FOR OHF USE IMPORTANT NOTICE LL1 THIS AGENCY IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARY TO ACCOMPLISH THE STATUTORY 2001 PURPOSE AS OUTLINED IN 210 ILCS 45/3-208. DISCLOSURE STATE OF ILLINOIS OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDE DEPARTMENT OF PUBLIC AID ANY INFORMATION ON OR BEFORE THE DUE DATE WILL FINANCIAL AND STATISTICAL REPORT FOR RESULT IN CESSATION OF PROGRAM PAYMENTS. THIS FORM LONG-TERM CARE FACILITIES HAS BEEN APPROVED BY THE FORMS MANAGEMENT CENTER. (FISCAL YEAR 2001) I. IDPH Facility ID Number: 0032938 II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER Facility Name: THE ARC OF JACKSONVILLE, LTD. I have examined the contents of the accompanying report to the Address: 1316 TENDICK JACKSONVILLE 62650 State of Illinois, for the period from 01/01/2001 to 12/31/2001 Number City Zip Code and certify to the best of my knowledge and belief that the said contents are true, accurate and complete statements in accordance with County: MORGAN applicable instructions. Declaration of preparer (other than provider) is based on all information of which preparer has any knowledge. Telephone Number: (217) 243-6405 Fax # (217) 245-1449 Intentional misrepresentation or falsification of any information IDPA ID Number: 37-1214771 in this cost report may be punishable by fine and/or imprisonment. Date of Initial License for Current Owners: 11/06/87 (Signed) Officer or (Date) Type of Ownership: Administrator (Type or Print Name) MELVIN SIEGEL of Provider VOLUNTARY,NON-PROFIT X PROPRIETARY GOVERNMENTAL (Title) PRESIDENT Charitable Corp. Individual State Trust Partnership County (Signed) (SEE ATTACHED ACCOUNTANTS' REPORT) IRS Exemption Code Corporation Other (Date) X "Sub-S" Corp. Paid (Print Name BOB KAGDA Limited Liability Co. Preparer and Title) PARTNER Trust Other (Firm Name KRUPNICK BOKOR KAGDA & BROOKS, LTD & Address) 3750 W DEVON AVE, LINCOLNWOOD, IL 60712-1124 (Telephone) ( 847) 675-3585 Fax #( 847 ) 675-5777 MAIL TO: OFFICE OF HEALTH FINANCE In the event there are further questions about this report, please contact: ILLINOIS DEPARTMENT OF PUBLIC AID Name:BOB KAGDA Telephone Number: ( 847 ) 675-3585 201 S. Grand Avenue East Springfield, IL 62763-0001 Phone # (217) 782-1630 STATE OF ILLINOIS Page 2 Facility Name & ID Number THE ARC OF JACKSONVILLE, LTD. # 0032938 Report Period Beginning: 01/01/2001 Ending: 12/31/2001 III. STATISTICAL DATA D. How many bed-hold days during this year were paid by Public Aid? A. Licensure/certification level(s) of care; enter number of beds/bed days, 0 (Do not include bed-hold days in Section B.) (must agree with license). Date of change in licensed beds E. List all services provided by your facility for non-patients. 1 2 3 4 (E.g., day care, "meals on wheels", outpatient therapy) NONE Beds at Licensed Beginning of Licensure Beds at End of Bed Days During F. Does the facility maintain a daily midnight census? YES Report Period Level of Care Report Period Report Period G. Do pages 3 & 4 include expenses for services or 1 Skilled (SNF) 1 investments not directly related to patient care? 2 Skilled Pediatric (SNF/PED) 2 YES NO X 3 93 Intermediate (ICF) 93 33,945 3 4 Intermediate/DD 4 H. Does the BALANCE SHEET (page 17) reflect any non-care assets? 5 Sheltered Care (SC) 5 YES NO X 6 ICF/DD 16 or Less 6 I. On what date did you start providing long term care at this location? 7 93 TOTALS 93 33,945 7 Date started 11/06/87 J. Was the facility purchased or leased after January 1, 1978? B. Census-For the entire report period. YES X Date 11/06/87 NO 1 2345 Level of Care Patient Days by Level of Care and Primary Source of Payment K. Was the facility certified for Medicare during the reporting year? Public Aid YES NO X If YES, enter number Recipient Private Pay Other Total of beds certified and days of care provided 8 SNF 8 9 SNF/PED 9 Medicare Intermediary 10 ICF 25,809 654 26,463 10 11 ICF/DD 11 IV. ACCOUNTING BASIS 12 SC 12 MODIFIED 13 DD 16 OR LESS 13 ACCRUAL X CASH* CASH* 14 TOTALS 25,809 654 26,463 14 Is your fiscal year identical to your tax year? YES X NO C. Percent Occupancy. (Column 5, line 14 divided by total licensed Tax Year: 12/31/01 Fiscal Year: 12/31/01 bed days on line 7, column 4.) 77.96% * All facilities other than governmental must report on the accrual basis. STATE OF ILLINOIS Page 3 Facility Name & ID Number THE ARC OF JACKSONVILLE, LTD. # 0032938 Report Period Beginning: 01/01/2001 Ending: 12/31/2001 V. COST CENTER EXPENSES (throughout the report, please round to the nearest dollar) Costs Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR OHF USE ONLY Operating Expenses Salary/Wage Supplies Other Total ification Total ments Total A. General Services 12345678910 1 Dietary 73,718 6,063 6,024 85,805 85,805 0 85,805 1 2 Food Purchase 94,554 94,554 (6,826) 87,728 (320) 87,408 2 3 Housekeeping 55,889 16,566 0 72,455 72,455 0 72,455 3 4 Laundry 22,864 6,261 0 29,125 29,125 0 29,125 4 5 Heat and Other Utilities 43,315 43,315 43,315 878 44,193 5 6 Maintenance 39,876 26,012 23,483 89,371 89,371 (5,414) 83,957 6 7 Other (specify):* 5,569 5,569 5,569 75 5,644 7 8 TOTAL General Services 192,347 149,456 78,391 420,194 (6,826) 413,368 (4,781) 408,587 8 B. Health Care and Programs 9 Medical Director 0 14,750 14,750 14,750 0 14,750 9 10 Nursing and Medical Records 564,770 13,926 9,604 588,300 588,300 8,178 596,478 10 10a Therapy 000 000 10a 11 Activities 33,600 6,075 3,300 42,975 42,975 (3,187) 39,788 11 12 Social Services 79,983 0 79,983 79,983 0 79,983 12 13 Nurse Aide Training 0 0 000 13 14 Program Transportation 120 120 120 0 120 14 15 Other (specify):* 0 000 15 16 TOTAL Health Care and Programs 678,353 20,001 27,774 726,128 0 726,128 4,991 731,119 16 C. General Administration 17 Administrative 48,216 0 48,216 48,216 15,036 63,252 17 18 Directors Fees 0 0 000 18 19 Professional Services 116,533 116,533 116,533 (88,569) 27,964 19 20 Dues, Fees, Subscriptions & Promotions 15,237 15,237 15,237 (5,419) 9,818 20 21 Clerical & General Office Expenses 34,987 15,866 15,768 66,621 66,621 39,506 106,127 21 22 Employee Benefits & Payroll Taxes 124,647 124,647 6,826 131,473 0 131,473 22 23 Inservice Training & Education 877 877 877 166 1,043 23 24 Travel and Seminar 1,004 1,004 1,004 15,305 16,309 24 25 Other Admin. Staff Transportation 6,846 6,846 6,846 0 6,846 25 26 Insurance-Prop.Liab.Malpractice 6,690 6,690 6,690 1,395 8,085 26 27 Other (specify):* 1,987 1,987 1,987 9,892 11,879 27 28 TOTAL General Administration 83,203 15,866 289,589 388,658 6,826 395,484 (12,688) 382,796 28 TOTAL Operating Expense 29 (sum of lines 8, 16 & 28) 953,903 185,323 395,754 1,534,980 0 1,534,980 (12,478) 1,522,502 29 *Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000. NOTE: Include a separate schedule detailing the reclassifications made in column 5. Be sure to include a detailed explanation of each reclassification. STATE OF ILLINOIS Page 4 Facility Name & ID Number THE ARC OF JACKSONVILLE, LTD. #0032938 Report Period Beginning: 01/01/2001 Ending: 12/31/2001 # V. COST CENTER EXPENSES (continued) Cost Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR OHF USE ONLY Capital Expense Salary/Wage Supplies Other Total ification Total ments Total D. Ownership 12345678910 30 Depreciation 6,513 6,513 6,513 29,178 35,691 30 31 Amortization of Pre-Op. & Org. 0 000 31 32 Interest 35,172 35,172 35,172 151,587 186,759 32 33 Real Estate Taxes 19,641 19,641 19,641 0 19,641 33 34 Rent-Facility & Grounds 98,745 98,745 98,745 (90,850) 7,895 34 35 Rent-Equipment & Vehicles 5,929 5,929 5,929 6,336 12,265 35 36 Other (specify):* 0 000 36 37 TOTAL Ownership 166,000 166,000 0 166,000 96,251 262,251 37 Ancillary Expense E. Special Cost Centers 38 Medically Necessary Transportation 0 000 38 39 Ancillary Service Centers 0 000 39 40 Barber and Beauty Shops 0 000 40 41 Coffee and Gift Shops 0 000 41 42 Provider Participation Fee 50,917 50,917 50,917 0 50,917 42 43 Other (specify):* 0 000 43 44 TOTAL Special Cost Centers 0 0 50,917 50,917 0 50,917 0 50,917 44 GRAND TOTAL COST 45 (sum of lines 29, 37 & 44) 953,903 185,323 612,671 1,751,897 0 1,751,897 83,773 1,835,670 45 *Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000. STATE OF ILLINOIS Page 5 Facility Name & ID Number THE ARC OF JACKSONVILLE, LTD.