2019-06-19T16:37:41-05:00 2018-06-30 910189318 MOSS ADAMS LLP 101 SECOND STREET SUITE 900 SAN FRANCISCO CA 94105 990 2017-07-01 200752156 INCLINE VILLAGE COMMUNITY HOSPITAL FOUNDATION INCL 7758334100 880 ALDER AVENUE INCLINE VILLAGE NV 89451 KARLI EPSTEIN EXECUTIVE DIRECTOR 7758334100 2019-06-17 1 TRACY S PAGLIA P00366884 4159561500 2019-06-17 12.129.7.100 2019-06-17 12:47:22 PD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 590998BD83A1AFC8298AB8E54118062D6841B7FE 2017 2019-02-21 02:37:17Z KARLI EPSTEIN 880 ALDER AVENUE INCLINE VILLAGE NV 89451 416975 0 X HTTPS://WWW.TFHD.COM/IVCH/IVCH-FOUNDATION X 2004 NV ASSIST INCLINE VILLAGE COMMUNITY HOSPITAL TO DELIVER QUALITY EMERGENCY & PRIMARY HEALTH CARE SERVICES 20 19 0 24 0 0 365458 416975 0 0 0 0 0 0 365458 416975 379347 435482 0 0 0 0 0 0 0 10091 12902 389438 448384 -23980 -31409 449594 469666 182000 229533 267594 240133 X OUR MISSION IS TO ASSIST THE INCLINE VILLAGE COMMUNITY HOSPITAL IN DELIVERING THE HIGHEST QUALITY EMERGENCY AND PRIMARY HEALTH CARE SERVICES BY PROCURING FINANCIAL RESOURCES, IMPROVING COMMUNITY AWARENESS AND INVOLVING COMMUNITY RESIDENTS AND VISITORS IN DEVELOPING A LONG-TERM VISION FOR COMPREHENSIVE HEALTH CARE IN THE COMMUNITIES OF THE NORTH SHORE OF LAKE TAHOE, INCLUDING KINGS BEACH, CRYSTAL BAY AND INCLINE VILLAGE 0 0 182000 182000 0 THE FOUNDATION PROVIDED $182,000 TO THE INCLINE VILLAGE COMMUNITY HOSPITAL TO SUPPORT THE LABORATORY AND EMERGENCY ROOM IMPROVEMENTS PROJECT. THIS PROJECT INCLUDES A NEW PATIENT WAITING AREA, NEW PATIENT GREETING AREA, RESTROOM IMPROVEMENTS, AND BETTER UTILIZATION OF THE EXISTING STAFF SPACE. THE PROJECT WILL ALSO COVER IMPROVEMENTS TO EMERGENCY ROOM #5. 177621 177621 0 THE FOUNDATION PROVIDED $177,621 TO THE INCLINE VILLAGE COMMUNITY HOSPITAL TO FUND DIAGNOSTIC IMAGING UPGRADES THAT INCLUDE A DIGITAL PORTABLE X-RAY MACHINE AND A DIGITAL RETROFIT KIT. THE NEW PIECE OF EQUIPMENT USES STATE OF THE ART TECHNOLOGY TO HELP MODERNIZE THE HOSPITAL'S IMAGING CAPABILITIES. IT REPLACED THE CURRENT MACHINE THAT WAS 20+ YEARS OLD. 27000 27000 0 GRANT FUNDS RECEIVED BY THE FOUNDATION AND TRANSFERRED TO THE HOSPITAL TO SUPPORT THE OPERATIONS OF THE INCLINE VILLAGE COMMUNITY HOSPITAL FAMILY HEALTH CLINIC. 48861 48861 0 THE FOUNDATION PROVIDES SUPPORT FOR VARIOUS OTHER EXPENSES TO ASSIST THE INCLINE VILLAGE COMMUNITY HOSPITAL IN DELIVERING OPTIMAL HEALTH CARE SERVICES IN NORTH LAKE TAHOE. 48861 48861 0 435482 1 1 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 20 19 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X TAHOE FOREST HOSPITAL DISTRICT JAYE CHASSEUR CONTROLLER 5305823489 10121 PINE AVENUE TRUCKEE CA 96160 GERRY EICK PRESIDENT 0.50 0.00 X X 0 0 0 WARREN KOCMOND PAST PRESIDENT 0.50 0.00 X X 0 0 0 JONATHAN SMITH OD VICE PRESIDENT 0.50 0.00 X X 0 0 0 MARY ANSARI SECRETARY 0.50 0.00 X X 0 0 0 KEVIN HANNA TREASURER 0.50 0.00 X X 0 0 0 WALTER BINDER DIRECTOR (THRU 9/17) 0.50 0.00 X 0 0 0 DAVID COLLINS DIRECTOR 0.50 0.00 X 0 0 0 GARY FINCH DIRECTOR 0.50 0.00 X 0 0 0 LINDSAY HARDIE DIRECTOR 0.50 0.00 X 0 0 0 NAN HEALY DIRECTOR 0.50 0.00 X 0 0 0 ROBERT HEYNEN DIRECTOR 0.50 0.00 X 0 0 0 SHANE JOHNSON DIRECTOR 0.50 0.00 X 0 0 0 ROGER KAHN DIRECTOR 0.50 0.00 X 0 0 0 ROBERT KENNEDY DIRECTOR 0.50 0.00 X 0 0 0 SUSANNA KINTZ DIRECTOR 0.50 0.00 X 0 0 0 RALPH KUHN MD DIRECTOR 0.50 0.00 X 0 0 0 MIKE LACEY DIRECTOR 0.50 0.00 X 0 0 0 MARGO LALCHANDANI DIRECTOR 0.50 0.00 X 0 0 0 DONALD MASON MD DIRECTOR 0.50 0.00 X 0 0 0 SEAN O'NEAL DIRECTOR 0.50 0.00 X 0 0 0 CHARLES ZIPKIN BOARD LIASON TFHD 0.50 1.00 X 0 0 0 HARRY WEIS DIRECTOR & TFHD CEO 0.50 44.50 X X 0 444093 55014 KARLI EPSTEIN EXECUTIVE DIRECTOR 40.00 0.00 X 0 104896 31512 JUDY NEWLAND ADMINISTRATOR IVCH 0.50 40.00 X 0 279082 66143 CRYSTAL BETTS CFO, TFHD 1.00 44.00 X 0 289083 40307 JAYE CHASSEUR CONTROLLER, TFHD 1.00 44.00 X 0 176259 33761 0 1293413 226737 0 0 1 0 0 20250 396725 416975 416975 0 0 0 435482 435482 12902 12902 448384 435482 12902 0 108198 125396 302484 302660 6750 0 32162 41610 449594 469666 182000 229533 182000 229533 X 201965 156227 36420 49197 29209 34709 267594 240133 449594 469666 X -31409 3948 X 0 1 X 1 0 X X 1 TAHOE FOREST HOSPITAL DISTRICT 946004062 6 1 435482 0 1 435482 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 32162 5500 3948 41610 29209 2953 32162 0.00000 0.83420 0.16580 1 0 0 ENDOWMENT: BENEFICIAL INTEREST IN TRUST 41610 41610 669457 248534 3948 252482 416975 0 416975 696918 248534 248534 448384 0 448384 PART V, LINE 4: THE PURPOSE OF THE ENDOWMENT AND IMPROVEMENT FUNDS IS TO PROVIDE SUPPORT TO OR FOR THE BENEFIT OF THE FOUNDATION AND ITS ACTIVITIES IN PURSUIT OF ITS MISSION TO DELIVER OPTIMAL HEALTH CARE SERVICES IN THE COMMUNITIES SERVED BY INCLINE VILLAGE COMMUNITY HOSPITAL. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST IN TRUST 3,948. 1 TAHOE FOREST HOSPITAL DISTRICT PO BOX 759 TRUCKEE CA 96160 946004062 115(1) 435482 TO SUPPORT AND ENHANCE HEALTHCARE IN THE DISTRICT'S SERVICE AREA 1 0 PART I, LINE 2: THE FOUNDATION EXISTS TO SUPPORT AND ENHANCE HEALTHCARE IN THE INCLINE VILLAGE COMMUNITY HOSPITAL'S SERVICE AREA. ACCORDINGLY, THE FOUNDATION'S ASSISTANCE REPRESENTS PAYMENTS DIRECTLY MADE TO THE DISTRICT IN FURTHERANCE OF THESE PURPOSES. THE BOARD OF DIRECTORS FROM THE FOUNDATION AND THE DISTRICT PERFORM MONITORING PROCEDURES TO ENSURE THAT THE ASSISTANCE PROVIDED BY THE FOUNDATION IS USED TO SUPPORT AND ENHANCE HEALTHCARE IN INCLINE VILLAGE COMMUNITY HOSPITAL'S SERVICE AREA. 0 0 0 0 0 0 1 1 0 HARRY WEIS DIRECTOR & TFHD CEO 0 388832 0 39039 0 16222 0 33744 0 21270 0 499107 0 0 JUDY NEWLAND ADMINISTRATOR IVCH 0 225906 0 42616 0 10560 0 36133 0 30010 0 345225 0 0 CRYSTAL BETTS CFO, TFHD 0 246520 0 34314 0 8249 0 14590 0 25717 0 329390 0 0 JAYE CHASSEUR CONTROLLER, TFHD 0 155738 0 19793 0 728 0 21983 0 11778 0 210020 0 0 PART I, LINE 3 THE FOUNDATION RELIED ON A RELATED ORGANIZATION THAT USED ONE OR MORE OF THE METHODS TO ESTABLISH THE TOP MANAGEMENT OFFICIAL'S COMPENSATION. PART I, LINE 6 CURRENT EMPLOYEES OF THE RELATED ORGANIZATION, TAHOE FOREST HOSPITAL DISTRICT (DISTRICT) WHO MEET THE PLAN CRITERIA ARE ELIGIBLE TO PARTICIPATE IN A GAIN SHARING PROGRAM. CERTAIN PROGRAM METRICS MUST BE ACHIEVED IN ORDER FOR THE GAIN SHARING POOL TO BE ACTIVE FOR THE FISCAL YEAR. THE POOL OF GAIN SHARING FUNDS IS CALCULATED AS A PERCENTAGE OF AUDITED NET INCOME OF THE DISTRICT, TIERED FOR DIFFERENT LEVELS OF NET INCOME OF THE DISTRICT OVERALL. ELIGIBLE EMPLOYEES, WHICH MAY INCLUDE OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES OF THE DISTRICT THAT ALSO SERVE THE FOUNDATION THAT ARE EMPLOYED BY THE DISTRICT RECEIVE A PRO-RATA SHARE OF THE GAIN SHARING POOL BY ALLOCATING THE EMPLOYEE'S SALARY AGAINST THE TOTAL SALARY OF ALL ELIGIBLE EMPLOYEES. THE FOUNDATION DOES NOT INCUR ANY EXPENSES UNDER THIS PLAN. PART I, LINE 7 CERTAIN KEY PERSONNEL OF THE RELATED ORGANIZATION, TAHOE FOREST HOSPITAL DISTRICT (DISTRICT) THAT SERVE THE FOUNDATION ARE ELIGIBLE FOR THE INCENTIVE COMPENSATION PLAN WHICH AWARDS A PERCENTAGE OF BASE COMPENSATION FOR THE FISCAL YEAR. ELIGIBLE EMPLOYEES OF THE DISTRICT INCLUDE OFFICERS, KEY PERSONNEL, AND OTHER EMPLOYEES AT THE DISCRETION OF THE CEO THAT MAY ALSO SERVE THE FOUNDATION. FOR THE INCENTIVE COMPENSATION TO BE AWARDED, CERTAIN FINANCIAL TARGETS AND ACHIEVEMENT OF ANNUAL GOALS AND STRATEGIC OBJECTIVES MUST BE MET. THE CEO MAY USE DISCRETION OVER THE INCENTIVE COMPENSATION AWARDED, BUT ALL PAYOUTS UNDER THE PLAN ARE DETERMINED AFTER ACCEPTANCE OF THE DISTRICT'S AUDITED FINANCIAL STATEMENT BY THE BOARD OF DIRECTORS. THE FOUNDATION DOES NOT INCUR ANY EXPENSES UNDER THIS PLAN. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE FOUNDATION IS TAHOE FOREST HOSPITAL DISTRICT. FORM 990, PART VI, SECTION A, LINE 7A THE FOUNDATION'S BOARD OF DIRECTORS ARE ELECTED BY THE SOLE MEMBER, TAHOE FOREST HOSPITAL DISTRICT. FORM 990, PART VI, SECTION A, LINE 7B AMENDMENTS TO THE BYLAWS AND CHANGES TO THE NUMBER OF DIRECTORS MUST BE APPROVED BY THE SOLE MEMBER, TAHOE FOREST HOSPITAL DISTRICT. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED BY THE EXECUTIVE DIRECTOR. THE EXECUTIVE DIRECTOR ALSO REVIEWS THE FORM 990 WITH THE CHAIRMAN OR TREASURER OF THE BOARD, AND THE FOUNDATION'S ACCOUNTANT IN PERSON, VIA EMAIL, OR THROUGH A BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C THE FOUNDATION'S CONFLICT OF INTEREST POLICY APPLIES TO ALL PERSONS HOLDING POSITIONS OF RESPONSIBILITY AND TRUST ON BEHALF OF TAHOE FOREST HEALTH SYSTEM FOUNDATION, INCLUDING, BUT NOT LIMITED TO MEMBERS OF THE BOARD OF DIRECTORS, VOLUNTEER COMMITTEE MEMBERS, AND TAHOE FOREST HEALTH SYSTEM FOUNDATION STAFF (BOARD/STAFF/VOLUNTEERS). COVERED PERSONS ARE REQUIRED TO ANNUALLY COMPLETE A DISCLOSURE STATEMENT FOR POTENTIAL RELATIONSHIPS AS WELL AS DISCLOSING ANY INTEREST THAT MAY IMPACT THE DECISION-MAKING PROCESS WHENEVER THERE IS ANY DOUBT ABOUT WHETHER DISCLOSURE IS REQUIRED. IF A COVERED PERSON HAS AN INTEREST IN A PROPOSED TRANSACTION WITH THE FOUNDATION, HE OR SHE MUST MAKE FULL DISCLOSURE OF SUCH INTEREST BEFORE ANY DISCUSSION OR NEGOTIATION OF THE TRANSACTION AND ABSTAIN FROM DECISION-TAKING ACTIONS. IF A CONFLICT, OR THE POTENTIAL APPEARANCE OF A CONFLICT, EXISTS, THE BOARD MEMBER MUST RECUSE THEMSELVES BY NOT INFLUENCING, ATTEMPTING TO INFLUENCE, OR PARTICIPATING IN THAT DISCUSSION AND/OR VOTE MADE BY REMAINING MEMBERS THAT DO NOT HAVE AN INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE ANNUAL CALIFORNIA HOSPITAL ASSOCIATION SURVEY IS USED TO DETERMINE APPROPRIATE SALARY RANGES ON GEOGRAPHICAL AREA BASED ON JOB. REVIEWED BY THE HUMAN RESOURCES DEPARTMENT OF TAHOE FOREST HOSPITAL DISTRICT ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19 ANY INTERESTED PARTIES WHO DESIRE TO OBTAIN A COPY OF ANY OF THE GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS CAN CONTACT THE OFFICE AND REQUEST A PAPER COPY. ANY DOCUMENTS REQUESTED ARE PRINTED AND HANDED TO THE INTERESTED PARTY AT THE OFFICE. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN TRUST 3,948. TAHOE FOREST HOSPITAL DISTRICT PO BOX 759 TRUCKEE CA 96160 946004062 HEALTHCARE CA N/A 0 TAHOE FOREST HEALTH SYSTEM FOUNDATION PO BOX 2508 TRUCKEE CA 96160 943047869 HEALTHCARE CA 501(C)(3) LINE 12A, I TAHOE FOREST HOSPITAL DISTRICT 0 TAHOE INSTITUTE FOR RURAL HEALTH RESEARCH PO BOX 759 TRUCKEE CA 96160 352372175 IMPROVE AFFORDABILITY OF HIGH QUALITY HEALTHCARE CA 501(C)(3) LINE 12A, I TAHOE FOREST HOSPITAL DISTRICT 0 THE TRUCKEE SURGERY CENTER LLC 10770 DONNER PASS ROAD SUITE 201 TRUCKEE CA 96161 273943102 AMBULATORY SURGERY CENTER CA TAHOE FOREST HOSPITAL DISTRICT C 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 1 0 1 0 0 TAHOE FOREST HOSPITAL DISTRICT B 435482 FMV TAHOE FOREST HOSPITAL DISTRICT N 248534 FMV LATE FILED RETURN DUE TO CCH SOFTWARE OUTAGE