California Code of Regulations › Title 17 - Public Health › Division 2 - Health and Welfare Agency-Department of Developmental Services Regulations › Chapter 3 - Community Services › Subchapter 12 - Rate Adjustments, Audit Adjustments and Rate Appeals for Community-Based Day Programs › Appendix B to Subchapter 12

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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INSTRUCTIONS
Form DS 1897 (6/94) -- Page 1
Line
Reference
1. Enter the reporting period of this cost
							 statement.
57431
2. Enter vendor name.
57433 (a)(1)
3. Enter the vendor number, service code, and
							 subcode.
57433 (a)(1)
4. Enter the address where the vendored service is
							 located.
57433 (a)(2)
5. Enter the mailing address for the vendored
							 service.
57433 (a)(2)
6. Enter the name of the management organization, if
							 the service is affiliated with a management organization.
57433
							 (a)(1)
7. Enter the name of the service director and
							 telephone number for the vendored service.
57433 (a)(3)
57433 (a)(2)
8. Enter the name of the vendoring regional
							 center.
57433 (a)(4)
9. Excluding the vendoring regional center, enter the
							 names of all regional centers for which you provide services.
57433
							 (a)(4)
10. If you are applying for a temporary payment rate,
							 enter the date you began or intend to begin providing services.
57433
							 (c)(1)
VENDORS REQUESTING A TEMPORARY PAYMENT
							 RATE, GO TO LINE 21 VENDORS REQUESTING A PERMANENT PAYMENT RATE, COMPLETE LINES
							 11 THROUGH 21
11 & 12. Enter the total actual number of client
							 days or hours of attendance during this reporting period, from page 2, column 4
							 or page 3, column 5.
57422 (a)(2)(A) or (B)
13. Enter the total gross salaries and wages,
							 including overtime, and staff relief time for the vendored
							 service.
57434 (a)(1)(A)
13a. Add the total salary and wage and fringe
							 benefits for the direct service function. Divide this total by the total hours
							 of employment for the direct service function. Enter this amount.
57434
							 (a)(1)(B)
14. Enter the total allowable fringe benefits
							 associated with the salaries and wages on line 13 above.
57434
							 (a)(2)
15. Enter the total allowable operating expenses from
							 page 4, line 17.
57434 (a)(3)
16. Enter the total allowable management organization
							 costs from page 5, line 2.
57434 (a)(4)
17. Enter the amount from page 6, line
							 4
57439 (b)
18. Enter the total of lines 13, 14, 15, 16, and
							 17.
19. Enter the total allowable vendor income from page
							 5, line 5.
57438
20. Subtract line 19 from line 18.
21. Sign and date Statement of
							 Certification.
57430 (a)
TEMPORARY PAYMENT RATE VENDORS: INCLUDE WITH THE
							 SIGNED COST STATEMENT, A COPY OF THE PROGRAM DESIGN AND VENDOR APPROVAL
							 LETTER.
57433 (a)(5) 57433 (c)(2)
PERMANENT PAYMENT RATE VENDORS: INCLUDE WITH THE
							 SIGNED COST STATEMENT, A COPY OF THE PROGRAM DESIGN.
57433 (a)(5)
INSTRUCTIONS
Page 2 -- UNITS OF SERVICE AND STAFFING
Page 2 applies to Activity Centers, Adult Development
					 Centers and Behavior Management Programs only.
For Social Recreation, Independent Living and Infant
					 Development Programs proceed to page 3.
This page is to report monthly data on the amount of staff
					 hours used to perform the direct service function and the units of service
					 provided. Unlike subsequent pages, data on this page is not transferred to page
					 1 but is used to verify the vendors annual staffing ratio per Section
					 57444.
Column
Reference
1.
Enter the number of direct service hours
							 actually provided to clients each month. Direct service hours are defined as
							 the number of hours during which direct services were provided to clients by
							 direct care staff and, for vendors reimbursed for absences, the number of
							 direct service hours for which the vendor received reimbursement.
57433
							 (b)(1) 57210 (a)(3)
2.
Enter the number of days in which the
							 service was actually provided to clients each month, which shall include the
							 number of days for which reimbursement for absences was received.
57433
							 (b)(2)(C)
3.
Enter the maximum number of clients
							 enrolled each month.
57433 (b)(2)(A)
4.
Enter the actual number of days of
							 attendance each month for all clients, which shall include the the actual
							 number of client days for which reimbursement for absences was
							 received.
57433 (b)(2)(B)
INSTRUCTIONS
Page 3 -- UNITS OF SERVICE AND STAFFING
Page 3 applies to Social Recreation, Independent Living,
					 and Infant Development Programs only.
