services

100.04 Other Ancillary Services - Other - Nonlabor

100.03 Other Ancillary Services - Agency Staff

100.02 Other Ancillary Services - Fringe Benefits

100.01 Other Ancillary Services - Salaries and Wages

100.00 Other Ancillary Services

95.04 Home Health Services - Other - Nonlabor

95.03 Home Health Services - Agency Staff

95.02 Home Health Services - Fringe Benefits

95.01 Home Health Services - Salaries and Wages

95.00 Home Health Services

90.04 Laboratory - Other - Nonlabor

90.03 Laboratory - Agency Staff

90.02 Laboratory - Fringe Benefits

90.01 Laboratory - Salaries and Wages

90.00 Laboratory

85.04 Pharmacy - Other - Nonlabor

85.03 Pharmacy - Agency Staff

27

AUDIT ADJ
28

AUDIT ADJ

AUDIT ADJ

206190124

ZZT05900F

GRANCELL VILLAGE

AUDIT ADJ

OSHPD Facility Number:

Provider No.:

RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT

Provider Name:

STATE OF CALIFORNIA

This is trial version
www.adultpdf.com

AUDIT ADJ

AUDIT ADJ

AUDIT ADJ

AUDIT ADJ

SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007

Fiscal Period:

Page 3

Schedule 8A-1

0

23

0

0

0

26

AUDIT ADJ

0

(34,063)

0

21,626

(3,751)

21,626

(21,626)

28

AUDIT ADJ

175.00

Total

170.04 Inservice Education - Nursing - Other - Nonlabor

(7,196)

170.02 Inservice Education - Nursing - Fringe Benefits

(5,027)

(1,603)

(6,719)

170.01 Inservice Education - Nursing - Salaries and Wages

170.03 Inservice Education - Nursing - Agency Staff

(12,827)

(18,016)

170.00 Inservice Education - Nursing

165.11 Administration - Other - Nonlabor

165.10 Administration - Quality Assurance Fees

165.09 Administration - Caregiver Training

165.08 Administration - Liability Insurance

165.07 Administration - DHS Licensing Fees

165.06 Administration - Medical Records - Other - Nonlabor

165.05 Administration - Medical Records - Agency Staff

165.04 Administration - Medical Records - Fringe Benefits

(2,249)

(10,625)

165.03 Administration - Medical Records - Salaries and Wages

165.02 Administration - Fringe Benefits

84,463

27

AUDIT ADJ

(39,775)

3,751

25

AUDIT ADJ

165.01 Administration - Salaries and Wages

165.00 Administration

160.04 Activities - Other - Nonlabor

2,249

24

AUDIT ADJ

29,762

160.03 Activities - Agency Staff

160.02 Activities - Fringe Benefits

160.01 Activities - Salaries and Wages

160.00 Activities

155.04 Social Services - Other - Nonlabor

155.03 Social Services - Agency Staff

155.02 Social Services - Fringe Benefits

AUDIT ADJ

22

0

AUDIT ADJ

206190124

ZZT05900F

GRANCELL VILLAGE

AUDIT ADJ

OSHPD Facility Number:

Provider No.:

RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT

Provider Name:

STATE OF CALIFORNIA

This is trial version
www.adultpdf.com
0

AUDIT ADJ

0

AUDIT ADJ

0

AUDIT ADJ

0

AUDIT ADJ

0

SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007

Fiscal Period:

Page 3

Schedule 8A-1


0

0

10.01 Housekeeping - Salaries and Wages
0

0

10.00 Housekeeping

(79,591)

5.04 Plant Operations and Maintenance - Other - Nonlabor

0
37,150

5.02 Plant Operations and Maintenance - Fringe Benefits

5.03 Plant Operations and Maintenance - Agency Staff

0

5.01 Plant Operations and Maintenance - Salaries and Wages

0

40.00 Property Taxes

0

0
0
0

82.00 Occupational Therapy

82.01 Occupational Therapy - Salaries and Wages

0

81.02 Respiratory Therapy - Fringe Benefits

81.04 Respiratory Therapy - Other - Nonlabor

0

81.01 Respiratory Therapy - Salaries and Wages

81.03 Respiratory Therapy - Agency Staff

0
0

0

80.03 Physical Therapy - Agency Staff

81.00 Respiratory Therapy

0

80.02 Physical Therapy - Fringe Benefits

80.04 Physical Therapy - Other - Nonlabor

0
0

80.01 Physical Therapy - Salaries and Wages

0

77.00 Specialized Support Surfaces

80.00 Physical Therapy

0
0

75.04 Patient Supplies - Other - Nonlabor

0

75.02 Patient Supplies - Fringe Benefits

75.03 Patient Supplies - Agency Staff

0
0

75.01 Patient Supplies - Salaries and Wages

0

70.00 Provision for Bad Debts

75.00 Patient Supplies

0
0

65.02 Dietary - Fringe Benefits

65.04 Dietary - Other - Nonlabor

0

65.01 Dietary - Salaries and Wages

65.03 Dietary - Agency Staff

0
0

65.00 Dietary

(149,685)

60.04 Laundry and Linen - Other - Nonlabor

0

60.02 Laundry and Linen - Fringe Benefits
149,685

0

60.01 Laundry and Linen - Salaries and Wages

60.03 Laundry and Linen - Agency Staff

0
0

60.00 Laundry and Linen

0

55.00 Interest-Other

50.00 Interest-Property, Plant, and Equipment

(2,960)

0

35.00 Leases and Rentals

45.00 Property Insurance

0

30.00 Depreciation and Amortization - Other

(26,613)

0

25.00 Depreciation: Equipment

(13,501)

10.04 Housekeeping - Other - Nonlabor

20.00 Depreciation: Leasehold Improvements

10.03 Housekeeping - Agency Staff

15.00 Depreciation: Bldgs and Improvements

0
0

10.02 Housekeeping - Fringe Benefits

(149,685)

149,685

29

5.00 Plant Operations and Maintenance

AUDIT ADJ

(Pages 1 & 2)

ZZT05900F

GRANCELL VILLAGE

TOTAL ADJ

Provider No.:

Provider Name:

STATE OF CALIFORNIA

This is trial version
www.adultpdf.com

(37,150)

37,150

30

AUDIT ADJ
31

AUDIT ADJ

ADJUSTMENTS TO REPORTED COSTS

32

AUDIT ADJ
33

AUDIT ADJ

206190124

(26,613)

(13,501)

34

AUDIT ADJ

OSHPD Facility Number:

(42,441)

35

AUDIT ADJ
36

AUDIT ADJ

37

AUDIT ADJ

SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007

Fiscal Period:

Page 1

Schedule 8A-2


0

0
0
0

83.00 Speech Pathology

83.01 Speech Pathology - Salaries and Wages

83.02 Speech Pathology - Fringe Benefits

83.03 Speech Pathology - Agency Staff
0

0
0

82.04 Occupational Therapy - Other - Nonlabor

0

82.03 Occupational Therapy - Agency Staff

29

82.02 Occupational Therapy - Fringe Benefits

AUDIT ADJ

(Pages 1 & 2)

ZZT05900F

GRANCELL VILLAGE

TOTAL ADJ

Provider No.:

Provider Name:

STATE OF CALIFORNIA

95.04 Home Health Services - Other - Nonlabor

0
0
0
0

125.03 Subacute Care - Agency Staff

125.04 Subacute Care - Other - Nonlabor

126.00 Subacute Care - Pediatrics

125.01 Subacute Care - Salaries and Wages

125.02 Subacute Care - Fringe Benefits

0
0

125.00 Subacute Care

0
0

120.00 Developmentally Disabled

0

110.00 Intermediate Care

115.00 Mentally Disordered

0

105.02 Skilled Nursing Care - Fringe Benefits

0

0

105.01 Skilled Nursing Care - Salaries and Wages

105.04 Skilled Nursing Care - Other - Nonlabor

0

105.00 Skilled Nursing Care

105.03 Skilled Nursing Care - Agency Staff

0
0

100.12 Subacute Pediatrics Ancillary Services

0
0

100.10 Subacute Ancillary Services - Other - Nonlabor

0

100.08 Subacute Ancillary Services - Fringe Benefits

100.09 Subacute Ancillary Services - Agency Staff

0
0

100.04 Other Ancillary Services - Other - Nonlabor

100.07 Subacute Ancillary Services - Salaries and Wages

0

100.03 Other Ancillary Services - Agency Staff

100.06 Subacute Ancillary Services

0
0

100.02 Other Ancillary Services - Fringe Benefits

0

95.03 Home Health Services - Agency Staff

0

0
0

95.02 Home Health Services - Fringe Benefits

100.01 Other Ancillary Services - Salaries and Wages

0

95.01 Home Health Services - Salaries and Wages

100.00 Other Ancillary Services

0
0

95.00 Home Health Services

0
0

90.02 Laboratory - Fringe Benefits

90.04 Laboratory - Other - Nonlabor

0

90.01 Laboratory - Salaries and Wages

90.03 Laboratory - Agency Staff

0
0

90.00 Laboratory

0
0

85.02 Pharmacy - Fringe Benefits

85.04 Pharmacy - Other - Nonlabor

0

85.01 Pharmacy - Salaries and Wages

85.03 Pharmacy - Agency Staff

0
0

85.00 Pharmacy

83.04 Speech Pathology - Other - Nonlabor

This is trial version
www.adultpdf.com

30

AUDIT ADJ
31

AUDIT ADJ

ADJUSTMENTS TO REPORTED COSTS

32

AUDIT ADJ
33

AUDIT ADJ

206190124

34

AUDIT ADJ

OSHPD Facility Number:

35

AUDIT ADJ
36

AUDIT ADJ

37

AUDIT ADJ

SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007

Fiscal Period:

Page 1

Schedule 8A-2


0

0
0

155.00 Social Services

155.01 Social Services - Salaries and Wages
0

0
0

145.00 Other Nonreimbursable

0

136.00 Residential Care

140.00 Beauty and Barber

0

135.00 Other Routine Services

29

130.00 Hospice Inpatient Care

AUDIT ADJ

(Pages 1 & 2)

ZZT05900F

GRANCELL VILLAGE

TOTAL ADJ

Provider No.:

Provider Name:

STATE OF CALIFORNIA

0

29,230

165.04 Administration - Medical Records - Fringe Benefits

0

165.10 Administration - Quality Assurance Fees

0
0

170.03 Inservice Education - Nursing - Agency Staff

170.04 Inservice Education - Nursing - Other - Nonlabor

(To Sch 8)

($224,934)

0

170.02 Inservice Education - Nursing - Fringe Benefits

Total

0

170.01 Inservice Education - Nursing - Salaries and Wages

175.00

0

170.00 Inservice Education - Nursing

(179,430)

0

165.11 Administration - Other - Nonlabor

131,400

165.08 Administration - Liability Insurance

165.07 Administration - DHS Licensing Fees

165.09 Administration - Caregiver Training

35,876
21,960

165.06 Administration - Medical Records - Other - Nonlabor

0

81,814

165.03 Administration - Medical Records - Salaries and Wages

165.05 Administration - Medical Records - Agency Staff

(77,093)

165.02 Administration - Fringe Benefits

(183,176)

165.00 Administration

165.01 Administration - Salaries and Wages

0
0

160.04 Activities - Other - Nonlabor

0

160.02 Activities - Fringe Benefits

160.03 Activities - Agency Staff

0
0

160.01 Activities - Salaries and Wages

155.04 Social Services - Other - Nonlabor

160.00 Activities

0
0

155.03 Social Services - Agency Staff

155.02 Social Services - Fringe Benefits

This is trial version
www.adultpdf.com
0

30

AUDIT ADJ

0

(50,527)

50,527

41,166

115,223

(41,166)

(115,223)

31

AUDIT ADJ

0

ADJUSTMENTS TO REPORTED COSTS

(131,400)

131,400

32

AUDIT ADJ

0

(21,960)

21,960

33

AUDIT ADJ

206190124

0

40,114

34

AUDIT ADJ

OSHPD Facility Number:

0

(42,441)

35

AUDIT ADJ

(15,657)

(15,657)

36

AUDIT ADJ

(59,996)

(14,651)

(11,936)

(33,409)

37

AUDIT ADJ

SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007

Fiscal Period:

Page 1

Schedule 8A-2


10.01 Housekeeping - Salaries and Wages

10.00 Housekeeping

5.04 Plant Operations and Maintenance - Other - Nonlabor

5.03 Plant Operations and Maintenance - Agency Staff

5.02 Plant Operations and Maintenance - Fringe Benefits

5.01 Plant Operations and Maintenance - Salaries and Wages

5.00 Plant Operations and Maintenance

82.01 Occupational Therapy - Salaries and Wages

82.00 Occupational Therapy

81.04 Respiratory Therapy - Other - Nonlabor

81.03 Respiratory Therapy - Agency Staff

81.02 Respiratory Therapy - Fringe Benefits

81.01 Respiratory Therapy - Salaries and Wages

81.00 Respiratory Therapy

80.04 Physical Therapy - Other - Nonlabor

80.03 Physical Therapy - Agency Staff

80.02 Physical Therapy - Fringe Benefits

80.01 Physical Therapy - Salaries and Wages

80.00 Physical Therapy

77.00 Specialized Support Surfaces

75.04 Patient Supplies - Other - Nonlabor

75.03 Patient Supplies - Agency Staff

75.02 Patient Supplies - Fringe Benefits

75.01 Patient Supplies - Salaries and Wages

75.00 Patient Supplies

70.00 Provision for Bad Debts

65.04 Dietary - Other - Nonlabor

65.03 Dietary - Agency Staff

65.02 Dietary - Fringe Benefits

65.01 Dietary - Salaries and Wages

65.00 Dietary

60.04 Laundry and Linen - Other - Nonlabor

60.03 Laundry and Linen - Agency Staff

60.02 Laundry and Linen - Fringe Benefits

60.01 Laundry and Linen - Salaries and Wages

60.00 Laundry and Linen

55.00 Interest-Other

50.00 Interest-Property, Plant, and Equipment

45.00 Property Insurance

40.00 Property Taxes

35.00 Leases and Rentals

30.00 Depreciation and Amortization - Other

25.00 Depreciation: Equipment

20.00 Depreciation: Leasehold Improvements

15.00 Depreciation: Bldgs and Improvements

10.04 Housekeeping - Other - Nonlabor

10.03 Housekeeping - Agency Staff

10.02 Housekeeping - Fringe Benefits

39

(2,960)

AUDIT ADJ

38

ZZT05900F

GRANCELL VILLAGE

AUDIT ADJ

Provider No.:

Provider Name:

STATE OF CALIFORNIA

This is trial version
www.adultpdf.com

AUDIT ADJ

AUDIT ADJ

ADJUSTMENTS TO REPORTED COSTS

AUDIT ADJ

AUDIT ADJ

206190124

OSHPD Facility Number:

AUDIT ADJ

AUDIT ADJ

AUDIT ADJ

AUDIT ADJ

SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007

Fiscal Period:

Page 2

Schedule 8A-2


83.03 Speech Pathology - Agency Staff

83.02 Speech Pathology - Fringe Benefits

83.01 Speech Pathology - Salaries and Wages

83.00 Speech Pathology

82.04 Occupational Therapy - Other - Nonlabor

82.03 Occupational Therapy - Agency Staff

82.02 Occupational Therapy - Fringe Benefits

126.00 Subacute Care - Pediatrics

125.04 Subacute Care - Other - Nonlabor

125.03 Subacute Care - Agency Staff

125.02 Subacute Care - Fringe Benefits

125.01 Subacute Care - Salaries and Wages

125.00 Subacute Care

120.00 Developmentally Disabled

115.00 Mentally Disordered

110.00 Intermediate Care

105.04 Skilled Nursing Care - Other - Nonlabor

105.03 Skilled Nursing Care - Agency Staff

105.02 Skilled Nursing Care - Fringe Benefits

105.01 Skilled Nursing Care - Salaries and Wages

105.00 Skilled Nursing Care

100.12 Subacute Pediatrics Ancillary Services

100.10 Subacute Ancillary Services - Other - Nonlabor

100.09 Subacute Ancillary Services - Agency Staff

100.08 Subacute Ancillary Services - Fringe Benefits

100.07 Subacute Ancillary Services - Salaries and Wages

100.06 Subacute Ancillary Services

100.04 Other Ancillary Services - Other - Nonlabor

100.03 Other Ancillary Services - Agency Staff

100.02 Other Ancillary Services - Fringe Benefits

100.01 Other Ancillary Services - Salaries and Wages

100.00 Other Ancillary Services

95.04 Home Health Services - Other - Nonlabor

95.03 Home Health Services - Agency Staff

95.02 Home Health Services - Fringe Benefits

95.01 Home Health Services - Salaries and Wages

95.00 Home Health Services

90.04 Laboratory - Other - Nonlabor

90.03 Laboratory - Agency Staff

90.02 Laboratory - Fringe Benefits

90.01 Laboratory - Salaries and Wages

90.00 Laboratory

85.04 Pharmacy - Other - Nonlabor

85.03 Pharmacy - Agency Staff

85.02 Pharmacy - Fringe Benefits

85.01 Pharmacy - Salaries and Wages

85.00 Pharmacy

83.04 Speech Pathology - Other - Nonlabor

AUDIT ADJ
39

38

ZZT05900F

GRANCELL VILLAGE

AUDIT ADJ

Provider No.:

Provider Name:

STATE OF CALIFORNIA

This is trial version
www.adultpdf.com

AUDIT ADJ

AUDIT ADJ

ADJUSTMENTS TO REPORTED COSTS

AUDIT ADJ

AUDIT ADJ

206190124

OSHPD Facility Number:

AUDIT ADJ

AUDIT ADJ

AUDIT ADJ

AUDIT ADJ

SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007

Fiscal Period:

Page 2

Schedule 8A-2


175.00

Total

170.04 Inservice Education - Nursing - Other - Nonlabor

170.03 Inservice Education - Nursing - Agency Staff

170.02 Inservice Education - Nursing - Fringe Benefits

170.01 Inservice Education - Nursing - Salaries and Wages

170.00 Inservice Education - Nursing

165.11 Administration - Other - Nonlabor

165.10 Administration - Quality Assurance Fees

165.09 Administration - Caregiver Training

165.08 Administration - Liability Insurance

165.07 Administration - DHS Licensing Fees

165.06 Administration - Medical Records - Other - Nonlabor

165.05 Administration - Medical Records - Agency Staff

165.04 Administration - Medical Records - Fringe Benefits

(103,880)

(35,927)

165.02 Administration - Fringe Benefits

165.03 Administration - Medical Records - Salaries and Wages

165.01 Administration - Salaries and Wages

165.00 Administration

160.04 Activities - Other - Nonlabor

160.03 Activities - Agency Staff

160.02 Activities - Fringe Benefits

160.01 Activities - Salaries and Wages

160.00 Activities

155.04 Social Services - Other - Nonlabor

155.03 Social Services - Agency Staff

155.02 Social Services - Fringe Benefits

(2,960)

39

(67,953)

155.01 Social Services - Salaries and Wages

155.00 Social Services

145.00 Other Nonreimbursable

140.00 Beauty and Barber

136.00 Residential Care

135.00 Other Routine Services

130.00 Hospice Inpatient Care

AUDIT ADJ

38

ZZT05900F

GRANCELL VILLAGE

AUDIT ADJ

Provider No.:

Provider Name:

STATE OF CALIFORNIA

This is trial version
www.adultpdf.com

AUDIT ADJ

0

AUDIT ADJ

0

ADJUSTMENTS TO REPORTED COSTS

AUDIT ADJ

0

AUDIT ADJ

206190124

0

OSHPD Facility Number:

AUDIT ADJ

0

AUDIT ADJ

0

AUDIT ADJ

0

AUDIT ADJ

0

SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007

Fiscal Period:

Page 2

Schedule 8A-2


1

Adj.
No.

6

5

4

3

2

10.1(4)
Not Reported
Not Reported
Not Reported

10.1(4)
Not Reported

Not Reported
Not Reported

10.1(4)
Not Reported
Not Reported
Not Reported

10.1(4)
Not Reported

10.1(4)
Not Reported
Not Reported
Not Reported

10.1(4)
Not Reported
Not Reported
Not Reported

155

105

65

60

10

05

14

14

14

14

14

14

Report References
Cost Report
MC530
Page or
Exhibit
Line
Col.

8A-1
8A-1
8A-1
8A-1

8A-1
8A-1

8A-1
8A-1

8A-1
8A-1
8A-1
8A-1

8A-1
8A-1

8A-1
8A-1
8A-1
8A-1

8A-1
8A-1
8A-1
8A-1

Sch

As

ZZT05900F

Housekeeping
Housekeeping - Salaries and Wages
Housekeeping - Fringe Benefits

Housekeeping - Other - Nonlabor

Plant Operations and Maintenance
Plant Operations and Maintenance - Salaries and Wages
Plant Operations and Maintenance - Fringe Benefits
Plant Operations and Maintenance - Other - Nonlabor

155.00
155.01
155.02
155.04

105.00
105.01
105.02
105.04

65.00
65.01
65.02
65.04

*Balance carried forward from prior/to subsequent adjustments

-Continued on next page-

Social Services
Social Services - Salaries and Wages
Social Services - Fringe Benefits
Social Services - Other - Nonlabor

Skilled Nursing Care
Skilled Nursing Care - Salaries and Wages
Skilled Nursing Care - Fringe Benefits
Skilled Nursing Care - Other - Nonlabor

Dietary
Dietary - Salaries and Wages
Dietary - Fringe Benefits
Dietary - Other - Nonlabor

60.00 Laundry and Linen
60.04 Laundry and Linen - Other - Nonlabor

10.00
10.01
10.02
10.04

5.00
5.01
5.02
5.04

$157,626
0
0
0

$4,604,531

0
0
0

$910,472
0
0
0

$198,534
0

$316,838
0
0
0

$430,640
0
0
0

As
Adjusted

43

*
*
*

*
($95,230) *
293,764 *

($604,815)
562,060
218,287
141,306

($221,994)
157,866
60,504
3,624

($4,691,862)
3,428,147
1,242,805
20,910

Page

($64,368)
157,866
60,504
3,624

*
*
*
*

($87,331) *
3,428,147 *
1,242,805 *
20,910

($1,925,684) ($1,015,212) *
873,753
873,753 *
290,802
290,802 *
761,129
761,129 *

($293,764)
293,764

($921,653)
562,060
218,287
141,306

1

Adjustments

($1,598,199) ($1,167,559) *
240,004
240,004 *
88,405

88,405 *
1,269,790
1,269,790 *

Increase
(Decrease)

Provider Number

Department of Health Care Services

Reported
Explanation of Audit Adjustments
RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT
Line

GRANCELL VILLAGE
Audit Report

Fiscal Period
SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007

Provider Name

State of California

This is trial version
www.adultpdf.com

10.1(4)
Not Reported
Not Reported
Not Reported

10.1(4)
Not Reported
Not Reported
Not Reported

8

9

170

165

-Continued from previous page7
10.1(4)
160
Not Reported
Not Reported
Not Reported

Adj.
No.

14

14

14

8A-1
8A-1
8A-1
8A-1

8A-1
8A-1
8A-1
8A-1

8A-1
8A-1
8A-1
8A-1

Sch

As

ZZT05900F

170.00
170.01
170.02
170.04

165.00
165.01
165.02
165.11

160.00
160.01
160.02
160.04

*Balance carried forward from prior/to subsequent adjustments

To reclassify reported expenses for proper cost determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304

Inservice Education - Nursing
Inservice Education - Nursing - Salaries and Wages
Inservice Education - Nursing - Fringe Benefits
Inservice Education - Nursing - Other - Nonlabor

Administration
Administration - Salaries and Wages
Administration - Fringe Benefits
Administration - Other - Nonlabor

Activities
Activities - Salaries and Wages
Activities - Fringe Benefits
Activities - Other - Nonlabor

$51,256
0
0
0

$2,243,289
0
0
0

$328,263
0
0
0

($102,644)
62,133
23,173
17,338

($1,433,045)
492,312
170,265
770,468

($462,313)
295,200
99,023
68,090

Increase
(Decrease)

Provider Number

Page

($51,388)
62,133
23,173
17,338

$810,244
492,312
170,265
770,468

($134,050)
295,200
99,023
68,090

As
Adjusted

43

*
*
*

*

*
*
*
*

*
*
*
*

2

Adjustments

Department of Health Care Services

Reported
Explanation of Audit Adjustments
RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT
Line

SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007

Report References
Cost Report
MC530
Page or
Exhibit

Line
Col.

GRANCELL VILLAGE
Audit Report

Fiscal Period

Provider Name

State of California

This is trial version
www.adultpdf.com


Not Reported
10.1(4)

Not Reported
Not Reported
10.1(4)

Not Reported
10.1(4)

10.1(4)
Not Reported

Not Reported

10.1(4)

10

11

12

13

14

Adj.
No.

165

165

165

105

65

14

14

14

14

14

8A-1
8A-1

8A-1
8A-1

8A-1
8A-1

8A-1
8A-1
8A-1

8A-1
8A-1

Sch

As

ZZT05900F

*Balance carried forward from prior/to subsequent adjustments

165.11 Administration - Other - Nonlabor

165.00 Administration
To reclassify the provider's adjustment of lobbying activity expenses
for proper cost determination.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8

165.00 Administration
165.11 Administration - Other - Nonlabor
To reclassify home office adjustment for proper cost determination.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8

To reclassify the reported revenue abatements for proper cost
determination.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8

165.11 Administration - Other - Nonlabor
165.00 Administration

105.01 Skilled Nursing Care - Salaries and Wages
105.02 Skilled Nursing Care - Fringe Benefits
105.00 Skilled Nursing Care

65.04 Dietary - Other - Nonlabor
65.00 Dietary

*
*

*
*

*
*

*
*
*

*
*

$2,060,677
(479,965)

$812,290
768,422

$770,468
810,244

$3,428,147
1,242,805
(87,331)

$761,129
(1,015,212)

($1,977)

1,977

($1,292,255)
1,292,255

($2,046)
2,046

($33,436)
(12,706)
46,142

($3,396)
3,396

Increase
(Decrease)

Provider Number

Page

$2,058,700 *
(477,988) *

($479,965) *
2,060,677 *

$768,422 *
812,290 *

$3,394,711 *
1,230,099 *
(41,189) *

$757,733 *
(1,011,816) *

As
Adjusted

43

3

Adjustments

Department of Health Care Services

Reported
Explanation of Audit Adjustments
RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT
Line

SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007

Report References
Cost Report
MC530
Page or

Exhibit
Line
Col.

GRANCELL VILLAGE
Audit Report

Fiscal Period

Provider Name

State of California

This is trial version
www.adultpdf.com