HomeMy WebLinkAboutAgreement A-21-352 with Kings View.pdf1
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AGREEMENT
This Agreement is made and entered into this ______ day of ___________ 2021, by and between
the COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter referred to as
“COUNTY”, and Kings View, a California non-profit corporation, whose address is 7170 N. Financial
Drive. Suite 110, Fresno, CA 93720, hereinafter referred to as "CONTRACTOR," (collectively the
“parties”).
W I T N E S S E T H:
WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), recognize the need for
a qualified agency to provide follow up call services for the Suicide Prevention Follow-Up Call Program,
which will provide real-time insight to possible external factors impacting persons with suicidal ideation
and increase linkages to appropriate behavioral health services for those who have called the lifeline in
crisis and/or with suicidal ideation, or persons who have recently been released from the emergency
departments, crisis stabilization center, or inpatient care for suicide ideation and/or attempt; and
WHEREAS, COUNTY, through its DBH, Mental Health Services Act (MHSA) Innovation (INN)
component, has a need for evaluation services for any Innovation plan; and
WHEREAS, CONTRACTOR, is qualified, willing and able to provide services required by the
COUNTY, pursuant to the terms and conditions of this Agreement.
NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties hereto
agree as follows:
1.SERVICES
A.CONTRACTOR shall perform all services and fulfill all responsibilities as set forth in
Exhibit A, “Summary of Services”, which is attached hereto and by this reference incorporated herein and
made part of this Agreement.
B.CONTRACTOR shall align services and practices with the vision, mission, and
guiding principles of the DBH, as further described in Exhibit B, "Fresno County Department
of Behavioral Health Guiding Principles of Care Delivery", attached hereto and by this reference
incorporated herein and made part of this Agreement.
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Agreement No. 21-352
7th September
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2.T ERM
The Agreement shall become effective upon execution and shall terminate on the 30th of
June, 2024.
3.T ERMINATION
A.Non Allocation of Funds - The terms of this Agreement, and the services to be
provided thereunder, 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
terminated at any time by giving CONTRACTOR thirty (30) days advance written notice.
B.Breach of Contract - COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of COUNTY there is:
1)An illegal or improper use of funds;
2)A failure to comply with any term of this Agreement;
3)A substantially incorrect or incomplete report submitted to COUNTY;
4)Improperly performed service.
In no event shall any payment by COUNTY constitute a waiver by COUNTY of any
breach of this Agreement or any default which may then exist on the part of CONTRACTOR. Neither
shall such payment impair or prejudice any remedy available to COUNTY with respect to the breach or
default. COUNTY shall have the right to demand of CONTRACTOR the repayment to COUNTY of any
funds disbursed to CONTRACTOR under this Agreement, which in the judgment of COUNTY were not
expended in accordance with the terms of this Agreement. CONTRACTOR shall promptly refund any
such funds upon demand or, at COUNTY’s option, such repayment shall be deducted from future
payments owing to CONTRACTOR under this Agreement.
C.Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by CONTRACTOR or COUNTY upon thirty (30) days advance written
notice of an intention to terminate the Agreement. COUNTY’s DBH Director, or designee, is authorized to
execute such written notice on behalf of COUNTY.
4.COMPENSATION
For actual services provided as identified in the terms and conditions of this Agreement,
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including Exhibit A, COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation in accordance with Exhibit C, “Budget Summary,” attached hereto and by this reference
incorporated herein. Payment shall be made upon certification or other proof satisfactory to COUNTY’s
DBH that services have actually been performed by CONTRACTOR as specified in this Agreement.
The maximum amount payable to CONTRACTOR for the period effective upon execution
through June 30, 2022 shall not exceed Two Hundred Fifty-Five Thousand and No/100 Dollars
($255,000.00).
The maximum amount payable to CONTRACTOR for the period effective July 1, 2022
through June 30, 2023 shall not exceed Two Hundred Fifty-Five Thousand and No/100 Dollars
($255,000.00).
The maximum amount payable to CONTRACTOR for the period effective July 1, 2023
through June 30, 2024 shall not exceed Two Hundred Fifty-Five Thousand and No/100 Dollars
($255,000.00).
In no event shall services performed under this Agreement be in excess of Seven Hundred
Sixty-Five Thousand, and No/100 Dollars ($765,000.00). It is understood that all expenses incidental to
CONTRACTOR’s performance of services under this Agreement shall be borne by CONTRACTOR.
Except as provided below regarding State payment delays, payments shall be made by
COUNTY to CONTRACTOR in arrears, for services provided during the preceding month, within forty-five
(45)days after the date of receipt, verification, and approval of CONTRACTOR’s invoices by COUNTY’s
DBH.
If CONTRACTOR should fail to comply with any provision of this Agreement, COUNTY
shall be relieved of its obligation for further compensation. All final invoices shall be submitted by
CONTRACTOR within sixty (60) days following the final month of service for which payment is claimed.
No action shall be taken by COUNTY on claims submitted beyond the sixty (60) day closeout period. Any
compensation which is not expended by CONTRACTOR pursuant to the terms and conditions of this
Agreement shall automatically revert to COUNTY.
The services provided by CONTRACTOR under this Agreement are funded in whole or in
part by the State of California. In the event that funding for these services is delayed by the State
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Controller, COUNTY may defer payment to CONTRACTOR. The amount of the deferred payment shall
not exceed the amount of funding delayed by the State Controller to COUNTY. The period of time of the
deferral by COUNTY shall not exceed the period of time of the State Controller’s delay of payment to
COUNTY plus forty-five (45) days.
5.INVOICING
CONTRACTOR shall invoice COUNTY in arrears by the tenth (10th) day of each month for
actual expenses incurred and services rendered in the previous month electronically to
dbh-invoices@fresnocountyca.gov, with a carbon copy email to the assigned COUNTY’s DBH Staff
Analyst.
CONTRACTOR shall submit to the COUNTY by the tenth (10th) of each month a detailed
general ledger (GL), itemizing costs incurred in the previous month. Failure to submit GL reports and
supporting documentation shall be deemed sufficient cause for COUNTY to withhold payments until there
is compliance, as further described in Section Five (5) herein. Supporting documentation shall include but
is not limited to receipts, invoices received, and documented administrative / overhead costs. No
reimbursement for services shall be made until invoices, reports and outcomes are received, reviewed
and approved by COUNTY’s DBH. Support documents will be made available upon request.
At the discretion of COUNTY’s DBH Director or designee, if an invoice is incorrect or is
otherwise not in proper form or substance, COUNTY’s DBH Director or designee shall have the right to
withhold payment as to only that portion of the invoice that is incorrect or improper after five (5) days prior
notice to CONTRACTOR. CONTRACTOR agrees to continue to provide services for a period of ninety
(90)days after notification of an incorrect or improper invoice. If after the ninety (90) day period, the
invoice(s) is still not corrected to COUNTY’s DBH satisfaction, COUNTY’s DBH Director or designee may
elect to terminate this Agreement, pursuant to the termination provisions stated in Paragraph Three (3) of
this Agreement. In addition, for invoices received ninety (90) days after the expiration of each term of this
Agreement or termination of this Agreement, at the discretion of COUNTY’s DBH Director or designee,
COUNTY’s DBH shall have the right to deny payment of any additional invoices received.
CONTRACTOR must maintain such financial records for a period of three (3) years or until
any dispute, audit or inspection is resolved, whichever is later. CONTRACTOR will be responsible for
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any disallowances related to inadequate documentation.
CONTRACTOR shall provide a monthly activity report with each invoice, further described
in Section Thirteen (13). In addition, each monthly invoice will be in the format as identified in Exhibit C,
showing each budget line item, expenses incurred, and the balance remaining for each budget line item
for all services and items as identified in Exhibit C.
CONTRACTOR shall submit monthly staff reports that identify all direct services and
support staff, applicable licensure/certifications, and full time hours worked to be used as a tracking tool to
determine if CONTRACTOR’s program is staffed according to the services provided under this
Agreement.
CONTRACTOR must attend COUNTY DBH’s Business Office trainings on equipment
reporting for assets, intangible and sensitive minor assets, when offered.
6.INDEPENDENT CONTRACTOR
In performance of the work, duties, and obligations assumed by CONTRACTOR under this
Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of
CONTRACTOR’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 CONTRACTOR shall perform its work and
function. However, COUNTY shall retain the right to administer this Agreement so as to verify that
CONTRACTOR is performing its obligations in accordance with the terms and conditions thereof.
CONTRACTOR and COUNTY shall comply with all applicable provisions of 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, CONTRACTOR shall have absolutely
no right to employment rights and benefits available to COUNTY employees. CONTRACTOR shall be
solely liable and responsible for providing to, or on behalf of, its employees all legally required employee
benefits. In addition, CONTRACTOR shall be solely responsible and save COUNTY harmless from all
matters relating to payment of CONTRACTOR's employees, including compliance with Social Security,
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withholding, and all other regulations governing such matters. It is acknowledged that during the term of
this Agreement, CONTRACTOR may be providing services to others unrelated to COUNTY or to this
Agreement.
7.MODIFICATION
Any matters of this Agreement may be modified from time to time by the written consent of
all the parties without, in any way, affecting the remainder.
Changes to expense category (i.e., Salary & Benefits, Client Support, Facilities/Equipment,
Operating Expenses, Administrative Expenses, Special Expenses, Fixed Assets, etc.) subtotals in the
budgets, and changes to the volume of units of services/types of service units to be provided as set forth
in Exhibit C, that do not exceed 10% of the maximum compensation payable to the CONTRACTOR may
be made with the written approval of COUNTY’s DBH Director, or designee. Said modifications shall not
result in any change to the annual maximum compensation amount payable to CONTRACTOR, as stated
in this Agreement.
8.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.
9.HOLD HARMLESS
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY’s request,
defend COUNTY, its officers, agents and employees from any and all costs and expenses, including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to COUNTY in
connection with the performance, or failure to perform, by CONTRACTOR, its officers, agents or
employees of covenants and duties under this Agreement, and from any and all costs and expenses,
including attorney fees and court 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 CONTRACTOR, their officers, agents or employees of covenants and duties under this Agreement.
CONTRACTOR agrees to indemnify COUNTY for Federal and/or State of California audit
exceptions resulting from noncompliance herein on the part of the CONTRACTOR.
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10.INSURANCE
Without limiting COUNTY's right to obtain indemnification from CONTRACTOR or any third
parties, CONTRACTOR, at its sole expense, shall maintain in full force and effect the following insurance
policies throughout the term of this Agreement:
A.Commercial General Liability
Commercial General Liability Insurance with limits of not less than Two Million
Dollars ($2,000,000) per occurrence and an annual aggregate of Four Million
Dollars ($4,000,000). This policy shall be issued on a per occurrence basis.
COUNTY may require specific coverages including completed operations, product
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 no less than One Million
Dollars ($1,000,000) per accident for bodily injury and property damage. Coverage
should include any automobile used in connection with this Agreement.
C.Professional Liability
If CONTRACTOR employs licensed professional staff (e.g. Ph.D., R.N., L.C.S.W.,
L.M.F.T., etc.) in providing services, Professional Liability Insurance with limits of
not less than One Million Dollars ($1,000,000) per occurrence, Three Million Dollars
($3,000,000) annual aggregate. CONTRACTOR agrees that it shall maintain, at its
sole expense, in full force and effect 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 Property Insurance
CONTRACTOR shall maintain a policy of insurance for all risk personal property
coverage which shall be endorsed naming the County of Fresno as an additional
loss payee. The personal property coverage shall be in an amount that will cover
the total COUNTY purchase and owned property, at a minimum, as discussed in
Section Twenty (20) of this Agreement.
All Risk Property Insurance
As applicable, CONTRACTOR will provide property coverage for the full
replacement value of the COUNTY’s personal property in possession of
CONTRACTOR and/or used in the execution of this Agreement. COUNTY will be
identified on an appropriate certificate of insurance as the certificate holder and will
be named as an Additional Loss Payee on the Property Insurance Policy.
E.Worker’s Compensation
A policy of Worker's Compensation Insurance as may be required by the California
Labor Code.
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F. Molestation
CONTRACTOR shall have either separate policy or an umbrella policy with
endorsements covering sexual abuse/molestation coverage or have a specific
endorsement on their General Commercial liability policy covering sexual
abuse/molestation. The policy limits for this policy shall be One Million Dollars
($1,000,000) per occurrence with a Two Million Dollars ($2,000,000) annual
aggregate. The policy shall be on a per occurrence basis.
CONTRACTOR 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.
CONTRACTOR 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 CONTRACTOR’s waiver of subrogation under
this paragraph is effective whether or not CONTRACTOR obtains such an endorsement.
Within thirty (30) days from the date each CONTRACTOR signs this Agreement, said
CONTRACTOR shall provide certificates of insurance and endorsements as stated above for all of the
foregoing policies, as required herein, to the County of Fresno, Department of Behavioral Health, 1925 E.
Dakota Ave, Fresno, California, 93726, Attention: Public Behavioral Health Division, stating that such
insurance coverages 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 for such worker’s
compensation insurance the CONTRACTOR has waived its right to recover from the COUNTY, its
officers, agents, and employees any amounts paid under the insurance policy and that waiver does not
invalidate the insurance policy; that such Commercial General Liability insurance names the County of
Fresno, its officers, agents and employees, individually and collectively, as additional insured, but only
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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
CONTRACTOR 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.
In the event CONTRACTOR fails to keep in effect at all times insurance coverage as herein
provided, COUNTY may, in addition to other remedies it may have, suspend or terminate this Agreement
upon the occurrence of such event.
All policies shall be with admitted insurers licensed to do business in the State of California.
Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating of A FSC VII or
better.
11.LICENSES/CERTIFICATES
Throughout each term of this Agreement, CONTRACTOR and CONTRACTOR’s staff shall
maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions necessary for
the provision of the services hereunder and required by the laws and regulations of the United States of
America, State of California, County of Fresno, and any other applicable governmental agencies.
CONTRACTOR shall notify COUNTY immediately in writing of its inability to obtain or maintain such
licenses, permits, approvals, certificates, waivers and exemptions irrespective of pendency of any appeal
related thereto. Additionally, CONTRACTOR and CONTRACTOR’s staff shall comply with all applicable
laws, rules or regulations, as may now exist or be hereafter changed.
12.RECORDS
Financial, statistical and demographic data shall be kept, and reports made as required by
the County’s Department of Behavioral Health Director and State. COUNTY shall be allowed to review all
records of services provided, including the goals and objectives of services, and how the services
provided is achieving the goals and objectives. All such records shall be available for inspection by the
designated Auditors of COUNTY or State at reasonable times during normal business hours. All such
records shall be maintained through the end of this Agreement. All records shall be considered property
of COUNTY and shall be retained by COUNTY at the termination or expiration of this Agreement.
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13.REPORTS
A.Outcomes Reports
CONTRACTOR shall submit to COUNTY’s DBH service outcome reports as
requested by COUNTY’s DBH. Outcome reports and outcome requirements are subject to change at
COUNTY’s DBH discretion.
B.Activity Reports
CONTRACTOR shall submit to County’s DBH by the 10th of each month all
monthly activity and budget reports for the preceding month.
C.Quarterly Progress Reports
CONTRACTOR shall complete Quarterly Progress Reports in the form set forth in
Exhibit A, attached hereto and by this reference incorporated herein and made part of this Agreement.
Quarterly reports shall be submitted to COUNTY’s DBH Contracts Division for review within thirty (30)
days of the end of each quarter
D.MHSA INN
CONTRACTOR shall submit to the County’s DBH MHSA INN reports and
participate in evaluation activities as described in Exhibit A.
E.Additional Reports
CONTRACTOR shall also furnish to COUNTY such statements, records, reports,
data, and other information as COUNTY’s DBH may request pertaining to matters covered by this
Agreement. In the event that CONTRACTOR fails to provide such reports or other information required
hereunder, it shall be deemed sufficient cause for COUNTY to withhold monthly payments until there is
compliance. In addition, CONTRACTOR shall provide written notification and explanation to COUNTY
within five (5) days of any funds received from another source to conduct the same services covered by
this Agreement.
14.MONITORING
CONTRACTOR agrees to extend to COUNTY’s staff, COUNTY’s DBH Director and the
State Department of Mental Health, or their designees, the right to review and monitor records, program
or procedures, at any time, in regard to clients, as well as the overall operation of CONTRACTOR’s
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program, in order to ensure compliance with the terms and conditions of this Agreement.
15.REFERENCES TO LAWS AND RULES
In the event any law, regulation, or policy referred to in this Agreement is amended during
the term thereof, the parties hereto agree to comply with the amended provision as of the effective date of
such amendment.
16.COMPLIANCE WITH STATE REQUIREMENTS
CONTRACTOR recognizes that COUNTY operates its mental health programs under an
agreement with the State Department of Health Care Services, and that under said agreement the State
imposes certain requirements on COUNTY and its subcontractors. CONTRACTOR shall adhere to all
State requirements, including those identified in Exhibit D, “State Mental Health Requirements”, attached
hereto and by this reference incorporated herein and made part of this Agreement. CONTRACTOR shall
also file an incident report for all incidents involving clients, following the Protocol and using the
Worksheet identified in Exhibit E, Incident Reporting, attached hereto and by this reference incorporated
herein and made part of this Agreement or a protocol and worksheet presented by CONTRACTOR that is
accepted by COUNTY’s DBH Director or designee.
17.CONFIDENTIALITY
All services performed by CONTRACTOR under this Agreement shall be in strict
conformance with all applicable Federal, State of California and/or local laws and regulations relating to
confidentiality.
18.HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and CONTRACTOR each consider and represent themselves as covered
entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law
104-191(HIPAA) and agree to use and disclose protected health information as required by law.
COUNTY and CONTRACTOR acknowledge that the exchange of protected health
information between them is only for treatment, payment, and health care operations.
COUNTY and CONTRACTOR intend to protect the privacy and provide for the security of
Protected Health Information (PHI) pursuant to the Agreement in compliance with HIPAA, the Health
Information Technology for Economic and Clinical Health Act, Public Law 111-005 (HITECH), and
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regulations promulgated thereunder by the U.S. Department of Health and Human Services (HIPAA
Regulations) and other applicable laws.
As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
CONTRACTOR to enter into a contract containing specific requirements prior to the disclosure of PHI,
as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504(e) of the Code of
Federal Regulations (CFR).
19.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 the COUNTY for the purpose of providing services under this Agreement
must employ adequate data security measures to protect the confidential information provided to
CONTRACTOR by the COUNTY, including but not limited to the following:
A.CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
CONTRACTOR may not connect to COUNTY networks via personally-owned
mobile, wireless or handheld devices, unless the following conditions are met:
1)CONTRACTOR 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.CONTRACTOR-Owned Computers or Computer Peripherals
CONTRACTOR may not bring CONTRACTOR-owned computers or computer
peripherals into the COUNTY for use without prior authorization from the COUNTY’s Chief Information
Officer, and/or his or her 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 the COUNTY and
transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
connection. Said data must be encrypted.
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C. COUNTY-Owned Computer Equipment
CONTRACTOR may not use COUNTY computers or computer peripherals on non-
COUNTY premises without prior authorization from the COUNTY’s Chief Information Officer, and/or his or
her designee(s).
D. CONTRACTOR may not store COUNTY’s private, confidential or sensitive data on
any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
E.CONTRACTOR shall be responsible to employ 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 pass phrase must be utilized.
G.CONTRACTOR 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 CONTRACTOR’s response to all incidents
arising from a possible breach of security related to COUNTY’s confidential client information provided to
CONTRACTOR. CONTRACTOR will be responsible to issue any notification to affected individuals as
required by law or as deemed necessary by COUNTY in its sole discretion. CONTRACTOR will be
responsible for all costs incurred as a result of providing the required notification.
20.PROPERTY OF COUNTY
A.COUNTY and CONTRACTOR recognize that fixed assets are tangible and
intangible property obtained or controlled under COUNTY's Mental Health Plan for use in operational
capacity and will benefit COUNTY for a period more than one year. Depreciation of the qualified items
will be on a straight-line basis.
For COUNTY purposes, fixed assets must fulfill three qualifications:
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1)Asset must have life span of over one year
2)The asset is not a repair part
3)The asset must be valued at or greater than the capitalization thresholds for the
asset type.
Asset type Threshold
•land $0
•buildings and improvements $100,000
•infrastructure $100,000
•be tangible $5,000
o equipment
o vehicles
•or intangible asset $100,000
o Internally generated software
o Purchased software
o Easements
o Patents
•capital lease equipment $5,000
Qualified fixed asset equipment is to be reported and approved by COUNTY. If it is
approved and identified as an asset it will be tagged with a COUNTY program number. A "Fixed Asset
Log'', attached hereto as Exhibit F and by this reference incorporated herein, will be maintained by
COUNTY's Asset Management System and inventoried annually until the asset is fully depreciated.
During the terms of this Agreement, CONTRACTOR's fixed assets may be inventoried in comparison
to COUNTY's DBH Asset Inventory System.
B.Certain purchases less than Five Thousand and No/100 Dollars ($5,000.00) with
over one-year life span and are mobile and high risk of theft or loss a1·e sensitive assets. Such
sensitive items are not limited to computers, copiers, televisions, cameras and other sensitive items as
determined by COUNTY's DBH Director or designee. CONTRACTOR(S) maintains a tracking system
on the items that are not required to be capitalized or depreciated. The items are subject to annual
inventory for compliance.
C.Assets shall be retained by COUNTY, as COUNTY property, in the event this
Agreement is terminated or upon expiration of this Agreement. CONTRACTOR agrees to participate in
an annual inventory of all COUNTY fixed and inventoried assets. Upon termination or expiration of this
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Agreement CONTRACTOR shall be physically present when fixed and inventoried assets are returned
to COUNTY possession. CONTRACTOR is responsible for returning to COUNTY all COUNTY owned
undepreciated fixed and inventoried assets, or the monetary value of said assets if unable to produce
the assets at the expiration or termination of this Agreement.
CONTRACTOR further agrees to the following:
1)To maintain all items of equipment in good working order and condition,
normal wear and tear is expected;
2)To label all items of equipment with COUNTY assigned program number,
to perform periodic inventories as required by COUNTY and to maintain
an inventory list showing where and how the equipment is being used, in
accordance with procedures developed by COUNTY. All such lists shall
be submitted to COUNTY within ten (10) days of any request; therefore,
and
3)To report in writing to COUNTY immediately after discovery, the lost or
theft of any items of equipment. For stolen items, the local law
enforcement agency must be contacted, and a copy of the police report
submitted to COUNTY.
D.The purchase of any equipment by CONTRACTOR with funds provided
hereunder shall require the prior written approval of COUNTY's DBH, shall fulfill the provisions of this
Agreement as appropriate, and must be directly related to CONTRACTOR's services or activity under
the terms of this Agreement. COUNTY's DBH may refuse reimbursement for any costs resulting from
equipment purchased, which are incurred by CONTRACTOR, if prior written approval has not been
obtained from COUNTY.
E.CONTRACTOR must obtain prior written approval from COUNTY's DBH
whenever there is any modification or change in the use of any property acquired or improved, in
whole or in part, using funds under this Agreement. If any real or personal property acquired or
improved with said funds identified herein is sold and/or is utilized by CONTRACTOR for a use which
does not qualify under this Agreement, CONTRACTOR shall reimburse COUNTY in an amount equal
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to the current fair market value of the property, less any portion thereof attributable to expenditures of
funds not provided under this Agreement. These requirements shall continue in effect for the life of the
property. In the event this Agreement expires, or terminates, the requirements for this Section shall
remain in effect for activities or property funded with said funds, unless action is taken by the State
government to relieve COUNTY of these obligations
21.NON-DISCRIMINATION
During the performance of this Agreement, CONTRACTOR and its subcontractors shall not
deny the contract’s benefits to any person on the basis of race, religious creed, color, national origin,
ancestry, physical disability, mental disability, medical condition, genetic information, marital status, sex,
gender, gender identity, gender expression, age, sexual orientation, or military and veteran status, nor
shall they discriminate unlawfully against any employee or applicant for employment because of race,
religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition,
genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual
orientation, or military or veteran status. CONTRACTOR shall insure that the evaluation and treatment of
employees and applicants for employment are free of such discrimination.
CONTRACTOR shall comply with the provisions of the Fair Employment and Housing Act
(Gov. Code §12800 et seq.), the regulations promulgated thereunder (Cal. Code Regs., tit. 2, §11000 et
seq.), the provisions of Article 9.5, Chapter 1, Part 1, Division 3, Title 2 of the Government Code (Gov.
Code §11135-11139.5), and the regulations or standards adopted by the awarding state agency to
implement such article. CONTRACTOR shall permit access by representatives of the Department of Fair
Employment and Housing and the awarding state agency upon reasonable notice at any time during the
normal business hours, but in no case less than twenty-four (24) hours notice, to such of its books,
records, accounts, and all other sources of information and its facilities as said Department or Agency
shall require to ascertain compliance with this clause. CONTRACTOR and its subcontractors shall give
written notice of their obligations under this clause to labor organizations with which they have a collective
bargaining or other agreement. (See Cal. Code Regs., tit. 2, §11105). CONTRACTOR shall include the
Non-Discrimination and compliance provisions of this clause in all subcontracts to perform work under this
Agreement.
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22.CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence, CONTRACTOR(S) shall comply with:
A.Title 6 of the Civil Rights Act of 1964 (42 U.S.C. Section 2000d, and 45 C.F.R.
Part 80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance
from discriminating against persons based on race, color, national origin, sex, disability or religion.
This is interpreted to mean that a limited English proficient (LEP) individual is entitled to equal access
and participation in federally funded programs through the provision of comprehensive and quality
bilingual services.
B.Policies and procedures for ensuring access and appropriate use of trained
interpreters and material translation services for all LEP consumers, including, but not limited to,
assessing the cultural and linguistic needs of its consumers, training of staff on the policies and
procedures, and monitoring its language assistance program. The CONTRACTOR's procedures must
include ensuring compliance of any sub-contracted providers with these requirements.
C.CONTRACTOR shall not use minors as interpreters.
D.CONTRACTOR shall provide and pay for interpreting and translation services to
persons participating in CONTRACTOR’s services who have limited or no English language
proficiency, including services to persons who are deaf or blind. Interpreter and translation services
shall be provided as necessary to allow such participants meaningful access to the programs, services
and benefits provided by CONTRACTOR. Interpreter and translation services, including translation of
CONTRACTOR's "vital documents" (those documents that contain information that is critical for
accessing CONTRACTOR's services or are required by law) shall be provided to participants at no
cost to the participant. CONTRACTOR shall ensure that any employees, agents, subcontractors, or
partners who interpret or translate for a program participant, or who directly communicate with a
program participant in a language other than English, demonstrate proficiency in the participant's
language and can effectively communicate any specialized terms and concepts peculiar to
CONTRACTOR's services.
E.In compliance with the State mandated Culturally and Linguistically Appropriate
Services standards as published by the Office of Minority Health, CONTRACTOR’s must submit to
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COUNTY for approval, within 60 days from date of contract execution, CONTRACTOR’s plan to
address all fifteen national cultural competency standards as set forth in the “National Standards on
Culturally and Linguistically Appropriate Services (CLAS).”
(http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf). COUNTY's annual on-site review of
CONTRACTOR shall include collection of documentation to ensure all national standards are
implemented. As the national competency standards are updated, CONTRACTOR's plan must be
updated accordingly.
23.AMERICANS WITH DISABILITIES ACT
CONTRACTOR agrees to ensure that deliverables developed and produced, pursuant to
this Agreement shall comply with the accessibility requirements of Section 508 of the Rehabilitation
Act and the Americans with Disabilities Act of 1973 as amended (29 U.S.C § 794 (d)), and regulations
implementing that Act as set forth in Part 1194 of Title 36 of the Code of Federal Regulations. In 1998,
Congress amended the Rehabilitation Act of 1973 to require Federal agencies to make their electronic
and information technology (EIT) accessible to people with disabilities. California Government Code
section 11135 codifies section 508 of the Act requiring accessibility of electronic and information
technology.
