State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 47 ` 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 WESTLAKE HEALTH CARE CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC55794F ADJUSTMENTS TO REPORTED STATISTICS 38 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 408 408 Not Reported 7 10.00 Housekeeping 0 396 396 Not Reported 7 60.00 Laundry and Linen 0 400 400 Not Reported 7 65.00 Dietary 0 3,140 3,140 11.1 (1 of 3) 40 2 7 105.00 Skilled Nursing Care 16,311 (6,316) 9,995 11.1 (1 of 3) 60 2 7 125.00 Subacute Care 4,130 (572) 3,558 11.1 (1 of 3) 75 2 7 140.00 Beauty and Barber 0 378 378 Not Reported 7 155.00 Social Services 0 126 126 Not Reported 7 160.00 Activities 0 1,764 1,764 Not Reported 7 165.00 Administration 0 288 288 Not Reported 7 165.00 Medical Records 0 240 240 Not Reported 7 170.00 Inservice Education - Nursing 0 126 126 11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 21,621 378 21,999 11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 21,621 (30) 21,591 11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 21,621 (426) 21,195 To adjust square footage statistics to agree with the prior year's audit findings and provider's records. 42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 39 11.1 (1 of 3) 40 4 7 105.00 Skilled Nursing Care (Pounds of Laundry) 274,290 (4,200) 270,090 11.1 (1 of 3) 60 4 7 125.00 Subacute Care 11,760 (250) 11,510 11.1 (1 of 3) 85 4 7 N/A Total Statistics - Pounds of Laundry 286,050 (4,450) 281,600 To adjust the pounds of laundry statistics for proper allocation of cost. 42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306 40 11.1 (2 of 3) 40 6 7 105.00 Skilled Nursing Care (Meals Served) 82,287 (1,260) 81,027 11.1 (2 of 3) 60 6 7 125.00 Subacute Care 3,528 (1,017) 2,511 11.1 (2 of 3) 85 6 7 N/A Total Statistics - Meals Served 85,815 (2,277) 83,538 To adjust meals served statistics for proper allocation of cost. 42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306 Page 10 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 47 ` 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 WESTLAKE HEALTH CARE CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC55794F ADJUSTMENT TO REPORTED PATIENT DAYS 41 4.3(1) 100 1 ASA1 48.00 Total Subacute Days - Ventilator 1,176 (862) 314 4.3(1) 115 1 ASA1 49.00 Total Subacute Days - Non-Ventilator 0 862 862 To adjust total Subacute ventilator patient days based on the ratio of Medi-Cal ventilator days to total ventilator days. 42 CFR 413.20 and 413.50 / CMS Pub. 15-1, Sections 2205 and 2304 Page 11 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 47 ` 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 WESTLAKE HEALTH CARE CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC55794F ADJUSTMENT TO REPORTED TOTAL CHARGES 42 13.1 20 4 ASA 2 77.00 Subacute Ancillary Charges - Pharmacy $138,616 ($138,616) $0 To eliminate the Subacute pharmacy ancillary charges for prescription drugs as these are not included in the Subacute per diem rate. CCR, Title 22, Sections 51511(c), 51511.5(c) and 51511.5(d) Page 12 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 47 ` 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 WESTLAKE HEALTH CARE CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC55794F ADJUSTMENT TO REPORTED MEDI-CAL SETTLEMENT DATA - SUBACUTE 43 4.3(1) 100 2 ASA 1 48.00 Medi-Cal Subacute Days - Ventilator 0 112 112 To adjust Medi-Cal Settlement Data to agree with the following EDS Paid Claims Summary: Report Date: June 17, 2009 Payment Period: January 1, 2008 through May 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 Page 13 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 47 ` 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 WESTLAKE HEALTH CARE CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC55794F ` ADJUSTMENTS TO OTHER MATTERS 44 Not Reported ASA1 41.00 Contracted Number of Adult Subacute Beds 0 22 22 To reflect the number of contracted Subacute beds in the audit report. CMS Pub. 15-1, Section 2300 and 2304 Not Reported 1 14.00 Overpayments - Skilled Nursing Care $0 45 To recover outstanding Medi-Cal credit balances. $9,924 CCR, Title 22, Sections 50761 and 51458.1 46 To recover Medi-Cal overpayments because the 6114's 324 were not provided. $10,248 $10,248 42 CFR 413.5 and 413.20 / CMS Pub. 15-1, Section 2409 47 Not Reported ASA1 39.00 Overpayments - Subacute $0 $2,290 $2,290 To recover outstanding Medi-Cal credit balances. CCR, Title 22, Sections 50761 and 51458.1 Page 14 This is trial version www.adultpdf.com . following EDS Paid Claims Summary: Report Date: June 17, 2009 Payment Period: January 1, 2008 through May 31, 2009 Service Period: January 1, 2008 through December 31, 2008 42 CFR 413.20, 413.50,. Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments WESTLAKE HEALTH CARE CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008. Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments WESTLAKE HEALTH CARE CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC55794F ADJUSTMENT TO REPORTED