State of California Health and Human Services Department of Health Care Services STATE OF CALIFOR by fnc27840

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									State of California - Health and Human Services                                                       Department of Health Care Services




                                      STATE OF CALIFORNIA
                               DEPARTMENT OF HEALTH CARE SERVICES
                                         COST REPORT
                                               for
                                                  ADULT DAY HEALTH CARE



        Legal Name of ADHC Center:
                                                              Just Faith for Healthy Living
                      (as it appears on State License)


                                                                      doing business as


   Business Name of ADHC Center:
                                                         <Enter Business Name of ADHC Center>


       National Provider Identification:                                 9999999991


                           Provider Number:                           ADU123456F



                            Reporting Period From:            7/1/2005      To:    6/30/2006


                             E-mail Address:                    JustinFaith@yahoo.com
                         must be the same e-mail address approved by DHCS to file cost report electronically
                                                   X      Check this box if filing electronically




         DHCS 9089 (Rev. 01.12.2010)
State of California - Health and Human Services                                                                                   Department of Health Care Services

                                                 ADULT DAY HEALTH CARE CENTER
                                                         COST REPORT
                                             GENERAL INFORMATION AND CERTIFICATION
1. Legal Name of ADHC Center (as noted on State License)                                  2. National Provider ID (NPI)      3. Provider Number
                          Just Faith for Healthy Living                                            9999999991                              ADU123456F
4. Service Street Address                              5. City                            6. County                          7. Zip Code (Nine Digits)
        3240 EAST ADAM STREET, SUITE 240                     LOS ANGELES                                                                    90109-1050
8. Administrator Name                                                                                                        9. Telephone Number
                                                 JUSTIN FAITH                                                                              323 832-5225
10. Report Contact Person                                                                                                    11. Contact Person Telephone Number
                                                  FIRST ADAM                                                                               310 719-1027
12. E-mail Address (of ADHC Center Contact Person)                                        13. ADHC Center Fax No.            14.
                                                                                                                                          For Future Use
15. Reporting Period Began                                                 16. Reporting Period End
                              7/1/2005                                                                                6/30/2006
17. Name of Home Office (if applicable)                                                                                      18. Home Office Phone Number
                                                           NONE

19.

Intentional misrepresentation or falsification of any information contained in this request resulting in reimbursement by the Department may be punishable by
fine and/or imprisonment under federal and state laws. (42 CFR 1003.102 "Basis for Civil Money Penalties and Assessments", 18 U.S.C 1347 "Health Care
Fraud", California Welfare and Institutions Code 14123.25 "Civil Penalties for Fraudulent Claims", and Title 22 of the California Code of Regulations 51485.1
"Civil Money Penalties")

Certification by Officer or Administrator of the Adult Daycare Health Center (ADHC)

I, __________________________________________               , certify under penalty of perjury as follows:

That I am the responsible person of the subject ADHC and am duly authorized to sign this certification and that to the best of my knowledge and information, I
believe each statement and amount in the accompanying report to be true, correct, and in compliance with Section 14161 of the California Welfare and
Institutions Code.

Officer or Administrator of ADHC

Print Name:                                  JUSTIN FAITH                                            Title:                     ADMINISTRATOR

Signature:                                                                                          Date:

Please be advised that continued submission of claims or cost reports for items or services which were not provided as claimed are not reimbursable under
the Medi-Cal program, or claimed in violation of an agreement with the State, may subject you (your organization) to civil money penalty assessment in
accordance with the Welfare and Institutions Code, Section 14123.2.

20. Mail the original and one (1) copy to:

                                               U.S. Mail                                                               FedEx, UPS, etc.
                             California Department of Health Care Services                                    California Department of Health Care Services
                             Audits and Investigations                                                        Audits and Investigations
                             Audit Review and Analysis Section                                                Audit Review and Analysis Section
                             1500 Capitol Avenue, MS 2100                                                     1500 Capitol Avenue, MS 2100
                             P.O. Box 997413                                                                  Sacramento, CA 95814
                             Sacramento, CA 95899-7413
                             (916) 650-6696

                                                  ELECTRONIC SUBMISSION OF ANNUAL COST REPORTS
                                     Electronic Filings should be e-mailed to: adhccr@dhcs.ca.gov
                           Please note that the e-mail address noted above is for Cost Report Submission Only!

      An approved application must be on file with DHCS in order to file Annual Cost Reports electronically. If you do not have an approved
          "Application and Agreement For Electronic Submission of Annual Cost Reports" on file with DHCS, please visit our website at
                                   http://www.dhcs.ca.gov/individuals/Pages/AdultDayHealthCare.aspx
                                        NOTE: A COMPLETED REPORT IS REQUIRED FOR EACH LICENSED ADHC




           DHCS 9089 (Rev. 01.12.2010)                                                                                                    General Information
State of California - Health and Human Services                                                                                  Department of Health Care Services

Legal Name of Facility:                                                                 National Provider ID           Provider Number:
                            Just Faith for Healthy Living                                       9999999991                            ADU123456F
                                                                                                                                          FPE:            6/30/2006
                                                    SECTION A - SERVICES AVAILABLE

  1    Did you provide any of the separately billable services for the cost report period? If yes, please check the
       appropriate type of service box.
       Does the center provide enhanced program services? If yes, please check the appropriate enhanced
  2
       program service box.


                                                                 Separately Billable Services

       Occupational Therapy Services                                                                                                          X
       Physical Therapy Services                                                                                                              X
       Mental Health Therapy Services                                                                                                         X
       Speech and Language Pathology Services                                                                                                 X
       Registered Dietician Services                                                                                                          X
       Transportation Services                                                                                                                X



                                                         Non-ADHC / Enhanced Program Services

       Adult Day Care Program                                                                                                                 X
       Alzheimer's Day Care Resource Center (if licensed separately)                                                                          X
       Other (Specify)




                                                  SECTION B - LICENSEE DESCRIPTION

                                  Type of Control                                                                     Legal Organization
Church Related Not-For-Profit                                                 x         Corporation
Other Not-For-Profit                                                                    Division of a Corporation
Investor Owned For Profit                                                               Partnership
Owner/Operator For-Profit                                                               Proprietorship
Other (Specify)                                                                         Government (specify)
                                                                                        Limited Liability Company
                                                                                        Other (specify)



                                                    SECTION C - ADHC CENTER CENSUS

                                                              Statistics                                                              1               2               3
Line                                                                                                                                              Non Medi-
                                                                                                                                   Medi-Cal                      Total
                                                                                                                                                     Cal

  1     Licensed Capacity                                                                                                                                                 75
  2     Days of Operation (total for the year)                                                                                                                            254
  3                                               This line intentionally left blank.
  4     Participant Days (include all Participant Days, Assessment Days, and Transition Days)                                        13,845          1,585       15,430
  5     Participant Initial Assessment Days                                                                                           1,580          1,050            2,630
  6     Average Daily Attendance (Line 4, Col. 3 / Line 2, Col. 3)                                                                                                        61
  7    Percent Medi-Cal Participant Days (Line 4, Col. 1 / Line 4, Col. 3)                                                                                                90%




           DHCS 9089 (Rev. 01.12.2010)                                                                                                                          Sections A, B, C
State of California - Health and Human Services                                                                                      Department of Health Care Services

Legal Name of Facility:                                                                           National Provider ID                Provider Number:
                                 Just Faith for Healthy Living                                              9999999991                          ADU123456F
                                                                                                                                                 FPE:     6/30/2006
                    SECTION D - SEPARATELY BILLABLE SERVICES UTILIZATION

                                                                                                                    Total Units of
        Line                                                   Statistics
                                                                                                                       Service
          1     Occupational Therapy Services                                                                             11,050
          2     Physical Therapy Services                                                                                 10,240
          3     Mental Health Therapy Services                                                                             7,852
          4     Speech and Language Pathology Services                                                                    11,467
          5     Registered Dietician Services                                                                             10,754
          6     Transportation Services                                                                                   24,500



                                        SECTION E - STATEMENT OF RELATED ORGANIZATIONS

1. Is the facility part of a chain organization? (If yes, please provide the information below)
2. If yes to question 1, did the facility file a Home office Cost Report?


                                                                                                                                                         Percent of
                                                         Home Office or Related Organization
                                                                                                                                                         Ownership

                                                                             N/A




                                 Please see instructions for further discussion of Related Organizations and Shared Services.



                       SECTION F - STATEMENT OF COMPENSATION TO OWNERS (For Profit Only)

                                                                                                                                               Compensation
                                                                                                  Average Hours       Average
                                                                                     Owners
                                           Title and Function (only if                             Worked per          Hours
         Name of Owners                                                            Investment                                          Current Fiscal    Prior Fiscal
                                              employed by Facility)                               Month Devoted      Worked per
                                                                                   Percentage                                              Year              Year
                                                                                                    to Facilty         Month


                 N/A




           DHCS 9089 (Rev. 01.12.2010)                                                                                                         Sections D, E, F
State of California - Health and Human Services                                                    Department of Health Care Services

Legal Name of Facility:                                         National Provider ID                           Provider Number:
                          Just Faith for Healthy Living                          9999999991                         ADU123456F
                                                                                                        FPE:         6/30/2006
                                SECTION G - REVENUE INFORMATION / FUNDING SOURCES

                                                                           1                   2                         3

                              Source of Revenue                   Gross Revenue /        Deductions or             Net Revenue
                                                                  Funding Source          Allowances
                                                                                                                  (Col. 1 - Col. 2)
Medi-Cal                                                                       468,785                 6,500                  462,285
Third Party Payors:
- Private Pay / Insurance (Commercial, Worker's Comp)                           84,261               25,411                    58,850
- Government (Veteran's Admin, Managed Care, Regional Center)
- Tribal Health
Government Funded Grants:
- Adult Day Care Food Program                                                   32,508                                         32,508
- Alzheimer's Day Care Resource Center                                          68,070                                         68,070
- Other Government Grants
Non-Government Funded Grants
In-Kind                                                                        170,000                                        170,000
Cash, Gifts, Donations
Title III (AoA)
Other Operating Revenues (specify)




                              TOTAL REVENUES                                   823,624               31,911                   791,713




           DHCS 9089 (Rev. 01.12.2010)                                                                                    Section G
State of California - Health and Human Services                                                                                                                                                                               Department of Health Care Services

Legal Name of Facility:                                                                                                                                            National Provider ID                              Provider Number:
                                                                Just Faith for Healthy Living                                                                                     9999999991                                        ADU123456F
                                                                                                                                                                                                                                     FPE:        6/30/2006

                                                                                             SECTION H - SUMMARY OF COSTS
                                                                  1                     2                  3                     4                 5                        6                         7                       8                      9
 C/R Line                                                                  Employees
                                  Cost Center                                                                           Total Compensation                             Total Costs               Reclasses              Adjustments             Net Costs
   No.                                                                                               Contract Staff                               Other
                                                                                                                                                                                             (From Sect. J-1, Col.   (From Sect. J-2, Col.
                                                               Salaries           Fringe Benefits                        (Sum Cols. 1 to 3)                          (Col. 4 + Col. 5)                                                        Sum (Cols. 6 -8)
                                                                                                                                                                                                     6)                      1)
                         ADMINISTRATIVE & GENERAL
     1       Depreciation - Building & Equipment                                                                                              -           15,000                 15,000                                                                   15,000
     2       Leases and Rentals                                                                                                               -            6,500                  6,500                                              (500)                   6,000
     3       Amortization                                                                                                                     -           25,000                 25,000                                                                   25,000
     4       Mortgage Interest                                                                                                                -           14,560                 14,560                                                                   14,560
     5       Real Property Taxes                                                                                                              -            3,850                  3,850                                              350                     4,200
     6       Other Property Taxes                                                                                                             -             650                      650                                                                      650
     7       Property Insurance                                                                                                               -            7,500                  7,500                                                                      7,500
     8       Repair and Maintenance                                    22,650                2,050                                    24,700                                     24,700                                                                   24,700
     9       Utilities                                                                                                                        -            3,250                  3,250                                                                      3,250
     10      Housekeeping                                              22,650                2,050                                    24,700                                     24,700                                                                   24,700
     11
     12      Administrator                                                3,500              3,460                                     6,960                                      6,960                                                                      6,960
     13      Executive Director                                        45,000                3,750                                    48,750                                     48,750                                                                   48,750
     14      Office Manager                                            28,341                2,310                                    30,651                                     30,651                                                                   30,651
     15      Accounting                                                24,150                1,830                                    25,980                                     25,980                                                                   25,980
     16      Billing Clerk                                             23,752               12,789                                    36,541                                     36,541                                                                   36,541
     17      Human Resource Expenses                                   20,350                1,250                                    21,600                                     21,600                                                                   21,600
     18      Workers Compensation Insurance                            34,650                3,150                                    37,800                                     37,800                                             4,100                 41,900
     19      Office Supplies and Equipment                                                                     24,500                 24,500                                     24,500                                                                   24,500
     20      Program Supplies and Equipment                                                                                                   -                                          -                                                                       -
     21      Postage and Freight Expenses                                                                                                     -             950                      950                                                                      950
     22      Taxes and Licenses (other than real estate)                                                                                      -           35,670                 35,670                                                                   35,670
     23      Interest Other (Specify)                                                                                                         -                                          -                                                                       -
     24      General & Liability Insurance                                                                                                    -            1,350                  1,350                                                                      1,350
     25      Travel/Conference Expenses                                                                                                       -            6,250                  6,250                                                                      6,250
     26      Administration Expenses                                                                                                          -            1,840                  1,840                                                                      1,840
             Home Office Costs (from Home Office cost report
     27                                                                                                                                       -                                          -                                        152,475                152,475
             Schedule 5)
     28      Other (Specify)                                                                                                                  -                                          -                                                                       -
     29                                                                                                                                       -                                          -                                                                       -
     30                                                                                                                                       -                                          -                                                                       -
     31                                                                                                                                       -                                          -                                                                       -
     32                                                                                                                                       -                                          -                                                                       -
     33                                                                                                                                       -                                          -                                                                       -
     34                                                                                                                                       -                                          -                                                                       -
     35                                                                                                                                       -                                          -                                                                       -
     36                                                                                                                                       -                                          -                                                                       -

