2011-05-11T17:15:38-05:00 2010-06-30 Henry & Horne LLP 7098 E Cochise Suite 100 Scottsdale AZ 852534517 990 2009-07-01 141906233 HACIENDA SKILLED NURSING FACILITY INC HACI 6022434231 1402 EAST SOUTH MOUNTAIN AVENUE PHOENIX AZ 85042 William TIMMONS 6022434231 2011-05-02 1 Colette Kamps CPA 4804831170 2011-04-29 2009 2016-02-24 21:20:13Z William Timmons 1402 EAST SOUTH MOUNTAIN AVENUE PHOENIX AZ 85042 7884185 0 X www.haciendahealthcare.org X 2004 AZ SKILLED NURSING AND RESPIRATORY INTERVENTION 12 12 151 0 0 0 59509 520732 6532129 7048292 8843 3213 301397 11715 6901878 7583952 0 0 3546770 3758195 0 0 3479103 3032749 7025873 6790944 -123995 793008 11843439 12618840 9101237 9131309 2742202 3487531 TO PROVIDE NURSING, REHABILITATIVE THERAPY AND RESPIRATORY CARE TO THOSE WHO REQUIRE FREQUENT SKILLED NURSING AND RESPIRATORY INTERVENTION, including infants, children and young adults. 0 0 6626377 7060007 ARIZONA'S FIRST SKILLED NURSING FACILITY (SNF) FOR INFANTS, CHILDREN, TEENS, AND YOUNG ADULTS. SNF provides CARE FOR MEDICALLY FRAGILE PATIENTS WHO REQUIRE FREQUENT SKILLED NURSING, rehabilitative therapy AND RESPIRATORY INTERVENTIONS. 244 patients were admitted to the SNF during the year ended June 30, 2010. 17,080 days of nursing care and 8,873 hours of physical, occupational and speech therapy were provided during the year to patients in the SNF. 6626377 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 1 3 0 151 1 0 0 0 0 0 0 0 12 12 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 AZ X The Organization 6022434231 1402 EAST SOUTH MOUNTAIN AVENUE PHOENIX AZ 85042 X Carl Munding 5.00 X 0 0 0 Thom Niemiec 5.00 X 0 0 0 Gary Orman 5.00 X 0 0 0 Ralph Wallwork 5.00 X 0 0 0 Patrick Walsh 5.00 X 0 0 0 Bruce Samuels 5.00 X 0 0 0 Wanda O'Malley 5.00 X 0 0 0 Patricia Shaw 5.00 X 0 0 0 Dick Kaupie 5.00 X X 0 0 0 Tom Pomeroy 5.00 X X 0 0 0 Michael Stone 5.00 X X 0 0 0 Peter Ranke 5.00 X X 0 0 0 Barry Goldstin 5.00 X X 0 0 0 William Timmons 50.00 X 0 360868 21188 Dale Skurdahl 50.00 X 0 220240 38679 Robert Miller 50.00 X 0 149760 7596 Jim Smith 50.00 X 0 0 0 RICHARD HART 40.00 X 0 35432 0 Joseph O'Malley 50.00 X 0 121388 12935 0 887688 80398 0 0 1 0 Los Ninos Hospital Inc 1402 E South Mountain Ave Phoenix AZ 85042 Nursing registry services and therapy se 897516 Hacienda Inc 1402 E South Mountain Ave phoenix AZ 85042 management services 159300 2 520732 2885 520732 PRIVATE SECTOR REVENUE 623000 6573210 6573210 GOVERNMENT REVENUES 623000 475082 475082 7048292 3213 3213 311948 300233 11715 11715 11715 7583952 7060007 0 3213 3112631 3112631 32202 32202 234159 234159 379203 379203 159300 159300 2250 2250 1011436 1008419 3017 5103 5103 847 847 248740 248740 192118 192118 218502 218502 151154 151154 SUPPLIES 428259 428259 FOOD 231005 231005 Medical Equipment 211510 211510 BAD DEBT EXPENSE 91933 91933 MISCELLANEOUS 80592 80592 6790944 6626377 164567 0 199926 379611 550336 411536 25000 1232070 853286 8584 13273 5011 10144405 893389 9513969 9251016 140000 333865 1544796 11843439 12618840 499760 672755 6000000 6000000 2601477 2458554 9101237 9131309 X 2736890 3079915 5312 407616 2742202 3487531 11843439 12618840 X 0 1 1 X 0 X 1239795 517920 278143 59509 520732 2616099 3103377 3369235 4335915 6833526 7060007 24702060 4343172 3887155 4614058 6893035 7580739 27318159 37224 300000 337224 0 37224 300000 337224 26980935 72460 184224 7893 8843 3213 276633 72460 184224 7893 8843 3213 276633 288 8366 8654 4415920 4071379 4630317 6901878 7583952 27603446 0.97740 0.95340 0.01000 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 9204689 609712 8594977 26451 4311 22140 370542 136245 234297 542723 143121 399602 9251016 DUE FROM RELATED AFFILIATE 1530379 School loans RECEIVABLE 14417 1544796 DUE TO RELATED AFFILIATE 1861198 INTEREST RATE SWAP AGREEMENT 597356 2458554 7583952 6790944 793008 -47679 -47679 745329 7884185 300233 300233 7583952 0 7583952 7138856 347912 347912 6790944 0 6790944 Part X: Description of Uncertain Tax Positions Under FIN 48: The Organization recognizes tax positions in the financial statements when it is more likely than not that the positions will not be sustained upon examination by the tax authorities. As of June 30, 2010, the Organization had no uncertain tax positions that qualify for either recognition or disclosure in the financial statements. The Organization's federal and state exempt returns (Form 990 and 99) for fiscal years ended June 30, 2007, 2008, 2009 and 2010 are subject to examination by the IRS and the State of Arizona, generally for three years after they were filed. Part XI, Line 8 - Other Adjustments: Loss on fair market value of interest rate swap agreement: -47679. Part XII, Line 2d - Other Adjustments: Interest expense included in rental expense in Statement of REvenue : 184584. depreciation expense included in rental expense in Statement of REvenue : 115649. Part XIII, Line 2d - Other Adjustments: Interest expense included in rental expense in Statement of REvenue : 184584. depreciation expense included in rental expense in Statement of REvenue : 115649. Loss on fair market value of interest rate swap agreement: 47679. X 0 0 0 0 0 0 0 0 0 William Timmons 0 310868 0 50000 0 0 0 13719 0 7469 0 382056 0 0 Dale Skurdahl 0 203377 0 16863 0 0 0 11437 0 27242 0 258919 0 0 Robert Miller 0 127794 0 21966 0 0 0 6589 0 1007 0 157356 0 0 Pomeroy & Pomeroy Entity more than 35% owned by T.Pomeroy, board member 0 Insurance brokerage services 0 Los Ninos Hospital Inc (LNH) Same Board of Directors 897516 LNH provides nursing registry services and therapy services to the filing organization. 0 Hacienda Inc Same board of Directors 159300 Hacienda provides management services to the filing organization. 0 Hacienda Inc Same Board of Directors 300233 The filing organization charges rent to Hacienda for use of its facility. 0 Los Ninos Hospital Inc (LNH) same Board of Directors 11423 The filing organization charges rent to LNH for use of its facility. 0 Form 990, Part VI, Section B, line 11 The Organization's CEO, CFO, Treasurer and Controller will review and approve the Form 990 prior to filing. The Organization's CEO has been authorized by the board of directors to sign the final Form 990. 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 OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION. Form 990, Part VI, Section C, line 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. SCHEDULE R- PART II AND PART IV THE FILING ORGANIZATION IS PART OF A GROUP OF ENTITIES WHICH ARE ALL AFFILIATED UNDER THE NAME HACIENDA HEALTHCARE. THIS GROUP OF ENTITIES ALSO INCLUDES LOS NINOS HOSPITAL, INC. (LNH)(A TAX EXEMPT ENTITY); HACIENDA, INC. (HACIENDA) (A TAX EXEMPT ENTITY); CHILDREN'S ANGEL FOUNDATION (A TAX EXEMPT ENTITY); AND SOUTH MOUNTAIN HEALTH SUPPLY, INC. (SMHS)(A TAXABLE ENTITY). SOUTH MOUNTAIN HEALTH SUPPLY is WHOLLY OWNED BY HACIENDA HEALTHCARE AND FILEs AS a SEPARATE TAXABLE ENTITY. HACIENDA EMPLOYS THE FOUR EMPLOYEES WHO SERVE AS THE TOP MANAGEMENT OFFICIALS OF ALL OF THESE ENTITIES. THE FILING ORGANIZATION, LNH, SMHS, AND CAF ALL PAY MANAGEMENT FEES TO HACIENDA FOR AN ALLOCATED PORTION OF THESE SERVICES AS WELL AS FOR OTHER SHARED SERVICES. THE SALARIES LISTED FOR THESE INDIVIDUALS ON PART 7 REPRESENT 100% OF THEIR SALARIES PER THEIR FORMS W-2. LOS NINOS HOSPITAL 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85040 860892673 CHILDREN'S HOSPITAL AZ 3 9 HACIENDA INC 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85040 860253158 HANDICAPPED SERVICES AZ 3 9 HACIENDA HEALTHCARE INC 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 272988610 BRAND NAME FOR RELATED ORGANIZATIONS AZ 3 7 SOUTH MOUNTAIN HEALTH SUPPLY 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 860858893 MEDICAL SUPPLY COMPANY AZ HACIENDA HEALTHCARE INC C INNOVATIVE HOME HEALTH INC 1402 E SOUTH MOUNTAIN AVE pHOENIX AZ 85042 262398755 HOME HEALTH NURSING SERVICES AZ HACIENDA HEALTHCARE INC C 0 0 1 1 1 0 0 0 1 0 0 1 1 1 0 0 0 0