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Home My WebLink About*Other - Renewfl� SCHEDULE A STATE OF WASHINGTON DEVELOPMENTAL DISABILITIES RESIDENTIAL SUPPORT PROGRAMS COST REPORT GENERAL INFORMATION AND CERTIFICATION PART A - PROVIDER IDENTIFYING INFORMATION "PROVED CY NAM >::::::::::::::::::::::::::: <::::::::::::::::'::< :::::> ::::: >:::::::::: >;::::::: > :::::....` :' :::::::::::::.. ER A GEN :: E.................................:................................................................ ............. :.::.::.::.:::.:::::::.:::::::::::::::::::..:.:............................................... . ..... ..................... ' ,:: `:.` :... "":::.` . ':: <:::::::»>::::::::::::::::::: >::::::<::::::::::::::::> >::>::::: 2 - P R ......... -C}V I.D E R O N E .I D...........-:-:.:.:.:.:.:.:::.:.::::.:.:.:-:.:.:::::::::.:::.:.:.:...... . 1N - Grant County Developmental Disabilities (DCL) 200012501 ....................................... 3 ...PROVIDER ..::::..:....::.....::.,:::,:,::: MAILING ADDRE ................ :.............:................ :,... :.,.................. ................................................................................ ::... . .. :::::::::::::::::::::::::::::::::'.::.::>:..:<>. 4 :CITY :.STAT...E ::ZIP................ -....................................-....:::.:.:.:.:::.....: .*..................I..........,...:.....................;.............:...::::::::.:...:.:.::.:.::.:::... . ..PROVI:DER::PH N ...:>.""".:.::.:-::..::::......:..:: ..............0.........NUMBER..:..:.:......................-... 1103 Lowry St. Moses Lake WA 98837 509 762-1161 ................::. ;;::::::< ..:-<:;:.:...:: AT :R: DAME->.......:<::::::::::::::::::::< ....................................................................................................... : ::.....:::._ .7,::ADMINIST:RATOR::ErMAIL.:....... ...................-.-......-.-........................................ ,...... ................ ........................,...,...,......,.......,........................................ , :.....::.:.....: . M I I.... STRATO.. R:. P.H C� ISI E:NUMBER.......;::.:.:.;.;...:.:.:. Missy Lopez mlopez@gantcountywa.gov 509 762.1161 .. ....... .: �....-;.....::.:::.::...: .. :: ................... 9.:HOME::OF.FICE CORP.ORATE::.NAME Cease :Jh trate. r NONE: &:SA - :;........:....:::::::::::::::::::::............ >........ ;:::::::....::::=:::::: : :::.::..:.::::::::.::::::::::::..:.........................................................-...-............................ ME5.1 B D.V. E ...................................... -................................................ . ..........:.......................................,...............................................-.....:.:......:.:J.:.:.:.:.:::.::::::::.::.:.:.::.:.::.:.::::.:::::.::::::.:.:::::::.:.:::::.::::.::.:::.:::::.::.::.: .... Same as above .... .. ........ ............:,. ...: AD............. ............DRESS...::::.:::> .............. ::<::::::::::: <::;..... 11:-.CITYr :STATE, ZLP.....:.:..............:::: 12..::HOM.E':QFFICE::PHONE:'............ ........... ....N UMBER .......................... ........... :....... (Provider Name) and I attest, it is a true, correct and complete representation of actual costs related to client supports prepared in accordance with applicable instructio . s prove d by DDA exce t s noted. A . .JJtiJ/UUA 5cneauie A (Rev. 11/LULL) 4/20/2023 PERSON SIGrkgNG MUST HAVE AUTHORITY T)6 BIND THE PROVIDER LISTED TITLE DATE Certificate.xlsx, A - General Info & Cert, Page 1 of 1 SCHEDULE D STATE OF WASHINGTON DEVELOPMENTAL DISABILIITIES 1N - Grant County Developmental Disabiliti( RESIDENTIAL SUPPORT PROGRAMS PROVIDER NAME PROGRAM REVENUE RESIDENTIAL SERVICES REVENUE TOTALS A B C SL Supportedg Living 0 0 1 REVENUE FOR SERVICES PROVIDED $1,441,806.76 $1,441,806.76 $0.00 $0.00 State Payments/Reimbursements for ISS/DSHS Clients (Total Daily Rate less covid add-on), ISS/DSHS Client Participation, Prior Years Settlements Deducted from State Payments, Non DSHS Client Payments 2 OTHER OPERATING REVENUE $0.00 $0.00 $0.00 $0.00 Summer Programs, Client Evaluation, Non-DSHS Revenue, & Covid Add -On 3 NON-OPERATING REVENUE $404,461.51 $393,637.67 $10,758.84 $65.00 Interest Income, Cash Donations & Contributions, Noncash Donations & Contributions TOTAL RESIDENTIAL SERVICES REVENUE $1,846,268.27 $1,835,444.43 $10,758.84 $65.00 vas ia/ �ur1 -it, lu USG v 1Rcv. 14/4VL41 4/20/2023 Schedule D- Revenue.xlsx, D - Revenue, Page 1 of 1 STATE OF WASHINGTON DEVELOPMENTAL DISABILIITIES RESIDENTIAL SUPPORT PROGRAMS ADMINISTRATIVE & OPERATING EXPENSES 1 IS THE AGENCY A NON-PROFIT ORGANIZATION 2 DOES THE AGENCY PAY B&O TAXES TO THE DEPARTMENT OF REVENUE? 3 DOES THE AGENCY PAY CITY B&O TAXES? IF YES, SELECT CITY crurni of r r 1N - Grant County Developmental Disabili PROVIDER NAME 4 ARE ISS ACCRUALS CLAIMED ON SCHEDULE B? 5 ARE PROFESSIONAL SERVICES CONTRACTED OR PURCHASED FOR CLIENTS SUPPORTED BY THE AGENCY? If Yes, include the cost of purchased or contracted professional services for settled programs on Schedule G, lines 20-22. Contracted or purchased professional services must be authorized in the client assessment. Provider must have supporting documentation for amounts reported and available to the department upon request. Yes No No Yes No 6 ALLOCATION OF SHARED COSTS Does your agency operate multiple programs contracted with DDA, e.g., Supported Living and Group Homes, a or a combination of DDA and other contracts? No b If yes to question 2a, do you allocate administrative and program overhead costs? No C What is your agency's method of allocating costs? utnerivietnod - Ple7 Nrnnni hr *If you answered "Other Method"for question 2c please describe your agencies allocation method in the box below: Direc:charges ADMINISTRATIVE & OPERATIONS COSTS (NON -ISS COSTS) AGENCY TYPE (Select from dropdown list) A B C SL Supported Living NON -CLIENT RELATED EXPENSES 1 ADMINISTRATIVE/ NON -ISS PAYROLL EXPENSES (Do not include adminstrative payroll expenses reported on Schedule B, Columns G & H) $44,431.84 $23,746.99 $20,684.85 $0.00 Adminstrator compensation for agencies with 21 or more FTE's, Administrative/Non-ISS staff compensation, Employer Paid Adminstrative/Non-ISS Payroll Taxes & Benefits, Administrative/Non-ISS Purchased Professional Services (i.e. CPA, Janitorial Svs, Lawn Svs), & Management Fees 2 PROGRAM OPERATIONS EXPENSES $36,826.32 $36,826.32 $0.00 $0.00 Administrative Supplies, Administrative Transportation Expenses (i.e. travel, mileage, lodging, public transportation), Advertising Expense, Professional Liability Insurance, & any other General Administrative Expenses 3 CAPITAL & PROPERTY EXPENSES $11,638.82 $11,638.82 $0.00 $0.00 Depreciation - Land Improvements, Buildings, Building Improvements, Leasehold Improvements, Furniture & Equipment, Communications Expense, Facility Insurance, Office Rent, Lease Payments, Utilities, Property Taxes, Minor Equipment, Other Property " 4 INTEREST & TAX EXPENSES $0.00 $0.00 $0.00 $0.00 Working Capital, Property, Line of Credit Debt Expense, Business Taxes (Does not include portion of B & O tax charged as ISS Payroll Tax) NON -ISS CLIENT RELATED EXPENSES „ NTENANCE LAUNDRY HOUSEKEEPING DIETARV__ FEX5 E NSESS (GROUP HOME ONLY) $0.00 $0.00 $0.00 1 _.$0.00T Salaries and Wages, Fringe Benefits and Payroll Taxes, Supplies & Materials, Purchased Services 6 TRANSPORTATION EXPENSES $13,611.74 $13,611.74 $0.00 $0.00 Staff Mileage Reimbursement, All Other Client Transportation Expense (Agency Vehicle Fuel, Maint., Depreciation; Public Trans. Etc.) OTHER NON -ISS CLIENT RELATED EXPENSES $14,973.80 $14,973.80 $0.00 $0.00 Overnight Staff Coverage Lodging Expenses (housing units provided for on -duty staff - not primary dwelling for staff), Education and In -Service Training & Supplies, Activities and Habilitative Supplies & Other Expenses, Nursing Supplies Expense, Food Costs - Resident (Group Homes primarily), Food Costs - Staff TOTAL NON -ISS PROGRAM EXPENSES $121,482.52 #REF! $20,684.85 $0.00 ngpq/nnn 4Zt-k=.4i Bio r 1D_.. 1 n innnni 4/21/2023 2022 Cost Report - Template-Reyna.xlsm, C - Non -ISS Expenses, Page 1 of 1 SCHM11LF n STATE OF WASHINGTON DEVELOPMENTAL DISABILIITIES IN - Grant County Developmental Disabilities RESIDENTIAL SUPPORT PROGRAMS = PROVIDER NAME PROGRAM REVENUE RESIDENTIAL SERVICES REVENUE TOTALS A B � sl Supportedg Living 0 0 1 REVENUE FOR SERVICES PROVIDED $1,441,806.76 $11441,806.76 $0.00 $0.00 State Payments/Reimbursements for ISS/DSHS Clients (Total Daily Rate less covid add-on), ISS/DSHS Client Participation, Prior Years Settlements Deducted from State Payments, Non DSHS Client Payments 2 2r OTHER OPERATING REVENUE $0.00 $0.00 $0.00 $0.00 Summer Programs, Client Evaluation, Non-DSHS Revenue, & Covid Add -On 3 NON-OPERATING REVENUE $404,461.51 $393,637.67 $101758.84 $65.00 Interest Income, Cash Donations & Contributions, Noncash Donations & Contributions TOTAL RESIDENTIAL SERVICES REVENUE $1,846,268.27 $1,835,444.43 $10,758.84 $65.00 UJnJ/UUH JGfIeQUle U (K@V. 1L/LULL) 4/21/2023 2022 Cost Report - Template-Reyna.xlsm, D - Revenue, Page 1 of 1 STATE OF WASHINGTON DDA -RESIDENTIAL SUPPORT PROGRAMS ISS COST CENTER SETTLEMENT SCHEDULE G 1N - Grant County Developmental Disa PROVIDER NAME �7 A 6 C REIMBURSEMENT SUMMARY L i e Tiered ISS Reimbursements by Program Type ISS Reimbursement 1 SL Supported Living $1,135,112.38 2 GH Group Home 3 GTH Group Training Home 4 Sub -Total $1,135,112.38 Nurse Delegation and Staff Add On ISS Reimbursement 5 SL Nurse Delegation $1,647.64 6 GH Nurse Delegation 7 GTH Nurse Delegation 8 SL Staff Add On 9 GH Staff Add On 10 GTH Staff Add On 11 Sub -Total $1,,647.64 Staffed Professional Services: (RN, LPN, DBT, Therapist, etc.) Professional Services ISS Reimbursement 12 SL Supported Living Staffed Professional Services $0.00 13 GH Group Home Staffed Professional Services 14 GTH Group Training Home Staffed Professional Services 15 Sub -Total $0.00 16 Total ISS Reimbursements paid by DSHS (carries to Line 1 7) $1,136,760.02 SETTLEMENT 17 TOTAL REIMBURSED DOLLARS (Auto-filled}rom Line 16) $1,136,760.02 18 ISS Staff Payroll & Allowable Administrator ISS Payroll less Overtime (Auto filled from Sch B, Row 65, Col R leas Sch B, Row 65, Col E) $1,240,734.79 19 ISS Overtime Staff Costs (Auto -)`filled from Sch R, Row 65, Col E) $20,977.23 Authorized Purchased or Contracted Professional Services: (RN, LPN, DBT, Therapist, etc.) 20 --- 21GH _ 22 SL Authorized ISS Purchased or Contracted Professional Services$0.00 - ------------------------------------------------------------------------------------------------------------------------------ Authorized ISS Purchased or Contracted Professional Services m-------------- ------------------------------------------- ----------------- GTH Authorized ISS Purchased or Contracted Professional Services ---------------------------------------- 23 TOTAL ALLOWABLE ISS COSTS PAID BY THE PROVIDER (Line 18+19+20+21+22) $1,261,712.02 24 TOTAL PRELIMINARY NET SETTLEMENT AMOUNT $0.00 IJ3113/UUH JL(ICUUIe U 133 3elLIeFTIe[1L IRev. 12_/ /-U/-/-) 4/21/2023 2022 Cost Report - Template-Reyna.xlsm, G - ISS Settlement, Page 1 of 1