REPORT ON THE RATE SETTING AUDIT CALIFORNIA HEALTHCARE AND REHABILITATION CENTER VAN NUYS, CALIFORNIA NATIONAL PROVIDER IDENTIFIER:

Transcription

1 REPORT ON THE RATE SETTING AUDIT CALIFORNIA HEALTHCARE AND REHABILITATION CENTER VAN NUYS, CALIFORNIA NATIONAL PROVIDER IDENTIFIER: FISCAL PERIOD ENDED DECEMBER 31, 2011 Audits Section - Gardena Financial Audits Branch Audits and Investigations Department of Health Care Services Section Chief: Maria Delgado Audit Supervisor: Ginn Sampson Auditor: Nicholas Lui

2 State of California Health and Human Services Agency Department of Health Care Services TOBY DOUGLAS DIRECTOR EDMUND G. BROWN, JR. GOVERNOR March 1 9, 2013 Jerry Catama, Administrator California Healthcare and Rehabilitation Center 6700 Sepulveda Boulevard Van Nuys, CA PROVIDER: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER NATIONAL PROVIDER IDENTIFIER (NPI): FISCAL PERIOD ENDED: DECEMBER 31, 2011 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 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 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 adjust ments that include a summary of the total due the State in the amount of $5,269 which resulted from Medi-Cal overpayments 3. Audited Allocation of Home Office Cost The audit settlement will be incorporated into a Statement of Account Status, which may reflect tentative retroactive adjustment determinations, payments from the provider, and other financial transactions initiated by the Department. The Statement of Account Status will be forwarded to the provider by the State s fiscal intermediary. Instructio ns regarding payment will be included with the Statement of Account Status. Financial Audits/Gardena/A & I, MS 2103, South Hamilton Avenue, Suite 280, Gardena, CA Telephone: (310) / FAX: (310) Internet Address:

3 Jerry Catama 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 Office of Administrative Appeals and Hearings 1029 J Street, Suite 200 Sacramento, CA (916) The written notice of disagreement must be received by the Department within 60 calendar days from the day you receive this letter. A copy of this notice should be sent to: United States Postal Service (USPS) Courier (UPS, FedEx, etc.) sistant Chief Counsel sistant Chief Counsel Department of Health Care Services Department of Health Care Services Office of Legal Services Office of Legal Services MS 0010 MS 0010 PO Box 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 51016, et seq. If you have questions regarding this report you may call the Audits Section Gardena at (310) Original Signed By: Maria Delgado, Chief Audits Section Gardena Financial Audits Branch Certified

4 Jerry Catama Page 3 cc: Zaid Pervaiz, Controller Longwood Management Corporation 4032 Wilshire Boulevard, Suite 600 Los Angeles, CA 90010

5 STATE OF CALIFORNIA SCHEDULE 1 SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY Provider Name: Fiscal Period: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 Provider NPI: OSHPD Facility : Line PROGRAM DESCRIPTION AUDITED COST PER AS REPORTED AS AUDITED PATIENT DAY SKILLED NURSING CARE 1 Cost of Direct Care - Labor (Sch. 2, Ln. 105) $ N/A $ 3,977,618 $ Cost of Indirect Care - Labor (Sch. 3, Ln. 105) $ N/A $ 967,369 $ Cost of Direct and Indirect Nonlabor - Other (Sch. 4, Ln. 105) $ N/A $ 864,182 $ Cost of Capital Related (Sch. 5, Ln. 105) $ N/A $ 912,830 $ Property Taxes (Sch. 5, Ln. 105) $ N/A $ 59,012 $ CDPH Licensing Fees (Sch. 6, Ln. 105) $ N/A $ 22,844 $ Professional Liability Insurance (Sch. 6, Ln. 105) $ N/A $ 62,456 $ Caregiver Training (Sch. 6, Ln. 105) $ N/A $ 0 $ Quality surance Fees (Sch. 6, Ln. 105) $ N/A $ 416,543 $ Cost of Administration (Sch. 6, Ln. 105) $ N/A $ 810,156 $ Cost of Routine Service/Audited Total Costs $ 8,233, $ 8,093,011 $ Total Patient Days (Adj ) 50,211 50, Cost Per Patient Day (Cost Divided by Days) $ $ Overpayments (Adj 27) $ $ 5, Medi-Cal Days (Adj 22) 35,515 32, Medi-Cal Managed Care Days (Adj ) 0 INTERMEDIATE CARE 17 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0 18 Total Patient Days (Adj ) 0 19 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ Overpayments (Adj ) $ $ 0 MENTALLY DISORDERED CARE 21 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0 22 Total Patient Days (Adj ) 0 23 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ Overpayments (Adj ) $ $ 0 DEVELOPMENTALLY DISABLED CARE 25 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0 26 Total Patient Days (Adj ) 0 27 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ Overpayments (Adj ) $ $ 0 SUBACUTE CARE 29 Cost of Direct Care - Labor (Subacute Care Sch. 1, Ln. 25) $ N/A $ 4,327,345 $ Cost of Indirect Care - Labor (Subacute Care Sch. 1, Ln. 26) $ N/A $ 358,713 $ Cost of Direct and Indirect Nonlabor - Other (Subacute Care Sch. 1, Ln. 27) $ N/A $ 962,756 $ Cost of Capital Related (Subacute Care Sch. 1, Ln. 28) $ N/A $ 324,262 $ Property Taxes (Subacute Care Sch. 1, Ln. 29) $ N/A $ 20,963 $ CDPH Licensing Fees (Subacute Care Sch. 1, Ln. 30) $ N/A $ 20,192 $ Professional Liability Insurance (Subacute Care Sch. 1, Ln. 31) $ N/A $ 55,208 $ Quality surance Fees (Subacute Care Sch. 1, Ln. 32) $ N/A $ 368,201 $ Caregiver Training (Subacute Care Sch. 1, Ln. 33) $ N/A $ 0 $ Cost of Administration (Subacute Care Sch.1, Ln. 34) $ N/A $ 716,133 $ Total Cost of Subacute Service (Subacute Care Sch. 1, Ln. 35) $ 7,122,602 $ 7,153,773 $ Total Patient Days (Subacute Care Sch. 1, Ln. 36) 16,613 16, Cost Per Patient Day (Cost Divided by Days) $ $ Amount Due Provider (State) (Subacute Care Sch. 1, Ln. 40) $ 0 $ 0

6 STATE OF CALIFORNIA SCHEDULE 1 SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY Provider Name: Fiscal Period: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 Provider NPI: OSHPD Facility : Line 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) $ 0 $ 0 44 Cost of Ancillary Service (Subacute Care - Pediatric, Sch. 1, Ln. 1 + Ln. 2) $ 0 $ 0 45 Total Cost of Subacute Care - Pediatric Service (Ln Ln. 44) $ 0 $ 0 46 Total Patient Days (Subacute Care - Pediatric, Sch. 1, Ln. 5) Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ Amount Due Provider (State) (Subacute Care - Pediatric, Sch. 1, Ln. 9) $ 0 $ 0 TRANSITIONAL INPATIENT CARE 49 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0 50 Total Patient Days (Adj ) 0 51 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ Overpayments (Adj ) $ $ 0 HOSPICE INPATIENT CARE 53 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0 54 Total Patient Days (Adj ) 0 55 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ Overpayments (Adj ) $ $ 0 OTHER ROUTINE SERVICES 57 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0 58 Total Patient Days (Adj ) 0 59 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ Overpayments (Adj ) $ $ 0 (From Subacute Care Schedule 1)

7 STATE OF CALIFORNIA SCHEDULE 2 ALLOCATION OF GENERAL SERVICES DIRECT CARE LABOR Provider Name: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER Fiscal Period: JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 Provider NPI: OSHPD Facility : Soc Srvs Activities Line DESCRIPTION Net Exp For Cost Alloc (From Sch 8) Total GENERAL SERVICES 005 Plant Operations and Maintenance 010 Housekeeping 060 Laundry and Linen 065 Dietary 155 Social Services $ 239,590 $ 239, Activities 148,015 $ 148, Administration 166 Medical Records 170 Inservice Education - Nursing ANCILLARY SERVICES 075 Patient Supplies Specialized Support Surfaces N/A Physical Therapy 488, , Respiratory Therapy Occupational Therapy 365, , Speech Pathology 91, , Pharmacy Laboratory Home Health Services Other Ancillary Services Subacute Care Ancillary Services 1,020, ,020, Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 105 Skilled Nursing Care 3,775, ,154 77,318 3,977, Intermediate Care Mentally Disordered Care Developmentally Disabled Care Subacute Care 3,002, ,436 70,697 3,187, Subacute Care - Pediatric Transitional Inpatient Care Hospice Inpatient Care Other Routine Services NONREIMBURSABLE 139 Residential Care Beauty and Barber Other Nonreimbursable TOTAL $ 9,131,574 $ 239,590 $ 148,015 $ 9,131,574 (To Schedule 1) (To Subacute Care Schedule 1) (To Subacute Care Schedule 2)

8 STATE OF CALIFORNIA SCHEDULE 3 ALLOCATION OF GENERAL SERVICES INDIRECT CARE LABOR Provider Name: Provider NPI: OSHPD Facility Number: Fiscal Period: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 Line DESCRIPTION Net Exp For Cost Alloc (From Sch 8) Plant Ops 005 Hskpng 010 Laundry 060 Dietary 065 Soc Srvs 155 Activities 160 Inserv. Ed 170 Accumulated Costs Admin 165 Medical Records 166 Total GENERAL SERVICES 005 Plant Operations and Maintenance $ 139,791 $ 139, Housekeeping 252,558 1,576 $ 254, Laundry and Linen 113,221 4,254 7,821 $ 125, Dietary 518,448 18,767 34,507 0 $ 571, Social Services N/A $ 1, Activities N/A 5,343 9, $ 15, Administration N/A 5,326 9, $ 15,118 $ 15, Medical Records 146,697 1,567 2, ,146 $ 151, Inservice Education - Nursing 198, $ 199,003 ANCILLARY SERVICES 075 Patient Supplies ,212 $ 2, Specialized Support Surfaces Physical Therapy 4,628 8, , ,301 20, Respiratory Therapy Occupational Therapy 4,628 8, , ,926 18, Speech Pathology , ,094 2, Pharmacy ,878 4, Laboratory Home Health Services Other Ancillary Services Subacute Care Ancillary Services ,104 11,038 12, Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 105 Skilled Nursing Care 69, ,562 94, , , , ,637 7,159 71, , Intermediate Care Mentally Disordered Care Developmentally Disabled Care Subacute Care 22,612 41,576 30,560 87, ,244 95, ,973 4,911 49, , Subacute Care - Pediatric Transitional Inpatient Care Hospice Inpatient Care Other Routine Services NONREIMBURSABLE 139 Residential Care Beauty and Barber Other Nonreimbursable TOTAL $ 1,369,327 $ 139,791 $ 254,134 $ 125,296 $ 571,722 $ 1,295 $ 15,167 $ 199,003 $ 1,203,063 $ 15,118 $ 151,146 $ 1,369,327 (To Schedule 1) (To Subacute Care Schedule 1) (To Subacute Care Schedule 2)

9 STATE OF CALIFORNIA SCHEDULE 4 ALLOCATION OF GENERAL SERVICES OTHER - NONLABOR Provider Name: Provider NPI: OSHPD Facility Number: Fiscal Period: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 Line DESCRIPTION Net Exp For Cost Alloc (From Sch 8) Plant Ops 5 Hskpng 10 Laundry 60 Dietary 65 Soc Srvs 155 Activities 160 Inserv. Ed 170 Accumulated Costs Admin 165 Medical Records 166 Total GENERAL SERVICES 005 Plant Operations and Maintenance $ 481,593 $ 481, Housekeeping 63,034 5,429 $ 68, Laundry and Linen 51,199 14,654 2,107 $ 67, Dietary 316,276 64,654 9,296 0 $ 390, Social Services 0 1, $ 1, Activities 4,152 18,407 2, $ 25, Administration N/A 18,348 2, $ 20,986 $ 20, Medical Records 14,143 5, ,318 $ 20, Inservice Education - Nursing ANCILLARY SERVICES 075 Patient Supplies 203, , $ 204, Specialized Support Surfaces Physical Therapy 17,730 15,945 2, , , Respiratory Therapy Occupational Therapy 13,259 15,945 2, , , Speech Pathology 3,316 1, , , Pharmacy 360, , , Laboratory 55, , , Home Health Services Other Ancillary Services 33, , , Subacute Care Ancillary Services ,069 1,533 1,484 4, Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 105 Skilled Nursing Care 174, ,009 34,365 51, , , ,623 9,938 9, , Intermediate Care Mentally Disordered Care Developmentally Disabled Care Subacute Care 609,538 77,900 11,200 16,576 59, , ,965 6,816 6, , Subacute Care - Pediatric Transitional Inpatient Care Hospice Inpatient Care Other Routine Services NONREIMBURSABLE 139 Residential Care Beauty and Barber 970 1, , , Other Nonreimbursable $ 543 TOTAL $ 2,402,871 $ 481,593 $ 68,463 $ 67,960 $ 390,226 $ 1,798 $ 25,206 $ 543 $ 2,361,567 $ 20,986 $ 20,318 $ 2,402,871 (To Schedule 1) (To Subacute Care Schedule 1) (To Subacute Care Schedule 2)

10 STATE OF CALIFORNIA SCHEDULE 5 ALLOCATION OF CAPITAL COSTS Provider Name: Fiscal Period: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 Provider NPI: OSHPD Facility Number: Capital Plant Ops Hskpng Laundry Dietary Soc Srvs Activities Line DESCRIPTION Net Exp For Cost Alloc (From Sch 8) Ratio Various GENERAL SERVICES Capital Related (excluding lines 40 & 45) $ 1,330,043 94% Property Tax (line 40) 85,983 6% $ 1,416, Plant Operations and Maintenance 47,216 $ 47, Housekeeping 15, $ 15, Laundry and Linen 41,652 1, $ 43, Dietary 183,764 6,339 2,167 0 $ 192, Social Services 4, $ 4, Activities 52,317 1, $ 54, Administration 52,149 1, Medical Records 15, Inservice Education - Nursing 1, ANCILLARY SERVICES 075 Patient Supplies 1, Specialized Support Surfaces Physical Therapy 45,319 1, Respiratory Therapy Occupational Therapy 45,319 1, Speech Pathology 3, Pharmacy Laboratory Home Health Services Other Ancillary Services Subacute Care Ancillary Services 2, Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 105 Skilled Nursing Care 679,325 23,433 8,012 32, ,907 2,442 28, Intermediate Care Mentally Disordered Care Developmentally Disabled Care Subacute Care 221,411 7,637 2,611 10,629 29,363 2,233 26, Subacute Care - Pediatric Transitional Inpatient Care Hospice Inpatient Care Other Routine Services NONREIMBURSABLE 139 Residential Care Beauty and Barber 3, Other Nonreimbursable TOTAL $ 1,416, % $ 1,416,026 $ 47,216 $ 15,962 $ 43,580 $ 192,270 $ 4,676 $ 54,739 (To Schedule 1) (To Subacute Care Schedule 1) (To Subacute Care Schedule 2)

11 STATE OF CALIFORNIA SCHEDULE 5 ALLOCATION OF CAPITAL COSTS Provider Name: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER Provider NPI: Fiscal Period: JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 OSHPD Facility Number: Line DESCRIPTION Net Exp For Cost Alloc (From Sch 8) Ratio Inserv. Ed 170 Accumulated Costs Admin 165 Medical Records 166 Total Capital Related 94% Of Total Property Tax 6% Of Total GENERAL SERVICES Capital Related (excluding lines 40 & 45) $ 1,330,043 94% Property Tax (line 40) 85,983 6% 005 Plant Operations and Maintenance 010 Housekeeping 060 Laundry and Linen 065 Dietary 155 Social Services 160 Activities 165 Administration $ 54,563 $ 54, Medical Records 16,056 $ 16, Inservice Education - Nursing $ 1,411 ANCILLARY SERVICES 075 Patient Supplies 0 1, $ 2,269 $ 2,131 $ Specialized Support Surfaces Physical Therapy 0 47,417 2, ,361 47,303 3, Respiratory Therapy Occupational Therapy 0 47,417 1, ,718 46,700 3, Speech Pathology 0 4, ,657 4, Pharmacy 0 0 1, ,812 1, Laboratory Home Health Services Other Ancillary Services Subacute Care Ancillary Services 0 2,779 3,985 1,173 7,936 7, Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 105 Skilled Nursing Care ,401 25,838 7, , ,830 59, Intermediate Care Mentally Disordered Care Developmentally Disabled Care Subacute Care ,704 17,723 5, , ,990 19, Subacute Care - Pediatric Transitional Inpatient Care Hospice Inpatient Care Other Routine Services NONREIMBURSABLE 139 Residential Care Beauty and Barber 0 3, ,341 3, Other Nonreimbursable TOTAL $ 1,416, % $ 1,411 $ 1,345,408 $ 54,563 $ 16,056 $ 1,416,026 $ 1,330,043 $ 85,983 (To Schedule 1) (To Subacute Care Schedule 1) (To Subacute Care Schedule 2)

