REPORT ON THE RATE SETTING AUDIT COUNTRY …€¦ · · 2017-08-22Laverne Bailey Page 2...
Transcript of REPORT ON THE RATE SETTING AUDIT COUNTRY …€¦ · · 2017-08-22Laverne Bailey Page 2...
REPORT ON THE
RATE SETTING AUDIT
COUNTRY VILLA NORTH HC LOS ANGELES, CALIFORNIA
NATIONAL PROVIDER IDENTIFIER: 1033103205
FISCAL PERIOD ENDED DECEMBER 31, 2010
Audits Section - Gardena Financial Audits Branch
Audits and Investigations Department of Health Care Services
Section Chief: Maria Delgado Audit Supervisor: Cyrus C. Lam Auditor: Derek Bradley
TO
OBY DOUGLAS DIRECTOR
Fina
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Laverne Bailey Page 2
Notwithstanding this audit report, overpayments to the provider are subject to recovery pursuant to Section 51458.1, Article 6 of Division 3, Title 22, California Code of Regulations. If you disagree with the decision of the Department, you may appeal by writing to: Chief Office of Administrative Appeals and Hearings 1029 J Street, Suite 200 Sacramento, CA 95814-2825 (916) 322-5603 The written notice of disagreement must be received by the Department within 60 calendar days from the day you receive this letter. A copy of this notice should be sent to: United States Postal Service (USPS) Courier (UPS, FedEx, etc.) Assistant Chief Counsel Assistant Chief Counsel Department of Health Care Services Department of Health Care Services Office of Legal Services Office of Legal Services MS 0010 MS 0010 PO Box 997413 1501 Capitol Avenue, Suite 71.5001 Sacramento, CA 95899 Sacramento, CA 95814 (916) 440-7700 The procedures that govern an appeal are contained in Welfare and Institutions Code, Section 14171, and California Code of Regulations, Title 22, Section 51016, et seq. If you have questions regarding this report, you may call the Audits Section—Gardena at (310) 516- 4757. Original Signed By: Maria Delgado, Chief Audits Section—Gardena Financial Audits Branch Certified
Laverne Bailey Page 3
cc: Ruth Santo Domingo Mendoza Director of Reimbursement Country Villa Health Services 5120 West Goldleaf Circle, Suite 400 Los Angeles, CA 90056
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:COUNTRY VILLA NORTH HC JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility No.:1033103205 206190774
LineNo.
SKILLED NURSING CARE1 Cost of Direct Care - Labor (Sch. 2, Ln. 105) $ N/A $ 3,041,186 $ 88.602 Cost of Indirect Care - Labor (Sch. 3, Ln. 105) $ N/A $ 752,070 $ 21.913 Cost of Direct and Indirect Nonlabor - Other (Sch. 4, Ln. 105) $ N/A $ 623,934 $ 18.184 Cost of Capital Related (Sch. 5, Ln. 105) $ N/A $ 262,922 $ 7.665 Property Taxes (Sch. 5, Ln. 105) $ N/A $ 31,472 $ 0.926 CDPH Licensing Fees (Sch. 6, Ln. 105) $ N/A $ 24,089 $ 0.707 Professional Liability Insurance (Sch. 6, Ln. 105) $ N/A $ 66,221 $ 1.938 Caregiver Training (Sch. 6, Ln. 105) $ N/A $ 0 $ 0.009 Quality Assurance Fees (Sch. 6, Ln. 105) $ N/A $ 348,291 $ 10.1510 Cost of Administration (Sch. 6, Ln. 105) $ N/A $ 676,734 $ 19.7211 Cost of Routine Service/Audited Total Costs $ 5,848,056.00 $ 5,826,918.01 $ 169.7612 Total Patient Days (Adj ) 34,325 34,32513 Cost Per Patient Day (Cost Divided by Days) $ 170.37 $ 169.76 14 Overpayments (Adj ) $ $ 015 Medi-Cal Days (Adj 7) 29,491 29,65516 Medi-Cal Managed Care Days (Adj ) 0
INTERMEDIATE CARE17 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 018 Total Patient Days (Adj ) 019 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0020 Overpayments (Adj ) $ $ 0
MENTALLY DISORDERED CARE21 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 022 Total Patient Days (Adj ) 023 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0024 Overpayments (Adj ) $ $ 0
DEVELOPMENTALLY DISABLED CARE25 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 026 Total Patient Days (Adj ) 027 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0028 Overpayments (Adj ) $ $ 0
SUBACUTE CARE29 Cost of Direct Care - Labor (Subacute Care Sch. 1, Ln. 25) $ N/A $ 0 $ 0.0030 Cost of Indirect Care - Labor (Subacute Care Sch. 1, Ln. 26) $ N/A $ 0 $ 0.0031 Cost of Direct and Indirect Nonlabor - Other (Subacute Care Sch. 1, Ln. 27) $ N/A $ 0 $ 0.0032 Cost of Capital Related (Subacute Care Sch. 1, Ln. 28) $ N/A $ 0 $ 0.0033 Property Taxes (Subacute Care Sch. 1, Ln. 29) $ N/A $ 0 $ 0.0034 CDPH Licensing Fees (Subacute Care Sch. 1, Ln. 30) $ N/A $ 0 $ 0.0035 Professional Liability Insurance (Subacute Care Sch. 1, Ln. 31) $ N/A $ 0 $ 0.0036 Quality Assurance Fees (Subacute Care Sch. 1, Ln. 32) $ N/A $ 0 $ 0.0037 Caregiver Training (Subacute Care Sch. 1, Ln. 33) $ N/A $ 0 $ 0.0038 Cost of Administration (Subacute Care Sch.1, Ln. 34) $ N/A $ 0 $ 0.0039 Total Cost of Subacute Service (Subacute Care Sch. 1, Ln. 35) $ 0 $ 0 $ 0.0040 Total Patient Days (Subacute Care Sch. 1, Ln. 36) 0 041 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0042 Amount Due Provider (State) (Subacute Care Sch. 1, Ln. 40) $ 0 $ 0
AS REPORTED AS AUDITED PATIENT DAY
SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY
COST PERAUDITED
PROGRAM DESCRIPTION
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:COUNTRY VILLA NORTH HC JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility No.:1033103205 206190774
LineNo. AS REPORTED AS AUDITED PATIENT DAY
SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY
COST PERAUDITED
PROGRAM DESCRIPTION
SUBACUTE CARE - PEDIATRIC43 Cost of Routine Service (Subacute Care - Pediatric, Sch. 1, Ln 3) $ 0 $ 044 Cost of Ancillary Service (Subacute Care - Pediatric, Sch. 1, Ln. 1 + Ln. 2) $ 0 $ 045 Total Cost of Subacute Care - Pediatric Service (Ln. 42 + Ln. 43) $ 0 $ 046 Total Patient Days (Subacute Care - Pediatric, Sch. 1, Ln. 5) 0 047 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0048 Amount Due Provider (State) (Subacute Care - Pediatric, Sch. 1, Ln. 9) $ 0 $ 0
TRANSITIONAL INPATIENT CARE49 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 050 Total Patient Days (Adj ) 051 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0052 Overpayments (Adj ) $ $ 0
HOSPICE INPATIENT CARE53 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 054 Total Patient Days (Adj ) 055 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0056 Overpayments (Adj ) $ $ 0
OTHER ROUTINE SERVICES57 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 058 Total Patient Days (Adj ) 059 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0060 Overpayments (Adj ) $ $ 0
STATE OF CALIFORNIA SCHEDULE 2
Provider Name: Fiscal Period:COUNTRY VILLA NORTH HC JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility No.:1033103205 206190774
Soc Srvs ActivitiesNet Exp For
Line DESCRIPTION Cost AllocNo. (From Sch 8) 155 160 Total
GENERAL SERVICES005 Plant Operations and Maintenance010 Housekeeping060 Laundry and Linen065 Dietary155 Social Services 62,552$ 62,552$ 160 Activities 89,014 89,014$ 165 Administration166 Medical Records170 Inservice Education - Nursing
ANCILLARY SERVICES075 Patient Supplies 5,326 0 0 5,326077 Specialized Support Surfaces N/A 0 0 0080 Physical Therapy 235,132 0 0 235,132081 Respiratory Therapy 0 0 0 0082 Occupational Therapy 191,988 0 0 191,988083 Speech Pathology 79,645 0 0 79,645085 Pharmacy 0 0 0 0090 Laboratory 2,009 0 0 2,009095 Home Health Services 0 0 0 0100 Other Ancillary Services 0 0 0 0101 Subacute Care Ancillary Services 0 0 0 0102 Subacute Care - Pediatric Ancillary Services 0 0 0 0
ROUTINE SERVICES105 Skilled Nursing Care 2,889,620 62,552 89,014 3,041,186 *110 Intermediate Care 0 0 0 0 *115 Mentally Disordered Care 0 0 0 0 *120 Developmentally Disabled Care 0 0 0 0 *125 Subacute Care 0 0 0 0 *126 Subacute Care - Pediatric 0 0 0 0 *128 Transitional Inpatient Care 0 0 0 0 *130 Hospice Inpatient Care 0 0 0 0 *135 Other Routine Services 0 0 0 0 *
NONREIMBURSABLE 139 Residential Care 0 0 0 0140 Beauty and Barber 0 0 0 0145 Other Nonreimbursable 0 0 0 0
TOTAL 3,555,286$ 62,552$ 89,014$ 3,555,286$ * (To Schedule 1)
ALLOCATION OF GENERAL SERVICES DIRECT CARE LABOR
ST
AT
E O
F C
AL
IFO
RN
IAS
CH
ED
UL
E 3
Pro
vid
er N
ame:
Pro
vid
er N
PI:
OS
HP
D F
acili
ty N
um
ber
:F
isca
l Per
iod
:C
OU
NT
RY
VIL
LA N
OR
TH
HC
10
3310
3205
2061
9077
4JA
NU
AR
Y 1
, 201
0 T
HR
OU
GH
DE
CE
MB
ER
31,
201
0
Pla
nt
Op
sH
skp
ng
Lau
nd
ryD
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ryS
oc
Srv
sA
ctiv
itie
sIn
serv
. Ed
Ad
min
Med
ical
Net
Ex p
Fo
rR
eco
rds
Lin
eD
ES
CR
IPT
ION
Co
st A
lloc
Acc
um
ula
ted
No
.(F
rom
Sch
8)
005
010
060
065
155
160
170
Co
sts
165
166
To
tal
GE
NE
RA
L S
ER
VIC
ES
005
Pla
nt O
pera
tions
and
Mai
nten
ance
64,8
69$
64,8
69$
010
Hou
seke
e pin
g15
9,21
186
0
160,
071
$
06
0La
undr
y an
d Li
nen
90,8
422,
213
5,53
398
,588
$
06
5D
ieta
r y38
8,55
16,
341
15,8
560
410,
748
$
15
5S
ocia
l Ser
vice
sN
/A
318
795
00
1,11
3$
16
0A
ctiv
ities
N/A
4,
136
10,3
430
00
14,4
79$
165
Adm
inis
trat
ion
N/A
4,
034
10,0
880
00
014
,123
$
14,1
23$
166
Med
ical
Rec
ords
69,2
8090
52,
262
00
00
72,4
4772
,447
$
17
0In
serv
ice
Edu
catio
n -
Nur
sin g
14,4
4236
390
70
00
015
,712
$
A
NC
ILL
AR
Y S
ER
VIC
ES
075
Pat
ient
Sup
plie
s70
91,
773
00
00
02,
482
7739
72,
957
