FOR BHF USE
IMPORTANT NOTIC
E
LL1
THIS AGENCY IS REQUESTING DISCLOSURE OF INFORMATION
THAT IS NECESSARY TO ACCOMPLISH THE STATUTOR
Y
2020
PURPOSE AS OUTLINED IN 210 ILCS 45/3-208. DISCLOSURE
STATE OF ILLINOIS
OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDE
DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
ANY INFORMATION ON OR BEFORE THE DUE DATE WILL
FINANCIAL AND STATISTICAL REPORT
(
COST REPORT
)
RESULT IN CESSATION OF PROGRAM PAYMENTS. THIS FORM
FOR LONG-TERM CARE FACILITIES
HAS BEEN APPROVED BY THE FORMS MANAGEMENT CENTER.
(
FISCAL YEAR 2020
)
I. IDPH License ID Number: 0052415 II. CERTIFICATION BY AUTHORIZED FACILITY OFFICE
R
Facility Name: Warren Barr Gold Coast
I have examined the contents of the accom
p
an
y
in
g
re
p
ort to the
Add
ress:
66
W
est
O
a
k
S
treet
Chi
cago
60610
State of Illinois, for the
p
eriod from
01/01/20
t
o
12/31/20
Numbe
r
Cit
y
Zi
p
Code
and certif
y
to the best of m
y
knowled
g
e and belief that the said contents
are true, accurate and com
p
lete statements in accordance with
C
ounty:
C
oo
k
a
pp
licable instructions. Declaration of
p
re
p
arer
(
other than
p
rovider
)
is based on all information of which
p
re
p
arer has an
y
knowled
g
e.
T
e
l
ep
h
one
N
um
b
er:
(312)
705
-
5100
F
ax
#
(312)
705
-
5041
Intentional misre
p
resentation or falsification of an
y
information
HFS
ID
N
um
b
er:
in this cost re
p
ort ma
y
be
p
unishable b
y
fine and/or im
p
risonment.
Date of Initial License for Current Owners: 8/1/2013 (Signed)
Officer or (Date)
Type of Ownership: Administrator (Type or Print Name)
of Provider
VOLUNTARY,NON-PROFIT X PROPRIETARY GOVERNMENTAL (Title)
Charitable Corp. Individual State
Trust Partnership County (Signed) 04/29/2021
IRS Exemption Code Corporation Other
* Subject to the attached Accountants' Consulting Report (Date)
"Sub-S" Corp. Paid
(Print Name
Steven N. Lavenda, CPA
X Limited Liability Co. Preparer
and Title)
Partner
Trust
Other
(
Firm Nam
e
Marcum, LLP
& Address)
9 Parkway North, Suite 200 Deerfield, IL 60015
(
Tele
p
hone
)
(847)
282
-
6300
F
ax
#
(847)
282
-
6301
MAIL TO: BUREAU OF HEALTH FINANCE
In the event there are further questions about this report, please contact:
ILLINOIS DEPT OF HEALTHCARE AND FAMILY SERVICES
Name
:
Steven N. Lavenda Tele
p
hone Number:
(
847
)
282-6300 201 S. Grand Avenue East
Email Address: S
p
rin
g
field
,
IL 62763-0001 Phone #
(
217
)
782-1630
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Page 2
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
III. STATISTICAL DATA D. How many bed reserve days during this year were paid by the Department?
A. Licensure/certification level(s) of care; enter number of beds/bed days, None (Do not include bed reserve days in Section B.)
(must agree with license). Date of change in licensed beds N/A
E. List all services provided by your facility for non-patients.
1 2 3 4 (E.g., day care, "meals on wheels", outpatient therapy)
None
Beds at Licensed
Beginning of Licensure Beds at End of Bed Days During F. Does the facility maintain a daily midnight census? Yes
Report Period Level of Care Report Period Report Period
G. Do pages 3 & 4 include expenses for services or
1 271 Skilled (SNF) 271 99,186 1 investments not directly related to patient care?
2 Skilled Pediatric (SNF/PED) 2 YES NO X
3 Intermediate (ICF) 3
4 Intermediate/DD 4 H. Does the BALANCE SHEET (page 17) reflect any non-care assets?
5 Sheltered Care (SC) 5 YES NO X
6 ICF/DD 16 or Less 6
I. On what date did
y
ou start
p
rovidin
g
lon
g
term care at this location?
7 271 TOTALS 271 99,186 7 Date started 8/1/2013
J. Was the facility purchased or leased after January 1, 1978?
B. Census-For the entire re
p
ort
p
eriod. YES X Date 8/1/2013 NO
1 2345
Level of Care Patient Days by Level of Care and Primary Source of Payment K. Was the facility certified for Medicare during the reporting year?
Medicaid YES X NO If YES, enter number
Recipient Private Pay Other Total of beds certified 271 and days of care provided 18,489
8 SNF 36,974 1,893 24,719 63,586 8
9 SNF/PED 9 Medicare Intermediary National Government Services
10 ICF 10
11 ICF/DD 11 IV. ACCOUNTING BASIS
12 SC 12 MODIFIED
13 DD 16 OR LESS 13 ACCRUAL X CASH* CASH*
14 TOTALS 36,974 1,893 24,719 63,586 14 Is
y
our fiscal
y
ear identical to
y
our tax
y
ear? YES X NO
C. Percent Occu
p
anc
y
. (Column 5, line 14 divided b
y
total licensed Tax Year: 12/31/2020 Fiscal Year: 12/31/2020
bed da
y
s on line 7, column 4.) 64.11% * All facilities other than
g
overnmental must re
p
ort on the accrual basis.
STATE
OF
ILLINOIS
P
a
g
e
3
F
ac
ili
t
y
N
ame
&
ID
N
um
b
er
W
arren
B
arr
G
o
ld
C
oast
#
0052415
R
e
p
ort
P
er
i
o
d
B
e
gi
nn
i
n
g
:
01/01/20
E
n
di
n
g
:
12/31/20
V. COST CENTER EXPENSES
(
throu
g
hout the re
p
ort
,
p
lease round to the nearest dollar
)
Costs Per General Led
g
e
r
Reclass- Reclassified Ad
j
ust- Ad
j
usted FOR BHF USE ONL
Y
O
p
eratin
g
Ex
p
enses Salar
y
/Wa
g
eSu
pp
lies Other Total ification Total ments Total
A. General Services 12345678910
1 Dietar
y
798,207 82,838 881,045 881,045 5,115 886,160 1
2
Food Purchase 500,379 500,379 500,379 9,582 509,961 2
3
Housekeeping 440,071 66,154 7,664 513,889 513,889 3,317 517,206 3
4
Laundr
y
12,888 71,758 188,086 272,732 272,732 225 272,957 4
5
Heat and Other Utilities 354,809 354,809 354,809 (15,632) 339,177 5
6
Maintenance 269,463 20,123 330,404 619,990 619,990 6,413 626,403 6
7
Other (specify):* 7
8
TOTAL General Services 1,520,629 741,252 880,963 3,142,844 3,142,844 9,020 3,151,864 8
B. Health Care and Pro
g
rams
9 Medical Director 61,168 61,168 61,168 61,168 9
10
Nursing and Medical Records 7,209,123 599,991 107,571 7,916,685 7,916,685 77,257 7,993,942 10
10a
Therap
y
301,005 301,005 301,005 301,005 10a
11
Activities 146,672 4,776 151,448 151,448 13 151,461 11
12
Social Services 631,591 79,776 8,815 720,182 720,182 8,885 729,067 12
13
CNA Training 13
14
Program Transportation 332,293 332,293 332,293 332,293 14
15
Other (specify):* 9,216 9,216 15
16
TOTAL Health Care and Programs 8,288,391 684,543 509,847 9,482,781 9,482,781 95,372 9,578,153 16
C. General Administration
17 Administrative 275,842 275,842 275,842 98,911 374,753 17
18
Directors Fees 18
19
Professional Services 592,508 592,508 (593) 591,915 1,426 593,341 19
20
Dues, Fees, Subscriptions & Promotions 127,240 127,240 127,240 (54,595) 72,645 20
21
Clerical & General Office Expenses 321,792 7,057 983,997 1,312,846 1,312,846 (352,859) 959,987 21
22
Employee Benefits & Payroll Taxe
s
1,675,486 1,675,486 1,675,486 1,675,486 22
23
Inservice Training & Education 23
24
Travel and Seminar 1,471 1,471 1,471 221 1,692 24
25
Other Admin. Staff Transportation 8,788 8,788 8,788 7,394 16,182 25
26
Insurance-Prop.Liab.Malpractice 669,839 669,839 669,839 629 670,468 26
27
Other (specify):* 39,644 39,644 27
28
TOTAL General Administration 597,634 7,057 4,059,329 4,664,020 (593) 4,663,427 (259,230) 4,404,198 28
TOTAL O
p
eratin
g
Ex
p
ense
29
(
sum of lines 8
,
16 & 28
)
10
,
406
,
654
1
,
432
,
852
5
,
450
,
139
17
,
289
,
645
(593)
17
,
289
,
052
(154
,
838)
17
,
134
,
214
29
*Attach a schedule if more than one t
yp
e of cost is included on this line
,
or if the total exceeds $1000.
NOTE: Include a se
p
arate schedule detailin
g
the reclassifications made in column 5. Be sure to include a detailed ex
p
lanation of each reclassification.
STATE OF ILLINOIS Pa
g
e 4
Facilit
y
Name & ID Number Warren Barr Gold Coast #0052415 Re
p
ort Period Be
g
innin
g
: 01/01/20 Endin
g
: 12/31/20
#
V. COST CENTER EXPENSES (continued)
Cost Per General Led
g
er Reclass- Reclassified Ad
j
ust- Ad
j
usted FOR BHF USE ONLY
Ca
p
ital Ex
p
ense Salar
y
/Wa
g
eSu
pp
lies Other Total ification Total ments Total
D. Ownershi
p
12345678910
30 Depreciation 1,351,463 1,351,463 30
31
Amortization of Pre-Op. & Org. 31
32
Interes
t
33,236 33,236 33,236 1,409,029 1,442,265 32
33
Real Estate Taxes 23,180 23,180 593 23,773 917,448 941,221 33
34
Rent-Facility & Grounds 3,412,250 3,412,250 3,412,250 (3,412,096) 154 34
35
Rent-Equipment & Vehicles 30,843 30,843 30,843 6,283 37,126 35
36
Other (specify):* 607,700 607,700 607,700 (607,700) 36
37
TOTAL Ownership 4,107,209 4,107,209 593 4,107,802 (335,572) 3,772,229 37
Ancillary Expense
E. Special Cost Centers
38 Medically Necessary Transportatio
n
38
39
Ancillary Service Centers 1,215,161 2,642,824 3,857,985 3,857,985 (38,200) 3,819,785 39
40
Barber and Beauty Shops 40
41
Coffee and Gift Shops 41
42
Provider Participation Fee 435,666 435,666 435,666 435,666 42
43
Other (specify):* 1,219,801 1,219,801 1,219,801 (1,219,801) (0) 43
44
TOTAL Special Cost Centers 1,215,161 4,298,291 5,513,452 5,513,452 (1,258,001) 4,255,451 44
GRAND TOTAL COST
45 (sum of lines 29, 37 & 44) 10,406,654 2,648,013 13,855,639 26,910,306 26,910,306 (1,748,412) 25,161,894 45
*Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000.
STATE OF ILLINOIS Page 5
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VI. ADJUSTMENT DETAIL A. The expenses indicated below are non-allowable and should be adjusted out of Schedule V, pages 3 or 4 via column 7.
In column 2 below, reference the line on which the particular cost was included. (See instructions.)
1
2
3
R
e
f
er-
BHF
USE
B
.
If
t
h
ere are expenses exper
i
ence
d
b
y t
h
e
f
ac
ili
ty w
hi
c
h
d
o not appear
i
n t
h
e
NON
-
ALLOWABLE
EXPENSES
A
mount ence
ONLY
genera
l
l
e
d
ger, t
h
ey s
h
ou
ld
b
e entere
d
b
e
l
ow.
(S
ee
i
nstruct
i
ons.
)
1 Day Car
e
$$1 12
2 Other Care for Outpatients 2 Amount Reference
3 Governmental Sponsored Special Program
s
331 Non-Paid Workers-Attach Schedule* $31
4 Non-Patient Meals 432 Donated Goods-Attach Schedule* 32
5 Telephone, TV & Radio in Resident Rooms (17,362) 05 5 Amortization of Organization
&
6 Rented Facility Spac
e
633 Pre-Operating Expense 33
7 Sale of Supplies to Non-Patients 7 Adjustments for Related Organizatio
n
8 Laundry for Non-Patient
s
834 Costs (Schedule VII) 352,421 34
9 Non-Straightline Depreciatio
n
790,325 30 935 Other- Attach Schedule 35
10 Interest and Other Investment Incom
e
(14,969) 32 10 36 SUBTOTAL (B): (sum of lines 31-35) $ 352,421 36
11 Discounts, Allowances, Rebates & Refunds 11 (sum of SUBTOTALS
12 Non-Working Officer's or Owner's Salar
y
12 37 TOTAL ADJUSTMENTS (A) and (B) ) $ (1,748,412) 37
13 Sales Tax (149) 02 13
14 Non-Care Related Interes
t
14 *These costs are only allowable if they are necessary to meet minimum
15 Non-Care Related Owner's Transaction
s
15 licensing standards. Attach a schedule detailing the items included
16 Personal Expenses (Including Transportation) 16 on these lines.
17 Non-Care Related Fees 17
18 Fines and Penalties (2,450) 21 18 C. Are the following expenses included in Sections A to D of pages 3
19 Entertainmen
t
(1,292) 21 19 and 4? If so, they should be reclassified into Section E. Please
20 Contributions (15,200) 20 20 reference the line on which they appear before reclassification.
21 Owner or Key-Man Insuranc
e
21 (See instructions.) 1 2 3 4
22 Special Legal Fees & Legal Retainer
s
22 Yes No Amount Reference
23 Malpractice Insurance for Individual
s
23 38 Medically Necessary Transport
.
$38
24 Bad Debt (603,041) 21 24 39 39
25 Fund Raising, Advertising and Promotional (16,054) 20 25 40 Gift and Coffee Shops 40
I
ncome
T
axes an
d
Illi
no
i
s
P
ersona
l
41
B
ar
b
er an
d
B
eauty
Sh
ops
41
26
P
roperty
R
ep
l
acement
T
a
x
26
42
L
a
b
oratory an
d
R
a
di
o
l
og
y
42
27
CNA
T
ra
i
n
i
ng
f
or
N
on-
E
mp
l
oyee
s
27
43
P
rescr
i
pt
i
on
D
rugs
43
28
Y
e
ll
ow
P
age
Ad
vert
i
s
i
n
g
28
44
44
29
O
t
h
er-
A
ttac
h
S
c
h
e
d
u
l
e
(2
,
220
,
641)
29
45
O
t
h
er-
A
ttac
h
S
c
h
e
d
u
l
e
45
30 SUBTOTAL (A): (Sum of lines 1-29) $ (2,100,833) $ 30 46 Other-Attach Schedule 46
47 TOTAL (C): (sum of lines 38-46) $ 47
BHF USE ONLY
48
49
50
51
52
STATE OF ILLINOIS Page 5A
Warren Barr Gold Coast
ID# 0052415
Report Period Beginning: 01/01/20
Ending: 12/31/20
Sch. V Line
NON-ALLOWABLE EXPENSES Amount Reference
1 Patient Personal Items $ (9,305) 10 1
2 Bank Charges (8,900) 21 2
3 Sequestration Expense (160,082) 21 3
4 Pharmacy Discounts (12,089) 10 4
5 Rebates (68,730) 10 5
6 Misc Income (4,682) 21 6
7 State Income Tax (1,000) 21 7
8 Non-Allowable Expense (1,218,109) 43 8
9 Capitalized R&M (11,304) 06 9
10 Non-Allowable Expense (1,692) 43 10
11 PAC Dues (28,367) 20 11
12 Non-Allowable Legal (19,199) 19 12
13 Building Co. - Bank Fees (6,347) 21 13
14 Building Co. - Accounting Fees (25,883) 19 14
15 Building Co. - Amortization (35,833) 36 15
16 Amortization (607,700) 36 16
17 Prior Year Dues (519) 20 17
18 Non-Allowable Auto Lease (900) 35 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29
29
30 30
31 31
32 32
33 33
34 34
35 35
36 36
37 37
38 38
39 39
40 40
41 41
42 42
43 43
44 44
45 45
46 46
47 47
48 48
49
Total (2,220,641) 49
STATE OF ILLINOIS Summary A
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I
SUMMARY
Operating Expenses PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE TOTALS
A. General Services 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7)
1 Dietar
y
5,115 5,115 1
2
Food Purchase (149) 9,731 9,582 2
3
Housekeepin
g
3,317 3,317 3
4
Laundr
y
225 225 4
5
Heat and Other Utilities (17,362) 1,730 (15,632) 5
6
Maintenance (11,304) 16,628 1,676 (588) 6,413 6
7
Other (specify):* 7
8
TOTAL General Services (28,815) 35,017 3,406 (588) 9,020 8
B. Health Care and Programs
9 Medical Directo
r
9
10
Nursing and Medical Records (90,124) 170,094 (2,713) 77,257 10
10a
Therap
y
10a
11
Activities 13 13 11
12
Social Services 8,885 8,885 12
13
CNA Trainin
g
13
14
Program Transportatio
n
14
15
Other (specify):* 9,216 9,216 15
16
TOTAL Health Care and Pro
g
rams (90,124) 178,993 9,216 (2,713) 95,372 16
C. General Administration
17 Administrativ
e
98,911 98,911 17
18
Directors Fees 18
19
Professional Services (45,082) 25,883 32,472 728 (12,575) 1,426 19
20
Fees, Subscriptions & Promotion
s
(60,140) 5,544 1 (54,595) 20
21
Clerical & General Office Expenses (787,794) 6,347 428,186 402 (352,859) 21
22
Employee Benefits & Payroll Taxe
s
22
23
Inservice Training & Educatio
n
23
24
Travel and Semina
r
221 221 24
25
Other Admin. Staff Transportatio
n
7,394 7,394 25
26
Insurance-Prop.Liab.Malpractic
e
195 434 629 26
27
Other (specify):* 39,644 39,644 27
28
TOTAL General Administration (893,016) 32,230 612,566 1,565 (12,575) (259,230) 28
TOTAL Operating Expense
29 (sum of lines 8,16 & 28) (1,011,955) 32,230 826,576 9,216 4,971 (588) (2,713) (12,575) (154,838) 29
STATE OF ILLINOIS Summary B
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I
SUMMARY
Capital Expense PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE TOTALS
D. Ownership 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7)
30 Depreciation 790,325 550,468 10,670 1,351,463 30
31
Amortization of Pre-Op. & Org. 31
32
Interest (14,969) 1,418,002 5,996 1,409,029 32
33
Real Estate Taxes 912,000 5,448 917,448 33
34
Rent-Facility & Grounds (3,412,250) 50,211 (50,057) (3,412,096) 34
35
Rent-Equipment & Vehicles (900) 7,183 6,283 35
36
Other (specify):* (643,533) 35,833 (607,700) 36
37 TOTAL Ownership 130,923 (495,947) 50,211 7,183 (27,943) (335,572) 37
Ancillary Expense
E. Special Cost Centers
38 Medically Necessary Transportation 38
39
Ancillary Service Centers (38,200) (38,200) 39
40
Barber and Beauty Shops 40
41
Coffee and Gift Shops 41
42
Provider Participation Fee 42
43
Other (specify):* (1,219,801) (1,219,801) 43
44 TOTAL Special Cost Centers (1,219,801) (38,200) (1,258,001) 44
GRAND TOTAL COST
45 (sum of lines 29, 37 & 44) (2,100,833) (463,717) 876,787 16,399 (22,971) (588) (2,713) (12,575) (38,200) (1,748,412) 45
STATE OF ILLINOIS Pa
g
e 6
Facilit
y
Name & ID Number Warren Barr Gold Coas
t
# 0052415 Report Period Be
g
innin
g
: 01/01/20 Endin
g
: 12/31/20
VII. RELATED PARTIES
A.
Enter below the names of ALL owners and related organizations (parties) as defined in the instructions. Use Page 6-Supplemental as necessary.
1 2 3
OWNERS RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES
Name Ownership % Name City Name City Type of Business
See Page 6-Supplemental See Page 6-Supplemental See Page 6-Supplemental
B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,
management fees, purchase of supplies, and so forth. X YES NO
If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance with
the instructions for determining costs as specified for this form.
1 2 3 Cost Per General Led
g
e
r
4 5 Cost to Related Or
g
anization 6 7 8 Difference:
Percen
t
Operatin
g
Cost Ad
j
ustments for
Schedule V Line Item Amount Name of Related Or
g
anization of of Related Related Or
g
anization
Ownership Or
g
anization Costs (7 minus 4)
1 V 34 Rent $ 3,412,250 FNR WB, LLC $$(3,412,250) 1
2
V 32 Interest FNR WB, LLC 1,418,002 1,418,002 2
3
V 33 Real Estate FNR WB, LLC 912,000 912,000 3
4
V 30 Depreciation FNR WB, LLC 550,468 550,468 4
5
V 21 Bank Fees FNR WB, LLC 6,347 6,347 5
6
V 19 Accountin
g
Fees FNR WB, LLC 25,883 25,883 6
7
V 36 Amortization 35,833 35,833 7
8
V 8
9
V 9
10
V 10
11
V 11
12
V 12
13
V 13
14
Total $ 3,412,250 $ 2,948,533 $ * (463,717) 14
*
Total must a
g
ree w
i
th the amount recorded on l
i
ne
34
o
f
S
chedule VI.
STATE OF ILLINOIS Page 6-Supplemental
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VII. RELATED PARTIES
A. (Continued)
Enter below the names of ALL owners and related organizations (parties) as defined in the instructions.
1 2 3
OWNERS RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES
Name Ownershi
p
% Name Cit
y
Name Cit
y
T
yp
e of Business
1 Chaim Rajchenbach 37.12% Astoria Place Skilled Nursing Facility LLC Chicago FNR WB, LLC Building Company 1
2
Menachem Shabat 37.12% Avantara Arlington Arlington, SD Legacy HC & Financial Services Lincolnwood Home Office/Bookkeeping 2
3
Ronald Shabat 10.38% Avantara Armour Armour, SD CF St. Louis LLC Skokie Building Company 3
4
Susan Friedman 5.00% Avantara Arrowhead Rapid City, SD ML Group Design & Development Skokie Asset Management 4
5
Jack Rajchenbach 6.69% Avantara Aurora Aurora ReMED Services LLC Lincolnwood Nursing Equipment 5
6
Yoseph & Naomi Rajchenbach 0.44% Avantara Billings Billings, MT Propay HR Evanston Payroll Processing 6
7
Avrohom & Chana Rajchenbach 0.44% Avantara Clark Clark, SD Ecobrite Linen Skokie Laundry Supplies 7
8
Shlomo Zalmain Busel & Chava Busel 0.44% Avantara Elgin Elgin Aurora Supportive Living Aurora Supportive Living 8
9
Pinchas & Nahama Schwartz 0.44% Avantara Evergreen Park Evergreen Park Terrace Gardens Morton Grove Assisted Living 9
10
Jack Rajchenbach 1.95% Avantara Groton Groton, SD Lincolnshire Assisted Livin
g
Cente
r
Lincolnshire Assisted Living 10
11
Avantara Huron Huron, SD Wellshire Park Place Milbank, SD Assisted Living 11
12
Avantara Ipswich Ipswich, SD Wellshire Huron Huron, SD Assisted Living 12
13
Avantara Lake Norden Lake Norden, SD Lifescan Labs of Illinois Skokie Laboratory 13
14
Avantara Long Grove Long Grove 14
15
Avantara Milbank Milbank, SD 15
16
Avantara Mountainview Rapid City, SD 16
17
Avantara North Rapid City, SD 17
18
Avantara Norton Sioux Falls, SD 18
19
Avantara Park Ridge Park Ridge 19
20
Avantara Pierre Pierre, SD 20
21
Avantara Redfield Redfield, SD 21
22
Avantara Salem Salem, SD 22
23
Avantara St. Cloud Rapid City, SD 23
24
Avantara Watertown Watertown, SD 24
25
Bella Terra Streamwood Streamwood 25
26
Bella Terra Wheeling Wheeling 26
27
Bethany Terrace Morton Grove 27
28
Carlton Skilled Nursing Facility LLC Chicago 28
29
Chalet Skilled Nursing Facility LLC Chicago 29
30
Clark Skilled Nursing Facility Chicago 30
STATE OF ILLINOIS Page 6-Supplemental (2)
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VII. RELATED PARTIES
A. (Continued)
Enter below the names of ALL owners and related organizations (parties) as defined in the instructions.
1 2 3
OWNERS RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES
Name Ownershi
p
% Name Cit
y
Name Cit
y
T
yp
e of Business
1 Elmbrook Skilled Nursing Facility LLC Elmhurst 1
2
Evanston Skilled Nursing Facility LLC Evanston 2
3
Grove at the Lake Skilled Nursing Facility LLC Zion 3
4
Grove of Berwyn Berwyn 4
5
Grove of Fox Valley Aurora 5
6
Grove of St. Charles St. Charles 6
7
Lagrange Skilled Nursing Facility LLC Lagrange Park 7
8
Lakefront Skilled Nursing Facility LLC Chicago 8
9
Lincoln Park Skilled Nursing Facility LLC Chicago 9
10
Lincolnshire Living & Rehab Center LLC Lincolnshire 10
11
Northbrook Skilled Nursing Facility LLC Northbrook 11
12
Peterson Park Associates Limited Partnership Chicago 12
13
Skokie Skilled Nursing Facility LLC Skokie 13
14
Valley Skilled Nursing Facility Billings, MT 14
15
Warren Barr North Shore Highland Park 15
16
Warren Barr South Loop Chicago 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
STATE OF ILLINOIS Page 6A
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VII. RELATED PARTIES (continued)
B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,
management fees, purchase of supplies, and so forth. X YES NO
If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance with
the instructions for determining costs as specified for this form.
1 2 3 Cost Per General Ledger 4 5 Cost to Related Organization 6 7 8 Difference:
Percent Operating Cost Adjustments for
Schedule V Line Item Amount Name of Related Organization of of Related Related Organization
Ownership Organization Costs (7 minus 4)
15 V 01 Dietician Salar
y
$ Le
g
ac
y
Healthcare Financial Service
s
$ 5,088 $ 5,088 15
16
V 01 Dietar
y
Su
pp
lies Le
g
ac
y
Healthcare Financial Service
s
27 27 16
17
V 02 Food Le
g
ac
y
Healthcare Financial Service
s
9,731 9,731 17
18
V 03 Housekee
p
in
g
Le
g
ac
y
Healthcare Financial Service
s
3,317 3,317 18
19
V 04 Linen Re
p
lacemen
t
Le
g
ac
y
Healthcare Financial Service
s
225 225 19
20
V 06 Maintenance Salar
y
Le
g
ac
y
Healthcare Financial Service
s
15,697 15,697 20
21
V 06 Re
p
airs & Maintenanc
e
Le
g
ac
y
Healthcare Financial Service
s
932 932 21
22
V 10 Nursin
g
Salar
y
Le
g
ac
y
Healthcare Financial Service
s
129,920 129,920 22
23
V 10 Nurse/Medical Director Consultan
t
Le
g
ac
y
Healthcare Financial Service
s
12,262 12,262 23
24
V 10 Medical Su
pp
lies Le
g
ac
y
Healthcare Financial Service
s
27,912 27,912 24
25
V 12 Social Service Salar
y
Le
g
ac
y
Healthcare Financial Service
s
8,851 8,851 25
26
V 11 Activities Pro
g
ra
m
Le
g
ac
y
Healthcare Financial Service
s
13 13 26
27
V 12 Social Service Consultan
t
Le
g
ac
y
Healthcare Financial Service
s
35 35 27
28
V 17 COO / Administrative Salar
y
Le
g
ac
y
Healthcare Financial Service
s
98,911 98,911 28
29
V 19 Professional Fee
s
Le
g
ac
y
Healthcare Financial Service
s
32,472 32,472 29
30
V 20 Dues / Licenses / Permit
s
Le
g
ac
y
Healthcare Financial Service
s
5,544 5,544 30
31
V 21 Clerical & General Wa
g
e
s
Le
g
ac
y
Healthcare Financial Service
s
399,084 399,084 31
32
V 21 Clerical & Office Ex
p
ens
e
Le
g
ac
y
Healthcare Financial Service
s
29,102 29,102 32
33
V 24 Education & Seminar
s
Le
g
ac
y
Healthcare Financial Service
s
221 221 33
34
V 25 Trave
l
Le
g
ac
y
Healthcare Financial Service
s
7,394 7,394 34
35
V 26 Insurance - Genera
l
Le
g
ac
y
Healthcare Financial Service
s
195 195 35
36
V 27 Non-Nursin
g
Pa
y
roll Taxes / Benefits Le
g
ac
y
Healthcare Financial Service
s
39,644 39,644 36
37
V 34 Ren
t
Le
g
ac
y
Healthcare Financial Service
s
50,057 50,057 37
38
V 34 Offsite Stora
g
e / Parkin
g
Le
g
ac
y
Healthcare Financial Service
s
154 154 38
39
Total $ $ 876,787 $ * 876,787 39
* Total must agree with the amount recorded on line 34 of Schedule VI.
STATE OF ILLINOIS Page 6B
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VII. RELATED PARTIES (continued)
B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,
management fees, purchase of supplies, and so forth. X YES NO
If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance with
the instructions for determining costs as specified for this form.
1 2 3 Cost Per General Ledger 4 5 Cost to Related Organization 6 7 8 Difference:
Percent Operating Cost Adjustments for
Schedule V Line Item Amount Name of Related Organization of of Related Related Organization
Ownership Organization Costs (7 minus 4)
15 V 35 E
q
ui
p
ment Renta
l
Le
g
ac
y
Healthcare Financial Service
s
668 $ 668 15
16
V 35 Auto Renta
l
Le
g
ac
y
Healthcare Financial Service
s
6,515 6,515 16
17
V 15 Nursin
g
Pa
y
roll Taxes / Benefits Le
g
ac
y
Healthcare Financial Service
s
9,216 9,216 17
18
V 18
19
V 19
20
V 20
21
V 21
22
V 22
23
V 23
24
V 24
25
V 25
26
V 26
27
V 27
28
V 28
29
V 29
30
V 30
31
V 31
32
V 32
33
V 33
34
V 34
35
V 35
36
V 36
37
V 37
38
V 38
39
Total $ $ 16,399 $ * 16,399 39
* Total must agree with the amount recorded on line 34 of Schedule VI.
STATE OF ILLINOIS Page 6C
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VII. RELATED PARTIES (continued)
B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,
management fees, purchase of supplies, and so forth. X YES NO
If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance with
the instructions for determining costs as specified for this form.
1 2 3 Cost Per General Ledger 4 5 Cost to Related Organization 6 7 8 Difference:
Percent Operating Cost Adjustments for
Schedule V Line Item Amount Name of Related Organization of of Related Related Organization
Ownership Organization Costs (7 minus 4)
15 V 5 Utilities $ CF St. Louis LLC $ 1,730 $ 1,730 15
16
V 6 Re
p
airs & Maintenanc
e
CF St. Louis LLC 1,676 1,676 16
17
V 19 Pro
p
ert
y
Valuation Fe
e
CF St. Louis LLC 593 593 17
18
V 19 Accountin
g
Fee
s
CF St. Louis LLC 135 135 18
19
V 20 Dues & Subscri
p
tion
s
CF St. Louis LLC 1 1 19
20
V 21 Office Ex
p
ense CF St. Louis LLC 402 402 20
21
V 26 Insuranc
e
CF St. Louis LLC 434 434 21
22
V 30 De
p
reciatio
n
CF St. Louis LLC 10,670 10,670 22
23
V 32 Interest Ex
p
ens
e
CF St. Louis LLC 5,996 5,996 23
24
V 33 Real Estate Taxes CF St. Louis LLC 5,448 5,448 24
25
V 25
26
V 34 Ren
t
50,057 CF St. Louis LLC (50,057) 26
27
V 27
28
V 28
29
V 29
30
V 30
31
V 31
32
V 32
33
V 33
34
V 34
35
V 35
36
V 36
37
V 37
38
V 38
39
Total $ 50,057 $ 27,086 $ * (22,971) 39
* Total must agree with the amount recorded on line 34 of Schedule VI.
STATE OF ILLINOIS Page 6D
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VII. RELATED PARTIES (continued)
B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,
management fees, purchase of supplies, and so forth. X YES NO
If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance with
the instructions for determining costs as specified for this form.
1 2 3 Cost Per General Ledger 4 5 Cost to Related Organization 6 7 8 Difference:
Percent Operating Cost Adjustments for
Schedule V Line Item Amount Name of Related Organization of of Related Related Organization
Ownership Organization Costs (7 minus 4)
15 V 06 Maintenanc
e
$ 24,000 ML Grou
p
Desi
g
n & Develo
p
men
t
$ 23,412 $ (588) 15
16
V 16
17
V 17
18
V 18
19
V 19
20
V 20
21
V 21
22
V 22
23
V 23
24
V 24
25
V 25
26
V 26
27
V 27
28
V 28
29
V 29
30
V 30
31
V 31
32
V 32
33
V 33
34
V 34
35
V 35
36
V 36
37
V 37
38
V 38
39
Total $ 24,000 $ 23,412 $ * (588) 39
* Total must agree with the amount recorded on line 34 of Schedule VI.
STATE OF ILLINOIS Page 6E
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VII. RELATED PARTIES (continued)
B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,
management fees, purchase of supplies, and so forth. X YES NO
If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance with
the instructions for determining costs as specified for this form.
1 2 3 Cost Per General Ledger 4 5 Cost to Related Organization 6 7 8 Difference:
Percent Operating Cost Adjustments for
Schedule V Line Item Amount Name of Related Organization of of Related Related Organization
Ownership Organization Costs (7 minus 4)
15 V 10 Medical Su
pp
lies $ 9,000 ReMED Services $ 6,287 $ (2,713) 15
16
V 16
17
V 17
18
V 18
19
V 19
20
V 20
21
V 21
22
V 22
23
V 23
24
V 24
25
V 25
26
V 26
27
V 27
28
V 28
29
V 29
30
V 30
31
V 31
32
V 32
33
V 33
34
V 34
35
V 35
36
V 36
37
V 37
38
V 38
39
Total $ 9,000 $ 6,287 $ * (2,713) 39
* Total must agree with the amount recorded on line 34 of Schedule VI.
STATE OF ILLINOIS Page 6F
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VII. RELATED PARTIES (continued)
B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,
management fees, purchase of supplies, and so forth. X YES NO
If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance with
the instructions for determining costs as specified for this form.
1 2 3 Cost Per General Ledger 4 5 Cost to Related Organization 6 7 8 Difference:
Percent Operating Cost Adjustments for
Schedule V Line Item Amount Name of Related Organization of of Related Related Organization
Ownership Organization Costs (7 minus 4)
15 V 19 Pa
y
roll Services $ 54,890 ProPa
y
HR LLC $ 42,315 $ (12,575) 15
16
V 16
17
V 17
18
V 18
19
V 19
20
V 20
21
V 21
22
V 22
23
V 23
24
V 24
25
V 25
26
V 26
27
V 27
28
V 28
29
V 29
30
V 30
31
V 31
32
V 32
33
V 33
34
V 34
35
V 35
36
V 36
37
V 37
38
V 38
39
Total $ 54,890 $ 42,315 $ * (12,575) 39
* Total must agree with the amount recorded on line 34 of Schedule VI.
STATE OF ILLINOIS Page 6G
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VII. RELATED PARTIES (continued)
B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,
management fees, purchase of supplies, and so forth. X YES NO
If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance with
the instructions for determining costs as specified for this form.
1 2 3 Cost Per General Ledger 4 5 Cost to Related Organization 6 7 8 Difference:
Percent Operating Cost Adjustments for
Schedule V Line Item Amount Name of Related Organization of of Related Related Organization
Ownership Organization Costs (7 minus 4)
15 V 04 Laundr
y
Service
s
$ 297,409 EcoBrite Linen $ 297,409 $15
16
V 16
17
V 17
18
V 18
19
V 19
20
V 20
21
V 21
22
V 22
23
V 23
24
V 24
25
V 25
26
V 26
27
V 27
28
V 28
29
V 29
30
V 30
31
V 31
32
V 32
33
V 33
34
V 34
35
V 35
36
V 36
37
V 37
38
V 38
39
Total $ 297,409 $ 297,409 $ * 39
* Total must agree with the amount recorded on line 34 of Schedule VI.
STATE OF ILLINOIS Page 6H
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VII. RELATED PARTIES (continued)
B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,
management fees, purchase of supplies, and so forth. X YES NO
If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance with
the instructions for determining costs as specified for this form.
1 2 3 Cost Per General Ledger 4 5 Cost to Related Organization 6 7 8 Difference:
Percent Operating Cost Adjustments for
Schedule V Line Item Amount Name of Related Organization of of Related Related Organization
Ownership Organization Costs (7 minus 4)
15 V 39 Laborator
y
$ 93,858 Lifescan Labs of Illinoi
s
$ 55,658 $ (38,200) 15
16
V 16
17
V 17
18
V 18
19
V 19
20
V 20
21
V 21
22
V 22
23
V 23
24
V 24
25
V 25
26
V 26
27
V 27
28
V 28
29
V 29
30
V 30
31
V 31
32
V 32
33
V 33
34
V 34
35
V 35
36
V 36
37
V 37
38
V 38
39
Total $ 93,858 $ 55,658 $ * (38,200) 39
* Total must agree with the amount recorded on line 34 of Schedule VI.
STATE OF ILLINOIS Page 6I
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VII. RELATED PARTIES (continued)
B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,
management fees, purchase of supplies, and so forth. YES NO
If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance with
the instructions for determining costs as specified for this form.
1 2 3 Cost Per General Ledger 4 5 Cost to Related Organization 6 7 8 Difference:
Percent Operating Cost Adjustments for
Schedule V Line Item Amount Name of Related Organization of of Related Related Organization
Ownership Organization Costs (7 minus 4)
15 V $ $$ 15
16
V 16
17
V 17
18
V 18
19
V 19
20
V 20
21
V 21
22
V 22
23
V 23
24
V 24
25
V 25
26
V 26
27
V 27
28
V 28
29
V 29
30
V 30
31
V 31
32
V 32
33
V 33
34
V 34
35
V 35
36
V 36
37
V 37
38
V 38
39
Total $ $$* 39
* Total must agree with the amount recorded on line 34 of Schedule VI.
STATE OF ILLINOIS Page 7
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VII. RELATED PARTIES (continued)
C. Statement of Compensation and Other Payments to Owners, Relatives and Members of Board of Directors.
NOTE: ALL owners ( even those with less than 5% ownership) and their relatives who receive any type of compensation from this home
must be listed on this schedule.
1 2 345 6 7 8
Average Hours Per Work
Compensation Week Devoted to this Compensation Included Schedule V.
Received Facility and % of Total in Costs for this Line &
Ownership From Other Work Week Reporting Period** Column
Name Title Function Interest Nursing Homes* Hours Percent Description Amount Reference
1
N/A $1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 TOTAL $ 13
* If the owner(s) of this facility or any other related parties listed above have received compensation from other nursing homes, attach a schedule detailing the name(s)
of the home(s) as well as the amount paid. THIS AMOUNT MUST AGREE TO THE AMOUNTS CLAIMED ON THE THE OTHER NURSING HOMES' COST REPORTS.
**
This must include all forms of compensation paid by related entities and allocated to Schedule V of this report (i.e., management fees).
FAILURE TO PROPERLY COMPLETE THIS SCHEDULE INDICATING ALL FORMS OF COMPENSATION RECEIVED FROM THIS HOME
,
ALL OTHER NURSING HOMES AND MANAGEMENT COMPANIES MAY RESULT IN THE DISALLOWANCE OF SUCH COMPENSATION
STATE OF ILLINOIS Page 8
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VIII. ALLOCATION OF INDIRECT COSTS
Name of Related Or
g
anization
A. Are there an
y
costs included in this re
p
ort which were derived from allocations of central office Street Addres
s
or
p
arent or
g
anization costs? (See instructions.) YES N
O
X Cit
y
/ State / Zi
p
Cod
e
Phone Numbe
r
( )
B. Show the allocation of costs below. If necessar
y
,
p
lease attach worksheets. Fax Numbe
r
( )
12 3456789
Schedule V Unit of Allocation Number of Total Indirect Amount of Salary
Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility Allocation
Reference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6
1 $$ $ 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 TOTALS $$ $ 25
STATE OF ILLINOIS Page 8A
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VIII. ALLOCATION OF INDIRECT COSTS
Name of Related Or
g
anization Legacy Healthcare Financial Services
A. Are there an
y
costs included in this re
p
ort which were derived from allocations of central office Street Addres
s
3450 Oakton Street
or
p
arent or
g
anization costs? (See instructions.) YES X N
O
Cit
y
/ State / Zi
p
Cod
e
Skokie, IL 60076
Phone Numbe
r
( 847) 679-9797
B. Show the allocation of costs below. If necessar
y
,
p
lease attach worksheets. Fax Numbe
r
( 847) 683-2900
12 3456789
Schedule V Unit of Allocation Number of Total Indirect Amount of Salary
Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility Allocation
Reference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6
1 01 Dietician Salar
y
Available Bed Da
y
s 2,540,133 53 $ 130,303 $ 130,303 99,186 $ 5,088 1
2 01 Dietar
y
Su
pp
lies Available Bed Da
y
s 2,540,133 53 697 99,186 27 2
3 02 Food Available Bed Da
y
s 2,540,133 53 249,220 99,186 9,731 3
4 03 Housekee
p
in
g
Available Bed Da
y
s 2,540,133 53 84,952 99,186 3,317 4
5 04 Linen Re
p
lacement Available Bed Da
y
s 2,540,133 53 5,771 99,186 225 5
6 06 Maintenance Salar
y
Available Bed Da
y
s 2,540,133 53 401,986 401,986 99,186 15,697 6
7 06 Re
p
airs & Maintenance Available Bed Da
y
s 2,540,133 53 23,857 99,186 932 7
8 10 Nursin
g
Salar
y
Available Bed Da
y
s 2,540,133 53 3,327,223 3,327,223 99,186 129,920 8
9 10 Nurse/Medical Director Consulta
n
Available Bed Da
y
s 2,540,133 53 314,035 99,186 12,262 9
10 10 Medical Su
pp
lies Available Bed Da
y
s 2,540,133 53 714,824 99,186 27,912 10
11 12 Social Service Salar
y
Available Bed Da
y
s 2,540,133 53 226,662 226,662 99,186 8,851 11
12 11 Activities Pro
g
ram Available Bed Da
y
s 2,540,133 53 335 99,186 13 12
13 12 Social Service Consultant Available Bed Da
y
s 2,540,133 53 893 99,186 35 13
14 17 COO / Administrative Salar
y
Available Bed Da
y
s 2,540,133 53 2,533,078 2,533,078 99,186 98,911 14
15 19 Professional Fees Available Bed Da
y
s 2,540,133 53 831,592 99,186 32,472 15
16 20 Dues / Licenses / Permits Available Bed Da
y
s 2,540,133 53 141,983 99,186 5,544 16
17 21 Clerical & General Wa
g
es Available Bed Da
y
s 2,540,133 53 10,220,453 10,220,453 99,186 399,084 17
18 21 Clerical & Office Ex
p
ense Available Bed Da
y
s 2,540,133 53 745,293 99,186 29,102 18
19 24 Education & Seminars Available Bed Da
y
s 2,540,133 53 5,655 99,186 221 19
20 25 Travel Available Bed Da
y
s 2,540,133 53 189,364 99,186 7,394 20
21 26 Insurance - General Available Bed Da
y
s 2,540,133 53 4,997 99,186 195 21
22 27 Non-Nursin
g
Pa
y
roll Taxes / Bene
f
Available Bed Da
y
s 2,540,133 53 1,015,274 99,186 39,644 22
23 34 Rent Available Bed Da
y
s 2,540,133 53 1,281,940 99,186 50,057 23
24 34 Offsite Stora
g
e / Parkin
g
Available Bed Da
y
s 2,540,133 53 3,949 99,186 154 24
25 TOTALS $ 22,454,338 $ 16,839,706 $ 876,787 25
STATE OF ILLINOIS Page 8B
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VIII. ALLOCATION OF INDIRECT COSTS
Name of Related Or
g
anization Legacy Healthcare Financial Services
A. Are there an
y
costs included in this re
p
ort which were derived from allocations of central office Street Addres
s
3450 Oakton Street
or
p
arent or
g
anization costs? (See instructions.) YES X N
O
Cit
y
/ State / Zi
p
Cod
e
Skokie, IL 60076
Phone Numbe
r
( 847) 679-9797
B. Show the allocation of costs below. If necessar
y
,
p
lease attach worksheets. Fax Numbe
r
( 847) 683-2900
12 3456789
Schedule V Unit of Allocation Number of Total Indirect Amount of Salary
Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility Allocation
Reference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6
1 35 E
q
ui
p
ment Renta
l
Available Bed Da
y
s 2,540,133 53 17,109 99,186 668 1
2 35 Auto Rental Available Bed Da
y
s 2,540,133 53 166,843 99,186 6,515 2
3 15 Nursin
g
Pa
y
roll Taxes / Benefits Available Bed Da
y
s 2,540,133 53 236,021 99,186 9,216 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 TOTALS $ 419,973 $ $ 16,399 25
STATE OF ILLINOIS Page 8C
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VIII. ALLOCATION OF INDIRECT COSTS
Name of Related Or
g
anization CF St. Louis LLC
A. Are there an
y
costs included in this re
p
ort which were derived from allocations of central office Street Addres
s
3450 Oakton Street
or
p
arent or
g
anization costs? (See instructions.) YES X N
O
Cit
y
/ State / Zi
p
Cod
e
Skokie, IL 60076
Phone Numbe
r
( 847) 676-5300
B. Show the allocation of costs below. If necessar
y
,
p
lease attach worksheets. Fax Numbe
r
( 847) 676-5348
12 3456789
Schedule V Unit of Allocation Number of Total Indirect Amount of Salary
Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility Allocation
Reference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6
1 5 Utilities Available Bed Da
y
s 2,540,133 53 $ 44,301 $ 99,186 $ 1,730 1
2 6Re
p
airs & Maintenance Available Bed Da
y
s 2,540,133 53 42,932 99,186 1,676 2
3 19 Pro
p
ert
y
Valuation Fee Available Bed Da
y
s 2,540,133 53 15,181 99,186 593 3
4 19 Accountin
g
Fees Available Bed Da
y
s 2,540,133 53 3,453 99,186 135 4
5 20 Dues & Subscri
p
tions Available Bed Da
y
s 2,540,133 53 23 99,186 15
6 21 Office Ex
p
ense Available Bed Da
y
s 2,540,133 53 10,298 99,186 402 6
7 26 Insurance Available Bed Da
y
s 2,540,133 53 11,124 99,186 434 7
8 30 De
p
reciation Available Bed Da
y
s 2,540,133 53 273,261 99,186 10,670 8
9 32 Interest Ex
p
ense Available Bed Da
y
s 2,540,133 53 153,558 99,186 5,996 9
10 33 Real Estate Taxes Available Bed Da
y
s 2,540,133 53 139,524 99,186 5,448 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 TOTALS $ 693,655 $ $ 27,086 25
STATE OF ILLINOIS Page 8D
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VIII. ALLOCATION OF INDIRECT COSTS
Name of Related Or
g
anization ML Group Design and Development
A. Are there an
y
costs included in this re
p
ort which were derived from allocations of central office Street Addres
s
3424 Oakton St
or
p
arent or
g
anization costs? (See instructions.) YES X N
O
Cit
y
/ State / Zi
p
Cod
e
Skokie, IL 60077
Phone Numbe
r
( 847) 676-5300
B. Show the allocation of costs below. If necessar
y
,
p
lease attach worksheets. Fax Numbe
r
( )
12 3456789
Schedule V Unit of Allocation Number of Total Indirect Amount of Salary
Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility Allocation
Reference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6
1 6 Maintenance Direct $ $ $ 23,412 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 TOTALS $ $ $ 23,412 25
STATE OF ILLINOIS Page 8E
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VIII. ALLOCATION OF INDIRECT COSTS
Name of Related Or
g
anization ReMED Services LLC
A. Are there an
y
costs included in this re
p
ort which were derived from allocations of central office Street Addres
s
3424 Oakton Street, Suite 102
or
p
arent or
g
anization costs? (See instructions.) YES X N
O
Cit
y
/ State / Zi
p
Cod
e
Skokie, IL
Phone Numbe
r
( 847) 440-2600
B. Show the allocation of costs below. If necessar
y
,
p
lease attach worksheets. Fax Numbe
r
( )
12 3456789
Schedule V Unit of Allocation Number of Total Indirect Amount of Salary
Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility Allocation
Reference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6
1 10 Medical Su
pp
lies Direct $ $ $ 6,287 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 TOTALS $ $ $ 6,287 25
STATE OF ILLINOIS Page 8F
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VIII. ALLOCATION OF INDIRECT COSTS
Name of Related Or
g
anization ProPay HR LLC
A. Are there an
y
costs included in this re
p
ort which were derived from allocations of central office Street Addres
s
2201 W. Main St.
or
p
arent or
g
anization costs? (See instructions.) YES X N
O
Cit
y
/ State / Zi
p
Cod
e
Evanston, Illinois 60202
Phone Numbe
r
( (847) 905 3268
B. Show the allocation of costs below. If necessar
y
,
p
lease attach worksheets. Fax Numbe
r
( )
12 3456789
Schedule V Unit of Allocation Number of Total Indirect Amount of Salary
Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility Allocation
Reference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6
1 19 Pa
y
roll Services Direct $ $ $ 42,315 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 TOTALS $ $ $ 42,315 25
STATE OF ILLINOIS Page 8G
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VIII. ALLOCATION OF INDIRECT COSTS
Name of Related Or
g
anization EcoBrite Linen
A. Are there an
y
costs included in this re
p
ort which were derived from allocations of central office Street Addres
s
3712 Jarvis Avenue
or
p
arent or
g
anization costs? (See instructions.) YES X N
O
Cit
y
/ State / Zi
p
Cod
e
Skokie, IL 60076
Phone Numbe
r
( 847) 582-4000
B. Show the allocation of costs below. If necessar
y
,
p
lease attach worksheets. Fax Numbe
r
( )
12 3456789
Schedule V Unit of Allocation Number of Total Indirect Amount of Salary
Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility Allocation
Reference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6
1 4 Laundr
y
Service Direct $ $ $ 297,409 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 TOTALS $ $ $ 297,409 25
STATE OF ILLINOIS Page 8H
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VIII. ALLOCATION OF INDIRECT COSTS
Name of Related Or
g
anization Lifescan Labs of Illinois, LLC
A. Are there an
y
costs included in this report which were derived from allocations of central office Street Address 5255 Golf Road
or parent or
g
anization costs? (See instructions.) YES
X
NO Cit
y
/ State / Zip Code Skokie, IL 60077
Phone Number ( 847) 663 - 8300
B. Show the allocation of costs below. If necessar
y
, please attach worksheets. Fax Number ( )
12 3456789
Schedule V Unit of Allocation Number of Total Indirect Amount of Salary
Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility Allocation
Reference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6
1 39 Laborator
y
Direc
t
$ $ $ 55,658 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 TOTALS $ $ $ 55,658 25
STATE OF ILLINOIS Page 8I
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
VIII. ALLOCATION OF INDIRECT COSTS
Name of Related Or
g
anization
A. Are there an
y
costs included in this re
p
ort which were derived from allocations of central office Street Addres
s
or
p
arent or
g
anization costs? (See instructions.) YES N
O
Cit
y
/ State / Zi
p
Cod
e
Phone Numbe
r
( )
B. Show the allocation of costs below. If necessar
y
,
p
lease attach worksheets. Fax Numbe
r
( )
12 3456789
Schedule V Unit of Allocation Number of Total Indirect Amount of Salary
Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility Allocation
Reference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6
1 $$ $ 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 TOTALS $$ $ 25
STATE OF ILLINOIS Page 9
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE
A. Interest: (Complete details must be provided for each loan - attach a separate schedule if necessary.)
12 3 45678910
Reporting
Monthly Maturity Interest Period
Name of Lender Related** Purpose of Loan Payment Date of Amount of Note Date Rate Interest
YES NO Required Note Original Balance (4 Digits) Expense
A. Directly Facility Related
Long-Term
1 CIBC X Mortgage $$39,695,654 $ 1,418,002 1
2 2
3 3
4 4
5 5
Working Capital
6 Interest Only X 33,236 6
7 Allocated from CF St. Louis X 5,996 7
8 8
9 TOTAL Facility Related $ $ 39,695,654 $ 1,457,234 9
B. Non-Facility Related*
10 Interest Income X (14,969) 10
11 11
12 12
13 13
14 TOTAL Non-Facility Related $ $ $ (14,969) 14
15 TOTALS (line 9+line14) $ $ 39,695,654 $ 1,442,265 15
16) Please indicate the total amount of mortgage insurance expense and the location of this expense on Sch. V. $ None Line # N/A
* Any interest expense reported in this section should be adjusted out on page 5, line 14 and, consequently, page 4, col. 7.
(S
ee
i
nstruct
i
ons.
)
** If there is ANY overlap in ownership between the facility and the lender, this must be indicated in column 2.
(See instructions.)
STATE OF ILLINOIS Pa
g
e 10
Facilit
y
Name & ID Number Warren Barr Gold Coast # 0052415 Re
p
ort Period Be
g
innin
g
: 01/01/20 Endin
g
: 12/31/20
IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE (continued
)
B. Real Estate Taxes
Im
p
ortant
,
p
lease see the next worksheet
,
"RE
_
Tax". The real estate ta
x
1. Real Estate Tax accrual used on 2019 report.
statement and bill must accompan
y
the cost report
.
$ 320,857 1
2. Real Estate Taxes paid during the year: (Indicate the tax year to which this payment applies. If payment covers more than one year, detail below.) $ 1,143,000 2
3. Under or (over) accrual (line 2 minus line 1). $ 822,143 3
4. Real Estate Tax accrual used for 2020 report. (Detail and explain your calculation of this accrual on the lines below.) $ 118,485 4
5. Direct costs of an appeal of tax assessments which has NOT been included in professional fees or other general operating costs on Schedule V, sections A, B or C.
(Describe appeal cost below. Attach copies of invoices to support the cost and a copy of the appeal filed with the county.
)
$ 593 5
6. Subtract a refund of real estate taxes. You must offset the full amount of any direct appeal costs
classified as a real estate tax cost plus one-half of any remaining refund.
TOTAL REFUND $ For Tax Year.
(Attach a copy of the real estate tax appeal board's decision.
)
$6
7. Real Estate Tax expense reported on Schedule V, line 33. This should be a combination of lines 3 thru 6. $ 941,221 7
Real Estate Tax History:
Real Estate Tax Bill for Calendar Year:
2015 832,183 8
FOR BHF USE ONL
Y
2016 909,580 9
2017
977,614 10 13 FROM R. E. TAX STATEMENT FOR 2019 $13
2018
1,088,384 11
2019
1,137,552 12 14 PLUS APPEAL COST FROM LINE 5 $14
2020 Accrual = $1,137,552, x .104 = $118,485 (Rounded)
Allocated from CF St. Louis: $5,448 15 LESS REFUND FROM LINE 6 $15
16 AMOUNT TO USE FOR RATE CALCULATION $16
NOTES: 1. Please indicate a ne
g
ative number b
y
use of brackets( ). Deduct an
y
overaccrual of
taxes from
p
rior
y
ear.
2. If facilit
y
is a non-
p
rofit which
p
a
y
s real estate taxes,
y
ou must attach a denial of an
a
pp
lication for real estate tax exem
p
tion unless the buildin
g
is rented from a for-
p
rofit entit
y
.
Thi
s
d
en
i
a
l
mus
t
b
e no more
th
an
f
our years o
ld
a
t
th
e
ti
me
th
e cos
t
repor
t
i
s
fil
e
d.
2019 LONG TERM CARE REAL ESTATE TAX STATEMENT
FACILITY NAME Warren Barr Gold Coast COUNTY Cook
FACILITY IDPH LICENSE NUMBER 0052415
CONTACT PERSON REGARDING THIS REPORT Steven Lavenda
TELEPHONE (847) 282-6330 FAX #: ( )
A. Summar
y
of Real Estate Tax Cost
Enter the tax index number and real estate tax assessed for 2019 on the lines provided below. Enter only the portion of the
cost that applies to the operation of the nursing home in Column D. Real estate tax applicable to any portion of the nursing
home property which is vacant, rented to other organizations, or used for purposes other than long term care must not be
entered in Column D. Do not include cost for any period other than calendar year 2019.
(A) (B) (C) (D)
Tax
A
pp
licable to
Tax Index Numbe
r
Pro
p
ert
y
Descri
p
tion Total Tax Nursin
g
Home
1. 17-04-423-006-0000 Long Term Care Property $ 23,071.17 $ 23,071.17
2. 17-04-423-019-0000 Long Term Care Property $ 1,114,480.79 $ 1,114,480.79
3. 10-23-406-034-0000 Home Office Allocation $ 459,532.44 $ 5,448.06
4. $ $
5. $ $
6. $ $
7. $ $
8. $ $
9. $ $
10. $ $
TOTALS $ 1,597,084.40 $ 1,143,000.02
B. Real Estate Tax Cost Allocations
Does any portion of the tax bill apply to more than one nursing home, vacant property, or property which is not directly
used for nursing home services? X YES NO
If YES, attach an explanation and a schedule which shows the calculation of the cost allocated to the nursing home.
(Generally the real estate tax cost must be allocated to the nursing home based upon sq. ft. of space used.)
C. Tax Bills
Attach copies of the original 2019 tax bills which were listed in Section A to this statement. Be sure to use the 2019
tax bill which is normally paid during 2020.
PLEASE NOTE: Payment information from the Internet or otherwise is not considered acceptable tax bill
documentation . Facilities located in Cook County are required to provide copies
of their original second
installmen
t
tax bill.
Page 10A
IMPORTANT NOTICE
TO: Long Term Care Facilities with Real Estate Tax Rates
RE: 2019 REAL ESTATE TAX COST DOCUMENTATIO
N
In order to set the real estate tax portion of the capital rate, it is necessary that we obtain additional
information regarding your calendar 2019 real estate tax costs, as well as copies of your original real estate
tax bills for calendar 2019.
Please complete the Real Estate Tax Statement below and include it in the 2020 cost report along with a
copy of your 2019 real estate tax bill.
The cost report will not be considered complete and timely filed until this statement and the corresponding
real estate tax bills are filed. If you have any questions, please call the Bureau of Health Finance at
(217) 782-1630.
2019 LONG TERM CARE REAL ESTATE TAX STATEMENT
FACILITY NAME Warren Barr Gold Coast COUNTY Cook
FACILITY IDPH LICENSE NUMBER 0052415
CONTACT PERSON REGARDING THIS REPORT Steven Lavenda
TELEPHONE ( ) FAX #: ( )
A. Summar
y
of Real Estate Tax Cost
Enter the tax index number and real estate tax assessed for 2015 on the lines provided below. Enter only the portion of the
cost that applies to the operation of the nursing home in Column D. Real estate tax applicable to any portion of the nursing
home property which is vacant, rented to other organizations, or used for purposes other than long term care must not be
entered in Column D. Do not include cost for any period other than calendar year 2015.
(A) (B) (C) (D)
Tax
A
pp
licable to
Tax Index Numbe
r
Pro
p
ert
y
Descri
p
tion Total Tax Nursin
g
Home
1. $$
2. $$
3. $$
4. $ $
5. $ $
6. $ $
7. $ $
8. $ $
9. $ $
10. $ $
TOTALS $$
B. Real Estate Tax Cost Allocations
Does any portion of the tax bill apply to more than one nursing home, vacant property, or property which is not directly
used for nursing home services? YES NO
If YES, attach an explanation and a schedule which shows the calculation of the cost allocated to the nursing home.
(Generally the real estate tax cost must be allocated to the nursing home based upon sq. ft. of space used.)
C. Tax Bills
Attach a copy of the original 2015 tax bills which were listed in Section A to this statement. Be sure to use the 2015
tax bill which is normally paid during 2016.
PLEASE NOTE: Payment information from the Internet or otherwise is not considered acceptable tax bill
documentation . Facilities located in Cook County are required to provide copies
of their original second
installmen
t
tax bill.
Page 10B
STATE OF ILLINOIS Pa
g
e 11
Facilit
y
Name & ID Number Warren Barr Gold Coas
t
# 0052415 Report Period Be
g
innin
g
: 01/01/20 Endin
g
: 12/31/20
X. BUILDING AND GENERAL INFORMATION:
A. Square Feet: 130,152 B. General Construction T
y
pe: Exterior Concrete Frame Steel Number of Stories 9
C. Does the Operatin
g
Entit
y
? (a) Own the Facilit
y
X
(b) Rent from a Related Or
g
anization. (c) Rent from Completel
y
Unrelated
O
r
g
an
i
zat
i
on.
(Facilities checkin
g
(a) or (b) must complete Schedule XI. Those checkin
g
(c) ma
y
complete Schedule XI or Schedule XII-A. See instructions.)
D. Does the Operatin
g
Entit
y
?
X
(a) Own the Equipment
X
(b) Rent equipment from a Related Or
g
anization.
X
(c) Rent equipment from Completel
y
Unrelated
O
r
g
an
i
zat
i
on.
(Facilities checkin
g
(a) or (b) must complete Schedule XI-C. Those checkin
g
(c) ma
y
complete Schedule XI-C or Schedule XII-B. See instructions.)
E. List all other business entities owned b
y
this operatin
g
entit
y
or related to the operatin
g
entit
y
that are located on or ad
j
acent to this nursin
g
home's
g
rounds
(such as, but not limited to, apartments, assisted livin
g
facilities, da
y
trainin
g
facilities, da
y
care, independent livin
g
facilities, CNA trainin
g
facilities, etc.)
List entit
y
name, t
y
pe of business, square foota
g
e, and number of beds/units available (where applicable).
None
F. Does this cost report reflect an
y
or
g
anization or pre-operatin
g
costs which are bein
g
amortized? YES
X
NO
If so, please complete the followin
g
:
1. Total Amount Incurred: 2. Number of Years Over Which it is Bein
g
Amortized:
3. Current Period Amortization: 4. Dates Incurred:
Nature of Costs:
(Attach a complete schedule detailin
g
the total amount of or
g
anization and pre-operatin
g
costs.)
XI. OWNERSHIP COSTS:
1 2 3 4
A. Land. Use Square Feet Year Acquired Cost
1 Facilit
y
$ 4,000,000 1
2 Allocated from CF St. Louis, LLC 7,706 2
3 TOTALS $ 4,007,706 3
STATE
OF
ILLINOIS
P
age
12
F
ac
ili
ty
N
ame
&
ID
N
um
b
er
W
arren
B
arr
G
o
ld
C
oast
#
0052415
R
eport
P
er
i
o
d
B
eg
i
nn
i
ng:
01/01/20
E
n
di
ng:
12/31/20
XI
.
OWNERSHIP
COSTS
(
cont
i
nue
d)
B
.
B
u
ildi
ng an
d
I
mprovement
C
osts-
I
nc
l
u
di
ng
Fi
xe
d
E
qu
i
pment.
(S
ee
i
nstruct
i
ons.
)
R
oun
d
a
ll
num
b
ers to nearest
d
o
ll
ar.
1
2
3
4
5
6
7
8
9
FOR
BHF
USE
ONLY
Y
ear
Y
ear
C
urrent
B
oo
k
Lif
e
S
tra
i
g
h
t
Li
ne
A
ccumu
l
ate
d
B
e
d
s
*
A
cqu
i
re
d
C
onstructe
d
C
ost
D
eprec
i
at
i
on
i
n
Y
ears
D
eprec
i
at
i
on
Adj
ustments
D
eprec
i
at
i
on
4 271 2013 1976 $ 30,630,000 $ 550,468 39 $ 785,385 $ 234,917 $ 5,186,053 4
5 5
6 6
7 7
8 8
I
mprovement
T
ype
**
1
9 Variou
s
2013
891
,
734
20
44
,
587
44
,
587
363
,
386
9
2
10 Variou
s
2014
589
,
334
20
29
,
467
29
,
467
237
,
992
10
3
11 Variou
s
2015
844
,
194
20
42
,
210
42
,
210
253
,
696
11
4
12 Variou
s
2016
3
,
550
,
079
20
177
,
504
177
,
504
891
,
877
12
5
13 13
6
14 14
7
15 15
8
16 16
9
17 17
10
18 18
11
19 19
12
20 20
13
21 21
14
22 22
15
23 23
16
24 24
17
25 25
18
26 26
19
27 27
20
28 28
21
29 29
22
30 30
23
31 31
24
32 32
25
33 33
26
34 34
27
35 35
28 36 36
*Total beds on this schedule must a
g
ree with
p
a
g
e 2
.
See Pa
g
e 12A
,
Line 70 for total
**Im
p
rovement t
yp
e must be detailed in order for the cost re
p
ort to be considered com
p
let
e
STATE
OF
ILLINOIS
P
age
12A
F
ac
ili
ty
N
ame
&
ID
N
um
b
er
W
arren
B
arr
G
o
ld
C
oast
#
0052415
R
eport
P
er
i
o
d
B
eg
i
nn
i
ng:
01/01/20
E
n
di
ng:
12/31/20
XI
.
OWNERSHIP
COSTS
(
cont
i
nue
d)
B
.
B
u
ildi
ng an
d
I
mprovement
C
osts-
I
nc
l
u
di
ng
Fi
xe
d
E
qu
i
pment.
(S
ee
i
nstruct
i
ons.
)
R
oun
d
a
ll
num
b
ers to nearest
d
o
ll
ar.
1
3
4
5
6
7
8
9
Y
ear
C
urrent
B
oo
k
Lif
e
S
tra
i
g
h
t
Li
ne
A
ccumu
l
ate
d
Improvement Type**
C
onstructe
d
C
ost
D
eprec
i
at
i
on
i
n
Y
ears
D
eprec
i
at
i
on
Adj
ustments
D
eprec
i
at
i
on
29 37 $ $ $$$ 37
30 38 38
31 39 39
32 40 40
33 41 41
34
42 42
35
43 43
36
44 44
37
45 45
38
46 46
39
47 47
40
48 48
41
49 49
42
50 50
43
51 51
44
52 52
45
53 53
46
54 54
47
55 55
48
56 56
49
57 57
50
58 58
51
59 59
52
60 60
53
61 61
54
62 62
55
63 63
56
64 64
57
65 65
58
66 66
67
Related Buildin
g
Com
p
an
y
(
Pa
g
es 12F & 12G
)
67
68
Related Part
y
Allocations
(
Pa
g
es 12H & 12I
)
362
,
687
9
,
837
17
,
245
7
,
408
77
,
150
68
69
Financial Statement De
p
reciation
69
70
TOTAL (lines 4 thru 69) $ 36,868,028 $ 560,305 $ 1,096,397 $ 536,092 $ 7,010,154 70
**Improvement type must be detailed in order for the cost report to be considered complete.
STATE
OF
ILLINOIS
P
age
12B
F
ac
ili
ty
N
ame
&
ID
N
um
b
er
W
arren
B
arr
G
o
ld
C
oast
#
0052415
R
eport
P
er
i
o
d
B
eg
i
nn
i
ng:
01/01/20
E
n
di
ng:
12/31/20
XI
.
OWNERSHIP
COSTS
(
cont
i
nue
d)
B
.
B
u
ildi
ng an
d
I
mprovement
C
osts-
I
nc
l
u
di
ng
Fi
xe
d
E
qu
i
pment.
(S
ee
i
nstruct
i
ons.
)
R
oun
d
a
ll
num
b
ers to nearest
d
o
ll
ar.
1
3
4
5
6
7
8
9
Y
ear
C
urrent
B
oo
k
Lif
e
S
tra
i
g
h
t
Li
ne
A
ccumu
l
ate
d
Improvement Type**
C
onstructe
d
C
ost
D
eprec
i
at
i
on
i
n
Y
ears
D
eprec
i
at
i
on
Adj
ustments
D
eprec
i
at
i
on
1
Totals from Pa
g
e 12A
,
Carried Forward
$ 36,868,028 $ 560,305 $ 1,096,397 $ 536,092 $ 7,010,154 1
1 2
Electrical Work For Corridor Door O
p
erato
r
2017 4,350 20 218 218 870 2
2 3
Installed Glass Mirror Rooms 401 And 405
2017 3,070 20 154 154 614
3
3 4
Installed Two Ke
yp
ads-3Rd Flr West Stairwell/E
g
ress Locks 2Nd
F
2017 8,876 20 444 444 1,775 4
4 5
Installed New Drain In Kitchen/Cut Floor Tile/Pi
p
es
2017 3,650 20 183 183 730
5
5
6
Re
p
aired Pi
p
es In Rooms 814 And 815 2017 3
,
870
20
194
194
774
6
6
7
Medical Curtains
2017
5
,
775
20
289
289
1
,
155
7
7
8
Fire S
p
rinkler S
y
stem Re
p
air
2017
3
,
473
20
174
174
695
8
8
9
Re
p
aired Leakin
g
Pi
p
es
2017
3
,
245
20
162
162
649
9
9
10
Hvac Re
p
air - Thermostat
,
Sensor
,
Wires
,
Rela
y
s
,
Filters
,
Belts
2017
3
,
682
20
184
184
736
10
10
11
Hvac-Air Handler Control S
y
stem
2017
10
,
892
20
545
545
2
,
178
11
11
12
Parkin
g
Entrance Door Re
p
air
2017
3
,
968
20
198
198
794
12
12
13
Hvac - Air Handler Control S
y
stem
2017
11
,
308
20
565
565
2
,
262
13
13
14
Cubicle Curtain Tracks For 5Th And 6Th Floor
2017
6
,
224
20
311
311
1
,
245
14
14
15
Removal & Re
p
air Of #1 Heatin
g
Pum
p
2017
4
,
250
20
213
213
850
15
15
16
Re
p
lace Broken Pi
p
e In Dishwasher Area
2017
3
,
500
20
175
175
700
16
16
17
Elevator Floorin
g
& 9Th Fl Outlets
2017
4
,
340
20
217
217
868
17
17
18
Re
p
air Handrails On 5Th
,
6Th
,
7Th Floors & 9Th Fl Hvac
2017
30
,
261
20
1
,
513
1
,
513
6
,
052
18
18
19
90 Cubicle Curtains
2017
18
,
749
20
937
937
3
,
750
19
19
20
Re
p
air & Ad
j
usted Elevator Roller Guide
2017
3
,
738
20
187
187
748
20
20
21
Dam
p
er Re
p
lacement
(
8
,
418
)
2018
7
,
792
20
390
390
1
,
169
21
21
22
Re
p
lace Com
p
ressor & Leakin
g
Pi
p
e
(
6
,
605
)
2018
6
,
114
20
306
306
917
22
22
23
Re
p
air Air Handler Coil
(
4
,
176
)
2018
3
,
866
20
193
193
580
23
23
24
Install Booster Pum
p
For Domestic Water S
y
stem
(
3
,
924
)
2018
3
,
632
20
182
182
545
24
24
25
Re
p
air Heat Circulatin
g
Pum
p
(
13
,
059
)
2018
12
,
087
20
604
604
1
,
813
25
25
26
Re
p
air Doors On 2
,
5
,
6-8 Floors
(
4
,
250
)
2018
3
,
934
20
197
197
590
26
26
27
Install New Buildin
g
Drain Pi
p
e
(
5
,
700
)
2018
5
,
276
20
264
264
791
27
27
28
21 Ke
yp
ad Deadbolt With Auto Lock
(
2
,
705
)
2018
2
,
504
20
125
125
376
28
28
29
Re
p
air 2Nd Fl Air Handlers In Boiler Rm
(
5
,
100
)
2018
4
,
721
20
236
236
708
29
29
30
Bathroom Wall & Fl Tiles
,
Wall
p
a
p
er
,
Lobb
y
Electrical
(
10
,
700
)
2018
9
,
904
20
495
495
1
,
486
30
30
31
Illuminated Lobb
y
Si
g
n
(
2
,
699
)
2018
2
,
498
20
125
125
375
31
31
32
2Nd Fl Mechanical Rm Chilled Water Pum
p
s
(
6
,
000
)
2018
5
,
554
20
278
278
833
32
32
33
Paint Resident Rms & Waitin
g
Area Ceilin
g
Re
p
air
(
8
,
550
)
2018
7
,
914
20
396
396
1
,
187
33
34
TOTAL (lines 1 thru 33) $ 37,081,042 $ 560,305 $ 1,107,048 $ 546,743 $ 7,048,967 34
**Improvement type must be detailed in order for the cost report to be considered complete.
STATE
OF
ILLINOIS
P
age
12C
F
ac
ili
ty
N
ame
&
ID
N
um
b
er
W
arren
B
arr
G
o
ld
C
oast
#
0052415
R
eport
P
er
i
o
d
B
eg
i
nn
i
ng:
01/01/20
E
n
di
ng:
12/31/20
XI
.
OWNERSHIP
COSTS
(
cont
i
nue
d)
B
.
B
u
ildi
ng an
d
I
mprovement
C
osts-
I
nc
l
u
di
ng
Fi
xe
d
E
qu
i
pment.
(S
ee
i
nstruct
i
ons.
)
R
oun
d
a
ll
num
b
ers to nearest
d
o
ll
ar.
1
3
4
5
6
7
8
9
Y
ear
C
urrent
B
oo
k
Lif
e
S
tra
i
g
h
t
Li
ne
A
ccumu
l
ate
d
Improvement Type**
C
onstructe
d
C
ost
D
eprec
i
at
i
on
i
n
Y
ears
D
eprec
i
at
i
on
Adj
ustments
D
eprec
i
at
i
on
1
Totals from Pa
g
e 12B
,
Carried Forward
$ 37,081,042 $ 560,305 $ 1,107,048 $ 546,743 $ 7,048,967 1
33 2
Re
p
aired Dr
y
walls In Resident Rms On Fl 5-8
(
4
,
250
)
2018 3,934 20 197 197 590 2
34 3
Install New Coil In Conference Rm A
(
3
,
560
)
2018 3,295 20 165 165 494 3
35 4
Door Holder Installation
(
7
,
529
)
2018 6,969 20 348 348 1,045 4
36 5
Re
p
air Door On East Side Of Buildin
g
(
3
,
785
)
2018 3,503 20 175 175 525 5
37
6
Refurbish Marle
y
Coolin
g
Tower
(
38
,
225
)
2018 35
,
381
20
1
,
769
1
,
769
5
,
307
6
38
7
Lobb
y
Chandelier & Car
p
et
,
Lobb
y
Bathroom Tile
(
13
,
119
)
2018
12
,
143
20
607
607
1
,
821
7
39
8
Paint Ceilin
g
& Install Li
g
htin
g
Fixtures In Lobb
y
(
10
,
897
)
2018
10
,
086
20
504
504
1
,
513
8
40
9
Lobb
y
Car
p
et
(
2
,
521
)
2018
2
,
333
20
117
117
350
9
41
10
9Th Fl Air Handler Controls Re
p
air
(
12
,
780
)
2018
11
,
829
20
591
591
1
,
774
10
42
11
Re
p
air Water Su
pp
l
y
Lines
(
8
,
955
)
2018
8
,
289
20
414
414
1
,
243
11
43
12
Re
p
air 9Th Fl Pt Walls
(
2
,
650
)
2018
2
,
453
20
123
123
368
12
44
13
Hallwa
y
& Lobb
y
Make-U
p
Air Controls Re
p
air
(
18
,
000
)
2018
16
,
661
20
833
833
2
,
499
13
45
14
Desi
g
n Fee For Tiles
(
12
,
750
)
2018
11
,
801
20
590
590
1
,
770
14
46
15
Pi
p
in
g
Re
p
airs On Dual Tem
p
S
y
stem
(
5
,
681
)
2018
5
,
258
20
263
263
789
15
47
16
Re
p
air Ducts On 3Rd & 4Th Fl Soc Serv Office
(
4
,
705
)
2018
4
,
355
20
218
218
653
16
48
17
Re
p
air Hot Water Valves On U
pp
er Floors
(
5
,
120
)
2018
4
,
739
20
237
237
711
17
49
18
Paint Third And Fourth Floor Hallwa
y
s
(
$36000
)
2019
34
,
888
20
1
,
744
1
,
744
2
,
644
18
50
19
Kitchen Floorin
g
(
$9850
)
2019
9
,
546
20
477
477
888
19
51
20
Intall New Am
p
lifier For Overhead Pa
g
in
g,
Rewire Cables
(
$5268
.
2019
5
,
106
20
255
255
563
20
52
21
Wire Re
p
air For Gara
g
e And Stairs Em Li
g
hts
(
$2778
)
2019
2
,
692
20
135
135
389
21
53
22
Install 2 New Circuit Breakers
,
Ptac Unit - 1St Floor
,
Exit Si
g
n G
a
2019
3
,
458
20
173
173
500
22
54
23
Heatin
g
S
y
stem Re
p
air - Coils/Water Leaks - Hr Office
,
2Nd/9Th
F
2019
18
,
598
20
930
930
2
,
689
23
55
24
Buildin
g
Im
p
rovement
(
$2519.79
)
2019
2
,
442
20
122
122
269
24
56
25
Install 2 Plenum Rated Heaters In Attic
(
$6200
)
2019
6
,
008
20
300
300
965
25
57
26
Installation Of Arial Call Station Communication S
y
stem
(
$3326
7
2019
10
,
746
20
537
537
2
,
914
26
58
27
Re
p
aired Pavement/As
p
halt
(
$2800
)
2019
2
,
713
20
136
136
206
27
59
28
Installed End Suction Pum
p
(
$6000
)
2019
5
,
815
20
291
291
441
28
60
29
Installed 8Th Floor Nurse Call S
y
stem
(
$35000
)
2019
33
,
919
20
1
,
696
1
,
696
2
,
279
29
61
30
Common Area /Restrooms Si
g
ns
(
$4598.78
)
2019
4
,
457
20
223
223
325
30
62
31
Hvac S
y
stems - Wirin
g,
Junction Box
(
$3125
)
2019
3
,
028
20
151
151
303
31
63
32
Re
p
aired Doors
(
$7378.51
)
2019
7
,
151
20
358
358
715
32
64
33
Re
p
aired And Re
p
laced Parts For Hvac/Boiler S
y
stem
(
$10
,
937.4
7
2019
10
,
600
20
530
530
1
,
060
33
34
TOTAL (lines 1 thru 33) $ 37,385,237 $ 560,305 $ 1,122,257 $ 561,952 $ 7,087,570 34
**Improvement type must be detailed in order for the cost report to be considered complete.
STATE
OF
ILLINOIS
P
age
12D
F
ac
ili
ty
N
ame
&
ID
N
um
b
er
W
arren
B
arr
G
o
ld
C
oast
#
0052415
R
eport
P
er
i
o
d
B
eg
i
nn
i
ng:
01/01/20
E
n
di
ng:
12/31/20
XI
.
OWNERSHIP
COSTS
(
cont
i
nue
d)
B
.
B
u
ildi
ng an
d
I
mprovement
C
osts-
I
nc
l
u
di
ng
Fi
xe
d
E
qu
i
pment.
(S
ee
i
nstruct
i
ons.
)
R
oun
d
a
ll
num
b
ers to nearest
d
o
ll
ar.
1
3
4
5
6
7
8
9
Y
ear
C
urrent
B
oo
k
Lif
e
S
tra
i
g
h
t
Li
ne
A
ccumu
l
ate
d
Improvement Type**
C
onstructe
d
C
ost
D
eprec
i
at
i
on
i
n
Y
ears
D
eprec
i
at
i
on
Adj
ustments
D
eprec
i
at
i
on
1
Totals from Pa
g
e 12C
,
Carried Forward
$ 37,385,237 $ 560,305 $ 1,122,257 $ 561,952 $ 7,087,570 1
65 2
Re
p
aired And Installed Condensate Pum
p
s For Hvac/Boiler S
y
ste
m
2019 3,792 20 190 190 379 2
66 3
Re
p
aired Leakin
g
Heatin
g
Pi
p
e In Laundr
y
Room
(
$14
,
755
)
2020 14,394 20 720 720 720 3
67 4
Install New Ddc Controls For Boiler S
y
stem
(
$22
,
578
)
2020 22,025 20 1,101 1,101 1,101 4
68 5
Coolin
g
Tower-Installed Drain Plu
g,
New Rin
g
-O Gasket
(
$3
,
964.
9
2020 3,868 20 193 193 198 5
69
6
Chiller Re
p
air - Rebuild 4 Contactors
(
$4
,
407.84
)
2020 4
,
300
20
215
215
220
6
70
7
Exhaust Fan Re
p
air
(
$3
,
622.84
)
2020
3
,
534
20
177
177
177
7
71
8
Boiler Re
p
air - Re
p
lace Ru
p
tured Freeze Plu
g
s
(
$7
,
416.26
)
2020
7
,
235
20
362
362
362
8
72
9
Re
p
air Broken Chilled Water Line-2Nd Flr Ahu Kitchen Unit
(
$1
5
2020
15
,
374
20
769
769
788
9
73
10
Ram
p
Gate Re
p
air-Re
p
lace Loo
p
s With Sensors
(
$3
,
921.19
)
2020
3
,
825
20
191
191
196
10
74
11
Heatin
g
/Coolin
g
Pi
p
in
g
Re
p
air
(
$17
,
865
)
2020
17
,
427
20
871
871
871
11
75
12
Install Drives On 2Nd Flr Mua And Penthouse Mua
(
$14
,
555.25
)
2020
14
,
199
20
710
710
728
12
76
13
Re
p
air Roof Cracks & Seams
,
Electrical Contractor Re
p
air-2Nd
F
2020
2
,
911
20
146
146
149
13
77
14
Re
p
lace Reader Interface Board For Gara
g
e Door
(
$2
,
688
)
2020
2
,
622
20
131
131
134
14
78
15
Re
p
air Door O
p
erator On Elevator
(
$5
,
632
)
2020
5
,
494
20
275
275
282
15
79
16 16
80
17 17
81
18 18
82
19 19
83
20 20
84
21 21
85
22 22
86
23 23
87
24 24
88
25 25
89
26 26
90
27 27
91
28 28
92
29 29
93
30 30
94
31 31
95
32 32
96
33 33
34
TOTAL (lines 1 thru 33) $ 37,506,235 $ 560,305 $ 1,128,307 $ 568,002 $ 7,093,875 34
**Improvement type must be detailed in order for the cost report to be considered complete.
STATE
OF
ILLINOIS
P
age
12E
F
ac
ili
ty
N
ame
&
ID
N
um
b
er
W
arren
B
arr
G
o
ld
C
oast
#
0052415
R
eport
P
er
i
o
d
B
eg
i
nn
i
ng:
01/01/20
E
n
di
ng:
12/31/20
XI
.
OWNERSHIP
COSTS
(
cont
i
nue
d)
B
.
B
u
ildi
ng an
d
I
mprovement
C
osts-
I
nc
l
u
di
ng
Fi
xe
d
E
qu
i
pment.
(S
ee
i
nstruct
i
ons.
)
R
oun
d
a
ll
num
b
ers to nearest
d
o
ll
ar.
1
3
4
5
6
7
8
9
Y
ear
C
urrent
B
oo
k
Lif
e
S
tra
i
g
h
t
Li
ne
A
ccumu
l
ate
d
Improvement Type**
C
onstructe
d
C
ost
D
eprec
i
at
i
on
i
n
Y
ears
D
eprec
i
at
i
on
Adj
ustments
D
eprec
i
at
i
on
1
Totals from Pa
g
e 12D
,
Carried Forward
$ 37,506,235 $ 560,305 $ 1,128,307 $ 568,002 $ 7,093,875 1
97 2 2
98 3 3
99 4 4
100 5 5
101
6 6
102
7 7
103
8 8
104
9 9
105
10 10
106
11 11
107
12 12
108
13 13
109
14 14
110
15 15
111
16 16
112
17 17
113
18 18
114
19 19
115
20 20
116
21 21
117
22 22
118
23 23
119
24 24
120
25 25
121
26 26
122
27 27
123
28 28
124
29 29
125
30 30
126
31 31
127
32 32
128
33 33
34
TOTAL (lines 1 thru 33) $ 37,506,235 $ 560,305 $ 1,128,307 $ 568,002 $ 7,093,875 34
**Improvement type must be detailed in order for the cost report to be considered complete.
STATE
OF
ILLINOIS
P
age
12F
F
ac
ili
ty
N
ame
&
ID
N
um
b
er
W
arren
B
arr
G
o
ld
C
oast
#
0052415
R
eport
P
er
i
o
d
B
eg
i
nn
i
ng:
01/01/20
E
n
di
ng:
12/31/20
XI
.
OWNERSHIP
COSTS
(
cont
i
nue
d)
B
.
B
u
ildi
ng an
d
I
mprovement
C
osts-
I
nc
l
u
di
ng
Fi
xe
d
E
qu
i
pment.
(S
ee
i
nstruct
i
ons.
)
R
oun
d
a
ll
num
b
ers to nearest
d
o
ll
ar.
1
3
4
5
6
7
8
9
Y
ear
C
urrent
B
oo
k
Lif
e
S
tra
i
g
h
t
Li
ne
A
ccumu
l
ate
d
Improvement Type**
C
onstructe
d
C
ost
D
eprec
i
at
i
on
i
n
Y
ears
D
eprec
i
at
i
on
Adj
ustments
D
eprec
i
at
i
on
1
Buildin
g
Com
p
an
y
$ $ $$$ 1
2 2
3 3
4 4
5 5
6 6
7 7
8
Leasehold Im
p
rovements:
8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31
32 32
33 33
34
TOTAL (lines 1 thru 33) $ $ $$$ 34
**Improvement type must be detailed in order for the cost report to be considered complete.
STATE
OF
ILLINOIS
P
age
12G
F
ac
ili
ty
N
ame
&
ID
N
um
b
er
W
arren
B
arr
G
o
ld
C
oast
#
0052415
R
eport
P
er
i
o
d
B
eg
i
nn
i
ng:
01/01/20
E
n
di
ng:
12/31/20
XI
.
OWNERSHIP
COSTS
(
cont
i
nue
d)
B
.
B
u
ildi
ng an
d
I
mprovement
C
osts-
I
nc
l
u
di
ng
Fi
xe
d
E
qu
i
pment.
(S
ee
i
nstruct
i
ons.
)
R
oun
d
a
ll
num
b
ers to nearest
d
o
ll
ar.
1
3
4
5
6
7
8
9
Y
ear
C
urrent
B
oo
k
Lif
e
S
tra
i
g
h
t
Li
ne
A
ccumu
l
ate
d
Improvement Type**
C
onstructe
d
C
ost
D
eprec
i
at
i
on
i
n
Y
ears
D
eprec
i
at
i
on
Adj
ustments
D
eprec
i
at
i
on
1
Totals from Pa
g
e 12F
,
Carried Forward
$ $ $$$ 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31
32 32
33 33
34
TOTAL (lines 1 thru 33) $ $ $$$ 34
**Improvement type must be detailed in order for the cost report to be considered complete.
STATE
OF
ILLINOIS
P
age
12H
F
ac
ili
ty
N
ame
&
ID
N
um
b
er
W
arren
B
arr
G
o
ld
C
oast
#
0052415
R
eport
P
er
i
o
d
B
eg
i
nn
i
ng:
01/01/20
E
n
di
ng:
12/31/20
XI
.
OWNERSHIP
COSTS
(
cont
i
nue
d)
B
.
B
u
ildi
ng an
d
I
mprovement
C
osts-
I
nc
l
u
di
ng
Fi
xe
d
E
qu
i
pment.
(S
ee
i
nstruct
i
ons.
)
R
oun
d
a
ll
num
b
ers to nearest
d
o
ll
ar.
1
3
4
5
6
7
8
9
Y
ear
C
urrent
B
oo
k
Lif
e
S
tra
i
g
h
t
Li
ne
A
ccumu
l
ate
d
Improvement Type**
C
onstructe
d
C
ost
D
eprec
i
at
i
on
i
n
Y
ears
D
eprec
i
at
i
on
Adj
ustments
D
eprec
i
at
i
on
1
Related Part
y
1
2
Buildin
g
s:
2
3
Allocated from CF St. Louis
,
LLC
2016 41,495 1,927 35 1,186 (741) 5,928
3
4 4
5 5
6 6
7 7
8
Leasehold Im
p
rovements:
8
9
Allocated from CF St. Louis
,
LLC
2016
257
,
625
6
,
356
20
12
,
881
6
,
526
64
,
406
9
10
Allocated from CF St. Louis
,
LLC
2017
5
,
980
148
20
299
151
1
,
196
10
11
Allocated from CF St. Louis
,
LLC
2019
54
,
197
1
,
337
20
2
,
710
1
,
373
5
,
420
11
12
Allocated from CF St. Louis
,
LLC
2019
2
,
851
70
20
143
72
143
12
13 13
14
Allocated from Le
g
ac
y
HC
2018
308
20
15
15
46
14
15
Allocated from Le
g
ac
y
HC
2020
232
20
12
12
12
15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31
32 32
33 33
34
TOTAL (lines 1 thru 33) $ 362,687 $ 9,837 $ 17,245 $ 7,408 $ 77,150 34
**Improvement type must be detailed in order for the cost report to be considered complete.
STATE
OF
ILLINOIS
P
age
12I
F
ac
ili
ty
N
ame
&
ID
N
um
b
er
W
arren
B
arr
G
o
ld
C
oast
#
0052415
R
eport
P
er
i
o
d
B
eg
i
nn
i
ng:
01/01/20
E
n
di
ng:
12/31/20
XI
.
OWNERSHIP
COSTS
(
cont
i
nue
d)
B
.
B
u
ildi
ng an
d
I
mprovement
C
osts-
I
nc
l
u
di
ng
Fi
xe
d
E
qu
i
pment.
(S
ee
i
nstruct
i
ons.
)
R
oun
d
a
ll
num
b
ers to nearest
d
o
ll
ar.
1
3
4
5
6
7
8
9
Y
ear
C
urrent
B
oo
k
Lif
e
S
tra
i
g
h
t
Li
ne
A
ccumu
l
ate
d
Improvement Type**
C
onstructe
d
C
ost
D
eprec
i
at
i
on
i
n
Y
ears
D
eprec
i
at
i
on
Adj
ustments
D
eprec
i
at
i
on
1
Totals from Pa
g
e 12H
,
Carried Forward
$ 362,687 $ 9,837 $ 17,245 $ 7,408 $ 77,150 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31
32 32
33 33
34
TOTAL (lines 1 thru 33) $ 362,687 $ 9,837 $ 17,245 $ 7,408 $ 77,150 34
**Improvement type must be detailed in order for the cost report to be considered complete.
STATE OF ILLINOIS Page 13
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
XI. OWNERSHIP COSTS (continued)
C. Equipment Costs-Excluding Transportation. (See instructions.)
Category of 1 Current Book Straight Line 4 Componen
t
Accumulated
Equipment Cost Depreciation 2 Depreciation 3 Adjustments Life 5 Depreciation 6
71 Purchased in Prior Years $ 2,147,827 $ 830 $ 215,797 $ 214,966 10 $ 1,400,193 71
72 Current Year Purchases 18,953 3 1,895 1,893 10 1,896 72
73 Fully Depreciated Assets 73
74 74
75 TOTALS $ 2,166,779 $ 833 $ 217,692 $ 216,859 $ 1,402,089 75
D. Vehicle Costs. (See instructions.)*
1 Model, Make Year 4 Current Book Straight Line 7 Life in Accumulated
Use and Year 2 Acquired 3 Cost Depreciation 5 Depreciation 6 Adjustments Years 8 Depreciation 9
76 Bus 2015 $ 23,822 $$4,764 $ 4,764 5 $ 23,822 76
77 Therapy Bus 2016 3,500 700 700 5 3,500 77
78 78
79 79
80 TOTALS $ 27,322 $ $ 5,464 $ 5,464 $ 27,322 80
E. Summary of Care-Related Assets 1 2
Reference Amoun
t
81 Total Historical Cost (line 3, col.4 + line 70, col.4 + line 75, col.1 + line 80, col.4) + (Pages 12B thru 12I, if applicable) $ 43,708,043 81
82 Current Book Depreciation (line 70, col.5 + line 75, col.2 + line 80, col.5) + (Pages 12B thru 12I, if applicable) $ 561,138 82
83 Straight Line Depreciation (line 70, col.7 + line 75, col.3 + line 80, col.6) + (Pages 12B thru 12I, if applicable) $ 1,351,463 83 **
84 Adjustments (line 70, col.8 + line 75, col.4 + line 80, col.7) + (Pages 12B thru 12I, if applicable) $ 790,325 84
85 Accumulated Depreciation (line 70, col.9 + line 75, col.6 + line 80, col.9) + (Pages 12B thru 12I, if applicable) $ 8,523,28685
F. Depreciable Non-Care Assets Included in General Ledger. (See instructions.) G. Construction-in-Progress
1 2 Current Book Accumulated
Description & Year Acquired Cost Depreciation 3 Depreciation 4 Description Cost
86 $ $ $ 86 92 CIP $ 25,607 92
87 87 93 93
88 88 94 94
89 89 95 $ 25,607 95
90 90
91 TOTALS $ $ $ 91
*
V
ehicles used to transport residents to & fro
m
d
ay
t
ra
i
n
i
ng mus
t
b
e recor
d
e
d
i
n
XI
-
F
, no
t
XI
-
D.
** This must agree with Schedule V line 30, column 8.
STATE OF ILLINOIS Page 14
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
XII. RENTAL COSTS
A. Building and Fixed Equipment (See instructions.)
1. Name of Party Holding Lease: N/A
2. Does the facility also pay real estate taxes in addition to rental amount shown below on line 7, column 4?
If NO, see instructions. YES NO 00
00
123 4 56
Year Number Original Rental Total Years Total Years
Constructed of Beds Lease Date Amount of Lease Renewal Option*
Original 10. Effective dates of current rental agreement:
3 Building: $ 3 Beginning
4 Additions 4 Ending
5 Allocated from Legacy HC 154 5
6 6 11. Rent to be paid in future years under the current
7 TOTAL $ 154 7 rental agreement:
**
8. List separately any amortization of lease expense included on page 4, line 34. Fiscal Year Ending Annual Rent
This amount was calculated by dividing the total amount to be amortized
by the length of the lease . 12. /2021 $
13. /2022 $
9. Option to Buy: YES NO Terms:
*
14. /2023 $
B. Equipment-Excluding Transportation and Fixed Equipment. (See instructions.)
15. Is Movable equipment rental included in building rental? YES NO
16. Rental Amount for movable equipment: $ 19,729 Description: See Attached
(Attach a schedule detailing the breakdown of movable equipment)
C. Vehicle Rental (See instructions.)
12 3 4
Model Year Monthly Lease Rental Expense
Use and Make Payment for this Period * If there is an option to buy the building,
17 2019 Dodge Caravan $ 989.28 $ 10,882 17 please provide complete details on attached
18 Allocated from Legacy HC 6,515 18 schedule.
19 19
20 20 ** This amount plus any amortization of lease
21 TOTAL $ 989 $ 17,397 21 expense must agree with page 4, line 34.
STATE OF ILLINOIS Pa
g
e 15
Facilit
y
Name & ID Number Warren Barr Gold Coast # 0052415 Re
p
ort Period Be
g
innin
g
: 01/01/20 Endin
g
: 12/31/20
XIII. EXPENSES RELATING TO CERTIFIED NURSE AIDE (CNA) TRAINING PROGRAMS (See instructions.
)
A. TYPE OF TRAINING PROGRAM (If CNAs are trained in another facilit
y
p
ro
g
ram, attach a schedule listin
g
the facilit
y
name, address and cost
p
er CNA trained in that facilit
y
.)
1. HAVE YOU TRAINED CNA
s
YES 2. CLASSROOM PORTION: 3. CLINICAL PORTION:
DURING THIS REPOR
T
PERIOD? X NO IN-HOUSE PROGRA
M
IN-HOUSE PROGRA
M
IN OTHER FACILIT
Y
IN OTHER FACILIT
Y
If "
y
es",
p
lease com
p
lete the remainder
of this schedule. If "no",
p
rovide an COMMUNITY COLLEGE HOURS PER CN
A
ex
p
lanation as to wh
y
this trainin
g
was
not necessar
y
. HOURS PER CN
A
B. EXPENSES C. CONTRACTUAL INCOM
E
ALLOCATION OF COSTS (d)
In the box below record the amount of income
y
our
1 2 3 4 facilit
y
received trainin
g
CNAs from other facilities.
Facilit
y
Dro
p
-outs Com
p
leted Contrac
t
Total $
1 Communit
y
Colle
g
e Tuition $$$$
2 Books and Su
pp
lies D. NUMBER OF CNAs TRAINE
D
3 Classroom Wa
g
es (a)
4 Clinical Wa
g
es (b) COMPLETED
5 In-House Trainer Wa
g
es (c) 1. From this facilit
y
6 Trans
p
ortation 2. From other facilities (f)
7 Contractual Pa
y
ments DROP-OUTS
8 CNA Com
p
etenc
y
Tests 1. From this facilit
y
9 TOTALS $$$$ 2. From other facilities (f)
10 SUM OF line 9, col. 1 and 2 (e) $ TOTAL TRAINED
(a) Include wa
g
es
p
aid durin
g
the classroom
p
ortion of trainin
g
. Do not include frin
g
e benefits. (e) The total amount of Dro
p
-out and Com
p
leted Costs for
(b) Include wa
g
es
p
aid durin
g
the clinical
p
ortion of trainin
g
. Do not include frin
g
e benefits.
y
our own CNAs must a
g
ree with Sch. V, line 13, col. 8.
(c) For in-house trainin
g
p
ro
g
rams onl
y
. Do not include frin
g
e benefits. (f) Attach a schedule of the facilit
y
names and addresses
(d) Allocate based on if the CNA is from
y
our facilit
y
or is bein
g
contracted to be trained in of those facilities for which
y
ou trained CNAs.
y
our facilit
y
. Dro
p
-out costs can onl
y
be for costs incurred b
y
y
our own CNAs.
STATE OF ILLINOIS Pa
g
e 16
Facilit
y
Name & ID Number Warren Barr Gold Coast # 0052415 Re
p
ort Period Be
g
innin
g
: 01/01/20 Endin
g
: 12/31/20
XIV. SPECIAL SERVICES (Direct Cost) (See instructions.
)
1 2 3 4 5 6 7 8
Schedule V Staff Outside Practitioner Supplies
Service Line & Column Units of Cost (other than consultant) (Actual or) Total Units Total Cost
Reference Service Units Cost Allocated) (Column 2 + 4) (Col. 3 + 5 + 6)
1 Licensed Occupational Therapist 39 - 03 hrs $ $ 990,351 $ $ 990,351 1
Licensed Speech and Language
2 Development Therapist 39 - 03 hrs 294,777 294,777 2
3 Licensed Recreational Therapist hrs 3
4 Licensed Physical Therapist 39 - 03 hrs 1,075,175 1,075,175 4
5 Physician Care visits 5
6 Dental Care visits 6
7 Work Related Program hrs 7
8 Habilitation hrs 8
# of
9 Pharmacy 39 - 02 prescrpts 840,881 840,881 9
Psychological Services
(Evaluation and Diagnosis/
10 Behavior Modification) hrs 10
11 Academic Education hrs 11
12 Other (specify): 12
13 Other (specify): See Attached 282,521 374,280 656,801 13
14 TOTAL $ $ 2,642,824 $ 1,215,161 $ 3,857,985 14
NOTE: This schedule should include fees (other than consultant fees)
p
aid to licensed
p
ractitioners. Consultant fees should be detailed on
Schedule XVIII-B. Salaries of unlicensed
p
ractitioners, such as CNAs, who hel
p
with the above activities should not be listed
on this schedule
.
STATE OF ILLINOI
S
Pa
g
e 17
Facilit
y
Name & ID Number Warren Barr Gold Coast # 0052415 Re
p
ort Period Be
g
innin
g
: 01/01/20 Endin
g
: 12/31/20
XV. BALANCE SHEET - Unrestricted O
p
eratin
g
Fund
.
As of 12/31/20 (last da
y
of re
p
ortin
g
y
ear)
This re
p
ort must be com
p
leted even if financial statements are attached.
1 2 After 1 2 After
O
p
eratin
g
Consolidation* O
p
eratin
g
Consolidation*
A. Current Assets C. Current Liabilities
1 Cash on Hand and in Banks $ 1,136,089 $ 1,884,439 126 Accounts Payable $ 1,607,498 $ 1,607,498 26
2 Cash-Patient Deposits 4,671 4,671 227 Officer's Accounts Payable 27
Accounts & Short-Term Notes Receivable- 28 Accounts Payable-Patient Deposits 28
3 Patients (less allowance ) 3,098,789 3,098,789 329 Short-Term Notes Payable 29
4 Supply Inventory (priced a
t
) 430 Accrued Salaries Payable 394,006 394,006 30
5 Short-Term Investments 5 Accrued Taxes Payable
6 Prepaid Insurance 22,349 22,349 631 (excluding real estate taxes) 449,531 449,531 31
7 Other Prepaid Expenses 698,030 734,705 732 Accrued Real Estate Taxes(Sch.IX-B) 118,485 32
8 Accounts Receivable (owners or related parties) 833 Accrued Interest Payable 238,664 2,924,787 33
9 Other(specify): See Attached 285,403 285,403 934 Deferred Compensation 34
TOTAL Current Assets 35 Federal and State Income Taxes 35
10 (sum of lines 1 thru 9) $ 5,245,331 $ 6,030,356 10 Other Current Liabilities(specify):
B. Long-Term Assets 36 See Attached 5,000,183 5,012,969 36
11 Long-Term Notes Receivable 11 37 37
12 Long-Term Investments 12 TOTAL Current Liabilities
13 Lan
d
23,562 4,325,933 13 38 (sum of lines 26 thru 37) $ 7,689,882 $ 10,507,276 38
14 Buildings, at Historical Cost 90,848 20,772,935 14 D. Lon
g
-Term Liabilities
15 Leasehold Improvements, at Historical Cost 7,475,564 7,475,564 15 39 Long-Term Notes Payabl
e
39
16 Equipment, at Historical Cost 3,011,782 7,700,324 16 40 Mortgage Payable 39,695,654 40
17 Accumulated Depreciation (book methods) (5,492,071) (14,241,153) 17 41 Bonds Payable 41
18 Deferred Charges 18 42 Deferred Compensation 42
19 Organization & Pre-Operating Costs 19 Other Lon
g
-Term Liabilities(s
p
ecif
y
):
Accumulated Amortization - 43 See Attached 9,327,141 4,332,647 43
20 Organization & Pre-Operating Costs 20 44 44
21 Restricted Funds 21 TOTAL Lon
g
-Term Liabilities
22 Other Long-Term Assets (specify): 22 45 (sum of lines 39 thru 44) $ 9,327,141 $ 44,028,301 45
23 Other(specify): See Attached 7,312,995 8,792,298 23 TOTAL LIABILITIES
TOTAL Long-Term Assets 46 (sum of lines 38 and 45) $ 17,017,023 $ 54,535,577 46
24 (sum of lines 11 thru 23) $ 12,422,680 $ 34,825,901 24
47 TOTAL EQUITY(page 18, line 24) $ 650,988 $ (13,679,320) 47
TOTAL ASSETS TOTAL LIABILITIES AND EQUITY
25 (sum of lines 10 and 24) $ 17,668,011 $ 40,856,257 25 48 (sum of lines 46 and 47) $ 17,668,011 $ 40,856,257 48
*(See instructions.)
STATE OF ILLINOIS Page 18
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
XVI. STATEMENT OF CHANGES IN EQUIT
Y
1
Total
1 Balance at Beginning of Year, as Previously Reported $ 4,749,971 1
2 Restatements (describe): 2
3 Depreciation (2,268,094) 3
4 Bad Debts (800,000) 4
5 Amortization, Legal Fees, Interest, Rounding (803,797) 5
6 Balance at Beginning of Year, as Restated (sum of lines 1-5) $ 878,080 6
A. Additions (deductions):
7 NET Income (Loss) (from page 19, line 43) (227,076) 7
8 Aquisitions of Pooled Companies 8
9 Proceeds from Sale of Stoc
k
9
10 Stock Options Exercised 10
11 Contributions and Grants 11
12 Expenditures for Specific Purposes 12
13 Dividends Paid or Other Distributions to Owners (16) 13
14 Donated Property, Plant, and Equipment 14
15 Other (describe) 15
16 Other (describe) 16
17 TOTAL Additions (deductions) (sum of lines 7-16) $ (227,092) 17
B. Transfers (Itemize):
18 18
19 19
20 20
21 21
22 22
23 TOTAL Transfers (sum of lines 18-22) $ 23
24 BALANCE AT END OF YEAR (sum of lines 6 + 17 + 23) $ 650,988 24 *
* This must agree with page 17, line 47.
STATE OF ILLINOIS Page 19
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
XVII. INCOME STATEMENT (attach any explanatory footnotes necessary to reconcile this schedule to Schedules V and VI.) All required
classifications of revenue and expense must be provided on this form, even if financial statements are attached.
Note: This schedule should show gross revenue and expenses. Do not net revenue against expense
1
2
I. Revenue Amount II. Expenses Amount
A. Inpatient Care A. Operating Expenses
1 Gross Revenue -- All Levels of Care
$ 25,585,403 131 General Services 3,142,844 31
2 Discounts and Allowances for all Levels (12,340,018) 232 Health Care 9,482,781 32
3 SUBTOTAL Inpatient Care (line 1 minus line 2)
$ 13,245,385 3 33 General Administration 4,664,020 33
B. Ancillary Revenue B. Capital Expense
4 Day Care 434 Ownership 4,107,209 34
5 Other Care for Outpatients 5 C. Ancillary Expense
6 Therapy 9,985,477 635 Special Cost Centers 5,077,786 35
7 Oxyge
n
136 736 Provider Participation Fee 435,666 36
8 SUBTOTAL Ancillary Revenue (lines 4 thru 7)
$ 9,985,613 8 D. Other Expenses (specify):
C. Other Operating Revenue 37 37
9 Payments for Education 938 38
10 Other Government Grants 10 39 39
11 CNA Training Reimbursements 11
12
Gif
t an
d
C
o
ff
ee
Sh
op
12
40
T
O
T
A
L EXPEN
S
E
S
(
sum o
f
l
i
nes
31
thru
39)*
$
26
,
910
,
306
40
13 Barber and Beauty Care 13
14 Non-Patient Meals 14 41 Income before Income Taxes (line 30 minus line 40)** (227,076) 41
15 Telephone, Television and Radio 15
16 Rental of Facility Space 16 42 Income Taxes 42
17 Sale of Drugs 813,671 17
18
S
a
l
e o
f
S
upp
li
es to Non-Pat
i
ents
18
43
NET IN
CO
ME
O
R L
OSS
F
O
R THE YE
A
R
(
l
i
ne
41
m
i
nus l
i
ne
42)
$
(22
7,
0
7
6)
43
19 Laboratory 223,118 19
20 Radiology and X-Ra
y
360 20 III. Net Inpatient Revenue detailed by Payer Source
21 Other Medical Services 106,196 21 44 Medicaid - Net Inpatient Revenue
$ 7,247,985 44
22 Laundry 22 45 Private Pay - Net Inpatient Revenue 544,830 45
23 SUBTOTAL Other Operating Revenue (lines 9 thru 22)
$ 1,143,345 23 46 Medicare - Net Inpatient Revenue 4,491,191 46
D. Non-Operating Revenue 47 Other-(specify) Insurance 961,379 47
24 Contributions 24 48 Other-(specify) 48
2
5 Interest an
d
O
t
h
er Investment Income
***
14
,
969
2
5
49
TOTAL In
p
atient Care Revenue
(
This total must a
g
ree to Line 3
)
$
13
,
245
,
385
49
26 SUBTOTAL Non-Operating Revenue (lines 24 and 25) $ 14,969 26
E. Other Revenue (specify):**** * This must agree with page 4, line 45, column 4.
27
S
e
ttl
emen
t
I
ncome
(I
nsurance,
L
ega
l
,
Et
c.
)
27 ** Does this agree with taxable income (loss) per Federal Income
28 See Attached 2,293,918 28 Tax Return? Not Complet
e
If not, please attach a reconciliation.
28a 28a *** See the instructions. If this total amount has not been offset against interest
29 SUBTOTAL Other Revenue (lines 27, 28 and 28a)
$ 2,293,918 29 expense on Schedule V, line 32, please include a detailed explanation.
30 TOTAL REVENUE (sum of lines 3, 8, 23, 26 and 29)
$ 26,683,230 30 ****Provide a detailed breakdown of "Other Revenue" on an attached sheet.
STATE OF ILLINOIS Page 20
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
XVIII. A. STAFFING AND SALARY COSTS (Please report each line separately.)
(This schedule must cover the entire reporting period.) B. CONSULTANT SERVICES
1 2** 3 4 1 2 3
# of Hrs. # of Hrs. Reporting Period Average Numbe
r
Total Consultant Schedule V
Actually Paid and Total Salaries, Hourly of Hrs. Cost for Line &
Worked Accrued Wages Wage Paid & Reporting Column
1 Director of Nursing 2,208 2,435
$ 170,540 $ 70.04 1 Accrued Period Reference
2 Assistant Director of Nursing 1,910 2,138 108,999 50.98 2 35 Dietary Consultant
$ 35
3 Registered Nurses 45,830 52,690 2,083,388 39.54 3 36 Medical Director Monthly 61,168 09-03 36
4 Licensed Practical Nurses 47,989 58,468 1,917,622 32.80 4 37 Medical Records Consultant 37
5 CNAs & Orderlies 120,002 150,578 2,815,896 18.70 5 38 Nurse Consultant Monthly 65,102 10-03 38
6 CNA Trainees 6 39 Pharmacist Consultant Monthly 21,309 10-03 39
7 Licensed Therapist 7 40 Physical Therapy Consultant 40
8 Rehab/Therapy Aides 10,519 12,489 301,005 24.10 8 41 Occupational Therapy Consultant 41
9 Activity Director 2,072 2,192 52,917 24.14 9 42 Respiratory Therapy Consultant 42
10 Activity Assistants 6,230 6,914 93,755 13.56 10 43 Speech Therapy Consultant 43
11 Social Service Workers 12,579 13,634 327,975 24.06 11 44 Activity Consultant 44
12 Dietician 6,458 6,995 139,875 20.00 12 45 Social Service Consultant Monthly 8,815 12-03 45
13 Food Service Supervisor 3,402 3,691 92,615 25.09 13 46 Other(specify) 46
14 Head Cook 6,849 7,638 130,626 17.10 14 47 47
15 Cook Helpers/Assistants 27,113 30,214 435,091 14.40 15 48 48
16 Dishwashers 16
17 Maintenance Workers 11,550 12,512 269,463 21.54 17 49 TOTAL (lines 35 - 48)
$ 156,394 49
18 Housekeepers 27,316 30,127 440,071 14.61 18
19 Laundry 659 853 12,888 15.11 19
20 Administrator 2,064 2,180 122,118 56.02 20
21 Assistant Administrator 1,914 2,112 54,687 25.89 21 C. CONTRACT NURSES
22 Other Administrative 2,104 2,200 99,037 45.02 22 1 2 3
23 Office Manager 1,702 1,929 32,364 16.78 23 Numbe
r
Schedule V
24 Clerical 14,376 15,706 289,428 18.43 24 of Hrs. Total Line &
25 Vocational Instruction 25 Paid & Contract Column
26 Academic Instruction 26 Accrued Wages Reference
27 Medical Director 27 50 Registered Nurses
$ 50
28 Qualified MR Prof. (QMRP) 28 51 Licensed Practical Nurses 51
29 Resident Services Coordinator 29 52 Certified Nurse Assistants/Aides 846 21,160 10-03 52
30 Habilitation Aides (DD Homes) 30
31 Medical Records 3,878 4,297 75,041 17.46 31 53 TOTAL (lines 50 - 52) 846
$ 21,160 53
32 Other Health Care(specify) 32
33 Other(specify) See Attached 20,263 21,866 341,251 15.61 33
34 TOTAL (lines 1 - 33) 378,987 443,858
$ 10,406,652
*
$ 23.45 34
* This total must agree with page 4, column 1, line 45. ** See instructions.
STATE OF ILLINOIS Page 21
Facility Name & ID Number Warren Barr Gold Coast # 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
XIX. SUPPORT SCHEDULES
A. Administrative Salaries Ownership D. Employee Benefits and Payroll Taxes F. Dues, Fees, Subscriptions and Promotions
Name Function % Amoun
t
Description Amoun
t
Description Amoun
t
Staci Palmer Administrator 0 $ 122,118 Workers' Compensation Insurance $ 98,695 IDPH License Fee $ 1,706
Lafayette Barlow Assistant Admin 0 54,687 Unemployment Compensation Insurance 78,130 Advertising: Employee Recruitment 483
Kate Gilday Executive Director 0 99,037 FICA Taxes 796,109 Health Care Worker Background Check
Employee Health Insurance 466,772 (Indicate # of checks performed 165 ) 1,646
Employee Meals Patient Background Checks 757 7,570
Illinois Municipal Retirement Fund (IMRF)* Dues & Subscriptions 53,025
Union Pension 95,778 Licenses & Fees 2,670
TOTAL (agree to Schedule V, line 17, col. 1) 401K Expense 31,630
(List each licensed administrator separately.) $ 275,842 Voluntary Benefit Contributions 30,899
B. Administrative - Other Employee Physical Exams 29,716 See Supplemental Schedule 5,545
Other Employee Benefits 47,757 Less: Public Relations Expense ( )
Description Amount Non-allowable advertising ( )
$ Yellow page advertising ( )
TOTAL (agree to Schedule V, $ 1,675,486 TOTAL (agree to Sch. V, $ 72,644
line 22, col.8) line 20, col. 8)
TOTAL (agree to Schedule V, line 17, col. 3) $ E. Schedule of Non-Cash Compensation Paid G. Schedule of Travel and Seminar**
(Attach a copy of any management service agreement) to Owners or Employees
C. Professional Services Description Amount
Vendor/Payee Type Amount Description Line # Amount
Marcum LLP Accounting $ 36,586 $ Out-of-State Travel $
ProPay HR Payroll Processing 54,890
Onyx Procurement Solutions Procurement Services 15,170
Achieve Accreditation Accreditation Services 11,315 In-State Travel
Compliagent Compliance 3,844
Cortex Health Inc Data Processing 15,070
Language Line Services Interpreter 4,153
Hygieneering Environmental Consultant 2,134 Seminar Expense 1,471
Telemedicine Risk Prevention Software 5,346
PatientPing, Inc. Care Collarborative Software 6,000
See Attached Legal 422,261 See Supplemental Schedule 221
See Supplemental Schedule 15,739 Entertainment Expense ( )
TOTAL (agree to Schedule V, line 19, column 3) TOTAL $ (agree to Sch. V,
(For legal fee disclosure, see page 39 of instructions) $ 592,508 TOTAL line 24, col. 8) $ 1,692
* Attach copy of IMRF notifications **See instructions.
STATE OF ILLINOIS Page 22
Facility Name & ID Numbe
r
Warren Barr Gold Coas
t
# 0052415 Report Period Beginning: 01/01/20 Ending: 12/31/20
XX. GENERAL INFORMATION:
(1) Are nursing employees (RN,LPN,NA) represented by a union
?
Yes (13) Have costs for all supplies and services which are of the type that can be billed t
o
the Department, in addition to the daily rate, been properly classifie
d
(2) Are there any dues to nursing home associations included on the cost report
?
Yes in the Ancillary Section of Schedule V
?
Yes
If YES, give association name and amount
.
HCCI - $44,195, IHCA - $22,813
(14) Is a portion of the building used for any function other than long term care services fo
r
(3) Did the nursing home make political contributions or payments to a politica
l
the patient census listed on page 2, Section B? No For example,
action organization? Yes If YES, have these cost
s
is a portion of the building used for rental, a pharmacy, day care, etc.) If YES, attac
h
b
een properly adjusted out of the cost report
?
Yes a schedule which explains how all related costs were allocated to these functions
.
(4) Does the bed capacity of the building differ from the number of beds licensed at th
e
(15) Indicate the cost of employee meals that has been reclassified to employee benefit
s
end of the fiscal year? No If YES, what is the capacity
?
N/A on Schedule V. $ Has any meal income been offset agains
t
related costs? N/A Indicate the amount. $
(5) Have you properly capitalized all major repairs and equipment purchases
?
Yes
What was the average life used for new equipment added during this period
?
10 Years (16) Travel and Transportatio
n
a. Are there costs included for out-of-state travel
?
No
(6) Indicate the total amount of both disposable and non-disposable diaper expens
e
If YES, attach a complete explanation.
and the location of this expense on Sch. V. $ 64,178 Line 10
b
. Do you have a separate contract with the Department to provide medical transportation fo
r
residents? No If YES, please indicate the amount of income earned from such
a
(7) Have all costs reported on this form been determined using accounting procedure
s
program during this reporting period.
$
N/A
consistent with prior reports
?
Yes If NO, attach a complete explanation. c. What percent of all travel expense relates to transportation of nurses and patients
?
100% Ln 14
d. Have vehicle usage logs been maintained
?
N/A
(8) Are you presently operating under a sale and leaseback arrangement
?
No e. Are all vehicles stored at the nursing home during the night and all othe
r
If YES, give effective date of lease
.
N/A times when not in use? N/A
f. Has the cost for commuting or other personal use of autos been adjuste
d
(9) Are you presently operating under a sublease agreement
?
YES X
N
O out of the cost report? N/A
g. Does the
f
ac
i
l
i
ty transport res
i
dents to and
f
rom day tra
i
n
i
ng
?
No
(10) Was this home previously operated by a related party (as is defined in the instructions fo
r
Ind
i
cate the amount o
f
i
ncome earned
f
rom prov
i
d
i
ng such
Schedule VII)? YES
N
O X If YES, please indicate name of the facility
,
transportat
i
on dur
i
ng th
i
s report
i
ng per
i
od. $ N/A
IDPH license number of this related party and the date the present owners took over
.
N/A (17) Has an audit been performed by an independent certified public accounting firm
?
No
Firm Name: N/A
(11) Indicate the amount of the Provider Participation Fees paid and accrued to the Departmen
t
during this cost report period.
$
435,666 (18) Have all costs which do not relate to the provision of long term care been adjusted ou
t
This amount is to be recorded on line 42 of Schedule V. out of Schedule V? Yes
(12) Are there any salary costs which have been allocated to more than one line on Schedule
V
(19) Has a schedule for the legal fees reported on the cost report been provided by the facility
?
for an individual employee
?
No If YES, attach an explanation of the allocation
.
See page 39 of the instructions for details. Yes
Attach invoices and a summary of services for all architect and appraisal fees
