2011-07-14T11:23:51-05:00 2010-08-31 DELOITTE TAX LLP 350 SOUTH GRAND AVENUE SUITE 200 LOS ANGELES CA 900713462 990 2009-09-01 951656366 GOOD SAMARITAN HOSPITAL GOOD 2139772010 616 SOUTH WITMER STREET LOS ANGELES CA 900171912 ALAN M INO 2139772010 2011-07-13 1 2136880800 2009 2016-02-24 21:20:13Z Andrew B Leeka 616 SOUTH WITMER STREET LOS ANGELES CA 900171912 368930220 0 X WWW.GOODSAM.ORG X 1885 CA Provide accessible, quality cost-effective, healthcare services at 408-bed hospital in LA. 32 31 1793 27 401724 25385 7362132 5705168 268828715 280801581 14003355 9024949 1105914 1672043 291300116 297203741 1968062 1830644 0 127752127 132452606 0 1558404 152206509 156836266 281926698 291119516 9373418 6084225 369344508 388901723 168714523 166869460 200629985 222032263 To provide accessible, quality, cost-effective community healthcare. The hospital operates a 408-bed facility in inner-city Los Angeles. 0 0 255525651 1830644 280801581 The Hospital is primarily engaged in providing inpatient and outpatient medical care for the general community regardless of ability to pay. Fiscal year August 31, 2010 patient days totaled 80,771 and outpatient visits totaled 92,960.The Hospital has a policy to treat emergency and certain other patients regardless of their ability to pay. Consistent with the Hospital's tax-exempt status and community service responsibilities, the Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than its established rates. Under the Hospital's policy, charity care may be provided to people who are uninsured or under-insured and can not afford to pay for their own medical care. Because the Hospital does not pursue collection or amounts determined to qualify as charity care, these are not included in net patient revenues. In some instances, charity care cases are identified subsequent to the occurrence of collection activities and may be classified as bad debts.Therefore, the Hospital is unable to determine actual total charity activity. Charitable care not included in net patient revenue was approximately $13,904,119 for fiscal year 2010.The Hospital also provides services to patients under Medi-Cal and other publicly sponsored programs which reimburse the Hospital at amounts less than the cost of the services provided to patients. In addition, health screenings and other benefits were provided for its community. The unreimbursed cost of these benefits and services were approximately $20,053,633 for fiscal year 2010. 255525651 1 1 0 1 0 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 458 0 1793 1 1 1 0 0 0 0 1 1 0 0 0 32 31 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 CA X Cris E de Leon 2139772010 637 S Lucas Ave 3rd Floor Los Angeles CA 90017 Andrew Leeka 55.00 X X 488476 0 11530 Sushma Adarkar MD 1.00 X 0 0 0 George A Bender 1.00 X 0 0 0 Bruce Bennett 1.00 X 0 0 0 George H Benter 1.00 X 0 0 0 William M Bitting 1.00 X 0 0 0 Mrs Jack L Blumenthal 1.00 X 0 0 0 Mrs William H Borthwick 1.00 X 0 0 0 Rt Rev Joseph Jon Bruno 1.00 X 0 0 0 Mrs Richard W Call 1.00 X 0 0 0 Arthur L Crowe Jr 1.00 X 0 0 0 Mrs Victoria Seaver Dean 1.00 X 0 0 0 Robert E Denham 1.00 X 0 0 0 Eben Feinstein 1.00 X 0 0 0 John B Frank 1.00 X 0 0 0 James H Gipson 1.00 X 0 0 0 Ms Mimi Grant 1.00 X 0 0 0 Robert K Maloney 1.00 X 0 0 0 Mrs Angus M McLeod 1.00 X 0 0 0 Charles P Meister 1.00 X 0 0 0 Glen H Mitchel 1.00 X 0 0 0 Peter W Mullin 1.00 X 0 0 0 Charles T Munger 1.00 X 0 0 0 Todd G Owens 1.00 X 0 0 0 Clark Willard Porter 1.00 X 0 0 0 Mrs Helen Lho Ryu 1.00 X 0 0 0 Thomas L Shook 1.00 X 0 0 0 Stephen L Smith 1.00 X 0 0 0 Norman F Sprague 1.00 X 0 0 0 Joseph P Van Der Meulen 1.00 X 0 0 0 Warren B Williamson 1.00 X 0 0 0 Edward A Wopschall 1.00 X 0 0 0 Alan M Ino 55.00 