2022-08-15T16:26:56-05:00 2021-09-30 111986323 MARCUM LLP 9 PARKWAY NORTH SUITE 200 DEERFIELD IL 60015 990 2020-10-01 370724112 GOOD SAMARITAN HOME OF QUINCY GOOD 2172238717 2130 HARRISON STREET QUINCY IL 62301 EMMA MCLEOD COO 2172238717 2022-08-12 1 EMMA MCLEOD 999009999 ARIANA WARREN P01441395 8472826300 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z EMMA MCLEOD 2130 HARRISON STREET QUINCY IL 62301 22512498 0 X WWW.GSHQ.ORG X 1925 IL SUPERIOR CHRISTIAN SERVICE IN A CHARITABLE COMMUNITY. 15 15 424 70 0 0 818771 3633141 16017464 14579127 506311 783734 299639 101573 17642185 19097575 0 0 0 0 12465245 12386384 0 0 0 6062803 6617015 18528048 19003399 -885863 94176 35532418 32676656 10558142 7286638 24974276 25390018 X SERVING OUR RESIDENTS, THEIR FAMILIES, STAFF AND THE GREATER COMMUNITY THROUGH COMPASSIONATE CARE. 0 0 13406046 11229255 GOOD SAMARITAN HOME OF QUINCY OPERATES A SKILLED NURSING FACILITY. THIS FACILITY OFFERS 24-HOUR CARE. THERE IS AN EXTENSIVE ACTIVITY PROGRAM THAT INCLUDES OUTINGS, CRAFTS, COOKING, ENTERTAINMENT, AND DAILY CHAPEL SERVICES TO HELP KEEP RESIDENTS ACTIVE. GOOD SAMARITAN PROVIDES CHARITY CARE TO PATIENTS WHO ARE UNABLE TO PAY FOR SERVICES. DURING FY 2021, THE ORGANIZATION SERVED A DAILY AVERAGE OF 131 RESIDENTS THROUGH ITS SKILLED NURSING FACILITY. 2072540 2256727 GOOD SAMARITAN HOME OF QUINCY OFFERS 180 COTTAGES FOR INDEPENDENT LIVING. THEY ALL OFFER THE PRIVACY AND INDEPENDENCE OF HAVING YOUR OWN APARTMENT. COTTAGERS ARE WELCOME TO PARTICIPATE IN ACTIVITIES AT THE HOME, SUCH AS AQUATIC EXERCISE CLASSES, OUTINGS, ENTERTAINMENT, AND DAILY CHAPEL SERVICES. DURING FY 2021, THE ORGANIZATION SERVED A DAILY AVERAGE OF 169 RESIDENTS THROUGH ITS INDEPENDENT LIVING PROGRAM. 1325873 1093145 GOOD SAMARITAN HOME OF QUINCY OFFERS AN ASSISTED LIVING FACILITY. THERE ARE SEVERAL ROOM SIZES, INCLUDING APARTMENT STYLE WITH A KITCHENETTE IN EACH ROOM. RESIDENTS ARE ALSO WELCOME TO USE A COMMUNAL FULL KITCHEN. THERE IS ALSO AN EXTENSIVE ACTIVITY PROGRAM THAT INCLUDES OUTINGS, CRAFTS, COOKING, ENTERTAINMENT, AND DAILY CHAPEL SERVICES. DURING FY 2021, THE ORGANIZATION SERVED A DAILY AVERAGE OF 23 RESIDENTS THROUGH ITS ASSISTED LIVING FACILITY. GOOD SAMARITAN PROVIDES MANAGEMENT SERVICES UNDER A MANAGEMENT AGREEMENT TO OPERATE AND ASSIST WITH FUNDRAISING NEEDS OF THE FOUNDATION. IN 2021, THE FOUNDATION PAID GOOD SAMARITAN $200,000 FOR THESE SERVICE. 