HomeMy WebLinkAbout*Other - Renew (002)GRANT COUNTY
COMMISSIONERS AGENDA MEETING REQUEST FORM
(Must be submitted to the Clerk of the Board by 12:00pm on Thursday)
REQUESTING DEPARTMENT: Renew
REQUEST SUBMITTED BY:Sarah Nelson
CONTACT PERSON ATTENDING ROUNDTABLE: Dell Anderson
CONFIDENTIAL INFORMATION: ❑YES *NO
oATE:4/18/2025
PHONE: Ext. 5434
H,
❑Agreement / Contract
❑AP Vouchers
❑Appointment / Reappointment
❑ARPA Related
❑ Bids / RFPs / Quotes Award
❑ Bid Opening Scheduled
❑ Boards / Committees
❑ Budget
❑Computer Related
❑County Code
El Emergency Purchase
El Employee Rel.
❑ Facilities Related
❑ Financial
❑ Funds
❑ Hearing
❑ Invoices / Purchase Orders
❑ Grants — Fed/State/County
❑ Leases
❑ MOA / MOU
❑Minutes
❑Ordinances
❑Out of State Travel
El Petty Cash
❑ Policies
❑ Proclamations
❑ Request for Purchase
❑ Resolution
❑Recommendation
El Professional Serv/Consultant
❑Support Letter
❑Surplus Req.
❑Tax Levies
❑Thank You's
❑Tax Title Property
❑WSLCB
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Please see attached, State of Washington DDA Residential Support Programs
Cost Repot, for your signature. Thank you.
If necessary, was this document reviewed by accounting? ❑ YES
documentLEGAL REVIEW:
If this requires
• legal
r! review,
a A • a
w prior,
If necessary, was this document reviewed by legal? ❑ YES ❑ NO
DATE OF ACTION: q, ZZ, z,-5
APPROVE: DENIED ABSTAIN
D1: P.7
D2:
D3:
❑NO ON/A
DEFERRED OR CONTINUED TO:
WITHDRAWN:
0 N/A
4/23/24
SCHEDULE A
STATE OF WASHINGTON
DEVELOPMENTAL DISABILITIES
RESIDENTIAL SUPPORT PROGRAMS COST REPORT
GENERAL INFORMATION AND CERTIFICATION
PART A - PROVIDER IDENTIFYING INFORMATION
13. COST: R-EPORT PRE PARER- 14. FIRM .NAME
_.
Reyna Gonzales Renew
REPOT p► I I D NTA 1S R CC. I T CT ND VI UAL(S) 1� Ct�.. CT PHONE N UMBER 17 CONTACT EMALL <:::
Reyna Gonzales/Missy Lopez 1509 764-2660 ronzales aa).grantcounfi vMa gov
.
...............
18 COST REPORT PERIOD 19. FEDERAE ID NUMBERS)
1/1/2024 12/31/2024 91-6001319
FROM. _ — TO .
PART B. - CERTIFICATION
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE
PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER STATE OR FEDERAL LAW
CERTIFICATION
I HEREBY CERTIFY under penalty of perjury that I have read the above statement and have examined the accompanying
cost report and supporting schedules prepared for:
1N - Grant County Developmental Disabilities
(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 instructions providgd'"yDA., except as noted.
PERSON SIGNING MUST HAVE AUTHORITY TO BIND THE PROVIDER LISTED
V 1, .P 'k I�f��P12A M r I •7iZZG
-
TITLE
DSHS/DDA Schedule A (Rev. 08/2023)
DATE
4/18/2025 2024 Cost Report - Template (1) Sch B -Reyna, A - General Info & Cert, Page 1 of 1
SCHEDULE G
STATE OF WASHINGTON
- 1N - grant County Developmental D�isa
DDA -RESIDENTIAL SUPPORT PROGRAMS - - _ _
PROVIDER NAME
ISS COST CENTER SETTLEMENT
A B C
REIMBURSEMENT SUMMARY'
L
i
e
Tiered ISS Reimbursements by Program Type
ISS Reimbursement
1
SL Supported Living
$1,362,209.21
2
GH Group Home
$0.00
3
GTH Group Training Home
$0.00
4
Sub -Total
$1,362,209.21
Nurse Delegation and Staff Add On
ISS Reimbursement
5
SL Nurse Delegation
$253.98
6
GH Nurse Delegation
$0.00
7
GTH Nurse Delegation
$0.00
8
SL Staff Add On
$0.00
9 IGH
Staff Add On
$0.00
10
GTH Staff Add On
$0.00
11
Sub -Total
$253.98
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
$0.00
14
GTH Group Training Home Staffed Professional Services
$0.00
15
Sub -Total
$0.00
16
Total ISS Reimbursements paid by DSHS (carries to Line 17)
$1,362,463.19
SETTLEMENT
17
TOTAL REIMBURSED DOLLARS (Auto filled from Line 16)
$1,362,463.19
18
ISS Staff Payroll & Allowable Administrator ISS Payroll less Overtime
(Auto filled from Sch 8, Row 65, Col R less Sch 8, Row 65, Col E)
$1, 316,446.29
191
ISS Overtime Staff Costs (Auto filled from Sch B, Row 65, col E)
$23,670.35
Authorized Purchased or Contracted Professional Services: (RN, LPN, DBT, Therapist, etc.)
20
21
22
SL Authorized ISS Purchased or Contracted Professional Services
GH Authorized ISS Purchased or Contracted Professional Services
GTH Authorized ISS Purchased or Contracted Professional Services
$0.00
$0.00
$0.00
23
TOTAL ALLOWABLE ISS COSTS PAID BY THE PROVIDER (Line 18+19+20+21+22)
$1,340,116.64
24
TOTAL PRELIMINARY NET SETTLEMENT AMOUNT
$22,346.55
DSHS/DDA Schedule G ISS Settlement (Rev. 08/2023)
4/18/2025 2024 Cost Report - Template (1) Sch B-Reyna, G - ISS Settlement, Page 1 of 1