2011-02-18T14:01:22-06:00 2010-09-30 DIXON HUGHES PLLC 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2009-10-01 561089384 CAROLINA ADVENTIST RETIREMENT SYSTEMS INC CARO 7046679851 95 HOLCOMBE COVE RD CANDLER NC 287159450 DEBORAH HAWKINS 7046679851 2011-02-18 1 Amy Bibby 8282542254 2009 2016-02-24 21:20:13Z DAVID KIDDER 95 HOLCOMBE COVE RD CANDLER NC 287159450 22732830 0 X WWW.PISGAHVALLEY.ORG X 1975 NC SERVING HEALTHCARE AND RESIDENTIAL NEEDS WHILE UPHOLDING CHRISTIAN PRINCIPLES. 24 12 624 10 91270 -8784 275538 619724 21031523 21709744 41444 46968 388225 355860 21736730 22732296 50990 76635 0 12490811 12061953 0 0 8206364 8827971 20748165 20966559 988565 1765737 21465648 23101642 10330003 10200260 11135645 12901382 AS A FAITH-BASED SEVENTH-DAY ADVENTIST ORGANIZATION, WE ARE DEDICATED TO SERVING THE HEALTHCARE AND RESIDENTIAL NEEDS OF OUR COMMUNITY WHILE UPHOLDING CHRISTIAN PRINCIPLES. 0 0 8483078 37965 10611944 PISGAH VALLEY RETIREMENT COMMUNITY OWNS AND OPERATES A LICENSED CONTINUING CARE RETIREMENT COMMUNITY WITH 13 INDEPENDENT LIVING DUPLEX CONDOMINIUM UNITS, A 24-UNIT MULTI-UNIT ASSISTED HOUSING WITH SERVICES FACILITY, AND A 118-BED SKILLED NURSING FACILITY IN CANDLER, NORTH CAROLINA. PROGRAM SERVICE ACCOMPLISHMENTS INCLUDE THE PROVIDING OF ROOM AND BOARD (SHELTER, UTILITIES, MEALS, HOUSEKEEPING, LAUNDRY, AND MAINTENANCE), TRANSPORTATION, WELLNESS CENTER/ACTIVITIES, ASSISTANCE WITH ACTIVITIES OF DAILY LIVING, AND MEDICAL SERVICES TO OUR COMMUNITY (PRIMARILY AGE 55 AND OLDER). 9391514 38670 11097800 WINSLOW OPERATES A RETIREMENT COMMUNITY WITH 24 INDEPENDENT LIVING STUDIO APARTMENT UNITS AND A 146-BED SKILLED NURSING FACILITY IN ELIZABETH CITY, NORTH CAROLINA. PROGRAM SERVICE ACCOMPLISHMENTS INCLUDE THE PROVIDING OF ROOM AND BOARD (SHELTER, UTILITIES, MEALS, HOUSEKEEPING, LAUNDRY, AND MAINTENANCE), TRANSPORTATION, ACTIVITIES, ASSISTANCE WITH ACTIVITIES OF DAILY LIVING, AND MEDICAL SERVICES TO OUR COMMUNITY (PRIMARILY AGE 55 AND OLDER). 17874592 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0 1 41 0 624 1 1 1 0 0 0 0 0 0 0 0 24 12 0 0 1 0 0 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X X DEBORAH HAWKINS 8284182334 95 HOLCOMBE COVE ROAD CANDLER NC 28715 RICHARD ANDERSON 1.00 X 1200 0 0 HOWARD ANDRUS 1.00 X 0 0 0 SAMUEL BONHAM 1.00 X 0 450 0 ERNEST BOUGHMAN JR 1.00 X 0 375 0 WILLIAM BRYAN 1.00 X 400 0 0 JIMM BUNCH 1.00 X 0 0 0 DEWAYNE BUTCHER MD 1.00 X 0 225 0 LOUIS CANOSA 1.00 X 1600 20388 1507 JOHN COELHO 1.00 X 400 62952 14065 KEN COONLEY 1.00 X 400 19720 203 JIM DAVIDSON 1.00 X 1600 74652 14501 DONOVAN DAVIS 1.00 X 0 60551 13478 FAITH DURKIN 1.00 X 0 375 0 JOHN EARNHARDT 1.00 X 0 64991 13680 CHARLES FERGUSON 1.00 X 0 67205 13957 J KENNETH FORD 1.00 X 0 85849 12834 SAMUEL GARCIA 1.00 X 0 300 0 MAURY GILMORE 1.00 X 0 375 0 CHAD GRUNDY 1.00 X 1600 64526 13794 CRYSTAL HALL 1.00 X 0 75 0 WILMA HARRIS 1.00 X 0 0 0 WANDA HINDMAN 1.00 X 0 450 0 RALPH HOLLENBECK 1.00 X 0 61803 13886 LARRY KROLL MD 1.00 X 0 150 0 MINERVINO LABRADOR JR 1.00 X 0 86415 13794 LISA LEATHERWOOD 1.00 X 400 0 0 GARY MOYER 1.00 X X 1200 72130 13869 MARK RUMSEY 1.00 X 0 0 0 RICHARD RUSSELL 1.00 X 1600 75402 13869 ANDRES SEQUERA 1.00 X 0 51733 3162 PAUL THARP 1.00 X 1600 0 0 GEORGE THOMAS 1.00 X 0 0 0 GARY TOLBERT 1.00 X 0 70793 14233 DAN TULLOCK 1.00 X 1200 0 0 ALBERT WILLIAMS 1.00 X 400 0 0 NEWTON ZANES 1.00 X 400 0 0 DEBORAH HAWKINS 40.00 X 113932 0 14041 DAVID KIDDER 40.00 X 137479 225 18686 265411 942110 203559 2 0 1 0 KINDRED REHAB SERVICES INC (DBA PEOPLEF 705 JUNIPER STREET NE ALTANTA GA 30308 PHYSICAL, SPEECH AND OCCUPATIONAL THERAP 827697 SYNERTX 7540 NORTH 19TH AVENUE PHOENIX AZ 85021 PHYSICAL, SPEECH AND OCCUPATIONAL THERAP 705964 DIXON HUGHES PLLC 500 RIDGEFIELD COURT ASHEVILLE NC 28806 AUDIT, TAX, DATA PROCESSING, CONSULTING 198772 3 464500 155224 433000 619724 MEDICARE/MEDICAID PAYM 623000 16618040 16618040 SKILLED NURSING, ASSIS 623000 4987790 4987790 AMORTIZATION OF ENTRAN 623000 103914 103914 21709744 45888 45888 30238 30238 30238 30238 1614 534 1080 1080 1080 MANAGEMENT FEES FROM H 531390 150300 150300 WELLNESS CENTER REVENU 713940 107181 15911 91270 MISCELLANEOUS INCOME 623000 68141 68141 325622 22732296 21725655 91270 295647 76635 76635 298764 298764 57075 57075 9585934 8845072 740862 1371792 1174414 197378 748388 653856 94532 30783 30783 100224 100224 2185026 2165950 19076 33283 33283 2780989 2543638 237351 139728 139728 1420228 1248403 171825 70511 51514 18997 54263 39089 15174 4201 4201 1068028 1060106 7922 117564 11714 105850 BAD DEBT 511667 511667 PROVIDER TAX 252270 252270 MISCELLANEOUS 59206 59206 20966559 17874592 3091967 0 900 900 4385219 5439870 89729 235000 1951632 2065225 92281 91400 223199 207094 19820260 4921499 14568244 14898761 154444 163392 21465648 23101642 1740409 1477089 1957176 2573241 6584926 6146115 47492 3815 10330003 10200260 X 11135645 12901382 11135645 12901382 21465648 23101642 X 0 1 1 X 0 X 46582 2170584 1638448 275538 619724 4750876 8888251 16463098 18804594 21068695 21709744 86934382 208296 270525 253795 236752 969368 8934833 18841978 20713567 21598028 22566220 92654626 0 0 0 92654626 23398 70683 80286 59082 74806 308255 23398 70683 80286 59082 74806 308255 8958231 18912661 20793853 21657110 22641026 92962881 0.99670 0.99680 0.00330 0.00320 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 640000 640000 6092416 965999 5126417 8414424 1342273 7072151 4037341 2258072 1779269 636079 355155 280924 14898761 ESTIMATED 3RD PARTY SETTLEMENTS 2337 DUE TO RELATED PARTIES 1478 3815 22732296 20966559 1765737 0 1765737 22709796 0 22709796 22500 22500 22732296 20944059 -22500 -22500 20966559 0 20966559 Part XII, Line 4b - Other Adjustments: MANAGEMENT FEES INCLUDED IN EXPENSES: 22500. Part XIII, Line 2d - Other Adjustments: MANAGEMENT FEES INCLUDED IN EXPENSES: -22500. 1 PISGAH ESTATES UNIT OWNERS ASSOCIATION 95 HOLCOMBE COVE ROAD CANDLER NC 28715 561769989 528 24000 FMV TO ASSIST WITH ROOF REPAIR MOUNT PISGAH ACADEMY 75 ACADEMY DRIVE CANDLER NC 28715 560713794 501(c)(3) 6545 FMV TO ASSIST WITH STUDENT SCHOLARSHIPS CAROLINA CONFERENCE ASSOCIAION OF SEVENTH-DAY ADVENTISTS 2701 WT HARRIS BLVD CHARLOTTE NC 28256 560773159 501(C)(3) 38670 FMV TO ASSIST WITH LOCAL PASTOR SALARY 2 1 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: ALTHOUGH THE ORGANIZATION DOES NOT HAVE A FORMAL WRITTEN MONITORING SYSTEM, THE ORGANIZATION CONTROLS ONE OF THE RECIPIENT ENTITIES (AS A RELATED ORGANIZATION) AND THE PRESIDENT IS ON THE BOARD OF THE OTHER TWO ORGANIZATIONS. THROUGH THESE CONTROL FACTORS, THERE IS AN INFORMAL MONITORING OF THE USE OF GRANT FUNDS. X X X 0 0 0 0 0 0 0 0 0 DAVID KIDDER 122813 0 800 0 13866 225 0 0 18686 0 156165 225 0 0 ELLA KIDDER FAMILY RELATIONSHIP WITH DAVID KIDDER, CEO 57075 ELLA KIDDER IS AN EMPLOYEE OF THE ORGANIZATION 0 X LAND 1 433000 FMV 0 0 0 Form 990, Part VI, Section A, line 4 THE ORGANIZATION'S BYLAWS WERE AMENDED TO CHANGE BOARD STRUCTURE. THE BOARD OF DIRECTORS IS NO LONGER A SELF-PERPETUATING BOARD. IT IS NOW CONTROLLED BY CAROLINA CONFERENCE OF SEVENTH-DAY ADVENTISTS, THE ORGANIZATION'S PARENT COMPANY. Form 990, Part VI, Section A, line 7a THE CAROLINA CONFERENCE OF SEVENTH-DAY ADVENTISTS, A RELATED ORGANIZATION, ESTABLISHES AN EXECUTIVE COMMITTEE THAT SERVES AS THE ORGANIZATION'S BOARD OF DIRECTORS. Form 990, Part VI, Section A, line 7b DECISIONS MADE BY THE ORGANIZATION ARE SUBJECT TO THE APPROVAL OF THE CAROLINA CONFERENCE OF SEVENTH-DAY ADVENTISTS. Form 990, Part VI, Section B, line 11 A DRAFT OF THE FORM 990 WAS REVIEWED BY THE PREPARER WITH THE EXECUTIVE BOARD OF THE BOARD DIRECTORS, CEO, AND CFO PRIOR TO ITS FILING DATE. IT WAS THEN FINALIZED BY THE PREPARER AND PROVIDED TO EACH BOARD OF DIRECTORS MEMBER PRIOR TO ITS FILING. Form 990, Part VI, Section B, line 12c AT THE BOARD OF DIRECTORS ANNUAL MEETING, THE PRESIDENT AND CEO OF CAROLINA ADVENTIST RETIREMENT SYSTEMS, INC. PRESENTS A "STATEMENT OF ACCEPTANCE" OF THE POLICY ON CONFLICT OF INTEREST TO EACH OFFICER, DIRECTOR (I.E., BOARD MEMBER), AND KEY EMPLOYEE (I.E., ADMINISTRATORS). EACH OF THESE INDIVIDUALS ARE ASKED TO REVIEW AND SIGN THE STATEMENT WHICH INCLUDES A REPRESENTATION THAT THEY DO NOT HAVE A CONFLICT OF INTEREST. ADDITIONALLY, EACH OFFICER, DIRECTOR, AND KEY EMPLOYEE RECEIVE AN ORIENTATION AND ANNUAL TRAINING RELATED TO THE ORGANIZATION'S CORPORATE COMPLIANCE POLICY, INCLUDING ITS CORE VALUE OF CARING, DEDICATION, INTEGRITY, PROFESSIONALISM, QUALITY, RESPECT, AND SAFETY. Form 990, Part VI, Section B, line 15 ANNUALLY MANAGEMENT PREPARES A SCHEDULE SHOWING THE PRIOR YEAR SALARIES PAID AND THE CURRENT YEAR BUDGETED SALARIES FOR THE CEO, OTHER OFFICERS, AND KEY EMPLOYEES. THE SCHEDULE COMPARES THE BUDGETED SALARY TO THE MOST CURRENT NORTH CAROLINA ASSOCIATION OF NOT-FOR-PROFIT HOMES FOR THE AGED WAGE & BENEFIT SURVEY AND SALARIES OF TWO LOCAL NOT-FOR-PROFIT CCRC'S AS OBTAINED FROM THEIR ORGANIZATION'S FORM 990 AS AVAILABLE ON GUIDESTAR. THIS SCHEDULE IS REVIEWED AND APPROVED BY THE EXECUTIVE BOARD OF THE BOARD OF DIRECTORS. THE EXECUTIVE BOARD THEN PRESENTS THIS INFORMATION AS PART OF THE BUDGET TO THE FULL BOARD OF DIRECTORS AT THEIR ANNUAL MEETING. Form 990, Part VI, Section C, line 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, FINANCIAL STATEMENTS, AND CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 2C: THE EXECUTIVE BOARD, A SUBCOMMITTEE OF THE BOARD OF DIRECTORS, IS RESPONSIBLE FOR THE OVERSIGHT OF THE AUDIT. CAROLINA CONFERENCE ASSOCIATION OF SEVENTH-DAY ADVENTISTS INC PO BOX 44270 CHARLOTTE NC 28215 560773159 SPIRITUAL DEVELOPMENT NC 501(C)(3) 1 N/A PISGAH ESTATES UNIT OWNERS ASSOCIATION 95 HOLCOMBE COVE ROAD CANDLER NC 28715 561769989 HOME OWNERS ASSOCIATION NC N/A C 0.70000 0 1 1 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 PISGAH ESTATES UNIT OWNERS ASSOCIATION K 150300