2016-05-09T18:41:11-05:00 2015-12-31 410746749 CLIFTONLARSONALLEN LLP 3000 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2015-01-01 910573114 FOSS HOME & VILLAGE FOSS 2063641300 13023 GREENWOOD AVENUE NORTH SEATTLE WA 981337397 DAVID CROUCH PRESIDENT & CEO 2063641300 2016-05-04 1 DANIEL M FREIN CPA P00856532 4252506100 2015 2016-09-27 15:27:22Z DAVID CROUCH 13023 GREENWOOD AVENUE NORTH SEATTLE WA 981337397 19113645 0 X WWW.FOSSCARE.ORG X 1929 WA NURSING HOME AND ASSISTED LIVING FACILITY 12 12 401 148 0 0 378895 312003 18264214 18479346 57055 62792 9822 150854 18709986 19004995 0 0 0 0 13027719 12642294 0 0 128173 5483078 5439031 18510797 18081325 199189 923670 15855930 16660156 7951535 7867680 7904395 8792476 NURSING HOME AND ASSISTED LIVING FACILITY. 0 0 13884814 0 18479346 NURSING HOME AND ASSISTED LIVING CARE, INCLUDING A SUBSTANTIAL NUMBER OF MEDICARE AND MEDICAID SUPPORTED RESIDENTS/PATIENTS. 52% OF REVENUE IS FROM MEDICARE/MEDICAID AND THE REMAINDER IS FROM PRIVATE PAY RESIDENTS. RATES ARE SET BASED ON MARKET RATES IN THE SEATTLE AREA, AND ARE NECESSARY TO MAKE THE ORGANIZATION VIABLE. 13884814 1 1 0 0 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 48 0 401 1 0 0 0 0 0 0 0 0 0 0 X 12 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 WA X PATRICIA UPDEFRAFF 2063641300 13023 GREENWOOD AVENUE NORTH SEATTLE WA 981337397 MS GAIL SCOTT CHAIRPERSON 2.00 X X 0 0 0 MR CARLOS GUANGORENA VICE-CHAIRPERSON 2.00 X X 0 0 0 MS NORMA BEERWELLER 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 MS KELLIE HESSLER TRUSTEE 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 MS JULIE YARI TRUSTEE 2.00 X 0 0 0 MR DAVID CROUCH PRESIDENT & CEO 40.00 X 178960 0 39436 MS PAT UPDEGRAFF TREASURER & CFO 40.00 X 121635 0 28769 MR JOHN HENRY JR VICE PRESIDENT & COO 40.00 X 117677 0 13802 MR GILBERT DIGA VP OF HUMAN RESOURCES & SUPPORT SERVICES 40.00 X 103969 0 16604 MS ELMYRA CHARTRAND RN DNS 40.00 X 108175 0 6806 MS BANAFSHEH BAHARLOO RN STAFF NURSE 40.00 X 100833 0 13923 731249 0 119340 6 0 1 0 CONSONUS REHAB 4560 SE INTERNATIONAL WAY SUITE 10 MILWAUKIE OR 97222 THERAPY SERVICES 1029456 1 312003 312003 RESIDENT FEES 623000 18479346 18479346 18479346 62792 62792 100310 94355 5955 5955 5955 32261 14295 17966 17966 MISCELLANEOUS INCOME 900099 125623 125623 GUEST MEAL INCOME 900099 1310 1310 126933 19004995 18479346 0 213646 733017 733017 9665858 7705678 1887349 72831 240204 223834 16157 213 1263342 993669 269071 602 739873 555104 180672 4097 31293 31293 45215 45215 1509953 1333741 176147 65 37194 1699 30133 5362 80430 25537 39326 15567 758258 517348 240910 5270 4642 604 24 28575 28575 166801 166801 447738 425351 22387 MEDICAL SUPPLIES 1190045 1190045 FOOD 741542 741542 MISCELLANEOUS 136378 8848 127530 EQUIPMENT 114551 74600 39951 145788 83176 61775 837 18081325 13884814 4068338 128173 4738520 4841742 1874700 1800678 58630 62845 137252 262984 20502816 13141614 6853953 7361202 2126498 2279096 47433 41378 18944 10231 15855930 16660156 1459447 1537489 144589 158432 18944 10231 4365314 4194597 1963241 1966931 7951535 7867680 X 7247097 8084609 657298 707867 7904395 8792476 15855930 16660156 923670 -35589 0 X 0 1 X 1 0 X 0 276129 268034 378895 312003 1235061 18015586 9313530 18680194 18116861 18479346 82605517 37936 33571 71507 18015586 9589659 18948228 18533692 18824920 83912085 0 0 0 83912085 107551 150561 125609 136905 173102 693728 107551 150561 125609 136905 173102 693728 158919 125623 284542 18123137 9740220 19073837 18829516 19123645 84890355 0.98850 0.98110 0.00820 0.00670 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 10386288 6713410 3672878 1094241 991536 102705 6223561 5436668 786893 28638 28638 7361202 DEFFERRED COMPENSATION 1966931 1966931 X 18882446 -35589 11099 -24490 18906936 98059 98059 19004995 18044934 0 18044934 36391 36391 18081325 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, 2015 AND 2014. 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, 2015 AND 2014. 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 2012. PART XI, LINE 2D - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTION 11,099. PART XI, LINE 4B - OTHER ADJUSTMENTS: RESTRICTED CONTRIBUTIONS FOR CAPITAL USE 61,668. SALON OPERATING EXPENSES 36,391. PART XII, LINE 4B - OTHER ADJUSTMENTS: SALON EXPENSES 36,391. X X X 0 1 0 0 0 0 0 0 0 MR DAVID CROUCH PRESIDENT & CEO 178960 0 0 0 0 0 23091 0 16345 0 218396 0 0 0 MS PAT UPDEGRAFF TREASURER & CFO 121635 0 0 0 0 0 12444 0 16325 0 150404 0 0 0 PART I, LINE 4B THE ORGANIZATOIN HAS A 457(F) DEFERRED COMPENSATION PLAN. CONTRIBUTIONS TO THE PLAN DURING 2015 WERE: DAVID CROUCH $19,464 PAT UPDEGRAFF $10,012 JOHN HENRY, JR $3,354 GILBERT DIGA $7,232 NANCY MOHRMAN $4,540 BANAFSHEH BAHARLOO $6,220 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 ORGNAIZATION. FORM 990, PART VI, SECTION B, LINE 11 A DRAFT OF THE FORM 990 WAS DISTRIBURED 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 2015. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST.