STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS Page 1 _part2 pdf

State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
35
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments
GRAND PARK CONVALESCENT HOSPITAL JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06244I
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
RECLASSIFICATIONS OF REPORTED COSTS
15 10.1(4) 100 14 8A-2 100.00 Other Ancillary Services $28,605 $600 $29,205 *
Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 248,787 (600) 248,187 *
To reclassify dental expense to the appropriate cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
CCR, Title 22, Section 51511(c)
16 10.1(4) 100 14 8A-2 100.00 Other Ancillary Services * $29,205 $279 $29,484
Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 248,187 (279) 247,908 *
To reclassify physician's services expense to the appropriate cost
center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
CCR, Title 22, Section 51511(c)
*Balance carried forward from prior/to subsequent adjustments Page 4
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number

35
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments
GRAND PARK CONVALESCENT HOSPITAL JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06244I
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
ADJUSTMENTS TO REPORTED COSTS
17 Not Reported 8A-2 10.03 Housekeeping - Agency Staff * $196,755 ($121) $196,634
To adjust housekeeping agency cost to agree with the provider's
invoices.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300 and 2304
18 Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * $20,079 ($233) $19,846
To adjust laundry agency cost to agree with the provider's invoices.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300 and 2304
19 Not Reported 8A-2 105.03 Skilled Nursing Care - Agency Staff * $337,316 ($12,756) $324,560
To eliminate screening expense not applicable to the fiscal year.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.1 and 2304
20 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $586,680 ($201,219) $385,461
Not Reported 8A-2 165.02 Administration - Fringe Benefits * 81,038 (16,380) 64,658
To adjust administrator's compensation based on the department
survey.
42 CFR 413.102
CMS Pub. 15-1, Chapter 9 / Medi-Cal Bulletin 371

SPA 05-005, Section (III)(J) / W&I Code, Section 14126.023(f)
21 10.1(4) 45 14 8A-2 45.00 Property Insurance * $29,265 ($16,446) $12,819
To adjust property insurance expense to agree with the provider's
invoices.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
22 10.1(4) 20 14 8A-2 20.00 Depreciation - Leasehold Improvements $4,250 ($4,250) $0
To eliminate depreciation expense due to insufficient documentation.
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
35
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments
GRAND PARK CONVALESCENT HOSPITAL JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06244I
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
ADJUSTMENTS TO REPORTED COSTS
23 Not Reported 8A-2 165.08 Administration - Liability Insurance * $122,014 ($8,091) $113,923
To adjust liability insurance expense to agree with the provider's
records.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
24 Not Reported 8A-2 165.10 Administration - Quality Assurance Fees * $521,737 ($65,127) $456,610
To adjust quality assurance fees to agree with the amount calculated

using the published rate.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $189,903
25 To eliminate tax expenses not related to patient care and not applicable ($24,074)
to the fiscal year.
42 CFR 413.5, 413.9(c)(3), 413.20 and 413.24
CMS Pub. 15-1, Sections 2102.3, 2300, 2302.1 and 2304
26 To eliminate administrative supplies expense due to insufficient (3,294)
documentation.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
27 To eliminate promotional, personal automobile, and management meals (9,075)
expenses not related to patient care. ($36,443) $153,460 *
42 CFR 413.5, 413.9 and 413.24
CMS Pub. 15-1, Sections 2102.3, 2105.5 and 2136.2
28 Not Reported 8A-2 5.04 Plant Operations and Maintenance - Other - Nonlabor * $252,184 ($2,806) $249,378
To eliminate maintenance supplies expense due to insufficient
documentation.
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
35
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments
GRAND PARK CONVALESCENT HOSPITAL JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06244I
Report References

Cost Report
Audit Report
Explanation of Audit Adjustments
ADJUSTMENTS TO REPORTED COSTS
Not Reported 8A-2 160.04 Activities - Other - Nonlabor * $19,825
29 To eliminate activities supplies expense due to insufficient ($4,956)
documentation.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
30 To eliminate marketing expense not related to patient care. (163)
42 CFR 413.20 and 413.24 ($5,119) $14,706
CMS Pub. 15-1, Sections 2102.3, 2105.5, 2300 and 2304
31 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * $247,908 ($196) $247,712
To eliminate nursing supplies expense due to insufficient
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 * $153,460
32 To eliminate franchise tax board expense due to insufficient ($800)
documentation.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
33 To abate interest revenue against related expense. (134)
42 CFR 413.153(b)(2)(iii) / CMS Pub. 15-1, Section 202.2 ($934) $152,526
*Balance carried forward from prior/to subsequent adjustments Page 7
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www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
35
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted

Adjustments
GRAND PARK CONVALESCENT HOSPITAL JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06244I
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
ADJUSTMENT TO REPORTED STATISTICS
34 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 231 231
Not Reported 7 10.00 Housekeeping 0 231 231
Not Reported 7 60.00 Laundry and Linen 0 536 536
Not Reported 7 65.00 Dietary 0 2,041 2,041
11.1 (1 of 3) 10 2 7 75.00 Patient Supplies 225 (19) 206
11.1 (1 of 3) 35 2 7 100.00 Other Ancillary Services 231 (181) 50
Not Reported 7 160.00 Activities 0 140 140
Not Reported 7 165.00 Administration 0 498 498
Not Reported 7 170.00 Inservice Education - Nursing 0 395 395
11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 15,605 3,872 19,477
11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 15,605 3,641 19,246
11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 15,605 3,410 19,015
To adjust square footage to agree with the provider's square footage
workpaper.
42 CFR 413.24 and 413.50 / CMS Pub. 15-1, Sections 2300, 2304 and 2306
Page 8
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
35
MC530
Adj. Page or As Increase As

No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments
GRAND PARK CONVALESCENT HOSPITAL JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06244I
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
ADJUSTMENT TO OTHER MATTERS
35 Not Reported 1 14.00 Overpayments $0 $3,884 $3,884
To recover Medi-Cal overpayments because the share of cost was
not properly deducted from the amount billed.
42 CFR 413.5 and 413.20 / CMS Pub. 15-1, Section 2409
Page 9
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