2024-08-06T13:53:39-05:00 2023-09-30 135565207 KPMG LLP 301 MAIN STREET SUITE 2150 BATON ROUGE LA 70801 990 2022-10-01 954016278 PIH HEALTH MANAGEMENT CORP PIHH 5626980811 12401 WASHINGTON BOULEVARD WHITTIER CA 90602 VID SHIVARAMAN CFO 5626980811 2024-07-31 1 0 BRITTANY ELLISER P01284594 2253444000 2024-07-22 2022 2024-08-08 14:25:15Z JAMES WEST 12401 WASHINGTON BOULEVARD WHITTIER CA 90602 2270400 0 X N/A X 1985 CA TO PROVIDE MANAGEMENT AND FINANCIAL SERVICES TO RELATED TAX-EXEMPT AFFILIATES. 4 0 0 0 0 0 0 0 1208994 1551459 76057 718941 0 0 1285051 2270400 0 0 0 0 0 0 0 0 0 1209511 1551658 1209511 1551658 75540 718742 17132657 27919893 4122799 14191293 13009858 13728600 PIH HEALTH MANAGEMENT CORP. PROVIDES MANAGEMENT AND FINANCIAL SERVICES TO OTHER RELATED TAX-EXEMPT ENTITIES. 0 0 1551658 1551459 FINANCIAL MANAGEMENT AND ACCOUNTING SERVICES PROVIDED TO PIH HEALTH, INC., A RELATED TAX-EXEMPT ORGANIZATION, AND ITS AFFILIATES. 1551658 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 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 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 4 0 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 CA X MARK KAWAUCHI 5626980811 12102 WASHINGTON BOULEVARD WHITTIER CA 90606 JAMES WEST DIRECTOR & CHAIR 1.50 50.70 X X 0 2046653 355723 ROSALIO LOPEZ MD SYSTEM CSO/CMO 1.50 44.70 X X 0 1114134 46447 PEGGY CHULACK DIRECTOR & SECRETARY 1.50 50.70 X X 0 995412 192712 BRIAN SMOLSKIS THRU 9282023 SYSTEM COO 1.50 46.20 X X 0 1034811 219042 VID SHIVARAMAN DIRECTOR & TREASURER 1.50 50.70 X X 0 749812 150468 ANITA CHOU FORMER DIRECTOR 0.00 0.00 X 0 119014 14 0 6059836 964406 0 1 1 0 0 MANAGEMENT SERVICES 551114 1551459 1551459 1551459 718941 718941 2270400 1551459 0 718941 BANK SERVICE CHARGES 1551459 1551459 199 199 1551658 1551658 0 0 17132657 27919893 17132657 27919893 4122799 14191293 4122799 14191293 X 13009858 13728600 13009858 13728600 17132657 27919893 718742 0 X 0 1 X 1 0 X X 5 PIH HEALTH PHYSICIANS 953942828 10 0 0 0 PIH HEALTH DOWNEY HOSPITAL 951903935 3 0 0 0 PIH HEALTH FOUNDATION 953761274 7 0 0 0 PIH HEALTH WHITTIER HOSPITAL 951934652 3 0 0 0 PIH HEALTH GOOD SAMARITAN HOSPITAL 951656366 3 0 0 0 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SCHEDULE A, PART IV, SECTION A, LINE 1 THE SUPPORTED ORGANIZATIONS ARE DESIGNATED BY CLASS OR PURPOSE WITHIN THE MEANING OF SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986 ("THE CODE") BY CONDUCTING OR SUPPORTING ACTIVITIES FOR THE BENEFIT OF, PERFORMING THE FUNCTIONS OF, OR CARRYING OUT THE PURPOSES OF QUALIFIED ORGANIZATIONS PROMOTING THE HEALTH OF THE COMMUNITY WITHIN THE MEANING OF SECTION 501(C)(3) OF THE CODE. SCHEDULE A, PART IV, SECTION C, LINE 1 THE MAJORITY OF THE BOARD OF DIRECTORS OF PIH HEALTH MANAGEMENT CORP. ALSO SERVE AS OFFICERS OF EACH OF ITS SUPPORTED ORGANIZATIONS AND ITS SOLE MEMBER PIH HEALTH, INC. AS OFFICERS OF ITS SUPPORTED ORGANIZATIONS AND SOLE MEMBER, THE INDIVIDUALS WHO COMPRISE THE MAJORITY OF THE BOARD OF DIRECTORS OF PIH HEALTH MANAGEMENT CORP. ALSO SHARE IN THE RESPONSIBILITY OF MANAGING, SUPERVISING AND CONTROLLING BOTH SUPPORTING AND SUPPORTED ORGANIZATION(S). 0 INTERCOMPANY RECEIVABLES 27919893 27919893 X PART X, LINE 2: THE PRINCIPAL OPERATIONS OF THE COMPANY ARE EXEMPT FROM INCOME TAXES PURSUANT TO INTERNAL REVENUE CODE (IRC) SECTION 501(C)(3) AND THE LAWS OF THE STATES IN WHICH IT OPERATES AND, AS SUCH, IS GENERALLY NOT SUBJECT TO FEDERAL OR STATE INCOME TAXES. HOWEVER, THE COMPANY IS SUBJECT TO INCOME TAXES ON NET INCOME DERIVED FROM A TRADE OR BUSINESS REGULARLY CARRIED ON THAT DOES NOT FURTHER THE ORGANIZATION'S EXEMPT PURPOSE. FURTHER, THE COMPANY IS ALSO SUBJECT TO FEDERAL EXCISE TAXES PURSUANT TO THE TAX CUTS AND JOBS ACT. NO SIGNIFICANT INCOME TAX PROVISION HAS BEEN RECORDED IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS FOR NET INCOME DERIVED FROM UNRELATED TRADE OR BUSINESS AND EXCISE TAXES. THE COMPANY MEASURES LIABILITIES FOR UNRECOGNIZED TAX UNCERTAINTIES IN ACCORDANCE WITH ASC 740, INCOME TAXES, WHICH PRESCRIBES A COMPREHENSIVE MODEL FOR HOW A COMPANY SHOULD RECOGNIZE, MEASURE, PRESENT AND DISCLOSE IN ITS FINANCIAL STATEMENTS UNCERTAIN TAX POSITIONS THAT A COMPANY HAS TAKEN OR EXPECTS TO TAKE ON A TAX RETURN. THE GUIDANCE IS APPLICABLE TO PROFIT-ORIENTED ENTITIES, PASS-THROUGH ENTITIES AND TAX-EXEMPT ORGANIZATIONS. MANAGEMENT BELIEVES IT HAS NO SIGNIFICANT UNCERTAIN TAX POSITIONS AND, AS SUCH, NO TAX LIABILITY, BENEFITS, INTEREST OR PENALTIES WERE ACCRUED AT SEPTEMBER 30, 2023 OR 2022. THE COMPANY IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE COMPANY BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO 2019 FOR FEDERAL PURPOSES AND 2017 FOR CALIFORNIA PURPOSES. 1 1 0 0 0 0 0 0 0 JAMES WEST DIRECTOR & CHAIR 0 1506821 0 0 0 539832 0 335520 0 20325 0 2402498 0 517243 BRIAN SMOLSKIS THRU 9282023 SYSTEM COO 0 838304 0 0 0 196507 0 196657 0 22507 0 1253975 0 188312 PEGGY CHULACK DIRECTOR & SECRETARY 0 826709 0 0 0 168703 0 178274 0 14760 0 1188446 0 120897 ROSALIO LOPEZ MD SYSTEM CSO/CMO 0 907438 0 0 0 206696 0 36700 0 9869 0 1160703 0 0 VID SHIVARAMAN DIRECTOR & TREASURER 0 681460 0 0 0 68352 0 141186 0 9404 0 900402 0 61131 ANITA CHOU FORMER DIRECTOR 0 -14 0 0 0 119028 0 0 0 14 0 119028 0 0 PART I, LINES 4A-B ANITA CHOU RECEIVED SEVERANCE PAYMENTS DURING THE CALENDAR YEAR. THE PAYMENTS INCLUDED IN PART VII, COLUMN E AND SCHEDULE J, PART II, COLUMN B(III). THE TERMS AND CONDITIONS OF THE CONFIDENTIAL SEVERANCE AGREEMENTS ARE AVAILABLE TO THE INTERNAL REVENUE SERVICES UPON REQUEST. PART 1, LINE 3: COMPENSATION FOR THE CEO WAS ESTABLISHED AND PAID BY PIH HEALTH WHITTIER HOSPITAL (PHWH), A RELATED ORGANIZATION. PHWH USED THE FOLLOWING TO ESTABLISH THE CEO'S COMPENSATION: (1) COMPENSATION COMMITTEE; (2) INDEPENDENT COMPENSATION CONSULTANT; (3) FORM 990 OF OTHER ORGAANIZATIONS; (4) COMPENSATION SURVEY OR STUDY; (5) APPROVAL BY THE BOARD. PART I, LINE 4B: PIH HEALTH INC. AND ITS AFFILIATES PROVIDE A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN FOR CERTAIN EXECUTIVES. THE FOLLOWING INDIVIDUALS PARTICIPATE IN THE PLAN: JAMES WEST PEGGY CHULACK ROSALIO LOPEZ BRIAN SMOLSKIS VID SHIVARAMAN THE FOLLOWING AMOUNTS BECAME VESTED OR WERE PAID-OUT IN 2022 AND ARE INCLUDED IN SCHEDULE J, PART II, COLUMN (B) (III) : JAMES WEST - $517,243 BRIAN SMOLSKIS - $188,312 PEGGY CHULACK - $120,897 VID SHIVARAMAN - $61,131 FORM 990, PART VI, SECTION A, LINE 2 PIH HEALTH MANAGEMENT CORP. IS A MEMBER OF AN INTEGRATED HEALTHCARE SYSTEM CONTROLLED BY PIH HEALTH, INC. THE FOLLOWING INDIVIDUALS HAVE A BUSINESS RELATIONSHIP BY VIRTUE OF THEIR POSITIONS AS OFFICER OR DIRECTORS OF RELATED ENTITIES WITHIN THE SYSTEM: JAMES WEST, PEGGY CHULACK, VID SHIVARAMAN, BRIAN SMOLSKIS FORM 990, PART VI, SECTION A, LINE 6 PIH HEALTH, INC. IS THE SOLE MEMBER OF PIH HEALTH MANAGEMENT CORP. FORM 990, PART VI, SECTION A, LINE 7A PIH HEALTH, INC. HAS AUTHORITY TO ELECT ALL THE MEMBERS OF THE BOARD OF DIRECTORS OF PIH HEALTH MANAGEMENT CORP. FORM 990, PART VI, SECTION A, LINE 7B PIH HEALTH, INC. HAS ALL VOTING RIGHTS AND THE POWER TO ELECT THE BOARD OF DIRECTORS OF PIH HEALTH MANAGEMENT CORP. FORM 990, PART VI, SECTION B, LINE 11B FORM 990 IS REVIEWED BY THE AUDIT COMMITTEE OF THE PARENT ORGANIZATION, WHICH IS MADE UP OF INDEPENDENT DIRECTORS. THE FORM 990 IS THEN PROVIDED TO THE BOARD FOR ITS INFORMATION. FORM 990, PART VI, SECTION B, LINE 12C EACH YEAR, ALL MANAGEMENT AND BOARD OF DIRECTORS MEMBERS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE FORM. ALL POSITIVE RESPONSES ARE REVIEWED BY THE CHIEF ADMINISTRATIVE OFFICER AND GENERAL COUNSEL. EACH POSITIVE RESPONSE IS CONSIDERED IN LIGHT OF MAGNITUDE OF OWNERSHIP INTEREST, FINANCIAL TRANSACTION(S), ETC. IF DEEMED NECESSARY, CONFLICTS OF INTEREST COULD BE RESOLVED BY INSISTING THAT THE INCUMBENT EITHER DIVEST THEIR OWNERSHIP INTEREST, THAT THE ORGANIZATION TERMINATE THE BUSINESS RELATIONSHIP, OR EVEN THAT THE DIRECTOR RESIGN. DIRECTORS WITH POTENTIAL CONFLICTS OF INTEREST MAY RECUSE THEMSELVES FROM VOTING ON CERTAIN MATTERS AND/OR MAY EXCUSE THEMSELVES FROM MEETINGS DURING THE DISCUSSION, DELIBERATION, AND VOTING ON OF MATTERS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990 AND FORM 990-T ARE AVAILABLE UPON REQUEST. THE ORGANIZATION IS NOT REQUIRED TO MAKE FORM 1023 AVAILABLE FOR PUBLIC INSPECTION AS IT RECEIVED ITS TAX EXEMPTION PRIOR TO JULY 15, 1987. PIH HEALTH FOUNDATION 12401 WASHINGTON BLVD WHITTIER CA 90602 953761274 FUNDRAISING CA 501(C)(3) LINE 7 PIH HEALTH INC 1 PIH HEALTH DOWNEY HOSPITAL 11500 BROOKSHIRE AVENUE DOWNEY CA 90241 951903935 HEALTHCARE CA 501(C)(3) LINE 3 PIH HEALTH INC 1 PIH HEALTH HOME HEALTHCARE 12401 WASHINGTON BLVD WHITTIER CA 90602 953036281 HEALTHCARE CA 501(C)(3) LINE 12B, II PIH HEALTH INC 1 PIH HEALTH INC 12401 WASHINGTON BLVD WHITTIER CA 90602 953619388 SUPPORT OF TAX-EXEMPT AFFILIATES CA 501(C)(3) LINE 12B, II N/A 0 PIH HEALTH ADULT DAY HEALTHCARE 12401 WASHINGTON BLVD WHITTIER CA 90602 953643829 HEALTHCARE CA 501(C)(3) LINE 12B, II PIH HEALTH INC 1 PIH HEALTH GOOD SAMARITAN HOSPITAL 1225 WILSHIRE BOULEVARD LOS ANGELES CA 90017 951656366 HEALTHCARE CA 501(C)(3) LINE 3 PIH HEALTH INC 1 GOOD SAMARITAN INSTITUTE FOR RESEARCH AND EDUCATION 1225 WILSHIRE BLVD LOS ANGELES CA 90017 954077161 RESEARCH CA 501(C)(3) LINE 4 PIH HEALTH GOOD SAMARITAN HOSPITAL 1 PIH HEALTH WHITTIER HOSPITAL 12401 WASHINGTON BLVD WHITTIER CA 90602 951934652 HEALTHCARE CA 501(C)(3) LINE 3 PIH HEALTH INC 1 PIH HEALTH PHYSICIANS 6557 GREENLEAF AVE WHITTIER CA 90601 953942828 HEALTHCARE CA 501(C)(3) LINE 10 PIH HEALTH INC 1 ORTHOPEDIC INSTITUTE OF THE GOOD SAMARITAN HOSPITAL 1225 WILSHIRE BLVD LOS ANGELES CA 90017 954346048 RESEARCH CA 501(C)(3) LINE 12A, I PIH HEALTH GOOD SAMARITAN HOSPITAL 1 SAMARITAN IMAGING CENTER 1225 WILSHIRE BLVD LOS ANGELES CA 90017 954252321 HEALTHCARE CA 501(C)(3) LINE 10 PIH HEALTH GOOD SAMARITAN HOSPITAL 1 GOOD SAMARITAN MEDICAL OFFICE BUILDING INC 1225 WILSHIRE BLVD LOS ANGELES CA 90017 953244046 MEDICAL OFFICES CA 501(C)(3) LINE 12A, I PIH HEALTH GOOD SAMARITAN HOSPITAL 1 KATE VAN NUYS PAGE FOUNDATION 1225 WILSHIRE BLVD LOS ANGELES CA 90017 956028032 GRANTS INCOME TO GOOD SAMARITAN HOSPITAL CA 501(C)(3) LINE 12A, I PIH HEALTH GOOD SAMARITAN HOSPITAL 1 PIH HEALTH INSURANCE COMPANY 733 BISHOP STREET STE 1555 HONOLULU HI 96813 263760243 CAPTIVE INSURANCE HI N/A T 1 PIH HEALTH CARE SOLUTIONS 6557 GREENLEAF AVENUE WHITTIER CA 90601 462072342 HEALTHCARE CA N/A C 1 DRMC PROPERTIES INC 12401 WASHINGTON BLVD WHITTIER CA 90602 954769768 REAL ESTATE CA N/A C 1 PIH HEALTH RE 733 BISHOP STREET STE 1555 HONOLULU HI 96813 472501390 CAPTIVE INSURANCE HI N/A T 1 HEALTHMED SERVICES INC 12401 WASHINGTON BLVD WHITTIER CA 90602 300831225 HEALTHCARE CA N/A C 1 PIONEER MEDICAL GROUP INC 12401 WASHINGTON BLVD WHITTIER CA 90602 330927283 MEDICAL SERVICES CA N/A C 1 PIONEER PROVIDER NETWORK A MEDICAL GROUP INC 12401 WASHINGTON BLVD WHITTIER CA 90602 330922631 MANAGEMENT SERVICES CA N/A C 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 1 0 PIH HEALTH WHITTIER HOSPITAL L 1551459 FMV PART IV, COLUMN (E): PIH INSURANCE COMPANY IS AN UNINCORPORATED RISK RETENTION GROUP. PART IV, COLUMN (E): PIH HEALTH CARE SOLUTIONS IS A NONPROFIT MUTUAL BENEFIT CORPORATION.