2021-10-08T12:04:23-05:00 2020-12-31 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2020-01-01 910573114 FOSS HOME & VILLAGE FOSS 2063641300 13023 GREENWOOD AVENUE NORTH SEATTLE WA 981337397 JOHN HENRY JR PRESIDENT & CEO 2063641300 2021-10-06 1 JOHN HENRY JR 999009999 KURT BENNION CPA P01469618 4252506100 2021-10-06 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z JOHN HENRY JR 13023 GREENWOOD AVENUE NORTH SEATTLE WA 981337397 18842622 0 X WWW.FOSSCARE.ORG X 1929 WA NURSING HOME AND ASSISTED LIVING FACILITY 9 9 367 20 0 0 366590 1660130 20638829 16588783 90179 125465 298928 283022 21394526 18657400 600 0 0 0 15486719 15241591 0 0 99967 5971932 5077958 21459251 20319549 -64725 -1662149 16994538 16533947 6712057 7829981 10282481 8703966 X NURSING HOME AND ASSISTED LIVING FACILITY 0 0 15817496 0 16588783 NURSING HOME AND ASSISTED LIVING CARE, INCLUDING A SUBSTANTIAL NUMBER OF MEDICAID AND MEDICARE SUPPORTED RESIDENTS/PATIENTS. 70% OF SERVICE REVENUE IS FROM MEDICARE/MEDICAID AND THE REMAINDER IS FROM PRIVATE PAY RESIDENTS. WE SERVED 299 NURSING HOME CLIENTS AND 59 ASSISTED LIVING CLIENTS. THE AVERAGE LENGTH OF STAY FOR SHORT-STAY RESIDENTS, DEFINED BY THOSE WHO STAYED 100 DAYS OR LESS, WAS 20.9 DAYS. RATES ARE SET BASED ON MARKET RATES IN THE SEATTLE AREA, AND ARE NECESSARY TO MAKE THE ORGANIZATION VIABLE. FOSS PARTNERS WITH COMMUNITY COLLEGES, COLLEGES AND UNIVERSITIES, TO PROVIDE A LEARNING ENVIRONMENT, FOR INTERN PROGRAMS IN THE AREAS OF DENTISTRY, PHARMACY, RESTORATIVE THERAPY, NURSING, AND NURSING ASSISTANT TRAINING. FOSS ALSO HAS AN ACTIVE VOLUNTEER PROGRAM THAT ENCOURAGES HIGH SCHOOL AND COLLEGE STUDENTS. 15817496 1 1 0 0 0 0 0 0 1 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 0 0 0 0 0 0 0 0 0 1 38 0 367 1 0 0 0 0 0 1 1 0 0 0 0 0 0 X 9 9 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X JOHN RICK HENRY JR 2063641300 13023 GREENWOOD AVENUE NORTH SEATTLE WA 981337397 PATRICIA UPDEGRAFF CFO & TREASURER (THROUGH MARCH 2020) 40.00 X 337920 0 6614 JOHN RICK HENRY JR PRESIDENT & CEO 40.00 X 234250 0 20491 BANAFSHEH BAHARLOO RN NURSE 40.00 X 203822 0 18481 RACHAEL GERDIS NHS VICE PRESIDENT & COO 40.00 X 143314 0 42199 LORINDA HOOPER DIRECTOR OF NURSING 40.00 X 139370 0 17714 SOLOMON G-KIDANE LPN NURSE 40.00 X 144674 0 12306 KIFLE SHEWANGIZAW LPN NURSE 40.00 X 138156 0 13610 ELLIOTT WESTERMAN CONTRACT CFO (MARCH-NOV 2020) 8.00 X 0 0 0 JULIE YARI CHAIR 0.50 X X 0 0 0 JEFF WEST RN VICE CHAIR 0.50 X X 0 0 0 LARRAINE KING SECRETARY 0.50 X X 0 0 0 KRIS CHICK TREASURER 0.50 X X 0 0 0 MARTA ACEDO TRUSTEE 0.50 X 0 0 0 LYNNE DASHER TRUSTEE 0.50 X 0 0 0 JOHN GIENAPP TRUSTEE 0.50 X 0 0 0 BEV ROACH TRUSTEE 0.50 X 0 0 0 JUDY WILDES TRUSTEE 0.50 X 0 0 0 1341506 0 131415 15 0 1 0 CONSONUS REHAB 4560 SE INTERNATIONAL WAY SUITE 10 MILWAUKIE OR 97222 THERAPY 559442 1 1358087 302043 1660130 RESIDENT FEES 623000 16588783 16588783 16588783 125465 125465 237960 178788 59172 59172 59172 19089 6434 12655 12655 MISCELLANEOUS INCOME 900099 210695 210695 GUEST MEAL INCOME 900099 500 500 211195 18657400 16588783 0 408487 593922 593922 11788169 9652286 2071998 63885 322865 256308 64861 1696 1423868 1124716 291708 7444 1112767 868969 238047 5751 19007 19007 53104 53104 1122725 786821 335394 510 32718 43 30338 2337 67402 25926 27015 14461 882753 592969 289784 7585 7585 130318 130318 554654 527224 27430 MEDICAL SUPPLIES 1096252 1096252 FOOD 640392 640392 BAD DEBT EXPENSE 171585 171585 REPAIRS & MAINTENANCE 122745 69325 53420 176718 4680 168155 3883 20319549 15817496 4402086 99967 4389720 3576068 1651379 1108484 57243 124040 198212 219915 24868827 15631955 8644519 9236872 2049084 2253631 4381 14937 16994538 16533947 1891912 1275771 201692 2430738 4381 14937 3424429 3223408 1189643 885127 6712057 7829981 X 9685437 8146808 597044 557158 10282481 8703966 16994538 16533947 -1662149 83634 0 X 0 1 X 1 0 X 477060 399150 332935 351078 1660130 3220353 18840234 19009743 19877132 20638829 16588783 94954721 34160 52968 58764 59524 19589 225005 19351454 19461861 20268831 21049431 18268502 98400079 0 0 0 98400079 216601 200940 288001 280969 363425 1349936 216601 200940 288001 280969 363425 1349936 40502 45972 140331 230959 210695 668459 19608557 19708773 20697163 21561359 18842622 100418474 0.97990 0.98270 0.01340 0.01150 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS INCOME RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 3528000 3528000 12962021 8441246 4520775 1306393 1115519 190874 7072413 6075190 997223 9236872 DEFFERRED COMPENSATION 885127 885127 X 18651158 83634 83634 18567524 89876 89876 18657400 20238218 0 20238218 81331 81331 20319549 PART IV, LINE 2B: THE ORGANIZATION HOLDS TRUST ACCOUNTS FOR RESIDENTS WHO REQUEST THAT WE DO SO AND FOR ANY RESIDENTS OF WHICH THE ORGANIZATION IS REPRESENTATIVE PAYEE FOR SOCIAL SECURITY PURPOSES. THE MONEY IS HELD IN AN INTEREST-BEARING CHECKING ACCOUNT. RESIDENTS CAN OBTAIN THEIR MONEY UPON REQUEST. PART X, LINE 2: FOSS IS A NONPROFIT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND FILES AN ANNUAL FEDERAL INFORMATION RETURN FORM 990. FOSS IS EXEMPT FROM INCOME TAXES EXCEPT FOR INCOME, IF ANY, DERIVED FROM UNRELATED BUSINESS ACTIVITIES. THERE WAS NO NET UNRELATED BUSINESS INCOME FOR THE YEARS ENDED DECEMBER 31, 2020 AND 2019. THE FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ISSUED ACCOUNTING STANDARDS CODIFICATION (ASC) TOPIC 740, INCOME TAXES (TOPIC 740) ON ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES. FOSS ADOPTED THIS GUIDANCE FOR THE YEARS ENDED DECEMBER 31, 2020 AND 2019. MANAGEMENT EVALUATED FOSS' TAX POSITIONS AND CONCLUDED THAT FOSS HAD TAKEN NO UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENTS TO THE FINANCIAL STATEMENTS TO COMPLY WITH THE PROVISIONS OF THIS GUIDANCE. FOSS IS NO LONGER SUBJECT TO U.S. FEDERAL INCOME TAX EXAMINATIONS BY TAX AUTHORITIES FOR THE YEARS BEFORE 2017. PART XI, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTIONS RESTRICTED FOR CAPITAL USE 8,545. EXPENSES NETTED AGAINST REVENUES IN THE FINANCIAL STATEMENTS 34,383. BAD DEBT EXPENSE 46,948. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUES IN THE FINANCIAL STATEMENTS 34,383. BAD DEBT EXPENSE 46,948. X X X X X 0 1 0 0 0 0 0 0 0 PATRICIA UPDEGRAFF CFO & TREASURER (THROUGH MARCH 2020) 337920 0 0 0 0 0 1336 0 5278 0 344534 0 0 0 JOHN RICK HENRY JR PRESIDENT & CEO 234250 0 0 0 0 0 9370 0 11121 0 254741 0 0 0 BANAFSHEH BAHARLOO RN NURSE 203822 0 0 0 0 0 8252 0 10229 0 222303 0 0 0 RACHAEL GERDIS NHS VICE PRESIDENT & COO 143314 0 0 0 0 0 5761 0 36438 0 185513 0 0 0 LORINDA HOOPER DIRECTOR OF NURSING 139370 0 0 0 0 0 5747 0 11967 0 157084 0 0 0 SOLOMON G-KIDANE LPN NURSE 144674 0 0 0 0 0 4195 0 8111 0 156980 0 0 0 KIFLE SHEWANGIZAW LPN NURSE 138156 0 0 0 0 0 5545 0 8065 0 151766 0 0 0 PART I, LINE 4B JOHN (RICK) HENRY, JR. AND PAT UPDEGRAFF PARTICIPATE IN A 457(F) SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. THERE WERE NO CONTRIBUTIONS INTO, ACCRUALS WITHIN, OR PAYMENTS OUT OF THE PLAN IN 2020. FORM 990, PART VI, SECTION A, LINE 1 THE ORGANIZATION HAS AN EXECUTIVE COMMITTEE CONSISTING OF THE OFFICERS OF THE BOARD, THE CHAIRPERSON OF THE FINANCE COMMITTEE, THE CHAIRPERSON OF THE STRATEGIC PLANNING COMMITTEE, AND THE CHAIRPERSON OF THE GOVERNANCE COMMITTEE. THE DUTIES OF THE EXECUTIVE COMMITTEE ARE TO (A) APPROVE THE AGENDA FOR EACH BOARD MEETING; (B) APPROVE ACTIONS ON BEHALF OF THE BOARD IN THE EVENT OF EMERGENCIES REQUIRING RESOLUTION BEFORE THE FULL BOARD CAN BE CONVENED OR BEFORE THE BOARD CAN APPROVE A UNANIMOUS WRITTEN CONSENT WITHOUT A MEETING; (C) SERVE AS THE SEARCH COMMITTEE FOR PRESIDENTIAL CANDIDATES; (D) ADOPT, SUBJECT TO RATIFICATION OR AMENDMENT BY THE BOARD, THE POSITION DESCRIPTION FOR THE PRESIDENT; (F) CONDUCT THE ANNUAL PERFORMANCE REVIEW WITH THE PRESIDENT; (F) PROVIDE FOR BOARD EDUCATION; (G) MAINTAIN INVOLVEMENT WITH THE OTHER STANDING COMMITTEES OF THE BOARD; AND (H) MAKE RECOMMENDATIONS TO THE BOARD FOR PERSONS TO FILL THE OFFICER POSITIONS OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 3 BETWEEN MARCH AND NOVEMBER 2020, CONTRACT CFO SERVICES WERE PROVIDED BY THE HEARTHSTONE, ANOTHER SENIOR LIVING ORGANIZATION IN SEATTLE, WASHINGTON. FORM 990, PART VI, SECTION B, LINE 11B PRIOR TO FILING, A DRAFT OF THE FORM 990 WAS REVIEWED BY THE CEO AND CFO, THEN SUBMITTED TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, THE CONFLICT OF INTEREST POLICY IS DISTRIBUTED AT THE BOARD MEETING, AND MEMBERS ARE REQUIRED TO COMPLETE AND SIGN THE FORM FOR PROPER DISCLOSURE. MEMBERS ARE DIRECTED TO NOTIFY THE BOARD DURING THE YEAR IF A CONFLICT OF INTEREST DEVELOPS. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD OF DIRECTORS REVIEWS SALARY DATA FROM A SALARY SURVEY COMPILED BY LEADINGAGE WASHINGTON AND FROM REVIEWING THE FORMS 990 OF COMPARABLE ORGANIZATIONS. THE CEO REVIEWS SALARY DATA IN A SIMILAR MANNER FOR THE OTHER OFFICERS. THE REVIEW PROCESS WAS LAST CONDUCTED IN 2019 FOR THE CEO AND IN 2018 FOR THE CFO. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST.