REPORT ON THE RATE SETTING AUDIT DOWNEY CARE CENTER DOWNEY, CALIFORNIA ... · PDF filereport on the rate setting audit downey care center downey, california provider number: zzt05519j

REPORT ON THE

RATE SETTING AUDIT

DOWNEY CARE CENTER DOWNEY, CALIFORNIA

PROVIDER NUMBER: ZZT05519J NATIONAL PROVIDER IDENTIFIER: 1942335062

FISCAL PERIOD ENDED DECEMBER 31, 2009

Audits Section – Santa Ana Financial Audits Branch

Audits and Investigations Department of Health Care Services

Section Chief: Margaret A. Varho Audit Supervisor: Stan Van Arsdale Auditor: Teri Hung

State of California—Health and Human Services Agency Department of Health Care Services

TOBY DOUGLAS EDMUND G. BROWN JR. DIRECTOR GOVERNOR

605 West Santa Ana Blvd., Building 28, Room 830, Santa Ana, CA 92701 (714) 558-4434 / (714) 558-4179 fax Internet Address: www.dhcs.ca.gov

Date: June 24, 2011 Carol Sparks Director of Reimbursement Covenant Care, LLC 27071 Aliso Creek Road, Suite 100 Aliso Viejo, CA 92656 PROVIDER: DOWNEY CARE CENTER PROVIDER NO. ZZT05519J NATIONAL PROVIDER IDENTIFIER: 1942335062 FISCAL PERIOD ENDED DECEMBER 31, 2009 We have examined the facility's Integrated Disclosure and Medi-Cal Cost Report for the above-referenced fiscal period. Our examination was made under the authority of Section 14170 of the Welfare and Institutions Code and was limited to a review of the cost report and accompanying financial statements, Medi-Cal Paid Claims Summary Report, prior fiscal period's Medi-Cal program audit report, and Medicare audit report for the current fiscal period, if applicable and available. In our opinion, the data presented in the accompanying Summary of Audited Facility Cost per Patient Day represents a proper determination of the allowable costs and patient days for the above fiscal period in accordance with Medi-Cal reimbursement principles. This audit report includes the: 1. Summary of Audited Facility Cost per Patient Day and supporting schedules 2. Audit Adjustments Schedule Future Medi-Cal long-term care prospective rates may be affected by this examination. The extent to which the rates change will be determined by the Department's Rate Development Branch. 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.

Carol Sparks Page 2

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 95899-7413 Sacramento, CA 95814-5005 (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—Santa Ana at (714) 558-4434. (Original signed by Margaret Varho) Margaret A. Varho, Chief Audits Section—Santa Ana Financial Audits Branch Certified

STATE OF CALIFORNIA SCHEDULE 1

Provider Name: Fiscal Period:DOWNEY CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009

Provider Number: NPI: OSHPD Facility No.:ZZT05519J 1942335062 206190874

LineNo.

SKILLED NURSING CARE1 Cost of Direct Care - Labor (Sch. 2, Ln. 105) $ N/A $ 2,874,557 $ 86.072 Cost of Indirect Care - Labor (Sch. 3, Ln. 105) $ N/A $ 674,933 $ 20.213 Cost of Direct and Indirect NonLabor - Other (Sch. 4, Ln. 105) $ N/A $ 455,584 $ 13.644 Cost of Capital Related (Sch. 5, Ln. 105) $ N/A $ 436,871 $ 13.085 Property Taxes (Sch. 5, Ln. 105) $ N/A $ 35,072 $ 1.056 DPH Licensing Fees (Sch. 6, Ln. 105) $ N/A $ 20,498 $ 0.617 Liability Insurance (Sch. 6, Ln. 105) $ N/A $ 160,636 $ 4.818 Caregiver Training (Sch. 6, Ln. 105) $ N/A $ 0 $ 0.009 Quality Assurance Fees (Sch. 6, Ln. 105) $ N/A $ 252,924 $ 7.57

10 Cost of Administration (Sch. 6, Ln. 105) $ N/A $ 739,495 $ 22.1411 Cost of Routine Service/Audited Total Costs $ 5,638,937 $ 5,650,569 $ 169.2012 Total Patient Days (Adj ) 33,396 33,39613 Cost Per Patient Day (Cost Divided by Days) $ 168.85 $ 169.20 14 Overpayments (Adj ) $ 0 $ 015

INTERMEDIATE CARE16 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 017 Total Patient Days (Adj ) 018 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0019 Overpayments (Adj ) $ $ 0

MENTALLY DISORDERED CARE20 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 021 Total Patient Days (Adj ) 022 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0023 Overpayments (Adj ) $ $ 0

DEVELOPMENTALLY DISABLED24 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 025 Total Patient Days (Adj ) 026 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0027 Overpayments (Adj ) $ $ 0

SUBACUTE CARE28 Cost of Direct Care - Labor (Adult Subacute Sch. 1, Ln. 25) $ N/A $ 0 $ 0.0029 Cost of Indirect Care - Labor (Adult Subacute Sch. 1, Ln. 26) $ N/A $ 0 $ 0.0030 Cost of Direct and Indirect NonLabor - Other (Adult SA Sch. 1, Ln. 27) $ N/A $ 0 $ 0.0031 Cost of Capital Related (Adult Subacute Sch. 1, Ln. 28) $ N/A $ 0 $ 0.0032 Property Taxes (Adult Subacute Sch. 1, Ln. 29) $ N/A $ 0 $ 0.0033 DPH Licensing Fees (Adult Subacute Sch. 1, Ln. 30) $ N/A $ 0 $ 0.0034 Liability Insurance (Adult Subacute Sch. 1, Ln. 31) $ N/A $ 0 $ 0.0035 Quality Assurance Fees (Adult Subacute Sch. 1, Ln. 32) $ N/A $ 0 $ 0.0036 Caregiver Training (Adult Subacute Sch. 1, Ln. 33) $ N/A $ 0 $ 0.0037 Cost of Administration (Adult Subacute Sch., Ln. 34) $ N/A $ 0 $ 0.0038 Total Cost of Subacute Service (Adult Subacute Sch. 1, Ln. 35) $ 0 $ 0 $ 0.0039 Total Patient Days (Adult Subacute Sch. 1, Ln. 36) 0 040 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0041 Overpayments (Adult Subacute Sch. 1, Ln. 38 + Ln. 39) $ 0 $ 0

SUMMARY OF AUDITED FACILITY COST PER PATIENT DAY

COST PERAUDITED

AS REPORTED AS AUDITED PATIENT DAYPROGRAM DESCRIPTION




LineNo.

SUMMARY OF AUDITED FACILITY COST PER PATIENT DAY

COST PERAUDITED

AS REPORTED AS AUDITED PATIENT DAYPROGRAM DESCRIPTION

SUBACUTE - PEDIATRIC SUBACUTE42 Cost of Routine Service (Ped-SA, Sch. 1, Ln 3) $ 0 $ 043 Cost of Ancillary Service (Ped-SA, Sch. 1, Ln. 1 + Ln. 2) $ 0 $ 044 Total Cost of Pediatric Subacute Service (Ln. 42 + Ln. 43) $ 0 $ 045 Total Patient Days (Ped-SA, Sch. 1, Ln. 5) 0 046 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0047 Overpayments (Ped-SA, Sch. 1, Ln. 7 + Ln. 8) $ 0 $ 0

TRANSITIONAL INPATIENT CARE48 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 049 Total Patient Days (Adj ) 050 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0051 Overpayments (Adj ) $ $ 0

HOSPICE INPATIENT CARE52 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 053 Total Patient Days (Adj ) 054 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0055 Overpayments (Adj ) $ $ 0

OTHER ROUTINE SERVICES56 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 057 Total Patient Days (Adj ) 058 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0059 Overpayments (Adj ) $ $ 0




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 (Salaries, Fringe Benefits, & Agency Labor) 111,749$ 111,749$ 160 Activities (Salaries, Fringe Benefits, & Agency Labor) 94,785 94,785$ 165 Administration166 Medical Records170 Inservice Education - Nursing

ANCILLARY SERVICES075 Patient Supplies 30,678 0 0 30,678 ***077 Specialized Support Surfaces N/A 0 0 0 ***080 Physical Therapy 385,993 0 0 385,993 ***081 Respiratory Therapy 0 0 0 0 ***082 Occupational Therapy 343,986 0 0 343,986 ***083 Speech Pathology 118,434 0 0 118,434 ***085 Pharmacy 335,351 0 0 335,351 ***090 Laboratory 39,057 0 0 39,057 ***095 Home Health Services 0 0 0 0100 Other Ancillary Services 26,054 0 0 26,054101 Subacute Ancillary Services 0 0 0 0102 Subacute Pediatrics Ancillary Services 0 0 0 0 **

ROUTINE SERVICES105 Skilled Nursing Care 2,668,023 111,749 94,785 2,874,557 *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 - Pediatrics 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 3,659 0 0 3,659145 Other Nonreimbursable 0 0 0 0

TOTAL 4,157,769$ 111,749$ 94,785$ 4,157,769$

* (To Schedule 1)** (To Pediatric Subacute Schedule 1)*** (To Pediatric Subacute Schedule 2)

ALLOCATION OF GENERAL SERVICES - LABOR (DIRECT CARE)

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ALLOCATION OF CAPITAL COSTS


Provider Number: NPI: OSHPD Facility Number:ZZT05519J 1942335062 206190874

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) 492,355$ 93%Property Tax (line 40) 39,526 7% 531,881$

005 Plant Operations and Maintenance 15,166 15,166$ 010 Housekeeping 8,593 252 8,845$ 060 Laundry and Linen 27,949 820 487 29,256$ 065 Dietary 64,853 1,903 1,129 0 67,886$ 155 Social Services 1,266 37 22 0 0 1,326$ 160 Activities 2,593 76 45 0 0 0 2,714$ 165 Administration 69,557 2,041 1,211 0 0 0 0166 Medical Records 21,859 642 381 0 0 0 0170 Inservice Education - Nursing 3,347 98 58 0 0 0 0

