2024-08-07T21:31:33-05:00 2023-09-30 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2022-10-01 391412320 CAPITOL LAKES INC CAPI 8887246424 333 WEST MAIN STREET MADISON WI 53703 TIM CONROY EXECUTIVE DIRECTOR 8887246424 2024-08-06 1 1 KURT BENNION P01469618 4252506100 2024-07-26 2022 2024-08-08 14:25:15Z SUE CENTER 1 WEST MAIN SUITE 303 MEDFORD OR 97501 24215924 0 X WWW.RETIREMENT.ORG X 1990 WI TO PROVIDE CARE AND HOUSING FOR THE ELDERLY. 6 6 439 75 0 0 2392786 325088 21524631 21328284 58041 19804 9914307 129515 33889765 21802691 0 0 0 0 12365530 11406330 0 0 0 12619062 13102317 24984592 24508647 8905173 -2705956 43546740 41854865 93765208 94705164 -50218468 -52850299 CAPITOL LAKES IS A PREMIER CONTINUING CARE RETIREMENT COMMUNITY DEDICATED TO ENRICHING LIVES. 0 0 19477170 0 21328284 CAPITOL LAKES IS A CONTINUING CARE RETIREMENT COMMUNITY, DEDICATED TO ENHANCING OUR RESIDENTS' QUALITY OF LIFE IN A STIMULATING, SECURE ENVIRONMENT. WE PROVIDE HIGH-QUALITY SERVICES INCLUDING HOUSING, NUTRITIOUS MEALS, NURSING, HOUSEKEEPING, MAINTENANCE, AND OTHER SUPPORT TO THOSE WE SERVE. OUR LEVELS OF SERVICE INCLUDE INDEPENDENT LIVING, ASSISTED LIVING, AND SKILLED NURSING. 19477170 1 1 0 1 0 0 0 0 1 0 1 0 0 0 1 1 0 1 0 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 0 0 1 1 1 0 0 1 46 0 1 439 1 0 0 0 0 0 0 0 0 0 0 0 0 X 6 6 0 1 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X KATRINA BYWATER 5416463300 1 WEST MAIN SUITE 303 MEDFORD OR 97501 X X TIM CONROY EXECUTIVE DIRECTOR 39.00 1.00 X 279824 0 50975 KRISTIN VATER HEALTH CENTER ADMINISTRATOR 39.00 1.00 X 154741 0 25915 STEVEN MELLSTROM HUMAN RESOURCES DIRECTOR 40.00 0.00 X 133988 0 20309 TSERING DAMDUL REGISTERED NURSE 40.00 0.00 X 122152 0 20309 HOLLY JOHNSON SALES DIRECTOR 40.00 0.00 X 117588 0 20309 DAYLE TESSNER DIRECTOR OF NURSING 40.00 0.00 X 123243 0 6370 SUE CENTER CHAIR 1.00 1.00 X X 0 0 0 CLAY NORRBOM VICE CHAIR 1.00 0.00 X X 0 0 0 SALLY DREW SECRETARY/TREASURER 1.00 0.00 X X 0 0 0 MARTY FOX RESIDENT DIRECTOR 1.00 0.00 X 0 0 0 STEVE JOHANNSEN DIRECTOR 1.00 0.00 X 0 0 0 HARRY PETERSON DIRECTOR 1.00 0.00 X 0 0 0 931536 0 144187 6 0 1 0 PACIFIC RETIREMENT SERVICES INC 1 WEST MAIN SUITE 303 MEDFORD OR 97502 MANAGEMENT SERVICES 430314 ORRICK HERRINGTON & SUTCLIFFE PO BOX 848066 LOS ANGELES CA 90084 LEGAL SERVICES 270537 COMPLETE CONTROL 640 25TH AVE WISCONSIN RAPIDS WI 54495 MAINTENANCE SERVICES 154337 3 109028 216060 325088 SERVICE FEES 623000 12708451 12708451 HEALTH CENTER 623000 6100719 6100719 ENTRANCE FEES 623000 1661771 1661771 ALL OTHER 623000 342250 342250 DIETARY 623000 240579 240579 274514 274514 21328284 133013 133013 24 24 17673 0 17673 17673 17673 2300000 2383656 29577 -83656 -29577 -113233 -113233 MANAGEMENT FEES 561000 111842 111842 111842 21802691 21328284 0 149319 303915 303915 8843643 7815808 1027835 394205 327963 66242 1184340 1023685 160655 680227 590471 89756 1625140 1625140 73891 73891 29138 29138 7241 7241 1123307 642765 480542 391597 391597 697650 585635 112015 251088 251088 1569463 1568291 1172 94158 21034 73124 44079 25908 18171 1811586 1811586 2402106 2402106 212295 212295 HEALTH CENTER EXPENSE 1169240 1169240 OTHER DIETARY EXPENSE 989302 989302 OTHER FACILITY SERVICE 406338 86383 319955 PROGRAM FUND EXPENSES 204698 204698 24508647 19477170 5031477 0 5566464 2765632 608196 1198309 862169 1453323 115297 81619 542172 345433 71745128 42667177 30735674 29077951 4362204 6256303 754564 676295 43546740 41854865 2751256 2721341 10074113 10503612 32945386 32987100 625075 733678 47369378 47759433 93765208 94705164 X -51008170 -53573094 789702 722795 -50218468 -52850299 43546740 41854865 X -2705956 152394 -78269 X X 0 1 X 1 0 X 207383 258965 234440 2392786 325088 3418662 22577973 21500974 21732097 21524631 21328284 108663959 22785356 21759939 21966537 23917417 21653372 112082621 0 0 0 112082621 97996 73154 72645 110174 150710 504679 97996 73154 72645 110174 150710 504679 9897149 111842 10008991 22883352 21833093 22039182 33924740 21915924 122596291 0.91420 0.91600 0.00410 0.00340 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: GAIN ON REFINANCING MANAGEMENT FEES RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 24508647 24508647 1000000 250000 0 0 1000000 1000000 1000000 1000000 4000000 6000000 250000 250000 250000 250000 1000000 1500000 0 1 X 8537600 8537600 58315813 39322624 18993189 4336061 3344553 991508 555654 555654 29077951 DUE TO AFFILIATES 3921251 OTHER CURRENT LIABILITIES 9319 ENTRANCE FEES REFUNDABLE UPON REOCCUPANCY 43828863 47759433 X PART IV, LINE 2B: RESIDENT SECURITY DEPOSITS ARE HELD IN A SEPARATE BANK ACCOUNT. WHEN THE RESIDENT LEAVES THE FACILITY THE SECURITY DEPOSIT, MINUS ANY AMOUNTS RETAINED FOR REPAIRS, IS REFUNDED. PART X, LINE 2: THE CORPORATION RECOGNIZES THE TAX BENEFIT FROM UNCERTAIN TAX POSITIONS ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITIONS WILL BE SUSTAINED ON EXAMINATION BY THE TAX AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE TAX BENEFIT IS MEASURED BASED ON THE LARGEST BENEFIT THAT HAS A GREATER THAN 50% LIKELIHOOD OF BEING REALIZED UPON ULTIMATE SETTLEMENT. THE CORPORATION RECOGNIZES INTEREST AND PENALTIES RELATED TO INCOME TAX MATTERS IN OPERATING EXPENSES. AT SEPTEMBER 30, 2023 AND 2022, THERE WERE NO SUCH UNCERTAIN TAX POSITIONS. 0 0 0 0 0 0 0 1 0 TIM CONROY EXECUTIVE DIRECTOR 249337 0 30487 0 0 0 20500 0 30475 0 330799 0 0 0 KRISTIN VATER HEALTH CENTER ADMINISTRATOR 143830 0 10911 0 0 0 15657 0 10258 0 180656 0 0 0 STEVEN MELLSTROM HUMAN RESOURCES DIRECTOR 128913 0 5075 0 0 0 0 0 20309 0 154297 0 0 0 PART I, LINE 3 COMPENSATION WAS RECOMMENDED BY PACIFIC RETIREMENT SERVICES, INC. AND APPROVED BY CAPITOL LAKES' BOARD AS PART OF THE ANNUAL BUDGET PROCESS. PART I, LINE 7 THE ORGANIZATION PAID BONUSES THIS YEAR. THE PROCESS FOR DETERMINING EXECUTIVE BONUSES IS DISCRETIONARY. IT IS DETERMINED BY THE VP OF OPERATIONS FOR PRS AND IT IS BASED ON THE PERFORMANCE OF THE COMMUNITY FOR THE YEAR. A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97712JFS7 2022-05-26 33880000 SEE PART VI 0 0 0 A 33880000 659600 33220400 1 0 0 1 A 0 1 1 1 0 0.02300 0.00000 0.02300 0 0 1 A 0 1 1 0 1 0 0 0 1 A 1 PART I, COLUMN F: BOND PROCEEDS WERE ISSUED TO REFUND A PRIOR LOAN ISSUED ON NOVEMBER 30, 2016. PART II, LINE 13: BECAUSE THE BONDS WERE ISSUED FOR A CURRENT REFUNDING PURPOSE, A SUBSTANTIAL COMPLETION DATE IS NOT APPLICABLE. PART III, LINE 7: AS PROVIDED IN TREASURY REGULATION SECTION 1.141-4(C)(2)(I)(B), THE AMOUNT OF PRIVATE PAYMENTS TAKEN INTO ACCOUNT UNDER THE PRIVATE SECURITY OR PAYMENT TEST MAY NOT EXCEED THE AMOUNT OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS USE. ACCORDINGLY, THE AMOUNT OF PRIVATE PAYMENTS FOR THE REPORTING PERIOD DOES NOT EXCEED THE AMOUNT STATED IN PART III, LINE 6. THE ORGANIZATION HAS NOT UNDERTAKEN AN ANALYSIS OF THE PRIVATE SECURITY OR PAYMENT TEST WITH RESPECT TO THE BONDS, AS THE LEVEL OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS USE REPORTED IN PART III, LINE 6 IS NOT IN EXCESS OF AMOUNTS PERMITTED UNDER SECTION 145 OF THE CODE. FORM 990, PART VI, SECTION A, LINE 3 CAPITOL LAKES' BOARD DELEGATES MANAGEMENT DUTIES TO PACIFIC RETIREMENT SERVICES, INC. FORM 990, PART VI, SECTION A, LINE 4 THE BYLAWS WERE AMENDED IN JANUARY 2023 TO STANDARDIZE THEM, CONSISTENT WITH OTHER SUBSIDIARIES OF PACIFIC RETIREMENT SERVICES, THE SOLE MEMBER. THESE AMENDMENTS INCLUDED UPDATING THE SOLE MEMBER'S EXCLUSIVE POWERS AND THOSE ACTIONS THAT REQUIRE THE SOLE MEMBER'S APPROVAL. ADDITIONALLY, (A) THE MINIMUM NUMBER OF DIRECTORS WAS CHANGED FROM 7 TO 3, (B) THE MAXIMUM NUMBER OF DIRECTORS WAS REMOVED, (C) THE NUMBER OF RESIDENT DIRECTORS WAS CHANGED FROM 2 TO 1, AND (D) THE CFO REPLACED THE TREASURER AS AN OFFICER OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS ONE MEMBER, PACIFIC RETIREMENT SERVICES, INC. FORM 990, PART VI, SECTION A, LINE 7A PACIFIC RETIREMENT SERVICES, INC. HAS THE RIGHT TO ELECT THE DIRECTORS OF THE BOARD OF CAPITOL LAKES, INC. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING ACTIONS ARE RESERVED TO PACIFIC RETIREMENT SERVICES, INC., THE SOLE MEMBER: (A) AMEND, RESTATE OR REPEAL THE BYLAWS, OR ADOPT NEW BYLAWS; (B) COORDINATE THE ACTIVITIES OF THE ORGANIZATION, AND ENGAGE IN THE OVERALL PLANNING, POLICY DEVELOPMENT, BUDGETING, AND RESOURCE ALLOCATION FOR THE ORGANIZATION; (C) APPOINT OUTSIDE AUDITORS FOR THE ORGANIZATION; (D) ELECT OR APPOINT THE ORGANIZATION'S DIRECTORS, INCLUDING THE RESIDENT DIRECTOR AND THE PRS REPRESENTATIVE DIRECTOR, AND FILL VACANCIES CAUSED BY THE DEATH, REMOVAL OR RESIGNATION OF A DIRECTOR; AND (E) REMOVE ANY OF THE ORGANIZATION'S DIRECTORS OR OFFICERS. THE PRIOR APPROVAL OF THE MEMBER IS REQUIRED BEFORE THE BOARD OF DIRECTORS MAY (A) APPROVE ANY MERGER OR CONSOLIDATION OF THE ORGANIZATION WITH ANOTHER ENTITY, OR ANY PARTIAL OR TOTAL LIQUIDATION OF THE ORGANIZATION'S ASSETS; (B) INCUR ANY DEBT, OR ENTER INTO ANY CONTRACT, NOT CONTEMPLATED BY THE ANNUAL BUDGET IF THE DOLLAR AMOUNT EXCEEDS THE SUM OF $100,000; (C) MAKE ANY GIFT OR GRATUITOUS TRANSFER IN EXCESS OF $15,000 IN ANY CALENDAR YEAR; (D) CREATE A TAXABLE OR TAX-EXEMPT SUBSIDIARY OR AFFILIATED ORGANIZATION; (E) ACQUIRE A CONTROLLING INTEREST IN ANOTHER ENTITY; OR (F) APPROVE ANY AMENDMENT, REPEAL, OR RESTATE OF THE ORGANIZATION'S ARTICLES OF INCORPORATION, OR ADOPT ANY NEW ARTICLES OF INCORPORATION. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS REVIEWED BY THE CORPORATE DIRECTOR OF ACCOUNTING, VICE PRESIDENT OF ACCOUNTING, CFO, AND THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY AND QUESTIONNAIRE ARE SENT TO ALL BOARD MEMBERS AND KEY EMPLOYEES ANNUALLY. THERE ARE TWO POLICIES RELATED TO CONFLICTS OF INTEREST: 1) BOARD OF DIRECTORS; 2)KEY EMPLOYEES, WHICH IDENTIFY THE PURPOSE, DEFINITIONS, AND PROCEDURES. IF A CONFLICT IS SELF-IDENTIFIED BY A BOARD MEMBER OR KEY EMPLOYEE IN THE QUESTIONNAIRE AND/OR MEETING, PROCEDURES ARE FOLLOWED AND DOCUMENTED ACCORDING TO THE POLICY. FORM 990, PART VI, SECTION B, LINE 15A A COMPENSATION COMMITTEE OF THE PRS BOARD EXISTS TO DETERMINE COMPENSATION FOR THE EXECUTIVE DIRECTOR OF EACH COMMUNITY. THIS COMMITTEE IS COMPRISED OF THE OFFICERS OF THE PRS BOARD OF DIRECTORS. THE COMMITTEE HAS A CHARTER THAT OUTLINES ITS DUTIES AND RESPONSIBILITIES. IT ALSO HAS AGENDA ELEMENTS THAT DESCRIBE THE ACTIVITIES THAT THE COMMITTEE UNDERTAKES DURING THE YEAR. THE VP OF HUMAN RESOURCES PROVIDED SALARY STUDIES FROM THE FOLLOWING RESOURCES TO THE COMMITTEE RELATIVE TO EXECUTIVE DIRECTOR COMPENSATION: SALARY.COM, PAYSCALE.COM, 990 REVIEW (LIKE SIZE ORGANIZATIONS), CEMO (CHIEF EXECUTIVE OFFICERS OF MULTI-FACILITY ORGANIZATIONS) SALARY STUDY RESULTS, AND INDUSTRY STATE ASSOCIATION SALARY STUDY RESULTS BASED ON GEOGRAPHICAL LOCATION. THE RECOMMENDATION FOR BASE COMPENSATION AND BONUS ARE PROVIDED BY THE EXECUTIVE DIRECTOR'S DIRECT SUPERVISOR (COO OR VP OF OPERATIONS). FORM 990, PART VI, SECTION C, LINE 19 CORPORATE FINANCIAL DATA AND GOVERNANCE INFORMATION IS NOT PUBLIC INFORMATION, AND AS SUCH, IS RELEASED ONLY PURSUANT TO LEGAL REGULATION, COURT ORDER, OR OTHER APPLICABLE LAW, AND AS DIRECTED BY CORPORATE COUNSEL. FORM 990, PART VII, SECTION A: NOTE THAT TIM CONROY AND KRISTIN VATER ARE LEASED EMPLOYEES OF PACIFIC RETIREMENT SERVICES, INC. AND PERFORM SERVICES ON BEHALF OF CAPITOL LAKES, INC. PURSUANT TO A MANAGEMENT SERVICES AGREEMENT BETWEEN CAPITOL LAKES, INC. AND PACIFIC RETIREMENT SERVICES, INC. UNDER THE MANAGEMENT SERVICES AGREEMENT, THEIR COMPENSATION IS REIMBURSED BY CAPITOL LAKES, INC. COMPENSATION HAS BEEN REPORTED IN PART VII, SECTION A IN ORDER TO HIGHLIGHT AMOUNTS PAID BY CAPITOL LAKES, INC., NOTWITHSTANDING THAT THEY ARE LEASED EMPLOYEES OF PACIFIC RETIREMENT SERVICES, INC. FORM 990, PART XI, LINE 9: CHANGES IN INTEREST IN NET ASSETS OF FOUNDATION -78,269. FORM 990, PART XII, LINE 2C: THE PROCESS AND AUTHORITY FOR SELECTING THE FINANCIAL STATEMENT AUDITOR AND FOR OVERSEEING THE FINANCIAL STATEMENT AUDIT DID NOT CHANGE DURING THE FISCAL YEAR. PACIFIC RETIREMENT SERVICES INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 931067253 SUPPORTING ORGANIZATION OR 501(C)(3) LINE 12C, III-FI N/A 0 PACIFIC RETIREMENT SERVICES FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 472352652 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 PACIFIC RETIREMENT SERVICES INC 0 ROGUE VALLEY MANOR 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930453216 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 THE CUMBERLAND REST INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 750891470 SENIOR HOUSING TX 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 CASCADE MANOR INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930557803 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 UNIVERSITY RETIREMENT COMMUNITY AT DAVIS 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 931179254 SENIOR HOUSING CA 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 HOLLADAY PARK PLAZA 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930513697 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 ROGUE VALLEY MANOR FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930712867 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 ROGUE VALLEY MANOR 0 UNIVERSITY RETIREMENT COMMUNITY FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 931301816 PUBLIC FOUNDATION CA 501(C)(3) LINE 7 UNIVERSITY RETIREMENT COMMUNITY AT DAVIS 0 MIRABELLA WASHINGTON FOUNDATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 450574348 PUBLIC FOUNDATION WA 501(C)(3) LINE 7 MIRABELLA 0 CASCADE MANOR FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 931330100 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 CASCADE MANOR INC 0 CAPITOL LAKES FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 383781089 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 CAPITOL LAKES INC 1 MIRABELLA 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 342030255 SENIOR HOUSING WA 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 MIRABELLA PORTLAND FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 452508860 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 MIRABELLA AT SOUTH WATERFRONT 0 MIRABELLA AT SOUTH WATERFRONT 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 711016384 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 COMMUNITY VOLUNTEER NETWORK 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930892261 COMMUNITY SERVICES OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 RVM HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930864466 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 RVM ASHLAND HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930942933 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 RVM GRANTS PASS HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 943136037 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 RVM ROSEBURG HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 943179782 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 0 RVM MYRTLE 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