TY 2012 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)
(1) LES PERRY........................................................................ BOARD MEMBER/VICE CHAIR	2.0 .......................0.0	X	0	0	0
(2) SISTER CHRISTINE RAY........................................................................ BOARD MEMBER (PART YEAR)	2.0 .......................0.0	X	0	0	0
(3) SISTER MARY ROGERS........................................................................ BOARD MEMBER (PART YEAR)	2.0 .......................0.0	X	0	0	0
(4) JAN SONANDER MD........................................................................ BOARD MEMBER, CHIEF OF STAFF	4.0 .......................0.0	X	37,105	0	0
(5) GENE TRAVERSO........................................................................ BOARD MEMBER	2.0 .......................0.0	X	0	0	0
(6) SHARON WRIGHT........................................................................ BOARD MEMBER	2.0 .......................0.0	X	0	0	0
(7) JEANNETTE CURIE MD........................................................................ BOARD MEMBER	2.0 .......................0.0	X	0	0	0
(8) SISTER LISA TURAY........................................................................ BOARD MEMBER	2.0 .......................0.0	X	0	0	0
(9) NANCY PRATT........................................................................ BOARD MEMEBER	2.0 .......................0.0	X	0	291,616	2,998
(10) ANNETTE WALKER........................................................................ BOARD MEMBER (PART YEAR)	2.0 .......................50.0	X	0	650,691	49,701
(11) SISTER MARIAN SCHUBERT........................................................................ BOARD MEMBER	2.0 .......................0.0	X	0	0	0
(12) JIM ADAMS........................................................................ BOARD MEMBER, CHAIR	4.0 .......................0.0	X	0	0	0
(13) SISTER LINDA BUCK........................................................................ BOARD MEMBER	2.0 .......................0.0	X	0	0	0
(14) PAM CHANTER........................................................................ BOARD MEMBER	2.0 .......................0.0	X	0	0	0
(15) SISTER JUDITH DUGAN........................................................................ BOARD MEMBER	2.0 .......................0.0	X	0	0	0
(16) HERB DWIGHT........................................................................ BOARD MEMBER	2.0 .......................0.0	X	0	0	0
(17) ABDUL HARRIS MD........................................................................ BOARD MEMBER	2.0 .......................0.0	X	29,162	0	0

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(18) TEEJAY K LOWE........................................................................ BOARD MEMBER	2.0 .......................0.0	X					0	0	0
(19) KEVIN KLOCKENGA........................................................................ REGIONAL EVP	10.0 .......................40.0		X				0	782,806	37,072
(20) JO SANDERSFELD........................................................................ SECTY/VP MISSION INTEGRATION	43.0 .......................7.0		X				309,054	0	37,587
(21) MICHEL RICCIONI........................................................................ CHIEF FINANCIAL OFFICER	19.0 .......................31.0		X				507,651	0	44,578
(22) TODD SALNAS........................................................................ COO (PART YEAR)/PRESIDENT	43.0 .......................7.0		X				234,614	279,349	36,362
(23) GARY GREENSWEIG........................................................................ CHIEF MEDICAL OFFICER	43.0 .......................7.0			X			318,686	0	23,236
(24) MARK KNIGHT........................................................................ VP - STRATEGIC SERVICES	0.0 .......................0.0			X			271,882	0	3,710
(25) ANDREA LEARNED........................................................................ VP - FUND DEVELOPMENT	43.0 .......................7.0			X			250,803	0	23,086
(26) DEBRA MILLER........................................................................ VP - HUMAN RESOURCES	43.0 .......................7.0			X			322,188	0	47,686
(27) RHONDA FOSTER........................................................................ CHIEF NURSING OFFICER	43.0 .......................7.0			X			272,946	0	7,794
(28) CATHERINE CAMENGA........................................................................ VP PERFORMANCE IMPROVEMENT	43.0 .......................7.0			X			177,674	0	4,527
(29) JAYNIE BOREN........................................................................ N. CA REG VP - STRATEGIC SVCS	18.0 .......................32.0			X			0	372,410	19,130
(30) REBECCA ALTHOFF........................................................................ STAFF NURSE IV-SNA	32.0 .......................0.0				X		431,846	0	46,258
(31) RICHARD HENRY........................................................................ STAFF NURSE IV-SNA	32.0 .......................0.0				X		243,640	0	45,954
(32) CAROLYNN TEDESCHI........................................................................ STAFF NURE IV	32.0 .......................0.0				X		269,019	0	16,423
(33) SUZAN HUGHES........................................................................ STAFF NURSE II	32.0 .......................0.0				X		245,957	0	1,636
(34) CHERI WHITING........................................................................ STAFF NURSE III	32.0 .......................0.0				X		219,973	0	44,910
(35) KATHERINE HARDIN........................................................................ CHIEF NURSING OFFICER (FMR KE)	0.0 .......................0.0					X	204,079	0	0

(A) Name and business address	(B) Description of services	(C) Compensation
MEDICAL STAFFING NETWORK HEALTHCARE, PO BOX 203000DALLASTX753203000	REGISTRY	4,248,356
US NURSING CORP, 6399 S FIDDLERS GREEN CIRCLE STE 1GREENWOOD VILLAGECA80111	REGISTRY	4,121,782
ANESTHESIA ANALGESIA MEDICAL GROU, 837 5TH STREET 2ND FLOORSANTA ROSACA95404	ANESTHESIA SERVICES	2,043,867
NORTH BAY NEUROSURGICAL ASSOC, 525 DOYLE PARK DRIVESANTA ROSACA95405	MEDICAL FEES	1,347,657
NORTHERN CALIFORNIA MEDICAL ASSOC, 3536 MENDOCINO AVENUESANTA ROSACA95403	MEDICAL FEES	1,296,299
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 34

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the United States. See Part IV, line 21	2,239,415	2,239,415
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0	0
4	Benefits paid to or for members	0	0
5	Compensation of current officers, directors, trustees, and key employees ....	2,096,101	306,928	1,537,178	251,995
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	61,257	61,257	0	0
7	Other salaries and wages	111,189,245	106,510,844	4,315,062	363,339
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	7,840,677	7,473,716	328,882	38,079
9	Other employee benefits .......	44,817,290	42,809,553	1,894,600	113,137
10	Payroll taxes ...........	9,553,311	9,084,262	425,148	43,901
11	Fees for services (non-employees):
a	Management ......	15,438,118	15,438,118	0	0
b	Legal .........	3,653,647	0	3,653,147	500
c	Accounting ...........	356,739	18,000	338,739	0
d	Lobbying ...........	46,063	46,063	0	0
e	Professional fundraising services. See Part IV, line 17	0			0
f	Investment management fees ......	0	0	0	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	50,267,704	45,005,954	5,176,416	85,334
12	Advertising and promotion ....	153,716	828	147,315	5,573
13	Office expenses .......	7,611,673	5,711,742	1,825,876	74,055
14	Information technology ......	8,337,495	8,323,817	9,028	4,650
15	Royalties ..	0	0	0	0
16	Occupancy ...........	5,190,296	4,613,619	571,487	5,190
17	Travel ............	499,862	372,018	120,258	7,586
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0	0	0	0
19	Conferences, conventions, and meetings ....	63,481	53,215	9,131	1,135
20	Interest ...........	6,091,168	5,820,336	266,837	3,995
21	Payments to affiliates .......	0	0	0	0
22	Depreciation, depletion, and amortization .....	14,400,981	14,130,906	269,857	218
23	Insurance ..............	1,722,501	1,645,955	75,452	1,094
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	MEDICAL SUPPLIES	37,328,876	37,328,876	0	0
b	CA HOSPITAL PROGRAM FEE	20,613,622	20,613,622	0	0
c	LOSS ON INVESTMENT IN SUB	35,504	35,504	0	0
d	MISCELLANEOUS	2,372,066	944,519	1,332,476	95,071
e	All other expenses
25	Total functional expenses. Add lines 1 through 24e	351,980,808	328,589,067	22,296,889	1,094,852
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............	7,403	1	7,339
2	Savings and temporary cash investments .........	3,484,589	2	6,226,360
3	Pledges and grants receivable, net ...........	0	3	0
4	Accounts receivable, net .............	53,270,052	4	45,308,579
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
		0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
		0	6	0
7	Notes and loans receivable, net .............	0	7	0
8	Inventories for sale or use ..............	4,007,957	8	4,248,556
9	Prepaid expenses and deferred charges ..........	3,852,606	9	3,498,678
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	375,000,135
b	Less: accumulated depreciation .....	10b	196,113,395	168,205,028	10c	178,886,740
11	Investments—publicly traded securities ..........	114,886,958	11	123,068,857
12	Investments—other securities. See Part IV, line 11 .....	144,835	12	1,081,430
13	Investments—program-related. See Part IV, line 11 .....	0	13	0
14	Intangible assets ...............	0	14	0
15	Other assets. See Part IV, line 11 ...........	46,388,510	15	45,081,085
16	Total assets. Add lines 1 through 15 (must equal line 34)......	394,247,938	16	407,407,624
	17	Accounts payable and accrued expenses .........	29,254,559	17	30,720,277
18	Grants payable .................	0	18	0
19	Deferred revenue ................	0	19	0
20	Tax-exempt bond liabilities .............	0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	0	23	0
24	Unsecured notes and loans payable to unrelated third parties ....	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	143,535,842	25	140,549,389
26	Total liabilities. Add lines 17 through 25.........	172,790,401	26	171,269,666
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	217,307,638	27	231,677,097
28	Temporarily restricted net assets ...........	3,074,732	28	3,385,694
29	Permanently restricted net assets ...........	1,075,167	29	1,075,167
	Organizations that do not follow SFAS 117 (ASC 958), check here 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 ...........	221,457,537	33	236,137,958
34	Total liabilities and net assets/fund balances ........	394,247,938	34	407,407,624

- TIN:

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.

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.

OMB No. 1545-0047

2012

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.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

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.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Non-functionally integrated

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).

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 ..................................................

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

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)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(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
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of monetary support


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2012

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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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).

Gross receipts from related activities, etc. (see instructions) ..................

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........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2012 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2011 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2012. 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 ....................... right arrow

33 1/3% support test—2011. 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 ..................... right arrow

17a

10%-facts-and-circumstances test—2012. 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 ..................................................... right arrow

10%-facts-and-circumstances test—2011. 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 ................................................ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2012

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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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.)..

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............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2012 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2011 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2011 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2012. 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 ........ right arrow

33 1/3% support tests—2011. 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 ..... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions ..... right arrow

Schedule A (Form 990 or 990-EZ) 2012

Page 4

Part IV

Supplemental Information. Complete this part to 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) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

OMB No. 1545-0047

2012

Name of the organization

SANTA ROSA MEMORIAL HOSPITAL

Employer identification number

94-1231005

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

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

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.

Special Rules

For a section 501(c)(3) organization filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi) and received from any one contributor, during the year, a contribution of the
greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 for use exclusively for religious, charitable,
scientific, literary, or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and
III.

For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not total to more than $1,000. If this box is checked, enter here the total contributions that were received during
the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more
during the year ......................... Arrow Bullet

Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 2

Name of organization SANTA ROSA MEMORIAL HOSPITAL

Part I	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	RESTRICTED RESTRICTED RESTRICTED RESTRICTED, RESTRICTED RESTRICTED	$RESTRICTED	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 3

Name of organization SANTA ROSA MEMORIAL HOSPITAL

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 4

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
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet

$
Use duplicate copies of Part III if additional space is needed.

(a) No.
from
Part I

(b) Purpose of gift

(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

(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

(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

(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) (2012)

Additional Data

Software ID:
Software Version:

- TIN:

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

2012

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 35c (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.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV.

Political expenditures .................................... SchCMd Bullet

Volunteer hours ........................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ......... SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ...... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............

Yes No

Was a correction made? .........................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ................................... SchCMd Bullet

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

Did the filing organization file Form 1120-POL for this year? ..........................

Yes No

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 Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2012

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 SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(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? ......................................	Yes No

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) 2009	(b) 2010	(c) 2011	(d) 2012	(e) Total

2a	Lobbying nontaxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2012

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes

(b)

Amount

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:

Volunteers? .........................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....

Media advertisements? ....................................

Mailings to members, legislators, or the public? .........................

Publications, or published or broadcast statements? .......................

Grants to other organizations for lobbying purposes? .......................

Direct contact with legislators, their staffs, government officials, or a legislative body? ........

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......

Other activities? ..........................

Yes

46,063

Total. Add lines 1c through 1i ...............................

46,063

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 .................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....

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

Were substantially all (90% or more) dues received nondeductible by members? ................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ................

Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered “No” OR (b) Part III-A, line 3, is answered “Yes."

Dues, assessments and similar amounts from members .....................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).

Current year .........................................

Carryover from last year ....................................

Total ............................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

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? ................................

Taxable amount of lobbying and political expenditures (see instructions) ..............

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; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. 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, 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) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2012

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 ........

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? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements .......................	2a
b	Total acreage restricted by conservation easements ..................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register ....................	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................

Yes No

In Part XIII, 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.

If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:

(i)

Revenues included in Form 990, Part VIII, line 1 ........................ SchDMd Bullet

(ii)

Assets included in Form 990, Part X .............................. SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2012

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

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?........

Yes No

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.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIII and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21? .....................

Yes No

If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	b (c)Two years back	(d)Three years back	(e)Four years back
1a	Beginning of year balance ....	1,030,684	651,671	545,843	455,582	560,257
b	Contributions ........		400,000		305	550
c	Net investment earnings, gains, and losses	3,991	-20,987	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 ......	1,034,675	1,030,684	651,671	545,843	455,582

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

100.000 %

Temporarily restricted endowment SchDMd Bullet

The percentages in lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

(ii) related organizations ........................

3a(ii)

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment. See Form 990, Part X, line 10.

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	9,368,443		9,368,443
b	Buildings ................	120,871,163	66,883,877	53,987,286
c	Leasehold improvements ............	95,077,853	36,447,451	58,630,402
d	Equipment ................	121,780,759	92,782,067	28,998,692
e	Other .................	27,901,917		27,901,917
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				178,886,740

Schedule D (Form 990) 2012

Page 3

Part VII

InvestmentsOther Securities. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)		(b)Book value	(c) Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. See Form 990, Part X, line 13.

(a) Description of investment type		(b) Book value	(c) Method of valuation: Cost or end-of-year market value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. See Form 990, Part X, line 15.

(a) Description				(b) Book value
(1) DUE FROM AFFILIATES				34,392,359
(2) HOSPITAL FEE RECEIVABLES				10,175,493
(3) OTHER RECEIVABLES				513,233






Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				45,081,085

Part X

Other Liabilities. See Form 990, Part X, line 25.

1.(a) Description of liability		(b) Book value
Federal income taxes		0
PAYABLE TO THIRD PARTY PAYORS		6,361,701
ACCRUED LIABILITIES		12,175,023
DUE TO RESTRICTED FUND		1,683,702
INTERCO WITH HEALTH SYSTEM-BOND		120,328,963





Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		140,549,389
2. Fin 48 (ASC 740) Footnote. In Part XIII, 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 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................

Schedule D (Form 990) 2012

Page 4

Part XI 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 XIII.) ............	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 XIII.) ...........	4b
c	Add lines 4a and 4b.......................		4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......		5

Part XII 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 XIII.) ............	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 XIII.) ............	4b
c	Add lines 4a and 4b.......................		4c
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......		5

Part XIII

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, line 2; Part XI, lines 2d and 4b; and Part XII, 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 COMMUNITIES 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 FOR TAX BENEFITS, INTEREST OR PENALTIES WAS ACCRUED AT JUNE 30, 2013 OR 2012.

Schedule D (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

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. Form 990-EZ filers are not required to complete this part. right arrow

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.

OMB No. 1545-0047

2012

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.

Indicate whether the organization raised funds through any of the following activities. Check all that apply.

a	Mail solicitations	e	Solicitation of non-government grants
b	Internet and email solicitations	f	Solicitation of government grants
c	Phone solicitations	g	Special fundraising events
d	In-person solicitations

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?

Yes

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.

(i) Name and address of individual or entity (fundraiser)	(iii) Did fundraiser have custody or control of contributions?
	Yes	No










Total .................

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 Paperwork Reduction Act Notice, see the Instructions for Form 990or 990-EZ.

Cat. No. 50083H

Schedule G (Form 990 or 990-EZ) 2012

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 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with gross receipts greater than $5,000.

		(a) Event #1 KEEGAN (event type)	(b) Event #2 PRO AM (event type)	(d) Total events (add col. (a) through col. (c))
1	Gross receipts . . .	76,027	84,960	160,987
2	Less: Contributions . .	60,637	57,960	118,597
3	Gross income (line 1 minus line 2) . . .	15,390	27,000	42,390
4	Cash prizes . . .	0	1,000	1,000
5	Noncash prizes . .	0	4,396	4,396
6	Rent/facility costs . .	500	12,500	13,000
7	Food and beverages .	11,662	21,890	33,552
8	Entertainment . . .	5,000	0	5,000
9	Other direct expenses .	9,893	12,995	22,888
10	Direct expense summary. Add lines 4 through 9 in column (d) ...........			79,836
11	Net income summary. Combine line 3, column (d), and line 10. ..........			-37,446

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.

(a) Bingo

(b) Pull tabs/Instant
bingo/progressive bingo

(c) Other gaming

(d) Total gaming (add col.(a) through col.(c))

Gross revenue . . . .

Cash prizes . . . .

Non-cash prizes . . .

Rent/facility costs . . .

Other direct expenses . .

Volunteer labor . . .

	Yes
	No

	Yes
	No

	Yes
	No

Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow

Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow

Enter the state(s) in which the organization operates gaming activities:

Is the organization licensed to operate gaming activities in each of these states? ............

YesNo

If "No," explain:

10a

Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....

YesNo

If "Yes," explain:

Schedule G (Form 990 or 990-EZ) 2012

Page 3

Does the organization operate gaming activities with nonmembers? .................

YesNo

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? ..........................

YesNo

Indicate the percentage of gaming activity operated in:

The organization's facility ......................

13a

0 %

An outside facility ........................

13b

Enter the name and address of the person who prepares the organization's gaming/special events books and records:

Name

Address

15a

Does the organization have a contract with a third party from whom the organization receives gaming

revenue? ......................................

YesNo

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

$ .

If "Yes," enter name and address of the third party:

Name

Address

Gaming manager information:

Name

Gaming manager compensation right arrow

Description of services provided right arrow

Director/officer Employee Independent contractor

Mandatory distributions:

Is the organization required under state law to make charitable distributions from the gaming proceeds to

retain the state gaming license? ............................

YesNo

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

Supplemental Information. Complete this part to provide the explanations required by Part I, line 2b, columns (iii) and (v), and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also complete this part to provide any additional information (see instructions).

Identifier	Return Reference	Explanation

Schedule G (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

2012

Open to Public Inspection

Name of the organization

SANTA ROSA MEMORIAL HOSPITAL

Employer identification number

94-1231005

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a ...

Yes

If "Yes," was it a written policy? .......................

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?

If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other %

Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate

which of the following was the family income limit for eligibility for discounted care: .........

Yes

200% 250% 300% 350% 400% Other 500 %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

Yes

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

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? ......

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? ..............

Did the organization prepare a community benefit report during the tax year? ..........

Yes

If "Yes," did the organization make it available to the public? ..............

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) ..	6,849,777		6,849,777	1.950 %
b	Medicaid (from Worksheet 3, column a) ....	72,734,883	56,236,320	16,498,563	4.690 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .	6,834,911	3,547,481	3,287,430	0.930 %
d	Total Financial Assistance and Means-Tested Government Programs .	86,419,571	59,783,801	26,635,770	7.570 %
Other Benefits		3,810,280	924,252	2,886,028	0.820 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	3,810,280	924,252	2,886,028	0.820 %
f	Health professions education (from Worksheet 5) ..
g	Subsidized health services (from Worksheet 6) ..	122,321		122,321	0.030 %
h	Research (from Worksheet 7)
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	80,947		80,947	0.020 %
j	Total. Other Benefits ..	4,013,548	924,252	3,089,296	0.870 %
k	Total. Add lines 7d and 7j .	90,433,119	60,708,053	29,725,066	8.440 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2012

Schedule H (Form 990) 2012

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(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
4	Environmental improvements
5	Leadership development and training for community members	340,206	19,794	320,412	0.010 %
6	Coalition building
7	Community health improvement advocacy	11,512		11,512	0 %
8	Workforce development
9	Other
10	Total	351,718	19,794	331,924	0.010 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

22,265,000

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

100,481,630

Enter Medicare allowable costs of care relating to payments on line 5.....

139,188,704

Subtract line 6 from line 5. This is the surplus (or shortfall)........

-38,707,074

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:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

Yes

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2012

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, and primary website address					Other (Describe)
1	SANTA ROSA MEMORIAL HOSPITAL 1165 MONTGOMERY DRIVE SANTA ROSA,CA95405 WWW.STJHS.ORG	X	X	X	DESIGNATED TRAUMA CENTER

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

	SANTA ROSA MEMORIAL HOSPITAL
Name of hospital facility or facility reporting group

For single facility filers only: line Number of Hospital Facility (from Schedule H, Part V, Section A)

Yes

Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9....................

Yes

If “Yes,” indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

Information gaps that limit the hospital facility’s ability to assess the community’s health needs

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20 12

In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served by the hospital facility, including those with special knowledge of or expertise in public health? 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 ....................

Yes

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI................................

Yes

Did the hospital facility make its CHNA report widely available to the public? .............

Yes

If “Yes,” indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date):

Adoption of an implementation strategy that addresses each of the community health needs identified through the CHNA

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

Adoption of a budget for provision of services that address the needs identified in the CHNA

Prioritization of health needs in its community

Prioritization of services that the hospital facility will undertake to meet health needs in its community

Other (describe in Part VI)

Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs ........

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ...........................

If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ......

If "Yes" to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 500.% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	Yes
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a	Income level
b	Asset level
c	Medical indigency
d	Insurance status
e	Uninsured discount
f	Medicaid/Medicare
g	State regulation
h	Other (describe in Part VI)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to 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 on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)
17	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........	17		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

Notified individuals of the financial assistance policy in communications with the patients regarding the patients’ bills

Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

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?..........

