2017-05-09T14:03:52-05:00 2016-09-30 910189318 MOSS ADAMS LLP 101 SECOND STREET SUITE 900 SAN FRANCISCO CA 94105 990 2015-10-01 952047121 CONGREGATIONAL HOMES INC CONG 9096245061 900 E HARRISON AVE POMONA CA 91767 MAUREEN BEITH PRESIDENT/CEO 9096245061 2017-05-04 1 RENIE BURBANK P00159653 4159561500 2015 2021-01-29 14:40:06Z MT SAN ANTONIO GARDENS MAUREEN BEITH 900 E HARRISON AVE POMONA CA 91767 32782295 0 X WWW.MSAGARDENS.ORG X 1957 CA THE MISSION OF CONGREGATIONAL HOMES, INC. IS TO HELP ENSURE A HIGH QUALITY OF LIFE FOR OLDER ADULTS BY PROVIDING COMPREHENSIVE AND SECURE SERVICES THAT PROMOTE WELLNESS, INDEPENDENCE, PARTICIPATION AND DIGNITY. 29 29 391 360 0 0 605863 831136 22587150 23326905 1034560 975158 2186581 3069520 26414154 28202719 405352 435268 0 0 13640446 14740114 0 0 0 12175368 12258738 26221166 27434120 192988 768599 92621188 93579866 56580592 55707276 36040596 37872590 X THE MISSION OF CONGREGATIONAL HOMES, INC IS TO HELP ENSURE A HIGH QUALITY OF LIFE FOR OLDER ADULTS BY PROVIDING COMPREHENSIVE AND SECURE SERVICES THAT PROMOTE WELLNESS, INDEPENDENCE, PARTICIPATION AND DIGNITY. 0 0 7313271 435268 6996082 MAINTENANCE/FACILITY SERVICES - PROVIDES THE UPKEEP OF THE BUILDINGS AND PLANT OPERATIONS INCLUDING ALL OCCUPANCY EXPENSES - HEAT, LIGHT, POWER, PROPERTY INSURANCE AND REAL ESTATE TAXES. THIS HOME FOR THE AGED FACILITY COVERS OVER 30 ACRES AND ALL BUILDINGS (86) ARE MAINTAINED TO FIT THE SPECIAL NEEDS OF THE ELDERLY POPULATION THAT LIVE HERE. THIS FACILITY WAS BUILT IN 1959-1961 WITH MANY RENOVATIONS OVER THE YEARS TO KEEP A MODERN YET SAFE AND COMFORTABLE FEEL FOR SENIOR LIVING THAT INCLUDES NOT ONLY RESIDENTIAL LIVING BUT ALSO ASSISTED LIVING AND SKILLED NURSING. THE EVERGREEN VILLAS WERE OPEN TO SKILLED NURSING RESIDENCE DURING FISCAL YEAR 2014. THE NEWEST RENOVATION WAS IN ASSISTED LIVING FOR MEMORY CARE RESIDENTS, WHICH OPENED IN MAY 2016. 6780751 0 6486659 HEALTH SERVICES - PROVIDED MEDICAL CARE AND OUTPATIENT SERVICES TO OUR AGED POPULATION AND 62 ELDERLY PEOPLE IN THE COMMUNITY. TOTAL PATIENT DAYS THIS YEAR WAS 23,952 AND INCLUDES 5,308 FOR THE COMMUNITY PATIENTS. 22,468 OF THE TOTAL DAYS WERE FOR CUSTODIAL CARE WHICH IS NOT REIMBURSED BY MEDICARE OR HEALTH INSURANCE COMPANIES. WE AVERAGED 65 ELDERLY PATIENTS IN OUR SKILLED NURSING FACILITY PER DAY. THE CLINIC AND HOME HEALTH DEPARTMENTS TRANSPORTED PATIENTS TO THEIR DOCTOR APPOINTMENTS AND PROVIDED HEALTH AND ASSISTANCE IN EACH OF OUR ELDER'S HOMES. 4790176 0 4582418 DIETARY SERVICES - PROVIDED THREE MEALS PER DAY TO OVER 600 ELDERLY PEOPLE PLUS STAFF, GUESTS, AND OTHERS. OVER 419,600 MEALS AND NUTRITIONAL SUPPLEMENTS WERE SERVED PLUS AN ADDITIONAL 9,795 MEALS WERE PROVIDED TO THE LOCAL MEALS ON WHEELS PROGRAM THAT PROVIDES MEALS TO SHUT-INS IN THE NEIGHBORING COMMUNITY. 5481181 5261746 OTHER PERSONAL CARE FACILITY, HOUSEKEEPING SERVICES, GROUNDS MAINTENANCE, WELLNESS CENTER, PHYSICAL THERAPY, AND SECURITY. 5481181 5261746 24365379 1 1 0 0 0 0 0 1 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 64 0 1 391 1 0 0 0 0 0 0 0 0 0 0 X 29 29 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 CA X PATRICIA L WILLIAMS 9096245061 900 E HARRISON AVE POMONA CA 91767 CURT MORRIS BOARD CHAIRPERSON 3.00 X X 0 0 0 JIM LEHMAN 1ST VICE CHAIRMAN 2.00 X X 0 0 0 JOAN ANDERSON DYM SECRETARY 2.00 X X 0 0 0 ROBIN ASPINALL DIRECTOR 1.00 X 0 0 0 BRENDA BARHAM-HILL DIRECTOR 1.00 X 0 0 0 MARGIE BEAL DIRECTOR 1.00 X 0 0 0 CATHIE BROWN DIRECTOR 1.00 X 0 0 0 CINDA CLAPROOD DIRECTOR 2.00 X 0 0 0 RON COLEMAN DIRECTOR 2.00 X 0 0 0 DAVID COONS DIRECTOR (THRU 12/2015) 1.00 X 0 0 0 MARILYN DALE DIRECTOR 1.00 X 0 0 0 TIMOTHY DAUWALDER DO DIRECTOR 1.00 X 0 0 0 MICHAEL DAVIS DIRECTOR 1.00 X 0 0 0 MARY DYER DIRECTOR 1.00 X 0 0 0 AMY FASS DIRECTOR (THRU 12/2015) 1.00 X 0 0 0 JIM GAMB DIRECTOR (THRU 12/2015) 1.00 X 0 0 0 NEIL GERARD DIRECTOR 1.00 X 0 0 0 JANE GOODFELLOW DIRECTOR 1.00 X 0 0 0 PAT HAUDUCOEUR DIRECTOR 1.00 X 0 0 0 FRANK HUNGERFORD DIRECTOR (THRU 12/2015) 1.00 X 0 0 0 LEE JACKMAN DIRECTOR 1.00 X 0 0 0 MICHAEL LAMKIN DIRECTOR 2.00 X 0 0 0 JOHN MAGUIRE DIRECTOR 1.00 X 0 0 0 CARLENE MILLER DIRECTOR 2.00 X 0 0 0 JOHN NELSON DIRECTOR 1.00 X 0 0 0 SHERI NAGEL DIRECTOR 2.00 X 0 0 0 FRANCES NOBERT DIRECTOR 1.00 X 0 0 0 PAULA PITZER DIRECTOR 1.00 X 0 0 0 RANDY PROUT DIRECTOR (THRU 12/2015) 1.00 X 0 0 0 TOM RIMER DIRECTOR 1.00 X 0 0 0 DENNIS SMITH DIRECTOR 1.00 X 0 0 0 PEGGY SPEAR DIRECTOR (THRU 12/2015) 1.00 X 0 0 0 LOUISE TAYLOR DIRECTOR 1.00 X 0 0 0 ROBERT TRANQUADA DIRECTOR (THRU 12/2015) 1.00 X 0 0 0 JOE UNIS MD DIRECTOR 1.00 X 0 0 0 KIMBERLEY VALENTINE DIRECTOR 2.00 X 0 0 0 FRITZ WEIS DIRECTOR (THRU 12/2015) 1.00 X 0 0 0 MAUREEN BEITH PRESIDENT & CEO 40.00 X 207654 0 9415 FRIEDERIKE MEDAK EXEC VP & ADMIN'R 40.00 X 137476 0 19249 PATRICIA WILLIAMS CFO 40.00 X 137181 0 9594 WILLIAM SMITH DIRECTOR OF MAINTENANCE 40.00 X 116702 0 15853 MONGKOL NICKERSON OPERATIONS MANAGER 40.00 X 101066 0 18722 LINNETTE GUIDERA HUMAN RESOURCES 40.00 X 100549 0 19813 800628 0 92646 6 0 1 0 HOGUE INTERIOR 20800 BEACH BLVD 100 HUNTINGTON BEACH CA 92648 INTERIOR DESIGN 456499 JACKMAN TILE 15098 HALINORE STREET HESPERIA CA 92345 TILE & COUNTER TOPS 262256 YVONNE ZUCHOWSKI 905 N SECOND AVE 135 UPLAND CA 91786 FLOOR & WINDOW COVERINGS 194043 RARE CONSTRUCTION INC 9330 ISAAC LORD DR RANCHO CUCAMONGA CA 91730 CONSTRUCTION 141619 PHILIP ALVARADO DBA 2063 S HILLMAN AVE G ONTARIO CA 91761 CABINTERY 135645 8 831136 64800 831136 CARE AND SERVICE FEES 623000 17794564 17794564 AMORT OF ADVANCE FEES 623000 5223665 5223665 HMO/MEDICARE INSURANCE 623000 308676 308676 23326905 800120 800120 75228 0 75228 75228 75228 4754614 4406227 173349 348387 -173349 175038 175038 NON RESIDENT HLTH SRVCS/ASSISTED 623000 2348683 2348683 OTHER SRVCS-RESIDENT/NON-RESIDENT 623000 408506 408506 NON-RESIDENT MEALS 623000 161365 161365 75738 75738 2994292 28202719 23326905 0 4044678 X 13500 13500 421768 421768 583951 583951 10669875 9853105 816770 450048 377189 72859 2189196 2074006 115190 847044 755801 91243 67312 67312 75816 75816 88165 88165 3485994 3294710 191284 136282 136282 757924 448575 309349 127417 991 126426 3029336 2764875 264461 58215 44342 13873 26454 7114 19340 11649 11649 3453199 3410767 42432 217642 195759 21883 MED SUPPLIES/EQUIPMENT 270867 270867 PHARMACEUTICALS 148481 148481 OTHER EMPLOYEE EXPENSES 118830 108456 10374 OTHER EXPENSES 115452 105370 10082 69703 69703 27434120 24365379 3068741 0 1952371 430156 682491 803734 1253988 1301440 44830 43853 663160 618720 97531012 45594895 50644949 51936117 37233828 38407781 145571 38065 92621188 93579866 2019381 1712700 33316047 33138663 19295000 18605000 389860 349482 1560304 1901431 56580592 55707276 X 24869593 25851680 4363719 5526196 6807284 6494714 36040596 37872590 92621188 93579866 X 768599 1484025 -420630 X 0 1 X 1 0 X 723561 656531 988549 605863 831136 3805640 19915939 19919904 20833693 22587150 23326905 106583591 1455974 1694045 1885686 2119621 2918554 10073880 22095474 22270480 23707928 25312634 27076595 120463111 289667 357609 203777 212398 320417 1383868 38799 38799 289667 357609 203777 251197 320417 1422667 119040444 1007363 898582 777976 856895 800120 4340936 1007363 898582 777976 856895 800120 4340936 123892 48785 42351 66960 75738 357726 23226729 23217847 24528255 26236489 27952453 125161773 0.95110 0.94670 0.03470 0.03800 X SCHEDULE A, PART III, LINE 12, EXPLANATION FOR OTHER INCOME: NON-MEMBER PATIENTS: ROOM AND BOARD FOR PEOPLE IN THE COMMUNITY WHO NEED A HIGHER LEVEL OF CARE BUT ARE NOT A CONTRACT RESIDENT OF MSAG; NON-RESIDENT MEALS: VISITORS AND GUESTS OF OUR CONTRACT RESIDENTS AND NON-MEMBER PATIENTS MAY PURCHASE MEALS (A LA RESTAURANT OR TRAY LIKE IN A HOSPITAL) SO THAT THEY MAY EAT WITH THEIR FRIENDS AND FAMILIES; AND DEPARTMENT REIMBURSEMENT FOR PRIVATE WORK: CONTRACT RESIDENTS AND NON-MEMBER PATIENTS MAY REQUEST ADDITIONAL STAFF SERVICES THAT GO BEYOND OUR CONTRACTED SERVICES (I.E., REPAIR A PERSONAL ITEM, WASHING OF CLOTHES, RUN ERRANDS, EXTRA HOUSECLEANING, ETC.) RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 68583 0 0 X ENJOYMENT OF RESIDENTS 0 14562377 49119 1523872 664503 380 15470485 15576397 123877 -1137897 14562377 14845641 4388 1346435 620067 15576397 13956850 60792 1437028 609029 14845641 13769323 10900 2343747 2167120 13956850 0.55500 0.39800 0.04700 0 0 1773859 1773859 77189326 35835346 41353980 4240358 2389772 1850586 14327469 7369777 6957692 51936117 REFUNDABLE DEPOSITS 270209 SPLIT-INTEREST AGREEMENTS 687758 ASSET RETIREMENT OBLIGATION 96864 WORKERS' COMPENSATION LIABILITY 846600 1901431 X 28844346 1484025 -842398 641627 28202719 0 28202719 27012352 0 27012352 421768 421768 27434120 PART III, LINE 4: FROM TIME TO TIME, MSAG RECEIVES DONATED WORKS OF ART WHICH ARE DISPLAYED AT THE FACILITY TO ENHANCE THE EXPERIENCE OF OUR RESIDENTS AND FAMILIES DURING THEIR VISIT. PART V, LINE 4: TO GENERATE INCOME TO OFFSET OPERATING EXPENSES AND PROVIDE A SAVINGS ACCOUNT WITH A LONG-TERM INVESTMENT STRATEGY. PART X, LINE 2: MSAG HAS EVALUATED ITS TAX POSITIONS AND THE CERTAINTY AS TO WHETHER THOSE POSITIONS WILL BE SUSTAINED IN THE EVENT OF AN AUDIT BY TAXING AUTHORITIES AT THE FEDERAL AND STATE LEVELS. THE PRIMARY TAX POSITIONS EVALUATED ARE RELATED TO MSAG'S CONTINUED QUALIFICATION AS A TAX-EXEMPT ORGANIZATION AND WHETHER THERE IS UNRELATED BUSINESS INCOME ACTIVITIES CONDUCTED THAT WOULD BE TAXABLE. MANAGEMENT HAS DETERMINED THAT ALL INCOME TAX POSITIONS ARE MORE LIKELY THAN NOT (>50%) OF BEING SUSTAINED UPON POTENTIAL AUDIT OR EXAMINATION; THEREFORE, NO DISCLOSURES OF UNCERTAIN INCOME TAX POSITIONS ARE REQUIRED. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN FAIR VALUE OF INTEREST RATE CAP -117,471. CHANGE IN ACTUARIAL VALUE OF SPLIT-INTERST AGREEMENTS -303,159. RECLASSIFICATION OF RESIDENT ASSISTANCE FROM REVENUE TO EXPENSES -421,768. PART XII, LINE 4B - OTHER ADJUSTMENTS: RECLASSIFICATION OF RESIDENT ASSISTANCE FROM REVENUE TO EXPENSES 421,768. 1 COMMUNITY SENIOR SERVICES 141 SPRING STREET CLAREMONT CA 91711 953100466 501(C)(3) 13500 FUNDING FOR SENIOR SERVICES 1 0 RESIDENT ASSISTANCE 17 421768 PART I, LINE 2: IF A RESIDENT IS UNABLE TO AFFORD HIS/HER MONTHLY CARE FEES, HE/SHE MAY REQUEST FINANCIAL ASSISTANCE FROM MT. SAN ANTONIO GARDENS. THE RESIDENT COMPLETES AN APPLICATION FOR ASSISTANCE AND MEETS WITH THE CFO TO REVIEW HIS/HER FINANCIAL RESOURCES. THE CFO AND CEO REVIEW AND APPROVE ANY APPLICATIONS FOR ASSISTANCE. THE FUNDS ARE CREDITED TO THE RESIDENT'S INTERNAL ACCOUNTS TO REDUCE THE COST FOR THEIR MONTHLY CARE AND SERVICES. MT. SAN ANTONIO GARDENS GRANTED FUNDS TO COMMUNITY SENIOR SERVICES TO ASSIST WITH EXPENSES FOR SENIOR SERVICES. MT. SAN ANTONIO GARDENS MEETS WITH COMMUNITY SENIOR SERVICES TO DISCUSS THE USE OF THE FUNDS FOR SERVICES TO SENIORS. A MUTUAL AGREEMENT AMONG THE TWO ORGANIZATIONS IS THAT THE FUNDS ARE USED TO SERVE SENIORS. X X X X X 0 0 0 0 0 0 0 0 0 MAUREEN BEITH PRESIDENT & CEO 207654 0 0 0 0 0 0 0 9415 0 217069 0 0 0 FRIEDERIKE MEDAK EXEC VP & ADMIN'R 137476 0 0 0 0 0 9834 0 9415 0 156725 0 0 0 A JP MORGAN CHASE BANK 134994650 2010-12-01 21775000 BUILD HOUSING 0 0 0 A 18645000 21775000 1905000 370605 816000 38395 2010 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 1 1 0 0 0 0 A 0 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: JP MORGAN CHASE BANK DATE THE REBATE COMPUTATION WAS PERFORMED: 02/09/2016 X BLDG IMPRMTS 21 62300 FAIR MARKET VALUE 0 0 1 0 FORM 990, PART VI, SECTION A, LINE 6 CONGREGATIONAL HOMES, INC. HAS ONE CLASS OF MEMBERS. THE CORPORATION CONSISTS OF AT LEAST 59 CORPORATE MEMBERS. THE CORPORATE MEMBERS CONSIST OF ELECTED MEMBERS OF THE BOARD OF DIRECTORS AND ELECTED MEMBERS AT LARGE. FORM 990, PART VI, SECTION A, LINE 7A CONGREGATIONAL HOMES, INC. HAS AT LEAST 59 CORPORATE MEMBERS WHO ELECT AND APPOINT THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS CONSIST OF NO LESS THAN 25 DIRECTORS AND NO MORE THAN 35 DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B GOVERNANCE DECISIONS ARE APPROVED BY CORPORATE MEMBERS OF WHICH CONSIST OF ELECTED MEMBERS OF THE BOARD OF DIRECTORS AND MEMBERS AT LARGE. FORM 990, PART VI, SECTION B, LINE 11 THE TAX RETURNS ARE FIRST SUBMITTED TO THE AUDIT COMMITTEE VIA EMAIL WHEN A DRAFT IS AVAILABLE, BUT PRIOR TO ITS IRS DUE DATE OR EXTENDED DUE DATE. QUESTIONS ARE ASKED OF THE CFO AND CEO. IF ACCEPTED, THE FORM 990 IS EMAILED VIA PDF FORMAT BY THE CFO TO ALL BOARD MEMBERS FOR THEIR REVIEW. QUESTIONS ARE EMAILED TO CFO. THE BOARD MEMBERS REPLY BY EMAIL IF THEY ACCEPT THE 990. THESE EMAILS ARE KEPT ON FILE. WHEN A QUORUM IS REACHED, THE 990 IS TRANSMITTED TO THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C THE CEO'S SECRETARY DISTRIBUTES THE FORMS AT THE START OF EACH CALENDAR YEAR. SHE IS RESPONSIBLE FOR ENSURING THAT ALL ARE RETURNED. THE COMPLETED FORMS ARE THEN REVIEWED BY THE CHAIRMAN AND SECRETARY OF THE BOARD OF DIRECTORS. IT IS THE RESPONSIBILITY OF EACH DIRECTOR TO IDENTIFY WHEN POTENTIAL CONFLICTS OF INTEREST MAY OCCUR DURING BOARD PROCEEDINGS. THE CHAIRMAN AND THE SECRETARY MAY FIND IT NECESSARY TO REMIND INDIVIDUAL MEMBERS OF POTENTIAL CONFLICTS, AS NECESSARY. IN THE EVENT A POTENTIAL CONFLICT ARISES THE CHAIRMAN DECIDES IF THE INDIVIDUAL MEMBER SHOULD RECUSE HIM OR HERSELF FROM THE DISCUSSION AND/OR VOTE. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMMITTEE SERVES AS THE MANAGEMENT COMPENSATION COMMITTEE. SALARY ADJUSTMENTS ARE BASED ON GENERAL SALARY ADJUSTMENTS FOR ALL EMPLOYEES, POSITION IN THE MARKET, INDIVIDUAL PERFORMANCE AND VALUE TO THE ORGANIZATION. COMPETITIVE SALARY REVIEWS ARE CONDUCTED ON A PERIODIC BASIS USING AN INDEPENDENT COMPENSATION CONSULTANT AND FORM 990 OF OTHER ORGANIZATIONS. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS ARE KEPT IN THE ADMINISTRATION OFFICE IN A BINDER - FOR PUBLIC REVIEW - THAT CONTAINS IRS TAX EXEMPTION LETTER, ARTICLES OF INCORPORATION, BYLAWS, CONFLICT OF INTEREST POLICY, CODE OF ETHICAL CONDUCT, AND THREE YEARS OF 990'S AND AUDITED FINANCIAL STATEMENTS. FORM 990, PART IX, LINE 11G OTHER FEES FOR SERVICES (NON-EMPLOYEES): PROGRAM SERVICE EXPENSES 3,294,710. MANAGEMENT AND GENERAL EXPENSES 191,284. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,485,994. FORM 990, PART XI, LINE 9: CHANGE IN FAIR VALUE OF INTEREST RATE CAP -117,471. CHANGES IN ACTUARIAL VALUE OF SPLIT-INTEREST AGREEMENTS -303,159.