2012-11-14T11:00:46-06:00 2011-12-31 910189318 MOSS ADAMS LLP 101 SECOND STREET 9TH FLOOR SAN FRANCISCO CA 94105 990 2011-01-01 956419205 SANSUM CLINIC SANS 8056817700 PO BOX 1200 SANTA BARBARA CA 931021200 CHAD HINE 8056817700 2012-11-14 1 RENIE BURBANK P00159653 4159561500 2011 2016-02-24 21:20:13Z CHAD HINE PO BOX 1200 SANTA BARBARA CA 931021200 177654615 0 X WWW.SANSUMCLINIC.ORG X 1921 CA TO PROVIDE MEDICAL SERVICES TO THE GENERAL PUBLIC. 20 19 1083 10 0 0 1920570 2169704 167248916 173022902 231381 221475 1884543 1701966 171285410 177116047 0 0 0 0 48027363 50887227 0 0 266130 118427296 122865722 166454659 173752949 4830751 3363098 82071771 86024320 55576392 56461831 26495379 29562489 X THE CLINIC PROVIDES MEDICAL SERVICES TO THE GENERAL PUBLIC, INCLUDING CHARITY CARE TO PATIENTS WHO ARE UNABLE TO PAY AND THOSE UNDER MEDICARE AND MEDI-CAL PROGRAMS AT LESS THAN STANDARD CHARGES. OTHER HEALTH SERVICES IN THE COMMUNITY ARE ALSO PROVIDED, SUCH AS WELLNESS PROGRAMS, EDUCATIONAL SERVICE, SPEAKING ENGAGEMENTS AND INTERNSHIP PROGRAMS. 0 0 159575890 173022902 SEE SCHEDULE O 159575890 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 416 0 1 1083 1 0 0 0 0 0 1 1 0 0 0 0 X 20 19 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 CA X CHAD HINE 8056817700 PO BOX 1200 SANTA BARBARA CA 931021200 KURT RANSOHOFF MD 40.00 X X 145172 0 0 MICHAEL BERNSTEIN MD 1.00 X 10000 0 0 VICKI HAZARD 1.00 X X 0 0 0 ED ROSENBLATT 1.00 X X 0 0 0 LARS BRUUN-ANDERSEN 1.00 X 0 0 0 KEN COATES 1.00 X 0 0 0 CHRIS CORPUZ 1.00 X 0 0 0 CHARLIE COX 1.00 X 0 0 0 ROGER CRATON 1.00 X 0 0 0 JANET GARUFIS 1.00 X 0 0 0 PAUL HARTLOFF 1.00 X 0 0 0 ROGER HORTON 1.00 X 0 0 0 CHUCK KAYE 1.00 X 0 0 0 VICKY MACGREGOR 1.00 X 0 0 0 JULIE MCGOVERN 1.00 X 0 0 0 JAMES MCNAMARA MD 1.00 X 0 0 0 DAVID RAPHAEL MD 1.00 X 0 0 0 MICHAEL STEIN 1.00 X 0 0 0 JOSEPH TUMBLER 1.00 X 0 0 0 BETH VOS 1.00 X 0 0 0 PAUL JACONETTE 40.00 X 318017 0 20128 CHAD HINE 40.00 X 303896 0 19108 CHRISTINE MCNAMARA 40.00 X 193315 0 9733 JENNIFER THOMAS 40.00 X 234688 0 25952 TOM COLBERT 40.00 X 171141 0 10965 MARJORIE NEWMAN 40.00 X 172032 0 8402 SEAN JOHNSON 40.00 X 183916 0 0 LOUIS GIAMBELUCA 40.00 X 137773 0 0 1869950 0 94288 31 0 1 0 SANSUM SANTA BARBARA MEDICAL CLINIC INC PO BOX 1200 SANTA BARBARA CA 93102 PROFESSIONAL SERVICES 49972000 PACIFIC DIAGNOSTIC LABORATORIES PO BOX 8180 GOLETA CA 93118 LABORATORY SERVICES 3974118 JACKSON MEDICAL GROUP 517 WEST JUNIPERO SANTA BARBARA CA 93105 PROFESSIONAL SERVICES 3257953 SANTA BARBARA RADIOLOGY MEDICAL GROUP 320 W PUEBLO SANTA BARBARA CA 93101 RADIOLOGY SERVICES 2713863 ANESTHESIA MEDICAL GROUP 514 W PUEBLO SANTA BARBARA CA 93105 PROFESSIONAL SERVICES 1655901 118 263400 1906304 2169704 MEDICAL SRVC REVENUE 621110 173022902 173022902 173022902 221475 221475 635096 404515 230581 230581 230581 30000 263400 134053 -104053 -104053 MISCELLANEOUS 624100 