2019-07-31T08:13:59-05:00 2018-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2018-01-01 410802697 MOUNT OLIVET CAREVIEW HOME MOUN 6128275677 5517 LYNDALE AVENUE SOUTH MINNEAPOLIS MN 55419 TIMOTHY HOKANSON ADMINISTRATOR 6128275677 2019-07-16 1 JED CHENEY P01587750 6123764500 67.137.57.251 2019-07-16 12:39:12 CD P 3018D2C7A8EF8E88940F980D8F52F9F97466C021 A6AD3476A9076C5B724E5E12CCE393A62F1B66BA 2018 2019-02-21 02:37:17Z TIMOTHY HOKANSON 5517 LYNDALE AVENUE SOUTH MINNEAPOLIS MN 55419 17895944 0 X WWW.MTOLIVETHOMES.ORG X 1965 MN TO PROVIDE HIGH QUALITY LONG TERM CARE FOR RESIDENTS IN A LOVING AND CARING ENVIRONMENT. 14 14 376 270 0 2378 259976 250117 14574824 17206425 151698 141888 93897 297514 15080395 17895944 103752 142058 0 0 10255341 10996829 0 0 16052 6401278 8475638 16760371 19614525 -1679976 -1718581 46115950 43546550 32894533 32320929 13221417 11225621 X TO PROVIDE HIGH QUALITY LONG TERM CARE FOR RESIDENTS IN A LOVING AND CARING ENVIRONMENT. 0 0 18559656 142058 17206425 MOUNT OLIVET CAREVIEW HOME (MOCH) IS A 155-BED SKILLED CARE FACILITY FEATURING MOSTLY DOUBLE ROOMS AND SOME SINGLE ROOMS. WE ALSO OFFER A 16-BED TRANSITIONAL CARE UNIT FOR PATIENTS WHO REQUIRE SHORT TERM SKILLED NURSING CARE OR DAILY REHABILITATION FOLLOWING A HOSPITALIZATION. IN ADDITION, WE PROVIDE A SECURED MEMORY UNIT FOR RESIDENTS COPING WITH LATE STAGES OF MEMORY LOSS, ALZHEIMER'S AND OTHER DEMENTIA-RELATED ILLNESSES. RESIDENTS ARE DEPENDENT ON THE NURSING STAFF TO ACCOMPLISH DAILY LIVING ACTIVITIES, INCLUDING DRESSING, GROOMING, BATHING, TOILETING, EATING, WALKING, AND TRANSFERRING. DAILY SERVICES ALSO INCLUDE OXYGEN AND IV THERAPY, AS NEEDED. ONSITE VISION, HEARING, DENTAL AND PODIATRY SERVICES ARE ALSO AVAILABLE. THREE NUTRITIOUS MEALS AND OTHER REFRESHMENTS ARE SERVED DAILY IN DINING ROOMS ON EACH FLOOR. FAMILY MEMBERS CAN ENJOY MEALS WITH THEIR LOVED ONE.SPACIOUS LOUNGES, OUTDOOR PATIOS, AND PRIVATE FAMILY AREAS MAKE THE FACILITY FEEL LIKE HOME. 18559656 1 1 0 0 0 0 0 0 1 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1 28 0 376 1 0 0 0 0 0 0 0 0 0 1 0 0 0 X 14 14 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 MN X X SHARON FLACK 6128275677 5517 LYNDALE AVE SOUTH MINNEAPOLIS MN 55419 DAVID LOSE PRESIDENT 2.00 4.00 X X 0 0 0 KURT HALVA VICE PRESIDENT 0.30 0.60 X X 0 0 0 RUTH JARCHO SECRETARY 0.30 0.60 X X 0 0 0 GORDON VETSCH TREASURER 0.30 0.60 X X 0 0 0 CLYDE ALLEN DIRECTOR 0.30 0.60 X 0 0 0 MARK BEESE DIRECTOR 0.30 0.60 X 0 0 0 CHRISTINE BENT DIRECTOR 0.30 0.60 X 0 0 0 ANDREA BROWN DIRECTOR (THROUGH FEB 2018) 0.30 0.60 X 0 0 0 DAVID CARLSON DIRECTOR 0.30 0.60 X 0 0 0 EILEEN CARTWRIGHT DIRECTOR 0.30 0.60 X 0 0 0 KAREN JOHNSON DIRECTOR (THROUGH FEB 2018) 0.30 0.60 X 0 0 0 JOHN KUEHN