2015-04-29T19:53:58-05:00 2014-12-31 410746749 CLIFTONLARSONALLEN LLP 3000 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2014-01-01 910573114 FOSS HOME & VILLAGE FOSS 2063641300 13023 GREENWOOD AVE N SEATTLE WA 981337397 DAVID CROUCH PRESIDENT & CEO 2063641300 2015-04-26 1 DAN FREIN P00004800 4252506100 2014 2016-02-25 16:41:14Z DAVID CROUCH 13023 GREENWOOD AVE N SEATTLE WA 981337397 18829516 0 X WWW.FOSSCARE.ORG X 1929 WA NURSING HOME & ASSISTED LIVING FACILITY 11 11 380 100 0 0 268034 378895 18680194 18116861 54009 57055 7447 194229 19009684 18747040 0 0 0 0 13055923 13064773 0 0 123780 5475023 5503078 18530946 18567851 478738 179189 15603079 15855930 8014216 7951535 7588863 7904395 NURSING HOME AND ASSISTED LIVING FACILITY. 0 0 14191661 0 18116861 NURSING HOME AND ASSISTED LIVING CARE, INCLUDING A SUBSTANTIAL NUMBER OF MEDICARE & MEDICAID SUPPORTED RESIDENTS/PATIENTS. 47% 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. 14191661 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 44 0 380 0 0 0 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 WA X PATRICIA UPDEGRAFF 2063641300 13023 GREENWOOD AVE N SEATTLE WA 981337397 DR MARYANN JOHNSTON CHAIRPERSON 2.00 X X 0 0 0 MS GAIL SCOTT TRUSTEE & CHAIRPERSON 2.00 X X 0 0 0 MR ART BATT VICE-CHAIRPERSON 2.00 X X 0 0 0 MR CARLOS GUANGORENA SECRETARY & VICE-CHAIRPERSON 2.00 X X 0 0 0 MS NORMA BEERWEILER SECRETARY 2.00 X X 0 0 0 MS MARTA ACEDO DIRECTOR 2.00 X 0 0 0 MR JOHN GIENAPP DIRECTOR 2.00 X 0 0 0 REV MARVIN R JONASEN DIRECTOR 2.00 X 0 0 0 MS JANE JONES DIRECTOR 2.00 X 0 0 0 MS LARRAINE KING DIRECTOR 2.00 X 0 0 0 MS BEV ROACH DIRECTOR 2.00 X 0 0 0 MR PAUL WOLD DIRECTOR 2.00 X 0 0 0 MS JULIE YARI DIRECTOR 2.00 X 0 0 0 MR DAVID CROUCH PRESIDENT, CEO 40.00 X 172760 0 87539 MS PATRICIA UPDEGRAFF TREASURER, CFO 40.00 X 108588 0 55789 MS VIOLET BANAFSHEH BAHARLOO RN, STAFF NURSE 40.00 X 110233 0 4409 MRS ELMYRA CHARTRAND RN DNS 40.00 X 108163 0 6314 MR JOHN HENRY JR COO 40.00 X 102752 0 26585 602496 0 180636 5 0 1 0 CONSONUS REHAB 14729 NORTHEAST 87TH ST REDMOND WA 98052 REHABILITATION SERVICES 1052061 1 378895 378895 RESIDENT FEES 623000 18116861 18116861 18116861 57055 57055 79850 66778 13072 13072 13072 36359 15698 20661 20661 MISCELLANEOUS INCOME 900099 158919 158919 GUEST MEAL INCOME 900099 1577 1577 160496 18747040 18116861 0 251284 424676 424676 10129504 7529831 2546938 52735 174056 151436 21704 916 1580991 1382719 198176 96 755546 660640 90800 4106 18420 18420 41416 41416 1487559 1300757 186482 320 55598 1056 27782 26760 67951 18048 48740 1163 755317 514380 240937 12596 11005 1580 11 22179 22179 172923 172923 441525 419449 22076 MEDICAL SUPPLIES 1212946 1211988 958 FOOD COSTS 781942 781942 MISCELLANEOUS 132571 14825 102252 15494 BAD DEBT EXPENSE 119013 119013 181122 74572 106550 18567851 14191661 4252410 123780 4798376 4738520 1632453 1874700 74871 58630 135770 137252 19602760 12748807 7008797 6853953 1886312 2126498 53488 47433 13012 18944 15603079 15855930 1544798 1459447 151426 144589 13012 18944 4529514 4365314 1775466 1963241 8014216 7951535 X 6959544 7247097 629319 657298 7588863 7904395 15603079 15855930 179189 136343 0 X 0 1 X 1 0 X 200000 276129 268034 378895 1123058 18045676 17731696 18718600 18477167 18116861 91090000 49512 44215 41260 40709 36359 212055 18295188 17775911 19035989 18785910 18532115 92425113 0 0 0 92425113 101491 110551 153561 128609 136905 631117 101491 110551 153561 128609 136905 631117 164854 284249 324851 219215 160496 1153665 18561533 18170711 19514401 19133734 18829516 94209895 0.98110 0.99710 0.00670 0.00280 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: GUEST MEAL INCOME MISCELLANEOUS INCOME RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 2278535 2278535 10009746 6440842 3568904 1085096 973778 111318 6229383 5334187 895196 6853953 DEFERRED COMPENSATION 1963241 1963241 X 18818350 136343 2021 138364 18679986 67054 67054 18747040 18530797 0 18530797 37054 37054 18567851 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 HOME AND VILLAGE 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, 2014 AND 2013. 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, 2014 AND 2013, RESPECTIVELY. MANAGEMENT EVALUATED FOSS' 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 2011. PART XI, LINE 2D - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTION 2,021. PART XI, LINE 4B - OTHER ADJUSTMENTS: SALON OPERATING EXPENSES 37,054. CONTRIBUTIONS RESTRICTED FOR CAPITAL USE 30,000. PART XII, LINE 4B - OTHER ADJUSTMENTS: SALON OPERATING EXPENSES 37,054. X X X 0 1 0 0 0 0 0 0 0 MR DAVID CROUCH PRESIDENT, CEO 172760 0 0 0 0 0 71245 0 16294 0 260299 0 0 0 MS PATRICIA UPDEGRAFF TREASURER, CFO 108588 0 0 0 0 0 39539 0 16250 0 164377 0 0 0 PART I, LINE 4B THE ORGANIZATION HAS A 457(F) DEFERRED COMPENSATION PLAN. CONTRIBUTIONS TO THE PLAN DURING 2014 WERE: DAVID CROUCH $26,274 PATRICIA UPDEGRAFF $16,288 JOHN HENRY $10,275 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; (E) 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 11 DRAFT TAX RETURN DISTRIBUTED AT BOARD MEETING FOR REVIEW AND APPROVAL. 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 990S OF COMPARABLE ORGANIZATIONS. THE CEO REVIEWS SALARY DATA IN A SIMILAR MANNER FOR THE OTHER OFFICERS. THE REVIEW PROCESS WAS LAST CONDUCTED IN 2014. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST.