2012-07-26T16:43:19-05:00 2011-12-31 381357951 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2011-01-01 310714767 MT HEALTHY CHRISTIAN HOME INC MTHE 5139315000 8097 HAMILTON AVENUE CINCINNATI OH 45231 ROGER H SCHWARTZ 5139315000 2012-07-13 1 BERNIE OSTROWSKI P00366367 6148493000 2011 2016-02-24 21:20:13Z J DONALD SAMS 411 WESTERN ROW ROAD MASON OH 45040 9938340 0 X WWW.CHRISTIANBENEVOLENT.ORG X 1964 OH FOUNDED IN 1964, THE ORGANIZATION IS A NOT-FOR-PROFIT PROVIDER OF RETIREMENT SERVICES, OFFERING A VARIETY OF LIVING STYLES, FROM RESIDENTIAL LIVING APARTMENTS, ASSISTED LIVING AND SKILLED NURSING CARE. THE ORGANIZATION'S MISSION IS TO PROVIDE SECURE, QUALITY LIVING IN A CHRISTIAN ENVIRONMENT, DIRECTED ESPECIALLY TO PERSONS IN THEIR RETIREMENT YEARS. THE ORGANIZATION'S MINISTRY SERVES OVER 150 OLDER ADULTS. OUR SERVICES ARE DEDICATED TO THE ENHANCEMENT OF THE SPIRITUAL, PHYSICAL, SOCIAL, CULTURAL AND EMOTIONAL WELL-BEING OF EACH RESIDENT IN AN ENVIRONMENT THAT RECOGNIZES AND PROMOTES PERSONAL DIGNITY. 9 9 278 70 0 0 2404 23530 8989559 9894723 2485 8583 35108 11504 9029556 9938340 49240 40141 0 0 5159938 5081758 0 0 0 4280045 3924655 9489223 9046554 -459667 891786 5397900 8481211 13158547 15350072 -7760647 -6868861 SERVING WITH EXCELLENCE REFLECTING JESUS' COMPASSION. 0 0 7734781 40141 9906227 NURSING CARE SERVICE PROGRAMS INCLUDE SEMI-PRIVATE ROOMS AND A LIMITED NUMBER OF PRIVATE ROOMS, ASSISTED LIVING AND RESPITE CARE WITH ALL THE AMENITIES OF RESIDENTIAL LIVING IN A PRIVATE/SHARED OCCUPANCY STUDIO. CHARGES ARE BASED ON INDIVIDUAL ASSESSMENTS TO DEVELOP PERSONALIZED CARE AND SERVICE. RESIDENTIAL SERVICES INCLUDE A FULL CALENDAR OF LIFE ENRICHING RELIGIOUS (CHAPEL AND PASTORAL CARE), SOCIAL AND EDUCATIONAL PROGRAMS, SERVICES AND ACTIVITIES. SERVICES INCLUDE WEEKLY HOUSEKEEPING, LAUNDRY, MAINTENANCE, UTILITIES, TRASH REMOVAL, AND DINING CONSISTING OF THREE MEALS A DAY. 7734781 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 1 1 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 1 1 0 0 0 1 33 0 1 278 1 0 0 0 0 0 0 0 0 0 0 X 9 9 0 1 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 0 OH X JOHN BARROW 3145877921 622 EMERSON ROAD SUITE 310 ST LOUIS MO 63141 X ROD HURON 1.00 X X 0 0 0 DAVID PHILLIPS 1.00 X X 0 0 0 ROBERT WALSH 1.00 X X 0 0 0 JAMES PLUNKETT 1.00 X X 0 0 0 PHYLLIS J SANDERS 1.00 X 0 0 0 LUDMILA GRACANIN 1.00 X 0 0 0 KITTY GARNER 1.00 X 0 0 0 BEVERLY YOUNG 1.00 X 0 0 0 MARK SPARKS 1.00 X 0 0 0 J DONALD SAMS 4.00 X 0 114649 42000 ROGER SCHWARTZ 12.00 X 0 97585 0 0 212234 42000 0 0 1 0 KINDRED REHAB SERVICES PO BOX 277365 ATLANTA GA 303847365 THERAPY SERVICES 589573 MIDWEST CHRISTIAN VILLAGES 200 N POSTVILLE DRIVE LINCOLN IL 62656 MANAGEMENT SERVICES 324556 SYSCO FOODS SERVICE PO BOX 62066 CINCINNATI OH 452620066 DIETARY & FOOD PRODUCTS 313620 MCKESSON MEDICAL SURGICAL PO BOX 630693 CINCINNATI OH 452740693 MEDICAL SUPPLIES & EQUIPMENT 133964 OMNICARE INC 100 EAST RIVERCENTER BLVD COVINGTON KY 41011 PHARMACY SERVICES 117967 5 23530 23530 RESIDENT REVENUE 532000 9894723 9894723 9894723 8583 8583 OTHER REVENUE 999999 11504 11504 11504 9938340 9906227 0 8583 40141 40141 3802728 3536537 266191 37687 35049 2638 843648 784593 59055 397695 369856 27839 504786 504786 71495 71495 861612 