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 953244046 GOOD SAMARITAN HOSPITAL MEDICAL OFFICE BUILDING INC GOOD 2139772121 1225 WILSHIRE BLVD LOS ANGELES CA 900172395 VID SHIVARAMAN CFO 2139772121 2024-07-31 1 0 BRITTANY ELLISER P01284594 2253444000 2024-07-22 2022 2024-08-08 14:25:15Z JAMES WEST 12401 WASHINGTON BLVD WHITTIER CA 90602 7922953 0 X N/A X 1978 CA PROVIDES PROFESSIONAL MEDICAL OFFICE SPACE TO HOSPITAL STAFF PHYSICIANS IN AN ADJACENT BUILDING. 4 0 0 0 0 0 0 0 2682517 2711817 0 0 -3323584 -2928674 -641067 -216857 0 0 0 0 0 0 0 0 0 5084911 4235867 5084911 4235867 -5725978 -4452724 117091286 119584726 152781776 159727940 -35690490 -40143214 TO INCREASE HOSPITAL EFFICIENCY, ENCOURAGE HIGHER UTILIZATION OF HOSPITAL FACILITIES AND IMPROVE THE OVERALL QUALITY OF PATIENT CARE BY PROVIDING PROFESSIONAL MEDICAL OFFICE SPACE TO STAFF PHYSICIANS IN A BUILDING ADJACENT TO THE HOSPITAL. 0 0 4143639 2711817 MEDICAL OFFICE FACILITIES FOR THE BENEFIT OF THE HOSPITAL TO FURTHER THE QUALITY AND AVAILABILITY OF MEDICAL CARE TO THE PUBLIC. 4143639 1 0 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 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 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 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 CA X MARK KAWAUCHI 5626980811 12102 WASHINGTON BLVD WHITTIER CA 90606 JAMES WEST SYSTEM PRESIDENT & CEO 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 SYSTEM CAO & ASST SECRETARY 1.50 50.70 X X 0 995412 192712 VID SHIVARAMAN SYSTEM CFO & ASST TREASURER 1.50 50.70 X X 0 749812 150468 BRIAN SMOLSKIS THRU 9282023 SYSTEM COO 1.50 46.20 X X 0 1034811 219042 ANITA CHOU FORMER CFO & ASST TREASURER 0.00 0.00 X 0 119014 14 0 6059836 964406 0 1 1 0 0 RENTAL INCOME 532000 2711817 2711817 2711817 5211136 8139810 -2928674 -2928674 -2928674 -216857 2711817 0 -2928674 407548 395322 12226 41 29 12 734939 712891 22048 1931385 1873443 57942 1161954 1161954 4235867 4143639 92228 0 0 426457 213286 14683 19483 132093380 12804994 116586512 119288386 63634 63571 117091286 119584726 3461196 776021 149320580 158951919 152781776 159727940 X -35690490 -40143214 -35690490 -40143214 117091286 119584726 -4452724 0 X 0 1 X 1 0 X X 1 PIH HEALTH GOOD SAMARITAN HOSPITAL 951656366 3 1 0 2711817 1 0 2711817 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 4950527 4950527 112518719 12717502 99801217 99961 9964 89997 14524173 77528 14446645 119288386 DUE TO AFFILIATES 158904197 RESERVE FOR ASSET RETIREMENT OBLIGATION 47722 158951919 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 SYSTEM PRESIDENT & CEO 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 SYSTEM CAO & ASST 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 SYSTEM CFO & ASST TREASURER 0 681460 0 0 0 68352 