REPORT ON THE COST REPORT REVIEW CENTINELA HOSPITAL MEDICAL CENTER INGLEWOOD, CALIFORNIA PROVIDER NUMBER: HSC30240H NATIONAL PROVIDER IDENTIFIERS: 1336328244 AND 1619936440 FISCAL PERIOD FEBRUARY 1, 2008 TO DECEMBER 31, 2008_part3 docx

STATE OF CALIFORNIA CONTRACT SCH 6

Provider Name: Fiscal Period Ended:
CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008
Provider No:
HSC30240H
ANCILLARY CHARGES
37.00 Operating Room $ 13,705,319 $ (2,835,092) $ 10,870,227
38.00 Recovery Room 0
39.00 Delivery Room and Labor Room 6,870,523 (4,061,823) 2,808,700
40.00 Anesthesiology 5,495,246 (1,913,076) 3,582,170
41.00 Radiology - Diagnostic 4,265,489 (66,140) 4,199,349
41.01 CAT Scan 7,081,545 (1,336,602) 5,744,943
41.02 Ultra Sound 2,747,636 (1,252,158) 1,495,478
41.03 Magnetic Resonance Imaging (MRI) 1,892,411 (516,680) 1,375,731
42.00 Radiology - Therapeutic 2,232,044 (829,163) 1,402,881
43.00 Radioisotope 0
44.00 Laboratory 34,634,380 (5,417,790) 29,216,590
44.01 Pathological Lab 344,646 (183,694) 160,952
46.00 Whole Blood 0
47.00 Blood Storing and Processing 615,525 (115,014) 500,511
49.00 Respiratory Therapy 13,272,773 (6,193,970) 7,078,803
50.00 Physical Therapy 653,702 (62,408) 591,294
51.00 Occupational Therapy 264,573 (83,824) 180,749
52.00 Speech Pathology 59,524 1,527 61,051
53.00 Electrocardiology 6,603,600 (2,697,042) 3,906,558
53.01 Cardiology 1,808,185 190,234 1,998,419
53.02
Cardiac Rehab 1,135,682 (1,135,682) 0
54.00 Electroencephalography 290,744 627,118 917,862
55.00 Medical Supplies Charged to Patients 36,458,083 (2,295,534) 34,162,549

56.00 Drugs Charged to Patients 61,362,782 (15,859,150) 45,503,632
57.00 Renal Dialysis 4,321,788 (362,016) 3,959,772
59.00 Lithotripsy 0
59.01 Pain Management 0
59.02 Rehab Nuero 0
60.00 Clinic 0
60.01 Other Clinic Services 0
61.00 Emergency 11,175,874 (2,901,576) 8,274,298
62.00 Observation Beds 0
71.00 0
82.00 0
83.00 0
84.00 0
85.00 0
86.00 0

TOTAL MEDI-CAL ANCILLARY CHARGES $ 217,292,074 $ (49,299,555) $ 167,992,519
(To Contract Sch 5)
ADJUSTMENTS TO MEDI-CAL CHARGES
(Adj 9)
AUDITEDADJUSTMENTSREPORTED
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STATE OF CALIFORNIA CONTRACT SCH 7
Provider Name: Fiscal Period Ended:
CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008
Provider No:
HSC30240H
PROFESSIONAL
SERVICE

COST CENTERS
40.00 Anesthesiology $ 0 $ 0 0.000000 $ $ 0
41.00 Radiology - Diagnostic 0 0 0.000000 0
43.00 Radioisotope 0 0 0.000000 0
44.00 Laboratory 0 0 0.000000 0
53.00 Electrocardiology 0 0 0.000000 0
54.00 Electroencephalography 0 0 0.000000 0
61.00 Emergency 0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0

0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
TOTAL $ 0 $ 0 $ 0 $ 0
(To Contract Sch 3)
(Adj )(Adj ) (Adj )
PHYSICIAN'S REMUNERATION
TO CHARGES
MEDI-CAL
CHARGES
MEDI-CAL
COSTREMUNERATION
COMPUTATION OF PROFESSIONAL
COMPONENT OF HOSPITAL BASED
TO ALL PATIENTS
RATIO OF
REMUNERATION
TOTAL CHARGES HBP
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STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period Ended:
CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008

NET EXP FOR
OLD CAPITAL
OLD
NEW CAPITAL
NEW
TRIAL BALANCE COST ALLOC BLDG & MOVABLE BLDG & MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST
0.00 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07
COMPUTATION OF COST ALLOCATION (W/S B)
GENERAL SERVICE COST CENTER
1.00
Old Cap Rel Costs-Bldg & Fixtures
0
2.00
Old Cap Rel Costs-Movable Equipmen
0
0
3.00
New Cap Rel Costs-Bldg & Fixtures
8,936,596
0
0
4.00
New Cap Rel Costs-Movable Equipme
4,845,922
0
0
0
4.01

0
0
0
0
0
4.02

0
0
0
0
0
0
4.03

0
0
0
0
0
0
0
4.04

0
0
0
0
0
0

0
0
4.05

0
0
0
0
0
0
0
0
0
4.06

0
0
0
0
0
0
0
0
0
0
4.07

0
0
0

0
0
0
0
0
0
0
0
4.08

0
0
0
0
0
0
0
0
0
0
0
0
5.00
Employee Benefits
874,680
0
0
65,816
35,689
0

0
0
0
0
0
0
6.01
Non-Patient Telephones
0
0
0
0
0
0
0
0
0
0
0
0
6.02
Data Processing
0
0
0
0
0
0
0
0

0
0
0
0
6.03
Purchasing/Receiving
0
0
0
0
0
0
0
0
0
0
0
0
6.04
Patient Admitting
0
0
0
0
0
0
0
0
0
0

0
0
6.05
Patient Business Office
0
0
0
0
0
0
0
0
0
0
0
0
6.06

0
0
0
0
0
0
0
0
0
0
0
0

6.07

0
0
0
0
0
0
0
0
0
0
0
0
6.08

0
0
0
0
0
0
0
0
0
0
0
0
6.00
Administrative and General

28,104,432
0
0
603,286
327,136
0
0
0
0
0
0
0
7.00
Maintenance and Repairs
6,773,264
0
0
280,130
151,902
0
0
0
0
0
0
0
8.00
Operation of Plant
2,968,824
0

0
1,242,485
673,745
0
0
0
0
0
0
0
9.00
Laundry and Linen Service
1,160,013
0
0
61,168
33,169
0
0
0
0
0
0
0
10.00
Housekeeping
4,097,116
0
0
40,391

21,902
0
0
0
0
0
0
0
11.00
Dietary
1,334,732
0
0
169,104
91,698
0
0
0
0
0
0
0
12.00
Cafeteria
0
0
0
33,645
18,244
0

0
0
0
0
0
0
13.00
Maintenance of Personnel
0
0
0
0
0
0
0
0
0
0
0
0
14.00
Nursing Administration
1,506,128
0
0
24,263
13,157
0
0
0

0
0
0
0
15.00 Central Services & Supply 380,76200000000000
16.00 Pharmacy 4,936,55900000000000
17.00 Medical Records and Library 4,091,346 0 0 229,024 124,1900000000
18.00
Social Service
1,975
0
0
43,339
23,501
0
0
0
0
0
0
0
19.00

0
0
0
0
0
0
0

0
0
0
0
0
19.02

0
0
0
0
0
0
0
0
0
0
0
0
19.03

0
0
0
0
0
0
0
0
0

0
0
0
20.00 000000000000
21.00 Nursing School 000000000000
22.00
Intern & Res Service-Salary & Fringes
0
0
0
0
0
0
0
0
0
0
0
0
23.00Intern & Res Other Program 000000000000
24.00Paramedical Ed Program 000000000000
INPATIENT ROUTINE COST CENTERS
25.00
Adults & Pediatrics (Gen Routine)
38,354,684
0
0
2,645,004
1,434,269
0

0
0
0
0
0
0
26.00 Intensive Care Unit 12,943,357 0 0 339,852 184,2870000000
27.00 Coronary Care Unit 000000000000
28.00 000000000000
29.00Surgical Intensive Care 000000000000
30.00 Neonatal Intensive Care Unit 3,026,401 0 0 20,011 10,8510000000
31.00 Subprovider II 000000000000
32.00 000000000000
33.00 Nursery 733,229 0 0 60,969 33,0610000000
34.00
Medicare Certified Nursing Facility
0
0
0
0
0
0
0
0
0
0
0
0
35.00
Distinct Part Nursing Facility

0
0
0
0
0
0
0
0
0
0
0
0
36.00
Adult Subacute Care Unit
0
0
0
0
0
0
0
0
0
0
0
0
36.01
Subacute Care Unit II
0
0

0
0
0
0
0
0
0
0
0
0
36.02 Transitional Care Unit 000000000000
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STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period Ended:
CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008
NET EXP FOR
OLD CAPITAL
OLD
NEW CAPITAL
NEW
TRIAL BALANCE COST ALLOC BLDG & MOVABLE BLDG & MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST
0.00 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07
COMPUTATION OF COST ALLOCATION (W/S B)
ANCILLARY COST CENTERS
37.00
Operating Room
12,146,523
0

0
834,606
452,570
0
0
0
0
0
0
0
38.00
Recovery Room
0
0
0
0
0
0
0
0
0
0
0
0
39.00
Delivery Room and Labor Room
3,271,283
0
0
155,612

84,381
0
0
0
0
0
0
0
40.00
Anesthesiology
224,325
0
0
6,491
3,520
0
0
0
0
0
0
0
41.00 Radiology - Diagnostic 4,260,722 0 0 289,965 157,2350000000
41.01 CAT Scan 949,832 0 0 36,508 19,7970000000
41.02
Ultra Sound
925,117
0
0
59,977

32,523
0
0
0
0
0
0
0
41.03
Magnetic Resonance Imaging (MRI)
755,004
0
0
21,429
11,620
0
0
0
0
0
0
0
42.00 Radiology - Therapeutic 839,017 0 0 34,467 18,6900000000
43.00Radioisotope 000000000000
44.00 Laboratory 7,785,099 0 0 163,520 88,6700000000
44.01 Pathological Lab 460,375 0 0 38,860 21,0720000000
46.00Whole Blood 000000000000
47.00 Blood Storing and Processing 2,212,743 0 0 25,142 13,6330000000
49.00 Respiratory Therapy 5,880,235 0 0 71,060 38,5330000000
50.00

Physical Therapy
1,488,686
0
0
14,739
7,992
0
0
0
0
0
0
0
51.00
Occupational Therapy
515,585
0
0
6,916
3,750
0
0
0
0
0
0
0
52.00 Speech Pathology 228,361 0 0 10,204 5,5330000000
53.00 Electrocardiology 1,420,107 0 0 48,016 26,0370000000
53.01 Cardiology 6,623,053 0 0 298,525 161,8770000000

53.02 Cardiac Rehab 125,28900000000000
54.00 Electroencephalography 210,50500000000000
55.00
Medical Supplies Charged to Patients
322,242
0
0
184,070
99,813
0
0
0
0
0
0
0
56.00
Drugs Charged to Patients
7,479,233
0
0
122,959
66,675
0
0
0
0
0
0
0

57.00 Renal Dialysis 1,817,43300000000000
59.00Lithotripsy 14,00000000000000
59.01 Pain Management 53,62200000000000
59.02 Rehab Nuero 51,01200000000000
60.00Clinic 000000000000
60.01
Other Clinic Services
0
0
0
0
0
0
0
0
0
0
0
0
61.00
Emergency
10,726,872
0
0
322,590
174,926
0
0
0
0

0
0
0
62.00Observation Beds 000000000000
71.00 000000000000
82.00 000000000000
83.00 000000000000
84.00

0
0
0
0
0
0
0
0
0
0
0
0
85.00

0
0
0
0
0
0
0

0
0
0
0
0
86.00

0
0
0
0
0
0
0
0
0
0
0
0
NONREIMBURSABLE COST CENTERS
96.00 Gift, Flower, Coffee Shop & Canteen 000000000000
97.00Research 000000000000
98.00Physicians' Private Office 000000000000
99.00 Nonpaid Workers 000000000000
99.01

0
0
0
0

0
0
0
0
0
0
0
0
99.02

0
0
0
0
0
0
0
0
0
0
0
0
99.03 000000000000
99.04 000000000000
99.05 000000000000
100.00 Cent Transport 54,17900000000000
100.01 Public Relations 1,286,455 0 0 8,022 4,3500000000
100.02 Mob I 1,040,89300000000000
100.03

0
0
0
0
0
0
0
0
0
0
0
0
100.07 Unoccupied Space 0 0 0 324,432 175,9250000000
TOTAL
198,237,822
0
0
8,936,596
4,845,922
0
0
0
0
0
0
0
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STATE OF CALIFORNIA
Provider Name:

CENTINELA HOSPITAL MEDICAL CENTER
TRIAL BALANCE
EXPENSES
GENERAL SERVICE COST CENTER
1.00
Old Cap Rel Costs-Bldg & Fixtures
2.00
Old Cap Rel Costs-Movable Equipmen
3.00
New Cap Rel Costs-Bldg & Fixtures
4.00
New Cap Rel Costs-Movable Equipme
4.01

4.02

4.03

4.04

4.05

4.06

4.07

4.08

5.00
Employee Benefits

6.01
Non-Patient Telephones
6.02
Data Processing
6.03
Purchasing/Receiving
6.04
Patient Admitting
6.05
Patient Business Office
6.06

6.07

6.08

6.00
Administrative and General
7.00
Maintenance and Repairs
8.00
Operation of Plant
9.00
Laundry and Linen Service
10.00
Housekeeping
11.00
Dietary
12.00
Cafeteria

13.00
Maintenance of Personnel
14.00
Nursing Administration
15.00 Central Services & Supply
16.00 Pharmacy
17.00 Medical Records and Library
18.00
Social Service
19.00

19.02

19.03

20.00
21.00 Nursing School
22.00
Intern & Res Service-Salary & Fringes
23.00 Intern & Res Other Program
24.00 Paramedical Ed Program
INPATIENT ROUTINE COST CENTER
25.00
Adults & Pediatrics (Gen Routine)
26.00 Intensive Care Unit
27.00 Coronary Care Unit
28.00
29.00 Surgical Intensive Care
30.00 Neonatal Intensive Care Unit
31.00 Subprovider II

32.00
33.00 Nursery
34.00
Medicare Certified Nursing Facility
35.00
Distinct Part Nursing Facility
36.00
Adult Subacute Care Unit
36.01
Subacute Care Unit II
36.02 Transitional Care Unit
SCHEDULE 8.1
Fiscal Period Ended:
DECEMBER 31, 2008
ADMINIS-
ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE &
COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL
4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00
COMPUTATION OF COST ALLOCATION (W/S B)
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
64,879
0
0
0
0
0
0
0
0
29,099,733
0
20,566
0
0
0
0
0
0
0
0
7,225,862
1,243,189
0
0
0

0
0
0
0
0
0
0
4,885,054
840,460
0
1,410
0
0
0
0
0
0
0
0
1,255,759
216,050
0
1,232
0
0
0
0
0
0
0

0
4,160,641
715,827
0
559
0
0
0
0
0
0
0
0
1,596,092
274,603
0
0
0
0
0
0
0
0
0
0
51,889
8,927
0
0
0

0
0
0
0
0
0
0
0
0
0
14,431
0
0
0
0
0
0
0
0
1,557,979
268,046
05,95700000000386,71966,534
048,863000000004,985,422857,728
026,758000000004,471,318769,278
0
0
0
0
0
0

0
0
0
0
68,815
11,839
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0000000000 00
0000000000 00
0
0
0
0
0
0
0
0
0
0
0
0
0000000000 00
0000000000 00
0
356,797

0
0
0
0
0
0
0
0
42,790,753
7,362,029
0 118,9210000000013,586,4162,337,505
0000000000 00
0000000000 00
0000000000 00
027,173000000003,084,437530,669
0000000000 00
0000000000 00
05,43000000000832,689143,262
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0000000000 00
This is trial version
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STATE OF CALIFORNIA
Provider Name:
CENTINELA HOSPITAL MEDICAL CENTER
TRIAL BALANCE
EXPENSES
ANCILLARY COST CENTERS
37.00
Operating Room
38.00
Recovery Room
39.00
Delivery Room and Labor Room
40.00
Anesthesiology
41.00 Radiology - Diagnostic
41.01 CAT Scan
41.02
Ultra Sound
41.03
Magnetic Resonance Imaging (MRI)
42.00 Radiology - Therapeutic

43.00 Radioisotope
44.00 Laboratory
44.01 Pathological Lab
46.00 Whole Blood
47.00 Blood Storing and Processing
49.00 Respiratory Therapy
50.00
Physical Therapy
51.00
Occupational Therapy
52.00 Speech Pathology
53.00 Electrocardiology
53.01 Cardiology
53.02 Cardiac Rehab
54.00 Electroencephalography
55.00
Medical Supplies Charged to Patients
56.00
Drugs Charged to Patients
57.00 Renal Dialysis
59.00 Lithotripsy
59.01 Pain Management
59.02 Rehab Nuero
60.00 Clinic
60.01
Other Clinic Services
61.00
Emergency
62.00 Observation Beds
71.00

82.00
83.00
84.00

85.00

86.00

NONREIMBURSABLE COST CENTER
96.00 Gift, Flower, Coffee Shop & Canteen
97.00 Research
98.00 Physicians' Private Office
99.00 Nonpaid Workers
99.01

99.02

99.03
99.04
99.05
100.00 Cent Transport
100.01 Public Relations
100.02 Mob I
100.03

100.07 Unoccupied Space
TOTAL
SCHEDULE 8.1
Fiscal Period Ended:
DECEMBER 31, 2008

ADMINIS-
ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE &
COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL
4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00
COMPUTATION OF COST ALLOCATION (W/S B)
0
48,943
0
0
0
0
0
0
0
0
13,482,643
2,319,651
0
0
0
0
0
0
0
0
0
0
0
0
0

25,346
0
0
0
0
0
0
0
0
3,536,622
608,466
0
594
0
0
0
0
0
0
0
0
234,930
40,419
029,265000000004,737,187815,020
08,275000000001,014,411174,527
0
8,040
0
0
0

0
0
0
0
0
1,025,657
176,461
0
4,232
0
0
0
0
0
0
0
0
792,284
136,310
04,54300000000896,717154,278
0000000000 00
051,982000000008,089,2701,391,736
02,11800000000522,42689,882
0000000000 00
00000000002,251,518387,367
050,109000000006,039,9371,039,154
0
16,921
0
0

0
0
0
0
0
0
1,528,339
262,946
0
6,355
0
0
0
0
0
0
0
0
532,606
91,633
02,50800000000246,60642,428
09,941000000001,504,101258,776
09,558000000007,093,0141,220,333
01,29600000000126,58521,779
01,56100000000212,06636,485
0
0
0
0
0

0
0
0
0
0
606,125
104,282
0
0
0
0
0
0
0
0
0
0
7,668,867
1,319,407
00000000001,817,433312,684
000000000014,0002,409
06020000000054,2249,329
05990000000051,6118,879
0000000000 00
0
0
0
0
0
0

0
0
0
0
0
0
0
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0
0
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11,224,388
1,931,124
0000000000 00
0000000000 00
0000000000 00
0000000000 00
0
0
0
0
0
0
0
0

0
0
0
0
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0000000000 00
0000000000 00
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0
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0
0000000000 00
0000000000 00
0000000000 00
04220000000054,6019,394

00000000001,298,826223,459
00000000001,040,893179,083
0
0
0
0
0
0
0
0
0
0
0
0
0000000000500,35786,085
0
976,185
0
0
0
0
0
0
0
0
198,237,822
29,099,733
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA

Provider Name:
CENTINELA HOSPITAL MEDICAL CENTER
TRIAL BALANCE
EXPENSES
GENERAL SERVICE COST CENTER
1.00
Old Cap Rel Costs-Bldg & Fixtures
2.00
Old Cap Rel Costs-Movable Equipmen
3.00
New Cap Rel Costs-Bldg & Fixtures
4.00
New Cap Rel Costs-Movable Equipme
4.01

4.02

4.03

4.04

4.05

4.06

4.07

4.08

5.00

Employee Benefits
6.01
Non-Patient Telephones
6.02
Data Processing
6.03
Purchasing/Receiving
6.04
Patient Admitting
6.05
Patient Business Office
6.06

6.07

6.08

6.00
Administrative and General
7.00
Maintenance and Repairs
8.00
Operation of Plant
9.00
Laundry and Linen Service
10.00
Housekeeping
11.00
Dietary
12.00

Cafeteria
13.00
Maintenance of Personnel
14.00
Nursing Administration
15.00 Central Services & Supply
16.00 Pharmacy
17.00 Medical Records and Library
18.00
Social Service
19.00

19.02

19.03

20.00
21.00 Nursing School
22.00
Intern & Res Service-Salary & Fringes
23.00 Intern & Res Other Program
24.00 Paramedical Ed Program
INPATIENT ROUTINE COST CENTER
25.00
Adults & Pediatrics (Gen Routine)
26.00 Intensive Care Unit
27.00 Coronary Care Unit
28.00
29.00 Surgical Intensive Care
30.00 Neonatal Intensive Care Unit

31.00 Subprovider II
32.00
33.00 Nursery
34.00
Medicare Certified Nursing Facility
35.00
Distinct Part Nursing Facility
36.00
Adult Subacute Care Unit
36.01
Subacute Care Unit II
36.02 Transitional Care Unit
SCHEDULE 8.2
Fiscal Period Ended:
DECEMBER 31, 2008
CENTRAL MEDICAL
MAINT & OPER LAUNDRY & MAINT OF NURSING SERVICE RECORDS SOCIAL
REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN & SUPPLY PHARMACY & LIBRARY SERVICE
7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00
COMPUTATION OF COST ALLOCATION (W/S B)
1,317,415
64,856
63,871
42,827
42,176
0
179,302
176,576
0
126,293

35,674
35,132
0
25,127
0
0
0
0
0
0
0
25,726
25,335
0
18,120
0
1,751
0
0 0 14,696 0 0 1,605 0 1,983
000000001,075
242,836 239,145 0 171,044 0 7,152 0 779 12 0
45,952
45,254
0
32,367
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
000000000000
000000000000
0
0
0
0
0
0
0
0
0
0
0
0
000000000000
000000000000
2,804,514
2,761,884
913,222
1,975,384
2,142,825
59,110

0
1,086,116
22,980
118,198
1,149,285
161,494
360,347 354,869 149,424 253,813 139,634 15,471 0 281,957 9,305 34,734 259,197 24,068
000000000000
000000000000
000000000000
21,218 20,896 0 14,945 0 3,795 0 75,733 2,973 7,877 82,520 7,250
000000000000
000000000000
64,646 63,663 20,330 45,534 0 876 0 18,802 41 0 30,139 11,415
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
000000000000
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
CENTINELA HOSPITAL MEDICAL CENTER
TRIAL BALANCE
EXPENSES
ANCILLARY COST CENTERS
37.00 Operating Room
38.00 Recovery Room
39.00 Delivery Room and Labor Room
40.00 Anesthesiology
41.00 Radiology - Diagnostic
41.01 CAT Scan
41.02 Ultra Sound
41.03 Magnetic Resonance Imaging (MRI)
42.00 Radiology - Therapeutic
43.00 Radioisotope
44.00 Laboratory
44.01 Pathological Lab
46.00 Whole Blood
47.00 Blood Storing and Processing
49.00 Respiratory Therapy
50.00 Physical Therapy
51.00 Occupational Therapy
52.00 Speech Pathology
53.00 Electrocardiology

53.01 Cardiology
53.02 Cardiac Rehab
54.00 Electroencephalography
55.00 Medical Supplies Charged to Patients
56.00 Drugs Charged to Patients
57.00 Renal Dialysis
59.00 Lithotripsy
59.01 Pain Management
59.02 Rehab Nuero
60.00 Clinic
60.01 Other Clinic Services
61.00 Emergency
62.00 Observation Beds
71.00
82.00
83.00
84.00
85.00
86.00
NONREIMBURSABLE COST CENTERS
96.00 Gift, Flower, Coffee Shop & Canteen
97.00 Research
98.00 Physicians' Private Office
99.00 Nonpaid Workers
99.01
99.02
99.03
99.04
99.05
100.00 Cent Transport

100.01 Public Relations
100.02 Mob I
100.03
100.07 Unoccupied Space
TOTAL
SCHEDULE 8.2
Fiscal Period Ended:
DECEMBER 31, 2008
CENTRAL MEDICAL
MAINT & OPER LAUNDRY & MAINT OF NURSING SERVICE RECORDS SOCIAL
REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN & SUPPLY PHARMACY & LIBRARY SERVICE
7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00
COMPUTATION OF COST ALLOCATION (W/S B)
884,938 871,487 90,607 623,314 0 7,297 0 84,417 145,027 15,543 409,267 0
000000000000
164,996 162,488 46,591 116,217 22,356 4,962 0 68,503 6,207 10,185 34,178 0
6,882 6,778 0 4,848 0 292 0 1,735 2,975 4,614 85,030 0
307,452 302,778 68,667 216,556 0 4,524 0 11,960 28,153 664 123,961 0
38,709 38,121 0 27,265 0 1,168 0 326 397 426 219,121 0
63,594 62,627 0 44,793 0 1,459 0 76 1,046 376 62,382 0
22,721 22,375 0 16,004 0 584 0 0 124 0 50,248 0
36,546 35,990 0 25,741 0 584 0 134 3,479 132,084 43,591 0
000000040,2090000
173,381 170,746 0 122,123 0 10,071 0 0 59,454 4,527 621,062 0
41,204 40,578 0 29,022 0 584 0 0 5,093 485 4,618 0
000000000000
26,65826,253918,777000059,2915,4359,7740
75,345 74,200 1,035 53,070 0 8,611 0 0 11,407 11,861 205,523 0
15,628 15,390 1,394 11,008 0 1,751 0 3,982 21 0 17,697 0
7,333 7,222 0 5,165 0 584 0 324 37 0 6,081 0

10,81910,65507,621029200101,5490
50,911 50,138 22,902 35,860 0 1,459 0 9,709 7,394 0 154,275 0
316,528 311,717 0 222,949 0 1,314 0 8,442 87,800 6,376 75,824 0
0000014601510035,7960
00000146076240216,0230
195,170 192,204 0 137,47000005,476646893,762 0
130,374 128,392 0 91,830 0 6,7140005,439,634 921,581 0
0000000016068,0090
00000000007280
00000000221442,0650
000000000020
000000000000
000000000000
342,044 336,845 271,660 240,922 48,051 14,303 0 201,544 11,439 50,395 328,275 0
000000000000
000000000000
000000000000
000000000000
000000000000
000000000000
000000000000
000000000000
000000000000
000000000000
000000000000
000000000000
000000000000
000000000000
000000000000
000000000000

00000146000000
8,5058,37605,991000055000
000000000000
000000000000
343,997 338,769 0 242,29800000000
8,469,051
7,042,929 1,600,536 4,961,471 2,352,866 156,750 0 1,896,958 471,538 5,844,225 5,901,562 204,228
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
CENTINELA HOSPITAL MEDICAL CENTER
TRIAL BALANCE
EXPENSES
GENERAL SERVICE COST CENTER
1.00
Old Cap Rel Costs-Bldg & Fixtures
2.00
Old Cap Rel Costs-Movable Equipmen
3.00
New Cap Rel Costs-Bldg & Fixtures
4.00
New Cap Rel Costs-Movable Equipme
4.01

4.02

4.03

4.04

4.05

4.06

4.07

4.08

5.00
Employee Benefits
6.01
Non-Patient Telephones
6.02
Data Processing
6.03
Purchasing/Receiving
6.04
Patient Admitting
6.05
Patient Business Office
6.06

6.07

6.08

6.00
Administrative and General
7.00

Maintenance and Repairs
8.00
Operation of Plant
9.00
Laundry and Linen Service
10.00
Housekeeping
11.00
Dietary
12.00
Cafeteria
13.00
Maintenance of Personnel
14.00
Nursing Administration
15.00 Central Services & Supply
16.00 Pharmacy
17.00 Medical Records and Library
18.00
Social Service
19.00

19.02

19.03

20.00
21.00 Nursing School
22.00
Intern & Res Service-Salary & Fringes

23.00 Intern & Res Other Program
24.00 Paramedical Ed Program
INPATIENT ROUTINE COST CENTER
25.00
Adults & Pediatrics (Gen Routine)
26.00 Intensive Care Unit
27.00 Coronary Care Unit
28.00
29.00 Surgical Intensive Care
30.00 Neonatal Intensive Care Unit
31.00 Subprovider II
32.00
33.00 Nursery
34.00
Medicare Certified Nursing Facility
35.00
Distinct Part Nursing Facility
36.00
Adult Subacute Care Unit
36.01
Subacute Care Unit II
36.02 Transitional Care Unit
SCHEDULE 8.3
Fiscal Period Ended:
DECEMBER 31, 2008
POST
NON- INT & RES STEP-DOWN TOTAL
ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY & INT & RES PARAMED SUBTOTAL
ADJUSTMENT
COST

COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT (Adj 1)
19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00
COMPUTATION OF COST ALLOCATION (W/S B)

0
0
0
000
0000
0
0
0
0
0
000000
0000000
0
0
0
0
0
0
0
0
63,347,793
63,347,793
0000000017,806,741 17,806,741
000000000 0
000000000 0
000000000 0

000000003,852,313 3,852,313
000000000 0
000000000 0
000000001,231,396 1,231,396
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
000000000 0
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
CENTINELA HOSPITAL MEDICAL CENTER
TRIAL BALANCE
EXPENSES
ANCILLARY COST CENTERS
37.00 Operating Room
38.00 Recovery Room
39.00 Delivery Room and Labor Room
40.00 Anesthesiology
41.00 Radiology - Diagnostic
41.01 CAT Scan
41.02 Ultra Sound

41.03 Magnetic Resonance Imaging (MRI)
42.00 Radiology - Therapeutic
43.00 Radioisotope
44.00 Laboratory
44.01 Pathological Lab
46.00 Whole Blood
47.00 Blood Storing and Processing
49.00 Respiratory Therapy
50.00 Physical Therapy
51.00 Occupational Therapy
52.00 Speech Pathology
53.00 Electrocardiology
53.01 Cardiology
53.02 Cardiac Rehab
54.00 Electroencephalography
55.00 Medical Supplies Charged to Patients
56.00 Drugs Charged to Patients
57.00 Renal Dialysis
59.00 Lithotripsy
59.01 Pain Management
59.02 Rehab Nuero
60.00 Clinic
60.01 Other Clinic Services
61.00 Emergency
62.00 Observation Beds
71.00
82.00
83.00
84.00
85.00

86.00
NONREIMBURSABLE COST CENTERS
96.00 Gift, Flower, Coffee Shop & Canteen
97.00 Research
98.00 Physicians' Private Office
99.00 Nonpaid Workers
99.01
99.02
99.03
99.04
99.05
100.00 Cent Transport
100.01 Public Relations
100.02 Mob I
100.03
100.07 Unoccupied Space
TOTAL
SCHEDULE 8.3
Fiscal Period Ended:
DECEMBER 31, 2008
POST
NON- INT & RES STEP-DOWN TOTAL
ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY & INT & RES PARAMED SUBTOTAL ADJUSTMENT COST
COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT (Adj 1)
19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00
COMPUTATION OF COST ALLOCATION (W/S B)
0000000018,934,192 18,934,192
000000000 0
000000004,781,770 4,781,770
00000000388,502 388,502

000000006,616,923 6,616,923
000000001,514,471 1,514,471
000000001,438,472 1,438,472
000000001,040,649 1,040,649
000000001,329,144 40,209 1,369,353
0000000040,209(40,209) 0
0000000010,642,370 10,642,370
00000000733,891 733,891
000000000 0
000000002,785,082 2,785,082
000000007,520,142 7,520,142
000000001,858,158 1,858,158
00000000650,986 650,986
00000000319,970 319,970
000000002,095,525 2,095,525
000000009,344,296 184,456 9,528,752
00000000184,456 (184,456) 0
00000000255,057 255,057
000000002,135,134 2,135,134
0000000015,706,800 15,706,800
000000002,198,142 2,198,142
0000000017,136 17,136
0000000065,785 65,785
0000000060,492 60,492
000000000 0
000000000 0
0000000015,000,989 15,000,989
000000000 0
000000000 0
000000000 0

000000000 0
000000000 0
000000000 0
000000000 0
000000000 0
000000000 0
000000000 0
000000000 0
000000000 0
000000000 0
000000000 0
000000000 0
000000000 0
0000000064,141 64,141
000000001,545,213 1,545,213
000000001,219,976 1,219,976
000000000 0
000000001,511,506 1,511,506
0
0 0 0 0 0 0 0 198,237,822 0 198,237,822
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA SCHEDULE 9
Provider Name: Fiscal Period Ended:
CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008
OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT
& FIXTURES EQUIP & FIXTURES EQUIP
(SQ FT) (SQ FT) (SQ FT) (SQ FT)
1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08
STATISTICS FOR COST ALLOCATION (W/S B-1)

GENERAL SERVICE COST CENTERS
1.00
Old Cap Rel Costs-Bldg & Fixtures
2.00
Old Cap Rel Costs-Movable Equipment
3.00
New Cap Rel Costs-Bldg & Fixtures
4.00
New Cap Rel Costs-Movable Equipment
4.01

4.02

4.03

4.04

4.05

4.06

4.07

4.08

5.00
Employee Benefits
2,322
2,322
6.01

Non-Patient Telephones
6.02
Data Processing
6.03
Purchasing/Receiving
6.04
Patient Admitting
6.05
Patient Business Office
6.06

6.07

6.08

6.00
Administrative and General
21,284
21,284
7.00
Maintenance and Repairs
9,883
9,883
8.00
Operation of Plant
43,835
43,835
9.00
Laundry and Linen Service
2,158

2,158
10.00
Housekeeping
1,425
1,425
11.00
Dietary
5,966
5,966
12.00
Cafeteria
1,187
1,187
13.00
Maintenance of Personnel
14.00
Nursing Administration
856
856
15.00 Central Services & Supply
16.00 Pharmacy
17.00 Medical Records and Library 8,080 8,080
18.00
Social Service
1,529
1,529
19.00

19.02

19.03

20.00
21.00 Nursing School
22.00
Intern & Res Service-Salary & Fringes
23.00 Intern & Res Other Program
24.00 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS
25.00
Adults & Pediatrics (Gen Routine)
93,316
93,316
26.00 Intensive Care Unit 11,990 11,990
27.00 Coronary Care Unit
28.00
29.00 Surgical Intensive Care
30.00 Neonatal Intensive Care Unit 706 706
31.00 Subprovider II
32.00
33.00 Nursery 2,151 2,151
34.00
Medicare Certified Nursing Facility
35.00
Distinct Part Nursing Facility
36.00
Adult Subacute Care Unit
36.01
Subacute Care Unit II

36.02 Transitional Care Unit
This is trial version
www.adultpdf.com