2022-11-15T11:51:40-05:00 2021-12-31 LARRY J OTTE CPA 10755 HAWTHORNE DR SAINT JOHN IN 46373 990 2021-01-01 201834903 PARK PLACE CHRISTIAN COMMUNITY OF ST JOHN INC PARK 7083428100 18601 N CREEK DR TINLEY PARK IL 60477 VANDERGENUGTEN BARRY CFO 7083428100 2022-11-10 BARRY VANDERGENUGTEN XXX-XX-XXXX LARRY J OTTE P01427347 7083593329 2022-11-11 X 2021 2022-09-23 18:48:47Z VANDERGENUGTEN BARRY 18601 N CREEK DR TINLEY PARK IL 60477 12217204 false X PROVIDENCELIFESERVICES.COM X 2004 IN TO MAINTAIN RESIDENTIAL AND RELATED FACILITIES AND PROVIDE FOR THE PROPER CARE AND NURTURE OF THE ELDERLY AND INFIRM PEOPLE WHO SEEK COMPASSIONATE SERVICES IN THE LATER YEARS OF THEIR LIFE. 7 7 196 15 0 1250913 83152 11499115 12134052 0 0 12750028 12217204 0 0 4060999 4539328 0 0 9481566 9797372 13542565 14336700 -792537 -2119496 45921533 43991406 44309367 43615845 1612166 375561 TO MAINTAIN RESIDENTIAL AND RELATED FACILITIES AND PROVIDE FOR THE PROPER CARE AND NURTURE OF THE ELDERLY AND INFIRM PEOPLE WHO SEEK COMPASSIONATE SERVICES IN THE LATER YEARS OF THEIR LIFE. false false 12512049 TO PROVIDE THE GENERAL PUBLIC LONG-TERM HEALTHCARE FACILITIES AND SERVICES FOR THE SICK, INJURED &/OR AGED. 12512049 true false false false false false false false false false true false false false true false false false false false false false false false false false false false false true false false false false false false true false false false false false false true false false false true 0 0 true 196 true false false false false false false false false false false false false false false X 7 7 false true false false true true true true true false false true true true true true true true true false IN X VANDERGENUGTEN BARRY 7083428100 18601 N CREEK DR TINLEY PARK IL 60477 SCHUTT RICHARD CEO 2.00 43.00 X 0 608196 25187 DEYOUNG WILLIAM COO 2.00 43.00 X 0 421351 75309 VANDERGENUGTEN BARRY CFO 2.00 43.00 X 0 338815 31595 ZANDSTRA BILL SECT/TREASUR 1.00 2.00 X X 0 0 0 GROENEWOLD JAKE DIRECTOR 1.00 2.00 X 0 0 0 RYNBERK HOWARD JR ASST SEC / T 1.00 2.00 X 0 0 0 HOVING KEN DIRECTOR 1.00 2.00 X 0 0 0 BOTMA KEVIN ASST SECT/TR 1.00 2.00 X X 0 0 0 KATS PAUL CHAIR 1.00 2.00 X X 0 0 0 BOEREMA ROGER VICE CHAIR 1.00 2.00 X X 0 0 0 1368362 132091 false true true PROVIDENCE LIFE SERVICES 18601 NORTH CREEK DR TINLEY PARK IL 60477 MGMT, EDUC, MKT 1439905 SYMBRIA REHAB 28100 TORCH PARKWAY SUITE 600 WARRENVILLE IL 60555 THERAPY 918434 SYMBRIA RX SERVICES 28100 TORCH PARKWAY SUITE 600 WARRENVILLE IL 60555 PHARMACY 485663 GORDON FOOD SERVICE PO BOZ 88029 CHICAGO IL 60680 DIETARY 436180 PROVINET SOLUTIONS 18645 W CREEK DR TINLEY PARK IL 60477 IT SERVICES 384746 6 77152 6000 83152 ROUTINE REVENUE 623000 12134052 12134052 12134052 12217204 12134052 X 3808986 3808986 43543 43543 407200 407200 279599 279599 1439905 1439905 64123 64123 67197 67197 49128 49128 277129 277129 384746 384746 452428 452428 1359441 1359441 1590632 1590632 322209 322209 THERAPY 918434 918434 PHARMACY 485663 485663 NURSING SUPPLIES 467221 467221 M&R 442378 442378 1476738 1476738 14336700 12512049 1824651 0 69736 105560 1045143 595437 97377 71575 50020402 6957204 44505169 43063198 204108 155636 45921533 43991406 1800899 1264106 34133391 33503127 8375077 8848612 44309367 43615845 X 1612166 375561 1612166 375561 45921533 43991406 X -2119496 882891 X X false true X true true false X 1250913 83152 1334065 5576726 7572372 10041990 11499115 12134052 46824255 5576726 7572372 10041990 12750028 12217204 48158320 48158320 5576726 7572372 10041990 12750028 12217204 48158320 1.00000 1.00000 0.00000 0.00000 X 1574154 1574154 45763118 5122542 40640576 2683130 1834662 848468 43063198 DUE TO AFFILIATES 8392454 INTEREST RATE SWAP VALUE 456158 8848612 X true true X X X X X false true false false false false false true false SCHUTT RICHARD CEO 532645 56166 19385 11200 13987 633383 DEYOUNG WILLIAM COO 370084 36220 15047 54371 20938 496660 VANDERGENUGTEN BARRY CFO 290974 28600 19241 11200 20395 370410 SCHEDULE J, PART III PART I, LINE 1A: THE ORGANIZATION PROVIDES AN ALLOWANCE FOR UP TO 10 BOARD MEMBERS TO ATTEND THE ANNUAL ASSOCIATION CONVENTION TO PROVIDE MORE IN DEPTH KNOWLEDGE OF THE SENIOR CARE INDUSTRY. THE COST OF TRAVEL FOR SPOUSES IS PERMITTED AS LONG AS THE TOTAL DOES NOT EXCEED THE ESTABLISHED ALLOWANCE AMOUNT. THE BENEFIT OF SPOUSAL TRAVEL IS INCLUDED IN TAXABLE COMPENSATION. DOCUMENTATION OF ATTENDANCE AT THE ANNUAL CONVENTION IS REQUIRED. PART I, LINE 4B: REST HAVEN HAS ESTABLISHED A NONQUALIFIED DEFERRED COMPENSATION PLAN IN AN EFFORT TO RETAIN SELECTED OFFICERS ON A LONG TERM BASIS. WILLIAM DEYOUNG PARTICIPATES IN THE PLAN. IN 2021, THERE WERE NO DISTRIBUTIONS FROM OR AMOUNTS VESTED IN THE PLAN. IN 2005, THE PLAN WAS SET UP BY THE BOARD OF DIRECTORS TO ESTABLISH A RETENTION INITIATIVE FOR CERTAIN OFFICERS. THIS PLAN RECOGNIZES THE HISTORIC CONTRIBUTION OF THE EXECUTIVES AND ESTABLISHES AN INCENTIVE FOR THEM TO CONTINUE THEIR EMPLOYMENT WITH THE ORGANIZATION UNTIL NORMAL RETIREMENT AGE. AMONG VARIOUS CRITERIA, IN ORDER TO QUALIFY FOR THE BENEFIT, THE EXECUTIVE WILL NEED TO BE CONTINOUSLY EMPLOYED THRU AND UNTIL THE A FUTURE DATE. THE ORGANIZATION'S PAYMENTS INTO THE PLAN ARE RECORDED ON THE 990 AS DEFERRED COMPENSATION. HOWEVER, THESE MONIES ARE ONLY ELIGIBLE TO BE RECIEVED BASED UPON ACHIEVEMENT OR SATISFACTION OF SOME FUTURE EVENTS. THE PLAN CONTRIBUTIONS ARE NOT UNDER THE CONTROL OF THE EXECUTIVES, THEY REMAIN THE ASSET OF THE ORGANIZATION, AND THE ENTIRE PLAN IS SUBJECT TO A FULL RISK FORFEITURE BY THE INDIVIDUAL. PART I, LINE 7: THE PARENT COMPANYS EXECUTIVE COMPENSATION PROGRAM HAS TWO MAJOR ELEMENTS: SALARY, OR BASE PAY, AND VARIABLE PAY. THE SALARY REFLECTS THE VALUE OF AN EXECUTIVE'S CAPABILITIES AND EXPERIENCE. THE VARIABLE PAY REFLECTS THE ORGANIZATIONS COMMITMENT TO PAY FOR SPECIFIC PERFORMANCE TOWARDS ORGANIZATION'S GOALS. THE VARIABLE PAY IS AWARDED SEMI-ANNUALLY BASED UPON A SPECIFIC REVIEW OF GOALS AND OBJECTIVES (INCLUDING THOSE WHICH RELATE TO MISSION, OPERATIONAL EFFICIENCY, FINANCIAL EFFECTIVENESS, AND STRATEGIC GOALS). THE COMPENSATION COMMITTEE REVIEWS, ASSESSES AND DETERMINES ANY AWARD UNDER THE VARIABLE PAY COMPONENT. EXECUTIVE EMPLOYEES ARE REVIEWED BY THE COMPENSATION COMMITTEE AND OUTSIDE CONSULTANTS TO ENSURE THEY ARE COMPETITIVE AND IN LINE WITH COMMON PRACTICE FOR SIMILAR POSTIONS IN SIMILARLY SIZED AND TYPE ORGANIZAITONS. THE COMMITTEE ROUTINELY RECEIEVES AN EXECUTIVE COMPENSATION OPINION NOTING THAT THE ORGANIZATIONS EXECUTIVE COMPENSATION FALLS WITHIN THE RANGE OF COMPARABLE POSITIONS WITHIN THE SAME INDUSTRY AND SCALE OF OPERATIONS. THE REPORT/OPINION ALSO NOTES THAT THE STATED REQUIREMENTS OF ENSURING INDEPENDENCE OF COMPENSATION DELIBERATIONS FOR SENIOR EXECUTIVES ARE MET. LINDA SCHUTT SPOUSE OF CEO 82939 EMPLOYMENT COMP false SCHEDULE L, PART V SCH L, PART IV, BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS: (A) NAME OF PERSON: LINDA SCHUTT (D) DESCRIPTION OF TRANSACTION: EMPLOYMENT COMPENSATION; MASTERS PREPARED R.N. THAT LEADS THE ORGANIZATION'S EDUCATION. SCH L, PART IV: THE TRANSACTIONS REPORTED ABOVE INVOLVING INTERESTED PERSONS ARE REVIEWED ANNUALLY BY THE PARENT COMPANY'S COMPENSATION COMMITTEE AND HAVE BEEN DEEMED APPROPRIATE BASED ON THE POSITIONS EMPLOYED. FORM 990, PAGE 6, PART VI, LINE 3 RESPONSIBILITIES PAID THROUGH MANAGEMENT FEES TO REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME DBA PROVIDENCE LIFE SERVICES. FORM 990, PAGE 6, PART VI, LINE 6 THE SOLE MEMBER OF THE CORPORATION IS REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME. THE AFFAIRS, BUSINESS AND ALL LEGAL MATTERS OF THE CORPORATION SHALL BE MANAGED BY ITS BOARD OF DIRECTORS. FORM 990, PAGE 6, PART VI, LINE 7A THE MEMBER SHALL HAVE AND EXERCISE THE FOLLOWING RESERVE POWERS: (1) TO APPOINT OR REMOVE DIRECTORS; (2) TO APPROVE AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS OF THE CORPORATION; (3) TO REVEIW ALL ANNUAL BUDGETS AND AUDITED FINANCIAL STATEMENTS, AND TO APPROVE ANY DEFICIT BUDGET; (4) TO APPROVE THE CONSTRUCTION OF ANY NEW OR THE ALTERATION OF ANY EXISTING FACILITY INVLOVING AN EXPENDITURE OF 500,000 OR MORE; (5) TO SELL, MORTGAGE, PLEDGE OR ALIENATE ALL OR ANY PART OF THE REAL ESTATE OR SUBSTANTIALLY ALL OF THE OTHER ASSETS OF THE CORPORATION; (6) TO DISSOLVE THE CORPORATION. FORM 990, PAGE 6, PART VI, LINE 7B THE MEMBER SHALL HAVE AND EXERCISE THE FOLLOWING RESERVE POWERS: (1) TO APPOINT OR REMOVE DIRECTORS; (2) TO APPROVE AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS OF THE CORPORATION; (3) TO REVEIW ALL ANNUAL BUDGETS AND AUDITED FINANCIAL STATEMENTS, AND TO APPROVE ANY DEFICIT BUDGET; (4) TO APPROVE THE CONSTRUCTION OF ANY NEW OR THE ALTERATION OF ANY EXISTING FACILITY INVOLVING AN EXPENDITURE OF 500,000 OR MORE; (5) TO SELL, MORTGAGE, PLEDGE OR ALIENATE ALL OR ANY PART OF THE REAL ESTATE OR SUBSTANTIALLY ALL OF THE OTHER ASSETS OF THE CORPORATION; (6) TO DISSOLVE THE CORPORATION. FORM 990, PAGE 6, PART VI, LINE 11B A DRAFT OF THE 990 WAS PREPARED AND SENT FOR INITIAL REVIEW BY THE CONTROLLER, CFO AND CEO. UPON REVIEW AND APPROVAL, THE 990 WAS MADE AVAILABLE TO THE ENTIRE BOARD PRIOR TO FILING. FORM 990, PAGE 6, PART VI, LINE 12C THE OFFICERS, DIRECTOR/TRUSTEES AND KEY EMPLOYEES ARE REQUIRED TO SUBMIT A CONFLICT OF INTEREST STATEMENT UPON BEGINNING THEIR POSITION. THEREAFTER, THE CONFLICT OF INTEREST STATEMENTS ARE UPDATED ON AN ANNUAL