2022-05-16T14:23:39-05:00 2021-06-30 910189318 MOSS ADAMS LLP 101 SECOND STREET SUITE 900 SAN FRANCISCO CA 94105 990 2020-07-01 680371679 PEACH TREE HEALTHCARE PEAC 5307493242 1114 YUBA STREET NO 220 MARYSVILLE CA 95901 JAMES ELLSWORTH CHIEF FINANCIAL OFFICER 5307493242 2022-05-13 1 JAMES ELLSWORTH 999009999 MICHAEL LUMSDEN P01262236 4159561500 2022-05-13 3 AAL1 IAL1 2020 2022-09-23 18:48:47Z GREG STONE 1114 YUBA STREET NO 220 MARYSVILLE CA 95901 32671880 0 X WWW.PICKPEACH.ORG X 1995 CA PEACH TREE HEALTH IS COMMITTED TO PROVIDING PERSONALIZED, AFFORDABLE, HIGH-QUALITY HEALTH SERVICES. 9 9 187 12 0 0 5090103 5294153 23092994 27312858 0 -30700 60039 60900 28243136 32637211 0 0 0 0 13309898 13504691 0 0 0 11967978 13903565 25277876 27408256 2965260 5228955 11668655 15991070 3545163 2638623 8123492 13352447 X PEACH TREE HEALTHCARE IS COMMITTED TO PROVIDING PERSONALIZED, AFFORDABLE, HIGH-QUALITY HEALTH SERVICES. 0 0 19481152 27312858 PEACH TREE HEALTHCARE IS A FEDERALLY QUALIFIED HEALTH CENTER (FQHC) OPERATING AT THE FOLLOWING LOCATIONS: THARP ROAD DENTAL CLINIC, LIVE OAK MEDICAL CLINIC (INCLUDING PEACH TREE VISION LIVE OAK), PEACH TREE - YUBA CITY/COLUSA, PEACH TREE CLINIC (INCLUDING PEACH TREE VISION LINDA), PEACH TREE OROVILLE EYE CENTER, PEACH TREE NORTH SACRAMENTO (INCLUDING PEACH TREE VISION NORTH SACRAMENTO AND SACRAMENTO IMMEDIATE CARE), AND PEACH TREE CHICO EYE CENTER. PEACH TREE HEALTHCARE PROVIDES PERSONALIZED, AFFORDABLE, HIGH-QUALITY HEALTH SERVICES INCLUDING DENTAL, VISION, BEHAVIORAL HEALTH, AND MEDICAL SPECIALTY SERVICES (FAMILY MEDICINE, PEDIATRICS, IMMEDIATE CARE, WOMEN'S HEALTH, ACUPUNCTURE, DIABETES, SPORTS PHYSICALS, NON-SURGERY ORTHOPEDICS, PHARMACY, AND PODIATRY). DURING THE JUNE 30, 2021 TAX YEAR 32,108 PATIENTS RECEIVED SERVICES AT OUR VARIOUS CLINICS. 19481152 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 39 0 1 187 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 CA X JAMES ELLSWORTH 5307493242 1114 YUBA STREET SUITE 220 MARYSVILLE CA 95901 TEJINDER GHUMAN MD PEDIATRICIAN 40.00 X 303003 0 20988 SUMIT JOHL MD PEDIATRICIAN 40.00 X 268995 0 20205 MARY PENA-PRIDEMORE MD PHYSICIAN 40.00 X 263036 0 13268 RAMESH PUNDI MD PHYSICIAN 40.00 X 231731 0 24286 AMANDA TAGLE MD PHYSICIAN 40.00 X 227973 0 23024 GREG STONE CHIEF EXECUTIVE OFFICER 40.00 X 205994 0 16211 RUPAUL GHUMAN DDS DENTAL DIRECTOR 40.00 X 194856 0 25379 RICHARD FURY MD CHIEF MEDICAL OFFICER 40.00 X 199930 0 3999 JAMES ELLSWORTH CHIEF FINANCIAL OFFICER 40.00 X 0 0 0 ED SMITH CHAIR THROUGH 7/2020 1.00 X X 0 0 0 ANDREW POTTER CHAIR START 7/2020 1.00 X X 0 0 0 ROBERTA D'ARCY VICE CHAIR THROUGH 7/2020 1.00 X X 0 0 0 JANE DALTON VICE CHAIR 7/2020 - 8/2020 1.00 X X 0 0 0 AWNI ALLABABIDI VICE CHAIR START 9/2020 1.00 X X 0 0 0 KIRAN SIBIA SECRETARY/TREASURER 1.00 X X 0 0 0 DON BLASER DIRECTOR 1.00 X 0 0 0 DAWN ESPARZA DIRECTOR 1.00 X 0 0 0 PHUONG LUU MD DIRECTOR 1.00 X 0 0 0 NAILAH KOKAYI DIRECTOR 1.00 X 0 0 0 ERICKA SUMMERS DIRECTOR 1.00 X 0 0 0 MATT WILLIAMS DIRECTOR 1.00 X 0 0 0 1895518 0 147360 29 0 1 0 RIDGE EYE CARE 114 MISSION RANCH BLVD 50 CHICO CA 95926 CONTRACTED OPTOMETRY SERVICES 2272480 MACMAN MANAGEMENT HEALTHCARE SERVICES 1300 NATIONAL DR 175 SACRAMENTO CA 95834 CONTRACTED MEDICAL BILLING SERVICES 1127090 TBN LLC PO BOX 8104 RENO NV 89507 CONTRACTED CFO 192000 WIPFLI LLP PO BOX 3160 MILWAUKEE WI 53201 ACCOUNTING/FINANCIAL CONSULTING 113456 MOSS ADAMS LLP 999 THIRD AVE STE 2800 SEATTLE WA 98104 AUDIT & TAX SERVICES 112891 6 5032156 261997 559193 5294153 NET PATIENT SERVICE REVENUE 621400 26811496 26811496 OTHER OPERATING REVENUE 621400 501362 501362 27312858 3969 3969 60900 0 60900 60900 60900 34669 -34669 -34669 -34669 32637211 27312858 0 30200 X 651999 426960 225039 9940911 7279829 2661082 177650 127178 50472 2064026 1508734 555292 670105 487791 182314 192000 192000 68154 68154 85484 85484 5003777 2841325 2162452 61945 61945 105677 76356 29321 1285496 249534 1035962 2127123 1846802 280321 52008 32684 19324 18537 30 18507 9415 9415 803143 659084 144059 176501 63483 113018 MEDICAL SUPPLIES/DRUGS 3749295 3746038 3257 LICENSES AND TAXES 58462 49967 8495 106548 85357 21191 27408256 19481152 7927104 0 3049742 4918057 133333 17000 4605498 2621039 151401 187895 236590 458062 9335592 6254406 3391812 3081186 100279 4707831 11668655 15991070 1796573 2143218 187189 118118 256960 71710 1304441 305577 3545163 2638623 X 8123492 13352447 8123492 13352447 11668655 15991070 5228955 0 X 0 1 X 1 1 1 X 2494135 2192986 2271944 5090103 5294153 17343321 2494135 2192986 2271944 5090103 5294153 17343321 17343321 55873 60122 60039 64869 240903 983997 983997 18568221 109535654 0.93400 0.92670 X SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: MISCELLANEOUS INCOME - 2016 AMOUNT: $ 983,997. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 7125 7125 0 PART II-B, LINE 1: THE ORGANIZATION PAYS DUES TO THE CALIFORNIA PRIMARY CARE ASSOCIATION; A PORTION OF THOSE DUES HAVE BEEN INDICATED AS USED FOR LOBBYING PURPOSES. 4225455 2140912 2084543 3568025 3143759 424266 1542112 969735 572377 3081186 DEPOSITS 102279 ESTIMATED THIRD-PARTY SETTLEMENT RECEIVABLE 4605552 4707831 DEFERRED LEASE LIABILITY 305577 305577 X 32671880 0 32671880 -34669 -34669 32637211 27442925 34669 34669 27408256 0 27408256 PART X, LINE 2: THE ORGANIZATION IS A NONPROFIT CORPORATION UNDER INTERNAL REVENUE CODE SECTION 501(C)(3) AND HAS BEEN GRANTED TAX-EXEMPT STATUSES BY THE INTERNAL REVENUE SERVICE AND THE CALIFORNIA REVENUE AND TAXATION CODE. AS OF JUNE 30, 2021 AND 2020, THE ORGANIZATION HAD NO UNRECOGNIZED TAX POSITIONS OR UNCERTAIN TAX POSITIONS REQUIRING ACCRUAL. THEREFORE, NO PROVISION FOR INCOME TAXES HAS BEEN PROVIDED IN THE FINANCIAL STATEMENTS. PART XI, LINE 4B - OTHER ADJUSTMENTS: LOSS ON DISPOSAL OF FIXED ASSETS RECLASSED TO FORM 990, PART VIII -34,669. PART XII, LINE 2D - OTHER ADJUSTMENTS: LOSS ON DISPOSAL OF FIXED ASSETS RECLASSED TO FORM 990, PART VIII 34,669. X X 0 0 0 0 0 0 0 0 0 TEJINDER GHUMAN MD PEDIATRICIAN 261603 0 28920 0 12480 0 5700 0 15288 0 323991 0 0 0 SUMIT JOHL MD PEDIATRICIAN 243280 0 19435 0 6280 0 4917 0 15288 0 289200 0 0 0 MARY PENA-PRIDEMORE MD PHYSICIAN 240685 0 12551 0 9800 0 5226 0 8042 0 276304 0 0 0 RAMESH PUNDI MD PHYSICIAN 231731 0 0 0 0 0 4558 0 19728 0 256017 0 0 0 AMANDA TAGLE MD PHYSICIAN 222943 0 5030 0 0 0 4460 0 18564 0 250997 0 0 0 GREG STONE CHIEF EXECUTIVE OFFICER 205994 0 0 0 0 0 923 0 15288 0 222205 0 0 0 RUPAUL GHUMAN DDS DENTAL DIRECTOR 192801 0 2055 0 0 0 3825 0 21554 0 220235 0 0 0 RICHARD FURY MD CHIEF MEDICAL OFFICER 197427 0 1650 0 853 0 3999 0 0 0 203929 0 0 0 X 11848 555936 COST OF DONATED PROPERTY X PPE 11500 3257 COST OF DONATED PROP 0 0 0 0 PART I, COLUMN (B): THE ORGANIZATION IS REPORTING THE NUMBER OF ITEMS CONTRIBUTED IN SCHEDULE M, PART I, COLUMN (B). FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION CONTRACTED WITH TBN LLC FOR CFO DUTIES WHICH WERE FULFILLED BY JAMES ELLSWORTH. TOTAL COMPENSATION PAID TO TBN LLC IN EXCHANGE FOR THESE SERVICES TOTALED $192,000 DURING THE 2020 CALENDAR YEAR AND $192,000 FOR THE 6/30/2021 FISCAL YEAR (7/1/2020 - 6/30/2021). FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED BY AN OUTSIDE ACCOUNTING FIRM, WHO WORKS IN CONJUNCTION WITH THE PEACH TREE HEALTHCARE ACCOUNTING AND FINANCE DEPARTMENT TO COMPLETE THE FORM 990. UPON REVIEW AND APPROVAL BY THE ORGANIZATION'S CFO, THE FORM 990 IS FILED WITH THE INTERNAL REVENUE SERVICE AND ALSO REVIEWED WITH THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C ALL DIRECTORS, OFFICERS, AND KEY EMPLOYEES RECEIVE A COPY OF THE CONFLICT OF INTEREST POLICY, AND ARE REQUIRED TO ANNUALLY RETURN A CONFLICT OF INTEREST DISCLOSURE STATEMENT TO THE CHIEF EXECUTIVE OFFICER. THE BOARD OF DIRECTORS HAS DELEGATED AUTHORITY TO DETERMINE IF A CONFLICT OF INTEREST EXISTS FOR DIRECTORS, CORPORATE OFFICERS, AND THE CEO, WHO MUST LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE FINANCIAL INTEREST IS DISCUSSED AND VOTED UPON. IN THE CASE OF A CONFLICT OF INTEREST DISCLOSURE MADE BY A MEDICAL STAFF MEMBER, PHYSICIAN, EXECUTIVE STAFF MEMBER, DEPARTMENT DIRECTOR, SUPERVISOR, OR OTHER INDIVIDUAL, THE CHIEF EXECUTIVE OFFICER DETERMINES, BASED ON THE FACTS AND CIRCUMSTANCES DISCLOSED, IF A CONFLICT OF INTEREST EXISTS AND SHALL ALSO REPORT THE RESULTS OF ALL DETERMINATIONS TO THE CHAIRMAN OF THE BOARD. FORM 990, PART VI, SECTION B, LINE 15 ALL COMPENSATION FOR SENIOR MANAGEMENT AND KEY EMPLOYEES IS APPROVED BY THE BOARD OF DIRECTORS. SENIOR MANAGEMENT COMPENSATION IS ESTABLISHED USING HISTORICAL BENCHMARKS FROM PREVIOUS EMPLOYEES, AS WELL AS THE SALARY GUIDE FROM THE CALIFORNIA PRIMARY CARE ASSOCIATION, WHICH IS EXAMINED ANNUALLY TO ENSURE SALARIES AND BENEFITS ARE ON PAR WITH COMPARABLE ORGANIZATIONS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G CONTRACTED MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 2,744,890. MANAGEMENT AND GENERAL EXPENSES 406,344. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,151,234. PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 63,468. MANAGEMENT AND GENERAL EXPENSES 1,585,619. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,649,087. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 32,967. MANAGEMENT AND GENERAL EXPENSES 170,489. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 203,456.