Ana's ICF/DD-N - Department of Health Care Services - State of ...

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STATE OF CALIFORNIA DDN SCHEDULE 1 Provider: Fiscal Period: ANA'S ICF/DD-N JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 Provider Number: Provider NPI: LTC80150G 1386855856 SUMMARY OF AUDITED FACILITY CENSUS AND AUDITED CLIENT COST PER DAY AS AS REPORTED AUDITED 1. Medi-Cal Client Days (Adj ) 2,196 2,196 2. Other Client Days (Adj ) 0 3. Total Client Days 2,196 2,196 4. Total Client Care Expenses (From Sch. 2) $ 428,862 $ 391,418 5. AVERAGE CLIENT COST PER DAY (Line 4 / Line 3) $ 195.29 $ 178.24 SHARE OF COST 1. Share of Cost Audit Adjustment (Adj ) $ NA $ 0 OVERPAYMENTS SUMMARY OF AUDITED FACILITY CENSUS AND AUDITED CLIENT COST PER DAY 1. Duplicate Payments (Adj ) $ $ 0 2. Credit Balances (Adj ) $ $ 0 3. Total Overpayments $ 0 $ 0
STATE OF CALIFORNIA DDN SCHEDULE 2 Provider: Fiscal Period: ANA'S ICF/DD-N JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 Provider Number: Provider NPI: LTC80150G 1386855856 Line ADJ No. DESCRIPTION NO. EXPENSES: CLIENT SERVICES Basic Facility Cost - Property Expenses 045 Depreciation and Amortization 1 $ 14,534 (10,993) $ 3,541 050 Leases and Rentals 0 055 Real Property Taxes 2 6,078 (225) 5,853 060 Personal Property Taxes 0 065 Mortgage Interest 3 57,487 (23,173) 34,314 070 Property Insurance 1,308 0 1,308 075 TOTAL PROPERTY EXPENSES (Lines 045 through 070) $ 79,407 $ (34,391) $ 45,016 Basic Facility Cost - General Home Expenses 080 Home Operations and Maintenance $ 10,106 $ 0 $ 10,106 085 Utilities 9,034 0 9,034 090 Client Transportation 5 3,419 (1,710) 1,709 095 Dietary 8,598 0 8,598 100 Personal Care and Laundry 3,306 0 3,306 105 TOTAL GENERAL HOME EXPENSES (Lines 080 through 100) $ 34,463 $ (1,710) $ 32,753 110 TOTAL BASIC FACILITY COST (Lines 075 plus 105) $ 113,870 $ (36,101) $ 77,769 EXPENSES: DIRECT CARE STAFF COSTS SUMMARY OF AUDITED FACILITY EXPENSES AS REPORTED AUDIT ADJUSTMENT AS AUDITED 115 QMRP Salaries $ 18,741 $ 0 $ 18,741 120 QMRP Fringe Benefits 4,743 0 4,743 125 Lead Salaries 83,432 0 83,432 130 Lead Fringe Benefits 14,743 0 14,743 135 Aides Salaries 70,779 0 70,779 140 Aides Fringe Benefits 11,088 0 11,088 145 Other Salaries 0 150 Other Fringe Benefits 0 155 TOTAL DIRECT CARE STAFF COSTS (Lines 115 through 150) $ 203,526 $ 0 $ 203,526 Page 1 of 2
Page 1 and 2: Section Chief: Louise Wong Audit Su
Page 3: Ursula Pagador Page 2 Notwithstandi
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Ana's ICF/DD-N - Department of Health Care Services - State of ...

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