2023-05-16T13:14:09-05:00 2022-06-30 910189318 MOSS ADAMS LLP 101 SECOND STREET SUITE 900 SAN FRANCISCO CA 94105 990 2021-07-01 200752156 INCLINE VILLAGE COMMUNITY HOSPITAL FOUNDATION INCL 7758334100 880 ALDER AVENUE INCLINE VILLAGE NV 89451 KARLI EPSTEIN EXECUTIVE DIRECTOR 7758334100 2023-05-12 1 KARLI EPSTEIN 999009999 TRACY S PAGLIA P00366884 4159561500 2023-05-10 3 AAL1 IAL1 2021 2023-04-26 12:10:37Z KARLI EPSTEIN 880 ALDER AVENUE INCLINE VILLAGE NV 89451 3037369 0 X HTTPS://WWW.TFHD.COM/IVCH/IVCH-FOUNDATION X 2004 NV ASSIST INCLINE VILLAGE COMMUNITY HOSPITAL TO DELIVER QUALITY EMERGENCY & PRIMARY HEALTH CARE SERVICES 11 10 0 11 0 0 1046482 2943119 0 0 0 0 0 45585 1046482 2988704 206586 993659 0 0 0 0 0 0 0 903 11285 207489 1004944 838993 1983760 2081101 4044481 0 0 2081101 4044481 X OUR MISSION IS TO ASSIST THE INCLINE VILLAGE COMMUNITY HOSPITAL IN DELIVERING THE HIGHEST QUALITY EMERGENCY AND PRIMARY HEALTH CARE SERVICES BY PROCURING FINANCIAL RESOURCES, IMPROVING COMMUNITY AWARENESS AND INVOLVING COMMUNITY RESIDENTS AND VISITORS IN DEVELOPING A LONG-TERM VISION FOR COMPREHENSIVE HEALTH CARE IN THE COMMUNITIES OF THE NORTH SHORE OF LAKE TAHOE, INCLUDING KINGS BEACH, CRYSTAL BAY AND INCLINE VILLAGE 0 0 600000 600000 0 RECONSTRUCTION OF THE STERILE PROCESSING DECONTAMINATION ROOM WITH NEW FURNITURE, EQUIPMENT, AND MECHANICAL EQUIPMENT FOR IMPROVED AIRFLOW AND TO MEET CURRENT STERILE PROCESSING REGULATIONS. 161220 161220 0 THE FOUNDATION PROVIDED SUPPORT FOR VARIOUS OTHER EXPENSES TO ASSIST THE INCLINE VILLAGE COMMUNITY HOSPITAL IN DELIVERING OPTIMAL HEALTH CARE SERVICES IN NORTH LAKE TAHOE. 114865 114865 0 THE FOUNDATION PROVIDED SUPPORT FOR THE EDUCATION AND TREATMENT OF BEHAVIORAL HEALTH. 117574 117574 0 TO PROVIDE FUNDING TO UPGRADE EXISTING DIAGNOSTIC IMAGING EQUIPMENT AND START UP NEW MODALITIES SUCH AS ULTRASOUND TO BETTER SERVE THE PATIENTS IN THE COMMUNITY. 117574 117574 0 993659 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 1 0 0 1 0 1 0 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 1 1 0 0 0 0 0 0 X 11 10 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X JAYE CHASSEUR CONTROLLER 5305823489 10121 PINE AVENUE TRUCKEE CA 96160 HARRY WEIS DIRECTOR & TFHD CEO 0.50 39.50 X X 0 704276 62819 JUDY NEWLAND COO, TFHD 0.50 39.50 X 0 523715 62819 CRYSTAL FELIX CFO, TFHD 0.50 39.00 X 0 448739 54256 KARLI EPSTEIN EXECUTIVE DIRECTOR 16.00 24.00 X 0 213276 48088 JAYE CHASSEUR CONTROLLER, TFHD 0.50 39.00 X 0 223957 31958 WARREN KOCMOND PRESIDENT 0.50 0.00 X X 0 0 0 WALTER L BINDER VICE PRESIDENT 0.50 0.00 X X 0 0 0 NAN HEALY SECRETARY 0.50 0.00 X X 0 0 0 KEVIN HANNA TREASURER 0.50 0.00 X X 0 0 0 DEBBIE CASTELLO DIRECTOR 0.50 0.00 X 0 0 0 GARY FINCH DIRECTOR 0.50 0.00 X 0 0 0 SHANE JOHNSON MD DIRECTOR (THRU 01/22) 0.50 0.00 X 0 0 0 ROGER KAHN DIRECTOR (THRU 06/22) 0.50 0.00 X 0 0 0 SUSANNA KINTZ DIRECTOR 0.50 0.00 X 0 0 0 DONALD M MASON MD DIRECTOR (THRU 01/22) 0.50 0.00 X 0 0 0 EARL NEMSER DIRECTOR 0.50 0.00 X 0 0 0 MYLES RINER DIRECTOR 0.50 0.00 X 0 0 0 JONATHAN SMITH OD DIRECTOR (THRU 03/22) 0.50 0.00 X 0 0 0 JULIE TEEL DIRECTOR 0.50 0.00 X 0 0 0 0 2113963 259940 0 0 1 0 0 562754 2380365 2943119 94250 562754 48665 45585 45585 2988704 0 0 45585 993659 993659 11285 11285 1004944 993659 11285 0 1468827 151469 507190 3804008 105084 89004 2081101 4044481 0 0 X 1734202 1980826 346899 2063655 2081101 4044481 2081101 4044481 X 1983760 -20380 X 0 1 X 1 0 X X 1 TAHOE FOREST HOSPITAL DISTRICT 946004062 6 1 993659 0 1 993659 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 105084 4300 -20380 89004 64806 20500 19778 105084 52432 11100 1274 64806 41610 8500 2322 52432 32162 5500 3948 41610 0.00000 0.62090 0.37910 1 0 0 3310024 293035 28285 321320 2988704 0 2988704 1346644 293035 48665 341700 1004944 0 1004944 PART V, LINE 4: THE PURPOSE OF THE ENDOWMENT AND IMPROVEMENT FUNDS IS TO PROVIDE SUPPORT TO OR FOR THE BENEFIT OF THE FOUNDATION AND ITS ACTIVITIES IN PURSUIT OF ITS MISSION TO DELIVER OPTIMAL HEALTH CARE SERVICES IN THE COMMUNITIES SERVED BY INCLINE VILLAGE COMMUNITY HOSPITAL. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST IN TRUST -20,380. SPECIAL EVENT EXPENSES 48,665. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES 48,665. BEACH BOYS CONCERT AND FUNDRAISER 657004 562754 94250 25991 17172 5502 657004 562754 94250 25991 17172 5502 48665 45585 1 TAHOE FOREST HOSPITAL DISTRICT PO BOX 759 TRUCKEE CA 96160 946004062 115(1) 993659 0 TO SUPPORT AND ENHANCE HEALTHCARE IN THE DISTRICT'S SERVICE AREA 1 0 PART I, LINE 2: THE FOUNDATION EXISTS TO SUPPORT AND ENHANCE HEALTHCARE IN THE INCLINE VILLAGE COMMUNITY HOSPITAL'S SERVICE AREA. ACCORDINGLY, THE FOUNDATION'S ASSISTANCE REPRESENTS PAYMENTS DIRECTLY MADE TO THE DISTRICT IN FURTHERANCE OF THESE PURPOSES. THE BOARD OF DIRECTORS FROM THE FOUNDATION AND THE DISTRICT PERFORM MONITORING PROCEDURES TO ENSURE THAT THE ASSISTANCE PROVIDED BY THE FOUNDATION IS USED TO SUPPORT AND ENHANCE HEALTHCARE IN INCLINE VILLAGE COMMUNITY HOSPITAL'S SERVICE AREA. 0 0 0 0 0 0 1 1 0 HARRY WEIS DIRECTOR & TFHD CEO 0 599101 0 85974 0 19201 0 39116 0 23703 0 767095 0 0 JUDY NEWLAND COO, TFHD 0 433185 0 76172 0 14358 0 39116 0 23703 0 586534 0 0 CRYSTAL FELIX CFO, TFHD 0 375299 0 64743 0 8697 0 32616 0 21640 0 502995 0 0 KARLI EPSTEIN EXECUTIVE DIRECTOR 0 171696 0 40108 0 1472 0 17684 0 30404 0 261364 0 0 JAYE CHASSEUR CONTROLLER, TFHD 0 199581 0 22565 0 1811 0 20216 0 11742 0 255915 0 0 PART I, LINE 3 THE FOUNDATION RELIED ON A RELATED ORGANIZATION THAT USED ONE OR MORE OF THE METHODS TO ESTABLISH THE TOP MANAGEMENT OFFICIAL'S COMPENSATION. PART I, LINE 6 CURRENT EMPLOYEES OF THE RELATED ORGANIZATION, TAHOE FOREST HOSPITAL DISTRICT (DISTRICT) WHO MEET THE PLAN CRITERIA ARE ELIGIBLE TO PARTICIPATE IN A GAIN SHARING PROGRAM. CERTAIN PROGRAM METRICS MUST BE ACHIEVED IN ORDER FOR THE GAIN SHARING POOL TO BE ACTIVE FOR THE FISCAL YEAR. THE POOL OF GAIN SHARING FUNDS IS CALCULATED AS A PERCENTAGE OF AUDITED NET INCOME OF THE DISTRICT, TIERED FOR DIFFERENT LEVELS OF NET INCOME OF THE DISTRICT OVERALL. ELIGIBLE EMPLOYEES, WHICH MAY INCLUDE OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES OF THE DISTRICT THAT ALSO SERVE THE FOUNDATION THAT ARE EMPLOYED BY THE DISTRICT RECEIVE A PRO-RATA SHARE OF THE GAIN SHARING POOL BY ALLOCATING THE EMPLOYEE'S SALARY AGAINST THE TOTAL SALARY OF ALL ELIGIBLE EMPLOYEES. THE FOUNDATION DOES NOT INCUR ANY EXPENSES UNDER THIS PLAN. PART I, LINE 7 CERTAIN KEY PERSONNEL OF THE RELATED ORGANIZATION, TAHOE FOREST HOSPITAL DISTRICT (DISTRICT) THAT SERVE THE FOUNDATION ARE ELIGIBLE FOR THE INCENTIVE COMPENSATION PLAN WHICH AWARDS A PERCENTAGE OF BASE COMPENSATION FOR THE FISCAL YEAR. ELIGIBLE EMPLOYEES OF THE DISTRICT INCLUDE OFFICERS, KEY PERSONNEL, AND OTHER EMPLOYEES AT THE DISCRETION OF THE CEO THAT MAY ALSO SERVE THE FOUNDATION. FOR THE INCENTIVE COMPENSATION TO BE AWARDED, CERTAIN FINANCIAL TARGETS AND ACHIEVEMENT OF ANNUAL GOALS AND STRATEGIC OBJECTIVES MUST BE MET. THE CEO MAY USE DISCRETION OVER THE INCENTIVE COMPENSATION AWARDED, BUT ALL PAYOUTS UNDER THE PLAN ARE DETERMINED AFTER ACCEPTANCE OF THE DISTRICT'S AUDITED FINANCIAL STATEMENT BY THE BOARD OF DIRECTORS. THE FOUNDATION DOES NOT INCUR ANY EXPENSES UNDER THIS PLAN. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE FOUNDATION IS TAHOE FOREST HOSPITAL DISTRICT. FORM 990, PART VI, SECTION A, LINE 7A THE FOUNDATION'S BOARD OF DIRECTORS ARE ELECTED BY THE SOLE MEMBER, TAHOE FOREST HOSPITAL DISTRICT. FORM 990, PART VI, SECTION A, LINE 7B AMENDMENTS TO THE BYLAWS AND CHANGES TO THE NUMBER OF DIRECTORS MUST BE APPROVED BY THE SOLE MEMBER, TAHOE FOREST HOSPITAL DISTRICT. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED BY THE EXECUTIVE DIRECTOR. THE EXECUTIVE DIRECTOR ALSO REVIEWS THE FORM 990 WITH THE CHAIRMAN OR TREASURER OF THE BOARD AND THE FOUNDATION'S ACCOUNTANT IN PERSON, VIA EMAIL, OR THROUGH A BOARD MEETING. A COPY OF FORM 990 IS DISTRIBUTED TO THE REMAINDER OF THE BOARD VIA EMAIL OR THROUGH A BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C THE FOUNDATION'S CONFLICT OF INTEREST POLICY APPLIES TO ALL PERSONS HOLDING POSITIONS OF RESPONSIBILITY AND TRUST ON BEHALF OF INCLINE VILLAGE COMMUNITY HOSPITAL FOUNDATION, INCLUDING, BUT NOT LIMITED TO MEMBERS OF THE BOARD OF DIRECTORS, VOLUNTEER COMMITTEE MEMBERS, AND TAHOE FOREST HOSPITAL DISTRICT STAFF (BOARD/STAFF/VOLUNTEERS). COVERED PERSONS ARE REQUIRED TO ANNUALLY COMPLETE A DISCLOSURE STATEMENT FOR POTENTIAL RELATIONSHIPS AS WELL AS DISCLOSING ANY INTEREST THAT MAY IMPACT THE DECISION-MAKING PROCESS WHENEVER THERE IS ANY DOUBT ABOUT WHETHER DISCLOSURE IS REQUIRED. IF A COVERED PERSON HAS AN INTEREST IN A PROPOSED TRANSACTION WITH THE FOUNDATION, HE OR SHE MUST MAKE FULL DISCLOSURE OF SUCH INTEREST BEFORE ANY DISCUSSION OR NEGOTIATION OF THE TRANSACTION AND ABSTAIN FROM DECISION-TAKING ACTIONS. IF A CONFLICT, OR THE POTENTIAL APPEARANCE OF A CONFLICT, EXISTS, THE BOARD MEMBER MUST RECUSE THEMSELVES BY NOT INFLUENCING, ATTEMPTING TO INFLUENCE, OR PARTICIPATING IN THAT DISCUSSION AND/OR VOTE MADE BY REMAINING MEMBERS THAT DO NOT HAVE AN INTEREST. FORM 990, PART VI, SECTION C, LINE 19 ANY INTERESTED PARTIES WHO DESIRE TO OBTAIN A COPY OF ANY OF THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS CAN CONTACT THE OFFICE AND REQUEST A PAPER COPY. ANY DOCUMENTS REQUESTED ARE PRINTED AND HANDED TO THE INTERESTED PARTY AT THE OFFICE. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN TRUST -20,380. TAHOE FOREST HOSPITAL DISTRICT PO BOX 759 TRUCKEE CA 96160 946004062 HEALTHCARE CA N/A 0 TAHOE FOREST HEALTH SYSTEM FOUNDATION PO BOX 2508 TRUCKEE CA 96160 943047869 HEALTHCARE CA 501(C)(3) LINE 12A, I TAHOE FOREST HOSPITAL DISTRICT 0 TAHOE INSTITUTE FOR RURAL HEALTH RESEARCH PO BOX 759 TRUCKEE CA 96160 352372175 IMPROVE AFFORDABILITY OF HIGH QUALITY HEALTHCARE CA 501(C)(3) LINE 12A, I TAHOE FOREST HOSPITAL DISTRICT 0 THE TRUCKEE SURGERY CENTER LLC 10770 DONNER PASS ROAD SUITE 201 TRUCKEE CA 96161 273943102 AMBULATORY SURGERY CENTER CA N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 TAHOE FOREST HOSPITAL DISTRICT B 993659 FMV TAHOE FOREST HOSPITAL DISTRICT O 131736 FMV TAHOE FOREST HOSPITAL DISTRICT Q 1006659 FMV