2012-05-15T10:46:31-05:00 2011-06-30 HENRY & HORNE LLP 7098 E COCHISE SUITE 100 SCOTTSDALE AZ 852534517 990 2010-07-01 141906233 HACIENDA SKILLED NURSING FACILITY INC HACI 6022434231 1402 EAST SOUTH MOUNTAIN AVENUE PHOENIX AZ 85042 WILLIAM TIMMONS 6022434231 2012-05-09 1 COLETTE KAMPS CPA 4804831170 2012-05-08 2010 2016-02-24 21:20:13Z WILLIAM TIMMONS 1402 EAST SOUTH MOUNTAIN AVENUE PHOENIX AZ 85042 8104910 0 X WWW.HACIENDAHEALTHCARE.ORG X 2004 AZ SKILLED NURSING AND RESPIRATORY INTERVENTION 12 12 179 0 0 0 520732 204464 7048292 7586675 3213 2003 11715 11531 7583952 7804673 0 0 0 0 3758195 5046339 0 0 0 3032749 2696318 6790944 7742657 793008 62016 12618840 13626916 9131309 9918887 3487531 3708029 TO PROVIDE NURSING AND RESPIRATORY CARE TO THOSE WHO REQUIRE FREQUENT SKILLED NURSING AND RESPIRATORY INTERVENTION. 0 0 7577779 7586675 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. 7577779 1 1 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 1 0 0 0 0 1 0 0 0 0 1 4 0 179 1 0 0 0 0 0 0 0 0 X 12 12 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 CARL MUNDING 1.00 X 0 0 0 THOM NIEMIEC 1.00 X 0 0 0 GARY ORMAN 1.00 X 0 0 0 RALPH WALLWORK 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 MICHAEL STONE 2.00 X X 0 0 0 PETER RANKE 2.00 X X 0 0 0 BARRY GOLDSTIN 2.00 X X 0 0 0 WILLIAM TIMMONS 40.00 X 0 378315 22964 DALE SKURDAHL 40.00 X 0 193366 41354 JAMES SMITH 40.00 X 0 161691 14379 ROBERT MILLER 40.00 X 0 137009 7989 STACI GLASS 40.00 X 0 142085 36590 JOSEPH O'MALLEY 40.00 X 0 116029 15719 MELINDA MORALES 40.00 X 0 110161 11300 JANET LOVELADY 40.00 X 0 110126 7086 ANN CRISLER 40.00 X 0 109276 13527 0 1458058 170908 0 0 1 0 LOS NINOS HOSPITAL INC 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 NURSING REGISTRY AND THERAPY SERVICES 649500 HACIENDA INC 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 MANAGEMENT SERVICES 159300 2 204464 68250 204464 PRIVATE SECTOR REVENUE 623000 7150284 7150284 GOVERNMENT REVENUES 623000 436391 436391 7586675 2003 2003 311768 300237 11531 11531 11531 7804673 7586675 0 13534 4321000 4321000 32202 32202 431917 431917 261220 261220 159300 159300 2250 2250 762560 759232 3328 9319 9319 4397 4397 248079 248079 1110 1110 192122 192122 243983 243983 188203 188203 SUPPLIES 397492 397492 FOOD 282445 282445 MISCELLANEOUS 83084 83084 MEDICAL EQUIPMENT 69608 69608 BAD DEBT EXPENSE 52366 52366 7742657 7577779 164878 0 379611 700 411536 1160895 25000 72373 853286 1196784 8584 26186 5011 13227 11296473 1253022 9251016 10043451 140000 1544796 1113300 12618840 13626916 672755 814372 6000000 6000000 2458554 3104515 9131309 9918887 X 3079915 3636823 407616 71206 3487531 3708029 12618840 13626916 X 62016 158482 X 0 1 1 X 0 X 517920 278143 59509 520732 204464 1580768 3369235 4335915 6833526 7060007 7598206 29196889 3887155 4614058 6893035 7580739 7802670 30777657 37224 300000 337224 0 37224 300000 337224 30440433 184224 7893 8843 3213 2003 206176 184224 7893 8843 3213 2003 206176 8366 8366 4071379 4630317 6901878 7583952 7804673 30992199 0.98220 0.97740 0.00670 0.01000 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 9204689 845730 8358959 87006 9875 77131 454342 202127 252215 1550436 195290 1355146 10043451 DUE FROM RELATED AFFILIATE 1100233 SCHOOL LOANS RECEIVABLE 13067 1113300 DUE TO RELATED AFFILIATE 2615641 INTEREST RATE SWAP AGREEMENT 488874 3104515 7804673 7742657 62016 50000 108482 158482 220498 8154910 50000 50000 8104910 -300237 -300237 7804673 8151376 408719 408719 7742657 0 7742657 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, 2011, THE ORGANIZATION HAD NO UNCERTAIN TAX POSITIONS THAT QUALIFY FOR EITHER RECOGNITION OR DISCLOSURE IN THE FINANCIAL STATEMENTS. PART XI, LINE 8 - OTHER ADJUSTMENTS: LOSS ON INTEREST RATE SWAP AGREEMENT 108,482. PART XII, LINE 4B - OTHER ADJUSTMENTS: INTEREST EXPENSE NETTED WITH RENTAL INCOME ON FORM 990 -184,588. DEPRECIATION EXPENSE NETTED WITH RENTAL INCOME ON FORM 990 -115,649. PART XIII, LINE 2D - OTHER ADJUSTMENTS: INTEREST EXPENSE NETTED WITH RENTAL INCOME ON FORM 990 184,588. DEPRECIATION EXPENSE NETTED WITH RENTAL INCOME ON FORM 990 115,649. LOSS ON INTEREST RATE SWAP AGREEMENT 108,482. X 0 1 0 0 0 0 0 0 0 WILLIAM TIMMONS 0 333315 0 45000 0 0 0 14512 0 8452 0 401279 0 0 DALE SKURDAHL 0 183904 0 9462 0 0 0 10210 0 31144 0 234720 0 0 JAMES SMITH 0 156741 0 4950 0 0 0 0 0 14379 0 176070 0 0 STACI GLASS 0 104918 0 37167 0 0 0 6206 0 30384 0 178675 0 0 X PATIO REMODEL 1 60554 FMV 0 0 0 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: DONATED SERVICES AND USE OF FACILITIES: 50,000. LOSS ON INTEREST RATE SWAP AGREEMENT 108,482. TOTAL TO FORM 990, PART XI, LINE 5: 158,482. 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 0 1 0 1 0 1 0 0 1 1 1 1 0 0 0