2019-05-14T01:26:59-05:00 2018-06-30 910189318 MOSS ADAMS LLP 101 SECOND STREET SUITE 900 SAN FRANCISCO CA 94105 990 2017-07-01 680437840 PETALUMA HEALTH CENTER INC PETA 7075597500 1179 NORTH MCDOWELL BLVD PETALUMA CA 94954 KATHRYN POWELL CEO 7075597500 2019-05-13 1 LAUREN A HAVERLOCK P00545829 4159561500 12.129.7.100 2019-05-13 18:09:20 PD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 32BFBF1104AA8EEBC72962A0CCB0C2C16BC479E3 2017 2019-02-21 02:37:17Z KATHRYN POWELL 1179 NORTH MCDOWELL BLVD PETALUMA CA 94954 42940902 0 X WWW.PHEALTHCENTER.ORG X 1999 CA TO ENSURE ACCESS & PROVIDE HIGH QUALITY PREVENTION-FOCUSED HEALTH CARE FOR THE COMMUNITIES WE SERVE. 11 10 448 15 0 19355 3762595 4451384 33913050 38052693 -11222 4011 210464 432814 37874887 42940902 0 0 0 0 27505730 29992157 0 0 0 10757886 11687351 38263616 41679508 -388729 1261394 30520452 34359866 15071083 17649103 15449369 16710763 X THE PETALUMA HEALTH CENTER'S MISSION IS TO ENSURE ACCESS, AND TO PROVIDE HIGH QUALITY PREVENTION-FOCUSED HEALTH CARE, FOR THE COMMUNITIES WE SERVE. 0 0 16883368 0 20696595 FAMILY PRACTICE SERVICES PROVIDED TO PATIENTS. THE TOTAL NUMBER OF FAMILY PRACTICE VISITS DURING FISCAL YEAR 2018 WERE 89,372. 6419465 0 6502813 GENERAL DENTISTRY AND FLUORIDE VARNISHING SERVICES PROVIDED TO PATIENTS. THE TOTAL NUMBER OF DENTAL VISITS DURING FISCAL YEAR 2018 WERE 30,363. 3387658 0 4152967 OBSTETRIC AND GYNECOLOGY SERVICES PROVIDED TO PATIENTS, INCLUDING BIRTHING AND PREGNANCY SERVICES. THE TOTAL NUMBER OF OB/GYN VISITS DURING FISCAL YEAR 2018 WERE 17,290. 7074745 0 6700318 OTHER PROGRAM SERVICES INCLUDE INTEGRATED BEHAVIORAL HEALTH, VISION, WELLNESS, AND NUTRITION SERVICES PROVIDED TO PATIENTS.ADDITIONALLY, IN MARCH 2018, PETALUMA HEALTH CENTER OPENED A FAMILY MEDICINE NURSE PRACTITIONER RESIDENCY PROGRAM TO TRAIN NEW NURSE PRACTITIONERS IN THE COMMUNITY MEDICINE MODEL OF CARE. 7074745 0 6700318 33765236 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 1 109 0 1 448 1 1 1 0 0 0 0 0 0 0 0 0 X 11 10 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 CA X KATIE GEBHARDT 7075597508 1179 NORTH MCDOWELL BLVD PETALUMA CA 94954 TONY SARNO PRESIDENT 2.00 0.00 X X 0 0 0 GLORIA ROBINSON VICE PRESIDENT 2.00 0.00 X X 0 0 0 MARC POUNDS CPA TREASURER 2.00 0.00 X X 0 0 0 GEORGINA WARMOTH SECRETARY 2.00 0.00 X X 0 0 0 MARY CELESTRE BOARD MEMBER 2.00 0.00 X 0 0 0 TOM ISAAK BOARD MEMBER 2.00 0.00 X 0 0 0 ELAD LEVINSON LCSW BOARD MEMBER 2.00 0.00 X 0 0 0 VANESSA LUNA SHANNON BOARD MEMBER 2.00 0.00 X 0 0 0 ROBERT RAMIREZ BOARD MEMBER 2.00 0.00 X 0 0 0 TERESA TAYLOR-KING BOARD MEMBER 2.00 0.00 X 0 0 0 JOE TAMBE BOARD MEMBER 2.00 0.00 X 0 0 0 KATHRYN POWELL CHIEF EXECUTIVE OFFICER 40.00 0.00 X 259456 0 33106 BRIAN BURNS CHIEF FINANCIAL OFFICER 40.00 0.00 X 179845 0 8970 PEDRO TOLEDO JD CHIEF ADMINISTRATIVE OFFICER 40.00 0.00 X 177133 0 20133 NURIT LICHT MD CHIEF MEDICAL OFFICER 36.00 0.00 X 194087 0 26480 DAYMON DOSS CHIEF OPERATIONS OFFICER 40.00 0.00 X 188659 0 7992 RAMONA ENGLISH DDS CHIEF DENTAL OFFICER 40.00 0.00 X 202278 0 25635 ANDREW ASHCROFT MD FAMILY PHYSICIAN 36.00 0.00 X 201397 0 36992 JONATHAN CHOE MD ASSOCIATE MEDICAL DIRECTOR 34.00 0.00 X 211589 0 11742 PHILIPPE EDOUARD MD FAMILY PHYSICIAN 40.00 0.00 X 255920 0 21020 DANIELLE ORYN DO CHIEF MEDICAL INFORMATICS OFFICER 40.00 0.00 X 234764 0 35891 FIONA REDWOOD MD OB/GYN 32.00 0.00 X 205997 0 29485 2311125 0 257446 58 0 1 0 SERVICO BUILDING MAINTENANCE PO BOX 25 GLEN ELLEN CA 954420025 JANITORIAL SERVICES 345418 NAJINE SHARIAT 427 DOYLE PARK DR SANTA ROSA CA 95405 NUTRITIONAL COUNSELING 268174 ELIZABETH VAN TASSELL DDS 135 KELLER ST PETALUMA CA 94952 DENTIST SERVICES 185498 BARBIER SECURITY GROUP 369-B THIRD ST SAN RAFAEL CA 94901 SECURITY SERVICES 160313 INDE ARCHITECTURE INC 690 TEXAS ST SAN FRANCISCO CA 94107 ARCHITECT SERVICES 143949 7 3331815 1119569 43690 4451384 NET PATIENT SERVICE REVENUE 621400 31572734 31572734 PERFORMANCE PYMNTS - HEALTH PLANS 621400 4472801 4472801 PHARMACY REVENUE 621400 1678418 1678418 MEANINGFUL USE REVENUE 621400 328740 328740 38052693 814 814 3197 3197 OTHER REVENUE 900099 432814 432814 432814 42940902 38052693 0 436825 1317607 593496 724111 21735391 18565593 3169798 733441 637534 95907 4477747 3761628 716119 1727971 1454290 273681 26135 26135 74869 74869 2859108 2058001 801107 57086 9035 48051 660796 413363 247433 1061255 847402 213853 2019915 1776492 243423 125798 62779 63019 153727 99187 54540 232938 232938 1645346 1322070 323276 65218 36030 29188 MEDICAL SUPPLIES/DRUGS 1563703 1563703 MINOR EQUIPMENT 507903 412315 95588 DUES AND SUBSCRIPTIONS 202337 95294 107043 431217 57024 374193 41679508 33765236 7914272 0 3166267 4698680 250702 251515 274536 268601 5492988 6208387 3644 403 73680 95670 730925 792841 28636419 9004990 18133001 19631429 155000 155000 2239709 2257340 30520452 34359866 3879858 4175779 145985 384404 5624112 5424163 1644476 2451121 3776652 5213636 15071083 17649103 X 15449369 16710763 15449369 16710763 30520452 34359866 1261394 0 X 0 1 X 1 1 1 X 2057963 3424063 4263609 3762595 4451384 17959614 2057963 3424063 