State of California Fiscal Period JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 _part2 pot

State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
77
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
TOPANGA TERRACE CONVALESCENT CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06092G
ADJUSTMENTS TO REPORTED STATISTICS
67 Not Reported 5.00 Plant Operations and Maintenance (Square Feet) 0 461 461
Not Reported 10.00 Housekeeping 0 168 168
Not Reported 65.00 Dietary 0 1,207 1,207
11.1 (1 of 3) 40 2 7 105.00 Skilled Nursing Care 7,203 198 7,401
11.1 (1 of 3) 60 2 7 125.00 Subacute Care 6,234 229 6,463
Not Reported 155.00 Social Services 08787
Not Reported 160.00 Activities 0 838 838
Not Reported 165.00 Administration 0 620 620
Not Reported 165.00 Medical Records 0 232 232
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 14,503 4,040 18,543
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 14,503 3,579 18,082
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 14,503 3,411 17,914
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
68 11.1(1 of 3) 60 4 7 125.00 Subacute Care (Clean, Dry Pounds) 161,920 (20) 161,900
11.1(1 of 3) 40 4 7 105.00 Skilled Nursing Care 213,760 20 213,780
To reclassify the reported laundry and linen statistics in order to

properly allocate indirect costs
42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306
69 11.1(2 of 3) 40 6 7 105.00 Skilled Nursing Care (Patient Meals) 64,128 6 64,134
11.1(2 of 3) 60 6 7 125.00 Subacute Care 48,576 (20,343) 28,233
11.1(2 of 3) 85 6 7 N/A Total Statistics - Patient Meals 112,704 (20,337) 92,367
To adjust the reported patient meals statistics in order to properly
allocate indirect costs.
42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
77
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
TOPANGA TERRACE CONVALESCENT CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06092G
ADJUSTMENTS TO REPORTED PATIENT DAYS
70 4.1 05 6 1 12.00 Skilled Nursing Patient Days - Total 21,616 2 21,618
4.1 25 6 ASA1 36.00 Subacute Care Patient Days - Total 16,670 (2) 16,668
To reclassify the reported patient days to agree with the provider's
patient census reports for proper cost determination.
42 CFR 413.20 and 413.50
CMS Pub. 15-1, Sections 2205 and 2304

71 4.3 (1) 100 1 ASA1 48.00 Subacute Patient Days - Ventilator 6,676 404 7,080
4.3 (1) 115 1 ASA1 49.00 Subacute Patient Days - Non Ventilator 9,994 (406) 9,588
To adjust the reported Subacute 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
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
77
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
TOPANGA TERRACE CONVALESCENT CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06092G
ADJUSTMENTS TO REPORTED TOTAL CHARGES
72 13.1 10 2 ASA2 11.00 Patient Supplies $688,286 ($199,761) $488,525
13.1 20 2 ASA2 77.00 Pharmacy 1,428,741 (691,783) 736,958
13.1 25 2 ASA2 88.00 Laboratory 144,663 (14,746) 129,917
13.1 35 2 ASA2 99.00 Other Ancillary Services 172,454 9,664 182,118
To adjust the total ancillary charges to agree with the provider's general
ledger and to account for the items included in the daily Medi-Cal rate.
42 CFR 413.20 and 413.50
CMS Pub. 15-1, Sections 2206, 2206.1 and 2304

CCR, Title 22, Sections 51511(c) and 51511.5 (d)
73 13.1 10 5 ASA2 11.00 Patient Supplies $409,433 ($67,203) $342,230
13.1 20 5 ASA2 77.00 Pharmacy 466,658 (225,951) 240,707
To adjust the total Subacute ancillary charges to agree with the
provider's general ledger and to account for the items included in the
daily Medi-Cal rate.
42 CFR 413.20 and 413.50
CMS Pub. 15-1, Sections 2206, 2206.1 and 2304
CCR, Title 22, Sections 51511(c) and 51511.5 (d)
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
77
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
TOPANGA TERRACE CONVALESCENT CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06092G
ADJUSTMENT TO REPORTED MEDI-CAL SETTLEMENT DATA - SUBACUTE CARE
74 4.3 (1) 120 2 ASA1 44.00 Medi-Cal Subacute Patient Days - Total 15,670 (121) 15,549
4.3 (1) 100 2 ASA1 48.00 Medi-Cal Subacute Patient Days - Ventilator 6,504 (127) 6,377
To adjust Medi-Cal Settlement Data to agree with the following
EDS Paid Claims Summary:
Report Date: September 29, 2009

Payment Period: January 1, 2008 through August 31, 2009
Service Period: January 1, 2008 through December 31, 2008
42 CFR 413.20, 413.50, 413.53, 413.60 and 413.64
CMS Pub. 15-1, Sections 2304 and 2408
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
77
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
TOPANGA TERRACE CONVALESCENT CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06092G
ADJUSTMENTS TO OTHER MATTERS
75 Not Reported 1 14.00 Overpayments $0 $4,350 $4,350
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
76 Not Reported ASA1 41.00 Contracted Number of Adult Subacute Beds 0 48 48
To include the contracted Subacute beds in the audit report.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
77 Not Reported ASA1 48.00 Ventilator Equipment $0 $180,186 $180,186
To include ventilator equipment expense.
42 CFR 413.24 / CMS Pub. 15-1, Section 2304

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