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

State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
28
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments
NEW VISTA NURSING & REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06031H
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT
15 10.1(4) 165 14 8A-1 165.00 Administration * ($286) $55,635 $55,349 *
Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 666,312 (55,635) 610,677 *
To reclassify the provider's elimination of public relations/ marketing
expense for proper cost determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
16 10.1(4) 165 14 8A-1 165.00 Administration * $55,349 $469,722 $525,071 *
Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 610,677 (469,722) 140,955 *
To reclassify the provider's elimination of management fees expense
for proper cost determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
17 10.1(4) 165 14 8A-1 165.00 Administration * $525,071 ($525,071) $0
Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 140,955 525,071 666,026 *
To reclassify the provider's home office expense adjustment
for proper cost determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
*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
28
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments
NEW VISTA NURSING & REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06031H
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
RECLASSIFICATIONS OF REPORTED COSTS
18 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $666,026 ($1,754) $664,272 *
10.1(4) 35 14 8A-2 35.00 Leases and Rentals 522,000 1,754 523,754 *
To reclassify lease and rental expense for proper cost determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
19 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $664,272 ($4,469) $659,803 *
10.1(4) 35 14 8A-2 35.00 Leases and Rentals * 523,754 4,469 528,223 *
To reclassify lease and rental expense for proper cost determination.
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
28
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted

Adjustments
NEW VISTA NURSING & REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06031H
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
ADJUSTMENTS TO REPORTED COSTS
20 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $288,407 ($61,420) $226,987
Not Reported 8A-2 165.02 Administration - Fringe Benefits * 62,829 (10,278) 52,551
To adjust administrator compensation based on Department of Health
Care Services guidelines.
42 CFR 413.102 / CMS Pub. 15-1, Chapter 9
SPA, Section (III)(J)
W&I, Section 14126.023(f)
Medi-Cal Bulletin 371
21 10.1(4) 35 14 8A-2 35.00 Leases and Rentals * $528,223 ($522,000) $6,223
To eliminate rental expenses applicable to a related facility.
42 CFR 413.17 and 413.134(h) / CMS Pub. 15-1, Section 1011.5
22 10.1(4) 40 14 8A-2 40.00 Property Taxes $1,070 $65,154 $66,224
Not Reported 8A-2 45.00 Property Insurance 0 20,240 20,240
Not Reported 8A-2 50.00 Interest - Property, Plant, and Equipment 0 166,994 166,994
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 659,803 15,831 675,634 *
To include cost of ownership in lieu of related party lease expense.
42 CFR 413.17, 413.20 and 413.24 / CMS Pub. 15-1, Section 1011.5
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $675,634
23 To eliminate dues and subscriptions expense for lobby fees. ($682)
42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2139
24 To eliminate the reported theft and losses expenses not (1,945)
reimbursable by Medi-Cal.
42 CFR 413.20 and 413.24

CMS Pub. 15-1, Sections 2300, 2304 and 2160.3
25 To adjust the reported Medical Director Fees expense to agree (1,060)
with the provider's invoices. ($3,687) $671,947
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
28
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments
NEW VISTA NURSING & REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06031H
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
ADJUSTMENTS TO REPORTED COSTS
26 Not Reported 8A-2 10.04 Housekeeping - Other - Nonlabor * $98,862 ($475) $98,387
To eliminate Housekeeping expense not applicable to period under
review.
42 CFR 413.20, 413.24 and 413.5
CMS Pub. 15-1, Sections 2300, 2302.1 and 2304
27 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * $387,337 $924 $388,261
To adjust the Skilled Nursing Care expense to agree with the
provider's invoices and check payments.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
*Balance carried forward from prior/to subsequent adjustments Page 7

This is trial version
www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
28
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments
NEW VISTA NURSING & REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06031H
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
ADJUSTMENT TO REPORTED STATISTICS
28 Not Reported 7 5 Plant Operations and Maintenance (Square Feet) 0 435 435
Not Reported 7 10 Housekeeping 0 105 105
Not Reported 7 60 Laundry and Linen 0 1,524 1,524
Not Reported 7 65 Dietary 0 4,325 4,325
Not Reported 7 155 Social Services 0 171 171
Not Reported 7 160 Activities 08080
Not Reported 7 165 Administration 0 680 680
Not Reported 7 170 Inservice Education - Nursing 0 154 154
11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 12,192 7,474 19,666
11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 12,192 7,039 19,231
11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 12,192 6,934 19,126
To adjust square footage statistics to agree with the prior year's audit
findings in order to properly allocate indirect costs.
42 CFR 413.24 and 413.50
CMS Pub. 15-1, Sections 2300, 2304 and 2306

Page 8
This is trial version
www.adultpdf.com