ANCILLARY SERVICES075 Patient Supplies 2,171 64 38 0 0 0 0077 Specialized Support Surfaces 0 0 0 0 0 0 0080 Physical Therapy 11,186 328 195 0 0 0 0081 Respiratory Therapy 0 0 0 0 0 0 0082 Occupational Therapy 8,261 242 144 0 0 0 0083 Speech Pathology 9,437 277 164 0 0 0 0085 Pharmacy 0 0 0 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 Ancillary Services 0 0 0 0 0 0 0102 Subacute Pediatrics Ancillary Services 0 0 0 0 0 0 0

ROUTINE SERVICES105 Skilled Nursing Care 281,242 8,254 4,896 29,256 67,886 1,326 2,714110 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 - Pediatrics 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 4,402 129 77 0 0 0 0145 Other Nonreimbursable 0 0 0 0 0 0 0

TOTAL 531,881$ 100% 531,881$ 15,166$ 8,845$ 29,256$ 67,886$ 1,326$ 2,714$

* (To Schedule 1)** (To Pediatric Subacute Schedule 1)*** (To Pediatric Subacute Schedule 2)

STATE OF CALIFORNIA

Provider Name:

DOWNEY CARE CENTER

Provider Number: NPI:

ZZT05519J 1942335062

Net Exp For

Line DESCRIPTION Cost AllocNo. (From Sch 8) Ratio

GENERAL SERVICES

Capital Related (excluding lines 40 & 45) 492,355$ 93%

Property Tax (line 40) 39,526 7%

005 Plant Operations and Maintenance

010 Housekeeping

060 Laundry and Linen

065 Dietary

155 Social Services

160 Activities

165 Administration

166 Medical Records

170 Inservice Education - Nursing

ANCILLARY SERVICES

075 Patient Supplies

077 Specialized Support Surfaces

080 Physical Therapy

081 Respiratory Therapy

082 Occupational Therapy

083 Speech Pathology

085 Pharmacy

090 Laboratory

095 Home Health Services

100 Other Ancillary Services

101 Subacute Ancillary Services

102 Subacute Pediatrics Ancillary Services

ROUTINE SERVICES

105 Skilled Nursing Care

110 Intermediate Care

115 Mentally Disordered Care

120 Developmentally Disabled Care

125 Subacute Care

126 Subacute Care - Pediatrics

128 Transitional Inpatient Care

130 Hospice Inpatient Care

135 Other Routine Services

NONREIMBURSABLE

139 Residential Care

140 Beauty and Barber

145 Other Nonreimbursable

TOTAL 531,881$ 100%

* (To Schedule 1)

** (To Pediatric Subacute Schedule 1)

*** (To Pediatric Subacute Schedule 2)

SCHEDULE 5

ALLOCATION OF CAPITAL COSTS

Fiscal Period:

JANUARY 1, 2009 THROUGH DECEMBER 31, 2009

OSHPD Facility Number:

206190874

In-serv. Ed Admin Medical Capital Property

Records Related Tax

Accumulated 93% 7%170 Costs 165 166 Total Of Total Of Total

72,809$ 72,809$

22,881 22,881$

3,503$

0 2,272 445 140 2,857$ 2,645$ 212$ ***

0 0 0 0 0 0 0 ***

0 11,709 5,236 1,645 18,590 17,208 1,381 ***

0 0 0 0 0 0 0 ***

0 8,647 4,627 1,454 14,729 13,634 1,095 ***

0 9,878 1,742 547 12,168 11,263 904 ***

0 0 4,329 1,361 5,690 5,267 423 ***

0 0 504 158 663 613 49 ***

0 0 0 0 0 0 0

0 0 336 106 442 409 33

0 0 0 0 0 0 0

0 0 0 0 0 0 0 **

3,503 399,076 55,443 17,423 471,943 436,871 35,072 *

0 0 0 0 0 0 0 *

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0 0 0 0 0 0 0

0 4,608 147 46 4,800 4,444 357

0 0 0 0 0 0 0

3,503$ 436,191$ 72,809$ 22,881$ 531,881$ 492,355$ 39,526$

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Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER

005 Plant Operations and Maintenance005 .01-.19 Salaries and Wages 6200 $ 50,339 $ 0 $ 50,339 (Sch 3)005 .20-.39 Fringe Benefits 6200 17,886 0 17,886 (Sch 3)005 .79 Agency Staff 6200 0 0 0 (Sch 3)005 .40-.99 Other - Nonlabor 6200 104,040 0 104,040 (Sch 4)005 Plant Operations and Maintenance - Total 6200 $ 172,265 $ 0 $ 172,265

010 Housekeeping010 .01-.19 Salaries and Wages 6300 $ 110,545 $ 0 $ 110,545 (Sch 3)010 .20-.39 Fringe Benefits 6300 35,313 0 35,313 (Sch 3)010 .79 Agency Staff 6300 0 0 0 (Sch 3)010 .40-.99 Other - Nonlabor 6300 38,163 0 38,163 (Sch 4)010 Housekeeping - Total 6300 $ 184,021 $ 0 $ 184,021

015 Depreciation: Buildings and Improvements 7110 - 7120 $ 0 0 $ 0 (Sch 5)020 Depreciation: Leasehold Improvements 7130 15,025 0 15,025 (Sch 5)025 Depreciation: Equipment 7140 45,852 0 45,852 (Sch 5)030 Depreciation and Amortization - Other 7150 - 7160 0 0 0 (Sch 5)035 Leases and Rentals 7200 427,381 0 427,381 (Sch 5)040 Property Taxes 7300 39,526 0 39,526 (Sch 5)045 Property Insurance 7400 10,889 0 10,889 (Sch 6)050 Interest-Property, Plant, and Equipment 7500 0 4,097 4,097 (Sch 5)055 Interest-Other 7600 4,097 (4,097) 0 (Sch 6)

057 Subtotal 005 - 055 $ 899,056 $ 0 $ 899,056

060 Laundry and Linen060 .01-.19 Salaries and Wages 6400 $ 56,677 $ 0 $ 56,677 (Sch 3)060 .20-.39 Fringe Benefits 6400 20,591 0 20,591 (Sch 3)060 .79 Agency Staff 6400 0 0 0 (Sch 3)060 .40-.99 Other - Nonlabor 6400 21,106 0 21,106 (Sch 4)060 Laundry and Linen - Total 6400 $ 98,374 $ 0 $ 98,374

065 Dietary065 .01-.19 Salaries and Wages 6500 $ 203,155 $ 0 $ 203,155 (Sch 3)065 .20-.39 Fringe Benefits 6500 69,513 0 69,513 (Sch 3)065 .79 Agency Staff 6500 0 0 0 (Sch 3)065 .40-.99 Other - Nonlabor 6500 174,230 0 174,230 (Sch 4)065 Dietary - Total 6500 $ 446,898 $ 0 $ 446,898

070 Provision for Bad Debts 7700 $ 0 0 $ 0

Ancillary Services (Note 1)075 Patient Supplies075 .01-.19 Salaries and Wages 8100 $ 0 $ 0 $ 0 (Sch 2)075 .20-.39 Fringe Benefits 8100 0 0 0 (Sch 2)075 .79 Agency Staff 8100 0 0 0 (Sch 2)075 .40-.99 Other - Nonlabor 8100 22,942 7,736 30,678075 Patient Supplies - Total 8100 $ 22,942 $ 7,736 $ 30,678 (Sch 2)

077 Specialized Support Surfaces077 .01-.19 Salaries and Wages 8150 $ 0 $ 0 $ 0 N/A077 .20-.39 Fringe Benefits 8150 0 0 0 N/A077 .79 Agency Staff 8150 0 0 0 N/A077 .40-.99 Other - Nonlabor 8150 0 0 0 (Sch 4)077 Specialized Support Surfaces - Total 8150 $ 0 $ 0 $ 0

8A-1 8A-2ADJUSTED ASADJUSTMENTS

SUMMARY OF AUDITED PROGRAM EXPENSES

AS AUDIT

AUDITED




Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER 8A-1 8A-2

ADJUSTED ASADJUSTMENTS


AS AUDIT

AUDITED

080 Physical Therapy080 .01-.19 Salaries and Wages 8200 $ 0 $ 0 $ 0 (Sch 2)080 .20-.39 Fringe Benefits 8200 0 0 0 (Sch 2)080 .79 Agency Staff 8200 0 0 0 (Sch 2)080 .40-.99 Other - Nonlabor 8200 385,993 0 385,993080 Physical Therapy - Total 8200 $ 385,993 $ 0 $ 385,993 (Sch 2)

081 Respiratory Therapy081 .01-.19 Salaries and Wages 8220 $ 0 $ 0 $ 0 (Sch 2)081 .20-.39 Fringe Benefits 8220 0 0 0 (Sch 2)081 .79 Agency Staff 8220 0 0 0 (Sch 2)081 .40-.99 Other - Nonlabor 8220 0 0 0081 Respiratory Therapy - Total 8220 $ 0 $ 0 $ 0 (Sch 2)

082 Occupational Therapy082 .01-.19 Salaries and Wages 8250 0 0 0 (Sch 2)082 .20-.39 Fringe Benefits 8250 0 0 0 (Sch 2)082 .79 Agency Staff 8250 0 0 0 (Sch 2)082 .40-.99 Other - Nonlabor 8250 343,986 0 343,986082 Occupational Therapy - Total 8250 $ 343,986 $ 0 $ 343,986 (Sch 2)

083 Speech Pathology083 .01-.19 Salaries and Wages 8280 $ 0 $ 0 $ 0 (Sch 2)083 .20-.39 Fringe Benefits 8280 0 0 0 (Sch 2)083 .79 Agency Staff 8280 0 0 0 (Sch 2)083 .40-.99 Other - Nonlabor 8280 118,434 0 118,434083 Speech Pathology - Total 8280 $ 118,434 $ 0 $ 118,434 (Sch 2)

085 Pharmacy085 .01-.19 Salaries and Wages 8300 $ 0 $ 0 $ 0 (Sch 2)085 .20-.39 Fringe Benefits 8300 0 0 0 (Sch 2)085 .79 Agency Staff 8300 0 0 0 (Sch 2)085 .40-.99 Other - Nonlabor 8300 335,351 0 335,351085 Pharmacy - Total 8300 $ 335,351 $ 0 $ 335,351 (Sch 2)

090 Laboratory090 .01-.19 Salaries and Wages 8400 $ 0 $ 0 $ 0 (Sch 2)090 .20-.39 Fringe Benefits 8400 0 0 0 (Sch 2)090 .79 Agency Staff 8400 0 0 0 (Sch 2)090 .40-.99 Other - Nonlabor 8400 35,600 3,457 39,057090 Laboratory - Total 8400 $ 35,600 $ 3,457 $ 39,057 (Sch 2)

095 Home Health Services095 .01-.19 Salaries and Wages 8800 $ 0 $ 0 $ 0 (Sch 2)095 .20-.39 Fringe Benefits 8800 0 0 0 (Sch 2)095 .79 Agency Staff 8800 0 0 0 (Sch 2)095 .40-.99 Other - Nonlabor 8800 0 0 0095 Home Health Services - Total 8800 $ 0 $ 0 $ 0 (Sch 2)

100 Other Ancillary Services100 .01-.19 Salaries and Wages 8900 $ 0 $ 0 $ 0 (Sch 2)100 .20-.39 Fringe Benefits 8900 0 0 0 (Sch 2)100 .79 Agency Staff 8900 0 0 0 (Sch 2)100 .40-.99 Other - Nonlabor 8900 26,054 0 26,054100 Other Ancillary Services - Total 8900 $ 26,054 $ 0 $ 26,054 (Sch 2)


Provider Name: Fiscal Period:

DOWNEY CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009

Provider Number: NPI: OSHPD Facility Number:

ZZT05519J 1942335062 206190874




AS AUDIT

AUDITED


101 .01-.19 Salaries and Wages 8100-8900 $ 0 $ 0 $ 0 (Sch 2)

101 .20-.39 Fringe Benefits 8100-8900 0 0 0 (Sch 2)

101 .79 Agency Staff 8100-8900 0 0 0 (Sch 2)

101 .40-.99 Other - Nonlabor 8100-8900 0 0 0

101 Subacute Ancillary Services - Total 8100-8900 $ 0 $ 0 $ 0 (Sch 2)


102 .01-.19 Salaries and Wages 8100-8900 $ 0 $ 0 $ 0 (Sch 2)

102 .20-.39 Fringe Benefits 8100-8900 0 0 0 (Sch 2)

102 .79 Agency Staff 8100-8900 0 0 0 (Sch 2)

102 .40-.99 Other - Nonlabor 8100-8900 0 0 0

102 Subacute Pediatrics Ancillary Services - Total 8100-8900 $ 0 $ 0 $ 0 (Sch 2)

104 Subtotal 075 - 102 $ 1,268,360 $ 11,193 $ 1,279,553

Routine Services


105 .01-.19 Salaries and Wages 6110 $ 2,009,405 $ (2,037) $ 2,007,368 (Sch 2)

105 .20-.39 Fringe Benefits 6110 661,268 (613) 660,655 (Sch 2)

105 .49 Agency Staff 6110 0 0 0 (Sch 2)

105 .40-.99 Other - Nonlabor 6110 161,816 (47,778) 114,038 (Sch 4)

105 Skilled Nursing Care - Total 6110 $ 2,832,489 $ (50,428) $ 2,782,061


110 .01-.19 Salaries and Wages 6120 $ 0 $ 0 $ 0

110 .20-.39 Fringe Benefits 6120 0 0 0

110 .49 Agency Staff 6120 0 0 0

110 .40-.99 Other - Nonlabor 6120 0 0 0

110 Intermediate Care - Total 6120 $ 0 $ 0 $ 0 (Sch 2)

115 Mentally Disordered Care


115 .20-.39 Fringe Benefits 6130 0 0 0

115 .49 Agency Staff 6130 0 0 0

115 .40-.99 Other - Nonlabor 6130 0 0 0

115 Mentally Disordered Care- Total 6130 $ 0 $ 0 $ 0 (Sch 2)

120 Developmentally Disabled Care


120 .20-.39 Fringe Benefits 6140 0 0 0

120 .49 Agency Staff 6140 0 0 0

120 .40-.99 Other - Nonlabor 6140 0 0 0

120 Developmentally Disabled Care- Total 6140 $ 0 $ 0 $ 0 (Sch 2)

125 Subacute Care

125 .01-.19 Salaries and Wages 6150 $ 0 $ 0 $ 0 (Sch 2)

125 .20-.39 Fringe Benefits 6150 0 0 0 (Sch 2)

125 .49 Agency Staff 6150 0 0 0 (Sch 2)

125 .40-.99 Other - Nonlabor 6150 0 0 0 (Sch 4)

125 Subacute Care - Total 6150 $ 0 $ 0 $ 0


126 .01-.19 Salaries and Wages 6160 $ 0 $ 0 $ 0 (Sch 2)

126 .20-.39 Fringe Benefits 6160 0 0 0 (Sch 2)

126 .49 Agency Staff 6160 0 0 0 (Sch 2)

126 .40-.99 Other - Nonlabor 6160 0 0 0126 Subacute Care - Pediatrics - Total 6160 $ 0 $ 0 $ 0







AS AUDIT

AUDITED

128 Transitional Inpatient Care128 .01-.19 Salaries and Wages 6170 $ 0 $ 0 $ 0128 .20-.39 Fringe Benefits 6170 0 0 0128 .49 Agency Staff 6170 0 0 0128 .40-.99 Other - Nonlabor 6170 0 0 0128 Transitional Inpatient Care - Total 6170 $ 0 $ 0 $ 0 (Sch 2)

130 Hospice Inpatient Care130 .01-.19 Salaries and Wages 6180 $ 0 $ 0 $ 0130 .20-.39 Fringe Benefits 6180 0 0 0130 .49 Agency Staff 6180 0 0 0130 .40-.99 Other - Nonlabor 6180 0 0 0130 Hospice Inpatient Care - Total 6180 $ 0 $ 0 $ 0 (Sch 2)

135 Other Routine Services135 .01-.19 Salaries and Wages 6190 $ 0 $ 0 $ 0135 .20-.39 Fringe Benefits 6190 0 0 0135 .49 Agency Staff 6190 0 0 0135 .40-.99 Other - Nonlabor 6190 0 0 0135 Other Routine Services - Total 6190 $ 0 $ 0 $ 0 (Sch 2)

Other Nonreimbursable139 Residential Care139 .01-.19 Salaries and Wages 9100 $ 0 $ 0 $ 0139 .20-.39 Fringe Benefits 9100 0 0 0139 .49 Agency Staff 9100 0 0 0139 .40-.99 Other - Nonlabor 9100 0 0 0139 Residential Care - Total 9100 $ 0 $ 0 $ 0 (Sch 2)

140 Beauty and Barber140 .01-.19 Salaries and Wages 8900 $ 0 $ 0 $ 0140 .20-.39 Fringe Benefits 8900 0 0 0140 .49 Agency Staff 8900 0 0 0140 .40-.99 Other - Nonlabor 8900 3,659 0 3,659140 Beauty and Barber - Total 8900 $ 3,659 $ 0 $ 3,659 (Sch 2)

145 Other Nonreimbursable145 .01-.19 Salaries and Wages 9100 $ 0 $ 0 $ 0145 .20-.39 Fringe Benefits 9100 0 0 0145 .49 Agency Staff 9100 0 0 0145 .40-.99 Other - Nonlabor 9100 0 0 0145 Other Nonreimbursable - Total 9100 $ 0 $ 0 $ 0 (Sch 2)

146 Subtotal 105 - 145 $ 2,836,148 $ (50,428) $ 2,785,720

155 Social Services155 .01-.19 Salaries and Wages 6600 $ 84,770 $ 0 $ 84,770 (Sch 2)155 .20-.39 Fringe Benefits 6600 26,979 0 26,979 (Sch 2)155 .49 Agency Staff 6600 0 0 0 (Sch 2)155 .40-.99 Other - Nonlabor 6600 5,383 0 5,383 (Sch 4)155 Social Services - Total 6600 $ 117,132 $ 0 $ 117,132







AS AUDIT

AUDITED

160 Activities160 .01-.19 Salaries and Wages 6700 $ 70,681 $ 0 $ 70,681 (Sch 2)160 .20-.39 Fringe Benefits 6700 24,104 0 24,104 (Sch 2)160 .49 Agency Staff 6700 0 0 0 (Sch 2)160 .40-.99 Other - Nonlabor 6700 8,246 0 8,246 (Sch 4)160 Activities - Total 6700 $ 103,031 $ 0 $ 103,031

165 Administration165 .01-.19 Salaries and Wages 6900 $ 349,616 $ 0 $ 349,616 (Sch 6)165 .20-.39 Fringe Benefits 6900 120,929 0 120,929 (Sch 6)165 .49 Agency Staff 6900 0 0 0 (Sch 6)165 .40-.99 Other - Nonlabor 6900 502,318 (12,624) 489,694 (Sch 6)165 Administration - Total 6900 $ 972,863 $ (12,624) $ 960,239

166 Medical Records166 .01-.19 Medical Records - Salaries and Wages 6900 $ 54,276 $ 0 $ 54,276 (Sch 3)166 .20-.39 Medical Records - Fringe Benefits 6900 17,902 0 17,902 (Sch 3)166 .49 Medical Records - Agency Staff 6900 0 0 0 (Sch 3)166 .40-.99 Medical Records - Other - Nonlabor 6900 7,640 0 7,640 (Sch 4)166 Medical Records - Total 6900 $ 79,818 $ 0 $ 79,818

167 DPH Licensing Fees 6900 $ 26,919 $ 0 $ 26,919 (Sch 6)168 Liability Insurance 6900 $ 110,952 $ 100,000 $ 210,952 (Sch 6)169 Quality Assurance Fees 6900 $ 332,147 $ 0 $ 332,147 (Sch 6)

170 Inservice Education - Nursing170 .01-.19 Salaries and Wages 6800 $ 58,171 $ 2,037 $ 60,208 (Sch 3)170 .20-.39 Fringe Benefits 6800 19,256 613 19,869 (Sch 3)170 .49 Agency Staff 6800 0 0 0 (Sch 3)170 .40-.99 Other - Nonlabor 6800 0 585 585 (Sch 4)170 Inservice Education - Nursing - Total 6800 $ 77,427 $ 3,235 $ 80,662

174 Caregiver Training 174 .01-.19 Salaries and Wages 6900 $ 0 $ 0 $ 0 (Sch 6)174 .20-.39 Fringe Benefits 6900 0 0 0 (Sch 6)174 .49 Agency Staff 6900 0 0 0 (Sch 6)174 .40-.99 Other - Nonlabor 6900 0 0 0 (Sch 6)174 Caregiver Training - Total 6900 $ 0 $ 0 $ 0

Subtotal 155 - 174 $ 1,820,289 $ 90,611 $ 1,910,900

200 Total $ 7,369,125 $ 51,376 $ 7,420,501

NOTE 1: Ancillary service costs are reclassified only if the facility has an Adult Subacute unit.

STATE OF CALIFORNIA SCHEDULE 8A-1



Line Sub ACCOUNT TITLE ADJ MEMONo. No. NO. ADJUSTMENT

005 Plant Operations and Maintenance005 1 Salaries and Wages $ 50,339 $ $ 50,339005 2 Fringe Benefits 17,886 17,886005 3 Agency Staff 0005 4 Other - Nonlabor 104,040 104,040005 5 Plant Operations and Maintenance - Total $ 172,265 $ 0 $ 172,265

010 Housekeeping010 1 Salaries and Wages $ 110,545 $ $ 110,545010 2 Fringe Benefits 35,313 35,313010 3 Agency Staff 0010 4 Other - Nonlabor 38,163 38,163010 5 Housekeeping - Total $ 184,021 $ 0 $ 184,021

015 4 Depreciation: Buildings and Improvements $ $ $ 0020 4 Depreciation: Leasehold Improvements 15,025 15,025025 4 Depreciation: Equipment 45,852 45,852030 4 Depreciation and Amortization - Other 0035 4 Leases and Rentals 427,381 427,381040 4 Property Taxes 39,526 39,526045 4 Property Insurance 10,889 10,889050 4 Interest-Property, Plant, and Equipment 0055 4 Interest-Other 4,097 4,097

Subtotal 005 - 055 899,056 0 899,056

060 Laundry and Linen060 1 Salaries and Wages $ 56,677 $ $ 56,677060 2 Fringe Benefits 20,591 20,591060 3 Agency Staff 0060 4 Other - Nonlabor 21,106 21,106060 5 Laundry and Linen - Total $ 98,374 $ 0 $ 98,374

065 Dietary065 1 Salaries and Wages $ 203,155 $ $ 203,155065 2 Fringe Benefits 69,513 69,513065 3 Agency Staff 0065 4 Other - Nonlabor 174,230 174,230065 5 Dietary - Total $ 446,898 $ 0 $ 446,898

070 4 Provision for Bad Debts $ $ $ 0

Ancillary Services (Note 1)075 Patient Supplies075 1 Salaries and Wages $ $ $ 0075 2 Fringe Benefits 0075 3 Agency Staff 0075 4 Other - Nonlabor 22,942 22,942075 5 Patient Supplies - Total $ 22,942 $ 0 $ 22,942

077 Specialized Support Surfaces077 1 Salaries and Wages $ $ $ 0077 2 Fringe Benefits 0077 3 Agency Staff 0077 4 Other - Nonlabor 0077 5 Specialized Support Surfaces - Total $ 0 $ 0 $ 0


REPORTEDASAS

ADJUSTED






REPORTEDASAS

ADJUSTED

080 Physical Therapy080 1 Salaries and Wages $ $ $ 0080 2 Fringe Benefits 0080 3 Agency Staff 0080 4 Other - Nonlabor 385,993 385,993080 5 Physical Therapy - Total $ 385,993 $ 0 $ 385,993

081 Respiratory Therapy081 1 Salaries and Wages $ $ $ 0081 2 Fringe Benefits 0081 3 Agency Staff 0081 4 Other - Nonlabor 0081 5 Respiratory Therapy - Total $ 0 $ 0 $ 0

082 Occupational Therapy082 1 Salaries and Wages $ $ $ 0082 2 Fringe Benefits 0082 3 Agency Staff 0082 4 Other - Nonlabor 343,986 343,986082 5 Occupational Therapy - Total $ 343,986 $ 0 $ 343,986

083 Speech Pathology083 1 Salaries and Wages $ $ $ 0083 2 Fringe Benefits 0083 3 Agency Staff 0083 4 Other - Nonlabor 118,434 118,434083 5 Speech Pathology - Total $ 118,434 $ 0 $ 118,434

085 Pharmacy085 1 Salaries and Wages $ $ $ 0085 2 Fringe Benefits 0085 3 Agency Staff 0085 4 Other - Nonlabor 335,351 335,351085 5 Pharmacy - Total $ 335,351 $ 0 $ 335,351

090 Laboratory090 1 Salaries and Wages $ $ $ 0090 2 Fringe Benefits 0090 3 Agency Staff 0090 4 Other - Nonlabor 35,600 35,600090 5 Laboratory - Total $ 35,600 $ 0 $ 35,600

095 Home Health Services095 1 Salaries and Wages $ $ $ 0095 2 Fringe Benefits 0095 3 Agency Staff 0095 4 Other - Nonlabor 0095 5 Home Health Services - Total $ 0 $ 0 $ 0

100 Other Ancillary Services100 1 Salaries and Wages $ $ $ 0100 2 Fringe Benefits 0100 3 Agency Staff 0100 4 Other - Nonlabor 26,054 26,054100 5 Other Ancillary Services - Total $ 26,054 $ 0 $ 26,054





ZZT05519J 1942335062 206190874



REPORTEDASAS

ADJUSTED


101 1 Salaries and Wages $ $ $ 0

101 2 Fringe Benefits 0

101 3 Agency Staff 0

101 4 Other - Nonlabor 0

101 5 Subacute Ancillary Services - Total $ 0 $ 0 $ 0






102 5 Subacute Pediatrics Ancillary Services - Total $ 0 $ 0 $ 0

104 Subtotal 075 - 102 $ 1,268,360 $ 0 $ 1,268,360

Routine Services


105 1 Salaries and Wages $ 2,009,405 $ $ 2,009,405

105 2 Fringe Benefits 661,268 661,268


105 4 Other - Nonlabor 161,816 161,816

105 5 Skilled Nursing Care - Total $ 2,832,489 $ 0 $ 2,832,489






110 5 Intermediate Care - Total $ 0 $ 0 $ 0

115 Mentally Disordered





115 5 Mentally Disordered - Total $ 0 $ 0 $ 0

120 Developmentally Disabled





120 5 Developmentally Disabled - Total $ 0 $ 0 $ 0

125 Subacute Care





125 5 Subacute Care - Total $ 0 $ 0 $ 0





126 4 Other - Nonlabor 0126 5 Subacute Care - Pediatrics - Total $ 0 $ 0 $ 0





ZZT05519J 1942335062 206190874



REPORTEDASAS

ADJUSTED

128 Transitional Inpatient Care





128 5 Transitional Inpatient Care - Total $ 0 $ 0 $ 0

130 Hospice Inpatient Care





130 5 Hospice Inpatient Care - Total $ 0 $ 0 $ 0

135 Other Routine Services





135 5 Other Routine Services - Total $ 0 $ 0 $ 0

Other Nonreimbursable

139 Residential Care **





139 5 Residential Care - Total $ 0 $ 0 $ 0

140 Beauty and Barber




140 4 Other - Nonlabor 3,659 3,659

140 5 Beauty and Barber - Total $ 3,659 $ 0 $ 3,659

145 Other Nonreimbursable





145 5 Other Nonreimbursable - Total $ 0 $ 0 $ 0

146 Subtotal 105 - 145 $ 2,836,148 $ 0 $ 2,836,148

155 Social Services

155 1 Salaries and Wages $ 84,770 $ $ 84,770

155 2 Fringe Benefits 26,979 26,979


155 4 Other - Nonlabor 5,383 5,383

155 5 Social Services - Total $ 117,132 $ 0 $ 117,132

160 Activities

160 1 Salaries and Wages $ 70,681 $ $ 70,681

160 2 Fringe Benefits 24,104 24,104


160 4 Other - Nonlabor 8,246 8,246160 5 Activities - Total $ 103,031 $ 0 $ 103,031






REPORTEDASAS

ADJUSTED

165 Administration165 1 Salaries and Wages $ 349,616 $ $ 349,616165 2 Fringe Benefits 120,929 120,929165 3 Agency Staff 0165 4 Other - Nonlabor 502,318 502,318165 5 Administration - Total $ 972,863 $ 0 $ 972,863

166 Medical Records166 1 Medical Records - Salaries and Wages $ 54,276 $ $ 54,276166 2 Medical Records - Fringe Benefits 17,902 17,902166 3 Medical Records - Agency Staff 0166 4 Medical Records - Other - Nonlabor 7,640 7,640166 5 Medical Records - Total $ 79,818 $ 0 $ 79,818

167 4 DPH Licensing Fees *** $ 26,919 $ $ 26,919168 4 Liability Insurance *** $ 110,952 $ $ 110,952169 4 Quality Assurance Fees *** $ 332,147 $ $ 332,147

170 Inservice Education - Nursing170 1 Salaries and Wages $ 58,171 $ $ 58,171170 2 Fringe Benefits 19,256 19,256170 3 Agency Staff 0170 4 Other - Nonlabor 0 0170 5 Inservice Education - Nursing - Total $ 77,427 $ 0 $ 77,427

174 Caregiver Training ***174 1 Salaries and Wages $ $ $ 0174 2 Fringe Benefits 0174 3 Agency Staff 0174 4 Other - Nonlabor 0174 5 Caregiver Training - Total $ 0 $ 0 $ 0

Subtotal 155 - 174 $ 1,820,289 $ 0 $ 1,820,289

200 Total $ 7,369,125 $ -$ $ 7,369,125

NOTE 1: Ancillary service costs are reclassified only if the facility has an Adult Subacute unit.* Amounts reclassified from ancillary service type accounts (lines 75 through 100)** Complete with Direct Residential Care Costs*** Amounts reclassified from Administration (line 165)**** Totals in column 5 must match page 10.1, column 14, for each respective cost center (except reclasses)

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