2013-07-08T17:03:03-05:00 2012-08-31 861065772 DELOITTE TAX LLP 695 TOWN CENTER DRIVE SUITE 1200 COSTA MESA CA 92626 990 2011-09-01 951656366 Good Samaritan Hospital GOOD 2139772010 616 South Witmer Street Los Angeles CA 900171912 ALAN M INO 2139772010 2013-07-08 1 DIANA J McCUTCHEN P00545657 7144367100 2011 2016-02-25 16:41:14Z Andrew B Leeka 616 South Witmer Street Los Angeles CA 900171912 387096828 0 X WWW.GOODSAM.ORG X 1885 CA Provide accessible, quality cost-effective, healthcare services at 408-bed hospital in LA. 31 30 1754 30 380392 0 8735356 7368138 304535116 299502103 9273290 10081490 1769308 3925129 324313070 320876860 2757061 3457353 0 0 140588254 137412341 0 0 1511296 157888340 163816070 301233655 304685764 23079415 16191096 413688317 452867218 158646027 161280204 255042290 291587014 X To provide accessible, quality, cost-effective community healthcare. The hospital operates a 408-bed facility in inner-city Los Angeles. 0 0 271457583 2758720 299502103 The Hospital is primarily engaged in providing inpatient and outpatient medical care for the general community regardless of ability to pay. Fiscal year August 31, 2012 patient days totaled 61,444 and outpatient visits totaled 88,622.The Hospital has a policy to treat emergency and certain other patients regardless of their ability to pay. Consistent with the Hospital's tax-exempt status and community service responsibilities, the Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than its established rates. Under the Hospital's policy, charity care may be provided to people who are uninsured or under-insured and can not afford to pay for their own medical care. Because the Hospital does not pursue collection or amounts determined to qualify as charity care, these are not included in net patient revenues. In some instances, charity care cases are identified subsequent to the occurrence of collection activities and may be classified as bad debts.Therefore, the Hospital is unable to determine actual total charity activity. Charitable care not included in net patient revenue was approximately $11,334,214 for fiscal year 2012.The Hospital also provides services to patients under Medi-Cal and other publicly sponsored programs which reimburse the Hospital at amounts less than the cost of the services provided to patients. In addition, health screenings and other benefits were provided for its community. The unreimbursed cost of these benefits and services were approximately $32,421,628 for fiscal year 2012. 271457583 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 471 0 1 1754 1 1 1 0 0 0 0 1 1 0 0 0 0 0 X 31 30 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 CA X Reuben V Barboza 2134822725 637 S Lucas Ave 3rd Floor Los Angeles CA 90017 X Andrew Leeka 55.00 X X 519335 0 10530 Sushma Adarkar MD 1.00 X 0 0 0 George A Bender 1.00 X 0 0 0 Bruce Bennett 1.00 X 0 0 0 William M Bitting 1.00 X 0 0 0 Mrs Jack L Blumenthal 1.00 X 0 0 0 Mrs William H Borthwick 1.00 X 0 0 0 Rt Rev Joseph Jon Bruno 1.00 X 0 0 0 Mrs Richard W Call 1.00 X 0 0 0 Arthur L Crowe Jr 1.00 X 0 0 0 Mrs Victoria Seaver Dean 1.00 X 0 0 0 Robert E Denham 1.00 X 0 0 0 Andrew Fishmann MD 1.00 X 0 0 0 John B Frank 1.00 X 0 0 0 James H Gipson 1.00 X 0 0 0 Ms Mimi Grant 1.00 X 0 0 0 Robert K Maloney 1.00 X 0 0 0 Mrs Angus M McLeod 1.00 X 0 0 0 Charles P Meister 1.00 X 0 0 0 Glen H Mitchel Jr 1.00 X 0 0 0 Peter W Mullin 1.00 X 0 0 0 Charles T Munger 1.00 X 0 0 0 Todd G Owens 1.00 X 0 0 0 Clark Willard Porter 1.00 X 0 0 0 Mrs Helen Lho Ryu 1.00 X 0 0 0 Thomas L Shook MD 1.00 X 0 0 0 Stephen L Smith 1.00 X 0 0 0 Norman F Sprague III MD 1.00 X 0 0 0 Joseph P Van der Meulen 1.00 X 0 0 0 Warren B Williamson 1.00 X 0 0 0 Edward A Wopschall 1.00 X 0 0 0 Alan M Ino 55.00 X 423096 0 9866 Susan Harlow 40.00 X 257857 0 7695 Lexie Schuster 40.00 X 261313 0 7350 Sammy Feuerlicht 40.00 X 235117 0 8993 Dan McLaughlin 40.00 X 245335 0 3730 Berniece Deol 40.00 X 294609 0 305 Ching Chen 40.00 X 247839 0 8166 Ira Meiselman 40.00 X 232154 0 11351 Hilarion Castillo 40.00 X 223749 0 8925 Elizabeth Pabros 40.00 X 193226 0 9659 Steve Garcia 40.00 X 186511 0 10827 3320141 0 97397 205 0 1 0 Crothall Healthcare Inc 955 Chesterbrook Blvd Suite 300 Wayne PA 19087 Environmental Services 4488222 Sodexho Marriott Services 711 Kimberly Avenue Suite 250 Placentia CA 92870 Dietary Services 3701273 Cross Country StaffFlex Staff P O Box 404674 Atlanta GA 30384 Employment Registry 1511431 Dell Marketing 120 Royall Street Canton MA 02021 Health Insurance Management 1395815 DVA Renal Healthcare Inc P O Box 403008 Atlanta GA 30384 Dialysis Services 1022394 88 78050 1193705 6096383 7368138 Net Patient Revenue 900099 298263927 298263927 Rental Income 532000 733547 733547 Child Care Center 624410 468350 468350 Symposium Revenue 900099 36279 36279 299502103 9058022 9058022 67105472 48118 66130122 0 975350 48118 1023468 1023468 65165 78050 89846 -24681 -24681 Parking Lot 812930 480116 29485 450631 Physician Mgmt Service 621110 242331 242331 Non-patient Lab 621500 108576 108576 3118787 3118787 3949810 320876860 299502103 380392 13626227 3457353 3457353 2285131 294914 1724665 265552 96308210 87719882 8281687 306641 5737654 5151382 586272 24598636 22203274 2324320 71042 8482710 7667436 770329 44945 861780 861780 382446 382446 25347 25347 42274267 33719771 8498657 55839 1128764 139580 988884 300 455407 454407 1000 156502 42638 106449 7415 4395038 4395038 9496239 6609971 2886268 1215388 601051 614337 Supplies 48376956 47660901 702857 13198 Hospital Fee Program 33533879 33533879 0 0 Bad Debts 12672008 12672008 0 0 Utilities 3237860 3145543 92317 5604189 1988555 2869270 746364 304685764 271457583 31716885 1511296 13112844 9451527 6559400 6586025 14111669 13618930 35763304 34511383 16034956 37668074 1399114 1288607 13918132 13240813 379364372 283489454 92634709 95874918 217975854 237981498 2178335 2645443 413688317 452867218 42837100 49742594 60880882 56472177 54928045 55065433 158646027 161280204 X 157290065 191733033 40418577 42520333 57333648 57333648 255042290 291587014 413688317 452867218 X 16191096 20353628 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED X X 0 0 0 0 0 0 0 0 1 25347 25347 0 Explanation of Lobbying Activities: Part II-B, Line 1: Lobbying represents a portion of the dues Good Samaritan Hospital pays to the Hospital Association of Southern California. 0 0 57333648 57333648 57333648 57333648 57316151 17497 57333648 57313907 2244 57316151 1.00000 1 0 11395670 11395670 128932121 98306726 30625395 213299598 182241237 31058361 25736983 2941491 22795492 95874918 Reserve For Self-Insured Programs 7613831 Pension Plan 21762129 Advances From Third Party Payors 4076311 Reserve For Asset Retirement Obligation 7686472 Other Long term Reserves/Liabilities 12735188 Other Annuity Payment Liability 1191502 55065433 Description of Intended Use of Endowment Funds: Part V, Line 4: For Specific purposes listed by the donors. Description of Uncertain Tax Positions Under FIN 48: Part X: The hospital, SIC, and MOB are not-for-profit corporations as described in section 501(c)(3) of the internal revenue code (the "code") and are exempt from federal income taxes pursuant to section 501(a) of the code. They are exempt from state franchise taxes under similar statutes. Accordingly, no provision for income taxes has been recorded in the accompanying consolidated financial statements. During the years ended August 31, 2012 and 2011, the hospital did not record any liability for unrecognized tax contingencies. Golf Tournament 143215 78050 65165 61841 28005 143215 78050 65165 61841 28005 89846 -24681 1 1 X 1 X 1 X 1 1 0 1 0 12271220 1500291 10770929 0.03690 92506663 85671161 6835502 0.02340 0.00000 104777883 87171452 17606431 0.06030 140504 140504 0.00050 0.00000 0.00000 2026741 682912 1343829 0.00460 1256688 1256688 0.00430 3423933 682912 2741021 0.00940 108201816 87854364 20347452 0.06970 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 1 1863325 0 90888067 83396579 7491488 X 1 1 1 1 Good Samaritan Hospital

616 South Witmer Street Los Angeles CA 90017

X X X X X Hospital research by Institutes GOOD SAMARITAN HOSPITAL 1 1 X X X X X X X X 10 1 1 1 X X X X X 1 1 1 200.000000000000 1 350.000000000000 1 X X X X X X X 1 1 X X X X 1 0 1 X 0 0 Part I, Line 3c: Discounted care is provided to patients that are uninsured and do not meet the charity care eligibility criteria. Part I, Line 7: 7 a) Charity care cost: applied FY 2012 Medi-Cal RCC of 20.59% (total patient cost to charges excluding Hospital Fee expense) to charity write-offs. 7 b) Unreimbursed Medi-Cal: Cost for all Medi-Cal patients calculated from cost accounting system less payments received and estimated outstanding. 7 e) Community health improvement services: General Ledger expenses for the hospital's volunteer program. 7 h) Research: Expenses from Research general ledger account less funding received.7 i) Cash in-kind contributions: Amounts paid to California Health Fund & Trust. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 12672008. Part III, Line 4: Bad debt cost determined by applying RCC from FY 2012 Medi-Cal cost report to bad debt transfers net of recoveries. These costs were not included in community benefit. Part III, Line 8: Filed Medicare cost report. Part III, Line 9b: The debt collection policy indicates that patients that qualify for charity will be adjudicated under that policy. Charity patients receive a 100% discount. Patients whose family income is between 200% and 350% of the FPL will receive a 60% discount on the cash price for uninsured patients. GOOD SAMARITAN HOSPITAL Part V, Section B, Line 3: Focus Groups - Two types of focus groups were conducted in order to collect information from both the community member perspective as well as the CBO perspective. CBOs included agencies that provide health, social, and other types of services. Information was gathered to identify areas of needs and services available or lacking to meet those needs. In addition, an online survey was made available to CBOs who were unable to attend a focus group. In total, there were ten focus groups conducted (5 with community memebers and 5 with CBOs) with a total of 158 participants. The focus group interviews were conducted in either English or Spanish, with a mixed age group, including both males and females. Groups included residents from major ethnic groups, geographic areas and service providers in the Collaborative's service areas. Seniors, community health promoters and service providers were gathered separately. Topics in the focus group included major areas from previous needs assessments and other issues anticipated to be important in health care. Areas covered were: health care utilization, preventative and primary care, health insurance, access and barriers to care, emergency room use, chronic disease management and community issues. Individual Interviews - Thirty interviews were conducted to gather information about the needs and challenges faced by the community in accessing and utilizing health care services, and to ensure reliable and representative information. Key informants included staff at collaborative hospitals and health care service organizations in the primary service areas. Interviews were conducted over the phone or in person and lasted approximately 45 minutes. GOOD SAMARITAN HOSPITAL Part V, Section B, Line 4: Good Samaritan Hospital conducted the Community Needs Assessment in collaboration with California Hospital Medical Center, Childrens Hospital of Los Angeles, Kaiser Foundation Hospital - Los Angeles, St. Vincent Medical Center. Part I, line 7b:In October 2010, CMS approved legislation enacted by the State of California that provided for supplemental Medi-Cal payments to be paid to certain hospitals from funds collected from participating hospitals under the state's quality assurance fee program. Such amounts were allocated and paid to the Good Samaritan Hospital based on prior year patient data, which includes Medi-Cal patients. If these amounts had not been included, the Hospital would have reported a total Community Benefit percentage in excess of 13%. Part VI, Line 2: Based on a community needs assessment conducted every three years in collaboration with neighboring hospitals and health care organizations, Good Samaritan Hospital develops a yearly community benefit plan that is submitted to the State. The plan includes proposed activities designed around disease prevention efforts and improvement of health status along a progress report on goals from the previous year. Seven major content areas were identified in previous needs assessments that is included in the community benefit plan: Access, Health Behaviors, Risk Behaviors, Chronic Disease, Communicable Diseases, Mental Health and Community and Social Issues. Part VI, Line 3: Signage describing the hospital's charity programs is posted at all points of registration in three languages. Also, all uninsured patients are sent a letter with their first bill informing them of the hospital's available charity care programs and personnel to contact for information and application. Part VI, Line 4: Good Samaritan Hospital's ("GSH") primary service area is defined by sixteen zip codes within a five mile radius. The zip codes in this area contain a population of one-half million residents, as described in the Year 2000 U.S. Census Report. The zip codes are as follows: 90004, 90005, 90006, 90007, 90010, 90012, 90013, 90014, 90015, 90017, 90018, 90020, 90021, 90026, 90057, 90071. Based on the last community needs assessment (2010), Latinos accounted for a majority of the population in the GSH service area (59.9%) and four out of five of its health districts (Central, Hollywood, Northeast and Southeast). The second largest ethnic group in the GSH service area is Asian/Pacific Islanders (32.1%). Part VI, Line 5: Good Samaritan Hospital maintains an active presence in the community through the volunteer and advocacy efforts of its physicians, employees and Board of Trustees. The hospital provides support to community clinics by providing services such as transportation for patients to the hospital. The hospital also hosts conferences open to the public at no cost on topics related to various health issues prevalent in the community. Good Samaritan Hospital publishes Good Health, a community newsletter that goes out to 16,000 households to increase awareness and understanding of medical advances related to cardiovascular care, orthopedic services, transfusion-free medicine and surgery, urology, oncology and womens and newborn services. Good Samaritan Hospital also provides community building activities to promote health, wellness and safety through: health fairs, health lecures, hosting cancer support groups, community policy advisory meetings to discuss neighborhood safety, annual Blessing of the Bicycles to promote bike and road safety as well as the benefits of cycling. Reports Filed With States Part VI, Line 7 CA 1 Heart Institute of the Good Samaritan Hospital 616 South Witmer Street Los Angeles CA 90017 954077161 501(c)(3) 1876038 Expenses paid by the Hospital Orthopedic Institute of the Good Samaritan Hospital 616 South Witmer Street Los Angeles CA 90017 954346048 501(c)(3) 324627 Expenses paid by the Hospital California Health Foundation and Trust 1215 K Street Suite 800 Sacramento CA 95814 941498687 501(c)(3) 1256688 Support charitable activities at hospitals & health systems in California 3 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The Institutes (Heart and Ortho) do not have their own checking accounts, so all of their expenses (including salaries, wages and benefits) are paid for by the hospital and are all recorded in each of the Institutes' accounts in the General Ledger, thru intercompany due to and from accounts on both sides(Institutes' and Hospital's). Grants will only be made to 501(c)(3) organizations to ensure the funds will be used properly. X X X X 0 0 0 0 0 0 0 0 0 Andrew Leeka 511436 0 0 0 7899 0 7350 0 3180 0 529865 0 0 0 Alan M Ino 423096 0 0 0 0 0 7350 0 2516 0 432962 0 0 0 Susan Harlow 257857 0 0 0 0 0 7350 0 345 0 265552 0 0 0 Lexie Schuster 261258 0 0 0 55 0 7350 0 0 0 268663 0 0 0 Sammy Feuerlicht 235117 0 0 0 0 0 7110 0 1883 0 244110 0 0 0 Dan McLaughlin 245335 0 0 0 0 0 1214 0 2516 0 249065 0 0 0 Berniece Deol 294609 0 0 0 0 0 0 0 305 0 294914 0 0 0 Ching Chen 247839 0 0 0 0 0 7350 0 816 0 256005 0 0 0 Ira Meiselman 232154 0 0 0 0 0 6335 0 5016 0 243505 0 0 0 Hilarion Castillo 223749 0 0 0 0 0 6602 0 2323 0 232674 0 0 0 Elizabeth Pabros 193226 0 0 0 0 0 9659 0 0 0 202885 0 0 0 Steve Garcia 186511 0 0 0 0 0 5611 0 5216 0 197338 0 0 0 Form 990, Part VI, Section A, line 1 The Executive Committee consists only of no less than five and no more than eleven members of the Board of Directors. Three of the members will be the Chairman of the Board, the President of the organization and the Chairman of the Medical Staff. The others will be appointed, after considering nominations by the Chairman. Between meetings of the Board of Directors, the Executive Committee will have and exercise all the authority of the Board in the management of the organization. At meetings of the board of Directors, the Executive Committee will report on actions taken between the meetings, and will propose actions to the Board of Directors. The Executive Committee will meet on the call of the Chairman of the Board or the President. Four members of the Committee shall constitute a quorum. Form 990, Part VI, Section A, line 2 Mrs. Borthwick, a board member of Good Samaritan Hospital has a family relationship with Mr. Charles Munger, chairman of the board. Clark Willard Porter has a family relationship with Glen H. Mitchel, Jr. who are board members. Form 990, Part VI, Section B, line 11 The organization works with an independent accountant, Deloitte Tax LLP, to prepare the Form 990. Once the return is prepared, the return is reviewed by the Chief Financial Officer and the Controller. The draft of the Form 990 is presented to the Audit Committee. Subsequent to review by the Audit Committee, the CFO and the Controller will provide any final comments to Deloitte Tax LLP. Deloitte Tax LLP makes all changes necessary and a final Form 990 is made available to all board members. Form 990, Part VI, Section B, line 12c All board members and officers are required to complete a conflict of interest disclosure statement each year. The policy requires each governing body member to disclose any conflict on a particular matter that may arise, and recuse him or herself from deliberations and votes on such matters. The policies are monitored by the Director of Risk Management of the Good Samaritan Hospital and are enforced by the Audit Committee Chairperson. Form 990, Part VI, Section B, line 15 A subcommittee of the governing board's executive committee is responsible for determining the Chief Executive Officer's compensation. This subcommittee is given comparison data on CEO salaries and benefits from comparable hospitals in the local area, prepared by human resources from 990s; and salary surveys completed by the local hospital association. The decision of the subcommittee on the CEO's salary is documented by the subcommittee in writing. The compensation of the organization's vice presidents are reviewed and approved by the organization's CEO. Their salaries and benefits are determined using comparable hospitals in the local area, prepared by human resources from 990s; and salary surveys completed by the local hospital association. Form 990, Part VI, Section C, line 19 Good Samaritan Hospital's organizing and governing documents and the conflict of interest policy are not made available to the public. The financial information from the financial statements is included in the organization's Form 990, which is available for public inspection upon request. The organiztion's financial statements were audited by an independent accountant and are included in the consolidated audited financial statements for Good Samaritan Hospital and affiliates. Good Samaraitan Hospital's audit committee assumes responsibility for the oversight of the audit and its financial statements and the selection of an independent accountant. Avg hours devoted to related org(s) when related comp is reported: Form 990, Part VII: Compensation reported on Form 990, Part VII was paid to each of these individuals in exchange for the fulfillment of their duties as full-time, 40+ hour-per-week employees at Good Samaritan Hospital and 2 hours-per-week employees at related organizations. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 20,623,878. Minimum Pension Liability -2,745,557. Intercompany Adjustments 2,475,307. Total to Form 990, Part XI, Line 5: 20,353,628. Heart Institute of the Good Samaritan Hospital 616 South Witmer Street Los Angeles CA 90017 954077161 Heart Research CA section 501(c)(3) 4 N/A 1 Orthopedic Institute of the Good Samaritan Hospital 616 South Witmer Street Los Angeles CA 90017 954346048 Orthopedic Research CA section 501(c)(3) 11, Type 1 N/A 1 Samaritan Imaging Center 616 South Witmer Street Los Angeles CA 90017 954252321 Outpatient Imaging Services CA section 501(c)(3) 9 N/A 1 Cancer Institute of the Good Samaritan Hospital 616 South Witmer Street Los Angeles CA 90017 954271815 Cancer Research CA section 501(c)(3) 4 N/A 1 Institute for reproductive research of the Hospital of the Good Samaritan 616 South Witmer Street Los Angeles CA 90017 954252306 Reproductive Research CA section 501(c)(3) 11, Type 1 N/A 1 Good Samaritan Hospital Medical Office Building Inc 616 South Witmer Street Los Angeles CA 90017 953244046 Physicians Medical Offices CA section 501(c)(3) 11, Type 1 N/A 1 Auxiliary of the Hospital of the Good Samaritan 616 South Witmer Street Los Angeles CA 90017 956051253 Welfare of the Good Samaritan Hospital CA section 501(c)(3) 11, Type 3 N/A 1 Kate Van Nuys Page Foundation 616 South Witmer Street Los Angeles CA 90017 956028032 Grants income to Good Samaritan Hospital CA section 501(c)(3) 11, Type 1 N/A 1 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 Good Samaritan Hospital Medical Office Bldg A 560615 FMV Good Samaritan Hospital Medical Office Bldg J 302245 FMV Heart Institute of the Good Samaritan Hosp B 1876038 FMV Heart Institute of the Good Samaritan Hosp C 652011 FMV Orthopedic Inst of the Good Samaritan Hosp B 324627 FMV