State of California Fiscal Period JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 Audit Report docx

State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
47
`
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
WESTLAKE HEALTH CARE CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC55794F
ADJUSTMENTS TO REPORTED STATISTICS
38 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 408 408
Not Reported 7 10.00 Housekeeping 0 396 396
Not Reported 7 60.00 Laundry and Linen 0 400 400
Not Reported 7 65.00 Dietary 0 3,140 3,140
11.1 (1 of 3) 40 2 7 105.00 Skilled Nursing Care 16,311 (6,316) 9,995
11.1 (1 of 3) 60 2 7 125.00 Subacute Care 4,130 (572) 3,558
11.1 (1 of 3) 75 2 7 140.00 Beauty and Barber 0 378 378
Not Reported 7 155.00 Social Services 0 126 126
Not Reported 7 160.00 Activities 0 1,764 1,764
Not Reported 7 165.00 Administration 0 288 288
Not Reported 7 165.00 Medical Records 0 240 240
Not Reported 7 170.00 Inservice Education - Nursing 0 126 126
11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 21,621 378 21,999
11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 21,621 (30) 21,591
11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 21,621 (426) 21,195
To adjust square footage statistics to agree with the prior year's
audit findings and provider's records.

42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
39 11.1 (1 of 3) 40 4 7 105.00 Skilled Nursing Care (Pounds of Laundry) 274,290 (4,200) 270,090
11.1 (1 of 3) 60 4 7 125.00 Subacute Care 11,760 (250) 11,510
11.1 (1 of 3) 85 4 7 N/A Total Statistics - Pounds of Laundry 286,050 (4,450) 281,600
To adjust the pounds of laundry statistics for proper allocation of cost.
42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306
40 11.1 (2 of 3) 40 6 7 105.00 Skilled Nursing Care (Meals Served) 82,287 (1,260) 81,027
11.1 (2 of 3) 60 6 7 125.00 Subacute Care 3,528 (1,017) 2,511
11.1 (2 of 3) 85 6 7 N/A Total Statistics - Meals Served 85,815 (2,277) 83,538
To adjust meals served statistics for proper allocation of cost.
42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
47
`
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
WESTLAKE HEALTH CARE CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC55794F
ADJUSTMENT TO REPORTED PATIENT DAYS
41 4.3(1) 100 1 ASA1 48.00 Total Subacute Days - Ventilator 1,176 (862) 314
4.3(1) 115 1 ASA1 49.00 Total Subacute Days - Non-Ventilator 0 862 862

To adjust total Subacute ventilator patient days based on the ratio of
Medi-Cal ventilator days to total ventilator days.
42 CFR 413.20 and 413.50 / CMS Pub. 15-1, Sections 2205 and 2304
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
47
`
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
WESTLAKE HEALTH CARE CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC55794F
ADJUSTMENT TO REPORTED TOTAL CHARGES
42 13.1 20 4 ASA 2 77.00 Subacute Ancillary Charges - Pharmacy $138,616 ($138,616) $0
To eliminate the Subacute pharmacy ancillary charges for prescription
drugs as these are not included in the Subacute per diem rate.
CCR, Title 22, Sections 51511(c), 51511.5(c) and 51511.5(d)
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
47

`
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
WESTLAKE HEALTH CARE CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC55794F
ADJUSTMENT TO REPORTED MEDI-CAL SETTLEMENT DATA - SUBACUTE
43 4.3(1) 100 2 ASA 1 48.00 Medi-Cal Subacute Days - Ventilator 0 112 112
To adjust Medi-Cal Settlement Data to agree with the following
EDS Paid Claims Summary:
Report Date: June 17, 2009
Payment Period: January 1, 2008 through May 31, 2009
Service Period: January 1, 2008 through December 31, 2008
42 CFR 413.20, 413.50, 413.53, 413.60 and 413.64
CMS Pub. 15-1, Sections 2304 and 2408
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www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
47
`
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
WESTLAKE HEALTH CARE CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC55794F
` ADJUSTMENTS TO OTHER MATTERS
44 Not Reported ASA1 41.00 Contracted Number of Adult Subacute Beds 0 22 22
To reflect the number of contracted Subacute beds in the audit report.
CMS Pub. 15-1, Section 2300 and 2304
Not Reported 1 14.00 Overpayments - Skilled Nursing Care $0
45 To recover outstanding Medi-Cal credit balances. $9,924
CCR, Title 22, Sections 50761 and 51458.1
46 To recover Medi-Cal overpayments because the 6114's 324
were not provided. $10,248 $10,248
42 CFR 413.5 and 413.20 / CMS Pub. 15-1, Section 2409
47 Not Reported ASA1 39.00 Overpayments - Subacute $0 $2,290 $2,290
To recover outstanding Medi-Cal credit balances.
CCR, Title 22, Sections 50761 and 51458.1
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