HomeMy WebLinkAboutAgreement A-21-215 with FHA.pdf-1-
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MEMORANDUM OF UNDERSTANDING
Between the
County of Fresno
and
Housing Authority of the City and County of Fresno
THIS MEMORANDUM OF UNDERSTANDING, hereinafter referred to as “MOU” or “Agreement”
is made and entered into this _ day of June, 2021, between the COUNTY OF FRESNO, a Political
Subdivision of the State of California, hereinafter referred to as “COUNTY,” and FRESNO HOUSING
AUTHORITY, a Public Agency hereinafter referred to as “FHA,” whose address is 1331 Fulton Street,
Fresno, CA 93721.
WITNESSETH:
WHEREAS, the Shelter Plus Care (SPC) Tenant-based Rental Assistance (TRA) Program is
funded by Subtitle C, Section 421 Continuum of Care Program of the Stewart B. McKinney Homeless
Assistance Act as amended by S. 896, The Homeless Emergency Assistance and Rapid Transition to
Housing (HEARTH) Act of 2009; and
WHEREAS, SPC program provides tenant based rental assistance and supportive services to
individuals experiencing homelessness who are diagnosed with a disability, such as serious mental
health issues; chronic substance use disorder; HIV and/or related diseases; physical health issues;
and/or developmental disabilities; and
WHEREAS, FHA has agreed to set aside at least fifty-one (51) SPC certificates for COUNTY’s
Department of Behavioral Health (DBH) and its selected contractors; and
WHEREAS, COUNTY’s DBH and its selected contractors have expressed commitment to
providing supportive services for the referred SPC participants under such certificates; and
WHEREAS, it is to the mutual benefit of the parties hereto that FHA and COUNTY’s DBH and its
selected contractors collaborate for the provision of SPC TRA program services to aid individuals
experiencing homelessness who are diagnosed with a disability, such as serious
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Agreement No. 21-215
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mental health issues; chronic substance use disorder; HIV and/or related diseases; physical health
issues; and/or developmental disabilities; and
WHEREAS, the purpose of this MOU is to clearly identify the roles and responsibilities of FHA
and COUNTY;
NOW, THEREFORE, the parties agree as follows:
1. SERVICES
A. COUNTY and FHA shall perform services and fulfill all responsibilities as set forth in
Exhibit A, “Shelter Plus Care Tenant-based Rental Assistance Program Scope of Work,”
attached hereto and by this reference incorporated herein and made part of this
Agreement.
B. COUNTY and FHA shall participate in monthly, or as needed, roundtable meetings
consisting of designated staff from both parties to discuss SPC requirements, data
reporting, training, discontinuation of supportive services for participants, policies and
procedures, overall program operations and any problems or foreseeable problems that
may arise.
C. Acknowledge COUNTY and FHA may request termination of housing assistance for a
SPC TRA program participant who is in violation of program requirements, and/or
conditions of occupancy.
D. Acknowledge FHA reserves the right to disperse SPC Certificate to other providers who
have a signed MOU, ability to utilize Certificates, and provide in-kind match.
E. Acknowledge that, if COUNTY and its selected contractors are unable to submit referrals
or provide the required in-kind match in supportive services, FHA will have the right to
reduce or eliminate allocated SPC TRA Certificates for COUNTY and its selected
contractors.
2. TERM
The term of this Agreement shall be for a period of three (3) years, commencing on the 1st day of
July, 2021 and terminating on the 30th day of June, 2024. This Agreement may be extended for two (2)
additional consecutive twelve (12) months periods upon written approval of both parties no later than
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thirty (30) days prior to the first day of the next twelve (12) month extension period upon the same terms
and conditions herein set forth, unless written notice of non-renewal is given no later than sixty (60) days
prior to the close of the current Agreement term.
3.TERMINATION
A.Non-Allocation of Funds – The terms of this Agreement, and the services to be provided
hereunder, are contingent on the approval of funds by the appropriating government
agency. Should sufficient funds not be allocated, the services provided may be modified,
or this Agreement may be terminated by thirty (30) days advance written notice prior
given by one party to the other.
B.Breach of Contract – The COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of COUNTY there is:
i.A failure to comply with any term of this Agreement;
ii.A substantially incorrect or incomplete report submitted to COUNTY
C.Without Cause – Under circumstances other than those set forth above, this Agreement
may be terminated by FHA or COUNTY or COUNTY’s DBH Director, or designee, upon
giving thirty (30) days advanced written notice of an intention to terminate.
4.COMPENSATION
The supportive services conducted pursuant to the terms and conditions of this Agreement shall be
performed without the payment of any monetary consideration by FHA or COUNTY, one to the other.
5.INDEPENDENT CONTRACTOR
In performance of the work, duties, and obligations assumed by FHA under this Agreement, it is
mutually understood and agreed that FHA, including any and all of FHA’s officers, agents, and
employees will at all times be acting and performing as an independent contractor, and shall act in an
independent capacity and not as an officer, agent, servant, employee, joint venturer, partner, or
associate of COUNTY. Furthermore, COUNTY shall have no right to control or supervise or direct the
manner or method by which FHA shall perform its work and function. However, COUNTY shall retain the
right to administer this Agreement so as to verify that FHA is performing its obligations in accordance
with the terms and conditions thereof. FHA and COUNTY shall comply with all applicable provisions of
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law and the rules and regulations, if any, of governmental authorities having jurisdiction over matters
which are directly or indirectly the subject of this Agreement.
Because of its status as an independent contractor, FHA shall have absolutely no right to
employment rights and benefits available to COUNTY employees. FHA shall be solely liable and
responsible for providing to, or on behalf of, its employees all legally required employee benefits. In
addition, FHA shall be solely responsible and save COUNTY harmless from all matters relating to
payment of FHA’s employees, including compliance with Social Security, withholding and all other
regulations governing such matters. It is acknowledged that during the term of this Agreement, FHA may
be providing services to others unrelated to COUNTY into this Agreement.
6.MODIFICATION
Any matters of this Agreement may be modified from time to time by the written consent of all parties
without, in any way, affecting the remainder.
Notwithstanding the above, changes in addresses to which notices are to be sent may be made by
written approval of COUNTY’s DBH Director or designee and FHA.
7.NON-ASSIGNMENT
Neither party shall assign, transfer, or subcontract this Agreement nor their rights or duties under
this Agreement without the prior written consent of the other party.
8.HOLD-HARMLESS
A.FHA agrees to indemnify, save, hold harmless, and at COUNTY'S request, defend the
COUNTY, its officers, agents, and employees from any and all costs and expenses
(including attorney’s fees and costs), damages, liabilities, claims, and losses occurring or
resulting to COUNTY in connection with the performance, or failure to perform, by FHA,
its officers, agents, or employees under this Agreement, and from any and all costs and
expenses (including attorney’s fees and costs), damages, liabilities, claims, and losses
occurring or resulting to any person, firm, or corporation who may be injured or
damaged by the performance, or failure to perform, of FHA, its officers, agents, or
employees under this Agreement.
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B. COUNTY and FHA shall give timely notice to the other of any claim, demand, lien, or suit
coming to its knowledge which in any way might affect the other party and each party
shall have the right to participate in the defense of the same to the extent of its interest.
COUNTY and FHA recognize that the significant mutual benefits of this Agreement
depend upon close cooperation and good faith handling of matters subject to such
indemnification provisions.
9. INSURANCE
Without limiting the COUNTY's right to obtain indemnification from FHA or any third parties, FHA, at
its sole expense, shall maintain in full force and effect, the following insurance policies or a program of
self-insurance, including but not limited to, an insurance pooling arrangement or Joint Powers
Agreement (JPA) throughout the term of the Agreement:
A. Commercial General Liability
Commercial General Liability insurance with limits of not less than Two Million Dollars
($2,000,000.00) per occurrence and an annual aggregate of Four Million Dollars
($4,000,000.00). This policy shall be issued on a per occurrence basis. COUNTY may
require specific coverages including completed operations, products liability, contractual
liability, Explosion-Collapse-Underground, fire legal liability or any other liability insurance
deemed necessary because of the nature of this contract.
B. Automobile Liability
Comprehensive Automobile Liability Insurance with limits of not less than One Million
Dollars ($1,000,000.00) per accident for bodily injury and for property damages.
Coverage should include any auto used in connection with this Agreement.
C. Professional Liability
If FHA employs licensed professional staff (e.g., Ph.D., R.N., L.C.S.W., M.F.C.C.) in
providing services, Professional Liability Insurance with limits of not less than One Million
Dollars ($1,000,000.00) per occurrence, Three Million Dollars ($3,000,000.00) annual
aggregate. FHA agrees that it shall maintain, at its sole expense, in full force and effect
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for a period of three (3) years following the termination of this Agreement, one or more
policies of professional liability insurance with limits of coverage as specified herein.
D. Worker’s Compensation
A policy of Worker’s Compensation Insurance as may be required by the California Labor
Code.
E. Cyber Liability (if applicable)
Cyber Liability Insurance, with limits not less than $2,000,000 per occurrence or claim,
$2,000,000 aggregate. Coverage shall be sufficiently broad to respond to the duties and
obligations as is undertaken by FHA in this Agreement and shall include, but not be
limited to, claims involving infringement of intellectual property, including but not limited to
infringement of copyright, trademark, trade dress, invasion of privacy violations,
information theft, damage to or destruction of electronic information, release of private
information, alteration of electronic information, extortion and network security. The policy
shall provide coverage for breach response costs as well as regulatory fines and
penalties as well as credit monitoring expenses with limits sufficient to respond to these
obligations.
F. Molestation
Sexual abuse / molestation liability insurance with limits of not less than One Million
Dollars ($1,000,000.00) per occurrence, Two Million Dollars ($2,000,000.00) annual
aggregate. This policy shall be issued on a per occurrence basis.
Additional Requirements Relating to Insurance
FHA shall obtain endorsements to the Commercial General Liability insurance naming the County of
Fresno, its officers, agents, and employees, individually and collectively, as additional insured, but only
insofar as the operations under this Agreement are concerned. Such coverage for additional insured
shall apply as primary insurance and any other insurance, or self-insurance, maintained by COUNTY, its
officers, agents and employees shall be excess only and not contributing with insurance provided under
CONTRACTOR's policies herein. This insurance shall not be cancelled or changed without a minimum
of thirty (30) days advance written notice given to COUNTY.
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FHA hereby waives its right to recover from COUNTY, its officers, agents, and employees any
amounts paid by the policy of worker’s compensation insurance required by this Agreement.
CONTRACTOR is solely responsible to obtain any endorsement to such policy that may be necessary
to accomplish such waiver of subrogation, but FHA’s waiver of subrogation under this paragraph is
effective whether or not FHA obtains such an endorsement.
Within Thirty (30) days from the date FHA signs and executes this Agreement, FHA shall provide
certificates of insurance and endorsement as stated above for all of the foregoing policies, as required
herein, to the County of Fresno, (Name and Address of the official who will administer this contract),
stating that such insurance coverage have been obtained and are in full force; that the County of
Fresno, its officers, agents and employees will not be responsible for any premiums on the policies; that
such Commercial General Liability insurance names the County of Fresno, its officers, agents and
employees, individually and collectively, as additional insured, but only insofar as the operations under
this Agreement are concerned; that such coverage for additional insured shall apply as primary
insurance and any other insurance, or self-insurance, maintained by COUNTY, its officers, agents and
employees, shall be excess only and not contributing with insurance provided under FHA's policies
herein; and that this insurance shall not be cancelled or changed without a minimum of thirty (30) days
advance, written notice given to COUNTY.
10.CONFIDENTIALITY
All services performed by FHA under this Agreement shall be in strict conformance with all
applicable Federal, State of California and/or local laws and regulations relating to confidentiality.
11.NON-DISCRIMINATION
During the performance of this Agreement, FHA shall not unlawfully discriminate against any
employee or applicant for employment, or recipient of services, because of race, religion, color, national
original, ancestry, physical disability, medical condition, marital status, age, or gender, pursuant to all
applicable State of California and Federal statutes and regulations.
12.CONFLICT OF INTEREST
No officer, agent, or employee of COUNTY who exercises any function or responsibility for planning
and carrying out the services provided under this Agreement shall have any direct or indirect personal
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financial interest in this Agreement. FHA shall comply with all Federal, State of California, and local
conflict of interest laws, statutes, and regulations, which shall be applicable to all parties and
beneficiaries under this Agreement and any officer, agent, or employee of COUNTY.
13.COMPLIANCE WITH STATE REQUIREMENTS
FHA recognized that COUNTY operates its mental health system under an agreement with the State
Department of Health Care Services and that under said agreement the State of California imposes
certain requirements on COUNTY and its subcontractors. FHA shall adhere to all State of California
requirements, including those identified in Exhibit B, attached hereto and by this reference incorporated
herein.
14.AUDITS AND INSPECTIONS
FHA shall at any time during business hours, and as often as COUNTY may deem necessary, make
available to COUNTY for examination all of its records and data with respect to the matters covered by
this Agreement. FHA shall, upon request by COUNTY, permit COUNTY to audit and inspect all such
records and data necessary to ensure FHA’s compliance with the terms of this Agreement.
15.NOTICES
The persons having authority to give and receive notices under this Agreement and their addresses
include the following:
COUNTY OF FRESNO FHA
Director, Fresno County Executive Director
Department of Behavioral Health Fresno Housing Authority
1925 E. Dakota Ave. 1331 Fulton Street
Fresno, CA 93276 Fresno, CA 93721
Any and all notices between COUNTY and FHA under this Agreement or by law shall be in writing and
be deemed duly served when personally delivered to one of the parties, or in lieu of such personal
service, when deposited in the United States Mail, postage prepaid, addressed to such party.
16.SEVERABILITY
The provisions of this Agreement are severable. The invalidity or unenforceability of any one
provision of this Agreement shall not affect the other provisions.
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17. DATA SECURITY
For the purpose of preventing the potential loss, misappropriation or inadvertent access, viewing,
use, or disclosure of COUNTY data including sensitive or personal client information; abuse of COUNTY
resources; and/or disruption to COUNTY operations, individuals and/or agencies that enter into a
contractual relationship with COUNTY for the purpose of providing services under this Agreement must
employ adequate data security measures to protect the confidential information provided to
CONTACTOR by COUNTY, including but not limited to the following:
A. FHA-Owned Mobile, Wireless, or Handheld Devices
i. FHA may not connect to COUNTY networks via personally owned mobile,
wireless, or handheld devices, unless the following conditions are met:
1. FHA has received authorization by COUNTY for telecommuting purposes;
2. Current virus protection software is in place;
3. Mobile device has the remote wipe feature enabled; and
4. A secure connection is used.
B. FHA-Owned Computers or Computer Peripherals
i. FHA may not bring FHA-owned computers or computer peripherals into COUNTY
for use without prior authorization from COUNTY’s Chief Information Officer,
and/or designee(s), including but not limited to mobile storage devices. If data is
approved to be transferred, data must be stored on a secure server approved by
COUNTY and transferred by means of a Virtual Private Network (VPN)
connection, or another type of secure connection. Said data must be encrypted.
C. COUNTY-Owned Computer Equipment
i. FHA may not use COUNTY computers or computer peripherals on non-COUNTY
premises without prior authorization from the COUNTY’s Chief Information
Officer, and/or designee(s).
D. FHA may not store COUNTY’s private, confidential, or sensitive data or any hard-disk
drive, portable storage device, or remote storage installation unless encrypted.
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E. FHA shall be responsible to employee strict controls to ensure the integrity and security
of COUNTY’s confidential information and to prevent unauthorized access, viewing, use,
or disclosure of data maintained in computer files, program documentation, data
processing systems, data files, and data processing equipment which stores or
processes COUNTY data internally and externally.
F. Confidential client information transmitted to one party by the other by means of
electronic transmissions must be encrypted according to Advanced Encryption Standards
(AES) of 128 BIT or higher. Additionally, a password or passphrase must be utilized.
G. FHA is responsible to immediately notify COUNTY of any violations, breaches, or
potential breaches of security related to COUNTY’s confidential information, data
maintained in computer files, program documentation, data processing systems, data
files, and data processing equipment which stores or processes COUNTY data internally
or externally.
H. COUNTY shall provide oversight to FHA’s response to all incidents arising from a
possible breach of security related to COUNTY’s confidential client information provided
to FHA. FHA will be responsible to issue any notification to affected individuals as
required by law or as deemed necessary by COUNTY in its sole discretion. FHA will be
responsible for all costs incurred as a result of providing the required notification.
18. PROHIBITION OF PUBLICITY
None of the funds, materials, property, or services provided directly or indirectly under this
Agreement shall be used for FHA’s advertising, fundraising, or publicity (i.e. purchasing of tickets/tables,
silent auction donations, etc.) for the purpose of self-promotion.
Notwithstanding the above, publicity of the services described in Section 1 and Exhibit A of this
Agreement shall be allowed as necessary to raise public awareness about the availability of such
specific services when approved in advance by COUNTY’s DBH Director or their designee and at a cost
to be provided in Exhibit A for such items as written/printed materials, the use of media (i.e. radio,
television, newspapers) and any other related expense(s).
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19.GOVERNING LAW
The parties agree that for the purpose of venue, performance under this Agreement is in Fresno
County, California.
The rights and obligations of the parties and all interpretation and performance of this Agreement
shall be governed in all respects by the laws of the State of California.
20.DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the FHA is operating as a corporation (a for-profit or non-profit
corporation) or if during the term of the agreement, the FHA changes its status to operate as a
corporation.
Members of the FHA’s Board of Directors shall disclose any self-dealing transactions that they are a
party to while FHA is providing goods or performing services under this agreement. A self-dealing
transaction shall mean a transaction to which the FHA is a party and in which one or more of its
directors has a material financial interest. Members of the Board of Directors shall disclose any self-
dealing transactions that they are a party to by completing and signing a Self-Dealing Transaction
Disclosure Form, attached hereto as Exhibit I and incorporated herein by reference, and submitting it to
the COUNTY prior to commencing with the self-dealing transaction or immediately thereafter.
21.ELECTRONIC SIGNATURE
The parties agree that this Agreement may be executed by electronic signature as provided in this
section. An “electronic signature” means any symbol or process intended by an individual signing this
Agreement to represent their signature, including but not limited to (1) a digital signature; (2) a faxed
version of an original handwritten signature; or (3) an electronically scanned and transmitted (for example
by PDF document) of a handwritten signature. Each electronic signature affixed or attached to this
Agreement (1) is deemed equivalent to a valid original handwritten signature of the person signing this
Agreement for all purposes, including but not limited to evidentiary proof in any administrative or judicial
proceeding, and (2) has the same force and effect as the valid original handwritten signature of that person.
The provisions of this section satisfy the requirements of Civil Code section 1633.5, subdivision (b), in the
Uniform Electronic Transaction Act (Civil Code, Division 3, Part 2, Title 2.5, beginning with section 1633.1).
Each party using a digital signature represents that it has undertaken and satisfied the requirements of
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Government Code section 16.5, subdivision (a), paragraphs (1) through (5), and agrees that each other
party may rely upon that representation. This Agreement is not conditioned upon the parties conducting the
transactions under it by electronic means and either party may sign this Agreement with an original
handwritten signature.
22. ENTIRE AGREEMENT
This Agreement, including all Exhibits, constitutes the entire agreement between FHA and COUNTY
with respect to the subject matter hereof and supersedes all previous agreements, negotiations,
proposals, commitments, writings, advertisements, publications, and understandings of any nature
whatsoever unless expressly included in this Agreement.
Exhibit A – Scope of Work
Exhibit B – Compliance with State Medi-Cal Requirements
Exhibit C – Accepted Match Form
Exhibit D – Application for Initial Occupancy
Exhibit E – HMIS Data Collection Form
Exhibit F – HMIS – Release of Information
Exhibit G – Participant Provider Agreement
Exhibit H – FMCoC – Release of Information
Exhibit I – Self-Dealing Transaction Disclosure Form
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IN WITNESS WHEREOF , the parties hereto have executed th is Agreement as of the day and
year first hereinabove written .
CONTRACTOR:
HOUSING AUTHORITY OF THE CITY
AND COUNTY OF FRESNO
By b /k =~ cs ~\
Print Name: Angelina Nguyen
Title : Interim CEO
Chief Executive Officer, or
President , or any Vice President
Mail ing Address :
Fresno Housing Authority
1331 Fulton Street
Fresno , CA 93727-2014
Phone No : 559-443-8400
Contact: Doreen Eley
Shelter Plus Care Program Manager
Fund/Subclass:
Organization:
Account#:
0001/10000
5630299
7295/0
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COUNTY OF FRESNO:
Steve Brandau , Chairman
of the Board of Supervisors of the
County of Fresno
Date : (fl>:N, ~,~\
ATTEST:
Bernice E . Seidel
Clerk of the Board of Supervisors
County of Fresno , State of Cal ifornia
By ~~
Dep
Date : CT"\.u,y 1-'l ?a.;l\
'
Exhibit A
Page 1 of 8
Shelter Plus Care Tenant-based Rental Assistance Program
Scope of Work
I. Definitions:
- Coordinated Entry System (CES): Community-wide system that facilitates coordination
and management of resources and services to ensure all people experiencing a housing
crisis have fair and equal access and are quickly identified, assessed for, referred, and
connected to housing and assistance based on their strengths and needs.
- Document Ready: In possession of the required documentation to apply and qualify for
the specified program.
- Homelessness:
o Literally Homeless –
Individual or family who lacks a fixed, regular, and adequate nighttime
residence, meaning: (i) Has a primary nighttime residence that is a public
or private place not meant for human habitation; (ii) Is living in a publicly
or privately operated shelter designated to provide temporary living
arrangements (including congregate shelters, transitional housing, and
hotels and motels paid for by charitable organizations or by federal,
state and local government programs); or (iii) Is exiting an institution
where (s)he has resided for 90 days or less and who resided in an
emergency shelter or place not meant for human habitation
immediately before entering that institution.
o Fleeing/Attempting to Flee Domestic –
Any individual or family who: (i) Is fleeing, or is attempting to flee,
domestic violence, dating violence, sexual assault, stalking or human
trafficking; (ii) Has no other residence; and (iii) Lacks the resources or
support networks to obtain other permanent housing
Exhibit A
Page 2 of 8
- Homeless Management Information System (HMIS): A HUD-mandated information
technology system used to collect client-level data and data on the provision of housing
and services to homeless individuals and families and persons at risk of homelessness.
- Fresno Madera Continuum of Care (FMCoC): A homeless housing and services delivery
system comprised of service providers, government entities, non-profits, businesses,
and community members that facilitates coordinated, unduplicated and seamless
services for the community’s homeless population.
- Permanent Supportive Housing (PSH): Permanent housing with indefinite leasing or
rental assistance paired with supportive services to assist homeless persons with a
disability or families with an adult or child member with a disability achieve housing
stability.
II. Program Description:
The Shelter Plus Care (SPC) Tenant-based Rental Assistance (TRA) Program links rental
assistance to supportive services for persons experiencing homelessness who have been
diagnosed with a disability. Participants will receive rental assistance from the Fresno Housing
Authority (FHA) and supportive services from COUNTY’s Department of Behavioral Health
(DBH) and/or its selected service contractors. Service levels will be equivalent to or in excess of
25% of the rental assistance provided by FHA.
TRA provides grants that permit participants to choose housing of an appropriate size in
which to reside. FHA requires participants to live in the same unit for the first year; they will
retain their rental assistance if they move into different units within Fresno County thereafter.
III. Eligibility Requirements:
1. Participants must be:
a. experiencing homelessness (if over the age of 18)
b. diagnosed with a disability such as a serious mental health illness, chronic substance
abuse, physical health disability, and/or developmental disability
c. eligible for mental health services and/or supportive services with an assigned case
manager through DBH or its service provider
Exhibit A
Page 3 of 8
d. document ready as described in Section IV “Required Documentation”
e. willing to sign a Release of Information (ROI) between DBH and FHA on an annual
basis
2. Persons served must complete the prioritization process via an assessment tool and be
enrolled into HMIS.
3. Persons served must be referred through CES via a community matcher/coordinator
from FMCoC.
IV. Required Documentation:
1. The person served and all other household members must have the required
documentation:
Current within 60 Days of Application Submission:
a. Accepted Match Form (Exhibit C)
b. Application for Initial Occupancy (Exhibit D)
c. Birth Certificate
d. General Release of Information
e. Government Issued Photo-Identification Card
f. HMIS Data Collection Form (Exhibit E)
g. HMIS ROI (Exhibit F)
h. Participant Provider Agreement (Exhibit G)
i. ROI with DBH, FHA, and all FMCoC affiliated agencies (Exhibit H)
j. Social Security Card
Current within 30 Days of Application Submission:
a. Disability Certification
b. FMCoC Homeless Verification and Letter
c. Proof of Income (if applicable)
2. Copies of the documents are accepted with the exception of the identification card.
3. Each form is to be completed as per the instructions on the respective form and in
conformance to SPC regulations. COUNTY and FHA shall provide and attach all necessary
supporting documentation as indicated within each form to FHA’s designated staff.
Exhibit A
Page 4 of 8
V. COUNTY Responsibilities:
COUNTY and its selected contractors shall:
1. Operate on the Housing First model in its delivery of services. Housing First is a
philosophy that homelessness can be most efficiently ended by providing someone with
access to safe, decent, and affordable housing. Although an individual experiencing
homelessness may benefit from supportive services such as mental health or substance
abuse counseling, participation in these services is not a prerequisite to access housing
or a condition of maintaining it. In fact, the stability that a housing unit provides bolsters
a tenant’s ability to participate in these services.
2. Provide SPC program outreach to eligible persons as defined in Section III “Eligibility
Requirements;”
3. Refer eligible persons to SPC TRA program through CES;
4. Assist program participants in securing housing using the SPC TRA certificate;
5. Upon advisement of SPC TRA availability, COUNTY’s designated DBH staff, FHA staff, and
FMCoC CES staff will work together to find appropriate referrals from FMCoC By Name
List using FMCoC priority system. Should there be no appropriate referrals, DBH staff
may submit eligible individuals/families to CES for possible match to SPC TRA;
6. Ensure In-Kind Match Report is submitted to FHA by the 5th of every month;
7. Identify DBH staff as liaisons between FHA and COUNTY. Said individuals are responsible
for:
a. Cash match reporting and maintaining supporting documentation;
b. Reviewing the referrals for pertinent documentation;
c. Eligibility;
d. Collaborating with CES staff for referrals to SPC TRA;
e. Submitting requests for SPC program training for staff of COUNTY and its
selected contractors as needed; and
f. Informing FHA if there is a liaison staff change.
8. Ensure SPC referral is signed by DBH Director or designee.
Exhibit A
Page 5 of 8
9. Provide confidential on-going case management and/or supportive services to
participants.
a. Case management services must be offered for at least six (6) months after
participant receives housing.
b. Participants may be considered for discontinuation of case management services
after six (6) months of participation in which they demonstrate the ability to live
independently. Participant would maintain contact with DBH Housing Team for
supportive services.
c. In the event participant begins to decompensate, the DBH SPC Housing
Coordinator will re-link participant to case management services.
d. Participants will be encouraged to remain engaged in mental health and/or
medication management services.
e. The parties agree that supportive services provided by COUNTY and its selected
contractor may be in the form of treatment, therapy, crisis intervention,
medication support, residential treatment, inpatient psychiatric care, vocational
rehabilitation, mental health services, and other services mutually agreed to be
considered supportive services. The parties agree that FHA shall make the final
determination of whether a service is considered a supportive service;
10. Ensure supportive services are equivalent or in excess of twenty-five (25) percent of the
amount paid in SPC Rental Assistance Payment (RAP) by FHA for the operating year, for
all SPC participants referred.
11. Complete an addendum to this MOU annually, detailing the grant number, operating
term, prospective services to be provided with the amounts for each (see attached).
12. Collect universal information for purposes of reporting on the HUD Annual Performance
Report
13. Provide access of supportive services documentation to FHA to ensure SPC program
compliance and accuracy of in-kind reporting.
VI. Role of COUNTY’s DBH Housing Coordinator
14. Prior to SPC Enrollment, the assigned DBH Housing Coordinator:
Exhibit A
Page 6 of 8
a. Receives a match referral of person served from the FMCoC Community
Coordinator
b. Reviews the referrals and pertinent documentation; eligibility and submits the
SPC referrals to the FHA designee.
c. DBH SPC Housing Coordinator waits for approval from FHA and then schedules
with individual for certificate issue.
d. Provides outreach to persons experiencing homeless who are eligible for SPC.
e. Ensures that persons served meets all eligibility criteria for SPC and assists them
in obtaining current documentation.
f. Schedules a case consultation with DBH Treatment Team’s representative
manager and person served. SPC is explained thoroughly and all questions are
answered at the time of consult. The person served makes a final decision
regarding their participation.
15. While Participant is Enrolled, the assigned DBH Housing Coordinator:
a. Provides ongoing coordination of confidential wrap around and supportive
services within the community.
b. Works with the identified case manager and other wrap around services for the
retention of individual housing and supportive services engagement.
c. Maintains contact with participants at least once per month.
d. Maintains a participant file with accurate documentation of supportive and wrap
around services, an Individual Service Plan (ISP), case notes, ROI tracking, and
other documents deemed necessary to meet the SPC requirements.
e. Conducts regular landlord outreach/engagement activities and initiates referrals
to assist with wrap around services such as housing searches to the DBH case
managers and other community partners.
f. Assists participant in locating suitable housing to meet the needs of person
served, including safety and affordability.
Exhibit A
Page 7 of 8
g. Schedules a staffing with the DBH case manager and/or clinician at the three (3)
and six (6) month marks to conduct a Housing Plan in which goals and stability
needs are reviewed and addressed.
FHA Responsibilities:
FHA shall:
1. Operate on the Housing First model in its delivery of services. Housing First is a
philosophy that homelessness can be most efficiently ended by providing someone with
access to safe, decent, and affordable housing. Although an individual experiencing
homelessness may benefit from supportive services such as mental health or substance
abuse counseling, participation in these services is not a prerequisite to access housing
or a condition of maintaining it. In fact, the stability that a housing unit provides bolsters
a tenant’s ability to participate in these services.
2. Administer SPC in compliance with applicable regulations;
3. Advise COUNTY’s designated DBH staff and FMCoC CES staff of SPC TRA availability. CES
staff will consult the By Name List for appropriate referrals using FMCoC priority system;
4. Coordinate participant intake;
5. Ensure SPC data and reports on HMIS are in compliance with FMCoC expectations;
6. Compile quarterly SPC data and reports on HMIS.
7. Provide technical assistance and training to DBH designated staff as needed;
8. Assist COUNTY and SPC participants in retaining rental housing assistance through
advocacy;
9. Provide eligibility/annual re-certifications and Housing Quality Standards Inspections for
SPC participants;
10. Monitor and updates monthly reports for COUNTY’s in-kind supportive services match;
11. Identify FHA staff as a liaison between FHA and COUNTY; and
12. Process SPC participant termination for non-compliance with SPC Program regulations,
including non-compliance with Participant-Service Provider Agreements as it pertains to
Exhibit A
Page 8 of 8
non-adherence to case management and subsequent non-compliance with lease
requirements and/or criminal behavior.
Exhibit B
Page 1 of 2
COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
CONTRACTOR shall be required to maintain organizational provider certification by the host
county. A copy of this renewal certificate must be furnished to COUNTY within thirty (30) days
of receipt of certificate from host county. The CONTRACTOR must meet Medi-Cal organization
provider standards as stated below. It is acknowledged that all references to Organizational
Provider and/or Provider below shall refer to the CONTRACTOR.
Medi-Cal Organizational Provider Standards
1. The organizational provider possesses the necessary license to operate, if applicable,
and any required certification.
2. The space owned, leased or operated by the provider and used for services or staff
meets local fire codes.
3. The physical plant of any site owned, leased, or operated by the provider and used for
services or staff is clean, sanitary and in good repair.
4. The organizational provider establishes and implements maintenance policies for any
site owned, leased, or operated by the provider and used for services or staff to ensure
the safety and well-being of beneficiaries and staff.
5. The organizational provider has a current administrative manual which includes:
personnel policies and procedures, general operating procedures, service delivery
policies, and procedures for reporting unusual occurrences relating to health and
safety issues.
6. The organizational provider maintains client records in a manner that meets applicable
state and federal standards.
7. The organization provider has staffing adequate to allow the COUNTY to claim federal
financial participation for the services the Provider delivers to beneficiaries, as
described in Division 1, Chapter 11, Subchapter 4 of Title 9, CCR, when applicable.
8. The organizational provider has as head of service a licensed mental health
professional or other appropriate individual as described in Title 9, CCR, Sections 622
through 630.
9. For organizational providers that provide or store medications, the provider stores and
dispenses medications in compliance with all pertinent state and federal standards. In
particular:
A. All drugs obtained by prescription are labeled in compliance with federal and state
laws. Prescription labels are altered only by persons legally authorized to do so.
B. Drugs intended for external use only or food stuffs are stored separately from drugs
for internal use.
C. All drugs are stored at proper temperatures, room temperature drugs at 59-86
degrees F and refrigerated drugs at 36-46 degrees F.
Exhibit B
Page 2 of 2
D. Drugs are stored in a locked area with access limited to those medical personnel
authorized to prescribe, dispense or administer medication.
E. Drugs are not retained after the expiration date. IM multi-dose vials are dated and
initialed when opened.
F. A drug log is maintained to ensure the provider disposes of expired, contaminated,
deteriorated and abandoned drugs in a manner consistent with state and federal
laws.
G. Policies and procedures are in place for dispensing, administering and storing
medications.
10. The COUNTY may accept the host county’s site certification and reserves the right to
conduct an on-site certification review at least every three years. The COUNTY may
also conduct additional certification reviews when:
• The provider makes major staffing changes.
• The provider makes organizational and/or corporate structure changes
(example: conversion from a non-profit status).
• The provider adds day treatment or medication support services when
medications shall be administered or dispensed from the provider site.
• There are significant changes in the physical plant of the provider site (some
physical plant changes could require a new fire clearance).
• There is change of ownership or location.
• There are complaints against the provider.
• There are unusual events, accidents, or injuries requiring medical treatment for
clients, staff or members of the community.
FMCoC Housing Match Confirmation &
Staffing Form
Navigator Name: ____________________________ Phone Number:________________________________
Email: _______________________________________
Client Preferences:
Type of unit needed: Individual Family with Children Adult Couple
Number of Adults in the Household: _____
Number of Children in the Household: _____
Should the option come available would you consider shared housing?: Yes No
Navigator Check List:
Confirmed Chronic Status/Date _______________ VI SPDAT Score _________________
Homelessness Verification ____________________ Disability Verification ______________
Attached Documents ________________________________________________________________
Client Housing Matches:
Match #1 Match #2 Match #3 Match #4
Type:
Permanent Supportive
Housing (PSH)
Rapid Re-Housing (RRH)
Diversion
Type:
Permanent Supportive
Housing (PSH)
Rapid Re-Housing (RRH)
Diversion
Type:
Permanent Supportive
Housing (PSH)
Rapid Re-Housing (RRH)
Diversion
Type:
Permanent Supportive
Housing (PSH)
Rapid Re-Housing (RRH)
Diversion
Program:
Client Acceptance
Client Refusal
Date Offered:
Program:
Client Acceptance
Client Refusal
Date Offered:
Program:
Client Acceptance
Client Refusal
Date Offered:
Program:
Client Acceptance
Client Refusal
Date Offered:
Staffing Notes:
Date: _____/_____/_______ HMIS ID: __________________________________________
First Name: MI: Last Name: _________________________ Suffix: ___________
Exhibit C
Page 1 of 1
Exhibit D
Exhibit D
Exhibit D
Exhibit D
Exhibit D
Exhibit D
Exhibit D
Exhibit D
Exhibit D
Exhibit D
HMIS DATA COLLECTION TEMPLATE: PROJECT START DATE
Form for all Project Types
Use block letters for text and bubble in the appropriate circles. Please complete a separate form for each household member.
PROJECT START DATE [All Clients]
__ __
Month Day Year
SOCIAL SECURITY NUMBER [All Clients]
__ __
QUALITY OF SOCIAL SECURITY
Full SSN reported Client doesn’t know
Approximate or partial SSN reported Client refused
DATE OF BIRTH [All Clients]
__ __
Month Day Year
QUALITY OF DATE OF BIRTH
Full DOB reported Client doesn’t know
Approximate or partial DOB reported Client refused
RELATIONSHIP TO HEAD OF HOUSEHOLD [All Clients]
Self
Head of household’s child
Head of household’s spouse or partner
Head of household – other relation to member
Other: non-relation member
NAME [All Clients]
First
Middle
Last
Suffix
Alias
QUALITY OF NAME
Full name reported
Partial, street name, or code name reported
Client doesn’t know
Client refused
VETERAN STATUS [All Adults]
No
Yes
Client doesn’t know
Client refused
Project
Name:
Date of
data
collection:
Time of
data
collection:
Collected
by:
Exhibit E
Page 1 of 6
GENDER [All Clients]
Female Gender Non-Conforming (i.e. not exclusively male
or female
Male Client doesn’t know
Trans Female (MTF or Male to Female) Client refused
Trans Male (FMT or Female to Male)
RACE [All Clients]
American Indian or Alaska Native Client doesn’t know
Asian Client refused
Black/African American
Hawaiian or Other Pacific Islander
White
ETHNICITY [All Clients]
Non-Hispanic Client doesn’t know
Hispanic/Latino Client refused
CURRENT LIVING SITUATION [Head of Household and Adults]
Place not meant for human habitation (e.g., a
vehicle, an abandoned building bus/train/subway
station/airport or anywhere outside
Staying or living in a family member’s room,
apartment or house
Emergency shelter, including hotel or motel paid
for with emergency shelter voucher, or RHY-
funded Host Home shelter
Rental by client, with GPD TIP housing subsidy
Safe Haven Rental by client, with VASH housing subsidy
Foster care home or foster care group home Permanent housing (other than RRH) for formerly
homeless persons
Hospital or other residential non-psychiatric
medical facility
Rental by client, with RRH or equivalent subsidy
Jail, prison or juvenile detention facility Rental by client, with HCV voucher (tenant or project
based)
Long-term care facility or nursing home Rental by client in a public housing unit
Psychiatric hospital or other psychiatric facility Rental by client, no ongoing housing subsidy
Substance abuse treatment facility or detox
center
Rental by client, with other ongoing housing subsidy
Residential project or halfway house with no
homeless criteria
Owned by client, with ongoing housing subsidy
Hotel or motel paid for without emergency
shelter voucher
Owned by client, no ongoing housing subsidy
Transitional housing for homeless persons
(including homeless youth)
Client doesn’t know
Host Home (non-crisis) Client refused
Staying or living in a friend’s room, apartment, or
house
Exhibit E
Page 2 of 6
LENGTH OF STAY IN PRIOR LIVING SITUATION
One night or less One month or more, but less than 90
days
Client doesn’t know
Two to six nights 90 days or more, but less than one
year
Client refused
One week or more, but
less than one month
One year or longer
If client is immediately coming from a TH/PH living situation, did they
stay less than 7 nights?
No
Yes
If client is immediately coming from an INSTUTIONAL living situation did
they stay less than 90 days?
No
Yes
On the night before the TH/PH OR INSTITUTIONAL living situation, did
client stay on the streets, emergency shelter, or Safe Haven?
No
Yes
APPROXIMATE DATE HOMELESSNESS STARTED
Date:
NUMBER OF TIMES THE CLIENT HAS BEEN ON THE STREETS, ES, OR SAFE
HAVEN IN THE LAST 3 YEARS
One time Client doesn’t know
Two times Client refused
Three times
Four or more times
NUMBER OF MONTHS THE CLIENT HAS BEEN ON THE STREETS, ES, OR SAFE
HAVEN IN THE LAST 3 YEARS
One month (this is the first time) Client doesn’t know
2 – 12 months (specify number of months): Client refused
More than 12 months
DISABLING CONDITION [All Clients]
No Client doesn’t know
Yes Client refused
Exhibit E
Page 3 of 6
Physical Disability [All Clients]
No Client Doesn’t Know
Yes Client Refused
If “Yes” to Physical Disability - Specify
Expected to be of long-continued and
indefinite duration and substantially
impairs ability to live independently?
No Client Doesn’t Know
Yes Client Refused
Developmental Disability [All Clients]
No Client Doesn’t Know
Yes Client Refused
Chronic Health Condition [All Clients]
No Client Doesn’t Know
Yes Client Refused
If “Yes” to Chronic Health Condition - Specify
Expected to be of long-continued and
indefinite duration and substantially
impairs ability to live independently?
No Client Doesn’t Know
Yes Client Refused
HIV/AIDS [All Clients]
No Client Doesn’t Know
Yes Client Refused
Mental Health Problem [All Clients]
No Client Doesn’t Know
Yes Client Refused
If “Yes” to Mental Health Problem - Specify
Expected to be of long-continued and
indefinite duration and substantially
impairs ability to live independently?
No Client Doesn’t Know
Yes Client Refused
Substance Abuse Problem [All Clients]
No Both alcohol and drug abuse
Alcohol abuse Client Doesn’t Know
Drug abuse Client Refused
If “Yes” to Substance Abuse Problem - Specify
Expected to be of long-continued and indefinite duration and
substantially impairs ability to live independently?
No Client Doesn’t Know
Yes Client Refused
INCOME FROM ANY SOURCE [Head of Household and Adults]
Exhibit E
Page 4 of 6
No Client Doesn’t Know
Yes Client Refused
If “Yes” to Income From Any Source – Indicate ALL sources that apply
(Round to the nearest dollar)
Income Source Amount Income Source Amount
Earned Income
Temporary Assistance for Needy
Families (TANF)
Unemployment Insurance
General Assistance (GA)
Supplemental Security Income
(SSI)
Retirement Income from Social
Security
Social Security Disability
Insurance (SSDI)
Pension or Retirement Income
from a Former Job
VA Service-Connected Disability
Compensation
Child Support
VA Non-Service-Connected
Disability Pension
Alimony and Other Spousal
Private Disability Compensation Other Source
Worker’s Compensation
Total Monthly Income for Individual:
RECEIVING NON-CASH BENEFITS [Head of Household and Adults]
No Client Doesn’t Know
Yes Client Refused
If “Yes” to Non-Cash Benefits – Indicate ALL sources that apply
Non-Cash Benefits
Supplemental Nutrition Assistance Program (SNAP)
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
TANF Childcare Services
TANF Transportation Services
Other TANF-funded services
Other (Specify):
COVERED BY HEALTH INSURANCE [All Clients]
No Client Doesn’t Know
Yes Client Refused
If “Yes” to Health Insurance – Health Insurance Coverage Details
MEDICAID Health Insurance Obtained Through COBRA
MEDICARE Private Pay Health Insurance
State Children’s Health Insurance (SCHIP) State Health Insurance for Adults
Veteran’s Adminstration (VA) Medical Services Indian Health Services Program
Other (Specify):
Exhibit E
Page 5 of 6
DOMESTIC VIOLENCE VICTIM/SURVIVOR [Head of Household and Adults]
No Client Doesn’t Know
Yes Client Refused
If “Yes” to Domestic Violence
When Experience Occurred
Within the past three months Client Doesn’t Know
Three to six months ago (excluding six
months exactly)
Client Refused
Six months to one year ago (excluding one year exactly)
One year ago or more
Exhibit E
Page 6 of 6
Fresno Madera Continuum of Care
Client Informed Consent & Release of Information Authorization
Homeless Management Information System (HMIS)
Fresno Housing is a Partner Agency in the Homeless Management Information System (HMIS). HMIS
is a shared homeless and housing database system administered by The Fresno Housing Authority
(FH). HMIS can improve the services and programs for homeless and low income households by
allowing authorized staff at Partner Agencies to share client information and to follow trends and
service patterns over time. HMIS operates over the internet and uses many security protections to
ensure confidentiality. This Agency will collect your information and enter it into HMIS.
Participation in the HMIS program is important to our community’s ability to provide you with the
best services and housing possible. As you receive services, Basic Information and Coordination of
Care and Housing Information (listed below) will be collected about you, the services provided to
you, and the outcomes these services help you to achieve.
A representative of this Agency is going to ask you for information about you and your dependents.
The word “dependent” is used in this documents to refer to any person under the age or 18 for whom
you consider yourself to be responsible for. Once your information is entered into HMIS it will be
shared as described below.
Basic Information:
This information will be shared through HMIS and partner agencies utilizing HMIS.
Personal Identifying Information (Name, Social Security Number, Date of Birth, Gender,
Race, Ethnicity, Veteran Status, and photo)
Household information
Personal Identifying Information about your dependents (if applicable)
Enrollment information
Coordination of Care and Housing Information:
This information, along with other information from the HMIS will be used or disclosed for the
purposes of matching you to the appropriate services and possible housing, to conduct referrals and
assessments, to determine program eligibility, to otherwise collaborate to address specific needs and
circumstances, and to share information in case conference meetings for the purposes of finding
and/or coordinating services for you and your dependents.
Contact Information
Experience with homelessness and living situation
Household income and source(s)
Presence of a current disabling condition
Services you receive
Documents to support homeless situation, income, disabling condition, and identity for the
purpose of housing match
As stated in our Notice of Privacy Policy, we are required by law to maintain the privacy of this
information and explain how, when and why we may use or disclose any of this information.
Your name and other identifying information will not be shared with any agency not
participating in the system (unless required to do so by law).
Exhibit F
Page 1 of 3
Your name, gender, race, social security number and date of birth and other Basic
Information may be shared with Partner Agencies for Identification purposes even if you
elect not to share other sensitive information.
Sensitive information, such as diagnosis or treatment or mental health disorders, drug or
alcohol disorders, HIV/AIDS, or domestic violence concerns, will not be shared between
Partner Agencies without specific written consent.
A list of Partner Agencies is available upon request.
Authorizing your information to be entered into the HMIS is voluntary.
Refusing to do so will not limit your access to shelter or services.
Please initial ONE of the following levels of consent:
____ (1) I give authorizations for my basic and coordination of care and housing information to be
entered into the HMIS and shared between Partner Agencies. I understand that I have the right to
receive a copy of all information shared between the Partner Agencies.
____ (2) I give authorization for my basic and relevant information to be entered into the HMIS, but
not shared between Partner Agencies. My information will not be shared, used or disclosed at case
conference meetings and may make it more difficult for participating agencies to qualify me for
assistance suited to my needs.
I understand that I may cancel this authorization at any time by written request, but the cancellation
will not be retroactive. I understand that I have the right to view my HMIS record and will have a
report prepared within 72 business hours of my written request. I understand that if I refuse consent
to share this information I cannot be denied services. I understand that this release is valid for
_____ years from the date of my signature.
Name and Date of Birth of dependents (under 18 only)
NAME Date of Birth
Client Name (please print) Client Signature Date
Agency Staff Name (please print) Agency Staff Signature Date
Exhibit F
Page 2 of 3
Fresno Madera Continuum of Care
HMIS Partner Agencies
Effective April 2020
Community Action Agency Partnership of Madera
Fresno EOC Sanctuary and Support Services
Fresno Housing Authority
Fresno Madera Coordinated Entry Agency Partners*
Kings View
Madera County Department of Behavioral Health Services
Mental Health Systems
Poverello House
RH Community Builders
Selma Community Outreach Ministries
Turning Point
Valley Teen Ranch
Veteran Administration
WestCare California
*Fresno Madera Coordinated Entry Agency Partners include:
Centro La Familia
Clinica Sierra Vista
Fresno County Department of Behavioral Health
Exhibit F
Page 3 of 3
Equal Housing
Opportunity
www.fresnohousing.org
1331 Fulton Mall, Fresno, California 93721 (559) 443-8400 TTY (800) 735-2929
Shelter Plus Care Program (SPC)
Participant-Service Provider Agreement
The purpose of this agreement is to document the commitment of the supportive services agency for
providing services to the SPC Program participant, and to clearly outline the roles and responsibilities of
the participant and service provider in regards to service provision for SPC program compliance.
Name of the Service Provider: _________________________________________________
Name of the Case Manager: ___________________________________________________
Phone Number of the Case Manager: __________________ Fax Number: _______________
Name of the Participant: ______________________________________________________
By signing the document, the Service Provider agrees to:
Act as the primary service provider for the above-named participant.
Assign a case manager to work with the participant and to be the main contact person for the Housing
Authority of the City of Fresno (Housing Authority).
Assist the participant to develop an Individual Service Plan designed to help maintain housing stability, and
meet the participant’s self-directed goals.
Assist the participant to access services he/she has identified in the Individual Service Plan.
Provide documentation of the services provided to the participant. Communicate promptly with the Housing
Authority, regarding any concerns about the participant’s housing stability.
Provide the participant and Housing Authority with a 180-day notice of intent to terminate this agreement.
Provide the Housing Authority with the required cash match in supportive services for the SPC participant
By signing this document, the Participant agrees to:
Maintain regular contact with the identified Case Manager.
Meet with the Case Manager at least once per month (or less if mutually agreed with case manager).
Work with the case manager to achieve the goals in the Individual Service Plan.
Communicate promptly with Housing Authority regarding any concerns with regard to the supportive services
received.
Provide the Service Provider and Housing Authority with 60-day notice of intent to terminate this agreement.
Authorize the staff of the Housing Authority and the Supportive Service agency to share information relating
to SPC rental assistance and supportive services required for SPC program participation.
Inform Service Provider if receiving supportive services from other service agencies.
_________________________________________ ___________________________
Authorized Service Provider Representative Date
________________________________________ ___________________________
Participant’s Signature Date
____________________________________ ___________________________
Housing Authority Staff Date
Exhibit G
1 of 1
TTY (800) 735-292 www.hafresno.org
www.fresnohousing.org
1331 Fulton Mall, Fresno, California 93721 (559) 443-8400 TTY (800) 735-2929
SHELTER PLUS CARE PROGRAM (SPC) Participant Name _______________________
AUTHORIZATION FOR RELEASE OF SPC Certificate Number __________________
CONFIDENTIAL INFORMATION Service Provider Name ___________________
Service Provider Staff ____________________
Date ___________________________________
I authorize the staff of Housing Authorities City and County of Fresno and personnel of the following
agencies below to share information relating to my SPC housing and supportive services.
Angels of Grace
Resources for Independence Central Valley
Central Valley Regional Center
Department of Behavioral Health
County of Fresno Employment & Temporary
Assistance
Fresno Interdenominational Refugee Ministries
West Care/The Living Room
Fresno County Economic Opportunities
Commission
CMC Specialty Health Center
Samaritan Woman
Poverello House
Alternative Vocational Services Employment
Fresno Center for New Americans
Spirit of Women
Fresno Unified School District- Project Access
Catholic Charities
Opportunity Assistance & Socially Integrated
Services
Department of Public Health
Department of Veterans Affairs
Fresno Unified School District- Lowell
Elementary School
Kings View
Marjaree Mason Center
Department of Children and Family Services
Fresno Rescue Mission
CMC Community Connections
Turning Point
Other ______________________
I understand that all information is confidential, and that no information will be released to any other person
outside of these agencies without my consent.
I understand that I can revoke this authorization at any time by providing the Housing Authorities City and
County of Fresno with written notification.
I certify that I have read (or had read to me) and understand the contents of this form.
I understand and agree that a photocopy of this form and my signature shall be considered as valid as the
original. This document is valid for two years.
Participant Signature:
Date:
If you are a person with disabilities and require reasonable accommodation, you must submit your request in writing or call Andrea
Garcia at 559 457-4264. The Housing Authority will make all reasonable efforts in assisting persons with disabilities. Examples of
reasonable accommodations include: Home Visits, TDD or TDY access and/or use of an interpreter.
Exhibit H
Page 1 of 1
Exhibit I
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “COUNTY”),
members of a CONTRACTOR’s board of directors (hereinafter referred to as “County
Contractor”), must disclose any self-dealing transactions that they are a party to while
providing goods, performing services, or both for the COUNTY. A self-dealing transaction is
defined below:
“A self-dealing transaction means a transaction to which the corporation is a party and in
which one or more of its directors has a material financial interest”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member’s name, job title (if applicable), and date this disclosure is being
made.
(2) Enter the board member’s company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to
the COUNTY. At a minimum, include a description of the following:
a. The name of the agency/company with which the corporation has the
transaction; and
b. The nature of the material financial interest in the corporation’s transaction that
the board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self-dealing
transaction described in Sections (3) and (4).
Exhibit I
Page 2 of 2
(1) Company Board Member Information:
Name: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a party to):
(4) Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233 (a):
(5) Authorized Signature
Signature: Date: