2023-07-25T09:36:42-05:00 2022-12-31 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2022-01-01 810856014 AGING IN PACE WASHINGTON AGIN 2067883656 PO BOX 3007 SEATTLE WA 981143007 KELLI NOMURA ICHS CEO 2067883656 2023-07-24 1 KELLI NOMURA XXX-XX-XXXX 0 KURT BENNION CPA P01469618 4252506100 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z KELLI NOMURA PO BOX 3007 SEATTLE WA 981143007 504902 0 X N/A X 2015 WA TO BE A SUPPORTING ORGANIZATION, OPERATED FOR THE BENEFIT OF AND TO SUPPORT INTERNATIONAL COMMUNITY HEALTH SERVICES. 3 3 0 13 0 0 704201 504752 0 0 0 0 0 150 704201 504902 0 1180689 0 0 0 0 0 0 61075 65807 72038 65807 1252727 638394 -747825 1180689 1884619 0 1451755 1180689 432864 X AIPACE IS A SUPPORTING ORGANIZATION, OPERATED FOR THE BENEFIT OF AND TO SUPPORT INTERNATIONAL COMMUNITY HEALTH SERVICES. 0 0 1180689 1180689 0 AGING IN PACE WASHINGTON IS A SUPPORTING ORGANIZATION, OPERATED FOR THE BENEFIT OF AND TO SUPPORT INTERNATIONAL COMMUNITY HEALTH SERVICES'S PACE PROGRAM. THE PACE PROGRAM IS AN INTEGRATED MODEL OF CARE THAT ENABLES MEDICARE AND MEDICAID BENEFICIARIES AGED 55 YEARS OLD OR OLDER WHO ARE CERTIFIED BY THEIR STATE AS NEEDING NURSING HOME CARE TO LIVE AS INDEPENDENTLY AS POSSIBLE IN THEIR OWN HOMES AND COMMUNITY. THE PACE PROGRAM COORDINATES AND PROVIDES ALL NEEDED PREVENTIVE, PRIMARY, ACUTE AND LONG TERM CARE SERVICES. THE PACE PROGRAM IS GOVERNED BY THE CENTER FOR MEDICARE AND MEDICAID SERVICES (CMS) AT THE FEDERAL LEVEL AND BY THE STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES (DSHS) AT THE STATE LEVEL. THIS PROGRAM IS HIGHLY REGULATED, SUBJECT TO COMPLIANCE WITH THE CMS RULES AND REGULATION. THE APPLICATION PROCESS IS EXTENSIVE AND REQUIRES PROFESSIONAL HELP FROM SPECIALIZED CONSULTING FIRMS SUCH AS ALTITUDE EDGE CONSULTANTS CURRENTLY ENGAGED IN THE APPLICATION PROCESS. 1180689 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 3 3 0 1 0 0 0 1 0 1 1 0 0 0 1 1 1 1 1 0 0 0 X HERMES SHAHBAZIAN 2067883618 720 8TH AVENUE S SUITE 100 SEATTLE WA 98104 TERESITA BATAYOLA PRESIDENT 2.00 52.00 X X 0 416636 34984 GILDAS CHEUNG SECRETARY 1.00 4.00 X X 0 0 0 HIROSHI NAKANO TREASURER 1.00 1.50 X X 0 0 0 HERMES SHAHBAZIAN CFO 2.00 42.00 X 0 239287 18031 0 655923 53015 0 0 1 0 0 21819 482933 504752 MISCELLANEOUS INCOME 900099 150 150 150 504902 0 0 150 1180689 1180689 1654 1654 66670 5595 61075 219 219 3327 3327 58 58 LICENSES & TAXES 110 110 1252727 1180689 10963 61075 597304 1137364 215033 145900 601355 0 368352 601355 1180689 1884619 11896 0 1439859 0 1451755 X 1180689 -69 432933 1180689 432864 1180689 1884619 -747825 0 X 0 1 X 1 1 1 X X 1 INTERNATIONAL COMMUNITY HEALTH SERVICES 910947084 3 1 1180689 0 1 1180689 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 601355 601355 601355 DUE TO RELATED ORGANIZATIONS 1439859 1439859 X PART X, LINE 2: THE ORGANIZATION HAS RECEIVED A DETERMINATION LETTER FROM THE INTERNAL REVENUE SERVICE (IRS) THAT STATES IT IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC). ACCORDINGLY, NO PROVISION FOR INCOME TAXES IS SHOWN IN THE FINANCIAL STATEMENTS. MANAGEMENT EVALUATED THE ORGANIZATION'S TAX POSITIONS AND CONCLUDED THAT THE ORGANIZATION HAD TAKEN NO UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENTS TO THE FINANCIAL STATEMENTS TO COMPLY WITH THE PROVISIONS OF TOPIC 740 OF THE ACCOUNTING STANDARDS CODIFICATION (ASC). 1 INTERNATIONAL COMMUNITY HEALTH SERVICES 720 8TH AVENUE SOUTH SUITE 100 SEATTLE WA 98104 910947084 501(C)(3) 1180689 0 TO SUPPORT CLINICAL OPERATIONS 1 0 PART I, LINE 2: AGING IN PACE WASHINGTON ONLY GRANTS MONEY TO INTERNATIONAL COMMUNITY HEALTH SERVICES, ITS SUPPORTED ORGANIZATION. BOTH ORGANIZATIONS ARE UNDER COMMON CONTROL. 0 0 0 0 0 0 1 0 0 TERESITA BATAYOLA PRESIDENT 0 359451 0 31295 0 25890 0 15972 0 19012 0 451620 0 0 HERMES SHAHBAZIAN CFO 0 232089 0 2710 0 4488 0 9382 0 8649 0 257318 0 0 PART I, LINE 3 THE BOARD PRESIDENT IS THE CEO OF INTERNATIONAL COMMUNITY HEALTH SERVICES ("ICHS"). THEIR COMPENSATION IS DETERMINED BY ICHS, THE SUPPORTED ORGANIZATION. ICHS USES THE FOLLOWING TO DETERMINE THE CEO'S COMPENSATION: 1. WRITTEN EMPLOYMENT CONTRACT 2. COMPENSATION SURVEY OR STUDY 3. APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PART I, LINE 6 AT THE DISCRETION OF THE ICHS BOARD, THE CEO RECEIVES PERFORMANCE BONUSES NOT TO EXCEED 20% OF THE CEO ANNUAL SALARY FOR THE CALENDAR YEAR. THE PERFORMANCE BONUS CRITERIA ARE AS FOLLOWS: - FINANCIAL: REMAIN 5% OF THE APPROVED ICHS ANNUAL BUDGET OR EXPECTED MARGIN - STRATEGY: PRESENTATION OF YEARLY IMPLEMENTATION PLAN AND PROGRESS ON AT LEAST 3 INITIATIVES - COMMUNITY: MEET WITH MINIMUM OF 12 EXISTING OR POTENTIAL PARTNERS TO UNDERSTAND COMMUNITY NEEDS AND REPORT BACK TO THE BOARD - PEOPLE: CONDUCT AND REPORT STAFF SATISFACTION SURVEY (2X A YEAR) AND STAFF TURNOVER OF <25% - QUALITY: MEET OR EXCEED 3 OF 7 QUALITY MEASURES FROM ICHS SCORECARD FORM 990, PART VI, SECTION A, LINE 3 MANAGEMENT SERVICES ARE PROVIDED BY INTERNATIONAL COMMUNITY HEALTH SERVICES. FORM 990, PART VI, SECTION A, LINE 7A THE CEO OF INTERNATIONAL COMMUNITY HEALTH SERVICES IS A DIRECTOR OF AGING IN PACE WASHINGTON. INTERNATIONAL COMMUNITY HEALTH SERVICES' BOARD APPOINTS AT LEAST A MAJORITY OF THE REMAINING INDIVIDUALS WHO SERVE AS DIRECTORS OF AGING IN PACE WASHINGTON; SUCH APPOINTED INDIVIDUALS MUST ALSO BE CURRENT DIRECTORS OF INTERNATIONAL COMMUNITY HEALTH SERVICES. FORM 990, PART VI, SECTION B, LINE 11B A DRAFT COPY OF THE FORM 990 WAS REVIEWED BY THE CFO AND DESIGNATED STAFF, INCLUDING THE CONTROLLER, OF ICHS. THE ICHS FINANCE DEPARTMENT THEN SUBMITTED A DRAFT COPY OF THE FORM 990 TO THE ORGANIZATION'S BOARD OF DIRECTORS FOR APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY APPLIES TO MEMBERS, BOARD MEMBERS AND OFFICERS. INDIVIDUALS ARE REQUIRED TO DISCLOSE AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST AND ARE GIVEN THE OPPORTUNITY TO DISCLOSE MATERIAL FACTS. IF IT'S UNCLEAR WHETHER A CONFLICT EXISTS, THE CONFLICTED INDIVIDUAL LEAVES THE MEETING WHILE THE REMAINING BOARD MEMBERS DECIDE WHETHER A CONFLICT EXISTS. THE BOARD MAY SEEK ALTERNATIVES TO THE PROPOSED TRANSACITON THAT DO NOT INVOLVE A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION IS NOT IDENTIFIED, THE CONFLICTED INDIVIDUAL LEAVES THE MEETING WHILE THE REMAINING BOARD MEMBERS DECIDE WHETHER TO ENTER THE TRANSACTION. IF THE BOARD HAS REASON TO BELIEVE THAT AN INDIVIDUAL FAILED TO DISCLOSE A RELEVANT CONFLICT, THE INDIVIDUAL IS GIVEN THE OPPORTUNITY TO EXPLAIN, AFTER WHICH THE BOARD MAY TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. INTERNATIONAL COMMUNITY HEALTH SERVICES 720 8TH AVE S SUITE 100 SEATTLE WA 98104 910947084 MEDICAL AND DENTAL CLINICS WA 501(C)(3) LINE 3 N/A 0 INTERNATIONAL COMMUNITY HEALTH SERVICES FOUNDATION 720 8TH AVENUE S SUITE 100 SEATTLE WA 98104 260493856 FUNDRAISING WA 501(C)(3) LINE 12A, I INTERNATIONAL COMMUNITY HEALTH SERVICES 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0