State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 43 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT 15 Not Reported 8A-1 5.01 Plant Operations and Maintenance - Salaries and Wages * $240,004 ($157,498) $82,506 Not Reported 8A-1 5.02 Plant Operations and Maintenance - Fringe Benefits * 88,405 (58,014) 30,391 Not Reported 8A-1 5.04 Plant Operations and Maintenance - Other - Nonlabor * 1,269,790 (833,273) 436,517 * 10.1(4) 05 14 8A-1 5.00 Plant Operations and Maintenance * (1,167,559) 1,048,785 (118,774) * 16 Not Reported 8A-1 10.01 Housekeeping - Salaries and Wages * $562,060 ($368,840) $193,220 Not Reported 8A-1 10.02 Housekeeping - Fringe Benefits * 218,287 (143,246) 75,041 Not Reported 8A-1 10.04 Housekeeping - Other - Nonlabor * 141,306 (92,729) 48,577 10.1(4) 10 14 8A-1 10.00 Housekeeping * (604,815) 604,815 0 17 Not Reported 8A-1 60.04 Laundry and Linen - Other - Nonlabor * $293,764 ($95,230) $198,534 * 10.1(4) 60 14 8A-1 60.00 Laundry and Linen * (95,230) 95,230 0 18 Not Reported 8A-1 65.01 Dietary - Salaries and Wages * $873,753 ($459,098) $414,655 Not Reported 8A-1 65.02 Dietary - Fringe Benefits * 290,802 (152,797) 138,005 Not Reported 8A-1 65.04 Dietary - Other - Nonlabor * 757,733 (399,921) 357,812 10.1(4) 65 14 8A-1 65.00 Dietary * (1,011,816) 1,011,816 0 19 Not Reported 8A-1 155.01 Social Services - Salaries and Wages * $157,866 ($45,774) $112,092 Not Reported 8A-1 155.02 Social Services - Fringe Benefits * 60,504 (17,543) 42,961 Not Reported 8A-1 155.04 Social Services - Other - Nonlabor * 3,624 (1,051) 2,573 10.1(4) 155 14 8A-1 155.00 Social Services * (64,368) 64,368 0 20 Not Reported 8A-1 160.01 Activities - Salaries and Wages * $295,200 ($85,595) $209,605 Not Reported 8A-1 160.02 Activities - Fringe Benefits * 99,023 (28,712) 70,311 Not Reported 8A-1 160.04 Activities - Other - Nonlabor * 68,090 (19,743) 48,347 10.1(4) 160 14 8A-1 160.00 Activities * (134,050) 134,050 0 . -Continued on next page- *Balance carried forward from prior/to subsequent adjustments Page 4 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 43 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT -Continued from previous page- 21 Not Reported 8A-1 165.01 Administration - Salaries and Wages * $492,312 ($142,748) $349,564 * Not Reported 8A-1 165.02 Administration - Fringe Benefits * 170,265 (49,369) 120,896 * Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 2,058,700 (217,034) 1,841,666 * 10.1(4) 165 14 8A-1 165.00 Administration * (477,988) 409,151 (68,837) * 22 Not Reported 8A-1 170.01 Inservice Education - Nursing - Salaries and Wages * $62,133 ($18,016) $44,117 * Not Reported 8A-1 170.02 Inservice Education - Nursing - Fringe Benefits * 23,173 (6,719) 16,454 * Not Reported 8A-1 170.04 Inservice Education - Nursing - Other - Nonlabor * 17,338 (5,027) 12,311 * 10.1(4) 170 14 8A-1 170.00 Inservice Education - Nursing * (51,388) 29,762 (21,626) * To reclassify the apportioned residential care adjustment for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 23 Not Reported 8A-1 5.04 Plant Operations and Maintenance - Other - Nonlabor * $436,517 ($118,774) $317,743 * 10.1(4) 05 14 8A-1 5.00 Plant Operations and Maintenance * (118,774) 118,774 0 To reclassify the reported excess gas expenses for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 24 Not Reported 8A-1 165.11 Administration - Other - Nonlabor * $1,841,666 ($2,249) $1,839,417 * 10.1(4) 165 14 8A-1 165.00 Administration * (68,837) 2,249 (66,588) * To reclassify expense adjustment reported for patient lost items for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 *Balance carried forward from prior/to subsequent adjustments Page 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 43 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT 25 Not Reported 8A-1 165.11 Administration - Other - Nonlabor * $1,839,417 ($3,751) $1,835,666 * 10.1(4) 165 14 8A-1 165.00 Administration * (66,588) 3,751 (62,837) * To adjust the provider's reclassification of gift shop expenses for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 26 Not Reported 8A-1 105.01 Skilled Nursing Care - Salaries and Wages * $3,394,711 ($29,847) $3,364,864 Not Reported 8A-1 105.02 Skilled Nursing Care - Fringe Benefits * 1,230,099 (11,342) 1,218,757 10.1(4) 105 14 8A-1 105.00 Skilled Nursing Care * (41,189) 41,189 0 To reclassify residential care nursing administration adjustment for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 27 Not Reported 8A-1 165.01 Administration - Salaries and Wages * $349,564 ($39,775) $309,789 * Not Reported 8A-1 165.02 Administration - Fringe Benefits * 120,896 (10,625) 110,271 * Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 1,835,666 (34,063) 1,801,603 * 10.1(4) 165 14 8A-1 165.00 Administration * (62,837) 84,463 21,626 * To adjust the provider's reclassification of Synagogue expenses for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 28 10.1(4) 165 14 8A-1 165.00 Administration * $21,626 ($21,626) $0 Not Reported 8A-1 170.01 Inservice Education - Nursing - Salaries and Wages * 44,117 (12,827) 31,290 Not Reported 8A-1 170.02 Inservice Education - Nursing - Fringe Benefits * 16,454 (1,603) 14,851 Not Reported 8A-1 170.04 Inservice Education - Nursing - Other - Nonlabor * 12,311 (7,196) 5,115 Not Reported 8A-1 165.09 Administration - Caregiver Training 0 21,626 21,626 10.1(4) 170 14 8A-1 170.00 Inservice Education - Nursing * (21,626) 21,626 0 To adjust the reported reclassification of caregiver training expenses for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 *Balance carried forward from prior/to subsequent adjustments Page 6 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 43 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F RECLASSIFICATIONS OF REPORTED COSTS 29 Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * $198,534 ($149,685) $48,849 Not Reported 8A-2 60.03 Laundry and Linen - Agency Staff 0 149,685 149,685 To reclassify laundry and linen contracted labor for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 30 Not Reported 8A-2 5.04 Plant Operations and Maintenance - Other - Nonlabor * $317,743 ($37,150) $280,593 * Not Reported 8A-2 5.03 Plant Operations and Maintenance - Agency Staff 0 37,150 37,150 To reclassify expenses related to security contract to the agency cost center for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 31 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $309,789 ($115,223) $194,566 * Not Reported 8A-2 165.02 Administration - Fringe Benefits * 110,271 (41,166) 69,105 * Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 1,801,603 (50,527) 1,751,076 * Not Reported 8A-2 165.03 Administration - Medical Records - Salaries and Wages * 0 115,223 115,223 * Not Reported 8A-2 165.04 Administration - Medical Records - Fringe Benefits 0 41,166 41,166 * Not Reported 8A-2 165.06 Administration - Medical Records - Other - Nonlabor 0 50,527 50,527 * To reclassify medical records expenses for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 32 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $1,751,076 ($131,400) $1,619,676 * Not Reported 8A-2 165.08 Administration - Liability Insurance 0 131,400 131,400 To reclassify liability insurance expenses for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 *Balance carried forward from prior/to subsequent adjustments Page 7 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 43 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F RECLASSIFICATIONS OF REPORTED COSTS 33 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $1,619,676 ($21,960) $1,597,716 * Not Reported 8A-2 165.07 Administration - DHS Licensing Fees 0 21,960 21,960 To reclassify Department of Health Care Services license fees for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 34 10.1(4) 15 14 8A-2 15.00 Depreciation - Buildings and Improvements $119,424 ($13,501) $105,923 10.1(4) 25 14 8A-2 25.00 Depreciation - Equipment 54,961 (26,613) 28,348 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 1,597,716 40,114 1,637,830 * To reclassify the reported home office expense for proper cost determination. 42 CFR 413.17 / CMS Pub. 15-1, Sections 2150.2 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 8 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 43 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F ADJUSTMENTS TO REPORTED COSTS 35 Not Reported 8A-2 5.04 Plant Operations and Maintenance - Other - Nonlabor * $280,593 ($42,441) $238,152 To eliminate security expenses related to the new construction. 42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3 36 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $1,637,830 ($15,657) $1,622,173 To eliminate medical director expenses not related to patient care. 42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3 37 Not Reported 8A-2 165.03 Administration - Medical Records - Salaries and Wages * $115,223 ($33,409) $81,814 Not Reported 8A-2 165.04 Administration - Medical Records - Fringe Benefits * 41,166 (11,936) 29,230 Not Reported 8A-2 165.06 Administration - Medical Records - Other - Nonlabor * 50,527 (14,651) 35,876 To eliminate medical records expenses related to the residential care facility. 42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3 38 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $194,566 ($67,953) $126,613 Not Reported 8A-2 165.02 Administration - Fringe Benefits * 69,105 (35,927) 33,178 To adjust administrator compensation based on the Department of Health Care Services Administrator Compensation Survey. 42 CFR 413.102 / CMS Pub. 15-1, Sections 901, 902.3, 904 and 1005 *Balance carried forward from prior/to subsequent adjustments Page 9 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 43 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F ADJUSTMENTS TO REPORTED COSTS 39 10.1(4) 45 14 8A-2 45.00 Property Insurance $11,160 ($2,960) $8,200 To adjust the reported property insurance expenses to agree with the invoices. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 Page 10 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 43 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F ADJUSTMENT TO REPORTED STATISTICS 40 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 4,867 4,867 Not Reported 7 10.00 Housekeeping 0 862 862 Not Reported 7 60.00 Laundry and Linen 0 2,043 2,043 Not Reported 7 65.00 Dietary 0 10,808 10,808 Not Reported 7 155.00 Social Services 0 3,943 3,943 Not Reported 7 160.00 Activities 09696 Not Reported 7 165.00 Administration 0 1,169 1,169 Not Reported 7 165.00 Medical Records 0 200 200 Not Reported 7 145.00 Other Nonreimbursable 258 10,026 10,284 Not Reported 7 145.00 Other Nonreimbursable 258 43,799 44,057 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 20,163 34,014 54,177 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 20,163 62,920 83,083 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 20,163 62,058 82,221 To adjust the square footage statistics to agree with the provider's working papers. . 42 CFR 413.24 and 413.50 / CMS Pub. 15-1, Sections 2304 and 2306 Page 11 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 43 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F ADJUSTMENT TO REPORTED PATIENT DAYS 41 4.1 05 6 1 12.00 Skilled Nursing Care - Total Patient Days 38,009 80 38,089 To adjust total patient days to agree with the provider's patient census reports. 42 CFR 413.20 and 413.50 CMS Pub. 15-1, Sections 2205 and 2304 Page 12 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 43 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31, 2007 ZZT05900F ADJUSTMENTS TO OTHER MATTERS 42 N/A NF1 14.00 Overpayments $0 $3,176 $3,176 * To recover Medi-Cal duplicate payments. CCR, Title 22, Section 51458.1 43 N/A NF1 14.00 Overpayments * $3,176 $44,184 $47,360 To recover outstanding Medi-Cal credit balances. CCR, Title 22, Sections 50761 and 51458.1 *Balance carried forward from prior/to subsequent adjustments Page 13 This is trial version www.adultpdf.com . Report Audit Report Explanation of Audit Adjustments Adjustments GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31 , 2007 ZZT05900F RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT 25. CFR 4 13. 20 and 4 13. 24 CMS Pub. 15-1, Sections 230 0, 230 2.4 and 230 2.8 30 Not Reported 8A-2 5.04 Plant Operations and Maintenance - Other - Nonlabor * $31 7,7 43 ( $37 ,150) $280,5 93 * Not Reported. Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments GRANCELL VILLAGE SEPTEMBER 1, 2006 THROUGH AUGUST 31 , 2007 ZZT05900F ADJUSTMENTS TO REPORTED COSTS 35