REPORT ON THE HOME OFFICE AUDIT EVERGREEN HEALTHCARE MANAGEMENT, LLC VANCOUVER, WASHINGTON FISCAL PERIOD ENDED DECEMBER 31, 2011
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1 REPORT ON THE HOME OFFICE AUDIT VANCOUVER, WASHINGTON FISCAL PERIOD ENDED DECEMBER 31, 211 Audits Section Sacramento Financial Audits Branch Audits and Investigations Department of Health Care Services Section Chief: Robert G. Kvick Audit Supervisor: Gary Diffenderffer Auditor: Jennifer A. White
2 State of California Health and Human Services Agency Department of Health Care Services TOBY DOUGLAS DIRECTOR EDMUND G. BROWN JR. GOVERNOR July 3, 213 Terri L. Roche Reimbursement Manager Evergreen Healthcare Management, LLC 461 NE 77 th Avenue, Suite 3 Vancouver, WA FISCAL PERIOD ENDED DECEMBER 31, 211 We have examined the Medi-Cal Home Office Cost Report for the fiscal period ended December 31, 211. Our examination was made under the authority of Section 1417 of the Welfare and Institutions Code and, accordingly, included such tests of the accounting records and such other auditing procedures as we considered necessary in the circumstances. In our opinion, the data presented in the Summary of Audited Home Office Costs to Health Care Facilities represents a proper determination of home office allowable costs for the above fiscal period in accordance with Medi-Cal reimbursement principles. The audited home office cost will be incorporated, by separate adjustment, into each applicable facility audit report. This audit report includes the: 1. Summary of Audited Home Office Costs to Health Care Facilities and Supporting Schedules 2. Audit Adjustments Schedule If you disagree with the decision of the Department, the results of the home office audit may only be appealed through each individual facili ty's audit report. Please refer to the appeal instructions in each facility s audit report. Financi al Audits Branch/Audits Section Sacramento MS 216, P.O. Box , Sacramento, CA (916) / (916) fax Internet Address:
3 Terri Roche Page 2 If you have questions regarding this report, you may call the Audits Section Sacramento at (916) Original Signed By Robert G. Kvick, Chief Audits Section Sacramento Financial Audits Branch Certified
4 TABLE OF CONTENTS SCHEDULES 1 - SUMMARY OF AUDITED HOME OFFICE CAPITAL AND NONCAPITAL RELATED COSTS TO CHAIN COMPONENTS 2 - COMPARISON OF REPORTED AND AUDITED HOME OFFICE COSTS 3 - SUMMARY ALLOCATION OF HOME OFFICE COSTS - CAPITAL RELATED SUMMARY ALLOCATION OF HOME OFFICE COSTS - NONCAPITAL RELATED 4 - POOLED ALLOCATION OF HOME OFFICE COSTS TO CHAIN COMPONENTS 5 - FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - CAPITAL RELATED FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED 6 - FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - CAPITAL RELATED FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED 7 - DIRECT ALLOCATION OF CAPITAL COSTS TO CHAIN COMPONENTS DIRECT ALLOCATION OF NONCAPITAL COSTS TO CHAIN COMPONENTS 8 - TRIAL BALANCE OF EXPENSES 9 - REPORTED HOME OFFICE COSTS
5 STATE OF CALIFORNIA SCHEDULE 1 SUMMARY OF AUDITED HOME OFFICE CAPITAL AND NONCAPITAL RELATED COSTS TO CHAIN COMPONENTS DECEMBER 31, 211 FISCAL PERIODS ENDING DURING HOME OFFICE FISCAL YEAR FROM TO CAPITAL RELATED (SCHEDULE 3) 1 NONCAPITAL RELATED (SCHEDULE 3-1) 2 TOTAL AUDITED H.O. COSTS (COLUMN 1 + 2) EVERGREEN ARVIN HEALTHCARE /1/11 12/31/11 $26,328 $295,132 $321, EVERGREEN BAKERSFIELD POST ACUTE CARE /1/11 12/31/11 38,83 432, , TWIN OAKS POST ACUTE REHAB /1/11 12/31/11 62,9 7, , FULLERTON POST ACUTE CARE /1/11 12/31/11 55,32 66, , EVERGREEN LAKEPORT HEALTHCARE /1/11 12/31/11 27, , , OLIVE RIDGE POST ACUTE CARE /1/11 12/31/11 49, ,798 62, PETALUMA HEALTH AND REHABILITATION /1/11 12/31/11 39, , , KATHERINE HEALTHCARE /1/11 12/31/11 21,135 24,69 261, NEW HOPE POST ACUTE CARE /1/11 12/31/11 53, , , HEARTWOOD AVENUE HEALTHCARE /1/11 12/31/11 19, , , SPRINGS ROAD HEALTHCARE /1/11 12/31/11 25,43 312, , ALL OTHER HEALTHCARE FACILITIES N/A 1/1/11 12/31/11 744,896 8,594,243 9,339,139 SUBTOTAL (LINES 1 THROUGH 2) $1,164,198 $13,318,55 $14,482,73 19 OREGON RETIREMENT CENTER N/A 1/1/11 12/31/11 $4,115 $42,481 $46, CONIFER HOUSE N/A 1/1/11 12/31/11 5,363 55,384 6, SANDPOINT ASSISTED LIVING N/A 1/1/11 12/31/11 6,35 62,385 68, PARKWAY THERAPIES N/A 1/1/11 12/31/ SUBTOTAL (LINES 21 THROUGH 35) $15,513 $16,25 $175,763 GRAND TOTAL $1,179,711 $13,478,755 $14,658,466
6 STATE OF CALIFORNIA SCHEDULE 2 COMPARISON OF REPORTED AND AUDITED HOME OFFICE COSTS DECEMBER 31, 211 FISCAL PERIODS ENDING DURING HOME OFFICE FISCAL YEAR FROM TO REPORTED HOME OFFICE COSTS (SCH. 9) 1 AUDITED H.O. COSTS (SCH. 3 & 3-1) 2 VARIANCE (COLUMN 2-1) EVERGREEN ARVIN HEALTHCARE /1/11 12/31/11 $323,19 $321,46 ($1,559) EVERGREEN BAKERSFIELD POST ACUTE CARE /1/11 12/31/11 473, ,552 (2,32) TWIN OAKS POST ACUTE REHAB /1/11 12/31/11 766, ,724 (3,728) FULLERTON POST ACUTE CARE /1/11 12/31/11 665, ,238 (3,286) EVERGREEN LAKEPORT HEALTHCARE /1/11 12/31/11 34,97 339,323 (1,647) 16.2 OLIVE RIDGE POST ACUTE CARE /1/11 12/31/11 65,651 62,691 (2,96) PETALUMA HEALTH AND REHABILITATION /1/11 12/31/11 49,95 488,526 (2,379) KATHERINE HEALTHCARE /1/11 12/31/11 263,2 261,743 (1,259) NEW HOPE POST ACUTE CARE /1/11 12/31/11 651, ,163 (3,164) HEARTWOOD AVENUE HEALTHCARE /1/11 12/31/11 248,6 246,856 (1,15) SPRINGS ROAD HEALTHCARE /1/11 12/31/11 339, ,286 (1,512) 17 ALL OTHER HEALTHCARE FACILITIES N/A 1/1/11 12/31/11 9,355,825 9,339,139 (16,686) SUBTOTAL (LINES 1 THROUGH 2) $14,524,333 $14,482,73 ($41,63) 19 OREGON RETIREMENT CENTER N/A 1/1/11 12/31/11 $46,841 $46,596 ($245) 2. CONIFER HOUSE N/A 1/1/11 12/31/11 61,66 6,747 (319) 21. SANDPOINT ASSISTED LIVING N/A 1/1/11 12/31/11 68,78 68,421 (36) 22. PARKWAY THERAPIES N/A 1/1/11 12/31/ SUBTOTAL (LINES 21 THROUGH 35) $176,687 $175,763 ($924) GRAND TOTAL $14,71,2 $14,658,466 ($42,554)
7 STATE OF CALIFORNIA SCHEDULE 3 SUMMARY ALLOCATION OF HOME OFFICE COSTS - CAPITAL RELATED DECEMBER 31, 211 FISCAL PERIODS ENDING DURING HOME OFFICE FISCAL YEAR FROM TO DIRECT FUNCTIONAL POOLED CAPITAL COSTS CAPITAL COSTSCAPITAL COSTS (SCHEDULE 7) 1 (SCHEDULE 5) 2 (SCHEDULE 4) 3 TOTAL CAPITAL COSTS (COL. 1 TO 3) EVERGREEN ARVIN HEALTHCARE /1/11 12/31/11 $ $ $26,328 $26, EVERGREEN BAKERSFIELD POST ACUTE CARE /1/11 12/31/11 38,83 38, TWIN OAKS POST ACUTE REHAB /1/11 12/31/11 62,9 62, FULLERTON POST ACUTE CARE /1/11 12/31/11 55,32 55, EVERGREEN LAKEPORT HEALTHCARE /1/11 12/31/11 27,682 27, OLIVE RIDGE POST ACUTE CARE /1/11 12/31/11 49,893 49, PETALUMA HEALTH AND REHABILITATION /1/11 12/31/11 39,948 39, KATHERINE HEALTHCARE /1/11 12/31/11 21,135 21, NEW HOPE POST ACUTE CARE /1/11 12/31/11 53,249 53, HEARTWOOD AVENUE HEALTHCARE /1/11 12/31/11 19,443 19, SPRINGS ROAD HEALTHCARE /1/11 12/31/11 25,43 25,43 17 ALL OTHER HEALTHCARE FACILITIES N/A 1/1/11 12/31/11 744, ,896 SUBTOTAL (LINES 1 THROUGH 2) $ $ $1,164,198 $1,164, OREGON RETIREMENT CENTER N/A 1/1/11 12/31/11 $ $ $4,115 $4, CONIFER HOUSE N/A 1/1/11 12/31/11 5,363 5, SANDPOINT ASSISTED LIVING N/A 1/1/11 12/31/11 6,35 6, PARKWAY THERAPIES N/A 1/1/11 12/31/ SUBTOTAL (LINES 21 THROUGH 35) $ $ $15,513 $15,513 GRAND TOTAL $ $ $1,179,711 $1,179,711 (To Schedule 1 & 2)
8 STATE OF CALIFORNIA SCHEDULE 3-1 SUMMARY ALLOCATION OF HOME OFFICE COSTS - NONCAPITAL RELATED DECEMBER 31, 211 FISCAL PERIODS ENDING DURING HOME OFFICE FISCAL YEAR FROM TO DIRECT COSTS (SCH. 7-1) 1 FUNCTIONAL COSTS (SCH. 5-1) 2 POOLED COSTS (SCH. 4) 3 TOTAL NONCAPITAL COSTS (COL. 1 TO 3) EVERGREEN ARVIN HEALTHCARE /1/11 12/31/11 $ $23,32 $271,812 $295, EVERGREEN BAKERSFIELD POST ACUTE CARE /1/11 12/31/11 31,834 4, , TWIN OAKS POST ACUTE REHAB /1/11 12/31/11 59, ,24 7, FULLERTON POST ACUTE CARE /1/11 12/31/11 35,989 57,947 66, EVERGREEN LAKEPORT HEALTHCARE /1/11 12/31/11 25, , , OLIVE RIDGE POST ACUTE CARE /1/11 12/31/11 37, ,19 552, PETALUMA HEALTH AND REHABILITATION /1/11 12/31/11 36, , , KATHERINE HEALTHCARE /1/11 12/31/11 22, ,197 24, NEW HOPE POST ACUTE CARE /1/11 12/31/11 45, , , HEARTWOOD AVENUE HEALTHCARE /1/11 12/31/11 26,684 2,73 227, SPRINGS ROAD HEALTHCARE /1/11 12/31/11 5, , , ALL OTHER HEALTHCARE FACILITIES N/A 1/1/11 12/31/11 27, ,22 7,69,437 8,594,243 SUBTOTAL (LINES 1 THROUGH 2) $27,586 $1,271,528 $12,19,391 $13,318,55 19 OREGON RETIREMENT CENTER N/A 1/1/11 12/31/11 $ $ $42,481 $42, CONIFER HOUSE N/A 1/1/11 12/31/ ,369 55, SANDPOINT ASSISTED LIVING N/A 1/1/11 12/31/ ,39 62, PARKWAY THERAPIES N/A 1/1/11 12/31/ SUBTOTAL (LINES 21 THROUGH 35) $ $91 $16,159 $16,25 GRAND TOTAL $27,586 $1,271,619 $12,179,55 $13,478,755 (To Schedule 1 & 2)
