2020-04-22T06:40:54-05:00 2019-06-30 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2018-07-01 390816900 PINE HAVEN CHRISTIAN HOME INC PINE 9204672401 531 GIDDINGS AVENUE SHEBOYGAN FALLS WI 53085 RONALD WALVOORT CHIEF EXECUTIVE OFFICER 9204672401 2020-03-27 1 MICHAEL J PETERSON CPA P01833529 2187224705 2020-03-27 184.59.22.73 2020-03-27 09:25:33 CD P 51EE487FFA723F16933CF5B8BD3577F2E9FFA893 CC322FB1B7FC8ED290785ACCB7D2994D8745AEAD 2018 2020-09-23 17:36:50Z RONALD WALVOORT 531 GIDDINGS AVENUE SHEBOYGAN FALLS WI 53085 18316743 0 X WWW.PINEHAVEN.ORG X 1950 WI PINE HAVEN CHRISTIAN HOME, INC. (PINE HAVEN CHRISTIAN COMMUNITIES) WILL PROVIDE THE AGING POPULATION WE SERVE AN ENVIRONMENT THAT IS A CHRIST-CENTERED, SAFE HAVEN OFFERING QUALITY, COMPASSIONATE CARE. 17 17 486 227 0 0 189886 246929 17895865 17518688 85238 79635 21201 20476 18192190 17865728 0 0 0 0 10358701 10210137 0 0 11469 7365935 7354664 17724636 17564801 467554 300927 42341659 42222322 27875011 27354014 14466648 14868308 X PINE HAVEN CHRISTIAN COMMUNITIES WILL PROVIDE THE AGING POPULATION WE SERVE AN ENVIRONMENT THAT IS A CHRIST-CENTERED, SAFE HAVEN OFFERING QUALITY, COMPASSIONATE CARE. 1 0 16146219 0 17518688 PINE HAVEN CHRISTIAN HOME, INC. PROVIDES HOUSING, HEALTH CARE AND OTHER RELATED SERVICES TO RESIDENTS IN A NURSING HOME AND ASSISTED LIVING FACILITIES. PINE HAVEN CHRISTIAN HOME, INC. OPERATES A SKILLED NURSING FACILITY AND AN ASSISTED LIVING COMMUNITY BASED RESIDENTIAL FACILITY (CBRF) AT ITS HAVEN DRIVE LOCATION; A CBRF INCLUDING MEMORY CARE AT ITS GIDDINGS AVE. LOCATION; A CBRF AT ITS OOSTBURG LOCATION; 14 INDEPENDENT LIVING DUPLEX UNITS NEAR ITS OOSTBURG CBRF. IT AVERAGED 89.7% OCCUPANCY IN FISCAL YEAR 2019 WITH A PREDOMINATELY PRIVATE PAY PAYER MIX. 16146219 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 62 0 486 1 0 0 0 0 0 0 0 0 0 0 0 0 X 17 17 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X RONALD WALVOORT 9204672401 531 GIDDINGS AVENUE SHEBOYGAN FALLS WI 53085 DENNIS BEACH DIRECTOR 1.00 X 0 0 0 JEFF BROETZMANN DIRECTOR 1.00 1.00 X 0 0 0 ROGER BUYZE DIRECTOR 1.00 X 0 0 0 CURTIS HANCOCK DIRECTOR 1.00 X 0 0 0 DARRYL HARMELINK DIRECTOR 1.00 X 0 0 0 DARRELL HAUSE DIRECTOR 1.00 X 0 0 0 NORENE HUIBREGTSE DIRECTOR 1.00 X 0 0 0 GENE JENTINK DIRECTOR 1.00 1.00 X 0 0 0 KEN KOEHLER DIRECTOR (UNTIL 9/18) 1.00 X 0 0 0 GLENN LEMMENES DIRECTOR 1.00 1.00 X 0 0 0 LARRY LORENZ DIRECTOR (UNTIL 9/18) 1.00 X 0 0 0 BETTY MOODY DIRECTOR 1.00 X 0 0 0 BOB NYHUIS DIRECTOR 1.00 X 0 0 0 BOB OSTERMANN DIRECTOR 1.00 X 0 0 0 ELAINE SCHOLL DIRECTOR 1.00 X 0 0 0 RANDY TEUNISSEN DIRECTOR (UNTIL 9/18) 1.00 X 0 0 0 CHRISTINE TEMPAS PRESIDENT (UNTIL 9/18) 1.00 1.00 X X 0 0 0 JERITH BUTEYN-GIER PRESIDENT (BEG 9/18) 1.00 1.00 X X 0 0 0 GENNY TEN PAS VICE PRESIDENT 1.00 1.00 X X 0 0 0 ROBERT DESMIDT SECRETARY (UNTIL 9/18) 1.00 X X 0 0 0 TIM GORTER TREASURER (9/18-5/19)/DIRECTOR 1.00 1.00 X X 0 0 0 JACK HOFFMAN SECRETARY (BEG 9/18)/TREASURER (BEG 5/19) 1.00 1.00 X X 0 0 0 RON WALVOORT CHIEF EXECUTIVE OFFICER 40.00 1.00 X 152693 0 31473 MARTIN HALVERSON CHIEF FINANCIAL OFFICER (UNTIL 7/18) 40.00 1.00 X 87150 0 17340 STANLEY KAYMEN CHIEF FINANCIAL OFFICER (BEG 8/18) 40.00 1.00 X 36698 0 0 STEVE HENDRIKSE CHIEF OPERATING OFFICER (UNTIL 5/19) 40.00 1.00 X 110126 0 20112 SHANNON OTTEN CHIEF OPERATING OFFICER (BEG 2/19) 40.00 1.00 X 0 0 0 386667 0 68925 2 0 1 0 QUASIUS CONSTRUCTION INC 1202A NORTH 8TH STREET SHEBOYGAN WI 53081 CONSTRUCTION SERVICES 1268229 REHABCARE INC 680 SOUTH FOURTH STREET LOUISVILLE KY 40202 THERAPY SERVICES 718642 ELITE NURSES INC 1987 SCHEUERING ROAD NO 8 DE PERE WI 54115 STAFFING SERVICES 184992 J F AHERN CO INC 855 MORRIS STREET FON DU LAC WI 54935 CONTRACTING SERVICES 171086 ASSURED STAFFING SERVICE LLC 7268 ARGUS DRIVE ROCKFORD IL 61107 STAFFING SERVICES 164226 7 241929 5000 246929 CBRF REVENUE 623000 10648737 10648737 NURSING HOME REVENUE 623000 4773364 4773364 RESIDENTIAL CARE REVENUE 623000 2013376 2013376 INDEPENDENT LIVING REVENUE 623000 83211 83211 17518688 121539 121539 398535 10576 433237 17778 -34702 -7202 -41904 -41904 20476 20476 20476 17865728 17518688 0 100111 X 533384 533384 7897126 7273739 614494 8893 102111 102111 1015428 1010700 4070 658 662088 574275 87813 45079 15798 28921 360 28243 9885 18358 24402 24402 1873418 1873418 79539 79539 86980 33460 53520 148212 148212 808024 800800 7224 22556 22556 875272 863053 12219 1626646 1603938 22708 162774 162774 FOOD EXPENSES 831822 831822 MEDICAL SUPPLIES 220133 220133 MAINTENANCE & REPAIRS 148150 148150 PROVISION FOR BAD DEBTS 48511 48511 324903 323345 1558 17564801 16146219 1407113 11469 0 569646 1600460 282583 948602 703298 18011 13341 134706 91881 48874325 14594833 31186831 34279492 7523015 6279741 930034 2340 42341659 42222322 1225223 1382430 26649788 25971584 27875011 27354014 X 13537444 14868308 929204 0 14466648 14868308 42341659 42222322 300927 100733 0 X 0 1 X 1 0 X 4729 1098178 230821 189886 246929 1770543 14452767 16611212 16942320 17895865 17518688 83420852 7401 21810 21201 20476 70888 14464897 17709390 17194951 18106952 17786093 85262283 0 0 0 85262283 13914 26159 54394 75276 121539 291282 13914 26159 54394 75276 121539 291282 14478811 17735549 17249345 18182228 17907632 85553565 0.99660 0.99680 0.00340 0.00250 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1345944 1345944 43244878 12239922 31004956 4211460 2354911 1856549 72043 72043 34279492 X X 0 0 0 0 0 0 0 0 0 RON WALVOORT CHIEF EXECUTIVE OFFICER 152693 0 0 0 0 0 4581 0 26892 0 184166 0 0 0 A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 2014-05-01 10000000 ADJUSTABLE RATE REFUNDING REVENUE BONDS, SERIES 2014A 0 0 0 B WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 2014-05-01 19100000 NEW PROJECT, SERIES 2014B 0 0 0 A 1202103 10000000 10000000 2006 1 0 1 1 B 1591168 19100000 18100000 1000000 2015 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 1 0 0 0 1 B 0 0 0 0 1 0 0 0 1 A 0 B 0 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 03/11/2019 FORM 990, PART III, LINE 2 IN JANUARY 2019, THE ORGANIZATION PURCHASED 14 DUPLEX UNITS IN OOSTBURG, WISCONSIN, THUS BEGINNING ITS FIRST INDEPENDENT LIVING OPERATION. FORM 990, PART VI, SECTION A, LINE 6 PINE HAVEN CHRISTIAN HOME, INC. HAS ONE CLASS OF MEMBERS. A PERSON WILL BE ADMITTED TO MEMBERSHIP OF PINE HAVEN CHRISTIAN HOME, INC. UPON THE CONDITIONS THAT (I) THE INDIVIDUAL BE A MEMBER OF GOOD STANDING IN ANY CONGREGATION, AND (II) SUCH INDIVIDUAL CONSENTS TO BEING A MEMBER OF PINE HAVEN CHRISTIAN HOME, INC. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS ELECT THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF THE FORM 990 WAS PROVIDED TO ALL BOARD MEMBERS PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C 1. THE PERSONS COVERED BY THE CONFLICT OF INTEREST POLICY ARE DIRECTORS AND OFFICERS. 2. DETERMINATIONS OF WHETHER A CONFLICT EXISTS ARE MADE BY THE BOARD OF DIRECTORS. 3. ACTUAL CONFLICTS ARE REVIEWED AT THE BOARD OF DIRECTORS LEVEL. 4. IF A CONFLICT EXISTS, THE BOARD'S OPTIONS INCLUDE BUT ARE NOT LIMITED TO I) PROHIBITING THE AFFECTED DIRECTOR OR OFFICER FROM PARTICIPATING IN ANY PINE HAVEN DISCUSSION OR DECISIONS INVOLVING THE CONFLICT OF INTEREST; II) MODIFYING OR REDEFINING THE DUTIES AND RESPONSIBILITIES OF THE AFFECTED DIRECTOR OR OFFICER; III) REQUIRING THE RESIGNATION OF THE AFFECTED DIRECTOR OR OFFICER. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION FOR THE CHIEF EXECUTIVE OFFICER AND OTHER KEY EMPLOYEES IS COMPARED TO INDUSTRY DATA COMPILED BY LEADING AGE WISCONSIN. THE SURVEY COMPARES COMPENSATION BASED ON THREE CRITERIA: GROSS REVENUES, GEOGRAPHIC AREA AND TOTAL BED RESPONSIBILITIES. THE CHIEF EXECUTIVE OFFICER HAS AN ANNUAL REVIEW COMPLETED BY THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC AT THIS TIME. FORM 990, PART IX, LINE 11G OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 339,824. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 339,824. MEDICAL PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,533,594. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,533,594. PINE HAVEN CHRISTIAN HOME FOUNDATION INC 531 GIDDINGS AVENUE SHEBOYGAN FALLS WI 53085 391963866 TO SUPPORT PINE HAVEN CHRISTIAN HOME, INC. WI 501(C)(3) LINE 12A, I PINE HAVEN CHRISTIAN HOME INC 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 PINE HAVEN CHRISTIAN RETIREMENT HOME FOUNDATION INC C 241929 FAIR MARKET VALUE