HomeMy WebLinkAboutAgreement A-21-328 with Westside Family.pdfCOUNTY OF FRESNO
Fresno, CA
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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 Westside Family Preservation Services Network, a private non-profit
California organization, whose business address is 16856 4th St, Huron California 93234, 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), Mental Health
Services Act (MHSA), Prevention and Early Intervention (PEI) component, and through input from the
MHSA community stakeholder process, recognizes the need to provide wellness and recovery support
services to children and transitional aged youth through Youth Empowerment Centers; and
WHEREAS, COUNTY, through its DBH, is a Mental Health Plan (MHP), as defined in Title 9 of
the California Code of Regulations (CCR), section 1810.226; and
WHEREAS, CONTRACTOR is qualified and willing to to provide said services 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 the Scope of Work, attached hereto as Exhibit A and incorporated herein by reference.
B.CONTRACTOR shall also perform all services and fulfill all responsibilities as
specified in COUNTY’s Request for Proposal (RFP) No. 21-040 dated March 4, 2021, Addendum No.
One (1) to COUNTY’s RFP No. 21-040 dated March 26, 2021, collectively referred to herein as
COUNTY’s Revised RFP, and CONTRACTOR’s response to said Revised RFP dated April 9, 2021; all
incorporated herein by reference and made part of this Agreement. In the event of any inconsistency
among these documents, the inconsistency shall be resolved by giving precedence in the following
order of priority: (1) to this Agreement, including all Exhibits; (2) to the Revised RFP; and (3) to the
CONTRACTOR’s Response to the Revised RFP. A copy of COUNTY’s Revised RFP No. 21-040 and
24th August
Agreement No. 21-328
COUNTY OF FRESNO
Fresno, CA
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CONTRACTOR’s response thereto shall be retained and made available during the term of this
Agreement by COUNTY’s DBH.
C. CONTRACTOR shall align programs, services, and practices with the vision,
mission, and guiding principles of the COUNTY’s DBH, as further described in Exhibit B “Guiding
Principles of Care Delivery”, attached hereto and by this reference incorporated herein and made part of
this Agreement.
D. CONTRACTOR shall provide tracking tools and measurements for effectiveness,
efficiency, and client satisfaction indicators as required by Commission on Accreditation of Rehabilitation
Facilities (CARF) standards and as further detailed in Exhibit A.
C. Any change to CONTRACTOR’s location of the service site(s) may be made only
upon sixty (60) days advance written notification to COUNTY’s DBH Director and upon written approval
from the COUNTY’s DBH Director or designee.
D. CONTRACTOR agrees that prior to providing services under the terms and
conditions of this Agreement, it shall have appropriate staff hired and in place for program services and
operations or COUNTY may, in addition to other remedies it may have, suspend referrals or terminate
this Agreement in accordance with Section Three (3) of this Agreement.
E. It is acknowledged by all parties hereto that COUNTY's DBH shall monitor the
services provided by CONTRACTOR, in accordance with Section Fourteen (14) of this Agreement.
F. CONTRACTOR shall participate in periodic workgroup meetings consisting of staff
from COUNTY's DBH to discuss service requirements, data reporting, outcomes measurement, training,
policies and procedures, overall program operations, and any problems or foreseeable problems that may
arise.
G. It is mutually agreed by all parties to this Agreement, that the program funded
under this Agreement shall be identified and subsequently named/branded through the review and
approval of COUNTY’s DBH Director or designee. All print or media materials, including program
branding and program references shall be reviewed and approved by the COUNTY’S DBH Director or
designee. The program funded under this Agreement shall be identified as a “County of Fresno,
Department of Behavioral Health funded program”, and operated by the CONTRACTOR under the
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terms and conditions of this Agreement.
2. TERM
The term of this Agreement shall be effective September 1, 2021 throughout and
including June 30, 2024.
This Agreement may be extended for two (2) additional consecutive twelve (12) month
periods upon the written approval of both parties not later than thirty (30) days prior to the first day of
the next twelve (12) month extension period. The COUNTY’s DBH Director or designee is authorized
to execute such written approval on behalf of COUNTY based on CONTRACTOR’s satisfactory
performance.
3. TERMINATION
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 sixty (60) 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 the COUNTY of any
breach of this Agreement or any default which may then exist on the part of the CONTRACTOR. Neither
shall such payment impair or prejudice any remedy available to the COUNTY with respect to the breach or
default. The COUNTY shall have the right to demand of the CONTRACTOR the repayment to the
COUNTY of any funds disbursed to CONTRACTOR under this Agreement, which in the judgment of the
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.
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C. Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by CONTRACTOR or COUNTY or COUNTY’s DBH Director, or designee,
upon the giving of sixty (60) days advance written notice of an intention to terminate.
4. COMPENSATION
COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation for actual expenditures incurred in accordance with the CONTRACTOR’s “budget”
documents approved by the COUNTY’s DBH Director or designee and attached hereto as Exhibit C
and incorporated herein by this reference.
A. Maximum Contract Amount
The maximum amount payable to CONTRACTOR for the period of September 1,
2021 through June 30, 2022 shall not exceed Three Hundred Fifty-Eight Thousand, Three Hundred
Thirty-Three and No/100 Dollars ($358,333.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2022
through June 30, 2023 shall not exceed Four Hundred and Thirty Thousand and No/100 Dollars
($430,000.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2023
through June 30, 2024 shall not exceed Four Hundred and Thirty Thousand and No/100 Dollars
($430,000.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2024
through June 30, 2025 shall not exceed Four Hundred and Thirty Thousand and No/100 Dollars
($430,000.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2025
through June 30, 2026 shall not exceed Four Hundred and Thirty Thousand and No/100 Dollars
($430,000.00).
In no event shall the maximum contract amount for the services provided by the
CONTRACTOR to COUNTY under the terms and conditions of this Agreement be in excess Two
Million, Seventy-Eight Thousand, Three Hundred Thirty-Three and No/100 Dollars ($2,078,333.00)
during the total Five (5) year term of the Agreement.
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Fresno, CA
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A. Travel shall be reimbursed based on actual expenditures and mileage
reimbursement shall be at CONTRACTOR’s adopted rate per mile, not to exceed the Federal Internal
Revenue Services (IRS) published rate.
B. It is understood that all expenses incidental to CONTRACTOR’s performance of
services under this Agreement shall be borne by CONTRACTOR. If CONTRACTOR fails to comply with
any provision of this Agreement, COUNTY shall be relieved of its obligation for further compensation.
C. 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 and approval by
COUNTY of the monthly invoicing as described in Section Five (5) herein. Payments shall be made after
receipt and verification of actual expenditures incurred by CONTRACTOR for monthly program costs, as
identified in Exhibit C, in the performance of this Agreement and shall be documented to COUNTY on a
monthly basis by the tenth (10th) of the month following the month of said expenditures.
CONTRACTOR shall submit to the COUNTY by the tenth (10th) of each month a detailed
general ledger (GL), itemizing the 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.
D. COUNTY shall not be obligated to make any payments under this Agreement if the
request for payment is received by COUNTY more than sixty (60) days after this Agreement has
terminated or expired.
E. All final invoices and/or any final budget modification requests 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 invoices 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.
F. 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 Controller, COUNTY may defer payments to CONTRACTOR. The amount of the deferred payment
shall not exceed the amount of funding delayed by the State Controller to the COUNTY. The period of
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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
A. CONTRACTOR shall invoice COUNTY in arrears by the tenth (10th) day of each
month for actual expenses incurred during the prior month electronicatlly to: 1)
dbhinvoicereview@fresnocountyca.gov, 2) dbh-invoices@fresnocountyca.gov; and 3)
dbhcontractedservicesdivision@fresnocountyca.gov with a copy to the assigned COUNTY’s DBH Staff
Analyst. Invoices and reports shall be in such detail as acceptable to COUNTY’s DBH, as described
herein and in Section Fifteen (15) of this Agreement. No reimbursement for costs incurred by
CONTRACTOR for services delivered under this Agreement shall be made until the invoice and supporting
documentation is received, verified, and approved by COUNTY’s DBH.
B. 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 is still not corrected to COUNTY DBH’s satisfaction, COUNTY’s DBH Director or designee, may
elect to terminate this Agreement, pursuant to the termination provisions stated in Section 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.
C. CONTRACTOR shall submit monthly invoices and general ledgers to COUNTY’s
DBH that itemize the line item charges for monthly program costs. Unallowable costs such as lobbying or
political donations must be deducted from the monthly invoice reimbursements. The invoices and general
ledgers will serve as tracking tools to determine if CONTRACTOR’s program costs are in accordance with
its budgeted cost. Failure to submit reports and other supporting documentation shall be deemed
sufficient cause for COUNTY to withhold payments until there is compliance, as further described in
Section Five (5) herein.
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D. CONTRACTOR shall submit monthly staffing reports that identify all direct service
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.
E. CONTRACTOR must maintain financial records for a period of seven (7) years or
until any dispute, audit or inspection is resolved, whichever is later. CONTRACTOR will be responsible for
any disallowances related to inadequate documentation.
F. CONTRACTOR must attend COUNTY DBH’s Business Office training on
equipment reporting for assets, intangible and sensitive minor assets.
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,
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
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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.
Notwithstanding the above, changes to expense category (i.e., Salary & Benefits,
Facilities/Equipment, Operating, Financial Services, Special Expenses, Fixed Assets, etc.) subtotals in the
budgets, as set forth in Exhibit C, that do not exceed ten percent (10%) of the maximum compensation
payable to CONTRACTOR, may be made with the written approval of COUNTY’s DBH Director or
designee.
In addition, changes to scope of services, staffing, and responsbiliites of the
CONTRACTOR, as set forth in Exhibit A, may be made with the signed written approval of COUNTY’s
DBH Director or designee and CONTRACTOR. Said changes shall not result in any change to the annual
maximum compensation amount payable to CONTRACTOR, as stated herein.
8. NON-ASSIGNMENT
No party shall assign, transfer or subcontract this Agreement nor their rights or duties under
this Agreement without the prior written consent of COUNTY.
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 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, its officers, agents, or employees under this Agreement.
CONTRACTOR agrees to indemnify COUNTY for Federal, State of California and/or local
audit exceptions resulting from noncompliance herein on the part of CONTRACTOR.
10. INSURANCE
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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 affect 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 (XCU), fire
legal liability, or any other liability insurance deemed necessary because of the
nature of the Agreement.
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. If CONTRACTOR’s employees are not covered by
CONTRACTOR’s automobile liability insurance policy, CONTRACTOR shall
ensure that each employee as part of this Agreement procures and maintains
their own private automobile coverage with the same limits of no less than One
Million Dollars ($1,000,000) per accident for bodily injury and property damage
and in force during the term of this Agreement, at the employee’s sole cost and
expense.
C. 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 of 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.
D. Professional Liability
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. This coverage shall be issued on a per claim basis. 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
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policies of professional liability insurance with limits of coverage as specified
herein.
E. Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
California Labor Code.
F. Molestation
Sexual abuse / molestation liability insurance with limits of not less than One
Million Dollars ($1,000,000.00) per occurrence, Two Million Dollars
($2,000,000.00) annual aggregate. This policy shall be issued on a per
occurrence basis
G. Cyber Liability
Cyber Liability Insurance, with limits not less than Two Million Dollars
($2,000,000) per occurrence or claim, Two Million Dollars ($2,000,000)
aggregate. Coverage shall be sufficiently broad to respond to duties and
obligations undertaken by CONTRACTOR in this agreement and shall include,
but not be limited to, claims involving infringement of intellectual property,
including but not limited to infringement of copyright, trademark, trade dress,
invasion of privacy violations, information theft, damage to or destruction of
electronic information, release of private information, alteration of electronic
information, extortion and network security. The policy shall provide coverage for
breach response costs as well as regulatory fines and penalties as well as credit
monitoring expenses with limits sufficient to respond to these obligations.
H. Waiver of Subrogation
CONTRACTOR hereby grants to COUNTY a waiver of any right to subrogation
which any insurer of said CONTRACTOR may acquire against COUNTY by
virtue of the payment of any loss under insurance. CONTRACTOR agrees to
obtain any endorsement that may be necessary to affect this waiver of
subrogation, but this provision applies regardless of whether or not COUNTY has
received a waiver of subrogation endorsement from the insurer.
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 CONTRACTORS 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
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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.
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 CONTRACTOR signs this Agreement,
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, 3133 N.
Millbrook Ave, Fresno, California, 93703, Attention: Contracted Services Division or electronically to
dbhcontractedservicesdivision@fresnocountyca.gov with a copy to the assigned COUNTY’s DBH Staff
Analyst, 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
such Commercial General Liability insurance names the County of Fresno, its officers, agents, and
employees, individually and collectively, as additional insured, but only insofar as the operations under this
Agreement are concerned; that such coverage for additional insured shall apply as primary insurance and
any other insurance, or self-insurance, maintained by COUNTY, its officers, agents, and employees, shall
be excess only and not contributing with insurance provided under CONTRACTOR’s policies herein; and
that this insurance shall not be cancelled or changed without a minimum of thirty (30) days advance,
written notice given to COUNTY.
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
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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, the 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 the 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
CONTRACTOR shall maintain its records in COUNTY’s EHR system (currently Avatar)
in accordance with Exhibit D, “Documentation Standards for Client Records,” attached hereto and
incorporated herein by reference and made part of this Agreement. The client record shall begin with
registration and intake and include client authorizations, assessments, plans of care, and progress
notes, as well as other documents as approved by the COUNTY’s DBH. COUNTY shall be allowed to
review records of services provided, including the goals and objectives of the treatment plan, and how
the therapy provided is achieving the goals and objectives. If CONTRACTOR determines to maintain
its records in COUNTY’s EHR system, it shall provide COUNTY’s DBH Director, or designee, with a
thirty (30) day notice. If at any time CONTRACTOR chooses not to maintain its records in COUNTY’s
EHR system, it shall provide COUNTY’S DBH Director, or designee, with a thirty (30) day notice and
CONTRACTOR will be responsible for obtaining its own system, at its own cost, for Electronic Health
Record management. Disclaimer – COUNTY makes no warranty or representation that information
entered into the COUNTY’s EHR system by CONTRACTOR will be accurate, adequate or satisfactory
for CONTRACTOR’s own purposes or that any information in CONTRACTOR’s possession or control,
or transmitted or received by CONTRACTOR, is or will be secure from unauthorized access, viewing,
use, disclosure, or breach. CONTRACTOR is solely responsible for client information entered by
CONTRACTOR into the COUNTY’s EHR system. CONTRACTOR agrees that all Private Health
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Information (PHI) maintained by CONTRACTOR in COUNTY’s EHR system will be maintained in
conformance with all Health Insurance Portability and Accountability Act (HIPAA) laws, as stated in
Section Eightteen (18), “Health Insurance Portability and Accountability Act”.
COUNTY shall be allowed to review all records of services provided, including the goals
and objectives of the treatment plan, and how the therapy provided is achieving the goals and objectives.
All mental health records shall be considered the property of the COUNTY and shall be retained by the
COUNTY upon termination or expiration of this Agreement.
CONTRACTOR shall maintain records in accordance with COUNTY’s “Documentation
Standards for Client Records,” attached hereto as Exhibit D and incorporated herein by reference.
During site visits, COUNTY shall be allowed to review records of services provided, including the goals
and objectives of the treatment plan, and how the therapy provided is achieving the goals and
objectives. All medical records shall be maintained for a minimum of ten (10) years from the date of the
end of the Agreement.
13. REPORTS
A. Outcome 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 PEI
CONTRACTOR shall submit to the County’s DBH MHSA PEI reports and participate in
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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 Health Care Services or their designees, the right to review and monitor records,
services, or procedures, at any time, in regard to clients, as well as the overall operation of
CONTRACTOR’s performance, 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 of California Department 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 E, “State Mental Health Requirements”,
attached hereto and by this reference incorporated herein and made part of this Agreement.
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
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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 (PHI) as required by law.
COUNTY and CONTRACTOR acknowledge that the exchange of PHI 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
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 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.
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 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 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
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4) A secure connection is used.
B. CONTRACTOR-Owned Computers or Computer Peripherals
CONTRACTOR may not bring contractor-owned computers or computer
peripherals into COUNTY for use without prior authorization from COUNTY’s Chief Information Officer
and/or designee(s), including but not limited to mobile storage devices. If data is approved to be
transferred, data must be encrypted and stored on a secure server approved by COUNTY and transferred
by means of a Virtual Private Network (VPN) connection, or another type of secure connection.
C. COUNTY-Owned Computer Equipment
CONTRACTOR may not use COUNTY computers or computer peripherals on non-
County premises without prior authorization from COUNTY’s Chief Information Officer and/or 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 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.
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20. PROPERTY OF COUNTY
A. COUNTY and CONTRACTOR recognize that fixed assets are tangible and
intangible property obtained or controlled under COUNTY 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 (3) qualifications:
1) Have life span of over one year;
2) Is not a repair part; and
3) 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
• Tangible $5,000
o Equipment
o Vehicles
• Intangible $100,000
o Internally Generated Software
o Purchased Software
o Easements
o Patents
• And Capital Lease $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 and made part of this
Agreement, will be maintained by COUNTY’s Asset Management System and annually inventoried 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) but
more than One Thousand and No/100 Dollars ($1,000.00), with over one year life span, and/or are mobile
and high risk of theft or loss are 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
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designee. CONTRACTOR will maintain a tracking system on the items on Exhibit F. Items are not
required to be capitalized or depreciated and 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
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) Maintain all items of equipment in good working order and condition, normal
wear and tear is expected;
2) Label all items of equipment with COUNTY assigned program number,
perform periodic inventories as required by COUNTY, and 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) Report in writing to COUNTY immediately after discovery, the loss 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 CONTRACTORS services or activities 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
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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 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, not 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 identity, gender expression, age, sexual orientation, or military and
veteran status.
CONTRACTOR shall ensure that the evaluation and treatment of employees and
applicants for employment are free of such discrimination. CONTRACTOR and subcontractors 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.
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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.
22. CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence:
A. CONTRACTOR shall not discriminate against beneficiaries based on race, color,
national origin, sex, disability, or religion. CONTRACTOR shall ensure that a limited and/or no English
proficient beneficiary is entitled to equal access and participation in federally funded programs through
the provision of comprehensive and quality bilingual services pursuant to 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.
B. CONTRACTOR shall comply with requirements of policies and procedures for
ensuring access and appropriate use of trained interpreters and material translation services for all
limited and/or no English proficient beneficiaries, including, but not limited to, assessing the cultural and
linguistic needs of the beneficiaries, training of staff on the policies and procedures, and monitoring its
language assistance program. CONTRACTOR’s policies and procedures shall ensure compliance of any
subcontracted providers with these requirements.
C. CONTRACTOR shall notify its beneficiaries that oral interpretation is available for
any language and written translation is available in prevalent languages and that auxiliary aids and
services are available upon request, at no cost and in a timely manner for limited and/or no English
proficient beneficiaries and/or beneficiaries with disabilities. CONTRACTOR shall avoid relying on an adult
or minor child accompanying the beneficiary to interpret or facilitate communication; however, if the
beneficiary refuses language assistance services, the CONTRACTOR must document the offer, refusal
and justification in the beneficiary’s file.
D. CONTRACTOR shall ensure that employees, agents, subcontractors, and/or
partners who interpret or translate for a beneficiary or who directly communicate with a beneficiary in a
language other than English (1) have completed annual training provided by COUNTY at no cost to
CONTRACTOR; (2) have demonstrated proficiency in the beneficiary’s language; (3) can effectively
communicate any specialized terms and concepts specific to CONTRACTOR’s services; and (4) adheres
to generally accepted interpreter ethic principles. As requested by COUNTY, CONTRACTOR shall identify
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all who interpret for or provide direct communication to any program beneficiary in a language other than
English, and identify when the CONTRACTOR last monitored the interpreter for language competence.
E. CONTRACTOR shall submit to COUNTY for approval, within ninety (90) days from
date of contract execution, CONTRACTOR’s plan to address all fifteen (15) National Standards for
Culturally and Linguistically Appropriate Service (CLAS), as published by the Office of Minority Health and
as set forth in Exhibit G “National Standards on Culturally and Linguistically Appropriate Services”,
attached hereto and incorporated herein by reference and made part of this Agreement. As the CLAS
standards are updated, CONTRACTOR’s plan must be updated accordingly. As requested by COUNTY,
CONTRACTOR shall be responsible for conducting an annual CLAS self-assessment and providing the
results of the self-assessment to the COUNTY. The annual CLAS self-assessment instruments shall be
reviewed by the COUNTY and revised as necessary to meet the approval of the COUNTY.
F. Cultural competency training for CONTRACTOR staff should be substantively
integrated into health professions education and training at all levels, both academically and functionally,
including core curriculum, professional licensure, and continuing professional development programs. As
requested by COUNTY, CONTRACTOR shall report on the completion of cultural competency trainings to
ensure direct service providers are completing a minimum of eight (8) hours of cultural competency
training annually.
G. CONTRACTOR shall create and sustain a forum that includes staff at all agency
levels to discuss cultural competence. COUNTY encourages a representative from CONTRACTOR’s
forum to attend COUNTY’s Cultural Humility Committee.
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.
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24. 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.
25. 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
written request to the Secretary of the United States Department of Health and Human Services, or 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 ($10,000.00) 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 organizations shall make available, upon written request
to the Secretary of the United States Department of Health and Human Services, or upon 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.
26. SINGLE AUDIT CLAUSE
A. If CONTRACTOR expends Seven Hundred Fifty Thousand and No/100 Dollars
($750,000.00) or more in Federal and Federal flow-through monies, CONTRACTOR agrees to conduct an
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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 Finance
Division 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
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 solvency. Said
audit report shall be delivered to COUNTY’s DBH Finance Division 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
paragraph shall be billed to CONTRACTOR at COUNTY 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
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least three (3) years following final payment under this Agreement or the closure of all other pending
matters, whichever is later.
27. COMPLIANCE
CONTRACTOR agrees to comply with COUNTY’s Contractor Code of Conduct and Ethics
and the COUNTY’s Compliance Program in accordance with Exhibit H. Within thirty (30) days of entering
into this Agreement with COUNTY, CONTRACTOR shall have all of 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 Contractor Code of Conduct is an element in evaluating 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 thirty (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 COUNTY’s DBH 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.
28. ASSURANCES
In entering into this Agreement, CONTRACTOR certifies that neither they, nor any of their
officers, are currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal
Health Care Programs; that neither they, nor any of their officers, have been convicted of a criminal
offense related to the provision of health care items or services; nor have they, nor any of their officers,
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been reinstated to participate 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 time as CONTRACTOR
is reinstated into participation in the Federal Health Care Programs.
A. If COUNTY has notice that either CONTRACTOR, or its officers, have been
charged with a criminal offense related to any Federal Health Care Program, or are 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 (3) they have
been reinstated to participate 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 Three (3) of this Agreement, or require adequate assurance (as
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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 time frame 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, 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 participate 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 time frame to be determined by COUNTY
to protect the interests of COUNTY consumers.
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
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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.
29. PUBLICITY 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
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 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).
30. COMPLAINTS
CONTRACTOR shall log complaints and the disposition of all complaints from a client or a
client's family. 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 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 I.
CONTRACTOR shall file an incident report for all incidents involving clients, following the protocol and
using the worksheet identified in Exhibit J.
31. CHILD ABUSE REPORTING ACT
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CONTRACTOR shall establish a procedure acceptable to the COUNTY’s DBH
Director, or his or her designee, to ensure that all of the CONTRACTOR’s employees, consultants,
subcontractors or agents described in the Child Abuse Reporting Act, section 1116 et seq. of the Penal
Code, and performing services under this Agreement shall report all known or suspected child abuse or
neglect to a child protective agency as defined in Penal Code section 11165.9. This procedure shall
include:
A. A requirement that all CONTRACTOR’s employees, consultants, subcontractors
or agents performing services shall sign a statement that he or she knows of and will comply with the
reporting requirements as defined in Penal Code section 11166(a).
B. Establishing procedures to ensure reporting even when employees, consultants,
subcontractors, or agents who are not required to report child abuse under Penal Code section 11166(a),
gain knowledge of or reasonably suspect that a child has been a victim of abuse or neglect
32. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION
This provision is only applicable if CONTRACTOR is disclosing entities, fiscal agents, or
managed care entities, 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 K, “Disclosure of
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 the 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 K. Submissions shall be
scanned portable document format (pdf) copies and are to be sent via email to COUNTY’s DBH assigned
Staff Analyst.
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
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method required in CFR, Title 42, Section 455.416. Submissions shall be scanned pdf copies and are
to be sent via email to DBHContractedServices@fresnocountyca.gov. 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.
33. 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 in this Section as
“CONTRACTOR”):
C. 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.
D. Within the three (3) year period preceding the Agreement award, they have had a
public transaction (federal, state, or local) terminated for cause or default.
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 this Agreement and any additional information or explanation that
CONTRACTOR elects to submit with the disclosed information will be considered. If it is later determined
that 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 L, attached hereto
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and by this reference incorporated herein and made part of this Agreement. Additionally, CONTRACTOR
must immediately advise COUNTY’s DBH 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 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.
34. DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if a CONTRACTOR is operating as a corporation (a for-
profit or non-profit corporation) or if during the term of this Agreement, CONTRACTOR changes its status
to operate as a corporation.
Members of a 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 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 M and incorporated herein by
reference and made part of this Agreement, and submitting it to COUNTY prior to commencing with the
self-dealing transaction or immediately thereafter.
35. AUDITS AND INSPECTIONS
After reasonable notice to CONTRACTOR, 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 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 Auditor General for a period of
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three (3) years after final payment under contract (California Government Code section 8546.7).
36. NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CONTRACTOR Director, Fresno County Chief Executive Officer Department of Behavioral Health Westside Family Preservation Services Network 1925 E. Dakota Ave PO Box 898 Fresno, CA 93726 Huron, CA 93234
All notices between 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).
37. 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
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Agreement shall be governed in all respects by the laws of the State of California.
38. 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.
39. ENTIRE AGREEMENT
This Agreement, including all Exhibits, Revised RFP No. 21-040 and CONTRACTOR’s
Response thereto, constitutes the entire agreement between CONTRACTOR and COUNTY with respect
to the subject matter hereof and supersedes all previous agreement negotiations, proposals,
commitments, writings, advertisements, publications, and understandings of any nature whatsoever unless
expressly included in this Agreement. This Agreement shall be effective retroactive to September 1, 2021.
///
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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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CONTRACTOR:
Westside Family Preservation
Services Network
By~"'/21, di{;/
Print Name~1'/:ia., /~, ~eJ...··, z_
Tille : ~£,k)/4;;24.«)u0
Chair of the Board, or President,
Board Treasurer, or any Vice President
B~~
Print Name : Y t/ 0 (') '1-e V. P ~
l
Title: 3 e,~e__, +C)V""" Y
Secretary of Corporatlo~ or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer
Mail ing Address :
PO Box898
Huron, CA 93234
Pho ne No .: (559) 945-1022
Contact : Dr Jeannemarie Caris-M cManus
FOR ACCOUNTING USE ONLY:
Fu nd/Subclass: 0001/10000
Organ ization: 56304770
Account No .: 7295
COUNTY OF FRESNO
Ste,e .LJ.,,k o,rd of
Supervisors of the County of Fresno
ATTEST:
Bern ice E. Seidel
Clerk of the Board of Supervisors
County of Fresno , State of Cal ifornia
-33 -COUNTY OF FRESNO
Fresno, CA
Youth Empowerment Centers (YEC)
Scope of Work
Organization: Westside Family Preservation Services Network
Address: PO Box 898, Huron CA 93234
Program Director: Aurora Ramirez
Westside Family Preservation Services Network, Huron
Phone Number: (559) 945-1022
I.Project Description
Contractor shall operate Youth Empowerment Centers that provide a range of prevention,
wellness and recovery focused activities. These centers will engage individuals who may be, but
are not limited to, trauma exposed individuals; individuals experiencing the first onset of serious
psychiatric illness; children, youth, adolescents, and transitional age youth from and/or in
stressed families; as well as those that may be considered un-served or underserved cultural
populations. The services provided to this population should offer wellness and recovery
activities that include, but are not be limited to education, socialization, life-skills training, and
other peer support activities.
Contractor will provide prevention services through wellness and recovery center format as
identified in the approved Mental Health Services Act (MHSA) Three-Year Plan currently entitled
“Youth Empowerment Centers”. Youth Empowerment Centers will be funded with MHSA
Prevention and Early Intervention (PEI) funds. MHSA PEI identifies PEI programs by strategies
and each strategy has its own regulatory and reporting requirements. Youth Wellness Centers is
designated as a Prevention (Primary) program.
II.Target Population
Fresno County residents 10-13 years old, 14-17 years old, and 16-24 years old or Transitional
Age Youth (TAY), including the unserved and underserved cultural, ethnic, and linguistic
communities.
III.Location of Services and Hours of Operation
Youth Empowerment Centers (YEC) may be co-located with other agencies and organizations
targeted to reach the unserved and underserved children, youth, and adolescent populations in
Fresno County.
Youth Empowerment Centers will take place at off-site locations that are approved by the
County that may be a school or appropriate natural community setting and not necessarily a
mental health facility. Sites will be determined based on community need, availability of the
meeting space, and willingness of the school or community center to allow youth to participate.
The program will have two sites in Huron and Firebaugh. Each of these sites will have mini-
centers in the surrounding area to reach more of the population to be served. Contractor and
Exhibit A - 1 of 8
County shall continue to assess the feasibility of adding centers and/or mini centers listed below
as well as beyond those listed.
Below are the proposed locations to be served:
•Huron: Contractor shall utilize their current home visiting program location until a
separate site is secured, 16856 4th Street, Huron, CA 93234
o Coalinga YEC Mini-Center
o Westside/Five Points Mini-Center
o Cantua Creek Mini-Center
•Firebaugh
o YEC Kerman Mini-Center
Contractor shall utilize their current home visiting program location until a
separate site is secured, 441 S. Madera Avenue, Suite D, Kerman, CA
93630
o Mendota Mini-Center
o Tranquility Mini-Center
o San Joaquin Mini-Center
IV.Description of Services
Youth Empowerment Centers will work with three, mutually reinforcing and overlapping
categories of activities: mentor/coaching and program design initiated by the College Interns; a
public program of activities designed and implemented by the youth, with support from the
Parent Partners and Program Supervisors; and, community work, which will follow an agenda of
collective impact led by youth in specific communities and including their families and other
community members.
Contractor shall provide activities and community programs in seven different arenas: Health &
Fitness; Dating Violence, Bullying & Homelessness; Employment, Workplace Skill Building;
Educational Accomplishment; Mindfulness and Stress Management; Restorative Justice and
Conflict Mediation; and Resources/Referrals for Mental Health Illness.
Activities at each Center will consist of the following but not limited to:
•Facilitated peer directed groups, with mental health themes like depression, self-esteem,
anger management, healthy lifestyles etc.
•Curriculum classes to both youth and families such as parenting classes, anger
management, self-esteem etc.
•One-to-one support to youth
•If necessary, linking individuals served to mental health resources for critical, Serious
Emotional Disturbance (SED) or Serious Mental Illness (SMI) children and youth
•Develop and foster mentor relationships between older teens and younger individuals
•Develop sports, arts/crafts, music, and other appropriate activities at all sites to draw
youth in, particularly high school teenagers
•Ensure that culturally specific approaches and activities are incorporated into the Youth
Empowerment Center
Exhibit A - 2 of 8
•Collaboration with other community groups to provide specialized activities at the
centers
aimed at increasing participation and penetration
•Explore need for youth literacy classes at each center, implement as appropriate
Contractor and Youth Councils will collaborate in the development of programs to target Risk
Factors, employing Protective Factors, as they face three interrelated categories: Individual,
Community, and Family.
Youth Council
Each of the Youth Empowerment Centers’ models of services shall be developed, assessed,
and adapted on an ongoing basis by the consumers guided by individual Youth Councils at
each center.
Contractor will encourage member involvement in program planning and decision making by
including a Youth Council in the program design, implementation, and evaluation of activities.
Councils are intended to meet once every two weeks but will have ongoing assessment to
adjust to better target program goals. Contractor shall provide an appropriate location for youth
councils to meet. Transitional Aged Youth shall have their own separate council.
Beyond the Youth Council, individual participants will be encouraged to identify community
improvement projects in which they want to volunteer their time in order to fulfill their school
requirements for community service. Program will add a public reflection and recognition piece
such that these participants receive certificates for their work in a public forum annually.
Contractor shall ensure Adult Facilitators complete training designed to prepare them for
working with youth. These trainings will address broad topics including but not limited to
addressing their own biases towards youth limitations.
Contractor will encourage youth to lead and utilize resources such as leadership skill
development, exercises, and other appropriate resources. Contractor will encourage our staff to
deliver content presentations and facilitate group discussions so that they too can be role
models. As the program progresses a structured training and skill building plan for youth that
focuses on leadership will be implemented
In each quarter, each age group will choose a focus – all will receive material that is age
appropriate, but the way the material is presented, the ensuing discussions, and the questions
from the participants will vary in depth as their experiences inform them. All age groups will
decide what their focus will be and how they want to implement the schedule that the Youth
Council sets each year.
Transitional Aged Youth (TAY)
The YEC Program shall include a wellness and recovery program plan to specifically address
transition age youth (ages 16-24.)
Contractor will support and nurture Transitional Aged Youth (TAY) members to become Youth
Ambassadors on community issues where the impact of their participation will be measured in
the overall increase of volunteer participation throughout the adults in the communities.
Exhibit A - 3 of 8
Contractor will encourage and provide support to the TAY participants to pursue college
education beyond earning their AA degree at community college as well as vocational training,
various career paths based on their interests. Contractor will provide programs/activities for TAY
population to broaden horizons and pursue career goals beyond perceived generational
boundaries.
Contractor shall provide appropriate linkages for the needs of the individual including but not
limited to mental health, substance use disorder, employment, physical health, and education
for all participants.
V.Staffing Level
The staffing plan for Youth Empowerment Centers should be clear and concise and allow for full
implementation of all program components. Any changes in staffing volume must be requested
in writing and approved by DBH Director or designee before implementation.
Specifically, wellness and recovery staff shall include persons who are bilingual and bicultural in
order to provide culturally and linguistically appropriate strength-based mental health supportive
services that are client and family driven. All bilingual staff will be required to meet the language
proficiency requirements set by County policy. Should a potential client require language
assistance outside the proficiency of the staff, a certified interpreter will be required.
Position titles do not fully define lived experienced as peer or family; a "peer position" is
reflective of lived experience. It is expected that services shall be provided by peer support
specialists and volunteers. All volunteers will participate in a volunteer training program prior to
volunteer service commencing. Staffing patterns should allow for staff specialization in services
to the different age groups and families to be served.
Senate Bill (SB) 803 requires the development of a peer support certification program and other
requirements around peer support services by DHCS. The Department acknowledges that
detailed requirements have not yet been published by DHCS. Bidder shall be flexible and
adaptable to ensure compliance with regulations and requirements as set forth by DHCS and
DBH.
VI.Performance and Outcome Measurements
CONTRACTOR shall comply with all project monitoring and compliance protocols, procedures,
data collection methods, and reporting requirements requested by the COUNTY. COUNTY and
CONTRACTOR shall use performance outcome measures for evaluating program and system
effectiveness to ensure services and service delivery strategies are positively impacting the
service population.
In addition, these measures shall be used to ensure the program is in alignment with MHSA
guiding principles which are inclusive of: an integrated service experience; community
collaboration; cultural competence; individual/family driven service; and wellness, resilience,
and recovery-focused services.
Performance outcome measures shall be tracked on an ongoing basis and used to update the
COUNTY monthly (by the 10th of the month following the report period). In addition,
Exhibit A - 4 of 8
performance outcome measures are reported to the COUNTY annually in accumulative reports
for overall program and contract evaluation. Forms and tools used to gather, and report data
reflecting services provided, populations served, and impact of those services are to be
developed by the COUNTY and CONTRACTOR. CONTRACTOR will work closely with the
COUNTY to analyze the data and make necessary adjustments to service delivery and
reporting requirements before the start of each new fiscal year and at appropriate intervals
during the fiscal year.
Measurable outcomes may be reviewed for input and approval by a designated DBH work
group upon contract execution and adjusted as needed each new fiscal year. The purpose of
this review process is to ensure a comprehensive system wide approach to the evaluation of
programs through an effective outcome reporting process.
The following items listed below represent program goals to be achieved by CONTRACTOR.
The program's success will be based on the number of goals it can achieve, resulting from
performance outcomes. Contractor will utilize a computerized tracking system with which
outcome measures and other relevant individual data, such as demographics, will be
maintained.
CONTRACTOR will collect data about the characteristics of the individuals served and measure
service delivery performance indicators in the four Commission on Accreditation of
Rehabilitation Facilities (CARF) domains, with at least one performance indicator for each of the
four domains. CONTRACTOR shall submit annual outcomes on a report template to be
provided by the County for each level of care provided.
Contractor shall actively participate with DBH and any outside consultants for performance
monitoring and reporting requirement.
Outcomes to be tracked include, but are not limited to:
•Activities Participation & General Participant Well-being
o Program sign in sheets
o Activity Facilitator Assessment of Individual Participation & Identification of any
concerns requiring follow-up and/or referrals for services, especially mental
health
•Youth Educational Outcomes
o Participant Survey & Testimonials
o Participant Grades
o School Attendance
o Annual Grade Level Promotions
•Youth Health & Wellness; Self Agency
o Youth Wellness Annual Physical Exam
o Follow-up Individual Plan for Health & Fitness
•Youth Reduction in School Suspension; Arrest; Drug, Tobacco & Alcohol Use/Addiction
o Youth Involvement in Justice System
o Youth Participation in Restorative Justice
•Youth Reduction of Embodied Stress Response & Increased Resiliency
o Self-Reported Improvement in Stress Reduction
o Application of Learned Techniques (to counter the effects of ACEs, and ongoing
interpersonal, family, gang, and community violence)
Exhibit A - 5 of 8
•Youth Enrichment & Increasing Choice
o Self-Reflected Improvement in Experience & Knowledge of
Other walks of life
Other cultures
Other communities
Other places
•Effectiveness
o Improvement in school and life success; lessening the impact of ACEs and other
factors that increase trauma and chronic stress
•Efficiency
o Cost per participant
•Access
o Programs available during non-school hours (weekends and after school)
•Satisfaction and Feedback of Persons Served and Stakeholders
o Program evaluation satisfaction surveys, 80% satisfaction with participant stating
they learned and applied at least one factor that benefited themselves
Additional Reporting Requirements
Contractor shall be responsible for meeting with DBH on a monthly basis, or more often as
agreed upon between DBH and the Contractor, for contract and performance monitoring.
Contractor will be required to submit a monthly report to the County that will include, but not be
limited to: actual expenses; the number of individuals served/anticipated to be served; utilization
of services by individuals; and staff composition. This report will be due within 30 days after the
last day of the previous month or payments may be delayed.
MHSA PEI-Contractor will be required to track and submit data as required by MHSA PEI
reporting requirements. Contractor shall comply with requests developed from PEI Program
Evaluation Project and DBH partnership with RAND Corporation.
COUNTY RESPONSIBILITIES
1.DBH MHSA Coordinator or designee shall assist the contractor in making linkages with
the total mental health system. This will be accomplished through regularly scheduled
meetings as well as formal and informal consultation.
2.DBH MHSA Coordinator or designee shall participate in evaluating the progress of the
overall program and the efficiency and will be available to the contractor for ongoing
consultation.
3.DBH MHSA Coordinator or designee will gather outcome information from target
consumer groups and CONTRACTOR throughout the term of contract. DBH MHSA
Coordinator or designee will notify CONTRACTOR when its participation is required. The
performance outcome measurement process will not be limited to survey instruments but
will also include, as appropriate, consumer and staff interviews, chart reviews, and other
methods of obtaining required information.
4.The County Department of Behavioral Health (DBH), Mental Health Services Act
Coordinator or designee will provide oversight of program services funded through
Exhibit A - 6 of 8
MHSA Prevention and Early Intervention (PEI) funding and collaborate with contactor(s)
and other County Departments and community agencies to help achieve State program
goals and outcomes. In addition to contract monitoring of program(s), oversight includes,
but is not limited to, coordination with the State Department of Mental Health in regard to
program administration and outcomes.
CONTRACTOR RESPONSIBILITIES
1.CONTRACTOR will maintain facilities and equipment and operate continuously with the
number and classification of staff required for the provision of services.
2.CONTRACTOR must have a location that is accessible by public transportation and
approved by COUNTY.
3.CONTRACTOR will be required to comply with all State regulations regarding State
Performance Outcomes measurement requirements and participate in the outcomes
measurement process as required by the County and applicable funding sources.
4.CONTRACTOR will participate in performance outcomes throughout the term of the
contract. DBH MHSA Coordinator or designee will notify CONTRACTOR when its
participation is required. The performance outcome measurement process will not be
limited to survey instruments but will also include, as appropriate, consumer and staff
interviews, chart reviews, and other methods of obtaining needed information, as
outlined in the Mental Health Services Act (MHSA) Prevention and Early Intervention
(PEI) Plan.
5.CONTRACTOR’s staff will possess appropriate licenses and certificates and be qualified
in accordance with applicable statutes and regulations. CONTRACTOR will obtain,
maintain and comply with all necessary government authorizations, permits and Exhibit
A licenses required to conduct its operations. In addition, the CONTRACTOR’s will
comply with all applicable Federal, State and local laws, rules, regulations and orders in
its operations including compliance with all applicable safety and health requirements as
to the CONTRACTOR’s employees.
6.CONTRACTOR shall log all complaints and the disposition of all complaints from a
consumer or a consumer’s family. CONTRACTOR shall provide a summary of the
complaint log entries concerning County-sponsored consumers to County at monthly
intervals, by the tenth (10th) fifteenth (15th) day of the following month, in a format that is
mutually agreed upon. CONTRACTOR shall post signs, provided by the County,
informing consumers of their right to file a grievance and appeal. CONTRACTOR will
abide by the Fresno County Mental Health Plan (MHP) grievance process (Exhibit I) and
notify County of all incidents reportable to state licensing bodies that affect County
consumers within twenty-four (24) hours of receipt of a complaint. CONTRACTOR shall
use existing County Department Incident Report form (Exhibit J) and submit to County a
copy of the Incident Report within 24 hours. Within fifteen (15) days after each incident
or complaint affecting County-sponsored consumers, CONTRACTOR shall provide
Exhibit A - 7 of 8
County with the complaint and CONTRACTOR’s disposition of, or corrective action
taken to resolve the complaint or incident.
7.CONTRACTOR shall provide a monthly staff work schedule to DBH MHSA Coordinator
or designee.
8.CONTRACTOR shall maintain a service log in collaboration with DBH staff that reports
type of activity/services attended, number of one-to-one peer support contacts, and
number of crisis contacts per month by consumer. This information will be provided to
the DBH Director or designee in a monthly report submitted with the monthly invoice or
as requested by DBH.
9.CONTRACTOR shall provide work schedules, cultural competency training, and
demographic ethnic information as required by the COUNTY.
10.CONTRACTOR shall arrange activities for consumers and provide supplies for such
activities. A schedule of activities and the number of participants will be included in the
monthly reports and submitted to the COUNTY.
11.CONTRACTOR shall attend a provider meeting hosted by DBH monthly or at intervals
determined by DBH
Exhibit A - 8 of 8
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
1
rev 01-02-2020
DBH VISION:
Health and well-being for our community.
DBH MISSION:
DBH, in partnership with our diverse community, is dedicated to providing quality, culturally
responsive, behavioral health services to promote wellness, recovery, and resiliency for
individuals and families in our community.
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 01-02-2020
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 values and preferences of those we serve
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 01-02-2020
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 person’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 01-02-2020
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
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Rural Westside YEC Network Program
Director 1.00 -$ 46,440$ 46,440$
1102 Chief Education Director (YEC-CED)0.25 - 9,925 9,925
1103 Firebaugh/Kerman/Mendota YEC Site & mini-
centers Supervisor 1.00 - 34,400 34,400
1104 Huron/Coalinga YEC Sites Supervisor 1.00 - 34,400 34,400
1105 Youth & Family Resource Navigator - YEC
Resources and Referrals 0.40 - 11,696 11,696
1106 YEC Parent Partners: Firebaugh; Kerman;
Huron; Coalinga 1.60 - 20,640 20,640
1107 Rural Westside YEC Network Stress
Management & Mindfulness Coach/Intern 0.25 - 6,880 6,880
1108 Rural Westside YEC Network Nutrition &
Fitness Coach/Intern 0.25 - 6,880 6,880
1109 Rural Westside YEC Network Restorative
Justice & Conflict Mediation Coach/Intern 0.25 - 6,880 6,880
1110
Rural Westside YEC Network Dating
Violence, Homelessness, & Bullying
Coach/Intern
0.25 - 6,880 6,880
1111
Rural Westside YEC Network Employment,
Job Interviews, Dress for Success, Resume
Builder, On-line Job Applications, &
Workplace Skills Coach/Intern
0.25 - 6,880 6,880
1112
Rural Westside YEC Network Youth
Navigator for Positive Mental Health
Resources & Referrals/Intern
0.25 - 6,880 6,880
1113 YEC Business Manager 0.05 - 1,806 1,806
1114 - - -
1115 - - -
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
1121 - - -
1122 - - -
1123 - - -
1124 - - -
1125 - - -
1126 - - -
1127 - - -
1128 - - -
1129 - - -
Youth Empowerment Centers
Westside Family Preservation Services Network - Huron
Fiscal Year (FY) 2021-22
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Exhibit C - 1 of 58
1130 - - -
1131 - - -
1132 - - -
1133 - - -
1134 - - -
1135 - - -
Personnel Salaries Subtotal 6.80 -$ 200,587$ 200,587$
Employee Benefits
Acct #Admin Direct Total
1201 -$ 3,457$ 3,457$
1202 - 1,504 1,504
1203 - 13,396 13,396
1204 - - -
1205 - - -
1206 - - -
-$ 18,357$ 18,357$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1301 -$ 12,436$ 12,436$
1302 - 2,909 2,909
1303 - 3,209 3,209
1304 - - -
1305 - - -
1306 - - -
-$ 18,554$ 18,554$
-$ 237,498$ 237,498$
2000: CLIENT SUPPORT
Acct #Amount
2001 1,200$
2002 -
2003 4,000
2004 4,200
2005 11,000
2006 2,200
2007 -
2008 -
2009 -
2010 -
2011 8,000
2012 -
2013 -
2014 -
2015 -
2016 -
30,600$
Other (specify)
Other (specify)
Client Transportation & Support
Client Housing Support
Child Care
Other (specify)
Other (specify)
Other (specify)
Employee Benefits Subtotal:
Description
Clothing, Food, & Hygiene
Education Support
Household Items for Clients
Employment Support
Retirement
Worker's Compensation
Health Insurance
Other (specify)
Other (specify)
OASDI
MEDICARE
SUI
Other (specify)
Utility Vouchers
Program Supplies - Medical
Medication Supports
Description
Payroll Taxes & Expenses Subtotal:
Line Item Description
DIRECT CLIENT CARE TOTAL
Other (specify)
Other (specify)
Other (specify)
EMPLOYEE SALARIES & BENEFITS TOTAL:
Program Supplies - Client Enrichment Trips
Exhibit C - 2 of 58
3000: OPERATING EXPENSES
Acct #Amount
3001 7,600$
3002 3,200
3003 2,000
3004 1,000
3005 2,200
3006 6,640
3007 -
3008 -
3009 8,500
3010 -
3011 -
3012 -
31,140$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 840$
4002 15,000
4003 -
4004 -
4005 -
4006 -
4007 -
4008 -
4009 -
4010 -
15,840$
5000: SPECIAL EXPENSES
Acct #Amount
5001 4,000$
5002 -
5003
5004 -
5005 5,000
5006 -
5007 -
5008 -
9,000$
Program Software - Apricot 360
Staff Mileage
Subscriptions & Memberships
Other (specify)
Other (specify)
Rent/Lease Equipment
Rent/Lease Building
Staff Development & Training
Vehicle Maintenance
Office, Household & Program Supplies
Telecommunications
Printing/Postage
HMIS (Health Management Information System)
Rent/Lease Vehicles
Security
Other (specify)
Other (specify)
Other (specify)
OPERATING EXPENSES TOTAL:
SPECIAL EXPENSES TOTAL:
Contractual/Consulting Services Higher Education 4 All
Other (specify)
Other (specify)
Other (specify)
Building Maintenance
Translation Services
Other (specify)
Utilities
Consultant (Network & Data Management)
Apricot 360 - One time consultant set-up fee
Line Item Description
Line Item Description
Line Item Description
Advertising
FACILITIES/EQUIPMENT TOTAL:
Other (specify)
Exhibit C - 3 of 58
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 21,005$
6002 -
6003 6,000
6004 2,000
6005 3,100
6006 650
6007 -
6008 -
6009 -
6010 -
6011 -
6012 -
32,755$
7000: FIXED ASSETS
Acct #Amount
7001 750$
7002
7003 750
7004 -
7005 -
7006 -
7007 -
7008 -
1,500$
Acct #Service Units Rate Amount
8001 Mental Health Services 0 - -$
8002 Case Management 0 - -
8003 Crisis Services 0 - -
8004 Medication Support 0 - -
8005 Collateral 0 - -
8006 Plan Development 0 - -
8007 Assessment 0 - -
8008 Rehabilitation 0 - -
8009 0 - -
8010 0 - -
0 -$
0%
-
0%-
-$
Line Item Description
Administrative Overhead
Other (specify)
Other (specify)
Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
Payroll Services - Valley Business Consulting & Training/Intuit payroll services
Line Item Description
External Audit - Jaribu Nelson CPA
Other (specify)
Other (specify)
MEDI-CAL FFP TOTAL
Line Item Description
Other (specify)
Insurance (Specify):
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Other (specify)
Other (Specify)
Other (Specify)
Leasehold/Tenant/Building Improvements
Furniture & Fixtures
PROGRAM FUNDING SOURCES
358,333$ TOTAL PROGRAM EXPENSES
Other Assets over $500 with Lifespan of 2 Years +
Estimated Specialty Mental Health Services Billing Totals:
Estimated % of Clients who are Medi-Cal Beneficiaries
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries
Federal Financial Participation (FFP) %
Other (specify)
Assets over $5,000/unit (Specify)
FIXED ASSETS EXPENSES TOTAL
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
Professional Liability Insurance
Accounting/Bookkeeping - Valley Business Consulting & Training
ADMINISTRATIVE EXPENSES TOTAL
Exhibit C - 4 of 58
Acct #Amount
8101 Drug Medi-Cal -$
8102 SABG -$
-$
Acct #Amount
8201 Realignment -$
-$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports -$
8302 PEI - Prevention & Early Intervention 358,333
8303 INN - Innovations -
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
358,333$
Acct #Amount
8401 Client Fees -$
8402 Client Insurance -
8403 -
8404 -
8405 -
-$
MHSA TOTAL
Line Item Description
8100 - SUBSTANCE USE DISORDER FUNDS
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
Line Item Description
REALIGNMENT TOTAL
8200 - REALIGNMENT
NET PROGRAM COST:
Grants (Specify)
Other (Specify)
Other (Specify)
Line Item Description
8400 - OTHER REVENUE
TOTAL PROGRAM FUNDING SOURCES:358,333$
-$
SUBSTANCE USE DISORDER FUNDS TOTAL
OTHER REVENUE TOTAL
MHSA Program Name
Exhibit C - 5 of 58
Budget Narrative
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES & BENEFITS 237,498
Employee Salaries 200,587
1101 Rural Westside YEC Network Program Director 46,440 40 hrs./wk. @ $27/hr. - salaried position Luisa Avila - Direct based on timesheet,
responsible for financial and operational goals for the program, completes reporting to
the CEO
1102 Chief Education Director (YEC-CED)9,925 Chief Education Director, retired Principal Golden Plains, Mr. Espi Sandoval @
$23.08/hr - Direct expense based on timesheet. Responsible for accomplishing the
education goals of the program such as activities and programs that direclty relate to
education attainment and progress
1103 Firebaugh/Kerman/Mendota YEC Site & mini-
centers Supervisor
34,400 Program Supervisor, 40 hrs./wk. @ $20/hr. Mr. Felipe Perez - Direct expense based on
timesheet. Reports to the Director and responsbilities include supporting youth
council, supervision of staff, program oversight at each location, works as a liason
among community partners and schools.
1104 Huron/Coalinga YEC Sites Supervisor 34,400 Program Supervisor, vacant @ $20.00/hr. - Direct expense based on timesheet. Reports
to the Director and responsbilities include supporting youth council, supervision of
staff, program oversight at each location, works as a liason among community partners
and schools.
1105 Youth & Family Resource Navigator - YEC
Resources and Referrals
11,696 Parent Partner, 20 hrs./wk. @ $17/hr. Ms. Nancy Peters - Direct expense based on
timesheet. Oversight on the referrals and resources available to the individuals and
families and coordinates the linkages including warm handoff.
1106 YEC Parent Partners: Firebaugh; Kerman;
Huron; Coalinga
20,640 Four part-time Parent Partner positions, one assigned to each YEC @ $15.00/hr. -
Direct expense based on timesheet. Provide support for the acitivies and services
provided at the centers.
1107 Rural Westside YEC Network Stress
Management & Mindfulness Coach/Intern
6,880 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1108 Rural Westside YEC Network Nutrition &
Fitness Coach/Intern
6,880 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1109 Rural Westside YEC Network Restorative
Justice & Conflict Mediation Coach/Intern
6,880 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
Westside Family Preservation Services Network - Huron
Youth Empowerment Centers
Fiscal Year (FY) 2021-22
PROGRAM EXPENSE
Exhibit C - 6 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
1110 Rural Westside YEC Network Dating Violence,
Homelessness, & Bullying Coach/Intern
6,880 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1111 Rural Westside YEC Network Employment, Job
Interviews, Dress for Success, Resume Builder,
On-line Job Applications, & Workplace Skills
Coach/Intern
6,880 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1112 Rural Westside YEC Network Youth Navigator
for Positive Mental Health Resources &
Referrals/Intern
6,880 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1113 YEC Business Manager 1,806 YEC Business Manager, Mrs. Rose Spafford @ $21.00/hr. - Direct expense based on
timesheet. This position will ensure all expenses are collected and correct for financial
reporting.
1114 0 -
1115 0 -
1116 0 -
1117 0 -
1118 0 -
1119 0 -
1120 0 -
1121 0 -
1122 0 -
1123 0 -
1124 0 -
1125 0 -
1126 0 -
1127 0 -
1128 0 -
1129 0 -
1130 0 -
1131 0 -
1132 0 -
1133 0 -
1134 0 -
1135 0 -
Exhibit C - 7 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
Employee Benefits 18,357
1201 Retirement 3,457 3% Match of 1.0 FTE Personnel Salaries - Direct expense
1202 Worker's Compensation 1,504 0.75% of total Personnel Salaries & Wages - Direct expense
1203 Health Insurance 13,396 $450 mo. for 3.0 FTE Full Time Salaried Positions - Direct expense
1204 Other (specify)-
1205 Other (specify)-
1206 Other (specify)-
Payroll Taxes & Expenses:18,554
1301 OASDI 12,436 6.2% - Direct expense
1302 MEDICARE 2,909 1.45% - Direct expense
1303 SUI 3,209 3.6% on the first $7000.00 of Salaries & Wages - Direct expense
1304 Other (specify)-
1305 Other (specify)-
1306 Other (specify)-
2000: CLIENT SUPPORT 30,600
2001 Child Care 1,200 For community events for Transistion Aged Youth (TAY) - Direct expense
2002 Client Housing Support -
2003 Client Transportation & Support 4,000 Gas/Mileage to drivers for transportation program participants to technology classes at
Bitwise if ZOOM classes are not available. Estimated @ $333/mo - Direct expense
2004 Clothing, Food, & Hygiene 4,200 $105/mo. for snacks and water at two centers: Huron and Firebaugh sites - Direct
expense
2005 Education Support 11,000 $550/mo. for books and materials at two centers: Huron and Firebaugh - Direct
expense
2006 Employment Support 2,200 $110/mo. For job readiness materials, including basic clothing to be distributed at two
centers: Huron and Firebaugh - Direct
2007 Household Items for Clients -
2008 Medication Supports -
2009 Program Supplies - Medical -
2010 Utility Vouchers -
2011 Program Supplies - Client Enrichment Trips 8,000 Trips for participants, where they choose, but to places like water amusement parks,
national parks, and/or aquariums - Direct expenses for admission and commercial
transportation
2012 Other (specify)-
2013 Other (specify)-
Exhibit C - 8 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
2014 Other (specify)-
2015 Other (specify)-
2016 Other (specify)-
3000: OPERATING EXPENSES 31,140
3001 Telecommunications 7,600 $40/mo. Cell phone stipend for 13 paid positions and allocation of phone/internet
connection at four sites - Direct expenses
3002 Printing/Postage 3,200 $160/mo. for outside and inside printing, toner & copier maintenance at Huron and
Firebaugh YEC - Direct expense
3003 Office, Household & Program Supplies 2,000 $100/mo. for office, program supplies for activities for participants, like craft supplies,
etc. - Direct expense
3004 Advertising 1,000 $100/mo for a share of website and social media placements - Direct expense
3005 Staff Development & Training 2,200 Program budget for staff and participant training. Will vary depending upon program
emphasis. For instance, Michael J. Meade's Mosaic Multicultural Foundation programs
on education and cultural healing - Direct expense
3006 Staff Mileage 6,640 About 600 miles a month for each YEC @ $.50/mile for 8.0 FTE - Direct based on
mileage vouchers
3007 Subscriptions & Memberships -
3008 Vehicle Maintenance -
3009 Program Software - Apricot 360 8,500 Estimated yearly subscription cost - Direct for this program
3010 Other (specify)-
3011 Other (specify)-
3012 Other (specify)-
4000: FACILITIES & EQUIPMENT 15,840
4001 Building Maintenance 840 Divided between two sites: Firebaugh and Huron - Direct
4002 Rent/Lease Building 15,000 $750/mo. X 10 mos. For Firebaugh YEC; $250/mo. X 10 mos. X 3 sites, For portion of
shared facilities costs in Huron and Coalinga and Kerman sites - Direct
4003 Rent/Lease Equipment -
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities -
4007 Other (specify)-
4008 Other (specify)-
4009 Other (specify)-
Exhibit C - 9 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
4010 Other (specify)-
5000: SPECIAL EXPENSES 9,000
5001 Consultant (Network & Data Management)4,000 $100/mo for four sites, Network management - Direct expense
5002 HMIS (Health Management Information
System)
-
5003 Contractual/Consulting Services Higher
Education 4 All
-
5004 Translation Services -
5005 Apricot 360 - One time consultant set-up fee 5,000 Initial set up and training for ten users at all YEC sites - Direct expense
5006 Other (specify)-
5007 Other (specify)-
5008 Other (specify)-
6000: ADMINISTRATIVE EXPENSES 32,755
6001 Administrative Overhead 21,005 Indirect costs cover additional health benefits to non-salaried staff such as vision,
dental also covers all contract expenses not otherwise included in a line item. Indirect
allows for the efficient use of staff time and effort in allocating direct expenses.
Indirect expense
6002 Professional Liability Insurance -
6003 Accounting/Bookkeeping - Valley Business
Consulting & Training
6,000 $600/mo. For program bookkeeping, including the production of monthly invoices,
review timesheets, expenditure accounting and general ledger - Direct billed expense
6004 External Audit - Jaribu Nelson CPA 2,000 Portion of annual A-133 Single Audit - indirect billed expense
6005 Insurance (Specify):3,100 Portion of liability, automotive insurance costs. We have no licensed professionals in
this program and therefore no professional liability insurance - Indirect expense
6006 Payroll Services - Valley Business Consulting &
Training/Intuit payroll services
650 Weekly payroll processing at $5.00 per month x 13 paid employees - Intuit Payroll
Services - indirect expense
6007 Depreciation (Provider-Owned Equipment to
be Used for Program Purposes)
-
6008 Other (specify)-
6009 Other (specify)-
Exhibit C - 10 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
6010 Other (specify)-
6011 Other (specify)-
6012 Other (specify)-
Exhibit C - 11 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
7000: FIXED ASSETS 1,500
7001 Computer Equipment & Software 750 Desktop and software for Program Director - Direct
7002 Copiers, Cell Phones, Tablets, Devices to
Contain HIPAA Data
-
7003 Furniture & Fixtures 750 Tables, chairs, file cabinets for YEC sites in Huron & Firebaugh - Direct
7004 Leasehold/Tenant/Building Improvements -
7005 Other Assets over $500 with Lifespan of 2
Years +
-
7006 Assets over $5,000/unit (Specify)-
7007 Other (specify)-
7008 Other (specify)-
ACCT #
PROVIDE DETAILS OF METHODOLOGY(IES) USED IN DETERMINING MEDI-CAL
SERVICE RATES AND/OR SERVICE UNITS, IF APPLICABLE AND/OR AS REQUIRED
BY THE RFP
8001
8002
8003
8004
8005
8006
8007
8008
8009
8010
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE:358,333
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE:358,333
BUDGET CHECK:-
Other (Specify)
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
Plan Development
Assessment
Rehabilitation
Other (Specify)
PROGRAM FUNDING SOURCES
Collateral
LINE ITEM
Mental Health Services
Case Management
Crisis Services
Medication Support
Exhibit C - 12 of 58
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Rural Westside YEC Network Program
Director 1.00 -$ 56,160$ 56,160$
1102 Chief Education Director (YEC-CED)0.25 - 12,000 12,000
1103 Firebaugh/Kerman/Mendota YEC Site & mini-
centers Supervisor 1.00 - 41,600 41,600
1104 Huron/Coalinga YEC Sites Supervisor 1.00 - 41,600 41,600
1105 Youth & Family Resource Navigator - YEC
Resources and Referrals 0.40 - 14,144 14,144
1106 YEC Parent Partners: Firebaugh; Kerman;
Huron; Coalinga 1.60 - 24,960 24,960
1107 Rural Westside YEC Network Stress
Management & Mindfulness Coach/Intern 0.25 - 8,320 8,320
1108 Rural Westside YEC Network Nutrition &
Fitness Coach/Intern 0.25 - 8,320 8,320
1109 Rural Westside YEC Network Restorative
Justice & Conflict Mediation Coach/Intern 0.25 - 8,320 8,320
1110
Rural Westside YEC Network Dating
Violence, Homelessness, & Bullying
Coach/Intern
0.25 - 8,320 8,320
1111
Rural Westside YEC Network Employment,
Job Interviews, Dress for Success, Resume
Builder, On-line Job Applications, &
Workplace Skills Coach/Intern
0.25 - 8,320 8,320
1112
Rural Westside YEC Network Youth
Navigator for Positive Mental Health
Resources & Referrals/Intern
0.25 - 8,320 8,320
1113 YEC Business Manager 0.05 - 2,184 2,184
1114 - - -
1115 - - -
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
1121 - - -
1122 - - -
1123 - - -
1124 - - -
1125 - - -
1126 - - -
1127 - - -
1128 - - -
1129 - - -
Youth Empowerment Centers
Westside Family Preservation Services Network - Huron
Fiscal Year (FY) 2022-23
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Exhibit C - 13 of 58
1130 - - -
1131 - - -
1132 - - -
1133 - - -
1134 - - -
1135 - - -
Personnel Salaries Subtotal 6.80 -$ 242,568$ 242,568$
Employee Benefits
Acct #Admin Direct Total
1201 -$ 4,181$ 4,181$
1202 - 1,819 1,819
1203 - 16,200 16,200
1204 - - -
1205 - - -
1206 - - -
-$ 22,200$ 22,200$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1301 -$ 15,039$ 15,039$
1302 - 3,517 3,517
1303 - 3,881 3,881
1304 - - -
1305 - -
1306 - -
-$ 22,437$ 22,437$
-$ 287,205$ 287,205$
2000: CLIENT SUPPORT
Acct #Amount
2001 1,440$
2002 -
2003 4,800
2004 5,000
2005 13,200
2006 2,600
2007 -
2008 -
2009 -
2010 -
2011 12,000
2012 -
2013 -
2014 -
2015 -
2016 -
39,040$
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
DIRECT CLIENT CARE TOTAL
Household Items for Clients
Medication Supports
Program Supplies - Medical
Utility Vouchers
Participant Enrichment Trips
Other (Specify)
Client Housing Support
Client Transportation & Support
Clothing, Food, & Hygiene
Education Support
Employment Support
Other (Specify)
Other (Specify)
Other (Specify)
Payroll Taxes & Expenses Subtotal:
EMPLOYEE SALARIES & BENEFITS TOTAL:
Line Item Description
FICA/MEDICARE
SUI
Retirement
Worker's Compensation
Health Insurance
Other (Specify)
Other (Specify)
Other (Specify)
Child Care
Description
Employee Benefits Subtotal:
Description
OASDI
Exhibit C - 14 of 58
3000: OPERATING EXPENSES
Acct #Amount
3001 9,100$
3002 3,800
3003 2,400
3004 1,200
3005 2,200
3006 9,600
3007 -
3008 -
3009 8,500
3010 -
3011 -
3012 -
36,800$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 1,000$
4002 18,000
4003 -
4004 -
4005 -
4006 -
4007 -
4008 -
4009 -
4010 -
19,000$
5000: SPECIAL EXPENSES
Acct #Amount
5001 5,500$
5002 -
5003 -
5004 -
5005 -
5006 -
5007 -
5008 -
5,500$
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 28,691$
6002
6003 7,200
6004 2,400
6005 3,384
6006 780
6007 -
6008 -
6009 -
Other (Specify)
Other (Specify)
Administrative Overhead
Professional Liability Insurance
Accounting/Bookkeeping
External Audit
Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
Payroll Services
SPECIAL EXPENSES TOTAL:
Line Item Description
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Insurance (Specify):Cyber Security
FACILITIES/EQUIPMENT TOTAL:
Line Item Description
Consultant (Network & Data Management)
HMIS (Health Management Information System)
Contractual/Consulting Services (Specify)
Translation Services
Security
Utilities
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
OPERATING EXPENSES TOTAL:
Line Item Description
Building Maintenance
Rent/Lease Building
Rent/Lease Equipment
Rent/Lease Vehicles
Subscriptions & Memberships
Vehicle Maintenance
Program Software - Apricot 360
Other (Specify)
Other (Specify)
Other (Specify)
Telecommunications
Printing/Postage
Office, Household & Program Supplies
Advertising
Staff Development & Training
Staff Mileage
Line Item Description
Exhibit C - 15 of 58
6010 -
6011 -
6012 -
42,455$
7000: FIXED ASSETS
Acct #Amount
7001 -$
7002 -
7003 -
7004 -
7005 -
7006 -
7007 -
7008 -
-$
Acct #Service Units Rate Amount
8001 Mental Health Services 0 - -$
8002 Case Management 0 - -
8003 Crisis Services 0 - -
8004 Medication Support 0 - -
8005 Collateral 0 - -
8006 Plan Development 0 - -
8007 Assessment 0 - -
8008 Rehabilitation 0 - -
8009 0 - -
8010 0 - -
0 -$
0%
-
0%-
-$
Acct #Amount
8101 Drug Medi-Cal -$
8102 SABG -$
-$
Acct #Amount
8201 Realignment -$
-$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports -$
Line Item Description
REALIGNMENT TOTAL
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
MHSA Program Name
Federal Financial Participation (FFP) %
MEDI-CAL FFP TOTAL
8100 - SUBSTANCE USE DISORDER FUNDS
Line Item Description
SUBSTANCE USE DISORDER FUNDS TOTAL
8200 - REALIGNMENT
PROGRAM FUNDING SOURCES
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
Line Item Description
Estimated Specialty Mental Health Services Billing Totals:
Estimated % of Clients who are Medi-Cal Beneficiaries
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries
FIXED ASSETS EXPENSES TOTAL
TOTAL PROGRAM EXPENSES 430,000$
Other (Specify)
Other (Specify)
Assets over $5,000/unit (Specify)
Other (Specify)
Other (Specify)
Line Item Description
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
Leasehold/Tenant/Building Improvements
Other Assets over $500 with Lifespan of 2 Years +
ADMINISTRATIVE EXPENSES TOTAL
Other (Specify)
Other (Specify)
Other (Specify)
Exhibit C - 16 of 58
8302 PEI - Prevention & Early Intervention 430,000
8303 INN - Innovations -
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
430,000$
Acct #Amount
8401 Client Fees -$
8402 Client Insurance -
8403
8404
8405 -
-$ OTHER REVENUE TOTAL
TOTAL PROGRAM FUNDING SOURCES:430,000$
NET PROGRAM COST: -$
MHSA TOTAL
8400 - OTHER REVENUE
Line Item Description
Grants (Specify)
Other (Specify)
Other (Specify)
Exhibit C - 17 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES & BENEFITS 287,205
Employee Salaries 242,568
1101 Rural Westside YEC Network Program Director 56,160 40 hrs./wk. @ $27/hr. - salaried position Luisa Avila - Direct based on timesheet,
responsible for financial and operational goals for the program, completes reporting to
1102 Chief Education Director (YEC-CED)12,000 Chief Education Director, retired Principal Golden Plains, Mr. Espi Sandoval @ $23.08/hr -
1103 Firebaugh/Kerman/Mendota YEC Site & mini-
centers Supervisor
41,600 Program Supervisor, 40 hrs./wk. @ $20/hr. Mr. Felipe Perez - Direct expense based on
timesheet. Reports to the Director and responsbilities include supporting youth council,
1104 Huron/Coalinga YEC Sites Supervisor 41,600 Program Supervisor, vacant @ $20.00/hr. - Direct expense based on timesheet. Reports
to the Director and responsbilities include supporting youth council, supervision of staff,
1105 Youth & Family Resource Navigator - YEC
Resources and Referrals
14,144 Parent Partner, 20 hrs./wk. @ $17/hr. Ms. Nancy Peters - Direct expense based on
timesheet. Oversight on the referrals and resources available to the individuals and
1106 YEC Parent Partners: Firebaugh; Kerman;
Huron; Coalinga
24,960 Four part-time Parent Partner positions, one assigned to each YEC @ $15.00/hr. - Direct
expense based on timesheet. Provide support for the acitivies and services provided at
1107 Rural Westside YEC Network Stress
Management & Mindfulness Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to build
and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1108 Rural Westside YEC Network Nutrition &
Fitness Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to build
and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1109 Rural Westside YEC Network Restorative
Justice & Conflict Mediation Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to build
and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1110 Rural Westside YEC Network Dating Violence,
Homelessness, & Bullying Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to build
and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1111 Rural Westside YEC Network Employment, Job
Interviews, Dress for Success, Resume Builder,
On-line Job Applications, & Workplace Skills
Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to build
and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1112 Rural Westside YEC Network Youth Navigator
for Positive Mental Health Resources &
Referrals/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to build
and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
Youth Empowerment Centers
Westside Family Preservation Services Network - Huron
Fiscal Year (FY) 2022-23 Budget Narrative
PROGRAM EXPENSE
Exhibit C - 18 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
1113 YEC Business Manager 2,184 YEC Business Manager, Mrs. Rose Spafford @ $21.00/hr. - Direct expense based on
timesheet. This position will ensure all expenses are collected and correct for financial
reporting.
1114 0 -
1115 0 -
1116 0 -
1117 0 -
1118 0 -
1119 0 -
1120 0 -
1121 0 -
1122 0 -
1123 0 -
1124 0 -
1125 0 -
1126 0 -
1127 0 -
1128 0 -
1129 0 -
1130 0 -
1131 0 -
1132 0 -
1133 0 -
1134 0 -
1135 0 -
Employee Benefits 22,200
1201 Retirement 4,181 3% Match of 1.0 FTE Personnel Salaries - Direct expense
1202 Worker's Compensation 1,819 0.75% of total Personnel Salaries & Wages - Direct expense
1203 Health Insurance 16,200 $450 mo. for 3.0 FTE Full Time Salaried Positions - Direct expense
1204 Other (Specify)-
1205 Other (Specify)-
1206 Other (Specify)-
Payroll Taxes & Expenses:22,437
1301 OASDI 15,039 6.2% - Direct expense
1302 FICA/MEDICARE 3,517 1.45% - Direct expense
Exhibit C - 19 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
1303 SUI 3,881 3.6% on the first $7000.00 of Salaries & Wages - Direct expense
1304 Other (Specify)-
1305 Other (Specify)-
1306 Other (Specify)-
2000: CLIENT SUPPORT 39,040
2001 Child Care 1,440 For community events for Transistion Aged Youth (TAY) - Direct expense
2002 Client Housing Support -
2003 Client Transportation & Support 4,800 Gas/Mileage to drivers for transportation program participants to technology classes at
Bitwise if ZOOM classes are not available. Estimated @ $333/mo - Direct expense
2004 Clothing, Food, & Hygiene 5,000 $105/mo. for snacks and water at two centers: Huron and Firebaugh sites - Direct
expense
2005 Education Support 13,200 $550/mo. for books and materials at two centers: Huron and Firebaugh - Direct expense
2006 Employment Support 2,600 $110/mo. For job readiness materials, including basic clothing to be distributed at two
centers: Huron and Firebaugh - Direct
2007 Household Items for Clients -
2008 Medication Supports -
2009 Program Supplies - Medical -
2010 Utility Vouchers -
2011 Participant Enrichment Trips 12,000 Trips for participants, where they choose, but to places like water amusement parks,
national parks, and/or aquariums - Direct expenses for admission and commercial
transportation
2012 Other (Specify)-
2013 Other (Specify)-
2014 Other (Specify)-
2015 Other (Specify)-
2016 Other (Specify)-
3000: OPERATING EXPENSES 36,800
3001 Telecommunications 9,100 $40/mo. Cell phone stipend for 13 paid positions and allocation of phone/internet
connection at four sites - Direct expenses
3002 Printing/Postage 3,800 $160/mo. for outside and inside printing, toner & copier maintenance at Huron and
Firebaugh YEC - Direct expense
3003 Office, Household & Program Supplies 2,400 $100/mo. for office, program supplies for activities for participants, like craft supplies,
etc. - Direct expense
Exhibit C - 20 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
3004 Advertising 1,200 $100/mo for a share of website and social media placements - Direct expense
3005 Staff Development & Training 2,200 Program budget for staff and participant training. Will vary depending upon program
emphasis. For instance, Michael J. Meade's Mosaic Multicultural Foundation programs
on education and cultural healing - Direct expense
3006 Staff Mileage 9,600 About 600 miles a month for each YEC @ $.50/mile for 8.0 FTE - Direct based on mileage
vouchers
3007 Subscriptions & Memberships - 0
3008 Vehicle Maintenance - 0
3009 Program Software - Apricot 360 8,500 Estimated yearly subscription cost - Direct for this program
3010 Other (Specify)-
3011 Other (Specify)-
3012 Other (Specify)-
4000: FACILITIES & EQUIPMENT 19,000
4001 Building Maintenance 1,000 Divided between two sites: Firebaugh and Huron - Direct
4002 Rent/Lease Building 18,000 $750/mo. X 10 mos. For Firebaugh YEC; $250/mo. X 10 mos. X 3 sites, For portion of
shared facilities costs in Huron and Coalinga and Kerman sites - Direct
4003 Rent/Lease Equipment -
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities -
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
5000: SPECIAL EXPENSES 5,500
5001 Consultant (Network & Data Management)5,500 $100/mo for four sites, Network management - Direct expense
5002 HMIS (Health Management Information
System)
-
5003 Contractual/Consulting Services (Specify)-
5004 Translation Services -
5005 Other (Specify)-
5006 Other (Specify)-
Exhibit C - 21 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
5007 Other (Specify)-
5008 Other (Specify)-
6000: ADMINISTRATIVE EXPENSES 42,455
6001 Administrative Overhead 28,691 Indirect costs cover additional health benefits to non-salaried staff such as vision, dental
also covers all contract expenses not otherwise included in a line item. Indirect allows for
the efficient use of staff time and effort in allocating direct expenses. Indirect expense
6002 Professional Liability Insurance - 0
6003 Accounting/Bookkeeping 7,200 $600/mo. For program bookkeeping, including the production of monthly invoices,
review timesheets, expenditure accounting and general ledger - Direct billed expense
6004 External Audit 2,400 Portion of annual A-133 Single Audit - indirect billed expense
6005 Insurance (Specify):Cyber Security 3,384 Portion of liability, automotive insurance costs. We have no licensed professionals in this
program and therefore no professional liability insurance - Indirect expense
6006 Payroll Services 780 Weekly payroll processing at $5.00 per month x 13 paid employees - Intuit Payroll
Services - indirect expense
6007 Depreciation (Provider-Owned Equipment to
be Used for Program Purposes)
-
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
7000: FIXED ASSETS -
7001 Computer Equipment & Software -
7002 Copiers, Cell Phones, Tablets, Devices to
Contain HIPAA Data
-
7003 Furniture & Fixtures -
7004 Leasehold/Tenant/Building Improvements -
7005 Other Assets over $500 with Lifespan of 2
Years +
-
7006 Assets over $5,000/unit (Specify)-
Exhibit C - 22 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
7007 Other (Specify)-
7008 Other (Specify)-
ACCT #
PROVIDE DETAILS OF METHODOLOGY(IES) USED IN DETERMINING MEDI-CAL
SERVICE RATES AND/OR SERVICE UNITS, IF APPLICABLE AND/OR AS REQUIRED
BY THE RFP
8001
8002
8003
8004
8005
8006
8007
8008
8009
8010
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE:430,000
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE:430,000
BUDGET CHECK:-
Other (Specify)
Collateral
Plan Development
Assessment
Rehabilitation
Other (Specify)
PROGRAM FUNDING SOURCES
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
Mental Health Services
Case Management
Crisis Services
Medication Support
LINE ITEM
Exhibit C - 23 of 58
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Rural Westside YEC Network Program
Director 1.00 -$ 56,160$ 56,160$
1102 Chief Education Director (YEC-CDE)0.25 - 12,000$ 12,000
1103 Firebaugh/Kerman/Mendota YEC Site & mini-
centers Supervisor 1.00 - 41,600$ 41,600
1104 Huron/Coalinga YEC Sites Supervisor 1.00 - 41,600$ 41,600
1105 Youth & Family Resource Navigator - YEC
Resources and Referrals 0.40 - 14,144$ 14,144
1106 YEC Parent Partners: Firebaugh; Kerman;
Huron; Coalinga 1.60 - 24,960$ 24,960
1107 Rural Westside YEC Net5work Stress
Management & Mindfulness Coach/Intern 0.25 - 8,320$ 8,320
1108 Rural Westside YEC Network Nutrition &
Fitness Coach/Intern 0.25 - 8,320$ 8,320
1109 Rural Westside YEC Network Restorative
Justice & Confilict Mediation Coach/Intern 0.25 - 8,320$ 8,320
1110
Rural Westside YEC Network Dating
Violence, Homelessness & Bullying
Coach/Intern
0.25 - 8,320$ 8,320
1111
Rural Westside YEC Network Employment,
Job Interviews, Dress for Success, Resume
Builder, On-line Job applications &
Workplace Skills Coach/Intern
0.25 - 8,320$ 8,320
1112
Rural Westside YEC Network Youth
Navigator for Positive Mental Health
Resources & Referrals/Intern
0.25 - 8,320$ 8,320
1113 YEC Business Manager 0.05 - 2,200$ 2,200
1114 - - -
1115 - - -
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
1121 - - -
1122 - - -
1123 - - -
1124 - - -
1125 - - -
Youth Empowerment Centers
Westside Family Preservation Services Network - Huron
Fiscal Year (FY) 2023-24
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Exhibit C - 24 of 58
1126 - - -
1127 - - -
1128 - - -
1129 - - -
1130 - - -
1131 - - -
1132 - - -
1133 - - -
1134 - - -
1135 - - -
Personnel Salaries Subtotal 6.80 -$ 242,584$ 242,584$
Employee Benefits
Acct #Admin Direct Total
1201 -$ 4,181$ 4,181$
1202 - 1,819$ 1,819
1203 - 17,100$ 17,100
1204 - - -
1205 - - -
1206 - - -
-$ 23,100$ 23,100$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1301 -$ 15,043$ 15,043$
1302 - 3,518$ 3,518
1303 - 3,882$ 3,882
1304 - - -
1305 - -
1306 - -
-$ 22,443$ 22,443$
-$ 288,127$ 288,127$
2000: CLIENT SUPPORT
Acct #Amount
2001 1,440$
2002 -$
2003 5,000$
2004 5,000$
2005 13,200$
2006 2,600$
2007 -$
2008 -$
2009 -$
2010 -$
2011 12,000$
2012 -
2013 -
2014 -
2015 -
2016 -
39,240$
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
DIRECT CLIENT CARE TOTAL
Household Items for Clients
Medication Supports
Program Supplies - Medical
Utility Vouchers
Participant Enrichment Trips
Other (Specify)
Client Housing Support
Client Transportation & Support
Clothing, Food, & Hygiene
Education Support
Employment Support
Other (Specify)
Other (Specify)
Other (Specify)
Payroll Taxes & Expenses Subtotal:
EMPLOYEE SALARIES & BENEFITS TOTAL:
Line Item Description
MEDICARE
SUI
Retirement
Worker's Compensation
Health Insurance
Other (Specify)
Other (Specify)
Other (Specify)
Child Care
Description
Employee Benefits Subtotal:
Description
OASDI
Exhibit C - 25 of 58
3000: OPERATING EXPENSES
Acct #Amount
3001 9,100$
3002 3,800$
3003 2,400$
3004 1,200$
3005 2,200$
3006 9,600$
3007 -$
3008 -$
3009 8,500$
3010 -
3011 -
3012 -
36,800$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 1,000$
4002 18,000$
4003 -
4004 -
4005 -
4006 -
4007 -
4008 -
4009 -
4010 -
19,000$
5000: SPECIAL EXPENSES
Acct #Amount
5001 5,500$
5002 -
5003 -
5004 -
5005 -
5006 -
5007 -
5008 -
5,500$ SPECIAL EXPENSES TOTAL:
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
FACILITIES/EQUIPMENT TOTAL:
Line Item Description
Consultant (Network & Data Management)
HMIS (Health Management Information System)
Contractual/Consulting Services (Specify)
Translation Services
Security
Utilities
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
OPERATING EXPENSES TOTAL:
Line Item Description
Building Maintenance
Rent/Lease Building
Rent/Lease Equipment
Rent/Lease Vehicles
Subscriptions & Memberships
Vehicle Maintenance
Program Software - Apricot 360
Other (Specify)
Other (Specify)
Other (Specify)
Telecommunications
Printing/Postage
Office, Household & Program Supplies
Advertising
Staff Development & Training
Staff Mileage
Line Item Description
Exhibit C - 26 of 58
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 27,569$
6002 -
6003 7,200
6004 2,400
6005 3,384
6006 780
6007 -
6008 -
6009 -
6010 -
6011 -
6012 -
41,333$
7000: FIXED ASSETS
Acct #Amount
7001 -$
7002 -
7003 -
7004 -
7005 -
7006 -
7007 -
7008 -
-$
Acct #Service Units Rate Amount
8001 Mental Health Services 0 - -$
8002 Case Management 0 - -
8003 Crisis Services 0 - -
8004 Medication Support 0 - -
8005 Collateral 0 - -
8006 Plan Development 0 - -
8007 Assessment 0 - -
8008 Rehabilitation 0 - -
8009 0 - -
8010 0 - -
0 -$
0%
-
0%-
-$
Federal Financial Participation (FFP) %
MEDI-CAL FFP TOTAL
8100 - SUBSTANCE USE DISORDER FUNDS
PROGRAM FUNDING SOURCES
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
Line Item Description
Estimated Specialty Mental Health Services Billing Totals:
Estimated % of Clients who are Medi-Cal Beneficiaries
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries
FIXED ASSETS EXPENSES TOTAL
TOTAL PROGRAM EXPENSES 430,000$
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Assets over $5,000/unit (Specify)
Line Item Description
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
Leasehold/Tenant/Building Improvements
Other Assets over $500 with Lifespan of 2 Years +
ADMINISTRATIVE EXPENSES TOTAL
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Administrative Overhead
Professional Liability Insurance
Accounting/Bookkeeping
External Audit
Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
Payroll Services
Line Item Description
Insurance (Specify):
Exhibit C - 27 of 58
Acct #Amount
8101 Drug Medi-Cal -$
8102 SABG -$
-$
Acct #Amount
8201 Realignment -$
-$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports -$
8302 PEI - Prevention & Early Intervention 430,000
8303 INN - Innovations -
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
430,000$
Acct #Amount
8401 Client Fees -$
8402 Client Insurance -
8403 -
8404 -
8405 -
-$ OTHER REVENUE TOTAL
TOTAL PROGRAM FUNDING SOURCES:430,000$
NET PROGRAM COST: -$
MHSA TOTAL
8400 - OTHER REVENUE
Line Item Description
Grants (Specify)
Other (Specify)
Other (Specify)
Line Item Description
REALIGNMENT TOTAL
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
MHSA Program Name
Line Item Description
SUBSTANCE USE DISORDER FUNDS TOTAL
8200 - REALIGNMENT
Exhibit C - 28 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES & BENEFITS 288,127
Employee Salaries 242,584
1101 Rural Westside YEC Network Program
Director
56,160 40 hrs./wk. @ $27/hr. - salaried position Luisa Avila - Direct based on timesheet,
responsible for financial and operational goals for the program, completes reporting to
1102 Chief Education Director (YEC-CDE)12,000 Chief Education Director, retired Principal Golden Plains, Mr. Espi Sandoval @ $23.08/hr
- Direct expense based on timesheet. Responsible for accomplishing the education goals
1103 Firebaugh/Kerman/Mendota YEC Site & mini-
centers Supervisor
41,600 Program Supervisor, 40 hrs./wk. @ $20/hr. Mr. Felipe Perez - Direct expense based on
timesheet. Reports to the Director and responsbilities include supporting youth council,
1104 Huron/Coalinga YEC Sites Supervisor 41,600 Program Supervisor, vacant @ $20.00/hr. - Direct expense based on timesheet. Reports
to the Director and responsbilities include supporting youth council, supervision of staff,
1105 Youth & Family Resource Navigator - YEC
Resources and Referrals
14,144 Parent Partner, 20 hrs./wk. @ $17/hr. Ms. Nancy Peters - Direct expense based on
timesheet. Oversight on the referrals and resources available to the individuals and
1106 YEC Parent Partners: Firebaugh; Kerman;
Huron; Coalinga
24,960 Four part-time Parent Partner positions, one assigned to each YEC @ $15.00/hr. - Direct
expense based on timesheet. Provide support for the acitivies and services provided at
1107 Rural Westside YEC Net5work Stress
Management & Mindfulness Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1108 Rural Westside YEC Network Nutrition &
Fitness Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
1109 Rural Westside YEC Network Restorative
Justice & Confilict Mediation Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1110 Rural Westside YEC Network Dating Violence,
Homelessness & Bullying Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1111 Rural Westside YEC Network Employment,
Job Interviews, Dress for Success, Resume
Builder, On-line Job applications &
Workplace Skills Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
Youth Empowerment Centers
Westside Family Preservation Services Network - Huron
Fiscal Year (FY) 2023-24 Budget Narrative
PROGRAM EXPENSE
Exhibit C - 29 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
1112 Rural Westside YEC Network Youth Navigator
for Positive Mental Health Resources &
Referrals/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1113 YEC Business Manager 2,200 YEC Business Manager, Mrs. Rose Spafford @ $21.00/hr. - Direct expense based on
timesheet. This position will ensure all expenses are collected and correct for financial
reporting.
1114 0 -
1115 0 -
1116 0 -
1117 0 -
1118 0 -
1119 0 -
1120 0 -
1121 0 -
1122 0 -
1123 0 -
1124 0 -
1125 0 -
1126 0 -
1127 0 -
1128 0 -
1129 0 -
1130 0 -
1131 0 -
1132 0 -
1133 0 -
1134 0 -
1135 0 -
Employee Benefits 23,100
1201 Retirement 4,181 3% Match of 1.0 FTE Personnel Salaries - Direct expense
1202 Worker's Compensation 1,819 0.75% of total Personnel Salaries & Wages - Direct expense
1203 Health Insurance 17,100 $450 mo. for 3.0 FTE Full Time Salaried Positions - Direct expense
1204 Other (Specify)-
1205 Other (Specify)-
Exhibit C - 30 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
1206 Other (Specify)-
Payroll Taxes & Expenses:22,443
1301 OASDI 15,043 6.2% - Direct expense
1302 MEDICARE 3,518 1.45% - Direct expense
1303 SUI 3,882 3.6% on the first $7000.00 of Salaries & Wages - Direct expense
1304 Other (Specify)-
1305 Other (Specify)-
1306 Other (Specify)-
2000: CLIENT SUPPORT 39,240
2001 Child Care 1,440 For community events for Transistion Aged Youth (TAY) - Direct expense
2002 Client Housing Support - 0
2003 Client Transportation & Support 5,000 Gas/Mileage to drivers for transportation program participants to technology classes at
Bitwise if ZOOM classes are not available. Estimated @ $333/mo - Direct expense
2004 Clothing, Food, & Hygiene 5,000 $105/mo. for snacks and water at two centers: Huron and Firebaugh sites - Direct
expense
2005 Education Support 13,200 $550/mo. for books and materials at two centers: Huron and Firebaugh - Direct expense
2006 Employment Support 2,600 $110/mo. For job readiness materials, including basic clothing to be distributed at two
centers: Huron and Firebaugh - Direct
2007 Household Items for Clients -
2008 Medication Supports -
2009 Program Supplies - Medical -
2010 Utility Vouchers -
2011 Participant Enrichment Trips 12,000 Trips for participants, where they choose, but to places like water amusement parks,
national parks, and/or aquariums - Direct expenses for admission and commercial
transportation
2012 Other (Specify)-
2013 Other (Specify)-
2014 Other (Specify)-
2015 Other (Specify)-
2016 Other (Specify)-
Exhibit C - 31 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
3000: OPERATING EXPENSES 36,800
3001 Telecommunications 9,100 $40/mo. Cell phone stipend for 13 paid positions and allocation of phone/internet
connection at four sites - Direct expenses
3002 Printing/Postage 3,800 $160/mo. for outside and inside printing, toner & copier maintenance at Huron and
Firebaugh YEC - Direct expense
3003 Office, Household & Program Supplies 2,400 $100/mo. for office, program supplies for activities for participants, like craft supplies,
etc. - Direct expense
3004 Advertising 1,200 $100/mo for a share of website and social media placements - Direct expense
3005 Staff Development & Training 2,200 Program budget for staff and participant training. Will vary depending upon program
emphasis. For instance, Michael J. Meade's Mosaic Multicultural Foundation programs
on education and cultural healing - Direct expense
3006 Staff Mileage 9,600 About 600 miles a month for each YEC @ $.50/mile for 8.0 FTE - Direct based on
mileage vouchers
3007 Subscriptions & Memberships - 0
3008 Vehicle Maintenance - 0
3009 Program Software - Apricot 360 8,500 Estimated yearly subscription cost - Direct for this program
3010 Other (Specify)-
3011 Other (Specify)-
3012 Other (Specify)-
4000: FACILITIES & EQUIPMENT 19,000
4001 Building Maintenance 1,000 Divided between two sites: Firebaugh and Huron - Direct
4002 Rent/Lease Building 18,000 $750/mo. X 10 mos. For Firebaugh YEC; $250/mo. X 10 mos. X 3 sites, For portion of
shared facilities costs in Huron and Coalinga and Kerman sites - Direct
4003 Rent/Lease Equipment -
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities -
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
Exhibit C - 32 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
5000: SPECIAL EXPENSES 5,500
5001 Consultant (Network & Data Management)5,500 $100/mo for four sites, Network management - Direct expense
5002 HMIS (Health Management Information
System)
-
5003 Contractual/Consulting Services (Specify)-
5004 Translation Services -
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
6000: ADMINISTRATIVE EXPENSES 41,333
6001 Administrative Overhead 27,569 Indirect costs cover additional health benefits to non-salaried staff such as vision, dental
also covers all contract expenses not otherwise included in a line item. Indirect allows
for the efficient use of staff time and effort in allocating direct expenses. Indirect
expense
6002 Professional Liability Insurance -
6003 Accounting/Bookkeeping 7,200 $600/mo. For program bookkeeping, including the production of monthly invoices,
review timesheets, expenditure accounting and general ledger - Direct billed expense
6004 External Audit 2,400 Portion of annual A-133 Single Audit - indirect billed expense
6005 Insurance (Specify):3,384 Portion of liability, automotive insurance costs. We have no licensed professionals in
this program and therefore no professional liability insurance - Indirect expense
6006 Payroll Services 780 Weekly payroll processing at $5.00 per month x 13 paid employees - Intuit Payroll
Services - indirect expense
6007 Depreciation (Provider-Owned Equipment to
be Used for Program Purposes)
-
6008 Other (Specify)-
6009 Other (Specify)-
Exhibit C - 33 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
7000: FIXED ASSETS -
7001 Computer Equipment & Software -
7002 Copiers, Cell Phones, Tablets, Devices to
Contain HIPAA Data
-
7003 Furniture & Fixtures -
7004 Leasehold/Tenant/Building Improvements -
7005 Other Assets over $500 with Lifespan of 2
Years +
-
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
ACCT #
PROVIDE DETAILS OF METHODOLOGY(IES) USED IN DETERMINING MEDI-CAL
SERVICE RATES AND/OR SERVICE UNITS, IF APPLICABLE AND/OR AS REQUIRED
BY THE RFP
8001
8002
8003
8004
8005
8006
8007
8008
8009
8010 Other (Specify)
Collateral
Plan Development
Assessment
Rehabilitation
Other (Specify)
PROGRAM FUNDING SOURCES
Medication Support
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
LINE ITEM
Mental Health Services
Case Management
Crisis Services
Exhibit C - 34 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE:430,000
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE:430,000
BUDGET CHECK:-
Exhibit C - 35 of 58
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Rural Westside YEC Network Program
Director 1.00 -$ 56,160$ 56,160$
1102 Chief Education Director (YEC-CED)0.25 - 12,000 12,000
1103 Firebaugh/Kerman/Mendota YEC Site & mini-
centers Supervisor 1.00 - 41,600 41,600
1104 Huron/Coalinga YEC Sites Supervisor 1.00 - 41,600 41,600
1105 Youth & Family Resource Navigator - YEC
Resources & Referrals 0.40 - 14,144 14,144
1106 YEC Parent Partners: Firebaugh; Kerman;
Huron; Coalinga 1.60 - 24,960 24,960
1107 Rural Westside YEC Network Stress
Management & Midfulness Coach/Intern 0.25 - 8,320 8,320
1108 Rural Westside YEC Network Nutrition &
Fitness Coach/Intern 0.25 - 8,320 8,320
1109 Rural Westside YEC Network Restorative
Justice & Conflict Mediation Coach/Intern 0.25 - 8,320 8,320
1110
Rural Westside YEC Network Dating
Violence, Homelessness & Bullying
Coach/Intern
0.25 - 8,320 8,320
1111
Rural Westside YEC Network Employment,
Job Interviews, Dress for Success, Resume
Builder, On-line Job Applications &
Workplace Skills Coach/Intern
0.25 - 8,320 8,320
1112
Rural Westside YEC Network Youth
Navigator for Positive Mental Health
Resources & Referrals/Intern
0.25 - 8,320 8,320
1113 YEC Business Manager 0.05 - 2,200 2,200
1114 - - -
1115 - - -
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
1121 - - -
1122 - - -
1123 - - -
1124 - - -
1125 - - -
1126 - - -
Youth Empowerment Centers
Westside Family Preservation Services Network - Huron
Fiscal Year (FY) 2024-25
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Exhibit C - 36 of 58
1127 - - -
1128 - - -
1129 - - -
1130 - - -
1131 - - -
1132 - - -
1133 - - -
1134 - - -
1135 - - -
Personnel Salaries Subtotal 6.80 -$ 242,584$ 242,584$
Employee Benefits
Acct #Admin Direct Total
1201 -$ 4,181$ 4,181$
1202 - 1,819 1,819
1203 - 17,100 17,100
1204 - - -
1205 - - -
1206 - - -
-$ 23,100$ 23,100$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1301 -$ 15,043$ 15,043$
1302 - 3,518 3,518
1303 - 3,882 3,882
1304 - - -
1305 - - -
1306 - - -
-$ 22,443$ 22,443$
-$ 288,127$ 288,127$
2000: CLIENT SUPPORT
Acct #Amount
2001 1,440$
2002 -
2003 5,000
2004 5,000
2005 13,200
2006 2,600
2007 -
2008 -
2009 -
2010 -
2011 12,000
2012 -
2013 -
2014 -
2015 -
2016 -
39,240$
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
DIRECT CLIENT CARE TOTAL
Household Items for Clients
Medication Supports
Program Supplies - Medical
Utility Vouchers
Participant Enrichment Trips
Other (Specify)
Client Housing Support
Client Transportation & Support
Clothing, Food, & Hygiene
Education Support
Employment Support
Other (Specify)
Other (Specify)
Other (Specify)
Payroll Taxes & Expenses Subtotal:
EMPLOYEE SALARIES & BENEFITS TOTAL:
Line Item Description
MEDICARE
SUI
Retirement
Worker's Compensation
Health Insurance
Other (Specify)
Other (Specify)
Other (Specify)
Child Care
Description
Employee Benefits Subtotal:
Description
OASDI
Exhibit C - 37 of 58
3000: OPERATING EXPENSES
Acct #Amount
3001 9,100$
3002 3,800
3003 2,400
3004 1,200
3005 2,200
3006 9,600
3007 -
3008 -
3009 8,500
3010 -
3011 -
3012 -
36,800$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 1,000$
4002 18,000
4003 -
4004 -
4005 -
4006 -
4007 -
4008 -
4009 -
4010 -
19,000$
5000: SPECIAL EXPENSES
Acct #Amount
5001 5,500$
5002 -
5003 -
5004 -
5005 -
5006 -
5007 -
5008 -
5,500$ SPECIAL EXPENSES TOTAL:
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
FACILITIES/EQUIPMENT TOTAL:
Line Item Description
Consultant (Network & Data Management)
HMIS (Health Management Information System)
Contractual/Consulting Services (Specify)
Translation Services
Security
Utilities
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
OPERATING EXPENSES TOTAL:
Line Item Description
Building Maintenance
Rent/Lease Building
Rent/Lease Equipment
Rent/Lease Vehicles
Subscriptions & Memberships
Vehicle Maintenance
Program Software - Apricot 360
Other (Specify)
Other (Specify)
Other (Specify)
Telecommunications
Printing/Postage
Office, Household & Program Supplies
Advertising
Staff Development & Training
Staff Mileage
Line Item Description
Exhibit C - 38 of 58
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 27,569$
6002 -
6003 7,200
6004 2,400
6005 3,384
6006 780
6007 -
6008 -
6009 -
6010 -
6011 -
6012 -
41,333$
7000: FIXED ASSETS
Acct #Amount
7001 -$
7002 -
7003 -
7004 -
7005 -
7006 -
7007 -
7008 -
-$
Acct #Service Units Rate Amount
8001 Mental Health Services 0 - -$
8002 Case Management 0 - -
8003 Crisis Services 0 - -
8004 Medication Support 0 - -
8005 Collateral 0 - -
8006 Plan Development 0 - -
8007 Assessment 0 - -
8008 Rehabilitation 0 - -
8009 0 - -
8010 0 - -
0 -$
0%
-
0%-
-$
Federal Financial Participation (FFP) %
MEDI-CAL FFP TOTAL
8100 - SUBSTANCE USE DISORDER FUNDS
PROGRAM FUNDING SOURCES
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
Line Item Description
Estimated Specialty Mental Health Services Billing Totals:
Estimated % of Clients who are Medi-Cal Beneficiaries
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries
FIXED ASSETS EXPENSES TOTAL
TOTAL PROGRAM EXPENSES 430,000$
Other (Specify)
Other (Specify)
Assets over $5,000/unit (Specify)
Other (Specify)
Other (Specify)
Line Item Description
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
Leasehold/Tenant/Building Improvements
Other Assets over $500 with Lifespan of 2 Years +
ADMINISTRATIVE EXPENSES TOTAL
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Administrative Overhead
Professional Liability Insurance
Accounting/Bookkeeping
External Audit
Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
Payroll Services
Line Item Description
Insurance (Gen. Liab, Cyber-security):
Exhibit C - 39 of 58
Acct #Amount
8101 Drug Medi-Cal -$
8102 SABG -$
-$
Acct #Amount
8201 Realignment -$
-$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports -$
8302 PEI - Prevention & Early Intervention 430,000
8303 INN - Innovations -
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
430,000$
Acct #Amount
8401 Client Fees -$
8402 Client Insurance -
8403 -
8404 -
8405 -
-$ OTHER REVENUE TOTAL
TOTAL PROGRAM FUNDING SOURCES:430,000$
NET PROGRAM COST: -$
MHSA TOTAL
8400 - OTHER REVENUE
Line Item Description
Grants (Specify)
Other (Specify)
Other (Specify)
Line Item Description
REALIGNMENT TOTAL
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
MHSA Program Name
Line Item Description
SUBSTANCE USE DISORDER FUNDS TOTAL
8200 - REALIGNMENT
Exhibit C - 40 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES & BENEFITS 288,127
Employee Salaries 242,584
1101 Rural Westside YEC Network Program
Director
56,160 40 hrs./wk. @ $27/hr. - salaried position Luisa Avila - Direct based on timesheet,
responsible for financial and operational goals for the program, completes reporting to
the CEO
1102 Chief Education Director (YEC-CED)12,000 Chief Education Director, retired Principal Golden Plains, Mr. Espi Sandoval @ $23.08/hr
- Direct expense based on timesheet. Responsible for accomplishing the education goals
of the program such as activities and programs that direclty relate to education
1103 Firebaugh/Kerman/Mendota YEC Site & mini-
centers Supervisor
41,600 Program Supervisor, 40 hrs./wk. @ $20/hr. Mr. Felipe Perez - Direct expense based on
timesheet. Reports to the Director and responsbilities include supporting youth council,
supervision of staff, program oversight at each location, works as a liason among
community partners and schools.
