2022-05-04T18:25:10-05:00 2021-06-30 910189318 MOSS ADAMS LLP 101 SECOND STREET SUITE 900 SAN FRANCISCO CA 94105 990 2020-07-01 680437840 PETALUMA HEALTH CENTER INC PETA 7075597500 1179 NORTH MCDOWELL BLVD PETALUMA CA 94954 MOLLY JOUANEH CFO 7075597500 2022-04-28 1 MOLLY JOUANEH 999009999 MICHAEL LUMSDEN P01262236 4159561500 3 AAL1 IAL1 2020 2022-09-23 18:48:47Z KATHRYN POWELL 1455 N MCDOWELL BLVD PETALUMA CA 94954 67331720 0 X WWW.PHEALTHCENTER.ORG X 1999 CA TO ENSURE ACCESS & PROVIDE HIGH QUALITY PREVENTION-FOCUSED HEALTH CARE FOR THE COMMUNITIES WE SERVE. 15 14 573 51 0 0 5027133 26697201 37527882 38580965 6755 150 1288063 2008112 43849833 67286428 0 0 0 0 34916968 39139803 0 0 0 13228251 14688823 48145219 53828626 -4295386 13457802 37659318 54716771 25207416 28836475 12451902 25880296 X THE PETALUMA HEALTH CENTER'S MISSION IS TO ENSURE ACCESS, AND TO PROVIDE HIGH QUALITY PREVENTION-FOCUSED HEALTH CARE FOR THE COMMUNITIES WE SERVE. 0 0 27427588 0 24565746 FAMILY PRACTICE SERVICES PROVIDED TO PATIENTS. THE TOTAL NUMBER OF FAMILY PRACTICE VISITS DURING FISCAL YEAR 2021 WERE 139,927. 6416946 0 4998709 GENERAL DENTISTRY AND FLUORIDE VARNISHING SERVICES PROVIDED TO PATIENTS. THE TOTAL NUMBER OF DENTAL VISITS DURING FISCAL YEAR 2021 WERE 22,004. 2859155 0 2299078 OBSTETRIC AND GYNECOLOGY SERVICES PROVIDED TO PATIENTS, INCLUDING BIRTHING AND PREGNANCY SERVICES. THE TOTAL NUMBER OF OB/GYN VISITS DURING FISCAL YEAR 2021 WERE 11,242. 7168228 0 6717432 OTHER PROGRAM SERVICES INCLUDE INTEGRATED BEHAVIORAL HEALTH, VISION, WELLNESS, AND NUTRITION PROGRAMS FOR PATIENTS; ADDITIONALLY, THE ORGANIZATION OPERATES A NURSE PRACTITIONER AND PHYSICIAN'S ASSISTANT RESIDENCY PROGRAM TO TRAIN NEW NP/PA'S IN THE COMMUNITY MEDICINE MODEL OF CARE. 7168228 0 6717432 43871917 1 1 0 1 0 0 0 0 0 0 1 0 0 1 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 1 1 0 0 0 0 0 0 0 0 1 87 0 1 573 1 0 0 0 0 0 0 0 0 0 0 0 0 X 15 14 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 CA X MOLLY JOUANEH 7075597578 1455 N MCDOWELL BLVD PETALUMA CA 94954 KATHRYN POWELL MHA MA CHIEF EXECUTIVE OFFICER 40.00 X 318608 0 47344 KEN WEINSTOCK MD DIR. OF BEHAVIORAL HEALTH SERVICES 40.00 X 294203 0 36871 NURIT LICHT MD CHIEF MEDICAL OFFICER 40.00 X 264220 0 30314 PHILIPPE EDOUARD MD FACP FAMILY PHYSICIAN 40.00 X 248539 0 26509 DANIELLE ORYN DO MPH CHIEF MEDICAL INFORMATICS OFFICER 40.00 X 236413 0 34883 RAMONA ENGLISH DMD CHIEF DENTAL OFFICER 40.00 X 235280 0 27111 REBECCA KATZ MD PRIMARY CARE SITE DIRECTOR 36.00 X 220511 0 38477 SAFI AHMED MD MPH FAMILY PHYSICIAN 36.00 X 250346 0 8516 ANDREW ASHCROFT MD MPH FAMILY PHYSICIAN 36.00 X 211356 0 43531 JONATHAN CHOE MD ASSOC. MEDICAL DIR, WOMEN'S HEALTH 34.00 X 227682 0 15065 JANE READ MSA RN COO THROUGH 4/2021 40.00 X 219914 0 16738 CASSIE IUTZI MD MPH FAMILY PHYSICIAN 40.00 X 207239 0 27188 PEDRO TOLEDO JD MA MHSA CHIEF ADMINISTRATIVE OFFICER 40.00 X 206801 0 23047 JOHN PENDLETON MD ASSOC. MEDICAL DIRECTOR, OPERATIONS 34.00 X 204520 0 23057 CARLIN CHI MD MEDICAL DIRECTOR, PRIMARY CARE 40.00 X 188145 0 31982 MICHELLE GLANCY MBA CHIEF HUMAN RESOURCES OFFICER 40.00 X 202120 0 15782 MOLLY JOUANEH CMA CHIEF FINANCIAL OFFICER 40.00 X 187941 0 726 TIFFANY JIMENEZ RN COO START 5/2021 40.00 X 0 0 0 TONY SARNO PRES THROUGH 12/2020 / BOARD MEMBER 2.00 X X 0 0 0 ROBERT RAMIREZ VP THROUGH 1/2021 / PRES START 1/2021 2.00 X X 0 0 0 ELISA VELASQUEZ-ANDRADE PHD VICE PRESIDENT 2.00 X X 0 0 0 MARC POUNDS CPA TREASURER 2.00 X X 0 0 0 VANESSA LUNA SHANNON SECRETARY 2.00 X X 0 0 0 WILLIAM BARRETT BOARD MEMBER 2.00 X 0 0 0 CECILIA CASTANEDA BOARD MEMBER 2.00 X 0 0 0 PHOEBE ELLIS BOARD MEMBER 2.00 X 0 0 0 ELIZABETH GOLDBLATT PHD MPAHA BOARD MEMBER 2.00 X 0 0 0 TOM ISAAK BOARD MEMBER 2.00 X 0 0 0 ELAD LEVINSON LCSW BOARD MEMBER THROUGH 12/2020 2.00 X 0 0 0 GLORIA ROBINSON BOARD MEMBER 2.00 X 0 0 0 JOE TAMBE BOARD MEMBER 2.00 X 0 0 0 TERESA TAYLOR-KING BOARD MEMBER 2.00 X 0 0 0 GEORGINA WARMOTH BOARD MEMBER 2.00 X 0 0 0 CATHERINE WEST MD DRPH BOARD MEMBER 2.00 X 0 0 0 3923838 0 447141 68 0 1 0 THE MEDCOR GROUP INC 1801 W OLYMPIC BLVD PASADENA CA 91199 BILLING SERVICES 920556 ECLINICALWORKS LLC TWO TECHNOLOGY DR WESTBOROUGH MA 01581 IT SUPPORT SERVICES 480972 SERVICO BUILDING MAINTENANCE PO BOX 25 GLEN ELLEN CA 95442 JANITORIAL SERVICES 408494 BARBIER SECURITY GROUP 369-B THIRD STREET 440 SAN RAFAEL CA 94901 SECURITY SERVICES 222928 MOSS ADAMS LLP PO BOX 101822 PASADENA CA 911891822 AUDITING & TAX SERVICES 145350 11 18030679 8666522 2970356 26697201 NET PATIENT SERVICE REVENUE 621400 32066034 32066034 PERFORMANCE PAYMENTS-HEALTH PLANS 621400 4329924 4329924 PHARMACY REVENUE 621400 2185007 2185007 38580965 44745 44745 697 697 45292 -45292 -45292 -45292 OTHER REVENUE 900099 2008112 2008112 2008112 67286428 38580965 0 2008262 3393714 2118932 1274782 26377187 23031098 3346089 1055725 928870 126855 6314452 5330854 983598 1998725 1678225 320500 148152 148152 156956 156956 4639567 3006894 1632673 59950 28293 31657 893850 609205 284645 780257 625755 154502 2433274 1910217 523057 79015 53647 25368 114104 69218 44886 279706 279706 1757885 1466836 291049 147582 74923 72659 MEDICAL SUPPLIES/DRUGS 1947485 1947485 MINOR EQUIPMENT 476065 382683 93382 DUES AND SUBSCRIPTIONS 308550 189759 118791 IN-KIND EXPENSE 124349 124349 342076 294674 47402 53828626 43871917 9956709 0 9723681 8789999 263398 5194654 403854 798592 3801615 4957638 7089 71920 75933 89135 833124 565978 32200214 11990332 17937712 20209882 4612912 14038973 37659318 54716771 5812070 6560933 1051981 777217 5103793 4920353 2130189 1307236 5939899 0 5169484 15270736 25207416 28836475 X 12423256 25820596 28646 59700 12451902 25880296 37659318 54716771 13457802 -29408 0 X 0 1 X 1 1 1 X 3762595 4451384 4608360 5027133 26697201 44546673 3762595 4451384 4608360 5027133 26697201 44546673 44546673 1060 4011 9966 6755 45442 67234 210464 432814 785952 1288063 2008112 4725405 49339312 187973214 0.90290 0.87250 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5745 5745 0 PART II-B, LINE 1: THE ORGANIZATION PAYS MEMBERSHIP DUES TO THE CALIFORNIA PRIMARY CARE ASSOCIATION; A PORTION OF THOSE MEMBERSHIP DUES WERE DESIGNATED AS UTILIZED FOR LOBBYING ACTIVITIES FOR LEGISLATION PERTINENT TO THE HEALTH CARE FIELD. 1835000 1835000 17900672 5429550 12471122 4235691 1003604 3232087 4665168 3313107 1352061 3563683 2244071 1319612 20209882 BOND RESERVE FUNDS 174711 OTHER RECEIVABLES 1864021 DEPOSITS 55658 BOND PRINCIPAL/INTEREST FUNDS 55889 ESTIMATED AMOUNTS DUE FROM THIRD-PARTY PAYORS 2965151 OPERATING LEASE RIGHT-OF-USE ASSETS 8923543 14038973 ESTIMATED AMOUNTS DUE TO THIRD-PARTY PAYORS 6558517 OPERATING LEASE LIABILITIES 8712219 15270736 X 67257020 -29408 -29408 67286428 0 67286428 53828626 0 53828626 0 53828626 PART X, LINE 2: THE ORGANIZATION IS A NONPROFIT CORPORATION UNDER INTERNAL REVENUE CODE SECTION 501(C)(3) AND HAS BEEN GRANTED TAX-EXEMPT STATUS BY THE INTERNAL REVENUE SERVICE AND THE CALIFORNIA REVENUE AND TAXATION CODE. AS OF JUNE 30, 2021, THE ORGANIZATION HAD NO UNRECOGNIZED TAX POSITIONS OR UNCERTAIN TAX POSITIONS REQUIRING ACCRUAL. THEREFORE, NO PROVISION FOR INCOME TAXES HAS BEEN PROVIDED IN THE FINANCIAL STATEMENTS. X X 0 0 0 0 0 0 0 0 0 KATHRYN POWELL MHA MA CHIEF EXECUTIVE OFFICER 283961 0 31622 0 3025 0 33644 0 13700 0 365952 0 0 0 KEN WEINSTOCK MD DIR. OF BEHAVIORAL HEALTH SERVICES 283393 0 8813 0 1997 0 14018 0 22853 0 331074 0 0 0 NURIT LICHT MD CHIEF MEDICAL OFFICER 253621 0 10000 0 599 0 14590 0 15724 0 294534 0 0 0 PHILIPPE EDOUARD MD FACP FAMILY PHYSICIAN 244010 0 3058 0 1471 0 13589 0 12920 0 275048 0 0 0 DANIELLE ORYN DO MPH CHIEF MEDICAL INFORMATICS OFFICER 234802 0 1055 0 556 0 11683 0 23200 0 271296 0 0 0 RAMONA ENGLISH DMD CHIEF DENTAL OFFICER 204803 0 30000 0 477 0 12554 0 14557 0 262391 0 0 0 REBECCA KATZ MD PRIMARY CARE SITE DIRECTOR 208505 0 11739 0 267 0 12160 0 26317 0 258988 0 0 0 SAFI AHMED MD MPH FAMILY PHYSICIAN 248580 0 1423 0 343 0 209 0 8307 0 258862 0 0 0 ANDREW ASHCROFT MD MPH FAMILY PHYSICIAN 203910 0 6814 0 632 0 12822 0 30709 0 254887 0 0 0 JONATHAN CHOE MD ASSOC. MEDICAL DIR, WOMEN'S HEALTH 222258 0 5039 0 385 0 12143 0 2922 0 242747 0 0 0 JANE READ MSA RN COO THROUGH 4/2021 197926 0 20000 0 1988 0 6335 0 10403 0 236652 0 0 0 CASSIE IUTZI MD MPH FAMILY PHYSICIAN 201007 0 5995 0 237 0 9198 0 17990 0 234427 0 0 0 PEDRO TOLEDO JD MA MHSA CHIEF ADMINISTRATIVE OFFICER 206483 0 0 0 318 0 11753 0 11294 0 229848 0 0 0 JOHN PENDLETON MD ASSOC. MEDICAL DIRECTOR, OPERATIONS 198109 0 6026 0 385 0 11524 0 11533 0 227577 0 0 0 CARLIN CHI MD MEDICAL DIRECTOR, PRIMARY CARE 182796 0 4736 0 613 0 10603 0 21379 0 220127 0 0 0 MICHELLE GLANCY MBA CHIEF HUMAN RESOURCES OFFICER 181474 0 20000 0 646 0 2590 0 13192 0 217902 0 0 0 MOLLY JOUANEH CMA CHIEF FINANCIAL OFFICER 187692 0 0 0 249 0 0 0 726 0 188667 0 0 0 A CALIFORNIA HEALTH FACILITIES FINANCING AUTHORITY 521643828 13032UET1 2016-09-13 5955305 REFUND OF BONDS ORIGINALLY ISSUED 6/2/2010 0 0 0 A 730000 5955305 174711 115500 153716 5511378 0 1 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 0 0 0 0 0 1 A 1 NORTH BAY OFFICE FURNITURE ENTITY IS SOLELY OWNED BY BOARD MEMBER ROBERT RAMIREZ 6281 THE ORGANIZATION PURCHASED OFFICE FURNITURE AT FAIR MARKET VALUE FROM NORTH BAY OFFICE FURNITURE, WHICH IS SOLELY OWNED BY BOARD MEMBER ROBERT RAMIREZ. 0 X 1 2881123 FMV X 7 89233 FMV 0 0 1 0 PART I, COLUMN (B): THE ORGANIZATION IS REPORTING THE NUMBER OF CONTRIBUTIONS RECEIVED IN SCHEDULE M, PART I, COLUMN (B). SCHEDULE M, PART I, LINE 16: ON JULY 1, 2020, THE ORGANIZATION OFFICIALLY MERGED-IN COASTAL HEALTH ALLIANCE, ANOTHER FQHC, WITH THE ORGANIZATION REMAINING AS THE SURVIVING CORPORATION. THE AMOUNT REPORTED ON SCHEDULE M, PART I, LINE 16 REPRESENTS THE FAIR MARKET VALUE OF PROPERTY, PLANT, AND EQUIPMENT TRANSFERRED OVER FROM COASTAL HEALTH ALLIANCE AND RECOGNIZED AS AN INHERENT CONTRIBUTION ON THE ORGANIZATION'S FINANCIAL STATEMENTS FOR THE JUNE 30, 2021 TAX YEAR. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED BY AN OUTSIDE TAX PREPARER IN CONJUNCTION WITH THE ORGANIZATION'S FINANCE AND ACCOUNTING TEAM. THE CEO AND MEMBERS OF THE FINANCE AND ACCOUNTING STAFF OF THE ORGANIZATION THEN REVIEW THE FORM 990 AND, UPON APPROVAL, SUBMITS THE FORM 990 TO THE BOARD FINANCE COMMITTEE FOR REVIEW BEFORE FILING WITH THE IRS; THE FORM 990 IS ALSO MADE AVAILABLE TO ALL BOARD MEMBERS FOR REVIEW PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C IT IS THE POLICY OF PETALUMA HEALTH CENTER THAT ALL FULL-TIME AND PART-TIME EMPLOYEES, CONTRACTORS, AND MEMBERS OF THE BOARD OF DIRECTORS AVOID CONFLICTS OF INTEREST, OR APPEARANCE OF CONFLICT, BETWEEN THEIR PERSONAL INTERESTS AND THE INTERESTS OF THE ORGANIZATION WHEN DEALING WITH ANY INDIVIDUAL OR OUTSIDE ORGANIZATION HAVING, OR SEEKING TO HAVE, A BUSINESS RELATIONSHIP WITH PETALUMA HEALTH CENTER. ALL MEMBERS OF THE PETALUMA HEALTH CENTER BOARD OF DIRECTORS ARE REQUIRED TO COMPLETE THE CONFLICT OF INTEREST DISCLOSURE STATEMENT; ALL STAFF MEMBERS, VOLUNTEERS, AND CONTRACTORS ARE REQUIRED TO DISCLOSE ANY POTENTIAL OR ACTUAL CONFLICT OF INTEREST THAT ARISES TO THE HUMAN RESOURCES DEPARTMENT WITHIN 10 BUSINESS DAYS OF LEARNING OF IT. AFTER DISCLOSURE OF A POSSIBLE CONFLICT OF INTEREST, THE CEO AFFORDS THE INTERESTED PERSON WHO MAKES THE DISCLOSURE AN OPPORTUNITY TO EXPLAIN TO THE SENIOR MANAGEMENT TEAM (FOR EMPLOYEES), OR THE EXECUTIVE COMMITTEE OF THE BOARD (FOR BOARD MEMBERS) THE FACTS AND CIRCUMSTANCES OF THE TRANSACTION OR ARRANGEMENT THAT LED TO SUCH DISCLOSURE. THE INTERESTED PERSON LEAVES THE SENIOR MANAGEMENT TEAM OR BOARD EXECUTIVE COMMITTEE MEETING WHILE THE INTEREST IS DISCUSSED AND VOTED UPON. FORM 990, PART VI, SECTION B, LINE 15 THE PROCESS FOR DETERMINING THE CHIEF EXECUTIVE OFFICER'S SALARY INCREASE INVOLVES A DISCUSSION AMONGST THE EXECUTIVE COMMITTEE OF THE BOARD, SALARY RESEARCH BY THE CHIEF HR OFFICER, AND RECOMMENDATION OF A NEW SALARY FROM THE EXECUTIVE COMMITTEE TO THE BOARD OF DIRECTORS FOR APPROVAL. THE CEO REVIEWS AND APPROVES THE COMPENSATION OF OTHER OFFICERS AND MANAGERS UTILIZING COMPARABILITY DATA. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST.