REPORT ON THE HOME OFFICE AUDIT VANCOUVER, WASHINGTON FISCAL PERIOD ENDED DECEMBER 31, 211 Audits Section Sacramento Financial Audits Branch Audits and Investigations Department of Health Care Services Section Chief: Robert G. Kvick Audit Supervisor: Gary Diffenderffer Auditor: Jennifer A. White
State of California Health and Human Services Agency Department of Health Care Services TOBY DOUGLAS DIRECTOR EDMUND G. BROWN JR. GOVERNOR July 3, 213 Terri L. Roche Reimbursement Manager Evergreen Healthcare Management, LLC 461 NE 77 th Avenue, Suite 3 Vancouver, WA 98662 FISCAL PERIOD ENDED DECEMBER 31, 211 We have examined the Medi-Cal Home Office Cost Report for the fiscal period ended December 31, 211. Our examination was made under the authority of Section 1417 of the Welfare and Institutions Code and, accordingly, included such tests of the accounting records and such other auditing procedures as we considered necessary in the circumstances. In our opinion, the data presented in the Summary of Audited Home Office Costs to Health Care Facilities represents a proper determination of home office allowable costs for the above fiscal period in accordance with Medi-Cal reimbursement principles. The audited home office cost will be incorporated, by separate adjustment, into each applicable facility audit report. This audit report includes the: 1. Summary of Audited Home Office Costs to Health Care Facilities and Supporting Schedules 2. Audit Adjustments Schedule If you disagree with the decision of the Department, the results of the home office audit may only be appealed through each individual facili ty's audit report. Please refer to the appeal instructions in each facility s audit report. Financi al Audits Branch/Audits Section Sacramento MS 216, P.O. Box 997413, Sacramento, CA 95899-7413 (916) 65-6994 / (916) 65-699 fax Internet Address: www.dhcs.ca.gov
Terri Roche Page 2 If you have questions regarding this report, you may call the Audits Section Sacramento at (916) 65-6994. Original Signed By Robert G. Kvick, Chief Audits Section Sacramento Financial Audits Branch Certified
TABLE OF CONTENTS SCHEDULES 1 - SUMMARY OF AUDITED HOME OFFICE CAPITAL AND NONCAPITAL RELATED COSTS TO CHAIN COMPONENTS 2 - COMPARISON OF REPORTED AND AUDITED HOME OFFICE COSTS 3 - SUMMARY ALLOCATION OF HOME OFFICE COSTS - CAPITAL RELATED 3-1 - SUMMARY ALLOCATION OF HOME OFFICE COSTS - NONCAPITAL RELATED 4 - POOLED ALLOCATION OF HOME OFFICE COSTS TO CHAIN COMPONENTS 5 - FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - CAPITAL RELATED 5-1 - FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED 6 - FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - CAPITAL RELATED 6-1 - FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED 7 - DIRECT ALLOCATION OF CAPITAL COSTS TO CHAIN COMPONENTS 7-1 - DIRECT ALLOCATION OF NONCAPITAL COSTS TO CHAIN COMPONENTS 8 - TRIAL BALANCE OF EXPENSES 9 - REPORTED HOME OFFICE COSTS
STATE OF CALIFORNIA SCHEDULE 1 SUMMARY OF AUDITED HOME OFFICE CAPITAL AND NONCAPITAL RELATED COSTS TO CHAIN COMPONENTS DECEMBER 31, 211 FISCAL PERIODS ENDING DURING HOME OFFICE FISCAL YEAR FROM TO CAPITAL RELATED (SCHEDULE 3) 1 NONCAPITAL RELATED (SCHEDULE 3-1) 2 TOTAL AUDITED H.O. COSTS (COLUMN 1 + 2) 3 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 1/1/11 12/31/11 $26,328 $295,132 $321,46 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 1/1/11 12/31/11 38,83 432,722 471,552 16.17 TWIN OAKS POST ACUTE REHAB 136894258 1/1/11 12/31/11 62,9 7,635 762,725 16.18 FULLERTON POST ACUTE CARE 114874239 1/1/11 12/31/11 55,32 66,936 662,238 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 1/1/11 12/31/11 27,682 311,641 339,323 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 1/1/11 12/31/11 49,893 552,798 62,691 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 1/1/11 12/31/11 39,948 448,578 488,526 16.22 KATHERINE HEALTHCARE 1811945652 1/1/11 12/31/11 21,135 24,69 261,743 16.23 NEW HOPE POST ACUTE CARE 1316995152 1/1/11 12/31/11 53,249 594,914 648,163 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 1/1/11 12/31/11 19,443 227,414 246,856 16.25 SPRINGS ROAD HEALTHCARE 12366966 1/1/11 12/31/11 25,43 312,883 338,286 17 ALL OTHER HEALTHCARE FACILITIES N/A 1/1/11 12/31/11 744,896 8,594,243 9,339,139 SUBTOTAL (LINES 1 THROUGH 2) $1,164,198 $13,318,55 $14,482,73 19 OREGON RETIREMENT CENTER N/A 1/1/11 12/31/11 $4,115 $42,481 $46,596 2. CONIFER HOUSE N/A 1/1/11 12/31/11 5,363 55,384 6,747 21. SANDPOINT ASSISTED LIVING N/A 1/1/11 12/31/11 6,35 62,385 68,421 22. PARKWAY THERAPIES N/A 1/1/11 12/31/11 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) $15,513 $16,25 $175,763 GRAND TOTAL $1,179,711 $13,478,755 $14,658,466
STATE OF CALIFORNIA SCHEDULE 2 COMPARISON OF REPORTED AND AUDITED HOME OFFICE COSTS DECEMBER 31, 211 FISCAL PERIODS ENDING DURING HOME OFFICE FISCAL YEAR FROM TO REPORTED HOME OFFICE COSTS (SCH. 9) 1 AUDITED H.O. COSTS (SCH. 3 & 3-1) 2 VARIANCE (COLUMN 2-1) 3 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 1/1/11 12/31/11 $323,19 $321,46 ($1,559) 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 1/1/11 12/31/11 473,854 471,552 (2,32) 16.17 TWIN OAKS POST ACUTE REHAB 136894258 1/1/11 12/31/11 766,452 762,724 (3,728) 16.18 FULLERTON POST ACUTE CARE 114874239 1/1/11 12/31/11 665,524 662,238 (3,286) 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 1/1/11 12/31/11 34,97 339,323 (1,647) 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 1/1/11 12/31/11 65,651 62,691 (2,96) 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 1/1/11 12/31/11 49,95 488,526 (2,379) 16.22 KATHERINE HEALTHCARE 1811945652 1/1/11 12/31/11 263,2 261,743 (1,259) 16.23 NEW HOPE POST ACUTE CARE 1316995152 1/1/11 12/31/11 651,327 648,163 (3,164) 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 1/1/11 12/31/11 248,6 246,856 (1,15) 16.25 SPRINGS ROAD HEALTHCARE 12366966 1/1/11 12/31/11 339,798 338,286 (1,512) 17 ALL OTHER HEALTHCARE FACILITIES N/A 1/1/11 12/31/11 9,355,825 9,339,139 (16,686) SUBTOTAL (LINES 1 THROUGH 2) $14,524,333 $14,482,73 ($41,63) 19 OREGON RETIREMENT CENTER N/A 1/1/11 12/31/11 $46,841 $46,596 ($245) 2. CONIFER HOUSE N/A 1/1/11 12/31/11 61,66 6,747 (319) 21. SANDPOINT ASSISTED LIVING N/A 1/1/11 12/31/11 68,78 68,421 (36) 22. PARKWAY THERAPIES N/A 1/1/11 12/31/11 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) $176,687 $175,763 ($924) GRAND TOTAL $14,71,2 $14,658,466 ($42,554)
STATE OF CALIFORNIA SCHEDULE 3 SUMMARY ALLOCATION OF HOME OFFICE COSTS - CAPITAL RELATED DECEMBER 31, 211 FISCAL PERIODS ENDING DURING HOME OFFICE FISCAL YEAR FROM TO DIRECT FUNCTIONAL POOLED CAPITAL COSTS CAPITAL COSTSCAPITAL COSTS (SCHEDULE 7) 1 (SCHEDULE 5) 2 (SCHEDULE 4) 3 TOTAL CAPITAL COSTS (COL. 1 TO 3) 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 1/1/11 12/31/11 $ $ $26,328 $26,328 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 1/1/11 12/31/11 38,83 38,83 16.17 TWIN OAKS POST ACUTE REHAB 136894258 1/1/11 12/31/11 62,9 62,9 16.18 FULLERTON POST ACUTE CARE 114874239 1/1/11 12/31/11 55,32 55,32 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 1/1/11 12/31/11 27,682 27,682 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 1/1/11 12/31/11 49,893 49,893 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 1/1/11 12/31/11 39,948 39,948 16.22 KATHERINE HEALTHCARE 1811945652 1/1/11 12/31/11 21,135 21,135 16.23 NEW HOPE POST ACUTE CARE 1316995152 1/1/11 12/31/11 53,249 53,249 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 1/1/11 12/31/11 19,443 19,443 16.25 SPRINGS ROAD HEALTHCARE 12366966 1/1/11 12/31/11 25,43 25,43 17 ALL OTHER HEALTHCARE FACILITIES N/A 1/1/11 12/31/11 744,896 744,896 SUBTOTAL (LINES 1 THROUGH 2) $ $ $1,164,198 $1,164,198 19 OREGON RETIREMENT CENTER N/A 1/1/11 12/31/11 $ $ $4,115 $4,115 2. CONIFER HOUSE N/A 1/1/11 12/31/11 5,363 5,363 21. SANDPOINT ASSISTED LIVING N/A 1/1/11 12/31/11 6,35 6,35 22. PARKWAY THERAPIES N/A 1/1/11 12/31/11 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) $ $ $15,513 $15,513 GRAND TOTAL $ $ $1,179,711 $1,179,711 (To Schedule 1 & 2)
STATE OF CALIFORNIA SCHEDULE 3-1 SUMMARY ALLOCATION OF HOME OFFICE COSTS - NONCAPITAL RELATED DECEMBER 31, 211 FISCAL PERIODS ENDING DURING HOME OFFICE FISCAL YEAR FROM TO DIRECT COSTS (SCH. 7-1) 1 FUNCTIONAL COSTS (SCH. 5-1) 2 POOLED COSTS (SCH. 4) 3 TOTAL NONCAPITAL COSTS (COL. 1 TO 3) 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 1/1/11 12/31/11 $ $23,32 $271,812 $295,132 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 1/1/11 12/31/11 31,834 4,888 432,722 16.17 TWIN OAKS POST ACUTE REHAB 136894258 1/1/11 12/31/11 59,611 641,24 7,635 16.18 FULLERTON POST ACUTE CARE 114874239 1/1/11 12/31/11 35,989 57,947 66,936 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 1/1/11 12/31/11 25,845 285,796 311,641 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 1/1/11 12/31/11 37,689 515,19 552,798 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 1/1/11 12/31/11 36,149 412,429 448,578 16.22 KATHERINE HEALTHCARE 1811945652 1/1/11 12/31/11 22,412 218,197 24,69 16.23 NEW HOPE POST ACUTE CARE 1316995152 1/1/11 12/31/11 45,157 549,757 594,914 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 1/1/11 12/31/11 26,684 2,73 227,414 16.25 SPRINGS ROAD HEALTHCARE 12366966 1/1/11 12/31/11 5,618 262,265 312,883 17 ALL OTHER HEALTHCARE FACILITIES N/A 1/1/11 12/31/11 27,586 876,22 7,69,437 8,594,243 SUBTOTAL (LINES 1 THROUGH 2) $27,586 $1,271,528 $12,19,391 $13,318,55 19 OREGON RETIREMENT CENTER N/A 1/1/11 12/31/11 $ $ $42,481 $42,481 2. CONIFER HOUSE N/A 1/1/11 12/31/11 15 55,369 55,384 21. SANDPOINT ASSISTED LIVING N/A 1/1/11 12/31/11 76 62,39 62,385 22. PARKWAY THERAPIES N/A 1/1/11 12/31/11 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) $ $91 $16,159 $16,25 GRAND TOTAL $27,586 $1,271,619 $12,179,55 $13,478,755 (To Schedule 1 & 2)
STATE OF CALIFORNIA SCHEDULE 4 POOLED ALLOCATION OF HOME OFFICE COSTS TO CHAIN COMPONENTS DECEMBER 31, 211 TOTAL COST (SCH. G, COL. 1) 1 CAPITAL (SCH. 8) 2 NONCAPITAL (SCH. 8) 3 TOTAL POOLED (COL. 2 + 3) 4 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 $5,591,468 $26,328 $271,812 $298,14 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 8,246,78 38,83 4,888 439,718 16.17 TWIN OAKS POST ACUTE REHAB 136894258 13,186,557 62,9 641,24 73,113 16.18 FULLERTON POST ACUTE CARE 114874239 11,745,4 55,32 57,947 626,249 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 5,879,128 27,682 285,796 313,478 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 1,596,35 49,893 515,19 565,2 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 8,484,113 39,948 412,429 452,377 16.22 KATHERINE HEALTHCARE 1811945652 4,488,54 21,135 218,197 239,331 16.23 NEW HOPE POST ACUTE CARE 1316995152 11,39,93 53,249 549,757 63,6 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 4,129,227 19,443 2,73 22,172 16.25 SPRINGS ROAD HEALTHCARE 12366966 5,395,81 25,43 262,265 287,668 17 ALL OTHER HEALTHCARE FACILITIES N/A 158,2,646 744,896 7,69,437 8,435,333 SUBTOTAL (LINES 1 THROUGH 2) $247,251,915 $1,164,198 $12,19,391 $13,183,589 19 OREGON RETIREMENT CENTER N/A $873,883 $4,115 $42,481 $46,596 2. CONIFER HOUSE N/A 1,139,2 5,363 55,369 6,732 21. SANDPOINT ASSISTED LIVING N/A 1,281,768 6,35 62,39 68,344 22. PARKWAY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) $3,294,653 $15,513 $16,159 $175,672 GRAND TOTAL $25,546,568 $1,179,711 $12,179,55 $13,359,261 (To Schedule 3) (To Schedule 3-1) MULTIPLIER.479.48612
STATE OF CALIFORNIA SCHEDULE 5 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - CAPITAL RELATED DECEMBER 31, 211 Old Cap. Related- Buildings & 1. Old Cap. Related- Movable 1.1 2. New Cap. Related- Buildings & 2.1 4. 4.1 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 $ $ $ $ $ $ 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 16.17 TWIN OAKS POST ACUTE REHAB 136894258 16.18 FULLERTON POST ACUTE CARE 114874239 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 16.22 KATHERINE HEALTHCARE 1811945652 16.23 NEW HOPE POST ACUTE CARE 1316995152 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 16.25 SPRINGS ROAD HEALTHCARE 12366966 17 ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ 19 OREGON RETIREMENT CENTER N/A $ $ $ $ $ $ 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $
STATE OF CALIFORNIA SCHEDULE 5 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - CAPITAL RELATED DECEMBER 31, 211 New Cap. Related- Movable 5. Insurance Premiums 5.1 7. Taxes and Licenses - Not INCM 8. Other 9. AUDITED TOTAL CAPITAL 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 $ $ $ $ $ $ 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 16.17 TWIN OAKS POST ACUTE REHAB 136894258 16.18 FULLERTON POST ACUTE CARE 114874239 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 16.22 KATHERINE HEALTHCARE 1811945652 16.23 NEW HOPE POST ACUTE CARE 1316995152 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 16.25 SPRINGS ROAD HEALTHCARE 12366966 17 ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ 19 OREGON RETIREMENT CENTER N/A $ $ $ $ $ $ 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ (To Schedule 3)
STATE OF CALIFORNIA SCHEDULE 5-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED DECEMBER 31, 211 Salaries of Officers 11 Salaries & Wages of Others 12 Payroll Taxes 13 Employee Benefits-Payroll Related 14 Employee Benefits- Nonpayroll 15 Profit Sharing/Pensio n Plans 16 Legal Fees 17 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 $ $ $ $ $ $ $ 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 16.17 TWIN OAKS POST ACUTE REHAB 136894258 16.18 FULLERTON POST ACUTE CARE 114874239 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 16.22 KATHERINE HEALTHCARE 1811945652 16.23 NEW HOPE POST ACUTE CARE 1316995152 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 16.25 SPRINGS ROAD HEALTHCARE 12366966 17 ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ $ 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ $
STATE OF CALIFORNIA SCHEDULE 5-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED DECEMBER 31, 211 Auditing & Accounting Fees 18 Utilities 19 Communication s 2 Travel & Entertainment 21 Transportation 22 Cleaning Office & Admin Supplies 23 Minor Equipment Expensed 24 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 $ $ $ $ $ $ $ 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 16.17 TWIN OAKS POST ACUTE REHAB 136894258 16.18 FULLERTON POST ACUTE CARE 114874239 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 16.22 KATHERINE HEALTHCARE 1811945652 16.23 NEW HOPE POST ACUTE CARE 1316995152 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 16.25 SPRINGS ROAD HEALTHCARE 12366966 17 ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ $ 19 OREGON RETIREMENT CENTER N/A $ $ $ $ $ $ $ 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ $
STATE OF CALIFORNIA SCHEDULE 5-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED DECEMBER 31, 211 Repairs & Maintenance 25 Dues & Subscriptions 26 Contributions 27 Insurance Premium-Non Capital Related 28 Taxes & Licenses - Non Capital Related 29 Interest Expense 3 Purchased Services 31 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 $ $ $ $ $ $ $ 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 16.17 TWIN OAKS POST ACUTE REHAB 136894258 16.18 FULLERTON POST ACUTE CARE 114874239 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 16.22 KATHERINE HEALTHCARE 1811945652 16.23 NEW HOPE POST ACUTE CARE 1316995152 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 16.25 SPRINGS ROAD HEALTHCARE 12366966 17 ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ $ 19 OREGON RETIREMENT CENTER N/A $ $ $ $ $ $ $ 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ $
STATE OF CALIFORNIA SCHEDULE 5-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED DECEMBER 31, 211 Education Training Lease Exp 32 Lease Acq & Amort Loan Fees 33 Marketing & Public Relations 34 Fines, Penalties, Late Fees 35 Regional Therapy Managers 35.1 Health Medx MIS 35.2 Dietary Consultant 35.3 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 $ $ $ $ $6,494 $7,893 $ 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 15,8 7,893 16.17 TWIN OAKS POST ACUTE REHAB 136894258 3,946 19,732 16.18 FULLERTON POST ACUTE CARE 114874239 19,163 7,893 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 9,19 7,893 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 2,863 7,893 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 19,323 7,893 16.22 KATHERINE HEALTHCARE 1811945652 9,532 3,946 16.23 NEW HOPE POST ACUTE CARE 1316995152 28,331 7,893 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 9,858 7,893 16.25 SPRINGS ROAD HEALTHCARE 12366966 14,6 27,625 17 ALL OTHER HEALTHCARE FACILITIES N/A 338,731 213,14 42,987 SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $521,328 $327,549 $42,987 19 OREGON RETIREMENT CENTER N/A $ $ $ $ $ $ $ 2. CONIFER HOUSE N/A 15 21. SANDPOINT ASSISTED LIVING N/A 76 22. PARKWAY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $91 GRAND TOTAL $ $ $ $ $521,328 $327,549 $43,78
STATE OF CALIFORNIA SCHEDULE 5-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED DECEMBER 31, 211 Nursing Consultant 35.4 35.5 35.6 35.7 35.8 AUDITED TOTAL NONCAPITAL 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 $8,933 $ $ $ $ $23,32 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 8,933 31,834 16.17 TWIN OAKS POST ACUTE REHAB 136894258 8,933 59,611 16.18 FULLERTON POST ACUTE CARE 114874239 8,933 35,989 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 8,933 25,845 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 8,933 37,689 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 8,933 36,149 16.22 KATHERINE HEALTHCARE 1811945652 8,933 22,412 16.23 NEW HOPE POST ACUTE CARE 1316995152 8,933 45,157 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 8,933 26,684 16.25 SPRINGS ROAD HEALTHCARE 12366966 8,933 5,618 17 ALL OTHER HEALTHCARE FACILITIES N/A 281,398 876,22 SUBTOTAL (LINES 1 THROUGH 2) $379,664 $ $ $ $ $1,271,528 19 OREGON RETIREMENT CENTER N/A $ $ $ $ $ $ 2. CONIFER HOUSE N/A 15 21. SANDPOINT ASSISTED LIVING N/A 76 22. PARKWAY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $91 GRAND TOTAL $379,664 $ $ $ $ $1,271,619
STATE OF CALIFORNIA SCHEDULE 6 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - CAPITAL RELATED DECEMBER 31, 211 Old Cap. Related- 1. 1.1 Old Cap. Related- 2. 2.1 New Cap. Related- 4. 4.1 (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 16.17 TWIN OAKS POST ACUTE REHAB 136894258 16.18 FULLERTON POST ACUTE CARE 114874239 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 16.22 KATHERINE HEALTHCARE 1811945652 16.23 NEW HOPE POST ACUTE CARE 1316995152 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 16.25 SPRINGS ROAD HEALTHCARE 12366966 17 ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ $ UNIT COST MULTIPLIER......
STATE OF CALIFORNIA SCHEDULE 6 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - CAPITAL RELATED DECEMBER 31, 211 New Cap. Insurance Taxes and Other Related- Premiums Licenses - Not 5. 5.1 7. 8. 9. (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 16.17 TWIN OAKS POST ACUTE REHAB 136894258 16.18 FULLERTON POST ACUTE CARE 114874239 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 16.22 KATHERINE HEALTHCARE 1811945652 16.23 NEW HOPE POST ACUTE CARE 1316995152 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 16.25 SPRINGS ROAD HEALTHCARE 12366966 17 ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ UNIT COST MULTIPLIER.....
STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, 211 Salaries of Officers Salaries & Wages of Payroll Taxes Employee Benefits-Payroll Employee Benefits- Profit Sharing/Pensio 11. 12. 13. 14. 15. 16. (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 16.17 TWIN OAKS POST ACUTE REHAB 136894258 16.18 FULLERTON POST ACUTE CARE 114874239 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 16.22 KATHERINE HEALTHCARE 1811945652 16.23 NEW HOPE POST ACUTE CARE 1316995152 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 16.25 SPRINGS ROAD HEALTHCARE 12366966 17 ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ $ UNIT COST MULTIPLIER......
STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, 211 Legal Fees Auditing & Utilities Communication Travel & Transportation 17. Accounting 18. 19. s 2. Entertainment 21. 22. (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 16.17 TWIN OAKS POST ACUTE REHAB 136894258 16.18 FULLERTON POST ACUTE CARE 114874239 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 16.22 KATHERINE HEALTHCARE 1811945652 16.23 NEW HOPE POST ACUTE CARE 1316995152 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 16.25 SPRINGS ROAD HEALTHCARE 12366966 17 ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ $ UNIT COST MULTIPLIER......
STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, 211 Cleaning Office & Admin Minor Equipment Repairs & Maintenance Dues & Subscriptions Contributions Insurance Premium-Non 23. 24. 25. 26. 27. 28. (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 16.17 TWIN OAKS POST ACUTE REHAB 136894258 16.18 FULLERTON POST ACUTE CARE 114874239 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 16.22 KATHERINE HEALTHCARE 1811945652 16.23 NEW HOPE POST ACUTE CARE 1316995152 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 16.25 SPRINGS ROAD HEALTHCARE 12366966 17 ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ $ UNIT COST MULTIPLIER......
STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, 211 Taxes & Licenses - Non Interest Expense Purchased Services Education Training Lease Lease Acq & Amort Loan Marketing & Public Relations 29. 3. 31. 32. 33. 34. (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 16.17 TWIN OAKS POST ACUTE REHAB 136894258 16.18 FULLERTON POST ACUTE CARE 114874239 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 16.22 KATHERINE HEALTHCARE 1811945652 16.23 NEW HOPE POST ACUTE CARE 1316995152 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 16.25 SPRINGS ROAD HEALTHCARE 12366966 17 ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ $ UNIT COST MULTIPLIER......
STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, 211 Fines, Penalties, Late 35. Regional Therapy (Minutes) 35.1 Health Medx MIS (No. of users) 35.2 Dietary Consultant (Total Cost) 35.3 Nursing Consultant (Total Cost) 35.4 35.5 (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 228,862 2 27,132 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 528,948 2 27,132 16.17 TWIN OAKS POST ACUTE REHAB 136894258 1,9,662 5 27,132 16.18 FULLERTON POST ACUTE CARE 114874239 675,366 2 27,132 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 317,869 2 27,132 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 735,289 2 27,132 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 681,2 2 27,132 16.22 KATHERINE HEALTHCARE 1811945652 335,957 1 27,132 16.23 NEW HOPE POST ACUTE CARE 1316995152 998,489 2 27,132 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 347,435 2 27,132 16.25 SPRINGS ROAD HEALTHCARE 12366966 495,532 7 27,132 17 ALL OTHER HEALTHCARE FACILITIES N/A 11,938,28 54 68,449 854,658 SUBTOTAL (LINES 1 THROUGH 2) 18,373,637 83 68,449 1,153,11 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 236 21. SANDPOINT ASSISTED LIVING N/A 127 22. PARKWAY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) 1,443 GRAND TOTAL 18,373,637 83 681,892 1,153,11 TOTAL STATISTICS 18,373,637 83 681,892 1,153,11 COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $521,328 $327,549 $43,78 $379,664 $ UNIT COST MULTIPLIER..28374 3946.373494.63174.329252.
STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, 211 35.6 35.7 35.8 (Adj. ) (Adj. ) (Adj. ) 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 16.17 TWIN OAKS POST ACUTE REHAB 136894258 16.18 FULLERTON POST ACUTE CARE 114874239 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 16.22 KATHERINE HEALTHCARE 1811945652 16.23 NEW HOPE POST ACUTE CARE 1316995152 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 16.25 SPRINGS ROAD HEALTHCARE 12366966 17 ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKWAY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ UNIT COST MULTIPLIER...
STATE OF CALIFORNIA SCHEDULE 7 DIRECT ALLOCATION OF CAPITAL COSTS TO CHAIN COMPONENTS DECEMBER 31, 211 REPORTED TOTAL (SCH. E) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) AUDITED TOTAL 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 $ $ $ $ $ $ $ 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 16.17 TW IN OAKS POST ACUTE REHAB 136894258 16.18 FULLERTON POST ACUTE CARE 114874239 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 16.22 KATHERINE HEALTHCARE 1811945652 16.23 NEW HOPE POST ACUTE CARE 1316995152 16.24 HEARTW OOD AVENUE HEALTHCARE 124528883 16.25 SPRINGS ROAD HEALTHCARE 12366966 17 ALL OTHER HEALTHCARE FACILITIES N/A SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ $ 19 OREGON RETIREMENT CENTER N/A $ $ $ $ $ $ $ 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKW AY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ $ (To Schedule 3)
STATE OF CALIFORNIA SCHEDULE 7-1 DIRECT ALLOCATION OF NONCAPITAL COSTS TO CHAIN COMPONENTS DECEMBER 31, 211 REPORTED TOTAL (SCH. E-1) TRAVEL AND ENTERTAINMENT (Adj. 1) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 $ $ $ $ $ $ $ $ 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 16.17 TW IN OAKS POST ACUTE REHAB 136894258 16.18 FULLERTON POST ACUTE CARE 114874239 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 16.22 KATHERINE HEALTHCARE 1811945652 16.23 NEW HOPE POST ACUTE CARE 1316995152 16.24 HEARTW OOD AVENUE HEALTHCARE 124528883 16.25 SPRINGS ROAD HEALTHCARE 12366966 17 ALL OTHER HEALTHCARE FACILITIES N/A 27,586 SUBTOTAL (LINES 1 THROUGH 2) $ $27,586 $ $ $ $ $ $ 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKW AY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ $ GRAND TOTAL $ $27,586 $ $ $ $ $ $
STATE OF CALIFORNIA SCHEDULE 7-1 DIRECT ALLOCATION OF NONCAPITAL COSTS TO CHAIN COMPONENTS DECEMBER 31, 211 (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) AUDITED TOTAL 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 $ $ $ $ $ $ $ 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 16.17 TW IN OAKS POST ACUTE REHAB 136894258 16.18 FULLERTON POST ACUTE CARE 114874239 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 16.22 KATHERINE HEALTHCARE 1811945652 16.23 NEW HOPE POST ACUTE CARE 1316995152 16.24 HEARTW OOD AVENUE HEALTHCARE 124528883 16.25 SPRINGS ROAD HEALTHCARE 12366966 17 ALL OTHER HEALTHCARE FACILITIES N/A 27,586 SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ $27,586 19 OREGON RETIREMENT CENTER N/A 2. CONIFER HOUSE N/A 21. SANDPOINT ASSISTED LIVING N/A 22. PARKW AY THERAPIES N/A 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ $27,586 (To Schedule 3-1)
STATE OF CALIFORNIA SCHEDULE 8 TRIAL BALANCE OF EXPENSES DECEMBER 31, 211 LINE NO. COST CENTER DESCRIPTION REPORTED ADJ. ADJUSTMENT AUDITED POOLED ALLOC. NO. AMOUNT(S) POOLED (SCH. B, COL 8) COSTS CAPITAL-RELATED COSTS - OLD 1. Old Cap. Related-Buildings & Fixtures $ $ $ 1.1 2. Old Cap. Related-Movable Equipment 2.1 3. SUBTOTAL (sum of lines 1 through 2.1) $ $ $ CAPITAL-RELATED COSTS - NEW 4. New Cap. Related-Buildings & Fixtures $24,599 $ $24,599 4.1 5. New Cap. Related-Movable Equipment 975,112 975,112 5.1 6. SUBTOTAL (sum of lines 4 through 5.1) $1,179,711 $ $1,179,711 OTHER CAPITAL-RELATED COSTS 7. Insurance Premiums $ $ $ 8. Taxes and Licenses - Not INCM 9. Other 1. SUBTOTAL (sum of lines 7 through 9) $ $ $ NON CAPITAL-RELATED COSTS 11. Salaries of Officers $ $ $ 12. Salaries & Wages of Others 7,975,898 7,975,898 13. Payroll Taxes 11,269 11,269 14. Employee Benefits-Payroll Related 58,775 58,775 15. Employee Benefits-Nonpayroll Related 1,4,35 2,3,4 (42,554) 1,357,481 16. Profit Sharing/Pension Plans 17. Legal Fees 82,48 82,48 18. Auditing & Accounting Fees 28,121 28,121 19. Utilities 2. Communications 434,498 434,498 21. Travel & Entertainment 75,62 1 (27,586) 723,16 22. Transportation 1,787 1,787 23. Cleaning Office & Admin Supplies 139,149 139,149 24. Minor Equipment Expensed 29,349 29,349 25. Repairs & Maintenance 47,531 47,531 26. Dues & Subscriptions 55,172 55,172 27. Contributions 