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 RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT 1 10.1(4) 5 14 8A-1 5.00 Plant Operations and Maintenance $334,015 ($334,015) $0 Not Reported 8A-1 5.01 Plant Operations and Maintenance - Salaries and Wages 0 80,145 80,145 Not Reported 8A-1 5.02 Plant Operations and Maintenance - Fringe Benefits 0 16,241 16,241 * Not Reported 8A-1 5.04 Plant Operations and Maintenance - Other - Nonlabor 0 237,629 237,629 * 2 10.1(4) 10 14 8A-1 10.00 Housekeeping $295,773 ($295,773) $0 Not Reported 8A-1 10.01 Housekeeping - Salaries and Wages 0 208,513 208,513 Not Reported 8A-1 10.02 Housekeeping - Fringe Benefits 0 46,344 46,344 * Not Reported 8A-1 10.04 Housekeeping - Other - Nonlabor 0 40,916 40,916 3 10.1(4) 60 14 8A-1 60.00 Laundry and Linen $177,451 ($177,451) $0 Not Reported 8A-1 60.01 Laundry and Linen - Salaries and Wages 0 111,619 111,619 Not Reported 8A-1 60.02 Laundry and Linen - Fringe Benefits 0 30,595 30,595 * Not Reported 8A-1 60.04 Laundry and Linen - Other - Nonlabor 0 35,237 35,237 4 10.1(4) 65 14 8A-1 65.00 Dietary $584,229 ($584,630) ($401) * Not Reported 8A-1 65.01 Dietary - Salaries and Wages 0 278,639 278,639 Not Reported 8A-1 65.02 Dietary - Fringe Benefits 0 62,462 62,462 * Not Reported 8A-1 65.04 Dietary - Other - Nonlabor 0 243,529 243,529 * 5 10.1(4) 105 14 8A-1 105.00 Skilled Nursing Care $3,308,285 ($3,308,285) $0 Not Reported 8A-1 105.01 Skilled Nursing Care - Salaries and Wages 0 2,733,043 2,733,043 * Not Reported 8A-1 105.02 Skilled Nursing Care - Fringe Benefits 0 547,523 547,523 * Not Reported 8A-1 105.04 Skilled Nursing Care - Other - Nonlabor 0 27,719 27,719 * 6 10.1(4) 155 14 8A-1 155.00 Social Services $49,521 ($49,521) $0 Not Reported 8A-1 155.01 Social Services - Salaries and Wages 0 43,682 43,682 Not Reported 8A-1 155.02 Social Services - Fringe Benefits 0 5,839 5,839 * -Continued on next page- *Balance carried forward from prior/to subsequent adjustments Page 1 Adjustments COLLEGE OAK NURSING AND REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZR06158H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 35 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments COLLEGE OAK NURSING AND REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZR06158H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT -Continued from previous page- 7 10.1(4) 160 14 8A-1 160.00 Activities $102,543 ($102,543) $0 Not Reported 8A-1 160.01 Activities - Salaries and Wages 0 65,352 65,352 Not Reported 8A-1 160.02 Activities - Fringe Benefits 0 13,105 13,105 * Not Reported 8A-1 160.04 Activities - Other - Nonlabor 0 24,086 24,086 8 10.1(4) 165 14 8A-1 165.00 Administration $1,276,551 ($1,147,203) $129,348 * Not Reported 8A-1 165.01 Administration - Salaries and Wages 0 321,447 321,447 * Not Reported 8A-1 165.02 Administration - Fringe Benefits 0 67,397 67,397 * Not Reported 8A-1 165.11 Administration - Other - Nonlabor 0 758,359 758,359 * 9 10.1(4) 170 14 8A-1 170.00 Inservice Education - Nursing $82,639 ($82,639) $0 Not Reported 8A-1 170.01 Inservice Education - Nursing - Salaries and Wages 0 72,803 72,803 Not Reported 8A-1 170.02 Inservice Education - Nursing - Fringe Benefits 0 9,836 9,836 * To reclassify reported expenses for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 W&I Code, Sections 14105.06 and 14126 et seq. *Balance carried forward from prior/to subsequent adjustments Page 2 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 35 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments COLLEGE OAK NURSING AND REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZR06158H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT 10 10.1(4) 65 14 8A-1 65.00 Dietary * ($401) $401 $0 Not Reported 8A-1 65.04 Dietary - Other - Nonlabor * 243,529 (401) 243,128 11 10.1(4) 165 14 8A-1 165.00 Administration * $129,348 ($129,348) $0 Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 758,359 129,348 887,707 * To reclassify the provider's adjustments for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 W&I Code, Sections 14105.06 and 14126 et seq. *Balance carried forward from prior/to subsequent adjustments Page 3 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 35 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments COLLEGE OAK NURSING AND REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZR06158H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments RECLASSIFICATIONS OF REPORTED COSTS 12 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $321,447 ($67,821) $253,626 Not Reported 8A-2 165.02 Administration - Fringe Benefits * 67,397 (10,365) 57,032 * Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 887,707 (287,577) 600,130 * Not Reported 8A-2 165.03 Administration - Medical Records - Salaries and Wages 0 67,821 67,821 Not Reported 8A-2 165.04 Administration - Medical Records - Fringe Benefits 0 10,365 10,365 * Not Reported 8A-2 165.10 Administration - Quality Assurance Fees 0 287,577 287,577 To reclassify medical records and quality assurance fees expenses to proper cost center line numbers to comply with AB 1629 requirement. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 W&I Code, Sections 14105.06 and 14126 et seq. 13 Not Reported 8A-2 105.01 Skilled Nursing Care - Salaries and Wages * $2,733,043 ($183) $2,732,860 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 27,719 183 27,902 * To reclassify Aides and C.N.A. registry cost reduction to the proper cost center line number. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 W&I Code, Sections 14105.06 and 14126 et seq. 14 Not Reported 8A-2 165.07 Administration - Facility Licensing Fees $0 $30,817 $30,817 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 600,130 (30,817) 569,313 * To reclassify DHCS licensing fees to comply with AB 1629 requirement. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 W&I Code, Sections 14105.06 and 14126 et seq. 15 Not Reported 8A-2 165.08 Administration - Liability Insurance $0 $94,982 $94,982 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 569,313 (94,982) 474,331 * To reclassify reported liability insurance expense for proper cost determination to comply with AB 1620 requirement. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 W&I Code, Sections 14105.06 and 14126 et seq. *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 35 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments COLLEGE OAK NURSING AND REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZR06158H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments RECLASSIFICATIONS OF REPORTED COSTS 16 10.1(4) 85 14 8A-2 85.00 Pharmacy $159,466 $21,773 $181,239 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 27,902 (21,773) 6,129 * To reclassify reported Pharmacy Consultant expense for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 W&I Code, Sections 14105.06 and 14126 et seq. 17 Not Reported 8A-2 5.04 Plant Operations and Maintenance - Other - Nonlabor * $237,629 ($1,818) $235,811 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 474,331 1,818 476,149 * To abate vending machine commissions against Plant Operation and Maintenance cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2304 and 2306 18 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * $6,129 ($3,112) $3,017 * Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 476,149 3,112 479,261 * To reclassify employee mileage reimbursements for proper cost determination. 42 CFR 413.5, 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2304, 2306 and 2307 19 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * $3,017 ($2,841) $176 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 479,261 2,841 482,102 * To reclassify reported seminar costs for proper cost determination. 42 CFR 413.5, 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2304, 2306 and 2307 20 10.1(4) 30 14 8A-2 30.00 Depreciation and Amortization - Other $0 $48,243 $48,243 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 482,102 (48,243) 433,859 * To include cost of ownership in lieu of related party lease expenses in the proper cost center line number. 42 CFR 413.17, 413.20 and 413.24 CMS Pub. 15-1, Sections 100 et seq. and 1011.5 *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 COLLEGE OAK NURSING AND REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZR06158H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED COSTS 21 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $433,859 To disallow FY 2007/2008 OSHPD license fee which was included ($1,471) in the provider's FYE 2007 general ledger. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 22 To eliminate retainer fee to comply with regulation. (2,459) 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2126.4, 2300 and 2304 23 (90,601) 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2161 et seq., 2300 and 2304 24 To eliminate donation expense not related to patient care. (250) 42 CFR 413.5(c)(7), 413.9 and 413.80 CMS Pub. 15-1, Section 2102.3 25 To eliminate travel expense due to lack of documentation. (253) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 ($95,034) $338,825 * *Balance carried forward from prior/to subsequent adjustments Page 6 To eliminate legal fee expenses greater than deductible per provider's malpractice insurance policy. 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 COLLEGE OAK NURSING AND REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZR06158H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED COSTS 26 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $338,825 To eliminate accounting expenses due to lack of documentation. ($50) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 27 To eliminate late payment finance charges and bank penalties (1,672) not related to patient care. 42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3 28 To eliminate duplicate payments of invoices. (11,818) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 ($13,540) $325,285 * *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 35 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments COLLEGE OAK NURSING AND REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZR06158H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED COSTS 29 10.1(4) 75 14 8A-2 75.00 Patient Supplies $181,456 $693 $182,149 To reverse the provider's ancillary cost elimination for proper cost determination. 42 CFR 413.5, 413.9, 413.20 and 413.24 CMS Pub. 15-1, Section 2328 30 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $325,285 ($16,607) $308,678 To adjust reported home office costs to agree with the Centurion Healthcare Home Office Audit Report for fiscal period ended ended December 31, 2008. 42 CFR 413.17 / CMS Pub. 15-1, Sections 2150.2 and 2304 31 Not Reported 8A-2 5.02 Plant Operations and Maintenance - Fringe Benefits * $16,241 ($90) $16,151 Not Reported 8A-2 10.02 Housekeeping - Fringe Benefits * 46,344 (235) 46,109 Not Reported 8A-2 60.02 Laundry and Linen - Fringe Benefits * 30,595 (126) 30,469 Not Reported 8A-2 65.02 Dietary - Fringe Benefits * 62,462 (313) 62,149 10.1(4) 80 14 8A-2 80.00 Physical Therapy 198,814 (181) 198,633 10.1(4) 82 14 8A-2 82.00 Occupational Therapy 108,342 (97) 108,245 10.1(4) 83 14 8A-2 83.00 Speech Pathology 66,874 (61) 66,813 Not Reported 8A-2 105.02 Skilled Nursing Care - Fringe Benefits * 547,523 (3,075) 544,448 Not Reported 8A-2 155.02 Social Services - Fringe Benefits * 5,839 (49) 5,790 Not Reported 8A-2 160.02 Activities - Fringe Benefits * 13,105 (74) 13,031 Not Reported 8A-2 165.02 Administration - Fringe Benefits * 57,032 (285) 56,747 Not Reported 8A-2 165.04 Administration - Medical Records - Fringe Benefits * 10,365 (76) 10,289 Not Reported 8A-2 170.02 Inservice Education - Nursing - Fringe Benefits * 9,836 (82) 9,754 To adjust the reported workers' compensation expense to agree with 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 8 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 35 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments COLLEGE OAK NURSING AND REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZR06158H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments ADJUSTMENT TO REPORTED STATISTICS 32 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 1,147 1,147 Not Reported 7 10.00 Housekeeping 0 450 450 Not Reported 7 60.00 Laundry and Linen 0 771 771 Not Reported 7 65.00 Dietary 0 4,454 4,454 Not Reported 7 155.00 Social Services 0 165 165 Not Reported 7 160.00 Activities 0 239 239 Not Reported 7 165.00 Administration 0 1,393 1,393 Not Reported 7 165.00 Medical Record 0 616 616 Not Reported 7 170.00 Inservice Education - Nursing 0 352 352 11.1(1 of 3) 85 2 7 N/A Total - Square Feet - Capital 19,664 9,587 29,251 11.1(1 of 3) 85 2 7 N/A Total - Square Feet - Plant Operations and Maintenance 19,664 8,440 28,104 11.1(1 of 3) 85 2 7 N/A Total - Square Feet - Housekeeping 19,664 7,990 27,654 To adjust square footage statistics to agree with the provider's documentation. 42 CFR 413.24 and 413.50 / CMS Pub. 15-1, Sections 2304 and 2306 W&I Code, Sections 14105.06 and 14126 et seq. Page 9 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 COLLEGE OAK NURSING AND REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZR06158H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments ADJUSTMENTS TO OTHER MATTERS 33 Not Reported 1 14.00 Overpayments $0 To recover Medi-Cal overpayments because the Share of Cost ($4,872) was not properly deducted from the amount billed. 42 CFR 413.5 and 413.20 / CMS Pub. 15-1, Section 2409 34 To recover Medi-Cal overpayments for the day of discharge. (830) CMS Pub. 15-1, Section 2205.1 CCR, Title 22, Section 51476 Medi-Cal Contract, Article 4.3 35 To recover outstanding Medi-Cal credit balances. (8,212) CCR, Title 22, Sections 50761 and 51458.1 ($13,914) ($13,914) Page 10 This is trial version www.adultpdf.com . REPORT Explanation of Audit Adjustments RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT 10 10.1(4) 65 14 8A-1 65.00 Dietary * ($401) $401 $0 Not Reported 8A-1 65.04 Dietary - Other -. ZZR06158H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED COSTS 26 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $338,825 To eliminate. REPORT Explanation of Audit Adjustments RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT -Continued from previous page- 7 10.1(4) 160 14 8A-1 160.00 Activities $102,543 ($102,543) $0 Not Reported