2017-05-10T10:48:02-05:00 2016-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2015-10-01 561089384 CAROLINA ADVENTIST RETIREMENT SYSTEMS INC CARO 7046679851 95 HOLCOMBE COVE RD CANDLER NC 287159450 DEBORAH HAWKINS TREASURER / CFO 7046679851 2017-05-10 1 AMY BIBBY P00445891 8282542254 2017-05-09 2015 2021-01-29 14:40:06Z DEBORAH HAWKINS 95 HOLCOMBE COVE RD CANDLER NC 287159450 30848263 0 X WWW.PISGAHVALLEY.ORG X 1975 NC SERVING HEALTHCARE AND RESIDENTIAL NEEDS WHILE UPHOLDING CHRISTIAN PRINCIPLES. X 25 12 689 15 108817 0 138175 97920 23372147 15112330 -105106 7895234 346545 352076 23751761 23457560 195003 206275 0 0 13090170 8999821 0 0 0 11245984 7510450 24531157 16716546 -779396 6741014 37542097 30884355 23838147 10155787 13703950 20728568 X AS A FAITH-BASED SEVENTH-DAY ADVENTIST ORGANIZATION, WE ARE DEDICATED TO SERVING THE HEALTHCARE AND RESIDENTIAL NEEDS OF OUR COMMUNITY WHILE UPHOLDING CHRISTIAN PRINCIPLES. 0 1 11386364 206275 12218753 PISGAH VALLEY RETIREMENT COMMUNITY OWNS AND OPERATES A LICENSED CONTINUING CARE RETIREMENT COMMUNITY WITH 49 INDEPENDENT LIVING DUPLEX CONDOMINIUM UNITS, A 24-UNIT MULTI-UNIT ASSISTED HOUSING WITH SERVICES FACILITY, AND A 118-BED SKILLED NURSING FACILITY IN CANDLER, NORTH CAROLINA. PROGRAM SERVICE ACCOMPLISHMENTS INCLUDE THE PROVIDING OF ROOM AND BOARD (SHELTER, UTILITIES, MEALS, HOUSEKEEPING, LAUNDRY, AND MAINTENANCE), TRANSPORTATION, WELLNESS CENTER/ACTIVITIES, ASSISTANCE WITH ACTIVITIES OF DAILY LIVING, AND MEDICAL SERVICES TO OUR COMMUNITY (PRIMARILY AGE 55 AND OLDER). 2275448 2949336 PRIOR TO DECEMBER 31, 2015, WINSLOW OPERATED A RETIREMENT COMMUNITY WITH A 146-BED SKILLED NURSING FACILITY IN ELIZABETH CITY, NORTH CAROLINA. PROGRAM SERVICE ACCOMPLISHMENTS INCLUDED PROVIDING OF ROOM AND BOARD (SHELTER, UTILITIES, MEALS, HOUSEKEEPING, LAUNDRY, AND MAINTENANCE), TRANSPORTATION, ACTIVITIES, ASSISTANCE WITH ACTIVITIES OF DAILY LIVING, AND MEDICAL SERVICES TO OUR COMMUNITY (PRIMARILY AGE 55 AND OLDER). ON DECEMBER 31, 2015 THE WINSLOW OPERATION WAS SOLD. 13661812 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 1 0 0 0 0 0 1 0 1 1 1 0 0 1 70 0 1 689 1 1 1 0 0 0 0 0 0 0 0 0 X 25 12 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X DEBORAH HAWKINS 8284182334 95 HOLCOMBE COVE ROAD CANDLER NC 28715 ERNEST BOUGHMAN SR DIRECTOR (ROTATED OFF) 1.00 X 0 375 0 BRENNA BOULANGER DIRECTOR (ROTATED OFF) 1.00 X 0 375 0 JIMM BUNCH DIRECTOR 1.00 X 0 0 0 DEWAYNE BUTCHER MD DIRECTOR (ROTATED OFF) 1.00 X 0 300 0 MAIKEL ARCE DIRECTOR 1.00 40.00 X 0 0 0 BRAD CAULEY DIRECTOR (ROTATED OFF) 1.00 40.00 X 0 71020 38656 DONOVAN DAVIS DIRECTOR (ROTATED OFF) 1.00 40.00 X 0 70472 27821 JEFF DONALDSON DIRECTOR 1.00 40.00 X 0 65119 34590 JOHN EARNHARDT DIRECTOR (ROTATED OFF) 1.00 40.00 X 0 66014 52265 SAMUEL GARCIA DIRECTOR (ROTATED OFF) 1.00 X 0 225 0 MAURY GILMORE DIRECTOR (ROTATED OFF) 1.00 X 0 150 0 CHAD GRUNDY DIRECTOR 1.00 40.00 X 0 71402 15255 JERRY LAFAVE DIRECTOR (ROTATED OFF) 1.00 40.00 X 0 66477 56054 WON LEE DIRECTOR (ROTATED OFF) 1.00 X 0 300 0 LESLIE LOUIS DIRECTOR/CHAIRMAN 1.00 40.00 X 0 79003 43521 GARY MOYER DIRECTOR/SECRETARY 1.00 40.00 X X 0 80396 41737 DEXTER RICHARDSON DIRECTOR 1.00 40.00 X 0 66890 50470 LESTER RILEA DIRECTOR 1.00 X 0 450 0 JOSE RIVERA DIRECTOR 1.00 40.00 X 0 65863 35373 RICHARD RUSSELL DIRECTOR 1.00 40.00 X 0 78234 29759 ANDRES HENRIQUEZ DIRECTOR 1.00 40.00 X 0 0 0 LINDA STAMP DIRECTOR 1.00 X 0 450 0 DON WETMORE DIRECTOR 1.00 X 0 300 0 ANDREW WILLIAMS DIRECTOR 1.00 X 0 300 0 CHARLES WILLIAMS DIRECTOR 1.00 X 0 225 0 KEVIN WORTH DIRECTOR 1.00 40.00 X 0 52739 10741 CHRISTIAN YASTE DIRECTOR 1.00 X 0 0 0 CHRISTINA HYMBAUGH DIRECTOR 1.00 X 0 0 0 BEN KOCHENOWER DIRECTOR 1.00 X 0 0 0 LANCE MORRISON DIRECTOR 1.00 X 0 69191 12210 RAYMOND SHEPARD DIRECTOR 1.00 X 0 0 0 HASKELL WILLIAMS DIRECTOR 1.00 X 0 72074 56830 PATRICK WILLIAMS DIRECTOR 1.00 X 0 68892 45098 GARY ROUSE DIRECTOR 1.00 X 0 70710 15495 DEBORAH HAWKINS TREASURER/CFO 40.00 1.00 X 154205 0 13534 DAVID KIDDER PRESIDENT/CEO 40.00 1.00 X 222415 0 35211 MICHELLE GRANDY ADMINISTRATOR 40.00 X 108275 0 12182 VICKIE HARDY DIRECTOR OF NURSING 40.00 X 101832 0 26942 586727 1117946 653744 4 0 1 0 REHABCARE GROUP EAST INC (DBA REHABCARE PO BOX 503534 ST LOUIS MO 63150 PHYSICAL, SPEECH AND OCCUPATIONAL THERAP 1219737 KINDRED REHAB SERVICES INC (DBA PEOPLEF PO BOX 277365 ALTANTA GA 30384 PHYSICAL, SPEECH AND OCCUPATIONAL THERAP 1119329 DIXON HUGHES GOODMAN LLP PO BOX 3049 ASHEVILLE NC 28802 AUDITING, ACCOUNTING, TAX, AND CONSULTIN 305135 SFCS INC 305 S JEFFERSON STREET ROANOKE VA 240112003 ARCHITECT 243781 WALKER MARKETING INC 805 TRADE STREET NW SUITE 101 CONCORD NC 28027 MARKETING 235800 6 97920 97920 MEDICARE/MEDICAID PAYMENTS 623000 10668339 10668339 SKILLED NURSING, ASSISTED LIVING, 623000 4251291 4251291 AMORTIZATION OF ENTRANCE FEE 623000 192700 192700 15112330 283137 283137 15002800 7390703 7612097 7612097 7612097 MANAGEMENT FEES FROM HOA 531390 187500 187500 WELLNESS CENTER REVENUE 713940 115638 6821 108817 MISCELLANEOUS INCOME 623000 48938 48938 352076 23457560 15168089 108817 8082734 206275 206275 420428 420428 14487 14487 6948861 6232978 715883 64976 62004 2972 1007618 857705 149913 543451 455981 87470 25147 25147 101350 101350 1631162 1625191 5971 249238 249238 1070924 729645 341279 152629 152629 1028031 926455 101576 68916 41239 27677 23546 5431 18115 5139 5139 1464308 1431680 32628 106762 12834 93928 MED. RELATED SUPPLIES 1069255 1069255 BAD DEBT 266557 266557 WRITE OFF TO FINANCING 180061 180061 PROVIDER TAX 63349 63349 4076 4076 16716546 13661812 3054734 0 900 500 9049090 4548425 94500 1625999 784073 121900 75100 440427 65962 27028454 7005951 26121060 20022503 5155907 88221 231885 37542097 30884355 1803271 940614 659417 745321 12797527 0 388926 43381 8189006 8426471 23838147 10155787 X 13703950 20728568 13703950 20728568 37542097 30884355 X 6741014 152366 131238 X X 0 1 X 1 0 X 146934 185451 175785 138175 97920 744265 21085506 22355989 23788657 23372147 15156576 105758875 220605 259285 265383 261856 199013 1206142 21453045 22800725 24229825 23772178 15453509 107709282 0 0 0 107709282 33238 22302 19959 160614 283137 519250 33238 22302 19959 160614 283137 519250 21486283 22823027 24249784 23932792 15736646 108228532 0.99520 0.99740 0.00480 0.00260 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1697 1697 0 PART II-B, LINE 1: THE ORGANIZATION IS A MEMBER OF THE HEALTHCARE FACILITIES ASSOCIATION (HFA) AND THE LEADING AGE ASSOCIATION (LAA). EACH YEAR, A PORTION OF THE DUES PAID TO THESE ORGANIZATIONS IS ALLOCATED TOWARDS LOBBYING EFFORTS ON BEHALF OF THEIR MEMBERSHIP BODIES. FOR FY 2016, AMOUNTS OF MEMBERSHIP DUES ALLOCATED TO THESE EXPENDITURES WERE $819 FOR HFA AND $878 FOR LAA. 770000 770000 20663375 4857477 15805898 188563 147960 40603 2242712 1258965 983747 3163804 741549 2422255 20022503 PATIENT TRUST FUND LIABILITY 12797 RESIDENT REFUNDS PAYABLE 8360674 RESIDENT DEPOSITS 53000 8426471 X 23712459 152366 136133 288499 23423960 33600 33600 23457560 16687841 4895 4895 16682946 33600 33600 16716546 PART X, LINE 2: INCOME TAXES - CARS IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC), AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE IRC. THE ORGANIZATION ACCOUNTS FOR UNCERTAIN TAX POSITIONS BY RECORDING A LIABILITY FOR ANY TAX POSITION TAKEN THAT IS BENEFICIAL TO THE ORGANIZATION, INCLUDING ANY RELATED INTEREST AND PENALTIES, WHEN IT IS MORE LIKELY THAN NOT THE POSITION TAKEN BY MANAGEMENT WITH RESPECT TO A TRANSACTION OR CLASS OF TRANSACTIONS WILL BE OVERTURNED BY A TAXING AUTHORITY UPON EXAMINATION. MANAGEMENT BELIEVES THERE WERE NO SUCH POSITIONS AS OF SEPTEMBER 30, 2016 AND 2015 AND, ACCORDINGLY, NO LIABILITY WAS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN INTEREST RATE SWAP 131,238. LOSS ON DISPOSAL OF ASSETS IN EXPENSES 4,895. PART XI, LINE 4B - OTHER ADJUSTMENTS: MANAGEMENT FEES REVENUE NET WITH EXPENSES 33,600. PART XII, LINE 2D - OTHER ADJUSTMENTS: LOSS ON DISPOSAL OF ASSETS IN EXPENSES 4,895. PART XII, LINE 4B - OTHER ADJUSTMENTS: MANAGEMENT FEES REVENUE NET WITH EXPENSES 33,600. 