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REPORT ON THE
RATE SETTING AUDIT
COUNTRY VILLA WEST COVINA HEALTHCARE CENTER
WEST COVINA, CALIFORNIA NATIONAL PROVIDER IDENTIFIER: 1326032814
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: Ginn Sampson Auditor: George Barbosa
TO
OBY DOUGLAS DIRECTOR
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Jim Samuel Page 2
If you disagree with the decision of the Department, you may appeal by writing to: 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: Ruth Santo Domingo Mendoza Director of Reimbursement Country Villa Health Services 5120 West Goldleaf Circle, Suite 400 Los Angeles, CA 90056
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:COUNTRY VILLA WEST COVINA HEALTHCARE JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility No.:1326032814 206190085
LineNo.
SKILLED NURSING CARE1 Cost of Direct Care - Labor (Sch. 2, Ln. 105) $ N/A $ 2,615,307 $ 81.652 Cost of Indirect Care - Labor (Sch. 3, Ln. 105) $ N/A $ 683,133 $ 21.333 Cost of Direct and Indirect Nonlabor - Other (Sch. 4, Ln. 105) $ N/A $ 552,018 $ 17.234 Cost of Capital Related (Sch. 5, Ln. 105) $ N/A $ 443,929 $ 13.865 Property Taxes (Sch. 5, Ln. 105) $ N/A $ 35,506 $ 1.116 CDPH Licensing Fees (Sch. 6, Ln. 105) $ N/A $ 22,592 $ 0.717 Professional Liability Insurance (Sch. 6, Ln. 105) $ N/A $ 90,162 $ 2.818 Caregiver Training (Sch. 6, Ln. 105) $ N/A $ 0 $ 0.009 Quality Assurance Fees (Sch. 6, Ln. 105) $ N/A $ 321,794 $ 10.0510 Cost of Administration (Sch. 6, Ln. 105) $ N/A $ 718,338 $ 22.4311 Cost of Routine Service/Audited Total Costs $ 5,478,247.00 $ 5,482,778.29 $ 171.1712 Total Patient Days (Adj ) 32,032 32,03213 Cost Per Patient Day (Cost Divided by Days) $ 171.02 $ 171.17 14 Overpayments (Adj ) $ $ 015 Medi-Cal Days (Adj 5) 25,942 25,93516 Medi-Cal Managed Care Days (Adj ) 0
INTERMEDIATE CARE17 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 018 Total Patient Days (Adj ) 019 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0020 Overpayments (Adj ) $ $ 0
MENTALLY DISORDERED CARE21 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 022 Total Patient Days (Adj ) 023 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0024 Overpayments (Adj ) $ $ 0
DEVELOPMENTALLY DISABLED CARE25 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 026 Total Patient Days (Adj ) 027 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0028 Overpayments (Adj ) $ $ 0
SUBACUTE CARE29 Cost of Direct Care - Labor (Subacute Care Sch. 1, Ln. 25) $ N/A $ 0 $ 0.0030 Cost of Indirect Care - Labor (Subacute Care Sch. 1, Ln. 26) $ N/A $ 0 $ 0.0031 Cost of Direct and Indirect Nonlabor - Other (Subacute Care Sch. 1, Ln. 27) $ N/A $ 0 $ 0.0032 Cost of Capital Related (Subacute Care Sch. 1, Ln. 28) $ N/A $ 0 $ 0.0033 Property Taxes (Subacute Care Sch. 1, Ln. 29) $ N/A $ 0 $ 0.0034 CDPH Licensing Fees (Subacute Care Sch. 1, Ln. 30) $ N/A $ 0 $ 0.0035 Professional Liability Insurance (Subacute Care Sch. 1, Ln. 31) $ N/A $ 0 $ 0.0036 Quality Assurance Fees (Subacute Care Sch. 1, Ln. 32) $ N/A $ 0 $ 0.0037 Caregiver Training (Subacute Care Sch. 1, Ln. 33) $ N/A $ 0 $ 0.0038 Cost of Administration (Subacute Care Sch.1, Ln. 34) $ N/A $ 0 $ 0.0039 Total Cost of Subacute Service (Subacute Care Sch. 1, Ln. 35) $ 0 $ 0 $ 0.0040 Total Patient Days (Subacute Care Sch. 1, Ln. 36) 0 041 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0042 Amount Due Provider (State) (Subacute Care Sch. 1, Ln. 40) $ 0 $ 0
AS REPORTED AS AUDITED PATIENT DAY
SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY
COST PERAUDITED
PROGRAM DESCRIPTION
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:COUNTRY VILLA WEST COVINA HEALTHCARE JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility No.:1326032814 206190085
LineNo. AS REPORTED AS AUDITED PATIENT DAY
SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY
COST PERAUDITED
PROGRAM DESCRIPTION
SUBACUTE CARE - PEDIATRIC43 Cost of Routine Service (Subacute Care - Pediatric, Sch. 1, Ln 3) $ 0 $ 044 Cost of Ancillary Service (Subacute Care - Pediatric, Sch. 1, Ln. 1 + Ln. 2) $ 0 $ 045 Total Cost of Subacute Care - Pediatric Service (Ln. 42 + Ln. 43) $ 0 $ 046 Total Patient Days (Subacute Care - Pediatric, Sch. 1, Ln. 5) 0 047 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0048 Amount Due Provider (State) (Subacute Care - Pediatric, Sch. 1, Ln. 9) $ 0 $ 0
TRANSITIONAL INPATIENT CARE49 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 050 Total Patient Days (Adj ) 051 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0052 Overpayments (Adj ) $ $ 0
HOSPICE INPATIENT CARE53 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 054 Total Patient Days (Adj ) 055 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0056 Overpayments (Adj ) $ $ 0
OTHER ROUTINE SERVICES57 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 058 Total Patient Days (Adj ) 059 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0060 Overpayments (Adj ) $ $ 0
STATE OF CALIFORNIA SCHEDULE 2
Provider Name: Fiscal Period:COUNTRY VILLA WEST COVINA HEALTHCARE JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility No.:1326032814 206190085
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 44,243$ 44,243$ 160 Activities 65,448 65,448$ 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 283,069 0 0 283,069081 Respiratory Therapy 0 0 0 0082 Occupational Therapy 245,039 0 0 245,039083 Speech Pathology 28,829 0 0 28,829085 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 2,505,616 44,243 65,448 2,615,307 *110 Intermediate Care 0 0 0 0 *115 Mentally Disordered Care 0 0 0 0 *120 Developmentally Disabled Care 0 0 0 0 *125 Subacute Care 0 0 0 0 *126 Subacute Care - Pediatric 0 0 0 0 *128 Transitional Inpatient Care 0 0 0 0 *130 Hospice Inpatient Care 0 0 0 0 *135 Other Routine Services 0 0 0 0 *
NONREIMBURSABLE 139 Residential Care 0 0 0 0140 Beauty and Barber 0 0 0 0145 Other Nonreimbursable 0 0 0 0
TOTAL 3,172,244$ 44,243$ 65,448$ 3,172,244$ * (To Schedule 1)
ALLOCATION OF GENERAL SERVICES DIRECT CARE LABOR
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160
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09,
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$
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4,
486
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00
011
,228
$
11,2
28$
166
Med
ical
Rec
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62,3
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686
60
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63,8
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Inse
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00
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70,7
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155
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Co
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165
166
To
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22,6
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206,
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1,07
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12,5
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$
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STATE OF CALIFORNIA SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Provider Name: Fiscal Period:COUNTRY VILLA WEST COVINA HEALTHCARE JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1326032814 206190085
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) 473,040$ 93%Property Tax (line 40) 37,834 7% 510,874$
005 Plant Operations and Maintenance 22,146 22,146$ 010 Housekeeping 3,212 146 3,358$ 060 Laundry and Linen 16,216 735 112 17,063$ 065 Dietary 62,855 2,848 435 0 66,138$ 155 Social Services 5,436 246 38 0 0 5,720$ 160 Activities 23,196 1,051 160 0 0 0 24,408$ 165 Administration 28,632 1,297 198 0 0 0 0166 Medical Records 3,676 167 25 0 0 0 0170 Inservice Education - Nursing 7,691 349 53 0 0 0 0
ANCILLARY SERVICES075 Patient Supplies 494 22 3 0 0 0 0077 Specialized Support Surfaces 0 0 0 0 0 0 0080 Physical Therapy 7,938 360 55 0 0 0 0081 Respiratory Therapy 0 0 0 0 0 0 0082 Occupational Therapy 13,065 592 90 0 0 0 0083 Speech Pathology 1,143 52 8 0 0 0 0085 Pharmacy 1,668 76 12 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 313,103 14,188 2,165 17,063 66,138 5,720 24,408110 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 402 18 3 0 0 0 0145 Other Nonreimbursable 0 0 0 0 0 0 0
TOTAL 510,874$ 100% 510,874$ 22,146$ 3,358$ 17,063$ 66,138$ 5,720$ 24,408$ * (To Schedule 1)
STATE OF CALIFORNIA
Provider Name:COUNTRY VILLA WEST COVINA HEALTHCARE
Provider NPI:1326032814
Net Exp ForLine DESCRIPTION Cost AllocNo. (From Sch 8) Ratio
GENERAL SERVICESCapital Related (excluding lines 40 & 45) 473,040$ 93%Property Tax (line 40) 37,834 7%
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 510,874$ 100%* (To Schedule 1)
SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Fiscal Period:JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
OSHPD Facility Number:206190085
Inserv. Ed Admin Medical Capital PropertyRecords Related Tax
Accumulated 93% 7%170 Costs 165 166 Total Of Total Of Total
30,128$ 30,128$ 3,868 3,868$
8,093$
0 520 93 12 625$ 579$ 46$ 0 0 221 28 249 231 180 8,353 1,782 229 10,363 9,596 7670 0 9 1 11 10 10 13,748 1,606 206 15,560 14,408 1,1520 1,203 185 24 1,411 1,307 1050 1,755 719 92 2,566 2,376 1900 0 94 12 106 98 80 0 0 0 0 0 00 0 92 12 104 97 80 0 0 0 0 0 00 0 0 0 0 0 0
8,093 450,878 25,308 3,249 479,435 443,929 35,506 *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 00 423 18 2 443 410 330 0 0 0 0 0 0
8,093$ 476,879$ 30,128$ 3,868$ 510,874$ 473,040$ 37,834$
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STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:COUNTRY VILLA WEST COVINA HEALTHCARE JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1326032814 206190085
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER005 Plant Operations and Maintenance005 .01-.19 Salaries and Wages 6200 $ 57,443 $ 0 $ 57,443 (Sch 3)005 .20-.39 Fringe Benefits 6200 19,124 0 19,124 (Sch 3)005 .79 Agency Staff 6200 0 0 (Sch 3)005 .40-.99 Other - Nonlabor 6200 131,049 0 131,049 (Sch 4)005 Plant Operations and Maintenance - Total 6200 $ 207,616 $ 0 $ 207,616
010 Housekeeping010 .01-.19 Salaries and Wages 6300 $ $ 0 $ 0 (Sch 3)010 .20-.39 Fringe Benefits 6300 0 0 (Sch 3)010 .79 Agency Staff 6300 113,826 0 113,826 (Sch 3)010 .40-.99 Other - Nonlabor 6300 21,653 0 21,653 (Sch 4)010 Housekeeping - Total 6300 $ 135,479 $ 0 $ 135,479
015 Depreciation: Buildings and Improvements 7110 - 7120 $ 1,326 $ 0 $ 1,326 (Sch 5)020 Depreciation: Leasehold Improvements 7130 17,598 0 17,598 (Sch 5)025 Depreciation: Equipment 7140 9,341 0 9,341 (Sch 5)030 Depreciation and Amortization - Other 7150 - 7160 0 0 (Sch 5)035 Leases and Rentals 7200 444,775 0 444,775 (Sch 5)040 Property Taxes 7300 37,834 0 37,834 (Sch 5)045 Property Insurance 7400 24,565 0 24,565 (Sch 6)050 Interest - Property, Plant, and Equipment 7500 0 0 (Sch 5)055 Interest - Other 7600 $ $ 0 $ 0 (Sch 6)
057 Subtotal 005 - 055 $ 878,534 $ 0 $ 878,534
060 Laundry and Linen060 .01-.19 Salaries and Wages 6400 $ $ 0 $ 0 (Sch 3)060 .20-.39 Fringe Benefits 6400 0 0 (Sch 3)060 .79 Agency Staff 6400 73,928 0 73,928 (Sch 3)060 .40-.99 Other - Nonlabor 6400 17,522 0 17,522 (Sch 4)060 Laundry and Linen - Total 6400 $ 91,450 $ 0 $ 91,450
065 Dietary065 .01-.19 Salaries and Wages 6500 $ 244,525 $ 0 $ 244,525 (Sch 3)065 .20-.39 Fringe Benefits 6500 65,909 0 65,909 (Sch 3)065 .79 Agency Staff 6500 0 0 (Sch 3)065 .40-.99 Other - Nonlabor 6500 206,302 0 206,302 (Sch 4)065 Dietary - Total 6500 $ 516,736 $ 0 $ 516,736
070 Provision for Bad Debts 7700 $ 0 $ 0
Ancillary Services 075 Patient Supplies075 .01-.19 Salaries and Wages 8100 $ 628 $ (628) $ 0 (Sch 2)075 .20-.39 Fringe Benefits 8100 251 (251) 0 (Sch 2)075 .79 Agency Staff 8100 0 0 (Sch 2)075 .40-.99 Other - Nonlabor 8100 14,677 0 14,677 (Sch 4)075 Patient Supplies - Total 8100 $ 15,556 $ (879) $ 14,677
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 36,879 0 36,879 (Sch 4)077 Specialized Support Surfaces - Total 8150 $ 36,879 $ 0 $ 36,879
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
REPORTEDAS AS
AUDITEDADJUSTMENTS
8A-1
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:COUNTRY VILLA WEST COVINA HEALTHCARE JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1326032814 206190085
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
REPORTEDAS AS
AUDITEDADJUSTMENTS
8A-1080 Physical Therapy080 .01-.19 Salaries and Wages 8200 $ $ 0 $ 0 (Sch 2)080 .20-.39 Fringe Benefits 8200 0 0 (Sch 2)080 .79 Agency Staff 8200 283,069 0 283,069 (Sch 2)080 .40-.99 Other - Nonlabor 8200 262 0 262 (Sch 4)080 Physical Therapy - Total 8200 $ 283,331 $ 0 $ 283,331
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 1,567 0 1,567 (Sch 4)081 Respiratory Therapy - Total 8220 $ 1,567 $ 0 $ 1,567
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 245,039 0 245,039 (Sch 2)082 .40-.99 Other - Nonlabor 8250 0 0 (Sch 4)082 Occupational Therapy - Total 8250 $ 245,039 $ 0 $ 245,039
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 28,829 0 28,829 (Sch 2)083 .40-.99 Other - Nonlabor 8280 0 0 (Sch 4)083 Speech Pathology - Total 8280 $ 28,829 $ 0 $ 28,829
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 117,034 0 117,034 (Sch 4)085 Pharmacy - Total 8300 $ 117,034 $ 0 $ 117,034
090 Laboratory090 .01-.19 Salaries and Wages 8400 $ 60 $ (60) $ 0 (Sch 2)090 .20-.39 Fringe Benefits 8400 24 (24) 0 (Sch 2)090 .79 Agency Staff 8400 0 0 (Sch 2)090 .40-.99 Other - Nonlabor 8400 15,614 0 15,614 (Sch 4)090 Laboratory - Total 8400 $ 15,698 $ (84) $ 15,614