X 370949 0 9866 Susan Harlow 40.00 X 241271 0 7593 Lexie Schuster 40.00 X 238702 0 7310 Sammy Feuerlicht 40.00 X 233710 0 9569 Cynthia Eggert 40.00 X 228302 0 8162 Dan McLaughlin 40.00 X 217484 0 9116 Patricia Reeves 40.00 X 225048 0 8485 Ching Chen 40.00 X 241638 0 9635 Ira Meiselman 40.00 X 212845 0 10952 Hilarion Castillo 40.00 X 205857 0 8774 Helen Yun Sun Paek 40.00 X 180361 0 7817 Steve Garcia 40.00 X 171882 0 10529 3256525 0 119338 252 0 1 0 Crothall Healthcare Inc 955 Chesterbrook Blvd Wayne PA 19087 Environmental/Laundry & Linen Services 4409336 Sodexho Marriott Services 711 Kimberly Avenue Suite 250 Placentia CA 92870 Dietary Services 2812733 Universal Hospital Services Inc PO Box 86 Minneapolis MN 55486 Equipment Rental 1566201 AMN Healthcare 100 W Cypress Creek Rd Suite 750 FtLauderdale FL 33309 Nursing Registry 1433741 RISARC Healthcare Consultants 303 N Glenoaks Blvd Ste 660 Burbank CA 91502 MediCal Eligibility Consultants 1272618 44 98625 751390 4855153 5705168 Net Patient Revenue 900099 279731729 279731729 Rental Income 532000 700331 700331 Child Care Center 624410 358314 358314 Symposium Revenue 900099 11207 11207 280801581 2516930 2516930 78163491 71655472 6508019 6508019 6508019 37555 98625 71007 -33452 -33452 Parking Lot 812930 533816 34399 499417 Physician Mgmt Service 621110 267861 267861 Non-Patient Lab 900099 99464 99464 804354 804354 1705495 297203741 280801581 401724 10295268 1830644 1830644 2315573 2315573 92485141 84241638 7582315 661188 5461975 4883157 578818 23962999 18558132 5329957 74910 8226918 7436407 739322 51189 1016680 716 1015964 384023 34023 350000 82688 82688 29134809 24867930 4182955 83924 568809 110703 457606 500 2102592 69385 2033207 454320 454320 117724 59458 51538 6728 4953253 4953253 9549235 6812894 2736341 3459760 2775224 684536 Supplies 54327520 53980496 325602 21422 Bad Debts 29743292 29743292 0 0 Repairs & Maintenance 5249623 4854554 394795 274 Utilities 3126926 3006097 120829 0 Other direct expenses 2304657 1794066 0 510591 10260355 5059262 5053415 147678 291119516 255525651 34035461 1558404 6228785 5990871 7042273 6301901 10401668 13415384 37679870 37448400 15011006 14539197 1302037 1412209 14983303 14711289 354445401 264403164 90076507 90042237 183644396 202818058 2974663 2222177 369344508 388901723 46491652 43712620 68849364 65001657 53373507 58155183 168714523 166869460 X 108903398 127198187 34410436 37500428 57316151 57333648 200629985 222032263 369344508 388901723 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 82688 82688 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: Lobbying represents a portion of the dues Good Samaritan Hospital pays to the Hospital Association of Southern California. 57316151 17497 57333648 57313907 2244 57316151 1.00000 1 0 11395670 11395670 128197957 91469824 36728133 205202940 170083499 35119441 9648834 2849841 6798993 90042237 Reserve For Self-Insured Programs 6630035 Pension Plan 23203990 Advances From Third Party Payors 20998058 Reserve For Asset Retirement Obligation 6840934 Intercompany Payable 482166 58155183 Part V, Line 4: Description of Intended Use of Endowment Funds: For specific purposes listed by the donors. Part X: Description of Uncertain Tax Positions Under FIN 48: THE HOSPITAL, SIC, AND MOB ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND ARE EXEMPT FROM FEDERAL INCOME TAXES PURSUANT TO SECTION 501(A) OF THE CODE. THEY ARE EXEMPT FROM STATE FRANCHISE TAXES UNDER SIMILAR STATUTES. ACCORDINGLY, NO PROVISION FOR INCOME TAXES HAS BEEN RECORDED IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. DURING THE YEARS ENDED AUGUST 31, 2010 AND 2009, THE HOSPITAL DID NOT RECORD ANY LIABILITY FOR UNRECOGNIZED TAX CONTINGENCIES. Golf Classic 136180 98625 37555 47258 23749 136180 98625 37555 47258 23749 71007 -33452 1 1 1 X 350.000000000000 0 1 1 1 0 1 0 3629725 3629725 0.01250 19043 48001828 31199903 16801925 0.05770 19043 51631553 31199903 20431650 0.07020 132573 132573 0.00050 1830567 566672 1263895 0.00430 1963140 566672 1396468 0.00480 19043 53594693 31766575 21828118 0.07500 5936071 101147575 93121440 8026135 X 1 1 Good Samaritan Hospital

616 South Witmer Street Los Angeles CA 90017

X X X X X Hospital researches by institutes Part I, Line 3c: Discounted care is provided to patients that are uninsured and do not meet the charity care eligibility criteria. Part I, Line 7: a) Charity care cost: applied cost-to-charge ratio (total patient cost to total charges from FY 2009 Medi-Cal cost report = 21.02%) to charity write offs.7 b) Unreimbursed Medi-Cal: cost from cost accounting system that calculated cost of care for all Medi-Cal patients net of payments received and estimated.7 h) Research: cost from Research general ledger accounts less funding received. Part III, Line 8: Filed Medicare cost report. Part III, Line 9b: Account balances for patients that qualify for charity care are written off. Part VI, Line 2: Based on a community needs assessment conducted every three years in collaboration with neighboring hospitals and health care organizations, Good Samaritan Hospital develops a yearly community benefit plan that is submitted to the State. The plan includes proposed activities designed around disease prevention efforts and improvement of health status along a progress report on goals from the previous year. Seven major content areas were identified in previous needs assessments that is included in the community benefit plan: Access, Health Behaviors, Risk Behaviors, Chronic Disease, Communicable Diseases, Mental Health and Community and Social Issues. Part VI, Line 3: Signage describing the hospital's charity programs is posted at all points of registration in three languages. Also, all uninsured patients are sent a letter with their first bill informing them of the hospital's available charity care programs and personnel to contact for information and application. Part VI, Line 4: Good Samaritan Hospital's primary service area is defined by sixteen zip codes within a five mile radius. The zip codes in this area contain a population of one-half million residents, as described in the Year 2000 U.S. Census Report. The zip codes are as follows: 90004, 90005, 90006, 90007, 90010, 90012, 90013, 90014, 90015, 90017, 90018, 90020, 90021, 90026, 90057, 90071. Based on the last community needs assessment (2007), Latinos accounted for a majority of the population in the GSH service area (58.7%) and four out of five of its health districts (Central, Hollywood, Northeast and Southeast). The second largest ethnic group in the GSH service area is Asian/Pacific Islanders (19.6%). Part VI, Line 5: Good Samaritan Hospital provides community building activities to promote health, wellness and safety: health fairs, health lectures, hosting cancer support groups, community police advisory board meetings to discuss neighborhood safety, annual Blessing of the Bicycles to promote bike and road safety as well as the benefits of cycling. Part VI, Line 6: Good Samaritan Hospital maintains an active presence in the community through the volunteer and advocacy efforts of its physicians, employees and Board of Trustees. The hospital provides support to community clinics by providing services such as transportation for patients to the hospital. The hospital also hosts conferences open to the public at no cost on topics related to various health issues prevalent in the community. Good Samaritan Hospital publishes