2019-11-14T18:37:59-06:00 2018-12-31 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2018-01-01 910573114 FOSS HOME & VILLAGE FOSS 2063641300 13023 GREENWOOD AVENUE NORTH SEATTLE WA 981337397 JOHN HENRY JR PRESIDENT & CEO 2063641300 2019-11-12 1 KURT BENNION CPA P01469618 4252506100 2019-11-12 67.137.57.251 2019-11-12 16:56:32 PS P 3C05182BCE949607266F40F8D21D5C2A178D6925 E09C09F2C4E2FA36523102FEE5AD791B68C33EF8 2018 2020-03-31 21:24:44Z JOHN HENRY JR 13023 GREENWOOD AVENUE NORTH SEATTLE WA 981337397 20697163 0 X WWW.FOSSCARE.ORG X 1929 WA NURSING HOME AND ASSISTED LIVING FACILITY 11 11 377 200 0 0 399150 332935 19009743 19877132 87540 131820 92742 166647 19589175 20508534 3000 2100 0 0 14138906 14283466 0 0 114866 5656734 5506553 19798640 19792119 -209465 716415 16470342 16941740 6980548 6883176 9489794 10058564 X NURSING HOME AND ASSISTED LIVING FACILITY. 0 0 15463398 2100 19877132 NURSING HOME AND ASSISTED LIVING CARE, INCLUDING A SUBSTANTIAL NUMBER OF MEDICARE AND MEDICAID SUPPORTED RESIDENTS/PATIENTS. 67% OF SERVICE REVENUE IS FROM MEDICARE/MEDICAID AND THE REMAINDER IS FROM PRIVATE PAY RESIDENTS. WE SERVED 489 NURSING HOME CLIENTS AND 83 ASSISTED LIVING CLIENTS. THE AVERAGE LENGTH OF STAY FOR SHORT-STAY RESIDENTS, DEFINED BY THOSE WHO STAYED 100 DAYS OR LESS, WAS 16.7 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 TO FULFILL THEIR REQUIREMENTS SERVING AND THEREFORE UNDERSTANDING THE NEEDS OF OUR GROWING ELDERLY POPULATION. 15463398 1 1 0 0 0 0 0 0 1 0 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 0 0 0 0 1 49 0 377 1 0 0 0 0 0 1 1 0 0 0 0 0 0 X 11 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X PATRICIA UPDEGRAFF 2063641300 13023 GREENWOOD AVENUE NORTH SEATTLE WA 981337397 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 MARTA ACEDO TRUSTEE 0.50 X 0 0 0 KRIS CHICK 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 CARLOS GUANGORENA TRUSTEE 0.50 X 0 0 0 JANE JONES TRUSTEE 0.50 X 0 0 0 BEV ROACH TRUSTEE 0.50 X 0 0 0 JUDY WILDS TRUSTEE 0.50 X 0 0 0 JOHN RICK HENRY JR PRESIDENT & CEO 40.00 X 188068 0 21904 PATRICIA UPDEGRAFF CFO & TREASURER 40.00 X 109131 0 35887 BANAFSHEH BAHARLOO RN NURSE 40.00 X 149628 0 13377 KIFLE SHEWANGIZAW LPN NURSE 40.00 X 133117 0 12549 LORINDA HOOPER DIRECTOR OF NURSING 40.00 X 128412 0 6601 JOSE GABUCAN RN NURSE 40.00 X 120334 0 12016 RACHAEL GERDIS NHA VICE PRESIDENT & COO 40.00 X 103895 0 31118 932585 0 133452 7 0 1 0 CONSONUS REHAB 4560 SE INTERNATIONAL WAY SUITE 10 MILWAUKIE OR 97222 THERAPY 955215 1 24000 308935 332935 RESIDENT FEES 623000 19877132 19877132 19877132 131820 131820 156181 168350 -12169 -12169 -12169 24542 24000 7803 16739 16739 32777 12476 20301 20301 MISCELLANEOUS INCOME 900099 140331 140331 GUEST MEAL INCOME 900099 1445 1445 141776 20508534 19877132 0 298467 2100 2100 354990 354990 11181588 8829702 2285969 65917 299986 242301 55876 1809 1345918 1071592 266326 8000 1100984 846776 247887 6321 9018 9018 48850 48850 1492285 1269344 220964 1977 59489 2883 34799 21807 48943 23408 23587 1948 727078 516132 210946 6685 4848 1837 146210 146210 485763 461475 24288 MEDICAL SUPPLIES 1197560 1197560 FOOD 713630 713630 BAD DEBT EXPENSE 200088 200088 MISCELLANEOUS EXPENSES 181361 1225 173049 7087 189593 80334 109259 19792119 15463398 4213855 114866 4800453 4616189 1633319 1762306 68372 71523 282081 140410 23014648 14364072 7962698 8650576 1711910 1683824 11509 16912 16470342 16941740 1827157 1898834 198123 203779 11509 16912 3805358 3619763 1138401 1143888 6980548 6883176 X 8864330 9407927 625464 650637 9489794 10058564 16470342 16941740 716415 -147645 0 X 0 1 X 1 0 X 378895 312003 477060 399150 332935 1900043 18116861 18479346 18840234 19009743 19877132 94323316 37936 33571 34160 52968 58764 217399 18533692 18824920 19351454 19461861 20268831 96440758 0 0 0 96440758 136905 173102 216601 200940 288001 1015549 136905 173102 216601 200940 288001 1015549 158919 125623 40502 45972 140331 511347 18829516 19123645 19608557 19708773 20697163 97967654 0.98440 0.98730 0.01040 0.00890 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS INCOME RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 3086638 3086638 12054386 7617430 4436956 1264256 1038419 225837 6609368 5708223 901145 8650576 DEFFERRED COMPENSATION 1143888 1143888 X 20203521 -147645 91067 -56578 20260099 248435 248435 20508534 19713024 7803 7803 19705221 86898 86898 19792119 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, 2018 AND 2017. THE FINANCIAL ACCOUNTING STANDARDS BOARD 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, 2018 AND 2017. MANAGEMENT EVALUATED FOSS'S 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 2016. PART XI, LINE 2D - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTION 83,264. FUNDRAISING EVENT EXPENSES 7,803. PART XI, LINE 4B - OTHER ADJUSTMENTS: CAPITAL CONTRIBUTIONS 53,100. RESTRICTED CONTRIBUTIONS FOR CAPITAL USE 108,437. EXPENSES NETTED AGAINST REVENUES IN THE FINANCIAL STATEMENTS 34,149. BAD DEBT EXPENSE 52,749. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EVENT EXPENSES 7,803. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUES IN THE FINANCIAL STATEMENTS 34,149. BAD DEBT EXPENSE 52,749. SPRING BRUNCH 21826 10791 11035 2105 800 564 CHRISTMAS SHIP 21660 10709 10951 936 1300 125 641 1 5056 2500 2556 500 630 202 48542 24000 24542 3541 2730 125 1407 7803 16739 X X X X X 0 1 0 0 0 0 0 0 0 JOHN RICK HENRY JR PRESIDENT & CEO 188068 0 0 0 0 0 8399 0 13505 0 209972 0 0 0 BANAFSHEH BAHARLOO RN NURSE 149628 0 0 0 0 0 6520 0 6857 0 163005 0 0 0 PART I, LINE 4B JOHN (RICK) HENRY, JR. AND PAT UPDEGRAFF PARTICIPATE IN A 457(F) SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. THERE WAS NO ACTIVITY WITHIN THE PLAN IN 2018. 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 B, LINE 11B THE FORM 990 WAS REVIEWED BY THE CEO AND CFO AND DISTRIBUTED TO ALL BOARD MEMBERS PRIOR TO FILING. IT WILL BE REVIEWED AT A BOARD MEETING AFTER FILING. 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 2017 FOR THE CEO AND IN 2016 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.