2024-08-06T13:53:39-05:00 2023-09-30 135565207 KPMG LLP 301 MAIN STREET SUITE 2150 BATON ROUGE LA 70801 990 2022-10-01 954077161 GOOD SAMARITAN INSTITUTE FOR RESEARCH AND EDUCATION GOOD 2139772121 1225 WILSHIRE BLVD LOS ANGELES CA 900172395 VID SHIVARAMAN CFO 2139772121 2024-07-31 1 0 BRITTANY ELLISER P01284594 2253444000 2024-07-22 2022 2024-08-08 14:25:15Z JAMES WEST 12401 WASHINGTON BLVD WHITTIER CA 90602 433148 0 X N/A X 1987 CA RESEARCH AND EDU. REGARDING THE CARE, CURE AND PREVENTION OF CARDIAC AND CARDIOVASCULAR DISEASES. 3 0 2 0 0 0 294808 426495 0 0 1534 6653 0 0 296342 433148 532428 15366 0 0 180128 298600 0 0 0 22359 7250 734915 321216 -438573 111932 638353 665031 4434878 4648283 -3796525 -3983252 THE INSTITUTE CARRIES OUT RESEARCH AND EDUCATIONAL ACTIVITY IN CONNECTION WITH THE OPERATION OF PIH HEALTH GOOD SAMARITAN HOSPITAL WITH A FOCUS ON CARDIOLOGY AND CARDIOVASCULAR SERVICES. 0 0 291206 15366 SCIENTIFIC AND MEDICAL RESEARCH AND EDUCATION REGARDING THE CARE, CURE AND PREVENTION OF CARDIAC AND CARDIOVASCULAR DISEASES. 291206 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 X 0 0 2 1 0 0 0 0 0 0 0 0 0 0 0 0 X 3 0 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 CA X MARK KAWAUCHI 5626980811 12102 WASHINGTON BLVD WHITTIER CA 90606 JAMES WEST SYSTEM PRESIDENT & CEO 1.50 50.70 X X 0 2046653 355723 PEGGY CHULACK SYSTEM CAO & ASST SECRETARY 1.50 50.70 X X 0 995412 192712 VID SHIVARAMAN SYSTEM CFO & ASST TREASURER 1.50 50.70 X X 0 749812 150468 CECILE MAYORALGO RESEARCH RN 40.00 0.00 X 167678 0 15248 YOUNG PARK RESEARCH RN 40.00 0.00 X 159849 0 26737 ANITA CHOU FORMER CFO & ASST TRASURER 0.00 0.00 X 0 119014 14 327527 3910891 740902 2 1 1 0 0 300100 126395 426495 6653 6653 433148 0 0 6653 15366 15366 258358 232522 25836 19724 17752 1972 20518 18466 2052 1500 1350 150 5750 5750 321216 291206 30010 0 55750 21556 39944 34194 598409 630837 638353 665031 4434878 4648283 4434878 4648283 X -3996701 -4302550 200176 319298 -3796525 -3983252 638353 665031 X 111932 1441 -300100 X 0 1 X 1 0 X PIH HEALTH GOOD SAMARITAN HOSPITAL LOS ANGELES CA RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 55750 21556 34194 34194 INTERCOMPANY PAYABLE 4648283 4648283 X PART X, LINE 2: THE PRINCIPAL OPERATIONS OF THE COMPANY ARE EXEMPT FROM INCOME TAXES PURSUANT TO INTERNAL REVENUE CODE (IRC) SECTION 501(C)(3) AND THE LAWS OF THE STATES IN WHICH IT OPERATES AND, AS SUCH, IS GENERALLY NOT SUBJECT TO FEDERAL OR STATE INCOME TAXES. HOWEVER, THE COMPANY IS SUBJECT TO INCOME TAXES ON NET INCOME DERIVED FROM A TRADE OR BUSINESS REGULARLY CARRIED ON THAT DOES NOT FURTHER THE ORGANIZATION'S EXEMPT PURPOSE. FURTHER, THE COMPANY IS ALSO SUBJECT TO FEDERAL EXCISE TAXES PURSUANT TO THE TAX CUTS AND JOBS ACT. NO SIGNIFICANT INCOME TAX PROVISION HAS BEEN RECORDED IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS FOR NET INCOME DERIVED FROM UNRELATED TRADE OR BUSINESS AND EXCISE TAXES. THE COMPANY MEASURES LIABILITIES FOR UNRECOGNIZED TAX UNCERTAINTIES IN ACCORDANCE WITH ASC 740, INCOME TAXES, WHICH PRESCRIBES A COMPREHENSIVE MODEL FOR HOW A COMPANY SHOULD RECOGNIZE, MEASURE, PRESENT AND DISCLOSE IN ITS FINANCIAL STATEMENTS UNCERTAIN TAX POSITIONS THAT A COMPANY HAS TAKEN OR EXPECTS TO TAKE ON A TAX RETURN. THE GUIDANCE IS APPLICABLE TO PROFIT-ORIENTED ENTITIES, PASS-THROUGH ENTITIES AND TAX-EXEMPT ORGANIZATIONS. MANAGEMENT BELIEVES IT HAS NO SIGNIFICANT UNCERTAIN TAX POSITIONS AND, AS SUCH, NO TAX LIABILITY, BENEFITS, INTEREST OR PENALTIES WERE ACCRUED AT SEPTEMBER 30, 2023 OR 2022. THE COMPANY IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE COMPANY BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO 2019 FOR FEDERAL PURPOSES AND 2017 FOR CALIFORNIA PURPOSES. 0 PIH HEALTH GOOD SAMARITAN HOSPITAL 1225 WILSHIRE BLVD LOS ANGELES CA 90017 951656366 501(C)(3) 15366 0 HEALTHCARE 1 1 1 0 0 0 0 0 0 0 JAMES WEST SYSTEM PRESIDENT & CEO 0 1506821 0 0 0 539832 0 335520 0 20325 0 2402498 0 517243 PEGGY CHULACK SYSTEM CAO & ASST SECRETARY 0 826709 0 0 0 168703 0 178274 0 14760 0 1188446 0 120897 VID SHIVARAMAN SYSTEM CFO & ASST TREASURER 0 681460 0 0 0 68352 0 141186 0 9404 0 900402 0 61131 YOUNG PARK RESEARCH RN 159849 0 0 0 0 0 9935 0 16847 0 186631 0 0 0 CECILE MAYORALGO RESEARCH RN 167678 0 0 0 0 0 8429 0 6863 0 182970 0 0 0 ANITA CHOU FORMER CFO & ASST TRASURER 0 -14 0 0 0 119028 0 0 0 14 0 119028 0 0 PART I, LINES 4A-B ANITA CHOU RECEIVED A SEVERANCE PAYMENT DURING THE CALENDAR YEAR. THE PAYMENT IS INCLUDED IN PART VII, COLUMN E AND SCHEDULE J, PART II, COLUMN B(III). THE TERMS AND CONDITIONS OF THE CONFIDENTIAL SEVERANCE AGREEMENT ARE AVAILABLE TO THE INTERNAL REVENUE SERVICE UPON REQUEST. PART I, LINE 3: COMPENSATION FOR THE CEO WAS ESTABLISHED AND PAID BY PIH HEALTH WHITTIER HOSPITAL (PIHW), A RELATED ORGANIZATION. PIHW USED THE FOLLOWING TO ESTABLISH THE CEO'S COMPENSATION: (1) COMPENSATION COMMITTEE; (2) INDEPENDENT COMPENSATION CONSULTANT; (3) FORM 990 OF OTHER ORGANIZATIONS; (4) COMPENSATION SURVEY OR STUDY; (5) APPROVAL BY THE BOARD. PART I, LINES 4A-B: A RELATED ORGANIZATION, PIH HEALTH, INC., PROVIDES A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN FOR CERTAIN EXECUTIVES. THE FOLLOWING INDIVIDUALS PARTICIPATE IN THE PLAN: VID SHIVARAMAN JAMES WEST PEGGY CHULACK PART II, COLUMN (B)(III): THE FOLLOWING AMOUNTS BECAME VESTED OR WERE PAID-OUT IN 2022 AND ARE INCLUDED IN SCHEDULE J, PART II, COLUMN (B)(III): JAMES WEST $517,243 VID SHIVARAMAN $61,131 PEGGY CHULACK $120,897 FORM 990, PART V, LINE 2A: GOOD SAMARITAN INSTITUTE FOR RESEARCH AND EDUCATION IS A MEMBER OF AN INTEGRATED HEALTHCARE SYSTEM. THE NUMBER OF EMPLOYEES REPORTED ON PART V, LINE 2A REPRESENTS THE NUMBER THE ORGANIZATION'S EMPLOYEES DURING TAX YEAR 2022 WHICH WERE REPORTED ON FORM W-3 BY PIH HEALTH GOOD SAMARITAN HOSPITAL (FEIN 95-1656366), A CONTROLLING RELATED ENTITY. SIMILARLY, THE SALARY EXPENSES REFLECTED ON FORM 990, PART IX, LINE 7 WERE ALL REPORTED ON THE FORM 941, EMPLOYER'S QUARTERLY FEDERAL TAX RETURN, OF PIH HEALTH GOOD SAMARITAN HOSPITAL. FORM 990, PART VI, SECTION A, LINE 2 THE ORGANIZATION IS A MEMBER OF AN INTEGRATED HEALTHCARE SYSTEM CONTROLLED BY PIH HEALTH, INC. THE FOLLOWING INDIVIDUALS HAVE A BUSINESS RELATIONSHIP BY VIRTUE OF THEIR POSITIONS AS OFFICERS OR DIRECTORS OF RELATED ENTITIES WITHIN THE SYSTEM: JAMES WEST, PEGGY CHULACK, AND VID SHIVARAMAN. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE ORGANIZATION IS PIH HEALTH GOOD SAMARITAN HOSPITAL, A CALIFORNIA NONPROFIT CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER HAS THE POWER TO APPOINT, REPLACE OR REMOVE THE MEMBERS OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE ORGANIZATION'S CORPORATE MEMBER IS PIH HEALTH GOOD SAMARITAN HOSPITAL ("PHGSH"). PURSUANT TO SECTION 3.2 OF THE ORGANIZATION'S BYLAWS, THE FOLLOWING DECISIONS REQUIRE APPROVAL BY PHGSH: - AMENDMENT OF THE ARTICLES OF INCORPORATION OR BYLAWS - REMOVAL OF A DIRECTOR FOR CAUSE - SALE OR DISPOSAL OF ALL OR SUBSTANTIALLY ALL OF THE ORGANIZATION'S ASSETS - DISSOLUTION OR WINDING UP OF THE ORGANIZATION - APPROVAL OF A MERGER - CONTRACTS RESULTING IN EXPENDITURES OF THE ORGANIZATION'S ASSETS IN EXCESS OF AN AMOUNT AS SHALL BE DETERMINED, FROM TIME TO TIME, BY RESOLUTION OF THE BOARD OF DIRECTORS OF PHGSH - CONTRACTS FOR THE PURCHASE, SALE, EXCHANGE, OR OTHER DISPOSITION OR GIFT OF ANY REAL ESTATE OWNED OR PARTIALLY OWNED BY THE ORGANIZATION - SHORT-TERM OR LONG-TERM BORROWINGS, MORTGAGES, PLEDGES OF, OR LEASES ENTAILING CUMULATIVE PAYMENTS BY THE ORGANIZATION IN EXCESS OF SUCH AMOUNT(S) RESPECTING SPECIFIC TYPES OF TRANSACTIONS AS SHALL BE DETERMINED FROM TIME TO TIME, BY RESOLUTION OF THE BOARD OF DIRECTORS OF PHGSH - HIRING OR FIRING OF THE ORGANIZATION'S SENIOR EXECUTIVES, AS SUCH TERM SHALL BE DEFINED BY RESOLUTION OF THE BOARD OF DIRECTORS OF PHGSH - FINAL APPROVAL OF THE ANNUAL OPERATING BUDGET OF THE ORGANIZATION - ACCEPTANCE OF A LEGACY OR GIFT IMPOSING A PERMANENT OR CONTINUING OBLIGATION ON THE ORGANIZATION - ESTABLISH AND/OR ACKNOWLEDGEMENT OF ANY AUXILIARY AND/OR AUXILIARY CORPORATION TO BE ASSOCIATION WITH THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION WORKS WITH AN INDEPENDENT ACCOUNTANT, KPMG LLP, TO PREPARE THE FORM 990. ONCE THE RETURN IS PREPARED, THE RETURN IS REVIEWED BY THE CHIEF FINANCIAL OFFICER AND VP OF FINANCE. FORM 990 IS THEN REVIEWED BY THE AUDIT COMMITTEE OF PIH HEALTH, INC., WHICH IS MADE UP OF INDEPENDENT DIRECTORS. KPMG LLP MAKES ALL CHANGES NECESSARY. THE FINAL FORM 990 IS PROVIDED TO THE BOARD PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION IS INCLUDED IN THE CONFLICT OF INTEREST POLICY FOR PIH HEALTH GOOD SAMARITAN HOSPITAL, THE ORGANIZATION'S SOLE MEMBER. ACCORDING TO THE POLICY, ALL BOARD MEMBERS AND OFFICERS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE STATEMENT EACH YEAR. THE POLICY REQUIRES EACH GOVERNING BODY MEMBER TO DISCLOSE ANY CONFLICT ON A PARTICULAR MATTER THAT MAY ARISE, AND RECUSE HIM OR HERSELF FROM DELIBERATIONS AND VOTES ON SUCH MATTERS. THE POLICIES ARE MONITORED AND ENFORCED BY THE AUDIT COMMITTEE CHAIRPERSON. FORM 990, PART VI, SECTION B, LINE 15 DURING THE TAX YEAR ENDED SEPTEMBER 30, 2023, NO OFFICERS, DIRECTORS, OR TRUSTEES RECEIVED COMPENSATION FROM THIS ORGANIZATION. THE COMPENSATION REPORTED IS PAID BY A RELATED ORGANIZATION AND IS DETERMINED BASED ON THE COMPENSATION REVIEW PRACTICES AND POLICIES OF PIH HEALTH GOOD SAMARITAN HOSPITAL, A CONTROLLING RELATED ENTITY. FORM 990, PART VI, SECTION C, LINE 19 GOOD SAMARITAN INSTITUTE FOR RESEARCH AND EDUCATION'S ORGANIZING AND GOVERNING DOCUMENTS AND THE CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. THE FINANCIAL INFORMATION FROM THE FINANCIAL STATEMENTS IS INCLUDED IN THE ORGANIZATION'S FORM 990, WHICH IS AVAILABLE FOR PUBLIC INSPECTION UPON REQUEST. FORM 990, PART XI, LINE 9: INTERCOMPANY TRANSFERS -300,100. PIH HEALTH GOOD SAMARITAN HOSPITAL 1225 WILSHIRE BLVD LOS ANGELES CA 90017 951656366 HOSPITAL CA 501(C)(3) LINE 3 PIH HEALTH INC 0 ORTHOPEDIC INSTITUTE OF THE GOOD SAMARITAN HOSPITAL 1225 WILSHIRE BLVD LOS ANGELES CA 90017 954346048 ORTHOPEDIC RESEARCH CA 501(C)(3) LINE 12A, I PIH HEALTH GOOD SAMARITAN HOSPITAL 1 SAMARITAN IMAGING CENTER 1225 WILSHIRE BLVD LOS ANGELES CA 90017 954252321 OUTPATIENT IMAGING CA 501(C)(3) LINE 10 PIH HEALTH GOOD SAMARITAN HOSPITAL 1 GOOD SAMARITAN MEDICAL OFFICE BUILDING INC 1225 WILSHIRE BLVD LOS ANGELES CA 90017 953244046 PHYSICIANS MEDICAL OFFICES CA 501(C)(3) LINE 12A, I PIH HEALTH GOOD SAMARITAN HOSPITAL 1 KATE VAN NUYS PAGE FOUNDATION 12401 WASHINGTON BLVD WHITTIER CA 90602 956028032 GRANTS INCOME TO PIH HEALTH GOOD SAMARITAN HOSPITAL CA 501(C)(3) LINE 12A, I PIH HEALTH GOOD SAMARITAN HOSPITAL 1 PIH HEALTH ADULT DAY HEALTHCARE 12401 WASHINGTON BLVD WHITTIER CA 90602 953643829 SUPPORT OF TAX-EXEMPT AFFILIATES CA 501(C)(3) LINE 12B, II PIH HEALTH INC 0 PIH HEALTH FOUNDATION 12401 WASHINGTON BLVD WHITTIER CA 90602 953761274 FUNDRAISING CA 501(C)(3) LINE 7 PIH HEALTH INC 0 PIH HEALTH HOME HEALTHCARE 12401 WASHINGTON BLVD WHITTIER CA 90602 953036281 SUPPORT OF TAX-EXEMPT AFFILIATES CA 501(C)(3) LINE 12B, II PIH HEALTH INC 0 PIH HEALTH DOWNEY HOSPITAL 11500 BROOKSHIRE AVE DOWNEY CA 90241 951903935 HEALTHCARE CA 501(C)(3) LINE 3 PIH HEALTH INC 0 PIH HEALTH WHITTIER HOSPITAL 12401 WASHINGTON BLVD WHITTIER CA 90602 951934652 HEALTHCARE CA 501(C)(3) LINE 3 PIH HEALTH INC 0 PIH HEALTH MANAGEMENT CORP 12401 WASHINGTON BLVD WHITTIER CA 90602 954016278 SUPPORT OF TAX-EXEMPT AFFILIATES CA 501(C)(3) LINE 12B, II PIH HEALTH INC 0 PIH HEALTH PHYSICIANS 6557 GREENLEAF AVE WHITTIER CA 90601 953942828 HEALTHCARE CA 501(C)(3) LINE 10 PIH HEALTH INC 0 PIH HEALTH INC 12401 WASHINGTON BLVD WHITTIER CA 90602 953619388 SUPPORT OF TAX-EXEMPT AFFILIATES CA 501(C)(3) LINE 12B, II N/A 0 PIH HEALTH INSURANCE COMPANY 733 BISHOP STREET STE 1555 HONOLULU HI 96813 263760243 CAPTIVE INSURANCE HI N/A T 0 PIH HEALTH CARE SOLUTIONS 6557 GREENLEAF AVENUE WHITTIER CA 90601 462072342 HEALTHCARE CA N/A C 0 DRMC PROPERTIES INC 12401 WASHINGTON BLVD WHITTIER CA 90602 954769768 REAL ESTATE CA N/A C 0 PIH HEALTH RE 733 BISHOP STREET STE 1555 HONOLULU HI 96813 472501390 CAPTIVE INSURANCE HI N/A T 0 HEALTHMED SERVICES INC 12401 WASHINGTON BLVD WHITTIER CA 90602 300831225 HEALTHCARE CA N/A C 0 PIONEER MEDICAL GROUP INC 12401 WASHINGTON BLVD WHITTIER CA 90602 330927283 MEDICAL SERVICES CA N/A C 0 PIONEER PROVIDER NETWORK A MEDICAL GROUP INC 12401 WASHINGTON BLVD WHITTIER CA 90602 330922631 MANAGEMENT SERVICES CA N/A C 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 PIH HEALTH GOOD SAMARITAN HOSPITAL C 300100 FMV