REPORT ON THE RATE SETTING AUDIT ROYALE HEALTH CARE CENTER SANTA ANA, CALIFORNIA NATIONAL PROVIDER IDENTIFIER:

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1 REPORT ON THE RATE SETTING AUDIT ROYALE HEALTH CARE CENTER SANTA ANA, CALIFORNIA NATIONAL PROVIDER IDENTIFIER: FISCAL PERIOD ENDED DECEMBER 31, 211 Audits Section Santa Ana Financial Audits Branch Audits and Investigations Department of Health Care Services Section Chief: Margaret A. Varho Audit Supervisor: Stan Van Arsdale Auditor: Mineo Gonzalez

2 State of California Health and Human Services Agency Department of Health Care Services TOBY DOUGLAS DIRECTOR EDMUND G. BROWN JR. GOVERNOR Date: July 15, 213 Michael Pierson, Administrator Royale Health Care Center 13 W. Warner Ave Santa Ana, CA 9277 ROYALE HEALTH CARE CE NTER NATIONAL PROVIDER IDENTIFIER (NPI) FISCAL PERIOD ENDED DECEMBER 31, 211 We have examined the facility's Integrated Disclosure and Medi-Cal Cost Report for the above-referenced fiscal period. Our exa mination was made under the authority of Section 1417 of the Welfare and Institutions Code and was limited to a review of the cost report and accompanying financial statements, Medi-Cal payment data reports, prior fiscal period's Medi-Cal program audit report, and Medicare audit report for the current fiscal period, if applicable and available. In our opinion, the data presented in the accompanying Summary of Audited Facility Cost per Patient Day represents a proper determination of the allowable costs and patient days for the above fiscal period in accordance with Me di-cal reimbursement principles. This audit report includes the: 1. Summary of Audited Facility Cost per Patient Day and supporting schedules 2. Audit Adjustments Schedule Future Medi-Cal long-term care prospective rates may be affected by this examination. The extent to which the rates change will be determined by the Department's Fee-For- Service Rate Deve lopment Division. Notwithstanding this audit report, overpayments to the provider are subject to recovery pursuant to Section , Article 6 of Division 3, Title 22, California Code of Regulations. 65 West Santa Ana Blvd., Building 28, Room 83, Santa Ana, CA 9271 (714) / (714) fax Internet Address:

3 Michael Pierson 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 129 J Street, Suite 2 Sacramento, CA (916) The written notice of disagreement must be received by the Department within 6 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 1 MS 1 PO Box Capitol Avenue, Suite Sacramento, CA Sacramento, CA (916) The procedures that govern an appeal are contained in Welfare and Institutions Code, Section 14171, and California Code of Regulations, Title 22, Section 5116, et seq. If you have questions regarding this report, you may call the Audits Section Santa Ana at (714) (Original signed by Margaret Varho) Margaret A. Varho, Chief Audits Section Santa Ana Financial Audits Branch Certified

4 STATE OF CALIFORNIA SCHEDULE 1 SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY Provider Name: Fiscal Period: ROYALE HEALTH CARE CENTER JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility : PROGRAM DESCRIPTION AUDITED COST PER AS REPORTED AS AUDITED PATIENT DAY SKILLED NURSING CARE 1 Cost of Direct Care - Labor (Sch. 2, Ln. 15) $ N/A $ 5,32,11 $ Cost of Indirect Care - Labor (Sch. 3, Ln. 15) $ N/A $ 1,29,36 $ Cost of Direct and Indirect Nonlabor - Other (Sch. 4, Ln. 15) $ N/A $ 888,69 $ Cost of Capital Related (Sch. 5, Ln. 15) $ N/A $ 28,614 $ Property Taxes (Sch. 5, Ln. 15) $ N/A $ 24 $. 6 CDPH Licensing Fees (Sch. 6, Ln. 15) $ N/A $ 14,49 $.32 7 Professional Liability Insurance (Sch. 6, Ln. 15) $ N/A $ 247,999 $ Caregiver Training (Sch. 6, Ln. 15) $ N/A $ $. 9 Quality Assurance Fees (Sch. 6, Ln. 15) $ N/A $ 434,567 $ Cost of Administration (Sch. 6, Ln. 15) $ N/A $ 1,16,725 $ Cost of Routine Service/Audited Total Costs $ 9,681,496 $ 9,637,93 $ Total Patient Days (Adj ) 44,956 44, Cost Per Patient Day (Cost Divided by Days) $ $ Overpayments (Adj ) $ $ 15 Medi-Cal Days (Adj 7) 35, Medi-Cal Managed Care Days (Adj 8) 35,399 INTERMEDIATE CARE 17 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 18 Total Patient Days (Adj ) 19 Cost Per Patient Day (Cost Divided by Days) $. $. 2 Overpayments (Adj ) $ $ MENTALLY DISORDERED CARE 21 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ 14,471,368 $ 14,468, Total Patient Days (Adj 9 ) 41,885 39, Cost Per Patient Day (Cost Divided by Days) $ $ Overpayments (Adj ) $ $ DEVELOPMENTALLY DISABLED CARE 25 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 26 Total Patient Days (Adj ) 27 Cost Per Patient Day (Cost Divided by Days) $. $. 28 Overpayments (Adj ) $ $ SUBACUTE CARE 29 Cost of Direct Care - Labor (Subacute Care Sch. 1, Ln. 25) $ N/A $ $. 3 Cost of Indirect Care - Labor (Subacute Care Sch. 1, Ln. 26) $ N/A $ $. 31 Cost of Direct and Indirect Nonlabor - Other (Subacute Care Sch. 1, Ln. 27) $ N/A $ $. 32 Cost of Capital Related (Subacute Care Sch. 1, Ln. 28) $ N/A $ $. 33 Property Taxes (Subacute Care Sch. 1, Ln. 29) $ N/A $ $. 34 CDPH Licensing Fees (Subacute Care Sch. 1, Ln. 3) $ N/A $ $. 35 Professional Liability Insurance (Subacute Care Sch. 1, Ln. 31) $ N/A $ $. 36 Quality Assurance Fees (Subacute Care Sch. 1, Ln. 32) $ N/A $ $. 37 Caregiver Training (Subacute Care Sch. 1, Ln. 33) $ N/A $ $. 38 Cost of Administration (Subacute Care Sch.1, Ln. 34) $ N/A $ $. 39 Total Cost of Subacute Service (Subacute Care Sch. 1, Ln. 35) $ $ $. 4 Total Patient Days (Subacute Care Sch. 1, Ln. 36) 41 Cost Per Patient Day (Cost Divided by Days) $. $. 42 Amount Due Provider (State) (Subacute Care Sch. 1, Ln. 4) $ $

5 STATE OF CALIFORNIA SCHEDULE 1 SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY Provider Name: Fiscal Period: ROYALE HEALTH CARE CENTER JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility : PROGRAM DESCRIPTION AUDITED COST PER AS REPORTED AS AUDITED PATIENT DAY SUBACUTE CARE - PEDIATRIC 43 Cost of Routine Service (Subacute Care - Pediatric, Sch. 1, Ln 3) $ $ 44 Cost of Ancillary Service (Subacute Care - Pediatric, Sch. 1, Ln. 1 + Ln. 2) $ $ 45 Total Cost of Subacute Care - Pediatric Service (Ln Ln. 44) $ $ 46 Total Patient Days (Subacute Care - Pediatric, Sch. 1, Ln. 5) 47 Cost Per Patient Day (Cost Divided by Days) $. $. 48 Amount Due Provider (State) (Subacute Care - Pediatric, Sch. 1, Ln. 9) $ $ TRANSITIONAL INPATIENT CARE 49 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 5 Total Patient Days (Adj ) 51 Cost Per Patient Day (Cost Divided by Days) $. $. 52 Overpayments (Adj ) $ $ HOSPICE INPATIENT CARE 53 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 54 Total Patient Days (Adj ) 55 Cost Per Patient Day (Cost Divided by Days) $. $. 56 Overpayments (Adj ) $ $ OTHER ROUTINE SERVICES 57 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 58 Total Patient Days (Adj ) 59 Cost Per Patient Day (Cost Divided by Days) $. $. 6 Overpayments (Adj ) $ $

6 STATE OF CALIFORNIA SCHEDULE 2 ALLOCATION OF GENERAL SERVICES DIRECT CARE LABOR Provider Name: Fiscal Period: ROYALE HEALTH CARE CENTER JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility : DESCRIPTION Net Exp For Cost Alloc (From Sch 8) Soc Srvs 155 Activities 16 Total GENERAL SERVICES 5 Plant Operations and Maintenance 1 Housekeeping 6 Laundry and n 65 Dietary 155 Social Services $ 749,683 $ 749, Activities 23,153 $ 23, Administration 166 Medical Records 17 Inservice Education - Nursing ANCILLARY SERVICES 75 Patient Supplies 77 Specialized Support Surfaces N/A 8 Physical Therapy 452, , Respiratory Therapy 82 Occupational Therapy 355, , Speech Pathology 16,689 16, Pharmacy 9 Laboratory 95 Home Health Services 1 Other Ancillary Services 46,723 46, Subacute Care Ancillary Services 12 Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 15 Skilled Nursing Care 4,963,339 28,75 76,67 5,32,11 11 Intermediate Care 115 Mentally Disordered Care 8,618, , ,86 9,214, Developmentally Disabled Care 125 Subacute Care 126 Subacute Care - Pediatric 128 Transitional Inpatient Care 13 Hospice Inpatient Care 135 Other Routine Services NONREIMBURSABLE 139 Residential Care 14 Beauty and Barber 145 Other Nonreimbursable TOTAL $ 15,496,1 $ 749,683 $ 23,153 $ 15,496,1 (To Schedule 1)

7 STATE OF CALIFORNIA SCHEDULE 3 ALLOCATION OF GENERAL SERVICES INDIRECT CARE LABOR Provider Name: Provider NPI: OSHPD Facility Number: Fiscal Period: ROYALE HEALTH CARE CENTER JANUARY 1, 211 THROUGH DECEMBER 31, 211 DESCRIPTION Net Exp For Cost Alloc (From Sch 8) Plant Ops 5 Hskpng 1 Laundry 6 Dietary 65 Soc Srvs 155 Activities 16 Inserv. Ed 17 Accumulated Costs Admin 165 Medical Records 166 Total GENERAL SERVICES 5 Plant Operations and Maintenance $ 36,623 $ 36,623 1 Housekeeping 527,8 2,448 $ 529,528 6 Laundry and n 311,42 6,969 12,132 $ 33, Dietary 992,427 15,786 27,48 $ 1,35, Social Services N/A $ 1, Activities N/A $ 1, Administration N/A 11,26 19,58 $ 3,715 $ 3, Medical Records 37,797 3,882 6, ,436 $ 318, Inservice Education - Nursing 185,63 1,4 1,81 $ 188,453 ANCILLARY SERVICES 75 Patient Supplies 81 1,394 2, ,21 $ 3, Specialized Support Surfaces 8 Physical Therapy 1,95 3,317 5, ,195 13, Respiratory Therapy 82 Occupational Therapy 833 1,45 2, ,589 8, Speech Pathology 833 1,45 2, ,736 4, Pharmacy 496 5,139 5,635 9 Laboratory Home Health Services 1 Other Ancillary Services 129 1,337 1, Subacute Care Ancillary Services 12 Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 15 Skilled Nursing Care 95,31 165,96 294, , ,563 1,16,791 11,37 117,875 1,29,36 11 Intermediate Care 115 Mentally Disordered Care 163, ,476 36,199 51, ,89 1,16,987 17,7 176,97 1,31,26 12 Developmentally Disabled Care 125 Subacute Care 126 Subacute Care - Pediatric 128 Transitional Inpatient Care 13 Hospice Inpatient Care 135 Other Routine Services NONREIMBURSABLE 139 Residential Care 14 Beauty and Barber 743 1,293 2, , Other Nonreimbursable TOTAL $ 2,63,95 $ 36,623 $ 529,528 $ 33,521 $ 1,35,693 $ 1,222 $ 1,222 $ 188,453 $ 2,281,799 $ 3,715 $ 318,436 $ 2,63,95 (To Schedule 1)

8 STATE OF CALIFORNIA SCHEDULE 4 ALLOCATION OF GENERAL SERVICES OTHER - NONLABOR Provider Name: Provider NPI: OSHPD Facility Number: Fiscal Period: ROYALE HEALTH CARE CENTER JANUARY 1, 211 THROUGH DECEMBER 31, 211 DESCRIPTION Net Exp For Cost Alloc (From Sch 8) Plant Ops 5 Hskpng 1 Laundry 6 Dietary 65 Soc Srvs 155 Activities 16 Inserv. Ed 17 Accumulated Costs Admin 165 Medical Records 166 Total GENERAL SERVICES 5 Plant Operations and Maintenance $ 371,894 $ 371,894 1 Housekeeping 95,51 2,969 $ 98,479 6 Laundry and n 83,164 8,453 2,256 $ 93, Dietary 8,813 19,146 5,111 $ 825, Social Services 9, $ 1, Activities 51, $ 52, Administration N/A 13,592 3,628 $ 17,22 $ 17, Medical Records 15,196 4,78 1,257 21,161 $ 21, Inservice Education - Nursing 1, $ 1,598 ANCILLARY SERVICES 75 Patient Supplies 72, , $ 74, Specialized Support Surfaces 8 Physical Therapy 2, , , Respiratory Therapy 82 Occupational Therapy 1, , , Speech Pathology 1, , ,49 85 Pharmacy 332, , ,961 9 Laboratory 41,82 41, , Home Health Services 1 Other Ancillary Services 39,74 39, ,91 11 Subacute Care Ancillary Services 12 Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 15 Skilled Nursing Care 195,15 115,588 3,854 83, ,231 3,982 19, ,42 6,374 7, ,69 11 Intermediate Care 115 Mentally Disordered Care 198,892 53,91 1, ,838 6,652 32,648 1, 72,43 9,57 11,76 723, Developmentally Disabled Care 125 Subacute Care 126 Subacute Care - Pediatric 128 Transitional Inpatient Care 13 Hospice Inpatient Care 135 Other Routine Services NONREIMBURSABLE 139 Residential Care 14 Beauty and Barber 43, , , Other Nonreimbursable TOTAL $ 2,152,561 $ 371,894 $ 98,479 $ 93,873 $ 825,69 $ 1,634 $ 52,19 $ 1,598 $ 2,114,18 $ 17,22 $ 21,161 $ 2,152,561 (To Schedule 1)

9 STATE OF CALIFORNIA SCHEDULE 5 ALLOCATION OF CAPITAL COSTS Provider Name: Fiscal Period: ROYALE HEALTH CARE CENTER JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility Number: DESCRIPTION Net Exp For Cost Alloc (From Sch 8) Ratio Capital Various Plant Ops 5 Hskpng 1 Laundry 6 Dietary 65 Soc Srvs 155 Activities 16 GENERAL SERVICES Capital Related (excluding lines 4 & 45) $ 736,139 1% Property Tax (line 4) 63 % $ 736,22 5 Plant Operations and Maintenance 2,151 $ 2,151 1 Housekeeping 5, $ 5,877 6 Laundry and n 16, $ 16, Dietary 36,864 1,37 35 $ 38, Social Services 1, $ 1,79 16 Activities 1, $ 1, Administration 26, Medical Records 9, Inservice Education - Nursing 2, ANCILLARY SERVICES 75 Patient Supplies 1, Specialized Support Surfaces 8 Physical Therapy 4, Respiratory Therapy 82 Occupational Therapy 1, Speech Pathology 1, Pharmacy 9 Laboratory 95 Home Health Services 1 Other Ancillary Services 11 Subacute Care Ancillary Services 12 Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 15 Skilled Nursing Care 222,554 6,263 1,841 15,2 19, Intermediate Care 115 Mentally Disordered Care 382,951 1,777 3,169 1,847 18, Developmentally Disabled Care 125 Subacute Care 126 Subacute Care - Pediatric 128 Transitional Inpatient Care 13 Hospice Inpatient Care 135 Other Routine Services NONREIMBURSABLE 139 Residential Care 14 Beauty and Barber 1, Other Nonreimbursable TOTAL $ 736,22 1% $ 736,22 $ 2,151 $ 5,877 $ 16,868 $ 38,26 $ 1,79 $ 1,79 (To Schedule 1)

10 STATE OF CALIFORNIA SCHEDULE 5 ALLOCATION OF CAPITAL COSTS Provider Name: ROYALE HEALTH CARE CENTER Provider NPI: Fiscal Period: JANUARY 1, 211 THROUGH DECEMBER 31, 211 OSHPD Facility Number: DESCRIPTION Net Exp For Cost Alloc (From Sch 8) Ratio Inserv. Ed 17 Accumulated Costs Admin 165 Medical Records 166 Total Capital Related 1% Of Total Property Tax % Of Total GENERAL SERVICES Capital Related (excluding lines 4 & 45) $ 736,139 1% Property Tax (line 4) 63 % 5 Plant Operations and Maintenance 1 Housekeeping 6 Laundry and n 65 Dietary 155 Social Services 16 Activities 165 Administration $ 27,123 $ 27, Medical Records 9,395 $ 9, Inservice Education - Nursing $ 2,517 ANCILLARY SERVICES 75 Patient Supplies 1, $ 2,77 $ 2,77 $ 77 Specialized Support Surfaces 8 Physical Therapy 4, ,437 5, Respiratory Therapy 82 Occupational Therapy 2, ,658 2, Speech Pathology 2, ,216 2, Pharmacy Laboratory Home Health Services 1 Other Ancillary Services Subacute Care Ancillary Services 12 Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 15 Skilled Nursing Care ,12 1,4 3,478 28,638 28, Intermediate Care 115 Mentally Disordered Care 1,574 42,183 15,73 5,221 44,477 44, Developmentally Disabled Care 125 Subacute Care 126 Subacute Care - Pediatric 128 Transitional Inpatient Care 13 Hospice Inpatient Care 135 Other Routine Services NONREIMBURSABLE 139 Residential Care 14 Beauty and Barber 1, ,884 1, Other Nonreimbursable TOTAL $ 736,22 1% $ 2,517 $ 699,684 $ 27,123 $ 9,395 $ 736,22 $ 736,139 $ 63 (To Schedule 1)

11 STATE OF CALIFORNIA SCHEDULE 6 ALLOCATION OF ADMINISTRATION AND OTHER DIRECT PASS-THROUGH COSTS Provider Name: Provider NPI: OSHPD Facility Number: Fiscal Period: ROYALE HEALTH CARE CENTER JANUARY 1, 211 THROUGH DECEMBER 31, 211 DESCRIPTION Net Exp For Cost Alloc (From Sch 8) Ratio Accum Costs (From Sch 2) Accum Costs (From Sch 3) Accum Costs (From Sch 4) Accum Costs (From Sch 5) Total Accum Costs Allocated Admin. Costs Admin. 62% of Total DPH Licensing Fees 1% of Total Professional Liability Ins. 13% of Total Quality Assur. Fees 23% of Total Caregiver Training % of Total GENERAL SERVICES 45 Property Insurance $ 8,31 55 Interest - Other 165 Administration (Salaries & Wages, Fringe Benefits, Agency Staff and Other - Nonlabor) 3,127,356 Total Costs Allocable as Administration 3,135,666 62% 167 CDPH Licensing Fees 38,925 1% 168 Professional Liability Insurance 669,961 13% 169 Quality Assurance Fees 1,173,97 23% 174 Caregiver Training % Total 5,18,522 1% $ 5,18,522 ANCILLARY SERVICES 75 Patient Supplies $ - $ 2,195 $ 74,12 $ 1,938 $ 78,253 19,72 $ 11,916 $ 148 $ 2,546 $ 4,461 $ - 77 Specialized Support Surfaces 8 Physical Therapy 452,521 5,222 2,928 4, , ,396 7, ,138 26, Respiratory Therapy 82 Occupational Therapy 355,833 2,284 1,28 2,17 361,414 88,82 55, ,759 2,65 83 Speech Pathology 16,689 2,284 1,28 2,17 112,27 27,362 17, ,653 6,41 85 Pharmacy 332, ,342 8,997 5, ,813 18,947 9 Laboratory 41,82 41,82 1,12 6, ,337 2, Home Health Services 1 Other Ancillary Services 46,723 39,74 86,463 21,72 13, ,813 4, Subacute Care Ancillary Services 12 Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 15 Skilled Nursing Care 5,32,11 1,16, ,42 267,12 7,622,424 1,857,699 1,16,725 14,49 247, , Intermediate Care 115 Mentally Disordered Care 9,214,224 1,16,987 72,43 42,183 11,443,796 2,789,25 1,742,635 21, , , Developmentally Disabled Care 125 Subacute Care 126 Subacute Care - Pediatric 128 Transitional Inpatient Care 13 Hospice Inpatient Care 135 Other Routine Services NONREIMBURSABLE 139 Residential Care 14 Beauty and Barber 2,36 44,63 1,798 48,437 11,85 7, ,576 2, Other Nonreimbursable SUBTOTAL $ 5,18,522 $ 15,496,1 $ 2,281,799 $ 2,114,18 $ 699,684 $ 2,591,764 $ 5,18,522 Total Administrative Costs $ 5,18,522 $ 3,135,666 $ 38,925 $ 669,961 $ 1,173,97 $ - Unit Cost Multiplier Accumulated Administration Costs (Sch 2 thru 5) $ 349,151 $ 38,381 $ 36,518 $ 424,49 TOTAL FACILITY COSTS $ 26,34,335 (To Schedule 1)

12 STATE OF CALIFORNIA SCHEDULE 7 STATISTICS FOR COST ALLOCATION Provider Name: Provider NPI: OSHPD Facility Number: Fiscal Period: ROYALE HEALTH CARE CENTER JANUARY 1, 211 THROUGH DECEMBER 31, 211 DESCRIPTION Capital (SQ FT) VARIOUS Plant Ops (SQ FT) 5 Hskpng (SQ FT) 1 Laundry (LBS) 6 Dietary (MEALS) 65 Soc Srvs (DIRECT EXP) 155 Activities (DIRECT EXP) 16 Inserv. Ed (DIRECT EXP) 17 Admin. (TOTAL ACCUM COST) Med Records (TOTAL (ACCUM COST) (Adj 3,5) (Adj 3,5) (Adj 3,5) (Adj 6) (Adj 4) (Adj ) (Adj ) (Adj ) GENERAL SERVICES 5 Plant Operations and Maintenance 1,336 1 Housekeeping Laundry and n 1,79 1,79 1,79 65 Dietary 2,444 2,444 2, Social Services Activities Administration 1,735 1,735 1, Medical Records Inservice Education - Nursing ANCILLARY SERVICES 75 Patient Supplies ,253 78, Specialized Support Surfaces 8 Physical Therapy , , Respiratory Therapy 82 Occupational Therapy , , Speech Pathology ,27 112,27 85 Pharmacy 332, ,342 9 Laboratory 41,82 41,82 95 Home Health Services 1 Other Ancillary Services 86,463 86, Subacute Care Ancillary Services 12 Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 15 Skilled Nursing Care 14,755 14,755 14,755 1,267, ,635 5,158,354 5,158,354 5,158,354 7,622,424 7,622, Intermediate Care 115 Mentally Disordered Care 25,389 25,389 25, , ,655 8,618,159 8,618,159 8,618,159 11,443,796 11,443, Developmentally Disabled Care 125 Subacute Care 126 Subacute Care - Pediatric 128 Transitional Inpatient Care 13 Hospice Inpatient Care 135 Other Routine Services NONREIMBURSABLE 139 Residential Care 14 Beauty and Barber ,437 48, Other Nonreimbursable TOTAL STATISTICS 48,89 47,473 47,94 1,423,87 259,29 13,776,513 13,776,513 13,776,513 2,591,764 2,591,764 TOTAL DIRECT SALARIES COSTS - SCH. 2 $ 749,683 $ 23,153 UNIT COST MULTIPLIER (DIRECT SALARIES) TOTAL INDIRECT SALARIES COSTS - SCH. 3 $ 36,623 $ 529,528 $ 33,521 $ 1,35,693 $ 1,222 $ 1,222 $ 188,453 $ 3,715 $ 318,436 UNIT COST MULTIPLIER (INDIRECT SALARIES) TOTAL INDIRECT OTHER COSTS - SCH. 4 $ 371,894 $ 98,479 $ 93,873 $ 825,69 $ 1,634 $ 52,19 $ 1,598 $ 17,22 $ 21,161 UNIT COST MULTIPLIER (INDIRECT OTHER) TOTAL CAPITAL COSTS - SCH. 5 $ 736,22 $ 2,151 $ 5,877 $ 16,868 $ 38,26 $ 1,79 $ 1,79 $ 2,517 $ 27,123 $ 9,395 UNIT COST MULTIPLIER (CAPITAL COSTS)

13 STATE OF CALIFORNIA SCHEDULE 8 SUMMARY OF AUDITED PROGRAM EXPENSES Provider Name: Fiscal Period: ROYALE HEALTH CARE CENTER JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility Number: Natural Class ACCOUNT TITLE ACCOUNT NUMBER AS REPORTED AUDIT ADJUSTMENTS 8A-1 AS AUDITED 5 Plant Operations and Maintenance Salaries and Wages 62 $ 228,75 $ $ 228, Fringe Benefits 62 78,548 78, Agency Staff Other - Nonlabor , ,894 5 Plant Operations and Maintenance - Total 62 $ 678,517 $ $ 678,517 1 Housekeeping Salaries and Wages 63 $ 393,52 $ $ 393, Fringe Benefits ,56 133, Agency Staff Other - Nonlabor 63 95,51 95,51 1 Housekeeping - Total 63 $ 622,59 $ $ 622,59 15 Depreciation: Buildings and Improvements $ $ $ 2 Depreciation: Leasehold Improvements ,35 11,35 25 Depreciation: Equipment , ,446 3 Depreciation and Amortization - Other Leases and Rentals , ,658 4 Property Taxes Property Insurance 74 8,31 8,31 5 Interest - Property, Plant, and Equipment Interest - Other 76 $ $ $ 57 Subtotal 5-55 $ 2,45,619 $ $ 2,45,619 (Sch 5) (Sch 5) (Sch 5) (Sch 5) (Sch 5) (Sch 5) (Sch 5) 6 Laundry and n Salaries and Wages 64 $ 241,244 $ $ 241, Fringe Benefits 64 7,176 7, Agency Staff Other - Nonlabor 64 83,164 83,164 6 Laundry and n - Total 64 $ 394,584 $ $ 394, Dietary Salaries and Wages 65 $ 75,736 $ $ 75, Fringe Benefits , , Agency Staff Other - Nonlabor 65 8,813 8, Dietary - Total 65 $ 1,793,24 $ $ 1,793,24 7 Provision for Bad Debts 77 $ $ Ancillary Services 75 Patient Supplies Salaries and Wages 81 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor 81 19,38 53,581 72, Patient Supplies - Total 81 $ 19,38 $ 53,581 $ 72, Specialized Support Surfaces Salaries and Wages 815 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor Specialized Support Surfaces - Total 815 $ $ $ N/A N/A N/A

