hilltop skilled nsg rehab 2016 0051441 - Illinois...37 TOTAL Ownership 342,182 342,182 342,182...

FOR BHF USE IMPORTANT NOTICELL1 THIS AGENCY IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARY TO ACCOMPLISH THE STATUTORY

2016 PURPOSE AS OUTLINED IN 210 ILCS 45/3-208. DISCLOSURESTATE OF ILLINOIS OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDE

DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES ANY INFORMATION ON OR BEFORE THE DUE DATE WILLFINANCIAL AND STATISTICAL REPORT (COST REPORT) RESULT IN CESSATION OF PROGRAM PAYMENTS. THIS FORM

FOR LONG-TERM CARE FACILITIES HAS BEEN APPROVED BY THE FORMS MANAGEMENT CENTER.(FISCAL YEAR 2016)

I. IDPH License ID Number: 0051441 II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER

Facility Name: Hilltop Skilled Nsg & Rehab I have examined the contents of the accompanying report to the

Address: 910 West Polk Street Charleston 61920 State of Illinois, for the period from 01/01/16 to 12/31/16Number 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 withCounty: Coles applicable instructions. Declaration of preparer (other than provider)

is based on all information of which preparer has any knowledge.Telephone Number: (217) 345-7066 Fax # (217) 345-6017

Intentional misrepresentation or falsification of any informationHFS ID Number: in this cost report may be punishable by fine and/or imprisonment.

Date of Initial License for Current Owners: 5/1/2011 (Signed)Officer or (Date)

Type of Ownership: Administrator (Type or Print Name)of Provider

VOLUNTARY,NON-PROFIT X PROPRIETARY GOVERNMENTAL (Title)Charitable Corp. Individual StateTrust Partnership County (Signed) *

IRS Exemption Code Corporation Other * Subject to the attached Accountants Consulting Report (Date)"Sub-S" Corp. Paid (Print Name

X Limited Liability Co. Preparer and Title)TrustOther (Firm Name Marcum, LLP

& Address) 111 Pfingsten Road, Suite 300 Deerfield, IL 60015

(Telephone) (847) 282-6300 Fax #(847) 282-6301 MAIL TO: BUREAU OF HEALTH FINANCE

In the event there are further questions about this report, please contact: ILLINOIS DEPT OF HEALTHCARE AND FAMILY SERVICESName: Steven N. Lavenda Telephone Number: (847) 282-6300 201 S. Grand Avenue East

Email Address: Springfield, IL 62763-0001 Phone # (217) 782-1630

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 2Facility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16

III. STATISTICAL DATA D. How many bed-hold days during this year were paid by the Department?A. Licensure/certification level(s) of care; enter number of beds/bed days, None (Do not include bed-hold days in Section B.) (must agree with license). Date of change in licensed beds N/A

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 or1 36 Skilled (SNF) 36 13,176 1 investments not directly related to patient care?2 Skilled Pediatric (SNF/PED) 2 YES NO X3 72 Intermediate (ICF) 72 26,352 34 Intermediate/DD 4 H. Does the BALANCE SHEET (page 17) reflect any non-care assets?5 Sheltered Care (SC) 5 YES NO X6 ICF/DD 16 or Less 6

I. On what date did you start providing long term care at this location?7 108 TOTALS 108 39,528 7 Date started 05/01/2011

J. Was the facility purchased or leased after January 1, 1978?B. Census-For the entire report period. YES X Date 05/01/2011 NO

1 2 3 4 5 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?

Medicaid YES X NO If YES, enter numberRecipient Private Pay Other Total of beds certified 25 and days of care provided 2,311

8 SNF 113 1,452 2,975 4,540 8 9 SNF/PED 9 Medicare Intermediary CGS Administrators10 ICF 6,366 5,170 231 11,767 1011 ICF/DD 11 IV. ACCOUNTING BASIS12 SC 12 MODIFIED13 DD 16 OR LESS 13 ACCRUAL X CASH* CASH*

14 TOTALS 6,479 6,622 3,206 16,307 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: 12/31/2016 Fiscal Year: 12/31/2016 bed days on line 7, column 4.) 41.25% * All facilities other than governmental must report on the accrual basis.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 3Facility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16V. COST CENTER EXPENSES (throughout the report, please round to the nearest dollar)

Costs Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR BHF USE ONLY Operating Expenses Salary/Wage Supplies Other Total ification Total ments TotalA. General Services 1 2 3 4 5 6 7 8 9 10

1 Dietary 104,737 10,716 11,258 126,711 126,711 (64) 126,647 12 Food Purchase 76,394 76,394 76,394 (310) 76,084 23 Housekeeping 44,534 9,456 1,626 55,616 55,616 55,616 34 Laundry 30,670 2,626 33,296 33,296 (266) 33,030 45 Heat and Other Utilities 77,703 77,703 77,703 (10,169) 67,534 56 Maintenance 36,152 5,663 59,522 101,337 101,337 15,068 116,405 67 Other (specify):* 78 TOTAL General Services 216,093 104,855 150,109 471,057 471,057 4,259 475,316 8

B. Health Care and Programs9 Medical Director 22,000 22,000 22,000 22,000 910 Nursing and Medical Records 986,120 41,267 5,527 1,032,914 1,032,914 (5,520) 1,027,394 10

10a Therapy 20,858 20,858 20,858 20,858 10a11 Activities 21,611 2,050 2,732 26,393 26,393 26,393 1112 Social Services 50,509 501 2,232 53,242 53,242 53,242 1213 CNA Training 1314 Program Transportation 3,418 3,418 3,418 3,418 1415 Other (specify):* 1516 TOTAL Health Care and Programs 1,058,240 64,676 35,909 1,158,825 1,158,825 (5,520) 1,153,305 16

C. General Administration17 Administrative 59,111 188,106 247,217 247,217 (81,731) 165,486 1718 Directors Fees 1819 Professional Services 37,565 37,565 37,565 40,548 78,113 1920 Dues, Fees, Subscriptions & Promotions 40,078 40,078 40,078 (29,359) 10,719 2021 Clerical & General Office Expenses 102,538 8,361 108,874 219,773 219,773 (77,504) 142,269 2122 Employee Benefits & Payroll Taxes 324,464 324,464 324,464 (6,739) 317,725 2223 Inservice Training & Education 2324 Travel and Seminar 600 600 600 15,336 15,936 2425 Other Admin. Staff Transportation 13,770 13,770 13,770 (248) 13,522 2526 Insurance-Prop.Liab.Malpractice 221,152 221,152 221,152 3,245 224,397 2627 Other (specify):* 28,697 28,697 2728 TOTAL General Administration 161,649 8,361 934,609 1,104,619 1,104,619 (107,755) 996,864 28

TOTAL Operating Expense29 (sum of lines 8, 16 & 28) 1,435,982 177,892 1,120,627 2,734,501 2,734,501 (109,017) 2,625,484 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.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 4Facility Name & ID Number Hilltop Skilled Nsg & Rehab #0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16

#V. COST CENTER EXPENSES (continued)

Cost Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR BHF USE ONLY Capital Expense Salary/Wage Supplies Other Total ification Total ments TotalD. Ownership 1 2 3 4 5 6 7 8 9 10

30 Depreciation 146,195 146,195 146,195 (25,730) 120,465 3031 Amortization of Pre-Op. & Org. 3132 Interest 50,867 50,867 3233 Real Estate Taxes 31,296 31,296 31,296 5,065 36,361 3334 Rent-Facility & Grounds 149,810 149,810 149,810 (149,088) 722 3435 Rent-Equipment & Vehicles 14,881 14,881 14,881 14,881 3536 Other (specify):* 19,776 19,776 36

37 TOTAL Ownership 342,182 342,182 342,182 (99,109) 243,073 37 Ancillary ExpenseE. Special Cost Centers

38 Medically Necessary Transportation 3839 Ancillary Service Centers 145,867 348,034 493,901 493,901 493,901 3940 Barber and Beauty Shops 4041 Coffee and Gift Shops 4142 Provider Participation Fee 144,248 144,248 144,248 144,248 4243 Other (specify):* 43

44 TOTAL Special Cost Centers 145,867 492,282 638,149 638,149 638,149 44GRAND TOTAL COST

45 (sum of lines 29, 37 & 44) 1,435,982 323,759 1,955,091 3,714,832 3,714,832 (208,126) 3,506,706 45

*Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 5Facility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16VI. ADJUSTMENT DETAIL A. The expenses indicated below are non-allowable and should be adjusted out of Schedule V, pages 3 or 4 via column 7.

