2023-08-11T16:16:48-05:00 2022-09-30 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2021-10-01 391412320 CAPITOL LAKES INC CAPI 8887246424 333 WEST MAIN STREET MADISON WI 53703 TIM CONROY EXECUTIVE DIRECTOR 8887246424 2023-08-10 1 TIM CONROY XXX-XX-XXXX KURT BENNION P01469618 4252506100 2023-08-10 3 AAL1 IAL1 2021 2023-04-26 12:10:37Z SUE CENTER 1 WEST MAIN SUITE 303 MEDFORD OR 97501 33924740 0 X WWW.RETIREMENT.ORG X 1990 WI TO PROVIDE CARE AND HOUSING FOR THE ELDERLY. 6 6 437 15 0 0 234440 2392786 21732097 21524631 71805 58041 16658 9914307 22055000 33889765 0 0 0 0 11384875 12365530 0 0 0 11518904 12619062 22903779 24984592 -848779 8905173 43454270 43546740 101839342 93765208 -58385072 -50218468 CAPITOL LAKES IS A VIBRANT CONTINUING CARE RETIREMENT COMMUNITY COMMITTED TO THE ENRICHMENT OF RESIDENTS' LIVES. 0 0 20019635 0 21524631 CAPITOL LAKES IS A CONTINUING CARE RETIREMENT COMMUNITY, DEDICATED TO ENHANCING OUR RESIDENTS' QUALITY OF LIFE IN A STIMULATING, SECURE ENVIRONMENT. WE PROVIDE HIGH-QUALITY SERVICES INCLUDING HOUSING, NUTRITIOUS MEALS, NURSING, HOUSEKEEPING, MAINTENANCE, AND OTHER SUPPORT TO THOSE WE SERVE. OUR LEVELS OF SERVICE INCLUDE INDEPENDENT LIVING, ASSISTED LIVING, AND SKILLED NURSING. 20019635 1 1 0 1 0 0 0 0 1 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 44 0 1 437 1 0 0 0 0 0 0 0 0 0 0 0 0 X 6 6 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X KATRINA BYWATER 5416463300 1 WEST MAIN SUITE 303 MEDFORD OR 97501 X X TIM CONROY EXECUTIVE DIRECTOR 40.00 1.00 X 256859 0 43313 KRISTIN VATER HEALTH CENTER ADMINISTRATOR 40.00 1.00 X 152109 0 17302 STEVEN MELLSTROM HR DIRECTOR 40.00 0.00 X 116291 0 26361 DAYLE TESSNER DIRECTOR OF NURSING 40.00 0.00 X 129725 0 10618 TSERING DAMDUL REGISTERED NURSE 40.00 0.00 X 106324 0 25179 SUE CENTER CHAIR 1.00 2.00 X X 0 0 0 CLAY NORRBOM VICE CHAIR 1.00 0.00 X X 0 0 0 SALLY DREW SECRETARY/TREASURER 1.00 0.00 X X 0 0 0 STEVE JOHANNSEN DIRECTOR 1.00 1.00 X 0 0 0 HARRY PETERSON DIRECTOR 1.00 0.00 X 0 0 0 PETE TAYLOR RESIDENT DIRECTOR 1.00 0.00 X 0 0 0 761308 0 122773 5 0 1 0 PACIFIC RETIREMENT SERVICES INC 1 WEST MAIN SUITE 303 MEDFORD OR 97501 MANAGEMENT SERVICES 1663299 CONSONUS REHAB PO BOX 4800 UNIT 12 PORTLAND OR 97208 THERAPY SERVICES 1112499 MCGANN CONSTRUCTION INC 3622 LEXINGTON AVENUE MADISON WI 53714 CONSTRUCTION SERVICES 595360 HOMETOWN LONG-TERM CARE PHARMACY LLC 1571 IVORY DRIVE SUN PRAIRIE WI 53590 PHARMACY SERVICES 508013 SENIOR CARE SOLUTIONS 2131 OAK GLEN TRAIL STILLWATER MN 55082 STAFFING SERVICES 151596 5 67200 2159805 165781 2392786 SERVICE FEES 623000 11773958 11773958 HEALTH CENTER 623000 7337131 7337131 ENTRANCE FEES 623000 1552260 1552260 HOME CARE 623000 281811 281811 DIETARY 623000 178939 178939 400532 400532 21524631 93013 93013 3 3 17158 0 17158 17158 17158 29581 5394 -29581 -5394 -34975 -34975 GAIN ON REFINANCING 900099 9897149 9897149 9897149 33889765 21524631 0 9972348 291902 291902 9887704 8874226 1013478 409896 346409 63487 1011414 900031 111383 764614 672498 92116 1826082 1826082 8057 8057 24107 24107 5471 5471 1166991 667602 499389 186456 186456 886474 772915 113559 240701 240701 1587798 1585003 2795 105926 34399 71527 59738 40523 19215 673806 673806 2477824 2477824 205004 205004 HEALTH CENTER EXPENSE 1542576 1542576 OTHER DIETARY EXPENSE 938931 938931 OTHER FACILITY SERVICE 494320 99088 395232 PROGRAM FUND EXPENSES 188800 188800 24984592 20019635 4964957 0 5175147 5566464 608196 1677292 862169 112619 115297 380767 542172 71024690 40289016 32510784 30735674 2764650 4362204 833011 754564 43454270 43546740 2350862 2751256 9547129 10074113 32945386 637132 625075 43912946 45391273 47369378 101839342 93765208 X -59278106 -51008170 893034 789702 -58385072 -50218468 43454270 43546740 X 8905173 -659926 -78643 X 0 1 X 1 0 X 208344 207383 258965 234440 2392786 3301918 21870492 22577973 21500974 21732097 21524631 109206167 22078836 22785356 21759939 21966537 23917417 112508085 0 0 0 112508085 64206 97996 73154 72645 110174 418175 64206 97996 73154 72645 110174 418175 9897149 9897149 22143042 22883352 21833093 22039182 33924740 122823409 0.91600 0.99670 0.00340 0.00330 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: GAIN ON REFINANCING RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 24984592 24984592 1000000 250000 0 0 1000000 1000000 1000000 1000000 4000000 6000000 250000 250000 250000 250000 1000000 1500000 0 1 X 8537600 8537600 57983279 37147397 20835882 4203247 3141619 1061628 300564 300564 30735674 DUE TO AFFILIATES 4313628 OTHER CURRENT LIABILITIES 12348 ENTRANCE FEES REFUNDABLE UPON REOCCUPANCY 43043402 47369378 X PART IV, LINE 2B: RESIDENT SECURITY DEPOSITS ARE HELD IN A SEPARATE BANK ACCOUNT. WHEN THE RESIDENT LEAVES THE FACILITY THE SECURITY DEPOSIT, MINUS ANY AMOUNTS RETAINED FOR REPAIRS, IS REFUNDED. PART X, LINE 2: THE CORPORATION RECOGNIZES THE TAX BENEFIT FROM UNCERTAIN TAX POSITIONS ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITIONS WILL BE SUSTAINED ON EXAMINATION BY THE TAX AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE TAX BENEFIT IS MEASURED BASED ON THE LARGEST BENEFIT THAT HAS A GREATER THAN 50% LIKELIHOOD OF BEING REALIZED UPON ULTIMATE SETTLEMENT. THE CORPORATION RECOGNIZES INTEREST AND PENALTIES RELATED TO INCOME TAX MATTERS IN OPERATING EXPENSES. AT SEPTEMBER 30, 2022 AND 2021, THERE WERE NO SUCH UNCERTAIN TAX POSITIONS. 0 0 0 0 0 0 0 1 0 TIM CONROY EXECUTIVE DIRECTOR 217393 0 39466 0 0 0 10949 0 32364 0 300172 0 0 0 KRISTIN VATER HEALTH CENTER ADMINISTRATOR 139346 0 12763 0 0 0 6072 0 11230 0 169411 0 0 0 PART I, LINE 3 COMPENSATION WAS DETERMINED BY PACIFIC RETIREMENT SERVICES, INC., A RELATED ORGANIZATION, THAT USED ONE OR MORE OF THE METHODS DESCRIBED ON LINE 3 TO ESTABLISH COMPENSATION. PART I, LINE 7 THE ORGANIZATION PAID BONUSES THIS YEAR. THE PROCESS FOR DETERMINING EXECUTIVE BONUSES IS DISCRETIONARY. IT IS DETERMINED BY THE VP OF OPERATIONS FOR PRS AND IT IS BASED ON THE PERFORMANCE OF THE COMMUNITY FOR THE YEAR. A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97712JFS7 2022-05-26 33880000 SEE PART VI 0 0 0 A 33880000 659600 18000 465 1 0 0 1 A 0 1 1 1 0 0.01800 0.00000 0.01800 0 0 1 