2012-11-14T15:06:06-06:00 2011-12-31 410746749 CLIFTONLARSONALLEN LLP 3000 NORTHUP WAY SUITE 200 BELLEVUE WA 980041446 990 2011-01-01 910573114 FOSS HOME & VILLAGE FOSS 2063641300 13023 GREENWOOD AVE N SEATTLE WA 981337397 DAVID CROUCH 2063641300 2012-10-29 1 STEVE BASS P00004800 4252506100 2012-10-29 2011 2016-02-24 21:20:13Z DAVID CROUCH 13023 GREENWOOD AVE N SEATTLE WA 981337397 18115846 0 X WWW.FOSSCARE.ORG X 1929 WA NURSING HOME & ASSISTED LIVING FACILITY 10 10 376 162 0 0 200000 0 18198386 18008295 41491 48851 9290 7291 18449167 18064437 0 0 0 0 13744323 13258828 0 0 0 4401040 4386833 18145363 17645661 303804 418776 11338239 11822134 7465352 7489943 3872887 4332191 NURSING HOME AND ASSISTED LIVING FACILITY. 0 0 15872180 18015586 NURSING HOME AND ASSISTED LIVING CARE, INCLUDING A SUBSTANTIAL NUMBER OF MEDICARE & MEDICAID SUPPORTED RESIDENTS/PATIENTS. 52% OF REVENUE IS FROM MEDICARE/MEDICAID AND THE REMAINDER IS FROM PRIVATE PAY RESIDENTS. RATES ARE SET BASED ON MARKET RATES IN THE SEATTLE AREA, AND ARE NECESSARY TO MAKE THE ORGANIZATION VIABLE. 15872180 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 41 0 1 376 1 0 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WA X PATRICIA UPDEGRAFF 2063641300 13023 GREENWOOD AVE N SEATTLE WA 981337397 ART BATT 2.00 X X 0 0 0 KELLIE HESSLER DE'ARTURET 2.00 X 0 0 0 MARYANN JOHNSTON 2.00 X X 0 0 0 DAWNELL LAMB 2.00 X 0 0 0 CARLOS GUANGORENA 2.00 X 0 0 0 PAUL WOLD 2.00 X 0 0 0 MARK CHURCHILL 2.00 X X 0 0 0 NORMA BEERWEILER 2.00 X 0 0 0 REVEREND MARVIN JONASEN 2.00 X 0 0 0 JANE JONES 2.00 X 0 0 0 DAVID CROUCH 40.00 X 168196 0 72805 PATRICIA L UPDEGRAFF 40.00 X 101074 0 39593 JOHN F HENRY JR 40.00 X 100886 0 21404 370156 0 133802 3 0 1 0 JEM PROFESSIONAL SERVICES 17912 25TH DRIVE SE BOTHELL WA 98012 CONTRACT THERAPIST 186693 1 RESIDENT FEES 623000 17733831 17733831 274464 274464 18008295 48851 48851 58700 51409 7291 7291 7291 18064437 18008295 0 56142 381668 381668 9844229 9210076 634153 290389 258446 31943 1650948 1477095 173853 1091594 1013674 77920 43960 43960 16701 16701 49475 49475 107605 107605 81400 81400 708320 672904 35416 17688 17688 102269 43771 58498 377792 358902 18890 PURCHASED SERVICES 744380 597339 147041 FOOD 733722 733722 SUPPLIES 718729 698250 20479 PHARMACY 449497 449497 235295 123075 112220 17645661 15872180 1773481 0 948698 996627 1860259 2012592 55878 61530 290021 266533 18300292 11448999 6630278 6851293 428397 467783 954695 1018359 170013 147417 11338239 11822134 2205248 2637965 5090000 4670000 170104 181978 7465352 7489943 X 3872887 4332191 3872887 4332191 11338239 11822134 X 418776 40528 X X 0 1 1 X 0 X 268971 757977 131773 200000 1358721 18371846 18235508 18705425 18198386 18015586 91526751 1253 -2186 4193 57000 58700 118960 18642070 18991299 18841391 18455386 18074286 93004432 0 0 0 93004432 139477 56248 39024 41491 48851 325091 139477 56248 39024 41491 48851 325091 35860 9290 45150 18781547 19083407 18889705 18496877 18123137 93374673 0.99600 0.99470 0.00350 0.00480 X 824380 1454155 2278535 1091940 8274224 5660541 3705623 5568290 4872561 695729 1087303 915897 171406 6851293 WELLESLEY INCOME FUND 503991 F WELLINGTON FUND ADMIRAL 514368 F 1018359 RESIDENT TRUST ACCTS 15934 DEPOSITS 166044 181978 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS REPORT THERE ARE NO MATTERS THAT WOULD CREATE UNRELATED BUSINESS INCOME TAX OR CALL INTO QUESTION ITS EXEMPT STATUS. X X X 0 1 0 0 0 0 0 0 0 DAVID CROUCH 168196 0 0 0 0 0 49841 0 22964 0 241001 0 0 0 PART I, LINE 4B DAVID CROUCH 49,841 FORM 990, PART VI, SECTION B, LINE 11 DRAFT TAX RETURN DISTRIBUTED AT BOARD MEETING FOR REVIEW AND APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY THE CONFLICT OF INTEREST POLICY IS DISTRIBUTED AT THE BOARD MEETING AND MEMBERS ARE REQUIRED TO COMPLETE AND SIGN THE FORM FOR PROPER DISCLOSURE. MEMBERS ARE DIRECTED TO NOTIFY THE BOARD DURING THE YEAR IF A CONFLICT OF INTEREST DEVELOPS. FORM 990, PART VI, SECTION B, LINE 15 BOARD OF DIRECTORS REVIEWS DATA ON SALARY FROM SALARY SURVEY COMPILED BY HOPSITAL ASSOCIATION, REVIEWS FROM 990'S OF COMPARABLE ORGANIZAITONS. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS AVAILABLE UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 40,528. AUDIT COMMITTEE RESPONSIBILITY FORM 990, PART XII, LINE 2C THE AUDIT COMMITTEE HAS OVERSIGHT RESPONSIBILITY FOR THE FINANCIAL STATEMENTS, AND THE SELECTION OF THE INDEPENDENT AUDITOR. THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FOSS FOUNDATION 13023 GREENWOOD AVE N SEATTLE WA 981337397 911640102 FUNDRAISING ACTIVITIES TO RAISE FUNDS TO PROVIDE GRANTS TO FOSS HOME & VILLA WA 501(C)(3) SEC 170(B)(1)(A)(I) N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0