STATE OF CALIFORNIA RECONCILIATION OF THE PROVIDER''''S ADJUSTMENTS TO THE AUDIT REPORT _part2 ppt

State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
25
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
SAN JOSE HEALTHCARE CENTER MARCH 6, 2007 THROUGH DECEMBER 31, 2007 ZZR06082H
RECLASSIFICATIONS OF REPORTED COSTS
10 10.1(4) 100 14 8A-2 100.00 Other Ancillary Services $14,140 $2,590 $16,730
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 1,180,091 (2,590) 1,177,501 *
To adjust the provider's reclassification of beauty and barber expense
for proper cost determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
11 Not Reported 8A-2 165.07 Administration - DHS Licensing Fees $0 $33,658 $33,658
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 1,177,501 (33,658) 1,143,843 *
To reclassify DHS licensing fees for proper cost determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
12 Not Reported 8A-2 165.10 Administration - Quality Assurance Fees $0 $407,033 $407,033
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 1,143,843 (407,033) 736,810 *
To reclassify Quality Assurance Fees for proper cost determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
13 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * $224,280 ($20,000) $204,280
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 736,810 20,000 756,810 *
To reclassify medical director fees 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 4
This is trial version
www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
25
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
SAN JOSE HEALTHCARE CENTER MARCH 6, 2007 THROUGH DECEMBER 31, 2007 ZZR06082H
ADJUSTMENTS TO REPORTED COSTS
14 10.1(4) 40 14 8A-2 40.00 Property Taxes $64,284 ($5,569) $58,715
To eliminate property tax expense due to insufficient documentation.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
15 10.1(4) 45 14 8A-2 45.00 Property Insurance $8,996 ($8,996) $0
To eliminate property insurance expense due to lack of documentation.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $756,810
16 To eliminate liability insurance due to lack of documentation. ($70,121)
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
17 To eliminate advertising expenses due to lack of documentation. (2,291)
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
18 To eliminate dues and subscriptions due to lack of documentation. (2,838)
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
19 To eliminate travel expenses due to lack of documentation. (6,248)

42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
20 To eliminate interest expenses due to lack of documentation. (88,985)
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
21 To eliminate bank charges due to lack of documentation. (2,630)
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
22 To adjust home office costs to agree with the filed Home Office (84,900)
Cost Report. ($258,013) $498,797
42 CFR 413.17 / CMS Pub. 15-1, Sections 2150.2 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
25
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
SAN JOSE HEALTHCARE CENTER MARCH 6, 2007 THROUGH DECEMBER 31, 2007 ZZR06082H
ADJUSTMENTS TO REPORTED COSTS
23 10.1(4) 5 14 8A-2 5.00 Plant Operations and Maintenance * $3,185 ($3,185) $0
10.1(4) 10 14 8A-2 10.00 Housekeeping * 17,775 (17,775) 0
10.1(4) 60 14 8A-2 60.00 Laundry and Linen * 7,952 (7,952) 0
10.1(4) 65 14 8A-2 65.00 Dietary * 24,343 (24,343) 0
10.1(4) 105 14 8A-2 105.00 Skilled Nursing Care * 173,599 (173,599) 0
10.1(4) 155 14 8A-2 155.00 Social Services * 8,039 (8,039) 0

10.1(4) 160 14 8A-2 160.00 Activities * 3,833 (3,833) 0
10.1(4) 165 14 8A-2 165.00 Administration * (15,341) 15,341 0
To adjust the reported expenses to agree with the provider's general
ledger.
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
25
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
SAN JOSE HEALTHCARE CENTER MARCH 6, 2007 THROUGH DECEMBER 31, 2007 ZZR06082H
ADJUSTMENT TO REPORTED STATISTICS
24 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 360 360
Not Reported 7 10.00 Housekeeping 0 101 101
Not Reported 7 60.00 Laundry and Linen 0 1,524 1,524
Not Reported 7 65.00 Dietary 0 3,491 3,491
11.1(1 of 3) 75 2 7 140.00 Beauty and Barber 0 141 141
Not Reported 7 155.00 Social Services 0 200 200
Not Reported 7 160.00 Activities 0 1,661 1,661
Not Reported 7 165.00 Administration 0 600 600
Not Reported 7 165.00 Medical Records 0 251 251

11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 41,748 8,329 50,077
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 41,748 7,969 49,717
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 41,748 7,868 49,616
To establish the correct square footage in order to properly allocate
indirect costs.
42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306
Page 7
This is trial version
www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
25
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
SAN JOSE HEALTHCARE CENTER MARCH 6, 2007 THROUGH DECEMBER 31, 2007 ZZR06082H
ADJUSTMENT TO OTHER MATTERS
25 Not Reported 1 14.00 Overpayments $0 $12,332 $12,332
To recover outstanding Medi-Cal credit balances.
CCR, Title 22, Sections 50761 and 51458.1
Page 8
This is trial version
www.adultpdf.com