report on the rate setting audit …€¦ · report on the rate setting audit sunnyside nursing...
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REPORT ON THE
RATE SETTING AUDIT
SUNNYSIDE NURSING CENTER TORRANCE, CALIFORNIA
NATIONAL PROVIDER IDENTIFIER: 1588660369
FISCAL PERIOD ENDED DECEMBER 31, 2011
Audits Section—Gardena Financial Audits Branch
Audits and Investigations Department of Health Care Services
Section Chief: Maria Delgado Audit Supervisor: Deborah Lee Auditor: Gary Chan
TO
OBY DOUGLAS DIRECTOR
October Shane DSunnysi22617 STorrance SUNNYNATIONFISCAL We haveabove-reSection cost repprior fisccurrent f In our opCost perpatient dprinciple This aud 1. S 2. A Future MThe exteService NotwithspursuanRegulati
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D G. BROWN JR. OVERNOR
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Shane Dahl Page 2
If you disagree with the decision of the Department, you may appeal by writing to: Chief Department of Health Care Services Office of Administrative Hearings and Appeals 1029 J Street, Suite 200 Sacramento, CA 95814 (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 Sacramento, CA 95814 (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—Gardena at (310) 516-4757. Original Signed By: Maria Delgado, Chief Audits Section—Gardena Financial Audits Branch Certified Enclosure cc: Wilma Belardo Business Office Manager 15760 Ventura Blvd, Suite 920 Encino, CA 91436
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:SUNNYSIDE NURSING CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility No.:1588660369 206190732
LineNo.
SKILLED NURSING CARE1 Cost of Direct Care - Labor (Sch. 2, Ln. 105) $ N/A $ 8,821,101 $ 105.442 Cost of Indirect Care - Labor (Sch. 3, Ln. 105) $ N/A $ 1,989,767 $ 23.783 Cost of Direct and Indirect Nonlabor - Other (Sch. 4, Ln. 105) $ N/A $ 1,403,639 $ 16.784 Cost of Capital Related (Sch. 5, Ln. 105) $ N/A $ 290,996 $ 3.485 Property Taxes (Sch. 5, Ln. 105) $ N/A $ 23,717 $ 0.286 CDPH Licensing Fees (Sch. 6, Ln. 105) $ N/A $ 56,185 $ 0.677 Professional Liability Insurance (Sch. 6, Ln. 105) $ N/A $ 337,977 $ 4.048 Caregiver Training (Sch. 6, Ln. 105) $ N/A $ 0 $ 0.009 Quality Assurance Fees (Sch. 6, Ln. 105) $ N/A $ 906,746 $ 10.8410 Cost of Administration (Sch. 6, Ln. 105) $ N/A $ 2,101,682 $ 25.1211 Cost of Routine Service/Audited Total Costs $ 15,971,197.00 $ 15,931,809 $ 190.4312 Total Patient Days (Adj ) 83,663 83,66313 Cost Per Patient Day (Cost Divided by Days) $ 190.90 $ 190.43 14 Overpayments (Adj ) $ $ 015 Medi-Cal Days (Adj 8) 55,214 55,08816 Medi-Cal Managed Care Days (Adj 9) 1,690
INTERMEDIATE CARE17 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 018 Total Patient Days (Adj ) 019 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0020 Overpayments (Adj ) $ $ 0
MENTALLY DISORDERED CARE21 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 022 Total Patient Days (Adj ) 023 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0024 Overpayments (Adj ) $ $ 0
DEVELOPMENTALLY DISABLED CARE25 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 026 Total Patient Days (Adj ) 027 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0028 Overpayments (Adj ) $ $ 0
SUBACUTE CARE29 Cost of Direct Care - Labor (Subacute Care Sch. 1, Ln. 25) $ N/A $ 0 $ 0.0030 Cost of Indirect Care - Labor (Subacute Care Sch. 1, Ln. 26) $ N/A $ 0 $ 0.0031 Cost of Direct and Indirect Nonlabor - Other (Subacute Care Sch. 1, Ln. 27) $ N/A $ 0 $ 0.0032 Cost of Capital Related (Subacute Care Sch. 1, Ln. 28) $ N/A $ 0 $ 0.0033 Property Taxes (Subacute Care Sch. 1, Ln. 29) $ N/A $ 0 $ 0.0034 CDPH Licensing Fees (Subacute Care Sch. 1, Ln. 30) $ N/A $ 0 $ 0.0035 Professional Liability Insurance (Subacute Care Sch. 1, Ln. 31) $ N/A $ 0 $ 0.0036 Quality Assurance Fees (Subacute Care Sch. 1, Ln. 32) $ N/A $ 0 $ 0.0037 Caregiver Training (Subacute Care Sch. 1, Ln. 33) $ N/A $ 0 $ 0.0038 Cost of Administration (Subacute Care Sch.1, Ln. 34) $ N/A $ 0 $ 0.0039 Total Cost of Subacute Service (Subacute Care Sch. 1, Ln. 35) $ 0 $ 0 $ 0.0040 Total Patient Days (Subacute Care Sch. 1, Ln. 36) 0 041 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0042 Amount Due Provider (State) (Subacute Care Sch. 1, Ln. 40) $ 0 $ 0
SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY
COST PERAUDITED
PROGRAM DESCRIPTIONAS REPORTED AS AUDITED PATIENT DAY
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:SUNNYSIDE NURSING CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility No.:1588660369 206190732
LineNo.
SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY
COST PERAUDITED
PROGRAM DESCRIPTIONAS REPORTED AS AUDITED PATIENT DAY
SUBACUTE CARE - PEDIATRIC43 Cost of Routine Service (Subacute Care - Pediatric, Sch. 1, Ln 3) $ 0 $ 044 Cost of Ancillary Service (Subacute Care - Pediatric, Sch. 1, Ln. 1 + Ln. 2) $ 0 $ 045 Total Cost of Subacute Care - Pediatric Service (Ln. 43 + Ln. 44) $ 0 $ 046 Total Patient Days (Subacute Care - Pediatric, Sch. 1, Ln. 5) 0 047 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0048 Amount Due Provider (State) (Subacute Care - Pediatric, Sch. 1, Ln. 9) $ 0 $ 0
TRANSITIONAL INPATIENT CARE49 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 050 Total Patient Days (Adj ) 051 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0052 Overpayments (Adj ) $ $ 0
HOSPICE INPATIENT CARE53 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 054 Total Patient Days (Adj ) 055 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0056 Overpayments (Adj ) $ $ 0
OTHER ROUTINE SERVICES57 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 058 Total Patient Days (Adj ) 059 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0060 Overpayments (Adj ) $ $ 0
STATE OF CALIFORNIA SCHEDULE 2
Provider Name: Fiscal Period:SUNNYSIDE NURSING CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility No.:1588660369 206190732
Soc Srvs ActivitiesNet Exp For
Line DESCRIPTION Cost AllocNo. (From Sch 8) 155 160 Total
GENERAL SERVICES005 Plant Operations and Maintenance010 Housekeeping060 Laundry and Linen065 Dietary155 Social Services 203,404$ 203,404$ 160 Activities 437,701 437,701$ 165 Administration166 Medical Records170 Inservice Education - Nursing
ANCILLARY SERVICES075 Patient Supplies 0 0 0 0077 Specialized Support Surfaces N/A 0 0 0080 Physical Therapy 833,403 0 0 833,403081 Respiratory Therapy 0 0 0 0082 Occupational Therapy 766,634 0 0 766,634083 Speech Pathology 145,457 0 0 145,457085 Pharmacy 0 0 0 0090 Laboratory 0 0 0 0095 Home Health Services 0 0 0 0100 Other Ancillary Services 0 0 0 0101 Subacute Care Ancillary Services 0 0 0 0102 Subacute Care - Pediatric Ancillary Services 0 0 0 0
ROUTINE SERVICES105 Skilled Nursing Care 8,179,996 203,404 437,701 8,821,101 *110 Intermediate Care 0 0 0 0 *115 Mentally Disordered Care 0 0 0 0 *120 Developmentally Disabled Care 0 0 0 0 *125 Subacute Care 0 0 0 0 *126 Subacute Care - Pediatric 0 0 0 0 *128 Transitional Inpatient Care 0 0 0 0 *130 Hospice Inpatient Care 0 0 0 0 *135 Other Routine Services 0 0 0 0 *
NONREIMBURSABLE 139 Residential Care 0 0 0 0140 Beauty and Barber 0 0 0 0145 Other Nonreimbursable 0 0 0 0
TOTAL 10,566,595$ 203,404$ 437,701$ 10,566,595$ * (To Schedule 1)
ALLOCATION OF GENERAL SERVICES DIRECT CARE LABOR
ST
AT
E O
F C
AL
IFO
RN
IAS
CH
ED
UL
E 3
Pro
vid
er N
ame:
Pro
vid
er N
PI:
OS
HP
D F
acili
ty N
um
ber
:F
isca
l Per
iod
:S
UN
NY
SID
E N
UR
SIN
G C
EN
TE
R15
8866
0369
2061
9073
2JA
NU
AR
Y 1
, 201
1 T
HR
OU
GH
DE
CE
MB
ER
31,
201
1
Pla
nt
Op
sH
skp
ng
Lau
nd
ryD
ieta
ryS
oc
Srv
sA
ctiv
itie
sIn
serv
. Ed
Ad
min
Med
ical
Net
Ex p
Fo
rR
eco
rds
Lin
eD
ES
CR
IPT
ION
Co
st A
lloc
Acc
um
ula
ted
No
.(F
rom
Sch
8)
005
010
060
065
155
160
170
Co
sts
165
166
To
tal
GE
NE
RA
L S
ER
VIC
ES
005
Pla
nt O
pera
tions
and
Mai
nten
ance
180,
203
$
180,
203
$
01
0H
ouse
kee p
ing
438,
579
1,46
8
44
0,04
7$
060
Laun
dry
and
Line
n37
5,78
66,
897
16,9
7939
9,66
2$
065
Die
tar y
543,
351
9,13
122
,480
057
4,96
1$
155
Soc
ial S
ervi
ces
N/A
82
52,
032
00
2,85
7$
16
0A
ctiv
ities
N/A
4,
397
10,8
250
00
15,2
21$
165
Adm
inis
trat
ion
N/A
14
,829
36,5
090
00
051
,337
$
51,3
37$
166
Med
ical
Rec
ords
375,
452
2,26
25,
569
00
00
383,
282
383,
282
$
17
0In
serv
ice
Edu
catio
n -
Nur
sin g
192,
937
2,38
95,
881
00
00
201,
207
$
A
NC
ILL
AR
Y S
ER
VIC
ES
075
Pat
ient
Sup
plie
s2,
583
6,36
00
00
00
8,94
348
83,
645
13,0
77$
077
Spe
cial
ized
Sup
port
Sur
face
s0
00
00
00
062
84,
688
5,31
608
0P
h ysi
cal T
hera
py3,
254
8,01
10
00
00
11,2
652,
908
21,7
0835
,881
081
Res
pira
tory
The
rapy
00
00
00
00
00
008
2O
ccu p
atio
nal T
hera
py1,
520
3,74
20
00
00
5,26
12,
635
19,6
7127
,567
083
Spe
ech
Pat
holo
gy0
00
00
00
049
23,
674
4,16
608
5P
harm
acy
238
586
00
00
082
42,
373
17,7
1920
,916
090
Labo
rato
r y0
00
00
00
044
63,
327
3,77
309
5H
ome
Hea
lth S
ervi
ces
00
00
00
00
00
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0O
ther
Anc
illar
y S
ervi
ces
00
00
00
00
421
3,14
13,
562
101
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
00
00
00
00
00
010
2S
ubac
ute
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e -
Ped
iatr
ic A
ncill
ary
Ser
vice
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00
00
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INE
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RV
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kille
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ursi
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are
129,
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319,
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399,
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574,
961
2,85
715
,221
201,
207
1,64
3,40
340
,913
305,
452
1,98
9,76
7*
110
Inte
rmed
iate
Car
e0
00
00
00
00
00
*11
5M
enta
ll y D
isor
dere
d C
are
00
00
00
00
00
0*
120
Dev
elo p
men
tally
Dis
able
d C
are
00
00
00
00
00
0*
125
Sub
acut
e C
are
00
00
00
00
00
0*
126
Sub
acut
e C
are
- P
edia
tric
00
00
00
00
00
0*
128
Tra
nsiti
onal
Inpa
tient
Car
e0
00
00
00
00
00
*13
0H
ospi
ce In
patie
nt C
are
00
00
00
00
00
0*
135
Oth
er R
outin
e S
ervi
ces
00
00
00
00
00
0*
NO
NR
EIM
BU
RS
AB
LE
13
9R
esid
entia
l Car
e0
00
00
00
00
00
140
Bea
uty
and
Bar
ber
575
1,41
70
00
00
1,99
234
257
2,28
414
5O
ther
Non
reim
burs
able
00
00
00
00
00
0
TO
TA
L2,
106,
308
$
18
0,20
3$
440,
047
$
39
9,66
2$
574,
961
$
2,
857
$
15,2
21$
201,
207
$
1,
671,
688
$
51
,337
$
38
3,28
2$
2,10
6,30
8$
*
(To
Sch
edul
e 1)
AL
LO
CA
TIO
N O
F G
EN
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AL
SE
RV
ICE
SIN
DIR
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Pro
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ame:
Pro
vid
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PI:
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HP
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acili
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um
ber
:F
isca
l Per
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:S
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NY
SID
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UR
SIN
G C
EN
TE
R15
8866
0369
2061
9073
2JA
NU
AR
Y 1
, 201
1 T
HR
OU
GH
DE
CE
MB
ER
31,
201
1
Pla
nt
Op
sH
skp
ng
Lau
nd
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ieta
ryS
oc
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sA
ctiv
itie
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serv
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Ad
min
Med
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Ex p
Fo
rR
eco
rds
Lin
eD
ES
CR
IPT
ION
Co
st A
lloc
Acc
um
ula
ted
No
.(F
rom
Sch
8)
510
6065
155
160
170
Co
sts
165
166
To
tal
GE
NE
RA
L S
ER
VIC
ES
005
Pla
nt O
pera
tions
and
Mai
nten
ance
400,
456
$
400,
456
$
01
0H
ouse
kee p
ing
75,7
493,
263
79,0
12$
060
Laun
dry
and
Line
n84
,510
15,3
263,
049
102,
885
$
06
5D
ieta
r y52
8,92
320
,290
4,03
60
553,
250
$
15
5S
ocia
l Ser
vice
s0
1,83
436
50
02,
199
$
160
Act
iviti
es24
,986
9,77
01,
944
00
036
,700
$
16
5A
dmin
istr
atio
nN
/A
32,9
536,
555
00
00
39,5
08$
39
,508
$
16
6M
edic
al R
ecor
ds34
,677
5,02
61,
000
00
00
40,7
0340
,703
$
17
0In
serv
ice
Edu
catio
n -
Nur
sin g
1,26
05,
308
1,05
60
00
07,
624
$
AN
CIL
LA
RY
SE
RV
ICE
S07
5P
atie
nt S
uppl
ies
123,
636
5,74
11,
142
00
00
013
0,51
937
638
713
1,28
1$
077
Spe
cial
ized
Sup
port
Sur
face
s18
5,60
30
00
00
00
185,
603
483
498
186,
584
080
Ph y
sica
l The
rapy
07,
231
1,43
80
00
00
8,66
92,
238
2,30
513
,212
081
Res
pira
tory
The
rapy
00
00
00
00
00
00
082
Occ
u pat
iona
l The
rapy
03,
377
672
00
00
04,
049
2,02
82,
089
8,16
608
3S
peec
h P
atho
logy
00
00
00
00
037
939
076
908
5P
harm
acy
699,
596
529
105
00
00
070
0,23
01,
826
1,88
270
3,93
809
0La
bora
tor y
131,
733
00
00
00
013
1,73
334
335
313
2,42
909
5H
ome
Hea
lth S
ervi
ces
00
00
00
00
00
00
100
Oth
er A
ncill
ary
Ser
vice
s12
4,35
50
00
00
00
124,
355
324
334
125,
012
101
Sub
acut
e C
are
Anc
illar
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ervi
ces
00
00
00
00
00
00
102
Sub
acut
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are
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ervi
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00
00
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RO
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RV
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S10
5S
kille
d N
ursi
ng C
are
291,
134
288,
528
57,3
9510
2,88
555
3,25
02,
199
36,7
007,
624
1,33
9,71
531
,486
32,4
381,
403,
639
*11
0In
term
edia
te C
are
00
00
00
00
00
0*
115
Men
tall y
Dis
orde
red
Car
e0
00
00
00
00
00
*12
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evel
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lly D
isab
led
Car
e0
00
00
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ubac
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00
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126
Sub
acut
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are
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edia
tric
00
00
00
00
00
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*12
8T
rans
ition
al In
patie
nt C
are
00
00
00
00
00
0*
130
Hos
pice
Inpa
tient
Car
e0
00
00
00
00
00
*13
5O
ther
Rou
tine
Ser
vice
s0
00
00
00
00
00
*N
ON
RE
IMB
UR
SA
BL
E
139
Res
iden
tial C
are
00
00
00
00
00
00
140
Bea
uty
and
Bar
ber
5,58
01,
279
254
00
00
07,
113
2727
7,16
714
5O
ther
Non
reim
burs
able
00
00
00
00
00
00
TO
TA
L2,
712,
198
$
40
0,45
6$
79,0
12$
102,
885
$
55
3,25
0$
2,19
9$
36
,700
$
7,
624
$
2,63
1,98
6$
39,5
08$
40,7
03$
2,71
2,19
8$
*
(To
Sch
edul
e 1)
AL
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ICE
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STATE OF CALIFORNIA SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Provider Name: Fiscal Period:SUNNYSIDE NURSING CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility Number:1588660369 206190732
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) 311,269$ 92%Property Tax (line 40) 25,369 8% 336,638$
005 Plant Operations and Maintenance 9,879 9,879$ 010 Housekeeping 2,662 80 2,743$ 060 Laundry and Linen 12,505 378 106 12,989$ 065 Dietary 16,556 501 140 0 17,197$ 155 Social Services 1,497 45 13 0 0 1,555$ 160 Activities 7,972 241 67 0 0 0 8,281$ 165 Administration 26,889 813 228 0 0 0 0166 Medical Records 4,101 124 35 0 0 0 0170 Inservice Education - Nursing 4,332 131 37 0 0 0 0
ANCILLARY SERVICES075 Patient Supplies 4,684 142 40 0 0 0 0077 Specialized Support Surfaces 0 0 0 0 0 0 0080 Physical Therapy 5,900 178 50 0 0 0 0081 Respiratory Therapy 0 0 0 0 0 0 0082 Occupational Therapy 2,756 83 23 0 0 0 0083 Speech Pathology 0 0 0 0 0 0 0085 Pharmacy 432 13 4 0 0 0 0090 Laboratory 0 0 0 0 0 0 0095 Home Health Services 0 0 0 0 0 0 0100 Other Ancillary Services 0 0 0 0 0 0 0101 Subacute Care Ancillary Services 0 0 0 0 0 0 0102 Subacute Care - Pediatric Ancillary Services 0 0 0 0 0 0 0
ROUTINE SERVICES105 Skilled Nursing Care 235,429 7,118 1,992 12,989 17,197 1,555 8,281110 Intermediate Care 0 0 0 0 0 0 0115 Mentally Disordered Care 0 0 0 0 0 0 0120 Developmentally Disabled Care 0 0 0 0 0 0 0125 Subacute Care 0 0 0 0 0 0 0126 Subacute Care - Pediatric 0 0 0 0 0 0 0128 Transitional Inpatient Care 0 0 0 0 0 0 0130 Hospice Inpatient Care 0 0 0 0 0 0 0135 Other Routine Services 0 0 0 0 0 0 0
NONREIMBURSABLE 139 Residential Care 0 0 0 0 0 0 0140 Beauty and Barber 1,043 32 9 0 0 0 0145 Other Nonreimbursable 0 0 0 0 0 0 0
TOTAL 336,638$ 100% 336,638$ 9,879$ 2,743$ 12,989$ 17,197$ 1,555$ 8,281$ * (To Schedule 1)
STATE OF CALIFORNIA
Provider Name:SUNNYSIDE NURSING CENTER
Provider NPI:1588660369
Net Exp ForLine DESCRIPTION Cost AllocNo. (From Sch 8) Ratio
GENERAL SERVICESCapital Related (excluding lines 40 & 45) 311,269$ 92%Property Tax (line 40) 25,369 8%
005 Plant Operations and Maintenance010 Housekeeping060 Laundry and Linen065 Dietary155 Social Services160 Activities165 Administration166 Medical Records170 Inservice Education - Nursing
ANCILLARY SERVICES075 Patient Supplies077 Specialized Support Surfaces080 Physical Therapy081 Respiratory Therapy082 Occupational Therapy083 Speech Pathology085 Pharmacy090 Laboratory095 Home Health Services100 Other Ancillary Services101 Subacute Care Ancillary Services102 Subacute Care - Pediatric Ancillary Services
ROUTINE SERVICES105 Skilled Nursing Care110 Intermediate Care115 Mentally Disordered Care120 Developmentally Disabled Care125 Subacute Care126 Subacute Care - Pediatric128 Transitional Inpatient Care130 Hospice Inpatient Care135 Other Routine Services
NONREIMBURSABLE 139 Residential Care140 Beauty and Barber145 Other Nonreimbursable
TOTAL 336,638$ 100%* (To Schedule 1)
SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Fiscal Period:JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
