2023-11-15T15:26:11-06:00 2022-12-31 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2022-01-01 990073521 PALOLO CHINESE HOME PALO 8087372555 2459 10TH AVENUE HONOLULU HI 96816 DARLENE NAKAYAMA CHIEF EXECUTIVE OFFICER 8087372555 2023-11-13 1 DARLENE NAKAYAMA 999009999 1 KURT BENNION CPA P01469618 4252506100 2023-10-31 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z DARLENE NAKAYAMA 2459 10TH AVENUE HONOLULU HI 96816 18169233 0 X WWW.PALOLOHOME.ORG X 1920 HI TO EDUCATE, SUPPORT AND CARE FOR SENIORS AND THEIR FAMILIES BY PROVIDING A CONTINUUM OF QUALITY CARE. 24 23 277 90 0 0 3171734 342562 16937762 17707100 77188 61406 109274 312 20295958 18111380 2400 0 0 0 10995230 10915809 0 0 102570 7667344 10269685 18664974 21185494 1630984 -3074114 34098800 30648968 7410810 7450419 26687990 23198549 X TO EDUCATE, SUPPORT, AND CARE FOR SENIORS AND THEIR FAMILIES BY PROVIDING A CONTINUUM OF QUALITY CARE IN A CULTURALLY SENSITIVE FAMILY SETTING. 0 0 12167472 0 14643000 ICF/SNF - PALOLO CHINESE HOME IS LICENSED AS AN ICF/SNF UNIT AND PROVIDES 113 NURSING HOME BEDS TO ELDERLY RESIDENTS, REGARDLESS OF RACE. 938891 0 1110058 ADULT RESIDENTIAL HOME - PALOLO CHINESE HOME IS LICENSED AS AN ADULT RESIDENTIAL CARE HOME TYPE II FACILITY (EARCH II) THAT HOUSES 18 ELDERLY RESIDENTS, REGARDLESS OF RACE. 442952 0 640580 ADULT DAY CARE - PALOLO CHINESE HOME IS LICENSED AS AN ADULT DAY CARE CENTER FOR 40 ELDERLY PARTICIPANTS, REGARDLESS OF RACE. 4707810 0 1313462 OTHER PROGRAM SERVICES INCLUDE COMMUNITY OUTREACH PROGRAMS SUCH AS MEALS HOME DELIVERY, HOME CLEANING, COMPANIONSHIP, PERSONAL CARE AND CATERING. 4707810 0 1313462 18257125 1 1 0 0 0 0 0 0 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 55 0 277 1 0 0 0 0 0 1 1 0 0 0 0 0 0 X 24 23 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 HI X BRANDON TRAN 8085645228 2459 10TH AVENUE HONOLULU HI 96816 DARLENE NAKAYAMA CEO 60.00 X 249300 0 15622 PAULINE NNAWUBA CHIEF OPERATING OFFICER (THROUGH SEP 2022) 40.00 X 177627 0 4881 AGNES DE LOS REYES REGISTERED NURSE 40.00 X 114988 0 10055 JASMINE XU REGISTERED NURSE 40.00 X 104828 0 10844 JAMIE SUZUKI REGISTERED NURSE 40.00 X 111179 0 4447 JUAN GONZALEZ DIRECTOR OF NURSING 40.00 X 100638 0 10764 PATRICIA BLANCHETTE MD MPH SECRETARY & MEDICAL DIRECTOR 4.00 X X 36000 0 0 PETER FONG ESQ CHAIR/PRESIDENT 2.00 X X 0 0 0 RENA HWANG 1ST VICE PRESIDENT 2.00 X X 0 0 0 ELVIRA LO 2ND VICE PRESIDENT 2.00 X X 0 0 0 ISOO OSHIMA CPA TREASURER 2.00 X X 0 0 0 GORDON AU DIRECTOR 2.00 X 0 0 0 PETER BACKUS CPA DIRECTOR 2.00 X 0 0 0 ANTHONY CHING DIRECTOR 2.00 X 0 0 0 ANDREW FONG MD DIRECTOR 2.00 X 0 0 0 FRANCES GOO BOARD REPRESENTATIVE 2.00 X 0 0 0 RUSSELL LAU DIRECTOR 2.00 X 0 0 0 GLADYS LEE DIRECTOR 2.00 X 0 0 0 ROGER LIU CPA DIRECTOR 2.00 X 0 0 0 ANDREW MOATS DIRECTOR 2.00 X 0 0 0 JEFFREY SCHMIDT ESQ DIRECTOR 2.00 X 0 0 0 GARY SIMON DIRECTOR 2.00 X 0 0 0 DOUGLAS SMITH ESQ IMMEDIATE PAST CHAIR/PRESIDENT 2.00 X 0 0 0 SANDRA SOUZA DIRECTOR 2.00 X 0 0 0 TYLER TOKIOKA DIRECTOR 2.00 X 0 0 0 LAWRENCE TSEU DDS DIRECTOR 2.00 X 0 0 0 ERIC WATANABE DIRECTOR 2.00 X 0 0 0 STACEY WONG DIRECTOR 2.00 X 0 0 0 BENJAMIN WOO DIRECTOR 2.00 X 0 0 0 REGINALD YEE ESQ DIRECTOR 2.00 X 0 0 0 894560 0 56613 6 0 1 0 PROLINK STAFFING 4600 MONTGOMERY ROAD SUITE 300 CINCINNATI OH 45212 STAFFING SERVICES 1002288 TRAVEL CARE HAWAII 610 NEWPORT CENTER DRIVE STE 1250 NEWPORT BEACH CA 92660 STAFFING SERVICES 770749 GENESIS ELDERCARE REHABILITATION PO BOX 821322 PHILADELPHIA PA 19182 REHABILITATION THERAPY 482011 EXPRESS EMPLOYMENT PROFESSIONALS 1130 N NIMITZ HWY STE A135 HONOLULU HI 96817 STAFFING SERVICES 372909 KAHU MALAMA NURSES 1357 KAPIOLANI BLVD SUITE 915 HONOLULU HI 96814 STAFFING SERVICES 257465 9 21098 18925 302539 342562 ICF/SNF UNIT AND NURSING HOME 623000 14643000 14643000 OTHER - COMM. OUTREACH, ETC. 624200 1313462 1313462 ADULT RESIDENTIAL CARE HOME 623000 1110058 1110058 ADULT DAY CARE CENTER 621400 640580 640580 17707100 56730 56730 89160 29905 59255 59255 59255 5090 0 414 5090 -414 4676 4676 16340 18925 27534 -11194 -11194 MISCELLANEOUS REVENUE 900099 18476 18476 CHANGE IN VALUE OF PERM TRUST 900099 -66225 -66225 -47749 18111380 17707100 0 61718 X 285300 36000 199440 49860 8625817 7772437 836210 17170 198171 173826 20461 3884 1130569 984146 140151 6272 675952 599190 73177 3585 89637 89637 238090 238090 21845 17233 4612 4675994 4034724 641270 137225 137225 40711 23516 13541 3654 183561 145411 37161 989 499744 483495 15216 1033 25208 21729 3479 11095 1080 10015 181160 181160 1072391 938419 128355 5617 233337 214787 15117 3433 NURSING AND DIETARY SUP 1676172 1676172 MISCELLANEOUS EXPENSE 571559 542352 26746 2461 REPAIRS AND MAINTENANCE 390689 388574 2115 BAD DEBTS 221267 221267 21185494 18257125 2825799 102570 1853933 411910 3241951 1614119 43198 14695 2137829 3206700 167483 143619 217866 203022 36750953 13883848 23831668 22867105 2251551 1900702 349321 283096 4000 4000 34098800 30648968 1170774 1565673 69044 64372 500 500 6170492 5819874 7410810 7450419 X 25822385 22437448 865605 761101 26687990 23198549 34098800 30648968 -3074114 -415327 0 X 0 1 X 1 0 X 500056 457023 788531 3171734 342562 5259906 500056 457023 788531 3171734 342562 5259906 178014 5081892 128921 191920 145480 152173 145890 764384 20538 29654 2791 18674 34816 106473 6130763 85715864 0.82890 0.84070 X SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: OTHER INCOME SPECIAL FUNDRAISING EVENT PROCEEDS RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 521322 96790 79663 538449 439074 120100 54648 92500 521322 393294 19550 34130 7900 439074 223102 132875 42417 5100 393294 150929 93600 -17168 4259 223102 0.00000 1.00000 0.00000 0 0 395050 395050 28908830 9343546 19565284 1911553 1911553 5368740 4540302 828438 166780 166780 22867105 X 17992346 124078 124078 17868268 21845 221267 243112 18111380 20999821 57439 57439 20942382 21845 221267 243112 21185494 PART IV, LINE 2B: THE ORGANIZATION HOLDS SECURITY DEPOSITS FOR TWO COMPANIES LEASING SPACE. THE TENANT'S SECURITY DEPOSIT IS REFUNDED UPON TERMINATION OF THE LEASE, LESS ANY REPAIRS AND MAINTENANCE. PART V, LINE 4: EARNINGS FROM THE ENDOWMENT FUNDS ARE USED TO SUPPLEMENT THE OPERATIONS OF THE HOME'S PROGRAMS IN ACCORDANCE WITH THE HOME'S MISSION STATEMENT. PART X, LINE 2: THE HOME IS EXEMPT FROM FEDERAL AND STATE INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND COMPARABLE STATE LAW. ACCORDINGLY, NO PROVISION HAS BEEN MADE FOR FEDERAL INCOME TAX IN THE ACCOMPANYING FINANCIAL STATEMENTS. MANAGEMENT EVALUATED THE HOME'S TAX POSITIONS AND CONCLUDED THAT THE HOME HAD TAKEN NO UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENTS TO THE FINANCIAL STATEMENTS TO COMPLY WITH THE PROVISIONS OF TOPIC 740 OF THE ACCOUNTING STANDARDS CODIFICATION. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 29,905. LOSS ON ASSET DISPOSAL 414. CHANGE IN VALUE OF PERMANENT TRUST 66,225. FUNDRAISING EVENT EXPENSES 27,534. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 221,267. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 29,905. FUNDRAISING EVENT EXPENSES 27,534. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 221,267. GOLF TOURNAMENT 35265 18925 16340 9004 5966 10389 90 2085 35265 18925 16340 9004 5966 10389 90 2085 27534 -11194 X 1 1 X X X X 0 0 0 0 0 0 0 0 0 DARLENE NAKAYAMA CEO 249300 0 0 0 0 0 10049 0 5573 0 264922 0 0 0 PAULINE NNAWUBA CHIEF OPERATING OFFICER (THROUGH SEP 2022) 177627 0 0 0 0 0 0 0 4881 0 182508 0 0 0 PART I, LINE 1A THE ORGANIZATION PROVIDES GROSS-UP PAYMENTS FOR THE ANNIVERSARY AWARDS AND EMPLOYEE OF THE YEAR AWARDS GIVEN TO EMPLOYEES, WHICH MAY INCLUDE EMPLOYEES LISTED IN FORM 990, PART VII, SECTION A. THESE GROSS-UP PAYMENTS ARE INCLUDED IN TAXABLE COMPENSATION. FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE IS COMPRISED OF THE CHIEF EXECUTIVE OFFICER, THE OFFICERS OF THE BOARD, THE IMMEDIATE PAST PRESIDENT, AND ONE OTHER DIRECTOR ELECTED BY THE BOARD OF DIRECTORS. ALL ACTIONS TAKEN BY THE EXECUTIVE COMMITTEE ARE SUBJECT TO RATIFICATION BY THE BOARD OF DIRECTORS. A MAJORITY OF THE MEMBERS OF THE EXECUTIVE COMMITTEE CONSTITUES A QUORUM TO TRANSACT BUSINESS, AND THE MAJORITY APPROVAL OF SUCH QUORUM ON ANY MATTER IS DEEMED VALID AND BINDING. FORM 990, PART VI, SECTION A, LINE 1A PATRICIA BLANCHETTE, MD IS A DIRECTOR AND IS ALSO THE MEDICAL DIRECTOR FOR PALOLO CHINESE HOME. SHE IS COMPENSATED FOR HER WORK AS MEDICAL DIRECTOR BUT HER POSITION ON THE BOARD IS VOLUNTARY. SHE RECUSES HERSELF DURING BOARD MEETINGS ON ISSUES THAT MAY CAUSE A POTENTIAL CONFLICT OF INTEREST (ONLY WHEN IT RELATES TO HER DUTIES AS MEDICAL DIRECTOR). FORM 990, PART VI, SECTION A, LINE 2 PETER FONG, ESQ., AND ANDREW FONG, MD, BOARD MEMBERS, HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION B, LINE 11B THE BUSINESS OFFICE MANAGER REVIEWED THE FORM 990. THE EXECUTIVE COMMITTEE OF THE BOARD REVIEWED THE FORM 990 AND UPON APPROVAL MADE A RECOMMENDATION TO THE BOARD OF DIRECTORS FOR FINAL APPROVAL. THE BOARD OF DIRECTORS REVIEWED AND APPROVED THE FORM 990 BEFORE IT WAS FILED. FORM 990, PART VI, SECTION B, LINE 12C PALOLO CHINESE HOME HAS A WRITTEN CONFLICT OF INTEREST POLICY THAT WAS CREATED BY AND FOR DIRECTORS AND OFFICERS OF THE ORGANIZATION. IF IT IS UNCLEAR WHETHER A CONFLICT EXISTS, THE DETERMINATION IS MADE BY THE OFFICERS AND BOARD OF DIRECTORS. IF A CONFLICT EXISTS, THE DIRECTOR OR OFFICER ABSTAINS FROM VOTING ON THE MATTER. THE BOARD OF DIRECTORS HAS THE AUTHORITY TO REMOVE A BOARD MEMBER WHO KNOWINGLY AND INTENTIONALLY DOES NOT DISCLOSE A CONFLICT OF INTEREST. ANNUAL CONFLICT OF INTEREST QUESTIONNAIRES ARE REQUIRED TO BE COMPLETED AND SIGNED BY ALL DIRECTORS AND OFFICERS. FORM 990, PART VI, SECTION B, LINE 15 PALOLO CHINESE HOME REVIEWS ANNUAL COMPENSATION ADJUSTMENTS AT THE EXECUTIVE BOARD MEETING BY DISCUSSING APPROPRIATE COMPENSATION AMOUNTS IN LIGHT OF MARKET COMPARABLES. RECOMMENDATIONS ARE MADE TO THE BOARD OF DIRECTORS, WHO HAVE FINAL APPROVAL, AS WELL AS APPROVAL OVER ANY ADDITIONAL OR EXTRAORDINARY COMPENSATION. THIS PROCESS WAS LAST COMPLETED IN 2020. FORM 990, PART VI, SECTION C, LINE 19 PALOLO CHINESE HOME'S ORGANIZING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. PALOLO CHINESE HOME PUBLISHES AN ANNUAL REPORT CONTAINING FINANCIAL INFORMATION. THE ANNUAL REPORT IS AVAILABLE ON PALOLO CHINESE HOME'S WEBSITE. FORM 990, PART IX, LINE 11G OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 4,034,724. MANAGEMENT AND GENERAL EXPENSES 641,270. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,675,994. PCH MANAGEMENT LLC 2459 10TH AVENUE HONOLULU HI 96816 461019166 MANAGEMENT & CONSULTING HI 0 0 PALOLO CHINESE HOME PCH LANDHOLDING LLC 2459 10TH AVENUE HONOLULU HI 96816 462398671 REAL ESTATE HOLDING HI 0 0 PALOLO CHINESE HOME