2019-11-14T15:44:04-06:00 2018-12-31 381357951 PLANTE & MORAN PLLC 10 S RIVERSIDE PLAZA 9TH FLOOR CHICAGO IL 60606 990 2018-01-01 362382853 REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME REST 7083428100 18601 NORTH CREEK DRIVE TINLEY PARK IL 60477 BARRY VANDERGENUGTEN CFO 7083428100 2019-11-07 1 DAVID LOWENTHAL P00378651 3122071040 2019-11-07 67.59.56.31 2019-11-07 08:50:06 CS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 E8885A5DE86C3E42C2EA91F2F4BBC110C3D198A0 2018 2020-04-17 16:48:07Z PROVIDENCE LIFE SERVICES RICHARD SCHUTT 18601 NORTH CREEK DRIVE TINLEY PARK IL 60477 89468408 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 1704 350 16018 1586 1337547 3724032 76091223 78588450 370793 856929 -105829 1515172 77693734 84684583 0 0 0 0 41095474 43934750 0 0 448686 37628969 38623198 78724443 82557948 -1030709 2126635 96055082 94538589 75195808 73003843 20859274 21534746 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 73542948 80188343 TO PROVIDE PROPER CARE FOR THE SICK AND ELDERLY. 998 BEDS/UNITS WITH OCCUPANCY OVER 84% ON THE FULL CONTINUUM OF CARE. 73542948 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 91 0 1 1704 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 X 16 15 0 0 0 0 0 0 0 1 1 0 0 0 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 988853 0 175074 RICH VAN HATTEM CHAIR 1.00 2.00 X X 0 0 0 JUSTIN KATS CHAIR (JAN-MAY 2018) 1.00 2.00 X X 0 0 0 DAVE LARSEN SECRETARY/TREASURER 1.00 2.00 X X 0 0 0 BOB VAN STAALDUINEN DIRECTOR 1.00 2.00 X 0 0 0 LUCETTE BAMFORD DIRECTOR 1.00 2.00 X 0 0 0 BILL ZANDSTRA DIRECTOR 1.00 2.00 X 0 0 0 ROBERT WORKMAN DIRECTOR 1.00 2.00 X 0 0 0 DON VAN DYK DIRECTOR 1.00 2.00 X 0 0 0 RICK VANDYKEN DIRECTOR 1.00 2.00 X 0 0 0 TIM SMITS DIRECTOR 1.00 2.00 X 0 0 0 HOWARD RYNBERK JR DIRECTOR 1.00 2.00 X 0 0 0 BASTIAN KNOPPERS DIRECTOR 1.00 2.00 X 0 0 0 PAUL KATS DIRECTOR 1.00 2.00 X 0 0 0 AL DIEPSTRA DIRECTOR 1.00 2.00 X 0 0 0 JEAN CAVANAUGH DIRECTOR 1.00 2.00 X 0 0 0 KEVIN BOTMA DIRECTOR 1.00 2.00 X 0 0 0 ROGER BOEREMA DIRECTOR 1.00 2.00 X 0 0 0 GARY SMIT DIRECTOR 1.00 2.00 X 0 0 0 WILLIAM DEYOUNG COO 40.00 10.00 X 373815 0 78752 BARRY VANDERGENUGTEN CFO 40.00 10.00 X 264383 0 35292 JEAN LAROCHE VP HOME & COMMUNITY BASED SERVICES 40.00 5.00 X 156019 0 12874 WILLIAM BUIKEMA VP MINISTRY ADVANCEMENT 40.00 5.00 X 156436 0 28555 SCOTT STUDEBAKER VP MINISTRY ADVANCEMENT & DEVELOPMENT 40.00 5.00 X 161783 0 22218 JEFF COURTNEY VP CONSTRUCTION 40.00 5.00 X 171221 0 37984 RAY HEMPHILL EVP PROJECT DEVELOPMENT 40.00 5.00 X 256576 0 45093 2529086 0 435842 36 0 1 0 PROVINET SOLUTIONS 18645 WEST CREEK DRIVE TINLEY PARK IL 60477 IT SERVICES 1448092 GORDON FOOD SERVICE INC PO BOX 88029 CHICAGO IL 60680 DINING SERVICES 1265010 SYMBRIA REHAB 28100 TORCH PARKWAY SUITE 600 WARRENVILLE IL 60555 THERAPY 1173515 CREATIVE DINING SERVICES ONE ROYAL PARK DRIVE STE 3 ZEELAND MI 49464 DINING SERVICES 991256 SYMBRIA RX SERVICES 28100 TORCH PARKWAY SUITE 600 WARRENVILLE IL 60555 PHARMACY 937782 23 304637 3419395 3724032 ROUTINE REVENUE 621610 74090961 74090961 ANCILLARY REVENUE 621610 4497489 4481471 16018 78588450 338317 338317 5051473 4532861 518612 518612 518612 150225 304637 250964 -100739 -100739 SALE OF OPERATING ENTITY 900099 1615911 1615911 1615911 84684583 80188343 16018 756190 1916169 1916169 34955692 30561284 4034224 360184 411526 334344 62715 14467 3965133 2885911 1029758 49464 2686230 2374242 287417 24571 30255 30255 127176 127176 5987724 5987724 2195397 2195397 1923695 1793018 130677 2543114 2409644 133470 3163629 3090071 73558 3215326 3122566 92760 NURSING EXPENSE 5122538 5122538 FOOD & DIETARY EXPENSE 3105757 3105757 PHARMACY EXPENSE 2202393 2202393 REPAIRS & MAINTENANCE 1656622 1656364 258 7349572 6701695 647877 82557948 73542948 8566314 448686 555531 4057296 307345 310788 13968152 13098933 224675 593237 82952104 34792096 52130522 48160008 14887425 5910844 13981432 22407483 96055082 94538589 8541119 8492802 2035426 1758323 59282271 57445884 5336992 5306834 75195808 73003843 X 20715151 21406190 144123 128556 20859274 21534746 96055082 94538589 X 2126635 -903839 -547324 X 0 1 X 1 1 1 X 1313214 1346503 1341054 1337547 3724032 9062350 57958718 63937921 71192640 76087087 80188343 349364709 59271932 65284424 72533694 77424634 83912375 358427059 60952 81468 96282 238702 1245568 1245568 60952 81468 1341850 1484270 356942789 1412613 4674310 491933 480665 338317 7397838 12268 6835 17576 4136 16018 56833 1424881 4681145 509509 484801 354335 7454671 60696813 69965569 73043203 77909435 84266710 365881730 0.97560 0.97690 0.02040 0.02260 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 4469746 4469746 69170524 31798617 37371907 6000459 2969191 3031268 3311375 24288 3287087 48160008 GROUND LEASE RECEIVABLES 1168106 ASSETS LIMITED TO USE 1107901 DUE FROM AFFILIATES 15239007 OTHER ASSETS 434299 LEGAL LIABILITY INS RECOVERIES 1404244 DEFERRED COMP GRANTOR TRUST 1562640 INVESTMENTS IN PMDC & PDG 333937 INTEREST RATE SWAP VALUE 1157349 22407483 ESTIMATED SELF-INS LIABILITIES 3064227 ASSET RETIREMENT OBLIGATION 349409 RESIDENT NOTES AND DEPOSITS 1632207 ACCRUED INTEREST PAYABLE 135741 CHARITABLE ANNUITY CONTRACTS 125250 5306834 BANQUET 205740 124320 81420 136435 GOLF OUTING 209055 150015 59040 77595 2 40067 30302 9765 36934 454862 304637 150225 250964 250964 -100739 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 $454,862 FOR 2018. THE COMBINED COSTS OF THE EVENTS TOTALED $250,964. THE NET INCOME TO THE ORGANIZATION FOR HOSTING ALL OF THE EVENTS WAS $203,898. X X 1 1 X X X X X 0 1 0 1 0 0 0 1 0 RICHARD SCHUTT DIRECTOR & CEO 486067 0 38241 0 464545 0 149145 0 25929 0 1163927 0 450000 0 WILLIAM DEYOUNG COO 338534 0 23848 0 11433 0 45752 0 33000 0 452567 0 0 0 BARRY VANDERGENUGTEN CFO 236387 0 16717 0 11279 0 9456 0 25836 0 299675 0 0 0 JEAN LAROCHE VP HOME & COMMUNITY BASED SERVICES 146363 0 7500 0 2156 0 0 0 12874 0 168893 0 0 0 WILLIAM BUIKEMA VP MINISTRY ADVANCEMENT 150087 0 0 0 6349 0 6004 0 22551 0 184991 0 0 0 SCOTT STUDEBAKER VP MINISTRY ADVANCEMENT & DEVELOPMEN 153988 0 0 0 7795 0 6159 0 16059 0 184001 0 0 0 JEFF COURTNEY VP CONSTRUCTION 152299 0 12229 0 6693 0 5796 0 32188 0 209205 0 0 0 RAY HEMPHILL EVP PROJECT DEVELOPMENT 231289 0 16293 0 8994 0 9252 0 35841 0 301669 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. THE ORGANIZATION HAS ESTABLISHED A SENIOR EXECUTIVE MANAGEMENT PROGRAM WHICH ALLOWS STATED EMPLOYEES TO JOIN A FITNESS CENTER. ELIGIBLE EMPLOYEES THAT ENROLL ARE REQUIRED TO BE ACTIVELY UTILIZING THE FITNESS CENTER. NO SENIOR EXECUTIVE RECEIVED THIS BENEFIT IN 2018. 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 2018, RICHARD RECEIVED A DISTRIBUTION FROM THE ACCOUNT OF $450,000. IN 2005, THE BOARD OF DIRECTORS ESTABLISHED A RETENTION INITIATIVE PLAN 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, THE EXECUTIVE HAS NOT RECEIVED THESE MONIES AND WILL ONLY BE ELIGIBLE TO RECEIVE THEM 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 5 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 RECEIVES AN EXECUTIVE COMPENSATION OPINION NOTING THAT THE ORGANIZATION'S EXECUTIVE COMPENSATION FALLS WITHIN THE RANGE OF COMPARABLE POSITIONS WITHIN THE SAME INDUSTRY. THE REPORT/OPINION ALSO NOTES THAT THE STATED REQUIREMENTS OF ENSURING INDEPENDENCE OF COMPENSATION DELIBERATIONS FOR SENIOR EXECUTIVES ARE MET. PART I, LINE 7 AS INDICATED IN SCHEDULE J, PART II, CERTAIN INDIVIDUALS RECEIVED BONUSES BASED ON PERFORMANCE AND THE FINANCIAL RESULTS OF THE ORGANIZATION. THESE BONUSES ARE APPROVED BY THE COMPENSATION COMMITTEE. LINDA SCHUTT SPOUSE OF CEO 99401 EMPLOYMENT COMPENSATION 0 BONNIE HEIRENDT SISTER OF CEO 52378 EMPLOYMENT COMPENSATION 0 ALLISON OLESHKO DAUGHTER OF CEO 19578 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, A COMPLETED COPY OF THE 990 IS PROVIDED TO THE FULL BOARD PRIOR TO SUBMISSION. 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 -865,935. UNREALIZED GAIN ON INTEREST RATE SWAP 318,611. PROVIDENCE DEVELOPMENT GROUP 18601 N CREEK DRIVE TINLEY PARK IL 60477 DEVELOPMENT IL 0 3257098 REST HAVEN PARK PLACE REALTY GROUP LLC 18601 N CREEK DRIVE TINLEY PARK IL 60477 REAL ESTATE IL 52637 86951 REST HAVEN PROVIDENCE OPERATIONS LLC 18601 N CREEK DRIVE TINLEY PARK IL 60477 OPERATIONS IL 38374916 7334652 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 813362 3428615 PROVIDENCE TENANT LLC PROVIDENCE DOWNERS GROVE LLC 18601 N CREEK DRIVE TINLEY PARK IL 60477 REAL ESTATE IL 939211 7073532 PROVIDENCE TENANT LLC PROVIDENCE GRAND RAPIDS LLC 18601 N CREEK DRIVE TINLEY PARK IL 60477 REAL ESTATE IL 414056 2337389 PROVIDENCE TENANT LLC PROVIDENCE ZEELAND LLC 18601 N CREEK DRIVE TINLEY PARK IL 60477 REAL ESTATE IL 107284 0 REST HAVEN ROYAL PARK PLACE II LLC 18601 N CREEK DRIVE TINLEY PARK IL 60477 REAL ESTATE IL 2947539 1482856 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 HAVEN PARK 18601 N CREEK DRIVE TINLEY PARK IL 60477 383026594 HEALTHCARE MI 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 THOMAS PLACE LP 18601 N CREEK DRIVE TINLEY PARK IL 60477 999999999 IL 0 0 PROVIDENCE MGMT & DEVELOPMENT 18601 N CREEK DRIVE TINLEY PARK IL 60477 363774205 IT SERVICES IL N/A C 14327 6094393 1.00000 1 PROVIDENCE HOUSING CORPORATION 18601 N CREEK DRIVE TINLEY PARK IL 60477 461379112 HOUSING IL REST HAVEN C 73725 592529 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 2195397 FMV PROVIDENCE MGMT & DEVELOPMENT Q 407582 FMV TIMOTHY PLACE Q 360000 FMV PARK PLACE OF ST JOHN Q 915897 FMV