STATE OF CALIFORNIA Page 3 RECONCILIATION OF THE PROVIDER''''S ADJUSTMENTS TO THE AUDIT REPORT _part2 pdf

State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
43
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
GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F
RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT
15 Not Reported 8A-1 5.01 Plant Operations and Maintenance - Salaries and Wages * $240,004 ($157,498) $82,506
Not Reported 8A-1 5.02 Plant Operations and Maintenance - Fringe Benefits * 88,405 (58,014) 30,391
Not Reported 8A-1 5.04 Plant Operations and Maintenance - Other - Nonlabor * 1,269,790 (833,273) 436,517 *
10.1(4) 05 14 8A-1 5.00 Plant Operations and Maintenance * (1,167,559) 1,048,785 (118,774) *
16 Not Reported 8A-1 10.01 Housekeeping - Salaries and Wages * $562,060 ($368,840) $193,220
Not Reported 8A-1 10.02 Housekeeping - Fringe Benefits * 218,287 (143,246) 75,041
Not Reported 8A-1 10.04 Housekeeping - Other - Nonlabor * 141,306 (92,729) 48,577
10.1(4) 10 14 8A-1 10.00 Housekeeping * (604,815) 604,815 0
17 Not Reported 8A-1 60.04 Laundry and Linen - Other - Nonlabor * $293,764 ($95,230) $198,534 *
10.1(4) 60 14 8A-1 60.00 Laundry and Linen * (95,230) 95,230 0
18 Not Reported 8A-1 65.01 Dietary - Salaries and Wages * $873,753 ($459,098) $414,655
Not Reported 8A-1 65.02 Dietary - Fringe Benefits * 290,802 (152,797) 138,005
Not Reported 8A-1 65.04 Dietary - Other - Nonlabor * 757,733 (399,921) 357,812
10.1(4) 65 14 8A-1 65.00 Dietary * (1,011,816) 1,011,816 0
19 Not Reported 8A-1 155.01 Social Services - Salaries and Wages * $157,866 ($45,774) $112,092
Not Reported 8A-1 155.02 Social Services - Fringe Benefits * 60,504 (17,543) 42,961
Not Reported 8A-1 155.04 Social Services - Other - Nonlabor * 3,624 (1,051) 2,573
10.1(4) 155 14 8A-1 155.00 Social Services * (64,368) 64,368 0

20 Not Reported 8A-1 160.01 Activities - Salaries and Wages * $295,200 ($85,595) $209,605
Not Reported 8A-1 160.02 Activities - Fringe Benefits * 99,023 (28,712) 70,311
Not Reported 8A-1 160.04 Activities - Other - Nonlabor * 68,090 (19,743) 48,347
10.1(4) 160 14 8A-1 160.00 Activities * (134,050) 134,050 0
.
-Continued on next page-
*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
43
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
GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F
RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT
-Continued from previous page-
21 Not Reported 8A-1 165.01 Administration - Salaries and Wages * $492,312 ($142,748) $349,564 *
Not Reported 8A-1 165.02 Administration - Fringe Benefits * 170,265 (49,369) 120,896 *
Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 2,058,700 (217,034) 1,841,666 *
10.1(4) 165 14 8A-1 165.00 Administration * (477,988) 409,151 (68,837) *
22 Not Reported 8A-1 170.01 Inservice Education - Nursing - Salaries and Wages * $62,133 ($18,016) $44,117 *
Not Reported 8A-1 170.02 Inservice Education - Nursing - Fringe Benefits * 23,173 (6,719) 16,454 *
Not Reported 8A-1 170.04 Inservice Education - Nursing - Other - Nonlabor * 17,338 (5,027) 12,311 *

10.1(4) 170 14 8A-1 170.00 Inservice Education - Nursing * (51,388) 29,762 (21,626) *
To reclassify the apportioned residential care adjustment for proper
cost determination.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
23 Not Reported 8A-1 5.04 Plant Operations and Maintenance - Other - Nonlabor * $436,517 ($118,774) $317,743 *
10.1(4) 05 14 8A-1 5.00 Plant Operations and Maintenance * (118,774) 118,774 0
To reclassify the reported excess gas expenses for proper cost
determination.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
24 Not Reported 8A-1 165.11 Administration - Other - Nonlabor * $1,841,666 ($2,249) $1,839,417 *
10.1(4) 165 14 8A-1 165.00 Administration * (68,837) 2,249 (66,588) *
To reclassify expense adjustment reported for patient lost items for
proper cost determination.
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 5
This is trial version
www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
43
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
GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F
RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT
25 Not Reported 8A-1 165.11 Administration - Other - Nonlabor * $1,839,417 ($3,751) $1,835,666 *
10.1(4) 165 14 8A-1 165.00 Administration * (66,588) 3,751 (62,837) *
To adjust the provider's reclassification of gift shop expenses for
proper cost determination.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
26 Not Reported 8A-1 105.01 Skilled Nursing Care - Salaries and Wages * $3,394,711 ($29,847) $3,364,864
Not Reported 8A-1 105.02 Skilled Nursing Care - Fringe Benefits * 1,230,099 (11,342) 1,218,757
10.1(4) 105 14 8A-1 105.00 Skilled Nursing Care * (41,189) 41,189 0
To reclassify residential care nursing administration adjustment for
proper cost determination.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
27 Not Reported 8A-1 165.01 Administration - Salaries and Wages * $349,564 ($39,775) $309,789 *
Not Reported 8A-1 165.02 Administration - Fringe Benefits * 120,896 (10,625) 110,271 *
Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 1,835,666 (34,063) 1,801,603 *
10.1(4) 165 14 8A-1 165.00 Administration * (62,837) 84,463 21,626 *
To adjust the provider's reclassification of Synagogue expenses for
proper cost determination.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
28 10.1(4) 165 14 8A-1 165.00 Administration * $21,626 ($21,626) $0
Not Reported 8A-1 170.01 Inservice Education - Nursing - Salaries and Wages * 44,117 (12,827) 31,290
Not Reported 8A-1 170.02 Inservice Education - Nursing - Fringe Benefits * 16,454 (1,603) 14,851
Not Reported 8A-1 170.04 Inservice Education - Nursing - Other - Nonlabor * 12,311 (7,196) 5,115
Not Reported 8A-1 165.09 Administration - Caregiver Training 0 21,626 21,626
10.1(4) 170 14 8A-1 170.00 Inservice Education - Nursing * (21,626) 21,626 0

To adjust the reported reclassification of caregiver training expenses
for proper cost determination.
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 6
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www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
43
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
GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F
RECLASSIFICATIONS OF REPORTED COSTS
29 Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * $198,534 ($149,685) $48,849
Not Reported 8A-2 60.03 Laundry and Linen - Agency Staff 0 149,685 149,685
To reclassify laundry and linen contracted labor for proper cost
determination.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
30 Not Reported 8A-2 5.04 Plant Operations and Maintenance - Other - Nonlabor * $317,743 ($37,150) $280,593 *
Not Reported 8A-2 5.03 Plant Operations and Maintenance - Agency Staff 0 37,150 37,150
To reclassify expenses related to security contract to the agency
cost center for proper cost determination.

42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
31 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $309,789 ($115,223) $194,566 *
Not Reported 8A-2 165.02 Administration - Fringe Benefits * 110,271 (41,166) 69,105 *
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 1,801,603 (50,527) 1,751,076 *
Not Reported 8A-2 165.03 Administration - Medical Records - Salaries and Wages * 0 115,223 115,223 *
Not Reported 8A-2 165.04 Administration - Medical Records - Fringe Benefits 0 41,166 41,166 *
Not Reported 8A-2 165.06 Administration - Medical Records - Other - Nonlabor 0 50,527 50,527 *
To reclassify medical records expenses for proper cost determination.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
32 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $1,751,076 ($131,400) $1,619,676 *
Not Reported 8A-2 165.08 Administration - Liability Insurance 0 131,400 131,400
To reclassify liability insurance expenses for proper cost determination.
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 7
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
43
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

GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F
RECLASSIFICATIONS OF REPORTED COSTS
33 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $1,619,676 ($21,960) $1,597,716 *
Not Reported 8A-2 165.07 Administration - DHS Licensing Fees 0 21,960 21,960
To reclassify Department of Health Care Services license fees for
proper cost determination.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
34 10.1(4) 15 14 8A-2 15.00 Depreciation - Buildings and Improvements $119,424 ($13,501) $105,923
10.1(4) 25 14 8A-2 25.00 Depreciation - Equipment 54,961 (26,613) 28,348
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 1,597,716 40,114 1,637,830 *
To reclassify the reported home office expense for proper cost
determination.
42 CFR 413.17 / CMS Pub. 15-1, Sections 2150.2 and 2304
*Balance carried forward from prior/to subsequent adjustments Page 8
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www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
43
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
GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F
ADJUSTMENTS TO REPORTED COSTS

35 Not Reported 8A-2 5.04 Plant Operations and Maintenance - Other - Nonlabor * $280,593 ($42,441) $238,152
To eliminate security expenses related to the new construction.
42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3
36 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $1,637,830 ($15,657) $1,622,173
To eliminate medical director expenses not related to patient care.
42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3
37 Not Reported 8A-2 165.03 Administration - Medical Records - Salaries and Wages * $115,223 ($33,409) $81,814
Not Reported 8A-2 165.04 Administration - Medical Records - Fringe Benefits * 41,166 (11,936) 29,230
Not Reported 8A-2 165.06 Administration - Medical Records - Other - Nonlabor * 50,527 (14,651) 35,876
To eliminate medical records expenses related to the residential
care facility.
42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3
38 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $194,566 ($67,953) $126,613
Not Reported 8A-2 165.02 Administration - Fringe Benefits * 69,105 (35,927) 33,178
To adjust administrator compensation based on the Department of
Health Care Services Administrator Compensation Survey.
42 CFR 413.102 / CMS Pub. 15-1, Sections 901, 902.3, 904 and 1005
*Balance carried forward from prior/to subsequent adjustments Page 9
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www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
43
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
GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F
ADJUSTMENTS TO REPORTED COSTS
39 10.1(4) 45 14 8A-2 45.00 Property Insurance $11,160 ($2,960) $8,200
To adjust the reported property insurance expenses to agree with the
invoices.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
Page 10
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
43
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
GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F
ADJUSTMENT TO REPORTED STATISTICS
40 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 4,867 4,867
Not Reported 7 10.00 Housekeeping 0 862 862
Not Reported 7 60.00 Laundry and Linen 0 2,043 2,043
Not Reported 7 65.00 Dietary 0 10,808 10,808
Not Reported 7 155.00 Social Services 0 3,943 3,943
Not Reported 7 160.00 Activities 09696
Not Reported 7 165.00 Administration 0 1,169 1,169

Not Reported 7 165.00 Medical Records 0 200 200
Not Reported 7 145.00 Other Nonreimbursable 258 10,026 10,284
Not Reported 7 145.00 Other Nonreimbursable 258 43,799 44,057
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 20,163 34,014 54,177
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 20,163 62,920 83,083
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 20,163 62,058 82,221
To adjust the square footage statistics to agree with the provider's
working papers. .
42 CFR 413.24 and 413.50 / CMS Pub. 15-1, Sections 2304 and 2306
Page 11
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
43
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
GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F
ADJUSTMENT TO REPORTED PATIENT DAYS
41 4.1 05 6 1 12.00 Skilled Nursing Care - Total Patient Days 38,009 80 38,089
To adjust total patient days to agree with the provider's
patient census reports.
42 CFR 413.20 and 413.50
CMS Pub. 15-1, Sections 2205 and 2304

Page 12
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
43
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
GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F
ADJUSTMENTS TO OTHER MATTERS
42 N/A NF1 14.00 Overpayments $0 $3,176 $3,176 *
To recover Medi-Cal duplicate payments.
CCR, Title 22, Section 51458.1
43 N/A NF1 14.00 Overpayments * $3,176 $44,184 $47,360
To recover outstanding Medi-Cal credit balances.
CCR, Title 22, Sections 50761 and 51458.1
*Balance carried forward from prior/to subsequent adjustments Page 13
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