A 0 1 1 0 1 0 0 0 1 A 1 PART I, COLUMN F: BOND PROCEEDS WERE ISSUED TO REFUND A PRIOR LOAN ISSUED ON NOVEMBER 30, 2016. PART II, LINE 13: BECAUSE THE BONDS WERE ISSUED FOR A CURRENT REFUNDING PURPOSE, A SUBSTANTIAL COMPLETION DATE IS NOT APPLICABLE. PART III, LINE 7: AS PROVIDED IN TREASURY REGULATION SECTION 1.141-4(C)(2)(I)(B), THE AMOUNT OF PRIVATE PAYMENTS TAKEN INTO ACCOUNT UNDER THE PRIVATE SECURITY OR PAYMENT TEST MAY NOT EXCEED THE AMOUNT OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS USE. ACCORDINGLY, THE AMOUNT OF PRIVATE PAYMENTS FOR THE REPORTING PERIOD DOES NOT EXCEED THE AMOUNT STATED IN PART III, LINE 6. THE ORGANIZATION HAS NOT UNDERTAKEN AN ANALYSIS OF THE PRIVATE SECURITY OR PAYMENT TEST WITH RESPECT TO THE BONDS, AS THE LEVEL OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS USE REPORTED IN PART III, LINE 6 IS NOT IN EXCESS OF AMOUNTS PERMITTED UNDER SECTION 145 OF THE CODE. FORM 990, PART VI, SECTION A, LINE 3 CAPITOL LAKES, INC. DELEGATES MANAGEMENT DUTIES TO PACIFIC RETIREMENT SERVICES, INC. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS ONE MEMBER, PACIFIC RETIREMENT SERVICES, INC. FORM 990, PART VI, SECTION A, LINE 7A PACIFIC RETIREMENT SERVICES, INC. HAS THE RIGHT TO ELECT THE DIRECTORS OF THE BOARD OF CAPITOL LAKES, INC. FORM 990, PART VI, SECTION A, LINE 7B THE AUTHORITY OF THE BOARD OF DIRECTORS TO EXERCISE THE FOLLOWING POWERS IS CONDITIONED UPON THE APPROVAL OF THE CORPORATE MEMBER: (A) MERGER, CONSOLIDATION OR DISSOLUTION OF THE ORGANIZATION; (B) AMENDMENT OR RESTATEMENT OF THE ARTICLES OF INCORPORATION OF THE ORGANIZATION; (C) SALE, LEASE, EXCHANGE, OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL THE PROPERTY AND ASSETS OF THE ORGANIZATION; (D) THE ESTABLISHMENT, FORMATION, ACQUISITION, MERGER, CONSOLIDATION OR DISSOLUTION OF ANY SUBSIDIARY ORGANIZATION; (E) THE ADOPTION OF THE AGGREGATE ANNUAL OPERATING AND CAPITAL BUDGETS OF THE ORGANIZATION; (F) AGGREGATE BORROWING FOR PERIODS OF ONE (1) YEAR OR LESS FOR ANY PURPOSE IN EXCESS OF A DOLLAR AMOUNT TO BE ESTABLISHED BY THE MEMBER FROM TIME TO TIME; AND AGGREGATE BORROWING FOR PERIODS OF MORE THAN ONE (1) YEAR FOR ANY PURPOSE IN EXCESS OF A DOLLAR AMOUNT TO BE ESTABLISHED BY THE MEMBER FROM TIME TO TIME; (G) THE PURCHASE, SALE, LEASE DISPOSITION HYPOTHECATION, EXCHANGE, GIFT, PLEDGE, AND ENCUMBRANCE OF ANY ASSET, REAL OR PERSONAL, WITH A VALUE IN EXCESS OF A DOLLAR AMOUNT TO BE ESTABLISHED BY THE MEMBER FROM TIME TO TIME, NOT PREVIOUSLY INCLUDED IN THE CAPITAL BUDGET; (H) THE APPOINTMENT OF AN INDEPENDENT AUDITOR; (I) GIFTS OR GRATUITOUS TRANSFERS IN EXCESS OF $5,000 IN A CALENDAR YEAR; (J) ADOPTION OR REVISION OF THE MISSION STATEMENT AND LONG RANGE PLANS; AND (K) INCUR ANY DEBT OR ENTER INTO ANY CONTRACT NOT CONTEMPLATED BY THE ANNUAL BUDGET IF THE DOLLAR AMOUNT EXCEEDS THE SUM OF $100,000. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS REVIEWED BY THE DIRECTOR OF FINANCE, CFO AND THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY AND QUESTIONNAIRE ARE SENT TO ALL BOARD MEMBERS AND KEY EMPLOYEES ANNUALLY. THERE ARE TWO POLICIES RELATED TO CONFLICTS OF INTEREST: 1) BOARD OF DIRECTORS; 2)KEY EMPLOYEES, WHICH IDENTIFY THE PURPOSE, DEFINITIONS, AND PROCEDURES. IF A CONFLICT IS SELF-IDENTIFIED BY A BOARD MEMBER OR KEY EMPLOYEE IN THE QUESTIONNAIRE AND/OR MEETING, PROCEDURES ARE FOLLOWED AND DOCUMENTED ACCORDING TO THE POLICY. FORM 990, PART VI, SECTION B, LINE 15A A COMPENSATION COMMITTEE OF THE PRS BOARD EXISTS TO DETERMINE COMPENSATION FOR THE EXECUTIVE DIRECTOR OF EACH COMMUNITY. THIS COMMITTEE IS COMPRISED OF THE OFFICERS OF THE PRS BOARD OF DIRECTORS. THE COMMITTEE HAS A CHARTER THAT OUTLINES ITS DUTIES AND RESPONSIBILITIES. IT ALSO HAS AGENDA ELEMENTS THAT DESCRIBE THE ACTIVITIES THAT THE COMMITTEE UNDERTAKES DURING THE YEAR. THE VP OF HUMAN RESOURCES PROVIDED SALARY STUDIES FROM THE FOLLOWING RESOURCES TO THE COMMITTEE RELATIVE TO EXECUTIVE DIRECTOR COMPENSATION: SALARY.COM, PAYSCALE.COM, 990 REVIEW (LIKE SIZE ORGANIZATIONS), CEMO (CHIEF EXECUTIVE OFFICERS OF MULTI-FACILITY ORGANIZATIONS) SALARY STUDY RESULTS, AND INDUSTRY STATE ASSOCIATION SALARY STUDY RESULTS BASED ON GEOGRAPHICAL LOCATION. THE RECOMMENDATION FOR BASE COMPENSATION AND BONUS ARE PROVIDED BY THE EXECUTIVE DIRECTOR'S DIRECT SUPERVISOR (COO OR VP OF OPERATIONS). FORM 990, PART VI, SECTION C, LINE 19 ALL REQUESTS GO THROUGH CORPORATE COUNSEL. FORM 990, PART VII, SECTION A: NOTE THAT TIM CONROY AND KRISTIN VATER ARE LEASED EMPLOYEES OF PACIFIC RETIREMENT SERVICES, INC. AND PERFORM SERVICES ON BEHALF OF CAPITOL LAKES, INC. PURSUANT TO A MANAGEMENT SERVICES AGREEMENT BETWEEN CAPITOL LAKES, INC. AND PACIFIC RETIREMENT SERVICES, INC. UNDER THE MANAGEMENT SERVICES AGREEMENT, THEIR COMPENSATION IS REIMBURSED BY CAPITOL LAKES, INC. COMPENSATION HAS BEEN REPORTED IN PART VII, SECTION A IN ORDER TO HIGHLIGHT AMOUNTS PAID BY CAPITOL LAKES, INC., NOTWITHSTANDING THAT THEY ARE LEASED EMPLOYEES OF PACIFIC RETIREMENT SERVICES, INC. FORM 990, PART XI, LINE 9: CHANGES IN INTEREST IN NET ASSETS OF FOUNDATION -78,447. NON OPERATING - MANAGEMENT FEES -196. PACIFIC RETIREMENT SERVICES INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 931067253 SUPPORTING ORGANIZATION OR 501(C)(3) LINE 12C, III-FI N/A 0 PACIFIC RETIREMENT SERVICES FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 472352652 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 PACIFIC RETIREMENT SERVICES INC 0 ROGUE VALLEY MANOR 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930453216 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 THE CUMBERLAND REST INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 750891470 SENIOR HOUSING TX 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 CASCADE MANOR INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930557803 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 UNIVERSITY RETIREMENT COMMUNITY AT DAVIS 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 931179254 SENIOR HOUSING CA 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 HOLLADAY PARK PLAZA 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930513697 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 ROGUE VALLEY MANOR FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930712867 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 ROGUE VALLEY MANOR 0 UNIVERSITY RETIREMENT COMMUNITY FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 931301816 PUBLIC FOUNDATION CA 501(C)(3) LINE 7 UNIVERSITY RETIREMENT COMMUNITY AT DAVIS 0 MIRABELLA WASHINGTON FOUNDATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 450574348 PUBLIC FOUNDATION WA 501(C)(3) LINE 7 MIRABELLA 0 CASCADE MANOR FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 931330100 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 CASCADE MANOR INC 0 CAPITOL LAKES FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 383781089 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 CAPITOL LAKES INC 1 MIRABELLA 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 342030255 SENIOR HOUSING WA 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 MIRABELLA PORTLAND FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 452508860 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 MIRABELLA AT SOUTH WATERFRONT 0 MIRABELLA AT SOUTH WATERFRONT 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 711016384 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 COMMUNITY VOLUNTEER NETWORK 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930892261 COMMUNITY SERVICES OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 RVM HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930864466 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 RVM ASHLAND HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930942933 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 RVM GRANTS PASS HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 943136037 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 RVM ROSEBURG HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 943179782 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 RVM MYRTLE 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CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 300315618 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 RVM MANSFIELD HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 900292647 SENIOR HOUSING TX 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 MIDDLETON GLEN INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 911859494 SENIOR HOUSING WI 501(C)(3) LINE 10 CAPITOL LAKES INC 1 SENIOR HOUSING OF MIDDLETON INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 470825736 SENIOR HOUSING WI 501(C)(3) LINE 10 CAPITOL LAKES INC 1 MIRABELLA AT ASU INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 813784956 SENIOR HOUSING AZ 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 BAY AREA SENIOR SERVICES INC 1 BALDWIN AVE SAN MATEO CA 94401 943008774 SENIOR HOUSING CA 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 PRS MANAGEMENT 1 WEST MAIN SUITE 303 MEDFORD OR 97501 931328250 MANAGEMENT COMPANY OR N/A C 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0 CAPITOL LAKES FOUNDATION INC C 67200 CASH