Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2011
Open to Public Inspection
A For the calendar year, or tax year beginning 01-01-2011 and ending 12-31-2011
BCheck if applicable:
CName of organization
POMONA VALLEY HOSPITAL MEDICAL CENTER
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
1798 NORTH GAREY AVENUE
 
Room/suite
City or town, state or country, and ZIP + 4
POMONA, CA91767
D Employer identification number

95-1115230
E Telephone number

G Gross receipts $ 437,813,844
F Name and address of principal officer:
RICHARD YOCHUM
1798 NORTH GAREY AVENUE
POMONA,CA91767
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.pvhmc.org
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1903
M State of legal domicile: CA
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: POMONA VALLEY HOSPITAL MEDICAL CENTER IS A NOT FOR PROFIT, REGIONAL MEDICAL CENTER DEDICATED TO PROVIDING HIGH QUALITY, COST EFFECTIVE HEALTH CARE SERVICES TO RESIDENTS OF THE GREATER POMONA VALLEY.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a)..... 3 23
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 18
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ... 5 3,191
6 Total number of volunteers (estimate if necessary) .... 6 941
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 305,467
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b 216,132
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 728,397 1,214,089
9 Program service revenue (Part VIII, line 2g) ......... 482,569,549 415,543,916
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 2,191,842 1,930,107
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 2,597,200 9,167,771
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 488,086,988 427,855,883
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 3,170,390 662,851
14 Benefits paid to or for members (Part IX, column (A), line 4)..... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 251,616,533 246,021,323
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 209,509,304 160,940,479
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 464,296,227 407,624,653
19 Revenue less expenses. Subtract line 18 from line 12....... 23,790,761 20,231,230
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 314,509,551 347,604,573
21 Total liabilities (Part X, line 26)............. 98,937,235 112,087,056
22 Net assets or fund balances. Subtract line 21 from line 20..... 215,572,316 235,517,517
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid preparer use only
Print/type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name Right pointing arrowhead image

Firm's EIN Right pointing arrowhead image
Firm's address Right pointing arrowhead image



Phone no.
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2011)
Form 990 (2011)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III .........
1
Briefly describe the organization’s mission: POMONA VALLEY HOSPITAL MEDICAL CENTER IS A NOT FOR PROFIT, REGIONAL MEDICAL CENTER DEDICATED TO PROVIDING HIGH QUALITY, COST EFFECTIVE HEALTH CARE SERVICES TO RESIDENTS OF THE GREATER POMONA VALLEY. SEE SCHEDULE O FOR MORE INFORMATION
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 369,070,428 including grants of $ 585,792 ) (Revenue $ 424,651,352 )
SEE SCHEDULE O
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet$ 369,070,428
Form 990 (2011)
Form 990 (2011)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? Click to see attachment........
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part IIClick to see attachment.........................
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part IIIClick to see attachment........................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment....................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IVClick to see attachment...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment
10
Yes
 
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.Click to see attachment
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.Click to see attachment
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.Click to see attachment
11d
Yes
 
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
 
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI, XII, and XIII Click to see attachment
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Part I.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II..
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III..
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II..........
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H..... Click to see attachment
20a
Yes
 
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statement to this return? Note. All Form 990 filers that operated one or more hospitals must attach audited financial statements. Click to see list of attachments
20b
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.. Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III..... Click to see attachment
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I...... Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................ Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II......................... Click to see attachment
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III......... Click to see attachment
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ......................... Click to see attachment
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV................... Click to see attachment
28b
Yes
 
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV.. Click to see attachment
28c
Yes
 
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule MClick to see attachment
29
Yes
 
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............ Click to see attachment
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2........... Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V .........
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
299
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
3,191
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2011)
Form 990 (2011)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI .........
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
If the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
1a
23
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
18
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
 
No
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? .................
7a
 
No
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ............
7b
 
No
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ..........
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? ....
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done ....................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes," to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
Yes
 
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
No
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
CA
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
JULI HESTER
1798 NORTH GAREY AVENUE
POMONA,CA91767
(909) 865-9881
Form 990 (2011)
Form 990 (2011)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII .........
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) BAO TRAN MD
DIRECTOR
 2.0 X           14,210 0 0
(2) JOHNSON LIGHTFOOTE MD
DIRECTOR
 2.0 X           0 0 0
(3) A MOHAN MD
DIRECTOR
 2.0 X           114,854 0 0
(4) RICHARD P CREAN
DIRECTOR
 2.0 X           0 0 0
(5) ROSANNE BADER
DIRECTOR
 2.0 X           0 0 0
(6) JAN PAULSON
DIRECTOR
 2.0 X           0 0 0
(7) DARYL OSBY
DIRECTOR
 2.0 X           0 0 0
(8) CURTIS W MORRIS
DIRECTOR
 2.0 X           0 0 0
(9) BERNARD A BERNSTEIN
DIRECTOR
 2.0 X           0 0 0
(10) BILL STEAD
DIRECTOR
 2.0 X           0 0 0
(11) REGINALD WEBB
DIRECTOR
 2.0 X           0 0 0
(12) STEPHEN MORGAN
DIRECTOR
 2.0 X           0 0 0
(13) BILL MCCOLLUM
DIRECTOR
 2.0 X           0 0 0
(14) RICHARD FASS
DIRECTOR
 2.0 X           0 0 0
(15) THOMAS F NUSS
DIRECTOR
 2.0 X           0 0 0
(16) TONY SPANO
DIRECTOR
 2.0 X           0 0 0
(17) KEVIN MCCARTHY
DIRECTOR
 2.0 X           0 0 0
Form 990 (2011)
Form 990 (2011)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) HELLEN RODRIGUEZ MD
DIRECTOR
 2.0 X           0 0 0
(19) MARCIA PAETAU
DIRECTOR
 2.0 X           0 0 0
(20) RICHARD YOCHUM
PRESIDENT/CEO
 36.0 X   X       542,345 0 144,362
(21) ROGER GINSBURG
CHAIRMAN
 2.0 X   X       0 0 0
(22) RONALD T VERA
VICE CHAIRMAN
 2.0 X   X       0 0 0
(23) JANE GOODFELLOW
VICE CHAIRMAN
 2.0 X   X       0 0 0
(24) MICHAEL NELSON
TREASURER/CFO
 38.0     X       387,305 0 152,977
(25) KURT WEINMEISTER
SECRETARY/COO
 40.0     X       362,432 0 31,783
(26) CHRIS ALDWORTH
ASST SEC/VP SATELITE DIVISION
 40.0     X       197,023 0 45,455
(27) JULI HESTER
ASSISTANT TREASURER/VP FINANCE
 38.0     X       203,084 0 33,705
(28) DARLENE SCAFFIDDI
VICE PRESIDENT OF NURSING
 40.0       X     239,386 0 49,277
(29) KENNETH K NAKAMOTO
VP MED STAFF AFF
 40.0         X   284,912 0 44,004
(30) KENT HOYOS
CIO
 40.0         X   263,631 0 43,657
(31) JOSEPH BAUMGARTNER
DIRECTOR PHYSICAL THERAPY
 40.0         X   263,554 0 46,640
(32) RICHARD ROSSMAN
ASST DIRECTOR PHYSICAL THERAPY
 40.0         X   247,899 0 46,814
(33) JAMES MCL DALE
VP DEVELOPMENT
 4.0         X   234,598 0 26,219
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 3,355,233 0 664,893
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet611
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
PREMIER FAMILY MEDICINE ASSO
1770 N Orange Grove
POMONA,CA91767 		MEDICAL SERVICES 5,026,364
HOOPER LUNDY BOOKMAN
1875 Century Park East 1600
LOS ANGELES,CA90067 		LEGAL SERVICES 1,648,007
INLAND VALLEY ANESTHESIOLOGY MED GR
PO Box 148
CLAREMONT,CA91711 		MEDICAL SERVICES 574,666
POMONA VALLEY IMAGING MED GRP
1798 N Garey Avenue
POMONA,CA91767 		MEDICAL SERVICES 555,062
QUEST DIAGNOSTIC
FILE NO 50368
LOS ANGELES,CA900740368 		LAB TESTS 512,361
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet40
Form 990 (2011)
Form 990 (2011)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d 331,872
e Government grants (contributions)1e 736,156
f All other contributions, gifts, grants, and
similar amounts not included above1f 		146,061
g Noncash contributions included in lines 1a-1f:$  
h Total. Add lines 1a-1f.......MediumBullet 1,214,089
Program Service Revenue Business Code
2a PATIENT CARE REVENUE 622,110 414,928,401 414,928,401    
b NON-PATIENT LAB REVENUE 621,511 257,284   257,284  
c PHYSICIAN OFFICE RENTAL 621,111 310,048 310,048    
d S-CORP 531,120 48,183   48,183  
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 415,543,916
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 1,107,222     1,107,222
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties............MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents 244,534  
b Less: rental expenses 184,199  
c Rental income or (loss) 60,335  
d Net rental income or (loss).......MediumBullet 60,335     60,335
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 10,596,647  
b Less: cost or other basis and sales expenses 9,773,762  
c Gain or (loss) 822,885  
d Net gain or (loss)..........MediumBullet 822,885     822,885
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a REBATES REFUNDS 622,110 2,986,394 2,986,394    
b FOOD SALES 722,212 1,164,191 1,164,191    
c HEALTH EDUC TRAINING 923,110 119,895 119,895    
d All other revenue .... 4,836,956 4,836,956    
e Total. Add lines 11a–11d ......MediumBullet 9,107,436
12 Total revenue. See Instructions....MediumBullet 427,855,883 424,345,885 305,467 1,990,442
Form 990 (2011)
Form 990 (2011)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Check if Schedule O contains a response to any question in this Part IX. .........
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 662,851 662,851
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 3,415,220 129,064 3,286,156  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 195,280,045 185,730,639 9,549,406  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 7,959,694 7,561,709 397,985  
9 Other employee benefits ....... 23,327,254 22,100,307 1,226,947  
10 Payroll taxes ........... 16,039,110 15,435,523 603,587  
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 2,511,905 265,394 2,246,511  
c Accounting ........... 304,960   304,960  
d Lobbying ........... 79,091   79,091  
e Professional fundraising. See Part IV, line 17.. 0  
f Investment management fees ...... 0      
g Other .......... 33,775,775 29,082,355 4,693,420  
12 Advertising and promotion .... 680,136 362,170 317,966  
13 Office expenses ....... 13,226,746 11,388,781 1,837,965  
14 Information technology ...... 5,391,407 4,642,227 749,180  
15 Royalties .. 0      
16 Occupancy ........... 8,891,469 7,655,927 1,235,542  
17 Travel ............ 207,416 139,490 67,926  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 413,938 256,927 157,011  
20 Interest ........... 2,630,692 2,312,726 317,966  
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 22,695,932 19,542,147 3,153,785  
23 Insurance .............. 3,731,099 3,212,632 518,467 0
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a MEDICAL SUPPLIES 53,628,975 46,176,791 7,452,184  
b CA HOSP QLTY ASSURANCE FEE 10,270,456 10,270,456    
c ALL OTHER EXPENSES 2,500,482 2,142,312 358,170  
d
e
f All other expenses        
25 Total functional expenses. Add lines 1 through 24f 407,624,653 369,070,428 38,554,225 0
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2011)
Form 990 (2011)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... 303,064 1 610,613
2 Savings and temporary cash investments ....... 46,329,435 2 2,658,737
3 Pledges and grants receivable, net ......... 0 3 0
4 Accounts receivable, net ......... 68,926,372 4 75,412,793
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L .......... 0 5 0
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L .......... 0 6 0
7 Notes and loans receivable, net ............. 608,654 7 283,512
8 Inventories for sale or use .............. 3,069,071 8 3,672,036
9 Prepaid expenses and deferred charges ............ 3,429,696 9 6,352,213
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 483,012,595
b Less: accumulated depreciation. ..... 10b 331,446,913 148,356,443 10c 151,565,682
11 Investments—publicly traded securities .......... 35,914,405 11 90,159,848
12 Investments—other securities. See Part IV, line 11 ...... 0 12 0
13 Investments—program-related. See Part IV, line 11 .. -860,436 13 -1,062,527
14 Intangible assets ......... 0 14 0
15 Other assets. See Part IV, line 11 ........... 8,432,847 15 17,951,666
16 Total assets. Add lines 1 through 15 (must equal line 34)... 314,509,551 16 347,604,573
Liabilities 17 Accounts payable and accrued expenses . 36,873,769 17 44,793,832
18 Grants payable .......... 0 18 0
19 Deferred revenue .......... 0 19 0
20 Tax-exempt bond liabilities .......... 46,720,000 20 42,205,000
21 Escrow or custodial account liability. Complete Part IV of Schedule D.. 0 21 0
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L.......... 0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 2,939,215 23 2,474,153
24 Unsecured notes and loans payable to unrelated third parties .... 0 24 0
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D..... 12,404,251 25 22,614,071
26 Total liabilities. Add lines 17 through 25..... 98,937,235 26 112,087,056
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 214,538,051 27 234,564,608
28 Temporarily restricted net assets ..... 328,243 28 246,881
29 Permanently restricted net assets ..... 706,022 29 706,028
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... 215,572,316 33 235,517,517
34 Total liabilities and net assets/fund balances ..... 314,509,551 34 347,604,573
Form 990 (2011)
Form 990 (2011)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI .........
1
Total revenue (must equal Part VIII, column (A), line 12) ...
1
427,855,883
2
Total expenses (must equal Part IX, column (A), line 25) ....
2
407,624,653
3
Revenue less expenses. Subtract line 2 from line 1 ...
3
20,231,230
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
215,572,316
5
Other changes in net assets or fund balances (explain in Schedule O) ...
5
-286,029
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) ....
6
235,517,517
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII .........
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?....
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O. ...........................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
 
 
Form 990 (2011)
Additional Data


Software ID:  
Software Version:  
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
POMONA VALLEY HOSPITAL MEDICAL CENTER
 
Employer identification number

95-1115230
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization? ................
11g(i)
 
 
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(iv)
Is the organization in col. (i) listed in your governing document? 		(v)
Did you notify the organization in col. (i) of your support? 		(vi)
Is the organization in col. (i) organized in the U.S.? 		(vii)
Amount of support?
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3..            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..            
6 Public Support. Subtract line 5 from line 4.            
Section B. Total Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public Support (Subtract line 7c from line 6.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)            
13 Total support (Add lines 9, 10c, 11 and 12.).            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 4
Part IV
Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2011
Name of organization
POMONA VALLEY HOSPITAL MEDICAL CENTER
 
Employer identification number

95-1115230
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......................... Arrow Bullet   $    
Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2, of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 2
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
POMONA VALLEY HOSPITAL MEDICAL CENTER
  		Employer identification number

95-1115230
Part I
Contributors (see Instructions). Use duplicate copies of Part I if additional space is needed.
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 3
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
POMONA VALLEY HOSPITAL MEDICAL CENTER
  		Employer identification number

95-1115230
Part II
Noncash Property (see Instructions). Use duplicate copies of Part II if additional space is needed.
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 4
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
POMONA VALLEY HOSPITAL MEDICAL CENTER
  		Employer identification number

95-1115230
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet $  
Use duplicate copies of Part III if additional space is needed
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Additional Data


Software ID:  
Software Version:  
SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.
SchCMd Bullet Attach to Form 990 or Form 990-EZ. SchCMd Bullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, line 35c (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
POMONA VALLEY HOSPITAL MEDICAL CENTER
 
Employer identification number

95-1115230
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 .........SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 ......SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............
4a
Was a correction made? .........................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c) except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ...................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b..SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from filing organization's funds. If none, enter -0-. (e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.










For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2011

Schedule C (Form 990 or 990-EZ) 2011
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check expenses, and share of excess lobbying expenditures).
B Check
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(b) Affiliated group
totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......    
b Total lobbying expenditures to influence a legislative body (direct lobbying) .......    
c Total lobbying expenditures (add lines 1a and 1b) ...................    
d Other exempt purpose expenditures ........................    
e Total exempt purpose expenditures (add lines 1c and 1d) ...............    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
  If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:    
  Not over $500,00020% of the amount on line 1e.    
  Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.    
  Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.    
  Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.    
  Over $17,000,000$1,000,000.    
       
g Grassroots nontaxable amount (enter 25% of line 1f) .................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ......................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
  Calendar year (or fiscal year
beginning in) 		(a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) Total
             
2a Lobbying non-taxable amount          
             
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		         
             
c Total lobbying expenditures          
             
d Grassroots nontaxable amount          
             
e Grassroots ceiling amount
(150% of line 2d, column (e))		          
             
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2011


Schedule C (Form 990 or 990-EZ) 2011
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.
(a)
Yes
No
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
No
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
 
No
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
 
No
 
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? ..........................
Yes
 
79,091
j
Total. Add lines 1c through 1i ...............................
79,091
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
 
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2 are answered “No” OR (b) Part III-A, line 3 is answered “Yes”.
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ...........................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, Part II-A; line 5; and Part ll-B, line 1.
Also, complete this part for any additional information.
Identifier Return Reference Explanation
Lobby Expense SCHEDULE C, PART II-B, QUESTION 1I LOBBYING EXPENSE IS INCLUDED IN THE ANNUAL DUES FOR HOSPITAL ASSOCIATION OF SOUTHERN CALIFORNIA, CHA/CAHHS, AND P.E.A.C.H. INC.
Schedule C (Form 990 or 990EZ) 2011

Additional Data


Software ID:  
Software Version:  

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
POMONA VALLEY HOSPITAL MEDICAL CENTER
 
Employer identification number

95-1115230
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .......    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) ...    
4 Aggregate value at end of year .......    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................
9
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958), relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIV.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current Year (b)Prior Year (c)Two Years Back (d)Three Years Back (e)Four Years Back
1a Beginning of year balance .... 706,022 706,017 706,011 705,996
b Contributions ........        
c Net investment earnings, gains, and losses ... 6 5 6 15
d Grants or scholarships .....        
e Other expenditures for facilities
and programs ........ 		       
f Administrative expenses ....        
g End of year balance ...... 706,028 706,022 706,017 706,011
2
Provide the estimated percentage of the year end balance (line 1g) held as:
a
Board designated or quasi-endowment SchDMd Bullet0 %
b
Permanent endowment SchDMd Bullet100.000 %
c
Temporarily restricted endowment SchDMd Bullet0 %
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
No
(ii) related organizations ........................
3a(ii)
Yes
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
Yes
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land ................. 7,643,689 11,054,200 18,697,889
b Buildings ................   111,561,685 78,266,624 33,295,061
c Leasehold improvements ............   10,370,092 3,956,066 6,414,026
d Equipment ................   316,014,267 249,224,223 66,790,044
e Other .................   26,368,662   26,368,662
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 151,565,682
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value
(1) MALPRACTICE RECEIVABLE 1,625,778
(2) WORKERS COMP RECEIVABLE 7,435,466
(3) CARDIAC SECRETARY RECEIVABLE 4,268
(4) RETIREMENT PLAN ASSETS 1,242,694
(5) INTEREST RECEIVABLE 6,824,466
(6) DEFERRED COMPENSATION 818,994



Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet 17,951,666
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Book value
Federal Income Taxes 0
SELF INSURANCE RESERVES 20,829,665
DEFERRED COMPENSATION 1,784,406







Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 22,614,071
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1  
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2  
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3  
4 Net unrealized gains (losses) on investments .......................... 4  
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV.) ................................. 8  
9 Total adjustments (net). Add lines 4 through 8 ......................... 9  
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10  
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total Revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
ENDOWMENT FUNDS SCHEDULE D, PART V, LINE 4 POMONA VALLEY HOSPITAL MEDICAL CENTER HAS A PERMANENTLY RESTRICTED ENDOWMENT FROM A RESTRICTED DONATION RECEIVED THROUGH A UNITRUST, THE INCOME FROM WHICH IS USED TO SUPPORT THE HOSPITAL'S OPERATIONS.
Schedule D (Form 990) 2011

Additional Data


Software ID:  
Software Version:  




SCHEDULE H (Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990. MediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
POMONA VALLEY HOSPITAL MEDICAL CENTER
 
Employer identification number

95-1115230
Part I
Charity Care and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a....
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Did the organization use FPG to determine eligibility for providing discounted care? If "Yes," indicate which of the
following was the family income limit for eligibility for discounted care: ............
3b
Yes
 
c
If the organization did not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount?......
5b
 
No
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care?...............
5c
 
 
6a
Did the organization prepare a community benefit report during the tax year?...........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ...............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance
and Means-Tested Government Programs		 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) .. 		    11,746,201   11,746,201 2.880 %
b Medicaid (from Worksheet 3, column a) .....     161,851,504 125,366,931 36,484,573 7.800 %
c Costs of other means-tested government programs (from Worksheet 3, column b) .     1,724,266 2,065,755 -341,489 0 %
dTotal Financial Assistance and
Means-Tested Government Programs ..... 		    175,321,971 127,432,686 47,889,285 10.680 %
Other Benefits
e Community health improvement
services and community
benefit operations (from
(Worksheet 4) .... 		59 34,317 2,895,227 1,526,657 1,368,570 0.340 %
f Health professions education
(from Worksheet 5) .. 		1 1,250 3,192,186 567,576 2,624,610 0.620 %
g Subsidized health services
(from Worksheet 6) .. 		12 0 2,499,375 0 2,499,375 0.610 %
h Research (from Worksheet 7) 1 28 70,000 9,400 60,600 0.010 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) .... 1   585,792 0 585,792 0.140 %
jTotal Other Benefits ... 74 35,595 9,242,580 2,103,633 7,138,947 1.720 %
kTotal. Add lines 7d and 7j. .. 74 35,595 184,564,551 129,536,319 55,028,232 12.400 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development 1 0 2,160 0 2,160  
3 Community support 2 644 2,525 0 2,525  
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development 1 270 400 0 400  
9 Other 15 18,297 132,376 0 132,376 0.030 %
10 Total 19 19,211 137,461 0 137,461 0.030 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
 
No
2
Enter the amount of the organization's bad debt expense........
2
16,572,250
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy .....
3
1,533,529
4
Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
71,632,927
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
64,849,117
7
Subtract line 6 from line 5. This is the surplus or (shortfall)........
7
6,783,810
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