24.TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowance of reimbursement under section
1861(v)(1) (I) of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[I]), until the expiration of four
(4) years after the furnishing of services under this Agreement, CONTRACTOR shall make available,
upon request to the Comptroller General of the United States General Accounting Office, or any of
their duly authorized representatives, a copy of this Agreement and such books, documents, and
records as are necessary to certify the nature and extent of the costs of these services provided by
CONTRACTOR under this Agreement. CONTRACTOR further agrees that in the event
CONTRACTOR carries out any of its duties under this Agreement through a subcontract, with a value
or cost of Ten Thousand and No/100 Dollars ($10,000) or more over a twelve (12) month period, with
a related organization, such Agreement shall contain a clause to the effect that until the expiration of
four (4) years after the furnishing of such services pursuant to such subcontract, the related
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organizations shall make available, upon written request to the Comptroller General of the United
States General Accounting Office, or any of their duly authorized representatives, a copy of such
subcontract and such books, documents, and records of such organization as are necessary to verify
the nature and extent of such costs.
25.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 financial interest in this Agreement. In addition, no employee of COUNTY shall be employed by
CONTRACTOR to fulfill any contractual obligations with COUNTY.
CONTRACTOR shall also 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.
26.SINGLE AUDIT CLAUSE
A.If CONTRACTOR expends Seven Hundred Fifty Thousand Dollars and No/100
Dollars ($750,000.00) or more in Federal and Federal flow-through monies, CONTRACTOR agrees to
conduct an annual audit in accordance with the requirements of the Single Audit Standards as set forth in
Office of Management and Budget (OMB) 2 CFR 200. CONTRACTOR shall submit said audit and
management letter to COUNTY. The audit must include a statement of findings or a statement that there
were no findings. If there were negative findings, CONTRACTOR must include a corrective action plan
signed by an authorized individual. CONTRACTOR agrees to take action to correct any material non-
compliance or weakness found as a result of such audit. Such audit shall be delivered to COUNTY’s
DBH Business Office for review within nine (9) months of the end of any fiscal year in which funds were
expended and/or received for the program. Failure to perform the requisite audit functions as required by
this Agreement may result in COUNTY performing the necessary audit tasks, or at COUNTY’s option,
contracting with a public accountant to perform said audit, or, may result in the inability of COUNTY to
enter into future agreements with CONTRACTOR. All audit costs related to this Agreement are the sole
responsibility of CONTRACTOR.
B.A single audit report is not applicable if CONTRACTOR’s Federal contracts do not
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exceed the Seven Hundred Fifty Thousand and No/100 Dollars ($750,000.00) requirement or
CONTRACTOR’s only funding is through Drug-related Medi-Cal. If a single audit is not applicable, a
program audit must be performed and a program audit report with management letter shall be submitted
by CONTRACTOR to COUNTY as a minimum requirement to attest to CONTRACTOR’s solvency. Said
audit report shall be delivered to COUNTY’s DBH Business Office for review, no later than nine (9)
months after the close of the fiscal year in which the funds supplied through this Agreement are
expended. Failure to comply with this Act may result in COUNTY performing the necessary audit tasks or
contracting with a qualified accountant to perform said audit. All audit costs related to this Agreement are
the sole responsibility of CONTRACTOR who agrees to take corrective action to eliminate any material
noncompliance or weakness found as a result of such audit. Audit work performed by COUNTY under
this Section shall be billed to the CONTRACTOR at COUNTY’s cost, as determined by COUNTY’s
Auditor-Controller/Treasurer-Tax Collector.
C. CONTRACTOR shall make available all records and accounts for inspection by
COUNTY, the State of California, if applicable, the Comptroller General of the United States, the Federal
Grantor Agency, or any of their duly authorized representatives, at all reasonable times for a period of at
least three (3) years following final payment under this Agreement or the closure of all other pending
matters, whichever is later.
27.ASSURANCES
In entering into this Agreement, CONTRACTOR certifies that it is not currently excluded,
suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs: that it
has not been convicted of a criminal offense related to the provision of health care items or services; nor
has it been reinstated to participation in the Federal Health Care Programs after a period of exclusion,
suspension, debarment, or ineligibility. If COUNTY learns, subsequent to entering into a contract, that
CONTRACTOR is ineligible on these grounds, COUNTY will remove CONTRACTOR from responsibility
for, or involvement with, COUNTY’s business operations related to the Federal Health Care Programs
and shall remove such CONTRACTOR from any position in which CONTRACTOR’s compensation, or
the items or services rendered, ordered or prescribed by CONTRACTOR may be paid in whole or part,
directly or indirectly, by Federal Health Care Programs or otherwise with Federal Funds at least until such
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time as CONTRACTOR is reinstated into participation in the Federal Health Care Programs.
A.If COUNTY has notice that CONTRACTOR has been charged with a criminal
offense related to any Federal Health Care Program, or is proposed for exclusion during the term of any
contract, CONTRACTOR and COUNTY shall take all appropriate actions to ensure the accuracy of any
claims submitted to any Federal Health Care Program. At its discretion given such circumstances,
COUNTY may request that CONTRACTOR cease providing services until resolution of the charges or the
proposed exclusion.
B.CONTRACTOR agrees that all potential new employees of CONTRACTOR or
subcontractors of CONTRACTOR who, in each case, are expected to perform professional services
under this Agreement, will be queried as to whether: (1) they are now or ever have been excluded,
suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) they
have been convicted of a criminal offense related to the provision of health care items or services; and or
(3) they have been reinstated to participation in the Federal Health Care Programs after a period of
exclusion, suspension, debarment, or ineligibility.
1)In the event the potential employee or subcontractor informs
CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible, or has been
convicted of a criminal offense relating to the provision of health care services, and CONTRACTOR hires
or engages such potential employee or subcontractor, CONTRACTOR will ensure that said employee or
subcontractor does no work, either directly or indirectly relating to services provided to COUNTY.
2)Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section Two (2) of this Agreement, or require adequate assurance (as
defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor of
CONTRACTOR will perform work, either directly or indirectly, relating to services provided to COUNTY.
Such demand for adequate assurance shall be effective upon a timeframe to be determined by COUNTY
to protect the interests of COUNTY consumers.
C. CONTRACTOR shall verify (by asking the applicable employees and
subcontractors) that all current employees and existing subcontractors who, in each case, are expected
to perform professional services under this Agreement (1) are not currently excluded, suspended,
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debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) have not been
convicted of a criminal offense related to the provision of health care items or services; and (3) have not
been reinstated to participation in the Federal Health Care Program after a period of exclusion,
suspension, debarment, or ineligibility. In the event any existing employee or subcontractor informs
CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible to participate in
the Federal Health Care Programs, or has been convicted of a criminal offense relating to the provision of
health care services, CONTRACTOR will ensure that said employee or subcontractor does no work,
either direct or indirect, relating to services provided to COUNTY.
1)CONTRACTOR agrees to notify COUNTY immediately during the term of
this Agreement whenever CONTRACTOR learns that an employee or subcontractor who, in each case,
is providing professional services under this Agreement is excluded, suspended, debarred or otherwise
ineligible to participate in the Federal Health Care Programs, or is convicted of a criminal offense relating
to the provision of health care services.
2)Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section Three (3) of this Agreement, or require adequate assurance (as
defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor of
CONTRACTOR will perform work, either directly or indirectly, relating to services provided to COUNTY.
Such demand for adequate assurance shall be effective upon a timeframe to be determined by COUNTY
to protect the interests of COUNTY clients.
D. CONTRACTOR agrees to cooperate fully with any reasonable requests for
information from COUNTY, which may be necessary to complete any internal or external audits relating to
CONTRACTOR’s compliance with the provisions of this Section.
E.CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty
imposed upon COUNTY by the Federal Government as a result of CONTRACTOR’s violation of
CONTRACTOR’s obligations as described in this Section.
28.PUBLIC PROHIBITION
None of the funds, materials, property or services provided directly or indirectly under this
Agreement shall be used for CONTRACTOR’s advertising, fundraising, or publicity (i.e., purchasing of
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tickets/tables, silent auction donations, etc.) for the purpose of self-promotion. Notwithstanding the
above, publicity of the services described in Section One (1) 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 his or her designee, and at a cost to be provided in Exhibit C for
such items as written/printed materials, the use of media (i.e., radio, television, newspapers) and any
other related expense(s).
29.COMPLAINTS
CONTRACTOR shall log complaints and the disposition of all complaints from clients and
clients’ families. CONTRACTOR shall provide a copy of the detailed complaint log entries concerning
COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (10th) day of the following
month, in a format that is mutually agreed upon. In addition, CONTRACTOR shall provide details and
attach documentation of each complaint with the log. CONTRACTOR shall post signs informing clients of
their right to file a complaint or grievance. CONTRACTOR shall notify COUNTY of all incidents reportable
to State licensing bodies that affect COUNTY clients within twenty-four (24) hours of receipt of a
complaint.
Within ten (10) days after each incident or complaint affecting COUNTY-sponsored clients,
CONTRACTOR shall provide COUNTY with information relevant to the complaint, investigative details of
the complaint, the complaint and CONTRACTOR’s disposition of, or corrective action taken to resolve the
complaint. In addition, CONTRACTOR shall inform every client of their rights as set forth in Exhibit G,
Grievances. CONTRACTOR shall file an incident report for all incidents involving clients, following the
protocol and using the worksheet identified in Exhibit E and incorporated herein by reference and made
part of this Agreement.
30.DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION
This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent, or
managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101 455.104, and
455.106(a)(1),(2).
In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and 455.106(a)(1),(2),
the following information must be disclosed by CONTRACTOR by completing Exhibit H, “Disclosure of
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Ownership and Control Interest Statement”, attached hereto and by this reference incorporated herein
and made part of this Agreement. CONTRACTOR shall submit this form to COUNTY’s DBH within thirty
(30)days of the effective date of this Agreement. Additionally, CONTRACTOR shall report any changes
to this information within thirty-five (35) days of occurrence by completing Exhibit H. CONTRACTOR is
required to submit a set of fingerprints for any person with a five (5) percent or greater direct or indirect
ownership interest in CONTRACTOR. COUNTY may terminate this Agreement where any person with a
five (5) percent or greater direct or indirect ownership interest in the CONTRACTOR did not submit timely
and accurate information and cooperate with any screening method required in CFR, Title 42, Section
455.416. Submissions shall be scanned portable document format (pdf) copies and are to be sent via
email to DBHAdministration@fresnocountyca.gov, Attention: Contracts Administration. COUNTY may
deny enrollment or terminate this Agreement where any person with a five (5) percent or greater direct or
indirect ownership interest in CONTRACTOR has been convicted of a criminal offense related to that
person’s involvement with the Medicare, Medicaid, or Title XXI program in the last ten (10) years.
31.DISCLOSURE – CRIMINAL HISTORY AND CIVIL ACTIONS
CONTRACTOR is required to disclose if any of the following conditions apply to them, their
owners, officers, corporate managers and partners (hereinafter collectively referred to as
“CONTRACTOR”):
A.Within the three (3) year period preceding the Agreement award, they have been
convicted of, or had a civil judgment rendered against them for:
1)Fraud or a criminal offense in connection with obtaining, attempting to
obtain, or performing a public (federal, state, or local) transaction or
contract under a public transaction;
2)Violation of a federal or state antitrust statute;
3)Embezzlement, theft, forgery, bribery, falsification, or destruction of records;
or
4)False statements or receipt of stolen property.
B.Within a three (3) year period preceding their Agreement award, they have had a
public transaction (federal, state, or local) terminated for cause or default.
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Disclosure of the above information will not automatically eliminate CONTRACTOR from
further business consideration. The information will be considered as part of the determination of whether
to continue and/or renew the Agreement and any additional information or explanation that a
CONTRACTOR elects to submit with the disclosed information will be considered. If it is later determined
that the CONTRACTOR failed to disclose required information, any contract awarded to such
CONTRACTOR may be immediately voided and terminated for material failure to comply with the terms
and conditions of the award.
CONTRACTOR must sign a “Certification Regarding Debarment, Suspension, and Other
Responsibility Matters- Primary Covered Transactions” in the form set forth in Exhibit I, attached hereto
and by this reference incorporated herein and made part of this Agreement. Additionally, CONTRACTOR
must immediately advise the COUNTY in writing if, during the term of this Agreement: (1)
CONTRACTOR becomes suspended, debarred, excluded or ineligible for participation in federal or state
funded programs or from receiving Federal funds as listed in the excluded parties’ list system
(http://www.epls.gov); or (2) any of the above listed conditions become applicable to CONTRACTOR.
CONTRACTOR shall indemnify, defend and hold the COUNTY harmless for any loss or damage
resulting from a conviction, debarment, exclusion, ineligibility or other matter listed in the signed
Certification Regarding Debarment, Suspension, and Other Responsibility Matters.
32.DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the CONTRACTOR is operating as a corporation (a for-
profit or non-profit corporation) or if during the term of this Agreement, the CONTRACTOR changes its
status to operate as a corporation.
Members of the CONTRACTOR’s Board of Directors shall disclose any self-dealing
transactions that they are a party to while CONTRACTOR is providing goods or performing services
under this Agreement. A self-dealing transaction shall mean a transaction to which the CONTRACTOR 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 J and incorporated herein by
reference and made part of this Agreement, and submitting it to the COUNTY prior to commencing with
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the self-dealing transaction or immediately thereafter.
33.COMPLIANCE
CONTRACTOR agrees to comply with the COUNTY’s Contractor Code of Conduct and
Ethics and the COUNTY’s Compliance Program in accordance with Exhibit K, attached hereto and
incorporated herein by reference and made part of this Agreement. Within thirty (30) days of entering into
this Agreement with the COUNTY, CONTRACTOR shall have all of the CONTRACTOR’s employees,
agents and subcontractors providing services under this Agreement certify in writing, that he or she has
received, read, understood, and shall abide by the Contractor Code of Conduct and Ethics.
CONTRACTOR shall ensure that within thirty (30) days of hire, all new employees, agents, and
subcontractors providing services under this Agreement shall certify in writing that he or she has received,
read, understood, and shall abide by the Contractor Code of Conduct and Ethics. CONTRACTOR
understands that the promotion of and adherence to the Code of Conduct is an element in evaluation the
performance of CONTRACTOR and its employees, agents and subcontractors.
Within thirty (30) days of entering into this Agreement, and annually thereafter, all
employees, agents, and subcontractors providing services under this Agreement shall complete general
compliance training and appropriate employees, agents and subcontractors shall complete
documentation and billing or billing/reimbursement training. All new employees, agents and
subcontractors shall attend the appropriate training within 30 days of hire. Each individual who is required
to attend training shall certify in writing that he or she has received the required training. The certification
shall specify the type of training received and the date received. The certification shall be provided to the
COUNTY’s Compliance Officer at 1925 E. Dakota Ave., Fresno, California 93726. CONTRACTOR
agrees to reimburse COUNTY for the entire cost of any penalty imposed upon COUNTY by the Federal
Government as a result of CONTRACTOR’s violation of the terms of this Agreement.
34.AUDITS AND INSPECTIONS
CONTRACTOR 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. CONTRACTOR shall, upon request by COUNTY, permit
COUNTY to audit and inspect all such records and data necessary to ensure CONTRACTOR's
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compliance with the terms of this Agreement.
If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
CONTRACTOR shall be subject to the examination and audit of the State of California Auditor General
for a period of three (3) years after final payment under contract (California Government Code section
8546.7).
35.NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CONTRACTOR
Director, County of Fresno Kings View
Department of Behavioral Health Cc to: Amanda Nugent Divine, CEO
1925 E. Dakota Ave 7170 N. Financial Dr. Ste 110
Fresno, CA 93726 Fresno, CA 93720
All notices between the COUNTY and CONTRACTOR provided for or permitted under this Agreement
must be in writing and delivered either by personal service, by first-class United States mail, by an
overnight commercial courier service, or by telephonic facsimile transmission. A notice delivered by
personal service is effective upon service to the recipient. A notice delivered by first-class United States
mail is effective three (3) COUNTY business days after deposit in the United States mail, postage
prepaid, addressed to the recipient. A notice delivered by an overnight commercial courier service is
effective one (1) COUNTY business day after deposit with the overnight commercial courier service,
delivery fees prepaid, with delivery instructions given for next day delivery, addressed to the recipient. A
notice delivered by telephonic facsimile is effective when transmission to the recipient is completed (but, if
such transmission is completed outside of COUNTY business hours, then such delivery shall be deemed
to be effective at the next beginning of a COUNTY business day), provided that the sender maintains a
machine record of the completed transmission. For all claims arising out of or related to this Agreement,
nothing in this Section establishes, waives, or modifies any claims presentation requirements or
procedures provided by law, including but not limited to the Government Claims Act (Division 3.6 of Title 1
of the Government Code, beginning with Section 810).
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36.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 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.
37.SEVERABILITY
If any non-material term, provision, covenant, or condition of this Agreement is held by a
court of competent jurisdiction to be invalid, void or unenforceable, the remainder of the provisions shall
remain in full force and effect, and shall in no way be affected, impaired or invalidated.
38.GOVERNING LAW
Venue for any action arising out of or related to the Agreement shall only be 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.
39.ENTIRE AGREEMENT
This Agreement, including all Exhibits, constitutes the entire Agreement between the
CONTRACTOR and COUNTY with respect to the subject matter hereof and supersedes all previous
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negotiations, proposals, commitments, writings, advertisements, publications, and understandings of any
nature whatsoever unless expressly included in this Agreement.
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II
Do cu S ig n Envelope ID : 5DAC3 2 FB-FB33-407B-BF88-F9C17D363489
1 IN WITNESS WHEREOF , the parties hereto have executed this Agreement as of the day and year
2 first hereinabove written.
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Kings View : ~Docu Slgne d by :
A~N~~~
Ae4F6 I 7F13! 1465 ...
(Authorized Signature)
Amanda Nugent Divine , CEO
Print Name & Title
7170 N. Financial Dr. Suite 11 O
Fresno , CA 93720
Mailing Address
COUNTzt+r:
Steve ~ Chairman of the Board of
Supervisors of the County of Fresno
ATTEST:
Bernice E. Se idel
Clerk of the Board of Supervisors
County of Fresno , State of California
r-:Do cuS lg ned by :
___ L,.._-m-i'!79'9!~!frl:5B11-fj:El~4B~6~e-t481!:~:::-... ---------By: __ ....,d\ __ ..... ~~=~'---~=-D-"e-=+-"u.,' ,__ _____ _
(Authorized ~ignature) ~
Michael Kosareff
Print Name
Chief Financial Officer
Title : Secretary (of Corporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer
FOR ACCOUNTING USE ONLY:
Fund:
Subclass :
ORG:
Account:
0001
10000
56304796
7295/0
30
Exhibit A - Page 1 of 5
SUMMARY OF SERVICES
ORGANIZATION: Kings View
SERVICE: Suicide Prevention Follow-Up Call Program
OFFICE ADDRESS: 7170 N. Financial Drive. Ste 110
Fresno, CA 93720
OFFICE TELEPHONE: (559) 256-4475 ext. 4004
CONTACT(S): Virginia Sparks, Regional Mental Health Director
David Lopez, Program Manager
CONTRACT PERIOD: Effective Upon Execution – June 30, 2024
AMOUNT: Effective Upon Execution – June 30, 2022: $255,000
FY 22-23: $ 255,000
FY 23-24: $ 255,000
Total: $ 765,000
A.SUMMARY OF SERVICES
CONTRACTOR shall provide follow up call services to individuals who have called the
lifeline in crisis with suicidal ideation, or persons who have recently been released from
the emergency department, crisis stabilization center or inpatient care for suicide
ideation and/or attempt. Due to the increased risk during the initial 30 days after a
suicidal crisis or attempt, the Follow-Up Call Program will contact the individual served
to provide them support, resources and recommendations to services. The Suicide
Prevention Follow-Up Call Program seeks to provide real-time insight to possible
external factors impacting persons with suicidal ideation and increase linkages to
appropriate behavioral health services for this high-risk population with suicidal ideation
and/or suicide attempts.
Exhibit A - Page 2 of 5
B.CONTRACTOR RESPONSIBILITIES
CONTRACTOR shall perform the activities below.
1)Services
a.Make follow-up contacts beginning 24-48 hours after initial follow-up referral
form is received from hospitals or crisis stabilization center.
b.Notify individual served in the initial contact that participation in the Follow-
Up Call Program is voluntary and they can request to stop follow-up services
at any time.
c.Attempt to call the individual served a minimum of five times via phone call
over a 3-day time period at various times of day, prior to closing referral.
d.Follow up a minimum of two times after initial phone contact within 15-30
days depending on the needs and requests of the individual served.
e.Calls should be structured and focus on continued assessment of risk,
protective factors and a review of the safety plan. Possible revisions, if
necessary, should be conducted.
f.Follow-Up Call Counselors will assess the well-being of the individual served
and assess the risk of suicide utilizing the Columbia Suicide Severity Rating
Scale (CSSR-S).
i.Follow-Up Counselor shall inquire about:
1.The individual’s mood
2.How the individual is feeling
3.Does the individual feel safe
4.Actions being taken to keep the individual safe
g.Research and identify the individual served’s linkage to services identified in
their safety/discharge plan and appointments.
h.Offer additional services and resources, as needed or requested, and remind
the individual served about the National Suicide Prevention Lifeline
i.Counselors shall work with the individual served in problem solving of
obstacles and barriers to obtaining treatment and encourage and support
them in attending their first appointment.
j.Provide follow-up services to the individual served up to 60 days or their first
appointment (if after the 60 days), or longer if requested by the individual
served.
k.Follow-up on the same individual served if they reenter the program based
upon subsequent crisis calls.
l.Assist in creating a safety plan for the individual served if they did not create
one at discharge or those who were never in a hospital or crisis stabilization
center. If safety plan is created upon discharge, CONTRACTOR can assist the
individual served in modifying their plan, if needed.
m.Calls shall be structured but individualized to the individual’s needs and
requests.
Exhibit A - Page 3 of 5
n.After each call, the CONTRACTOR shall rate and record the individual’s
suicidality score based off the CSSR-S score between 1 and 5 (1 being the
lowest and 5 being the highest).
i.If the score is high (4 or 5), CONTRACTOR shall assess for immediate
safety and provide intervention if necessary, per Central Valley
Suicide Prevention Hotline procedures.
ii.If the score is lower (1-3), CONTRACTOR shall explore what helped
the individual served achieve this lowered score. They will work
together to identify and reinforce the successful coping skills or
activities they utilized.
o.Create a profile for each individual served as the referral is received.
p.Provide basic and limited clinical support, if needed.
q.Provide appointment reminders for individuals served and discuss and
problem solve the barriers to attending their first appointment.
r.Document all call attempts, along with time and date, in the profile for the
individual served. This includes:
i.Successful and unsuccessful calls
ii.Narrative of the call
iii.Protective factors identified
iv.Problem solving actions
v.Current risk assessment
vi.Emergency dispatch, if applicable
2)Data Collection
a.CONTRACTOR shall collect data including, but not limited to:
i.Demographic information to meet Mental Health Services Act
Innovation requirements
1.Age Group
2.Race
3.Ethnicity
4.Primary Language
5.Sexual Orientation
6.Disability
7.Veteran Status
8.Current Gender Identity
9.Gender Assigned at Birth
ii.Number of referrals for follow-up
iii.Number of follow-ups agreed to and initiated
iv.Number of refusals for follow-up
v.Number of individuals served who are being contacted after two or
more crisis stabilization discharge events
vi.Time it takes for an individual served to access services
vii.Information about the initial crisis event
Exhibit A - Page 4 of 5
viii.Elements relevant to real-time insight to external factors impacting
an individual’s crisis and/or suicidal ideation or attempt.
ix.During the receipt of follow-up services, was the individual served
admitted to a hospital or inpatient setting, and/or did they attempt
suicide
x.Identify whether the individual accessed referral services and
linkages
1.For Medi-Cal individuals, verify in Avatar
2.For non Medi-Cal individuals, self-reporting will be
sufficient
xi.Satisfaction of the Follow-Up Call Program
b.Data shall be compared to national data for similar follow-up programs.
3)Written Reports
a.CONTRACTOR shall work with evaluator to prepare an evaluation report
annually and submit to the COUNTY’s DBH. Each annual evaluation report
will comply with all State regulations regarding State Performance Outcomes
measurement requirements, including MHSA Innovations regulations, and
participate in the outcomes measurement process as required by DBH.
b.Additional reports/outcomes may also be requested by the COUNTY’s
Department of Behavioral Health, based on State required
reports/outcomes, as needed.
4)Provide Assistance in Communication of Findings
a.CONTRACTOR shall work with and assist DBH with communicating the
produced research findings to stakeholders, public, and social media.
b.CONTRACTOR shall assist DBH in presentations of the program and its
findings.
5)Compliance with County
a.CONTRACTOR shall comply with all contract monitoring and compliance
protocols, procedures, data collection methods, trainings and reporting
requirements conducted by the COUNTY.
b.CONTRACTOR, or CONTRACTOR’s staff, shall participate in meetings to discuss the
program, contract issues or data findings when requested by DBH or CONTRACTOR.
DBH shall coordinate the meetings.
C.COUNTY RESPONSIBILITIES
County shall:
1)Participate in monthly meetings with CONTRACTOR to discuss program, contractual
issues, and/or findings. Meetings frequency may be changed after the first year of
implementation. DBH will be responsible for coordination of these meetings.
Exhibit A - Page 5 of 5
2)Participate in evaluation of the progress of the overall program and the efficiency of
the collaboration with CONTRACTOR and will be available to CONTRACTOR for
ongoing consultation.
3)Gather outcome information from CONTRACTOR throughout each term of this
Agreement. COUNTY DBH staff shall notify the CONTRACTOR when its participation
is required.
4)DBH shall include CONTRACTOR in DBH trainings that are relevant to the services as
described in this Agreement, if there is sufficient space available, at no cost.
Guiding Principles of Care Delivery
1
rev 2017 Dec
DBH VISION:
Health and well-being for our community.
DBH MISSION:
The Department of Behavioral Health is dedicated to supporting the wellness of individuals,
families and communities in Fresno County who are affected by, or are at risk of, mental illness
and/or substance use disorders through cultivation of strengths toward promoting recovery in
the least restrictive environment.
DBH GOALS:
Quadruple Aim
•Deliver quality care
•Maximize resources while focusing on efficiency
•Provide an excellent care experience
•Promote workforce well-being
GUIDING PRINCIPLES OF CARE DELIVERY:
The DBH 11 principles of care delivery define and guide a system that strives for excellence in the
provision of behavioral health services where the values of wellness, resiliency, and recovery are
central to the development of programs, services, and workforce. The principles provide the
clinical framework that influences decision-making on all aspects of care delivery including
program design and implementation, service delivery, training of the workforce, allocation of
resources, and measurement of outcomes.
1.Principle One - Timely Access & Integrated Services
o Individuals and families are connected with services in a manner that is streamlined,
effective, and seamless
o Collaborative care coordination occurs across agencies, plans for care are integrated,
and whole person care considers all life domains such as health, education,
employment, housing, and spirituality
o Barriers to access and treatment are identified and addressed
o Excellent customer service ensures individuals and families are transitioned from one
point of care to another without disruption of care
Exhibit B - Page 1 of 4
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
2
rev 2017 Dec
2.Principle Two - Strengths-based
o Positive change occurs within the context of genuine trusting relationships
o Individuals, families, and communities are resourceful and resilient in the way they
solve problems
o Hope and optimism is created through identification of, and focus on, the unique
abilities of individuals and families
3.Principle Three - Person-driven and Family-driven
o Self-determination and self-direction are the foundations for recovery
o Individuals and families optimize their autonomy and independence by leading the
process, including the identification of strengths, needs, and preferences
o Providers contribute clinical expertise, provide options, and support individuals and
families in informed decision making, developing goals and objectives, and identifying
pathways to recovery
o Individuals and families partner with their provider in determining the services and
supports that would be most effective and helpful and they exercise choice in the
services and supports they receive
4.Principle Four - Inclusive of Natural Supports
o The person served identifies and defines family and other natural supports to be
included in care
o Individuals and families speak for themselves
o Natural support systems are vital to successful recovery and the maintaining of
ongoing wellness; these supports include personal associations and relationships
typically developed in the community that enhance a person’s quality of life
o Providers assist individuals and families in developing and utilizing natural supports.
5.Principle Five - Clinical Significance and Evidence Based Practices (EBP)
o Services are effective, resulting in a noticeable change in daily life that is measurable.
o Clinical practice is informed by best available research evidence, best clinical
expertise, and client values and preferences
o Other clinically significant interventions such as innovative, promising, and emerging
practices are embraced
Exhibit B - Page 2 of 4
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
3
rev 2017 Dec
6.Principle Six - Culturally Responsive
o Values, traditions, and beliefs specific to an individual’s or family’s culture(s) are
valued and referenced in the path of wellness, resilience, and recovery
o Services are culturally grounded, congruent, and personalized to reflect the unique
cultural experience of each individual and family
o Providers exhibit the highest level of cultural humility and sensitivity to the self-
identified culture(s) of the person or family served in striving to achieve the greatest
competency in care delivery
7.Principle Seven - Trauma-informed and Trauma-responsive
o The widespread impacts of all types of trauma are recognized and the various
potential paths for recovery from trauma are understood
o Signs and symptoms of trauma in individuals, families, staff, and others are recognized
and persons receive trauma-informed responses
o Physical, psychological and emotional safety for individuals, families, and providers is
emphasized
8.Principle Eight - Co-occurring Capable
o Services are reflective of whole-person care; providers understand the influence of
bio-psycho-social factors and the interactions between physical health, mental health,
and substance use disorders
o Treatment of substance use disorders and mental health disorders are integrated; a
provider or team may deliver treatment for mental health and substance use
disorders at the same time
9.Principle Nine - Stages of Change, Motivation, and Harm Reduction
o Interventions are motivation-based and adapted to the client’s stage of change
o Progression though stages of change are supported through positive working
relationships and alliances that are motivating
o Providers support individuals and families to develop strategies aimed at reducing
negative outcomes of substance misuse though a harm reduction approach
o Each individual defines their own recovery and recovers at their own pace when
provided with sufficient time and support
Exhibit B - Page 3 of 4
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
4
rev 2017 Dec
10.Principle Ten - Continuous Quality Improvement and Outcomes-Driven
o Individual and program outcomes are collected and evaluated for quality and efficacy
o Strategies are implemented to achieve a system of continuous quality improvement
and improved performance outcomes
o Providers participate in ongoing professional development activities needed for
proficiency in practice and implementation of treatment models
11.Principle Eleven - Health and Wellness Promotion, Illness and Harm Prevention, and Stigma
Reduction
o The rights of all people are respected
o Behavioral health is recognized as integral to individual and community well-being
o Promotion of health and wellness is interwoven throughout all aspects of DBH services
o Specific strategies to prevent illness and harm are implemented at the individual,
family, program, and community levels
o Stigma is actively reduced by promoting awareness, accountability, and positive
change in attitudes, beliefs, practices, and policies within all systems
o The vision of health and well-being for our community is continually addressed
through collaborations between providers, individuals, families, and community
members
Exhibit B - Page 4 of 4
Fresno County Department of Behavioral Health
Exhibit C
Page 1 of 12
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Executive Director 0.01 790$ -$ 790$
1102 Executive Director Assistant 0.01 252 - 252
1103 Regional Director 0.01 1,297 - 1,297
1104 Program Manager 0.05 5,499 5,499
1105 Counselor 2.50 - 140,400 140,400
Personnel Salaries Subtotal 2.57 2,339$ 145,899$ 148,238$
Employee Benefits
Acct #Admin Direct Total
1101 37$ 2,261$ 2,298$
1102 59 3,647 3,706
1103 318 19,842 20,160
414$ 25,750$ 26,164$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1201 -$ -$ -$
1202 179 11,161 11,340
1203 40 2,480 2,520
219$ 13,641$ 13,860$
2,972$ 185,290$ 188,262$
3000: OPERATING EXPENSES
Acct #Amount
3001 4,265$
3002 670
3003 924
3004 -
3005 1,500
3006 1,000
3007 -
3008 -
3009 500
8,859$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 3,330$
4002 7,800
4003 700
4004 -
4005 -
4006 1,800
13,630$
SUICIDE PREVENTION FOLLOW-UP CALL PROGRAM
Kings View Corporation
Effective Upon Execution - June 30, 2022
Description
Payroll Taxes & Expenses Subtotal:
Line Item Description
Line Item Description
EMPLOYEE SALARIES & BENEFITS TOTAL:
Advertising
Rent/Lease Building
Building Maintenance
PROGRAM EXPENSES
FACILITIES/EQUIPMENT TOTAL:
OPERATING EXPENSES TOTAL:
Staff Development & Training
Vehicle Maintenance
Rent/Lease Vehicles
Security
Utilities
Rent/Lease Equipment
1000: SALARIES & BENEFITS
Telecommunications
Printing/Postage
Retirement
Worker's Compensation
Health Insurance
OASDI
FICA/MEDICARE
SUI
Other (Staff Recruitment)
Employee Benefits Subtotal:
Employee Benefits %:
Description
Office Supplies & Equipment
Staff Mileage
Subscriptions & Memberships
Exhibit C
Page 2 of 12
5000: SPECIAL EXPENSES
Acct #Amount
5001 8,637$
8,637$
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 23,182
6002 3,840
6003 -
6004 -
6005 Insurance (Liability):180
27,202$
7000: FIXED ASSETS
Acct #Amount
7001 6,910$
7002 -
7003 1,500
8,410$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports -$
8302 PEI - Prevention & Early Intervention -
8303 INN - Innovations 255,000
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
255,000$
Line Item Description
Professional Liability Insurance
Accounting/Bookkeeping
NET PROGRAM COST:
PROGRAM FUNDING SOURCES
255,000$ TOTAL PROGRAM EXPENSES
TOTAL PROGRAM FUNDING SOURCES:255,000$
-$
FIXED ASSETS EXPENSES TOTAL
ADMINISTRATIVE EXPENSES TOTAL
MHSA TOTAL
SPECIAL EXPENSES TOTAL:
External Audit
Line Item Description
Suicide Prevention Follow-Up Call Program
MHSA Program Name
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Administrative Overhead
Consultant (Network & Data Management)
Furniture & Fixtures
Line Item Description
Exhibit C
Page 3 of 12
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES & BENEFITS 188,262
Employee Salaries 148,238
1101 Executive Director 790 $6,583/month x 12 months x 0.01 FTE = $790 Position will provide agency specific
staff oversight and represent and maintain the collaborative relationship between
agencies.
1102 Executive Director Assistant 252 $2,100/month x 12 months x 0.01 FTE = $252 This position will assist Executive
Director with staff oversight and representing and maintaining the collaborative
relationship between agencies.
1103 Regional Director 1,297 $10,808/month x 12 months x 0.01 FTE = $1,297 Provide program management
and direction. Ensures operations are running smoothly and in compliance with
contract requirements.
1104 Program Manager 5,499 $9,165/month x 12 months x 0.05 FTE = $5,499 Provides supervision of all staff and
direct oversight of program management. Program Manager to provide clinical
support to individuals served as needed.
1105 Counselor 140,400 2 Follow-up Counselors at $4,680/mon. x 12 months x 100% FTE = $56,160 1
Follow-up Counselor at $4,680/mon. x 12 months x 50% FTE = $28,080 This
position will contact referred clients via telephone to conduct follow up counseling
services to support client post suicidal crisis. Provide suicide telephone intervention
and counseling if they are in crisis. Conduct safety assessments during each
intervention and create or review existing safety plan. The intent is to prevent
recidivism, re-hospitalizations, or crisis stabilization via counseling and support. This
position will also conduct presentations and trainings to our stakeholder partners of
the counties we serve regarding the follow up innovation plan.
Employee Benefits 26,164
1101 Retirement 2,298 Cost of 401K @ $148,238 total salaries x 1.55 (%)= $2,298
1102 Worker's Compensation 3,706 Workers Comp Insurance @ $148,238 total salaries x 2.5 (%)= $3,706
1103 Health Insurance 20,160 Cost of Medical, Vision, Dental, Life and Long Term Disability Insurance @ $148,238
total salaries x 13.6 (%)= $20,160
Payroll Taxes & Expenses:13,860
1201 OASDI -
1202 FICA/MEDICARE 11,340 FICA/MEDICARE @ $148,238 total salaries x 7.65 (%) = $11,340
1203 SUI 2,520 Cost of SUI @ $148,238 total salaries x 1.70 (%)= $2,520
3000: OPERATING EXPENSES 8,859
3001 Telecommunications 4,265 Cost of landline telephone services, cell phones service, data connectivity. Estimate
at $355.42/month x 12 months $4,265.
3002 Printing/Postage 670 Anticipating courier services and postage necessary for program. Business cards and
other special printing services. Estimate at $55.83 a month x 12 months = $670
3003 Office Supplies & Equipment 924 Includes desk supplies & minor equipment used by staff in the course of providing
services. Estimates at $77 a month x 12 months = $924
3004 Advertising -
3005 Staff Development & Training 1,500 Cost of continuation of staff development and training. Estimates at $125 a month x
12 months = $1,500
3006 Staff Mileage 1,000 Reimbursements to staff for personal vehicle use require to conduct presentations
and trainings to other agencies or other program needs, paid at IRS rate. Any travel
transportation fees, such as parking fees. Estimates 148.81 miles monthly x 12
months x .56/mile = $1,000
3007 Subscriptions & Memberships -
3008 Vehicle Maintenance -
3009 Other (Staff Recruitment)500 Thorough background check and drug testing.
Kings View Corporation
SUICIDE PREVENTION FOLLOW-UP CALL PROGRAM
Effective Upon Execution - June 30, 2022 Budget Narrative
Exhibit C
Page 4 of 12
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
4000: FACILITIES & EQUIPMENT 13,630
4001 Building Maintenance 3,330 Shared cost of copier maintenance, inspection services, pest control, alarm services,
janitorial services, facility supplies, and minor building repairs and maintenance.
$277.50/month x 12 months = $3,330
4002 Rent/Lease Building 7,800 Shared cost of building space lease. $650/month x 12 months = $7,800
4003 Rent/Lease Equipment 700 Shared cost of copier leases. $58.33/month x 12 months = $700
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities 1,800 Shared cost of gas and electric. $150/month x 12 months = $1,800
5000: SPECIAL EXPENSES 8,637
5001 Consultant (Network & Data Management)8,637 Kings View Information Technology Department (KVIT) will provide hardware and
software support for successful data collection. Information services and
management consisting of management of internet service provider, network and
desktop management, project management, technology procurement,
telecommunication management, strategic technology planning, system
documentation, application/data hosting, access to data, documents and
applications 24/7. After hours support via email and phone 24/7. Estimates at
$719.75 per month x 12 months = $8,637
6000: ADMINISTRATIVE EXPENSES 27,202
6001 Administrative Overhead 23,182 Expenses provides corporate management, fiscal services, payroll, human resources,
accounts payable and other administrative functions. Administrative Costs are
below 15% of direct costs. $27,202 + $2,972= $30,174 $255,000-$30,174=
$224,826 $30,174/$224,826= 13%
6002 Professional Liability Insurance 3,840 Cost general and professional liability insurance. $320/month x 12 months = $3,840
6003 Accounting/Bookkeeping -
6004 External Audit -
6005 Insurance (Liability):180 Cost of personal property and accidental insurance. $15/month x 12 months = $180.
7000: FIXED ASSETS 8,410
7001 Computer Equipment & Software 6,910 Anticipating additional computer equipment needed for new staff and or
replacement. Duo factor licensing and other computer software necessary to
provide services. Estimate $230.33 a month x 12 months x 2.5 FTE = $6,910
7002 Copiers, Cell Phones, Tablets, Devices to
Contain HIPAA Data
-
7003 Furniture & Fixtures 1,500 Anticipating additional furniture cost for new staff and or replacement or shared
cost for replacement needs. 2.5 FTE x $600 estimate = $1,500
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE:255,000
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE:255,000
-
Exhibit C
Page 5 of 12
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Executive Director 0.01 813$ -$ 813$
1102 Executive Director Assistant 0.01 259 - 259
1103 Regional Director 0.01 1,336 - 1,336
1104 Program Manager 0.05 - 5,665 5,665
1105 Counselor 2.50 - 144,612 144,612
Personnel Salaries Subtotal 2.57 2,408$ 150,277$ 152,685$
Employee Benefits
Acct #Admin Direct Total
1101 38$ 2,329$ 2,367$
1102 60 3,757 3,817
1103 327 20,438 20,765
425$ 26,524$ 26,949$
0.161408952
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1201 -$ -$ -$
1202 184 11,496 11,680
1203 41 2,555 2,596
225$ 14,051$ 14,276$
3,058$ 190,852$ 193,910$
3000: OPERATING EXPENSES
Acct #Amount
3001 4,350$
3002 670
3003 975
3004 -
3005 1,500
3006 1,000
3007 -
3008 -
3009 500
8,995$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 3,330$
4002 7,800
4003 700
4004 -
4005 -
4006 1,800
13,630$
Retirement
Worker's Compensation
Health Insurance
SUICIDE PREVENTION FOLLOW-UP CALL PROGRAM
Kings View Corporation
Fiscal Year (FY 2022-23)
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Description
Payroll Taxes & Expenses Subtotal:
EMPLOYEE SALARIES & BENEFITS TOTAL:
Employee Benefits Subtotal:
Employee Benefits %:
Description
OASDI
FICA/MEDICARE
SUI
Telecommunications
Printing/Postage
Office Supplies & Equipment
Advertising
Staff Development & Training
Staff Mileage
Line Item Description
OPERATING EXPENSES TOTAL:
Line Item Description
Building Maintenance
Rent/Lease Building
Rent/Lease Equipment
Rent/Lease Vehicles
Subscriptions & Memberships
Vehicle Maintenance
Other (Staff Recruitment)
FACILITIES/EQUIPMENT TOTAL:
Security
Utilities
Exhibit C
Page 6 of 12
5000: SPECIAL EXPENSES
Acct #Amount
5001 8,637$
8,637$
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 23,182$
6002 3,840
6003 -
6004 -
6005 Insurance (Liability):180
27,202$
7000: FIXED ASSETS
Acct #Amount
7001 2,126$
7002 -
7003 500
2,626$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports -$
8302 PEI - Prevention & Early Intervention -
8303 INN - Innovations 255,000
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
255,000$
Line Item Description
Consultant (Network & Data Management)
Administrative Overhead
Professional Liability Insurance
Accounting/Bookkeeping
External Audit
SPECIAL EXPENSES TOTAL:
Line Item Description
Line Item Description
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
ADMINISTRATIVE EXPENSES TOTAL
PROGRAM FUNDING SOURCES
FIXED ASSETS EXPENSES TOTAL
TOTAL PROGRAM EXPENSES 255,000$
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
MHSA Program Name
Suicide Prevention Follow-Up Call Program
TOTAL PROGRAM FUNDING SOURCES:255,000$
NET PROGRAM COST: -$
MHSA TOTAL
Exhibit C
Page 7 of 12
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES & BENEFITS 193,910
Employee Salaries 152,685
1101 Executive Director 813 $6,775/month x 12 months x 0.01 FTE = $813 Position will provide agency specific
staff oversight and represent and maintain the collaborative relationship between
agencies.
