I. IDPH License ID Number: II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER

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1 FOR BHF USE IMPORTANT NOTICE LL1 THIS AGENCY IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARY TO ACCOMPLISH THE STATUTORY 2008 PURPOSE AS OUTLINED IN 210 ILCS 45/ DISCLOSURE STATE OF ILLINOIS OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDE DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES ANY INFORMATION ON OR BEFORE THE DUE DATE WILL FINANCIAL AND STATISTICAL REPORT (COST REPORT) RESULT IN CESSATION OF PROGRAM PAYMENTS. THIS FORM FOR LONG-TERM CARE FACILITIES HAS BEEN APPROVED BY THE FORMS MANAGEMENT CENTER. (FISCAL YEAR 2008) I. IDPH License ID Number: II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER Facility Name: HILLCREST HEALTHCARE CENTER Address: 777 DRAPER JOLIET I have examined the contents of the accompanying report to the State of Illinois, for the period from 01/01/2008 to 12/31/2008 Number City Zip Code and certify to the best of my knowledge and belief that the said contents County: WILL are true, accurate and complete statements in accordance with applicable instructions. Declaration of preparer (other than provider) Telephone Number: ( 847) Fax # ( 847 ) is based on all information of which preparer has any knowledge. HFS ID Number: Intentional misrepresentation or falsification of any information in this cost report may be punishable by fine and/or imprisonment. Date of Initial License for Current Owners: 09/15/91 (Signed) Officer or (Date) Type of Ownership: Administrator (Type or Print Name) SHERWIN I. RAY of Provider VOLUNTARY,NON-PROFIT X PROPRIETARY GOVERNMENTAL (Title) PRESIDENT Charitable Corp. Individual State Trust Partnership County (Signed) (SEE ATTACHED ACCOUNTANTS' REPORT) IRS Exemption Code Corporation Other (Date) X "Sub-S" Corp. Paid (Print Name BOB KAGDA Limited Liability Co. Preparer and Title) VICE PRESIDENT Trust Other (Firm Name KRUPNICK, BOKOR, KAGDA & BROOKS, LTD & Address) 3750 W DEVON, LINCOLNWOOD, IL (Telephone) ( 847 ) Fax #( 847 ) MAIL TO: BUREAU OF HEALTH FINANCE In the event there are further questions about this report, please contact: ILLINOIS DEPT OF HEALTHCARE AND FAMILY SERVICES Name:BOB KAGDA Telephone Number: ( 847 ) S. Grand Avenue East Address: Springfield, IL Phone # (217)

2 STATE OF ILLINOIS Page 2 III. STATISTICAL DATA D. How many bed-hold days during this year were paid by the Department? A. Licensure/certification level(s) of care; enter number of beds/bed days, 1,172 (Do not include bed-hold days in Section B.) (must agree with license). Date of change in licensed beds E. List all services provided by your facility for non-patients (E.g., day care, "meals on wheels", outpatient therapy) NONE Beds at Licensed Beginning of Licensure Beds at End of Bed Days During F. Does the facility maintain a daily midnight census? YES Report Period Level of Care Report Period Report Period G. Do pages 3 & 4 include expenses for services or 1 84 Skilled (SNF) 84 30,744 1 investments not directly related to patient care? 2 Skilled Pediatric (SNF/PED) 2 YES NO X 3 84 Intermediate (ICF) 84 30, Intermediate/DD 4 H. Does the BALANCE SHEET (page 17) reflect any non-care assets? 5 Sheltered Care (SC) 5 YES NO X 6 ICF/DD 16 or Less 6 I. On what date did you start providing long term care at this location? TOTALS ,488 7 Date started 09/15/91 J. Was the facility purchased or leased after January 1, 1978? B. Census-For the entire report period. YES X Date 09/15/91 NO Level of Care Patient Days by Level of Care and Primary Source of Payment K. Was the facility certified for Medicare during the reporting year? Medicaid YES X NO If YES, enter number Recipient Private Pay Other Total of beds certified 84 and days of care provided 1,290 8 SNF 1,290 1, SNF/PED 9 Medicare Intermediary ADMINASTAR 10 ICF 54, , ICF/DD 11 IV. ACCOUNTING BASIS 12 SC 12 MODIFIED 13 DD 16 OR LESS 13 ACCRUAL X CASH* CASH* 14 TOTALS 54, ,290 56, Is your fiscal year identical to your tax year? YES X NO C. Percent Occupancy. (Column 5, line 14 divided by total licensed Tax Year: 12/31/2008 Fiscal Year: 12/31/2008 bed days on line 7, column 4.) 91.10% * All facilities other than governmental must report on the accrual basis.

3 Facility Name & ID Number HILLCREST HEALTHCARE CENTER STATE OF ILLINOIS # Report Period Beginning: 01/01/2008 Ending: Page 3 12/31/2008 V. COST CENTER EXPENSES (throughout the report, please round to the nearest dollar) Costs Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR BHF USE ONLY Operating Expenses Salary/Wage Supplies Other Total ification Total ments Total A. General Services Dietary 191,666 19,106 11, , , , Food Purchase 235, ,584 (14,384) 221,200 (896) 220, Housekeeping 224,028 35, , , , Laundry 27,067 14,814 41,881 41,881 41, Heat and Other Utilities 157, , , , Maintenance 35,294 28,693 67, , ,227 18, , Other (specify):* SECURITY 75,343 20,124 95,467 95, , TOTAL General Services 553, , ,915 1,144,362 (14,384) 1,129,978 18,203 1,148,181 8 B. Health Care and Programs 9 Medical Director 21,600 21,600 21,600 21, Nursing and Medical Records 1,559,721 65,537 8,189 1,633,447 1,633,447 42,434 1,675, a Therapy 69,990 4,184 36, , ,478 6, ,460 10a 11 Activities 97,638 43,162 12, , , , Social Services 347, , , , CNA Training Program Transportation Other (specify):* TOTAL Health Care and Programs 2,075, ,883 78,210 2,266,278 2,266,278 49,416 2,315, C. General Administration 17 Administrative 108, , , ,849 (132,949) 245, Directors Fees Professional Services 314, , ,751 (238,896) 75, Dues, Fees, Subscriptions & Promotions 22,247 22,247 22,247 (10,423) 11, Clerical & General Office Expenses 53,154 19, , , ,374 (26,286) 232, Employee Benefits & Payroll Taxes 398, ,369 14, , , Inservice Training & Education 4,157 4,157 4,157 2,496 6, Travel and Seminar Other Admin. Staff Transportation 3,966 3,966 3,966 14,864 18, Insurance-Prop.Liab.Malpractice 83,948 83,948 83,948 2,867 86, Other (specify):* 64,743 64, TOTAL General Administration 162,003 19,053 1,283,763 1,464,819 14,384 1,479,203 (323,492) 1,155, TOTAL Operating Expense 29 (sum of lines 8, 16 & 28) 2,790, ,985 1,618,888 4,875,459 4,875,459 (255,873) 4,619, *Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000. NOTE: Include a separate schedule detailing the reclassifications made in column 5. Be sure to include a detailed explanation of each reclassification.

4 Facility Name & ID#: HILLCREST HEALTHCARE CENTER # Report Period Beginning: 01/01/2008 Ending: 12/31/2008 V.COST CENTER EXPENSES PAGE 3 COLUMN 3 OTHER LINE SCHED REF TOTAL LINE SCHED REF TOTAL 1 DIETARY 10 NURSING DIETITIAN CONSULTANT XVIII B ,248 CONTRACT NURSING XVIII C 53-2 REPAIRS & MAINTENANCE 2,322 LABORATORY & XRAY EXPENSE ,570 PURCHASED SERVICES 2,756 3 HOUSEKEEPING PSYCHO-SOCIAL CONSULTANT XVIII B RESTORATIVE NURSING CONSULTANTXVIII B MEDICAL RECORDS CONSULTANT XVIII B ,317 4 LAUNDRY PHARMACY CONSULTANT XVIII B ,016 EQUIPMENT REPAIRS & MAINTENANCE 0 UTILIZATION REVIEW FEES XVIII B PHYSICIANS XVIII B HEAT & OTHER UTILITIES PSYCHIATRIC XVIII B -2 0 GAS HEAT 21,672 RN CONSULTANT XVIII B ELECTRICITY 106,489 DENTAL SERVICES 2,100 WATER 29, ,189 CABLE TV - LOBBY 0 10a THERAPY 0 157,981 PHYSICAL THERAPY SERVICES MAINTENANCE SPEECH THERAPY SERVICES 0 GROUNDS MAINTENANCE 11,900 OCCUPATIONAL THERAPY SERVICES 0 PAINTING & DECORATING 838 REHABILITATION CONSULTANT XVIII B -2 0 BUILDING REPAIRS 4,840 PHYSICAL THERAPY CONSULTANT XVIII B ,400 MAINTENANCE TRAVEL 0 OCCUPATIONAL THERAPY CONSULTA XVIII B ,400 EQUIPMENT MAINTENANCE & REPAIR 21,552 RESPIRATORY THERAPY CONSULTANTXVIII B ELEVATOR MAINTENANCE & REPAIR 8,368 SPEECH THERAPY CONSULTANT XVIII B OUTSIDE LABOR 0 THERAPY CONTRACT SERVICES 25,069 EXTERMINATING SERVICE 5,279 FIRE SERVICE 14,463 36, ACTIVITIES 0 CABLE TV - PATIENT ROOMS 12,117 0 ACTIVITY REHAB CONSULTANT XVIII B , ,117 7 OTHER 12 SOCIAL SERVICES SCAVENGER 20,124 SOCIAL REHABILITATION SERVICES SECURITY SERVICE 0 SOCIAL REHABILITATION CONSULTANTXVIII B SOCIAL WORKER XVIII B , MEDICAL DIRECTOR 13 NURSE AIDE TRAINING MEDICAL DIRECTOR FEES XVIII B ,600 21,600 NURSE AIDE TRAINING COSTS XIII 0 0

5 Facility Name & ID Number HILLCREST HEALTHCARE CENTER # Report Period Beginning: 01/01/2008 Ending: 12/31/2008 V.COST CENTER EXPENSES PAGE 3 COLUMN 3 OTHER LINE SCHED REF TOTAL LINE SCHED REF TOTAL 14 PROGRAM TRANSPORTATION 22 EMPLOYEE BENEFITS & PAYROLL TAXES PATIENT TRANSPORTATION 0 0 FICA TAXES XIX D 210,655 UNEMPLOYMENT COMPENSATION XIX D 37, ADMINISTRATIVE 0 WORKERS COMPENSATION INSURANC XIX D 65,669 MANAGEMENT FEES XIX B 270, ,000 HOSPITALIZATION INSURANCE XIX D 47,623 DIRECTORS FEES EMPLOYEE BENEFITS - OTHER XIX D 36, DIRECTORS FEES 0 0 EMPLOYEE PHYSICAL EXAMS XIX D PROFESSIONAL SERVICES 0 INSURANCE - EXECUTIVE LIFE VI 21/XIX D 0 DATA PROCESSING XIX C 46,687 PENSION/PROFIT SHARING PLANS XIX D 0 ADMINISTRATIVE CONSULTANTS XIX C 228,000 CHICAGO HEAD TAX XIX D 0 PROFESSIONAL FEES XIX C 40, , , INSERVICE TRAINING & EDUCATION 20 FEES,SUBSCRIPTIONS,PROMOTIONS EDUCATION & SEMINARS 4,157 ENTERTAINMENT & MARKETING VI 19 XIX F 0 4,157 ADV & PROMO-NON PATIENT RELATED VI 25 XIX F 13, TRAVEL & SEMINARS EMPLOYEE WANT ADS XIX F 5,874 EDUCATION & SEMINARS XIX G 0 CONTRIBUTIONS VI 20 XIX F 0 TRAVEL XIX G 158 DUES & SUBSCRIPTIONS XIX F 240 LICENSES & PERMITS XIX F PUBLIC RELATIONS-PATIENT RELATED XIX F 0 25 ADMIN. STAFF TRANSPORTATION ADVERTISING-YELLOW PAGES VI 28 XIX F 1,038 TRANSPORTATION - STAFF 3,966 TRUST FEES / FRANCHISE TAX / ETC VI 17 XIX F 650 3,966 CONTRIBUTIONS - POLITICAL VI 20 XIX F 0 26 INSURANCE - PROP. LIAB & MALPRACTICE HEALTH CARE WORKER BACKGROUND CHEC XIX F 125 GENERAL INSURANCE 83,948 PATIENT BACKGROUND CHECKS XIX F 0 22,247 83, CLERICAL & GENERAL OFFICE EXPENSES 0 27 OTHER BANK CHARGES (INCLUDES NO OVERDRAFT CHARGES) 1,425 BAD DEBTS VI 24 0 EQUIPMENT REPAIR & MAINTENANCE 12,642 0 OUTSIDE CLERICAL SERVICES 132,000 PENALTIES / OVERDRAFT CHARGES VI 18 15,412 HOME OFFICE EXPENSE 0 THEFT & DAMAGE LOSS 0 GRAND TOTAL COLUMN 3 OTHER 1,618,888 TELEPHONE 22,814 MESSENGER SERVICE 1, ,167

6 HILLCREST HEALTHCARE CENTER SCHEDULES 12/31/2008 EMPLOYEE MEAL RECLASSIFICATION PROFESSIONAL FEES EDUCATION AND SEMINARS PAGE 3 SCHEDULE V COLUMN 5 LINES 2 AND 22 PAGE 21 SCHEDULE XIX PART C PAGE 3 LINE 23 COLUMN 3 OTHER TOTAL FOOD PURCHASE 235,584 CAREPLUS MGT DATA PROCESSING 31,272 LESS SALES TAX (896) ACHIEVE HEALTHCARE DATA PROCESSING 3,203 DATE SPONSOR OF SEMINAR SEMINAR PURPOSE EMPLOYEE LOC COST NET FOOD 234,688 AMERICAN DATA DATA PROCESSING 4,063 NATIONAL DATA CARE DATA PROCESSING 3,513 JAN IL COUNCIL ON LONG TERM CARE BE PREPARED FOR MDS MEDICAID AUDITS AMY WALKO IL 580 TOTAL PATIENT CENSUS 56,013 e-health DATA SOLUTIONS DATA PROCESSING 3,805 MAUREEN PRESTLEGAARD TIME 3 MEALS PER DAY 3 ADAPTASOFT DATA PROCESSING 403 BRUCE SIMONSON TOTAL PATIENT MEALS 168,039 EMDEON DATA PROCESSING 428 LYNN RINKE CAREPLUS MGT ADMINISTRATIVE CONSULTANT 228,000 MAR CROSS COUNTRY EDUCATION ETHICAL PITFALLS: AVOIDING PROFESSIONAL HAZARDS KRISTIN BELL IL 169 ADD # EMPLOYEE MEALS/DAY 30 KRUPNICK, BOKOR, KAGDA, LTD ACCOUNTING 27,700 MAR HEARTLAND TRAINING CENTER TRAIN THE TRAINERS CARRIE THERRIEN IL 400 TIME # DAYS 366 ABRAHAM A GUTNICKI ESQ LEGAL 677 APR CMI EDUCATION INSTITUTE OBESITY COMPULSIVE EATING AND BODY IMAGE CARRIE THERRIEN IL 149 TOTAL EMPLOYEE MEALS 10,980 MEYER MAGENCE LEGAL 5,378 MAY PATHWAY HEALTH SERVICES ACCIDENT PREVENTION PROGRAM TO MEET F323 GUIDELINES AMY WALKO IL 258 PERSONNEL PLANNER UC CONSULTANT 1,509 MAUREEN PRESTEGAARD PATIENT MEALS 168,039 RICHARD PEELO MEDICARE COST REPORT 4,800 MAY BARNES & NOBLE DIALECTICAL BEHAVIOR THERAPY SKILL WORKBOOK IL 18 ADD EMPLOYEE MEALS 10, MAY CMI EDUCATION INSTITUTE HOW THERAPISTS FAIL CARRIE THERRIEN IL 159 TOTAL MEALS/YEAR 179,019 TOTAL PROFESSIONAL FEES 314,751 JUN CLINICAL REIMBURSEMENT MEDICARE WORKSHOP JENNY SHAN-MARTIN IL 594 ======== JUN PATHWAY HEALTH SERVICES MARKETING 2008 A FOCUS ON CENSUS DEVELOPMENT & CENSUS RECOVERY AMY ZUMPF IL 129 NET FOOD 234,688 JUN CROSS COUNTRY EDUCATION THE NEXT STEP: USING COGNITIVE-BEHAVIORAL THERAPY TO IDENTIFY AND KRISTIN BELL IL 159 DIVIDE TOTAL MEALS/YEAR 179,019 CORRECT HIGHLY IRRATIONAL THOUGHTS JUN SAFE FOOD HANDLERS CORP 2008 ILLINOIS FOOD SERVICE SANITATION COURSE 2 EMPLOYEES IL 330 COST PER MEAL 1.31 AUG MEDS-PDN SKIN & WOUND CARE MANAGEMENT AMY WALKO IL 198 TIME EMPLOYEE MEALS 10,980 SEP IMHCA IL 120 EMPLOYEE MEAL RECLASSIFICATION 14,384 SEP CAREPLUS MANAGEMENT IL 215 ======== EQUIPMENT RENTAL EXPENSE SEP ILLINOIS COUNCIL ON LONG TERM CARE IL 380 PAGE 14 SCHEDULE XII PART B LINES 15 OCT PESI THE TEN BEST-EVER ANXIETY TREATMENT TECHNIQUES KRISTIN BELL IL 184 NOV HCPRO IL 116 STAFF TRANSPORTATION UNIVERSAL HOSPITAL NURSING EQUIPMENT PAGE 3 LINE 25 COLUMN 3 OTHER JOHNSON WATER CONDITION PLANT EQUIPMENT 300 TOTAL 4158 AIR CLEANING SPECIALISTS SMOKEETERS 780 ======= AMY WALKO 3,966 FAMILY PRIDE WASHER/DRYER 9, GE CAPITAL COPIER 7,525 TOTAL 3,966 STORAGE STORAGE 745 ======== GASOLINE FOR FACILITY BANKING, MAINTENANCE, TOTAL EQUIPMENT RENTAL EXPENSE 18,770 MARKETING AND ACTIVITIES ========

7 STATE OF ILLINOIS Page 4 Facility Name & ID Number HILLCREST HEALTHCARE CENTER # Report Period Beginning: 01/01/2008 Ending: 12/31/2008 # V. COST CENTER EXPENSES (continued) Cost Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR BHF USE ONLY Capital Expense Salary/Wage Supplies Other Total ification Total ments Total D. Ownership Depreciation 67,024 67,024 67, , , Amortization of Pre-Op. & Org Interest 14,467 14,467 14, , , Real Estate Taxes 71,379 71,379 71,379 9,365 80, Rent-Facility & Grounds 606, , ,229 (606,229) Rent-Equipment & Vehicles 24,947 24,947 24,947 10,356 35, Other (specify):* OFFICE RENT 24,000 24,000 24,000 (24,000) TOTAL Ownership 808, , ,046 59, , Ancillary Expense E. Special Cost Centers 38 Medically Necessary Transportation Ancillary Service Centers 62,533 65, , , , Barber and Beauty Shops Coffee and Gift Shops Provider Participation Fee 92,232 92,232 92,232 92, Other (specify):* TOTAL Special Cost Centers 62, , , , , GRAND TOTAL COST 45 (sum of lines 29, 37 & 44) 2,790, ,518 2,584,621 5,903,725 5,903,725 (196,487) 5,707, *Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000.

8 STATE OF ILLINOIS Page 5 VI. ADJUSTMENT DETAIL A. The expenses indicated below are non-allowable and should be adjusted out of Schedule V, pages 3 or 4 via column 7. In column 2 below, reference the line on which the particular cost was included. (See instructions.) 1 2 Refer- 3 BHF USE B. If there are expenses experienced by the facility which do not appear in the NON-ALLOWABLE EXPENSES Amount ence ONLY general ledger, they should be entered below.(see instructions.) 1 Day Care $ $ Other Care for Outpatients 2 Amount Reference 3 Governmental Sponsored Special Programs 3 31 Non-Paid Workers-Attach Schedule* $ 31 4 Non-Patient Meals 4 32 Donated Goods-Attach Schedule* 32 5 Telephone, TV & Radio in Resident Rooms 5 Amortization of Organization & 6 Rented Facility Space 6 33 Pre-Operating Expense 33 7 Sale of Supplies to Non-Patients 7 Adjustments for Related Organization 8 Laundry for Non-Patients 8 34 Costs (Schedule VII) (133,750) 34 9 Non-Straightline Depreciation (7,235) Other- Attach Schedule Interest and Other Investment Income (11,953) SUBTOTAL (B): (sum of lines 31-35) $ (133,750) Discounts, Allowances, Rebates & Refunds 11 (sum of SUBTOTALS 12 Non-Working Officer's or Owner's Salary TOTAL ADJUSTMENTS (A) and (B) ) $ (196,487) Sales Tax (896) Non-Care Related Interest (12,068) *These costs are only allowable if they are necessary to meet minimum 15 Non-Care Related Owner's Transactions 15 licensing standards. Attach a schedule detailing the items included 16 Personal Expenses (Including Transportation) 16 on these lines. 17 Non-Care Related Fees (650) Fines and Penalties (15,412) C. Are the following expenses included in Sections A to D of pages 3 19 Entertainment 19 and 4? If so, they should be reclassified into Section E. Please 20 Contributions 20 reference the line on which they appear before reclassification. 21 Owner or Key-Man Insurance 21 (See instructions.) Special Legal Fees & Legal Retainers 22 Yes No Amount Reference 23 Malpractice Insurance for Individuals Medically Necessary Transport. X $ Bad Debt Fund Raising, Advertising and Promotional (13,485) Gift and Coffee Shops X 40 Income Taxes and Illinois Personal 41 Barber and Beauty Shops X Property Replacement Tax Laboratory and Radiology X CNA Training for Non-Employees Prescription Drugs X Yellow Page Advertising (1,038) Other-Attach Schedule Other-Attach Schedule SUBTOTAL (A): (Sum of lines 1-29) $ (62,737) $ Other-Attach Schedule TOTAL (C): (sum of lines 38-46) $ BHF USE ONLY

9 STATE OF ILLINOIS Page 5A HILLCREST HEALTHCARE CENTER ID# Report Period Beginning: 01/01/2008 Ending: 12/31/2008 Sch. V Line NON-ALLOWABLE EXPENSES Amount Reference 1 $ Total 0 49

10 STATE OF ILLINOIS Summary A SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I SUMMARY Operating Expenses PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE TOTALS A. General Services 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7) 1 Dietary Food Purchase (896) (896) 2 3 Housekeeping Laundry Heat and Other Utilities Maintenance 0 18, , Other (specify):* TOTAL General Services (896) 19, ,203 8 B. Health Care and Programs 9 Medical Director Nursing and Medical Records 0 42, , a Therapy 0 6, ,982 10a 11 Activities Social Services CNA Training Program Transportation Other (specify):* TOTAL Health Care and Programs 0 49, , C. General Administration 17 Administrative 0 (132,949) (132,949) Directors Fees Professional Services 0 (238,896) (238,896) Fees, Subscriptions & Promotions (15,173) 4, (10,423) Clerical & General Office Expenses (15,412) (132,000) 121, (26,286) Employee Benefits & Payroll Taxes Inservice Training & Education 0 0 2, , Travel and Seminar Other Admin. Staff Transportation , , Insurance-Prop.Liab.Malpractice 0 0 2, , Other (specify):* , , TOTAL General Administration (30,585) (499,095) 206, (323,492) 28 TOTAL Operating Expense 29 (sum of lines 8,16 & 28) (31,481) (430,580) 206, (255,873) 29

11 STATE OF ILLINOIS Summary B SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I SUMMARY Capital Expense PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE TOTALS D. Ownership 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7) 30 Depreciation (7,235) 0 16, , , Amortization of Pre-Op. & Org Interest (24,021) 0 55, , , Real Estate Taxes 0 0 9, , Rent-Facility & Grounds (606,229) (606,229) Rent-Equipment & Vehicles , , Other (specify):* 0 (24,000) (24,000) TOTAL Ownership (31,256) (24,000) 91,653 22, , Ancillary Expense E. Special Cost Centers 38 Medically Necessary Transportation Ancillary Service Centers Barber and Beauty Shops Coffee and Gift Shops Provider Participation Fee Other (specify):* TOTAL Special Cost Centers GRAND TOTAL COST 45 (sum of lines 29, 37 & 44) (62,737) (454,580) 297,841 22, (196,487) 45

12 STATE OF ILLINOIS Page 6 VII. RELATED PARTIES A. Enter below the names of ALL owners and related organizations (parties) as defined in the instructions. Attach an additional schedule if necessary OWNERS RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES Name Ownership % Name City Name City Type of Business CAREPLUS MGMT SKOKIE MGMT/CLERICAL CAREPLUS REHABILITATIVE SERVICES SEE ATTACHED SCHEDULES SKOKIE THERAPY HILLCREST REALTY LLC SKOKIE REAL ESTATE B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent, management fees, purchase of supplies, and so forth. X YES NO If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance with the instructions for determining costs as specified for this form Cost Per General Ledger 4 5 Cost to Related Organization Difference: Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 1 V 17 MANAGEMENT FEES $ 270,000 CAREPLUS MGMT INC $ $ (270,000) 1 2 V 19 ADMIN. CONSULTANT FEES 228,000 " " (228,000) 2 3 V 19 DATA PROCESSING FEES 31,272 " " (31,272) 3 4 V 21 CLERICAL FEES 132,000 " " (132,000) 4 5 V 36 OFFICE RENT 24,000 " " (24,000) 5 6 V 5 UTILITIES " " V 6 MAINTENANCE " " 18,942 18, V 7 SECURITY " " V 10 NURSING " " 42,434 42, V 10a THERAPY " " 6,982 6, V 17 ADMIN " " 137, , V 19 PROFESSIONAL FEES " " 20,376 20, V 20 DUES/LICENSES/WANT ADS " " 4,750 4, Total $ 685,272 $ 230,692 $ * (454,580) 14 * Total must agree with the amount recorded on line 34 of Schedule VI.

13 STATE OF ILLINOIS Page 6A VII. RELATED PARTIES (continued) B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent, management fees, purchase of supplies, and so forth. X YES NO If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance with the instructions for determining costs as specified for this form Cost Per General Ledger 4 5 Cost to Related Organization Difference: Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 15 V 21 OFFICE $ CAREPLUS MGMT INC $ 121,126 $ 121, V 23 SEMINARS " " 2,496 2, V 24 IN-STATE TRAVEL/LODGING " " V 25 TRANSPORTATION " " 14,864 14, V 26 INSURANCE " " 2,867 2, V 27 EMPLOYEE BENEFITS " " 64,743 64, V 30 SL DEPRECIATION " " 11,126 11, V 32 INTEREST " " 54,696 54, V 33 REAL ESTATE TAX " " 9,365 9, V 35 EQUIPMENT RENT " " 10,356 10, V V V V V V V V V V V 30 SL DEPRECIATION CAREPLUS REHABILITATIVE SERVICES 4,967 4, V 32 INTEREST " " 1,143 1, V V Total $ $ 297,841 $ * 297, * Total must agree with the amount recorded on line 34 of Schedule VI.

14 STATE OF ILLINOIS Page 6B VII. RELATED PARTIES (continued) B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent, management fees, purchase of supplies, and so forth. X YES NO If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance with the instructions for determining costs as specified for this form Cost Per General Ledger 4 5 Cost to Related Organization Difference: Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 15 V 34 RENT $ 606,229 HILLCREST REALTY LLC $ $ (606,229) V 30 SL DEPRECIATION " " 169, , V 32 INTEREST " " 450, , V 32 AMORT LOAN COST " " 9,573 9, V " " V V V V V V V V V V V V V V V V V V V Total $ 606,229 $ 629,218 $ * 22, * Total must agree with the amount recorded on line 34 of Schedule VI.

15 STATE OF ILLINOIS Page 7 VII. RELATED PARTIES (continued) C. Statement of Compensation and Other Payments to Owners, Relatives and Members of Board of Directors. NOTE: ALL owners ( even those with less than 5% ownership) and their relatives who receive any type of compensation from this home must be listed on this schedule Average Hours Per Work Compensation Week Devoted to this Compensation Included Schedule V. Received Facility and % of Total in Costs for this Line & Ownership From Other Work Week Reporting Period** Column Name Title Function Interest Nursing Homes* Hours Percent Description Amount Reference 1 CAREPLUS MGMT ALLOCATIONS: $ 1 2 SHERWIN RAY PRESIDENT ADMIN/FINANCE SEE ATTACHED SALARY 29, JAKOB BAKST DIR OPERATIONS ADMIN/CONS. SCHEDULES " " 29, ROSLYN INDICH EXECUTIVE ASST A/P MGMT " " " " 9, TOTAL $ 67, * If the owner(s) of this facility or any other related parties listed above have received compensation from other nursing homes, attach a schedule detailing the name(s) of the home(s) as well as the amount paid. THIS AMOUNT MUST AGREE TO THE AMOUNTS CLAIMED ON THE THE OTHER NURSING HOMES' COST REPORTS. ** This must include all forms of compensation paid by related entities and allocated to Schedule V of this report (i.e., management fees). FAILURE TO PROPERLY COMPLETE THIS SCHEDULE INDICATING ALL FORMS OF COMPENSATION RECEIVED FROM THIS HOME, ALL OTHER NURSING HOMES AND MANAGEMENT COMPANIES MAY RESULT IN THE DISALLOWANCE OF SUCH COMPENSATION

16 STATE OF ILLINOIS Page 8 Facility Name & ID Number HILLCREST HEALTHCARE CENTER # Report Period Beginning: 01/01/2008 Ending: 2/31/2008 VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization CAREPLUS MANAGEMENT INC A. Are there any costs included in this report which were derived from allocations of central office Street Address 8320 SKOKIE BLVD or parent organization costs? (See instructions.) YES X NO City / State / Zip Code SKOKIE, IL Phone Number ( 847) B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( 847) Schedule V Unit of Allocation Number of Total Indirect Amount of Salary Line (i.e.,days, Direct Cost, Subunits Being Cost Being Cost Contained Facility Allocation Reference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col UTILITIES CENSUS DAYS 373, FACILITIES$ 739 $ 56,013 $ MAINTENANCE " " 373, FACILITIES 126,444 52,396 56,013 18, SECURITY " " 373, FACILITIES , NURSING " " 373, FACILITIES 283, ,260 56,013 42, a THERAPY " " 373, FACILITIES 46,604 46,472 56,013 6, ADMIN SALARIES " " 373, FACILITIES 914, ,862 56, , PROFESSIONAL FEES " " 373, FACILITIES 136,016 56,013 20, DUES/LICENSES/WANT ADS " " 373, FACILITIES 31,710 56,013 4, OFFICE EXPENSES " " 373, FACILITIES 808, ,409 56, , SEMINARS " " 373, FACILITIES 16,659 56,013 2, TRAVEL " " 373, FACILITIES , TRANSPORTATION " " 373, FACILITIES 99,225 56,013 14, INSURANCE " " 373, FACILITIES 19,140 56,013 2, EMPLOYEE BENEFITS " " 373, FACILITIES 432,184 56,013 64, SL DEPRECIATION " " 373, FACILITIES 74,261 56,013 11, INTEREST-TAG MTG/LOC/EQ LOAN " " 373, FACILITIES 365,115 56,013 54, REAL ESTATE TAX " " 373, FACILITIES 62,515 56,013 9, EQUIP RENT/AUTO LEASE " " 373, FACILITIES 69,127 56,013 10, TOTALS $ 3,487,339 $ 1,925,399 $ 522,423 25

17 STATE OF ILLINOIS Page 9 IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE A. Interest: (Complete details must be provided for each loan - attach a separate schedule if necessary.) Reporting Monthly Maturity Interest Period Name of Lender Related** Purpose of Loan Payment Date of Amount of Note Date Rate Interest YES NO Required Note Original Balance (4 Digits) Expense A. Directly Facility Related Long-Term 1 RELATED PARTY: HILLCREST REALTY LLC $ $ $ 1 2 LAKE FOREST BK X MORTGAGE $50, /07 6,400,000 6,111,385 02/22/ , LOAN COSTS X LOAN COSTS W/O OVER LOAN 02/07 47,863 29,914 02/22/12 9, FOX VALLEY FIRE X SPRINKLER SYSTEM LOAN $6, /08 78,809 53,234 09/ ,847 5 Working Capital 6 INSURANCE FINANCING X INSUR. FINANCE CAREPLUS MGMT ALLOCATION: TAG MTG INT/LOC/EQ LOAN 54, CAREPLUS REHAB ALLOCATION: EQUIP LOAN 1, TOTAL Facility Related $57, $ 6,526,672 $ 6,194,533 $ 518,269 9 B. Non-Facility Related* 10 IRS, IDR, ETC X LATE FEES 12, TOTAL Non-Facility Related $ $ $ 12, TOTALS (line 9+line14) $ 6,526,672 $ 6,194,533 $ 530, ) Please indicate the total amount of mortgage insurance expense and the location of this expense on Sch. V. $ N/A Line # 32-7 * Any interest expense reported in this section should be adjusted out on page 5, line 14 and, consequently, page 4, col. 7. (See instructions.) ** If there is ANY overlap in ownership between the facility and the lender, this must be indicated in column 2. (See instructions.)

18 STATE OF ILLINOIS Page 10 IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE (continued) B. Real Estate Taxes Important, please see the next worksheet, "RE_Tax". The real estate tax statement and 1. Real Estate Tax accrual used on 2007 report. bill must accompany the cost report. $ 72, Real Estate Taxes paid during the year: (Indicate the tax year to which this payment applies. If payment covers more than one year, detail below.) $ 71, Under or (over) accrual (line 2 minus line 1). $ (891) 3 4. Real Estate Tax accrual used for 2008 report. (Detail and explain your calculation of this accrual on the lines below.) $ 72, Direct costs of an appeal of tax assessments which has NOT been included in professional fees or other general operating costs on Schedule V, sections A, B or C. (Describe appeal cost below. Attach copies of invoices to support the cost and a copy of the appeal filed with the county.) $ 5 6. Subtract a refund of real estate taxes. You must offset the full amount of any direct appeal costs classified as a real estate tax cost plus one-half of any remaining refund. TOTAL REFUND $ For Tax Year. (Attach a copy of the real estate tax appeal board's decision.) $ 6 7. Real Estate Tax expense reported on Schedule V, line 33. This should be a combination of lines 3 thru 6. $ 71,379 7 Real Estate Tax History: Real Estate Tax Bill for Calendar Year: ,328 8 FOR BHF USE ONLY , , FROM R. E. TAX STATEMENT FOR 2007 $ , , PLUS APPEAL COST FROM LINE 5 $ 14 THE CURRENT YEAR REAL ESTATE TAX ACCRUAL IS BASED ON ~ 101% OF THE PRIOR YEAR REAL ESTATE TAX BILL 15 LESS REFUND FROM LINE 6 $ 15 THE PAYMENT ON LINE 2 APPLIES TO THE 2007 TAX BILL. 16 AMOUNT TO USE FOR RATE CALCULATION $ 16 NOTES: 1. Please indicate a negative number by use of brackets( ). Deduct any overaccrual of taxes from prior year. 2. If facility is a non-profit which pays real estate taxes, you must attach a denial of an application for real estate tax exemption unless the building is rented from a for-profit entity. This denial must be no more than four years old at the time the cost report is filed.

19 IMPORTANT NOTICE TO: Long Term Care Facilities with Real Estate Tax Rates RE: 2007 REAL ESTATE TAX COST DOCUMENTATION In order to set the real estate tax portion of the capital rate, it is necessary that we obtain additional information regarding your calendar 2007 real estate tax costs, as well as copies of your original real estate tax bills for calendar Please complete the Real Estate Tax Statement below and forward with a copy of your 2007 real estate tax bill to Healthcare and Family Services, Bureau of Health Finance, 201 South Grand Avenue East, Springfield, Illinois Please send these items in with your completed 2008 cost report. The cost report will not be considered complete and timely filed until this statement and the corresponding real estate tax bills are filed. If you have any questions, please call the Bureau of Health Finance at (217) LONG TERM CARE REAL ESTATE TAX STATEMENT FACILITY NAME HILLCREST HEALTHCARE CENTER COUNTY WILL FACILITY IDPH LICENSE NUMBER CONTACT PERSON REGARDING THIS REPORT BOB KAGDA TELEPHONE ( 847 ) FAX #: ( 847 ) A. Summary of Real Estate Tax Cost Enter the tax index number and real estate tax assessed for 2007 on the lines provided below. Enter only the portion of the cost that applies to the operation of the nursing home in Column D. Real estate tax applicable to any portion of the nursing home property which is vacant, rented to other organizations, or used for purposes other than long term care must not be entered in Column D. Do not include cost for any period other than calendar year (A) (B) (C) (D) Tax Applicable to Tax Index Number Property Description Total Tax Nursing Home NURSING HOME $ 71, $ 71, $ $ 3. $ $ 4. $ $ 5. $ $ 6. $ $ 7. $ $ 8. $ $ 9. $ $ 10. $ $ B. Real Estate Tax Cost Allocations TOTALS $ 71, $ 71, Does any portion of the tax bill apply to more than one nursing home, vacant property, or property which is not directly used for nursing home services? YES X NO If YES, attach an explanation & a schedule which shows the calculation of the cost allocated to the nursing home. (Generally the real estate tax cost must be allocated to the nursing home based upon sq. ft. of space used.) C. Tax Bills Attach a copy of the original 2007 tax bills which were listed in Section A to this statement. Be sure to use the 2007 tax bill which is normally paid during PLEASE NOTE: Payment information from the Internet or otherwise is not considered acceptable tax bill documentation. Facilities located in Cook County are required to provide copies of their original second installment tax bill. Page 10A

20 STATE OF ILLINOIS Page 11 X. BUILDING AND GENERAL INFORMATION: A. Square Feet: 23,039 B. General Construction Type: Exterior BRICK Frame STEEL Number of Stories 3 C. Does the Operating Entity? (a) Own the Facility X (b) Rent from a Related Organization. (c) Rent from Completely Unrelated Organization. (Facilities checking (a) or (b) must complete Schedule XI. Those checking (c) may complete Schedule XI or Schedule XII-A. See instructions.) D. Does the Operating Entity? X (a) Own the Equipment X (b) Rent equipment from a Related Organization. X (c) Rent equipment from Completely Unrelated Organization. (Facilities checking (a) or (b) must complete Schedule XI-C. Those checking (c) may complete Schedule XI-C or Schedule XII-B. See instructions.) E. List all other business entities owned by this operating entity or related to the operating entity that are located on or adjacent to this nursing home's grounds (such as, but not limited to, apartments, assisted living facilities, day training facilities, day care, independent living facilities, CNA training facilities, etc.) List entity name, type of business, square footage, and number of beds/units available (where applicable). N/A F. Does this cost report reflect any organization or pre-operating costs which are being amortized? YES X NO If so, please complete the following: 1. Total Amount Incurred: 2. Number of Years Over Which it is Being Amortized: 3. Current Period Amortization: 4. Dates Incurred: Nature of Costs: (Attach a complete schedule detailing the total amount of organization and pre-operating costs.) XI. OWNERSHIP COSTS: A. Land. Use Square Feet Year Acquired Cost 1 RELATED PARTY:HILLCREST REALTY LLC $ 1 2 NURSING HOME 132, , TOTALS 132,928 $ 336,000 3

