2020-11-16T12:55:11-06:00 2019-12-31 951777440 GREEN HASSON & JANKS LLP 10990 WILSHIRE BLVD 16TH FLOOR LOS ANGELES CA 900243929 990 2019-01-01 475552178 PACIFIC NEUROSCIENCE INSTITUTE FOUNDATION PACI 3105827450 2125 ARIZONA AVE SANTA MONICA CA 90404 MELISSA B COLEMAN ESQ VICE PRESIDENT 3105827450 2020-11-15 1 LIZBETH G NEVAREZ P01399868 3108731600 75.82.225.227 2020-11-15 18:13:35 PS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 6A5B9BBBC0C15FAE84D58941C3D029285B6C5672 2019 2021-01-29 14:40:06Z MELISSA B COLEMAN ESQ 2125 ARIZONA AVE SANTA MONICA CA 90404 7030351 0 X WWW.PACIFICNEUROSCIENCEINSTITUTE.ORG X 2015 CA TO PROMOTE ADVANCES IN NEUROSCIENCE CLINICAL CARE AND RESEARCH THROUGH NOVEL TREATMENT APPROACHES THAT OPTIMIZE BRAIN HEALTH AND QUALITY OF LIFE, TO TRAIN THE NEXT GENERATION OF NEUROSCIENTISTS AND CLINICIANS, AND TO EDUCATE PATIENTS AND THE COMMUNITY AT LARGE ON VITAL NEUROSCIENCE ISSUES. 9 5 7 13 0 0 3003853 7001807 26685 28333 82 211 0 0 3030620 7030351 240000 1516055 0 0 502307 1986247 0 0 85717 2301692 2130006 3043999 5632308 -13379 1398043 5515222 7787547 236481 247135 5278741 7540412 X TO FUNDAMENTALLY ADVANCE NEUROSCIENCE CLINICAL CARE THROUGH NOVEL TREATMENT APPROACHES THAT OPTIMIZE BRAIN HEALTH AND QUALITY OF LIFE, TO TRAIN THE NEXT GENERATION OF NEUROSCIENTISTS AND CLINICIANS, AND TO EDUCATE PATIENTS AND THE COMMUNITY AT LARGE ON VITAL NEUROSCIENCE ISSUES. 1 0 1459582 0 0 THE PACIFIC BRAIN HEALTH CENTER IS DEDICATED TO PROVIDING COMPREHENSIVE AND HOLISTIC CARE TO PATIENTS WITH DEMENTIA AND ASSOCIATED NEUROLOGICAL DISORDERS, AS WELL AS PROBLEMS OF MEMORY LOSS, DEPRESSION, ANXIETY AND ADDICTION. 3773726 1516055 28333 SUPPORT OF THE EDUCATION AND COLLABORATION OF NEUROSCIENTISTS AND CLINICIANS REGARDING TECHNIQUES FOR THE OPTIMIZATION OF BRAIN HEALTH.EDUCATING AND INFORMING THE PUBLIC ABOUT NEW DEVELOPMENTS IN NEUROSCIENCE RESEARCH, TREATMENTS AND CLINICAL TRIALS.PRODUCTION OF EDUCATIONAL VIDEOS AND IMAGES TO ADVANCE AND EDUCATE THE PUBLIC AND CLINICIANS REGARDING NEW AND IMPROVED NEUROSCIENCE TECHNIQUES. 5233308 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 0 1 0 1 0 0 0 0 0 1 0 0 0 1 19 0 1 7 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 5 1 0 0 0 1 1 1 1 0 0 0 1 1 1 1 0 0 0 0 0 CA X HOWARD R KRAUSS MD 3105827450 2125 ARIZONA AVENUE SANTA MONICA CA 90404 X SARAH MCEWEN DIRECTOR OF RESEARCH 40.00 0.00 X 202531 0 16738 KARTER WHITE ADMINSTRATIVE DIRECTOR 40.00 0.00 X 121117 0 7305 RITA JETHANI TITLE 40.00 0.00 X 100796 0 4369 DANIEL F KELLY MD PRESIDENT & CEO 10.00 2.00 X X 0 0 0 CHESTER F GRIFFITHS MD CHAIRPERSON 8.00 2.00 X X 0 0 0 HOWARD R KRAUSS MD CFO 3.00 1.00 X X 0 0 0 SANTOSH KESARI MD SECRETARY 4.00 1.00 X X 0 0 0 DONNA TUTTLE BOARD MEMBER 1.00 1.00 X 0 0 0 CAROLE SCHWARTZ BOARD MEMBER 1.00 1.00 X 0 0 0 JAE GOODMAN BOARD MEMBER 1.00 1.00 X 0 0 0 CARLA MANN WOODS BOARD MEMBER 1.00 0.00 X 0 0 0 BLAINE LOURD BOARD MEMBER 1.00 0.00 X 0 0 0 424444 0 28412 3 0 1 0 PACIFIC NEUROSCIENCE INSTITUTE MEDICAL G 2125 ARIZONA AVENUE SANTA MONICA CA 90404 RESEARCH & ADMINSTRATIVE SERVICES 2062571 1 7001807 7001807 PROGRAM EVENT INCOME 900099 28333 28333 28333 211 211 7030351 28333 0 211 1516055 1516055 202531 189183 5339 8009 1613142 1506832 42524 63786 130151 128238 1913 40423 40423 140542 140542 29051 29051 175768 118256 57512 24147 23349 798 16584 6751 9311 522 260336 256184 4152 132000 124000 5000 3000 5704 5471 233 3532 2991 252 289 103114 82491 15467 5156 1115 1115 RESEARCH EXPENSE 1189242 1189242 DUES AND SUBSCRIPTIONS 16535 14464 1941 130 COMMUNITY OUTREACH AND 16400 14519 1881 MEDICAL RECORDS AND SUP 1573 1573 14363 13286 1077 5632308 5233308 313283 85717 97458 542624 235713 1307257 10899 5945 16400 3778 15902 12622 217670 117836 4937580 5801263 5515222 7787547 236481 166677 80458 236481 247135 X 341161 1739149 4937580 5801263 5278741 7540412 5515222 7787547 X 1398043 -55 863683 X 0 0 0 X 749455 1266968 3003853 7001807 12022083 749455 1266968 3003853 7001807 12022083 12022083 55 74 82 211 422 12022505 54991 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 16400 3778 12622 12622 BENEFICIAL INTEREST IN ASSETS HELD BY SJHCF 5801263 5801263 1 JOHN WAYNE CANCER INSTITUTE 2200 SANTA MONICA BLVD SANTA MONICA CA 90404 954291515 501(C)(3) 1516055 RESEARCH SUPPORT 1 PART I, LINE 2: PACIFIC NEUROSCIENCE INSTITUTE FOUNDATION MONITORS THE USE OF THE GRANTS THROUGH ONGOING COMMUNICATION WITH THE GRANTEE ORGANIZATION. 0 0 0 0 0 0 0 0 0 SARAH MCEWEN DIRECTOR OF RESEARCH 202531 0 0 0 0 0 16738 0 0 0 219269 0 0 0 DANIEL F KELLY MD DFK INC PRESIDENT AND CEO OF THE FOUNDATION OPERATIONS LOAN X 80458 80458 0 1 0 80458 PACIFIC NEUROSCIENCE INSTITUTE MEDICAL GROUP INC OWNED BY 4 OFFICERS OF THE FOUNDATION 2062571 THE ORGANIZATION CONTRACTED WITH PNIMG, INC. TO PROVIDE RESEARCH AND ADMINISTRATIVE SERVICES TO THE ORGANIZATION. 0 FORM 990, PART III, LINE 2 LAUNCHING OF "TRIP" (TREATMENT RESEARCH AND PSYCHODELICS) PROGRAM IN THE PACIFIC BRAIN HEALTH CENTER. FORM 990, PART VI, SECTION A, LINE 2 THE OFFICERS AND DIRECTORS OF THE ORGANIZATION ARE ALSO: I) MEMBERS AND MANAGERS IN PACIFIC NEUROSCIENCE INSTITUTE, LLC; AND II) SHAREHOLDERS, OFFICERS AND DIRECTORS IN A PROFESSIONAL MEDICAL CORPORATION (PACIFIC NEUROSCIENCE INSTITUTE MEDICAL GROUP, INC.). FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS TWO MEMBERS PACIFIC NEUROSCIENCE INSTITUTE, LLC AND SAINT JOHN'S HEALTH CENTER FOUNDATION FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS ELECT THE GOVERNING BODY OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7B THE MEMBERS HAVE THE AUTHORITY TO APPROVE THE GOVERNING BODY'S DECISION TO FILL A VACANCY ON THE GOVERNING BODY IF SUCH VACANCY WAS CREATED BY REMOVAL OF A DIRECTOR, AND TO APPROVE THE AMENDMENT OF THE BY-LAWS. FORM 990, PART VI, SECTION A, LINE 8B THIS QUESTION IS NOT APPLICABLE SINCE THE ORGANIZATION HAS NO COMMITTEES FORMED. FORM 990, PART VI, SECTION B, LINE 11B AN ELECTRONIC COPY OF THE FORM 990 AND ITS SUPPORTING SCHEDULES WERE DISTRIBUTED TO THE ORGANIZATION'S GOVERNING BODY FOR REVIEW PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S GOVERNING BODY PERIODICALLY REVIEWS ACTIVITIES IN WHICH IT AND MEMBERS OF ITS GOVERNING BODY ARE PARTICIPATING TO ENSURE THAT ANY AND ALL ARRANGEMENTS (AND ESPECIALLY THOSE WHICH MAY APPEAR TO POSE A CONFLICT OF INTEREST) ARE PROPERLY DOCUMENTED AND REFLECT REASONABLE AND SUPPORTABLE ECONOMIC COMPONENTS SO AS TO NOT RESULT IN INUREMENT, IMPERMISSIBLE PRIVATE BENEFITS OR EXCESS BENEFIT TRANSACTIONS. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN ASSETS HELD BY AFFILIATE 863,683. SAINT JOHN'S HEALTH CENTER FOUNDATION 2121 SANTA MONICA BLVD SANTA MONICA CA 90404 956100079 NON-PROFIT/FUNDRAISING CA 501(C)(3) LINE 7 0 PACIFIC NEUROSCIENCE INSTITUTE LLC 11645 WILSHIRE BLVD 6TH FL LOS ANGELES CA 90064 472490586 MANAGEMENT/INVESTMENT CA N/A N/A 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0