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STATE OF CALIFORNIA RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT _part2

STATE OF CALIFORNIA RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT Schedule 8A-1 Page 2 Provider Name: ZZT05650J 1790779288 206361114 Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period: JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 COUNTRY VILLA REDLANDS HEALTHCARE AUDIT ADJ 10 11 12 13 14 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 155.02 Social Services - Fringe Benefits 155.03 Social Services - Agency Staff 155.04 Social Services - Other - Nonlabor 160.00 Activities 160.01 Activities - Salaries and Wages 160.02 Activities - Fringe Benefits 160.03 Activities - Agency Staff 160.04 Activities - Other - Nonlabor 165.00 Administration 100,574 1,222 165.01 Administration - Salaries and Wages 165.02 Administration - Fringe Benefits 165.03 Administration - Medical Records -. | STATE OF CALIFORNIA RECONCILIATION OF THE PROVIDER S ADJUSTMENTS TO THE AUDIT REPORT Schedule 8A-1 Page 2 Provider Name COUNTRY VILLA REDLANDS HEALTHCARE Provider Number ZZT05650J Provider NPI 1790779288 OSHPD Facility Number 206361114 Fiscal Period JANUARY 1 2008 THROUGH DECEMBER 31 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 10 11 12 13 14 155.02 Social Services - Fringe Benefits 155.03 Social Services - Agency staff 155.04 Social Services - other - Nonlabor 160.00 Activities 160.01 Activities - Salaries and Wages 160.02 Activities - Fringe Benefits les - Agency staff les - Other - Nonlabor 100 574 1 222 165. í YYỈmiơ strati on - Salaries and Wages 165 ni strati on - Fringe Benefits 165.03 Administration - Medical Records - Salaries and Wages 165. C Ạíỉmió strati on - Medical Records - Fringe Benefits 165. 5 ninistration - Medical Records - Agency staff 165.06 Administration - Medical Records - other - Nonlabor stration - Caregiver Training 170.01 irvice Education - Nursing - Salaries and Wages 70.Í irvice Education - Nursing - Agency staff inistration - Liability Insurance inistration - Quality Assurance Fees Administration - other - Nonlabor 100 574 1 222 170.00 t dsrvice Education - Nursing rvice Education - Nursing - Fringe Benefits ervice Education - Nursing - other - Nonlabor STATE OF CALIFORNIA ADJUSTMENTS TO R Provider Name COUNTRY VILLA REDLANDS HEALTHCARE Provider Number ZZT05650J TOTAL ADJ AUDIT ADJ AUDIT ADJ Pages 1 2 15 16 5.ŨŨ 5.Ũ1 5.Ũ2 5.Ũ3 5.04 10.00 10.01 30.00 4 _ 35.00 io.00 75.02 75.03 75.04 77.00 80.00 80.01 80.02 80.03 80.04 81.00 81.01 81.02 81.03 81.04 82.00 82.01 Plant Operations and Maintenance Plant Operations and Maintenance - Salaries and Wages Plant Operations and Maintenance - Fringe Benefits Plant Operations and Maintenance - Agency staff Plant Operations and Maintenance - other - Nonlabor Housekeeping Housekeeping - Salaries and Wages Housekeeping - .