In column 2 below, reference the line on which the particular cost was included. (See instructions.) 1 2 3

Refer- BHF USE B. If there are expenses experienced by the facility which do not appear in the NON-ALLOWABLE EXPENSES Amount ence ONLY general ledger, they should be entered below.(See instructions.)

1 Day Care $ $ 1 1 22 Other Care for Outpatients 2 Amount Reference3 Governmental Sponsored Special Programs 3 31 Non-Paid Workers-Attach Schedule* $ 314 Non-Patient Meals 4 32 Donated Goods-Attach Schedule* 325 Telephone, TV & Radio in Resident Rooms (10,169) 05 5 Amortization of Organization &6 Rented Facility Space 6 33 Pre-Operating Expense 337 Sale of Supplies to Non-Patients 7 Adjustments for Related Organization8 Laundry for Non-Patients 8 34 Costs (Schedule VII) 28,527 349 Non-Straightline Depreciation (124,144) 30 9 35 Other- Attach Schedule 35

10 Interest and Other Investment Income (66) 32 10 36 SUBTOTAL (B): (sum of lines 31-35) $ 28,527 3611 Discounts, Allowances, Rebates & Refunds 11 (sum of SUBTOTALS12 Non-Working Officer's or Owner's Salary 12 37 TOTAL ADJUSTMENTS (A) and (B) ) $ (208,126) 3713 Sales Tax (310) 02 1314 Non-Care Related Interest 14 *These costs are only allowable if they are necessary to meet minimum15 Non-Care Related Owner's Transactions 15 licensing standards. Attach a schedule detailing the items included16 Personal Expenses (Including Transportation) 16 on these lines.17 Non-Care Related Fees 1718 Fines and Penalties 18 C. Are the following expenses included in Sections A to D of pages 319 Entertainment 19 and 4? If so, they should be reclassified into Section E. Please 20 Contributions 20 reference the line on which they appear before reclassification.21 Owner or Key-Man Insurance 21 (See instructions.) 1 2 3 422 Special Legal Fees & Legal Retainers 22 Yes No Amount Reference23 Malpractice Insurance for Individuals 23 38 Medically Necessary Transport. $ 3824 Bad Debt (66,154) 21 24 39 3925 Fund Raising, Advertising and Promotional (25,847) 20 25 40 Gift and Coffee Shops 40

Income Taxes and Illinois Personal 41 Barber and Beauty Shops 4126 Property Replacement Tax 26 42 Laboratory and Radiology 4227 CNA Training for Non-Employees 27 43 Prescription Drugs 4328 Yellow Page Advertising 28 44 4429 Other-Attach Schedule (9,963) 29 45 Other-Attach Schedule 4530 SUBTOTAL (A): (Sum of lines 1-29) $ (236,653) $ 30 46 Other-Attach Schedule 46

47 TOTAL (C): (sum of lines 38-46) $ 47BHF USE ONLY

48 49 50 51 52

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 5AHilltop Skilled Nsg & Rehab

ID# 0051441Report Period Beginning: 01/01/16

Ending: 12/31/16Sch. V Line

NON-ALLOWABLE EXPENSES Amount Reference1 Bank Charges $ (2,805) 21 12 Public Relations (730) 20 23 Business Taxes (191) 21 34 Patient Theft or Loss (69) 21 45 Prior Year Expense (9,227) 21 56 Personal Items (5,520) 10 67 Collection Agency Fees (10) 21 78 Donations (300) 20 89 Real Estate Taxes 5,065 33 910 Additional R&M 13,964 06 1011 Non Allowable Travel (248) 25 1112 Employee Bonus (6,739) 22 1213 Chamber of Commerce (660) 20 1314 PAC Dues (2,493) 20 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 3233 3334 3435 3536 3637 3738 3839 3940 4041 4142 4243 4344 4445 4546 4647 4748 4849 Total (9,963) 49

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 5BHilltop Skilled Nsg & Rehab

ID# 0051441Report Period Beginning: 01/01/16

Ending: 12/31/16Sch. V Line

NON-ALLOWABLE EXPENSES Amount Reference50 $ 151 252 353 454 555 656 757 858 959 1060 1161 1262 1363 1464 1565 1666 1767 1868 1969 2070 2171 2272 2373 2474 2575 2676 2777 2878 2979 3080 3181 3282 3383 3484 3585 3686 3787 3888 3989 4090 4191 4292 4393 4494 4595 4696 4797 4898 Total 49

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Summary AFacility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I

SUMMARY Operating Expenses PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE TOTALSA. General Services 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7)

1 Dietary (64) (64) 12 Food Purchase (310) (310) 23 Housekeeping 34 Laundry (266) (266) 45 Heat and Other Utilities (10,169) (10,169) 56 Maintenance 13,964 1,104 15,068 67 Other (specify):* 78 TOTAL General Services 3,485 (330) 1,104 4,259 8

B. Health Care and Programs9 Medical Director 9

10 Nursing and Medical Records (5,520) (5,520) 10 10a Therapy 10a11 Activities 1112 Social Services 1213 CNA Training 1314 Program Transportation 1415 Other (specify):* 1516 TOTAL Health Care and Programs (5,520) (5,520) 16

C. General Administration17 Administrative (81,731) (81,731) 1718 Directors Fees 1819 Professional Services 40,548 40,548 1920 Fees, Subscriptions & Promotions (30,030) 671 (29,359) 2021 Clerical & General Office Expenses (78,456) 952 (77,504) 2122 Employee Benefits & Payroll Taxes (6,739) (6,739) 2223 Inservice Training & Education 2324 Travel and Seminar 15,336 15,336 2425 Other Admin. Staff Transportation (248) (248) 2526 Insurance-Prop.Liab.Malpractice 3,245 3,245 2627 Other (specify):* 28,697 28,697 2728 TOTAL General Administration (115,473) 7,717 (107,755) 28

TOTAL Operating Expense29 (sum of lines 8,16 & 28) (117,508) (330) 8,821 (109,017) 29

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Summary BFacility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16

SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I

SUMMARY Capital Expense PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE TOTALSD. Ownership 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7)

30 Depreciation (124,144) 98,414 (25,730) 3031 Amortization of Pre-Op. & Org. 3132 Interest (66) 50,933 50,867 3233 Real Estate Taxes 5,065 5,065 3334 Rent-Facility & Grounds (149,088) (149,088) 3435 Rent-Equipment & Vehicles 3536 Other (specify):* 19,776 19,776 3637 TOTAL Ownership (119,145) (50,674) 70,710 (99,109) 37

Ancillary ExpenseE. Special Cost Centers

38 Medically Necessary Transportation 3839 Ancillary Service Centers 3940 Barber and Beauty Shops 4041 Coffee and Gift Shops 4142 Provider Participation Fee 4243 Other (specify):* 4344 TOTAL Special Cost Centers 44

GRAND TOTAL COST45 (sum of lines 29, 37 & 44) (236,653) (51,004) 79,531 (208,126) 45

HFS 3745 (N-4-99) IL478-2471


VII. RELATED PARTIES A. Enter below the names of ALL owners and related organizations (parties) as defined in the instructions. Use Page 6-Supplemental as necessary.

1 2 3 OWNERS RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES

Name Ownership % Name City Name City Type of BusinessSee Page 6-Supplemental See Page 6-Supplemental See Page 6-Supplemental

B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,management fees, purchase of supplies, and so forth. X YES NO

If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance withthe instructions for determining costs as specified for this form.1 2 3 Cost Per General Ledger 4 5 Cost to Related Organization 6 7 8 Difference:

Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization

Ownership Organization Costs (7 minus 4)1 V 34 Rent $ 149,088 CC Charleston, LLC 100.00% $ $ (149,088) 12 V 30 Depreciation CC Charleston, LLC 100.00% 98,414 98,414 23 V 04 Laundry Cleaning Supplies 266 CC Charleston, LLC 100.00% (266) 34 V 01 Dietary Cleaning Supplies 64 CC Charleston, LLC 100.00% (64) 45 V 56 V 67 V 78 V 89 V 9

10 V 1011 V 1112 V 1213 V 1314 Total $ 149,418 $ 98,414 $ * (51,004) 14

* Total must agree with the amount recorded on line 34 of Schedule VI.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6AFacility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16

VII. RELATED PARTIES (continued) B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,

management fees, purchase of supplies, and so forth. X YES NO



Ownership Organization Costs (7 minus 4)15 V 39 Physical Therapy $ 206,643 Affirma Rehabilitation 100.00% $ 206,643 $ 1516 V 39 Occupational Therapy 87,387 Affirma Rehabilitation 100.00% 87,387 1617 V 39 Speech Therapy 35,830 Affirma Rehabilitation 100.00% 35,830 1718 V 1819 V 1920 V 2021 V 2122 V 2223 V 2324 V 2425 V 2526 V 2627 V 2728 V 2829 V 2930 V 3031 V 3132 V 3233 V 3334 V 3435 V 3536 V 3637 V 3738 V 3839 Total $ 329,860 $ 329,860 $ * 39


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6BFacility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16


management fees, purchase of supplies, and so forth. X YES NO



Ownership Organization Costs (7 minus 4)15 V 6 Maintenance $ Covenant Care California, LLC 100.00% $ 1,104 $ 1,104 1516 V 17 Administrative Covenant Care California, LLC 100.00% 106,375 106,375 1617 V 19 Professional Services Covenant Care California, LLC 100.00% 40,548 40,548 1718 V 20 Dues & Subscriptions Covenant Care California, LLC 100.00% 671 671 1819 V 21 Clerical / Office Covenant Care California, LLC 100.00% 952 952 1920 V 24 Seminar Covenant Care California, LLC 100.00% 15,336 15,336 2021 V 26 Insurance Covenant Care California, LLC 100.00% 3,245 3,245 2122 V 27 Employee Benefits Covenant Care California, LLC 100.00% 28,697 28,697 2223 V 32 Interest Covenant Care California, LLC 100.00% 50,933 50,933 2324 V 36 Building, Equipment, Fixtures Covenant Care California, LLC 100.00% 19,776 19,776 2425 V 2526 V 17 Management Fees 188,106 Covenant Care California, LLC 100.00% (188,106) 2627 V 2728 V 2829 V 2930 V 3031 V 3132 V 3233 V 3334 V 3435 V 3536 V 3637 V 3738 V 3839 Total $ 188,106 $ 267,637 $ * 79,531 39


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6CFacility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16


management fees, purchase of supplies, and so forth. YES NO



Ownership Organization Costs (7 minus 4)15 V $ $ $ 1516 V 1617 V 1718 V 1819 V 1920 V 2021 V 2122 V 2223 V 2324 V 2425 V 2526 V 2627 V 2728 V 2829 V 2930 V 3031 V 3132 V 3233 V 3334 V 3435 V 3536 V 3637 V 3738 V 3839 Total $ $ $ * 39


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6DFacility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16







HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6EFacility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16







HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6FFacility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16







HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6GFacility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16







HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6HFacility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16







HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6IFacility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16







HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6-SupplementalFacility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16

VII. RELATED PARTIES A. (Continued) Enter below the names of ALL owners and related organizations (parties) as defined in the instructions


Name Ownership % Name City Name City Type of Business

1 COVENANT CARE CALIFORNIA, LLC 100.00% ARBOR NURSING CENTER CALIFORNIA COVENANT CARE CALIFORNIAALISO VIEJO, CA MANAGEMENT CO. 12 ARBOR PLACE CALIFORNIA AFFIRMA REHABILITATION ALISO VIEJO, CA THERAPY 23 BUENA VISTA CARE CENTER, A NURSING & REHAB FACILITY CALIFORNIA CC CHARLESTON, LLC CHARLESTON, IL BUILDING CO. 34 CARSON NURSING & REHAB CENTER NEVADA 45 CATERED MANOR CALIFORNIA 56 CLINTON HOUSE HEALTH & REHABILITATION CENTER INDIANA 67 COURTYARD HEALTHCARE CENTER CALIFORNIA 78 COVENANT CARE HILLTOP,LLC D/B/A HILLTOP SKILLED NSG & RCHARLESTON 89 COVENANT CARE JACKSONVILLE,LLC D/B/A JACKSONVILLE SKLJACKSONVILLE 910 COVENANT CARE MEADOW MANOR,LLC D/B/A MEADOW MANORTAYLORVILLE 1011 COVENANT CARE MIDWEST, INC. D/B/A CEDAR RIDGE HEALTH &LEBANON 1112 COVENANT CARE SUNRISE,LLC D/B/A SUNRISE SKILLED NURSINGVIRDEN 1213 COVINGTON MANOR INDIANA 1314 DOWNEY CARE CALIFORNIA 1415 EAGLE POINT NUSING AND REHAB CENTER IOWA 1516 EDGEWOOD MANOR NURSING CENTER OHIO 1617 EMERALD GARDENS NURSING CENTER CALIFORNIA 1718 ENCINITAS NURSING AND REHABILITATION CENTER CALIFORNIA 1819 ENNOBLE SKILLED NURSING & REHAB CENTER IOWA 1920 FAIRVIEW MANOR NURSING CENTER OHIO 2021 FRIENDSHIP HOME CARLINVILLE, IL 2122 GILROY HEALTHCARE & REHABILITATION CENTER CALIFORNIA 2223 GRANT CUESTA NURSING & REHABILITATION CENTER CALIFORNIA 2324 HIGHLAND HEALTH CARE CENTER ILLINOIS 2425 HUNTINGTON PARK NURSING CENTER CALIFORNIA 2526 LA JOLLA NURSING AND REHABILITATION CENTER CALIFORNIA 2627 LAKELAND NURSING CENTER INDIANA 2728 LOS ALTOS SUB-ACUTE & REHABILITATION CENTER CALIFORNIA 2829 MISSION SKILLED NURSING & SUBACUTE CENTER CALIFORNIA 2930 NEBRASKA SKILLED NURSING CENTER NEBRASKA 30

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6-Supplemental (2)Facility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16

VII. RELATED PARTIES A. (Continued) Enter below the names of ALL owners and related organizations (parties) as defined in the instructions


Name Ownership % Name City Name City Type of Business

1 NORWOOD NURSING CENTER INDIANA 12 PACIFIC COAST MANOR CALIFORNIA 23 PACIFIC GARDENS NURSING & REHABILITATION CENTER CALIFORNIA 34 PACIFIC HILLS MANOR CALIFORNIA 45 PALO ALTO NURSING CENTER CALIFORNIA 56 ROYAL CARE SKILLED NURSING CENTER CALIFORNIA 67 SHORELINE CARE CENTER CALIFORNIA 78 SILVER HILLS HEALTH CARE CENTER NEVADA 89 SILVER RIDGE HEALTHCARE CENTER NEVADA 910 ST. EDNA SUBACUTE & REHABILITATION CENTER CALIFORNIA 1011 THE RESIDENCE AT MCCORMICK'S CREEK INDIANA 1112 TURLOCK NURSING AND REHABILITATION CENTER CALIFORNIA 1213 TURLOCK RESIDENTIAL CALIFORNIA 1314 UNIVERSITY PARK NURSING CENTER INDIANA 1415 VALLE VISTA CONVALESCENT CENTER CALIFORNIA 1516 VERSAILLES HEALTH CARE CENTER OHIO 1617 VILLA GEORGETOWN OHIO 1718 VILLA SPRINGFIELD OHIO 1819 VINTAGE FAIRE NURSING & REHABILITATION CENTER CALIFORNIA 1920 VINTAGE FAIRE RESIDENTIAL CALIFORNIA 2021 WAGNER HEIGHTS NURSING & REHABILITATION CENTER CALIFORNIA 2122 WAGNER HEIGHTS RESIDENTIAL CALIFORNIA 2223 WALDRON HEALTH AND REHAB CENTER INDIANA 2324 WILLOW TREE NURSING & REHABILITATION CENTER CALIFORNIA 2425 WRIGHT NURSING & REHAB CENTER (VILLA FAIRBORN) OHIO 2526 MARION REHAB AND ASSISTED LIVING CENTER INDIANA 2627 PYRAMID POINT POST ACUTE REHABILITATION CENTER INDIANA 2728 2829 2930 30

HFS 3745 (N-4-99) IL478-2471


VII. RELATED PARTIES (continued)C. Statement of Compensation and Other Payments to Owners, Relatives and Members of Board of Directors. NOTE: ALL owners ( even those with less than 5% ownership) and their relatives who receive any type of compensation from this home must be listed on this schedule.

1 2 3 4 5 6 7 8Average Hours Per Work

Compensation Week Devoted to this Compensation Included Schedule V.Received Facility and % of Total in Costs for this Line &

Ownership From Other Work Week Reporting Period** ColumnName Title Function Interest Nursing Homes* Hours Percent Description Amount Reference

1 $ 12 23 34 45 56 67 78 89 9

10 1011 Where applicable, the amounts reported on this page have been adjusted from the actual costs to reflect only the amounts 1112 anticipated to be considered allowable by the IL. Dept. of HFS. 1213 TOTAL $ 13

* If the owner(s) of this facility or any other related parties listed above have received compensation from other nursing homes, attach a schedule detailing the name(s)of the home(s) as well as the amount paid. THIS AMOUNT MUST AGREE TO THE AMOUNTS CLAIMED ON THE THE OTHER NURSING HOMES' COST REPORTS.

** This must include all forms of compensation paid by related entities and allocated to Schedule V of this report (i.e., management fees).FAILURE TO PROPERLY COMPLETE THIS SCHEDULE INDICATING ALL FORMS OF COMPENSATION RECEIVED FROM THIS HOME,ALL OTHER NURSING HOMES AND MANAGEMENT COMPANIES MAY RESULT IN THE DISALLOWANCE OF SUCH COMPENSATION

HFS 3745 (N-4-99) IL478-2471


VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization

A. Are there any costs included in this report which were derived from allocations of central office Street Address or parent organization costs? (See instructions.) YES NO X City / State / Zip Code

Phone Number ( ) B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( )

1 2 3 4 5 6 7 8 9Schedule V Unit of Allocation Number of Total Indirect Amount of Salary

Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility AllocationReference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6

1 $ $ $ 12 23 34 45 56 67 78 89 910 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 TOTALS $ $ $ 25

HFS 3745 (N-4-99) IL478-2471


VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization Affirma Rehabilitation

A. Are there any costs included in this report which were derived from allocations of central office Street Address 27071 Aliso Creek Road or parent organization costs? (See instructions.) YES X NO City / State / Zip Code Aliso Viejo, CA 92656

Phone Number ( 888) 468-4372 B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( )



1 39 Physical Therapy Direct Allocation $ $ $ 206,643 12 39 Occupational Therapy Direct Allocation 87,387 23 39 Speech Therapy Direct Allocation 35,830 34 45 56 67 78 89 910 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 TOTALS $ $ $ 329,860 25

HFS 3745 (N-4-99) IL478-2471


VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization Covenant Care California, LLC

A. Are there any costs included in this report which were derived from allocations of central office Street Address 27071 Aliso Creek Rd or parent organization costs? (See instructions.) YES X NO City / State / Zip Code Aliso Viejo, CA 92656

Phone Number ( 949) 349-1200 B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( 949) 349-1900



1 6 Maintenance Accumulated Cost $ $ $ 1,104 12 17 Administrative Accumulated Cost 106,375 23 19 Professional Services Accumulated Cost 40,548 34 20 Dues & Subscriptions Accumulated Cost 671 45 21 Clerical / Office Accumulated Cost 952 56 24 Seminar Accumulated Cost 15,336 67 26 Insurance Accumulated Cost 3,245 78 27 Employee Benefits Accumulated Cost 28,697 89 32 Interest Accumulated Cost 50,933 910 36 Building, Equipment, Fixtures Accumulated Cost 19,776 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 TOTALS $ $ $ 267,637 25

HFS 3745 (N-4-99) IL478-2471



A. Are there any costs included in this report which were derived from allocations of central office Street Address or parent organization costs? (See instructions.) YES NO City / State / Zip Code

Phone Number ( B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number (



1 $ $ $ 12 23 34 45 56 67 78 89 910 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 TOTALS $ $ $ 25

HFS 3745 (N-4-99) IL478-2471







1 $ $ $ 12 23 34 45 56 67 78 89 910 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 TOTALS $ $ $ 25

HFS 3745 (N-4-99) IL478-2471


IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE A. Interest: (Complete details must be provided for each loan - attach a separate schedule if necessary.)

1 2 3 4 5 6 7 8 9 10Reporting

Monthly Maturity Interest PeriodName of Lender Related** Purpose of Loan Payment Date of Amount of Note Date Rate Interest

YES NO Required Note Original Balance (4 Digits) ExpenseA. Directly Facility Related Long-Term

1 $ $ $ 12 23 34 45 - 5

Working Capital6 Allocated from Covenant Care Inc X 50,933 67 78 - 8

9 TOTAL Facility Related $ $ $ 50,933 9B. Non-Facility Related*

10 Interest Income X (66) 1011 1112 1213 - 13

14 TOTAL Non-Facility Related $ $ $ (66) 14

15 TOTALS (line 9+line14) $ $ $ 50,867 15

16) Please indicate the total amount of mortgage insurance expense and the location of this expense on Sch. V. $ None Line # N/A

* Any interest expense reported in this section should be adjusted out on page 5, line 14 and, consequently, page 4, col. 7.(See instructions.)

** If there is ANY overlap in ownership between the facility and the lender, this must be indicated in column 2.(See instructions.)

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 9 - SUPPLEMENTALFacility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16

IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE - SUPPLEMENTAL SCHEDULE A. Interest: (Complete details must be provided for each loan - attach a separate schedule if necessary.)

1 2 3 4 5 6 7 8 9 10Reporting

Monthly Maturity Interest PeriodName of Lender Related** Purpose of Loan Payment Date of Amount of Note Date Rate Interest

YES NO Required Note Original Balance (4 Digits) ExpenseA. Directly Facility Related Long-Term

1 $ $ $ 12 23 34 45 56 67 TOTAL Long-Term 7

Working Capital8 $ $ $ 89 9

10 1011 1112 1213 1314 TOTAL Working Capital 14

B. Non-Facility Related*15 $ $ $ 1516 1617 1718 1819 1920 TOTAL Non-Facility Related 20

* Any interest expense reported in this section should be adjusted out on page 5, line 14 and, consequently, page 4, col. 7.(See instructions.) SEE ACCOUNTANTS' COMPILATION REPORT

** If there is ANY overlap in ownership between the facility and the lender, this must be indicated in column 2.(See instructions.)

HFS 3745 (N-4-99) IL478-2471


IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE (continued) B. Real Estate Taxes

Important, please see the next worksheet, "RE_Tax". The real estate tax 1. Real Estate Tax accrual used on 2015 report. statement and bill must accompany the cost report. $ 1

2. Real Estate Taxes paid during the year: (Indicate the tax year to which this payment applies. If payment covers more than one year, detail below.) $ 36,361 2

3. Under or (over) accrual (line 2 minus line 1). $ 36,361 3

4. Real Estate Tax accrual used for 2016 report. (Detail and explain your calculation of this accrual on the lines below.) $ 4

5. Direct costs of an appeal of tax assessments which has NOT been included in professional fees or other general operating costs on Schedule V, sections A, B or C. (Describe appeal cost below. Attach copies of invoices to support the cost and a copy of the appeal filed with the county.) $ 5

6. Subtract a refund of real estate taxes. You must offset the full amount of any direct appeal costs classified as a real estate tax cost plus one-half of any remaining refund. TOTAL REFUND $ For Tax Year. (Attach a copy of the real estate tax appeal board's decision.) $ 6

7. Real Estate Tax expense reported on Schedule V, line 33. This should be a combination of lines 3 thru 6. $ 36,361 7

Real Estate Tax History:

Real Estate Tax Bill for Calendar Year: 2011 32,915 8 FOR BHF USE ONLY2012 33,931 92013 33,258 10 13 FROM R. E. TAX STATEMENT FOR 2015 $ 132014 31,063 112015 36,361 12 14 PLUS APPEAL COST FROM LINE 5 $ 14

Facility does not accrue real estate taxes. 15 LESS REFUND FROM LINE 6 $ 15

16 AMOUNT TO USE FOR RATE CALCULATION $ 16

NOTES: 1. Please indicate a negative number by use of brackets( ). Deduct any overaccrual of taxes from prior year.

2. If facility is a non-profit which pays real estate taxes, you must attach a denial of an application for real estate tax exemption unless the building is rented from a for-profit entity. This denial must be no more than four years old at the time the cost report is filed.

HFS 3745 (N-4-99) IL478-2471

2015 LONG TERM CARE REAL ESTATE TAX STATEMENTFACILITY NAME Hilltop Skilled Nsg & Rehab COUNTY Coles

FACILITY IDPH LICENSE NUMBER 0051441

CONTACT PERSON REGARDING THIS REPORT Steve Lavenda

TELEPHONE (847) 236-6300 FAX #: (847) 236-6301

A. Summary of Real Estate Tax Cost

Enter the tax index number and real estate tax assessed for 2015 on the lines provided below. Enter only the portion of thecost that applies to the operation of the nursing home in Column D. Real estate tax applicable to any portion of the nursinghome property which is vacant, rented to other organizations, or used for purposes other than long term care must not beentered in Column D. Do not include cost for any period other than calendar year 2015.

(A) (B) (C) (D)Tax

Applicable toTax Index Number Property Description Total Tax Nursing Home

1. 02-1-00706-000 Long Term Care Property $ 36,361.20 $ 36,361.20

2. $ $

3. $ $

4. $ $

5. $ $

6. $ $

7. $ $

8. $ $

9. $ $

10. $ $

TOTALS $ 36,361.20 $ 36,361.20

B. Real Estate Tax Cost Allocations

Does any portion of the tax bill apply to more than one nursing home, vacant property, or property which is not directlyused for nursing home services? YES X NO

If YES, attach an explanation and a schedule which shows the calculation of the cost allocated to the nursing home.(Generally the real estate tax cost must be allocated to the nursing home based upon sq. ft. of space used.)

C. Tax Bills

Attach a copy of the original 2015 tax bills which were listed in Section A to this statement. Be sure to use the 2015tax bill which is normally paid during 2016.

PLEASE NOTE: Payment information from the Internet or otherwise is not considered acceptable tax billdocumentation . Facilities located in Cook County are required to provide copies of their original second installment tax bill.

Page 10A

HFS 3745 (N-4-99) IL478-2471

IMPORTANT NOTICE

TO: Long Term Care Facilities with Real Estate Tax RatesRE: 2015 REAL ESTATE TAX COST DOCUMENTATION

In order to set the real estate tax portion of the capital rate, it is necessary that we obtain additionalinformation regarding your calendar 2015 real estate tax costs, as well as copies of your original real estatetax bills for calendar 2015.

Please complete the Real Estate Tax Statement below and include it in the 2016 cost report along with acopy of your 2015 real estate tax bill.

The cost report will not be considered complete and timely filed until this statement and the correspondingreal estate tax bills are filed. If you have any questions, please call the Bureau of Health Finance at(217) 782-1630.

2015 LONG TERM CARE REAL ESTATE TAX STATEMENTFACILITY NAME Hilltop Skilled Nsg & Rehab COUNTY Coles

FACILITY IDPH LICENSE NUMBER 0051441

CONTACT PERSON REGARDING THIS REPORT Steve Lavenda

TELEPHONE (847) 236-6300 FAX #: (847) 236-6301

A. Summary of Real Estate Tax Cost

Enter the tax index number and real estate tax assessed for 2015 on the lines provided below. Enter only the portion of thecost that applies to the operation of the nursing home in Column D. Real estate tax applicable to any portion of the nursinghome property which is vacant, rented to other organizations, or used for purposes other than long term care must not beentered in Column D. Do not include cost for any period other than calendar year 2015.

(A) (B) (C) (D)Tax

Applicable toTax Index Number Property Description Total Tax Nursing Home

1. $ $

2. $ $

3. $ $

4. $ $

5. $ $

6. $ $

7. $ $

8. $ $

9. $ $

10. $ $

TOTALS $ $

B. Real Estate Tax Cost Allocations

Does any portion of the tax bill apply to more than one nursing home, vacant property, or property which is not directlyused for nursing home services? YES NO

If YES, attach an explanation and a schedule which shows the calculation of the cost allocated to the nursing home.(Generally the real estate tax cost must be allocated to the nursing home based upon sq. ft. of space used.)

C. Tax Bills

Attach a copy of the original 2015 tax bills which were listed in Section A to this statement. Be sure to use the 2015tax bill which is normally paid during 2016.

PLEASE NOTE: Payment information from the Internet or otherwise is not considered acceptable tax billdocumentation . Facilities located in Cook County are required to provide copies of their original second installment tax bill.

Page 10B

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 11Facility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16X. BUILDING AND GENERAL INFORMATION:

A. Square Feet: 24,709 B. General Construction Type: Exterior Masonry Frame Wood & Steel Number of Stories 1

C. Does the Operating Entity? (a) Own the Facility X (b) Rent from a Related Organization. (c) Rent from Completely Unrelated Organization.

(Facilities checking (a) or (b) must complete Schedule XI. Those checking (c) may complete Schedule XI or Schedule XII-A. See instructions.)

D. Does the Operating Entity? X (a) Own the Equipment (b) Rent equipment from a Related Organization. X (c) Rent equipment from Completely Unrelated Organization.

(Facilities checking (a) or (b) must complete Schedule XI-C. Those checking (c) may complete Schedule XI-C or Schedule XII-B. See instructions.)

E. List all other business entities owned by this operating entity or related to the operating entity that are located on or adjacent to this nursing home's grounds(such as, but not limited to, apartments, assisted living facilities, day training facilities, day care, independent living facilities, CNA training facilities, etc.)List entity name, type of business, square footage, and number of beds/units available (where applicable).None

F. Does this cost report reflect any organization or pre-operating costs which are being amortized? YES X NOIf so, please complete the following:

1. Total Amount Incurred: 2. Number of Years Over Which it is Being Amortized:

3. Current Period Amortization: 4. Dates Incurred:

Nature of Costs:(Attach a complete schedule detailing the total amount of organization and pre-operating costs.)

XI. OWNERSHIP COSTS: 1 2 3 4

A. Land. Use Square Feet Year Acquired Cost1 $ 12 23 TOTALS $ 3

HFS 3745 (N-4-99) IL478-2471


XI. OWNERSHIP COSTS (continued) B. Building and Improvement Costs-Including Fixed Equipment. (See instructions.) Round all numbers to nearest dollar.

1 2 3 4 5 6 7 8 9 FOR BHF USE ONLY Year Year Current Book Life Straight Line Accumulated

Beds* Acquired Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation4 108 2015 1966 $ 885,730 $ 98,414 35 $ 25,307 $ (73,107) $ 50,614 45 56 67 78 8

Improvement Type**1 9 Various 2011 33,819 20 1,691 1,691 10,146 92 10 Various 2012 689,049 20 34,452 34,452 172,262 103 11 114 12 125 13 136 14 147 15 158 16 169 17 17

10 18 1811 19 1912 20 2013 21 2114 22 2215 23 2316 24 2417 25 2518 26 2619 27 2720 28 2821 29 2922 30 3023 31 3124 32 3225 33 3326 34 3427 35 3528 36 36

*Total beds on this schedule must agree with page 2. See Page 12A, Line 70 for total**Improvement type must be detailed in order for the cost report to be considered complete

HFS 3745 (N-4-99) IL478-2471



1 3 4 5 6 7 8 9Year Current Book Life Straight Line Accumulated

Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation29 37 $ $ $ $ $ 3730 38 3831 39 3932 40 4033 41 4134 42 4235 43 4336 44 4437 45 4538 46 4639 47 4740 48 4841 49 4942 50 5043 51 5144 52 5245 53 5346 54 5447 55 5548 56 5649 57 5750 58 5851 59 5952 60 6053 61 6154 62 6255 63 6356 64 6457 65 6558 66 66

67 Related Building Company (Pages 12F & 12G) 6768 Related Party Allocations (Pages 12H & 12I) 6869 Financial Statement Depreciation 146,195 (146,195) 6970 TOTAL (lines 4 thru 69) $ 1,608,598 $ 244,609 $ 61,450 $ (183,159) $ 233,022 70

**Improvement type must be detailed in order for the cost report to be considered complete.

HFS 3745 (N-4-99) IL478-2471




Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12A, Carried Forward $ 1,608,598 $ 244,609 $ 61,450 $ (183,159) $ 233,022 1

1 2 2 Ton A/C Unit 2013 4,162 20 208 208 832 22 3 Repair Roof 2013 3,000 20 150 150 600 33 4 5 Ton 3 Phase Condensor Ac Unit 2014 3,150 20 158 158 473 44 5 Booster Heater Water Heater 2016 2,543 20 254 254 254 55 6 Asphalt Paving, Sidewalk Replacement, Roofing, Plumbing 2016 85,887 20 4,294 4,294 4,294 66 7 77 8 88 9 99 10 10

10 11 1111 12 1212 13 1313 14 1414 15 1515 16 1616 17 1717 18 1818 19 1919 20 2020 21 2121 22 2222 23 2323 24 2424 25 2525 26 2626 27 2727 28 2828 29 2929 30 3030 31 3131 32 3232 33 33

34 TOTAL (lines 1 thru 33) $ 1,707,340 $ 244,609 $ 66,515 $ (178,095) $ 239,475 34


HFS 3745 (N-4-99) IL478-2471




Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12B, Carried Forward $ 1,707,340 $ 244,609 $ 66,515 $ (178,095) $ 239,475 1

33 2 234 3 335 4 436 5 537 6 638 7 739 8 840 9 941 10 1042 11 1143 12 1244 13 1345 14 1446 15 1547 16 1648 17 1749 18 1850 19 1951 20 2052 21 2153 22 2254 23 2355 24 2456 25 2557 26 2658 27 2759 28 2860 29 2961 30 3062 31 3163 32 3264 33 33

34 TOTAL (lines 1 thru 33) $ 1,707,340 $ 244,609 $ 66,515 $ (178,095) $ 239,475 34


HFS 3745 (N-4-99) IL478-2471




Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12C, Carried Forward $ 1,707,340 $ 244,609 $ 66,515 $ (178,095) $ 239,475 1

65 2 266 3 367 4 468 5 569 6 670 7 771 8 872 9 973 10 1074 11 1175 12 1276 13 1377 14 1478 15 1579 16 1680 17 1781 18 1882 19 1983 20 2084 21 2185 22 2286 23 2387 24 2488 25 2589 26 2690 27 2791 28 2892 29 2993 30 3094 31 3195 32 3296 33 33

34 TOTAL (lines 1 thru 33) $ 1,707,340 $ 244,609 $ 66,515 $ (178,095) $ 239,475 34


HFS 3745 (N-4-99) IL478-2471




Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12D, Carried Forward $ 1,707,340 $ 244,609 $ 66,515 $ (178,095) $ 239,475 1

97 2 298 3 399 4 4

100 5 5101 6 6102 7 7103 8 8104 9 9105 10 10106 11 11107 12 12108 13 13109 14 14110 15 15111 16 16112 17 17113 18 18114 19 19115 20 20116 21 21117 22 22118 23 23119 24 24120 25 25121 26 26122 27 27123 28 28124 29 29125 30 30126 31 31127 32 32128 33 33

34 TOTAL (lines 1 thru 33) $ 1,707,340 $ 244,609 $ 66,515 $ (178,095) $ 239,475 34


HFS 3745 (N-4-99) IL478-2471




Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Building Company $ $ $ $ $ 12 23 34 45 56 67 78 Leasehold Improvements: 89 9

10 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 3233 3334 TOTAL (lines 1 thru 33) $ $ $ $ $ 34


HFS 3745 (N-4-99) IL478-2471




Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12F, Carried Forward $ $ $ $ $ 12 23 34 45 56 67 78 89 9

10 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 3233 3334 TOTAL (lines 1 thru 33) $ $ $ $ $ 34


HFS 3745 (N-4-99) IL478-2471




Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Related Party $ $ $ $ $ 12 Buildings: 23 34 45 56 67 78 Leasehold Improvements: 89 9

10 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 3233 3334 TOTAL (lines 1 thru 33) $ $ $ $ $ 34


HFS 3745 (N-4-99) IL478-2471




Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12H, Carried Forward $ $ $ $ $ 12 23 34 45 56 67 78 89 9

10 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 3233 3334 TOTAL (lines 1 thru 33) $ $ $ $ $ 34


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 13Facility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16XI. OWNERSHIP COSTS (continued)

C. Equipment Costs-Excluding Transportation. (See instructions.) Category of 1 Current Book Straight Line 4 Component Accumulated Equipment Cost Depreciation 2 Depreciation 3 Adjustments Life 5 Depreciation 6

71 Purchased in Prior Years $ 538,414 $ $ 53,694 $ 53,694 10 $ 172,089 7172 Current Year Purchases 2,567 257 257 10 257 7273 Fully Depreciated Assets 7374 7475 TOTALS $ 540,980 $ $ 53,951 $ 53,951 $ 172,346 75

D. Vehicle Costs. (See instructions.)*1 Model, Make Year 4 Current Book Straight Line 7 Life in Accumulated

Use and Year 2 Acquired 3 Cost Depreciation 5 Depreciation 6 Adjustments Years 8 Depreciation 976 $ $ $ $ $ 7677 7778 7879 7980 TOTALS $ $ $ $ $ 80

E. Summary of Care-Related Assets 1 2Reference Amount

81 Total Historical Cost (line 3, col.4 + line 70, col.4 + line 75, col.1 + line 80, col.4) + (Pages 12B thru 12I, if applicable) $ 2,248,320 8182 Current Book Depreciation (line 70, col.5 + line 75, col.2 + line 80, col.5) + (Pages 12B thru 12I, if applicable) $ 244,609 8283 Straight Line Depreciation (line 70, col.7 + line 75, col.3 + line 80, col.6) + (Pages 12B thru 12I, if applicable) $ 120,465 83 **84 Adjustments (line 70, col.8 + line 75, col.4 + line 80, col.7) + (Pages 12B thru 12I, if applicable) $ (124,144) 8485 Accumulated Depreciation (line 70, col.9 + line 75, col.6 + line 80, col.9) + (Pages 12B thru 12I, if applicable) $ 411,821 85

F. Depreciable Non-Care Assets Included in General Ledger. (See instructions.) G. Construction-in-Progress1 2 Current Book Accumulated

Description & Year Acquired Cost Depreciation 3 Depreciation 4 Description Cost86 $ $ $ 86 92 $ 9287 87 93 9388 88 94 9489 89 95 $ 9590 9091 TOTALS $ $ $ 91 * Vehicles used to transport residents to & from

day training must be recorded in XI-F, not XI-D.

** This must agree with Schedule V line 30, column 8.

HFS 3745 (N-4-99) IL478-2471


XII. RENTAL COSTSA. Building and Fixed Equipment (See instructions.) 1. Name of Party Holding Lease: N/A 2. Does the facility also pay real estate taxes in addition to rental amount shown below on line 7, column 4? If NO, see instructions. YES NO 00

001 2 3 4 5 6

Year Number Original Rental Total Years Total YearsConstructed of Beds Lease Date Amount of Lease Renewal Option*

Original 10. Effective dates of current rental agreement:3 Building: $ 3 Beginning4 Additions 4 Ending5 Storage 722 56 6 11. Rent to be paid in future years under the current7 TOTAL $ 722 7 rental agreement:

** 8. List separately any amortization of lease expense included on page 4, line 34. Fiscal Year Ending Annual Rent This amount was calculated by dividing the total amount to be amortized by the length of the lease . 12. /2017 $

13. /2018 $ 9. Option to Buy: YES NO Terms: * 14. /2019 $

B. Equipment-Excluding Transportation and Fixed Equipment. (See instructions.) 15. Is Movable equipment rental included in building rental? YES NO 16. Rental Amount for movable equipment: $ 4,452 Description: See Attached Schedule

(Attach a schedule detailing the breakdown of movable equipment)C. Vehicle Rental (See instructions.)

1 2 3 4Model Year Monthly Lease Rental Expense

Use and Make Payment for this Period * If there is an option to buy the building,17 Facility Van $ 1,148 $ 10,428 17 please provide complete details on attached18 18 schedule.19 1920 20 ** This amount plus any amortization of lease21 TOTAL $ 1,148 $ 10,428 21 expense must agree with page 4, line 34.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 15Facility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16XIII. EXPENSES RELATING TO CERTIFIED NURSE AIDE (CNA) TRAINING PROGRAMS (See instructions.)