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 15,419 0 15,419 (Sch 4)100 Other Ancillary Services - Total 8900 $ 15,419 $ 0 $ 15,419
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:COUNTRY VILLA WEST COVINA HEALTHCARE JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1326032814 206190085
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
REPORTEDAS AS
AUDITEDADJUSTMENTS
8A-1101 Subacute Care Ancillary Services101 .01-.19 Salaries and Wages 8100-8900 $ $ 0 $ 0 (Sch 2)101 .20-.39 Fringe Benefits 8100-8900 0 0 (Sch 2)101 .79 Agency Staff 8100-8900 0 0 (Sch 2)101 .40-.99 Other - Nonlabor 8100-8900 0 0 (Sch 4)101 Subacute Care Ancillary Services - Total 8100-8900 $ 0 $ 0 $ 0
102 Subacute Care - Pediatric Ancillary Services102 .01-.19 Salaries and Wages 8100-8900 $ $ 0 $ 0 (Sch 2)102 .20-.39 Fringe Benefits 8100-8900 0 0 (Sch 2)102 .79 Agency Staff 8100-8900 0 0 (Sch 2)102 .40-.99 Other - Nonlabor 8100-8900 0 0 (Sch 4)102 Subacute Care - Pediatric Ancillary Services - Total 8100-8900 $ 0 $ 0 $ 0
104 Subtotal 075 - 102 $ 759,352 $ (963) $ 758,389
Routine Services105 Skilled Nursing Care105 .01-.19 Salaries and Wages 6110 $ 1,953,843 $ (6,318) $ 1,947,525 (Sch 2)105 .20-.39 Fringe Benefits 6110 560,614 (2,523) 558,091 (Sch 2)105 .49 Agency Staff 6110 0 0 (Sch 2)105 .40-.99 Other - Nonlabor 6110 166,216 0 166,216 (Sch 4)105 Skilled Nursing Care - Total 6110 $ 2,680,673 $ (8,841) $ 2,671,832
110 Intermediate Care110 .01-.19 Salaries and Wages 6120 $ $ 0 $ 0110 .20-.39 Fringe Benefits 6120 0 0110 .49 Agency Staff 6120 0 0110 .40-.99 Other - Nonlabor 6120 0 0110 Intermediate Care - Total 6120 $ 0 $ 0 $ 0 (Sch 2)
115 Mentally Disordered Care115 .01-.19 Salaries and Wages 6130 $ $ 0 $ 0115 .20-.39 Fringe Benefits 6130 0 0115 .49 Agency Staff 6130 0 0115 .40-.99 Other - Nonlabor 6130 0 0115 Mentally Disordered Care - Total 6130 $ 0 $ 0 $ 0 (Sch 2)
120 Developmentally Disabled Care120 .01-.19 Salaries and Wages 6140 $ $ 0 $ 0120 .20-.39 Fringe Benefits 6140 0 0120 .49 Agency Staff 6140 0 0120 .40-.99 Other - Nonlabor 6140 0 0120 Developmentally Disabled Care - Total 6140 $ 0 $ 0 $ 0 (Sch 2)
125 Subacute Care125 .01-.19 Salaries and Wages 6150 $ $ 0 $ 0 (Sch 2)125 .20-.39 Fringe Benefits 6150 0 0 (Sch 2)125 .49 Agency Staff 6150 0 0 (Sch 2)125 .40-.99 Other - Nonlabor 6150 0 0 (Sch 4)125 Subacute Care - Total 6150 $ 0 $ 0 $ 0
126 Subacute Care - Pediatric126 .01-.19 Salaries and Wages 6160 $ $ 0 $ 0 (Sch 2)126 .20-.39 Fringe Benefits 6160 0 0 (Sch 2)126 .49 Agency Staff 6160 0 0 (Sch 2)126 .40-.99 Other - Nonlabor 6160 0 0 (Sch 4)126 Subacute Care - Pediatric - Total 6160 $ 0 $ 0 $ 0
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:COUNTRY VILLA WEST COVINA HEALTHCARE JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1326032814 206190085
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
REPORTEDAS AS
AUDITEDADJUSTMENTS
8A-1128 Transitional Inpatient Care128 .01-.19 Salaries and Wages 6170 $ $ 0 $ 0128 .20-.39 Fringe Benefits 6170 0 0128 .49 Agency Staff 6170 0 0128 .40-.99 Other - Nonlabor 6170 0 0128 Transitional Inpatient Care - Total 6170 $ 0 $ 0 $ 0 (Sch 2)
130 Hospice Inpatient Care130 .01-.19 Salaries and Wages 6180 $ $ 0 $ 0130 .20-.39 Fringe Benefits 6180 0 0130 .49 Agency Staff 6180 0 0130 .40-.99 Other - Nonlabor 6180 0 0130 Hospice Inpatient Care - Total 6180 $ 0 $ 0 $ 0 (Sch 2)
