2022-08-08T06:40:09-05:00 2021-09-30 390859910 BAKER TILLY US LLP 225 S 6TH ST 2300 MINNEAPOLIS MN 55402 990 2020-10-01 952821104 HENRY MAYO NEWHALL MEMORIAL HOSPITAL HENR 6612002000 23845 MCBEAN PARKWAY VALENCIA CA 91355 TED D SIROTTA SENIOR VP/CFO 6612002000 2022-08-05 1 TED SIROTTA XXX-XX-XXXX LAWRENCE H MOHR CPA P00447603 6128764500 2022-08-03 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z ROGER E SEAVER 23845 MCBEAN PARKWAY VALENCIA CA 91355 442063868 0 X WWW.HENRYMAYO.COM X 1972 CA BE THE TRUSTED REGIONAL LEADER TO INSPIRE AND DELIVER OPTIMAL HEALTH AND WELLNESS. 15 13 2149 151 308303 0 12016098 5775437 359809714 405891441 2800082 3644069 7376443 4415795 382002337 419726742 5234300 6193451 0 0 157621849 163819648 0 0 0 217975009 238027282 380831158 408040381 1171179 11686361 558511458 625737572 351466463 406757573 207044995 218979999 BE THE TRUSTED REGIONAL LEADER TO INSPIRE AND DELIVER OPTIMAL HEALTH AND WELLNESS. 0 0 369020611 5551691 407056341 TO PROVIDE HEALTH CARE SERVICES TO THE CITIZENS OF SANTA CLARITA VALLEY AND SURROUNDING AREAS. THE HOSPITAL HAD 59,042 PATIENT DAYS DURING THE YEAR. WE ALSO PROVIDED SERVICES FOR 57,472 EMERGENCY VISITS. 78% OF TOTAL HOSPITAL INPATIENT ADMITS (EXCLUDING NEWBORNS) ARE ADMITTED THROUGH THE EMERGENCY ROOM. 641760 641760 TO SUPPORT GENERAL OPERATIONS OF HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION, AN AFFILIATE TO THE HOSPITAL. 369662371 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 1 1 1 0 0 0 0 1 1 1 1 0 0 1 249 0 1 2149 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 15 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 CA X RICHARD KIM 6612002000 23845 MCBEAN PARKWAY VALENCIA CA 91355 ROGER E SEAVER PRESIDENT/CEO 40.00 0.50 X X 827852 0 76966 KINGMAN HO MD CHIEF MEDICAL OFFICER (THROUGH 01/2021) 40.00 X 587440 0 57283 TED D SIROTTA SR VP/CFO 40.00 X 445451 0 61804 LARRY R KIDD SR VP/CCO 40.00 X 451750 0 45922 RAY B MOSS VP/CIO 40.00 X 321405 0 57705 MARK A PULEO VP/CHRO 40.00 X 286058 0 62674 JONATHAN S MILLER VP-FACILTY/SUPPORT (THROUGH 05/2020) 40.00 X 311611 0 14851 MARIA SARTE CLINCAL RN 40.00 X 230372 0 11519 CARISSA BORTUGNO DIRECTOR PHARMACY 40.00 X 193972 0 36528 LISA BARRETT CLINCAL RN 40.00 X 195458 0 21307 KIMBERLY CLARK CLINCAL RN 40.00 X 191205 0 23983 JOSEPHINE KAPLAN DIRECTOR CASE MANAGEMENT 40.00 X 191142 0 16402 JENNIFER R CASTALDO VP/CNO (THROUGH 05/2020) 40.00 X 177603 0 16315 JOHN BARSTIS MD TRUSTEE 0.50 X 0 0 0 ROBERT BENJAMIN TRUSTEE 0.50 X 0 0 0 MARK CHAMBERLAIN TRUSTEE 0.50 X 0 0 0 LAKHBINDER DHANDA MD TRUSTEE 3.60 X 0 0 0 DALE R DONOHOE TRUSTEE 0.50 X 0 0 0 SONYA ENGLE TRUSTEE 0.50 X 0 0 0 JUDY FISH TRUSTEE 0.50 X 0 0 0 CHERI FLEMING TRUSTEE 0.50 X 0 0 0 RUSSELL HANLIN TRUSTEE 0.50 X 0 0 0 DONALD KIMBALL TRUSTEE 0.50 X 0 0 0 CHRIS LUECHTEFELD TRUSTEE 0.50 X 0 0 0 ROSCOE MARTER MD TRUSTEE 0.50 X 0 0 0 DON NISHIGUCHI MD TRUSTEE 9.00 X 0 0 0 HOLLY SCHROEDER TRUSTEE 0.50 X 0 0 0 TODD STEVENS TRUSTEE 0.50 X 0 0 0 4411319 0 503259 462 1 1 0 SODEXO INC & AFFILIATES 9801 WASHINGTON BLVD GAITHERSBURG MD 20878 OTHER PURCHASED SERVICES 12422537 INTERSTATE REHABILITATION LLC 333 E GLENOAKS BLVD SUITE 204 GLENDALE CA 61207 MEDICAL PURCHASED SERVICES 6764732 FACEY MEDICAL