2023-05-12T20:25:51-05:00 2022-06-30 910189318 MOSS ADAMS LLP 101 SECOND STREET SUITE 900 SAN FRANCISCO CA 94105 990 2021-07-01 680371679 PEACH TREE HEALTHCARE PEAC 5307493242 1114 YUBA STREET 220 MARYSVILLE CA 95901 JAMES ELLSWORTH CHIEF FINANCIAL OFFICER 5307493242 2023-05-12 1 JAMES ELLSWORTH 999009999 MICHAEL LUMSDEN P01262236 4159561500 2023-05-12 3 AAL1 IAL1 2021 2023-04-26 12:10:37Z GREG STONE 1114 YUBA STREET 220 MARYSVILLE CA 95901 33052045 0 X WWW.PICKPEACH.ORG X 1995 CA PEACH TREE HEALTH IS COMMITTED TO PROVIDING PERSONALIZED, AFFORDABLE, HIGH-QUALITY HEALTH SERVICES. 10 10 212 10 0 0 5294153 8349342 27312858 24672280 -30700 5048 60900 25375 32637211 33052045 0 0 0 0 13504691 15110495 0 0 0 13903565 13632765 27408256 28743260 5228955 4308785 15991070 20403638 2638623 2742406 13352447 17661232 X PEACH TREE HEALTHCARE IS COMMITTED TO PROVIDING PERSONALIZED, AFFORDABLE, HIGH-QUALITY HEALTH SERVICES. 0 0 20062316 0 24672280 PEACH TREE HEALTHCARE IS A FEDERALLY QUALIFIED HEALTH CENTER (FQHC) OPERATING AT THE FOLLOWING LOCATIONS: THARP ROAD DENTAL CLINIC, LIVE OAK MEDICAL CLINIC (INCLUDING PEACH TREE VISION LIVE OAK AND PEACH TREE CHIROPRACTIC), PEACH TREE YUBA CITY/COLUSA, PEACH TREE CLINIC (INCLUDING PEACH TREE VISION LINDA), PEACH TREE OROVILLE EYE CENTER, PEACH TREE NORTH SACRAMENTO (INCLUDING PEACH TREE VISION NORTH SACRAMENTO AND SACRAMENTO IMMEDIATE CARE), AND PEACH TREE CHICO EYE CENTER. PEACH TREE HEALTHCARE PROVIDES PERSONALIZED, AFFORDABLE, HIGH-QUALITY HEALTH SERVICES INCLUDING DENTAL, VISION, BEHAVIORAL HEALTH, AND MEDICAL SPECIALTY SERVICES (FAMILY MEDICINE, PEDIATRICS, IMMEDIATE CARE, WOMEN'S HEALTH, ACUPUNCTURE, DIABETES, SPORTS PHYSICALS, NON-SURGERY ORTHOPEDICS, PHARMACY, AND PODIATRY). DURING THE JUNE 30, 2022 TAX YEAR, 94,443 PATIENTS RECEIVED SERVICES AT OUR VARIOUS CLINICS. 20062316 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 49 0 1 212 1 0 0 0 0 0 0 0 0 0 0 0 0 X 10 10 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 CA X JAMES ELLSWORTH 5307493242 1114 YUBA STREET SUITE 220 MARYSVILLE CA 95901 TEJINDER GHUMAN MD PEDIATRICIAN 40.00 X 306390 0 22059 MARY PENA-PRIDMORE MD PHYSICIAN 40.00 X 279327 0 20295 SUMIT JOHL MD PEDIATRICIAN 40.00 X 275175 0 21471 RAMESH PUNDI MD PHYSICIAN 40.00 X 253773 0 30588 AMANDA TAGLE MD PHYSICIAN 40.00 X 228981 0 24832 GREG STONE CHIEF EXECUTIVE OFFICER 40.00 X 222633 0 20628 RUPAUL GHUMAN DDS DENTAL DIRECTOR 40.00 X 197031 0 27002 JAMES ELLSWORTH CHIEF FINANCIAL OFFICER 40.00 X 202296 0 3820 RICHARD FURY MD CHIEF MEDICAL OFFICER 40.00 X 201645 0 4033 MICHELLE WOODARD CHIEF ADMINISTRATIVE OFFICER 40.00 X 168610 0 4300 ANDY POTTER CHAIR THRU 9/2021 / VICE CHAIR START 9/2021 1.00 X X 0 0 0 DAWN TREHARNE-ESPARZA VICE CHAIR THRU 9/2021 / CHAIR START 9/2021 1.00 X X 0 0 0 KIRAN SIBIA SECRETARY/TREASURER 1.00 X X 0 0 0 AWNI ALLABABIDI DIRECTOR 1.00 X 0 0 0 DON BLASER DIRECTOR 1.00 X 0 0 0 NAILAH KOKAYI DIRECTOR 1.00 X 0 0 0 ATIEN KOUASSI DIRECTOR 1.00 X 0 0 0 PHUONG LUU MD DIRECTOR 1.00 X 0 0 0 ERICKA SUMMERS DIRECTOR 1.00 X 0 0 0 MATT WILLIAMS DIRECTOR 1.00 X 0 0 0 2335861 0 179028 34 0 1 0 RIDGE EYE CARE 1700 BRUCE RD CHICO CA 95928 CONTRACTED OPTOMETRY SERVICES 2053620 MACMAN MANAGEMENT HEALTHCARE SERVICES 1930 DEL PASO RD 120 SACRAMENTO CA 95834 CONTRACTED BILLING SERVICES 1073887 TRINITY BUILT 3601 BUENA VISTA DR SHINGLE SPRINGS CA 95682 CONTRACTED CONSTUCTION SERVICES 471399 OSIS PO BOX 772852 CHICAGO IL 606772852 CONTRACTED IT SERVICES 469683 GROUP ONE CONSULTING INC 13405 FOLSOM BLVD STE 511 FOLSOM CA 95630 CONTRACTED IT SERVICES 412769 6 8234484 114858 941413 8349342 NET PATIENT SERVICE REVENUE 621400 24374461 24374461 OTHER OPERATING REVENUE 621400 297819 297819 24672280 5048 5048 25375 0 25375 25375 25375 33052045 24672280 0 30423 X 1049348 430914 618434 11087169 7949104 3138065 447923 313308 134615 1758114 1229996 528118 767941 531323 236618 56711 56711 100199 100199 5987513 3557715 2429798 58210 49647 8563 167557 103898 63659 894831 233701 661130 2342430 1995088 347342 73089 62337 10752 21299 18166 3133 52788 35268 17520 783271 644165 139106 243277 67403 175874 MEDICAL SUPPLIES/DRUGS 2774733 2774733 LICENSES AND TAXES 41326 35247 6079 35531 30303 5228 28743260 20062316 8680944 0 411257 408521 4506800 8251994 17000 27000 2621039 2601752 187895 285594 458062 480084 10055063 6993536 3081186 3061527 4707831 5287166 15991070 20403638 2143218 2309314 118118 140260 71710 0 305577 292832 2638623 2742406 X 13352447 17661232 13352447 17661232 15991070 20403638 4308785 0 X 0 1 X 1 1 1 X 2192986 2271944 5090103 5294153 8349342 23198528 2192986 2271944 5090103 5294153 8349342 23198528 23198528 55873 60122 60039 64869 30423 271326 23469854 116228835 0.98840 0.93400 X SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: MISCELLANEOUS INCOME - RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 0 PART II-B, LINE 1: DURING THE JUNE 30, 2022 TAX YEAR, THE ORGANIZATION INCURRED INDIRECT LOBBYING EXPENDITURES THROUGH DUES PAID TO OUTSIDE ORGANIZATIONS, INCLUDING THE CALIFORNIA PRIMARY CARE ASSOCIATION. THE PORTION OF THESE DUES WHICH WAS UTILIZED FOR LOBBYING ACTIVITIES COULD NOT BE ASCERTAINED, BUT ARE DE MINIMIS IN RELATION TO THE OVERALL ACTIVITIES OF THE ORGANIZATION. 4509321 2566456 1942865 3706264 3315200 391064 1839478 1111880 727598 3061527 DEPOSITS 111097 ESTIMATED THIRD-PARTY SETTLEMENT RECEIVABLE 5176069 5287166 DEFERRED LEASE LIABILITY 292832 292832 X 33052045 0 33052045 0 33052045 28743260 0 28743260 0 28743260 PART X, LINE 2: THE ORGANIZATION IS A NONPROFIT CORPORATION UNDER INTERNAL REVENUE CODE SECTION 501(C)(3) AND HAS BEEN GRANTED TAX-EXEMPT STATUSES BY THE INTERNAL REVENUE SERVICE AND THE CALIFORNIA REVENUE AND TAXATION CODE. AS OF JUNE 30, 2022 AND 2021, THE ORGANIZATION HAD NO UNRECOGNIZED TAX POSITIONS OR UNCERTAIN TAX POSITIONS REQUIRING ACCRUAL. THEREFORE, NO PROVISION FOR INCOME TAXES HAS BEEN PROVIDED IN THE FINANCIAL STATEMENTS. X X 0 0 0 0 0 0 0 0 0 TEJINDER GHUMAN MD PEDIATRICIAN 281371 0 14285 0 10734 0 5700 0 16359 0 328449 0 0 0 MARY PENA-PRIDMORE MD PHYSICIAN 257996 0 12369 0 8962 0 5586 0 14709 0 299622 0 0 0 SUMIT JOHL MD PEDIATRICIAN 259822 0 7365 0 7988 0 5112 0 16359 0 296646 0 0 0 RAMESH PUNDI MD PHYSICIAN 233772 0 495 0 19506 0 4777 0 25811 0 284361 0 0 0 AMANDA TAGLE MD PHYSICIAN 228681 0 300 0 0 0 4580 0 20252 0 253813 0 0 0 GREG STONE CHIEF EXECUTIVE OFFICER 222633 0 0 0 0 0 2029 0 18599 0 243261 0 0 0 RUPAUL GHUMAN DDS DENTAL DIRECTOR 194436 0 2595 0 0 0 3941 0 23061 0 224033 0 0 0 JAMES ELLSWORTH CHIEF FINANCIAL OFFICER 196996 0 5300 0 0 0 1086 0 2734 0 206116 0 0 0 RICHARD FURY MD CHIEF MEDICAL OFFICER 199279 0 525 0 1841 0 4033 0 0 0 205678 0 0 0 MICHELLE WOODARD CHIEF ADMINISTRATIVE OFFICER 135414 0 33196 0 0 0 3390 0 910 0 172910 0 0 0 X 19838 941413 COST OF DONATED PROPERTY 0 0 0 0 PART I, COLUMN (B): THE ORGANIZATION IS REPORTING THE NUMBER OF ITEMS CONTRIBUTED IN SCHEDULE M, PART I, COLUMN (B). FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION CONTRACTED WITH TBN LLC FOR CFO DUTIES WHICH WERE FULFILLED BY JAMES ELLSWORTH UNTIL SEPTEMBER 2021 (AT WHICH POINT, JAMES ELLSWORTH BECAME A FULL-TIME EMPLOYEE OF THE ORGANIZATION). TOTAL COMPENSATION PAID TO TBN LLC IN EXCHANGE FOR THESE SERVICES TOTALED $148,000 DURING THE 2021 CALENDAR YEAR AND $68,000 FOR THE 6/30/2022 FISCAL YEAR (7/1/2021 - 6/30/2022). FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED BY AN OUTSIDE ACCOUNTING FIRM, WHO WORKS IN CONJUNCTION WITH THE PEACH TREE HEALTHCARE ACCOUNTING AND FINANCE DEPARTMENT TO COMPLETE THE FORM 990. UPON REVIEW AND APPROVAL BY THE ORGANIZATION'S CFO, THE FORM 990 IS FILED WITH THE INTERNAL REVENUE SERVICE AND ALSO REVIEWED WITH THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C ALL DIRECTORS, OFFICERS, AND KEY EMPLOYEES RECEIVE A COPY OF THE CONFLICT OF INTEREST POLICY, AND ARE REQUIRED TO ANNUALLY RETURN A CONFLICT OF INTEREST DISCLOSURE STATEMENT TO THE CHIEF EXECUTIVE OFFICER. THE BOARD OF DIRECTORS HAS DELEGATED AUTHORITY TO DETERMINE IF A CONFLICT OF INTEREST EXISTS FOR DIRECTORS, CORPORATE OFFICERS, AND THE CEO, WHO MUST LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE FINANCIAL INTEREST IS DISCUSSED AND VOTED UPON. IN THE CASE OF A CONFLICT OF INTEREST DISCLOSURE MADE BY A MEDICAL STAFF MEMBER, PHYSICIAN, EXECUTIVE STAFF MEMBER, DEPARTMENT DIRECTOR, SUPERVISOR, OR OTHER INDIVIDUAL, THE CHIEF EXECUTIVE OFFICER DETERMINES, BASED ON THE FACTS AND CIRCUMSTANCES DISCLOSED, IF A CONFLICT OF INTEREST EXISTS AND SHALL ALSO REPORT THE RESULTS OF ALL DETERMINATIONS TO THE CHAIRMAN OF THE BOARD. FORM 990, PART VI, SECTION B, LINE 15 ALL COMPENSATION FOR SENIOR MANAGEMENT AND KEY EMPLOYEES IS APPROVED BY THE BOARD OF DIRECTORS. SENIOR MANAGEMENT COMPENSATION IS ESTABLISHED USING HISTORICAL BENCHMARKS FROM PREVIOUS EMPLOYEES, AS WELL AS THE SALARY GUIDE FROM THE CALIFORNIA PRIMARY CARE ASSOCIATION, WHICH IS EXAMINED ANNUALLY TO ENSURE SALARIES AND BENEFITS ARE ON PAR WITH COMPARABLE ORGANIZATIONS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G CONTRACTED MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 3,388,561. MANAGEMENT AND GENERAL EXPENSES 444,245. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,832,806. PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 6,295. MANAGEMENT AND GENERAL EXPENSES 1,633,800. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,640,095. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 162,859. MANAGEMENT AND GENERAL EXPENSES 351,753. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 514,612.