9 STATE OF CALIFORNIA SCHEDULE 4 POOLED ALLOCATION OF HOME OFFICE COSTS TO CHAIN COMPONENTS DECEMBER 31, 211 TOTAL COST (SCH. G, COL. 1) 1 CAPITAL (SCH. 8) 2 NONCAPITAL (SCH. 8) 3 TOTAL POOLED (COL ) EVERGREEN ARVIN HEALTHCARE $5,591,468 $26,328 $271,812 $298, EVERGREEN BAKERSFIELD POST ACUTE CARE ,246,78 38,83 4, , TWIN OAKS POST ACUTE REHAB ,186,557 62,9 641,24 73, FULLERTON POST ACUTE CARE ,745,4 55,32 57, , EVERGREEN LAKEPORT HEALTHCARE ,879,128 27, , , OLIVE RIDGE POST ACUTE CARE ,596,35 49, ,19 565, PETALUMA HEALTH AND REHABILITATION ,484,113 39, , , KATHERINE HEALTHCARE ,488,54 21, , , NEW HOPE POST ACUTE CARE ,39,93 53, ,757 63, HEARTWOOD AVENUE HEALTHCARE ,129,227 19,443 2,73 22, SPRINGS ROAD HEALTHCARE ,395,81 25,43 262, , ALL OTHER HEALTHCARE FACILITIES N/A 158,2, ,896 7,69,437 8,435,333 SUBTOTAL (LINES 1 THROUGH 2) $247,251,915 $1,164,198 $12,19,391 $13,183, OREGON RETIREMENT CENTER N/A $873,883 $4,115 $42,481 $46, CONIFER HOUSE N/A 1,139,2 5,363 55,369 6, SANDPOINT ASSISTED LIVING N/A 1,281,768 6,35 62,39 68, PARKWAY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) $3,294,653 $15,513 $16,159 $175,672 GRAND TOTAL $25,546,568 $1,179,711 $12,179,55 $13,359,261 (To Schedule 3) (To Schedule 3-1) MULTIPLIER
10 STATE OF CALIFORNIA SCHEDULE 5 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - CAPITAL RELATED DECEMBER 31, 211 Old Cap. Related- Buildings & 1. Old Cap. Related- Movable New Cap. Related- Buildings & EVERGREEN ARVIN HEALTHCARE $ $ $ $ $ $ EVERGREEN BAKERSFIELD POST ACUTE CARE TWIN OAKS POST ACUTE REHAB FULLERTON POST ACUTE CARE EVERGREEN LAKEPORT HEALTHCARE OLIVE RIDGE POST ACUTE CARE PETALUMA HEALTH AND REHABILITATION KATHERINE HEALTHCARE NEW HOPE POST ACUTE CARE HEARTWOOD AVENUE HEALTHCARE SPRINGS ROAD HEALTHCARE ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ 19 OREGON RETIREMENT CENTER N/A $ $ $ $ $ $ 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $
11 STATE OF CALIFORNIA SCHEDULE 5 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - CAPITAL RELATED DECEMBER 31, 211 New Cap. Related- Movable 5. Insurance Premiums Taxes and Licenses - Not INCM 8. Other 9. AUDITED TOTAL CAPITAL EVERGREEN ARVIN HEALTHCARE $ $ $ $ $ $ EVERGREEN BAKERSFIELD POST ACUTE CARE TWIN OAKS POST ACUTE REHAB FULLERTON POST ACUTE CARE EVERGREEN LAKEPORT HEALTHCARE OLIVE RIDGE POST ACUTE CARE PETALUMA HEALTH AND REHABILITATION KATHERINE HEALTHCARE NEW HOPE POST ACUTE CARE HEARTWOOD AVENUE HEALTHCARE SPRINGS ROAD HEALTHCARE ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ 19 OREGON RETIREMENT CENTER N/A $ $ $ $ $ $ 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ (To Schedule 3)
12 STATE OF CALIFORNIA SCHEDULE 5-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED DECEMBER 31, 211 Salaries of Officers 11 Salaries & Wages of Others 12 Payroll Taxes 13 Employee Benefits-Payroll Related 14 Employee Benefits- Nonpayroll 15 Profit Sharing/Pensio n Plans 16 Legal Fees EVERGREEN ARVIN HEALTHCARE $ $ $ $ $ $ $ EVERGREEN BAKERSFIELD POST ACUTE CARE TWIN OAKS POST ACUTE REHAB FULLERTON POST ACUTE CARE EVERGREEN LAKEPORT HEALTHCARE OLIVE RIDGE POST ACUTE CARE PETALUMA HEALTH AND REHABILITATION KATHERINE HEALTHCARE NEW HOPE POST ACUTE CARE HEARTWOOD AVENUE HEALTHCARE SPRINGS ROAD HEALTHCARE ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ $ 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ $
13 STATE OF CALIFORNIA SCHEDULE 5-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED DECEMBER 31, 211 Auditing & Accounting Fees 18 Utilities 19 Communication s 2 Travel & Entertainment 21 Transportation 22 Cleaning Office & Admin Supplies 23 Minor Equipment Expensed EVERGREEN ARVIN HEALTHCARE $ $ $ $ $ $ $ EVERGREEN BAKERSFIELD POST ACUTE CARE TWIN OAKS POST ACUTE REHAB FULLERTON POST ACUTE CARE EVERGREEN LAKEPORT HEALTHCARE OLIVE RIDGE POST ACUTE CARE PETALUMA HEALTH AND REHABILITATION KATHERINE HEALTHCARE NEW HOPE POST ACUTE CARE HEARTWOOD AVENUE HEALTHCARE SPRINGS ROAD HEALTHCARE ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ $ 19 OREGON RETIREMENT CENTER N/A $ $ $ $ $ $ $ 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ $
14 STATE OF CALIFORNIA SCHEDULE 5-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED DECEMBER 31, 211 Repairs & Maintenance 25 Dues & Subscriptions 26 Contributions 27 Insurance Premium-Non Capital Related 28 Taxes & Licenses - Non Capital Related 29 Interest Expense 3 Purchased Services EVERGREEN ARVIN HEALTHCARE $ $ $ $ $ $ $ EVERGREEN BAKERSFIELD POST ACUTE CARE TWIN OAKS POST ACUTE REHAB FULLERTON POST ACUTE CARE EVERGREEN LAKEPORT HEALTHCARE OLIVE RIDGE POST ACUTE CARE PETALUMA HEALTH AND REHABILITATION KATHERINE HEALTHCARE NEW HOPE POST ACUTE CARE HEARTWOOD AVENUE HEALTHCARE SPRINGS ROAD HEALTHCARE ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ $ 19 OREGON RETIREMENT CENTER N/A $ $ $ $ $ $ $ 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ $
15 STATE OF CALIFORNIA SCHEDULE 5-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED DECEMBER 31, 211 Education Training Lease Exp 32 Lease Acq & Amort Loan Fees 33 Marketing & Public Relations 34 Fines, Penalties, Late Fees 35 Regional Therapy Managers 35.1 Health Medx MIS 35.2 Dietary Consultant EVERGREEN ARVIN HEALTHCARE $ $ $ $ $6,494 $7,893 $ EVERGREEN BAKERSFIELD POST ACUTE CARE ,8 7, TWIN OAKS POST ACUTE REHAB ,946 19, FULLERTON POST ACUTE CARE ,163 7, EVERGREEN LAKEPORT HEALTHCARE ,19 7, OLIVE RIDGE POST ACUTE CARE ,863 7, PETALUMA HEALTH AND REHABILITATION ,323 7, KATHERINE HEALTHCARE ,532 3, NEW HOPE POST ACUTE CARE ,331 7, HEARTWOOD AVENUE HEALTHCARE ,858 7, SPRINGS ROAD HEALTHCARE ,6 27, ALL OTHER HEALTHCARE FACILITIES N/A 338, ,14 42,987 SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $521,328 $327,549 $42, OREGON RETIREMENT CENTER N/A $ $ $ $ $ $ $ 2. CONIFER HOUSE N/A SANDPOINT ASSISTED LIVING N/A PARKWAY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $91 GRAND TOTAL $ $ $ $ $521,328 $327,549 $43,78
16 STATE OF CALIFORNIA SCHEDULE 5-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED DECEMBER 31, 211 Nursing Consultant AUDITED TOTAL NONCAPITAL EVERGREEN ARVIN HEALTHCARE $8,933 $ $ $ $ $23, EVERGREEN BAKERSFIELD POST ACUTE CARE ,933 31, TWIN OAKS POST ACUTE REHAB ,933 59, FULLERTON POST ACUTE CARE ,933 35, EVERGREEN LAKEPORT HEALTHCARE ,933 25, OLIVE RIDGE POST ACUTE CARE ,933 37, PETALUMA HEALTH AND REHABILITATION ,933 36, KATHERINE HEALTHCARE ,933 22, NEW HOPE POST ACUTE CARE ,933 45, HEARTWOOD AVENUE HEALTHCARE ,933 26, SPRINGS ROAD HEALTHCARE ,933 5, ALL OTHER HEALTHCARE FACILITIES N/A 281, ,22 SUBTOTAL (LINES 1 THROUGH 2) $379,664 $ $ $ $ $1,271, OREGON RETIREMENT CENTER N/A $ $ $ $ $ $ 2. CONIFER HOUSE N/A SANDPOINT ASSISTED LIVING N/A PARKWAY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $91 GRAND TOTAL $379,664 $ $ $ $ $1,271,619
17 STATE OF CALIFORNIA SCHEDULE 6 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - CAPITAL RELATED DECEMBER 31, 211 Old Cap. Related Old Cap. Related New Cap. Related (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) EVERGREEN ARVIN HEALTHCARE EVERGREEN BAKERSFIELD POST ACUTE CARE TWIN OAKS POST ACUTE REHAB FULLERTON POST ACUTE CARE EVERGREEN LAKEPORT HEALTHCARE OLIVE RIDGE POST ACUTE CARE PETALUMA HEALTH AND REHABILITATION KATHERINE HEALTHCARE NEW HOPE POST ACUTE CARE HEARTWOOD AVENUE HEALTHCARE SPRINGS ROAD HEALTHCARE ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ $ UNIT COST MULTIPLIER......
18 STATE OF CALIFORNIA SCHEDULE 6 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - CAPITAL RELATED DECEMBER 31, 211 New Cap. Insurance Taxes and Other Related- Premiums Licenses - Not (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) EVERGREEN ARVIN HEALTHCARE EVERGREEN BAKERSFIELD POST ACUTE CARE TWIN OAKS POST ACUTE REHAB FULLERTON POST ACUTE CARE EVERGREEN LAKEPORT HEALTHCARE OLIVE RIDGE POST ACUTE CARE PETALUMA HEALTH AND REHABILITATION KATHERINE HEALTHCARE NEW HOPE POST ACUTE CARE HEARTWOOD AVENUE HEALTHCARE SPRINGS ROAD HEALTHCARE ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ UNIT COST MULTIPLIER.....
19 STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, 211 Salaries of Officers Salaries & Wages of Payroll Taxes Employee Benefits-Payroll Employee Benefits- Profit Sharing/Pensio (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) EVERGREEN ARVIN HEALTHCARE EVERGREEN BAKERSFIELD POST ACUTE CARE TWIN OAKS POST ACUTE REHAB FULLERTON POST ACUTE CARE EVERGREEN LAKEPORT HEALTHCARE OLIVE RIDGE POST ACUTE CARE PETALUMA HEALTH AND REHABILITATION KATHERINE HEALTHCARE NEW HOPE POST ACUTE CARE HEARTWOOD AVENUE HEALTHCARE SPRINGS ROAD HEALTHCARE ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ $ UNIT COST MULTIPLIER......
20 STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, 211 Legal Fees Auditing & Utilities Communication Travel & Transportation 17. Accounting s 2. Entertainment (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) EVERGREEN ARVIN HEALTHCARE EVERGREEN BAKERSFIELD POST ACUTE CARE TWIN OAKS POST ACUTE REHAB FULLERTON POST ACUTE CARE EVERGREEN LAKEPORT HEALTHCARE OLIVE RIDGE POST ACUTE CARE PETALUMA HEALTH AND REHABILITATION KATHERINE HEALTHCARE NEW HOPE POST ACUTE CARE HEARTWOOD AVENUE HEALTHCARE SPRINGS ROAD HEALTHCARE ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ $ UNIT COST MULTIPLIER......
21 STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, 211 Cleaning Office & Admin Minor Equipment Repairs & Maintenance Dues & Subscriptions Contributions Insurance Premium-Non (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) EVERGREEN ARVIN HEALTHCARE EVERGREEN BAKERSFIELD POST ACUTE CARE TWIN OAKS POST ACUTE REHAB FULLERTON POST ACUTE CARE EVERGREEN LAKEPORT HEALTHCARE OLIVE RIDGE POST ACUTE CARE PETALUMA HEALTH AND REHABILITATION KATHERINE HEALTHCARE NEW HOPE POST ACUTE CARE HEARTWOOD AVENUE HEALTHCARE SPRINGS ROAD HEALTHCARE ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ $ UNIT COST MULTIPLIER......
22 STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, 211 Taxes & Licenses - Non Interest Expense Purchased Services Education Training Lease Lease Acq & Amort Loan Marketing & Public Relations (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) EVERGREEN ARVIN HEALTHCARE EVERGREEN BAKERSFIELD POST ACUTE CARE TWIN OAKS POST ACUTE REHAB FULLERTON POST ACUTE CARE EVERGREEN LAKEPORT HEALTHCARE OLIVE RIDGE POST ACUTE CARE PETALUMA HEALTH AND REHABILITATION KATHERINE HEALTHCARE NEW HOPE POST ACUTE CARE HEARTWOOD AVENUE HEALTHCARE SPRINGS ROAD HEALTHCARE ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ $ UNIT COST MULTIPLIER......
23 STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, 211 Fines, Penalties, Late 35. Regional Therapy (Minutes) 35.1 Health Medx MIS (No. of users) 35.2 Dietary Consultant (Total Cost) 35.3 Nursing Consultant (Total Cost) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) EVERGREEN ARVIN HEALTHCARE , , EVERGREEN BAKERSFIELD POST ACUTE CARE , , TWIN OAKS POST ACUTE REHAB ,9, , FULLERTON POST ACUTE CARE , , EVERGREEN LAKEPORT HEALTHCARE , , OLIVE RIDGE POST ACUTE CARE , , PETALUMA HEALTH AND REHABILITATION ,2 2 27, KATHERINE HEALTHCARE , , NEW HOPE POST ACUTE CARE , , HEARTWOOD AVENUE HEALTHCARE , , SPRINGS ROAD HEALTHCARE , , ALL OTHER HEALTHCARE FACILITIES N/A 11,938, , ,658 SUBTOTAL (LINES 1 THROUGH 2) 18,373, ,449 1,153,11 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A SANDPOINT ASSISTED LIVING N/A PARKWAY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) 1,443 GRAND TOTAL 18,373, ,892 1,153,11 TOTAL STATISTICS 18,373, ,892 1,153,11 COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $521,328 $327,549 $43,78 $379,664 $ UNIT COST MULTIPLIER
24 STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, (Adj. ) (Adj. ) (Adj. ) EVERGREEN ARVIN HEALTHCARE EVERGREEN BAKERSFIELD POST ACUTE CARE TWIN OAKS POST ACUTE REHAB FULLERTON POST ACUTE CARE EVERGREEN LAKEPORT HEALTHCARE OLIVE RIDGE POST ACUTE CARE PETALUMA HEALTH AND REHABILITATION KATHERINE HEALTHCARE NEW HOPE POST ACUTE CARE HEARTWOOD AVENUE HEALTHCARE SPRINGS ROAD HEALTHCARE ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ UNIT COST MULTIPLIER...
25 STATE OF CALIFORNIA SCHEDULE 7 DIRECT ALLOCATION OF CAPITAL COSTS TO CHAIN COMPONENTS DECEMBER 31, 211 REPORTED TOTAL (SCH. E) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) AUDITED TOTAL EVERGREEN ARVIN HEALTHCARE $ $ $ $ $ $ $ EVERGREEN BAKERSFIELD POST ACUTE CARE TW IN OAKS POST ACUTE REHAB FULLERTON POST ACUTE CARE EVERGREEN LAKEPORT HEALTHCARE OLIVE RIDGE POST ACUTE CARE PETALUMA HEALTH AND REHABILITATION KATHERINE HEALTHCARE NEW HOPE POST ACUTE CARE HEARTW OOD AVENUE HEALTHCARE SPRINGS ROAD HEALTHCARE ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ $ 19 OREGON RETIREMENT CENTER N/A $ $ $ $ $ $ $ 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKW AY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ $ (To Schedule 3)
26 STATE OF CALIFORNIA SCHEDULE 7-1 DIRECT ALLOCATION OF NONCAPITAL COSTS TO CHAIN COMPONENTS DECEMBER 31, 211 REPORTED TOTAL (SCH. E-1) TRAVEL AND ENTERTAINMENT (Adj. 1) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) EVERGREEN ARVIN HEALTHCARE $ $ $ $ $ $ $ $ EVERGREEN BAKERSFIELD POST ACUTE CARE TW IN OAKS POST ACUTE REHAB FULLERTON POST ACUTE CARE EVERGREEN LAKEPORT HEALTHCARE OLIVE RIDGE POST ACUTE CARE PETALUMA HEALTH AND REHABILITATION KATHERINE HEALTHCARE NEW HOPE POST ACUTE CARE HEARTW OOD AVENUE HEALTHCARE SPRINGS ROAD HEALTHCARE ALL OTHER HEALTHCARE FACILITIES N/A 27,586 SUBTOTAL (LINES 1 THROUGH 2) $ $27,586 $ $ $ $ $ $ 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKW AY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ $ GRAND TOTAL $ $27,586 $ $ $ $ $ $
27 STATE OF CALIFORNIA SCHEDULE 7-1 DIRECT ALLOCATION OF NONCAPITAL COSTS TO CHAIN COMPONENTS DECEMBER 31, 211 (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) AUDITED TOTAL EVERGREEN ARVIN HEALTHCARE $ $ $ $ $ $ $ EVERGREEN BAKERSFIELD POST ACUTE CARE TW IN OAKS POST ACUTE REHAB FULLERTON POST ACUTE CARE EVERGREEN LAKEPORT HEALTHCARE OLIVE RIDGE POST ACUTE CARE PETALUMA HEALTH AND REHABILITATION KATHERINE HEALTHCARE NEW HOPE POST ACUTE CARE HEARTW OOD AVENUE HEALTHCARE SPRINGS ROAD HEALTHCARE ALL OTHER HEALTHCARE FACILITIES N/A 27,586 SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ $27, OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKW AY THERAPIES N/A SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ $27,586 (To Schedule 3-1)
28 STATE OF CALIFORNIA SCHEDULE 8 TRIAL BALANCE OF EXPENSES DECEMBER 31, 211 LINE NO. COST CENTER DESCRIPTION REPORTED ADJ. ADJUSTMENT AUDITED POOLED ALLOC. NO. AMOUNT(S) POOLED (SCH. B, COL 8) COSTS CAPITAL-RELATED COSTS - OLD 1. Old Cap. Related-Buildings & Fixtures $ $ $ Old Cap. Related-Movable Equipment SUBTOTAL (sum of lines 1 through 2.1) $ $ $ CAPITAL-RELATED COSTS - NEW 4. New Cap. Related-Buildings & Fixtures $24,599 $ $24, New Cap. Related-Movable Equipment 975, , SUBTOTAL (sum of lines 4 through 5.1) $1,179,711 $ $1,179,711 OTHER CAPITAL-RELATED COSTS 7. Insurance Premiums $ $ $ 8. Taxes and Licenses - Not INCM 9. Other 1. SUBTOTAL (sum of lines 7 through 9) $ $ $ NON CAPITAL-RELATED COSTS 11. Salaries of Officers $ $ $ 12. Salaries & Wages of Others 7,975,898 7,975, Payroll Taxes 11,269 11, Employee Benefits-Payroll Related 58,775 58, Employee Benefits-Nonpayroll Related 1,4,35 2,3,4 (42,554) 1,357, Profit Sharing/Pension Plans 17. Legal Fees 82,48 82, Auditing & Accounting Fees 28,121 28, Utilities 2. Communications 434, , Travel & Entertainment 75,62 1 (27,586) 723, Transportation 1,787 1, Cleaning Office & Admin Supplies 139, , Minor Equipment Expensed 29,349 29, Repairs & Maintenance 47,531 47, Dues & Subscriptions 55,172 55, Contributions 28. Insurance Premium-Non Capital Related 76,43 76, Taxes & Licenses - Non Capital Related 448,73 448,73 3. Interest Expense 35,732 35, Purchased Services 468, , Education Training Lease Exp 116, , Lease Acq & Amort Loan Fees 34. Marketing & Public Relations 11,585 11, Fines, Penalties, Late Fees (11,246) (11,246) 35.1 Regional Therapy Managers 35.2 Health Medx MIS 35.3 Dietary Consultant 35.4 Nursing Consultant SUBTOTAL (sum of lines 11 through 35.8) $12,249,69 ($7,14) $12,179, TOTAL ALLOWABLE EXPENSES $13,429,41 ($7,14) $13,359,261 (To Sch. 4) 38. NONREIMBURSABLE EXPENSES $ $ $ TOTAL EXPENSES $13,429,41 ($7,14) $13,359,261
29 STATE OF CALIFORNIA SCHEDULE 8 TRIAL BALANCE OF EXPENSES DECEMBER 31, 211 LINE NO. COST CENTER DESCRIPTION REPORTED ADJ. ADJUSTMENT AUDITED DIRECT ALLOC. NO. AMOUNT(S) DIRECT (SCH. B, COL 6) COSTS CAPITAL-RELATED COSTS - OLD 1. Old Cap. Related-Buildings & Fixtures Old Cap. Related-Movable Equipment SUBTOTAL (sum of lines 1 through 2.1) CAPITAL-RELATED COSTS - NEW 4. New Cap. Related-Buildings & Fixtures New Cap. Related-Movable Equipment SUBTOTAL (sum of lines 4 through 5.1) OTHER CAPITAL-RELATED COSTS 7. Insurance Premiums 8. Taxes and Licenses - Not INCM 9. Other 1. SUBTOTAL (sum of lines 7 through 9) NON CAPITAL-RELATED COSTS 11. Salaries of Officers 12. Salaries & Wages of Others 13. Payroll Taxes 14. Employee Benefits-Payroll Related 15. Employee Benefits-Nonpayroll Related 16. Profit Sharing/Pension Plans 17. Legal Fees 18. Auditing & Accounting Fees 19. Utilities 2. Communications 21. Travel & Entertainment 22. Transportation 23. Cleaning Office & Admin Supplies 24. Minor Equipment Expensed 25. Repairs & Maintenance 26. Dues & Subscriptions 27. Contributions 28. Insurance Premium-Non Capital Related 29. Taxes & Licenses - Non Capital Related 3. Interest Expense 31. Purchased Services 32. Education Training Lease Exp 33. Lease Acq & Amort Loan Fees 34. Marketing & Public Relations 35. Fines, Penalties, Late Fees 35.1 Regional Therapy Managers 35.2 Health Medx MIS 35.3 Dietary Consultant 35.4 Nursing Consultant SUBTOTAL (sum of lines 11 through 35.8) 37. TOTAL ALLOWABLE EXPENSES 38. NONREIMBURSABLE EXPENSES TOTAL EXPENSES $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 1 27,586 27,586 $ $27,586 $27,586 $ $27,586 $27,586 (To Sch. 7, 7-1) $ $ $ $ $27,586 $27,586
30 STATE OF CALIFORNIA SCHEDULE 8 TRIAL BALANCE OF EXPENSES DECEMBER 31, 211 LINE NO. COST CENTER DESCRIPTION REPORTED ADJ. ADJUSTMENT AUDITED FUNCTIONAL COSTS NO. AMOUNT(S) FUNCTIONAL (SCH. B, COL 7) COSTS CAPITAL-RELATED COSTS - OLD 1. Old Cap. Related-Buildings & Fixtures Old Cap. Related-Movable Equipment SUBTOTAL (sum of lines 1 through 2.1) CAPITAL-RELATED COSTS - NEW 4. New Cap. Related-Buildings & Fixtures New Cap. Related-Movable Equipment SUBTOTAL (sum of lines 4 through 5.1) OTHER CAPITAL-RELATED COSTS 7. Insurance Premiums 8. Taxes and Licenses - Not INCM 9. Other 1. SUBTOTAL (sum of lines 7 through 9) NON CAPITAL-RELATED COSTS 11. Salaries of Officers 12. Salaries & Wages of Others 13. Payroll Taxes 14. Employee Benefits-Payroll Related 15. Employee Benefits-Nonpayroll Related 16. Profit Sharing/Pension Plans 17. Legal Fees 18. Auditing & Accounting Fees 19. Utilities 2. Communications 