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REPORT ON THE
RATE SETTING AUDIT
SANTA MONICA CONVALESCENT CENTER I SANTA MONICA, CALIFORNIA
PROVIDER NUMBER: LTC90076F NATIONAL PROVIDER IDENTIFIER: 1699857193
FISCAL PERIOD ENDED
DECEMBER 31, 2007
Audits Section - Gardena Financial Audits Branch
Audits and Investigations Department of Health Care Services
Section Chief: Cheryl Phillips Audit Supervisor: Cyrus Lam Auditor: Gary Chan
State of California—Health and Human Services Agency
Department of Health Care Services
DAVID MAXWELL-JOLLY ARNOLD SCHWARZENEGGER Director Governor
Financial Audits/Gardena/A & I, MS 2103, 19300 South Hamilton Avenue, Suite 280, Gardena, CA 90248
Telephone: (310) 516-4757 / FAX: (310) 217-6918 Internet Address: www.dhcs.ca.gov
May 27, 2009
Art B. Crispino, Administrator Santa Monica Convalescent Center I 2250 29th Street Santa Monica, CA 90405 PROVIDER: SANTA MONICA CONVALESCENT CENTER I PROVIDER NO.: LTC90076F NATIONAL PROVIDER IDENTIFIER: 1699857193 FISCAL PERIOD ENDED: DECEMBER 31, 2007 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.
Art B. Crispino 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—Gardena at (310) 516-4757. Signed By: Cheryl Phillips, Chief Audits Section—Gardena Financial Audits Branch Certified
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:SANTA MONICA CONVALESCENT CENTER I JANUARY 1, 2007 THROUGH DECEMBER 31, 2007
Provider Number: OSHPD Facility No.:LTC90076F 206190688
LineNo.
SKILLED NURSING CARE1 Cost of Direct Care - Labor (Sch. 2, Ln. 105) $ N/A $ 837,013 $ 60.86
2 Cost of Indirect Care - Labor (Sch. 3, Ln. 105) $ N/A $ 241,728 $ 17.58
3 Cost of Direct and Indirect NonLabor - Other (Sch. 4, Ln. 105) $ N/A $ 180,167 $ 13.10
4 Cost of Capital Related (Sch. 5, Ln. 105) $ N/A $ 198,103 $ 14.41
5 Property Taxes (Sch. 5, Ln. 105) $ N/A $ 5,301 $ 0.39
6 DHS Licensing Fees (Sch. 6, Ln. 105) $ N/A $ 7,943 $ 0.58
7 Liability Insurance (Sch. 6, Ln. 105) $ N/A $ 31,360 $ 2.28
8 Caregiver Training (Sch. 6, Ln. 105) $ N/A $ 0 $ 0.00
9 Quality Assurance Fees (Sch. 6, Ln. 105) $ N/A $ 103,479 $ 7.52
10 Cost of Administration (Sch. 6, Ln. 105) $ N/A $ 174,008 $ 12.65
11 Cost of Routine Service/Audited Total Costs $ 1,801,168 $ 1,779,103 $ 129.37
12 Total Patient Days (Adj ) 13,752 13,752
13 Cost Per Patient Day (Cost Divided by Days) $ 130.97 $ 129.37
14 Overpayments (Adj ) $ $ 0
15 Total Licensed Nursing Facility Beds - Level B (Adj ) 41 41
INTERMEDIATE CARE16 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0
17 Total Patient Days (Adj ) 0
18 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
19 Overpayments (Adj ) $ $ 0
MENTALLY DISORDERED20 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0
21 Total Patient Days (Adj ) 0
22 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
23 Overpayments (Adj ) $ $ 0
DEVELOPMENTALLY DISABLED24 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0
25 Total Patient Days (Adj ) 0
26 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
27 Overpayments (Adj ) $ $ 0
ADULT SUBACUTE28 Cost of Direct Care - Labor (Adult Subacute Sch. 1, Ln. 25) $ N/A $ 0 $ 0.00
29 Cost of Indirect Care - Labor (Adult Subacute Sch. 1, Ln. 26) $ N/A $ 0 $ 0.00
30 Cost of Direct and Indirect NonLabor - Other (Adult SA Sch. 1, Ln. 27) $ N/A $ 0 $ 0.00
31 Cost of Capital Related (Adult Subacute Sch. 1, Ln. 28) $ N/A $ 0 $ 0.00
32 Property Taxes (Adult Subacute Sch. 1, Ln. 29) $ N/A $ 0 $ 0.00
33 DHS Licensing Fees (Adult Subacute Sch. 1, Ln. 30) $ N/A $ 0 $ 0.00
34 Liability Insurance (Adult Subacute Sch. 1, Ln. 31) $ N/A $ 0 $ 0.00
35 Caregiver Training (Adult Subacute Sch. 1, Ln. 32) $ N/A $ 0 $ 0.00
36 Quality Assurance Fees (Adult Subacute Sch. 1, Ln. 33) $ N/A $ 0 $ 0.00
37 Cost of Administration (Adult Subacute Sch., Ln. 34) $ N/A $ 0 $ 0.00
38 Total Cost of Subacute Service (Adult Subacute Sch. 1, Ln. 35) $ 0 $ 0 $ 0.00
39 Total Patient Days (Adult Subacute Sch. 1, Ln. 36) 0 0
40 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
41 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
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:SANTA MONICA CONVALESCENT CENTER I JANUARY 1, 2007 THROUGH DECEMBER 31, 2007
Provider Number: OSHPD Facility No.:LTC90076F 206190688
LineNo.
SUMMARY OF AUDITED FACILITY COST PER PATIENT DAY
COST PERAUDITED
AS REPORTED AS AUDITED PATIENT DAYPROGRAM DESCRIPTION
PEDIATRIC SUBACUTE42 Cost of Routine Service (Ped-SA, Sch. 1, Ln 3) $ 0 $ 0
43 Cost of Ancillary Service (Ped-SA, Sch. 1, Ln. 1 + Ln. 2) $ 0 $ 0
44 Total Cost of Pediatric Subacute Service (Ln. 42 + Ln. 43) $ 0 $ 0
45 Total Patient Days (Ped-SA, Sch. 1, Ln. 5) 0 0
46 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
47 Overpayments (Ped-SA, Sch. 1, Ln. 7 + Ln. 8) $ 0 $ 0
HOSPICE INPATIENT CARE48 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0
49 Total Patient Days (Adj ) 0
50 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
51 Overpayments (Adj ) $ $ 0
OTHER ROUTINE SERVICES52 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0
53 Total Patient Days (Adj ) 0
54 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
55 Overpayments (Adj ) $ $ 0
STATE OF CALIFORNIA SCHEDULE 2
Provider Name: Fiscal Period:SANTA MONICA CONVALESCENT CENTER I JANUARY 1, 2007 THROUGH DECEMBER 31, 2007
Provider Number: OSHPD Facility No.:LTC90076F 206190688
Soc Srvs ActivitiesNet Exp For
Line DESCRIPTION Cost AllocNo. (From Sch 8) 155 160 Total
GENERAL SERVICES5.00 Plant Operations and Maintenance
10.00 Housekeeping60.00 Laundry and Linen65.00 Dietary
155.00 Social Services (Salaries, Fringe Benefits, & Agency Labor) 12,208$ 12,208$ 160.00 Activities (Salaries, Fringe Benefits, & Agency Labor) 45,347 45,347$ 165.00 Administration165.00 Medical Records170.00 Inservice Education - Nursing
ANCILLARY SERVICES75.00 Patient Supplies 650 0 0 650$ 77.00 Specialized Support Surfaces N/A 0 0 080.00 Physical Therapy 46,319 0 0 46,31981.00 Respiratory Therapy 0 0 0 082.00 Occupational Therapy 1,094 0 0 1,09483.00 Speech Pathology 14,483 0 0 14,48385.00 Pharmacy 11,775 0 0 11,77590.00 Laboratory 0 0 0 095.00 Home Health Services 0 0 0 0
100.00 Other Ancillary Services 5,931 0 0 5,931100.06 Subacute Ancillary Services 0 0 0 0100.12 Subacute Pediatrics Ancillary Services 0 0 0 0
ROUTINE SERVICES105.00 Skilled Nursing Care 779,458 12,208 45,347 837,013 *110.00 Intermediate Care 0 0 0 0 *115.00 Mentally Disordered 0 0 0 0 *120.00 Developmentally Disabled 0 0 0 0 *125.00 Subacute Care 0 0 0 0 *126.00 Subacute Care - Pediatrics 0 0 0 0 *130.00 Hospice Inpatient Care 0 0 0 0 *135.00 Other Routine Services 0 0 0 0 *
NONREIMBURSABLE 136.00 Residential Care 0 0 0 0140.00 Beauty and Barber 0 0 0 0145.00 Other Nonreimbursable 0 0 0 0
TOTAL 917,265$ 12,208$ 45,347$ 917,265$
* (To Schedule 1)
ALLOCATION OF GENERAL SERVICES - LABOR (DIRECT CARE)
ST
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Pro
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6190
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31,
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Hou
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$
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Laun
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65.0
0
Die
tary
111,
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06,
313
011
8,28
2$
155.
00
Soc
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ervi
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N/A
0
00
0-
$
160.
00
Act
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/A
00
00
0-
$
165.
00
Adm
inis
trat
ion
N/A
0
11,6
910
00
011
,691
$
11
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$
165.
00
Med
ical
Rec
ords
19,1
250
316
00
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19,4
4119
,441
$
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00
Inse
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- N
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00
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26,5
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AN
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S75
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P
atie
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uppl
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00
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77.0
0
Spe
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Sup
port
Sur
face
s0
00
00
00
00
00
80.0
0
Phy
sica
l The
rapy
00
00
00
00
366
608
974
81.0
0
Res
pira
tory
The
rapy
00
00
00
00
00
0
82.0
0
Occ
upat
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l The
rapy
00
00
00
00
914
23
83.0
0
Spe
ech
Pat
holo
gy0
00
00
00
011
419
030
4
85.0
0
Pha
rmac
y0
00
00
00
093
155
248
90.0
0
Labo
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00
00
00
00
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95.0
0
Hom
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Ser
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s0
00
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100.
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Ser
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5
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Ser
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12
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S
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8,28
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212,
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11,0
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,300
241,
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*
110.
00
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Car
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115.
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Men
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00
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126.
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NO
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13
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R
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140.
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00
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0
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Oth
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1,56
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871,
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TOTA
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$
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5,
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$
118,
282
$
-
$
-$
26
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$
213,
988
$
11,6
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19
,441
$
245,
120
$
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Pla
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64,7
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64,7
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Hou
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9,84
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60.0
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4,29
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412
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$
65.0
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73,3
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664
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$
155.
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Soc
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1,86
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01,
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$
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00
Act
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643
00
00
03,
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$
165.
00
Adm
inis
trat
ion
N/A
8,
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1,31
60
00
09,
954
$
9,
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$
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00
Med
ical
Rec
ords
2,57
123
336
00
00
2,84
02,
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$
170.
00
Inse
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port
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00
00
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0
80.0
0
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00
00
00
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031
189
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81.0
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00
00
00
00
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83.0
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85.0
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Pha
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176
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$
9,84
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$
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$
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$
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$
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STATE OF CALIFORNIA SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Provider Name: Fiscal Period:SANTA MONICA CONVALESCENT CENTER I JANUARY 1, 2007 THROUGH DECEMBER 31, 2007
Provider Number: OSHPD Facility Number:LTC90076F 206190688
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) 203,377$ 97%
Property Tax (line 40) 5,442 3% 208,819$
5.00 Plant Operations and Maintenance 1,954 1,954$
10.00 Housekeeping 434 4 438$
60.00 Laundry and Linen 13,712 130 29 13,871$
65.00 Dietary 14,891 141 32 0 15,064$
155.00 Social Services 0 0 0 0 0 -$
160.00 Activities 0 0 0 0 0 0 -$
165.00 Administration 27,580 261 59 0 0 0 0
165.00 Medical Records 745 7 2 0 0 0 0
170.00 Inservice Education - Nursing 0 0 0 0 0 0 0
ANCILLARY SERVICES75.00 Patient Supplies 0 0 0 0 0 0 0
77.00 Specialized Support Surfaces 0 0 0 0 0 0 0
80.00 Physical Therapy 0 0 0 0 0 0 0
81.00 Respiratory Therapy 0 0 0 0 0 0 0
82.00 Occupational Therapy 0 0 0 0 0 0 0
83.00 Speech Pathology 0 0 0 0 0 0 0
85.00 Pharmacy 0 0 0 0 0 0 0
90.00 Laboratory 0 0 0 0 0 0 0
95.00 Home Health Services 0 0 0 0 0 0 0
100.00 Other Ancillary Services 0 0 0 0 0 0 0
100.06 Subacute Ancillary Services 0 0 0 0 0 0 0
100.12 Subacute Pediatrics Ancillary Services 0 0 0 0 0 0 0
ROUTINE SERVICES105.00 Skilled Nursing Care 145,810 1,378 310 13,871 15,064 0 0
110.00 Intermediate Care 0 0 0 0 0 0 0
115.00 Mentally Disordered 0 0 0 0 0 0 0
120.00 Developmentally Disabled 0 0 0 0 0 0 0
125.00 Subacute Care 0 0 0 0 0 0 0
126.00 Subacute Care - Pediatrics 0 0 0 0 0 0 0
130.00 Hospice Inpatient Care 0 0 0 0 0 0 0
135.00 Other Routine Services 0 0 0 0 0 0 0
NONREIMBURSABLE 136.00 Residential Care 0 0 0 0 0 0 0
140.00 Beauty and Barber 0 0 0 0 0 0 0
145.00 Other Nonreimbursable 3,692 35 8 0 0 0 0
TOTAL 208,819$ 100% 208,819$ 1,954$ 438$ 13,871$ 15,064$ -$ -$
* (To Schedule 1)
STATE OF CALIFORNIA
Provider Name:SANTA MONICA CONVALESCENT CENTER I
Provider Number:LTC90076F
Net Exp ForLine DESCRIPTION Cost AllocNo. (From Sch 8) Ratio
GENERAL SERVICESCapital Related (excluding lines 40 & 45) 203,377$ 97%Property Tax (line 40) 5,442 3%
5.00 Plant Operations and Maintenance10.00 Housekeeping60.00 Laundry and Linen65.00 Dietary
155.00 Social Services160.00 Activities165.00 Administration165.00 Medical Records170.00 Inservice Education - Nursing
ANCILLARY SERVICES75.00 Patient Supplies77.00 Specialized Support Surfaces80.00 Physical Therapy81.00 Respiratory Therapy82.00 Occupational Therapy83.00 Speech Pathology85.00 Pharmacy90.00 Laboratory95.00 Home Health Services
100.00 Other Ancillary Services100.06 Subacute Ancillary Services100.12 Subacute Pediatrics Ancillary Services
ROUTINE SERVICES105.00 Skilled Nursing Care110.00 Intermediate Care115.00 Mentally Disordered120.00 Developmentally Disabled125.00 Subacute Care126.00 Subacute Care - Pediatrics130.00 Hospice Inpatient Care135.00 Other Routine Services
NONREIMBURSABLE 136.00 Residential Care140.00 Beauty and Barber145.00 Other Nonreimbursable
TOTAL 208,819$ 100%
* (To Schedule 1)
SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Fiscal Period:JANUARY 1, 2007 THROUGH DECEMBER 31, 2007
OSHPD Facility Number:206190688
In-serv. Ed Admin Medical Capital PropertyRecords Related Tax
Accumulated 97% 3%170 Costs 165 165 Total Of Total Of Total
27,899$ 27,899$ 753 753$
-$
0 0 12 0 13$ 12$ 0$ 0 0 0 0 0 0 00 0 873 24 896 873 230 0 0 0 0 0 00 0 21 1 21 21 10 0 273 7 280 273 70 0 222 6 228 222 60 0 0 0 0 0 00 0 0 0 0 0 00 0 112 3 115 112 30 0 0 0 0 0 00 0 0 0 0 0 0
0 176,432 26,262 709 203,403 198,103 5,301 *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 0 0 0 0 0 00 3,735 125 3 3,863 3,762 101
-$ 180,167$ 27,899$ 753$ 208,819$ 203,377$ 5,442$
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STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:SANTA MONICA CONVALESCENT CENTER I JANUARY 1, 2007 THROUGH DECEMBER 31, 2007
Provider Number: OSHPD Facility Number:LTC90076F 206190688
Line Natural ACCOUNT TITLE AccountNo. Class Number
5.00 Plant Operations and Maintenance 6200 $ 64,794 $ (64,794) $ 0 $ 0 $ 05.01 .01-.19 Salaries and Wages 6200 0 0 0 0 (Sch 3)5.02 .20-.39 Fringe Benefits 6200 0 0 0 0 (Sch 3)5.03 .79 Agency Staff 6200 0 0 0 0 (Sch 3)5.04 .40-.99 Other - Nonlabor 6200 64,794 64,794 0 64,794 (Sch 4)5.05 Plant Operations and Maintenance - Total 6200 $ 64,794 $ 0 $ 64,794 $ 0 $ 64,794
10.00 Housekeeping 6300 $ 97,219 $ (97,219) $ 0 $ 0 $ 010.01 .01-.19 Salaries and Wages 6300 16,341 16,341 0 16,341 (Sch 3)10.02 .20-.39 Fringe Benefits 6300 4,040 4,040 0 4,040 (Sch 3)10.03 .79 Agency Staff 6300 0 0 67,127 67,127 (Sch 3)10.04 .40-.99 Other - Nonlabor 6300 76,838 76,838 (67,127) 9,711 (Sch 4)10.05 Housekeeping - Total 6300 $ 97,219 $ 0 $ 97,219 $ 0 $ 97,219
15.00 Depreciation: Bldgs and Improvements 7110 - 7120 $ $ 0 $ 0 $ 0 (Sch 5)20.00 Depreciation: Leasehold Improvements 7130 0 0 0 (Sch 5)25.00 Depreciation: Equipment 7140 0 0 0 (Sch 5)30.00 Depreciation and Amortization - Other 7150 - 7160 0 0 0 (Sch 5)35.00 Leases and Rentals 7200 191,430 191,430 792 192,222 (Sch 5)40.00 Property Taxes 7300 5,442 5,442 0 5,442 (Sch 5)45.00 Property Insurance 7400 20,217 20,217 0 20,217 (Sch 6)50.00 Interest-Property, Plant, and Equipment 7500 11,155 11,155 0 11,155 (Sch 5)55.00 Interest-Other 7600 0 0 0 (Sch 6)
57.00 Subtotal 005 - 055 $ 390,257 $ 0 $ 390,257 $ 792 $ 391,049
60.00 Laundry and Linen 6400 $ 8,546 $ (8,546) $ 0 $ 0 $ 060.01 .01-.19 Salaries and Wages 6400 0 0 0 0 (Sch 3)60.02 .20-.39 Fringe Benefits 6400 0 0 0 0 (Sch 3)60.03 .79 Agency Staff 6400 0 0 0 0 (Sch 3)60.04 .40-.99 Other - Nonlabor 6400 8,546 8,546 (792) 7,754 (Sch 4)60.05 Laundry and Linen - Total 6400 $ 8,546 $ 0 $ 8,546 $ (792) $ 7,754
65.00 Dietary 6500 $ 185,300 $ (185,300) $ 0 $ 0 $ 065.01 .01-.19 Salaries and Wages 6500 92,467 92,467 0 92,467 (Sch 3)65.02 .20-.39 Fringe Benefits 6500 19,502 19,502 0 19,502 (Sch 3)65.03 .79 Agency Staff 6500 0 0 0 0 (Sch 3)65.04 .40-.99 Other - Nonlabor 6500 73,331 73,331 0 73,331 (Sch 4)65.05 Dietary - Total 6500 $ 185,300 $ 0 $ 185,300 $ 0 $ 185,300
70.00 Provision for Bad Debts 7700 $ $ 0 $ 0 $ 0
Ancillary Services (Note 1)75.00 Patient Supplies 8100 $ 650 $ 0 $ 650 $ 0 $ 650 (Sch 2)75.01 .01-.19 Salaries and Wages 8100 0 0 0 0 (Sch 2)75.02 .20-.39 Fringe Benefits 8100 0 0 0 0 (Sch 2)75.03 .79 Agency Staff 8100 0 0 0 0 (Sch 2)75.04 .40-.99 Other - Nonlabor 8100 0 0 0 0 (Sch 4)75.05 Patient Supplies - Total 8100 $ 650 $ 0 $ 650 $ 0 $ 650
77.00 Specialized Support Surfaces 8150 $ 0 $ 0 $ 0 (Sch 4)
80.00 Physical Therapy 8200 $ 46,319 $ 0 $ 46,319 $ 0 $ 46,319 (Sch 2)80.01 .01-.19 Salaries and Wages 8200 0 0 0 0 (Sch 2)80.02 .20-.39 Fringe Benefits 8200 0 0 0 0 (Sch 2)80.03 .79 Agency Staff 8200 0 0 0 0 (Sch 2)80.04 .40-.99 Other - Nonlabor 8200 0 0 0 0 (Sch 4)80.05 Physical Therapy - Total 8200 $ 46,319 $ 0 $ 46,319 $ 0 $ 46,319
81.00 Respiratory Therapy 8220 $ $ 0 $ 0 $ 0 $ 0 (Sch 2)81.01 .01-.19 Salaries and Wages 8220 0 0 0 0 (Sch 2)81.02 .20-.39 Fringe Benefits 8220 0 0 0 0 (Sch 2)81.03 .79 Agency Staff 8220 0 0 0 0 (Sch 2)81.04 .40-.99 Other - Nonlabor 8220 0 0 0 0 (Sch 4)81.05 Respiratory Therapy - Total 8220 $ 0 $ 0 $ 0 $ 0 $ 0
REPORTED AUDITED(SCHEDULE 8A-1)AS AS
SUBTOTAL (SCHEDULE 8A-2)
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT ADJUSTMENTS
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:SANTA MONICA CONVALESCENT CENTER I JANUARY 1, 2007 THROUGH DECEMBER 31, 2007
Provider Number: OSHPD Facility Number:LTC90076F 206190688
Line Natural ACCOUNT TITLE AccountNo. Class Number REPORTED AUDITED(SCHEDULE 8A-1)
AS ASSUBTOTAL (SCHEDULE 8A-2)
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT ADJUSTMENTS
82.00 Occupational Therapy 8250 $ 1,094 $ 0 $ 1,094 $ 0 $ 1,094 (Sch 2)82.01 .01-.19 Salaries and Wages 8250 0 0 0 0 (Sch 2)82.02 .20-.39 Fringe Benefits 8250 0 0 0 0 (Sch 2)82.03 .79 Agency Staff 8250 0 0 0 0 (Sch 2)82.04 .40-.99 Other - Nonlabor 8250 0 0 0 0 (Sch 4)82.05 Occupational Therapy - Total 8250 $ 1,094 $ 0 $ 1,094 $ 0 $ 1,094
83.00 Speech Pathology 8280 $ 14,483 $ 0 $ 14,483 $ 0 $ 14,483 (Sch 2)83.01 .01-.19 Salaries and Wages 8280 0 0 0 0 (Sch 2)83.02 .20-.39 Fringe Benefits 8280 0 0 0 0 (Sch 2)83.03 .79 Agency Staff 8280 0 0 0 0 (Sch 2)83.04 .40-.99 Other - Nonlabor 8280 0 0 0 0 (Sch 4)83.05 Speech Pathology - Total 8280 $ 14,483 $ 0 $ 14,483 $ 0 $ 14,483
85.00 Pharmacy 8300 $ 11,775 $ 0 $ 11,775 $ 0 $ 11,775 (Sch 2)85.01 .01-.19 Salaries and Wages 8300 0 0 0 0 (Sch 2)85.02 .20-.39 Fringe Benefits 8300 0 0 0 0 (Sch 2)85.03 .79 Agency Staff 8300 0 0 0 0 (Sch 2)85.04 .40-.99 Other - Nonlabor 8300 0 0 0 0 (Sch 4)85.05 Pharmacy - Total 8300 $ 11,775 $ 0 $ 11,775 $ 0 $ 11,775
90.00 Laboratory 8400 $ $ 0 $ 0 $ 0 $ 0 (Sch 2)90.01 .01-.19 Salaries and Wages 8400 0 0 0 0 (Sch 2)90.02 .20-.39 Fringe Benefits 8400 0 0 0 0 (Sch 2)90.03 .79 Agency Staff 8400 0 0 0 0 (Sch 2)90.04 .40-.99 Other - Nonlabor 8400 0 0 0 0 (Sch 4)90.05 Laboratory - Total 8400 $ 0 $ 0 $ 0 $ 0 $ 0
95.00 Home Health Services 8800 $ $ 0 $ 0 $ 0 $ 0 (Sch 2)95.01 .01-.19 Salaries and Wages 8800 0 0 0 0 (Sch 2)95.02 .20-.39 Fringe Benefits 8800 0 0 0 0 (Sch 2)95.03 .79 Agency Staff 8800 0 0 0 0 (Sch 2)95.04 .40-.99 Other - Nonlabor 8800 0 0 0 0 (Sch 4)95.05 Home Health Services - Total 8800 $ 0 $ 0 $ 0 $ 0 $ 0
100.00 Other Ancillary Services 8900 $ 5,931 $ 0 $ 5,931 $ 0 $ 5,931 (Sch 2)100.01 .01-.19 Salaries and Wages 8900 0 0 0 0 (Sch 2)100.02 .20-.39 Fringe Benefits 8900 0 0 0 0 (Sch 2)100.03 .79 Agency Staff 8900 0 0 0 0 (Sch 2)100.04 .40-.99 Other - Nonlabor 8900 0 0 0 0 (Sch 4)100.05 Other Ancillary Services - Total 8900 $ 5,931 $ 0 $ 5,931 $ 0 $ 5,931
100.06 Subacute Ancillary Services $ $ 0 $ 0 $ 0 $ 0 (Sch 2)100.07 .01-.19 Salaries and Wages 0 0 0 0 (Sch 2)100.08 .20-.39 Fringe Benefits 0 0 0 0 (Sch 2)100.09 .79 Agency Staff 0 0 0 0 (Sch 2)100.10 .40-.99 Other - Nonlabor 0 0 0 0 (Sch 4)100.11 Subacute Ancillary Services - Total $ 0 $ 0 $ 0 $ 0 $ 0
100.12 Subacute Pediatrics Ancillary Services $ $ 0 $ 0 $ 0 (Sch 2)
101.00 Subtotal 075 - 100.12 $ 80,252 $ 0 $ 80,252 $ 0 $ 80,252
Routine Services105.00 Skilled Nursing Care 6110 $ 815,879 $ (815,879) $ 0 $ 0 $ 0105.01 .01-.19 Salaries and Wages 6110 597,325 597,325 26,560 623,885 (Sch 2)105.02 .20-.39 Fringe Benefits 6110 155,747 155,747 (19,161) 136,586 (Sch 2)105.03 .49 Agency Staff 6110 0 0 18,987 18,987 (Sch 2)105.04 .40-.99 Other - Nonlabor 6110 63,419 63,419 (45,548) 17,871 (Sch 4)105.05 Skilled Nursing Care - Total 6110 $ 815,879 $ 612 $ 816,491 $ (19,162) $ 797,329
110.00 Intermediate Care 6120 $ $ 0 $ 0 $ 0 (Sch 2)115.00 Mentally Disordered 6130 0 0 0 (Sch 2)120.00 Developmentally Disabled 6140 0 0 0 (Sch 2)
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:SANTA MONICA CONVALESCENT CENTER I JANUARY 1, 2007 THROUGH DECEMBER 31, 2007
Provider Number: OSHPD Facility Number:LTC90076F 206190688
Line Natural ACCOUNT TITLE AccountNo. Class Number REPORTED AUDITED(SCHEDULE 8A-1)
AS ASSUBTOTAL (SCHEDULE 8A-2)
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT ADJUSTMENTS
125.00 Subacute Care 6150 $ $ 0 $ 0 $ 0 $ 0125.01 .01-.19 Salaries and Wages 6150 0 0 0 0 (Sch 2)125.02 .20-.39 Fringe Benefits 6150 0 0 0 0 (Sch 2)125.03 .49 Agency Staff 6150 0 0 0 0 (Sch 2)125.04 .40-.99 Other - Nonlabor 6150 0 0 0 0 (Sch 4)125.05 Subacute Care - Total 6150 $ 0 $ 0 $ 0 $ 0 $ 0
