2018-11-15T16:07:41-06:00 2017-12-31 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2017-01-01 910573114 FOSS HOME & VILLAGE FOSS 2063641300 13023 GREENWOOD AVENUE NORTH SEATTLE WA 981337397 JOHN HENRY JR PRESIDENT & CEO 2063641300 2018-11-14 1 KURT BENNION P01469618 4252506100 2018-11-14 67.137.57.251 2018-11-14 13:37:09 PS P 6A821D0B274B5855642737A0F5B4B79E08AAF2E9 9C3E08EBF53FA5FA3C7B2B5BD0B3E335DF999A73 2017 2019-02-21 02:37:17Z JOHN HENRY JR 13023 GREENWOOD AVENUE NORTH SEATTLE WA 981337397 19708773 0 X WWW.FOSSCARE.ORG X 1929 WA NURSING HOME AND ASSISTED LIVING FACILITY 10 10 377 125 0 0 477060 399150 18840234 19009743 102801 87540 61418 92742 19481513 19589175 1500 3000 0 0 13539269 14138906 0 0 126067 5255207 5656734 18795976 19798640 685537 -209465 17121906 16470342 7535050 6980548 9586856 9489794 X NURSING HOME AND ASSISTED LIVING FACILITY. 1 0 15498607 3000 19009743 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 541 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 21.83 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. 15498607 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 45 0 377 1 0 0 0 0 0 1 1 0 0 0 0 X 10 10 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 2.00 X X 0 0 0 JEFF WEST VICE CHAIR 2.00 X X 0 0 0 NORMA BEERWEILER SECRETARY (THROUGH JANUARY 2017) 2.00 X X 0 0 0 LARRAINE KING TRUSTEE & SECRETARY 2.00 X X 0 0 0 MS MARTA ACEDO TRUSTEE 2.00 X 0 0 0 KRIS CHICK TRUSTEE 2.00 X 0 0 0 MS LYNNE DASHER TRUSTEE 2.00 X 0 0 0 MR JOHN GIENAPP TRUSTEE 2.00 X 0 0 0 MR CARLOS GUANGORENA TRUSTEE 2.00 X 0 0 0 MS JANE JONES TRUSTEE 2.00 X 0 0 0 MS BEV ROACH TRUSTEE 2.00 X 0 0 0 PAUL WOLD TRUSTEE (THROUGH JULY 2017) 2.00 X 0 0 0 DAVID CROUCH PRESIDENT & CEO (THROUGH APRIL 2017) 40.00 X 604591 0 11888 JOHN RICK HENRY JR PRESIDENT & CEO 40.00 X 172791 0 19638 PATRICIA UPDEGRAFF CFO & TREASURER 40.00 X 146567 0 34084 KIFLE SHEWANGIZAW LPN NURSE 40.00 X 122979 0 11224 GILBERT DIGA VICE PRESIDENT & HR DIRECTOR 40.00 X 119044 0 21766 BANAFSHEH BAHARLOO RN NURSE 40.00 X 117965 0 11451 RACHAEL GERDIS VICE PRESIDENT & COO 40.00 X 108010 0 24091 NANCY MOHRMAN VICE PRESIDENT & PROGRAM DIRECTOR 40.00 X 106340 0 20716 1498287 0 154858 9 0 1 0 CONSONUS REHAB 4560 SE INTERNATIONAL WAY SUITE 10 MILWAUKIE OR 97222 THERAPY 885702 WG CLARK 408 AURORA AVENUE N SEATTLE WA 98109 CONSTRUCTION 214939 2 20000 379150 399150 RESIDENT FEES 623000 19009743 19009743 19009743 87540 87540 113400 100130 13270 13270 13270 19695 20000 6010 13685 13685 31328 13458 17870 17870 MISCELLANEOUS INCOME 900099 45972 45972 GUEST MEAL INCOME 900099 1945 1945 47917 19589175 19009743 0 180282 3000 3000 989559 989559 10728213 8941597 1712311 74305 287535 243604 41871 2060 1294804 1026423 267889 492 838795 644867 189989 3939 37029 37029 48830 48830 1401731 1192118 207429 2184 62362 2731 26612 33019 51102 27367 22249 1486 796438 558117 238321 11144 9189 1955 153549 153549 465077 441823 23254 MEDICAL SUPPLIES 1160333 1159919 414 FOOD 708898 708898 BAD DEBT 455195 455195 REPAIRS & MAINTENANCE 121953 79176 42777 183093 4583 169928 8582 19798640 15498607 4173966 126067 5091113 4800453 1987258 1633319 74876 68372 149248 282081 21832191 13869493 7325205 7962698 2484659 1711910 9547 11509 17121906 16470342 1667623 1827157 191556 198123 9547 11509 3982816 3805358 1683508 1138401 7535050 6980548 X 8971355 8864330 615501 625464 9586856 9489794 17121906 16470342 -209465 112403 0 X 0 1 X 1 0 X 268034 378895 312003 477060 399150 1835142 18680194 18116861 18479346 18840234 19009743 93126378 37936 33571 34160 52968 158635 18948228 18533692 18824920 19351454 19461861 95120155 0 0 0 95120155 125609 136905 173102 216601 200940 853157 125609 136905 173102 216601 200940 853157 158919 125623 40502 45972 371016 19073837 18829516 19123645 19608557 19708773 96344328 0.98730 0.98690 0.00890 0.00930 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS INCOME 0 1 X 2770088 2770088 11547585 7307872 4239713 1131698 1009817 121881 6381133 5551804 829329 1687 1687 7962698 DEFFERRED COMPENSATION 1138401 1138401 X 19614567 112403 54592 166995 19447572 141603 141603 19589175 19721592 6010 6010 19715582 83058 83058 19798640 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, 2017 AND 2016. 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, 2017 AND 2016. 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 2015. PART XI, LINE 2D - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTION 48,582. SPECIAL FUNDRAISING EVENT EXPENSES 6,010. PART XI, LINE 4B - OTHER ADJUSTMENTS: RESTRICTED CONTRIBUTIONS FOR CAPITAL USE 58,545. SALON OPERATING EXPENSES 24,121. BAD DEBT EXPENSE 58,937. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL FUNDRAISING EVENT EXPENSES 6,010. PART XII, LINE 4B - OTHER ADJUSTMENTS: SALON EXPENSES 24,121. BAD DEBT EXPENSE 58,937. CHRISTMAS CELEBRATION 34445 17355 17090 1075 2626 719 SPRING BRUNCH 5250 2645 2605 500 1090 39695 20000 19695 1075 2626 500 1809 6010 13685 X 0 1 X X X X X 0 1 0 0 0 0 0 0 0 DAVID CROUCH PRESIDENT & CEO (THROUGH APRIL 2017) 71586 0 0 0 533005 0 2898 0 8990 0 616479 0 0 0 JOHN RICK HENRY JR PRESIDENT & CEO 172791 0 0 0 0 0 10540 0 9098 0 192429 0 0 0 PATRICIA UPDEGRAFF CFO & TREASURER 146567 0 0 0 0 0 16691 0 17393 0 180651 0 0 0 PART I, LINE 1A DAVID CROUCH RECEIVED SOCIAL CLUB DUES OF $525 IN 2017. THIS AMOUNT WAS NOT INCLUDED IN HIS 2017 W-2. PART I, LINE 1B THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS DISCUSSED AND APPROVED THE ORGANIZATION'S PAYMENT OF DAVID CROUCH'S SOCIAL CLUB DUES. PART I, LINE 4B DAVID CROUCH RECEIVED A PAYMENT OF $533,003 FROM A 457(F) SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. FORM 990, PART III, LINE 2 DURING 2017, WE EXPANDED OUR DENTAL SERVICES TO THE ELDERLY. 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 A DRAFT OF THE FORM 990 WAS REVIEWED BY THE FINANCE COMMITTEE WITH THE CEO AND CFO, THEN DISTRIBUTED AT A BOARD MEETING FOR REVIEW AND APPROVAL PRIOR TO 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.