21. Travel & Entertainment 22. Transportation 23. Cleaning Office & Admin Supplies 24. Minor Equipment Expensed 25. Repairs & Maintenance 26. Dues & Subscriptions 27. Contributions 28. Insurance Premium-Non Capital Related 29. Taxes & Licenses - Non Capital Related 3. Interest Expense 31. Purchased Services 32. Education Training Lease Exp 33. Lease Acq & Amort Loan Fees 34. Marketing & Public Relations 35. Fines, Penalties, Late Fees 35.1 Regional Therapy Managers 35.2 Health Medx MIS 35.3 Dietary Consultant 35.4 Nursing Consultant SUBTOTAL (sum of lines 11 through 35.8) 37. TOTAL ALLOWABLE EXPENSES 38. NONREIMBURSABLE EXPENSES TOTAL EXPENSES $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 521, , , ,549 43,78 43,78 379, ,664 $1,271,619 $ $1,271,619 $1,271,619 $ $1,271,619 (To Sch. 6, 6-1) $ $ $ $1,271,619 $ $1,271,619
31 STATE OF CALIFORNIA SCHEDULE 9 REPORTED HOME OFFICE COSTS DECEMBER 31, 211 FISCAL PERIODS ENDING DURING HOME OFFICE FISCAL YEAR FROM TO DIRECT ALLOCATION FUNCTIONAL ALLOCATION POOLED ALLOCATION TOTAL NON-CAPITAL CAPITAL NON-CAPITAL CAPITAL NON-CAPITAL RELATED RELATED RELATED RELATED RELATED COSTS COSTS COSTS COSTS COSTS (SCH. E-1) (SCH. F) (SCH. F-1) (SCH. G) (SCH. G) CAPITAL RELATED COSTS (SCH. E) ALLOCATION HOME OFFICE COSTS EVERGREEN ARVIN HEALTHCARE /1/11 12/31/11 $23,32 $26,327 $273,372 $323, EVERGREEN BAKERSFIELD POST ACUTE CARE /1/11 12/31/11 31,834 38,829 43, , TWIN OAKS POST ACUTE REHAB /1/11 12/31/11 59,68 62,97 644, , FULLERTON POST ACUTE CARE /1/11 12/31/11 35,989 55,32 574, , EVERGREEN LAKEPORT HEALTHCARE /1/11 12/31/11 25,845 27, ,443 34, OLIVE RIDGE POST ACUTE CARE /1/11 12/31/11 37,689 49, ,69 65, PETALUMA HEALTH AND REHABILITATION /1/11 12/31/11 36,149 39, ,88 49, KATHERINE HEALTHCARE /1/11 12/31/11 22,411 21, , , NEW HOPE POST ACUTE CARE /1/11 12/31/11 45,157 53, , , HEARTWOOD AVENUE HEALTHCARE /1/11 12/31/11 26,684 19,442 21,88 248, SPRINGS ROAD HEALTHCARE /1/11 12/31/11 5,622 25,43 263, , ALL OTHER HEALTHCARE FACILITIES N/A 1/1/11 12/31/11 876,22 744,892 7,734,713 9,355,825 SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $1,271,528 $1,164,198 $12,88,67 $14,524, OREGON RETIREMENT CENTER N/A 1/1/11 12/31/11 $4,115 $42,726 $46, CONIFER HOUSE N/A 1/1/11 12/31/ ,363 55,688 61, SANDPOINT ASSISTED LIVING N/A 1/1/11 12/31/ ,35 62,669 68, PARKWAY THERAPIES N/A 1/1/11 12/31/ SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $91 $15,513 $161,83 $176,687 GRAND TOTAL $ $ $ $1,271,619 $1,179,711 $12,249,69 $14,71,2 (To Sch. 2, Col. 1)
32 State of California Department of Health Care Services Provider Name Report References Fiscal Period JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider Adjustments N/A 4 Adj. No. Audit Report Cost Report Work Sheet Part Title Line Col. Explanation of Audit Adjustments RECLASSIFICATION OF REPORTED COSTS As Reported Increase (Decrease) As Adjusted Not Reported Travel and Entertainment - All Other Healthcare Facilitie $ $27,586 $27,586 8 B Travel and Entertainment 27,586 27,586 8 B Travel and Entertainment 75,62 (27,586) 723,16 To directly assign travel expense to the using cost center 42 CFR and CMS Pub. 15-1, Sections 215.3B, 23, and 234 Page 1
33 State of California Department of Health Care Services Provider Name Report References Fiscal Period JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider Adjustments N/A 4 Adj. No. Audit Report Cost Report Work Sheet Part Title Line Col. Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED POOLED COSTS As Reported Increase (Decrease) As Adjusted 2 8 B Employee Benefits - Non-Payroll $1,4,35 To eliminate self insured pooled costs in conjunction with ($13,821) adjustments 3 and CFR and CMS Pub. 15-1, Sections 2161, , , , , 23, and To eliminate health insurance expense for the self insurance plan (449,342) reported in account in conjunction with adjustments 2 and CFR and CMS Pub. 15-1, Sections 2161, , , , , 23, and To include self insurance health paid claims and administrative fees 537,69 to agree with provider's records in conjunction with adjustments ($42,554) $1,357,481 2 and 3 42 CFR and CMS Pub. 15-1, Sections 23 and 234 Page 2
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