126.00 Subacute Care - Pediatrics 6160 $ $ 0 $ 0 $ 0130.00 Hospice Inpatient Care 6180 0 0 0 (Sch 2)135.00 Other Routine Services 6190 0 0 0 (Sch 2)
Other Nonreimbursable136.00 Residential Care 9100 $ $ 0 $ 0 $ 0 (Sch 2)140.00 Beauty and Barber 8900 0 0 0 (Sch 2)145.00 Other Nonreimbursable 9100 0 0 0 (Sch 2)
146.00 Subtotal 105 - 145 $ 815,879 $ 612 $ 816,491 $ (19,162) $ 797,329
155.00 Social Services 6600 $ 14,074 $ (14,074) $ 0 $ 0 $ 0155.01 .01-.19 Salaries and Wages 6600 9,770 9,770 0 9,770 (Sch 2)155.02 .20-.39 Fringe Benefits 6600 2,438 2,438 0 2,438 (Sch 2)155.03 .79 Agency Staff 6600 0 0 0 0 (Sch 2)155.04 .40-.99 Other - Nonlabor 6600 1,866 1,866 0 1,866 (Sch 4)155.05 Social Services - Total 6600 $ 14,074 $ 0 $ 14,074 $ 0 $ 14,074
160.00 Activities 6700 $ 48,990 $ (48,990) $ 0 $ 0 $ 0160.01 .01-.19 Salaries and Wages 6700 35,671 35,671 0 35,671 (Sch 2)160.02 .20-.39 Fringe Benefits 6700 9,676 9,676 0 9,676 (Sch 2)160.03 .79 Agency Staff 6700 0 0 0 0 (Sch 2)160.04 .40-.99 Other - Nonlabor 6700 3,643 3,643 0 3,643 (Sch 4)160.05 Activities - Total 6700 $ 48,990 $ 0 $ 48,990 $ 0 $ 48,990
165.00 Administration 6900 $ 338,968 $ (338,968) $ 0 $ 0 $ 0165.01 .01-.19 Salaries and Wages 6900 105,903 105,903 (16,560) 89,343 (Sch 6)165.02 .20-.39 Fringe Benefits 6900 26,964 26,964 (2,565) 24,399 (Sch 6)165.03 .01-.19 Medical Records - Salaries and Wages 6900 0 0 16,560 16,560 (Sch 3)165.04 .20-.39 Medical Records - Fringe Benefits 6900 0 0 2,565 2,565 (Sch 3)165.05 .79 Medical Records - Agency Staff 6900 0 0 0 0 (Sch 3)165.06 .40-.99 Medical Records - Other - Nonlabor 6900 0 0 2,571 2,571 (Sch 4)165.07 DHS Licensing Fees 6900 0 0 8,438 8,438 (Sch 6)165.08 Liability Insurance 6900 0 0 33,315 33,315 (Sch 6)165.09 Caregiver Training 6900 0 0 0 0 (Sch 6)165.10 Quality Assurance Fees 6900 0 0 109,929 109,929 (Sch 6)165.11 .40-.99 Other - Nonlabor 6900 205,489 205,489 (154,594) 50,895 (Sch 6)165.12 Administration - Total 6900 $ 338,968 $ (612) $ 338,356 $ (341) $ 338,015
170.00 Inservice Education - Nursing 6800 $ 27,227 $ (27,227) $ 0 $ 0 $ 0170.01 .01-.19 Salaries and Wages 6800 20,882 20,882 0 20,882 (Sch 3)170.02 .20-.39 Fringe Benefits 6800 5,636 5,636 0 5,636 (Sch 3)170.03 .79 Agency Staff 6800 0 0 0 0 (Sch 3)170.04 .40-.99 Other - Nonlabor 6800 709 709 0 709 (Sch 4)170.05 Inservice Education - Nursing - Total 6800 $ 27,227 $ 0 $ 27,227 $ 0 $ 27,227
171.00 Subtotal 155 - 170.05 $ 429,259 $ (612) $ 428,647 $ (341) $ 428,306
175.00 Total $ 1,909,493 $ 0 $ 1,909,493 $ (19,503) $ 1,889,990
NOTE 1: Ancillary service costs are reclassified only if the facility has an Adult Subacute unit.
ST
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Sch
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Per
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Sch
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OS
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ST
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Sch
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Pag
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Pro
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Pro
vide
r N
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OS
HP
D F
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r:Fi
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Per
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(Pag
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s0
165.
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dmin
istr
atio
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rain
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165.
10A
dmin
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atio
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lity
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11A
dmin
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Oth
er -
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nlab
or
205,
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170.
00In
serv
ice
Edu
catio
n -
Nur
sing
(27,
227)
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serv
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efits
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00
To
tal
$00
00
00
00
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(To
Sch
8)
ST
AT
E O
F C
ALI
FOR
NIA
Pro
vide
r N
ame:
SA
NT
A M
ON
ICA
CO
NV
ALE
SC
EN
T C
EN
TE
R I
5.00
Pla
nt O
pera
tions
and
Mai
nten
ance
5.01
Pla
nt O
pera
tions
and
Mai
nten
ance
- S
alar
ies
and
Wag
es
5.02
Pla
nt O
pera
tions
and
Mai
nten
ance
- F
ringe
Ben
efits
5.03
Pla
nt O
pera
tions
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Mai
nten
ance
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genc
y S
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5.04
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nt O
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Mai
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ther
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Ben
efits
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ther
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undr
y an
d Li
nen
60.0
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undr
y an
d Li
nen
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ies
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es
60.0
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y an
d Li
nen
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ringe
Ben
efits
60.0
3La
undr
y an
d Li
nen
- A
genc
y S
taff
60.0
4La
undr
y an
d Li
nen
- O
ther
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onl
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r
65.0
0D
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ry
65.0
1D
ieta
ry -
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arie
s an
d W
ages
65.0
2D
ieta
ry -
Frin
ge B
enef
its
65.0
3D
ieta
ry -
Age
ncy
Sta
ff
65.0
4D
ieta
ry -
Oth
er -
No
nlab
or
75.0
0P
atie
nt S
uppl
ies
75.0
1P
atie
nt S
uppl
ies
- S
alar
ies
and
Wag
es
75.0
2P
atie
nt S
uppl
ies
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ringe
Ben
efits
75.0
3P
atie
nt S
uppl
ies
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genc
y S
taff
75.0
4P
atie
nt S
uppl
ies
- O
ther
- N
onl
abo
r
80.0
0P
hysi
cal T
hera
py
80.0
1P
hysi
cal T
hera
py -
Sal
arie
s an
d W
ages
80.0
2P
hysi
cal T
hera
py -
Frin
ge B
enef
its
80.0
3P
hysi
cal T
hera
py -
Age
ncy
Sta
ff
80.0
4P
hysi
cal T
hera
py -
Oth
er -
No
nlab
or
81.0
0R
espi
rato
ry T
hera
py
81.0
1R
espi
rato
ry T
hera
py -
Sal
arie
s an
d W
ages
81.0
2R
espi
rato
ry T
hera
py -
Frin
ge B
enef
its
81.0
3R
espi
rato
ry T
hera
py -
Age
ncy
Sta
ff
81.0
4R
espi
rato
ry T
hera
py -
Oth
er -
No
nlab
or
82.0
0O
ccup
atio
nal T
hera
py
82.0
1O
ccup
atio
nal T
hera
py -
Sal
arie
s an
d W
ages
82.0
2O
ccup
atio
nal T
hera
py -
Frin
ge B
enef
its
82.0
3O
ccup
atio
nal T
hera
py -
Age
ncy
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ff
82.0
4O
ccup
atio
nal T
hera
py -
Oth
er -
No
nlab
or
83.0
0S
peec
h P
atho
logy
Sch
edul
e 8A
-1
Pag
e 2
Pro
vide
r N
o.:
OS
HP
D F
acili
ty N
umbe
r:Fi
scal
Per
iod:
LTC
9007
6F20
6190
688
JAN
UA
RY
1, 2
007
TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
007
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
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IT A
DJ
AU
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AD
JA
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AU
DIT
AD
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1011
RE
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ILIA
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N O
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TM
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TO
TH
E A
UD
IT R
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T
ST
AT
E O
F C
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FOR
NIA
Pro
vide
r N
ame:
SA
NT
A M
ON
ICA
CO
NV
ALE
SC
EN
T C
EN
TE
R I
83.0
1S
peec
h P
atho
logy
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alar
ies
and
Wag
es
83.0
2S
peec
h P
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logy
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ringe
Ben
efits
83.0
3S
peec
h P
atho
logy
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genc
y S
taff
83.0
4S
peec
h P
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ther
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onl
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r
85.0
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harm
acy
85.0
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harm
acy
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alar
ies
and
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85.0
2P
harm
acy
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ringe
Ben
efits
85.0
3P
harm
acy
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genc
y S
taff
85.0
4P
harm
acy
- O
ther
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onl
abo
r
90.0
0La
bora
tory
90.0
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bora
tory
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alar
ies
and
Wag
es
90.0
2La
bora
tory
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ringe
Ben
efits
90.0
3La
bora
tory
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genc
y S
taff
90.0
4La
bora
tory
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ther
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onl
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r
95.0
0H
om
e H
ealth
Ser
vice
s
95.0
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om
e H
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vice
s -
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arie
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d W
ages
95.0
2H
om
e H
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vice
s -
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ge B
enef
its
95.0
3H
om
e H
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Ser
vice
s -
Age
ncy
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ff
95.0
4H
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e H
ealth
Ser
vice
s -
Oth
er -
No
nlab
or
100.
00O
ther
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illar
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ces
100.
01O
ther
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y S
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es
100.
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ther
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ces
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ringe
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efits
100.
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ther
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genc
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100.
04O
ther
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ther
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onl
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r
100.
06S
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ute
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100.
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100.
08S
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ces
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100.
09S
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100.
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00S
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105.
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105.
04S
kille
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ther
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125.
00S
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125.
01S
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d W
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125.
02S
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125.
03S
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ncy
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ff
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04S
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er -
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nlab
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155.
00S
oci
al S
ervi
ces
155.
01S
oci
al S
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alar
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and
Wag
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Sch
edul
e 8A
-1
Pag
e 2
Pro
vide
r N
o.:
OS
HP
D F
acili
ty N
umbe
r:Fi
scal
Per
iod:
LTC
9007
6F20
6190
688
JAN
UA
RY
1, 2
007
TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
007
AU
DIT
AD
JA
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DJ
AU
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AD
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AD
JA
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AU
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AD
JA
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DJ
1011
RE
CO
NC
ILIA
TIO
N O
F T
HE
PR
OV
IDE
R'S
AD
JUS
TM
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TS
TO
TH
E A
UD
IT R
EP
OR
T
612
ST
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FOR
NIA
Pro
vide
r N
ame:
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NT
A M
ON
ICA
CO
NV
ALE
SC
EN
T C
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TE
R I
155.
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155.
03S
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genc
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155.
04S
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ther
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onl
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r
160.
00A
ctiv
ities
160.
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ities
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alar
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and
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es
160.
02A
ctiv
ities
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160.
03A
ctiv
ities
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genc
y S
taff
160.
04A
ctiv
ities
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ther
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onl
abo
r
165.
00A
dmin
istr
atio
n
165.
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165.
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165.
03A
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s -
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165.
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dmin
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165.
05A
dmin
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ff
165.
06A
dmin
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s -
Oth
er -
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nlab
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165.
07A
dmin
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n -
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S L
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sing
Fee
s
165.
08A
dmin
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atio
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165.
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dmin
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165.
11A
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170.
00In
serv
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catio
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sing
170.
01In
serv
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170.
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170.
03In
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04In
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00
To
tal
Sch
edul
e 8A
-1
Pag
e 2
Pro
vide
r N
o.:
OS
HP
D F
acili
ty N
umbe
r:Fi
scal
Per
iod:
LTC
9007
6F20
6190
688
JAN
UA
RY
1, 2
007
TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
007
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DIT
AD
JA
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1011
RE
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NC
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TIO
N O
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R'S
AD
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TS
TO
TH
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OR
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4,59
1
(612
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00
00
00
00
00
00
ST
AT
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F C
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Pag
e 1
Pro
vid
er N
ame:
Pro
vid
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o.:
OS
HP
D F
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ity
Nu
mb
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Fis
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d:
SA
NT
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ICA
CO
NV
ALE
SC
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TE
R I
LTC
9007
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6190
688
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1, 2
007
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RO
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L A
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(Pag
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1314
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Pla
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0
5.01
Pla
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tions
and
Mai
nten
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alar
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es0
5.02
Pla
nt O
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tions
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Mai
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Ben
efits
0
5.03
Pla
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0
5.04
Pla
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bor
0
10.0
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keep
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alar
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10.0
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keep
ing
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0
10.0
3H
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67,1
27
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15.0
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prov
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seho
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25.0
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ion:
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ipm
ent
0
30.0
0D
epre
ciat
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and
Am
ortiz
atio
n -
Oth
er0
35.0
0Le
ases
and
Ren
tals
792
792
40.0
0P
rope
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es0
45.0
0P
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50.0
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st-P
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nd E
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t0
55.0
0In
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0
60.0
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60.0
1La
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Ben
efits
0
60.0
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4La
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onla
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(792
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92)
65.0
0D
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0
65.0
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65.0
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ff0
65.0
4D
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ry -
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er -
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labo
r0
70.0
0P
rovi
sion
for
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ts0
75.0
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nt S
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0
77.0
0S
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0
80.0
0P
hysi
cal T
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80.0
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hysi
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py -
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arie
s an
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0
80.0
2P
hysi
cal T
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py -
Frin
ge B
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80.0
3P
hysi
cal T
hera
py -
Age
ncy
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ff0
80.0
4P
hysi
cal T
hera
py -
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er -
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labo
r0
81.0
0R
espi
rato
ry T
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81.0
1R
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ry T
hera
py -
Sal
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0
81.0
2R
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81.0
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82.0
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(Pag
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0
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0
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8A
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Pag
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Pro
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Pro
vid
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OS
HP
D F
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ity
Nu
mb
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Fis
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SA
NT
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NV
ALE
SC
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LTC
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(Pag
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160.
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0
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165.
03
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2,56
52,
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0
165.
06
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2,57
12,
571
165.
07
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dmin
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8
165.
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ranc
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34,8
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165.
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165.
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lity
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109,
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0
170.
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0
170.
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0
175.
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($19
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ST
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F C
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IA
Pro
vid
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SA
NT
A M
ON
ICA
CO
NV
ALE
SC
EN
T C
EN
TE
R I
5.00
Pla
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pera
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5.01
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5.02
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5.03
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5.04
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10.0
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15.0
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20.0
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25.0
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30.0
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35.0
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40.0
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45.0
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50.0
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tere
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55.0
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60.0
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alar
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60.0
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60.0
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genc
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taff
60.0
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d Li
nen
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ther
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onla
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65.0
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65.0
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ieta
ry -
Sal
arie
s an
d W
ages
65.0
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ge B
enef
its
65.0
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ieta
ry -
Age
ncy
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ff
65.0
4D
ieta
ry -
Oth
er -
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labo
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70.0
0P
rovi
sion
for
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ts
75.0
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75.0
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75.0
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75.0
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75.0
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77.0
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aliz
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80.0
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hysi
cal T
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hysi
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80.0
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py -
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80.0
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hysi
cal T
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py -
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80.0
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hysi
cal T
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py -
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labo
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81.0
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81.0
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81.0
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rato
ry T
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py -
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ge B
enef
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81.0
3R
espi
rato
ry T
hera
py -
Age
ncy
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ff
81.0
4R
espi
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ry T
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py -
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82.0
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atio
nal T
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py
82.0
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py -
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s an
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Sch
edu
le 8
A-2
Pag
e 2
Pro
vid
er N
o.:
OS
HP
D F
acil
ity
Nu
mb
er:
Fis
cal P
erio
d:
LTC
9007
6F20
6190
688
JAN
UA
RY
1, 2
007
TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
007
AU
DIT
AD
JA
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AU
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JA
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DJ
AU
DIT
AD
JA
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IT A
DJ
AU
DIT
AD
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DJ
1718
67,1
27
(67,
127)
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S
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RN
IA
Pro
vid
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NT
A M
ON
ICA
CO
NV
ALE
SC
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T C
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TE
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82.0
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py -
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82.0
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py -
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ff
82.0
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py -
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83.0
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peec
h P
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83.0
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peec
h P
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alar
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and
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83.0
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peec
h P
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Ben
efits
83.0
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peec
h P
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taff
83.0
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peec
h P
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ther
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bor
85.0
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harm
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85.0
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85.0
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harm
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85.0
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harm
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taff
85.0
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harm
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ther
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onla
bor
90.0
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bora
tory
90.0
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bora
tory
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alar
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90.0
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bora
tory
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ringe
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efits
90.0
3La
bora
tory
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genc
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taff
90.0
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bora
tory
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ther
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onla
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95.0
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95.0
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95.0
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95.0
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95.0
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ther
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onla
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100.
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ther
Anc
illary
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vice
s
100.
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Ser
vice
s -
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s an
d W
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100.
02O
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illary
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vice
s -
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ge B
enef
its
100.
03O
ther
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illary
Ser
vice
s -
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ncy
Sta
ff
100.
04O
ther
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illary
Ser
vice
s -
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er -
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labo
r
100.
06S
ubac
ute
Anc
illary
Ser
vice
s
100.
07S
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ute
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illary
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vice
s -
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s an
d W
ages
100.
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vice
s -
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100.
09S
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vice
s -
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ncy
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ff
100.
10S
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vice
s -
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er -
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labo
r
100.
12S
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illary
Ser
vice
s
105.
00S
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4 an
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06
Pag
e7
