2014-08-14T10:40:11-05:00 2013-09-30 910189318 MOSS ADAMS LLP 3121 W MARCH LN STE 100 STOCKTON CA 952192303 990 2012-10-01 342030255 MIRABELLA MIRA 8887246424 116 FAIRVIEW AVE NORTH SEATTLE WA 98109 JOHN LARSON 8887246424 2014-08-10 1 TRACY S PAGLIA P00366884 2099556100 2012 2015-11-30 17:44:51Z C TODD MARTIN 965 ELLENDALE DRIVE MEDFORD OR 97504 24181119 0 X RETIREMENT.ORG X 2005 WA TO PROVIDE COMPREHENSIVE CARE AND HOUSING FOR THE ELDERLY. 8 8 321 10 0 0 0 0 22265373 24019330 25915 86277 64459 75512 22355747 24181119 0 0 0 0 9186851 9396803 0 0 0 19761267 19810624 28948118 29207427 -6592371 -5026308 233840365 239125370 296768380 308415259 -62928015 -69289889 NONE 0 0 25688567 0 24019330 MIRABELLA IS A CONTINUING CARE RETIREMENT COMMUNITY, DEDICATED TO ENHANCING OUR RESIDENTS QUALITY OF LIFE IN A STIMULATING, SECURE ENVIRONMENT. WE PROVIDE HIGH-QUALITY SERVICES INCLUDING HOUSING, NUTRITIOUS MEALS, NURSING, HOUSEKEEPING, MAINTENANCE, AND OTHER SUPPORT TO THOSE WE SERVE. OUR LEVELS OF SERVICE INCLUDE INDEPENDENT LIVING, ASSISTED LIVING, AND SKILLED NURSING. 25688567 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 64 0 1 321 1 0 0 0 0 0 0 0 0 0 0 X 8 8 0 1 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X SHERI LOYA 5418577644 965 ELLENDALE DRIVE MEDFORD OR 97504 X C TODD MARTIN 1.00 1.00 X X 0 0 0 STAN SCHILL 1.00 X X 0 0 0 LARRY BOECK 1.00 3.00 X X 0 0 0 ANTHONY P WARTNIK 1.00 X 0 0 0 NANCY HOOYMAN 1.00 X 0 0 0 JOSEPH PHILLIPS 1.00 X 0 0 0 WILLIAM POOLE 1.00 X 0 0 0 HELLMUT GOLDE 1.00 X 0 0 0 JOHN LARSON 40.00 X 169004 61203 49304 169004 61203 49304 1 0 1 0 PACIFIC RETIREMENT SERVICES 965 ELLENDALE DRIVE MEDFORD OR 97504 MANAGEMENT SERVICES 1222573 CONSONUS REHAB P O BOX 4800 UNIT 12 PORTLAND OR 97208 THERAPY SERVICES 669081 ORRICK HERRINGTON & SUTCLIFFE LLP DEPT 34461 P O BOX 39000 SAN FRANCISCO CA 94139 LEGAL SERVICES 129634 SNR DENTON US LLP 525 MARKET STREET 26TH FLOOR SAN FRANCISCO CA 94105 LEGAL SERVICES 114285 4 SERVICE FEES 623000 15713919 15713919 ENTRANCE FEES 623000 4673989 4673989 HEALTH CENTER REVENUE 623000 2663908 2663908 DIETARY 623000 459631 459631 GARAGE & CARPORT 623000 235700 235700 272183 272183 24019330 10513 10513 75764 75764 75512 0 75512 75512 75512 24181119 24019330 0 161789 266130 266130 7221324 6496244 725080 185025 153270 31755 1172161 953703 218458 552163 484987 67176 1246121 1246121 65914 65914 60008 60008 18955 18955 422795 310399 112396 281530 926 280604 552686 463442 89244 71938 71938 1664499 1663673 826 54560 15682 38878 22060 19735 2325 6480684 6480684 6270444 6270444 292604 186700 105904 DIETARY EXPENSE 1207897 1207897 HEALTH CENTER EXPENSE 756522 756522 FACILITY SERVICE EXPENS 327026 209878 117148 ASSET DISPOSAL 14381 14381 29207427 25688567 3518860 0 1089696 3015453 16787604 24510178 463656 1186748 121074 94816 1233817 349323 235956333 30085777 211524446 205870556 2620072 4098296 233840365 239125370 1429871 4217597 145137013 158550424 117650000 115940000 647530 645751 31903966 29061487 296768380 308415259 X -62996496 -69398548 68481 108659 -62928015 -69289889 233840365 239125370 X -5026308 -62194 -1273372 X 0 1 X 1 0 X 5418410 16053247 19460492 22265373 24019330 87216852 5418410 16053247 19460492 22265373 24019330 87216852 52341 52341 0 52341 52341 87164511 580091 73561 54888 90374 161789 960703 580091 73561 54888 90374 161789 960703 5998501 16126808 19515380 22355747 24181119 88177555 0.98850 0.98750 0.01090 0.01250 X 29207427 29207427 1000000 250000 0 0 1000000 1000000 1000000 3000000 4500000 250000 250000 250000 750000 1125000 21194646 21194646 208494895 27519064 180975831 191631 23954 167677 2760936 1064289 1696647 3314225 1478470 1835755 205870556 REFUNDABLE DEPOSITS 486551 ENTRANCE FEES REFUNDABLE-REOCCUPANCY 6310650 DUE TO AFFILIATES 14481665 CONTINGENT LIABILITY 7782621 29061487 X 22826598 -62194 40178 -22016 22848614 18955 1313550 1332505 24181119 29188472 0 29188472 18955 18955 29207427 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE CORPORATION RECOGNIZES THE TAX BENEFIT FROM UNCERTAIN TAX POSITIONS ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITIONS WILL BE SUSTAINED ON EXAMINATION BY THE TAX AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE TAX BENEFIT IS MEASURED BASED ON THE LARGEST BENEFIT THAT HAS A GREATER THAN 50% LIKELIHOOD OF BEING REALIZED UPON ULTIMATE SETTLEMENT. THE CORPORATION RECOGNIZES INTEREST AND PENALTIES RELATED TO INCOME TAX MATTERS IN OPERATING EXPENSES. AT SEPTEMBER 30, 2013 AND 2012, THERE WERE NO SUCH UNCERTAIN TAX POSITIONS. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST OF MIRABELLA WASHINGTON FOUNDATION, INC 40,178. PART XI, LINE 4B - OTHER ADJUSTMENTS: LOSS ON EXTINGUISHMENT OF DEBT 1,313,550. 0 0 0 0 0 0 0 0 0 JOHN LARSON 128515 61203 36707 0 3782 0 23658 0 17075 8571 209737 69774 12535 0 PART I, LINE 3 COMPENSATION WAS RECOMMENDED BY PACIFIC RETIREMENT SERVICES, INC. AND APPROVED BY MIRABELLA BOARD AS PART OF THE ANNUAL BUDGET PROCESS. A WASHINGTON STATE HOUSING FINANCE COMMISSION 911874730 939783RB4 2012-12-27 119990000 CURRENT REFUNDING AND TO FINANCE CERTAIN CAPITAL IMPROVEMENTS 0 0 0 A 4050000 120000389 6075588 6423 1784800 1016649 115871547 1320969 1 0 0 1 A 0 1 1 1 0 0.00600 0.00000 0.00600 0 0 1 A 0 1 1 0 1 0 0 0 1 A 1 SCHEDULE K SUPPLENTAL INFORMATION PART II, LINE 3: DIFFERENCE BETWEEN PART I (E) AND PART II, LINE 3 IS DUE TO INTEREST EARNINGS ON BOND PROCEEDS. PART III, LINE 7: AS PROVIDED IN TREASURY REGULATION SECTION 1.141-4(C)(2)(I)(B), THE AMOUNT OF PRIVATE PAYMENTS TAKEN INTO ACCOUNT UNDER THE PRIVATE PAYMENT TEST MAY NOT EXCEED THE AMOUNT OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS USE. ACCORDINGLY, THE AMOUNT OF PRIVATE PAYMENTS FOR THE REPORTING PERIOD DOES NOT EXCEED THE AMOUNT STATED IN PART III, LINE 6. THE ORGANIZATION HAS NOT UNDERTAKEN AN ANALYSIS OF THE PRIVATE SECURITY TEST WITH RESPECT TO THE BONDS, AS THE LEVEL OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS REPORTED IN PART III, LINE 6, IS NOT IN EXCESS OF AMOUNTS PERMITTED UNDER SECTION 145 OF THE CODE. PART IV, LINE 2: THE 5TH BOND YEAR HAS NOT OCCURRED, AND THUS NO REBATE COULD BE DUE. THE BONDS CONSIST OF BOTH A CURRENT REFUNDING, WHICH HAS MET AN EXCEPTION TO THE REBATE REQUIREMENT, AND A NEW MONEY FINANCING, WHICH WILL NOT MEET AN EXCEPTION TO THE REBATE REQUIREMENT. NO COMPUTATION HAS BEEN MADE THAT WOULD INDICATE WHETHER ANY REBATE WOULD BE DUE ON THE NEW MONEY COMPONENT OF THE FINANCING. FORM 990, PART VI, SECTION A, LINE 3 MIRABELLA'S BOARD DELEGATES MANAGEMENT TO PACIFIC RETIREMENT SERVICES. FORM 990, PART VI, SECTION A, LINE 4 THE BYLAWS OF THE ORGANIZATION WERE CHANGED DURING THE YEAR TO ADD ONE RESIDENT VOTING MEMBER. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS ONE MEMBER, PACIFIC RETIREMENT SERVICES, INC. FORM 990, PART VI, SECTION A, LINE 7A PACIFIC RETIREMENT SERVICES HAS THE RIGHT TO VOTE ON THE ELECTION OF DIRECTORS FOR THE BOARD OF MIRABELLA. FORM 990, PART VI, SECTION A, LINE 7B SOME DECISIONS OF THE BOARD ARE SUBJECT TO APPROVAL BY PACIFIC RETIREMENT SERVICES, AS OUTLINED IN THE BYLAWS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE CFO, ASSISTANT CONTROLLER AND THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY AND QUESTIONNAIRE ARE SENT TO ALL BOARD MEMBERS AND KEY EMPLOYEES ANNUALLY. THERE ARE TWO POLICIES RELATED TO CONFLICTS OF INTEREST: 1) BOARD OF DIRECTORS; 2) KEY EMPLOYEES, WHICH IDENTIFY THE PURPOSE, DEFINITIONS, AND PROCEDURES. IF A CONFLICT IS SELF-IDENTIFIED BY A BOARD MEMBER OR KEY EMPLOYEE IN THE QUESTIONNAIRE AND/OR MEETING, PROCEDURES ARE FOLLOWED AND DOCUMENTED ACCORDING TO THE POLICY. FORM 990, PART VI, SECTION B, LINE 15A A COMPENSATION COMMITTEE OF THE PRS BOARD EXISTS TO DETERMINE COMPENSATION FOR THE EXECUTIVE DIRECTOR OF EACH COMMUNITY. THIS COMMITTEE IS COMPRISED OF THE OFFICERS OF THE PRS BOARD OF DIRECTORS. THE COMMITTEE HAS A CHARTER THAT OUTLINES ITS DUTIES AND RESPONSIBILITIES. IT ALSO HAS AGENDA ELEMENTS THAT DESCRIBE THE ACTIVITIES THAT THE COMMITTEE UNDERTAKES DURING THE YEAR. THE VP OF HUMAN RESOURCES PROVIDED SALARY STUDIES FROM THE FOLLOWING RESOURCES TO THE COMMITTEE RELATIVE TO EXECUTIVE DIRECTOR COMPENSATION: SALARY.COM, PAYSCALE.COM, 990 REVIEW (LIKE SIZE ORGANIZATIONS), CEMO (CHIEF EXECUTIVE OFFICERS OF MULTI-FACILITY ORGANIZATIONS) SALARY STUDY RESULTS, AND INDUSTRY STATE ASSOCIATION SALARY STUDY RESULTS BASED ON GEOGRAPHICAL LOCATION. THE RECOMMENDATION FOR BASE COMPENSATION AND BONUS ARE PROVIDED BY THE ED'S DIRECT SUPERVISOR (COO OR VP OF OPERATIONS). FORM 990, PART VI, SECTION C, LINE 19 ALL REQUESTS GO THROUGH CORPORATE COUNSEL. FORM 990, PART VII, SECTION A: NOTE THAT JOHN LARSON IS AN EMPLOYEE OF RETIREMENT SERVICES, INC. AND PERFORMS SERVICES ON BEHALF OF MIRABELLA PURSUANT TO A MANAGEMENT SERVICES AGREEMENT BETWEEN MIRABELLA AND PACIFIC RETIREMENT SERVICES. UNDER THE MANAGEMENT SERVICES AGREEMENT, HIS COMPENSATION IS REIMBURSED BY MIRABELLA. HIS COMPENSATION IS REPORTED IN PART VII SECTION A IN ORDER TO HIGHLIGHT AMOUNTS PAID BY MIRABELLA, NOTWITHSTANDING THAT HE IS EMPLOYED BY RETIREMENT SERVICES, INC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST OF MIRABELLA WASHINGTON FOUNDATION, INC. 40,178. LOSS OF EXTINGUISHMENT OF DEBT -1,313,550. PACIFIC RETIREMENT SERVICES INC 965 ELLENDALE DRIVE MEDFORD OR 97504 931067253 SUPPORTING ORGANIZATION OR 501(C)(3) LINE 11C, III-FI N/A 0 ROGUE VALLEY MANOR 965 ELLENDALE DRIVE MEDFORD OR 97504 930453216 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 THE CUMBERLAND REST INC 965 ELLENDALE DRIVE MEDFORD OR 97504 750891470 SENIOR HOUSING TX 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 CASCADE MANOR INC 965 ELLENDALE DRIVE MEDFORD OR 97504 930557803 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 UNIVERSITY RETIREMENT COMMUNITY AT DAVIS 965 ELLENDALE DRIVE MEDFORD OR 97504 931179254 SENIOR HOUSING CA 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 HOLLADAY PARK PLAZA 965 ELLENDALE DRIVE MEDFORD OR 97504 930513697 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 CAPITOL LAKES INC 965 ELLENDALE DRIVE MEDFORD OR 97504 391412320 SENIOR HOUSING WI 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 TRINITY TERRACE FOUNDATION INC 965 ELLENDALE DRIVE MEDFORD OR 97504 912162130 PUBLIC FOUNDATION TX 501(C)(3) LINE 7 PACIFIC RETIREMENT SERVICES INC 0 HOLLADAY PARK PLAZA FOUNDATION 965 ELLENDALE DRIVE MEDFORD OR 97504 264529118 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 PACIFIC RETIREMENT SERVICES INC 0 MIRABELLA WASHINGTON FOUNDATION 965 ELLENDALE DRIVE MEDFORD OR 97504 450574348 PUBLIC FOUNDATION WA 501(C)(3) LINE 7 PACIFIC RETIREMENT SERVICES INC 0 CASCADE MANOR FOUNDATION 965 ELLENDALE DRIVE MEDFORD OR 97504 931330100 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 PACIFIC RETIREMENT SERVICES INC 0 MIRABELLA AT SOUTH WATERFRONT 965 ELLENDALE DRIVE MEDFORD OR 97504 711016384 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM COMMUNITY SERVICES INC 965 ELLENDALE DRIVE MEDFORD OR 97504 930892261 COMM SRVCS OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM EAGLE POINT HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 943191447 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM KLAMATH FALLS HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 943196455 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM MEDFORD II HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 943212537 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM LIVELY OAKS HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 943194409 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM REEDSPORT HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 943212538 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM YREKA HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 943212540 SENIOR HOUSING CA 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM EUGENE HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 943247154 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM BEND II HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 943260016 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM MANSFIELD HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 900292647 SENIOR HOUSING TX 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RETIREMENT SERVICES INC 965 ELLENDALE DRIVE MEDFORD OR 97504 931328250 MANAGEMENT COMPANY OR N/A C 0 CREST PARK 965 ELLENDALE DRIVE MEDFORD OR 97504 931169683 HOTEL OR N/A C 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 1 0 0 0