STATE OF CALIFORNIA SCHEDULE 4B PROGRAM: NONCONTRACT COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST _part4 doc

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STATE OF CALIFORNIA
Provider Name:
SAN FRANCISCO GENERAL HOSPITAL
ANCILLARY COST CENTERS
37.00
Operating Room
39.00
Delivery Room and Labor Room
40.00
Anesthesiology
41.00
Radiology - Diagnostic
43.00
Radioisotope
44.00
Laboratory
44.01
Laboratory Pathology
46.00
Whole Blood
49.00
Respiratory Therapy
50.00
Physical Therapy
51.00
Occupational Therapy
53.00
Electrocardiology
54.00
Electroencephalography
55.00

Medical Supplies Charged to Patients
55.01
Implantable Devices
56.00
Drugs Charged to Patients
57.00
Renal Dialysis
59.00
Other Ancillary Services
59.01

59.02

59.03

59.04

59.05

59.06

59.07

59.08

59.09

59.10

60.00

Clinic
61.00
Emergency
61.01
Psych Emergency
62.00
Observation Beds
63.60
Adult Medical Center FQHC I
63.61
Women's Health Center FQHC II
63.62
Family Health Center FQHC III
63.63
Children's Health Center FQHC IV
63.64
Urgent Care FQHC V
64.00
Home Program Dialysis

NONREIMBURSABLE COST CENTERS
96.00
Gift, Flower, Coffee Shop and Canteen
96.01
Other Than Hospital
98.00

99.00

99.01

99.02

99.03

99.04

99.05

99.06

99.07

99.08

99.09

99.10

TOTAL
COST TO BE ALLOCATED
UNIT COST MULTIPLIER - SCH 8
STATISTICS FOR COST ALLOCATION (W/S B-1) Fiscal Period Ended: JUNE 30, 2009 SCHEDULE 9.3
HOUSEKEEP DIETARY CAFETERIA
NURSING ADM
CTRL SERV PHARMACY MED REC SOC SERV I&R-SAL
(MEALS (NURSING SUPPLIES (COSTS (GROSS (GROSS & FRINGES
(SQ FT) SERVED) (FTE) FTE) (COST REQ) REQUIS) CHARGES) CHARGES) (ASG TIME)
10.01 11.00 12.00 14.00 15.00 16.00 17.00 18.00 22.00
(Adj 13) (Adj 14) (Adjs 15, 16) (Adj 17) (Adj 18) (Adj 18) (Adj 19)

23,401
10,587
6,902
8,872,693
36,969
77,824,637
77,824,637
7,804
5,430
2,603
2,400
90,655
10,194
4,642,051
4,642,051
5,632
3,218
304,082
440,663
55,955,476
55,955,476
4,976
32,299
9,551
242
1,092,079
6,293
106,236,045
106,236,045
4,428

26,515
15,407
67,914
152
124,559,091
124,559,091
24,348
1,805
48,788
11,664,392
11,664,392
4,246
5,017,971
5,017,971
1,909
4,264
163,625
21,779,813
21,779,813
6,880
3,362
41,494
7
8,575,913
8,575,913
718
506
44,765
3,598,702
3,598,702

7,503
1,418
178
720,158
122,938
12,735,645
12,735,645
195
375
266
236
86,333
86,333
215
2,531,289
58,257,007
58,257,007
4,306,295
8,387,370
8,387,370
3,566
364,050
16,634,382
195,603,755
195,603,755
3,308
2,986
268,468
149
9,880,790

9,880,790
8,029
1,044
555
96,889
1,775
5,262,883
5,262,883
40,537
7,724
2,372
155,461
82,307
19,131,357
19,131,357
46,512
11,352
19,011
13,265
9,097
340,492
21,698
99,660,181
99,660,181
2,954
1,887
24,273
3,049
1,994
5,001