$
077
Spe
cial
ized
Sup
port
Sur
face
s0
00
00
00
061
314
375
080
Ph y
sica
l The
rapy
2,99
57,
490
00
00
010
,485
708
3,63
014
,822
081
Res
pira
tory
The
rapy
00
00
00
00
14
508
2O
ccu p
atio
nal T
hera
py1,
752
4,38
20
00
00
6,13
455
72,
855
9,54
608
3S
peec
h P
atho
logy
342
856
00
00
01,
198
219
1,12
12,
538
085
Pha
rmac
y37
192
70
00
00
1,29
844
22,
269
4,00
909
0La
bora
tor y
00
00
00
00
5830
035
909
5H
ome
Hea
lth S
ervi
ces
00
00
00
00
00
010
0O
ther
Anc
illar
y S
ervi
ces
00
00
00
00
2311
613
910
1S
ubac
ute
Car
e A
ncill
ary
Ser
vice
s0
00
00
00
00
00
102
Sub
acut
e C
are
- P
edia
tric
Anc
illar
y S
ervi
ces
00
00
00
00
00
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OU
TIN
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ER
VIC
ES
105
Ski
lled
Nur
sing
Car
e39
,429
98,6
0298
,588
410,
748
1,11
314
,479
15,7
1267
8,67
111
,974
61,4
2575
2,07
0*
110
Inte
rmed
iate
Car
e0
00
00
00
00
00
*11
5M
enta
ll y D
isor
dere
d C
are
00
00
00
00
00
0*
120
Dev
elo p
men
tally
Dis
able
d C
are
00
00
00
00
00
0*
125
Sub
acut
e C
are
00
00
00
00
00
0*
126
Sub
acut
e C
are
- P
edia
tric
00
00
00
00
00
0*
128
Tra
nsiti
onal
Inpa
tient
Car
e0
00
00
00
00
00
*13
0H
ospi
ce In
patie
nt C
are
00
00
00
00
00
0*
135
Oth
er R
outin
e S
ervi
ces
00
00
00
00
00
0*
NO
NR
EIM
BU
RS
AB
LE
13
9R
esid
entia
l Car
e0
00
00
00
00
00
140
Bea
uty
and
Bar
ber
102
255
00
00
035
73
1637
614
5O
ther
Non
reim
burs
able
00
00
00
00
00
0
TO
TA
L78
7,19
5$
64
,869
$
16
0,07
1$
98,5
88$
410,
748
$
1,
113
$
14,4
79$
15,7
12$
700,
625
$
14,1
23$
72,4
47$
787,
195
$
*
(To
Sch
edul
e 1)
AL
LO
CA
TIO
N O
F G
EN
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AL
SE
RV
ICE
SIN
DIR
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T C
AR
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AB
OR
ST
AT
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AL
IFO
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IAS
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UL
E 4
Pro
vid
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ame:
Pro
vid
er N
PI:
OS
HP
D F
acili
ty N
um
ber
:F
isca
l Per
iod
:C
OU
NT
RY
VIL
LA N
OR
TH
HC
10
3310
3205
2061
9077
4JA
NU
AR
Y 1
, 201
0 T
HR
OU
GH
DE
CE
MB
ER
31,
201
0
Pla
nt
Op
sH
skp
ng
Lau
nd
ryD
ieta
ryS
oc
Srv
sA
ctiv
itie
sIn
serv
. Ed
Ad
min
Med
ical
Net
Ex p
Fo
rR
eco
rds
Lin
eD
ES
CR
IPT
ION
Co
st A
lloc
Acc
um
ula
ted
No
.(F
rom
Sch
8)
510
6065
155
160
170
Co
sts
165
166
To
tal
GE
NE
RA
L S
ER
VIC
ES
005
Pla
nt O
pera
tions
and
Mai
nten
ance
178,
484
$
178,
484
$
01
0H
ouse
kee p
ing
30,3
792,
366
32,7
45$
060
Laun
dry
and
Line
n23
,289
6,08
81,
132
30,5
09$
065
Die
tar y
223,
924
17,4
463,
244
024
4,61
4$
155
Soc
ial S
ervi
ces
7,95
487
516
30
08,
991
$
160
Act
iviti
es6,
527
11,3
802,
116
00
020
,023
$
16
5A
dmin
istr
atio
nN
/A
11,1
002,
064
00
00
13,1
64$
13
,164
$
16
6M
edic
al R
ecor
ds18
,597
2,48
946
30
00
021
,549
21,5
49$
170
Inse
rvic
e E
duca
tion
- N
ursi
n g0
998
186
00
00
1,18
3$
A
NC
ILL
AR
Y S
ER
VIC
ES
075
Pat
ient
Sup
plie
s15
,897
1,95
136
30
00
00
18,2
1172
118
18,4
01$
077
Spe
cial
ized
Sup
port
Sur
face
s23
,415
00
00
00
023
,415
5793
23,5
6508
0P
h ysi
cal T
hera
py18
88,
241
1,53
20
00
00
9,96
165
91,
080
11,7
0008
1R
espi
rato
ry T
hera
py31
70
00
00
00
317
11
319
082
Occ
u pat
iona
l The
rapy
315
4,82
189
60
00
00
6,03
351
984
97,
400
083
Spe
ech
Pat
holo
gy0
942
175
00
00
01,
117
204
333
1,65
408
5P
harm
acy
165,
024
1,02
019
00
00
00
166,
234
412
675
167,
321
090
Labo
rato
r y20
,396
00
00
00
020
,396
5589
20,5
4009
5H
ome
Hea
lth S
ervi
ces
00
00
00
00
00
00
100
Oth
er A
ncill
ary
Ser
vice
s8,
668
00
00
00
08,
668
2135
8,72
410
1S
ubac
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e A
ncill
ary
Ser
vice
s0
00
00
00
00
00
010
2S
ubac
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Ped
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ic A
ncill
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vice
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00
00
00
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ER
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105
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lled
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sing
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0,52
510
8,48
720
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30,5
0924
4,61
48,
991
20,0
231,
183
594,
503
11,1
6118
,270
623,
934
*11
0In
term
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te C
are
00
00
00
00
00
0*
115