690594 171018 36223 36223 460773 428519 32254 21179 21179 489799 455513 34286 5692 3103 2589 3440 3440 319790 319790 353524 328777 24747 70422 70422 FOOD 380204 380204 LICENSES & FEES 283342 263508 19834 BAD DEBT EXPENSE 25000 25000 DEFERRED BOND COSTS 23994 23994 13380 13380 9046554 7734781 1311773 0 564063 442663 766665 1778062 0 1835000 10273 10273 41518 50917 11484501 7915033 3198075 3569468 817306 794828 5397900 8481211 820038 1087178 6157739 6069934 6180770 8192960 13158547 15350072 X -7760647 -6868861 -7760647 -6868861 5397900 8481211 891786 0 X X 0 1 1 X 1 1 X 4000 58613 7176 2404 23530 95723 8340096 8305472 8611527 9024667 9867109 44148871 8344096 8364085 8618703 9027071 9890639 44244594 40141 40141 50295 50295 50295 40141 90436 44154158 17250 8469 4149 2485 8583 40936 17250 8469 4149 2485 8583 40936 8361346 8372554 8622852 9029556 9899222 44285530 0.99700 0.99770 0.00090 0.00110 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 821 821 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: A PORTION OF DUES PAYMENTS TO AOPHA ARE RELATED TO LOBBYING ACTIVITIES. THE AMOUNT ABOVE REPRESENTS 9% OF AOPHA DUES IN 2011. 161975 161975 8731843 5849331 2882512 2253455 1769827 483628 337228 295875 41353 3569468 SECURITY DEPOSIT AND OTHER ESCROW ACCOUNTS 535845 DEFERRED COSTS 202983 REFUNDABLE DEPOSITS 56000 794828 RESIDENT DEPOSITS 291126 RELATED PARTY PAYABLE 7901834 8192960 9938340 9046554 891786 891786 9937798 0 9937798 542 542 9938340 9046012 -542 -542 9046554 0 9046554 PART XII, LINE 4B - OTHER ADJUSTMENTS: RECLASS OF CONSULTING SERVICES 542. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RECLASS OF CONSULTING SERVICES -542. 1 RESIDENT SUBSIDY 8 40141 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: A RESIDENT OR THEIR FAMILY CAN SUBMIT A REQUEST TO THE ORGANIZATION FOR SUBSIDY OF THEIR RENT AT MT. HEALTHY CHRISTIAN HOME. A COMMITTEE HAS BEEN ESTABLISHED WHICH WILL REVIEW THE APPLICANT'S CIRCUMSTANCES AND WILL DETERMINE WHETHER ASSISTANCE WILL BE GRANTED BASED ON SPECIFIC CRITERIA. THE COMMITTEE HAS A RESTRICTION ON THE AMOUNT OF FUNDS TO USE FOR SUBSIDY PURPOSES, WHICH WILL ONLY BE EXCEEDED IN THE CASE OF RESIDENTS WHO WERE GRANDFATHERED IN UNDER PREVIOUS ARRANGEMENTS. X 1 1 0 0 0 0 0 0 0 0 0 J DONALD SAMS 0 114649 0 0 0 0 0 0 0 42000 0 156649 0 0 PART I, LINE 1A J. DONALD SAMS RECEIVED A HOUSING ALLOWANCE IN THE AMOUNT OF $42,000 IN 2011. FORM 990, PART VI, SECTION A, LINE 3 EFFECTIVE APRIL 1ST OF 2010, THE MANAGEMENT SERVICES WERE PROVIDED BY MIDWEST CHRISTIAN VILLAGES. MIDWEST CHRISTIAN VILLAGES PROVIDES AN EXECUTIVE DIRECTOR FOR THE CAMPUS. IN ADDITION, MIDWEST CHRISTIAN VILLAGES PROVIDES OPERATIONS, ACCOUNTING, BILLING, AND OTHER SUPPORT. FORM 990, PART VI, SECTION A, LINE 6 THE RELATED TAX-EXEMPT ORGANIZATION, CHRISTIAN BENEVOLENT ASSOCIATION OF GREATER CINCINNATI, INC. ("CBA"), IS THE SOLE MEMBER OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A CBA, THE MEMBER OF THE FILING ORGANIZATION, HAS THE RIGHT TO ELECT OR APPOINT ONE OF MORE MEMBERS OF THE ORGANIZATION'S GOVERNING BODY, WHETHER PERIODICALLY, OR AS VACANCIES ARISE, OR OTHERWISE. FORM 990, PART VI, SECTION A, LINE 7B CBA, THE MEMBER OF THE FILING ORGANIZATION, HAS THE RIGHT TO APPROVE OR RATIFY DECISIONS OF THE ORGANIZATION'S GOVERNING BODY SUCH AS APPROVAL OF THE GOVERNING'S BODY'S DECISION TO DISSOLVE THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 8B WITH THE EXCEPTION OF THE DEVELOPMENT COMMITTEE, INDIVIDUAL COMMITTEES DO NOT CONTEMPORANEOUSLY DOCUMENT MEETINGS HELD OR WRITTEN ACTIONS UNDERTAKEN DURING THE YEAR. ACTIONS OF THE ANNUAL NOMINATING COMMITTEE ARE DOCUMENTED IN THE GOVERNING BODY'S MINUTES. FORM 990, PART VI, SECTION B, LINE 11 THE CFO REVIEWS THE FORM 990 AND THEN WILL PROVIDE ELECTRONIC COPIES OF THE FORM 990 TO ALL BOARD MEMBERS PRIOR TO FILING. MAJOR POINTS OF THE FORM ARE ADDRESSED WITH THE BOARD EITHER VIA EMAIL OR AT THE CLOSEST BOARD MEETING DATE. FORM 990, PART VI, SECTION B, LINE 12C OFFICERS AND DIRECTORS REVIEW AND SIGN THE CONFLICT OF INTEREST STATEMENT ON AN ANNUAL BASIS. IT IS THE RESPONSIBILITY OF OFFICERS AND DIRECTORS TO DISCLOSE THE EXISTENCE OF A CONFLICT AND SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF THE CONFLICT IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT OF INTEREST EXISTS. THOSE WITH CONFLICTS ARE SUBJECT TO VOTING AND PARTICIPATION RESTRICTIONS. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD OF DIRECTORS OF A RELATED ORGANIZATION, CHRISTIAN BENEVOLENT ASSOCIATON OF GREATER CINCINNATI, INC., DETERMINES THE CEO'S COMPENSATION THROUGH USE OF REVIEW BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DECISION. THE PROCESS WAS LAST COMPLETED IN 2011. FORM 990, PART VI, SECTION C, LINE 18 FORM 1023 AND 990 ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VII, AVERAGE HOURS PER WEEK TO RELATED ORGANIZATION: HOURS DISTRIBUTION FOR J. DONALD SAMS: (40 HOUR WORK WEEK) A. CBA: 50% - 20 HOURS B. CBA FOUNDATION: 15% - 6 HOURS C. MT HEALTHY: 10% - 4 HOURS D. MCV HEALTH CARE FACILITY: 12.5% - 5 HOURS E. MASON CHRISTIAN VILLAGE: 12.5% - 5 HOURS HOURS DISTRIBUTION FOR ROGER SCHWARTZ: (30 HOUR WORK WEEK) A. CBA: 15% - 4.5 HOURS B. CBA FOUNDATION: 5% - 1.5 HOURS C. MT HEALTHY: 40% - 12 HOURS D. MCV HEALTH CARE FACILITY: 30% - 9 HOURS E. MASON CHRISTIAN VILLAGE: 10% - 3 HOURS FORM 990, PART XI, LINE 2C: CHRISTIAN BENEVOLENT ASSOCIATION, A RELATED ORGANIZATION HAS AN AUDIT COMMITTEE WHICH OVERSEES AUDIT OF THE FINANCIAL STATEMENTS AND IS INVOLVED IN THE SELECTION OF THE INDEPENDENT ACCOUNTANT WHICH COMPLETES THE AUDIT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. CHRISTIAN BENEVOLENT ASSOCIATION OF GREATER CINCINNATI INC 8097 HAMILTON AVENUE CINCINNATI OH 45231 310675610 MANAGEMENT/SUPPORT SERVICES FOR RELATED TAX-EXEMPT RETIREMENT COMMUNITIES OH 501(C)(3) 509(A)(1) N/A 0 MASON CHRISTIAN VILLAGE INC 8097 HAMILTON AVENUE CINCINNATI OH 45231 311173965 RETIREMENT SERVICES OH 501(C)(3) 509(A)(2) CHRISTIAN BENEVOLENT ASSOCIATION OF GREATER CINCINNATI INC 1 MCV HEALTH CARE FACILITIES INC 8097 HAMILTON AVENUE CINCINNATI OH 45231 311257250 RETIREMENT SERVICES OH 501(C)(3) 509(A)(2) CHRISTIAN BENEVOLENT ASSOCIATION OF GREATER CINCINNATI INC 1 CHRISTIAN BENEVOLENT ASSOCIATION FOUNDATION FOR THE AGING INC 8097 HAMILTON AVENUE CINCINNATI OH 45231 311413825 FUNDRAISING & FINANCIAL SUPPORT FOR CBA OF GREATER CINCINNATI OH 501(C)(3) 509(A)(3) CHRISTIAN BENEVOLENT ASSOCIATION OF GREATER CINCINNATI INC 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0