2017-05-09T19:09:12-05:00 2016-12-31 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2016-01-01 910573114 FOSS HOME & VILLAGE FOSS 2063641300 13023 GREENWOOD AVENUE NORTH SEATTLE WA 981337397 JOHN HENRY JR PRESIDENT & CEO 2063641300 2017-05-03 1 KURT BENNION P01469618 4252506100 67.137.57.251 2017-05-03 11:16:22 PD P 3A69748B60C5562FF1572AE4C29EA0C331661B82 5C00B405BF4A66E7F27E07300AA9AC0D580A9EB8 2016 2021-01-29 14:40:06Z JOHN HENRY JR 13023 GREENWOOD AVENUE NORTH SEATTLE WA 981337397 19608557 0 X WWW.FOSSCARE.ORG X 1929 WA NURSING HOME AND ASSISTED LIVING FACILITY 10 10 378 182 0 0 312003 477060 18479346 18840234 62792 102801 150854 61418 19004995 19481513 0 1500 0 0 12642294 13539269 0 0 113747 5439031 5255207 18081325 18795976 923670 685537 16618778 17121906 7826302 7535050 8792476 9586856 X NURSING HOME AND ASSISTED LIVING FACILITY. 0 0 14642233 1500 18840234 NURSING HOME AND ASSISTED LIVING CARE, INCLUDING A SUBSTANTIAL NUMBER OF MEDICARE AND MEDICAID SUPPORTED RESIDENTS/PATIENTS. 64% OF SERVICE REVENUE IS FROM MEDICARE/MEDICAID AND THE REMAINDER IS FROM PRIVATE PAY RESIDENTS. WE SERVED 564 CLIENTS, THE AVERAGE LENGTH OF STAY FOR SHORT-STAY RESIDENTS, DEFINED BY THOSE WHO STAYED 100 DAYS OR LESS, WAS 21.44 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. 14642233 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 0 378 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 MS GAIL SCOTT CHAIRPERSON (THROUGH JAN 2016) 2.00 X X 0 0 0 MS JULIE YARI CHAIRPERSON 2.00 X X 0 0 0 MS NORMA BEERWEILER SECRETARY 2.00 X X 0 0 0 MS MARTA ACEDO 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 KELLIE HESSLER TRUSTEE (THROUGH OCT 2016) 2.00 X 0 0 0 MS JANE JONES TRUSTEE 2.00 X 0 0 0 MS LARRAINE KING TRUSTEE 2.00 X 0 0 0 MS BEV ROACH TRUSTEE 2.00 X 0 0 0 MR PAUL WOLD TRUSTEE 2.00 X 0 0 0 MR DAVID CROUCH PRESIDENT & CEO 40.00 X 224545 0 41102 MS PAT UPDEGRAFF TREASURER & CFO 40.00 X 143669 0 29643 MR JOHN HENRY JR VICE PRESIDENT & COO 40.00 X 126170 0 14601 MR GILBERT DIGA VP OF HUMAN RESOURCES & SUPPORT SERVICES 40.00 X 111429 0 17754 MS KIFLE SHEWANGIZAW STAFF NURSE 40.00 X 118356 0 8442 MS ALLISON JACOBS LEGENDRE DENTIST 40.00 X 112549 0 5215 836718 0 116757 6 0 1 0 CONSONUS REHAB 4560 SE INTERNATIONAL WAY SUITE 10 MILWAUKIE OR 97222 THERAPY SERVICES 915907 1 21414 455646 477060 RESIDENT FEES 623000 18840234 18840234 18840234 102801 102801 113800 101710 12090 12090 12090 4621 21414 11767 -7146 -7146 28504 13567 14937 14937 MISCELLANEOUS INCOME 900099 40502 40502 GUEST MEAL INCOME 900099 1035 1035 41537 19481513 18840234 0 164219 1500 1500 438960 438960 10770573 8529093 2168613 72867 278331 243195 34608 528 1258818 994457 264254 107 792587 607921 180837 3829 6247 6247 46029 46029 1385538 1195199 190339 71161 2152 33210 35799 63784 30512 33041 231 759848 516747 243101 12179 10416 1763 161040 161040 432853 411210 21643 MEDICAL SUPPLIES 1177588 1177356 232 FOOD 707636 707636 EQUIPMENT 128569 86911 41658 MISCELLANEOUS 121826 10587 110853 386 180909 117341 63568 18795976 14642233 4039996 113747 4841742 5091113 1800678 1987258 62845 74876 262984 149248 20854451 13529246 7361202 7325205 2279096 2484659 10231 9547 16618778 17121906 1537489 1667623 158432 191556 10231 9547 4153219 3982816 1966931 1683508 7826302 7535050 X 8084609 8971355 707867 615501 8792476 9586856 16618778 17121906 685537 108843 0 X 0 1 X 1 0 X 276129 268034 378895 312003 477060 1712121 9313530 18680194 18116861 18479346 18840234 83430165 37936 33571 34160 105667 9589659 18948228 18533692 18824920 19351454 85247953 0 0 0 85247953 150561 125609 136905 173102 216601 802778 150561 125609 136905 173102 216601 802778 158919 125623 40502 325044 9740220 19073837 18829516 19123645 19608557 86375775 0.98690 0.98850 0.00930 0.00820 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS INCOME RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 2770088 2770088 10515126 6991878 3523248 1125809 985283 140526 6413726 5552085 861641 29702 29702 7325205 DEFFERRED COMPENSATION 1683508 1683508 X 19657736 108843 266731 375574 19282162 199351 199351 19481513 18770990 11767 11767 18759223 36753 36753 18795976 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, 2016 AND 2015. 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, 2016 AND 2015. 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 2014. PART XI, LINE 2D - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTION 254,964. SPECIAL FUNDRAISING EVENT EXPENSES 11,767. PART XI, LINE 4B - OTHER ADJUSTMENTS: RESTRICTED CONTRIBUTIONS FOR CAPITAL USE 162,598. SALON OPERATING EXPENSES 36,753. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL FUNDRAISING EVENT EXPENSES 11,767. PART XII, LINE 4B - OTHER ADJUSTMENTS: SALON EXPENSES 36,753. FARMERS MARKET 6664 2043 4621 6755 3062 LUNCH 7221 7221 145 200 1025 4 12150 12150 580 26035 21414 4621 7480 200 4087 11767 -7146 X X 0 1 X X X 0 0 0 0 0 0 0 0 0 MR DAVID CROUCH PRESIDENT & CEO 224545 0 0 0 0 0 24734 0 16368 0 265647 0 0 0 MS PAT UPDEGRAFF TREASURER & CFO 143669 0 0 0 0 0 13285 0 16358 0 173312 0 0 0 PART I, LINE 1A DAVID CROUCH RECEIVED TRAVEL FOR COMPANIONS AND HEALTH CLUB DUES. THESE AMOUNTS WERE NOT INCLUDED IN HIS 2016 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. THERE WAS NO FORMAL DISCUSSION OR APPROVAL FOR THE PAYMENT OF COMPANION TRAVEL COSTS. 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 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 MEMEBERS ARE REQUIRES TO COMPLETE AND SIGN THE FORM FOR PROPER DISCLOSURE. MEMBERS ARE DIRECTED TO NOTIFY THE BOARD DURING THE YEAR IF A CONFICT 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 2016. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST.