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REPORT ON THE
RATE SETTING AUDIT
LIFEHOUSE PARKVIEW BAKERSFIELD, CALIFORNIA
PROVIDER NUMBER: LTC55336G / NPI 1558382424
FISCAL PERIOD JANUARY 12, 2007 THROUGH DECEMBER 31, 2007
Audits Section - Burbank Financial Audits Branch
Audits and Investigations California Department of Health Care Services
Section Chief: Daniel J. Giardinelli Audit Supervisor: Gertrude Lake Auditor: Cynthia L. Richardson
State of California—Health and Human Services Agency
Department of Health Care Services
DAVID MAXWELL-JOLLY ARNOLD SCHWARZENEGGER Director Governor
Financial Audits/Burbank/A & I, MS 2101, 1405 North San Fernando Boulevard, Room 203, Burbank, CA 91504
Telephone (818) 295-2620 FAX: (818) 563-3324 Internet Address: www.dhcs.ca.gov
May 6, 2009 Administrator Lifehouse Parkview 329 North Real Road Bakersfield, CA 93309 PROVIDER: LIFEHOUSE PARKVIEW PROVIDER NO. LTC55336G / NPI 1558382424 FISCAL PERIOD JANUARY 12, 2007 THROUGH DECEMBER 31, 2007
We have examined the facility's Integrated Disclosure and Medi-Cal Cost Report for the above-referenced fiscal period. We also examined the facility's use of and Records of Noncovered Services deducted from patient share of cost. Our examination was made under the authority of Section 14170 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, patient days and use of share of cost for the above fiscal period in accordance with Medi-Cal reimbursement principles.
This audit report includes the:
1. Summary of Audited Facility Cost per Patient Day and supporting schedules
2. Audit adjustments that include a summary of the total due the State in the amount of $9,348, which resulted from Medi-Cal overbillings and share of cost overpayments.
The audit settlement will be incorporated into a Statement(s) of Account Status, which may reflect tentative retroactive adjustment determinations, payments from the provider, and other financial transactions initiated by the Department. The Statement(s) of Account Status will be forwarded to the provider by the State’s fiscal intermediary. Instructions regarding payment will be included with the Statement(s) of Account Status.
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 Rate Development Branch.
Administrator Page 2
Notwithstanding this audit report, overpayments to the provider are subject to recovery pursuant to Section 51458.1, 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 95814-2825 (916) 322-5603 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.) Assistant Chief Counsel Assistant Chief Counsel Department of Health Care Services Department of Health Care Services Office of Legal Services Office of Legal Services MS 0010 MS 0010 PO Box 997413 1501 Capitol Avenue, Suite 71.5001 Sacramento, CA 95899-7413 Sacramento, CA 95814-5005 (916) 440-7700 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—Burbank at (818) 295-2620. Original Signed By Daniel J. Giardinelli, Chief Audits Section—Burbank Financial Audits Branch Certified cc: Robert Mayhall, Controller
Lifehouse Health Services, LLC. 27200 Tourney Road, Suite 275 Valencia, CA 91355
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:LIFEHOUSE PARKVIEW JANUARY 12, 2007 THROUGH DECEMBER 31, 2007
Provider Number: OSHPD Facility No.:LTC55336G 206150774
LineNo.
SKILLED NURSING CARE1 Cost of Direct Care - Labor (Sch. 2, Ln. 105) $ N/A $ 3,514,112 $ 68.56
2 Cost of Indirect Care - Labor (Sch. 3, Ln. 105) $ N/A $ 513,069 $ 10.01
3 Cost of Direct and Indirect NonLabor - Other (Sch. 4, Ln. 105) $ N/A $ 1,269,087 $ 24.76
4 Cost of Capital Related (Sch. 5, Ln. 105) $ N/A $ 1,105,575 $ 21.57
5 Property Taxes (Sch. 5, Ln. 105) $ N/A $ 0 $ 0.00
6 DHS Licensing Fees (Sch. 6, Ln. 105) $ N/A $ 37,694 $ 0.74
7 Liability Insurance (Sch. 6, Ln. 105) $ N/A $ 0 $ 0.00
8 Caregiver Training (Sch. 6, Ln. 105) $ N/A $ 0 $ 0.00
9 Quality Assurance Fees (Sch. 6, Ln. 105) $ N/A $ 357,396 $ 6.97
10 Cost of Administration (Sch. 6, Ln. 105) $ N/A $ 929,877 $ 18.14
11 Cost of Routine Service/Audited Total Costs $ 8,170,177 $ 7,726,808 $ 150.76
12 Total Patient Days (Adj ) 51,254 51,254
13 Cost Per Patient Day (Cost Divided by Days) $ 159.41 $ 150.76
14 Overpayments (Adjs 21, 22) $ 0 $ 9,348
15 Total Licensed Nursing Facility Beds - Level B (Adj ) 184 184
INTERMEDIATE CARE16 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ 0 $ 0
17 Total Patient Days (Adj ) 0 0
18 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
19 Overpayments (Adj ) $ 0 $ 0
MENTALLY DISORDERED20 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ 0 $ 0
21 Total Patient Days (Adj ) 0 0
22 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
23 Overpayments (Adj ) $ 0 $ 0
DEVELOPMENTALLY DISABLED24 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ 0 $ 0
25 Total Patient Days (Adj ) 0 0
26 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
27 Overpayments (Adj ) $ 0 $ 0
ADULT SUBACUTE28 Cost of Direct Care - Labor (Adult Subacute Sch. 1, Ln. 25) $ N/A $ 0 $ 0.00
29 Cost of Indirect Care - Labor (Adult Subacute Sch. 1, Ln. 26) $ N/A $ 0 $ 0.00
30 Cost of Direct and Indirect NonLabor - Other (Adult SA Sch. 1, Ln. 27) $ N/A $ 0 $ 0.00
31 Cost of Capital Related (Adult Subacute Sch. 1, Ln. 28) $ N/A $ 0 $ 0.00
32 Property Taxes (Adult Subacute Sch. 1, Ln. 29) $ N/A $ 0 $ 0.00
33 DHS Licensing Fees (Adult Subacute Sch. 1, Ln. 30) $ N/A $ 0 $ 0.00
34 Liability Insurance (Adult Subacute Sch. 1, Ln. 31) $ N/A $ 0 $ 0.00
35 Caregiver Training (Adult Subacute Sch. 1, Ln. 32) $ N/A $ 0 $ 0.00
36 Quality Assurance Fees (Adult Subacute Sch. 1, Ln. 33) $ N/A $ 0 $ 0.00
37 Cost of Administration (Adult Subacute Sch., Ln. 34) $ N/A $ 0 $ 0.00
38 Total Cost of Subacute Service (Adult Subacute Sch. 1, Ln. 35) $ 0 $ 0 $ 0.00
39 Total Patient Days (Adult Subacute Sch. 1, Ln. 36) 0 0
40 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
41 Overpayments (Adult Subacute Sch. 1, Ln. 38 + Ln. 39) $ 0 $ 0
SUMMARY OF AUDITED FACILITY COST PER PATIENT DAY
COST PERAUDITED
AS REPORTED AS AUDITED PATIENT DAYPROGRAM DESCRIPTION
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:LIFEHOUSE PARKVIEW JANUARY 12, 2007 THROUGH DECEMBER 31, 2007
Provider Number: OSHPD Facility No.:LTC55336G 206150774
LineNo.
SUMMARY OF AUDITED FACILITY COST PER PATIENT DAY
COST PERAUDITED
AS REPORTED AS AUDITED PATIENT DAYPROGRAM DESCRIPTION
PEDIATRIC SUBACUTE42 Cost of Routine Service (Ped-SA, Sch. 1, Ln 3) $ 0 $ 0
43 Cost of Ancillary Service (Ped-SA, Sch. 1, Ln. 1 + Ln. 2) $ 0 $ 0
44 Total Cost of Pediatric Subacute Service (Ln. 42 + Ln. 43) $ 0 $ 0
45 Total Patient Days (Ped-SA, Sch. 1, Ln. 5) 0 0
46 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
47 Overpayments (Ped-SA, Sch. 1, Ln. 7 + Ln. 8) $ 0 $ 0
HOSPICE INPATIENT CARE48 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ 0 $ 0
49 Total Patient Days (Adj ) 0 0
50 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
51 Overpayments (Adj ) $ 0 $ 0
OTHER ROUTINE SERVICES52 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ 0 $ 0
53 Total Patient Days (Adj ) 0 0
54 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
55 Overpayments (Adj ) $ 0 $ 0
STATE OF CALIFORNIA SCHEDULE 2
Provider Name: Fiscal Period:LIFEHOUSE PARKVIEW JANUARY 12, 2007 THROUGH DECEMBER 31, 2007
Provider Number: OSHPD Facility No.:LTC55336G 206150774
Soc Srvs ActivitiesNet Exp For
Line DESCRIPTION Cost AllocNo. (From Sch 8) 155 160 Total
GENERAL SERVICES5.00 Plant Operations and Maintenance
10.00 Housekeeping60.00 Laundry and Linen65.00 Dietary
155.00 Social Services (Salaries, Fringe Benefits, & Agency Labor) 86,845$ 86,845$ 160.00 Activities (Salaries, Fringe Benefits, & Agency Labor) 95,641 95,641$ 165.00 Administration165.00 Medical Records170.00 Inservice Education - Nursing
ANCILLARY SERVICES75.00 Patient Supplies 9,624 0 0 9,624$ 77.00 Specialized Support Surfaces N/A 0 0 080.00 Physical Therapy 169,214 0 0 169,21481.00 Respiratory Therapy 1,232 0 0 1,23282.00 Occupational Therapy 119,093 0 0 119,09383.00 Speech Pathology 12,534 0 0 12,53485.00 Pharmacy 142,038 0 0 142,03890.00 Laboratory 7,563 0 0 7,56395.00 Home Health Services 0 0 0 0
100.00 Other Ancillary Services 17,287 0 0 17,287100.06 Subacute Ancillary Services 0 0 0 0100.12 Subacute Pediatrics Ancillary Services 0 0 0 0
ROUTINE SERVICES105.00 Skilled Nursing Care 3,331,626 86,845 95,641 3,514,112 *110.00 Intermediate Care 0 0 0 0 *115.00 Mentally Disordered 0 0 0 0 *120.00 Developmentally Disabled 0 0 0 0 *125.00 Subacute Care 0 0 0 0 *126.00 Subacute Care - Pediatrics 0 0 0 0 *130.00 Hospice Inpatient Care 0 0 0 0 *135.00 Other Routine Services 0 0 0 0 *
NONREIMBURSABLE 136.00 Residential Care 0 0 0 0140.00 Beauty and Barber 8,215 0 0 8,215145.00 Other Nonreimbursable 0 0 0 0
TOTAL 4,000,912$ 86,845$ 95,641$ 4,000,912$
* (To Schedule 1)
ALLOCATION OF GENERAL SERVICES - LABOR (DIRECT CARE)
ST
AT
E O
F C
AL
IFO
RN
IAS
CH
ED
UL
E 3
Pro
vid
er N
ame:
Pro
vid
er N
um
ber
:O
SH
PD
Fac
ility
Nu
mb
er:
Fis
cal P
erio
d:
LIF
EH
OU
SE
PA
RK
VIE
WLT
C55
336G
2061
5077
4JA
NU
AR
Y 1
2, 2
007
THR
OU
GH
DE
CE
MB
ER
31,
200
7
Pla
nt
Op
sH
skp
ng
Lau
nd
ryD
ieta
ryS
oc
Srv
sA
ctiv
itie
sIn
-ser
v. E
dA
dm
inM
edic
alN
et E
xp F
or
Rec
ord
sL
ine
DE
SC
RIP
TIO
NC
ost
Allo
cA
ccu
mu
late
dN
o.
(Fro
m S
ch 8
)5
1060
6515
516
017
0C
ost
s16
516
5T
ota
l
GE
NE
RA
L S
ER
VIC
ES
5.00
Pla
nt O
pera
tions
and
Mai
nten
ance
49,3
04$
49,3
04$
10.0
0
Hou
seke
epin
g1,
723
01,
723
$
60.0
0
Laun
dry
and
Line
n0
2,34
682
2,42
8$
65.0
0
Die
tary
316,
481
5,14
918
00
321,
810
$
155.
00
Soc
ial S
ervi
ces
N/A
82
229
00
851
$
160.
00
Act
iviti
esN
/A
344
120
00
356
$
165.
00
Adm
inis
trat
ion
N/A
7,
401
259
00
00
7,65
9$
7,65
9$
165.
00
Med
ical
Rec
ords
73,5
5934
412
00
00
73,9
1573
,915
$
170.
00
Inse
rvic
e E
duca
tion
- N
ursi
ng81
,269
2,39
884
00
00
83,7
50$
AN
CIL
LA
RY
SE
RV
ICE
S75
.00
P
atie
nt S
uppl
ies
344
120
00
00
356
2524
562
6$
77.0
0
Spe
cial
ized
Sup
port
Sur
face
s0
00
00
00
017
165
182
80.0
0
Phy
sica
l The
rapy
394
140
00
00
407
211
2,03
62,
655
81.0
0
Res
pira
tory
The
rapy
903
00
00
094
550
149
82.0
0
Occ
upat
iona
l The
rapy
256
90
00
00
265
148
1,42
51,
838
83.0
0
Spe
ech
Pat
holo
gy44
20
00
00
4516
157
218
85.0
0
Pha
rmac
y56
220
00
00
058
218
71,
802
2,57
1
90.0
0
Labo
rato
ry16
46
00
00
017
016
150
335
95.0
0
Hom
e H
ealth
Ser
vice
s0
00
00
00
00
00
100.
00
Oth
er A
ncill
ary
Ser
vice
s0
00
00
00
020
192
212
100.
06
Sub
acut
e A
ncill
ary
Ser
vice
s0
00
00
00
00
00
100.
12
Sub
acut
e P
edia
tric
s A
ncill
ary
Ser
vice
s0
00
00
00
00
00
RO
UT
INE
SE
RV
ICE
S10
5.00
S
kille
d N
ursi
ng C
are
28,3
8899
22,
428
321,
810
851
356
83,7
5043
8,57
56,
995
67,4
9951
3,06
9*
110.
00
Inte
rmed
iate
Car
e0
00
00
00
00
00
*
115.
00
Men
tally
Dis
orde
red
00
00
00
00
00
0*
120.
00
Dev
elop
men
tally
Dis
able
d0
00
00
00
00
00
*
125.
00
Sub
acut
e C
are
00
00
00
00
00
0*
126.
00
Sub
acut
e C
are
- P
edia
tric
s0
00
00
00
00
00
*
130.
00
Hos
pice
Inpa
tient
Car
e0
00
00
00
00
00
*
135.
00
Oth
er R
outin
e S
ervi
ces
00
00
00
00
00
0*
NO
NR
EIM
BU
RS
AB
LE
13
6.00
R
esid
entia
l Car
e0
00
00
00
00
00
140.
00
Bea
uty
and
Bar
ber
258
90
00
00
267
2019
448
2
145.
00
Oth
er N
onre
imbu
rsab
le0
00
00
00
00
00
TOTA
L52
2,33
6$
49
,304
$
1,72
3$
2,
428
$
321,
810
$
85
1$
356
$
83
,750
$
440,
762
$
7,65
9$
73
,915
$
522,
336
$
*(T
o S
ched
ule
1)
AL
LO
CA
TIO
N O
F G
EN
ER
AL
SE
RV
ICE
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BO
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ND
IRE
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CA
RE
)
ST
AT
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F C
AL
IFO
RN
IAS
CH
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UL
E 4
Pro
vid
er N
ame:
Pro
vid
er N
um
ber
:O
SH
PD
Fac
ility
Nu
mb
er:
Fis
cal P
erio
d:
LIF
EH
OU
SE
PA
RK
VIE
WLT
C55
336G
2061
5077
4JA
NU
AR
Y 1
2, 2
007
THR
OU
GH
DE
CE
MB
ER
31,
200
7
Pla
nt
Op
sH
skp
ng
Lau
nd
ryD
ieta
ryS
oc
Srv
sA
ctiv
itie
sIn
-ser
v. E
dA
dm
inM
edic
alN
et E
xp F
or
Rec
ord
sL
ine
DE
SC
RIP
TIO
NC
ost
Allo
cA
ccu
mu
late
dN
o.
(Fro
m S
ch 8
)5
1060
6515
516
017
0C
ost
s16
516
5T
ota
l
GE
NE
RA
L S
ER
VIC
ES
5.00
Pla
nt O
pera
tions
and
Mai
nten
ance
302,
392
$
302,
392
$
10.0
0
Hou
seke
epin
g25
3,58
80
253,
588
$
60.0
0
Laun
dry
and
Line
n14
4,44
714
,390
12,0
6817
0,90
5$
65.0
0
Die
tary
361,
800
31,5
8326
,486
041
9,86
9$
155.
00
Soc
ial S
ervi
ces
3,07
95,
040
4,22
70
012
,346
$
160.
00
Act
iviti
es18
,198
2,10
91,
768
00
022
,075
$
165.
00
Adm
inis
trat
ion
N/A
45
,391
38,0
650
00
083
,456
$
83
,456
$
165.
00
Med
ical
Rec
ords
02,
109
1,76
80
00
03,
877
3,87
7$
170.
00
Inse
rvic
e E
duca
tion
- N
ursi
ng15
014
,705
12,3
320
00
027
,186
$
AN
CIL
LA
RY
SE
RV
ICE
S75
.00
P
atie
nt S
uppl
ies
02,
109
1,76
80
00
00
3,87
727
613
4,16
6$
77.0
0
Spe
cial
ized
Sup
port
Sur
face
s14
,871
00
00
00
014
,871
186
915
,066
80.0
0
Phy
sica
l The
rapy
02,
414
2,02
40
00
00
4,43
82,
299
107
6,84
4
81.0
0
Res
pira
tory
The
rapy
055
546
50
00
00
1,02
056
31,
079
82.0
0
Occ
upat
iona
l The
rapy
01,
572
1,31
80
00
00
2,89
11,
609
754,
574
83.0
0
Spe
ech
Pat
holo
gy0
268
225
00
00
049
317
78
678
85.0
0
Pha
rmac
y0
3,45
02,
893
00
00
06,
342
2,03
595
8,47
2
90.0
0
Labo
rato
ry0
1,00
884
50
00
00
1,85
316
98
2,03
0
95.0
0
Hom
e H
ealth
Ser
vice
s0
00
00
00
00
00
0
100.
00
Oth
er A
ncill
ary
Ser
vice
s0
00
00
00
00
217
1022
7
100.
06
Sub
acut
e A
ncill
ary
Ser
vice
s0
00
00
00
00
00
0
100.
12
Sub
acut
e P
edia
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s A
ncill
ary
Ser
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00
00
00
00
00
RO
UT
INE
SE
RV
ICE
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5.00
S
kille
d N
ursi
ng C
are
216,
836
174,
109
146,
009
170,
905
419,
869
12,3
4622
,075
27,1
861,
189,
335
76,2
113,
540
1,26
9,08
7*
110.
00
Inte
rmed
iate
Car
e0
00
00
00
00
00
*
115.
00
Men
tally
Dis
orde
red
00
00
00
00
00
0*
120.
00
Dev
elop
men
tally
Dis
able
d0
00
00
00
00
00
*
125.
00
Sub
acut
e C
are
00
00
00
00
00
00
*
126.
00
Sub
acut
e C
are
- P
edia
tric
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00
00
00
00
00
*
130.
00
Hos
pice
Inpa
tient
Car
e0
00
00
00
00
00
*
135.
00
Oth
er R
outin
e S
ervi
ces
00
00
00
00
00
0*
NO
NR
EIM
BU
RS
AB
LE
13
6.00
R
esid
entia
l Car
e0
00
00
00
00
00
140.
00
Bea
uty
and
Bar
ber
1,58
11,
326
00
00
02,
908
220
103,
137
145.
00
Oth
er N
onre
imbu
rsab
le0
00
00
00
00
00
TOTA
L1,
315,
361
$
30
2,39
2$
253,
588
$
17
0,90
5$
419,
869
$
12
,346
$
22,0
75$
27
,186
$
1,22
8,02
8$
83,4
56$
3,
877
$
1,31
5,36
1$
*(T
o S
ched
ule
1)
AL
LO
CA
TIO
N O
F G
EN
ER
AL
SE
RV
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OT
HE
R N
ON
LA
BO
R(D
IRE
CT
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D IN
DIR
EC
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AR
E)
STATE OF CALIFORNIA SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Provider Name: Fiscal Period:LIFEHOUSE PARKVIEW JANUARY 12, 2007 THROUGH DECEMBER 31, 2007
Provider Number: OSHPD Facility Number:LTC55336G 206150774
Capital Plant Ops Hskpng Laundry Dietary Soc Srvs ActivitiesNet Exp For
Line DESCRIPTION Cost AllocNo. (From Sch 8) Ratio Various 5 10 60 65 155 160
GENERAL SERVICESCapital Related (excluding lines 40 & 45) 1,171,759$ 100%
Property Tax (line 40) 0 0% 1,171,759$
5.00 Plant Operations and Maintenance 34,773 34,773$
10.00 Housekeeping 0 0 -$
60.00 Laundry and Linen 54,107 1,655 0 55,762$
65.00 Dietary 118,751 3,632 0 0 122,383$
155.00 Social Services 18,951 580 0 0 0 19,531$
160.00 Activities 7,928 242 0 0 0 0 8,171$
165.00 Administration 170,668 5,220 0 0 0 0 0
165.00 Medical Records 7,928 242 0 0 0 0 0
170.00 Inservice Education - Nursing 55,290 1,691 0 0 0 0 0
ANCILLARY SERVICES75.00 Patient Supplies 7,928 242 0 0 0 0 0
77.00 Specialized Support Surfaces 0 0 0 0 0 0 0
80.00 Physical Therapy 9,076 278 0 0 0 0 0
81.00 Respiratory Therapy 2,086 64 0 0 0 0 0
82.00 Occupational Therapy 5,911 181 0 0 0 0 0
83.00 Speech Pathology 1,008 31 0 0 0 0 0
85.00 Pharmacy 12,970 397 0 0 0 0 0
90.00 Laboratory 3,790 116 0 0 0 0 0
95.00 Home Health Services 0 0 0 0 0 0 0
100.00 Other Ancillary Services 0 0 0 0 0 0 0
100.06 Subacute Ancillary Services 0 0 0 0 0 0 0
100.12 Subacute Pediatrics Ancillary Services 0 0 0 0 0 0 0
ROUTINE SERVICES105.00 Skilled Nursing Care 654,644 20,022 0 55,762 122,383 19,531 8,171
110.00 Intermediate Care 0 0 0 0 0 0 0
115.00 Mentally Disordered 0 0 0 0 0 0 0
120.00 Developmentally Disabled 0 0 0 0 0 0 0
125.00 Subacute Care 0 0 0 0 0 0 0
126.00 Subacute Care - Pediatrics 0 0 0 0 0 0 0
130.00 Hospice Inpatient Care 0 0 0 0 0 0 0
135.00 Other Routine Services 0 0 0 0 0 0 0
NONREIMBURSABLE 136.00 Residential Care 0 0 0 0 0 0 0
140.00 Beauty and Barber 5,946 182 0 0 0 0 0
145.00 Other Nonreimbursable 0 0 0 0 0 0 0
TOTAL 1,171,759$ 100% 1,171,759$ 34,773$ -$ 55,762$ 122,383$ 19,531$ 8,171$
* (To Schedule 1)
STATE OF CALIFORNIA
Provider Name:LIFEHOUSE PARKVIEW
Provider Number:LTC55336G
Net Exp ForLine DESCRIPTION Cost AllocNo. (From Sch 8) Ratio
GENERAL SERVICESCapital Related (excluding lines 40 & 45) 1,171,759$ 100%Property Tax (line 40) 0 0%
5.00 Plant Operations and Maintenance10.00 Housekeeping60.00 Laundry and Linen65.00 Dietary
155.00 Social Services160.00 Activities165.00 Administration165.00 Medical Records170.00 Inservice Education - Nursing
ANCILLARY SERVICES75.00 Patient Supplies77.00 Specialized Support Surfaces80.00 Physical Therapy81.00 Respiratory Therapy82.00 Occupational Therapy83.00 Speech Pathology85.00 Pharmacy90.00 Laboratory95.00 Home Health Services
100.00 Other Ancillary Services100.06 Subacute Ancillary Services100.12 Subacute Pediatrics Ancillary Services
ROUTINE SERVICES105.00 Skilled Nursing Care110.00 Intermediate Care115.00 Mentally Disordered120.00 Developmentally Disabled125.00 Subacute Care126.00 Subacute Care - Pediatrics130.00 Hospice Inpatient Care135.00 Other Routine Services
NONREIMBURSABLE 136.00 Residential Care140.00 Beauty and Barber145.00 Other Nonreimbursable
TOTAL 1,171,759$ 100%
* (To Schedule 1)
SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Fiscal Period:JANUARY 12, 2007 THROUGH DECEMBER 31, 2007
OSHPD Facility Number:206150774
In-serv. Ed Admin Medical Capital PropertyRecords Related Tax
Accumulated 100% 0%170 Costs 165 165 Total Of Total Of Total
175,887$ 175,887$ 8,171 8,171$
56,981$
0 8,171 582 27 8,780$ 8,780$ -$ 0 0 393 18 411 411 00 9,353 4,846 225 14,424 14,424 00 2,150 119 6 2,275 2,275 00 6,092 3,391 158 9,641 9,641 00 1,039 373 17 1,429 1,429 00 13,367 4,289 199 17,855 17,855 00 3,906 356 17 4,279 4,279 00 0 0 0 0 0 00 0 457 21 478 478 00 0 0 0 0 0 00 0 0 0 0 0 0
56,981 937,493 160,620 7,462 1,105,575 1,105,575 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *
0 0 0 0 0 0 00 6,128 463 21 6,612 6,612 00 0 0 0 0 0 0
56,981$ 987,701$ 175,887$ 8,171$ 1,171,759$ 1,171,759$ -$
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ST
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STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:LIFEHOUSE PARKVIEW JANUARY 12, 2007 THROUGH DECEMBER 31, 2007
Provider Number: OSHPD Facility Number:LTC55336G 206150774
Line Natural ACCOUNT TITLE AccountNo. Class Number
5.00 Plant Operations and Maintenance 6200 $ 352,976 $ (351,696) $ 1,280 $ (1,280) $ 05.01 .01-.19 Salaries and Wages 6200 39,856 39,856 0 39,856 (Sch 3)5.02 .20-.39 Fringe Benefits 6200 9,448 9,448 0 9,448 (Sch 3)5.03 .79 Agency Staff 6200 0 0 0 0 (Sch 3)5.04 .40-.99 Other - Nonlabor 6200 302,392 302,392 0 302,392 (Sch 4)5.05 Plant Operations and Maintenance - Total 6200 $ 352,976 $ 0 $ 352,976 $ (1,280) $ 351,696
