2021-09-05T10:38:29-05:00 2020-12-31 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2020-01-01 990073521 PALOLO CHINESE HOME PALO 8087372555 2459 10TH AVENUE HONOLULU HI 96816 DARLENE NAKAYAMA CHIEF EXECUTIVE OFFICER 8087372555 2021-08-25 1 DARLENE NAKAYAMA 999009999 KURT BENNION CPA P01469618 4252506100 2021-08-25 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z DARLENE NAKAYAMA 2459 10TH AVENUE HONOLULU HI 96816 18482875 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 23 264 37 0 0 457023 788531 17014070 17531109 97760 6888 103497 97164 17672350 18423692 3814 4250 0 0 10080433 10951349 0 0 173577 6442860 7403553 16527107 18359152 1145243 64540 34424119 35246255 9883841 10431140 24540278 24815115 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 13581256 4250 15145848 ICF/SNF - PALOLO CHINESE HOME IS LICENSED AS AN ICF/SNF UNIT AND PROVIDES 113 NURSING HOME BEDS TO ELDERLY RESIDENTS, REGARDLESS OF RACE. 1147689 0 1066351 ADULT RESIDENTIAL HOME - PALOLO CHINESE HOME IS LICENSED AS AN ADULT RESIDENTIAL CARE HOME TYPE II FACILITY (AARCH II) THAT HOUSES 18 ELDERLY RESIDENTS, REGARDLESS OF RACE. 500450 0 453591 ADULT DAY CARE - PALOLO CHINESE HOME IS LICENSED AS AN ADULT DAY CARE CENTER FOR 40 ELDERLY PARTICIPANTS, REGARDLESS OF RACE. 835803 0 736000 OTHER PROGRAM SERVICES INCLUDE COMMUNITY OUTREACH PROGRAMS SUCH AS MEALS HOME DELIVERY, HOME CLEANING, COMPANIONSHIP, PERSONAL CARE AND CATERING. 835803 0 736000 16065198 1 1 0 0 0 0 0 0 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 49 0 264 1 0 0 0 0 0 1 1 0 0 0 0 0 0 X 24 23 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 HI X TESS NOVIO 8085645228 2459 10TH AVENUE HONOLULU HI 96816 DARLENE NAKAYAMA CEO 60.00 X 262370 0 15968 DARIN YOSHIMOTO ADMINISTRATOR 60.00 X 126320 0 10308 PORNCHAI THOMPSON REGISTERED NURSE 40.00 X 126200 0 0 LAUREN KAGIHARA DIRECTOR OF HUMAN RESOURCES 40.00 X 104834 0 10483 JAMIE SUZUKI REGISTERED NURSE 40.00 X 109395 0 4376 BRIAN LIM EVS MANAGER 40.00 X 105322 0 4323 PATRICIA BLANCHETTE MD MPH SECRETARY & MEDICAL DIRECTOR 4.00 X X 36000 0 0 DOUGLAS SMITH ESQ CHAIR/PRESIDENT 2.00 X X 0 0 0 PETER FONG ESQ 1ST VICE PRESIDENT 2.00 X X 0 0 0 WALTON SHIM MD FACS 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 FRANCES GOO BOARD REPRESENTATIVE 2.00 X 0 0 0 RENA HWANG DIRECTOR 2.00 X 0 0 0 RUSSELL LAU DIRECTOR 2.00 X 0 0 0 GLADYS LEE DIRECTOR 2.00 X 0 0 0 LENORA LEE DIRECTOR 2.00 X 0 0 0 LESTER LEU ESQ 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 TYLER TOKIOKA DIRECTOR 2.00 X 0 0 0 LAWRENCE TSEU DDS DIRECTOR 2.00 X 0 0 0 GENE TSUJI DIRECTOR 2.00 X 0 0 0 ERIC WATANABE CPA IMMEDIATE PAST CHAIR/PRESIDENT 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 870441 0 45458 7 0 1 0 GENESIS ELDERCARE REHABILITATION 101 E STATE STREET KENNETT SQUARE PA 19348 REHABILITATION THERAPY 505494 UNITED LAUNDRY SERVICE INC 2291 ALAHAO PLACE HONOLULU HI 96819 LAUNDRY 195696 AEGIS THERAPIES INC 1000 FIANNA WAY FORT SMITH AR 72919 REHABILITATION THERAPY 126337 3 18882 769649 788531 ICF/SNF UNIT AND NURSING HOME 623000 15145848 15145848 ADULT RESIDENTIAL CARE HOME 623000 1066351 1066351 OTHER - COMM. OUTREACH, ETC. 624200 736000 736000 ADULT DAY CARE CENTER 621400 453591 453591 CONSULTING REVENUE 541610 129319 129319 17531109 46024 46024 99456 15583 83873 83873 83873 4464 42964 636 -38500 -636 -39136 -39136 CHANGE IN VALUE OF PERM TRUST 900099 10500 10500 MISCELLANEOUS REVENUE 900099 2791 2791 13291 18423692 17531109 0 104052 4250 4250 314336 36000 222669 55667 8742154 7988944 676417 76793 196094 173799 22261 34 1028728 893326 128329 7073 670037 601745 62039 6253 48440 48440 46308 46308 18212 14911 3301 1752264 1487393 264871 62361 62361 37240 20067 14047 3126 155155 115596 39559 348765 339531 9234 7849 7849 15085 6869 7962 254 339345 339345 1209464 1108617 93764 7083 543260 498627 35672 8961 NURSING AND DIETARY SUP 1765071 1765071 MISCELLANEOUS EXPENSE 607874 573228 29614 5032 REPAIRS AND MAINTENANCE 394390 391816 2574 BAD DEBTS 52470 52470 18359152 16065198 2120377 173577 3131936 1145560 1006691 4966611 124940 83202 2218422 1823683 115338 146273 139519 253352 36260958 11665884 25660383 24595074 1709299 1904409 313591 324091 4000 4000 34424119 35246255 1267308 1146290 14350 2314386 2200 500 8599983 6969964 9883841 10431140 X 23831171 24051950 709107 763165 24540278 24815115 34424119 35246255 64540 210297 0 X 0 1 X 1 0 X 1620118 449365 500056 457023 788531 3815093 1620118 449365 500056 457023 788531 3815093 126130 3688963 101531 101102 128921 191920 145480 668954 21411 15147 20538 29654 2791 89541 4573588 77743273 0.80660 0.83300 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 393294 19550 34130 7900 439074 223102 132875 42417 5100 393294 150929 93600 -17168 4259 223102 91606 42903 16420 150929 85640 600 5366 91606 0.00000 1.00000 0.00000 0 0 395050 395050 28655367 7899762 20755605 1911553 1911553 5200143 3766122 1434021 98845 98845 24595074 X 18358729 16219 16219 18342510 18212 62970 81182 18423692 18304053 15583 15583 18288470 18212 52470 70682 18359152 PART IV, LINE 2B: THE ORGANIZATION HOLDS SECURITY DEPOSITS FOR TWO COMPANIES LEASING SPACE. EACH 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 15,583. LOSS ON ASSET DISPOSALS 636. PART XI, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN VALUE OF PERM TRUST 10,500. BAD DEBT EXPENSE 52,470. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 15,583. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 52,470. X X X X 0 0 0 0 0 0 0 0 0 DARLENE NAKAYAMA CEO 226684 0 7620 0 28066 0 10577 0 5391 0 278338 0 0 0 FORM 990, PART VI, SECTION A, LINE 1 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 1 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 B, LINE 11B THE DIRECTOR OF BUSINESS OFFICE REVIEWED THE FORM 990. THE FINANCE COMMITTEE OF THE BOARD REVIEWED THE FORM 990 AND UPON APPROVAL MADE A RECOMMENDATION TO THE EXECUTIVE COMMITTEE FOR APPROVAL. 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. 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