1102 Executive Director Assistant 259 $2,158.33/month x 12 months x 0.01 FTE = $259 This position will assist Executive
Director with staff oversight and representing and maintaining the collaborative
relationship between agencies.
1103 Regional Director 1,336 $11,133.33/month x 12 months x 0.01 FTE = $1,336 Provide program management
and direction. Ensures operations are running smoothly and in compliance with
contract requirements.
1104 Program Manager 5,665 $9,441.67/month x 12 months x 0.05 FTE = $5,665 Provides supervision of all staff
and direct oversight of program management. Program Manager to provide clinical
support to individuals served as needed.
1105 Counselor 144,612 2 Follow-up Counselors at $4,820.40/mon. x 12 months x 100% FTE = $57,844.80; 1
Follow-up Counselor at $4,820.40/mon. x 12 months x 50% FTE = $28,922.40 This
position will contact referred clients via telephone to conduct follow up counseling
services to support client post suicidal crisis. Provide suicide telephone intervention
and counseling if they are in crisis. Conduct safety assessments during each
intervention and create or review existing safety plan. The intent is to prevent
recidivism, re-hospitalizations, or crisis stabilization via counseling and support. This
position will also conduct presentations and trainings to our stakeholder partners of
the counties we serve regarding the follow up innovation plan.
Employee Benefits 26,949
1101 Retirement 2,367 Cost of 401K @ $152,685 total salaries x 1.55 (%)= $2,298
1102 Worker's Compensation 3,817 Workers Comp Insurance @ $152,685 total salaries x 2.5 (%)= $3,706
1103 Health Insurance 20,765 Cost of Medical, Vision, Dental, Life and Long Term Disability Insurance @ $152,685
total salaries x 13.6 (%)= $20,160
Payroll Taxes & Expenses:14,276
1201 OASDI -
1202 FICA/MEDICARE 11,680 Cost of FICA/Medicare @ $152,685 total salaries x 7.65 (%)= $11,340
1203 SUI 2,596 Cost of SUI @ $152,685 total salaries x 1.70 (%)= $2,520
3000: OPERATING EXPENSES 8,995
3001 Telecommunications 4,350 Cost of landline telephone services, cell phones service, data connectivity. Estimate
at $362.50/month x 12 months $4,350
3002 Printing/Postage 670 Anticipating courier services and postage necessary for program. Business cards and
other special printing services. Estimate at $55.83 a month x 12 months = $670
3003 Office Supplies & Equipment 975 Includes desk supplies & minor equipment used by staff in the course of providing
services. Estimates at $81.25 a month x 12 months = $975
3004 Advertising -
3005 Staff Development & Training 1,500 Cost of continuation of staff development and training. Estimates at $125 a month x
12 months = $1,500
3006 Staff Mileage 1,000 Reimbursements to staff for personal vehicle use require to conduct presentations
and trainings to other agencies or other program needs, paid at IRS rate. Any travel
transportation fees, such as parking fees. Estimates 148.81 miles monthly x 12
months x .56/mile = $1,000
3007 Subscriptions & Memberships -
3008 Vehicle Maintenance -
3009 Other (Staff Recruitment)500 Thorough background check and drug testing.
SUICIDE PREVENTION FOLLOW-UP CALL PROGRAM
Kings View Corporation
Fiscal Year (FY 2022-23) Budget Narrative
Exhibit C
Page 8 of 12
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
4000: FACILITIES & EQUIPMENT 13,630
4001 Building Maintenance 3,330 Shared cost of copier maintenance, inspection services, pest control, alarm services,
janitorial services, facility supplies, and minor building repairs and maintenance.
$277.50/month x 12 months = $3,330
4002 Rent/Lease Building 7,800 Shared cost of building space lease. $650/month x 12 months = $7,800
4003 Rent/Lease Equipment 700 Shared cost of copier leases. $58.33/month x 12 months = $700
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities 1,800 Shared cost of gas and electric. $150/month x 12 months = $1,800
5000: SPECIAL EXPENSES 8,637
5001 Consultant (Network & Data Management)8,637 Kings View Information Technology Department (KVIT) will provide hardware and
software support for successful data collection. Information services and
management consisting of management of internet service provider, network and
desktop management, project management, technology procurement,
telecommunication management, strategic technology planning, system
documentation, application/data hosting, access to data, documents and
applications 24/7. After hours support via email and phone 24/7. Estimates at
$719.75 per month x 12 months = $8,637
6000: ADMINISTRATIVE EXPENSES 27,202
6001 Administrative Overhead 23,182 Expenses provides corporate management, fiscal services, payroll, human resources,
accounts payable and other administrative functions. Administrative Costs are
below 15% of direct costs. $27,202 + $3,058= $30,260 $255,000-$30,260=
$224,740 $30,260/$224,740= 13%
6002 Professional Liability Insurance 3,840 Cost general and professional liability insurance. $320/month x 12 months = $3,840
6003 Accounting/Bookkeeping -
6004 External Audit -
6005 Insurance (Liability):180 Cost of personal property and accidental insurance. $15/month x 12 months = $180
7000: FIXED ASSETS 2,626
7001 Computer Equipment & Software 2,126 Anticipating additional computer equipment neededs and or replacement. Duo
factor licensing and other computer software necessary to provide services.
Estimate $70.87 monthly x 12 month x 2.5 FTE = $2,126
7002 Copiers, Cell Phones, Tablets, Devices to
Contain HIPAA Data
-
7003 Furniture & Fixtures 500 Anticipating additional furniture needs and or replacement or shared cost for
replacement needs. 2.5 FTE x $200 estimate = $500
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE:255,000
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE:255,000
-
Exhibit C
Page 9 of 12
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Executive Director 0.01 838$ -$ 838$
1102 Executive Director Assistant 0.01 267 - 267
1103 Regional Director 0.01 1,376 - 1,376
1104 Program Manager 0.05 - 5,835 5,835
1105 Counselor 2.50 - 148,950 148,950
Personnel Salaries Subtotal 2.57 2,481$ 154,785$ 157,266$
Employee Benefits
Acct #Admin Direct Total
1101 39$ 2,399$ 2,438$
1102 62 3,870 3,932
1103 337 21,051 21,388
438$ 27,320$ 27,758$
0.161411874
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1201 -$ -$ -$
1202 190 11,841 12,031
1203 42 2,631 2,673
232$ 14,472$ 14,704$
3,151$ 196,577$ 199,728$
3000: OPERATING EXPENSES
Acct #Amount
3001 4,350$
3002 400
3003 403
3004 -
3005 250
3006 700
3007 -
3008 -
3009 250
6,353$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 2,380$
4002 7,800
4003 700
4004 -
4005 -
4006 1,800
12,680$
Retirement
Worker's Compensation
Health Insurance
SUICIDE PREVENTION FOLLOW-UP CALL PROGRAM
Kings View Corporation
Fiscal Year (FY 2023-24)
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Description
Payroll Taxes & Expenses Subtotal:
EMPLOYEE SALARIES & BENEFITS TOTAL:
Employee Benefits Subtotal:
Employee Benefits %:
Description
OASDI
FICA/MEDICARE
SUI
Telecommunications
Printing/Postage
Office Supplies & Equipment
Advertising
Staff Development & Training
Staff Mileage
Line Item Description
OPERATING EXPENSES TOTAL:
Line Item Description
Building Maintenance
Rent/Lease Building
Rent/Lease Equipment
Rent/Lease Vehicles
Subscriptions & Memberships
Vehicle Maintenance
Other (Staff Recruitment)
FACILITIES/EQUIPMENT TOTAL:
Security
Utilities
Exhibit C
Page 10 of 12
5000: SPECIAL EXPENSES
Acct #Amount
5001 8,637$
8,637$
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 23,182$
6002 3,840
6003 -
6004 -
6005 Insurance (Liability):180
27,202$
7000: FIXED ASSETS
Acct #Amount
7001 300$
7002 -
7003 100
400$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports -$
8302 PEI - Prevention & Early Intervention -
8303 INN - Innovations 255,000
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
255,000$
Line Item Description
Consultant (Network & Data Management)
Administrative Overhead
Professional Liability Insurance
Accounting/Bookkeeping
External Audit
SPECIAL EXPENSES TOTAL:
Line Item Description
Line Item Description
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
ADMINISTRATIVE EXPENSES TOTAL
PROGRAM FUNDING SOURCES
FIXED ASSETS EXPENSES TOTAL
TOTAL PROGRAM EXPENSES 255,000$
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
MHSA Program Name
Suicide Prevention Follow-Up Call Program
TOTAL PROGRAM FUNDING SOURCES:255,000$
NET PROGRAM COST: -$
MHSA TOTAL
Exhibit C
Page 11 of 12
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES & BENEFITS 199,728
Employee Salaries 157,266
1101 Executive Director 838 $6,983.33/month x 12 months x 0.01 FTE = $838 Position will provide agency
specific staff oversight and represent and maintain the collaborative relationship
between agencies.
1102 Executive Director Assistant 267 $2,225/month x 12 months x 0.01 FTE = $267 This position will assist Executive
Director with staff oversight and representing and maintaining the collaborative
relationship between agencies.
1103 Regional Director 1,376 $11,466.67/month x 12 months x 0.01 FTE = $1,376 Provide program management
and direction. Ensures operations are running smoothly and in compliance with
contract requirements.
1104 Program Manager 5,835 $9,724.92/month x 12 months x 0.05 FTE = $5,835 Provides supervision of all staff
and direct oversight of program management. Program Manager to provide clinical
support to individuals served as needed.
1105 Counselor 148,950 2 Follow-up Counselors at $4,965/mon. x 12 months x 100% FTE = $59,580; 1 Follow-
up Counselor at $4,965/mon. x 12 months x 50% FTE = $29,790 This position will
contact referred clients via telephone to conduct follow up counseling services to
support client post suicidal crisis. Provide suicide telephone intervention and
counseling if they are in crisis. Conduct safety assessments during each intervention
and create or review existing safety plan. The intent is to prevent recidivism, re-
hospitalizations, or crisis stabilization via counseling and support. This position will
also conduct presentations and trainings to our stakeholder partners of the counties
we serve regarding the follow up innovation plan.
Employee Benefits 27,758
1101 Retirement 2,438 Cost of 401K @ $157,266 total salaries x 1.55 (%)= $2,298
1102 Worker's Compensation 3,932 Workers Comp Insurance @ $157,266 total salaries x 2.5 (%)= $3,706
1103 Health Insurance 21,388 Cost of Medical, Vision, Dental, Life and Long Term Disability Insurance @ $157,266
total salaries x 13.6 (%)= $20,160
Payroll Taxes & Expenses:14,704
1201 OASDI -
1202 FICA/MEDICARE 12,031 Cost of FICA/Medicare @ $157,266 total salaries x 7.65 (%)= $11,340
1203 SUI 2,673 Cost of SUI @ $157,266 total salaries x 1.70 (%)= $2,520
3000: OPERATING EXPENSES 6,353
3001 Telecommunications 4,350 Cost of landline telephone services, cell phones service, data connectivity. Estimate
at $362.50/month x 12 months $4,350
3002 Printing/Postage 400 Anticipating courier services and postage necessary for program. Business cards and
other special printing services. Estimate at $33.33 a month x 12 months = $400
3003 Office Supplies & Equipment 403 Includes desk supplies & minor equipment used by staff in the course of providing
services. Estimates at $33.58 a month x 12 months = $403
3004 Advertising -
3005 Staff Development & Training 250 Cost of continuation of staff development and training. Estimate at $20.83 per
month x 12 months = $250
3006 Staff Mileage 700 Reimbursements to staff for personal vehicle use require to conduct presentations
and trainings to other agencies or other program needs, paid at IRS rate. Any travel
transportation fees, such as parking fees. Estimates 104.17 miles monthly x 12
months x .56/mile = $700
3007 Subscriptions & Memberships -
3008 Vehicle Maintenance -
3009 Other (Staff Recruitment)250 Thorough background check and drug testing.
SUICIDE PREVENTION FOLLOW-UP CALL PROGRAM
Kings View Corporation
Fiscal Year (FY 2023-24) Budget Narrative
Exhibit C
Page 12 of 12
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
4000: FACILITIES & EQUIPMENT 12,680
4001 Building Maintenance 2,380 Shared cost of copier maintenance, inspection services, pest control, alarm services,
janitorial services, facility supplies, and minor building repairs and maintenance.
$198.33/month x 12 months = $2,380
4002 Rent/Lease Building 7,800 Shared cost of building space lease. $650/month x 12 months = $7,800
4003 Rent/Lease Equipment 700 Shared cost of copier leases. $58.33/month x 12 months = $700
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities 1,800 Shared cost of gas and electric. $150/month x 12 months = $1,800
5000: SPECIAL EXPENSES 8,637
5001 Consultant (Network & Data Management)8,637 Kings View Information Technology Department (KVIT) will provide hardware and
software support for successful data collection. Information services and
management consisting of management of internet service provider, network and
desktop management, project management, technology procurement,
telecommunication management, strategic technology planning, system
documentation, application/data hosting, access to data, documents and
applications 24/7. After hours support via email and phone 24/7. Estimates at
$719.75 per month x 12 months = $8,637
6000: ADMINISTRATIVE EXPENSES 27,202
6001 Administrative Overhead 23,182 Expenses provides corporate management, fiscal services, payroll, human resources,
accounts payable and other administrative functions. Administrative Costs are
below 15% of direct costs. $27,202 + $3,151= $30,353 $255,000-$30,353=
$224,647 $30,353/$224,647= 13%
6002 Professional Liability Insurance 3,840 Cost general and professional liability insurance. $320/month x 12 months = $3,840
6003 Accounting/Bookkeeping -
6004 External Audit -
6005 Insurance (Liability):180 Cost of personal property and accidental insurance. $15/month x 12 months = $180
7000: FIXED ASSETS 400
7001 Computer Equipment & Software 300 Anticipating additional computer equipment neededs and or replacement. Duo
factor licensing and other computer software necessary to provide services.
Estimates at $25 a month x 12 months = $300
7002 Copiers, Cell Phones, Tablets, Devices to
Contain HIPAA Data
-
7003 Furniture & Fixtures 100 Anticipating additional furniture needs and or replacement or shared cost for
replacement needs. 2.5 FTE x $40 estimate = $100
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE:255,000
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE:255,000
-
Exhibit D - Page 1 of 6
STATE MENTAL HEALTH REQUIREMENTS
1.CONTROL REQUIREMENTS
The COUNTY and its subcontractors shall provide services in accordance with all
applicable Federal and State statutes and regulations.
2.PROFESSIONAL LICENSURE
All (professional level) persons employed by the COUNTY Mental Health
Program (directly or through contract) providing Short-Doyle/Medi-Cal services
have met applicable professional licensure requirements pursuant to Business
and Professions and Welfare and Institutions Codes.
3.CONFIDENTIALITY
CONTRACTOR shall conform to and COUNTY shall monitor compliance with all
State of California and Federal statutes and regulations regarding confidentiality,
including but not limited to confidentiality of information requirements at 42, Code
of Federal Regulations sections 2.1 et seq; California Welfare and Institutions
Code, sections 14100.2, 11977, 11812, 5328; Division 10.5 and 10.6 of the
California Health and Safety Code; Title 22, California Code of Regulations,
section 51009; and Division 1, Part 2.6, Chapters 1-7 of the California Civil Code.
4.NON-DISCRIMINATION
A.Eligibility for Services
CONTRACTOR shall prepare and make available to COUNTY and to the
public all eligibility requirements to participate in the program plan set
forth in the Agreement. No person shall, because of ethnic group
identification, age, gender, color, disability, medical condition, national
origin, race, ancestry, marital status, religion, religious creed, political
belief or sexual preference be excluded from participation, be denied
benefits of, or be subject to discrimination under any program or activity
receiving Federal or State of California assistance.
B.Employment Opportunity
CONTRACTOR shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices. Such practices include retirement, recruitment
advertising, hiring, layoff, termination, upgrading, demotion, transfer, rates
of pay or other forms of compensation, use of facilities, and other terms
and conditions of employment.
Exhibit D - Page 2 of 6
C.Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all further
funds, until CONTRACTOR can show clear and convincing evidence to
the satisfaction of COUNTY that funds provided under this Agreement
were not used in connection with the alleged discrimination.
D.Nepotism
Except by consent of COUNTY’s Department of Behavioral Health
Director, or designee, no person shall be employed by CONTRACTOR
who is related by blood or marriage to, or who is a member of the Board
of Directors or an officer of CONTRACTOR.
5.PATIENTS' RIGHTS
CONTRACTOR shall comply with applicable laws and regulations, including but
not limited to, laws, regulations, and State policies relating to patients' rights.
STATE CONTRACTOR CERTIFICATION CLAUSES
1.STATEMENT OF COMPLIANCE: CONTRACTOR has, unless exempted,
complied with the non-discrimination program requirements. (Gov. Code§ 12990 (a-f)
and CCR, Title 2, Section 111 02) (Not applicable to public entities.)
2.DRUG-FREE WORKPLACE REQUIREMENTS: CONTRACTOR will comply
with the requirements of the Drug-Free Workplace Act of 1990 and will provide a drug-
free workplace by taking the following actions:
a.Publish a statement notifying employees that unlawful manufacture,
distribution, dispensation, possession or use of a controlled substance is prohibited and
specifying actions to be taken against employees for violations.
b.Establish a Drug-Free Awareness Program to inform employees about:
1)the dangers of drug abuse in the workplace;
2)the person's or organization's policy of maintaining a drug-free
workplace;
3)any available counseling, rehabilitation and employee assistance
programs; and,
4)penalties that may be imposed upon employees for drug abuse
violations.
c.Every employee who works on this Agreement will:
1)receive a copy of the company's drug -free workplace policy
statement; and,
2)agree to abide by the terms of the company's statement as a
condition of employment on this Agreement.
Exhibit D - Page 3 of 6
Failure to comply with these requirements may result in suspension of payments under
this Agreement or termination of this Agreement or both and CONTRACTOR may be
ineligible for award of any future State agreements if the department determines that any
of the following has occurred: the CONTRACTOR has made false certification, or
violated the certification by failing to carry out the requirements as noted above. (Gov.
Code §8350 et seq.)
3.NATIONAL LABOR RELATIONS BOARD CERTIFICATION: CONTRACTOR
certifies that no more than one (1) final unappealable finding of contempt of court by a
Federal court has been issued against CONTRACTOR within the immediately preceding
two (2) year period because of CONTRACTOR’s failure to comply with an order of a
Federal court, which orders CONTRACTOR to comply with an order of the National
Labor Relations Board. (Pub. Contract Code §10296) (Not applicable to public entities.)
4.CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO
REQUIREMENT: CONTRACTOR hereby certifies that CONTRACTOR will comply with
the requirements of Section 6072 of the Business and Professions Code, effective
January 1, 2003.
CONTRACTOR agrees to make a good faith effort to provide a minimum number of
hours of pro bono legal services during each year of the contract equal to the lessor of
30 multiplied by the number of full time attorneys in the firm’s offices in the State, with
the number of hours prorated on an actual day basis for any contract period of less than
a full year or 10% of its contract with the State.
Failure to make a good faith effort may be cause for non-renewal of a state contract for
legal services, and may be taken into account when determining the award of future
contracts with the State for legal services.
5.EXPATRIATE CORPORATIONS: CONTRACTOR hereby declares that it is not
an expatriate corporation or subsidiary of an expatriate corporation within the meaning of
Public Contract Code Section 10286 and 10286.1, and is eligible to contract with the
State of California.
6.SWEATFREE CODE OF CONDUCT:
a.All CONTRACTORS contracting for the procurement or laundering of
apparel, garments or corresponding accessories, or the procurement of equipment,
materials, or supplies, other than procurement related to a public works contract, declare
under penalty of perjury that no apparel, garments or corresponding accessories,
equipment, materials, or supplies furnished to the state pursuant to the contract have
been laundered or produced in whole or in part by sweatshop labor, forced labor, convict
labor, indentured labor under penal sanction, abusive forms of child labor or exploitation
of children in sweatshop labor, or with the benefit of sweatshop labor, forced labor,
convict labor, indentured labor under penal sanction, abusive forms of child labor or
exploitation of children in sweatshop labor. CONTRACTOR further declares under
penalty of perjury that they adhere to the Sweatfree Code of Conduct as set forth on the
California Department of Industrial Relations website located at www.dir.ca.gov, and
Public Contract Code Section 6108.
Exhibit D - Page 4 of 6
b.CONTRACTOR agrees to cooperate fully in providing reasonable access
to the CONTRACTOR’s records, documents, agents or employees, or premises if
reasonably required by authorized officials of the contracting agency, the Department of
Industrial Relations, or the Department of Justice to determine the contractor’s
compliance with the requirements under paragraph (a).
7.DOMESTIC PARTNERS: For contracts of $100,000 or more, CONTRACTOR
certifies that CONTRACTOR is in compliance with Public Contract Code Section
10295.3.
8.GENDER IDENTITY: For contracts of $100,000 or more, CONTRACTOR
certifies that CONTRACTOR is in compliance with Public Contract Code Section
10295.35.
DOING BUSINESS WITH THE STATE OF CALIFORNIA
The following laws apply to persons or entities doing business with the State of
California.
1.CONFLICT OF INTEREST: CONTRACTOR needs to be aware of the following
provisions regarding current or former state employees. If CONTRACTOR has any
questions on the status of any person rendering services or involved with this
Agreement, the awarding agency must be contacted immediately for clarification.
Current State Employees (Pub. Contract Code §10410):
a). No officer or employee shall engage in any employment, activity or
enterprise from which the officer or employee receives compensation or has a financial
interest and which is sponsored or funded by any state agency, unless the employment,
activity or enterprise is required as a condition of regular state employment.
b). No officer or employee shall contract on his or her own behalf as an
independent contractor with any state agency to provide goods or services.
Former State Employees (Pub. Contract Code §10411):
a). For the two (2) year period from the date he or she left state employment,
no former state officer or employee may enter into a contract in which he or she
engaged in any of the negotiations, transactions, planning, arrangements or any part of
the decision-making process relevant to the contract while employed in any capacity by
any state agency.
b). For the twelve (12) month period from the date he or she left state
employment, no former state officer or employee may enter into a contract with any state
agency if he or she was employed by that state agency in a policy-making position in the
same general subject area as the proposed contract within the twelve (12) month period
prior to his or her leaving state service.
If CONTRACTOR violates any provisions of above paragraphs, such action by
CONTRACTOR shall render this Agreement void. (Pub. Contract Code §10420)
Exhibit D - Page 5 of 6
Members of boards and commissions are exempt from this section if they do not receive
payment other than payment of each meeting of the board or commission, payment for
preparatory time and payment for per diem. (Pub. Contract Code §10430 (e))
2.LABOR CODE/WORKERS' COMPENSATION: CONTRACTOR needs to be
aware of the provisions which require every employer to be insured against liability for
Worker's Compensation or to undertake self-insurance in accordance with the
provisions, and CONTRACTOR affirms to comply with such provisions before
commencing the performance of the work of this Agreement. (Labor Code Section 3700)
3.AMERICANS WITH DISABILITIES ACT: CONTRACTOR assures the State that
it complies with the Americans with Disabilities Act (ADA) of 1990, which prohibits
discrimination on the basis of disability, as well as all applicable regulations and
guidelines issued pursuant to the ADA. (42 U.S.C. 12101 et seq.)
4.CONTRACTOR NAME CHANGE: An amendment is required to change the
CONTRACTOR’s name as listed on this Agreement. Upon receipt of legal
documentation of the name change the State will process the amendment. Payment of
invoices presented with a new name cannot be paid prior to approval of said
amendment.
5.CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA:
a.When agreements are to be performed in the state by corporations, the
contracting agencies will be verifying that the CONTRACTOR is currently qualified to do
business in California in order to ensure that all obligations due to the state are fulfilled.
b."Doing business" is defined in R&TC Section 23101 as actively engaging
in any transaction for the purpose of financial or pecuniary gain or profit. Although there
are some statutory exceptions to taxation, rarely will a corporate contractor performing
within the state not be subject to the franchise tax.
c.Both domestic and foreign corporations (those incorporated outside of
California) must be in good standing in order to be qualified to do business in California.
Agencies will determine whether a corporation is in good standing by calling the Office of
the Secretary of State.
6.RESOLUTION: A county, city, district, or other local public body must provide
the State with a copy of a resolution, order, motion, or ordinance of the local governing
body, which by law has authority to enter into an agreement, authorizing execution of the
agreement.
7.AIR OR WATER POLLUTION VIOLATION: Under the State laws, the
CONTRACTOR shall not be: (1) in violation of any order or resolution not subject to
review promulgated by the State Air Resources Board or an air pollution control district;
(2) subject to cease and desist order not subject to review issued pursuant to Section
13301 of the Water Code for violation of waste discharge requirements or discharge
prohibitions; or (3) finally determined to be in violation of provisions of federal law
relating to air or water pollution.
Exhibit D - Page 6 of 6
8.PAYEE DATA RECORD FORM STD. 204: This form must be completed by all
contractors that are not another state agency or other governmental entity.
9.INSPECTION and Audit of Records and access to Facilities.
The State, CMS, the Office of the Inspector General, the Comptroller General, and their
designees may, at any time, inspect and audit any records or documents of
CONTRACTOR or its subcontractors, and may, at any time, inspect the premises,
physical facilities, and equipment where Medicaid-related activities or work is conducted.
The right to audit under this section exists for ten (10) years from the final date of the
contract period or from the date of completion of any audit, whichever is later.
Federal database checks.
Consistent with the requirements at § 455.436 of this chapter, the State must confirm the
identity and determine the exclusion status of CONTRACTOR, any subcontractor, as
well as any person with an ownership or control interest, or who is an agent or managing
employee of CONTRACTOR through routine checks of Federal databases. This
includes the Social Security Administration's Death Master File, the National Plan and
Provider Enumeration System (NPPES), the List of Excluded Individuals/Entities (LEIE),
the System for Award Management (SAM), and any other databases as the State or
Secretary may prescribe. These databases must be consulted upon contracting and no
less frequently than monthly thereafter. If the State finds a party that is excluded, it must
promptly notify the CONTRACTOR and take action consistent with § 438.610(c).
The State must ensure that CONTRACTOR with which the State contracts under this
part is not located outside of the United States and that no claims paid by a
CONTRACTOR to a network provider, out-of-network provider, subcontractor or financial
institution located outside of the U.S. are considered in the development of actuarially
sound capitation rates.
