2016-11-15T15:12:23-06:00 2015-12-31 381357951 PLANTE & MORAN PLLC 10 S Riverside Plaza 9th Floor Chicago IL 60606 990 2015-01-01 362382853 REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME REST 7083428100 18601 NORTH CREEK DRIVE TINLEY PARK IL 60477 Barry VanderGenugten CFO 7083428100 2016-11-15 1 David Lowenthal P00378651 3122071040 2016-11-15 2015 2017-02-10 21:41:12Z PROVIDENCE LIFE SERVICES RICHARD SCHUTT 18601 NORTH CREEK DRIVE TINLEY PARK IL 60477 92595362 0 X www.providencelifeservices.com X 1956 IL REST HAVEN'S PURPOSE IS TO PROVIDE SERVICES FOR THE AGED INCLUDING SKILLED NURSING AND REHAB SERVICES, HOME HEALTH CARE, TOWN HOME LIVING, INDEPENDENT AND ASSISTED LIVING. 16 16 1349 350 6835 0 1313214 1346503 57971086 63944756 1449987 6805784 -157998 -154288 60576289 71942755 0 0 0 0 30332536 33580261 0 0 0 28378846 32359483 58711382 65939744 1864907 6003011 107674828 105228782 70691215 73282519 36983613 31946263 X REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME D/B/A PROVIDENCE LIFE SERVICES (REST HAVEN) IS A NOT-FOR-PROFIT ILLINOIS CORPORATION WHOSE PURPOSE IS TO PROVIDE NURSING AND RESIDENTIAL LIVING ARRANGEMENTS FOR THE AGED INCLUDING SKILLED NURSING AND REHABILITATION SERVICES, HOME HEALTH CARE, TOWNHOME LIVING, INDEPENDENT LIVING, AND ASSISTED LIVING. 0 0 59275322 63937921 TO PROVIDE PROPER CARE FOR THE SICK AND ELDERLY. 819 BEDS/UNITS WITH OCCUPANCY OVER 88% ON THE FULL CONTINUUM OF CARE. 59275322 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 1 0 0 1 74 0 1 1349 1 1 1 0 0 0 0 1 1 0 0 0 0 X 16 16 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 IL X WILLIAM DEYOUNG 7083428139 18601 NORTH CREEK DRIVE TINLEY PARK IL 60477 TIM BREEMS CHAIR (BEG. MAY 2015) 1.00 2.00 X X 0 0 0 NORM AARDEMA CHAIR (THRU MAY 2015) 1.00 2.00 X X 0 0 0 CAL TAMELING VICE CHAIR 1.00 2.00 X X 0 0 0 JUSTIN KATS SECRETARY/TREASURER (BEG. MAY 2015) 1.00 2.00 X X 0 0 0 SHARON CLOUSING ASST. SECRETARY/TREASURER (BEG. MAY 2015) 1.00 2.00 X X 0 0 0 HOWARD HOFF ASST. SECRETARY/TREASURER (THRU MAY 2015) 1.00 2.00 X X 0 0 0 LUCETTE BAMFORD DIRECTOR 1.00 2.00 X 0 0 0 DR DAVE BEEZHOLD DIRECTOR (THRU MAY 2015) 1.00 2.00 X 0 0 0 HAL BROWN DIRECTOR 1.00 2.00 X 0 0 0 JEAN CAVANAUGH DIRECTOR 1.00 2.00 X 0 0 0 AL DIEPSTRA DIRECTOR 1.00 2.00 X 0 0 0 GARY ELLENS DIRECTOR 1.00 2.00 X 0 0 0 KEN SCHOON DIRECTOR 1.00 2.00 X 0 0 0 TIM SMITS DIRECTOR 1.00 2.00 X 0 0 0 DON VAN DYK DIRECTOR 1.00 2.00 X 0 0 0 RICH VAN HATTEM DIRECTOR 1.00 2.00 X 0 0 0 BOB VAN STAALDUINEN DIRECTOR 1.00 2.00 X 0 0 0 BOB WORKMAN DIRECTOR 1.00 2.00 X 0 0 0 RICH SCHUTT CEO 40.00 5.00 X X 505834 0 33492 WILLIAM DE YOUNG CFO 40.00 5.00 X 335109 0 44495 CHERYL WIDDOWSON EXEC. VP OF HEALTHCARE SERVICES 40.00 5.00 X 691679 0 18508 RAY HEMPHILL VP OF PROJECT DEVELOPMENT 40.00 5.00 X 257438 0 44536 MANUEL PEDRE VP OF CLINICAL DEVELOPMENT 40.00 5.00 X 167410 0 24720 BARRY VANDERGENUGTEN VP OF FINANCE 40.00 5.00 X 176027 0 29613 MARY KAY KACMAREK VP CLINICAL SERVICES 40.00 5.00 X 144759 0 35256 JEFFREY COURTNEY VP CONSTRUCTION 40.00 5.00 X 149933 0 39476 2428189 0 270096 28 0 1 0 SYMBRIA RX SERVICES 28100 TORCH PARKWAY SUITE 600 WARRENVILLE IL 60555 PHARMACY 2939250 GORDON FOOD SERVICE INC PO BOX 88029 CHICAGO IL 60680 DIETARY 2044735 PROVINET SOLUTIONS 18645 WEST CREEK DRIVE TINLEY PARK IL 60477 IT SERVICES 1554047 CREATIVE DINING SERVICES ONE ROYAL PARK DRIVE SUITE 3 ZEELAND MI 49464 DIETARY 898416 MARIANJOY 13259 S CENTRAL AVENUE PALOS HEIGHTS IL 60463 THERAPY 750000 42 255026 1091477 1346503 Routine Revenue 621610 59915092 59915092 Ancillary Revenue 621610 4029664 4022829 6835 63944756 642412 642412 26512655 20349283 6163372 6163372 6163372 149036 255026 303324 -154288 -154288 71942755 63937921 6835 6651496 1629117 1408787 220330 27031426 23564769 3466657 421252 312564 108688 2440504 1853010 587494 2057962 1845099 212863 37792 37792 323675 323675 4311793 4311793 768942 768942 1833502 1462284 371218 2470585 2443620 26965 2789655 2773856 15799 2614801 2518083 96718 Nursing Expense 3403924 3403924 Food & Dietary Expense 3162820 3162820 Pharmacy Expense 2699203 2699203 RepAIRS & MAINTENANCE 1800493 1800493 6142298 4584608 1557690 65939744 59275322 6664422 0 9218822 3598689 2573354 837947 34500 22800 7625283 10862730 418117 59588 113615892 61189998 54464092 52425894 19180975 22008963 14159685 15412171 107674828 105228782 9117944 9281655 4609197 1724979 6730566 7086283 46691520 49816359 3541988 5373243 70691215 73282519 X 36804797 31784414 178816 161849 0 0 36983613 31946263 107674828 105228782 X 6003011 -2131474 -8908887 X 0 1 X 1 1 1 X 1657909 741230 1449177 1313214 1346503 6508033 73255481 73371512 70682235 57958718 63937921 339205867 74913390 74112742 72131412 59271932 65284424 345713900 0 0 0 345713900 181696 1344675 932659 1412613 4674310 8545953 0 0 0 12268 6835 19103 181696 1344675 932659 1424881 4681145 8565056 75095086 75457417 73064071 60696813 69965569 354278956 0.97580 0.98710 0.02420 0.01290 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 4761212 4761212 85552225 44088888 41463337 19120992 16645195 2475797 4181463 455915 3725548 52425894 GROUND LEASE RECEIVABLES 1245957 DEFERRED FINANCING COSTS 1191765 ASSETS LIMITED TO USE 1743535 DUE FROM AFFILIATES 1558833 OTHER ASSETS 364332 LEGAL LIABILITY INS RECOVERIES 369430 DEFERRED COMP GRANTOR TRUST 1414361 Investments in PMDC & PDG 7523958 15412171 CHARITABLE ANNUITY CONTRACTS 230790 ACCRUED INTEREST PAYABLE 205991 RESIDENT NOTES AND DEPOSITS 2887724 ASSET RETIREMENT OBLIGATION 319794 ESTIMATED SELF-INS LIABILITIES 1728944 5373243 Banquet 180976 109726 71250 227692 Golf Outing 157330 94218 63112 57131 3 65756 51082 14674 18501 404062 255026 149036 303324 303324 -154288 FORM 990, SCHEDULE G, PART II: THE ORGANIZATION HOSTS EVENTS FOR PUBLIC RELATIONS AND FUNDRAISING PURPOSES. THESE EVENTS ARE OFTEN UNDERWRITTEN BY LEADERSHIP SPONSORS OF WHICH THEIR SPONSORSHIPS ARE ALLOCATED AMONGST THE VARIOUS EVENTS. THE COMBINED GROSS RECEIPTS OF THE EVENTS TOTALED $404,062 FOR 2015. THE COMBINED COSTS OF THE EVENTS TOTALED $303,324. THE NET INCOME TO THE ORGANIZATION FOR HOSTING ALL OF THE EVENTS WAS $100,738. X X 1 1 X X X X X 0 1 0 0 0 0 0 1 0 RICH SCHUTT CEO 451063 0 37762 0 17009 0 10600 0 22892 0 539326 0 0 0 WILLIAM DE YOUNG CFO 297262 0 25490 0 12357 0 10600 0 33895 0 379604 0 0 0 CHERYL WIDDOWSON EXEC. VP OF HEALTHCARE SERVICES 96868 0 9200 0 585611 0 10600 0 7908 0 710187 0 582099 0 RAY HEMPHILL VP OF PROJECT DEVELOPMENT 197822 0 50500 0 9116 0 10600 0 33936 0 301974 0 0 0 MANUEL PEDRE VP OF CLINICAL DEVELOPMENT 160470 0 0 0 6940 0 6693 0 18027 0 192130 0 0 0 BARRY VANDERGENUGTEN VP OF FINANCE 159560 0 5250 0 11217 0 7000 0 22613 0 205640 0 0 0 MARY KAY KACMAREK VP CLINICAL SERVICES 142538 0 0 0 2221 0 4677 0 30579 0 180015 0 0 0 JEFFREY COURTNEY VP CONSTRUCTION 131209 0 12358 0 6366 0 6281 0 33195 0 189409 0 0 0 Part I, Line 1a THE ORGANIZATION PROVIDES AN ALLOWANCE FOR UP TO 10 BOARD MEMBERS TO ATTEND THE ANNUAL ASSOCIATION CONVENTION TO PROVIDE MORE IN DEPTH KNOWLEDGE OF THE SENIOR CARE INDUSTRY. THE COST OF TRAVEL FOR SPOUSES IS PERMITTED AS LONG AS THE TOTAL DOES NOT EXCEED THE ESTABLISHED ALLOWANCE AMOUNT. DOCUMENTATION OF ATTENDANCE AT THE ANNUAL CONVENTION IS REQUIRED. THE ORGANIZATION HAS ESTABLISHED A SENIOR EXECUTIVE MANAGEMENT PROGRAM WHICH ALLOWS STATED EMPLOYEES TO JOIN A FITNESS CENTER. ELIGIBLE EMPLOYEES THAT ENROLL ARE REQUIRED TO BE ACTIVELY UTILIZING THE FITNESS CENTER. Part I, Line 4b REST HAVEN HAS ESTABLISHED A NONQUALIFIED DEFERRED COMPENSATION PLAN IN AN EFFORT TO RETAIN SELECTED OFFICERS ON A LONG TERM BASIS. THE FOLLOWING IS A SCHEDULE OF THE OFFICERS AND THE ANNUAL CONTRIBUTION TO OR DISTRIBUTION FROM THE PLAN IN 2015. - RICHARD SCHUTT RECEIVED A CONTRIBUTION OF $111,151. - WILL DEYOUNG RECEIVED A CONTRIBUTION OF $27,973. - CHERYL WIDDOWSON RECEIVED A DISTRIBUTION OF $582,099. IN 2005, THE BOARD OF DIRECTORS ESTABLISHED A RETENTION INITIATIVE PLAN FOR CERTAIN OFFICERS. THIS PLAN RECOGNIZES THE HISTORIC CONTRIBUTION OF THE EXECUTIVES AND ESTABLISHES AN INCENTIVE FOR THEM TO CONTINUE THEIR EMPLOYMENT WITH THE ORGANIZATION UNTIL NORMAL RETIREMENT AGE. AMONG VARIOUS CRITERIA, IN ORDER TO QUALIFY FOR THE BENEFIT, THE EXECUTIVE WILL NEED TO BE CONTINUOUSLY EMPLOYED THRU AND UNTIL A FUTURE DATE. THE ORGANIZATION'S PAYMENTS INTO THE PLAN ARE RECORDED ON THE 990 AS DEFERRED COMPENSATION. HOWEVER, THE EXECUTIVE HAS NOT RECEIVED THESE MONIES AND WILL ONLY BE ELIGIBLE TO RECEIVE THEM BASED UPON THE ACHIEVEMENT OR SATISFACTION OF SOME FUTURE EVENTS. THE PLAN CONTRIBUTIONS ARE NOT UNDER THE CONTROL OF THE EXECUTIVE, THEY REMAIN THE ASSET OF THE ORGANIZATION, AND THE ENTIRE PLAN IS SUBJECT TO A FULL RISK OF FORFEITURE BY THE INDIVIDUAL. Part I, Line 5 THE EXECUTIVE COMPENSATION PROGRAM HAS TWO MAJOR ELEMENTS, SALARY, OR BASE PAY, AND VARIABLE PAY. THE SALARY REFLECTS THE VALUE OF AN EXECUTIVE'S CAPABILITIES AND EXPERIENCE. THE VARIABLE PAY REFLECTS THE ORGANIZATION'S COMMITMENT TO PAY FOR SPECIFIC PERFORMANCE TOWARDS THE ORGANIZATION'S GOALS. THE VARIABLE PAY IS AWARDED BASED UPON A SPECIFIC REVIEW OF GOALS AND OBJECTIVES (INCLUDING THOSE WHICH RELATE TO MISSION, OPERATIONAL EFFICIENCY, FINANCIAL EFFECTIVENESS, AND STRATEGIC GOALS) SEMI-ANNUALLY. THE COMPENSATION COMMITTEE REVIEWS, ASSESSES AND DETERMINES ANY AWARD UNDER THE VARIABLE PAY COMPONENT. EXECUTIVE EMPLOYEES ARE REVIEWED BY THE COMPENSATION COMMITTEE AND OUTSIDE CONSULTANTS TO ENSURE THEY ARE COMPETITIVE AND IN LINE WITH COMMON PRACTICE FOR SIMILAR POSITIONS IN SIMILARLY SIZED AND TYPE ORGANIZATIONS. THE COMMITTEE RECEIVES AN EXECUTIVE COMPENSATION OPINION NOTING THAT THE ORGANIZATION'S EXECUTIVE COMPENSATION FALLS WITHIN THE RANGE OF COMPARABLE POSITIONS WITHIN THE SAME INDUSTRY. THE REPORT/OPINION ALSO NOTES THAT THE STATED REQUIREMENTS OF ENSURING INDEPENDENCE OF COMPENSATION DELIBERATIONS FOR SENIOR EXECUTIVES ARE MET. Part I, Line 7 AS INDICATED IN SCHEDULE J, PART II, CERTAIN INDIVIDUALS RECEIVED BONUSES BASED ON PERFORMANCE AND THE FINANCIAL RESULTS OF THE ORGANIZATION. THESE BONUSES ARE APPROVED BY THE EXECUTIVE COMMITTEE. A Illinois Finance Authority 861091967 2009-12-29 27689940 Refinancing 0 0 0 A 20353657 27689940 329940 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 1 0 0 0 0 0 A 1 LINDA SCHUTT SPOUSE OF CEO 100715 EMPLOYMENT COMPENSATION 0 BONNIE HEIRENDT SISTER OF CEO 51702 EMPLOYMENT COMPENSATION 0 ALLISON OLESHKO DAUGHTER OF CEO 54828 EMPLOYMENT COMPENSATION 0 SCH L, PART IV: THE TRANSACTIONS REPORTED ABOVE INVOLVING INTERESTED PERSONS ARE REVIEWED ANNUALLY BY THE BOARD'S COMPENSATION COMMITTEE AND HAVE BEEN DEEMED APPROPRIATE BASED ON THE POSITION EMPLOYED. Form 990, Part VI, Section B, line 11 A DRAFT OF THE 990 WAS PREPARED AND SENT FOR INITIAL REVIEW BY THE CONTROLLER, CFO AND CEO. UPON REVIEW AND APPROVAL, THE FINAL DRAFT IS FORWARDED TO THE EXECUTIVE COMMITTEE BEFORE SUBMISSION. A COMPLETED COPY OF THE 990 IS PROVIDED TO THE FULL BOARD AT THE SUBSEQUENT BOARD MEETING, AFTER FILING. Form 990, Part VI, Section B, line 12c THE OFFICERS, DIRECTORS/TRUSTEES AND KEY EMPLOYEES ARE REQUIRED TO SUBMIT A CONFLICT OF INTEREST STATEMENT UPON BEGINNING THEIR POSITION. THEREAFTER, THE CONFLICT OF INTEREST STATEMENTS ARE UPDATED ON AN ANNUAL BASIS. ANY POTENTIAL CONFLICTS ARE REVIEWED AND ADDRESSED BY THE BOARD AS NECESSARY. Form 990, Part VI, Section B, line 15 THE EXECUTIVE COMPENSATION PROGRAM'S PRIMARY OBJECTIVE IS TO PROVIDE COMPETITVE TOTAL PAY OPPORTUNITIES THAT HELP ATTRACT, REWARD AND RETAIN CRITICAL LEADERSHIP TALENT IN ORDER TO ACHIEVE THE ORANIZATION'S MISSION AND STRATEGIC INITIATIVES. REST HAVEN ESTABLISHES ITS EXECUTIVE COMPENSATION RANGES THROUGH A WRITTEN POLICY AND BY COMPARING ITSELF TO ORGANIZATIONS OF SIMILAR SIZE AND TYPE - USING OBJECTIVE, THIRD-PARTY DATA. A COMPENSATION COMMITTEE OF INDEPENDENT DIRECTORS RECOMMENDS, AND THE BOARD OF DIRECTORS APPROVES, THE SALARY RANGES AND REVIEWS TOTAL COMPENSATION FOR EXECUTIVES ON AN ANNUAL BASIS. THE ORGANIZATION ROUTINELY USES KNOWLEDGEABLE EXTERNAL CONSULTANTS TO ADVISE ON THE PROCESS AND HAS RECEIVED AFFIRMATION OF COMPLIANCE WITH IRS GUIDELINES FOR REASONABLENESS OF EXECUTIVE COMPENSATION IN TAX-EXEMPT ENTITIES. Form 990, Part VI, Section C, line 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. Form 990, Part XI, line 9: TRANSFER OF EQUITY TO RELATED ENTITIES -8,908,887. providence development group 18601 N Creek Drive Tinley Park IL 60477 Development IL 22621 7091495 Rest Haven Park place realty group 18601 N Creek Drive Tinley Park IL 60477 Real Estate IL 36908 197306 N/A Providence Operations LLC 18601 N Creek Drive Tinley Park IL 60477 Operations IL 36632634 7127724 Rest Haven Providence Tenant LLC 18601 N Creek Drive Tinley Park IL 60477 Real Estate IL 0 0 Rest Haven Providence Palos Heights LLC 18601 N Creek Drive Tinley Park IL 60477 Real Estate IL 793294 4474710 Rest Haven Providence Downers Grove LLC 18601 N Creek Drive Tinley Park IL 60477 Real Estate IL 961175 8832433 Rest Haven Providence Grand Rapids LLC 18601 N Creek Drive Tinley Park IL 60477 Real Estate IL 409016 2835937 Rest Haven Providence Zeeland LLC 18601 N Creek Drive Tinley Park IL 60477 Real Estate IL 1306649 9040040 Rest Haven RP Lisle Managing Partner LLC 18601 N Creek Drive Tinley Park IL 60477 REAL ESTATE IL 0 0 PROVIDENCE HOUSING CORPORATION Christian Healthcare Foundation 18601 N Creek Drive Tinley Park IL 60477 200722359 Research IL 501(c)(3) Line 9 Rest Haven 0 Christian Living Campus 18601 N Creek Drive tinley Park IL 60477 200226221 Senior Living IL 501(c)(3) Line 9 Rest Haven 0 Haven Park 18601 N Creek Drive tinley Park IL 60477 383026594 Healthcare MI 501(c)(3) Line 9 Rest Haven 0 Timothy Place 18601 N Creek Drive tinley Park IL 60477 201835089 Senior Living IL 501(c)(3) Line 9 Rest Haven 0 Park Place of St John 18601 N Creek Drive tinley Park IL 60477 201834903 Senior Living IL 501(c)(3) Line 9 Rest Haven 0 Hudsonville Park Place 18601 N Creek Drive tinley Park IL 60477 201834667 Senior Living IL 501(c)(3) Line 9 Rest Haven 0 Providence Mgmt & Development 18601 N Creek Drive Tinley Park IL 60477 363774205 IT Services IL N/A C -577393 6307061 1.00000 1 Home Aide Health Network 18601 N Creek Drive Tinley Park IL 60477 364167569 Home Care MI PROVIDENCE MGMT & DEVELOPMENT C 1.00000 1 Providence Housing Corporation 18601 N Creek Drive Tinley Park IL 60477 461379112 Housing IL Rest Haven C 10516 299785 1.00000 1 0 0 0 1 0 0 0 0 0 0 1 0 0 1 1 1 1 1 1 PROVIDENCE MGMT & DEVELOPMENT P 760021 fmv PROVIDENCE MGMT & DEVELOPMENT Q 654300 fmv Timothy Place Q 503448 fmv Haven Park Q 1140889 fmv Haven Park K 1306070 fmv