On June 28, 2023 a
Exhibit,Appendix
was filed
involving a dispute between
People Of The State Of New York, By Letitia James, Attorney General Of The State Of New York,
and
Abraham Operations Associates Llc Dba Beth Abraham Center For Rehabilitation And Nursing,
Aharon Lantzitsky,
Amir Abramchik,
Aron Gittleson,
Beth Rozenberg,
Bis Funding Capital Llc,
Centers For Care Llc Dba Centers Health Care,
Cfsc Downstate Llc,
Daryl Hagler,
David Greenberg,
Delaware Operations Associates Llc Dba Buffalo Center For Rehabilitation And Nursing,
Delaware Real Property Associates Llc,
Elliot Kahan,
Hollis Operating Co Llc Dba Holliswood Center For Rehabilitation And Healthcare,
Hollis Real Estate Co Llc,
Jeffrey Sicklick,
Jonathan Hagler,
Kenneth Rozenberg,
Leo Lerner,
Light Property Holdings Ii Associates Llc,
Mordechai Moti Hellman,
Reuven Kaufman,
Schnur Operations Associates Llc Dba Martine Center For Rehabilitation And Nursing,
Skilled Staffing Llc,
Sol Blumenfeld,
for Commercial - Other - Commercial Division
in the District Court of New York County.
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FILED: NEW YORK COUNTY CLERK 06/28/2023 02:27 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 185 RECEIVED NYSCEF: 06/28/2023
BUDIMIR EXHIBIT 55D
FILED: NEW YORK COUNTY CLERK 06/28/2023 02:27 PM INDEX NO. 451549/2023
2/18/22, 8:54 AM Nursing Home Certification Submission System
NYSCEF DOC. NO. 185 RECEIVED NYSCEF: 06/28/2023
New York State Department of Health
Bureau of Long Term Care Reimbursement
Division of Finance and Rate Setting
Feb 18, 2022 8:54 AM
Back | Nursing Home Cost Report >> Nursing Home Certification Submission System
Nursing Home Certification Submission System
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH SYSTEMS MANAGEMENT
RHCF-4 (4/06) DOH-490
FACILITY: HOLLISWOOD CENTER FOR REHABILITATION
OPERATING CERTIFICATE NUMBER: 7003409N
REPORT FOR THE PERIOD ENDED: 12/31/2020
DECLARATION CONTROL NUMBER (DCN): 12301510
Operators Certification
The following statement must be read and a certification of such be signed pursuant to Part 86-2.6(a). This subpart states "The Financial
and statistical reports shall be certified by the operator of a proprietary medical facility, an officer of a voluntary facility or the public
official responsible for the operation of a public medical facility". Please enter only one signature.
Certification Statement
Misrepresentation or falsification of any information contained on this form may be punishable by fine and / or imprisonment under New
York State Law and Federal Law.
Certification of Operator
I hereby certify that I am the Operator and have read the above statement and I have examined and compared the information contained
in the RHCF -4 report file with the information provided in my electronically transmitted Department of Health file, DCN identified above,
and that to the best of my knowledge and belief, they are true and complete and that these files are identical.
I also certify that Parts I and II were completed in accordance with the RHCF - 4 instructions and that Part IV was completed in
accordance with the residential Health Care Facility Accounting and Reporting Manual (RHCFARM). I also certify, the Part(s) III, if
required to be filed as part of this report, was (were) completed in accordance with RHCFARM and the information called for in Part III
has been reported for each lender or organization related to the provider as defined in Schedule 16 of Part II.
I also certify that all salary and non-salary expenses presented in the RHCF - 4 (with the exception of those expenses attributable to
Research, Physicians Offices and other Rentals, Gift Shop, Public Restaurant, Fund Raising and Sold Services) considering the
adjustments contained in the Part II and the recoveries of expense detailed in Exhibit I of the Part IV were incurred to provide patient
care in the facility.
AUG 19 2021 05:47:12 PM kr305547
Date Signature
KENNETH ROZENBERG
Operator
DOH 490 (4/06)
* * * * End of Certification * * * *
DCN 12301510 was previously certified by HCS ID kr305547,
https://commerce.health.state.ny.us/hpn/cgi-bin/applinks/rhcfr/cert4.cgi 1/2
FILED: NEW YORK COUNTY CLERK 06/28/2023 02:27 PM INDEX NO. 451549/2023
2/18/22, 8:54 AM Nursing Home Certification Submission System
NYSCEF DOC. NO. 185 RECEIVED NYSCEF: 06/28/2023
KENNETH ROZENBERG , Operator for HOLLISWOOD CENTER FOR REHABILITATION.
Continue
Nursing Home Cost Report Main Page
https://commerce.health.state.ny.us/hpn/cgi-bin/applinks/rhcfr/cert4.cgi 2/2
Document Filed Date
June 28, 2023
Case Filing Date
June 28, 2023
Category
Commercial - Other - Commercial Division
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FILED: NEW YORK COUNTY CLERK 06/28/2023 02:27 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 185 RECEIVED NYSCEF: 06/28/2023 BUDIMIR EXHIBIT 55D FILED: NEW YORK COUNTY CLERK 06/28/2023 02:27 PM INDEX NO. 451549/2023 2/18/22, 8:54 AM Nursing Home Certification Submission System NYSCEF DOC. NO. 185 RECEIVED NYSCEF: 06/28/2023 New York State Department of Health Bureau of Long Term Care Reimbursement Division of Finance and Rate Setting Feb 18, 2022 8:54 AM Back | Nursing Home Cost Report >> Nursing Home Certification Submission System Nursing Home Certification Submission System NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH SYSTEMS MANAGEMENT RHCF-4 (4/06) DOH-490 FACILITY: HOLLISWOOD CENTER FOR REHABILITATION OPERATING CERTIFICATE NUMBER: 7003409N REPORT FOR THE PERIOD ENDED: 12/31/2020 DECLARATION CONTROL NUMBER (DCN): 12301510 Operators Certification The following statement must be read and a certification of such be signed pursuant to Part 86-2.6(a). This subpart states "The Financial and statistical reports shall be certified by the operator of a proprietary medical facility, an officer of a voluntary facility or the public official responsible for the operation of a public medical facility". Please enter only one signature. Certification Statement Misrepresentation or falsification of any information contained on this form may be punishable by fine and / or imprisonment under New York State Law and Federal Law. Certification of Operator I hereby certify that I am the Operator and have read the above statement and I have examined and compared the information contained in the RHCF -4 report file with the information provided in my electronically transmitted Department of Health file, DCN identified above, and that to the best of my knowledge and belief, they are true and complete and that these files are identical. I also certify that Parts I and II were completed in accordance with the RHCF - 4 instructions and that Part IV was completed in accordance with the residential Health Care Facility Accounting and Reporting Manual (RHCFARM). I also certify, the Part(s) III, if required to be filed as part of this report, was (were) completed in accordance with RHCFARM and the information called for in Part III has been reported for each lender or organization related to the provider as defined in Schedule 16 of Part II. I also certify that all salary and non-salary expenses presented in the RHCF - 4 (with the exception of those expenses attributable to Research, Physicians Offices and other Rentals, Gift Shop, Public Restaurant, Fund Raising and Sold Services) considering the adjustments contained in the Part II and the recoveries of expense detailed in Exhibit I of the Part IV were incurred to provide patient care in the facility. AUG 19 2021 05:47:12 PM kr305547 Date Signature KENNETH ROZENBERG Operator DOH 490 (4/06) * * * * End of Certification * * * * DCN 12301510 was previously certified by HCS ID kr305547, https://commerce.health.state.ny.us/hpn/cgi-bin/applinks/rhcfr/cert4.cgi 1/2 FILED: NEW YORK COUNTY CLERK 06/28/2023 02:27 PM INDEX NO. 451549/2023 2/18/22, 8:54 AM Nursing Home Certification Submission System NYSCEF DOC. NO. 185 RECEIVED NYSCEF: 06/28/2023 KENNETH ROZENBERG , Operator for HOLLISWOOD CENTER FOR REHABILITATION. Continue Nursing Home Cost Report Main Page https://commerce.health.state.ny.us/hpn/cgi-bin/applinks/rhcfr/cert4.cgi 2/2