2022-08-15T12:18:48-05:00 2021-09-30 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2020-10-01 410944721 PINE HAVEN INC PINE 5073568304 210 3RD STREET NW PINE ISLAND MN 55963 CRAIG SMITH CEO/ADMINISTRATOR 5073568304 2022-08-15 1 CRAIG SMITH 999009999 MICHAEL J PETERSON CPA P01833529 2187224705 2022-08-15 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z CRAIG SMITH 210 3RD STREET NW PINE ISLAND MN 55963 9079459 0 X WWW.PINEHAVENCOMMUNITY.ORG X 1964 MN PROVIDE QUALITY, AFFORDABLE SERVICES FOR OLDER ADULTS AND FAMILIES IN OUR COMMUNITY. 7 7 283 80 0 0 751511 699725 7607692 8160383 1599 2297 32163 217054 8392965 9079459 0 0 0 0 4763772 5993010 0 0 0 3457356 3198308 8221128 9191318 171837 -111859 7846455 7119498 7051486 6439186 794969 680312 PINE HAVEN COMMUNITY PROVIDES A CONTINUUM OF CARE THROUGH THE BELIEF THAT EVERY PERSON IS UNIQUE. 0 0 7986365 0 8160383 PINE HAVEN, INC. (PINE HAVEN COMMUNITY) IS RESPONSIBLE FOR PROVIDING NURSING CARE AND HOUSING FOR THE ELDERLY AND DISABLED, OPERATING A 70 BED LICENSED NURSING FACILITY LOCATED IN PINE ISLAND, MINNESOTA. PROVIDE MANAGEMENT SERVICES TO EVERGREEN PLACE, AN ASSISTED LIVING HOUSING FACILITY OWNED BY THE CITY OF PINE ISLAND, MINNESOTA. DURING THE YEAR 24,209 INPATIENT DAYS WERE PROVIDED. 7986365 1 1 0 0 0 0 0 0 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 20 0 283 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 1 1 0 0 MN X JESSICA RIVERA 5073568304 210 3RD STREET NW PINE ISLAND MN 55963 RANDY HOFFARTH CHAIR 1.00 1.00 X X 0 0 0 JOANNE JUDGE-DIETZ CHAIR / VICE CHAIR 1.00 X X 0 0 0 GLEN HEMANN TREASURER 1.00 1.00 X X 0 0 0 TERESA BUCK SECRETARY 1.00 X X 0 0 0 RON FLEMKE DIRECTOR 1.00 X 0 0 0 JERRY VETTEL DIRECTOR 1.00 1.00 X 0 0 0 WAYNE WELLIK DIRECTOR 1.00 1.00 X 0 0 0 MARCUS PARENCE CEO/ADMINISTRATOR 40.00 1.00 X 107434 0 1867 JESSICA RIVERA FINANCE DIRECTOR 40.00 X 46646 0 90 154080 0 1957 1 0 0 0 AEGIS THERAPIES PO BOX 936653 ATLANTA GA 31193 THERAPY SERVICES 368055 PRIME TIME HEALTHCARE PO BOX 3544 OMAHA NE 68103 NURSING POOL STAFF 153622 2 699608 117 699725 RESIDENT SERVICES 623000 7801825 7801825 APARTMENT REVENUE 623000 294683 294683 MANAGEMENT SERVICES 623000 63875 63875 8160383 2297 2297 217054 217054 217054 9079459 8160383 0 219351 163064 163064 4826277 4519373 306904 18209 18209 611871 555037 56834 373589 338567 35022 53180 53180 840919 779581 61338 74190 74190 58875 8980 49895 152006 152006 146228 140665 5563 1535 976 559 175483 168903 6580 365340 351640 13700 63460 63460 NURSING SUPPLIES 656879 656879 FOOD EXPENSE 225936 225936 NURSING HOME SURCHARGE 129021 129021 REPAIRS & MAINTENANCE 43526 41841 1685 211730 50757 160973 9191318 7986365 1204953 0 5791 -2047 960937 25509 730026 1304237 32371 50042 11202888 5464647 6107144 5738241 3516 3516 6670 0 7846455 7119498 809638 734445 465589 0 6548 12260 5769711 5682687 0 9794 7051486 6439186 X 794969 680312 794969 680312 7846455 7119498 X -111859 -2798 X 0 0 0 X 151688 40821 6495 751511 699725 1650240 6303897 7128723 6981446 7607692 8160383 36182141 575 43874 5553 32163 217054 299219 6456160 7213418 6993494 8391366 9077162 38131600 0 0 0 38131600 964 1159 803 1599 2297 6822 964 1159 803 1599 2297 6822 6457124 7214577 6994297 8392965 9079459 38138422 0.99980 0.99980 0.00020 0.00020 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 116790 116790 9472044 4183582 5288462 1566029 1233040 332989 48025 48025 0 5738241 DUE TO PINE HAVEN FOUNDATION 9794 9794 PART IV, LINE 2B: THE ORGANIZATION IS THE TRUSTEE OF VARIOUS RESIDENT FUNDS AND HAS FIDUCIARY RESPONSIBILITY FOR THE ADMINISTRATION AND DISTRIBUTION OF THESE FUNDS FOR THE RESIDENTS. THESE FUNDS ARE ON DEPOSIT IN A SEPARATE BANK ACCOUNT. FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BOARD. FORM 990, PART VI, SECTION B, LINE 11B MANAGEMENT OF THE ORGANIZATION REVIEWS FORM 990 PRIOR TO SUBMISSION TO THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY APPLIES TO ANY DIRECTOR, PRINCIPAL OFFICER, OR MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS, WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER DISCUSSION WITH THE INTERESTED PERSON, HE/SHE SHALL LEAVE THE GOVERNING BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF THE CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT EXISTS. UPON DETERMINATION OF THE CONFLICT OF INTEREST, THE INTERESTED PERSON MUST LEAVE THE MEETING DURING THE DISCUSSION AND VOTE UPON THE TRANSACTION AT HAND. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD OF DIRECTORS REVIEWS AND DETERMINES COMPENSATION FOR THE ADMINISTRATOR DURING THE ADMINISTRATOR'S ANNUAL PERFORMANCE APPRAISAL. THE BENCHMARK WHICH THE BOARD COMPARES THE SALARY FOR THE ADMINISTRATOR IS PROVIDED BY THE SALARY SURVEY COMPLETED BY LEADINGAGE MINNESOTA. THIS IS THE AGING SERVICES TRADE ORGANIZATION WHICH THE ORGANIZATION BELONGS TO. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: OTHER CHANGES IN NET ASSETS -2,798. PINE HAVEN FOUNDATION INC 210 3RD STREET NW PINE ISLAND MN 55963 411580669 SUPPORT PINE HAVEN, INC MN 501(C)(3) LINE 12A, I PINE HAVEN INC 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0