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. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
TEMPE LIFE CARE VILLAGE INC
Employer identification number
86-0335417
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 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 monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 2
Part II
Support Schedule for Organizations Described in Sections 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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
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 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
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—2012.
If the organization did not check a 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—2013.
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—2012.
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) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 3
Part III
Support Schedule for Organizations Described in Section 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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
295,270
671,636
971,778
595,956
351,221
2,885,861
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......
31,832,282
31,347,463
32,108,625
33,739,100
36,104,647
165,132,117
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
0
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
0
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
0
6
Total. Add lines 1 through 5.
32,127,552
32,019,099
33,080,403
34,335,056
36,455,868
168,017,978
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
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.
0
c
Add lines 7a and 7b..
0
8
Public support (Subtract line 7c from line 6.)
168,017,978
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
9
Amounts from line 6...
32,127,552
32,019,099
33,080,403
34,335,056
36,455,868
168,017,978
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
735,921
625,726
732,664
646,407
611,139
3,351,857
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
735,921
625,726
732,664
646,407
611,139
3,351,857
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
0
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
0
13
Total support. (Add lines 9, 10c, 11, and 12.)..
32,863,473
32,644,825
33,813,067
34,981,463
37,067,007
171,369,835
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 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
98.044 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
97.757 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
1.956 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
2.243 %
19a
33 1/3% support tests—2013.
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—2012.
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) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and 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) 2013
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.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
TEMPE LIFE CARE VILLAGE INC
Employer identification number
86-0335417
Return Reference
Explanation
SKILLED NURSING CARE
FORM 990, PART III, LINE 4B DURING 2013, THE HEALTH CARE CENTER HAD AN AVERAGE OCCUPANCY OF 120 RESIDENTS, WITH A TOTAL OF 43,612 PATIENT DAYS, INCLUDING MEDICARE, HMO, PRIVATE PAY, AND PERMANENT AND TEMPORARY ASSIGNMENT OF VILLAGE RESIDENTS. LIKE ASSISTED LIVING, SKILLED NURSING IS AVAILABLE TO RESIDENTS OF FRIENDSHIP VILLAGE, AS WELL AS TO NON-RESIDENTS IF SPACE IS AVAILABLE. IF EVER NEEDED, RESIDENTS ALSO HAVE ACCESS TO MEMORY CARE AS PART OF THEIR LIFE CARE PLAN. THE MONTESSORI PROGRAM FOR MEMORY CARE IS UNIQUE. THE FOCUS IS ON THE RESIDENT AS AN INDIVIDUAL AND CARE IS TAILORED AROUND THEIR SPECIFIC NEEDS. FRIENDSHIP VILLAGE TEMPE UNDERSTANDS AND APPRECIATES THE DIFFICULTIES FACED BY THE FAMILIES AND LOVED ONES OF THOSE SUFFERING FROM ALZHEIMER'S, DEMENTIA OR OTHER FORMS OF MEMORY LOSS. THESE CONDITIONS NOT ONLY AFFECT THE PERSON WHO HAS THEM, BUT ALSO THE PEOPLE AROUND THEM. THAT'S WHY THE FAMILY AND LOVED ONES OF RESIDENTS ARE INVOLVED IN THE PROGRAMS. THE BELIEF IS, WITH EVERYONE PARTICIPATING, THE RESIDENT'S EXPERIENCE WILL BE EVEN MORE POSITIVE AND MEANINGFUL. DEVELOPED WITH THE PRIMARY GOAL THAT EACH RESIDENT EXPERIENCE MEANINGFUL AND PURPOSEFUL ACTIVITIES, THE MONTESSORI-BASED DEMENTIA PROGRAM AT FRIENDSHIP VILLAGE MAINTAINS THE INDEPENDENCE, INDIVIDUALITY, PRIVACY, AND COMPANIONSHIP OF THE RESIDENT. THE STAFF HAS BEEN SPECIFICALLY TRAINED IN THE MONTESSORI PROGRAM, AND HAS A STRONG, CARING DESIRE TO PROVIDE RESIDENTS WITH A HIGHER QUALITY OF LIFE.
ON-SITE ASSISTED LIVING APARTMENTS
FORM 990, PART III, LINE 4C A WIDE RANGE OF ON-SITE THERAPY IS AVAILABLE, INCLUDING OCCUPATIONAL, PHYSICAL, AND REHABILITATIVE. AT THE NUNNENKAMP CENTER, RESIDENTS HAVE A CUSTOMIZED TREATMENT PLAN BASED ON INDIVIDUAL NEEDS. THE HIGHLY TRAINED STAFF HAS EARNED A STELLAR REPUTATION FOR THEIR COMMITMENT TO SENIOR CARE AT THE COMMUNITY. MEMORY CARE ASSISTED LIVING FORM 990, PART III, LINE 4D MEMORY CARE ASSISTED LIVING (ASSISTED LIVING DEMENTIA) IS FOR RESIDENTS WHO REQUIRE THE ATTENTION OF SPECIALLY-TRAINED STAFF FOR THE TREATMENT OF DEMENTIA OR COGNITIVE IMPAIRMENT. MEMORY CARE PROGRAMS PROVIDE ASSISTANCE WITH DAILY LIVING, INCLUDING THREE MEALS A DAY. STAFF IS TRAINED TO MEET THE NEEDS OF RESIDENTS IN THE DEMENTIA CARE AREAS. STAFFING IS MORE CONCENTRATED IN THE MEMORY CARE PORTION OF THE HEALTH CARE CENTER THAN IN THE NON-SPECIAL NEEDS AREAS. DURING 2013 THE MEMORY CARE PROGRAM HAD AN AVERAGE OF 22 RESIDENTS AND A TOTAL OF 8,079 DAYS OF OCCUPANCY.
DELEGATION OF MANAGEMENT DUTIES
FORM 990, PART VI, SECTION A, LINE 3 TEMPE LIFE CARE VILLAGE HAS A MANAGEMENT CONTRACT WITH LIFE CARE SERVICES, LLC ("LCS"), UNDER WHICH LCS PROVIDES MANAGEMENT SERVICES INCLUDING, BUT NOT LIMITED TO, MARKETING, HUMAN RESOURCES, ACCOUNTING, INFORMATION TECHNOLOGY SERVICES, CLINICAL OVERSIGHT AND INSURANCE. IN ADDITION, LCS PROVIDES COMPENSATION FOR TEMPE LIFE CARE VILLAGE'S EXECUTIVE DIRECTOR AND ADMINISTRATOR OF RESIDENT SERVICES. TEMPE LIFE CARE VILLAGE ALSO REIMBURSES LCS WITH MONTHLY MANAGEMENT FEES FOR THE COMPENSATION PAID AND OTHER SERVICES PROVIDED.
COMMITTEE DOCUMENTATION
FORM 990, PART VI, SECTION A, LINE 8B THERE IS NO FORMAL DOCUMENTATION OF THE COMMITTEE MEETINGS AND ACTIONS. HOWEVER, EACH COMMITTEE REPORTS ITS ACTIVITY FOR THE MONTH AT EACH MONTHLY BOARD OF DIRECTORS GENERAL MEETING. THESE REPORTS ARE DOCUMENTED IN THE MINUTES OF THE BOARD OF DIRECTORS GENERAL MEETING.
FORM 990 REVIEW PROCESS
FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM BASED ON AUDITED FINANCIAL STATEMENTS AND INFORMATION PROVIDED BY THE ACCOUNTING DEPARTMENT OF THE ORGANIZATION. A DRAFT OF THE 990 IS REVIEWED IN DETAIL BY THE SENIOR MANAGEMENT TEAM OF TEMPE LIFE CARE VILLAGE. AFTER THE INTERNAL REVIEW, A DRAFT COPY OF THE 990 IS PRESENTED TO THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS. FINALLY, A DRAFT COPY OF THE 990 IS E-MAILED TO ALL MEMBERS OF THE BOARD OF DIRECTORS PRIOR TO FILING.
CONFLICT OF INTEREST POLICY COMPLIANCE
FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST FORMS ARE DISTRIBUTED ANNUALLY TO THE BOARD OF DIRECTORS. THE SENIOR MANAGEMENT TEAM REVIEWS THOSE FORMS AND INFORMS THE CHAIRMAN OF THE BOARD OF ANY CONFLICTS OF INTEREST. IF A CONFLICT ARISES, THE AFFECTED BOARD MEMBER IS REQUIRED TO ABSTAIN FROM VOTING ON THE ISSUE. COMPENSATION DETERMINATION FORM 990, PART VI, SECTION B, LINES 15A & 15B THE ORGANIZATION'S MANAGEMENT COMPANY COMPENSATES THE CEO AND THE ADMINISTRATOR OF RESIDENT SERVICES. REIMBURSEMENT OF THEIR SALARIES AND OTHER COMPENSATION IS COVERED IN THE MANAGEMENT CONTRACT, WHICH THE BOARD APPROVED EFFECTIVE JUNE 1, 2012. ANY INCREASES ARE APPROVED AS PART OF THE ANNUAL BUDGET PROCESS DESCRIBED BELOW. THE CHIEF FINANCIAL OFFICER'S COMPENSATION IS DETERMINED BY WAGE AND SALARY SURVEYS USED BY THE ORGANIZATION'S HUMAN RESOURCES DEPARTMENT. IT IS APPROVED AS PART OF THE GENERAL BUDGET APPROVAL PROCESS BY THE BOARD FINANCE COMMITTEE AND THE ENTIRE BOARD OF DIRECTORS. APPROVAL IS RECORDED IN THE BOARD MEETING MINUTES IN NOVEMBER OF EACH YEAR.
GOVERNING DOCUMENT AVAILABILITY
FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S ARTICLES OF INCORPORATION AND BYLAWS, INCLUDING THE CONFLICT OF INTEREST POLICY, ARE FILED WITH THE ARIZONA CORPORATION COMMISSION. FINANCIAL REPORTS ARE PART OF THE ARIZONA DEPARTMENT OF INSURANCE ANNUAL REPORT AND ALSO REPORTED ON THE NRMSIRs (EMMA).
BOARD MEMBER COMPENSATION
FORM 990, PART VII MR. G. ROBERT EUBANKS IS AN ARCHITECT AND IS INVOLVED IN CONSULTATIONS WITH CONSTRUCTION COMPANIES AND OTHER ARCHITECTS DURING MAJOR BUILDING AND RENOVATION PROJECTS AT THE VILLAGE. HE RECEIVES COMPENSATION FOR HIS TIME AND EXPENSES. HIS TOTAL COMPENSATION DURING 2013 WAS $27,850. HE RECEIVES NO COMPENSATION FOR HIS SERVICES AS A BOARD MEMBER.
EXECUTIVE DIRECTOR COMPENSATION
FORM 990, PART VII, SECTION A THE ORGANIZATION'S EXECUTIVE DIRECTOR IS COMPENSATED BY A MANAGEMENT COMPANY. SEE SCHEDULE O NARRATIVE FOR FORM 990, PART VI, SECTION B, LINES 15A & 15B FOR ADDITIONAL INFORMATION.
OTHER CHANGES IN NET ASSETS
FORM 990, PART XI, LINE 9 ACTUARIAL CHANGE IN SPLIT-INTEREST AGREEMENTS $(50,761)
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.