4263609 3762595 4451384 17959614 159435 17800179 1310 1382 843 1060 4011 8606 108781 337379 322105 210464 432814 1411543 19379763 139228382 0.91850 0.92980 X 1500000 1500000 14565400 3526240 11039160 2102431 406647 1695784 4054784 2450558 1604226 6413804 2621545 3792259 19631429 DEBT SERVICE FUND 176057 OTHER RECEIVABLES 1980335 DEPOSITS 48050 RESERVE FOR UNEMPLOYMENT 13479 BOND PRINCIPAL/INTEREST FUNDS 39419 2257340 ESTIMATED AMOUNTS DUE TO 3RD PARTY PAYERS 5213636 5213636 X 42975767 34865 34865 42940902 0 42940902 41714373 34865 34865 41679508 0 41679508 PART X, LINE 2: THE ORGANIZATION IS A NONPROFIT CORPORATION UNDER INTERNAL REVENUE CODE SECTION 501(C)(3) AND HAS BEEN GRANTED TAX-EXEMPT STATUS BY THE INTERNAL REVENUE SERVICE AND THE CALIFORNIA REVENUE AND TAXATION CODE. AS OF JUNE 30, 2018, THE ORGANIZATION HAD NO UNRECOGNIZED TAX POSITIONS OR UNCERTAIN TAX POSITIONS REQUIRING ACCRUAL. THEREFORE, NO PROVISION FOR INCOME TAXES HAS BEEN PROVIDED IN THE FINANCIAL STATEMENTS. X X 0 0 0 0 0 0 0 0 0 KATHRYN POWELL CHIEF EXECUTIVE OFFICER 256854 0 0 0 2602 0 20887 0 12219 0 292562 0 0 0 BRIAN BURNS CHIEF FINANCIAL OFFICER 179180 0 0 0 665 0 0 0 8970 0 188815 0 0 0 PEDRO TOLEDO JD CHIEF ADMINISTRATIVE OFFICER 176818 0 0 0 315 0 9843 0 10290 0 197266 0 0 0 NURIT LICHT MD CHIEF MEDICAL OFFICER 181157 0 0 0 12930 0 10825 0 15655 0 220567 0 0 0 DAYMON DOSS CHIEF OPERATIONS OFFICER 167003 0 20000 0 1656 0 7396 0 596 0 196651 0 0 0 RAMONA ENGLISH DDS CHIEF DENTAL OFFICER 181928 0 20000 0 350 0 10774 0 14861 0 227913 0 0 0 ANDREW ASHCROFT MD FAMILY PHYSICIAN 149606 0 23281 0 28510 0 10960 0 26032 0 238389 0 0 0 JONATHAN CHOE MD ASSOCIATE MEDICAL DIRECTOR 161057 0 25219 0 25313 0 10998 0 744 0 223331 0 0 0 PHILIPPE EDOUARD MD FAMILY PHYSICIAN 232953 0 19725 0 3242 0 12133 0 8887 0 276940 0 0 0 DANIELLE ORYN DO CHIEF MEDICAL INFORMATICS OFFICER 209872 0 23266 0 1626 0 10916 0 24975 0 270655 0 0 0 FIONA REDWOOD MD OB/GYN 189933 0 12500 0 3564 0 10430 0 19055 0 235482 0 0 0 A CA HEALTH FACILITIES FINANCING AUTHORITY 521643828 13032UET1 2016-09-13 5955305 REFUND OF BONDS ORIGINALLY ISSUED 6/2/2010 0 0 0 A 175000 5956658 176057 115500 153716 5511385 0 1 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 SCHEDULE K, PART II, LINE 3 THE DIFFERENCE BETWEEN THE "TOTAL PROCEEDS OF ISSUE" IN SCHEDULE K, PART II, LINE 3 AND THE ISSUE PRICE LISTED IN SCHEDULE K, PART I, COLUMN (E) REPRESENTS INVESTMENTS EARNINGS ON GROSS PROCEEDS IN RESERVE FUNDS. NORTH BAY OFFICE FURNITURE ENTITY IS SOLELY OWNED BY BOARD MEMBER ROBERT RAMIREZ 143688 THE ORGANIZATION PURCHASED OFFICE FURNITURE AT FAIR MARKET VALUE FROM NORTH BAY OFFICE FURNITURE, WHICH IS SOLELY OWNED BY BOARD MEMBER ROBERT RAMIREZ. 0 X SOFTWARE PRODUCTS 1 43690 FMV 0 0 0 0 PART I, COLUMN (B): THE ORGANIZATION IS REPORTING THE NUMBER OF CONTRIBUTIONS ON SCHEDULE M, PART I, COLUMN (B). FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED BY AN OUTSIDE TAX PREPARER IN CONJUNCTION WITH THE ORGANIZATION'S FINANCE AND ACCOUNTING TEAM. THE CEO AND MEMBERS OF THE FINANCE AND ACCOUNTING STAFF OF THE ORGANIZATION THEN REVIEW THE FORM 990 AND, UPON APPROVAL, SUBMITS THE FORM 990 TO THE BOARD FINANCE COMMITTEE FOR REVIEW AND APPROVAL FOR FILING WITH THE INTERNAL REVENUE SERVICE; THE FORM 990 IS ALSO MADE AVAILABLE TO ALL BOARD MEMBERS FOR REVIEW PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C IT IS THE POLICY OF PETALUMA HEALTH CENTER THAT ALL FULL-TIME AND PART-TIME EMPLOYEES, CONTRACTORS, AND MEMBERS OF THE BOARD OF DIRECTORS AVOID CONFLICTS OF INTEREST, OR APPEARANCE OF CONFLICT, BETWEEN THEIR PERSONAL INTERESTS AND THE INTERESTS OF THE ORGANIZATION WHEN DEALING WITH ANY INDIVIDUAL OR OUTSIDE ORGANIZATION HAVING, OR SEEKING TO HAVE, A BUSINESS RELATIONSHIP WITH PETALUMA HEALTH CENTER. ALL MEMBERS OF THE PETALUMA HEALTH CENTER BOARD OF DIRECTORS ARE REQUIRED TO COMPLETE THE CONFLICT OF INTEREST DISCLOSURE STATEMENT; ALL STAFF MEMBERS, VOLUNTEERS, AND CONTRACTORS ARE REQUIRED TO DISCLOSE ANY POTENTIAL OR ACTUAL CONFLICT OF INTEREST THAT ARISES TO THE HUMAN RESOURCES DEPARTMENT WITHIN 10 BUSINESS DAYS OF LEARNING OF IT. AFTER DISCLOSURE OF A POSSIBLE CONFLICT OF INTEREST, THE CEO AFFORDS THE INTERESTED PERSON WHO MAKES THE DISCLOSURE AN OPPORTUNITY TO EXPLAIN TO THE SENIOR MANAGEMENT TEAM (FOR EMPLOYEES), OR THE EXECUTIVE COMMITTEE OF THE BOARD (FOR BOARD MEMBERS) THE FACTS AND CIRCUMSTANCES OF THE TRANSACTION OR ARRANGEMENT THAT LED TO SUCH DISCLOSURE. THE INTERESTED PERSON LEAVES THE SENIOR MANAGEMENT TEAM OR BOARD EXECUTIVE COMMITTEE MEETING WHILE THE INTEREST IS DISCUSSED AND VOTED UPON. FORM 990, PART VI, SECTION B, LINE 15A THE PROCESS FOR DETERMINING THE CHIEF EXECUTIVE OFFICER'S SALARY INCREASE INVOLVES A DISCUSSION AMONGST THE EXECUTIVE COMMITTEE OF THE BOARD, SALARY RESEARCH BY THE DIRECTOR OF HUMAN RESOURCES, AND RECOMMENDATION OF A NEW SALARY FROM THE EXECUTIVE COMMITTEE TO THE BOARD OF DIRECTORS FOR APPROVAL. THE CEO REVIEWS AND APPROVES THE COMPENSATION OF OTHER OFFICERS AND MANAGERS. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST.