STATE OF CALIFORNIA CONTRACT SCH 5
Provider Name: Fiscal Period Ended:
ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008
Provider No:
HSC 30616I
RATIO
COST TO
CHARGES
ANCILLARY COST CENTERS
37.00 Operating Room $ 5,113,492 $ 54,808,109 0.093298 $ 828,670 $ 77,313
38.00 Recovery Room 0 0 0.000000 0 0
39.00 Delivery Room and Labor Room 137,285 1,479,613 0.092785 208,082 19,307
40.00 Anesthesiology 0 0 0.000000 0 0
41.00 Radiology - Diagnostic 3,592,122 14,713,725 0.244134 134,282 32,783
42.00 Radiology - Therapeutic 0 0 0.000000 0 0
42.01 Ultrasound 435,198 2,322,099 0.187416 27,387 5,133
42.02 CAT Scan 829,868 14,621,127 0.056758 167,503 9,507
43.00 Radioisotope 345,042 1,571,726 0.219531 17,763 3,900
44.00 Laboratory 4,380,098 35,372,413 0.123828 854,289 105,785
44.01 Pathological Lab 0 0 0.000000 0 0
46.00 Whole Blood 0 0 0.000000 0 0
47.00 Blood Storing and Processing 0 0 0.000000 0 0
48.00 Intravenous Therapy 0 0 0.000000 0 0
49.00 Respiratory Therapy 2,668,925 44,775,936 0.059606 455,419 27,146
49.01 Hyperbaric Chamber 1,399,828 10,624,124 0.131759 0 0
50.00 Physical Therapy 1,612,854 3,947,415 0.408585 57,121 23,339
51.00 Occupational Therapy 305,168 1,291,834 0.236228 6,303 1,489
52.00 Speech Pathology 129,738 569,919 0.227643 12,528 2,852
53.00 Electrocardiology 870,858 5,487,247 0.158706 155,700 24,711
54.00 Electroencephalography 0 0 0.000000 0 0
55.00 Medical Supplies Charged to Patients 3,462,472 15,268,493 0.226772 255,778 58,003

55.01 Implants Charged to Patients 3,287,181 3,246,746 1.012454 19,982 20,231
56.00 Drugs Charged to Patients 4,525,666 34,060,494 0.132871 1,174,697 156,084
57.00 Renal Dialysis 590,817 1,556,728 0.379525 82,556 31,332
58.00 ASC (Non-Distinct Part) 0 0 0.000000 0 0
59.00 0 0 0.000000 0 0
59.01 0 0 0.000000 0 0
60.00 Clinic 0 0 0.000000 0 0
60.01 Other Clinic Services 0 0 0.000000 0 0
61.00 Emergency 4,660,533 14,447,754 0.322578 243,569 78,570
62.00 Observation Beds 0 0 0.000000 0 0
TOTAL $ 38,347,145 $ 260,165,502 $ 4,701,629 $ 677,485
(To Contract Sch 3)
* From Schedule 8, Column 27
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
TOTAL MEDI-CAL
CHARGES
TOTAL ANCILLARY
MEDI-CAL
ANCILLARY
COST*
COST
(Contract Sch 6)
CHARGES
(Adj )
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STATE OF CALIFORNIA CONTRACT SCH 6

Provider Name: Fiscal Period Ended:
ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008

Provider No:
HSC 30616I
ANCILLARY CHARGES
37.00 Operating Room $ 927,451 $ (98,781) $ 828,670
38.00 Recovery Room 0 0
39.00 Delivery Room and Labor Room 273,192 (65,110) 208,082
40.00 Anesthesiology 0 0
41.00 Radiology - Diagnostic 193,808 (59,526) 134,282
42.00 Radiology - Therapeutic 0 0
42.01 Ultrasound 47,082 (19,695) 27,387
42.02 CAT Scan 226,454 (58,951) 167,503
43.00 Radioisotope 15,308 2,455 17,763
44.00 Laboratory 997,503 (143,214) 854,289
44.01 Pathological Lab 0 0
46.00 Whole Blood 0 0
47.00 Blood Storing and Processing 0 0
48.00 Intravenous Therapy 0 0
49.00 Respiratory Therapy 1,049,495 (594,076) 455,419
49.01 Hyperbaric Chamber 60,146 (60,146) 0
50.00 Physical Therapy 97,283 (40,162) 57,121
51.00 Occupational Therapy 22,879 (16,576) 6,303
52.00 Speech Pathology 5,738 6,790 12,528
53.00 Electrocardiology 139,964 15,736 155,700
54.00 Electroencephalography 0 0
55.00 Medical Supplies Charged to Patients 56,845 198,933 255,778
55.01 Implants Charged to Patients 0 19,982 19,982
56.00 Drugs Charged to Patients 1,556,001 (381,304) 1,174,697
57.00 Renal Dialysis 145,590 (63,034) 82,556
58.00 ASC (Non-Distinct Part) 0 0
59.00 0 0

59.01 0 0
60.00 Clinic 0 0
60.01 Other Clinic Services 0 0
61.00 Emergency 162,721 80,848 243,569
62.00 Observation Beds 0 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 5,977,460 $ (1,275,831) $ 4,701,629
(To Contract Sch 5)
ADJUSTMENTS TO MEDI-CAL CHARGES
(Adj 18)
AUDITEDADJUSTMENTSREPORTED
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STATE OF CALIFORNIA CONTRACT SCH 7
Provider Name: Fiscal Period Ended:
ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008
Provider No:
HSC 30616I
PROFESSIONAL
SERVICE
COST CENTERS
40.00 Anesthesiology $ 0 $ 0 0.000000 $ $ 0
41.00 Radiology - Diagnostic 0 0 0.000000 0
43.00 Radioisotope 0 0 0.000000 0
44.00 Laboratory 0 0 0.000000 0
53.00 Electrocardiology 0 0 0.000000 0
54.00 Electroencephalography 0 0 0.000000 0
61.00 Emergency 0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0

0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
TOTAL $ 0 $ 0 $ 0 $ 0

(To Contract Sch 3)
(Adj )(Adj ) (Adj )
PHYSICIAN'S REMUNERATION
TO CHARGES
MEDI-CAL
CHARGES
MEDI-CAL
COSTREMUNERATION
COMPUTATION OF PROFESSIONAL
COMPONENT OF HOSPITAL BASED
TO ALL PATIENTS
RATIO OF
REMUNERATION
TOTAL CHARGES HBP
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STATE OF CALIFORNIA
ADULT SUBACUTE SCH 1
Provider Name:
Fiscal Period Ended:
ST. JOHN'S PLEASANT VALLEY HOSPITAL
JUNE 30, 2008
Provider No:
LTC 70024G
REPORTED
AUDITED
DIFFERENCE
COMPUTATION OF SUBACUTE PER DIEM
1. Adult Subacute Ancillary Cost (Adult Subacute Sch 3) $ 828,465 $ 2,829,037 $ 2,000,572
2. Adult Subacute Routine Cost (Adult Subacute Sch 2) $ 10,060,321 $ 9,497,283 $ (563,038)

3. Total Adult Subacute Facility Cost (Lines 1 & 2) $ 10,888,786 $ 12,326,320 $ 1,437,534

4. Total Adult Subacute Patient Days (Adj 15) 15,517 15,525 8
5. Average Adult Subacute Per Diem Cost (L3 / L4) $ 701.73 $ 793.97 $ 92.24
ADULT SUBACUTE OVERPAYMENT & OVERBILLINGS
6. Medi-Cal Overpayments (Adj 26) $ 0 $ (2,811) $ (2,811)
6. Medi-Cal Overpayments (Adj 27) $ 0 $ (100,197) $ (100,197)
8. MEDI-CAL SETTLEMENT Due Provider (State) $ 0 $ (103,008) $ (103,008)
(To Summary of Findings)
GENERAL INFORMATION
9. Contracted Number of Adult Subacute Beds (Adj 23) 0 48 48
10. Total Licensed Nursing Facility Beds (Adj ) 99 99 * 0
11. Total Licensed Capacity (All levels of care)(Adj ) 180 180 0
12. Total Medi-Cal Adult Subacute Patient Days (Adj 21) 3,756 8,661 4,905
* 51 of 99 Licensed Nursing Facility beds are unstaffed. Hospital stopped providing Distinct Part Nursing services effective June 30, 2006.
CAPITAL RELATED COST
13. Direct Capital Related Cost N/A $ 0 N/A
14. Indirect Capital Related Cost (Adult Subacute Sch 5) N/A $ 789,762 N/A
15. Total Capital Related Cost (Lines 13 & 14) N/A $ 789,762 N/A
TOTAL SALARY & BENEFITS
16. Direct Salary & Benefits Expenses N/A $ 0 N/A
17. Alloc Salary & Benefits Expenses (Adult Subacute Sch 5) N/A $ 2,828,018 N/A
18. Total Salary & Benefits Expenses (Lines 16 & 17) N/A $ 2,828,018 N/A
AUDITED ADULT SUBACUTE COST-VENTILATOR AND NONVENTILATOR
AUDITED
AUDITED
AUDITED
COSTS
TOTAL DAYS
MEDI-CAL DAYS

(Adj 24)
(Adj 16)
(Adj 21)
19. Ventilator (Equipment Cost Only) $ 68,167 6,426 3,410
20. Nonventilator N/A 9,099 N/A
21. TOTAL N/A 15,525 N/A
COMPUTATION OF ADULT SUBACUTE PER DIEM
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STATE OF CALIFORNIA ADULT SUBACUTE SCH 2
Provider Name: Fiscal Period Ended:
ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008
Provider No:
LTC 70024G
COST CENTER
COL. DIRECT AND ALLOCATED EXPENSE
0.00 Adult Subacute $ 4,732,619 $ 4,725,861 $ (6,758)
1.00 Old Cap Rel Costs-Bldg and Fixtures 0 0 0
2.00 Old Cap Rel Costs-Movable Equipment 0 0 0
3.00 New Cap Rel Costs-Bldg and Fixtures 227,029 190,490 (36,539)
4.00 New Cap Rel Costs-Movable Equipment 303,372 290,629 (12,743)
4.01 0 0 0
4.02 0 0 0
4.03 0 0 0
4.04 0 0 0
4.05 0 0 0
4.06 0 0 0
4.07 0 0 0
4.08 0 0 0
5.00 Employee Benefits 1,368,117 1,184,100 (184,017)

6.01 Non-Patient Telephones 0 0 0
6.02 Data Processing 0 0 0
6.03 Purchasing/Receiving 0 0 0
6.04 Patient Admitting 0 0 0
6.05 Patient Business Office 0 0 0
6.06 0 0 0
6.07 0 0 0
6.08 0 0 0
6.00 Administrative and General 1,315,485 1,100,635 (214,850)
7.00 Maintenance and Repairs 364,978 511,213 146,235
8.00 Operation of Plant 235,400 221,063 (14,337)
9.00 Laundry and Linen Service 182,550 98,450 (84,100)
10.00 Housekeeping 174,695 182,609 7,914
11.00 Dietary 82,871 87,526 4,655
12.00 Cafeteria 373,417 348,579 (24,838)
13.00 Maintenance of Personnel 0 0 0
14.00 Nursing Administration 574,567 440,451 (134,116)
15.00 Central Services and Supply 10,214 8,106 (2,108)
16.00 Pharmacy 0 0 0
17.00 Medical Records and Library 115,007 107,571 (7,436)
18.00 Social Service 0 0 0
19.00 0 0 0
19.02 0 0 0
19.03 0 0 0
20.00 0 0 0
21.00 Nursing School 0 0 0
22.00 Intern & Res Service-Salary & Fringes 0 0 0
23.00 Intern & Res Other Program 0 0 0
24.00 Paramedical Ed Program 0 0 0
TOTAL DIRECT AND

101.00 ALLOCATED EXPENSES $ 10,060,321 $ 9,497,283 $ (563,038)
(To Adult Subacute Sch 1)
* From Schedule 8, Part I, Line 36.00
REPORTED AUDITED * DIFFERENCE
SUMMARY OF ADULT SUBACUTE FACILITY EXPENSES
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STATE OF CALIFORNIA ADULT SUBACUTE SCH 3
Provider Name: Fiscal Period Ended:
ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008
Provider No:
LTC 70024G
TOTAL RATIO
TOTAL SUBACUTE
SUBACUTE
ANCILLARY CHARGES COST TO ANCILLARY ANCILLARY
COST * CHARGES CHARGES ** COSTS***
ANCILLARY COST CENTERS (Adult SA Sch 4)
37.00 Operating Room $ 5,113,492 $ 54,808,109 0.093298 $ 0 $ 0
41.00 Radiology - Diagnostic 3,592,122 14,713,725 0.244134 344,652 84,141
42.01 Ultrasound 435,198 2,322,099 0.187416 27,281 5,113
42.02 CAT Scan 829,868 14,621,127 0.056758 101,131 5,740
43.00 Radioisotope 345,042 1,571,726 0.219531 14,584 3,202
44.00 Laboratory 4,380,098 35,372,413 0.123828 2,252,908 278,973
49.00 Respiratory Therapy 2,668,925 44,775,936 0.059606 31,212,887 1,860,483
49.01 Hyperbaric Chamber 1,399,828 10,624,124 0.131759 0 0
50.00 Physical Therapy 1,612,854 3,947,415 0.408585 768,722 314,088
51.00 Occupational Therapy 305,168 1,291,834 0.236228 604,314 142,756
52.00 Speech Pathology 129,738 569,919 0.227643 449,989 102,437
53.00 Electrocardiology 870,858 5,487,247 0.158706 0 0

55.00
Med Supplies Charged to Patients 3,462,472 15,268,493 0.226772 109,145 24,751
56.00 Drugs Charged to Patients 4,525,666 34,060,494 0.132871 55,337 7,353
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0

0.000000 0 0
101.00 TOTAL $ 29,671,329 $ 239,434,661 $ 35,940,950 $ 2,829,037
* From Schedule 8, Column 27
** Total Other Allowable Ancillary Charges included in the rate.
*** Total Other Ancillary Costs included in the rate.
(To Adult Subacute Sch 1)
TOTAL ANCILLARY
SCHEDULE OF TOTAL OTHER ALLOWABLE ADULT SUBACUTE ANCILLARY COSTS**
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STATE OF CALIFORNIA ADULT SUBACUTE SCH 4
Provider Name: Fiscal Period Ended:
ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008
Provider No:
LTC 70024G
ANCILLARY CHARGES
37.00 Operating Room $ 1,741 $ (1,741) $ 0
41.00 Radiology - Diagnostic 95,832 248,820 344,652
42.01 Ultrasound 3,637 23,644 27,281
42.02 CAT Scan 27,162 73,969 101,131
43.00 Radioisotope 4,316 10,268 14,584
44.00 Laboratory 520,362 1,732,546 2,252,908
49.00 Respiratory Therapy 6,136,680 25,076,207 31,212,887
49.01 Hyperbaric Chamber 38,401 (38,401) 0
50.00 Physical Therapy 127,728 640,994 768,722
51.00 Occupational Therapy 114,094 490,220 604,314
52.00 Speech Pathology 77,755 372,234 449,989
53.00 Electrocardiology 8,655 (8,655) 0
55.00
Med Supplies Charged to Patients 22,360 86,785 109,145

56.00 Drugs Charged to Patients 1,653,655 (1,598,318) 55,337
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
101.00

TOTAL ANCILLARY CHARGES
$ 8,832,378 $ 27,108,572 $ 35,940,950
(To Adult Subacute Sch 3)
REPORTED ADJUSTMENTS
ADULT SUBACUTE ANCILLARY CHARGES
ADJUSTMENTS TO OTHER ALLOWABLE
(Adj 22)
AUDITED
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STATE OF CALIFORNIA
Provider Name: Fiscal Period Ended:
ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008
Provider No:
LTC 70024G
COL.
1.00 Old Cap Rel Costs-Bldg and Fixtures $ 0 $ N/A
2.00 Old Cap Rel Costs-Movable Equipment 0 N/A
3.00 New Cap Rel Costs-Bldg and Fixtures 190,490 N/A
4.00 New Cap Rel Costs-Movable Equipment 290,629 N/A
4.01 0N/A
4.02 0N/A
4.03 0N/A
4.04 0N/A
4.05 0N/A
4.06 0N/A
4.07 0N/A
4.08 0N/A
5.00 Employee Benefits 1,557 1,182,543
6.01 Non-Patient Telephones 0 0

