2024-07-30T08:47:10-05:00 2023-09-30 410746749 CLIFTONLARSONALLEN LLP 220 S 6TH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2022-10-01 363570759 SHOLOM HOME WEST INC SHOL 9529356311 3620 PHILLIPS PARKWAY ST LOUIS PARK MN 55426 DAVID BERRYMAN CFO 9529356311 2024-07-29 1 0 RYAN STRUSZ P01604381 6123764500 2024-06-24 2022 2024-08-08 14:25:15Z JIM NEWBROUGH 3620 PHILLIPS PARKWAY ST LOUIS PARK MN 55426 17123527 0 X WWW.SHOLOM.COM X 1986 MN NURSING HOME FOR THE ELDERLY. 19 19 217 80 0 0 1732868 282985 13377246 16759021 34965 15357 73954 66164 15219033 17123527 24581 31917 0 0 11807196 12462881 0 0 0 7272595 7847977 19104372 20342775 -3885339 -3219248 8393662 9457721 2156764 6284151 6236898 3173570 SHOLOM IS A NOT-FOR-PROFIT ORGANIZATION PROVIDING A BROAD CONTINUUM OF RESIDENTIAL, SOCIAL SERVICE, AND HEALTH CARE SERVICES PRIMARILY FOR OLDER ADULTS AND WITHIN A JEWISH ENVIRONMENT. 0 0 18403769 31917 16759021 A 169-BED LICENSED CARE CENTER WITH SERVICES THAT INCLUDE 24-HOUR LICENSED NURSING STAFF (WITH RN SUPERVISION); SPEECH, PHYSICAL, AND OCCUPATIONAL THERAPY; DEMENTIA CARE, HOUSEKEEPING, MAINTENANCE AND LAUNDRY SERVICES, A WIDE VARIETY OF RECREATIONAL ACTIVITIES, RABBI/CHAPLAIN AND HOLIDAY SERVICES AND PROGRAMS, AND KOSHER MEALS; BEAUTY/BARBER SHOP; RESIDENT LOUNGES ON EACH WING; CLOSED CIRCUIT TV SYSTEMS; AND RESIDENT SECURITY SYSTEM. THE FACILITY ALSO PROVIDES COMMUNITY MEALS ON WHEELS. 18403769 1 1 0 0 0 0 0 0 1 0 1 0 1 0 1 1 0 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 0 0 0 1 19 0 1 217 1 0 0 0 0 0 0 0 0 0 0 0 0 X 19 19 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 MN X DAVID BERRYMAN 9529356311 3620 PHILLIPS PARKWAY ST LOUIS PARK MN 55426 SCOTT SEILER PRESIDENT 1.00 1.00 X X 0 0 0 BOB MEICHES MD VICE PRESIDENT 1.00 0.00 X X 0 0 0 DAVID NIRENSTEIN TREASURER 1.00 2.00 X X 0 0 0 LAYNE ROSEN SECRETARY 1.00 0.00 X X 0 0 0 NEIL BORENSTEIN (IMMEDIATE PAST PRESIDENT) 1.00 0.00 X X 0 0 0 LISA EDSTROM DIRECTOR 1.00 0.00 X 0 0 0 JON GORDON DIRECTOR 1.00 2.00 X 0 0 0 JEREMY PIEROTTI DIRECTOR 1.00 0.00 X 0 0 0 JERRY RUDICK DIRECTOR 1.00 1.00 X 0 0 0 SHERYL RUTZICK DIRECTOR 1.00 2.00 X 0 0 0 MICHAEL SAXON DIRECTOR 1.00 1.00 X 0 0 0 PAUL SCHANFIELD DIRECTOR 1.00 0.00 X 0 0 0 CHUCK SELCER DIRECTOR 1.00 1.00 X 0 0 0 LINDA STEIN DIRECTOR 1.00 0.00 X 0 0 0 RENEE LAMPERT DIRECTOR 1.00 0.00 X 0 0 0 JON STONE DIRECTOR 1.00 0.00 X 0 0 0 MICHAEL BLUM DIRECTOR 1.00 1.00 X 0 0 0 KIM WOLSON DIRECTOR 1.00 0.00 X 0 0 0 DOUG WEISSMAN DIRECTOR 1.00 1.00 X 0 0 0 BARB KLICK CEO 5.00 35.00 X 0 336897 10255 DAVID BERRYMAN CFO 5.00 35.00 X 0 214723 12892 ANN THOLE COO 5.00 35.00 X 0 210638 3574 JONATHAN OMOTOYINBO LPN 40.00 0.00 X 215185 0 4837 COUMBA CISSE TMA 40.00 0.00 X 183293 0 8422 AUGUSTINE ANOJE TMA 40.00 0.00 X 207466 0 0 MAI CRUSOA NAR 40.00 0.00 X 164133 0 7180 ANDREW PYNE NAR 40.00 0.00 X 145113 0 5242 915190 762258 52402 22 0 1 0 SHOLOM COMMUNITY ALLIANCE 3620 PHILLIPS PARKWAY ST LOUIS PARK MN 55426 MANAGEMENT SERVICES 1567922 TC SERVICES PO BOX 85198 CHICAGO IL 60689 JANITORIAL SERVICES 106218 2 234550 48435 282985 RESIDENT REVENUE 623000 16759021 16759021 16759021 15357 15357 MEALS 623000 58370 58370 MISCELLANEOUS REVENUE 623000 5316 5316 BEAUTY SHOP 623000 2478 2478 66164 17123527 16759021 0 81521 X 31917 31917 10822600 10591738 230862 53675 51538 2137 794211 762595 31616 792395 760851 31544 1564619 1564619 5801 5801 2693410 2661493 31917 2757 2757 368729 338284 30445 652113 647584 4529 5730 5730 2145 2145 766950 766950 FOOD 734361 734017 344 PROGRAM SUPPLIES 591128 591128 SURCHARGE 370172 370172 REPAIRS & MAINTENANCE 44720 44430 290 45342 45342 20342775 18403769 1939006 0 109636 945459 105041 57616 1652953 2099205 19511 32935 24173539 20081913 4435568 4091626 1988307 2144227 82646 86653 8393662 9457721 902388 1088586 371565 74874 67094 1179502 4756906 2156764 6284151 X 4149253 977430 2087645 2196140 6236898 3173570 8393662 9457721 X -3219248 155920 X 0 1 X 1 0 X 174750 1283289 3450863 1732868 282985 6924755 16907730 15663454 12006595 13377246 16759021 74714046 17082480 16946743 15457458 15110114 17042006 81638801 0 0 0 81638801 16727 40374 83270 34965 15357 190693 16727 40374 83270 34965 15357 190693 123861 838584 75174 73954 66164 1177737 17223068 17825701 15615902 15219033 17123527 83007231 0.98350 0.98320 0.00230 0.00220 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: OTHER INCOME MEALS REVENUE BEAUTY SHOP REVENUE RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 1075965 1075965 18247920 15635309 2612611 4803799 4446604 357195 45855 45855 4091626 INVESTMENTS IN FOUNDATION 2144227 F 2144227 DUE TO AFFILIATES 4756906 4756906 X PART IV, LINE 2B: TENANTS MAKE SECURITY DEPOSITS WHEN THEY MOVE IN TO THE FACILITY. THE MONEY IS MAINTAINED IN A SEPARATE BANK ACCOUNT. DEPOSITS, WITH INTEREST, LESS ANY COSTS OF REPAIRS, ARE RETURNED TO TENANTS OR THEIR ESTATES WHEN THE TENANT LEAVES THE FACILITY. THE ORGANIZATION HOLDS SMALL AMOUNTS IN TRUST ON BEHALF OF RESIDENTS OF THE FACILITY. RESIDENTS MAY MAKE DEPOSITS AND WITHDRAWALS AT ANY TIME. THE FUNDS ARE HELD IN A SEPARATE BANK ACCOUNT. PART X, LINE 2: SHOLOM AND ITS AFFILIATES QUALIFY AS TAX-EXEMPT ENTITIES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. ACCORDINGLY, THE ORGANIZATIONS ARE NOT SUBJECT TO FEDERAL INCOME TAXES UNDER SECTION 501(A) OF THE CODE. THE ORGANIZATIONS ARE CLASSIFIED AS PUBLICLY SUPPORTED CHARITABLE ORGANIZATIONS UNDER EITHER SECTION 509(A)(2) OR SECTION 509(A)(3) OF THE CODE AND CONTRIBUTIONS TO THE ORGANIZATIONS QUALIFY AS A CHARITABLE TAX DEDUCTION BY THE CONTRIBUTOR. SHOLOM'S ANNUAL TAX FILINGS ARE SUBJECT TO REVIEW BY FEDERAL, STATE, AND LOCAL AUTHORITIES. SHOLOM IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. SHOLOM IS NOT AWARE OF ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OTHER TAXES. 0 SCHOLARSHIPS 8 31917 N/A N/A PART I, LINE 2: SCHOLARSHIP FUNDS ARE AVAILABLE TO REIMBURSE LONG-TERM CARE EMPLOYEES FOR TRAINING THAT WILL ENABLE THEM TO ADVANCE IN THE FIELD OF LONG TERM CARE. TO BE ELIGIBLE FOR THESE SCHOLARSHIPS, EMPLOYEES ARE REQUIRED TO WORK AN AVERAGE OF 20 HOURS/WEEK. AWARDS ARE BASED ON ADDITIONAL CRITERIA INCLUDING THE AVAILABILTY OF FUNDS. 0 0 0 0 0 0 0 0 0 BARB KLICK CEO 0 336897 0 0 0 0 0 0 0 10255 0 347152 0 0 DAVID BERRYMAN CFO 0 214723 0 0 0 0 0 3221 0 9671 0 227615 0 0 JONATHAN OMOTOYINBO LPN 215185 0 0 0 0 0 0 0 4837 0 220022 0 0 0 ANN THOLE COO 0 210638 0 0 0 0 0 3159 0 415 0 214212 0 0 AUGUSTINE ANOJE TMA 207466 0 0 0 0 0 0 0 0 0 207466 0 0 0 COUMBA CISSE TMA 183293 0 0 0 0 0 0 0 8422 0 191715 0 0 0 MAI CRUSOA NAR 164133 0 0 0 0 0 2462 0 4718 0 171313 0 0 0 ANDREW PYNE NAR 145113 0 0 0 0 0 0 0 5242 0 150355 0 0 0 PART I, LINE 3 THE CEO'S COMPENSATION IS DETERMINED BY SHOLOM COMMUNITY ALLIANCE, THE SOLE MEMBER OF SHOLOM HOME WEST. THE FOLLOWING WERE USED BY SHOLOM COMMUNITY ALLIANCE IN DETERMINING THE CEO'S COMPENSATION: 1. EXECUTIVE COMMITTEE 2. INDEPENDENT COMPENSATION CONSULTANT 3. WRITTEN EMPLOYMENT CONTRACT 4. COMPENSATION SURVEY OR STUDY 5. APPROVAL BY THE BOARD OR EXECUTIVE COMMITTEE FORM 990, PART VI, SECTION A, LINE 1A THE BUDGET AND FINANCE COMMITTEE HAS BEEN DELEGATED THE AUTHORITY TO APPROVE THE 990 TAX RETURN ON BEHALF OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 3 SHOLOM COMMUNITY ALLIANCE CORPORATE CHARGES A MANAGEMENT FEE TO ALL THE AFFILIATED ENTITIES FOR ADMINISTRATIVE AND GENERAL SERVICES. THE MANAGEMENT FEES ON THE AFFILIATED ENTITIES ARE REVENUE TO SHOLOM COMMUNITY ALLIANCE. THESE TRANSACTIONS ARE ELIMINATED IN THE CONSOLIDATED FINANCIAL STATEMENTS. FORM 990, PART VI, SECTION A, LINE 6 SHOLOM COMMUNITY ALLIANCE IS THE SOLE MEMBER OF SHOLOM HOME WEST, INC. FORM 990, PART VI, SECTION A, LINE 7A THE DIRECTORS ARE ELECTED AT THE ANNUAL MEETING OF THE SOLE MEMBER, SHOLOM COMMUNITY ALLIANCE. THE BOARD MEMBERS OF SHOLOM COMMUNITY ALLIANCE HAVE ELECTED THEMSELVES TO BE THE BOARD OF DIRECTORS OF SHOLOM HOME WEST. FORM 990, PART VI, SECTION A, LINE 7B AMENDMENTS TO THE ARTICLES OF INCORPORATION AND BYLAWS REQUIRE THE APPROVAL OF THE BOARD OF DIRECTORS OF SHOLOM COMMUNITY ALLIANCE. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 TAX RETURN WAS REVIEWED BY MANAGEMENT IN DETAIL, REVIEWED AND APPROVED BY A SUBCOMMITTEE OF THE BOARD OF DIRECTORS, AND PROVIDED TO THE FULL BOARD OF DIRECTORS ELECTRONICALLY PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS AND EMPLOYEES SIGN FOR RECEIPT OF POLICY WHICH COVERS ALL EMPLOYEES AND OFFICERS. COMPLIANCE IS MONITORED VIA VARIOUS MEANS INCLUDING FINANCIAL AUDIT, BOARD MINUTES, AND INVESTIGATION OF COMPLAINTS. ANY POTENTIAL CONFLICT OF INTEREST MUST BE DISCLOSED AT THE TIME OF KNOWLEDGE OF THE POTENTIAL CONFLICT TO THE PRESIDENT OF THE BOARD OF DIRECTORS, OR, IF APPROPRIATE, THE CHAIR OF THE COMMITTEE EVALUATING THE PARTICULAR MATTER AND THE CEO. THE PRESIDENT OF THE BOARD OF DIRECTORS OR ANY DESIGNEE WILL EVALUATE THE APPROPRIATENESS OF THE BOARD MEMBER TO BE INVOLVED IN ANY DISCUSSIONS AND/OR VOTING ON THE POTENTIAL CONFLICT OF INTEREST ISSUE. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT OPEN TO PUBLIC INSPECTION. FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 2,661,493. MANAGEMENT AND GENERAL EXPENSES 31,917. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,693,410. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NET ASSETS OF AFFILIATE 155,920. SHOLOM COMMUNITY ALLIANCE 3620 PHILLIPS PARKWAY ST LOUIS PARK MN 55426 411837022 SUPPORT RELATED ENTITIES IN ELDERLY NURSING HOME, HOUSING AND COMMUNITY SERV MN 501(C)(3) LINE 12B, II N/A 0 SHOLOM HOME EAST INC 3620 PHILLIPS PARKWAY ST LOUIS PARK MN 55426 410695462 NURSING HOME FOR THE ELDERLY MN 501(C)(3) LINE 10 SHOLOM COMMUNITY ALLIANCE 0 COMMUNITY HOUSING & SERVICE CORP 3620 PHILLIPS PARKWAY ST LOUIS PARK MN 55426 410982770 PROVIDE HOUSING FOR THE ELDERLY MN 501(C)(3) LINE 10 SHOLOM COMMUNITY ALLIANCE 0 KNOLLWOOD COMMUNITY HOUSING CORP 3620 PHILLIPS PARKWAY ST LOUIS PARK MN 55426 411518579 LOW INCOME HOUSING MN 501(C)(3) LINE 10 SHOLOM COMMUNITY ALLIANCE AND COMMUNITY HOUSING AND SERVICE CORP 0 MENORAH PLAZA HOUSING CORP 3620 PHILLIPS PARKWAY ST LOUIS PARK MN 55426 363512438 LOW INCOME HOUSING MN 501(C)(3) LINE 10 SHOLOM COMMUNITY ALLIANCE AND COMMUNITY HOUSING AND SERVICE CORP 0 SHOLOM COMMUNITY ALLIANCE HOME HEALTH CARE 3620 PHILLIPS PARKWAY ST LOUIS PARK MN 55426 010628051 PROVIDE HOME HEALTH CARE AND HOSPICE SERVICES TO THE COMMUNITY. MN 501(C)(3) LINE 10 SHOLOM COMMUNITY ALLIANCE 0 SHOLOM ST PAUL SENIOR HOUSING INC 760 PERLMAN STREET ST PAUL MN 55102 204844785 LOW INCOME HOUSING MN 501(C)(3) LINE 10 SHOLOM COMMUNITY ALLIANCE 0 SHOLOM FOUNDATION 3610 PHILLIPS PARKWAY ST LOUIS PARK MN 55426 363411361 SUPPORT TO AFFILIATES THROUGH FUNDRAISING MN 501(C)(3) LINE 7 N/A 0 SHOLOM ST PAUL 3620 PHILLIPS PARKWAY ST LOUIS PARK MN 55426 300256100 INACTIVE SHELL COMPANY MN 501(C)(3) LINE 10 SHOLOM COMMUNITY ALLIANCE 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0