Yes

If “No,” indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)

Other (describe in Part VI)

Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)

Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.

The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged

The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged

The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged

Other (describe in Part VI)

During the tax year, did the hospital facility charge any FAP-eligible individuals 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? ............................

If “Yes,” explain in Part VI.

During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross charge for any service provided to that individual? .........................

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?10
Name and address		Type of Facility (describe)
1	SANTA ROSA AMBULATORY SURGERY CENTER 525 DOYLE PARK DRIVE SANTA ROSA,CA95401	AMBULATORY SURGERY CENTER
2	URGENT CARE - ROHNERT PARK 1450 MEDICAL CENTER DRIVE ROHNERT PARK,CA95428	URGENT CARE
3	SANTA ROSA MEMORIAL OUTPATIENT LAB 500 DOYLE PARK DRIVE SANTA ROSA,CA95405	LABORATORY SERVICES
4	URGENT CARE - SANTA ROSA 925 CORPORATE CENTER PARKWAY STE A SANTA ROSA,CA95409	URGENT CARE
5	BEHAVIORAL HEALTH 405 W COLLEGE AVENUE SUITE F SANTA ROSA,CA95405	BEHAVIORAL HEALTH SERVICES
6	OUTPATIENT THERAPY CLINIC 1170 MONTGOMERY DRIVE SANTA ROSA,CA95405	THERAPY SERVICES
7	SANTA ROSA MEMORIAL RADIOLOGY 500 DOYLE PARK DRIVE SANTA ROSA,CA95405	RADIOLOGY SERVICES
8	WOUND CARE CLINIC 500 DOYLE PARK DRIVE SANTA ROSA,CA95405	WOUND CARE
9	URGENT CARE - WINDSOR 6580 HEMBREE LANE SUITE 270 WINDSOR,CA95492	URGENT CARE
10	ST JOSEPH DENTAL CLINICMOBILE VAN 1450 MEDICAL CENTER DRIVE ROHNERT PARK,CA95428	DENTAL SERVICES

Schedule H (Form 990) 2012

Page

Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
8	Facility reporting group(s). If applicable, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.

Identifier	ReturnReference	Explanation
SCHEDULE H, PART I, LINES 7A - 7I	COSTING METHODOLOGY	THE AMOUNTS REPORTED IN THE TABLE WERE CALCULATED USING THE ORGANIZATION'S COST ACCOUNTING SYSTEM.
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 HOSPITALS 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 ADDDITION TO COUNTYWIDE COLLABORATION AND PARTNERSHIP DEVELOPMENT TO SUPPORT THESE ACTIONS, THE PROGRAMS ESPECIALLY FOCUSED ON COMMUNITY BUILDING ARE THE NEIGHBORHOOD CARE STAFF (NCS), AGENTS OF CHANGE TRAINING IN OUR NEIGHBORHOODS (ACTION) AND CIRCLE OF SISTERS. THESE PROGRAMS ARE AN INTEGRAL PART OF THE HOSPITALS PRIORITY INITIATIVES TO IMPROVE COMMUNITY, ADDRESSING THE SOCIAL DETERMINANTS OF HEALTH AFFECTING THE FOLLOWING KEY AREAS: CHILDHOOD OBESITY, YOUTH SUBSTANCE ABUSE, CHILDRENS ORAL HEALTH AND CARE MANAGEMENT FOR HOMEBOUND LOW-INCOME SENIORS. THE NEIGHBORHOOD CARE STAFF (NCS) IS A PROGRAM THAT MENTORS 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 DIALOG, 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. AGENTS OF CHANGE TRAINING IN OUR NEIGHBORHOODS (ACTION) IS A COMPANION PROGRAM TO NCS THAT PROVIDES LEADERSHIP AND ADVOCACY TRAINING. IN FY 13, THIS PROGRAM CONTINUED TO TRAIN GRASSROOTS COMMUNITY VOLUNTEERS AS LEADERS IN THE COMMUNITY ACTIVITY AND NUTRITION COALITION'S "HEALTHY EATING, ACTIVE LIVING" (HEAL) PROJECT IN SOUTH SANTA ROSA. ACTION GRADUATES PARTICIPATING IN THE HEAL PROJECT ENGAGED IN ADVOCACY THAT HELPED TO IMPROVE FOOD POLICY IN THE ROSELAND SCHOOL DISTRICT, DESIGNING, IMPLEMENTING AND ANALYZING STUDENT SURVEYS REGARDING FOOD SERVICE QUALITY AND CHOICES, IN WHICH 154 ROSELAND ELEMENTARY SCHOOL STUDENTS PARTICIPATED. AN INTRODUCTION TO ACTION TRAINING WAS ALSO PRESENTED TO REPRESENTATIVES OF 58 COMMUNITY GARDENS PARTICIPATING IN THE SONOMA COUNTY COMMUNITY GARDEN NETWORK. 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 2013, CIRCLE OF SISTERS SERVED 250 GIRLS AND THEIR FAMILIES THROUGH OVER 6,400 ENCOUNTERS. THE MENTORING PROVIDED THROUGH CIRCLE OF SISTERS SUPPORTS THE PARTICIPANTS IN MAKING HEALTHIER CHOICES, AS REFLECTED IN THE RESULTS OF THE PROGRAMS PRE-AND POST-TESTING, WHICH SHOWS THAT 100% OF THE PARTICIPANTS IN 7TH AND 8TH GRADE REPORT THEY DO NOT DRINK ALCOHOL AT YEAR-END.
SCHEDULE H, PART III, SECTION A, LINE 2	COSTING METHODOLOGY	THE AMOUNTS REPORTED 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, SECTION A, LINE 4		PAGE 11 OF THE AUDITED FINANCIAL STATEMENTS - 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.
SCHEDULE H, PART III, SECTION B, 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, SECTION C, LINE 9B		PATIENT ACCOUNTS WERE NOT FORWARDED TO COLLECTION STATUS WHEN THE PATIENT MADE 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 PERFORMED AN EVALUATION TO IDENTIFY IF THE ACCOUNTS FOR PATIENTS WHO QUALIFIED FOR FREE CARE (100 PERCENT FINANCIAL ASSISTANCE) WERE WRITTEN OFF AND COLLECTION EFFORTS WERE NOT PURSUED. THE ORGANIZATION'S COLLECTIONS POLICY APPLIED TO ACCOUNTS FOR PATIENTS WHO QUALIFIED FOR A PARTIAL DISCOUNT.
SANTA ROSA MEMORIAL HOSPITAL (1)	SCHEDULE H, PART V, SECTION B, LINE 3	LOCAL LEADERS PROVIDED INPUT TO THE KEY INFORMANT PANELS, RESIDENT FOCUS GROUPS, AND THE DEVELOPMENT OF THE STRATEGIC PLANS. KEY INFORMANT PANELS AND RESIDENT FOCUS GROUPS WERE HELD IN CONFIDENTIALITY TO ENSURE CANDID DIALOGUE SURROUNDING COMMUNITY NEEDS, THESE NAMES CANNOT BE SHARED DURING THIS NEEDS ASSESSMENT. COMMUNITY INPUT WAS ALSO OBTAINED FROM THE FOLLOWING: COMMUNITY INPUT WAS COLLECTED THROUGH KEY INFORMANT PANELS, RESIDENT FOCUS GROUPS, AND THE DEVELOPMENT OF THE STRATEGIC PLANS. BECAUSE KEY INFORMANT PANELS AND RESIDENT FOCUS GROUPS WERE HELD IN CONFIDENTIALITY TO ENSURE CANDID DIALOGUE SURROUNDING COMMUNITY NEEDS. SONOMA COUNTY DEPT OF HEALTH SERVICES: HEALTH OFFICER AND PUBLIC HEALTH DIVISION DIRECTOR; DIRECTOR OF PUBLIC HEALTH NURSING; MATERNAL CHILD HEALTH COORDINATOR, SUPERVISING PH NURSE; HEALTH INFORMATION SPECIALIST, HEALTHY COMMUNITIES SECTION; EPIDEMIOLOGIST; MENTAL HEALTH AOD SERVICES DIVISION; ALCOHOL AND OTHER DRUGS PREVENTION COORDINATOR; EXECUTIVE DIRECTOR, FIRST FIVE SONOMA COUNTY. HEALTH CARE AND DENTAL CARE: CEO PEDIATRIC DENTAL INITIATIVE; REDWOOD COMMUNITY HEALTH COALITION, DIRECTOR OF COMMUNITY AND GOVERNMENT RELATIONS; HEALTH CARE CONSULTANT. SCHOOLS: SAFE SCHOOLS PROJECT DIRECTOR, SONOMA COUNTY OFFICE OF EDUCATION. SOCIAL SERVICES: DIRECTOR OF HEALTH PROGRAMS, COMMUNITY ACTION PARTNERSHIP OF SONOMA COUNTY; EXECUTIVE DIRECTOR, DRUG ABUSE ALTERNATIVES CENTER; OUTPATIENT SERVICES DIRECTOR, DRUG ABUSE ALTERNATIVES CENTER. COMMUNITY HEALTH IMPROVEMENT COMMITTEE, SONOMA COUNTY ALLIANCE: COMMUNITY BENEFIT/COMMUNITY HEALTH MANAGER PUBLIC AFFAIRS MARIN SONOMA SERVICE AREA KAISER PERMANENTE; VP MISSION INTEGRATION, ST. JOSEPH HEALTH, SONOMA COUNTY; FUND DEVELOPMENT AND COMMUNITY RELATIONS MANAGER, SUTTER MEDICAL CENTER OF SANTA ROSA; HEALTH ACTION PROGRAM MANAGER, SONOMA COUNTY DEPARTMENT OF HEALTH SERVICES. INDIVIDUALS PROVIDING PUBLIC HEALTH EXPERTISE: HEALTH OFFICER AND PUBLIC HEALTH DIVISION DIRECTOR; DIRECTOR OF PUBLIC HEALTH NURSING; MATERNAL CHILD HEALTH COORDINATOR, SUPERVISING PH NURSE; HEALTH INFORMATION SPECIALIST, HEALTHY COMMUNITIES SECTION; MENTAL HEALTH AOD SERVICES DIVISION; ALCOHOL AND OTHER DRUGS PREVENTION COORDINATOR; EXECUTIVE DIRECTOR, FIRST FIVE SONOMA COUNTY; HEALTH ACTION PROGRAM MANAGER, SONOMA COUNTY DEPARTMENT OF HEALTH SERVICES.
SANTA ROSA MEMORIAL HOSPITAL (1)	SCHEDULE H, PART V, SECTION B, LINE 4	THE NEEDS ASSESSMENT WAS A COLLABORATIVE EFFORT BY SUTTER MEDICAL CENTER OF SANTA ROSA, SANTA ROSA MEMORIAL HOSPITAL, PETALUMA VALLEY HOSPITAL, KAISER PERMANENTE MEDICAL CENTER - SANTA ROSA AND THE SONOMA COUNTY DEPARTMENT OF HEALTH SERVICES.
SANTA ROSA MEMORIAL HOSPITAL (1)	SCHEDULE H, PART V, SECTION B, LINE 5A	THE WEB ADDRESS IS: http://www.stjosephhealth.org/documents/SRM-2011-CHNA-Written-Report_FINAL _For-CBC.pdf
SANTA ROSA MEMORIAL HOSPITAL (1)	SCHEDULE H, PART V, SECTION B, LINE 7	THE FOLLOWING HEALTH NEED WILL NOT BE ADDRESSED DIRECTLY IN THE SANTA ROSA MEMORIAL COMMUNITY BENEFIT PLAN/IMPLEMENTATION STRATEGY, AS THEY ARE EITHER BEING ADDRESSED BY LOCAL NONPROFIT ORGANIZATIONS WITH GREATER EXPERTISE AND/OR RESOURCES TO RESPOND TO THE PROBLEM. SANTA ROSA MEMORIAL HOSPITAL WILL NOT ADDRESS PERINATAL ALCOHOL, TOBACCO AND OTHER DRUG USE IN ITS COMMUNITY BENEFIT PROGRAMS. THIS ISSUE IS BEING ADDRESSED BY LOCAL NONPROFIT ORGANIZATIONS WITH GREATER EXPERTISE OR RESOURCES TO RESPOND TO THE PROBLEM. IN THE CASE OF YOUTH AND PERI-NATAL SUBSTANCE ABUSE, GIVEN THE SCOPE OF ITS COMMUNITY BENEFIT PROGRAMS AND CLINICS SANTA ROSA MEMORIAL HAS ELECTED TO RESPOND TO THE NEEDS ASSOCIATED WITH SUBSTANCE ABUSE BY FOCUSING ON THE COUNTY'S VULNERABLE YOUTH. IT WILL CONTINUE TO PARTNER WITH OTHER PUBLIC AND PRIVATE AGENCIES ADDRESSING THIS URGENT PROBLEM, SUPPORTING THE COMMUNICATION OF AVAILABLE SERVICES TO THE FAMILIES SERVED AND LEVERAGING RESOURCES WHEN POSSIBLE TO SUPPORT THE SERVICES PROVIDED BY ITS COMMUNITY PARTNERS. SANTA ROSA MEMORIAL WILL ENDORSE LOCAL NONPROFIT ORGANIZATIONAL PARTNERS TO APPLY FOR FUNDING THROUGH THE ST. JOSEPH HEALTH SYSTEM FOUNDATION, TO MEET COMMUNITY NEED. ORGANIZATIONS THAT RECEIVE FUNDING PROVIDE SPECIFIC PERINATAL SERVICES, RESOURCES AND MEET THE NEEDS OF THIS VULNERABLE POPULATION THAT SANTA ROSA MEMORIAL DOES NOT, IN ORDER TO MAKE BEST USE OF LIMITED RESOURCES AND AVOID DUPLICATION OF EFFORTS WITH ITS COMMUNITY PARTNERS. FOR FURTHER INFORMATION, PLEASE SEE THE IMPLEMENTATION STRATEGY FOUND AT: http://www.stjosephhealth.org/documents/SRM_FY12_FY14_CB_Plan_501r_alignme nt_FINAL.pdf
SANTA ROSA MEMORIAL HOSPITAL (1)	SCHEDULE H, PART V, SECTION B, LINE 12H	THE ORGANIZATION RECOGNIZES THAT A PORTION OF THE UNINSURED OR UNDERINSURED PATIENT POPULATION MAY NOT ENGAGE IN THE TRADITIONAL 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.
SANTA ROSA MEMORIAL HOSPITAL (1)	SCHEDULE H, PART V, SECTION B, LINE 14G	THE ORGANIZATION ADHERES TO STATE REGULATIONS IN PUBLICIZING ITS FINANCIAL ASSISTANCE POLICY. THESE REGULATIONS INCLUDE THE POSTING OF THE FULL POLICY ON THE OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT (OSHPD) WEBSITE. IN ADDITION, POLICY NOTICES ARE POSTED IN CONSPICUOUS AREAS SUCH AS EMERGENCY DEPARTMENTS, BILLING OFFICES, ADMISSIONS OFFICES AND OTHER OUTPATIENT SETTINGS. INDIVIDUAL NOTICES OF FINANCIAL ASSISTANCE ARE INCLUDED WITH BILLINGS FOR PATIENTS WHO HAVE NOT PROVIDED PROOF OF THIRD-PARTY COVERAGE ALONG WITH CONTACT INFORMATION IN THE EVENT OF ADDITIONAL INQUIRIES. NOTICES OF FINANCIAL ASSISTANCE ARE ALSO PROVIDED UPON INQUIRY. WRITTEN NOTICES ARE PROVIDED IN ALL LANGUAGES SPOKEN BY 5% OR MORE OF THE HOSPITAL'S PATIENT POPULATION.
SANTA ROSA MEMORIAL HOSPITAL (1)	SCHEDULE H, PART V, SECTION B, LINE 18E	THE ORGANIZATION ADHERES TO STATE REGULATIONS IN PUBLICIZING ITS FINANCIAL ASSISTANCE POLICY. THESE REGULATIONS INCLUDE THE POSTING OF THE FULL POLICY ON THE OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT (OSHPD) WEBSITE. IN ADDITION, POLICY NOTICES ARE POSTED IN CONSPICUOUS AREAS SUCH AS EMERGENCY DEPARTMENTS, BILLING OFFICES, ADMISSIONS OFFICES AND OTHER OUTPATIENT SETTINGS. INDIVIDUAL NOTICES OF FINANCIAL ASSISTANCE ARE INCLUDED WITH BILLINGS FOR PATIENTS WHO HAVE NOT PROVIDED PROOF OF THIRD-PARTY COVERAGE ALONG WITH CONTACT INFORMATION IN THE EVENT OF ADDITIONAL INQUIRIES. NOTICES OF FINANCIAL ASSISTANCE ARE ALSO PROVIDED UPON INQUIRY. WRITTEN NOTICES ARE PROVIDED IN ALL LANGUAGES SPOKEN BY 5% OR MORE OF THE HOSPITAL'S SERVICE AREA.
SANTA ROSA MEMORIAL HOSPITAL (1)	SCHEDULE H, PART V, SECTION B, LINE 20D	FOR PATIENTS WITH A FAMILY INCOME BETWEEN 201% AND 350% OF FEDERAL POVERTY GUIDELINES (FPG), THE ORGANIZATION USES MEDICARE RATES WHEN CALCULATING THE MAXIMUM AMOUNTS THAT CAN BE CHARGED. FOR PATIENTS WITH A FAMILY INCOME BETWEEN 351% AND 500% OF FPG, THE AVERAGE OF NEGOTIATED COMMERCIAL INSURANCE RATES IS USED TO DETERMINE THE MAXIMUM AMOUNT THAT CAN BE CHARGED.
NEEDS ASSESSMENT	SCHEDULE H, PART VI, LINE 2	THE COMMUNITY HEALTH NEEDS ASSESSMENT IS A COLLABORATIVE EFFORT BY SUTTER MEDICAL CENTER OF SANTA ROSA, ST. JOSEPH HEALTH 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. THE 2011 CHNA WAS UPDATED IN 2012 TO ALIGN WITH THE PATIENT PROTECTION AND AFFORDABLE CARE ACT (PUB. L. 111-148) WHICH ADDED SECTION 501(R) TO THE INTERNAL REVENUE CODE. SECTION 501(R) IMPOSES NEW REQUIREMENTS ON NON-PROFIT HOSPITALS. SECTION 501(R)(3) REQUIRES A HOSPITAL ORGANIZATION TO CONDUCT A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) EVERY THREE YEARS AND ADOPT AN IMPLEMENTATION STRATEGY TO MEET THE COMMUNITY HEALTH NEEDS IDENTIFIED THROUGH SUCH ASSESSMENT. THE CHNA MUST (1) TAKE INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL FACILITY, INCLUDING THOSE WITH SPECIAL KNOWLEDGE OF OR EXPERTISE IN PUBLIC HEALTH AND (2) BE MADE WIDELY AVAILABLE TO THE PUBLIC. SECTION 501(R)(3)(B). SANTA ROSA MEMORIAL HOSPITAL RELIED ON NOTICE 2011-52: NOTICE AND REQUEST FOR COMMENTS REGARDING THE COMMUNITY HEALTH NEEDS ASSESSMENT REQUIREMENTS FOR TAX-EXEMPT HOSPITALS TO MEET THE REQUIREMENTS.
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	SCHEDULE H, PART VI, LINE 3	OUR COMMITMENT 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 HOSPITAL POSTS NOTICES INFORMING THE PUBLIC OF THE FINANCIAL ASSISTANCE PROGRAM IN HIGH VOLUME INPATIENT AND OUTPATIENT SERVICE AREAS OF THE HOSPITAL INCLUDING BUT NOT LIMITED TO THE EMERGENCY DEPARTMENT, BILLING OFFICE, INPATIENT ADMISSION AND OUTPATIENT REGISTRATION AREAS OR OTHER COMMON PATIENT WAITING AREAS OF THE HOSPITAL. NOTICES ARE ALSO POSTED AT ANY LOCATION WHERE A PATIENT MAY PAY THEIR BILL AND INCLUDE CONTACT INFORMATION ON HOW A PATIENT MAY OBTAIN MORE INFORMATION ON FINANCIAL ASSISTANCE AS WELL AS WHERE TO APPLY FOR SUCH ASSISTANCE. THESE NOTICES ARE POSTED IN ENGLISH AND SPANISH AND ANY OTHER LANGUAGES THAT ARE REPRESENTATIVE OF 5% OR GREATER OF PATIENTS IN THE HOSPITAL'S SERVICE AREA. A PATIENT INFORMATION BROCHURE THAT DESCRIBES THE FEATURES OF THE FINANCIAL ASSISTANCE PROGRAM IS AVAILABLE TO PATIENTS AND MEMBERS OF THE GENERAL PUBLIC; AND A COPY OF THE FINANCIAL ASSISTANCE POLICY IS AVAILABLE TO THE PUBLIC ON A REASONABLE BASIS.
COMMUNITY INFORMATION	SCHEDULE H, PART VI, LINE 4	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. SONOMA COUNTY HAD THE 17TH LARGEST COUNTY POPULATION OF THE 58 COUNTIES IN CALIFORNIA. 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. MUCH 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). OTHER HOSPITALS IN SERVICE AREA INCLUDE: PETALUMA VALLEY HOSPITAL, SUTTER MEDICAL CENTER OF SANTA ROSA, HEALDSBURG DISTRICT HOSPITAL, SONOMA VALLEY HOSPITAL, AND PALM DRIVE HOSPITAL.
PROMOTION OF COMMUNITY HEALTH	SCHEDULE H, PART VI, LINE 5	THE GOVERNING BODY WAS COMPRISED OF A MAJORITY OF PERSONS WHO RESIDE IN THE HOSPITAL'S 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, OVERSAW 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. GIVING BACK TO THE COMMUNITY IS HARDWIRED INTO EVERY ASPECT OF OUR ORGANIZATION. AS A MEMBER OF THE FAITH-BASED HEALTH MINISTRY OF ST. JOSEPH HEALTH, WE PROVIDED 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 COMMITMENT TO COMMUNITY IS FURTHER DEMONSTRATED THROUGH OUR STRATEGIC COMMUNITY INVESTMENTS. 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. THE FOLLOWING PROGRAMS IN FY13 WERE MADE POSSIBLE THROUGH CARE FOR THE POOR FUNDS AND EXEMPLIFY OUR COMMITMENT TO PROMOTE HEALTH AND ACCESS TO CARE TO THE LOW-INCOME: MOBILE DENTAL, MOBILE HEALTH, ST. JOSEPH DENTAL CLINIC, HOUSE CALLS, AND PROMOTERES DE SALUD (HEALTH PROMOTERS). WE ARE ALSO COMMITTED TO PROMOTING HEALTH AND ACCESS TO CARE FOR THE BROADER COMMUNITY. THIS IS DEMONSTRATED THROUGH THE FOLLOWING FY13 BROADER COMMUNITY PROGRAMS: AGENTS OF CHANGE TRAINING IN OUR NEIGHBORHOODS ACTION, CIRCLE OF SISTERS AND HEALTHY FOR LIFE AN OBESITY PREVENTION PROGRAM.
AFFILIATED HEALTH CARE SYSTEM	SCHEDULE H, PART VI, LINE 6	SANTA ROSA MEMORIAL HOSPITAL IS A HEALING MINISTRY OF ST. JOSEPH HEALTH, AN INTEGRATED HEALTHCARE DELIVERY SYSTEM SPONSORED BY THE ST. JOSEPH HEALTH MINISTRY. ST. JOSEPH HEALTH 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 TO EXTEND 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 THE COMMUNITIES IT SERVES. IN 1986, ST. JOSEPH HEALTH 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 FINANCIAL ASSISTANCE FOR THOSE IN NEED OF ACUTE SERVICES, ST. JOSEPH HEALTH CREATED THE ST. JOSEPH HEALTH SYSTEM FOUNDATION TO IMPROVE THE HEALTH OF LOW-INCOME INDIVIDUALS RESIDING IN LOCAL COMMUNITIES. OUR FOUNDATIONAL DOCUMENT, A VISION OF VALUES, FORMALIZED A POLICY THROUGH WHICH THE HOSPITAL MINISTRIES RETURN TEN PERCENT OF THEIR NET INCOME TO THE ST. JOSEPH HEALTH COMMUNITY PARTNERSHIP FUND TO SUPPORT OUTREACH EFFORTS FOR THE MATERIALLY POOR. THE FOUNDATION THEN FUNDS PROGRAMS IN COMMUNITIES SERVED BY SYSTEM HOSPITALS THAT EXEMPLIFY THE FOUR CORE VALUES OF THE ST. JOSEPH HEALTH SYSTEM: SERVICE, EXCELLENCE, DIGNITY, AND JUSTICE.
STATE FILING OF COMMUNITY BENEFIT REPORT	SCHEDULE H, PART VI, LINE 7	CALIFORNIA

Schedule H (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

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

2012

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

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? ....................................

Yes No

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. Part II can be duplicated if additional space is needed.

(a) Name and address of organization or government	(b) EIN	(c) IRC Code section if applicable	(d) Amount of cash grant	(h) Purpose of grant or assistance
(1) ST JOSEPH HEALTH SYSTEM FOUNDATION 3345 MICHELSON DR STE 100 IRVINE,CA92612	33-0143024	501(c)(3)	2,101,700	CARE FOR THE POOR PROGRAM FUND
(2) COMMUNITY FOUNDATION SONOMA COUNTY 250 D STREET STE 205 SANTA ROSA,CA95404	68-0003212	501(c)(3)	20,250	PROGRAM SUPPORT
(3) NORTHERN CALIFORNIA CENTER FOR WELL BEING 365B TESCONI CIRCLE Santa Rosa,CA95409	93-1144835	501(c)(3)	45,765	HEART WORKS PROGRAM
(4) COUNTY OF SONOMA DEPARTMENT OF HEALTH SERVICE 3313 CHANATE RD SANTA ROSA,CA95404	94-6000539	501(c)(3)	40,500	PROGRAM SUPPORT
(5) AMERICAN RED CROSS 5297 AERO DRIVE SANTA ROSA,CA95403	95-2147698	501(c)(3)	8,100	PROGRAM SUPPORT
(6) SONOMA COUNTY BEST 1260 NORTH DUTTON AVE SANTA ROSA,CA95401	68-0074807	501(c)(3)	8,100	FUTURE GROWTH OF SONOMA COUNTY
(7) SONOMA HEALTH ALLIANCE 1154 MONTGOMERY DR 1 SANTA ROSA,CA95405	94-1231005	501(c)(3)	10,000	PROGRAM SUPPORT

Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image

Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50055P

Schedule I (Form 990) 2012

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.
Part III can be duplicated 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, Part III, column (b), 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) 2012

Additional Data

Software ID:
Software Version:

- TIN:

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

2012

Open to Public Inspection

Name of the organization

SANTA ROSA MEMORIAL HOSPITAL

Employer identification number

94-1231005

Part I

Questions Regarding Compensation

Yes

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.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....

Yes

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? .......

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

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:

Receive a severance payment or change-of-control payment? ................

Yes

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? .........

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.

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:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

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:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

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 ............

Yes

Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2012

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1)KEVIN KLOCKENGAREGIONAL EVP	(i) (ii)	0 494,978	0 132,985	0 154,843	0 10,000	0 27,072	0 819,878	0 0
(2)JO SANDERSFELDSECTY/VP MISSION INTEGRATION	(i) (ii)	189,813 0	57,225 0	62,016 0	18,867 0	18,720 0	346,641 0	0 0
(3)MICHEL RICCIONICHIEF FINANCIAL OFFICER	(i) (ii)	318,025 0	95,066 0	94,560 0	17,298 0	27,280 0	552,229 0	111,217 0
(4)GARY GREENSWEIGCHIEF MEDICAL OFFICER	(i) (ii)	176,792 0	92,806 0	49,088 0	12,400 0	10,836 0	341,922 0	0 0
(5)KATHERINE HARDINCHIEF NURSING OFFICER (FMR KE)	(i) (ii)	0 0	0 0	204,079 0	0 0	0 0	204,079 0	0 0
(6)MARK KNIGHTVP - STRATEGIC SERVICES	(i) (ii)	62,681 0	0 0	209,201 0	1,966 0	1,744 0	275,592 0	0 0
(7)ANDREA LEARNEDVP - FUND DEVELOPMENT	(i) (ii)	159,914 0	45,040 0	45,849 0	14,054 0	9,032 0	273,889 0	0 0
(8)DEBRA MILLERVP - HUMAN RESOURCES	(i) (ii)	201,672 0	60,016 0	60,500 0	19,389 0	28,297 0	369,874 0	0 0
(9)TODD SALNASCOO (PART YEAR)/PRESIDENT	(i) (ii)	177,442 146,814	25,000 93,264	32,172 39,271	8,121 1,879	15,645 10,717	258,380 291,945	0 0
(10)REBECCA ALTHOFFSTAFF NURSE IV-SNA	(i) (ii)	431,585 0	0 0	261 0	26,566 0	19,692 0	478,104 0	0 0
(11)RICHARD HENRYSTAFF NURSE IV-SNA	(i) (ii)	242,462 0	0 0	1,178 0	26,297 0	19,657 0	289,594 0	0 0
(12)RHONDA FOSTERCHIEF NURSING OFFICER	(i) (ii)	193,566 0	30,515 0	48,865 0	0 0	7,794 0	280,740 0	0 0
(13)CATHERINE CAMENGAVP PERFORMANCE IMPROVEMENT	(i) (ii)	126,774 0	25,000 0	25,900 0	0 0	4,527 0	182,201 0	0 0
(14)CAROLYNN TEDESCHISTAFF NURE IV	(i) (ii)	268,994 0	0 0	25 0	16,423 0	0 0	285,442 0	0 0
(15)SUZAN HUGHESSTAFF NURSE II	(i) (ii)	245,907 0	0 0	50 0	1,636 0	0 0	247,593 0	0 0
(16)NANCY PRATTBOARD MEMEBER	(i) (ii)	0 115,421	0 124,412	0 51,783	0 0	0 2,998	0 294,614	0 0
(17)ANNETTE WALKERBOARD MEMBER (PART YEAR)	(i) (ii)	0 418,127	0 120,668	0 111,896	0 11,152	0 38,549	0 700,392	0 0
(18)CHERI WHITINGSTAFF NURSE III	(i) (ii)	211,850 0	240 0	7,883 0	17,080 0	27,830 0	264,883 0	0 0
(19)JAYNIE BORENN. CA REG VP - STRATEGIC SVCS	(i) (ii)	0 243,040	0 63,275	0 66,095	0 0	0 19,130	0 391,540	0 0

Schedule J (Form 990) 2012

Page 3

Part III

Supplemental Information

Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.

Identifier	Return Reference	Explanation
SUPPLEMENTAL COMPENSATION INFORMATION	SCHEDULE J, PART I, LINE 1A	DISCRETIONARY SPENDING ACCOUNT 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 PRESIDENT IS PAID BY ITS TAX EXEMPT PARENT, ST. JOSEPH HEALTH SYSTEM, AND IS DISCLOSED AS A PERSON PAID BY A RELATED ORGANIZATION.
SCHEDULE J, PART I, LINE 4A		THE FOLLOWING INDIVIDUALS RECEIVED SEVERANCE PAYMENTS FOR EITHER PART OR ALL OF THE YEAR: KATHERINE HARDIN $204,079 MARK KNIGHT $209,201
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 RECEIVED PAYMENT FROM THE SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN (SERP): MICHEL RICCIONI $111,217
SCHEDULE J, PART I, LINE 7		A PORTION OF EXECUTIVES SALARIES ARE PLACED "AT RISK" AND ARE 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) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

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, line 38a or 40b.
MediumBullet

Attach to Form 990 or Form 990-EZ. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

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	(c) Description of transaction	(d) Corrected?
1(a) Name of disqualified person	(c) Description of transaction	Yes	No

Enter the amount of tax incurred by organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image

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-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22

(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	(d) Loan to or from the organization?		(e)Original principal amount	(f)Balance due	(g) In default?		(h) Approved by board or committee?		(i)Written agreement?
(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	To	From	(e)Original principal amount	(f)Balance due	Yes	No	Yes	No	Yes	No






Total ...... $						0

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 assistance	(d) Type of assistance	(e) Purpose of assistance

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2012

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?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) LYDIA ADAMS	SPOUSE OF BOARD MEMBER	61,257	EMPLOYEE COMPENSATION		No
(2) VERIHEALTH INC	JIM ADAMS, BOARD MEMBER	291,316	AMBULANCE TRANSPORTATION CO.		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	LYDIA ADAMS IS THE SPOUSE OF JIM ADAMS, A BOARD MEMBER OF SANTA ROSA MEMORIAL HOSPITAL (SRMH). LYDIA IS AN EMPLOYEE OF SRMH. JIM ADAMS IS A BOARD MEMBER OF SANTA ROSA MEMORIAL HOSPITAL (SRMH) AND A BOARD MEMBER OF VERIHEALTH, INC.