Good Health, a community newsletter that goes out to 16,000 households to increase awareness and understanding of medical advances related to cardiovascular care, orthopedic services, transfusion-free medicine and surgery, urology, oncology and womens and newborn services. CA 1 Heart Institute of the Good Samaritan Hospital 616 South Witmer Street Los Angeles CA 90017 954077161 501(c)(3) 1514185 Expenses Paid by the Hospital Orthopedic Institute of the Good Samaritan Hospital 616 South Witmer Street Los Angeles CA 90017 954346048 501(c)(3) 316459 Expenses Paid by the Hospital 2 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The Institute (Heart and Ortho) do not have their own checking accounts, so all of their expenses (including salaries, wages and benefits) are paid for by the hospital and are all recorded in each of the Institutes' accounts in the General Ledger, thru intercompany due to and from accounts on both sides (Institutes' and Hospital's). X X X X 0 0 0 0 0 0 0 0 0 Andrew Leeka 428820 0 0 0 59656 0 7350 0 4180 0 500006 0 0 0 Alan M Ino 348949 0 0 0 22000 0 7350 0 2516 0 380815 0 0 0 Susan Harlow 224771 0 0 0 16500 0 7248 0 345 0 248864 0 0 0 Lexie Schuster 224371 0 0 0 14331 0 7165 0 145 0 246012 0 0 0 Sammy Feuerlicht 217210 0 0 0 16500 0 7086 0 2483 0 243279 0 0 0 Cynthia Eggert 206302 0 0 0 22000 0 6887 0 1275 0 236464 0 0 0 Dan McLaughlin 204284 0 0 0 13200 0 6600 0 2516 0 226600 0 0 0 Patricia Reeves 203048 0 0 0 22000 0 6802 0 1683 0 233533 0 0 0 Ching Chen 222121 0 0 0 19517 0 7319 0 2316 0 251273 0 0 0 Ira Meiselman 171237 0 20000 0 21608 0 5936 0 5016 0 223797 0 0 0 Hilarion Castillo 184807 0 0 0 21050 0 6251 0 2523 0 214631 0 0 0 Helen Yun Sun Paek 163861 0 0 0 16500 0 5481 0 2336 0 188178 0 0 0 Steve Garcia 161256 0 0 0 10626 0 5313 0 5216 0 182411 0 0 0 Form 990, Part VI, Section A, line 1 The Executive Committee consists only of no less than five and no more than eleven members of the Board of Directors. Three of the members will be the Chairman of the Board, the President of the organization and the Chairman of the Medical Staff. The others will be appointed, after considering nominations by the Chairman. Between meetings of the Board of Directors, the Executive Committee will have and exercise all the authority of the Board in the management of the organization. At meetings of the board of Directors, the Executive Committee will report on actions taken between the meetings, and will propose actions to the Board of Directors. The Executive Committee will meet on the call of the Chairman of the Board or the President. Four members of the Committee shall constitute a quorum. Form 990, Part VI, Section A, line 2 Mrs. Borthwick, a board member of Good Samaritan Hospital has a family relationship with Mr. Charles Munger, chairman of the board. Clark Willard Porter has a family relationship with Glen H. Mitchel, Jr. who are board members. Form 990, Part VI, Section B, line 11 The organization works with an independent accountant, Deloitte Tax LLP, to prepare the Form 990. Once the return is prepared, the return is reviewed by the Chief Financial Officer and the Controller. The draft of the Form 990 is presented to the Audit Committee. Subsequent to review by the Audit Committee, the CFO and the Controller will provide any final comments to Deloitte Tax LLP. Deloitte Tax LLP makes all changes necessary and a final Form 990 is made available to all board members. Form 990, Part VI, Section B, line 12c All board members and officers are required to complete a conflict of interest disclosure statement each year. The policy requires each governing body member to disclose any conflict on a particular matter that may arise, and recuse