16804459 1 1 0 1 0 0 0 0 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 10 0 424 1 0 0 0 0 0 0 0 0 0 0 0 0 X 15 15 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X MATTHEW DORIAN 2172238717 2130 HARRISON STREET QUINCY IL 62301 RANDY RILEY PRESIDENT 0.50 1.00 X X 0 0 0 PAUL KEMNER 1ST VP 0.50 X X 0 0 0 GARY BLICKHAN 2ND VP 0.50 1.00 X X 0 0 0 JEFF SPEAR SECRETARY/TREASURER 0.50 X X 0 0 0 RICHARD BOWMAN DIRECTOR 0.50 X 0 0 0 ANDREW CASHMAN DIRECTOR 0.50 X 0 0 0 CHRIS DANIELS DIRECTOR 0.50 X 0 0 0 SHARON HIGGINS DIRECTOR 0.50 X 0 0 0 PATRICIA HUBBARD DIRECTOR 0.50 X 0 0 0 JERRY JACKSON DIRECTOR 0.50 X 0 0 0 MIKE OBERDAHLHOFF DIRECTOR 0.50 X 0 0 0 JOE OTT DIRECTOR 0.50 X 0 0 0 ROB OVERHOLSER DIRECTOR 0.50 X 0 0 0 LARRY SHEPHERD DIRECTOR 0.50 X 0 0 0 STEVE WAVERING DIRECTOR 0.50 X 0 0 0 CHARLES NEWTON CEO 40.00 5.00 X 128618 0 9821 EMMA MCLEOD COO 40.00 X 81564 0 6348 DAVID STIEGLITZ CFO - UNTIL 3/2021 40.00 10.00 X 79502 0 21738 MATTHEW DORIAN CFO - AS OF 5/2021 40.00 5.00 X 0 0 0 289684 0 37907 1 0 0 0 MIDWEST PHYSICAL THERAPY 62718 COLLECTION CENTER DRIVE CHICAGO IL 606930627 CONTRACTED THERAPY PROVIDER - PT, OT, ST 372723 GALE HEALTHCARE SOLUTIONS LLC PO BOX 4729 WINTER PARK FL 327934729 STAFFING PROVIDER 234074 MATRIXCARE PO BOX 1414 MINNEAPOLIS MN 554801414 ELECTRONIC MEDICAL RECORDS & A/R BILLING 133991 INTEGRATED TECHNOLOGY ASSOCIATES CORP 202-C WEST MAIN GLEN CARBON IL 62034 CONTRACTED IT PROVIDER 118346 4 3150 408336 3074613 147042 3633141 NET PATIENT SERVICE REVENUE 900099 12165533 12165533 COTTAGE RENTAL 900099 2213252 2213252 MANAGEMENT FEE 900099 200000 200000 CAFETERIA 900099 342 342 14579127 138743 138743 4059914 3414923 644991 644991 644991 MISCELLANEOUS INCOME 900099 101573 101573 101573 19097575 14579127 0 885307 336565 336565 9931270 9327501 603769 154233 144933 9300 1175035 1048277 126758 789281 714287 74994 40330 40330 76814 76814 52181 52181 437590 433257 4333 26943 26943 563620 387226 176394 304283 267355 36928 767763 696641 71122 15891 14302 1589 4242 4242 126383 126383 1685597 1517037 168560 274434 249735 24699 MEDICAL SUPPLIES/DRUGS 908610 908610 FOOD AND PROG. SUPPLIES 788812 709931 78881 PROVIDER TAX 384335 384335 OTHER 135265 1032 134233 23922 23922 19003399 16804459 2198940 0 3150 1650 2975681 230789 12050 808149 896155 70839 144318 50839757 27507021 24457361 23332736 7205188 7869254 201754 35532418 32676656 1248796 1124475 1990009 1855900 4438900 4148259 140797 158004 2739640 10558142 7286638 X 24874276 25290018 100000 100000 24974276 25390018 35532418 32676656 94176 321566 0 X 0 1 X 1 1 1 X 2131725 214672 380771 818771 3633140 7179079 16810671 16670514 16196785 16017464 14579127 80274561 18942396 16885186 16577556 16836235 18212267 87453640 265450 223725 166008 340813 322616 1318612 0 265450 223725 166008 340813 322616 1318612 86135028 199906 196707 179582 150616 138743 865554 199906 196707 179582 150616 138743 865554 39920 15614 54479 135491 101574 347078 19182222 17097507 16811617 17122342 18452584 88666272 0.97150 0.96670 0.00980 0.01230 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS INCOME - 2016 AMOUNT: $ 39,920. 2017 AMOUNT: $ 15,614. 2018 AMOUNT: $ 54,479. 2019 AMOUNT: $ 135,491. 2020 AMOUNT: $ 101,574. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 297 297 0 PART II-B, LINE 1: THE ORGANIZATION PAYS DUES TO LEADING AGE ILLINOIS. THE PORTION OF DUES ATTRIBUTABLE TO LOBBYING IS $297 0 1 X 106417 15356 732 121041 100000 6972 555 106417 100000 100000 100000 100000 100000 100000 1.00000 0 0 1135037 1135037 37028017 18591106 18436911 9929660 7038092 2891568 2747043 1877823 869220 23332736 X 19366960 321566 321566 19045394 52181 52181 19097575 18951218 0 18951218 52181 52181 19003399 PART IV, LINE 2B: THE ORGANIZATION IS THE TRUSTEE OF FUNDS RECEIVED ON BEHALF OF VARIOUS RESIDENTS. THE ORGANIZATION HAS A FIDUCIARY RESPONSIBILITY FOR THE ADMINISTRATION OF THE BANK ACCOUNT AND THE DISTRIBUTION OF THE FUNDS TO RESIDENTS. PART V, LINE 4: THE ORGANIZATION'S ENDOWMENT IS INVESTED TO PROVIDE INVESTMENT RETURNS TO FUND GENERAL OPERATIONS. PART X, LINE 2: THE ORGANIZATION DOES NOT BELIEVE THAT IT HAS TAKEN ANY TAX POSITIONS THAT WOULD REQUIRE THE RECORDING OF ANY ADDITIONAL TAX LIABILITY NOR DOES IT BELIEVE THAT THERE ARE ANY UNREALIZED TAX BENEFITS THAT WOULD EITHER INCREASE OR DECREASE WITHIN THE NEXT TWELVE MONTHS. IF THE ORGANIZATION WERE TO INCUR AN INCOME TAX LIABILITY IN THE FUTURE, THE INTEREST ON ANY TAX LIABILITY WOULD BE REPORTED AS INTEREST EXPENSE AND PENALTIES ON ANY INCOME TAX LIABILITY WOULD BE REPORTED AS INCOME TAXES. X X 0 0 0 0 0 0 0 0 0 A CITY OF QUINCY 376000378 2013-07-11 8000000 FINANCE PORTION OF GOOD SAMARITAN HOME 0 0 0 A 3210393 7960000 7960000 2013 1 0 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 1 0 0 0 1 A 1 FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS 7 TYPES OF MEMBERS: PATRON MEMBER, SUSTAINING MEMBER, SUPPORTING MEMBERS, ASSOCIATE MEMBER, REGULAR MEMBER, AND LIFETIME MEMBER. FORM 990, PART VI, SECTION A, LINE 7A EACH MEMBER OVER 18 YEARS OF AGE OF EACH CLASS SHALL BE ENTITLED TO ONE VOTE ON EACH MATTER SUBMITTED TO A VOTE OF THE MEMBERS. MEMBERS SHALL ATTEND AN ANNUAL MEETING TO ELECT BOARD MEMBERS. TWELVE (12) DIRECTORS OF THE BOARD SHALL BE ELECTED BY THE MEMBERSHIP, EACH SERVING A THREE-YEAR TERM, WHICH TERMS SHALL BE STAGGERED SO FOUR DIRECTORS SHALL BE ELECTED AT EACH ANNUAL MEETING. UP TO SEVEN (7) DIRECTORS OF THE BOARD MAY BE APPOINTED FROM ONE OR MORE OF THE FOLLOWING CORPORATION AFFILIATES AS FOLLOWS: UP TO TWO (2) DIRECTORS MAY BE APPOINTED BY THE IOWA CONFERENCE OF THE UNITED CHURCH OF CHRIST, UP TO THREE (3) DIRECTORS MAY BE APPOINTED BY ILLINOIS CONFERENCE OF THE UNITED CHURCH OF CHRIST, UP TO ONE (1) DIRECTOR MAY BE APPOINTED BY THE AUXILIARY OF THE CORPORATION, AND UP TO ONE (1) DIRECTOR MAY BE APPOINTED BY THE UNCLE SAMS OF THE CORPORATION, BOTH OF WHOM (AUXILIARY AND UNCLE SAMS) SHALL ALSO BE A MEMBER OF THE CORPORATION. THE APPOINTED MEMBERS OF THE BOARD SHALL SERVE FOR SUCH A PERIOD OF TIME, WITHOUT LIMITATION, AS IS DETERMINED BY THE APPOINTING BODY. FORM 990, PART VI, SECTION A, LINE 7B EACH MEMBER OVER 18 YEARS OF AGE OF EACH CLASS SHALL BE ENTITLED TO ONE VOTE ON EACH MATTER SUBMITTED TO A VOTE OF THE MEMBERS. MEMBERS SHALL ATTEND AN ANNUAL MEETING TO ELECT BOARD MEMBERS. TWELVE (12) DIRECTORS OF THE BOARD SHALL BE ELECTED BY THE MEMBERSHIP, EACH SERVING A THREE-YEAR TERM, WHICH TERMS SHALL BE STAGGERED SO FOUR DIRECTORS SHALL BE ELECTED AT EACH ANNUAL MEETING. UP TO SEVEN (7) DIRECTORS OF THE BOARD MAY BE APPOINTED FROM ONE OR MORE OF THE FOLLOWING CORPORATION AFFILIATES AS FOLLOWS: UP TO TWO (2) DIRECTORS MAY BE APPOINTED BY THE IOWA CONFERENCE OF THE UNITED CHURCH OF CHRIST, UP TO THREE (3) DIRECTORS MAY BE APPOINTED BY ILLINOIS CONFERENCE OF THE UNITED CHURCH OF CHRIST, UP TO ONE (1) DIRECTOR MAY BE APPOINTED BY THE AUXILIARY OF THE CORPORATION, AND UP TO ONE (1) DIRECTOR MAY BE APPOINTED BY THE UNCLE SAMS OF THE CORPORATION, BOTH OF WHOM (AUXILIARY AND UNCLE SAMS) SHALL ALSO BE A MEMBER OF THE CORPORATION. THE APPOINTED MEMBERS OF THE BOARD SHALL SERVE FOR SUCH A PERIOD OF TIME, WITHOUT LIMITATION, AS IS DETERMINED BY THE APPOINTING BODY. FORM 990, PART VI, SECTION B, LINE 11B THE FEDERAL FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM BASED ON THE AUDITED FINANCIAL STATEMENTS AND INFORMATION PROVIDED BY THE ACCOUNTING DEPARTMENT OF THE ORGANIZATION. THE FORM 990 IS SENT TO THE BOARD MEMBERS FOR REVIEW BEFORE FILING WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C EACH BOARD MEMBER IS REQUIRED TO SIGN A CONFLICT OF INTEREST STATEMENT AND CONFIDENTIALITY AGREEMENT. ANY CONFLICTS ARE ADDRESSED IMMEDIATELY OR BOARD MEMBERS ABSTAIN FROM VOTING IF THERE APPEARS TO BE A CONFLICT ON A CERTAIN ISSUE. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION OF THE CEO, AND CFO IS REVIEWED ANNUALLY. FOR THE CEO THIS REVIEW WAS PERFORMED BY THE EXECUTIVE COMMITTEE. FOR THE CFO, THIS REVIEW WAS PERFORMED BY THE CEO AND BOARD OF DIRECTORS. COMPENSATION SURVEYS ARE UTILIZED DURING THE REVIEW PROCESSES. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE BY REQUEST. GOOD SAMARITAN HOME FOUNDATION 2130 HARRISON STREET QUINCY IL 62301 461945910 SUPPORTING ORGANIZATION IL 501(C)(3) LINE 12B, II GOOD SAMARITAN HOME OF QUINCY 1 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 GOOD SAMARITAN HOME FOUNDATION C 405059 FMV GOOD SAMARITAN HOME FOUNDATION L 200000 FMV