ANNUAL REPORT CHECKLIST

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1 ANNUAL REPORT CHECKLIST FISCAL YEAR ENDED: / / JHA WEST 16 LLC & LOS ANGELES HOME FOR THE AGING PROVIDER(S): FOUNTAINVIEW AT GONDA WESTSIDE CCRC(S): PROVIDER CONTACT PERSON: TELEPHONE NO.: ( ) A complete annual report must consist of 3 copies of all of the following: Annual Report Checklist. 11,610 Annual Provider Fee in the amount of: $ If applicable, late fee in the amount of: $ Certification by the provider s Chief Executive Officer that: The reports are correct to the best of his/her knowledge. Each continuing care contract form in use or offered to new residents has been approved by the Department. The provider is maintaining the required liquid reserves and, when applicable, the required refund reserve. Evidence of the provider s fidelity bond, as required by H&SC section Provider s audited financial statements, with an accompanying certified public accountant s opinion thereon. Provider s audited reserve reports (prepared on Department forms), with an accompanying certified public accountant s opinion thereon. (NOTE: Form 5 5 must be signed and have the required disclosures attached (H&SC section 1790(a)(2) and (3)). Continuing Care Retirement Community Disclosure Statement for each community. Form 7 1, Report on CCRC Monthly Service Fees for each community. Form 9 1, Calculation of Refund Reserve Amount, if applicable. Key Indicators Report (signed by CEO or CFO (or by the authorized person who signed the provider s annual report)). The KIR may be submitted along with the annual report, but is not required until 30 days later. June 2014

3 FORM 1-1 RESIDENT POPULATION Line Continuing Care Residents TOTAL [1] Number at beginning of fiscal year [2] Number at end of fiscal year [3] Total Lines 1 and 2 [4] Multiply Line 3 by.50 and enter result on Line 5. x.50 [5] Mean number of continuing care residents All Residents [6] Number at beginning of fiscal year [7] Number at end of fiscal year [8] Total Lines 6 and 7 [9] Multiply Line 8 by.50 and enter result on Line 10. x.50 [10] Mean number of all residents [11] Divide the mean number of continuing care residents (Line 5) by the mean number of all residents (Line 10) and enter the result (round to two decimal places). Line FORM 1-2 ANNUAL PROVIDER FEE TOTAL [1] Total Operating Expenses (including depreciation and debt service interest only) [a] Depreciation [b] Debt Service (Interest Only) [2] Subtotal (add Line 1a and 1b) [3] Subtract Line 2 from Line 1 and enter result. [4] Percentage allocated to continuing care residents (Form 1-1, Line 11) [5] Total Operating Expense for Continuing Care Residents (multiply Line 3 by Line 4) [6] Total Amount Due (multiply Line 5 by.001) x.001 PROVIDER: COMMUNITY:

4 R * B0 * 05/01/2018 * SAA Great American Insurance Company SP (Ed ) Policy No. SAA CRIME PROTECTION POLICY DECLARATIONS Item 1. NAMED INSURED AND ADDRESS: Los Angeles Jewish Home for the Aging 7150 Tampa Ave Reseda, CA Item 2. POLICY PERIOD: 12:01 A.M. Standard Time at the address of the Named Insured shown at left From 05/01/2018 To 05/01/2019 Insurance is afforded by: Great American Insurance Company (a capital stock corporation, hereinafter called the Company) Item 3. INSURING AGREEMENTS, LIMITS OF INSURANCE AND DEDUCTIBLES Insuring Agreement Limits of Insurance Per Occurrence Deductible Amount Per Occurrence 1. Employee Dishonesty 2. Forgery or Alteration 3. Inside the Premises 4. Outside the Premises 5. Computer Fraud 6. Money Orders and Counterfeit Paper Currency $ $ $ $ $ $ 3,000,000 3,000,000 3,000,000 3,000,000 3,000,000 3,000,000 $ $ $ $ $ $ 25,000 25,000 25,000 25,000 25,000 25,000 If added by Endorsement, Insuring Agreement(s): 7. Loss of Clients' Property Resulting from Employee Dishonesty $ 3,000,000 $ 25, Funds Transfer Fraud $ 3,000,000 $ 25, Fraudulently Induced Transfers $ 250,000 $ 50,000 If "Not Covered" is inserted above opposite any specified Insuring Agreement, or if no amount is inserted, such Insuring Agreement and any other reference thereto in this Policy shall be deemed to be deleted. Item 4. ENDORSEMENTS FORMING PART OF THIS POLICY WHEN ISSUED See Form IL8801 Item 5. CANCELLATION OF PRIOR INSURANCE By acceptance of this Policy you give us notice cancelling prior policy Nos. SAA Copyright, The Surety and Fidelity Association of America, 2012 SP (Ed. 04/12) (Page 1 of 20)

54 12/28/2018 Date Prepared: Continuing Care Retirement Community Disclosure Statement FACILITY NAME: FOUNTAINVIEW AT GONDA WEST ADDRESS: FIELDING CIRCLE PLAYA VISTA CA ZIP CODE: PHONE: (424) PROVIDER NAME: JHA WEST 16 LLC FACILITY OPERATOR: LOS ANGELES JEWISH HOME FOR THE AGING RELATED FACILITIES: FOUNTAINVIEW AT EISENBERG VILLAGE RELIGIOUS AFFILIATION: JEWISH X MULTI.02 YEAR # OF SINGLE MILES TO SHOPPING CTR: OPENED: ACRES: STORY STORY OTHER: MILES TO HOSPITAL: * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * NUMBER OF UNITS: RESIDENTIAL LIVING 0 APARTMENTS STUDIO: APARTMENTS 1 BDRM: 86 APARTMENTS 2 BDRM: 89 COTTAGES/HOUSES: 0 95% RLU OCCUPANCY (%) AT YEAR END: HEALTH CARE ASSISTED LIVING: SKILLED NURSING: 24 SPECIAL CARE: DESCRIPTION: > 24 Memory Care units OVERALL CCRC OCCUPANCY (%) AT YEAR END: 30% * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * XNOT-FOR-PROFIT FOR- PROFIT ACCREDITED?: YES NO BY: TYPE OF OWNERSHIP: FORM OF CONTRACT: (Check all that apply) X CONTINUING CARE ASSIGNMENT OF ASSETS REFUND PROVISIONS: (Check all that apply) LIFE CARE EQUITY Refundable Repayable 550,000 2,035,000 RANGE OF ENTRANCE FEES: $ - $ HEALTH CARE BENEFITS INCLUDED IN CONTRACT: 60 ENTRY REQUIREMENTS: MIN. AGE: ENTRANCE FEE MEMBERSHIP X 90% 75% FEE FOR SERVICE RENTAL 50% OTHER: LONG-TERM CARE INSURANCE REQUIRED? YES XNO 10 days per year of nursing care at no charge. Days reset each year. PRIOR PROFESSION: OTHER: RESIDENT REPRESENTATIVE(S) TO, AND RESIDENT MEMBER(S) ON, THE BOARD: (briefly describe provider s compliance and residents roles) > 2 residents voted on by residents as governing board. > * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * FACILITY SERVICES AND AMENITIES COMMON AREA AMENITIES AVAILABLE FEE FOR SERVICE SERVICES AVAILABLE INCLUDED IN FEE FOR EXTRA CHARGE 4 TIMES/MONTH) x BEAUTY/BARBER SHOP HOUSEKEEPING ( x x 1 BILLIARD ROOM MEALS ( /DAY) x BOWLING GREEN SPECIAL DIETS AVAILABLE x x CARD ROOMS CHAPEL 24-HOUR EMERGENCY RESPONSE x x COFFEE SHOP ACTIVITIES PROGRAM CRAFT ROOMS ALL UTILITIES EXCEPT PHONE x x EXERCISE ROOM APARTMENT MAINTENANCE x x GOLF COURSE ACCESS CABLE TV x LIBRARY LINENS FURNISHED x x PUTTING GREEN LINENS LAUNDERED x SHUFFLEBOARD MEDICATION MANAGEMENT x SPA x NURSING/WELLNESS CLINIC x SWIMMING POOL-INDOOR PERSONAL HOME CARE x x SWIMMING POOL-OUTDOOR TRANSPORTATION-PERSONAL x TENNIS COURT TRANSPORTATION-PREARRANGED WORKSHOP OTHER Art Studio OTHER x All providers are required by Health and Safety Code section to provide this report to prospective residents before executing a deposit agreement or continuing care contract, or receiving any payment. Many communities are part of multi-facility operations which may influence financial reporting. Consumers are encouraged to ask questions of the continuing care retirement community that they are considering and to seek advice from professional advisors. Page 1 of 4

55 PROVIDER NAME: OTHER CCRCs LOCATION (City, State) PHONE (with area code) MULTI-LEVEL RETIREMENT COMMUNITIES LOCATION (City, State) PHONE (with area code) FREE-STANDING SKILLED NURSING LOCATION (City, State) PHONE (with area code) SUBSIDIZED SENIOR HOUSING LOCATION (City, State) PHONE (with area code) NOTE: PLEASE INDICATE IF THE FACILITY IS A LIFE CARE FACILITY. Page 2 of 4

56 JHA WEST 16 LLC PROVIDER NAME: INCOME FROM ONGOING OPERATIONS OPERATING INCOME (Excluding amortization of entrance fee income) 21,377,278 LESS OPERATING EXPENSES (Excluding depreciation, amortization, and interest) 30,167, ,451,639 37,219,236 (1,767,597) (8,790,480) NET INCOME FROM OPERATIONS 6,999,127 5,972,381 (1,791,353) 5,972,381 LESS INTEREST EXPENSE PLUS CONTRIBUTIONS PLUS NON-OPERATING INCOME (EXPENSES) (excluding extraordinary items) NET INCOME (LOSS) BEFORE ENTRANCE FEES, DEPRECIATION AND AMORTIZATION NET CASH FLOW FROM ENTRANCE FEES (Total Deposits Less Refunds) 33,387, ,581,627 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * DESCRIPTION OF SECURED DEBT (as of most recent fiscal year end) OUTSTANDING INTEREST LENDER BALANCE RATE DATE OF ORIGINATION DATE OF MATURITY AMORTIZATION PERIOD * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * FINANCIAL RATIOS (see next page for ratio formulas) 2017 CCAC Medians 50th Percentile (optional) 2016 DEBT TO ASSET RATIO OPERATING RATIO DEBT SERVICE COVERAGE RATIO DAYS CASH ON HAND RATIO * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * HISTORICAL MONTHLY SERVICE FEES (Average Fee and Change Percentage) 2015 % 2016 STUDIO ONE BEDROOM TWO BEDROOM COTTAGE/HOUSE ASSISTED LIVING SKILLED NURSING SPECIAL CARE % 2017 % 3,328 3,200 5,475 11, ,694-11,500 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * COMMENTS FROM PROVIDER: > Refer to Appendix 1 - Audited Financial Statements > > Page 3 of 4

57 PROVIDER NAME: FINANCIAL RATIO FORMULAS LONG-TERM DEBT TO TOTAL ASSETS RATIO Long-Term Debt, less Current Portion Total Assets Total Operating Revenues OPERATING RATIO Total Operating Expenses Depreciation Expense Amortization Expense Amortization of Deferred Revenue DEBT SERVICE COVERAGE RATIO Total Excess of Revenues over Expenses + Interest, Depreciation, and Amortization Expenses Amortization of Deferred Revenue + Net Proceeds from Entrance Fees Annual Debt Service DAYS CASH ON HAND RATIO Unrestricted Current Cash & Investments + Unrestricted Non-Current Cash & Investments (Operating Expenses Depreciation Amortization)/365 NOTE: These formulas are also used by the Continuing Care Accreditation Commission. For each formula, that organization also publishes annual median figures for certain continuing care retirement communities. Page 4 of 4

58 FORM 7-1 REPORT ON CCRC MONTHLY SERVICE FEES RESIDENTIAL LIVING [1] [2] Monthly Service Fees at beginning of reporting period: (indicate range, if applicable) ASSISTED LIVING SKILLED NURSING $3,328 - $5,694 Indicate percentage of increase in fees imposed during reporting period: (indicate range, if applicable) x Check here if monthly service fees at this community were not increased during the reporting period. (If you checked this box, please skip down to the bottom of this form and specify the names of the provider and community.) [3] Indicate the date the fee increase was implemented: (If more than 1 increase was implemented, indicate the dates for each increase.) [4] Check each of the appropriate boxes: Each fee increase is based on the provider s projected costs, prior year per capita costs, and economic indicators. All affected residents were given written notice of this fee increase at least 30 days prior to its implementation. At least 30 days prior to the increase in monthly service fees, the designated representative of the provider convened a meeting that all residents were invited to attend. At the meeting with residents, the provider discussed and explained the reasons for the increase, the basis for determining the amount of the increase, and the data used for calculating the increase. The provider provided residents with at least 14 days advance notice of each meeting held to discuss the fee increases. The governing body of the provider, or the designated representative of the provider posted the notice of, and the agenda for, the meeting in a conspicuous place in the community at least 14 days prior to the meeting. [5] On an attached page, provide a concise explanation for the increase in monthly service fees including the amount of the increase. JHA WEST LLC PROVIDER: FOUNTAINVIEW AT GONDA WEST COMMUNITY:

Covenant Retirement Communities West, Inc.

Covenant Retirement Communities West, Inc. Report on Audit of Liquid Reserves and Additional Information as of and for the Year Ended January 31, 2017, and Independent Auditors Report COVENANT RETIREMENT