efile Public Visual Render ObjectId: 201801359349313660 - Submission: 2018-05-15 Compensation Information Schedule J (Form 990) Department of the Treasury Internal Revenue Service TIN: 95-2977147 OMB No. 1545-0047 For certain Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees Complete if the organization answered "Yes" on Form 990, Part IV, line 23. Attach to Form 990. Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990. Name of the organization 2016 Open to Public Inspection Employer identification number Clinicas Del Camino Real 95-2977147 Part I Questions Regarding Compensation Yes 1a b 2 Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form 990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items. First-class or charter travel Housing allowance or residence for personal use Travel for companions Payments for business use of personal residence Tax idemnification and gross-up payments Health or social club dues or initiation fees Discretionary spending account Personal services (e.g., maid, chauffeur, chef) If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain . . . . . . . . . Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all directors, trustees, officers, including the CEO/Executive Director, regarding the items checked in line 1a? . 3 No 1b 2 Yes Yes . Indicate which, if any, of the following the filing organization used to establish the compensation of the organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III. 4 Compensation committee Written employment contract Independent compensation consultant Compensation survey or study Form 990 of other organizations Approval by the board or compensation committee During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization: a Receive a severance payment or change-of-control payment? . . . . . . . . . . . . . b Participate in, or receive payment from, a supplemental nonqualified retirement plan? . . . . . . . . c Participate in, or receive payment from, an equity-based compensation arrangement? . . . . . . If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III. . . 4a No . 4b No . 4c No 5a No 5b No Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9. 5 For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any compensation contingent on the revenues of: a The organization? . . . . . . . . . . . . . . b Any related organization? . . . . . . If "Yes," on line 5a or 5b, describe in Part III. . . . . . . . . . . . . 6 . . . . . . . . . . . . . . . For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any compensation contingent on the net earnings of: a The organization? . . . . . . . . . . . . . . . . . b Any related organization? . . . . . . . . . . . . . . . . . . . 6a No 6b No 7 No 8 No 9 No If "Yes," on line 6a or 6b, describe in Part III. 7 8 9 For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed payments not described in lines 5 and 6? If "Yes," describe in Part III . . . . . . . . . . . Were any amounts reported on Form 990, Part VII, paid or accured pursuant to a contract that was subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe in Part III . . . . . . . . . . . . . . . . . . . . . . . . . . . If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? . . . . . . . . . . . . . . . . . . . . . . . . . For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50053T Schedule J (Form 990) 2016 Page 2 Schedule J (Form 990) 2016 Part II Page 2 Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed. For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII. Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual. (A) Name and Title 1Antonio Alatorre COO (B) Breakdown of W-2 and/or 1099-MISC compensation (i) Base (ii) (iii) Other compensation Bonus & incentive reportable compensation compensation (i) (ii) 2Christina M Velasco CFO (i) (ii) 3Fred Deharo COO (i) (ii) 4Gagan Pawar Medical Director (i) (ii) 5Jaspreet Bal Dental Director (i) (ii) 6Kelly Lynn Bennett Human Resources Director (i) (ii) 7Menashe Ehrenburg Physician (i) (ii) 8Rafael Diaz CIO (i) (ii) 9Roberto S Juarez CEO (i) (ii) 10Ta Thuc Ngu Dinh Physician (i) (ii) 11Tihele L Walkousky Physician (i) (ii) 12Todd Wayne Monroe Physician (i) (ii) 13Yasmin Sarafzadeh Physician (i) (ii) 240,651 - - - - - - - - - - - - 446,537 15,740 6,250 727,642 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 10,924 913,762 16,727 6,250 1,204,442 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 6,250 244,840 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 14,195 6,250 272,914 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 9,800 6,250 169,015 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 18,550 12,500 1,109,486 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1,000 - - - - - - - - - - - - 250,969 - - - - - - - - - - - - 1,500 - - - - - - - - - - - - 153,032 - - - - - - - - - - - - 2,250 3,468 - - - - - - - - - - - - 340,143 - - - - - - - - - - - - 1,500 35,067 437,257 - - - - - - - - - - - - 641,179 - - - - - - - - - - - - 318,989 - - - - - - - - - - - - 1,500 321,038 - - - - - - - - - - - - 1,000 321,587 - - - - - - - - - - - - 1,500 308,934 - - - - - - - - - - - - 1,500 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 335,892 12,373 - - - - - - - - - - - - - - - - - - - - - - - - 334,068 12,805 - - - - - - - - - - - - - - - - - - - - - - - - 333,193 12,030 - - - - - - - - - - - - - - - - - - - - - - - - 250,711 12,704 - - - - - - - - - - - - - - - - - - - - - - - - 354,661 13,664 - - - - - - - - - - - - (F) Compensation in column (B) reported as deferred on prior Form 990 164,877 13,018 - - - - - - - - - - - - 201,980 - - - - - - - - - - - - 9,595 - - - - - - - - - - - - 149,497 - - - - - - - - - - - - (E) Total of columns (B)(i)-(D) 18,464 237,590 - - - - - - - - - - - - (D) Nontaxable benefits - - - - - - - - - - - - 256,779 - - - - - - - - - - - - (C) Retirement and other deferred compensation - - - - - - - - - - - - 322,807 - - - - - - - - - - - - Schedule J (Form 990) 2016 Page 3 Schedule J (Form 990) 2016 Part III Page 3 Supplemental Information Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information. Return Reference Explanation Part I, Line 1a: Relevant information in regards to selections on 1a. Schedule J (Form 990) 2016 Additional Data Return to Form Software ID: 16000303 Software Version: 2016v3.0