HomeMy WebLinkAboutAgreement A-17-377-2 Master Agreement.pdf1
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AMENDMENT I TO AGREEMENT
THIS AMENDMENT, hereinafter referred to as Amendment I, is made and entered into
this _______ day of ______________, 2021, by and between the COUNTY OF FRESNO, a Political
COUNTY provider listed in
Exhibit A, attached to this Agreement and by this reference incorporated herein, and collectively
WHEREAS, the parties entered into that certain Agreement identified as COUNTY
Agreement No. A-17-377, effective July 1, 2017, whereby COUNTY has identified a need for
individuals with mental health conditions to be placed at licensed residential care facilities that are
able to provide supplemental board and care home services, in accordance with various provisions of
the California Welfare and Institutions Code; and
WHEREAS, certain CONTRACTORS have the licensed residential care facilities, staff
and expertise, to provide supplemental board and care home services for COUNTY placed individuals
with a mental health condition; and
WHEREAS, the parties desire to amend COUNTY Agreement No. 17-377, regarding
changes as stated below and restate the Agreement in its entirety.
NOW, THEREFORE, in consideration of their mutual promises, covenants and
conditions, hereinafter set forth, the sufficiency of which is acknowledged, the parties agree as
follows:
1. That all references in Agreement No. 17-
is attached hereto and incorporated herein by this
reference.
2. That all references in Agreement No. 17-
. Revised Exhibit C is attached hereto and incorporated herein by this
reference.
3. That all references in Agreement No. 17-
reference.
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4. That all references in Agreement No. 17-ial Services
Home Services
5. That the existing COUNTY Agreement No. A-17-377, Page Five (5), Section
Four (4),
Line Twenty-
place:
COUNTY agrees to pay and CONTRACTOR(S) agrees to receive compensation
for delivering services to individuals placed by COUNTY, whether or not the individual receives
Supplemental Security Income (SSI)/State Supplementary Payment (SSP) funds, has Medi-Cal,
private insurance, or has no other coverage, at the rates set within each CONTRACTOR(S)
Revised Exhibit C , attached hereto and by this reference
incorporated herein.
B. The above rates identified within Revised Exhibit C include a prorated/daily
SSI/SSP amount for Basic Services which includes the following components: Room and Board,
and Care and Supervision (Maximum) and shall be determined by the Federal SSI
Administration and the State of California Department of Health Care Services (DHCS) and may
be subject to adjustment by the SSI Administration or DHCS, as appropriate, during each term
of this Agreement. COUNTY agrees to pay CONTRACTOR(S) the adjusted SSI/SSP amount
after the effective date of the adjustment is authorized by the Federal SSI Administration or
DHCS, as appropriate, and CONTRACTOR(S) agree to accept such reimbursement as of the
effective date of such adjustment, whether or not the cost of providing such services shall have
exceeded the amount of the payments hereunder. COUNTY shall notify CONTRACTOR(S) in
writing of any rate change within thirty (30) days of COUNTY receiving notice of any rate
change from the SSI Administration or DHCS. All parties acknowledge that no additional
SSI/SSP monies will be paid to the CONTRACTOR(S) by the COUNTY Public Guardian
Office (PGO) , for authorized individuals placed in their facilities that are SSI/SSP recipients.
C. In addition, the COUNTY agrees to pay and CONTRACTOR(S) agree to
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receive compensation for delivering specialized services authorization (SSA) services to
augment services under this Agreement for individuals as authorized by COUNTY. An SSA
Form must be used to request services for individuals who require services above and
beyond Exhibit B of this Agreement. The SSA Form may be approved/denied on a case by
case basis by COUNTY when necessary and applicable, and is in addition to the approved
daily rate identified in Revised Exhibit C. SSA Forms will be reviewed/approved up to a
maximum of 30 days with justification. CONTRACTOR(S) must submit an SSA Form, Exhibit
a determination is made that SSA services are needed for an authorized individual, but no
later than two business days after such determination is made. CONTRACTOR(S) shall
:
DBHLPSConservatorship@fresnocountyca.gov.
D. It is acknowledged by all parties hereto that any/all rates may be changed by the
Federal SSI Administration and/or DHCS during the term of this Agreement and such rate changes
shall become part of this Agreement as set forth in Subsection B above. Any/all rate adjustments
shall not result in an increase to the maximum compensation amount of this Agreement as
stated herein. A day shall be defined as any portion of a twenty-four (24) hour day beginning at
8:00 a.m. and ending at 7:59 a.m. the following day.
E. If a CONTRACTOR is informed that an authorized individual placed in their
facility by COUNTY has access to a third-party source for reimbursement other than COUNTY,
said CONTRACTOR shall attempt to obtain payment for the services (rendered by said
CONTRACTOR) directly from the third-party source. In the event that CONTRACTOR(S) is paid
from a third-party source for any authorized individual placed in their facility by the COUNTY
from a third-party source, CONTRACTOR(S) shall deduct the amount collected from the third-
party source from the amount invoiced to COUNTY for the services provided to any such
individual. All amounts collected by CONTRACTOR(S) shall be deducted from the amount
otherwise payable to CONTRACTOR(S) pursuant to this Agreement. CONTRACTOR(S) shall
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maintain and forward to COUNTY, monthly with their invoice, a list of all individuals who have
third-party resources.
F. CONTRACTOR(S) understand that COUNTY may seek reimbursement from
applicable third-party payors (e.g., Medicare, Medi-Cal or other insurance) for services rendered
by CONTRACTOR(S) and paid for by COUNTY. Upon request by COUNTY, CONTRACTOR(S)
shall prepare and submit information as it relates to authorized individuals placed by COUNTY
for the COUNTY to seek reimbursement from such third-party payors.
G. In no event shall services performed under this Agreement for all
CONTRACTOR(S) combined be in excess of Five Million and No/100 Dollars ($5,000,000.00)
for each fiscal year beginning with FY 2017-18 through FY 2019-20.
In no event shall services performed under this Agreement for all
CONTRACTOR(S) combined be in excess of Six Million Two Hundred Seventy-Five Thousand
and No/100 Dollars ($6,275,000) for the period of July 1, 2020 through June 30, 2021.
In no event shall the maximum compensation under this Agreement for all
CONTRACTOR(S) combined be in excess of Seven Million Five Hundred Thousand and
No/100 Dollars ($7,500,000) for the period of July 1, 2021 through June 30, 2022.
In no event shall the total maximum amount for the service provided by
CONTRACTOR(S) collectively under the terms and conditions of this Agreement for the entire
five-year term exceed Twenty-Eight Million Seven Hundred Seventy-Five Thousand and No/100
Dollars ($28,775,000.00). It is understood that all expenses incidental to CONTRACTOR(S)
performance of services under this Agreement shall be borne by CONTRACTOR(S).
H.
invoice submitted for services provided during the preceding month, within forty-five (45) days
Director or designee, COUNTY reserves the right to deny payment of any additional invoices
received ninety (90) days after the expiration of each term of this Agreement or termination of
this Agreement. If CONTRACTOR should fail to comply with any provision of this Agreement,
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COUNTY shall withhold payment until such time as the non-compliance has been corrected, or
COUNTY shall be relieved of its obligation for further compensation.
I. In the event the maximum compensation amount in any individual fiscal year as
noted above, is not fully expended, said remaining unspent funding amounts shall rollover to each
6. That the existing COUNTY Agreement No. A-17-377, Page Seven (7), Section
Five (5), beginning with Line One (1), with ONTRACTOR Seven (7),
Line Seventeen (1 received
th day of each month for
actual expenses incurred and services rendered in the previous month in which the services
were provided via email addressed to: 1) dbhinvoicereview@fresnocountyca.gov, 2) dbh-
invoices@fresnocountyca.gov; and 3) dbhcontractedservicesdivision@fresnocountyca.gov with a
copy to the assigned COUNTY DBH Staff Analyst.
CONTRACTOR(S) shall utilize the invoice templates, Revised Exhibit E attached hereto
and by this reference incorporated herein. All invoices submitted should be completed in their
entirety. In no event shall CONTRACTORS submit claims to COUNTY for clients that are not
duly authorized by COUNTY to receive services.
Payments by COUNTY shall be in arrears, within forty-five (45) days after receipt and
ver s DBH in an amount equivalent to the
rates set in each CONTRACTOR(S) Revised ,
including any rate adjustment provided for herein. However, if invoice(s) is not received in
proper form or substance as stated herein, COUNTY may withhold subsequent payment(s) until
such invoice(s) is received.
7. The parties agree that this Amendment I is sufficient to amend the Agreement; and that
upon execution of this Amendment I, the Agreement and Amendment I together shall be
considered the Agreement.
The Agreement, as hereby amended, is ratified and continued. All provisions, terms, covenants,
conditions and promises contained in the Agreement, and not amended herein, shall remain in full force
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and effect. This Amendment I shall become effective March 1, 2021.
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1 IN WITNESS WHEREOF , the parties hereto have executed this Amendment I to
2 Agreement No. A-17-377 as of the day and year first hereinabove written.
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CONTRACTOR($):
PLEASE SEE SIGNATURE
PAGES ATTACHED
FOR ACCOUNTING USE ONLY :
Fund/Subclass: 0001/10000
Organization: 56302175
Account/Program : 7295/0
COUNTY OF FRESNO
Steve Bra Af::::e Board
of Supervisors of the County of Fresno
ATTEST:
Bernice E. Seidel
Clerk of the Board of Supervisors
County of Fresno, State of California
By :~~~~• ~e.~~~~-
Deputy Q
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CONTRACTOR:
FILLMORE CHRISTIAN GARDEN
By _________________________________
Print Name __________________________
Title: _______________________________
Mailing Address:
4826 E. Fillmore Ave
Fresno, CA 93727
(559) 307-4170
Contact: Inthone Milly
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CONTRACTOR:
JAN-ROY PLACE OF FRESNO
By _________________________________
Print Name __________________________
_______________________________
Mailing Address:
4766 E. Illinois Ave
Fresno
(559)
Contact:
4266 N 9th Street
Fresno CA 93726
559-940-9708/559-797-9284
CONTRACTOR:
GAREM ASSISTED LIVING
By:
_______________________
_____________________________
Print Name: JOYCELYN BARE HOPPER
Title: Administrator
By:______________________________
Print Name: GARY RIEMER
Title: President
By: ______________________________
Print Name: MAXIMA DIONISIO
Title: Vice President
Mailing Address:
4266 N 9th Street
Fresno CA 93726
Tel. No 559-940-9708/559-797-9284
Contact: Joycelyn Bare Hopper
Revised Exhibit C
Page 1 of 4
Revised Exhibit C
Page 2 of 4
Revised Exhibit C
Page 3 of 4
Revised Exhibit C
Page 4 of 4
Revised Exhibit C
Page 1 of 4
Revised Exhibit C
Page 2 of 4
Revised Exhibit C
Page 3 of 4
Revised Exhibit C
Page 4 of 4
Revised Exhibit C
Page 1 of 4
Revised Exhibit C
Page 2 of 4
Revised Exhibit C
Page 3 of 4
Revised Exhibit C
Page 4 of 4
Supplemental Board & Care Home Services Rates
Dailey's Haven
4479 N. Eddy Ave, Fresno CA 93724
Estelle Dailey
August 4 2021
1-Jul-21
I. Social Security Income (SSI) Services - subject to change yearly * (rate indicated is 2021 rate)
Daily
$ 17.27
$ 18.21
$ 35.49
$0.00
$40.00
$35.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
9).
10).
11).
12).
13).
4).
5).
6).
7).
8).
II. Supplemental services in addition to the SSI Care and Supervision listed above (per RFSQ 17-067)
Daily
1). Bilingual/bicultural programming
2). Self-sufficiency skills
3). Enhancement of independent living skills
Effective Date of Rates:
Monthly
1) Room and Board $ 525.37
2) Care and Supervision (maximum)* $ 554.00
Total SSI Portion $ 1,079.37
Name of Facility:
Facility Address:
Submitted by:
Approved by:
Date Submitted:
Revised Exhibit C
Page 1 of 4
$0.00
$0.00
$0.00
$ 75.00
$ 110.49
Supplemental Board & Care Home Services Target Populations
Dailey's Haven
4479 N. Eddy Ave
Estelle Dailey
x
Individuals with a visual impairments, including legal blindness*
Individuals with colostomy bags*
Individuals with diabetes (for maintenance, including but not limited to, insulin injections and blood sugar monitoring)*
Individuals dependent on oxygen*
Submitted by:
Please indicate if you are capable of serving the following individuals in your facility(ies) by placing a check in the appropriate boxes below:
Individuals dependent on wheelchairs*
Individuals dependent on walking devices (walkers or other walking assistance devices)*
Individuals with amputated limbs*
(F) Supervision of resident schedules and activities;
(G) Maintenance and supervision of resident monies or property;
(H) Monitoring food intake or special diets.
Name of Facility:
Facility Address:
(A) Assistance in dressing, grooming, bathing and other personal hygiene;
(B) Assistance with taking medication, as specified in Section 87465, Incidental Medical and Dental Care Services;
(C) Central storing and distribution of medications, as specified in Section 87465, Incidental Medical and Dental Care Services;
(D) Arrangement of and assistance with medical and dental care. This may include transportation, as specified in Section 87465, Incidental
(E) Maintenance of house rules for the protection of residents;
*Care and supervision as defined in Section 87101(c)(3)
to, any one or more of the following activities provided by a person or facility to meet the needs of the residents:
Total Supplemental Services Portion (No #1.
III. Total Daily Rate for Services (Room & Board, Care & Supervision, and Supplemental Services)
14).
15).
16)
Revised Exhibit C
Page 2 of 4
x
x
x
*Please note: possession of care exemptions approved by Community Care Licensing (CCL) will be required to provide services to individuals with specialized medical needs.
Other (please describe):
Other (please describe)
Other (please describe):
Individuals with a history of fire setting
Individuals with previous convictions for sexual assault, or identified as sex offenders
Individuals with mild development delays, such as borderline intellectual functioning with an IQ of just below 80
Other (please describe):
Individuals chronically inebriated (due to alcohol addiction and/or dependence)
Individuals on a LPS Conservatorship moving from locked out of town Institutes of Mental Disease (IMD)
Individuals from acute inpatient psychiatric facilities
Individuals with a history of aggressive behaviors such as recent physical aggressive episodes toward others, including staff
Individuals with a history of elopements (not returning to the facility by curfew)
Individuals requiring assistance with catheters *
Revised Exhibit C
Page 3 of 4
Revised Exhibit C
Page 4 of 4
Supplemental Board & Care Home Services Rates
Fillmore Christian Garden
4826 E. Fillmore Avenue, Fresno CA 93727
Inthone Milly
5-Aug-21
July 1, 2021 (FY2021-22)
I. Social Security Income (SSI) Services - subject to change yearly * (rate indicated is 2021 rate)
Daily
$ 17.27
$ 18.21
$ 35.49
$20.00
$25.00
$25.00
$20.00
$20.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
11).
II. Supplemental services in addition to the SSI Care and Supervision listed above (per RFSQ 17-067)
Daily
Effective Date of Rates:
Monthly
1) Room and Board $ 525.37
2) Care and Supervision (maximum)*$ 554.00
Total SSI Portion $ 1,079.37
Name of Facility:
Facility Address:
Submitted by:
Approved by:
Date Submitted:
Revised Exhibit C
Page 1 of 4
$0.00
$0.00
$0.00
$ 110.00
$ 145.49
Supplemental Board & Care Home Services Target Populations
Fillmore Christian Garden
4826 E. Fillmore Avenue, Fresno CA 93727
Inthone Milly
X
X
X
X
X
X
X
Individuals with a visual impairments, including legal blindness*
Individuals with colostomy bags*
Individuals with diabetes (for maintenance, including but not limited to, insulin injections and blood sugar monitoring)*
Individuals dependent on oxygen*
Submitted by:
Please indicate if you are capable of serving the following individuals in your facility(ies) by placing a check in the appropriate boxes below:
Individuals dependent on wheelchairs*
Individuals dependent on walking devices (walkers or other walking assistance devices)*
Individuals with amputated limbs*
(F) Supervision of resident schedules and activities;
(G) Maintenance and supervision of resident monies or property;
(H) Monitoring food intake or special diets.
Name of Facility:
Facility Address:
(A) Assistance in dressing, grooming, bathing and other personal hygiene;
(B) Assistance with taking medication, as specified in Section 87465, Incidental Medical and Dental Care Services;
(C) Central storing and distribution of medications, as specified in Section 87465, Incidental Medical and Dental Care Services;
(D) Arrangement of and assistance with medical and dental care. This may include transportation, as specified in Section 87465, Incidental
(E) Maintenance of house rules for the protection of residents;
*Care and supervision as defined in Section 87101(c)(3)
“Care and Supervision” means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living
and the assumption of varying degrees of responsibility for the safety and well-being of residents. “Residents. “Care and Supervision” shall include, but not be
limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents:
Total Supplemental Services Portion (No #1.
III. Total Daily Rate for Services (Room & Board, Care & Supervision, and Supplemental Services)
15).
16)
Revised Exhibit C
Page 2 of 4
X
X
X
X
X
X
X
*Please note: possession of care exemptions approved by Community Care Licensing (CCL) will be required to provide services to individuals with specialized medical n
Other (please describe):
Other (please describe)
Other (please describe):
Individuals with a history of fire setting
Individuals with previous convictions for sexual assault, or identified as sex offenders
Young adults between the ages of 18 – 24 years old
Individuals with mild development delays, such as borderline intellectual functioning with an IQ of just below 80
Other (please describe):
Individuals chronically inebriated (due to alcohol addiction and/or dependence)
Individuals on a LPS Conservatorship moving from locked out of town Institutes of Mental Disease (IMD)
Individuals from acute inpatient psychiatric facilities
Individuals with a history of aggressive behaviors such as recent physical aggressive episodes toward others, including staff
Individuals with a history of elopements (not returning to the facility by curfew)
Individuals requiring assistance with catheters *
Revised Exhibit C
Page 3 of 4
By _________________________________
Print Name __________________________
Title: _______________________________
Mailing Address:
4826 E. Fillmore Ave
Fresno, CA 93727
(559) 307-4170
Contact: Inthone Milly
Revised Exhibit C
Page 4 of 4
Supplemental Board & Care Home Services Rates
Garden Manor
4983 E. Olive Ave. Fresno, CA 93727
Joan Black
I. Social Security Income (SSI) Services - subject to change yearly * (rate indicated is 2021 rate)
Daily
$ 17.27
$ 18.21
$ 35.49
$14.90
$14.90
$14.90
$14.90
$14.91
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Name of Facility:
Facility Address:
Submitted by:
Approved by:
Date Submitted:
Effective Date of Rates:
Monthly
1) Room and Board $ 525.37
2) Care and Supervision (maximum)* $ 554.00
Total SSI Portion $ 1,079.37
II. Supplemental services in addition to the SSI Care and Supervision listed above (per RFSQ 17-067)
Daily
1). Bilingual/bicultural programming $ Reasonable access to required medical treatment
2). Self-sufficiency skills
3). Enhancement of independent living skills
4). Substance Abuse Program (on and off site supportive services)
5). See page 2 & 3 for Service Target Population
6).
7).
8).
9).
10).
11).
12).
13).
Revised Exhibit C
Page 1 of 4
$0.00
$0.00
$0.00
$ 74.51
$ 110.00
Supplemental Board & Care Home Services Target Populations
Garden Manor
4983 E. Olive Ave Fresno, CA 93727
Joan Black
X
X
X
X
*Care and supervision as defined in Section 87101(c)(3)
limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents:
Total Supplemental Services Portion (No #1.
III. Total Daily Rate for Services (Room & Board, Care & Supervision, and Supplemental Services)
14).
15).
16)
(A) Assistance in dressing, grooming, bathing and other personal hygiene;
(B) Assistance with taking medication, as specified in Section 87465, Incidental Medical and Dental Care Services;
(C) Central storing and distribution of medications, as specified in Section 87465, Incidental Medical and Dental Care Services;
(D) Arrangement of and assistance with medical and dental care. This may include transportation, as specified in Section 87465, Incidental
(E) Maintenance of house rules for the protection of residents;
(F) Supervision of resident schedules and activities;
(G) Maintenance and supervision of resident monies or property;
(H) Monitoring food intake or special diets.
Name of Facility:
Facility Address:
Submitted by:
Please indicate if you are capable of serving the following individuals in your facility(ies) by placing a check in the appropriate boxes below:
Individuals dependent on wheelchairs*
Individuals dependent on walking devices (walkers or other walking assistance devices)*
Individuals with amputated limbs*
Individuals with a visual impairments, including legal blindness*
Individuals with colostomy bags*
Individuals with diabetes (for maintenance, including but not limited to, insulin injections and blood sugar monitoring)*
Individuals dependent on oxygen*
Revised Exhibit C
Page 2 of 4
X
X
X
X
X
X
X
X
*Please note: possession of care exemptions approved by Community Care Licensing (CCL) will be required to provide services to individuals with specialized medical needs.
Individuals requiring assistance with catheters *
Individuals chronically inebriated (due to alcohol addiction and/or dependence)
Individuals on a LPS Conservatorship moving from locked out of town Institutes of Mental Disease (IMD)
Individuals from acute inpatient psychiatric facilities
Individuals with a history of aggressive behaviors such as recent physical aggressive episodes toward others, including staff
Individuals with a history of elopements (not returning to the facility by curfew)
Other (please describe):
Other (please describe)
Other (please describe):
Individuals with a history of fire setting
Individuals with previous convictions for sexual assault, or identified as sex offenders
Individuals with mild development delays, such as borderline intellectual functioning with an IQ of just below 80
Other (please describe):
Revised Exhibit C
Page 3 of 4
Revised Exhibit C
Page 4 of 4
Revised Exhibit C
Page 1 of 3
Revised Exhibit C
Page 2 of 3
FY 2021-22 Exhibit C Signature Page
COUNTY OF FRESNO
Fresno, CA
- 9 -
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By _
Print Name __________________________
Title: _______________________________
GAREM ASSISTED LIVING
Print Name: GARY RIEMER
Title: President
Print Name: JOYCELYN BARE HOPPER
Title: President
____________________________
CONTRACTOR:
GAREM ASSISTED LIVING
By: _____________________________
Print Name: JOYCELYN BARE HOPPER
Title: Administrator
By:______________________________
Print Name: GARY RIEMER
Title: President
By: ______________________________
Print Name: MAXIMA S DIONISIO
Title: Vice President
Mailing Address:
4266 N 9th Street
Fresno CA 93726
Tel No. 559-940-9708/559-797-9284
Contact: Joycelyn Bare Hopper
Revised Exhibit C
Page 3 of 3
Supplemental Board & Care Home Services Rates
HASKINS RESIDENTIAL CASE
1037 S. CHESTNUT AVENUE, FRESNO CA, 93702
DONALD HASKINS
DONALD HASKINS
8/4/2021
I. Social Security Income (SSI) Services - subject to change yearly * (rate indicated is 2021 rate)
Monthly Daily
$ 525.37 $ 17.27
$ 554.00 $ 18.21
$ 35.49
Daily
Total Supplemental Services Portion (No #1. through No #16.)
11.14$
11.14$
11.14$
III. Total Daily Rate for Services (Room & Board, Care & Supervision, and Supplemental Services)
$ 35.49
11.14$
11.14$
11.14$
11.14$
11.14$
Effective Date of Rates:
8). Individuals with mild development delays, such as borderline intellectual functioning with an IQ of just below 80
11). Individuals requiring assistance with catheters
10). Individuals dependent on oxygen
9). Individuals with diabetes (for maintenance, including but not limited to, insulin injections and blood sugar monitoring)
Name of Facility:
Facility Address:
Submitted by:
Approved by:
Date Submitted:
11.14$
11.14$
Total SSI Portion $ 1,079.37
II. Supplemental services in addition to the SSI Care and Supervision listed above (per RFSQ 17-067)
7). Individuals from acute inpatient psychiatric facilities
1). Bilingual/bicultural programming $ Reasonable access to required
2). Self-sufficiency skills
3). Enhancement of independent living skills
5). Individuals chronically inebriated (due to alcohol addiction and/or
March 1, 2021
11.14$
11.14$
11.14$
11.14$
2) Care and Supervision (maximum)*
1) Room and Board
11.14$
$178.24
16) Individuals with mild development delays, such as borderline intellectual functioning with an IQ of just below 80
15). Individuals with previous convictions for sex offenders
14). Individuals from acute inpatient psychiatric facilities
13). Individuals on a LPS Conservatorship moving from locked out of town Institutes of Mental Disease (IMD)
12). Individuals chronically inebriated (due to alcohol addiction and/or dependence)
11.14$
4). Individuals with diabetes (for maintenance, including but not limited to, insulin injections and blood sugar monitoring)*
6). Individuals on a LPS Conservatorship moving from locked out of town Institutes of Mental Disease (IMD)
213.73$
Revised Exhibit C
Page 1 of 4
Supplemental Board & Care Home Services Target Populations
HASKINS RESIDENTIAL CARE
1037 S CHESTNUT AVE., FRESNO CA, 93702
DONALD HASKINS
X
X
X
X
X
X
X
X
X
X
X
(E) Maintenance of house rules for the protection of residents;
(F) Supervision of resident schedules and activities;
*Care and supervision as defined in Section 87101(c)(3)
Individuals dependent on oxygen*
Individuals requiring assistance with catheters *
Individuals chronically inebriated (due to alcohol addiction and/or dependence)
Individuals on a LPS Conservatorship moving from locked out of town Institutes of Mental Disease (IMD)
one or more of the following activities provided by a person or facility to meet the needs of the residents:
Please indicate if you are capable of serving the following individuals in your facility(ies) by placing a check in the appropriate boxes below:
Individuals with amputated limbs*
Individuals with a visual impairments, including legal blindness*
Individuals with colostomy bags*
Individuals with diabetes (for maintenance, including but not limited to, insulin injections and blood sugar monitoring)*
(G) Maintenance and supervision of resident monies or property;
(H) Monitoring food intake or special diets.
Name of Facility:
Facility Address:
Submitted by:
(A) Assistance in dressing, grooming, bathing and other personal hygiene;
(B) Assistance with taking medication, as specified in Section 87465, Incidental
(C) Central storing and distribution of medications, as specified in Section 87465,
(D) Arrangement of and assistance with medical and dental care. This may include
Individuals from acute inpatient psychiatric facilities
Individuals with a history of aggressive behaviors such as recent physical aggressive episodes toward others, including staff
Individuals with a history of elopements (not returning to the facility by curfew)
Individuals dependent on wheelchairs*
Individuals dependent on walking devices (walkers or other walking assistance devices)*
Revised Exhibit C
Page 2 of 4
X
X
*Please note: possession of care exemptions approved by Community Care Licensing (CCL) will be required to provide services to individuals with specialized medical needs.
Other (please describe):
Individuals with mild development delays, such as borderline intellectual functioning with an IQ of just below 80
Other (please describe):
Other (please describe)
Other (please describe):
Individuals with a history of fire setting
Individuals with previous convictions for sexual assault, or identified as sex offenders
Revised Exhibit C
Page 3 of 4
Revised Exhibit C
Page 4 of 4
Revised Exhibit C
Page 1 of 3
Revised Exhibit C
Page 2 of 3
16
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
CONTRACTOR:
JAN-ROY PLACE OF FRESNO
By _________________________________
Print Name __________________________
Title: _______________________________
Mailing Address:
4766 E. Illinois Ave
Fresno, CA 93702
(559) 453-6832/352-5240
Contact: Joycelyn Hopper
Administrator
940-9708/559-797-9284
JOYCELYN BARE HOPPER
FY 2021-22 Exhibit C Signature PageRevised Exhibit C
Page 3 of 3
Supplemental Board & Care Home Services Rates
August 5, 2021
I. Social Security Income (SSI) Services - subject to change yearly * (rate indicated is 2021 rate)
Daily
$ 17.27
$ 18.21
$ 35.49
Total Supplemental Services Portion (No #1. through No #8.) $ 96.00
III. Total Daily Rate for Services (Room & Board, Care & Supervis ion, and Supplemental Services) $
*Care and supervision as defined in Section 87101(c)(3)
4). $ -
5). $ -
6). $ -
7). $ -
8). $ -
II. Supplemental services in addition to the SSI Care and Supervision listed above (per RFSQ 17-067)
Daily
1). Bilingual/bicultural programming $ Reasonable access to required medical treatment $ 34. 00
2). Self-sufficiency skills $ 32.00
3). Enhancement of independent living skills $ 30.00
Effective Date of Rates:
Monthly
1) Room and Board $ 525.37
2) Care and Supervision (maximum)* $ 554.00
Total SSI Portion $ 1,079.37
Name of Facility: Lakewood
Haven
Facility Address: 362 W. Stuart
Ave., Fresno, CA, 93704
Submitted by: Elsa Pollan
Approved by: Elsa Pollan
Date Submitted:
Revised Exhibit C
Page 1 of 4
Supplemental Board & Care Home Services Target Populations
Individuals chronically inebriated (due to alcohol addiction and/or dependence)
Individuals on a LPS Conservatorship moving from locked out of town Institutes of Mental Disease (IMD)
Individuals from acute inpatient psychiatric facilities
Individuals with a history of aggressive behaviors such as recent physical aggressive episodes toward others, including staff
Individuals with a visual impairments, including legal blindness*
Individuals with colostomy bags*
Individuals with diabetes (for maintenance, including but not limited to, insulin injections and blood sugar monitoring)*
Individuals dependent on oxygen*
Individuals requiring assistance with catheters *
Submitted by: Elsa Pollan
Please indicate if you are capable of serving the following individuals in your facility(ies) by placing a check in the appropriate boxes below:
Individuals dependent on wheelchairs*
Individuals dependent on walking devices (walkers or other walking assistance devices)*
Individuals with amputated limbs*
(F) Supervision of resident schedules and activities;
(G) Maintenance and supervision of resident monies or property;
(H) Monitoring food intake or special diets.
Name of Facility: Lakewood
Facility Address: 362 W. Stuart
Ave, Fresno, CA, 93704
(A) Assistance in dressing, grooming, bathing and other personal hygiene;
(B) Assistance with taking medication, as specified in Section 87465, Incidental Medical and Dental Care Services;
(C) Central storing and distribution of medications, as specified in Section 87465, Incidental Medical and Dental Care Services;
(D) Arrangement of and assistance with medical and dental care. This may include transportation, as specified in Section 87465, Incidental
(E) Maintenance of house rules for the protection of residents;
include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents:
Revised Exhibit C
Page 2 of 4
*Please note: possession of care exemptions approved by Community Care Licensing (CCL) will be required to provide services to individuals with specialized medical needs.
Other (please describe)
Other (please describe):
Individuals with a history of elopements (not returning to the facility by curfew)
Individuals with a history of fire setting
Individuals with previous convictions for sexual assault, or identified as sex offenders
Individuals with mild development delays, such as borderline intellectual functioning with an IQ of just below 80
Other (please describe):
Other (please describe):
Revised Exhibit C
Page 3 of 4
Revised Exhibit C
Page 4 of 4
Supplemental Board & Care Home Services Rates
I. Social Security Income (SSI) Services - subject to change yearly * (rate indicated is 2021 rate)
Daily
$ 17.27
$ 18.21
$ 35.49
Total Supplemental Services Portion (No #1. through No #8.) $ 96.00
III. Total Daily Rate for Services (Room & Board, Care & Supervision, and Supplemental $131.49
*Care and supervision as defined in Section 87101(c)(3)
4). $ -
5). $ -
6). $ -
7). $ -
8). $ -
II. Supplemental services in addition to the SSI Care and Supervision listed above (per RFSQ 17-067)
Daily
1). Bilingual/bicultural programming $ Reasonable access to required medical treatment $ 34. 00
2). Self-sufficiency skills $ 32.00
3). Enhancement of independent living skills $ 30.00
Effective Date of Rates:
Monthly
1) Room and Board $ 525.37
2) Care and Supervision (maximum)* $ 554.00
Total SSI Portion $ 1,079.37
Name of Facility: Lakewood Haven 2
Facility Address: 6111 N. Palm Ave., Fresno, CA, 93704
Submitted by: Elsa Pollan
Approved by: Elsa Pollan
Date Submitted: August 5,2021
Revised Exhibit C
Page 1 of 4
Supplemental Board & Care Home Services Target Populations
Individuals chronically inebriated (due to alcohol addiction and/or dependence)
Individuals on a LPS Conservatorship moving from locked out of town Institutes of Mental Disease (IMD)
Individuals from acute inpatient psychiatric facilities
Individuals with a visual impairments, including legal blindness*
Individuals with colostomy bags*
Individuals with diabetes (for maintenance, including but not limited to, insulin injections and blood sugar monitoring)*
Individuals dependent on oxygen*
Individuals requiring assistance with catheters *
Submitted by: Elsa Pollan
Please indicate if you are capable of serving the following individuals in your facility(ies) by placing a check in the appropriate boxes below:
Individuals dependent on wheelchairs*
Individuals dependent on walking devices (walkers or other walking assistance devices)*
Individuals with amputated limbs*
(F) Supervision of resident schedules and activities;
(G) Maintenance and supervision of resident monies or property;
(H) Monitoring food intake or special diets.
Name of Facility: Lakewood
Haven 2Facility Address: 6111 N. Palm
Ave, Fresno, CA, 93704
(A) Assistance in dressing, grooming, bathing and other personal hygiene;
(B) Assistance with taking medication, as specified in Section 87465, Incidental Medical and Dental Care Services;
(C) Central storing and distribution of medications, as specified in Section 87465, Incidental Medical and Dental Care Services;
(D) Arrangement of and assistance with medical and dental care. This may include transportation, as specified in Section 87465, Incidental
(E) Maintenance of house rules for the protection of residents;
be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents:
Revised Exhibit C
Page 2 of 4
*Please note: possession of care exemptions approved by Community Care Licensing (CCL) will be required to provide services to individuals with specialized medical needs.
Individuals with a history of aggressive behaviors such as recent physical aggressive episodes toward others, including staff
Other (please describe)
Other (please describe):
Individuals with a history of elopements (not returning to the facility by curfew)
Individuals with a history of fire setting
Individuals with previous convictions for sexual assault, or identified as sex offenders
Individuals with mild development delays, such as borderline intellectual functioning with an IQ of just below 80
Other (please describe):
Other (please describe):
Revised Exhibit C
Page 3 of 4
Revised Exhibit C
Page 4 of 4
Supplemental Board & Care Home Services Rates
Leonie House
2931 Caesar Avenue, Clovis, CA 93611
Sundari Susan Kendakur
4-Aug-21
1-Apr-20
I. Social Security Income (SSI) Services - subject to change yearly * (rate indicated is 2021 rate)
Daily
$ 17.27
$ 18.21
$ 35.49
$91.67
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Name of Facility:
Facility Address:
Submitted by:
Approved by:
Date Submitted:
Effective Date of Rates:
Monthly
1) Room and Board $ 525.37
2) Care and Supervision (maximum)*$ 554.00
Total SSI Portion $ 1,079.37
II. Supplemental services in addition to the SSI Care and Supervision listed above (per RFSQ 17-067)
Daily
1). Bilingual/bicultural programming; Self-sufficiency; Enhancement of independent living; Personal needs access
2). Reasonable access to required medical treatment (will be arranged)
3). Transportation to needed off-site services (will be arranged)
4).
5).
6).
7).
8).
9).
10).
11).
12).
13).
Revised Exhibit C
Page 1 of 4
$0.00
$0.00
$0.00
$ 91.67
$ 127.16
Supplemental Board & Care Home Services Target Populations
Leonie House
2931 Caesar Avenue, Clovis, CA 93611
Sundari Susan Kendakur
Yes
Yes
Yes
Yes
Yes
Yes
Yes
*Care and supervision as defined in Section 87101(c)(3)
“Care and Supervision” means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living
and the assumption of varying degrees of responsibility for the safety and well-being of residents. “Residents. “Care and Supervision” shall include, but not be
limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents:
Total Supplemental Services Portion (No #1.
III. Total Daily Rate for Services (Room & Board, Care & Supervision, and Supplemental Services)
14).
15).
16)
(A) Assistance in dressing, grooming, bathing and other personal hygiene;
(B) Assistance with taking medication, as specified in Section 87465, Incidental Medical and Dental Care Services;
(C) Central storing and distribution of medications, as specified in Section 87465, Incidental Medical and Dental Care Services;
(D) Arrangement of and assistance with medical and dental care. This may include transportation, as specified in Section 87465, Incidental
(E) Maintenance of house rules for the protection of residents;
(F) Supervision of resident schedules and activities;
(G) Maintenance and supervision of resident monies or property;
(H) Monitoring food intake or special diets.
Name of Facility:
Facility Address:
Submitted by:
Please indicate if you are capable of serving the following individuals in your facility(ies) by placing a check in the appropriate boxes below:
Individuals dependent on wheelchairs*
Individuals dependent on walking devices (walkers or other walking assistance devices)*
Individuals with amputated limbs*
Individuals with a visual impairments, including legal blindness*
Individuals with colostomy bags*
Individuals with diabetes (for maintenance, including but not limited to, insulin injections and blood sugar monitoring)*
Individuals dependent on oxygen*
Revised Exhibit C
Page 2 of 4
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
*Please note: possession of care exemptions approved by Community Care Licensing (CCL) will be required to provide services to individuals with specialized medical n
Individuals requiring assistance with catheters *
Individuals chronically inebriated (due to alcohol addiction and/or dependence)
Individuals on a LPS Conservatorship moving from locked out of town Institutes of Mental Disease (IMD)
Individuals from acute inpatient psychiatric facilities
Individuals with a history of aggressive behaviors such as recent physical aggressive episodes toward others, including staff
Individuals with a history of elopements (not returning to the facility by curfew)
Other (please describe):
Other (please describe)
Other (please describe):
Individuals with a history of fire setting
Individuals with previous convictions for sexual assault, or identified as sex offenders
Young adults between the ages of 18 – 24 years old
Individuals with mild development delays, such as borderline intellectual functioning with an IQ of just below 80
Other (please describe):
Revised Exhibit C
Page 3 of 4
Revised Exhibit C
Page 4 of 4
Supplemental Board & Care Home Services Rates
Sierra Villa Rest Home
175 W. Sierra Avenue, Clovis, CA 93612
Sundari Susan Kendakur
4-Aug-21
23-Sep-19
I. Social Security Income (SSI) Services - subject to change yearly * (rate indicated is 2021 rate)
Daily
$ 17.27
$ 18.21
$ 35.49
$91.67
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Name of Facility:
Facility Address:
Submitted by:
Approved by:
Date Submitted:
Effective Date of Rates:
Monthly
1) Room and Board $ 525.37
2) Care and Supervision (maximum)*$ 554.00
Total SSI Portion $ 1,079.37
II. Supplemental services in addition to the SSI Care and Supervision listed above (per RFSQ 17-067)
Daily
1). Bilingual/bicultural programming; Self-sufficiency; Enhancement of independent living; Personal needs access
2). Reasonable access to required medical treatment (will be arranged)
3). Transportation to needed off-site services (will be arranged)
4).
5).
6).
7).
8).
9).
10).
11).
12).
13).
Revised Exhibit C
Page 1 of 4
$0.00
$0.00
$0.00
$ 91.67
$ 127.16
Supplemental Board & Care Home Services Target Populations
Sierra Villa Rest Home
175 W. Sierra Avenue, Clovis, CA 93612
Sundari Susan Kendakur
Yes
Yes
Yes
Yes
Yes
Yes
Yes
*Care and supervision as defined in Section 87101(c)(3)
“Care and Supervision” means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living
and the assumption of varying degrees of responsibility for the safety and well-being of residents. “Residents. “Care and Supervision” shall include, but not be
limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents:
Total Supplemental Services Portion (No #1.
III. Total Daily Rate for Services (Room & Board, Care & Supervision, and Supplemental Services)
14).
15).
16)
(A) Assistance in dressing, grooming, bathing and other personal hygiene;
(B) Assistance with taking medication, as specified in Section 87465, Incidental Medical and Dental Care Services;
(C) Central storing and distribution of medications, as specified in Section 87465, Incidental Medical and Dental Care Services;
(D) Arrangement of and assistance with medical and dental care. This may include transportation, as specified in Section 87465, Incidental
(E) Maintenance of house rules for the protection of residents;
(F) Supervision of resident schedules and activities;
(G) Maintenance and supervision of resident monies or property;
(H) Monitoring food intake or special diets.
Name of Facility:
Facility Address:
Submitted by:
Please indicate if you are capable of serving the following individuals in your facility(ies) by placing a check in the appropriate boxes below:
Individuals dependent on wheelchairs*
Individuals dependent on walking devices (walkers or other walking assistance devices)*
Individuals with amputated limbs*
Individuals with a visual impairments, including legal blindness*
Individuals with colostomy bags*
Individuals with diabetes (for maintenance, including but not limited to, insulin injections and blood sugar monitoring)*
Individuals dependent on oxygen*
Revised Exhibit C
Page 2 of 4
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
*Please note: possession of care exemptions approved by Community Care Licensing (CCL) will be required to provide services to individuals with specialized medical n
Individuals requiring assistance with catheters *
Individuals chronically inebriated (due to alcohol addiction and/or dependence)
Individuals on a LPS Conservatorship moving from locked out of town Institutes of Mental Disease (IMD)
Individuals from acute inpatient psychiatric facilities
Individuals with a history of aggressive behaviors such as recent physical aggressive episodes toward others, including staff
Individuals with a history of elopements (not returning to the facility by curfew)
Other (please describe):
Other (please describe)
Other (please describe):
Individuals with a history of fire setting
Individuals with previous convictions for sexual assault, or identified as sex offenders
Young adults between the ages of 18 – 24 years old
Individuals with mild development delays, such as borderline intellectual functioning with an IQ of just below 80
Other (please describe):
Revised Exhibit C
Page 3 of 4
Revised Exhibit C
Page 4 of 4
Revised Exhibit C
Page 1 of 4
Revised Exhibit C
Page 2 of 4
Revised Exhibit C
Page 3 of 4
Revised Exhibit C
Page 4 of 4
Supplemental Board & Care Home Services Rates
Ratanakone Home
2220 N. Prospect Ave Fresno, CA 93722
Kevin Ratanakone
August 5, 2021
July 1, 2021
I. Social Security Income (SSI) Services - subject to change yearly * (rate indicated is 2021 rate)
Daily
$ 17.27
$ 18.21
$ 35.49
$8.00
$6.00
$5.00
$5.00
$5.00
$35.00
$36.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Name of Facility:
Submitted by:
II. Supplemental services in addition to the SSI Care and Supervision listed above (per RFSQ 17-067)
Facility Address:
Total SSI Portion $ 1079.37
10).
Monthly
Effective Date of Rates:
Date Submitted:
Approved by:
2) Care and Supervision (maximum)*$ 554.00
1) Room and Board $ 525.37
4). Reasonable access to required medical treatment
3). Enhancement of independent living skills
2). Self-sufficiency skills
1). Bilingual/bicultural programming $ Reasonable access to required medical treatment
Daily
9).
8).
7). Laundering personal clothing and hygiene
6) Clean bed and both linens weekly, or more often as needed
5) Basic Care and tray service for minor temporary illnesses or recovery from surgery
13).
12).
11).
1
Revised Exhibit C
Page 1 of 4
$0.00
$0.00
$0.00
$ 100.00
$ 135.49
Supplemental Board & Care Home Services Target Populations
Ratanakone Home
2220 N. Prospect Ave Fresno, CA 93722
Kevin Ratanakone
x
x
x
x
Submitted by:
Facility Address:
Please indicate if you are capable of serving the following individuals in your facility(ies) by placing a check in the appropriate boxes below:
*Care and supervision as defined in Section 87101(c)(3)
Individuals with amputated limbs*
Individuals dependent on walking devices (walkers or other walking assistance devices)*
14).
III. Total Daily Rate for Services (Room & Board, Care & Supervision, and Supplemental Services)
Total Supplemental Services Portion (No #1.
(C) Central storing and distribution of medications, as specified in Section 87465, Incidental Medical and Dental Care Services;
(B) Assistance with taking medication, as specified in Section 87465, Incidental Medical and Dental Care Services;
(A) Assistance in dressing, grooming, bathing and other personal hygiene;
16)
15).
“Care and Supervision” means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living
and the assumption of varying degrees of responsibility for the safety and well-being of residents. “Residents. “Care and Supervision” shall include, but not be limited
to, any one or more of the following activities provided by a person or facility to meet the needs of the residents:
(H) Monitoring food intake or special diets.
(G) Maintenance and supervision of resident monies or property;
(F) Supervision of resident schedules and activities;
(E) Maintenance of house rules for the protection of residents;
(D) Arrangement of and assistance with medical and dental care. This may include transportation, as specified in Section 87465, Incidental
Individuals with diabetes (for maintenance, including but not limited to, insulin injections and blood sugar monitoring)*
Individuals with colostomy bags*
Individuals with a visual impairments, including legal blindness*
Individuals dependent on wheelchairs*
Name of Facility:
Individuals dependent on oxygen*
2
Revised Exhibit C
Page 2 of 4
x
x
x
x
x
x
*Please note: possession of care exemptions approved by Community Care Licensing (CCL) will be required to provide services to individuals with specialized medical n
Individuals from acute inpatient psychiatric facilities
Individuals on a LPS Conservatorship moving from locked out of town Institutes of Mental Disease (IMD)
Individuals chronically inebriated (due to alcohol addiction and/or dependence)
Individuals requiring assistance with catheters *
Other (please describe):
Other (please describe)
Other (please describe):
Individuals with a history of elopements (not returning to the facility by curfew)
Individuals with a history of aggressive behaviors such as recent physical aggressive episodes toward others, including staff
Other (please describe):
Individuals with mild development delays, such as borderline intellectual functioning with an IQ of just below 80
Young adults between the ages of 18 – 24 years old
Individuals with previous convictions for sexual assault, or identified as sex offenders
Individuals with a history of fire setting
3
Revised Exhibit C
Page 3 of 4
Revised Exhibit C
Page 4 of 4
Revised Exhibit C
Page 1 of 4
Revised Exhibit C
Page 2 of 4
Revised Exhibit C
Page 3 of 4
Revised Exhibit C
Page 4 of 4
Supplemental Board & Care Home Services Rates
Ruby's Valley Care Home
9919 South Elm Ave., Fresno, CA 93706
Mark & Mary Gisler
5-Aug-21
I. Social Security Income (SSI) Services - subject to change yearly * (rate indicated is 2021 rate)
Daily
$ 17.27
$ 18.21
$ 35.49
$142.11
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Name of Facility:
Facility Address:
Submitted by:
Approved by:
Date Submitted:
Effective Date of Rates:
Monthly
1) Room and Board $ 525.37
2) Care and Supervision (maximum)* $ 554.00
Total SSI Portion $ 1,079.37
II. Supplemental services in addition to the SSI Care and Supervision listed above (per RFSQ 17-067)
Daily
1). All inclusive rate for enhanced programming to develop independent living skills and vocational training, manage clients
clients with difficult behaviors and special needs as indicated below, and other needs as outlined in attached exhibit D.
4).
5).
6).
7).
8).
9).
10).
11).
12).
13).
Revised Exhibit C
Page 1 of 7
$0.00
$0.00
$0.00
$ 142.11
$ 177.60
Supplemental Board & Care Home Services Target Populations
Ruby's Valley Care Home
9919 South Elm Ave., Fresno, CA 93706
Mark & Mary Gisler
X
X
X
X
X
*Care and supervision as defined in Section 87101(c)(3)
limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents:
Total Supplemental Services Portion (No #1.
III. Total Daily Rate for Services (Room & Board, Care & Supervision, and Supplemental Services)
14).
15).
16)
(A) Assistance in dressing, grooming, bathing and other personal hygiene;
(B) Assistance with taking medication, as specified in Section 87465, Incidental Medical and Dental Care Services;
(C) Central storing and distribution of medications, as specified in Section 87465, Incidental Medical and Dental Care Services;
(D) Arrangement of and assistance with medical and dental care. This may include transportation, as specified in Section 87465, Incidental
(E) Maintenance of house rules for the protection of residents;
(F) Supervision of resident schedules and activities;
(G) Maintenance and supervision of resident monies or property;
(H) Monitoring food intake or special diets.
Name of Facility:
Facility Address:
Submitted by:
Please indicate if you are capable of serving the following individuals in your facility(ies) by placing a check in the appropriate boxes below:
Individuals dependent on wheelchairs*
Individuals dependent on walking devices (walkers or other walking assistance devices)*
Individuals with amputated limbs*
Individuals with a visual impairments, including legal blindness*
Individuals with colostomy bags*
Individuals with diabetes (for maintenance, including but not limited to, insulin injections and blood sugar monitoring)*
Individuals dependent on oxygen*
Revised Exhibit C
Page 2 of 7
X
X
X
X
X
X
X
X
*Please note: possession of care exemptions approved by Community Care Licensing (CCL) will be required to provide services to individuals with specialized medical needs.
Individuals requiring assistance with catheters *
Individuals chronically inebriated (due to alcohol addiction and/or dependence)
Individuals on a LPS Conservatorship moving from locked out of town Institutes of Mental Disease (IMD)
Individuals from acute inpatient psychiatric facilities
Individuals with a history of aggressive behaviors such as recent physical aggressive episodes toward others, including staff
Individuals with a history of elopements (not returning to the facility by curfew)
Other (please describe):
Other (please describe)
Other (please describe):
Individuals with a history of fire setting
Individuals with previous convictions for sexual assault, or identified as sex offenders
Individuals with mild development delays, such as borderline intellectual functioning with an IQ of just below 80
Other (please describe):
Revised Exhibit C
Page 3 of 7
Revised Exhibit C
Page 4 of 7
Revised Exhibit C
Page 5 of 7
Revised Exhibit C
Page 6 of 7
Revised Exhibit C
Page 7 of 7
Revised Exhibit C
Page 1 of 4
Revised Exhibit C
Page 2 of 4
Revised Exhibit C
Page 3 of 4
Revised Exhibit C
Page 4 of 4
Revised Exhibit C
Page 1 of 4
Revised Exhibit C
Page 2 of 4
Revised Exhibit C
Page 3 of 4
Revised Exhibit C
Page 4 of 4
Revised Exhibit C
Page 1 of 4
Revised Exhibit C
Page 2 of 4
Revised Exhibit C
Page 3 of 4
Revised Exhibit C
Page 4 of 4
Revised Exhibit E
Page 1 of 2
Billing Month:Invoice Date:
Name of Facility:Capacity:
Facility Address: Vacancy(ies):
Please Remit To:
Contract Daily Rate -$
Resident Name Admit Date Discharge Date # Days in
Facility
Total Charge
(# Days x
Contract Rate)
Minus Third
Party
Revenue
Collected by
Facility
Net Charge Comments
1 -$-$-$
2 -$-$-$
3 -$-$-$
4 -$-$-$
5 -$-$-$
6 -$-$-$
7 -$-$-$
8 -$-$-$
9 -$-$-$
10 -$-$-$
11 -$-$-$
12 -$-$-$
13 -$-$-$
14 -$-$-$
15 -$-$-$
16 -$-$-$
17 -$-$-$
18 -$-$-$
19 -$-$-$
20 -$-$-$
21 -$-$-$
22 -$-$-$
23 -$-$-$
24 -$-$-$
TOTAL -$-$-$
Supplemental Board & Care Home Services Monthly Billing Invoice
Administrator Signature:
Revised Exhibit E
Page 2 of 2
Billing Month:Invoice Date:
Name of Facility:Capacity:
Facility Address: Vacancy(ies):
Please Remit To:
Contract Daily Rate -$
Resident Name Admit Date Discharge Date # Days in
Facility
Approved
Special
Services
Rate/Day*
Minus Third
Party
Revenue
Collected by
Facility
Total
Supplemental
Charge
Comments
1 -$-$-$
2 -$-$-$
3 -$-$-$
4 -$-$-$
5 -$-$-$
6 -$-$-$
7 -$-$-$
8 -$-$-$
9 -$-$-$
10 -$-$-$
11 -$-$-$
12 -$-$-$
13 -$-$-$
14 -$-$-$
15 -$-$-$
16 -$-$-$
17 -$-$-$
18 -$-$-$
19 -$-$-$
20 -$-$-$
TOTAL -$-$-$
Supplemental Board & Care Home Services Monthly Specialized Services Authorization (SSA) Billing Invoice
Administrator Signature:
Exhibit I
1925 E. Dakota Ave., Fresno, CA 93726
FAX (559) 600-7673 www.co.fresno.ca.us
The County of Fresno is an Equal Employment Opportunity Employer
County of Fresno
DEPARTMENT OF BEHAVIORAL HEALTH
DAWAN UTECHT
DIRECTOR
SPECIAL SERVICES AUTHORIZATION FORM
Date:
Whereas the Fresno County Client:
Name:
Has exhibited the following behaviors:
Fresno County hereby authorizes: Facility:
Address:
City: Zip Code:
Phone: Fax:
To provide the following special services on behalf of this client:
Service:
Daily Duration:
For the period of time (please fill by month):
Beginning Date:
Ending Date:
The treatment strategy upon completion of these services will be:
In consideration of these services, Fresno County agrees to pay this Facility the additional amount of:
$ Per:
This agreement is authorized by:
Division Manager (Print Name): Signature Date
Supervisor (Print Name): Signature Date
This Facility agrees to provide these special services and to abide by the term of Agreement 17-377, as
amended, and this Authorization Form.
Authorized Person (Print Name): Signature Date