STATE OF CA RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS Page 1 Schedule 8A-2 Provider Nam Provider Number: ZZR05417K 1215928387 206341014 JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 NPI: OSHPD Facility Number: Fiscal Period: SAYLOR LAN TOTAL ADJ (Pages 1, 2, & 3) 4 5 6 7 8 9 10 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ Line Sub No. 0 (6,447) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 No. 167 4 168 4 169 4 170 1 170 2 170 3 170 4 174 1 174 2 174 3 174 4 180 4 200 ($164,664) (To Sch 8) 0 0 0 This is trial version 0 0 0 0 State of California Fiscal Period JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387 Department of Health Care.
