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
2010
Open to Public Inspection
A For the calendar year, or tax year beginning 07-01-2010 and ending 06-30-2011
BCheck if applicable:
CName of organization
SANTA ROSA MEMORIAL HOSPITAL
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
1165 MONTGOMERY DRIVE
 
Room/suite
City or town, state or country, and ZIP + 4
SANTA ROSA, CA95405
D Employer identification number

94-1231005
E Telephone number

G Gross receipts $ 351,454,107
F Name and address of principal officer:
KEVIN KLOCKENGA
 
 
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.STJHS.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 MediumBullet0928
K Form of organization:
 
L Year of formation: 1948
M State of legal domicile: CA
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: We are committed to extending the tradition of the Sisters of St. Joseph of Orange by continually improving the health and quality of life in the communities we serve.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) .... 3 16
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 10
5 Total number of individuals employed in calendar year 2010 (Part V, line 2a) ... 5 1,937
6 Total number of volunteers (estimate if necessary) .... 6 184
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 120,340
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b 28,392
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 2,964,554 2,443,553
9 Program service revenue (Part VIII, line 2g) ......... 353,583,926 343,660,800
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 552,803 5,307,291
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) -14,873 -126,099
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 357,086,410 351,285,545
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 2,056,554 2,169,020
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) 174,289,014 167,665,402
16a Professional fundraising fees (Part IX, column (A), line 11e).... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet804,986    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 182,735,319 161,389,112
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 359,080,887 331,223,534
19 Revenue less expenses. Subtract line 18 from line 12...... -1,994,477 20,062,011
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............ 326,194,519 361,368,065
21 Total liabilities (Part X, line 26)............ 165,778,297 179,492,166
22 Net assets or fund balances. Subtract line 21 from line 20 ..... 160,416,222 181,875,899
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's Use Only Preparer's
signatureBig Right Arrow 		Date
right pointing bullet image Preparer’s taxpayer identification number
(see instructions)
Firm’s name (or yours
if self-employed),
address, and ZIP + 4Big Right Arrow




 		EIN right pointing bullet image
Phone no. right pointing bullet image
May the IRS discuss this return with the preparer shown above? (see instructions) .........
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2010)
Form 990 (2010)
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: SEE SCHEDULE O
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 exempt purpose achievements for each of the organization’s three largest program services 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 $ 296,755,318 including grants of $ 2,169,020 ) (Revenue $ 343,660,800 )
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$ 296,755,318
Form 990 (2010)
Form 990 (2010)
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 III........................
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts where 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 term, permanent,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
Yes
 
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, and program service activities outside the United States? If “Yes,” complete Schedule F, Part I......... Click to see attachment
14b
Yes
 
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.. Click to see attachment
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.. Click to see attachment
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 IClick to see attachment
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.......... Click to see attachment
18
Yes
 
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................... Click to see attachment
19
 
No
Form 990 (2010)
Form 990 (2010)
Page 4
Part IV
Checklist of Required Schedules (continued)
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H..... Click to see attachment
20a
Yes
 
b
Did the organization attach its audited financial statement to this return? Note: All Form 990 filers that operate one or more hospitals must attach audited financial statements. ..... Click to see list of attachments
20b
Yes
 
21
Did the organization report more than $5,000 of grants and other assistance to governments and organizations 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 a grant selection committee member, or to a person related to such an individual? 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 M
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............
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
 
35
Is any related organization a controlled entity within the meaning of section 512(b)(13)? .....
35
Yes
 
a
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
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 (2010)
Form 990 (2010)
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
288
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
1,937
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
Yes
 
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
Yes
 
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 (2010)
Form 990 (2010)
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 ..............
1a
16
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
10
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
Does the organization have members or stockholders? ................
6
Yes
 
7a
Does the organization have members, stockholders, or other persons who may elect one or more members of the governing body? .........................
7a
Yes
 
b
Are any decisions of the governing body subject to approval by members, stockholders, or other persons? ..
7b
Yes
 
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
Does the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” does the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with those of the organization? ....
10b
 
 
11a
Has the organization provided a 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
Does the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
 
No
b
Are officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ...........................
12b
 
 
c
Does the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this is done ....................
12c
 
 
13
Does the organization have a written whistleblower policy? ...............
13
 
No
14
Does the organization have a written document retention and destruction policy? .........
14
 
No
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 a or b, 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
 
No
b
If “Yes,” has the organization adopted a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and taken steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
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 make these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization makes its governing documents, conflict of interest policy, and financial statements available to the public.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
JANE STONE
141 STONY CIRCLE SUITE 140
SANTA ROSA,CA95401
(707) 547-5485
Form 990 (2010)
Form 990 (2010)
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 (check all that apply) 		(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) JIM ADAMS
BOARD MEMBER/COMMITTEE CHAIR
 4.0 X           0 0 0
(2) SISTER SHARON BECKER
BOARD MEMBER
 2.0 X           0 0 0
(3) PAM CHANTER
BOARD MEMBER
 2.0 X           0 0 0
(4) SISTER JUDITH DUGAN
BOARD MEMBER
 2.0 X           0 0 0
(5) HERB DWIGHT
BOARD MEMBER
 2.0 X           0 0 0
(6) LOGAN FAUST MD
BOARD MEMBER
 2.0 X           29,400 0 0
(7) ABDUL HARRIS MD
BOARD MEMBER/CHIEF OF STAFF
 4.0 X           149,800 0 0
(8) BILL FINLEY MD
BOARD MEM./FORMER COS-PART YR
 2.0 X           22,200 0 0
(9) JEN EZBON
BOARD MEMBER - PART YEAR
 2.0 X           0 0 0
(10) TIMOTHY MORATTO
BOARD MEMBER
 2.0 X           0 0 0
(11) LES PERRY
BOARD MEMBER/COMMITTEE CHAIR
 4.0 X           0 0 0
(12) SISTER CHRISTINE RAY
BOARD MEMBER
 2.0 X           0 0 0
(13) SISTER MARY ROGERS
BOARD MEMBER
 2.0 X           0 0 0
(14) CHRISTOPHER SILVA
BOARD CHAIR
 4.0 X           0 0 0
(15) GENE TRAVERSO
BOARD MEMBER - PART YEAR
 2.0 X           0 0 0
(16) JAN SONANDER MD
BOARD MEMBER
 2.0 X           25,200 0 0
(17) ANNETTE WALKER
BOARD MEMBER
 2.0 X           0 593,574 43,000
Form 990 (2010)
Form 990 (2010)
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 (check all that apply) 		(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) SHARON WRIGHT
BOARD MEMBER
 2.0 X           0 0 0
(19) KEVIN KLOCKENGA
CEO
 43.0 X   X       0 617,060 37,035
(20) JO SANDERSFELD
SECRETARY/VP MISSION INTEGRTN
 43.0     X       378,891 0 24,981
(21) MICHEL RICCIONI
CHIEF FINANCIAL OFFICER
 43.0     X       484,960 0 38,999
(22) GARY GREENSWEIG
CHIEF MEDICAL OFFICER
 43.0       X     555,775 0 35,087
(23) KATHERINE HARDIN
CHIEF NURSING OFFICER
 43.0       X     388,493 0 45,475
(24) MARK KNIGHT
VP - STRATEGIC SERVICES
 43.0       X     359,962 0 20,429
(25) DEBRA MILLER
VP - HUMAN RESOURCES
 43.0       X     346,991 0 35,709
(26) ANDREA LEARNED
VP - FUND DEVELOPMENT
 43.0       X     285,775 0 19,560
(27) TODD SALNAS
CHIEF OPERATING OFFICER
 43.0       X     417,613 0 28,325
(28) REBECCA ALTHOFF
STAFF NURSE IV
 50.0         X   449,033 0 45,538
(29) TRACY GENOVESE
STAFF NURSE IV
 47.0         X   236,216 0 36,176
(30) SHARON MCDONALD
STAFF NURSE II
 41.0         X   228,334 0 20,073
(31) RICHARD HENRY
STAFF NURSE IV
 32.0         X   228,223 0 44,370
(32) CAROLYNN TEDESCHI
STAFF NURSE IV
 34.0         X   209,485 0 13,963
(33) GEORGE PEREZ
FORMER CEO
 0.0           X 0 317,152 0
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 4,796,351 1,527,786 488,720
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 in reportable compensation from the organizationMediumBullet491
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
Yes
 
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.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
MEDICAL STAFFING NETWORK HEALTHCARE
PO BOX 203000
DALLAS,TX753203000 		REGISTRY 5,844,475
ANESTHESIA ANALGESIA MED GROUP
837 5th Street 2nd Floor
SANTA ROSA,CA95405 		ANESTHESIOLOGISTS 2,147,505
NORTH BAY NEUROSURGICAL ASSOCIATES
525 DOYLE PARK DRIVE
SANTA ROSA,CA95405 		MEDICAL FEES 1,265,453
ST JOSEPH HERITAGE HEALTHCARE
279 E IMPERIAL HWY STE 710
FULLERTON,CA92835 		MEDICAL FEES 1,023,570
SANTA ROSA SUGRICAL MGMT CO LLC
525 DOYLE PARK DRIVE
SANTA ROSA,CA95405 		MANAGEMENT FEES 781,852
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization MediumBullet29
Form 990 (2010)
Form 990 (2010)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, gifts, grants and other similar amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c 256,648
d Related organizations...1d 1,014,430
e Government grants (contributions)1e 155,853
f All other contributions, gifts, grants, and
similar amounts not included above1f 		1,016,622
g Noncash contributions included in lines 1a-1f:$  
h Total. Add lines 1a-1f.......MediumBullet 2,443,553
Program Service Revenue Business Code
2a NET PATIENT REVENUE 622,110 339,888,467 339,888,467    
b MEDICAL OFFICE BUILDING 531,120 2,150,388 2,150,388    
c CAFETERIA 722,310 899,001 899,001    
d OTHER OPERATING REVENUE 900,099 602,604 602,604    
e PATHOLOGY & LABORATORY 621,500 120,340   120,340  
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 343,660,800
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 5,290,247     5,290,247
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties............MediumBullet 0      
(i) Real (ii) Personal
6a Gross Rents    
b Less: rental expenses    
c Rental income or (loss)    
d Net rental income or (loss).......MediumBullet        
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory   20,377
b Less: cost or other basis and sales expenses   3,333
c Gain or (loss)   17,044
d Net gain or (loss)..........MediumBullet 17,044     17,044
8a Gross income from fundraising events (not including
$ 256,648
of contributions reported on line 1c). See Part IV, line 18 ...
a 28,422
b Less: direct expenses ...b 162,030
c Net income or (loss) from fundraising events..MediumBullet -133,608   -133,608
9a Gross income from gaming activities.
See Part IV, line 19 ...
a 10,708
b Less: direct expenses ...b 3,199
c Net income or (loss) from gaming activities...MediumBullet 7,509     7,509
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            
b            
c            
d All other revenue ....        
e Total. Add lines 11a–11d ......MediumBullet 0
12 Total revenue. See Instructions....MediumBullet 351,285,545 343,540,460 120,340 5,181,192
Form 990 (2010)
Form 990 (2010)
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).
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 U.S. See Part IV, line 21 2,169,020 2,169,020
2 Grants and other assistance to individuals in the U.S. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the U.S. 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 .... 2,453,666 638,172 1,590,810 224,684
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 57,974 57,974 0 0
7 Other salaries and wages 127,251,623 122,004,270 4,980,158 267,195
8 Pension plan contributions (include section 401(k) and section 403(b) employer contributions) .... 7,814,859 7,315,892 469,464 29,503
9 Other employee benefits ....... 20,750,004 20,246,524 373,074 130,406
10 Payroll taxes ........... 9,337,276 8,741,489 560,921 34,866
11 Fees for services (non-employees):        
a Management ...... 13,151,704 13,151,704 0 0
b Legal ......... 1,869,629 0 1,869,379 250
c Accounting ........... 387,932 30,920 357,012 0
d Lobbying ........... 66,330 66,330 0 0
e Professional fundraising. See Part IV, line 17.. 0  
f Investment management fees ...... 0      
g Other .......... 41,562,924 23,109,701 18,408,478 44,745
12 Advertising and promotion .... 1,658,023 0 1,656,503 1,520
13 Office expenses ....... 44,642,897 44,336,879 268,982 37,036
14 Information technology ...... 1,571,764 1,552,850 17,008 1,906
15 Royalties .. 0      
16 Occupancy ........... 5,184,629 4,608,530 569,713 6,386
17 Travel ............ 335,334 192,659 140,259 2,416
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 41,326 31,015 9,581 730
20 Interest ........... 7,781,487 7,429,767 340,622 11,098
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 18,404,011 18,058,540 344,864 607
23 Insurance .............. 1,777,148 1,696,907 77,788 2,453
24 Other expenses. Itemize expenses not covered above. (Expenses grouped together and labeled miscellaneous may not exceed 5% of total expenses shown on line 25 below.)
a HOSPITAL PROGRAM FEES 19,824,152 19,824,152 0 0
b ALL OTHER EXPENSES 3,129,822 1,492,023 1,628,614 9,185
c
d
e
f All other expenses        
25 Total functional expenses. Add lines 1 through 24f 331,223,534 296,755,318 33,663,230 804,986
26 Joint costs. Check here MediumBullet if following
SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation 		       
Form 990 (2010)
Form 990 (2010)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... 7,143 1 7,418
2 Savings and temporary cash investments ....... 70,188,023 2 23,375,526
3 Pledges and grants receivable, net .........   3  
4 Accounts receivable, net ......... 50,696,971 4 46,976,239
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..........   5  
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 ..........   6  
7 Notes and loans receivable, net ............. 613,244 7 496,100
8 Inventories for sale or use .............. 4,029,720 8 4,254,224
9 Prepaid expenses and deferred charges ............ 3,259,874 9 2,978,464
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 336,444,544
b Less: accumulated depreciation. ..... 10b 164,497,843 179,747,424 10c 171,946,701
11 Investments—publicly traded securities .......... 4,466,992 11 91,143,982
12 Investments—other securities. See Part IV, line 11 ...... 344,001 12 149,478
13 Investments—program-related. See Part IV, line 11 ..   13  
14 Intangible assets .........   14  
15 Other assets. See Part IV, line 11 ........... 12,841,127 15 20,039,933
16 Total assets. Add lines 1 through 15 (must equal line 34)... 326,194,519 16 361,368,065
Liabilities 17 Accounts payable and accrued expenses . 28,879,230 17 31,277,514
18 Grants payable ..........   18  
19 Deferred revenue ..........   19  
20 Tax-exempt bond liabilities ..........   20  
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22  
23 Secured mortgages and notes payable to unrelated third parties ..   23  
24 Unsecured notes and loans payable to unrelated third parties ....   24  
25 Other liabilities. Complete Part X of Schedule D..... 136,899,067 25 148,214,652
26 Total liabilities. Add lines 17 through 25..... 165,778,297 26 179,492,166
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 ..... 158,178,667 27 179,844,557
28 Temporarily restricted net assets ..... 1,483,425 28 1,356,175
29 Permanently restricted net assets ..... 754,130 29 675,167
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 ..... 160,416,222 33 181,875,899
34 Total liabilities and net assets/fund balances ..... 326,194,519 34 361,368,065
Form 990 (2010)
Form 990 (2010)
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
351,285,545
2
Total expenses (must equal Part IX, column (A), line 25) . . . . .
2
331,223,534
3
Revenue less expenses. Subtract line 2 from line 1 . . . .
3
20,062,011
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) . .
4
160,416,222
5
Other changes in net assets or fund balances (explain in Schedule O) . . . .
5
1,397,666
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
181,875,899
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
Yes
 
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
Yes
 
Form 990 (2010)
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
2010
Open to Public
Inspection
Name of the organization
SANTA ROSA MEMORIAL HOSPITAL
 
Employer identification number

94-1231005
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) 2010
Schedule A (Form 990 or 990-EZ) 2010
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) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (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) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (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) 2010
Schedule A (Form 990 or 990-EZ) 2010
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) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (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) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (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) 2010
Schedule A (Form 990 or 990-EZ) 2010
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) 2010

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
2010
Name of organization
SANTA ROSA MEMORIAL HOSPITAL
 
Employer identification number

94-1231005
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 in the heading of its
Form 990-EZ, or on 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) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part I
Name of organization
SANTA ROSA MEMORIAL HOSPITAL
  		Employer identification number

94-1231005
Part I
Contributors (see Instructions)
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate 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)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




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

     
 
   

$  




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

     
 
   

$  




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

     
 
   

$  




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

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part II
Name of organization
SANTA ROSA MEMORIAL HOSPITAL
  		Employer identification number

94-1231005
Part II
Noncash Property (see Instructions)
     
(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) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part III
Name of organization
SANTA ROSA MEMORIAL HOSPITAL
  		Employer identification number

94-1231005
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
aggregating 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 $  
(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) (2010)

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
2010
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, Part V, line 35a (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
SANTA ROSA MEMORIAL HOSPITAL
 
Employer identification number

94-1231005
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 on behalf of or in opposition to candidates for public office 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 funtion 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) 2010

Schedule C (Form 990 or 990-EZ) 2010
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
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) 2007 (b) 2008 (c) 2009 (d) 2010 (e) Total
             
2a Lobbying non-taxable amount          
             
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		         
             
c Total lobbying expenditures          
             
d Grassroots non-taxable amount          
             
e Grassroots ceiling amount
(150% of line 2d, column (e))		          
             
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2010


Schedule C (Form 990 or 990-EZ) 2010
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)).
(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? If "Yes," describe in Part IV ..........................
Yes
 
66,330
j
Total. lines 1c through 1i ...................................
66,330
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 carryover 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) if BOTH Part III-A, lines 1 and 2 are answered “No” OR if Part III-A, line 3 is answered “Yes”.
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) non-deductible 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, line 5; and Part ll-B, line 1i.
Also, complete this part for any additional information.
Identifier Return Reference Explanation
PORTION OF DUES PAID TO HOSPITAL ASSOCIATIONS FOR LOBBYING ACTIVITIES SCHEDULE C, PART II-B, LINE 1I DURING THE PAST YEAR, THE ST. JOSEPH HEALTH SYSTEM HAS CONDUCTED AN ADVOCACY EFFORT WHICH INCLUDED SOME LOBBYING ACTIVITY. THESE INCLUDED MEETING WITH LOCAL, STATE, AND FEDERAL LEGISLATORS, THEIR STAFF AND OTHER GOVERNMENTAL OFFICIALS; AND COMMUNICATIONS TO LEGISLATORS ADVOCATING POSITIONS ON LEGISLATION.
Schedule C (Form 990 or 990EZ) 2010

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, 11, or 12.
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
SANTA ROSA MEMORIAL HOSPITAL
 
Employer identification number

94-1231005
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 may 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–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 ........ 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the taxable 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, 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, 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 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) 2010

Schedule D (Form 990) 2010
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 .... 545,843 455,582 560,257
b Contributions ........   305 550
c Investment earnings or losses ... 105,828 89,956 -105,225
d Grants or scholarships .....      
e Other expenditures for facilities
and programs ........ 		     
f Administrative expenses ....      
g End of year balance ...... 651,671 545,843 455,582
2
Provide the estimated percentage of the year end balance held as:
a
Board designated or quasi-endowment: SchDMd Bullet0 %
b
Permanent endowment: SchDMd Bullet100.000 %
c
Term endowment: SchDMd Bullet0 %
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)
 
No
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Investments—Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of investment (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   8,954,011 8,954,011
b Buildings ................   120,076,953 61,120,252 58,956,701
c Leasehold improvements ............   86,470,396 24,195,931 62,274,465
d Equipment ................   110,630,228 79,181,660 31,448,568
e Other .................   10,312,956   10,312,956
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........SchDMdBullet 171,946,701
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
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) should 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) should 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) DUE FROM AFFILIATES 20,039,933








Total. (Column (b) should equal Form 990, Part X, col.(B) line 15.)...........Small Bullet 20,039,933
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Amount
Federal Income Taxes 0
PAYABLE TO THIRD PARTY PAYORS 12,930,349
ACCRUED LIABILITIES 10,722,844
DUE TO RESTRICTED FUND 439,366
INTERCO WITH HEATH SYSTEM-BONDS 124,113,993
OTHER PAYABLES 8,100




Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)Small Bullet 148,214,652
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) 2010

Schedule D (Form 990) 2010
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 - 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 should 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 should 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
INTENDED USES OF THE ORGANIZATIONS ENDOWMENT FUNDS SCHEDULE D, PART V, LINE 4 THE INTENDED USE FOR THE ENDOWMENT FUNDS INCLUDES SCHOLARSHIPS TO EMPLOYEES WHO WISH TO RETURN TO SCHOOL TO BECOME NURSES, MAINTAIN AND UPGRADE THE CARDIAC CATHETERIZATION PROGRAM, AND MEET THE NEEDS OF THE HOSPITAL, AS WELL AS THE COMMUNITY'S NEEDIEST INDIVIDUALS.
ASC 740 (FIN48) FOOTNOTE SCHEDULE D, PART X, LINE 2 ACCOUNTING STANDARDS CODIFICATION (ASC) 740, INCOME TAXES, CLARIFIES THE ACCOUNTING FOR INCOME TAXES BY PRESCRIBING A MINIMUM RECOGNITION THRESHOLD THAT A TAX POSITION IS REQUIRED TO MEET BEFORE BEING RECOGNIZED IN THE FINANCIAL STATEMENTS. ASC 740 ALSO PROVIDES GUIDANCE ON DERECOGNITION, MEASUREMENT, CLASSIFICATION, INTEREST AND PENALTIES, DISCLOSURE, AND TRANSITION. THE GUIDANCE IS APPLICABLE TO PASS-THROUGH ENTITIES AND TAX-EXEMPT ORGANIZATIONS. NO SIGNIFICANT TAX LIABILITY OR TAX BENEFITS, INTEREST OR PENALTIES HAS BEEN ACCRUED AT JUNE 30, 2011 OR 2010.
Schedule D (Form 990) 2010

Additional Data


Software ID:  
Software Version:  




SCHEDULE F
(Form 990)

Department of the Treasury
Internal Revenue Service
Statement of Activities Outside the United States
Right pointing arrow large image Complete if the organization answered "Yes" to Form 990,
Part IV, line 14b, 15, or 16.
Right pointing arrow large image Attach to Form 990. Right pointing arrow large image See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
SANTA ROSA MEMORIAL HOSPITAL
 
Employer identification number

94-1231005
Part I
General Information on Activities Outside the United States. Complete if the organization answered
“Yes” to Form 990, Part IV, line 14b.
1
For grantmakers. 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
For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of grant funds outside the
United States.
3
Activites per Region. (Use Part V if additional space is needed.)
(a) Region (b) Number of offices in the region (c) Number of employees or agents in region or independent contractors (d) Activities conducted in region (by type) (e.g., fundraising, program services, investments, grants to recipients located in the region) (e) If activity listed in (d) is a program service, describe specific type of
service(s) in region		 (f) Total
expenditures for region/investments
in region
Central America and the Caribbean 0 0 Program Services CAPTIVE INSURANCE 1,052,341
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
3a Sub-total ..... 0 0 1,052,341
b Total from continuation sheets to Part I ...      
c Totals (add lines 3a and 3b) 0 0 1,052,341
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.Cat. No. 50082W Schedule F (Form 990) 2010
Schedule F (Form 990) 2010
Page 2
Part II
Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered "Yes" to Form 990,
Part IV, line 15, for any recipient who received more than $5,000. Check this box if no one recipient received more than $5,000 ........ MediumBullet
Use Part V if additional space is needed.
1 (a) Name of organization (b) IRS code section
and EIN (if applicable)		 (c) Region (d) Purpose of
grant 		(e) Amount of
cash grant 		(f) Manner of
cash
disbursement 		(g) Amount of
of non-cash
assistance 		(h) Description
of non-cash
assistance 		(i) Method of
valuation
(book, FMV,
appraisal, other)
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
2
Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter .....MediumBullet
 
3
Enter total number of other organizations or entities ........................MediumBullet
 
Schedule F (Form 990) 2010
Schedule F (Form 990) 2010Page 3
Part III
Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 16.
Use Part V if additional space is needed.
(a) Type of grant or assistance (b) Region (c) Number of recipients (d) Amount of
cash grant 		(e) Manner of cash
disbursement 		(f) Amount of
non-cash
assistance 		(g) Description
of non-cash
assistance 		(h) Method of
valuation
(book, FMV,
appraisal, other)
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
Schedule F (Form 990) 2010
Schedule F (Form 990) 2010
Page 4
Part IV
Foreign Forms
1 Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 926 (see instructions for Form 926).................
2 Did the organization have an interest in a foreign trust during the tax year? If " Yes," the organization may be required to file Form 3520 and/or Form 3520-A. (see instructions for Forms 3520 and 3520-A)..........
3 Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons with respect to Certain Foreign Corporations. (see instructions for Form 5471)..............................
4 Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If "Yes," the organization may be required to file Form 8621, Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund. (see instructions for Form 8621)
5 Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons with respect to Certain Foreign Partnerships. (see instructions for Form 8865)....................................
6 Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to file Form 5713, International Boycott Report (see instructions for Form 5713)................................................
Schedule F (Form 990) 2010
Schedule F (Form 990) 2010
Page 5
Part V
Supplemental Information
Complete this part to provide the information (see instructions) required in Part I, line 2, and any additional information.
Identifier ReturnReference Explanation
METHOD OF ACCOUNTING PART I, LINE 3, COLUMN (F) THE AMOUNT IN COLUMN F WAS DETERMINED USING THE ACCRUAL METHOD OF ACCOUNTING.
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
Schedule F (Form 990) 2010
Additional Data


Software ID:  
Software Version:  



SCHEDULE G
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Supplemental Information Regarding
Fundraising or Gaming Activities
Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19,
or if the organization entered more than $15,000 on Form 990-EZ, line 6a.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
SANTA ROSA MEMORIAL HOSPITAL
 
Employer identification number

94-1231005
Part I
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
1
Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a e
b f
c g
d
2a
Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?
b
If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization. Form 990-EZ filers are not required to complete this table.
(i) Name and address of individual
or entity (fundraiser) 		(ii) Activity (iii) Did fundraiser have custody or control of contributions? (iv) Gross receipts
from activity 		(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i) 		(vi) Amount paid to
(or retained by)
organization
Yes No
Total .................right arrow      
3
List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50083H
Schedule G (Form 990 or 990-EZ) 2010
Schedule G (Form 990 or 990-EZ) 2010
Page 2
Part II
Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000.
(a) Event #1

GALA BALL
(event type) 		(b) Event #2

PRO AM GOLF
(event type) 		(c) Other Events

1
(total number) 		(d) Total Events
(Add col. (a) through col. (c))
VerticalRevenue 1 Gross receipts . . . 126,687 78,623 79,760 285,070
2 Less: Charitable
contributions . . . 		119,020 71,324 66,304 256,648
3 Gross income (line 1
minus line 2) . . . 		7,667 7,299 13,456 28,422
VerticalDirectExpenses 4 Cash prizes . . . 0 1,000 0 1,000
5 Non-cash prizes . . 16,622 8,889 0 25,511
6 Rent/facility costs . . 3,000 10,500 500 14,000
7 Food and beverages . . 12,456 18,529 13,800 44,785
8 Entertainment . . . 8,000 0 7,928 15,928
9 Other direct expenses . 30,296 24,376 6,134 60,806
10 Direct expense summary. Add lines 4 through 9 in column (d) ........... right arrow 162,030
11 Net income summary. Combine lines 3 and 10 in column (d)............ right arrow -133,608
Part III
Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.
VerticalRevenue (a) Bingo (b) Pull tabs/Instant
bingo/progressive bingo 		(c) Other gaming (d) Total gaming (Add col. (a) through col. (c))
1 Gross revenue . . . .        
VerticalDirectExpenses 2 Cash prizes . . . .        
3 Non-cash prizes . . .        
4 Rent/facility costs . . .        
5 Other direct expenses . .        
6 Volunteer labor . . .
 
 
 
7 Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow  
8 Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow  
9
Enter the state(s) in which the organization operates gaming activities:
a
Is the organization licensed to operate gaming activities in each of these states? ............
b
If "No," Explain:
 
10a
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....
b
If "Yes," Explain:
 
11
Does the organization operate gaming activities with nonmembers? .................
12
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming? ...........................
Schedule G (Form 990 or 990-EZ) 2010
Schedule G (Form 990 or 990-EZ) 2010
Page 3
13
Indicate the percentage of gaming activity operated in:
a
The organization's facility ......................
13a
 
b
An outside facility ........................
13b
 
14
Provide the name and address of the person who prepares the organization's gaming/special events books and records:
Name right arrow
Address right arrow
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue? ......................................
b
If "Yes," enter the amount of gaming revenue received by the organization right arrow $   and the
amount of gaming revenue retained by the third party right arrow $   .
c
If "Yes," enter name and address:
Name right arrow
Address right arrow
 
 
16
Gaming manager information:
Name right arrow
Gaming manager compensation right arrow $  
Description of services provided right arrow
 
17
Mandatory distributions:
a
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? ............................
b
Enter the amount of distributions required under state law distributed to other exempt organizations or spent
in the organization's own exempt activities during the tax year right arrow$  
Part IV
Complete this part to provide additional information for responses to quuestion on Schedule G (see instructions.)
Identifier ReturnReference Explanation
Schedule G (Form 990 or 990-EZ) 2010
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
2010
Open to Public Inspection
Name of the organization
SANTA ROSA MEMORIAL HOSPITAL
 
Employer identification number

94-1231005
Part I
Charity Care and Certain Other Community Benefits at Cost
Yes
No
1a
Does the organization have a charity care policy? If "No," skip to question 6a...........
1a
Yes
 
b
If "Yes," is it a written policy? .......................
1b
Yes
 
2
If the organization has multiple hospitals, indicate which of the following best describes application of the charity care policy to the various hospitals.
3
Answer the following based on the charity care eligibility criteria that applies to the largest number of the organization's patients.
a
Does the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care to low
income individuals? If "Yes," indicate which of the following is the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Does the organization use FPG to determine eligibility for providing discounted care to low income individuals? If
"Yes," indicate which of the following is the family income limit for eligibility for discounted care: .....
3b
Yes
 
c
If the organization does 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 uses an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4
Does the organization's policy provide free or discounted care to the "medically indigent"? ......
4
Yes
 
5a
Does the organization budget amounts for free or discounted care provided under its charity care policy? ...
5a
Yes
 
b
If "Yes," did the organization's charity care expenses exceed the budgeted amount?.........
5b
Yes
 
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discounted
care to a patient who was eligibile for free or discounted care?...............
5c
 
No
6a
Does the organization prepare an annual community benefit report?.............
6a
Yes
 
6b
If "Yes," does 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
Charity Care and Certain Other Community Benefits at Cost
Charity Care 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 Charity care at cost (from
Worksheets 1 and 2) .. 		    8,561,760 0 8,561,760 2.590 %
b Unreimbursed Medicaid (from
Worksheet 3, column a) . 		    54,371,253 35,834,005 18,537,248 5.610 %
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....     20,486,218 15,220,644 5,265,574 1.590 %
dTotal Charity Care and
Means-Tested Government Programs ..... 		    83,419,231 51,054,649 32,364,582 9.790 %
Other Benefits
e Community health improvement
services and community
benefit operations (from
(Worksheet 4) .... 		    2,828,888 880,041 1,948,847 0.590 %
f Health professions education
(from Worksheet 5) .. 		           
g Subsidized health services
(from Worksheet 6) .. 		    195,610 0 195,610 0.060 %
h Research (from Worksheet 7)            
i Cash and in-kind contributions
to community groups
(from Worksheet 8) .. 		    241,017 0 241,017 0.070 %
jTotal Other Benefits ...     3,265,515 880,041 2,385,474 0.720 %
kTotal. Add lines 7d and 7j. ..     86,684,746 51,934,690 34,750,056 10.510 %
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 2
Part II
Community Building Activities Complete this table if the organization conducted any community building activities.
(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            
3 Community support     17,670 0 17,670 0.010 %
4 Environmental improvements            
5 Leadership development and training for community members     176,704 0 176,704 0.050 %
6 Coalition building     88,352 0 88,352 0.030 %
7 Community health improvement advocacy     70,681 0 70,681 0.020 %
8 Workforce development            
9 Other            
10 Total     353,407 0 353,407 0.110 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Does the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense (at cost).....
2
2,575,121
3
Enter the estimated amount of the organization's bad debt expense (at cost) attributable to patients eligible under the organization's charity care policy ..
3
0
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
108,257,370
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
143,196,908
7
Subtract line 6 from line 5. This is the surplus or (shortfall)........
7
-34,939,538
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
Does the organization have a written debt collection policy? ...............
9a
Yes
 
b
If "Yes," does the organization's collection policy contain provisions on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance? Describe in Part VI......
9b
Yes
 
Part IV
Management Companies and Joint Ventures
(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) 2010
Schedule H (Form 990) 2010
Page 3
Part VFacility Information
Section A. Hospital Facilities
(list in order of size, measured by total revenue per facility, 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 SANTA ROSA MEMORIAL HOSPITAL
1165 MONTGOMERY DRIVE
SANTA ROSA,CA95405 		X X         X   DESIGNATED TRAUMA CENTER
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 4
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)
Name of Hospital Facility:SANTA ROSA MEMORIAL HOSPITAL
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 2010)
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 those 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 all of 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 Development of a community benefit plan for the facility
d Participation in 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 CHNA
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 together with 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 Explains eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8    
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care to low incomeindividuals?.. 9    
If “Yes,” indicate the FPG family income limit for eligibility for free care:   %
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 5
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care to low income individuals?......... 10    
If “Yes,” indicate the FPG family income limit for eligibility for discounted care:   %
11 Explained the basis for calculating amounts charged to patients?................. 11    
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    
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13    
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted at all times 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 that explained actions the hospital facility may take upon non-payment?........ 14    
15 Check all of the following collection actions against a patient that were permitted under the hospital facility's policies at any time during the tax year:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments or arrests
e Other (describe in Part VI)
16 Did the hospital facility engage in or authorize a third party to engage in any of the following collection actions during the tax year?................................... 16    
If “Yes,” check all collection actions in which the hospital facility or a third party engaged (check all that apply):
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other (describe in Part VI)
17 Indicate which actions the hospital facility took before initiating any of the collection actions checked in question 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 a patient who applied for financial assistance under the financial assistance policy qualified for financial assistance
e Other (describe in Part VI)
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 6
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    
If “No,” indicate the reasons why (check all that apply):
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility did not have a policy relating to emergency medical care
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)
Charges for Medical Care
19 Indicate how the hospital facility determined the amounts generally billed to individuals who had insurance covering emergency or other medically necessary care (check all that apply):
a The hospital facility used the lowest negotiated commercial insurance rate for those services at the hospital facility
b The hospital facility used the average of the three lowest negotiated commercial insurance rates for those services at the hospital facility
c The hospital facility used the Medicare rate for those services
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    
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its patients an amount equal to the gross charge for services provided to that patient?................................... 21    
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 7
Part VFacility Information (continued)

Section C. Other Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, measured by total revenue per facility, from largest to smallest)
How many non-hospital facilities did the organization operate during the tax year?9
Name and address Type of Facility (Describe)
1 SANTA ROSA AMBULATORY SURGERY CENTER
525 DOYLE PARK DRIVE
SANTA ROSA,CA95401 		AMBULATORY SURGERY CENTER
2 SANTA ROSA AMBULATORY SURGERY CENTER
525 DOYLE PARK DRIVE
SANTA ROSA,CA95401 		AMBULATORY SURGERY CENTER
3 SANTA ROSA AMBULATORY SURGERY CENTER
525 DOYLE PARK DRIVE
SANTA ROSA,CA95401 		AMBULATORY SURGERY CENTER
4 SANTA ROSA AMBULATORY SURGERY CENTER
525 DOYLE PARK DRIVE
SANTA ROSA,CA95401 		AMBULATORY SURGERY CENTER
5 SANTA ROSA AMBULATORY SURGERY CENTER
525 DOYLE PARK DRIVE
SANTA ROSA,CA95401 		AMBULATORY SURGERY CENTER
6 SANTA ROSA AMBULATORY SURGERY CENTER
525 DOYLE PARK DRIVE
SANTA ROSA,CA95401 		AMBULATORY SURGERY CENTER
7 SANTA ROSA AMBULATORY SURGERY CENTER
525 DOYLE PARK DRIVE
SANTA ROSA,CA95401 		AMBULATORY SURGERY CENTER
8 SANTA ROSA AMBULATORY SURGERY CENTER
525 DOYLE PARK DRIVE
SANTA ROSA,CA95401 		AMBULATORY SURGERY CENTER
9 SANTA ROSA AMBULATORY SURGERY CENTER
525 DOYLE PARK DRIVE
SANTA ROSA,CA95401 		AMBULATORY SURGERY CENTER
10
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 8
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the description 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, 2, 4c, 6i, 7, 11i, 13i, 17l, 18l, 19e, 21d, 25, and 26.
2 Community health needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any community health 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
SCHEDULE H, PART I, LINE 7:   THE AMOUNTS REPORTED IN THE TABLE WERE CALCULATED USING THE ORGANIZATION'S COST ACCOUNTING SYSTEM, THAT UTILIZES COSTS FOR ALL SEGMENTS AND PATIENT TYPES. SCHEDULE H, PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES NO COSTS ATTRIBUTABLE TO PHYSICIAN CLINICS WERE INCLUDED.
SCHEDULE H, PART II: COMMUNITY BUILDING ACTIVITIES SANTA ROSA MEMORIAL HOSPITAL'S COMMUNITY BENEFIT DEPARTMENT INTEGRATES ACTIONS THAT ADDRESS THE POLITICAL, SOCIAL, BEHAVIORAL AND PHYSIOLOGICAL DETERMINANTS OF HEALTH. THE PRIMARY STRATEGIES EMPLOYED TO ADDRESS COMMUNITY NEEDS ARE COMMUNITY CAPACITY BUILDING, IMPROVING HEALTH OUTCOMES FOR VULNERABLE POPULATIONS AND REDUCING SOCIAL ISOLATION OF SPECIAL POPULATIONS. ITS HEALTHY COMMUNITIES PROGRAMS FOCUS ON BUILDING COMMUNITY CAPACITY AND EMPOWERMENT TO ADDRESS QUALITY OF LIFE CONCERNS. IN ADDITION TO COUNTYWIDE COLLABORATION AND PARTNERSHIP DEVELOPMENT TO SUPPORT THESE ACTIONS, THERE ARE THREE PROGRAMS ESPECIALLY FOCUSED ON COMMUNITY BUILDING. THE NEIGHBORHOOD CARE STAFF (NCS) MENTOR GRASSROOTS LEADERSHIP TO ADDRESS LOCAL COMMUNITY HEALTH AND QUALITY OF LIFE ISSUES. NCS MODELS AND MENTORS COMMUNITY REPRESENTATIVES IN THESE KEY FUNCTIONS: THE IDENTIFICATION OF LOCAL ASSETS, PROVIDING FORUMS FOR DIALOGUE, SURFACING AND SUPPORTING LOCAL LEADERS, FACILITATING THE DEVELOPMENT OF SELF-SUSTAINING COMMUNITY GROUPS, FACILITATING COMMUNITY-BASED STRATEGIC PLANNING, HELPING TO BUILD LINKAGES TO AND BETWEEN COMMUNITY RESOURCES, AND ADVOCATING FOR COMMUNITY PARTICIPATION IN THE ISSUES THAT MOST AFFECT IT. IN FY11, NCS MENTORED GRASSROOTS COMMUNITY LEADERS IN LOW-INCOME NEIGHBORHOODS IN 5 COMMUNITIES (PETALUMA, ROHNERT PARK, SOUTH SANTA ROSA, FULTON, AND THE SONOMA VALLEY) WITH DISPROPORTIONATE UNMET HEALTH NEEDS. THESE RESIDENT LEADERS DEVELOPED LOCAL ACTION PLANS ADDRESSING TWO KEY SOCIAL DETERMINANTS OF HEALTH THAT RESULTED IN OVER 5,000 ACTIONS OF ADVOCACY, EDUCATION, AND ORGANIZING TO REDUCE OBSTACLES TO HEALTHY FOOD AND PHYSICAL ACTIVITY; AND OVER 1,500 ACTIONS TO INCREASE NEIGHBORHOOD SAFETY. IN ADDITION, NCS SUPPORTED THE CITY OF ROHNERT PARK IN OBTAINING $75K TO TRANSFORM A FORMER PUBLIC POOL INTO A COMMUNITY GARDEN AND SUPPORTED APPROXIMATELY 100 LOW-INCOME RESIDENTS THROUGHOUT THE COUNTY IN JOINING THE 350 GARDEN CHALLENGE. THROUGH THE LEADERSHIP OF THESE RESIDENTS AND THEIR ACTION PLANS, RESIDENTS IN THESE VULNERABLE COMMUNITIES PARTICIPATED IN APPROXIMATELY 7,500 ACTS OF CIVIC ENGAGEMENT THAT INCLUDED SAFETY FORUMS, COMMUNITY GARDENING, NEIGHBORHOOD BEAUTIFICATION, CULTURAL CELEBRATIONS, COMMUNITY THEATER AND MEDIA WORK, WALKING GROUPS, AND OTHER LOCAL ADVOCACY AND VOLUNTEERISM TO INCREASE NEIGHBORHOOD SAFETY AND ACCESS TO HEALTHY EATING AND PHYSICAL ACTIVITY. AGENTS OF CHANGE TRAINING IN OUR NEIGHBORHOODS (ACTION) IS A COMPANION PROGRAM TO NCS THAT PROVIDES LEADERSHIP AND ADVOCACY TRAINING. IN FY11 THIS PROGRAM CONTINUED TO PROVIDE LEADERSHIP TRAINING TO SANTA ROSA RESIDENTS PARTICIPATING IN THE COMMUNITY ACTION & NUTRITION COALITION'S "HEALTHY EATING/ACTIVE LIVING" (HEAL) PROJECT, AS WELL AS PROVIDING ADVANCED TRAINING TO PAST ACTION GRADUATES IN SANTA ROSA, ROHNERT PARK AND THE SONOMA VALLEY. NCS ALSO PROVIDED ACTION TRAINING AND MENTORING TO AN ADDITIONAL 24 RESIDENTS FROM LOW-INCOME NEIGHBORHOODS IN SOUTH SANTA ROSA, AS PARTNER IN HEAL. AS A RESULT OF THE INCREASE IN CIVIC ENGAGEMENT AND GRASSROOTS LEADERSHIP IN THESE COMMUNITIES, 6 NEW COMMUNITY GARDENS WERE FORMED, 4 NEIGHBORHOOD-BASED GROUPS WERE CONSOLIDATED AND BECAME AUTONOMOUS LOCAL ORGANIZATIONS, AND LOCAL POLICIES WERE CHANGED IN 4 JURISDICTIONS TO SUPPORT NEIGHBORHOOD BEAUTIFICATION, COMMUNITY GARDENS AND HEALTHY SCHOOL MENUS. CIRCLE OF SISTERS IS A FREE VIOLENCE PREVENTION AFTER-SCHOOL PROGRAM FOR GIRLS AGES 10 TO 14. THE PROGRAM PARTICIPANTS ATTEND SCHOOLS WITH HIGH RATES OF FREE AND REDUCED LUNCHES. IN FY 2011, CIRCLE OF SISTERS SERVED 279 GIRLS AT 13 DIFFERENT COMMUNITY SITES. IT ALSO DEVELOPED A YOUTH ADVISORY COMMITTEE, PARTNERING WITH NEIGHBORHOOD CARE STAFF TO PROVIDE INTENSIVE LEADERSHIP DEVELOPMENT TO SIX GIRLS WHO ADVOCATED FOR INCREASED FUNDING FOR FREE LUNCH, VISITED LOCAL COMMUNITY GARDENS AND PROPOSED A "HEALTHY LUNCH CLUB" TO PROVIDE FREE COOKING LESSONS WITH LOW COST FRESH INGREDIENTS.
SCHEDULE H, PART III, LINE 4:   THE ORGANIZATION RECOGNIZES THAT A PORTION OF THE UNINSURED OR UNDERINSURED PATIENT POPULATION MAY NOT ENGAGE IN THE TRADITONAL FINANCIAL ASSISTANCE APPLICATION PROCESS. THEREFORE, THE ORGANIZATION ALSO USES AN AUTOMATED PREDICTIVE SCORING TOOL TO IDENTIFY AND QUALIFY PATIENTS FOR FINANCIAL ASSISTANCE FOR ACCOUNTS THAT ARE INITIALLY CLASSIFIED AS BAD DEBT. COLLECTION ACTIONS ARE NOT PURSUED ON THESE ACCOUNTS ONCE THEY ARE RECLASSIFIED AS FINANCIAL ASSISTANCE. THERE IS NO OTHER AMOUNT OF BAD DEBT THAT SHOULD BE REPORTED AS FINANCIAL ASSISTANCE. FINANCIAL STATEMENT FOOTNOTE DESCRIBING BAD DEBT: THE ORGANIZATION RECEIVES PAYMENT FOR SERVICES RENDERED TO PATIENTS FROM FEDERAL AND STATE GOVERNMENTS UNDER THE MEDICARE AND MEDICAID PROGRAMS, PRIVATELY SPONSORED MANAGED CARE PROGRAMS FOR WHICH PAYMENT IS MADE BASED ON TERMS DEFINED UNDER FORMAL CONTRACTS, AND OTHER PAYORS. THE ORGANIZATION BELIEVES THERE ARE NO SIGNIFICANT RISKS ASSOCIATED WITH RECEIVABLES FROM GOVERNMENT PROGRAMS. RECEIVABLES FROM CONTRACTED AND OTHERS ARE FROM VARIOUS PAYORS WHO ARE SUBJECT TO DIFFERING ECONOMIC CONDITIONS, AND DO NOT REPRESENT ANY CONCENTRATED RISKS TO THE ORGANIZATION. THE ORGANIZATION ANALYZES ITS HISTORICAL EXPERIENCE AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE AMOUNTS REPORTED IN THE TABLE WERE CALCULATED USING A COST-TO-CHARGE RATIO. WE CALCULATE THE OVERALL HOSPITAL COST TO CHARGE RATIO USING GROSS CHARGES AND OPERATIONAL COSTS. WE APPLIED THAT RATIO TO THE GROSS CHARGES WRITTEN OFF TO BAD DEBT. ANY PAYMENTS ON PATIENT ACCOUNTS REDUCE THE AMOUNT CALCULATED FOR BAD DEBT. NO DISCOUNTS ARE APPLIED.
SCHEDULE H, PART III, LINE 8:   AS A CATHOLIC HEALTH CARE MINISTRY, THE ORGANIZATION FOLLOWS THE CATHOLIC HEALTH ASSOCIATION'S COMMUNITY BENEFIT REPORTING GUIDELINES AND THEREFORE DOES NOT REPORT MEDICARE AS A COMMUNITY BENEFIT. THE COST ACCOUNTING SYSTEM CALCULATES COSTS AT THE DEPARTMENTAL LEVEL AND APPLIES IT TO EACH PATIENT ACCOUNT. WE THEN USE THE TOTAL COSTS OF ALL THE APPLICABLE ACCOUNTS TO DETERMINE MEDICARE COSTS.
SCHEDULE H, PART III, LINE 9B:   SJHS PATIENT ACCOUNTS ARE NOT FORWARDED TO COLLECTION STATUS WHEN THE PATIENT MAKES A GOOD FAITH EFFORT TO RESOLVE OUTSTANDING ACCOUNT BALANCES. SUCH EFFORTS INCLUDE APPLYING FOR FINANCIAL ASSISTANCE, NEGOTIATING A PAYMENT PLAN OR APPLYING FOR MEDICAID COVERAGE. PRIOR TO ADVANCING ANY ACCOUNT FOR EXTERNAL COLLECTION, THE ORGANIZATION PERFORMS AN EVALUATION TO IDENTIFY IF THE ACCOUNT QUALIFIES FOR CHARITY CARE. ACCOUNTS FOR PATIENTS WHO QUALIFY FOR CHARITY CARE ARE WRITTEN OFF AND COLLECTION EFFORTS ARE NOT PURSUED.
SCHEDULE H, PART VI, LINE 2: NEEDS ASSESSMENT THE COMMUNITY HEALTH NEEDS ASSESSMENT 2008 IS A COLLABORATIVE EFFORT BY SUTTER MEDICAL CENTER OF SANTA ROSA, ST. JOSEPH HEALTH SYSTEM - SONOMA COUNTY (SANTA ROSA MEMORIAL HOSPITAL & PETALUMA VALLEY HOSPITAL), KAISER PERMANENTE MEDICAL CENTER - SANTA ROSA AND THE SONOMA COUNTY DEPARTMENT OF HEALTH SERVICES TO SPOTLIGHT THE HEALTH, WELL-BEING AND FUTURE OF THE CHILDREN OF SONOMA COUNTY, WITH INPUT GATHERED FROM HOSPITAL BOARDS AND STAFF, AS WELL AS COMMUNITY MEMBERS, WHO PARTICIPATED IN FOCUS GROUPS THROUGHOUT THE COUNTY. THESE PARTNERS HAVE JOINED FORCES IN THE PAST IN THEIR JOINT NEEDS ASSESSMENTS TO ADDRESS A NUMBER OF SIGNIFICANT COMMUNITY HEALTH ISSUES - PREVENTION OF DANGEROUS FALLS BY SENIORS, THE LACK OF DIVERSITY IN THE HEALTH CARE WORKFORCE, AND THE NEED FOR IMMUNIZATION CLINICS. THE HEALTH PROBLEMS RAISED IN THE NEEDS ASSESSMENT ARE PREVENTABLE WITH CONCERTED ACTION ON THE PART OF PARTNERS AND THE COMMUNITY. TO THIS END, THE NEEDS ASSESSMENT EMPLOYS THE SPECTRUM OF PREVENTION - A FUNDAMENTAL MODEL IN PUBLIC HEALTH, WHICH ACKNOWLEDGES THAT A BROAD RANGE OF FACTORS PLAY A ROLE IN HEALTH. POLICIES, LEGISLATION AND ORGANIZATIONAL PRACTICES ARE ALL POWERFUL INFLUENCES IN SHAPING AN INDIVIDUAL'S ATTITUDES AND THE ENVIRONMENT THAT DETERMINES THE WAY PEOPLE LIVE.
SCHEDULE H, PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE OUR MISSION IS TO PROVIDE QUALITY CARE TO ALL OUR PATIENTS, REGARDLESS OF ABILITY TO PAY. WE BELIEVE THAT NO ONE SHOULD DELAY SEEKING NEEDED MEDICAL CARE BECAUSE THEY LACK HEALTH INSURANCE. THAT IS WHY SANTA ROSA MEMORIAL HOSPITAL HAS A PATIENT FINANCIAL ASSISTANCE PROGRAM THAT PROVIDES FREE OR DISCOUNTED SERVICES TO ELIGIBLE PATIENTS. THE ORGANIZATION POSTS NOTICES INFORMING THE PUBLIC OF THE FINANCIAL ASSISTANCE PROGRAM. NOTICES ARE POSTED IN HIGH VOLUME INPATIENT AND OUTPATIENT SERVICE AREAS. NOTICES ARE ALSO POSTED AT LOCATIONS WHERE A PATIENT MAY PAY THEIR BILL. NOTICES INCLUDE CONTACT INFORMATION ON HOW A PATIENT CAN OBTAIN MORE INFORMATION ON FINANCIAL ASSISTANCE AS WELL AS WHERE TO APPLY FOR 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. ALL PATIENTS WHO DEMONSTRATE LACK OF FINANCIAL COVERAGE BY THIRD PARTY INSURERS ARE OFFERED AN OPPORTUNITY TO COMPLETE THE FINANCIAL ASSISTANCE APPLICATION AND ARE OFFERED INFORMATION, ASSISTANCE, AND REFERRAL AS APPROPRIATE TO GOVERNMENT SPONSORED PROGRAMS FOR WHICH THEY MAY BE ELIGIBLE.
SCHEDULE H, PART VI, LINE 4: COMMUNITY INFORMATION SONOMA COUNTY, THE NORTHERNMOST OF THE NINE GREATER SAN FRANCISCO BAY AREA COUNTIES, IS BORDERED ON THE NORTH BY MENDOCINO COUNTY, ON THE EAST BY LAKE AND NAPA COUNTIES, ON THE SOUTH BY MARIN COUNTY AND SAN PABLO BAY, AND ON THE WEST BY THE PACIFIC OCEAN. IN 2006, SONOMA COUNTY HAD THE 17TH LARGEST COUNTY POPULATION OF THE 58 COUNTIES IN CALIFORNIA, WITH 480,000 RESIDENTS, WITH 110,000 CHILDREN AGES 0 TO 17. SANTA ROSA, THE COUNTY SEAT AND LARGEST CITY, HAS ONE-THIRD OF THE TOTAL POPULATION OF SONOMA COUNTY AND RANKS AS THE 30TH LARGEST CITY IN THE STATE. ALTHOUGH SANTA ROSA MEMORIAL HOSPITAL IS IN A METROPOLITAN STATISTICAL AREA (SANTA ROSA), MUCH OF THE REST OF SONOMA COUNTY IS IN AREAS DEFINED AS RURAL. THESE RURAL AREAS HAVE BEEN FEDERALLY CLASSIFIED AS A MEDICALLY UNDERSERVED POPULATION (MUP) BASED ON LOW-INCOME POPULATION FACTORS AND ALSO AS PRIMARY CARE HEALTH PROFESSIONAL SHORTAGE AREAS (HPSA). ALMOST ONE-QUARTER OF SONOMA COUNTY'S POPULATION IS UNDER 18-YEARS OLD, ONE THIRD OF WHOM ARE YOUNGER THAN SCHOOL-AGE (0 TO 5 YEARS OLD). MORE THAN 10% ARE 65-YEARS AND OLDER, AND THE REMAINDER (62%) IS BETWEEN 19- AND 64-YEARS OLD. ALTHOUGH ITS RACIAL/ETHNIC COMPOSITION IS CHANGING, SONOMA COUNTY IS STILL SUBSTANTIALLY LESS DIVERSE THAN THE STATE AS A WHOLE: 71% OF SONOMA COUNTY RESIDENTS ARE WHITE AND 19% ARE LATINO. THE LATINO POPULATION IN SONOMA COUNTY IS THE FASTEST GROWING ETHNIC GROUP, PROJECTED TO INCREASE TO 21% OF THE POPULATION BY 2010, AND TO 23% BY 2020. THE TOTAL LATINO POPULATION IS PROJECTED TO INCREASE 300% BY 2050 - FROM 80,742 IN 2000 TO 250,692 IN 2050.
SCHEDULE H, PART VI, LINE 5: PROMOTION OF COMMUNITY HEALTH SANTA ROSA MEMORIAL HOSPITAL DEMONSTRATES ORGANIZATIONAL COMMITMENT TO THE COMMUNITY THROUGH THE ALLOCATION OF STAFF, FINANCIAL RESOURCES, PARTICIPATION AND COLLABORATION. ITS VICE PRESIDENT OF MISSION INTEGRATION IS RESPONSIBLE FOR COORDINATING IMPLEMENTATION OF SENATE BILL 697 PROVISIONS AS WELL AS THE OPPORTUNITIES FOR EXECUTIVE MANAGEMENT TEAM, PHYSICIANS, AND OTHER MANAGEMENT AND STAFF TO PARTICIPATE IN PLANNING AND CARRYING OUT THE COMMUNITY BENEFIT PLAN THROUGH PARTICIPATION IN COMMUNITY BOARDS AND COMMITTEES; AS WELL AS THROUGH VOLUNTEERISM WITH ORGANIZATIONS SUCH AS THE REDWOOD EMPIRE FOOD BANK, UNITED WAY, SONOMA COUNTY VOLUNTEER CENTER, AMERICAN HEART ASSOCIATION, AND OTHERS. THE HOSPITAL'S COMMUNITY BENEFIT COMMITTEE IS A JOINT COMMITTEE OF THE BOARDS OF TRUSTEES OF SANTA ROSA MEMORIAL AND PETALUMA VALLEY HOSPITALS (SJHS-SC ENTITIES), AND SUPPORTS THESE BOARDS IN OVERSEEING COMMUNITY BENEFIT ACTIVITIES IN ACCORDANCE WITH ITS BOARD APPROVED CHARTER. THE COMMITTEE CONSISTS OF AT LEAST THREE MEMBERS OF THE BOARDS OF TRUSTEES AND HAS A MAJORITY OF MEMBERS FROM THE COMMUNITY WHO HAVE KNOWLEDGE OR EXPERIENCE WITH POPULATIONS WITH DISPROPORTIONATE UNMET HEALTH NEEDS IN THE COMMUNITIES SERVED. THE GOVERNING BODY IS COMPRISED OF A MAJORITY OF PERSONS WHO RESIDE IN THE HOSPITALS PRIMARY SERVICE AREA AND WHO ARE NOT EMPLOYEES, CONTRACTORS, OR FAMILY MEMBERS. THE SUB-COMMITTEE OF THE BOARD OF TRUSTEES, KNOWN AS THE COMMUNITY BENEFIT COMMITTEE, OVERSEES THE DEVELOPMENT AND IMPLEMENTATION OF THE COMMUNITY HEALTH NEEDS ASSESSMENT AND COMMUNITY BENEFIT PLAN EVERY THREE YEARS, AS WELL AS AN ANNUAL COMMUNITY BENEFIT REPORT. THE COMMITTEE ALSO PROVIDES GENERAL DIRECTION TO SANTA ROSA MEMORIAL HOSPITAL REGARDING: 1) BUDGETING DECISIONS, 2) COMMUNITY BENEFIT PROGRAM CONTENT, 3) COMMUNITY BENEFIT PROGRAM DESIGN, 4) TARGET GEOGRAPHIC/POPULATION, 5) PROGRAM CONTINUATION OR DISCONTINUATION, 6) FUND DEVELOPMENT SUPPORT, AND 7) COMMUNITY-WIDE ENGAGEMENT. MEDICAL STAFF PRIVILEGES ARE EXTENDED TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. GIVING BACK TO THE COMMUNITY IS INTEGRATED INTO EVERY ASPECT OF OUR ORGANIZATION. AS A MEMBER OF THE FAITH-BASED HEALTH MINISTRY OF ST. JOSEPH HEALTH SYSTEM, WE PROVIDE FREE AND DISCOUNTED CARE VIA OUR FINANCIAL ASSISTANCE PROGRAM AND HAVE A FUNDING STREAM TO ADDRESS THE NEEDS OF THE ECONOMICALLY POOR AND VULNERABLE IN THE COMMUNITIES WE SERVE. OUR MISSION IS TO PROVIDE QUALITY CARE TO ALL OUR PATIENTS, REGARDLESS OF ABILITY TO PAY. WE BELIEVE THAT NO ONE SHOULD DELAY SEEKING NEEDED MEDICAL CARE BECAUSE THEY LACK HEALTH INSURANCE. THAT IS WHY SANTA ROSA MEMORIAL HOSPITAL, AS A MINISTRY OF ST. JOSEPH HEALTH SYSTEM, HAS A PATIENT FINANCIAL ASSISTANCE PROGRAM THAT PROVIDES FREE OR DISCOUNTED SERVICES TO ELIGIBLE PATIENTS. ON AN ANNUAL BASIS, TEN PERCENT OF OUR NET INCOME IS DEVOTED TO FUND COMMUNITY PROGRAMS FOR THE ECONOMICALLY POOR (CARE FOR THE POOR FUNDS). SPECIFICALLY, FUNDS ARE USED FOR OUTREACH PROGRAMS, DEFINED AS THOSE SERVICES THAT ADDRESS A SPECIFIC UNMET HEALTH NEED AND ARE SEPARATE FROM TRADITIONAL ACUTE CARE SERVICES. IN ADDITION TO DEVOTING A PERCENTAGE OF OUR NET INCOME TO COMMUNITY PROGRAMS FOR THE ECONOMICALLY POOR VIA CARE FOR THE POOR FUNDS, WE STRIVE TO ANNUALLY BUDGET A PORTION OF OUR TOTAL OPERATING EXPENSES FOR HEALTHY COMMUNITIES AND COMMUNITY HEALTH EFFORTS. DURING THE PAST YEAR, SANTA ROSA MEMORIAL HOSPITAL DEDICATED $1,864,697 TO CARE FOR THE POOR FUNDS AND $1,724,443 TO HEALTHY COMMUNITIES AND COMMUNITY HEALTH INITIATIVES. THIS FUNDING MADE THE FOLLOWING INITIATIVES POSSIBLE: REDUCING CHILDHOOD OBESITY, PREVENTING YOUTH SUBSTANCE ABUSE AND PROMOTING CHILDREN'S ORAL HEALTH.
SCHEDULE H, PART VI, LINE 6: AFFILIATED HEALTH CARE SYSTEM SANTA ROSA MEMORIAL HOSPITAL IS A HEALING MINISTRY OF ST. JOSEPH HEALTH SYSTEM, AN INTEGRATED HEALTHCARE DELIVERY SYSTEM SPONSORED BY THE ST. JOSEPH HEALTH MINISTRY. ST. JOSEPH HEALTH SYSTEM IS ORGANIZED INTO THREE REGIONS: NORTHERN CALIFORNIA, SOUTHERN CALIFORNIA, AND WEST TEXAS/EASTERN NEW MEXICO. THE SYSTEM INCLUDES 14 ACUTE CARE HOSPITALS, HOME HEALTH AGENCIES, HOSPICE CARE, OUTPATIENT SERVICES, COMMUNITY CLINICS, AND PHYSICIAN ORGANIZATIONS. EACH ASSOCIATED MINISTRY WORKS TO LIVE OUT ITS MISSION OF IMPROVING THE HEALTH AND QUALITY OF LIFE OF THE COMMUNITIES IT SERVES. IN 1986, ST. JOSEPH HEALTH SYSTEM CREATED A PLAN AND BEGAN AN EFFORT TO FURTHER ITS COMMITMENT TO NEIGHBORS IN NEED. WITH A VISION OF REACHING BEYOND THE WALLS OF ITS HEALTHCARE FACILITIES AND TRANSCENDING TRADITIONAL EFFORTS OF PROVIDING FREE CARE FOR THOSE IN NEED OF ACUTE SERVICES, ST. JOSEPH HEALTH SYSTEM CREATED THE ST. JOSEPH HEALTH SYSTEM FOUNDTION TO IMPROVE THE HEALTH OF LOW-INCOME INDIVIDUALS RESIDING IN LOCAL COMMUNITIES. OUR FOUNDATIONAL DOCUMENT, A VISION OF VALUES, FORMALIZES A PROCESS THROUGH WHICH THE HOSPITAL MINISTRIES RETURN TEN PERCENT OF THEIR NET INCOME TO THE ST. JOSEPH HEALTH SYSTEM FOUNDATION TO SUPPORT OUTREACH EFFORTS FOR THE MATERIALLY POOR. THE FOUNDATION FUNDS PROGRAMS THAT EXEMPLIFY THE FOUR CORE VALUES OF ST. JOSEPH HEALTH SYSTEM: SERVICE, EXCELLENCE, DIGNITY, AND JUSTICE. SANTA ROSA MEMORIAL HOSPITAL IS THE HEART OF ST. JOSEPH SONOMA COUNTY HEALTH SYSTEM - SONOMA COUNTY, ONE OF THE NORTHERN CALIFORNIA MINISTRIES OF A STATEWIDE NETWORK OF HOSPITALS AND CLINICS KNOWN AS ST. JOSEPH HEALTH SYSTEM (SJHS), THE CENTRAL OFFICES OF WHICH ARE IN ORANGE COUNTY. SJHS-SC OPERATES TWO HOSPITALS, URGENT CARE AND COMMUNITY CLINICS, HOSPICE, HOME HEALTH SERVICES, AND OTHER FACILITIES FOR TREATING THE HEALTHCARE NEEDS OF THE COMMUNITY IN SONOMA COUNTY AND THE REGION. OUR CORE FACILITIES ARE: - PETALUMA VALLEY HOSPITAL, APPROXIMATELY 40 MILES NORTH OF SAN FRANCISCO IN THE TOWN OF PETALUMA, WHICH IS AN 80-BED ACUTE CARE HOSPITAL; AND - SANTA ROSA MEMORIAL HOSPITAL, WHICH IS A FULL SERVICE STATE-OF-THE-ART AND SCIENCE, 289-BED ACUTE CARE HOSPITAL PROVIDING A WIDE RANGE OF SPECIALTY SERVICES (INCLUDING A LEVEL II REGIONAL TRAUMA CENTER) THAT SERVES COASTAL COUNTIES IN CALIFORNIA UP TO THE OREGON BORDER.
SCHEDULE H, PART VI, LINE 7: STATE FILING OF COMMUNITY BENEFIT REPORT CALIFORNIA MINISTRIES REPORT TO CALIFORNIA OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT IN ACCORDANCE WITH CALIFORNIA SENATE BILL 697.
Schedule H (Form 990) 2010
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
2010
Open to Public
Inspection
Name of the organization
SANTA ROSA MEMORIAL HOSPITAL
 
Employer identification number
94-1231005
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) ST JOSEPH HEALTH FOUNDATION1165 MONTGOMERY DRIVE
SANTA ROSA,CA95405 		95-3589356 501(C)(3) 1,864,697       CARE FOR THE POOR
(2) SONOMA COUNTY DEPARTMENT OF HEALTH SERVICES475 AVIATION BLVD
SANTA ROSA,CA95403 		94-6000539 GOVERNMENT 40,500       SONOMA COUNTY HEALTH
(3) NORTHERN CALIFORNIA CENTER FOR WELL BEING365B TESCONI CIRCLE
Santa Rosa,CA95409 		93-1144835 501(c)(3) 33,615       HEART WORKS PROGRAM
(4) SONOMA COUNTY BEST637 FIRST STREET
SANTA ROSA,CA95404 		68-0074807 GOVERNMENT 8,100       FUTURE GROWTH OF
(5) CALIFORNIA HEALTH FOUNDATION & TRUST1215 K ST STE 800
SACRAMENTO,CA95814 		94-1498697 501(c)(3) 217,108       CA HOSPITAL FEE














2
Enter total number of section 501(c)(3) and government organizations ......................... Bullet Image
5
3
Enter total number of other organizations ................................ . Bullet Image
0
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2010

Schedule I (Form 990) 2010
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 SCHEDULE I, PART I, LINE 2 DONATIONS TO OTHER ORGANIZATIONS ARE APPROVED BY MANAGEMENT TO ENSURE THEY SUPPORT THE MISSION OF SANTA ROSA MEMORIAL HOSPITAL. WE DO NOT MONITOR DONATIONS MADE.
Schedule I (Form 990) 2010


Additional Data


Software ID:  
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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
2010
Open to Public Inspection
Name of the organization
SANTA ROSA MEMORIAL HOSPITAL
 
Employer identification number

94-1231005
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 orprovision of all the expenses described above? If "No," complete Part III to explain....
1b
Yes
 
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
Yes
 
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.
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
Yes
 
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 Regs. 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) 2010

Schedule J (Form 990) 2010
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use Schedule J-1 if additional space 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) must equal the applicable column (D) or column (E) amounts on Form 990, Part VII, line 1a.
(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 in prior
Form 990 or
Form 990-EZ
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) ANNETTE WALKER (i)
(ii)		 0
369,652 		0
122,580 		0
101,342 		0
9,201 		0
33,799 		0
636,574 		0
0
(2) KEVIN KLOCKENGA (i)
(ii)		 0
350,926 		0
137,694 		0
128,440 		0
9,769 		0
27,266 		0
654,095 		0
0
(3) JO SANDERSFELD (i)
(ii)		 189,038
0 		62,260
0 		127,593
0 		16,084
0 		8,897
0 		403,872
0 		50,793
0
(4) MICHEL RICCIONI (i)
(ii)		 276,727
0 		91,288
0 		116,945
0 		12,057
0 		26,942
0 		523,959
0 		0
0
(5) GARY GREENSWEIG (i)
(ii)		 300,357
0 		98,029
0 		157,389
0 		16,562
0 		18,525
0 		590,862
0 		0
0
(6) KATHERINE HARDIN (i)
(ii)		 199,428
0 		65,155
0 		123,910
0 		26,950
0 		18,525
0 		433,968
0 		33,177
0
(7) MARK KNIGHT (i)
(ii)		 202,567
0 		66,708
0 		90,687
0 		11,532
0 		8,897
0 		380,391
0 		0
0
(8) DEBRA MILLER (i)
(ii)		 194,021
0 		63,394
0 		89,576
0 		17,150
0 		18,559
0 		382,700
0 		0
0
(9) ANDREA LEARNED (i)
(ii)		 155,840
0 		50,856
0 		79,079
0 		10,663
0 		8,897
0 		305,335
0 		21,846
0
(10) TODD SALNAS (i)
(ii)		 276,509
0 		76,011
0 		65,093
0 		1,532
0 		26,793
0 		445,938
0 		0
0
(11) REBECCA ALTHOFF (i)
(ii)		 422,097
0 		0
0 		26,936
0 		25,924
0 		19,614
0 		494,571
0 		0
0
(12) TRACY GENOVESE (i)
(ii)		 216,019
0 		0
0 		20,197
0 		9,483
0 		26,693
0 		272,392
0 		0
0
(13) SHARON MCDONALD (i)
(ii)		 215,547
0 		0
0 		12,787
0 		11,176
0 		8,897
0 		248,407
0 		0
0
(14) RICHARD HENRY (i)
(ii)		 209,518
0 		0
0 		18,705
0 		24,791
0 		19,579
0 		272,593
0 		0
0
(15) CAROLYNN TEDESCHI (i)
(ii)		 193,352
0 		0
0 		16,133
0 		13,963
0 		0
0 		223,448
0 		0
0
(16) GEORGE PEREZ (i)
(ii)		 0
0 		0
0 		0
317,152 		0
0 		0
0 		0
317,152 		0
0
Schedule J (Form 990) 2010

Schedule J (Form 990) 2010
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 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 1A ST. JOSEPH HEALTH SYSTEM ALLOWS FOR COMPANION TRAVEL TO CERTAIN PRE-APPROVED, MINISTRY SPONSORED EVENTS. COMPANION TRAVEL IS TREATED AS TAXABLE COMPENSATION IN MOST CASES. IN THE CASE THAT COMPANION TRAVEL IS NOT TAXABLE COMPENSATION, THE INDIVIDUAL IS PROVIDING A SERVICE TO THE HEALTH SYSTEM AS A REPRESENTATIVE WITH KNOWLEDGE OF THE COMMUNITIES AND MINISTRIES WE SERVE. MEMBERS OF THE BOARD AND EXECUTIVE MANAGEMENT TEAM ARE SELECTED TO PARTICIPATE IN AN ANNUAL PILGRIMAGE TO LE PUY, FRANCE, WHERE THE SISTER'S FIRST CONGREGATION WAS FORMED. THE PURPOSE OF THE PILGRIMAGE IS FOR THE ORGANIZATION'S LEADER TO DEVELOP A DEEPER UNDERSTANDING OF THE ROOTS AND HERITAGE OF THE ORGANIZATION IN ORDER TO CARRY OUT THE MISSION. COMPANION TRAVEL IS CONSIDERED TO BE AN ESSENTIAL PART OF THIS EXPERIENCE AND THE COMPANION ACTS AS A REPRESENTATIVE WITH KNOWLEDGE OF THE COMMUNITIES AND MINISTRIES WE SERVE. THE FOLLOWING TRUSTEES AND OFFICERS RECEIVED A BENEFIT FOR COMPANION TRAVEL THAT WAS INTENDED TO BE COMPENSATION. THE BENEFITS WERE PAID BY SANTA ROSA MEMORIAL HOSPITAL'S TAX-EXEMPT PARENT, ST. JOSEPH HEALTH SYSTEM. KEVIN KLOCKENGA - $6,884 JO SANDERSFELD - $6,574 COMPANION ATTENDANCE IS ALSO AN ESSENTIAL PART OF THE TRUSTEE CONFERENCE. THE FOLLOWING TRUSTEES RECEIVED A BENEFIT FOR COMPANION TRAVEL THAT WAS INTENDED TO BE COMPENSATION. SHARON WRIGHT - $185 TIMOTHY MORATTO - $119 EXECUTIVES RECEIVE A PERCENTAGE OF BASE COMPENSATION FOR DISCRETIONARY SPENDING. THESE AMOUNTS ARE INCLUDED IN OTHER REPORTABLE COMPENSATION.
SCHEDULE J, PART I, LINE 3   THE ORGANIZATION'S CHIEF EXECUTIVE OFFICER IS PAID BY ITS TAX EXEMPT PARENT, ST. JOSEPH HEALTH SYSTEM, AND IS DISCLOSED AS A PERSON PAID BY A RELATED ORGANIZATION. SEE SCHEDULE O FORM 990, PART VI, LINE 15A FOR THE PROCESS THAT IS COMPLETED BY THE ST. JOSEPH HEALTH SYSTEM.
SCHEDULE J, PART I, LINE 4A   THE FOLLOWING INDIVIDUALS RECEIVED SEVERANCE PAYMENTS FOR EITHER PART OR ALL OF THE YEAR: GEORGE PEREZ: $317,152
SCHEDULE J, PART I, LINE 4B   EXECUTIVES COULD PARTICIPATE IN A NON-QUALIFIED DEFERRED COMPENSATION PLAN UNDER INTERNAL REVENUE CODE 457(F). THE PLAN WAS FROZEN EFFECTIVE DECEMBER 31, 2007 AFTER WHICH TIME NO FURTHER CONTRIBUTIONS WERE PERMITTED TO THE PLAN. THIS PLAN WILL CEASE TO EXIST ONCE ALL BENEFITS HAVE BEEN DISTRIBUTED IN ACCORDANCE WITH PROVISIONS OF THE PLAN. THE FOLLOWING INDIVIDUALS INCLUDED IN FORM 990, PART VII RECEIVED PAYMENT FROM THE NON-QUALIFIED DEFERRED COMPENSATION PLAN: ANDREA LEARNED - $21,846 JO SANDERSFELD - $50,793 KATHERINE HARDIN - $33,177
SCHEDULE J, PART I, LINE 7   A PORTION OF THE EXECUTIVE'S SALARY IS PLACED "AT-RISK" AND IS NOT AWARDED UNLESS SPECIFIC STRATEGIC OBJECTIVE TARGETS ARE MET OR EXCEEDED. THE AT-RISK EXECUTIVE PLAN IS DESIGNED TO MOTIVATE AND REWARD EXECUTIVES FOR TEAM PERFORMANCE THAT SUPPORTS THE STRATEGIC GOALS AND SUCCESSFUL PERFORMANCE OF ST. JOSEPH HEALTH SYSTEM. AT-RISK PAY IS AWARDED TO ASSISTANT VICE PRESIDENTS, VICE PRESIDENTS, SENIOR VICE PRESIDENTS, EXECUTIVE VICE PRESIDENTS, AND THE CHIEF EXECUTIVE OFFICER BASED ON ACHIEVING OR SURPASSING SPECIFIC GOALS THAT ARE PREDETERMINED BY THE BOARD OF TRUSTEES PRIOR TO THE BEGINNING OF THE FISCAL YEAR. THE GOALS INCLUDE OUR STRATEGIC OBJECTIVES OF PERFECT CARE, SACRED ENCOUNTERS, AND HEALTHIEST COMMUNITIES AS WELL AS FISCAL STEWARDSHIP. EACH OF THESE FACTORS IS TAKEN INTO CONSIDERATION WHEN DETERMINING THE PERCENTAGE OF AT-RISK PAY.
Schedule J (Form 990) 2010

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
2010
Open to Public Inspection
Name of the organization
SANTA ROSA MEMORIAL HOSPITAL
 
Employer identification number

94-1231005
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) 2010
Schedule L (Form 990 or 990-EZ) 2010
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) VERIHEALTH INC JIM ADAMS, BOARD MEMBER 219,542 AMBULANCE TRANSPORTATION CO.   No
(2) LYDIA ADAMS SPOUSE OF BOARD MEMBER 57,974 EMPLOYEE COMPENSATION   No
(3) GASTROINTESTINAL CARE MEDICAL ASSOC LOGAN FAUST, BOARD MEMBER 237,250 ON-CALL MEDICAL SVCS.   No
(4) ANESTHESIA ANALGESIA BILL FINLEY, BOARD MEMBER 2,147,505 ANESTHESIA SERVICES   No
(5) ABDUL K HARRIS MD INC ABDUL HARRIS, BD MEMBER 149,800 PHYSICIAN 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
RELATIONSHIPS WITH INTERESTED PERSONS SCHEDULE L, PART IV JIM ADAMS IS A BOARD MEMBER OF SANTA ROSA MEMORIAL HOSPITAL (SRMH) AND A BOARD MEMBER OF VERIHEALTH, INC. LYDIA ADAMS IS THE SPOUSE OF JIM ADAMS, A BOARD MEMBER OF SRMH. LYDIA IS AN EMPLOYEE OF SRMH. LOGAN FAUST, M.D. IS A BOARD MEMBER OF SRMH AND A PARTNER OF GASTROINTESTINAL CARE MEDICAL ASSOCIATES. BILL FINLEY, M.D. IS A BOARD MEMBER OF SRMH AND AN OFFICER OF ANESTHESIA & ANALGESIA MEDICAL GROUP, INC.
Schedule L (Form 990 or 990-EZ) 2010

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
2010
Open to Public
Inspection
Name of the organization
SANTA ROSA MEMORIAL HOSPITAL
 
Employer identification number

94-1231005
Identifier Return Reference Explanation
ORGANIZATION'S MISSION STATEMENT FORM 990, PART I, LINE 1 & PART III, LINE 1 AS A MEMBER OF THE ST. JOSEPH HEALTH SYSTEM, SANTA ROSA MEMORIAL HOSPITAL IS COMMITTED TO EXTENDING THE HEALING MINISTRY OF JESUS IN THE TRADITION OF THE SISTERS OF ST. JOSEPH OF ORANGE BY CONTINUALLY IMPROVING THE HEALTH AND QUALITY OF LIFE OF PEOPLE IN THE COMMUNITIES WE SERVE.
PROGRAM SERVICE ACCOMPLISHMENTS FORM 990, PART III, LINE 4A REALIZING OUR MISSION AS A NOT-FOR-PROFIT, SANTA ROSA MEMORIAL HOSPITAL HAS BEEN MEETING THE HEALTH AND QUALITY OF LIFE NEEDS OF THE LOCAL COMMUNITY FOR OVER 64 YEARS. SERVING THE SONOMA, MENDOCINO, NAPA AND LAKE COUNTY REGIONS, SANTA ROSA MEMORIAL HOSPITAL IS A STATE-OF-THE-ART, 278-BED ACUTE CARE HOSPITAL WITH 1,937 EMPLOYEES. THE HOSPITAL PROVIDES A WIDE RANGE OF IN-PATIENT AND OUT-PATIENT SERVICES, INCLUDING: - STATE-DESIGNATED LEVEL II REGIONAL TRAUMA CENTER; - CARDIOVASCULAR DIAGNOSTIC AND SURGICAL SERVICES; - NORM & EVERT PERSON HEART & VASCULAR INSTITUTE; - INTENSIVE CARE NURSERY; - WOMEN'S AND CHILDREN'S SERVICES; - CRITICAL CARE; - ONCOLOGY; - STROKE CARE; - ACUTE REHABILITATION; - OUTPATIENT THERAPIES & REHABILITATION; - WOUNDCARE; - OUTPATIENT BEHAVIORAL HEALTH; - PALLIATIVE CARE; - ORTHOPEDICS; - OUTPATIENT LABORATORY SERVICES; - 3 URGENT CARE CENTERS; AND AN - AMBULATORY SURGERY CENTER. SANTA ROSA MEMORIAL HOSPITAL, A MEMBER OF THE ST. JOSEPH HEALTH SYSTEM, IS COMMITTED TO EXTENDING THE HEALING MINISTRY OF JESUS IN THE TRADITION OF THE SISTERS OF ST. JOSEPH OF ORANGE. THIS MISSION HAS GUIDED OUR CATHOLIC HEALTHCARE MINISTRY SINCE THE OPENING OF OUR FIRST HOSPITAL IN EUREKA, CALIFORNIA NEARLY 100 YEARS AGO. THE SISTERS OF ST. JOSEPH OF ORANGE TRACE THEIR ROOTS BACK TO 17TH CENTURY FRANCE AND THE UNIQUE VISION OF A JESUIT PRIEST NAMED JEAN-PIERRE MEDAILLE. HE SOUGHT TO ORGANIZE AN ORDER OF RELIGIOUS WOMEN WHO, RATHER THAN REMAINING SAFELY CLOISTERED IN A CONVENT, VENTURED OUT INTO THE COMMUNITY TO SEEK OUT "THE DEAR NEIGHBORS" AND MINISTER TO THEIR NEEDS. THE CONGREGATION MANAGED TO SURVIVE THE TURBULENCE OF THE FRENCH REVOLUTION AND EVENTUALLY EXPANDED, NOT ONLY THROUGHOUT FRANCE, BUT THROUGHOUT THE WORLD. IN 1912 A SMALL GROUP OF SISTERS OF ST. JOSEPH WENT TO EUREKA, CALIFORNIA, AT THE INVITATION OF THE LOCAL BISHOP, TO ESTABLISH A SCHOOL. A FEW YEARS LATER, THE GREAT INFLUENZA EPIDEMIC OF 1918 CAUSED THE SISTERS TO TEMPORARILY SET ASIDE THEIR EDUCATION EFFORTS TO CARE FOR THE ILL. THEY REALIZED IMMEDIATELY THAT THE SMALL COMMUNITY DESPERATELY NEEDED A HOSPITAL. THROUGH BOLD FAITH, FORESIGHT, AND FLEXIBILITY IN 1920, THE SISTERS OPENED THE 28-BED ST. JOSEPH HOSPITAL OF EUREKA, THE FIRST ST. JOSEPH HEALTH SYSTEM MINISTRY. TODAY THE ST. JOSEPH HEALTH SYSTEM IS AN INTEGRATED HEALTHCARE DELIVERY SYSTEM SPONSORED BY THE ST. JOSEPH HEALTH MINISTRY AND ORGANIZED INTO THREE REGIONS: NORTHERN CALIFORNIA, SOUTHERN CALIFORNIA, AND WEST TEXAS/EASTERN NEW MEXICO. THE SYSTEM INCLUDES 14 ACUTE CARE HOSPITALS, HOME HEALTH AGENCIES, HOSPICE CARE, OUTPATIENT SERVICES, COMMUNITY CLINICS, AND PHYSICIAN ORGANIZATIONS. OUR MISSION IS REALIZED THROUGH THE DELIVERY OF QUALITY IN-PATIENT AND OUT-PATIENT SERVICES, AND FOCUSED COMMUNITY INITIATIVES AND PROGRAMS THAT ARE DEDICATED TO IMPROVING THE LIVES OF ALL WE SERVE. THREE MISSION OUTCOMES SANTA ROSA MEMORIAL HOSPITAL IS COMMITTED TO THREE SYSTEMWIDE MISSION OUTCOMES: EVERY INTERACTION WILL BE EXPERIENCED AS A SACRED ENCOUNTER. THE GOAL OF SACRED ENCOUNTER HAS A DIRECT CONNECTION TO THE OVERALL MISSION. OUR VALUE OF DIGNITY CALLS FOR US TO RESPECT EACH PERSON AS AN INHERENTLY VALUABLE MEMBER OF THE HUMAN COMMUNITY AND AS A UNIQUE EXPRESSION OF LIFE. WE STRIVE TO DO THIS BY KEEPING AT THE FOREFRONT OF OUR MINDS THE UNDERSTANDING OF THE IMPACT WE CAN HAVE ON ONE ANOTHER WITH EVERY ACTION WE TAKE. THE MAIN GOAL SURROUNDING SACRED ENCOUNTERS IS TO PROVIDE CARE TO PATIENTS DISTINGUISHED BY EASE OF USE, TIMELY ACCESS, SAFETY, AND HIGH RELIABILITY WITH AN EMPHASIS ON PATIENT SAFETY AND PATIENT SATISFACTION. SANTA ROSA MEMORIAL HAS BEEN WORKING TO DEVELOP AND IMPLEMENT PATIENT EXPERIENCE BEST PRACTICE TECHNIQUES IN THE FOLLOWING AREAS: - QUIETNESS - COMMUNICATION WITH NURSES - COMMUNICATION WITH DOCTORS - RESPONSIVENESS OF HOSPITALS STAFF - DISCHARGE PHONE CALLS ALL OF THESE INITIATIVES HAVE EDUCATION, STANDARD WORK AND COACHING/MENTORING OF STAFF. AUDITS WITH VISUAL MANAGEMENT BOARDS TRACK PROJECTS AND UNITS ARE CONSIDERED HARDWIRED IF ALL AUDITS ARE AT 90% FOR 2 SIMULTANEOUS WEEKS. THIS HAS ALREADY BEEN COMPLETED WITH QUIETNESS AND COMMUNICATION WITH NURSES. IN ADDITION, SANTA ROSA MEMORIAL HOSPITAL IMPLEMENTED A "SPOTLIGHTING PROGRAM," WHICH IS AN INITIATIVE THAT GIVES CAREGIVERS NEW TOOLS TO SHOW THEIR COMPASSION, HONOR PATIENT DIGNITY AND FOSTER AN ENVIRONMENT IN WHICH PATIENTS FEEL SAFE AND NURTURED. SPECIFICALLY, THE FOCUS WILL BE ON THREE MOMENTS: ADMISSION, BED TIME AND DISCHARGE. DEPARTMENTS LOOK CLOSELY AT EVERY ASPECT OF THESE EXPERIENCES, DETERMINE THE TONE THEY WANT TO ESTABLISH, AND THEN EXPLORE WHAT CAREGIVERS CAN DO AND SAY TO FOSTER A SACRED ENCOUNTER. THE IDEA IS TO CREATE TOOLS THAT ALLOW THE CAREGIVER TO REACH OUT AND HAVE AUTHENTIC ENCOUNTERS WITH THE PATIENTS. ALL PATIENTS WILL RECEIVE PERFECT CARE. IT IS OUR ATTENTION TO DETAIL AND THE SMALLEST IMPERFECTIONS OF EACH PATIENT'S EXPERIENCE THAT DRIVES A DEEPER UNDERSTANDING AND ULTIMATELY A SUSTAINABLE APPROACH TO THE ACHIEVEMENT OF PERFECT CARE. CHF CORE MEASURES - A GREAT DEAL OF FOCUS HAS BEEN APPLIED TO OUR CONGESTIVE HEART FAILURE PATIENTS. THIS WORK HAS INCLUDED EDUCATION FOR THE NURSING STAFF ABOUT CONGESTIVE HEART FAILURE AND CONGESTIVE HEART FAILURE CORE MEASURES ALONG WITH CONCURRENT REVIEW OF THESE PATIENTS WHILE THEY ARE IN THE HOSPITAL. AS YOU CAN SEE THERE HAS BEEN A DOWNWARD TREND BEGINNING IN THE 4TH QUARTER OF CALENDAR YEAR 2010 AND CONTINUING UNTIL THE 3RD QUARTER OF CALENDAR YEAR 2011 AT WHICH TIME THERE WAS A 0% FAILURE RATE. JOINT COMMISSION SURVEY - SANTA ROSA MEMORIAL HOSPITAL HAS RECEIVED THEIR FINAL ACCREDITATION FOLLOWING THE JOINT COMMISSION SURVEY. THE PROCESS INVOLVES ACCEPTANCE OF A PLAN OF CORRECTION BY THE HOSPITAL TO EACH OF THE SPECIFIED "REQUESTS FOR IMPROVEMENT" AND THE SUBMISSION IN CERTAIN CASES OF PROCESS MEASUREMENTS OVER A 4 MONTH PERIOD. THE PLANS OF CORRECTION HAVE BEEN SUBMITTED AND ACCEPTED. MEANINGFUL USE- WE ARE COMPLETING A VERY SIGNIFICANT PHASE OF A MULTI-YEAR ELECTRONIC MEDICAL RECORDS PROJECT AT SANTA ROSA MEMORIAL HOSPITAL. JUNE 30TH WILL MARK OUR DEADLINE TO "ATTEST" THAT WE HAVE REACHED PHASE I OF THE ELECTRONIC MEDICAL RECORD MEANINGFUL USE CRITERIA AS ESTABLISHED BY THE FEDERAL GOVERNMENT. IN MAY, OUR ADULT HOSPITALISTS, AND EMERGENCY ROOM PHYSICIANS WENT LIVE WITH COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE). ON JUNE 13TH WE WILL ADD THE ORTHOPEDISTS, PEDIATRIC HOSPITALISTS, NEONATOLOGISTS, UROLOGISTS, AND NEPHROLOGISTS. CPOE FOR THE REMAINDER OF THE MEDICAL STAFF WILL ROLL OUT IN "WAVES OF GO-LIVES" APPROXIMATELY EVERY TWO WEEKS UNTIL OCTOBER. AS OF JUNE 30TH WE WILL HAVE SATISFIED ALL 18 "PHASE 1 MEANINGFUL USE" MEASURES. THE COMMUNITIES WE SERVE WILL BE AMONG THE HEALTHIEST IN OUR NATION. WE SEEK TO DEVELOP COMMUNITY HEALTH INITIATIVES THAT IMPACT LONG-TERM HEALTH ACROSS THE ENTIRE COMMUNITY. SANTA ROSA MEMORIAL HOSPITAL COMPLETED A SUCCESSFUL PILOT OF THE HEALTHY FOR LIFE PROGRAM IN TWO CHARTER ELEMENTARY SCHOOLS IN THE SONOMA VALLEY, SERVING OVER 40 LOW-INCOME CHILDREN DIRECTLY AND 400 INDIRECTLY THROUGH TEACHER TRAINING, PE RESOURCES, NUTRITION EDUCATION AND ENGAGING SCHOOL WELLNESS COMMITTEES IN ENVIRONMENTAL AND POLICY CHANGE EFFORTS. THE PARTICIPATING STUDENTS SHOWED A REDUCTION OF OBESITY FROM 13% TO 7% AND OF UNDERWEIGHT FROM 7% TO 5%. SANTA ROSA MEMORIAL HOSPITAL IS AN ACUTE-CARE HOSPITAL SERVING THE SONOMA, MENDOCINO, NAPA AND LAKE COUNTIES REGION. DURING FISCAL YEAR 2011, WE INVESTED A TOTAL OF $34,886,355 (10.6% OF OUR TOTAL OPERATING EXPENSES) IN COMMUNITY BENEFIT (INCLUDING TRADITIONAL CHARITY CARE, UNPAID COST TO STATE AND LOCAL PROGRAMS AND COMMUNITY BENEFIT SERVICES TO THE LOW-INCOME AND BROADER COMMUNITY.), IN ALIGNMENT WITH CATHOLIC HEALTH ASSOCIATION GUIDELINES. IN ADDITION, OUR UNPAID COST OF MEDICARE PROGRAMS TOTALED $34,939,538.
FINANCIAL ASSISTANCE POLICY (TRADITIONAL CHARITY CARE)   OUR MISSION IS TO PROVIDE QUALITY CARE TO ALL OUR PATIENTS, REGARDLESS OF ABILITY TO PAY. WE BELIEVE THAT NO ONE SHOULD DELAY SEEKING NEEDED MEDICAL CARE BECAUSE THEY LACK HEALTH INSURANCE. THAT IS WHY ST. JOSEPH HEALTH SYSTEM HAS A PATIENT FINANCIAL ASSISTANCE PROGRAM THAT PROVIDES FREE OR DISCOUNTED SERVICES TO ELIGIBLE PATIENTS. IN FY 11, THE SANTA ROSA MEMORIAL HOSPITAL MINISTRY, PROVIDED $8,561,780 IN TRADITIONAL CHARITY CARE ORGANIZATIONAL COMMITMENT AS A VALUES BASED ORGANIZATION, SANTA ROSA MEMORIAL HOSPITAL HAS A LONG-STANDING COMMITMENT TO THE COMMUNITY. FY 11 COMMUNITY BENEFIT INITIATIVES AND/OR PROGRAMS NAME OF INITIATIVE OR PROGRAM: CHILDHOOD OBESITY INITIATIVE GOAL: THE GOAL OF THE CHILDHOOD OBESITY INITIATIVE IS TO REDUCE CHILDHOOD OBESITY IN LOW-INCOME, IMMIGRANT, AND LATINO CHILDREN AND THEIR FAMILIES BY 3%, BY 2011 KEY COMMUNITY PARTNERS: THE HOSPITAL'S PRIMARY COMMUNITY PARTNERS IN THIS ENDEAVOR ARE THE COMMUNITY ACTIVITY & NUTRITION COALITION, HEALTH ACTION (ITS IWALK, IGROW, AND HEALTHY STUDENTS INITIATIVE), AND THE REDWOOD COMMUNITY HEALTH COALITION. FY11 ACCOMPLISHMENTS: CHILDHOOD OBESITY PREVENTION HAS BEEN THE FOCUS OF ST. JOSEPH HEALTH SYSTEM'S LONG-TERM HEALTHIEST COMMUNITIES GOAL, FOR WHICH A SIGNIFICANT NUMBER OF LOCAL ACTIVITIES FOCUSED ON THIS CRITICAL COMMUNITY HEALTH CONDITION. SJHS-SC COMPLETED A SUCCESSFUL PILOT OF THE HEALTHY FOR LIFE PROGRAM IN TWO CHARTER ELEMENTARY SCHOOLS IN THE SONOMA VALLEY, SERVING OVER 40 LOW-INCOME CHILDREN DIRECTLY AND 400 INDIRECTLY THROUGH TEACHER TRAINING, PE RESOURCES, NUTRITION EDUCATION, AND ENGAGING SCHOOL WELLNESS COMMITTEES IN ENVIRONMENTAL AND POLICY CHANGE EFFORTS. THE PARTICIPATING STUDENTS SHOWED A REDUCTION OF OBESITY FROM 13% TO 7% AND OF UNDERWEIGHT FROM 7% TO 5%. RESIDENTS FROM THROUGHOUT SONOMA COUNTY ENGAGED IN COMMUNITY ORGANIZING, EDUCATION AND ADVOCACY EFFORTS TO ADDRESS SOCIAL DETERMINANTS OF CHILDHOOD OBESITY, CREATING COMMUNITY GARDENS AND SUCCESSFULLY ADVOCATING FOR LAND USE AND OTHER SUPPORTING PUBLIC POLICY CHANGES. HEALTH PROMOTION ACTIVITIES INCLUDED THE MENTORING OF 8 NEW COMMUNITY VOLUNTEERS WHO PROVIDED YOUR HEART, YOUR HEALTH TRAINING TO OTHER LOW-INCOME RESIDENTS; AS WELL AS OBESITY PREVENTION EDUCATION PROVIDED TO 75% OF ALL PARTICIPANTS IN SJHS-SC'S AFTER-SCHOOL PROGRAM, CIRCLE OF SISTERS. SJHS-SC ACHIEVED MANY ACCOMPLISHMENTS IN ITS INITIATIVE TO REDUCE CHILDHOOD OBESITY DURING FISCAL YEAR 2011. SJHS-SC WAS A FOUNDING MEMBER OF THE HEALTHY STUDENTS INITIATIVE OF THE HEALTH ACTION COALITION, CONTRIBUTING TO COMPLETION A COUNTYWIDE SURVEY OF SCHOOLS ON POLICIES AND PROGRAMS THAT SUPPORT HEALTHY EATING AND PHYSICAL ACTIVITY. THIS COLLABORATIVE GROUP ALSO EMBRACED ST. JOSEPH HEALTH SYSTEM'S HEALTHY FOR LIFE PROJECT, AND COLLABORATED IN PLANNING SONOMA COUNTY'S PILOT PROJECT IN THE SONOMA VALLEY'S TWO CHARTER SCHOOLS. HEALTHY FOR LIFE WAS ACCEPTED INTO SONOMA COUNTY'S "UPSTREAM INVESTMENTS" PORTFOLIO. OTHER HIGHLIGHTS OF THE CHILDHOOD OBESITY PREVENTION INITIATIVE INCLUDE NCS TRAINING AND MENTORING OF COMMUNITY LEADERS FROM LOW- INCOME NEIGHBORHOODS IN ADDRESSING TWO KEY SOCIAL DETERMINANTS OF HEALTH: OVER 5,000 ACTIONS OF ADVOCACY, EDUCATION, AND ORGANIZING TO REDUCE OBSTACLES TO HEALTH FOOD AND PHYSICAL ACTIVITY; AND OVER 1,500 ACTIONS TO INCREASE NEIGHBORHOOD SAFETY. NCS SUPPORTED CITY OF ROHNERT PARK IN OBTAINING $75,000 TO TRANSFORM FORMER PUBLIC POOL INTO COMMUNITY GARDEN. IWALK ROSELAND GROUP PARTNERED WITH SAFE ROUTES TO SCHOOL TO FORM A WALKING SCHOOL BUS WITH 35 STUDENTS AND 15 PARENTS. SUNRISE COMMUNITY GARDEN COMMITTEE MEMBERS MADE SUCCESSFUL PRESENTATIONS TO THE PETALUMA RECREATIONS AND PARKS COMMISSION FOR FINAL APPROVAL OF THE LAND USE CHANGES AND RESOURCE ALLOCATION FOR THEIR GARDEN. NCS SUPPORTED APPROXIMATELY 100 LOW-INCOME RESIDENTS THROUGHOUT THE COUNTY IN JOINING THE 350 GARDEN CHALLENGE. ADVOCACY BY CIELO AZUL COOP FARM MEMBERS RESULTED IN POLICY CHANGES BY SANTA ROSA COMMUNITY DEVELOPMENT DEPT ON COMMUNITY GARDEN PERMITS. NCS PROVIDED ACTION TRAINING AND MENTORING TO AN ADDITIONAL 24 RESIDENTS FROM LOW-INCOME NEIGHBORHOODS IN SOUTH SANTA ROSA, AS A PARTNER IN THE HEAL INITIATIVE. CIRCLE OF SISTERS (COS) EDUCATION EFFORTS CONTINUE TO REPORT POSITIVE RESULTS. 37 GIRLS PARTICIPATED IN CIRCLE OF SISTERS MENTOR PEERS IN HEALTHY EATING AND PHYSICAL ACTIVITY. PRE- AND POST-TESTS WITH CIRCLE OF SISTERS PARTICIPANTS SHOWED AN IMPROVEMENT FROM 81% TO 100% EATING BREAKFAST EACH DAY. 100% OF RETURNING COS PARTICIPANTS REPORTED INCREASED KNOWLEDGE ABOUT OBESITY PREVENTION. 82% OF CHILDREN SEEN BY MOBILE HEALTH CENTER RECEIVED BMI SCREENING. DATA COLLECTED ON BMI FOR PATIENTS DURING FISCAL YEAR 2011 SEEN BY THE SJHS-SC MOBILE HEALTH CLINIC SHOWS: CHILDREN 2-4 CHILDREN 5-11 CHILDREN 12-19 TOTAL # OF PTS 22 70 107 BMI SCREENED 15 68% 62 89% 99 93% OVERWEIGHT 1 7% 6 10% 13 13% OBESE 2 13% 12 19% 30 30% TOTAL EXPENSES: $950,691.65 TOTAL REVENUE: $329,672.00 NAME OF INITIATIVE OR PROGRAM: CHILDREN'S ORAL HEALTH GOAL: THE GOAL OF THE CHILDREN'S ORAL HEALTH INITIATIVE IS REDUCE CARIES IN LOW-INCOME, IMMIGRANT, AND LATINO CHILDREN BY 3% BY 2011. KEY COMMUNITY PARTNERS: THE HOSPITAL'S PRIMARY COMMUNITY PARTNERS IN THIS ENDEAVOR ARE THE SONOMA COUNTY ORAL HEALTH COALITION AND WOMEN, INFANTS & CHILDREN (WIC).
FY11 ACCOMPLISHMENTS:   SJHS-SC'S ORAL HEALTH SERVICES INCLUDE ST. JOSEPH'S DENTAL CLINIC, SERVING CHILDREN AGES 0-16 BY PROVIDING BASIC, PREVENTIVE, RESTORATIVE, EMERGENCY AND DENTAL CARE AND TREATMENT WITH A STRONG FOCUS ON EDUCATION; AS WELL AS EMERGENCY DENTAL CARE TO ADULTS ON A FIRST COME FIRST SERVED BASIS AND A SPECIAL PROGRAM FOR PREGNANT WOMEN (MOMMY AND ME). THE CHILDREN'S ORAL HEALTH INITIATIVE, FOR WHICH THE SONOMA COUNTY ORAL HEALTH ACCESS COALITION (SCOHAC) IS THE PRIMARY COLLABORATIVE VEHICLE FOR EFFECTING COMMUNITY CHANGE. SCOHAC WAS RECOGNIZED BY STATE SENATOR MARK LENO AND ASSEMBLYMAN JARED HUFFMAN FOR ITS ADVOCACY EFFORTS ON BEHALF OF CHILDREN'S ORAL HEALTH. IN ADDITION TO PARTICIPATION IN SCOHAC'S ADVOCACY, SJHS-SC'S ACTIVE PARTICIPATION IN THIS KEY STAKEHOLDER GROUP FACILITATED ITS PROVISION OF ORAL HEALTH EDUCATION TO WIC PROVIDERS AND HEALTHCARE PROVIDERS AT SANTA ROSA COMMUNITY HEALTH CENTER, PRIMARY CARE RESIDENTS, AND PEDIATRICIANS AND EMERGENCY DEPARTMENT PHYSICIANS, AMONG OTHERS. 100% OF PARTICIPATING WIC PROGRAM PROVIDERS HAVE BEEN EDUCATED AND ARE PROVIDING TRAINING AT THEIR SITES, THEREBY INCREASING ORAL HEALTH AWARENESS AT WIC. AS A RESULT, THE MOMMY & ME PROGRAM HAS EXPANDED INTO ONE WIC SITE. IN ADDITION, 272 WIC CHILDREN WERE SEEN BY THE MOBILE DENTAL CLINIC IN FY 11, AND 2,329 WIC PARTICIPANTS RECEIVED ORAL HEALTH EDUCATION AT THEIR WIC SITE IN THAT YEAR. ORAL HEALTH CARE SERVICES PROVIDED TO CHILDREN AGES 0-5 INCREASED BY 30%, WITH A 28% INCREASE IN CHILDREN RECEIVING THEIR FIRST DENTAL EXAM BY THEIR FIRST BIRTHDAY. IN FY 2011, THE ST. JOSEPH DENTAL CLINIC PROVIDED NEARLY 6,650 VISITS FOR 2,984 PATIENTS, WITH AN ADDITIONAL 5,589 VISITS PROVIDED TO 3,498 PATIENTS ON THE CULTIVANDO LA SALUD MOBILE DENTAL CLINIC, INCLUDING MIGHTY MOUTH SCHOOL BASED CARE. TWO THOUSAND SIXTY ONE (2061) CHILDREN AGES 0-5 YEARS WERE CARED FOR BY THE TWO DENTAL CLINICS, AN INCREASE OF 15% FROM 2010. THE CLINIC OFFERS A SPECIAL DESENSITIZATION PROGRAM FOR PATIENTS WITH DEVELOPMENTAL DISABILITIES. THREE HUNDRED AND SEVENTY SIX (376) ONE-YEAR OLDS RECEIVED THEIR FIRST DENTAL VISITS IN THE LAST YEAR WHICH IS A 251% INCREASE FROM 2010. MOMMY & ME CHILDREN HAD A 2% DECAY RATE, COMPARED TO 33% FOR CHILDREN OF THE SAME AGE GROUP NOT PARTICIPATING IN MOMMY & ME. SJHS-SONOMA COUNTY ALSO PARTICIPATED IN THE SONOMA COUNTY ORAL HEALTH TASK FORCE IN 2011, WHICH PRODUCED A REPORT WITH RECOMMENDATIONS FOR IMPROVEMENT OVER THE NEXT THREE YEARS. TOTAL EXPENSES: $ 1,189,854.00 TOTAL REVENUE: $ 982,248.00 NAME OF INITIATIVE OR PROGRAM: YOUTH & PERI-NATAL SUBSTANCE ABUSE PREVENTION GOAL: THE GOAL OF THE YOUTH & PERI-NATAL SUBSTANCE ABUSE PREVENTION INITIATIVE IS REDUCE ABUSE OF ALCOHOL, TOBACCO, MARIJUANA, AND OTHER SUBSTANCES BY LOW-INCOME, IMMIGRANT, AND LATINO YOUTH AND WOMEN OF CHILD-BEARING YEARS TO COUNTY TARGETS BY 2011. KEY COMMUNITY PARTNERS: THE HOSPITAL'S PRIMARY COMMUNITY PARTNERS IN THIS ENDEAVOR ARE THE DRUG ABUSE ALTERNATIVE CENTER, SONOMA COUNTY PREVENTION PARTNERSHIP, SANTA ROSA GANG PREVENTION TASK FORCE, AND SONOMA COUNTY MATERNAL, CHILD & ADOLESCENT HEALTH FY11 ACCOMPLISHMENTS: YOUTH AND PERI-NATAL SUBSTANCE ABUSE: SJHS-SONOMA COUNTY HAS TAKEN A PROACTIVE LEADERSHIP ROLE TO ADDRESS YOUTH AND PERI-NATAL SUBSTANCE ABUSE. MOST RECENTLY, PETALUMA VALLEY HOSPITAL'S EMERGENCY DEPARTMENT MANAGER SERVED AS COALITION CHAIR OF PETALUMA'S COALITION TO PREVENT ABUSE OF ALCOHOL, TOBACCO, AND OTHER DRUGS. DURING FISCAL YEAR 2011, THE COALITION BEGAN IMPLEMENTATION OF A FEDERAL DRUG FREE COMMUNITY GRANT BY FORMING A SPEAKERS BUREAU AND MAKING EDUCATIONAL PRESENTATIONS TO PETALUMA CITY SCHOOLS AND THE CITY COUNCIL. IN ADDITION, ADVOCACY WAS DONE AT THE LOCAL GOVERNMENT FOR MODIFICATIONS TO THE CONDITIONAL USE PERMITS AND ALCOHOL RELATED NUISANCE ORDINANCES. IN THE SONOMA VALLEY, SJHS-SONOMA COUNTY ALSO WORKED WITH COMMUNITY PARTNERS TO SUPPORT LOCAL COLLABORATIVE EFFORTS TO REDUCE SUBSTANCE ABUSE. THEY SUCCESSFULLY ADVOCATED CLOSING AN UNLICENSED MARIJUANA DISPENSARY THAT WAS LOCATED IN FRONT OF A LOCAL TEEN CENTER AND WITHIN ONE BLOCK OF A CHARTER ELEMENTARY SCHOOL. YOUTH AND PERI-NATAL SUBSTANCE ABUSE INITIATIVE ENGAGED SJHS-SC'S COMMUNITY BENEFIT DEPARTMENT STAFF IN EDUCATION AND COMMUNITY MOBILIZATION ACTIVITIES THAT INCLUDED INCREASED PARTICIPATION OF YOUTH IN LOCAL SUBSTANCE ABUSE PREVENTION COALITIONS IN PETALUMA AND SONOMA THROUGH COMMUNITY RADIO SHOWS, COMMUNITY THEATER, OUTREACH, AND POLICY ADVOCACY. THE NEIGHBORHOOD CARE STAFF (NCS) AND HEALTHY COMMUNITIES CONSORTIUM PARTNERED ON LATINO YOUTH ENGAGEMENT PROJECTS IN PETALUMA; PROVIDING LEADERSHIP TRAINING AND MENTORING TO YOUTH AND WORKING WITH THEM TO ORGANIZE THE FIRST LATINO ENGAGEMENT YOUTH FORUM AT THE PETALUMA SR JUNIOR COLLEGE CAMPUS (70 PARTICIPANTS). NCS AND NUESTRA VOZ ENGAGED LATINO YOUTH IN A FOCUS GROUP ABOUT SUBSTANCE ABUSE IN SONOMA VALLEY. NCS FACILITATED THE UNIFICATION OF TWO LOCAL PREVENTION COALITIONS IN SONOMA VALLEY, WHICH DEVELOPED A UNIFIED ACTION PLAN AND NCS LED THE EFFORT TO ENGAGE RESIDENTS IN ADVOCATING FOR REMOVAL OF AN UNPERMITTED MARIJUANA DISPENSARY ON HIGHWAY 12 IN FRONT OF THE TEEN CENTER. PARTNERSHIP WITH THE DRUG ABUSE ALTERNATIVE CENTER CONTRIBUTED TO THE EDUCATION OF COMMUNITY BENEFIT STAFF IN SUBSTANCE ABUSE-RELATED ISSUES AND RESOURCES IN SONOMA COUNTY; CIRCLE OF SISTERS (COS) YOUTH LEADER PARTICIPANTS IN COS YOUTH ADVISORY COUNCIL (YAC) MENTORED OTHER GIRLS IN SITE BASED ATOD PREVENTION ACTIVITIES. ALL COS PARTICIPANTS (279) RECEIVED ATOD PREVENTION EDUCATION AND 100% OF RETURNING COS PARTICIPANTS REPORTED INCREASED UNDERSTANDING OF THE RISKS ASSOCIATED WITH ALCOHOL AND MARIJUANA USE. TOTAL EXPENSES: $ 155,299.65 TOTAL REVENUE: $ 29,601.00 FOR MORE INFORMATION ABOUT SANTA ROSA MEMORIAL HOSPITAL, PLEASE VISIT WWW.STJOSEPHHEALTH.ORG. FOR MORE INFORMATION ABOUT ST. JOSEPH HEALTH SYSTEM, PLEASE VISIT WWW.STJOE.ORG.
DESCRIPTION OF CLASSES OF MEMBERS OR STOCKHOLDERS FORM 990, PART VI, LINE 6 ST. JOSEPH HEALTH SYSTEM IS THE SOLE CORPORATE MEMBER OF SANTA ROSA MEMORIAL HOSPITAL.
DESCRIPTION OF CLASSES OF PERSONS AND THE NATURE OF THEIR RIGHTS FORM 990, PART VI, LINE 7A SANTA ROSA MEMORIAL HAS A TIERED GOVERNANCE IN WHICH THE CORPORATE MEMBERS RESERVE THE RIGHT TO APPOINT TRUSTEES TO THE SANTA ROSA MEMORIAL HOSPITAL BOARD. ALL TRUSTEE APPOINTMENTS THAT COME FROM THE SANTA ROSA MEMORIAL HOSPITAL BOARD AS NOMINATIONS MUST BE APPROVED BY THE ST. JOSEPH HEALTH SYSTEM, AS THE CORPORATE MEMBER AND THE ST. JOSEPH HEALTH MINISTRY, AS THE ORGANIZATIONAL SPONSOR.
DESCR CLASSES OF PERSONS, DECISIONS REQUIRING APPR & TYPE OF VOTING RIGHTS FORM 990, PART VI, LINE 7B THE RESERVED RIGHTS IN OUR TIERED GOVERNANCE STRUCTURE CONTEMPLATE APPROVAL BY THE ST. JOSEPH HEALTH SYSTEM MEMBER OF FINANCING, BUDGETS, UNBUDGETED EXPENDITURE OF DEFINED AMOUNTS, STRATEGIC PLAN, APPOINTMENT OF AUDITORS, CREATION OR INVESTMENT IN A LEGALLY RECOGNIZED ENTITY, JOINT VENTURES, PURPOSES, SALE OR DISPOSITION OF REAL PROPERTY, MERGER OR SALE OF SUBSTANTIALLY ALL ASSETS, APPOINTMENT AND REMOVAL OF TRUSTEES, ADOPTION OR AMENDMENT OF ARTICLES OR BYLAWS.
DESCRIBE THE PROCESS USED BY MANAGEMENT &/OR GOVERNING BODY TO REVIEW 990 FORM 990, PART VI, LINE 11B THE FORM 990 IS PREPARED BY THE FINANCE DEPARTMENT BASED ON INFORMATION RECEIVED FROM VARIOUS DEPARTMENTS OF THE ORGANIZATION AS APPLICABLE. THE FORM 990 IS THEN REVIEWED BY AN OFFICER OF THE ORGANIZATION. A COPY OF THE FORM 990 FILING IS DISTRIBUTED TO ALL VOTING MEMBERS OF THE BOARD FOR THE MARCH 2012 MEETING. DURING THE FINANCE COMMITTEE MEETING, MANAGEMENT PRESENTS AND DISCUSSES CERTAIN DISCLOSURES AND INFORMATION INCLUDED IN THE FORM 990. THE FINANCE COMMITTEE CHAIR THEN PROVIDES A SUMMARY AT THE FULL BOARD MEETING.
CONFLICT OF INTEREST POLICY FORM 990, PART VI, LINES 12A AND 12C THE CONFLICT OF INTEREST POLICY WAS DEVELOPED BY ST. JOSEPH HEALTH SYSTEM AND IMPLEMENTED BY SANTA ROSA MEMORIAL HOSPITAL. IT WAS ADOPTED BY THE SANTA ROSA MEMORIAL BOARD ON JANUARY 17, 2012. OFFICERS, TRUSTEES, AND KEY EMPLOYEES ARE REQUIRED TO DISCLOSE ANNUALLY ON THE CONFLICT OF INTEREST DISCLOSURE FORM THE EXISTENCE AND NATURE OF ANY ACTUAL, APPARENT, OR POTENTIAL CONFLICTS OF INTEREST HE/SHE MAY HAVE. ADDITIONALLY, DISCLOSURES SHALL BE MADE PROMPTLY ANY TIME AN ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST ARISES AND BEFORE THE CONSUMMATION OF ANY CONTRACT, TRANSACTION, OR ARRANGEMENT THAT IS THE SUBJECT OF THE POTENTIAL CONFLICT OF INTEREST. WHEN A CONFLICT OF INTEREST IS IDENTIFIED, SUCH CONFLICT IS DISCLOSED TO EXECUTIVE COMPLIANCE COMMITTEE. IF THE CONFLICT INVOLVES A MEMBER OF THAT COMMITTEE, THE REMAINING COMMITTEE MEMBERS REVIEW THE MATTER AND DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. THE OFFICER, TRUSTEE, OR KEY EMPLOYEE MAY NOT BE PRESENT DURING ANY MEETING IN WHICH THE COMMITTEE CONDUCTS ITS EVALUATION, EXCEPT TO ANSWER QUESTIONS AS MAY BE NECESSARY. ONCE ALL NECESSARY INFORMATION HAS BEEN OBTAINED, THE COMMITTEE CONDUCTS ITS EVALUATION AND FORWARDS ITS FINDINGS AND RECOMMENDATIONS TO THE SJHS CHIEF COMPLIANCE OFFICER. IF THE COMMITTEE DETERMINES AN UNRESOLVED CONFLICT OF INTEREST EXISTS, THE COMMITTEE WILL EVALUATE AND RECOMMEND CONFLICT MITIGATION STRATEGIES. THE SJHS CHIEF COMPLIANCE OFFICER, IN CONSULTATION WITH SJHS GENERAL COUNSEL, WILL REVIEW THE COMMITTEE FINDINGS, RECOMMENDATIONS, AND MITIGATION STRATEGIES, AND PRESENT RECOMMENDATIONS TO THE BOARD FOR DISCUSSION AND VOTE.
WHISTLEBLOWER POLICY FORM 990, PART VI, LINE 13 THE WHISTLEBLOWER POLICY WAS DEVELOPED BY ST. JOSEPH HEALTH SYSTEM AND IMPLEMENTED BY SANTA ROSA MEMORIAL HOSPITAL. IT WAS ADOPTED BY THE SANTA ROSA MEMORIAL BOARD ON JANUARY 17, 2012.
DOCUMENT RETENTION AND DESTRUCTION POLICY FORM 990, PART VI, LINE 14 THE DOCUMENT RETENTION AND DESTRUCTION POLICY WAS DEVELOPED BY ST. JOSEPH HEALTH SYSTEM AND IMPLEMENTED BY SANTA ROSA MEMORIAL HOSPITAL. IT WAS ADOPTED BY SANTA ROSA MEMORIAL HOSPITAL BOARD ON JANUARY 17, 2012.
PROCESS USED TO DETERMINE COMPENSATION FORM 990, PART VI, LINES 15A & 15B THE EXECUTIVE COMPENSATION PROCESS AT ST. JOSEPH HEALTH SYSTEM IS ADMINISTERED BY A COMMITTEE OF INDEPENDENT TRUSTEES. THEY FOLLOW A BOARD-APPROVED CHARTER AND OVERALL EXECUTIVE COMPENSATION PHILOSOPHY. THE CHARTER EMPOWERS THE SJHS BOARD WORKLIFE COMMITTEE TO ADMINISTER THE EXECUTIVE COMPENSATION PROGRAM AND PROCESS ON BEHALF OF THE FULL BOARD OF TRUSTEES OF SJHS. OVERALL, THE PHILOSOPHY IS INTENDED TO REWARD A BROAD SPECTRUM OF HIGH ORGANIZATIONAL AND INDIVIDUAL PERFORMANCE EXPECTATIONS, AS WELL AS THE RETENTION OF KEY MANAGEMENT TALENT. THE SJHS EXECUTIVE COMPENSATION PHILOSOPHY DEFINES THE MARKET FOR ADMINISTERING COMPENSATION AS A COMPARABLE SET OF NOT-FOR-PROFIT AND FOR-PROFIT HEALTH CARE DELIVERY SYSTEMS. SJHS PROVIDES COMPENSATION TO ITS SENIOR EXECUTIVE IN THE FORM OF BASE SALARY AN ANNUAL INCENTIVE PROGRAM AND BENEFITS. TO FULFILL THEIR RESPONSIBILITY, THE COMMITTEE REGULARLY REVIEWS INFORMATION FROM MULTIPLE SOURCES OF MARKET DATA. THEY USE THIS INFORMATION TO SUPPORT THEIR DECISIONS REGARDING ONGOING EFFECTIVENESS AND ADMINISTRATION OF THE PROGRAM. THE WORKLIFE COMMITTEE IS COMPRISED OF SEVERAL INDEPENDENT MEMBERS OF THE BOARD. THEY MEET FOUR TIMES A YEAR AND ALL CRITICAL DECISIONS ARE MADE DURING THE WORKLIFE COMMITTEE MEETINGS OR IN EXECUTIVE SESSION. THESE DECISIONS ARE DOCUMENTED IN DETAILED MINUTES AND APPROVED IN SUBSEQUENT MEETINGS. THE COMMITTEE IS EMPOWERED TO ENGAGE OUTSIDE COUNSEL AND CONSULTING SUPPORT AS NEEDED. THE WORKLIFE COMMITTEE PREFORMED ITS LAST COMPENSATION REVIEW FOR ASSISTANT VICE PRESIDENTS, VICE PRESIDENTS, SENIOR VICE PRESIDENTS, EXECUTIVE VICE PRESIDENTS, AND THE CHIEF EXECUTIVE OFFICER IN SEPTEMBER 2011.
AVAIL OF GOV DOCS, CONFLICT OF INTEREST POLICY, & FIN STMTS TO GEN PUBLIC FORM 990, PART VI, QUESTION 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. THE SJHS COMMUNITY BENEFIT REPORTS, FINANCIAL REPORTS, AND PHILANTHROPY REPORTS ARE ALSO AVAILABLE ON THE SJHS INTERNET SITE.
HOURS DEVOTED TO RELATED ORGANIZATIONS FORM 990, PART VII SISTER JUDITH DUGAN SERVES ON THE BOARD OF SANTA ROSA MEMORIAL HOSPITAL (SRMH) AND SRM ALLIANCE HOSPITAL SERVICES (PVH). SHE DEVOTES 2 HOURS PER WEEK TO SRMH AND 2 HOURS PER WEEK TO PVH. SISTER CHRISTINE RAY SERVES ON THE BOARD OF SANTA ROSA MEMORIAL HOSPITAL (SRMH) AND SRM ALLIANCE HOSPITAL SERVICES (PVH). SHE DEVOTES 2 HOURS PER WEEK TO SRMH AND 2 HOURS PER WEEK TO PVH. ANNETTE WALKER SERVES ON THE BOARD OF DIRECTORS OF SANTA ROSA MEMORIAL HOSPITAL (SRMH) AND IS AN EMPLOYEE OF ST. JOSEPH HEALTH SYSTEM (SJHS), THE TAX-EXEMPT PARENT OF SRMH. SHE DEVOTES 50 HOURS PER WEEK TO HER ROLE AS EVP OF STRATEGIC IMPLEMENTATION AT SJHS. KEVIN KLOCKENGA IS THE CEO OF SANTA ROSA MEMORIAL HOSPITAL (SRMH) AND SRM ALLIANCE HOSPITAL SERVICES (PVH) AND IS PAID BY ST. JOSEPH HEALTH SYSTEM (SJHS), THE TAX-EXEMPT PARENT OF SRMH AND PVH. HE DEVOTES 43 HOURS PER WEEK TO SRMH, 7 HOURS PER WEEK TO PVH AND 0 HOURS TO SJHS. JO SANDERSFELD, MICHEL RICCIONI, GARY GREENSWEIG, DEBRA MILLER, MARK KNIGHT, KATHERINE HARDIN, TODD SALNAS AND ANDREA LEARNED ALL DEVOTE 43 HOURS PER WEEK TO SRMH AND 7 HOURS PER WEEK TO PVH.
OTHER CHANGES IN NET ASSETS FORM 990, PART XI, LINE 5 UNREALIZED GAINS $ 4,855,723 EQUITY TRANSFER $(3,498,599) OTHER UNRESTRICTED CHANGE TO NET ASSETS $ 40,542 ----------- $ 1,397,666 ===========
OVERSIGHT OR SELECTION PROCESS FORM 990, PART XII, QUESTION 2C THE ST. JOSEPH HEALTH SYSTEM BOARD APPROVES THE AUDITED CONSOLIDATED FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT.
SECTION 409A DOCUMENT CORRECTION UNDER SECTION VI.B, VII.C AND XI.A OF IRS NOTICE 2010-6 DOCUMENT DEFECTS 1) NAME AND SOCIAL SECURITY NUMBERS OF AFFECTED PARTICIPANTS: NOT APPLICABLE. 2) THE 409A FAILURE OCCURRED WITH RESPECT TO THE ST. JOSEPH HEALTH SYSTEM 457(F) PLAN ("PLAN"). 3) THE 409A PLAN FAILURES ARE ELIGIBLE FOR CORRECTION UNDER THE TERMS OF SECTION VI.B, VII.C AND XI.A OF IRS NOTICE 2010-6. THE EMPLOYER HAS TAKEN ALL ACTIONS REQUIRED BEFORE DECEMBER 31, 2010, AND OTHERWISE MET ALL REQUIREMENTS FOR SUCH CORRECTION. NO PARTICIPANT IS REQUIRED TO REPAY ANY AMOUNT TO THE PLAN IN A SUBSEQUENT TAX YEAR, NOR IS ANY AMOUNT REQUIRED TO BE INCLUDED IN INCOME UNDER SECTION 409A AS PART OF THE CORRECTION. THE CORRECTIVE AMENDMENT WAS SIGNED ON OCTOBER 6, 2010. THE DATE OF THE EVENT CAUSING THE AFFECTED PARTICIPANT TO INCLUDE HIS PLAN ACCOUNT IN GROSS INCOME WAS HIS VOLUNTARY TERMINATION DATE. 4) DESCRIPTION OF EACH FAILURE: THIS EMPLOYER DID NOT HAVE ANY EMPLOYEES WHO VOLUNTARILY TERMINATED AND WERE DUE A DISTRIBUTION. THEREFORE NO EMPLOYEE WAS AFFECTED BY THIS DEFECT IN THE PLAN'S WRITTEN TERMS.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  
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
2010
Open to Public Inspection
Name of the organization
SANTA ROSA MEMORIAL HOSPITAL
 
Employer identification number

94-1231005
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) CAMINO HEALTH CENTER

30300 CAMINO CAPISTRANO

SAN JUAN CAPISTRANO,CA92675
33-0574214 		HEALTHCARE CA 501(C)(3) 7 MHRMC
 
 
 
(2) COVENANT HEALTH PARTNERS

3615 19TH STREET

LUBBOCK,TX79410
61-1573313 		HEALTHCARE TX 501(C)(3) 11, I CHS
 
 
 
(3) COVENANT HEALTH SYSTEM

3615 19TH STREET

LUBBOCK,TX79410
75-2765566 		HEALTHCARE TX 501(C)(3) 3 SJHS
 
 
 
(4) COVENANT HEALTH SYSTEM FOUNDATION

4000 24TH STREET

LUBBOCK,TX79410
75-2897026 		HEALTHCARE TX 501(C)(3) 7 CHS
 
 
 
(5) COVENANT MEDICAL GROUP

3420 22ND PLACE

LUBBOCK,TX79410
75-2743883 		HEALTHCARE TX 501(C)(3) 3 CHS
 
 
 
(6) HOME CARE PARTNERS

1165 MONTGOMERY DR

SANTA ROSA,CA95405
68-0318656 		INACTIVE CA 501(C)(3) 3 SRMH
 
 
 
(7) HOSPICE OF LUBBOCK

1102 SLIDE ROAD

LUBBOCK,TX79414
75-2133781 		HEALTHCARE TX 501(C)(3) 9 CHS
 
 
 
(8) LUBBOCK METHODIST HOSPITAL FOUNDATION

3615 19TH STREET

LUBBOCK,TX79410
75-2220963 		HEALTHCARE TX 501(C)(3) 7 CHS
 
 
 
(9) METHODIST CHILDREN'S HOSPITAL

3610 21ST STREET

LUBBOCK,TX79410
75-2428911 		HEALTHCARE TX 501(C)(3) 3 CHS
 
 
 
(10) METHODIST HOSPITAL LEVELLAND

1900 COLLEGE AVENUE

LEVELLAND,TX79336
75-2246348 		HEALTHCARE TX 501(C)(3) 3 CHS
 
 
 
(11) METHODIST HOSPITAL PLAINVIEW

2601 DIMMITT ROAD

PLAINVIEW,TX79072
75-2426010 		HEALTHCARE TX 501(C)(3) 3 CHS
 
 
 
(12) MISSION HOSPITAL REG MED CTR FDN

27700 MEDICAL CENTER ROAD

MISSION VIEJO,CA92691
33-0406118 		HEALTHCARE CA 501(C)(3) 7 MHRMC
 
 
 
(13) MISSION HOSPITAL REGIONAL MEDICAL CENTER

27700 MEDICAL CENTER ROAD

MISSION VIEJO,CA92691
95-1643360 		HEALTHCARE CA 501(C)(3) 3 SJHS
 
 
 
(14) QUEEN OF THE VALLEY MEDICAL CENTER

1000 TRANCAS STREET

NAPA,CA94558
94-1243669 		HEALTHCARE CA 501(C)(3) 3 SJHS
 
 
 
(15) REDWOOD MEMORIAL FOUNDATION

3300 RENNER DRIVE

FORTUNA,CA95540
94-2779313 		FOUNDATION CA 501(C)(3) 7 RMH
 
 
 
(16) REDWOOD MEMORIAL HOSPITAL

3300 RENNER DRIVE

FORTUNA,CA95540
94-1384665 		HEALTHCARE CA 501(C)(3) 3 SJHS
 
 
 
(17) SANTA ROSA MEMORIAL HOSPITAL AUXILIARY

PO BOX 522

SANTA ROSA,CA95402
94-6104507 		SUPPORT CA 501(C)(3) 11, III SRMH
 
 
 
(18) SISTERS OF ST JOSEPH OF ORANGE

480 S BATAVIA

ORANGE,CA92868
95-1643383 		RELIGIOUS ORG CA 501(C)(3) 1 NA
 
 
 
(19) SRM ALLIANCE HOSPITAL SERVICES

400 NORTH MCDOWELL BLVD

PETALUMA,CA94954
68-0395200 		HEALTHCARE CA 501(C)(3) 3 SRMH
 
 
 
(20) ST JOSEPH HEALTH FDN OF N CALIFORNIA

PO BOX 552

SANTA ROSA,CA95405
68-0338070 		INACTIVE CA 501(C)(3) 11, I SRMH
 
 
 
(21) ST JOSEPH HEALTH MINISTRY

500 S MAIN STREET SUITE 400

ORANGE,CA92868
27-1666576 		RELIGIOUS ORG CA 501(C)(3) 1 SSJO
 
 
 
(22) ST JOSEPH HEALTH SYSTEM

500 S MAIN STREET SUITE 700

ORANGE,CA92868
95-3589356 		HEALTHCARE CA 501(C)(3) 11, I SJHM
 
 
 
(23) ST JOSEPH HEALTH SYSTEM FOUNDATION

500 S MAIN STREET SUITE 1000

ORANGE,CA92868
33-0143024 		HEALTHCARE CA 501(C)(3) 7 SJHS
 
 
 
(24) ST JOSEPH HOME CARE NETWORK

170 PROFESSIONAL CENTER DR B

ROHNERT PARK,CA94928
68-0331084 		HEALTHCARE CA 501(C)(3) 9 SJHS
 
 
 
(25) ST JOSEPH HOSPITAL OF EUREKA

2700 DOLBEER STREET

EUREKA,CA95501
94-1156596 		HEALTHCARE CA 501(C)(3) 3 SJHS
 
 
 
(26) ST JOSEPH HOSPITAL OF ORANGE

1100 WEST STEWART DRIVE

ORANGE,CA92868
95-1643359 		HEALTHCARE CA 501(C)(3) 3 SJHS
 
 
 
(27) ST JUDE HOSPITAL YORBA LINDA

279 E IMPERIAL HWY 750

FULLERTON,CA92835
33-0185031 		HEALTHCARE CA 501(C)(3) 3 SJHS
 
 
 
(28) ST JUDE HOSPITAL INC

101 EAST VALENCIA MESA DRIVE

FULLERTON,CA92835
95-1643325 		HEALTHCARE CA 501(C)(3) 3 SJHS
 
 
 
(29) ST JUDE MEMORIAL FOUNDATION

1440 N HARBOR BLVD 200

FULLERTON,CA92835
95-3607229 		HEALTHCARE CA 501(C)(3) 11, I SJMC
 
 
 
(30) ST MARY MEDICAL CENTER

18300 HIGHWAY 18

APPLE VALLEY,CA92307
95-1914489 		HEALTHCARE CA 501(C)(3) 3 SJHS
 
 
 
(31) ST MARY OF THE PLAINS HOSPITAL FDN

4000 24TH STREET

LUBBOCK,TX79410
75-1653181 		HEALTHCARE TX 501(C)(3) 7 CHS
 
 
 
(32) TALLER SAN JOSE

801 NORTH BROADWAY

SANTA ANA,CA92701
59-3816355 		WORKFORCE DEV CA 501(C)(3) 2 SSJO
 
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
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) ST JOSEPH HLTH SYS HOME HLTH

 
 
HOME HEALTH CA NA
  		N/A 0 0   No 0   No 0 %
(2) ST JOSEPH HLTH SYS HOME CARE

 
 
HOME HEALTH CA NA
  		N/A 0 0   No 0   No 0 %
(3) METHODIST DIAGNOSTIC IMAGING

 
 
HEALTHCARE SVCS TX NA
  		N/A 0 0   No 0   No 0 %
(4) SHA LLC

 
 
HEALTHCARE SVCS TX NA
  		N/A 0 0   No 0   No 0 %
(5) LUBBOCK SURGERY CENTER LTD

 
 
HEALTHCARE SVCS TX NA
  		N/A 0 0   No 0   No 0 %
(6) COVENANT LONG-TERM CARE LP

 
 
HEALTHCARE SVCS TX NA
  		N/A 0 0   No 0   No 0 %
(7) HERITAGE INVESTMENT GROUP

 
 
INVESTMENT CA NA
  		N/A 0 0   No 0   No 0 %
(8) MISSION AMBULATORY SURGICENTER

 
 
HEALTHCARE SVCS CA NA
  		N/A 0 0   No 0   No 0 %
(9) COMPREHENSIVE IMAGING PARTNERS

 
 
HEALTHCARE SVCS CA NA
  		N/A 0 0   No 0   No 0 %
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) ST JOSEPH PROF SVCS ENTERPRISES INC
500 S MAIN STREET SUITE 700
ORANGE,CA92868
33-0155323 		HEALTHCARE SVCS CA NA
  		C-CORP 0 0 0 %
(2) AMERICAN UNITY GROUP LTD
58 PAR-LA-VILLE ROAD
HAMILTON HM HX    
BD
CAPTIVE INSURANCE BD NA
  		C-CORP 0 0 0 %
(3) ALLIANCE PHYSICIAN SERVICES
 
 
INACTIVE CA NA
  		C-CORP 0 0 100.000 %
(4) MISSION VIEJO MEDICAL VENTURES
27800 MEDICAL CENTER RD 354
MISSION VIEJO,CA92691
33-0212905 		HEALTHCARE SVCS CA NA
  		C-CORP 0 0 0 %
(5) MISSION MEDICAL CENTER ASSOCIATION
27800 MEDICAL CENTER RD 354
MISSION VIEJO,CA92691
33-0201044 		HEALTHCARE SVCS CA NA
  		C-CORP 0 0 0 %
(6) ST JOSEPH YORBA PARK
 
 
INACTIVE CA NA
  		C-CORP 0 0 0 %
(7) LUBBOCK METHODIST HOSPITAL SERVICES
PO BOX 1201
LUBBOCK,TX79410
75-2118585 		HEALTHCARE SVCS TX NA
  		C-CORP 0 0 0 %
(8) LUBBOCK METHODIST HOSPITAL PRACTICE MGMT
2107 OXFORD STREET SUITE 300
LUBBOCK,TX79410
75-2578995 		INACTIVE TX NA
  		C-CORP 0 0 0 %
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
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
 
No
b Gift, grant, or capital contribution to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Sale of assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Performance of services or membership or fundraising solicitations for other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations by other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Sharing of facilities, equipment, mailing lists, or other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of paid employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Reimbursement paid to other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid by other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Other transfer of cash or property to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
Yes
 
r Other transfer of cash or property from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
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) ST JOSEPH HEALTH SYSTEM FOUNDATION

 B 1,864,697  
(2) ST JOSEPH HEALTH SYSTEM FOUNDATION

 C 992,438  
(3) SRM ALLIANCE HOSPITAL SERVICES

 N 284,466  
(4) SRM ALLIANCE HOSPITAL SERVICES

 P 23,597,000  
(5) QUEEN OF THE VALLEY MEDICAL CENTER

 N 62,399  
(6) QUEEN OF THE VALLEY MEDICAL CENTER

 P 82,500  
(7) AMERICAN UNITY GROUP LTD

 Q 1,052,341  
(8) CAMINO HEALTH CENTER

   0  
(9) COVENANT HEALTH PARTNERS

   0  
(10) COVENANT HEALTH SYSTEM

   0  
(11) COVENANT HEALTH SYSTEM FOUNDATION

   0  
(12) COVENANT MEDICAL GROUP

   0  
(13) HOME CARE PARTNERS

   0  
(14) HOSPICE OF LUBBOCK

   0  
(15) LUBBOCK METHODIST HOSPITAL FOUNDATION

   0  
(16) METHODIST CHILDREN'S HOSPITAL

   0  
(17) METHODIST HOSPITAL LEVELLAND

   0  
(18) METHODIST HOSPITAL PLAINVIEW

   0  
(19) MISSION HOSPITAL REG MED CTR FDN

   0  
(20) MISSION HOSPITAL REGIONAL MEDICAL CENTER

   0  
(21) REDWOOD MEMORIAL FOUNDATION

   0  
(22) REDWOOD MEMORIAL HOSPITAL

   0  
(23) ST JOSEPH HEALTH FDN OF N CALIFORNIA

   0  
(24) ST JOSEPH HOME CARE NETWORK

   0  
(25) ST JOSEPH HOSPITAL OF EUREKA

   0  
(26) ST JOSEPH HOSPITAL OF ORANGE

   0  
(27) ST JUDE HOSPITAL YORBA LINDA

   0  
(28) ST JUDE HOSPITAL INC

   0  
(29) ST JUDE MEMORIAL FOUNDATION

   0  
(30) ST MARY MEDICAL CENTER

   0  
(31) ST MARY OF THE PLAINS HOSPITAL FDN

   0  
(32) ST JOSEPH HEALTH SYSTEM HOME HEALTH AGENCY

   0  
(33) ST JOSEPH HEALTH SYSTEM HOME CARE SERVICES

   0  
(34) METHODIST DIAGNOSTIC IMAGING

   0  
(35) SHA LLC

   0  
(36) LUBBOCK SURGERY CENTER LTD

   0  
(37) COVENANT LONG-TERM CARE LP

   0  
(38) HERITAGE INVESTMENT GROUP I LLC

   0  
(39) MISSION AMBULATORY SURGICENTER LTD

   0  
(40) COMPREHENSIVE IMAGING PARTNERS OF OC LLC

   0  
(41) ST JOSEPH PROF SVCS ENTERPRISES INC

   0  
(42) ALLIANCE PHYSICIAN SERVICES

   0  
(43) MISSION VIEJO MEDICAL VENTURES

   0  
(44) MISSION MEDICAL CENTER ASSOCIATION

   0  
(45) ST JOSEPH YORBA PARK

   0  
(46) LUBBOCK METHODIST HOSPITAL SERVICES

   0  
(47) LUBBOCK METHODIST HOSPITAL PRACTICE MGMT

   0  
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
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)
Are all
partners
section
501(c)(3)
organizations? 		(e)
Share of
end-of-year
assets 		(f)
Disproprtionate allocations? 		(g)
Code V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(h)
General or
managing
partner?
Yes No Yes No Yes No






























Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
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 ST. JOSEPH HEALTH SYSTEM HOME HEALTH AGENCY EIN: 33-0282945 ADDRESS: 1845 W. ORANGEWOOD AVENUE, STE. 200 ORANGE, CA 92868-2012 ST. JOSEPH HEALTH SYSTEM HOME CARE SERVICES EIN: 33-0307672 ADDRESS: 1845 W. ORANGEWOOD AVENUE, STE. 100 ORANGE, CA 92868-2012 METHODIST DIAGNOSTIC IMAGING EIN: 75-2343261 ADDRESS: 4005 24TH STREET LUBBOCK, TX 79410 SHA, LLC EIN: 75-2569094 ADDRESS: 12940 NORTH HIGHWAY 183 AUSTIN, TX 78750 LUBBOCK SURGERY CENTER, LTD. EIN: 75-2177401 ADDRESS: 4000 24TH STREET LUBBOCK, TX 79410 COVENANT LONG-TERM CARE, LP EIN: 20-5033419 ADDRESS: 4000 24TH STREET LUBBOCK, TX 79410 HERITAGE INVESTMENT GROUP I, LLC EIN: 27-1000061 ADDRESS: 500 S. MAIN STREET STE. 1000 ORANGE, CA 92868 MISSION AMBULATORY SURGICENTER, LTD EIN: 33-0355575 ADDRESS: 27800 MEDICAL CENTER ROAD, STE. 362 MISSION VIEJO, CA 92691 COMPREHENSIVE IMAGING PARTNERS OF ORANGE COUNTY, LLC EIN: 26-4591502 ADDRESS: ONE CITY BOULEVARD WEST, SUITE 1100 ORANGE, CA 92868
Additional Data


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