2022-04-15T13:50:12-05:00 2021-06-30 410746749 CLIFTONLARSONALLEN LLP 2210 EAST ROUTE 66 GLENDORA CA 91740 990 2020-07-01 710876594 HOLLENBECK PALMS HOLL 3232636195 573 SOUTH BOYLE AVENUE LOS ANGELES CA 90033 MORRIS SHOCKLEY PRESIDENT/CEO 3232636195 2022-04-14 1 MORRIS SHOCKLEY 999009999 TINA HENTON P00630282 6268577300 2022-04-13 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z MORRIS SHOCKLEY 573 SOUTH BOYLE AVENUE LOS ANGELES CA 90033 34206410 0 X WWW.HOLLENBECKPALMS.COM X 2001 CA THE VERY FIRST NON-PROFIT, LICENSED CONTINUING CARE RETIREMENT COMMUNITY IN CALIFORNIA, HOLLENBECK PALMS PROVIDES FOR AND SERVES ITS ELDERLY RESIDENTS WITH GREAT COMPASSION, HONEST DIGNITY AND GENUINE LOVE THROUGH RESIDENTIAL, ASSISTED AND SKILLED NURSING LIVING. WE OFFER A REWARDING AND GRATIFYING LIFESTYLE, FULL OF ACTIVITIES, PROGRAMS AND SERVICES, AND ALL LEVELS OF CARE THEY MAY NEED AT VARIOUS STAGES OF THEIR LIVES. 7 7 191 0 0 0 326015 3453587 13803684 14618615 3955946 4116762 227809 162702 18313454 22351666 0 0 0 0 9933493 10188118 0 0 167561 8891130 9710181 18824623 19898299 -511169 2453367 83559690 91601425 41945222 40867722 41614468 50733703 X HOLLENBECK PALMS IS COMMITTED TO PROVIDING A RESIDENCE FOR THOSE IN THE LATER YEARS OF THEIR LIVES THAT ENCOMPASSES A HEALTHY ENVIRONMENT OF COMFORT, SAFETY, AND ENJOYMENT; THAT ATTENDS TO THEIR PHYSICAL, MENTAL, AND SPIRITUAL NEEDS; AND THAT IS QUICK TO RESPOND TO AND ASSIST IN THOSE NEEDS WHETHER IMMEDIATE OR LONG TERM, AND TO DO SO WITH GREAT COMPASSION, HONESTY, DIGNITY AND GENUINE LOVE. 0 0 15619853 14650973 HOLLENBECK PALMS PROVIDES CARE FOR THE AGING, INCLUDING RESIDENTIAL, ASSISTED LIVING, AND SKILLED NURSING CARE LIVING ARRANGEMENTS FOR THEIR MEMBERS. DURING THE YEAR, SERVICES WERE PROVIDED TO APPROXIMATELY 200 MEMBERS. 15619853 1 1 0 0 0 0 0 0 0 1 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 35 0 191 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 CA X JOHNNY YOUNG 3232636195 573 SOUTH BOYLE AVENUE LOS ANGELES CA 90033 MORRIS SHOCKLEY PRESIDENT/CEO 40.00 X 219549 0 28224 GARY ZUPPARDO CHIEF ENGINEER 40.00 X 173035 0 20640 JOHNNY YOUNG CFO 40.00 X 140834 0 25181 IVANIA RAMIREZ DIRECTOR OF NURSING 40.00 X 155208 0 2845 ZHANA DUBIN ADMISSIONS DIRECTOR 40.00 X 137020 0 14012 AKHERE OSEZUA ASSISTANT DIRECTOR OF NURSING 40.00 X 138142 0 10470 JESSE ALEJANDRINO RN CHARGE NURSE 40.00 X 123063 0 3111 PATRICIA MURPHY VICE PRESIDENT 1.00 X 0 0 0 CAROL A JOHNSTON BOARD CHAIR 1.00 X 0 0 0 CASEY ADAMS SECRETARY 1.00 X 0 0 0 MICHAEL DAVIS BOARD MEMBER 1.00 X 0 0 0 EDWARD S GARLOCK BOARD MEMBER 1.00 X 0 0 0 WILLIAM KUMAGAI BOARD MEMBER 1.00 X 0 0 0 ROSAMOND FLORES RESIDENT REPRESENTATIVE 1.00 X 0 0 0 KATHERINE A KIRCHHOFF BOARD MEMBER 1.00 X 0 0 0 1086851 0 104483 15 0 1 0 LE WATERS CONSTRUCTION CO 6767 FOREST LAWN DR 300 LOS ANGELES CA 90068 CONSTRUCTION 3300678 SODEXO AMERICA LLC 600 CITY PARKWAY WEST SUITE 610 ORANGE CA 92868 FOOD SERVICES 2203543 TEAM REHAB INC 6531 SILENT HARBOR DR HUNTINGTON BEACH CA 92648 THERAPY 471056 SKILLED NURSING PHARMACY 16666 E JOHNSON DRIVE CITY OF INDUSTRY CA 91745 PHARMACY 241418 GSSI INC 639 N MARINE AVE WILMINGTON CA 90744 SECURITY SERVICES 183629 12 2149466 1304121 40494 3453587 SKILLED NURSING/RESIDENTIAL 623000 9757530 9757530 MEDICARE/MEDICAID 623000 4861085 4861085 14618615 849145 849145 52732 52732 77612 0 77612 77612 77612 15122361 11854744 3267617 3267617 3267617 OTHER REVENUE 623000 32358 32358 32358 22351666 14650973 0 4247106 X 407194 194640 200507 12047 7060374 5951213 1000082 109079 229599 209754 16611 3234 1877575 1587107 259970 30498 613376 515522 87803 10051 135777 135777 113129 113129 90185 90185 2527765 1784910 742206 649 127854 127854 73430 73430 813972 794913 18389 670 41028 19893 21122 13 13612 5881 7731 1179883 1179883 1556700 1527181 28481 1038 341937 333930 7725 282 VARIOUS MEDICAL EXPENSE 1758356 1758356 FOOD EXPENSE 936553 936553 19898299 15619853 4110885 167561 2946910 1989955 4924341 2815865 3993 103982 1374312 1556804 105848 97570 295354 284735 63454895 24953395 35679634 38501500 33931150 39149031 4298148 7101983 83559690 91601425 5565856 4387883 5100343 3689697 16964721 16179967 9104737 12826945 1479100 0 3730465 3783230 41945222 40867722 X 38876989 46735421 2737479 3998282 41614468 50733703 83559690 91601425 X 2453367 5504167 1161701 X X 0 1 X 1 0 X 193524 241915 235937 326015 3453587 4450978 14498822 13134990 13261109 13803684 14618615 69317220 14692346 13376905 13497046 14129699 18072202 73768198 40000 51766 70042 25957 952516 1140281 0 40000 51766 70042 25957 952516 1140281 72627917 2485757 4436749 3552103 4116072 4247106 18837787 2485757 4436749 3552103 4116072 4247106 18837787 137491 131420 143015 63593 32361 507880 17315594 17945074 17192164 18309364 22351669 93113865 0.78000 0.80190 0.20230 0.18890 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: ICE CREAM AND GUEST MEALS AND ROOM - 2016 AMOUNT: $ 32,349. 2017 AMOUNT: $ 32,534. 2018 AMOUNT: $ 27,142. 2019 AMOUNT: $ 22,338. 2020 AMOUNT: $ 1,714. BAZAAR - 2016 AMOUNT: $ 26,020. 2017 AMOUNT: $ 9,406. 2018 AMOUNT: $ 10,992. 2019 AMOUNT: $ 6,084. 2020 AMOUNT: $ 4,451. BEAUTY AND BARBER SHOP - 2016 AMOUNT: $ 47,449. 2017 AMOUNT: $ 54,550. 2018 AMOUNT: $ 42,496. 2019 AMOUNT: $ 32,974. 2020 AMOUNT: $ 12,957. MISCELLANEOUS - 2016 AMOUNT: $ 31,673. 2017 AMOUNT: $ 34,930. 2018 AMOUNT: $ 62,385. 2019 AMOUNT: $ 2,197. 2020 AMOUNT: $ 13,239. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2737479 683809 300000 3121288 2759362 152116 173999 2737479 2604960 154402 2759362 2361530 243430 2604960 2087491 274039 2361530 0.24780 0.75220 0 0 32412 32412 53181245 20986596 32194649 5709675 3966799 1742876 4531563 4531563 38501500 CORPORATE BONDS 5540224 F MORTGAGE-BACKED SECURITIES 497204 F MUNICIPAL BONDS 899884 F ANNUITY AND LIFE INSURANCE POLICIES 162840 F OIL INTEREST 1831 F 7101983 ASSIGNED ASSETS, NET 3783230 3783230 X 28927349 5504167 1161701 6665868 22261481 90185 90185 22351666 19808114 0 19808114 90185 90185 19898299 PART V, LINE 4: THE PALMS' ENDOWMENT CONSISTS OF FUNDS ESTABLISHED TO PROVIDE LIFE CARE MEMBERSHIP FOR SENIORS WHOSE LIMITED RESOURCES PREVENT THEIR ENTRY INTO THE PALMS WITHOUT SUCH ASSISTANCE. PART X, LINE 2: THE PALMS IS A NOT-FOR-PROFIT CORPORATION AND IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(A) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM CALIFORNIA FRANCHISE TAXES SECTION 23701D OF THE CALIFORNIA REVENUE AND TAXATION CODE. THE PALMS IS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS LISTED IN INTERNAL REVENUE SERVICE PUBLICATION 78 AS A CHARITABLE ORGANIZATION QUALIFIED TO RECEIVE DONATIONS. THE PALMS MAINTAINS ITS TAX-EXEMPT STATUS THROUGH DEVOTING ITS RESOURCES TO MEET THE PRIMARY NEEDS OF AGED PERSONS. THESE NEEDS ARE FOR HOUSING, HEALTH CARE, AND FINANCIAL SECURITY. THE PALMS HAS EVALUATED ITS TAX POSITIONS AND THE CERTAINTY AS TO WHETHER THOSE POSITIONS WILL BE SUSTAINED IN THE EVENT OF AN AUDIT BY TAXING AUTHORITIES AT THE FEDERAL AND STATE LEVELS. THE PRIMARY TAX POSITIONS EVALUATED ARE RELATED TO THE PALMS' CONTINUED QUALIFICATION AS A TAX-EXEMPT ORGANIZATION AND WHETHER THERE ARE UNRELATED BUSINESS INCOME ACTIVITIES CONDUCTED THAT WOULD BE TAXABLE. MANAGEMENT HAS DETERMINED THAT ALL INCOME TAX POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED UPON POTENTIAL AUDIT OR EXAMINATION; THEREFORE, NO DISCLOSURES OF UNCERTAIN INCOME TAX POSITIONS ARE REQUIRED. THE PALMS FILES INFORMATIONAL RETURNS IN THE U.S. FEDERAL JURISDICTION AND THE STATE OF CALIFORNIA. THE STATUTE OF LIMITATIONS FOR FEDERAL AND CALIFORNIA STATE PURPOSES IS GENERALLY THREE AND FOUR YEARS, RESPECTIVELY. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN PENSION LIABILITY 1,161,701. X X X 0 0 0 0 0 0 0 0 0 MORRIS SHOCKLEY PRESIDENT/CEO 219549 0 0 0 0 0 19377 0 8847 0 247773 0 0 0 GARY ZUPPARDO CHIEF ENGINEER 173035 0 0 0 0 0 2434 0 18206 0 193675 0 0 0 JOHNNY YOUNG CFO 140834 0 0 0 0 0 15205 0 9976 0 166015 0 0 0 IVANIA RAMIREZ DIRECTOR OF NURSING 155208 0 0 0 0 0 2845 0 0 0 158053 0 0 0 ZHANA DUBIN ADMISSIONS DIRECTOR 137020 0 0 0 0 0 1692 0 12320 0 151032 0 0 0 A CALIFORNIA STATEWIDE COMMUNITIES DEVELOPMENT AUTHORITY 680164610 2016-12-01 20435000 RETIRE SERIES 2007 BONDS 0 0 0 A 4020000 20435000 304908 20130092 2017 1 0 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 X 2 40494 FMV 0 0 0 PART I, COLUMN (B): 2 STOCK DONATIONS FORM 990, PART VI, SECTION A, LINE 1 THE GOVERNING BODY HAS DELEGATED TO THE AUDIT COMMITTEE, CONSISTING OF MIKE DAVIS AND EDWARD GARLOCK, THE AUTHORITY TO OVERSEE THE FINANCIAL AND DISCLOSURE PROCESS, MONITOR ACCOUNTING POLICIES, AND THE HIRING AND PERFORMANCE OF THE EXTERNAL AUDITORS. FORM 990, PART VI, SECTION B, LINE 11B THE GOVERNING BODY HAS DELEGATED TO THE AUDIT COMMITTEE THE AUTHORITY TO REVIEW THE FORM 990. A COMPLETE COPY OF THE FORM 990 WAS PROVIDED TO ALL MEMBERS OF THE AUDIT COMMITTEE FOR REVIEW PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C MONITORING IS DONE REGULARLY BY THE OFFICERS TO IDENTIFY POTENTIAL CONFLICTS OF INTEREST AS ISSUES ARISE. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, ANY INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE TRUSTEES. AFTER DISCLOSURE AND DISCUSSION, THE TRUSTEES WILL DETERMINE IF A CONFLICT OF INTEREST EXISTS, AND IF SO, DETERMINE THE PROPER COURSE OF ACTION. FORM 990, PART VI, SECTION B, LINE 15 BOARD OF TRUSTEES DETERMINES COMPENSATION FOR ALL OFFICERS AND KEY EMPLOYEES, BASED ON COMPARABLE SALARIES IN THE LOCAL AREA. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G PROFESSIONAL AND CONTRACT SERVICES: PROGRAM SERVICE EXPENSES 1,150,405. MANAGEMENT AND GENERAL EXPENSES 303,600. FUNDRAISING EXPENSES 500. TOTAL EXPENSES 1,454,505. PROGRAM ACTIVITIES: PROGRAM SERVICE EXPENSES 31,205. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 31,205. REPAIRS AND MAINTENANCE: PROGRAM SERVICE EXPENSES 55,215. MANAGEMENT AND GENERAL EXPENSES 1,219. FUNDRAISING EXPENSES 26. TOTAL EXPENSES 56,460. MISCELLANEOUS EXPENSES: PROGRAM SERVICE EXPENSES 548,085. MANAGEMENT AND GENERAL EXPENSES 437,387. FUNDRAISING EXPENSES 123. TOTAL EXPENSES 985,595. FORM 990, PART XI, LINE 9: CHANGE IN PENSION LIABILITY 1,161,701. FORM 990, PART XII, LINE 2C THE ORGANIZATION DID NOT CHANGE ITS OVERSIGHT PROCESS OR SELECTION PROCESS DURING THE YEAR.