2019-08-14T10:57:31-05:00 2018-09-30 390859910 BAKER TILLY VIRCHOW KRAUSE LLP 225 S 6TH ST 2300 MINNEAPOLIS MN 55402 990 2017-10-01 952821104 HENRY MAYO NEWHALL MEMORIAL HOSPITAL HENR 6612002000 23845 MCBEAN PARKWAY VALENCIA CA 91355 TED D SIROTTA SENIOR VP/CFO 6612002000 2019-08-14 1 LAWRENCE H MOHR CPA P00447603 6128764500 2019-08-12 73.24.24.118 2019-08-14 07:09:55 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 F928441D2398D0B4DCF9932C1CB380BE5D4089C9 2017 2019-02-21 02:37:17Z ROGER E SEAVER 23845 MCBEAN PARKWAY VALENCIA CA 91355 406523387 0 X WWW.HENRYMAYO.COM X 1972 CA TO PROVIDE HEALTH CARE SERVICES TO THE CITIZENS OF SANTA CLARITA VALLEY AND SURROUNDING AREAS, AND IMPROVE THE HEALTH OF OUR COMMUNITY THROUGH COMPASSION AND EXCELLENCE. 15 12 2354 442 0 0 4740818 9169520 329529917 359299917 1095058 8188003 5897227 7352818 341263020 384010258 6587768 20957656 0 0 156148412 164741774 0 0 0 171911685 201124412 334647865 386823842 6615155 -2813584 487164798 497226293 306836451 318729654 180328347 178496639 TO PROVIDE HEALTH CARE SERVICES TO THE CITIZENS OF SANTA CLARITA VALLEY AND SURROUNDING AREAS, AND IMPROVE THE HEALTH OF OUR COMMUNITY THROUGH COMPASSION AND EXCELLENCE IN HEALTHCARE SERVICES. 0 0 327683569 4086122 371051985 TO PROVIDE HEALTH CARE SERVICES TO THE CITIZENS OF SANTA CLARITA VALLEY AND SURROUNDING AREAS. THE HOSPITAL HAD 56,853 PATIENT DAYS DURING THE YEAR. WE ALSO PROVIDED SERVICES FOR 69,959 EMERGENCY VISITS. 80% OF TOTAL HOSPITAL INPATIENT ADMITS (EXCLUDING NEWBORNS) ARE ADMITTED THROUGH THE EMERGENCY ROOM. 16971534 16871534 TO SUPPORT GENERAL OPERATIONS OF HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION, AN AFFILIATE TO THE HOSPITAL. DURING FISCAL YEAR 2018, A UNIQUE TRANSFER WAS MADE TO THE FOUNDATION TO FINANCE A REAL PROPERTRY ACQUISITION. 344655103 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 1 1 1 0 0 1 313 0 1 2354 1 0 0 0 0 0 0 0 0 0 0 X 15 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 CA X RICHARD KIM 6612002000 23845 MCBEAN PARKWAY VALENCIA CA 91355 ROGER E SEAVER PRESIDENT/CEO 40.00 0.50 X X 949386 0 53015 JOHN BARSTIS MD TRUSTEE 0.00 0.50 X 0 0 0 ROBERT BENJAMIN TRUSTEE 0.00 0.50 X 0 0 0 MARK CHAMBERLAIN TRUSTEE 0.00 0.50 X 0 0 0 LAKHBINDER DHANDA MD TRUSTEE 0.00 0.50 X 0 0 0 SONYA ENGLE TRUSTEE 0.00 0.50 X 0 0 0 JUDY FISH TRUSTEE 0.00 0.50 X 0 0 0 CHERI FLEMING TRUSTEE 0.00 0.50 X 0 0 0 RUSSELL HANLIN TRUSTEE 0.00 0.50 X 0 0 0 DONALD KIMBALL TRUSTEE 0.00 0.50 X 0 0 0 CHRIS LUECHTEFELD TRUSTEE 0.00 0.50 X 0 0 0 ROSCOE MARTER MD TRUSTEE 0.00 0.50 X 0 0 0 DON NISHIGUCHI MD TRUSTEE 0.00 0.50 X 0 0 0 CRAIG PETERS TRUSTEE 0.00 0.50 X 0 0 0 TODD STEVENS TRUSTEE 0.00 0.50 X 0 0 0 LARRY R KIDD SR VP/CCO 40.00 0.00 X 431335 0 39380 TED D SIROTTA SR VP/CFO 40.00 0.00 X 71996 0 8089 MARK A PULEO VP/CHRO 40.00 0.00 X 240608 0 53505 JONATHAN S MILLER VP-FACILTY/SUPPORT 40.00 0.00 X 231367 0 44615 KINGMAN HO MD CHIEF MEDICAL OFFICER 40.00 0.00 X 389484 0 46330 PAIGE E HEAPHY VP PERFORMANCE MGMT 40.00 0.00 X 249570 0 42921 JENNIFER R CASTALDO VP/CNO 40.00 0.00 X 164346 0 10595 RAY B MOSS VP/CIO 40.00 0.00 X 115827 0 14428 KEITH BOYLE DIRECTOR OF SERVICE EXCELLENCE 40.00 0.00 X 197706 0 24355 ADNAN E HAMID DIRECTOR OF IT 40.00 0.00 X 198437 0 28612 DONNA G FERGUSON DIRECTOR OF SURGERY 40.00 0.00 X 192549 0 29131 MARIA B SARTE CLINICAL RN 40.00 0.00 X 196929 0 6212 HAROUTIOUN SHAMAMIAN DIRECTOR OF PHARMACY 40.00 0.00 X 226743 0 17025 CR BOB HUDSON VP/CFO (FORMER) 40.00 0.00 X 349090 0 27341 CYNTHIA A PETERSON VP/CIO (FORMER) 40.00 0.00 X 180544 0 1196 4385917 0 446750 367 1 1 0 BERNARDS BROS INC 555 FIRST ST SAN FERNANDO CA 91340 CONSTRUCTION 50784605 SODEXO INC & AFFILIATES 9801 WASHINGTON BLVD GAITHERSBURG MD 20878 OTHER PURCHASED SERVICES 9139565 CALIFORNIA REHABILITATION SERVICES 333 E GLENOAKS BLVD STE 204 GLENDALE CA 91207 MEDICAL PURCHASED SERVICES 7042219 FACEY MEDICAL GROUP 26357 MCBEAN PARKWAY VALENCIA CA 91355 MEDICAL PURCHASED SERVICES 3301912 MEDEFIS INC 2121 N 117TH AVE STE 200 OMAHA NE 68164 MEDICAL PURCHASED SERVICES 2685491 108 2335977 6710256 123287 9169520 HEALTHCARE SERVICES 621110 359299917 359299917 359299917 2670714 2670714 1179609 0 1179609 1179609 1179609 24246432 3783986 21223796 1289333 3022636 2494653 5517289 5517289 REBATES & REFUNDS 621110 1694514 1694514 FITNESS CENTER REVENUE 621110 1614357 1614357 CAFETERIA SALES 621110 1118039 1118039 1746299 1746299 6173209 384010258 371051985 0 3788753 X 17581626 17581626 3376030 3376030 3826461 3350241 476220 130854687 114837148 16017539 3546371 3156270 390101 16615683 13723681 2892002 9898572 8819496 1079076 1786554 62335 1724219 542749 22985 519764 16918 16918 201062 201062 51351622 42733165 8618457 799539 216447 583092 2246191 330238 1915953 3858188 3858188 8341044 7754840 586204 339149 115985 223164 142604 90553 52051 4225307 4218921 6386 17245743 17245743 2741916 2741916 MEDICAL SUPPLIES 47288741 47288741 QUALITY ASSURANCE FEES 23343858 23343858 BAD DEBT 21642387 21642387 SOFTWARE IMPAIRMENT 5850830 5850830 9160010 6151667 3008343 386823842 344655103 42168739 0 34087066 36228877 18990467 5535319 53335450 53193930 5944383 5990170 3219582 3051232 473465136 189950501 229632334 283514635 98949891 95371751 28547814 1089771 14457811 13250608 487164798 497226293 67118291 69559616 2387587 2345110 230119412 225001900 10500000 7211161 11323028 306836451 318729654 X 171669347 169354607 8659000 9142032 180328347 178496639 487164798 497226293 -2813584 981876 0 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 16918 16918 0 PART II-B, LINE 1: FOR THE FISCAL YEAR ENDED 9/30/18, THE ORGANIZATION PARTICIPATED WITH THE CALIFORNIA HOSPITAL ASSOCIATION TO ADVOCATE POSITIVE HEALTHCARE POLICIES FOR HOSPITALS. 