Spreadsheet: 59828d1260371805-generate-a-master-worksheet-from-individual-worksheets-rc1272
Sheet: CostReport

RESIDENTIAL CARE FACILITY
GENERAL INFORMATION
 |  |  | 1st Facility | 2nd Facility | 3rd Facility | 4th Facility
 |  | FACILITY NAME: | South Island
 |  | COST REPORT PERIOD: | 7/1/2008 - 6/30/2009 |  |  | (Due Sept 1, 2009)
 |  | PROVIDER # (Ex. RC9999) | RC1272
 |  |  | 1st Facility | 2nd Facility | 3rd Facility | 4th Facility
1. FACILITY DATA
NAME | South Island Assisted Living |  |  |  | PROVIDER # |  | RC1272
FACILITY LOCATION (STREET ADDRESS)
MAILING ADDRESS (STREET OR P.O. BOX)
CITY |  |  | STATE |  | ZIP CODE
PHONE # (Area Code) |  |  |  | FAX #
[NAME]
CONTROL TYPE (X one): |  | FOR-PROFIT |  | NON-PROFIT |  |  | GOVERNMENT
2. ADMINISTRATOR DATA
NAME |  |  |  | LICENSE NO.
3. IF YOU HAVE AN ACCOUNTING FIRM, PLEASE [NAME]
ACCOUNTING FIRM
ADDRESS
PHONE
4. REPORT PREPARER-PLEASE LIST THE NAME OF THE PERSON COMPLETING THIS FORM
NAME
ADDRESS
PHONE
5. FACILITY OPERATOR AND COST REPORT PREPARER CERTIFICATION
Under penalties of perjury, I declare that I have examined this cost report, including any accompanying
schedule and/or statement, and to the best of my knowledge and belief,  it is true, correct, and complete.
Declaration of the preparer (other than facility owners/personnel) is based on all information of which
preparer has knowledge.
Owner's Name and Signature |  |  | Report Preparer's Name |  |  | Date
6. OPERATING  OWNER(S) (OWNER OF CURRENTLY LICENSED BUSINESS)
NAME
ADDRESS
PHONE
RESIDENTIAL CARE FACILITY
GENERAL INFORMATION
 |  | FACILITY NAME: | South Island
 |  | COST REPORT PERIOD: | 7/1/2008 - 6/30/2009
 |  | PROVIDER # (Ex. RC9999) | RC1272
7. OWNER(S) OF THE RCF BUILDING AND LAND
NAME
ADDRESS
PHONE
8.  IS THE RCF OWNER A PAID EMPLOYEE OF THE RCF?
 | No.  The Owner is not paid and is not an employee.  GO TO QUESTION 9.
 | No.  The Owner is NOT paid, but IS AN EMPLOYEE--[NAME] name, job title, & hours worked at the RCF below.
YES | YES.  The Owner IS an employee AND is PAID--[NAME] box below (this would include any owner draws
 | from the RCF bank account).
NOTE: If the owner and/or an owner relative of the RCF is the administrator and also performs other tasks within the RCF
(e.g. Dietary, [NAME], etc.), all salary costs may be claimed under Administration if you are unable to allocate
the salary to the other cost areas.
NAME |  | JOB TITLE      (if several jobs, please list each) | TOTAL HOURS WORKED | YEARLY SALARY | Cost Report Reference |  | Did owner work at another RCF facility during the cost report period?
 |  |  |  | AMOUNT | PAGE | LINE
 |  | Administrator/Activity | 2081 | 26000 | 6 | 1 | no
 |  | Maintenance/Assist Administrator | 1812 | 16800 | 9 | 3 | no
9. DOES THE RCF OWNER [NAME] RELATIVES WHO ARE PAID?
NO | No.  The Relative is not paid and is not an employee.  GO TO QUESTION 10.
 | No.  The Relative is not paid, but IS AN EMPLOYEE--[NAME] name, job title, and hours worked at the RCF below.
 | YES.  The Relative IS an employee AND is PAID--[NAME] box below.
NAME |  | JOB TITLE     (if several jobs, please list each) | TOTAL HOURS WORKED | YEARLY SALARY | Cost Report Reference |  | Did owner work at another RCF facility during the cost report period?
 |  |  |  | AMOUNT | PAGE | LINE
10. IF THE OWNER OF THE LICENSED RCF OWNS ANY OTHER RCF FACILITY, PLEASE LIST
FACILITY NAME |  | RC # | [NAME]
 |  |  | CITY |  | STATE
RESIDENTIAL CARE FACILITY
GENERAL INFORMATION; CONSTRUCTION, RENTAL OR ACQUISITION COST OF RCF
 |  | FACILITY NAME: | South Island
 |  | COST REPORT PERIOD: | 7/1/2008 - 6/30/2009
 |  | PROVIDER # (Ex. RC9999) | RC1272
11. DOES THE RCF DO BUSINESS WITH OTHER BUSINESSES OWNED BY THE RCF OWNER?
(Includes a related party lease)
NO | No.  You do not need to complete this section.
 | Yes.  The following information must be completed.
EXAMPLE
The owner of the Residential Care Facility also owns a grocery store.  The owner purchases groceries from his grocery store
for his Residential Care Facility and charges the Residential Care Facility $100.  The $100 would be the cost to the Residential
Care Facility.  The owner’s actual cost of the groceries is $80, which is the cost to the related business.
EXPENSES  (SUPPLIES, RENT, MANAGEMENT FEES, ETC.)
RELATED BUSINESS NAME |  | [NAME] | COST TO THE RCF | COST TO RELATED BUSINESS | Cost Report Reference
 |  |  |  |  | PAGE | LINE
12. IS THE RCF RENTED OR LEASED?
 | No.  Go to  QUESTION #13 below.
 | Yes.  The following information must be completed.
ASSET |  | # OF MONTHS OR YEARS OF LEASE | EXPIRATION DATE |  | MONTHLY PAYMENT
Building Only |  | 10 years | 2013-03-01 00:00:00 |  | 9000
Equipment and Furniture Only
Building, Equipment and Furniture
13. PLEASE LIST THE CONSTRUCTION OR PURCHASE PRICE OF THE RCF
ORIGINAL PURCHASE PRICE OF BUILDING |  | YEAR | SQUARE FEET |  | # OF DHEC [NAME] BEDS |  | CONSTRUCTION COST
BUILDING ADDITIONS  (DESCRIBE)
TOTALS |  |  | 0 |  | 0 |  | 0
RESIDENTIAL CARE FACILITY
CENSUS REPORT AND SQUARE FOOTAGE
 |  | FACILITY NAME: | South Island
 |  | COST REPORT PERIOD: | 7/1/2008 - 6/30/2009
 |  | PROVIDER # (Ex. RC9999) | RC1272
COMPLETE THE FOLLOWING RESIDENT DAY INFORMATION CORRECTLY.  REFER TO YOUR MONTHLY TAD
OR  DHEC STATISTICAL REPORT DURING THE COST REPORT PERIOD.  [NAME] TOTAL DAYS FOR
ALL RESIDENTS.
Ex:  IF YOU HAVE 4 OSS RESIDENTS FOR ALL 31 DAYS IN JULY, THEN TOTAL OSS DAYS FOR JULY
WOULD BE 124 DAYS OR (4 x 31).
IF YOU HAVE 1 PRIVATE PAY RESIDENT FOR ONLY 15 DAYS IN JULY, THEN TOTAL PRIVATE PAY DAYS
FOR JULY WOULD BE 15 DAYS OR (1 x 15).
TOTAL DAYS FOR JULY WOULD BE 139 OR (124 + 15).
 | Private Pay Days |  | OSS Days |  |  | IPC Days |  | Total Days
July Days | 217 |  | 743 |  |  | 403 |  | 1363
Aug Days | 186 |  | 713 |  |  | 496 |  | 1395
Sept Days | 240 |  | 690 |  |  | 493 |  | 1423
Oct Days | 217 |  | 683 |  |  | 465 |  | 1365
Nov Days | 221 |  | 629 |  |  | 420 |  | 1270
Dec Days | 248 |  | 687 |  |  | 488 |  | 1423
Jan Days | 186 |  | 651 |  |  | 396 |  | 1233
Feb Days | 168 |  | 546 |  |  | 350 |  | 1064
Mar Days | 186 |  | 589 |  |  | 341 |  | 1116
Apr Days | 180 |  | 589 |  |  | 319 |  | 1088
May Days | 184 |  | 692 |  |  | 310 |  | 1186
June Days | 150 |  | 720 |  |  | 300 |  | 1170
GRAND TOTAL | 2383 |  | 3151 |  |  | 4781 |  | 15096
Are you an IPC Provider?
YES | YES |  | **Removed IPC FROM OSS days**
 | NO
Number of DHEC [NAME] BEDS @ 7/01/08: |  |  |  | 32
Number of DHEC [NAME] BEDS @ 6/30/09: |  |  |  | 32
If you had licensed bed changes during the cost reporting period, please identify date of change
and number of licensed RCF beds:
RESIDENTIAL CARE FACILITY
INCOME/MONIES RECEIVED
 |  | FACILITY NAME: | South Island
 |  | COST REPORT PERIOD: | 7/1/2008 - 6/30/2009
 |  | PROVIDER # (Ex. RC9999) | RC1272
ONLY COMPLETE AREAS THAT APPLY.  ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.
 | ACCOUNT NUMBER* | PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS INCOME AND EXPENSES |  |  |  | INCOME
 |  |  |  |  |  | (Do Not Estimate)
 |  | INCOME  (Post as positive)
1 |  | ROOM & BOARD INCOME - PRIVATE |  |  |  | 126129
2 |  | ROOM & BOARD INCOME - OSS less Personal Needs Allowance |  |  |  | 100690
3 |  | ROOM & BOARD INCOME - Social Security and SSI |  |  |  | 158066
4 |  | INTEGRATED PERSONAL CARE (IPC) INCOME |  |  |  | 29332
5 |  | ROOM & BOARD INCOME - Dept of Mental Health (DMH)
6 |  | ROOM & BOARD INCOME - Dept of Disabilities and Special Needs (DDSN)
7 |  | MEALS ON WHEELS INCOME
8 |  | ADULT DAY CARE INCOME
9 |  | RESIDENT HEALTH SUPPLIES INCOME – OSS
10 |  | RESIDENT HEALTH SUPPLIES INCOME - OTHER
11 |  | PHARMACY INCOME - PRIVATE
12 |  | PHARMACY INCOME - OSS
13 |  | OTHER SERVICES INCOME - PRIVATE
14 |  | EMPLOYEE & GUEST MEAL INCOME
15 |  | BEAUTY & BARBER INCOME
16 |  | VENDING MACHINE INCOME |  |  |  | 422
17 |  | TELEPHONE INCOME
18 |  | INTEREST INCOME-BANKS & SAVINGS
19 |  | RENTAL INCOME
20 |  | CONTRIBUTION INCOME
21 |  | CABLE T.V. INCOME
22 |  | GRANT INCOME
23 |  | OTHER INCOME
24 |  | [NAME]    (negative amount)
25 |  | [NAME](negative amount)
26 |  | TOTAL INCOME |  |  |  | 414639
27 |  | PATIENT PERSONAL NEEDS ALLOWANCE - INCOME
28 |  | PATIENT PERSONAL NEEDS ALLOWANCE - DISBURSEMENTS (negative amount)
Notes:
RESIDENTIAL CARE FACILITY
ADMINISTRATIVE EXPENSE
 |  | FACILITY NAME: | South Island
 |  | COST REPORT PERIOD: | 7/1/2008 - 6/30/2009
 |  | PROVIDER # (Ex. RC9999) | RC1272
ONLY COMPLETE AREAS THAT APPLY.  ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.
 | ACCOUNT NUMBER* | PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS INCOME AND EXPENSES
 |  |  |  |  |  | COST
 |  |  |  |  |  | (Do Not Estimate)
 |  | ADMINISTRATION EXPENSES
1 |  | ADMINISTRATOR SALARIES |  |  |  | 26000
2 |  | ASSISTANT ADMINISTRATOR SALARIES
3 |  | BOOKKEEPING SALARIES
4 |  | SECRETARY SALARIES
5 |  | ADVERTISING |  |  |  | 1206
6 |  | MANAGEMENT FEES
7 |  | PURCHASED SERVICES
8 |  | PRINTING AND COPIER |  |  |  | 535
9 |  | DUES |  |  |  | 35
10 |  | SUBSCRIPTIONS
11 |  | OFFICE SUPPLIES AND POSTAGE |  |  |  | 1053
12 |  | PROFESSIONAL ACCOUNTING |  |  |  | 3475
13 |  | PROFESSIONAL OTHER |  |  |  | 1075
14 |  | TELEPHONE - LAND and MOBILE LINES |  |  |  | 2558
15 |  | SEMINARS AND TRAINING |  |  |  | 589
16 |  | EQUIPMENT RENTAL
17 |  | BANK AND FREIGHT CHARGES |  |  |  | 444
18 |  | SMALL EQUIPMENT (LESS THAN $5,000)
19 |  | AUTO EXPENSE and MILEAGE REIMBURSEMENT
20 |  | LEGAL FEES
21 |  | ADMINISTRATION-OTHER
 |  | EMPLOYEE BENEFITS AND FRINGES
22 |  | FUTA, SUTA, FICA |  |  |  | 997
23 |  | WORKMEN'S COMPENSATION
24 |  | HEALTH AND LIFE INSURANCE |  |  |  | 5172
25 |  | TOTAL ADMINISTRATION EXPENSES |  |  |  | 43139
Notes:
RESIDENTIAL CARE FACILITY
RESIDENT CARE AND ACTIVITY EXPENSE
 |  | FACILITY NAME: | South Island
 |  | COST REPORT PERIOD: | 7/1/2008 - 6/30/2009
 |  | PROVIDER # (Ex. RC9999) | RC1272
ONLY COMPLETE AREAS THAT APPLY.  ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.
 | ACCOUNT NUMBER* | PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS INCOME AND EXPENSES
 |  |  |  |  |  | COST
 |  |  |  |  |  | (Do Not Estimate)
 |  | RESIDENT CARE AND ACTIVITY EXPENSES
1 |  | RESIDENT CARE SUPERVISOR SALARIES
2 |  | CARE GIVER SALARIES |  |  |  | 65388
3 |  | ACTIVITIES & SOCIAL SERVICES SALARIES
4 |  | INTEGRATED PERSONAL CARE (IPC) - RN and LPN SALARIES |  |  |  | 2844
5 |  | INTEGRATED PERSONAL CARE (IPC) - AIDE SALARIES |  |  |  | 35146
6 |  | INTERATED PERSONAL CARE (IPC) - CONTRACTED SVCS
7 |  | INTERATED PERSONAL CARE (IPC) - AMERICAN DISABILITY ACT (ADA) -BUILDING and EQUIPMENT
8 |  | OVER THE COUNTER DRUGS
9 |  | PRESCRIPTION DRUGS
10 |  | DIAPERS AND UNDERPADS
11 |  | MEDICAL TRANSPORTATION COST |  |  |  | 5978
12 |  | ACTIVITY TRANSPORTATION COST |  |  |  | 2351
13 |  | RESIDENT HEALTH SUPPLIES (Toothbrush, Toothpaste, Soap, Deodorant, Razor, Etc.) |  |  |  | 366
14 |  | RCF PET CARE
15 |  | EMPLOYEE UNIFORM
16 |  | EMPLOYEE BLOOD TEST/SKIN TEST |  |  |  | 21
17 |  | ACTIVITY SUPPLIES
18 |  | SMALL EQUIPMENT (LESS THAN $5,000)
19 |  | DRUG and BACKGROUND CHECKS |  |  |  | 200
20 |  | RESIDENT CARE-OTHER
 |  | EMPLOYEE BENEFITS AND FRINGES
21 |  | FUTA, SUTA, FICA |  |  |  | 959
22 |  | WORKMEN'S COMPENSATION |  |  |  | 5877
23 |  | HEALTH AND LIFE INSURANCE |  |  |  | 1900
24 |  | INTEGRATED PERSONAL CARE - RN, LPN and AIDE BENEFITS AND PAYROLL TAXES
25 |  | TOTAL RESIDENT CARE AND ACTIVITY EXPENSES |  |  |  | 121030
Notes:
RESIDENTIAL CARE FACILITY
DIETARY EXPENSE
 |  | FACILITY NAME: | South Island
 |  | COST REPORT PERIOD: | 7/1/2008 - 6/30/2009
 |  | PROVIDER # (Ex. RC9999) | RC1272
ONLY COMPLETE AREAS THAT APPLY.  ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.
 | ACCOUNT NUMBER* | PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS INCOME AND EXPENSES
 |  |  |  |  |  | COST
 |  |  |  |  |  | (Do Not Estimate)
 |  | DIETARY EXPENSES
1 |  | DIETARY SALARIES |  |  |  | 28777
2 |  | DIETARY CONSULTANT
3 |  | DIETARY AIDES
4 |  | SMALL EQUIPMENT (LESS THAN $5,000)
5 |  | FOOD |  |  |  | 30431
6 |  | DIETARY SUPPLIES
7 |  | DISHES AND UTENSILS
8 |  | DIETARY EQUIPMENT RENTAL
9 |  | MENU PLANS
10 |  | PURCHASED SERVICES
11 |  | DIETARY-OTHER
 |  | EMPLOYEE BENEFITS AND FRINGES
12 |  | FUTA, SUTA, FICA |  |  |  | 222
13 |  | WORKMEN'S COMPENSATION |  |  |  | 1964
14 |  | HEALTH AND LIFE INSURANCE |  |  |  | 480
15 |  | TOTAL DIETARY EXPENSES |  |  |  | 61874
Notes:
RESIDENTIAL CARE FACILITY
LAUNDRY, HOUSEKEEPING AND MAINTENANCE EXPENSES
 |  | FACILITY NAME: | South Island
 |  | COST REPORT PERIOD: | 7/1/2008 - 6/30/2009
 |  | PROVIDER # (Ex. RC9999) | RC1272
ONLY COMPLETE AREAS THAT APPLY.  ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.
 | ACCOUNT NUMBER* | PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS INCOME AND EXPENSES
 |  |  |  |  |  | COST
 |  |  |  |  |  | (Do Not Estimate)
 |  | LAUNDRY, HOUSEKEEPING, [NAME]
1 |  | LAUNDRY SALARIES
2 |  | HOUSEKEEPING SALARIES
3 |  | MAINTENANCE SALARIES |  |  |  | 16800
4 |  | [NAME] |  |  |  | 513
5 |  | LINENS
6 |  | LAUNDRY, HOUSEKEEPING AND MAINTENANCE SUPPLIES |  |  |  | 6954
7 |  | PURCHASED SERVICES
8 |  | FIRE ALARM AND LIFE SAFETY CERTIFICATION |  |  |  | 1556
9 |  | SECURITY (ALARM) |  |  |  | 1112
10 |  | PAINTING
11 |  | REPAIRS |  |  |  | 4900
12 |  | PEST CONTROL |  |  |  | 1175
13 |  | LAWN and GARDENING |  |  |  | 1276
14 |  | SMALL EQUIPMENT (LESS THAN $5,000) |  |  |  | 687
15 |  | LAUNDRY, HOUSEKEEPING, [NAME]
 |  | EMPLOYEE BENEFITS AND FRINGES
16 |  | FUTA, SUTA, FICA |  |  |  | 56
17 |  | WORKMEN'S COMPENSATION
18 |  | HEALTH AND LIFE INSURANCE |  |  |  | 230
19 |  | TOTAL LAUNDRY, HOUSEKEEPING AND MAINTENANCE EXPENSES |  |  |  | 35259
Notes:
RESIDENTIAL CARE FACILITY
UTILITIES EXPENSES
TAXES, INSURANCE AND LICENSE EXPENSES
 |  | FACILITY NAME: | South Island
 |  | COST REPORT PERIOD: | 7/1/2008 - 6/30/2009
 |  | PROVIDER # (Ex. RC9999) | RC1272
ONLY COMPLETE AREAS THAT APPLY.  ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.
 | ACCOUNT NUMBER* | PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS INCOME AND EXPENSES
 |  |  |  |  |  | COST
 |  |  |  |  |  | (Do Not Estimate)
 |  | UTILITIES EXPENSES
1 |  | HEATING
2 |  | ELECTRICITY |  |  |  | 15922
3 |  | WATER |  |  |  | 2388
4 |  | SEWER |  |  |  | 5192
5 |  | GARBAGE |  |  |  | 1327
6 |  | CABLE OR SATELLITE |  |  |  | 1480
7 |  | UTILITIES-OTHER |  |  |  | 3122
8 |  | TOTAL UTILITIES EXPENSES |  |  |  | 29431
Notes: | utilities other is natural gas--cannot separate the heating out of the electricity
ONLY COMPLETE AREAS THAT APPLY.  ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.
 | ACCOUNT NUMBER* | PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS INCOME AND EXPENSES
 |  |  |  |  |  | COST
 |  |  |  |  |  | (Do Not Estimate)
 |  | TAXES, INSURANCE AND LICENSES EXPENSES (1)
9 |  | TAXES - PROPERTY |  |  |  | 16178
10 |  | TAXES - PERSONAL
11 |  | TAXES - BUSINESS
12 |  | INSURANCE - PROPERTY |  |  |  | 7882
13 |  | INSURANCE - LIABILITY
14 |  | INSURANCE - GENERAL
15 |  | LICENSES |  |  |  | 1962
16 |  | TAXES, INSURANCE, LICENSES-OTHER
17 |  | TOTAL TAXES, INSURANCE AND LICENSES EXPENSES |  |  |  | 26022
(1)  State and Federal Income Tax Expense should not be included here, but under “OTHER EXPENSES” on Page 11.
Notes:
RESIDENTIAL CARE FACILITY
COST OF CAPITAL EXPENSES
OTHER EXPENSES
 |  | FACILITY NAME: | South Island
 |  | COST REPORT PERIOD: | 7/1/2008 - 6/30/2009
 |  | PROVIDER # (Ex. RC9999) | RC1272
ONLY COMPLETE AREAS THAT APPLY.  ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.
 | ACCOUNT NUMBER* | PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS INCOME AND EXPENSES
 |  |  |  |  |  | COST
 |  |  |  |  |  | (Do Not Estimate)
 |  | COST OF CAPITAL EXPENSES
1 |  | DEPRECIATION - CAPITAL IMPROVEMENTS
2 |  | DEPRECIATION - BUILDING
3 |  | DEPRECIATION - EQUIPMENT AND FURNITURE |  |  |  | 3918
4 |  | RENT - BUILDING |  |  |  | 67485
5 |  | RENT - EQUIPMENT AND FURNITURE
6 |  | AMORTIZATION |  |  |  | 10
7 |  | INTEREST - BUILDING                      (Identify on Page 12)
8 |  | INTEREST - EQUIPMENT AND FURNITURE (Id on Page 12)
9 |  | INTEREST - OTHER                          (Identify on page 12)
10 |  | COST OF CAPITAL-OTHER
11 |  | TOTAL COST OF CAPITAL EXPENSES |  |  |  | 71413
Notes:
ONLY COMPLETE AREAS THAT APPLY.  ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.
 | ACCOUNT NUMBER* | PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS INCOME AND EXPENSES
 |  |  |  |  |  | COST
 |  |  |  |  |  | (Do Not Estimate)
 |  | OTHER EXPENSES
12 |  | VENDING MACHINE
13 |  | FEDERAL INCOME TAX
14 |  | STATE INCOME TAX
15 |  | PENALTIES AND FINES
16 |  | CONTRIBUTIONS |  |  |  | 460
17 |  | OTHER
18 |  | TOTAL OTHER EXPENSES |  |  |  | 460
Notes:
RESIDENTIAL CARE FACILITY
LOAN PAYMENTS AND MAJOR PURCHASES
 |  | FACILITY NAME: | South Island
 |  | COST REPORT PERIOD: | 7/1/2008 - 6/30/2009
 |  | PROVIDER # (Ex. RC9999) | RC1272
MORTGAGE(S) AND ALL OTHER LOANS PAYABLE
INTEREST RATE | TYPE DEBT | REASON FOR FINANCING | INTEREST PAID 7/1/08-6/30/09 | COST REPORT REFERENCE |  | NAME OF LENDING INSTITUTE |  | ENDING BALANCE @ 6/30/09
 |  |  |  | PAGE | LINE
Totals |  |  | 0 |  |  |  |  | 0
Notes:
RESIDENTIAL CARE FACILITY
SUMMARY OF INCOME AND EXPENSES
 |  | FACILITY NAME: | South Island
 |  | COST REPORT PERIOD: | 7/1/2008 - 6/30/2009
 |  | PROVIDER # (Ex. RC9999) | RC1272
 |  |  | ACCOUNT |  |  | AMOUNT
 |  | 1 | TOTAL INCOME |  |  | 414639
 |  |  | EXPENSES
 |  | 2 | Administration |  |  | 43139
 |  | 3 | Resident Care & Activity |  |  | 121030
 |  | 4 | Dietary |  |  | 61874
 |  | 5 | Laundry, Housekeeping and Maintenance |  |  | 35259
 |  | 6 | Utilities |  |  | 29431
 |  | 7 | Taxes, Insurance and Licenses |  |  | 26022
 |  | 8 | Cost of Capital |  |  | 71413
 |  | 9 | Other |  |  | 460
 |  | 10 | TOTAL EXPENSES |  |  | 388628
 |  | 11 | NET INCOME OR (LOSS) |  |  | 26011