135 Other Routine Services135 .01-.19 Salaries and Wages 6190 $ $ 0 $ 0135 .20-.39 Fringe Benefits 6190 0 0135 .49 Agency Staff 6190 0 0135 .40-.99 Other - Nonlabor 6190 0 0135 Other Routine Services - Total 6190 $ 0 $ 0 $ 0 (Sch 2)
Other Nonreimbursable139 Residential Care139 .01-.19 Salaries and Wages 9100 $ $ 0 $ 0 (Sch 2)139 .20-.39 Fringe Benefits 9100 0 0 (Sch 2)139 .49 Agency Staff 9100 0 0 (Sch 2)139 .40-.99 Other - Nonlabor 9100 0 0 (Sch 4)139 Residential Care - Total 9100 $ 0 $ 0 $ 0
140 Beauty and Barber140 .01-.19 Salaries and Wages 8900 $ $ 0 $ 0 (Sch 2)140 .20-.39 Fringe Benefits 8900 0 0 (Sch 2)140 .49 Agency Staff 8900 0 0 (Sch 2)140 .40-.99 Other - Nonlabor 8900 2,275 0 2,275 (Sch 4)140 Beauty and Barber - Total 8900 $ 2,275 $ 0 $ 2,275
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 $ 2,682,948 $ (8,841) $ 2,674,107
155 Social Services155 .01-.19 Salaries and Wages 6600 $ 34,908 $ 0 $ 34,908 (Sch 2)155 .20-.39 Fringe Benefits 6600 9,335 0 9,335 (Sch 2)155 .49 Agency Staff 6600 0 0 (Sch 2)155 .40-.99 Other - Nonlabor 6600 5,361 0 5,361 (Sch 4)155 Social Services - Total 6600 $ 49,604 $ 0 $ 49,604
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:COUNTRY VILLA WEST COVINA HEALTHCARE JANUARY 1, 2010 THROUGH DECEMBER 31, 2010
Provider NPI: OSHPD Facility Number:1326032814 206190085
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
REPORTEDAS AS
AUDITEDADJUSTMENTS
8A-1160 Activities160 .01-.19 Salaries and Wages 6700 $ 51,766 $ 0 $ 51,766 (Sch 2)160 .20-.39 Fringe Benefits 6700 13,682 0 13,682 (Sch 2)160 .49 Agency Staff 6700 0 0 (Sch 2)160 .40-.99 Other - Nonlabor 6700 5,238 0 5,238 (Sch 4)160 Activities - Total 6700 $ 70,686 $ 0 $ 70,686
165 Administration165 .01-.19 Salaries and Wages 6900 $ 280,310 $ 7,006 $ 287,316 (Sch 6)165 .20-.39 Fringe Benefits 6900 80,542 2,798 83,340 (Sch 6)165 .49 Agency Staff 6900 0 0 (Sch 6)165 .40-.99 Other - Nonlabor 6900 457,600 2,320 459,920 (Sch 6)165 Administration - Total 6900 $ 818,452 $ 12,124 $ 830,576
166 Medical Records166 .01-.19 Salaries and Wages 6900 $ 49,352 $ 0 $ 49,352 (Sch 3)166 .20-.39 Fringe Benefits 6900 13,030 0 13,030 (Sch 3)166 .49 Agency Staff 6900 0 0 (Sch 3)166 .40-.99 Other - Nonlabor 6900 8,770 0 8,770 (Sch 4)166 Medical Records - Total 6900 $ 71,152 $ 0 $ 71,152
167 CDPH Licensing Fees 6900 $ 26,894 $ 0 $ 26,894 (Sch 6)168 Professional Liability Insurance 6900 $ 115,160 $ (7,827) $ 107,333 (Sch 6)169 Quality Assurance Fees 6900 $ 383,077 $ 0 $ 383,077 (Sch 6)
170 Inservice Education - Nursing170 .01-.19 Salaries and Wages 6800 $ 52,400 $ 0 $ 52,400 (Sch 3)170 .20-.39 Fringe Benefits 6800 15,292 0 15,292 (Sch 3)170 .49 Agency Staff 6800 0 0 (Sch 3)170 .40-.99 Other - Nonlabor 6800 707 0 707 (Sch 4)170 Inservice Education - Nursing - Total 6800 $ 68,399 $ 0 $ 68,399
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 $ 1,603,424 $ 4,297 $ 1,607,721
200 Total $ 6,532,444 $ (5,507) $ 6,526,937
STA
TE O
F C
ALI
FOR
NIA
Sche
dule
8A
-1Pa
ge 1
Prov
ider
Nam
e:Pr
ovid
er N
PI:
OSH
PD F
acili
ty N
umbe
r:Fi
scal
Per
iod:
CO
UN
TRY
VIL
LA W
ES
T C
OV
INA
HE
ALT
HC
AR
E13
2603
2814
2061
9008
5JA
NU
AR
Y 1
, 201
0 TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
010
TOTA
L A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
Line
Sub
(Pag
e 1)
12
34
No.
No.
005
1P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Sal
arie
s an
d W
ages
000
52
Pla
nt O
pera
tions
and
Mai
nten
ance
- Fr
inge
Ben
efits
000
53
Pla
nt O
pera
tions
and
Mai
nten
ance
- A
genc
y S
taff
000
54
Pla
nt O
pera
tions
and
Mai
nten
ance
- O
ther
- N
onla
bor
001
01
Hou
seke
epin
g - S
alar
ies
and
Wag
es0
010
2H
ouse
keep
ing
- Frin
ge B
enef
its0
010
3H
ouse
keep
ing
- Age
ncy
Sta
ff0
010
4H
ouse
keep
ing
- Oth
er -
Non
labo
r0
015
4D
epre
ciat
ion:
Bui
ldin
gs a
nd Im
prov
emen
ts0
020
4D
epre
ciat
ion:
Lea
seho
ld Im
prov
emen
ts0
025
4D
epre
ciat
ion:
Equ
ipm
ent
003
04
Dep
reci
atio
n an
d A
mor
tizat
ion
- Oth
er0
035
4Le
ases
and
Ren
tals
004
04
Pro
perty
Tax
es0
045
4P
rope
rty In
sura
nce
005
04
Inte
rest
- P
rope
rty, P
lant
, and
Equ
ipm
ent
005
54
Inte
rest
- O
ther
006
01
Laun
dry
and
Line
n - S
alar
ies
and
Wag
es0
060
2La
undr
y an
d Li
nen
- Frin
ge B
enef
its0
060
3La
undr
y an
d Li
nen
- Age
ncy
Sta
ff0
060
4La
undr
y an
d Li
nen
- Oth
er -
Non
labo
r0
065
1D
ieta
ry -
Sal
arie
s an
d W
ages
006
52
Die
tary
- Fr
inge
Ben
efits
006
53
Die
tary
- A
genc
y S
taff
006
54
Die
tary
- O
ther
- N
onla
bor
007
04
Pro
visi
on fo
r Bad
Deb
ts0
075
1P
atie
nt S
uppl
ies
- Sal
arie
s an
d W
ages
(628
)(6
28)
075
2P
atie
nt S
uppl
ies
- Frin
ge B
enef
its(2
51)
(251
)07
53
Pat
ient
Sup
plie
s - A
genc
y S
taff
007
54
Pat
ient
Sup
plie
s - O
ther
- N
onla
bor
007
71
Spe
cial
ized
Sup
port
Sur
face
s - S
alar
ies
and
Wag
es0
077
2S
peci
aliz
ed S
uppo
rt S
urfa
ces
- Frin
ge B
enef
its0
077
3S
peci
aliz
ed S
uppo
rt S
urfa
ces
- Age
ncy
Sta
ff0
077
4S
peci
aliz
ed S
uppo
rt S
urfa
ces
- Oth
er -
Non
labo
r0
080
1P
hysi
cal T
hera
py -
Sal
arie
s an
d W
ages
008
02
Phy
sica
l The
rapy
- Fr
inge
Ben
efits
008
03
Phy
sica
l The
rapy
- A
genc
y S
taff
008
04
Phy
sica
l The
rapy
- O
ther
- N
onla
bor
008
11
Res
pira
tory
The
rapy
- S
alar
ies
and
Wag
es0
081
2R
espi
rato
ry T
hera
py -
Frin
ge B
enef
its0
081
3R
espi
rato
ry T
hera
py -
Age
ncy
Sta
ff0
081
4R
espi
rato
ry T
hera
py -
Oth
er -
Non
labo
r0
082
1O
ccup
atio
nal T
hera
py -
Sal
arie
s an
d W
ages
008
22
Occ
upat
iona
l The
rapy
- Fr
inge
Ben
efits
008
23
Occ
upat
iona
l The
rapy
- A
genc
y S
taff
008
24
Occ
upat
iona
l The
rapy
- O
ther
- N
onla
bor
008
31
Spe
ech
Pat
holo
gy -
Sal
arie
s an
d W
ages
008
32
Spe
ech
Pat
holo
gy -
Frin
ge B
enef
its0
083
3S
peec
h P
atho
logy
- A
genc
y S
taff
0
REC
LASS
IFIC
ATI
ON
S A
ND
/OR
AD
JUST
MEN
TS T
O R
EPO
RTE
D C
OST
S
STA
TE O
F C
ALI
FOR
NIA
Sche
dule
8A
-1Pa
ge 1
Prov
ider
Nam
e:Pr
ovid
er N
PI:
OSH
PD F
acili
ty N
umbe
r:Fi
scal
Per
iod:
CO
UN
TRY
VIL
LA W
ES
T C
OV
INA
HE
ALT
HC
AR
E13
2603
2814
2061
9008
5JA
NU
AR
Y 1
, 201
0 TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
010
TOTA
L A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
Line
Sub
(Pag
e 1)
12
34
No.
No.
REC
LASS
IFIC
ATI
ON
S A
ND
/OR
AD
JUST
MEN
TS T
O R
EPO
RTE
D C
OST
S
083
4S
peec
h P
atho
logy
- O
ther
- N
onla
bor
008
51
Pha
rmac
y - S
alar
ies
and
Wag
es0
085
2P
harm
acy
- Frin
ge B
enef
its0
085
3P
harm
acy
- Age
ncy
Sta
ff0
085
4P
harm
acy
- Oth
er -
Non
labo
r0
090
1La
bora
tory
- S
alar
ies
and
Wag
es(6
0)(6
0)09
02
Labo
rato
ry -
Frin
ge B
enef
its(2
4)(2
4)09
03
Labo
rato
ry -
Age
ncy
Sta
ff0
090
4La
bora
tory
- O
ther
- N
onla
bor
009
51
Hom
e H
ealth
Ser
vice
s - S
alar
ies
and
Wag
es0
095
2H
ome
Hea
lth S
ervi
ces
- Frin
ge B
enef
its0
095
3H
ome
Hea
lth S
ervi
ces
- Age
ncy
Sta
ff0
095
4H
ome
Hea
lth S
ervi
ces
- Oth
er -
Non
labo
r0
100
1O
ther
Anc
illar
y S
ervi
ces
- Sal
arie
s an
d W
ages
010
02
Oth
er A
ncill
ary
Ser
vice
s - F
ringe
Ben
efits
010
03
Oth
er A
ncill
ary
Ser
vice
s - A
genc
y S
taff
010
04
Oth
er A
ncill
ary
Ser
vice
s - O
ther
- N
onla
bor
010
11
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Sal
arie
s an
d W
ages
010
12
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Frin
ge B
enef
its0
101
3S
ubac
ute
Car
e A
ncill
ary
Ser
vice
s - A
genc
y S
taff
010
14
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Oth
er -
Non
labo
r0
102
1S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - S
alar
ies
and
Wag
es0
102
2S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - F
ringe
Ben
efits
010
23
Sub
acut
e P
edia
tric
Anc
illar
y S
ervi
ces
- Age
ncy
Sta
ff0
102
4S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - O
ther
- N
onla
bor
010
51
Ski
lled
Nur
sing
Car
e - S
alar
ies
and
Wag
es(6
,318
)(6
,318
)10
52
Ski
lled
Nur
sing
Car
e - F
ringe
Ben
efits
(2,5
23)
(2,5
23)
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
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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
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iatri
c - O
ther
- N
onla
bor
0
STA
TE O
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Sche
dule
8A
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ge 1
Prov
ider
Nam
e:Pr
ovid
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PI:
OSH
PD F
acili
ty N
umbe
r:Fi
scal
Per
iod:
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UN
TRY
VIL
LA W
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2603
2814
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9008
5JA
NU
AR
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0 TH
RO
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H D
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BE
R 3
1, 2
010
TOTA
L A
DJ
AU
DIT
AD
JA
UD
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DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
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IT A
DJ
Line
Sub
(Pag
e 1)
12
34
No.
No.
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
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arie
s an
d W
ages
012
82
Tran
sitio
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npat
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Car
e - F
ringe
Ben
efits
012
83
Tran
sitio
nal I
npat
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Car
e - A
genc
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taff
012
84
Tran
sitio
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npat
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Car
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ther
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bor
013
01
Hos
pice
Inpa
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Car
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alar
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130
2H
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enef
its0
130
3H
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ff0
130
4H
ospi
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patie
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are
- Oth
er -
Non
labo
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135
1O
ther
Rou
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Ser
vice
s - S
alar
ies
and
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es0
135
2O
ther
Rou
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Ser
vice
s - F
ringe
Ben
efits
013
53
Oth
er R
outin
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ervi
ces
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ncy
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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
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genc
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taff
014
54
Oth
er N
onre
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rsab
le -
Oth
er -
Non
labo
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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
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genc
y S
taff
016
04
Act
iviti
es -
Oth
er -
Non
labo
r0
165
1A
dmin
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tion
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s an
d W
ages
7,00
67,
006
165
2A
dmin
istra
tion
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ge B
enef
its2,
798
2,79
816
53
Adm
inis
tratio
n - A
genc
y S
taff
016
54
Adm
inis
tratio
n - O
ther
- N
onla
bor
2,32
03,
493
(1,1
73)
166
1M
edic
al R
ecor
ds -
Sal
arie
s an
d W
ages
016
62
Med
ical
Rec
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inge
Ben
efits
016
63
Med
ical
Rec
ords
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genc
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taff
016
64
Med
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Rec
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ther
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onla
bor
016
74
CD
PH
Lic
ensi
ng F
ees
016
84
Pro
fess
iona
l Lia
bilit
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sura
nce
(7,8
27)
(3,4
93)
(4,3
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169
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170
1In
serv
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017
02
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017
03
Inse
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017
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41
Car
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42
Car
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STA
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Sche
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Prov
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12
34
No.
No.
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JUST
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