Schedule L (Form 990 or 990-EZ) 2012

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.
MediumBullet

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2012

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	SANTA ROSA MEMORIAL HOSPITAL HAS BEEN MEETING THE HEALTH AND QUALITY OF LIFE NEEDS OF THE LOCAL COMMUNITY FOR OVER 66 YEARS. SERVING THE COMMUNITIES OF SONOMA, MENDOCINO, NAPA AND LAKE COUNTY REGIONS, SANTA ROSA MEMORIAL HOSPITAL IS A STATE-OF-THE-ART 278-BED ACUTE CARE HOSPITAL, WITH 1904 EMPLOYEES. THE HOSPITAL PROVIDES QUALITY CARE WITH 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 CENTERS AND AN AMBULATORY SURGERY CENTER. AS A MEMBER OF THE ST. JOSEPH HEALTH, SANTA ROSA MEMORIAL HOSPITAL IS COMMITTED TO EXTEND 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. THREE MISSION OUTCOMES STRATEGICALLY GUIDE OUR MINISTRY WORK SANTA ROSA MEMORIAL HOSPITAL IS COMMITTED TO THREE SYSTEMWIDE MISSION OUTCOMES: 1) SACRED ENCOUNTERS, 2) PERFECT CARE, AND 3) HEALTHIEST COMMUNITIES. EVERY INTERACTION WILL BE EXPERIENCED AS A SACRED ENCOUNTER. THE GOAL OF SACRED ENCOUNTERS 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 IMPLEMENTED EVIDENCED BASED BEST PRACTICE STANDARD WORK TO ADDRESS WHAT WE DO & HOW WE DO WHAT WE DO TO ADDRESS ALL EIGHT KEY HCAHPS COMPOSITE MEASURES OF PATIENT EXPERIENCE. ANY LOCATION PERFORMING BELOW MINISTRY HCAHPS PERFORMANCE GOALS MUST PROVIDE COUNTERMEASURE FOR IMPROVEMENT TO EXECUTIVE LEADERSHIP. ALL STANDARD WORK INCLUDES EDUCATION, MONITORING & COACHING, IS AUDITED DAILY FOR REAL TIME PROGRESS REPORT TO ALL LEVELS OF THE ORGANIZATION, AND RELIES ON THE INFRASTRUCTURE PROVIDED BY SONOMA WAY AND OUR PERFORMANCE IMPROVEMENT AND IMPLEMENTATION TEAM OF EDUCATORS TO SUPPORT SUSTAINMENT. STANDARD WORK IS CONSIDERED HARD WIRED WHEN IT IS PERFORMED CONSISTENTLY AT 90% ON AUDIT OUTCOME DATA. FALLOUTS FROM 90% PERFORMANCE LASTING TWO WEEKS REQUIRE IMMEDIATE ACTION PLANS FOR RESTORATION OF PERFORMANCE. 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. 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 WAS ON THREE MOMENTS: ADMISSION, BED TIME AND DISCHARGE. DEPARTMENTS LOOKED CLOSELY AT EVERY ASPECT OF THESE EXPERIENCES, DETERMINED THE TONE THEY WANTED TO ESTABLISH AND THEN EXPLORED WHAT CAREGIVERS COULD DO AND SAY TO FOSTER A SACRED ENCOUNTER. THE IDEA WAS TO CREATE TOOLS THAT ALLOW THE CAREGIVERS 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.
PROGRAM SERVICE ACCOMPLISHMENTS, CONTINUED		OUR MISSION IS TO CONTINUALLY IMPROVE THE HEALTH AND QUALITY OF LIFE OF PEOPLE IN THE COMMUNITIES WE SERVE. OUR VISION IS THAT EVERY PATIENT WE CARE FOR RECEIVES PERFECT CARE. PERFECT CARE MEANS THAT EVERY PATIENT GETS THE HIGHEST STANDARD OF CARE, EVERY TIME. TO ACHIEVE THOSE GOALS, WE PARTICIPATE IN THE FOLLOWING QUALITY PROGRAMS: - AMERICA COLLEGE OF SURGEONS (ACS) VERIFIED LEVEL 2 TRAUMA CENTER. - AMERICAN COLLEGE OF SURGEONS (ACS) ACCREDITED CANCER PROGRAM. - THE JOINT COMMISSION ADVANCED PRIMARY STROKE CENTER. - CENTER FOR MEDICARE & MEDICAID SERVICES PARTICIPANT IN THE PARTNERSHIP FOR PATIENTS; HOSPITAL ENGAGEMENT NETWORK-A VOLUNTARY PROGRAM TO REDUCE HARM AND IMPROVE CARE IN THE U.S. -PARTICIPATION IN THE NATIONAL DATA REGISTRIES: CATH PCI & ICD; SOCIETY FOR THORACIC SURGEONS; NATIONAL TRAUMA DATA BANK. IN ADDITION WE HAVE RECEIVED THE FOLLOWING NATIONAL RECOGNITION: - LEAPFROG RECOGNITION 2012: "A" RATING FOR HOSPITAL SAFETY - BECKER'S HOSPITAL REVIEW: RANKED 3RD AMONG 50 HOSPITALS FOR LOWEST AMI READMISSION RATES 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. IN PURSUIT OF THIS OUTCOME, SANTA ROSA MEMORIAL HOSPITAL ENGAGED LOW-INCOME COMMUNITY MEMBERS IN PREVENTION ACTIVITIES THAT SUPPORT HEALTHY NUTRITION AND PHYSICAL ACTIVITY. IN FY13, THE PROMOTORES DE SALUD SERVED 760 LOW-INCOME INDIVIDUALS IN THE HOSPITAL'S COMMUNITY BENEFIT SERVICE AREA THROUGH 2,449 SERVICE ENCOUNTERS. IN ADDITION, THEY ESTABLISHED A NEW SYSTEM OF COORDINATION TO PROVIDE LOW-INCOME, SPANISH-SPEAKING PATIENTS WHO CAME TO THE EMERGENCY DEPARTMENT FOR CARDIAC-RELATED CONCERNS THE OPPORTUNITY TO PARTICIPATE IN THEIR EVIDENCE-BASED PROGRAM, "YOUR HEART, YOUR LIFE". A TOTAL OF 34 PARTICIPANTS SERVED AS VOLUNTEER TRAINERS FOLLOWING THEIR GRADUATION FROM THE PROGRAM. THE NEIGHBORHOOD CARE STAFF SUCCESSFULLY ADVOCATED, IN PARTNERSHIP WITH THE MULTI-AGENCY TEAM IMPLEMENTING THE CONTINUING COMMUNITIES OF EXCELLENCE (CX3) PROJECT, FOR THE REDUCTION OF YOUTH ACCESS TO ALCOHOL. THREE LOCAL ALCOHOL OUTLETS MOVED ALCOHOL PRODUCTS TO LESS VISIBLE AND ACCESSIBLE LOCATIONS WITHIN THEIR STORES. TWENTY-SEVEN COMMUNITY MEMBERS FROM LOW-INCOME NEIGHBORHOODS PARTICIPATED IN THIS CAMPAIGN. PROGRAM SERVICE ACCOMPLISHMENTS CONTINUED FINANCIAL ASSISTANCE PROGRAM, MEDICAID AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS WE BELIEVE THAT NO ONE SHOULD DELAY SEEKING MEDICAL CARE BECAUSE THEY LACK HEALTH INSURANCE. THAT IS WHY SANTA ROSA MEMORIAL HOSPITAL HAS A PATIENT FINANCIAL ASSISTANCE PROGRAM THAT PROVIDES FREE AND/OR DISCOUNTED SERVICES TO ELIGIBLE PATIENTS. FACTORS USED IN DETERMINING ELIGIBILITY FOR PATIENT ASSISTANCE INCLUDE INCOME LEVEL, ASSET LEVEL AND MEDICAL INDIGENCE. IN FISCAL YEAR 2013, SANTA ROSA MEMORIAL HOSPITAL PROVIDED $6,849,777 IN CHARITY CARE WITH 5,181 ENCOUNTERS COMPLETED. IN ADDITION, AS A NOT-FOR-PROFIT HOSPITAL, SANTA ROSA MEMORIAL PARTICIPATES IN THE MEDI-CAL AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS. IN FY 13, $16,498,563 IN COMMUNITY BENEFIT WAS PROVIDED TO PATIENTS WITH MEDI-CAL AND $3,287,430 WAS PROVIDED TO PERSONS WHO PARTICIPATE IN OTHER MEANS-TESTED GOVERNMENT PROGRAMS. CHILDREN'S ORAL HEALTH THE HOSPITAL'S ORAL HEALTH CLINICS HELPED BUILD COMMUNITY CAPACITY TO IMPROVE CHILDREN'S ORAL HEALTH BY TRAINING AND SUPPORTING LOCAL WIC PROVIDERS AT 5 SITES TO INCORPORATE ORAL HEALTH EDUCATION DURING PROVISION OF THEIR NUTRITIONAL SERVICES. IN ADDITION, THE CLINICS CONTINUED IMPLEMENTATION OF ITS MOMMY AND ME PROGRAM, SUSTAINING AN IMPRESSIVE RATE OF ONLY 2% DECAY AMONG PARTICIPATING INFANTS AND CHILDREN, BOTH FIRST TIME AND RETURNING PARTICIPANTS. THIS COMPARES TO A RATE OF 34% AMONG THEIR PATIENTS WHO DO NOT PARTICIPATE IN MOMMY AND ME. A TOTAL OF 1,815 CHILDREN AGES 0-5 AND THEIR PARENTS WERE SERVED THROUGH THE MOMMY AND ME PROGRAM. THE HOSPITAL'S CONTINUUM OF ORAL HEALTH SERVICES, INCLUDING THE DENTAL CLINIC, MOBILE DENTAL CLINIC AND DENTAL DISEASE PREVENTION PROGRAM, SERVED 7,734 INDIVIDUALS, OF WHOM 7,734 WERE LOW-INCOME. THE COST OF THESE SERVICES WAS $1,386,017. CHILDHOOD OBESITY PREVENTION SANTA ROSA MEMORIAL HOSPITAL CONTINUES TO ADDRESS THE ISSUES OF CHILDHOOD OBESITY WITH ITS IN-SCHOOL PROGRAM, HEALTHY FOR LIFE, AS WELL AS THROUGH ITS OWN AFTER-SCHOOL PROGRAM, CIRCLE OF SISTERS. HEALTHY FOR LIFE INCLUDES TEACHER AND STAFF TRAINING IN SPARK PHYSICAL EDUCATION CURRICULUM, WHICH BRINGS PHYSICAL ACTIVITY INTO CLASSROOM TEACHING, COMMUNITY VOLUNTEERS TO TEACH ZUMBA, NUTRITION EDUCATION AND WORKING WITH SCHOOL WELLNESS COMMITTEES TO MAKE NEEDED ENVIRONMENTAL AND POLICY CHANGES THAT SUPPORT STUDENTS' HEALTHY CHOICES. PARTICIPATING IN THE HEALTHY FOR LIFE PROGRAM WERE 7 SCHOOLS AND 2 BOYS AND GIRLS CLUBS. AS A RESULT OF THESE COMBINED EFFORTS, 20% OF THE STUDENTS WHO BEGAN THE PROGRAM CLASSIFIED AS EITHER OVERWEIGHT OR OBESE IMPROVED THEIR WEIGHT STATUS BY THE END OF THE SCHOOL YEAR, WHICH WAS DOUBLE THE TEAM'S GOAL OF A 10% IMPROVEMENT. PROVIDING THESE SERVICES AT A COST OF $279,409, THESE PROGRAMS SERVED 908 CHILDREN AND YOUTH. FOR MORE INFORMATION ABOUT SANTA ROSA MEMORIAL HOSPITAL, PLEASE VISIT WWW.STJOSEPHHEALTH.ORG FOR MORE INFORMATION ABOUT ST. JOSEPH HEALTH SYSTEM, PLEASE VISIT WWW.STJHS.ORG
SIGNIFICANT CHANGES TO GOVERNING DOCUMENTS	FORM 990, PART VI, LINE 4	THE ORGANIZATION'S BYLAWS WERE AMENDED TO INCLUDE THE POSITION OF PRESIDENT AS AN OFFICER OF THE ORGANIZATION.
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 HOSPITAL HAS A TIERED GOVERNANCE IN WHICH THE CORPORATE MEMBERS RESERVE THE RIGHT TO APPOINT TRUSTEES TO THE SANTA ROSA BOARD. ALL TRUSTEE APPOINTMENTS THAT HAVE COME FROM 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 EXPENDITURES 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 WAS PREPARED BY THE FINANCE DEPARTMENT BASED ON INFORMATION RECEIVED FROM VARIOUS DEPARTMENTS OF THE ORGANIZATION AS APPLICABLE. THE FORM 990 WAS THEN REVIEWED BY AN OFFICER OF THE ORGANIZATION. A COPY OF THE FORM 990 FILING WAS DISTRIBUTED TO ALL VOTING MEMBERS OF THE BOARD FOR THE MARCH, 2014 MEETING. DURING THE FINANCE COMMITTEE MEETING, MANAGEMENT PRESENTED AND DISCUSSED CERTAIN DISCLOSURES AND INFORMATION INCLUDED IN THE FORM 990. THE FINANCE COMMITTEE CHAIR THEN PROVIDED A SUMMARY AT THE FULL BOARD MEETING.
CONFLICT OF INTEREST POLICY	FORM 990, PART VI, LINE 12C	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 THE 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.
PROCESS USED TO DETERMINE COMPENSATION	FORM 990, PART VI, LINES 15A & 15B	THE ORGANIZATION'S PRESIDENT IS PAID BY ITS TAX EXEMPT PARENT, ST. JOSEPH HEALTH SYSTEM, AND IS DISCLOSED AS A PERSON PAID BY A RELATED ORGANIZATION. 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 HEALTH CARE DELIVERY SYSTEMS. SJHS PROVIDES COMPENSATION TO ITS SENIOR EXECUTIVES 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 AT LEAST 3 TIMES A YEAR AND MAKE ALL CRITICAL DECISIONS 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 PERFORMED ITS LAST COMPENSATION REVIEW FOR ASSISTANT VICE PRESIDENTS, VICE PRESIDENTS, SENIOR VICE PRESIDENTS, EXECUTIVE VICE PRESIDENTS, AND THE CHIEF EXECUTIVE OFFICER IN JUNE 2013.
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. SANTA ROSA MEMORIAL HOSPITAL'S AUDITED FINANCIAL STATEMENTS ARE ATTACHED TO FORM 990.
OTHER FEES EXCEEDING 10%	FORM 990, PART IX, LINE 11G	PHYSICIAN FEES $13,486,990 REGISTRY/TEMP HELP 14,808,982 COLLECTION AGENCIES 2,621,048 SOFTWARE MAINTENANCE 3,881,123 REPAIRS/MAINTENANCE 1,107,650 CAPITATED PURCHASED SERVICES 1,186,323 MEDICAL PURCHASED SERVICES 2,511,641 OTHER PURCHASED SERVICES 10,663,947 --------------- TOTAL 50,267,704
OTHER CHANGES IN NET ASSETS	FORM 990, PART XI, LINE 9	EQUITY TRANSFER ($10,329,357) CONTRIBUTION OF SERVICES RECEIVED 540 ------------- TOTAL ($10,328,817)

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

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" to Form 990, Part IV, line 33.)

(a) Name, address, and EIN (if applicable) 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" to 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 entity?
(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	Yes	No
(1) COVENANT HEALTH NETWORK INC 3345 MICHELSON DR STE 100 IRVINE,CA92612 46-1259908	HEALTHCARE	CA	501(C)(3)	11, III	SJHS	Yes
(2) COVENANT HEALTH PARTNERS 3615 19TH STREET LUBBOCK,TX79410 61-1573313	HEALTHCARE	TX	501(C)(3)	11,I	CHS	Yes
(3) COVENANT HEALTH SYSTEM 3615 19TH STREET LUBBOCK,TX79410 75-2765566	HEALTHCARE	TX	501(C)(3)	3	SJHS	Yes
(4) COVENANT HEALTH SYSTEM FOUNDATION 4000 24TH STREET LUBBOCK,TX79410 75-2897026	HEALTHCARE	TX	501(C)(3)	7	CHS	Yes
(5) COVENANT MEDICAL GROUP 3420 22ND PLACE LUBBOCK,TX79410 75-2743883	HEALTHCARE	TX	501(C)(3)	3	CHS	Yes
(6) HOAG CHARITY SPORTS 3920 BIRCH ST STE 105 NEWPORT BEACH,CA92660 45-2982422	SUPPORT	CA	501(C)(3)	7	HHF	Yes
(7) HOAG HOSPITAL FOUNDATION 1 HOAG DR BOX 6100 NEWPORT BEACH,CA92663 95-3222343	FUNDRAISING	CA	501(C)(3)	7	HMHP	Yes
(8) HOAG MEMORIAL HOSPITAL PRESBYTERIAN 1 HOAG DR BOX 6100 NEWPORT BEACH,CA92663 95-1643327	HEALTHCARE	CA	501(C)(3)	3	SJHS	Yes
(9) HOME CARE PARTNERS 1165 MONTGOMERY DR SANTA ROSA,CA95405 68-0318656	INACTIVE	CA	501(C)(3)	3	SRMH	Yes
(10) HOSPICE OF LUBBOCK 1102 SLIDE ROAD LUBBOCK,TX79414 75-2133781	HEALTHCARE	TX	501(C)(3)	9	CHS	Yes
(11) LUBBOCK METHODIST HOSPITAL FOUNDATION 3615 19TH STREET LUBBOCK,TX79410 75-2220963	HEALTHCARE	TX	501(C)(3)	7	CHS	Yes
(12) METHODIST CHILDREN'S HOSPITAL 3610 21ST STREET LUBBOCK,TX79410 75-2428911	HEALTHCARE	TX	501(C)(3)	3	CHS	Yes
(13) METHODIST HOSPITAL LEVELLAND 1900 COLLEGE AVENUE LEVELLAND,TX79336 75-2246348	HEALTHCARE	TX	501(C)(3)	3	CHS	Yes
(14) METHODIST HOSPITAL PLAINVIEW 2601 DIMMITT ROAD PLAINVIEW,TX79072 75-2426010	HEALTHCARE	TX	501(C)(3)	3	CHS	Yes
(15) MISSION HOSPITAL REGIONAL MEDICAL CENTER 27700 MEDICAL CENTER ROAD MISSION VIEJO,CA92691 95-1643360	HEALTHCARE	CA	501(C)(3)	3	SJHS	Yes
(16) QUEEN OF THE VALLEY MEDICAL CENTER 1000 TRANCAS STREET NAPA,CA94558 94-1243669	HEALTHCARE	CA	501(C)(3)	3	SJHS	Yes
(17) REDWOOD MEMORIAL FOUNDATION 3300 RENNER DRIVE FORTUNA,CA95540 94-2779313	FOUNDATION	CA	501(C)(3)	7	RMH	Yes
(18) REDWOOD MEMORIAL HOSPITAL 3300 RENNER DRIVE FORTUNA,CA95540 94-1384665	HEALTHCARE	CA	501(C)(3)	3	SJHS	Yes
(19) SISTERS OF ST JOSEPH OF ORANGE 480 S BATAVIA ORANGE,CA92868 95-1643383	RELIGIOUS ORG	CA	501(C)(3)	1	NA		No
(20) SRM ALLIANCE HOSPITAL SERVICES 400 NORTH MCDOWELL BLVD PETALUMA,CA94954 68-0395200	HEALTHCARE	CA	501(C)(3)	3	SRMH	Yes
(21) ST JOSEPH HEALTH MINISTRY 3345 MICHELSON DR STE 100 IRVINE,CA92612 27-1666576	RELIGIOUS ORG	CA	501(C)(3)	1	SSJO		No
(22) ST JOSEPH HEALTH SYSTEM 3345 MICHELSON DR STE 100 IRVINE,CA92612 95-3589356	HEALTHCARE	CA	501(C)(3)	11, I	SJHM		No
(23) ST JOSEPH HEALTH SYSTEM FOUNDATION 3345 MICHELSON DR STE 100 IRVINE,CA92612 33-0143024	FOUNDATION	CA	501(C)(3)	7	SJHS	Yes
(24) ST JOSEPH HOME CARE NETWORK 170 PROFESSIONAL CENTER DR B ROHNERT PARK,CA94928 68-0331084	HEALTHCARE	CA	501(C)(3)	9	SJHS	Yes
(25) ST JOSEPH HOSPITAL OF EUREKA 2700 DOLBEER STREET EUREKA,CA95501 94-1156596	HEALTHCARE	CA	501(C)(3)	3	SJHS	Yes
(26) ST JOSEPH HOSPITAL OF ORANGE 1100 WEST STEWART DRIVE ORANGE,CA92868 95-1643359	HEALTHCARE	CA	501(C)(3)	3	SJHS	Yes
(27) ST JUDE HOSPITAL YORBA LINDA 500 S MAIN STREET STE 1000 ORANGE,CA92868 33-0185031	HEALTHCARE	CA	501(C)(3)	3	SJHS	Yes
(28) ST JUDE HOSPITAL INC 101 EAST VALENCIA MESA DRIVE FULLERTON,CA92635 95-1643325	HEALTHCARE	CA	501(C)(3)	3	SJHS	Yes
(29) ST MARY MEDICAL CENTER 18300 HIGHWAY 18 APPLE VALLEY,CA92307 95-1914489	HEALTHCARE	CA	501(C)(3)	3	SJHS	Yes
(30) ST MARY OF THE PLAINS HOSPITAL FDN 4000 24TH STREET LUBBOCK,TX79410 75-1653181	HEALTHCARE	TX	501(C)(3)	7	CHS	Yes
(31) TALLER SAN JOSE 801 NORTH BROADWAY SANTA ANA,CA92701 59-3816355	WORKFORCE DEV	CA	501(C)(3)	2	SSJO	Yes
(32) SANTA ROSA MEMORIAL HOSPITAL AUXILIARY PO BOX 522 SANTA ROSA,CA95402 94-6104507	SUPPORT	CA	501(C)(3)	11,III	SRMH		No

