2016-07-29T13:14:43-05:00 2015-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2014-10-01 561089384 CAROLINA ADVENTIST RETIREMENT SYSTEMS INC CARO 7046679851 95 HOLCOMBE COVE RD CANDLER NC 287159450 DEBORAH HAWKINS TREASURER / CFO 7046679851 2016-07-29 1 AMY BIBBY P00445891 8282542254 2014 2016-12-15 16:53:06Z DAVID KIDDER 95 HOLCOMBE COVE RD CANDLER NC 287159450 24017481 0 X WWW.PISGAHVALLEY.ORG X 1975 NC SERVING HEALTHCARE AND RESIDENTIAL NEEDS WHILE UPHOLDING CHRISTIAN PRINCIPLES. 25 13 673 16 84689 -33814 175785 138175 23788657 23372147 -218481 -105106 346020 346545 24091981 23751761 246500 195003 0 0 12733118 13090170 0 0 0 11168282 11245984 24147900 24531157 -55919 -779396 37266484 37542097 22385656 23838147 14880828 13703950 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 0 10391617 195003 11785527 PISGAH VALLEY RETIREMENT COMMUNITY OWNS AND OPERATES A LICENSED CONTINUING CARE RETIREMENT COMMUNITY WITH 43 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). 9941987 11682276 WINSLOW OPERATES A RETIREMENT COMMUNITY WITH A 146-BED SKILLED NURSING FACILITY IN ELIZABETH CITY, NORTH CAROLINA. PROGRAM SERVICE ACCOMPLISHMENTS INCLUDE THE 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). 20333604 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 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 70 0 1 673 1 1 1 0 0 0 0 0 0 0 0 0 X 25 13 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 1.00 X 0 375 0 BRENNA BOULANGER DIRECTOR 1.00 X 0 300 0 JIMM BUNCH DIRECTOR 1.00 X 0 0 0 DEWAYNE BUTCHER MD DIRECTOR 1.00 X 0 150 0 JOHN COEHLO DIRECTOR 1.00 40.00 X 0 65840 26529 BRAD CAULEY DIRECTOR 1.00 40.00 X 0 68248 35264 DONOVAN DAVIS DIRECTOR 1.00 40.00 X 0 69346 37766 JEFF DONALDSON DIRECTOR 1.00 40.00 X 0 65658 35038 JOHN EARNHARDT DIRECTOR 1.00 40.00 X 0 67876 35151 SAMUEL GARCIA DIRECTOR 1.00 X 0 75 0 MAURY GILMORE DIRECTOR 1.00 X 0 75 0 CHAD GRUNDY DIRECTOR 1.00 40.00 X 0 70627 21007 JERRY LAFAVE DIRECTOR 1.00 40.00 X 0 64432 60032 WON LEE DIRECTOR/CHAIRMAN 1.00 X 0 375 0 LESLIE LOUIS DIRECTOR 1.00 40.00 X 0 76725 14266 GARY MOYER DIRECTOR 1.00 40.00 X X 0 78000 36219 DEXTER RICHARDSON DIRECTOR 1.00 40.00 X 0 66068 50406 LESTER RILEA DIRECTOR 1.00 X 0 300 0 RIVERA JOSE DIRECTOR 1.00 40.00 X 0 65503 41875 RICHARD RUSSELL DIRECTOR 1.00 40.00 X 0 76706 28061 STAN SHIREMAN DIRECTOR 1.00 40.00 X 0 57786 14327 LINDA STAMP DIRECTOR 1.00 X 0 225 0 DON WETMORE DIRECTOR 1.00 X 0 150 0 ANDREW WILLIAMS DIRECTOR 1.00 X 0 375 0 CHARLES WILLIAMS DIRECTOR 1.00 X 0 225 0 KEVIN WORTH DIRECTOR 1.00 40.00 X 0 51790 14391 CHRISTIAN YASTE DIRECTOR 1.00 X 0 0 0 DEBORAH HAWKINS TREASURER/CFO 40.00 1.00 X 163024 0 14251 DAVID KIDDER PRESIDENT/CEO 40.00 1.00 X 232875 0 33909 MICHELLE GRANDY ADMINISTRATOR 40.00 X 108759 0 11872 HARDY VICKIE DIRECTOR OF NURSING 40.00 X 102070 0 25194 606728 947230 535558 4 0 1 0 REHABCARE GROUP EAST INC (DBA REHABCARE PO BOX 503534 ST LOUIS MO 63150 PHYSICAL, SPEECH AND OCCUPATIONAL THERAP 1322859 KINDRED REHAB SERVICES INC (DBA PEOPLEF PO BOX 277365 ALTANTA GA 30384 PHYSICAL, SPEECH AND OCCUPATIONAL THERAP 1289779 DIXON HUGHES GOODMAN LLP PO BOX 3049 ASHEVILLE NC 28802 AUDITING, ACCOUNTING, TAX, AND CONSULTIN 238915 INDOFF INCORPORATED PO BOX 842808 KANSAS CITY MO 64184 INTERIOR DESIGN 145444 CASE CONSTRUCTION PO BOX 1780 CANDLER NC 28715 BUILDING DEMOLITION 125719 6 12000 126175 138175 MEDICARE/MEDICAID PAYMENTS 623000 18384342 18384342 SKILLED NURSING, ASSISTED LIVING, 623000 4883079 4883079 AMORTIZATION OF ENTRANCE FEE 623000 104726 104726 23372147 160614 160614 260465 5255 -260465 -5255 -265720 -265720 MANAGEMENT FEES FROM HOA 531390 166200 166200 WELLNESS CENTER REVENUE 713940 122367 37678 84689 MISCELLANEOUS INCOME 623000 57978 57978 346545 23751761 23467803 84689 61094 X 195003 195003 426259 426259 99843 99843 10090170 9071360 1018810 125977 116366 9611 1577685 1424635 153050 770236 662219 108017 18599 18599 96107 96107 2673635 2667093 6542 275749 275749 1584925 1191750 393175 157159 157159 1604495 1116398 488097 98532 67205 31327 55490 34442 21048 6970 6970 1751150 1707008 44142 135209 15904 119305 MED. RELATED SUPPLIES 1804931 1804931 BAD DEBT 723919 723919 PROVIDER TAX 252320 252320 MISCELLANEOUS 6794 6794 24531157 20333604 4197553 0 900 900 8833204 9049090 94500 94500 2079566 1625999 134500 121900 359806 440427 35921652 9800592 25577269 26121060 186739 88221 37266484 37542097 1834195 1803271 587220 659417 12905584 12797527 617957 388926 6440700 8189006 22385656 23838147 X 14880828 13703950 14880828 13703950 37266484 37542097 -779396 -397482 0 X X 0 1 X 1 0 X 24378 146934 185451 175785 138175 670723 22585889 21085506 22355989 23788657 23372147 113188188 288899 220605 259285 265383 261856 1296028 22899166 21453045 22800725 24229825 23772178 115154939 0 0 0 115154939 63194 33238 22302 19959 160614 299307 63194 33238 22302 19959 160614 299307 22962360 21486283 22823027 24249784 23932792 115454246 0.99740 0.99810 0.00260 0.00190 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2644 2644 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 2015, AMOUNTS OF MEMBERSHIP DUES ALLOCATED TO THESE EXPENDITURES WERE $1,831 FOR HFA AND $813 FOR LAA. 1720000 1720000 27457245 6566703 20890542 236692 132989 103703 4111173 2510514 1600659 2396542 590386 1806156 26121060 INTEREST RATE SWAP LIABILITY 649649 PATIENT TRUST FUND LIABILITY 41034 RESIDENT REFUNDS PAYABLE 7355359 ESTIMATED 3RD PARTY SETTLEMENTS 142964 8189006 X 23984181 0 23984181 -232420 -232420 23751761 25161059 629902 629902 24531157 0 24531157 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, 2014 AND 2015 AND, ACCORDINGLY, NO LIABILITY WAS ACCRUED. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2012 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 4B - OTHER ADJUSTMENTS: LOSS ON DISPOSAL OF ASSETS -5,255. MANAGEMENT FEES REVENUE NET WITH EXPENSES 33,300. LOSS ON DISPOSAL OF INVESTMENTS -260,465. PART XII, LINE 2D - OTHER ADJUSTMENTS: LOSS ON DISPOSAL OF ASSETS 5,255. UNREALIZED LOSS ON SWAPS 397,482. MANAGEMENT FEES REVENUE NET WITH EXPENSES -33,300. LOSS ON DISPOSAL OF INVESTMENTS 260,465. 1 CAROLINA CONFERENCE OF SEVENTH-DAY ADVENTISTS 2701 WT HARRIS BLVD CHARLOTTE NC 28256 454284485 501(C)(3) 42000 FMV TO ASSIST WITH LOCAL PASTOR SALARY MOUNT PISGAH ACADEMY 75 ACADEMY DRIVE CANDLER NC 28715 560713794 501(C)(3) 148680 FMV STUDENT SCHOLARSHIPS AND GENERAL OPERATIONS 2 0 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 PASTOR SALARIES); 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 127501 0 1085 0 34438 0 4195 0 10056 0 177275 0 0 0 DAVID KIDDER PRESIDENT/CEO 194364 0 1564 0 36947 0 6234 0 27675 0 266784 0 0 0 PART I, LINE 1A CARS WAIVES 100% OF THE STANDARD MEMBERSHIP FEE FOR THE CEO AND ADMINISTRATOR AND 50% FOR THE CFO RELATED TO 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. A NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 2012-03-27 13045000 REFUNDING, NEW CONSTRUCTION 0 0 0 A 55000 13054913 304559 225591 8913558 3611204 2013 1 0 0 1 A 0 0 0 0 0 0 0 A 0 1 0 0 1 1 BB&T 10.000000000000 0 0 0 0 0 A 1 SCHEDULE K, PART I, DESCRIPTION OF PURPOSE: THE PURPOSE OF THE ISSUE IS TO PROVIDE FUNDS TO (1) REFUND A PORTION OF THE 2008 BANK LOAN ALLOCABLE TO THE PRIOR PROJECT, (2) PAY OR REIMBURSE THE ORGANIZATION FOR PAYING A PORTION OF THE COST OF ACQUIRING, CONSTRUCTING AND EQUIPPING A NEW APPROXIMATELY 66,000 SQUARE-FOOT, 118-BED SKILLED NURSING FACILITY TO REPLACE THE PISGAH VALLEY RETIREMENT MANOR, (3) PAY INTEREST ON THE NEW MONEY PORTION OF THE BONDS FOR APPROXIMATELY 13 MONTHS, AND (4) PAY CERTAIN COSTS INCURRED IN CONNECTION WITH THE ISSUANCE OF THE BONDS. SCHEDULE K, PART II, LINE 3, TOTAL PROCEEDS: TOTAL PROCEEDS PRESENTED ON LINE 3 INCLUDE INVESTMENT EARNINGS TO DATE, CALCULATED AS SHOWN: BOND (A) - SALE PROCEEDS: $ 13,045,000 INVESTMENT EARNINGS: 9,913 TOTAL TO LINE 3: 13,054,913 SCHEDULE K, PART II, LINE 11, OTHER SPENT PROCEEDS: THE AMOUNT PRESENTED ON LINE 11 REPRESENTS AMOUNTS USED TO CURRENTLY REFUND A PORTION OF A PRIOR BANK LOAN ISSUED IN 2008. ELLA KIDDER FAMILY RELATIONSHIP WITH DAVID KIDDER, CEO 67322 ELLA KIDDER IS AN EMPLOYEE OF THE ORGANIZATION 0 KELLY KIMBLEY FAMILY RELATIONSHIP WITH DAVID KIDDER, CEO 32521 KELLY KIMBLEY IS AN EMPLOYEE OF THE ORGANIZATION 0 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 EXECUTIVE BOARD. THE EXECUTIVE BOARD MAKES RECOMMENDATIONS FOR CEO AND CFO ANNUAL SALARY ADJUSTMENTS, WHICH MANAGEMENT INCORPORATES INTO THE ORGANIZATION'S ANNUAL BUDGET. THE EXECUTIVE BOARD THEN PRESENTS THIS INFORMATION AS PART OF THE BUDGET TO THE FULL BOARD OF DIRECTORS FOR APPROVAL AT THEIR ANNUAL MEETING. 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 IX, LINE 11G CONTRACT SERVICES: PROGRAM SERVICE EXPENSES 2,667,093. MANAGEMENT AND GENERAL EXPENSES 6,542. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,673,635. FORM 990, PART XII, LINE 2C: THE PROCESS FOR THIS HAS NOT CHANGED SINCE 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 166200 CASH PISGAH ESTATES UNIT OWNERS ASSOCIATION M 129913 CASH