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.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
EISENHOWER MEDICAL CENTER
Employer identification number
95-6130458
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
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(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
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2011.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2010.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2011.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public Support (Subtract line 7c from line 6.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13
Total support (Add lines 9, 10c, 11 and 12.).
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2011 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2010 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2010 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2011.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2010.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2011
Additional Data
Software ID:
Software Version:
-
TIN:
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.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
EISENHOWER MEDICAL CENTER
Employer identification number
95-6130458
Identifier
Return Reference
Explanation
PROGRAM SERVICE ACCOMPLISHMENTS
FORM 990, PART III, LINE 4A
KEY ACHIEVEMENTS (FISCAL YEAR 2012) ON JULY 1, 2011, THE EISENHOWER INPATIENT REHABILITATION CENTER OPENS, OFFERING INTENSIVE THERAPY FOR STROKE PATIENTS, ORTHOPEDICS PATIENTS AND OTHERS WITH DEBILITATING MEDICAL CONDITIONS REQUIRING PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY. IN JULY 2011, EISENHOWER MEDICAL CENTER IS RANKED #4 IN GYNECOLOGY IN U.S. NEWS MEDIA & WORLD REPORT'S 2011-12 BEST HOSPITALS RANKINGS. IN OCTOBER 2011, EISENHOWER RECEIVES A FULL, THREE-YEAR ACCREDITATION BY THE ACCREDITATION COUNCIL OF GRADUATE MEDICAL EDUCATION, MAKING EISENHOWER THE FIRST IN THE VALLEY TO BECOME A TEACHING HOSPITAL. IN FALL 2011, EISENHOWER OPENS A 10,000-SQUARE-FOOT GASTROINTESTINAL LABORATORY IN THE DOLORES HOPE OUTPATIENT CARE CENTER. IN JANUARY 2012, EISENHOWER EMPLOYEES SUPPORT THE HUMANA CHALLENGE WALK-IT PROGRAM BY COLLECTIVELY WALKING NEARLY 40 MILLION STEPS IN 10 DAYS TO SUPPORT THE MESSAGE OF FITNESS AND GOOD HEALTH. ON JANUARY 10, 2012, EISENHOWER CELEBRATES THE NAMING OF THE JOEL M. HIRSCHBERG CENTER FOR INTERNAL MEDICINE AT THE UIHLEIN BUILDING ON THE MAIN HOSPITAL CAMPUS. IN FEBRUARY 2012, EISENHOWER MEDICAL CENTER HOSTS THE 9TH ANNUAL COMMUNITY HEART CONFERENCE AT THE ANNENBERG CENTER FOR HEALTH SCIENCES. ON MARCH 10, 2012, EISENHOWER HOSTS THE SECOND ANNUAL HIV CONFERENCE WITH THE HIV PROVIDER NETWORK AT THE ANNENBERG CENTER FOR HEALTH SCIENCES AT EISENHOWER. ON MARCH 17, 2012, EISENHOWER HOSTS THE 17TH ANNUAL JIM COOK DAY OF HOPE FOR DIABETES, THE LARGEST EDUCATIONAL AND INSPIRATIONAL EVENT OF ITS KIND IN THE 11 WESTERN UNITED STATES, AT THE ANNENBERG CENTER FOR HEALTH SCIENCES AT EISENHOWER. IN JUNE 2012, EISENHOWER MEDICAL CENTER'S HEALTHY LIVING MAGAZINE RECEIVES THE GOLD AWARD IN THE CATEGORY OF PUBLICATIONS/EXTERNAL MAGAZINE BY THE HEALTHCARE PUBLICATIONS & MARKETING ASSOCIATION (HPRMA) AT ITS ANNUAL GOLDEN ADVOCATE AWARD CEREMONY. THE GOLDEN ADVOCATE AWARDS MEASURE HEALTH CARE MARKETING AND PUBLIC RELATIONS COMMUNICATIONS EXCELLENCE AMONG SOUTHERN CALIFORNIA HEALTH CARE PROFESSIONALS. IN JUNE 2012, EISENHOWER INPATIENT REHABILITATION CENTER EARNS A THREE-YEAR ACCREDITATION FROM THE COMMISSION ON ACCREDITATION OF REHABILITATION FACILITIES (CARF). EISENHOWER MEDICAL CENTER IS FIRST HOSPITAL IN RIVERSIDE COUNTY WITH THE PRESTIGIOUS CARF ACCREDITATION, WHICH IS EARNED LESS THAN ONE YEAR AFTER OPENING THE CENTER. ON JUNE 27, 2012, EISENHOWER MARKS WORLD SPIROMETRY DAY WITH FREE LUNG CAPACITY TESTS FOR MEMBERS OF THE COMMUNITY.
