2016-06-29T08:12:55-05:00 2015-12-31 450250958 EIDE BAILLY LLP 200 EAST 10TH ST PO BOX 5125 SIOUX FALLS SD 571175125 990 2015-01-01 481209650 CEDAR LAKE VILLAGE INC CEDA 6053623100 4800 W 57TH STREET PO BOX 5038 SIOUX FALLS SD 571175038 JOSEPH HERDINA TREASURER 6053623100 2016-06-23 1 LAURIE HANSON P00851848 6053391999 2016-06-23 2015 2016-09-27 15:27:22Z JOSEPH HERDINA 4800 W 57TH STREET PO BOX 5038 SIOUX FALLS SD 571175038 30558829 0 X WWW.CEDARLAKEVILLAGEKC.ORG X 1998 KS IMPROVING THE WELL-BEING AND QUALITY OF LIFE FOR OLDER PERSONS AND OTHERS IN NEED THROUGH THE PROVISION OF HOUSING, PROGRAMS, AND SERVICES. 6 6 0 101 0 0 258684 161782 10537220 10998654 91913 104509 0 0 10887817 11264945 0 0 0 0 3545889 3910126 0 0 30427 6050510 6564748 9596399 10474874 1291418 790071 38112776 48068249 25910105 35803175 12202671 12265074 IMPROVING THE WELL-BEING AND QUALITY OF LIFE FOR OLDER PERSONS AND OTHERS IN NEED THROUGH THE PROVISION OF HOUSING, PROGRAMS, AND SERVICES. 0 0 8250495 10997283 PROVIDING HOUSING, PROGRAMS, AND SERVICES IN AN EFFORT TO IMPROVE THE QUALITY OF LIFE FOR OLDER PERSONS AND OTHERS IN NEED. 10,608 ASSISTED LIVING RESIDENT DAYS, 41,121 SENIOR HOUSING RESIDENT DAYS, AND 9,534 SKILLED NURSING RESIDENT DAYS IN 2015. 8250495 1 1 0 0 0 0 0 0 0 1 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 X 6 6 0 1 0 0 1 1 1 1 0 1 0 1 1 1 1 1 1 1 0 0 X JOSEPH HERDINA 6053623100 4800 W 57TH STREET PO BOX 5038 SIOUX FALLS SD 571175038 X THOMAS A SYVERSON PRESIDENT 1.00 X X 0 0 0 JAMES R HUBBARD VICE-PRESIDENT 1.00 X X 0 0 0 JOSEPH HERDINA TREASURER 1.00 X X 0 0 0 RANDY FITZGERALD SECRETARY 1.00 X X 0 0 0 JAMES K BRADLEY BOARD OF TRUSTEES 1.00 X 0 0 0 J MACK BOWEN BOARD OF TRUSTEES 1.00 X 0 0 0 JOANNA RANDALL ADMINISTRATOR 31.00 X 0 0 0 0 0 0 0 0 0 0 A L HUBER CONSTRUCTION INC 10770 EL MONTE OVERLAND PARK KS 66211 GENERAL CONTRACTOR 6205449 THE EVANGELICAL LUTHERAN GOOD SAMARITAN 4800 W 57TH STREET PO BOX 5038 SIOUX FALLS SD 57117 MANAGEMENT FEES, BILLING SERVICES, AND S 4446860 SUMMIT CARE INC 6830 W 121 OVERLAND PARK KS 66209 THERAPY SERVICES 899976 BOULDER ASSOCIATES INC 1426 PEARL ST SUITE 300 BOULDER CO 80302 ARCHITECTURE SERVICES 347619 BANK OF AMERICA 1 FLEET WAY SCRANTON PA 18507 LETTER OF CREDIT FEES 139257 6 161782 161782 ROOM REVENUE & ANCILLARY SERVICES 623000 10881081 10881081 MEALS, GUEST ROOMS, AND OTHER REV 623000 116202 116202 CHANGE IN TELGSS FDTN INTEREST 623000 1371 1371 10998654 38862 38862 19359031 500 19292161 1723 66870 -1223 65647 65647 11264945 10997283 0 105880 X 3186107 2636463 525014 24630 724019 233068 488915 2036 552246 552246 3350 3350 1242267 1158420 83847 103786 103786 880204 757785 122398 21 777635 669974 107661 65067 61455 3583 29 784381 784381 1414365 1414365 52120 52120 SUPPLIES 524235 524104 131 EMPLOYEE, PUBLIC & RESI 75060 4948 70081 31 BAD DEBT 65000 65000 TAXES AND LICENSES 15938 15938 9094 5532 13 3549 10474874 8250495 2193952 30427 228095 232116 784981 1236857 97335 333 718793 739144 32951 40320 5449 70183 48278780 12268473 28850471 36010307 7255368 9343971 139333 395018 38112776 48068249 1603093 3118025 8680000 18837000 2781071 0 12845941 13848150 25910105 35803175 X 11739151 11666558 322921 457929 140599 140587 12202671 12265074 38112776 48068249 790071 -727669 0 X 0 1 X 1 0 X 41732 113337 57960 258684 161782 633495 9962191 9917277 9909828 10527710 10997283 51314289 10003923 10030614 9967788 10786394 11159065 51947784 66630 101200 167830 0 66630 101200 167830 51779954 82006 50307 68041 50126 38862 289342 82006 50307 68041 50126 38862 289342 10085929 10080921 10035829 10836520 11197927 52237126 0.99120 0.99330 0.00550 0.00650 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 140599 12 140611 133936 1987 4676 140599 101574 17900 14462 133936 12002 89572 101574 12002 12002 1.00000 1 0 1922557 1922557 31857220 9882343 21974877 2531576 1352770 1178806 11967427 1033360 10934067 36010307 FUNDED DEPRECIATION 1884533 F OTHER INVESTMENT 32792 F HOUSING ENTRY FEES 4968463 F CONSTRUCTION FUND 2458183 C 9343971 SPECIAL ASSESSMENTS PAYABLE 215578 HOUSING ENTRY FEES AND OTHER LIABILITIES 6650991 SECURED MORTGAGES AND NOTES PAYABLE TO RELATED PARTIES 6151528 SECURITY DEPOSITS 180388 ACCM UNREALIZED SWAP ADJ. 649665 13848150 X 10402280 -727669 9926 -717743 11120023 144922 144922 11264945 10474873 0 10474873 0 10474873 PART V, LINE 4: EARNINGS ON THE CEDAR LAKE VILLAGE ENDOWMENT FUNDS WILL BE USED AS DIRECTED BY DONOR RESTRICTIONS OR THE BOARD'S DESIGNATION, ABSENT DONOR RESTRICTIONS. PART X, LINE 2: CEDAR LAKE VILLAGE INC. IS ORGANIZED AS A NONPROFIT ORGANIZATION AND HAS BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE 501(C)(3). THE ORGANIZATION IS ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. THE ORGANIZATION HAS DETERMINED IT IS NOT SUBJECT TO UNRELATED BUSINESS INCOME TAX AND HAS NOT FILED AN EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURN (FORM 990T) WITH THE IRS. THE ORGANIZATION BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE WOULD BE RECOGNIZED IF SUCH INTEREST AND PENALTIES WERE INCURRED. THE ORGANIZATION IS SUBJECT TO FEDERAL AND STATE TAX EXAMINATIONS BY TAX AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: NET ASSET RELEASED FROM RESTRICTION 9,926. PART XI, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTIONS AND EARNINGS - TEMP RESTRICTED NET ASSETS 143,551. CHANGE IN BENEFICIAL INTEREST IN TELGSS FOUNDATION 1,371. A CITY OF OLATHE KANSAS 486034756 2015-05-15 19200000 SEE NARRATIVE 0 0 0 A 363000 19200000 270367 7509781 11419852 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 1 0 0 1 1 CENTER STATE BANK OF FLORIDA NA 20.600000000000 0 0 0 0 1 A 1 SCHEDULE K, PART I, COLUMN F, LINE A CONSTRUCT ADDITIONAL FACILITIES, PAY COSTS RELATED TO BOND ISSUANCE, REFUND OF CITY OF OLATHE, KS BOND ISSUE DATED 12/16/04, CUSIP 679390FB5, AND REFUND OF BANK OF AMERICA TAXABLE LINE OF CREDIT. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION HAS DELEGATED MANAGEMENT DUTIES TO THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY, A MEMBER OF THE ORGANIZATION. JOANNA RANDALL, THE ADMINISTRATOR FOR THE ORGANIZATION, RECEIVED COMPENSATION OF $114,393 PLUS EMPLOYER PAID BENEFITS OF $5,331 FOR SERVICES PROVIDED TO CEDAR LAKE VILLAGE, INC. DURING 2015. FORM 990, PART VI, SECTION A, LINE 6 THE MEMBERS ARE OLATHE MEDICAL CENTER, INC. AND THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY. FORM 990, PART VI, SECTION A, LINE 7A THE TRUSTEES ARE APPOINTED BY THE MEMBERS. FORM 990, PART VI, SECTION A, LINE 7B THE DECISIONS OF THE GOVERNING BODY THAT ARE SUBJECT TO APPROVAL INCLUDE: ELECTION OF TRUSTEES AND OFFICERS; APPROVE ARTICLE AND BYLAW CHANGES; APPROVE OR REJECT NON-BUDGETED ACQUISITIONS, EXPENDITURES, OR DISPOSALS OF A VALUE IN EXCESS OF $100,000; DISTRIBUTIONS TO MEMBERS; APPROVE INCURRENCE OF DEBT BY CEDAR LAKE VILLAGE, INC ("CLV") IN EXCESS OF $100,000; AND APPROVE LIENS OF ANY CLV PROPERTY HAVING A VALUE IN EXCESS OF $100,000. FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE ANY COMMITTEES. FORM 990, PART VI, SECTION B, LINE 11 AN ELECTRONIC COPY OF FORM 990 IS SENT TO EACH MEMBER OF THE BOARD PRIOR TO ITS FILING. THE ORGANIZATION'S OFFICERS AND MANAGEMENT ARE AN INTEGRAL PART OF THE PREPARATION OF THE FORM 990 AND HAVE AN ON-GOING REVIEW OF THE FORM 990 AS IT IS PREPARED. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION ASKS THAT ALL OFFICERS AND DIRECTORS COMPLY WITH THE IRS CONFLICT OF INTEREST AND DISCLOSURE CERTIFICATION. THE ORGANIZATION REQUIRES ALL OFFICERS AND DIRECTORS TO PROVIDE A SIGNED COPY TO THE CORPORATION'S MAIN OFFICE ANNUALLY. FORM 990, PART VI, SECTION B, LINE 15A THE ADMINISTRATOR FOR THE ORGANIZATION IS COMPENSATED THROUGH A MANAGEMENT AGREEMENT WITH AN UNRELATED MANAGEMENT COMPANY, THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY. THE COMPENSATION IS REVIEWED AND DETERMINED BY THE UNRELATED MANAGEMENT COMPANY ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART VII JAMES R. HUBBARD - 15325 S LONE ELM ROAD, OLATHE, KS 66061. JAMES K. BRADLEY - 15325 S LONE ELM ROAD, OLATHE, KS 66061. J. MACK BOWEN - 15325 S LONE ELM ROAD, OLATHE, KS 66061. JOANNA RANDALL - 15325 S LONE ELM ROAD, OLATHE, KS 66061. FORM 990, PART IX, LINE 11G CONTRACT SERVICES : PROGRAM SERVICE EXPENSES 974,812. MANAGEMENT AND GENERAL EXPENSES 83,847. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,058,659. PROFESSIONAL MEDICAL SERVICES : PROGRAM SERVICE EXPENSES 97,369. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 97,369. MAINTENANCE CONTRACTS : PROGRAM SERVICE EXPENSES 86,239. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 86,239. FORM 990, SCHEDULE D, PART VI, LINE 1E, COLUMNS B AND C: OTHER PROPERTY SHOWN IN THE OTHER COLUMN CONSISTS OF LAND IMPROVEMENTS OF $2,916,949 WITH RELATED ACCUMULATED DEPRECIATION OF $1,033,360 AND CONSTRUCTION AND DEVELOPMENT OF $9,050,478 WITH NO RELATED ACCUMULATED DEPRECIATION. DEPRECIATION WILL BE RECOGNIZED FOR THE CONSTRUCTION AND DEVELOPMENT ASSETS ONCE CONSTRUCTION HAS BEEN COMPLETED AND THE ASSETS HAVE BEEN PLACED INTO SERVICE.