2013-05-14T09:47:16-05:00 2012-06-30 860133881 HENRY & HORNE LLP 2055 E WARNER RD STE 101 TEMPE AZ 85284 990 2011-07-01 141906233 HACIENDA SKILLED NURSING FACILITY INC HACI 6022434231 1402 EAST SOUTH MOUNTAIN AVENUE PHOENIX AZ 85042 WILLIAM TIMMONS 6022434231 2013-05-13 1 COLETTE KAMPS P00367616 4808394900 2013-05-13 2011 2016-02-24 21:20:13Z WILLIAM TIMMONS 1402 EAST SOUTH MOUNTAIN AVENUE PHOENIX AZ 85042 8772416 0 X WWW.HACIENDAHEALTHCARE.ORG X 2004 AZ SKILLED NURSING AND RESPIRATORY INTERVENTION 9 9 177 0 0 0 204464 420618 7586675 8037896 2003 671 11531 12489 7804673 8471674 0 0 0 0 5046339 5195378 0 0 0 2696318 2465838 7742657 7661216 62016 810458 13626916 13507841 9918887 8763257 3708029 4744584 TO PROVIDE NURSING AND RESPIRATORY CARE TO THOSE WHO REQUIRE FREQUENT SKILLED NURSING AND RESPIRATORY INTERVENTION. 0 0 7465096 8037896 ARIZONA'S FIRST SKILLED NURSING FACILITY FOR INFANTS, CHILDREN, TEENS, AND YOUNG ADULTS. CARE FOR MEDICALLY FRAGILE PATIENTS WHO REQUIRE FREQUENT SKILLED NURSING AND RESPIRATORY INTERVENTIONS. 7465096 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 1 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 1 0 0 0 0 1 7 0 177 1 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 AZ X THE ORGANIZATION 6022434231 1402 EAST SOUTH MOUNTAIN AVENUE PHOENIX AZ 85042 X THOM NIEMIEC 1.00 X 0 0 0 PATRICK WALSH 1.00 X 0 0 0 WANDA O'MALLEY 1.00 X 0 0 0 PATRICIA SHAW 1.00 X 0 0 0 DICK KAUPIE 2.00 X X 0 0 0 TOM POMEROY 2.00 X X 0 0 0 GARY ORMAN 2.00 X X 0 0 0 RALPH WALLWORK 2.00 X X 0 0 0 BARRY GOLDSTIN 2.00 X X 0 0 0 WILLIAM TIMMONS 40.00 X 0 346827 30244 DALE SKURDAHL 40.00 X 0 195761 42730 PERRY F PETRILLI 40.00 X 0 116004 15652 JOSEPH O'MALLEY 40.00 X 0 108158 15485 JANET LOVELADY 40.00 X 0 123311 9853 0 890061 113964 0 0 1 0 LOS NINOS HOSPITAL INC 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 NURSING REGISTRY AND THERAPY SERVICES 389316 HACIENDA INC 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 MANAGEMENT SERVICES 159300 2 420618 7567 420618 PRIVATE SECTOR REVENUE 623000 7332357 7332357 GOVERNMENT REVENUES 623000 705539 705539 8037896 671 671 313231 300742 12489 12489 12489 8471674 8037896 0 13160 4414947 4414947 60316 60316 361591 361591 358524 358524 159300 159300 11550 11550 548533 523263 25270 10314 10314 6507 6507 262151 262151 192648 192648 253761 253761 202333 202333 SUPPLIES 332282 332282 BAD DEBT EXPENSE 152347 152347 FOOD 144637 144637 MEDICAL EQUIPMENT 78065 78065 111410 111410 7661216 7465096 196120 0 700 700 1160895 1412093 72373 24255 1196784 1027835 26186 4355 13227 2416 11326923 1622432 10043451 9704491 1113300 1331696 13626916 13507841 814372 260312 6000000 6000000 3104515 2502945 9918887 8763257 X 3636823 4317502 71206 427082 3708029 4744584 13626916 13507841 X 810458 226097 X X 0 1 1 X 0 X 278143 59509 520732 204464 420618 1483466 4335915 6833526 7060007 7598206 8037896 33865550 4614058 6893035 7580739 7802670 8458514 35349016 37224 300000 265600 602824 0 37224 300000 265600 602824 34746192 7893 8843 3213 2003 671 22623 7893 8843 3213 2003 671 22623 8366 8366 4630317 6901878 7583952 7804673 8459185 35380005 0.98210 0.98220 0.00060 0.00670 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 10180219 1081748 9098471 87006 17963 69043 1059698 522721 536977 9704491 DUE FROM RELATED AFFILIATE 1320829 SCHOOL LOANS RECEIVABLE 10867 1331696 DUE TO RELATED AFFILIATE 2240168 INTEREST RATE SWAP AGREEMENT 262777 2502945 8471674 7661216 810458 226097 226097 1036555 8998513 0 8998513 -526839 -526839 8471674 7961958 300742 300742 7661216 0 7661216 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE ORGANIZATION RECOGNIZES UNCERTAIN TAX POSITIONS IN THE FINANCIAL STATEMENTS WHEN IT IS MORE LIKELY THAN NOT THE POSITIONS WILL NOT BE SUSTAINED UPON EXAMINATION BY THE TAX AUTHORITIES. AS OF JUNE 30, 2012, THE ORGANIZATION HAD NO UNCERTAIN TAX POSITIONS THAT QUALIFY FOR EITHER RECOGNITION OR DISCLOSURE IN THE FINANCIAL STATEMENTS. PART XI, LINE 8 - OTHER ADJUSTMENTS: GAIN ON INTEREST RATE SWAP AGREEMENT 226,097. PART XII, LINE 4B - OTHER ADJUSTMENTS: INTEREST EXPENSE NETTED WITH RENTAL INCOME ON FORM 990 -115,648. DEPRECIATION EXPENSE NETTED WITH RENTAL INCOME ON FORM 990 -185,094. GAIN ON INTEREST RATE SWAP AGREEMENT -226,097. PART XIII, LINE 2D - OTHER ADJUSTMENTS: INTEREST EXPENSE NETTED WITH RENTAL INCOME ON FORM 990 115,648. DEPRECIATION EXPENSE NETTED WITH RENTAL INCOME ON FORM 990 185,094. X 0 1 0 0 0 0 0 0 0 WILLIAM TIMMONS 0 346827 0 0 0 0 0 22000 0 8244 0 377071 0 0 DALE SKURDAHL 0 195761 0 0 0 0 0 21205 0 21525 0 238491 0 0 SUPPLEMENTAL INFORMATION PART III CERTAIN EMPLOYEES PARTICIPATED IN A SECTION 457B PLAN. THE AMOUNTS LISTED BELOW ARE THE EMPLOYEE CONTRIBUTIONS TO THIS PLAN IN CALENDAR YEAR 2011. WILLIAM TIMMONS - $22,000 DALE SKURDAHL - $22,000 JANET LOVELADY - $ 1,350 FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S BOARD TREASURER, CEO AND CONTROLLER WILL REVIEW AND APPROVE THE FORM 990 PRIOR TO FILING. THEY WILL THEN REVIEW THE FINAL FORM 990 WITH THE ENTIRE BOARD. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY THAT ADDRESSES THE CONSIDERATION OF POTENTIAL CONFLICTS OF INTEREST BY THE BOARD OF DIRECTORS, COMMITTEE MEMBERS, KEY EMPLOYEES, AND THEIR RELATIVES. AS PER THE POLICY, SUCH PERSONS MUST MAKE DISCLOSURE OF ANY POTENTIAL CONFLICTS OF INTEREST AND MUST ABSTAIN FROM VOTING ON ANY ACTION IN WHICH THEY MAY HAVE AN INTEREST. ON AN ANNUAL BASIS, ALL BOARD MEMBERS ARE REQUIRED TO SIGN OFF ON AN ANNUAL CONFLICT OF INTEREST FORM, EITHER STATING ANY KNOWN CONFLICTS, OR STATING THAT THERE ARE NONE. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS DETERMINES REASONABLE AND APPROPRIATE SALARIES FOR KEY EMPLOYEES OF THE ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION GENERALLY MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. COMPENSATION FROM RELATED ORGANIZATION FORM 990, PART VII, LINE 1A HACIENDA SKILLED NURSING FACILITY, INC. IS RELATED TO TWO TAX EXEMPT AFFILIATES, HACIENDA, INC. AND LOS NINOS HOSPITAL, INC. THESE THREE ORGANIZATIONS SHARE A COMMON MANAGEMENT TEAM. THE INDIVIDUALS ON THE MANAGEMENT TEAM ARE COMPENSATED AS EMPLOYEES THROUGH HACIENDA, INC. HACIENDA, INC. CHARGES A MANAGEMENT FEE FOR THESE SERVICES TO BOTH LOS NINOS HOSPITAL, INC. AND TO HACIENDA SKILLED NURSING FACILITY, INC. THE COMPENSATION AMOUNTS LISTED IN PART VII ARE THE TOTAL GROSS WAGES AND OTHER COMPENSATION PAID TO THESE INDIVIDUALS FOR THEIR SERVICES TO ALL THREE ORGANIZATIONS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: GAIN ON INTEREST RATE SWAP AGREEMENT 226,097. TOTAL TO FORM 990, PART XI, LINE 5: 226,097. FORM 990, PART XII, LINE 2C THE ORGANIZATION'S BOARD OF DIRECTORS, CEO, AND FINANCE DIRECTOR ARE RESPONSIBLE FOR THE OVERSIGHT OF THE FINANCIAL STATEMENTS AND THE AUDIT OF THE FINANCIAL STATEMENTS. HACIENDA HEALTHCARE 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 272988610 BRAND NAME FOR RELATED ORGAIZATIONS AZ 501(C)(3) LINE 9 N/A 0 HACIENDA INC 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 860253158 NURSING CARE & RESPIRATORY INTERVENTION AZ 501(C)(3) LINE 9 N/A 0 LOS NINOS HOSPITAL INC 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 860892673 NON-PROFIT CHILDREN'S HOSPITAL AZ 501(C)(3) LINE 9 N/A 0 SOUTH MOUNTAIN HEALTH SUPPLY 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 860858893 MEDICAL SUPPLY COMPANY AZ HACIENDA HEALTHCARE C INNOVATIVE HOME HEALTH INC 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 262398755 HOME HEALTH NURSING SERVICES AZ HACIENDA HEALTHCARE C 0 0 1 1 1 0 0 0 1 0 0 1 1 1 1 0 0 0