DESCRIPTION OF RELATIONSHIPS
FORM 990, PART VI, QUESTION 2
KATHRYN B. SAMPLE AND STEVEN B. SAMPLE, BOTH ON THE BOARD TRUSTEES, ARE MARRIED.
DESCRIPTION OF CLASSES OF MEMBERS OR STOCKHOLDERS
FORM 990, PART VI, QUESTION 6
THE BOARD OF TRUSTEES ARE MEMBERS OF EISENHOWER MEDICAL CENTER.
DESCRIPTION OF CLASSES OF PERSONS AND THE NATURE OF THEIR RIGHTS
FORM 990, PART VI, QUESTION 7A
TRUSTEES HAVE THE RIGHT TO ELECT THE GOVERNING BODY MEMBERS OF THE EISENHOWER MEDICAL CENTER BOARD OF DIRECTORS.
DESCR CLASSES OF PERSONS, DECISIONS REQUIRING APPR & TYPE OF VOTING RIGHTS
FORM 990, PART VI, QUESTION 7B
MEMBERS HAVE THE RIGHT TO VOTE ON THE FOLLOWING MAJOR DECISIONS: ANY MATERIAL CHANGE IN THE MISSION OF EMC; THE MERGER OF EMC WITH ANY OTHER BUSINESS ENTITY; THE DISSOLUTION OF EMC; THE SALE OF ALL OR SUBSTANTIALLY ALL OF EMC'S ASSETS; AND ANY MATTER ON WHICH A MEMBER OF A CALIFORNIA NON-PROFIT CORPORATION IS REQUIRED TO BE PERMITTED TO VOTE ON UNDER APPLICABLE LAW.
DESCRIBE THE PROCESS USED BY MANAGEMENT &/OR GOVERNING BODY TO REVIEW 990
FORM 990, PART VI, QUESTION 11B
THE FORM 990 IS PREPARED BY AN OUTSIDE ACCOUNTING FIRM AND SUBSEQUENTLY REVIEWED BY MANAGEMENT. AFTER MANAGEMENT REVIEW, THE FORM 990 IS PRESENTED TO THE BOARD AFTER FILING.
DESCRIPTION OF PROCESS TO MONITOR TRANSACTIONS FOR CONFLICTS OF INTEREST
FORM 990, PART VI, QUESTION 12C
ANNUALLY RELATED PARTIES, INCLUDING OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES ARE SURVEYED FOR TRANSACTIONS THAT COULD GIVE RISE TO CONFLICTS. WRITTEN QUESTIONAIRES ARE REVIEWED BY LEGAL AND FINANCE TO DETERMINE IF ADDITIONAL QUESTIONS OR INFORMATION SHOULD BE DOCUMENTED REGARDING SPECIFIC TRANSACTIONS. ALL NEW CONTRACTS ARE REVIEWED BY EXECUTIVE MANAGEMENT FOR CONFLICT CONSIDERATIONS. GENERAL COUNSEL REVIEWS ALL STATEMENTS SUBMITTED BY BOARD MEMBERS WHO INDICATE A POTENTIAL CONFLICT. GENERAL COUNSEL ADVISES THE CEO AND CHAIRMAN OF THE BOARD OF ANY MATERIAL CONFLICTS SO THAT THE INDIVIDUAL CAN BE RECUSED FROM ANY DISCUSSION OR DELIBERATION PERTAINING TO THE CONFLICT.
OFFICES & POSITIONS FOR WHICH PROCESS WAS USED, & YEAR PROCESS WAS BEGUN
FORM 990, PART VI, QUESTIONS 15A AND 15B
EISENHOWER MEDICAL CENTER ENGAGES AN INDEPENDENT CONSULTING FIRM TO PROVIDE THE BOARD'S COMPENSATION COMMITTEE TO PROVIDE BENCHMARKED SURVEY DATA FOR THE EXECUTIVE LEADERSHIP TEAM IN THE ORGANIZATION. THE CONSULTANT PROVIDES ANALYSIS OF SALARIES, INCENTIVE PLANS AND BENEFITS AS COMPARED TO PEER GROUP OF OTHER NOT-FOR-PROFIT HEALTH CARE ORGANIZATIONS. THIS REVIEW WAS COMPLETED AND PRESENTED TO THE COMPENSATION COMMITTEE IN JANUARY 2012. THIS PROCESS WAS CONTEMPORANEOUSLY SUBSTANTIATED IN THE MEETING MINUTES OF THE COMPENSATION COMMITTEE.