1 CAROLINA CONFERENCE OF SEVENTH-DAY ADVENTISTS 2701 WT HARRIS BLVD CHARLOTTE NC 28256 454284485 501(C)(3) 148560 FMV TO ASSIST WITH EDUCATIONAL MINISTRY MOUNT PISGAH ACADEMY 75 ACADEMY DRIVE CANDLER NC 28715 560713794 501(C)(3) 47760 FMV STUDENT SCHOLARSHIPS AND GENERAL OPERATIONS 2 PART I, LINE 2: THE ORGANIZATION PROVIDES ASSISTANCE TO OTHER SEVENTH-DAY ADVENTIST NOT-FOR-PROFIT ORGANIZATIONS FOR SPECIFIC PURPOSES RELATED TO ONE-TIME TRANSACTIONS (STUDENT SCHOLARSHIPS AND OTHER EDUCATIONAL MINISTRIES); THEREFORE, MONITORING OF THE EXPENDITURES IS ACCOMPLISHED THROUGH OBSERVATIONS. X 1 0 X X X X 0 0 0 0 0 0 0 0 0 DEBORAH HAWKINS TREASURER/CFO 111098 0 1107 0 42000 0 3298 0 10236 0 167739 0 0 0 DAVID KIDDER PRESIDENT/CEO 179370 0 1605 0 41440 0 6226 0 28985 0 257626 0 0 0 PART I, LINE 1A CARS WAIVES 100% AND 50% OF THE STANDARD MEMBERSHIP FEE FOR THE CEO AND CFO, RESPECTIVELY, FOR MEMBERSHIP AT CARS' PISGAH VALLEY WELLNESS CENTER. ANY REMAINING PORTION OF THE MEMBERSHIP FEE DUE IS PAID BY THE EMPLOYEE THROUGH PAYROLL DEDUCTIONS. ALL EMPLOYEES AT CARS' PISGAH VALLEY RETIREMENT COMMUNITY CAMPUS ARE ELIGIBLE FOR WAIVER OF SOME PORTION OF PISGAH VALLEY WELLNESS CENTER MEMBERSHIP FEES. ELLA KIDDER FAMILY RELATIONSHIP WITH DAVID KIDDER, CEO 14487 ELLA KIDDER IS AN EMPLOYEE OF THE ORGANIZATION 0 0 0 0 0 1 0 0 0 0 WINSLOW FACILITY - LAND, BUILDING, AND EQUIPMENT 2015-12-31 15000000 FMV 561089384 ELIZABETH CITY HEALTH AND REHABILITIATION LLC 1075 US HIGHWAY 17 SOUTH ELIZABETH CITY NC 27909 LIMITED LIABILITY CORPORATION 0 0 0 0 FORM 990, PART III, LINE 3 PRIOR TO DECEMBER 31, 2015, CARS OPERATED A RETIREMENT COMMUNITY WITH A 146-BED SKILLED NURSING FACILITY IN ELIZABETH CITY, NORTH CAROLINA. PROGRAM SERVICE ACCOMPLISHMENTS INCLUDED PROVIDING OF ROOM AND BOARD (SHELTER, UTILITIES, MEALS, HOUSEKEEPING, LAUNDRY, AND MAINTENANCE), TRANSPORTATION, ACTIVITIES, ASSISTANCE WITH ACTIVITIES OF DAILY LIVING, AND MEDICAL SERVICES TO OUR COMMUNITY (PRIMARILY AGE 55 AND OLDER). ON DECEMBER 31, 2015 THE WINSLOW OPERATION WAS SOLD. FORM 990, PART VI, SECTION A, LINE 6 AS STATED IN CARS' BYLAWS SECTION 3.1 "THE MEMBERS OF THE CORPORATION SHALL BE THE MEMBERS OF THE EXECUTIVE COMMITTEE OF THE CAROLINA CONFERENCE." FORM 990, PART VI, SECTION A, LINE 7A AS STATED IN CARS' BYLAWS SECTION 4.3 "EACH VOTING MEMBER OF THE EXECUTIVE COMMITTEE OF THE CAROLINA CONFERENCE SHALL SERVE EX OFFICIO AS A VOTING MEMBER OF THE CARS BOARD OF DIRECTORS (I.E., CONSTITUENT BOARD)." FORM 990, PART VI, SECTION A, LINE 7B AS STATED IN CARS' BYLAWS SECTION 4.1 "THE BUSINESS AND AFFAIRS OF THE CORPORATION SHALL BE MANAGED BY A BOARD OF DIRECTORS, REFERRED TO HEREIN AS THE "CONSTITUENT BOARD AND SECTION 4.13 "EXCEPT AS OTHERWISE PROVIDED IN THESE BYLAWS, THE ACT OF THE MAJORITY OF THE DIRECTORS PRESENT AT A MEETING AT WHICH A QUORUM IS PRESENT SHALL BE THE ACT OF THE CONSTITUENT BOARD." FORM 990, PART VI, SECTION B, LINE 11 THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM WITH ASSISTANCE AND OVERSIGHT BY MANAGEMENT. A COPY OF THE RETURN WAS PROVIDED TO EACH BOARD OF DIRECTORS MEMBER PRIOR TO ITS FILING. THE RETURN WAS REVIEWED AND DISCUSSED BY THE BOARD OF DIRECTORS AT THEIR REGULARY SCHEDULED MEETING. FORM 990, PART VI, SECTION B, LINE 12C AT THE BOARD OF DIRECTORS ANNUAL MEETING, THE PRESIDENT AND CEO OF CAROLINA ADVENTIST RETIREMENT SYSTEMS, INC. PRESENTS A "STATEMENT OF ACCEPTANCE" OF THE POLICY ON CONFLICT OF INTEREST TO EACH OFFICER, DIRECTOR (I.E., BOARD MEMBER), AND KEY EMPLOYEE (I.E., ADMINISTRATORS). EACH OF THESE INDIVIDUALS ARE ASKED TO REVIEW AND SIGN THE STATEMENT WHICH INCLUDES A REPRESENTATION THAT THEY DO NOT HAVE A CONFLICT OF INTEREST. ADDITIONALLY, EACH OFFICER, DIRECTOR, AND KEY EMPLOYEE RECEIVE AN ORIENTATION AND ANNUAL TRAINING RELATED TO THE ORGANIZATION'S CORPORATE COMPLIANCE POLICY, INCLUDING ITS CORE VALUE OF CARING, DEDICATION, INTEGRITY, PROFESSIONALISM, QUALITY, RESPECT, AND SAFETY. FORM 990, PART VI, SECTION B, LINE 15 ANNUALLY MANAGEMENT OBTAINS A LETTER PREPARED BY A 3RD PARTY CONSULTANT COMPARING A RANGE OF CEO AND CFO SALARIES BASED ON HISTORICAL SALARIES OF COMPARABLE ORGANIZATIONS TO THE ORGANIZATION'S CEO AND CFO CURRENT SALARIES. IN THIS LETTER THE CONSULTANT PROVIDES COMMENTS AS TO THE REASONABLENESS OF THE ORGANIZATION'S CEO AND CFO'S SALARIES, WHICH IS REVIEWED BY THE ORGANIZATION'S BOARD OF DIRECTORS. THE BOARD MAKES RECOMMENDATIONS FOR CEO AND CFO ANNUAL SALARY ADJUSTMENTS, WHICH MANAGEMENT INCORPORATES INTO THE ORGANIZATION'S ANNUAL BUDGET. T FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION MAKES ITS FORM 990 AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, FINANCIAL STATEMENTS, AND CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC UPON REQUEST. AUDITED FINANCIAL STATEMENTS ARE ALSO AVAILABLE TO THE PUBLIC ON THE NORTH CAROLINA DEPARTMENT OF INSURANCE'S WEBSITE. THE ORGANIZATION MAKES ITS FORM 990 AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST RATE SWAP 131,238. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. CAROLINA CONFERENCE OF SEVENTH-DAY ADVENTISTS INC PO BOX 44270 CHARLOTTE NC 28215 454284485 SPIRITUAL DEVELOPMENT NC 501(C)(3) 1 N/A 0 PISGAH ESTATES UNIT OWNERS ASSOCIATION 95 HOLCOMBE COVE ROAD CANDLER NC 28715 561769989 HOME OWNERS ASSOCIATION NC N/A C 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 PISGAH ESTATES UNIT OWNERS ASSOCIATION L 187500 CASH PISGAH ESTATES UNIT OWNERS ASSOCIATION M 160310 CASH