STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS_part2 docx

STATE OF CALIFORNIA Schedule 8A-2
Page 1
Provider Name: Provider No.: OSHPD Facility Number: Fiscal Period:
VILLA GARDENS HEALTH CARE UNIT LTC55429H 206190515 APRIL 1, 2006 THROUGH MARCH 31, 2007
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
(Page 1) 10 11 12 13 14 15
ADJUSTMENTS TO REPORTED COSTS
130.00 Hospice Inpatient Care 0
135.00 Other Routine Services 0
136.00 Residential Care 0
140.00 Beauty and Barber 0
145.00 Other Nonreimbursable 0
155.00 Social Services 0
155.01 Social Services - Salaries and Wages 0
155.02 Social Services - Fringe Benefits 0
155.03 Social Services - Agency Staff 0
155.04 Social Services - Other - Nonlabor 0
160.00 Activities 0
160.01 Activities - Salaries and Wages 0
160.02 Activities - Fringe Benefits 0
160.03 Activities - Agency Staff 0
160.04 Activities - Other - Nonlabor 0
165.00 Administration 0
165.01 Administration - Salaries and Wages 0
165.02 Administration - Fringe Benefits (6,463) (6,463)
165.03 Administration - Medical Records - Salaries and Wages 0
165.04 Administration - Medical Records - Fringe Benefits 6,463 6,463
165.05 Administration - Medical Records - Agency Staff 0
165.06 Administration - Medical Records - Other - Nonlabor 0
165.07 Administration - DHS Licensing Fees 11,127 11,127
165.08 Administration - Liability Insurance 0

165.09 Administration - Caregiver Training 0
165.10 Administration - Quality Assurance Fees 0
165.11 Administration - Other - Nonlabor (11,377) (11,127) (4,250) 4,000
170.00 Inservice Education - Nursing 0
170.01 Inservice Education - Nursing - Salaries and Wages 0
170.02 Inservice Education - Nursing - Fringe Benefits 0
170.03 Inservice Education - Nursing - Agency Staff 0
170.04 Inservice Education - Nursing - Other - Nonlabor 0
175.00 Total ($16,990) 0 0 (8,490) (8,250) (4,250) 4,000000
(To Sch 8)
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
16
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT
1 10.1(4) 05 14 8A-1 5.00 Plant Operations and Maintenance $213,092 ($213,092) $0
Not Reported 8A-1 5.01 Plant Operations and Maintenance - Salaries and Wages 0 56,789 56,789
Not Reported 8A-1 5.02 Plant Operations and Maintenance - Fringe Benefits 0 25,138 25,138
Not Reported 8A-1 5.04 Plant Operations and Maintenance - Other - Nonlabor 0 131,165 131,165
2 10.1(4) 10 14 8A-1 10.00 Housekeeping $61,808 ($61,808) $0
Not Reported 8A-1 10.01 Housekeeping - Salaries and Wages 0 31,944 31,944
Not Reported 8A-1 10.02 Housekeeping - Fringe Benefits 0 15,035 15,035
Not Reported 8A-1 10.04 Housekeeping - Other - Nonlabor 0 14,829 14,829
3 10.1(4) 60 14 8A-1 60.00 Laundry and Linen $57,438 ($57,438) $0
Not Reported 8A-1 60.01 Laundry and Linen - Salaries and Wages 0 31,777 31,777
Not Reported 8A-1 60.02 Laundry and Linen - Fringe Benefits 0 13,132 13,132

Not Reported 8A-1 60.04 Laundry and Linen - Other - Nonlabor 0 12,529 12,529 *
4 10.1(4) 65 14 8A-1 65.00 Dietary $498,369 ($498,369) $0
Not Reported 8A-1 65.01 Dietary - Salaries and Wages 0 254,567 254,567
Not Reported 8A-1 65.02 Dietary - Fringe Benefits 0 103,538 103,538
Not Reported 8A-1 65.04 Dietary - Other - Nonlabor 0 140,264 140,264
5 10.1(4) 105 14 8A-1 105.00 Skilled Nursing Care $1,491,602 ($1,491,602) $0
Not Reported 8A-1 105.01 Skilled Nursing Care - Salaries and Wages 0 1,027,270 1,027,270
Not Reported 8A-1 105.02 Skilled Nursing Care - Fringe Benefits 0 387,215 387,215
Not Reported 8A-1 105.04 Skilled Nursing Care - Other - Nonlabor 0 77,117 77,117 *
6 10.1(4) 155 14 8A-1 155.00 Social Services $48,282 ($48,282) $0
Not Reported 8A-1 155.01 Social Services - Salaries and Wages 0 34,577 34,577
Not Reported 8A-1 155.02 Social Services - Fringe Benefits 0 12,625 12,625
Not Reported 8A-1 155.04 Social Services - Other - Nonlabor 0 1,080 1,080
-Continued on next page-
*Balance carried forward from prior/to subsequent adjustments Page 1
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
Adjustments
VILLA GARDENS HEALTH CARE UNIT APRIL 1, 2006 THROUGH MARCH 31, 2007 LTC55429H
This is trial version
www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
16
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
VILLA GARDENS HEALTH CARE UNIT APRIL 1, 2006 THROUGH MARCH 31, 2007 LTC55429H
RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT
-Continued from previous page-
7 10.1(4) 160 14 8A-1 160.00 Activities $73,717 ($73,717) $0
Not Reported 8A-1 160.01 Activities - Salaries and Wages 0 45,270 45,270
Not Reported 8A-1 160.02 Activities - Fringe Benefits 0 15,547 15,547
Not Reported 8A-1 160.04 Activities - Other - Nonlabor 0 12,900 12,900
8 10.1(4) 165 14 8A-1 165.00 Administration $599,402 ($599,402) $0
Not Reported 8A-1 165.01 Administration - Salaries and Wages 0 141,734 141,734
Not Reported 8A-1 165.02 Administration - Fringe Benefits 0 40,791 40,791 *
Not Reported 8A-1 165.03 Administration - Medical Records - Salaries and Wages 0 26,685 26,685
Not Reported 8A-1 165.11 Administration - Other - Nonlabor 0 390,192 390,192 *
9 10.1(4) 170 14 8A-1 170.00 Inservice Education - Nursing $74,246 ($74,246) $0
Not Reported 8A-1 170.01 Inservice Education - Nursing - Salaries and Wages 0 53,352 53,352
Not Reported 8A-1 170.02 Inservice Education - Nursing - Fringe Benefits 0 20,775 20,775
Not Reported 8A-1 170.04 Inservice Education - Nursing - Other - Nonlabor 0 119 119
To reclassify reported expenses 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
This is trial version
www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
16
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
VILLA GARDENS HEALTH CARE UNIT APRIL 1, 2006 THROUGH MARCH 31, 2007 LTC55429H
RECLASSIFICATIONS OF REPORTED COSTS
10 Not Reported 8A-2 165.07 Administration - DHS Licensing Fees $0 $11,127 $11,127
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 390,192 (11,127) 379,065 *
To reclassify Department of Health Care Services licensing fees to the
appropriate cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
11 Not Reported 8A-2 165.04 Administration - Medical Records - Fringe Benefits $0 $6,463 $6,463
Not Reported 8A-2 165.02 Administration - Fringe Benefits * 40,791 (6,463) 34,328
To reclassify medical records employee benefits 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 3
This is trial version
www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
16
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
VILLA GARDENS HEALTH CARE UNIT APRIL 1, 2006 THROUGH MARCH 31, 2007 LTC55429H
ADJUSTMENTS TO REPORTED COSTS
12 Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * $12,529 ($8,490) $4,039
To abate laundry and linen revenue against related costs.
42 CFR 413.5 and 413.9 / CMS Pub. 15-1, Section 2328
13 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * $77,117 ($8,250) $68,867
To eliminate utilization review expense due to the fact that the
State performs its own utilization review.
CMS Pub. 15-1, Section 2126
CCR, Title 22, Sections 50009.1 and 51159
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $379,065
14 To adjust licensing fees to agree with the Department of Health Care ($4,250)
Services licensing fees applicable to the audit period.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
15 To adjust home office costs to agree with the filed Home Office 4,000
Cost Report for fiscal year ended March 31, 2007. ($250) $378,815
42 CFR 413.17 / CMS Pub. 15-1, Sections 2150.2 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
16
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
VILLA GARDENS HEALTH CARE UNIT APRIL 1, 2006 THROUGH MARCH 31, 2007 LTC55429H
ADJUSTMENT TO REPORTED STATISTICS
16 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 2,156 2,156
Not Reported 7 60.00 Laundry and Linen 0 140 140
Not Reported 7 65.00 Dietary 0 1,005 1,005
11.1(1 of 3) 10 2 7 75.00 Patient Supplies 2,925 (2,687) 238
11.1(1 of 3) 40 2 7 105.00 Skilled Nursing Care 15,091 (3,298) 11,793
Not Reported 7 155.00 Social Services 0 121 121
Not Reported 7 160.00 Activities 0 664 664
Not Reported 7 165.00 Administration 04242
Not Reported 7 165.00 Medical Records 09090
Not Reported 7 170.00 Inservice Education - Nursing 0 600 600
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 18,798 (1,167) 17,631
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 18,798 (3,323) 15,475
To adjust square footage statistics to agree with the provider's prior year
records.
42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306
Page 5
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