10.00 Housekeeping 6300 $ 255,311 $ (255,311) $ 0 $ 0 $ 010.01 .01-.19 Salaries and Wages 6300 1,578 1,578 0 1,578 (Sch 3)10.02 .20-.39 Fringe Benefits 6300 145 145 0 145 (Sch 3)10.03 .79 Agency Staff 6300 0 0 0 0 (Sch 3)10.04 .40-.99 Other - Nonlabor 6300 253,588 253,588 0 253,588 (Sch 4)10.05 Housekeeping - Total 6300 $ 255,311 $ 0 $ 255,311 $ 0 $ 255,311
15.00 Depreciation: Bldgs and Improvements 7110 - 7120 $ 0 $ 0 $ 0 $ 0 (Sch 5)20.00 Depreciation: Leasehold Improvements 7130 3,497 3,497 0 3,497 (Sch 5)25.00 Depreciation: Equipment 7140 3,884 3,884 0 3,884 (Sch 5)30.00 Depreciation and Amortization - Other 7150 - 7160 238 238 0 238 (Sch 5)35.00 Leases and Rentals 7200 1,164,140 1,164,140 0 1,164,140 (Sch 5)40.00 Property Taxes 7300 47,538 47,538 (47,538) 0 (Sch 5)45.00 Property Insurance 7400 9,546 9,546 0 9,546 (Sch 6)50.00 Interest-Property, Plant, and Equipment 7500 0 0 0 0 (Sch 5)55.00 Interest-Other 7600 0 0 0 0 (Sch 6)
57.00 Subtotal 005 - 055 $ 1,837,130 $ 0 $ 1,837,130 $ (48,818) $ 1,788,312
60.00 Laundry and Linen 6400 $ 144,447 $ (144,447) $ 0 $ 0 $ 060.01 .01-.19 Salaries and Wages 6400 0 0 0 0 (Sch 3)60.02 .20-.39 Fringe Benefits 6400 0 0 0 0 (Sch 3)60.03 .79 Agency Staff 6400 0 0 0 0 (Sch 3)60.04 .40-.99 Other - Nonlabor 6400 144,447 144,447 0 144,447 (Sch 4)60.05 Laundry and Linen - Total 6400 $ 144,447 $ 0 $ 144,447 $ 0 $ 144,447
65.00 Dietary 6500 $ 687,037 $ (678,281) $ 8,756 $ (8,756) $ 065.01 .01-.19 Salaries and Wages 6500 259,734 259,734 0 259,734 (Sch 3)65.02 .20-.39 Fringe Benefits 6500 56,747 56,747 0 56,747 (Sch 3)65.03 .79 Agency Staff 6500 0 0 0 0 (Sch 3)65.04 .40-.99 Other - Nonlabor 6500 361,800 361,800 0 361,800 (Sch 4)65.05 Dietary - Total 6500 $ 687,037 $ 0 $ 687,037 $ (8,756) $ 678,281
70.00 Provision for Bad Debts 7700 $ 0 $ 0 $ 0 $ 0
Ancillary Services (Note 1)75.00 Patient Supplies 8100 $ 9,624 $ 0 $ 9,624 $ 0 $ 9,624 (Sch 2)75.01 .01-.19 Salaries and Wages 8100 0 0 0 0 (Sch 2)75.02 .20-.39 Fringe Benefits 8100 0 0 0 0 (Sch 2)75.03 .79 Agency Staff 8100 0 0 0 0 (Sch 2)75.04 .40-.99 Other - Nonlabor 8100 0 0 0 0 (Sch 4)75.05 Patient Supplies - Total 8100 $ 9,624 $ 0 $ 9,624 $ 0 $ 9,624
77.00 Specialized Support Surfaces 8150 14,871 $ 14,871 $ 0 $ 14,871 (Sch 4)
80.00 Physical Therapy 8200 $ 150,698 $ 0 $ 150,698 $ 18,516 $ 169,214 (Sch 2)80.01 .01-.19 Salaries and Wages 8200 0 0 0 0 (Sch 2)80.02 .20-.39 Fringe Benefits 8200 0 0 0 0 (Sch 2)80.03 .79 Agency Staff 8200 0 0 0 0 (Sch 2)80.04 .40-.99 Other - Nonlabor 8200 0 0 0 0 (Sch 4)80.05 Physical Therapy - Total 8200 $ 150,698 $ 0 $ 150,698 $ 18,516 $ 169,214
81.00 Respiratory Therapy 8220 $ 1,232 $ 0 $ 1,232 $ 0 $ 1,232 (Sch 2)81.01 .01-.19 Salaries and Wages 8220 0 0 0 0 (Sch 2)81.02 .20-.39 Fringe Benefits 8220 0 0 0 0 (Sch 2)81.03 .79 Agency Staff 8220 0 0 0 0 (Sch 2)81.04 .40-.99 Other - Nonlabor 8220 0 0 0 0 (Sch 4)81.05 Respiratory Therapy - Total 8220 $ 1,232 $ 0 $ 1,232 $ 0 $ 1,232
REPORTED AUDITED(SCHEDULE 8A-1)AS AS
SUBTOTAL (SCHEDULE 8A-2)
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT ADJUSTMENTS
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:LIFEHOUSE PARKVIEW JANUARY 12, 2007 THROUGH DECEMBER 31, 2007
Provider Number: OSHPD Facility Number:LTC55336G 206150774
Line Natural ACCOUNT TITLE AccountNo. Class Number REPORTED AUDITED(SCHEDULE 8A-1)
AS ASSUBTOTAL (SCHEDULE 8A-2)
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT ADJUSTMENTS
82.00 Occupational Therapy 8250 $ 107,271 $ 0 $ 107,271 $ 11,822 $ 119,093 (Sch 2)82.01 .01-.19 Salaries and Wages 8250 0 0 0 0 (Sch 2)82.02 .20-.39 Fringe Benefits 8250 0 0 0 0 (Sch 2)82.03 .79 Agency Staff 8250 0 0 0 0 (Sch 2)82.04 .40-.99 Other - Nonlabor 8250 0 0 0 0 (Sch 4)82.05 Occupational Therapy - Total 8250 $ 107,271 $ 0 $ 107,271 $ 11,822 $ 119,093
83.00 Speech Pathology 8280 $ 11,359 $ 0 $ 11,359 $ 1,175 $ 12,534 (Sch 2)83.01 .01-.19 Salaries and Wages 8280 0 0 0 0 (Sch 2)83.02 .20-.39 Fringe Benefits 8280 0 0 0 0 (Sch 2)83.03 .79 Agency Staff 8280 0 0 0 0 (Sch 2)83.04 .40-.99 Other - Nonlabor 8280 0 0 0 0 (Sch 4)83.05 Speech Pathology - Total 8280 $ 11,359 $ 0 $ 11,359 $ 1,175 $ 12,534
85.00 Pharmacy 8300 $ 142,038 $ 0 $ 142,038 $ 0 $ 142,038 (Sch 2)85.01 .01-.19 Salaries and Wages 8300 0 0 0 0 (Sch 2)85.02 .20-.39 Fringe Benefits 8300 0 0 0 0 (Sch 2)85.03 .79 Agency Staff 8300 0 0 0 0 (Sch 2)85.04 .40-.99 Other - Nonlabor 8300 0 0 0 0 (Sch 4)85.05 Pharmacy - Total 8300 $ 142,038 $ 0 $ 142,038 $ 0 $ 142,038
90.00 Laboratory 8400 $ 7,563 $ 0 $ 7,563 $ 0 $ 7,563 (Sch 2)90.01 .01-.19 Salaries and Wages 8400 0 0 0 0 (Sch 2)90.02 .20-.39 Fringe Benefits 8400 0 0 0 0 (Sch 2)90.03 .79 Agency Staff 8400 0 0 0 0 (Sch 2)90.04 .40-.99 Other - Nonlabor 8400 0 0 0 0 (Sch 4)90.05 Laboratory - Total 8400 $ 7,563 $ 0 $ 7,563 $ 0 $ 7,563
95.00 Home Health Services 8800 $ 0 $ 0 $ 0 $ 0 $ 0 (Sch 2)95.01 .01-.19 Salaries and Wages 8800 0 0 0 0 (Sch 2)95.02 .20-.39 Fringe Benefits 8800 0 0 0 0 (Sch 2)95.03 .79 Agency Staff 8800 0 0 0 0 (Sch 2)95.04 .40-.99 Other - Nonlabor 8800 0 0 0 0 (Sch 4)95.05 Home Health Services - Total 8800 $ 0 $ 0 $ 0 $ 0 $ 0
100.00 Other Ancillary Services 8900 $ 9,072 $ 0 $ 9,072 $ 8,215 $ 17,287 (Sch 2)100.01 .01-.19 Salaries and Wages 8900 0 0 0 0 (Sch 2)100.02 .20-.39 Fringe Benefits 8900 0 0 0 0 (Sch 2)100.03 .79 Agency Staff 8900 0 0 0 0 (Sch 2)100.04 .40-.99 Other - Nonlabor 8900 0 0 0 0 (Sch 4)100.05 Other Ancillary Services - Total 8900 $ 9,072 $ 0 $ 9,072 $ 8,215 $ 17,287
100.06 Subacute Ancillary Services $ 0 $ 0 $ 0 $ 0 $ 0 (Sch 2)100.07 .01-.19 Salaries and Wages 0 0 0 0 (Sch 2)100.08 .20-.39 Fringe Benefits 0 0 0 0 (Sch 2)100.09 .79 Agency Staff 0 0 0 0 (Sch 2)100.10 .40-.99 Other - Nonlabor 0 0 0 0 (Sch 4)100.11 Subacute Ancillary Services - Total $ 0 $ 0 $ 0 $ 0 $ 0
100.12 Subacute Pediatrics Ancillary Services $ 0 $ 0 $ 0 $ 0 (Sch 2)
101.00 Subtotal 075 - 100.12 $ 453,728 $ 0 $ 453,728 $ 39,728 $ 493,456
Routine Services105.00 Skilled Nursing Care 6110 $ 3,625,137 $ (3,556,462) $ 68,675 $ (68,675) $ 0105.01 .01-.19 Salaries and Wages 6110 2,155,046 2,155,046 0 2,155,046 (Sch 2)105.02 .20-.39 Fringe Benefits 6110 433,756 433,756 0 433,756 (Sch 2)105.03 .49 Agency Staff 6110 742,824 742,824 0 742,824 (Sch 2)105.04 .40-.99 Other - Nonlabor 6110 224,836 224,836 (8,000) 216,836 (Sch 4)105.05 Skilled Nursing Care - Total 6110 $ 3,625,137 $ 0 $ 3,625,137 $ (76,675) $ 3,548,462
110.00 Intermediate Care 6120 $ 0 $ 0 $ 0 $ 0 (Sch 2)115.00 Mentally Disordered 6130 0 0 0 0 (Sch 2)120.00 Developmentally Disabled 6140 0 0 0 0 (Sch 2)
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:LIFEHOUSE PARKVIEW JANUARY 12, 2007 THROUGH DECEMBER 31, 2007
Provider Number: OSHPD Facility Number:LTC55336G 206150774
Line Natural ACCOUNT TITLE AccountNo. Class Number REPORTED AUDITED(SCHEDULE 8A-1)
AS ASSUBTOTAL (SCHEDULE 8A-2)
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT ADJUSTMENTS
125.00 Subacute Care 6150 $ 0 $ 0 $ 0 $ 0 $ 0125.01 .01-.19 Salaries and Wages 6150 0 0 0 0 (Sch 2)125.02 .20-.39 Fringe Benefits 6150 0 0 0 0 (Sch 2)125.03 .49 Agency Staff 6150 0 0 0 0 (Sch 2)125.04 .40-.99 Other - Nonlabor 6150 0 0 0 0 (Sch 4)125.05 Subacute Care - Total 6150 $ 0 $ 0 $ 0 $ 0 $ 0
126.00 Subacute Care - Pediatrics 6160 $ 0 $ 0 $ 0 $ 0130.00 Hospice Inpatient Care 6180 0 0 0 0 (Sch 2)135.00 Other Routine Services 6190 0 0 0 0 (Sch 2)
Other Nonreimbursable136.00 Residential Care 9100 $ 0 $ 0 $ 0 $ 0 (Sch 2)140.00 Beauty and Barber 8900 8,215 8,215 0 8,215 (Sch 2)145.00 Other Nonreimbursable 9100 0 0 0 0 (Sch 2)
146.00 Subtotal 105 - 145 $ 3,633,352 $ 0 $ 3,633,352 $ (76,675) $ 3,556,677
155.00 Social Services 6600 $ 91,168 $ (89,924) $ 1,244 $ (1,244) $ 0155.01 .01-.19 Salaries and Wages 6600 75,392 75,392 0 75,392 (Sch 2)155.02 .20-.39 Fringe Benefits 6600 11,453 11,453 0 11,453 (Sch 2)155.03 .79 Agency Staff 6600 0 0 0 0 (Sch 2)155.04 .40-.99 Other - Nonlabor 6600 3,079 3,079 0 3,079 (Sch 4)155.05 Social Services - Total 6600 $ 91,168 $ 0 $ 91,168 $ (1,244) $ 89,924
160.00 Activities 6700 $ 116,596 $ (113,839) $ 2,757 $ (2,757) $ 0160.01 .01-.19 Salaries and Wages 6700 76,116 76,116 0 76,116 (Sch 2)160.02 .20-.39 Fringe Benefits 6700 19,525 19,525 0 19,525 (Sch 2)160.03 .79 Agency Staff 6700 0 0 0 0 (Sch 2)160.04 .40-.99 Other - Nonlabor 6700 18,198 18,198 0 18,198 (Sch 4)160.05 Activities - Total 6700 $ 116,596 $ 0 $ 116,596 $ (2,757) $ 113,839
165.00 Administration 6900 $ 1,866,973 $ (1,855,906) $ 11,067 $ (11,067) $ 0165.01 .01-.19 Salaries and Wages 6900 248,089 248,089 0 248,089 (Sch 6)165.02 .20-.39 Fringe Benefits 6900 49,726 49,726 0 49,726 (Sch 6)165.03 .01-.19 Medical Records - Salaries and Wages 6900 61,277 61,277 0 61,277 (Sch 3)165.04 .20-.39 Medical Records - Fringe Benefits 6900 12,282 12,282 0 12,282 (Sch 3)165.05 .79 Medical Records - Agency Staff 6900 0 0 0 0 (Sch 3)165.06 .40-.99 Medical Records - Other - Nonlabor 6900 0 0 0 0 (Sch 4)165.07 DHS Licensing Fees 6900 0 0 41,277 41,277 (Sch 6)165.08 Liability Insurance 6900 0 0 0 0 (Sch 6)165.09 Caregiver Training 6900 0 0 0 0 (Sch 6)165.10 Quality Assurance Fees 6900 0 0 391,368 391,368 (Sch 6)165.11 .40-.99 Other - Nonlabor 6900 1,484,532 1,484,532 (773,627) 710,905 (Sch 6)165.12 Administration - Total 6900 $ 1,866,973 $ 0 $ 1,866,973 $ (352,049) $ 1,514,924
170.00 Inservice Education - Nursing 6800 $ 84,997 $ (81,419) $ 3,578 $ (3,578) $ 0170.01 .01-.19 Salaries and Wages 6800 71,433 71,433 0 71,433 (Sch 3)170.02 .20-.39 Fringe Benefits 6800 9,836 9,836 0 9,836 (Sch 3)170.03 .79 Agency Staff 6800 0 0 0 0 (Sch 3)170.04 .40-.99 Other - Nonlabor 6800 150 150 0 150 (Sch 4)170.05 Inservice Education - Nursing - Total 6800 $ 84,997 $ 0 $ 84,997 $ (3,578) $ 81,419
171.00 Subtotal 155 - 170.05 $ 2,159,734 $ 0 $ 2,159,734 $ (359,628) $ 1,800,106
175.00 Total $ 8,915,428 $ 0 $ 8,915,428 $ (454,149) $ 8,461,279
NOTE 1: Ancillary service costs are reclassified only if the facility has an Adult Subacute unit.
ST
AT
E O
F C
ALI
FOR
NIA
Sch
edul
e 8A
-1
Pag
e 1
Pro
vide
r N
ame:
Pro
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r N
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OS
HP
D F
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ty N
umbe
r:Fi
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Per
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LIF
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C55
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2061
5077
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259,
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259,
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65.0
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56,7
47
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OS
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D F
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Per
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ST
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F C
ALI
FOR
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Sch
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-1
Pag
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Pro
vide
r N
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Pro
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OS
HP
D F
acili
ty N
umbe
r:Fi
scal
Per
iod:
LIF
EH
OU
SE
PA
RK
VIE
WLT
C55
336G
2061
5077
4JA
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AR
Y 1
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R 3
1, 2
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L A
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AU
DIT
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IT A
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AU
DIT
AD
JA
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IT A
DJ
AU
DIT
AD
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(Pag
es 1
& 2
)1
23
45
67
89
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ILIA
TIO
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F T
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IDE
R'S
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efits
11,4
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efits
19,5
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248,
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248,
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165.
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S L
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165.
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165.
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n -
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0
165.
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dmin
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n -
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lity
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uran
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0
165.
11A
dmin
istr
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n -
Oth
er -
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nlab
or
1,48
4,53
21,
460,
564
170.
00In
serv
ice
Edu
catio
n -
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sing
(81,
419)
(81,
419)
170.
01In
serv
ice
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catio
n -
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sing
- S
alar
ies
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es71
,433
71,4
33
170.
02In
serv
ice
Edu
catio
n -
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sing
- F
ringe
Ben
efits
9,83
69,
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serv
ice
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00
To
tal
$00
00
00
00
00
(To
Sch
8)
ST
AT
E O
F C
ALI
FOR
NIA
Pro
vide
r N
ame:
LIF
EH
OU
SE
PA
RK
VIE
W
5.00
Pla
nt O
pera
tions
and
Mai
nten
ance
5.01
Pla
nt O
pera
tions
and
Mai
nten
ance
- S
alar
ies
and
Wag
es
5.02
Pla
nt O
pera
tions
and
Mai
nten
ance
- F
ringe
Ben
efits
5.03
Pla
nt O
pera
tions
and
Mai
nten
ance
- A
genc
y S
taff
5.04
Pla
nt O
pera
tions
and
Mai
nten
ance
- O
ther
- N
onl
abo
r
10.0
0H
ous
ekee
ping
10.0
1H
ous
ekee
ping
- S
alar
ies
and
Wag
es
10.0
2H
ous
ekee
ping
- F
ringe
Ben
efits
10.0
3H
ous
ekee
ping
- A
genc
y S
taff
10.0
4H
ous
ekee
ping
- O
ther
- N
onl
abo
r
60.0
0La
undr
y an
d Li
nen
60.0
1La
undr
y an
d Li
nen
- S
alar
ies
and
Wag
es
60.0
2La
undr
y an
d Li
nen
- F
ringe
Ben
efits
60.0
3La
undr
y an
d Li
nen
- A
genc
y S
taff
60.0
4La
undr
y an
d Li
nen
- O
ther
- N
onl
abo
r
65.0
0D
ieta
ry
65.0
1D
ieta
ry -
Sal
arie
s an
d W
ages
65.0
2D
ieta
ry -
Frin
ge B
enef
its
65.0
3D
ieta
ry -
Age
ncy
Sta
ff
65.0
4D
ieta
ry -
Oth
er -
No
nlab
or
75.0
0P
atie
nt S
uppl
ies
75.0
1P
atie
nt S
uppl
ies
- S
alar
ies
and
Wag
es
75.0
2P
atie
nt S
uppl
ies
- F
ringe
Ben
efits
75.0
3P
atie
nt S
uppl
ies
- A
genc
y S
taff
75.0
4P
atie
nt S
uppl
ies
- O
ther
- N
onl
abo
r
80.0
0P
hysi
cal T
hera
py
80.0
1P
hysi
cal T
hera
py -
Sal
arie
s an
d W
ages
80.0
2P
hysi
cal T
hera
py -
Frin
ge B
enef
its
80.0
3P
hysi
cal T
hera
py -
Age
ncy
Sta
ff
80.0
4P
hysi
cal T
hera
py -
Oth
er -
No
nlab
or
81.0
0R
espi
rato
ry T
hera
py
81.0
1R
espi
rato
ry T
hera
py -
Sal
arie
s an
d W
ages
81.0
2R
espi
rato
ry T
hera
py -
Frin
ge B
enef
its
81.0
3R
espi
rato
ry T
hera
py -
Age
ncy
Sta
ff
81.0
4R
espi
rato
ry T
hera
py -
Oth
er -
No
nlab
or
82.0
0O
ccup
atio
nal T
hera
py
82.0
1O
ccup
atio
nal T
hera
py -
Sal
arie
s an
d W
ages
82.0
2O
ccup
atio
nal T
hera
py -
Frin
ge B
enef
its
82.0
3O
ccup
atio
nal T
hera
py -
Age
ncy
Sta
ff
82.0
4O
ccup
atio
nal T
hera
py -
Oth
er -
No
nlab
or
83.0
0S
peec
h P
atho
logy
Sch
edul
e 8A
-1
Pag
e 2
Pro
vide
r N
o.:
OS
HP
D F
acili
ty N
umbe
r:Fi
scal
Per
iod:
LTC
5533
6G20
6150
774
JAN
UA
RY
12,
200
7 T
HR
OU
GH
DE
CE
MB
ER
31,
200
7
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
10 433
(433
)
RE
CO
NC
ILIA
TIO
N O
F T
HE
PR
OV
IDE
R'S
AD
JUS
TM
EN
TS
TO
TH
E A
UD
IT R
EP
OR
T
ST
AT
E O
F C
ALI
FOR
NIA
Pro
vide
r N
ame:
LIF
EH
OU
SE
PA
RK
VIE
W
83.0
1S
peec
h P
atho
logy
- S
alar
ies
and
Wag
es
83.0
2S
peec
h P
atho
logy
- F
ringe
Ben
efits
83.0
3S
peec
h P
atho
logy
- A
genc
y S
taff
83.0
4S
peec
h P
atho
logy
- O
ther
- N
onl
abo
r
85.0
0P
harm
acy
85.0
1P
harm
acy
- S
alar
ies
and
Wag
es
85.0
2P
harm
acy
- F
ringe
Ben
efits
85.0
3P
harm
acy
- A
genc
y S
taff
85.0
4P
harm
acy
- O
ther
- N
onl
abo
r
90.0
0La
bora
tory
90.0
1La
bora
tory
- S
alar
ies
and
Wag
es
90.0
2La
bora
tory
- F
ringe
Ben
efits
90.0
3La
bora
tory
- A
genc
y S
taff
90.0
4La
bora
tory
- O
ther
- N
onl
abo
r
95.0
0H
om
e H
ealth
Ser
vice
s
95.0
1H
om
e H
ealth
Ser
vice
s -
Sal
arie
s an
d W
ages
95.0
2H
om
e H
ealth
Ser
vice
s -
Frin
ge B
enef
its
95.0
3H
om
e H
ealth
Ser
vice
s -
Age
ncy
Sta
ff
95.0
4H
om
e H
ealth
Ser
vice
s -
Oth
er -
No
nlab
or
100.
00O
ther
Anc
illar
y S
ervi
ces
100.
01O
ther
Anc
illar
y S
ervi
ces
- S
alar
ies
and
Wag
es
100.
02O
ther
Anc
illar
y S
ervi
ces
- F
ringe
Ben
efits
100.
03O
ther
Anc
illar
y S
ervi
ces
- A
genc
y S
taff
100.
04O
ther
Anc
illar
y S
ervi
ces
- O
ther
- N
onl
abo
r
100.
06S
ubac
ute
Anc
illar
y S
ervi
ces
100.
07S
ubac
ute
Anc
illar
y S
ervi
ces
- S
alar
ies
and
Wag
es
100.
08S
ubac
ute
Anc
illar
y S
ervi
ces
- F
ringe
Ben
efits
100.
09S
ubac
ute
Anc
illar
y S
ervi
ces
- A
genc
y S
taff
100.
10S
ubac
ute
Anc
illar
y S
ervi
ces
- O
ther
- N
onl
abo
r
105.
00S
kille
d N
ursi
ng C
are
105.
01S
kille
d N
ursi
ng C
are
- S
alar
ies
and
Wag
es
105.
02S
kille
d N
ursi
ng C
are
- F
ringe
Ben
efits
105.
03S
kille
d N
ursi
ng C
are
- A
genc
y S
taff
105.
04S
kille
d N
ursi
ng C
are
- O
ther
- N
onl
abo
r
125.
00S
ubac
ute
Car
e
125.
01S
ubac
ute
Car
e -
Sal
arie
s an
d W
ages
125.
02S
ubac
ute
Car
e -
Frin
ge B
enef
its
125.
03S
ubac
ute
Car
e -
Age
ncy
Sta
ff
125.
04S
ubac
ute
Car
e -
Oth
er -
No
nlab
or
155.
00S
oci
al S
ervi
ces
155.
01S
oci
al S
ervi
ces
- S
alar
ies
and
Wag
es
Sch
edul
e 8A
-1
Pag
e 2
Pro
vide
r N
o.:
OS
HP
D F
acili
ty N
umbe
r:Fi
scal
Per
iod:
LTC
5533
6G20
6150
774
JAN
UA
RY
12,
200
7 T
HR
OU
GH
DE
CE
MB
ER
31,
200
7
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
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DJ
AU
DIT
AD
JA
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10
RE
CO
NC
ILIA
TIO
N O
F T
HE
PR
OV
IDE
R'S
AD
JUS
TM
EN
TS
TO
TH
E A
UD
IT R
EP
OR
T
ST
AT
E O
F C
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FOR
NIA
Pro
vide
r N
ame:
LIF
EH
OU
SE
PA
RK
VIE
W
155.
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oci
al S
ervi
ces
- F
ringe
Ben
efits
155.
03S
oci
al S
ervi
ces
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genc
y S
taff
155.
04S
oci
al S
ervi
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- O
ther
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onl
abo
r
160.
00A
ctiv
ities
160.
01A
ctiv
ities
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alar
ies
and
Wag
es
160.
02A
ctiv
ities
- F
ringe
Ben
efits
160.
03A
ctiv
ities
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genc
y S
taff
160.
04A
ctiv
ities
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ther
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onl
abo
r
165.
00A
dmin
istr
atio
n
165.
01A
dmin
istr
atio
n -
Sal
arie
s an
d W
ages
165.
02A
dmin
istr
atio
n -
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ge B
enef
its
165.
03A
dmin
istr
atio
n -
Med
ical
Rec
ord
s -
Sal
arie
s an
d W
ages
165.
04A
dmin
istr
atio
n -
Med
ical
Rec
ord
s -
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ge B
enef
its
165.
05A
dmin
istr
atio
n -
Med
ical
Rec
ord
s -
Age
ncy
Sta
ff
165.
06A
dmin
istr
atio
n -
Med
ical
Rec
ord
s -
Oth
er -
No
nlab
or
165.
07A
dmin
istr
atio
n -
DH
S L
icen
sing
Fee
s
165.
08A
dmin
istr
atio
n -
Liab
ility
Insu
ranc
e
165.
09A
dmin
istr
atio
n -
Car
egiv
er T
rain
ing
165.
10A
dmin
istr
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n -
Qua
lity
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uran
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ees
165.
11A
dmin
istr
atio
n -
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er -
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nlab
or
170.
00In
serv
ice
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catio
n -
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sing
170.
01In
serv
ice
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catio
n -
Nur
sing
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alar
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170.
02In
serv
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sing
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ringe
Ben
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170.
03In
serv
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n -
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sing
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170.
04In
serv
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n -
Nur
sing
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ther
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onl
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r
175.
00
To
tal
Sch
edul
e 8A
-1
Pag
e 2
Pro
vide
r N
o.:
OS
HP
D F
acili
ty N
umbe
r:Fi
scal
Per
iod:
LTC
5533
6G20
6150
774
JAN
UA
RY
12,
200
7 T
HR
OU
GH
DE
CE
MB
ER
31,
200
7
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
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IT A
DJ
AU
DIT
AD
JA
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IT A
DJ
10
RE
CO
NC
ILIA
TIO
N O
F T
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PR
OV
IDE
R'S
AD
JUS
TM
EN
TS
TO
TH
E A
UD
IT R
EP
OR
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(23,
968)
23,9
68
00
00
00
00
00
00
ST
AT
E O
F C
AL
IFO
RN
IAS
ched
ule
8A
-2
Pag
e 1
Pro
vid
er N
ame:
Pro
vid
er N
o.:
OS
HP
D F
acil
ity
Nu
mb
er:
Fis
cal P
erio
d:
LIF
EH
OU
SE
PA
RK
VIE
WLT
C55
336G
2061
5077
4JA
NU
AR
Y 1
2, 2
007
TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
007
TO
TA
L A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
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DJ
AU
DIT
AD
JA
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DJ
AU
DIT
AD
J
(Pag
e 1)
1112
1314
1516
1718
19
5.00
Pla
nt O
pera
tions
and
Mai
nten
ance
(1,2
80)
(1,2
80)
5.01
Pla
nt O
pera
tions
and
Mai
nten
ance
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alar
ies
and
Wag
es0
5.02
Pla
nt O
pera
tions
and
Mai
nten
ance
- F
ringe
Ben
efits
0
5.03
Pla
nt O
pera
tions
and
Mai
nten
ance
- A
genc
y S
taff
0
5.04
Pla
nt O
pera
tions
and
Mai
nten
ance
- O
ther
- N
onla
bor
0
10.0
0H
ouse
keep
ing
0
10.0
1H
ouse
keep
ing
- S
alar
ies
and
Wag
es0
10.0
2H
ouse
keep
ing
- F
ringe
Ben
efits
0
10.0
3H
ouse
keep
ing
- A
genc
y S
taff
0
10.0
4H
ouse
keep
ing
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ther
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onla
bor
0
15.0
0D
epre
ciat
ion:
Bld
gs a
nd Im
prov
emen
ts0
20.0
0D
epre
ciat
ion:
Lea
seho
ld Im
prov
emen
ts0
25.0
0D
epre
ciat
ion:
Equ
ipm
ent
0
30.0
0D
epre
ciat
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as n
ot p
rope
rly d
educ
ted
from
the
amou
nt b
illed
.42
CF
R 4
13.5
and
413
.20
/ CM
S P
ub. 1
5-1,
Sec
tion
2409
*Bal
ance
car
ried
forw
ard
from
prio
r/to
sub
sequ
ent a
djus
tmen
tsP
age
7