OSHPD Facility Number:206190732
Inserv. Ed Admin Medical Capital PropertyRecords Related Tax
Accumulated 92% 8%170 Costs 165 166 Total Of Total Of Total
27,929$ 27,929$ 4,260 4,260$
4,499$
0 4,865 266 41 5,172$ 4,782$ 390$ 0 0 342 52 394 364 300 6,128 1,582 241 7,952 7,352 5990 0 0 0 0 0 00 2,862 1,433 219 4,514 4,174 3400 0 268 41 309 285 230 448 1,291 197 1,936 1,791 1460 0 242 37 279 258 210 0 0 0 0 0 00 0 229 35 264 244 200 0 0 0 0 0 00 0 0 0 0 0 0
4,499 289,060 22,258 3,395 314,713 290,996 23,717 *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 *
0 0 0 0 0 0 00 1,084 19 3 1,105 1,022 830 0 0 0 0 0 0
4,499$ 304,449$ 27,929$ 4,260$ 336,638$ 311,269$ 25,369$
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STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:SUNNYSIDE NURSING CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility Number:1588660369 206190732
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER005 Plant Operations and Maintenance005 .01-.19 Salaries and Wages 6200 $ 134,474 $ 0 $ 134,474 (Sch 3)005 .20-.39 Fringe Benefits 6200 45,729 0 45,729 (Sch 3)005 .79 Agency Staff 6200 0 0 (Sch 3)005 .40-.99 Other - Nonlabor 6200 400,456 0 400,456 (Sch 4)005 Plant Operations and Maintenance - Total 6200 $ 580,659 $ 0 $ 580,659
010 Housekeeping010 .01-.19 Salaries and Wages 6300 $ 345,934 $ 0 $ 345,934 (Sch 3)010 .20-.39 Fringe Benefits 6300 92,645 0 92,645 (Sch 3)010 .79 Agency Staff 6300 0 0 (Sch 3)010 .40-.99 Other - Nonlabor 6300 75,749 0 75,749 (Sch 4)010 Housekeeping - Total 6300 $ 514,328 $ 0 $ 514,328
015 Depreciation: Buildings and Improvements 7110 - 7120 $ 36,179 $ 0 $ 36,179 (Sch 5)020 Depreciation: Leasehold Improvements 7130 49,109 0 49,109 (Sch 5)025 Depreciation: Equipment 7140 116,002 0 116,002 (Sch 5)030 Depreciation and Amortization - Other 7150 - 7160 3,000 0 3,000 (Sch 5)035 Leases and Rentals 7200 74,205 74,205 (Sch 5)040 Property Taxes 7300 76,817 (51,448) 25,369 (Sch 5)045 Property Insurance 7400 32,891 43,398 76,289 (Sch 6)050 Interest - Property, Plant, and Equipment 7500 32,774 0 32,774 (Sch 5)055 Interest - Other 7600 $ 67,012 $ 0 $ 67,012 (Sch 6)
057 Subtotal 005 - 055 $ 1,508,771 $ 66,155 $ 1,574,926
060 Laundry and Linen060 .01-.19 Salaries and Wages 6400 $ 312,833 $ 0 $ 312,833 (Sch 3)060 .20-.39 Fringe Benefits 6400 62,953 0 62,953 (Sch 3)060 .79 Agency Staff 6400 0 0 (Sch 3)060 .40-.99 Other - Nonlabor 6400 84,510 0 84,510 (Sch 4)060 Laundry and Linen - Total 6400 $ 460,296 $ 0 $ 460,296
065 Dietary065 .01-.19 Salaries and Wages 6500 $ 428,483 $ 0 $ 428,483 (Sch 3)065 .20-.39 Fringe Benefits 6500 114,868 0 114,868 (Sch 3)065 .79 Agency Staff 6500 0 0 (Sch 3)065 .40-.99 Other - Nonlabor 6500 530,006 (1,083) 528,923 (Sch 4)065 Dietary - Total 6500 $ 1,073,357 $ (1,083) $ 1,072,274
070 Provision for Bad Debts 7700 $ 0 $ 0
Ancillary Services 075 Patient Supplies075 .01-.19 Salaries and Wages 8100 $ $ 0 $ 0 (Sch 2)075 .20-.39 Fringe Benefits 8100 0 0 (Sch 2)075 .79 Agency Staff 8100 0 0 (Sch 2)075 .40-.99 Other - Nonlabor 8100 123,636 0 123,636 (Sch 4)075 Patient Supplies - Total 8100 $ 123,636 $ 0 $ 123,636
077 Specialized Support Surfaces077 .01-.19 Salaries and Wages 8150 $ $ 0 $ 0 N/A077 .20-.39 Fringe Benefits 8150 0 0 N/A077 .79 Agency Staff 8150 0 0 N/A077 .40-.99 Other - Nonlabor 8150 185,603 0 185,603 (Sch 4)077 Specialized Support Surfaces - Total 8150 $ 185,603 $ 0 $ 185,603
REPORTEDAS AS
AUDITEDADJUSTMENTS
8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:SUNNYSIDE NURSING CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility Number:1588660369 206190732
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER REPORTED
AS ASAUDITED
ADJUSTMENTS8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
080 Physical Therapy080 .01-.19 Salaries and Wages 8200 $ $ 0 $ 0 (Sch 2)080 .20-.39 Fringe Benefits 8200 0 0 (Sch 2)080 .79 Agency Staff 8200 833,403 0 833,403 (Sch 2)080 .40-.99 Other - Nonlabor 8200 0 0 (Sch 4)080 Physical Therapy - Total 8200 $ 833,403 $ 0 $ 833,403
081 Respiratory Therapy081 .01-.19 Salaries and Wages 8220 $ $ 0 $ 0 (Sch 2)081 .20-.39 Fringe Benefits 8220 0 0 (Sch 2)081 .79 Agency Staff 8220 0 0 (Sch 2)081 .40-.99 Other - Nonlabor 8220 0 0 (Sch 4)081 Respiratory Therapy - Total 8220 $ 0 $ 0 $ 0
