2022-06-15T16:01:08-05:00 2022-01-31 410746749 CLIFTONLARSONALLEN LLP 8390 EAST CRESCENT PARKWAY SUITE 300 GREENWOOD VILLAGE CO 80111 990 2021-02-01 840743432 CLINICA CAMPESINA FAMILY HEALTH SERVICES CLIN 3036504460 1735 SOUTH PUBLIC ROAD LAFAYETTE CO 80026 SIMON SMITH PRESIDENT & CEO 3036504460 2022-06-14 1 SIMON SMITH 999009999 SARAH HINTZ P00492291 3037795710 2022-06-09 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z CLINICA FAMILY HEALTH SIMON SMITH 1735 SOUTH PUBLIC ROAD LAFAYETTE CO 80026 74832192 0 X WWW.CLINICA.ORG X 1977 CO PROVIDE HIGH-QUALITY, CULTURALLY APPROPRIATE CARE TO LOW-INCOME AND OTHER UNDERSERVED PEOPLE. 12 12 798 17 0 0 21923500 35190999 36236288 37990885 172410 187038 630436 1463270 58962634 74832192 264596 36421 0 0 41648052 46552873 0 0 376728 15448088 19495366 57360736 66084660 1601898 8747532 46990882 54834686 15786925 14417166 31203957 40417520 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 52810881 36421 37990885 FOR THE FISCAL YEAR ENDED JANUARY 31, 2022, CLINICA PROVIDED 183,973 MEDICAL VISITS, 41,407 DENTAL VISITS, 30,919 BEHAVIORAL HEALTH VISITS, 3,422 REGISTERED DIETICIAN VISITS, AND 28,069 CASE MANAGEMENT VISITS. 52810881 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 0 0 1 23 0 1 798 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 CO X BRIAN JOHNSTON 3036653036 1735 S PUBLIC ROAD LAFAYETTE CO 80026 PHILIP KEPPELER PHYSICIAN 38.00 0.00 X 289321 0 55017 KAREN FUNK CHIEF MEDICAL OFFICER 40.00 0.00 X 285910 0 42117 ANGELA FRYER PHYSICIAN 40.00 0.00 X 242147 0 47927 MICHELLE DRURY PHYSICIAN 40.00 0.00 X 234189 0 47071 ALEX BULKACZ PHYSICIAN 40.00 0.00 X 237715 0 38147 SIMON SMITH PRESIDENT & CEO 39.00 1.00 X 233910 0 39714 BREANNA TOMLIN PHYSICIAN 40.00 0.00 X 235171 0 30148 AN NGUYEN CHIEF DENTAL OFFICER 40.00 0.00 X 222681 0 28996 BRIAN JOHNSTON CFO 39.00 1.00 X 119942 0 31962 CHERLYN MARRIOT CHAIR 0.10 0.00 X X 0 0 0 ELLA PADILLA VICE CHAIR 0.10 0.00 X X 0 0 0 HEATHER ELKINS SECRETARY 0.10 0.10 X X 0 0 0 MATTHEW ANTUSH TREASURER 0.10 0.00 X X 0 0 0 INEZ BUGGS DIRECTOR 0.10 0.00 X 0 0 0 LIZANDRO GONZALEZ DIRECTOR 0.10 0.00 X 0 0 0 EDSON HERNANDEZ DIRECTOR 0.10 0.00 X 0 0 0 W DOUGLAS JONES DIRECTOR 0.10 0.00 X 0 0 0 CAROLINA FLORES MANROSS 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 JEFF ZAYACH DIRECTOR 0.10 0.00 X 0 0 0 2100986 0 361099 74 0 1 0 OHIO SHARED INFORMATION SERVICES 8790 GOVERNORS HILL DR CINCINNATI OH 45249 SOFTWARE SUPPORT SERVICES 927806 WSI PERSONNEL SERVICES 8301 E PRENTICE SUITE 207 GREENWOOD VILLAGE CO 80111 TEMPORARY PERSONNEL 476375 MOJOS CLEANING SERVICES 8330 E 124TH PL THORNTON CO 80602 JANITORIAL SERVICES 365258 MEDIX STAFFING SOLUTIONS INC 222 S RIVERDALE PLAZA CHICAGO IL 60606 TEMPORARY PERSONNEL 344124 TECHNICAL MOMENTUM 5197 S VERSAILLES ST AURORA CO 80015 IT SERVICES 232128 17 76823 34050167 1064009 3963390 35190999 PATIENT SERVICE REV. 621110 35612923 35612923 PHARMACY REVENUE 621110 2377962 2377962 37990885 187038 187038 OTHER REVENUE 900099 1463270 1463270 1463270 74832192 37990885 0 1650308 27966 27966 8455 8455 1015847 184341 831506 38763693 32795144 5716119 252430 322779 268269 52609 1901 3488095 2937078 530172 20845 2962459 2414085 531367 17007 18174 4193 13032 949 87996 20302 63097 4597 2689846 2042459 635367 12020 82826 15056 65781 1989 1278119 872379 381436 24304 1779430 277969 1484966 16495 2744324 1743099 999911 1314 32457 22746 9607 104 33917 23769 10039 109 412013 235797 176216 1454871 960215 494656 221095 106921 110907 3267 MEDICAL SUPPLIES 7309661 7309661 EDUCATION 410559 288528 120508 1523 EQUIP RENTAL & REPAIRS 395981 148803 245103 2075 MISCELLANEOUS 242229 43305 193529 5395 301868 60341 231123 10404 66084660 52810881 12897051 376728 3108789 3417997 7994606 15342404 1346756 1011352 5008416 6459865 12469400 12469400 27845 34074 705277 605161 30506466 15130860 16188553 15375606 141240 118827 46990882 54834686 7123203 6176179 465519 392125 6438868 6414434 1759335 1434428 15786925 14417166 X 30278578 39776171 925379 641349 31203957 40417520 46990882 54834686 X 8747532 466031 X X 0 1 X 1 1 1 X 19150082 18761551 18662293 21921691 35190999 113686616 19150082 18761551 18662293 21921691 35190999 113686616 113686616 130 775 165115 172410 187038 525468 292881 1269471 434287 630436 1463270 4090345 118302429 191321616 0.96100 0.96550 X SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: OTHER INCOME RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 9423 9423 65698509 65707932 1000000 250000 0 0 1000000 1000000 1000000 1000000 4000000 6000000 13527 13770 13942 9423 50662 250000 250000 250000 250000 1000000 1500000 3835786 3835786 16019938 6983745 9036193 10620106 8147115 2472991 30636 30636 15375606 INTEREST RATE SWAP AGREEMENT 384428 PAYABLES TO RELATED ORGANIZATIONS 1050000 1434428 X 76677747 1223098 699280 1922378 74755369 76823 76823 74832192 67810955 1223098 531163 1754261 66056694 27966 27966 66084660 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. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENT 466,031. HOLDING COMPANY REVENUE NOT INCLUDED 833,249. ELIMINATING ENTRY TO CONSOLIDATE FINANCIAL STATEMETNS -600,000. PART XI, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTION FROM RELATED ORGANIZATION NOT SHOWN ON FINANCIAL STATEMENTS 76,823. PART XII, LINE 2D - OTHER ADJUSTMENTS: HOLDING COMPANY EXPENSES NOT INCLUDED 1,131,163. ELIMINATING ENTRY TO CONSOLIDATE FINANCIAL STATEMENTS -600,000. PART XII, LINE 4B - OTHER ADJUSTMENTS: GRANT TO RELATED ORGANIZATION NOT SHOWN ON FINANCIAL STATEMENTS 27,966. 1 CLINICA HOLDING COMPANY 1735 SOUTH PUBLIC ROAD LAFAYETTE CO 80026 823052286 501(C)(3) 27966 0 N/A N/A CONTRIBUTE ASSETS TO CLINICA HOLDING COMPANY 1 0 PATIENT TRANSPORTATION ASSISTANCE 384 8455 N/A N/A PART I, LINE 2: GRANTS TO THE RELATED ORGANIZATION ARE MONITORED THROUGH COMMON MANAGEMENT AND BOARD OVERSIGHT BETWEEN THE TWO ORGANIZATIONS. THE ORGANIZATION ENSURES APPROPRIATE USE OF TRANSPORTATION ASSISTANCE BY GIVING INDIVIDUALS TRANSPORTATION VOUCHERS THAT ARE ONLY GOOD FOR TRANSPORTATION OR BY PAYING THE TRANSPORTATION COMPANY DIRECTLY. X X X X 0 0 0 0 0 0 0 0 0 PHILIP KEPPELER PHYSICIAN 288321 0 1000 0 0 0 27239 0 27778 0 344338 0 0 0 KAREN FUNK CHIEF MEDICAL OFFICER 284910 0 1000 0 0 0 21429 0 20688 0 328027 0 0 0 ANGELA FRYER PHYSICIAN 241147 0 1000 0 0 0 24899 0 23028 0 290074 0 0 0 MICHELLE DRURY PHYSICIAN 233189 0 1000 0 0 0 21098 0 25973 0 281260 0 0 0 ALEX BULKACZ PHYSICIAN 236715 0 1000 0 0 0 27566 0 10581 0 275862 0 0 0 SIMON SMITH PRESIDENT & CEO 232910 0 1000 0 0 0 20833 0 18881 0 273624 0 0 0 BREANNA TOMLIN PHYSICIAN 234171 0 1000 0 0 0 19762 0 10386 0 265319 0 0 0 AN NGUYEN CHIEF DENTAL OFFICER 221681 0 1000 0 0 0 20958 0 8038 0 251677 0 0 0 BRIAN JOHNSTON CFO 118942 0 1000 0 0 0 897 0 31065 0 151904 0 0 0 X 63460 3963390 FMV 0 0 1 0 PART I, COLUMN (B): THE NUMBER OF ITEMS RECEIVED IS REPORTED IN PART I. FORM 990, PART VI, SECTION A, LINE 1A THE GOVERNING BOARD OF DIRECTORS SHALL HAVE THE POWER TO DESIGNATE AND APPOINT ONE OR MORE COMMITTEES, EACH OF WHICH SHALL CONSIST OF TWO OR MORE DIRECTORS, WHICH COMMITTEES SHALL HAVE SUCH AUTHORITY AS DELEGATED BY THE BOARD, EXCEPT THAT NO SUCH COMMITTEE SHALL HAVE THE AUTHORITY TO AMEND, ALTER OR REPEAL THE BYLAWS; ELECT, APPOINT OR REMOVE ANY OFFICER OR DIRECTOR OF THE CORPORATION; AMEND THE ARTICLES OF INCORPORATION; RESTATE THE ARTICLES OF INCORPORATION; ADOPT A PLAN OF MERGER OR ADOPT A PLAN OF CONSOLIDATION WITH ANOTHER CORPORATION; AUTHORIZE THE SALE, LEASE, EXCHANGE, OR MORTGAGE OF ALL OR SUBSTANTIALLY ALL OF THE PROPERTY AND ASSETS OF THE CORPORATION; AUTHORIZE THE VOLUNTARY DISSOLUTION OF THE CORPORATION OR REVOKE PROCEEDINGS THEREFOR; ADOPT A PLAN FOR THE DISTRIBUTION OF ASSETS OF THE CORPORATION; AND/OR AMEND, ALTER OR REPEAL ANY RESOLUTION OF THE BOARD OF DIRECTORS WHICH BY ITS TERMS PROVIDES THAT IT SHALL NOT BE AMENDED, ALTERED, OR REPEALED BY SUCH COMMITTEE. 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 THE ORGANIZATION'S CONFLICT OF INTEREST POLICY APPLIES TO ALL BOARD MEMBERS, VOTING COMMITTEE MEMBERS, AND OFFICERS. EACH INDIVIDUAL IS REQUIRED TO DISCLOSE THE EXISTENCE OF ANY ACTUAL OR POTENTIAL CONFLICT OF INTEREST AND IS GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS. AFTER SUCH DISCLOSURE, THE INDIVIDUAL DOES NOT PARTICIPATE IN THE REMAINDER OF THE PROCESS, INCLUDING DISCUSSIONS AND VOTES. IF IT IS UNCLEAR WHETHER A CONFLICT EXISTS, THE REMAINING BOARD OR COMMITTEE MEMBERS MAKE THE DETERMINATION. THE CHAIR MAY APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE TRANSACTION. IF A MORE ADVANTAGEOUS TRANSACTION IS NOT IDENTIFIED, THE BOARD OR COMMITTEE VOTES ON WHETHER TO ENTER THE TRANSACTION. IF THE BOARD OR A COMMITEE BELIEVES A PERSON HAS FAILED TO DISCLOSE A CONFLICT, THE INDIVIDUAL IS GIVEN AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE. IF THE BOARD OR COMMITTEE DETERMINES THAT A FAILURE HAS OCCURRED, APPROPRIATE DISCIPLINARY ACTION IS TAKEN. DELIBERATIONS AND DECICIONS MADE ARE DOCUMENTED IN THE BOARD MINUTES. 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 CHIEF HR OFFICER, USING INFORMATION AVAILABLE FROM THE 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 LAST COMPENSATION REVIEW TOOK PLACE IN 2021. THE COMPENSATION OF OTHER OFFICERS IS EVALUATED USING AN ANALYSIS OF MARKET SALARIES COMPILED BY THE CHIEF HR OFFICER, USING INFORMATION AVAILABLE FROM THE EMPLOYERS COUNCIL, THE NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS AND THE COLORADO COMMUNITY HEALTH NETWORK. THE CEO DETERMINES ANY COMPENSATION ADJUSTMENTS AND THE 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. A COMPENSATION ANALYSIS WAS COMPLETED IN 2021. 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 466,031. FORM 990 PART XII LINE 2C THE PROCESS FOR OVERSIGHT AND SELECTION OF AN INDEPENDENT ACCOUNTANT HAS NOT CHANGED FROM THE PRIOR YEAR. 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 1 0 1 0 0 0 0 0 1 1 0 1 1 1 1 1 1 CLINICA HOLDING COMPANY K 600000 FAIR MARKET VALUE CLINICA HOLDING COMPANY C 76823 FAIR MARKET VALUE CLINICA HOLDING COMPANY E 1050000 FAIR MARKET VALUE