2022-08-23T09:41:06-05:00 2021-09-30 420714325 RSM US LLP 30 S Wacker Drive Ste 3300 Chicago IL 60606 990 2020-10-01 951656366 PIH Health Good Samaritan Hospital PIHH 2139772121 1225 Wilshire Blvd Los Angeles CA 900172395 Vid Shivaraman CFO 2139772121 2022-08-23 1 Vid Shivaraman XXX-XX-XXXX Rebekuh Eley P01247672 3126343400 3 AAL1 IAL1 2020 2022-09-23 18:48:47Z X James West 12401 Washington Blvd Whittier CA 90602 439553865 0 X www.PIHHealth.org X 1885 CA Provide accessible, quality, cost-effective healthcare services at 408-bed hospital in LA. 12 12 2029 346 240408 0 175957 15082179 32416200 400932901 721556 12384612 345383 7637121 33659096 436036813 1899 53083 0 0 14425016 185710516 0 0 505600 21612245 268873341 36039160 454636940 -2380064 -18600127 756574899 663025397 270419568 193503519 486155331 469521878 X To provide accessible, quality, cost-effective community healthcare. The Hospital operates a 408-bed facility in inner-city Los Angeles. 0 0 231777011 53083 292837429 Patient Care: Founded in 1885, PIH Health Good Samaritan Hospital became part of PIH Health in December 2019. As a 501(c)(3) nonprofit, 408-bed acute care hospital, the downtown Los Angeles campus serves the healthcare needs of a growing and diverse community. Patient Care in Fiscal Year 2020-2021Employees 1,598Volunteers 346Number of Emergency Department (ED) Visits 42,460Number of Births 1,611Medical Staff 722 173505724 0 107486160 Financial Assistance and Means-Tested Government Programs: Financial Assistance, also known as charity care, is defined as free or discounted health services provided to individuals who cannot afford to pay and who meet the eligibility criteria of the organization's financial assistance policy. PIH Health Good Samaritan Hospital offers a generous Financial Assistance Program, providing charity care to those with family income(s) at or below 350% of Federal Poverty Level guidelines. The hospital has a policy to treat emergency and certain other patients regardless of their ability to pay. Under the charity care policy, charity care may be provided to people who are uninsured or underinsured and cannot afford to pay for their own medical care.In providing services to those patients participating in means-tested government health programs, such as Medi-Cal, PIH Health Good Samaritan Hospital realizes a collective net loss each fiscal year due to the shortfall created when the payments received from these programs are less than the cost of caring for public program beneficiaries. Number of persons served by financial assistance and means-tested government programs: 32,582 5958295 0 609312 Other Community Benefit Services: Community health improvement services and community benefit operations, health professions education, subsidized services, research and cash and in-kind contributions for community benefit are comprised of the following: COMMUNITY HEALTH IMPROVEMENT SERVICES: Defined as community health improvement activities, which extend beyond patient care activities. This category includes community health education, community social service helpline, flu and COVID-19 vaccination clinics, Medi-Cal eligibility workers and transportation services.Snapshot of Outcomes:- 16,436 community members were reached through a variety of community health improvement activities.HEALTH PROFESSIONS EDUCATION: This category includes educational programs for physicians, nurses, chaplain and other health professionals when education is necessary or required by state law, accrediting body or health profession society. Snapshot of Outcomes:- 34 medical residents and ancillary professions students were provided with mentorship, internship and training opportunities. SUBSIDIZED HEALTH SERVICES: Subsidized services are clinical programs, which are provided despite a financial loss so significant that negative margins remain after removing the effects of financial assistance, bad debt and Medi-cal shortfalls. Nevertheless, the sevice is provided because it meets an identified community need and, if no longer offered, would either be unavailable in the area or fall to the responsiblity of government or another nonprofit organization to provide. PIH Health Good Samaritan Hospital subsidized Emergency Department On-Call Physicians and the Neonatal Intensive Care Unit (NICU). Snapshot of Outcomes:- $794,691 in expenses were incurred in subsidized services in Fiscal Year 2020-2021. RESEARCH: Research that may be reported as community benefit includes clinical and community health research as well as studies on healthcare delivery that are generalizable and shared with the public. PIH Health Good Samaritan Hosptial has been offering clinical trials and research studies aimed at improving health. Snapshot of Outcomes: - Over $25,575 in expenses have been incurred in research in Fiscal Year 2020-2021.CASH & IN-KIND CONTRIBUTIONS: This category includes funds and in-kind services donated by PIH Health Good Samaritan Hospital to community organizations or to the community-at-large for a community benefit purpose. These donations include cash donations to community organizations, in-kind hours contributed by staff to the community while on PIH Health work time, the cost of office and meeting space provided to community groups, and the donations of equipment, medications, supplies and services.Snapshot of Outcomes:- 3,202 at-risk individuals were provided with in-kind durable medical equipment or services, such as skilled nuring or mental healthcare.Total number of persons served by other community benefit services: 19,725For additional information, please refer to PIH Health's community benefit report at https://www.PIHHealth.org/about-us/community-benefit/ 411241030 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 366 0 1 2029 1 1 1 0 0 0 0 1 1 0 0 0 0 1 0 X 12 12 1 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 CA X Mark Kawauchi 5626980811 12102 Washington Blvd Whittier CA 90606 X Jeffrey Hamar Chairman 1.50 6.00 X X 0 0 0 Patrick Monroe Vice Chairman 1.50 6.00 X X 0 0 0 Charlotte Weaver PhD Secretary 1.50 6.00 X X 0 0 0 Alex Alvarez Treasurer 1.50 6.00 X X 0 0 0 J Richard Atwood Trustee 1.50 7.50 X 0 0 0 Paula Cowan Trustee 1.50 6.00 X 0 0 0 Blayne Cutler MD PhD Trustee 1.50 6.00 X 0 0 0 Jane Dicus Trustee 1.50 6.00 X 0 0 0 Peter Greaney MD Trustee 1.50 6.00 X 0 0 0 Allison Hill MD Trustee 1.50 0.00 X 0 0 0 Paul Treinen Trustee 1.50 6.00 X 0 0 0 Kenton Woods Trustee 1.50 6.00 X 0 0 0 James West President & CEO 10.00 43.20 X 0 2804484 309663 Rosalio Lopez MD Chief Strategy Officer 10.00 33.00 X 0 1635578 205137 Peggy Chulack COO & Asst. Secretary 10.00 43.20 X 0 911398 150543 Anita Chou CFO & Asst. Treasurer (Until 2/2021) 10.00 43.10 X 0 732572 21929 Jaime Diaz MD CMO & Co-Site Administrator 40.00 0.00 X 0 476480 28770 Vid Shivaraman CFO & Assistant Treasurer 10.00 43.10 X 0 360336 70274 Irena Zuanic CNO & Co-Site Administrator 40.00 0.00 X 322554 0 13016 Phillip Wolfe VP Prof. Services (Until 5/2020) 40.00 0.00 X 660456 0 3068 Brian Thorne VP Fund Development (Until 5/2020) 40.00 0.00 X 610666 0 8535 Todd Goodall VP Bus. Development (Until 3/2020) 40.00 0.00 X 603887 0 3971 Sammy Feuerlicht CSO (Until 3/2020) 40.00 0.00 X 574124 0 4594 Adnan Hamid VP IT Services (Until 3/2020) 40.00 0.00 X 411384 0 5826 Jean Meussner VP Human Resources (Until 9/2021) 40.00 0.00 X 304153 0 22169 Hilarion Castillo Controller 40.00 0.00 X 301079 0 16077 Ira Meiselman Director Managed Care 40.00 0.00 X 294059 0 20761 Noli Perillo Staff RN 40.00 0.00 X 259585 0 16418 Elena Bochove Staff RN 40.00 0.00 X 226809 0 23016 Tai Kang Staff RN 40.00 0.00 X 202010 0 27045 Andrew B Leeka Former President & CEO 0.00 0.00 X 2156681 0 4337 Alan M Ino Former CFO 0.00 0.00 X 242310 0 5222 7169757 6920848 960371 626 1 1 0 Cross Country Staffing PO Box 404674 Atlanta GA 30384 Nursing Registry Services 10349020 Crothall Healthcare Inc 955 Chesterbrook Blvd Ste 300 Wayne PA 19087 Environmental Services 6998508 Morrison Management Specialists 5801 Peachtree Dunwoody Road Atlanta GA 30342 Dietary Services 4207988 Orange Commercial Credit PO Box 25229 Anaheim CA 92825 Nursing Registry Services 3562307 RehabCare Group of California LLC PO Box 502096 St Louis MO 63150 Rehabilitation Services 3049088 91 137937 12943039 2001203 15082179 Patient Revenue 621990 354392472 354392472 Hospital Fee Program 900099 46436107 46436107 Rental Income 532000 104322 104322 400932901 10396135 10396135 5505354 175 3517052 0 1988302 175 1988477 1988477 Parking Lot 812930 1807883 7674 1800209 Child Care Center 624410 405933 133958 271975 Physician Mngmt Svcs 621110 54600 54600 5368705 44176 5324529 7637121 436036813 400932901 240408 19781325 X 53083 53083 3038878 983011 2048673 7194 131902273 127364597 4537676 5031193 4831421 199772 34507728 32357020 2150708 11230444 10704806 525087 551 500257 500257 420000 420000 16108 16108 94759 94759 113964742 105833789 7970700 160253 420566 93524 327042 2605696 2568218 37478 6322 5957 365 217911 217911 9243636 5221339 4022297 3680952 1708022 1972930 Supplies 83974861 83699611 275250 Hospital Fee Program 24829969 24829969 Bad Debt Expense 12948674 12948674 Utilities 5912266 5802077 110189 10036622 4966675 4732345 337602 454636940 411241030 42890310 505600 117150567 976293 1100000 1200000 60178942 69185535 185414279 176172569 5671931 6533573 4465149 4086698 312058425 18476079 277324403 293582346 99843336 105045419 5426292 6242964 756574899 663025397 168751014 92772461 50000000 51668554 100731058 270419568 193503519 X 418638249 400357909 67517082 69163969 486155331 469521878 756574899 663025397 X -18600127 -1553832 -58838 3579344 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 16108 16108 0 Part II-B, Line 1: Lobbying expenses represent a portion of the dues PIH Health Good Samaritan Hospital pays to the Hospital Association of Southern California. PIH Health Good Samaritan Hospital does not participate in or intervene in (including the publishing or distributing of statements), any political campaign on behalf of (or in opposition to) any candidate for public office. 68288340 35438 5607660 3656122 138346 70136970 68269283 20070 1013 68288340 72033292 9678 -1950120 1648396 175171 68269283 73767150 108951 4068889 5875119 36579 72033292 74567557 16756 5368619 6185782 73767150 0.16204 0.79151 0.04645 0 0 204149473 204149473 43798722 2328251 41470471 36745959 13803763 22942196 27364271 2344065 25020206 293582346 Reserve for Self-Insured Programs 3381543 Pension Plan 9518698 Advances from Third Party Payors 8236603 Reserve for Asset Retirement Obligation 12029743 Other Annuity Payment Liability 1678712 Other Long Term Reserves 12950095 Right-of-Use Liability 791295 CARES Act Provider Relief Funds 33635335 Other Deferred Revenues 18509034 100731058 X Part V, Line 4: The organization's endowment consists of funds established for health care services, as specified by donors or the organization's board of directors. Part X, Line 2: The principal operations of the Company are exempt from income taxes pursuant to Internal Revenue Code (IRC) Section 501(c)(3) and the laws of the states in which it operates and, as such, is generally not subject to federal or state income taxes. However, the Company is subject to income taxes on net income derived from a trade or business regularly carried on that does not further the organization's exempt purpose. Further, the Company is also subject to federal excise taxes pursuant to the Tax Cuts and Jobs Act. No significant income tax provision has been recorded in the accompanying consolidated financial statements for net income derived from unrelated trade or business and excise taxes. The Company measures liabilities for unrecognized tax uncertainties in accordance with ASC 740, Income Taxes, which prescribes a comprehensive model for how a company should recognize, measure, present and disclose in its financial statements uncertain tax positions that a company has taken or expects to take on a tax return. The guidance is applicable to profit-oriented entities, pass-through entities and tax-exempt organizations. Management believes it has no significant uncertain tax positions and, as such, no tax liability, benefits, interest or penalties were accrued at September 30, 2021 or 2020. The Company is subject to routine audits by taxing jurisdictions; however, there are currently no audits for any tax periods in progress. The Company believes it is no longer subject to income tax examinations for years prior to 2017 for federal purposes and 2015 for California purposes. 1 1 X 1 X 1 X 1 0 1 1 5203 5655032 5655032 0.01280 27379 164675094 107486160 57188934 0.12950 32582 170330126 107486160 62843966 0.14230 8 16436 1328428 1328428 0.00300 3 34 1935449 584312 1351137 0.00310 2 41 794691 794691 0.00180 1 50575 25000 25575 0.00010 3 3209 1849152 1849152 0.00420 17 19720 5958295 609312 5348983 0.01220 17 52302 176288421 108095472 68192949 0.15450 1 5 5417 5417 0.00000 1 5 5417 5417 0.00000 854777 0 95418489 111493287 -16074798 X 1 1 1 1 PIH Health Good Samaritan Hospital 1225 Wilshire Blvd Los Angeles CA 90017 www.pihhealth.org 930000071 X X X X X PIH Health Good Samaritan Hospital 1 0 1 1 X X X X X X X X X 18 1 1 0 1 X See Part V, Page 8 X 1 19 1 See Part V, Page 8 0 1 X 200.000000000000 350.000000000000 X X X 1 1 X X X 1 X See Part V, Page 8 X See Part V, Page 8 X See Part V, Page 8 X X X X X X 1 X 0 X X X X 1 X 0 0 PIH Health Good Samaritan Hospital Part V, Section B, Line 2: On December 18, 2019, the State of California Attorney General provided consent to a proposed change in control and governance of Good Samaritan Hospital (GSH), a 408-bed facility based in Los Angeles, whereby PIH Health Inc. (PIH) would effect a membership transfer of GSH to PIH. On December 23, 2019, the amended articles of incorporation for GSH were successfully filed with the California Secretary of State, and PIH became the sole corporate member of GSH. On December 31, 2019, all of the members of GSH's board of directors were removed and replaced with the same individuals comprising PIH's board of directors. The purpose of the affiliation of PIH and GSH is to further the goal of expanding the integrated healthcare delivery system to improve the quality of healthcare within their communities and to further their mission of advancing the quality of care and furthering charitable service. PIH Health Good Samaritan Hospital Part V, Section B, Line 5: PIH Health Good Samaritan Hospital conducted targeted interviews to gather information and opinions from persons who represent the broad interests of the community served by the medical center.Twenty-nine (29) interviews were completed from November 2018 to January 2019. Community stakeholders identified by the Metro Los Angeles Collaborative were contacted and asked to participate in the needs assessment. Interviewees included individuals who are leaders and/or representatives of medically underserved, low-income, and minority populations, local health or other departments or agencies that have current data or other information relevant to the health needs of the community. Input was obtained from the Los Angeles County Department of Public Health.The identified stakeholders were invited by email to participate in a phone interview. Appointments for the interviews were made on dates and times convenient to the stakeholders. At the beginning of each interview, the purpose of the interview in the context of the needs assessment was explained, the stakeholders were assured their responses would remain confidential, and consent to proceed was given. Interview questions focused on the following topics: - Health issues in the community - Challenges and barriers people face in addressing these issues - Socioeconomic, behavioral, or environmental factors contributing to poor health in the community - Potential resources to address the identified health needs, such as services, programs and/or community efforts - Additional comments and concerns, a list of the stakeholder interview respondents, their titles and organizations can be found in Attachment 2.The full Community Health Needs Assessment can be found at: https://www.pihhealth.org/about-us/community-benefit/ PIH Health Good Samaritan Hospital Part V, Section B, Line 6a: PIH Health Good Samaritan Hospital participated in a collaborative process for the Community Health Needs Assessment, in partnership with St. Vincent Medical Center and California Hospital Medical Center. PIH Health Good Samaritan Hospital Part V, Section B, Line 11: PIH Health, Inc. acquired Good Samaritan Hospital (GSH) on December 23, 2019. As a result, during tax year 2019, GSH updated its existing Community Health Improvement Plan, as adopted July 25, 2019, to align with its new affiliates, PIH Health Whittier Hospital and PIH Health Downey Hospital. GSH's board approved the 2020-2022 Community Health Improvement Plan on April 8, 2020.PIH Health's Community Health Improvement Plan (CHIP) ensures alignment of CHNA findings, our community health improvement programs and PIH Health's organizational strategy. To view the 2020-2022 CHIP and the initiatives identified to address areas of focus (cancer incidence/mortality, diabetes incidence/mortality, heart disease/stroke incidence/mortality, overweight/obesity, substance use and misuse, preventative screenings and immunizations with emphasis on flu and pneumonia vaccines and cancer screenings, food insecurity, housing/homelessness, dental care and mental health), visit https://www.pihhealth.org/app/files/public/a8f558ef-640a-446c-875b-b273453fa4ce/2020-2022-pih-health-community-health-improvement-plan.pdfFor the health needs not prioritized as areas of focus - access to healthcare, asthma incidence, birth indicators, economic insecurity, education, kidney disease mortality, liver disease mortality, sexually transmitted infections, violence and injury - it was determined that PIH Health has neither the expertise nor the infrastructure to lead efforts in these areas. As these health needs are still very important to PIH Health and the community it serves, emphasis will be placed on referral relationships with community-based agencies already working in these areas. Part V, Section B, Line 7, CHNA Policy Website: https://www.pihhealth.org/about-us/community-benefit/ Part V, Section B, Line 10, Implementation Strategy Website: https://www.pihhealth.org/wellness/community-benefit/ Part V, Section B, Line 16a, FAP website: https://www.pihhealth.org/patients-visitors/billing-financial-assistance/financial-assistance/ Part V, Section B, Line 16b, FAP Application website: https://www.pihhealth.org/patients-visitors/billing-financial-assistance/financial-assistance/ Part V, Section B, Line 16c, FAP Plain Language Summary website: https://www.pihhealth.org/patients-visitors/billing-financial-assistance/financial-assistance/ Part I, Line 6a: PIH Health's Community Benefit Report, prepared annually, accounts for the organization's programs and services that promote the health of the community. The report separates out community benefit investment figures for each hospital. The report was made widely available to the public via social media, our organization's website and a community e-newsletter. It will also be shared with certain internal and community stakeholders via presentation.To view the full report, visit PIHHealth.org/cbannualreport Part I, Line 7: Patient care cost to charge ratio derived from Worksheet 2 was used to calculate the financial assistance and Medi-Cal cost. Direct and indirect costs from Medicare Cost Report were used for Graduate Medical Education (GME) Program, Clinical Pastoral Education (CPE) Program and NICU Department. Actual costs from general ledger or departments were used for all other costs including Research Cost. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 12,948,674. Part II, Community Building Activities: PIH Health undertakes disaster preparedness training above and beyond licensure requirements to ensure we are effectively prepared to serve the community in a disaster. Part III, Line 2: Bad debt expense is determined by applying cost to charge ratio to bad debt transfers net of recoveries. This expense was not included in community benefit expense. Part III, Line 3: PIH Health Good Samaritan Hospital actively provides all patients the option to apply for financial assistance, therefore, no estimate is made for bad debt attributable to patients eligible under the financial assistance policy. Part III, Line 4: From the audited financial statements of PIH Health, Inc. and Subsidiaries for the year ended September 30, 2021: "Implicit price concessions are based upon management's assessment of historical and expected net collections, taking into consideration historical business and economic conditions, trends in healthcare coverage and other collection indicators. Management routinely assesses the adequacy of the implicit price concessions based upon historical write-off experience by payor category. Implicit price concessions are included as a deduction from patient services revenues since the Company generally accepts and treats all patients without regard to the ability to pay."The bad debt expense on line 2 is calculated using total cost to charge ratio applying to total bad debt transfers net of recoveries and none of the bad debt expense is included in community benefit expense. Part III, Line 8: The amounts on lines 5 and 6 are from the FY 2021 Medicare cost report and we believe do not qualify as community benefit. Part III, Line 9b: Patients are advised that they have the opportunity to submit a charity application or apply for a discount under the Hospital's Charity Care Policy or Cash Price Policy. Part VI, Line 2: PIH Health Good Samaritan Hospital addresses the healthcare needs of the communities it serves through participation in various community collaboratives and networking meetings. PIH Health Good Samaritan Hospital is able to assess the healthcare needs of the community and identify partnership opportunities. Part VI, Line 3: Uninsured patients are screened for Medi-Cal linkage and if they meet the criteria, the patient is referred to RISARC to assist with the application and eligibility process. If the patient does not have Medi-Cal linkage, they are screened for Queens Care which is a program for uninsured patients that reside within specific zip codes in Los Angeles County and meet income qualification. Financial Assistance Applications are provided to all patients who are uninsured, underinsured, financial hardship, have catastrophic illness or have excessive medical expenses. The following hospital policies are available on our website; Charity Care / Discount Policy, Financial Assistance Application and Cash Price Policy. The statements mailed to patients provides information regarding Financial Assistance, Covered California Health Benefits, Medi-Cal and Medicare. Part VI, Line 4: PIH Health Good Samaritan Hospital is located at 1225 Wilshire Blvd., Los Angeles, California 90017. The hospital service area includes 18 ZIP Codes in Los Angeles City Council District 1. The service area is comprised of portions of Service Planning Areas (SPAs) 4 and 6. The hospital service area is detailed below by community and ZIP Code and was determined from the ZIP Codes that reflect a majority of patient admissions from the local geographic area.Based on the 2019 Community Health Needs Assessment, the population for the PHGSH service area is 516,340. Children and youth, ages 0-17, make up 15.6% of the population, 74% are 18-64 years of age, and 10.4% are seniors, 65 years and older. In the service area, 53.1% of the population are Hispanic/Latino, 22.5% are Asian, 13.2% are White, 8.9% are Black/African American; and the remaining 2.3% are American Indian/Alaskan Native, Native Hawaiian/Pacific Islander, other or multiple races. English is spoken in the home among 32.8% of the service area population. Spanish is spoken at home among 42.3% of the population, and 21.1% of the population speaks an Asian language in the home. In the service area, 30% of the population is at or below 100% of the federal poverty level. Among area adults, ages 25 and older, 30.2% lack a high school diploma, 19% are high school graduates and 35.6% are college graduates. Part VI, Line 5: Community BoardPIH Health's community Board of Directors works to advance the commitment to helping our communities get well and stay healthy.Open Medical StaffPIH Health extends medical staff privileges to all qualified physicians in its community for some or all of its departments or specialties.Donation of TimeMany PIH Health providers are living out their passion to serve people in need by donating their time and talents both in our community and overseas. Environmental and Recycling ProjectsPIH Health continues to implement "green" initiatives, including increased usage of LED lighting to decrease consumption of electricity and developing energy management projects.Volunteer ContributionsSome 1,282 PIH Health System volunteers collectively contributed 111,535 hours of service, supporting departments throughout the organization. Part VI, Line 6: PIH Health Good Samaritan Hospital is a member of an integrated healthcare system controlled by PIH Health, Inc. As such, the hospital has several affiliates, as outlined in Schedule R, which conduct, support, and promote the health of the community within the meaning of Section 501(c)(3) of the code. Key affiliates include: 1) PIH Health, Inc., PIH Health Good Samaritan Hospital's parent company; 2) PIH Health Downey Hospital; 3) PIH Health Whittier Hospital 4) PIH Health Physicians, a nonprofit medical foundation; 5) PIH Health Home Healthcare and 6) the PIH Health Foundation, a nonprofit organization that exists to raise philanthropic funds in support of PIH Health's charitable mission.1) PIH Health, Inc. provides technical, facility and support services for tax-exempt affiliates whose charitable purpose is to provide a broad range of healthcare services to their community by way of an integrated health care delivery system.2) PIH Health Downey Hospital officially became part of PIH Health in October 2013. As a 501(c)(3) nonprofit, 199-bed hospital, the Downey campus has provided quality care in a welcoming environment for more than 100 years. As a nonprofit hospital with a charitable mission, PIH Health Hospital Downey is a dedicated community health and wellness partner. This commitment and leadership gives back to the community through charity care, health professions education and more.3) PIH Health Whittier Hospital opened in 1959. As a 501(c)(3) nonprofit, 523-bed hospital, the Whittier campus has developed into a health system offering a multitude of services. As a nonprofit hospital with a charitable mission, PIH Health Hospital Whittier is a dedicated community health and wellness partner. This commitment and leadership gives back to the community through charity care, medical research, donations, health professions education and more.4) PIH Health Physicians (PHP) A 501(c)(3) nonprofit medical group that is exclusively affiliated with PIH Health, the group is comprised of more than 121 primary care physicians and over 186 specialists who coordinate care from diagnosis to recovery. PHP supports the local community through its financial assistance program, Whittier First Day Health & Wellness Center for the homeless and those at-risk for homelessness, health professions education, and other community health improvement services.5) PIH Health Home Healthcare provides around-the-clock, quality care for patients in their own home. PIH Health Home Healthcare is certified by the Centers for Medicare and Medicaid Services.6) The PIH Health Foundation raises funds in support of PIH Health to ensure the health and well-being of our communities for years to come through supporting programs that directly impact the community, including PIH Health's community benefit programs. Healthy Living - Healthy Giving is an opportunity for everyone to play a role in the overall health of their friends, family, neighbors and everyone who lives, works, learns and plays in our community. Gifts - big, small and all will support PIH Health's work to provide access to quality healthcare, screenings, preventative care, prevention-focused education and other important initiatives.For detailed information regarding these PIH Health affiliates' additional activities to support and promote community health, please see each respective organization's IRS Form 990. Part VI, Line 7, Reports Filed With States CA 1 Good Samaritan Institute for Research and Education 1225 Wilshire Blvd Los Angeles CA 90017 954077161 501(c)(3) 53083 Expenses paid by the Organization 1 0 Part I, Line 2: The Institutes (Good Samaritan Institute for Research and Education and Orthopedic Institute of the Good Samaritan Hospital) do not have their own checking accounts, so all of their expenses (including salaries, wages and benefits) are paid for by the Hospital and are all recorded in each of the Institutes' accounts in the general ledger, through intercompany due to and from accounts on both sides (Institutes and Hospital's). Grants will only be made to 501(c)(3) organizations to ensure the funds will be used properly. 1 1 0 0 0 0 0 0 0 James West President & CEO 0 1347488 0 275638 0 1181358 0 290280 0 19383 0 3114147 0 1168584 Andrew B Leeka Former President & CEO 331681 0 0 0 1825000 0 0 0 4337 0 2161018 0 0 0 Rosalio Lopez MD Chief Strategy Officer 0 837160 0 107647 0 690771 0 195921 0 9216 0 1840715 0 397219 Peggy Chulack COO & Asst. Secretary 0 698611 0 82933 0 129854 0 136456 0 14087 0 1061941 0 122666 Anita Chou CFO & Asst. Treasurer (Until 2/2021) 0 675702 0 50000 0 6870 0 7800 0 14129 0 754501 0 0 Phillip Wolfe VP Prof. Services (Until 5/2020) 150456 0 0 0 510000 0 0 0 3068 0 663524 0 0 0 Brian Thorne VP Fund Development (Until 5/2020) 160666 0 0 0 450000 0 0 0 8535 0 619201 0 0 0 Todd Goodall VP Bus. Development (Until 3/2020) 93887 0 0 0 510000 0 0 0 3971 0 607858 0 0 0 Sammy Feuerlicht CSO (Until 3/2020) 124124 0 0 0 450000 0 0 0 4594 0 578718 0 0 0 Jaime Diaz MD CMO & Co-Site Administrator 0 419160 0 0 0 57320 0 7800 0 20970 0 505250 0 0 Vid Shivaraman CFO & Assistant Treasurer 0 354174 0 0 0 6162 0 64019 0 6255 0 430610 0 0 Adnan Hamid VP IT Services (Until 3/2020) 71389 0 0 0 339995 0 0 0 5826 0 417210 0 0 0 Irena Zuanic CNO & Co-Site Administrator 322554 0 0 0 0 0 0 0 13016 0 335570 0 0 0 Jean Meussner VP Human Resources (Until 9/2021) 304153 0 0 0 0 0 8400 0 13769 0 326322 0 0 0 Hilarion Castillo Controller 301079 0 0 0 0 0 8400 0 7677 0 317156 0 0 0 Ira Meiselman Director Managed Care 287450 0 6609 0 0 0 8400 0 12361 0 314820 0 0 0 Noli Perillo Staff RN 259585 0 0 0 0 0 9100 0 7318 0 276003 0 0 0 Elena Bochove Staff RN 226809 0 0 0 0 0 15905 0 7111 0 249825 0 0 0 Alan M Ino Former CFO 242310 0 0 0 0 0 0 0 5222 0 247532 0 0 0 Tai Kang Staff RN 202010 0 0 0 0 0 14217 0 12828 0 229055 0 0 0 Part I, Line 3 Compensation for the CEO was established and paid by PIH Health Whittier Hospital (PIH), a related organization. PIH used the following to establish the CEO's compensation: (1) Compensation Committee; (2) Independent Compensation Consultant; (3) Form 990 of other organizations; (4) Compensation Survey or Study; (5) Approval by the Board. Part I, Lines 4a-b Part I, Line 4A: Andrew Leeka, Phillip Wolfe, Todd Goodall, Adnan Hamid, Brian Thorne, and Sammy Feuerlicht received severance payments during the calendar year. The payments are included in Part VII, Column D and Schedule J, Part II, Column B(iii). The terms and conditions of the confidential severance agreements are available to the Internal Revenue Service upon request. Part I, Line 4B: A related organization, PIH Health, Inc., provides a supplemental executive retirement plan for certain executives. The following individuals participate in the plan: James West Peggy Chulack Anita Chou Rosalio Lopez Vid Shivaraman The following amounts became vested or were paid-out in 2020 and are included in Schedule J, Part II, Column (b) (iii): James West $1,168,584 Peggy Chulack $122,666 Rosalio Lopez $397,219 Form 990, Part VI, Section A, line 2 The Organization is a member of an integrated healthcare system controlled by PIH Health, Inc. The following individuals have a business relationship by virtue of their positions as officers or directors of related entities within the system: J. Richard Atwood, Jeffrey Hamar, Paula Cowan, Alex Alvarez, Blayne Cutler, Jane Dicus, Patrick Monroe, Charlotte Weaver, Kenton Woods, Peter Greaney, Paul Treinen, James West, Peggy Chulack, Anita Chou, Vid Shivaraman and Rosalio Lopez. Form 990, Part VI, Section A, line 4 On May 6, 2021, Good Samaritan Hospital changed its name to PIH Health Good Samaritan Hospital. Form 990, Part VI, Section A, line 6 PIH Health, Inc. is the sole member of PIH Health Good Samaritan Hospital. Form 990, Part VI, Section A, line 7a PIH Health, Inc. has authority to elect all the members of the board of directors of PIH Health Good Samaritan Hospital. Form 990, Part VI, Section A, line 7b PIH Health, Inc. has all voting rights and the power to elect the board of directors of PIH Health Good Samaritan Hospital. Form 990, Part VI, Section B, line 11b The Organization works with an independent accountant, RSM US LLP, to prepare the Form 990. Once the return is prepared, the return is reviewed by the Chief Financial Officer and VP of Finance. Form 990 is then reviewed by the Audit Committee of PIH Health, Inc., which is made up of independent directors. RSM US LLP makes all changes necessary. The final Form 990 is provided to the board prior to filing. Form 990, Part VI, Section B, line 12c Each year, all management and board of directors members are required to complete a conflict of interest disclosure form. All positive responses are reviewed by the General Counsel and Chief Administrative Officer of PIH Health, Inc. Each positive response is considered in light of magnitude of ownership interest, financial transaction(s), etc. If deemed necessary, conflicts of interest could be resolved by insisting that the incumbent either divest their ownership interest, that the organization terminate the business relationship, or even that the director resign. Directors with potential conflicts of interest may recuse themselves from voting on certain matters and/or may excuse themselves from meetings during the discussion, deliberation, and voting on of matters. Form 990, Part VI, Section B, line 15 A subcommittee of the Governing Board's Executive Committee is responsible for determining the Chief Executive Officer's compensation. This Subcommittee is given comparison data on CEO salaries and benefits from comparable hospitals in the local area, prepared by human resources from 990s; and salary surveys completed by the local association. The decision of the Subcommittee on the CEO's salary is documented by the Subcommittee in writing. The compensation of the Organization's Vice Presidents are reviewed and approved by the Organization's CEO. Their salaries and benefits are determined using comparable hospitals in the local area, prepared by human resources from 990s; and salary surveys completed by the local hospital association. Form 990, Part VI, Section C, line 19 PIH Health Good Samaritan Hospital's organizing documents and the Conflict of Interest Policy are not made available to the public. The financial information from the financial statements is included in the Organization's Form 990, which is available for public inspection upon request. Form 990, Part VI, Section B, Line 16b: PIH Health Good Samaritan Hospital holds a 12.5% interest a joint venture arrangement that exists to further the charitable and community-based health care purposes, mission, vision, and values of its controlling tax exempt members. PIH Health Good Samaritan Hospital annually evaluates its participation in joint venture arrangements. Form 990, Part VII, Section A, Line 1: One of the filing organization's officers, Rosalio Lopez, is an employee of PIH Health Downey Medical Group, Inc. (DMG), which has a professional service agreement with PIH Health Physicians, an affiliate of the filing organization, to provide physician services. The individuals received compensation from DMG, as follows: Rosalio Lopez: Reportable Base Compensation - $63,985 Other Compensation - $0 Form 990, Part IX, line 11g Physician Fees: Program service expenses 15,550,839. Management and general expenses 0. Fundraising expenses 0. Total expenses 15,550,839. Consulting and Management Fees: Program service expenses 786,881. Management and general expenses 1,169,542. Fundraising expenses 119,996. Total expenses 2,076,419. Medical Purchased Services: Program service expenses 3,375,404. Management and general expenses 94,800. Fundraising expenses 0. Total expenses 3,470,204. Repairs and Maintenance: Program service expenses 7,628,844. Management and general expenses 181,863. Fundraising expenses 0. Total expenses 7,810,707. Software Maintenance: Program service expenses 4,193,384. Management and general expenses 0. Fundraising expenses 0. Total expenses 4,193,384. Other Purchased Services: Program service expenses 24,845,483. Management and general expenses 6,267,495. Fundraising expenses 40,257. Total expenses 31,153,235. Outside Provider Cost: Program service expenses 14,987,722. Management and general expenses 0. Fundraising expenses 0. Total expenses 14,987,722. Purchased Labor: Program service expenses 30,679,773. Management and general expenses 43,236. Fundraising expenses 0. Total expenses 30,723,009. Other Contracted Services: Program service expenses 3,766,471. Management and general expenses 14,449. Fundraising expenses 0. Total expenses 3,780,920. Other Professional Services: Program service expenses 18,988. Management and general expenses 0. Fundraising expenses 0. Total expenses 18,988. Collection Fees: Program service expenses 0. Management and general expenses 199,315. Fundraising expenses 0. Total expenses 199,315. Form 990, Part XI, line 9: Pension related changes 3,485,035. Net assets released from restrictions 41,226. Intercompany transfer 50,575. Grant Refund 2,508. Good Samaritan Institute for Research and Education 1225 Wilshire Blvd Los Angeles CA 90017 954077161 Heart Research CA 501(c)(3) Line 4 PIH Health Good Samaritan Hospital 1 Orthopedic Institute of the Good Samaritan Hospital 1225 Wilshire Blvd Los Angeles CA 90017 954346048 Orthopedic Research CA 501(c)(3) Line 12a, I PIH Health Good Samaritan Hospital 1 Samaritan Imaging Center 1225 Wilshire Blvd Los Angeles CA 90017 954252321 Outpatient Imaging Services CA 501(c)(3) Line 10 PIH Health Good Samaritan Hospital 1 Good Samaritan Medical Office Building Inc 1225 Wilshire Blvd Los Angeles CA 90017 953244046 Physicians Medical Offices CA 501(c)(3) Line 12a, I PIH Health Good Samaritan Hospital 1 Kate Van Nuys Page Foundation 1225 Wilshire Blvd Los Angeles CA 90017 956028032 Grants Income to Good Samaritan Hospital CA 501(c)(3) Line 12a, I PIH Health Good Samaritan Hospital 1 PIH Health Adult Day Healthcare 12401 Washington Boulevard Whittier CA 90602 953643829 Support of Tax-Exempt Affiliates CA 501(c)(3) Line 12b, II PIH Health Inc 1 PIH Health Foundation 12401 Washington Boulevard Whittier CA 90602 953761274 Fundraising CA 501(c)(3) Line 7 PIH Health Inc 1 PIH Health Home Healthcare 12401 Washington Boulevard Whittier CA 90602 953036281 Support of Tax-Exempt Affiliates CA 501(c)(3) Line 12b, II PIH Health Inc 1 PIH Health Downey Hospital 11500 Brookshire Avenue Downey CA 90241 951903935 Healthcare CA 501(c)(3) Line 3 PIH Health Inc 1 PIH Health Whittier Hospital 12401 Washington Boulevard Whittier CA 90602 951934652 Healthcare CA 501(c)(3) Line 3 PIH Health Inc 1 PIH Health Management Corp 12401 Washington Boulevard Whittier CA 90602 954016278 Support of Tax-Exempt Affiliates CA 501(c)(3) Line 12b, II PIH Health Inc 1 PIH Health Physicians 6557 Greenleaf Ave Whittier CA 90601 953942828 Healthcare CA 501(c)(3) Line 10 PIH Health Inc 1 PIH Health Inc 12401 Washington Boulevard Whittier CA 90602 953619388 Support of Tax-Exempt Affiliates CA 501(c)(3) Line 12b, II N/A 0 Auxiliary of the Hospital of the Good Samaritan 1225 Wilshire Blvd Los Angeles CA 90017 956051253 Welfare of the Good Samaritan Hospital CA 501(c)(3) Line 12c, III-FI N/A 0 PIH Health Insurance Company 1003 Bishop Street Honolulu HI 96813 263760243 Captive Insurance HI N/A T 1 PIH Health Care Solutions 6557 Greenleaf Avenue Whittier CA 90601 462072342 Healthcare CA N/A C 1 DRMC Properties Inc 11500 Brookshire Avenue Downey CA 90241 954769768 Real Estate CA N/A C 1 PIH Health RE 1003 Bishop Street Honolulu HI 96813 472501390 Captive Insurance HI N/A T 1 HealthMed Services Inc 12401 Washington Boulevard Whittier CA 90602 300831225 Healthcare CA N/A C 1 Pioneer Medical Group Inc 12401 Washington Boulevard Whittier CA 90602 330927283 Medical Services CA N/A C 1 Pioneer Provider Network A Medical Group Inc 12401 Washington Boulevard Whittier CA 90602 330922631 Management Services CA N/A C 1 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 Good Samaritan Hospital Medical Office Building Inc K 2547720 FMV Good Samaritan Hospital Medical Office Building Inc A 5109755 FMV Good Samaritan Institute for Research and Education C 25000 FMV Good Samaritan Institute for Research and Education B 53083 FMV Kate Van Nuys Page Foundation C 92937 FMV