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tall y
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orde
red
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00
00
00
00
00
*12
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isab
led
Car
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00
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ubac
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00
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00
00
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126
Sub
acut
e C
are
- P
edia
tric
00
00
00
00
00
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*12
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rans
ition
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patie
nt C
are
00
00
00
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130
Hos
pice
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tient
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00
00
00
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ther
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tine
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UR
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139
Res
iden
tial C
are
00
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Bea
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and
Bar
ber
028
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00
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ther
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burs
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00
00
00
00
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9$
17
8,48
4$
32,7
45$
30,5
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244,
614
$
8,
991
$
20,0
23$
1,18
3$
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9,18
7$
13
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$
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$
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*(T
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ched
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1)
AL
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LA
BO
R
STATE OF CALIFORNIA SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Provider Name: Fiscal Period:COUNTRY VILLA NORTH HC JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1033103205 206190774
Capital Plant Ops Hskpng Laundry Dietary Soc Srvs ActivitiesNet Exp For
Line DESCRIPTION Cost AllocNo. (From Sch 8) Ratio Various 5 10 60 65 155 160
GENERAL SERVICESCapital Related (excluding lines 40 & 45) 295,323$ 89%Property Tax (line 40) 35,350 11% 330,673$
005 Plant Operations and Maintenance 13,164 13,164$ 010 Housekeeping 4,208 174 4,383$ 060 Laundry and Linen 10,830 449 152 11,431$ 065 Dietary 31,035 1,287 434 0 32,756$ 155 Social Services 1,556 65 22 0 0 1,642$ 160 Activities 20,244 839 283 0 0 0 21,367$ 165 Administration 19,746 819 276 0 0 0 0166 Medical Records 4,428 184 62 0 0 0 0170 Inservice Education - Nursing 1,775 74 25 0 0 0 0
ANCILLARY SERVICES075 Patient Supplies 3,470 144 49 0 0 0 0077 Specialized Support Surfaces 0 0 0 0 0 0 0080 Physical Therapy 14,660 608 205 0 0 0 0081 Respiratory Therapy 0 0 0 0 0 0 0082 Occupational Therapy 8,576 356 120 0 0 0 0083 Speech Pathology 1,675 69 23 0 0 0 0085 Pharmacy 1,815 75 25 0 0 0 0090 Laboratory 0 0 0 0 0 0 0095 Home Health Services 0 0 0 0 0 0 0100 Other Ancillary Services 0 0 0 0 0 0 0101 Subacute Care Ancillary Services 0 0 0 0 0 0 0102 Subacute Care - Pediatric Ancillary Services 0 0 0 0 0 0 0
ROUTINE SERVICES105 Skilled Nursing Care 192,991 8,001 2,700 11,431 32,756 1,642 21,367110 Intermediate Care 0 0 0 0 0 0 0115 Mentally Disordered Care 0 0 0 0 0 0 0120 Developmentally Disabled Care 0 0 0 0 0 0 0125 Subacute Care 0 0 0 0 0 0 0126 Subacute Care - Pediatric 0 0 0 0 0 0 0128 Transitional Inpatient Care 0 0 0 0 0 0 0130 Hospice Inpatient Care 0 0 0 0 0 0 0135 Other Routine Services 0 0 0 0 0 0 0
NONREIMBURSABLE 139 Residential Care 0 0 0 0 0 0 0140 Beauty and Barber 499 21 7 0 0 0 0145 Other Nonreimbursable 0 0 0 0 0 0 0
TOTAL 330,673$ 100% 330,673$ 13,164$ 4,383$ 11,431$ 32,756$ 1,642$ 21,367$ * (To Schedule 1)
STATE OF CALIFORNIA
Provider Name:COUNTRY VILLA NORTH HC
Provider NPI:1033103205
Net Exp ForLine DESCRIPTION Cost AllocNo. (From Sch 8) Ratio
GENERAL SERVICESCapital Related (excluding lines 40 & 45) 295,323$ 89%Property Tax (line 40) 35,350 11%
005 Plant Operations and Maintenance010 Housekeeping060 Laundry and Linen065 Dietary155 Social Services160 Activities165 Administration166 Medical Records170 Inservice Education - Nursing
ANCILLARY SERVICES075 Patient Supplies077 Specialized Support Surfaces080 Physical Therapy081 Respiratory Therapy082 Occupational Therapy083 Speech Pathology085 Pharmacy090 Laboratory095 Home Health Services100 Other Ancillary Services101 Subacute Care Ancillary Services102 Subacute Care - Pediatric Ancillary Services
ROUTINE SERVICES105 Skilled Nursing Care110 Intermediate Care115 Mentally Disordered Care120 Developmentally Disabled Care125 Subacute Care126 Subacute Care - Pediatric128 Transitional Inpatient Care130 Hospice Inpatient Care135 Other Routine Services
NONREIMBURSABLE 139 Residential Care140 Beauty and Barber145 Other Nonreimbursable
TOTAL 330,673$ 100%* (To Schedule 1)
SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Fiscal Period:JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
OSHPD Facility Number:206190774
Inserv. Ed Admin Medical Capital PropertyRecords Related Tax
Accumulated 89% 11%170 Costs 165 166 Total Of Total Of Total
20,841$ 20,841$ 4,673 4,673$
1,874$
0 3,663 114 26 3,803$ 3,396$ 407$ 0 0 90 20 110 99 120 15,473 1,044 234 16,751 14,960 1,7910 0 1 0 1 1 00 9,052 821 184 10,057 8,982 1,0750 1,768 323 72 2,163 1,932 2310 1,916 653 146 2,715 2,425 2900 0 86 19 106 94 110 0 0 0 0 0 00 0 33 7 41 37 40 0 0 0 0 0 00 0 0 0 0 0 0
1,874 272,761 17,670 3,962 294,393 262,922 31,472 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *
0 0 0 0 0 0 00 526 5 1 532 475 570 0 0 0 0 0 0
1,874$ 305,159$ 20,841$ 4,673$ 330,673$ 295,323$ 35,350$
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STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:COUNTRY VILLA NORTH HC JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1033103205 206190774
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER005 Plant Operations and Maintenance005 .01-.19 Salaries and Wages 6200 $ 50,330 $ 0 $ 50,330 (Sch 3)005 .20-.39 Fringe Benefits 6200 14,539 0 14,539 (Sch 3)005 .79 Agency Staff 6200 0 0 (Sch 3)005 .40-.99 Other - Nonlabor 6200 178,484 0 178,484 (Sch 4)005 Plant Operations and Maintenance - Total 6200 $ 243,353 $ 0 $ 243,353
010 Housekeeping010 .01-.19 Salaries and Wages 6300 $ 121,966 $ 0 $ 121,966 (Sch 3)010 .20-.39 Fringe Benefits 6300 37,245 0 37,245 (Sch 3)010 .79 Agency Staff 6300 0 0 (Sch 3)010 .40-.99 Other - Nonlabor 6300 30,379 0 30,379 (Sch 4)010 Housekeeping - Total 6300 $ 189,590 $ 0 $ 189,590
015 Depreciation: Buildings and Improvements 7110 - 7120 $ 40,165 $ 0 $ 40,165 (Sch 5)020 Depreciation: Leasehold Improvements 7130 14,606 0 14,606 (Sch 5)025 Depreciation: Equipment 7140 21,782 0 21,782 (Sch 5)030 Depreciation and Amortization - Other 7150 - 7160 0 0 (Sch 5)035 Leases and Rentals 7200 27,803 0 27,803 (Sch 5)040 Property Taxes 7300 35,350 0 35,350 (Sch 5)045 Property Insurance 7400 3,328 0 3,328 (Sch 6)050 Interest - Property, Plant, and Equipment 7500 190,967 0 190,967 (Sch 5)055 Interest - Other 7600 $ 1,224 $ 0 $ 1,224 (Sch 6)
057 Subtotal 005 - 055 $ 768,168 $ 0 $ 768,168
060 Laundry and Linen060 .01-.19 Salaries and Wages 6400 $ 74,300 $ 0 $ 74,300 (Sch 3)060 .20-.39 Fringe Benefits 6400 16,542 0 16,542 (Sch 3)060 .79 Agency Staff 6400 0 0 (Sch 3)060 .40-.99 Other - Nonlabor 6400 23,289 0 23,289 (Sch 4)060 Laundry and Linen - Total 6400 $ 114,131 $ 0 $ 114,131
065 Dietary065 .01-.19 Salaries and Wages 6500 $ 303,607 $ 0 $ 303,607 (Sch 3)065 .20-.39 Fringe Benefits 6500 84,944 0 84,944 (Sch 3)065 .79 Agency Staff 6500 0 0 (Sch 3)065 .40-.99 Other - Nonlabor 6500 223,924 0 223,924 (Sch 4)065 Dietary - Total 6500 $ 612,475 $ 0 $ 612,475
070 Provision for Bad Debts 7700 $ 0 0 $ 0
Ancillary Services 075 Patient Supplies075 .01-.19 Salaries and Wages 8100 $ 4,304 $ 0 $ 4,304 (Sch 2)075 .20-.39 Fringe Benefits 8100 1,022 0 1,022 (Sch 2)075 .79 Agency Staff 8100 0 0 (Sch 2)075 .40-.99 Other - Nonlabor 8100 18,026 (2,129) 15,897 (Sch 4)075 Patient Supplies - Total 8100 $ 23,352 $ (2,129) $ 21,223
077 Specialized Support Surfaces077 .01-.19 Salaries and Wages 8150 $ $ 0 $ 0 N/A077 .20-.39 Fringe Benefits 8150 0 0 N/A077 .79 Agency Staff 8150 0 0 N/A077 .40-.99 Other - Nonlabor 8150 23,415 0 23,415 (Sch 4)077 Specialized Support Surfaces - Total 8150 $ 23,415 $ 0 $ 23,415
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
REPORTEDAS AS
AUDITEDADJUSTMENTS
8A-1
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:COUNTRY VILLA NORTH HC JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1033103205 206190774