6,395
16,775,979
16,775,979
25,905
9,538
2,778
102,872
3,590,083
42,651,814
42,651,814
6,031
8,269
3,387
2,315
64,163
465,264
13,112,752
13,112,752
4,701
28,796
5,245
1,189
43,511
93,834
13,935,626
13,935,626
5,519
13,969
1,844
1,339

14,983
83,927
9,930,227
9,930,227
3,999
7,192
1,654
1,219
14,874
746
6,905,864
6,905,864
2,380
1,543,286
1,543,286
352,204
90,247
7,583
4,678
101,615
861,647

929,003 487,660 243,440 98,894 20,954,192 22,536,063 1,429,044,687 1,429,044,687 116,491
0
7,444,454
1,613,995
16,148,839
4,177,534
20,257,425
9,877,829

5,928,593
29,157,236
0.000000
15.265664
6.629950
163.294430
0.199365
0.898889
0.006912
0.004149
250.296039
This is trial version
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STATE OF CALIFORNIA SCHEDULE 10
Provider Name: Fiscal Period Ended:
SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009

GENERAL SERVICE COST CENTERS
1.00 Old Cap Rel Cost - Buildings and Fixtures $ 0 $ 0 $ 0
1.01 Old Cap Rel Cost - Building 2 56,715 0 56,715
1.02 Old Cap Rel Cost - Building 3 0 0 0
1.03 Old Cap Rel Cost - Building 5 287,858 0 287,858
1.05 Old Cap Rel Cost - Building 10 448 0 448
1.06 Old Cap Rel Cost - Building 20 0 0
1.07 Old Cap Rel Cost - Building 30 0 0
1.09 Old Cap Rel Cost - MRI Building 0 0 0
1.10 Old Cap Rel Cost - Building 80 0 0
1.11 Old Cap Rel Cost - Building 90 0 0 0
1.13 Old Cap Rel Cost - Land Improvements 0 0 0
2.00 Old Cap Rel Cost - Moveable Equipment 0 0

3.00 New Cap Rel Cost - Buildings and Fixtures 6,319 0 6,319
3.01 New Cap Rel Cost - Building 2 21,223 0 21,223
3.02 New Cap Rel Cost - Building 3 15,587 0 15,587
3.03 New Cap Rel Cost - Building 5 1,862,470 0 1,862,470
3.04 New Cap Rel Cost - Building 9 7,617 0 7,617
3.05 New Cap Rel Cost - Building 10 21,950 0 21,950
3.06 New Cap Rel Cost - Building 20 61,016 0 61,016
3.07 New Cap Rel Cost - Building 30 12,374 0 12,374
3.08 New Cap Rel Cost - Building 40 390 0 390
3.09 New Cap Rel Cost - MRI Building 0 0 0
3.10 New Cap Rel Cost - Building 80 13,692 0 13,692
3.11 New Cap Rel Cost - Building 90 25,675 0 25,675
3.12 New Cap Rel Cost - Building 100 129,031 0 129,031
3.13 New Cap Rel Costs - Land Imp 17,581 0 17,581
3.14 New Cap Rel Costs - MHRF 1,083,165 0 1,083,165
4.00 New Cap Rel Costs - Moveable Equipment 3,079,983 39,064 3,119,047
4.01 New Cap Rel Costs - Moveable Equipment 0 0
5.00 Employee Benefits 8,968,395 0 8,968,395
6.00 Administrative and General 94,002,497 (8,911,136) 85,091,361
7.00 Maintenance and Repairs 17,309,415 0 17,309,415
8.00 Operation of Plant 12,933,989 0 12,933,989
9.00 Laundry and Linen Service 2,202,501 0 2,202,501
10.00 Housekeeping 12,976,153 0 12,976,153
10.01 Housekeeping 0 0 0
11.00 Dietary 5,103,379 0 5,103,379
12.00 Cafeteria 930,280 0 930,280
14.00 Nursing Administration 12,922,527 0 12,922,527
15.00 Central Services and Supply 2,441,584 539,100 2,980,684
16.00 Pharmacy 15,558,314 924,584 16,482,898
17.00 Medical Records and Library 6,882,411 0 6,882,411

18.00 Social Service 4,750,593 0 4,750,593
22.00 Intern and Res Services - Salary and Fringes 23,660,682 0 23,660,682
INPATIENT ROUTINE COST CENTER
25.00 Adults and Pediatrics 77,714,254 (533,960) 77,180,294
26.00 Intensive Care Unit 13,171,074 (22,247) 13,148,827
27.00 Coronary Care Unit 9,924,604 122,152 10,046,756
28.00 Subprovider I 00
29.00 Subprovider II 00
30.00 NICU 1,152,665 136,679 1,289,344
33.00 Nursery 4,704,466 (34,766) 4,669,700
34.00 Medicare Certified Nursing Facility 11,401,801 (934) 11,400,867
35.00 Distinct Part Nursing Facility 0 0
36.00 00
36.01 Subacute Care Unit 0 0
36.02 Transitional Care Unit 0 0
(From Sch 10A)
AUDITEDREPORTED
TRIAL BALANCE OF EXPENSES
ADJUSTMENTS
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STATE OF CALIFORNIA SCHEDULE 10
Provider Name: Fiscal Period Ended:
SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009

(From Sch 10A)
AUDITEDREPORTED
TRIAL BALANCE OF EXPENSES
ADJUSTMENTS
ANCILLARY COST CENTERS

37.00 Operating Room $ 25,997,293 $ 581,839 $ 26,579,132
39.00 Delivery Room and Labor Room 4,758,443 113,869 4,872,312
40.00 Anesthesiology 5,068,243 (2,329) 5,065,914
41.00 Radiology - Diagnostic 22,056,998 (75,069) 21,981,929
43.00 Radioisotope 0 0 0
44.00 Laboratory 22,017,739 5,993 22,023,732
44.01 Laboratory Pathology 1,516,844 (2,431) 1,514,413
46.00 Whole Blood 3,118,600 0 3,118,600
49.00 Respiratory Therapy 4,554,704 (11,713) 4,542,991
50.00 Physical Therapy 5,418,058 (7,617) 5,410,441
51.00 Occupational Therapy 797,622 (9,341) 788,281
53.00 Electrocardiology 3,312,606 (4,926) 3,307,680
54.00 Electroencephalography 156,431 0 156,431
55.00 Medical Supplies Charged to Patients 2,942,693 (411,405) 2,531,288
55.01 Implantable Devices 4,306,295 0 4,306,295
56.00 Drugs Charged to Patients 17,505,076 (1,499,271) 16,005,805
57.00 Renal Dialysis 2,431,093 299,217 2,730,310
59.00 Other Ancillary Services 2,023,190 (3,819) 2,019,371
59.01 00
59.02 00
59.03 00
59.04 00
59.05 00
59.06 00
59.07 00
59.08 00
59.09 00
59.10 00
60.00 Clinic 8,110,588 (49,453) 8,061,135
61.00 Emergency 21,643,164 (29,932) 21,613,232

61.01 Psych Emergency 8,015,100 (1,568,392) 6,446,708
62.00 Observation Beds 0 0
63.60 Adult Medical Center FQHC I 15,850,573 3,583,204 19,433,777
63.61 Women's Health Center FQHC II 6,118,102 1,056,780 7,174,882
63.62 Family Health Center FQHC III 5,257,837 1,690,847 6,948,684
63.63 Children's Health Center FQHC IV 3,564,803 841,770 4,406,573
63.64 Urgent Care FQHC V 2,501,858 (10,117) 2,491,741
64.00 Home Program Dialysis 404,743 59,017 463,760
SUBTOTAL $ 544,863,374 $ (3,194,743) $ 541,668,631
NONREIMBURSABLE COST CENTERS
96.00 Gift, Flower, Coffee Shop and Canteen 0 0
96.01 Other Than Hospital 20,722,323 10,242,123 30,964,446
98.00 00
99.00 00
99.01 00
99.02 00
99.03 00
99.04 00
99.05 00
99.06 00
99.07 00
99.08 00
99.09 00
99.10 00
99.99 SUBTOTAL $ 20,722,323 $ 10,242,123 $ 30,964,446
101 TOTAL $ 565,585,697 $ 7,047,380 $ 572,633,077
(To Schedule 8)
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STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A

Page 1
Provider Name: Fiscal Period Ended: JUNE 30, 2009
SAN FRANCISCO GENERAL HOSPITAL

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
(Pages 1 & 2)
2 345 6 7891011
GENERAL SERVICE COST CENTER
1.00 Old Cap Rel Cost - Buildings and Fixtures $0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
1.01 Old Cap Rel Cost - Building 2 0
__________
__________
__________
__________
__________
__________
__________
__________

__________
__________
__________
__________
1.02 Old Cap Rel Cost - Building 3 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
1.03 Old Cap Rel Cost - Building 5 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________

1.05 Old Cap Rel Cost - Building 10 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
1.06 Old Cap Rel Cost - Building 20 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
1.07 Old Cap Rel Cost - Building 30 0
__________
__________
__________

__________
__________
__________
__________
__________
__________
__________
__________
__________
1.09 Old Cap Rel Cost - MRI Building 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
1.10 Old Cap Rel Cost - Building 80 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
1.11 Old Cap Rel Cost - Building 90 0
__________
__________
__________
__________
__________
__________

__________
__________
__________
__________
__________
__________
1.13 Old Cap Rel Cost - Land Improvements 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
2.00 Old Cap Rel Cost - Moveable Equipment 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________

__________
__________
3.00 New Cap Rel Cost - Buildings and Fixtures 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
3.01 New Cap Rel Cost - Building 2 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
3.02 New Cap Rel Cost - Building 3 0
__________

__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
3.03 New Cap Rel Cost - Building 5 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
3.04 New Cap Rel Cost - Building 9 0
__________
__________
__________
__________
__________

__________
__________
__________
__________
__________
__________
__________
3.05 New Cap Rel Cost - Building 10 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
3.06 New Cap Rel Cost - Building 20 0
__________
__________
__________
__________
__________
__________
__________
__________
__________

__________
__________
__________
3.07 New Cap Rel Cost - Building 30 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
3.08 New Cap Rel Cost - Building 40 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
3.09 New Cap Rel Cost - MRI Building 0

__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
3.10 New Cap Rel Cost - Building 80 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
3.11 New Cap Rel Cost - Building 90 0
__________
__________
__________
__________

__________
__________
__________
__________
__________
__________
__________
__________
3.12 New Cap Rel Cost - Building 100 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
3.13 New Cap Rel Costs - Land Imp 0
__________
__________
__________
__________
__________
__________
__________
__________

__________
__________
__________
__________
3.14 New Cap Rel Costs - MHRF 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
4.00 New Cap Rel Costs - Moveable Equipment 39,064
__________
__________
__________
__________
__________
__________
__________
__________
39,064
__________
__________
__________

4.01 New Cap Rel Costs - Moveable Equipment 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
5.00 Employee Benefits 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
6.00 Administrative and General (8,911,136) __________ (6,475) __________ __________ (8,703,429) __________ __________ (201,232) __________ __________ __________ __________
7.00 Maintenance and Repairs 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
8.00 Operation of Plant 0
__________

__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
9.00 Laundry and Linen Service 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
10.00 Housekeeping 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
10.01 Housekeeping 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
11.00 Dietary 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
12.00 Cafeteria 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
14.00 Nursing Administration 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
15.00 Central Services and Supply 539,100 __________ (2,848) __________ __________ __________ 541,948 __________ __________ __________ __________ __________ __________

16.00 Pharmacy 924,584 __________ 7,534 __________ __________ __________ __________ 917,050 __________ __________ __________ __________ __________
17.00 Medical Records and Library 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
18.00 Social Service 0
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
22.00 Intern and Res Services - Salary and Fringes 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
INPATIENT ROUTINE COST CENTER `
25.00 Adults and Pediatrics (533,960)

__________
(371,136)
__________
(162,824)
__________
__________
__________
__________
__________
__________
__________
__________
26.00 Intensive Care Unit (22,247)
__________
(22,247)
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
27.00 Coronary Care Unit 122,152 __________ 122,152 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
28.00 Subprovider I 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
29.00 Subprovider II 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
30.00 NICU 136,679
__________

136,679
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
33.00 Nursery (34,766)
__________
(34,766)
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
34.00 Medicare Certified Nursing Facility (934) __________ (934) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
35.00 Distinct Part Nursing Facility 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
36.00 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
36.01 Subacute Care Unit 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
36.02 Transitional Care Unit 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
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STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A
Page 1
Provider Name: Fiscal Period Ended: JUNE 30, 2009
SAN FRANCISCO GENERAL HOSPITAL

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
(Pages 1 & 2)
2 345 6 7891011
ANCILLARY COST CENTERS
37.00 Operating Room 581,839
__________ 581,839 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
39.00 Delivery Room and Labor Room 113,869 __________ (48,955) __________ 162,824
__________
__________ __________ __________ __________ __________ __________ __________
40.00 Anesthesiology (2,329) __________ (2,329) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
41.00 Radiology - Diagnostic (75,069) __________ (75,069) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
43.00 Radioisotope 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
44.00 Laboratory 5,993 __________ 5,993 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
44.01 Laboratory Pathology (2,431) __________ (2,431) __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
46.00 Whole Blood 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
49.00 Respiratory Therapy (11,713) __________ (11,713) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
50.00 Physical Therapy (7,617) __________ (7,617) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
51.00 Occupational Therapy (9,341) __________ (9,341) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________

53.00 Electrocardiology (4,926) __________ (4,926) __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
54.00 Electroencephalography 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
55.00 Medical Supplies Charged to Patients (411,405) __________ 1,057 (412,462) __________
__________
__________ __________ __________ __________ __________ __________ __________
55.01 Implantable Devices 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
56.00 Drugs Charged to Patients (1,499,271) __________ (40,273) __________ __________ __________ (541,948) (917,050) __________ __________ __________ __________ __________
57.00 Renal Dialysis 299,217 __________ (54,228) 353,445 __________
__________
__________ __________ __________ __________ __________ __________ __________
59.00 Other Ancillary Services (3,819) __________ (3,819) __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
59.01 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
59.02 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
59.03 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
59.04 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
59.05 0 __________ __________ __________ __________

__________
__________ __________ __________ __________ __________ __________ __________
59.06 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
59.07 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
59.08 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
59.09 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
59.10 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
60.00 Clinic (49,453) __________ (49,453) __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
61.00 Emergency (29,932) __________ (29,932) __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
61.01 Psych Emergency (1,568,392) (1,559,613) (8,779) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
62.00 Observation Beds 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
63.60 Adult Medical Center FQHC I 3,583,204 __________ 49,867 __________ __________
__________
__________ __________ __________ __________ 3,533,337 __________ __________
63.61 Women's Health Center FQHC II 1,056,780 __________ (49,344) __________ __________
__________
__________ __________ __________ __________ 1,106,124 __________ __________
63.62 Family Health Center FQHC III 1,690,847 __________ (22,245) __________ __________
__________
__________ __________ __________ __________ 1,713,092 __________ __________

