submitting the completed worksheet - london, ontario · 2015-09-29 · ontario 2014 long-termcare...

Ontario Ministry of Health and Long Term Care2014 Long-Term Care Facility Annual Report INSTRUCTION SHEET

INSTRUCTIONS - PLEASE READ ENTIRELYDo not attempt to alter the structure of this workbook in any way. The MOHLTCFinancial Management Branch needs to import the data from this workbook in itscurrent format.Do not re-name the tabs/sheets in this workbook. Do not change headings, insertcolumns or rows, or change cell formulas.

All dates in this workbook need to be entered in ISO format: YYYY-MM-DD.

Grey spreadsheet cells indicate calculated totals and/or for Ministry use only;those cells do not accept data entry.FOR OPERATORS WITH MULTIPLE HOMES - Please log-in to the websiteseparately for each home, to download the blank workbooks and to submit thecompleted workbooks individually. Do not attempt to merge the files and submiteverything under just one account, because the Ministry’s software will not be ableto process the data.

If there are workbook bugs or fixes required, current details will be listed in a pdfcalled “2014 AR Workbook Fixes” at https://hsimi.ca/LTCHome.

This template is in Excel 97-2003 format. Please submit this workbook in thatsame format. The file extension is “.xls” (not “.xlsx”)If you require further assistance, please contact the MOHLTC FinancialManagement Branch.

Submitting the completed WorksheetSign-in to the same website where you initially retrieved your blank Annual Reportworksheet https://hsimi.ca/LTCH0meClick on the “2014 Annual Report (AR) “link.Click on the “Browse...” button at the lower right of the screen. A dialogue windowshould appear.Within the dialogue window, select your completed Annual Report worksheet filewhich you have saved, and click the “Open” button; that will enter the file path andname into the “Upload Saved Annual Report” text-box. If no dialogue windowappeared, you must manually type in the file path and name of your completedworksheet.Click the “Upload” button. A message should appear on your screen once the filehas been successfully unloaded.OR

If you do not have the necessary internet access, please find another means tosend in your completed Annual Report worksheet file, ensuring that it reaches theMOHLTC Financial Management Branch on or before the due date.And finally, please MAIL the completed, signed, and audited hard copy of the2014 Long-Term Care Home Annual Report to the MOHLTC FinancialManagement Branch by the due date.

Ontario 2014 Long-Term Care Home Annual ReportMinistiyoi Health and Lang-Term Care For the period from I 2014-01-Oil to I 2014-12-31Mieistere 00 Ia Sante et aes Soins ice longue auree

MOHLTC Facilcty# Operator Name

Hi 1483 Dearness Home for Senior CitizensCHIN Name

South West Local Health lnteqration Network

Section A - Level of Care (LOC) Actual Resident Occupancy, Resident Revenue and Resident Bad Debt

Resident Days Resident Revenue

January to July to Total Days Basic Fees. April to June Preferred Fees

Current Revenue Period March December 3(la) tic) (id) (2)

A001Long-Stay-Private 10,863 11,097 23,433 45,393 2,560,165 903,758

A002Long-Stay-Semi -Private 180 182 368 730 41,175 5,840

A003Long-Stay-Basic 10,372 10,183 20,201 40,756 1,880,004

A004 Long-Stay two-bed room (Shared by 0spouses)A005

Short-Stay-RespiteCare 76 109 144 329 11,998

A006 Total Level of Care Long-Stay and ShortSlay-ResplteCereBeds.(Sianofiines 21.491 21,571 44,146 87,208 4,493,342 909,598P.001 Uwough A005)

A007Interim Short-Stay - Private

A008 0Interim Short Stay - Semi-Private

A009Interim Short Stay - Basic

AO10Interim Short-Stay - two-bed room 0IShared by spouses)

AOl 1 Tot Level of Care tnteim Street-Stay0 0 0 0 0

beds (Sum of tines A007 teough AO10)

AOl 2Co,waiesceet Care Beds 0

Resident-DaysActual Occupancy of Awarded Beds and Replacement ‘0’ beds, andReptacement ‘B’. ‘C’ and upgraded ‘D’ beds during the Orientation January to April to June

July toTotal Days

and Fill rate period in 2014 and the Pre-Move Occupancy Days for March DecemberClassified “0” Replacement beds. (to be completed by Licensees (ia) (Ic)operating such beds)

A020a Actual Resident-days in lines AGO; through A005 that was attributed tothe orientation and Fill-Rate period for awarded beds and replacement“0” beds, replacement “B”, ‘C” and Upgraded “0” beds, the Pre-Move 0Occupancy Days for Classified “0” Replacement beds, and the 90 dayfill-rale period for specialized unit beds.

A020b .

Actual Short-stay Respite-days in line A005 that was attributed toawarded beds and replacement “0’, replacement “B’, “C’ andUpgraded ‘0” beds during the Orientation and/or Fill rate Period andthe Pre-Move Occupancy Days for Classified “0” Replacement beds

Resident-Days

. . . . . January to . July toOrientation/Fill-rate Period - Interim Short-Slay beds and April to June Total Days

March DecemberConvalescent Care beds (ib) (id)

(la) (ic)A021a

Actual Interim Short-Stay bed resident-days in lines A007-A010 duringthe Fill-Rate Period

A021b .

Actual Convalescent Care bed resident-days in line A012 during the 90day Orientation Period

Resident-Days

Actual occupancy of beds approved for Occupancy ReductionJanuary to

April to JuneJuly to

Total Days. March DecemberProtection (ORP(

(la)(ib)

(ic)(id)

A022a Actual Resident-days in lines AOO1-A004 during ORP Period 0

A022b Actual Resident-days in line A007-A010 during ORP Period 0

A022c Actual Resident-days in line A012 during ORP Period 0

Mayl,2015 . Page 1 0119

Ontario 2014 Long-Term Care Home Annual ReportMinistry of Heatth and Long-Term Care For the period from 2014-01-01 to 201 4-1 2-31Ministere de Ia Sante et des Soins Sc ongue duree

[HLTC Facility # Operator Name

H11483 Dearness Home for Senior Citizens

Section A - Level of Care (LOC) Actual Resident Occupancy, ResidentRevenue and Resident Bad Debt, continued

Prior Period Revenue Revenue For Ministry Use Only

A030Basic Revenue: July 1 1994 to December31 2013

I Resident Bad Debt on 2014 Basic Accomodation Fees For Ministry Use Only

A040 Basic Accomodation Fees - Bad Debt 5,267

A041 Collection Costs

A042 Total Bad Debt Costs (A040 ÷ A041) $5,267

Section B - Actual Other Recoverable Revenue

Description Revenue For Ministry Use Only

(1) Recoverable Revenue(2)

j•T Interest Earned

8002 Other LTC Home funding provided by Government

B003 Other

8004 Total - Actual Other Recoverable Revenue (Sum of lines BO01 through 8003) $0 -

May 1,2015 Page 2 of 19

Ontario 2014 Long-Term Care Home Annual Report

________

_mo’Iernho. ForUm poood 1mm 2014-01-01 I to I 2014-12-311

ISection C - Actual Exeeeditures - Norslnq and Personal Care

Nor, CIdm-ha02noltohmm(udol

:bed. (enlud.bor.u.o.nr br. (2)

cede)p-—.---0

43,211depol Ore lot, sTorm, funded hon (he 078 cuialoe Nob TOn n.mrnenn mudre rnrmled loon COOl hror Color en erricaNo The 1,14 ommneoo lonerled m Inn

7025.31114 usa) to dolooroo ary unrcnd 22.0109 hon me ops nplobnn

0021

cool

Fhe AgIng at Home Fund IAAHL the Ornont Priced)., Fond IUPFI, theOrternalice L.oat ci care Investment Fond aedlor toed, reallocated inner nih.,

dew) under bdumn I coot, vNo copnme under the Nureog and Fneora Coo .rtm’çre14 Auokn Stnnl-dloy Not. Coda) bough no Audi OFF, AlonainLnde&Con Inmeunerl

‘.4 otmo lunds reatunuled Non 20m eodoe 0°w ot,n od,mn 2 nomi drNosTance. iCon no Nosing wit Persona Coo nnidope to Conoaneonrl Coc bole loetodbooaglr me Audi, OFF, AunnOe Lnn& 01 Coo (nmemrnrl Ford wt,00 lords realuuuded hon,Fm ‘noOns no, The eqorene nmd am he ‘tooled en Inns COOl nnor 0221.00

nb

omoemnereeycoernm1,70) tb 000 legMo esrse. lunCo Iron 0000) MOO Com&rbo Oiondedflld FteetnqNo,: The 0000mm mud 0214 reI14 en hero Coot Oeo4r cool. acerObdeIn The 1401ewon. owlet two COOT en he used to delernon o aemerl hmdsrg hon no Out MOO

000thndOnS.tet,n020 Faming Cngmreo rSdIed 000 One-Ten. judo hrnglernont,torFuming must NOT in rewInd rr Ocuton Cd, 00 e,701

oh (.erudoe

e.d.t

bed. oh mret.

Suds)

140001

her. led, oh

(2)

beu, oh o,rbde

40 Ott

Ce. beds oh

0220

P.reoeet Support Worker )PSW) - 800 tome me

newl no ma 4900 eqonme funded Iron 0° POW- 050 .ouaum Nd’ Imoporersmud am herorono ‘F (son COOl through Cool. an apØcdeln ISo lot, omer.co owleten ho COOS *4(14 usnl to aNomno orb oruod using tram Fe POW - mud coheIr.

bed, oh (sounds

57.511

F t0ew1 rho rot, Orobeoorroeoe hon the NFC onodop. 02 fonda) arerly Iron edatot,2831 I1nno woo02 In deelgr02 .peuodoni untIe The o’tron,m mmcl dma) rewInd or hr..

L__LrutI FImghCO2l.a.anacaN..

_________

I.u000roCoNn

St(3)

Fe Bran0 u,.

4) 0) IT)

2o00s14t,.022

It)

I

CIII 8,073.020 8,073,020 0

0002 o,roe,eos 2,eln.875 5 a

0

hOOd .ere:1r.do.n.8fldFoe $10,740,808 $0 $10,740,928 $0 $5 $5

Nenhrg and Per.orml Cam INPCI - Admkt,tnIbn0205

SNauha 420,032 d70.532 .

C200Zmclosne connOte 118,000 110,000 0

COOtForohusnlnodooe 10,800 10,800

COOS‘dedod end NursIng Suede, 185,000 In5,000 . -

c’o 0 .:oZ4 0hgimpoonl - Nod . -,

0010hodoronl.Oedounnonts 10,111 .,: 0

cTh 0b(mnm

401.’ 17,018 0

COldOdroolito & T: 8,130 0

COld52m.4ame’ -o 8220 9,228 ‘-‘‘0

128,280 128,280 - ‘h‘molnonho Suedes

corn28,888 2,O8

dedcathrmloeree —

r36i 24 178 24,170 - . 0°hy.ttmOn-CdeCmerven

COlt U000 0 ‘FrOnd. dnehll1rl(or . - -.

°°‘wetI 0 emblem, lot 10,0071 (5,007) —

-

!o :::1..0dmInhdrbdI1m 81.000,470 $0 81.000470 r’ ‘ $5 5$

[6g3, Tore) Nur.IngendFereme(here$11,750,378 $0 511,7003781 “ I sol °I,, ‘OumoII(r,,COOd,ndhtOII

COOl

0.ahl.r.d Ness (ON) end Regirered Fracrital None. )RPN) - 800 mobIle.

den.r no ma oroNon0000 runam Iron em one nnu - 000 esoano 5012 the

onmrm.muoamhergacheoltuOeCo0l nuoAuICOOr,aomrduodc Themacqoormo

rewInd or (cm COOn on he used Iodemn,ne silo onuend luodero Iron thoRN OOPN’ BOO

Enhanced Tnanedhen 0007001 FundIng btuannc, Cm, rev, o.o

F 0or 0° 014 dr’gSo aToner lunCo Iron rho Fnhu,02 Orarelmo Ouowb Fuming Th’emonmondor4mherowhemtinuoCaOr rhrougnCOdr,anito,.

Designated Speobllzod Unit, - AddkMtceI FundIng1Omt her.

Page 3 of It

Ontario

5001

0000

5001

5004Soppede

OoorO.o.e 000,100.0 000-TOO Fokaoor,rOaFor&ecáouNOrer 0.,. Co. 0*

Norooro

1011.030..(7)

0 -oh-

Rspet004er040nr I Oet000heueeopeoeeoodortheneeFord

I modoperor Irleorrr ShoO-Nleybed. Sorrded lhrorghtboedH, UPF Ar.eete

10004 olcoee lroarnmr Ford .rWor rord. odborared Coo deor sede, O.per onder

I deorrod mean .0gb. “p.o... under tO, Roc Feed erurdopelooorredoroerrr

I Cae.b.d.tood.d000oghOreMOt UPF AIlmrd.horarotCore

I er_clod. rsboreOM FerrMrerseoms NO.. The ap.r.e. moo

L__ -.pesed er’OOS peel e,..ogh P000,

2014 Long-Term Care Home Annual ReportFor the period from I 2014-01-Oil to I 2014-12-all

I HI“•°

Dearness Home for Senior Citizen,

anti.. 0- Mt,,I Eop,odaer.. - Pr,qrem cod Seppert SoMe..

oes-LoroO0._c

141

Sub-total

let000020 590029 0

204000 204403 i 0

705100 200100 - ° --

eROtI gRolr - 0

- 90431 00433

bor2 otiorProed. Oeooipron 0

- -

°rsperdrur.Reooenee leorer a. rmahml (120101 —

Solo feral Pregr.o cod Suppee O.ro0.. Sr color to tr 02 071 50 $0 $0lion er en.. 5003 rrreoer SIlo)

The Aeioa .1 Rem, rood IAAHI, the Urgent Prierities Food For

the Alteroetioe Leo.) et Core inoestmeot Food cod/er Cmudeeeeor u0lr

funds reallocated trem eth leo. 004000.4,1

Iepoo order o4uor r thotod digbluoepeosee 0000rthe Progron aod hooper

Snoop, eooelrp.urlrberlo5007-orarbederurdadorooohthendob,uPF.Roomers LsuO rICer, lrorero,nr Fund eodbor rood, redloeerod boro ahersedee.

003 opel order odonr 0 0’ rod 0’o’0, eopnoee order 0. Prooram end Sopoorr

berdoeo orudrpe to Corrdo,oorr Cere bed, Nrded through 0.004 OFF,

Nlemee boO rICe, lroa.roorl Ford esdbor 5,02. raaoseIed hen orror .00°n.

Nd,: The olforsoe 03cr dsr ber.poOod or hr.. toOt through Sold,..

orsheblel

For LlSlhrerhnbed, erR For

Additional Neelihoare Ferseooel - iso loilietioe

Core 390,1 41—

O.ponrhe1440gibleeopor.eoCrdedhootheoddhordllea8000rePenorrd-Rnoeuetoe See Sreeepor.e,ou0000ber.poeedorhra5001 through

s°op4ieeO. Sherod peers.. reororod or 10, Solo ci beueedro

dz.rnioeorrorooadroraron000eoddooraHeaohmreP000rd-eSO

- bemnPuhileip Fonded Physletherepy Semi.,, lPhpniethorepp bednorlr Fe

Fuodiog .1 5759 per bed per Seer Jenuary t threegh Morph 31Coot Cr

cod 5760 per hed per peer eff,otioe April 0, 2tld I Ceo.nedel 121-

Roperthe rod digtb0eopormn hndod nero ho PuboOr Funded Fhrsdeh.ropr

SIte 010(phrNotermrFordColteoro-on-orephrenlhermoendom She t04,24tmpmsmoo.r dee bereporled orlira. Soor througH 5034 a appoee5o. Sfemdemorsm repoeed or hoe 0020 0111 be used to ddmn0o err onoeed hordrg Poorefoblrdr Forded P01,idC.000 hereoo

Puhiloly Funded Phynietherepy aerolcee for ConoalesoeniForL0004e000 I For

Core Bed. en1p lPhpsi,lherepy auheidy .3 510.27 per diem leedode I Cereed.oortJenoery I through Maruh 31 cod 5154$ per diem effeulioe Corudeeeot ICercedsorIrApril 1, 20141

Cer&eode_J 121

Oopetr the ted diolNe peers.. larded Pao the PuNid0 Forded Fhr.bdhereo)

5001 bereoo(Phmidhoapruobodr(Ororeror-orephrodher001.oreoee010ddedteCorodooort uca b_c. deprOeeNe. be eoporooo oust dso beoepoeed or hoe,Deer inwoNOer4, a eppa_cle. She040 e,pereee reporled or Irre000ra 5°’eeerheelbeleaudueoodeeerporo_clardrg he000P0044rForded

-Th-._.

Rmnr0.ldd digthd erpor... hooded Perr the Pub4dr Funded ph10015ere0p0.0dm, )Phpledreape SohedpO$ro 27 per 4,30) for rOteuteeror eod era

‘21 her..e pled490 hooredeeo.R Core bode, lteppoeehte She eepm,ce muu0,0 be r,pared erOs.. 0001 hoeooh Sold, ee oppheebla She rod anal...r.pa.red or hoe 5021.ptu. Detrbodll beosed to dderodoeoryoo..Whodioa

err the °r Forded P0p.,00.epo nero..,

For L0015e.oobed’ edr Fm

Eehann.4 Trans leer nupport FundlotCr’ZIOCeoOed,l (2)

F nopor the Ida dnlue ,,poro.. landed Pao Ihe Pohorood SroruooreupporrS0t2 Fundrrg The.epors.. ou,10oo be raperodorhloes Soot Poeogh Sold,..

—-

ForLlCbedeorlr leedode

Dsnlgoet.d Speuleiloed Unto - Mdlgen.l Fonding 0000 beds 004

Se. bed.)

F 6._c the Ida digrNe esporeze Oem the Pub oredope ord ntoded Orday Sen0003 oddRerd hrdeg prodded lodoeigroed spmideeed orbs She doer,.. muM dee

L srepered or Ones 0000 thoeeuh SOrd,ae 20540010

Setline B - Acted Eepeoddures - Ram Peed TlEo.,e 010.04 ‘Oem Sob-Ted FohuaermaCm4 Com,0...ol Oo-dmze Uola500 04o

ons-04ooO SenOr,. OOoodirho 0.00t:000 If) Mmd4ieImeo.emor. 0’°eth Feperedese b.ooeooroe L.oeth Popeodsos

R..o Feed 0) 101 reoeetor. it)

te2P, 050

Omoel 1104501 110453/I- I I

00 $127,350 I

The Aaing .t home Fund (AAR), the Urgent Fderilies Fond Zr’?tjt’ Fe

IUPFII the Altereetioe Leoel et Cere lno.stm.ot Fund eodler CmodmemrCam oer

tuods realiecated from ether neoters Corolrthi121

83th1591 I I oj I

I °l soil

Page 4,015

Ontario 2014 Long-Term Care Home Annual ReportMotryotHealthdLog-TermCare For the period from I 2014-01-Oil to I 2014-12-311Ministére de Ix Sante et den Soir de loegne dvree

MONLTC Facy# OperxtvrNxree

Hi 1483 Dearness Home for Senior Citizens

Section F - Actual Expenditures - Other Accommodation

LTC and Interim LTC and lntermr Sub-Total Convalenvent Care Convalescent Sub-Total For MbndbyBed Bed For t.r45y Use Only Arms-Length Care Use Deity

Aeern-Length Non-Ames- (3) Trevsactiees Non-thereTransactthrrs Length Allowable (5) Length Allowable

(I) Transxctens Expenditure Transactions Expenditure(21 (4) t61 (8)

Housekeeping Services tHS)FOOl

Salaries 748088 748088 0

F002Employee Benefits 290316 290316 0

F003Purchased Services 4054 4054 0

F004Supplies 80343 80,343 0

F005Equipment - New 299 299 0

F006Equipment - Replacements 10,327 10,327 0

F007Equipment - Leasing 0 0

F008Equipment - Maintenance 0 0

F009Education & Training - Supplies and Services 0 0

poloAttendance Costs - Meetings, Conventions and Training 0 0

FOil Other:Provide description

0 0

F012Expenditure Recoveries (enter as negative) 1169) (169) 0

F013 Total HousekeepIng ServicestSum of lines FOOl through P012) $1.1 33,258 $0 $1,133,258 $0 $0 $0

Mayi.2x15 Page5ofl9

Ontario 2014 Long-Term Care Home Annual ReportMorist fHeahh and Long-Term Care For the period from I 2014-01-Oil to I 2014-12-311MinistCre de Ia Sante et des Solos de bngue duree

MOHLTC Facillly# OperotorNarne -

Hi 1483 Dearness Home for Senior CitizensSection F - Actual Expenditures - Other Accommodation, continued

LTC and lnten,n CTC and Interim Sub-Total For Ministry Use Cenvalesnent Care Conoslesnent Sob-Total For Ministry Useend Bed Only Arms-Length Care Only

Aens-Length Non-Arms-Length (3) Transactions Non-Arms-LengthTranoactrons Transaneons Allowable (5) Transadosra Allowable

Building and Property - Operations and Maintenance (B&P-OM) (I) (2) Euperrdfture (6)(7) Expenditure

(4) (8)

P017Salaries 253,525 253,525 0

FOl 8EmployeeBenefrts 71835 71835 0

FOl 9Purchased Services 6545 6,545 0

F020Supplies 48,744 48.744 0

P02 1Equipment - New 0 0

F022Equipment - Replacements 0 0

P023Oquipment - Leasing 27553 27553 0

F024Equipment - Maintenance 157.421 157,421 0

F025Building and Property - Maintenance 149,517 149,517 0

P026Education & Training - Supplies and Services 0 0

F027Attendance Costs - Meetings. Conventions and Training 0 0

P028 jmer.Provide description 0 0

F029xpenditure Recoveries (enter as negative) 0 0

F030 Total Building and Property - Operations and MaIntenance(Sum of lines P017 through F029) $715,140 $0 $715,140 $0 $0 SO

May r,2515 Page 6 of 19

Ontario 2014 Long-Term Care Home_Annual ReportMirutryofheafthandLeng-TermCare Forthe period from I 2014-01-Oil to I 2014-12-311Meistere de Ia Sante et den 50ev de lemon dared

MOHLTC Facilfty# Operator Name


Section F - Actual Expenditures - Other Accommodation, continued

________ ________ _______ _________ ________ _________ ________

LTC and Interim LTC and mIcron Sub-Total Fer.bndtry Conoalenuent Care Convalescent Sub-Total Poe Ministry UseBed Bed Use oniy Arms-Length Care Oniy

Amrs.Length Non-Avers- 13 Transactions Non-Arms-LerrgthTransactions Length Allowable (5) Transactions Allowable

Dietary Services (OS) (1) Transactions Expenditure (6)(7) Expenditure

(2) (4) (8)

P034Salaries

1,403145 1,403,145 0

F035Fmployee Benetto 475,301 475,301 0

P036Purchased Services 2,558 2558 0

F037Supplies

63,240 63,240 0

F038Equipment —New 0 0

F039Equipment - Replacements 10,256 10,256 0


F041Equipment - Maintenance 22,867 22,867 0

P042Education & Training - Supplies and Services 0 0

4ttendance Costs - Meetings, Conventions and Training 362 362 0

081Cr:Provide description 0 0

Eapenditure Recoveries (enter as negative) (7,863) (7,863) 0

F046 Total DIetary Services $1,969,866 $0 $1,969,866 $0 $0 $0iSum of lines F034 through F045)

Mayl,2015 Page 7 of 19

2014 Long-Term Care Home Annual ReportForthe period from I 2014-01-Oil to I 2014-12-311

OntarioMinisnyof Health and Long-Term Care

Minrutére de Ia Sante ci de Soirr de Ioeoue dorée

MOHLTC Facilfy# Operator Name


Laundry and Linen Services (C & LS)

LTC and lnterhn LTC and Interen Sub-Total 0r “°Y °“ Conroaleocent Care Convaleenent Sub-Total r-or rameey ace

Bed Bed Oy Arms-Length CareArms-Length Non-Promo- (31 Transactions Non-Arms-LengthTransactions Length Allowable isi Transactions A9OY5bl8

(I) Transactions E)pendlture (6) (71 Expenditure(21 (4) (8)

F050Salaries 377.206 377,206 0

F051Employee Benefits 146,731 146,731 0

F052Purchased Services 0 0

F054Laundry Supplies 25,194 25,194 0

F055 -

Equipment - New 0 0

F056Equipment - Replacements 0 0


F058Equipment- Maintenance 1,729 1,729 0

F059Education 8 Training - Supplies and Services 0 0

F060“ittendance Costs - Meetings. Conventions and Training 0 0

F061Sitflet.

Provide description LINENS 23,792 23,792 0

F062Expenditure Recoveries (enter as negative) 0 0

F063 total Laundry and Linen Services(Sum of lines F050 through F062) $574,652 $0 $574,652 $0 $0 $0

May 1,2015 Page 8 of 19


_________

Ministry of Heaith and Long-Tarrn care For the period from I 2014-01-01 to I 2014-12-31Miroslere do a Sante at den Soino de 100900 dordo

MOHLTC Fanilty 8 OPerator None


LTC and Inferno LTC and Interior Sub-Total Fm M000try Uca Convul000ent Care Connalescent Sub-Total Fm Ministry UseBed Bed Only Ares-Length Care Only

Mms-Lenglh Non-Arms- (3) Transactions Non-Arms-Transactions Length Allowable (5) Length Allowable

General and Administrative fG&A) (I) Transactions Expenditure Transactions(7) Expenditure

(2) (4) (6) (6)

F 067Salaries 265,716 265.716 0

P068Employee Benefits

70,833 70,633 0

F069Purchased Services

48,464 48,464 0

P070Management Fees

0 0

P071Allocated Administration Costs

0 0

F072 - -

Aadrt Fees2,849 2,849 0

P073 -

Legal and Other Professional Fees0 - ••c 0

F074Feneral and Banal

0 0

P075Supplies

86,083 86,083 0

F076Equipment and Furnishings- New

0 0

P077Equipment and Furnishings - Replacements

15,494 16,494 0

P078Equipment and Furnishings - Leasing 0 0

P079Equipment and Puntishlngs - Maintenance 11,289 11,289 -. 0

F081License Fees and Dues

0 0

F082Consulting Fees

565.368 565,368 0

P083Accreditation Fees

0 0

F084Assostation Memberships

15.967 15,967 0

P085Education and Training - Supplies and Services

0 0

P086‘,Oendance Costs- Meetings, Conventions and Trardng 13,065 13.065 0

P087Horerranums and Donations

0 0

pO8 eymoan on-call coverage (tot the component aboveEtc NPC allocation)

0 0

F089 linerProvide description Staff apreaciations , Nursing week etc 2.506 2,506 0

P090Expenditure Recavones (enter as negative) 118,877) (18.877) 0

pgg, otal i.,eneral and AdminIstrative(Sum of lines F067 through P090) 51,078,757 $0 $1,078,757 so so so

May 1.2015

Page 9 of 19

MOHLTC Facthty# Operator Name

H11483 Dearness Home for Senior CitizensSection F - Actual Expenditures - Other Accommodation, continued

LTC and Interim LTC and Interim Bed Sub-Total rr Mwtmrri Connelescent Care Convalescent Care Sub-Total ror ,emOf

Bed Non-Arms-Length Arms-Length Non-Arms-Length Use OnlyArms-Length Transactions Transactions Transactions

. Transactions (2)(3) Allowable (5) (6) Allowable

Facility costs (FC)(I) Expenditure Expenditure

(4) (7) (8)

10097Utilities 703362 703,362 0

F098Insurance 0 0

10099Communications 0 0

FlOGMunicipal Property Tax 0 0

10102Rent 0 0

Fl 03Mortgage Interest 0 0

Fl 04Interest on Operating Line of Credit 0 0

Fl 05Other Interest 0 0

F106Amortization/Depreciation 0 0

F107 mtmm

Provide description 0- 0

F108Expenditure Recoveries (enter as negative) 0 0

Flog Total FacIlity CostS10108) $703362 $0 $703,362 $0 $0 $0

Full Total Other Accomodation(LIne F013 + Line 10030+ Line 10046 + Line 10063 + LIne FOOl + Line $6,175,03510109)

$0 $6,175,035 $0 $0 $0 -,

Fill Total Inadmissable Expenditures, Other Accomodation(Line F087+Ltne F103+Line F104+Ltne F105+Line F106) $0 $0 $0 , $0 $o so

Fll2Total OtherAccommodation after Inadmissable Expenditures(Line$6,175,035 $0 $6,175,035 I $0 $0FilO- Line Fill)

For Interim bedsonly (excludeConvalescentCare Beds)(1

For convalescentrare beds only (2

OntarioMinistry of Health and Long-Term Care

Ministere de Ia Sante et des Coins de longue daree

2014 Long-Term Care Home Annual ReportFor the period from I 2014-01-01 to I 2014-12-311

The Aging at Home Fund (AAH), the Urgent PrioritiesFund (UPF), the Alternative Level of Care InvestmentFund andlor funds reallocated from other sectors

Report under column 1 the total eligible expenses under the OtherAccommodation envelope for Interim Short-Stay beds funded through theH, UPF, Alternate Level of Care Investment Fund and/or funds

Fullreallocated from other sectors. Report under column 2 the total eligibleexpenses under the Other Accommodation envelope for ConvalescentCare beds funded through the AAH, UPF. Alternate Level of CareInvestment Fund and/or funds reallocated from other sectors. Note: Theexpenses must also be reported on lines FOOl through F109, asapplicable).

For LTC/lntermmbeds only(eoclode

Enhanced Transition Support Funding Convalescent CareFor Connatescent

Beds)are sony

Report the total eligible expenses funded from the Enhanced Transition10117 Support Funding. The expenses must also be reported on lines FOOl

through Flog, as applicable.

May I, 2015 Page 10 of 19

Ontario 2014 Long-Term Care Home Annual ReportMinistry of Health and Long-Term Care For the period from I 2014-01-Oil to I 2014-12-311

Ministère de a Sante et des Solos de longue durëe

Replacement Category “D”Beds and Replacement “B”,“C” and Upgraded “0” beds

G051 Phase Ri

0052 Phase R2 —

0053 Phase R3

0054 Phase R4(B andC beds)

0055 Phase R5 (B and C beds)

G056 Phase R6(B andC beds)

G057 Phase R7 (B and C beds)

0058 Phase RB (B and C beds)

G059 Phase R9 (B and C beds)

0060 Phase RiO (LHIN beds)

G098 Subtotal

a

0099 Total

a Efl

MOHLTC Facility # Opetator Name


Section G - Awarded Beds and Replacement “D” Beds

To be completed by

operators who operated Number of Date of Ministry Ministry Number of Bed- Funding Total Funding

Awarded beds, Replacement Beds Admission of Approved Approved Days in 2014 Per Diem forFirst Resident to Orientation Fill Rate eligible for for Construction

“D” beds, EDAP beds, andthe Beds in Days Days Construction Constructio Costs

Replacement “B”, “C” and column (1) Funding n CostsUpgraded “D” beds, with (yyyy-mm-dd)Start-Up Periods in 2014

Awarded Beds and

EDAP beds(1) (3) (4a) (5) (7)

fAh\

0001 Phase Al

0002 Phase A2

0003 PhaseA3

0004 PhaseA4

0005 Phase A5

0006 EDAP

0050 Subtotal

May 1,2015 Page 11 of 19


_______ _______

Minotry of Health and Long-Term Care For the enhod fe-rn I h##hhh## I to I 0####### IMin’wlern de Ia Sante et den Caine de tongue doréeMOHLTC Facitrty6 Operator Name

Ml 1483 Dearness Home for Senior Citzeno

Section I: Part ALine laOl- The Nurse Practitioner in Long-Term Care Home Program

In a000rdance with the Loon-Teen Care ILTC) Naree Praothorer (NP) Progran Fandog Poky report on ire faSt Salary earafto and Oaethead cnere Hon the Narsa PensIoner poobon for thepenod horn Janaary 1 2014 to Dnonnber 31. 2014 DO NOT REPORT THESE COSTS IN SECTONO C THOU P of the Long-Teen Care Hone Annaal Repon.

Enpenson for 12 months, Janaary 1.2014 to Oeonmbnr 31,2014Unethead

Enpeeses -

Salem Beeeflte eparstieg Tetat Costs

laSt $0

Line ibOl- One-time Funding of uo to $ldM for the 2013-14 fiscal near to enhance fire and electrIcal safety ineligible Long-Term Care ILTCIHomes.

Report 001cc IbSI the total onst for all eigibh anode and earmee rhated to Ire ard eleonioal eatery purchaend between January 1. 2014 and Maroh 31 2014 and reoeiand by March Sf, 2014 ardlarded hoe thin 2013-14 ore-bee hinding inibabae 00 NOT REPORTTHESE COSTS IN SECTIONS C THOU P The niniuhywill odd the oonta reposed on inn Ibol to eligible coole reported inSoabon I of the 2013 LTCH Annual Report mr alt elgibb up gradee and earleneo related to Ire safety purohauad barwean April 1, 2013 and December 31.2013 and reneiaed by Deoenber 31. 2013The can of the nosto will be reoanoilad againot tha total 2013114 one-inc Ire eafety landing and anyonspent funds ml) be reonvered or part of the 2014 rannncEabon

Total eopaneas for 3-month period hoe January 1.2014a Mach 31. 2014

I IbSI

Lice IbOIb- One-time FundIng for the 2014-15 fiscal year to enhance fire and electrical safety in eligible Long-Term Care ILTC) Homes.

Report an Ire I botb the total oost for all eligible gondo and earcoen related to Ire and eleothoal nobly parnhared between Apri 1 2014 and Deoanbar 31 2014 and renerned by Deoeeber 312014 and funded horn the 2014-IN one-lee funding inibalue DO NOT REPORT THESE COSTS IN SECTIONS C THRU P Tha rninisthywill add tha 00cm reported on line lbOlb to eligible castereported n Seobon tol the 2010 LTCH Annual Report for ci elg.ble argradns and sar.ioes related to the safely parchanad between January 1,2010 and Ktawh 31 2010 and recewnd by Elaroh 31.2015 The sun nftha costa oil be reooncded agamnor the tolal 201415 ore-One Ire safety fundrtg and any unepant undo oil be recnmred ao part of the 2010 reoonnirarhn

Total eopenoan fur 0-earth pemd hoe Op0 1 2014 to

December31. 2014

ihnlb

Lines leSla and leSib- One-time Funding of unto $10.557M for the 2013-14 fiscal year for Training and Oeveloomnnt of LTCH Staff.

Report on mnee leOfa and leDib the total oanto for all ebgbb carting goode and saruloes porohaead between January 1. 2014 and March 31.2014 and renaiand by March 31 2014 and funded hon 201 3—14nne-tbna oanag fund’eg ‘ortanue DO NOT REPORT THESE COSTS IN SECTIONS C THRU P The ninisnywrl add the onste rapanad an men lenla and leOlb to efgibla node reported a Se000n I of the2013 LTC Hone Annual Reponfur at ebgob thae’eg good card sarenee puroharad between Herd 1.2013 and December 31. 2013 and raoaiad byoanernber3l. 2013 The one of the north ml berecnnciedagahnr the total 201 3114 one-Lee nainhg fundeg Enpenditures oil be broken down by Ian thee. al carte to purchaoe na’ehg sar*ae and neroumee and b) nests for baob5 Anyanenent funds audi bereonerad bytha rnnienyae pan of the 201 4reoonc.daLnn

Total enpensas mr 3-north period horn January1.2014th Mach 31, 2014

laOle Costa In parnhase tnaioing SomElaelb Cost for baobfdf 526.414

Line mi Investment in Addittonal Convalescent Care Beds - One-time Start-Un Fundiog for 2013114 -

Report on line Ital total noota far all eligible eopeneae moaned Iron January 1,2014 to March 31, 2014 related to ntart-ap conIc lnrnonunrn’nn to, or creator of new nonualnonant care bede and funded hoe this201 3-14 one-Inc funding hibatue DO NOT REPORT THESE COSTS IN SECTIONS C THOU P Tha niniotny will add the coota reported on Inc 1101 to eligible cnota reported in senior I of the 2013 LTCHAnnual Report foe all efigibla oneta incaned hon Apnl 1,2013 to Deoenben 31,2013 for onrerehn to. nr creatwn of new onnuabsoentoare beds The sun of the costs will be reconciled agahst the total 201 3114one-One etart-op funding and anyonopant funds oil be recnuared ao part of the 201 4raonociiabon

Total enpensee br 3-month period hon January r 2014to March 31, 2014

I 001

Moyi,2015 Pognl2oflS


_________

Ministry of Health and Long-Term Care For the period from I 2014-01-01 I to I 2014—12—31 IMinistCre de Ia Sante et des Soins de longae darde

MOHLTC Facility P Operator Name:


Section I: Part B One-time Funding and Other Initiatives.

Please use Column D to report the expenses applicable to and funded from the funding initiatives below. The expenses reported inColumn D must not be included in Sections C thru F and Section I: Pad A of the LTCH Annual Report.

The items reported in Section I: Part B are to be limited to the expenses that were incurred from January 1, 2014 thru December31,2014 only for funding that is received directly by the LTC Home based on the funding provided in the LTCH Payment CalculationNotice. The expenses reported in Section I, Part B are reconciled via alternate processes and shall be excluded from the calculationused to determine the Allowable Subsidy in the 2014 Overall Reconciliation.

Line Funding Initiative Description Expenses(A) (B) (C) (D)

Report expenses for salaries and wages ot nurses from January 1,Nurse Led Outreach 2014 to December 31, 2014 to ensure timely access to care by LTC

Ibi

Home residents and avoid emergency room and hospital admissions.

4eport eapenses eligible for reimbursement incurred from January 1,. . . 2014 to December31, 2014 by LTC Homes for supplementary staffing,

High Intensity Needs Fund (HINF) Claims-Based . . . 44 189exceptional mound care, preferred accommodation and transportation

1b2 for dialysis.Report expenses eligible for reimbursement incurred from January 1,

Laboratory services claims 2014 to December 31, 2014 for phlebotomy services purchased by 12,860

1b3 LTC Homes.

Report espenses eligible for reimbursement incurred from January 1,. . 2014 to December31, 2014 for the purchase of computer hardmare

RAI-MD5 one- time fundingand software, including RAI-MD5 software, to meet cIHI reporting

1b4requirements.

Report expenses eligible for reimbursement incurred by the home fromPedtoneal Dialysis January 1, 2014 to December31, 2014 for the provision of services to

1b5 Pedtoneal Dialysis residents.

. . Report expenses eligible for reimbursement incurred by approvedLTCH Centre of Learning Research and Innovation

. homes from January 1, 2014 to December31, 2014 to operate a LTCHProgram funding

1b6centre of Learning, Research and Innovation program.

use lines 167 through 1611, column 0 to report eapenses eligible for reimbursementincurred by the home from January 1, 2014 to December31, 2014 for any one-time and

One-time and project funding project funding, based on the funding provided in the LTCH Payment Calculation Notice.Please report separate each funding item and provide a description below. e.g. WaterDuality Testing, one-time start-up costs for designated specialized unit beds.

1b7 : Description:

1b8 Description:

1b9 Description:

Ibi 0 bescription:

lbll Description:Total Expenses from Section I, Part B (sum of lines Ibi to IblI) 57,049

Mayl,2g15 Pagel3ofl9

2014 Long-Term Care Home Annual ReportFortheperiodfroml 2014-01-Oil to 12014-12-311

MOHLTC Facility # Operator Name


—

KOO1(a) Is the Home Accredited? Accreditation Start Accreditation End

Date (if yes) Date (if yes)

Nol Yesj______ I IPlease mark choice with x (yyyy-mm-dd) (yyyy-mm-dd)

. Days MaximumFrom To Operating Maximum

• Accredited(yyyy-mm-dd) (yyyy-mm-dd) Capacity Resident-Days

DaysKiOla KlOlb KlOlc KiOid KiOle KlOlf

K102a K102b K102c K102d K102e KiO2f

January K103a K103b K103c K103d K93e K103f

To K104a K104b K104c K104d KiO4&. K104f

March KtO,a K105b K105c KIOSd K105e K105f

K106a K106b K106c K106d K106e 6f

K107a K107b K107c K107d f

K108a KlO$b K108c KlOSd K108e

Orientation Days K109a K109b K109c K109d K109e

Total January to March (sum of lines KIOl throubh K109) KilOd KilOc KilOf

Killa KIlib KItIc K111 Kille Kilif

April K112a K112b K112c Kfl2d K112e K112f

To K113a K113b K113e Kil3d Kii3e K113f

June K114a K114b K114c K114d K114e K114f

K115a K115b K115c KiiSd Kii5e

K116a K116b K116c K116d K116e

K117a K117b K117c K117d K117e

Klt8a K118b K118c Kii8d KHSe

Orientation Days K119a K119b K119c K119d

Total April to June (sum of lines KIll through KI 19) K120d

Kl2la Kl2lb Kl2lc K121d

K122a Kl22b Kl22c K122d

Kt23a K123b K123c K123d K123f

Kl24a Kl24b Kl24c K124d C Ki24f

K125a Kl25b Kl25c K125d 1C125e K125f

K126a K126b Kl26c K126d

Kl27s Kl27b K127c K127d K117.

July K128a Kl2Sb Kl28c K128d K128e

To Kl29a K129b Kl29c K129d K129e

December Kl3Oa K130b K130c K130d K130eK131a Kl3lb Kl3tc Ki3Id K131e

Kl32a K132b Kl32c K132d

Kl33a K133b K133c K133d - -

K134a Kl34b Kl34c K134d I - — K134f

K135a Kl35b Kl3Sc — K135fKl36a Kl36b K136c Kl3d r K136fK137a K137b Kl37c K137d Ki37f

Kt38a K138b Kl38c K138d K138f

Orientation Days Kl39a K139b K139c K139d Ki39f

Total July to December (lines Kl21 through Kl39) K140d K140f

Total January to December (lines KI lO—Kl20—K140) K.141d KI41C Ki4lf

c

frr

r

r


Ministère de Ia Sante et des Soins de lonque duree

Section K(a) Calculation ot Maximum Kesident-Days and Accredited bed-Days for Classified and Unclassified beds fromJanuary Ito December 31. (Excludes Interim Short-Stay beds and Convalescent Care beds)

May 1,2015 Page 14 of 19

2014 Long-Term Care Home Annual ReportFor the period! 2014-01-011 to 2014-12-31 I


H 11483 Dearness Home for Senior CitizensSection K(b) Calculation of Maximum Resident-Days and Accredited Bed-Days for InterimShort-Stay Beds from January 1 to December 31

K001(b) Is the Home Accredited? Accreditation Start Accreditation End

Date f if yes) Date (if yes)

No! I Yesj I I I I I(yyyy-mm-dd) (yyyy-mm-dd)

jo MaximumFrom Operating Maximum

(yyyy-mm- . Days Accredited(yyyy-mm-dd)

diiiCapacity Resident-Days

KlOlg KIOlh KiOli KtOij KiOlk KiOll

K102g K102h K102i X102j K102k K1021

January K103g K103h K103i K103j K103k 1(1031

To K104g K104h KtO4i KiO4j K104k 1(1041

March K105g K105h K105i KlOSj KIOSk K1051

K106 K106h K106i K106] K106k .K1061

K107i, K107h K107i 1(lO7j K107k KI071

Fill Rate Admission P Ki08 K108h K108i K1O$j 1(108k IC1O$1

Orientation Period K109b K109h K109i K109j 1(109k 1ClO91

Total January to March (Sum ofhnes KIOl throui,h K109) K110.j 1(110k K1101

Kilig KlIih KIlli KIIij 1(111k 1(1111

April K112g Kii2h K112i K112j 1(112k K1121

To K113g K113h KiI3i K113j 1(113k 1(1131

June Kli4g Kii4h K114i K114j 1(114k K1141

K115g Kll5h K115i K115j K115k K1151

Kil6 K116h K116i K1163 K116k K116i

Ki17 K117h K117i K117j K117k 1(1171

Fill RateAdmission p KI i8g Ki ith Ki iii K118j K118k 1(1181

OrientationPeriod K119g Kll9h K119i K119j K119k K1I91

Total April to June (sum of lines Kill through Ki 191 K120i 1(120k C K1201

K121g K121h Ki2li K121j K121k C 1(1211

K122g Kt22h K122i K122j 1(122k 1(1221

K123& K123h K12,i K123j Kl231 K1231

K124& K124h K124i K124j 1(124k K1241

Ki25 Kl2h K125i K125j 1(125k K1251

K126 K126h Kl26i 1(1263 1(126k K1261

K127g K127h K127i K127j K127k C-” (1271

July Kl2Sg K128h K128i K128j 1(128k 1(1281

To K129g K129h K129i K129j 1(129k 1(1291

December K130g K130h Kl3Oi K130j K]30k 1(1301

K131g K131h Kl3ii K131j K131k 1(1311

Ki32 K132h K132i K132j 1(132k 1(1321

Kl331, K133h K133i K133 1(133k 1(1331

K134b K134h K134i K.1t; 1(134k 1341

K135 K135h K135i K135J 1(135k 1(151

Kl36 K136h K136i K136j 1(136k 1(1361

K137g K137h K137i K137j 1(137k 1(1371

Fill Rate Admission P Kl38 K138h K138i K138j 1(138k 1381

Orientation Period Kl39 K139h K139i K139j 1(139k K1391

Total July to December (lines Kl21 throui,h K139) K14b 1(140k E1401

Total January to December (lines KI lO+K120+K140) K1413 1(141k 1(1411


Ministére de Ia Sante et des Soins de ionque durée

May 1,2015 Page 15 of 19


Ministére de Ia Sante et des Soins de longue durée

2014 Long-Term Care Home Annual ReportFor the period from 2014-01-Oil to I 2014-12-311


Hi 1483 Dearness Home for Senior CitizensSection K(c) - Calculation of Maximum Resident-Days and Accredited Bed-Days for Convalescent Care BedsFrom January 1 to December 31

K0O1(c) Is the Home Accredited? Accreditation Start Accreditation End

Date (if yes) Date (if yes)

Nol Yesi I I I(yyyy-mm-dd) (yyyy-mm-dd)

. . MaximumFrom To Operating Maximum Resident. Days Accredited

(yyyy-mm-dd) (yyyy-mm-dd) Capacity DaysKlOlm KlOln KiOlo KiOlp KtOlq KlOJr

K102m K102n Ki02o K102p K102q KiO2r

January K103m K103n K103o KIO3p Ki03q K103r

To K104m K104n K104o K1O4p K104q K104r

March K105m K105n K105o K1O5p K105q KiO5r

K106m Kl06n KiO6o KiO6p K106q K106r

K107m K107n K107o K107p 34i7q K107rKi0$m K108n K108o KIOSp KiO$r

Orientation Days K109m K109n K109o K109p K1O9L K109r

Total January to March (sum of linen Ki 01 through 1(1 09) KI I Op KI iOq Xi JOt

Kitim Kitin Killo Kilip Kiilq Kilir

April K112m Ktt2n Kii2o Kli2p K112q Kl12r

To K1l3m K113n K113o K113p K113q K113r

June K114m Ki14n Klt4o K114p K114q K1I4r

K115m KtISn Kii5o KliSp K115q K115r

Klt6m K116n Kiiéo K116p KiJ6q K116r

Ktllm K117n K117o K117p K117q K117r

K1i8m K118n K118o Kilip KiiSq Kii8r

Orientation Days K119m K119n K119o Ktl9p K119q K119r

Total April to June (sum of lines Kill through Ki 19) K120p K120q K120r

K121m K121n K121o Ki2ip .1C121q KJ21r

K122m K122n K122o K122pV

V

K122q K)22r

K123m K123n K123o K123p K123q K123r

Kl24m K124n K124o Kt24p K124q Ki24r

K125m K125n K125o IQ25j K125q V

r

K126m K126n K126o K126p K126q VI r

K127m K127n K127o K127p K127q r

July K128m Ki2Sn K128o K128p Kl28q rTo K129m K129n K129o p KJ29q

V

December K130m Ki3On K130o p K130qV

VV V

K131m Ki3in Kl31o K131qK132m K132n K132o •VVV iU32q

K133m K133n K133oV•Kl34m K134n K134o

K135m K135n K135o

K136m K136n Kl36o

K137m K137n Kl37o

-

K138m K13$n K138o K138p V

Orientation Days K139m K139n K139o K139p V

V

Total July to December (lines K121 through K139) K140pV

Total January to December (lines Ki l0+K120+K140) Ki4ip

K138r

l Ki39rV

K140r

Hq K141r

May 1,2015 Page 16 of 19

I 2014-12-311

MOHLTC Faciliiy# Licensee Name:


Check if no accrual amounts as of December31, 2014

Section 0 - Accrual Report

NURSING AND PERSONAL CARE

Please complete lines 0001 through 0020, as applicable. Do not Opening Payment Current Period Closing Accrual Balance

include any cost related to the administration of employee and union Accrual Settlements in Accrual. . . . . . Balance 2014 (4) = (1)-(2)+(3)

agreements e.g, the cost of conducting union negotiations, arbitration (2) (3)hearings,and pay equity negotiations must be reported in the Other

(1)

Accommodation envelope.

0001 Salaries - Collective Agreement Settlements: 228,258 51,007 279,265

0002 Salaries - Pay Equity (PE): . 0

0003 Salaries - Vacation Pay: 0

0004 Salaries - (Payroll): 0

0005 Total Salaries (Sum of lines 0001 through 0004) $228,258 $0 $51,007

0006 Employee Benefits 45,669 9,452 55121

0007 Other (specify): 0

0008 Other (specify): 00009 TOTAL NURSING AND PERSONAL CARE

(sum of lines 0005 through 0008) $273,927 $0 $60,459 $334,386

DETAILS OF COLLECTIVE AGREEMENT SETTLEMENTS FOR NURSING AND PERSONAL CARE (Line 0001)(A) (B) (C) (D) (E) (F) (C)

Is the settlement arbitrated. Please Enter date of contract Enter expected date of Enter contract Enter the Enter the Enter as a percentage, the

check YES or NO with an “X” settlement, If contract contract settlement (yyyy- settlement name of the accrued settlement/negotiated rate

not settled leave blank mm-dd): expiry date or union: amount: used to determine the

and proceed to column expected accrued amount:

(C) contract

(yyyy-mm-dd): settlement

—

ooiil No

00121 No

100131 No 4JPlease ensure the most recent arbitration settlements are taken into consideration when estimating accruals for expected contract settlements.

DETAILS OF PAYROLL ACCRUALS FOR NURSING AND PERSONAL CARE (Line 0004)Salaries AccrualsExpenditure Line Closing Accrual Description / Details of Accruals

Balance

0014 Unifor, Local 302 - Salary accrual 279,265 Contract Expired June 30, 2012 .0.75% represent an estimat

00150016 Total (sum of lines 0014 through 0015) Column 4 line 0004 is not equal to sum of line 0014 to

$279,265 0015

Employee Benefits AccrualsEmployee Benefits (individual list not required) Closing Accrual Description I Details of Accruals

Balance

Total 55,121 Benefits for salary accrual

Other AccrualsExpenditure Line (specify) Closing Accrual Description / Details of Accruals

Balance

0018

0019

0020 Total (sum of lines 0018 through 0019) $0

OntarioMinisiry of Health and Long-Term Care

Ministére de a Sante et des Soins de longue durée

2014 Long-Term Care Home Annual ReportFor the period from I 201 4-01-01 I to

May 1,2015 Page l7of 19

2014 Long-Term Care Home Annual ReportFor the period from I 2014-01-01 I to


Ministére de is Sante St des Soins de longue durCe

I 2014-12-311

MOHLTC Facility # Licensee Name:



Program and Support ServicesPlease complete lines 0101 through 0120, as applicable. Do not Opening Payment Current Period Closing Accrual Balance

include any cost related to the administration of employee and union Accrual Settlements in Accrual

. . . . . . Balance 2014 (4) = (1)-(2)+(3)agreements e.g. the cost of conducting union negotiations, arbitration(2) (3)

hearings,and pay equity negotiations must be reported in the Other (1)

Accommodation envelope.0101 Salaries - Collective Agreement Settlemenis: 13,115 3,323 16,4380102 Salaries - Pay Equity (PE): 0

0103 Salaries - Vacation Pay: a0104 Salaries - (Payroll): 0

0105 Total Salaries (sum of lines 0101 through 0104) $13,115 :,.‘ $0 $3,323 $16,438

0106 Employee Benefits 2,668 616 3,2840107 Other (specify): 00108 Other (specify): 00109 TOTAL PROGRAM AND SUPPORT SERVICES

(sum of lines 0105 through 0108) $15,783 $0 $3,939 $19,722

DETAILS OF COLLECTIVE AGREEMENT SET11EMENTS FOR PROGRAM AND SUPPORT SERVICES (Line 0101)(A) (B) (C) (D) (0) (F) (G)

is the settlement arbitrated. Please Enter date of contract Enter expected date of Enter contract Enter the name Enter the Enter as a percentage, the

check YES or NO with an X settlement, if contract contract settlement (yyyy- settlement of the union, accrued settlement/negotiated rate

not settled leave blank mm-dd): expiry date or amount: used to determine theand proceed to column expected accrued amount:

(C) contract

(yyyy-mm-dd): settlementexpiry date

______

No :‘:YesIgI No ..‘...

Please ensure the most recent arbitration settlements are taken into consideration when estimating accruals for expected contract settlements.

DETAILS OF PAYROLL ACCRUALS FOR PROGRAM AND SUPPORT SERVICES (Line 0104)Salaries AccrualsExpenditure Line Closing Accrual Description / Details of Accruals

Balance0114 Unifor, Local 302 - Salary accrual 16,438 Contract Expired June 30, 2012 .0.75% represent an estimate01150116 Total (sum of lines 0114 through 0115) Column 4 line 0104 is not equal to sum ot line 0114 to

$16,438 0115

Employee Benefits AccrualsEmployee Benefits (individual list not required) Closing Description / Details of Accruals

Accrual

Total 3,284 Benefits for salary accrual

Other AccrualsExpenditure Line (specify) Closing Description I Details of Accruals

Accrual

01180119

0120 Total (sum of lInes 0118 through 0119) $0

May 1,2015 Page 18 of 19

2014 Long-Term Care Home Annual Report

_______

Fortheperiodfrom 12014-01-Oil to 12014-12-311

MOHLTC Facility # Licensee Name



Other Accommodation - To Be Completed by Red-Circled HomesPlease complete lines 0201 through 0220 , as applicable. Include Opening Payment Current Period Closing Accrual

any cost related to the administration of employee and union Accrual Settlements in Accrual Balance

agreements e.g, the cost of conducting union negotiations, arbitrationBalance 2014 (4) = (1)-(2)+(3)

hearings,and pay equity negotiations must be reported in the OtherAccommodation envelope.

0201 Salaries - Collective Agreement Settlements: 0

0202 Salaries - Pay Equity (PE): 0

0203 Salaries - Vacation Pay: 0

0204 Salaries - (Payroll): 0

0205 Total Salaries (sum of lines 0207 through 0204) $0 $0 $0 $0

0206 Employee Benefits 0

0207 Other (specify): 0

0208 Other (specify): 00209 TOTAL OTHER ACCOMMODATION

(sum of lines 0205 through 0208) $0 $0 $0 $0

DETAILS OF PAYROLL ACCRUALS FOR OTHER ACCOMMODATION (To be completed by red-circled homes) (Line

0204)

Salaries Accruals

102150216 Total (sum of lines 0214 through 0215)

$0

Employee Benefits AccrualsEmployee Benefits (individual list not required) Closing Description I Details of Accruals

Accrual

Jj Total

Other AccrualsExpenditure Line (specify) Closing Description I Details of Accruals

Accrual

0218

0219

0220 Total (sum of lines 0218 through 0219) $0

OntarioMinistry of Health and Long-Term care

Ministère do Ia Sante et des Soins de longue durée

Is the settlement arbitrated. Pleasecheck YES or NO

DETAILS OF COLLECTIVE AGREEMENT SETTLEMENTS FOR OTHER ACCOMMODATION (To be completed by red-circled homes) (Line 0201)

(A) (B) (C) (D) (E) (F) (G)

Enter date of contractsettlement. If contractnot settled leave blankand proceed to column

(C)(yyyy-mm-dd):

Enter expected date ofcontract settlement (yyyy

mm-dd):

Enter the nameof the union:

Enter contractsettlement

expiry date orexpectedcontract

settlementexpiry date

(yyyy-mm-dd):

Enter theaccruedamount:

Enter as apercentage, thesettlemenUneg

otiated rateused to

determine theaccruedamount:

0210 No

0211 No Yes

O2_No

O213l —

I Please ensure the most recent arbitration settlements are takcn into consideration when

Expenditure Line

10214

stimating accruals for expected contract settlements.

ClosingAccrual

Description I Details of Accruals

May 1,2015 Page 19 of 19


Ministére de Ia Sante et des Soins de longue duree

MOHLTC Facility #

H 11483Section p - Notes to the Report

Significant Accounting Principles

Basis of Accounting

Sections A through G, Section I, and Section 0 of the report have been prepared inaccordance with generally accepted accounting principles (GAAP)and applicable legislation, regulations, policies and direr. as.

If there is no trust account, please check here and please explain:

2014 Long-Term Care Home Annual Report_______Forthed2ol4-01-011 to 12014-12-311

Licensee Name

Dearness Home for Senior Citizens

May 1,2015

Ontario

_________

Ministry of Health and Long-Term Care



H11483 Dearness Home for Senior CitizensSection Q - Licensee’s Statement and Approval

The information contained in Sections A through G, Sections I through K, and Sections 0 and P of this Long-TermCare Home Annual Report of (legal name of Licensee)

for the Period from to

__________________was

provided by management.

This Report has been prepared in conformity with the basis or bases of accounting described in , Section P - Notes to the

Report and adheres to the technical instructions and guidelines as provided by the Ministry of Health and Long-Term Care.

The information contained in this report is in accordance with the L-SAA, any direct funding agreement between theMinister and the licensee, and all applicable policies pertaining to the program funding provided to the home for theperiod being submitted.

Sections C thru F of the report excludes expenditures, as applicable, for: the development of new long-term care bedsawarded by the Ministry, the redevelopment of a Category D” Home, and redevelopment of Replacement “B”, “C” andUpgraded “D” beds. Sections C thru F also excludes, as applicable, expenditures funded from the initiatives reported on inSection I: Part A and Part B.

Systems of internal accounting control are maintained in order to assure the reliability of this financial

information. These systems include formal policies and procedures, the careful selection and training of qualified

personnel, and an organization providing for appropriate delegation of authority and segregation of responsibilities.

Approved by the Licensee on the 24th day of , 20 15

_______

PL (c’V ó

LCAJ

______________

(If charitable or municipal corporation, affix corporate seal where Licensee is a municipality or a non-profit corporation. Where the

Licensee is a for profit nursing home provide a witness signature.)

2014 Long-Term Care Home Annual ReportForthe period from 12014-01-011 to I 2014-12-311

September

4Witness

Sandra Datars Bere(Print Licensee’s Name)

By%

NAME: r9(t$4- DrrTh-(5

TITLE:

May 1, 2015

Ontario 2014 Long-Term Care Home Annual ReportMinistry of Health and Long-Term Care For the period from 2014—01—01 I to I 2014-12-31 IMinistére de a Sante et des Soins de longue durée



Independent Auditors’ Report

To the Minister of Health and long-Term Care:

We have audited Sections A through G, Section I, and Section 0 of the accompanying 2014 Long-Term Care Home Annual Report of(legal name of licensee) ‘the

Long-Term Care Home’ for the year ended December31 2014 and a summary of significant accounting policies and other explanatory information (together “theReport’). The Report has been prepared by management of the Long-Term Care Home based on the reporting provisions of the 2014 Long-Term Care AnnualReport Technical Instructions and Guidelines (Technical Instructions and Guidelines) and in accordance with the LHIN Service Accountability Agreement, anydirect funding agreement between the Minister and the Long-Term Care Home, and all applicable policies pertaining to the program funding provided for the yearended December31.

