STATE OF CARECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS Page 1Schedule 8A-2Provider doc

S
TATE OF
CA
Provider Nam
SAYLOR LAN
Line Sub
No. No.
167 4
168 4
169 4
170 1
170 2
170 3
170 4
174 1
174 2
174 3
174 4
180 4
200
Schedule 8A-2
Page 1
Provider Number: NPI: OSHPD Facility Number: Fiscal Period:
ZZR05417K 1215928387 206341014 JANUARY 1, 2009 THROUGH DECEMBER 31, 2009
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
(Pages 1, 2, & 3) 45678910
RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS
0
(6,447)
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
($164,664) 0000000
(To Sch 8)
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State of California
Department of Health Care Serv
Provider Name Fiscal Period Provider Number
30
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease)
Adjusted
MEMORANDUM ADJUSTMENTS
1 10.7 075 1,2,3 N/A N/A N/A Patient Supplies (Square Feet) 0 149 149
10.7 080 1,2,3 N/A N/A N/A Physical Therapy 0 184 184

10.7 082 1,2,3 N/A N/A N/A Occupational Therapy 0 106 106
10.7 083 1,2,3 N/A N/A N/A Speech Pathology 01616
10.7 085 1,2,3 N/A N/A N/A Pharmacy 05050
10.7 105 1,2,3 N/A N/A N/A Skilled Nursing Care 0 4,260 4,260
2 10.7 105 4 N/A N/A N/A Skilled Nursing Care (Pounds of Laundry) 0 63,390 63,390
3 10.7 105 5 N/A N/A N/A Skilled Nursing Care (Meals Served) 0 38,034 38,034
To reconcile the provider’s reported statistics on page 10.7 to the
provider's reported statistics on page 11(1).
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
Page
Adjustmen
SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387
Cost Report
Explanation of Audit Adjustments
Report References
Audit Report
This is trial version
www.adultpdf.com
State of California
Department of Health Care Serv
Provider Name Fiscal Period Provider Number
30
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease)
Adjusted
Adjustmen
SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387
Cost Report
Explanation of Audit Adjustments

Report References
Audit Report
RECLASSIFICATIONS OF REPORTED COSTS
4 10.5 005 2 8A-2 005 2 Plant Operations and Maintenance - Fringe Benefits $1,707 $1,403 $3,110
10.5
010
2
8A-2
010
2
Housekeeping - Fringe Benefits
25,507
5,955
31,462
10.5
060
2
8A-2
060
2
Laundry and Linen - Fringe Benefits
6,533
2,063
8,596
10.5
065
2
8A-2
065
2

Dietary - Fringe Benefits
43,852
11,175
55,027
10.5 080 2 8A-2 080 2 Physical Therapy - Fringe Benefits 19,287 6,522 25,809
10.5 082 2 8A-2 082 2 Occupational Therapy - Fringe Benefits 10,324 3,569 13,893
10.5 083 2 8A-2 083 2 Speech Pathology - Fringe Benefits 3,992 1,361 5,353
10.5 105 2 8A-2 105 2 Skilled Nursing Care - Fringe Benefits 346,396 63,760 410,156
10.5 155 2 8A-2 155 2 Social Services - Fringe Benefits 11,023 3,996 15,019
10.5 160 2 8A-2 160 2 Activities - Fringe Benefits 7,815 1,836 9,651
10.5 165 2 8A-2 165 2 Administration - Fringe Benefits 54,557 17,775 72,332
10.5 166 2 8A-2 166 2 Administration - Medical Records - Fringe Benefits 6,428 2,298 8,726
10.5 105 2 8A-2 105 2 Skilled Nursing Care - Fringe Benefits * 410,156 (121,713) 288,443
To reclassify workers' compensation paid claims expense for proper
allocation of costs.
42 CFR 413.24 / CMS Pub. 15-1, Section 2302.8
5 10.5 035 4 8A-2 035 4 Leases and Rentals $129,740 $849 $130,589
10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor 73,133 (849) 72,284
To reclassify Xerox copier lease expense for proper cost finding
and to agree with AB1629 requirements.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
Welfare and Institutions Code Section 14126.023
6 10.5 085 4 8A-2 085 4 Pharmacy - Other - Nonlabor $83,946 $18,636 $102,582
10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor 83,665 (18,636) 65,029
To reclassify pharmacy costs to an ancillary cost center.
42 CFR 413.24 / CMS Pub. 15-1, Sections 2202.8 and 2203.2
CCR Title 22, Section 51511
*Balance carried forward from prior/to subsequent adjustments Page
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State of California
Department of Health Care Serv
Provider Name Fiscal Period Provider Number
30
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease)
Adjusted
Adjustmen
SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387
Cost Report
Explanation of Audit Adjustments
Report References
Audit Report
RECLASSIFICATIONS OF REPORTED COSTS
7 10.5 100 4 8A-2 100 4 Other Ancillary Services - Other - Nonlabor $1,348 $1,320 $2,668
10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * 72,284 (1,320) 70,964
To reclassify dental services to the Other Ancillary Services cost center.
42 CFR 413.24 / CMS Pub. 15-1, Sections 2202.8 and 2203.2
CCR, Title 22, Sections 51511 and 51123
8 10.5 100 4 8A-2 100 4 Other Ancillary Services - Other - Nonlabor * $2,668 $8,193 $10,861
10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * 70,964 (8,193) 62,771
To reclassify Community Mobile Diagnostic expenses from
Administration to the Other Ancillary Services cost center.
CCR, Title 22, Section 51511
9 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $62,771 $4,814 $67,585
10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * 65,029 (4,814) 60,215
To reclassify pharmacy consultant fees to the appropriate cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4, 2302.8, and 2304

10 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $67,585 $163,030 $230,615
10.5 165 1 8A-2 165 1 Administration - Salaries and Wages 242,105 (163,030) 79,075
To reclassify Administrative Salary expense adjustment 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
This is trial version
www.adultpdf.com
State of California
Department of Health Care Serv
Provider Name Fiscal Period Provider Number
30
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease)
Adjusted
Adjustmen
SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387
Cost Report
Explanation of Audit Adjustments
Report References
Audit Report
ADJUSTMENTS TO REPORTED COSTS
11 10.5 005 2 8A-2 005 2 Plant Operations and Maintenance - Fringe Benefits * $3,110 ($30) $3,080
10.5 010 2 8A-2 010 2 Housekeeping - Fringe Benefits * 31,462 (129) 31,333
10.5 060 2 8A-2 060 2 Laundry and Linen - Fringe Benefits * 8,596 (45) 8,551
10.5 065 2 8A-2 065 2 Dietary - Fringe Benefits * 55,027 (243) 54,784
10.5 080 2 8A-2 080 2 Physical Therapy - Fringe Benefits * 25,809 (142) 25,667
10.5 082 2 8A-2 082 2 Occupational Therapy - Fringe Benefits * 13,893 (78) 13,815

10.5 083 2 8A-2 083 2 Speech Pathology - Fringe Benefits * 5,353 (30) 5,323
10.5 105 2 8A-2 105 2 Skilled Nursing Care - Fringe Benefits * 288,443 (1,385) 287,058
10.5 155 2 8A-2 155 2 Social Services - Fringe Benefits * 15,019 (87) 14,932
10.5 160 2 8A-2 160 2 Activities - Fringe Benefits * 9,651 (40) 9,611
10.5 165 2 8A-2 165 2 Administration - Fringe Benefits * 72,332 (386) 71,946
10.5 166 2 8A-2 166 2 Administration - Medical Records - Fringe Benefits * 8,726 (50) 8,676
To adjust the reported workers' compensation premiums to agree with
the provider's records.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
12 10.5 005 4 8A-2 005 4 Plant Operations and Maintenance - Other - Nonlabor $93,232 ($2,865) $90,367
To eliminate Plant Operations and Maintenance expenses due to lack
of documentation.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * $60,215
13 To eliminate Skilled Nursing Care expenses due to lack of ($502)
documentation.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
14 To eliminate health insurance expenses not related to patient care (780)
at Saylor Lane. ($1,282) $58,933
42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3
15 10.5 165 1 8A-2 165 1 Administration - Salaries and Wages * $79,075 ($4,727) $74,348
To eliminate salary expense related to the home office.
42 CFR 413.17 / CMS Pub. 15-1, Section 1005
*Balance carried forward from prior/to subsequent adjustments Page
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State of California
Department of Health Care Serv
Provider Name Fiscal Period Provider Number
30

MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease)
Adjusted
Adjustmen
SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387
Cost Report
Explanation of Audit Adjustments
Report References
Audit Report
ADJUSTMENTS TO REPORTED COSTS
10.5 165 2 8A-2 165 2 Administration - Fringe Benefits * $71,946
16 To eliminate retirement expense due to lack of documentation. ($714)
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
17 To eliminate tax penalty not related to patient care. (188)
42 CFR 413.9(c)(3) / CMS Pub. 15-1, Sections 2102.3 and 2122.1 ($902) $71,044
10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $230,615
18 To eliminate legal fees due to lack of documentation. ($139,844)
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
19 To eliminate dental costs for individual patients. (1,100)
42 CFR 413.9 / CMS Pub. 15-1, Section 2104.4
CCR, Title 22, Section 51123
20 To eliminate Administrative expenses due to lack of documentation. (2,420)
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
21 To eliminate legal and consultant fees in connection with a fair hearing (585)
or other litigation against or involving any governmental agency or
department.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
Welfare and Institutions Code Section 14126.023
22 To eliminate Kellogg and Andelson expenses due to lack of documentation. (7,592)

42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
23 To eliminate tax preparation expense not related to patient care. (2,400)
42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3 ($153,941) $76,674
*Balance carried forward from prior/to subsequent adjustments Page
This is trial version
www.adultpdf.com
State of California
Department of Health Care Serv
Provider Name Fiscal Period Provider Number
30
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease)
Adjusted
Adjustmen
SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387
Cost Report
Explanation of Audit Adjustments
Report References
Audit Report
ADJUSTMENTS TO REPORTED COSTS
10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $76,674
24 To adjust reported home office costs to agree with the Centurion, Inc. $8,982
Home Office Audit Report for fiscal period ended December 31, 2009.
42 CFR 413.17 / CMS Pub. 15-1, Sections 2150.2 and 2304
25 To eliminate Administrative expense due to insufficient documentation. (837)
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 $8,145 $84,819
26 10.5 168 4 8A-2 168 4 Liability Insurance $61,819 ($6,447) $55,372
To adjust the reported 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
*Balance carried forward from prior/to subsequent adjustments Page
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www.adultpdf.com
State of California
Department of Health Care Serv
Provider Name Fiscal Period Provider Number
30
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease)
Adjusted
Adjustmen
SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387
Cost Report
Explanation of Audit Adjustments
Report References
Audit Report
ADJUSTMENT TO REPORTED STATISTICS
27 10.7 005 1 7 005 N/A Plant Operations and Maintenance (Square Feet) 0 144 144
10.7 010 1,2 7 010 N/A Housekeeping 03636
10.7 060 1,2,3 7 060 N/A Laundry and Linen 0 173 173
10.7 065 1,2,3 7 065 N/A Dietary 0 974 974
10.7 155 1,2,3 7 155 N/A Social Services 0 121 121
10.7 165 1,2,3 7 165 N/A Administration 0 284 284
10.7 175 1 7 N/A N/A Total - Square Feet Column 1 4,765 1,732 6,497
10.7 175 2 7 N/A N/A Total - Square Feet Column 2 4,765 1,588 6,353
10.7 175 3 7 N/A N/A Total - Square Feet Column 3 4,765 1,552 6,317
To adjust reported square feet statistics to agree with the provider's
square footage worksheet.

42 CFR 413.24 and 413.50 / CMS Pub. 15-1, Sections 2300 and 2304
Page
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State of California
Department of Health Care Serv
Provider Name Fiscal Period Provider Number
30
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease)
Adjusted
Adjustmen
SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387
Cost Report
Explanation of Audit Adjustments
Report References
Audit Report
ADJUSTMENT TO REPORTED PATIENT DAYS
28 11(2) 105 1 1 12 Total Patient Days 12,682 (4) 12,678
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
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State of California
Department of Health Care Serv
Provider Name Fiscal Period Provider Number
30

MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease)
Adjusted
Adjustmen
SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387
Cost Report
Explanation of Audit Adjustments
Report References
Audit Report
ADJUSTMENTS TO OTHER MATTERS
29 Not Reported 1 14 Overpayments $0 $2,359 $2,359
To recover outstanding Medi-Cal Credit balances.
CCR, Title 22, Section 50761 and 51458.1
30 Not Reported 1 14 Overpayments * $2,359 $1,514 $3,873
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
*Balance carried forward from prior/to subsequent adjustments Page
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