2013-08-15T18:42:09-05:00 2012-09-30 910189318 MOSS ADAMS LLP 3121 WEST MARCH LANE SUITE 100 STOCKTON CA 952192303 990 2011-10-01 342030255 MIRABELLA MIRA 8887246424 116 FAIRVIEW AVE NORTH SEATTLE WA 98109 JOHN LARSON 8887246424 2013-08-15 1 TRACY S PAGLIA P00366884 2099556100 2011 2016-02-24 21:20:13Z LEN MERRYMAN 965 ELLENDALE DRIVE MEDFORD OR 97504 22355747 0 X RETIREMENT.ORG X 2005 WA TO PROVIDE COMPREHENSIVE CARE AND HOUSING FOR THE ELDERLY. 5 5 322 5 0 0 0 0 19460492 22265373 28979 25915 25909 64459 19515380 22355747 0 0 0 0 8719337 9186851 0 0 0 20204138 19761267 28923475 28948118 -9408095 -6592371 235182341 233840365 291586466 296768380 -56404125 -62928015 NONE 0 0 25357577 0 22265373 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. 25357577 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 0 1 49 0 1 322 1 0 0 0 0 0 0 0 0 0 0 X 5 5 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X SHERI DRESSLER 5418577644 965 ELLENDALE DRIVE MEDFORD OR 97504 X TODD MARTIN 1.00 X X 0 3000 0 LARRY BOECK 1.00 X X 0 1000 0 BILL HAZZARD 1.00 X 0 0 0 STAN SCHILL 1.00 X X 0 0 0 LEN MERRYMAN 1.00 X X 0 0 0 ANTHONY P WARTNIK 1.00 X 0 0 0 JAMES MUNN 40.00 X 163931 0 32547 JOHN LARSON 40.00 X 0 175487 44773 KAREN HERNDON 40.00 X 110873 0 21377 274804 179487 98697 2 0 1 0 PACIFIC RETIREMENT SERVICES 965 ELLENDALE DRIVE MEDFORD OR 97504 MANAGEMENT SERVICES 902092 CONSONUS REHAB UNIT 12 PO BOX 4800 PORTLAND OR 97208 THERAPY SERVICES 788348 REGENCE BLUESHIELD PO BOX 91128 SEATTLE WA 98111 EMPLOYEE BENEFITS 444706 CAIN BROTHERS & CO LLC 360 MADISON AVE 5TH FLOOR NEW YORK NY 10017 INVESTMENT BANKING 258424 ADP INSURANCE AGENCY 2835 SOUTH DECKER LAKE DRIVE SALT LAKE CITY UT 84119 EMPLOYEE BENEFITS 243827 10 SERVICE FEES 623000 13892519 13892519 ENTRANCE FEES 623000 4377445 4377445 HEALTH CENTER REVENUE 623000 3086697 3086697 DINING REVENUE 623000 340823 340823 PARKING REVENUE 623000 212978 212978 354911 354911 22265373 25915 25915 64459 0 64459 64459 64459 22355747 22265373 0 90374 156554 156554 7174355 6305787 868568 162516 128409 34107 1184086 938978 245108 509340 441477 67863 1201074 1201074 156859 156859 69137 69137 462398 304737 157661 255784 255784 532479 445839 86640 50585 50585 1568528 1568528 61198 14459 46739 22635 20635 2000 6495310 6495310 6291145 6291145 256053 256053 DIETARY EXPENSE 1074812 1074812 HEALTHCARE SERVICES 952021 952021 FACILITY EXPENSE 265691 119387 146304 ASSET DISPOSAL 45558 45558 28948118 25357577 3590541 0 636420 1089696 11961570 16787604 1135672 463656 89656 121074 1265127 1233817 235500135 23975689 217346791 211524446 2747105 2620072 235182341 233840365 1149896 1429871 140272338 145137013 119950000 117650000 649186 647530 29565046 31903966 291586466 296768380 X -56404125 -62996496 68481 -56404125 -62928015 235182341 233840365 X -6592371 68481 X 0 1 1 X 0 X 5418410 16053247 19460492 22265373 63197522 5418410 16053247 19460492 22265373 63197522 0 0 0 63197522 580091 73561 54888 90374 798914 580091 73561 54888 90374 798914 5998501 16126808 19515380 22355747 63996436 0.98750 0.98300 0.01250 0.01700 X 0 28948118 28948118 1000000 250000 0 0 1000000 1000000 2000000 3000000 250000 250000 500000 750000 21194646 21194646 208176657 21846020 186330637 5343300 1817936 3525364 785532 311733 473799 211524446 REFUNDABLE DEPOSITS 1804049 ENTRANCE FEES REFUNDABLE-REOCCUPANCY 8119950 DUE TO AFFILIATES 14197346 CONTINGENT LIABILITY 7782621 31903966 22355747 28948118 -6592371 68481 68481 -6523890 22424228 68481 68481 22355747 0 22355747 28948118 0 28948118 0 28948118 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: 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, 2012 AND 2011, THERE WERE NO SUCH UNCERTAIN TAX POSITIONS. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST OF MIRABELLA SEATTLE FOUNDATION, INC. 68,481. PART XII, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST OF MIRABELLA SEATTLE FOUNDATION, INC 68,481. 0 0 0 0 0 0 0 0 0 JAMES MUNN 153931 0 10000 0 0 0 17221 0 15326 0 196478 0 0 0 JOHN LARSON 0 146887 0 28600 0 0 0 27638 0 17135 0 220260 0 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. WASHINGTON STATE HOUSING FINANCE COMMISSION 911874730 939783PV2 2006-11-03 250745000 FACILITY ACQUISITION, CONSTRUCTION AND EQUIPPING 0 0 0 139095000 276536357 8000876 21287144 2400271 24121896 3780198 216945973 2008 0 0 1 1 0 1 1 1 0 0.00300 0.00000 0.00300 1 0 1 1 LEHMAN BROTHERS SPEC FIN INC 4.900000000000 0 1 1 PALLAS CAPITAL CORP 2.600000000000 0 1 0 X SCHEDULE K SUPPLENTAL INFORMATION DIFFERENCE BETWEEN PART I, COLUMN (E) AND PART II, LINE 3 IS DUE TO INTEREST EARNINGS ON BOND PROCEEDS. FORM 990, PART VI, SECTION A, LINE 3 MIRABELLA'S BOARD DELEGATES MANAGEMENT TO PACIFIC RETIREMENT SERVICES. 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. HOURS PER WEEK DEVOTED TO RELATED ORGANIZATIONS: FORM 990, PART VII, SECTION A TODD MARTIN DEVOTES TIME TO RELATED ORGANIZATIONS AS FOLLOWS: PACIFIC RETIREMENT SERVICES, INC. (THROUGH 8/2/12) 1 HR MIRABELLA PORTLAND 1 HR MIRABELLA PORTLAND FOUNDATION 1 HR HOLLADAY PARK PLAZA ENDOWMENT FUND (THROUGH 11/14/11) 1 HR LEN MERRYMAN DEVOTES TIME TO RELATED ORGANIZATIONS AS FOLLOWS: ROGUE VALLEY MANOR (THRU 5/1/12) 1 HR CAPITOL LAKES, INC. (THRU 5/1/12) 1 HR MIRABELLA PORTLAND (THRU 5/1/12) 1 HR LARRY BOECK DEVOTES TIME TO RELATED ORGANIZATIONS AS FOLLOWS: CAPITOL LAKES FOUNDATION 1 HR CAPITOL LAKES, INC. 1 HR PACIFIC RETIREMENT SERVICES, INC. 1 HR MIRABELLA PORTLAND (THRU 1/24/12) 1 HR JAMES MUNN DEVOTES TIME TO RELATED ORGANIZATIONS AS FOLLOWS: MIRABELLA WASHINGTON FOUNDATION 1 HR CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN BENEFICIAL INTEREST OF MIRABELLA SEATTLE FOUNDATION, INC. 68,481. TOTAL TO FORM 990, PART XI, LINE 5: 68,481. 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 HOLLADAY PARK PLAZA ENDOWMENT FUND 965 ELLENDALE DRIVE MEDFORD OR 97504 930776291 ASSISTANCE TRUST OR 501(C)(3) LINE 7 HOLLADAY PARK PLAZA 0 CAPITOL LAKES INC 965 ELLENDALE DRIVE MEDFORD OR 97504 391412320 SENIOR HOUSING WI 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 ROGUE VALLEY MANOR FOUNDATION 965 ELLENDALE DRIVE MEDFORD OR 97504 930712867 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 PACIFIC RETIREMENT SERVICES INC 0 UNIVERSITY RETIREMENT COMMUNITY AT DAVIS FOUNDATION 965 ELLENDALE DRIVE MEDFORD OR 97504 931301816 PUBLIC FOUNDATION CA 501(C)(3) LINE 7 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 CAPITOL LAKES FOUNDATION 965 ELLENDALE DRIVE MEDFORD OR 97504 383781089 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 CAPITOL LAKES INC 0 MIRABELLA PORTLAND FOUNDATION 965 ELLENDALE DRIVE MEDFORD OR 97504 452508860 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 MIRABELLA SAN FRANCISCO BAY 965 ELLENDALE DRIVE MEDFORD OR 97504 200428927 SENIOR HOUSING CA 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 HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 930864466 SENIOR HOUSING OR 501(C)(3) LINE 9 ROGUE VALLEY MANOR 0 RVM ASHLAND HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 930942933 SENIOR HOUSING OR 501(C)(3) LINE 9 ROGUE VALLEY MANOR 0 RVM GRANTS PASS HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 943136037 SENIOR HOUSING OR 501(C)(3) LINE 9 ROGUE VALLEY MANOR 0 RVM ROSEBURG HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 943179782 SENIOR HOUSING OR 501(C)(3) LINE 9 ROGUE VALLEY MANOR 0 RVM MYRTLE CREEK HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 943162074 SENIOR HOUSING OR 501(C)(3) LINE 9 ROGUE VALLEY MANOR 0 RVM BEND HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 943163349 SENIOR HOUSING OR 501(C)(3) LINE 9 ROGUE VALLEY MANOR 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 FORT WORTH I HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 311520436 SENIOR HOUSING TX 501(C)(3) LINE 9 ROGUE VALLEY MANOR 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 FORT WORTH II HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 311587415 SENIOR HOUSING TX 501(C)(3) LINE 9 ROGUE VALLEY MANOR 0 RVM MEDFORD III HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 311587418 SENIOR HOUSING OR 501(C)(3) LINE 9 ROGUE VALLEY MANOR 0 RVM ROSEBURG II HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 311587420 SENIOR HOUSING OR 501(C)(3) LINE 9 ROGUE VALLEY MANOR 0 RVM GRANTS PASS II HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 311662259 SENIOR HOUSING OR 501(C)(3) LINE 9 ROGUE VALLEY MANOR 0 RVM DAVIS HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 311662208 SENIOR HOUSING CA 501(C)(3) LINE 9 ROGUE VALLEY MANOR 0 RVM MYRTLE CREEK II HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 311715321 SENIOR HOUSING OR 501(C)(3) LINE 9 ROGUE VALLEY MANOR 0 RVM PORTLAND HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 311780332 SENIOR HOUSING OR 501(C)(3) LINE 9 ROGUE VALLEY MANOR 0 RVM PORTLAND II HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 300037898 SENIOR HOUSING OR 501(C)(3) LINE 9 ROGUE VALLEY MANOR 0 RVM CENTRAL POINT HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 300315618 SENIOR HOUSING OR 501(C)(3) LINE 9 ROGUE VALLEY MANOR 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 CORBINTON RETIREMENT 965 ELLENDALE DRIVE MEDFORD OR 97504 262987036 SENIOR HOUSING NC 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 MIRABELLA AT MORRISON 965 ELLENDALE DRIVE MEDFORD OR 97504 271016196 SENIOR HOUSING NC 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 CREST PARK 965 ELLENDALE DRIVE MEDFORD OR 97504 931169683 HOTEL OR N/A C 0 0 0 0 1 0 0 0 0 0 0 1 0 0 1 0 0 0