This page is to report monthly data on the amount of staff
					 hours used to perform the direct service function and the units of service
					 provided. Unlike subsequent pages, data on this page is not transferred to page
					 1 but is used to verify the vendors annual staffing ratio per Section
					 57444.
Column
Reference
1.
Enter the number of direct service hours
							 actually provided to clients. Direct service hours are defined as the number of
							 hours during which direct services were provided to clients by direct care
							 staff and, for vendors reimbursed for absences, the number of direct service
							 hours for which the vendor received reimbursement.
57433 (b)(1) 57210
							 (a)(3)
2.
Enter the authorized number of direct
							 service hours each month for all clients.
57433 (b)(3)(A)
3.
Enter the number of clients scheduled to
							 receive services each month within the hours identified in column
							 2.
57433 (b)(3)(B)
4.
Enter the number of clients who actually
							 received services each month within the hours identified in column 2, which
							 shall include the number of clients for whom reimbursement for absences was
							 received.
57433 (b)(3)(C)
5.
Enter the actual number of hours of
							 attendance each month for all clients, which shall include the actual number of
							 hours for which reimbursement for absences was received.
57433
							 (b)(3)(D)
INSTRUCTIONS
Page 4 -- OPERATING EXPENSE DETAIL SHEET
Line
Reference
1.
Enter the cost for accounting
							 fees.
57434 (a)(3)(A)
2.
Enter the cost for bank service
							 fees.
57434 (a)(3)(B)
3.
Enter the communication costs including
							 telephone, telegraph, teletype, centrex, telepak, postage, message service,
							 facsimiles, and TDD.
57434 (a)(3)(C)
4.
Enter the cost for contractual/consultant
							 fees that do not have a specific cost category.
57434 (a)(3)(D)
5.
Enter the depreciation cost excluding
							 vehicle depreciation which is reported on line 16.
57434 (a)(3)(E)
6.
Enter the cost for general expenses. See
							 section referenced for items allowable under general expense.
57434
							 (a)(3)(F)
7.
Enter the insurance costs.
57434
							 (a)(3)(G)
8.
Enter the janitorial costs.
57434
							 (a)(3)(H)
9.
Enter the cost for legal
							 fees.
57434 (a)(3)(I)
10.
Enter the maintenance costs. See section
							 referenced for items allowable under maintenance costs.
57434
							 (a)(3)(J)
11.
Enter the office and program supplies
							 costs. See section referenced for allowable office and supplies
							 costs.
57434 (a)(3)(K)
12.
Enter the rental and lease costs. See
							 section referenced for items allowable under rental and lease
							 costs.
57434 (a)(3)(L)
13.
Enter the staff training
							 costs.
57434 (a)(3)(M)
14.
Enter the travel costs.
57434
							 (a)(3)(N)
15.
Enter the utilities costs.
57434
							 (a)(3)(O)
16.
Enter the vehicle depreciation costs. See
							 referenced section regarding depreciation methodology and useful
							 life.
57434 (a)(3)(P)
17.
Enter the total of lines 1 through 16
							 here and on page 1, line 15.
INSTRUCTIONS
Page 5 -- MANAGEMENT ORGANIZATION COST AND VENDOR INCOME
					 DETAIL SHEET
MANAGEMENT ORGANIZATION COST
Line
Reference
1.
Enter the total allowed cost of the
							 management organization.
57434 (a)(4)(C)2.
2.
Enter the amount of management
							 organization costs allocated to this service here and on page 1, line
							 16.
57434 (a)(4)(C)
3.
Check the method of allocation
							 used.
57434 (a)(4)(C)1.a. 57434 (a)(4)(C)1.b.
VENDOR INCOME
4.
Enter the name of each source of vendor
							 income, duration of funding, and total income.
57438 (a)
5.
Enter the total of all vendor income here
							 and on page 1, line 19.
57438 (a)
INSTRUCTIONS
Page 6 -- REGIONAL CENTER PAYMENT INFORMATION DETAIL
					 SHEET
APPLICABLE ONLY TO VENDORS WHO NEGOTIATED A LOWER
					 LEVEL OF PAYMENT
Regional Center Payment Information
Line
Reference
1.
Enter the name of each regional center,
							 total amount of the actual regional center payment received from the regional
							 center, and maximum amount of the regional center payment which you would have
							 received from the regional center based upon the established rate and the units
							 of service actually provided, and the difference between the two
							 amounts.
57439 (a)(1) 57439 (a)(2)
2.
Enter the total amount of all actual
							 regional center payments received and the total of all maximum amounts of
							 regional center payments, and the total difference between the two
							 amounts.
57439 (a)(1) 57439 (a)(2)
3.
Enter the total amount of cost reductions
							 implemented as a result of the negotiated level of payment.
57439
							 (b)
4.
Enter the lesser of the amounts entered on
							 line 2D or line 3 here and on page 1, line 17.