2020-08-14T13:58:24-05:00 2019-09-30 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2018-10-01 391412320 CAPITOL LAKES INC CAPI 8887246424 333 WEST MAIN STREET MADISON WI 53703 TIM CONROY EXECUTIVE DIRECTOR 8887246424 2020-08-11 1 KURT BENNION P01469618 4252506100 2020-08-11 67.137.57.251 2020-08-11 21:38:00 PD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 CB8FE41F7A1541848066F2058C3AF12D9D3FCB15 2018 2020-09-23 17:36:50Z SUE CENTER 1 WEST MAIN SUITE 303 MEDFORD OR 97501 24834829 0 X WWW.RETIREMENT.ORG X 1990 WI TO PROVIDE CARE AND HOUSING FOR THE ELDERLY. 7 7 405 100 0 0 208344 207383 21870492 22577973 72411 75198 15174 15702 22166421 22876256 0 0 0 0 11781417 11874450 0 0 0 12383261 12508738 24164678 24383188 -1998257 -1506932 45660123 44358065 100767254 100919690 -55107131 -56561625 CAPITOL LAKES IS A VIBRANT CONTINUING CARE RETIREMENT COMMUNITY COMMITTED TO THE ENRICHMENT OF RESIDENTS' LIVES. 0 0 19987549 0 22577973 CAPITOL LAKES IS A CONTINUING CARE RETIREMENT COMMUNITY, DEDICATED TO ENHANCING OUR RESIDENTS' QUALITY OF LIFE IN A STIMULATING, SECURE ENVIRONMENT. WE PROVIDE HIGH-QUALITY SERVICES INCLUDING HOUSING, NUTRITIOUS MEALS, NURSING, HOUSEKEEPING, MAINTENANCE, AND OTHER SUPPORT TO THOSE WE SERVE. OUR LEVELS OF SERVICE INCLUDE INDEPENDENT LIVING, ASSISTED LIVING, AND SKILLED NURSING. 19987549 1 1 0 1 0 0 0 0 1 0 1 0 0 0 1 1 0 1 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 1 1 1 0 0 1 64 0 1 405 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 7 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X JOSH BLACKSON 5418577205 1 WEST MAIN SUITE 303 MEDFORD OR 97501 X X SUE CENTER CHAIR 1.00 2.00 X X 0 0 0 CLAY NORRBOM VICE CHAIR 1.00 0.00 X X 0 0 0 SALLY DREW SECRETARY/TREASURER 1.00 0.00 X X 0 0 0 STEVE JOHANNSEN DIRECTOR 1.00 1.00 X 0 0 0 HARRY PETERSON DIRECTOR 1.00 0.00 X 0 0 0 INGRID ROTHE RESIDENT DIRECTOR 1.00 0.00 X 0 0 0 KARIL WALTHER DIRECTOR 1.00 0.00 X 0 0 0 TIM CONROY EXECUTIVE DIRECTOR 40.00 1.00 X 235158 0 51539 KRISTIN VATER HEALTH CENTER ADMINISTRATOR 40.00 1.00 X 128045 0 24976 STEVEN MELLSTROM HR DIRECTOR 40.00 0.00 X 112951 0 22516 TSERING DAMDUL REGISTERED NURSE 40.00 0.00 X 103940 0 21574 580094 0 120605 4 0 1 0 CONSONUS REHAB PO BOX 4800 UNIT 12 PORTLAND OR 97208 THERAPY SERVICES 1726544 PACIFIC RETIREMENT SERVICES INC 1 WEST MAIN SUITE 303 MEDFORD OR 97501 MANAGEMENT SERVICES 1664694 MCGANN CONSTRUCTION INC 3622 LEXINGTON AVENUE MADISON WI 53714 CONSTRUCTION SERVICES 183771 CREATIVE SOLUTIONS 4 LLC 2310 DANIELS STREET SUITE A MADISON WI 53718 FLOORING AND DESIGN SERVICES 146667 MADISON UNITED HEALTHCARE LINEN LTD 1310 W BADGER ROAD MADISON WI 53713 LINEN SERVICES 116603 5 59231 148152 207383 SERVICE FEES 623000 10401650 10401650 HEALTH CENTER 623000 10040880 10040880 ENTRANCE FEES 623000 1294629 1294629 DIETARY 623000 268835 268835 GARAGE & CARPORT 623000 58075 58075 513904 513904 22577973 82294 82294 15702 0 15702 15702 15702 1951477 1958573 -7096 -7096 -7096 22876256 22577973 0 90900 238386 238386 9115474 8217343 898131 425661 365650 60011 1403365 1240026 163339 691564 614831 76733 1643578 1643578 17043 17043 24500 24500 5582 5582 891925 532938 358987 350672 115 350557 898337 790388 107949 226271 226271 1313639 1311397 2242 104784 34027 70757 49386 34175 15211 35077 35077 2930671 2930671 202870 202870 HEALTH CENTER EXPENSE 2510505 2510505 OTHER DIETARY EXPENSE 945947 945947 OTHER FACILITY SERVICE 217380 81018 136362 PROGRAM FUND EXPENSES 140571 140571 24383188 19987549 4395639 0 1924153 3279612 1612075 1812684 86788 94862 329101 298797 67580293 32732264 36485450 34848029 4270602 3102532 951954 921549 45660123 44358065 1757782 1870224 8327318 8847989 606890 655341 49729327 47407144 40345937 42138992 100767254 100919690 X -56084640 -57516309 901182 878357 76327 76327 -55107131 -56561625 45660123 44358065 X -1506932 82843 -30405 X 0 1 X 1 0 X 74655 3626110 153353 208344 207383 4269845 20589111 20773042 20867694 21870492 22577973 106678312 20663766 24399152 21021047 22078836 22785356 110948157 41383 41383 0 41383 41383 110906774 286356 175326 59231 64206 97996 683115 286356 175326 59231 64206 97996 683115 20950122 24574478 21080278 22143042 22883352 111631272 0.99350 0.99190 0.00610 0.00770 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 24383188 24383188 1000000 250000 0 0 1000000 1000000 1000000 1000000 4000000 6000000 250000 250000 250000 250000 1000000 1500000 0 1 X 8537600 8537600 54587346 30178511 24408835 3511938 2553753 958185 943409 943409 34848029 DUE TO AFFILIATES 2276591 OTHER CURRENT LIABILITIES 25175 ENTRANCE FEES REFUNDABLE UPON REOCCUPANCY 39837226 42138992 X PART IV, LINE 2B: RESIDENT SECURITY DEPOSITS ARE HELD IN A SEPARATE BANK ACCOUNT. WHEN THE RESIDENT LEAVES THE FACILITY THE SECURITY DEPOSIT, MINUS ANY AMOUNTS RETAINED FOR REPAIRS, IS REFUNDED. PART X, LINE 2: THE CORPORATION RECOGNIZES THE TAX BENEFIT FROM UNCERTAIN TAX POSITIONS ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITIONS WILL BE SUSTAINED ON EXAMINATION BY THE TAX AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE TAX BENEFIT IS MEASURED BASED ON THE LARGEST BENEFIT THAT HAS A GREATER THAN 50% LIKELIHOOD OF BEING REALIZED UPON ULTIMATE SETTLEMENT. THE CORPORATION RECOGNIZES INTEREST AND PENALTIES RELATED TO INCOME TAX MATTERS IN OPERATING EXPENSES. AT SEPTEMBER 30, 2019 AND 2018, THERE WERE NO SUCH UNCERTAIN TAX POSITIONS. 0 0 0 0 0 0 0 1 0 TIM CONROY EXECUTIVE DIRECTOR 205770 0 29388 0 0 0 31131 0 20408 0 286697 0 0 0 KRISTIN VATER HEALTH CENTER ADMINISTRATOR 116195 0 11850 0 0 0 14085 0 10891 0 153021 0 0 0 PART I, LINE 3 COMPENSATION WAS DETERMINED BY PACIFIC RETIREMENT SERVICES, INC., A RELATED ORGANIZATION, THAT USED ONE OR MORE OF THE METHODS DESCRIBED ON LINE 3 TO ESTABLISH COMPENSATION. PART I, LINE 7 THE ORGANIZATION PAID BONUSES THIS YEAR. THE PROCESS FOR DETERMINING EXECUTIVE BONUSES IS DISCRETIONARY. IT IS DETERMINED BY THE VP OF OPERATIONS FOR PRS AND IT IS BASED ON THE PERFORMANCE OF THE COMMUNITY FOR THE YEAR. FORM 990, PART VI, SECTION A, LINE 3 CAPITOL LAKES, INC. DELEGATES MANAGEMENT DUTIES TO PACIFIC RETIREMENT SERVICES, INC. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS ONE MEMBER, PACIFIC RETIREMENT SERVICES, INC. FORM 990, PART VI, SECTION A, LINE 7A PACIFIC RETIREMENT SERVICES, INC. HAS THE RIGHT TO ELECT THE DIRECTORS OF THE BOARD OF CAPITOL LAKES, INC. FORM 990, PART VI, SECTION A, LINE 7B THE AUTHORITY OF THE BOARD OF DIRECTORS TO EXERCISE THE FOLLOWING POWERS IS CONDITIONED UPON THE APPROVAL OF THE CORPORATE MEMBER: (A) MERGER, CONSOLIDATION OR DISSOLUTION OF THE ORGANIZATION; (B) AMENDMENT OR RESTATEMENT OF THE ARTICLES OF INCORPORATION OF THE ORGANIZATION; (C) SALE, LEASE, EXCHANGE, OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL THE PROPERTY AND ASSETS OF THE ORGANIZATION; (D) THE ESTABLISHMENT, FORMATION, ACQUISITION, MERGER, CONSOLIDATION OR DISSOLUTION OF ANY SUBSIDIARY ORGANIZATION; (E) THE ADOPTION OF THE AGGREGATE ANNUAL OPERATING AND CAPITAL BUDGETS OF THE ORGANIZATION; (F) AGGREGATE BORROWING FOR PERIODS OF ONE (1) YEAR OR LESS FOR ANY PURPOSE IN EXCESS OF A DOLLAR AMOUNT TO BE ESTABLISHED BY THE MEMBER FROM TIME TO TIME; AND AGGREGATE BORROWING FOR PERIODS OF MORE THAN ONE (1) YEAR FOR ANY PURPOSE IN EXCESS OF A DOLLAR AMOUNT TO BE ESTABLISHED BY THE MEMBER FROM TIME TO TIME; (G) THE PURCHASE, SALE, LEASE DISPOSITION HYPOTHECATION, EXCHANGE, GIFT, PLEDGE, AND ENCUMBRANCE OF ANY ASSET, REAL OR PERSONAL, WITH A VALUE IN EXCESS OF A DOLLAR AMOUNT TO BE ESTABLISHED BY THE MEMBER FROM TIME TO TIME, NOT PREVIOUSLY INCLUDED IN THE CAPITAL BUDGET; (H) THE APPOINTMENT OF AN INDEPENDENT AUDITOR; (I) GIFTS OR GRATUITOUS TRANSFERS IN EXCESS OF $5,000 IN A CALENDAR YEAR; (J) ADOPTION OR REVISION OF THE MISSION STATEMENT AND LONG RANGE PLANS; AND (K) INCUR ANY DEBT OR ENTER INTO ANY CONTRACT NOT CONTEMPLATED BY THE ANNUAL BUDGET IF THE DOLLAR AMOUNT EXCEEDS THE SUM OF $100,000. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS REVIEWED BY THE CFO, ASSISTANT CONTROLLER AND THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY AND QUESTIONNAIRE ARE SENT TO ALL BOARD MEMBERS AND KEY EMPLOYEES ANNUALLY. THERE ARE TWO POLICIES RELATED TO CONFLICTS OF INTEREST: 1) BOARD OF DIRECTORS; 2)KEY EMPLOYEES, WHICH IDENTIFY THE PURPOSE, DEFINITIONS, AND PROCEDURES. IF A CONFLICT IS SELF-IDENTIFIED BY A BOARD MEMBER OR KEY EMPLOYEE IN THE QUESTIONNAIRE AND/OR MEETING, PROCEDURES ARE FOLLOWED AND DOCUMENTED ACCORDING TO THE POLICY. FORM 990, PART VI, SECTION B, LINE 15A A COMPENSATION COMMITTEE OF THE PRS BOARD EXISTS TO DETERMINE COMPENSATION FOR THE EXECUTIVE DIRECTOR OF EACH COMMUNITY. THIS COMMITTEE IS COMPRISED OF THE OFFICERS OF THE PRS BOARD OF DIRECTORS. THE COMMITTEE HAS A CHARTER THAT OUTLINES ITS DUTIES AND RESPONSIBILITIES. IT ALSO HAS AGENDA ELEMENTS THAT DESCRIBE THE ACTIVITIES THAT THE COMMITTEE UNDERTAKES DURING THE YEAR. THE VP OF HUMAN RESOURCES PROVIDED SALARY STUDIES FROM THE FOLLOWING RESOURCES TO THE COMMITTEE RELATIVE TO EXECUTIVE DIRECTOR COMPENSATION: SALARY.COM, PAYSCALE.COM, 990 REVIEW (LIKE SIZE ORGANIZATIONS), CEMO (CHIEF EXECUTIVE OFFICERS OF MULTI-FACILITY ORGANIZATIONS) SALARY STUDY RESULTS, AND INDUSTRY STATE ASSOCIATION SALARY STUDY RESULTS BASED ON GEOGRAPHICAL LOCATION. THE RECOMMENDATION FOR BASE COMPENSATION AND BONUS ARE PROVIDED BY THE EXECUTIVE DIRECTOR'S DIRECT SUPERVISOR (COO OR VP OF OPERATIONS). FORM 990, PART VI, SECTION C, LINE 19 ALL REQUESTS GO THROUGH CORPORATE COUNSEL. FORM 990, PART VII, SECTION A: NOTE THAT TIM CONROY AND KRISTIN VATER ARE LEASED EMPLOYEES OF PACIFIC RETIREMENT SERVICES, INC. AND PERFORM SERVICES ON BEHALF OF CAPITOL LAKES, INC. PURSUANT TO A MANAGEMENT SERVICES AGREEMENT BETWEEN CAPITOL LAKES, INC. AND PACIFIC RETIREMENT SERVICES, INC. UNDER THE MANAGEMENT SERVICES AGREEMENT, THEIR COMPENSATION IS REIMBURSED BY CAPITOL LAKES, INC. COMPENSATION HAS BEEN REPORTED IN PART VII, SECTION A IN ORDER TO HIGHLIGHT AMOUNTS PAID BY CAPITOL LAKES, INC., NOTWITHSTANDING THAT THEY ARE LEASED EMPLOYEES OF PACIFIC RETIREMENT SERVICES, INC. FORM 990, PART XI, LINE 9: CHANGES IN INTEREST IN NET ASSETS OF FOUNDATION -30,405. 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INC 0 BAY AREA SENIOR SERVICES INC 1 BALDWIN AVE SAN MATEO CA 94401 943008774 SENIOR HOUSING CA 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 CREST PARK INC 1 WEST MAIN SUITE 303 MEDFORD OR 97501 931169683 REAL ESTATE OR N/A C 0 PRS MANAGEMENT 1 WEST MAIN SUITE 303 MEDFORD OR 97501 931328250 MANAGEMENT COMPANY OR N/A C 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0 CAPITOL LAKES FOUNDATION INC C 59231 CASH