AVAIL OF GOV DOCS, CONFLICT OF INTEREST POLICY, & FIN STMTS TO GEN PUBLIC
FORM 990, PART VI, LINE 19
EISENHOWER MEDICAL CENTER RELEASES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS TO THE GENERAL PUBLIC UPON REQUEST. THAT REQUEST MAY BE EITHER VERBAL OR WRITTEN.
HOURS DEVOTED TO RELATED ORGANIZATIONS
FORM 990, PART VII
G. AUBREY SERFLING, PRESIDENT AND CEO OF EMC, IS ALSO THE BOARD DIRECTOR (EX-OFFICIO) OF EISENHOWER HEALTH SERVICES (EHS). HE DEVOTES 1 HOUR PER WEEK TO EHS. HE ALSO DEVOTES 1 HOUR PER WEEK TO ANNENBERG CENTER FOR HEALTH SCIENCES AND THE BARBARA SINATRA CHILDREN'S CENTER, IN ADDITION TO THE 50 HOURS PER WEEK HE DEVOTES TO EMC. KIMBERLY OSBORNE, CHIEF FINANCIAL OFFICER OF EMC, IS ALSO THE BOARD DIRECTOR AND TREASURER AT EHS. SHE DEVOTES 50 HOURS PER WEEK TO THE POSITION AT EMC AND 1 HOUR PER WEEK AT EHS. MARY KROLL IS THE CORPORATE SECRETARY OF EMC, ACHS, BSCC AND EHS. SHE DEVOTES 40 HOURS PER WEEK TO HER POSITION AT EMC, 2 HOURS PER WEEK AT BSCC AND 1 HOUR PER WEEK TO ACHS AND EHS. MARTIN MASSIELLO, CHIEF OPERATING OFFICER OF EMC, IS ALSO THE BOARD DIRECTOR AND PRESIDENT OF EHS. HE DEVOTES 50 HOURS PER WEEK TO HIS POSITION AT EMC AND 1 HOUR PER WEEK AT EHS. HELENE V. GALEN, BOARD TRUSTEE/DIRECTOR OF EISENHOWER MEDICAL CENTER, DEVOTES 2 HOUR PER WEEK TO THE BARBARA SINATRA CHILDREN'S CENTER AS THE PRESIDENT. WILLIAM N. OSTERMAN, BOARD TRUSTEE/DIRECTOR OF EISENHOWER MEDICAL CENTER, DEVOTES 2 HOUR PER WEEK TO THE BARBARA SINATRA CHILDREN'S CENTER AS THE SECRETARY.
PAYMENT FOR SERVICES OTHER THAN BOARD SERVICES
FORM 990, PART VII
SHAHIN ETEBAR, MD RECEIVED A TOTAL OF $101,600 AS A STIPEND FOR NEUROLOGY SERVICES. EUTHYM KONTAXIS, MD RECEIVED A TOTAL OF $120,275 AS A STIPEND FOR EMERGENCY ROOM ADMINISTRATIVE SERVICES. QUINTEN VANDERWERF, MD RECEIVED A TOTAL OF $57,800 AS A STIPEND FOR EMERGENCY ROOM ON-CALL SERVICES.
CHANGES IN NET ASSETS/FUND BALANCES
FORM 990, PART XI, LINE 5
PENSION RELATED CHANGES ($24,262,108) CHANGE IN NPV OF PLEDGES ($ 1,031,546) CHANGE IN VALUE OF CHARITABLE REMAINDER TRUSTS ($ 3,462,943) TRANSFER FROM ACHS $ 2,465,160 UNREALIZED LOSS ON INVESTMENTS ($ 336,588) ROUNDING $ 3 ------------- TOTAL ($26,628,022)
TAX EXEMPT BONDS
DESCRIPTION OF PURPOSE
SCHEDULE K, PART I, COLUMN F A - CONSTRUCTION OF HOSPITAL AND REFUND A PORTION OF TAXABLE LOAN B - CONSTRUCTION OF HOSPITAL AND REFUNDING BOND ISSUES DATED 2/19/1997 and 5/27/2004.
TOTAL PROCEEDS OF ISSUE
SCHEDULE K, PART II, COLUMN A & B, LINE 3
THE DIFFERENCE BETWEEN THE TOTAL PROCEEDS AND ISSUE PRICE IS INVESTMENT INCOME OF 7,895 FOR THE 2010 BONDS AND 2,653,488 FOR THE 2007 BONDS.
OTHER SPENT PROCEEDS
SCHEDULE K, PART II, LINE 11
THE AMOUNT OF OTHER SPENT PROCEEDS RELATES TO CURRENT REFUNDING PROCEEDS OF THE ISSUES: A: REPAYMENT OF TAXABLE LOC B: REFUNDED 1997 ISSUE
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.