     39            TOTAL ADMINISTRATIVE & GENERAL                     225,043               32,639             24,500                282,182           122,370                  404,552                         -                 156,425                560,977

Line 11 intentially left blank. Lines 37 thru 38 omitted for future.
             DHCS 9089 (Rev. 01.12.2010)                                                                                                                                                                                                Section H, Page 1 of 3
State of California - Health and Human Services                                                                                                                                                                                               Department of Health Care Services

Legal Name of Facility:                                                                                                                                                         National Provider ID                                 Provider Number:
                                                            Just Faith for Healthy Living                                                                                                        9999999991                                         ADU123456F
                                                                                                                                                                                                                                                     FPE:           6/30/2006

                                                                                             SECTION H - SUMMARY OF COSTS
                                                              1                         2                      3                          4                     5                          6                         7                        8                          9
 C/R Line                                                              Employees
                                  Cost Center                                                                                 Total Compensation                                     Total Costs                Reclasses                Adjustments                Net Costs
   No.                                                                                                   Contract Staff                                        Other
                                                                                                                                                                                                            (From Sect. J-1, Col.    (From Sect. J-2, Col.
                                                           Salaries               Fringe Benefits                                 (Sum Cols. 1 to 3)                                (Col. 4 + Col. 5)                                                             Sum (Cols. 6 -8)
                                                                                                                                                                                                                    6)                       1)
                          ADHC CORE SERVICES
     40      Registered Nurse(s)                       $           19,477     $              8,121                            $                27,598                           $               27,598                                                        $               27,598
     41      Licensed Vocational Nurse(s)              $           14,677     $             22,365                            $                37,042                           $               37,042                                                        $               37,042
     42      Certified Nurses Aides                    $              8,166   $             14,397                            $                22,563                           $               22,563                                                        $               22,563
     43      Nurse Practitioner                        $           17,934     $              3,485                            $                21,419                           $               21,419                                                        $               21,419
     44      Other (Specify)                                                                                                  $                   -        $           25,000   $               25,000                                                        $               25,000
     45      Total Nursing Services                    $           60,254     $             48,368   $                -       $               108,622      $           25,000   $              133,622      $                -       $                -       $              133,622
     46      Social Worker                             $           16,000     $              4,530                            $                20,530                           $               20,530                                                        $               20,530
     47      Social Worker Assistant                   $           12,350     $              3,456                            $                15,806                           $               15,806                                                        $               15,806
     48      Other (Specify)                                                                                                  $                   -        $            2,222   $                2,222                                                        $                 2,222
     49      Total Social Worker Services              $           28,350     $              7,986   $                -       $                36,336      $            2,222   $               38,558      $                -       $                -       $               38,558
     50      Therapeutic Activity Director             $           12,000     $              8,156                            $                20,156                           $               20,156                                                        $               20,156
     51      Therapeutic Activity Assistant                           4,000                  5,555                                              9,555                                            9,555                                                                          9,555
     52      Other (Specify)                                                                                                                           -                                                -                                                                            -

     53      Total Therapeutic Activity Services                   16,000                   13,711                        -                    29,711                       -                   29,711                           -                        -                   29,711

     54      Program Aide(s)                                       34,222                    7,222                                             41,444                                           41,444                                                                        41,444
     55      Licensed Occupational Therapist                       33,000                    3,745                                             36,745                       -                   36,745                   (21,697)                                             15,048
     56      Occupational Therapy Assistant                        43,000                    3,400                                             46,400                       -                   46,400                   (25,931)                                             20,469

     57      Total Occupational Therapy Services                   76,000                    7,145                        -                    83,145                       -                   83,145                   (47,628)                         -                   35,517

     58      Licensed Physical Therapist                           33,000                    3,745                                             36,745                       -                   36,745                   (25,619)                                             11,126
     59      Physical Therapy Assistant                            30,000                    2,514                                             32,514                       -                   32,514                   (20,714)                                             11,800
     60       Total Physical Therapy Services                      63,000                    6,259                        -                    69,259                       -                   69,259                   (46,333)                         -                   22,926
     61      Licensed Psychiatrist                                 33,560                    3,185                                             36,745                                           36,745                   (21,967)                                             14,778
     62      Licensed Psychologist                                 33,560                    3,185                                             36,745                                           36,745                   (23,517)                                             13,228
     63      Licensed Clinical Social Worker                                                                                                           -                                                -                                                                            -
     64      Advanced Practice Registered Nurse                                                                                                        -                                                -                                                                            -

     65      Psychiatric/Psychological Assistant                   30,120                    2,230                                             32,350                                           32,350                   (19,410)                                             12,940

             Licensed Marriage, Family and Child
     66      Counselor/Licensed Marriage and Family                20,560                    1,575                                             22,135                                           22,135                   (13,091)                                               9,044
             Therapist
     67      Certified Rehabilitation Counselor                    20,560                    1,575                                             22,135                                           22,135                   (12,838)                                               9,297

     68      Associate Clinical Social Worker                                                                                                          -

     69      Total Mental Health Services                         138,360                   11,750                        -                   150,110                       -                  150,110                   (90,823)                         -                   59,287
     70      Speech and Language Pathologist                       33,560                    3,185                                             36,745                                           36,745                   (19,466)                                             17,279

     71      Speech & Language Pathologist Assistant               20,456                    1,870                                             22,326                                           22,326                   (14,385)                                               7,941

     72      Total Speech & Language Path Services                 54,016                    5,055                        -                    59,071                       -                   59,071                   (33,851)                         -                   25,220




             DHCS 9089 (Rev. 01.12.2010)                                                                                                                                                                                                                  Section H, Page 2 of 3
State of California - Health and Human Services                                                                                                                                                                                                    Department of Health Care Services

Legal Name of Facility:                                                                                                                                                                National Provider ID                               Provider Number:
                                                                           Just Faith for Healthy Living                                                                                              9999999991                                         ADU123456F
                                                                                                                                                                                                                                                          FPE:        6/30/2006

                                                                                                           SECTION H - SUMMARY OF COSTS
                                                                             1                       2                      3                      4                   5                        6                         7                        8                      9
 C/R Line                                                                             Employees
                                 Cost Center                                                                                              Total Compensation                               Total Costs               Reclasses               Adjustments             Net Costs
   No.                                                                                                               Contract Staff                                   Other
                                                                                                                                                                                                                 (From Sect. J-1, Col.    (From Sect. J-2, Col.
                                                                          Salaries           Fringe Benefits                               (Sum Cols. 1 to 3)                            (Col. 4 + Col. 5)                                                         Sum (Cols. 6 -8)
                                                                                                                                                                                                                         6)                       1)
     73      Registered Dietitian Labor                                           45,000                   1,500                                        46,500                                       46,500                    (31,937)                                         14,563
     74      Nutrition (Food Supplies)                                                                                           4,560                   4,560             113,500                  118,060                                                                    118,060
     75      Other (Specify)                                                                                                                                    -                                            -                                                                        -
     76      Total Registered Dietitian Services                                  45,000                   1,500                 4,560                  51,060             113,500                  164,560                    (31,937)                      -                 132,623
     77      Transportation Labor                                                    1,850                 1,850                25,600                  29,300                                       29,300
     78      Vehicle Repairs and Maintenances                                        4,575                 4,575                                         9,150                 6,500                 15,650
     79      Transportation Lease                                                                                                                               -                                            -
     80      Transportation Vouchers                                                                                                                            -              1,050                  1,050
     81      Transportation Contracted                                                                                                                          -                                            -
     82      Vehicle Insurance                                                                                                                                  -              1,525                  1,525
     83      License Fees                                                                                                                                       -              1,025                  1,025
     84      Depreciation - Vehicle                                                                                                                             -              2,385                  2,385
     85      Other (Specify)                                                                                                                                    -                                            -
     86      Total Transportation Services                                           6,425                 6,425                25,600                  38,450                12,485                 50,935                    (46,740)                      -                    4,195
     87      Program Director                                                                                                                                   -                                            -                                                                        -
     88      Staff Physician                                                                                                                                    -                                            -                                                                        -
     89      Pharmacist                                                                                                                                         -                                            -                                                                        -
     90                   Total ADHC CORE SERVICES                               521,627                 115,421                30,160                 667,208             153,207                  820,415                   (297,312)                      -                 523,103
                    SEPARATELY BILLABLE SERVICES

     91      Separately Billable Occupational Therapy Services                                                                                                                                                                 50,128                                           50,128

     92      Separately Billable Physical Therapy Services                                                                                                                                                                     43,833                                           43,833

     93      Separately Billable Mental Health Services                                                                                                                                                                        90,823                                           90,823
             Separately Billable Speech and Language
     94                                                                                                                                                                                                                        33,851                                           33,851
             Pathology Services

     95      Separately Billable Registered Dietitian Services                                                                                                                                                                 31,937                                           31,937

     96      Separately Billable Transportation Services                                                                                                                                                                       46,740                                           46,740
     97              Total Separately Billable Services                                                                                                                                                                       297,312                        -                 297,312

     98          Non-ADHC / Enhanced Program Services

     99      Adult Day Care Program                                                                                                                             -                                            -                                                                        -
    100      Alzheimer's Daycare Resource Center                                                                                                                -                                            -                                                                        -
    101      Other (Specify)                                                                                                                                    -                                            -                                                                        -
    102                                                                                                                                                         -                                            -                                                                        -

    103       Total Non-ADHC / Enhanced Program Services                                 -                     -                      -                         -                  -                         -                       -                       -                        -

    104                   TOTAL CENTER EXPENSES                                  746,670                 148,060                54,660                 949,390             275,577               1,224,967                           -                 156,425                1,381,392


* Transfer total compensation amounts from Section H, lines 55 through 86, Col. 4 to Section I, Col. 4 for the appropriate lines identified as "total compensation"




             DHCS 9089 (Rev. 01.12.2010)                                                                                                                                                                                                                     Section H, Page 3 of 3
State of California - Health and Human Services                                                                           Department of Health Care Services

Legal Name of Facility:                                                                     National Provider ID          Provider Number:
                               Just Faith for Healthy Living                                          9999999991                       ADU123456F
                                                                                                                                        FPE:      6/30/2006
                           SECTION I - ALLOCATION OF SEPARATELY BILLABLE SERVICES COST

                                                                                  1               2                3              4                   5
                                                                                                                                                 Cost of
                                                                                                                                               Separately
                                                                                             Separately      Separately
                                                                                                                          Total Cost to be Billable Svcs
C/R Line                                                                     Total Hours      Billable        Billable
                                    COST CENTER                                                                           Allocated (From Col. 4 x Col. 3
  No.                                                                          / Trips        Hours /       Percentage
                                                                                                                           Sect. H, Col. 6)   (Forward to
                                                                                               Trips        Col. 2/Col. 1
                                                                                                                                            Sect. J-1, Cols. 3
                                                                                                                                                   & 6)
   55      Licensed Occupational Therapist                                            840             496       59%       $           36,745               21,697
   56      Occupational Therapist Assistant                                       1,020               625       61%                   46,400               28,431
   57      Total Occupational Therapy Services                                                                            $           83,145               50,128


   58      Licensed Physical Therapist                                            1,255               875       70%       $           36,745               25,619
   59      Physical Therapy Assistant                                             1,080               605       56%                   32,514               18,214
   60      Total Physical Therapy Services                                                                                $           69,259               43,833


   61      Licensed Psychiatrist                                                      460             275       60%       $           36,745               21,967
   62      Licensed Psychologist                                                      125              80       64%                   36,745               23,517
   63      Licensed Clinical Social Worker                                                                                                 -
   64      Advanced Practice Registered Nurse                                                                                              -
   65      Recognized Psychiatric/Psychological Assistant                             225             135       60%                   32,350               19,410
           Licensed Marriage, Family and Child Counselor/Licensed Marriage
   66                                                                                 350             207       59%                   22,135               13,091
           and Family Therapist
   67      Certified Rehabilitation Counselor                                         250             145       58%                   22,135               12,838
   68      Recognized Associate Clinical Social Worker                                                                                     -
   69      Total Mental Health Services                                                                                   $       150,110                  90,823


   70      Speech and Language Pathologist                                        1,025               543       53%       $           36,745               19,466
   71      Speech and Language Pathologist Assistant                                  970             625       64%                   22,326               14,385
   72      Total Speech and Language Pathology Services                                                                   $           59,071               33,851


   73      Registered Dietitian Labor                                             1,820            1,250        69%       $           46,500               31,937
   76      Total Registered Dietician Services                                                                            $           46,500               31,937


   86      Total Transportation Services                                         26,699          24,500         92%       $           50,935               46,740




           DHCS 9089 (Rev. 01.12.2010)                                                                                                         Section I
State of California - Health and Human Services                                                                                                                                                         Department of Health Care Services

Legal Name of Facility:                                                                                                                       National Provider ID                                              Provider Number:
                                                         Just Faith for Healthy Living                                                                                    9999999991                                    ADU123456F
                                                                                                                                                                                                                  FPE:                 6/30/06

                                                                               SECTION J-1 - RECLASSIFICATION OF EXPENSES


                                                                                                    INCREASE                                                                            DECREASE
 Line                                                                                                               C/R                                                                                          C/R
                      EXPLANATION OF ENTRY                                          Cost Center                                Amount                                     Cost Center                                         Amount
 No.                                                                                                                Line                                                                                         Line
                                                                                          1                           2          3*                                            4                                   5             6*
   1    Reclassify Separately Billable Services        Separately Billable Occupational Therapy Services            91                50,128 Licensed Occupational Therapist                                      55               (21,697)
   2    Reclassify Separately Billable Services                                                                                              Occupational Therapist Assistant                                     56               (28,431)
   3    Reclassify Separately Billable Services        Separately Billable Physical Therapy Services                92                43,833 Licensed Physical Therapist                                          58               (25,619)
   4    Reclassify Separately Billable Services                                                                                              Physical Therapy Assistant                                           59               (18,214)
   5    Reclassify Separately Billable Services        Separately Billable Mental Health Services                   93                90,823 Licensed Psychiatrist                                                61               (21,967)
   6    Reclassify Separately Billable Services                                                                                              Licensed Psychologist                                                62               (23,517)
   7    Reclassify Separately Billable Services                                                                                              Licensed Clinical Social Worker                                      63
   8    Reclassify Separately Billable Services                                                                                              Advanced Practice Registered Nurse                                   64
   9    Reclassify Separately Billable Services                                                                                              Recognized Psychiatric/Psychological Assistant                       65               (19,410)
                                                                                                                                             Licensed Marriage, Family and Child Counselor/Licensed Marriage
  10    Reclassify Separately Billable Services                                                                                                                                                                   66               (13,091)
                                                                                                                                             and Family Therapist
  11    Reclassify Separately Billable Services                                                                                              Certified Rehabilitation Counselor                                   67               (12,838)
  12    Reclassify Separately Billable Services                                                                                              Recognized Associate Clinical Social Worker                          68
  13    Reclassify Separately Billable Services        Separately Billable Speech and Language Pathology Services   94                33,851 Speech and Language Pathologist                                      70               (19,466)
  14    Reclassify Separately Billable Services                                                                                              Speech and Language Pathologist Assistant                            71               (14,385)
  15    Reclassify Separately Billable Services        Separately Billable Registered Dietitian Services            95                31,937 Registered Dietician Labor                                           73               (31,937)
  16    Reclassify Separately Billable Services        Separately Billable Transportation Services                  96                46,740 Transportation Services                                              86               (46,740)
  17
  18    Reclassify OTA to PTA salaries                 Occupational Therapist Assistant                             56     $           2,500 Physical Therapy Assistant                                           59     $             (2,500)
  19
  20
  21
  22
  23
  24
  25
  26
  27
  28
  29
  30
  31
  32
  33
  34

        Total Reclassifications
  35                                                                                                                       $      299,813                                                                                $       (299,813)
        (Sum of column 4 must equal sum of column 7)




                 Important Reminder: All amounts from Columns 3 and 6 MUST BE
                             manually input into Section H, Column 7.
            DHCS 9089 (Rev. 01.12.2010)                                                                                                                                                                                  Section J-1
State of California - Health and Human Services                                                                Department of Health Care Services

Legal Name of Facility:                                                       National Provider ID                 Provider Number:
                           Just Faith for Healthy Living                                  9999999991                         ADU123456F
                                                                                                                      FPE:         6/30/2006

                                      SECTION J-2 - ADJUSTMENTS TO EXPENSES

                                                                 1                 2                                  3
Line No.                          Cost Center                                  C/R Line
                                                               Amount                                     Adjustment Explanation
                                                                                 No.
    1       Leases and Rentals                             $          (500)        2       Eliminate rental expense not related to patient care
    2       Real Property Taxes                            $          350          5       To include prop tax assessment rec'd late
    3       Home Office Costs                              $     152,475           27      To include allocation of Home Office costs
    4       Worker's Compensation Insurance                $         4,100         18      To true-up losses
    5
    6
    7
    8
    9
    10
    11
    12
    13
    14
    15
    16
    17
    18
    19
    20
    21
    22
    23
    24
    25
    26
    27
    28
    29
    30

    31      TOTAL                                          $     156,425




         Important Reminder: All amounts from Column 1
        MUST BE manually input into Section H, Column 8.


           DHCS 9089 (Rev. 01.12.2010)                                                                                            Section J-2
State of California - Health and Human Services                                                                                    Department of Health Care Services

Legal Name of Facility:                                                                          National Provider ID                  Provider Number:
                                           Just Faith for Healthy Living                                      9999999991                        ADU123456F
                                                                                                                                              FPE:         6/30/2006

                                             SECTION K - ALLOCATION OF ADMINISTRATIVE OVERHEAD


                                                                                   1                      2                        3                           4
                                                                           Total Cost prior to
C/R Line                                                                                                                     Allocation of
                                              Cost Center                     Allocation of        Percentage of
  No.                                                                                                                                                     Total Costs
                                                                            Administrative &        Total Costs         Administrative & General
                                                                                 General
                                                                           From Sect. H, Col 9                                                             To Sch L
                                          ADHC Core Services
    90     Total ADHC Core Services                                                    523,103        63.76077961%                         357,683                 880,786

                                       Separately Billable Services
    91     Separately Billable Occupational Therapy Services                            50,128         6.11007844%                          34,276                  84,404
    92     Separately Billable Physical Therapy Services                                43,833         5.34278384%                          29,972                  73,805
    93     Separately Billable Mental Health Services                                   90,823        11.07037292%                          62,102                 152,925
    94     Separately Billable Speech and Language Pathology Services                   33,851         4.12608253%                          23,146                  56,997
    95     Separately Billable Registered Dietitian Services                            31,937         3.89278597%                          21,838                  53,775
    96     Separately Billable Transportation Services                                  46,740         5.69711670%                          31,960                  78,700

                              Non-ADHC / Enhanced Program Services
    99     Adult Day Care Program                                                            -
   100     Alzheimer's Daycare Resource Center                                               -
   101     Other (Specify)                                                                   -
                                                                                             -
   104     Totals                                                                      820,415      100.00000000%                          560,977            1,381,392




         DHCS 9089 (Rev. 01.12.2010)                                                                                                                                         Section K
State of California - Health and Human Services                                                                Department of Health Care Services


Legal Name of Facility:                                                                 National Provider ID       Provider Number:

                           Just Faith for Healthy Living                                          9999999991               ADU123456F

                                                                                                                            FPE:      6/30/2006

                  SECTION L - DETERMINATION OF AVERAGE COST PER UNIT OF SERVICE


                                                     Computation of ADHC Core Cost Per Day

    1      Total ADHC Core Services Cost (Section K, Part A, C/R line 90, col 4)                                                         880,786

    2      Total ADHC Participant Days (Section C, line 4, Col 3)                                                                         15,430

    3      ADHC Average Core Cost Per Day (line 1-:- line 2)                                                                               57.08



                                 Computation of ADHC Separately Billable Services Cost Per Unit of Service

    4      Total Occupational Therapy Services cost (Section K, Part A, C/R line 91, col 4)                                               84,404

    5      Total Occupational Therapy Units of Service (Section D, line 1)                                                                11,050

    6      Occupational Therapy Services Average Cost Per Unit (line 1 -:- line 2)                                                          7.64

    7      Total Physical Therapy Services cost (Section K, Part A, C/R line 92, col 4)                                                   73,805

    8      Total Physical Therapy Units of Service (Section D, line 2)                                                                    10,240

    9      Physical Therapy Services Average Cost Per Unit (line 4 -:- line 5)                                                              7.21

    10     Total Mental Health Services cost (Section K, Part A, C/R line 93, col 4)                                                     152,925

    11     Total Mental Health Units of Service (Section D, line 3)                                                                        7,852

    12     Mental Health Services Average Cost Per Unit (line 7 -:- Line 8)                                                                19.48

    13     Total Speech and Language Pathology Services cost (Section K, Part A, C/R line 94, col 4)                                      56,997

    14     Total Speech and Language Pathology Units of Service (Section D, line 4)                                                       11,467

    15     Speech and Language Pathology Services Cost Per Unit (line 10 -:- line 11)                                                       4.97

    16     Total Registered Dietitian services cost (Section K, Part A, C/R line 95, col 4)                                               53,775

    17     Total Registered Dietitian Center Units of Service (Section D, line 5)                                                         10,754

    18     Registered Dietitian Average Cost Per Unit (line 13 -:- line 14)                                                                 5.00

    19     Total Transportation services cost (Section K, Part A, C/R line 96, col 4)                                                     78,700

    20     Total Transportation Units of Service (Section D, line 6)                                                                      24,500

    21     Transportation Service Average Cost Per Unit (line 16 -:- Line 17)                                                               3.21




         DHCS 9089 (Rev. 01.12.2010)                                                                                                    Section L

								
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