State of California Fiscal Period JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 _part1 doc

State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
CASTRO VALLEY HEALTHCARE AND REHABILITATION CENTER
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted
MEMORANDUM ADJUSTMENT
1 10.7 075 2, 3 7 075 Patient Supplies (Square Feet) 0 108 108
10.7
080
2, 3
7
080
Physical Therapy
0
200
200

10.7
082
2, 3
7
082
Occupational Therapy
0
200
200
10.7
083
2, 3
7

083
Speech Pathology
0
133
133
10.7 085 2, 3 7 085 Pharmacy 0 134 134
10.7 105 2, 3 7 105 Skilled Nursing Care 0 8,505 8,505 *
10.7 175 2, 3 7 N/A Total - Square Feet 0 9,280 9,280 *
To reconcile provider's reported statistics on page 10.7 to
provider's reported statistics on page 11.1.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304





*Balance carried forward from prior/to subsequent adjustments Page 1
Adjustments
JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05239J
Cost Report
Explanation of Audit Adjustments
Report References
Audit Report
17
This is trial version
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
CASTRO VALLEY HEALTHCARE AND REHABILITATION CENTER
MC530

Adj. Page or As Increase As
No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted
Adjustments
JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05239J
Cost Report
Explanation of Audit Adjustments
Report References
Audit Report
17
RECLASSIFICATIONS OF REPORTED COSTS

2 10.5 065 3 8A-2 065 3 Dietary - Agency Staff $17,148 ($17,148) $0
10.5 065 4 8A-2 065 4 Dietary - Other - Nonlabor 131,085 17,148 148,233 *
To reclassify dietary consultant expenses for proper cost determination.
41 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304

3 10.5 105 3 8A-2 105 3 Skilled Nursing Care - Agency Staff $22,420 ($22,420) $0
10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor 131,134 2,643 133,777 *
10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor 587,880 19,777 607,657 *
To reclassify reported SNF agency staff expenses for proper
cost determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304

4 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * $133,777 ($3,931) $129,846 *
10.5 035 4 8A-2 035 4 Leases and Rentals 412,050 2,256 414,306 *
10.5 090 4 8A-2 090 4 Laboratory - Other - Nonlabor 70,347 142 70,489
10.5 100 4 8A-2 100 4 Other Ancillary Services - Other - Nonlabor 7,579 1,011 8,590
10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * 607,657 522 608,179 *
To reclassify reported non- SNF expenses for proper
cost determination.

42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304

5 10.5 105 1 8A-2 105 1 Skilled Nursing Care - Salaries and Wages $1,557,282 ($5,609) $1,551,673
10.5 105 2 8A-2 105 2 Skilled Nursing Care - Fringe Benefits 307,186 (1,602) 305,584
10.5 075 1 8A-2 075 1 Patient Supplies - Salaries and Wages 0 2,622 2,622
10.5 075 2 8A-2 075 2 Patient Supplies - Fringe Benefits 0 749 749
10.5 165 1 8A-2 165 1 Administration - Salaries and Wages 192,109 2,987 195,096
10.5 165 2 8A-2 165 2 Administration - Fringe Benefits 49,998 853 50,851
To reclassify payroll expenses of central supply 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
CASTRO VALLEY HEALTHCARE AND REHABILITATION CENTER
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted
Adjustments
JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05239J
Cost Report
Explanation of Audit Adjustments
Report References
Audit Report
17
RECLASSIFICATIONS OF REPORTED COSTS

6 10.5 075 4 8A-2 075 4 Patient Supplies - Other - Nonlabor $21,438 ($11,417) $10,021 *

10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * 129,846 11,417 141,263 *
To reclassify enteral expenses for proper cost determination.
41 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304

7 10.5 085 4 8A-2 085 4 Pharmacy - Other - Nonlabor $141,838 $2,871 $144,709
10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * 141,263 (2,871) 138,392 *
To reclassify prescription drug expenses for proper cost determination.
41 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304

8 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $608,179 ($1,099) $607,080 *
10.5 167 4 8A-2 167 4 Administration - DPH Licensing Fees 25,018 1,099 26,117
To reclassify DPH licensing fees for proper cost determination.
41 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304

9 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $607,080 $2,527 $609,607 *
10.5 168 4 8A-2 168 4 Administration - Liability Insurance 51,718 (2,527) 49,191 *
To reclassify liability insurance expenses other than premiums
for proper cost determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304

10 10.5 005 4 8A-2 005 4 Plant Operations and Maintenance - Other - Nonlabor $145,914 ($176) $145,738
10.5 060 4 8A-2 060 4 Laundry and Linen - Other - Nonlabor 18,699 (487) 18,212
10.5 065 4 8A-2 065 4 Dietary - Other - Nonlabor * 148,233 (383) 147,850
10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * 138,392 (10,191) 128,201
10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * 609,607 (2,825) 606,782 *
10.5 035 4 8A-2 035 4 Leases and Rentals * 414,306 14,062 428,368
To reclassify equipment rental expenses for proper cost determination.
41 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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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
CASTRO VALLEY HEALTHCARE AND REHABILITATION CENTER
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted
Adjustments
JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05239J
Cost Report
Explanation of Audit Adjustments
Report References
Audit Report
17
ADJUSTMENTS TO REPORTED COSTS

11 10.5 040 4 8A-2 040 4 Property Taxes $35,358 $16,619 $51,977
To adjust property taxes expenses to agree with the provider's
documentation.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
12 10.5 075 4 8A-2 075 4 Patient Supplies - Other - Nonlabor * $10,021 ($1,194) $8,827
To eliminate enteral expenses due to insufficient documentation.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
13 10.5 168 4 8A-2 168 4 Administration - Liability Insurance * $49,191 ($1,505) $47,686
To adjust liability insurance expense to agree with the provider's
documentation.
43 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
14 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $606,782 $2,264 $609,046
To adjust taxes and finance charges related to liability insurance
expense for proper cost determination.

43 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
*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
CASTRO VALLEY HEALTHCARE AND REHABILITATION CENTER
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted
Adjustments
JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05239J
Cost Report
Explanation of Audit Adjustments
Report References
Audit Report
17
ADJUSTMENTS TO REPORTED STATISTICS

15 10.7 010 2, 3 7 010 Housekeeping (Square Feet) 0 576 576
10.7 060 2, 3 7 060 Laundry and Linen 0 314 314
10.7 065 2, 3 7 065 Dietary 0 1,833 1,833
10.7 105 2, 3 7 105 Skilled Nursing Care * 8,505 (152) 8,353 *
10.7 155 2, 3 7 155 Social Services 0 565 565
10.7 165 2, 3 7 165 Administration 0 1,546 1,546
10.7 175 2 7 N/A Total - Square Feet * 9,280 4,682 13,962 *
10.7 175 3 7 N/A Total - Square Feet * 9,280 4,106 13,386 *
To reconcile provider's reported statistics on page 10.7, Column 2
and Column 3 to Column 1.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304

16 10.7 005 1, 2, 3 7 005 Plant Operations and Maintenance (Square Feet) 1,078 30 1,108
10.7 010 1, 2, 3 7 010 Housekeeping 576 (456) 120
10.7 060 1, 2, 3 7 060 Laundry and Linen 314 (62) 252
10.7 065 1, 2, 3 7 065 Dietary 1,833 (803) 1,030
10.7 075 1, 2, 3 7 075 Patient Supplies 108 76 184
10.7 080 1, 2, 3 7 080 Physical Therapy 200 430 630
10.7 082 1, 2, 3 7 082 Occupational Therapy 200 (200) 0
10.7 083 1, 2, 3 7 083 Speech Pathology 133 (133) 0
10.7 085 1, 2, 3 7 085 Pharmacy 134 (134) 0
10.7 105 1, 2, 3 7 105 Skilled Nursing Care * 8,353 (731) 7,622
10.7 140 1, 2, 3 7 140 Beauty and Barber 0 144 144
10.7 145 1, 2, 3 7 145 Other Nonreimbursable 0 90 90
10.7 155 1, 2, 3 7 155 Social Services 565 (405) 160
10.7 165 1, 2, 3 7 165 Administration 1,546 (878) 668
10.7 166 1, 2, 3 7 166 Medical Records 0 900 900
10.7 170 1, 2, 3 7 170 Inservice Education - Nursing 0 196 196
10.7 175 1 7 N/A Total - Square Feet 15,040 (1,936) 13,104
10.7 175 2 7 N/A Total - Square Feet * 13,962 (1,966) 11,996
10.7 175 3 7 N/A Total - Square Feet * 13,386 (1,510) 11,876
To adjust square footage statistics to agree with the provider's
documentation.
42 CFR 413.24 and 413.50 / CMS Pub. 15-1, Sections 2304 and 2306
*Balance carried forward from prior/to subsequent adjustments Page 5
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
CASTRO VALLEY HEALTHCARE AND REHABILITATION CENTER
MC530

Adj. Page or As Increase As
No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted
Adjustments
JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05239J
Cost Report
Explanation of Audit Adjustments
Report References
Audit Report
17
ADJUSTMENT TO REPORTED PATIENT DAYS

17 4.1 70 6 1 12 Total Patient Days 22,845 1 22,846
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 6
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