FOUNDATION 15451 SAN FERNANDO MISSION BLVD S MISSION HILLS CA 91345 PROFESSIONAL SERVICES 3894567 MEDEFIS INC 12400 HIGH BLUFF DRIVE SUITE 100 SAN DIEGO CA 92130 PROFESSIONAL SERVICES 2693417 SCCT MEDICAL GROUP 11333 N SEPULVEDA BLVD MISSION HILLS CA 91345 PROFESSIONAL SERVICES 2148850 228 844707 4930730 5775437 HEALTHCARE SERVICES 621110 405891441 405891441 405891441 2545724 2545724 455 455 973992 650170 323822 323822 323822 22784846 21651108 35848 1133738 -35848 1097890 1097890 FITNESS CENTER REVENUE 621110 687764 687764 INCOME FROM CARE NETWO 621110 477136 477136 SUPPORT SERVICES 621110 308303 308303 2618770 2618770 4091973 419726742 407056341 308303 6586661 X 854494 854494 5338957 5338957 3087985 2721814 366171 118537271 106188404 12348867 4240744 3797405 443339 28019569 24742557 3277012 9934079 9057861 876218 1771238 8957 1762281 356476 356476 16457 16457 147518 147518 60748280 53964992 6783288 121404 3847 117557 2301525 2201639 99886 7303427 6600867 702560 8967033 4307653 4659380 88077 79358 8719 53312 41954 11358 9917157 7679251 2237906 22838302 22838302 1873566 1873566 MEDICAL SUPPLIES 57186710 56712401 474309 BAD DEBT 34461458 34461458 QUALITY ASSURANCE FEES 21909386 21909386 REPAIR & MAINTENANCE 2139192 1905917 233275 5826764 2371331 3455433 408040381 369662371 38378010 0 62625820 66762900 26467277 21269535 55774860 54237213 6768080 7557468 4007320 5797981 513271844 233870215 291294775 279401629 80642756 103089886 1638005 3658870 29292565 83962090 558511458 625737572 81404769 81546657 6530229 3666047 215959112 232857418 10479084 6720053 37093269 81967398 351466463 406757573 X 199290075 209927480 7754920 9052519 207044995 218979999 558511458 625737572 X 11686361 10679303 -10430660 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 0 1 16754 16754 0 PART II-B, LINE 1: FOR THE FISCAL YEAR ENDED 9/30/21, THE ORGANIZATION PARTICIPATED WITH THE CALIFORNIA HOSPITAL ASSOCIATION TO ADVOCATE POSITIVE HEALTHCARE POLICIES FOR HOSPITALS. 6302340 6302340 369800100 130550665 239249435 129983115 103319550 26663565 7186289 7186289 279401629 RECEIVABLE FROM HENRY MAYO NEWHALL FOUNDATION 9222358 RECEIVABLE FROM HENRY MAYO MSO 612317 PLEDGED LEASE 2213789 OTHER RECEIVABLES 20528108 RECEIVABLE FOR HENRY MAYO CIN 61004 OTHER CURRENT ASSETS 29640 RIGHT-OF-USE ASSET 51294874 83962090 ESTIMATED THIRD PARTY LIABILITIES 5977924 ADVANCE PAYMENTS 20585559 PAYABLE TO AFFILIATE 223629 OTHER LIABILITIES 8087023 LEASE OBLIGATIONS 47093263 81967398 X 380869571 10679303 44431 -50231075 -39507341 420376912 -650170 -650170 419726742 368934567 44431 650170 694601 368239966 39800415 39800415 408040381 PART X, LINE 2: THE ORGANIZATION IS EXEMPT FROM INCOME TAXES PURSUANT TO SECTION 501 (C)(3) OF THE INTERNAL REVENUE CODE ("IRC") AND A SIMILAR PROVISION OF STATE LAW. ACCORDINGLY, NO PROVISION FOR INCOME TAXES FOR THIS ENTITY HAS BEEN MADE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE ORGANIZATION IS SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. THE ORGANIZATION HAS NO UNCERTAIN TAX POSITIONS AT SEPTEMBER 30, 2021 AND 2020. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -34,461,458. CHARITY CARE (GROSS CHARGES) -5,338,957. NET ASSET TRANSFER FROM HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION 1,720,497. LOSS ON BOND DEFEASANCE -12,151,157. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -650,170. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 650,170. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 34,461,458. CHARITY CARE (GROSS CHARGES) 5,338,957. 1 1 X 1 X 1 X 1 1 1 0 1 1 1345701 1345701 0.00330 25594771 10302003 15292768 0.03750 26940472 10302003 16638469 0.04080 765114 765114 0.00190 2662852 2662852 0.00650 703351 703351 0.00170 4131317 4131317 0.01010 31071789 10302003 20769786 0.05090 1 34461457 58860202 76604617 -17744415 X 1 1 1 TOWER IMAGING VALENCIA OUTPATIENT RADIOLOGY SERVICE 0.50000 0.00000 0.50000 2 HENRY MAYO NEWHALL URGENT CARE CLINICS LLC URGENT CARE OPERATION 0.51000 0.49000 3 KECK MEDICINE OF USC AND HENRY MAYO NEWHALL MEMORIAL HOSPITAL LLC CANCER SERVICE LINE 0.50000 1 1 HENRY MAYO NEWHALL MEMORIAL HOSPITAL 23845 MCBEAN PKWY VALENCIA CA 91355 WWW.HENRYMAYO.COM 930000206 X X X TRAUMA CENTER HENRY MAYO NEWHALL MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 18 1 0 0 1 X SEE SCHEDULE H, PART V, SECTION C X 1 19 1 HTTPS://WWW.HENRYMAYO.COM/COMMUNITY/ 0 1 X 200.000000000000 350.000000000000 X X X X 1 1 X X X X 1 X SEE SCHEDULE H, PART V, SECTION C X SEE SCHEDULE H, PART V, SECTION C X SEE SCHEDULE H, PART V, SECTION C X X X X X X 1 X 0 X X X X 1 X 0 0 HENRY MAYO NEWHALL MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: HENRY MAYO NEWHALL HOSPITAL COMPLETED A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) IN TAX YEAR 2018 (FISCAL YEAR 2019) AS REQUIRED BY STATE AND FEDERAL LAW. THE ASSESSMENT INCORPORATED COMPONENTS OF PRIMARY DATA COLLECTION AND SECONDARY DATA ANALYSIS THAT FOCUSED ON THE HEALTH AND SOCIAL NEEDS OF THE SERVICE AREA. THE CHNA EXAMINED UP-TO-DATE DATA SOURCES FOR THE SERVICE AREA TO PRESENT COMMUNITY DEMOGRAPHICS, SOCIAL DETERMINANTS OF HEALTH, HEALTH CARE ACCESS, MATERNAL AND INFANT HEALTH, LEADING CAUSES OF DEATH, DISABILITY AND DISEASE, HEALTH BEHAVIORS, MENTAL HEALTH, SUBSTANCE USE AND MISUSE, AND PREVENTIVE PRACTICES. WHEN APPLICABLE, THESE DATA SETS WERE PRESENTED IN THE CONTEXT OF CALIFORNIA AND COMPARED TO THE HEALTHY PEOPLE 2021 OBJECTIVES. TARGETED INTERVIEWS WERE USED TO GATHER INFORMATION AND OPINIONS FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL. TWENTY-ONE (21) INTERVIEWS WERE COMPLETED IN JUNE 2019. INTERVIEWEES INCLUDED INDIVIDUALS WHO ARE LEADERS AND/OR REPRESENTATIVES OF MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS, LOCAL HEALTH OR OTHER DEPARTMENTS OR AGENCIES THAT HAVE CURRENT DATA OR OTHER INFORMATION RELEVANT TO THE HEALTH NEEDS OF THE COMMUNITY. INPUT WAS OBTAINED FROM THE LOS ANGELES COUNTY DEPARTMENT OF PUBLIC HEALTH. HENRY MAYO NEWHALL MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: ACCESS TO HEALTH CARE, CANCER, DIABETES, HEART DISEASE AND MENTAL HEALTH WERE RANKED AS THE TOP FIVE PRIORITY NEEDS IN THE SERVICE AREA. THE CALCULATIONS OF THE COMMUNITY INPUT RESULTED IN THE FOLLOWING PRIORITY ORDERING OF THE SIGNIFICANT HEALTH NEEDS:1. ACCESS TO HEALTH CARE2. CANCER3. DIABETES4. HEART DISEASE5. MENTAL HEALTH6. SUBSTANCE USE AND MISUSE7. PREMATURE BIRTHS8. ALZHEIMER'S DISEASE9. PREVENTIVE PRACTICES (SCREENINGS AND IMMUNIZATIONS)10. OVERWEIGHT AND OBESITY11. HOUSING AND HOMELESSNESS12. ASTHMA13. LIVER DISEASEFOR SPECIFIC PLAN AND OTHER NEEDS NOT ADDRESSED, PLEASE REFER TO THE ATTACHED COMMUNITY BENEFIT REPORT, PAGES 8-10. SCHEDULE H, PART V, LINE 7A CHNA REPORT DIRECT LINK: HTTPS://WWW.HENRYMAYO.COM/APP/FILES/PUBLIC/EA9348AC-AE05-48BD-ADA8-7218E89F6B2A/COMMUNITY%20BENEFIT/HENRY-MAYO-2019-CHNA-1.PDF SCHEDULE H, PART V, LINE 16A FINANCIAL ASSISTANCE POLICY (FAP): HTTPS://WWW.HENRYMAYO.COM/APP/FILES/PUBLIC/5627EA95-5D2E-4289-8708-D8D58C1BABC4/FINANCIAL%20ASSISSTANCE%20PROGRAM.PDF SCHEDULE H, PART V, LINE 16B FAP APPLICATION FORM: HTTPS://WWW.HENRYMAYO.COM/APP/FILES/PUBLIC/D851BA5C-3632-4C9C-85ED-058F2A7AA327/V2-FAP%20APPLICATION%202022.PDF SCHEDULE H, PART V, LINE 16C FAP PLAIN LANGUAGE SUMMARY: HTTPS://WWW.HENRYMAYO.COM/APP/FILES/PUBLIC/0995F2AD-7A89-48F2-8F45-C5B237B3C5C2/MR242D-%20FINAL%20COPY.PDF PART I, LINE 3C: INDIVIDUAL OR HOUSEHOLD UNIT INCOME - UP TO 350% OF THE FPL. EMPLOYMENT STATUS SHALL BE CONSIDERED WHEN DETERMINING INCOME LEVELS. PRIOR INCOME LEVELS MAY NOT MEET THE ESTABLISHED POVERTY LEVEL GUIDELINES; HOWEVER, RECENT UNEMPLOYMENT SHOULD BE CONSIDERED AS THE CURRENT SOURCE OF INCOME. INDIVIDUAL OR HOUSEHOLD UNIT NET WORTH - UP TO $250,000 (EXCLUDING NET WORTH IN PRIMARY HOMES OF UP TO $500,000 AND RETIREMENT OR DEFERRED COMPENSATION PLANS). WHEN REVIEWING NET WORTH, OTHER FINANCIAL OBLIGATIONS SUCH AS HIGH MEDICAL BILLS SHOULD BE CONSIDERED. PATIENTS WITH HIGH NET WORTH THAT WOULD OTHERWISE DISQUALIFY THEM FOR FINANCIAL ASSISTANCE MAY BE CONSIDERED FOR ELIGIBILITY IF THEY HAVE, FOR EXAMPLE, UNINSURED CATASTROPHIC HEALTH CARE COSTS THAT WOULD SIGNIFICANTLY REDUCE THEIR NET WORTH. HIGH MEDICAL COSTS SHALL MEAN:1. ANNUAL OUT-OF-POCKET COSTS INCURRED BY A PATIENT AT HMNH THAT EXCEED 10% OF THE PATIENT'S FAMILY INCOME IN THE PRIOR 12 MONTHS;2. ANNUAL OUT-OF-POCKET MEDICAL EXPENSES THAT EXCEED 10% OF THE PATIENT'S FAMILY INCOME, IF THE PATIENT PROVIDES DOCUMENTATION OF THE PATIENT'S MEDICAL EXPENSES PAID BY THE PATIENT OR THE PATIENT'S FAMILY IN THE PRIOR 12 MONTHS;SELF-PAY PATIENTS ADMITTED THROUGH THE EMERGENCY DEPARTMENT, PER EMTALA GUIDELINES,WITH INSUFFICIENT INFORMATION PROVIDED BY THE PATIENT TO FULLY EVALUATE ELIGIBILITY TESTS, AND THE ABILITY TO PAY WHICH CANNOT BE RELIABLY DETERMINED, WILL BE CLASSIFIED AS CHARITY. IF INFORMATION BECOMES AVAILABLE LATER THAT WOULD DISQUALIFY THE PATIENT FROM MEETING THE FINANCIAL ASSISTANCE CRITERIA, THEN THE PATIENT ACCOUNT WILL BE RECLASSIFIED TO THE APPROPRIATE PAYER CLASS.PATIENTS WHO QUALIFY FOR MEDI-CAL, BUT WHERE HMNH DOES NOT RECEIVE PAYMENT FOR THEIR ENTIRE STAY ARE ELIGIBLE FOR CHARITY CARE FOR DENIED STAYS, DENIED DAYS OF CARE, AND NONCOVERED SERVICES. THESE DENIALS AND ANY LACK OF PAYMENT FOR NON-COVERED SERVICES PROVIDED TO MEDI-CAL PATIENTS ARE TO BE CLASSIFIED AS CHARITY. THESE PATIENTS ARE RECEIVING THE SERVICE, AND THEY DO NOT HAVE THE ABILITY TO PAY FOR IT. IN ADDITION, MEDICARE PATIENTS WHO HAVE MEDI-CAL COVERAGE FOR THEIR CO-INSURANCE/DEDUCTIBLES, FOR WHICH MEDI-CAL DOES NOT MAKE PAYMENT, AND MEDICARE DOES NOT ULTIMATELY PROVIDE BAD DEBT REIMBURSEMENT WILL ALSO BE INCLUDED AS CHARITY. THESE PATIENTS ARE RECEIVING A SERVICE FOR WHICH A PORTION OF THE RESULTING BILL IS NOT BEING REIMBURSED.TRAUMA SERVICES RENDERED TO PATIENT MEDICAL CONDITIONS MEETING THE DEFINITION OF BILLABLE TRAUMA CARE, PER OUR TRAUMA CARE AGREEMENTS WITH THE LOS ANGELES COUNTY AND THE STATE OF CALIFORNIA, WILL BE CLASSIFIED AS CHARITY CARE. THESE PATIENTS WILL NOT BE BILLED FOR THEIR SERVICES.HMNH DEEMS PATIENTS WHO ARE ELIGIBLE FOR GOVERNMENT SPONSORED, LOW-INCOME ASSISTANCE PROGRAMS (I.E., MEDI-CAL, OUT OF STATE MEDICAID, CALIFORNIA CHILDREN'S SERVICES AND ANY OTHER APPLICABLE FEDERAL, STATE OR LOCAL LOW-INCOME PROGRAM) TO BE INDIGENT. THEREFORE, SUCH PATIENTS MAY BE CONSIDERED AS ELIGIBLE PRESUMPTIVELY UNDER THE FAP WHEN PAYMENT IS NOT MADE BY THE GOVERNMENTAL PROGRAM. RATIONALE FOR SUCH PRESUMPTIVE DETERMINATION SHALL BE DOCUMENTED IN THE PATIENT ACCOUNT. PART III, LINE 2: THE ORGANIZATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE CARRYING AMOUNT OF PATIENT ACCOUNTS RECEIVABLE IS REDUCED BY BAD DEBT ALLOWANCES THAT REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. PART III, LINE 4: FROM PAGE 17 OF THE AUDITED FINANCIAL STATEMENTS, ATTACHED:GENERALLY, PATIENTS WHO ARE COVERED BY THIRD-PARTY PAYORS ARE RESPONSIBLE FOR RELATED DEDUCTIBLES AND COINSURANCE, WHICH VARY IN AMOUNT. THE HOSPITAL ALSO PROVIDES SERVICES TO UNINSURED PATIENTS, AND OFFERS THOSE UNINSURED OR UNDERINSURED PATIENTS A DISCOUNT, EITHER BY POLICY OR LAW, FROM STANDARD CHARGES. THE HOSPITAL ESTIMATES THE TRANSACTION PRICE FOR PATIENTS WITH DEDUCTIBLES AND COINSURANCE AND FROM THOSE WHO ARE UNINSURED BASED ON HISTORICAL EXPERIENCE AND CURRENT MARKET CONDITIONS. THE INITIAL ESTIMATE OF THE TRANSACTION PRICE IS DETERMINED BY REDUCING THE STANDARD CHARGES, BY ANY CONTRACTUAL ADJUSTMENT, DISCOUNTS, AND IMPLICIT PRICE CONCESSIONS. SUBSEQUENT CHANGES TO THE ESTIMATE OF THE TRANSACTION PRICE ARE GENERALLY RECORDED AS ADJUSTMENT TO NET PATIENT SERVICE REVENUE IN THE PERIOD OF THE CHANGE. SUBSEQUENT CHANGES THAT ARE DETERMINED TO BE THE RESULT OF AN ADVERSE CHANGE IN THE PATIENT'S ABILITY TO PAY ARE RECORDED AS BAD DEBT EXPENSE. CONSISTENT WITH THE HOSPITAL'S MISSION, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THEREFORE, THE HOSPITAL HAS DETERMINED IT HAS PROVIDED IMPLICIT PRICE CONCESSIONS TO UNINSURED PATIENTS AND OTHER PATIENT BALANCES (FOR EXAMPLE, COPAYS AND DEDUCTIBLES). THE IMPLICIT PRICE CONCESSIONS INCLUDED IN ESTIMATING THE TRANSACTION PRICE REPRESENT THE DIFFERENCE BETWEEN AMOUNTS BILLED TO PATIENTS AND THE AMOUNTS THE HOSPITAL EXPECTS TO COLLECT BASED ON ITS COLLECTION HISTORY WITH THOSE PATIENTS. PART III, LINE 8: 100% INCLUDED IN THE COMMUNITY BENEFIT PACKAGE. COST METHODOLOGY IS COST ACCOUNTING SYSTEM. PART VI, LINE 2: HENRY MAYO COMPLETED A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) IN TAX YEAR 2018 (FISCAL YEAR 2019), AS REQUIRED BY STATE AND FEDERAL LAW. THE COMMUNITY HEALTH NEEDS ASSESSMENT IS A PRIMARY TOOL USED BY HENRY MAYO TO DETERMINE ITS COMMUNITY BENEFIT PLAN, WHICH OUTLINES HOW IT WILL GIVE BACK TO THE COMMUNITY, IN THE FORM OF HEALTH CARE AND OTHER COMMUNITY SERVICES, TO ADDRESS UNMET COMMUNITY NEEDS. THE ASSESSMENT INCORPORATED COMPONENTS OF PRIMARY DATA COLLECTION AND SECONDARY DATA ANALYSIS THAT FOCUS ON THE HEALTH AND SOCIAL NEEDS OF THE SERVICE AREA. PART VI, LINE 3: PAGE 9- 11 OF THE COMMUNITY BENEFIT PACKAGE WHICH IS ATTACHED. PART VI, LINE 4: PAGE 4 - 6 OF THE COMMUNITY BENEFIT PACKAGE WHICH IS ATTACHED. PART VI, LINE 5: PAGE 9-17 OF THE COMMUNITY BENEFIT PACKAGE WHICH IS ATTACHED. PART VI, LINE 7, REPORTS FILED WITH STATES CA 1 HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION 23845 MCBEAN PKWY VALENCIA CA 91355 953849903 501(C)(3) 641760 TO SUPPORT GENERAL OPERATIONS OF THE FOUNDATION, AN AFFILIATE OF THE HOSPITAL. WILLIAM S HART UNION HIGH SCHOOL DISTRICT 21380 CENTRE POINTE PARKWAY SANTA CLARITA CA 91350 611454418 501(C)(3) 154778 TO PROVIDE ATHLETIC TRAINERS AT HIGH SCHOOLS IN THE COMMUNITY TO HELP REDUCE INJURIES AND KEEP STUDENT ATHLETES SAFE SANTA CLARITA VALLEY ECONOMIC 26455 ROCKWELL CANYON ROAD UNIVERSITY CENTER 263 VALENCIA CA 91355 954133918 501(C)(3) 26800 TO SUPPORT LOCAL ECONOMIC DEVELOPMENT ID ME PROMOTIONS 18401 BURBANK BLVD SUITE 116 TARZANA CA 91356 470941148 501(C)(3) 13390 TO SUPPORT COMMUNITY HEALTH EDUCATION UNITED STATES POSTAL SERVICE 28201 FRANKLIN PARKWAY SANTA CLARITA CA 91383 410760000 GOVERNMENT 10265 TO PROVIDE COMMUNITY HEALTH EDUCATION THROUGH YOUR HEALTH MAGAZINE 2021 AMERICAN CANCER SOCIETY 25020 W AVENUE STANFORD SUITE170 VALENCIA CA 91355 131788491 501(C)(3) 7500 COMMUNITY CANCER EDUCATION 6 0 CHARITY CARE (GROSS CHARGES) - HENRY MAYO NEWHALL HOSPITAL 1141 5338957 PART I, LINE 2: THE HOSPITAL ASSISTS INDIVIDUALS WHO ARE UNINSURED OR UNDERINSURED BY PROVIDING CHARITY CARE. THIS IS APPLIED BY FOLLOWING THE HOSPITAL'S CHARITY CARE POLICY. THIS POLICY IS ADMINISTERED THROUGH THE PATIENT FINANCIAL SERVICE AND PATIENT ACCESS DEPARTMENTS OF THE HOSPITAL. PART II: THE HOSPITAL SUPPORTS (PROVIDES GRANTS TO) ORGANIZATIONS THAT EITHER DO WORK IN AREAS RELATED TO THE HEALTH NEEDS IDENTIFIED IN OUR COMMUNITY HEALTH NEEDS ASSESSMENT, AND TO ORGANIZATIONS THAT SUPPORT ECONOMIC DEVELOPMENT. FOR THE HEALTH-RELATED ACTIVITIES WE TRACK HOW MANY PEOPLE WE REACH AT PARTICULAR EVENTS, CLASSES OR SEMINARS. FOR ECONOMIC ACTIVITIES WE SUPPORT ORGANIZATIONS THAT HAVE BROAD COMMUNITY PARTICIPATION. GRANTS ARE ALSO PROVIDED TO SUPPORT GENERAL OPERATIONS OF HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION, AN AFFILIATE TO THE HOSPITAL. PART III: PATIENTS MEETING CERTAIN CRITERIA UNDER THE CHARITY CARE POLICY MAY RECEIVE HEALTHCARE SERVICES AT NO CHARGE OR AT AMOUNTS LESS THAN ESTABLISHED RATES. X 1 1 X X X X 1 1 0 0 0 0 0 1 0 ROGER E SEAVER PRESIDENT/CEO 508472 0 223000 0 96380 0 33750 0 43216 0 904818 0 159000 0 KINGMAN HO MD CHIEF MEDICAL OFFICER (THROUGH 01/20 403908 0 58732 0 124800 0 33750 0 23533 0 644723 0 0 0 TED D SIROTTA SR VP/CFO 340548 0 59051 0 45852 0 33750 0 28054 0 507255 0 0 0 LARRY R KIDD SR VP/CCO 349366 0 55356 0 47028 0 33750 0 12172 0 497672 0 0 0 RAY B MOSS VP/CIO 256121 0 31084 0 34200 0 33750 0 23955 0 379110 0 0 0 MARK A PULEO VP/CHRO 227603 0 30409 0 28046 0 33750 0 28924 0 348732 0 0 0 JONATHAN S MILLER VP-FACILTY/SUPPORT (THROUGH 05/2020) 91173 0 34049 0 186389 0 8125 0 6726 0 326462 0 0 0 MARIA SARTE CLINCAL RN 230372 0 0 0 0 0 11519 0 0 0 241891 0 0 0 CARISSA BORTUGNO DIRECTOR PHARMACY 173795 0 0 0 20177 0 10103 0 26425 0 230500 0 0 0 LISA BARRETT CLINCAL RN 191798 0 0 0 3660 0 9923 0 11384 0 216765 0 0 0 KIMBERLY CLARK CLINCAL RN 181731 0 0 0 9474 0 2700 0 21283 0 215188 0 0 0 JOSEPHINE KAPLAN DIRECTOR CASE MANAGEMENT 166578 0 5000 0 19564 0 0 0 16402 0 207544 0 0 0 JENNIFER R CASTALDO VP/CNO (THROUGH 05/2020) 99446 0 26311 0 51846 0 8125 0 8190 0 193918 0 0 0 PART I, LINES 4A-B SOME EMPLOYEES RECEIVED A SEVERANCE PAYMENT DURING THE CALENDER YEAR. THE TERMS AND CONDITIONS OF THE CONFIDENTIAL SEVERANCE AGREEMENT ARE AVAILABLE TO THE INTERNAL REVENUE SERVICE UPON REQUEST. HENRY MAYO NEWHALL MEMORIAL HOSPITAL HAS A SERP (SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN) OF WHICH ONLY ONE OF ITS EMPLOYEES PARTICIPATES, ROGER SEAVER. THE AMOUNT OF BENEFIT PAID IN THE CURRENT YEAR INCLUDED ON SCHEDULE J, PART II, (B)(II) IS $164,000. PART I, LINE 7 BONUSES ARE TIED TO QUANTITATIVE AND QUALITATIVE CRITERIA. ONE OF THE CRITERIA FOR THE BONUSES IS TIED TO FINANCIAL METRICS SUCH AS EBITDA MARGIN AND ACHIEVING COST PER UNIT OF SERVICE. A CA STATEWIDE COMMUNITIES DEVELOPMENT AUTHORITY 680164610 13080SCJ1 2014-02-05 70780579 FINANCE AND REFINANCE FACILITY 1 0 0 B CALIFORNIA PUBLIC FINANCE AUTHORITY 474447476 13057EAL8 2017-02-03 115072912 FINANCE AND REFINANCE FACILITY 0 0 0 C CALIFORNIA PUBLIC FINANCE AUTHORITY 474447476 13057EDN1 2021-03-10 33921350 REFINANCE SERIES 2013A AND 2013B BONDS 0 0 0 D CALIFORNIA PUBLIC FINANCE AUTHORITY 474447476 13057EDW1 2021-03-10 6539029 FINANCE AND REFINANCE FACILITY 0 0 0 A 4475000 59665000 70780579 1141054 1692946 29092467 38854112 2017 0 1 1 1 B 780000 115072912 1455316 85000000 28194396 2019 1 0 1 1 C 33921350 221771 33699579 2021 1 0 1 1 D 6539029 39029 6500000 0 0 0 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 C 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 D 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 1 0 0 0 0 0 0 1 C 0 1 0 0 0 0 0 0 1 D 0 1 0 0 0 0 0 0 1 A 1 B 1 C 1 D 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: CA STATEWIDE COMMUNITIES DEVELOPMENT AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 01/28/2019 DON NISHIGUCHI DON NISHIGUCHI, MD - TRUSTEE 61920 PROFESSIONAL FEES AS DETERMINED AT ARMS-LENGTH AMOUNT 0 LAKHBINDER DHANDA LAKHBINDER DHANDA, MD - TRUSTEE 28088 PROFESSIONAL FEES AS DETERMINED AT ARMS-LENGTH AMOUNT 0 KATHERINE DUNN FAMILY MEMBER OF TRUSTEE 101598 WAGES 0 PARTIKSHA DHANDA FAMILY MEMBER OF TRUSTEE 98565 WAGES 0 FORM 990, PART VI, SECTION B, LINE 11B THE BOARD OF DIRECTORS, CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER REVIEWED THE ENTIRE FORM 990 RETURN BEFORE DISTRIBUTION TO THE BOARD AND PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ALL BOARD MEMBERS ARE REQUIRED TO READ THE CONFLICT OF INTEREST POLICY AND COMPLETE A FORMAL CONFLICT OF INTEREST QUESTIONNAIRE AND RESULTS OF ANY CONFLICT, IF ANY, WOULD BE REPORTED TO THE FULL BOARD. BOARD MEMBERS ARE AWARE AND REMINDED OF THE HOSPITAL'S FIDUCIARY RESPONSIBILITY IN REPORTING CONFLICTS OF INTEREST. THERE HAVE BEEN CIRCUMSTANCES WHERE A CONFLICT OF INTEREST EXISTS AND IT HAS BEEN DISCLOSED TO THE BOARD OF DIRECTORS. THE CONFLICT OF INTEREST FORMS ARE REQUIRED TO BE UPDATED ON AN ANNUAL BASIS. IF A CONFLICT IS IDENTIFIED, THE BOARD MEMBER WOULD BE EXCUSED FROM VOTING ON ANY APPLICABLE MATTERS. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATIONS'S CEO AND EXECUTIVE MANAGEMENT COMPENSATION ARE DETERMINED THROUGH THE USE OF A COMPENSATION COMMITTEE, INDEPENDENT CONSULTANT, AND BOARD OF DIRECTOR APPROVAL. OTHER KEY EMPLOYEES AND MANAGEMENT OF THE ORGANIZATION RECEIVE PERFORMANCE REVIEWS ANNUALLY AND RATINGS ARE APPLIED THAT SUGGEST THE PERCENTAGE OF SALARY INCREASE. PERCENTAGES ARE DETERMINED THROUGH MARKET SURVEYS DONE BY HUMAN RESOURCES AND APPROVED EACH YEAR VIA THE BUDGET AND APPROVAL PROCESS. FORM 990, PART VI, SECTION C, LINE 19 THE FINANCIAL STATEMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 41,520,091. MANAGEMENT AND GENERAL EXPENSES 5,778,514. TOTAL EXPENSES 47,298,605. CONSULTING AND MANAGEMENT FEES: PROGRAM SERVICE EXPENSES 72,500. TOTAL EXPENSES 72,500. REGISTRY: PROGRAM SERVICE EXPENSES 12,372,401. MANAGEMENT AND GENERAL EXPENSES 198,244. TOTAL EXPENSES 12,570,645. OTHER PURCHASED SERVICES - CIN: MANAGEMENT AND GENERAL EXPENSES 762,430. TOTAL EXPENSES 762,430. OTHER SERVICES- CLINICS: MANAGEMENT AND GENERAL EXPENSES 44,100. TOTAL EXPENSES 44,100. FORM 990, PART XI, LINE 9: NET ASSET TRANSFER FROM HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION 1,720,497. LOSS ON BOND DEFEASANCE -12,151,157. FORM 990, PART XII, LINE 2C: NEITHER THE OVERSIGHT PROCESS FOR THE AUDIT OR THE SELECTION PROCESS OF THE INDEPENDENT ACCOUNTANT CHANGED DURING THE TAX YEAR. HENRY MAYO CARE NETWORK LLC 23845 MCBEAN PKWY VALENCIA CA 91355 824876499 HEALTHCARE NETWORK CA 477136 23088 HENRY MAYO NEWHALL MEMORIAL HOSPITAL HENRY MAYO NEWHALL CLINICS LLC 23845 MCBEAN PKWY VALENCIA CA 91355 833940984 HEALTHCARE CLINICS CA 0 48234 HENRY MAYO NEWHALL MEMORIAL HOSPITAL HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION 23845 MCBEAN PKWY VALENCIA CA 91355 953849903 RAISE FUNDS CA 501(C)(3) LINE 7 HOSPITAL 1 SANTA CLARITA HEALTHCARE ASSOCIATION 23845 MCBEAN PKWY VALENCIA CA 91355 953921194 INACTIVE CA 501(C)(3) LINE 3 HOSPITAL 0 TOWER IMAGING VALENCIA 13400 RIVERSIDE DR STE 102 SHERMAN OAKS CA 91423 201345767 RADIOLOGY SERVICES CA HOSPITAL RELATED 298433 1031984 0 0 0.50000 HENRY MAYO NEWHALL URGENT CARE CLINICS LLC 23929 MCBEAN PARKWAY STE 102 VALENCIA CA 91355 843120192 HEALTHCARE CLINICS CA HOSPITAL RELATED -282078 935042 0 0 0.51000 KECK MEDICINE OF USC AND HENRY MAYO NEWHALL 1441 EASTLAKE AVE LOS ANGELAS CA 90033 853779519 MEDICAL CENTER CA HOSPITAL RELATED -400 1121956 0 0 0.50000 HENRY MAYO MANAGEMENT SERVICE ORGANIZATION 23845 MCBEAN PKWY VALENCIA CA 91355 475250569 MANAGEMENT CA HOSPITAL C 1035848 1300329 1.00000 1 0 1 1 1 0 0 0 0 0 1 1 1 1 1 1 1 0 1 1 HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION B 641760 ACTUAL AMOUNT HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION C 732637 AMOUNT GUARANTEED HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION D 11352655 ACTUAL AMOUNT HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION K 849738 ACTUAL AMOUNT HENRY MAYO MSO D 600000 ACTUAL AMOUNT KECK MEDICINE OF USC AND HENRY MAYO NEWHALL B 1000000 ACTUAL AMOUNT TOWER IMAGING VALENCIA LLC J 570235 ACTUAL AMOUNT