2012-08-15T13:30:57-05:00 2011-09-30 MOSS ADAMS LLP 3121 WEST MARCH LANE SUITE 100 STOCKTON CA 952192303 990 2010-10-01 342030255 MIRABELLA MIRA 8887246424 116 FAIRVIEW AVE NORTH SEATTLE WA 98109 BRIAN MCLEMORE 8887246424 2012-08-14 1 TRACY S PAGLIA 2099556100 2010 2016-02-24 21:20:13Z X LEN MERRYMAN 965 ELLENDALE DRIVE MEDFORD OR 97504 19515380 0 X RETIREMENT.ORG X 2005 WA TO PROVIDE COMPREHENSIVE CARE AND HOUSING FOR THE ELDERLY. 5 5 321 5 0 0 0 0 16053247 19460492 52044 28979 0 25909 16105291 19515380 0 0 0 0 7906374 8719337 0 0 0 20484222 20204138 28390596 28923475 -12285305 -9408095 246241704 235182341 293237734 291586466 -46996030 -56404125 NONE 0 0 25244997 0 19460492 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. 25244997 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 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 1 321 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 4000 0 LARRY BOECK 1.00 X X 0 0 0 BILL HAZZARD 1.00 X 0 0 0 STAN SCHILL 1.00 X 0 0 0 LEN MERRYMAN 1.00 X X 0 0 0 JAMES MUNN 40.00 X 144429 0 37941 KAREN E HERNDON 40.00 X 106492 0 17297 250921 4000 55238 2 0 1 0 PACIFIC RETIREMENT SERVICES 965 ELLENDALE DRIVE MEDFORD OR 97501 MANAGEMENT SERVICES 605275 EBMS INC PO BOX 1400 PORTLAND OR 97207 EMPLOYEE BENEFITS 403312 CONSONUS REHAB UNIT 12 PO BOX 4800 PORTLAND OR 97208 THERAPY SERVICES 384827 3 SERVICE FEES 623990 11591891 11591891 ENTRANCE FEES 623990 3857324 3857324 HEALTH CENTER REVENUE 623990 3134946 3134946 DINING REVENUE 623990 286388 286388 PARKING REVENUE 623990 195336 195336 394607 394607 19460492 28979 28979 25909 25909 25909 25909 19515380 19460492 0 54888 6968677 6049976 918701 158362 111333 47029 988666 759584 229082 603632 530324 73308 1080281 1080281 468527 468527 1000 1000 534407 360941 173466 338085 338085 430981 345102 85879 48050 48050 1441367 1441367 45051 11389 33662 19329 10841 8488 6818121 6818121 6300698 6300698 275422 275422 HEALTHCARE SERVICES 1069532 1069532 DIETARY EXPENSE 979347 979347 FACILITY EXPENSE 325440 181020 144420 ASSET DISPOSAL 28500 28500 28923475 25244997 3678478 0 2258366 636420 15396666 11961570 612562 1135672 57805 89656 150469 1265127 235200154 17853363 223416403 217346791 0 4349433 2747105 246241704 235182341 954653 1149896 130034262 140272338 134950000 119950000 650728 649186 26648091 29565046 293237734 291586466 X -46996030 -56404125 -46996030 -56404125 246241704 235182341 -9408095 0 X 0 1 1 X 0 X 5418410 16053247 19460492 40932149 5418410 16053247 19460492 40932149 0 0 0 40932149 580091 73561 54888 708540 580091 73561 54888 708540 5998501 16126808 19515380 41640689 0.98300 0.01700 X 0 25244997 25244997 1000000 250000 0 0 1000000 1000000 1500000 250000 250000 375000 21194646 21194646 208154357 16156743 191997614 5215707 1463963 3751744 635444 232657 402787 217346791 REFUNDABLE DEPOSITS 1215024 ENTRANCE FEES REFUNDABLE-REOCCUPANCY 6767300 DUE TO AFFILIATES 13788373 CONTINGENT LIABILITY 7782621 OTHER LIABILITIES 11728 29565046 19515380 28923475 -9408095 0 -9408095 19515380 0 19515380 0 19515380 28923475 0 28923475 0 28923475 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE CORPORATION HAS BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE AS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL AND STATE INCOME TAXES ON RELATED ACTIVITIES. NO TAX PROVISION HAS BEEN MADE IN THE ACCOMPANYING STATEMENTS OF ACTIVITIES AND CHANGES IN NET DEFICIT. 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, 2011 AND 2010, THERE WERE NO SUCH UNCERTAIN TAX POSITIONS. X X X 0 0 0 0 0 0 0 1 0 JAMES MUNN 121329 0 23100 0 0 0 18794 0 19147 0 182370 0 0 0 PART I, LINE 7 THE RECOMMENDATION FOR BONUS ARE PROVIDED BY THE EXECUTIVE DIRECTOR'S DIRECT SUPERVISOR (COO OR VP OF OPERATIONS), WHICH ARE BASED ON A MYRIAD OF FACTORS, AS DESCRIBED IN THE ORGANIZATION'S STRATEGIC MATRIX. WASHINGTON STATE HOUSING FINANCE COMMISSION 911874730 939783PV2 2006-11-03 250745000 FACILITY ACQUISITION, CONSTRUCTION AND EQUIPPING 0 0 0 136795000 276536357 8000876 21287144 2400271 24121896 3780198 216945973 2008 0 0 1 1 0 1 1 0 1 0.00300 0.00000 0.00300 1 0 1 1 LEHMAN BROTHERS SPEC FIN INC 4.900000000000 0 1 1 PALLAS CAPITAL CORP 2.500000000000 0 1 0 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 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. 1HR HOLLADAY PARK PLAZA 1HR MIRABELLA AT SOUTH WATERFRONT 1HR MIRABELLA PORTLAND FOUNDATION 1HR LEN MERRYMAN DEVOTES TIME TO RELATED ORGANIZATIONS AS FOLLOWS: ROGUE VALLEY MANOR 1HR UNIVERSITY RETIREMENT COMMUNITY AT DAVIS 1HR CAPITOL LAKES, INC. 1HR MIRABELLA AT SOUTH WATERFRONT 1HR MIRABELLA WASHINGTON FOUNDATION 1HR LARRY BOECK DEVOTES TIME TO RELATED ORGANIZATIONS AS FOLLOWS: UNIVERSITY RETIREMENT COMMUNITY AT DAVIS 1HR CAPITOL LAKES, INC. 1HR MIRABELLA AT SOUTH WATERFRONT 1HR MIRABELLA WASHINGTON FOUNDATION 1HR JAMES MUNN DEVOTES TIME TO RELATED ORGANIZATIONS AS FOLLOWS: MIRABELLA WASHINGTON FOUNDATION 1HR 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 PACIFIC RETIREMENT SERVICES 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 PACIFIC RETIREMENT SERVICES INC 0 RVM ASHLAND HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 930942933 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM GRANTS PASS HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 943136037 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM ROSEBURG HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 943179782 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM MYRTLE CREEK HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 943162074 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM BEND HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 943163349 SENIOR HOUSING 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 FORT WORTH I HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 311520436 SENIOR HOUSING TX 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 FORT WORTH II HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 311587415 SENIOR HOUSING TX 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM MEDFORD III HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 311587418 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM ROSEBURG II HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 311587420 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM GRANTS PASS II HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 311662259 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM DAVIS HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 311662208 SENIOR HOUSING CA 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM MYRTLE CREEK II HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 311715321 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM PORTLAND HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 311780332 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM PORTLAND II HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 300037898 SENIOR HOUSING OR 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 RVM CENTRAL POINT HOUSING CORPORATION 965 ELLENDALE DRIVE MEDFORD OR 97504 300315618 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 CORBINTON RETIREMENT 965 ELLENDALE DRIVE MEDFORD OR 97504 262987036 SENIOR HOUSING NC 501(C)(3) LINE 9 PACIFIC RETIREMENT SERVICES INC 0 MIRABELLA MARIN 965 ELLENDALE DRIVE MEDFORD OR 97504 263800433 SENIOR HOUSING CA 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 CO OR N/A C CREST PARK 965 ELLENDALE DRIVE MEDFORD OR 97504 931169683 HOTEL OR N/A C PRS SCHOOL OF AGING SERVICES INC 965 ELLENDALE DRIVE MEDFORD OR 97504 262477424 SCHOOL OR N/A C 0 0 0 0 1 0 0 0 0 0 0 1 0 0 1 0 0 0