State of California Fiscal Period JANUARY 1, 2008 THROUGH DECEMBER 31, 2008_part4 doc

State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
26
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
COUNTRY VILLA REDLANDS HEALTHCARE JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT05650J
RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT
14 10.1(4) 65 14 8A-1 65.00 Dietary * $125 ($125) $0
Not Reported 8A-1 65.04 Dietary - Other - Nonlabor * 172,014 125 172,139
To reclassify the provider's adjustment of dietary expense
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 4
This is trial version
www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
26
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
COUNTRY VILLA REDLANDS HEALTHCARE JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT05650J
RECLASSIFICATIONS OF REPORTED COSTS
15 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $244,040 ($36,738) $207,302
Not Reported 8A-2 165.02 Administration - Fringe Benefits * 79,436 (12,275) 67,161
Not Reported 8A-2 165.03 Administration - Medical Records - Salaries and Wages 0 36,738 36,738
Not Reported 8A-2 165.04 Administration - Medical Records - Fringe Benefits 0 12,275 12,275 *
Not Reported 8A-2 165.06 Administration - Medical Records - Other - Nonlabor 0 5,344 5,344
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 714,349 (5,344) 709,005 *
To reclassify medical records salaries, fringe benefits and
other non labor expenses for proper cost determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
16 Not Reported 8A-2 105.03 Skilled Nursing Care - Agency Staff $0 $883 $883
Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 103,975 (883) 103,092 *
To reclassify wound care expense to the appropriate
cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
17 Not Reported 8A-2 65.02 Dietary - Fringe Benefits * $46,006 $4 $46,010
10.1(4) 85 14 8A-2 85.00 Pharmacy 93,207 1,668 94,875
Not Reported 8A-2 105.02 Skilled Nursing Care - Fringe Benefits * 502,570 43 502,613
Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 103,092 (1,727) 101,365 *
Not Reported 8A-2 155.02 Social Services - Fringe Benefits * 12,384 8 12,392
Not Reported 8A-2 165.04 Administration - Medical Records - Fringe Benefits * 12,275 4 12,279
To reclassify the reported expenses to the appropriate cost centers.
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
This is trial version
www.adultpdf.com
State of California Department of Health Care Services

Provider Name Fiscal Period Provider Number
26
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
COUNTRY VILLA REDLANDS HEALTHCARE JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT05650J
RECLASSIFICATIONS OF REPORTED COSTS
18 10.1(4) 100 14 8A-2 100.00 Other Ancillary Services $5,242 $1,561 $6,803
Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 101,365 (1,561) 99,804
To reclassify transportation expense to the appropriate cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
19 Not Reported 8A-2 10.03 Housekeeping - Agency Staff $0 $95,566 $95,566
Not Reported 8A-2 10.04 Housekeeping - Other - Nonlabor * 107,534 (95,566) 11,968 *
To reclassify agency staff expenses 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 60.03 Laundry and Linen - Agency Staff $0 $58,951 $58,951
Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * 73,987 (58,951) 15,036 *
To reclassify agency staff expenses 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 10.04 Housekeeping - Other - Nonlabor * $11,968 $1,477 $13,445
Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * 15,036 (1,477) 13,559
To reconcile the reported housekeeping expense to agree with

the provider's invoices.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
*Balance carried forward from prior/to subsequent adjustments Page 6
This is trial version
www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
26
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
COUNTRY VILLA REDLANDS HEALTHCARE JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT05650J
RECLASSIFICATIONS OF REPORTED COSTS
22 Not Reported 8A-2 165.07 Administration - Facility Licensing Fees $0 $21,938 $21,938
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 709,005 (21,938) 687,067 *
To reclassify the facility licensing fees for proper cost determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
23 Not Reported 8A-2 165.10 Administration - Quality Assurance Fees $0 $237,241 $237,241
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 687,067 (237,241) 449,826 *
To reclassify the Quality Assurance Fees for proper cost
determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
24 Not Reported 8A-2 165.08 Administration - Liability Insurance $0 $22,009 $22,009
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 449,826 (22,009) 427,817 *
To reclassify the liability insurance expense 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 7
This is trial version
www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
26
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
COUNTRY VILLA REDLANDS HEALTHCARE JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT05650J
ADJUSTMENT TO REPORTED COSTS
25 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $427,817 ($246) $427,571
To reconcile the reported liability insurance expense to agree with
the provider's invoices.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300 and 2304
*Balance carried forward from prior/to subsequent adjustments Page 8
This is trial version
www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
26
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
COUNTRY VILLA REDLANDS HEALTHCARE JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT05650J
ADJUSTMENT TO REPORTED STATISTICS
26 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 544 544
Not Reported 7 10.00 Housekeeping 05353
Not Reported 7 60.00 Laundry and Linen 0 426 426
Not Reported 7 65.00 Dietary 0 1,304 1,304
Not Reported 7 155.00 Social Services 0 158 158
Not Reported 7 160.00 Activities 0 1,184 1,184
Not Reported 7 165.00 Administration 0 738 738
Not Reported 7 165.00 Medical Records 0 150 150
Not Reported 7 170.00 Inservice Education - Nursing 0 184 184
11.1(1 of 3) 85 2 7 N/A Total - Square Feet 9,658 4,741 14,399
11.1(1 of 3) 85 2 7 N/A Total - Square Feet 9,658 4,197 13,855
11.1(1 of 3) 85 2 7 N/A Total - Square Feet 9,658 4,144 13,802
To adjust the square footage statistics to agree with the provider's
records.
42 CFR 413.24 and 413.50 / CMS Pub. 15-1, Sections 2304 and 2306
Page 9
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