BASIS. ANY POTENTIAL CONFLICTS ARE REVIEWED AND ADDRESSED BY THE BOARD AS NECESSARY. FORM 990, PAGE 6, PART VI, LINE 15A THE PARENT COMPANY'S EXECUTIVE COMPENSATION PROGRAMS PRIMARY OBJECTIVE IS TO PROVIDE COMPETITIVE TOTAL PAY OPPORTUNITIES THAT HELP ATTRACT, REWARD AND RETAIN CRITICAL LEADERSHIP TALENT IN ORDER TO ACHIEVE THE ORGANIZATIONS MISSION AND STRATEGIC INITIATIVES. REST HAVEN ESTABLISHES ITS EXECUTIVE COMPENSATION RANGES THROUGH A WRITTEN POLICY AND BY COMPARING ITSELF TO ORGANIZATIONS OF SIMILAR SIZE AND TYPE - USING OBJECTIVE, THIRD-PARTY DATA. A COMPENSATION COMMITTEE OF INDEPENDENT DIRECTORS RECOMMENDS, AND THE BOARD OF DIRECTORS APPROVES, THE SALARY RANGES AND REVIEWS TOTAL COMPENSATION FOR EXECUTIVES ON AN ANNUAL BASIS. THE ORGANIZATION ROUTINELY USES KNOWLEDGABLE EXTERNAL CONSULTANTS TO ADVISE ON THE PROCESS AND HAS RECEIVED AFFIRMATION OF COMPLIANCE WITH IRS GUIDELINES FOR THE REASONABLENESS OF EXECUTIVE COMPENSATION IN TAX-EXEMPT ENTITIES. FORM 990, PAGE 6, PART VI, LINE 15B THE EXECUTIVE COMPENSATION OF THE PARENT (REST HAVEN) COMPANYS EXECUTIVES IS SET BY THE PARENT COMPANYS BOARD OF DIRECTORS THROUGH BOARD OVERSIGHT. THE EXECUTIVE COMPENSATION PROGRAM'S PRIMARY OBJECTIVE IS TO PROVIDE COMPETITIVE TOTAL PAY OPPORTUNITIES THAT HELP ATTRACT, REWARD AND RETAIN CRITICAL LEADERSHIP TALENT IN ORDER TO ACHIEVE THE ORGANIZATIONS MISSION AND STRATEGIC INITIATIVES. REST HAVEN ESTABLISHES ITS EXECUTIVE COMPENSATION RANGES THROUGH A WRITTEN POLICY AND BY COMPARING ITSELF TO ORGANIZATIONS OF SIMILAR SIZE AND TYPE - USING OBJECTIVE, THIRD-PARTY DATA. A COMPENSATION COMMITTEE OF INDEPENDENT DIRECTORS RECOMMENDS, AND THE BOARD OF DIRECTORS APPROVES, THE SALARY RANGES AND REVIEWS TOTAL COMPENSATION FOR EXECUTIVES ON AN ANNUAL BASIS. THE ORGANIZATION ROUTINELY USES KNOWLEDGABLE EXTERNAL CONSULTANTS TO ADVISE ON THE PROCESS AND HAS RECEIVED AFFIRMATION OF COMPLIANCE WITH IRS GUIDELINES FOR THE REASONABLENESS OF EXECUTIVE COMPENSATION IN TAX-EXEMPT ENTITIES. FORM 990, PAGE 6, PART VI, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 24E DIETARY 436,180 0 0 CONTRACT NURSING 334,689 0 0 BAD DEBT 202,761 0 0 PROVIDER BED TAX 111,709 0 0 SENIOR TV 84,928 0 0 COVID SUPPLIES 76,327 0 0 LAUNDRY 68,321 0 0 SOCIAL SERVICES 62,723 0 0 ACTIVITIES 49,586 0 0 HOUSEKEEPING 35,589 0 0 VEHICLE EXP 13,925 0 0 TOTAL 1,476,738 0 0 FORM 990, PART XI, LINE 9 CHANGE IN FMV OF INTEREST RATE SWAP 882,891 FORM 990, PAGE 12, PART XII, LINE 3B THE ORGANIZATION IS REQUIRED TO UNDERGO SINGLE AUDITS AS SET FORTH IN THE SINGLE AUDIT ACT AND OMB CIRCULAR A-133. THE AUDITS ARE PLANNED TO BE COMPLETED BY THE EXTENDED DUE DATE AS ESTABLISHED IN THE RELEVANT GUIDANCE. REST HAVEN ILLIANA CHRISTIAN 18601 N CREEK DRIVE TINLEY PARK IL 60477 362382853 HEALTHCARE IL 501C3 7 NA false PROVIDENCE MANAGMENT & DEVELOPMENT 18601 N CREEK DRIVE TINLEY PARK IL 60477 363774205 IT SERVICE IL NA C CORP -477774 4545218 false false false false false false false false false false false false false false false false true false true false PROVIDENCE MANAGEMENT DEVELOPEMENT P 384706 FMV REST HAVEN ILLIANA CHRISTIAN P 1439904 FMV