State of California Fiscal Period JANUARY 1, 2007 AUDIT REPORT ppt

State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
39
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
SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H
RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT
-Continued from previous page-
14 10.1(4) 125 14 8A-1 125.00 Subacute Care $1,487,558 ($1,487,558) $0
Not Reported 8A-1 125.01 Subacute Care - Salaries and Wages 0 782,831 782,831 *
Not Reported 8A-1 125.02 Subacute Care - Fringe Benefits 0 225,562 225,562 *
Not Reported 8A-1 125.03 Subacute Care - Agency Staff 0 149,752 149,752
Not Reported 8A-1 125.04 Subacute Care - Other - Nonlabor 0 329,413 329,413 *
15 10.1(4) 155 14 8A-1 155.00 Social Services $50,035 ($50,035) $0
Not Reported 8A-1 155.01 Social Services - Salaries and Wages 0 38,491 38,491
Not Reported 8A-1 155.02 Social Services - Fringe Benefits 0 7,829 7,829
Not Reported 8A-1 155.04 Social Services - Other - Nonlabor 0 3,715 3,715
16 10.1(4) 160 14 8A-1 160.00 Activities $105,177 ($105,177) $0
Not Reported 8A-1 160.01 Activities - Salaries and Wages 0 80,167 80,167
Not Reported 8A-1 160.02 Activities - Fringe Benefits 0 16,537 16,537
Not Reported 8A-1 160.04 Activities - Other - Nonlabor 0 8,473 8,473
17 10.1(4) 165 14 8A-1 165.00 Administration $1,342,031 ($1,342,031) $0
Not Reported 8A-1 165.01 Administration - Salaries and Wages 0 280,867 280,867 *
Not Reported 8A-1 165.02 Administration - Fringe Benefits 0 71,388 71,388

Not Reported 8A-1 165.03 Administration - Medical Records - Salaries and Wages 0 44,757 44,757
Not Reported 8A-1 165.04 Administration - Medical Records - Fringe Benefits 0 9,925 9,925
Not Reported 8A-1 165.06 Administration - Medical Records - Other - Nonlabor 0 29,885 29,885
Not Reported 8A-1 165.07 Administration - DHS Licensing Fees 0 24,521 24,521 *
Not Reported 8A-1 165.08 Administration - Liability Insurance 0 118,952 118,952 *
Not Reported 8A-1 165.10 Administration - Quality Assurance Fees 0 266,064 266,064
Not Reported 8A-1 165.11 Administration - Other - Nonlabor 0 495,672 495,672 *
-Continued on next page-
*Balance carried forward from prior/to subsequent adjustments Page 3
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
39
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
SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H
RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT
-Continued from previous page-
18 10.1(4) 170 14 8A-1 170.00 Inservice Education - Nursing $75,427 ($75,427) $0
Not Reported 8A-1 170.01 Inservice Education - Nursing - Salaries and Wages 0 59,737 59,737
Not Reported 8A-1 170.02 Inservice Education - Nursing - Fringe Benefits 0 11,661 11,661
Not Reported 8A-1 170.04 Inservice Education - Nursing - Other - Nonlabor 0 4,029 4,029

To reclassify the reported expenses for proper cost determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
Page 4
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
39
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
SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H
RECLASSIFICATIONS OF REPORTED COSTS
19 10.1(4) 70 14 8A-2 70.00 Provision for Bad Debts $56,673 ($56,673) $0
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 495,672 56,673 552,345 *
To reverse provider's elimination of bad debts expense 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 - DHS Licensing Fees * $24,521 ($3,047) $21,474
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 552,345 3,047 555,392 *
To reclassify other 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

21 Not Reported 8A-2 125.04 Subacute Care - Other - Nonlabor * $329,413 ($30,000) $299,413 *
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 555,392 30,000 585,392 *
To reclassify medical director fees to the appropriate cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
CCR, Title 22, Section 72305
22 Not Reported 8A-2 75.04 Patient Supplies - Other - Nonlabor * $7,299 $111,857 $119,156
Not Reported 8A-2 105.01 Skilled Nursing Care - Salaries and Wages * 1,611,471 (75,044) 1,536,427
Not Reported 8A-2 105.02 Skilled Nursing Care - Fringe Benefits * 359,956 22,714 382,670
Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 238,421 (140,441) 97,980
Not Reported 8A-2 125.01 Subacute Care - Salaries and Wages * 782,831 75,044 857,875
Not Reported 8A-2 125.02 Subacute Care - Fringe Benefits * 225,562 (22,714) 202,848
Not Reported 8A-2 125.04 Subacute Care - Other - Nonlabor * 299,413 28,584 327,997
To reclassify reported expense to agree with the provider's
general ledger.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
*Balance carried forward from prior/to subsequent adjustments Page 5
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www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
39
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
SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H
ADJUSTMENTS TO REPORTED COSTS
23 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $280,867 ($83,465) $197,402
To adjust administrator compensation based on the Department of
Health Care Services guidelines.
42 CFR 413.102
CMS Pub. 15-1, Sections 901, 902.3, 904 and 905
24 10.1(4) 40 14 8A-2 40.00 Property Taxes $39,066 $27,576 $66,642
To adjust property taxes to agree with the provider's property tax bill.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
25 Not Reported 8A-2 165.08 Administration - Liability Insurance * $118,952 ($7,117) $111,835
To adjust liability insurance to agree with the provider's
liability insurance cancelled checks.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $585,392
26 To eliminate meals expense not related to patient care. ($4,113)
42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3
27 To eliminate travel and entertainment expense not related (1,067)
to patient care.
42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3
28 To adjust auto/gas expense to agree with the provider's (7,521)
mileage report. ($12,701) $572,691
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
29 10.1(4) 35 14 8A-2 35.00 Leases and Rentals $609,313 $270 $609,583
To adjust home office costs to agree with the filed Home Office
Cost Report.
42 CFR 413.17 / CMS Pub. 15-1, Sections 2150.2 and 2304
*Balance carried forward from prior/to subsequent adjustments Page 6
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www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
39
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
SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H
ADJUSTMENTS TO REPORTED STATISTICS
30 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 195 195
Not Reported 7 60.00 Laundry and Linen 0 361 361
Not Reported 7 65.00 Dietary 0 768 768
11.1(1 of 3) 10 2 7 75.00 Patient Supplies 521 (248) 273
11.1(1 of 3) 15 2 7 80.00 Physical Therapy 460 (219) 241
11.1(1 of 3) 16 2 7 81.00 Respiratory Therapy 386 (184) 202
11.1(1 of 3) 17 2 7 82.00 Occupational Therapy 527 (251) 276
11.1(1 of 3) 20 2 7 85.00 Pharmacy 401 (191) 210
11.1(1 of 3) 40 2 7 105.00 Skilled Nursing Care 15,048 (7,167) 7,881
11.1(1 of 3) 60 2 7 125.00 Subacute Care 4,829 (2,300) 2,529
Not Reported 7 155.00 Social Services 0 297 297
Not Reported 7 160.00 Activities 0 924 924
Not Reported 7 165.00 Administration 0 672 672
Not Reported 7 165.00 Medical Records 0 491 491
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 22,214 (6,852) 15,362

