REPORT ON THE RATE SETTING AUDIT WINE …€¦ · nch/Audits Sec Suite 280, MS 6-4757/FAX: (ess:...
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REPORT ON THE RATE SETTING AUDIT WINE COUNTRY CARE CENTER LODI, CALIFORNIA NATIONAL PROVIDER IDENTIFIER: 1053311225 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: Maria Delgado Auditor: Darryl Kitashima
Transcript of REPORT ON THE RATE SETTING AUDIT WINE …€¦ · nch/Audits Sec Suite 280, MS 6-4757/FAX: (ess:...
REPORT ON THE
RATE SETTING AUDIT
WINE COUNTRY CARE CENTER LODI, CALIFORNIA
NATIONAL PROVIDER IDENTIFIER: 1053311225
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: Maria Delgado Auditor: Darryl Kitashima
TO
OBY DOUGLAS DIRECTOR
June 20
Paul GroWine Co321 WesLodi, CA NATIONFISCAL We haveabove-reSection tests of necessa In our opCost perpatient dprinciple This aud 1. S 2. A Future MThe exteBenefits NotwithspursuanRegulati If you di
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Chief Department of Health Care Services Office of Administrative Hearings and Appeals 1029 J Street, Suite 200 Sacramento, CA 95814 (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 cc: Stephen David, CFO Accurate Business Results, LLC 4541 East Anaheim Street Long Beach, CA 90804
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:WINE COUNTRY CARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility No.:1053311225 206390894
LineNo.
SKILLED NURSING CARE1 Cost of Direct Care - Labor (Sch. 2, Ln. 105) $ N/A $ 2,071,428 $ 72.472 Cost of Indirect Care - Labor (Sch. 3, Ln. 105) $ N/A $ 628,231 $ 21.983 Cost of Direct and Indirect Nonlabor - Other (Sch. 4, Ln. 105) $ N/A $ 688,545 $ 24.094 Cost of Capital Related (Sch. 5, Ln. 105) $ N/A $ 14,008 $ 0.495 Property Taxes (Sch. 5, Ln. 105) $ N/A $ 13,322 $ 0.476 CDPH Licensing Fees (Sch. 6, Ln. 105) $ N/A $ 20,503 $ 0.727 Professional Liability Insurance (Sch. 6, Ln. 105) $ N/A $ 59,756 $ 2.098 Caregiver Training (Sch. 6, Ln. 105) $ N/A $ 0 $ 0.009 Quality Assurance Fees (Sch. 6, Ln. 105) $ N/A $ 116,825 $ 4.0910 Cost of Administration (Sch. 6, Ln. 105) $ N/A $ 347,961 $ 12.1711 Cost of Routine Service/Audited Total Costs $ 4,130,526.00 $ 3,960,579.28 $ 138.5712 Total Patient Days (Adj ) 28,582 28,58213 Cost Per Patient Day (Cost Divided by Days) $ 144.51 $ 138.57 14 Overpayments (Adj ) $ $ 015 Medi-Cal Days (Adj 13) 19,344 16,89616 Medi-Cal Managed Care Days (Adj 14) 295
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
SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY
COST PERAUDITED
PROGRAM DESCRIPTIONAS REPORTED AS AUDITED PATIENT DAY
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:WINE COUNTRY CARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility No.:1053311225 206390894
LineNo.
SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY
COST PERAUDITED
PROGRAM DESCRIPTIONAS REPORTED AS AUDITED PATIENT DAY
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:WINE COUNTRY CARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility No.:1053311225 206390894
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 26,593$ 26,593$ 160 Activities 101,823 101,823$ 165 Administration166 Medical Records170 Inservice Education - Nursing
ANCILLARY SERVICES075 Patient Supplies 0 0 0 0077 Specialized Support Surfaces N/A 0 0 0080 Physical Therapy 224,199 0 0 224,199081 Respiratory Therapy 0 0 0 0082 Occupational Therapy 156,240 0 0 156,240083 Speech Pathology 26,974 0 0 26,974085 Pharmacy 0 0 0 0090 Laboratory 0 0 0 0095 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 1,943,012 26,593 101,823 2,071,428 *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 2,478,841$ 26,593$ 101,823$ 2,478,841$ * (To Schedule 1)
ALLOCATION OF GENERAL SERVICES DIRECT CARE LABOR
ST
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6,70
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21
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$
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STATE OF CALIFORNIA SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Provider Name: Fiscal Period:WINE COUNTRY CARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1053311225 206390894
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) 14,621$ 51%Property Tax (line 40) 13,905 49% 28,526$
005 Plant Operations and Maintenance 237 237$ 010 Housekeeping 166 1 167$ 060 Laundry and Linen 305 3 2 309$ 065 Dietary 5,330 45 32 0 5,406$ 155 Social Services 169 1 1 0 0 172$ 160 Activities 1,117 9 7 0 0 0 1,133$ 165 Administration 1,210 10 7 0 0 0 0166 Medical Records 344 3 2 0 0 0 0170 Inservice Education - Nursing 169 1 1 0 0 0 0
ANCILLARY SERVICES075 Patient Supplies 205 2 1 0 0 0 0077 Specialized Support Surfaces 0 0 0 0 0 0 0080 Physical Therapy 135 1 1 0 0 0 0081 Respiratory Therapy 0 0 0 0 0 0 0082 Occupational Therapy 135 1 1 0 0 0 0083 Speech Pathology 135 1 1 0 0 0 0085 Pharmacy 122 1 1 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 18,564 155 110 309 5,406 172 1,133110 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 183 2 1 0 0 0 0145 Other Nonreimbursable 0 0 0 0 0 0 0
TOTAL 28,526$ 100% 28,526$ 237$ 167$ 309$ 5,406$ 172$ 1,133$ * (To Schedule 1)
STATE OF CALIFORNIA
Provider Name:WINE COUNTRY CARE CENTER
Provider NPI:1053311225
Net Exp ForLine DESCRIPTION Cost AllocNo. (From Sch 8) Ratio
GENERAL SERVICESCapital Related (excluding lines 40 & 45) 14,621$ 51%Property Tax (line 40) 13,905 49%
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 28,526$ 100%* (To Schedule 1)
SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Fiscal Period:JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
OSHPD Facility Number:206390894
Inserv. Ed Admin Medical Capital PropertyRecords Related Tax
Accumulated 51% 49%170 Costs 165 166 Total Of Total Of Total
1,227$ 1,227$ 349 349$
172$
0 208 7 2 216$ 111$ 105$ 0 0 0 0 0 0 00 137 69 20 226 116 1100 0 0 0 0 0 00 137 48 14 199 102 970 137 9 3 149 76 720 124 61 17 202 103 980 0 6 2 8 4 40 0 0 0 0 0 00 0 7 2 9 5 40 0 0 0 0 0 00 0 0 0 0 0 0
172 26,021 1,020 290 27,330 14,008 13,322 *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 00 185 2 0 187 96 910 0 0 0 0 0 0
172$ 26,950$ 1,227$ 349$ 28,526$ 14,621$ 13,905$
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STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:WINE COUNTRY CARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1053311225 206390894
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER005 Plant Operations and Maintenance005 .01-.19 Salaries and Wages 6200 $ 28,192 $ 0 $ 28,192 (Sch 3)005 .20-.39 Fringe Benefits 6200 7,373 0 7,373 (Sch 3)005 .79 Agency Staff 6200 0 0 (Sch 3)005 .40-.99 Other - Nonlabor 6200 190,596 0 190,596 (Sch 4)005 Plant Operations and Maintenance - Total 6200 $ 226,161 $ 0 $ 226,161
010 Housekeeping010 .01-.19 Salaries and Wages 6300 $ 110,170 $ 0 $ 110,170 (Sch 3)010 .20-.39 Fringe Benefits 6300 17,659 0 17,659 (Sch 3)010 .79 Agency Staff 6300 0 0 (Sch 3)010 .40-.99 Other - Nonlabor 6300 50,994 0 50,994 (Sch 4)010 Housekeeping - Total 6300 $ 178,823 $ 0 $ 178,823
015 Depreciation: Buildings and Improvements 7110 - 7120 $ $ 0 $ 0 (Sch 5)020 Depreciation: Leasehold Improvements 7130 0 0 (Sch 5)025 Depreciation: Equipment 7140 0 0 (Sch 5)030 Depreciation and Amortization - Other 7150 - 7160 0 0 (Sch 5)035 Leases and Rentals 7200 14,621 0 14,621 (Sch 5)040 Property Taxes 7300 15,527 (1,622) 13,905 (Sch 5)045 Property Insurance 7400 0 0 (Sch 6)050 Interest - Property, Plant, and Equipment 7500 0 0 (Sch 5)055 Interest - Other 7600 $ 57,026 $ (57,026) $ 0 (Sch 6)
057 Subtotal 005 - 055 $ 492,158 $ (58,648) $ 433,510
060 Laundry and Linen060 .01-.19 Salaries and Wages 6400 $ 71,943 $ 0 $ 71,943 (Sch 3)060 .20-.39 Fringe Benefits 6400 9,144 0 9,144 (Sch 3)060 .79 Agency Staff 6400 0 0 (Sch 3)060 .40-.99 Other - Nonlabor 6400 38,576 0 38,576 (Sch 4)060 Laundry and Linen - Total 6400 $ 119,663 $ 0 $ 119,663
065 Dietary065 .01-.19 Salaries and Wages 6500 $ 262,632 $ 0 $ 262,632 (Sch 3)065 .20-.39 Fringe Benefits 6500 36,020 0 36,020 (Sch 3)065 .79 Agency Staff 6500 0 0 (Sch 3)065 .40-.99 Other - Nonlabor 6500 245,197 0 245,197 (Sch 4)065 Dietary - Total 6500 $ 543,849 $ 0 $ 543,849
070 Provision for Bad Debts 7700 $ 0 $ 0
Ancillary Services 075 Patient Supplies075 .01-.19 Salaries and Wages 8100 $ $ 0 $ 0 (Sch 2)075 .20-.39 Fringe Benefits 8100 0 0 (Sch 2)075 .79 Agency Staff 8100 0 0 (Sch 2)075 .40-.99 Other - Nonlabor 8100 18,944 0 18,944 (Sch 4)075 Patient Supplies - Total 8100 $ 18,944 $ 0 $ 18,944
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 0 0 (Sch 4)077 Specialized Support Surfaces - Total 8150 $ 0 $ 0 $ 0
REPORTEDAS AS
AUDITEDADJUSTMENTS
8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:WINE COUNTRY CARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1053311225 206390894
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER REPORTED
AS ASAUDITED
ADJUSTMENTS8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
080 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 224,199 0 224,199 (Sch 2)080 .40-.99 Other - Nonlabor 8200 0 0 (Sch 4)080 Physical Therapy - Total 8200 $ 224,199 $ 0 $ 224,199
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 0 0 (Sch 4)081 Respiratory Therapy - Total 8220 $ 0 $ 0 $ 0
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 156,240 0 156,240 (Sch 2)082 .40-.99 Other - Nonlabor 8250 0 0 (Sch 4)082 Occupational Therapy - Total 8250 $ 156,240 $ 0 $ 156,240
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 26,974 0 26,974 (Sch 2)083 .40-.99 Other - Nonlabor 8280 0 0 (Sch 4)083 Speech Pathology - Total 8280 $ 26,974 $ 0 $ 26,974
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 198,396 0 198,396 (Sch 4)085 Pharmacy - Total 8300 $ 198,396 $ 0 $ 198,396
090 Laboratory090 .01-.19 Salaries and Wages 8400 $ $ 0 $ 0 (Sch 2)090 .20-.39 Fringe Benefits 8400 0 0 (Sch 2)090 .79 Agency Staff 8400 0 0 (Sch 2)090 .40-.99 Other - Nonlabor 8400 19,441 0 19,441 (Sch 4)090 Laboratory - Total 8400 $ 19,441 $ 0 $ 19,441
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 23,544 0 23,544 (Sch 4)100 Other Ancillary Services - Total 8900 $ 23,544 $ 0 $ 23,544
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:WINE COUNTRY CARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1053311225 206390894
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER REPORTED
AS ASAUDITED
ADJUSTMENTS8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
101 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 $ 667,738 $ 0 $ 667,738
Routine Services105 Skilled Nursing Care105 .01-.19 Salaries and Wages 6110 $ 1,692,887 $ 0 $ 1,692,887 (Sch 2)105 .20-.39 Fringe Benefits 6110 235,295 0 235,295 (Sch 2)105 .49 Agency Staff 6110 14,830 0 14,830 (Sch 2)105 .40-.99 Other - Nonlabor 6110 151,271 0 151,271 (Sch 4)105 Skilled Nursing Care - Total 6110 $ 2,094,283 $ 0 $ 2,094,283
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:WINE COUNTRY CARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1053311225 206390894
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER REPORTED
AS ASAUDITED
ADJUSTMENTS8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
128 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 2,140 0 2,140 (Sch 4)140 Beauty and Barber - Total 8900 $ 2,140 $ 0 $ 2,140
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 $ 2,096,423 $ 0 $ 2,096,423
155 Social Services155 .01-.19 Salaries and Wages 6600 $ 21,034 $ 0 $ 21,034 (Sch 2)155 .20-.39 Fringe Benefits 6600 5,559 0 5,559 (Sch 2)155 .49 Agency Staff 6600 0 0 (Sch 2)155 .40-.99 Other - Nonlabor 6600 950 0 950 (Sch 4)155 Social Services - Total 6600 $ 27,543 $ 0 $ 27,543
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:WINE COUNTRY CARE CENTER JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1053311225 206390894
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER REPORTED
AS ASAUDITED
ADJUSTMENTS8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
160 Activities160 .01-.19 Salaries and Wages 6700 $ 91,176 $ 0 $ 91,176 (Sch 2)160 .20-.39 Fringe Benefits 6700 10,647 0 10,647 (Sch 2)160 .49 Agency Staff 6700 0 0 (Sch 2)160 .40-.99 Other - Nonlabor 6700 4,266 0 4,266 (Sch 4)160 Activities - Total 6700 $ 106,089 $ 0 $ 106,089
165 Administration165 .01-.19 Salaries and Wages 6900 $ 434,895 $ (279,458) $ 155,437 (Sch 6)165 .20-.39 Fringe Benefits 6900 113,251 0 113,251 (Sch 6)165 .49 Agency Staff 6900 0 0 (Sch 6)165 .40-.99 Other - Nonlabor 6900 2,200 147,988 150,188 (Sch 6)165 Administration - Total 6900 $ 550,346 $ (131,470) $ 418,876
166 Medical Records166 .01-.19 Salaries and Wages 6900 $ 26,469 $ (3,207) $ 23,262 (Sch 3)166 .20-.39 Fringe Benefits 6900 4,138 3,207 7,345 (Sch 3)166 .49 Agency Staff 6900 0 0 (Sch 3)166 .40-.99 Other - Nonlabor 6900 16,838 100 16,938 (Sch 4)166 Medical Records - Total 6900 $ 47,445 $ 100 $ 47,545
167 CDPH Licensing Fees 6900 $ 24,682 $ 0 $ 24,682 (Sch 6)168 Professional Liability Insurance 6900 $ 79,302 $ (7,367) $ 71,935 (Sch 6)169 Quality Assurance Fees 6900 $ 140,634 $ 0 $ 140,634 (Sch 6)
170 Inservice Education - Nursing170 .01-.19 Salaries and Wages 6800 $ 59,028 $ 0 $ 59,028 (Sch 3)170 .20-.39 Fringe Benefits 6800 7,493 0 7,493 (Sch 3)170 .49 Agency Staff 6800 0 0 (Sch 3)170 .40-.99 Other - Nonlabor 6800 2,750 0 2,750 (Sch 4)170 Inservice Education - Nursing - Total 6800 $ 69,271 $ 0 $ 69,271
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 $ 1,045,312 $ (138,737) $ 906,575
200 Total $ 4,965,143 $ (197,385) $ 4,767,758
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:
WIN
E C
OU
NTR
Y C
AR
E C
EN
TER
1053
3112
2520
6390
894
JAN
UA
RY
1, 2
010
THR
OU
GH
DE
CE
MB
ER
31,
201
0
TOTA
L A
DJ
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JA
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DIT
AD
JA
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DJ
AU
DIT
AD
JA
UD
IT A
DJ
Line
Sub
(Pag
es 1
& 2
)1
23
45
67
8N
o.N
o.00
51
Pla
nt O
pera
tions
and
Mai
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- S
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2P
lant
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nd M
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3P
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Age
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ff0
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4P
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Oth
er -
Non
labo
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1H
ouse
keep
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- Sal
arie
s an
d W
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001
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Hou
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001
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Hou
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001
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Hou
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- N
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54
Dep
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and
Impr
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002
04
Dep
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Impr
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54
Dep
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quip
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t0
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4D
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003
54
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4P
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(1,6
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4P
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005
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Inte
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- P
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rty, P
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, and
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54
Inte
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- O
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(57,
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(57,
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060
1La
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- Sal
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006
02
Laun
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and
Line
n - F
ringe
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efits
006
03
Laun
dry
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Line
n - A
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006
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Laun
dry
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n - O
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- N
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51
Die
tary
- S
alar
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and
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es0
065
2D
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065
3D
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Age
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065
4D
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Oth
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labo
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070
4P
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007
51
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- Frin
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- Age
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4P
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- Oth
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077
1S
peci
aliz
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- Sal
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007
72
Spe
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ized
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007
73
Spe
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007
74
Spe
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Sup
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s - O
ther
- N
onla
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008
01
Phy
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l The
rapy
- S
alar
ies
and
Wag
es0
080
2P
hysi
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Frin
ge B
enef
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080
3P
hysi
cal T
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py -
Age
ncy
Sta
ff0
080
4P
hysi
cal T
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Oth
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Non
labo
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081
1R
espi
rato
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hera
py -
Sal
arie
s an
d W
ages
008
12
Res
pira
tory
The
rapy
- Fr
inge
Ben
efits
008
13
Res
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The
rapy
- A
genc
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taff
008
14
Res
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rapy
- O
ther
- N
onla
bor
008
21
Occ
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l The
rapy
- S
alar
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082
2O
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083
1S
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- S
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083
2S
peec
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- Fr
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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:
WIN
E C
OU
NTR
Y C
AR
E C
EN
TER
1053
3112
2520
6390
894
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
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IT A
DJ
AU
DIT
AD
JA
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DJ
AU
DIT
AD
JA
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Line
Sub
(Pag
es 1
& 2
)1
23
45
67
8N
o.N
o.
REC
LASS
IFIC
ATI
ON
S A
ND
/OR
AD
JUST
MEN
TS T
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EPO
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D C
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S
083
4S
peec
h P
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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
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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
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- O
ther
- N
onla
bor
009
51
Hom
e H
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Ser
vice
s - S
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and
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es0
095
2H
ome
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- Frin
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3H
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- Age
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Sta
ff0
095
4H
ome
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lth S
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- Oth
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labo
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100
1O
ther
Anc
illar
y S
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- Sal
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s an
d W
ages
010
02
Oth
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ncill
ary
Ser
vice
s - F
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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
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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
- Oth
er -
Non
labo
r0
110
1In
term
edia
te C
are
- Sal
arie
s an
d W
ages
011
02
Inte
rmed
iate
Car
e - F
ringe
Ben
efits
011
03
Inte
rmed
iate
Car
e - A
genc
y S
taff
011
04
Inte
rmed
iate
Car
e - O
ther
- N
onla
bor
011
51
Men
tally
Dis
orde
red
Car
e - S
alar
ies
and
Wag
es0
115
2M
enta
lly D
isor
dere
d C
are
- Frin
ge B
enef
its0
115
3M
enta
lly D
isor
dere
d C
are
- Age
ncy
Sta
ff0
115
4M
enta
lly D
isor
dere
d C
are
- Oth
er -
Non
labo
r0
120
1D
evel
opm
enta
lly D
isab
led
Car
e - S
alar
ies
and
Wag
es0
120
2D
evel
opm
enta
lly D
isab
led
Car
e - F
ringe
Ben
efits
012
03
Dev
elop
men
tally
Dis
able
d C
are
- Age
ncy
Sta
ff0
120
4D
evel
opm
enta
lly D
isab
led
Car
e - O
ther
- N
onla
bor
012
51
Sub
acut
e C
are
- Sal
arie
s an
d W
ages
012
52
Sub
acut
e C
are
- Frin
ge B
enef
its0
125
3S
ubac
ute
Car
e - A
genc
y S
taff
012
54
Sub
acut
e C
are
- Oth
er -
Non
labo
r0
126
1S
ubac
ute
Car
e - P
edia
tric
- Sal
arie
s an
d W
ages
012
62
Sub
acut
e C
are
- Ped
iatri
c - F
ringe
Ben
efits
012
63
Sub
acut
e C
are
- Ped
iatri
c - A
genc
y S
taff
012
64
Sub
acut
e C
are
- Ped
iatri
c - O
ther
- N
onla
bor
0
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:
WIN
E C
OU
NTR
Y C
AR
E C
EN
TER
1053
3112
2520
6390
894
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
es 1
& 2
)1
23
45
67
8N
o.N
o.
REC
LASS
IFIC
ATI
ON
S A
ND
/OR
AD
JUST
MEN
TS T
O R
EPO
RTE
D C
OST
S
128
1Tr
ansi
tiona
l Inp
atie
nt C
are
- Sal
arie
s an
d W
ages
012
82
Tran
sitio
nal I
npat
ient
Car
e - F
ringe
Ben
efits
012
83
Tran
sitio
nal I
npat
ient
Car
e - A
genc
y S
taff
012
84
Tran
sitio
nal I
npat
ient
Car
e - O
ther
- N
onla
bor
013
01
Hos
pice
Inpa
tient
Car
e - S
alar
ies
and
Wag
es0
130
2H
ospi
ce In
patie
nt C
are
- Frin
ge B
enef
its0
130
3H
ospi
ce In
patie
nt C
are
- Age
ncy
Sta
ff0
130
4H
ospi
ce In
patie
nt C
are
- Oth
er -
Non
labo
r0
135
1O
ther
Rou
tine
Ser
vice
s - S
alar
ies
and
Wag
es0
135
2O
ther
Rou
tine
Ser
vice
s - F
ringe
Ben
efits
013
53
Oth
er R
outin
e S
ervi
ces
- Age
ncy
Sta
ff0
135
4O
ther
Rou
tine
Ser
vice
s - O
ther
- N
onla
bor
013
91
Res
iden
tial C
are
- Sal
arie
s an
d W
ages
013
92
Res
iden
tial C
are
- Frin
ge B
enef
its0
139
3R
esid
entia
l Car
e - A
genc
y S
taff
013
94
Res
iden
tial C
are
- Oth
er -
Non
labo
r0
140
1B
eaut
y an
d B
arbe
r - S
alar
ies
and
Wag
es0
140
2B
eaut
y an
d B
arbe
r - F
ringe
Ben
efits
014
03
Bea
uty
and
Bar
ber -
Age
ncy
Sta
ff0
140
4B
eaut
y an
d B
arbe
r - O
ther
- N
onla
bor
014
51
Oth
er N
onre
imbu
rsab
le -
Sal
arie
s an
d W
ages
014
52
Oth
er N
onre
imbu
rsab
le -
Frin
ge B
enef
its0
145
3O
ther
Non
reim
burs
able
- A
genc
y S
taff
014
54
Oth
er N
onre
imbu
rsab
le -
Oth
er -
Non
labo
r0
155
1S
ocia
l Ser
vice
s - S
alar
ies
and
Wag
es0
155
2S
ocia
l Ser
vice
s - F
ringe
Ben
efits
015
53
Soc
ial S
ervi
ces
- Age
ncy
Sta
ff0
155
4S
ocia
l Ser
vice
s - O
ther
- N
onla
bor
016
01
Act
iviti
es -
Sal
arie
s an
d W
ages
016
02
Act
iviti
es -
Frin
ge B
enef
its0
160
3A
ctiv
ities
- A
genc
y S
taff
016
04
Act
iviti
es -
Oth
er -
Non
labo
r0
165
1A
dmin
istra
tion
- Sal
arie
s an
d W
ages
(279
,458
)(2
06,7
41)
(72,
717)
165
2A
dmin
istra
tion
- Frin
ge B
enef
its0
165
3A
dmin
istra
tion
- Age
ncy
Sta
ff0
165
4A
dmin
istra
tion
- Oth
er -
Non
labo
r14
7,98
82,
327
206,
741
(2,5
59)
(103
)(1
4,01
3)16
61
Med
ical
Rec
ords
- S
alar
ies
and
Wag
es(3
,207
)(3
,207
)16
62
Med
ical
Rec
ords
- Fr
inge
Ben
efits
3,20
73,
207
166
3M
edic
al R
ecor
ds -
Age
ncy
Sta
ff0
166
4M
edic
al R
ecor
ds -
Oth
er -
Non
labo
r10
010
016
74
CD
PH
Lic
ensi
ng F
ees
016
84
Pro
fess
iona
l Lia
bilit
y In
sura
nce
(7,3
67)
(2,3
27)
(5,0
40)
169
4Q
ualit
y A
ssur
ance
Fee
s0
170
1In
serv
ice
Edu
catio
n - N
ursi
ng -
Sal
arie
s an
d W
ages
017
02
Inse
rvic
e E
duca
tion
- Nur
sing
- Fr
inge
Ben
efits
017
03
Inse
rvic
e E
duca
tion
- Nur
sing
- A
genc
y S
taff
017
04
Inse
rvic
e E
duca
tion
- Nur
sing
- O
ther
- N
onla
bor
017
41
Car
egiv
er T
rain
ing
- Sal
arie
s an
d W
ages
017
42
Car
egiv
er T
rain
ing
- Frin
ge B
enef
its0
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:
WIN
E C
OU
NTR
Y C
AR
E C
EN
TER
1053
3112
2520
6390
894
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
es 1
& 2
)1
23
45
67
8N
o.N
o.
REC
LASS
IFIC
ATI
ON
S A
ND
/OR
AD
JUST
MEN
TS T
O R
EPO
RTE
D C
OST
S
174
3C
areg
iver
Tra
inin
g - A
genc
y S
taff
017
44
Car
egiv
er T
rain
ing
- Oth
er -
Non
labo
r0
200
T
otal
($
197,
385)
010
0(7
2,71
7)(1
,622
)(2
,559
)(5
,040
)(1
03)
(71,
039)
(To
Sch
8)
STA
TE O
F C
ALI
FOR
NIA
Prov
ider
Nam
e:W
INE
CO
UN
TRY
CA
RE
CE
NTE
R
Line
Sub
No.
No.
005
1P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Sal
arie
s an
d W
ages
005
2P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Frin
ge B
enef
its00
53
Pla
nt O
pera
tions
and
Mai
nten
ance
- A
genc
y S
taff
005
4P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Oth
er -
Non
labo
r01
01
Hou
seke
epin
g - S
alar
ies
and
Wag
es01
02
Hou
seke
epin
g - F
ringe
Ben
efits
010
3H
ouse
keep
ing
- Age
ncy
Sta
ff01
04
Hou
seke
epin
g - O
ther
- N
onla
bor
015
4D
epre
ciat
ion:
Bui
ldin
gs a
nd Im
prov
emen
ts02
04
Dep
reci
atio
n: L
ease
hold
Impr
ovem
ents
025
4D
epre
ciat
ion:
Equ
ipm
ent
030
4D
epre
ciat
ion
and
Am
ortiz
atio
n - O
ther
035
4Le
ases
and
Ren
tals
040
4P
rope
rty T
axes
045
4P
rope
rty In
sura
nce
050
4In
tere
st -
Pro
perty
, Pla
nt, a
nd E
quip
men
t05
54
Inte
rest
- O
ther
060
1La
undr
y an
d Li
nen
- Sal
arie
s an
d W
ages
060
2La
undr
y an
d Li
nen
- Frin
ge B
enef
its06
03
Laun
dry
and
Line
n - A
genc
y S
taff
060
4La
undr
y an
d Li
nen
- Oth
er -
Non
labo
r06
51
Die
tary
- S
alar
ies
and
Wag
es06
52
Die
tary
- Fr
inge
Ben
efits
065
3D
ieta
ry -
Age
ncy
Sta
ff06
54
Die
tary
- O
ther
- N
onla
bor
070
4P
rovi
sion
for B
ad D
ebts
075
1P
atie
nt S
uppl
ies
- Sal
arie
s an
d W
ages
075
2P
atie
nt S
uppl
ies
- Frin
ge B
enef
its07
53
Pat
ient
Sup
plie
s - A
genc
y S
taff
075
4P
atie
nt S
uppl
ies
- Oth
er -
Non
labo
r07
71
Spe
cial
ized
Sup
port
Sur
face
s - S
alar
ies
and
Wag
es07
72
Spe
cial
ized
Sup
port
Sur
face
s - F
ringe
Ben
efits
077
3S
peci
aliz
ed S
uppo
rt S
urfa
ces
- Age
ncy
Sta
ff07
74
Spe
cial
ized
Sup
port
Sur
face
s - O
ther
- N
onla
bor
080
1P
hysi
cal T
hera
py -
Sal
arie
s an
d W
ages
080
2P
hysi
cal T
hera
py -
Frin
ge B
enef
its08
03
Phy
sica
l The
rapy
- A
genc
y S
taff
080
4P
hysi
cal T
hera
py -
Oth
er -
Non
labo
r08
11
Res
pira
tory
The
rapy
- S
alar
ies
and
Wag
es08
12
Res
pira
tory
The
rapy
- Fr
inge
Ben
efits
081
3R
espi
rato
ry T
hera
py -
Age
ncy
Sta
ff08
14
Res
pira
tory
The
rapy
- O
ther
- N
onla
bor
082
1O
ccup
atio
nal T
hera
py -
Sal
arie
s an
d W
ages
082
2O
ccup
atio
nal T
hera
py -
Frin
ge B
enef
its08
23
Occ
upat
iona
l The
rapy
- A
genc
y S
taff
082
4O
ccup
atio
nal T
hera
py -
Oth
er -
Non
labo
r08
31
Spe
ech
Pat
holo
gy -
Sal
arie
s an
d W
ages
083
2S
peec
h P
atho
logy
- Fr
inge
Ben
efits
083
3S
peec
h P
atho
logy
- A
genc
y S
taff
Sche
dule
8A
-1Pa
ge 2
Prov
ider
NPI
:O
SHPD
Fac
ility
Num
ber:
Fisc
al P
erio
d:10
5331
1225
2063
9089
4JA
NU
AR
Y 1
, 201
0 TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
010
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
AU
DIT
AD
J9
1011
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
Prov
ider
Nam
e:W
INE
CO
UN
TRY
CA
RE
CE
NTE
R
Line
Sub
No.
No.
083
4S
peec
h P
atho
logy
- O
ther
- N
onla
bor
085
1P
harm
acy
- Sal
arie
s an
d W
ages
085
2P
harm
acy
- Frin
ge B
enef
its08
53
Pha
rmac
y - A
genc
y S
taff
085
4P
harm
acy
- Oth
er -
Non
labo
r09
01
Labo
rato
ry -
Sal
arie
s an
d W
ages
090
2La
bora
tory
- Fr
inge
Ben
efits
090
3La
bora
tory
- A
genc
y S
taff
090
4La
bora
tory
- O
ther
- N
onla
bor
095
1H
ome
Hea
lth S
ervi
ces
- Sal
arie
s an
d W
ages
095
2H
ome
Hea
lth S
ervi
ces
- Frin
ge B
enef
its09
53
Hom
e H
ealth
Ser
vice
s - A
genc
y S
taff
095
4H
ome
Hea
lth S
ervi
ces
- Oth
er -
Non
labo
r10
01
Oth
er A
ncill
ary
Ser
vice
s - S
alar
ies
and
Wag
es10
02
Oth
er A
ncill
ary
Ser
vice
s - F
ringe
Ben
efits
100
3O
ther
Anc
illar
y S
ervi
ces
- Age
ncy
Sta
ff10
04
Oth
er A
ncill
ary
Ser
vice
s - O
ther
- N
onla
bor
101
1S
ubac
ute
Car
e A
ncill
ary
Ser
vice
s - S
alar
ies
and
Wag
es10
12
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Frin
ge B
enef
its10
13
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Age
ncy
Sta
ff10
14
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Oth
er -
Non
labo
r10
21
Sub
acut
e P
edia
tric
Anc
illar
y S
ervi
ces
- Sal
arie
s an
d W
ages
102
2S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - F
ringe
Ben
efits
102
3S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - A
genc
y S
taff
102
4S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - O
ther
- N
onla
bor
105
1S
kille
d N
ursi
ng C
are
- Sal
arie
s an
d W
ages
105
2S
kille
d N
ursi
ng C
are
- Frin
ge B
enef
its10
53
Ski
lled
Nur
sing
Car
e - A
genc
y S
taff
105
4S
kille
d N
ursi
ng C
are
- Oth
er -
Non
labo
r11
01
Inte
rmed
iate
Car
e - S
alar
ies
and
Wag
es11
02
Inte
rmed
iate
Car
e - F
ringe
Ben
efits
110
3In
term
edia
te C
are
- Age
ncy
Sta
ff11
04
Inte
rmed
iate
Car
e - O
ther
- N
onla
bor
115
1M
enta
lly D
isor
dere
d C
are
- Sal
arie
s an
d W
ages
115
2M
enta
lly D
isor
dere
d C
are
- Frin
ge B
enef
its11
53
Men
tally
Dis
orde
red
Car
e - A
genc
y S
taff
115
4M
enta
lly D
isor
dere
d C
are
- Oth
er -
Non
labo
r12
01
Dev
elop
men
tally
Dis
able
d C
are
- Sal
arie
s an
d W
ages
120
2D
evel
opm
enta
lly D
isab
led
Car
e - F
ringe
Ben
efits
120
3D
evel
opm
enta
lly D
isab
led
Car
e - A
genc
y S
taff
120
4D
evel
opm
enta
lly D
isab
led
Car
e - O
ther
- N
onla
bor
125
1S
ubac
ute
Car
e - S
alar
ies
and
Wag
es12
52
Sub
acut
e C
are
- Frin
ge B
enef
its12
53
Sub
acut
e C
are
- Age
ncy
Sta
ff12
54
Sub
acut
e C
are
- Oth
er -
Non
labo
r12
61
Sub
acut
e C
are
- Ped
iatri
c - S
alar
ies
and
Wag
es12
62
Sub
acut
e C
are
- Ped
iatri
c - F
ringe
Ben
efits
126
3S
ubac
ute
Car
e - P
edia
tric
- Age
ncy
Sta
ff12
64
Sub
acut
e C
are
- Ped
iatri
c - O
ther
- N
onla
bor
Sche
dule
8A
-1Pa
ge 2
Prov
ider
NPI
:O
SHPD
Fac
ility
Num
ber:
Fisc
al P
erio
d:10
5331
1225
2063
9089
4JA
NU
AR
Y 1
, 201
0 TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
010
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
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660
660
10.7
165
2,3
716
5A
dmin
istr
atio
n0
715
715
10.7
166
2,3
716
6M
edic
al R
ecor
ds0
203
203
10.7
170
2,3
717
0In
serv
ice
Edu
catio
n0
100
100
10.7
175
27
175
Tot
al S
tatis
tics
016
,714
16,7
1410
.717
53
717
5T
otal
Sta
tistic
s0
16,6
1616
,616
To
esta
blis
h sq
uare
foot
age
for
prop
er c
ost d
eter
min
atio
n.42
CF
R 4
13.2
0 ad
413
.24
CM
S P
ub. 1
5-1,
Sec
tions
230
0 an
d 23
04
Pag
e4
Sta
te o
f C
alif
orn
iaD
epar
tmen
t o
f H
ealt
h C
are
Ser
vice
s
Pro
vid
er N
ame
Fis
cal P
erio
dP
rovi
der
NP
I14
MC
530
Adj
.P
age
orA
sIn
crea
seA
sN
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xhib
itLi
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. L
ine
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orte
d(D
ecre
ase)
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uste
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xpla
natio
n of
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it A
djus
tmen
ts
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ort R
efer
ence
sA
udit
Rep
ort
Ad
just
men
tsW
INE
CO
UN
TR
Y C
AR
E C
EN
TE
RJA
NU
AR
Y 1
, 201
0 T
HR
OU
GH
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CE
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ER
31,
201
010
5331
1225
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t Rep
ort
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TM
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TS
TO
RE
PO
RT
ED
PA
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NT
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YS
134.
15
21
15
1M
edi-C
al D
ays
19,3
44(2
,448
)16
,896
To
adju
st r
epor
ted
Med
i-Cal
Nur
sing
Fac
ility
day
s ba
sed
on th
e fo
llow
ing
Fis
cal I
nter
med
iary
Pay
men
t Dat
a:
Ser
vice
Per
iod:
Jan
uary
1, 2
010
thro
ugh
Dec
embe
r 31
, 201
0
Pay
men
t Per
iod:
Jan
uary
1, 2
010
thro
ugh
Feb
ruar
y 29
, 201
2 R
epor
t Dat
e: M
arch
23,
2012
42 C
FR
413
.20,
413
.24,
413
.50,
413
.53,
413
.60,
413
.64,
and
433
.139
CM
S P
ub. 1
5-1,
Sec
tions
230
0, 2
304,
240
4, a
nd 2
408
CC
R, T
itle
22, S
ectio
n 51
541
14N
/A1
16
1M
edi-C
al M
anag
ed C
are
Day
s0
295
295
To
incl
ude
Med
i-Cal
Man
aged
Car
e da
ys to
agr
ee w
ith th
epr
ovid
er's
pat
ient
cen
sus
reco
rds.
42 C
FR
413
.20
and
413.
50C
MS
Pub
. 15-
1, S
ectio
ns 2
205
and
2304
Pag
e5