63.63 Children's Health Center FQHC IV 841,770 __________ (15,225) __________ __________
__________
__________ __________ __________ __________ 856,995 __________ __________
63.64 Urgent Care FQHC V (10,117) __________ (10,117) __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
64.00 Home Program Dialysis 59,017 __________ __________ 59,017 __________ __________ __________ __________ __________ __________ __________ __________ __________
NONREIMBURSABLE COST CENTERS
96.00 Gift, Flower, Coffee Shop and Canteen 0
__________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
96.01 Other Than Hospital 10,242,123 1,559,613 (20,919) __________ __________ 8,703,429 __________ __________ __________ __________ __________ __________ __________
98.00 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
99.00 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
99.01 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
99.02 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
99.03 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
99.04 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
99.05 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
99.06 0 __________ __________ __________ __________
__________

__________ __________ __________ __________ __________ __________ __________
99.07 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
99.08 0 __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________ __________
99.09 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
99.10 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
101.00 TOTAL $7,047,380 0000 000(201,232) 39,064 7,209,548 0 0
(To Sch 10)
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STATE OF CALIFORNIA
Provider Name:
SAN FRANCISCO GENERAL HOSPITAL
GENERAL SERVICE COST CENTER
1.00 Old Cap Rel Cost - Buildings and Fixtures
1.01 Old Cap Rel Cost - Building 2
1.02 Old Cap Rel Cost - Building 3
1.03 Old Cap Rel Cost - Building 5
1.05 Old Cap Rel Cost - Building 10
1.06 Old Cap Rel Cost - Building 20
1.07 Old Cap Rel Cost - Building 30
1.09 Old Cap Rel Cost - MRI Building
1.10 Old Cap Rel Cost - Building 80
1.11 Old Cap Rel Cost - Building 90
1.13 Old Cap Rel Cost - Land Improvements
2.00 Old Cap Rel Cost - Moveable Equipment
3.00 New Cap Rel Cost - Buildings and Fixtures

3.01 New Cap Rel Cost - Building 2
3.02 New Cap Rel Cost - Building 3
3.03 New Cap Rel Cost - Building 5
3.04 New Cap Rel Cost - Building 9
3.05 New Cap Rel Cost - Building 10
3.06 New Cap Rel Cost - Building 20
3.07 New Cap Rel Cost - Building 30
3.08 New Cap Rel Cost - Building 40
3.09 New Cap Rel Cost - MRI Building
3.10 New Cap Rel Cost - Building 80
3.11 New Cap Rel Cost - Building 90
3.12 New Cap Rel Cost - Building 100
3.13 New Cap Rel Costs - Land Imp
3.14 New Cap Rel Costs - MHRF
4.00 New Cap Rel Costs - Moveable Equipment
4.01 New Cap Rel Costs - Moveable Equipment
5.00 Employee Benefits
6.00 Administrative and General
7.00 Maintenance and Repairs
8.00 Operation of Plant
9.00 Laundry and Linen Service
10.00 Housekeeping
10.01 Housekeeping
11.00 Dietary
12.00 Cafeteria
14.00 Nursing Administration
15.00 Central Services and Supply
16.00 Pharmacy
17.00 Medical Records and Library
18.00 Social Service

22.00
Intern and Res Services - Salary and Fringes
INPATIENT ROUTINE COST CENTER
25.00 Adults and Pediatrics
26.00 Intensive Care Unit
27.00 Coronary Care Unit
28.00 Subprovider I
29.00 Subprovider II
30.00 NICU
33.00 Nursery
34.00 Medicare Certified Nursing Facility
35.00 Distinct Part Nursing Facility
36.00
36.01 Subacute Care Unit
36.02 Transitional Care Unit
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A
Page 2
JUNE 30, 2009

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
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STATE OF CALIFORNIA
Provider Name:
SAN FRANCISCO GENERAL HOSPITAL
ANCILLARY COST CENTERS
37.00 Operating Room
39.00 Delivery Room and Labor Room
40.00 Anesthesiology
41.00 Radiology - Diagnostic
43.00 Radioisotope
44.00 Laboratory

44.01 Laboratory Pathology
46.00 Whole Blood
49.00 Respiratory Therapy
50.00 Physical Therapy
51.00 Occupational Therapy
53.00 Electrocardiology
54.00 Electroencephalography
55.00 Medical Supplies Charged to Patients
55.01 Implantable Devices
56.00 Drugs Charged to Patients
57.00 Renal Dialysis
59.00 Other Ancillary Services
59.01
59.02
59.03
59.04
59.05
59.06
59.07
59.08
59.09
59.10
60.00 Clinic
61.00 Emergency
61.01 Psych Emergency
62.00 Observation Beds
63.60 Adult Medical Center FQHC I
63.61 Women's Health Center FQHC II
63.62 Family Health Center FQHC III
63.63 Children's Health Center FQHC IV

63.64 Urgent Care FQHC V
64.00 Home Program Dialysis
NONREIMBURSABLE COST CENTERS
96.00 Gift, Flower, Coffee Shop and Canteen
96.01 Other Than Hospital
98.00
99.00
99.01
99.02
99.03
99.04
99.05
99.06
99.07
99.08
99.09
99.10
101.00 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A
Page 2
JUNE 30, 2009

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
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0000000000000

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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
31
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
MEMORANDUM ADJUSTMENT
1 The provider's post step-down adjustments, Column 26, for Interns and
Residents, Epoietin, and Aranesp will be reversed on the audit report as
they are not applicable to the Medi-Cal Program.
CMS Pub. 15-1, Sections 2300, 2302, 2304, and 2306
Page 1
Report References
SAN FRANCISCO GENERAL HOSPITAL
Adjustments
Explanation of Audit Adjustments
JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W
Cost Report
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
31
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
Report References
SAN FRANCISCO GENERAL HOSPITAL
Adjustments
Explanation of Audit Adjustments

JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W
Cost Report
RECLASSIFICATIONS OF REPORTED COSTS
2 10A A 61.01 7 Psych Emergency $8,015,100 ($1,559,613) $6,455,487 *
10A A 96.01 7 Other Than Hospital 20,722,323 1,559,613 22,281,936 *
To reclassify reported expense to the proper cost center for proper
cost determination.
CMS Pub. 15-1, Sections 2300, 2304, and 2306
3 10A A 6.00 7 Administrative and General $94,002,497 ($6,475) $93,996,022 *
10A A 15.00 7 Central Services and Supply 2,441,584 (2,848) 2,438,736 *
10A A 25.00 7 Adults and Pediatrics 77,714,254 (371,136) 77,343,118 *
10A A 26.00 7 Intensive Care Unit 13,171,074 (22,247) 13,148,827
10A A 33.00 7 Nursery 4,704,466 (34,766) 4,669,700
10A A 34.00 7 Medicare Certified Nursing Facility 11,401,801 (934) 11,400,867
10A A 39.00 7 Delivery Room and Labor Room 4,758,443 (48,955) 4,709,488 *
10A A 40.00 7 Anesthesiology 5,068,243 (2,329) 5,065,914
10A A 41.00 7 Radiology - Diagnostic 22,056,998 (75,069) 21,981,929
10A A 44.01 7 Laboratory Pathology 1,516,844 (2,431) 1,514,413
10A A 49.00 7 Respiratory Therapy 4,554,704 (11,713) 4,542,991
10A A 50.00 7 Physical Therapy 5,418,058 (7,617) 5,410,441
10A A 51.00 7 Occupational Therapy 797,622 (9,341) 788,281
10A A 53.00 7 Electrocardiology 3,312,606 (4,926) 3,307,680
10A A 56.00 7 Drugs Charged to Patients 17,505,076 (40,273) 17,464,803 *
10A A 57.00 7 Renal Dialysis 2,431,093 (54,228) 2,376,865 *
10A A 59.00 7 Other Ancillary Services 2,023,190 (3,819) 2,019,371
10A A 60.00 7 Clinic 8,110,588 (49,453) 8,061,135
10A A 61.00 7 Emergency 21,643,164 (29,932) 21,613,232
10A A 61.01 7 Psych Emergency * 6,455,487 (8,779) 6,446,708
10A A 63.61 7 Women's Health Center FQHC II 6,118,102 (49,344) 6,068,758 *
10A A 63.62 7 Family Health Center FQHC III 5,257,837 (22,245) 5,235,592 *

10A A 63.63 7 Children's Health Center FQHC IV 3,564,803 (15,225) 3,549,578 *
10A A 63.64 7 Urgent Care FQHC V 2,501,858 (10,117) 2,491,741
10A A 96.01 7 Other Than Hospital * 22,281,936 (20,919) 22,261,017 *
10A A 16.00 7 Pharmacy 15,558,314 7,534 15,565,848 *
-Continued on next page-
*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
31
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
Report References
SAN FRANCISCO GENERAL HOSPITAL
Adjustments
Explanation of Audit Adjustments
JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W
Cost Report
RECLASSIFICATIONS OF REPORTED COSTS
-Continued from previous page-
10A A 27.00 7 Coronary Care Unit $9,924,604 $122,152 $10,046,756
10A A 30.00 7 NICU 1,152,665 136,679 1,289,344
10A A 37.00 7 Operating Room 25,997,293 581,839 26,579,132
10A A 44.00 7 Laboratory 22,017,739 5,993 22,023,732
10A A 55.00 7 Medical Supplies Charged to Patients 2,942,693 1,057 2,943,750 *
10A A 63.60 7 Adult Medical Center FQHC I 15,850,573 49,867 15,900,440 *
To adjust the provider's reclassification of medical supplies charged
to patients to agree with the supporting documentations.
CMS Pub. 15-1, Sections 2300, 2304, and 2306

4 10A A 55.00 7 Medical Supplies Charged to Patients * $2,943,750 ($412,462) $2,531,288
10A A 57.00 7 Renal Dialysis * 2,376,865 353,445 2,730,310
10A A 64.00 7 Home Program Dialysis 404,743 59,017 463,760
To reverse the provider's reclassification of medical supplies charged
to patients to agree with the provider's general ledger.
CMS Pub. 15-1, Sections 2300, 2304, and 2306
5 10A A 25.00 7 Adults and Pediatrics * $77,343,118 ($162,824) $77,180,294
10A A 39.00 7 Delivery Room and Labor Room * 4,709,488 162,824 4,872,312
To adjust the provider's reclassification to agree with the supporting
documentations.
CMS Pub. 15-1, Sections 2300, 2304, and 2306
6 10A A 6.00 7 Administrative and General * $93,996,022 ($8,703,429) $85,292,593 *
10A A 96.01 7 Other Than Hospital * 22,261,017 8,703,429 30,964,446
To adjust the provider's reclassification of Healthy San Francisco to agree
with the supporting documentations.
CMS Pub. 15-1, Sections 2300, 2304, and 2306
*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
31
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
Report References
SAN FRANCISCO GENERAL HOSPITAL
Adjustments
Explanation of Audit Adjustments
JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W
Cost Report

RECLASSIFICATIONS OF REPORTED COSTS
7 10A A 56.00 7 Drugs Charged to Patients * $17,464,803 ($541,948) $16,922,855 *
10A A 15.00 7 Central Services and Supply * 2,438,736 541,948 2,980,684
To reclassify other and nonchargeable supply expenses to the
appropriate cost center for proper cost determination.
CMS Pub. 15-1, Sections 2300, 2302, 2304, and 2306
8 10A A 56.00 7 Drugs Charged to Patients * $16,922,855 ($917,050) $16,005,805
10A A 16.00 7 Pharmacy * 15,565,848 917,050 16,482,898
To reclassify Drugs Sold overhead expense to the appropriate
cost center for proper cost determination.
CMS Pub. 15-1, Sections 2300, 2302, 2304, and 2306
*Balance carried forward from prior/to subsequent adjustments Page 4
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STATE OF CALIFORNIA SCHEDULE 4B PROGRAM: NONCONTRACT COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST _part4 doc

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