11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 22,214 (7,047) 15,167
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 22,214 (7,047) 15,167
To establish the correct square footage in order to properly allocate
indirect costs.
42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306
31 11.1(1 of 3) 40 4 7 105.00 Skilled Nursing Care (Clean, Dry Pounds) 63,138 (1,188) 61,950
11.1(1 of 3) 60 4 7 125.00 Subacute Care 20,110 (1,883) 18,227
11.1(1 of 3) 85 4 7 N/A Total Statistics - Clean, Dry Pounds 83,248 (3,071) 80,177
To adjust laundry pounds statistics to properly allocate laundry costs.
42 CFR 413.24 / CMS Pub. 15-1, Sections 2304 and 2306
32 11.1(2 of 3) 40 6 7 105.00 Skilled Nursing Care (Number of Patient Meals) 75,765 (1,425) 74,340
11.1(2 of 3) 60 6 7 125.00 Subacute Care 24,132 (16,386) 7,746
11.1(2 of 3) 85 6 7 N/A Total Statistics - Number of Patient Meals 99,897 (17,811) 82,086
To adjust dietary meals statistics to properly allocate dietary costs.
42 CFR 413.24 / CMS Pub. 15-1, Sections 2304 and 2306
Page 7
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
39
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

SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H
ADJUSTMENT TO REPORTED PATIENT DAYS
33 4.1 5 6 1 12.00 Total Patient Days - Skilled Nursing Care 25,255 (3) 25,252
4.3(1) 120 1 SA 1 36.00 Total Patient Days - Subacute 8,044 (27) 8,017
4.3(1) 100 1 SA 1 48.00 Total Subacute Days - Ventilator 4,986 394 5,380
4.3(1) 115 1 SA 1 49.00 Total Subacute Days - Nonventilator 3,058 (421) 2,637
To adjust total patient days to agree with the provider's
patient census reports.
42 CFR 413.20 and 413.50
CMS Pub. 15-1, Sections 2205 and 2304
Page 8
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
39
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
SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H
ADJUSTMENTS TO REPORTED TOTAL CHARGES
34 13.1 12 4 SA 2 22.00 Specialized Support Surfaces (Total Subacute Ancillary Charges) $3,065 ($3,065) $0
To eliminate Subacute ancillary charges not included in the rate.
CCR, Title 22, Sections 51511(c) and 51511.5

35 13.1 20 4 SA 2 77.00 Pharmacy (Total Subacute Ancillary Charges) $99,446 ($34,683) $64,763
To exclude Subacute outlier drug charges from Subacute pharmacy
charges for proper determination of Subacute costs.
CMS Pub. 15-1, Section 2304
CCR, Title 22, Section 51511.5
Page 9
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
39
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
SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H
ADJUSTMENT TO REPORTED MEDI-CAL SETTLEMENT DATA - SUBACUTE
36 4.3(1) 100 2 SA 1 48.00 Medi-Cal Subacute Days - Ventilator 3,358 68 3,426
4.3(1) 120 2 SA 1 44.00 Medi-Cal Subacute Days - Total 5,441 32 5,473
To adjust Medi-Cal Settlement Data to agree with the following
EDS Paid Claims Summary:
Report Date: November 18, 2008
Payment Period: January 1, 2007 through November 18, 2008
Service Period: January 1, 2007 through December 31, 2007
42 CFR 413.20, 413.50, 413.53, 413.60 and 413.64

CMS Pub. 15-1, Sections 2304 and 2408
Page 10
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
39
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
SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H
ADJUSTMENTS TO OTHER MATTERS
37 Not Reported SA 1 41.00 Contracted Number of Subacute Beds 0 24 24
To reflect the number of contracted Subacute care beds on
the audit report schedule.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
38 4.3(1) 20 1 1 15.00 Total Licensed Nursing Facility Beds 99 (24) 75
To adjust total available licensed nursing facility beds.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
39 Not Reported SA 1 48.00 Subacute Ventilator Equipment Cost $0 $41,514 $41,514
To include ventilator equipment expense.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
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