2020-11-16T15:23:43-06:00 2019-12-31 381357951 PLANTE & MORAN PLLC 10 S RIVERSIDE PLAZA 9TH FLOOR CHICAGO IL 60606 990 2019-01-01 362382853 REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME REST 7083428100 18601 NORTH CREEK DRIVE TINLEY PARK IL 60477 BARRY VANDERGENUGTEN CFO 7083428100 2020-11-14 1 DAVID LOWENTHAL P00378651 3122071040 2020-11-14 99.137.156.52 2020-11-14 13:07:11 CS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 23D9C3BAD3C11415BCA5E3AEE50D281DF37E870F 2019 2021-01-29 14:40:06Z PROVIDENCE LIFE SERVICES RICHARD SCHUTT 18601 NORTH CREEK DRIVE TINLEY PARK IL 60477 101397324 0 X WWW.PROVIDENCELIFESERVICES.COM X 1956 IL REST HAVEN'S PURPOSE IS TO PROVIDE SERVICES FOR THE AGED INCLUDING SKILLED NURSING AND REHAB SERVICES, HOME HEALTH CARE, TOWN HOME LIVING, INDEPENDENT AND ASSISTED LIVING. 16 15 1619 350 418723 34313 3724032 1651685 78588450 63117604 856929 1095432 1515172 14265341 84684583 80130062 0 0 0 0 43934750 37398602 0 0 443514 38623198 30895808 82557948 68294410 2126635 11835652 94538589 92895917 73003843 67292282 21534746 25603635 X REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME D/B/A PROVIDENCE LIFE SERVICES (REST HAVEN) IS A NOT-FOR-PROFIT ILLINOIS CORPORATION WHOSE PURPOSE IS TO PROVIDE NURSING AND RESIDENTIAL LIVING ARRANGEMENTS FOR THE AGED INCLUDING SKILLED NURSING AND REHABILITATION SERVICES, HOME HEALTH CARE, TOWNHOME LIVING, INDEPENDENT LIVING, AND ASSISTED LIVING. 0 0 57437983 77415333 TO PROVIDE PROPER CARE FOR THE SICK AND ELDERLY. 926 BEDS/UNITS WITH OCCUPANCY OVER 84% ON THE FULL CONTINUUM OF CARE. 57437983 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 1 0 0 1 132 0 1 1619 1 1 1 0 0 0 0 1 1 0 0 0 0 1 0 X 16 15 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X BARRY VANDERGENUGTEN 7083428100 18601 NORTH CREEK DRIVE TINLEY PARK IL 60477 RICHARD SCHUTT DIRECTOR & CEO 40.00 10.00 X X 1995413 0 26022 BARRY VANDERGENUGTEN CFO 40.00 10.00 X 285879 0 30526 RAY HEMPHILL EVP PROJECT DEVELOPMENT 40.00 5.00 X 257816 0 30859 WILLIAM DEYOUNG COO 40.00 10.00 X 372252 0 70380 SCOTT STUDEBAKER VP MINISTRY ADVANCEMENT & DEV 40.00 5.00 X 167330 0 19267 WILLIAM BUIKEMA VP MINISTRY ADVANCEMENT 40.00 5.00 X 162731 0 16581 JEFF COURTNEY VP CONSTRUCTION 40.00 5.00 X 171283 0 27002 MEGAN TENGERSTORM VP OF SNF OPERATIONS 40.00 5.00 X 174529 0 10009 ROBERT WORKMAN CHAIR 1.00 2.00 X X 0 0 0 RICH VAN HATTEM CHAIR (JAN-MAY 2019) 1.00 2.00 X 0 0 0 DAVE LARSEN VICE CHAIR 1.00 2.00 X X 0 0 0 KEVIN BOTMA ASST. SECRETARY/TREASURER 1.00 2.00 X X 0 0 0 BILL ZANDSTRA SECRETARY/TREASURER 1.00 2.00 X X 0 0 0 ROGER BOEREMA DIRECTOR 1.00 2.00 X 0 0 0 JEAN CAVANAUGH DIRECTOR 1.00 2.00 X 0 0 0 AL DIEPSTRA DIRECTOR 1.00 2.00 X 0 0 0 JACOB GROENEWOLD DIRECTOR 1.00 2.00 X 0 0 0 SHERYL HAMMER DIRECTOR 1.00 2.00 X 0 0 0 PAUL KATS DIRECTOR 1.00 2.00 X 0 0 0 BASTIAN KNOPPERS DIRECTOR 1.00 2.00 X 0 0 0 EMILY MCMASTER DIRECTOR 1.00 2.00 X 0 0 0 HOWARD RYNBERK JR DIRECTOR 1.00 2.00 X 0 0 0 GARY SMIT DIRECTOR 1.00 2.00 X 0 0 0 TIM SMITS DIRECTOR 1.00 2.00 X 0 0 0 RICK VANDYKEN DIRECTOR 1.00 2.00 X 0 0 0 BOB VAN STAALDUINEN DIRECTOR 1.00 2.00 X 0 0 0 3587233 0 230646 22 0 1 0 SYMBRIA REHAB 28100 TORCH PARKWAY SUITE 600 WARRENVILLE IL 60555 THERAPY 2067721 PROVINET SOLUTIONS 18645 WEST CREEK DRIVE TINLEY PARK IL 60477 IT SERVICES 1508480 GORDON FOOD SERVICE INC PO BOX 88029 CHICAGO IL 60680 DINING SERVICES 1169215 SYMBRIA RX SERVICES 28100 TORCH PARKWAY SUITE 600 WARRENVILLE IL 60555 PHARMACY 1081472 CREATIVE DINING SERVICES ONE ROYAL PARK DRIVE STE 3 ZEELAND MI 49464 DINING SERVICES 946359 41 231900 1419785 1651685 ROUTINE REVENUE 621610 57286808 57286808 ANCILLARY REVENUE 621610 5830796 5412073 418723 63117604 543487 543487 813737 20750000 208457 20803335 605280 -53335 551945 -53335 605280 165289 231900 255470 -90181 -90181 SALE OF OPERATING ENTITY 900099 14355522 14355522 14355522 80130062 77001068 418723 1058586 2916012 2916012 28646885 24122773 4160522 363590 316445 256473 45428 14544 3115587 2385079 689832 40676 2403673 1851953 527016 24704 639560 639560 27000 27000 3662476 3400752 261724 1627599 1627599 1811936 1694673 117263 2321681 2184873 136808 2852908 2766247 86661 1736425 1646838 89587 NURSING EXPENSE 2969174 2969174 FOOD & DIETARY EXPENSE 2732743 2732743 REPAIRS & MAINTENANCE 1286767 1286767 PHARMACY EXPENSE 1230808 1230808 7996731 7281231 715500 68294410 57437983 10412913 443514 4057296 597747 310788 314306 13098933 9083700 593237 1291738 77273290 32937904 48160008 44335386 5910844 18584499 22407483 18688541 94538589 92895917 8492802 6256084 1758323 447654 57445884 49457062 5306834 11131482 73003843 67292282 X 21406190 25475079 128556 128556 21534746 25603635 94538589 92895917 X 11835652 1194013 -8960776 X 0 1 X 1 1 1 X 1346503 1341054 1337547 3724032 1651685 9400821 63937921 71192640 76087087 80188343 77473126 368879117 65284424 72533694 77424634 83912375 79124811 378279938 60952 81468 96282 142964 381666 0 60952 81468 96282 142964 381666 377898272 4674310 491933 480665 338317 542541 6527766 6835 17576 4136 16018 0 44565 4681145 509509 484801 354335 542541 6572331 69965569 73043203 77909435 84266710 79667352 384852269 0.98190 0.97560 0.01710 0.02040 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 4439747 4439747 65248060 30329845 34918215 4494096 2574535 1919561 3091387 33524 3057863 44335386 GROUND LEASE RECEIVABLES 1092336 ASSETS LIMITED TO USE 780689 DUE FROM AFFILIATES 9940310 OTHER ASSETS 432581 LEGAL LIABILITY INS RECOVERIES 5732428 DEFERRED COMP GRANTOR TRUST 376260 INVESTMENTS IN PMDC & PDG 333937 18688541 ESTIMATED SELF-INS LIABILITIES 7890300 ASSET RETIREMENT OBLIGATION 174135 RESIDENT NOTES AND DEPOSITS 1698307 ACCRUED INTEREST PAYABLE 128364 CHARITABLE ANNUITY CONTRACTS 125250 FMV INTEREST RATE SWAP VALUE 1115126 11131482 BANQUET 190858 115988 74870 133806 GOLF OUTING 163506 103866 59640 78466 2 42825 12046 30779 43198 397189 231900 165289 255470 255470 -90181 FORM 990, SCHEDULE G, PART II: THE ORGANIZATION HOSTS EVENTS FOR PUBLIC RELATIONS AND FUNDRAISING PURPOSES. THESE EVENTS ARE OFTEN UNDERWRITTEN BY LEADERSHIP SPONSORS OF WHICH THEIR SPONSORSHIPS ARE ALLOCATED AMONGST THE VARIOUS EVENTS. THE COMBINED GROSS RECEIPTS OF THE EVENTS TOTALED $397,189 FOR 2019. THE COMBINED COSTS OF THE EVENTS TOTALED $255,470. THE NET INCOME TO THE ORGANIZATION FOR HOSTING ALL OF THE EVENTS WAS $141,719. X 1 1 X X X X X 0 1 0 0 0 0 0 1 0 RICHARD SCHUTT DIRECTOR & CEO 500649 0 25186 0 1469578 0 11200 0 14822 0 2021435 0 1372554 0 BARRY VANDERGENUGTEN CFO 261580 0 11427 0 12872 0 10463 0 20063 0 316405 0 0 0 RAY HEMPHILL EVP PROJECT DEVELOPMENT 238228 0 10081 0 9507 0 9529 0 21330 0 288675 0 0 0 WILLIAM DEYOUNG COO 348691 0 14755 0 8806 0 48557 0 21823 0 442632 0 0 0 SCOTT STUDEBAKER VP MINISTRY ADVANCEMENT & DEV 158608 0 0 0 8722 0 6344 0 12923 0 186597 0 0 0 WILLIAM BUIKEMA VP MINISTRY ADVANCEMENT 154590 0 0 0 8141 0 6184 0 10397 0 179312 0 0 0 JEFF COURTNEY VP CONSTRUCTION 156867 0 7727 0 6689 0 6584 0 20418 0 198285 0 0 0 MEGAN TENGERSTORM VP OF SNF OPERATIONS 153111 0 19688 0 1730 0 2795 0 7214 0 184538 0 0 0 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. RICHARD SCHUTT AND WILLIAM DEYOUNG PARTICIPATE IN THE PLAN. IN 2019, RICHARD RECEIVED A DISTRIBUTION FROM THE ACCOUNT OF $1,450,030; HAVING ACHIEVED NORMAL RETIREMENT AGE AND OVER 40 YEARS OF EMPLOYMENT WITH REST HAVEN. 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 CONTINUOUSLY EMPLOYED THRU AND UNTIL 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 RECEIVED BASED UPON THE ACHIEVEMENT OR SATISFACTION OF SOME FUTURE EVENTS. THE PLAN CONTRIBUTIONS ARE NOT UNDER THE CONTROL OF THE EXECUTIVE, THEY REMAIN THE ASSET OF THE ORGANIZATION, AND THE ENTIRE PLAN IS SUBJECT TO A FULL RISK OF FORFEITURE BY THE INDIVIDUAL. PART I, LINE 7 THE 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 ORGANIZATION'S COMMITMENT TO PAY FOR SPECIFIC PERFORMANCE TOWARDS THE 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 POSITIONS IN SIMILARLY SIZED AND TYPE ORGANIZATIONS. THE COMMITTEE ROUTINELY RECEIVES AN EXECUTIVE COMPENSATION OPINION NOTING THAT THE ORGANIZATION'S 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 104843 EMPLOYMENT COMPENSATION; MASTERS PREPARED R.N. THAT LEADS THE ORGANZATION'S EDUCATION. 