14 STATE OF CALIFORNIA SCHEDULE 8 SUMMARY OF AUDITED PROGRAM EXPENSES Provider Name: Fiscal Period: ROYALE HEALTH CARE CENTER JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility Number: Natural Class ACCOUNT TITLE ACCOUNT NUMBER AS REPORTED AUDIT ADJUSTMENTS 8A-1 AS AUDITED 8 Physical Therapy Salaries and Wages 82 $ $ $ Fringe Benefits Agency Staff , , Other - Nonlabor 82 8 Physical Therapy - Total 82 $ 452,521 $ $ 452, Respiratory Therapy Salaries and Wages 822 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor Respiratory Therapy - Total 822 $ $ $ 82 Occupational Therapy Salaries and Wages 825 $ $ $ Fringe Benefits Agency Staff , , Other - Nonlabor Occupational Therapy - Total 825 $ 355,833 $ $ 355, Speech Pathology Salaries and Wages 828 $ $ $ Fringe Benefits Agency Staff ,689 16, Other - Nonlabor Speech Pathology - Total 828 $ 16,689 $ $ 16, Pharmacy Salaries and Wages 83 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor , , Pharmacy - Total 83 $ 332,342 $ $ 332,342 9 Laboratory Salaries and Wages 84 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor 84 41,82 41,82 9 Laboratory - Total 84 $ 41,82 $ $ 41,82 95 Home Health Services Salaries and Wages 88 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor Home Health Services - Total 88 $ $ $ 1 Other Ancillary Services Salaries and Wages 89 $ 32,812 $ $ 32, Fringe Benefits 89 13,911 13, Agency Staff Other - Nonlabor 89 39,74 39,74 1 Other Ancillary Services - Total 89 $ 86,463 $ $ 86,463

15 STATE OF CALIFORNIA SCHEDULE 8 SUMMARY OF AUDITED PROGRAM EXPENSES Provider Name: Fiscal Period: ROYALE HEALTH CARE CENTER JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility Number: Natural Class ACCOUNT TITLE Subacute Care Ancillary Services Salaries and Wages Fringe Benefits.79 Agency Staff Other - Nonlabor Subacute Care Ancillary Services - Total ACCOUNT NUMBER AS REPORTED AUDIT ADJUSTMENTS 8A $ $ $ $ $ $ AS AUDITED Subacute Care - Pediatric Ancillary Services Salaries and Wages Fringe Benefits.79 Agency Staff Other - Nonlabor Subacute Care - Pediatric Ancillary Services - Total $ $ $ $ $ $ 14 Subtotal $ 1,394,238 $ 53,581 $ 1,447, Routine Services Skilled Nursing Care Salaries and Wages Fringe Benefits.49 Agency Staff Other - Nonlabor Skilled Nursing Care - Total 611 $ 3,788,938 $ (56,472) $ 611 1,235,767 (4,894) ,596 (53,581) 611 $ 5,273,31 $ (114,947) $ 3,732,466 1,23, ,15 5,158, Intermediate Care Salaries and Wages Fringe Benefits.49 Agency Staff Other - Nonlabor Intermediate Care - Total 612 $ $ $ $ $ $ Mentally Disordered Care Salaries and Wages Fringe Benefits.49 Agency Staff Other - Nonlabor Mentally Disordered Care - Total 613 $ 6,4,5 $ $ 613 1,918, , $ 8,618,159 $ $ 6,4,5 1,918, ,133 8,618, Developmentally Disabled Care Salaries and Wages Fringe Benefits.49 Agency Staff Other - Nonlabor Developmentally Disabled Care - Total 614 $ $ $ $ $ $ Subacute Care Salaries and Wages Fringe Benefits.49 Agency Staff Other - Nonlabor Subacute Care - Total 615 $ $ $ $ $ $ Subacute Care - Pediatric Salaries and Wages Fringe Benefits.49 Agency Staff Other - Nonlabor Subacute Care - Pediatric - Total 616 $ $ $ $ $ $

16 STATE OF CALIFORNIA SCHEDULE 8 SUMMARY OF AUDITED PROGRAM EXPENSES Provider Name: Fiscal Period: ROYALE HEALTH CARE CENTER JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility Number: Natural Class ACCOUNT TITLE ACCOUNT NUMBER AS REPORTED AUDIT ADJUSTMENTS 8A-1 AS AUDITED 128 Transitional Inpatient Care Salaries and Wages 617 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor Transitional Inpatient Care - Total 617 $ $ $ 13 Hospice Inpatient Care Salaries and Wages 618 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor Hospice Inpatient Care - Total 618 $ $ $ 135 Other Routine Services Salaries and Wages 619 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor Other Routine Services - Total 619 $ $ $ Other Nonreimbursable 139 Residential Care Salaries and Wages 91 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor Residential Care - Total 91 $ $ $ 14 Beauty and Barber Salaries and Wages 89 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor 89 43,462 43, Beauty and Barber - Total 89 $ 43,462 $ $ 43, Other Nonreimbursable Salaries and Wages 91 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor Other Nonreimbursable - Total 91 $ $ $ 146 Subtotal $ 13,934,922 $ (114,947) $ 13,819, Social Services Salaries and Wages 66 $ 67,27 $ $ 67, Fringe Benefits , , Agency Staff Other - Nonlabor 66 9,949 9, Social Services - Total 66 $ 759,632 $ $ 759,632

17 STATE OF CALIFORNIA SCHEDULE 8 SUMMARY OF AUDITED PROGRAM EXPENSES Provider Name: Fiscal Period: ROYALE HEALTH CARE CENTER JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility Number: Natural Class ACCOUNT TITLE ACCOUNT NUMBER AS REPORTED AUDIT ADJUSTMENTS 8A-1 AS AUDITED 16 Activities Salaries and Wages 67 $ 152,532 $ $ 152, Fringe Benefits 67 5,621 5, Agency Staff Other - Nonlabor 67 51,55 51,55 16 Activities - Total 67 $ 254,658 $ $ 254, Administration Salaries and Wages 69 $ 1,72,26 $ 56,472 $ 1,776, Fringe Benefits ,388 4,894 45, Agency Staff Other - Nonlabor 69 9,576 9, Administration - Total 69 $ 3,65,99 $ 61,366 $ 3,127, Medical Records Salaries and Wages 69 $ 229,839 $ $ 229, Fringe Benefits 69 77,958 77, Agency Staff Other - Nonlabor 69 15,196 15, Medical Records - Total 69 $ 322,993 $ $ 322, CDPH Licensing Fees 69 $ 38,925 $ $ 38, Professional Liability Insurance 69 $ 669,961 $ $ 669, Quality Assurance Fees 69 $ 1,173,97 $ $ 1,173,97 17 Inservice Education - Nursing Salaries and Wages 68 $ 143,61 $ $ 143, Fringe Benefits 68 42,2 42, Agency Staff Other - Nonlabor Inservice Education - Nursing - Total 68 $ 185,63 $ $ 185, Caregiver Training Salaries and Wages 69 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor Caregiver Training - Total 69 $ $ $ Subtotal $ 6,471,732 $ 61,366 $ 6,533,98 2 Total $ 26,34,335 $ $ 26,34, Total Facility Group Health Insurance 69 $ For informational purposes only, this amount is included in various cost centers above..

18 STATE OF CALIFORNIA RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS Schedule 8A-1 Page 1 Provider Name: Provider NPI: OSHPD Facility Number: Fiscal Period: ROYALE HEALTH CARE CENTER JANUARY 1, 211 THROUGH DECEMBER 31, 211 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ Sub (Page 1) Plant Operations and Maintenance - Salaries and Wages 5 2 Plant Operations and Maintenance - Fringe Benefits 5 3 Plant Operations and Maintenance - Agency Staff 5 4 Plant Operations and Maintenance - Other - Nonlabor 1 1 Housekeeping - Salaries and Wages 1 2 Housekeeping - Fringe Benefits 1 3 Housekeeping - Agency Staff 1 4 Housekeeping - Other - Nonlabor 15 4 Depreciation: Buildings and Improvements 2 4 Depreciation: Leasehold Improvements 25 4 Depreciation: Equipment 3 4 Depreciation and Amortization - Other 35 4 Leases and Rentals 4 4 Property Taxes 45 4 Property Insurance 5 4 Interest - Property, Plant, and Equipment 55 4 Interest - Other 6 1 Laundry and n - Salaries and Wages 6 2 Laundry and n - Fringe Benefits 6 3 Laundry and n - Agency Staff 6 4 Laundry and n - Other - Nonlabor 65 1 Dietary - Salaries and Wages 65 2 Dietary - Fringe Benefits 65 3 Dietary - Agency Staff 65 4 Dietary - Other - Nonlabor 7 4 Provision for Bad Debts 75 1 Patient Supplies - Salaries and Wages 75 2 Patient Supplies - Fringe Benefits 75 3 Patient Supplies - Agency Staff 75 4 Patient Supplies - Other - Nonlabor 53,581 53, Specialized Support Surfaces - Salaries and Wages 77 2 Specialized Support Surfaces - Fringe Benefits 77 3 Specialized Support Surfaces - Agency Staff 77 4 Specialized Support Surfaces - Other - Nonlabor 8 1 Physical Therapy - Salaries and Wages 8 2 Physical Therapy - Fringe Benefits 8 3 Physical Therapy - Agency Staff 8 4 Physical Therapy - Other - Nonlabor 81 1 Respiratory Therapy - Salaries and Wages 81 2 Respiratory Therapy - Fringe Benefits 81 3 Respiratory Therapy - Agency Staff 81 4 Respiratory Therapy - Other - Nonlabor 82 1 Occupational Therapy - Salaries and Wages 82 2 Occupational Therapy - Fringe Benefits 82 3 Occupational Therapy - Agency Staff 82 4 Occupational Therapy - Other - Nonlabor 83 1 Speech Pathology - Salaries and Wages 83 2 Speech Pathology - Fringe Benefits 83 3 Speech Pathology - Agency Staff

19 STATE OF CALIFORNIA RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS Schedule 8A-1 Page 1 Provider Name: Provider NPI: OSHPD Facility Number: Fiscal Period: ROYALE HEALTH CARE CENTER JANUARY 1, 211 THROUGH DECEMBER 31, 211 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ Sub (Page 1) Speech Pathology - Other - Nonlabor 85 1 Pharmacy - Salaries and Wages 85 2 Pharmacy - Fringe Benefits 85 3 Pharmacy - Agency Staff 85 4 Pharmacy - Other - Nonlabor 9 1 Laboratory - Salaries and Wages 9 2 Laboratory - Fringe Benefits 9 3 Laboratory - Agency Staff 9 4 Laboratory - Other - Nonlabor 95 1 Home Health Services - Salaries and Wages 95 2 Home Health Services - Fringe Benefits 95 3 Home Health Services - Agency Staff 95 4 Home Health Services - Other - Nonlabor 1 1 Other Ancillary Services - Salaries and Wages 1 2 Other Ancillary Services - Fringe Benefits 1 3 Other Ancillary Services - Agency Staff 1 4 Other Ancillary Services - Other - Nonlabor 11 1 Subacute Care Ancillary Services - Salaries and Wages 11 2 Subacute Care Ancillary Services - Fringe Benefits 11 3 Subacute Care Ancillary Services - Agency Staff 11 4 Subacute Care Ancillary Services - Other - Nonlabor 12 1 Subacute Pediatric Ancillary Services - Salaries and Wages 12 2 Subacute Pediatric Ancillary Services - Fringe Benefits 12 3 Subacute Pediatric Ancillary Services - Agency Staff 12 4 Subacute Pediatric Ancillary Services - Other - Nonlabor 15 1 Skilled Nursing Care - Salaries and Wages (56,472) (56,472) 15 2 Skilled Nursing Care - Fringe Benefits (4,894) (4,894) 15 3 Skilled Nursing Care - Agency Staff 15 4 Skilled Nursing Care - Other - Nonlabor (53,581) (53,581) 11 1 Intermediate Care - Salaries and Wages 11 2 Intermediate Care - Fringe Benefits 11 3 Intermediate Care - Agency Staff 11 4 Intermediate Care - Other - Nonlabor Mentally Disordered Care - Salaries and Wages Mentally Disordered Care - Fringe Benefits Mentally Disordered Care - Agency Staff Mentally Disordered Care - Other - Nonlabor 12 1 Developmentally Disabled Care - Salaries and Wages 12 2 Developmentally Disabled Care - Fringe Benefits 12 3 Developmentally Disabled Care - Agency Staff 12 4 Developmentally Disabled Care - Other - Nonlabor Subacute Care - Salaries and Wages Subacute Care - Fringe Benefits Subacute Care - Agency Staff Subacute Care - Other - Nonlabor Subacute Care - Pediatric - Salaries and Wages Subacute Care - Pediatric - Fringe Benefits Subacute Care - Pediatric - Agency Staff Subacute Care - Pediatric - Other - Nonlabor

20 STATE OF CALIFORNIA RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS Schedule 8A-1 Page 1 Provider Name: Provider NPI: OSHPD Facility Number: Fiscal Period: ROYALE HEALTH CARE CENTER JANUARY 1, 211 THROUGH DECEMBER 31, 211 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ Sub (Page 1) Transitional Inpatient Care - Salaries and Wages Transitional Inpatient Care - Fringe Benefits Transitional Inpatient Care - Agency Staff Transitional Inpatient Care - Other - Nonlabor 13 1 Hospice Inpatient Care - Salaries and Wages 13 2 Hospice Inpatient Care - Fringe Benefits 13 3 Hospice Inpatient Care - Agency Staff 13 4 Hospice Inpatient Care - Other - Nonlabor Other Routine Services - Salaries and Wages Other Routine Services - Fringe Benefits Other Routine Services - Agency Staff Other Routine Services - Other - Nonlabor Residential Care - Salaries and Wages Residential Care - Fringe Benefits Residential Care - Agency Staff Residential Care - Other - Nonlabor 14 1 Beauty and Barber - Salaries and Wages 14 2 Beauty and Barber - Fringe Benefits 14 3 Beauty and Barber - Agency Staff 14 4 Beauty and Barber - Other - Nonlabor Other Nonreimbursable - Salaries and Wages Other Nonreimbursable - Fringe Benefits Other Nonreimbursable - Agency Staff Other Nonreimbursable - Other - Nonlabor Social Services - Salaries and Wages Social Services - Fringe Benefits Social Services - Agency Staff Social Services - Other - Nonlabor 16 1 Activities - Salaries and Wages 16 2 Activities - Fringe Benefits 16 3 Activities - Agency Staff 16 4 Activities - Other - Nonlabor Administration - Salaries and Wages 56,472 56, Administration - Fringe Benefits 4,894 4, Administration - Agency Staff Administration - Other - Nonlabor Medical Records - Salaries and Wages Medical Records - Fringe Benefits Medical Records - Agency Staff Medical Records - Other - Nonlabor CDPH Licensing Fees Professional Liability Insurance Quality Assurance Fees 17 1 Inservice Education - Nursing - Salaries and Wages 17 2 Inservice Education - Nursing - Fringe Benefits 17 3 Inservice Education - Nursing - Agency Staff 17 4 Inservice Education - Nursing - Other - Nonlabor Caregiver Training - Salaries and Wages Caregiver Training - Fringe Benefits

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