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2012

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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 VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) ST JOSEPH HLTH SYS HOME HLTH	HOME HEALTH	CA	NA	N/A								0 %
(2) ST JOSEPH HLTH SYS HOME CARE	HOME HEALTH	CA	NA	N/A								0 %
(3) METHODIST DIAGNOSTIC IMAGING	HEALTHCARE SVCS	TX	NA	N/A								0 %
(4) SHA LLC	HEALTHCARE SVCS	TX	NA	N/A								0 %
(5) LUBBOCK SURGERY CENTER LTD	HEALTHCARE SVCS	TX	NA	N/A								0 %
(6) COVENANT LONG-TERM CARE LP	HEALTHCARE SVCS	TX	NA	N/A								0 %
(7) HERITAGE INVESTMENT GROUP	INVESTMENT	CA	NA	N/A								0 %
(8) MISSION AMBULATORY SURGICENTER	HEALTHCARE SVCS	CA	NA	N/A								0 %
(9) COMPREHENSIVE IMAGING PARTNERS	HEALTHCARE SVCS	CA	NA	N/A								0 %
(10) ST JOSEPH PHYSICIAN VENTURES	REAL ESTATE	CA	NA	N/A								0 %
(11) NEWPORT IMAGING CENTER	HEALTHCARE SVCS	CA	NA	N/A								0 %
(12) HOAG ORTHOPEDIC INSTITUTE	HEALTHCARE	CA	NA	N/A								0 %
(13) MAIN ST SPECIALTY SURGERY CNTR	HEALTHCARE SVCS	CA	NA	N/A								0 %
(14) ORTHOPEDIC SURGERY CNTR OF OC	HEALTHCARE SVCS	CA	NA	N/A								0 %
(15) ADVANCED SURGERY INSTITUTE LLC	HEALTHCARE SVCS	CA	SRMH	RELATED	-214,737	1,085,966		No	0		No	51.000 %

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to 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	(i) Section 512(b)(13) controlled entity?
(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	Yes	No
(1) ST JOSEPH PROF SVCS ENTERPRISES INC 3345 MICHELSON DR STE 100 IRVINE,CA92612 33-0155323	HEALTHCARE SVCS	CA	NA	C CORP
(2) AMERICAN UNITY GROUP LTD 58 PAR-LA-VILLE HAMILTON,HM HX BD	CAPTIVE INSURANCE	BD	NA	C CORP
(3) ALLIANCE PHYSICIAN SERVICES	INACTIVE	CA	NA	C CORP
(4) MISSION VIEJO MEDICAL VENTURES 27800 MEDICAL CENTER RD 354 MISSION VIEJO,CA92691 33-0212905	HEALTHCARE SVCS	CA	NA	C CORP
(5) MISSION MEDICAL CENTER ASSOCIATION 27800 MEDICAL CENTER RD 354 MISSION VIEJO,CA92691 33-0201044	HEALTHCARE SVCS	CA	NA	C CORP
(6) ST JOSEPH YORBA PARK	INACTIVE	CA	NA	C CORP
(7) LUBBOCK METHODIST HOSP SVCS PO BOX 1201 LUBBOCK,TX79410 75-2118585	HEALTHCARE SVCS	TX	NA	C CORP
(8) LUBBOCK METHODIST HOSP PRACTICE MGMT 2107 OXFORD STREET SUITE 300 LUBBOCK,TX79410 75-2578995	INACTIVE	TX	NA	C CORP
(9) ST JOSEPH HEALTH SOURCE INC 3345 MICHELSON DR STE 100 IRVINE,CA92612 46-1900168	HEALTHCARE SVCS	CA	NA	C CORP
(10) HOAG MANAGEMENT SERVICES INC 1 HOAG DR BOX 6100 NEWPORT BEACH,CA92658 33-0731587	HEALTHCARE SVCS	CA	NA	C CORP
(11) COASTAL MANAGEMENT SERVICES ORG 1 HOAG DR BOX 6100 NEWPORT BEACH,CA92658 33-0676831	HEALTHCARE SVCS	CA	NA	C CORP
(12) DATU HEALTH INC 16150 MAIN CIRCLE DR STE 250 CHESTERFIELD,MO63017 46-3070062	IT SVCS	MO	NA	C CORP
(13) HOAG MEDICAL FOUNDATION 1 HOAG DR BOX 6100 NEWPORT BEACH,CA92663 45-3583707	HEALTHCARE SVCS	CA	NA	C CORP

Schedule R (Form 990) 2012

Page 3

Part V

Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

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 or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .

m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .

Yes

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .

o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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-s)	(c) Amount involved	(d) Method of determining amount involved
(1) ST JOSEPH HEALTH SYSTEM FOUNDATION	B	2,101,700	ACCRUAL
(2) ST JOSEPH HEALTH SYSTEM FOUNDATION	C	1,469,206	ACCRUAL
(3) SRM ALLIANCE HOSPITAL SERVICES	O	158,914	ACCRUAL
(4) ST JUDE HOSPITAL YORBA LINDA	R	10,329,357	ACCRUAL
(5) SRM ALLIANCE HOSPITAL SERVICES	Q	18,423,500	ACCRUAL
(6) QUEEN OF THE VALLEY MEDICAL CENTER	O	313,519	ACCRUAL
(7) ST JOSEPH HOSPITAL - EUREKA	O	277,539	ACCRUAL
(8) ST JUDE HOSPITAL YORBA LINDA	B	7,551,830	ACCRUAL
(9) ST JUDE HOSPITAL YORBA LINDA	J	561,884	ACCRUAL
(10) ST JUDE HOSPITAL YORBA LINDA	Q	214,333	ACCRUAL

Schedule R (Form 990) 2012

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2012

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: 3345 MICHELSON DRIVE, STE. 100 IRVINE, CA 92612 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 ST. JOSEPH PHYSICIAN VENTURES I, LLC EIN: 45-4521884 ADDRESS: 1100 WEST STEWART DRIVE ORANGE, CA 92868 NEWPORT IMAGING CENTER EIN: 33-0191776 ADDRESS: 360 SAN MIGUEL, NEWPORT BEACH, CA 92660 HOAG ORTHOPEDIC INSTITUTE EIN: 61-1588294 ADDRESS: 1 HOAG DRIVE, BOX 6100, NEWPORT BEACH, CA 92658 MAIN ST SPECIALTY SURGERY CENTER EIN: 95-4813223 ADDRESS: 280 MAIN STREET, ST 100, ORANGE, CA 92868 ORTHOPEDIC SURGERY CENTER OF OC, LLC EIN: 33-0841806 ADDRESS: 22 CORPORATE PLAZA, NEWPORT BEACH, CA 92660 ADVANCED SURGERY INSTITUTE, LLC EIN: 26-2299255 ADDRESS: 1739 4TH STREET, SANTA ROSA, CA 95404

Additional Data

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Software Version:

1	Briefly describe the organization’s mission or most significant activities: WE ARE 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 THE COMMUNITIES WE SERVE.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	15
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	11
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	1,910
6	Total number of volunteers (estimate if necessary) .............	6	200
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	203,983
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	118,067

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	3,888,506	6,510,140
9	Program service revenue (Part VIII, line 2g) .........	366,313,772	361,512,764
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	3,835,741	9,919,468
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	-100,584	-37,446
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	373,937,435	377,904,926
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	3,380,800	2,239,415
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)	174,240,651	175,557,881
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 1,094,852
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	155,929,070	174,183,512
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	333,550,521	351,980,808
19	Revenue less expenses. Subtract line 18 from line 12.......	40,386,914	25,924,118
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	394,247,938	407,407,624
21	Total liabilities (Part X, line 26).............	172,790,401	171,269,666
22	Net assets or fund balances. Subtract line 21 from line 20.....	221,457,537	236,137,958

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 328,589,067 including grants of $ 2,239,415 ) (Revenue $ 361,512,764 )
	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 expenses328,589,067

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	4,346,279	2,376,872	492,648

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c		118,597
d	Related organizations...1d		1,469,206
e	Government grants (contributions)1e		191,710

f	All other contributions, gifts, grants, and similar amounts not included above1f		4,730,627

g	Noncash contributions included in lines 1a-1f:$		7,192
h	Total. Add lines 1a-1f.......			6,510,140
			Business Code
2a	NET PATIENT REVENUE		622110	356,572,036	356,572,036	0	0
b	MEDICAL OFFICE BUILDING		531120	2,253,831	2,253,831	0	0
c	CAFETERIA		722310	926,625	926,625	0	0
d	CAPITATION REVENUE		525120	938,223	938,223		0
e	PATHOLOGY AND LABORATORY		621500	203,983		203,983	0
f	All other program service revenue .			618,066	618,066		0
g	Total. Add lines 2a–2f........			361,512,764
3	Investment income (including dividends, interest, and other similar amounts).......			9,910,968			9,910,968
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties...........			0
		(i) Real	(ii) Personal
6a	Gross rents
b	Less: rental expenses
c	Rental income or (loss)	0	0
d	Net rental income or (loss).......			0
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	0	8,500
b	Less: cost or other basis and sales expenses	0	0
c	Gain or (loss)	0	8,500
d	Net gain or (loss)..........			8,500			8,500
8a	Gross income from fundraising events (not including $ 118,597 of contributions reported on line 1c). See Part IV, line 18 ..
	a		42,390
b	Less: direct expenses ...b		79,836
c	Net income or (loss) from fundraising events..			-37,446			-37,446
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a
b
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			0
12	Total revenue. See Instructions......			377,904,926	361,308,781	203,983	9,882,022


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			7,403	1	7,339
2	Savings and temporary cash investments .........			3,484,589	2	6,226,360
3	Pledges and grants receivable, net ...........			0	3	0
4	Accounts receivable, net .............			53,270,052	4	45,308,579
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net .............			0	7	0
8	Inventories for sale or use ..............			4,007,957	8	4,248,556
9	Prepaid expenses and deferred charges ..........			3,852,606	9	3,498,678
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	375,000,135
b	Less: accumulated depreciation .....	10b	196,113,395	168,205,028	10c	178,886,740
11	Investments—publicly traded securities ..........			114,886,958	11	123,068,857
12	Investments—other securities. See Part IV, line 11 .....			144,835	12	1,081,430
13	Investments—program-related. See Part IV, line 11 .....			0	13	0
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			46,388,510	15	45,081,085
16	Total assets. Add lines 1 through 15 (must equal line 34)......			394,247,938	16	407,407,624
17	Accounts payable and accrued expenses .........			29,254,559	17	30,720,277
18	Grants payable .................			0	18	0
19	Deferred revenue ................			0	19	0
20	Tax-exempt bond liabilities .............			0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........			0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..			0	23	0
24	Unsecured notes and loans payable to unrelated third parties ....			0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			143,535,842	25	140,549,389
26	Total liabilities. Add lines 17 through 25.........			172,790,401	26	171,269,666
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			217,307,638	27	231,677,097
28	Temporarily restricted net assets ...........			3,074,732	28	3,385,694
29	Permanently restricted net assets ...........			1,075,167	29	1,075,167
	Organizations that do not follow SFAS 117 (ASC 958), check here 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 ...........			221,457,537	33	236,137,958
34	Total liabilities and net assets/fund balances ........			394,247,938	34	407,407,624