12 STATE OF CALIFORNIA SCHEDULE 6 ALLOCATION OF ADMINISTRATION AND OTHER DIRECT PASS-THROUGH COSTS Provider Name: Provider NPI: OSHPD Facility Number: Fiscal Period: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 Line 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 2% of Total Professional Liability Ins. 5% of Total Quality sur. Fees 32% of Total Caregiver Training 0% of Total GENERAL SERVICES 045 Property Insurance $ 7, Interest - Other Administration (Salaries & Wages, Fringe Benefits, Agency Staff and Other - Nonlabor) 1,703,012 Total Costs Allocable as Administration 1,710,847 62% 167 CDPH Licensing Fees 48,240 2% 168 Professional Liability Insurance 131,892 5% 169 Quality surance Fees 879,635 32% 174 Caregiver Training 0 0% Total 2,770, % $ 2,770,614 ANCILLARY SERVICES 075 Patient Supplies $ - $ 342 $ 203,958 $ 1,235 $ 205,535 40,555 $ 25,043 $ 706 $ 1,931 $ 12,876 $ Specialized Support Surfaces Physical Therapy 488,831 13,138 35,967 47, , ,499 71,320 2,011 5,498 36, Respiratory Therapy Occupational Therapy 365,573 13,138 31,496 47, ,625 90,296 55,758 1,572 4,298 28, Speech Pathology 91,441 1,149 4,911 4, ,647 20,056 12, , Pharmacy , ,239 71,080 43,892 1,238 3,384 22, Laboratory , ,529 10,957 6, , Home Health Services Other Ancillary Services , ,567 6,623 4, , Subacute Care Ancillary Services 1,020, ,069 2,779 1,025, , ,939 3,523 9,632 64, Subacute Care - Pediatric Ancillary Services ROUTINE SERVICES 105 Skilled Nursing Care 3,977, , , ,401 6,649,279 1,311, ,156 22,844 62, , Intermediate Care Mentally Disordered Care Developmentally Disabled Care Subacute Care 3,187, , , ,704 4,560, , ,711 15,669 42, , Subacute Care - Pediatric Transitional Inpatient Care Hospice Inpatient Care Other Routine Services NONREIMBURSABLE 139 Residential Care Beauty and Barber ,242 3,308 6,467 1, Other Nonreimbursable SUBTOTAL $ 2,770,614 $ 9,131,574 $ 1,203,063 $ 2,361,567 $ 1,345,408 $ 14,041,612 $ 2,770,614 Total Administrative Costs $ 2,770,614 $ 1,710,847 $ 48,240 $ 131,892 $ 879,635 $ - Unit Cost Multiplier Accumulated Administration Costs (Sch 2 thru 5) $ 166,264 $ 41,304 $ 70,618 $ 278,186 TOTAL FACILITY COSTS $ 17,090,412 (To Schedule 1) (To Subacute Care Schedule 1) (To Subacute Care Schedule 2)

13 STATE OF CALIFORNIA SCHEDULE 7 STATISTICS FOR COST ALLOCATION Provider Name: Provider NPI: OSHPD Facility Number: Fiscal Period: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 Line GENERAL SERVICES DESCRIPTION Capital (SQ FT) VARIOUS Plant Ops (SQ FT) 5 Hskpng (SQ FT) 10 Laundry (LBS) 60 Dietary (MEALS) 65 Soc Srvs (DIRECT EXP) 155 Activities (DIRECT EXP) 160 Inserv. Ed (DIRECT EXP) 170 (Adj 19) (Adj 19) (Adj 19) (Adj ) (Adj 18) (Adj ) (Adj ) (Adj ) Admin. (TOTAL ACCUM COST) Med Records (TOTAL (ACCUM COST) 005 Plant Operations and Maintenance 1, Housekeeping Laundry and Linen Dietary 4,359 4,359 4, Social Services Activities 1,241 1,241 1, Administration 1,237 1,237 1, Medical Records Inservice Education - Nursing ANCILLARY SERVICES 075 Patient Supplies , , Specialized Support Surfaces Physical Therapy 1,075 1,075 1, , , Respiratory Therapy Occupational Therapy 1,075 1,075 1, , , Speech Pathology , , Pharmacy 360, , Laboratory 55,529 55, Home Health Services Other Ancillary Services 33,567 33, Subacute Care Ancillary Services ,025,425 1,025, Subacute Care - Pediatric Ancillary Services 0 0 ROUTINE SERVICES 105 Skilled Nursing Care 16,114 16,114 16, , ,816 3,949,989 3,949,989 3,949,989 6,649,279 6,649, Intermediate Care Mentally Disordered Care Developmentally Disabled Care Subacute Care 5,252 5,252 5, ,930 26,643 3,611,709 3,611,709 3,611,709 4,560,946 4,560, Subacute Care - Pediatric Transitional Inpatient Care Hospice Inpatient Care Other Routine Services NONREIMBURSABLE 139 Residential Care Beauty and Barber ,467 6, Other Nonreimbursable 0 0 TOTAL STATISTICS 33,589 32,469 32, , ,459 7,561,698 7,561,698 7,561,698 14,041,612 14,041,612 TOTAL DIRECT SALARIES COSTS - SCH. 2 $ 239,590 $ 148,015 UNIT COST MULTIPLIER (DIRECT SALARIES) TOTAL INDIRECT SALARIES COSTS - SCH. 3 $ 139,791 $ 254,134 $ 125,296 $ 571,722 $ 1,295 $ 15,167 $ 199,003 $ 15,118 $ 151,146 UNIT COST MULTIPLIER (INDIRECT SALARIES) TOTAL INDIRECT OTHER COSTS - SCH. 4 $ 481,593 $ 68,463 $ 67,960 $ 390,226 $ 1,798 $ 25,206 $ 543 $ 20,986 $ 20,318 UNIT COST MULTIPLIER (INDIRECT OTHER) TOTAL CAPITAL COSTS - SCH. 5 $ 1,416,026 $ 47,216 $ 15,962 $ 43,580 $ 192,270 $ 4,676 $ 54,739 $ 1,411 $ 54,563 $ 16,056 UNIT COST MULTIPLIER (CAPITAL COSTS)

14 STATE OF CALIFORNIA SCHEDULE 8 SUMMARY OF AUDITED PROGRAM EXPENSES Provider Name: Fiscal Period: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 Provider NPI: OSHPD Facility Number: Line Natural Class ACCOUNT TITLE ACCOUNT NUMBER AS REPORTED AUDIT ADJUSTMENTS 8A-1 AS AUDITED 005 Plant Operations and Maintenance Salaries and Wages 6200 $ 228,773 $ (114,412) $ 114, Fringe Benefits , , Agency Staff Other - Nonlabor ,611 (6,018) 481, Plant Operations and Maintenance - Total Housekeeping 6200 $ 741,814 $ (120,430) $ 621, Salaries and Wages 6300 $ 206,615 $ 0 $ 206, Fringe Benefits , , Agency Staff Other - Nonlabor , , Housekeeping - Total 6300 $ 315,592 $ 0 $ 315, Depreciation: Buildings and Improvements $ $ 0 $ 020 Depreciation: Leasehold Improvements Depreciation: Equipment , , Depreciation and Amortization - Other Leases and Rentals ,180, ,880 1,309, Property Taxes ,113 (35,130) 85, Property Insurance , , Interest - Property, Plant, and Equipment Interest - Other 7600 $ $ 0 $ 0 (Sch 3) (Sch 3) (Sch 3) (Sch 3) (Sch 3) (Sch 3) 0 (Sch 5) (Sch 5) (Sch 5) (Sch 5) (Sch 5) (Sch 5) (Sch 6) (Sch 5) (Sch 6) 057 Subtotal $ 2,386,517 $ (25,680) $ 2,360, Laundry and Linen Salaries and Wages 6400 $ 92,625 $ 0 $ 92, Fringe Benefits , , Agency Staff ,376 (6,376) Other - Nonlabor ,823 6,376 51, Laundry and Linen - Total Dietary 6400 $ 164,420 $ 0 $ 164, Salaries and Wages 6500 $ 456,809 $ (32,673) $ 424, Fringe Benefits , , Agency Staff Other - Nonlabor , , Dietary - Total 6500 $ 867,397 $ (32,673) $ 834,724 (Sch 3) (Sch 3) (Sch 3) (Sch 3) (Sch 3) (Sch 3) 070 Provision for Bad Debts 7700 $ 0 $ 0 Ancillary Services 075 Patient Supplies Salaries and Wages 8100 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor , , Patient Supplies - Total Specialized Support Surfaces 8100 $ 203,483 $ 0 $ 203, Salaries and Wages 8150 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor Specialized Support Surfaces - Total 8150 $ 0 $ 0 $ N/A N/A N/A

15 STATE OF CALIFORNIA SCHEDULE 8 SUMMARY OF AUDITED PROGRAM EXPENSES Provider Name: Fiscal Period: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 Provider NPI: OSHPD Facility Number: Line Natural Class ACCOUNT TITLE ACCOUNT NUMBER AS REPORTED AUDIT ADJUSTMENTS 8A-1 AS AUDITED 080 Physical Therapy Salaries and Wages 8200 $ $ 0 $ Fringe Benefits Agency Staff ,561 (17,730) 488, Other - Nonlabor ,730 17, Physical Therapy - Total Respiratory Therapy 8200 $ 506,561 $ 0 $ 506, Salaries and Wages 8220 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor Respiratory Therapy - Total Occupational Therapy 8220 $ 0 $ 0 $ Salaries and Wages 8250 $ $ 0 $ Fringe Benefits Agency Staff ,832 (13,259) 365, Other - Nonlabor ,259 13, Occupational Therapy - Total 8250 $ 378,832 $ 0 $ 378, Speech Pathology Salaries and Wages 8280 $ $ 0 $ Fringe Benefits Agency Staff ,757 (3,316) 91, Other - Nonlabor ,316 3, Speech Pathology - Total 8280 $ 94,757 $ 0 $ 94, Pharmacy Salaries and Wages 8300 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor , , Pharmacy - Total Laboratory 8300 $ 360,239 $ 0 $ 360, Salaries and Wages 8400 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor , , Laboratory - Total Home Health Services 8400 $ 55,529 $ 0 $ 55, Salaries and Wages 8800 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor Home Health Services - Total Other Ancillary Services 8800 $ 0 $ 0 $ Salaries and Wages 8900 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor , , Other Ancillary Services - Total 8900 $ 33,567 $ 0 $ 33,

16 STATE OF CALIFORNIA SCHEDULE 8 SUMMARY OF AUDITED PROGRAM EXPENSES Provider Name: Fiscal Period: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 Provider NPI: OSHPD Facility Number: Line Natural Class ACCOUNT TITLE ACCOUNT NUMBER AS REPORTED AUDIT ADJUSTMENTS 8A-1 AS AUDITED 101 Subacute Care Ancillary Services Salaries and Wages $ $ 835,109 $ 835, Fringe Benefits , , Agency Staff Other - Nonlabor Subacute Care Ancillary Services - Total Subacute Care - Pediatric Ancillary Services $ 0 $ 1,020,807 $ 1,020, Salaries and Wages $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor Subacute Care - Pediatric Ancillary Services - Total $ 0 $ 0 $ Subtotal $ 1,632,968 $ 1,020,807 $ 2,653,775 Routine Services 105 Skilled Nursing Care Salaries and Wages 6110 $ 3,264,250 $ (175,850) $ 3,088, Fringe Benefits ,773 (15,027) 686, Agency Staff Other - Nonlabor ,707 (78,864) 174, Skilled Nursing Care - Total 6110 $ 4,219,730 $ (269,741) $ 3,949, Intermediate Care Salaries and Wages 6120 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor Intermediate Care - Total 6120 $ 0 $ 0 $ Mentally Disordered Care Salaries and Wages 6130 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor Mentally Disordered Care - Total 6130 $ 0 $ 0 $ Developmentally Disabled Care Salaries and Wages 6140 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor Developmentally Disabled Care - Total 6140 $ 0 $ 0 $ Subacute Care Salaries and Wages 6150 $ 3,254,860 $ (798,821) $ 2,456, Fringe Benefits ,761 (177,629) 546, Agency Staff Other - Nonlabor ,645 (90,107) 609, Subacute Care - Total 6150 $ 4,678,266 $ (1,066,557) $ 3,611, Subacute Care - Pediatric Salaries and Wages 6160 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor Subacute Care - Pediatric - Total 6160 $ 0 $ 0 $ 0 0 0

17 STATE OF CALIFORNIA SCHEDULE 8 SUMMARY OF AUDITED PROGRAM EXPENSES Provider Name: Fiscal Period: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 Provider NPI: OSHPD Facility Number: Line Natural Class ACCOUNT TITLE ACCOUNT NUMBER AS REPORTED AUDIT ADJUSTMENTS 8A-1 AS AUDITED 128 Transitional Inpatient Care Salaries and Wages 6170 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor Transitional Inpatient Care - Total 6170 $ 0 $ 0 $ Hospice Inpatient Care Salaries and Wages 6180 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor Hospice Inpatient Care - Total 6180 $ 0 $ 0 $ Other Routine Services Salaries and Wages 6190 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor Other Routine Services - Total 6190 $ 0 $ 0 $ 0 Other Nonreimbursable 139 Residential Care Salaries and Wages 9100 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor Residential Care - Total 9100 $ 0 $ 0 $ Beauty and Barber Salaries and Wages 8900 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor Beauty and Barber - Total Other Nonreimbursable 8900 $ 970 $ 0 $ Salaries and Wages 9100 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor Other Nonreimbursable - Total 9100 $ 0 $ 0 $ Subtotal $ 8,898,966 $ (1,336,298) $ 7,562, Social Services Salaries and Wages 6600 $ 196,006 $ 0 $ 196, Fringe Benefits , , Agency Staff Other - Nonlabor Social Services - Total 6600 $ 239,590 $ 0 $ 239,590

18 STATE OF CALIFORNIA SCHEDULE 8 SUMMARY OF AUDITED PROGRAM EXPENSES Provider Name: Fiscal Period: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 Provider NPI: OSHPD Facility Number: Line Natural Class ACCOUNT TITLE ACCOUNT NUMBER AS REPORTED AUDIT ADJUSTMENTS 8A-1 AS AUDITED 160 Activities Salaries and Wages 6700 $ 121,089 $ 0 $ 121, Fringe Benefits , , Agency Staff Other - Nonlabor , , Activities - Total 6700 $ 152,167 $ 0 $ 152, Administration Salaries and Wages 6900 $ 647,162 $ (170,433) $ 476, Fringe Benefits ,049 6, , Agency Staff Other - Nonlabor , ,193 1,120, Administration - Total 6900 $ 1,489,294 $ 213,718 $ 1,703, Medical Records Salaries and Wages 6900 $ 120,011 $ 0 $ 120, Fringe Benefits , , Agency Staff Other - Nonlabor , , Medical Records - Total CDPH Licensing Fees $ $ 160,840 48,240 $ 0 $ 0 $ $ 160, Professional Liability Insurance 6900 $ 145,525 $ (13,633) $ 131, Quality surance Fees 6900 $ 879,635 $ 0 $ 879, Inservice Education - Nursing Salaries and Wages 6800 $ 162,482 $ 0 $ 162, Fringe Benefits , , Agency Staff Other - Nonlabor Inservice Education - Nursing - Total Caregiver Training 48, $ 198,612 $ 0 $ 198, Salaries and Wages 6900 $ $ 0 $ Fringe Benefits Agency Staff Other - Nonlabor Caregiver Training - Total 6900 $ 0 $ 0 $ 0 Subtotal $ 3,313,903 $ 200,085 $ 3,513, Total $ 17,264,171 $ (173,759) $ 17,090,412 (Sch 6) (Sch 6) (Sch 6) (Sch 6) (Sch 3) (Sch 3) (Sch 3) (Sch 6) (Sch 6) (Sch 6) (Sch 3) (Sch 3) (Sch 3) 0 (Sch 6) (Sch 6) (Sch 6) (Sch 6) Total Facility Group Health Insurance (Adj 1) 6900 $ 157,025 For informational purposes only, this amount is included in various cost centers above..

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: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ Line Sub (Pages 1 & 2) Plant Operations and Maintenance - Salaries and Wages (114,412) Plant Operations and Maintenance - Fringe Benefits Plant Operations and Maintenance - Agency Staff Plant Operations and Maintenance - Other - Nonlabor (6,018) Housekeeping - Salaries and Wages Housekeeping - Fringe Benefits Housekeeping - Agency Staff Housekeeping - Other - Nonlabor Depreciation: Buildings and Improvements Depreciation: Leasehold Improvements Depreciation: Equipment Depreciation and Amortization - Other Leases and Rentals 129,880 90,107 39, Property Taxes (35,130) (39,773) Property Insurance Interest - Property, Plant, and Equipment Interest - Other Laundry and Linen - Salaries and Wages Laundry and Linen - Fringe Benefits Laundry and Linen - Agency Staff (6,376) (6,376) Laundry and Linen - Other - Nonlabor 6,376 6, Dietary - Salaries and Wages (32,673) Dietary - Fringe Benefits Dietary - Agency Staff Dietary - Other - Nonlabor Provision for Bad Debts Patient Supplies - Salaries and Wages Patient Supplies - Fringe Benefits Patient Supplies - Agency Staff Patient Supplies - Other - Nonlabor Specialized Support Surfaces - Salaries and Wages Specialized Support Surfaces - Fringe Benefits Specialized Support Surfaces - Agency Staff Specialized Support Surfaces - Other - Nonlabor Physical Therapy - Salaries and Wages Physical Therapy - Fringe Benefits Physical Therapy - Agency Staff (17,730) (17,730) Physical Therapy - Other - Nonlabor 17,730 17, Respiratory Therapy - Salaries and Wages Respiratory Therapy - Fringe Benefits Respiratory Therapy - Agency Staff Respiratory Therapy - Other - Nonlabor Occupational Therapy - Salaries and Wages Occupational Therapy - Fringe Benefits Occupational Therapy - Agency Staff (13,259) (13,259) Occupational Therapy - Other - Nonlabor 13,259 13, Speech Pathology - Salaries and Wages Speech Pathology - Fringe Benefits Speech Pathology - Agency Staff (3,316) (3,316)

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: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ Line Sub (Pages 1 & 2) Speech Pathology - Other - Nonlabor 3,316 3, Pharmacy - Salaries and Wages Pharmacy - Fringe Benefits Pharmacy - Agency Staff Pharmacy - Other - Nonlabor Laboratory - Salaries and Wages Laboratory - Fringe Benefits Laboratory - Agency Staff Laboratory - Other - Nonlabor Home Health Services - Salaries and Wages Home Health Services - Fringe Benefits Home Health Services - Agency Staff Home Health Services - Other - Nonlabor Other Ancillary Services - Salaries and Wages Other Ancillary Services - Fringe Benefits Other Ancillary Services - Agency Staff Other Ancillary Services - Other - Nonlabor Subacute Care Ancillary Services - Salaries and Wages 835, , Subacute Care Ancillary Services - Fringe Benefits 185, , Subacute Care Ancillary Services - Agency Staff Subacute Care Ancillary Services - Other - Nonlabor Subacute Pediatric Ancillary Services - Salaries and Wages Subacute Pediatric Ancillary Services - Fringe Benefits Subacute Pediatric Ancillary Services - Agency Staff Subacute Pediatric Ancillary Services - Other - Nonlabor Skilled Nursing Care - Salaries and Wages (175,850) (31,289) Skilled Nursing Care - Fringe Benefits (15,027) (6,958) Skilled Nursing Care - Agency Staff Skilled Nursing Care - Other - Nonlabor (78,864) (11,459) (64,000) Intermediate Care - Salaries and Wages Intermediate Care - Fringe Benefits Intermediate Care - Agency Staff 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 Developmentally Disabled Care - Salaries and Wages Developmentally Disabled Care - Fringe Benefits Developmentally Disabled Care - Agency Staff Developmentally Disabled Care - Other - Nonlabor Subacute Care - Salaries and Wages (798,821) (835,109) Subacute Care - Fringe Benefits (177,629) (185,698) Subacute Care - Agency Staff Subacute Care - Other - Nonlabor (90,107) (90,107) Subacute Care - Pediatric - Salaries and Wages Subacute Care - Pediatric - Fringe Benefits Subacute Care - Pediatric - Agency Staff Subacute Care - Pediatric - Other - Nonlabor 0

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: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ Line Sub (Pages 1 & 2) Transitional Inpatient Care - Salaries and Wages Transitional Inpatient Care - Fringe Benefits Transitional Inpatient Care - Agency Staff Transitional Inpatient Care - Other - Nonlabor Hospice Inpatient Care - Salaries and Wages Hospice Inpatient Care - Fringe Benefits Hospice Inpatient Care - Agency Staff 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 Beauty and Barber - Salaries and Wages Beauty and Barber - Fringe Benefits Beauty and Barber - Agency Staff 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 Activities - Salaries and Wages Activities - Fringe Benefits Activities - Agency Staff Activities - Other - Nonlabor Administration - Salaries and Wages (170,433) 31, Administration - Fringe Benefits 6,958 6, Administration - Agency Staff Administration - Other - Nonlabor 377,193 11,459 64, Medical Records - Salaries and Wages Medical Records - Fringe Benefits Medical Records - Agency Staff Medical Records - Other - Nonlabor CDPH Licensing Fees Professional Liability Insurance (13,633) Quality surance Fees Inservice Education - Nursing - Salaries and Wages Inservice Education - Nursing - Fringe Benefits Inservice Education - Nursing - Agency Staff Inservice Education - Nursing - Other - Nonlabor Caregiver Training - Salaries and Wages Caregiver Training - Fringe Benefits 0

22 STATE OF CALIFORNIA RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS Schedule 8A-1 Page 1 Provider Name: Provider NPI: OSHPD Facility Number: Fiscal Period: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ Line Sub (Pages 1 & 2) Caregiver Training - Agency Staff Caregiver Training - Other - Nonlabor Total ($173,759) (To Sch 8)

23 STATE OF CALIFORNIA RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS Schedule 8A-1 Page 2 Provider Name: Provider NPI: OSHPD Facility Number: Fiscal Period: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ Line Sub Plant Operations and Maintenance - Salaries and Wages (114,412) Plant Operations and Maintenance - Fringe Benefits Plant Operations and Maintenance - Agency Staff Plant Operations and Maintenance - Other - Nonlabor (6,018) Housekeeping - Salaries and Wages Housekeeping - Fringe Benefits Housekeeping - Agency Staff Housekeeping - Other - Nonlabor Depreciation: Buildings and Improvements Depreciation: Leasehold Improvements Depreciation: Equipment Depreciation and Amortization - Other Leases and Rentals Property Taxes 4, Property Insurance Interest - Property, Plant, and Equipment Interest - Other Laundry and Linen - Salaries and Wages Laundry and Linen - Fringe Benefits Laundry and Linen - Agency Staff Laundry and Linen - Other - Nonlabor Dietary - Salaries and Wages (32,673) Dietary - Fringe Benefits Dietary - Agency Staff Dietary - Other - Nonlabor Provision for Bad Debts Patient Supplies - Salaries and Wages Patient Supplies - Fringe Benefits Patient Supplies - Agency Staff Patient Supplies - Other - Nonlabor Specialized Support Surfaces - Salaries and Wages Specialized Support Surfaces - Fringe Benefits Specialized Support Surfaces - Agency Staff Specialized Support Surfaces - Other - Nonlabor Physical Therapy - Salaries and Wages Physical Therapy - Fringe Benefits Physical Therapy - Agency Staff Physical Therapy - Other - Nonlabor Respiratory Therapy - Salaries and Wages Respiratory Therapy - Fringe Benefits Respiratory Therapy - Agency Staff Respiratory Therapy - Other - Nonlabor Occupational Therapy - Salaries and Wages Occupational Therapy - Fringe Benefits Occupational Therapy - Agency Staff Occupational Therapy - Other - Nonlabor Speech Pathology - Salaries and Wages Speech Pathology - Fringe Benefits Speech Pathology - Agency Staff

24 STATE OF CALIFORNIA RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS Schedule 8A-1 Page 2 Provider Name: Provider NPI: OSHPD Facility Number: Fiscal Period: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ Line Sub Speech Pathology - Other - Nonlabor Pharmacy - Salaries and Wages Pharmacy - Fringe Benefits Pharmacy - Agency Staff Pharmacy - Other - Nonlabor Laboratory - Salaries and Wages Laboratory - Fringe Benefits Laboratory - Agency Staff Laboratory - Other - Nonlabor Home Health Services - Salaries and Wages Home Health Services - Fringe Benefits Home Health Services - Agency Staff Home Health Services - Other - Nonlabor Other Ancillary Services - Salaries and Wages Other Ancillary Services - Fringe Benefits Other Ancillary Services - Agency Staff Other Ancillary Services - Other - Nonlabor Subacute Care Ancillary Services - Salaries and Wages Subacute Care Ancillary Services - Fringe Benefits Subacute Care Ancillary Services - Agency Staff Subacute Care Ancillary Services - Other - Nonlabor Subacute Pediatric Ancillary Services - Salaries and Wages Subacute Pediatric Ancillary Services - Fringe Benefits Subacute Pediatric Ancillary Services - Agency Staff Subacute Pediatric Ancillary Services - Other - Nonlabor Skilled Nursing Care - Salaries and Wages (36,288) (108,273) Skilled Nursing Care - Fringe Benefits (8,069) Skilled Nursing Care - Agency Staff Skilled Nursing Care - Other - Nonlabor (3,405) Intermediate Care - Salaries and Wages Intermediate Care - Fringe Benefits Intermediate Care - Agency Staff 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 Developmentally Disabled Care - Salaries and Wages Developmentally Disabled Care - Fringe Benefits Developmentally Disabled Care - Agency Staff Developmentally Disabled Care - Other - Nonlabor Subacute Care - Salaries and Wages 36, Subacute Care - Fringe Benefits 8, 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