2023-11-15T11:24:14-06:00 2022-12-31 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2022-01-01 910573114 FOSS HOME & VILLAGE FOSS 2063641300 13023 GREENWOOD AVENUE NORTH SEATTLE WA 981337397 R KEVIN MCFEELY PRESIDENT & CEO 2063641300 2023-11-14 1 R KEVIN MCFEELY XXX-XX-XXXX 0 KURT BENNION CPA P01469618 4252506100 2023-11-14 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z R KEVIN MCFEELY 13023 GREENWOOD AVENUE NORTH SEATTLE WA 981337397 18168669 0 X WWW.FOSSCARE.ORG X 1929 WA NURSING HOME AND ASSISTED LIVING FACILITY. 5 5 318 20 0 0 5766978 294489 14477342 17502492 98615 11807 207579 159476 20550514 17968264 0 0 0 0 13483125 13206618 0 0 132423 5560566 9017927 19043691 22224545 1506823 -4256281 15479734 11552384 5069922 5570489 10409812 5981895 X NURSING HOME AND ASSISTED LIVING FACILITY. 0 0 16978553 0 17502492 SINCE 1929 FOSS HOME AND VILLAGE HAS PROVIDED CARE FOR THE COMMUNITY IN A NURSING HOME AND ASSISTED LIVING SETTING. FOSS SERVES A POPULATION WITH A SUBSTANTIAL NUMBER OF MEDICAID AND MEDICARE SUPPORTED RESIDENTS AND PATIENTS, WITH 70% OF ITS SERVICE REVENUE FROM MEDICAID/MEDICARE. IN ADDITION TO PROVIDING CARE, FOSS STRIVES TO BE ACTIVE IN THE COMMUNITY BY PARTNERING WITH THE UNIVERSITY OF WASHINGTON, SHORELINE COMMUNITY COLLEGE AND OTHER COLLEGES AND UNIVERSITIES. FOSS PROVIDES A LEARNING ENVIRONMENT FOR INTERNSHIPS BASED IN THE FIELDS OF DENTISTRY, PHARMACY, RESTORATIVE THERAPY, NURSING, AND NURSING ASSISTANT TRAINING. FOSS ALSO HAS AN ACTIVE VOLUNTEER PROGRAM THAT ENCOURAGES HIGH SCHOOL AND COLLEGE STUDENTS. FOSS SERVED 262 NURSING HOME CLIENTS AND 49 ASSISTED LIVING CLIENTS, (CONTINUED IN SCHEDULE O)WITH THE AVERAGE LENGTH OF STAY FOR SHORT-STAY RESIDENTS, DEFINED BY THOSE WHO STAYED 100 DAYS OR LESS, OF APPROXIMATELY 22 DAYS. RATES ARE SET BASED ON THE MARKET IN THE SEATTLE AREA, WHICH ARE NECESSARY TO MAKE THE ORGANIZATION VIABLE. 16978553 1 1 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 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 1 45 0 318 1 0 0 0 0 0 0 0 0 0 0 0 0 X 5 5 0 0 0 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 1 0 0 X R KEVIN MCFEELY 2063641300 13023 GREENWOOD AVENUE NORTH SEATTLE WA 981337397 JULIE YARI CHAIR & DIRECTOR 0.50 0.00 X X 0 0 0 JEFF WEST RN VICE CHAIR & CHAIR 0.50 0.00 X X 0 0 0 KRIS CHICK TREASURER 0.50 0.00 X X 0 0 0 JUDY WILDES TRUSTEE & VICE CHAIR 0.50 0.00 X X 0 0 0 BEV ROACH TRUSTEE & SECRETARY 0.50 0.00 X X 0 0 0 JOHN RICK HENRY JR PRESIDENT & CEO (THROUGH APRIL 2022) 40.00 0.00 X 222668 0 0 R KEVIN MCFEELY PRESIDENT/CEO 20.00 30.00 X 0 414994 34788 NANCY MOHRMAN ALU DIRECTOR 40.00 0.00 X 284074 0 0 LAURA MOLZAHN EXECUTIVE DIRECTOR 40.00 0.00 X 216141 0 0 SOLOMON G-KIDANE LPN NURSE 40.00 0.00 X 187087 0 0 BANAFSHEH BAHARLOO RN NURSE 40.00 0.00 X 185647 0 0 MILAGROS ALMAZAN NURSE 40.00 0.00 X 148280 0 0 1243897 414994 34788 7 0 1 0 STURDY MEDICAL STAFFING 1200 E CAMPBELL ROAD SUITE 108 RICHLAND TX 75081 STAFFING SERVICES 2174812 EASTGATE STAFFING AGENCY LLC 4957 LAKEMONT BOULEVARD SE BELLEVUE WA 98006 NURSES/NURSING ASSISTANTS 842828 CONSONUS REHAB 4560 SE INTERNATIONAL WAY MILWAUKIE OR 97222 THERAPY SERVICES 750799 A KIND HEART 23005 76TH AVENUE W EDMONDS WA 98026 NURSES/NURSING ASSISTANTS 164219 4 294489 294489 RESIDENT FEES 623000 17502492 17502492 17502492 11807 11807 269875 195503 74372 74372 74372 15435 4902 10533 10533 MISCELLANEOUS INCOME 900099 74571 74571 74571 17968264 17502492 0 171283 X 222668 222668 10582397 8236680 2288482 57235 308901 235475 71790 1636 1126389 858644 261778 5967 966263 736581 224564 5118 40140 40140 69248 69248 4769322 3737405 1022766 9151 81623 81017 606 405868 216261 137495 52112 133214 106571 26643 585955 364947 221008 13909 13909 114885 114885 530518 503992 26526 356905 285524 71381 MEDICAL SUPPLIES 990811 990600 211 FOOD 642880 642880 TAXES & LICENSES 123529 123529 MISCELLANEOUS EXPENSES 87274 158 86518 598 71846 62835 9011 22224545 16978553 5113569 132423 2639674 292794 1512058 2303655 122885 154039 265825 305489 25289974 16806970 8791425 8483004 2140355 4514 7512 8889 15479734 11552384 1392087 2656711 125678 129486 7512 8889 3013777 2775403 530868 0 5069922 5570489 X 9836579 5981895 573233 0 10409812 5981895 15479734 11552384 -4256281 -171636 0 X 0 0 0 X 332935 351078 1660130 5766978 294489 8405610 19877132 20638829 16588783 14477342 17502492 89084578 58764 59524 19589 13866 15435 167178 20268831 21049431 18268502 20258186 17812416 97657366 1923 1923 0 1923 1923 97655443 288001 280969 363425 370622 281682 1584699 288001 280969 363425 370622 281682 1584699 140331 230959 210695 131610 74571 788166 20697163 21561359 18842622 20760418 18168669 100030231 0.97630 0.97770 0.01580 0.01480 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS INCOME RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 3525501 3525501 12999282 9148753 3850529 1343186 1157236 185950 7422005 6500981 921024 8483004 PART IV, LINE 2B: THE ORGANIZATION HOLDS TRUST ACCOUNTS FOR RESIDENTS WHO REQUEST THAT WE DO SO AND FOR ANY RESIDENTS OF WHICH THE ORGANIZATION IS REPRESENTATIVE PAYEE FOR SOCIAL SECURITY PURPOSES. THE MONEY IS HELD IN AN INTEREST-BEARING CHECKING ACCOUNT. RESIDENTS CAN OBTAIN THEIR MONEY UPON REQUEST. THE ORGANIZATION HOLDS SECURITY DEPOSITS FOR ASSISTED LIVING RESIDENTS AND OTHER RENTAL TENANTS. SECURITY DEPOSITS ARE HELD IN NON-INTEREST BEARING ACCOUNTS. SECURITY DEPOSITS ARE RETURNED TO TENANTS WHEN THE LEASE IS TERMINATED, LESS ANY AMOUNTS FOR DAMAGES. X X X X X 0 1 0 0 0 0 0 0 0 R KEVIN MCFEELY PRESIDENT/CEO 0 414994 0 0 0 0 0 0 0 34788 0 449782 0 0 NANCY MOHRMAN ALU DIRECTOR 284074 0 0 0 0 0 0 0 0 0 284074 0 0 0 JOHN RICK HENRY JR PRESIDENT & CEO (THROUGH APRIL 2022) 222668 0 0 0 0 0 0 0 0 0 222668 0 0 0 LAURA MOLZAHN EXECUTIVE DIRECTOR 216141 0 0 0 0 0 0 0 0 0 216141 0 0 0 SOLOMON G-KIDANE LPN NURSE 187087 0 0 0 0 0 0 0 0 0 187087 0 0 0 BANAFSHEH BAHARLOO RN NURSE 185647 0 0 0 0 0 0 0 0 0 185647 0 0 0 PART I, LINE 4B JOHN (RICK) HENRY, JR. PARTICIPATED IN A 457(F) SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN. DURING 2022, $0 WAS CONTRIBUTED TO THE PLAN, $0 ACCRUED WITHIN THE PLAN, AND $106,111 WAS PAID OUT OF THE PLAN. NANCY MOHRMAN PARTICIPATED IN A 457(F) SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN. DURING 2022, $0 WAS CONTRIBUTED TO THE PLAN, $0 ACCRUED WITHIN THE PLAN, AND $238,501 WAS PAID OUT OF THE PLAN. LAURA MOLZAHN PARTICIPATED IN A 457(F) SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN. DURING 2022, $0 WAS CONTRIBUTED TO THE PLAN, $0 ACCRUED WITHIN THE PLAN, AND $186,256 WAS PAID OUT OF THE PLAN. FORM 990, PART VI, SECTION A, LINE 1A THE ORGANIZATION HAS AN EXECUTIVE COMMITTEE CONSISTING OF THE OFFICERS OF THE BOARD. THE DUTIES OF THE EXECUTIVE COMMITTEE ARE TO (A) PERFORM SPECIFIC TASKS ASSIGNED TO IT BY THE BOARD; (B) TAKE ACTION ON BEHALF OF THE BOARD BETWEEN REGULARLY SCHEDULED MEETINGS OF THE BOARD WHEN IT IS NOT FEASIBLE FOR THE BOARD TO ACT OR WHEN THE MATTER(S) ARE OF AN ADMINISTRATIVE NATURE; AND (C) COORDINATE THE PLANNING OF THE BOARD'S ACTIVITIES AND PRIORITIES, SUCH AS COMMITTEE STRUCTURE AND ASSIGNMENTS AND SPECIAL TASK FORCES. THE EXECUTIVE COMMITTEE IS PROHIBITED FROM (A) AMENDING, ALTERING OR REPEALING THE BYLAWS OR ARTICLES OF INCORPORATION; (B) ELECTING, APPOINTING OR REMOVING ANY MEMBER OF ANY COMMITTEE, BOARD MEMBER OR OFFICER; (C) ADOPTING A PLAN OF MERGER OR CONSOLIDATION; (D) AUTHORIZING THE SALE, LEASE, EXCHANGE OR MORTGAGE OF ALL OR SUBSTANTIALLY ALL OF THE ORGANIZATION'S PROPERTY OR ASSETS OR REVOKING THE PROCEEDINGS THEREOF; (E) ADOPTING A PLAN FOR THE DISTRIBUTION OF THE ORGANIZATION'S ASSETS; AND (F) AMENDING, ALTERING OR REPEALING ANY RESOLUTION OF THE BOARD THAT BY ITS TERMS PROVIDES THAT IT SHALL NOT BE AMENDED, ALTERED OR REPEALED BY ANY COMMITTEE. FORM 990, PART VI, SECTION B, LINE 11B PRIOR TO FILING, A DRAFT OF THE FORM 990 WAS REVIEWED BY THE CEO AND CFO, THEN SUBMITTED TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR 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 15A THE BOARD OF DIRECTORS REVIEWS SALARY DATA FROM A SALARY SURVEY COMPILED BY LEADINGAGE WASHINGTON AND FROM REVIEWING THE FORMS 990 OF COMPARABLE ORGANIZATIONS. THE CEO REVIEWS SALARY DATA IN A SIMILAR MANNER FOR THE OTHER OFFICERS. THE REVIEW PROCESS WAS LAST CONDUCTED IN 2019 FOR THE CEO AND IN 2018 FOR THE CFO. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER SERVICES: PROGRAM SERVICE EXPENSES 3,737,405. MANAGEMENT AND GENERAL EXPENSES 1,022,766. FUNDRAISING EXPENSES 9,151. TOTAL EXPENSES 4,769,322. FUTURA AGE 1301 N HIGHLANDS PARKWAY TACOMA WA 98406 882748740 MANAGEMENT SERVICES WA 501(C)(3) N/A 0 ELISEO 1301 N HIGHLANDS PARKWAY TACOMA WA 98406 910963214 LIFE PLAN COMMUNITY WA 501(C)(3) LINE 10 N/A 0 ELISEO FOUNDATION 1301 N HIGHLANDS PARKWAY TACOMA WA 98406 943031579 FUNDRAISING WA 501(C)(3) LINE 12A, I ELISEO 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0