STATE OF CALIFORNIA Schedule 8A-2 Page 1 Provider Name: Provider No.: OSHPD Facility Number: Fiscal Period: LA CUMBRE SENIOR LIVING CONCEPTS ZZT05383H 206421102 JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1) 13 14 15 16 17 18 19 20 ADJUSTMENTS TO REPORTED COSTS 82.02 Occupational Therapy - Fringe Benefits 0 82.03 Occupational Therapy - Agency Staff 0 82.04 Occupational Therapy - Other - Nonlabor 0 83.00 Speech Pathology 0 83.01 Speech Pathology - Salaries and Wages 0 83.02 Speech Pathology - Fringe Benefits 0 83.03 Speech Pathology - Agency Staff 0 83.04 Speech Pathology - Other - Nonlabor 0 85.00 Pharmacy 0 85.01 Pharmacy - Salaries and Wages 0 85.02 Pharmacy - Fringe Benefits 0 85.03 Pharmacy - Agency Staff 0 85.04 Pharmacy - Other - Nonlabor 0 90.00 Laboratory 0 90.01 Laboratory - Salaries and Wages 0 90.02 Laboratory - Fringe Benefits 0 90.03 Laboratory - Agency Staff 0 90.04 Laboratory - Other - Nonlabor 0 95.00 Home Health Services 0 95.01 Home Health Services - Salaries and Wages 0 95.02 Home Health Services - Fringe Benefits 0 95.03 Home Health Services - Agency Staff 0 95.04 Home Health Services - Other - Nonlabor 0 100.00 Other Ancillary Services 0 100.01 Other Ancillary Services - Salaries and Wages 0 100.02 Other Ancillary Services - Fringe Benefits 0 100.03 Other Ancillary Services - Agency Staff 0 100.04 Other Ancillary Services - Other - Nonlabor 0 100.06 Subacute Ancillary Services 0 100.07 Subacute Ancillary Services - Salaries and Wages 0 100.08 Subacute Ancillary Services - Fringe Benefits 0 100.09 Subacute Ancillary Services - Agency Staff 0 100.10 Subacute Ancillary Services - Other - Nonlabor 0 100.12 Subacute Pediatrics Ancillary Services 0 105.00 Skilled Nursing Care 0 105.01 Skilled Nursing Care - Salaries and Wages 0 105.02 Skilled Nursing Care - Fringe Benefits 0 105.03 Skilled Nursing Care - Agency Staff 0 105.04 Skilled Nursing Care - Other - Nonlabor (46,945) (46,945) 110.00 Intermediate Care 0 115.00 Mentally Disordered 0 120.00 Developmentally Disabled 0 125.00 Subacute Care 0 125.01 Subacute Care - Salaries and Wages 0 125.02 Subacute Care - Fringe Benefits 0 125.03 Subacute Care - Agency Staff 0 125.04 Subacute Care - Other - Nonlabor 0 126.00 Subacute Care - Pediatrics 0 This is trial version www.adultpdf.com STATE OF CALIFORNIA Schedule 8A-2 Page 1 Provider Name: Provider No.: OSHPD Facility Number: Fiscal Period: LA CUMBRE SENIOR LIVING CONCEPTS ZZT05383H 206421102 JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1) 13 14 15 16 17 18 19 20 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 0 165.03 Administration - Medical Records - Salaries and Wages 0 165.04 Administration - Medical Records - Fringe Benefits 0 165.05 Administration - Medical Records - Agency Staff 0 165.06 Administration - Medical Records - Other - Nonlabor 0 165.07 Administration - DHS Licensing Fees (47,000) (49,153) 2,153 165.08 Administration - Liability Insurance 0 165.09 Administration - Caregiver Training 0 165.10 Administration - Quality Assurance Fees (32,486) (28,920) (3,566) 165.11 Administration - Other - Nonlabor 121,483 49,153 28,920 46,945 (1,318) (2,217) 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 $2,25300005,8832,153(2,217) (3,566) 0 (To Sch 8) This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 22 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted RECONCILIATIONS OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT 1 10.1(4) 5 14 8A-1 5.00 Plant Operations and Maintenance $439,599 ($439,599) $0 Not Reported 8A-1 5.01 Plant Operations and Maintenance - Salaries and Wages 0 112,807 112,807 Not Reported 8A-1 5.02 Plant Operations and Maintenance - Fringe Benefits 0 34,483 34,483 Not Reported 8A-1 5.04 Plant Operations and Maintenance - Other - Nonlabor 0 292,309 292,309 2 10.1(4) 10 14 8A-1 10.00 Housekeeping $202,431 ($202,431) $0 Not Reported 8A-1 10.01 Housekeeping - Salaries and Wages 0 116,309 116,309 Not Reported 8A-1 10.02 Housekeeping - Fringe Benefits 0 38,011 38,011 Not Reported 8A-1 10.04 Housekeeping - Other - Nonlabor 0 48,111 48,111 3 10.1(4) 60 14 8A-1 60.00 Laundry and Linen $107,698 ($107,698) $0 Not Reported 8A-1 60.01 Laundry and Linen - Salaries and Wages 0 73,088 73,088 Not Reported 8A-1 60.02 Laundry and Linen - Fringe Benefits 0 24,174 24,174 Not Reported 8A-1 60.04 Laundry and Linen - Other - Nonlabor 0 10,436 10,436 4 10.1(4) 65 14 8A-1 65.00 Dietary $758,655 ($758,655) $0 Not Reported 8A-1 65.01 Dietary - Salaries and Wages 0 283,337 283,337 Not Reported 8A-1 65.02 Dietary - Fringe Benefits 0 85,364 85,364 Not Reported 8A-1 65.04 Dietary - Other - Nonlabor 0 389,954 389,954 5 10.1(4) 105 14 8A-1 105.00 Skilled Nursing Care $4,834,458 ($4,834,458) $0 Not Reported 8A-1 105.01 Skilled Nursing Care - Salaries and Wages 0 3,521,973 3,521,973 Not Reported 8A-1 105.02 Skilled Nursing Care - Fringe Benefits 0 1,093,734 1,093,734 Not Reported 8A-1 105.04 Skilled Nursing Care - Other - Nonlabor 0 218,751 218,751 * 6 10.1(4) 155 14 8A-1 155.00 Social Services $104,374 ($104,374) $0 Not Reported 8A-1 155.01 Social Services - Salaries and Wages 0 77,546 77,546 Not Reported 8A-1 155.02 Social Services - Fringe Benefits 0 23,151 23,151 Not Reported 8A-1 155.04 Social Services - Other - Nonlabor 0 3,677 3,677 -Continued on next page- *Balance carried forward from prior/to subsequent adjustments Page 1 Adjustments LA CUMBRE SENIOR LIVING CONCEPTS JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05383H 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 22 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments LA CUMBRE SENIOR LIVING CONCEPTS JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05383H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments RECONCILIATIONS OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT -Continued from previous page- 7 10.1(4) 160 14 8A-1 160.00 Activities $174,984 ($175,090) ($106) * Not Reported 8A-1 160.01 Activities - Salaries and Wages 0 124,256 124,256 Not Reported 8A-1 160.02 Activities - Fringe Benefits 0 39,913 39,913 Not Reported 8A-1 160.04 Activities - Other - Nonlabor 0 10,921 10,921 * 8 10.1(4) 165 14 8A-1 165.00 Administration $1,621,153 ($1,717,129) ($95,976) * Not Reported 8A-1 165.01 Administration - Salaries and Wages 0 237,073 237,073 Not Reported 8A-1 165.02 Administration - Fringe Benefits 0 76,824 76,824 Not Reported 8A-1 165.03 Administration - Medical Records - Salaries and Wages 0 115,970 115,970 Not Reported 8A-1 165.04 Administration - Medical Records - Fringe Benefits 0 36,982 36,982 Not Reported 8A-1 165.06 Administration - Medical Records - Other - Nonlabor 0 3,745 3,745 Not Reported 8A-1 165.07 Administration - DHS Licensing Fees 0 80,582 80,582 * Not Reported 8A-1 165.08 Administration - Liability Insurance 0 79,004 79,004 * Not Reported 8A-1 165.10 Administration - Quality Assurance Fees 0 413,445 413,445 * Not Reported 8A-1 165.11 Administration - Other - Nonlabor 0 673,504 673,504 * 9 10.1(4) 170 14 8A-1 170.00 Inservice Education - Nursing $79,881 ($79,881) $0 Not Reported 8A-1 170.01 Inservice Education - Nursing - Salaries and Wages 0 62,007 62,007 Not Reported 8A-1 170.02 Inservice Education - Nursing - Fringe Benefits 0 17,874 17,874 To reclassify the 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 22 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments LA CUMBRE SENIOR LIVING CONCEPTS JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05383H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments RECONCILIATIONS OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT 10 10.1(4) 165 14 8A-1 165.00 Administration * ($95,976) $16,972 ($79,004) * Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 673,504 (16,972) 656,532 * 11 10.1(4) 165 14 8A-1 165.00 Administration * ($79,004) $79,004 $0 Not Reported 8A-1 165.08 Administration - Liability Insurance * 79,004 (79,004) 0 12 10.1(4) 160 14 8A-1 160.00 Activities * ($106) $106 $0 Not Reported 8A-1 160.04 Activities - Other - Nonlabor * 10,921 (106) 10,815 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 *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 22 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments LA CUMBRE SENIOR LIVING CONCEPTS JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05383H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments RECLASSIFICATIONS OF REPORTED COSTS 13 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $656,532 $49,153 $705,685 * Not Reported 8A-2 165.07 Administration - DHS Licensing Fees * 80,582 (49,153) 31,429 * To reclassify non-Department Health Care Services fees for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 14 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $705,685 $28,920 $734,605 * Not Reported 8A-2 165.10 Administration - Quality Assurance Fees * 413,445 (28,920) 384,525 * To reclassify administrative expenses for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 15 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $734,605 $46,945 $781,550 * Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 218,751 (46,945) 171,806 To reclassify Medical Director's salary to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 16 10.1(4) 45 14 8A-2 45.00 Property Insurance $15,551 $1,318 $16,869 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 781,550 (1,318) 780,232 * To reclassify home office property insurance expenses 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 4 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 22 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments LA CUMBRE SENIOR LIVING CONCEPTS JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05383H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED COSTS 17 Not Reported 40 14 8A-2 40.00 Property Taxes $21,883 $5,883 $27,766 To reflect the proper accrual of real property taxes applicable to the audit period. 42 CFR 413.5 and 413.24 CMS Pub. 15-1, Sections 2300 and 2302.1 18 Not Reported 8A-2 165.07 Administration - DHS Licensing Fees * $31,429 $2,153 $33,582 To adjust the Department Health Care Services licensing fees to reflect current year expenses. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 19 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $780,232 ($2,217) $778,015 To eliminate tax expenses not related to patient care. 42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3 20 Not Reported 8A-2 165.10 Administration - Quality Assurance Fees * $384,525 ($3,566) $380,959 To adjust the quality assurance fees to agree with the provider's records. 42 CFR 413.24 and 413.50 / CMS Pub. 15-1, Sections 2300 and 2304 *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 22 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments LA CUMBRE SENIOR LIVING CONCEPTS JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05383H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments ADJUSTMENT TO REPORTED STATISTICS 21 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 616 616 Not Reported 7 10.00 Housekeeping 0 1,357 1,357 Not Reported 7 60.00 Laundry and Linen 0 805 805 Not Reported 7 65.00 Dietary 0 2,730 2,730 11.1(1 of 3) 15 2 7 80.00 Physical Therapy 1,575 (1,156) 419 11.1(1 of 3) 17 2 7 82.00 Occupational Therapy 153 11 164 11.1(1 of 3) 18 2 7 83.00 Speech Pathology 283 (119) 164 11.1(1 of 3) 40 2 7 105.00 Skilled Nursing Care 21,355 (5,639) 15,716 Not Reported 7 140.00 Beauty and Barber 0 189 189 Not Reported 7 155.00 Social Services 0 375 375 Not Reported 7 160.00 Activities 0 998 998 Not Reported 7 165.00 Administration-Medical Records 0 447 447 Not Reported 7 165.00 Administration 0 1,055 1,055 Not Reported 7 170.00 Inservice Education - Nursing 0 302 302 11.1(1 of 3) 85 2 7 N/A Total - Square Feet 23,366 1,971 25,337 11.1(1 of 3) 85 2 7 N/A Total - Square Feet 23,366 1,355 24,721 11.1(1 of 3) 85 2 7 N/A Total - Square Feet 23,366 (2) 23,364 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 Page 6 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 22 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments LA CUMBRE SENIOR LIVING CONCEPTS JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05383H Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments ADJUSTMENT TO REPORTED PATIENT DAYS 22 11.1(3 of 3) 105 1 1 12.00 Total Patient Days 47,559 119 47,678 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 7 This is trial version www.adultpdf.com . Audit Adjustments ADJUSTMENTS TO REPORTED COSTS 17 Not Reported 40 14 8A-2 40.00 Property Taxes $21,883 $5,883 $27,766 To reflect the proper accrual of real property taxes applicable to the audit. REPORT Explanation of Audit Adjustments ADJUSTMENT TO REPORTED PATIENT DAYS 22 11.1(3 of 3) 105 1 1 12.00 Total Patient Days 47,559 119 47,678 To adjust total patient days to agree with the provider's patient. Nursing - Other - Nonlabor 0 175.00 Total $2,25300005,8832,153(2,217) (3,566) 0 (To Sch 8) This is trial version www.adultpdf.com State of California Department of Health Care Services Provider