REPORT ON THE

COST REPORT REVIEW

FAIRVIEW DEVELOPMENTAL CENTER COSTA MESA CALIFORNIA

NATIONAL PROVIDER IDENTIFIER 1225089592

FISCAL PERIOD ENDED JUNE 30 2010

Audits SectionmdashSacramento Financial Audits Branch

Audits and Investigations Department of Health Care Services

Section Chief Robert G Kvick Audit Supervisor Delia Valencia Auditors Gene Bannister and Ellada Kalachov

Sttate of CalifoorniamdashHealth and Humman Servicees Agency DDepartmment of HHealth CCare Seervices

TOOBY DOUGLAS EDMUNDD G BROWN JR DIRECTOR GOVERNOR

May 22 2013

Carolinee Castaneda Financiaal Systems Branch Maanager Departmment of Devvelopmental Services Fiscal Systems Secction 1600 9thh Street Rooom 206 MS 2-9 Sacrameento CA 955814

FAIRVIEEW DEVELLOPMENTAAL CENTERR NATIONNAL PROVIDER IDENNTIFIER (NPPI) 12250899592 FISCAL PERIOD EENDED Junne 30 20100

We havee examinedd the Facilittyrsquos Integratted Disclosure and Meedi-Cal Cosst Report foor the abovve-referencced fiscal peeriod Our examinatioon was madde under the authority of Section 14170 of thhe Welfare and Instituttions Code and accorrdingly inclluded such tests of the accounnting records and suchh other audiiting proceddures as wee considereed necessaary in the circumstancees

In our oppinion the audited setttlement forr the fiscal pperiod due the State inn the amouunt of $35691154 presennted in the SSummary oof Findings representss a proper ddeterminatioon in accordance with the reimbursement princciples of appplicable prrograms

The resuults of our eexaminationn are as follows

AACUTE CARRE Repoorted Cost pper Day $ 2729220

Adjusstment (60555)

Audited Cost Peer Day $ 2668665

Financi al Audits BrancchAudits SectiionmdashSacramennto MS 2106 PO Box 9974413 Sacramennto CA 95899--7413

(916) 650-69994 (916) 650--6990 fax Internet Addrress wwwdhccscagov

Sttate of CalifoorniamdashHealth and Humman Servicees Agency DDepartmment of HHealth CCare Seervices

TOOBY DOUGLAS EDMUNDD G BROWN JR DIRECTOR GOVERNOR

May 22 2013

Carolinee Castaneda Financiaal Systems Branch Maanager Departmment of Devvelopmental Services Fiscal Systems Secction 1600 9thh Street Rooom 206 MS 2-9 Sacrameento CA 955814

FAIRVIEEW DEVELLOPMENTAAL CENTERR NATIONNAL PROVIDER IDENNTIFIER (NPPI) 12250899592 FISCAL PERIOD EENDED Junne 30 20100

We havee examinedd the Facilittyrsquos Integratted Disclosure and Meedi-Cal Cosst Report foor the abovve-referencced fiscal peeriod Our examinatioon was madde under the authority of Section 14170 of thhe Welfare and Instituttions Code and accorrdingly inclluded such tests of the accounnting records and suchh other audiiting proceddures as wee considereed necessaary in the circumstancees

In our oppinion the audited setttlement forr the fiscal pperiod due the State inn the amouunt of $35691154 presennted in the SSummary oof Findings representss a proper ddeterminatioon in accordance with the reimbursement princciples of appplicable prrograms

The resuults of our eexaminationn are as follows

AACUTE CARRE Repoorted Cost pper Day $ 2729220

Adjusstment (60555)

Audited Cost Peer Day $ 2668665

Financi al Audits BrancchAudits SectiionmdashSacramennto MS 2106 PO Box 9974413 Sacramennto CA 95899--7413

(916) 650-69994 (916) 650--6990 fax Internet Addrress wwwdhccscagov

Caroline Castaneda Page 2

SKILLED NURSING LEVEL B Reported Cost per Day $ 68986

Adjustment (1775)

Audited Cost Per Day $ 67211

NURSING FACILITY LEVEL Reported Cost per Day $ 71484

Adjustment (2036)

Audited Cost Per Day $ 69448

This audit report includes the

1 Summary of Findings

2 Computation of Medi-Cal Reimbursement Settlement (STATE HOSPITAL Schedules)

3 Audit Adjustments Schedule

The audited settlement will be incorporated into a Statement of Accounts Receivables The Statement of Accounts Receivable will be forwarded to the Department of Developmental Services by the Medi-Cal Accounting Section Department of Health Care Services Instructions regarding recovery will be included with the Statement of Accounts Receivable Notwithstanding this audit report overpayments to the provider are subject to recovery pursuant to section 514581 Article 6 of Division 3 Title 22 California Code of Regulation

Future long-term care prospective rates may be affected by this examination The extent of the rate changes will be determined by the Departments Fee-For-Service Rates Development Division

Notwithstanding this audit report overpayments to the provider are subject to recovery pursuant to Section 514581 Article 6 of Division 3 Title 22 California Code of Regulations

Caroline Castaneda Page 3

If you disagree with the decision of the Department you may appeal by writing to

John Melton Chief Department of Health Care Services Office of Administrative Hearings and Appeals 1029 J Street Suite 200 Sacramento CA 95814 (916) 322-5603

The written notice of disagreement must be received by the Department within 60 calendar days from the day you receive this letter A copy of this notice should be sent to

United States Postal Service (USPS) Courier (UPS FedEx etc) Assistant Chief Counsel Assistant Chief Counsel Department of Health Care Services Department of Health Care Services Office of Legal Services Office of Legal Services MS 0010 MS 0010 PO Box 997413 1501 Capitol Avenue Suite 715001 Sacramento CA 95899 Sacramento CA 95814

(916) 440-7700

The procedures that govern an appeal are contained in Welfare and Institutions Code Section 14171 and California Code of Regulations Title 22 Section 51016 et seq

If you have questions regarding this report you may call the Audits Sectionmdash Sacramento at (916) 650-6994

Original Signed By

Robert G Kvick Chief Audits SectionmdashSacramento Financial Audits Branch

Certified

cc Chief Financial Services Branch Department of Developmental Services

1600 9th Street Room 310 MS 3-3 Sacramento CA 95814

Caroline Castaneda Page 4

Deputy Director Administration Division

Department of Developmental Services 1600 9th Street Room 310 MS 3-3

Sacramento CA 95814

Chief Department of Health Care Services

Financial ManagementAccounting Section MS 1101

PO Box 997413 Sacramento CA 95899-7413

Chief Department of Health Care Services Rate Development Branch

MS 4612 PO Box 997413 Sacramento CA 95899-7413

Chief Department of Health Care Services Third Party Liability BranchRecovery Section

MS 4720 PO Box 997413 Sacramento CA 95899-7413

Chief Department of Health Care Services Medi-Cal Operations DivisionOperations Management amp Policy Section

MS 4505 PO Box 997413 Sacramento CA 95899-7413

SUMMARY OF FINDINGS

Provider Name Fiscal Period Ended

FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

SETTLEMENT COST

1 Medi-Cal STATE HOSPITAL (SCHEDULE 1) Provider NPI 1225089592 Reported

Net Change

Audited Amount Due Provider (State)

$ 30818994

$ (34388149)

$ (3569154)

2 Subprovider I (SCHEDULE 1-1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

3 Subprovider II (SCHEDULE 1-2) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

4 Medi-Cal Contract Cost (CONTRACT SCH 1) Provider NPI Reported

Net Change

Audited Cost

Audited Amount Due Provider (State)

$

$

$

0

0

0

$ 0

5 Distinct Part Nursing Facility (DPNF SCH 1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

6 Distinct Part Nursing Facility (DPNF SCH 1-1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

7 Adult Subacute (ADULT SUBACUTE SCH 1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

8 Total Medi-Cal Settlement Due Provider (State) - (Lines 1 through 7) $ (3569154)

9 Total Medi-Cal Cost $ 0

SUMMARY OF FINDINGS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

SETTLEMENT COST

10 Subacute (SUBACUTE SCH 1-1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

11 Rural Health Clinic (RHC SCH 1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

12 Rural Health Clinic (RHC 95-210 SCH 1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

13 Rural Health Clinic (RHC 95-210 SCH 1-1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

14 County Medical Services Program (CMSP SCH 1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

15 Transitional Care (TC SCH 1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

16 Total Other Settlement Due Provider - (Lines 10 through 15) $ 0

17 Total Combined Audited Settlement Due Provider (StateCMSPRHC) - (Line 8 + Line 16) $ (3569154)

STATE OF CALIFORNIA SCHEDULE 1 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REPORTED AUDITED

1 Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3) $ 128544663 $ 124176375

2 Excess Reasonable Cost Over Charges (Schedule 2) $ 0 $ 0

3 Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ NA

4 $ 0 $ 0

5 TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 128544663 $ 124176375

6 Interim Payments (Adj 1215) $ (95007525) $ (126946438)

7 Balance Due Provider (State) $ 33537138 $ (2770063)

8 Duplicate Payments (Adj ) $ 0 $ 0

9 Medicare Payments (Adj 12) $ (746407) $ (799091)

10 Adjustment for Pharmacy Dispensings (Adj 16) $ (1971737) $ 0

11 TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 30818994 $ (3569154) (To Summary of Findings)

STATE OF CALIFORNIA SCHEDULE 2 PROGRAM STATE HOSPITAL

COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REASONABLE COST OF MEDI-CAL INPATIENT SERVICES

1 Cost of Covered Services (Schedule 3)

CHARGES FOR MEDI-CAL INPATIENT SERVICES

2 Inpatient Routine Service Charges (Adj )

3 Inpatient Ancillary Service Charges (Adj )

4 Total Charges - Medi-Cal Inpatient Services

5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1)

6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4)

REPORTED AUDITED

$ 132260954 $ 128010350

$ 0 $ 0

$ 0 $ 1435172

$ 0 $ 1435172

$ 0 $ 0

$ NA $ NA (To Schedule 1)

If charges exceed reasonable cost no further calculation necessary for this schedule

STATE OF CALIFORNIA SCHEDULE 3 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REPORTED AUDITED

1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 0 $ 9544176

2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 132260954 $ 118466174

3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0

4 $ 0 $ 0

5 $ 0 $ 0

6 SUBTOTAL (Sum of Lines 1 through 5) $ 132260954 $ 128010350

7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0

8 SUBTOTAL $ 132260954 $ 128010350 (To Schedule 2)

9 Deductibles (Share of Cost)(Adj 12) $ (3685524) $ (3717366)

10 Coinsurance (Third Party Payers) (Adj 12) $ (30767) $ (116609)

11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 128544663 $ 124176375

(To Schedule 1)

STATE OF CALIFORNIA SCHEDULE 4 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED

INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 2 Inpatient Days (include private exclude swing-bed) 3 Private Room Days (exclude swing-bed private room) (Adj ) 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 9 Medi-Cal Days (excluding swing-bed) (Adj 9)

942 942

0 0 0 0 0 0

127

942942

000000

721

SWING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj )18 Medicare NF Swing-Bed Rates after Dec 31 (Adj )19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj )20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj )21 Total Routine Serv Cost (Sch 8 Line 25 Col 27)22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17)23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18)24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19)25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20)26 Total Swing-Bed Cost (Sum of Lines 22 to 25)27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26)

$ $ $ $ $ $ $ $ $ $ $

000000000000

257090400000

2570904

$ $ $ $ $ $ $ $ $ $ $

000 000 000 000

2513868 0 0 0 0 0

2513868

PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges)29 Private Room Charges (excluding swing-bed charges)30 Semi-Private Room Charges (excluding swing-bed charges)31 Gen Inpatient Routine Service CostCharge Ratio (L 27 L 28)32 Average Private Room Per Diem Charge (L 29 L 3)33 Average Semi-Private Room Per Diem Charge (L 30 L 4)34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33)35 Average Per Diem Private Room Cost Differential (L 31 x L 34)36 Private Room Cost Differential Adjustment (L 35 x L 3)37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36)

$ $ $ $ $ $ $ $ $ $

257090400

1000000000000000000

02570904

$ $ $ $ $ $ $ $ $ $

2570904 0 0

0977815 000 000 000 000

0 2513868

PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 L 2)39 Program General Inpatient Routine Service Cost (L 9 x L 38)

$ $

272920346608

$ $

266865 1924097

40 Cost Applicable to Medi-Cal (Sch 4A)41 Cost Applicable to Medi-Cal (Sch 4B)

$ $

11859640413317942

$ $

116542077 0

42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 132260954 $ 118466174 ( To Schedule 3 )

STATE OF CALIFORNIA SCHEDULE 4A PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE ANDOR NURSERY UNITS SKILLED NURSERY FACILITY 1 Total Inpatient Routine Cost (Sch 8 Line 33 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 9) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

4657466167513 6898664810

44709827

$

$

$

AUDITED

45376178675136721165288

43880718

NURSIING FACILITY 6 Total Inpatient Routine Cost (Sch 8 Line 26 Col 27) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj 9) 10 Cost Applicable to Medi-Cal

$

$

$

74993296104909 71484

103361 73886577

$

$

$

7285742610490969448

104627 72661359

CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 27 Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

NEONATAL INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 28 Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 29 Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

ADMINISTRATIVE DAYS 26 Per Diem Rate (Adj )27 Medi-Cal Inpatient Days (Adj ) 28 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

ADMINISTRATIVE DAYS 29 Per Diem Rate (Adj )30 Medi-Cal Inpatient Days (Adj ) 31 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

32 Medi-Cal Routine Cost (Sum of Lines 5101520252831) $ 118596404 $ 116542077 (To Schedule 4)

STATE OF CALIFORNIA SCHEDULE 4B PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE UNITS ALL INCLUSIVE ANCILLARY SERVICES 1 Total Ancillary Cost(Sch 63 Line 37 to 86 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 13) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

9692908173364

5591168171

9402441

$

$

$

AUDITED

9692908173364

559100

DRUG DISPENSING FEE 6 Total Inpatient Routine Cost (Sch 63 LIne 35 Col 27) 7 Total Dispensings (Adj ) 8 Cost Per Dispensings 9 Medi-Cal Dispensings (Adj 14) 10 Cost Applicable to Medi-Cal

$

$

$

3994970179166

2230175583

3915501

$

$

$

3994970179166

22300 0

11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

0 26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 13317942 $ (To Schedule 4)

0

STATE OF CALIFORNIA SCHEDULE 5 PROGRAM STATE HOSPITAL

SCHEDULE OF MEDI-CAL ANCILLARY COSTS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

TOTAL ANCILLARY

COST

TOTAL ANCILLARY UNITS

(Adj 78)

RATIO COST TO CHARGES (From Schedule 6)

MEDI-CAL UNITS COST

MEDI-CAL

ANCILLARY COST CENTERS 3700 Operating Room $ 0 $ 0 0000000 $ 0 $ 0 3800 Recovery Room 0 0 0000000 0 0 3900 Delivery Room and Labor Room 0 0 0000000 0 0 4000 Anesthesiology 0 0 0000000 0 0 4100 Radiology - Diagnostics 409054 173364 2359508 168501 397579 4101 0 0 0000000 0 0 4102 0 0 0000000 0 0 4200 Radiology - Therapeutic 0 0 0000000 0 0 4300 Radioisotope 0 0 0000000 0 0 4400 Laboratory 798223 173364 4604318 168501 775832 4401 Pathological Lab 0 0 0000000 0 0 4600 Whole Blood 0 0 0000000 0 0 4700 Blood Storing and Processing 0 0 0000000 0 0 4800 Intravenous Therapy 0 0 0000000 0 0 4900 Respiratory Therapy 1370883 173364 7907543 168501 1332429 5000 Physical Therapy 1105485 173364 6376668 168501 1074475 5100 Occupational Therapy 0 0 0000000 0 0 5200 Speech Pathology 0 0 0000000 0 0 5300 Electrocardiology 116339 173364 0671067 168501 113076 5400 Electroencephalography 0 0 0000000 0 0 5500 Medical Supplies Charged to Patients 0 0 0000000 0 0 5600 Drugs Charged to Patients 3342357 173364 19279416 168501 3248601 5700 Pharmacist 2832574 179166 15809772 87164 1378043 5800 ASC (Non-Distinct Part) 0 0 0000000 0 0 5900 Other Ancillary Services-Dentistry 1062703 173364 6129893 168501 1032893 5901 Other Ancillary Services-Podiatry 196768 173364 1134997 168501 191248 5902 0 0 0000000 0 0 5903 0 0 0000000 0 0 6000 Clinic 1976589 0 0000000 0 0 6001 Other Clinic Services 0 0 0000000 0 0 6100 Emergency 0 0 0000000 0 0 6200 Observation Beds 0 0 0000000 0 0 7100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0

TOTAL $ 13210973 $ 1566078 $ 1435172 $ 9544176 (To Schedule 3)

STATE OF CALIFORNIA PROG

SCHEDULE 6 RAM STATE HOSPITAL

ADJUSTMENTS TO MEDI-CAL CHARGES DAYS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

ANCILLARY CHARGES REPORTED

(Adj 1011) ADJUSTMENTS AUDITED

3700 Operating Room $ $ $ 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 168501 168501 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 168501 168501 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 168501 168501 5000 Physical Therapy 168501 168501 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 168501 168501 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 168501 168501 5700 Pharmacist 87164 87164 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 168501 168501 5901 Other Ancillary Services-Podiatry 168501 168501 5902 0 5903 0 6000 Clinic 0 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 1435172 $ 1435172 (To Schedule 5)

STATE OF CALIFORNIA SCHEDULE 7 PROGRAM STATE HOSPITAL

COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED

PHYSICIANS REMUNERATION

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

PROFESSIONAL SERVICE

COST CENTERS REMUNERATION

HBP

(Adj )

TOTAL CHARGES TO ALL PATIENTS

(Adj ) TO CHARGES

RATIO OF REMUNERATION CHARGES

MEDI-CAL

(Adj )

MEDI-CAL COST

4000 Anesthesiology $ 0 $ 0 0000000 $ $ 0 4100 Radiology - Diagnostic 0 0 0000000 0 4300 Radioisotope 0 0 0000000 0 4400 Laboratory 0 0 0000000 0 5300 Electrocardiology 0 0 0000000 0 5400 Electroencephalography 0 0 0000000 0 6100 Emergency 0 0 0000000 0

0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0

TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp MOVABLE BLDG amp MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 741495 200 Old Cap Rel Costs-Movable Equipmen 142 0 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 0 400 New Cap Rel Costs-Movable Equipme 386440 0 0 0 401 0 0 0 0 0 402 0 0 0 0 0 0 403 0 0 0 0 0 0 0 404 0 0 0 0 0 0 0 0 405 0 0 0 0 0 0 0 0 0 406 0 0 0 0 0 0 0 0 0 0 407 0 0 0 0 0 0 0 0 0 0 0 408 0 0 0 0 0 0 0 0 0 0 0 0 500 Employee Benefits 33531229 0 0 0 0 0 0 0 0 0 0 0 601 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 602 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 603 PurchasingReceiving 0 0 0 0 0 0 0 0 0 0 0 0 604 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 606 0 0 0 0 0 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 0 0 0 600 Administrative and General 32159423 171956 35 341828 96524 0 0 0 0 0 0 0 700 Maintenance and Repairs 2016844 20402 4 40557 11452 0 0 0 0 0 0 0 800 Operation of Plant 3181146 103383 21 205513 58032 0 0 0 0 0 0 0 900 Laundry and Linen Service 1380724 25645 5 50979 14395 0 0 0 0 0 0 0

1000 Housekeeping 2191511 3084 1 6130 1731 0 0 0 0 0 0 0 1100 Dietary 5061559 26463 5 52606 14855 0 0 0 0 0 0 0 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 840794 1519 0 3019 853 0 0 0 0 0 0 0 1600 Pharmacy 1262471 6135 1 12195 3444 0 0 0 0 0 0 0 1700 Medical Records and Library 672290 2664 1 5296 1495 0 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 7050 1 14014 3957 0 0 0 0 0 0 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 15680960 86484 18 171920 48546 0 0 0 0 0 0 0 3500 Nursing Facility 25040095 226193 47 449645 126968 0 0 0 0 0 0 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp M OVABLE BLDG amp M OVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 168426 706 0 1404 397 0 0 0 0 0 0 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 407939 1269 0 2523 712 0 0 0 0 0 0 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 615078 0 0 0 0 0 0 0 0 0 0 0 5000 Physical Therapy 522259 1246 0 2477 699 0 0 0 0 0 0 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 43549 317 0 630 178 0 0 0 0 0 0 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 2320599 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 474568 867 0 1723 486 0 0 0 0 0 0 0 5901 Other Ancillary Services-Podiatry 88211 105 0 208 59 0 0 0 0 0 0 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 639725 2952 1 5869 1657 0 0 0 0 0 0 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 53055 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 131509127 741495 142 1368536 386440 0 0 0 0 0 0 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

Caroline Castaneda Page 3

If you disagree with the decision of the Department you may appeal by writing to

John Melton Chief Department of Health Care Services Office of Administrative Hearings and Appeals 1029 J Street Suite 200 Sacramento CA 95814 (916) 322-5603

The written notice of disagreement must be received by the Department within 60 calendar days from the day you receive this letter A copy of this notice should be sent to

United States Postal Service (USPS) Courier (UPS FedEx etc) Assistant Chief Counsel Assistant Chief Counsel Department of Health Care Services Department of Health Care Services Office of Legal Services Office of Legal Services MS 0010 MS 0010 PO Box 997413 1501 Capitol Avenue Suite 715001 Sacramento CA 95899 Sacramento CA 95814

(916) 440-7700

The procedures that govern an appeal are contained in Welfare and Institutions Code Section 14171 and California Code of Regulations Title 22 Section 51016 et seq

If you have questions regarding this report you may call the Audits Sectionmdash Sacramento at (916) 650-6994

Original Signed By

Robert G Kvick Chief Audits SectionmdashSacramento Financial Audits Branch

Certified

cc Chief Financial Services Branch Department of Developmental Services

1600 9th Street Room 310 MS 3-3 Sacramento CA 95814

Caroline Castaneda Page 4

Deputy Director Administration Division

Department of Developmental Services 1600 9th Street Room 310 MS 3-3

Sacramento CA 95814

Chief Department of Health Care Services

Financial ManagementAccounting Section MS 1101

PO Box 997413 Sacramento CA 95899-7413

Chief Department of Health Care Services Rate Development Branch

MS 4612 PO Box 997413 Sacramento CA 95899-7413

Chief Department of Health Care Services Third Party Liability BranchRecovery Section

MS 4720 PO Box 997413 Sacramento CA 95899-7413

Chief Department of Health Care Services Medi-Cal Operations DivisionOperations Management amp Policy Section

MS 4505 PO Box 997413 Sacramento CA 95899-7413

SUMMARY OF FINDINGS

Provider Name Fiscal Period Ended

FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

SETTLEMENT COST

1 Medi-Cal STATE HOSPITAL (SCHEDULE 1) Provider NPI 1225089592 Reported

Net Change

Audited Amount Due Provider (State)

$ 30818994

$ (34388149)

$ (3569154)

2 Subprovider I (SCHEDULE 1-1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

3 Subprovider II (SCHEDULE 1-2) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

4 Medi-Cal Contract Cost (CONTRACT SCH 1) Provider NPI Reported

Net Change

Audited Cost

Audited Amount Due Provider (State)

$

$

$

0

0

0

$ 0

5 Distinct Part Nursing Facility (DPNF SCH 1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

6 Distinct Part Nursing Facility (DPNF SCH 1-1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

7 Adult Subacute (ADULT SUBACUTE SCH 1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

8 Total Medi-Cal Settlement Due Provider (State) - (Lines 1 through 7) $ (3569154)

9 Total Medi-Cal Cost $ 0

SUMMARY OF FINDINGS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

SETTLEMENT COST

10 Subacute (SUBACUTE SCH 1-1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

11 Rural Health Clinic (RHC SCH 1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

12 Rural Health Clinic (RHC 95-210 SCH 1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

13 Rural Health Clinic (RHC 95-210 SCH 1-1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

14 County Medical Services Program (CMSP SCH 1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

15 Transitional Care (TC SCH 1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

16 Total Other Settlement Due Provider - (Lines 10 through 15) $ 0

17 Total Combined Audited Settlement Due Provider (StateCMSPRHC) - (Line 8 + Line 16) $ (3569154)

STATE OF CALIFORNIA SCHEDULE 1 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REPORTED AUDITED

1 Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3) $ 128544663 $ 124176375

2 Excess Reasonable Cost Over Charges (Schedule 2) $ 0 $ 0

3 Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ NA

4 $ 0 $ 0

5 TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 128544663 $ 124176375

6 Interim Payments (Adj 1215) $ (95007525) $ (126946438)

7 Balance Due Provider (State) $ 33537138 $ (2770063)

8 Duplicate Payments (Adj ) $ 0 $ 0

9 Medicare Payments (Adj 12) $ (746407) $ (799091)

10 Adjustment for Pharmacy Dispensings (Adj 16) $ (1971737) $ 0

11 TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 30818994 $ (3569154) (To Summary of Findings)

STATE OF CALIFORNIA SCHEDULE 2 PROGRAM STATE HOSPITAL

COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REASONABLE COST OF MEDI-CAL INPATIENT SERVICES

1 Cost of Covered Services (Schedule 3)

CHARGES FOR MEDI-CAL INPATIENT SERVICES

2 Inpatient Routine Service Charges (Adj )

3 Inpatient Ancillary Service Charges (Adj )

4 Total Charges - Medi-Cal Inpatient Services

5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1)

6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4)

REPORTED AUDITED

$ 132260954 $ 128010350

$ 0 $ 0

$ 0 $ 1435172

$ 0 $ 1435172

$ 0 $ 0

$ NA $ NA (To Schedule 1)

If charges exceed reasonable cost no further calculation necessary for this schedule

STATE OF CALIFORNIA SCHEDULE 3 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REPORTED AUDITED

1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 0 $ 9544176

2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 132260954 $ 118466174

3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0

4 $ 0 $ 0

5 $ 0 $ 0

6 SUBTOTAL (Sum of Lines 1 through 5) $ 132260954 $ 128010350

7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0

8 SUBTOTAL $ 132260954 $ 128010350 (To Schedule 2)

9 Deductibles (Share of Cost)(Adj 12) $ (3685524) $ (3717366)

10 Coinsurance (Third Party Payers) (Adj 12) $ (30767) $ (116609)

11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 128544663 $ 124176375

(To Schedule 1)

STATE OF CALIFORNIA SCHEDULE 4 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED

INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 2 Inpatient Days (include private exclude swing-bed) 3 Private Room Days (exclude swing-bed private room) (Adj ) 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 9 Medi-Cal Days (excluding swing-bed) (Adj 9)

942 942

0 0 0 0 0 0

127

942942

000000

721

SWING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj )18 Medicare NF Swing-Bed Rates after Dec 31 (Adj )19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj )20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj )21 Total Routine Serv Cost (Sch 8 Line 25 Col 27)22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17)23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18)24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19)25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20)26 Total Swing-Bed Cost (Sum of Lines 22 to 25)27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26)

$ $ $ $ $ $ $ $ $ $ $

000000000000

257090400000

2570904

$ $ $ $ $ $ $ $ $ $ $

000 000 000 000

2513868 0 0 0 0 0

2513868

PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges)29 Private Room Charges (excluding swing-bed charges)30 Semi-Private Room Charges (excluding swing-bed charges)31 Gen Inpatient Routine Service CostCharge Ratio (L 27 L 28)32 Average Private Room Per Diem Charge (L 29 L 3)33 Average Semi-Private Room Per Diem Charge (L 30 L 4)34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33)35 Average Per Diem Private Room Cost Differential (L 31 x L 34)36 Private Room Cost Differential Adjustment (L 35 x L 3)37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36)

$ $ $ $ $ $ $ $ $ $

257090400

1000000000000000000

02570904

$ $ $ $ $ $ $ $ $ $

2570904 0 0

0977815 000 000 000 000

0 2513868

PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 L 2)39 Program General Inpatient Routine Service Cost (L 9 x L 38)

$ $

272920346608

$ $

266865 1924097

40 Cost Applicable to Medi-Cal (Sch 4A)41 Cost Applicable to Medi-Cal (Sch 4B)

$ $

11859640413317942

$ $

116542077 0

42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 132260954 $ 118466174 ( To Schedule 3 )

STATE OF CALIFORNIA SCHEDULE 4A PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE ANDOR NURSERY UNITS SKILLED NURSERY FACILITY 1 Total Inpatient Routine Cost (Sch 8 Line 33 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 9) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

4657466167513 6898664810

44709827

$

$

$

AUDITED

45376178675136721165288

43880718

NURSIING FACILITY 6 Total Inpatient Routine Cost (Sch 8 Line 26 Col 27) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj 9) 10 Cost Applicable to Medi-Cal

$

$

$

74993296104909 71484

103361 73886577

$

$

$

7285742610490969448

104627 72661359

CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 27 Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

NEONATAL INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 28 Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 29 Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

ADMINISTRATIVE DAYS 26 Per Diem Rate (Adj )27 Medi-Cal Inpatient Days (Adj ) 28 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

ADMINISTRATIVE DAYS 29 Per Diem Rate (Adj )30 Medi-Cal Inpatient Days (Adj ) 31 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

32 Medi-Cal Routine Cost (Sum of Lines 5101520252831) $ 118596404 $ 116542077 (To Schedule 4)

STATE OF CALIFORNIA SCHEDULE 4B PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE UNITS ALL INCLUSIVE ANCILLARY SERVICES 1 Total Ancillary Cost(Sch 63 Line 37 to 86 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 13) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

9692908173364

5591168171

9402441

$

$

$

AUDITED

9692908173364

559100

DRUG DISPENSING FEE 6 Total Inpatient Routine Cost (Sch 63 LIne 35 Col 27) 7 Total Dispensings (Adj ) 8 Cost Per Dispensings 9 Medi-Cal Dispensings (Adj 14) 10 Cost Applicable to Medi-Cal

$

$

$

3994970179166

2230175583

3915501

$

$

$

3994970179166

22300 0

11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

0 26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 13317942 $ (To Schedule 4)

0

STATE OF CALIFORNIA SCHEDULE 5 PROGRAM STATE HOSPITAL

SCHEDULE OF MEDI-CAL ANCILLARY COSTS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

TOTAL ANCILLARY

COST

TOTAL ANCILLARY UNITS

(Adj 78)

RATIO COST TO CHARGES (From Schedule 6)

MEDI-CAL UNITS COST

MEDI-CAL

ANCILLARY COST CENTERS 3700 Operating Room $ 0 $ 0 0000000 $ 0 $ 0 3800 Recovery Room 0 0 0000000 0 0 3900 Delivery Room and Labor Room 0 0 0000000 0 0 4000 Anesthesiology 0 0 0000000 0 0 4100 Radiology - Diagnostics 409054 173364 2359508 168501 397579 4101 0 0 0000000 0 0 4102 0 0 0000000 0 0 4200 Radiology - Therapeutic 0 0 0000000 0 0 4300 Radioisotope 0 0 0000000 0 0 4400 Laboratory 798223 173364 4604318 168501 775832 4401 Pathological Lab 0 0 0000000 0 0 4600 Whole Blood 0 0 0000000 0 0 4700 Blood Storing and Processing 0 0 0000000 0 0 4800 Intravenous Therapy 0 0 0000000 0 0 4900 Respiratory Therapy 1370883 173364 7907543 168501 1332429 5000 Physical Therapy 1105485 173364 6376668 168501 1074475 5100 Occupational Therapy 0 0 0000000 0 0 5200 Speech Pathology 0 0 0000000 0 0 5300 Electrocardiology 116339 173364 0671067 168501 113076 5400 Electroencephalography 0 0 0000000 0 0 5500 Medical Supplies Charged to Patients 0 0 0000000 0 0 5600 Drugs Charged to Patients 3342357 173364 19279416 168501 3248601 5700 Pharmacist 2832574 179166 15809772 87164 1378043 5800 ASC (Non-Distinct Part) 0 0 0000000 0 0 5900 Other Ancillary Services-Dentistry 1062703 173364 6129893 168501 1032893 5901 Other Ancillary Services-Podiatry 196768 173364 1134997 168501 191248 5902 0 0 0000000 0 0 5903 0 0 0000000 0 0 6000 Clinic 1976589 0 0000000 0 0 6001 Other Clinic Services 0 0 0000000 0 0 6100 Emergency 0 0 0000000 0 0 6200 Observation Beds 0 0 0000000 0 0 7100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0

TOTAL $ 13210973 $ 1566078 $ 1435172 $ 9544176 (To Schedule 3)

STATE OF CALIFORNIA PROG

SCHEDULE 6 RAM STATE HOSPITAL

ADJUSTMENTS TO MEDI-CAL CHARGES DAYS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

ANCILLARY CHARGES REPORTED

(Adj 1011) ADJUSTMENTS AUDITED

3700 Operating Room $ $ $ 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 168501 168501 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 168501 168501 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 168501 168501 5000 Physical Therapy 168501 168501 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 168501 168501 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 168501 168501 5700 Pharmacist 87164 87164 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 168501 168501 5901 Other Ancillary Services-Podiatry 168501 168501 5902 0 5903 0 6000 Clinic 0 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 1435172 $ 1435172 (To Schedule 5)

STATE OF CALIFORNIA SCHEDULE 7 PROGRAM STATE HOSPITAL

COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED

PHYSICIANS REMUNERATION

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

PROFESSIONAL SERVICE

COST CENTERS REMUNERATION

HBP

(Adj )

TOTAL CHARGES TO ALL PATIENTS

(Adj ) TO CHARGES

RATIO OF REMUNERATION CHARGES

MEDI-CAL

(Adj )

MEDI-CAL COST

4000 Anesthesiology $ 0 $ 0 0000000 $ $ 0 4100 Radiology - Diagnostic 0 0 0000000 0 4300 Radioisotope 0 0 0000000 0 4400 Laboratory 0 0 0000000 0 5300 Electrocardiology 0 0 0000000 0 5400 Electroencephalography 0 0 0000000 0 6100 Emergency 0 0 0000000 0

0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0

TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp MOVABLE BLDG amp MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 741495 200 Old Cap Rel Costs-Movable Equipmen 142 0 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 0 400 New Cap Rel Costs-Movable Equipme 386440 0 0 0 401 0 0 0 0 0 402 0 0 0 0 0 0 403 0 0 0 0 0 0 0 404 0 0 0 0 0 0 0 0 405 0 0 0 0 0 0 0 0 0 406 0 0 0 0 0 0 0 0 0 0 407 0 0 0 0 0 0 0 0 0 0 0 408 0 0 0 0 0 0 0 0 0 0 0 0 500 Employee Benefits 33531229 0 0 0 0 0 0 0 0 0 0 0 601 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 602 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 603 PurchasingReceiving 0 0 0 0 0 0 0 0 0 0 0 0 604 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 606 0 0 0 0 0 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 0 0 0 600 Administrative and General 32159423 171956 35 341828 96524 0 0 0 0 0 0 0 700 Maintenance and Repairs 2016844 20402 4 40557 11452 0 0 0 0 0 0 0 800 Operation of Plant 3181146 103383 21 205513 58032 0 0 0 0 0 0 0 900 Laundry and Linen Service 1380724 25645 5 50979 14395 0 0 0 0 0 0 0

1000 Housekeeping 2191511 3084 1 6130 1731 0 0 0 0 0 0 0 1100 Dietary 5061559 26463 5 52606 14855 0 0 0 0 0 0 0 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 840794 1519 0 3019 853 0 0 0 0 0 0 0 1600 Pharmacy 1262471 6135 1 12195 3444 0 0 0 0 0 0 0 1700 Medical Records and Library 672290 2664 1 5296 1495 0 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 7050 1 14014 3957 0 0 0 0 0 0 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 15680960 86484 18 171920 48546 0 0 0 0 0 0 0 3500 Nursing Facility 25040095 226193 47 449645 126968 0 0 0 0 0 0 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp M OVABLE BLDG amp M OVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 168426 706 0 1404 397 0 0 0 0 0 0 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 407939 1269 0 2523 712 0 0 0 0 0 0 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 615078 0 0 0 0 0 0 0 0 0 0 0 5000 Physical Therapy 522259 1246 0 2477 699 0 0 0 0 0 0 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 43549 317 0 630 178 0 0 0 0 0 0 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 2320599 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 474568 867 0 1723 486 0 0 0 0 0 0 0 5901 Other Ancillary Services-Podiatry 88211 105 0 208 59 0 0 0 0 0 0 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 639725 2952 1 5869 1657 0 0 0 0 0 0 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 53055 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 131509127 741495 142 1368536 386440 0 0 0 0 0 0 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

Caroline Castaneda Page 4

Deputy Director Administration Division

Department of Developmental Services 1600 9th Street Room 310 MS 3-3

Sacramento CA 95814

Chief Department of Health Care Services

Financial ManagementAccounting Section MS 1101

PO Box 997413 Sacramento CA 95899-7413

Chief Department of Health Care Services Rate Development Branch

MS 4612 PO Box 997413 Sacramento CA 95899-7413

Chief Department of Health Care Services Third Party Liability BranchRecovery Section

MS 4720 PO Box 997413 Sacramento CA 95899-7413

Chief Department of Health Care Services Medi-Cal Operations DivisionOperations Management amp Policy Section

MS 4505 PO Box 997413 Sacramento CA 95899-7413

SUMMARY OF FINDINGS

Provider Name Fiscal Period Ended

FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

SETTLEMENT COST

1 Medi-Cal STATE HOSPITAL (SCHEDULE 1) Provider NPI 1225089592 Reported

Net Change

Audited Amount Due Provider (State)

$ 30818994

$ (34388149)

$ (3569154)

2 Subprovider I (SCHEDULE 1-1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

3 Subprovider II (SCHEDULE 1-2) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

4 Medi-Cal Contract Cost (CONTRACT SCH 1) Provider NPI Reported

Net Change

Audited Cost

Audited Amount Due Provider (State)

$

$

$

0

0

0

$ 0

5 Distinct Part Nursing Facility (DPNF SCH 1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

6 Distinct Part Nursing Facility (DPNF SCH 1-1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

7 Adult Subacute (ADULT SUBACUTE SCH 1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

8 Total Medi-Cal Settlement Due Provider (State) - (Lines 1 through 7) $ (3569154)

9 Total Medi-Cal Cost $ 0

SUMMARY OF FINDINGS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

SETTLEMENT COST

10 Subacute (SUBACUTE SCH 1-1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

11 Rural Health Clinic (RHC SCH 1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

12 Rural Health Clinic (RHC 95-210 SCH 1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

13 Rural Health Clinic (RHC 95-210 SCH 1-1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

14 County Medical Services Program (CMSP SCH 1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

15 Transitional Care (TC SCH 1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

16 Total Other Settlement Due Provider - (Lines 10 through 15) $ 0

17 Total Combined Audited Settlement Due Provider (StateCMSPRHC) - (Line 8 + Line 16) $ (3569154)

STATE OF CALIFORNIA SCHEDULE 1 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REPORTED AUDITED

1 Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3) $ 128544663 $ 124176375

2 Excess Reasonable Cost Over Charges (Schedule 2) $ 0 $ 0

3 Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ NA

4 $ 0 $ 0

5 TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 128544663 $ 124176375

6 Interim Payments (Adj 1215) $ (95007525) $ (126946438)

7 Balance Due Provider (State) $ 33537138 $ (2770063)

8 Duplicate Payments (Adj ) $ 0 $ 0

9 Medicare Payments (Adj 12) $ (746407) $ (799091)

10 Adjustment for Pharmacy Dispensings (Adj 16) $ (1971737) $ 0

11 TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 30818994 $ (3569154) (To Summary of Findings)

STATE OF CALIFORNIA SCHEDULE 2 PROGRAM STATE HOSPITAL

COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REASONABLE COST OF MEDI-CAL INPATIENT SERVICES

1 Cost of Covered Services (Schedule 3)

CHARGES FOR MEDI-CAL INPATIENT SERVICES

2 Inpatient Routine Service Charges (Adj )

3 Inpatient Ancillary Service Charges (Adj )

4 Total Charges - Medi-Cal Inpatient Services

5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1)

6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4)

REPORTED AUDITED

$ 132260954 $ 128010350

$ 0 $ 0

$ 0 $ 1435172

$ 0 $ 1435172

$ 0 $ 0

$ NA $ NA (To Schedule 1)

If charges exceed reasonable cost no further calculation necessary for this schedule

STATE OF CALIFORNIA SCHEDULE 3 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REPORTED AUDITED

1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 0 $ 9544176

2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 132260954 $ 118466174

3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0

4 $ 0 $ 0

5 $ 0 $ 0

6 SUBTOTAL (Sum of Lines 1 through 5) $ 132260954 $ 128010350

7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0

8 SUBTOTAL $ 132260954 $ 128010350 (To Schedule 2)

9 Deductibles (Share of Cost)(Adj 12) $ (3685524) $ (3717366)

10 Coinsurance (Third Party Payers) (Adj 12) $ (30767) $ (116609)

11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 128544663 $ 124176375

(To Schedule 1)

STATE OF CALIFORNIA SCHEDULE 4 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED

INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 2 Inpatient Days (include private exclude swing-bed) 3 Private Room Days (exclude swing-bed private room) (Adj ) 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 9 Medi-Cal Days (excluding swing-bed) (Adj 9)

942 942

0 0 0 0 0 0

127

942942

000000

721

SWING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj )18 Medicare NF Swing-Bed Rates after Dec 31 (Adj )19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj )20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj )21 Total Routine Serv Cost (Sch 8 Line 25 Col 27)22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17)23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18)24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19)25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20)26 Total Swing-Bed Cost (Sum of Lines 22 to 25)27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26)

$ $ $ $ $ $ $ $ $ $ $

000000000000

257090400000

2570904

$ $ $ $ $ $ $ $ $ $ $

000 000 000 000

2513868 0 0 0 0 0

2513868

PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges)29 Private Room Charges (excluding swing-bed charges)30 Semi-Private Room Charges (excluding swing-bed charges)31 Gen Inpatient Routine Service CostCharge Ratio (L 27 L 28)32 Average Private Room Per Diem Charge (L 29 L 3)33 Average Semi-Private Room Per Diem Charge (L 30 L 4)34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33)35 Average Per Diem Private Room Cost Differential (L 31 x L 34)36 Private Room Cost Differential Adjustment (L 35 x L 3)37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36)

$ $ $ $ $ $ $ $ $ $

257090400

1000000000000000000

02570904

$ $ $ $ $ $ $ $ $ $

2570904 0 0

0977815 000 000 000 000

0 2513868

PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 L 2)39 Program General Inpatient Routine Service Cost (L 9 x L 38)

$ $

272920346608

$ $

266865 1924097

40 Cost Applicable to Medi-Cal (Sch 4A)41 Cost Applicable to Medi-Cal (Sch 4B)

$ $

11859640413317942

$ $

116542077 0

42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 132260954 $ 118466174 ( To Schedule 3 )

STATE OF CALIFORNIA SCHEDULE 4A PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE ANDOR NURSERY UNITS SKILLED NURSERY FACILITY 1 Total Inpatient Routine Cost (Sch 8 Line 33 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 9) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

4657466167513 6898664810

44709827

$

$

$

AUDITED

45376178675136721165288

43880718

NURSIING FACILITY 6 Total Inpatient Routine Cost (Sch 8 Line 26 Col 27) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj 9) 10 Cost Applicable to Medi-Cal

$

$

$

74993296104909 71484

103361 73886577

$

$

$

7285742610490969448

104627 72661359

CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 27 Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

NEONATAL INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 28 Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 29 Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

ADMINISTRATIVE DAYS 26 Per Diem Rate (Adj )27 Medi-Cal Inpatient Days (Adj ) 28 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

ADMINISTRATIVE DAYS 29 Per Diem Rate (Adj )30 Medi-Cal Inpatient Days (Adj ) 31 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

32 Medi-Cal Routine Cost (Sum of Lines 5101520252831) $ 118596404 $ 116542077 (To Schedule 4)

STATE OF CALIFORNIA SCHEDULE 4B PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE UNITS ALL INCLUSIVE ANCILLARY SERVICES 1 Total Ancillary Cost(Sch 63 Line 37 to 86 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 13) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

9692908173364

5591168171

9402441

$

$

$

AUDITED

9692908173364

559100

DRUG DISPENSING FEE 6 Total Inpatient Routine Cost (Sch 63 LIne 35 Col 27) 7 Total Dispensings (Adj ) 8 Cost Per Dispensings 9 Medi-Cal Dispensings (Adj 14) 10 Cost Applicable to Medi-Cal

$

$

$

3994970179166

2230175583

3915501

$

$

$

3994970179166

22300 0

11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

0 26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 13317942 $ (To Schedule 4)

0

STATE OF CALIFORNIA SCHEDULE 5 PROGRAM STATE HOSPITAL

SCHEDULE OF MEDI-CAL ANCILLARY COSTS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

TOTAL ANCILLARY

COST

TOTAL ANCILLARY UNITS

(Adj 78)

RATIO COST TO CHARGES (From Schedule 6)

MEDI-CAL UNITS COST

MEDI-CAL

ANCILLARY COST CENTERS 3700 Operating Room $ 0 $ 0 0000000 $ 0 $ 0 3800 Recovery Room 0 0 0000000 0 0 3900 Delivery Room and Labor Room 0 0 0000000 0 0 4000 Anesthesiology 0 0 0000000 0 0 4100 Radiology - Diagnostics 409054 173364 2359508 168501 397579 4101 0 0 0000000 0 0 4102 0 0 0000000 0 0 4200 Radiology - Therapeutic 0 0 0000000 0 0 4300 Radioisotope 0 0 0000000 0 0 4400 Laboratory 798223 173364 4604318 168501 775832 4401 Pathological Lab 0 0 0000000 0 0 4600 Whole Blood 0 0 0000000 0 0 4700 Blood Storing and Processing 0 0 0000000 0 0 4800 Intravenous Therapy 0 0 0000000 0 0 4900 Respiratory Therapy 1370883 173364 7907543 168501 1332429 5000 Physical Therapy 1105485 173364 6376668 168501 1074475 5100 Occupational Therapy 0 0 0000000 0 0 5200 Speech Pathology 0 0 0000000 0 0 5300 Electrocardiology 116339 173364 0671067 168501 113076 5400 Electroencephalography 0 0 0000000 0 0 5500 Medical Supplies Charged to Patients 0 0 0000000 0 0 5600 Drugs Charged to Patients 3342357 173364 19279416 168501 3248601 5700 Pharmacist 2832574 179166 15809772 87164 1378043 5800 ASC (Non-Distinct Part) 0 0 0000000 0 0 5900 Other Ancillary Services-Dentistry 1062703 173364 6129893 168501 1032893 5901 Other Ancillary Services-Podiatry 196768 173364 1134997 168501 191248 5902 0 0 0000000 0 0 5903 0 0 0000000 0 0 6000 Clinic 1976589 0 0000000 0 0 6001 Other Clinic Services 0 0 0000000 0 0 6100 Emergency 0 0 0000000 0 0 6200 Observation Beds 0 0 0000000 0 0 7100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0

TOTAL $ 13210973 $ 1566078 $ 1435172 $ 9544176 (To Schedule 3)

STATE OF CALIFORNIA PROG

SCHEDULE 6 RAM STATE HOSPITAL

ADJUSTMENTS TO MEDI-CAL CHARGES DAYS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

ANCILLARY CHARGES REPORTED

(Adj 1011) ADJUSTMENTS AUDITED

3700 Operating Room $ $ $ 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 168501 168501 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 168501 168501 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 168501 168501 5000 Physical Therapy 168501 168501 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 168501 168501 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 168501 168501 5700 Pharmacist 87164 87164 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 168501 168501 5901 Other Ancillary Services-Podiatry 168501 168501 5902 0 5903 0 6000 Clinic 0 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 1435172 $ 1435172 (To Schedule 5)

STATE OF CALIFORNIA SCHEDULE 7 PROGRAM STATE HOSPITAL

COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED

PHYSICIANS REMUNERATION

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

PROFESSIONAL SERVICE

COST CENTERS REMUNERATION

HBP

(Adj )

TOTAL CHARGES TO ALL PATIENTS

(Adj ) TO CHARGES

RATIO OF REMUNERATION CHARGES

MEDI-CAL

(Adj )

MEDI-CAL COST

4000 Anesthesiology $ 0 $ 0 0000000 $ $ 0 4100 Radiology - Diagnostic 0 0 0000000 0 4300 Radioisotope 0 0 0000000 0 4400 Laboratory 0 0 0000000 0 5300 Electrocardiology 0 0 0000000 0 5400 Electroencephalography 0 0 0000000 0 6100 Emergency 0 0 0000000 0

0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0

TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp MOVABLE BLDG amp MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 741495 200 Old Cap Rel Costs-Movable Equipmen 142 0 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 0 400 New Cap Rel Costs-Movable Equipme 386440 0 0 0 401 0 0 0 0 0 402 0 0 0 0 0 0 403 0 0 0 0 0 0 0 404 0 0 0 0 0 0 0 0 405 0 0 0 0 0 0 0 0 0 406 0 0 0 0 0 0 0 0 0 0 407 0 0 0 0 0 0 0 0 0 0 0 408 0 0 0 0 0 0 0 0 0 0 0 0 500 Employee Benefits 33531229 0 0 0 0 0 0 0 0 0 0 0 601 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 602 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 603 PurchasingReceiving 0 0 0 0 0 0 0 0 0 0 0 0 604 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 606 0 0 0 0 0 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 0 0 0 600 Administrative and General 32159423 171956 35 341828 96524 0 0 0 0 0 0 0 700 Maintenance and Repairs 2016844 20402 4 40557 11452 0 0 0 0 0 0 0 800 Operation of Plant 3181146 103383 21 205513 58032 0 0 0 0 0 0 0 900 Laundry and Linen Service 1380724 25645 5 50979 14395 0 0 0 0 0 0 0

1000 Housekeeping 2191511 3084 1 6130 1731 0 0 0 0 0 0 0 1100 Dietary 5061559 26463 5 52606 14855 0 0 0 0 0 0 0 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 840794 1519 0 3019 853 0 0 0 0 0 0 0 1600 Pharmacy 1262471 6135 1 12195 3444 0 0 0 0 0 0 0 1700 Medical Records and Library 672290 2664 1 5296 1495 0 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 7050 1 14014 3957 0 0 0 0 0 0 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 15680960 86484 18 171920 48546 0 0 0 0 0 0 0 3500 Nursing Facility 25040095 226193 47 449645 126968 0 0 0 0 0 0 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp M OVABLE BLDG amp M OVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 168426 706 0 1404 397 0 0 0 0 0 0 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 407939 1269 0 2523 712 0 0 0 0 0 0 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 615078 0 0 0 0 0 0 0 0 0 0 0 5000 Physical Therapy 522259 1246 0 2477 699 0 0 0 0 0 0 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 43549 317 0 630 178 0 0 0 0 0 0 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 2320599 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 474568 867 0 1723 486 0 0 0 0 0 0 0 5901 Other Ancillary Services-Podiatry 88211 105 0 208 59 0 0 0 0 0 0 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 639725 2952 1 5869 1657 0 0 0 0 0 0 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 53055 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 131509127 741495 142 1368536 386440 0 0 0 0 0 0 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

SUMMARY OF FINDINGS

Provider Name Fiscal Period Ended

FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

SETTLEMENT COST

1 Medi-Cal STATE HOSPITAL (SCHEDULE 1) Provider NPI 1225089592 Reported

Net Change

Audited Amount Due Provider (State)

$ 30818994

$ (34388149)

$ (3569154)

2 Subprovider I (SCHEDULE 1-1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

3 Subprovider II (SCHEDULE 1-2) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

4 Medi-Cal Contract Cost (CONTRACT SCH 1) Provider NPI Reported

Net Change

Audited Cost

Audited Amount Due Provider (State)

$

$

$

0

0

0

$ 0

5 Distinct Part Nursing Facility (DPNF SCH 1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

6 Distinct Part Nursing Facility (DPNF SCH 1-1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

7 Adult Subacute (ADULT SUBACUTE SCH 1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

8 Total Medi-Cal Settlement Due Provider (State) - (Lines 1 through 7) $ (3569154)

9 Total Medi-Cal Cost $ 0

SUMMARY OF FINDINGS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

SETTLEMENT COST

10 Subacute (SUBACUTE SCH 1-1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

11 Rural Health Clinic (RHC SCH 1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

12 Rural Health Clinic (RHC 95-210 SCH 1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

13 Rural Health Clinic (RHC 95-210 SCH 1-1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

14 County Medical Services Program (CMSP SCH 1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

15 Transitional Care (TC SCH 1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

16 Total Other Settlement Due Provider - (Lines 10 through 15) $ 0

17 Total Combined Audited Settlement Due Provider (StateCMSPRHC) - (Line 8 + Line 16) $ (3569154)

STATE OF CALIFORNIA SCHEDULE 1 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REPORTED AUDITED

1 Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3) $ 128544663 $ 124176375

2 Excess Reasonable Cost Over Charges (Schedule 2) $ 0 $ 0

3 Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ NA

4 $ 0 $ 0

5 TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 128544663 $ 124176375

6 Interim Payments (Adj 1215) $ (95007525) $ (126946438)

7 Balance Due Provider (State) $ 33537138 $ (2770063)

8 Duplicate Payments (Adj ) $ 0 $ 0

9 Medicare Payments (Adj 12) $ (746407) $ (799091)

10 Adjustment for Pharmacy Dispensings (Adj 16) $ (1971737) $ 0

11 TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 30818994 $ (3569154) (To Summary of Findings)

STATE OF CALIFORNIA SCHEDULE 2 PROGRAM STATE HOSPITAL

COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REASONABLE COST OF MEDI-CAL INPATIENT SERVICES

1 Cost of Covered Services (Schedule 3)

CHARGES FOR MEDI-CAL INPATIENT SERVICES

2 Inpatient Routine Service Charges (Adj )

3 Inpatient Ancillary Service Charges (Adj )

4 Total Charges - Medi-Cal Inpatient Services

5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1)

6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4)

REPORTED AUDITED

$ 132260954 $ 128010350

$ 0 $ 0

$ 0 $ 1435172

$ 0 $ 1435172

$ 0 $ 0

$ NA $ NA (To Schedule 1)

If charges exceed reasonable cost no further calculation necessary for this schedule

STATE OF CALIFORNIA SCHEDULE 3 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REPORTED AUDITED

1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 0 $ 9544176

2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 132260954 $ 118466174

3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0

4 $ 0 $ 0

5 $ 0 $ 0

6 SUBTOTAL (Sum of Lines 1 through 5) $ 132260954 $ 128010350

7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0

8 SUBTOTAL $ 132260954 $ 128010350 (To Schedule 2)

9 Deductibles (Share of Cost)(Adj 12) $ (3685524) $ (3717366)

10 Coinsurance (Third Party Payers) (Adj 12) $ (30767) $ (116609)

11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 128544663 $ 124176375

(To Schedule 1)

STATE OF CALIFORNIA SCHEDULE 4 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED

INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 2 Inpatient Days (include private exclude swing-bed) 3 Private Room Days (exclude swing-bed private room) (Adj ) 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 9 Medi-Cal Days (excluding swing-bed) (Adj 9)

942 942

0 0 0 0 0 0

127

942942

000000

721

SWING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj )18 Medicare NF Swing-Bed Rates after Dec 31 (Adj )19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj )20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj )21 Total Routine Serv Cost (Sch 8 Line 25 Col 27)22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17)23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18)24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19)25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20)26 Total Swing-Bed Cost (Sum of Lines 22 to 25)27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26)

$ $ $ $ $ $ $ $ $ $ $

000000000000

257090400000

2570904

$ $ $ $ $ $ $ $ $ $ $

000 000 000 000

2513868 0 0 0 0 0

2513868

PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges)29 Private Room Charges (excluding swing-bed charges)30 Semi-Private Room Charges (excluding swing-bed charges)31 Gen Inpatient Routine Service CostCharge Ratio (L 27 L 28)32 Average Private Room Per Diem Charge (L 29 L 3)33 Average Semi-Private Room Per Diem Charge (L 30 L 4)34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33)35 Average Per Diem Private Room Cost Differential (L 31 x L 34)36 Private Room Cost Differential Adjustment (L 35 x L 3)37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36)

$ $ $ $ $ $ $ $ $ $

257090400

1000000000000000000

02570904

$ $ $ $ $ $ $ $ $ $

2570904 0 0

0977815 000 000 000 000

0 2513868

PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 L 2)39 Program General Inpatient Routine Service Cost (L 9 x L 38)

$ $

272920346608

$ $

266865 1924097

40 Cost Applicable to Medi-Cal (Sch 4A)41 Cost Applicable to Medi-Cal (Sch 4B)

$ $

11859640413317942

$ $

116542077 0

42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 132260954 $ 118466174 ( To Schedule 3 )

STATE OF CALIFORNIA SCHEDULE 4A PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE ANDOR NURSERY UNITS SKILLED NURSERY FACILITY 1 Total Inpatient Routine Cost (Sch 8 Line 33 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 9) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

4657466167513 6898664810

44709827

$

$

$

AUDITED

45376178675136721165288

43880718

NURSIING FACILITY 6 Total Inpatient Routine Cost (Sch 8 Line 26 Col 27) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj 9) 10 Cost Applicable to Medi-Cal

$

$

$

74993296104909 71484

103361 73886577

$

$

$

7285742610490969448

104627 72661359

CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 27 Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

NEONATAL INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 28 Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 29 Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

ADMINISTRATIVE DAYS 26 Per Diem Rate (Adj )27 Medi-Cal Inpatient Days (Adj ) 28 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

ADMINISTRATIVE DAYS 29 Per Diem Rate (Adj )30 Medi-Cal Inpatient Days (Adj ) 31 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

32 Medi-Cal Routine Cost (Sum of Lines 5101520252831) $ 118596404 $ 116542077 (To Schedule 4)

STATE OF CALIFORNIA SCHEDULE 4B PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE UNITS ALL INCLUSIVE ANCILLARY SERVICES 1 Total Ancillary Cost(Sch 63 Line 37 to 86 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 13) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

9692908173364

5591168171

9402441

$

$

$

AUDITED

9692908173364

559100

DRUG DISPENSING FEE 6 Total Inpatient Routine Cost (Sch 63 LIne 35 Col 27) 7 Total Dispensings (Adj ) 8 Cost Per Dispensings 9 Medi-Cal Dispensings (Adj 14) 10 Cost Applicable to Medi-Cal

$

$

$

3994970179166

2230175583

3915501

$

$

$

3994970179166

22300 0

11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

0 26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 13317942 $ (To Schedule 4)

0

STATE OF CALIFORNIA SCHEDULE 5 PROGRAM STATE HOSPITAL

SCHEDULE OF MEDI-CAL ANCILLARY COSTS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

TOTAL ANCILLARY

COST

TOTAL ANCILLARY UNITS

(Adj 78)

RATIO COST TO CHARGES (From Schedule 6)

MEDI-CAL UNITS COST

MEDI-CAL

ANCILLARY COST CENTERS 3700 Operating Room $ 0 $ 0 0000000 $ 0 $ 0 3800 Recovery Room 0 0 0000000 0 0 3900 Delivery Room and Labor Room 0 0 0000000 0 0 4000 Anesthesiology 0 0 0000000 0 0 4100 Radiology - Diagnostics 409054 173364 2359508 168501 397579 4101 0 0 0000000 0 0 4102 0 0 0000000 0 0 4200 Radiology - Therapeutic 0 0 0000000 0 0 4300 Radioisotope 0 0 0000000 0 0 4400 Laboratory 798223 173364 4604318 168501 775832 4401 Pathological Lab 0 0 0000000 0 0 4600 Whole Blood 0 0 0000000 0 0 4700 Blood Storing and Processing 0 0 0000000 0 0 4800 Intravenous Therapy 0 0 0000000 0 0 4900 Respiratory Therapy 1370883 173364 7907543 168501 1332429 5000 Physical Therapy 1105485 173364 6376668 168501 1074475 5100 Occupational Therapy 0 0 0000000 0 0 5200 Speech Pathology 0 0 0000000 0 0 5300 Electrocardiology 116339 173364 0671067 168501 113076 5400 Electroencephalography 0 0 0000000 0 0 5500 Medical Supplies Charged to Patients 0 0 0000000 0 0 5600 Drugs Charged to Patients 3342357 173364 19279416 168501 3248601 5700 Pharmacist 2832574 179166 15809772 87164 1378043 5800 ASC (Non-Distinct Part) 0 0 0000000 0 0 5900 Other Ancillary Services-Dentistry 1062703 173364 6129893 168501 1032893 5901 Other Ancillary Services-Podiatry 196768 173364 1134997 168501 191248 5902 0 0 0000000 0 0 5903 0 0 0000000 0 0 6000 Clinic 1976589 0 0000000 0 0 6001 Other Clinic Services 0 0 0000000 0 0 6100 Emergency 0 0 0000000 0 0 6200 Observation Beds 0 0 0000000 0 0 7100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0

TOTAL $ 13210973 $ 1566078 $ 1435172 $ 9544176 (To Schedule 3)

STATE OF CALIFORNIA PROG

SCHEDULE 6 RAM STATE HOSPITAL

ADJUSTMENTS TO MEDI-CAL CHARGES DAYS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

ANCILLARY CHARGES REPORTED

(Adj 1011) ADJUSTMENTS AUDITED

3700 Operating Room $ $ $ 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 168501 168501 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 168501 168501 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 168501 168501 5000 Physical Therapy 168501 168501 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 168501 168501 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 168501 168501 5700 Pharmacist 87164 87164 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 168501 168501 5901 Other Ancillary Services-Podiatry 168501 168501 5902 0 5903 0 6000 Clinic 0 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 1435172 $ 1435172 (To Schedule 5)

STATE OF CALIFORNIA SCHEDULE 7 PROGRAM STATE HOSPITAL

COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED

PHYSICIANS REMUNERATION

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

PROFESSIONAL SERVICE

COST CENTERS REMUNERATION

HBP

(Adj )

TOTAL CHARGES TO ALL PATIENTS

(Adj ) TO CHARGES

RATIO OF REMUNERATION CHARGES

MEDI-CAL

(Adj )

MEDI-CAL COST

4000 Anesthesiology $ 0 $ 0 0000000 $ $ 0 4100 Radiology - Diagnostic 0 0 0000000 0 4300 Radioisotope 0 0 0000000 0 4400 Laboratory 0 0 0000000 0 5300 Electrocardiology 0 0 0000000 0 5400 Electroencephalography 0 0 0000000 0 6100 Emergency 0 0 0000000 0

0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0

TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp MOVABLE BLDG amp MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 741495 200 Old Cap Rel Costs-Movable Equipmen 142 0 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 0 400 New Cap Rel Costs-Movable Equipme 386440 0 0 0 401 0 0 0 0 0 402 0 0 0 0 0 0 403 0 0 0 0 0 0 0 404 0 0 0 0 0 0 0 0 405 0 0 0 0 0 0 0 0 0 406 0 0 0 0 0 0 0 0 0 0 407 0 0 0 0 0 0 0 0 0 0 0 408 0 0 0 0 0 0 0 0 0 0 0 0 500 Employee Benefits 33531229 0 0 0 0 0 0 0 0 0 0 0 601 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 602 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 603 PurchasingReceiving 0 0 0 0 0 0 0 0 0 0 0 0 604 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 606 0 0 0 0 0 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 0 0 0 600 Administrative and General 32159423 171956 35 341828 96524 0 0 0 0 0 0 0 700 Maintenance and Repairs 2016844 20402 4 40557 11452 0 0 0 0 0 0 0 800 Operation of Plant 3181146 103383 21 205513 58032 0 0 0 0 0 0 0 900 Laundry and Linen Service 1380724 25645 5 50979 14395 0 0 0 0 0 0 0

1000 Housekeeping 2191511 3084 1 6130 1731 0 0 0 0 0 0 0 1100 Dietary 5061559 26463 5 52606 14855 0 0 0 0 0 0 0 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 840794 1519 0 3019 853 0 0 0 0 0 0 0 1600 Pharmacy 1262471 6135 1 12195 3444 0 0 0 0 0 0 0 1700 Medical Records and Library 672290 2664 1 5296 1495 0 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 7050 1 14014 3957 0 0 0 0 0 0 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 15680960 86484 18 171920 48546 0 0 0 0 0 0 0 3500 Nursing Facility 25040095 226193 47 449645 126968 0 0 0 0 0 0 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp M OVABLE BLDG amp M OVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 168426 706 0 1404 397 0 0 0 0 0 0 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 407939 1269 0 2523 712 0 0 0 0 0 0 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 615078 0 0 0 0 0 0 0 0 0 0 0 5000 Physical Therapy 522259 1246 0 2477 699 0 0 0 0 0 0 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 43549 317 0 630 178 0 0 0 0 0 0 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 2320599 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 474568 867 0 1723 486 0 0 0 0 0 0 0 5901 Other Ancillary Services-Podiatry 88211 105 0 208 59 0 0 0 0 0 0 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 639725 2952 1 5869 1657 0 0 0 0 0 0 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 53055 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 131509127 741495 142 1368536 386440 0 0 0 0 0 0 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

SUMMARY OF FINDINGS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

SETTLEMENT COST

10 Subacute (SUBACUTE SCH 1-1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

11 Rural Health Clinic (RHC SCH 1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

12 Rural Health Clinic (RHC 95-210 SCH 1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

13 Rural Health Clinic (RHC 95-210 SCH 1-1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

14 County Medical Services Program (CMSP SCH 1) Provider NPI Reported

Net Change

Audited Amount Due Provider (State)

$ 0

$ 0

$ 0

15 Transitional Care (TC SCH 1) Provider NPI Reported

Net Change

Audited Cost Per Day

Audited Amount Due Provider (State)

$

$

$

000

000

000

$ 0

16 Total Other Settlement Due Provider - (Lines 10 through 15) $ 0

17 Total Combined Audited Settlement Due Provider (StateCMSPRHC) - (Line 8 + Line 16) $ (3569154)

STATE OF CALIFORNIA SCHEDULE 1 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REPORTED AUDITED

1 Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3) $ 128544663 $ 124176375

2 Excess Reasonable Cost Over Charges (Schedule 2) $ 0 $ 0

3 Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ NA

4 $ 0 $ 0

5 TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 128544663 $ 124176375

6 Interim Payments (Adj 1215) $ (95007525) $ (126946438)

7 Balance Due Provider (State) $ 33537138 $ (2770063)

8 Duplicate Payments (Adj ) $ 0 $ 0

9 Medicare Payments (Adj 12) $ (746407) $ (799091)

10 Adjustment for Pharmacy Dispensings (Adj 16) $ (1971737) $ 0

11 TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 30818994 $ (3569154) (To Summary of Findings)

STATE OF CALIFORNIA SCHEDULE 2 PROGRAM STATE HOSPITAL

COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REASONABLE COST OF MEDI-CAL INPATIENT SERVICES

1 Cost of Covered Services (Schedule 3)

CHARGES FOR MEDI-CAL INPATIENT SERVICES

2 Inpatient Routine Service Charges (Adj )

3 Inpatient Ancillary Service Charges (Adj )

4 Total Charges - Medi-Cal Inpatient Services

5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1)

6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4)

REPORTED AUDITED

$ 132260954 $ 128010350

$ 0 $ 0

$ 0 $ 1435172

$ 0 $ 1435172

$ 0 $ 0

$ NA $ NA (To Schedule 1)

If charges exceed reasonable cost no further calculation necessary for this schedule

STATE OF CALIFORNIA SCHEDULE 3 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REPORTED AUDITED

1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 0 $ 9544176

2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 132260954 $ 118466174

3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0

4 $ 0 $ 0

5 $ 0 $ 0

6 SUBTOTAL (Sum of Lines 1 through 5) $ 132260954 $ 128010350

7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0

8 SUBTOTAL $ 132260954 $ 128010350 (To Schedule 2)

9 Deductibles (Share of Cost)(Adj 12) $ (3685524) $ (3717366)

10 Coinsurance (Third Party Payers) (Adj 12) $ (30767) $ (116609)

11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 128544663 $ 124176375

(To Schedule 1)

STATE OF CALIFORNIA SCHEDULE 4 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED

INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 2 Inpatient Days (include private exclude swing-bed) 3 Private Room Days (exclude swing-bed private room) (Adj ) 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 9 Medi-Cal Days (excluding swing-bed) (Adj 9)

942 942

0 0 0 0 0 0

127

942942

000000

721

SWING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj )18 Medicare NF Swing-Bed Rates after Dec 31 (Adj )19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj )20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj )21 Total Routine Serv Cost (Sch 8 Line 25 Col 27)22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17)23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18)24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19)25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20)26 Total Swing-Bed Cost (Sum of Lines 22 to 25)27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26)

$ $ $ $ $ $ $ $ $ $ $

000000000000

257090400000

2570904

$ $ $ $ $ $ $ $ $ $ $

000 000 000 000

2513868 0 0 0 0 0

2513868

PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges)29 Private Room Charges (excluding swing-bed charges)30 Semi-Private Room Charges (excluding swing-bed charges)31 Gen Inpatient Routine Service CostCharge Ratio (L 27 L 28)32 Average Private Room Per Diem Charge (L 29 L 3)33 Average Semi-Private Room Per Diem Charge (L 30 L 4)34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33)35 Average Per Diem Private Room Cost Differential (L 31 x L 34)36 Private Room Cost Differential Adjustment (L 35 x L 3)37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36)

$ $ $ $ $ $ $ $ $ $

257090400

1000000000000000000

02570904

$ $ $ $ $ $ $ $ $ $

2570904 0 0

0977815 000 000 000 000

0 2513868

PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 L 2)39 Program General Inpatient Routine Service Cost (L 9 x L 38)

$ $

272920346608

$ $

266865 1924097

40 Cost Applicable to Medi-Cal (Sch 4A)41 Cost Applicable to Medi-Cal (Sch 4B)

$ $

11859640413317942

$ $

116542077 0

42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 132260954 $ 118466174 ( To Schedule 3 )

STATE OF CALIFORNIA SCHEDULE 4A PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE ANDOR NURSERY UNITS SKILLED NURSERY FACILITY 1 Total Inpatient Routine Cost (Sch 8 Line 33 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 9) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

4657466167513 6898664810

44709827

$

$

$

AUDITED

45376178675136721165288

43880718

NURSIING FACILITY 6 Total Inpatient Routine Cost (Sch 8 Line 26 Col 27) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj 9) 10 Cost Applicable to Medi-Cal

$

$

$

74993296104909 71484

103361 73886577

$

$

$

7285742610490969448

104627 72661359

CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 27 Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

NEONATAL INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 28 Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 29 Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

ADMINISTRATIVE DAYS 26 Per Diem Rate (Adj )27 Medi-Cal Inpatient Days (Adj ) 28 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

ADMINISTRATIVE DAYS 29 Per Diem Rate (Adj )30 Medi-Cal Inpatient Days (Adj ) 31 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

32 Medi-Cal Routine Cost (Sum of Lines 5101520252831) $ 118596404 $ 116542077 (To Schedule 4)

STATE OF CALIFORNIA SCHEDULE 4B PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE UNITS ALL INCLUSIVE ANCILLARY SERVICES 1 Total Ancillary Cost(Sch 63 Line 37 to 86 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 13) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

9692908173364

5591168171

9402441

$

$

$

AUDITED

9692908173364

559100

DRUG DISPENSING FEE 6 Total Inpatient Routine Cost (Sch 63 LIne 35 Col 27) 7 Total Dispensings (Adj ) 8 Cost Per Dispensings 9 Medi-Cal Dispensings (Adj 14) 10 Cost Applicable to Medi-Cal

$

$

$

3994970179166

2230175583

3915501

$

$

$

3994970179166

22300 0

11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

0 26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 13317942 $ (To Schedule 4)

0

STATE OF CALIFORNIA SCHEDULE 5 PROGRAM STATE HOSPITAL

SCHEDULE OF MEDI-CAL ANCILLARY COSTS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

TOTAL ANCILLARY

COST

TOTAL ANCILLARY UNITS

(Adj 78)

RATIO COST TO CHARGES (From Schedule 6)

MEDI-CAL UNITS COST

MEDI-CAL

ANCILLARY COST CENTERS 3700 Operating Room $ 0 $ 0 0000000 $ 0 $ 0 3800 Recovery Room 0 0 0000000 0 0 3900 Delivery Room and Labor Room 0 0 0000000 0 0 4000 Anesthesiology 0 0 0000000 0 0 4100 Radiology - Diagnostics 409054 173364 2359508 168501 397579 4101 0 0 0000000 0 0 4102 0 0 0000000 0 0 4200 Radiology - Therapeutic 0 0 0000000 0 0 4300 Radioisotope 0 0 0000000 0 0 4400 Laboratory 798223 173364 4604318 168501 775832 4401 Pathological Lab 0 0 0000000 0 0 4600 Whole Blood 0 0 0000000 0 0 4700 Blood Storing and Processing 0 0 0000000 0 0 4800 Intravenous Therapy 0 0 0000000 0 0 4900 Respiratory Therapy 1370883 173364 7907543 168501 1332429 5000 Physical Therapy 1105485 173364 6376668 168501 1074475 5100 Occupational Therapy 0 0 0000000 0 0 5200 Speech Pathology 0 0 0000000 0 0 5300 Electrocardiology 116339 173364 0671067 168501 113076 5400 Electroencephalography 0 0 0000000 0 0 5500 Medical Supplies Charged to Patients 0 0 0000000 0 0 5600 Drugs Charged to Patients 3342357 173364 19279416 168501 3248601 5700 Pharmacist 2832574 179166 15809772 87164 1378043 5800 ASC (Non-Distinct Part) 0 0 0000000 0 0 5900 Other Ancillary Services-Dentistry 1062703 173364 6129893 168501 1032893 5901 Other Ancillary Services-Podiatry 196768 173364 1134997 168501 191248 5902 0 0 0000000 0 0 5903 0 0 0000000 0 0 6000 Clinic 1976589 0 0000000 0 0 6001 Other Clinic Services 0 0 0000000 0 0 6100 Emergency 0 0 0000000 0 0 6200 Observation Beds 0 0 0000000 0 0 7100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0

TOTAL $ 13210973 $ 1566078 $ 1435172 $ 9544176 (To Schedule 3)

STATE OF CALIFORNIA PROG

SCHEDULE 6 RAM STATE HOSPITAL

ADJUSTMENTS TO MEDI-CAL CHARGES DAYS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

ANCILLARY CHARGES REPORTED

(Adj 1011) ADJUSTMENTS AUDITED

3700 Operating Room $ $ $ 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 168501 168501 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 168501 168501 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 168501 168501 5000 Physical Therapy 168501 168501 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 168501 168501 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 168501 168501 5700 Pharmacist 87164 87164 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 168501 168501 5901 Other Ancillary Services-Podiatry 168501 168501 5902 0 5903 0 6000 Clinic 0 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 1435172 $ 1435172 (To Schedule 5)

STATE OF CALIFORNIA SCHEDULE 7 PROGRAM STATE HOSPITAL

COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED

PHYSICIANS REMUNERATION

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

PROFESSIONAL SERVICE

COST CENTERS REMUNERATION

HBP

(Adj )

TOTAL CHARGES TO ALL PATIENTS

(Adj ) TO CHARGES

RATIO OF REMUNERATION CHARGES

MEDI-CAL

(Adj )

MEDI-CAL COST

4000 Anesthesiology $ 0 $ 0 0000000 $ $ 0 4100 Radiology - Diagnostic 0 0 0000000 0 4300 Radioisotope 0 0 0000000 0 4400 Laboratory 0 0 0000000 0 5300 Electrocardiology 0 0 0000000 0 5400 Electroencephalography 0 0 0000000 0 6100 Emergency 0 0 0000000 0

0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0

TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp MOVABLE BLDG amp MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 741495 200 Old Cap Rel Costs-Movable Equipmen 142 0 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 0 400 New Cap Rel Costs-Movable Equipme 386440 0 0 0 401 0 0 0 0 0 402 0 0 0 0 0 0 403 0 0 0 0 0 0 0 404 0 0 0 0 0 0 0 0 405 0 0 0 0 0 0 0 0 0 406 0 0 0 0 0 0 0 0 0 0 407 0 0 0 0 0 0 0 0 0 0 0 408 0 0 0 0 0 0 0 0 0 0 0 0 500 Employee Benefits 33531229 0 0 0 0 0 0 0 0 0 0 0 601 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 602 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 603 PurchasingReceiving 0 0 0 0 0 0 0 0 0 0 0 0 604 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 606 0 0 0 0 0 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 0 0 0 600 Administrative and General 32159423 171956 35 341828 96524 0 0 0 0 0 0 0 700 Maintenance and Repairs 2016844 20402 4 40557 11452 0 0 0 0 0 0 0 800 Operation of Plant 3181146 103383 21 205513 58032 0 0 0 0 0 0 0 900 Laundry and Linen Service 1380724 25645 5 50979 14395 0 0 0 0 0 0 0

1000 Housekeeping 2191511 3084 1 6130 1731 0 0 0 0 0 0 0 1100 Dietary 5061559 26463 5 52606 14855 0 0 0 0 0 0 0 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 840794 1519 0 3019 853 0 0 0 0 0 0 0 1600 Pharmacy 1262471 6135 1 12195 3444 0 0 0 0 0 0 0 1700 Medical Records and Library 672290 2664 1 5296 1495 0 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 7050 1 14014 3957 0 0 0 0 0 0 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 15680960 86484 18 171920 48546 0 0 0 0 0 0 0 3500 Nursing Facility 25040095 226193 47 449645 126968 0 0 0 0 0 0 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp M OVABLE BLDG amp M OVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 168426 706 0 1404 397 0 0 0 0 0 0 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 407939 1269 0 2523 712 0 0 0 0 0 0 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 615078 0 0 0 0 0 0 0 0 0 0 0 5000 Physical Therapy 522259 1246 0 2477 699 0 0 0 0 0 0 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 43549 317 0 630 178 0 0 0 0 0 0 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 2320599 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 474568 867 0 1723 486 0 0 0 0 0 0 0 5901 Other Ancillary Services-Podiatry 88211 105 0 208 59 0 0 0 0 0 0 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 639725 2952 1 5869 1657 0 0 0 0 0 0 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 53055 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 131509127 741495 142 1368536 386440 0 0 0 0 0 0 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA SCHEDULE 1 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REPORTED AUDITED

1 Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3) $ 128544663 $ 124176375

2 Excess Reasonable Cost Over Charges (Schedule 2) $ 0 $ 0

3 Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ NA

4 $ 0 $ 0

5 TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 128544663 $ 124176375

6 Interim Payments (Adj 1215) $ (95007525) $ (126946438)

7 Balance Due Provider (State) $ 33537138 $ (2770063)

8 Duplicate Payments (Adj ) $ 0 $ 0

9 Medicare Payments (Adj 12) $ (746407) $ (799091)

10 Adjustment for Pharmacy Dispensings (Adj 16) $ (1971737) $ 0

11 TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 30818994 $ (3569154) (To Summary of Findings)

STATE OF CALIFORNIA SCHEDULE 2 PROGRAM STATE HOSPITAL

COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REASONABLE COST OF MEDI-CAL INPATIENT SERVICES

1 Cost of Covered Services (Schedule 3)

CHARGES FOR MEDI-CAL INPATIENT SERVICES

2 Inpatient Routine Service Charges (Adj )

3 Inpatient Ancillary Service Charges (Adj )

4 Total Charges - Medi-Cal Inpatient Services

5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1)

6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4)

REPORTED AUDITED

$ 132260954 $ 128010350

$ 0 $ 0

$ 0 $ 1435172

$ 0 $ 1435172

$ 0 $ 0

$ NA $ NA (To Schedule 1)

If charges exceed reasonable cost no further calculation necessary for this schedule

STATE OF CALIFORNIA SCHEDULE 3 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REPORTED AUDITED

1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 0 $ 9544176

2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 132260954 $ 118466174

3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0

4 $ 0 $ 0

5 $ 0 $ 0

6 SUBTOTAL (Sum of Lines 1 through 5) $ 132260954 $ 128010350

7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0

8 SUBTOTAL $ 132260954 $ 128010350 (To Schedule 2)

9 Deductibles (Share of Cost)(Adj 12) $ (3685524) $ (3717366)

10 Coinsurance (Third Party Payers) (Adj 12) $ (30767) $ (116609)

11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 128544663 $ 124176375

(To Schedule 1)

STATE OF CALIFORNIA SCHEDULE 4 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED

INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 2 Inpatient Days (include private exclude swing-bed) 3 Private Room Days (exclude swing-bed private room) (Adj ) 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 9 Medi-Cal Days (excluding swing-bed) (Adj 9)

942 942

0 0 0 0 0 0

127

942942

000000

721

SWING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj )18 Medicare NF Swing-Bed Rates after Dec 31 (Adj )19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj )20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj )21 Total Routine Serv Cost (Sch 8 Line 25 Col 27)22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17)23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18)24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19)25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20)26 Total Swing-Bed Cost (Sum of Lines 22 to 25)27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26)

$ $ $ $ $ $ $ $ $ $ $

000000000000

257090400000

2570904

$ $ $ $ $ $ $ $ $ $ $

000 000 000 000

2513868 0 0 0 0 0

2513868

PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges)29 Private Room Charges (excluding swing-bed charges)30 Semi-Private Room Charges (excluding swing-bed charges)31 Gen Inpatient Routine Service CostCharge Ratio (L 27 L 28)32 Average Private Room Per Diem Charge (L 29 L 3)33 Average Semi-Private Room Per Diem Charge (L 30 L 4)34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33)35 Average Per Diem Private Room Cost Differential (L 31 x L 34)36 Private Room Cost Differential Adjustment (L 35 x L 3)37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36)

$ $ $ $ $ $ $ $ $ $

257090400

1000000000000000000

02570904

$ $ $ $ $ $ $ $ $ $

2570904 0 0

0977815 000 000 000 000

0 2513868

PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 L 2)39 Program General Inpatient Routine Service Cost (L 9 x L 38)

$ $

272920346608

$ $

266865 1924097

40 Cost Applicable to Medi-Cal (Sch 4A)41 Cost Applicable to Medi-Cal (Sch 4B)

$ $

11859640413317942

$ $

116542077 0

42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 132260954 $ 118466174 ( To Schedule 3 )

STATE OF CALIFORNIA SCHEDULE 4A PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE ANDOR NURSERY UNITS SKILLED NURSERY FACILITY 1 Total Inpatient Routine Cost (Sch 8 Line 33 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 9) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

4657466167513 6898664810

44709827

$

$

$

AUDITED

45376178675136721165288

43880718

NURSIING FACILITY 6 Total Inpatient Routine Cost (Sch 8 Line 26 Col 27) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj 9) 10 Cost Applicable to Medi-Cal

$

$

$

74993296104909 71484

103361 73886577

$

$

$

7285742610490969448

104627 72661359

CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 27 Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

NEONATAL INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 28 Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 29 Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

ADMINISTRATIVE DAYS 26 Per Diem Rate (Adj )27 Medi-Cal Inpatient Days (Adj ) 28 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

ADMINISTRATIVE DAYS 29 Per Diem Rate (Adj )30 Medi-Cal Inpatient Days (Adj ) 31 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

32 Medi-Cal Routine Cost (Sum of Lines 5101520252831) $ 118596404 $ 116542077 (To Schedule 4)

STATE OF CALIFORNIA SCHEDULE 4B PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE UNITS ALL INCLUSIVE ANCILLARY SERVICES 1 Total Ancillary Cost(Sch 63 Line 37 to 86 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 13) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

9692908173364

5591168171

9402441

$

$

$

AUDITED

9692908173364

559100

DRUG DISPENSING FEE 6 Total Inpatient Routine Cost (Sch 63 LIne 35 Col 27) 7 Total Dispensings (Adj ) 8 Cost Per Dispensings 9 Medi-Cal Dispensings (Adj 14) 10 Cost Applicable to Medi-Cal

$

$

$

3994970179166

2230175583

3915501

$

$

$

3994970179166

22300 0

11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

0 26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 13317942 $ (To Schedule 4)

0

STATE OF CALIFORNIA SCHEDULE 5 PROGRAM STATE HOSPITAL

SCHEDULE OF MEDI-CAL ANCILLARY COSTS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

TOTAL ANCILLARY

COST

TOTAL ANCILLARY UNITS

(Adj 78)

RATIO COST TO CHARGES (From Schedule 6)

MEDI-CAL UNITS COST

MEDI-CAL

ANCILLARY COST CENTERS 3700 Operating Room $ 0 $ 0 0000000 $ 0 $ 0 3800 Recovery Room 0 0 0000000 0 0 3900 Delivery Room and Labor Room 0 0 0000000 0 0 4000 Anesthesiology 0 0 0000000 0 0 4100 Radiology - Diagnostics 409054 173364 2359508 168501 397579 4101 0 0 0000000 0 0 4102 0 0 0000000 0 0 4200 Radiology - Therapeutic 0 0 0000000 0 0 4300 Radioisotope 0 0 0000000 0 0 4400 Laboratory 798223 173364 4604318 168501 775832 4401 Pathological Lab 0 0 0000000 0 0 4600 Whole Blood 0 0 0000000 0 0 4700 Blood Storing and Processing 0 0 0000000 0 0 4800 Intravenous Therapy 0 0 0000000 0 0 4900 Respiratory Therapy 1370883 173364 7907543 168501 1332429 5000 Physical Therapy 1105485 173364 6376668 168501 1074475 5100 Occupational Therapy 0 0 0000000 0 0 5200 Speech Pathology 0 0 0000000 0 0 5300 Electrocardiology 116339 173364 0671067 168501 113076 5400 Electroencephalography 0 0 0000000 0 0 5500 Medical Supplies Charged to Patients 0 0 0000000 0 0 5600 Drugs Charged to Patients 3342357 173364 19279416 168501 3248601 5700 Pharmacist 2832574 179166 15809772 87164 1378043 5800 ASC (Non-Distinct Part) 0 0 0000000 0 0 5900 Other Ancillary Services-Dentistry 1062703 173364 6129893 168501 1032893 5901 Other Ancillary Services-Podiatry 196768 173364 1134997 168501 191248 5902 0 0 0000000 0 0 5903 0 0 0000000 0 0 6000 Clinic 1976589 0 0000000 0 0 6001 Other Clinic Services 0 0 0000000 0 0 6100 Emergency 0 0 0000000 0 0 6200 Observation Beds 0 0 0000000 0 0 7100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0

TOTAL $ 13210973 $ 1566078 $ 1435172 $ 9544176 (To Schedule 3)

STATE OF CALIFORNIA PROG

SCHEDULE 6 RAM STATE HOSPITAL

ADJUSTMENTS TO MEDI-CAL CHARGES DAYS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

ANCILLARY CHARGES REPORTED

(Adj 1011) ADJUSTMENTS AUDITED

3700 Operating Room $ $ $ 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 168501 168501 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 168501 168501 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 168501 168501 5000 Physical Therapy 168501 168501 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 168501 168501 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 168501 168501 5700 Pharmacist 87164 87164 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 168501 168501 5901 Other Ancillary Services-Podiatry 168501 168501 5902 0 5903 0 6000 Clinic 0 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 1435172 $ 1435172 (To Schedule 5)

STATE OF CALIFORNIA SCHEDULE 7 PROGRAM STATE HOSPITAL

COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED

PHYSICIANS REMUNERATION

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

PROFESSIONAL SERVICE

COST CENTERS REMUNERATION

HBP

(Adj )

TOTAL CHARGES TO ALL PATIENTS

(Adj ) TO CHARGES

RATIO OF REMUNERATION CHARGES

MEDI-CAL

(Adj )

MEDI-CAL COST

4000 Anesthesiology $ 0 $ 0 0000000 $ $ 0 4100 Radiology - Diagnostic 0 0 0000000 0 4300 Radioisotope 0 0 0000000 0 4400 Laboratory 0 0 0000000 0 5300 Electrocardiology 0 0 0000000 0 5400 Electroencephalography 0 0 0000000 0 6100 Emergency 0 0 0000000 0

0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0

TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp MOVABLE BLDG amp MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 741495 200 Old Cap Rel Costs-Movable Equipmen 142 0 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 0 400 New Cap Rel Costs-Movable Equipme 386440 0 0 0 401 0 0 0 0 0 402 0 0 0 0 0 0 403 0 0 0 0 0 0 0 404 0 0 0 0 0 0 0 0 405 0 0 0 0 0 0 0 0 0 406 0 0 0 0 0 0 0 0 0 0 407 0 0 0 0 0 0 0 0 0 0 0 408 0 0 0 0 0 0 0 0 0 0 0 0 500 Employee Benefits 33531229 0 0 0 0 0 0 0 0 0 0 0 601 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 602 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 603 PurchasingReceiving 0 0 0 0 0 0 0 0 0 0 0 0 604 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 606 0 0 0 0 0 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 0 0 0 600 Administrative and General 32159423 171956 35 341828 96524 0 0 0 0 0 0 0 700 Maintenance and Repairs 2016844 20402 4 40557 11452 0 0 0 0 0 0 0 800 Operation of Plant 3181146 103383 21 205513 58032 0 0 0 0 0 0 0 900 Laundry and Linen Service 1380724 25645 5 50979 14395 0 0 0 0 0 0 0

1000 Housekeeping 2191511 3084 1 6130 1731 0 0 0 0 0 0 0 1100 Dietary 5061559 26463 5 52606 14855 0 0 0 0 0 0 0 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 840794 1519 0 3019 853 0 0 0 0 0 0 0 1600 Pharmacy 1262471 6135 1 12195 3444 0 0 0 0 0 0 0 1700 Medical Records and Library 672290 2664 1 5296 1495 0 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 7050 1 14014 3957 0 0 0 0 0 0 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 15680960 86484 18 171920 48546 0 0 0 0 0 0 0 3500 Nursing Facility 25040095 226193 47 449645 126968 0 0 0 0 0 0 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp M OVABLE BLDG amp M OVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 168426 706 0 1404 397 0 0 0 0 0 0 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 407939 1269 0 2523 712 0 0 0 0 0 0 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 615078 0 0 0 0 0 0 0 0 0 0 0 5000 Physical Therapy 522259 1246 0 2477 699 0 0 0 0 0 0 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 43549 317 0 630 178 0 0 0 0 0 0 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 2320599 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 474568 867 0 1723 486 0 0 0 0 0 0 0 5901 Other Ancillary Services-Podiatry 88211 105 0 208 59 0 0 0 0 0 0 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 639725 2952 1 5869 1657 0 0 0 0 0 0 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 53055 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 131509127 741495 142 1368536 386440 0 0 0 0 0 0 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA SCHEDULE 2 PROGRAM STATE HOSPITAL

COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REASONABLE COST OF MEDI-CAL INPATIENT SERVICES

1 Cost of Covered Services (Schedule 3)

CHARGES FOR MEDI-CAL INPATIENT SERVICES

2 Inpatient Routine Service Charges (Adj )

3 Inpatient Ancillary Service Charges (Adj )

4 Total Charges - Medi-Cal Inpatient Services

5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1)

6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4)

REPORTED AUDITED

$ 132260954 $ 128010350

$ 0 $ 0

$ 0 $ 1435172

$ 0 $ 1435172

$ 0 $ 0

$ NA $ NA (To Schedule 1)

If charges exceed reasonable cost no further calculation necessary for this schedule

STATE OF CALIFORNIA SCHEDULE 3 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REPORTED AUDITED

1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 0 $ 9544176

2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 132260954 $ 118466174

3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0

4 $ 0 $ 0

5 $ 0 $ 0

6 SUBTOTAL (Sum of Lines 1 through 5) $ 132260954 $ 128010350

7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0

8 SUBTOTAL $ 132260954 $ 128010350 (To Schedule 2)

9 Deductibles (Share of Cost)(Adj 12) $ (3685524) $ (3717366)

10 Coinsurance (Third Party Payers) (Adj 12) $ (30767) $ (116609)

11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 128544663 $ 124176375

(To Schedule 1)

STATE OF CALIFORNIA SCHEDULE 4 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED

INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 2 Inpatient Days (include private exclude swing-bed) 3 Private Room Days (exclude swing-bed private room) (Adj ) 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 9 Medi-Cal Days (excluding swing-bed) (Adj 9)

942 942

0 0 0 0 0 0

127

942942

000000

721

SWING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj )18 Medicare NF Swing-Bed Rates after Dec 31 (Adj )19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj )20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj )21 Total Routine Serv Cost (Sch 8 Line 25 Col 27)22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17)23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18)24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19)25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20)26 Total Swing-Bed Cost (Sum of Lines 22 to 25)27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26)

$ $ $ $ $ $ $ $ $ $ $

000000000000

257090400000

2570904

$ $ $ $ $ $ $ $ $ $ $

000 000 000 000

2513868 0 0 0 0 0

2513868

PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges)29 Private Room Charges (excluding swing-bed charges)30 Semi-Private Room Charges (excluding swing-bed charges)31 Gen Inpatient Routine Service CostCharge Ratio (L 27 L 28)32 Average Private Room Per Diem Charge (L 29 L 3)33 Average Semi-Private Room Per Diem Charge (L 30 L 4)34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33)35 Average Per Diem Private Room Cost Differential (L 31 x L 34)36 Private Room Cost Differential Adjustment (L 35 x L 3)37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36)

$ $ $ $ $ $ $ $ $ $

257090400

1000000000000000000

02570904

$ $ $ $ $ $ $ $ $ $

2570904 0 0

0977815 000 000 000 000

0 2513868

PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 L 2)39 Program General Inpatient Routine Service Cost (L 9 x L 38)

$ $

272920346608

$ $

266865 1924097

40 Cost Applicable to Medi-Cal (Sch 4A)41 Cost Applicable to Medi-Cal (Sch 4B)

$ $

11859640413317942

$ $

116542077 0

42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 132260954 $ 118466174 ( To Schedule 3 )

STATE OF CALIFORNIA SCHEDULE 4A PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE ANDOR NURSERY UNITS SKILLED NURSERY FACILITY 1 Total Inpatient Routine Cost (Sch 8 Line 33 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 9) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

4657466167513 6898664810

44709827

$

$

$

AUDITED

45376178675136721165288

43880718

NURSIING FACILITY 6 Total Inpatient Routine Cost (Sch 8 Line 26 Col 27) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj 9) 10 Cost Applicable to Medi-Cal

$

$

$

74993296104909 71484

103361 73886577

$

$

$

7285742610490969448

104627 72661359

CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 27 Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

NEONATAL INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 28 Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 29 Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

ADMINISTRATIVE DAYS 26 Per Diem Rate (Adj )27 Medi-Cal Inpatient Days (Adj ) 28 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

ADMINISTRATIVE DAYS 29 Per Diem Rate (Adj )30 Medi-Cal Inpatient Days (Adj ) 31 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

32 Medi-Cal Routine Cost (Sum of Lines 5101520252831) $ 118596404 $ 116542077 (To Schedule 4)

STATE OF CALIFORNIA SCHEDULE 4B PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE UNITS ALL INCLUSIVE ANCILLARY SERVICES 1 Total Ancillary Cost(Sch 63 Line 37 to 86 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 13) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

9692908173364

5591168171

9402441

$

$

$

AUDITED

9692908173364

559100

DRUG DISPENSING FEE 6 Total Inpatient Routine Cost (Sch 63 LIne 35 Col 27) 7 Total Dispensings (Adj ) 8 Cost Per Dispensings 9 Medi-Cal Dispensings (Adj 14) 10 Cost Applicable to Medi-Cal

$

$

$

3994970179166

2230175583

3915501

$

$

$

3994970179166

22300 0

11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

0 26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 13317942 $ (To Schedule 4)

0

STATE OF CALIFORNIA SCHEDULE 5 PROGRAM STATE HOSPITAL

SCHEDULE OF MEDI-CAL ANCILLARY COSTS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

TOTAL ANCILLARY

COST

TOTAL ANCILLARY UNITS

(Adj 78)

RATIO COST TO CHARGES (From Schedule 6)

MEDI-CAL UNITS COST

MEDI-CAL

ANCILLARY COST CENTERS 3700 Operating Room $ 0 $ 0 0000000 $ 0 $ 0 3800 Recovery Room 0 0 0000000 0 0 3900 Delivery Room and Labor Room 0 0 0000000 0 0 4000 Anesthesiology 0 0 0000000 0 0 4100 Radiology - Diagnostics 409054 173364 2359508 168501 397579 4101 0 0 0000000 0 0 4102 0 0 0000000 0 0 4200 Radiology - Therapeutic 0 0 0000000 0 0 4300 Radioisotope 0 0 0000000 0 0 4400 Laboratory 798223 173364 4604318 168501 775832 4401 Pathological Lab 0 0 0000000 0 0 4600 Whole Blood 0 0 0000000 0 0 4700 Blood Storing and Processing 0 0 0000000 0 0 4800 Intravenous Therapy 0 0 0000000 0 0 4900 Respiratory Therapy 1370883 173364 7907543 168501 1332429 5000 Physical Therapy 1105485 173364 6376668 168501 1074475 5100 Occupational Therapy 0 0 0000000 0 0 5200 Speech Pathology 0 0 0000000 0 0 5300 Electrocardiology 116339 173364 0671067 168501 113076 5400 Electroencephalography 0 0 0000000 0 0 5500 Medical Supplies Charged to Patients 0 0 0000000 0 0 5600 Drugs Charged to Patients 3342357 173364 19279416 168501 3248601 5700 Pharmacist 2832574 179166 15809772 87164 1378043 5800 ASC (Non-Distinct Part) 0 0 0000000 0 0 5900 Other Ancillary Services-Dentistry 1062703 173364 6129893 168501 1032893 5901 Other Ancillary Services-Podiatry 196768 173364 1134997 168501 191248 5902 0 0 0000000 0 0 5903 0 0 0000000 0 0 6000 Clinic 1976589 0 0000000 0 0 6001 Other Clinic Services 0 0 0000000 0 0 6100 Emergency 0 0 0000000 0 0 6200 Observation Beds 0 0 0000000 0 0 7100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0

TOTAL $ 13210973 $ 1566078 $ 1435172 $ 9544176 (To Schedule 3)

STATE OF CALIFORNIA PROG

SCHEDULE 6 RAM STATE HOSPITAL

ADJUSTMENTS TO MEDI-CAL CHARGES DAYS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

ANCILLARY CHARGES REPORTED

(Adj 1011) ADJUSTMENTS AUDITED

3700 Operating Room $ $ $ 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 168501 168501 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 168501 168501 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 168501 168501 5000 Physical Therapy 168501 168501 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 168501 168501 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 168501 168501 5700 Pharmacist 87164 87164 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 168501 168501 5901 Other Ancillary Services-Podiatry 168501 168501 5902 0 5903 0 6000 Clinic 0 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 1435172 $ 1435172 (To Schedule 5)

STATE OF CALIFORNIA SCHEDULE 7 PROGRAM STATE HOSPITAL

COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED

PHYSICIANS REMUNERATION

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

PROFESSIONAL SERVICE

COST CENTERS REMUNERATION

HBP

(Adj )

TOTAL CHARGES TO ALL PATIENTS

(Adj ) TO CHARGES

RATIO OF REMUNERATION CHARGES

MEDI-CAL

(Adj )

MEDI-CAL COST

4000 Anesthesiology $ 0 $ 0 0000000 $ $ 0 4100 Radiology - Diagnostic 0 0 0000000 0 4300 Radioisotope 0 0 0000000 0 4400 Laboratory 0 0 0000000 0 5300 Electrocardiology 0 0 0000000 0 5400 Electroencephalography 0 0 0000000 0 6100 Emergency 0 0 0000000 0

0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0

TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp MOVABLE BLDG amp MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 741495 200 Old Cap Rel Costs-Movable Equipmen 142 0 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 0 400 New Cap Rel Costs-Movable Equipme 386440 0 0 0 401 0 0 0 0 0 402 0 0 0 0 0 0 403 0 0 0 0 0 0 0 404 0 0 0 0 0 0 0 0 405 0 0 0 0 0 0 0 0 0 406 0 0 0 0 0 0 0 0 0 0 407 0 0 0 0 0 0 0 0 0 0 0 408 0 0 0 0 0 0 0 0 0 0 0 0 500 Employee Benefits 33531229 0 0 0 0 0 0 0 0 0 0 0 601 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 602 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 603 PurchasingReceiving 0 0 0 0 0 0 0 0 0 0 0 0 604 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 606 0 0 0 0 0 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 0 0 0 600 Administrative and General 32159423 171956 35 341828 96524 0 0 0 0 0 0 0 700 Maintenance and Repairs 2016844 20402 4 40557 11452 0 0 0 0 0 0 0 800 Operation of Plant 3181146 103383 21 205513 58032 0 0 0 0 0 0 0 900 Laundry and Linen Service 1380724 25645 5 50979 14395 0 0 0 0 0 0 0

1000 Housekeeping 2191511 3084 1 6130 1731 0 0 0 0 0 0 0 1100 Dietary 5061559 26463 5 52606 14855 0 0 0 0 0 0 0 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 840794 1519 0 3019 853 0 0 0 0 0 0 0 1600 Pharmacy 1262471 6135 1 12195 3444 0 0 0 0 0 0 0 1700 Medical Records and Library 672290 2664 1 5296 1495 0 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 7050 1 14014 3957 0 0 0 0 0 0 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 15680960 86484 18 171920 48546 0 0 0 0 0 0 0 3500 Nursing Facility 25040095 226193 47 449645 126968 0 0 0 0 0 0 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp M OVABLE BLDG amp M OVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 168426 706 0 1404 397 0 0 0 0 0 0 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 407939 1269 0 2523 712 0 0 0 0 0 0 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 615078 0 0 0 0 0 0 0 0 0 0 0 5000 Physical Therapy 522259 1246 0 2477 699 0 0 0 0 0 0 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 43549 317 0 630 178 0 0 0 0 0 0 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 2320599 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 474568 867 0 1723 486 0 0 0 0 0 0 0 5901 Other Ancillary Services-Podiatry 88211 105 0 208 59 0 0 0 0 0 0 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 639725 2952 1 5869 1657 0 0 0 0 0 0 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 53055 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 131509127 741495 142 1368536 386440 0 0 0 0 0 0 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA SCHEDULE 3 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

REPORTED AUDITED

1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 0 $ 9544176

2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 132260954 $ 118466174

3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0

4 $ 0 $ 0

5 $ 0 $ 0

6 SUBTOTAL (Sum of Lines 1 through 5) $ 132260954 $ 128010350

7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0

8 SUBTOTAL $ 132260954 $ 128010350 (To Schedule 2)

9 Deductibles (Share of Cost)(Adj 12) $ (3685524) $ (3717366)

10 Coinsurance (Third Party Payers) (Adj 12) $ (30767) $ (116609)

11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 128544663 $ 124176375

(To Schedule 1)

STATE OF CALIFORNIA SCHEDULE 4 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED

INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 2 Inpatient Days (include private exclude swing-bed) 3 Private Room Days (exclude swing-bed private room) (Adj ) 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 9 Medi-Cal Days (excluding swing-bed) (Adj 9)

942 942

0 0 0 0 0 0

127

942942

000000

721

SWING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj )18 Medicare NF Swing-Bed Rates after Dec 31 (Adj )19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj )20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj )21 Total Routine Serv Cost (Sch 8 Line 25 Col 27)22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17)23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18)24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19)25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20)26 Total Swing-Bed Cost (Sum of Lines 22 to 25)27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26)

$ $ $ $ $ $ $ $ $ $ $

000000000000

257090400000

2570904

$ $ $ $ $ $ $ $ $ $ $

000 000 000 000

2513868 0 0 0 0 0

2513868

PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges)29 Private Room Charges (excluding swing-bed charges)30 Semi-Private Room Charges (excluding swing-bed charges)31 Gen Inpatient Routine Service CostCharge Ratio (L 27 L 28)32 Average Private Room Per Diem Charge (L 29 L 3)33 Average Semi-Private Room Per Diem Charge (L 30 L 4)34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33)35 Average Per Diem Private Room Cost Differential (L 31 x L 34)36 Private Room Cost Differential Adjustment (L 35 x L 3)37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36)

$ $ $ $ $ $ $ $ $ $

257090400

1000000000000000000

02570904

$ $ $ $ $ $ $ $ $ $

2570904 0 0

0977815 000 000 000 000

0 2513868

PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 L 2)39 Program General Inpatient Routine Service Cost (L 9 x L 38)

$ $

272920346608

$ $

266865 1924097

40 Cost Applicable to Medi-Cal (Sch 4A)41 Cost Applicable to Medi-Cal (Sch 4B)

$ $

11859640413317942

$ $

116542077 0

42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 132260954 $ 118466174 ( To Schedule 3 )

STATE OF CALIFORNIA SCHEDULE 4A PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE ANDOR NURSERY UNITS SKILLED NURSERY FACILITY 1 Total Inpatient Routine Cost (Sch 8 Line 33 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 9) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

4657466167513 6898664810

44709827

$

$

$

AUDITED

45376178675136721165288

43880718

NURSIING FACILITY 6 Total Inpatient Routine Cost (Sch 8 Line 26 Col 27) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj 9) 10 Cost Applicable to Medi-Cal

$

$

$

74993296104909 71484

103361 73886577

$

$

$

7285742610490969448

104627 72661359

CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 27 Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

NEONATAL INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 28 Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 29 Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

ADMINISTRATIVE DAYS 26 Per Diem Rate (Adj )27 Medi-Cal Inpatient Days (Adj ) 28 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

ADMINISTRATIVE DAYS 29 Per Diem Rate (Adj )30 Medi-Cal Inpatient Days (Adj ) 31 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

32 Medi-Cal Routine Cost (Sum of Lines 5101520252831) $ 118596404 $ 116542077 (To Schedule 4)

STATE OF CALIFORNIA SCHEDULE 4B PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE UNITS ALL INCLUSIVE ANCILLARY SERVICES 1 Total Ancillary Cost(Sch 63 Line 37 to 86 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 13) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

9692908173364

5591168171

9402441

$

$

$

AUDITED

9692908173364

559100

DRUG DISPENSING FEE 6 Total Inpatient Routine Cost (Sch 63 LIne 35 Col 27) 7 Total Dispensings (Adj ) 8 Cost Per Dispensings 9 Medi-Cal Dispensings (Adj 14) 10 Cost Applicable to Medi-Cal

$

$

$

3994970179166

2230175583

3915501

$

$

$

3994970179166

22300 0

11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

0 26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 13317942 $ (To Schedule 4)

0

STATE OF CALIFORNIA SCHEDULE 5 PROGRAM STATE HOSPITAL

SCHEDULE OF MEDI-CAL ANCILLARY COSTS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

TOTAL ANCILLARY

COST

TOTAL ANCILLARY UNITS

(Adj 78)

RATIO COST TO CHARGES (From Schedule 6)

MEDI-CAL UNITS COST

MEDI-CAL

ANCILLARY COST CENTERS 3700 Operating Room $ 0 $ 0 0000000 $ 0 $ 0 3800 Recovery Room 0 0 0000000 0 0 3900 Delivery Room and Labor Room 0 0 0000000 0 0 4000 Anesthesiology 0 0 0000000 0 0 4100 Radiology - Diagnostics 409054 173364 2359508 168501 397579 4101 0 0 0000000 0 0 4102 0 0 0000000 0 0 4200 Radiology - Therapeutic 0 0 0000000 0 0 4300 Radioisotope 0 0 0000000 0 0 4400 Laboratory 798223 173364 4604318 168501 775832 4401 Pathological Lab 0 0 0000000 0 0 4600 Whole Blood 0 0 0000000 0 0 4700 Blood Storing and Processing 0 0 0000000 0 0 4800 Intravenous Therapy 0 0 0000000 0 0 4900 Respiratory Therapy 1370883 173364 7907543 168501 1332429 5000 Physical Therapy 1105485 173364 6376668 168501 1074475 5100 Occupational Therapy 0 0 0000000 0 0 5200 Speech Pathology 0 0 0000000 0 0 5300 Electrocardiology 116339 173364 0671067 168501 113076 5400 Electroencephalography 0 0 0000000 0 0 5500 Medical Supplies Charged to Patients 0 0 0000000 0 0 5600 Drugs Charged to Patients 3342357 173364 19279416 168501 3248601 5700 Pharmacist 2832574 179166 15809772 87164 1378043 5800 ASC (Non-Distinct Part) 0 0 0000000 0 0 5900 Other Ancillary Services-Dentistry 1062703 173364 6129893 168501 1032893 5901 Other Ancillary Services-Podiatry 196768 173364 1134997 168501 191248 5902 0 0 0000000 0 0 5903 0 0 0000000 0 0 6000 Clinic 1976589 0 0000000 0 0 6001 Other Clinic Services 0 0 0000000 0 0 6100 Emergency 0 0 0000000 0 0 6200 Observation Beds 0 0 0000000 0 0 7100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0

TOTAL $ 13210973 $ 1566078 $ 1435172 $ 9544176 (To Schedule 3)

STATE OF CALIFORNIA PROG

SCHEDULE 6 RAM STATE HOSPITAL

ADJUSTMENTS TO MEDI-CAL CHARGES DAYS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

ANCILLARY CHARGES REPORTED

(Adj 1011) ADJUSTMENTS AUDITED

3700 Operating Room $ $ $ 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 168501 168501 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 168501 168501 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 168501 168501 5000 Physical Therapy 168501 168501 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 168501 168501 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 168501 168501 5700 Pharmacist 87164 87164 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 168501 168501 5901 Other Ancillary Services-Podiatry 168501 168501 5902 0 5903 0 6000 Clinic 0 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 1435172 $ 1435172 (To Schedule 5)

STATE OF CALIFORNIA SCHEDULE 7 PROGRAM STATE HOSPITAL

COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED

PHYSICIANS REMUNERATION

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

PROFESSIONAL SERVICE

COST CENTERS REMUNERATION

HBP

(Adj )

TOTAL CHARGES TO ALL PATIENTS

(Adj ) TO CHARGES

RATIO OF REMUNERATION CHARGES

MEDI-CAL

(Adj )

MEDI-CAL COST

4000 Anesthesiology $ 0 $ 0 0000000 $ $ 0 4100 Radiology - Diagnostic 0 0 0000000 0 4300 Radioisotope 0 0 0000000 0 4400 Laboratory 0 0 0000000 0 5300 Electrocardiology 0 0 0000000 0 5400 Electroencephalography 0 0 0000000 0 6100 Emergency 0 0 0000000 0

0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0

TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp MOVABLE BLDG amp MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 741495 200 Old Cap Rel Costs-Movable Equipmen 142 0 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 0 400 New Cap Rel Costs-Movable Equipme 386440 0 0 0 401 0 0 0 0 0 402 0 0 0 0 0 0 403 0 0 0 0 0 0 0 404 0 0 0 0 0 0 0 0 405 0 0 0 0 0 0 0 0 0 406 0 0 0 0 0 0 0 0 0 0 407 0 0 0 0 0 0 0 0 0 0 0 408 0 0 0 0 0 0 0 0 0 0 0 0 500 Employee Benefits 33531229 0 0 0 0 0 0 0 0 0 0 0 601 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 602 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 603 PurchasingReceiving 0 0 0 0 0 0 0 0 0 0 0 0 604 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 606 0 0 0 0 0 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 0 0 0 600 Administrative and General 32159423 171956 35 341828 96524 0 0 0 0 0 0 0 700 Maintenance and Repairs 2016844 20402 4 40557 11452 0 0 0 0 0 0 0 800 Operation of Plant 3181146 103383 21 205513 58032 0 0 0 0 0 0 0 900 Laundry and Linen Service 1380724 25645 5 50979 14395 0 0 0 0 0 0 0

1000 Housekeeping 2191511 3084 1 6130 1731 0 0 0 0 0 0 0 1100 Dietary 5061559 26463 5 52606 14855 0 0 0 0 0 0 0 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 840794 1519 0 3019 853 0 0 0 0 0 0 0 1600 Pharmacy 1262471 6135 1 12195 3444 0 0 0 0 0 0 0 1700 Medical Records and Library 672290 2664 1 5296 1495 0 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 7050 1 14014 3957 0 0 0 0 0 0 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 15680960 86484 18 171920 48546 0 0 0 0 0 0 0 3500 Nursing Facility 25040095 226193 47 449645 126968 0 0 0 0 0 0 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp M OVABLE BLDG amp M OVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 168426 706 0 1404 397 0 0 0 0 0 0 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 407939 1269 0 2523 712 0 0 0 0 0 0 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 615078 0 0 0 0 0 0 0 0 0 0 0 5000 Physical Therapy 522259 1246 0 2477 699 0 0 0 0 0 0 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 43549 317 0 630 178 0 0 0 0 0 0 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 2320599 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 474568 867 0 1723 486 0 0 0 0 0 0 0 5901 Other Ancillary Services-Podiatry 88211 105 0 208 59 0 0 0 0 0 0 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 639725 2952 1 5869 1657 0 0 0 0 0 0 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 53055 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 131509127 741495 142 1368536 386440 0 0 0 0 0 0 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA SCHEDULE 4 PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED

INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 2 Inpatient Days (include private exclude swing-bed) 3 Private Room Days (exclude swing-bed private room) (Adj ) 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 9 Medi-Cal Days (excluding swing-bed) (Adj 9)

942 942

0 0 0 0 0 0

127

942942

000000

721

SWING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj )18 Medicare NF Swing-Bed Rates after Dec 31 (Adj )19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj )20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj )21 Total Routine Serv Cost (Sch 8 Line 25 Col 27)22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17)23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18)24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19)25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20)26 Total Swing-Bed Cost (Sum of Lines 22 to 25)27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26)

$ $ $ $ $ $ $ $ $ $ $

000000000000

257090400000

2570904

$ $ $ $ $ $ $ $ $ $ $

000 000 000 000

2513868 0 0 0 0 0

2513868

PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges)29 Private Room Charges (excluding swing-bed charges)30 Semi-Private Room Charges (excluding swing-bed charges)31 Gen Inpatient Routine Service CostCharge Ratio (L 27 L 28)32 Average Private Room Per Diem Charge (L 29 L 3)33 Average Semi-Private Room Per Diem Charge (L 30 L 4)34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33)35 Average Per Diem Private Room Cost Differential (L 31 x L 34)36 Private Room Cost Differential Adjustment (L 35 x L 3)37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36)

$ $ $ $ $ $ $ $ $ $

257090400

1000000000000000000

02570904

$ $ $ $ $ $ $ $ $ $

2570904 0 0

0977815 000 000 000 000

0 2513868

PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 L 2)39 Program General Inpatient Routine Service Cost (L 9 x L 38)

$ $

272920346608

$ $

266865 1924097

40 Cost Applicable to Medi-Cal (Sch 4A)41 Cost Applicable to Medi-Cal (Sch 4B)

$ $

11859640413317942

$ $

116542077 0

42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 132260954 $ 118466174 ( To Schedule 3 )

STATE OF CALIFORNIA SCHEDULE 4A PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE ANDOR NURSERY UNITS SKILLED NURSERY FACILITY 1 Total Inpatient Routine Cost (Sch 8 Line 33 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 9) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

4657466167513 6898664810

44709827

$

$

$

AUDITED

45376178675136721165288

43880718

NURSIING FACILITY 6 Total Inpatient Routine Cost (Sch 8 Line 26 Col 27) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj 9) 10 Cost Applicable to Medi-Cal

$

$

$

74993296104909 71484

103361 73886577

$

$

$

7285742610490969448

104627 72661359

CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 27 Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

NEONATAL INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 28 Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 29 Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

ADMINISTRATIVE DAYS 26 Per Diem Rate (Adj )27 Medi-Cal Inpatient Days (Adj ) 28 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

ADMINISTRATIVE DAYS 29 Per Diem Rate (Adj )30 Medi-Cal Inpatient Days (Adj ) 31 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

32 Medi-Cal Routine Cost (Sum of Lines 5101520252831) $ 118596404 $ 116542077 (To Schedule 4)

STATE OF CALIFORNIA SCHEDULE 4B PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE UNITS ALL INCLUSIVE ANCILLARY SERVICES 1 Total Ancillary Cost(Sch 63 Line 37 to 86 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 13) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

9692908173364

5591168171

9402441

$

$

$

AUDITED

9692908173364

559100

DRUG DISPENSING FEE 6 Total Inpatient Routine Cost (Sch 63 LIne 35 Col 27) 7 Total Dispensings (Adj ) 8 Cost Per Dispensings 9 Medi-Cal Dispensings (Adj 14) 10 Cost Applicable to Medi-Cal

$

$

$

3994970179166

2230175583

3915501

$

$

$

3994970179166

22300 0

11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

0 26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 13317942 $ (To Schedule 4)

0

STATE OF CALIFORNIA SCHEDULE 5 PROGRAM STATE HOSPITAL

SCHEDULE OF MEDI-CAL ANCILLARY COSTS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

TOTAL ANCILLARY

COST

TOTAL ANCILLARY UNITS

(Adj 78)

RATIO COST TO CHARGES (From Schedule 6)

MEDI-CAL UNITS COST

MEDI-CAL

ANCILLARY COST CENTERS 3700 Operating Room $ 0 $ 0 0000000 $ 0 $ 0 3800 Recovery Room 0 0 0000000 0 0 3900 Delivery Room and Labor Room 0 0 0000000 0 0 4000 Anesthesiology 0 0 0000000 0 0 4100 Radiology - Diagnostics 409054 173364 2359508 168501 397579 4101 0 0 0000000 0 0 4102 0 0 0000000 0 0 4200 Radiology - Therapeutic 0 0 0000000 0 0 4300 Radioisotope 0 0 0000000 0 0 4400 Laboratory 798223 173364 4604318 168501 775832 4401 Pathological Lab 0 0 0000000 0 0 4600 Whole Blood 0 0 0000000 0 0 4700 Blood Storing and Processing 0 0 0000000 0 0 4800 Intravenous Therapy 0 0 0000000 0 0 4900 Respiratory Therapy 1370883 173364 7907543 168501 1332429 5000 Physical Therapy 1105485 173364 6376668 168501 1074475 5100 Occupational Therapy 0 0 0000000 0 0 5200 Speech Pathology 0 0 0000000 0 0 5300 Electrocardiology 116339 173364 0671067 168501 113076 5400 Electroencephalography 0 0 0000000 0 0 5500 Medical Supplies Charged to Patients 0 0 0000000 0 0 5600 Drugs Charged to Patients 3342357 173364 19279416 168501 3248601 5700 Pharmacist 2832574 179166 15809772 87164 1378043 5800 ASC (Non-Distinct Part) 0 0 0000000 0 0 5900 Other Ancillary Services-Dentistry 1062703 173364 6129893 168501 1032893 5901 Other Ancillary Services-Podiatry 196768 173364 1134997 168501 191248 5902 0 0 0000000 0 0 5903 0 0 0000000 0 0 6000 Clinic 1976589 0 0000000 0 0 6001 Other Clinic Services 0 0 0000000 0 0 6100 Emergency 0 0 0000000 0 0 6200 Observation Beds 0 0 0000000 0 0 7100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0

TOTAL $ 13210973 $ 1566078 $ 1435172 $ 9544176 (To Schedule 3)

STATE OF CALIFORNIA PROG

SCHEDULE 6 RAM STATE HOSPITAL

ADJUSTMENTS TO MEDI-CAL CHARGES DAYS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

ANCILLARY CHARGES REPORTED

(Adj 1011) ADJUSTMENTS AUDITED

3700 Operating Room $ $ $ 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 168501 168501 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 168501 168501 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 168501 168501 5000 Physical Therapy 168501 168501 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 168501 168501 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 168501 168501 5700 Pharmacist 87164 87164 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 168501 168501 5901 Other Ancillary Services-Podiatry 168501 168501 5902 0 5903 0 6000 Clinic 0 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 1435172 $ 1435172 (To Schedule 5)

STATE OF CALIFORNIA SCHEDULE 7 PROGRAM STATE HOSPITAL

COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED

PHYSICIANS REMUNERATION

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

PROFESSIONAL SERVICE

COST CENTERS REMUNERATION

HBP

(Adj )

TOTAL CHARGES TO ALL PATIENTS

(Adj ) TO CHARGES

RATIO OF REMUNERATION CHARGES

MEDI-CAL

(Adj )

MEDI-CAL COST

4000 Anesthesiology $ 0 $ 0 0000000 $ $ 0 4100 Radiology - Diagnostic 0 0 0000000 0 4300 Radioisotope 0 0 0000000 0 4400 Laboratory 0 0 0000000 0 5300 Electrocardiology 0 0 0000000 0 5400 Electroencephalography 0 0 0000000 0 6100 Emergency 0 0 0000000 0

0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0

TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp MOVABLE BLDG amp MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 741495 200 Old Cap Rel Costs-Movable Equipmen 142 0 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 0 400 New Cap Rel Costs-Movable Equipme 386440 0 0 0 401 0 0 0 0 0 402 0 0 0 0 0 0 403 0 0 0 0 0 0 0 404 0 0 0 0 0 0 0 0 405 0 0 0 0 0 0 0 0 0 406 0 0 0 0 0 0 0 0 0 0 407 0 0 0 0 0 0 0 0 0 0 0 408 0 0 0 0 0 0 0 0 0 0 0 0 500 Employee Benefits 33531229 0 0 0 0 0 0 0 0 0 0 0 601 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 602 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 603 PurchasingReceiving 0 0 0 0 0 0 0 0 0 0 0 0 604 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 606 0 0 0 0 0 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 0 0 0 600 Administrative and General 32159423 171956 35 341828 96524 0 0 0 0 0 0 0 700 Maintenance and Repairs 2016844 20402 4 40557 11452 0 0 0 0 0 0 0 800 Operation of Plant 3181146 103383 21 205513 58032 0 0 0 0 0 0 0 900 Laundry and Linen Service 1380724 25645 5 50979 14395 0 0 0 0 0 0 0

1000 Housekeeping 2191511 3084 1 6130 1731 0 0 0 0 0 0 0 1100 Dietary 5061559 26463 5 52606 14855 0 0 0 0 0 0 0 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 840794 1519 0 3019 853 0 0 0 0 0 0 0 1600 Pharmacy 1262471 6135 1 12195 3444 0 0 0 0 0 0 0 1700 Medical Records and Library 672290 2664 1 5296 1495 0 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 7050 1 14014 3957 0 0 0 0 0 0 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 15680960 86484 18 171920 48546 0 0 0 0 0 0 0 3500 Nursing Facility 25040095 226193 47 449645 126968 0 0 0 0 0 0 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp M OVABLE BLDG amp M OVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 168426 706 0 1404 397 0 0 0 0 0 0 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 407939 1269 0 2523 712 0 0 0 0 0 0 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 615078 0 0 0 0 0 0 0 0 0 0 0 5000 Physical Therapy 522259 1246 0 2477 699 0 0 0 0 0 0 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 43549 317 0 630 178 0 0 0 0 0 0 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 2320599 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 474568 867 0 1723 486 0 0 0 0 0 0 0 5901 Other Ancillary Services-Podiatry 88211 105 0 208 59 0 0 0 0 0 0 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 639725 2952 1 5869 1657 0 0 0 0 0 0 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 53055 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 131509127 741495 142 1368536 386440 0 0 0 0 0 0 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA SCHEDULE 4A PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE ANDOR NURSERY UNITS SKILLED NURSERY FACILITY 1 Total Inpatient Routine Cost (Sch 8 Line 33 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 9) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

4657466167513 6898664810

44709827

$

$

$

AUDITED

45376178675136721165288

43880718

NURSIING FACILITY 6 Total Inpatient Routine Cost (Sch 8 Line 26 Col 27) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj 9) 10 Cost Applicable to Medi-Cal

$

$

$

74993296104909 71484

103361 73886577

$

$

$

7285742610490969448

104627 72661359

CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 27 Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

NEONATAL INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 28 Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 29 Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

ADMINISTRATIVE DAYS 26 Per Diem Rate (Adj )27 Medi-Cal Inpatient Days (Adj ) 28 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

ADMINISTRATIVE DAYS 29 Per Diem Rate (Adj )30 Medi-Cal Inpatient Days (Adj ) 31 Cost Applicable to Medi-Cal

$

$

0000 0

$

$

000 0 0

32 Medi-Cal Routine Cost (Sum of Lines 5101520252831) $ 118596404 $ 116542077 (To Schedule 4)

STATE OF CALIFORNIA SCHEDULE 4B PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE UNITS ALL INCLUSIVE ANCILLARY SERVICES 1 Total Ancillary Cost(Sch 63 Line 37 to 86 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 13) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

9692908173364

5591168171

9402441

$

$

$

AUDITED

9692908173364

559100

DRUG DISPENSING FEE 6 Total Inpatient Routine Cost (Sch 63 LIne 35 Col 27) 7 Total Dispensings (Adj ) 8 Cost Per Dispensings 9 Medi-Cal Dispensings (Adj 14) 10 Cost Applicable to Medi-Cal

$

$

$

3994970179166

2230175583

3915501

$

$

$

3994970179166

22300 0

11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

0 26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 13317942 $ (To Schedule 4)

0

STATE OF CALIFORNIA SCHEDULE 5 PROGRAM STATE HOSPITAL

SCHEDULE OF MEDI-CAL ANCILLARY COSTS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

TOTAL ANCILLARY

COST

TOTAL ANCILLARY UNITS

(Adj 78)

RATIO COST TO CHARGES (From Schedule 6)

MEDI-CAL UNITS COST

MEDI-CAL

ANCILLARY COST CENTERS 3700 Operating Room $ 0 $ 0 0000000 $ 0 $ 0 3800 Recovery Room 0 0 0000000 0 0 3900 Delivery Room and Labor Room 0 0 0000000 0 0 4000 Anesthesiology 0 0 0000000 0 0 4100 Radiology - Diagnostics 409054 173364 2359508 168501 397579 4101 0 0 0000000 0 0 4102 0 0 0000000 0 0 4200 Radiology - Therapeutic 0 0 0000000 0 0 4300 Radioisotope 0 0 0000000 0 0 4400 Laboratory 798223 173364 4604318 168501 775832 4401 Pathological Lab 0 0 0000000 0 0 4600 Whole Blood 0 0 0000000 0 0 4700 Blood Storing and Processing 0 0 0000000 0 0 4800 Intravenous Therapy 0 0 0000000 0 0 4900 Respiratory Therapy 1370883 173364 7907543 168501 1332429 5000 Physical Therapy 1105485 173364 6376668 168501 1074475 5100 Occupational Therapy 0 0 0000000 0 0 5200 Speech Pathology 0 0 0000000 0 0 5300 Electrocardiology 116339 173364 0671067 168501 113076 5400 Electroencephalography 0 0 0000000 0 0 5500 Medical Supplies Charged to Patients 0 0 0000000 0 0 5600 Drugs Charged to Patients 3342357 173364 19279416 168501 3248601 5700 Pharmacist 2832574 179166 15809772 87164 1378043 5800 ASC (Non-Distinct Part) 0 0 0000000 0 0 5900 Other Ancillary Services-Dentistry 1062703 173364 6129893 168501 1032893 5901 Other Ancillary Services-Podiatry 196768 173364 1134997 168501 191248 5902 0 0 0000000 0 0 5903 0 0 0000000 0 0 6000 Clinic 1976589 0 0000000 0 0 6001 Other Clinic Services 0 0 0000000 0 0 6100 Emergency 0 0 0000000 0 0 6200 Observation Beds 0 0 0000000 0 0 7100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0

TOTAL $ 13210973 $ 1566078 $ 1435172 $ 9544176 (To Schedule 3)

STATE OF CALIFORNIA PROG

SCHEDULE 6 RAM STATE HOSPITAL

ADJUSTMENTS TO MEDI-CAL CHARGES DAYS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

ANCILLARY CHARGES REPORTED

(Adj 1011) ADJUSTMENTS AUDITED

3700 Operating Room $ $ $ 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 168501 168501 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 168501 168501 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 168501 168501 5000 Physical Therapy 168501 168501 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 168501 168501 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 168501 168501 5700 Pharmacist 87164 87164 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 168501 168501 5901 Other Ancillary Services-Podiatry 168501 168501 5902 0 5903 0 6000 Clinic 0 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 1435172 $ 1435172 (To Schedule 5)

STATE OF CALIFORNIA SCHEDULE 7 PROGRAM STATE HOSPITAL

COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED

PHYSICIANS REMUNERATION

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

PROFESSIONAL SERVICE

COST CENTERS REMUNERATION

HBP

(Adj )

TOTAL CHARGES TO ALL PATIENTS

(Adj ) TO CHARGES

RATIO OF REMUNERATION CHARGES

MEDI-CAL

(Adj )

MEDI-CAL COST

4000 Anesthesiology $ 0 $ 0 0000000 $ $ 0 4100 Radiology - Diagnostic 0 0 0000000 0 4300 Radioisotope 0 0 0000000 0 4400 Laboratory 0 0 0000000 0 5300 Electrocardiology 0 0 0000000 0 5400 Electroencephalography 0 0 0000000 0 6100 Emergency 0 0 0000000 0

0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0

TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp MOVABLE BLDG amp MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 741495 200 Old Cap Rel Costs-Movable Equipmen 142 0 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 0 400 New Cap Rel Costs-Movable Equipme 386440 0 0 0 401 0 0 0 0 0 402 0 0 0 0 0 0 403 0 0 0 0 0 0 0 404 0 0 0 0 0 0 0 0 405 0 0 0 0 0 0 0 0 0 406 0 0 0 0 0 0 0 0 0 0 407 0 0 0 0 0 0 0 0 0 0 0 408 0 0 0 0 0 0 0 0 0 0 0 0 500 Employee Benefits 33531229 0 0 0 0 0 0 0 0 0 0 0 601 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 602 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 603 PurchasingReceiving 0 0 0 0 0 0 0 0 0 0 0 0 604 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 606 0 0 0 0 0 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 0 0 0 600 Administrative and General 32159423 171956 35 341828 96524 0 0 0 0 0 0 0 700 Maintenance and Repairs 2016844 20402 4 40557 11452 0 0 0 0 0 0 0 800 Operation of Plant 3181146 103383 21 205513 58032 0 0 0 0 0 0 0 900 Laundry and Linen Service 1380724 25645 5 50979 14395 0 0 0 0 0 0 0

1000 Housekeeping 2191511 3084 1 6130 1731 0 0 0 0 0 0 0 1100 Dietary 5061559 26463 5 52606 14855 0 0 0 0 0 0 0 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 840794 1519 0 3019 853 0 0 0 0 0 0 0 1600 Pharmacy 1262471 6135 1 12195 3444 0 0 0 0 0 0 0 1700 Medical Records and Library 672290 2664 1 5296 1495 0 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 7050 1 14014 3957 0 0 0 0 0 0 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 15680960 86484 18 171920 48546 0 0 0 0 0 0 0 3500 Nursing Facility 25040095 226193 47 449645 126968 0 0 0 0 0 0 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp M OVABLE BLDG amp M OVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 168426 706 0 1404 397 0 0 0 0 0 0 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 407939 1269 0 2523 712 0 0 0 0 0 0 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 615078 0 0 0 0 0 0 0 0 0 0 0 5000 Physical Therapy 522259 1246 0 2477 699 0 0 0 0 0 0 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 43549 317 0 630 178 0 0 0 0 0 0 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 2320599 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 474568 867 0 1723 486 0 0 0 0 0 0 0 5901 Other Ancillary Services-Podiatry 88211 105 0 208 59 0 0 0 0 0 0 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 639725 2952 1 5869 1657 0 0 0 0 0 0 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 53055 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 131509127 741495 142 1368536 386440 0 0 0 0 0 0 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA SCHEDULE 4B PROGRAM STATE HOSPITAL

COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period Ended JUNE 30 2010

Provider NPI 1225089592

SPECIAL CARE UNITS ALL INCLUSIVE ANCILLARY SERVICES 1 Total Ancillary Cost(Sch 63 Line 37 to 86 Col 27) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj 13) 5 Cost Applicable to Medi-Cal

$

$

$

REPORTED

9692908173364

5591168171

9402441

$

$

$

AUDITED

9692908173364

559100

DRUG DISPENSING FEE 6 Total Inpatient Routine Cost (Sch 63 LIne 35 Col 27) 7 Total Dispensings (Adj ) 8 Cost Per Dispensings 9 Medi-Cal Dispensings (Adj 14) 10 Cost Applicable to Medi-Cal

$

$

$

3994970179166

2230175583

3915501

$

$

$

3994970179166

22300 0

11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

0 26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 27)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal

$

$

$

00

0000 0

$

$

$

0 0

000 0 0

31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 13317942 $ (To Schedule 4)

0

STATE OF CALIFORNIA SCHEDULE 5 PROGRAM STATE HOSPITAL

SCHEDULE OF MEDI-CAL ANCILLARY COSTS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

TOTAL ANCILLARY

COST

TOTAL ANCILLARY UNITS

(Adj 78)

RATIO COST TO CHARGES (From Schedule 6)

MEDI-CAL UNITS COST

MEDI-CAL

ANCILLARY COST CENTERS 3700 Operating Room $ 0 $ 0 0000000 $ 0 $ 0 3800 Recovery Room 0 0 0000000 0 0 3900 Delivery Room and Labor Room 0 0 0000000 0 0 4000 Anesthesiology 0 0 0000000 0 0 4100 Radiology - Diagnostics 409054 173364 2359508 168501 397579 4101 0 0 0000000 0 0 4102 0 0 0000000 0 0 4200 Radiology - Therapeutic 0 0 0000000 0 0 4300 Radioisotope 0 0 0000000 0 0 4400 Laboratory 798223 173364 4604318 168501 775832 4401 Pathological Lab 0 0 0000000 0 0 4600 Whole Blood 0 0 0000000 0 0 4700 Blood Storing and Processing 0 0 0000000 0 0 4800 Intravenous Therapy 0 0 0000000 0 0 4900 Respiratory Therapy 1370883 173364 7907543 168501 1332429 5000 Physical Therapy 1105485 173364 6376668 168501 1074475 5100 Occupational Therapy 0 0 0000000 0 0 5200 Speech Pathology 0 0 0000000 0 0 5300 Electrocardiology 116339 173364 0671067 168501 113076 5400 Electroencephalography 0 0 0000000 0 0 5500 Medical Supplies Charged to Patients 0 0 0000000 0 0 5600 Drugs Charged to Patients 3342357 173364 19279416 168501 3248601 5700 Pharmacist 2832574 179166 15809772 87164 1378043 5800 ASC (Non-Distinct Part) 0 0 0000000 0 0 5900 Other Ancillary Services-Dentistry 1062703 173364 6129893 168501 1032893 5901 Other Ancillary Services-Podiatry 196768 173364 1134997 168501 191248 5902 0 0 0000000 0 0 5903 0 0 0000000 0 0 6000 Clinic 1976589 0 0000000 0 0 6001 Other Clinic Services 0 0 0000000 0 0 6100 Emergency 0 0 0000000 0 0 6200 Observation Beds 0 0 0000000 0 0 7100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0

TOTAL $ 13210973 $ 1566078 $ 1435172 $ 9544176 (To Schedule 3)

STATE OF CALIFORNIA PROG

SCHEDULE 6 RAM STATE HOSPITAL

ADJUSTMENTS TO MEDI-CAL CHARGES DAYS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

ANCILLARY CHARGES REPORTED

(Adj 1011) ADJUSTMENTS AUDITED

3700 Operating Room $ $ $ 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 168501 168501 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 168501 168501 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 168501 168501 5000 Physical Therapy 168501 168501 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 168501 168501 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 168501 168501 5700 Pharmacist 87164 87164 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 168501 168501 5901 Other Ancillary Services-Podiatry 168501 168501 5902 0 5903 0 6000 Clinic 0 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 1435172 $ 1435172 (To Schedule 5)

STATE OF CALIFORNIA SCHEDULE 7 PROGRAM STATE HOSPITAL

COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED

PHYSICIANS REMUNERATION

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

PROFESSIONAL SERVICE

COST CENTERS REMUNERATION

HBP

(Adj )

TOTAL CHARGES TO ALL PATIENTS

(Adj ) TO CHARGES

RATIO OF REMUNERATION CHARGES

MEDI-CAL

(Adj )

MEDI-CAL COST

4000 Anesthesiology $ 0 $ 0 0000000 $ $ 0 4100 Radiology - Diagnostic 0 0 0000000 0 4300 Radioisotope 0 0 0000000 0 4400 Laboratory 0 0 0000000 0 5300 Electrocardiology 0 0 0000000 0 5400 Electroencephalography 0 0 0000000 0 6100 Emergency 0 0 0000000 0

0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0

TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp MOVABLE BLDG amp MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 741495 200 Old Cap Rel Costs-Movable Equipmen 142 0 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 0 400 New Cap Rel Costs-Movable Equipme 386440 0 0 0 401 0 0 0 0 0 402 0 0 0 0 0 0 403 0 0 0 0 0 0 0 404 0 0 0 0 0 0 0 0 405 0 0 0 0 0 0 0 0 0 406 0 0 0 0 0 0 0 0 0 0 407 0 0 0 0 0 0 0 0 0 0 0 408 0 0 0 0 0 0 0 0 0 0 0 0 500 Employee Benefits 33531229 0 0 0 0 0 0 0 0 0 0 0 601 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 602 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 603 PurchasingReceiving 0 0 0 0 0 0 0 0 0 0 0 0 604 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 606 0 0 0 0 0 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 0 0 0 600 Administrative and General 32159423 171956 35 341828 96524 0 0 0 0 0 0 0 700 Maintenance and Repairs 2016844 20402 4 40557 11452 0 0 0 0 0 0 0 800 Operation of Plant 3181146 103383 21 205513 58032 0 0 0 0 0 0 0 900 Laundry and Linen Service 1380724 25645 5 50979 14395 0 0 0 0 0 0 0

1000 Housekeeping 2191511 3084 1 6130 1731 0 0 0 0 0 0 0 1100 Dietary 5061559 26463 5 52606 14855 0 0 0 0 0 0 0 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 840794 1519 0 3019 853 0 0 0 0 0 0 0 1600 Pharmacy 1262471 6135 1 12195 3444 0 0 0 0 0 0 0 1700 Medical Records and Library 672290 2664 1 5296 1495 0 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 7050 1 14014 3957 0 0 0 0 0 0 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 15680960 86484 18 171920 48546 0 0 0 0 0 0 0 3500 Nursing Facility 25040095 226193 47 449645 126968 0 0 0 0 0 0 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp M OVABLE BLDG amp M OVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 168426 706 0 1404 397 0 0 0 0 0 0 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 407939 1269 0 2523 712 0 0 0 0 0 0 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 615078 0 0 0 0 0 0 0 0 0 0 0 5000 Physical Therapy 522259 1246 0 2477 699 0 0 0 0 0 0 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 43549 317 0 630 178 0 0 0 0 0 0 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 2320599 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 474568 867 0 1723 486 0 0 0 0 0 0 0 5901 Other Ancillary Services-Podiatry 88211 105 0 208 59 0 0 0 0 0 0 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 639725 2952 1 5869 1657 0 0 0 0 0 0 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 53055 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 131509127 741495 142 1368536 386440 0 0 0 0 0 0 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA SCHEDULE 5 PROGRAM STATE HOSPITAL

SCHEDULE OF MEDI-CAL ANCILLARY COSTS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

TOTAL ANCILLARY

COST

TOTAL ANCILLARY UNITS

(Adj 78)

RATIO COST TO CHARGES (From Schedule 6)

MEDI-CAL UNITS COST

MEDI-CAL

ANCILLARY COST CENTERS 3700 Operating Room $ 0 $ 0 0000000 $ 0 $ 0 3800 Recovery Room 0 0 0000000 0 0 3900 Delivery Room and Labor Room 0 0 0000000 0 0 4000 Anesthesiology 0 0 0000000 0 0 4100 Radiology - Diagnostics 409054 173364 2359508 168501 397579 4101 0 0 0000000 0 0 4102 0 0 0000000 0 0 4200 Radiology - Therapeutic 0 0 0000000 0 0 4300 Radioisotope 0 0 0000000 0 0 4400 Laboratory 798223 173364 4604318 168501 775832 4401 Pathological Lab 0 0 0000000 0 0 4600 Whole Blood 0 0 0000000 0 0 4700 Blood Storing and Processing 0 0 0000000 0 0 4800 Intravenous Therapy 0 0 0000000 0 0 4900 Respiratory Therapy 1370883 173364 7907543 168501 1332429 5000 Physical Therapy 1105485 173364 6376668 168501 1074475 5100 Occupational Therapy 0 0 0000000 0 0 5200 Speech Pathology 0 0 0000000 0 0 5300 Electrocardiology 116339 173364 0671067 168501 113076 5400 Electroencephalography 0 0 0000000 0 0 5500 Medical Supplies Charged to Patients 0 0 0000000 0 0 5600 Drugs Charged to Patients 3342357 173364 19279416 168501 3248601 5700 Pharmacist 2832574 179166 15809772 87164 1378043 5800 ASC (Non-Distinct Part) 0 0 0000000 0 0 5900 Other Ancillary Services-Dentistry 1062703 173364 6129893 168501 1032893 5901 Other Ancillary Services-Podiatry 196768 173364 1134997 168501 191248 5902 0 0 0000000 0 0 5903 0 0 0000000 0 0 6000 Clinic 1976589 0 0000000 0 0 6001 Other Clinic Services 0 0 0000000 0 0 6100 Emergency 0 0 0000000 0 0 6200 Observation Beds 0 0 0000000 0 0 7100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0

TOTAL $ 13210973 $ 1566078 $ 1435172 $ 9544176 (To Schedule 3)

STATE OF CALIFORNIA PROG

SCHEDULE 6 RAM STATE HOSPITAL

ADJUSTMENTS TO MEDI-CAL CHARGES DAYS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

ANCILLARY CHARGES REPORTED

(Adj 1011) ADJUSTMENTS AUDITED

3700 Operating Room $ $ $ 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 168501 168501 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 168501 168501 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 168501 168501 5000 Physical Therapy 168501 168501 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 168501 168501 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 168501 168501 5700 Pharmacist 87164 87164 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 168501 168501 5901 Other Ancillary Services-Podiatry 168501 168501 5902 0 5903 0 6000 Clinic 0 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 1435172 $ 1435172 (To Schedule 5)

STATE OF CALIFORNIA SCHEDULE 7 PROGRAM STATE HOSPITAL

COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED

PHYSICIANS REMUNERATION

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

PROFESSIONAL SERVICE

COST CENTERS REMUNERATION

HBP

(Adj )

TOTAL CHARGES TO ALL PATIENTS

(Adj ) TO CHARGES

RATIO OF REMUNERATION CHARGES

MEDI-CAL

(Adj )

MEDI-CAL COST

4000 Anesthesiology $ 0 $ 0 0000000 $ $ 0 4100 Radiology - Diagnostic 0 0 0000000 0 4300 Radioisotope 0 0 0000000 0 4400 Laboratory 0 0 0000000 0 5300 Electrocardiology 0 0 0000000 0 5400 Electroencephalography 0 0 0000000 0 6100 Emergency 0 0 0000000 0

0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0

TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp MOVABLE BLDG amp MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 741495 200 Old Cap Rel Costs-Movable Equipmen 142 0 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 0 400 New Cap Rel Costs-Movable Equipme 386440 0 0 0 401 0 0 0 0 0 402 0 0 0 0 0 0 403 0 0 0 0 0 0 0 404 0 0 0 0 0 0 0 0 405 0 0 0 0 0 0 0 0 0 406 0 0 0 0 0 0 0 0 0 0 407 0 0 0 0 0 0 0 0 0 0 0 408 0 0 0 0 0 0 0 0 0 0 0 0 500 Employee Benefits 33531229 0 0 0 0 0 0 0 0 0 0 0 601 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 602 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 603 PurchasingReceiving 0 0 0 0 0 0 0 0 0 0 0 0 604 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 606 0 0 0 0 0 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 0 0 0 600 Administrative and General 32159423 171956 35 341828 96524 0 0 0 0 0 0 0 700 Maintenance and Repairs 2016844 20402 4 40557 11452 0 0 0 0 0 0 0 800 Operation of Plant 3181146 103383 21 205513 58032 0 0 0 0 0 0 0 900 Laundry and Linen Service 1380724 25645 5 50979 14395 0 0 0 0 0 0 0

1000 Housekeeping 2191511 3084 1 6130 1731 0 0 0 0 0 0 0 1100 Dietary 5061559 26463 5 52606 14855 0 0 0 0 0 0 0 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 840794 1519 0 3019 853 0 0 0 0 0 0 0 1600 Pharmacy 1262471 6135 1 12195 3444 0 0 0 0 0 0 0 1700 Medical Records and Library 672290 2664 1 5296 1495 0 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 7050 1 14014 3957 0 0 0 0 0 0 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 15680960 86484 18 171920 48546 0 0 0 0 0 0 0 3500 Nursing Facility 25040095 226193 47 449645 126968 0 0 0 0 0 0 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp M OVABLE BLDG amp M OVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 168426 706 0 1404 397 0 0 0 0 0 0 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 407939 1269 0 2523 712 0 0 0 0 0 0 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 615078 0 0 0 0 0 0 0 0 0 0 0 5000 Physical Therapy 522259 1246 0 2477 699 0 0 0 0 0 0 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 43549 317 0 630 178 0 0 0 0 0 0 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 2320599 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 474568 867 0 1723 486 0 0 0 0 0 0 0 5901 Other Ancillary Services-Podiatry 88211 105 0 208 59 0 0 0 0 0 0 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 639725 2952 1 5869 1657 0 0 0 0 0 0 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 53055 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 131509127 741495 142 1368536 386440 0 0 0 0 0 0 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA PROG

SCHEDULE 6 RAM STATE HOSPITAL

ADJUSTMENTS TO MEDI-CAL CHARGES DAYS

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

ANCILLARY CHARGES REPORTED

(Adj 1011) ADJUSTMENTS AUDITED

3700 Operating Room $ $ $ 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 168501 168501 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 168501 168501 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 168501 168501 5000 Physical Therapy 168501 168501 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 168501 168501 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 168501 168501 5700 Pharmacist 87164 87164 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 168501 168501 5901 Other Ancillary Services-Podiatry 168501 168501 5902 0 5903 0 6000 Clinic 0 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 1435172 $ 1435172 (To Schedule 5)

STATE OF CALIFORNIA SCHEDULE 7 PROGRAM STATE HOSPITAL

COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED

PHYSICIANS REMUNERATION

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

PROFESSIONAL SERVICE

COST CENTERS REMUNERATION

HBP

(Adj )

TOTAL CHARGES TO ALL PATIENTS

(Adj ) TO CHARGES

RATIO OF REMUNERATION CHARGES

MEDI-CAL

(Adj )

MEDI-CAL COST

4000 Anesthesiology $ 0 $ 0 0000000 $ $ 0 4100 Radiology - Diagnostic 0 0 0000000 0 4300 Radioisotope 0 0 0000000 0 4400 Laboratory 0 0 0000000 0 5300 Electrocardiology 0 0 0000000 0 5400 Electroencephalography 0 0 0000000 0 6100 Emergency 0 0 0000000 0

0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0

TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp MOVABLE BLDG amp MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 741495 200 Old Cap Rel Costs-Movable Equipmen 142 0 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 0 400 New Cap Rel Costs-Movable Equipme 386440 0 0 0 401 0 0 0 0 0 402 0 0 0 0 0 0 403 0 0 0 0 0 0 0 404 0 0 0 0 0 0 0 0 405 0 0 0 0 0 0 0 0 0 406 0 0 0 0 0 0 0 0 0 0 407 0 0 0 0 0 0 0 0 0 0 0 408 0 0 0 0 0 0 0 0 0 0 0 0 500 Employee Benefits 33531229 0 0 0 0 0 0 0 0 0 0 0 601 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 602 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 603 PurchasingReceiving 0 0 0 0 0 0 0 0 0 0 0 0 604 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 606 0 0 0 0 0 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 0 0 0 600 Administrative and General 32159423 171956 35 341828 96524 0 0 0 0 0 0 0 700 Maintenance and Repairs 2016844 20402 4 40557 11452 0 0 0 0 0 0 0 800 Operation of Plant 3181146 103383 21 205513 58032 0 0 0 0 0 0 0 900 Laundry and Linen Service 1380724 25645 5 50979 14395 0 0 0 0 0 0 0

1000 Housekeeping 2191511 3084 1 6130 1731 0 0 0 0 0 0 0 1100 Dietary 5061559 26463 5 52606 14855 0 0 0 0 0 0 0 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 840794 1519 0 3019 853 0 0 0 0 0 0 0 1600 Pharmacy 1262471 6135 1 12195 3444 0 0 0 0 0 0 0 1700 Medical Records and Library 672290 2664 1 5296 1495 0 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 7050 1 14014 3957 0 0 0 0 0 0 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 15680960 86484 18 171920 48546 0 0 0 0 0 0 0 3500 Nursing Facility 25040095 226193 47 449645 126968 0 0 0 0 0 0 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp M OVABLE BLDG amp M OVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 168426 706 0 1404 397 0 0 0 0 0 0 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 407939 1269 0 2523 712 0 0 0 0 0 0 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 615078 0 0 0 0 0 0 0 0 0 0 0 5000 Physical Therapy 522259 1246 0 2477 699 0 0 0 0 0 0 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 43549 317 0 630 178 0 0 0 0 0 0 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 2320599 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 474568 867 0 1723 486 0 0 0 0 0 0 0 5901 Other Ancillary Services-Podiatry 88211 105 0 208 59 0 0 0 0 0 0 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 639725 2952 1 5869 1657 0 0 0 0 0 0 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 53055 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 131509127 741495 142 1368536 386440 0 0 0 0 0 0 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA SCHEDULE 7 PROGRAM STATE HOSPITAL

COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED

PHYSICIANS REMUNERATION

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

Provider NPI 1225089592

PROFESSIONAL SERVICE

COST CENTERS REMUNERATION

HBP

(Adj )

TOTAL CHARGES TO ALL PATIENTS

(Adj ) TO CHARGES

RATIO OF REMUNERATION CHARGES

MEDI-CAL

(Adj )

MEDI-CAL COST

4000 Anesthesiology $ 0 $ 0 0000000 $ $ 0 4100 Radiology - Diagnostic 0 0 0000000 0 4300 Radioisotope 0 0 0000000 0 4400 Laboratory 0 0 0000000 0 5300 Electrocardiology 0 0 0000000 0 5400 Electroencephalography 0 0 0000000 0 6100 Emergency 0 0 0000000 0

0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0

TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp MOVABLE BLDG amp MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 741495 200 Old Cap Rel Costs-Movable Equipmen 142 0 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 0 400 New Cap Rel Costs-Movable Equipme 386440 0 0 0 401 0 0 0 0 0 402 0 0 0 0 0 0 403 0 0 0 0 0 0 0 404 0 0 0 0 0 0 0 0 405 0 0 0 0 0 0 0 0 0 406 0 0 0 0 0 0 0 0 0 0 407 0 0 0 0 0 0 0 0 0 0 0 408 0 0 0 0 0 0 0 0 0 0 0 0 500 Employee Benefits 33531229 0 0 0 0 0 0 0 0 0 0 0 601 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 602 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 603 PurchasingReceiving 0 0 0 0 0 0 0 0 0 0 0 0 604 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 606 0 0 0 0 0 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 0 0 0 600 Administrative and General 32159423 171956 35 341828 96524 0 0 0 0 0 0 0 700 Maintenance and Repairs 2016844 20402 4 40557 11452 0 0 0 0 0 0 0 800 Operation of Plant 3181146 103383 21 205513 58032 0 0 0 0 0 0 0 900 Laundry and Linen Service 1380724 25645 5 50979 14395 0 0 0 0 0 0 0

1000 Housekeeping 2191511 3084 1 6130 1731 0 0 0 0 0 0 0 1100 Dietary 5061559 26463 5 52606 14855 0 0 0 0 0 0 0 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 840794 1519 0 3019 853 0 0 0 0 0 0 0 1600 Pharmacy 1262471 6135 1 12195 3444 0 0 0 0 0 0 0 1700 Medical Records and Library 672290 2664 1 5296 1495 0 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 7050 1 14014 3957 0 0 0 0 0 0 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 15680960 86484 18 171920 48546 0 0 0 0 0 0 0 3500 Nursing Facility 25040095 226193 47 449645 126968 0 0 0 0 0 0 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp M OVABLE BLDG amp M OVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 168426 706 0 1404 397 0 0 0 0 0 0 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 407939 1269 0 2523 712 0 0 0 0 0 0 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 615078 0 0 0 0 0 0 0 0 0 0 0 5000 Physical Therapy 522259 1246 0 2477 699 0 0 0 0 0 0 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 43549 317 0 630 178 0 0 0 0 0 0 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 2320599 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 474568 867 0 1723 486 0 0 0 0 0 0 0 5901 Other Ancillary Services-Podiatry 88211 105 0 208 59 0 0 0 0 0 0 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 639725 2952 1 5869 1657 0 0 0 0 0 0 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 53055 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 131509127 741495 142 1368536 386440 0 0 0 0 0 0 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp MOVABLE BLDG amp MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 741495 200 Old Cap Rel Costs-Movable Equipmen 142 0 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 0 400 New Cap Rel Costs-Movable Equipme 386440 0 0 0 401 0 0 0 0 0 402 0 0 0 0 0 0 403 0 0 0 0 0 0 0 404 0 0 0 0 0 0 0 0 405 0 0 0 0 0 0 0 0 0 406 0 0 0 0 0 0 0 0 0 0 407 0 0 0 0 0 0 0 0 0 0 0 408 0 0 0 0 0 0 0 0 0 0 0 0 500 Employee Benefits 33531229 0 0 0 0 0 0 0 0 0 0 0 601 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 602 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 603 PurchasingReceiving 0 0 0 0 0 0 0 0 0 0 0 0 604 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 606 0 0 0 0 0 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 0 0 0 600 Administrative and General 32159423 171956 35 341828 96524 0 0 0 0 0 0 0 700 Maintenance and Repairs 2016844 20402 4 40557 11452 0 0 0 0 0 0 0 800 Operation of Plant 3181146 103383 21 205513 58032 0 0 0 0 0 0 0 900 Laundry and Linen Service 1380724 25645 5 50979 14395 0 0 0 0 0 0 0

1000 Housekeeping 2191511 3084 1 6130 1731 0 0 0 0 0 0 0 1100 Dietary 5061559 26463 5 52606 14855 0 0 0 0 0 0 0 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 840794 1519 0 3019 853 0 0 0 0 0 0 0 1600 Pharmacy 1262471 6135 1 12195 3444 0 0 0 0 0 0 0 1700 Medical Records and Library 672290 2664 1 5296 1495 0 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 7050 1 14014 3957 0 0 0 0 0 0 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 15680960 86484 18 171920 48546 0 0 0 0 0 0 0 3500 Nursing Facility 25040095 226193 47 449645 126968 0 0 0 0 0 0 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp M OVABLE BLDG amp M OVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 168426 706 0 1404 397 0 0 0 0 0 0 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 407939 1269 0 2523 712 0 0 0 0 0 0 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 615078 0 0 0 0 0 0 0 0 0 0 0 5000 Physical Therapy 522259 1246 0 2477 699 0 0 0 0 0 0 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 43549 317 0 630 178 0 0 0 0 0 0 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 2320599 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 474568 867 0 1723 486 0 0 0 0 0 0 0 5901 Other Ancillary Services-Podiatry 88211 105 0 208 59 0 0 0 0 0 0 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 639725 2952 1 5869 1657 0 0 0 0 0 0 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 53055 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 131509127 741495 142 1368536 386440 0 0 0 0 0 0 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 8

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG amp M OVABLE BLDG amp M OVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC

EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 000 100 200 300 400 401 402 403 404 405 406 407

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 168426 706 0 1404 397 0 0 0 0 0 0 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 407939 1269 0 2523 712 0 0 0 0 0 0 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 615078 0 0 0 0 0 0 0 0 0 0 0 5000 Physical Therapy 522259 1246 0 2477 699 0 0 0 0 0 0 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 43549 317 0 630 178 0 0 0 0 0 0 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 2320599 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 474568 867 0 1723 486 0 0 0 0 0 0 0 5901 Other Ancillary Services-Podiatry 88211 105 0 208 59 0 0 0 0 0 0 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 639725 2952 1 5869 1657 0 0 0 0 0 0 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 53055 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 131509127 741495 142 1368536 386440 0 0 0 0 0 0 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 0 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 0 603 PurchasingReceiving 0 0 0 0 604 Patient Admitting 0 0 0 0 0 605 Patient Business Office 0 0 0 0 0 0 606 0 0 0 0 0 0 0 607 0 0 0 0 0 0 0 0 608 0 0 0 0 0 0 0 0 0 600 Administrative and General 0 7432545 0 0 0 0 0 0 0 0 40202311 700 Maintenance and Repairs 0 501526 0 0 0 0 0 0 0 0 2590785 1140720 800 Operation of Plant 0 684177 0 0 0 0 0 0 0 0 4232272 1863466 900 Laundry and Linen Service 0 102333 0 0 0 0 0 0 0 0 1574080 693066

1000 Housekeeping 0 884738 0 0 0 0 0 0 0 0 3087195 1359289 1100 Dietary 0 1764481 0 0 0 0 0 0 0 0 6919969 3046856 1200 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 0 0 0 0 0 1500 Central Services amp Supply 0 68042 0 0 0 0 0 0 0 0 914227 402534 1600 Pharmacy 0 573620 0 0 0 0 0 0 0 0 1857865 818016 1700 Medical Records and Library 0 267168 0 0 0 0 0 0 0 0 948913 417806 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 466002 0 0 0 0 0 0 0 0 1204139 530181

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 7570746 0 0 0 0 0 0 0 0 23558674 10372864 3500 Nursing Facility 0 11928908 0 0 0 0 0 0 0 0 37771855 16630915 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 81

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

ADM INIS-TRIAL BALANCE ALLOC EM PLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUM ULATE TRATIVE amp

EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 408 500 601 602 603 604 605 606 607 608 600

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 78440 0 0 0 0 0 0 0 0 249374 109799 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 106697 0 0 0 0 0 0 0 0 519140 228577 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 259508 0 0 0 0 0 0 0 0 874586 385080 5000 Physical Therapy 0 170863 0 0 0 0 0 0 0 0 697545 307128 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 19363 0 0 0 0 0 0 0 0 64037 28196 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 2320599 1021758 5700 Pharmacist 0 0 0 0 0 0 0 0 0 0 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 201553 0 0 0 0 0 0 0 0 679197 299050 5901 Other Ancillary Services-Podiatry 0 39946 0 0 0 0 0 0 0 0 128528 56591 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 410575 0 0 0 0 0 0 0 0 1060779 467060 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 0 0 53055 23360 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 33531229 0 0 0 0 0 0 0 0 131509127 40202311

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPER LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 731485 900 Laundry and Linen Service 181448 421578

1000 Housekeeping 21820 50696 71995 1100 Dietary 187241 435036 36770 905185 1200 Cafeteria 0 0 0 0 0 1300 Maintenance of Personnel 0 0 0 0 0 0 1400 Nursing Administration 0 0 0 0 0 0 0 1500 Central Services amp Supply 10747 24969 0 2840 0 0 0 0 1600 Pharmacy 43406 100850 0 12436 0 0 0 0 0 1700 Medical Records and Library 18849 43793 0 4455 0 0 0 0 0 0 1800 Social Service 0 0 0 0 0 0 0 0 0 0 0 1900 0 0 0 0 0 0 0 0 0 0 0 0 1902 0 0 0 0 0 0 0 0 0 0 0 0 1903 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2100 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 0 0 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 49881 115895 27606 133369 62656 0 0 0 56708 0 21330 0

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 611916 1421729 1049022 1638225 4490530 0 0 0 759889 0 469654 0 3500 Nursing Facility 1600426 3718434 1683958 1832892 6977871 0 0 0 317565 0 854472 0 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 82

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

CENTRAL M EDICAL TRIAL BALANCE M AINT amp OPER LAUNDRY amp M AINT OF NURSING SERVICE RECORDS SOCIAL

EXPENSES REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADM IN amp SUPPLY PHARM ACY amp LIBRARY SERVICE 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 4999 11614 0 2840 0 0 0 0 10638 0 4098 0 4101 0 0 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 8979 20862 0 9939 0 0 0 0 0 0 10725 0 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 85520 0 25697 0 5000 Physical Therapy 8816 20483 0 3133 0 0 0 0 57226 0 11153 0 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 2244 5213 0 13121 0 0 0 0 2345 0 1183 0 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 5700 Pharmacist 0 0 0 0 0 0 0 0 0 2832574 0 0 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 6132 14246 0 12436 0 0 0 0 36928 0 14714 0 5901 Other Ancillary Services-Podiatry 741 1721 0 2252 0 0 0 0 5036 0 1898 0 5902 0 0 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 0 0 6000 Clinic 20890 48535 823 17871 0 0 0 0 23461 0 18892 0 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 221487 371568 0 0 0 0 0 0 0 0 0 0 9700 Research 0 0 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3731505 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAMED SUBTOTAL ADJUSTMENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipmen 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipme 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 0 1903 0 0 2000 0 0 0 2100 Nursing School 0 0 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 0 0 0 2300 Intern amp Res Other Program 0 0 0 0 0 0 2400 Paramedical Ed Program 0 0 0 0 0 0 0

INPATIENT ROUTINE COST CENTE 2500 Adults amp Pediatrics (Gen Routine) 0 0 0 0 0 0 0 0 2201765 312103 2513868

2600 Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2700 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 2800 Neonatal Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 2900 Surgical Intensive Care 0 0 0 0 0 0 0 0 0 0 3000 Subprovider I 0 0 0 0 0 0 0 0 0 0 3100 Subprovider II 0 0 0 0 0 0 0 0 0 0 3200 0 0 0 0 0 0 0 0 0 0 3300 Nursery 0 0 0 0 0 0 0 0 0 0 3400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 44372503 1003675 45376178 3500 Nursing Facility 0 0 0 0 0 0 0 0 71388387 1469039 72857426 3600 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 3601 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 3602 Transitional Care Unit 0 0 0 0 0 0 0 0 0 0

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA COM PUTATION OF COST ALLOCATION (WS B) SCHEDULE 83

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

POST NON- INT amp RES STEP-DOWN TOTAL

TRIAL BALANCE ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY amp INT amp RES PARAM ED SUBTOTAL ADJUSTM ENT COST EXPENSES COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT

1900 1902 1903 2000 2100 2200 2300 2400 2500 2600 2700

ANCILLARY COST CENTERS 3700 Operating Room 0 0 0 0 0 0 0 0 0 0 3800 Recovery Room 0 0 0 0 0 0 0 0 0 0 3900 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 4000 Anesthesiology 0 0 0 0 0 0 0 0 0 0 4100 Radiology - Diagnostics 0 0 0 0 0 0 0 0 393361 15693 409054 4101 0 0 0 0 0 0 0 0 0 0 4102 0 0 0 0 0 0 0 0 0 0 4200 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 4300 Radioisotope 0 0 0 0 0 0 0 0 0 0 4400 Laboratory 0 0 0 0 0 0 0 0 798223 798223 4401 Pathological Lab 0 0 0 0 0 0 0 0 0 0 4600 Whole Blood 0 0 0 0 0 0 0 0 0 0 4700 Blood Storing and Processing 0 0 0 0 0 0 0 0 0 0 4800 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 4900 Respiratory Therapy 0 0 0 0 0 0 0 0 1370883 1370883 5000 Physical Therapy 0 0 0 0 0 0 0 0 1105485 1105485 5100 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 5200 Speech Pathology 0 0 0 0 0 0 0 0 0 0 5300 Electrocardiology 0 0 0 0 0 0 0 0 116339 116339 5400 Electroencephalography 0 0 0 0 0 0 0 0 0 0 5500 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 5600 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3342357 3342357 5700 Pharmacist 0 0 0 0 0 0 0 0 2832574 2832574 5800 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 5900 Other Ancillary Services-Dentistry 0 0 0 0 0 0 0 0 1062703 1062703 5901 Other Ancillary Services-Podiatry 0 0 0 0 0 0 0 0 196768 196768 5902 0 0 0 0 0 0 0 0 0 0 5903 0 0 0 0 0 0 0 0 0 0 6000 Clinic 0 0 0 0 0 0 0 0 1658312 318277 1976589 6001 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 6100 Emergency 0 0 0 0 0 0 0 0 0 0 6200 Observation Beds 0 0 0 0 0 0 0 0 0 0 7100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 0 0 0 0 0 0 0 669470 669470 9700 Research 0 0 0 0 0 0 0 0 0 0 9800 Physicians Private Office 0 0 0 0 0 0 0 0 0 0 9900 Nonpaid Workers 0 0 0 0 0 0 0 0 0 0 9901 0 0 0 0 0 0 0 0 0 0 9902 0 0 0 0 0 0 0 0 0 0 9903 0 0 0 0 0 0 0 0 0 0 9904 0 0 0 0 0 0 0 0 0 0 9905 0 0 0 0 0 0 0 0 0 0

10000 0 0 0 0 0 0 0 0 0 0 10001 0 0 0 0 0 0 0 0 0 0 10002 0 0 0 0 0 0 0 0 0 0 10003 0 0 0 0 0 0 0 0 0 0 10004 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0 0 0 131509127 3118787 134627914

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 276012 276012 276012 276012 700 Maintenance and Repairs 32748 32748 32748 32748 800 Operation of Plant 165943 165943 165943 165943 900 Laundry and Linen Service 41163 41163 41163 41163

1000 Housekeeping 4950 4950 4950 4950 1100 Dietary 42477 42477 42477 42477 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 2438 2438 2438 1600 Pharmacy 9847 9847 9847 9847 1700 Medical Records and Library 4276 4276 4276 4276 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 11316 11316 11316

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 138818 138818 138818 3500 Nursing Facility 363069 363069 363069 363069 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT amp FIXTURES EQUIP amp FIXTURES EQUIP

(SQ FT) (DV OR SQ FT) (SQ FT) (DV OR SQ FT) 100 200 300 400 401 402 403 404 405 406 407 408 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 1134 1134 1134 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 2037 2037 2037 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 2000 2000 2000 2000 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 509 509 509 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 1391 1391 1391 5901 Other Ancillary Services-Podiatry 168 168 168 168 5902 5903 6000 Clinic 4739 4739 4739 4739 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 85160 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 1190195 1105035 1105035 1105035 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 741495 142 1368536 386440 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0623003 0000129 1238455 0349708 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 16338923 700 Maintenance and Repairs 1102501 2590785 800 Operation of Plant 1504023 4232272 165943 900 Laundry and Linen Service 224958 1574080 41163

1000 Housekeeping 1944914 3087195 4950 1100 Dietary 3878849 6919969 42477 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply 149577 914227 2438 1600 Pharmacy 1260985 1857865 9847 1700 Medical Records and Library 587313 948913 4276 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 1024409 1204139 11316

2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility 16642731 23558674 138818 3500 Nursing Facility 26223254 37771855 363069 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM amp GEN MAINT amp (GROSS (ACCUM REPAIRS

SALARIES) COST) (SQ FT) 500 601 602 603 604 605 606 607 608 700 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics 172434 249374 1134 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory 234551 519140 2037 4401 Pathological Lab 0 4600 W hole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy 570476 874586 5000 Physical Therapy 375608 697545 2000 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 42565 64037 509 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 2320599 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry 443073 679197 1391 5901 Other Ancillary Services-Podiatry 87813 128528 168 5902 0 5903 0 6000 Clinic 902565 1060779 4739 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 53055 50246 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid W orkers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

TOTAL 73711522 0 0 0 0 0 0 0 0 91306816 846521 COST TO BE ALLOCATED 33531229 0 0 0 0 0 0 0 0 40202311 3731505 UNIT COST MULTIPLIER - SCH 8 0454898 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0440299 4408048

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service 41163

1000 Housekeeping 4950 46430 1100 Dietary 42477 23713 18488 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 2438 58 1600 Pharmacy 9847 254 1700 Medical Records and Library 4276 91 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 11316 17803 2724 942 23792 1847599

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 138818 676522 33460 67513 318811 40681953 3500 Nursing Facility 363069 1085997 37436 104909 133234 74015217 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT amp LINEN KEEPING (MEALS PERSONNEL ADMIN amp SUPPLY (COSTS (TIME (TIME (SQ FT) (LB LNDRY) (HR SERV) SERVED) ( HOUSED) (NURSE HR) (CST REQ) REQUIS) SPENT) SPENT)

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 6 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 1134 58 4463 354991 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 2037 203 929032 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 35880 2225881 5000 Physical Therapy 2000 64 24009 966048 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 509 268 984 102433 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 100 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 1391 254 15493 1274578 5901 Other Ancillary Services-Podiatry 168 46 2113 164445 5902 5903 6000 Clinic 4739 531 365 9843 1636461 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 36280 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 666612 1850996 93769 173364 0 0 0 568622 100 124198638 0 0 COST TO BE ALLOCATED 6827222 2870173 4590995 11531056 0 0 0 1355317 2832574 1433816 0 0 UNIT COST MULTIPLIER - SCH 8 10241674 1550610 48960686 66513558 0000000 0000000 0000000 2383511 28325735422 0011545 0000000 0000000

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine)

2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

STAT STAT NONPHY NURSE IampR-SAL IampR-PRG PARAMED ANESTH SCHOOL amp FRINGES COST EDUCAT

(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 1902 1903 2000 2100 2200 2300 2400 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 W hole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIMBURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid W orkers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

TOTAL 0 0 0 0 0 0 0 COST TO BE ALLOCATED 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 0000000 0000000 0000000 0000000 0000000

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

GENERAL SERVICE COST CENTERS 100 Old Cap Rel Costs-Bldg amp Fixtures $ 741495 $ 0 $ 741495 200 Old Cap Rel Costs-Movable Equipment 142 0 142 300 New Cap Rel Costs-Bldg amp Fixtures 1368536 0 1368536 400 New Cap Rel Costs-Movable Equipment 386440 0 386440 401 0 0 402 0 0 403 0 0 404 0 0 405 0 0 406 0 0 407 0 0 408 0 0 500 Employee Benefits 33531229 0 33531229 601 Non-Patient Telephones 0 0 602 Data Processing 0 0 603 PurchasingReceiving 0 0 604 Patient Admitting 0 0 605 Patient Business Office 0 0 606 0 0 607 0 0 608 0 0 600 Administrative and General 34801297 (2641874) 32159423 700 Maintenance and Repairs 2391625 (374781) 2016844 800 Operation of Plant 3197919 (16773) 3181146 900 Laundry and Linen Service 1544751 (164027) 1380724

1000 Housekeeping 2222832 (31321) 2191511 1100 Dietary 5245411 (183852) 5061559 1200 Cafeteria 0 0 1300 Maintenance of Personnel 0 0 1400 Nursing Administration 0 0 1500 Central Services amp Supply 894067 (53273) 840794 1600 Pharmacy 1283591 (21120) 1262471 1700 Medical Records and Library 760547 (88257) 672290 1800 Social Service 0 0 1900 0 0 1902 0 0 1903 0 0 2000 0 0 2100 Nursing School 0 0 2200 Intern amp Res Service-Salary amp Fringes 0 0 2300 Intern amp Res Other Program 0 0 2400 Paramedical Ed Program 0 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 713114 0 713114 2600 Intensive Care Unit 0 0 2700 Coronary Care Unit 0 0 2800 Neonatal Intensive Care Unit 0 0 2900 Surgical Intensive Care 0 0 3000 Subprovider I 0 0 3100 Subprovider II 0 0 3200 0 0 3300 Nursery 0 0 3400 Skilled Nursing Facility 15694458 (13498) 15680960 3500 Nursing Facility 25164900 (124805) 25040095 3600 Adult Subacute Care Unit 0 0 3601 Subacute Care Unit II 0 0 3602 Transitional Care Unit 0 0

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA SCHEDULE 10

TRIAL BALANCE OF EXPENSES

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPMENTAL CENTER JUNE 30 2010

REPORTED (From Sch 10A) ADJUSTMENTS AUDITED

ANCILLARY COST CENTERS 3700 Operating Room $ $ 0 $ 0 3800 Recovery Room 0 0 3900 Delivery Room and Labor Room 0 0 4000 Anesthesiology 0 0 4100 Radiology - Diagnostics 169338 (912) 168426 4101 0 0 4102 0 0 4200 Radiology - Therapeutic 0 0 4300 Radioisotope 0 0 4400 Laboratory 421779 (13840) 407939 4401 Pathological Lab 0 0 4600 W hole Blood 0 0 4700 Blood Storing and Processing 0 0 4800 Intravenous Therapy 0 0 4900 Respiratory Therapy 616878 (1800) 615078 5000 Physical Therapy 522259 0 522259 5100 Occupational Therapy 0 0 5200 Speech Pathology 0 0 5300 Electrocardiology 43549 0 43549 5400 Electroencephalography 0 0 5500 Medical Supplies Charged to Patients 0 0 5600 Drugs Charged to Patients 2320599 0 2320599 5700 Pharmacist 0 0 5800 ASC (Non-Distinct Part) 0 0 5900 Other Ancillary Services-Dentistry 484655 (10087) 474568 5901 Other Ancillary Services-Podiatry 88211 0 88211 5902 0 0 5903 0 0 6000 Clinic 641804 (2079) 639725 6001 Other Clinic Services 0 0 6100 Emergency 0 0 6200 Observation Beds 0 0 7100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0

SUBTOTAL $ 135251426 $ (3742299) $ 131509127 NONREIMBURSABLE COST CENTERS

9600 Nonreimbursable Cost Centers 0 0 9700 Research 0 0 9800 Physicians Private Office 0 0 9900 Nonpaid W orkers 0 0 9901 0 0 9902 0 0 9903 0 0 9904 0 0 9905 0 0

10000 0 0 10001 0 0 10002 0 0 10003 0 0 10004 0 0 10099 SUBTOTAL $ 0 $ 0 $ 0 101 TOTAL $ 135251426 $ (3742299) $ 131509127

(To Schedule 8)

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures $0 200 Old Cap Rel Costs-Movable Equipment 0 300 New Cap Rel Costs-Bldg amp Fixtures 0 400 New Cap Rel Costs-Movable Equipment 0 401 0 402 0 403 0 404 0 405 0 406 0 407 0 408 0 500 Employee Benefits 0 601 Non-Patient Telephones 0 602 Data Processing 0 603 PurchasingReceiving 0 604 Patient Admitting 0 605 Patient Business Office 0 606 0 607 0 608 0 600 Administrative and General (2641874) (504461) (2095307) (42106) 700 Maintenance and Repairs (374781) (374781) 800 Operation of Plant (16773) (16773) 900 Laundry and Linen Service (164027) (164027)

1000 Housekeeping (31321) (31321) 1100 Dietary (183852) (183852) 1200 Cafeteria 0 1300 Maintenance of Personnel 0 1400 Nursing Administration 0 1500 Central Services amp Supply (53273) (53273) 1600 Pharmacy (21120) (21120) 1700 Medical Records and Library (88257) (88257) 1800 Social Service 0 1900 0 1902 0 1903 0 2000 0 2100 Nursing School 0 2200 Intern amp Res Service-Salary amp Fringes 0 2300 Intern amp Res Other Program 0 2400 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 0 2600 Intensive Care Unit 0 2700 Coronary Care Unit 0 2800 Neonatal Intensive Care Unit 0 2900 Surgical Intensive Care 0 3000 Subprovider I 0 3100 Subprovider II 0 3200 0 3300 Nursery 0 3400 Skilled Nursing Facility (13498) (13498) 3500 Nursing Facility (124805) (124805) 3600 Adult Subacute Care Unit 0 3601 Subacute Care Unit II 0 3602 Transitional Care Unit 0

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 1

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5

ANCILLARY COST CENTERS 3700 Operating Room 0 3800 Recovery Room 0 3900 Delivery Room and Labor Room 0 4000 Anesthesiology 0 4100 Radiology - Diagnostics (912) (912) 4101 0 4102 0 4200 Radiology - Therapeutic 0 4300 Radioisotope 0 4400 Laboratory (13840) (13840) 4401 Pathological Lab 0 4600 Whole Blood 0 4700 Blood Storing and Processing 0 4800 Intravenous Therapy 0 4900 Respiratory Therapy (1800) (1800) 5000 Physical Therapy 0 5100 Occupational Therapy 0 5200 Speech Pathology 0 5300 Electrocardiology 0 5400 Electroencephalography 0 5500 Medical Supplies Charged to Patients 0 5600 Drugs Charged to Patients 0 5700 Pharmacist 0 5800 ASC (Non-Distinct Part) 0 5900 Other Ancillary Services-Dentistry (10087) (10087) 5901 Other Ancillary Services-Podiatry 0 5902 0 5903 0 6000 Clinic (2079) (2079) 6001 Other Clinic Services 0 6100 Emergency 0 6200 Observation Beds 0 7100 0 8200 0 8300 0 8400 0 8500 0 8600 0

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 0 9700 Research 0 9800 Physicians Private Office 0 9900 Nonpaid Workers 0 9901 0 9902 0 9903 0 9904 0 9905 0

10000 0 10001 0 10002 0 10003 0 10004 0

10100 TOTAL ($3742299) (1604886) (2095307) (42106) 0 0 0 0 0 0 0 0 0 (To Sch 10)

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA

Provider Name FAIRVIEW DEVELOPM ENTAL CENTER

GENERAL SERVICE COST CENTER 100 Old Cap Rel Costs-Bldg amp Fixtures 200 Old Cap Rel Costs-Movable Equipment 300 New Cap Rel Costs-Bldg amp Fixtures 400 New Cap Rel Costs-Movable Equipment 401 402 403 404 405 406 407 408 500 Employee Benefits 601 Non-Patient Telephones 602 Data Processing 603 PurchasingReceiving 604 Patient Admitting 605 Patient Business Office 606 607 608 600 Administrative and General 700 Maintenance and Repairs 800 Operation of Plant 900 Laundry and Linen Service

1000 Housekeeping 1100 Dietary 1200 Cafeteria 1300 Maintenance of Personnel 1400 Nursing Administration 1500 Central Services amp Supply 1600 Pharmacy 1700 Medical Records and Library 1800 Social Service 1900 1902 1903 2000 2100 Nursing School 2200 Intern amp Res Service-Salary amp Fringes 2300 Intern amp Res Other Program 2400 Paramedical Ed Program

INPATIENT ROUTINE COST CENTERS 2500 Adults amp Pediatrics (Gen Routine) 2600 Intensive Care Unit 2700 Coronary Care Unit 2800 Neonatal Intensive Care Unit 2900 Surgical Intensive Care 3000 Subprovider I 3100 Subprovider II 3200 3300 Nursery 3400 Skilled Nursing Facility 3500 Nursing Facility 3600 Adult Subacute Care Unit 3601 Subacute Care Unit II 3602 Transitional Care Unit

ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Fiscal Period Ended JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

STATE OF CALIFORNIA ADJUSTM ENTS TO REPORTED COSTS SCHEDULE 10A Page 2

Provider Name Fiscal Period Ended FAIRVIEW DEVELOPM ENTAL CENTER JUNE 30 2010

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

ANCILLARY COST CENTERS 3700 Operating Room 3800 Recovery Room 3900 Delivery Room and Labor Room 4000 Anesthesiology 4100 Radiology - Diagnostics 4101 4102 4200 Radiology - Therapeutic 4300 Radioisotope 4400 Laboratory 4401 Pathological Lab 4600 Whole Blood 4700 Blood Storing and Processing 4800 Intravenous Therapy 4900 Respiratory Therapy 5000 Physical Therapy 5100 Occupational Therapy 5200 Speech Pathology 5300 Electrocardiology 5400 Electroencephalography 5500 Medical Supplies Charged to Patients 5600 Drugs Charged to Patients 5700 Pharmacist 5800 ASC (Non-Distinct Part) 5900 Other Ancillary Services-Dentistry 5901 Other Ancillary Services-Podiatry 5902 5903 6000 Clinic 6001 Other Clinic Services 6100 Emergency 6200 Observation Beds 7100 8200 8300 8400 8500 8600

NONREIM BURSABLE COST CENTERS 9600 Nonreimbursable Cost Centers 9700 Research 9800 Physicians Private Office 9900 Nonpaid Workers 9901 9902 9903 9904 9905

10000 10001 10002 10003 10004

10100 TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

MEMORANDUM ADJUSTMENTS

1 The filed cost report had a flow through error on schedule 4B for All Inclusive Total Ancillary Costs The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

2 The filed cost report has a flow through error on worksheet B-1 for the accumulated cost statistic for non-reimbursable cost centers The flow through error has been corrected on the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 2306 and 2328

Page 1

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED COSTS

3 10A A 600 7 Administrative and General $34801297 ($504461) $34296836 10A A 700 7 Maintenance and Repairs 2391625 (374781) 2016844 10A A 800 7 Operation of Plant 3197919 (16773) 3181146 10A A 900 7 Laundry and Linen Service 1544751 (164027) 1380724 10A A 1000 7 Housekeeping 2222832 (31321) 2191511 10A A 1100 7 Dietary 5245411 (183852) 5061559 10A A 1500 7 Central Services amp Supply 894067 (53273) 840794 10A A 1600 7 Pharmacy 1283591 (21120) 1262471 10A A 1700 7 Medical Records and Library 760547 (88257) 672290 10A A 3400 7 Skilled Nursing Facility 15694458 (13498) 15680960 10A A 3500 7 Nursing Facility 25164900 (124805) 25040095 10A A 4100 7 Radiology - Diagnostics 169338 (912) 168426 10A A 4400 7 Laboratory 421779 (13840) 407939 10A A 4900 7 Respiratory Therapy 616878 (1800) 615078 10A A 5900 7 Dentistry 484655 (10087) 474568 10A A 6000 7 Clinic 641804 (2079) 639725

To eliminate reported encumbrance amounts due to lack of documentation of the services provided associated with the encumbrances and liquidation of encumbrances 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 23021 2304 and 2305 WampI Code 141242(b)

4 10A A 600 7 Administrative and General $34296836 ($2095307) $32201529 To eliminate workers compensation and warm shutdown closure costs not related to patient care 42 CFR 4139(c ) CMS Pub 15-1 Sections 21021 21022 21023 21761 and 21762

Balance carried forward from priorto subsequent adjustments Page 2

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED COSTS

5 10A A 600 7 Administrative and General $32201529 ($42106) $32159423 To adjust reported home office costs to agree with the California State Department of Developmental Services Home Office Audit Report for fiscal period ended June 30 2010 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

Balance carried forward from priorto subsequent adjustments Page 3

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENT TO REPORTED STATISTICS

6 9 Not Reported 5700 16 Pharmacist (Costed Requisitions) 0 100 100 9 B-1 10100 16 Total - Cost of Requisitions 0 100 100

To include cost of requisitions statistics for proper cost finding 42 CFR 41324 and 41350 CMS Pub 15-1 Section 2306

Page 4

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED UNITS

7 5 Not Reported 4100 Total Inpatient Days - Radiology - Diagnostic 0 173364 173364 5 Not Reported 4400 Total Inpatient Days - Laboratory 0 173364 173364 5 Not Reported 4900 Total Inpatient Days -Respiratory Therapy 0 173364 173364 5 Not Reported 5000 Total Inpatient Days - Physical Therapy 0 173364 173364 5 Not Reported 5300 Total Inpatient Days - Electrocardiology 0 173364 173364 5 Not Reported 5600 Total Inpatient Days - Drugs Charged to Patients 0 173364 173364 5 Not Reported 5900 Total Inpatient Days - Other Ancillary Services Dentistry 0 173364 173364 5 Not Reported 5901 Total Inpatient Days - Other Ancillary Services Podiatry 0 173364 173364

To set up a Total Ancillary Days statistic for apportioning ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

8 5 Not Reported 5700 Total Inpatient Dispensings - Pharmacist To set up a Total Ancillary Dispensing statistic for apportioning 0 179166 179166 ancillary cost 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Page 5

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

9 4 4 900 1 Medi-Cal Days - Adults and Pediatrics 127 594 721 4A 4A 400 1 Medi-Cal Days - Skilled Nursing Facility 64810 478 65288 4A 4A 900 1 Medi-Cal Days - Nursing Facility 103361 1266 104627

10 6 Not Reported 4100 Medi-Cal Inpatient Days - Radiology - Diagnostics 0 168501 168501 6 Not Reported 4400 Medi-Cal Inpatient Days - Laboratory 0 168501 168501 6 Not Reported 4900 Medi-Cal Inpatient Days - Respiratory Therapy 0 168501 168501 6 Not Reported 5000 Medi-Cal Inpatient Days - Physical Therapy 0 168501 168501 6 Not Reported 5300 Medi-Cal Inpatient Days - Electrocardiology 0 168501 168501 6 Not Reported 5600 Medi-Cal Inpatient Days - Drugs Charged to Patients 0 168501 168501 6 Not Reported 5900 Medi-Cal Inpatient Days - Other Ancillary Services Dentistry 0 168501 168501 6 Not Reported 5901 Medi-Cal Inpatient Days - Other Ancillary Services Podiatry 0 168501 168501

11 6 Not Reported 5700 Medi-Cal Dispensings - Pharmacist 0 87164 87164

12 3 Supplemental 400 1 Medi-Cal Share of Cost $3685524 $31842 $3717366 3 Supplemental 500 1 Medi-Cal Third Party 30767 85842 116609 1 Supplemental 700 1 Medicare Payments 746407 52684 799091 1 Supplemental 800 1 Medi-Cal Interim Payment 95007525 746276 95753801

To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period July 1 2009 through June 30 2010 Payment Period July 1 2009 through December 21 2011

42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542

Balance carried forward from priorto subsequent adjustments Page 6

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7

State of California Department of Health Care Services

Provider Name FAIRVIEW DEVELOPMENTAL CENTER

Fiscal Period JULY 1 2009 THROUGH JUNE 30 2010

Provider NPI 1225089592 16

Adjustments

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Audit Report

Cost Report Work Sheet Part Title Line Col

ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA

13 4B 4B 400 1 Medi-Cal Inpatient Days - Ancillary Service 168171 (168171) 0 To eliminate Medi-Cal inpatient days applicable to ancillary costs in conjunction with adjustment 10 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

14 4B 4B 900 1 Medi-Cal Inpatient Days - Drug Dispensing Fee 175583 (175583) 0 To eliminate Medi-Cal inpatient days applicable to drug dispensing fee in conjunction with adjustment 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

15 1 Supplemental 800 Medi-Cal Interim Payments $95753801 $31192637 $126946438

To include End of Year Settlement to agree with the Invoice Summary and detail invoices 42 CFR 41320 and 41324 CMS Pub 15-1 Section 2304

16 1 Supplemental 600 Adjustment for Pharmacy Dispensings $1971737 ($1971737) $0 To eliminate adjustment for pharmacy dispensings for proper cost finding and in conjunction with adjustments 6 and 11 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Balance carried forward from priorto subsequent adjustments Page 7