Exhibit E
Page 1 of 2
FFRREESSNNOO CCOOUUNNTTYY MMEENNTTAALL HHEEAALLTTHH PPLLAANN
GGRRIIEEVVAANNCCEESS AANNDD IINNCCIIDDEENNTT RREEPPOORRTTIINNGG
PPRROOTTOOCCOOLL FFOORR CCOOMMPPLLEETTIIOONN OOFF IINNCCIIDDEENNTT RREEPPOORRTT
The Incident Report must be completed for all incidents involving clients. The staff person
who becomes aware of the incident completes this form, and the supervisor co-signs it.
When more than one client is involved in an incident, a separate form must be completed
for each client.
Where the forms should be sent - within 24 hours from the time of the incident
Incident Report should be sent to:
DBH Program Supervisor
Exhibit E
Page 2 of 2
INCIDENT REPORT WORKSHEET
When did this happen? (date/time)Where did this happen?
Name/DMH #
1. Background information of the incident:
2. Method of investigation: (chart review, face-to-face interview, etc.)
Who was affected? (If other than consumer)
List key people involved. (witnesses, visitors, physicians, employees)
3. Preliminary findings: How did it happen? Sequence of events. Be specific. If attachments are needed write
comments on an 8 1/2 sheet of paper and attach to worksheet.
Outcome severity:Nonexistent inconsequential consequential death not applicable unknown
4. Response: a) corrective action, b) Plan of Action, c) other
Completed by (print name)
Completed by (signature)Date completed
Reviewed by Supervisor (print name)
Supervisor Signature Date
Vendor: Contract#
Item Make/Brand Model I Serial#
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Date Prepared:
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
Date Received:
Contact Person Contact#
.&.&.....I ......,.., I P I 1 ft I I� I Pr • I P P I L.I L.P: a I It l I P f
li !? Date Date Ill � EE Requested Approved ( Purchase Location "Cl Ill GI (If Fixed If Fixed Date c-GI GI ->C Cl) Asset) Assset) ii: I
X 3/27/2008 4/1/2008 4/10/2008 Heritage
X n/a n/a 4/1/2008 Heritage
Condition
New
New
Fresno
County
Exhibit F
Page 1 of 2
Inventory Cost
Number
$6,500.00
$450.00
Fi el d l'wnber
Header
Header
Header
Header
Header
Header
a
b
C
d
e
f
g
h
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k
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Fl XED �ET AND SENSI Tl VE I TEM TRACl<I NG
Field
Descr i pt i on
Vendor
Program
Contract #
Cont act Per son
Cont act #
Cate Prepared
I tern
Mike/ Brand
M>del
Seri al #
Fixed Asset
Sensi ti ve I t em
Cate Requested
Cate Approved
Purchase Cate
Location
Condition
Fresno County
I nvent or y
l\tlrrber
Cost
I nst r uct i on or Corment s
I ndi cat e the I egal narre of the agency contracted to
provide services.
Indicate the till e of the pr oj eel as described in the
contract v.i t h t he County.
Indicate the assigned County contract nurrber. I f not
know,, County staff can pr ovi de.
I ndi cat e the f i r st and I ast narre of the pr i rrar y agency
cont act for t he cont r act .
I ndi cat e the rrost appropriate telephone nurrber of the
pri rrary agency contact for the contract.
I ndi cat e the rrost current date that t he t r acki ng form
v.as corrpl eted by the vendor.
I dent i f y the i t em by pr ovi di ng a comronly recognized
descr i pt i on of the it em
I dent i f v the corrpany t hat rranufactured the
I dent i f y t he rrodel nurrber for the i tern i f
I dent i f y t he serial nurrber for the i tern i f
appl i cabl e.
Mir k t he box v.i t h an II X'I if the cost of the
$5,000 or rror e to i ndi cat e t hat the it em is
asset.
it em
appl i cabl e.
it em is
a fixed
Mir k the box v.i th an II X'I if the i t em rreet s t he
criteria of a sensi ti ve i t em as defined by the County.
Indicate the date that t he agency subni t t ed a request
to t he County to purchase t he i t em
Indicate the date that the County approved the request
to purchase the it em
Indicate the date the aqencv purchased the it em
I ndi cat e the phvsi cal I ocat ion of the it em
I ndi cat e the general condi t i on of the it em ( New, G:>od,
W>rn, Bad).
I ndi cat e the FR# provided by the County for the it em
I ndi cat e the tot al purchase price of the it em
including sales tax and other costs, such as shipping.
Exhibit F
Page 2 of 2
Required or
Condi t i onal
Required
Required
Required
Required
Required
Required
Required
Required
Condi t i onal
Condi t i onal
Condi t i onal
Condi t i onal
Required
Required
Required
Required
Required
Condi t i onal
Required
Exhibit
Page 1 of 2
Fresno County Mental Health Plan
Grievances
Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance
and appeal process and an expedited appeal process to resolve grievances and
disputes at the earliest and the lowest possible level.
Title 9 of the California Code of Regulations requires that the MHP and its fee-
for-service providers give verbal and written information to Medi-Cal beneficiaries
regarding the following:
How to access specialty mental health services
How to file a grievance about services
How to file for a State Fair Hearing
The MHP has developed a Consumer Guide, a beneficiary rights poster, a
grievance form, an appeal form, and Request for Change of Provider Form. All
of these beneficiary materials must be posted in prominent locations where Medi-
Cal beneficiaries receive outpatient specialty mental health services, including
the waiting rooms of providers’ offices of service.
Please note that all fee-for-service providers and contract agencies are required
to give their clients copies of all current beneficiary information annually at the
time their treatment plans are updated and at intake.
Beneficiaries have the right to use the grievance and/or appeal process without
any penalty, change in mental health services, or any form of retaliation. All
Medi-Cal beneficiaries can file an appeal or state hearing.
Grievances and appeals forms and self addressed envelopes must be available
for beneficiaries to pick up at all provider sites without having to make a verbal or
written request. Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 45003
Fresno, CA 93718-9886
(800) 654-3937 (for more information)
(559) 488-3055 (TTY)
Provider Problem Resolution and Appeals Process
The MHP uses a simple, informal procedure in identifying and resolving provider
concerns and problems regarding payment authorization issues, other
complaints and concerns.
Exhibit
Page 2 of 2
Informal provider problem resolution process – the provider may first speak to a
Provider Relations Specialist (PRS) regarding his or her complaint or concern.
The PRS will attempt to settle the complaint or concern with the provider. If the
attempt is unsuccessful and the provider chooses to forego the informal
grievance process, the provider will be advised to file a written complaint to the
MHP address (listed above).
Formal provider appeal process – the provider has the right to access the
provider appeal process at any time before, during, or after the provider problem
resolution process has begun, when the complaint concerns a denied or modified
request for MHP payment authorization, or the process or payment of a
provider’s claim to the MHP.
Payment authorization issues – the provider may appeal a denied or modified
request for payment authorization or a dispute with the MHP regarding the
processing or payment of a provider’s claim to the MHP. The written appeal
must be submitted to the MHP within 90 calendar days of the date of the receipt
of the non-approval of payment.
The MHP shall have 60 calendar days from its receipt of the appeal to inform the
provider in writing of the decision, including a statement of the reasons for the
decision that addresses each issue raised by the provider, and any action
required by the provider to implement the decision.
If the appeal concerns a denial or modification of payment authorization request,
the MHP utilizes a Managed Care staff who was not involved in the initial denial
or modification decision to determine the appeal decision.
If the Managed Care staff reverses the appealed decision, the provider will be
asked to submit a revised request for payment within 30 calendar days of receipt
of the decision
Other complaints – if there are other issues or complaints, which are not related
to payment authorization issues, providers are encouraged to send a letter of
complaint to the MHP. The provider will receive a written response from the
MHP within 60 calendar days of receipt of the complaint. The decision rendered
buy the MHP is final.
Exhibit H – Page 1 of 2
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I.Identifying Information
Name of entity D/B/A
Address (number, street) City State ZIP code
CLIA number Taxpayer ID number (EIN) Telephone number
( )
II.Answer the following questions by checking “Yes” or “No.” If any of the questions are answered “Yes,” list names and
addresses of individuals or corporations under “Remarks” on page 2. Identify each item number to be continued.
A.Are there any individuals or organizations having a direct or indirect ownership or control interest
of five percent or more in the institution, organizations, or agency that have been convicted of a criminal
offense related to the involvement of such persons or organizations in any of the programs established
YES NO
by Titles XVIII, XIX, or XX? ......................................................................................................................... ❒ ❒
B.Are there any directors, officers, agents, or managing employees of the institution, agency, or
organization who have ever been convicted of a criminal offense related to their involvement in such
programs established by Titles XVIII, XIX, or XX? ...................................................................................... ❒ ❒
C.Are there any individuals currently employed by the institution, agency, or organization in a managerial,
accounting, auditing, or similar capacity who were employed by the institution’s, organization’s, or
agency’s fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only) ........... ❒ ❒
III.A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling
interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names
and addresses under “Remarks” on page 2. If more than one individual is reported and any of these persons are
related to each other, this must be reported under “Remarks.”
NAME ADDRESS EIN
B.Type of entity: ❒ Sole proprietorship ❒Partnership ❒Corporation❒Unincorporated Associations ❒Other (specify)
C.If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations
under “Remarks.”
D.Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities?
(Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses
of individuals, and provider numbers. .......................................................................................................... ❒❒
NAME ADDRESS PROVIDER NUMBER
Exhibit H – Page 2 of 2
YES NO
IV. A. Has there been a change in ownership or control within the last year? ....................................................... ❒ ❒
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... ❒ ❒
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................ ❒ ❒
If yes, when?
V.Is the facility operated by a management company or leased in whole or part by another organization?.......... ❒ ❒
If yes, give date of change in operations.
VI.Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?......... ❒ ❒
VII. A. Is this facility chain affiliated? ...................................................................................................................... ❒ ❒
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
B.If the answer to question VII.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative (typed) Title
Signature Date
Remarks
Exhibit I - Page 1 of 2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1.By signing and submitting this proposal, the prospective primary participant is providing
the certification set out below.
2.The inability of a person to provide the certification required below will not necessarily
result in denial of participation in this covered transaction. The prospective participant shall
submit an explanation of why it cannot provide the certification set out below. The
certification or explanation will be considered in connection with the department or
agency's determination whether to enter into this transaction. However, failure of the
prospective primary participant to furnish a certification or an explanation shall disqualify
such person from participation in this transaction.
3.The certification in this clause is a material representation of fact upon which reliance was
placed when the department or agency determined to enter into this transaction. If it is
later determined that the prospective primary participant knowingly rendered an erroneous
certification, in addition to other remedies available to the Federal Government, the
department or agency may terminate this transaction for cause or default.
4.The prospective primary participant shall provide immediate written notice to the
department or agency to which this proposal is submitted if at any time the prospective
primary participant learns that its certification was erroneous when submitted or has
become erroneous by reason of changed circumstances.
5.The terms covered transaction, debarred, suspended, ineligible, participant, person,
primary covered transaction, principal, proposal, and voluntarily excluded, as used in this
clause, have the meanings set out in the Definitions and Coverage sections of the rules
implementing Executive Order 12549. You may contact the department or agency to which
this proposal is being submitted for assistance in obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment of a system
of records in order to render in good faith the certification required by this clause. The
knowledge and information of a participant is not required to exceed that which is normally
possessed by a prudent person in the ordinary course of business dealings.
CERTIFICATION
(1)The prospective primary participant certifies to the best of its knowledge and belief, that it,
its owners, officers, corporate managers and partners:
(a)Are not presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded by any Federal department or agency;
(b)Have not within a three-year period preceding this proposal been convicted of or had a
civil judgment rendered against them for commission of fraud or a criminal offense in
connection with obtaining, attempting to obtain, or performing a public (Federal, State
or local) transaction or contract under a public transaction; violation of Federal or State
antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;
Exhibit I - Page 2 of 2
(c)Have not within a three-year period preceding this application/proposal had one or
more public transactions (Federal, State or local) terminated for cause or default.
(2)Where the prospective primary participant is unable to certify to any of the statements in
this certification, such prospective participant shall attach an explanation to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or Company)
Exhibit J - Page 1 of 2
SELF-DE ALING TRANSAC TION 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 J - 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:
Exhibit K
Page 1 of
FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable laws,
regulations, rules and guidelines that apply to the provision and payment of mental health services.
Mental health contractors and the manner in which they conduct themselves are a vital part of this
commitment.
Fresno County has established this Contractor Code of Conduct and Ethics with which
contractor and its employees and subcontractors shall comply. Contractor shall require its employees
and subcontractors to attend a compliance training that will be provided by Fresno County. After
completion of this training, each contractor, contractor’s employee and subcontractor must sign the
Contractor Acknowledgment and Agreement form and return this form to the Compliance officer or
designee.
Contractor and its employees and subcontractor shall:
1. Comply with all applicable laws, regulations, rules or guidelines when providing and billing
for mental health services.
2. Conduct themselves honestly, fairly, courteously and with a high degree of integrity in their
professional dealing related to their contract with the County and avoid any conduct that could
reasonably be expected to reflect adversely upon the integrity of the County.
3. Treat County employees, consumers, and other mental health contractors fairly and with
respect.
4. NOT engage in any activity in violation of the County’s Compliance Program, nor engage in
any other conduct which violates any applicable law, regulation, rule or guideline
5. Take precautions to ensure that claims are prepared and submitted accurately, timely and are
consistent with all applicable laws, regulations, rules or guidelines.
6. Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or reimbursement
of any kind are submitted.
7. Bill only for eligible services actually rendered and fully documented. Use billing codes that
accurately describe the services provided.
Exhibit K
Page 2 of
8. Act promptly to investigate and correct problems if errors in claims or billing are discovered.
9. Promptly report to the Compliance Officer any suspected violation(s) of this Code of Conduct
and Ethics by County employees or other mental health contractors, or report any activity that
they believe may violate the standards of the Compliance Program, or any other applicable
law, regulation, rule or guideline. Fresno County prohibits retaliation against any person
making a report. Any person engaging in any form of retaliation will be subject to disciplinary
or other appropriate action by the County. Contractor may report anonymously.
10. Consult with the Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law, regulation, rule or guideline.
11. Immediately notify the Compliance Officer if they become or may become an Ineligible person
and therefore excluded from participation in the Federal Health Care Programs.