2022-11-11T14:33:00-06:00 2021-12-31 911623649 JOHNSON STONE & PAGANO PS 1501 REGENTS BLVD SUITE 100 FIRCREST WA 98466 990 2021-01-01 943080307 ASHLEY HOUSE ASHL 2535339050 33811 9TH AVE S FEDERAL WAY WA 98003 STEPHEN L FREEBORN PRESIDENT 2535339050 2022-11-10 1 STEPHEN FREEBORN XXX-XX-XXXX CORA P THORDARSON P01332199 2535667070 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z STEPHEN L FREEBORN 33811 9TH AVE S FEDERAL WAY WA 98003 11161851 0 X WWW.AH-NW.ORG X 1989 WA ASHLEY HOUSE PROVIDES COMPREHENSIVE, COST EFFECTIVE, QUALITY CARE TO MEDICALLY FRAGILE CHILDREN AND YOUNG ADULTS IN A HOME-LIKE SETTING. 5 5 177 7 0 0 346287 224805 9158182 9631259 105335 318104 36289 11276 9646093 10185444 185898 135218 0 0 7653867 8144060 0 0 795408 1246048 1787216 9085813 10066494 560280 118950 13301517 16832773 4164145 7555612 9137372 9277161 WE ARE DEDICATED TO PROVIDING EDUCATION TO FAMILIES AND CAREGIVERS, BUILDING SUPPORT SYSTEMS, COORDINATING SERVICES AND NURTURING THE DEVELOPMENT OF EACH INDIVIDUAL. 0 0 5662414 135218 7416721 ASHLEY HOUSE PROVIDED TRANSITIONAL NURSING CARE SERVICES, HOSPICE SERVICES, CASE MANAGEMENT AND SOCIAL SERVICES TO 27 MEDICALLY FRAGILE CHILDREN IN 2021. FREE SERVICES WERE PROVIDED TO NEEDY CHILDREN IN 2021 VALUED AT APPROXIMATELY $135,218. ASHLEY HOUSE PROVIDES THESE SERVICES IN FIVE GROUP HOMES, IN FAMILY-LIKE SETTINGS. THE HOMES ARE STAFFED 24 HOURS A DAY WITH NURSES AND CNA'S. ADDITIONAL STAFF ARE UTILIZED TO TAKE CHILDREN TO MEDICAL APPOINTMENTS, AND ON OUTINGS. OUR SPECIFIC OBJECTIVE IS TO ENABLE CHILDREN TO BE RETURNED TO THEIR OWN HOME, OR TO SEEK ADOPTION OR FOSTER CARE. HENCE, WE ARE A SETTING FOR TRANSITIONAL CARE UNTIL PERMANENCY IS OBTAINED. 1975903 2225814 ASHLEY HOUSE YOUNG ADULT RESIDENTIAL GROUP HOME ACCEPTS UP TO 6 YOUNG ADULTS (18-30 YEARS OLD) WITH MEDICAL COMPLEXITY TO LIVE IN A HOME-LIKE SETTING (SHORT OR LONG TERM). THESE MEDICALLY FRAGILE YOUNG ADULTS ARE OFTEN INDIVIDUALS WITH COMPLICATED MEDICAL HISTORIES, SUCH AS ORGAN TRANSPLANTATION, VENTILATOR DEPENDENCY OR TRAUMATIC BRAIN INJURY AND EXPERIENCE LENGTHY HOSPITALIZATIONS, NEED SPECIALIZED CAREGIVER TRAINING, AND HAVE EQUIPMENT OR NURSING NEEDS THAT MAY EXCEED WHAT CAN BE PROVIDED IN THEIR FAMILY HOMES. 7638317 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 16 0 1 177 1 0 0 0 0 0 0 0 0 0 0 0 0 X 5 5 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WA X X KEN MAAZ 2535339050 33811 9TH AVE S FEDERAL WAY WA 98003 TOM VERTETIS BOARD MEMBER 0.50 X 0 0 0 STEPHEN L FREEBORN PRESIDENT 1.00 X X 0 0 0 CINDY GRADY SECRETARY 1.00 X X 0 0 0 DAN BOGART TREASURER 1.00 X X 0 0 0 KAREN QUANDT BOARD MEMBER 1.00 X 0 0 0 BETH KAUKL BOARD MEMBER 1.00 X 0 0 0 JULIE FOLEY BOARD MEMBER 1.00 X 0 0 0 KEN MAAZ EXECUTIVE DIRECTOR 40.00 X 169988 0 12176 ERICA PERNELA DIRECTOR OF CLINICAL SERVI 40.00 X 132326 0 18852 MARK SCHINDLER DIRECTOR OF HUMAN RESOURCE 40.00 X 124054 0 18428 SARA EDWARDS CONTROLLER 40.00 X 109378 0 17694 MICHAELA GOULD DEVELOPEMENT LIASON 40.00 X 149932 0 19513 MICHAEL PUGSLEY DIRECTOR OF DEVELOPMENT 40.00 X 144056 0 19476 KRISTINE SPENCER LPN 40.00 X 104980 0 15395 CAROL JACKSON REGISTERED NURSE 40.00 X 100465 0 14999 JENIFFER STONE REGISTERED NURSE 40.00 X 102148 0 14702 1137327 0 151235 9 0 1 0 SQUARE PEG CONSTRUCTION LLC PO BOX 77570 SEATTLE WA 98177 CONTRACTOR FOR NEW SHORELINE BUILDING 1935962 KUKULU LLC 812 E MAIN ST SUITE 201 PUYALLUP WA 98372 CONTRACTOR FOR REMODELING OLYMPIA HOUSE 363743 CROWN BUILDING CO 705 10TH AVE MILTON WA 98354 CONTRACTOR FOR REMODELING BROWNS POINT H 297355 SWINERTON BUILDERS 2001 CLAYTON ROAD 7TH FL CONCORD CA 94520 CONTRACTOR FOR REMODELING SPOKANE HOUSE 251858 TURK SCHACHLE 6605 86TH ST CT NW GIG HARBOR WA 98332 INTEREST PAYMENTS ON SHORT TERM LOAN 126875 5 224805 120418 224805 INSURANCE 623000 5530665 5530665 MEDICAID: STATE FEE FOR SERVICE P 623000 4100594 4100594 9631259 44750 44750 1248761 1000 976407 0 272354 1000 273354 273354 MISCELLANEOUS 623000 11276 11276 11276 10185444 9642535 0 318104 135218 135218 602896 490844 84859 27193 5889156 4784828 832743 271585 1108437 917136 150256 41045 543571 446273 74163 23135 96473 96473 24815 24815 20969 20969 325404 8940 37700 278764 19429 16912 2175 342 68636 36525 23397 8714 110373 110373 105693 87808 14540 3345 24476 21123 2363 990 6628 2639 3363 626 262497 127346 30986 104165 214118 161456 52662 114416 86756 23830 3830 HOUSEHOLD, CLEANING, CH 187937 184437 3500 MISC OTHER 99591 86274 1406 11911 TAXES & LICENSES 47065 18706 11237 17122 BANK FEES 33600 30959 2641 25096 25096 10066494 7638317 1632769 795408 386192 150012 83571 79490 1356998 1657638 157880 182852 6890746 2093541 4950722 4797205 2546160 2366849 3819994 7598727 13301517 16832773 994585 1862567 3169560 5693045 4164145 7555612 X 9127372 9217161 10000 60000 9137372 9277161 13301517 16832773 118950 20839 0 X X 0 1 X 1 0 X 646529 34396 24999 346287 224805 1277016 5116343 6889328 7681141 9158182 9631259 38476253 5762872 6923724 7706140 9504469 9856064 39753269 0 0 0 39753269 95646 64557 47817 42950 44750 295720 95646 64557 47817 42950 44750 295720 5829 7489 7813 36164 11276 68571 5864347 6995770 7761770 9583583 9912090 40117560 0.99090 0.98840 0.00740 0.00990 X PART III SECTION B LINE 12 OTHER INCOME CPR/FIRST AID FEES, REBATES, CLASS ACTION PROCEEDS FROM SECURITIES RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 0 0 0 1 34000 34000 1 0 0 PART II-B, LINE 1: ASHLEY HOUSE PAID A CONSULTANT TO LOBBY ON THEIR BEHALF FOR FUNDING TO PURCHASE AND REMODEL A HOME IN SPOKANE, WA FOR CRITICALLY ILL CHILDREN. 1176435 1176435 4715201 1359077 3356124 816377 652311 164066 182733 82153 100580 4797205 CONSTRUCTION IN PROGRESS 7597114 PERSONAL FUNDS- CUSTODIAL 1613 7598727 10050096 20839 20839 10029257 20969 135218 156187 10185444 9910307 0 9910307 20969 135218 156187 10066494 PART XI, LINE 4B - OTHER ADJUSTMENTS: UNCOMPENSATED CARE 135,218. PART XII, LINE 4B - OTHER ADJUSTMENTS: UNCOMPENSATED CARE 135,218. 0 GROUP HOME - ROOM & BOARD - UNCOMPENSATED CARE 12 135218 OTHER ROOM & BOARD PROVIDED AT NO COST. PART III LINE 1 FUNDS ARE NOT GIVEN TO ANY INDIVIDUAL. THE COST TO THE AGENCY FOR ROOM AND BOARD IS INCLUDED AS A GRANT TO INDIVIDUALS WHEN ASHLEY HOUSE DOES NOT RECEIVE ANY REIMBURSEMENT FOR THESE SERVICES. X X X X 0 0 0 0 0 0 0 0 0 KEN MAAZ EXECUTIVE DIRECTOR 169988 0 0 0 0 0 0 0 12176 0 182164 0 0 0 MICHAELA GOULD DEVELOPEMENT LIASON 149932 0 0 0 0 0 7337 0 12176 0 169445 0 0 0 MICHAEL PUGSLEY DIRECTOR OF DEVELOPMENT 144056 0 0 0 0 0 7300 0 12176 0 163532 0 0 0 ERICA PERNELA DIRECTOR OF CLINICAL SERVI 132326 0 0 0 0 0 6676 0 12176 0 151178 0 0 0 X HOSPITAL EQUIPMENT 15 59976 FMV X MISCELLANEOUS 0 49673 FMV X WINDOWS PROGRAM 3 10769 FMV 0 0 0 FORM 990, PART VI, SECTION B, LINE 11B THE 990 REVIEW IS LISTED ON THE YEARLY BOARD OF DIRECTORS COMPLIANCE CALENDAR TO REMIND ALL BOARD MEMBERS OF THE REVIEW. FORM 990 IS PREPARED AFTER THE COMPLETION OF THE INDEPENDENT FINANCIAL AUDIT. A COMPLETE COPY OF THE 990 IS INDIVIDUALLY PROVIDED TO ALL BOARD MEMBERS WHO REVIEW THE RETURN PRIOR TO FILING. ANY QUESTIONS OR CONCERNS ARE COMPILED BY THE BOARD TREASURER, WHO THEN CONTACTS THE RETURN PREPARER AND/OR AUDITORS AS NECESSARY. AFTER THE BOARD HAS REVIEWED AND ACCEPTED THE RETURN, BY VOTE AT A REGULARLY SCHEDULED BOARD MEETING, IT IS SIGNED BY THE BOARD PRESIDENT AND FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD COMPLIANCE CALENDAR LISTS AS AN ITEM TO BE COMPLETED IN THE FIRST QUARTER OF THE YEAR, REVIEW THE CONFLICT OF INTEREST POLICY. IT REQUIRES ALL BOARD MEMBERS TO ANNUALLY SIGN A CONFLICT OF INTEREST STATEMENT. THE POLICY ALSO REQUIRES A DUTY TO DISCLOSE ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST. IT OUTLINES PROCEDURES FOR THE BOARD TO FOLLOW IN DETERMINING WHETHER A CONFLICT OF INTEREST EXISTS AND PROCEDURES FOR ADDRESSING ANY CONFLICT OF INTEREST THAT MAY ARISE. ADDITIONALLY, INDEPENDENT FINANCIAL AUDITORS ANNUALLY REVIEW AND TEST THE ORGANIZATION'S RECORDS FOR POSSIBLE CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 A BOARD COMMITTEE CONDUCTS AN ANNUAL PERFORMANCE AND COMPENSATION REVIEW FOR THE EXECUTIVE DIRECTOR. THE COMMITTEE ALSO OBTAINS COMPARABLE SALARY INFORMATION FROM INDEPENDENT THIRD-PARTY SOURCES AND DETERMINES ANY RECOMMENDATION FOR SALARY ADJUSTMENT. A WRITTEN EMPLOYMENT CONTRACT IS USED TO DOCUMENT ALL TERMS OF THE EXECUTIVE DIRECTOR'S EMPLOYMENT. THE EXECUTIVE DIRECTOR COMPLETES PERFORMANCE REVIEW AND OBTAINS COMPARABLE SALARY INFORMATION FOR ALL KEY EMPLOYEES. THE FULL BOARD REVIEW AND APPROVES COMPENSATION PACKAGES FOR BOTH THE EXECUTIVE DIRECTOR AND KEY EMPLOYEES. FORM 990, PART VI, SECTION C, LINE 19 DISCLOSURE OF GOVERNING DOCUMENTS, FINANCIAL STATEMENTS AND CONFLICT OF INTEREST POLICY ARE NOT GENERALLY MADE AVAILABLE TO THE PUBLIC, BUT ARE PROVIDED ON A REQUEST BASIS. FORM 990 PART XII, LINE 2C THERE HAVE BEEN NO CHANGES TO THE PROCESS FROM THE PRIOR YEAR.