3225812 3225812 200926938 98285588 102641350 119131744 91664557 27467187 150180642 356 150180286 283514635 DEFERRED RENT 1161279 QUALITY ASSURANCE FEE DEFERRED REVENUE 8980966 ESTIMATED THIRD PARTY LIABILITIES 1180783 11323028 X 381616104 981876 981876 380634228 3376030 3376030 384010258 383447812 0 383447812 3376030 3376030 386823842 PART X, LINE 2: THE ORGANIZATION IS EXEMPT FROM INCOME TAXES PURSUANT TO SECTION 501 (C)(3) OF THE INTERNAL REVENUE CODE ("IRC") AND A SIMILAR PROVISION OF STATE LAW. ACCORDINGLY, NO PROVISION FOR INCOME TAXES FOR THIS ENTITY HAS BEEN MADE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE ORGANIZATION IS SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. THE ORGANIZATION HAS NO UNCERTAIN TAX POSITIONS AT SEPTEMBER 30, 2018 AND 2017. PART XI, LINE 4B - OTHER ADJUSTMENTS: CHARITY CARE (GROSS CHARGES) 3,376,030. PART XII, LINE 4B - OTHER ADJUSTMENTS: CHARITY CARE (GROSS CHARGES) 3,376,030. 1 1 X 1 X 1 X 1 1 0 1 1 576000 576000 0.00150 12925090 12925090 0.03340 13501090 13501090 0.03490 5319669 5319669 0.01380 5319669 5319669 0.01380 18820759 18820759 0.04870 1 21642387 63475733 87857404 -24381671 X 1 1 1 TOWER IMAGING VALENCIA OUTPATIENT RADIOLOGY SERVICE 0.50000 0.50000 1 1 HENRY MAYO NEWHALL MEMORIAL HOSPITAL 23845 MCBEAN PKWY VALENCIA CA 91355 WWW.HENRYMAYO.COM 930000206 X X X TRAUMA CENTER HENRY MAYO NEWHALL MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 16 1 0 0 1 X HTPPS://WWW.HENRYMAYO.COM/COMMUNITY X 1 17 1 HENRYMAYO.COM/DOCUMENTS/HENRY-MAYO-2017-IMPLEMENTATION-STRATEGY-FINAL.PDF 0 1 X 200.000000000000 400.000000000000 X X X X 1 1 X X X X 1 X HTTPS://WWW.HENRYMAYO.COM/SITE-SEARCH/?C=FAP X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X X X X X X 1 X 0 X X X X 1 X 0 0 HENRY MAYO NEWHALL MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: HENRY MAYO NEWHALL HOSPITAL COMPLETED A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) IN 2016 AS REQUIRED BY STATE AND FEDERAL LAW. DATA COLLECTION:THIS ASSESSMENT INCORPORATED COMPONENTS OF PRIMARY DATA COLLECTION AND SECONDARY DATA ANALYSIS THAT FOCUSED ON THE HEALTH AND SOCIAL NEEDS OF THE SERVICE AREA. THE CHNA EXAMINED UP-TO-DATE DATA SOURCES TO PRESENT COMMUNITY DEMOGRAPHICS, SOCIAL AND ECONOMIC FACTORS, HEALTH CARE ACCESS, BIRTH CHARACTERISTICS, LEADING CAUSES OF DEATH, CHRONIC DISEASE, HEALTH BEHAVIORS, MENTAL HEALTH AND SUBSTANCE ABUSE, AND PREVENTIVE PRACTICES. THESE DATA ARE PRESENTED IN THE CONTEXT OF LOS ANGELES COUNTY AND CALIFORNIA STATE, FRAMING THE SCOPE OF AN ISSUE AS IT RELATES TO THE BROADER COMMUNITY. INPUT FROM PERSONS WHO REPRESENT THE COMMUNITY:TARGETED INTERVIEWS WERE USED TO GATHER INFORMATION AND OPINIONS FROM PEOPLE WHO REPRESENTED THE INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL. TWENTY-TWO (22) INTERVIEWS WERE COMPLETED FROM JUNE THROUGH SEPTEMBER 2016. INTERVIEWEES INCLUDED INDIVIDUALS WHO ARE LEADERS AND REPRESENTATIVES OF MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS, OR REGIONAL, STATE OR LOCAL HEALTH OR OTHER DEPARTMENTS OR AGENCIES THAT HAVE CURRENT DATA OR OTHER INFORMATION RELEVANT TO THE HEALTH NEEDS OF THE COMMUNITY SERVED BY THE HOSPITAL FACILITY. HENRY MAYO NEWHALL MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE CHNA IDENTIFIED SIGNIFICANT HEALTH NEEDS IN THE HOSPITAL SERVICE AREA. THESE NEEDS WERE PRIORITIZED, WITH INPUT FROM THE COMMUNITY:1. MENTAL HEALTH2. ACCESS TO HEALTH CARE3. SUBSTANCE USE AND MISUSE (ALCOHOL, DRUGS, TOBACCO)4. HEART DISEASE5. OVERWEIGHT/OBESITY6. CANCER7. DIABETES8. PREVENTIVE PRACTICES (SCREENINGS, VACCINES)9. ASTHMA10. DENTAL CARE PART V, SECTION B: HENRY MAYO NEWHALL MEMORIAL HOSPITALLINE 16B, FAP APPLICATION WEBSITE:HTTPS://WWW.HENRYMAYO.COM/PATIENTS-VISITORS/PATIENT/BILLING-AND-INSURANCE/FINANCIAL-APPLICATION-PROCESS/HENRY MAYO NEWHALL MEMORIAL HOSPITALLINE 16C, FAP PLAIN LANGUAGE SUMMARY WEBSITE: HTTPS://WWW.HENRYMAYO.COM/SITE-SEARCH/?C=FAP PART II, COMMUNITY BUILDING ACTIVITIES: PAGE 9 - 10 OF THE COMMUNITY BENEFIT PACKAGE WHICH IS ATTACHED. PART III, LINE 2: THE ORGANIZATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE CARRYING AMOUNT OF PATIENT ACCOUNTS RECEIVABLE IS REDUCED BY BAD DEBT ALLOWANCES THAT REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. DURING THE TAX YEAR, THE ORGANIZATION MADE A CHANGE IN POLICY LARGELY ELIMINATING THE CONTRACTUAL DISCOUNT FOR SELF-PAY ACCOUNTS AND INCREASING THE ESTIMATED ALLOWANCE FOR DOUBTFUL ACCOUNTS ON SELF-PAY BALANCES WHICH RESULTED IN HIGHER BAD DEBT EXPENSE AMOUNT IN THE CURRENT TAX YEAR COMPARED TO THE PRIOR TAX YEAR. PART III, LINE 8: 100% INCLUDED IN THE COMMUNITY BENEFIT PACKAGE. COST METHODOLOGY IS COST ACCOUNTING SYSTEM. PART VI, LINE 2: HENRY MAYO COMPLETED A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) IN 2016, AS REQUIRED BY STATE AND FEDERAL LAW. CALIFORNIA SENATE BILL 697 AND THE PATIENT PROTECTION AND AFFORDABLE CARE ACT AND IRS SECTION 501(R)(3) DIRECT TAX-EXEMPT HOSPITALS TO CONDUCT A COMMUNITY HEALTH NEEDS ASSESSMENT AND DEVELOP AN IMPLEMENTATION STRATEGY, EVERY THREE YEARS. THE COMMUNITY HEALTH NEEDS ASSESSMENT IS A PRIMARY TOOL USED BY THE HOSPITAL TO DETERMINE ITS COMMUNITY BENEFIT PLAN, WHICH OUTLINES HOW IT WILL GIVE BACK TO THE COMMUNITY, IN THE FORM OF HEALTH CARE AND OTHER COMMUNITY SERVICES, TO ADDRESS UNMET COMMUNITY HEALTH NEEDS. PART VI, LINE 3: PAGE 7 - 10 OF THE COMMUNITY BENEFIT PACKAGE WHICH IS ATTACHED. PART VI, LINE 4: PAGE 3 - 4 OF THE COMMUNITY BENEFIT PACKAGE WHICH IS ATTACHED. PART VI, LINE 5: PAGE 7 - 10 OF THE COMMUNITY BENEFIT PACKAGE WHICH IS ATTACHED. PART VI, LINE 6: PAGE 12 - 13 OF THE COMMUNITY BENEFIT PACKAGE WHICH IS ATTACHED. PART VI, LINE 7, REPORTS FILED WITH STATES CA 1 HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION 23845 MCBEAN PKWY VALENCIA CA 91355 953849903 501(C)(3) 16047120 TO FINANCE REAL PROPERTY ACQUISITION OF ACC BUILDING HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION 23845 MCBEAN PKWY VALENCIA CA 91355 953849903 501(C)(3) 824414 TO SUPPORT GENERAL OPERATIONS OF THE FOUNDATION, AN AFFILIATE TO THE HOSPITAL HENRY MAYO MANAGEMENT SERVICE ORGANIZATION 23845 MCBEAN PKWY VALENCIA CA 91355 475250569 100000 TO SUPPORT GENERAL OPERATIONS AMERICAN CANCER SOCIETY 250 WILLIAMS STREET NW ATLANTA GA 30303 131788491 501(C)(3) 10500 2018 SPONSORSHIP WALK TO END ALZHEIMER AMERICAN DIABETES ASSOCIATION 2451 CRYSTAL DRIVE SUITE 900 ARLINGTON VA 22202 131623888 501(C)(3) 10000 PLATINUM SPONSORSHIP - RELAY FOR LIFE AMERICAN HEART ASSOCIATION 7272 GREENVILLE AVENUE DALLAS TX 75231 135613797 501(C)(3) 10000 SPONSORSHIP-LA F18 HEART WALK CHILD AND FAMILY CENTER 21545 CENTRE POINTE PARKWAY SANTA CLARITA CA 91350 953941342 501(C)(3) 7500 SILVER & TITLE SPONSOR-KID EXPO CITY OF SANTA CLARITA 23920 VALENCIA BLVD SUITE 100 SANTA CLARITA CA 91355 954133918 GOVERNMENT 14000 2018 BUSINESS SPONSORSHIP-CITY OF SANTA CLARITA EVENTS COLLEGE OF THE CANYONS FOUNDATION 26455 ROCKWELL CYN RD UNIVERSITY CENTER 263 VALENCIA CA 91355 953574259 501(C)(3) 112830 FUNDING FULL TIME INSTRUCTOR POSITION IN NURSING. SPONSORSHIP CHANCELLOR CIRCLE BENEFIT NORTH EAST VALLEY HEALTH CORPORATION 1172 N MACLAY AVE SAN FERNANDO CA 91340 237120632 501(C)(3) 266000 SUPPORT CONSTRUCTION OF THE NEW CLINIC ON LYONS AVE, NEWHALL. SPONSORSHIP 45TH ANNIV GALA. SPONSORSHIP TEAM NEVHC FOR SC MARATHON. SANTA CLARITA COMMUNITY DEVELOPMENT 23752 NEWHALL AVE SANTA CLARITA CA 91321 954587823 501(C)(3) 71012 FUNDING LABOR & SPONSORSHIP SOUP FOR THE SOUL EVENT SANTA CLARITA VALLEY CHAMBER OF COMMERCE 28494 WESTINGHOUSE PLACE 114 SANTA CLARITA CA 91355 611386679 501(C)(6) 5900 SPONSORSHIPS FOR STATE OF THE COUNTY LUNCHEON AND 2018 INSTALLATION GALA. SANTA CLARITA VALLEY ECONOMIC 26455 ROCKWELL CYN RD UNIVERSITY CENTER 263 VALENCIA CA 91355 954133918 501(C)(6) 18600 2018 BOARD & ANNUAL INVESTOR CONTRIBUTIONS SOROPTIMIST INTERNATIONAL OF VALENCIA PO BOX 802275 SANTA CLARITA CA 91380 954834196 501(C)(3) 9000 SPONSORSHIP-RED CARPET RUNWAY (DIOR LEVEL). PLATINUM SPONSORSHIP-BRAS FOR A CAUSE WILLIAM S HART EDUCATION FOUNDATION 24343 MAGIC MOUNTAIN PKWY VALENCIA CA 91355 454705593 501(C)(3) 25000 "STOP THE BLEED" 10 3 CHARITY CARE (GROSS CHARGES) - HENRY MAYO NEWHALL HOSPITAL 2285 3376030 OTHER PART I, LINE 2: THE HOSPITAL ASSISTS INDIVIDUALS WHO ARE UNINSURED BY PROVIDING CHARITY CARE. THIS IS APPLIED BY FOLLOWING THE HOSPITAL'S CHARITY CARE POLICY. THIS POLICY IS ADMINISTERED THROUGH THE BUSINESS SERVICE AND PATIENT ACCESS DEPARTMENTS OF THE HOSPITAL. PART II: GRANTS ARE PROVIDED TO SUPPORT GENERAL OPERATIONS OF HENRY MAYO MANAGEMENT SERVICE ORGANIZATION AND HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION, AFFILIATES TO THE HOSPITAL. PART III: PATIENTS MEETING CERTAIN CRITERIA UNDER THE CHARITY CARE POLICY MAY RECEIVE HEALTHCARE SERVICES AT NO CHARGE OR AT AMOUNTS LESS THAN ESTABLISHED RATES. X 1 1 X X X X 1 1 0 0 0 0 0 0 0 ROGER E SEAVER PRESIDENT/CEO 509559 0 384800 0 55027 0 31500 0 21515 0 1002401 0 0 0 LARRY R KIDD SR VP/CCO 341312 0 75000 0 15023 0 31500 0 7880 0 470715 0 0 0 MARK A PULEO VP/CHRO 229098 0 1154 0 10356 0 21718 0 31787 0 294113 0 0 0 JONATHAN S MILLER VP-FACILTY/SUPPORT 215073 0 0 0 16294 0 19903 0 24712 0 275982 0 0 0 KINGMAN HO MD CHIEF MEDICAL OFFICER 366491 0 14000 0 8993 0 19303 0 27027 0 435814 0 0 0 PAIGE E HEAPHY VP PERFORMANCE MGMT 248632 0 0 0 938 0 18494 0 24427 0 292491 0 0 0 JENNIFER R CASTALDO VP/CNO 146807 0 15175 0 2364 0 5624 0 4971 0 174941 0 0 0 RAY B MOSS VP/CIO 105115 0 10175 0 537 0 4250 0 10178 0 130255 0 0 0 KEITH BOYLE DIRECTOR OF SERVICE EXCELLENCE 186653 0 9281 0 1772 0 9733 0 14622 0 222061 0 0 0 ADNAN E HAMID DIRECTOR OF IT 184492 0 10445 0 3500 0 3900 0 24712 0 227049 0 0 0 DONNA G FERGUSON DIRECTOR OF SURGERY 179893 0 10680 0 1976 0 9703 0 19428 0 221680 0 0 0 MARIA B SARTE CLINICAL RN 192471 0 3609 0 849 0 6212 0 0 0 203141 0 0 0 HAROUTIOUN SHAMAMIAN DIRECTOR OF PHARMACY 207336 0 18408 0 999 0 0 0 17025 0 243768 0 0 0 CR BOB HUDSON VP/CFO (FORMER) 193487 0 144000 0 11603 0 21923 0 5418 0 376431 0 0 0 CYNTHIA A PETERSON VP/CIO (FORMER) 39539 0 7208 0 133797 0 1196 0 0 0 181740 0 0 0 PART I, LINE 1A THE HOSPITAL HAS A POLICY AND PROCEDURE THAT PROVIDES GUIDELINES AND RESTRICTIONS FOR TRAVEL EXPENSE REIMBURSEMENT. THE WRITTEN POLICY STIPULATES THAT IF AN EMPLOYEE, FOR PERSONAL REASONS, HAS HIS OR HER SPOUSE OR OTHER MEMBERS OF HIS OR HER FAMILY ACCOMPANY HIM OR HER WHILE TRAVELING ON HOSPITAL BUSINESS, REIMBURSEMENT WILL BE FOR THE EMPLOYEE'S QUALIFIED EXPENSES ONLY. HOSPITAL EXECUTIVES MAY HAVE SPOUSE OR OTHER FAMILY MEMBER'S TRAVEL EXPENSES REIMBURSED BY THE HOSPITAL IF SUCH TRAVEL IS DEEMED TO HAVE A HOSPITAL BUSINESS PURPOSE. PART I, LINES 4A-B CYNTHIA PETERSON RECEIVED A SEVERANCE PAYMENT OF $109,800 WHICH IS INCLUDED ON SCH J PART II, COLUMN B (III) HENRY MAYO NEWHALL MEMORIAL HOSPITAL HAS A SERP (SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN) OF WHICH ONLY ONE OF ITS EMPLOYEES PARTICIPATES, ROGER SEAVER. THE AMOUNT OF BENEFIT PAID IN THE CURRENT YEAR INCLUDED ON SCHEDULE J, PART II, (B)(II) IS $128,800. A CA STATEWIDE COMMUNITIES DEVELOPMENT AUTHORITY 680164610 2013-12-06 25000000 FINANCE AND REFINANCE FACILITY 0 0 0 B CA STATEWIDE COMMUNITIES DEVELOPMENT AUTHORITY 680164610 2013-12-06 35000000 FINANCE AND REFINANCE FACILITY 0 0 0 C CA STATEWIDE COMMUNITIES DEVELOPMENT AUTHORITY 680164610 13080SCJ1 2014-02-05 70780579 FINANCE AND REFINANCE FACILITY 0 0 0 D CALIFORNIA PUBLIC FINANCE AUTHORITY 474447476 13057EAL8 2017-02-03 115072912 FINANCE AND REFINANCE FACILITY 0 0 0 A 5650000 25000000 272183 5002611 19725206 2016 1 1 1 1 B 9350000 35000000 381056 7003656 27615288 2016 1 1 1 1 C 1330000 70780579 1141054 1692946 20092467 38854112 2017 0 1 1 1 D 115072912 1455316 85000000 28617596 2019 1 0 0 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 C 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 D 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 1 0 0 0 0 0 0 0 B 0 1 0 0 0 0 0 0 0 C 0 1 0 0 0 0 0 0 0 D 0 1 0 0 0 0 0 0 0 A 0 B 0 C 0 D 0 PART IV, LINE 7: HAS BEEN ANSWERED NO FOR THE 2017 FORM 990 (YEAR ENDING 09/30/18). THE ORGANIZATION HAS ESTABLISHED WRITTEN PROCEDURES AFTER YEAR-END. THIS WILL BE ANSWERED YES GOING FORWARD. PART V: HAS BEEN ANSWERED NO FOR THE 2017 FORM 990 (YEAR ENDING 09/30/18). THE ORGANIZATION HAS ESTABLISHED WRITTEN PROCEDURES AFTER YEAR-END. THIS WILL BE ANSWERED YES GOING FORWARD. DON NISHIGUCHI DON NISHIGUCHI, MD - TRUSTEE 36000 PROFESSIONAL FEES 0 LAKHBINDER DHANDA LAKHBINDER DHANDA, MD - TRUSTEE 23850 PROFESSIONAL FEES 0 KRYSTLE SEAVER FAMILY MEMBER OF OFFICER 62366 WAGES 0 KATHERINE DUNN FAMILY MEMBER OF TRUSTEE 90759 WAGES 0 FORM 990, PART VI, SECTION B, LINE 11B THE BOARD OF DIRECTORS, CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER REVIEWED THE ENTIRE FORM 990 RETURN PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ALL BOARD MEMBERS ARE REQUIRED TO READ THE CONFLICT