6.02 Data Processing 0 0
6.03 Purchasing/Receiving 0 0
6.04 Patient Admitting 0 0
6.05 Patient Business Office 0 0
6.06 00
6.07 00
6.08 00
6.00 Administrative and General 118,219 631,336
7.00 Maintenance and Repairs 119,986 188,904
8.00 Operation of Plant 3,488 18,629
9.00 Laundry and Linen Service 1,554 8,297
10.00 Housekeeping 10,898 113,497
11.00 Dietary 7,923 50,391
12.00 Cafeteria 31,554 200,686
13.00 Maintenance of Personnel 0 0
14.00 Nursing Administration 7,943 377,966
15.00 Central Services and Supply 632 5,138
16.00 Pharmacy 0 0
17.00 Medical Records and Library 4,889 50,631
18.00 Social Service 0 0
19.00 00
19.02 00
19.03 00
20.00 00
21.00 Nursing School 0 0
22.00 Intern & Res Service-Salary & Fringes 0 0
23.00 Intern & Res Other Program 0 0
24.00 Paramedical Ed Program 0 0
101.00 TOTAL ALLOCATED INDIRECT EXPENSES $ 789,762 $ 2,828,018
(To Adult Subacute Sch 1)

(COL 2)
RELATED
(COL 1)ALLOCATED EXPENSES
ADULT SUBACUTE SCH 5
COST CENTER
EMP BENEFITS
AUDITED SAL &AUDITED CAP
ALLOCATION OF INDIRECT EXPENSES
ADULT SUBACUTE
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STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period Ended:
ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008
NET EXP FOR
OLD CAPITAL
OLD
NEW CAP REL
NEW CAP REL

COST ALLOC BLDG & MOVABLE BLDG & MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
TRIAL BALANCE (From Sch 10) FIXTURES EQUIP FIXTURES EQUIPMENT COST COST COST COST COST COST COST
EXPENSES
0.00 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07
COMPUTATION OF COST ALLOCATION (W/S B)
GENERAL SERVICE COST CENTER
1.00
Old Cap Rel Costs-Bldg and Fixtures
0
2.00

Old Cap Rel Costs-Movable Equipmen
0
0
3.00
New Cap Rel Costs-Bldg and Fixtures
1,871,259
0
0
4.00
New Cap Rel Costs-Movable Equipme
2,854,962
0
0
0
4.01

0
0
0
0
0
4.02

0
0
0
0
0
0
4.03


0
0
0
0
0
0
0
4.04

0
0
0
0
0
0
0
0
4.05

0
0
0
0
0
0
0
0
0
4.06


0
0
0
0
0
0
0
0
0
0
4.07

0
0
0
0
0
0
0
0
0
0
0
4.08

0
0
0
0

0
0
0
0
0
0
0
0
5.00
Employee Benefits
8,958,700
0
0
4,671
7,126
0
0
0
0
0
0
0
6.01
Non-Patient Telephones
0
0
0
0
0
0

0
0
0
0
0
0
6.02
Data Processing
0
0
0
0
0
0
0
0
0
0
0
0
6.03
Purchasing/Receiving
0
0
0
0
0
0
0
0

0
0
0
0
6.04
Patient Admitting
0
0
0
0
0
0
0
0
0
0
0
0
6.05
Patient Business Office
0
0
0
0
0
0
0
0
0
0

0
0
6.06

0
0
0
0
0
0
0
0
0
0
0
0
6.07

0
0
0
0
0
0
0
0
0
0
0
0

6.08

0
0
0
0
0
0
0
0
0
0
0
0
6.00
Administrative and General
7,859,489
0
0
432,829
660,363
0
0
0
0
0
0
0
7.00
Maintenance and Repairs

1,791,058
0
0
270,502
412,702
0
0
0
0
0
0
0
8.00
Operation of Plant
1,151,626
0
0
0
0
0
0
0
0
0
0
0
9.00
Laundry and Linen Service
368,835
0

0
0
0
0
0
0
0
0
0
0
10.00
Housekeeping
726,000
0
0
15,463
23,591
0
0
0
0
0
0
0
11.00
Dietary
1,333,927
0
0
52,691

80,390
0
0
0
0
0
0
0
12.00
Cafeteria
0
0
0
0
0
0
0
0
0
0
0
0
13.00
Maintenance of Personnel
0
0
0
0
0
0

0
0
0
0
0
0
14.00
Nursing Administration
899,620
0
0
0
0
0
0
0
0
0
0
0
15.00 Central Services and Supply 389,402 0 0 12,392 18,9060000000
16.00 Pharmacy 1,034,335 0 0 6,654 10,1520000000
17.00 Medical Records and Library 1,049,956 0 0 13,277 20,2560000000
18.00
Social Service
0
0
0
0
0

0
0
0
0
0
0
0
19.00

0
0
0
0
0
0
0
0
0
0
0
0
19.02

0
0
0
0
0
0
0

0
0
0
0
0
19.03

0
0
0
0
0
0
0
0
0
0
0
0
20.00 000000000000
21.00 Nursing School 000000000000
22.00
Intern & Res Service-Salary & Fringes
0
0
0
0
0
0
0

0
0
0
0
0
23.00Intern & Res Other Program 000000000000
24.00Paramedical Ed Program 000000000000
INPATIENT ROUTINE COST CENTERS
25.00
Adults and Pediatrics (Gen Routine)
6,815,127
0
0
307,677
469,419
0
0
0
0
0
0
0
26.00 Intensive Care Unit 3,143,645 0 0 55,303 84,3760000000
27.00 Coronary Care Unit 000000000000
28.00 Neonatal Intensive Care Unit 000000000000
29.00Surgical Intensive Care 000000000000
30.00 Subprovider I 000000000000
31.00 Subprovider II 000000000000
32.00 000000000000
33.00 Nursery 418,116 0 0 4,617 7,0450000000

34.00
Distinct Part Nursing Facility
0
0
0
0
0
0
0
0
0
0
0
0
35.00
0
0
0
0
0
0
0
0
0
0
0
0
36.00
Subacute Care Unit
4,725,861

0
0
190,490
290,629
0
0
0
0
0
0
0
36.01
Subacute Care Unit II
0
0
0
0
0
0
0
0
0
0
0
0
36.02 Transitional Care Unit 000000000000
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STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period Ended:

ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008
NET EXP FOR
OLD CAPITAL
OLD
NEW CAP REL
NEW CAP REL

COST ALLOC BLDG & MOVABLE BLDG & MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
TRIAL BALANCE (From Sch 10) FIXTURES EQUIP FIXTURES EQUIPMENT COST COST COST COST COST COST COST
EXPENSES
0.00 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07
COMPUTATION OF COST ALLOCATION (W/S B)
ANCILLARY COST CENTERS
37.00
Operating Room
2,700,117
0
0
67,354
102,761
0
0
0
0
0
0
0
38.00
Recovery Room
0

0
0
0
0
0
0
0
0
0
0
0
39.00
Delivery Room and Labor Room
53,437
0
0
6,537
9,973
0
0
0
0
0
0
0
40.00
Anesthesiology
0
0
0

0
0
0
0
0
0
0
0
0
41.00 Radiology - Diagnostic 2,093,899 0 0 79,596 121,4390000000
42.00 Radiology - Therapeutic 000000000000
42.01
Ultrasound
291,890
0
0
2,645
4,035
0
0
0
0
0
0
0
42.02
CAT Scan
534,436
0
0

4,436
6,768
0
0
0
0
0
0
0
43.00 Radioisotope 216,545 0 0 6,142 9,3710000000
44.00 Laboratory 2,846,419 0 0 44,000 67,1300000000
44.01Pathological Lab 000000000000
46.00Whole Blood 000000000000
47.00 Blood Storing and Processing 000000000000
48.00 Intravenous Therapy 000000000000
49.00 Respiratory Therapy 1,597,262 0 0 6,974 10,6410000000
49.01
Hyperbaric Chamber
829,750
0
0
3,999
6,101
0
0
0
0
0
0
0

50.00
Physical Therapy
884,209
0
0
27,822
42,448
0
0
0
0
0
0
0
51.00 Occupational Therapy 188,163 0 0 1,450 2,2130000000
52.00 Speech Pathology 95,28500000000000
53.00 Electrocardiology 402,709 0 0 33,943 51,7870000000
54.00 Electroencephalography 000000000000
55.00 Medical Supplies Charged to Patients 2,729,48500000000000
55.01
Implants Charged to Patients
2,625,601
0
0
0
0
0
0
0
0

0
0
0
56.00
Drugs Charged to Patients
2,334,155
0
0
0
0
0
0
0
0
0
0
0
57.00 Renal Dialysis 497,96100000000000
58.00ASC (Non-Distinct Part) 000000000000
59.00 000000000000
59.01 000000000000
60.00Clinic 000000000000
60.01
Other Clinic Services
0
0
0
0
0
0

0
0
0
0
0
0
61.00
Emergency
2,612,538
0
0
55,037
83,969
0
0
0
0
0
0
0
62.00Observation Beds 000000000000
71.00 000000000000
82.00 000000000000
83.00 000000000000
84.00

0
0
0
0

0
0
0
0
0
0
0
0
85.00

0
0
0
0
0
0
0
0
0
0
0
0
86.00

0
0
0
0
0
0

0
0
0
0
0
0
NONREIMBURSABLE COST CENTERS
96.00 Gift, Flower, Coffee Shop & Canteen 0 0 0 5,023 7,6630000000
97.00Research 000000000000
98.00Physicians' Private Office 000000000000
99.00 Nonpaid Workers 000000000000
99.01

0
0
0
0
0
0
0
0
0
0
0
0
99.02

0
0
0

0
0
0
0
0
0
0
0
0
99.03 000000000000
99.04 000000000000
100.00 Community Benefits 378,09900000000000
100.01 Unused Space 0 0 0 151,695 231,4390000000
100.10 Medical Transporation Services 76,87100000000000
100.20 Non-Patient Meals 000000000000
100.30
Foundation
0
0
0
1,066
1,627
0
0
0
0
0
0
0
100.40 Doctor's Lounge 0 0 0 6,974 10,6410000000

TOTAL
69,380,749
0
0
1,871,259
2,854,962
0
0
0
0
0
0
0
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
ST. JOHN'S PLEASANT VALLEY HOSPITAL
TRIAL BALANCE
EXPENSES
GENERAL SERVICE COST CENTER
1.00
Old Cap Rel Costs-Bldg and Fixtures
2.00
Old Cap Rel Costs-Movable Equipmen
3.00
New Cap Rel Costs-Bldg and Fixtures
4.00
New Cap Rel Costs-Movable Equipme
4.01


4.02

4.03

4.04

4.05

4.06

4.07

4.08

5.00
Employee Benefits
6.01
Non-Patient Telephones
6.02
Data Processing
6.03
Purchasing/Receiving
6.04
Patient Admitting
6.05
Patient Business Office
6.06

6.07


6.08

6.00
Administrative and General
7.00
Maintenance and Repairs
8.00
Operation of Plant
9.00
Laundry and Linen Service
10.00
Housekeeping
11.00
Dietary
12.00
Cafeteria
13.00
Maintenance of Personnel
14.00
Nursing Administration
15.00 Central Services and Supply
16.00 Pharmacy
17.00 Medical Records and Library
18.00
Social Service
19.00

19.02


19.03

20.00
21.00 Nursing School
22.00
Intern & Res Service-Salary & Fringes
23.00 Intern & Res Other Program
24.00 Paramedical Ed Program
INPATIENT ROUTINE COST CENTER
25.00
Adults and Pediatrics (Gen Routine)
26.00 Intensive Care Unit
27.00 Coronary Care Unit
28.00 Neonatal Intensive Care Unit
29.00 Surgical Intensive Care
30.00 Subprovider I
31.00 Subprovider II
32.00
33.00 Nursery
34.00
Distinct Part Nursing Facility
35.00
36.00
Subacute Care Unit
36.01
Subacute Care Unit II
36.02 Transitional Care Unit
SCHEDULE 8.1
Fiscal Period Ended:
JUNE 30, 2008

ADMINIS-
ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE &
COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL
4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00
COMPUTATION OF COST ALLOCATION (W/S B)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1,240,294
0
0
0
0
0
0
0
0

10,192,975
0
188,902
0
0
0
0
0
0
0
0
2,663,164
458,635
0
0
0
0
0
0
0
0
0
0
1,151,626
198,326
0
0
0
0
0

0
0
0
0
0
368,835
63,519
0
122,891
0
0
0
0
0
0
0
0
887,945
152,917
0
217,988
0
0
0
0
0
0
0
0
1,684,995

290,180
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
217,093
0
0
0

0
0
0
0
0
1,116,713
192,314
071,14700000000491,84684,703
0 273,868000000001,325,010228,186
0 116,097000000001,199,585206,586
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0000000000 00
0000000000 00

0
0
0
0
0
0
0
0
0
0
0
0
0000000000 00
0000000000 00
0
1,547,101
0
0
0
0
0
0
0
0
9,139,324
1,573,921
0 708,308000000003,991,632687,416
0000000000 00
0000000000 00
0000000000 00

0000000000 00
0000000000 00
0000000000 00
0 104,75100000000534,52992,053
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1,184,100

0
0
0
0
0
0
0
0
6,391,081
1,100,635
0
0
0
0
0
0
0
0
0
0
0
0
0000000000 00
This is trial version
www.adultpdf.com