Management’s responsibility for the Report

Management of the Long-Term Care Home is responsible for the preparation of the Report in accordance with the reporting provisions of the 2014 Long-TermCare HomeAnnual ReportTechnical Instructions and Guidelines, and in accordancewith the LHIN ServiceAccountabilityAgreement, anydirectfundingagreement between the Minister and the Long-Term Care Home, all applicable policies pertaining to the program funding provided for the year ended December31, and for such internal control as management of the Long-Term Care Home determines is necessary to enable the preparation of the Report that is free frommaterial misstatement, whether due to fraud or error.

Auditor’s responsibility

Our responsibility is to express an opinion on the Report based on our audit. We conducted our audit in accordance with Canadian Auditing Standards (CAS)under the CPA Canada Standards and Guidance Collection (specifically CAS 200). Those standards require that we comply with ethical requirements and planand perform the audit to obtain reasonable assurance about whether the Report is free from material misstatement.

An audit involves performing procedures to obtain audit evidence about the amounts and disclosures in the Report. The procedures selected depend on theauditor’s judgment, including the assessment of the risks of material misstatement of the Report, whether due to fraud or error. In making those risk assessments,the auditor considers internal control relevant to the Long-Term Care Home’s preparation of the Report in order to design audit procedures that are appropriate inthe circumstances, but not for the purpose of expressing an opinion on the effectiveness of the Long-Term Care Home’s internal control. An audit also includesevaluating the appropriateness of accounting policies used and the reasonableness of accounting estimates made by management, as well as evaluating theoverall presentation of the Report.

We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our audit opinion.

Opinion

In our opinion, Sections A through G, Section I, and Section 0 of the 2014 Long-Term Care Home Annual Report for the year ended December 31, 2014 isprepared, in all material respects, in accordance with the reporting provisions of the 2014 Long-Term Care Home Annual Report Technical Instructions andGuidelines, the LHIN Service Accountability Agreement, any direct funding agreement between the Minister and the Long-Term Care Home, and all applicablepolicies pertaining to the program funding provided for the year ended December31.

Restriction on distribution and use

Without modifying our opinion, we draw attention to Section P of the Report, which describes the basis of accounting. The Report is prepared to enable theMinistry of Health and Long-Term Care, and on behalf of the Local Health Integration Network (LHIN), to calculate the allowable subsidy for the Long-Term CareHome for the January 1, 2014 to December31, 2014 funding period. As a result, the Report may not be suitable for another purpose. Our report is intended solelyfor the directors of the Long-Term Care Home, the Ministry of Health and Long-Term Care, and the LHIN and should not be distributed to or used by parties otherthan the directors of the Long-Term Care Home, the Ministry of Health and Long-Term Care and the LHIN.

Chartered Accountants, Licensed Public Accountants

(place)

(date)

May 1,2015



MOHLTC Facility # Licensee Name

[jj83 Dearness Home for Senior CitizensAppendix A

Auditor’s Report - Statement of Trust Account

To the Minister of Health and Long-Term Care:

We have audited the Statement of Trust Account (Statement of Trust Fund Receipts and Disbursement) of (legal name of Licensee)

for the period from 2014-01-01 to 2014-12-31

prepared in accordance with the Ontario Regulation 79/10 section 241. The Statement is the responsibility of the Home’s management. Ourresponsibility is to express an opinion on the Report based upon our audit.

We conducted our audit in accordance with Canadian Auditing Standards (CAS) under CPA Canada Standards and Guidance Collection (specificallyCAS 200). Those standards require that we plan and perform an audit to obtain reasonable assurance whether the Report is free of materialmisstatement. An audit includes examining, on a test basis, evidence supporting the amounts and disclosures in the Statement. An audit alsoincludes assessing the significant accounting principles used and the significant estimates made by management, as well as evaluating the overallStatement presentation.

In our opinion, Statement of Trust Account (Statement of Trust Fund Receipts and Disbursement) present fairly in all material respects, the position ofthe trust fund at year end and the activity of the funds during the year in accordance with generally accepted accounting principles.

(place)

(date)

Licensed Public Accountant

KPMG

140 Fullarton Street, London , Ontario, P0 BOX

September08 & 09, 2015

2014 Long-Term Care Home Annual ReportForthe period from 12014-01-011 to 2014-12-311

May 1,2015

SCHEDULES OF REVENUES AND EXPENDITURES

CORPORATION OF THE CITY OFLONDON

DEARNESS HOME

For the period from January 1, 2014 to December 31, 2014

KPMG LLP Telephone (519) 672-4880

140 Eu)Iarton Street Suite 1400 Fax t519) 672-5684London ON N6A 5P2 Internet wwwkpmg.ca

Canada

INDEPENDENT AUDITORS’ REPORT

To the Minister of Health and Long-Term Care

We have audited the schedules of revenues and expenditures contained in Sections A through G, Section I

and Section 0 of the Corporation of the City of London Dearness Home Long-Term Care Facility

(Dearness) Annual Report (the Report’) for the period from January 1, 2014 to December 31, 2014. This

Report has been prepared by management in accordance with the reporting provisions of the 2014 Long-

Term Care Annual Report Technical Instructions and Guidelines (the “Technical Instructions and

Guidelines’) which form part of the Report, and in accordance with the Local Health Integration Network

(“LHIN”) Service Accountability Agreement.

Management’s Responsibility for the Schedule

Management is responsible for the preparation of the Report in accordance with the financial reporting

provisions in the Technical Instructions and Guidelines, and for such internal control as management

determines is necessary to enable the preparation of the Report that is free from material misstatement,

whether due to fraud or error.

Auditors’ Responsibility

Our responsibility is to express an opinion on the Report based on our audit, We conducted our audit in

accordance with Canadian generally accepted auditing standards. Those standards require that we comply

with ethical requirements and plan and perform the audit to obtain reasonable assurance about whether the

Report is free from material misstatement.

An audit involves performing procedures to obtain audit evidence about the amounts and disclosures in the

Report The procedures selected depend on our judgment, including the assessment of the risks of material

misstatement of the Report, whether due to fraud or error. In making those risk assessments, we consider

internal control relevant to the entity’s preparation of the Report in order to design audit procedures that are

appropriate in the circumstances, but not for the purpose of expressing an opinion on the effectiveness of

the entity’s internal control. An audit also includes evaluating the appropriateness of accounting policies

used and the reasonableness of accounting estimates made by management, as well as evaluating the

overall presentation of the Report.

We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our

audit opinion.

Opinion

In our opinion, Sections A through G, Section I and Section 0 of the Report present fairly in all material

respects, the revenues and expenditures of the Corporation of the City of London Dearness Home Long

Term Care Facility for the period from January 1, 2014 to December 31, 2014 in accordance with the

Technical Instructions and Guidelines referred to above.

KPMG LLP o a Caoad,ar I,,,oted I,abd,t0 paloershp aod a member lam of the KPMGnetwo,k of ndeeodenl member ems aftliatea wlh KPMG Inte,nasonal Cooperative(KPMG lste,rratiooal”). a Swiss enirty.KPMG Canada proaldes sererces to KPMG LU’

Basis of Accounting and Restriction on Use

Without modifying our opinion, we draw attention to note I to the Report, which describes the basis ofaccounting The Report is prepared, on behalf of the LHIN, to enable the Ministry of Health and Long-Term

Care to calculate the allowable subsidy for Dearness for the January 1 2014 to December 31 2014 fundingperiod. As a result, the Report may not be suitable for another purpose. Our report is intended solely forthe directors of Dearness, the Ministry of Health and Long-Term Care, and the LHIN and should not bedistributed to or used by parties other than the directors of Dearness, the Ministry of Health and Long-TermCare and the LHIN.

a

Chartered Professional Accountants, Licensed Public Accountants

September 18, 2015

London, Canada

DEARNESS HOMENotes to the Report

For period from January 1 2014 to December 31, 2014

1. Basis of accounting:

Revenues and expenditures are reported in accordance with the 2014 Long-Term CareFacility Annual Report Technical Instructions and Guidelines, dated May 1, 2015 as providedby the Ministry of Health and Long-Term Care, using the accrual basis of accounting.

2. Significant accounting policies:

(i) The accrual basis of accounting recognizes revenues as they become available andmeasurable; expenditures are recognized as they are incurred and measurable as aresult of the receipt of goods or services and the creation of a legal obligation to pay.

(ii) Minor capital asset purchases are reported as expenses in the year of acquisition.

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