0 141186 0 9404 0 900402 0 61131 ANITA CHOU FORMER CFO & ASST TREASURER 0 -14 0 0 0 119028 0 0 0 14 0 119028 0 0 PART I, LINES 4A-B ANITA CHOU RECEIVED A SEVERANCE PAYMENT DURING THE CALENDAR YEAR. THE PAYMENT IS INCLUDED IN PART VII, COLUMN E AND SCHEDULE J, PART II, COLUMN B(III). THE TERMS AND CONDITIONS OF THE CONFIDENTIAL SEVERANCE AGREEMENT ARE AVAILABLE TO THE INTERNAL REVENUE SERVICE UPON REQUEST. PART I, LINE 3: COMPENSATION FOR THE CEO WAS ESTABLISHED AND PAID BY PIH HEALTH WHITTIER HOSPITAL (PIHW), A RELATED ORGANIZATION. PIHW USED THE FOLLOWING TO ESTABLISH THE CEO'S COMPENSATION: (1) COMPENSATION COMMITTEE; (2) INDEPENDENT COMPENSATION CONSULTANT; (3) FORM 990 OF OTHER ORGANIZATIONS; (4) COMPENSATION SURVEY OR STUDY; (5) APPROVAL BY THE BOARD. PART I, LINES 4A-B: A RELATED ORGANIZATION, PIH HEALTH, INC., PROVIDES A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN FOR CERTAIN EXECUTIVES. THE FOLLOWING INDIVIDUALS PARTICIPATE IN THE PLAN: JAMES WEST PEGGY CHULACK VID SHIVARAMAN ROSALIO LOPEZ, MD BRIAN SMOLSKIS 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 THE ORGANIZATION 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 OFFICERS OR DIRECTORS OF RELATED ENTITIES WITHIN THE SYSTEM: JAMES WEST, PEGGY CHULACK, VID SHIVARAMAN, ROSALIO LOPEZ, AND BRIAN SMOLSKIS. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION WORKS WITH AN INDEPENDENT ACCOUNTANT, KPMG LLP, TO PREPARE THE FORM 990. ONCE THE RETURN IS PREPARED, THE RETURN IS REVIEWED BY THE CHIEF FINANCIAL OFFICER AND VP OF FINANCE. FORM 990 IS THEN REVIEWED BY THE AUDIT COMMITTEE OF PIH HEALTH, INC., WHICH IS MADE UP OF INDEPENDENT DIRECTORS. KPMG LLP MAKES ALL CHANGES NECESSARY. THE FINAL FORM 990 IS PROVIDED TO THE BOARD PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION IS INCLUDED IN THE CONFLICT OF INTEREST POLICY FOR PIH HEALTH GOOD SAMARITAN HOSPITAL, THE ORGANIZATION'S SOLE MEMBER. ACCORDING TO THE POLICY, ALL BOARD MEMBERS AND OFFICERS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE STATEMENT EACH YEAR. THE POLICY REQUIRES EACH GOVERNING BODY MEMBER TO DISCLOSE ANY CONFLICT ON A PARTICULAR MATTER THAT MAY ARISE, AND RECUSE HIM OR HERSELF FROM DELIBERATIONS AND VOTES ON SUCH MATTERS. THE POLICIES ARE MONITORED AND ENFORCED BY THE AUDIT COMMITTEE CHAIRPERSON. FORM 990, PART VI, SECTION B, LINE 15 DURING THE TAX YEAR ENDED SEPTEMBER 30, 2023, NO OFFICERS, DIRECTORS, OR TRUSTEES RECEIVED COMPENSATION FROM THIS ORGANIZATION. THE COMPENSATION REPORTED IS PAID BY A RELATED ORGANIZATION AND IS DETERMINED BASED ON THE COMPENSATION REVIEW PRACTICES AND POLICIES OF PIH HEALTH GOOD SAMARITAN HOSPITAL, A CONTROLLING RELATED ENTITY. FORM 990, PART VI, SECTION C, LINE 19 GOOD SAMARITAN HOSPITAL MEDICAL OFFICE BUILDING, INC.'S ORGANIZING AND GOVERNING DOCUMENTS AND THE CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. THE FINANCIAL INFORMATION FROM THE FINANCIAL STATEMENTS IS INCLUDED IN THE ORGANIZATION'S FORM 990, WHICH IS AVAILABLE FOR PUBLIC INSPECTION UPON REQUEST. PIH HEALTH GOOD SAMARITAN HOSPITAL 1225 WILSHIRE BLVD LOS ANGELES CA 90017 951656366 HOSPITAL CA 501(C)(3) LINE 3 PIH HEALTH INC 0 GOOD SAMARITAN INSTITUTE FOR RESEARCH AND EDUCATION 1225 WILSHIRE BLVD LOS ANGELES CA 90017 954077161 HEART RESEARCH CA 501(C)(3) LINE 4 PIH HEALTH GOOD SAMARITAN HOSPITAL 1 ORTHOPEDIC INSTITUTE OF THE GOOD SAMARITAN HOSPITAL 1225 WILSHIRE BLVD LOS ANGELES CA 90017 954346048 ORTHOPEDIC 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 OUTPATIENT IMAGING CA 501(C)(3) LINE 10 PIH HEALTH GOOD SAMARITAN HOSPITAL 1 KATE VAN NUYS PAGE FOUNDATION 12401 WASHINGTON BLVD WHITTIER CA 90602 956028032 GRANTS INCOME TO PIH HEALTH GOOD SAMARITAN HOSP CA 501(C)(3) LINE 12A, I PIH HEALTH GOOD SAMARITAN HOSPITAL 1 PIH HEALTH ADULT DAY HEALTHCARE 12401 WASHINGTON BLVD WHITTIER CA 90602 953643829 SUPPORT OF TAX-EXEMPT AFFILIATES CA 501(C)(3) LINE 12B, II PIH HEALTH INC 0 PIH HEALTH FOUNDATION 12401 WASHINGTON BLVD WHITTIER CA 90602 953761274 FUNDRAISING CA 501(C)(3) LINE 7 PIH HEALTH INC 0 PIH HEALTH HOME HEALTHCARE 12401 WASHINGTON BLVD WHITTIER CA 90602 953036281 SUPPORT OF TAX-EXEMPT AFFILIATES CA 501(C)(3) LINE 12B, II PIH HEALTH INC 0 PIH HEALTH DOWNEY HOSPITAL 11500 BROOKSHIRE AVE DOWNEY CA 90241 951903935 HEALTHCARE CA 501(C)(3) LINE 3 PIH HEALTH INC 0 PIH HEALTH WHITTIER HOSPITAL 12401 WASHINGTON BLVD WHITTIER CA 90602 951934652 HEALTHCARE CA 501(C)(3) LINE 3 PIH HEALTH INC 0 PIH HEALTH MANAGEMENT CORP 12401 WASHINGTON BLVD WHITTIER CA 90602 954016278 SUPPORT OF TAX-EXEMPT AFFILIATES CA 501(C)(3) LINE 12B, II PIH HEALTH INC 0 PIH HEALTH PHYSICIANS 6557 GREENLEAF AVE WHITTIER CA 90601 953942828 HEALTHCARE CA 501(C)(3) LINE 10 PIH HEALTH INC 0 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 INSURANCE COMPANY 733 BISHOP STREET STE 1555 HONOLULU HI 96813 263760243 CAPTIVE INSURANCE HI N/A T 0 PIH HEALTH CARE SOLUTIONS 6557 GREENLEAF AVENUE WHITTIER CA 90601 462072342 HEALTHCARE CA N/A C 0 DRMC PROPERTIES INC 12401 WASHINGTON BLVD WHITTIER CA 90602 954769768 REAL ESTATE CA N/A C 0 PIH HEALTH RE 733 BISHOP STREET STE 1555 HONOLULU HI 96813 472501390 CAPTIVE INSURANCE HI N/A T 0 HEALTHMED SERVICES INC 12401 WASHINGTON BLVD WHITTIER CA 90602 300831225 HEALTHCARE CA N/A C 0 PIONEER MEDICAL GROUP INC 12401 WASHINGTON BLVD WHITTIER CA 90602 330927283 MEDICAL SERVICES CA N/A C 0 PIONEER PROVIDER NETWORK A MEDICAL GROUP INC 12401 WASHINGTON BLVD WHITTIER CA 90602 330922631 MANAGEMENT SERVICES CA N/A C 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0