2019-06-13T09:42:53-05:00 2019-01-31 410746749 CLIFTONLARSONALLEN LLP 370 INTERLOCKEN BLVD SUITE 500 BROOMFIELD CO 80021 990 2018-02-01 840743432 CLINICA CAMPESINA FAMILY HEALTH SERVICES CLIN 3036504460 1735 SOUTH PUBLIC ROAD LAFAYETTE CO 80026 SIMON SMITH PRESIDENT & CEO 3036504460 2019-06-08 1 KURT BENNION P01469618 3034668822 2019-06-08 67.137.57.251 2019-06-08 08:42:18 PD P 69F6FFF9F679693B87929AA2CD1E4BEAEDA23E9B 5FDBAA4BB10DC37B886353302A6A7E613F599072 2018 2019-02-21 02:37:17Z CLINICA FAMILY HEALTH SIMON SMITH 1735 SOUTH PUBLIC ROAD LAFAYETTE CO 80026 59768208 0 X WWW.CLINICA.ORG X 1977 CO PROVIDE HIGH-QUALITY, CULTURALLY APPROPRIATE CARE TO LOW-INCOME AND OTHER UNDERSERVED PEOPLE. 13 13 737 15 0 26781 19150082 18761551 36804082 38080411 616416 127734 213685 1269471 56784265 58239167 0 476187 0 0 38532836 41432234 0 0 623129 14854933 16407733 53387769 58316154 3396496 -76987 64383468 45391786 31942146 13098124 32441322 32293662 X TO BE THE MEDICAL, BEHAVIORAL HEALTH AND DENTAL CARE PROVIDER OF CHOICE FOR LOW-INCOME AND OTHER UNDERSERVED PEOPLE IN SOUTH BOULDER, BROOMFIELD AND WEST ADAMS COUNTIES. OUR CARE SHALL BE CULTURALLY APPROPRIATE AND PREVENTION FOCUSED. OUR VISION IS TO ASSURE THAT EVERY LOW-INCOME AND OTHER UNDERSERVED PERSON IN THESE AREAS HAVE ACCESS TO HIGH-QUALITY, PREVENTATIVE MEDICAL, BEHAVIORAL HEALTH AND DENTAL CARE. 0 0 46083888 476187 38080411 FOR THE FISCAL YEAR ENDED JANUARY 31, 2019, CLINICA PROVIDED 182,863 MEDICAL VISITS, 34,033 DENTAL VISITS, 25,502 BEHAVIORAL HEALTH VISITS, 2,767 REGISTERED DIETICIAN VISITS, AND 29,010 CASE MANAGEMENT VISITS. 46083888 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 1 1 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 0 0 1 25 0 737 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 13 13 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 CO X GRETCHEN CROKER 3036504460 1735 SOUTH PUBLIC ROAD LAFAYETTE CO 80026 W DOUGLAS JONES CHAIR 0.10 0.00 X 0 0 0 LOIS LACROIX VICE CHAIR 0.10 0.00 X 0 0 0 MARYANN KELLER SECRETARY (THROUGH APRIL 2018) 0.10 0.00 X 0 0 0 CHERLYN MARRIOTT DIRECTOR & SECRETARY 0.10 0.00 X 0 0 0 BEN GOLDSTEIN TREASURER 0.10 0.10 X 0 0 0 CHRISTINA ARGUELLO DIRECTOR 0.10 0.00 X 0 0 0 INEZ BUGGS DIRECTOR 0.10 0.00 X 0 0 0 HEATHER ELKINS DIRECTOR 0.10 0.10 X 0 0 0 EDSON HERNANDEZ DIRECTOR 0.10 0.00 X 0 0 0 YULIA HERNANDEZ DIRECTOR 0.10 0.00 X 0 0 0 MAYRA MARTINEZ DIRECTOR 0.10 0.00 X 0 0 0 HEIDY ORDONEZ DIRECTOR 0.10 0.00 X 0 0 0 ELLA PADILLA DIRECTOR 0.10 0.00 X 0 0 0 TOM RAZO DIRECTOR (THROUGH MAY 2018) 0.10 0.10 X 0 0 0 DONOVAN TULLOCH DIRECTOR 0.10 0.00 X 0 0 0 SIMON SMITH PRESIDENT & CEO 39.00 1.00 X 227768 0 42679 ELIZABETH DAVID CFO (THROUGH AUGUST 2018) 39.00 1.00 X 122266 0 10223 KEN STEWART INTERIM CFO 12.00 1.00 X 0 0 0 KAREN FUNK VP OF CLINICAL SERVICES 40.00 0.00 X 246636 0 51882 JUSTIN WHEELER VP OF CLINICAL SERVICES 40.00 0.00 X 247777 0 34016 AN NGUYEN VP OF DENTAL SERVICES 40.00 0.00 X 197075 0 29385 ALEX BULKACZ PHYSICIAN 40.00 0.00 X 232245 0 41102 BREANNA TOMLIN PHYSICIAN 40.00 0.00 X 231053 0 16389 PHILIP KEPPELER PHYSICIAN 38.00 0.00 X 252247 0 44830 MICHELLE DRURY PHYSICIAN 40.00 0.00 X 230171 0 45793 ANGELA FRYER PHYSICIAN 40.00 0.00 X 239377 0 39862 2226615 0 356161 60 0 1 0 BRINKMAN CONTRUCTORS 16650 CHESTERFIELD GROVE RD STE 10 CHESTERFIELD MO 63005 GENERAL CONTRACTOR 3724737 OHIO SHARED INFORMATION SERVICES 8790 GOVERNORS HILL DR 202 CINCINNATI OH 45249 SOFTWARE LICENSE MAINTENANCE 633264 NETGAIN 720 W SAINT GERMAIN ST SAINT CLOUD MN 56301 SOFTWARE LICENSE MAINTENANCE 494916 FAUROT CONSTRUCTION INC 5311 WESTERN AVE STE 110 BOULDER CO 80301 GENERAL CONTRACTOR 288998 MOJOS CLEANING SERVICES 8330 E 124TH PL THORNTON CO 80602 JANITORIAL SERVICES 264463 17 16714939 2046612 2135540 18761551 PATIENT SERVICE REVENUE 621110 36340008 36340008 PHARMACY REVENUE 621110 1740403 1740403 38080411 775 775 1656000 1529041 126959 126959 126959 OTHER REVENUE 900099 1269471 1269471 1269471 58239167 38080411 0 1397205 476187 476187 1193609 237703 955906 33995953 28101120 5631441 263392 540890 436453 100354 4083 3142181 2637392 479805 24984 2559601 2065385 474896 19320 54919 9763 29848 15308 84292 14985 45812 23495 2514345 1904184 547601 62560 218497 33922 141368 43207 1205104 792863 345640 66601 1521011 156881 1348319 15811 2397908 1636331 760705 872 148755 88629 59365 761 79158 47163 31590 405 195450 111857 83593 1352369 1323882 28487 147230 72596 60426 14208 UBI TAXES 5624 5624 MEDICAL SUPPLIES 5580611 5580554 57 EDUCATION 332993 200071 130210 2712 EQUIPMENT RENTAL & REPA 178414 98161 79697 556 391053 57806 268393 64854 58316154 46083888 11609137 623129 6302761 9230393 505595 153185 574457 1591480 4636691 3531473 12469400 12469400 49924 43313 279807 424089 28489153 10651628 17436657 17837525 22128176 110928 64383468 45391786 4325740 5666030 233141 287792 6786477 6788596 20596788 355706 31942146 13098124 X 32126983 31829565 314339 464097 32441322 32293662 64383468 45391786 X -76987 -70673 X 0 1 X 1 1 1 X 13349799 14888186 17522367 19150082 18761551 83671985 13349799 14888186 17522367 19150082 18761551 83671985 83671985 1177 1095 1064 130 775 4241 334604 303088 468732 292881 1269471 2668776 86345002 162136884 0.96900 0.98010 X SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: OTHER INCOME 0 13527 13527 57679498 57693025 1000000 250000 0 0 1000000 1000000 1000000 1000000 4000000 6000000 17441 14038 13228 13527 58234 250000 250000 250000 250000 1000000 1500000 3835786 3835786 15386899 5125471 10261428 9263157 5526157 3737000 3311 3311 17837525 DUE TO RELATED ORGANIZATION 304438 INTEREST RATE SWAP AGREEMENT 51268 355706 X PART X, LINE 2: THE ORGANIZATION QUALIFIES AS A TAX-EXEMPT CORPORATION DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE ORGANIZATION IS NOT A PRIVATE FOUNDATION, AND CONTRIBUTIONS TO THE ORGANIZATION QUALIFY AS CHARITABLE TAX DEDUCTIONS BY THE CONTRIBUTOR. THE ORGANIZATION FOLLOWS GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX PROVISIONS. THE APPLICATION OF THIS STANDARD HAS NO EFFECT ON THE ORGANIZATION'S FINANCIAL STATEMENTS. THE ORGANIZATION IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS OR AWARE OF ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES. MIDDLE EAST & NORTH AFRICA 0 1 PROGRAM SERVICES PROVIDER SCHEDULING 31708 0 1 0 0 0 1 31708 0 31708 0 0 0 0 0 0 1 PORTERCARE ADVENTIST HEALTH SYSTEM 98100 E MINERAL CIRCLE CENTENNIAL CO 80112 840438224 501(C)(3) 340982 TO PROVIDE FINANCIAL ASSISTANCE TO PATIENTS OF AVISTA HOSPITAL. CLINICA HOLDING COMPANY 1735 S PUBLIC ROAD LAFAYETTE CO 80026 823052286 501(C)(3) 135205 EQUITY TRANSFER 2 0 PART I, LINE 2: GRANTS TO THE RELATED ORGANIZATION ARE MONITORED THROUGH COMMON MANAGEMENT AND BOARD OVERSIGHT BETWEEN THE TWO ORGANIZATIONS. GRANTS TO OTHER ORGANIZATIONS ARE MONITORED THROUGH MONTHLY FINANCIAL AND OPERATING REPORTS. ADDITIONAL REVIEW PROCEDURES ARE DETERMINED AS NEEDED. X X X X X 0 0 0 0 0 0 0 0 0 SIMON SMITH PRESIDENT & CEO 207768 0 20000 0 0 0 23556 0 19123 0 270447 0 0 0 KAREN FUNK VP OF CLINICAL SERVICES 246636 0 0 0 0 0 30264 0 21618 0 298518 0 0 0 JUSTIN WHEELER VP OF CLINICAL SERVICES 247777 0 0 0 0 0 24106 0 9910 0 281793 0 0 0 AN NGUYEN VP OF DENTAL SERVICES 197075 0 0 0 0 0 21561 0 7824 0 226460 0 0 0 ALEX BULKACZ PHYSICIAN 232245 0 0 0 0 0 26477 0 14625 0 273347 0 0 0 BREANNA TOMLIN PHYSICIAN 231053 0 0 0 0 0 6500 0 9889 0 247442 0 0 0 PHILIP KEPPELER PHYSICIAN 252247 0 0 0 0 0 22895 0 21935 0 297077 0 0 0 MICHELLE DRURY PHYSICIAN 230171 0 0 0 0 0 24042 0 21751 0 275964 0 0 0 ANGELA FRYER PHYSICIAN 239377 0 0 0 0 0 25384 0 14478 0 279239 0 0 0 X 1 2135540 FMV 0 0 1 0 FORM 990, PART VI, SECTION A, LINE 3 AS OF JULY, 2018, COMMUNITY LINK CONSULTING PROVIDES CONTRACTED CFO SERVICES. FORM 990, PART VI, SECTION B, LINE 11B THE BOARD OF DIRECTORS REVIEWED THE FORM 990 PRIOR TO IT BEING FILED WITH THE IRS. THE CFO REVIEWED THE FORM 990 AND PRESENTED IT TO THE BOARD'S FINANCE COMMITTEE BEFORE IT WAS PRESENTED TO THE FULL BOARD. THE REVIEW INCLUDED A RECONCILIATION OF THE FORM 990 INFORMATION TO THE DATA IN THE AUDITED FINANCIAL STATEMENTS AND A COMPARISON OF THE DATA TO PRIOR YEAR FINANCIAL STATEMENTS TO CONFIRM REASONABLENESS. FORM 990, PART VI, SECTION B, LINE 12C NEW EMPLOYEES AND BOARD MEMBERS RECEIVE TRAINING AND ARE ASKED TO SIGN A CONFLICT OF INTEREST DISCLOSURE FORM ON THE FIRST DAY OF EMPLOYMENT OR SERVICE, AND THEN ANNUALLY. ALL EMPLOYEES AND BOARD MEMBERS ARE INFORMED OF THEIR OBLIGATION TO IMMEDIATELY REPORT ANY CONFLICTS WHEN THEY OCCUR OUTSIDE OF THE ANNUAL PROCESS. THE COMPLIANCE OFFICER, CFO, AND/OR CEO REVIEWS ANY CONFLICTS IDENTIFIED AND A WRITTEN MANAGEMENT PLAN IS DEVELOPED, SIGNED BY THE EMPLOYEE AND HIS/HER MANAGER, AND REMAINS A PART OF THE EMPLOYEE'S HR FILE. ANY VIOLATIONS OF THE WRITTEN MANAGEMENT PLAN WILL RESULT IN DISCIPLINARY ACTION UP TO AND INCLUDING TERMINATION. NO EMPLOYEE, OFFICER, DIRECTOR OR AGENT OF THE ORGANIZATION CAN PARTICIPATE IN THE SELECTION OF A CONTRACT, INCLUDING PURCHASE ORDERS, OR IN THE ADMINISTRATION OF A CONTRACT, IF A REAL OR APPARENT CONFLICT OF INTEREST EXISTS. ALL SUPPLIERS COMPLETE A SUPPLIER CONFLICT OF INTEREST DISCLOSURE. EXCEPTIONS MAY BE APPROVED BY THE CEO OR CFO. THE EXCEPTION IS DOCUMENTED AND APPROPRIATELY DISCLOSED. MONITORING OF THE CONFLICTS OF INTEREST POLICY IS A STANDARD BOARD OF DIRECTORS MEETING AGENDA ITEM. BOARD MEMBERS IDENTIFY POTENTIAL CONFLICTS OF INTEREST BEFORE THE BOARD MEETING COMMENCES SO THAT THEY CAN BE ADDED TO THE AGENDA. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD OF DIRECTORS' COMPENSATION COMMITTEE DETERMINES THE COMPENSATION OF THE CEO USING AN ANALYSIS OF MARKET SALARIES COMPILED BY THE VICE PRESIDENT, HUMAN RESOURCES, USING INFORMATION AVAILABLE FROM MOUNTAIN STATES EMPLOYERS COUNCIL, THE NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS AND THE COLORADO COMMUNITY HEALTH NETWORK. THE DISCUSSION/ DELIBERATION IS DOCUMENTED IN THE BOARD'S COMPENSATION COMMITTEE NOTES AND NOTED IN THE BOARD'S MEETING MINUTES. A PAYROLL NOTE DOCUMENTS THE FINAL DECISION AND IS APPROVED BY THE MEMBERS OF THE BOARD'S COMPENSATION COMMITTEE. THE COMPENSATION OF OTHER OFFICERS IS EVALUATED USING AN ANALYSIS OF MARKET SALARIES COMPILED BY THE VICE PRESIDENT, HUMAN RESOURCES, USING INFORMATION AVAILABLE FROM MOUNTAIN STATES EMPLOYERS COUNCIL, THE NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS AND THE COLORADO COMMUNITY HEALTH NETWORK. THE CEO DETERMINES ANY COMPENSATION ADJUSTMENTS AND HIS DECISION IS DOCUMENTED IN A PAYROLL NOTE APPROVED BY THE CEO. IN ADDITION, THE ORGANIZATION PERIODICALLY USES AN EXTERNAL COMPENSATION CONSULTANT TO DETERMINE COMPENSATION OF THE CEO, OFFICERS, KEY EMPLOYEES, AND CERTAIN OTHER EMPLOYEES OF THE ORGANIZATION. THE CONSULTANT REVIEWS THE ORGANIZATION'S STRATEGIC OBJECTIVES, RELEVANT POLICIES AND PROCEDURES AND CURRENT COMPENSATION DOCUMENTATION. THE CONSULTANT USES SURVEYS AND OTHER INFORMATION TO DEVELOP UP-TO-DATE MARKET INFORMATION BASED ON THE DETAILED JOB DESCRIPTIONS PROVIDED BY THE ORGANIZATION. THE CONSULTANT WORKS WITH LEADERSHIP TO DEVELOP BASE COMPENSATION SALARY RANGES INCLUDING COST ANALYSIS FOR PROPOSED PAY ADJUSTMENTS TO THOSE SALARIES FALLING OUTSIDE THE RANGE. THE LAST COMPENSATION ANALYSIS WAS PERFORMED IN 2018. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENT -70,673. CLINICA HOLDING COMPANY 1735 SOUTH PUBLIC ROAD LAFAYETTE CO 80026 823052286 PROPERTY HOLDING CO 501(C)(3) LINE 12A, I CLINICA CAMPESINA FAMILY HEALTH SERVICES 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 1 1 1 1 CLINICA HOLDING COMPANY B 135025 CASH CLINICA HOLDING COMPANY K 350000 FAIR MARKET VALUE