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
REPORTEDAS AS
AUDITEDADJUSTMENTS
8A-1080 Physical Therapy080 .01-.19 Salaries and Wages 8200 $ $ 0 $ 0 (Sch 2)080 .20-.39 Fringe Benefits 8200 0 0 (Sch 2)080 .79 Agency Staff 8200 235,132 0 235,132 (Sch 2)080 .40-.99 Other - Nonlabor 8200 188 0 188 (Sch 4)080 Physical Therapy - Total 8200 $ 235,320 $ 0 $ 235,320
081 Respiratory Therapy081 .01-.19 Salaries and Wages 8220 $ $ 0 $ 0 (Sch 2)081 .20-.39 Fringe Benefits 8220 0 0 (Sch 2)081 .79 Agency Staff 8220 0 0 (Sch 2)081 .40-.99 Other - Nonlabor 8220 317 0 317 (Sch 4)081 Respiratory Therapy - Total 8220 $ 317 $ 0 $ 317
082 Occupational Therapy082 .01-.19 Salaries and Wages 8250 $ $ 0 $ 0 (Sch 2)082 .20-.39 Fringe Benefits 8250 0 0 (Sch 2)082 .79 Agency Staff 8250 191,988 0 191,988 (Sch 2)082 .40-.99 Other - Nonlabor 8250 315 0 315 (Sch 4)082 Occupational Therapy - Total 8250 $ 192,303 $ 0 $ 192,303
083 Speech Pathology083 .01-.19 Salaries and Wages 8280 $ $ 0 $ 0 (Sch 2)083 .20-.39 Fringe Benefits 8280 0 0 (Sch 2)083 .79 Agency Staff 8280 79,645 0 79,645 (Sch 2)083 .40-.99 Other - Nonlabor 8280 0 0 (Sch 4)083 Speech Pathology - Total 8280 $ 79,645 $ 0 $ 79,645
085 Pharmacy085 .01-.19 Salaries and Wages 8300 $ $ 0 $ 0 (Sch 2)085 .20-.39 Fringe Benefits 8300 0 0 (Sch 2)085 .79 Agency Staff 8300 0 0 (Sch 2)085 .40-.99 Other - Nonlabor 8300 165,024 0 165,024 (Sch 4)085 Pharmacy - Total 8300 $ 165,024 $ 0 $ 165,024
090 Laboratory090 .01-.19 Salaries and Wages 8400 $ 1,620 $ 0 $ 1,620 (Sch 2)090 .20-.39 Fringe Benefits 8400 389 0 389 (Sch 2)090 .79 Agency Staff 8400 0 0 (Sch 2)090 .40-.99 Other - Nonlabor 8400 20,396 0 20,396 (Sch 4)090 Laboratory - Total 8400 $ 22,405 $ 0 $ 22,405
095 Home Health Services095 .01-.19 Salaries and Wages 8800 $ $ 0 $ 0 (Sch 2)095 .20-.39 Fringe Benefits 8800 0 0 (Sch 2)095 .79 Agency Staff 8800 0 0 (Sch 2)095 .40-.99 Other - Nonlabor 8800 0 0 (Sch 4)095 Home Health Services - Total 8800 $ 0 $ 0 $ 0
100 Other Ancillary Services100 .01-.19 Salaries and Wages 8900 $ $ 0 $ 0 (Sch 2)100 .20-.39 Fringe Benefits 8900 0 0 (Sch 2)100 .79 Agency Staff 8900 0 0 (Sch 2)100 .40-.99 Other - Nonlabor 8900 8,668 0 8,668 (Sch 4)100 Other Ancillary Services - Total 8900 $ 8,668 $ 0 $ 8,668
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:COUNTRY VILLA NORTH HC JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1033103205 206190774
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
REPORTEDAS AS
AUDITEDADJUSTMENTS
8A-1101 Subacute Care Ancillary Services101 .01-.19 Salaries and Wages 8100-8900 $ $ 0 $ 0 (Sch 2)101 .20-.39 Fringe Benefits 8100-8900 0 0 (Sch 2)101 .79 Agency Staff 8100-8900 0 0 (Sch 2)101 .40-.99 Other - Nonlabor 8100-8900 0 0 (Sch 4)101 Subacute Care Ancillary Services - Total 8100-8900 $ 0 $ 0 $ 0
102 Subacute Care - Pediatric Ancillary Services102 .01-.19 Salaries and Wages 8100-8900 $ $ 0 $ 0 (Sch 2)102 .20-.39 Fringe Benefits 8100-8900 0 0 (Sch 2)102 .79 Agency Staff 8100-8900 0 0 (Sch 2)102 .40-.99 Other - Nonlabor 8100-8900 0 0 (Sch 4)102 Subacute Care - Pediatric Ancillary Services - Total 8100-8900 $ 0 $ 0 $ 0
104 Subtotal 075 - 102 $ 750,449 $ (2,129) $ 748,320
Routine Services105 Skilled Nursing Care105 .01-.19 Salaries and Wages 6110 $ 2,255,009 $ 0 $ 2,255,009 (Sch 2)105 .20-.39 Fringe Benefits 6110 634,611 0 634,611 (Sch 2)105 .49 Agency Staff 6110 0 0 (Sch 2)105 .40-.99 Other - Nonlabor 6110 158,396 2,129 160,525 (Sch 4)105 Skilled Nursing Care - Total 6110 $ 3,048,016 $ 2,129 $ 3,050,145
110 Intermediate Care110 .01-.19 Salaries and Wages 6120 $ $ 0 $ 0110 .20-.39 Fringe Benefits 6120 0 0110 .49 Agency Staff 6120 0 0110 .40-.99 Other - Nonlabor 6120 0 0110 Intermediate Care - Total 6120 $ 0 $ 0 $ 0 (Sch 2)
115 Mentally Disordered Care115 .01-.19 Salaries and Wages 6130 $ $ 0 $ 0115 .20-.39 Fringe Benefits 6130 0 0115 .49 Agency Staff 6130 0 0115 .40-.99 Other - Nonlabor 6130 0 0115 Mentally Disordered Care - Total 6130 $ 0 $ 0 $ 0 (Sch 2)
120 Developmentally Disabled Care120 .01-.19 Salaries and Wages 6140 $ $ 0 $ 0120 .20-.39 Fringe Benefits 6140 0 0120 .49 Agency Staff 6140 0 0120 .40-.99 Other - Nonlabor 6140 0 0120 Developmentally Disabled Care - Total 6140 $ 0 $ 0 $ 0 (Sch 2)
125 Subacute Care125 .01-.19 Salaries and Wages 6150 $ $ 0 $ 0 (Sch 2)125 .20-.39 Fringe Benefits 6150 0 0 (Sch 2)125 .49 Agency Staff 6150 0 0 (Sch 2)125 .40-.99 Other - Nonlabor 6150 0 0 (Sch 4)125 Subacute Care - Total 6150 $ 0 $ 0 $ 0
126 Subacute Care - Pediatric126 .01-.19 Salaries and Wages 6160 $ $ 0 $ 0 (Sch 2)126 .20-.39 Fringe Benefits 6160 0 0 (Sch 2)126 .49 Agency Staff 6160 0 0 (Sch 2)126 .40-.99 Other - Nonlabor 6160 0 0 (Sch 4)126 Subacute Care - Pediatric - Total 6160 $ 0 $ 0 $ 0
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:COUNTRY VILLA NORTH HC JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1033103205 206190774
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
REPORTEDAS AS
AUDITEDADJUSTMENTS
8A-1128 Transitional Inpatient Care128 .01-.19 Salaries and Wages 6170 $ $ 0 $ 0128 .20-.39 Fringe Benefits 6170 0 0128 .49 Agency Staff 6170 0 0128 .40-.99 Other - Nonlabor 6170 0 0128 Transitional Inpatient Care - Total 6170 $ 0 $ 0 $ 0 (Sch 2)
130 Hospice Inpatient Care130 .01-.19 Salaries and Wages 6180 $ $ 0 $ 0130 .20-.39 Fringe Benefits 6180 0 0130 .49 Agency Staff 6180 0 0130 .40-.99 Other - Nonlabor 6180 0 0130 Hospice Inpatient Care - Total 6180 $ 0 $ 0 $ 0 (Sch 2)
135 Other Routine Services135 .01-.19 Salaries and Wages 6190 $ $ 0 $ 0135 .20-.39 Fringe Benefits 6190 0 0135 .49 Agency Staff 6190 0 0135 .40-.99 Other - Nonlabor 6190 0 0135 Other Routine Services - Total 6190 $ 0 $ 0 $ 0 (Sch 2)
Other Nonreimbursable139 Residential Care139 .01-.19 Salaries and Wages 9100 $ $ 0 $ 0 (Sch 2)139 .20-.39 Fringe Benefits 9100 0 0 (Sch 2)139 .49 Agency Staff 9100 0 0 (Sch 2)139 .40-.99 Other - Nonlabor 9100 0 0 (Sch 4)139 Residential Care - Total 9100 $ 0 $ 0 $ 0
140 Beauty and Barber140 .01-.19 Salaries and Wages 8900 $ $ 0 $ 0 (Sch 2)140 .20-.39 Fringe Benefits 8900 0 0 (Sch 2)140 .49 Agency Staff 8900 0 0 (Sch 2)140 .40-.99 Other - Nonlabor 8900 0 0 (Sch 4)140 Beauty and Barber - Total 8900 $ 0 $ 0 $ 0
145 Other Nonreimbursable145 .01-.19 Salaries and Wages 9100 $ $ 0 $ 0 (Sch 2)145 .20-.39 Fringe Benefits 9100 0 0 (Sch 2)145 .49 Agency Staff 9100 0 0 (Sch 2)145 .40-.99 Other - Nonlabor 9100 0 0 (Sch 4)145 Other Nonreimbursable - Total 9100 $ 0 $ 0 $ 0
146 Subtotal 105 - 145 $ 3,048,016 $ 2,129 $ 3,050,145
155 Social Services155 .01-.19 Salaries and Wages 6600 $ 49,756 $ 0 $ 49,756 (Sch 2)155 .20-.39 Fringe Benefits 6600 12,796 0 12,796 (Sch 2)155 .49 Agency Staff 6600 0 0 (Sch 2)155 .40-.99 Other - Nonlabor 6600 7,954 0 7,954 (Sch 4)155 Social Services - Total 6600 $ 70,506 $ 0 $ 70,506
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:COUNTRY VILLA NORTH HC JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1033103205 206190774
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
REPORTEDAS AS
AUDITEDADJUSTMENTS
8A-1160 Activities160 .01-.19 Salaries and Wages 6700 $ 69,932 $ 0 $ 69,932 (Sch 2)160 .20-.39 Fringe Benefits 6700 19,082 0 19,082 (Sch 2)160 .49 Agency Staff 6700 0 0 (Sch 2)160 .40-.99 Other - Nonlabor 6700 6,527 0 6,527 (Sch 4)160 Activities - Total 6700 $ 95,541 $ 0 $ 95,541
165 Administration165 .01-.19 Salaries and Wages 6900 $ 231,993 $ 0 $ 231,993 (Sch 6)165 .20-.39 Fringe Benefits 6900 71,109 0 71,109 (Sch 6)165 .49 Agency Staff 6900 0 0 (Sch 6)165 .40-.99 Other - Nonlabor 6900 481,239 9,277 490,516 (Sch 6)165 Administration - Total 6900 $ 784,341 $ 9,277 $ 793,618
166 Medical Records166 .01-.19 Salaries and Wages 6900 $ 55,758 $ 0 $ 55,758 (Sch 3)166 .20-.39 Fringe Benefits 6900 13,522 0 13,522 (Sch 3)166 .49 Agency Staff 6900 0 0 (Sch 3)166 .40-.99 Other - Nonlabor 6900 18,597 0 18,597 (Sch 4)166 Medical Records - Total 6900 $ 87,877 $ 0 $ 87,877
167 CDPH Licensing Fees 6900 $ 28,412 $ 0 $ 28,412 (Sch 6)168 Professional Liability Insurance 6900 $ 146,771 $ (68,667) $ 78,104 (Sch 6)169 Quality Assurance Fees 6900 $ 410,790 $ 0 $ 410,790 (Sch 6)
170 Inservice Education - Nursing170 .01-.19 Salaries and Wages 6800 $ 10,570 $ 0 $ 10,570 (Sch 3)170 .20-.39 Fringe Benefits 6800 3,872 0 3,872 (Sch 3)170 .49 Agency Staff 6800 0 0 (Sch 3)170 .40-.99 Other - Nonlabor 6800 0 0 (Sch 4)170 Inservice Education - Nursing - Total 6800 $ 14,442 $ 0 $ 14,442
174 Caregiver Training 174 .01-.19 Salaries and Wages 6900 $ $ 0 $ 0 (Sch 6)174 .20-.39 Fringe Benefits 6900 0 0 (Sch 6)174 .49 Agency Staff 6900 0 0 (Sch 6)174 .40-.99 Other - Nonlabor 6900 0 0 (Sch 6)174 Caregiver Training - Total 6900 $ 0 $ 0 $ 0
Subtotal 155 - 174 $ 1,638,680 $ (59,390) $ 1,579,290
200 Total $ 6,931,919 $ (59,390) $ 6,872,529
STA
TE O
F C
ALI
FOR
NIA
Sche
dule
8A
-1Pa
ge 1
Prov
ider
Nam
e:Pr
ovid
er N
PI:
OSH
PD F
acili
ty N
umbe
r:Fi
scal
Per
iod:
CO
UN
TRY
VIL
LA N
OR
TH H
C
1033
1032
0520
6190
774
JAN
UA
RY
1, 2
010
THR
OU
GH
DE
CE
MB
ER
31,
201
0
TOTA
L A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
Line
Sub
(Pag
e 1)
12
34
56
No.
No.
005
1P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Sal
arie
s an
d W
ages
000
52
Pla
nt O
pera
tions
and
Mai
nten
ance
- Fr
inge
Ben
efits
000
53
Pla
nt O
pera
tions
and
Mai
nten
ance
- A
genc
y S
taff
000
54
Pla
nt O
pera
tions
and
Mai
nten
ance
- O
ther
- N
onla
bor
001
01
Hou
seke
epin
g - S
alar
ies
and
Wag
es0
010
2H
ouse
keep
ing
- Frin
ge B
enef
its0
010
3H
ouse
keep
ing
- Age
ncy
Sta
ff0
010
4H
ouse
keep
ing
- Oth
er -
Non
labo
r0
015
4D
epre
ciat
ion:
Bui
ldin
gs a
nd Im
prov
emen
ts0
020
4D
epre
ciat
ion:
Lea
seho
ld Im
prov
emen
ts0
025
4D
epre
ciat
ion:
Equ
ipm
ent
003
04
Dep
reci
atio
n an
d A
mor
tizat
ion
- Oth
er0
035
4Le
ases
and
Ren
tals
004
04
Pro
perty
Tax
es0
045
4P
rope
rty In
sura
nce
005
04
Inte
rest
- P
rope
rty, P
lant
, and
Equ
ipm
ent
005
54
Inte
rest
- O
ther
006
01
Laun
dry
and
Line
n - S
alar
ies
and
Wag
es0
060
2La
undr
y an
d Li
nen
- Frin
ge B
enef
its0
060
3La
undr
y an
d Li
nen
- Age
ncy
Sta
ff0
060
4La
undr
y an
d Li
nen
- Oth
er -
Non
labo
r0
065
1D
ieta
ry -
Sal
arie
s an
d W
ages
006
52
Die
tary
- Fr
inge
Ben
efits
006
53
Die
tary
- A
genc
y S
taff
006
54
Die
tary
- O
ther
- N
onla
bor
007
04
Pro
visi
on fo
r Bad
Deb
ts0
075
1P
atie
nt S
uppl
ies
- Sal
arie
s an
d W
ages
007
52
Pat
ient
Sup
plie
s - F
ringe
Ben
efits
007
53
Pat
ient
Sup
plie
s - A
genc
y S
taff
007
54
Pat
ient
Sup
plie
s - O
ther
- N
onla
bor
(2,1
29)
(2,1
29)
077
1S
peci
aliz
ed S
uppo
rt S
urfa
ces
- Sal
arie
s an
d W
ages
007
72
Spe
cial
ized
Sup
port
Sur
face
s - F
ringe
Ben
efits
007
73
Spe
cial
ized
Sup
port
Sur
face
s - A
genc
y S
taff
007
74
Spe
cial
ized
Sup
port
Sur
face
s - O
ther
- N
onla
bor
008
01
Phy
sica
l The
rapy
- S
alar
ies
and
Wag
es0
080
2P
hysi
cal T
hera
py -
Frin
ge B
enef
its0
080
3P
hysi
cal T
hera
py -
Age
ncy
Sta
ff0
080
4P
hysi
cal T
hera
py -
Oth
er -
Non
labo
r0
081
1R
espi
rato
ry T
hera
py -
Sal
arie
s an
d W
ages
008
12
Res
pira
tory
The
rapy
- Fr
inge
Ben
efits
008
13
Res
pira
tory
The
rapy
- A
genc
y S
taff
008
14
Res
pira
tory
The
rapy
- O
ther
- N
onla
bor
008
21
Occ
upat
iona
l The
rapy
- S
alar
ies
and
Wag
es0
082
2O
ccup
atio
nal T
hera
py -
Frin
ge B
enef
its0
082
3O
ccup
atio
nal T
hera
py -
Age
ncy
Sta
ff0
082
4O
ccup
atio
nal T
hera
py -
Oth
er -
Non
labo
r0
083
1S
peec
h P
atho
logy
- S
alar
ies
and
Wag
es0
083
2S
peec
h P
atho
logy
- Fr
inge
Ben
efits
008
33
Spe
ech
Pat
holo
gy -
Age
ncy
Sta
ff0
REC
LASS
IFIC
ATI
ON
S A
ND
/OR
AD
JUST
MEN
TS T
O R
EPO
RTE
D C
OST
S
STA
TE O
F C
ALI
FOR
NIA
Sche
dule
8A
-1Pa
ge 1
Prov
ider
Nam
e:Pr
ovid
er N
PI:
OSH
PD F
acili
ty N
umbe
r:Fi
scal
Per
iod:
CO
UN
TRY
VIL
LA N
OR
TH H
C
1033
1032
0520
6190
774
JAN
UA
RY
1, 2
010
THR
OU
GH
DE
CE
MB
ER
31,
201
0
TOTA
L A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
Line
Sub
(Pag
e 1)
12
34
56
No.
No.
REC
LASS
IFIC
ATI
ON
S A
ND
/OR
AD
JUST
MEN
TS T
O R
EPO
RTE
D C
OST
S
083
4S
peec
h P
atho
logy
- O
ther
- N
onla
bor
008
51
Pha
rmac
y - S
alar
ies
and
Wag
es0
085
2P
harm
acy
- Frin
ge B
enef
its0
085
3P
harm
acy
- Age
ncy
Sta
ff0
085
4P
harm
acy
- Oth
er -
Non
labo
r0
090
1La
bora
tory
- S
alar
ies
and
Wag
es0
090
2La
bora
tory
- Fr
inge
Ben
efits
009
03
Labo
rato
ry -
Age
ncy
Sta
ff0
090
4La
bora
tory
- O
ther
- N
onla
bor
009
51
Hom
e H
ealth
Ser
vice
s - S
alar
ies
and
Wag
es0
095
2H
ome
Hea
lth S
ervi
ces
- Frin
ge B
enef
its0
095
3H
ome
Hea
lth S
ervi
ces
- Age
ncy
Sta
ff0
095
4H
ome
Hea
lth S
ervi
ces
- Oth
er -
Non
labo
r0
100
1O
ther
Anc
illar
y S
ervi
ces
- Sal
arie
s an
d W
ages
010
02
Oth
er A
ncill
ary
Ser
vice
s - F
ringe
Ben
efits
010
03
Oth
er A
ncill
ary
Ser
vice
s - A
genc
y S
taff
010
04
Oth
er A
ncill
ary
Ser
vice
s - O
ther
- N
onla
bor
010
11
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Sal
arie
s an
d W
ages
010
12
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Frin
ge B
enef
its0
101
3S
ubac
ute
Car
e A
ncill
ary
Ser
vice
s - A
genc
y S
taff
010
14
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Oth
er -
Non
labo
r0
102
1S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - S
alar
ies
and
Wag
es0
102
2S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - F
ringe
Ben
efits
010
23
Sub
acut
e P
edia
tric
Anc
illar
y S
ervi
ces
- Age
ncy
Sta
ff0
102
4S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - O
ther
- N
onla
bor
010
51
Ski
lled
Nur
sing
Car
e - S
alar
ies
and
Wag
es0
105
2S
kille
d N
ursi
ng C
are
- Frin
ge B
enef
its0
105
3S
kille
d N
ursi
ng C
are
- Age
ncy
Sta
ff0
105
4S
kille
d N
ursi
ng C
are
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