Audits Section Burbank Financial Audits Branch Audits and Investigations Department of Health Care Services

Transcription

1 REPORT ON THE RATE SETTING AUDIT SOUTH PASADENA CONVALESCENT HOSPITAL SOUTH PASADENA, CALIFORNIA NATIONAL PROVIDER IDENTIFIER: FISCAL PERIOD ENDED DECEMBER 31, 211 Audits Section Burbank Financial Audits Branch Audits and Investigations Department of Health Care Services Section Chief: Daniel J. Giardinelli Audit Supervisor: Gertrude Lake Auditors: Alison Dowling and Diane Wu

2 State of California Health and Human Services Agency Department of Health Care Services TOBY DOUGLAS DIRECTOR EDMUND G. BROWN JR. GOVERNOR July 22, 213 Adminis trator South Pasadena Convalescent Hospital 94 Mission Street South Pasadena, CA 913 SOUTH PASADENA CONVALESCENT HOSPITAL 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. We also examined the facility's use of and Records of Noncovered Services deducted from patient share of cost. Our examination 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, patient days, and use of share of cost for the above fiscal period in accordance with Medi-Cal reimbursement principles. This audit report includes the: 1. Summary of Audited Facility Cost per Patient Day and supporting schedules 2. Audit adjust ments that include a summary of the total due the State in the amount of $36,93, which resulted from Medi-Cal overpayments The audit settlement will be incorporated into a Statement(s) of Account Status, which may reflect tentative retroactive adjustment determinations, payments from the provider, and other financial transactions initiated by the Department. The Statement(s) of Account Status will be forwarded to the provider by the State s fiscal intermediary. Instructions regarding payment will be included with the Statement(s) of Account Status. Financial Audits/Burbank/A & I, MS 211, 145 North San Fernando Boulevard, Room 23, Burbank, CA 9154 Telephone (818) FAX: (818) Internet Address:

3 Administrator Page 2 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 Rates Development 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. 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) Assistant Chief Counsel Department of Health Care Services Office of Legal Services MS 1 PO Box Sacramento, CA Courier (UPS, FedEx, etc.) Assistant Chief Counsel Department of Health Care Services Office of Legal Services MS Capitol Avenue, Suite 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 Burbank at (818) Original Signed By Daniel J. Giardinelli, Chief Audits Section Burbank Financial Audits Branch Certified

4 STATE OF CALIFORNIA SCHEDULE 1 SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY Provider Name: Fiscal Period: SOUTH PASADENA CONVALESCENT HOSPITAL JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility No.: Line No. 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 $ 3,845,193 $ Cost of Indirect Care - Labor (Sch. 3, Ln. 15) $ N/A $ 921,696 $ Cost of Direct and Indirect Nonlabor - Other (Sch. 4, Ln. 15) $ N/A $ 1,469,673 $ Cost of Capital Related (Sch. 5, Ln. 15) $ N/A $ 727,914 $ Property Taxes (Sch. 5, Ln. 15) $ N/A $ 37,13 $.69 6 CDPH Licensing Fees (Sch. 6, Ln. 15) $ N/A $ 28,154 $.52 7 Professional Liability Insurance (Sch. 6, Ln. 15) $ N/A $ 17,584 $ Caregiver Training (Sch. 6, Ln. 15) $ N/A $ $. 9 Quality Assurance Fees (Sch. 6, Ln. 15) $ N/A $ 561,97 $ Cost of Administration (Sch. 6, Ln. 15) $ N/A $ 864,772 $ Cost of Routine Service/Audited Total Costs $ 8,847,661 $ 8,564,22 $ Total Patient Days (Adj ) 53,628 53, Cost Per Patient Day (Cost Divided by Days) $ $ Overpayments (Adjs 14-16) $ $ 36,93 15 Medi-Cal Days (Adj 13) 34,141 33, Medi-Cal Managed Care Days (Adj ) 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) $ $ 22 Total Patient Days (Adj ) 23 Cost Per Patient Day (Cost Divided by Days) $. $. 24 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: SOUTH PASADENA CONVALESCENT HOSPITAL JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility No.: Line No. 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: SOUTH PASADENA CONVALESCENT HOSPITAL JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility No.: Line No. 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 Linen 65 Dietary 155 Social Services $ 153,56 $ 153,56 16 Activities 13,782 $ 13, Administration 166 Medical Records 17 Inservice Education - Nursing ANCILLARY SERVICES 75 Patient Supplies 77 Specialized Support Surfaces N/A 8 Physical Therapy 87,79 87,79 81 Respiratory Therapy 82 Occupational Therapy 644, , Speech Pathology 12,565 12, 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 3,561, ,56 13,782 3,845, Intermediate Care 115 Mentally Disordered Care 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 145 Other Nonreimbursable TOTAL $ 5,31,39 $ 153,56 $ 13,782 $ 5,31,39 (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: SOUTH PASADENA CONVALESCENT HOSPITAL JANUARY 1, 211 THROUGH DECEMBER 31, 211 Line No. 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 $ 113,46 $ 113,46 1 Housekeeping 161,681 8,891 $ 17,572 6 Laundry and Linen 124,171 $ 124, Dietary 316,748 12,341 2,141 $ 349, Social Services N/A 778 1,27 $ 2,48 16 Activities N/A 1,56 1,723 $ 2, Administration N/A 5,473 8,933 $ 14,46 $ 14, Medical Records 167,751 1,395 2, ,422 $ 171, Inservice Education - Nursing 96, $ 97,774 ANCILLARY SERVICES 75 Patient Supplies 833 1,36 2, $ 3,23 77 Specialized Support Surfaces 8 Physical Therapy 3,46 5,559 8,965 1,428 16,993 27, Respiratory Therapy 82 Occupational Therapy 1,56 12,562 13, Speech Pathology Pharmacy 967 1,578 2, ,884 1,8 9 Laboratory Home Health Services 1 Other Ancillary Services Subacute Care Ancillary Services 12 Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 15 Skilled Nursing Care 76, , , ,231 2,48 2,779 97, ,548 11,97 132,51 921, Intermediate Care 115 Mentally Disordered Care 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 867 1,415 2, , Other Nonreimbursable TOTAL $ 98,361 $ 113,46 $ 17,572 $ 124,171 $ 349,231 $ 2,48 $ 2,779 $ 97,774 $ 794,533 $ 14,46 $ 171,422 $ 98,361 (To Schedule 1)

8 STATE OF CALIFORNIA SCHEDULE 4 ALLOCATION OF GENERAL SERVICES OTHER - NONLABOR Provider Name: Provider NPI: OSHPD Facility Number: Fiscal Period: SOUTH PASADENA CONVALESCENT HOSPITAL JANUARY 1, 211 THROUGH DECEMBER 31, 211 Line No. 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 $ 495,952 $ 495,952 1 Housekeeping 4,268 38,881 $ 79,149 6 Laundry and Linen 2,479 $ 2, Dietary 367,58 53,972 9,346 $ 43, Social Services 14,4 3, $ 18, Activities 19,759 4,617 8 $ 25, Administration N/A 23,936 4,145 $ 28,81 $ 28, Medical Records 15,529 6,99 1,56 22,685 $ 22, Inservice Education - Nursing 1, $ 2,281 ANCILLARY SERVICES 75 Patient Supplies 34,79 3, , $ 39, Specialized Support Surfaces 8 Physical Therapy 11,62 14,896 2,58 28,538 2,784 2,249 33,57 81 Respiratory Therapy 82 Occupational Therapy 2,58 1,662 3,72 83 Speech Pathology Pharmacy 338,28 4, ,169 1, ,27 9 Laboratory 34,983 34, , Home Health Services 1 Other Ancillary Services 39,191 39, , Subacute Care Ancillary Services 12 Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 15 Skilled Nursing Care 538, ,54 58,277 2,479 43,826 18,391 25,176 2,281 1,43,567 21,632 17,475 1,469, Intermediate Care 115 Mentally Disordered Care 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 2,355 3, , , Other Nonreimbursable TOTAL $ 1,973,1 $ 495,952 $ 79,149 $ 2,479 $ 43,826 $ 18,391 $ 25,176 $ 2,281 $ 1,922,235 $ 28,81 $ 22,685 $ 1,973,1 (To Schedule 1)

9 STATE OF CALIFORNIA SCHEDULE 5 ALLOCATION OF CAPITAL COSTS Provider Name: Fiscal Period: SOUTH PASADENA CONVALESCENT HOSPITAL JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility Number: Line No. 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) $ 785,48 95% Property Tax (line 4) 4,63 5% $ 825,471 5 Plant Operations and Maintenance 1,454 $ 1,454 1 Housekeeping 64,6 114 $ 64,714 6 Laundry and Linen $ - 65 Dietary 89, ,642 $ 97, Social Services 5, $ 6, Activities 7, $ 8, Administration 39,77 7 3, Medical Records 1, Inservice Education - Nursing 3, ANCILLARY SERVICES 75 Patient Supplies 6, Specialized Support Surfaces 8 Physical Therapy 24, ,19 81 Respiratory Therapy 82 Occupational Therapy 83 Speech Pathology 85 Pharmacy 7, 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 559, ,649 97,473 6,144 8, Intermediate Care 115 Mentally Disordered Care 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 6, Other Nonreimbursable TOTAL $ 825,471 1% $ 825,471 $ 1,454 $ 64,714 $ - $ 97,473 $ 6,144 $ 8,339 (To Schedule 1)

10 STATE OF CALIFORNIA SCHEDULE 5 ALLOCATION OF CAPITAL COSTS Provider Name: SOUTH PASADENA CONVALESCENT HOSPITAL Provider NPI: Fiscal Period: JANUARY 1, 211 THROUGH DECEMBER 31, 211 OSHPD Facility Number: Line No. DESCRIPTION Net Exp For Cost Alloc (From Sch 8) Ratio Inserv. Ed 17 Accumulated Costs Admin 165 Medical Records 166 Total Capital Related 95% Of Total Property Tax 5% Of Total GENERAL SERVICES Capital Related (excluding lines 4 & 45) $ 785,48 95% Property Tax (line 4) 4,63 5% 5 Plant Operations and Maintenance 1 Housekeeping 6 Laundry and Linen 65 Dietary 155 Social Services 16 Activities 165 Administration $ 43,229 $ 43, Medical Records 11,16 $ 11,16 17 Inservice Education - Nursing $ 3,511 ANCILLARY SERVICES 75 Patient Supplies 6, $ 6,878 $ 6,544 $ Specialized Support Surfaces 8 Physical Therapy 26,93 4,285 1,92 32,28 3,713 1, Respiratory Therapy 82 Occupational Therapy 3, ,975 3, Speech Pathology Pharmacy 7,636 1, ,815 9, Laboratory Home Health Services 1 Other Ancillary Services Subacute Care Ancillary Services 12 Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 15 Skilled Nursing Care 3, ,258 33,3 8, ,44 727,914 37,13 11 Intermediate Care 115 Mentally Disordered Care 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 6, ,945 6, Other Nonreimbursable TOTAL $ 825,471 1% $ 3,511 $ 771,227 $ 43,229 $ 11,16 $ 825,471 $ 785,48 $ 4,63 (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: SOUTH PASADENA CONVALESCENT HOSPITAL JANUARY 1, 211 THROUGH DECEMBER 31, 211 Line No. 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. 55% of Total DPH Licensing Fees 2% of Total Professional Liability Ins. 7% of Total Quality Assur. Fees 36% of Total Caregiver Training % of Total GENERAL SERVICES 45 Property Insurance $ 29, Interest - Other 165 Administration (Salaries & Wages, Fringe Benefits, 1,93,387 Agency Staff and Other - Nonlabor) Total Costs Allocable as Administration 1,122,64 55% 167 CDPH Licensing Fees 36,548 2% 168 Professional Liability Insurance 139,66 7% 169 Quality Assurance Fees 729,44 36% 174 Caregiver Training % Total 2,28,252 1% $ 2,28,252 ANCILLARY SERVICES 75 Patient Supplies $ - $ 2,194 $ 38,985 $ 6,583 $ 47,762 11,1 $ 6,94 $ 198 $ 758 $ 3,96 $ - 77 Specialized Support Surfaces 8 Physical Therapy 87,79 8,965 28,538 26,93 872,196 21,65 111,286 3,623 13,845 72, Respiratory Therapy 82 Occupational Therapy 644, , ,635 82,267 2,678 1,235 53, Speech Pathology 12,565 12,565 2,897 1, ,42 85 Pharmacy 2, ,169 7, ,35 81,457 45,85 1,468 5,69 29,295 9 Laboratory 34,983 34,983 8,65 4, ,9 95 Home Health Services 1 Other Ancillary Services 39,191 39,191 9,35 5, , Subacute Care Ancillary Services 12 Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 15 Skilled Nursing Care 3,845, ,548 1,43, ,258 6,777,566 1,562, ,772 28,154 17, ,97 11 Intermediate Care 115 Mentally Disordered Care 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 2,282 6,82 6,846 15,93 3,672 2, , Other Nonreimbursable SUBTOTAL $ 2,28,252 $ 5,31,39 $ 794,533 $ 1,922,235 $ 771,227 $ 8,798,34 $ 2,28,252 Total Administrative Costs $ 2,28,252 Unit Cost Multiplier Accumulated Administration Costs (Sch 2 thru 5) $ 185,828 $ 5,766 $ 54,244 $ 29,838 $ 1,122,64 $ 36,548 $ 139,66 $ 729,44 $ - TOTAL FACILITY COSTS $ 11,117,394 (To Schedule 1)

12 STATE OF CALIFORNIA SCHEDULE 7 STATISTICS FOR COST ALLOCATION Provider Name: SOUTH PASADENA CONVALESCENT HOSPITAL Provider NPI: OSHPD Facility Number: Fiscal Period: JANUARY 1, 211 THROUGH DECEMBER 31, 211 Line No. DESCRIPTION Capital (SQ FT) VARIOUS (Adj ) 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 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) Admin. (TOTAL ACCUM COST) Med Records (TOTAL (ACCUM COST) GENERAL SERVICES 5 Plant Operations and Maintenance 36 1 Housekeeping 1,6 1,6 6 Laundry and Linen 65 Dietary 2,221 2,221 2, Social Services Activities Administration Medical Records Inservice Education - Nursing ANCILLARY SERVICES 75 Patient Supplies ,762 47, Specialized Support Surfaces 8 Physical Therapy , , Respiratory Therapy 82 Occupational Therapy 644, , Speech Pathology 12,565 12, Pharmacy ,35 353,35 9 Laboratory 34,983 34, Home Health Services 1 Other Ancillary Services 39,191 39, Subacute Care Ancillary Services 12 Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 15 Skilled Nursing Care 13,849 13,849 13, ,52 156,756 4,99,953 4,99,953 4,99,953 6,777,566 6,777, Intermediate Care 115 Mentally Disordered Care 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 ,93 15, Other Nonreimbursable TOTAL STATISTICS 2,445 2,49 18,89 522,52 156,756 4,99,953 4,99,953 4,99,953 8,798,34 8,798,34 TOTAL DIRECT SALARIES COSTS - SCH. 2 $ 153,56 $ 13,782 UNIT COST MULTIPLIER (DIRECT SALARIES) TOTAL INDIRECT SALARIES COSTS - SCH. 3 $ 113,46 $ 17,572 $ 124,171 $ 349,231 $ 2,48 $ 2,779 $ 97,774 $ 14,46 $ 171,422 UNIT COST MULTIPLIER (INDIRECT SALARIES) TOTAL INDIRECT OTHER COSTS - SCH. 4 $ 495,952 $ 79,149 $ 2,479 $ 43,826 $ 18,391 $ 25,176 $ 2,281 $ 28,81 $ 22,685 UNIT COST MULTIPLIER (INDIRECT OTHER) TOTAL CAPITAL COSTS - SCH. 5 $ 825,471 $ 1,454 $ 64,714 $ - $ 97,473 $ 6,144 $ 8,339 $ 3,511 $ 43,229 $ 11,16 UNIT COST MULTIPLIER (CAPITAL COSTS)

13 STATE OF CALIFORNIA SCHEDULE 8 SUMMARY OF AUDITED PROGRAM EXPENSES Provider Name: Fiscal Period: SOUTH PASADENA CONVALESCENT HOSPITAL JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility Number: Line No. Natural Class ACCOUNT TITLE ACCOUNT NUMBER AS REPORTED AUDIT ADJUSTMENTS 8A-1 AS AUDITED 5 Plant Operations and Maintenance Salaries and Wages 62 $ 89,43 $ $ 89, Fringe Benefits 62 24,3 24, Agency Staff Other - Nonlabor , ,952 5 Plant Operations and Maintenance - Total 62 $ 69,358 $ $ 69,358 1 Housekeeping Salaries and Wages 63 $ $ $ Fringe Benefits Agency Staff 63 21,44 (39,723) 161, Other - Nonlabor ,37 4,268 1 Housekeeping - Total 63 $ 22,365 $ (416) $ 21, Depreciation: Buildings and Improvements $ 1,8 $ $ 1,8 2 Depreciation: Leasehold Improvements ,293 13, Depreciation: Equipment 714 8,167 8,167 3 Depreciation and Amortization - Other ,564 2, Leases and Rentals , ,584 4 Property Taxes 73 69,76 (29,697) 4,63 45 Property Insurance 74 29,217 29,217 5 Interest - Property, Plant, and Equipment Interest - Other 76 $ $ $ 57 Subtotal 5-55 $ 1,666,891 $ (896) $ 1,665,995 (Sch 5) (Sch 5) (Sch 5) (Sch 5) (Sch 5) (Sch 5) (Sch 6) (Sch 5) (Sch 6) 6 Laundry and Linen Salaries and Wages 64 $ $ $ Fringe Benefits Agency Staff ,299 (1,128) 124, Other - Nonlabor 64 1,658 9,821 2,479 6 Laundry and Linen - Total 64 $ 144,957 $ (37) $ 144,65 65 Dietary Salaries and Wages 65 $ 252,555 $ $ 252, Fringe Benefits 65 64,193 64, Agency Staff Other - Nonlabor ,58 367,58 65 Dietary - Total 65 $ 684,256 $ $ 684,256 7 Provision for Bad Debts 77 $ $ Ancillary Services 75 Patient Supplies Salaries and Wages 81 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor 81 34,79 34,79 75 Patient Supplies - Total 81 $ 34,79 $ $ 34,79 77 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: SOUTH PASADENA CONVALESCENT HOSPITAL JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility Number: Line No. 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 82 87,79 87, Other - Nonlabor 82 11,62 11,62 8 Physical Therapy - Total 82 $ 818,852 $ $ 818, 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 $ 644,761 $ $ 644, Speech Pathology Salaries and Wages 828 $ $ $ Fringe Benefits Agency Staff ,565 12, Other - Nonlabor Speech Pathology - Total 828 $ 12,565 $ $ 12, Pharmacy Salaries and Wages 83 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor ,28 338,28 85 Pharmacy - Total 83 $ 338,28 $ $ 338,28 9 Laboratory Salaries and Wages 84 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor 84 34,983 34,983 9 Laboratory - Total 84 $ 34,983 $ $ 34, 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 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor 89 39,191 39,191 1 Other Ancillary Services - Total 89 $ 39,191 $ $ 39,191

15 STATE OF CALIFORNIA SCHEDULE 8 SUMMARY OF AUDITED PROGRAM EXPENSES Provider Name: Fiscal Period: SOUTH PASADENA CONVALESCENT HOSPITAL JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility Number: Line No 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 $ 1,923,269 $ $ 1,923, Routine Services Skilled Nursing Care Salaries and Wages Fringe Benefits.49 Agency Staff Other - Nonlabor Skilled Nursing Care - Total 611 $ 2,899,792 $ $ ,621 (2,58) ,54 2, $ 4,99,953 $ $ 2,899, , ,598 4,99, 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 $ $ $ $ $ $ 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: SOUTH PASADENA CONVALESCENT HOSPITAL JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility Number: Line No. 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 2,355 2, Beauty and Barber - Total 89 $ 2,355 $ $ 2, Other Nonreimbursable Salaries and Wages 91 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor Other Nonreimbursable - Total 91 $ $ $ 146 Subtotal $ 4,12,38 $ $ 4,12, Social Services Salaries and Wages 66 $ 121,916 $ $ 121, Fringe Benefits 66 31,14 31, Agency Staff Other - Nonlabor 66 14,4 14,4 155 Social Services - Total 66 $ 167,456 $ $ 167,456

17 STATE OF CALIFORNIA SCHEDULE 8 SUMMARY OF AUDITED PROGRAM EXPENSES Provider Name: Fiscal Period: SOUTH PASADENA CONVALESCENT HOSPITAL JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider NPI: OSHPD Facility Number: Line No. Natural Class ACCOUNT TITLE ACCOUNT NUMBER AS REPORTED AUDIT ADJUSTMENTS 8A-1 AS AUDITED 16 Activities Salaries and Wages 67 $ 13,655 $ $ 13, Fringe Benefits 67 27,127 27, Agency Staff Other - Nonlabor 67 19,759 19, Activities - Total 67 $ 15,541 $ $ 15, Administration Salaries and Wages 69 $ 587,867 $ (124,33) $ 463, Fringe Benefits ,574 (72,37) 122, Agency Staff Other - Nonlabor ,713 (136,427) 57, Administration - Total 69 $ 1,426,154 $ (332,767) $ 1,93,387 (Sch 6) (Sch 6) (Sch 6) (Sch 6) 166 Medical Records Salaries and Wages 69 $ 138,886 $ $ 138, Fringe Benefits 69 28,865 28, Agency Staff Other - Nonlabor 69 15,529 15, Medical Records - Total 69 $ 183,28 $ $ 183, CDPH Licensing Fees 69 $ 36,548 $ $ 36, Professional Liability Insurance 69 $ 165,774 $ (26,114) $ 139, Quality Assurance Fees 69 $ 729,44 $ $ 729,44 17 Inservice Education - Nursing Salaries and Wages 68 $ 76,551 $ $ 76, Fringe Benefits 68 2,53 2, Agency Staff Other - Nonlabor Inservice Education - Nursing - Total 68 $ 96,64 $ $ 96,64 (Sch 6) (Sch 6) (Sch 6) 174 Caregiver Training Salaries and Wages 69 $ $ $ Fringe Benefits Agency Staff Other - Nonlabor Caregiver Training - Total 69 $ $ $ (Sch 6) (Sch 6) (Sch 6) (Sch 6) Subtotal $ 2,955,797 $ (358,881) $ 2,596,916 2 Total $ 11,477,478 $ (36,84) $ 11,117, Total Facility Group Health Insurance 69 $ 164,953 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: SOUTH PASADENA CONVALESCENT HOSPITAL 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 Line Sub (Pages 1 & 2) No. No. 5 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 (39,723) (39,37) (416) 1 4 Housekeeping - Other - Nonlabor 39,37 39, 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 (29,697) (29,217) (48) 45 4 Property Insurance 29,217 29, Interest - Property, Plant, and Equipment 55 4 Interest - Other 6 1 Laundry and Linen - Salaries and Wages 6 2 Laundry and Linen - Fringe Benefits 6 3 Laundry and Linen - Agency Staff (1,128) (9,821) (37) 6 4 Laundry and Linen - Other - Nonlabor 9,821 9, 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 77 1 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: SOUTH PASADENA CONVALESCENT HOSPITAL 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 Line Sub (Pages 1 & 2) No. No 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 15 2 Skilled Nursing Care - Fringe Benefits (2,58) (2,58) 15 3 Skilled Nursing Care - Agency Staff 15 4 Skilled Nursing Care - Other - Nonlabor 2,58 2, 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: SOUTH PASADENA CONVALESCENT HOSPITAL 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 Line Sub (Pages 1 & 2) No. No 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 (124,33) Administration - Fringe Benefits (72,37) (39,179) Administration - Agency Staff Administration - Other - Nonlabor (136,427) 25,24 (72,729) Medical Records - Salaries and Wages Medical Records - Fringe Benefits Medical Records - Agency Staff Medical Records - Other - Nonlabor CDPH Licensing Fees Professional Liability Insurance (26,114) (25,24) (1,9) 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

21 STATE OF CALIFORNIA RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS Schedule 8A-1 Page 1 Provider Name: Provider NPI: OSHPD Facility Number: Fiscal Period: SOUTH PASADENA CONVALESCENT HOSPITAL 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 Line Sub (Pages 1 & 2) No. No Caregiver Training - Agency Staff Caregiver Training - Other - Nonlabor 2 Total ($36,84) (72,729) (39,179) (1,9) (48) (723) (To Sch 8)

22 STATE OF CALIFORNIA RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS Schedule 8A-1 Page 2 Provider Name: SOUTH PASADENA CONVALESCENT HOSPITAL Provider NPI: OSHPD Facility Number: Fiscal Period: JANUARY 1, 211 THROUGH DECEMBER 31, 211 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ Line Sub No. No. 5 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 Linen - Salaries and Wages 6 2 Laundry and Linen - Fringe Benefits 6 3 Laundry and Linen - Agency Staff 6 4 Laundry and Linen - 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 77 1 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

23 STATE OF CALIFORNIA RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS Schedule 8A-1 Page 2 Provider Name: SOUTH PASADENA CONVALESCENT HOSPITAL Provider NPI: OSHPD Facility Number: Fiscal Period: JANUARY 1, 211 THROUGH DECEMBER 31, 211 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ Line Sub No. No 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 15 2 Skilled Nursing Care - Fringe Benefits 15 3 Skilled Nursing Care - Agency Staff 15 4 Skilled Nursing Care - Other - Nonlabor 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

24 STATE OF CALIFORNIA RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS Schedule 8A-1 Page 2 Provider Name: SOUTH PASADENA CONVALESCENT HOSPITAL Provider NPI: OSHPD Facility Number: Fiscal Period: JANUARY 1, 211 THROUGH DECEMBER 31, 211 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ Line Sub No. No 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 (124,33) Administration - Fringe Benefits (32,858) Administration - Agency Staff Administration - Other - Nonlabor (78,722) (1,) 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

25 STATE OF CALIFORNIA RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS Schedule 8A-1 Page 2 Provider Name: SOUTH PASADENA CONVALESCENT HOSPITAL Provider NPI: OSHPD Facility Number: Fiscal Period: JANUARY 1, 211 THROUGH DECEMBER 31, 211 Line Sub No. No Caregiver Training - Agency Staff Caregiver Training - Other - Nonlabor AUDIT ADJ 1 AUDIT ADJ 11 AUDIT ADJ 12 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 2 (78,722) (157,161) (1,) Total

26 State of California Department of Health Care Services Provider Name SOUTH PASADENA CONVALESCENT HOSPITAL Report References Cost Report Audit Report MC53 Adj. Page or No. Exhibit Line Col. Sch. Line Sub No Fiscal Period JANUARY 1, 211 THROUGH DECEMBER 31, 211 Explanation of Audit Adjustments MEMORANDUM ADJUSTMENT Provider NPI Adjustments As Reported Increase (Decrease) As Adjusted 1 Not Reported 8 21 N/A Total Facility Group Health Insurance To include total group health insurance costs for informational purpose 42 CFR and CMS Pub. 15-1, Sections 23 and 234 $ $164,953 $164,953 Page 1

27 State of California Department of Health Care Services Provider Name SOUTH PASADENA CONVALESCENT HOSPITAL Report References Cost Report Audit Report MC53 Adj. Page or No. Exhibit Line Col. Sch. Line Sub No Fiscal Period JANUARY 1, 211 THROUGH DECEMBER 31, 211 Explanation of Audit Adjustments RECLASSIFICATIONS OF REPORTED COSTS Provider NPI Adjustments As Reported Increase (Decrease) As Adjusted A A A A Property Taxes Skilled Nursing Care - Fringe Benefits Property Insurance Skilled Nursing Care - Other - Nonlabor To reclassify the reported expenses for proper cost determination. 42 CFR and CMS Pub. 15-1, Sections 23 and 234 $69,76 663, ,54 ($29,217) (2,58) 29,217 2,58 $4, ,563 29, , A A Administration - Professional Liability Insurance Administration - Other - Nonlabor To reclassify finance fees, taxes and other fees associated with liability insurance to the administration cost center. 42 CFR / CMS Pub. 15-1, Section 2162 CCR, Title 22, Sections 52(b) and 5251 $165, ,713 ($25,24) 25,24 $14,75 668, A A A A Housekeeping - Agency Staff Laundry and Linen - Agency Staff Housekeeping - Other - Nonlabor Laundry and Linen - Other - Nonlabor To reclassify the non labor portion of the contract labor expense for proper cost determination. 42 CFR and / CMS Pub. 15-1, Sections 23 and 234 CCR, Title 22, Section 5252(c)(1) $21,44 134, ,658 ($39,37) (9,821) 39,37 9,821 $162,97 124,478 4,268 2,479 Balance carried forward from prior/to subsequent adjustments Page 2