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  5. BELMONT NURSING HOME, INC.

BELMONT NURSING HOME, INC.

Company Details

Entity Name: BELMONT NURSING HOME, INC.
Jurisdiction: Illinois
Entity Type: Corporation - Domestic BCA
Status: Goodstanding
Date Formed: 26 Jun 1979
Company Number: CORP_51785002
File Number: 51785002
Address 1936 W BELMONT AVE 1, CHICAGO, IL, 60657
Place of Formation: ILLINOIS

Unique Entity ID

Unique Entity ID Expiration Date Physical Address Mailing Address
TKWWKNQTCNG3 2024-10-09 1936 W BELMONT AVE, CHICAGO, IL, 60657, 2025, USA 930 PARKVIEW LANE, DES PLAINES, IL, 60016, USA

Business Information
Congressional District 05
State/Country of Incorporation IL, USA
Activation Date 2023-10-10
Initial Registration Date 2023-10-07
Entity Start Date 1979-06-26
Fiscal Year End Close Date Dec 31

Points of Contacts
Electronic Business
Title PRIMARY POC
Name EILEEN L CONWAY
Role PRESIDENT
Address 930 PARKVIEW LANE, DES PLAINES, IL, 60016, USA
Government Business
Title PRIMARY POC
Name EILEEN L CONWAY
Role PRESIDENT
Address 930 PARKVIEW LANE, DES PLAINES, IL, 60016, USA
Past Performance Information not Available

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
BELMONT NURSING HOME SAFE HARBOR 401K PSP 2021 363049440 2022-02-23 BELMONT NURSING HOME 22
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 623000
Sponsor’s telephone number 7735257176
Plan sponsor’s address 1936 WEST BELMONT, CHICAGO, IL, 60657

Signature of
Role Plan administrator
Date 2022-02-23
Name of individual signing EILEEN CONWAY
Valid signature Filed with authorized/valid electronic signature
BELMONT NURSING HOME SAFE HARBOR 401K PSP 2021 363049440 2022-06-23 BELMONT NURSING HOME 17
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 623000
Sponsor’s telephone number 7735257176
Plan sponsor’s address 1936 WEST BELMONT, CHICAGO, IL, 60657

Signature of
Role Plan administrator
Date 2022-06-23
Name of individual signing EILEEN CONWAY
Valid signature Filed with authorized/valid electronic signature
BELMONT NURSING HOME SAFE HARBOR 401K PSP 2020 363049440 2021-04-09 BELMONT NURSING HOME 24
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 623000
Sponsor’s telephone number 7735257176
Plan sponsor’s address 1936 WEST BELMONT, CHICAGO, IL, 60657

Signature of
Role Plan administrator
Date 2021-04-09
Name of individual signing EILEEN CONWAY
Valid signature Filed with authorized/valid electronic signature
BELMONT NURSING HOME SAFE HARBOR 401K PSP 2019 363049440 2020-05-20 BELMONT NURSING HOME 22
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 623000
Sponsor’s telephone number 7735257176
Plan sponsor’s address 1936 WEST BELMONT, CHICAGO, IL, 60657

Signature of
Role Plan administrator
Date 2020-05-20
Name of individual signing EILEEN CONWAY
Valid signature Filed with authorized/valid electronic signature
BELMONT NURSING HOME SAFE HARBOR 401K PSP 2018 363049440 2019-04-18 BELMONT NURSING HOME, INC 25
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 623000
Sponsor’s telephone number 7735257176
Plan sponsor’s address 1936 WEST BELMONT, CHICAGO, IL, 60657

Signature of
Role Plan administrator
Date 2019-04-18
Name of individual signing EILEEN CONWAY
Valid signature Filed with authorized/valid electronic signature
BELMONT NURSING HOME SAFE HARBOR 401K PSP 2017 363049440 2018-04-09 BELMONT NURSING HOME, INC 22
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 623000
Sponsor’s telephone number 7735257176
Plan sponsor’s address 1936 WEST BELMONT, CHICAGO, IL, 60657

Signature of
Role Plan administrator
Date 2018-04-09
Name of individual signing EILEEN CONWAY
Valid signature Filed with authorized/valid electronic signature
BELMONT NURSING HOME SAFE HARBOR 401K PSP 2016 363049440 2017-04-24 BELMONT NURSING HOME, INC 25
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 623000
Sponsor’s telephone number 7735257176
Plan sponsor’s address 1936 WEST BELMONT, CHICAGO, IL, 60657

Signature of
Role Plan administrator
Date 2017-04-24
Name of individual signing EILEEN CONWAY
Valid signature Filed with authorized/valid electronic signature
BELMONT NURSING HOME SAFE HARBOR 401K PSP 2015 363049440 2016-05-12 BELMONT NURSING HOME, INC 18
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 623000
Sponsor’s telephone number 7735257176
Plan sponsor’s address 1936 WEST BELMONT, CHICAGO, IL, 60657

Signature of
Role Plan administrator
Date 2016-05-12
Name of individual signing EILEEN CONWAY
Valid signature Filed with authorized/valid electronic signature
BELMONT NURSING HOME SAFE HARBOR 401K PSP 2014 363049440 2015-06-30 BELMONT NURSING HOME, INC 17
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 623000
Sponsor’s telephone number 7735257176
Plan sponsor’s address 1936 WEST BELMONT, CHICAGO, IL, 60657

Signature of
Role Plan administrator
Date 2015-06-30
Name of individual signing EILEEN CONWAY
Valid signature Filed with authorized/valid electronic signature
BELMONT NURSING HOME SAFE HARBOR 401K PSP 2013 363049440 2014-04-29 BELMONT NURSING HOME, INC 20
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 623000
Sponsor’s telephone number 7735257176
Plan sponsor’s address 1936 WEST BELMONT, CHICAGO, IL, 60657

Signature of
Role Plan administrator
Date 2014-04-29
Name of individual signing EILEEN CONWAY
Valid signature Filed with authorized/valid electronic signature

Agent

Name and Address Role Appointment Date
EILEEN CONWAY, 930 PARKVIEW LN, DES PLAINES, 60016, COOK-NOT IN CITY OF CHICAGO Agent 2023-01-25

Secretary

Name and Address Role
EILEEN CONWAY 930 PARKVIEW LANE DES PLAINES IL, 60016 Secretary

President

Name and Address Role Account Number
EILEEN CONWAY 930 PARKVIEW LANE DES PLAINES IL, 60016 President 27160

License

License Type License Number Status License Code License Description Business Activity Date Issued Effective Date Expiration Date
BUSINESS LICENSE 2204532 Cancelled 4404 Regulated Business License 699 - Long Term Care Facility 2021-02-08 2021-02-16 2023-02-15
BUSINESS LICENSE 13001 Cancelled 1005 Long-Term Care Facility No data 2011-02-08 2011-02-16 2013-02-15

Inspection

Inspection ID Inspection Type Inspection Date License Facility Type Address Risk Results
2568771 Canvass 2022-12-20 2204532 Long Term Care 1936 W BELMONT AVE, CHICAGO, IL, 60657 Risk 1 (High) Out of Business
2315275 Canvass 2019-10-03 2204532 Long Term Care 1936 W BELMONT AVE, CHICAGO, IL, 60657 Risk 1 (High) Pass w/ Conditions
2222359 Canvass 2018-09-14 2204532 Long Term Care 1936 W BELMONT AVE, CHICAGO, IL, 60657 Risk 1 (High) Pass w/ Conditions
2052275 Canvass 2017-08-04 2204532 Long Term Care 1936 W BELMONT AVE, CHICAGO, IL, 60657 Risk 1 (High) Pass
1770622 Canvass 2016-05-12 2204532 Long Term Care 1936 W BELMONT AVE, CHICAGO, IL, 60657 Risk 1 (High) Pass
1527693 Canvass 2015-03-11 2204532 Long Term Care 1936 W BELMONT AVE, CHICAGO, IL, 60657 Risk 1 (High) Pass
1375847 Complaint Re-Inspection 2013-12-05 2204532 Long Term Care 1936 W BELMONT AVE, CHICAGO, IL, 60657 Risk 1 (High) Pass
1375734 Complaint Re-Inspection 2013-11-29 2204532 Long Term Care 1936 W BELMONT AVE, CHICAGO, IL, 60657 Risk 1 (High) Fail
1375645 Complaint 2013-11-25 13001 Long Term Care 1936 W BELMONT AVE, CHICAGO, IL, 60657 Risk 1 (High) Fail
1375689 Complaint 2013-11-25 2204532 Long Term Care 1936 W BELMONT AVE, CHICAGO, IL, 60657 Risk 1 (High) Fail

Assumed Names

Name Type Effective Date Cancellation Date Cancellation Type Last Renewal Date
BELMONT CROSSING OF LAKEVIEW Assume Name 2007-11-19 No data No data No data

Shares

Class Series Voting Rights Authorized Shares Issued Shares Par Value
COMM No data Voting Rights 100000 1000000 1

Related by officers

No related officers

Related by address

No related companies by address

Date of last update: 23 Jan 2025

Sources: Illinois Office of the Secretary of State

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