28. Insurance Premium-Non Capital Related 76,43 76,43 29. Taxes & Licenses - Non Capital Related 448,73 448,73 3. Interest Expense 35,732 35,732 31. Purchased Services 468,522 468,522 32. Education Training Lease Exp 116,387 116,387 33. Lease Acq & Amort Loan Fees 34. Marketing & Public Relations 11,585 11,585 35. Fines, Penalties, Late Fees (11,246) (11,246) 35.1 Regional Therapy Managers 35.2 Health Medx MIS 35.3 Dietary Consultant 35.4 Nursing Consultant 35.5 35.6 35.7 35.8 36. SUBTOTAL (sum of lines 11 through 35.8) $12,249,69 ($7,14) $12,179,55 37. TOTAL ALLOWABLE EXPENSES $13,429,41 ($7,14) $13,359,261 (To Sch. 4) 38. NONREIMBURSABLE EXPENSES $ $ $ TOTAL EXPENSES $13,429,41 ($7,14) $13,359,261
STATE OF CALIFORNIA SCHEDULE 8 TRIAL BALANCE OF EXPENSES DECEMBER 31, 211 LINE NO. COST CENTER DESCRIPTION REPORTED ADJ. ADJUSTMENT AUDITED DIRECT ALLOC. NO. AMOUNT(S) DIRECT (SCH. B, COL 6) COSTS CAPITAL-RELATED COSTS - OLD 1. Old Cap. Related-Buildings & Fixtures 1.1 2. Old Cap. Related-Movable Equipment 2.1 3. SUBTOTAL (sum of lines 1 through 2.1) CAPITAL-RELATED COSTS - NEW 4. New Cap. Related-Buildings & Fixtures 4.1 5. New Cap. Related-Movable Equipment 5.1 6. SUBTOTAL (sum of lines 4 through 5.1) OTHER CAPITAL-RELATED COSTS 7. Insurance Premiums 8. Taxes and Licenses - Not INCM 9. Other 1. SUBTOTAL (sum of lines 7 through 9) NON CAPITAL-RELATED COSTS 11. Salaries of Officers 12. Salaries & Wages of Others 13. Payroll Taxes 14. Employee Benefits-Payroll Related 15. Employee Benefits-Nonpayroll Related 16. Profit Sharing/Pension Plans 17. Legal Fees 18. Auditing & Accounting Fees 19. Utilities 2. Communications 21. Travel & Entertainment 22. Transportation 23. Cleaning Office & Admin Supplies 24. Minor Equipment Expensed 25. Repairs & Maintenance 26. Dues & Subscriptions 27. Contributions 28. Insurance Premium-Non Capital Related 29. Taxes & Licenses - Non Capital Related 3. Interest Expense 31. Purchased Services 32. Education Training Lease Exp 33. Lease Acq & Amort Loan Fees 34. Marketing & Public Relations 35. Fines, Penalties, Late Fees 35.1 Regional Therapy Managers 35.2 Health Medx MIS 35.3 Dietary Consultant 35.4 Nursing Consultant 35.5 35.6 35.7 35.8 36. SUBTOTAL (sum of lines 11 through 35.8) 37. TOTAL ALLOWABLE EXPENSES 38. NONREIMBURSABLE EXPENSES TOTAL EXPENSES $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 1 27,586 27,586 $ $27,586 $27,586 $ $27,586 $27,586 (To Sch. 7, 7-1) $ $ $ $ $27,586 $27,586
STATE OF CALIFORNIA SCHEDULE 8 TRIAL BALANCE OF EXPENSES DECEMBER 31, 211 LINE NO. COST CENTER DESCRIPTION REPORTED ADJ. ADJUSTMENT AUDITED FUNCTIONAL COSTS NO. AMOUNT(S) FUNCTIONAL (SCH. B, COL 7) COSTS CAPITAL-RELATED COSTS - OLD 1. Old Cap. Related-Buildings & Fixtures 1.1 2. Old Cap. Related-Movable Equipment 2.1 3. SUBTOTAL (sum of lines 1 through 2.1) CAPITAL-RELATED COSTS - NEW 4. New Cap. Related-Buildings & Fixtures 4.1 5. New Cap. Related-Movable Equipment 5.1 6. SUBTOTAL (sum of lines 4 through 5.1) OTHER CAPITAL-RELATED COSTS 7. Insurance Premiums 8. Taxes and Licenses - Not INCM 9. Other 1. SUBTOTAL (sum of lines 7 through 9) NON CAPITAL-RELATED COSTS 11. Salaries of Officers 12. Salaries & Wages of Others 13. Payroll Taxes 14. Employee Benefits-Payroll Related 15. Employee Benefits-Nonpayroll Related 16. Profit Sharing/Pension Plans 17. Legal Fees 18. Auditing & Accounting Fees 19. Utilities 2. Communications 21. Travel & Entertainment 22. Transportation 23. Cleaning Office & Admin Supplies 24. Minor Equipment Expensed 25. Repairs & Maintenance 26. Dues & Subscriptions 27. Contributions 28. Insurance Premium-Non Capital Related 29. Taxes & Licenses - Non Capital Related 3. Interest Expense 31. Purchased Services 32. Education Training Lease Exp 33. Lease Acq & Amort Loan Fees 34. Marketing & Public Relations 35. Fines, Penalties, Late Fees 35.1 Regional Therapy Managers 35.2 Health Medx MIS 35.3 Dietary Consultant 35.4 Nursing Consultant 35.5 35.6 35.7 35.8 36. SUBTOTAL (sum of lines 11 through 35.8) 37. TOTAL ALLOWABLE EXPENSES 38. NONREIMBURSABLE EXPENSES TOTAL EXPENSES $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 521,328 521,328 327,549 327,549 43,78 43,78 379,664 379,664 $1,271,619 $ $1,271,619 $1,271,619 $ $1,271,619 (To Sch. 6, 6-1) $ $ $ $1,271,619 $ $1,271,619
STATE OF CALIFORNIA SCHEDULE 9 REPORTED HOME OFFICE COSTS DECEMBER 31, 211 FISCAL PERIODS ENDING DURING HOME OFFICE FISCAL YEAR FROM TO DIRECT ALLOCATION FUNCTIONAL ALLOCATION POOLED ALLOCATION TOTAL NON-CAPITAL CAPITAL NON-CAPITAL CAPITAL NON-CAPITAL RELATED RELATED RELATED RELATED RELATED COSTS COSTS COSTS COSTS COSTS (SCH. E-1) (SCH. F) (SCH. F-1) (SCH. G) (SCH. G) CAPITAL RELATED COSTS (SCH. E) ALLOCATION HOME OFFICE COSTS 16.14 EVERGREEN ARVIN HEALTHCARE 156841769 1/1/11 12/31/11 $23,32 $26,327 $273,372 $323,19 16.15 EVERGREEN BAKERSFIELD POST ACUTE CARE 1255389318 1/1/11 12/31/11 31,834 38,829 43,191 473,854 16.17 TWIN OAKS POST ACUTE REHAB 136894258 1/1/11 12/31/11 59,68 62,97 644,747 766,452 16.18 FULLERTON POST ACUTE CARE 114874239 1/1/11 12/31/11 35,989 55,32 574,233 665,524 16.19 EVERGREEN LAKEPORT HEALTHCARE 169972346 1/1/11 12/31/11 25,845 27,682 287,443 34,97 16.2 OLIVE RIDGE POST ACUTE CARE 14276485 1/1/11 12/31/11 37,689 49,893 518,69 65,651 16.21 PETALUMA HEALTH AND REHABILITATION 11487494 1/1/11 12/31/11 36,149 39,948 414,88 49,95 16.22 KATHERINE HEALTHCARE 1811945652 1/1/11 12/31/11 22,411 21,134 219,457 263,2 16.23 NEW HOPE POST ACUTE CARE 1316995152 1/1/11 12/31/11 45,157 53,249 552,921 651,327 16.24 HEARTWOOD AVENUE HEALTHCARE 124528883 1/1/11 12/31/11 26,684 19,442 21,88 248,6 16.25 SPRINGS ROAD HEALTHCARE 12366966 1/1/11 12/31/11 5,622 25,43 263,773 339,798 17 ALL OTHER HEALTHCARE FACILITIES N/A 1/1/11 12/31/11 876,22 744,892 7,734,713 9,355,825 SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $1,271,528 $1,164,198 $12,88,67 $14,524,333 19 OREGON RETIREMENT CENTER N/A 1/1/11 12/31/11 $4,115 $42,726 $46,841 2. CONIFER HOUSE N/A 1/1/11 12/31/11 15 5,363 55,688 61,66 21. SANDPOINT ASSISTED LIVING N/A 1/1/11 12/31/11 76 6,35 62,669 68,78 22. PARKWAY THERAPIES N/A 1/1/11 12/31/11 23. 24. 25. 26. 27. 28. 29. 3. 31. 32. 33. SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $91 $15,513 $161,83 $176,687 GRAND TOTAL $ $ $ $1,271,619 $1,179,711 $12,249,69 $14,71,2 (To Sch. 2, Col. 1)
State of California Department of Health Care Services Provider Name Report References Fiscal Period JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider Adjustments N/A 4 Adj. No. Audit Report Cost Report Work Sheet Part Title Line Col. Explanation of Audit Adjustments RECLASSIFICATION OF REPORTED COSTS As Reported Increase (Decrease) As Adjusted 1 7-1 Not Reported 21. 6 Travel and Entertainment - All Other Healthcare Facilitie $ $27,586 $27,586 8 B 21. 6 Travel and Entertainment 27,586 27,586 8 B 21. 8 Travel and Entertainment 75,62 (27,586) 723,16 To directly assign travel expense to the using cost center 42 CFR 413.17 and 413.24 CMS Pub. 15-1, Sections 215.3B, 23, and 234 Page 1
State of California Department of Health Care Services Provider Name Report References Fiscal Period JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider Adjustments N/A 4 Adj. No. Audit Report Cost Report Work Sheet Part Title Line Col. Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED POOLED COSTS As Reported Increase (Decrease) As Adjusted 2 8 B 15. 8 Employee Benefits - Non-Payroll $1,4,35 To eliminate self insured pooled costs in conjunction with ($13,821) adjustments 3 and 4. 42 CFR 413.2 and 413.24 CMS Pub. 15-1, Sections 2161, 2162.2, 2162.5, 2162.7, 2162.9, 23, and 234 3 To eliminate health insurance expense for the self insurance plan (449,342) reported in account 7-62-877--1 in conjunction with adjustments 2 and 4. 42 CFR 413.2 and 413.24 CMS Pub. 15-1, Sections 2161, 2162.2, 2162.5, 2162.7, 2162.9, 23, and 234 4 To include self insurance health paid claims and administrative fees 537,69 to agree with provider's records in conjunction with adjustments ($42,554) $1,357,481 2 and 3 42 CFR 413.2 and 413.24 CMS Pub. 15-1, Sections 23 and 234 Page 2