1469830 1469830 INCOME FROM K-1S 900099 105608 105608 1575438 177116047 173022902 0 1923441 993261 993261 38596475 32297364 6129119 169992 873759 695856 177903 7554047 6257448 1267807 28792 2869685 2335350 521682 12653 182405 148441 33964 128650 104695 23955 77614628 76719890 885076 9662 543678 442445 63364 37869 4831864 4041263 783439 7162 1721706 1401124 320582 5067637 4124043 943594 58890 47925 10965 181322 147560 33762 1410780 1148093 262687 4352493 3542059 810434 1328851 1081419 247432 MEDICAL SUPPLIES 14201997 14201997 PHARMACEUTICAL SUPPLIES 7832770 7832770 REPAIRS/MAINTENANCE 2143920 1744722 399198 PROV. FOR UNCOLLECTIBLE 1249602 1249602 14529 11824 2705 173752949 159575890 13910929 266130 128997 8210280 23817386 12109844 10657278 9346085 2000000 2817077 1483708 1676876 774059 1242836 98083655 60683900 31017780 37399755 3047301 2880357 474919 432130 8670343 9909080 82071771 86024320 20171416 19154118 25862430 24785745 4486366 6489814 5056180 6032154 55576392 56461831 X 22510247 25818949 3199695 2944304 785437 799236 26495379 29562489 82071771 86024320 X 3363098 -295988 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3256051 13799 -78121 3191729 2933851 33680 288520 3256051 2292447 255486 385918 2933851 1952796 839584 -499933 2292447 0.75000 0.25000 0 0 6033858 6033858 33109764 17955945 15153819 53732539 42727955 11004584 5207494 5207494 37399755 BOND CONSTRUCTION AND RESERVE FUNDS 4077881 BOND ISSUANCE COSTS, NET OF AMORTIZATION 1199710 DEFERRED COMPENSATION PLAN ASSETS 2144151 OTHER ASSETS 461338 INSURANCE RECEIVABLE 2026000 9909080 DEFERRED COMPENSATION PLAN LIABILITIES 2144154 MEDICAL MALPRACTICE LIABILITY 3888000 6032154 177116047 173752949 3363098 -306537 10549 -295988 3067110 176723531 -306537 -306537 177030068 85979 85979 177116047 173656421 0 173656421 96528 96528 173752949 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INTENDED USE OF ENDOWMENT FUNDS ARE RELATED TO THE PURPOSE FOR WHICH THEY WERE GIVEN. THERE ARE RESTRICTED FUNDS SET UP FOR DIGITAL MAMMOGRAPHY, CYSTIC FIBROSIS, PHYSICIAN HOUSING, TECHNOLOGY IMPROVEMENTS, AND COLONOSCOPIES FOR NEIGHBORHOOD CLINIC PATIENTS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE CLINIC RECOGNIZES THE TAX BENEFIT FROM UNCERTAIN TAX POSITIONS ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITIONS WILL BE SUSTAINED ON EXAMINATION BY THE TAX AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE TAX BENEFIT IS MEASURED BASED ON THE LARGEST BENEFIT THAT HAS A GREATER THAN 50% LIKELIHOOD OF BEING REALIZED UPON ULTIMATE SETTLEMENT. THERE WERE NO UNCERTAIN TAX POSITIONS AS OF DECEMBER 31, 2011 OR 2010. PART XI, LINE 8 - OTHER ADJUSTMENTS: BOOK/TAX DIFFERENCE IN PARTNERSHIP INCOME 10,549. PART XII, LINE 4B - OTHER ADJUSTMENTS: GROSS RENTAL INCOME RECLASSIED FROM EXPENSE SECTION 635,096. BOOK/TAX DIFFERENCE IN PARTNERSHIP INCOME -10,549. RENTAL EXPENSES NETTED WITH RENTAL INCOME -404,515. FUNDRAISING EXPENSES RECLASSIFIED TO REVENUES -134,053. PART XIII, LINE 4B - OTHER ADJUSTMENTS: GROSS RENTAL INCOME RECLASSIFIED TO REVENUES 635,096. RENTAL EXPENSES RECLASSIFIED TO REVENUES -404,515. FUNDRAISING EXPENSES RECLASSIFIED TO REVENUES -134,053. 90TH ANNIVERSARY 293400 263400 30000 134053 293400 263400 30000 134053 134053 -104053 X 1 1 X X X X 1 0 0 0 0 0 0 0 0 PAUL JACONETTE 225096 0 0 0 92921 0 9685 0 10443 0 338145 0 0 0 CHAD HINE 303896 0 0 0 0 0 3443 0 15665 0 323004 0 0 0 CHRISTINE MCNAMARA 193315 0 0 0 0 0 9733 0 0 0 203048 0 0 0 JENNIFER THOMAS 234688 0 0 0 0 0 10287 0 15665 0 260640 0 0 0 TOM COLBERT 171141 0 0 0 0 0 0 0 10965 0 182106 0 0 0 MARJORIE NEWMAN 172032 0 0 0 0 0 8402 0 0 0 180434 0 0 0 SEAN JOHNSON 183916 0 0 0 0 0 0 0 0 0 183916 0 0 0 PART I, LINE 1A KURT RANSOHOFF AND PAUL JACONETTE RECEIVED MONTHLY CLUB DUES TOTALING $4,008 PER YEAR FOR EACH INDIVIDUAL. THESE AMOUNTS HAVE BEEN INCLUDED IN 2011 W-2 WAGES. PART I, LINE 4A IN 2011, PAUL JACONETTE RECEIVED A SEVERANCE IN THE AMOUNT OF $92,921, WHICH WAS INCLUDED IN HIS 2011 W-2 WAGES. FORM 990, PART VI, SECTION A, LINE 2 CHRISTINE MCNAMARA, VICE PRESIDENT OF PROFESSIONAL SERVICES, AND DR. JAMES MCNAMARA, MEMBER OF THE BOARD OF TRUSTEES, HAVE A FAMILY RELATIONSHIP. ALSO, MICHAEL STEIN, MEMBER OF THE BOARD OF TRUSTEES, HAS A BROTHER THAT WORKS FOR SANSUM CLINIC. FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF TRUSTEES HAS DELEGATED THE FIDUCIARY RESPONSIBILITY OF THE REVIEW AND APPROVAL PROCESS OF THE 990 TAX RETURN TO THE EXECUTIVE COMMITTEE AND THE CHIEF FINANCIAL OFFICER; UPON APPROVAL BY THE EXECUTIVE COMMITTEE THE 990 TAX RETURN GOES TO THE BOARD OF TRUSTEES FOR FINAL APPROVAL. THE FORM 990 WAS PROVIDED TO ALL MEMBERS OF THE BOARD OF TRUSTEES AND OFFICERS ELECTRONICALLY PRIOR TO FILING WITH THE IRS. ONCE FINAL APPROVAL IS GIVEN, THE 990 TAX RETURN IS SUBMITTED TO THE IRS. FORM 990, PART VI, SECTION B, LINE 12C IT IS THE POLICY OF SANSUM CLINIC TO MAIL OUT, ON AN ANNUAL BASIS, A CONFLICT OF INTEREST STATEMENT TO THE BOARD OF TRUSTEES FOR COMPLETION. THE CONFLICT OF INTEREST STATEMENTS ARE REVIEWED AND ALL RESPONSES ARE FILED. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES REVIEWS EXECUTIVE COMPENSATION PERIODICALLY. NO CHANGES TO EXECUTIVE COMPENSATION ARE IMPLEMENTED THAT ARE NOT BUDGETED FOR AND THAT ARE NOT CONSISTENT WITH THE AVERAGE RATE OF PAY INCREASES FOR OTHER COMPANY EMPLOYEES. ANY EXCEPTIONS TO THIS ARE APPROVED, IN ADVANCE, BY THE EXECUTIVE COMMITTEE PRIOR TO IMPLEMENTATION. FORM 990, PART VI, SECTION C, LINE 19 IT IS THE POLICY OF SANSUM CLINIC TO PROVIDE DOCUMENTATION UPON WRITTEN REQUEST BY MAIL TO THE CORPORATE LOCATION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -306,537. BOOK/TAX DIFFERENCE IN PARTNERSHIP INCOME 10,549. TOTAL TO FORM 990, PART XI, LINE 5: -295,988. AUDIT COMMITTEE AND OVERSIGHT 990, PART XII, LINE 2C THE BOARD OF TRUSTEES HAS DELEGATED FIDUCIARY RESPONSIBILITY OF THE OVERSIGHT OF THE AUDIT TO THE AUDIT COMMITTEE. THERE HAVE BEEN NO CHANGES TO THIS PROCESS FROM PRIOR YEAR. EXEMPT PURPOSE ACHIEVEMENTS FORM 990, PART III, LINE 4A IN FURTHERANCE OF ITS CHARITABLE PURPOSE, THE CLINIC PROVIDES MEDICAL CARE WITHOUT CHARGE OR AT REDUCED CHARGE TO RESIDENTS OF THE COMMUNITY, PRIMARILY THROUGH: (A) SERVICES PROVIDED AT NO CHARGE TO THE UNINSURED; (B) THE DIFFERENCE BETWEEN PUBLIC PROGRAM PAYMENTS (PRIMARILY MEDI-CAL) AND THE RELATED COSTS OF PROVIDING SUCH SERVICES; AND (C) THE SERVICES PROVIDED TO PATIENTS EXPRESSING A WILLINGNESS TO PAY BUT WHO ARE UNABLE DUE TO SOCIO-ECONOMIC FACTORS. ADDITIONAL ACTIVITIES UNDERTAKEN TO BENEFIT THE COMMUNITY AND TO FULFILL ITS MISSION OF PROVIDING HIGH QUALITY HEALTHCARE TO EVERY PATIENT IN AN ENVIRONMENT THAT FOSTERS CARING AND COMPASSION AND PROMOTES EDUCATION AND RESEARCH INCLUDE THE FOLLOWING: - PROVIDING FREE SPORTS PHYSICALS TO YOUTH WHO COULD NOT OTHERWISE AFFORD THEM. - PROVIDING THE LARGEST LOCAL FLU IMMUNIZATION CLINICS ANNUALLY FOR FREE OR FOR A NOMINAL DONATION. - PROVIDING FREE EYE EXAMINATIONS THROUGH SEE INTERNATIONAL TO CHILDREN WHO COULD NOT OTHERWISE AFFORD THEM. - PROVIDING MORE THAN 300 HEALTH EDUCATION CLASSES (E.G. ASTHMA, BACK AND NECK CARE, CHOLESTEROL, DIABETES, HEALTHY AGING, JOINT REPLACEMENT, STRESS, WEIGHT MANAGEMENT FOR CHILDREN AND ADULTS) THAT ARE OFFERED EACH YEAR. THE CLASSES ARE OPEN TO THE COMMUNITY, ARE OFFERED FOR FREE OR AT A NOMINAL FEE AND ARE AVAILABLE THROUGHOUT THE COUNTY. - LEADING CAMP WHEEZ AND PROVIDING PHYSICIANS AND SUPPORT STAFF FOR THIS WEEKLONG SUMMER CAMP FOR CHILDREN LIVING WITH ASTHMA. - COLLABORATING WITH SANTA BARBARA NEIGHBORHOOD CLINICS TO PROVIDE DIAGNOSTIC CARE AND SPECIALTY MEDICAL SERVICES TO RESIDENTS WHO COULD OTHERWISE NOT AFFORD THESE TESTS. - PROVIDING RELIABLE HEALTH AND RESOURCE INFORMATION FREE OF CHARGE TO ANY COMMUNITY MEMBER, PATIENTS AND NON-PATIENTS ALIKE, THROUGH OUR HEALTH RESOURCE CENTER. - PARTICIPATING IN A VARIETY OF RESEARCH PROJECT WITH PARTNERS SUCH AS UCLA, THE RAND CORPORATION AND SEVERAL PHARMACEUTICAL COMPANIES. - PARTICIPATING IN OVER A DOZEN ANNUAL HEALTH FAIRS AND FREE HEALTH SCREENING EVENTS. INVESTMENT IN OR PARTICIPATION IN A JOINT VENTURE OR SIMILAR ARRANGEMENT: 990, PART VI, LINE 16B DUE DILIGENCE WAS PERFORMED BY LEGAL COUNSEL AT THE TIME OF THE INITIAL INVESTMENT. THE FACILITY, WHICH IS MANAGED BY THE PARTNERSHIP, IS USED BY SANSUM CLINIC FOR OUTPATIENT SURGERY PROCEDURES. SANSUM CLINICS ENGAGE LEGAL COUNSEL FOR ANY CHANGES RELATING TO PARTNERSHIP ACTIVITIES TO ENSURE PROCEDURES ARE FOLLOWED TO SAFEGUARD THEIR EXEMPT STATUS. EFFECTIVE NOVEMBER 2011, SANSUM CLINIC SOLD THEIR INVESTMENT INTEREST IN SANTA BARBARA SURGERY CENTER, LP.