2021-08-16T13:01:08-05:00 2020-09-30 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2019-10-01 410944721 PINE HAVEN INC PINE 5073568304 210 3RD STREET NW PINE ISLAND MN 55963 MARCUS PARENCE CEO/ADMINISTRATOR 5073568304 2021-08-13 1 MICHAEL J PETERSON CPA P01833529 2187224705 2021-08-12 2019 2022-09-23 18:48:47Z MARCUS PARENCE 210 3RD STREET NW PINE ISLAND MN 55963 8392965 0 X WWW.PINEHAVENCOMMUNITY.ORG X 1964 MN PROVIDE QUALITY, AFFORDABLE SERVICES FOR OLDER ADULTS AND FAMILIES IN OUR COMMUNITY. 8 8 218 80 0 0 6495 751511 6981446 7607692 803 1599 5553 32163 6994297 8392965 0 0 0 0 4109315 4763772 0 0 0 2768591 3457356 6877906 8221128 116391 171837 7280552 7846455 6657420 7051486 623132 794969 PINE HAVEN COMMUNITY PROVIDES A CONTINUUM OF CARE THROUGH THE BELIEF THAT EVERY PERSON IS UNIQUE. 0 0 7212322 0 7607692 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 23,792 INPATIENT DAYS WERE PROVIDED. 7212322 1 1 0 0 0 0 0 0 1 0 1 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 0 0 0 0 0 0 1 1 0 0 0 1 17 0 218 1 0 0 0 0 0 0 0 0 0 0 0 0 X 8 8 0 1 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 1 0 0 MN X JESSICA RIVERA 5073568304 210 3RD STREET NW PINE ISLAND MN 55963 CRAIG SMITH ADMINISTRATOR (THRU JAN) 40.00 X 0 0 0 MARCUS PARENCE CEO/ADMINISTRATOR 40.00 1.00 X 0 0 0 JESSICA RIVERA FINANCE DIRECTOR 40.00 X 16717 0 0 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 BRIAN HALE VICE CHAIR 1.00 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 16717 0 0 0 0 0 0 AEGIS THERAPIES PO BOX 936653 ATLANTA GA 31193 THERAPY SERVICES 445874 PRIME TIME HEALTHCARE PO BOX 3544 OMAHA NE 68103 NURSING POOL STAFF 187914 SENIOR CARE SOLUTIONS PO BOX 2283 STILLWATER MN 55082 NURSING INTERIM STAFF 114593 3 725557 25954 751511 RESIDENT SERVICES 623000 7258865 7258865 APARTMENT REVENUE 623000 289827 289827 MANAGEMENT SERVICES 623000 59000 59000 7607692 1599 1599 32163 32163 32163 8392965 7607692 0 33762 X 187198 187198 3970545 3831994 138551 17242 16137 1105 306358 282441 23917 282429 260322 22107 11045 11045 85668 1106 84562 994644 916861 77783 87075 87075 135834 30909 104925 75457 75457 171450 145311 26139 1520 48 1472 47056 2955 44101 179500 176891 2609 447977 361874 86103 NURSING SUPPLIES 439932 439932 FOOD EXPENSE 281766 281766 NURSING HOME SURCHARGE 197050 197050 BAD DEBT EXPENSE 195843 195843 105539 70882 34657 8221128 7212322 1008806 0 7941 5791 224556 960937 614390 730026 22518 32371 11202888 5095744 6407631 6107144 3516 3516 0 6670 7280552 7846455 715302 809638 0 465589 3655 6548 5847507 5769711 90956 0 6657420 7051486 X 623132 794969 623132 794969 7280552 7846455 171837 0 X 0 1 X 1 0 X 232712 151688 40821 6495 751511 1183227 4860358 6303897 7128723 6981446 7607692 32882116 12817 575 43874 5553 32163 94982 5105887 6456160 7213418 6993494 8391366 34160325 0 0 0 34160325 927 964 1159 803 1599 5452 927 964 1159 803 1599 5452 5106814 6457124 7214577 6994297 8392965 34165777 0.99980 0.99990 0.00020 0.00010 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 116790 116790 9472044 3886919 5585125 1566029 1160800 405229 48025 48025 0 6107144 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 3 THE ORGANIZATION CONTRACTED PATHWAY HEALTH FOR THE SERVICES OF CRAIG SMTIH AS THE ADMINISTRATOR FROM JUNE 2019 UNTIL JANUARY 2020. 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 THEN PRESENTS FORM 990 TO THE BOARD OF DIRECTORS FOR APPROVAL 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 IX, LINE 11G PHARMACY SERVICES: PROGRAM SERVICE EXPENSES 5,930. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,930. THERAPY SERVICES: PROGRAM SERVICE EXPENSES 421,059. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 421,059. OTHER HEALTH CARE PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 489,872. MANAGEMENT AND GENERAL EXPENSES 77,783. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 567,655. 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