DIRECTOR 0.30 0.60 X 0 0 0 TRUDY OLSON DIRECTOR 0.30 0.60 X 0 0 0 GREG PAGE DIRECTOR 0.30 0.60 X 0 0 0 WILLIAM TELLEEN DIRECTOR 0.30 0.60 X 0 0 0 PETER YOUNGDAHL DIRECTOR 0.30 0.60 X 0 0 0 TIMOTHY HOKANSON ADMINISTRATOR 38.00 2.00 X 165994 0 44168 SHARON FLACK CONTROLLER 38.00 2.00 X 94663 0 11252 KRISTINA IJOMAH DIRECTOR OF NURSING (THROUGH MARCH 2018) 40.00 X 147456 0 30839 BENSON NYANGAU NURSE SUPERVISOR 40.00 X 122930 0 9090 531043 0 95349 3 0 1 0 CENTREX REHAB 8120 PENN AVE S SUITE 227 BLOOMINGTON MN 55431 REHABILITATION SERVICES 1759352 MOUNT OLIVET HOME 5517 LYNDALE AVE S MINNEAPOLIS MN 55419 DIETARY SERVICES 1508102 CINTAS PO BOX 650838 DALLAS TX 75265 LAUNDRY SERVICES 212619 3 250117 250117 RESIDENT SERVICES 623000 14372636 14372636 ANCILLARY SERVICES 623000 2833789 2833789 17206425 141888 141888 22525 0 22525 22525 22525 MISCELLANEOUS 900099 135471 135471 LAUNDRY REVENUE 623000 133064 133064 GUEST MEALS 722210 7225 7225 -771 -771 274989 17895944 17206425 0 439402 X 142058 142058 316077 316077 8919885 8884071 32607 3207 90177 87265 2912 990899 953938 36961 679791 657838 21953 72981 72981 44090 44090 3073685 3022179 50164 1342 40948 40948 179910 124310 55389 211 429398 418749 9315 1334 25231 25231 9271 9271 717831 694282 20597 2952 1336062 1292232 38336 5494 195102 188702 5598 802 PROGRAM SUPPLIES 851233 846242 4365 626 FOOD 590539 590539 LICENSE SURCHARGE 433070 433070 MISCELLANEOUS EXPENSES 229098 229098 247189 224181 22924 84 19614525 18559656 1038817 16052 11551 88588 2629032 2561112 70203 68574 47088256 12699466 31047668 34388790 5482447 4745602 75000 75000 431737 527422 6368312 1091462 46115950 43546550 1087191 1343841 25616385 25455410 23207 31967 600000 1500000 5567750 3989711 32894533 32320929 X 11525371 9884485 600505 245595 1095541 1095541 13221417 11225621 46115950 43546550 -1718581 -277215 0 X 0 1 X 1 0 X 175217 283244 358162 259976 250117 1326716 12212217 12533161 14970233 14574824 17198670 71489105 23605 162275 143542 128986 139518 597926 12411039 12978680 15471937 14963786 17588305 73413747 10000 38022 38525 66475 60000 213022 0 10000 38022 38525 66475 60000 213022 73200725 173574 191275 170126 172346 164413 871734 173574 191275 170126 172346 164413 871734 86182 124640 42961 -55737 143227 341273 12670795 13294595 15685024 15080395 17895945 74626754 0.98090 0.98110 0.01170 0.01320 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS REVENUE LOSS ON REFINANCING 0 1 X 1095541 28142 28142 1095541 1095541 28348 28348 1095541 1095541 24501 24501 1095541 1095541 25703 25703 1095541 1079491 16050 23098 23098 1095541 0.00000 1.00000 0.00000 0 1 1 46183 46183 38138978 6823862 31315116 743020 368554 374466 8158182 5507050 2651132 1893 1893 34388790 ASSET RETIREMENT OBLIGATION 9368 DUE TO AFFILIATE 3815705 CONSTRUCTION PAYABLE 164638 3989711 X PART IV, LINE 2B: THE ORGANIZATION IS THE TRUSTEE OF VARIOUS RESIDENT FUNDS AND HAS A FIDUCIARY RESPONSIBILITY FOR THE ADMINISTRATION AND DISTRIBUTION OF THESE FUNDS FOR THE RESIDENTS. THESE FUNDS ARE ON DEPOSIT IN A SEPARATE BANK ACCOUNT. PART V, LINE 4: TO PROVIDE A PERMANENT SOURCE OF INCOME FOR CAPITAL, EQUIPMENT, EDUCATION, AND OTHER OPERATING PURPOSES. PART X, LINE 2: THE INTERNAL REVENUE SERVICE HAS CLASSIFIED THE ENTITIES AS TAX-EXEMPT ORGANIZATIONS UNDER THE PROVISIONS OF INTERNAL REVENUE CODE SECTION 501(C)(3). THE ORGANIZATION FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES IN EVALUATING UNCERTAIN TAX POSITIONS. THE ORGANIZATION'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE ORGANIZATION IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. THE ORGANIZATION IS NOT AWARE OF ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER ITEMS. 1 EMPLOYEE SCHOLARSHIPS 8 7500 EMPLOYEE LOAN FORGIVENESS 8 36338 TUITION REIMBURSEMENT 26 98220 PART I, LINE 2: SCHOLARSHIPS, TUITION REIMBURSEMENT, AND STUDENT LOAN FORGIVENESS PROGRAMS ARE AWARDED ANNUALLY THROUGH A PROGRAM ESTABLISHED BY THE ORGANIZATION'S DEVELOPMENT AND HUMAN RESOURCE TEAM. SCHOLARSHIP, TUITION REIMBURSEMENT, AND STUDENT LOAN FORGIVENESS RECIPIENTS ARE REQUIRED TO PROVIDE RECEIPTS TO DOCUMENT APPROPRIATE USE OF FUNDS. X 0 0 0 0 0 0 0 0 0 TIMOTHY HOKANSON ADMINISTRATOR 149648 0 0 0 16346 0 0 0 44168 0 210162 0 0 0 KRISTINA IJOMAH DIRECTOR OF NURSING (THROUGH MARCH 2 138992 0 0 0 8464 0 0 0 30839 0 178295 0 0 0 A CITY OF ST LOUIS PARK 416005519 791748FP6 2016-05-31 26295000 SERIES 2016B AND C BONDS FOR MT. OLIVET CAREVIEW HOME CONSTRUCTION PROJECT 0 0 0 A 445000 26295000 800000 525900 24802390 166710 2018 0 0 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE PRESIDENT, VICE PRESIDENT, TREASURER AND SECRETARY OF THE BOARD OF DIRECTORS. OTHER PERSONS MAY BE ELECTED OR APPOINTED BY THE BOARD, BUT UNDER NO CIRCUMSTANCES MAY THE EXECUTIVE COMMITTEE EXCEED SEVEN MEMBERS. THE EXECUTIVE COMMITTEE, IN THE INTERIM BETWEEN MEETINGS OF THE BOARD, EXERCISES THE POWERS OF THE BOARD IN ACCORDANCE WITH THE GENERAL POLICY OF THE ORGANIZATION AND THE BOARD. THE EXECUTIVE COMMITTEE IS SUBJECT AT ALL TIMES TO THE DIRECTION AND CONTROL OF THE BOARD. FORM 990, PART VI, SECTION B, LINE 11B THE OPTION TO VIEW A DRAFT 990 IS PROVIDED TO SELECT REPRESENTATIVES OF THE BOARD OF DIRECTORS FOR DETAIL REVIEW AND APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C COVERED INDIVIDUALS ARE REQUIRED TO COMPLETE AN ANNUAL STATEMENT THAT INCLUDES A DUTY TO DISCLOSE. COVERED INDIVIDUALS MUST DISCLOSE THE EXISTENCE OF ANY POTENTIAL CONFLICT OF INTEREST AND MUST BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE ADMINISTRATOR. THE ADMINISTRATOR WILL REPORT MATERIAL FACTS TO THE BOARD OF DIRECTORS OR THE BOARD EXECUTIVE COMMITTEE FOR DETERMINATION OF WHETHER A CONFLICT OF INTEREST EXISTS. INDIVIDUALS WITH POTENTIAL CONFLICTS OF INTEREST MAY NOT BE PRESENT DURING THE DISCUSSION NOR VOTE ON THE TRANSACTION OR ARRANGEMENT WHERE A CONFLICT EXISTS. THE MINUTES OF THE BOARD OF DIRECTORS OR BOARD EXECUTIVE COMMITTEE WILL RECORD ALL PROCEEDINGS RELATED TO CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 TOP MANAGEMENT AND KEY EMPLOYEE COMPENSATION IS REVIEWED BY THE PRESIDENT AND VICE PRESIDENT OF THE BOARD. THE COMPENSATION OF THESE INDIVIDUALS WAS LAST COMPARED TO THE 2018 ELCA SALARY SURVEY. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION'S FORM 990 IS AVAILABLE UPON REQUEST AND AT WWW.GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G NURSING CONSULTANTS: PROGRAM SERVICE EXPENSES 80,456. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 80,456. SOCIAL SERVICES PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 10,807. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 10,807. ANCILLARY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,556,738. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,556,738. DIETARY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 918,013. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 918,013. LAUNDRY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 140,552. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 140,552. MAINTENANCE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 315,613. MANAGEMENT AND GENERAL EXPENSES 9,363. FUNDRAISING EXPENSES 1,342. TOTAL EXPENSES 326,318. MEDICARE BILLING FEE: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 40,801. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 40,801. MOUNT OLIVET CAREVIEW HOME FOUNDATION LLC 5025 KNOX AVENUE SOUTH MINNEAPOLIS MN 55419 FOUNDATION MN 109123 4745602 MOUNT OLIVET CAREVIEW HOME MOUNT OLIVET HOME 5517 LYNDALE AVE S MINNEAPOLIS MN 55419 410838344 BOARD AND CARE MN 501(C)(3) LINE 10 SEE SCHEDULE R PART VII 1 MOUNT OLIVET DAY SERVICES 5601 LYNDALE AVE S MINNEAPOLIS MN 55419 411785649 CHILD & ADULT DAYCARE MN 501(C)(3) LINE 10 SEE SCHEDULE R PART VII 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 MOUNT OLIVET HOME P 1508102 ACTUAL AMOUNT MOUNT OLIVET HOME Q 261051 ACTUAL AMOUNT SCHEDULE R, PART II MOUNT OLIVET CAREVIEW HOME, MOUNT OLIVET HOME, AND MOUNT OLIVET DAY SERVICES EACH HAVE IDENTICAL BOARDS OF DIRECTORS. ALTHOUGH NONE OF THE ORGANIZATIONS' BYLAWS GIVES ONE ORGANIZATION CONTROL OVER THE OTHERS, EACH ORGANIZATION MEETS THE IRS' DEFINITION OF CONTROL FOR BOTH OF THE OTHER ORGANIZATIONS.