2023-09-19T14:08:22-05:00 2022-12-31 911623649 JOHNSON STONE & PAGANO PS 1501 REGENTS BLVD SUITE 100 FIRCREST WA 98466 990 2022-01-01 943080307 ASHLEY HOUSE ASHL 2535339050 33811 9TH AVE S FEDERAL WAY WA 98003 STEPHEN L FREEBORN PRESIDENT 2535339050 2023-09-15 1 STEPHEN FREEBORN XXX-XX-XXXX 1 CORA P THORDARSON P01332199 2535667070 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z STEPHEN L FREEBORN 33811 9TH AVE S FEDERAL WAY WA 98003 15786944 0 X WWW.AH-NW.ORG X 1989 WA ASHLEY HOUSE PROVIDES COMPREHENSIVE, COST EFFECTIVE, QUALITY CARE TO MEDICALLY FRAGILE CHILDREN AND YOUNG ADULTS IN A HOME-LIKE SETTING. 6 6 189 0 0 0 224805 2720583 9631259 10462365 318104 764767 11276 28736 10185444 13976451 135218 201613 0 0 8144060 9288028 0 0 643420 1787216 2115072 10066494 11604713 118950 2371738 16832773 20132456 7555612 9001572 9277161 11130884 WE ARE DEDICATED TO PROVIDING EDUCATION TO FAMILIES AND CAREGIVERS, BUILDING SUPPORT SYSTEMS, COORDINATING SERVICES AND NURTURING THE DEVELOPMENT OF EACH INDIVIDUAL. 0 0 7134387 201613 8756408 ASHLEY HOUSE PROVIDED TRANSITIONAL NURSING CARE SERVICES, HOSPICE SERVICES, CASE MANAGEMENT AND SOCIAL SERVICES TO 38 MEDICALLY FRAGILE CHILDREN IN 2022. ASHLEY HOUSE PROVIDES THESE SERVICES IN SIX GROUP HOMES, IN FAMILY-LIKE SETTINGS. THE HOMES ARE STAFFED 24 HOURS A DAY WITH NURSES AND CNA'S. ADDITIONAL STAFF ARE UTILIZED TO TAKE CHILDREN TO MEDICAL APPOINTMENTS, AND ON OUTINGS. OUR SPECIFIC OBJECTIVE IS TO ENABLE CHILDREN TO BE RETURNED TO THEIR OWN HOME, OR TO SEEK ADOPTION OR FOSTER CARE. HENCE, WE ARE A SETTING FOR TRANSITIONAL CARE UNTIL PERMANENCY IS OBTAINED. 2175082 1734693 ASHLEY HOUSE YOUNG ADULT RESIDENTIAL GROUP HOME ACCEPTS UP TO 6 YOUNG ADULTS (18-30 YEARS OLD) WITH MEDICAL COMPLEXITY TO LIVE IN A HOME-LIKE SETTING (SHORT OR LONG TERM). THESE MEDICALLY FRAGILE YOUNG ADULTS ARE OFTEN INDIVIDUALS WITH COMPLICATED MEDICAL HISTORIES, SUCH AS ORGAN TRANSPLANTATION, VENTILATOR DEPENDENCY OR TRAUMATIC BRAIN INJURY AND EXPERIENCE LENGTHY HOSPITALIZATIONS, NEED SPECIALIZED CAREGIVER TRAINING, AND HAVE EQUIPMENT OR NURSING NEEDS THAT MAY EXCEED WHAT CAN BE PROVIDED IN THEIR FAMILY HOMES. 9309469 1 1 0 1 0 0 0 0 0 0 1 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 1 0 0 0 0 0 0 0 0 1 18 0 1 189 1 0 0 0 0 0 0 0 0 0 0 0 0 X 6 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WA X X KEN MAAZ 2535339050 33811 9TH AVE S FEDERAL WAY WA 98003 TOM VERTETIS BOARD MEMBER 0.50 X 0 0 0 STEPHEN L FREEBORN PRESIDENT 1.00 X X 0 0 0 CINDY GRADY SECRETARY 1.00 X X 0 0 0 DAN BOGART TREASURER 1.00 X X 0 0 0 BETH KAUKL BOARD MEMBER 1.00 X 0 0 0 DEB LEMKE BOARD MEMBER 1.00 X 0 0 0 KEN MAAZ EXECUTIVE DIRECTOR 40.00 X 146063 0 12430 ERICA PERNELA DIRECTOR OF CLINICAL SERVI 40.00 X 167989 0 20892 MARK SCHINDLER DIRECTOR OF HUMAN RESOURCE 40.00 X 150102 0 19987 SARA EDWARDS CONTROLLER 40.00 X 116732 0 18319 ERIN LARSEN REGISTERED NURSE 40.00 X 125722 0 18858 MICHAEL PUGSLEY DIRECTOR OF DEVELOPMENT 40.00 X 158081 0 20303 GAILENE MAST REGISTERED NURSE 40.00 X 126087 0 18770 MALYNDA MCCARTER REGISTERED NURSE 40.00 X 132879 0 16426 CHAWEEWAN FITZTHUM CNA 40.00 X 160195 0 17213 1283850 0 163198 9 0 1 0 RYAN GENERAL CONTRACTORS INC 16628 44TH AVE W LYNWOOD WA 98037 CONTRACTOR FOR REMODELING SHORELINE BUIL 5587539 ROB'S ELECTRIC INC 4405 103RD AVE SE LAKE STEVENS WA 98258 CONTRACTOR FOR SHORELINE BUILDING 965336 SWINERTON BUILDERS 2001 CLAYTON ROAD 7TH FL CONCORD CA 94520 CONTRACTCONTRACTOR FOR REMODELING SPOKAN 842638 HERITAGE BANK PO BOX 1578 OLYMPIA WA 98507 INTEREST PAYMENTS ON SHORELINE BUILDING 282279 IT SOURCE 1010 S 336TH ST SUITE 108 FEDREAL WAY WA 98003 CONTRACTED IT ASSISTANCE 228147 5 2239785 480798 98288 2720583 INSURANCE 623000 6968886 6968886 MEDICAID: STATE FEE FOR SERVICE P 623000 3493479 3493479 10462365 37258 37258 1872345 665657 1572125 238368 300220 427289 727509 727509 MISCELLANEOUS 623000 28736 28736 28736 13976451 10491101 0 764767 201613 201613 652513 557945 76386 18182 6920986 5928430 803517 189039 1076522 907253 134455 34814 638007 547076 74532 16399 46924 46924 27555 27555 16167 16167 293795 83421 42125 168249 40761 31776 8105 880 97307 59393 33965 3949 121651 100614 16690 4347 60010 44179 7250 8581 44527 31551 10877 2099 264650 73876 49635 141139 257125 211403 45722 156728 119282 32799 4647 MISC OTHER 357191 175781 148315 33095 HOUSEHOLD, CLEANING, CH 230261 221796 8465 BANK FEES 57490 1694 53660 2136 TAXES & LICENSES 42930 12386 14680 15864 11604713 9309469 1651824 643420 150012 462262 79490 369649 1657638 1416157 182852 125892 9268027 2005745 4797205 7262282 2366849 1219793 7598727 9276421 16832773 20132456 1862567 1747092 5693045 7133983 0 120497 7555612 9001572 X 9217161 11130884 60000 0 9277161 11130884 16832773 20132456 2371738 -518015 0 X X 0 1 X 1 0 X 34396 24999 346287 224805 2720583 3351070 6889328 7681141 9158182 9631259 10462365 43822275 6923724 7706140 9504469 9856064 13182948 47173345 0 0 0 47173345 64557 47817 42950 44750 37258 237332 64557 47817 42950 44750 37258 237332 7489 7813 36164 11276 28736 91478 6995770 7761770 9583583 9912090 13248942 47502155 0.99310 0.99090 0.00500 0.00740 X PART III SECTION B LINE 12 OTHER INCOME CPR/FIRST AID FEES, REBATES, CLASS ACTION PROCEEDS FROM SECURITIES RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 0 0 0 1 15000 15000 1 0 0 PART II-B, LINE 1: ASHLEY HOUSE PAID A CONSULTANT TO LOBBY ON THEIR BEHALF FOR FUNDING TO PURCHASE AND REMODEL A HOME IN SPOKANE, WA FOR CRITICALLY ILL CHILDREN. 1325178 1325178 6845648 1244924 5600724 818538 664198 154340 278663 96623 182040 7262282 CONSTRUCTION IN PROGRESS 9151388 PERSONAL FUNDS- CUSTODIAL 4910 OPERATING ROUA 22144 FINANCING LEASE 97979 9276421 OPERATING LEASE LIABILITY 22512 FINANCING LEASE LIABILITY 97985 120497 13240656 -518015 -518015 13758671 16167 201613 217780 13976451 11386933 0 11386933 16167 201613 217780 11604713 PART XI, LINE 4B - OTHER ADJUSTMENTS: UNCOMPENSATED CARE 201,613. PART XII, LINE 4B - OTHER ADJUSTMENTS: UNCOMPENSATED CARE 201,613. 0 GROUP HOME - ROOM & BOARD - UNCOMPENSATED CARE 16 201613 OTHER ROOM & BOARD PROVIDED AT NO COST. PART III LINE 1 FUNDS ARE NOT GIVEN TO ANY INDIVIDUAL. THE COST TO THE AGENCY FOR ROOM AND BOARD IS INCLUDED AS A GRANT TO INDIVIDUALS WHEN ASHLEY HOUSE DOES NOT RECEIVE ANY REIMBURSEMENT FOR THESE SERVICES. X X X X 0 0 0 0 0 0 0 0 0 ERICA PERNELA DIRECTOR OF CLINICAL SERVI 167989 0 0 0 0 0 8462 0 12430 0 188881 0 0 0 MICHAEL PUGSLEY DIRECTOR OF DEVELOPMENT 158081 0 0 0 0 0 7873 0 12430 0 178384 0 0 0 CHAWEEWAN FITZTHUM CNA 160195 0 0 0 0 0 4853 0 12360 0 177408 0 0 0 MARK SCHINDLER DIRECTOR OF HUMAN RESOURCE 150102 0 0 0 0 0 7557 0 12430 0 170089 0 0 0 KEN MAAZ EXECUTIVE DIRECTOR 146063 0 0 0 0 0 0 0 12430 0 158493 0 0 0 X HOSPITAL EQUIPMENT 15 50000 FMV X HAIR CARE PRODUCTS 3 31578 FMV X MISCELLANEOUS 0 16710 FMV 0 0 0 FORM 990, PART VI, SECTION B, LINE 11B THE 990 REVIEW IS LISTED ON THE YEARLY BOARD OF DIRECTORS COMPLIANCE CALENDAR TO REMIND ALL BOARD MEMBERS OF THE REVIEW. FORM 990 IS PREPARED AFTER THE COMPLETION OF THE INDEPENDENT FINANCIAL AUDIT. A COMPLETE COPY OF THE 990 IS INDIVIDUALLY PROVIDED TO ALL BOARD MEMBERS WHO REVIEW THE RETURN PRIOR TO FILING. ANY QUESTIONS OR CONCERNS ARE COMPILED BY THE BOARD TREASURER, WHO THEN CONTACTS THE RETURN PREPARER AND/OR AUDITORS AS NECESSARY. AFTER THE BOARD HAS REVIEWED AND ACCEPTED THE RETURN, BY VOTE AT A REGULARLY SCHEDULED BOARD MEETING, IT IS SIGNED BY THE BOARD PRESIDENT AND FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD COMPLIANCE CALENDAR LISTS AS AN ITEM TO BE COMPLETED IN THE FIRST QUARTER OF THE YEAR, REVIEW THE CONFLICT OF INTEREST POLICY. IT REQUIRES ALL BOARD MEMBERS TO ANNUALLY SIGN A CONFLICT OF INTEREST STATEMENT. THE POLICY ALSO REQUIRES A DUTY TO DISCLOSE ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST. IT OUTLINES PROCEDURES FOR THE BOARD TO FOLLOW IN DETERMINING WHETHER A CONFLICT OF INTEREST EXISTS AND PROCEDURES FOR ADDRESSING ANY CONFLICT OF INTEREST THAT MAY ARISE. ADDITIONALLY, INDEPENDENT FINANCIAL AUDITORS ANNUALLY REVIEW AND TEST THE ORGANIZATION'S RECORDS FOR POSSIBLE CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 A BOARD COMMITTEE CONDUCTS AN ANNUAL PERFORMANCE AND COMPENSATION REVIEW FOR THE EXECUTIVE DIRECTOR. THE COMMITTEE ALSO OBTAINS COMPARABLE SALARY INFORMATION FROM INDEPENDENT THIRD-PARTY SOURCES AND DETERMINES ANY RECOMMENDATION FOR SALARY ADJUSTMENT. A WRITTEN EMPLOYMENT CONTRACT IS USED TO DOCUMENT ALL TERMS OF THE EXECUTIVE DIRECTOR'S EMPLOYMENT. THE EXECUTIVE DIRECTOR COMPLETES PERFORMANCE REVIEW AND OBTAINS COMPARABLE SALARY INFORMATION FOR ALL KEY EMPLOYEES. THE FULL BOARD REVIEW AND APPROVES COMPENSATION PACKAGES FOR BOTH THE EXECUTIVE DIRECTOR AND KEY EMPLOYEES. FORM 990, PART VI, SECTION C, LINE 19 DISCLOSURE OF GOVERNING DOCUMENTS, FINANCIAL STATEMENTS AND CONFLICT OF INTEREST POLICY ARE NOT GENERALLY MADE AVAILABLE TO THE PUBLIC, BUT ARE PROVIDED ON A REQUEST BASIS. FORM 990 PART XII, LINE 2C THERE HAVE BEEN NO CHANGES TO THE PROCESS FROM THE PRIOR YEAR.