2022-04-20T16:00:36-05:00 2021-06-30 390758449 WIPFLI LLP 170 NORTH RADNOR-CHESTER ROAD SUITE 200 RADNOR PA 19087 990 2020-07-01 390816900 PINE HAVEN CHRISTIAN HOME INC PINE 9204672401 531 GIDDINGS AVENUE SHEBOYGAN FALLS WI 53085 LINDA EVRAETS CHIEF FINANCIAL OFFICER 9204672401 2022-03-28 1 LINDA EVRAETS 999009999 SOLOMON MARDAKHAEV P01806552 6105653930 2022-03-28 3 AAL1 IAL1 2020 2022-09-23 18:48:47Z RONALD WALVOORT 531 GIDDINGS AVENUE SHEBOYGAN FALLS WI 53085 25580922 0 X WWW.PINEHAVEN.ORG X 1950 WI PINE HAVEN CHRISTIAN HOME, INC. (PINE HAVEN CHRISTIAN COMMUNITIES) WILL PROVIDE THE AGING POPULATION WE SERVE AN ENVIRONMENT THAT IS A CHRIST-CENTERED, SAFE HAVEN OFFERING QUALITY, COMPASSIONATE CARE. 15 15 538 76 77279 0 266001 2880254 17794613 16225478 145134 126241 83228 87818 18288976 19319791 0 0 0 0 10140723 9936430 0 0 9542 8240237 8655273 18380960 18591703 -91984 728088 43487731 46878229 28748958 27084219 14738773 19794010 PINE HAVEN CHRISTIAN COMMUNITIES WILL PROVIDE THE AGING POPULATION WE SERVE AN ENVIRONMENT THAT IS A CHRIST-CENTERED, SAFE HAVEN OFFERING QUALITY, COMPASSIONATE CARE. 0 0 17087797 0 16225478 PINE HAVEN CHRISTIAN HOME, INC. PROVIDES HOUSING, HEALTH CARE AND OTHER RELATED SERVICES TO RESIDENTS IN A NURSING HOME, ASSISTED LIVING FACILITIES, AND SENIOR HOUSING FACILITIES. PINE HAVEN CHRISTIAN HOME, INC. OPERATES A SKILLED NURSING FACILITY, AN ASSISTED LIVING COMMUNITY BASED RESIDENTIAL FACILITY (CBRF) INCLUDING MEMORY CARE AND AN ASSISTED LIVING RESIDENTIAL CARE APARTMENT COMPLEX (RCAC) AT ITS HAVEN DRIVE LOCATION; A CBRF INCLUDING MEMORY CARE AT ITS GIDDINGS AVE. LOCATION; AND A CBRF AND SENIOR HOUSING UNITS AT ITS OOSTBURG LOCATION. 17087797 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 63 0 538 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 15 15 0 0 1 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X LINDA EVRAETS 9204672401 531 GIDDINGS AVENUE SHEBOYGAN FALLS WI 53085 RONALD WALVOORT CHIEF EXECUTIVE OFFICER 40.00 1.00 X 168105 0 31602 STANLEY KAYMEN CHIEF FINANCIAL OFFICER (THRU MARCH) 40.00 1.00 X 128342 0 3836 SHANNON OTTEN CHIEF OPERATING OFFICER 40.00 1.00 X 100848 0 25933 LINDA EVRAETS CHIEF FINANCIAL OFFICER (BEG. MARCH) 40.00 1.00 X 0 0 0 JERITH BUTEYN-GIER PRESIDENT (THRU SEPTEMBER)/DIRECTOR 1.00 1.00 X X 0 0 0 DENNIS BEACH PRESIDENT (BEG. SEPTEMBER) 1.00 1.00 X X 0 0 0 DARRELL HAUSE VICE PRESIDENT (BEG. SEPTEMBER) 1.00 1.00 X X 0 0 0 KEVIN VELDHORST SECRETARY (BEG. SEPTEMBER) 1.00 X X 0 0 0 JACK HOFFMAN TREASURER 1.00 1.00 X X 0 0 0 JEFF BROETZMANN DIRECTOR 1.00 X 0 0 0 ROGER BUYZE DIRECTOR 1.00 X 0 0 0 TIM GORTER DIRECTOR 1.00 1.00 X 0 0 0 DR CURTIS HANCOCK DIRECTOR 1.00 X 0 0 0 DARRYL HARMELINK DIRECTOR 1.00 X 0 0 0 MARY HUENINK DIRECTOR 1.00 X 0 0 0 NORENE HUIBREGTSE DIRECTOR 1.00 X 0 0 0 GLENN LEMMENES DIRECTOR (THRU SEPTEMBER) 1.00 X 0 0 0 BETTY MOODY DIRECTOR (THRU SEPTEMBER) 1.00 X 0 0 0 VIRGIL NAVIS DIRECTOR 1.00 X 0 0 0 ROBERT NYHUIS DIRECTOR 1.00 1.00 X 0 0 0 JEWEL RAUWERDINK DIRECTOR 1.00 1.00 X 0 0 0 397295 0 61371 3 0 1 0 GREENFIELD REHABILITATION AGENCY INC 19395 WEST CAPITAL DRIVE SUITE 200 BROOKFIELD WI 53005 THERAPY SERVICES 803630 STAT NURSING SOLUTIONS LLC 1117 SOUTH 16TH STREET SHEBOYGAN WI 53081 STAFFING SERVICES 451985 ALLIANCE SERVICES INC 910 SOUTH MAIN STREET WEST BEND WI 53095 STAFFING SERVICES 227541 AYA HEALTHCARE INC 5930 CORNERSTONE COURT WEST SUITE SAN DIEGO CA 92121 STAFFING SERVICES 153484 ELITE NURSES INC 808 BAYLAND COURT GREEN BAY WI 54304 STAFFING SERVICES 150336 8 186640 2693614 2880254 CBRF REVENUE 623000 9544676 9544676 NURSING HOME REVENUE 623000 4747073 4747073 RESIDENTIAL CARE REVENUE 623000 1758544 1758544 INDEPENDENT LIVING REVENUE 623000 175185 175185 16225478 171039 171039 6216333 6241376 19755 -25043 -19755 -44798 -44798 MANAGEMENT SERVICES REVENUE 541610 77279 77279 10539 10539 87818 19319791 16225478 77279 136780 X 501788 501788 7882770 7183804 692545 6421 94943 94943 826561 824376 1746 439 630368 539002 91366 49771 49771 30000 30000 26774 26774 2927260 2926798 462 104561 104561 88754 32321 56433 181342 181342 791039 783253 7786 14880 14880 847917 836266 11651 1755340 1730836 24504 173599 173599 FOOD EXPENSES 762235 762235 MEDICAL SUPPLIES 431820 431820 MAINTENANCE & REPAIRS 156954 156954 PROVISION FOR BAD DEBTS 5600 5600 307427 305207 2220 18591703 17087797 1494364 9542 583244 395916 566232 754471 647311 862366 117722 135156 49394200 17490097 33167722 31904103 8403262 12826217 2238 0 43487731 46878229 1281591 1190699 277764 201169 25272503 25692351 1917100 0 28748958 27084219 X 14738773 19782821 11189 14738773 19794010 43487731 46878229 X 728088 48958 4278191 X 0 1 X 1 0 X 230821 189886 246929 266001 2880254 3813891 16942320 17895865 17518688 17794613 16225478 86376964 21810 21201 20476 10774 10539 84800 17194951 18106952 17786093 18071388 19116271 90275655 0 0 0 90275655 54394 75276 121539 140920 171039 563168 1132 1132 54394 75276 121539 142052 171039 564300 17249345 18182228 17907632 18213440 19287310 90839955 0.99380 0.99530 0.00620 0.00470 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1345944 1345944 43318785 14870147 28448638 4363061 2619950 1743111 366410 366410 31904103 X X 0 0 0 0 0 0 0 0 0 RONALD WALVOORT CHIEF EXECUTIVE OFFICER 163571 0 1460 0 3074 0 4748 0 26854 0 199707 0 0 0 A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 2014-05-01 10000000 ADJUSTABLE RATE REFUNDING REVENUE BONDS, SERIES 2014A 0 0 0 B WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 2014-05-01 19100000 NEW PROJECT, SERIES 2014B 0 0 0 A 2166273 10000000 10000000 2006 1 0 1 1 B 2060757 19100000 18100000 1000000 2015 0 0 1 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 A 0 0 0 1 1 0 0 0 1 B 0 0 0 0 1 0 0 0 1 A 0 B 0 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 04/13/2021 FORM 990, PART VI, SECTION A, LINE 4 THE BYLAWS HAVE BEEN UPDATED TO REFLECT THE MERGER WITH PINE HAVEN CHRISTIAN FOUNDATION HOME, INC. THE OUTREACH COMMITTEE WAS CREATED TO FUNCTION ON BEHALF OF THE BOARD OF DIRECTORS AND CARRY ON THE ACTIVITIES FORMALLY PERFORMED BY THE FOUNDATION. FORM 990, PART VI, SECTION A, LINE 6 PINE HAVEN CHRISTIAN HOME, INC. HAS ONE CLASS OF MEMBERS. A PERSON WILL BE ADMITTED TO MEMBERSHIP OF PINE HAVEN CHRISTIAN HOME, INC. UPON THE CONDITIONS THAT (I) THE INDIVIDUAL BE A MEMBER OF GOOD STANDING IN ANY CONGREGATION, AND (II) SUCH INDIVIDUAL CONSENTS TO BEING A MEMBER OF PINE HAVEN CHRISTIAN HOME, INC. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS ELECT THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF THE FORM 990 WAS PROVIDED TO ALL BOARD MEMBERS PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C 1. THE PERSONS COVERED BY THE CONFLICT OF INTEREST POLICY ARE DIRECTORS AND OFFICERS. 2. DETERMINATIONS OF WHETHER A CONFLICT EXISTS ARE MADE BY THE BOARD OF DIRECTORS. 3. ACTUAL CONFLICTS ARE REVIEWED AT THE BOARD OF DIRECTORS LEVEL. 4. IF A CONFLICT EXISTS, THE BOARD'S OPTIONS INCLUDE BUT ARE NOT LIMITED TO I) PROHIBITING THE AFFECTED DIRECTOR OR OFFICER FROM PARTICIPATING IN ANY PINE HAVEN DISCUSSION OR DECISIONS INVOLVING THE CONFLICT OF INTEREST; II) MODIFYING OR REDEFINING THE DUTIES AND RESPONSIBILITIES OF THE AFFECTED DIRECTOR OR OFFICER; III) REQUIRING THE RESIGNATION OF THE AFFECTED DIRECTOR OR OFFICER. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION FOR THE CHIEF EXECUTIVE OFFICER AND OTHER OFFICERS IS COMPARED TO INDUSTRY DATA COMPILED BY LEADING AGE WISCONSIN. THE SURVEY COMPARES COMPENSATION BASED ON THREE CRITERIA: GROSS REVENUES, GEOGRAPHIC AREA AND TOTAL BED RESPONSIBILITIES. THE CHIEF EXECUTIVE OFFICER HAS AN ANNUAL REVIEW COMPLETED BY THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC AT THIS TIME. FORM 990, PART IX, LINE 11G CNA PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 767,989. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 767,989. LPN PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 587,406. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 587,406. RN PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 363,454. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 363,454. THERAPY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 731,216. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 731,216. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 476,733. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 462. TOTAL EXPENSES 477,195. FORM 990, PART XI, LINE 9: TRANSFER DUE TO MERGER OF PINE HAVEN CHRISTIAN HOME FOUNDATION, INC. 4,278,191. PINE HAVEN CHRISTIAN HOME FOUNDATION INC 531 GIDDINGS AVENUE SHEBOYGAN WI 53085 391963866 TO SUPPORT PINE HAVEN CHRISTIAN HOME, INC. WI 501(C)(3) LINE 12A, I PINE HAVEN CHIRSTIAN HOME INC 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 PINE HAVEN CHRISTIAN HOME FOUNDATION INC C 186640 FAIR MARKET VALUE