2022-11-08T16:34:22-06:00 2021-12-31 861065772 DELOITTE TAX LLP 50 S 6TH STREET MINNEAPOLIS MN 55402 990 2021-01-01 481209650 CEDAR LAKE VILLAGE INC CEDA 6053331000 PO BOX 5039 RTE 5218 SIOUX FALLS SD 571175039 ERIC VANDEN HULL TREASURER 6053331000 2022-10-21 1 ERIC VANDEN HULL XXX-XX-XXXX CHRIS MESKIMEN P01314196 6123974000 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z NATHAN SCHEMA 4800 W 57TH STREET SIOUX FALLS SD 57117 13837677 0 X WWW.SANFORDHEALTH.ORG X 1998 KS HOUSING, PROGRAMS AND SERVICES FOR ELDERLY PERSONS AND OTHER IN NEED 5 5 0 19 0 0 584497 191518 11684248 12484080 299345 291909 0 8409 12568090 12975916 0 0 0 0 0 0 0 0 84 12519790 13053892 12519790 13053892 48300 -77976 39774121 38142658 31107968 29141515 8666153 9001143 IMPROVING THE WELL-BEING AND QUALITY OF LIFE FOR OLDER PERSONS AND OTHERS IN NEED THROUGH THE PROVISION OF HOUSING, PROGRAMS, AND SERVICES. 0 0 11121016 0 12484080 PROVIDING HOUSING, PROGRAMS, AND SERVICES IN AN EFFORT TO IMPROVE THE QUALITY OF LIFE FOR OLDER PERSONS AND OTHERS IN NEED. 19,508 ASSISTED LIVING RESIDENT DAYS, 36,513 SENIOR HOUSING RESIDENT DAYS AND 8,658 SKILLED NURSING RESIDENT DAYS IN 2021. 11121016 1 1 0 0 0 0 0 0 0 1 1 1 0 0 1 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 0 0 0 0 1 X 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 5 5 0 1 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 0 KS X ERIC VANDEN HULL 6053623100 4800 W 57TH STREET SIOUX FALLS SD 571175038 X JAMES HUBBARD TRUSTEE, VICE CHAIR, VP 1.00 0.00 X X 0 0 0 ERIC VANDEN HULL TRUSTEE, TREASURER 1.00 0.00 X X 0 0 0 AIMEE MIDDLETON TRUSTEE, SECRETARY 1.00 0.00 X X 0 0 0 J MACK BOWEN TRUSTEE 1.00 0.00 X 0 0 0 VINCE DONOFRIO TRUSTEE 1.00 0.00 X 0 0 0 NATHAN SCHEMA TRUSTEE, CHAIR, PRESIDENT 1.00 0.00 X 0 0 0 JOANNA RANDALL EXECUTIVE DIRECTOR 45.00 0.00 X 0 0 0 0 0 0 0 0 0 0 THE EVANGELICAL LUTHERAN GOOD SAMARITAN 4800 W 57TH STREET SIOUX FALLS SD 57108 MNGMT FEES & SHARED EMPLOYEES 6638385 SELECT REHABILITATION INC PO BOX 809056 CHICAGO IL 606809056 CONTRACT THERAPY SERVICES 506864 2 167253 24265 191518 ROOM REV, ANCILL SVCS 623000 12421332 12421332 MEALS, GUEST RM, OTHER 623000 62748 62748 12484080 253076 253076 812334 88260 772576 89185 39758 -925 38833 38833 EMPLOYEE MEALS 722514 8409 8409 8409 12975916 12484080 0 300318 582410 582410 342 342 13958 13958 15110 15110 804704 709029 95675 64044 50579 13465 117545 41059 76486 893071 893071 25358 24027 1331 32569 18491 14078 823939 823939 1638681 1638681 180316 180316 CONTRACT SERVICES 5969905 5147899 821922 84 MEDICAL SUPPLIES 1240103 1199485 40618 PURCHASED SERVICES - SH 251489 251489 UNCOLLECTIBLE EXPENSE 183690 183690 216658 142951 73707 13053892 11121016 1932792 84 745396 1933400 481538 573862 35571 6563 2936 193279 49759860 21160730 29936627 28599130 8394269 6648097 177784 188327 39774121 38142658 476483 521925 152015 92484 15236535 14485304 15242935 14041802 31107968 29141515 X 8435795 8765351 230358 235792 8666153 9001143 39774121 38142658 X -77976 -358272 771238 X 0 1 X 1 0 X 22110 7251 41737 584497 191518 847113 11178236 11389121 11906674 11684248 12492489 58650768 11200346 11396372 11948411 12268745 12684007 59497881 0 0 0 59497881 105639 154630 68915 238709 253076 820969 105639 154630 68915 238709 253076 820969 11305985 11551002 12017326 12507454 12937083 60318850 0.98640 0.98910 0.01360 0.01090 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 177093 -64970 112123 170538 6555 177093 174356 -3818 170538 165876 8480 174356 148937 16939 165876 0.00000 1.00000 0.00000 1 0 1957128 1957128 41322612 17191524 24131088 3326966 2218803 1108163 3153154 1750403 1402751 28599130 HOUSING ENTRY FEES 6648097 F 6648097 SPECIAL ASSESSMENTS PAYABLE 64674 SEC MORT & NOTE PAY TO MEMB 5562006 SECURITY DEPOSITS 245269 HOUSING ENTRY FEES AND OTHER 7146623 INTEREST RATE SWAP 1023230 14041802 X 12405224 -358272 -184417 -542689 12947913 18385 9618 28003 12975916 12852705 925 925 12851780 18385 183727 202112 13053892 PART V, LINE 4: EARNINGS ON THE CEDAR LAKE VILLAGE ENDOWMENT FUNDS WILL BE USED AS DIRECTED BY DONOR RESTRICTIONS OR THE BOARD'S DESIGNATION, ABSENT DONOR RESTRICTIONS. PART X, LINE 2: THE ORGANIZATION BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE ORGANIZATION WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES WERE INCURRED. THE ORGANIZATION IS SUBJECT TO FEDERAL AND STATE TAX EXAMINATIONS BY TAX AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -183,690. OTHER EXPENSES -727. PART XI, LINE 4B - OTHER ADJUSTMENTS: GAIN/LOSS SALE OF ASSETS -925. CHANGE IN BENEFICIAL INTEREST 10,543. PART XII, LINE 2D - OTHER ADJUSTMENTS: GAIN/LOSS SALE OF ASSETS 925. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 183,690. OTHER EXPENSE 37. A CITY OF OLATHE KANSAS 486034756 000000000 2015-05-15 19200000 SEE PART V 0 0 0 A 4621000 19200000 270367 7509781 11419852 2015 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 0 1 1 CENTER STATE BANK 20.600000000000 0 0 0 0 1 A 1 SCHEDULE K, PART I, COLUMN (F) DESCRIPTION OF PURPOSE: 2015: CONSTRUCT ADDITIONAL FACILITIES, PAY COSTS RELATED TO BOND ISSUANCE, REFUND OF CITY OF OLATHE, KS BOND ISSUE DATED 12/16/04, CUSIP 679390FB5, AND REFUND OF BANK OF AMERICA LINE OF CREDIT. FORM 990, PART V, LINES 1A AND 2A FORM 1099 AND W-2 PROCESSING IS COMPLETED BY THE MANAGEMENT COMPANY, THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY, A MEMBER OF THE ORGANIZATION. AS SUCH, PART V LINES 1A AND 2A REPORT NO 1099'S OR W-2'S FOR THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION HAS DELEGATED MANAGEMENT DUTIES TO THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY, A MEMBER OF THE ORGANIZATION. JOANNA RANDALL, THE ADMINISTRATOR FOR THE ORGANIZATION, RECEIVED COMPENSATION OF $142,650 PLUS EMPLOYER PAID BENEFITS OF $13,371 FOR SERVICES PROVIDED TO CEDAR LAKE VILLAGE, INC. DURING 2021. FORM 990, PART VI, SECTION A, LINE 6 THE MEMBERS ARE OLATHE MEDICAL CENTER, INC. AND THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY. FORM 990, PART VI, SECTION A, LINE 7A THE TRUSTEES ARE APPOINTED BY THE MEMBERS. FORM 990, PART VI, SECTION A, LINE 7B THE DECISIONS OF THE GOVERNING BODY THAT ARE SUBJECT TO APPROVAL INCLUDE: ELECTION OF TRUSTEES AND OFFICERS; APPROVE ARTICLE AND BYLAW CHANGES; APPROVE OR REJECT NON-BUDGETED ACQUISITIONS, EXPENDITURES, OR DISPOSALS OF A VALUE IN EXCESS OF $100,000; DISTRIBUTIONS TO MEMBERS; APPROVE INCURRENCE OF DEBT BY CEDAR LAKE VILLAGE, INC ("CLV") IN EXCESS OF $100,000; AND APPROVE LIENS OF ANY CLV PROPERTY HAVING A VALUE IN EXCESS OF $100,000. FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE ANY COMMITTEES. FORM 990, PART VI, SECTION B, LINE 11B AN ELECTRONIC COPY OF FORM 990 IS SENT TO EACH MEMBER OF THE BOARD PRIOR TO ITS FILING. THE ORGANIZATION'S OFFICERS AND MANAGEMENT ARE AN INTEGRAL PART OF THE PREPARATION OF THE FORM 990 AND HAVE AN ON-GOING REVIEW OF THE FORM 990 AS IT IS PREPARED. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION ASKS THAT ALL OFFICERS AND DIRECTORS COMPLY WITH THE IRS CONFLICT OF INTEREST AND DISCLOSURE CERTIFICATION. THE ORGANIZATION REQUIRES ALL OFFICERS AND DIRECTORS TO PROVIDE A SIGNED COPY TO THE CORPORATION'S MAIN OFFICE ANNUALLY. FORM 990, PART VI, SECTION B, LINE 15A THE ADMINISTRATOR FOR THE ORGANIZATION IS COMPENSATED THROUGH A MANAGEMENT AGREEMENT WITH AN UNRELATED MANAGEMENT COMPANY, THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY. THE COMPENSATION IS REVIEWED AND DETERMINED BY THE UNRELATED MANAGEMENT COMPANY ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: SWAP VALUATION CHANGE 771,238.