California Code of Regulations › Title 17 - Public Health › Division 2 - Health and Welfare Agency-Department of Developmental Services Regulations › Chapter 3 - Community Services › Subchapter 17 - Rate Adjustments, Audit Adjustments and Rate Appeals for in-Home Respite Services Agency Vendors › Appendix C to Subchapter 17

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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INSTRUCTIONS
Form DS 1897B (6/94) -- Page 1
Line
Reference
1.
Enter the reporting period of this cost
							 statement.
58031
2.
Enter vendor name.
58033
							 (a)(1)
3.
Enter vendor number, service code, and
							 subcode.
58033 (a)(1)
4.
Enter the address where the vendored
							 service is located.
58033 (a)(2)
5.
Enter the mailing address for the vendored
							 service.
58033 (a)(2)
6.
Enter the name of the management
							 organization, if the service is affiliated with a management
							 organization.
58033 (a)(1)
7.
Enter the name of the service director and
							 telephone number for the vendored service.
58033 (a)(3)
58033 (a)(2)
8.
Enter the name of the vendoring regional
							 center.
58033 (a)(4)
9.
Excluding the vendoring regional center,
							 enter the names of all regional centers for which you provide
							 services.
58033 (a)(4)
10.
If you are applying for a temporary
							 payment rate, enter the date you began or intend to begin providing
							 services.
58033 (c)(1)
VENDORS REQUESTING A TEMPORARY PAYMENT RATE, GO TO
					 LINE 20 VENDORS REQUESTING A PERMANENT PAYMENT RATE, COMPLETE LINES 11 THROUGH
					 20
11.
Enter the total actual number of direct
							 service hours provided to clients during this reporting period, and, for
							 vendors reimbursed for absences, the number of direct service hours for which
							 reimbursement was received.
58033 (b)
12.
Enter the total gross salaries and wages,
							 including overtime, for the vendored service.
58034 (a)(1)
13.
Enter the cost of allowable fringe
							 benefits associated with the salaries and wages on line 12 above.
58034
							 (a)(2)
14.
Enter the total allowable operating
							 expenses from page 2, line 17.
58034 (a)(3)
15.
Enter the total allowable management
							 organization costs from page 3, line 2.
58034 (a)(4)
16.
Enter the amount from page 4, line
							 4.
58039 (b)
17.
Enter the total of lines 12, 13, 14, 15,
							 and 16.
18.
Enter the total allowable vendor income
							 from page 3, line 4.
58038
19.
Subtract line 18 from line
							 17.
20.
Sign and date Statement of
							 Certification.
58030 (a)
TEMPORARY PAYMENT RATE
							 VENDORS:
INCLUDE WITH THE
58033 (a)(5)
SIGNED COST STATEMENT, A COPY OF THE
							 SERVICE
58033 (c)(2)
DESIGN AND VENDOR APPROVAL
							 LETTER.
PERMANENT PAYMENT RATE
							 VENDORS:
INCLUDE WITH THE
58033 (a)(5)
SIGNED COST STATEMENT, A COPY OF THE
							 SERVICE DESIGN.
INSTRUCTIONS
Page 2 -- OPERATING EXPENSE DETAIL SHEET
Line
Reference
1.
Enter the cost for accounting
							 fees.
58034 (a)(3)(A)
2.
Enter the cost for bank service
							 fee.
58034 (a)(3)(B)
3.
Enter the communication costs including
							 telephone, telegraph, teletype, centrex, telepak, postage, message service,
							 facsimiles and TDD.
58034 (a)(3)(C)
4.
Enter the cost for contractual/consultant
							 fees that do not have a specific cost category.
58034 (a)(3)(D)
5.
Enter the depreciation cost excluding
							 vehicle depreciation which is reported on line 16.
58034 (a)(3)(E)
6.
Enter the cost for general expenses. See
							 section referenced for items allowable under general expense.
58034
							 (a)(3)(F)
7.
Enter the insurance costs.
							 58034
(a)(3)(G)
8.
Enter the janitorial costs.
							 58034
(a)(3)(H)
9.
Enter the cost for legal
							 fees.
58034 (a)(3)(I)
10.
Enter the maintenance costs. See section
							 referenced for items allowable under maintenance costs.
58034
							 (a)(3)(J)
11.
Enter the office supplies costs. See
							 section referenced for allowable office supplies costs.
58034
							 (a)(3)(K)
12.
Enter the rental and lease costs. See
							 section referenced for items allowable under rental and lease
							 costs.
58034 (a)(3)(L)
13.
Enter the staff training costs.
							 58034
(a)(3)(M)
14.
Enter the costs for staff
							 travel.
58034 (a)(3)(N)
15.
Enter the utilities costs.
58034
							 (a)(3)(O)
16.
Enter the vehicle depreciation costs. See
							 referenced section regarding depreciation methodology and useful
							 life.
58034 (a)(3)(P)
17.
Enter total of lines 1 through 16 here
							 and on page 1, line 14.
INSTRUCTIONS
Page 3 -- MANAGEMENT ORGANIZATION COST AND VENDOR INCOME
					 DETAIL SHEET
MANAGEMENT ORGANIZATION COST
Line
Reference
1.
Enter the total allowed cost of the
							 management organization.
58034 (a)(4)(C)2.
2.
Enter the amount of management
							 organization costs allocated to this service here and on page 1, line
							 15.
58034 (a)(4)(C)
3.
Check the method of allocation
							 used.
58034 (a)(4)(C)1.a.
58034 (a)(4)(C)1.b.
VENDOR INCOME
Line
Reference
4.
Enter name of each source of vendor
							 income, duration of funding and total income.
58038 (a)
5.
Enter the total of all vendor income here
							 and on page 1, line 18.
58038 (a)
INSTRUCTIONS
Page 4 -- 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
							 actual units of service provided, and the difference between the two
							 amounts.
58039 (a)(1) 58039 (a)(2)
2.
Enter the total amount of all actual
							 regional center payments received, the total of all maximum amounts of regional
							 center payments, and the total difference between the two
							 amounts.
58039 (a)(1) 58039 (a)(2)
3.
Enter the total amount of cost reductions
							 implemented as a result of the negotiated level of payment.
58039
							 (b)
4.
Enter the lesser of the amounts entered on
							 line 2D or line 3 here and on page 1, line 16.