082 Occupational Therapy082 .01-.19 Salaries and Wages 8250 $ $ 0 $ 0 (Sch 2)082 .20-.39 Fringe Benefits 8250 0 0 (Sch 2)082 .79 Agency Staff 8250 766,634 0 766,634 (Sch 2)082 .40-.99 Other - Nonlabor 8250 0 0 (Sch 4)082 Occupational Therapy - Total 8250 $ 766,634 $ 0 $ 766,634
083 Speech Pathology083 .01-.19 Salaries and Wages 8280 $ $ 0 $ 0 (Sch 2)083 .20-.39 Fringe Benefits 8280 0 0 (Sch 2)083 .79 Agency Staff 8280 145,457 0 145,457 (Sch 2)083 .40-.99 Other - Nonlabor 8280 0 0 (Sch 4)083 Speech Pathology - Total 8280 $ 145,457 $ 0 $ 145,457
085 Pharmacy085 .01-.19 Salaries and Wages 8300 $ $ 0 $ 0 (Sch 2)085 .20-.39 Fringe Benefits 8300 0 0 (Sch 2)085 .79 Agency Staff 8300 0 0 (Sch 2)085 .40-.99 Other - Nonlabor 8300 699,596 0 699,596 (Sch 4)085 Pharmacy - Total 8300 $ 699,596 $ 0 $ 699,596
090 Laboratory090 .01-.19 Salaries and Wages 8400 $ $ 0 $ 0 (Sch 2)090 .20-.39 Fringe Benefits 8400 0 0 (Sch 2)090 .79 Agency Staff 8400 0 0 (Sch 2)090 .40-.99 Other - Nonlabor 8400 131,733 0 131,733 (Sch 4)090 Laboratory - Total 8400 $ 131,733 $ 0 $ 131,733
095 Home Health Services095 .01-.19 Salaries and Wages 8800 $ $ 0 $ 0 (Sch 2)095 .20-.39 Fringe Benefits 8800 0 0 (Sch 2)095 .79 Agency Staff 8800 0 0 (Sch 2)095 .40-.99 Other - Nonlabor 8800 0 0 (Sch 4)095 Home Health Services - Total 8800 $ 0 $ 0 $ 0
100 Other Ancillary Services100 .01-.19 Salaries and Wages 8900 $ $ 0 $ 0 (Sch 2)100 .20-.39 Fringe Benefits 8900 0 0 (Sch 2)100 .79 Agency Staff 8900 0 0 (Sch 2)100 .40-.99 Other - Nonlabor 8900 124,355 0 124,355 (Sch 4)100 Other Ancillary Services - Total 8900 $ 124,355 $ 0 $ 124,355
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:SUNNYSIDE NURSING CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility Number:1588660369 206190732
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER REPORTED
AS ASAUDITED
ADJUSTMENTS8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
101 Subacute Care Ancillary Services101 .01-.19 Salaries and Wages 8100-8900 $ $ 0 $ 0 (Sch 2)101 .20-.39 Fringe Benefits 8100-8900 0 0 (Sch 2)101 .79 Agency Staff 8100-8900 0 0 (Sch 2)101 .40-.99 Other - Nonlabor 8100-8900 0 0 (Sch 4)101 Subacute Care Ancillary Services - Total 8100-8900 $ 0 $ 0 $ 0
102 Subacute Care - Pediatric Ancillary Services102 .01-.19 Salaries and Wages 8100-8900 $ $ 0 $ 0 (Sch 2)102 .20-.39 Fringe Benefits 8100-8900 0 0 (Sch 2)102 .79 Agency Staff 8100-8900 0 0 (Sch 2)102 .40-.99 Other - Nonlabor 8100-8900 0 0 (Sch 4)102 Subacute Care - Pediatric Ancillary Services - Total 8100-8900 $ 0 $ 0 $ 0
104 Subtotal 075 - 102 $ 3,010,417 $ 0 $ 3,010,417
Routine Services105 Skilled Nursing Care105 .01-.19 Salaries and Wages 6110 $ 6,528,306 $ 0 $ 6,528,306 (Sch 2)105 .20-.39 Fringe Benefits 6110 1,651,690 0 1,651,690 (Sch 2)105 .49 Agency Staff 6110 0 0 (Sch 2)105 .40-.99 Other - Nonlabor 6110 314,111 (22,977) 291,134 (Sch 4)105 Skilled Nursing Care - Total 6110 $ 8,494,107 $ (22,977) $ 8,471,130
110 Intermediate Care110 .01-.19 Salaries and Wages 6120 $ $ 0 $ 0110 .20-.39 Fringe Benefits 6120 0 0110 .49 Agency Staff 6120 0 0110 .40-.99 Other - Nonlabor 6120 0 0110 Intermediate Care - Total 6120 $ 0 $ 0 $ 0 (Sch 2)
115 Mentally Disordered Care115 .01-.19 Salaries and Wages 6130 $ $ 0 $ 0115 .20-.39 Fringe Benefits 6130 0 0115 .49 Agency Staff 6130 0 0115 .40-.99 Other - Nonlabor 6130 0 0115 Mentally Disordered Care - Total 6130 $ 0 $ 0 $ 0 (Sch 2)
120 Developmentally Disabled Care120 .01-.19 Salaries and Wages 6140 $ $ 0 $ 0120 .20-.39 Fringe Benefits 6140 0 0120 .49 Agency Staff 6140 0 0120 .40-.99 Other - Nonlabor 6140 0 0120 Developmentally Disabled Care - Total 6140 $ 0 $ 0 $ 0 (Sch 2)
125 Subacute Care125 .01-.19 Salaries and Wages 6150 $ $ 0 $ 0 (Sch 2)125 .20-.39 Fringe Benefits 6150 0 0 (Sch 2)125 .49 Agency Staff 6150 0 0 (Sch 2)125 .40-.99 Other - Nonlabor 6150 0 0 (Sch 4)125 Subacute Care - Total 6150 $ 0 $ 0 $ 0
126 Subacute Care - Pediatric126 .01-.19 Salaries and Wages 6160 $ $ 0 $ 0 (Sch 2)126 .20-.39 Fringe Benefits 6160 0 0 (Sch 2)126 .49 Agency Staff 6160 0 0 (Sch 2)126 .40-.99 Other - Nonlabor 6160 0 0 (Sch 4)126 Subacute Care - Pediatric - Total 6160 $ 0 $ 0 $ 0
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:SUNNYSIDE NURSING CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility Number:1588660369 206190732
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER REPORTED
AS ASAUDITED
ADJUSTMENTS8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
128 Transitional Inpatient Care128 .01-.19 Salaries and Wages 6170 $ $ 0 $ 0128 .20-.39 Fringe Benefits 6170 0 0128 .49 Agency Staff 6170 0 0128 .40-.99 Other - Nonlabor 6170 0 0128 Transitional Inpatient Care - Total 6170 $ 0 $ 0 $ 0 (Sch 2)
130 Hospice Inpatient Care130 .01-.19 Salaries and Wages 6180 $ $ 0 $ 0130 .20-.39 Fringe Benefits 6180 0 0130 .49 Agency Staff 6180 0 0130 .40-.99 Other - Nonlabor 6180 0 0130 Hospice Inpatient Care - Total 6180 $ 0 $ 0 $ 0 (Sch 2)
135 Other Routine Services135 .01-.19 Salaries and Wages 6190 $ $ 0 $ 0135 .20-.39 Fringe Benefits 6190 0 0135 .49 Agency Staff 6190 0 0135 .40-.99 Other - Nonlabor 6190 0 0135 Other Routine Services - Total 6190 $ 0 $ 0 $ 0 (Sch 2)
Other Nonreimbursable139 Residential Care139 .01-.19 Salaries and Wages 9100 $ $ 0 $ 0 (Sch 2)139 .20-.39 Fringe Benefits 9100 0 0 (Sch 2)139 .49 Agency Staff 9100 0 0 (Sch 2)139 .40-.99 Other - Nonlabor 9100 0 0 (Sch 4)139 Residential Care - Total 9100 $ 0 $ 0 $ 0
140 Beauty and Barber140 .01-.19 Salaries and Wages 8900 $ $ 0 $ 0 (Sch 2)140 .20-.39 Fringe Benefits 8900 0 0 (Sch 2)140 .49 Agency Staff 8900 0 0 (Sch 2)140 .40-.99 Other - Nonlabor 8900 5,580 0 5,580 (Sch 4)140 Beauty and Barber - Total 8900 $ 5,580 $ 0 $ 5,580
145 Other Nonreimbursable145 .01-.19 Salaries and Wages 9100 $ $ 0 $ 0 (Sch 2)145 .20-.39 Fringe Benefits 9100 0 0 (Sch 2)145 .49 Agency Staff 9100 0 0 (Sch 2)145 .40-.99 Other - Nonlabor 9100 0 0 (Sch 4)145 Other Nonreimbursable - Total 9100 $ 0 $ 0 $ 0
146 Subtotal 105 - 145 $ 8,499,687 $ (22,977) $ 8,476,710
155 Social Services155 .01-.19 Salaries and Wages 6600 $ 162,917 $ 0 $ 162,917 (Sch 2)155 .20-.39 Fringe Benefits 6600 40,487 0 40,487 (Sch 2)155 .49 Agency Staff 6600 0 0 (Sch 2)155 .40-.99 Other - Nonlabor 6600 0 0 (Sch 4)155 Social Services - Total 6600 $ 203,404 $ 0 $ 203,404
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:SUNNYSIDE NURSING CENTER JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility Number:1588660369 206190732
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER REPORTED
AS ASAUDITED
ADJUSTMENTS8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
160 Activities160 .01-.19 Salaries and Wages 6700 $ 348,885 $ 0 $ 348,885 (Sch 2)160 .20-.39 Fringe Benefits 6700 88,816 0 88,816 (Sch 2)160 .49 Agency Staff 6700 0 0 (Sch 2)160 .40-.99 Other - Nonlabor 6700 24,986 0 24,986 (Sch 4)160 Activities - Total 6700 $ 462,687 $ 0 $ 462,687
165 Administration165 .01-.19 Salaries and Wages 6900 $ 816,932 $ 0 $ 816,932 (Sch 6)165 .20-.39 Fringe Benefits 6900 196,514 0 196,514 (Sch 6)165 .49 Agency Staff 6900 0 0 (Sch 6)165 .40-.99 Other - Nonlabor 6900 1,469,512 10,944 1,480,456 (Sch 6)165 Administration - Total 6900 $ 2,482,958 $ 10,944 $ 2,493,902
166 Medical Records166 .01-.19 Salaries and Wages 6900 $ 293,856 $ 0 $ 293,856 (Sch 3)166 .20-.39 Fringe Benefits 6900 81,596 0 81,596 (Sch 3)166 .49 Agency Staff 6900 0 0 (Sch 3)166 .40-.99 Other - Nonlabor 6900 34,677 0 34,677 (Sch 4)166 Medical Records - Total 6900 $ 410,129 $ 0 $ 410,129
167 CDPH Licensing Fees 6900 $ 70,501 $ 0 $ 70,501 (Sch 6)168 Professional Liability Insurance 6900 $ 486,714 $ (62,618) $ 424,096 (Sch 6)169 Quality Assurance Fees 6900 $ 1,137,790 $ 0 $ 1,137,790 (Sch 6)
170 Inservice Education - Nursing170 .01-.19 Salaries and Wages 6800 $ 158,569 $ 0 $ 158,569 (Sch 3)170 .20-.39 Fringe Benefits 6800 34,368 0 34,368 (Sch 3)170 .49 Agency Staff 6800 0 0 (Sch 3)170 .40-.99 Other - Nonlabor 6800 1,260 0 1,260 (Sch 4)170 Inservice Education - Nursing - Total 6800 $ 194,197 $ 0 $ 194,197
174 Caregiver Training 174 .01-.19 Salaries and Wages 6900 $ $ 0 $ 0 (Sch 6)174 .20-.39 Fringe Benefits 6900 0 0 (Sch 6)174 .49 Agency Staff 6900 0 0 (Sch 6)174 .40-.99 Other - Nonlabor 6900 0 0 (Sch 6)174 Caregiver Training - Total 6900 $ 0 $ 0 $ 0
Subtotal 155 - 174 $ 5,448,380 $ (51,674) $ 5,396,706
200 Total $ 20,000,908 $ (9,579) $ 19,991,329
210 0.24 Total Facility Group Health Insurance (Adj 10)* 6900 $ 7,767
* For informational purposes only, this amount is included in various cost centers above. .
STA
TE O
F C
ALI
FOR
NIA
Sche
dule
8A
-1Pa
ge 1
Prov
ider
Nam
e:Pr
ovid
er N
PI:
OSH
PD F
acili
ty N
umbe
r:Fi
scal
Per
iod:
SU
NN
YS
IDE
NU
RS
ING
CE
NTE
R15
8866
0369
2061
9073
2JA
NU
AR
Y 1
, 201
1 TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
011
TOTA
L 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
Line
Sub
(Pag
e 1)
12
34
56
No.
No.
005
1P
lant
Ope
ratio
ns a
nd M
aint
enan
ce -
Sal
arie
s an
d W
ages
000
52
Pla
nt O
pera
tions
and
Mai
nten
ance
- Fr
inge
Ben
efits
000
53
Pla
nt O
pera
tions
and
Mai
nten
ance
- A
genc
y S
taff
000
54
Pla
nt O
pera
tions
and
Mai
nten
ance
- O
ther
- N
onla
bor
001
01
Hou
seke
epin
g - S
alar
ies
and
Wag
es0
010
2H
ouse
keep
ing
- Frin
ge B
enef
its0
010
3H
ouse
keep
ing
- Age
ncy
Sta
ff0
010
4H
ouse
keep
ing
- Oth
er -
Non
labo
r0
015
4D
epre
ciat
ion:
Bui
ldin
gs a
nd Im
prov
emen
ts0
020
4D
epre
ciat
ion:
Lea
seho
ld Im
prov
emen
ts0
025
4D
epre
ciat
ion:
Equ
ipm
ent
003
04
Dep
reci
atio
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d A
mor
tizat
ion
- Oth
er0
035
4Le
ases
and
Ren
tals
74,2
0574
,205
040
4P
rope
rty T
axes
(51,
448)
(43,
398)
(8,0
50)
045
4P
rope
rty In
sura
nce
43,3
9843
,398
050
4In
tere
st -
Pro
perty
, Pla
nt, a
nd E
quip
men
t0
055
4In
tere
st -
Oth
er0
060
1La
undr
y an
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nen
- Sal
arie
s an
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ages
006
02
Laun
dry
and
Line
n - F
ringe
Ben
efits
006
03
Laun
dry
and
Line
n - A
genc
y S
taff
006
04
Laun
dry
and
Line
n - O
ther
- N
onla
bor
006
51
Die
tary
- S
alar
ies
and
Wag
es0
065
2D
ieta
ry -
Frin
ge B
enef
its0
065
3D
ieta
ry -
Age
ncy
Sta
ff0
065
4D
ieta
ry -
Oth
er -
Non
labo
r(1
,083
)(1
,083
)07
04
Pro
visi
on fo
r Bad
Deb
ts0
075
1P
atie
nt S
uppl
ies
- Sal
arie
s an
d W
ages
007
52
Pat
ient
Sup
plie
s - F
ringe
Ben
efits
007
53
Pat
ient
Sup
plie
s - A
genc
y S
taff
007
54
Pat
ient
Sup
plie
s - O
ther
- N
onla
bor
007
71
Spe
cial
ized
Sup
port
Sur
face
s - S
alar
ies
and
Wag
es0
077
2S
peci
aliz
ed S
uppo
rt S
urfa
ces
- Frin
ge B
enef
its0
077
3S
peci
aliz
ed S
uppo
rt S
urfa
ces
- Age
ncy
Sta
ff0
077
4S
peci
aliz
ed S
uppo
rt S
urfa
ces
- Oth
er -
Non
labo
r0
080
1P
hysi
cal T
hera
py -
Sal
arie
s an
d W
ages
008
02
Phy
sica
l The
rapy
- Fr
inge
Ben
efits
008
03
Phy
sica
l The
rapy
- A
genc
y S
taff
008
04
Phy
sica
l The
rapy
- O
ther
- N
onla
bor
008
11
Res
pira
tory
The
rapy
- S
alar
ies
and
Wag
es0
081
2R
espi
rato
ry T
hera
py -
Frin
ge B
enef
its0
081
3R
espi
rato
ry T
hera
py -
Age
ncy
Sta
ff0
081
4R
espi
rato
ry T
hera
py -
Oth
er -
Non
labo
r0
082
1O
ccup
atio
nal T
hera
py -
Sal
arie
s an
d W
ages
008
22
Occ
upat
iona
l The
rapy
- Fr
inge
Ben
efits
008
23
Occ
upat
iona
l The
rapy
- A
genc
y S
taff
008
24
Occ
upat
iona
l The
rapy
- O
ther
- N
onla
bor
008
31
Spe
ech
Pat
holo
gy -
Sal
arie
s an
d W
ages
0
REC
LASS
IFIC
ATI
ON
S A
ND
/OR
AD
JUST
MEN
TS T
O R
EPO
RTE
D C
OST
S
STA
TE O
F C
ALI
FOR
NIA
Sche
dule
8A
-1Pa
ge 1
Prov
ider
Nam
e:Pr
ovid
er N
PI:
OSH
PD F
acili
ty N
umbe
r:Fi
scal
Per
iod:
SU
NN
YS
IDE
NU
RS
ING
CE
NTE
R15
8866
0369
2061
9073
2JA
NU
AR
Y 1
, 201
1 TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
011
TOTA
L A
DJ
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DIT
AD
JA
UD
IT A
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AD
JA
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IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
Line
Sub
(Pag
e 1)
12
34
56
No.
No.
REC
LASS
IFIC
ATI
ON
S A
ND
/OR
AD
JUST
MEN
TS T
O R
EPO
RTE
D C
OST
S
083
2S
peec
h P
atho
logy
- Fr
inge
Ben
efits
008
33
Spe
ech
Pat
holo
gy -
Age
ncy
Sta
ff0
083
4S
peec
h P
atho
logy
- O
ther
- N
onla
bor
008
51
Pha
rmac
y - S
alar
ies
and
Wag
es0
085
2P
harm
acy
- Frin
ge B
enef
its0
085
3P
harm
acy
- Age
ncy
Sta
ff0
085
4P
harm
acy
- Oth
er -
Non
labo
r0
090
1La
bora
tory
- S
alar
ies
and
Wag
es0
090
2La
bora
tory
- Fr
inge
Ben
efits
009
03
Labo
rato
ry -
Age
ncy
Sta
ff0
090
4La
bora
tory
- O
ther
- N
onla
bor
009
51
Hom
e H
ealth
Ser
vice
s - S
alar
ies
and
Wag
es0
095
2H
ome
Hea
lth S
ervi
ces
- Frin
ge B
enef
its0
095
3H
ome
Hea
lth S
ervi
ces
- Age
ncy
Sta
ff0
095
4H
ome
Hea
lth S
ervi
ces
- Oth
er -
Non
labo
r0
100
1O
ther
Anc
illar
y S
ervi
ces
- Sal
arie
s an
d W
ages
010
02
Oth
er A
ncill
ary
Ser
vice
s - F
ringe
Ben
efits
010
03
Oth
er A
ncill
ary
Ser
vice
s - A
genc
y S
taff
010
04
Oth
er A
ncill
ary
Ser
vice
s - O
ther
- N
onla
bor
010
11
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Sal
arie
s an
d W
ages
010
12
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Frin
ge B
enef
its0
101
3S
ubac
ute
Car
e A
ncill
ary
Ser
vice
s - A
genc
y S
taff
010
14
Sub
acut
e C
are
Anc
illar
y S
ervi
ces
- Oth
er -
Non
labo
r0
102
1S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - S
alar
ies
and
Wag
es0
102
2S
ubac
ute
Ped
iatri
c A
ncill
ary
Ser
vice
s - F
ringe
Ben
efits
010
23
Sub
acut
e P
edia
tric
Anc
illar
y S
ervi
ces
- Age
ncy
Sta
ff0
102
4S
ubac
ute
Ped
iatri
c A
ncill
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Ser
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