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Profit and Loss Statement for Child Care Provider

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					                                                            NC Department of Health and Human Services
                                                                      Office of the Controller

                                                                                                                   Report Due Date:              March 15, 2011

                        Residential Treatment and Foster Care Cost Report 2011                                                                    Schedule A
                                                                                                                                       Reporting Basis
                                                                       Part I - General                                     [ ] Cash                   [ ] Accrual
1.   Federal Tax ID#:                         0             Agency ID:          -       9.   Licensed Bed Capacity for Agency by Type of Care.
2.   Fiscal Year Ending Date:                                                                                  NonTreatment Beds
3.   Agency Name:           -                                                                    Family Setting                   Program/Group Setting
Mailing Address                                                                         Family
4.   Street or P.O.:                                                                    Foster                                 Residential Care 0
     City, State, Zip:                                                                                             Treatment Beds
5.   Name of Contact Person/Director/Administrator                                               Family Setting                   Program/Group Setting
                                                                                                                       Level II            0    Level III            0
6.   Telephone No.                                                                      Therapeutic
7.   Email Address:                                                                     Foster                      9 Level IV             0 Other MH                0
8.   Fax Number:                                                                        10. Total Number of Facilities:                                0

                                                                     Part II - Tax Information
11. Entity Type:             12. Tax Status                                             13. Organizational Structure (select one)
[ ] Government                          [ ]       Non-profit                            [ ] Sole proprietorship                      [ ]       Partnership
[ ] Private                             [ ]       For profit                            [ ] Corporation                              [ ]       Other
                                                                      Part III - Resident Days
                                                                            Non Treatment
14. Total Number of Non-Treatment Child Care Days                                       14a.Source of Information for Child Care Days (Attach a copy)
     Family Foster                                Residential Care                  0       Internal Database
15. Total LICENSED Non-Treatment Bed Days Available for Child Care 15a.Total of AVAILABLE Non-Treatment Bed Days for Child Care
     Family Foster                                Residential Care                      Family Foster                             Residential Care
                                                                              Treatment
16. Total No. of Treatment Days
     Family Setting                      Program/Group Setting

                                     Level II           0       Level III           0 16a. Source of Information for Treatment Days (Attach a copy)
     Therapeutic
       Family                        Level IV           0 Other MH                  0
17. Total LICENSED Bed Days Available for Treatment                                     17a. Total of AVAILABLE Bed Days for Treatment
     Family Setting              Program/Group Setting                                    Family Setting                    Program/Group Setting

                                     Level II                   Level III                                              Level II                 Level III
     Therapeutic                                                                        Therapeutic
       Family                       Level IV                   Other MH                   Family                     Level IV                  Other MH
                                                    Part IV - Certification of Accuracy
 Intentional misrepresentation or falsification of any information contained in this cost report may be punishable by criminal, civil and
                    administrative action, fine and/or imprisonment under federal and state laws and regulations.
I certify that I have read the above statement and that I have examined the accompanying cost report prepared by myself and/or my staff. To the
best of my knowledge and belief, it is a true, correct and complete cost report, containing no material misstatement and no material omissions,
prepared from the books and records of the provider in accordance with the IV-E Foster Care Cost Report Manual except as noted. I further
certify that I am familiar with the laws and regulations regarding the provision of foster care services, and that the services identified in this cost
report were provided in compliance with such laws and regulations.

      Chief Executive/Agency Official's Signature:                                                                         Date:

                                Preparer's Signature:                                                                      Date:

                        Preparer's Phone Number:


         7/11/2011                                                326c37c7-51f2-4a1d-b438-17dbb7834216.xls                                                 Sched A
                                           NC Department of Health and Human Services
                                                     Office of the Controller

                               Residential Treatment and Foster Care Cost Report 2011
                                        Residential Facility Physical Locations
                                                     Schedule A-1
Tax ID: 0                     Agency Name: -                                                              Agency ID:           -
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:

     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:

     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:

     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:

     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:
                                                                               -
     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:
                                                                               -
     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:




                                                                                            326c37c7-51f2-4a1d-b438-17dbb7834216.xls
                                                                                                                          Sched A-1
                                           NC Department of Health and Human Services
                                                     Office of the Controller

                               Residential Treatment and Foster Care Cost Report 2011
                                        Residential Facility Physical Locations
                                                     Schedule A-1
Tax ID: 0                     Agency Name: -                                                              Agency ID:           -
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:
                                                                               -
     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:
                                                                               -
     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:
                                                                               -
     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:
                                                                               -
     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:
                                                                               -
     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:
                                                                               -
     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:




                                                                                            326c37c7-51f2-4a1d-b438-17dbb7834216.xls
                                                                                                                          Sched A-1
                                           NC Department of Health and Human Services
                                                     Office of the Controller

                               Residential Treatment and Foster Care Cost Report 2011
                                        Residential Facility Physical Locations
                                                     Schedule A-1
Tax ID: 0                     Agency Name: -                                                              Agency ID:           -
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:
                                                                               -
     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:
                                                                               -
     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:
                                                                               -
     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:
                                                                               -
     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:
                                                                               -
     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:
1.   Name of Facility:                                      5. DHSR License #:                      6. DSS Facility ID #:

2.   Street :                                               7. Level:
                                                                               -
     City, State, Zip Code:                                 8. Licensed Bed Capacity:

3.   Medicaid Provider #                                    9. Resident or Occupied Days:
      Old provider no.                                                                                   Non-Treatment:
4.
     County
                                                                                                              Treatment:




                                                                                            326c37c7-51f2-4a1d-b438-17dbb7834216.xls
                                                                                                                          Sched A-1
                                   NC Deprtment of Health and Human Services
                                            Office of the Controller


                       Residential Treatment and Foster Care Cost Report 2011
                                             Schedule B
 Agency ID #:          -
 Agency Name:          -
 Audit Year:           January 0, 1900

 Revenues:

 1.   Medicaid
      a. HRI-R
      b. CAP-MR
      c. Other Medicaid
 2.   Total Medicaid                                                                  $     -

 3.   Other Federal Funds
      a. IV-E Funds
      b. IV-B Funds
      c. Federal Grants
      d. USDA School Food Service
      e. All Other Federal Funds
 4.   Total Other Federal Funds                                                       $     -

 5.   State Funds
      a. State Funds (Old Grant-in-Aide)
      b. JJDP Funds
      c. Non-Medicaid covered treatment (including At Risk)
      d. State Training Funds
      e. Non IV-E Foster Care Funds (SFHF)
      f. Other State Funding
 6.   Total State Funds                                                               $     -

 7.   County Funds
 8.   Investment Income
 9.   Private Contributions
 10. Other
 11. Total Revenues (Total of Lines 2,4,6,7,8,9,10)                                   $     -
 12. Less: Total Expenses                                              $          -
 13. Fund Balance or Net Profit (Loss)                                                $     -




7/11/2011 7:25 PM                      326c37c7-51f2-4a1d-b438-17dbb7834216.xls           Sched B
                 Residential Treatment and Foster Care Cost Report - Due Date - March 15, 2011                                                                                              NC Department of Health and Human Services - Office of the Controller
                                                                                                                                                                                                                                               - Rate Year 2011


Schedule C - Expenses                                         Child Mental Health Treatment           Child Mental Health Residential Room & Board              Child Placing Agency Cost
Agency ID:       -                                                                                   Room &             Room &             Room &             Therapeutic
Agency:          -                                           Mental Health                            Board              Board              Board             Foster Care
Audit Date:                                                   Treatment            Other Mental     Residential        Residential        Residential        Family Setting       Family Foster                                             Fund-
                                                              Levels I-IV        Health Treatment    LEVEL ll          LEVEL lll              LEVEL IV        LEVEL I & II           Care             Residential Care   Other Programs    Raising         Admin                Total
                                                                  1                     2               3                  4                     5                 6                    7                    8                 9             10              11                  12
        Position Count/FTEs per category

                     Medicaid Treatment Expense
    1   Salaries and Wages - Paraprofessional Staff                          -                  -                                                                                                                                                                                       -
   2a   Salaries and Wages - Licensed Professional (LP)                      -                  -                                                                                                                                                                                       -
   2b   Salaries and Wages - Qualified Professional (QP)                     -                  -                                                                                                                                                                                       -
    3   Salaries and Wages - Associate Professional (AP)                     -                  -                                                                                                                                                                                       -
    4   Employee Benefit Program                                             -                  -                                                                                                                                                                                       -
    5   Payroll Taxes                                                        -                  -                                                                                                                                                                                       -
    6   Total Treatment Labor Expense                                        -                  -                                                                                                                                                                                       -
    7   Medicaid Supplies                                                    -                  -                                                                                                                                                                                       -
    8   Contract Labor                                                       -                  -                                                                                                                                                                                       -
    9   Bloodborne Pathogen (OSHA) Medicaid Program FTEs                     -                  -                                                                                                                                                                                       -
   10   Employee Criminal Records Check Fees Medicaid FTEs                   -                  -                                                                                                                                                                                       -
   11   Other                                                                -                  -                                                                                                                                                                                       -
   12   Total Medicaid Treatment Expense                                     -                  -                                                                                                                                                                                       -
   13   Total Medicaid Resident Days Provided                                -                  -                                                                                                                                                                                       -

                           Program Expense
Daily Supervison Salary Expense
   14   Salaries and Wages                                                                      -                                                                                                                                                                                       -
   15   Employee Benefit Program                                                                -                                                                                                                                                                                       -
   16   Payroll Taxes                                                                           -                                                                                                                                                                                       -
   17   Total Daily Supervision Salary Expense                                                  -                                                                                                                   -                 -                                                 -
Foster Care Activities/Soc. Svcs Salary Expense
   18   Salaries and Wages                                                                      -                                                                                                                                                                                       -
   19   Employee Benefit Program                                                                -                                                                                                                                                                                       -
   20   Payroll Taxes                                                                           -                                                                                                                                                                                       -
   21   Foster Care Activities/Soc. Svcs Salary Expense                                         -                                                                                                 -                 -                 -                                                 -

                       Room & Board Expense
   22   Housekeeping/Shelter                                                                    -                                                                                                                                                                                       -
   23   Dietary/Food                                                                            -                                                                                                                                                                                       -
   24   Clothing                                                                                -                                                                                                                                                                                       -
   25   Personal Incidentals                                                                    -                                                                                                                                                                                       -
   26   Therapeutic Recreation                                                                  -                                                                                                                                                                                       -
   27   School Supplies                                                                         -                                                                                                                                                                                       -
   28   Liability Insurance on Foster Child                                                                                                                                                                                                                                             -
   29   Transportation for Family Visitation                                                    -                                                                                                                                                                                       -
   30   Travel                                                                                  -                                                                                                                                                                                       -
   31   Miscellaneous Travel                                                                    -                                                                                                                                                                                       -
   32   Foster Care Board Payments to Foster Parents                                                                                                                                                                                                                                    -
   33   Total Room & Board Expense                                                              -                 -                  -                   -                    -                   -                 -                 -                                                 -




                                                                                                                                                                                                                                     326c37c7-51f2-4a1d-b438-17dbb7834216.xls
              7/11/2011                                                                                                        Page 6 of 50                                                                                                                          Sched C
               Residential Treatment and Foster Care Cost Report - Due Date - March 15, 2011                                                                                           NC Department of Health and Human Services - Office of the Controller
                                                                                                                                                                                                                                          - Rate Year 2011


Schedule C - Expenses                                      Child Mental Health Treatment         Child Mental Health Residential Room & Board              Child Placing Agency Cost
Agency ID:      -                                                                               Room &             Room &             Room &             Therapeutic
Agency:         -                                         Mental Health                          Board              Board              Board             Foster Care
Audit Date:                                                Treatment        Other Mental       Residential        Residential        Residential        Family Setting       Family Foster                                             Fund-
                                                           Levels I-IV    Health Treatment      LEVEL ll          LEVEL lll              LEVEL IV        LEVEL I & II           Care             Residential Care   Other Programs    Raising         Admin                Total
                                                               1                  2                3                  4                     5                 6                    7                    8                 9             10              11                  12
                                  Other Costs
                          Other Costs - Cost of Care
Allowable Program Facility Expense
   34   Facility Rent                                                                      -                                                                                                                                                                                       -
   35   Repairs & Maintenance Building & Grounds                                           -                                                                                                                                                                                       -
   36   Depreciation - Building & Improvement                                              -                                                                                                                                                                                       -
   37   Mortgage Interest                                                                  -                                                                                                                                                                                       -
   38   Fixed Asset Interest                                                               -                                                                                                                                                                                       -
   39   Total Allowable Program Facility Expense                                           -                 -                  -                   -                    -                   -                 -                 -              -                                  -
Support Staff Labor Expense
   40   Salaries and Wages                                                                 -                                                                                                                                                                                       -
   41   Employee Benefit Program                                                           -                                                                                                                                                                                       -
   42   Payroll Taxes                                                                      -                                                                                                                                                                                       -
   43   Total Support Staff Labor Expense                                                  -                 -                  -                   -                                                          -                 -                                                 -
   44   Insurance - Vehicles                                                               -                                                                                                                                                                                       -
   45   Insurance - Fixed Assets                                                           -                                                                                                                                                                                       -
   46   Insurance - General                                                                -                                                                                                                                                                                       -
   47   Vehicle Maintenance                                                                -                                                                                                                                                                                       -
   48   Interest - Automobile                                                              -                                                                                                                                                                                       -
   49   Interest - Operating                                                               -                                                                                                                                                                                       -
   50   Rent - Automotive/Equipment                                                        -                                                                                                                                                                                       -
   51   Real Estate Taxes                                                                  -                                                                                                                                                                                       -
   52   Business Travel                                                                    -                                                                                                                                                                                       -
   53   Licenses for individuals                                                           -                                                                                                                                                                                       -
   54   Licenses for facilities                                                            -                                                                                                                                                                                       -
   55   Bloodborne Pathogen (OSHA)                                                         -                                                                                                                                                                                       -
   56   Employee Criminal Records Check Fees                                               -                                                                                                                                                                                       -
   57   Advertising                                                                        -                                                                                                                                                                                       -
   58   Meetings/Seminars/Training                                                         -                                                                                                                                                                                       -
   59   Depreciation - Automotive                                                          -                                                                                                                                                                                       -
   60   Depreciation - Equipment                                                           -                                                                                                                                                                                       -
   61   Total Other Costs - Cost of Care                                                   -                 -                  -                   -                    -                   -                 -                 -              -              -                   -
                          Other Costs - Administration
Allowable Administrative Facility Expense
   62   Facility Rent                                                                      -                                                                                                                                                                                       -
   63   Repairs & Maintenance Building & Grounds                                           -                                                                                                                                                                                       -
   64   Depreciation - Building & Improvement                                              -                                                                                                                                                                                       -
   65   Mortgage Interest                                                                  -                                                                                                                                                                                       -
   66   Fixed Asset Interest                                                               -                                                                                                                                                                                       -
   67   Total Allowable Administrative Facility Expense                                    -                 -                  -                   -                    -                   -                 -                 -              -              -                   -




                                                                                                                                                                                                                                326c37c7-51f2-4a1d-b438-17dbb7834216.xls
              7/11/2011                                                                                                   Page 7 of 50                                                                                                                          Sched C
                   Residential Treatment and Foster Care Cost Report - Due Date - March 15, 2011                                                                                              NC Department of Health and Human Services - Office of the Controller
                                                                                                                                                                                                                                                 - Rate Year 2011


Schedule C - Expenses                                           Child Mental Health Treatment           Child Mental Health Residential Room & Board              Child Placing Agency Cost
Agency ID:          -                                                                                  Room &             Room &             Room &             Therapeutic
Agency:             -                                          Mental Health                            Board              Board              Board             Foster Care
Audit Date:                                                     Treatment            Other Mental     Residential        Residential        Residential        Family Setting       Family Foster                                             Fund-
                                                                Levels I-IV        Health Treatment    LEVEL ll          LEVEL lll              LEVEL IV        LEVEL I & II           Care             Residential Care   Other Programs    Raising         Admin                Total
                                                                    1                     2               3                  4                     5                 6                    7                    8                 9             10              11                  12
Administrative & Management Labor Expense
      68   Salaries and Wages                                                                     -                                                                                                                                                                                       -
      69   Employee Benefits Program                                                              -                                                                                                                                                                                       -
      70   Payroll Taxes                                                                          -                                                                                                                                                                                       -
      71   Total Administrative & Management Labor Expense                                        -                 -                  -                   -                    -                   -                 -                 -              -              -                   -
      72   Office Supplies                                                                        -                                                                                                                                                                                       -
      73   Telephone                                                                              -                                                                                                                                                                                       -
      74   Postage                                                                                -                                                                                                                                                                                       -
      75   Dues & Subscriptions                                                                   -                                                                                                                                                                                       -
      76   Legal & Accounting                                                                     -                                                                                                                                                                                       -
      77   Interest - Operating                                                                   -                                                                                                                                                                                       -
      78   Audit                                                                                  -                                                                                                                                                                                       -
      79   Data Processing                                                                        -                                                                                                                                                                                       -
      80   Management Services                                                                    -                                                                                                                                                                                       -
      81   Printing                                                                               -                                                                                                                                                                                       -
      82   Business Travel                                                                        -                                                                                                                                                                                       -
      83   Vehicle Maintenance                                                                    -                                                                                                                                                                                       -
      84   Rent - Automotive/Equipment                                                            -                                                                                                                                                                                       -
      85   Depreciation - Automotive                                                              -                                                                                                                                                                                       -
      86   Depreciation - Equipment                                                               -                                                                                                                                                                                       -
      87   Office Utilities and Cleaning Services                                                 -                                                                                                                                                                                       -
      88   Miscellaneous                                                                          -                                                                                                                                                                                       -
      89   Total Other Costs - Administration                                                     -                 -                  -                   -                    -                   -                 -                 -              -              -                   -
      90   Total Other Costs                                                                      -                 -                  -                   -                    -                   -                 -                 -              -              -                   -

      91   Total Rate Setting Expense                                          -                  -                 -                  -                   -                    -                   -                 -                 -              -              -                   -

                               Non-Allowable Expense
      92   Child Development                                                                      -                                                                                                                                                                                       -
      93   Other Child and Family Services                                                        -                                                                                                                                                                                       -
      94   Higher Education                                                                       -                                                                                                                                                                                       -
      95   Bad Debts                                                                              -                                                                                                                                                                                       -
      96   Multi-Purpose Group Home                                                               -                                                                                                                                                                                       -
      97   Non-Allowable Costs                                                                    -                                                                                                                                                                                       -
      98   In Kind Donations / Contributions                                                      -                                                                                                                                                                                       -
      99   Penalties                                                                              -                                                                                                                                                                                       -
  100      Total Non-Allowable Expense                                                            -                 -                  -                   -                    -                   -                 -                 -              -              -                   -
  101      Total to Match Audit                                                -                  -                 -                  -                   -                    -                   -                 -                 -              -              -                   -
Schedule B Total Expense from line 12                                                                                                                                                                                                                                                     -
Difference: (Total Column line 101, less Schedule B line 12)                                                                                                                                                                                                                              -
102        Total Resident Days Provided
                   Days for Title IV-E in DSS custody
                   Days for non-Title IV-E in DSS custody
                   Days not in DSS custody




                                                                                                                                                                                                                                       326c37c7-51f2-4a1d-b438-17dbb7834216.xls
                   7/11/2011                                                                                                     Page 8 of 50                                                                                                                          Sched C
                                                                                                 NC DEPARTMENT OF HEALTH AND HUMAN SERVICES
                                                                                                           OFFICE OF THE CONTROLLER
                                                                                              RESIDENTIAL TREATMENT AND FOSTER CARE COST REPORT



SCHEDULE C-1 MEDICAID HRI EXPENSE                                                                                                               CHILDRENS RESIDENTIAL MEDICAID PROVIDERS
                                                          Mental Health         Foster Care       Therapeutic        Behavioral Health     Behavioral Health     Behavioral Health     Behavioral Health
                                                            Service           Therapeutic Child    Behavioral            Long Term             Long Term             Long Term             Long Term
Agency ID:        -                                                                                 Service         Residential 4 Beds or Residential 5 Beds or Residential 4 Beds or Residential 5 Beds or                Other - CAP
Agency:       -                                                                                                            Less                  More                  Less                  More                          MR, ICF MR,
Audit Date: 1/0/1900                                        LEVEL l               LEVEL ll         LEVEL ll                LEVEL lll                      LEVEL lll       LEVEL lV          LEVEL lV           PRTF            etc.             Total
                                                             H0046                 S5145            H2020                    H0019                         H0019           H0019             H0019

     Position Count/FTE's per category                                                                                                                                                                                                                   0.00
                      Medicaid Treatment Expense
1    Salaries and Wages - Paraprofessional Staff                                                                                                                                                                                                            -
2a   Salaries and Wages - Licensed Professional (LP)                                                                                                                                                                                                        -
2b   Salaries and Wages - Qualified Professional (QP)                                                                                                                                                                                                       -
3    Salaries and Wages - Associate Professional (AP)                                                                                                                                                                                                       -
4    Employee Benefit Program                                                                                                                                                                                                                               -
5    Payroll Taxes                                                                                                                                                                                                                                          -
6    Total Treatment Labor Expense                                        -                   -                 -                           -                         -              -                   -             -              -                     -
7    Medicaid Supplies                                                                                                                                                                                                                                      -
8    Contract Labor                                                                                                                                                                                                                                         -
9    Bloodborne Pathogen (OSHA) Medicaid Program FTEs                                                                                                                                                                                                       -
10   Employee Criminal Records Check Fees Medicaid FTEs                                                                                                                                                                                                     -
11   Other                                                                                                                                                                                                                                                  -
12   Total Medicaid Treatment Expense                                     -                   -                 -                           -                         -              -                   -             -              -                     -
13   Total Medicaid Resident Days Provided                                                    -                 -                                                                                                                                           -
                           Program Expense
Daily Supervison Salary Expense
14   Salaries and Wages                                                                                                                                                                                                                                     -
15   Employee Benefit Program                                                                                                                                                                                                                               -
16   Payroll Taxes                                                                                                                                                                                                                                          -
17   Total Daily Supervision Salary Expense                                                                                                                                                                            -              -                     -
Social Services Salary Expense
18   Salaries and Wages                                                                                                                                                                                                                                     -
19   Employee Benefit Program                                                                                                                                                                                                                               -
20   Payroll Taxes                                                                                                                                                                                                                                          -
21   Total Social Services Salary Expense                                                                                                                                                                              -              -                     -
                        Room & Board Expense
22   Housekeeping/Shelter                                                                                                                                                                                                                                   -
23   Dietary/Food                                                                                                                                                                                                                                           -
24   Clothing                                                                                                                                                                                                                                               -
25   Personal Incidentals                                                                                                                                                                                                                                   -
26   Therapeutic Recreation                                                                                                                                                                                                                                 -
27   School Supplies                                                                                                                                                                                                                                        -
29   Transportation for Family Visitation                                                                                                                                                                                                                   -
30   Travel                                                                                                                                                                                                                                                 -
31   Miscellaneous Travel                                                                                                                                                                                                                                   -
33   Total Room & Board Expense                                                                                                                                                                                        -              -                     -




                                                                                                                                                                                                              326c37c7-51f2-4a1d-b438-17dbb7834216.xls
       7/11/2011 7:25 PM                                                                                Please Round Funds to the nearest Whole Dollar.                                                                                     Sched C-1
                                                                                           NC DEPARTMENT OF HEALTH AND HUMAN SERVICES
                                                                                                     OFFICE OF THE CONTROLLER
                                                                                        RESIDENTIAL TREATMENT AND FOSTER CARE COST REPORT



SCHEDULE C-1 MEDICAID HRI EXPENSE                                                                                                       CHILDRENS RESIDENTIAL MEDICAID PROVIDERS
                                                        Mental Health     Foster Care       Therapeutic       Behavioral Health     Behavioral Health     Behavioral Health     Behavioral Health
                                                          Service       Therapeutic Child    Behavioral           Long Term             Long Term             Long Term             Long Term
Agency ID:        -                                                                           Service        Residential 4 Beds or Residential 5 Beds or Residential 4 Beds or Residential 5 Beds or                Other - CAP
Agency:       -                                                                                                     Less                  More                  Less                  More                          MR, ICF MR,
Audit Date: 1/0/1900                                      LEVEL l           LEVEL ll         LEVEL ll                LEVEL lll                      LEVEL lll   LEVEL lV             LEVEL lV           PRTF            etc.             Total
                                                           H0046             S5145            H2020                    H0019                         H0019       H0019                H0019

                                Other Costs
                        Other Costs - Cost of Care
Allowable Program Facility Expense
34    Facility Rent                                                                                                                                                                                                                               -
35    Repairs & Maintenance Building & Grounds                                                                                                                                                                                                    -
36    Depreciation - Building & Improvement                                                                                                                                                                                                       -
37    Mortgage Interest                                                                                                                                                                                                                           -
38    Fixed Asset Interest                                                                                                                                                                                                                        -
39    Total Allowable Program Facility Expense                                                                                                                                                                  -              -                  -
Support Staff Labor Expense
40    Salaries and Wages                                                                                                                                                                                                                          -
41    Employee Benefit Program                                                                                                                                                                                                                    -
42    Payroll Taxes                                                                                                                                                                                                                               -
43    Total Support Staff Labor Expense                                                                                                                                                                         -              -                  -
44    Insurance - Vehicles                                                                                                                                                                                                                        -
45    Insurance - Fixed Assets                                                                                                                                                                                                                    -
46    Insurance - General                                                                                                                                                                                                                         -
47    Vehicle Maintenance                                                                                                                                                                                                                         -
48    Interest - Automobile                                                                                                                                                                                                                       -
49    Interest - Operating                                                                                                                                                                                                                        -
50    Rent - Automotive/Equipment                                                                                                                                                                                                                 -
51    Real Estate Taxes                                                                                                                                                                                                                           -
52    Business Travel                                                                                                                                                                                                                             -
53    Licenses for individuals                                                                                                                                                                                                                    -
54    Licenses for facilities                                                                                                                                                                                                                     -
55    Bloodborne Pathogen (OSHA)                                                                                                                                                                                                                  -
56    Employee Criminal Records Check Fees                                                                                                                                                                                                        -
57    Advertising                                                                                                                                                                                                                                 -
58    Meetings/Seminars/Training                                                                                                                                                                                                                  -
59    Depreciation - Automotive                                                                                                                                                                                                                   -
60    Depreciation - Equipment                                                                                                                                                                                                                    -
61    Total Other Costs - Cost of Care                                                                                                                                                                          -              -                  -
                      Other Costs - Administration
Allowable Administrative Facility Expense
62    Facility Rent                                                                                                                                                                                                                               -
63    Repairs & Maintenance Building & Grounds                                                                                                                                                                                                    -
64    Depreciation - Building & Improvement                                                                                                                                                                                                       -
65    Mortgage Interest                                                                                                                                                                                                                           -
66    Fixed Asset Interest                                                                                                                                                                                                                        -
67    Total Allowable Administrative Facility Expense                                                                                                                                                           -              -                  -
Administrative & Management Labor Expense
68    Salaries and Wages                                                                                                                                                                                                                          -
69    Employee Benefits Program                                                                                                                                                                                                                   -
70    Payroll Taxes                                                                                                                                                                                                                               -
71    Total Administrative & Management Labor Expense                                                                                                                                                           -              -                  -
72    Office Supplies                                                                                                                                                                                                                             -
73    Telephone                                                                                                                                                                                                                                   -
74    Postage                                                                                                                                                                                                                                     -
                                                                                                                                                                                                       326c37c7-51f2-4a1d-b438-17dbb7834216.xls
       7/11/2011 7:25 PM                                                                          Please Round Funds to the nearest Whole Dollar.                                                                                    Sched C-1
                                                                                      NC DEPARTMENT OF HEALTH AND HUMAN SERVICES
                                                                                                OFFICE OF THE CONTROLLER
                                                                                   RESIDENTIAL TREATMENT AND FOSTER CARE COST REPORT



SCHEDULE C-1 MEDICAID HRI EXPENSE                                                                                                       CHILDRENS RESIDENTIAL MEDICAID PROVIDERS
                                               Mental Health         Foster Care       Therapeutic          Behavioral Health     Behavioral Health     Behavioral Health     Behavioral Health
                                                 Service           Therapeutic Child    Behavioral              Long Term             Long Term             Long Term             Long Term
Agency ID:        -                                                                      Service           Residential 4 Beds or Residential 5 Beds or Residential 4 Beds or Residential 5 Beds or                Other - CAP
Agency:       -                                                                                                   Less                  More                  Less                  More                          MR, ICF MR,
Audit Date: 1/0/1900                             LEVEL l               LEVEL ll         LEVEL ll                   LEVEL lll                      LEVEL lll       LEVEL lV         LEVEL lV           PRTF            etc.             Total
                                                  H0046                 S5145            H2020                       H0019                         H0019           H0019            H0019

75    Dues & Subscriptions                                                                                                                                                                                                                      -
76    Legal & Accounting                                                                                                                                                                                                                        -
77    Interest - Operating                                                                                                                                                                                                                      -
78    Audit                                                                                                                                                                                                                                     -
79    Data Processing                                                                                                                                                                                                                           -
80    Management Services                                                                                                                                                                                                                       -
81    Printing                                                                                                                                                                                                                                  -
82    Business Travel                                                                                                                                                                                                                           -
83    Vehicle Maintenance                                                                                                                                                                                                                       -
84    Rent - Automotive/Equipment                                                                                                                                                                                                               -
85    Depreciation - Automotive                                                                                                                                                                                                                 -
86    Depreciation - Equipment                                                                                                                                                                                                                  -
87    Office Utilities and Cleaning Services                                                                                                                                                                                                    -
88    Miscellaneous                                                                                                                                                                                                                             -
89    Total Other Costs - Administration                                                                                                                                                                      -              -                  -
90    Total Other Costs                                                                                                                                                                                       -              -                  -

91    Total Rate Setting Expense                               -                   -                   -                            -                         -              -                  -             -              -                  -

Non-Allowable Expense
92    Child Development                                                                                                                                                                                                                         -
93    Other Child and Family Services                                                                                                                                                                                                           -
94    Higher Education                                                                                                                                                                                                                          -
95    Bad Debts                                                                                                                                                                                                                                 -
96    Multi-Purpose Group Home                                                                                                                                                                                                                  -
97    Miscellaneous & Non-Allowable costs                                                                                                                                                                                                       -
98    In Kind Donations / Contributions                                                                                                                                                                                                         -
99    Penalties                                                                                                                                                                                                                                 -
100   Total Non-Allowable Expense                                                                                                                                                                             -              -                  -
101   Total to Match Audit                                     -                   -                   -                            -                         -              -                  -             -              -                  -


102   Total Resident Days Provided                   0                     0                0                           0                            0               0                 0                0              0                        0




                                                                                                                                                                                                     326c37c7-51f2-4a1d-b438-17dbb7834216.xls
       7/11/2011 7:25 PM                                                                        Please Round Funds to the nearest Whole Dollar.                                                                                    Sched C-1
                                                            NC Department of Health and Human Services
                                                                      Office of the Controller


                                   2011 MENTAL HEALTH RESIDENTIAL TREATMENT COST REPORT

Federal Tax ID #: 0
Corporate Name: -

SCHEDULE C-2                                  POSITION / FTE's by Level of Care
                         LIST THE JOB TITLE, LEVEL OF STAFF AND THE NUMBER OF FTEs ASSOCIATED WITH THE JOB TITLE

                                                      MEDICAID TREATMENT EXPENSES
                                                                      Mental                                     5 Beds          5 Beds
                                                                       Health     Therapeutic Group 4 Beds or or More 4 Beds or More
                                                                      Service     Foster Care Homes     Less     LEVEL or Less LEVEL
                                                                      LEVEL I      LEVEL II   LEVEL II LEVEL III    III LEVEL IV   IV
             JOB TITLE                      Staff Qualification        H0046        S5145      H2020    H0019    H0019   H0019   H0019 TOTALS
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                        -                                                                                                                   -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                                                                                                                            -
                                                        Total FTEs:          -               -           -   -             -          -          -          -
                                            FTEs from Schedule C-1:          -               -           -   -             -          -          -          -




                                                                             12 of 50                            326c37c7-51f2-4a1d-b438-17dbb7834216.xls
     7/11/2011 7:25 PM                                                                                                                         Sched C-2
                                 NORTH CAROLINA DIVISION OF MEDICAL ASSISTANCE
                            2011 MENTAL HEALTH RESIDENTIAL TREATMENT COST REPORT
                                        SCHEDULE OF RELATED PARTY TRANSACTIONS                                                  SCHEDULE D
Agency Name:                       -

Tax ID:                            0
                                                                                                                                          Number of
 Description of Line Item   Line          Program/Cost                                                                     Expense        Paid Hours
    (Expense/Cost)            #        Center/Column Name         Name of Related Party                 Relationship       Amount          (If Applicable)

NONE




                                                                            13
Revised (09/05)                                                                                                        326c37c7-51f2-4a1d-b438-17dbb7834216.xls
DMA Rate Setting                                      Please Round Funds to the Nearest Whole Dollar.                                                  Sched D
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Expenses                                    (Rows
2 through 51 are available to add or edit your                                  Audit Total
audit expense descriptions.)                                      Audit Total    Lookup                       Column 1   Schedule C                   Column 2   Schedule C                   Column 3   Schedule C                   Column 4   Schedule C                   Column 5   Schedule C
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                                                                          -
                                                                          -
                                                                          -
                                                                          -
                                                                          -
                                                                          -
                                                                          -
                                                                          -
       Total Expenses                                           $         -     $       -                 $         -    $      -                 $         -    $      -                 $         -    $      -                 $         -    $      -                 $         -    $      -
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Expenses                                    (Rows
2 through 51 are available to add or edit your
audit expense descriptions.)                                        Column 6   Schedule C                   Column 7   Schedule C                   Column 8   Schedule C                   Column 9   Schedule C                   Column 10   Schedule C




       Total Expenses                                           $         -    $      -                 $         -    $      -                 $         -    $      -                 $         -    $      -                 $          -    $      -
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                                                                               Child                                                                                                                  Mental                    Other                  Room &
                         Schedule C Expenses                               Placement /                                                                                                                Health                    Mental                  Board
Line
                                                                              Family                                             Other                                                              Treatment                   Health                Residential
                                                                              Foster                 Residential               Programs               Fundraising               Admin               Levels I-IV               Treatment                LEVEL ll
       Medicaid Treatment Expense
 1     Salaries and Wages - Paraprofessional Staff                                -                         -                        -                       -                      -                      -        z               -                        -
2a     Salaries and Wages - Licensed Professional (LP)                            -                         -                        -                       -                      -                      -        z               -                        -
2b     Salaries and Wages - Qualified Professional (QP)                           -                         -                        -                       -                      -                      -        z               -                        -
 3     Salaries and Wages - Associate Professional (AP)                           -                         -                        -                       -                      -                      -        z               -                        -
 4     Employee Benefit Program                                                   -                         -                        -                       -                      -                      -        z               -                        -
 5     Payroll Taxes                                                              -                         -                        -                       -                      -                      -        z               -                        -
 6     Total Treatment Labor Expense                                              -                         -                        -                       -                      -                      -        z               -                        -
 7     Medicaid Supplies                                                          -                         -                        -                       -                      -                      -                        -                        -
 8     Contract Labor                                                             -                         -                        -                       -                      -                      -        z               -                        -
 9     Bloodborne Pathogen (OSHA) Medicaid Program FTEs                           -                         -                        -                       -                      -                      -                        -                        -
10     Employee Criminal Records Check Fees Medicaid FTEs                         -                         -                        -                       -                      -                      -                        -                        -
11     Other                                                                      -                         -                        -                       -                      -                      -        z               -                        -
12     Total Medicaid Treatment Expense                                           -                         -                        -                       -                      -                      -                        -                        -
       Daily Supervision Salary Expense
14     Salaries and Wages                                                         -                         -                        -                       -                      -                      -        z               -                        -
15     Employee Benefit Program                                                   -                         -                        -                       -                      -                      -        z               -                        -
16     Payroll Taxes                                                              -                         -                        -                       -                      -                      -        z               -                        -
17     Total Daily Supervision Salary Expense                                     -                         -                        -                       -                      -                      -        z               -                        -
       Foster Care Activities/Social Services Salary Expense
18     Salaries and Wages                                                         -                         -                        -                       -                      -                      -                        -                        -
19     Employee Benefit Program                                                   -                         -                        -                       -                      -                      -                        -                        -
20     Payroll Taxes                                                              -                         -                        -                       -                      -                      -                        -                        -
21     Total Foster Care Activities/Soc Svcs Salary Expense                       -                         -                        -                       -                      -                      -                        -                        -
       Room & Board Expenses
22     Housekeeping/Shelter                                                       -                         -                        -                       -                      -                      -       H                -                        -
23     Dietary/Food                                                               -                         -                        -                       -                      -                      -       z                -                        -
24     Clothing                                                                   -                         -                        -                       -                      -                      -       z                -                        -
25     Personal Incidentals                                                       -                         -                        -                       -                      -                      -       z                -                        -
26     Therapeutic Recreation                                                     -                         -                        -                       -                      -                      -                        -                        -
27     School Supplies                                                            -                         -                        -                       -                      -                      -        z               -                        -
28     Liability Insurance on Foster Child                                        -                         -                        -                       -                      -                      -                        -                        -
29     Transportation for Family Visitation                                       -                         -                        -                       -                      -                      -                        -                        -
30     Travel                                                                     -                         -                        -                       -                      -                      -                        -                        -
31 Miscellaneous Travel                                                           -                         -                        -                       -                      -                      -                        -                        -
32 Foster Care Board Payments to Foster Parents                                   -                         -                        -                       -                      -                      -                        -                        -

 326c37c7-51f2-4a1d-b438-17dbb7834216.xls (Sched C-R)                                                     Page 16 of 50                                                                                                                               7/11/2011
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                                                                        Child                                                                                                                  Mental                    Other                  Room &
                     Schedule C Expenses                            Placement /                                                                                                                Health                    Mental                  Board
Line
                                                                       Family                                             Other                                                              Treatment                   Health                Residential
                                                                       Foster                 Residential               Programs               Fundraising               Admin               Levels I-IV               Treatment                LEVEL ll
33 Total Room & Board Expense                                              -                         -                        -                       -                      -                      -        z               -                        -
   Other Costs                                                             -                         -                        -                       -                      -                      -                        -                        -
   Other Costs - Costs of Care                                             -                         -                        -                       -                      -                      -                        -                        -
   Allowable Program Facility Expense
34 Facility Rent                                                           -                         -                        -                       -                      -                      -                        -                        -
35 Repairs & Maintenance Building & Grounds                                -                         -                        -                       -                      -                      -      M                 -                        -
36 Depreciation - Building & Improvement                                   -                         -                        -                       -                      -                      -      z                 -                        -
37 Mortgage Interest                                                       -                         -                        -                       -                      -                      -                        -                        -
38 Fixed Asset Interest                                                    -                         -                        -                       -                      -                      -                        -                        -
39 Total Allowable Program Facility Expense                                -                         -                        -                       -                      -                      -        z               -                        -
   Support Staff Labor Expense
40 Salaries and Wages                                                      -                         -                        -                       -                      -                      -        z               -                        -
41 Employee Benefit Program                                                -                         -                        -                       -                      -                      -        z               -                        -
42 Payroll Taxes                                                           -                         -                        -                       -                      -                      -        z               -                        -
43 Total Support Staff Labor Expense                                       -                         -                        -                       -                      -                      -                        -                        -
44 Insurance - Vehicles                                                    -                         -                        -                       -                      -                      -                        -                        -
45 Insurance - Fixed Assets                                                -                         -                        -                       -                      -                      -                        -                        -
46 Insurance - General                                                     -                         -                        -                       -        z             -                      -        z               -                        -
47 Vehicle Maintenance                                                     -                         -                        -                       -        z             -                      -        z               -                        -
48 Interest - Automobile                                                   -                         -                        -                       -                      -                      -                        -                        -
49 Interest - Operating                                                    -                         -                        -                       -                      -                      -                        -                        -
50 Rent - Automotive/Equipment                                             -                         -                        -                       -        z             -                      -                        -                        -
51 Real Estate Taxes                                                       -                         -                        -                       -                      -                      -                        -                        -
52 Business Travel                                                         -                         -                        -                       -                      -                      -                        -                        -
53 Licenses for individuals                                                -                         -                        -      z                -       L              -                      -        z               -                        -
54 Licenses for facilities                                                 -                         -                        -                       -                      -                      -                        -                        -
55 Bloodborne Pathogen (OSHA)                                              -                         -                        -                       -                      -                      -                        -                        -
56 Employee Criminal Records Check Fees                                    -                         -                        -                       -                      -                      -                        -                        -
57 Advertising                                                             -                         -                        -      z                -                      -                      -        z               -                        -
58 Meetings/Seminars/Training                                              -                         -                        -      z                -        z             -                      -        z               -                        -
59 Depreciation - Automotive                                               -                         -                        -                       -                      -                      -        z               -                        -
60 Depreciation - Equipment                                                -                         -                        -                       -                      -                      -        z               -                        -
61 Total Other Costs - Cost of Care                                        -                         -                        -      z                -        z             -                      -        z               -                        -
   Other Costs - Administration                                            -                         -                        -                       -                      -                      -                        -                        -
   Allowable Administrative Facility Expense
62 Facility Rent                                                           -                         -                        -                       -                      -                      -                        -                        -
63 Repairs & Maintenance Building & Grounds                                -                         -                        -      z                -        z             -                      -                        -                        -
64 Depreciation - Building & Improvement                                   -                         -                        -      z                -        z             -                      -        z               -                        -
65 Mortgage Interest                                                       -                         -                        -                       -        z             -                      -                        -                        -
 326c37c7-51f2-4a1d-b438-17dbb7834216.xls (Sched C-R)                                              Page 17 of 50                                                                                                                               7/11/2011
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                                                                        Child                                                                                                                  Mental                    Other                  Room &
                        Schedule C Expenses                         Placement /                                                                                                                Health                    Mental                  Board
Line
                                                                       Family                                             Other                                                              Treatment                   Health                Residential
                                                                       Foster                 Residential               Programs               Fundraising               Admin               Levels I-IV               Treatment                LEVEL ll
66 Fixed Asset Interest                                                    -                         -                        -                       -                      -                      -                        -                        -
67 Total Allowable Administrative Facility Expense                         -                         -                        -      z                -        z             -                      -        z               -                        -
   Administrative & Management Labor Expense
68 Salaries and Wages                                                      -                         -                        -      z                -        s             -                      -        z               -                        -
69 Employee Benefit Program                                                -                         -                        -      z                -        z             -                      -        z               -                        -
70 Payroll Taxes                                                           -                         -                        -      z                -        t             -                      -        z               -                        -
71 Total Administrative & Management Labor Expense                         -                         -                        -                       -                      -                      -                        -                        -
72 Office Supplies                                                         -                         -                        -      z                -        z             -                      -        z               -                        -
73 Telephone                                                               -                         -                        -      z                -        z             -                      -        z               -                        -
74 Postage                                                                 -                         -                        -      z                -        z             -                      -        z               -                        -
75 Dues & Subscriptions                                                    -                         -                        -      z                -        z             -                      -        z               -                        -
76 Legal & Accounting                                                      -                         -                        -                       -        z             -                      -        z               -                        -
77 Interest - Operating                                                    -                         -                        -                       -                      -                      -                        -                        -
78 Audit                                                                   -                         -                        -                       -                      -                      -        z               -                        -
79 Data Processing                                                         -                         -                        -      z                -        z             -                      -        z               -                        -
80 Management Services                                                     -                         -                        -                       -                      -                      -                        -                        -
81 Printing                                                                -                         -                        -      z                -        z             -                      -        z               -                        -
82 Business Travel                                                         -                         -                        -      z                -        z             -                      -        z               -                        -
83 Vehicle Maintenance                                                     -                         -                        -                       -                      -                      -        z               -                        -
84 Rent - Automotive/Equipment                                             -                         -                        -                       -                      -                      -        z               -                        -
85 Depreciation - Automotive                                               -                         -                        -                       -        z             -                      -        z               -                        -
86 Depreciation - Equipment                                                -                         -                        -      z                -        z             -                      -        z               -                        -
87 Office Utilities and Cleaning Services                                  -                         -                        -                       -                      -                      -        z               -                        -
88 Miscellaneous                                                           -                         -                        -      z                -        z             -                      -        z               -                        -
89 Total Other Costs - Administration                                      -                         -                        -      z                -                      -                      -        z               -                        -
90 Total Other Costs                                                       -                         -                        -      z                -        z             -                      -        z               -                        -
 91 Total Rate Setting Expenses                                            -                         -                        -      z                -        z             -     z                -        z               -                        -
    Non-Allowable Expense
 92 Child Development                                                      -                         -                        -                       -                      -                      -                        -                        -
 93 Other Child and Family Services                                        -                         -                        -                       -                      -                      -                        -                        -
 94 Higher Education                                                       -                         -                        -                       -                      -                      -                        -                        -
 95 Bad Debts                                                              -                         -                        -      z                -                      -                      -        z               -                        -
 96 Multi-Purpose Group Home                                               -                         -                        -                       -                      -                      -                        -                        -
 97 Non-Allowable costs                                                    -                         -                        -                       -                      -                      -        z               -                        -
 98 In Kind Donations / Contributions                                      -                         -                        -                       -                      -                      -                        -                        -
 99 Penalties                                                              -                         -                        -                       -                      -                      -                        -                        -
100 Total Non-Allowable Expense                                            -                         -                        -                       -                      -                      -                        -                        -
101 Total to Match Audit                                                   -                         -                        -                       -                      -                      -                        -                        -

 326c37c7-51f2-4a1d-b438-17dbb7834216.xls (Sched C-R)                                              Page 18 of 50                                                                                                                               7/11/2011
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                                                                             Room &                    Room &                  Foster Care
                         Schedule C Expenses                                 Board                     Board                     Family
Line
                                                                           Residential               Residential                 Setting
                                                                            LEVEL lll                 LEVEL IV                 LEVEL I & II   Total
       Medicaid Treatment Expense
 1     Salaries and Wages - Paraprofessional Staff                                -                         -        z                 -          -
2a     Salaries and Wages - Licensed Professional (LP)                            -                         -        z                 -          -
2b     Salaries and Wages - Qualified Professional (QP)                           -                         -        z                 -          -
 3     Salaries and Wages - Associate Professional (AP)                           -                         -        z                 -          -
 4     Employee Benefit Program                                                   -                         -        z                 -          -
 5     Payroll Taxes                                                              -                         -        z                 -          -
 6     Total Treatment Labor Expense                                              -                         -        z                 -          -
 7     Medicaid Supplies                                                          -                         -                          -          -
 8     Contract Labor                                                             -                         -        z                 -          -
 9     Bloodborne Pathogen (OSHA) Medicaid Program FTEs                           -                         -                          -          -
10     Employee Criminal Records Check Fees Medicaid FTEs                         -                         -                          -          -
11     Other                                                                      -                         -        z                 -          -
12     Total Medicaid Treatment Expense                                           -                         -                          -          -
       Daily Supervision Salary Expense
14     Salaries and Wages                                                         -                         -        z                 -          -
15     Employee Benefit Program                                                   -                         -        z                 -          -
16     Payroll Taxes                                                              -                         -        z                 -          -
17     Total Daily Supervision Salary Expense                                     -                         -        z                 -          -
       Foster Care Activities/Social Services Salary Expense
18     Salaries and Wages                                                         -                         -        z                 -          -
19     Employee Benefit Program                                                   -                         -        z                 -          -
20     Payroll Taxes                                                              -                         -        z                 -          -
21     Total Foster Care Activities/Soc Svcs Salary Expense                       -                         -                          -          -
       Room & Board Expenses
22     Housekeeping/Shelter                                                       -                         -        z                 -          -
23     Dietary/Food                                                               -                         -        z                 -          -
24     Clothing                                                                   -                         -        z                 -          -
25     Personal Incidentals                                                       -                         -                          -          -
26     Therapeutic Recreation                                                     -                         -                          -          -
27     School Supplies                                                            -                         -        z                 -          -
28     Liability Insurance on Foster Child                                        -                         -                          -          -
29     Transportation for Family Visitation                                       -                         -                          -          -
30     Travel                                                                     -                         -                          -          -
31 Miscellaneous Travel                                                           -                         -                          -          -
32 Foster Care Board Payments to Foster Parents                                   -                         -        z                 -          -

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                                                                                                                        Therapeutic




                                                        Reference




                                                                                  Reference




                                                                                                            Reference
                                                                      Room &                    Room &                  Foster Care
                     Schedule C Expenses                              Board                     Board                     Family
Line
                                                                    Residential               Residential                 Setting
                                                                     LEVEL lll                 LEVEL IV                 LEVEL I & II   Total
33 Total Room & Board Expense                                              -                         -        z                 -          -
   Other Costs                                                             -                         -                          -          -
   Other Costs - Costs of Care                                             -                         -                          -          -
   Allowable Program Facility Expense
34 Facility Rent                                                           -                         -                          -          -
35 Repairs & Maintenance Building & Grounds                                -                         -        z                 -          -
36 Depreciation - Building & Improvement                                   -                         -        z                 -          -
37 Mortgage Interest                                                       -                         -                          -          -
38 Fixed Asset Interest                                                    -                         -                          -          -
39 Total Allowable Program Facility Expense                                -                         -        z                 -          -
   Support Staff Labor Expense
40 Salaries and Wages                                                      -                         -        z                 -          -
41 Employee Benefit Program                                                -                         -        z                 -          -
42 Payroll Taxes                                                           -                         -        z                 -          -
43 Total Support Staff Labor Expense                                       -                         -        z                 -          -
44 Insurance - Vehicles                                                    -                         -                          -          -
45 Insurance - Fixed Assets                                                -                         -                          -          -
46 Insurance - General                                                     -                         -        z                 -          -
47 Vehicle Maintenance                                                     -                         -                          -          -
48 Interest - Automobile                                                   -                         -                          -          -
49 Interest - Operating                                                    -                         -                          -          -
50 Rent - Automotive/Equipment                                             -                         -        z                 -          -
51 Real Estate Taxes                                                       -                         -                          -          -
52 Business Travel                                                         -                         -                          -          -
53 Licenses for individuals                                                -                         -                          -          -
54 Licenses for facilities                                                 -                         -                          -          -
55 Bloodborne Pathogen (OSHA)                                              -                         -                          -          -
56 Employee Criminal Records Check Fees                                    -                         -        z                 -          -
57 Advertising                                                             -                         -        z                 -          -
58 Meetings/Seminars/Training                                              -                         -        z                 -          -
59 Depreciation - Automotive                                               -                         -        z                 -          -
60 Depreciation - Equipment                                                -                         -        z                 -          -
61 Total Other Costs - Cost of Care                                        -                         -        z                 -          -
   Other Costs - Administration                                            -                         -                          -          -
   Allowable Administrative Facility Expense
62 Facility Rent                                                           -                         -                          -          -
63 Repairs & Maintenance Building & Grounds                                -                         -                          -          -
64 Depreciation - Building & Improvement                                   -                         -        z                 -          -
65 Mortgage Interest                                                       -                         -                          -          -
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                                                                                                                        Therapeutic




                                                        Reference




                                                                                  Reference




                                                                                                            Reference
                                                                      Room &                    Room &                  Foster Care
                        Schedule C Expenses                           Board                     Board                     Family
Line
                                                                    Residential               Residential                 Setting
                                                                     LEVEL lll                 LEVEL IV                 LEVEL I & II   Total
66 Fixed Asset Interest                                                    -                         -                          -          -
67 Total Allowable Administrative Facility Expense                         -                         -        z                 -          -
   Administrative & Management Labor Expense
68 Salaries and Wages                                                      -                         -        z                 -          -
69 Employee Benefit Program                                                -                         -        z                 -          -
70 Payroll Taxes                                                           -                         -        z                 -          -
71 Total Administrative & Management Labor Expense                         -                         -                          -          -
72 Office Supplies                                                         -                         -        z                 -          -
73 Telephone                                                               -                         -        z                 -          -
74 Postage                                                                 -                         -        z                 -          -
75 Dues & Subscriptions                                                    -                         -        z                 -          -
76 Legal & Accounting                                                      -                         -        z                 -          -
77 Interest - Operating                                                    -                         -                          -          -
78 Audit                                                                   -                         -        z                 -          -
79 Data Processing                                                         -                         -        z                 -          -
80 Management Services                                                     -                         -                          -          -
81 Printing                                                                -                         -        z                 -          -
82 Business Travel                                                         -                         -        z                 -          -
83 Vehicle Maintenance                                                     -                         -        z                 -          -
84 Rent - Automotive/Equipment                                             -                         -        z                 -          -
85 Depreciation - Automotive                                               -                         -        z                 -          -
86 Depreciation - Equipment                                                -                         -        z                 -          -
87 Office Utilities and Cleaning Services                                  -                         -        z                 -          -
88 Miscellaneous                                                           -                         -        z                 -          -
89 Total Other Costs - Administration                                      -                         -        z                 -          -
90 Total Other Costs                                                       -                         -        z                 -          -
 91 Total Rate Setting Expenses                                            -                         -        z                 -          -
    Non-Allowable Expense
 92 Child Development                                                      -                         -                          -          -
 93 Other Child and Family Services                                        -                         -                          -          -
 94 Higher Education                                                       -                         -                          -          -
 95 Bad Debts                                                              -                         -        z                 -          -
 96 Multi-Purpose Group Home                                               -                         -                          -          -
 97 Non-Allowable costs                                                    -                         -        z                 -          -
 98 In Kind Donations / Contributions                                      -                         -                          -          -
 99 Penalties                                                              -                         -                          -          -
100 Total Non-Allowable Expense                                            -                         -                          -          -
101 Total to Match Audit                                                   -                         -                          -          -

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   326c37c7-51f2-4a1d-b438-17dbb7834216.xls                                                                                  BreakDown

Use this page if a line item on Schedule C consists of more than one expense item from the audit.