OF INTEREST POLICY AND COMPLETE A FORMAL CONFLICT OF INTEREST QUESTIONNAIRE AND RESULTS OF ANY CONFLICT, IF ANY, WOULD BE REPORTED TO THE FULL BOARD. BOARD MEMBERS ARE AWARE AND REMINDED OF THE HOSPITAL'S FIDUCIARY RESPONSIBILITY IN REPORTING CONFLICTS OF INTEREST. THERE HAVE BEEN CIRCUMSTANCES WHERE A CONFLICT OF INTEREST EXISTS AND IT HAS BEEN DISCLOSED TO THE BOARD OF DIRECTORS. THE CONFLICT OF INTEREST FORMS ARE REQUIRED TO BE UPDATED ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATIONS'S CEO AND EXECUTIVE MANAGEMENT COMPENSATION ARE DETERMINED THROUGH THE USE OF A COMPENSATION COMMITTEE, INDEPENDENT CONSULTANT, AND BOARD OF DIRECTOR APPROVAL. OTHER KEY EMPLOYEES AND MANAGEMENT OF THE ORGANIZATION RECEIVE PERFORMANCE REVIEWS ANNUALLY AND RATINGS ARE APPLIED THAT SUGGEST THE PERCENTAGE OF SALARY INCREASE. PERCENTAGES ARE DETERMINED THROUGH MARKET SURVEYS DONE BY HUMAN RESOURCES AND APPROVED EACH YEAR VIA THE BUDGET AND APPROVAL PROCESS. FORM 990, PART VI, SECTION C, LINE 19 THE CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 41,801,432. MANAGEMENT AND GENERAL EXPENSES 5,968,044. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 47,769,476. CONSULTING AND MANAGEMENT FEES: PROGRAM SERVICE EXPENSES 931,733. MANAGEMENT AND GENERAL EXPENSES 2,650,413. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,582,146. FORM 990, PART XII, LINE 2C: NEITHER THE OVERSIGHT PROCESS FOR THE AUDIT OR THE SELECTION PROCESS OF THE INDEPENDENT ACCOUNTANT CHANGED DURING THE TAX YEAR. HENRY MAYO CARE NETWORK LLC 23845 MCBEAN PKWY VALENCIA CA 91355 824876499 HEALTHCARE NETWORK CA 0 0 HENRY MAYO NEWHALL MEMORIAL HOSPITAL HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION 23845 MCBEAN PKWY VALENCIA CA 91355 953849903 RAISE FUNDS CA 501(C)(3) LINE 7 HOSPITAL 1 SANTA CLARITA HEALTHCARE ASSOCIATION 23845 MCBEAN PKWY VALENCIA CA 91355 953921194 INACTIVE CA 501(C)(3) LINE 3 HOSPITAL 0 TOWER IMAGING VALENCIA 5455 WILSHIRE BLVD STE 1120 LOS ANGELES CA 90036 201345767 RADIOLOGY SERVICES CA HOSPITAL RELATED 725587 1360815 0 0 0.50000 HENRY MAYO MANAGEMENT SERVICE ORGANIZATION 23845 MCBEAN PKWY VALENCIA CA 91355 475250569 MANAGEMENT CA HOSPITAL C 100000 462047 1.00000 1 0 1 1 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 1 HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION C 2335977 ACTUAL AMOUNT HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION D 12489701 AMOUNT GUARANTEED HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION B 16871534 ACTUAL AMOUNT HENRY MAYO MANAGEMENT SERVICE ORGANIZATION B 100000 ACTUAL AMOUNT HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION K 185214 ACTUAL AMOUNT