him or herself from deliberations and votes on such matters. The policies are monitored by the Director of Risk Management of the Good Samaritan Hospital and are enforced by the Audit Committee Chairperson. Form 990, Part VI, Section B, line 15a A subcommittee of the governing board's executive committee is responsible for determining the Chief Executive Officer's compensation. This subcommittee is given comparison data on CEO salaries and benefits from comparable hospitals in the local area, prepared by human resources from 990s; and salary surveys completed by the local hospital association. The decision of the subcommittee on the CEO's salary is documented by the subcommittee in writing. The compensation of the organization's vice presidents are reviewed and approved by the organization's CEO. Their salaries and benefits are determined using comparable hospitals in the local area, prepared by human resources from 990s; and salary surveys completed by the local hospital association. Form 990, Part VI, Section C, line 19 Good Samaritan Hospital's organizing and governing documents and the conflict of interest policy are not made available to the public. The financial information from the financial statements is included in the organizations Form 990, which is available for public inspection upon request. The organiztion's financial statements were audited by an independent accountant and are included in the consolidated audited financial statements for Good Samaritan Hospital and affiliates. Good Samaraitan Hospital's audit committee assumes responsibility for the oversight of the audit and its financial statements and the selection of an independent accountant. Form 990, Part VII: Compensation reported on Form 990, Part VII was paid to each of these individuals in exchange for the fulfillment of their duties as full-time, 40+ hour-per-week employees at Good Samaritan Hospital and 2 hours-per-week employees at related organizations. Heart Institute of the Good Samaritan Hospital 616 South Witmer Street Los Angeles CA 90017 954077161 Heart Research CA section 501(c)(3) 4 N/A Orthopedic Institute of the Good Samaritan Hospital 616 South Witmer Street Los Angeles CA 90017 954346048 Orthopedic Research CA section 501(c)(3) 11, Type 1 N/A Samaritan Imaging Center 1245 Wilshire Blvd Los Angeles CA 90017 954252321 Outpatient Imaging Services CA section 501(c)(3) 9 N/A Cancer Institute of the Good Samaritan Hospital 616 South Witmer Street Los Angeles CA 90017 954271815 Cancer Research CA section 501(c)(3) 4 N/A Institute for Reproductive Research of the Hospital of the Good Samaritan 616 South Witmer Street Los Angeles CA 90017 954252306 Reproductive Research CA section 501(c)(3) 11, Type 1 N/A Good Samaritan Hospital Medical Office Building Inc 1245 Wilshire Blvd Los Angeles CA 90017 953244046 Physicians Medical Offices CA section 501(c)(3) 11, Type 1 N/A Auxiliary of the Hospital of the Good Samaritan 616 South Witmer Street Los Angeles CA 90017 956051253 Welfare of the Good Samaritan Hospital CA section 501(c)(3) 11, Type 3 N/A Kate Van Nuys Page Foundation 616 South Witmer Street Los Angeles CA 90017 956028032 Grants income to Good Samaritan Hospital CA section 501(c)(3) 11, Type 1 N/A 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 Good Samaritan Hospital Medical Office Building Inc A 627194 Good Samaritan Hospital Medical Office Building Inc J 228465 Heart Institute of the Good Samaritan Hospital B 1514185 Heart Institute of the Good Samaritan Hospital C 647244 Orthopedic Institute of the Good Samaritan Hospital B 316459 Orthopedic Institute of the Good Samaritan Hospital C 64111 Samaritan Imaging Center A 135053 Kate Van Nuys Page Foundation C 171475