STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS_part4 potx

STATE OF CALIFORNIA Schedule 8A-2
Page 1
Provider Name: Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period:
VILLA SCALABRINI LTC90058F 1538221288 206194113 JANUARY 1, 2008 THROUGH DECEMBER 31, 2008
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 16
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 (3,780) (3,780)
165.02 Administration - Fringe Benefits (872) (872)
165.03 Administration - Medical Records - Salaries and Wages 0
165.04 Administration - Medical Records - Fringe Benefits 0
165.05 Administration - Medical Records - Agency Staff 0
165.06 Administration - Medical Records - Other - Nonlabor 0
165.07 Administration - Facility License Fees 14,654 14,654
165.08 Administration - Liability Insurance 5,710 5,710

165.09 Administration - Caregiver Training 0
165.10 Administration - Quality Assurance Fees 0
165.11 Administration - Other - Nonlabor (14,172) (14,654) (5,710) 6,687 (495)
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 $74,302000(4,652) 184,449 (105,000) (495) 0 0
(To Sch 8)
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
17
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 $303,013 ($303,013) $0
Not Reported 8A-1 5.01 Plant Operations and Maintenance - Salaries and Wages 0 41,313 41,313
Not Reported 8A-1 5.02 Plant Operations and Maintenance - Fringe Benefits 0 13,941 13,941
Not Reported 8A-1 5.04 Plant Operations and Maintenance - Other - Nonlabor 0 247,759 247,759 *
2 10.1(4) 10 14 8A-1 10.00 Housekeeping $198,735 ($198,735) $0
Not Reported 8A-1 10.01 Housekeeping - Salaries and Wages 0 119,417 119,417
Not Reported 8A-1 10.02 Housekeeping - Fringe Benefits 0 40,296 40,296
Not Reported 8A-1 10.04 Housekeeping - Other - Nonlabor 0 39,022 39,022
3 10.1(4) 60 14 8A-1 60.00 Laundry and Linen $118,200 ($118,200) $0
Not Reported 8A-1 60.04 Laundry and Linen - Other - Nonlabor 0 118,200 118,200
4 10.1(4) 65 14 8A-1 65.00 Dietary $354,407 ($354,407) $0

Not Reported 8A-1 65.01 Dietary - Salaries and Wages 0 152,727 152,727
Not Reported 8A-1 65.02 Dietary - Fringe Benefits 0 51,536 51,536
Not Reported 8A-1 65.04 Dietary - Other - Nonlabor 0 150,144 150,144
5 10.1(4) 105 14 8A-1 105.00 Skilled Nursing Care $1,641,591 ($1,641,591) $0
Not Reported 8A-1 105.01 Skilled Nursing Care - Salaries and Wages 0 1,173,925 1,173,925
Not Reported 8A-1 105.02 Skilled Nursing Care - Fringe Benefits 0 396,128 396,128
Not Reported 8A-1 105.04 Skilled Nursing Care - Other - Nonlabor 0 71,538 71,538
6 10.1(4) 155 14 8A-1 155.00 Social Services $41,352 ($41,352) $0
Not Reported 8A-1 155.01 Social Services - Salaries and Wages 0 17,850 17,850
Not Reported 8A-1 155.02 Social Services - Fringe Benefits 0 6,023 6,023
Not Reported 8A-1 155.04 Social Services - Other - Nonlabor 0 17,479 17,479
7 10.1(4) 160 14 8A-1 160.00 Activities $26,953 ($26,953) $0
Not Reported 8A-1 160.01 Activities - Salaries and Wages 0 17,850 17,850
Not Reported 8A-1 160.02 Activities - Fringe Benefits 0 6,023 6,023
Not Reported 8A-1 160.04 Activities - Other - Nonlabor 0 3,080 3,080
-Continued on next page-
*Balance carried forward from prior/to subsequent adjustments Page 1
Adjustments
VILLA SCALABRINI JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC90058F
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
This is trial version
www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
17
MC530
Adj. Page or As Increase As

No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments
VILLA SCALABRINI JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC90058F
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT
-Continued from previous page-
8 10.1(4) 165 14 8A-1 165.00 Administration $521,271 ($521,271) $0
Not Reported 8A-1 165.01 Administration - Salaries and Wages 0 264,375 264,375 *
Not Reported 8A-1 165.02 Administration - Fringe Benefits 0 89,209 89,209 *
Not Reported 8A-1 165.06 Administration - Medical Records - Other - Nonlabor 0 793 793
Not Reported 8A-1 165.11 Administration - Other - Nonlabor 0 166,894 166,894 *
9 10.1(4) 170 14 8A-1 170.00 Inservice Education - Nursing $37,800 ($37,800) $0
Not Reported 8A-1 170.01 Inservice Education - Nursing - Salaries and Wages 0 27,373 27,373
Not Reported 8A-1 170.02 Inservice Education - Nursing - Fringe Benefits 0 9,237 9,237
Not Reported 8A-1 170.04 Inservice Education - Nursing - Other - Nonlabor 0 1,190 1,190
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
17
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments

VILLA SCALABRINI JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC90058F
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
RECLASSIFICATIONS OF REPORTED COSTS
10 Not Reported 8A-2 165.07 Administration - Facility License Fees $0 $14,654 $14,654
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 166,894 (14,654) 152,240 *
To reclassify facility 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-2 165.08 Administration - Liability Insurance $0 $5,710 $5,710
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 152,240 (5,710) 146,530 *
To reclassify professional liability insurance expense to the appropriate
cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
12 Not Reported 8A-2 5.04 Plant Operations and Maintenance - Other - Nonlabor * $247,759 ($6,687) $241,072 *
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 146,530 6,687 153,217 *
To reclassify telephone expenses 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
17
MC530
Adj. Page or As Increase As

No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments
VILLA SCALABRINI JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC90058F
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
ADJUSTMENTS TO REPORTED COSTS
13 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $264,375 ($3,780) $260,595
Not Reported 8A-2 165.02 Administration - Fringe Benefits * 89,209 (872) 88,337
To adjust administrator's compensation based on the department survey.
42 CFR 413.102
CMS Pub. 15-1, Sections 901, 902.3, 904 and 1005
SPA 05-005, Section (III)(J) / W&I Code, Section 14126.023(f)
14 10.1(4) 15 14 8A-2 15.00 Depreciation - Buildings and Improvements ($104,778) $147,090 $42,312
10.1(4) 25 14 8A-2 25.00 Depreciation - Equipment (16,041) 37,359 21,318
To adjust depreciation expense to agree with the provider's
depreciation schedule.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
15 Not Reported 8A-2 5.04 Plant Operations and Maintenance - Other - Nonlabor * $241,072 ($105,000) $136,072
To eliminate capital related expense for assets that should have been
capitalized.
42 CFR 413.20 and 413.134 / CMS Pub. 15-1, Section 108
16 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $153,217 ($495) $152,722
To eliminate contribution expenses not related to patient care.
42 CFR 413.9(c)(3) / CMS Pub. 15-1, Sections 2102.3 and 2105.7
*Balance carried forward from prior/to subsequent adjustments Page 4
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State of California Department of Health Care Services

Provider Name Fiscal Period Provider Number
17
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments
VILLA SCALABRINI JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC90058F
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
ADJUSTMENT TO REPORTED STATISTICS
17 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 439 439
Not Reported 7 10.00 Housekeeping 02222
Not Reported 7 60.00 Laundry and Linen 02929
Not Reported 7 65.00 Dietary 0 1,076 1,076
11.1(1 of 3) 10 2 7 75.00 Patient Supplies 0 253 253
11.1(1 of 3) 15 2 7 80.00 Physical Therapy 0 348 348
11.1(1 of 3) 40 2 7 105.00 Skilled Nursing Care 11,762 (4,808) 6,954
Not Reported 7 155.00 Social Services 0 902 902
Not Reported 7 160.00 Activities 0 741 741
Not Reported 7 165.00 Administration 0 517 517
Not Reported 7 165.00 Medical Records 0 105 105
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 11,762 (376) 11,386
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 11,762 (815) 10,947
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 11,762 (837) 10,925
To adjust square footage to agree with the audited totals for the fiscal
year ended December 31, 2007.
42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306
Page 5

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