0 BONNIE HEIRENDT SISTER OF CEO 14130 EMPLOYMENT COMPENSATION 0 SCH L, PART IV: THE TRANSACTIONS REPORTED ABOVE INVOLVING INTERESTED PERSONS ARE REVIEWED ANNUALLY BY THE BOARD'S COMPENSATION COMMITTEE AND HAVE BEEN DEEMED APPROPRIATE BASED ON THE POSITION EMPLOYED. FORM 990, PART VI, SECTION B, 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 ITS FILING. FORM 990, PART VI, SECTION B, LINE 12C THE OFFICERS, DIRECTORS/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, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMPENSATION PROGRAM'S PRIMARY OBJECTIVE IS TO PROVIDE COMPETITVE TOTAL PAY OPPORTUNITIES THAT HELP ATTRACT, REWARD AND RETAIN CRITICAL LEADERSHIP TALENT IN ORDER TO ACHIEVE THE ORANIZATION'S 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 KNOWLEDGEABLE EXTERNAL CONSULTANTS TO ADVISE ON THE PROCESS AND HAS RECEIVED AFFIRMATION OF COMPLIANCE WITH IRS GUIDELINES FOR REASONABLENESS OF EXECUTIVE COMPENSATION IN TAX-EXEMPT ENTITIES. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: TRANSFER OF EQUITY TO RELATED ENTITIES -7,584,709. UNREALIZED LOSS ON INTEREST RATE SWAP -1,376,067. PROVIDENCE DEVELOPMENT GROUP 18601 N CREEK DRIVE TINLEY PARK IL 60477 DEVELOPMENT IL 0 3013198 REST HAVEN PARK PLACE REALTY GROUP LLC 18601 N CREEK DRIVE TINLEY PARK IL 60477 REAL ESTATE IL 47373 130687 REST HAVEN PROVIDENCE OPERATIONS LLC 18601 N CREEK DRIVE TINLEY PARK IL 60477 OPERATIONS IL 19768324 6202684 REST HAVEN PROVIDENCE TENANT LLC 18601 N CREEK DRIVE TINLEY PARK IL 60477 REAL ESTATE IL 0 0 REST HAVEN PROVIDENCE PALOS HEIGHTS LLC 18601 N CREEK DRIVE TINLEY PARK IL 60477 REAL ESTATE IL 135698 0 PROVIDENCE TENANT LLC PROVIDENCE DOWNERS GROVE LLC 18601 N CREEK DRIVE TINLEY PARK IL 60477 REAL ESTATE IL 983346 7062234 PROVIDENCE TENANT LLC PROVIDENCE GRAND RAPIDS LLC 18601 N CREEK DRIVE TINLEY PARK IL 60477 REAL ESTATE IL 414152 2293712 PROVIDENCE TENANT LLC ROYAL PARK PLACE II LLC 18601 N CREEK DRIVE TINLEY PARK IL 60477 REAL ESTATE IL 3181186 4803105 REST HAVEN CHRISTIAN HEALTHCARE FOUNDATION 18601 N CREEK DRIVE TINLEY PARK IL 60477 200722359 RESEARCH IL 501(C)(3) LINE 10 REST HAVEN 1 CHRISTIAN LIVING CAMPUS 18601 N CREEK DRIVE TINLEY PARK IL 60477 200226221 SENIOR LIVING IL 501(C)(3) LINE 10 REST HAVEN 1 TIMOTHY PLACE 18601 N CREEK DRIVE TINLEY PARK IL 60477 201835089 SENIOR LIVING IL 501(C)(3) LINE 10 REST HAVEN 1 PARK PLACE OF ST JOHN 18601 N CREEK DRIVE TINLEY PARK IL 60477 201834903 SENIOR LIVING IL 501(C)(3) LINE 10 REST HAVEN 1 HUDSONVILLE PARK PLACE 18601 N CREEK DRIVE TINLEY PARK IL 60477 201834667 SENIOR LIVING IL 501(C)(3) LINE 10 REST HAVEN 1 PROVIDENCE MGMT & DEVELOPMENT 18601 N CREEK DRIVE TINLEY PARK IL 60477 363774205 IT SERVICES IL N/A C -70947 5757600 1.00000 1 PROVIDENCE HOUSING CORPORATION 18601 N CREEK DRIVE TINLEY PARK IL 60477 461379112 HOUSING IL REST HAVEN C 43465 633092 1.00000 1 0 0 0 1 0 0 0 0 0 0 1 0 0 1 1 1 1 1 1 PROVIDENCE MGMT & DEVELOPMENT P 1627599 FMV PROVIDENCE MGMT & DEVELOPMENT Q 684596 FMV TIMOTHY PLACE Q 360000 FMV PARK PLACE OF ST JOHN Q 1132776 FMV