STATE OF CALIFORNIA Schedule 8A-2 Page 1 Provider Name: Provider No.: OSHPD Facility Number: Fiscal Period: VILLA GARDENS HEALTH CARE UNIT LTC55429H 206190515 APRIL 1, 2006 THROUGH MARCH 31, 2007 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1) 10 11 12 13 14 15 ADJUSTMENTS TO REPORTED COSTS 130.00 Hospice Inpatient Care 0 135.00 Other Routine Services 0 136.00 Residential Care 0 140.00 Beauty and Barber 0 145.00 Other Nonreimbursable 0 155.00 Social Services 0 155.01 Social Services - Salaries and Wages 0 155.02 Social Services - Fringe Benefits 0 155.03 Social Services - Agency Staff 0 155.04 Social Services - Other - Nonlabor 0 160.00 Activities 0 160.01 Activities - Salaries and Wages 0 160.02 Activities - Fringe Benefits 0 160.03 Activities - Agency Staff 0 160.04 Activities - Other - Nonlabor 0 165.00 Administration 0 165.01 Administration - Salaries and Wages 0 165.02 Administration - Fringe Benefits (6,463) (6,463) 165.03 Administration - Medical Records - Salaries and Wages 0 165.04 Administration - Medical Records - Fringe Benefits 6,463 6,463 165.05 Administration - Medical Records - Agency Staff 0 165.06 Administration - Medical Records - Other - Nonlabor 0 165.07 Administration - DHS Licensing Fees 11,127 11,127 165.08 Administration - Liability Insurance 0 165.09 Administration - Caregiver Training 0 165.10 Administration - Quality Assurance Fees 0 165.11 Administration - Other - Nonlabor (11,377) (11,127) (4,250) 4,000 170.00 Inservice Education - Nursing 0 170.01 Inservice Education - Nursing - Salaries and Wages 0 170.02 Inservice Education - Nursing - Fringe Benefits 0 170.03 Inservice Education - Nursing - Agency Staff 0 170.04 Inservice Education - Nursing - Other - Nonlabor 0 175.00 Total ($16,990) 0 0 (8,490) (8,250) (4,250) 4,000000 (To Sch 8) This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 16 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT 1 10.1(4) 05 14 8A-1 5.00 Plant Operations and Maintenance $213,092 ($213,092) $0 Not Reported 8A-1 5.01 Plant Operations and Maintenance - Salaries and Wages 0 56,789 56,789 Not Reported 8A-1 5.02 Plant Operations and Maintenance - Fringe Benefits 0 25,138 25,138 Not Reported 8A-1 5.04 Plant Operations and Maintenance - Other - Nonlabor 0 131,165 131,165 2 10.1(4) 10 14 8A-1 10.00 Housekeeping $61,808 ($61,808) $0 Not Reported 8A-1 10.01 Housekeeping - Salaries and Wages 0 31,944 31,944 Not Reported 8A-1 10.02 Housekeeping - Fringe Benefits 0 15,035 15,035 Not Reported 8A-1 10.04 Housekeeping - Other - Nonlabor 0 14,829 14,829 3 10.1(4) 60 14 8A-1 60.00 Laundry and Linen $57,438 ($57,438) $0 Not Reported 8A-1 60.01 Laundry and Linen - Salaries and Wages 0 31,777 31,777 Not Reported 8A-1 60.02 Laundry and Linen - Fringe Benefits 0 13,132 13,132 Not Reported 8A-1 60.04 Laundry and Linen - Other - Nonlabor 0 12,529 12,529 * 4 10.1(4) 65 14 8A-1 65.00 Dietary $498,369 ($498,369) $0 Not Reported 8A-1 65.01 Dietary - Salaries and Wages 0 254,567 254,567 Not Reported 8A-1 65.02 Dietary - Fringe Benefits 0 103,538 103,538 Not Reported 8A-1 65.04 Dietary - Other - Nonlabor 0 140,264 140,264 5 10.1(4) 105 14 8A-1 105.00 Skilled Nursing Care $1,491,602 ($1,491,602) $0 Not Reported 8A-1 105.01 Skilled Nursing Care - Salaries and Wages 0 1,027,270 1,027,270 Not Reported 8A-1 105.02 Skilled Nursing Care - Fringe Benefits 0 387,215 387,215 Not Reported 8A-1 105.04 Skilled Nursing Care - Other - Nonlabor 0 77,117 77,117 * 6 10.1(4) 155 14 8A-1 155.00 Social Services $48,282 ($48,282) $0 Not Reported 8A-1 155.01 Social Services - Salaries and Wages 0 34,577 34,577 Not Reported 8A-1 155.02 Social Services - Fringe Benefits 0 12,625 12,625 Not Reported 8A-1 155.04 Social Services - Other - Nonlabor 0 1,080 1,080 -Continued on next page- *Balance carried forward from prior/to subsequent adjustments Page 1 Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments VILLA GARDENS HEALTH CARE UNIT APRIL 1, 2006 THROUGH MARCH 31, 2007 LTC55429H This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 16 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments VILLA GARDENS HEALTH CARE UNIT APRIL 1, 2006 THROUGH MARCH 31, 2007 LTC55429H 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 $73,717 ($73,717) $0 Not Reported 8A-1 160.01 Activities - Salaries and Wages 0 45,270 45,270 Not Reported 8A-1 160.02 Activities - Fringe Benefits 0 15,547 15,547 Not Reported 8A-1 160.04 Activities - Other - Nonlabor 0 12,900 12,900 8 10.1(4) 165 14 8A-1 165.00 Administration $599,402 ($599,402) $0 Not Reported 8A-1 165.01 Administration - Salaries and Wages 0 141,734 141,734 Not Reported 8A-1 165.02 Administration - Fringe Benefits 0 40,791 40,791 * Not Reported 8A-1 165.03 Administration - Medical Records - Salaries and Wages 0 26,685 26,685 Not Reported 8A-1 165.11 Administration - Other - Nonlabor 0 390,192 390,192 * 9 10.1(4) 170 14 8A-1 170.00 Inservice Education - Nursing $74,246 ($74,246) $0 Not Reported 8A-1 170.01 Inservice Education - Nursing - Salaries and Wages 0 53,352 53,352 Not Reported 8A-1 170.02 Inservice Education - Nursing - Fringe Benefits 0 20,775 20,775 Not Reported 8A-1 170.04 Inservice Education - Nursing - Other - Nonlabor 0 119 119 To reclassify reported expenses 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 2 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 16 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments VILLA GARDENS HEALTH CARE UNIT APRIL 1, 2006 THROUGH MARCH 31, 2007 LTC55429H RECLASSIFICATIONS OF REPORTED COSTS 10 Not Reported 8A-2 165.07 Administration - DHS Licensing Fees $0 $11,127 $11,127 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 390,192 (11,127) 379,065 * To reclassify Department of Health Care Services licensing fees to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 11 Not Reported 8A-2 165.04 Administration - Medical Records - Fringe Benefits $0 $6,463 $6,463 Not Reported 8A-2 165.02 Administration - Fringe Benefits * 40,791 (6,463) 34,328 To reclassify medical records employee benefits 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 3 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 16 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 VILLA GARDENS HEALTH CARE UNIT APRIL 1, 2006 THROUGH MARCH 31, 2007 LTC55429H ADJUSTMENTS TO REPORTED COSTS 12 Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * $12,529 ($8,490) $4,039 To abate laundry and linen revenue against related costs. 42 CFR 413.5 and 413.9 / CMS Pub. 15-1, Section 2328 13 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * $77,117 ($8,250) $68,867 To eliminate utilization review expense due to the fact that the State performs its own utilization review. CMS Pub. 15-1, Section 2126 CCR, Title 22, Sections 50009.1 and 51159 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $379,065 14 To adjust licensing fees to agree with the Department of Health Care ($4,250) Services licensing fees applicable to the audit period. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 15 To adjust home office costs to agree with the filed Home Office 4,000 Cost Report for fiscal year ended March 31, 2007. ($250) $378,815 42 CFR 413.17 / CMS Pub. 15-1, Sections 2150.2 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 16 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 VILLA GARDENS HEALTH CARE UNIT APRIL 1, 2006 THROUGH MARCH 31, 2007 LTC55429H ADJUSTMENT TO REPORTED STATISTICS 16 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 2,156 2,156 Not Reported 7 60.00 Laundry and Linen 0 140 140 Not Reported 7 65.00 Dietary 0 1,005 1,005 11.1(1 of 3) 10 2 7 75.00 Patient Supplies 2,925 (2,687) 238 11.1(1 of 3) 40 2 7 105.00 Skilled Nursing Care 15,091 (3,298) 11,793 Not Reported 7 155.00 Social Services 0 121 121 Not Reported 7 160.00 Activities 0 664 664 Not Reported 7 165.00 Administration 04242 Not Reported 7 165.00 Medical Records 09090 Not Reported 7 170.00 Inservice Education - Nursing 0 600 600 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 18,798 (1,167) 17,631 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 18,798 (3,323) 15,475 To adjust square footage statistics to agree with the provider's prior year records. 42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306 Page 5 This is trial version www.adultpdf.com . LTC55429H ADJUSTMENTS TO REPORTED COSTS 12 Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * $12,529 ($8,490) $4,039 To abate laundry and linen revenue against related costs. 42. and 2304 *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. LTC55429H RECLASSIFICATIONS OF REPORTED COSTS 10 Not Reported 8A-2 165.07 Administration - DHS Licensing Fees $0 $11,127 $11,127 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 390,192 (11,127) 379,065 * To