A. TYPE OF TRAINING PROGRAM (If CNAs are trained in another facility program, attach a schedule listing the facility name, address and cost per CNA trained in that facility.)

1. HAVE YOU TRAINED CNAs YES 2. CLASSROOM PORTION: 3. CLINICAL PORTION: DURING THIS REPORT PERIOD? X NO IN-HOUSE PROGRAM IN-HOUSE PROGRAM

IN OTHER FACILITY IN OTHER FACILITY If "yes", please complete the remainder of this schedule. If "no", provide an COMMUNITY COLLEGE HOURS PER CNA explanation as to why this training was not necessary. HOURS PER CNA

B. EXPENSES C. CONTRACTUAL INCOMEALLOCATION OF COSTS (d)

In the box below record the amount of income your1 2 3 4 facility received training CNAs from other facilities.

FacilityDrop-outs Completed Contract Total $

1 Community College Tuition $ $ $ $2 Books and Supplies D. NUMBER OF CNAs TRAINED3 Classroom Wages (a)4 Clinical Wages (b) COMPLETED5 In-House Trainer Wages (c) 1. From this facility6 Transportation 2. From other facilities (f)7 Contractual Payments DROP-OUTS8 CNA Competency Tests 1. From this facility9 TOTALS $ $ $ $ 2. From other facilities (f)10 SUM OF line 9, col. 1 and 2 (e) $ TOTAL TRAINED

(a) Include wages paid during the classroom portion of training. Do not include fringe benefits. (e) The total amount of Drop-out and Completed Costs for(b) Include wages paid during the clinical portion of training. Do not include fringe benefits. your own CNAs must agree with Sch. V, line 13, col. 8.(c) For in-house training programs only. Do not include fringe benefits. (f) Attach a schedule of the facility names and addresses(d) Allocate based on if the CNA is from your facility or is being contracted to be trained in of those facilities for which you trained CNAs. your facility. Drop-out costs can only be for costs incurred by your own CNAs.

HFS 3745 (N-4-99) IL478-2471


XIV. SPECIAL SERVICES (Direct Cost) (See instructions.)1 2 3 4 5 6 7 8

Schedule V Staff Outside Practitioner SuppliesService Line & Column Units of Cost (other than consultant) (Actual or) Total Units Total Cost

Reference Service Units Cost Allocated) (Column 2 + 4) (Col. 3 + 5 + 6)1 Licensed Occupational Therapist 39 - 03 hrs $ $ 87,387 $ $ 87,387 1

Licensed Speech and Language2 Development Therapist 39 - 03 hrs 35,830 35,830 23 Licensed Recreational Therapist hrs 34 Licensed Physical Therapist 39 - 03 hrs 206,643 206,643 45 Physician Care visits 56 Dental Care visits 67 Work Related Program hrs 78 Habilitation hrs 8

# of9 Pharmacy 39 - 02 prescrpts 116,949 116,949 9

Psychological Services (Evaluation and Diagnosis/

10 Behavior Modification) hrs 1011 Academic Education hrs 1112 Other (specify): 12

13 Other (specify): See Supplemental 18,174 28,918 47,092 13

14 TOTAL $ $ 348,034 $ 145,867 $ 493,901 14

NOTE: This schedule should include fees (other than consultant fees) paid to licensed practitioners. Consultant fees should be detailed on Schedule XVIII-B. Salaries of unlicensed practitioners, such as CNAs, who help with the above activities should not be listed on this schedule.

HFS 3745 (N-4-99) IL478-2471


XV. BALANCE SHEET - Unrestricted Operating Fund. As of 12/31/16 (last day of reporting year) This report must be completed even if financial statements are attached.

1 2 After 1 2 After Operating Consolidation* Operating Consolidation*

A. Current Assets C. Current Liabilities1 Cash on Hand and in Banks $ 1,000 $ 1,000 1 26 Accounts Payable $ 7,125 $ 7,125 262 Cash-Patient Deposits 2 27 Officer's Accounts Payable 27

Accounts & Short-Term Notes Receivable- 28 Accounts Payable-Patient Deposits 283 Patients (less allowance ) 569,640 569,640 3 29 Short-Term Notes Payable 294 Supply Inventory (priced at ) 54,712 54,712 4 30 Accrued Salaries Payable 56,476 56,476 305 Short-Term Investments 5 Accrued Taxes Payable6 Prepaid Insurance 6 31 (excluding real estate taxes) 317 Other Prepaid Expenses 7,236 7,236 7 32 Accrued Real Estate Taxes(Sch.IX-B) 328 Accounts Receivable (owners or related parties) 8 33 Accrued Interest Payable 339 Other(specify): 9 34 Deferred Compensation 34

TOTAL Current Assets 35 Federal and State Income Taxes 3510 (sum of lines 1 thru 9) $ 632,588 $ 632,588 10 Other Current Liabilities(specify):

B. Long-Term Assets 36 See Attached Schedule 42,133 42,133 3611 Long-Term Notes Receivable 11 37 3712 Long-Term Investments 12 TOTAL Current Liabilities13 Land 13 38 (sum of lines 26 thru 37) $ 105,734 $ 105,734 3814 Buildings, at Historical Cost 885,730 14 D. Long-Term Liabilities15 Leasehold Improvements, at Historical Cost 831,402 831,402 15 39 Long-Term Notes Payable 3916 Equipment, at Historical Cost 250,387 594,837 16 40 Mortgage Payable 4017 Accumulated Depreciation (book methods) (665,147) (812,768) 17 41 Bonds Payable 4118 Deferred Charges 18 42 Deferred Compensation 4219 Organization & Pre-Operating Costs 19 Other Long-Term Liabilities(specify):

Accumulated Amortization - 43 See Attached Schedule 2,239,451 3,320,213 4320 Organization & Pre-Operating Costs 20 44 4421 Restricted Funds 21 TOTAL Long-Term Liabilities22 Other Long-Term Assets (specify): 22 45 (sum of lines 39 thru 44) $ 2,239,451 $ 3,320,213 4523 Other(specify): 23 TOTAL LIABILITIES

TOTAL Long-Term Assets 46 (sum of lines 38 and 45) $ 2,345,185 $ 3,425,947 4624 (sum of lines 11 thru 23) $ 416,642 $ 1,499,201 24

47 TOTAL EQUITY(page 18, line 24) $ (1,295,955) $ (1,294,158) 47TOTAL ASSETS TOTAL LIABILITIES AND EQUITY

25 (sum of lines 10 and 24) $ 1,049,230 $ 2,131,789 25 48 (sum of lines 46 and 47) $ 1,049,230 $ 2,131,789 48

*(See instructions.)

HFS 3745 (N-4-99) IL478-2471


XVI. STATEMENT OF CHANGES IN EQUITY1

Total1 Balance at Beginning of Year, as Previously Reported $ (1,002,917) 12 Restatements (describe): 23 Rounding (3) 34 45 56 Balance at Beginning of Year, as Restated (sum of lines 1-5) $ (1,002,920) 6

A. Additions (deductions):7 NET Income (Loss) (from page 19, line 43) (293,035) 78 Aquisitions of Pooled Companies 89 Proceeds from Sale of Stock 910 Stock Options Exercised 1011 Contributions and Grants 1112 Expenditures for Specific Purposes 1213 Dividends Paid or Other Distributions to Owners ( ) 1314 Donated Property, Plant, and Equipment 1415 Other (describe) 1516 Other (describe) 1617 TOTAL Additions (deductions) (sum of lines 7-16) $ (293,035) 17

B. Transfers (Itemize):18 1819 1920 2021 2122 2223 TOTAL Transfers (sum of lines 18-22) $ 2324 BALANCE AT END OF YEAR (sum of lines 6 + 17 + 23) $ (1,295,955) 24 *

* This must agree with page 17, line 47.

HFS 3745 (N-4-99) IL478-2471


XVII. INCOME STATEMENT (attach any explanatory footnotes necessary to reconcile this schedule to Schedules V and VI.) All required classifications of revenue and expense must be provided on this form, even if financial statements are attached. Note: This schedule should show gross revenue and expenses. Do not net revenue against expense

1 2I. Revenue Amount II. Expenses Amount

A. Inpatient Care A. Operating Expenses1 Gross Revenue -- All Levels of Care $ 2,481,454 1 31 General Services 471,057 312 Discounts and Allowances for all Levels 798,533 2 32 Health Care 1,158,825 323 SUBTOTAL Inpatient Care (line 1 minus line 2) $ 3,279,987 3 33 General Administration 1,104,619 33

B. Ancillary Revenue B. Capital Expense4 Day Care 4 34 Ownership 342,182 345 Other Care for Outpatients 5 C. Ancillary Expense6 Therapy 115,155 6 35 Special Cost Centers 493,901 357 Oxygen 2,304 7 36 Provider Participation Fee 144,248 368 SUBTOTAL Ancillary Revenue (lines 4 thru 7) $ 117,459 8 D. Other Expenses (specify):

C. Other Operating Revenue 37 379 Payments for Education 9 38 38

10 Other Government Grants 10 39 3911 CNA Training Reimbursements 1112 Gift and Coffee Shop 12 40 TOTAL EXPENSES (sum of lines 31 thru 39)* $ 3,714,832 4013 Barber and Beauty Care 1314 Non-Patient Meals 14 41 Income before Income Taxes (line 30 minus line 40)** (293,035) 4115 Telephone, Television and Radio 1516 Rental of Facility Space 16 42 Income Taxes 4217 Sale of Drugs 16,537 1718 Sale of Supplies to Non-Patients 18 43 NET INCOME OR LOSS FOR THE YEAR (line 41 minus line 42) $ (293,035) 4319 Laboratory 1920 Radiology and X-Ray 78 20 III. Net Inpatient Revenue detailed by Payer Source21 Other Medical Services 2,150 21 44 Medicaid - Net Inpatient Revenue $ 849,154 4422 Laundry 22 45 Private Pay - Net Inpatient Revenue 1,016,941 4523 SUBTOTAL Other Operating Revenue (lines 9 thru 22) $ 18,765 23 46 Medicare - Net Inpatient Revenue 1,138,670 46

D. Non-Operating Revenue 47 Other-(specify) HMO 270,749 4724 Contributions 24 48 Other-(specify) Hospice 4,473 4825 Interest and Other Investment Income*** 66 25 49 TOTAL Inpatient Care Revenue (This total must agree to Line 3) $ 3,279,987 4926 SUBTOTAL Non-Operating Revenue (lines 24 and 25) $ 66 26

E. Other Revenue (specify):**** * This must agree with page 4, line 45, column 4.27 Settlement Income (Insurance, Legal, Etc.) 27 ** Does this agree with taxable income (loss) per Federal Income28 See Supplemental Schedule 5,520 28 Tax Return? Not Complete If not, please attach a reconciliation.

28a 28a *** See the instructions. If this total amount has not been offset against interest29 SUBTOTAL Other Revenue (lines 27, 28 and 28a) $ 5,520 29 expense on Schedule V, line 32, please include a detailed explanation.

30 TOTAL REVENUE (sum of lines 3, 8, 23, 26 and 29) $ 3,421,797 30 ****Provide a detailed breakdown of "Other Revenue" on an attached sheet.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 20Facility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16XVIII. A. STAFFING AND SALARY COSTS (Please report each line separately.) (This schedule must cover the entire reporting period.) B. CONSULTANT SERVICES

1 2** 3 4 1 2 3# of Hrs. # of Hrs. Reporting Period Average Number Total Consultant Schedule VActually Paid and Total Salaries, Hourly of Hrs. Cost for Line &Worked Accrued Wages Wage Paid & Reporting Column

1 Director of Nursing 1,895 2,160 $ 73,788 $ 34.16 1 Accrued Period Reference2 Assistant Director of Nursing 2 35 Dietary Consultant 239 $ 11,258 01-03 353 Registered Nurses 4,948 5,589 153,630 27.49 3 36 Medical Director Monthly 22,000 09-03 364 Licensed Practical Nurses 16,467 18,045 391,493 21.70 4 37 Medical Records Consultant 16 2,040 10-03 375 CNAs & Orderlies 30,107 33,081 361,839 10.94 5 38 Nurse Consultant 386 CNA Trainees 6 39 Pharmacist Consultant Monthly 3,487 10-03 397 Licensed Therapist 7 40 Physical Therapy Consultant 408 Rehab/Therapy Aides 8 41 Occupational Therapy Consultant 419 Activity Director 479 512 5,994 11.71 9 42 Respiratory Therapy Consultant 42

10 Activity Assistants 1,331 1,438 15,617 10.86 10 43 Speech Therapy Consultant 4311 Social Service Workers 1,874 2,057 35,067 17.05 11 44 Activity Consultant 30 2,732 11-03 4412 Dietician 12 45 Social Service Consultant 30 2,232 12-03 4513 Food Service Supervisor 1,909 2,049 33,231 16.22 13 46 Other(specify) 4614 Head Cook 14 47 4715 Cook Helpers/Assistants 7,338 7,963 71,506 8.98 15 48 4816 Dishwashers 1617 Maintenance Workers 1,843 2,058 36,152 17.57 17 49 TOTAL (lines 35 - 48) 315 $ 43,749 4918 Housekeepers 3,228 3,566 44,534 12.49 1819 Laundry 3,359 3,664 30,670 8.37 1920 Administrator 1,289 1,492 59,111 39.62 2021 Assistant Administrator 21 C. CONTRACT NURSES22 Other Administrative 22 1 2 323 Office Manager 23 Number Schedule V24 Clerical 5,272 5,796 102,538 17.69 24 of Hrs. Total Line &25 Vocational Instruction 25 Paid & Contract Column26 Academic Instruction 26 Accrued Wages Reference27 Medical Director 27 50 Registered Nurses $ 5028 Qualified MR Prof. (QMRP) 28 51 Licensed Practical Nurses 5129 Resident Services Coordinator 29 52 Certified Nurse Assistants/Aides 5230 Habilitation Aides (DD Homes) 3031 Medical Records 419 460 5,370 11.67 31 53 TOTAL (lines 50 - 52) $ 5332 Other Health Care(specify) 3233 Other(specify) 1,094 1,190 15,442 12.98 3334 TOTAL (lines 1 - 33) 82,852 91,120 $ 1,435,982 * $ 15.76 34

* This total must agree with page 4, column 1, line 45. ** See instructions.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 21Facility Name & ID Number Hilltop Skilled Nsg & Rehab # 0051441 Report Period Beginning: 01/01/16 Ending: 12/31/16XIX. SUPPORT SCHEDULES A. Administrative Salaries Ownership D. Employee Benefits and Payroll Taxes F. Dues, Fees, Subscriptions and Promotions

Name Function % Amount Description Amount Description AmountAraceli Henson (1/1/16 - 6/13/16) Administrator 0 $ 28,767 Workers' Compensation Insurance $ 73,334 IDPH License Fee $ 1,975Emily Masulis (6/14/16 - 12/31/16) Administrator 0 30,344 Unemployment Compensation Insurance 38,683 Advertising: Employee Recruitment 2,038

FICA Taxes 107,228 Health Care Worker Background Check Employee Health Insurance 71,101 (Indicate # of checks performed ) Employee Meals Patient Background Checks Illinois Municipal Retirement Fund (IMRF)* Dues & Subscriptions 4,935Dental Insurance 234 Licenses & Permits 1,100

TOTAL (agree to Schedule V, line 17, col. 1) Vision Insurance 57 Allocated from Covenant Care California 671(List each licensed administrator separately.) $ 59,111 Other Employee Benefits 23,497B. Administrative - Other Group Life & Disability 1,815

Employee Physicals/X-Rays 1,778 Less: Public Relations Expense ( ) Description Amount Non-allowable advertising ( )Management Fees - Covenant Care California, LLC $ 188,106 Yellow page advertising ( )

TOTAL (agree to Schedule V, $ 317,726 TOTAL (agree to Sch. V, $ 10,719 line 22, col.8) line 20, col. 8)

TOTAL (agree to Schedule V, line 17, col. 3) $ 188,106 E. Schedule of Non-Cash Compensation Paid G. Schedule of Travel and Seminar**(Attach a

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