21 STATE OF ILLINOIS Page 12 XI. OWNERSHIP COSTS (continued) B. Building Depreciation-Including Fixed Equipment. (See instructions.) Round all numbers to nearest dollar FOR BHF USE ONLY Year Year Current Book Life Straight Line Accumulated Beds* Acquired Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation 4 RELATED PARTY: HILLCREST REALTY LLC: $ $ $ $ $ ,288, , , , Improvement Type** 9 LEASEHOLD IMPROVEMENTS , , LEASEHOLD IMPROVEMENTS ,072 1, , , LEASEHOLD IMPROVEMENTS , , , LEASEHOLD IMPROVEMENTS , , ROOF REPAIR , , CONDENSING UNITS , , CEILING TILES , ROOF REPAIR , , DOORS , WINDOWS & ROOF VENTILATOR , , WINDOWS , , ROOF REPAIRS/DOORS/ELEC. REPAIRS/LOT LIGHTS , , WALLCOVER/RAILS/NURSE STNS/WINDOW TREATMENTS ,436 3, ,985 41, WINDOWS/DECORATING/CEILING TILE/ROOF REPAIR ,751 1, ,814 17, WINDOWS/FLOORING/DOOR , , CARPETING , , DOORS/ELEVATOR REPAIRS/SECURITY SYSTEM UPGRADE ,268 1, , , FENCE , , ROOF REPAIRS/CEILING TILE/FIRE DAMPERS/LIGHTING ,148 1, , , ROOF REPAIRS/HEAT/AC REPAIRS , (1) 2, FENCE , , DOOR REPLACEMENTS/DUCTWORK-FIRE CODE , (1) 1, DURO-LAST ROOF SYSTEM ,500 3, ,355 17, WALL A/C UNIT INSTALLATIONS / ELEVATOR BUTTONS ,265 2, ,418 12, FENCE / PARKING LOT SEAL , , EXTERIOR DOORS , BATHROOM REMODELING , SPRINKLERS/PIPING , *Total beds on this schedule must agree with page 2. **Improvement type must be detailed in order for the cost report to be considered complete. See Page 12A, Line 70 for total

22 STATE OF ILLINOIS Page 12A XI. OWNERSHIP COSTS (continued) B. Building Depreciation-Including Fixed Equipment. (See instructions.) Round all numbers to nearest dollar Year Current Book Life Straight Line Accumulated Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation 37 WALL UNIT A/C 2005 $ 7,074 $ $ 257 $ $ BATHROOMS/KITCHEN REMODELING ,970 1, ,890 6, FIRE ALARM SYSTEM ,833 2, ,248 8, DOORS , (1) WALL A/C UNITS / SMOKE ROOM EXHAUST / TILE ,088 1, , , WALL A/C /DOORS/LOCKERS/GUTTERS/ELECTRICAL ,233 1, ,645 2, CEDAR FENCE , DEMOLITION/FRAMING/INSULATION/DRYWALL/WALL TILE/FLOOR TILE/BASEBOARDS/PLUMBING/ELECTRICAL/TOILETS/SINKS/FIXTURES/CABINETS/CEILINGS/ WALL PREP/PAINTING/CARPETING ,414 4, ,341 4, ELEVATOR/DOORS/AC/DUCTWORK/SPRINKLER SYST ,390 3, ,104 3, BLACKTOP/SIDEWALK/PATIO/CONCRETE BENCHES , RELATED PARTY ALLOCATION - CAREPLUS REHAB WALL UNIT A/C'S,BRICKWORK,DRYWALL,ELECTRICAL , , CEILINGS/DRYWALL , FIRE DAMPERS/DUCTWORK , , RELATED PARTY ALLOCATION - CAREPLUS MGMT BUILDING-TAG-18 PROPERTIES ,244 2, ,343 7, BUILDING IMPROVEMENTS-TAG-18 PROPERTIES ,882 1, ,772 4, BUILDING IMPROVEMENTS-CAREPLUS MGMT TOTAL (lines 4 thru 69) $ 6,714,484 $ 179,171 $ 179,458 $ 287 $ 469, **Improvement type must be detailed in order for the cost report to be considered complete.

23 STATE OF ILLINOIS Page 13 XI. OWNERSHIP COSTS (continued) C. Equipment Depreciation-Excluding Transportation. (See instructions.) Category of 1 Current Book Straight Line 4 Component Accumulated Equipment Cost Depreciation 2 Depreciation 3 Adjustments Life 5 Depreciation 6 71 Purchased in Prior Years $ 227,140 $ 17,276 $ 18,101 $ YRS $ 133, Current Year Purchases 17,278 9, (8,888) 8-15 YRS Fully Depreciated Assets 44,376 44, **REL'D PARTY-SL DEPN:CAREPL MGT, 7,001 /CP REHAB, 3,775 /HILLCREST LLC, 33, TOTALS $ 244,418 $ 71,344 $ 63,281 $ (8,063) $ 133, D. Vehicle Depreciation (See instructions.)* 1 Model, Make Year 4 Current Book Straight Line 7 Life in Accumulated Use and Year 2 Acquired 3 Cost Depreciation 5 Depreciation 6 Adjustments Years 8 Depreciation 9 76 FACILITY VAN '02 DODGE RAM BR $ 9,319 $ 1,789 $ 2,330 $ YRS $ 5, TOTALS $ 9,319 $ 1,789 $ 2,330 $ 541 $ 5, E. Summary of Care-Related Assets 1 2 Reference Amount 81 Total Historical Cost (line 3, col.4 + line 70, col.4 + line 75, col.1 + line 80, col.4) + (Pages 12B thru 12I, if applicable) $ 7,304, Current Book Depreciation (line 70, col.5 + line 75, col.2 + line 80, col.5) + (Pages 12B thru 12I, if applicable) $ 252, Straight Line Depreciation (line 70, col.7 + line 75, col.3 + line 80, col.6) + (Pages 12B thru 12I, if applicable) $ 245, ** 84 Adjustments (line 70, col.8 + line 75, col.4 + line 80, col.7) + (Pages 12B thru 12I, if applicable) $ (7,235) Accumulated Depreciation (line 70, col.9 + line 75, col.6 + line 80, col.9) + (Pages 12B thru 12I, if applicable) $ 609, F. Depreciable Non-Care Assets Included in General Ledger. (See instructions.) G. Construction-in-Progress 1 2 Current Book Accumulated Description & Year Acquired Cost Depreciation 3 Depreciation 4 Description Cost 86 $ $ $ $ $ TOTALS $ $ $ 91 * Vehicles used to transport residents to & from day training must be recorded in XI-F, not XI-D. ** This must agree with Schedule V line 30, column 8.

24 STATE OF ILLINOIS Page 14 XII. RENTAL COSTS A. Building and Fixed Equipment (See instructions.) 1. Name of Party Holding Lease: N/A - RELATED PARTY 2. Does the facility also pay real estate taxes in addition to rental amount shown below on line 7, column 4? If NO, see instructions. YES NO Year Number Original Rental Total Years Total Years Constructed of Beds Lease Date Amount of Lease Renewal Option* Original 10. Effective dates of current rental agreement: 3 Building: $ 3 Beginning 4 Additions 4 Ending Rent to be paid in future years under the current 7 TOTAL $ ** 7 rental agreement: 8. List separately any amortization of lease expense included on page 4, line 34. Fiscal Year Ending Annual Rent This amount was calculated by dividing the total amount to be amortized by the length of the lease. 12. /2009 $ 13. /2010 $ 9. Option to Buy: YES NO Terms: * 14. /2011 $ B. Equipment-Excluding Transportation and Fixed Equipment. (See instructions.) 15. Is Movable equipment rental included in building rental? YES NO 16. Rental Amount for movable equipment: $ 18,770 Description: SEE SCHEDULE ATTACHED (Attach a schedule detailing the breakdown of movable equipment) C. Vehicle Rental (See instructions.) Model Year Monthly Lease Rental Expense Use and Make Payment for this Period * If there is an option to buy the building, 17 ACTIVITY/HSKP/ $ $ 6, please provide complete details on attached 18 MAINT/BANKING/ 18 schedule. 19 ADMIN/ETC ** This amount plus any amortization of lease 21 TOTAL $ $ 6, expense must agree with page 4, line 34.

25 STATE OF ILLINOIS Page 15 XIII. EXPENSES RELATING TO CERTIFIED NURSE AIDE (CNA) TRAINING PROGRAMS (See instructions.) A. TYPE OF TRAINING PROGRAM (If CNAs are trained in another facility program, attach a schedule listing the facility name, address and cost per CNA trained in that facility.) 1. HAVE YOU TRAINED CNAs YES 2. CLASSROOM PORTION: 3. CLINICAL PORTION: DURING THIS REPORT PERIOD? X NO IN-HOUSE PROGRAM IN-HOUSE PROGRAM IN OTHER FACILITY IN OTHER FACILITY If "yes", please complete the remainder of this schedule. If "no", provide an COMMUNITY COLLEGE HOURS PER CNA explanation as to why this training was not necessary. HOURS PER CNA THE FACILITY HIRES ONLY CERTIFIED NURSES AIDES B. EXPENSES C. CONTRACTUAL INCOME ALLOCATION OF COSTS (d) In the box below record the amount of income your facility received training CNAs from other facilities. Facility Drop-outs Completed Contract Total $ 1 Community College Tuition $ $ $ $ 2 Books and Supplies D. NUMBER OF CNAs TRAINED 3 Classroom Wages (a) 4 Clinical Wages (b) COMPLETED 5 In-House Trainer Wages (c) 1. From this facility 6 Transportation 2. From other facilities (f) 7 Contractual Payments DROP-OUTS 8 CNA Competency Tests 1. From this facility 9 TOTALS $ $ $ $ 2. From other facilities (f) 10 SUM OF line 9, col. 1 and 2 (e) $ TOTAL TRAINED (a) Include wages paid during the classroom portion of training. Do not include fringe benefits. (e) The total amount of Drop-out and Completed Costs for (b) Include wages paid during the clinical portion of training. Do not include fringe benefits. your own CNAs must agree with Sch. V, line 13, col. 8. (c) For in-house training programs only. Do not include fringe benefits. (f) Attach a schedule of the facility names and addresses (d) Allocate based on if the CNA is from your facility or is being contracted to be trained in of those facilities for which you trained CNAs. your facility. Drop-out costs can only be for costs incurred by your own CNAs.

26 STATE OF ILLINOIS Page 16 XIV. SPECIAL SERVICES (Direct Cost) (See instructions.) Schedule V Staff Outside Practitioner Supplies Service Line & Column Units of Cost (other than consultant) (Actual or) Total Units Total Cost Reference Service Units Cost Allocated) (Column 2 + 4) (Col ) 1 Licensed Occupational Therapist 39-3 hrs $ $ 9,695 $ $ 9,695 1 Licensed Speech and Language 2 Development Therapist 39-3 hrs Licensed Recreational Therapist hrs 3 4 Licensed Physical Therapist 39-3 hrs 55,640 55, Physician Care visits 5 6 Dental Care visits 6 7 Work Related Program hrs 7 8 Habilitation hrs 8 # of 9 Pharmacy 39-2 prescrpts 60,741 60,741 9 Psychological Services (Evaluation and Diagnosis/ 10 Behavior Modification) hrs Academic Education hrs Other (specify): 12 MED.SUPPLIES/LAB/RENTALS 13 Other (specify): ,792 1, TOTAL $ $ 65,455 $ 62,533 $ 127, NOTE: This schedule should include fees (other than consultant fees) paid to licensed practitioners. Consultant fees should be detailed on Schedule XVIII-B. Salaries of unlicensed practitioners, such as CNAs, who help with the above activities should not be listed on this schedule.

27 STATE OF ILLINOIS Page 17 XV. BALANCE SHEET - Unrestricted Operating Fund. As of 12/31/2008 (last day of reporting year) This report must be completed even if financial statements are attached. 1 2 After 1 2 After Operating Consolidation* Operating Consolidation* A. Current Assets C. Current Liabilities 1 Cash on Hand and in Banks $ 498 $ 1 26 Accounts Payable $ 803,131 $ 26 2 Cash-Patient Deposits 2 27 Officer's Accounts Payable 27 Accounts & Short-Term Notes Receivable- 28 Accounts Payable-Patient Deposits Patients (less allowance 110,000 ) 3,382, Short-Term Notes Payable 53, Supply Inventory (priced at ) 4 30 Accrued Salaries Payable 207, Short-Term Investments 408,441 5 Accrued Taxes Payable 6 Prepaid Insurance 87, (excluding real estate taxes) 17, Other Prepaid Expenses 2, Accrued Real Estate Taxes(Sch.IX-B) 72, Accounts Receivable (owners or related parties) 25, Accrued Interest Payable 33 9 Other(specify): R.E.TAX ESCROW 32, Deferred Compensation 34 TOTAL Current Assets 35 Federal and State Income Taxes (sum of lines 1 thru 9) $ 3,939,402 $ 10 Other Current Liabilities(specify): B. Long-Term Assets Long-Term Notes Receivable Long-Term Investments 12 TOTAL Current Liabilities 13 Land (sum of lines 26 thru 37) $ 1,153,613 $ Buildings, at Historical Cost 14 D. Long-Term Liabilities 15 Leasehold Improvements, at Historical Cost 1,298, Long-Term Notes Payable 290, Equipment, at Historical Cost 253, Mortgage Payable Accumulated Depreciation (book methods) (449,565) Bonds Payable Deferred Charges Deferred Compensation Organization & Pre-Operating Costs 19 Other Long-Term Liabilities(specify): Accumulated Amortization - 43 DUE TO LLC 424, Organization & Pre-Operating Costs Restricted Funds 21 TOTAL Long-Term Liabilities 22 Other Long-Term Assets (specify): (sum of lines 39 thru 44) $ 714,710 $ Other(specify): SECURITY DEPOSITS 17, TOTAL LIABILITIES TOTAL Long-Term Assets 46 (sum of lines 38 and 45) $ 1,868,323 $ (sum of lines 11 thru 23) $ 1,120,231 $ TOTAL EQUITY(page 18, line 24) $ 3,191,310 $ 47 TOTAL ASSETS TOTAL LIABILITIES AND EQUITY 25 (sum of lines 10 and 24) $ 5,059,633 $ (sum of lines 46 and 47) $ 5,059,633 $ 48 *(See instructions.)