2021-11-19T13:15:27-06:00 2021-06-30 410746749 CLIFTONLARSONALLEN LLP 5001 SPRING VALLEY ROAD SUITE 600W DALLAS TX 75244 990 2020-07-01 760139802 ST DOMINIC VILLAGE STDO 7137418701 2401 HOLCOMBE BOULEVARD HOUSTON TX 77021 GRADY MULLINS CFO 7137418701 2021-11-18 1 GRADY MULLINS 999009999 MICHAEL SIEGEL P01587323 9723835700 2021-11-17 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z AMY SHIELDS 2401 HOLCOMBE BOULEVARD HOUSTON TX 77021 17034064 0 0928 X WWW.STDOMINICVILLAGE.ORG X 1998 TX CARING FOR OUR ELDERS WITH THE COMPASSION OF CHRIST BY HONORING OUR BELIEF IN THE DIGNITY OF LIFE AND SERVING A COMPASSIONATE COMMUNITY. 18 16 496 78 0 0 2268145 3215285 14712148 12472037 15019 32748 607004 1273694 17602316 16993764 0 0 0 0 7630684 6837092 0 0 518176 9588682 8954274 17219366 15791366 382950 1202398 15791091 15129243 7199144 5255348 8591947 9873895 X CARING FOR OUR ELDERS WITH THE COMPASSION OF CHRIST. 0 0 9153386 0 8724387 SKILLED NURSING FACILITY (SNF) - OUR REHABILITATION AND NURSING CENTER OFFERS BOTH SHORT TERM (SNF) AND LONG TERM SERVICES. WE HAVE MEDICARE AND MEDICAID CERTIFIED BEDS IN ADDITION TO ACCEPTING PRIVATE PAY AND HOSPICE RESIDENTS. 1646206 0 1569052 INDEPENDENT LIVING - OUR INDEPENDENT LIVING FACILITY HAS 120 ROOMS AVAILABLE ON A PRIVATE PAY BASIS ONLY. WE HAVE THREE LOCATIONS TO CHOOSE FROM FOR OUR INDEPENDENT ROOMS - CHARLOTTE HALL, DOROTHY HALL AND THE TOWER. 1504174 0 1433677 ASSISTED LIVING - OUR ASSISTED LIVING FACILITY HAS 48 ROOMS AVAILABLE ON A PRIVATE PAY BASIS ONLY. THE ROOMS ARE LOCATED IN THE TOP THREE FLOORS OF THE TOWER. THERE IS A FULL TIME NURSING STAFF THERE TO ASSIST THE RESIDENTS IN THIS FACILITY. 671264 0 639800 PRIEST RETIREMENT HOME - OUR PRIEST RETIREMENT FACILITY HAS 24 ROOMS AVAILABLE FOR RETIRED PRIESTS. WE HAVE A COOK THAT PREPARES ALL OF THEIR MEALS AND A DEACON THAT ASSISTS WITH OVERSIGHT OF THE PRIEST RETIREMENT HOME. 110290 0 105121 WARREN CHAPEL - THE WARREN CHAPEL IS LOCATED ON OUR CAMPUS AND OFFERS A PLACE OF WORSHIP FOR BOTH CATHOLICS AND OTHER DENOMINATIONS THAT LIVE HERE AT ST. DOMINIC VILLAGE. THE DAILY AND WEEKEND MASSES ARE OPEN TO THE PUBLIC. 781554 0 744921 13085320 1 1 0 0 0 0 0 0 1 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 67 0 496 1 0 0 0 0 0 1 1 0 0 0 0 0 0 X 18 16 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X GRADY MULLINS 7137418701 2401 HOLCOMBE BLVD HOUSTON TX 77021 MICHELE MALLOY CHAIR 0.50 0.00 X X 0 0 0 AIMEE GARCIA MD SECRETARY 0.50 0.00 X X 0 0 0 DR REED YOUNG BOARD MEMBER 0.50 0.00 X 0 0 0 HIS EMINENCE DANIEL CARDINAL DINARD STL, ARCHBISHOP OF GALVEST 0.50 0.00 X 0 0 0 HUBERT HAWTHORN BOARD MEMBER 0.50 0.00 X 0 0 0 JOHN MICHAEL GRIFFIN BOARD MEMBER 0.50 0.00 X 0 0 0 DEIDRA SMITH BOARD MEMBER 0.50 0.00 X 0 0 0 AAD DE LANGE BOARD MEMBER 0.50 40.00 X 0 182673 13242 VERY REV LAWRENCE W JOZWIAK BOARD MEMBER 0.50 0.00 X 0 0 0 SR DONNA POLLARD BOARD MEMBER 0.50 0.00 X 0 0 0 VICTOR J NARCISSE III MD BOARD MEMBER 0.50 0.00 X 0 0 0 JAMES J DAVIS BOARD MEMBER 0.50 0.00 X 0 0 0 MARK PROVENZANO MD BOARD MEMBER 0.50 0.00 X 0 0 0 JUDITH RAINES BOARD MEMBER 0.50 0.00 X 0 0 0 MOST REV GEORGE SHELTZ AUXILIARY BISHOP 0.50 40.00 X 0 45782 9500 FAITH SEPE BOARD MEMBER 0.50 0.00 X 0 0 0 MARGARET MCCONN BOARD MEMBER 0.50 0.00 X 0 0 0 JORGE GUZMAN BOARD MEMBER 0.50 0.00 X 0 0 0 AMY SHIELDS CEO 40.00 0.00 X 217813 0 2474 GRADY MULLINS CFO 40.00 0.00 X 151763 0 11209 ROBBIE BRADFORD DIRECTOR OF NURSING 40.00 0.00 X 131420 0 9733 500996 228455 46158 3 0 1 0 LUBYS FUDDRUCKERS RESTAURANTS LLC 13111 NORTHWEST FREEWAY SUITE 600 HOUSTON TX 77040 CAFETERIA 1500420 REHABCARE PO BOX 503534 ST LOUIS MO 60680 THERAPY 1137524 HEALTHCARE SERVICES GROUP 3220 TILLMAN DRIVE SUITE 300 BENSALEM PA 19020 DIETARY AND JANITORIAL 688950 UHS PREMIUM BILLING PO BOX 94017 PALATINE IL 60094 OUTSOURCED BILLING 630716 TWOMAGNETS INC 340 S LEMON AVE 5028 WALNUT CA 91789 STAFFING AGENCY 471349 11 19000 164494 1827621 1204170 7500 3215285 PROGRAM SERVICE FEES 623000 12472037 12472037 12472037 32748 32748 246411 19000 40300 206111 206111 INSURANCE REFUND 900099 557977 557977 MANAGEMENT SERVICES REVENUE 623990 442835 442835 OTHER REVENUE 623990 66771 66771 1067583 16993764 12472037 0 1306442 X 383259 357971 25288 5439765 4463024 676931 299810 167275 114305 43594 9376 410586 338822 49690 22074 436207 360062 55692 20453 35526 35526 4227364 3879482 254647 93235 35365 3961 19071 12333 1133956 1049077 78655 6224 989343 829823 147706 11814 4129 215 1477 2437 56886 40 56766 80 256947 102269 154678 774915 726192 48723 269881 250039 19842 REPAIRS AND MAINTENANCE 823055 745690 66137 11228 BAD DEBT 188206 188206 RECOGNITION EVENTS 106561 32800 70616 3145 OTHER EXPENSES 52140 1313 50148 679 15791366 13085320 2187870 518176 3253930 3005604 298292 613221 833194 747935 28173805 17857450 11033069 10316355 372606 446128 15791091 15129243 1221558 953693 159109 0 40534 38662 5672988 4247847 104955 15146 7199144 5255348 X 7520359 8118166 1071588 1755729 8591947 9873895 15791091 15129243 1202398 79550 0 X X 0 1 X 1 0 X 1927022 1764369 1102301 2268145 3215285 10277122 15515520 15867091 15278403 14712148 12472037 73845199 47200 61862 66725 23501 246411 445699 17489742 17693322 16447429 17003794 15933733 84568020 0 0 0 84568020 29622 12425 20280 15019 32748 110094 29622 12425 20280 15019 32748 110094 21363 47910 528114 498613 509606 1605606 17540727 17753657 16995823 17517426 16476087 86283720 0.98010 0.98590 0.00130 0.00110 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: OTHER REVENUE - 2016 AMOUNT: $ 20,969. 2017 AMOUNT: $ 47,910. 2018 AMOUNT: $ 57,920. 2019 AMOUNT: $ 86,340. 2020 AMOUNT: $ 66,771. INVENTORY SALES - 2016 AMOUNT: $ 394. MANAGEMENT SERVICE FEE - 2018 AMOUNT: $ 470,194. 2019 AMOUNT: $ 412,273. 2020 AMOUNT: $ 442,835. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 372606 86589 13067 446128 347927 7500 26629 9450 372606 314060 9125 24742 347927 254146 42388 17526 314060 98437 140664 15045 254146 0.65090 0.21790 0.13120 0 1 1 1362314 1362314 19049924 11986611 7063313 4181202 2644329 1536873 3522165 3226510 295655 58200 58200 10316355 ACCOUNTS PAYABLE TO THE ARCHDIOCESE 15146 15146 X 17113614 79550 40300 119850 16993764 0 16993764 15831666 40300 40300 15791366 0 15791366 PART IV, LINE 2B: THE ORGANIZATION HOLDS RESIDENT FUNDS IN A CUSTODIAL / TRUST ACCOUNT RECORDED ON ITS BALANCE SHEET. THOSE FUNDS ARE USED FOR THE BENEFIT OF EACH RESPECTIVE RESIDENT AS NEEDED. PART V, LINE 4: FUTURE USE FOR ST. DOMINIC VILLAGE PART X, LINE 2: SDV'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL AND STATE AUTHORITIES. SDV IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS EXEMPT STATUS. SDV IS NOT AWARE OF ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES. PART XI, LINE 2D - OTHER ADJUSTMENTS: DIRECT DONOR BENEFIT COSTS 40,300. PART XII, LINE 2D - OTHER ADJUSTMENTS: DIRECT DONOR BENEFIT COSTS 40,300. BISHOP RIZZOTO GOLF CLASSIC 126908 15500 111408 17038 6674 EVENING WITH THE BISHOPS 138503 3500 135003 11560 5028 265411 19000 246411 28598 11702 40300 206111 X X 0 0 0 0 0 0 0 0 0 AMY SHIELDS CEO 172898 0 44915 0 0 0 2474 0 0 0 220287 0 0 0 AAD DE LANGE BOARD MEMBER 0 170720 0 300 0 11653 0 13242 0 0 0 195915 0 0 GRADY MULLINS CFO 123422 0 28341 0 0 0 11209 0 0 0 162972 0 0 0 PART I, LINE 7 THE ORGANIZATION PAID PERFORMANCE BASED BONUSES. FORM 990, PART VI, SECTION A, LINE 1 THE ORGANIZATION HAS AN EXECUTIVE COMMITTEE CONSISTING OF THE CEO, THE OFFICERS OF THE BOARD OF DIRECTORS, AND THE CHAIR OF EACH COMMITTEE OF THE BOARD OF DIRECTORS. THE SPECIFIC DUTIES OF THE EXECUTIVE COMMITTEE INCLUDE, BUT ARE NOT LIMITED TO (I) RECOMMEND THE AGENDA FOR MEETINGS OF THE BOARD OF DIRECTORS; (II) COORDINATE THE WORK OF OTHER COMMITTEES, STAYING INFORMED ON PROPOSALS BEING PREPARED BY COMMITTEES AND WORKING WITH COMMITTEE CHAIRS TO SCHEDULE AND REVIEW PROPOSALS PRIOR TO PRESENTATION TO THE FULL BOARD OF DIRECTORS; (III) APPOINT CHAIRS OF STANDING AND AD HOC COMMITTEES; (IV) APPROVE POLICIES FOR OVERSIGHT AND GOVERNANCE OF THE ORGANIZATION; (V) OVERSEE MANAGEMENT OF COMMITTEES; (VI) REVIEW THE PERFORMANCE OF THE EXECUTIVE DIRECTOR ANNUALLY AND REPORT THE PERFORMANCE SUMMARY TO THE SOLE MEMBER; AND (VII) RECOMMEND TO THE BOARD OF DIRECTORS THE ANNUAL OPERATING BUDGET, STRATEGIC PLANS AND MAJOR FUNDRAISING ACTIVITIES. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF ST. DOMINIC VILLAGE IS THE BISHOP OF THE ARCHDIOCESE OF GALVESTON-HOUSTON. FORM 990, PART VI, SECTION A, LINE 7A THE DIRECTORS ARE APPOINTED BY THE ARCHDIOCESE OF GALVESTON-HOUSTON'S SELECTION COMMITTEE. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE MEMBER HAS THE FOLLOWING RIGHTS AND RESPONSIBILITIES. (I) REMOVE ANY DIRECTOR, WITH OR WITHOUT CAUSE, AT ANY TIME; (II) APPROVE ALL AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS; (III) APPROVE THE INCURRENCE OF INDEBTEDNESS IN EXCESS OF $10,000 IN ANY ONE TRANSACTION, THE GRANTING OF ANY MORTGAGE OR SECURITY INTEREST IN PROPERTY TO SECURE INDEBTEDNESS, OR THE SALE, LEASE OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL, OF THE ORGANIZATION'S ASSETS; AND (IV) THE POWER TO HIRE AND DISMISS THE EXECUTIVE DIRECTOR, IN CONNECTION WITH WHICH THE MEMBER MAY APPOINT A COMMITTEE TO ASSIST IN THE SEARCH FOR AN EXECUTIVE DIRECTOR. FORM 990, PART VI, SECTION B, LINE 11B THE 990 WILL BE REVIEWED BY THE FINANCE COMMITTEE AND THE CFO FOR ST. DOMINIC VILLAGE WILL LEAD THE DISCUSSION WITH THE FINANCE COMMITTEE. FORM 990, PART VI, SECTION B, LINE 12C EACH DIRECTOR, PRINCIPAL OFFICER, AND MEMBER OF A COMMITTEE WITH BOARD-DELEGATED POWERS SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS SUCH PERSON HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY, HAS READ AND UNDERSTANDS THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY, AND UNDERSTANDS THAT THE ORGANIZATION IS CHARITABLE AND IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX EXEMPT PURPOSES. EACH BOARD MEMBER IS REQUIRED TO DISCLOSE ANY CONFLICTS. IF A CONFLICT IS BROUGHT TO THE BOARD'S ATTENTION OR IT BECOMES AWARE OF A POTENTIAL CONFLICT, THE BOARD MEMBER MUST REMOVE HIMSELF/HERSELF FROM THE MEETING WHILE INDEPENDENT BOARD MEMBERS VOTE ON THE TRANSACTION OR ARRANGEMENT. THE DISINTERESTED BOARD MEMBERS DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. FORM 990, PART VI, SECTION B, LINE 15 ST. DOMINIC VILLAGE'S BOARD OF DIRECTORS REVIEWS AND APPROVES THE CEO'S COMPENSATION. MANAGEMENT UTILIZES THE HOSPITAL AND HEALTHCARE COMPENSATION SURVEY TO ASSIST IN REVIEWING THE SALARIES OF OTHER MANAGEMENT. FORM 990, PART VI, SECTION C, LINE 19 ST. DOMINIC VILLAGE MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 3,879,482. MANAGEMENT AND GENERAL EXPENSES 254,647. FUNDRAISING EXPENSES 93,235. TOTAL EXPENSES 4,227,364. FORM 990, PAGE 12, PART XII, LINE 2C THE ORGANIZATION HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. THIS PROCESS IS CONSISTENT WITH PRIOR YEARS. ARCHDIOCESE OF GALVESTON-HOUSTON 1700 SAN JACINTO HOUSTON TX 77002 746018777 RELIGIOUS TX 501(C)(3) LINE 1 N/A 0 0 0 1 0 1 0 0 0 0 0 1 0 0 1 0 0 1 0 0