9b

Yes

 
Part IV
Management Companies and Joint Ventures
(see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership% 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest)
How many hospital facilities did the organization operate during the tax year?1
Name and address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe)
1 Pomona Valley Hospital Medical Center
1798 North Garey Ave
Pomona,CA91767 		X X   X     X    
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)
Pomona Valley Hospital Medical Center
Name of Hospital Facility:  
Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet the community health needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Participation in the development of a community-wide community benefit plan
d Participation in the execution of a community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the Needs Assessment
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs. .... 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8 Yes  
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care?........... 9 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 200.%
If "No," explain in Part VI the criteria the hospital facility used.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care?................. 10 Yes  
If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 500.%
If "No," explain in Part VI the criteria the hospital facility used.
11 Explained the basis for calculating amounts charged to patients?................. 11 Yes  
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12 Yes  
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13 Yes  
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?....... 14 Yes  
15 Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
16 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 16   No
If “Yes,” check all actions in which the hospital facility or a third party engaged:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
17 Indicate which efforts the hospital facility made before initiating any of the actions checked in line 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
e Other (describe in Part VI)
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18 Yes  
If “No,” indicate why:
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility’s policy was not in writing
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Individuals Eligible for Financial Assistance
19 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
b The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
c The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20   No
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?............................... 21   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?17
Name and address Type of Facility (describe)
1 PVHMC Imaging Claremont
1601 Monte Vista Avenue
CLAREMONT,CA91711 		DIAGNOSTIC CENTER
2 PVHMC Imaging Chino Hills
2140 Grand Avenue STE 125
CHINO HILLS,CA91709 		DIAGNOSTIC CENTER
3 PVHMC Physical Therapy Chino Hills
2140 Grand Avenue STE 125
CHINO HILLS,CA91709 		REHABILITATION CENTER
4 PVHMC Milestone Physical Therapy Center
1775 Monte Vista Avenue
CLAREMONT,CA91711 		REHABILITATION CENTER
5 PVHMC Covina OP Physical Therapy Clinic
420 W Rowland Street
COVINA,CA91723 		REHABILITATION CENTER
6 Pomona Valley Health Center
1770 N Orange Grove
POMONA,CA91767 		OUTPATIENT PHYSICIAN CLINIC
7 PVHC Claremont Urgent Care
1601 Monte Vista Avenue
CLAREMONT,CA91711 		OUTPATIENT PHYSICIAN CLINIC
8 PVHC Crossroads Urgent Care
3110 Chino Avenue STE 150
CHINO HILLS,CA91709 		OUTPATIENT PHYSICIAN CLINIC
9 PVHC Chino Hills
2140 Grand Avenue STE 125
CHINO HILLS,CA91709 		OUTPATIENT PHYSICIAN CLINIC
10 PVHC Claremont Primary Care
1601 Monte Vista Avenue
CLAREMONT,CA91711 		OUTPATIENT PHYSICIAN CLINIC
11 PVHMC Physical Therapy Claremont
1601 Monte Vista Avenue
CLAREMONT,CA91711 		REHABILITATION CENTER
12 PVHC Crossroads Primary Care
3110 Chino Avenue STE 150
CHINO HILLS,CA91709 		OUTPATIENT PHYSICIAN CLINIC
13 PVHMC Imaging Crossroads
3110 Chino Avenue STE 150
CHINO HLLS,CA91709 		DIAGNOSTIC CENTER
14 Pomona Valley Imaging Center Grandview
13768 Roswell Avenue STE 103
CHINO HILLS,CA91709 		DIAGNOSTIC CENTER
15 Pomona Clinic Coalition
Park Avenue
POMONA,CA91767 		COMMUNITY CLINIC
16 PVHMC Imaging Western University
309 Pomona Mall
POMONA,CA91767 		DIAGNOSTIC CENTER
17 PVHMC Claremont Aquatic Therapy Pool
481 S Indian Hill Blvd
CLAREMONT,CA91711 		REHABILITATION CENTER
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 9, 10, 11h, 13g, 15e, 16e, 17e, 18d, 19d, 20, and 21.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Identifier ReturnReference Explanation
PART I, LINE 7B & 7I   THE CALIFORNIA HOSPITAL FEE PROGRAM (THE PROGRAM) WAS SIGNED INTO LAW BY THE GOVERNOR OF CALIFORNIA AND BECAME EFFECTIVE ON JANUARY 1, 2010. AMENDING LEGISLATION, TO CONFORM TO CHANGES REQUESTED BY THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) DURING THE APPROVAL PROCESS, WAS SIGNED INTO LAW BY THE GOVERNOR OF CALIFORNIA AND BECAME EFFECTIVE SEPTEMBER 8, 2010. THE PRIMARY LEGISLATION (AB 1383) AND AMENDING LEGISLATION (AB 1653) CONTAIN TWO COMPONENTS. THE QUALITY ASSURANCE FEE ACT GOVERNS THE "HOSPITAL FEE" OR "QUALITY ASSURANCE FEE" (QA FEE) PAID BY PARTICIPATING HOSPITALS. THE MEDI-CAL HOSPITAL PROVIDER STABILIZATION ACT GOVERNS SUPPLEMENTAL MEDI-CAL PAYMENTS (SUPPLEMENTAL PAYMENTS) MADE TO PROVIDERS FROM THE FUND. HOSPITAL PARTICIPATION IS MANDATORY WITH LIMITED EXCEPTIONS. THE PROGRAM WAS APPROVED BY CMS IN DECEMBER 2010. THE AMENDED LEGISLATION ALLOWED CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES (DHCS) TO BEGIN ASSESSING FEES AND MAKING SUPPLEMENTAL PAYMENTS IN SEPTEMBER 2010. DHCS BEGAN ASSESSING FEES IN OCTOBER 2010. POMONA VALLEY HOSPITAL MEDICAL CENTER ("THE HOSPITAL") MADE PAYMENTS TO DHCS FOR THE QA FEE IN THE AMOUNT OF $10,270,456 IN 2011, INCLUDED ON SCHEDULE H, PART I, LINE 7B, COLUMN C. THE HOSPITAL ALSO MADE PLEDGE PAYMENTS OF $585,792 TO THE CALIFORNIA HEALTH FOUNDATION AND TRUST IN CONJUNCTION WITH THE PROGRAM, WHICH ARE REPORTED ON SCHEDULE H, PART I, LINE 7I, COLUMN C. THE HOSPITAL RECEIVED SUPPLEMENTAL PAYMENTS OF APPROXIMATELY $30,564,784, INCLUDED ON SCHEDULE H, PART I, LINE 7B, COLUMN D OVER THE COURSE OF THE PROGRAM IN 2011, WHICH PERTAINS TO THE PERIOD FROM JANUARY 1, 2011 TO JUNE 30, 2011. THE INCLUSION OF THESE AMOUNTS ON LINE 7B OF PART I IN THE CURRENT YEAR DECREASE THE PERCENTAGE OF TOTAL EXPENSE, AS COMPARED TO 2009 (THE LAST YEAR WHEN THE PROGRAM WAS NOT IN EFFECT).
PART I, LINES 7A-7I   COSTING METHODOLOGY USED IS COST-TO-CHARGE RATIO USING WORKSHEETS 1, 2, AND 3.
PART I, LINE 7G   NONE OF THE MONEY IDENTIFIED UNDER THE SUBSIDIZED HEALTH SERVICES CATEGORY PERTAINS TO A PHYSICIAN CLINIC IN OUR COMMUNITY BENEFIT REPORT.
COMMUNITY BUILDING ACTIVITIES PART II POMONA VALLEY HOSPITAL MEDICAL CENTER SUPPORTS THE ECONOMIC DEVELOPMENT OF THE COMMUNITY BY ALLOWING A LOCAL NOT-FOR-PROFIT ORGANIZATION TO PARTICIPATE IN CREATING A SPONSORSHIP AD FOR THEIR ORGANIZATION IN OUR HOSPITAL'S PROGRAM BOOKS FOR COMMUNITY EVENTS. THE COSTS AND PERSONS SERVED ARE REFLECTED ON LINE 2 OF PART II AS ECONOMIC DEVELOPMENT. POMONA VALLEY HOSPITAL MEDICAL CENTER PARTICIPATES ON THE STEERING COMMITTEE FOR THE LOS ANGELES COUNTY SERVICE PLANNING AREA (SPA 3'S) HEALTH PLANNING GROUP AND SPECIALTY CARE COALITION. WE PARTICIPATE TO LOOK AT ACCESS TO CARE, PROMOTION OF HEALTH AND ACCESS AND AVAILABILITY OF SPECIALTY CARE. THE COSTS AND PERSONS SERVED ARE REFLECTED ON LINE 3 OF PART II AS COMMUNITY SUPPORT. POMONA VALLEY HOSPITAL MEDICAL CENTER IS ONE OF 13 DESIGNATED DISASTER RESOURCE CENTERS (DRC) IN LOS ANGELES COUNTY AS PART OF THE NATIONAL BIOTERRORISM HOSPITAL PREPAREDNESS PROGRAM. AS THE DRC FOR THE REGION, POMONA VALLEY HOSPITAL MEDICAL CENTER IS RESPONSIBLE FOR 10 "UMBRELLA" FACILITIES IN THE AREA AND COORDINATES DRILLS, TRAINING, AND SHARING OF PLANS TO BRING TOGETHER THE COMMUNITY AND OUR RESOURCES FOR DISASTER PREPAREDNESS. THE COSTS AND PERSONS SERVED ARE REFLECTED ON LINE 3 OF PART II AS COMMUNITY SUPPORT. POMONA VALLEY HOSPITAL MEDICAL CENTER WORKS WITH LOCAL AREA MIDDLE AND HIGH SCHOOLS AS WELL AS GIRL SCOUTS AND SCHOOL GROUPS TO INTRODUCE CAREERS IN HEALTH CARE BY INVITING THEM TO TOUR OUR HOSPITAL AND BY VISITING THEM ON THEIR CAMPUS (CLAREMONT HIGH SCHOOL CAREER DAY). THE COSTS AND PERSONS SERVED ARE REFLECTED ON LINE 3 OF PART II AS COMMUNITY SUPPORT. POMONA VALLEY HOSPITAL MEDICAL CENTER ASSISTS LOCAL SCHOOLS (E.G. CHAFFEY COLLEGE, WESTERN UNIVERSITY OF HEALTH SCIENCES, MOUNT SAN ANTONIO COLLEGE, CITRUS COLLEGE) IN MEETING REQUIREMENTS FOR THEIR NURSING PROGRAMS AND OUR EDUCATION DEPARTMENT SERVES ON THE ADVISORY BOARDS TO THESE SCHOOLS. THE COSTS AND PERSONS SERVED ARE REFLECTED ON LINES 3 & 8 OF PART II AS COMMUNITY SUPPORT As AND WORKFORCE DEVELOPMENT. CASH AND IN-KIND CONTRIBUTIONS - OUR HOSPITAL PROVIDES SUPPORT TO VARIOUS LOCAL COMMUNITY SERVICE ORGANIZATIONS INCLUDING THE HOUSE OF RUTH (SERVICES AND ASSISTANCE TO VICTIMS OF DOMESTIC VIOLENCE), PROJECT SISTER (SEXUAL ASSAULT CRISIS AND PREVENTION SERVICES), AND YMCA. IN-KIND CONTRIBUTIONS TO OUR PATIENTS AND TO THE COMMUNITY INCLUDE TOYS GIVEN TO PEDIATRIC SURGERY PATIENTS. THE FACILITIES DEPARTMENT PARTICIPATES IN THE CITY-WIDE CLEAN BY DONATING STAFF AND SUPPLIES. FOOD AND NUTRITION SERVICES "MEALS ON WHEELS" PROGRAM PROVIDES FOOD TO HOMEBOUND MEMBERS OF OUR COMMUNITY AND DONATES CANNED FOODS TO THE SALVATION ARMY "PROJECT SHIELD & SHELTER." OUR VOLUNTEER SERVICES DEPARTMENT GIVES INFANT LAYETTES AND CAR SEATS TO NEEDY FAMILIES. THE CANCER CARE CENTER GIVES WIGS TO PATIENTS AT NO COST.
PART III, LINE 4   THE HOSPITAL'S FINANCIAL STATEMENT INCLUDES A BAD DEBT FOOTNOTE REGARDING FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ISSUED ACCOUNTING STANDARDS UPDATE(ASU) NO. 2011-07, "HEALTH CARE ENTITIES" (TOPIC 954) REGARDING THE PRESENTATION AND DISCLOSURE OF PATIENT SERVICE REVENUE, PROVISION FOR BAD DEBTS, AND THE ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR CERTAIN HEALTH CARE ENTITIES. ASU 2011-07 IS EFFECTIVE FOR FISCAL YEARS AND INTERIM PERIODS BEGINNING AFTER DECEMBER 31, 2011, WITH EARLY ADOPTION PERMITTED. THE HOSPITAL MADE THE PRESENTATION CHANGES OF PROVISION FOR BAD DEBTS RELATED TO PATIENT SERVICE REVENUE IN 2011. BAD DEBT EXPENSE IS ESTIMATED APPLYING HISTORICAL PERCENTAGES (BASED ON THE PRIOR YEARS' BAD DEBT ACTIVITY) TO THE CURRENT ACCOUNTS RECEIVABLE PATIENT RESPONSIBILITY PAYOR CLASSES. PATIENTS WITHOUT INSURANCE ARE OFFERED A PROMPT PAY DISCOUNT, GREATLY DISCOUNTING THEIR BALANCE IF PAID WITHIN 30 DAYS. ALL DISCOUNTS AND PAYMENTS ARE APPLIED TO THE BAD DEBT ACCOUNT BEFORE THE ACCOUNT IS WRITTEN OFF. WHEN A FINANCIAL ASSISTANCE APPLICATION IS RECEIVED FROM A PATIENT, THE PATIENT'S ACCOUNT IS ASSIGNED A SPECIFIC USER DEFINED CODE. THIS CODE ALLOWS THE HOSPITAL TO IDENTIFY ALL ACCOUNTS PENDING FINANCIAL ASSISTANCE REVIEW AND PREVENTS THE ACCOUNT FROM PROGRESSING THROUGH THE NORMAL COLLECTION PROCESS. AFTER THE FINANCIAL ASSISTANCE APPLICATION AND THE PATIENT'S REQUIRED SUPPORTING DOCUMENTATION IS REVIEWED, THE PATIENT IS INFORMED OF THE RESULTS OF THE REVIEW OF THEIR APPLICATION. IF THE PATIENT'S APPLICATION IS APPROVED, THE ACCOUNT BALANCE IS ADJUSTED ACCORDING TO THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. IF THE PATIENT DOES NOT QUALIFY FOR FINANCIAL ASSISTANCE, THE USER DEFINED CODE IS REMOVED AND THE ACCOUNT PROCEEDS THROUGH THE NORMAL COLLECTION CYCLE WHICH ENDS IN A TRANSFER TO A COLLECTION AGENCY IF THE PATIENT FAILS TO PAY THEIR BALANCE IN FULL. ACCOUNTS RETURNED FROM THE COLLECTION AGENCY ARE WRITTEN OFF TO BAD DEBT EXPENSE. LINE 3 CONSISTS OF THE ACCOUNTS WRITTEN OFF, WHICH WERE ALSO DECLINED FOR FINANCIAL ASSISTANCE PER THE HISTORICAL ACCOUNT RECORDS.
PART III, LINE 8   THE COSTING METHOD USED IS COST TO CHARGE RATIO. THE SOURCE OF INFORMATION IS THE MEDICARE COST REPORT.
PART III, LINE 9B   THE CREDIT & COLLECTIONS DEPARTMENT SENDS A STATEMENT TO EACH PATIENT/GUARANTOR AS NOTIFICATION OF THE PATIENT RESPONSIBILITY AND AMOUNT DUE. IF THE PATIENT HAS INSURANCE COVERAGE, THE CHARGES INCURRED ARE BILLED TO THE INSURANCE PLAN/CARRIER PROVIDED BY THE PATIENT AND VERIFIED AS ELIGIBLE COVERAGE BY POMONA VALLEY HOSPITAL MEDICAL CENTER STAFF. THE AMOUNT BILLED TO THE PATIENT IS THE AMOUNT DETERMINED BY THE INSURANCE CARRIER AS PATIENT RESPONSIBILITY. FOR UNINSURED PATIENTS, A COMPLETE ITEMIZED STATEMENT OF CHARGES IS MAILED TO THE PATIENT. THE HOSPITAL SENDS FIRST PARTY LETTERS TO THE PATIENT WHEN BILLING THE PATIENT THEIR PORTION AFTER INSURANCE HAS PAID OR THEIR BALANCE IF UNINSURED. FIRST PARTY LETTERS ARE GENERATED FROM THE PATIENT ACCOUNTING FINANCIAL SYSTEM AND MAILED TO EACH PATIENT/GUARANTOR IN AN EFFORT TO COLLECT MONIES OWED. THE LETTER SERIES CONSISTS OF THREE SYSTEM GENERATED LETTERS. EACH LETTER MAILED INDICATES THE AMOUNT OWED AND INSTRUCTS THE PATIENT TO CONTACT THE BUSINESS OFFICE TO DISCUSS THEIR OPTIONS AND/OR MAKE PAYMENT ARRANGEMENTS. IF THE PATIENT CALLS AND EXPRESSES AN INABILITY TO PAY, THE BUSINESS OFFICE ASSOCIATE WILL EXPLAIN THE OPTIONS AVAILABLE INCLUDING 1) A MONTHLY INSTALLMENT OPTION AT NO INTEREST IF PAID WITHIN 12 MONTHS OR AN AGREED UPON PERIOD, 2) PATIENTS WITHOUT INSURANCE ARE OFFERED A PROMPT PAY DISCOUNT, GREATLY DISCOUNTING THEIR BALANCE IF PAID WITHIN 30 DAYS, AND 3) WHEN A PATIENT EXPRESSES AN INABILITY TO PAY, THE PATIENT IS INFORMED OF THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM AND IF THE PATIENT IS INTERESTED, A FINANCIAL ASSISTANCE APPLICATION IS MAILED TO THE PATIENT. IF THE PATIENT FAILS TO RESPOND TO THE FIRST STATEMENT/ LETTER MAILED TO THE PATIENT, A PHONE CALL IS PLACED. DURING THE CALL, THE OPTIONS ABOVE ARE SHARED WITH THE PATIENT. IF THE COLLECTOR IS UNABLE TO CONTACT THE PATIENT BY PHONE DUE TO A DISCONNECTED PHONE NUMBER, AN "UNABLE TO REACH BY PHONE" LETTER IS SENT TO THE PATIENT. THIS LETTER INFORMS THE PATIENT OF PAYMENT ARRANGEMENT OPTIONS AND OTHER FINANCIAL ASSISTANCE PROGRAMS AVAILABLE TO ASSIST THEM WITH THEIR FINANCIAL OBLIGATIONS. A SECOND STATEMENT IS MAILED TO THE PATIENT ADVISING THE PATIENT TO CONTACT THE BUSINESS OFFICE IF THE PATIENT IS UNABLE TO REMIT THE FULL AMOUNT DUE. IF AND WHEN A PATIENT CALLS THE BUSINESS OFFICE IN RESPONSE TO PVHMC'S COLLECTION CORRESPONDENCE, THE PATIENT IS INFORMED OF THE VARIOUS FINANCIAL ASSISTANCE OPTIONS. IN THE EVENT A PATIENT HAS A QUESTION IN COMPLETING THE APPLICATION, THE BUSINESS OFFICE SUPERVISOR, MANAGER AND/OR DIRECTOR ARE AVAILABLE TO ASSIST THE PATIENT IN COMPLETING THE APPLICATION. PART V, LINE 13G THE HOSPITAL FACILITY PUBLICIZED THE FINANCIAL ASSISTANCE POLICY BY MAKING A SUMMARY AVAILABLE IN THE FOLLOWING WAYS: - ATTACHING TO BILLING INVOICES - POSTING IN THE EMERGENCY/WAITING ROOMS - POSTING IN THE ADMISSIONS OFFICES - PROVIDING, IN WRITING, TO PATIENTS ON ADMISSION TO THE HOSPITAL - PROVIDING THE POLICY UPON REQUEST
PART V, LINE 19   THE MAXIMUM INPATIENT RATES CHARGED TO PATIENTS ELIGIBLE FOR THE HOSPITAL'S FAP PROGRAM ARE ON A SLIDING SCALE: 200% OR BELOW ARE FULLY WRITTEN OFF. 200-300% PRICING COMPARABLE TO MEDI-CAL RATES. 300-400% PRICING BASED ON MEDICARE FEE SCHEDULE. 400-500% PRICING BASED ON WORKERS COMP FEE SCHEDULE. SINCE THE HOSPITAL'S FAP COVERS PATIENTS WITH INCOME UP TO 500% FPG AND THE CALIFORNIA GOVERNMENT REQUIREMENT IS 350% FPG, WE PROVIDE FAP TO MORE PATIENTS THAN WE ARE REQUIRED TO.
NEEDS ASSESSMENT PART VI, LINE 2 IN 2012, A COMMUNITY NEEDS ASSESSMENT WAS COMPLETED BY RESEARCHERS FROM A LOCAL UNIVERSITY. OUR METHODOLOGY INCLUDED COLLECTING PRIMARY DATA FROM A RANDOM SAMPLE OF RESIDENTS LIVING IN THE HOSPITAL'S PRIMARY SERVICE AREA THROUGH TELEPHONE SURVEYS GIVEN IN BOTH ENGLISH AND SPANISH. INFORMATION GATHERED FROM THE NEEDS ASSESSMENT INCLUDED DEMOGRAPHIC PROFILE AND SELF-REPORTED HEALTH EVALUATION, HEALTH INSURANCE COVERAGE, BARRIERS TO RECEIVING NEEDED HEALTH SERVICES, UTILIZATION OF HEALTH CARE SERVICES FOR ROUTINE PRIMARY/PREVENTATIVE CARE, UTILIZATION OF URGENT CARE SERVICES, NEED FOR SPECIALTY HEALTH CARE, AND EXPERIENCE WITH POMONA VALLEY HOSPITAL MEDICAL CENTER (INCLUDING VISITS TO THE EMERGENCY DEPARTMENT, OR THROUGH EDUCATION). THE COSTS AND PERSONS SERVED ASSOCIATED WITH CONDUCTING OUR NEEDS ASSESSMENT ARE REFLECTED ON LINE 3 & 8 OF PART II AS COMMUNITY SUPPORT.
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE PART VI, LINE 3 PUBLIC NOTICE: PUBLIC NOTICES ARE POSTED IN PVHMC'S REGISTRATION AND BILLING AREAS NOTIFYING PATIENTS, FAMILY AND GENERAL PUBLIC THAT WE OFFER CHARITABLE ASSISTANCE TO THOSE WHO QUALIFY. THE NOTICE PROVIDES A BUSINESS OFFICE PHONE NUMBER WHERE THEY MAY CONTACT A BUSINESS OFFICE REPRESENTATIVE TO OBTAIN ADDITIONAL INFORMATION ABOUT THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAMS. THE NOTICES ARE POSTED IN BOTH ENGLISH AND SPANISH. THESE PUBLIC POSTINGS ARE LOCATED IN THE AREAS LISTED BELOW: - ADMITTING REGISTRATION SITE I - ADMITTING REGISTRATION SITE II - ADMITTING REGISTRATION LAB - ADMITTING REGISTRATION PRE OPERATIVE UNIT - CASHIERS OFFICE - ADMITTING SOUTH REGISTRATION - ADMITTING WOMEN'S CENTER REGISTRATION - ADMITTING EMERGENCY REGISTRATION - OFF-SITE INSURANCE VERIFICATION - CONTRACTS BILLING SUITE 120 AND 160 - BUSINESS SERVICES SYSTEMS - GOVERNMENT AND PATIENT BILLING FINANCIAL COUNSELING - EMERGENCY SERVICES: AN ELIGIBILITY LIAISON IS STAFFED IN THE EMERGENCY SERVICES DEPARTMENT AT TIMES WHEN HIGH VOLUMES ARE EXPECTED, SUNDAY THROUGH FRIDAY, 12:00 PM TO 10:30 PM, TO ASSIST OUR UNINSURED OR UNDERINSURED PATIENTS WITH POSSIBLE LINKS TO MEDI-CAL, THE STATE OF CALIFORNIA'S MEDICAID PROGRAM OR REFERRALS TO CHARITY ASSISTANCE. - PRIOR TO ELECTIVE SERVICE: FINANCIAL COUNSELORS FROM OUR INSURANCE VERIFICATION DEPARTMENT ARE AVAILABLE TO MEET WITH PATIENTS PRIOR TO RENDERING MEDICAL SERVICES TO DISCUSS POSSIBLE LINKS TO GOVERNMENT PROGRAMS SUCH AS MEDI-CAL, HEALTHY FAMILIES, MEDICARE OR OTHER FINANCIAL ASSISTANCE PROGRAMS OFFERED BY PVHMC. FINANCIAL COUNSELORS MAY REFER PATIENTS TO PVHMC'S ELIGIBILITY SERVICES DEPARTMENT FOR ASSISTANCE IN APPLYING FOR GOVERNMENT PROGRAMS. FINANCIAL COUNSELORS ALSO DISTRIBUTE AND ASSIST PATIENTS IN COMPLETING THE UNCOMPENSATED CARE APPLICATION. FOR THOSE PATIENTS WHO HAVE THE ABILITY TO PAY, FINANCIAL OPTIONS ARE DISCUSSED AND PAYMENT ARRANGEMENTS ARE ESTABLISHED. - DURING A PATIENT'S CONFINEMENT: FINANCIAL COUNSELORS ARE ALSO ASSIGNED TO ALL UNINSURED OR UNDERINSURED PATIENTS ADMITTED TO PVHMC IF FINANCIAL COUNSELING DID NOT OCCUR IN ADVANCE OF THE ADMISSION OR DURING THE EMERGENCY VISIT. THE FINANCIAL COUNSELOR PROVIDES THE SAME LEVEL OF SERVICE TO THESE PATIENTS AS DESCRIBED ABOVE UNDER "PRIOR TO ELECTIVE SERVICE." ELIGIBILITY SERVICES: PATIENTS MAY BE REFERRED TO OUR ELIGIBILITY SERVICES TEAM WHO ASSIST OUR PATIENTS WITH LINKS TO MEDI-CAL AND THE HEALTH FAMILIES PROGRAMS. THE ELIGIBILITY SERVICES REPRESENTATIVES ASSIST THE PATIENT IN COMPLETING THE PROGRAM APPLICATION(S) AND SUBMIT THE COMPLETED APPLICATION TO THE APPLICABLE PROGRAM ON BEHALF OF THE PATIENT. IF THE PATIENT DOES NOT QUALIFY FOR MEDI-CAL OR THE HEALTHY FAMILIES PROGRAM, THE PATIENT IS PROVIDED INFORMATION REGARDING THE FOLLOWING ASSISTANCE PROGRAMS: - ACCESS FOR INFANTS & MOTHERS (AIM): COVERS OBSTETRIC PATIENTS WHO ARE AT HIGHER INCOME LEVELS AND ARE NOT ELIGIBLE FOR MEDI-CAL - OUTPATIENT REDUCED-COST SIMPLIFIED APPLICATION (ORSA): LOS ANGELES COUNTY PROGRAM FOR ADULTS WHO DO NOT QUALIFY FOR MEDI-CAL AND RESIDE WITHIN LOS ANGELES COUNTY - PUBLIC PRIVATE PARTNERSHIP PROGRAM (PPP ALSO KNOWN AS THE PCC PROGRAM): LOS ANGELES COUNTY PROGRAM FOR ADULTS WHO DO NOT QUALIFY FOR MEDI-CAL AND RESIDE WITHIN LOS ANGELES COUNTY IN POMONA AND SURROUNDING COMMUNITIES - MEDICALLY INDIGENT ADULT PROGRAM (MIA): FOR ADULTS WHO DO NOT QUALIFY FOR MEDI-CAL AND RESIDE WITHIN SAN BERNARDINO COUNTY BILLING: FIRST PARTY LETTERS ARE GENERATED FROM THE PATIENT ACCOUNTING FINANCIAL SYSTEM AND MAILED TO EACH PATIENT/GUARANTOR IN AN EFFORT TO COLLECT MONIES OWED. THE LETTERS PROVIDE THE PHONE NUMBER AND BUSINESS HOURS OF THE HOSPITAL'S BUSINESS OFFICE. THE CUSTOMER SERVICE REPRESENTATIVES IN THE BUSINESS OFFICE ARE AVAILABLE TO DISCUSS THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAMS AND MAKE PAYMENT ARRANGEMENTS. A CHARITY LIAISON IS ALSO AVAILABLE TO ASSIST PATIENTS IN COMPLETING THE FINANCIAL ASSISTANCE APPLICATION. ENGLISH AS A SECOND LANGUAGE ALL FINANCIAL ASSISTANCE FORMS ARE AVAILABLE IN SPANISH IN ADDITION TO THE AVAILABILITY OF BILINGUAL STAFF IN ALL ADMITTING AND REGISTRATION AREAS, ELIGIBILITY SERVICES AND THE BUSINESS OFFICE. THE STAFF IN ALL PATIENT ACCESS AND BILLING AREAS HAS BEEN TRAINED ON ACCESSING EXTERNAL INTERPRETATIVE SERVICES WHEN PATIENTS SPEAK A LANGUAGE OTHER THAN ENGLISH AND SPANISH. TRAINING: IN DECEMBER 2007, ALL PATIENT ACCESS AND BILLING OFFICE STAFF WERE TRAINED ON THE REQUIREMENTS OF AB774 AND THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. THE STAFF IS UPDATED ON THE HOSPITAL'S POLICY ON AN AS NEEDED BASIS. BEGINNING IN 2010, KEY PATIENT ACCESS STAFF AND PATIENT COLLECTION STAFF WILL BE UPDATED ON BOTH THE FINANCIAL ASSISTANCE AND CREDIT AND COLLECTION POLICIES AT LEAST ANNUALLY. ANNUAL REVIEW OF FINANCIAL ASSISTANCE PROGRAM: THE PATIENT FINANCIAL ASSISTANCE PROGRAM POLICY IS REVIEWED ANNUALLY FOR ANY SIGNIFICANT CHANGES TO THE DISCOUNT PAYMENT, CHARITY, ELIGIBILITY PROCEDURES AND REVIEW PROCESS. THE BUSINESS OFFICE IS RESPONSIBLE FOR THE ELECTRONIC SUBMISSION OF THE APPROVED POLICY AND ANY APPLICABLE CHANGES TO OSHPD IN ACCORDANCE TO TITLE 22, SECTIONS 96040-96050.
COMMUNITY INFORMATION PART VI, LINE 4 OUR MISSION - PVHMC IS A NOT-FOR-PROFIT REGIONAL MEDICAL CENTER DEDICATED TO PROVIDING HIGH QUALITY, COST EFFECTIVE HEALTH CARE SERVICES TO RESIDENTS OF THE GREATER POMONA VALLEY. THE MEDICAL CENTER OFFERS A FULL RANGE OF SERVICES FROM LOCAL PRIMARY ACUTE CARE TO HIGHLY SPECIALIZED REGIONAL SERVICE. SELECTION OF ALL SERVICES IS BASED ON COMMUNITY NEED, AVAILABILITY OF FINANCING AND THE ORGANIZATION'S TECHNICAL ABILITY TO PROVIDE HIGH QUALITY RESULTS. BASIC TO OUR MISSION IS OUR COMMITMENT TO STRIVE CONTINUOUSLY TO IMPROVE THE STATUS OF HEALTH BY REACHING OUT AND SERVING THE NEEDS OF OUR DIVERSE ETHNIC, RELIGIOUS AND CULTURAL COMMUNITY. OUR COMMUNITY - PVHMC IS DEDICATED TO MEETING THE HEALTH CARE DEMANDS OF THE GROWING POPULATIONS OF LOS ANGELES AND SAN BERNARDINO COUNTIES. OUR PRIMARY SERVICE AREA IS DEFINED AS THE CITIES OF POMONA, CLAREMONT, CHINO, CHINO HILLS, LA VERNE, MONTCLAIR, ONTARIO, RANCHO CUCAMONGA, ALTA LOMA, UPLAND AND SAN DIMAS AND MAKE UP A POPULATION OF 840,789. IN 2010 AS DERIVED FROM THE STATISTICS REPORTED BY THE U.S. CENSUS BUREAU, THE ETHNIC DIVERSITY REPRESENTED BY THE DEMOGRAPHICS OF THE CITY OF POMONA IN 2010 WAS SUCH THAT 33.6% IS HISPANIC OR LATINO, 14.4% IS WHITE, 7.3% IS BLACK/AFRICAN-AMERICAN, 8.5% IS ASIAN, 1.2% IS AMERICAN INDIAN, 0.2% HAWAIIAN/PACIFIC ISLANDER, 30.3% IS OTHER, AND 4.5% IS TWO OR MORE RACES, ACCORDING TO THE U.S. CENSUS BUREAU. THE AVERAGE INCOME OF THE POMONA VALLEY COMMUNITY WAS $50,426 AND THE PERCENTAGE OF COMMUNITY RESIDENTS WITH INCOME BELOW THE FEDERAL POVERTY LINE WAS 30.46%.
PROMOTION OF COMMUNITY HEALTH PART VI, LINE 5 POMONA VALLEY HOSPITAL MEDICAL CENTER IS GOVERNED BY A BOARD OF DIRECTORS WHOSE MEMBERS ARE REPRESENTATIVE OF THE COMMUNITY, HOSPITAL AND MEDICAL STAFF LEADERSHIP. CONSISTENT WITH THE IRS "COMMUNITY BENEFIT STANDARD" A MAJORITY OF THE BOARD OF DIRECTORS ARE NEITHER EMPLOYEES, CONTRACTORS OR FAMILY MEMBERS OF THE ORGANIZATION. POMONA VALLEY HOSPITAL MEDICAL CENTER IS A COMMUNITY BASED, DISPROPORTIONATE SHARE HOSPITAL. IN ADDITION, WE PARTICIPATE IN MEDICARE, MEDI-CAL, CHAMPUS, AND TRICARE. POMONA VALLEY HOSPITAL MEDICAL CENTER IS AN OPEN MEDICAL STAFF, EXTENDING STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS FOR ALL AREAS AND DEPARTMENTS OF OUR FACILITY. POMONA VALLEY HOSPITAL MEDICAL CENTER IS HOME TO THE ONLY 24-HOURS-A-DAY, FULL SERVICE EMERGENCY DEPARTMENT (ED) IN POMONA. OUR ED TREATS ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY; POMONA VALLEY HOSPITAL MEDICAL CENTER PROVIDES EMERGENCY SERVICES TO ALL PATIENTS WITH OUR WITHOUT INSURANCE. THE EMERGENCY DEPARTMENT'S DEDICATED STAFF IS EXPERIENCED IN PROVIDING PROMPT, ACCURATE DIAGNOSIS AND SKILLFUL MEDICAL TREATMENT. THIS EXPERT TEAM INCLUDES BOARD-CERTIFIED EMERGENCY PHYSICIANS, PHYSICIAN ASSISTANTS; BOARD CERTIFIED NURSES, EMERGENCY MEDICAL TECHNICIANS, RESPIRATORY THERAPISTS AND OTHER HIGHLY TRAINED EMERGENCY CARE PROFESSIONALS. ALL ARE DEDICATED TO PROVIDING TECHNOLOGICALLY ADVANCED, LIFESAVING MEDICAL SERVICES WITH COMPASSIONATE, CULTURALLY APPROPRIATE CARE.
AFFILIATED HEALTH CARE SYSTEM PART VI, LINE 6 POMONA VALLEY HOSPITAL MEDICAL CENTER IS A STAND ALONE HOSPITAL, NOT PART OF A HEALTH CARE SYSTEM.
STATE FILING OF COMMUNITY BENEFIT REPORT PART VI, LINE 7 CALIFORNIA
Schedule H (Form 990) 2011
Additional Data


Software ID:  
Software Version:  
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
POMONA VALLEY HOSPITAL MEDICAL CENTER
 
Employer identification number
95-1115230
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21 for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Use
Part IV and Schedule I-1 (Form 990) if additional space is needed ......................... lBullet
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) CALIFORNIA HEALTH FOUNDATION & TRUST1215 K STREET STE 800
SACRAMENTO,CA95814 		94-1498697 501(C)(3) 585,792       HOSPITAL FEE PROGRAM
(2) BOYS REPUBLIC1907 BOYS REPUBLIC DR
CHINO HILLS,CA91709 		95-1647813 501(C)(3) 11,409       PROGRAM SUPPORT
(3) YES FOR SCHOOLS22100 RIM FIRE LANE
DIAMOND BAR,CA91765 		52-2178069 501(C)(3) 10,000       DONATIONS FOR SCHOOLS IN THE POMONA UNIFIED SHOOL DISTRICT.
(4) POMONA COMMUNITY CLINIC750 PARK AVE
POMONA,CA91767 		22-3914738 501(C)(3) 40,000       PROGRAM SUPPORT
















2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
3
3
Enter total number of other organizations listed in the line 1 table ......................... . Bullet Image
1
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2011

Schedule I (Form 990) 2011
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Use Schedule I-1 (Form 990) if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance













Part IV
Supplemental Information. Complete this part to provide the information required in Part I, line 2, and any other additional information.
Identifier Return Reference Explanation
DESCRIPTION OF ORGANIZATION'S PROCEDURES FOR MONITORING THE USE OF GRANTS FORM 990, SCHEDULE I, PART I, LINE 2 THE CALIFORNIA HOSPITAL FEE PROGRAM (THE PROGRAM) WAS SIGNED INTO LAW BY THE GOVERNOR OF CALIFORNIA AND BECAME EFFECTIVE ON JANUARY 1, 2010. THE HOSPITAL MADE PLEDGE PAYMENTS (GRANT) TO THE CALIFORNIA HEALTH FOUNDATION & TRUST TOTALING $585,792 IN CONJUNCTION WITH THIS PROGRAM. NO MONITORING IS COMPLETED AFTER THE GRANT IS MADE.
Schedule I (Form 990) 2011


Additional Data


Software ID:  
Software Version:  


Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
POMONA VALLEY HOSPITAL MEDICAL CENTER
 
Employer identification number

95-1115230
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
 
 
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
Yes
 
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) RICHARD YOCHUM (i)
(ii)		 532,827
0 		0
0 		9,518
0 		121,741
0 		22,621
0 		686,707
0 		0
0
(2) MICHAEL NELSON (i)
(ii)		 378,518
0 		0
0 		8,787
0 		130,341
0 		22,636
0 		540,282
0 		0
0
(3) KURT WEINMEISTER (i)
(ii)		 356,143
0 		0
0 		6,289
0 		14,700
0 		17,083
0 		394,215
0 		0
0
(4) CHRIS ALDWORTH (i)
(ii)		 185,401
0 		0
0 		11,622
0 		14,832
0 		30,623
0 		242,478
0 		0
0
(5) JULI HESTER (i)
(ii)		 197,316
0 		0
0 		5,768
0 		11,346
0 		22,359
0 		236,789
0 		0
0
(6) DARLENE SCAFFIDDI (i)
(ii)		 223,706
0 		0
0 		15,680
0 		17,306
0 		31,971
0 		288,663
0 		0
0
(7) KENNETH K NAKAMOTO (i)
(ii)		 264,030
0 		0
0 		20,882
0 		12,250
0 		31,754
0 		328,916
0 		0
0
(8) KENT HOYOS (i)
(ii)		 259,887
0 		0
0 		3,744
0 		11,903
0 		31,754
0 		307,288
0 		0
0
(9) JOSEPH BAUMGARTNER (i)
(ii)		 212,414
0 		47,054
0 		4,086
0 		16,498
0 		30,142
0 		310,194
0 		0
0
(10) RICHARD ROSSMAN (i)
(ii)		 199,010
0 		42,733
0 		6,156
0 		14,899
0 		31,915
0 		294,713
0 		0
0
(11) JAMES MCL DALE (i)
(ii)		 223,058
0 		0
0 		11,540
0 		3,615
0 		22,604
0 		260,817
0 		0
0





Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
SUPPLEMENTAL COMPENSATION INFORMATION SCHEDULE J, PART I, LINE 4B THE HOSPITAL HAS EMPLOYMENT CONTRACTS WITH MR. YOCHUM AND MR. NELSON. THE CONTRACTS PROVIDE FOR A PAYMENT OF 5.24 FOR MR. NELSON AND 4.77 FOR MR. YOCHUM TIMES ANNUAL CASH COMPENSATION IF THE EXECUTIVE REMAINS EMPLOYED UNTIL THE END OF THE CONTRACT. EMPLOYMENT REQUIREMENTS ARE 36 YEARS FOR MR. YOCHUM AND 34 YEARS FOR MR. NELSON. IN THE EVENT OF VOLUNTARY TERMINATION OR TERMINATION FOR CAUSE, ALL BENEFITS UNDER THE CONTRACT ARE FORFEITED. IN THE EVENT OF EARLY TERMINATION BECAUSE OF DEATH OR DISABILITY, A PRORATED BENEFIT WOULD BE PAID. THE CONTRACT AFFIRMS THE THE BOARD OF DIRECTORS HAS THE RIGHT TO TERMINATE THE CONTRACT, WITH OR WITHOUT CAUSE, AT ITS DISCRETION, AND PROVIDES A FORMULA FOR CALCULATING THE SEVERANCE PAYMENT IN THE EVENT OF INVOLUNTARY TERMINATION. ONCE THE EMPLOYEE HAS MET ALL VESTING REQUIREMENTS, AND THE AMOUNT IS NOT SUBJECT TO SUBSTANTIAL RISK OF FORFEITURE, THE AMOUNT IS INCLUDED IN OTHER REPORTABLE COMPENSATION (SCHEDULE J, PART II, B(III)). SCHEDULE J, PART II, C INCLUDES DEFERRED COMPENSATION OF $102,141 FOR MR. YOCHUM AND $110,741 FOR MR. NELSON.
NON-FIXED PAYMENTS SCHEDULE J, PART I, LINE 7 CERTAIN MEMBERS OF MANAGEMENT ARE AWARDED INCENTIVE COMPENSATION IN RECOGNITION OF SIGNIFICANT CONTRIBUTIONS TO ACHEIVING CORPORATE GOALS. THESE AMOUNTS ARE LISTED IN SCHEDULE J, PART II, COUMN B(II).
Schedule J (Form 990) 2011

Additional Data


Software ID:  
Software Version:  
Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V lines 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBulletSee separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
POMONA VALLEY HOSPITAL MEDICAL CENTER
 
Employer identification number

95-1115230
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Description of transaction (c) Corrected?
Yes No





2
Enter the amount of tax imposed on the organization managers or disqualified persons during the year under section 4958. ......................... Bullet Image$
 
3
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image$
 

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.
(a) Name of interested person and purpose (b) Loan to or from the organization? (c)Original principal amount (d)Balance due (e) In default? (f) Approved by board or committee? (g)Written agreement?
To From Yes No Yes No Yes No
Total ...............Small Bullet $  
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b)Relationship between interested person and the organization (c)Amount of grant or type of assistance
For Privacy Act and Paperwork Reduction Act Notice, see the
Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2011
Schedule L (Form 990 or 990-EZ) 2011
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) POMONA VALLEY IMAGING MED GRP SEE PART V 690,784 COMPENSATION FOR SERVICES   No
(2) POMONA VALLEY IMAGING MED GRP SEE PART V 555,062 PRINCIPAL & INT ON CAP LEASE   No
(3) SAN GABRIEL VALLEY PERINATAL MED GR SEE PART V 200,000 COMPENSATION FOR SERVICES   No
(4) GREGORY DALY SEE PART V 126,273 COMPENSATION FOR SERVICES   No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
BUSINESS TRANSACTIONS WITH INTERESTED PERSONS SCHEDULE L, PART IV 1 & 2. JOHNSON LIGHTFOOTE, MD, A DIRECTOR OF THE ORGANIZATION'S BOARD, IS A GREATER THAN 5% OWNER OF POMONA VALLEY IMAGING MEDICAL GROUP. 3. HELLEN RODRIGUEZ, MD, A DIRECTOR OF THE ORGANIZATION'S BOARD IS A GREATER THAN 5% OWNER OF SAN GABRIEL VALLEY PERINATAL MEDICAL GROUP. 4. GREGORY DALY IS THE BROTHER OF DARLENE SCAFFIDDI, A KEY EMPLOYEE OF THE ORGANIZATION.
Schedule L (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  




SCHEDULE M
(Form 990)

Department of the Treasury
Internal Revenue Service
NonCash Contributions
Right pointing arrow large imageComplete if the organization answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image Attach to Form 990.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
POMONA VALLEY HOSPITAL MEDICAL CENTER
 
Employer identification number

95-1115230
Part I
Types of Property
(a)
Check if applicable 		(b)
Number of Contributions or items contributed 		(c)
Noncash contribution amounts reported on
Form 990, Part VIII, line 1g 		(d)
Method of determining
noncash contribution amounts
1 Art—Works of art ....        
2 Art—Historical treasures .        
3 Art—Fractional interests ..        
4 Books and publications ..      
5 Clothing and household
goods ....... 		     
6 Cars and other vehicles ..        
7 Boats and planes ....        
8 Intellectual property ...        
9 Securities—Publicly traded .        
10 Securities—Closely held stock .        
11 Securities—Partnership, LLC,
or trust interests .... 		       
12 Securities—Miscellaneous ..        
13 Qualified conservation
contribution—Historic
structures ..... 		       
14 Qualified conservation
contribution—Other ... 		       
15 Real estate—Residential .        
16 Real estate—Commercial ..        
17 Real estate—Other ...        
18 Collectibles .....        
19 Food inventory ...        
20 Drugs and medical supplies .        
21 Taxidermy ......        
22 Historical artifacts ....        
23 Scientific specimens ..        
24 Archeological artifacts ...        
25 Other Right pointing arrow large image ( MEDICAL EQUIPMENT ) X 1 0 NONE
26 Other Right pointing arrow large image( )
27 Other Right pointing arrow large image( )
28 Other Right pointing arrow large image ( )
29
Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement ...
29
0
Yes
No
30a
During the year, did the organization receive by contribution any property reported in Part I, lines 1-28 that it
must hold for at least three years from the date of the initial contribution, and which is not required to be used
for exempt purposes for the entire holding period? ..................
30a
 
No
b
If "Yes," describe the arrangement in Part II.
31
Does the organization have a gift acceptance policy that requires the review of any non-standard contributions?
31
 
No
32a
Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash
contributions? ............................
32a
 
No
b
If "Yes," describe in Part II.
33
If the organization did not report revenues in column (c) for a type of property for which column (a) is checked,
describe in Part II.
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 51227J
Schedule M (Form 990) 2011
Schedule M (Form 990) 2011
Page 2
Part II
Supplemental Information. Complete this part to provide the information required by Part I, lines 30b,
32b, and 33 and whether the organization is reporting in Part I, column (b) the number of contributions, the number of items received, or a combination of both. Also complete this part for any additional information.
Identifier Return Reference Explanation
NON-CASH CONTRIBUTIONS SCHEDULE M, PART I, LINE 25 MEDICAL EQUIPMENT WAS DONATED TO THE HOSPITAL BY THE POMONA VALLEY HOSPITAL MEDICAL CENTER FOUNDATION, A RELATED ORGANIZATION. THE DONATION WAS NOT RECORDED ON THE HOSPITAL'S BOOKS.
Schedule M (Form 990) 2011
Additional Data


Software ID:  
Software Version:  
SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
POMONA VALLEY HOSPITAL MEDICAL CENTER
 
Employer identification number

95-1115230
Identifier Return Reference Explanation
ORGANIZATION'S MISSION FORM 990, PART III, LINE 1 POMONA VALLEY HOSPITAL MEDICAL CENTER IS A NOT FOR PROFIT, REGIONAL MEDICAL CENTER DEDICATED TO PROVIDING HIGH QUALITY, COST EFFECTIVE HEALTH CARE SERVICES TO RESIDENTS OF THE GREATER POMONA VALLEY. THE MEDICAL CENTER OFFERS A FULL RANGE OF SERVICES FROM LOCAL PRIMARY ACUTE CARE TO HIGHLY SPECIALIZED REGIONAL SERVICES. SELECTION OF ALL SERVICES IS BASED UPON COMMUNITY NEED, AVAILABILITY OF FINANCING, AND THE ORGANIZATION'S TECHNICAL ABILITY TO PROVIDE HIGH QUALITY RESULTS. BASIC TO OUR MISSION IS OUR COMMITMENT TO STRIVE CONTINUOUSLY TO IMPROVE THE STATUS OF HEALTH BY REACHING OUT AND SERVING THE NEEDS OF OUR DIVERSE COMMUNITY.
PROGRAM SERVICE ACCOMPLISHMENTS FORM 990, PART III, LINE 4A A NATIONALLY RECOGNIZED, NOT-FOR-PROFIT FACILITY, THE HOSPITAL'S SERVICES INCLUDE CENTERS OF EXCELLENCE IN ONCOLOGY AND CANCER CARE, CARDIAC AND VASCULAR CARE, WOMEN'S AND CHILDREN'S SERVICES, AND KIDNEY STONES. SPECIALIZED SERVICES INCLUDING CENTERS FOR BREAST HEALTH, SLEEP DISORDERS, A NEONATAL ICU, A PERINATAL CENTER, PHYSICAL THERAPY/SPORTS MEDICINE, A FULL-SERVICE EMERGENCY DEPARTMENT WHICH INCLUDES OUR LOS ANGELES COUNTY AND SAN BERNARDINO COUNTY STEMI RECEIVING CENTER DESIGNATION, ROBOTIC SURGERY, AND THE FAMILY MEDICINE RESIDENCY PROGRAM AFFILIATED WITH UCLA. SATELLITE CENTERS IN CHINO HILLS, CLAREMONT AND POMONA PROVIDE A WIDE RANGE OF OUTPATIENT SERVICES INCLUDING PHYSICAL THERAPY, URGENT CARE, RADIOLOGY AND OCCUPATIONAL HEALTH. WE HAVE RECENTLY EARNED OUR PRIMARY STROKE CENTER CERTIFICATION. THE JOINT COMMISSION RECENTLY NOTIFIED US THAT WE HAVE EARNED THE GOLD SEAL OF APPROVAL FOR CERTIFICATION AS A PRIMARY STROKE CENTER FOR LOS ANGELES COUNTY, ALONG WITH BEING NAMED ONE OF THOMSON REUTER'S 2011 50 TOP CARDIO HOSPITALS IN THE NATION DEMONSTRATES WHAT WE HAVE BEEN DOING ALL ALONG; PROVIDING QUALITY CARDIOVASCULAR CARE IN THE HEART OF OUR COMMUNITY. AS A COMMUNITY HOSPITAL, WE CONTINUOUSLY REFLECT UPON OUR RESPONSIBILITY TO PROVIDE HIGH QUALITY HEALTH CARE SERVICES, ESPECIALLY TO OUR MOST VULNERABLE POPULATIONS IN NEED, AND TO RENEW OUR COMMITMENT WHILE FINDING NEW WAYS TO FULFILL OUR CHARITABLE PURPOSE. PART OF THAT COMMITMENT IS SUPPORTING ADVANCED LEVELS OF TECHNOLOGY, STAFFING, TRAINING, EQUIPMENT, AND FACILITIES. PVHMC WORKS VIGOROUSLY TO MEET OUR ROLE IN MAINTAINING A HEALTHY COMMUNITY BY IDENTIFYING HEALTH-RELATED PROBLEMS AND DEVELOPING WAYS TO ADDRESS THEM. PVHMC DEMONSTRATES ITS PROFOUND COMMITMENT TO ITS LOCAL COMMUNITY, BOTH HISTORICALLY AND ON A CONTINUING BASIS. PVHMC HAS WELCOMED THIS OCCASION TO FORMALIZE, ENHANCE AND DOCUMENT THE MULTITUDE OF COMMUNITY BENEFIT INITIATIVES IN WHICH THE HOSPITAL IS IMMERSED. OUR EMERGENCY DEPARTMENT (ED) IS ONE OF THE FOCUSES FOR THIS YEAR'S COMMUNITY BENEFIT PLAN. IN RECOGNIZING THAT OVERCROWDED ED'S IS A NATIONWIDE CRISIS, PVHMC WANTED TO EXPLORE HOW THE HOSPITAL MET THE NEEDS OF OUR COMMUNITY AND WHAT THE HOSPITAL WAS DOING FOR THE FUTURE TO DETER MUCH OF THE PRESSURE BEING PLACED ON OUR OVERCROWDED ED. THE EMERGENCY DEPARTMENT IS OFTEN STILL THE SOURCE OF PRIMARY HEALTH CARE FOR MANY OF OUR RESIDENTS, ALTHOUGH WE CONTINUE TO PROVIDE OUTREACH AND EDUCATE THE COMMUNITY ON OTHER RESOURCES AVAILABLE TO THEM. THE ED AT PVHMC IS A VITAL COMPONENT OF THE WELL-BEING OF OUR COMMUNITY RESIDENTS. AS A PRIVATE COMMUNITY SAFETY NET HOSPITAL, ALSO WITH THE DESIGNATION AS A DISPROPORTIONATE SHARE HOSPITAL ("DSH"), WE CARE FOR A GREATER POPULATION OF LOW-INCOME, MEDICALLY VULNERABLE PATIENTS. THEY OFTEN REQUIRE AN INCREASED NEED OF ACCESSIBLE, HIGH QUALITY, AND COST-EFFECTIVE HEALTH CARE SERVICES. WE DELIVER CARE TO ALL PATIENTS IN OUR ED, WITH OR WITHOUT INSURANCE. THE NECESSITY TO IMPROVE AND BUILD UPON THE EFFICIENCY OF OUR ED IS CRITICAL FOR PVHMC IN ORDER FOR US TO KEEP UP WITH THE GROWING DEMANDS BEING PLACED UPON OUR SYSTEM EVERY DAY. IN ADDITION TO THE EMERGENCY DEPARTMENT AS A FOCUS FOR THIS YEAR'S COMMUNITY BENEFIT PLAN WE WILL BE EXPLORING COMMUNITY REQUESTS FOR MORE CLASSES AND SUPPORT GROUPS ON A VARIETY OF HEALTH RELATED TOPICS. IN 2012, A COMMUNITY NEEDS ASSESSMENT WAS COMPLETED. THE ASSESSMENT IS INTENDED TO BE A RESOURCE FOR PVHMC TO BECOME INVOLVED WITH DEVELOPING AND MAINTAINING ACTIVITIES AND PROGRAMS THAT CAN HELP IMPROVE THE HEALTH AND WELL-BEING OF THE RESIDENTS OF POMONA VALLEY. THE RESEARCH OBJECTIVES WERE TO LOOK AT THE DEMOGRAPHIC PROFILE OF THE COMMUNITY, HEALTH INSURANCE COVERAGE, HEALTH ACCESS BARRIERS, UTILIZATION OF HEALTH CARE SERVICES FOR ROUTINE PRIMARY/PREVENTATIVE CARE, UTILIZATION OF URGENT CARE SERVICES, NEED FOR SPECIALTY HEALTH CARE AND EXPERIENCE WITH PVHMC INCLUDING CLASSES, SUPPORT GROUPS, AND THE EMERGENCY ROOM. IN THE 2012 FINDINGS, OUT OF 138 RESPONSES, 99 (OR 73.3%) OF THE PATIENTS WHO VISITED THE EMERGENCY DEPARTMENT (ED) SAID THEY DID NOT TRY TO SEE THEIR DOCTOR BEFORE GOING TO THE ED. THE MAIN REASONS GIVEN FOR NOT TRYING TO SEE THEIR DOCTOR FIRST WERE BECAUSE IT WAS AFTER HOURS (32 OR 36%), IT WAS AN EMERGENCY SITUATION (22 OR 24.7%), OR THEY WERE BROUGHT BY AMBULANCE (15 OR 16.9%). MORE PATIENTS USED THE ED WHEN IT SEEMED APPROPRIATE AS IT RELATED TO THE DAY AND TO THE EXTENT OF THE EMERGENCY COMPARED TO THE 2008 COMMUNITY NEEDS ASSESSMENT. WE ARE DOING A BETTER JOB OF INFORMING OUR COMMUNITIES OF THE DIFFERENCES BETWEEN EMERGENT SITUATIONS AND WHAT CAN WAIT FOR A VISIT WITH THEIR PRIMARY CARE PHYSICIAN, AND THE USE OF URGENT CARE SERVICES. IN ADDITION, WE CAN DO MORE TO MAKE USE OF OUR PRIMARY CARE AND URGENT CARE SERVICES TO MEET THE NEEDS OF OUR COMMUNITY AND OFFLOAD A LARGE PROPORTION OF THE PRESSURE ON OUR EMERGENCY DEPARTMENT. MANY OF THE ACTIVITIES AND PROGRAMS IN OUR COMMUNITY BENEFIT PLAN ADDRESS IDENTIFIED PUBLIC HEALTH NEEDS. THE MAJORITY OF OUR SERVICES ARE TIED INTO PROVIDING INFORMATION AND EDUCATION TO THE COMMUNITY REGARDING AVAILABILITY AND ACCESSIBILITY TO HEALTH AND SOCIAL SERVICES. BY FOSTERING GREATER COORDINATION AND COLLABORATION AMONG LOCAL SERVICE PROVIDERS, WE ARE ABLE TO CONTINUE TO OFFER COMPREHENSIVE MEDICAL SERVICES AND PROGRAMS TO A LARGE COMMUNITY. OUR SERVICES SHOW HOW THE COMMUNITY'S NEEDS DRIVE THE CONCEPTION AND ESTABLISHMENT OF THE SERVICES WE PROVIDE AND CONTRIBUTE TO ITS GROWTH AND IMPROVEMENT. EVERY ACTIVITY AND PROGRAM IS BUDGETED TO MANAGE THE USE OF AVAILABLE RESOURCES. OUR COMMITMENT TO THESE VITAL SERVICES IS DEMONSTRATED THROUGH THE CONCERTED EFFORTS OF EACH DEPARTMENT TO ENSURE THAT ESSENTIAL SERVICES CONTINUE TO BE PROVIDED TO THE COMMUNITY. OUR COMMUNITY IS CENTRAL TO US, AND IT IS REPRESENTED IN ALL OF THE WORK WE DO. PVHMC HAS SERVED THE POMONA VALLEY FOR OVER 100 YEARS, AND WE VALUE MAINTAINING THE HEALTH OF OUR COMMUNITY BY PROVIDING ACCESSIBLE, HIGH QUALITY MEDICAL CARE. THANK YOU FOR TAKING THE TIME TO ALLOW US TO SHARE WITH YOU OUR COMMUNITY ACTIVITIES AND PROGRAMS FOR THE MOST RECENT YEAR.
ABOUT PVHMC   PRESIDENT/CHIEF EXECUTIVE OFFICER, RICHARD E. YOCHUM AND CHAIRMAN, BOARD OF DIRECTORS, ROGER GINSBURG. OUR ORGANIZATIONAL STRUCTURE - PVHMC IS GOVERNED BY A BOARD OF DIRECTORS WHOSE MEMBERS ARE REPRESENTATIVE OF THE COMMUNITY, HOSPITAL AND MEDICAL STAFF LEADERSHIP. OUR MISSION - PVHMC IS A NOT-FOR-PROFIT REGIONAL MEDICAL CENTER DEDICATED TO PROVIDING HIGH QUALITY, COST EFFECTIVE HEALTH CARE SERVICES TO RESIDENTS OF THE GREATER POMONA VALLEY. THE MEDICAL CENTER OFFERS A FULL RANGE OF SERVICES FROM LOCAL PRIMARY ACUTE CARE TO HIGHLY SPECIALIZED REGIONAL SERVICE. SELECTION OF ALL SERVICES IS BASED ON COMMUNITY NEED, AVAILABILITY OF FINANCING AND THE ORGANIZATION'S TECHNICAL ABILITY TO PROVIDE HIGH QUALITY RESULTS. BASIC TO OUR MISSION IS OUR COMMITMENT TO STRIVE CONTINUOUSLY TO IMPROVE THE STATUS OF HEALTH BY REACHING OUT AND SERVING THE NEEDS OF OUR DIVERSE ETHNIC, RELIGIOUS AND CULTURAL COMMUNITY. OUR COMMUNITY - PVHMC IS DEDICATED TO MEETING THE HEALTH CARE DEMANDS OF THE GROWING POPULATIONS OF LOS ANGELES AND SAN BERNARDINO COUNTIES. OUR PRIMARY SERVICE AREA IS DEFINED AS THE CITIES OF POMONA, CLAREMONT, CHINO, CHINO HILLS, LA VERNE, MONTCLAIR, ONTARIO, RANCHO CUCAMONGA, ALTA LOMA, UPLAND AND SAN DIMAS AND MAKE UP A POPULATION OF 840,789. IN 2010 AS DERIVED FROM THE STATISTICS REPORTED BY THE U.S. CENSUS BUREAU. THE ETHNIC DIVERSITY REPRESENTED BY THE DEMOGRAPHICS OF THE CITY OF POMONA IN 2010 WAS SUCH THAT 33.6% IS HISPANIC OR LATINO, 14.4% IS WHITE, 7.3% IS BLACK/AFRICAN-AMERICAN, 8.5% IS ASIAN, 1.2% IS AMERICAN INDIAN, 0.2% HAWAIIAN/PACIFIC ISLANDER, 30.3% IS OTHER, AND 4.5% IS TWO OR MORE RACES, ACCORDING TO THE U.S. CENSUS BUREAU. COMMUNITY BENEFIT PLAN FOCUS STUDY - DURING THE SUMMER OF 2009, THE EMERGENCY DEPARTMENT RECEIVED A MODERATE COSMETIC RECONSTRUCTION THAT INCLUDED A REFRESH OF THE WAITING ROOM. THE CHANGE PROVIDED MORE COMFORT FOR OUR PATIENTS AS WE EXPAND OUR SERVICES. PVHMC RECOGNIZES THE IMPORTANCE OF EMERGENCY CARE SERVICES TO THE COMMUNITY AND WE ARE COMMITTED TO MEETING THE NEEDS OF OUR PATIENTS. OUR HOSPITAL HAS LEARNED FROM EVALUATIONS OF THE ED THAT THE NECESSITY TO IMPROVE AND BUILD UPON THE EFFICIENCY OF OUR ED IS CRITICAL IN ORDER TO KEEP UP WITH THE GROWING DEMANDS BEING PLACED UPON OUR SYSTEM EVERYDAY. OUR ED HAS BEEN ENHANCED WITH ROUND THE CLOCK PHYSICIAN COVERAGE OF FULL-TIME LABORISTS (HOSPITAL-BASED OBSTETRICS/GYNECOLOGY PHYSICIANS WHO DO DELIVERIES), A HOSPITALIST TEAM, AND A DEDICATED INTENSIVIST PROGRAM IN THE INTENSIVE CARE UNIT (ICU). A FULL SERVICE ED BACK UP CALL PROVIDES ADEQUATE COVERAGE OF SPECIALISTS WHICH IS CRITICAL TO THE ABILITY OF THE HOSPITAL TO PROVIDE SPECIALTY MEDICINE TO PATIENTS. THE CALIFORNIA EMERGENCY PHYSICIAN GROUP (CEP) AT POMONA VALLEY HOSPITAL MEDICAL CENTER HAS DEVELOPED AND PIONEERED A NUMBER OF PROVEN BEST PRACTICES REFERRED TO COLLECTIVELY AS THE RAPID MEDICAL EVALUATION (RME) METHODOLOGY TO EXPEDITE ED CARE AND THROUGHPUT. THIS ALLOWS THE PROVIDER TO EVALUATE THE PATIENT AND BEGIN TREATMENT AS QUICKLY AS POSSIBLE. IT ALLOWS FOR PARALLEL PROCESSING OF ED PATIENT THUS IMPROVING OPERATIONAL EFFICIENCY, PATIENT FLOW, AND PATIENT'S SATISFACTION, WHILE DECREASING DIVERSION TIME AND ED OVERCROWDING. GOALS OF THE RME PROGRAM INCLUDE: - INITIAL PROVIDER EVALUATION WILL OCCUR IMMEDIATELY UPON A PATIENT'S ARRIVAL; - ORDERS WILL BE INITIATED IMMEDIATELY; AND, - BED AVAILABILITY WILL NOT DELAY A PATIENT FROM SEEING A PROVIDER IMMEDIATELY. AS ED VOLUME CONTINUED TO INCREASE, THE ED HAS ADDED ADDITIONAL NURSING STAFF (A TOTAL OF 23 LICENSED AS COMPARED TO 19 IN 2009) AS WELL AS ADDITIONAL PROVIDER (PHYSICIAN/PHYSICIAN ASSISTANT) COVERAGE TO HAVE A PROVIDER IN TRIAGE DURING THE TIMES OF HEAVIEST PATIENT VOLUMES. SHIFTS ARE FROM 10:00 AM TO 10:00 PM. WE HAVE REDUCED THE PERCENT OF "LEFT WITHOUT BEING SEEN" TO 1.07% FOR 2011 (COMPARED WITH THE NATIONAL AVERAGE OF 1.4%). WE HAVE DECREASED OUR AVERAGE "DOOR-TO-PROVIDER TIME" IN 2011 TO 25-MINUTES AND REACHED OUR GOAL OF 40-MINUTES (CALIFORNIA EMERGENCY PHYSICIAN GROUP) WHICH CONTINUES TO BE OUR GOAL FOR 2012. AS A DESIGNATED STEMI RECEIVING CENTER (SRC) IN BOTH LOS ANGELES AND SAN BERNARDINO COUNTIES, PVHMC BECAME THE FIRST HOSPITAL IN THE REGION WITH DUAL COUNTY DESIGNATION. AN ACUTE HEART ATTACK CAUSED BY BLOOD CLOTS IS CALLED AN ST-ELEVATED MYOCARDIAL INFARCTION, OR STEMI. WITHOUT RAPID ANGIOPLASTY, HEART MUSCLE IS PERMANENTLY DAMAGED. IN ORDER TO QUALIFY FOR THIS DESIGNATION, HOSPITALS ARE REQUIRED TO PROVIDE ANGIOPLASTY TREATMENT IN LESS THAN 90 MINUTES. CURRENTLY, PVHMC AVERAGES 50-MINUTE DOOR-TO-BALLOON TIMES, RANKING IN THE TOP 5 PERCENT NATIONALLY. THE STEAD HEART AND VASCULAR CENTER OFFERS ONE OF THE MOST COMPLETE LINES OF CARDIOVASCULAR AND STROKE SERVICES IN LOS ANGELES AND SAN BERNARDINO COUNTIES. STROKE IS A MAJOR PUBLIC HEALTH CONCERN FOR OUR COMMUNITY. AS THE 2ND LEADING CAUSE OF DEATH, IN THE SAN GABRIEL VALLEY, PVHMC RECOGNIZED THAT OUR COMMUNITY WAS SIGNIFICANTLY UNDERSERVED WITH REGARD TO STROKE CARE, CARING FOR MORE THAN 500 STROKE PATIENTS ANNUALLY. PVHMC BEGAN TO WORK WITH THE LOS ANGELES COUNTY EMS AGENCY TO ADDRESS THIS NEED. IN 2009 LOS ANGELES COUNTY EMS AGENCY ESTABLISHED A PRIMARY STROKE CENTER APPROACH, DIRECTING EMS PROVIDERS TO BYPASS LOCAL COMMUNITY HOSPITALS AND TAKE STROKE VICTIMS TO PRIMARY STROKE CENTERS. PRIMARY STROKE CENTERS ARE REQUIRED TO ABIDE BY THE REGULATORY GUIDELINES SET FORTH BY THE JOINT COMMISSION. IN 2010 ONLY 13 PRIMARY STROKE CENTERS WERE RECOGNIZED BY LOS ANGELES COUNTY, ALL MORE THAN THIRTY MILES WEST OF THE POMONA VALLEY, WITH TRANSPORT TIMES DURING PEAK COMMUTE TRAFFIC OF MORE THAN 60 MINUTES. THE COORDINATION OF CARE FOR SAN BERNARDINO COUNTY STROKE VICTIMS WAS EVEN MORE DISMAL WITH VERY LIMITED SERVICES SPREAD ACROSS THE LARGEST COUNTY IN AMERICA. IN 2011 PVHMC BECAME ONE OF THE FIRST TWO PRIMARY STROKE CENTER FOR SAN BERNARDINO COUNTY, PRIMARY STROKE CENTERS. POMONA VALLEY HOSPITAL MEDICAL CENTER DEVELOPED AND CONTINUES TO SUPPORT A PRIMARY STROKE CENTER PROGRAM IMPLEMENTING CARE COORDINATION TO MEET THE NEEDS OF OUR COMMUNITY: - CALL COVERAGE CONTRACT TO ADDRESS 24/7/365 RAPID AND TIMELY RESPONSE OF OUR NEUROLOGISTS * $172,500/YEAR CALL COVERAGE - CONDUCTED A MINIMUM OF 8 HOURS OF TRAINING FOR ALL NURSING STAFF IN STROKE UNITS WITHIN THE HOSPITAL (OVER 300 NURSES). * $96,000/ YEAR OF MANDATED TRAINING - MANDATED NATIONAL INSTITUTE OF HEALTH STROKE SCALE TRAINING AND CERTIFICATION OF ALL ED STAFF NURSES AND STROKE UNIT CHARGE NURSES ( APPROX. 150 NURSES) * $24,000/YEAR OF MAINTAINED CERTIFICATION - PROVIDE 3 ANNUAL PHYSICIAN CME/EDUCATIONAL FORUMS * $12,000/YEAR - DEVELOPED A STROKE COORDINATOR POSITION TO PROVIDE CARE COORDINATION, PROGRAM IMPLEMENTATION AND COMPLIANCE * $120,000/YEAR - PROVIDE 20 COMMUNITY EDUCATION FORUMS, SYMPOSIUMS AND OUTREACH ANNUALLY * $3,900/YEAR - DEVELOPED EDUCATIONAL AND OUTREACH MATERIAL TO EDUCATE THE COMMUNITY OF THE EARLY WARNING SIGNS OF STROKE * $15,000/YEAR - PROVIDE MONTHLY EMS AGENCY EDUCATION PROGRAMS * $7,800 - PRIMARY STROKE CENTER CERTIFICATION FEES * $5,000/ YEAR THE JOINT COMMISSION FEE * $20,000/YEAR SAN BERNARDINO PRIMARY STROKE CENTER DESIGNATION FEE
POMONA VALLEY HOSPITAL MEDICAL CENTER NOW SERVES MORE THAN 650 STROKE AND TIA VICTIMS ANNUALLY. ANOTHER ACCOMPLISHMENT IN THE ED IS THE ADDITION OF BIOSITE CARDIAC/SHORTNESS OF BREATH LABORATORY POINT-OF-CARE TESTING. THIS ALLOWS FOR A FASTER, RELIABLE BEDSIDE LAB TEST FOR ANY PATIENTS THAT COME TO THE ED PRESENTING WITH CHEST PAIN AND SHORTNESS OF BREATH. USING BIOSITE REDUCES THE TIME TO RECEIVE RESULTS FROM 1-1.5 HOURS TO 15 MINUTES AND REDUCES A PATIENT'S OVERALL TURN-AROUND TIME BY AS MUCH AS AN HOUR. INITIALLY ESTABLISHED IN 2009, WE CONTINUE TO UTILIZE THE ED SURGE CAPACITY PLAN CALLED "CAPACITY ALERT". THIS ALERT IS INITIATED DURING PERIODS OF HIGH ED CENSUS AND ESTABLISHES A HOSPITAL WIDE RESPONSE TO ASSIST IN FACILITATING ED ADMISSIONS TO THE FLOOR AND THEREBY RESTORING ED CAPACITY. ALONG WITH THE PROGRESS WE HAVE MADE TO IMPROVE EMERGENCY CARE SERVICES ON OUR MAIN CAMPUS, AND RECOGNIZING THAT THE ED IS STILL A SOURCE OF PRIMARY HEALTH CARE FOR THE COMMUNITY, WE HAVE INCREASED ACCESS TO PRIMARY HEALTH CARE SERVICES OUTSIDE OF THE HOSPITAL'S ED. WE ADDRESSED THE NEED FOR ADDITIONAL ACCESS THROUGH THE DEVELOPMENT OF OUR FAMILY MEDICINE RESIDENCY PROGRAM IN THE MID 1990'S TO HELP ADDRESS THE LOOMING SHORTAGE IN PRIMARY CARE PROVIDERS. OVER TIME, PVHMC AND THE RESIDENCY FACULTY MEDICAL GROUP WORKED TOGETHER TO PROVIDE ADDITIONAL ACCESS POINTS THROUGHOUT OUR COMMUNITY IN ADDITION TO THE POMONA BASED FAMILY HEALTH CENTER. THROUGH THE RECRUITMENT OF GRADUATING RESIDENTS WE OPENED AND STAFFED THE POMONA VALLEY HEALTH CENTER IN CHINO HILLS (OPENED IN 2003, REPLACING A SMALLER OFFICE THAT HAD OPENED IN 1999); THE POMONA VALLEY HEALTH CENTER AT CROSSROADS (ALSO IN CHINO HILLS, OPENED IN 2007) AND THE POMONA VALLEY HEALTH CENTER IN CLAREMONT (OPENED IN 2009). IN TOTAL, THESE NETWORKED CENTERS OFFER FAMILY MEDICINE, URGENT CARE, PHYSICAL THERAPY AND REHABILITATION, SLEEP MEDICINE AND WIDE RANGING IMAGING SERVICES. THESE SITES ARE DIGITALLY CONNECTED THROUGH AN ELECTRONIC MEDICAL RECORD THAT ALLOWS ACCESS TO PATIENT HISTORY THROUGHOUT THE SYSTEM. ANOTHER PROJECT TO EXPAND ACCESS TO PRIMARY CARE SERVICES IN OUR COMMUNITY IS THE GROWTH OF THE POMONA COMMUNITY HEALTH CENTER. BEGINNING IN THE MID 1990'S, AND PARTNERING WITH A GRADUATING FAMILY MEDICINE RESIDENT, THE HOSPITAL WORKED WITH LOS ANGELES COUNTY AND OTHER COMMUNITY PARTNERS TO OPEN THE POMONA COMMUNITY HEALTH CENTER WITHIN THE L.A. COUNTY DEPARTMENT OF PUBLIC HEALTH. THIS SMALL, TWO EXAM ROOM CLINIC, OFFERED FREE PRIMARY CARE TO UNINSURED COUNTY RESIDENTS AS AN OUTPATIENT SERVICE OF THE HOSPITAL. IN 2010, THE CLINIC AND HOSPITAL ORCHESTRATED A SUCCESSFUL SEPARATION OF THE CLINIC INTO ITS OWN NOT-FOR-PROFIT COMMUNITY CLINIC AND BEGAN A PROCESS THAT WOULD ALLOW IT TO BE ACCREDITED AS A FEDERALLY QUALIFIED HEALTH CENTER WHILE EMBARKING ON A CAPITAL GRANT CAMPAIGN TO ALLOW FOR EXPANSION TO BOTH ADD CAPACITY AND ALLOW FOR IT TO SERVE UN AND UNDERINSURED RESIDENTS OF SAN BERNARDINO COUNTY AS WELL. IN OCTOBER OF 2011 THE PCHC RECEIVED THEIR FEDERAL DESIGNATION, AND A SUCCESSFUL CAPITAL CAMPAIGN HAS ALLOWED FOR THE RECENT COMPLETION AND FURNISHING OF A 13 BED FEDERALLY QUALIFIED HEALTH CENTER. THE NEW SITE IS LOCATED IN POMONA, IN A MULTI SERVICES MALL OWNED BY THE POMONA UNIFIED SCHOOL DISTRICT, AND SITS A FEW HUNDRED YARDS FROM THE SAN BERNARDINO COUNTY LINE, ALLOWING FOR EASY ACCESS. THE SITE IS SCHEDULED TO OPEN IN MID-2012 AND IS SIZED TO PROVIDE A MEDICAL HOME THAT HAS THE CAPACITY FOR 25,000 ANNUAL PATIENT VISITS THAT WILL BE TARGETED TO THE LOW INCOME COMMUNITY. THE HOSPITAL CONTINUES TO PROVIDE GAP OPERATIONAL FUNDING FOR THE PROGRAM IN THE FORM OF A COMMUNITY BENEFIT GRANT OF UP TO $1.5 MILLION PER YEAR. SINCE THE OPENING OF THESE NEW SITES WE HAVE SEEN YEAR OVER YEAR GROWTH IN OUR PRIMARY CARE AND URGENT CARE BASE. THE ADDITION OF THESE 29 URGENT CARE BEDS TO THE REGION HAS HELPED RELIEVE PVHMC'S EMERGENCY ROOM BURDEN BY OFFERING A MORE DISEASE APPROPRIATE SETTING FOR MANY PRIMARY CARE NEEDS. THE INTEGRATED PRIMARY CARE COMPONENTS, LICENSED AS COMMUNITY HEALTH CENTERS, ARE THEN AVAILABLE TO SERVE AS PRIMARY CARE HOMES FOR PATIENTS WHO MAY HAVE SEEN THE EMERGENCY ROOM AS THEIR PRIMARY SOURCE OF HEALTH CARE. COMMUNITY BENEFIT ACTIVITIES AND PROGRAMS - THE EXAMPLES PRESENTED IN THIS REPORT ARE INSIGHTS INTO A COMMUNITY ACTIVELY INVOLVED IN IMPROVING THE HEALTH STATUS OF RESIDENTS LIVING IN THE POMONA VALLEY. COMMUNITY HEALTH IMPROVEMENT SERVICES AND COMMUNITY BENEFIT OPERATIONS-IN ADDITION TO THE ASSISTANCE IN OPENING THE POMONA COMMUNITY HEALTH CENTER THE HOSPITAL ALSO HAS OTHER IMPORTANT COMMUNITY BASED PROGRAMS. THE NEWBORN ABANDONMENT PREVENTION LAW ALLOWS A PARENT OF A NEWBORN LESS THAN 72 HOURS OF AGE TO RELINQUISH THEIR BABY ANONYMOUSLY TO AN EMPLOYEE AT ANY HOSPITAL ED WITHIN THE STATE OF CALIFORNIA. PVHMC CREATED A PRIVATE AREA OUTSIDE OF THE ED FOR THIS PURPOSE, THE SAFE SURRENDER PROGRAM. THE PROGRAM HAS BEEN SHARED WITH LOCAL SCHOOLS AND COMMUNITY PROGRAMS; HOWEVER, THE NEED TO INCREASE AWARENESS IS CRUCIAL TO THE ONGOING SUCCESS OF THE PROGRAM. MANY DEPARTMENTS IN THE HOSPITAL OFFER CLASSES TO THE COMMUNITY AND SUPPORT GROUPS WITH TRAINED PROFESSIONALS. IN WOMEN'S AND CHILDREN'S SERVICES, MANY OF THE CLASSES ("CHILDBIRTH PREPARATION", "YOUR CESAREAN", "BIG BROTHER/BIG SISTER") OFFERED AT THE HOSPITAL ARE NOT AVAILABLE AT NEIGHBORING HOSPITALS. PVHMC OFFERS FREE SUPPORT GROUPS ("BOOTCAMP FOR DADS", "MOMMY N ME"). A HEALTH NEWSLETTER "REGARDING WOMEN" IS DISTRIBUTED QUARTERLY TO RESIDENTS IN THE COMMUNITY. AT THE ROBERT AND BEVERLY LEWIS FAMILY CANCER CARE CENTER (CCC), THERE ARE PATIENT WORKSHOPS ("LAUGHTER YOGA"), AND SUPPORT GROUPS ("LOOK GOOD...FEEL BETTER", "LIVING IN THE HERE & NOW"). WE ALSO HAVE A SPECIAL "KIDS GROUP" FOR AGES 7 THROUGH 17 WHO HAVE A PARENT OR LOVED ONE WITH CANCER TO PROVIDE UNDERSTANDING AND COPING SKILLS. THE STEAD HEART AND VASCULAR CENTER (SHVC) OFFERS HEART FAILURE EDUCATION AND AWARENESS TO RECOGNIZE RISK FACTORS, SIGNS AND SYMPTOMS. THERE IS ALSO A HEART FAILURE PROGRAM THAT HELPS PATIENTS IN MAINTAINING THEIR DISEASE AND PROVIDES SUPPORT LEADING TO DECREASED SUBSEQUENT HOSPITALIZATIONS. THE STEAD HEART FOR WOMEN PROGRAM PROVIDES EDUCATION, SUPPORT AND RESOURCES SPECIFICALLY ON HEART DISEASE AND STROKE PREVENTION. WE RECOGNIZE THE IMPORTANCE OF PREVENTIVE HEALTH AND WE PARTICIPATE AND ORGANIZE COMMUNITY HEALTH FAIRS WITH HEALTH CARE INFORMATION AND HEALTH SCREENINGS. THE VOLUNTEER SERVICES DEPARTMENT ORGANIZES FLU SHOTS IN A DRIVE-THRU SETTING WITH THE HELP OF PVHMC'S NURSES. PVHMC WORKS WITH LA COUNTY AND LOCAL NOT-FOR-PROFIT ORGANIZATIONS TO PUT TOGETHER AN ANNUAL KIDS HEALTH FAIR PROVIDING FREE HEALTH SCREENINGS, IMMUNIZATIONS AND MEDICAL INFORMATION FOR UNINSURED AND UNDER-INSURED CHILDREN AGES TWO MONTHS TO 18 YEARS. THE CCC OFFERS EARLY DETECTION (SKIN SCREENINGS) AND PREVENTION. THE EPIDEMIOLOGY AND INFECTION CONTROL DEPARTMENT EDUCATES THE COMMUNITY ON INFECTION CONTROL AWARENESS, HAND HYGIENE AND DEMONSTRATION, AND HOME CLEANLINESS. THEY ALSO OFFER EDUCATION TO THE COMMUNITY REGARDING FLU SEASON AND COUGH ETIQUETTE. THE SLEEP CENTER PROVIDES AWAKE MEETINGS TO EDUCATE THE COMMUNITY ON NEW MASKS AND MACHINES. THE RESPIRATORY SERVICES DEPARTMENT OFFERS FREE ASTHMA EDUCATION, AVAILABLE IN SPANISH, AND A SMOKING CESSATION PROGRAM. BREATHING BUDDIES IS A SUPPORT GROUP FOR SENIORS WHO HAVE CHRONIC LUNG DISEASE BY PROVIDING THE LATEST HEALTH INFORMATION, REVIEWING THEIR MEDICATIONS, AND PROVIDING INSTRUCTION (E.G., ON HOW TO TRAVEL WITH OXYGEN). THE FOOD AND NUTRITION SERVICES DEPARTMENT OFFERS POR LA VIDA NUTRITION CLASSES FOR SPANISH SPEAKING COMMUNITY MEMBERS TO LEARN ABOUT HEALTHY EATING. HEALTH PROFESSIONS EDUCATION - OUR HOSPITAL PROVIDES MANY TRAINING OPPORTUNITIES THROUGH THE VARIOUS DEPARTMENTS THAT WORK WITH THE LOCAL COLLEGES AND HEALTH PROFESSIONAL PROGRAMS. PVHMC IS A CLINICAL SITE FOR NURSING STUDENTS IN PROGRAMS AT THE LOCAL COMMUNITY COLLEGES AND UNIVERSITIES. THE PARISH NURSE PROGRAM THROUGH THE SHVC EDUCATES AND TRAINS BOTH CLINICAL AND NON-CLINICAL SUPPORT STAFF. PVHMC'S FMRP TRAINS NURSE PRACTITIONER AND MEDICAL STUDENTS AT THE FHC. FNS PROVIDES OPPORTUNITIES FOR DIETETIC STUDENTS TO DO THEIR INTERNSHIP ROTATIONS AT PVHMC WHERE THEY LEARN ABOUT FOOD PRODUCTION AND MANAGEMENT. THE HOSPITAL IS ALSO A TRAINING LOCATION FOR PHLEBOTOMY, PHYSICIAN BILLING, RESPIRATORY AND SURGICAL TECH STUDENTS. IN RADIOLOGY, OUR HOSPITAL IS A TRAINING SITE FOR RADIOLOGIC TECHNOLOGY, ULTRASOUND AND NUCLEAR MEDICINE STUDENTS. WE ALSO WELCOME CHAPLAINS IN THE COMMUNITY TO RECEIVE CLINICAL CHAPLAIN TRAINING AT PVHMC. FOR THE MEDICAL COMMUNITY, THE HOSPITAL ORGANIZES WEEKLY CONTINUING MEDICAL EDUCATION AT NO COST TO PHYSICIANS. WE OFFER A PERINATAL SYMPOSIUM WHICH IS LABOR AND DELIVERY AND NEONATAL EDUCATION. THE CCC OFFERS SEMINARS ON LUNG AND GASTROINTESTINAL CANCERS.
SUBSIDIZED HEALTH SERVICES   PVHMC IS A MAJOR PROVIDER IN OUR REGION, PARTICULARLY FOR MEDI-CAL AND INDIGENT PATIENTS IN BOTH LOS ANGELES AND SAN BERNARDINO COUNTIES. IT IS ESSENTIAL FOR OUR HOSPITAL'S ED TO HAVE ADEQUATE COVERAGE OF SPECIALISTS TO PROVIDE NEEDED SPECIALTY MEDICINE TO PATIENTS. IN ADDITION, WE HAVE ROUND THE CLOCK PHYSICIAN COVERAGE OF FULL-TIME LABORISTS (HOSPITAL-BASED OB/GYN PHYSICIANS WHO DO DELIVERIES), A HOSPITALIST TEAM, AND A DEDICATED INTENSIVIST PROGRAM IN THE INTENSIVE CARE UNIT. RESEARCH - THE ROBERT AND BEVERLY LEWIS FAMILY CANCER CARE CENTER OF PVHMC PARTICIPATES IN CLINICAL RESEARCH STUDIES IN BREAST CANCER, GASTROINTESTINAL CANCERS, HEAD & NECK CANCERS, LUNG CANCER, PROSTATE CANCER, AND SYMPTOM MANAGEMENT. CASH AND IN-KIND CONTRIBUTIONS - OUR HOSPITAL PROVIDES SUPPORT TO VARIOUS LOCAL COMMUNITY SERVICE ORGANIZATIONS INCLUDING THE HOUSE OF RUTH (SERVICES AND ASSISTANCE TO VICTIMS OF DOMESTIC VIOLENCE), PROJECT SISTER (SEXUAL ASSAULT CRISIS AND PREVENTION SERVICES), AND YMCA. IN-KIND CONTRIBUTIONS TO OUR PATIENTS AND TO THE COMMUNITY INCLUDE TOYS GIVEN TO PEDIATRIC SURGERY PATIENTS. THE FACILITIES DEPARTMENT PARTICIPATES IN THE CITY-WIDE CLEAN BY DONATING STAFF AND SUPPLIES. FOOD AND NUTRITION SERVICES "MEALS ON WHEELS" PROGRAM PROVIDES FOOD TO HOMEBOUND MEMBERS OF OUR COMMUNITY AND DONATES CANNED FOODS TO THE SALVATION ARMY "PROJECT SHIELD & SHELTER." OUR VOLUNTEER SERVICES DEPARTMENT GIVES INFANT LAYETTES AND CAR SEATS TO NEEDY FAMILIES. THE CANCER CARE CENTER GIVES WIGS TO PATIENTS AT NO COST. COMMUNITY BUILDING ACTIVITIES - PVHMC WORKS WITH LOCAL AREA MIDDLE AND HIGH SCHOOLS AS WELL AS GIRL SCOUTS AND SCHOOL GROUPS TO INTRODUCE CAREERS IN HEALTH CARE BY INVITING THEM TO TOUR OUR HOSPITAL AND BY VISITING THEM ON THEIR CAMPUS (CLAREMONT HIGH SCHOOL CAREER DAY). PVHMC PARTICIPATES IN LA COUNTY SERVICE PLANNING AREA 3'S HEALTH PLANNING GROUP ON THE STEERING COMMITTEE AND THE SPECIALTY CARE COALITION. PVHMC IS A ONE OF 13 DESIGNATED DISASTER RESOURCE CENTERS (DRC) IN LOS ANGELES COUNTY AS PART OF THE NATIONAL BIOTERRORISM HOSPITAL PREPAREDNESS PROGRAM. AS THE DRC FOR THE REGION, PVHMC IS RESPONSIBLE FOR 10 "UMBRELLA" FACILITIES IN THE AREA AND COORDINATES DRILLS, TRAINING, AND SHARING OF PLANS TO BRING TOGETHER THE COMMUNITY AND OUR RESOURCES FOR DISASTER PREPAREDNESS. PLANS FOR 2012/2013 PUBLIC REVIEW - PVHMC PLANS TO CONTINUE SUPPORTING ITS VARIED COMMUNITY BENEFIT ACTIVITIES AND PROGRAMS CURRENTLY IN PLACE. THE COMMUNICATION OF OUR COMMUNITY BENEFIT IS A COMBINATION OF PRESENTATIONS GIVEN TO VARIOUS ORGANIZATIONS INCLUDING THE CITY GOVERNMENT, AND DISTRIBUTION OF COPIES OF THE REPORT TO ALL INTERESTED MEMBERS (COMMUNITY COLLABORATORS, LIBRARIES, COMMUNITY CENTERS, AND BUSINESSES) WITHIN OUR COMMUNITY UPON THEIR REQUEST. PVHMC'S CHARITY CARE POLICY - PVHMC POSTS NOTICES INFORMING THE PUBLIC OF THE FINANCIAL ASSISTANCE PROGRAM. SUCH NOTICES ARE POSTED IN HIGH VOLUME INPATIENT, AND OUTPATIENT SERVICE AREAS OF THE HOSPITAL, INCLUDING BUT NOT LIMITED TO THE EMERGENCY DEPARTMENT, INPATIENT ADMISSION AND OUTPATIENT REGISTRATION AREAS OR OTHER COMMON PATIENT WAITING AREAS OF THE HOSPITAL. NOTICES ARE POSTED AT ANY LOCATION WHERE A PATIENT MAY PAY THEIR BILL. NOTICES INCLUDE CONTACT INFORMATION ON HOW A PATIENT MAY OBTAIN MORE INFORMATION ON FINANCIAL ASSISTANCE AS WELL AS WHERE TO APPLY FOR SUCH ASSISTANCE. THESE NOTICES ARE POSTED IN ENGLISH AND SPANISH AND ANY OTHER LANGUAGES THAT ARE REPRESENTATIVE OF 5% OR GREATER OF PATIENTS IN THE HOSPITAL'S SERVICE AREA. A COPY OF THE FINANCIAL ASSISTANCE POLICY IS MADE AVAILABLE TO THE PUBLIC ON A REASONABLE BASIS.
DESCRIBE THE PROCESS USED BY MANAGEMENT &/OR GOVERNING BODY TO REVIEW 990 FORM 990, PART VI, LINE 11B A COPY OF THE TAX RETURN ALONG WITH A NARRATIVE FROM ERNST & YOUNG, THE HOSPITAL'S EXTERNAL ACCOUNTING FIRM, IS DISTRIBUTED TO THE BOARD OF DIRECTORS PRIOR TO FILING IN NOVEMBER 2012. THE INTERNAL PROCESS INCLUDES PREPARATION OF THE FINANCIAL DATA BY HOSPITAL PERSONNEL, SURVEYS OF DIRECTORS, OFFICERS AND KEY EMPLOYEES REGARDING INFORMATION IN RESPONSE TO QUESTIONS IN PART IV, AND DISCLOSED IN SCHEDULE L. THE COMPLETE 990 IS REVIEWED FOR OVERALL COMPLETENESS AND ACCURACY BY THE CEO AND CFO.
WRITTEN CONFLICT OF INTEREST POLICY ENFORCEMENT FORM 990, PART VI, SECTION B, LINE 12C EACH YEAR OFFICERS, DIRECTORS, AND KEY EMPLOYEES SUBMIT CONFLICT OF INTEREST STATEMENTS PURSUANT TO HOSPITAL POLICY. THE STATEMENTS ARE THEN REVIEWED BY THE OFFICERS OF THE BOARD (THE CHAIRMAN AND THE TWO VICE CHAIRMEN) BEFORE PRESENTED TO THE FULL BOARD AT THE ANNUAL ORGANIZATIONAL MEETING OF THE BOARD. ANY CONFLICTS OF CONCERN ARE ADDRESSED BY THE OFFICERS AND DISCUSSED BY THE FULL BOARD AT THE ORGANIZATIONAL MEETING. THEREAFTER, IT IS THE RESPONSIBILITY OF EACH MEMBER TO RAISE AN ISSUE OF POTENTIAL CONFLICT TO THE BOARD AND/OR ITS OFFICERS FOR DISPOSITION. IF A CONFLICT IS DEEMED TO EXIST, THE MEMBER IS EXCUSED FROM THE MEETING AND/OR TOPIC WHERE THE CONFLICT EXISTS.
DETERMINATION OF COMPENSATION FOR CEO Form 990, Part VI, SECTION B, LINE 15A THE BOARD OF DIRECTORS HAS A COMPENSATION COMMITTEE WHO ANNUALLY REVIEW AND DETERMINE THE COMPENSATION FOR THE CEO. THEIR REVIEW DETERMINATION OF THE CEO'S COMPENSATION IS BASED UPON INDEPENDENT REVIEW OF THE CEO COMPENSATION COMPARED TO INDUSTRY PRACTICE. IN 2011 THE COMPENSATION COMMITTEE USED THE HAY GROUP FOR THIS PURPOSE. THE COMPENSATION REVIEW PROCESS IS DOCUMENTED IN THE MINUTES OF THE COMPENSATION COMMITTEE.
DETERMINATION OF COMPENSATION FOR OTHER KEY EMPLOYEES FORM 990, PART VI, SECTION B, LINE 15B FOR OTHER OFFICERS AND KEY EMPLOYEES, THE SAME PROCESS IS USED AS ABOVE, WITH THE EXCEPTION, THAT THE CEO PRESENTS HIS RECOMMENDATION FOR COMPENSATION TO THE COMPENSATION COMMITTEE BASED UPON THE REPORT FOR TOTAL COMPENSATION COMPARISONS SUPPLIED BY THE HAY GROUP. THE POSITIONS COVERED BY THE PROCESS ARE THE COO, CFO, VP SATELLITES, VP NURSING, VP MEDICAL STAFF AFFAIRS, VP HUMAN RESOURCES, CHIEF INFORMATION OFFICER, VICE PRESIDENT OF FINANCE, VP SUPPORT SERVICES, DIRECTOR OF MANAGED CARE, COMPLIANCE OFFICER, DIRECTOR OF UTILIZATION MANAGEMENT. THIS PROCESS WAS LAST COMPLETED IN 2011 FOR THE VICE PRESIDENT OF FINANCE DUE TO PROMOTION AND WAS ALSO DOCUMENTED IN THE MINUTES OF THE COMPENSATION COMMITTEE.
REASON WHY FORMS ARE NOT MADE AVAILABLE TO THE PUBLIC FORM 990, PART VI, QUESTION 18 THE HOSPITAL IS NOT REQUIRED TO MAKE ITS FORM 1023 AVAILABLE AS IT FILED FOR TAX EXEMPT STATUS PRIOR TO JULY 15, 1987. THE HOSPITAL MAKES ITS 990 AND 990T AVAILABLE TO THE PUBLIC UPON REQUEST.
AVAIL OF GOV DOCS, CONFLICT OF INTEREST POLICY, & FIN STMTS TO GEN PUBLIC FORM 990, PART VI, QUESTION 19 THE HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. THE AUDITED FINANCIAL STATEMENTS ARE ALSO ATTACHED TO THIS FORM 990, IN ACCORDANCE WITH THE IRS INSTRUCTIONS.
HOURS DEVOTED TO RELATED ORGANIZATIONS FORM 990, PART VII HELLEN RODRIGUEZ, MD, BERNARD A. BERNSTEIN, CURTIS W. MORRIS, JAN PAULSON, JANE GOODFELLOW, KEVIN MCCARTHY, RICHARD P. CREAN AND ROSANNE BADER DEVOTE TWO HOURS PER WEEK SERVING ON THE BOARD OF POMONA VALLEY HOSPITAL MEDICAL CENTER FOUNDATION. RICHARD YOCHUM DEVOTES 4 HOURS PER WEEK SERVING ON THE BOARD OF POMONA VALLEY HOSPITAL MEDICAL CENTER FOUNDATION. MICHAEL NELSON AND JULI HESTER DEVOTE 2 HOURS PER WEEK SERVING AS TREASURER/CFO AND ASSISTANT TREASURER, RESPECTIVELY, FOR POMONA VALLEY HOSPITAL MEDICAL CENTER FOUNDATION. JAMES MCL DALE DEVOTES 36 HOURS PER WEEK SERVING AS THE SECRETARY/VP OF DEVELOPMENT FOR POMONA VALLEY HOSPITAL MEDICAL CENTER FOUNDATION.
RECONCILIATION OF NET ASSETS FORM 990, PART XI, LINE 5 NET UNREALIZED GAIN(LOSS) FROM INVESTMENTS $ 570,169 EFFECT OF ADOPTION OF FASB STATEMENT 158 $(339,272) LOSS FROM SUBSIDIARIES $(468,742) S-CORP K1 $( 48,183) ROUNDING $( 1) ------------ TOTAL OTHER CHANGES IN NET ASSETS OR FUND BALANCES $(286,029)
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
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SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
POMONA VALLEY HOSPITAL MEDICAL CENTER
 
Employer identification number

95-1115230
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)
(a)
Name, address, and EIN of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income
(e)
End-of-year assets


 		(f)
Direct controlling
entity

















Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled organization
Yes No
(1) Pomona Valley Hospital Medical Ctr Fdn

1798 North Garey Avenue

Pomona,CA91767
95-3403287 		SUPPORT PVHMC CA 501( C)(3) 7 NA
 
 
No
(2) Pomona Valley Hospital Medical Ctr Aux

1798 North Garey Avenue

Pomona,CA91767
95-6053224 		Support PVHMC CA 501( C)(3) 11, I PVHMC
 
Yes
 










For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) Pomona Valley Medical Plaza

1798 NORTH GAREY AVENUE
POMONA,CA91767
95-4175295 		LEASING CA PVHMC
  		RELATED -436,695 4,429,560   No 0   No 90.000 %












Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of related organization



 		(b)
Primary activity



 		(c)
Legal domicile
(state or
foreign
country)
 		(d)
Direct controlling
entity


 		(e)
Type of entity
(C corp, S corp,
or trust)

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) Pomona Valley Health Facilities
1798 North Garey Avenue
Pomona,CA91767
95-4104554 		R.E. OPERATION CA PVHMC
  		C CORP 31,776 -60,746 100.000 %
(2) Pomona North Medical Building Inc
1798 North Garey Avenue
Pomona,CA91767
95-2629873 		R.E. Rental CA PVHMC
  		S CORP 48,183 576,118 100.000 %










Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
Yes
 
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
Yes
 
k Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1m
Yes
 
n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
Yes
 
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type(a-r) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) POMONA VALLEY NORTH MEDICAL BUILDING

 J 165,460 ACCRUAL METHOD
(2) POMONA VALLEY NORTH MEDICAL BUILDING

 P 68,100 ACCRUAL METHOD
(3) POMONA VALLEY MEDICAL PLAZA

 A - ( 463,961 ACCRUAL METHOD
(4) POMONA VALLEY MEDICAL PLAZA

 A - ( 90,321 ACCRUAL METHOD
(5)
(6)
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(e)
Are all
partners
section
501(c)(3)
organizations? 		(f)
Share of total income




 		(g)
Share of
end-of-year
assets 		(h)
Disproprtionate allocations? 		(i)
Code V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation
IDENTIFICATION OF RELATED ORGANIZATIONS TAXABLE AS A PARTNERSHIP SCHEDULE R, PART III, COLUMN (A) POMONA VALLEY MEDICAL PLAZA 1798 NORTH GAREY AVENUE POMONA, CA 91767 EIN: 95-4175295
Additional Data


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