2025-03-13T16:47:07-05:00 2024-05-31 390758449 WIPFLI LLP 170 N RADNOR-CHESTER RD SUITE 200 RADNOR PA 19087 990 2023-06-01 264321839 LAKESHORE COMMUNITY HEALTH CARE INC LAKE 9207836633 1721 SAEMANN AVENUE SHEBOYGAN WI 53081 KRISTIN BLANCHARD STEARNS CEO 9207836633 2025-03-13 1 1 SOLOMON MARDAKHAEV P01806552 6105653930 2025-03-13 2023 2025-03-06 01:10:19Z KRISTIN BLANCHARD STEARNS 1721 SAEMANN AVENUE SHEBOYGAN WI 53081 18312485 0 X WWW.LAKESHORECHC.ORG X 2009 WI LCHC STRIVES TO CREATE COMMUNITIES WHERE ALL PEOPLE LIVE HEALTHY, ACTIVE, AND PROSPEROUS LIVES. LCHC ASPIRES TO BE A PREFERRED PROVIDER AND AN EMPLOYER OF CHOICE. 11 11 179 12 0 0 4208382 3339826 12424643 14809479 101665 -235361 29742 14520 16764432 17928464 0 0 0 0 11781035 12639137 0 0 0 5012623 6113977 16793658 18753114 -29226 -824650 15947200 15725508 4603030 4775918 11344170 10949590 X LAKESHORE COMMUNITY HEALTH CARE PROVIDES ACCESS TO COMPREHENSIVE, INTEGRATED HEALTH CARE, REGARDLESS OF ABILITY TO PAY, ELIMINATING HEALTH DISPARITIES AMONG THE UNDERSERVED. 0 0 14091881 0 14809479 LAKESHORE COMMUNITY HEALTH CARE, INC. PROVIDES HEALTH CARE SERVICES TO PEOPLE WHO STRUGGLE TO FIND A DOCTOR, DENTIST, OR A COUNSELOR FOR CARE. THE ORGANIZATION ALSO PROVIDES PHARMACY AND CHIROPRACTIC SERVICES. THE ORGANIZATION WORKS WITH OUR COMMUNITY PARTNERS TO REFER PATIENTS FOR ANY SERVICES THE ORGANIZATION IS UNABLE TO PROVIDE. THE ORGANIZATION WORKS VERY HARD TO MAKE SURE PATIENTS GET WHAT THEY NEED AND PROVIDES UP TO 90% DISCOUNTS FOR ANYONE WHO CANNOT AFFORD TO PAY FOR THESE SERVICES.LAKESHORE PROVIDED SERVICES TO 12,971 UNDUPLICATED PATIENTS IN OUR 2024 FISCAL YEAR. THESE PATIENTS WERE SEEN FOR 27,965 DENTAL VISITS 3,616 OF THOSE THROUGH OUR SCHOOL-BASED DENTAL PROGRAM), 8,232 MEDICAL VISITS, 12,220 BEHAVIORAL HEALTH VISITS (8,080 OF THOSE THROUGH OUR SCHOOL-BASED PATH PROGRAM), AND 4,474 CHIROPRACTIC VISITS. LAKESHORE ALSO PROVIDED 38,602 PRESCRIPTIONS TO OUR PATIENTS THROUGH OUR 340B PHARMACY PROGRAM. 14091881 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 0 0 1 17 0 179 1 0 0 0 0 0 1 1 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 1 0 WI X CALEB JENSEMA CFO 9207836633 1721 SAEMANN AVENUE SHEBOYGAN WI 53081 LEIGHANNE MATTER-JENSEN PRESIDENT 2.00 1.00 X X 0 0 0 DENISE WITTSTOCK VICE PRESIDENT 2.00 X X 0 0 0 WILLIAM PFEFFERKORN TREASURER 2.00 X X 0 0 0 KELYN NETZ SECRETARY 2.00 X X 0 0 0 SHERRIE BOETTCHER BOARD MEMBER (THRU JUNE 2023) 2.00 X 0 0 0 HEATHER FEEST BOARD MEMBER 2.00 X 0 0 0 RUTH HENKLE BOARD MEMBER 2.00 X 0 0 0 SHENITA SALAAM BOARD MEMBER (THRU MAY 2024) 2.00 X 0 0 0 BRENDA SMITH BOARD MEMBER (THRU MAY 2024) 2.00 X 0 0 0 JIM STRACHOTA BOARD MEMBER 2.00 X 0 0 0 AMALIA VARGAS BOARD MEMBER 2.00 X 0 0 0 ROBERT ZIEGELBAUER BOARD MEMBER (THRU MAY 2024) 2.00 X 0 0 0 KRISTIN BLANCHARD STEARNS CEO 40.00 1.00 X 184146 0 46555 MICHELE SCHMITT COO 40.00 X 128790 0 17204 CALEB JENSEMA CFO 40.00 X 108875 0 8881 PAJ NTAUB VANG MD FAMILY PHYSICIAN 40.00 X 202272 0 20548 CASEY WILSON DDS DENTAL DIRECTOR 40.00 X 190442 0 19241 OLAIFA TURNER DDS DENTIST 40.00 X 169140 0 15492 SUBHASHISH DAS DDS DENTIST 40.00 X 167015 0 17669 CHRISTINA TORKILSEN DDS DENTIST 40.00 X 158750 0 8451 1309430 0 154041 23 0 1 0 PLEXUS HEALTH SOLUTIONS INC PO BOX 0655 KENOSHA WI 53141 CONTRACT BILLING SERVICES 479383 OCHIN PO BOX 8426 PORTLAND OR 97228 ELECTRIC HEALTH RECORD PROVIDER 426208 STRATUS INDEMAND PO BOX 675248 DETROIT MI 48267 TRANSLATION SERVICES 274430 NDX LORDS DENTAL STUDIO PO BOX 19048 GREEN BAY WI 54307 CONTRACT DENTAL LAB 234522 BARTON ASSOCIATES PO BOX 417844 BOSTON MA 02241 LOCUM DENTIST 227329 6 15000 26046 50535 2264345 983900 390935 3339826 PATIENT SERVICE REVENUE 621400 13655154 13655154 PHARMACY REVENUE 621400 1136465 1136465 17860 17860 14809479 131624 131624 20823 0 20823 20823 20823 366985 -366985 -366985 -366985 0 26046 17036 -17036 -17036 10733 10733 10733 17928464 14809479 0 -220841 X 495273 495273 9585670 7145906 2439764 324037 238623 85414 1514441 1054816 459625 719716 516560 203156 37634 1579 36055 77395 4812 72583 2014144 1812733 201411 34492 13434 21058 69663 54679 14984 135007 84003 51004 472754 304743 168011 58014 39840 18174 57842 40968 16874 197600 103232 94368 425852 337572 88280 50319 29863 20456 MEDICAL SUPPLIES 1414766 1414766 ELECTRONIC HEALTH RECOR 539739 539739 EQUIPMENT 235740 202089 33651 LICENSES & DUES 194874 91304 103570 98142 60620 37522 18753114 14091881 4661233 0 755607 773469 2854592 2563093 39795 40010 917150 845579 4955250 76924 76389 146281 151696 14862499 3606066 6163582 11256433 38019 18839 15947200 15725508 1225536 1493574 22028 17045 3327653 3245268 27813 20031 4603030 4775918 X 10687793 10266884 656377 682706 11344170 10949590 15947200 15725508 X -824650 -10539 440609 X 0 1 X 1 1 1 X SCHEDULE A: THE ORGANIZATION IS NOT LICENSED AS A HOSPITAL IN THE STATE OF WISCONSIN. THE ORGANIZATION HAS RECEIVED ITS IRS DETERMINATION LETTER SHOWING THAT THE ORGANIZATION'S PUBLIC CHARITY STATUS IS SECTION 170(B)(1)(A)(III). RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 351364 351364 10669005 1348197 9320808 220622 150408 70214 3621508 2107461 1514047 11256433 CAPITAL LEASE OBLIGATIONS 20031 20031 X 20279718 10396 2374172 2384568 17895150 33314 33314 17928464 18912937 20935 172202 193137 18719800 33314 33314 18753114 PART X, LINE 2: THE ORGANIZATION RECOGNIZES THE BENEFITS OF A TAX POSITION ONLY AFTER DETERMINING WHETHER IT IS MORE LIKELY THAN NOT THAT THE TAXING AUTHORITY WOULD SUSTAIN THE TAX POSITION UPON EXAMINATION OF THE TECHNICAL MERITS OF THE TAX POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. THE ORGANIZATION RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS. PART XI, LINE 2D - OTHER ADJUSTMENTS: INTERCOMPANY RENT ELIMINATION -84,000. LCHC QALICB INCOME 2,458,172. PART XI, LINE 4B - OTHER ADJUSTMENTS: INTERCOMPANY GRANTS 50,350. FUNDRAISING EXPENSES -17,036. PART XII, LINE 2D - OTHER ADJUSTMENTS: INTERCOMPANY RENT ELIMINATION -84,000. LCHC QALICB EXPENSES 256,202. PART XII, LINE 4B - OTHER ADJUSTMENTS: INTERCOMPANY GRANTS 50,350. FUNDRAISING EXPENSES -17,036. CAVEMAN RUN 26046 26046 17036 26046 26046 17036 17036 -17036 X X 0 0 0 0 0 0 0 0 0 KRISTIN BLANCHARD STEARNS CEO 183696 0 0 0 450 0 7720 0 38835 0 230701 0 0 0 PAJ NTAUB VANG MD FAMILY PHYSICIAN 202002 0 0 0 270 0 8194 0 12354 0 222820 0 0 0 CASEY WILSON DDS DENTAL DIRECTOR 190172 0 0 0 270 0 7897 0 11344 0 209683 0 0 0 SUBHASHISH DAS DDS DENTIST 166775 0 0 0 240 0 6480 0 11189 0 184684 0 0 0 OLAIFA TURNER DDS DENTIST 160985 0 0 0 8155 0 3568 0 11924 0 184632 0 0 0 CHRISTINA TORKILSEN DDS DENTIST 158510 0 0 0 240 0 6305 0 2146 0 167201 0 0 0 X 1 390935 FMV 0 0 0 0 PART I, LINE 16: THE ORGANIZATION IS REPORTING THE NUMBER OF CONTRIBUTIONS IN PART I, COLUMN (B). FORM 990, PART VI, SECTION B, LINE 11B BOARD MEMBERS ARE GIVEN COPIES OF THE FORM 990 TO REVIEW BEFORE FILING WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C 1. AT LEAST ANNUALLY, THE FOLLOWING INDIVIDUALS MUST REVIEW THIS POLICY AND THE ATTACHED "CONFLICT OF INTEREST DISCLOSURE" FORM. COMPLETED FORMS ARE SUBMITTED TO THE CEO OR COMPLIANCE OFFICER FOR REVIEW: A. MEMBERS OF THE BOARD OF DIRECTORS. B. MEMBERS OF SENIOR MANAGEMENT. C. NON-EMPLOYED COMMITTEE MEMBERS. D. EMPLOYEES WITH PURCHASING AUTHORITY. 2. AT ANY TIME DURING THE YEAR, WHEN AN ACTUAL, POTENTIAL, OR PERCEIVED CONFLICT OF INTEREST ARISES, A RESPONSIBLE PERSON MUST CONTACT, AS APPROPRIATE, THE CHAIRPERSON OF THE BOARD OF DIRECTORS OR OTHER COMMITTEE, THE CEO, OR THE COMPLIANCE OFFICER. ALL POTENTIAL CONFLICT OF INTEREST DISCLOSURES MUST BE FORWARDED TO THE CEO OR THE COMPLIANCE OFFICER FOR REVIEW PROCESS MANAGEMENT. 3. THE CEO OR THE COMPLIANCE OFFICER WILL ENSURE THAT THE POTENTIAL CONFLICT OF INTEREST IS REVIEWED TO DETERMINE IF FURTHER ACTION IS REQUIRED. 4. EMPLOYEE DISCLOSURES ARE REVIEWED BY THE CEO. THE CEO'S DISCLOSURES AND THOSE OF MEMBERS OF THE BOARD OF DIRECTORS ARE REVIEWED BY THE BOARD OF DIRECTORS CHAIRPERSON. COMMITTEE MEMBER DISCLOSURES ARE REVIEWED BY THE COMMITTEE CHAIR. 5. PRIOR TO BOARD OR COMMITTEE ACTION ON A CONTRACT OR TRANSACTION INVOLVING A CONFLICT OF INTEREST, A RESPONSIBLE INDIVIDUAL HAVING A CONFLICT OF INTEREST AND WHO IS IN ATTENDANCE AT THE MEETING MUST DISCLOSE ALL FACTS MATERIAL TO THE CONFLICT OF INTEREST. SUCH DISCLOSURE MUST BE REFLECTED IN THE MINUTES OF THE MEETING. 6. A RESPONSIBLE PERSON WHO PLANS NOT TO ATTEND A MEETING AT WHICH HE OR SHE HAS REASON TO BELIEVE THAT THE BOARD OR COMMITTEE WILL ACT ON A MATTER IN WHICH THE PERSON HAS A CONFLICT OF INTEREST SHALL DISCLOSE TO THE BOARD OR COMMITTEE CHAIR ALL FACTS MATERIAL TO THE CONFLICT OF INTEREST. THE BOARD OR COMMITTEE CHAIR WILL REPORT THE DISCLOSURE AT THE MEETING AND THE DISCLOSURE WILL BE REFLECTED IN THE MINUTES OF THE MEETING. 7. A PERSON WHO HAS A CONFLICT OF INTEREST WILL NOT PARTICIPATE IN OR BE PERMITTED TO HEAR THE BOARD'S OR COMMITTEE'S DISCUSSION OF THE MATTER EXCEPT TO DISCLOSE MATERIAL FACTS AND TO RESPOND TO QUESTIONS. SUCH PERSON MUST NOT ATTEMPT TO EXERT HIS OR HER PERSONAL INFLUENCE WITH RESPECT TO THE MATTER, EITHER AT OR OUTSIDE OF THE MEETING. SUCH PERSON WILL NOT BE ALLOWED TO PARTICIPATE IN THE SELECTION, AWARD, OR ADMINISTRATION OF RELEVANT CONTRACTS. SUCH PERSON WILL NOT BE ALLOWED TO PARTICIPATE IN THE SELECTION, AWARD, OR ADMINISTRATION OF RELEVANT CONTRACTS. 8. A PERSON WHO HAS A CONFLICT OF INTEREST WITH RESPECT TO A CONTRACT OR TRANSACTION THAT WILL BE VOTED ON AT A MEETING SHALL NOT BE COUNTED IN DETERMINING THE PRESENCE OF A QUORUM FOR PURPOSES OF THE VOTE. THE PERSON HAVING THE CONFLICT OF INTEREST MAY NOT VOTE ON THE CONTRACTOR TRANSACTION AND MUST NOT BE PRESENT IN THE MEETING ROOM WHEN THE VOTE IS TAKEN, UNLESS THE VOTE IS BY SECRET BALLOT. THE MEETING MINUTES MUST REFLECT THE PERSON'S INELIGIBILITY TO VOTE. 9. RESPONSIBLE PERSONS WHO ARE EMPLOYED BY LCHC, OR WHO HAVE A POTENTIAL CONFLICT OF INTEREST WITH RESPECT TO A CONTRACT OR TRANSACTION THAT IS NOT THE SUBJECT OF BOARD OR COMMITTEE ACTION, MUST DISCLOSE THE POTENTIAL CONFLICT OF INTEREST TO THE CEO OR THE COMPLIANCE OFFICER, WHO WILL DETERMINE WHETHER THERE EXISTS A CONFLICT OF INTEREST THAT IS SUBJECT TO THIS POLICY. SUCH DISCLOSURE MUST BE MADE AS SOON AS THE RESPONSIBLE PERSON BECOMES AWARE OF THE POTENTIAL CONFLICT. THE RESPONSIBLE PERSON MUST REFRAIN FROM ANY ACTION THAT MAY AFFECT LCHC PARTICIPATION IN THE CONTRACT OR TRANSACTION. 10. PER LCHC BOARD MANUAL AND/OR LCHC STANDARDS OF CONDUCT, VIOLATION OF THIS POLICY MAY LEAD TO DISCIPLINARY ACTIONS INCLUDING TERMINATION. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION LOOKS AT NATIONAL AND LOCAL COMPARISON DATA FROM NACHC AND MGMA TO SET SALARY RANGES FOR EACH POSITION. ACTUAL SALARIES ARE BASED ON QUALIFICATIONS AND DETERMINED BY HR AND THE CFO. THE BOARD OF DIRECTORS HAS THE POWER TO ESTABLISH AND PERIODICALLY UPDATE THE SALARY AND BENEFITS SCALES AND MOST RECENTLY APPROVED THE ENGAGEMENT WITH A CONSULTING FIRM TO CONDUCT A WAGE RANGE STUDY FOR ALL OF OUR EMPLOYEES WHICH CONCLUDED AT THE END OF 2021 AND UTILIZED DATA FROM NACHC AS WELL AS MGMA. THESE NEW SALARY RANGES FROM THIS PROPOSAL SET FORTH BY THE CONSULTING FIRM ARE ALL TO BE REVIEWED AND APPROVED BY THE BOARD OF DIRECTORS BEFORE BEING IMPLEMENTED IN ANY CAPACITY. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G ADMINISTRATIVE SERVICES: PROGRAM SERVICE EXPENSES 40,787. MANAGEMENT AND GENERAL EXPENSES 57,058. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 97,845. BILLING SERVICES: PROGRAM SERVICE EXPENSES 525,706. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 525,706. CLINICAL SERVICES: PROGRAM SERVICE EXPENSES 650,135. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 650,135. DENTAL LAB SERVICES: PROGRAM SERVICE EXPENSES 256,549. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 256,549. GRANT WRITING: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 55,781. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 55,781. HOUSEKEEPING SERVICES: PROGRAM SERVICE EXPENSES 90,781. MANAGEMENT AND GENERAL EXPENSES 45,916. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 136,697. IT SERVICES: PROGRAM SERVICE EXPENSES 17,185. MANAGEMENT AND GENERAL EXPENSES 35,964. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 53,149. TRANSLATION SERVICES: PROGRAM SERVICE EXPENSES 231,590. MANAGEMENT AND GENERAL EXPENSES 6,692. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 238,282. FORM 990, PART XI, LINE 9: TRANSFER OF NET ASSETS UPON MERGER WITH LCHC QALICB 440,609. LCHC QALICB INC 1721 SAEMANN AVENUE SHEBOYGAN WI 53081 815453995 TO SUPPORT LAKESHORE COMMUNITY HEALTH CARE, INC. WI 501(C)(3) LINE 12A, I LAKESHORE COMMUNITY HEALTH CARE INC 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 LCHC QALICB INC K 84000 CASH LCHC QALICB INC C 50350 CASH