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Home My WebLink About*Other - RenewGRANT 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: Reyna Gonzales CONTACT PERSON ATTENDING ROUNDTABLE: Dell Anderson CONFIDENTIAL INFORMATION: ❑YES ®NO DATE. 04/23/2026 PHONE: 509 764-2660 ❑Agreement / Contract ❑AP Vouchers ❑Appointment / Reappointment ❑ARPA Related ❑ Bids / RFPs / Quotes Award ❑ Bid Opening Scheduled ❑ Boards / Committees ❑ Budget ❑Computer Related ❑County Code ❑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 ❑Professional Serv/Consultant ❑Support Letter ❑Surplus Req. ❑Tax Levies ❑Thank You's ❑Tax Title Property ❑WSLCB PleaseNffio W W-W Program 2025 Cost Report. Schedule A will need to be signed and the original copy returned. Thank you If necessary, was this document reviewed by accounting? ❑ YES ❑ NO 0 N/A If necessary, was this document reviewed by legal? ❑ YES ❑ NO 0 N/A 1. DATE OF ACTION: 4 '�"'�` DEFERRED OR CONTINUED TO. APPROVE: DENIED ABSTAIN D1: A� A r D2: D3: WITHDRAWN: 4/23/24 SCHEDULE A DEVELOPMENTAL DISABILITIES RESIDENTIAL SUPPORT PROGRAMS COST REPORT GENERAL INFORMATION AND CERTIFICATION PART A -PROVIDER IDENTIFYING INFORMATION 1. PROVIDER AGENCY NAME 2. PROVIDER ONE ID 1N -Grant County Developmental Disabilities 200012501 3. PROVIDER MAILING ADDRESS 4, CITY, STATE, ZIP 5 PROVIDER PHONE NUMBER 1103 Lowery Moses Lake, WA 98837 509 762-1161 6. ADMINISTRATOR -NAME 7. ADMINISTRATOR E-MAIL 8. ADMINISTRATOR PHONE NUMBER Missy Lopez mlopez(c�grantcountywa.c�ov 509 762-1161 9. HOME OFFICE/CORPORATE NAME (please indicate if NONE or SAME AS ABOVE) SAME AS ABOVE 10. HOME OFFICE., MAILING ADDRESS 11. CITY, STATE, ZIP 12. HOME OFFICE PHONE NUMBER 13. COST REPORT PREPARER 14. FIRM NAME Reyna Gonzales Renew 15. REPORT CONTACT INDIVIDUAL(S) 16. CONTACT PHONE NUMBER 17. CONTACT EMAIL Reyna Gonzales/Missy Lopez 509 7642660 rgonzalesCaD-grantcountywa.gov 18. COST REPORT PERIOD 19. FEDERAL ID NUMBER(S) 1/1/2025 12/31/2025 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 -Grunt 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 provided by DDA, except as noted. PERSON SIGNING MUST JA#fE AUTHORITY TO BIND THE PROVIDER LISTED TITLE DATE STATE OF WASHINGTON u�nS/uuH Scneauie H �Kev. U6/LUL4) 4/24/2026 2025 DID Cost Report Schedule A, A -General Info & Cert, Page 1 of 1 SCHEDULE G STATE OF WASHINGTON DDA - RESIDENTIAL SUPPORT PROGRAMS ISS COST CENTER SETTLEMENT 1N - Grant County Developmental Disabilit PROVIDER NAME A B C REIMBURSEMENT SUMMARY L i e Tiered ISS Reimbursements by Program Type ISS Reimbursement 1 SL Supported Living $1,5301249.29 2 GH Group Home 3 GTH Group Training Home 4 Sub -Total $1,530,249.29 Nurse Delegation and Staff Add On ISS Reimbursement 5 SL Nurse Delegation $2,317.57 6 GH Nurse Delegation 7 GTH Nurse Delegation 8 SL Staff Add On $4,034.40 9 GH Staff Add On 10 GTH Staff Add On 11 Sub -Total $6,351.97 Staffed Professional Services: (RN, LPN, DBT, Therapist, etc.) Professional Services ISS Reimbursement 12 SL Supported Living Staffed Professional Services 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 17) $1,536 601.26 SETTLEMENT 17 TOTAL REIMBURSED DOLLARS (Auto filled from Line 16) $1,536,601.26 18 ISS Staff Payroll & Allowable Administrator ISS Payroll less Overtime (Auto filled from Sch B, Row 65, Col R less Sch B, Row 65, Col E) $1, 511, 286.09 19 ISS Overtime Staff Costs (Auto filled from Sch B, Row 65, Col E) $471754.19 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 -------------------------------------------- -------------------------------------------- 23 TOTAL ALLOWABLE ISS COSTS PAID BY THE PROVIDER (Line 18+19+20+21+22) $1,559,040.28 24 TOTAL PRELIMINARY NET SETTLEMENT AMOUNT �rr� Jar- w n _1_ - _1 _ inn n - i.. .. /.mow.. - $0.00 vJl IJ/ LJL-f J%- 11=UUIC V IJJ Jt=LL C1I ICI 11 kRCV. VO/ LVL�F� 4/24/2026 Schedule G- Cost Report, G - ISS Settlement, Page 1 of 1