            Schedule C Line                      Schedule C Column              Audit Expense Description   Audit Column




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        Schedule C Line                    Schedule C Column   Audit Expense Description   Audit Column




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        Schedule C Line                    Schedule C Column   Audit Expense Description   Audit Column




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        Schedule C Line                    Schedule C Column   Audit Expense Description   Audit Column




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        Schedule C Line                    Schedule C Column   Audit Expense Description   Audit Column




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        Schedule C Line                    Schedule C Column   Audit Expense Description   Audit Column




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        Schedule C Line                    Schedule C Column   Audit Expense Description   Audit Column




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        Schedule C Line                    Schedule C Column   Audit Expense Description   Audit Column




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        Schedule C Line                    Schedule C Column   Audit Expense Description   Audit Column




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        Schedule C Line                    Schedule C Column   Audit Expense Description   Audit Column




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        Schedule C Line                    Schedule C Column   Audit Expense Description   Audit Column




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        Schedule C Line                    Schedule C Column   Audit Expense Description   Audit Column




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        Schedule C Line                    Schedule C Column   Audit Expense Description   Audit Column




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   Agency ID & Name:        -                                                                                             Phone:

   Date Received:                                                                                                         Contact:
                                                                                                                          Date
   Date Started:                                                                                                          Completed:

   Reviewer:                                                        Was extension Granted?        Yes      /      No      Agency Notified:


                                                                                                                         Comments If any of these items are missing from the submitted Cost
          PART I.      Did the Agency Submit the Following Completed Forms:                                       Yes/No Report the report will not be considered complete.
                       Residential Treatment and Foster Care Cost Report Schedules:
   Schedule A
   Schedule A1
   Schedule B
   Schedule C
   Schedule C1              Residential Treatment Providers Only
   Schedule C2              Residential Treatment Providers Only
   Schedule D               Residential Treatment Providers Only

   Documentation of child care days
   KIDS Report                      Paper                                 Excel
   Shelter Log                      Paper                                 Excel
   Other                            Paper                                 Excel
   Copy of agency audit by independent auditor received
     PART II.       SCHEDULES                                                                                         Yes / No Comments
         SCH A - Part I     Are the general information items completed in Part I? (Reporting Basis,_______
                            Report Dates______ tax ID ______?)
         SCH A - Part I     If agency has residential facilities, is all of the physical location information entered on
                            Schedule A-1s for each facility? If not request Sch A1 for all facilities.
         Sch A, item 10     Does #10 show the number of facilities that are listed on Schedule A-1?

         SCH A - Part II    Is the tax status of the facility entered in Part II?
         SCH A - Part III   Are CHILD CARE DAYS (item #14) listed by Type of Foster Care? If not, request
                            correction.
    Documentation of        The time period of the Child Care Days log must coincide with the financial audit
     child care days        submitted. If it does not or if no date is referenced, request correction.




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                                                                      326c37c7-51f2-4a1d-b438-17dbb7834216.xls

                        All other agencies must submit a list of children for the designated FY that verifies the
                        number of child care days by category of funding and legal custodian. Is the
                        submitted documentation totaled?
         item 14        Does the supporting documentation submitted for child care days match the source name
                        provided in item #14a? If not, request correction.
                        Does the supporting documentation for the child care days match the Child Care days
                        Reported in item # 14? If not, request correction.
         item 15        For Program/Group settings, are Total Licensed Bed Days (#15) equal to the value in
                        #9 times 365? If not, ask if agency has had a change in licensed capacity, and the date to
                        calculate licensed bed days.
         item 15        Is #15 (Total Licensed Bed Days available) greater than or equal to 15a (Available Bed
                        Days)?
     item 15 and 15a    Is #15 (Total Licensed Bed Days available) and 15a (Available bed days) equal to or
                        greater than the sum of the Total No of Child Care days provided in #14? If not
                        determine if some of the days were provided in a higher level placement, i.e. family fost

         item 16        If Treatment Days (Mental Health) are listed, does the supporting documentation
                        referenced in 16a, support the Treatment Days listed in item #16? If not, request
                        correction.
                        Does the supporting documentation match the source name provided in item # 16a? If
                        not request correction.
         item 17        For Program/Group Settings, is #17 Total Licensed Bed Days for Treatment equal to the
                        value in #9 times 365? If not determine if there has been a change in capacity and the
                        date to calculate licensed bed days.
     item 17 and 17 a   Are each #17 (Total Licensed Bed Days available) and 17a (Available bed days) equal to
                        or greater than the sum of the Total No of Child Care days provided in #16? If not,
                        request clarification/correction.
         Sch A-1        Did the agency provide a Schedule A1 to report all residential facilities?
                        Does licensed capacity information and service type match published licensure
                        information? If not, contact Licensure for verification.
                        Is the sum of Non-Treatment and Treatment Days listed in item# 9 LESS THAN the
                        Licensed Bed Capacity in item #8 times 365? If not, have the agency correct.
         SCH C1         Does the agency provide Mental Health Residential Treatment service?
                        a) Does the Sch C1 Total (line 91) Carry forward to Sch C (line 12)?
                        b) Do the Resident Days from the Sch C1 Total (line 102) carry forward to Sch C (line




Review                                                                                 7/11/2011 7:25 PM             Page 49 of 50
                                                                        326c37c7-51f2-4a1d-b438-17dbb7834216.xls

            SCH C          Does every service with costs have FTEs Provided? Does every service with FTEs
                           Provided have costs? If not, have Agency correct.
                           Are there a corresponding Room and Board expense/days for the Treatment
     Therapeutic Family    expense/days?
                           Does this agency provide Therapeutic Family Foster Care? If YES , have those Dollars
          Foster           and CC Days been reported as Foster Care Therapeutic Child on Schedule C-1 and
                           Therapeutic Foster Care Family Setting Level I & II on Schedule C?
      Maternity Home       Is this a Maternity Home? If so, are IV-E resident days and expenses separated from
           Check           maternity resident days and expenses? If not request corrections.
     Daily Supervision     Does the audit detail for each type of care provide salary expenses for staff who provide
      Salary Expense       the daily supervision of children exclusive of Social Workers, Admin. or other staff? If
     Sch C lines 14-17     not provided, request method of determining values from agency.
    Social Work Salary Exp. Are Social Worker salary expenses separated on the audit? If not, request method of
      Sch C Lines 18-21     determining values from the agency.
   Board payment check Do the Foster Care Board payments balance to the line item in the audit? If not request
      Sch C, line 32   explanation or correction.
    Audit to Sch C check Do the "Total to Match Audit" amounts by column, for each Type of Care reported
      Sch C line 101     on Sch C, balance to the audit for program expenses? If not, have them provide
                         reconciliation and explain all items or correct cost report.
    Resident days check Do the Total Resident Days provided by type of care in the cost report Sch C reconcile to
      Sch C line 102    the value from Sch A item 14 and item 16? If not, ask agency to correct.
         Non Allowable     Is any bad debt expense reported in the audit? If so, have agency move it to line 95?
           Expense         Does the audit contain any therapy cost in non-treatment services? If so, have the agency
                           move the cost to line 97.
                           Are any contributions/donations made by the agency reported in the audit? If so, have the
                           agency move them to line 98.
                           Are any penalty expenses reported in the audit? If so, have the agency move them to line
                           99?
          Fundraising      Is Fundraising separated from administration/general support in the audit?
                           Is Fundraising entered correctly in the Fundraising column? If not, have moved to the
                           Fundraising Column.
                           Is the Fundraising expense totaled on line 101 equal to the Fundraising expense per
                           audit? If not request correction or explanation.
         Administration    Is Administration separated from program services in the audit ?
                           Is the Administration Expense entered in the administrative columns Admin/General
                           Support in the audit?
                           Has the Administration expense been allocated to Program services in the Audit? If so,
                           ensure administrative expenses are reported on administrative cost lines 62-88.

                           If allocated in the audit, did the agency provide an explanation of allocation method used
                           for admin expense? If not provided, request the explanation of allocation method used.

     Room and Board        Do room and board expenses appear to be appropriate, per the foster care cost report
                           manual? (Does not include facility expenses, etc)




Review                                                                                   7/11/2011 7:25 PM              Page 50 of 50

				
DOCUMENT INFO
Description: Profit and Loss Statement for Child Care Provider document sample