1104 Huron/Coalinga YEC Sites Supervisor 41,600 Program Supervisor, vacant @ $20.00/hr. - Direct expense based on timesheet. Reports
to the Director and responsbilities include supporting youth council, supervision of staff,
program oversight at each location, works as a liason among community partners and
schools.
1105 Youth & Family Resource Navigator - YEC
Resources & Referrals
14,144 Parent Partner, 20 hrs./wk. @ $17/hr. Ms. Nancy Peters - Direct expense based on
timesheet. Oversight on the referrals and resources available to the individuals and
families and coordinates the linkages including warm handoff.
1106 YEC Parent Partners: Firebaugh; Kerman;
Huron; Coalinga
24,960 Four part-time Parent Partner positions, one assigned to each YEC @ $15.00/hr. - Direct
expense based on timesheet. Provide support for the acitivies and services provided at
the centers.
1107 Rural Westside YEC Network Stress
Management & Midfulness Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1108 Rural Westside YEC Network Nutrition &
Fitness Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
Youth Empowerment Centers
Westside Family Preservation Services Network - Huron
Fiscal Year (FY) 2024-25 Budget Narrative
PROGRAM EXPENSE
Exhibit C - 41 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
1109 Rural Westside YEC Network Restorative
Justice & Conflict Mediation Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1110 Rural Westside YEC Network Dating Violence,
Homelessness & Bullying Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1111 Rural Westside YEC Network Employment,
Job Interviews, Dress for Success, Resume
Builder, On-line Job Applications &
Workplace Skills Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1112 Rural Westside YEC Network Youth Navigator
for Positive Mental Health Resources &
Referrals/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to
build and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct
expense based on timesheet
1113 YEC Business Manager 2,200 YEC Business Manager, Mrs. Rose Spafford @ $21.00/hr. - Direct expense based on
timesheet. This position will ensure all expenses are collected and correct for financial
reporting.
1114 0 -
1115 0 -
1116 0 -
1117 0 -
1118 0 -
1119 0 -
1120 0 -
1121 0 -
1122 0 -
1123 0 -
1124 0 -
1125 0 -
1126 0 -
1127 0 -
1128 0 -
1129 0 -
1130 0 -
1131 0 -
Exhibit C - 42 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
1132 0 -
1133 0 -
1134 0 -
1135 0 -
Employee Benefits 23,100
1201 Retirement 4,181 3% Match of 1.0 FTE Personnel Salaries - Direct expense
1202 Worker's Compensation 1,819 0.75% of total Personnel Salaries & Wages - Direct expense
1203 Health Insurance 17,100 $450 mo. for 3.0 FTE Full Time Salaried Positions - Direct expense
1204 Other (Specify)-
1205 Other (Specify)-
1206 Other (Specify)-
Payroll Taxes & Expenses:22,443
1301 OASDI 15,043 6.2% - Direct expense
1302 MEDICARE 3,518 1.45% - Direct expense
1303 SUI 3,882 3.6% on the first $7000.00 of Salaries & Wages - Direct expense
1304 Other (Specify)-
1305 Other (Specify)-
1306 Other (Specify)-
2000: CLIENT SUPPORT 39,240
2001 Child Care 1,440 For community events for Transistion Aged Youth (TAY) - Direct expense
2002 Client Housing Support -
2003 Client Transportation & Support 5,000 Gas/Mileage to drivers for transportation program participants to technology classes at
Bitwise if ZOOM classes are not available. Estimated @ $333/mo - Direct expense
2004 Clothing, Food, & Hygiene 5,000 $105/mo. for snacks and water at two centers: Huron and Firebaugh sites - Direct
expense
2005 Education Support 13,200 $550/mo. for books and materials at two centers: Huron and Firebaugh - Direct expense
2006 Employment Support 2,600 $110/mo. For job readiness materials, including basic clothing to be distributed at two
centers: Huron and Firebaugh - Direct
2007 Household Items for Clients -
2008 Medication Supports -
Exhibit C - 43 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
2009 Program Supplies - Medical -
2010 Utility Vouchers -
2011 Participant Enrichment Trips 12,000 Trips for participants, where they choose, but to places like water amusement parks,
national parks, and/or aquariums - Direct expenses for admission and commercial
transportation
2012 Other (Specify)-
2013 Other (Specify)-
2014 Other (Specify)-
2015 Other (Specify)-
2016 Other (Specify)-
3000: OPERATING EXPENSES 36,800
3001 Telecommunications 9,100 $40/mo. Cell phone stipend for 13 paid positions and allocation of phone/internet
connection at four sites - Direct expenses
3002 Printing/Postage 3,800 $160/mo. for outside and inside printing, toner & copier maintenance at Huron and
Firebaugh YEC - Direct expense
3003 Office, Household & Program Supplies 2,400 $100/mo. for office, program supplies for activities for participants, like craft supplies,
etc. - Direct expense
3004 Advertising 1,200 $100/mo for a share of website and social media placements - Direct expense
3005 Staff Development & Training 2,200 Program budget for staff and participant training. Will vary depending upon program
emphasis. For instance, Michael J. Meade's Mosaic Multicultural Foundation programs
on education and cultural healing - Direct expense
3006 Staff Mileage 9,600 About 600 miles a month for each YEC @ $.50/mile for 8.0 FTE - Direct based on mileage
vouchers
3007 Subscriptions & Memberships -
3008 Vehicle Maintenance -
3009 Program Software - Apricot 360 8,500 Estimated yearly subscription cost - Direct for this program
3010 Other (Specify)-
3011 Other (Specify)-
3012 Other (Specify)-
4000: FACILITIES & EQUIPMENT 19,000
4001 Building Maintenance 1,000 Divided between two sites: Firebaugh and Huron - Direct
Exhibit C - 44 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
4002 Rent/Lease Building 18,000 $750/mo. X 10 mos. For Firebaugh YEC; $250/mo. X 10 mos. X 3 sites, For portion of
shared facilities costs in Huron and Coalinga and Kerman sites - Direct
4003 Rent/Lease Equipment -
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities -
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
5000: SPECIAL EXPENSES 5,500
5001 Consultant (Network & Data Management)5,500 $100/mo for four sites, Network management - Direct expense
5002 HMIS (Health Management Information
System)
-
5003 Contractual/Consulting Services (Specify)-
5004 Translation Services -
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
6000: ADMINISTRATIVE EXPENSES 41,333
6001 Administrative Overhead 27,569 Indirect costs cover additional health benefits to non-salaried staff such as vision, dental
also covers all contract expenses not otherwise included in a line item. Indirect allows
for the efficient use of staff time and effort in allocating direct expenses. Indirect
expense
6002 Professional Liability Insurance -
6003 Accounting/Bookkeeping 7,200 $600/mo. For program bookkeeping, including the production of monthly invoices,
review timesheets, expenditure accounting and general ledger - Direct billed expense
Exhibit C - 45 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
6004 External Audit 2,400 Portion of annual A-133 Single Audit - indirect billed expense
6005 Insurance (Gen. Liab, Cyber-security):3,384 Portion of liability, automotive insurance costs. We have no licensed professionals in
this program and therefore no professional liability insurance - Indirect expense
6006 Payroll Services 780 Weekly payroll processing at $5.00 per month x 13 paid employees - Intuit Payroll
Services - indirect expense
6007 Depreciation (Provider-Owned Equipment to
be Used for Program Purposes)
-
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
7000: FIXED ASSETS -
7001 Computer Equipment & Software -
7002 Copiers, Cell Phones, Tablets, Devices to
Contain HIPAA Data
-
7003 Furniture & Fixtures -
7004 Leasehold/Tenant/Building Improvements -
7005 Other Assets over $500 with Lifespan of 2
Years +
-
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
ACCT #
PROVIDE DETAILS OF METHODOLOGY(IES) USED IN DETERMINING MEDI-CAL
SERVICE RATES AND/OR SERVICE UNITS, IF APPLICABLE AND/OR AS REQUIRED
BY THE RFP
PROGRAM FUNDING SOURCES
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
LINE ITEM
Exhibit C - 46 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
8001
8002
8003
8004
8005
8006
8007
8008
8009
8010
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE:430,000
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE:430,000
BUDGET CHECK:-
Mental Health Services
Case Management
Rehabilitation
Other (Specify)
Other (Specify)
Crisis Services
Medication Support
Collateral
Plan Development
Assessment
Exhibit C - 47 of 58
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Rural Westside YEC Network Program
Director 1.00 -$ 56,160$ 56,160$
1102 Chief Education Director (YEC-CED)0.25 - 12,000 12,000
1103 Firebaugh/Kerman/Mendota YEC Site & mini-
centers Supervisor 1.00 - 41,600 41,600
1104 Huron/Coalinga YEC Sites Supervisor 1.00 - 41,600 41,600
1105 Youth & Family Resource Navigator - YEC
Resources and Referrals 0.40 - 14,144 14,144
1106 YEC Parent Partners: Firebaugh; Kerman;
Huron; Coalinga 1.60 - 24,960 24,960
1107 Rural Westside YEC Network Stress
Management & Mindfulness Coach/Intern 0.25 - 8,320 8,320
1108 Rural Westside YEC Network Nutrition &
fitness Coach/Intern 0.25 - 8,320 8,320
1109 Rural Westside YEC Network Restorative
Justice & conflict Mediation Coach/Intern 0.25 - 8,320 8,320
1110
Rural Westside YEC Network Dating
Violence, Homelessness & Bullying
Coach/Intern
0.25 - 8,320 8,320
1111
Rural Westside YEC Network Employment,
Job Interviews, Dress for Success, Resume
builder, On-line Job applications &
Workplace Skills Coach/Intern
0.25 - 8,320 8,320
1112
Rural Westside YEC Network Youth
Navigator for Positive Mental Health
Resources & Referrals/Intern
0.25 - 8,320 8,320
1113 YEC Business Manager 0.05 - 2,200 2,200
1114 - - -
1115 - - -
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
1121 - - -
1122 - - -
1123 - - -
1124 - - -
1125 - - -
1126 - - -
Youth Empowerment Centers
Westside Family Preservation Services Network - Huron
Fiscal Year (FY) 2025-26
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Exhibit C - 48 of 58
1127 - - -
1128 - - -
1129 - - -
1130 - - -
1131 - - -
1132 - - -
1133 - - -
1134 - - -
1135 - - -
Personnel Salaries Subtotal 6.80 -$ 242,584$ 242,584$
Employee Benefits
Acct #Admin Direct Total
1201 -$ 4,181$ 4,181$
1202 - 1,819 1,819
1203 - 17,100 17,100
1204 - - -
1205 - - -
1206 - - -
-$ 23,100$ 23,100$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1301 -$ 15,043$ 15,043$
1302 - 3,518 3,518
1303 - 3,882 3,882
1304 - - -
1305 - -
1306 - -
-$ 22,443$ 22,443$
-$ 288,127$ 288,127$
2000: CLIENT SUPPORT
Acct #Amount
2001 1,440$
2002 -
2003 5,000
2004 5,000
2005 13,200
2006 2,600
2007 -
2008 -
2009 -
2010 -
2011 12,000
2012 -
2013 -
2014 -
2015 -
2016 -
39,240$
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
DIRECT CLIENT CARE TOTAL
Household Items for Clients
Medication Supports
Program Supplies - Medical
Utility Vouchers
Participant Enrichment Trips
Other (Specify)
Client Housing Support
Client Transportation & Support
Clothing, Food, & Hygiene
Education Support
Employment Support
Other (Specify)
Other (Specify)
Other (Specify)
Payroll Taxes & Expenses Subtotal:
EMPLOYEE SALARIES & BENEFITS TOTAL:
Line Item Description
MEDICARE
SUI
Retirement
Worker's Compensation
Health Insurance
Other (Specify)
Other (Specify)
Other (Specify)
Child Care
Description
Employee Benefits Subtotal:
Description
OASDI
Exhibit C - 49 of 58
3000: OPERATING EXPENSES
Acct #Amount
3001 9,100$
3002 3,800
3003 2,400
3004 1,200
3005 2,200
3006 9,600
3007 -
3008 -
3009 8,500
3010 -
3011 -
3012 -
36,800$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 1,000$
4002 18,000
4003 -
4004 -
4005 -
4006 -
4007 -
4008 -
4009 -
4010 -
19,000$
5000: SPECIAL EXPENSES
Acct #Amount
5001 5,500$
5002 -
5003 -
5004 -
5005 -
5006 -
5007 -
5008 -
5,500$ SPECIAL EXPENSES TOTAL:
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
FACILITIES/EQUIPMENT TOTAL:
Line Item Description
Consultant (Network & Data Management)
HMIS (Health Management Information System)
Contractual/Consulting Services (Specify)
Translation Services
Security
Utilities
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
OPERATING EXPENSES TOTAL:
Line Item Description
Building Maintenance
Rent/Lease Building
Rent/Lease Equipment
Rent/Lease Vehicles
Subscriptions & Memberships
Vehicle Maintenance
Program Software - Apricot 360
Other (Specify)
Other (Specify)
Other (Specify)
Telecommunications
Printing/Postage
Office, Household & Program Supplies
Advertising
Staff Development & Training
Staff Mileage
Line Item Description
Exhibit C - 50 of 58
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 27,569$
6002 -
6003 7,200
6004 2,400
6005 3,384
6006 780
6007 -
6008 -
6009 -
6010 -
6011 -
6012 -
41,333$
7000: FIXED ASSETS
Acct #Amount
7001 -$
7002 -
7003 -
7004 -
7005 -
7006 -
7007 -
7008 -
-$
Acct #Service Units Rate Amount
8001 Mental Health Services 0 - -$
8002 Case Management 0 - -
8003 Crisis Services 0 - -
8004 Medication Support 0 - -
8005 Collateral 0 - -
8006 Plan Development 0 - -
8007 Assessment 0 - -
8008 Rehabilitation 0 - -
8009 0 - -
8010 0 - -
0 -$
0%
-
0%-
-$
Federal Financial Participation (FFP) %
MEDI-CAL FFP TOTAL
8100 - SUBSTANCE USE DISORDER FUNDS
PROGRAM FUNDING SOURCES
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
Line Item Description
Estimated Specialty Mental Health Services Billing Totals:
Estimated % of Clients who are Medi-Cal Beneficiaries
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries
FIXED ASSETS EXPENSES TOTAL
TOTAL PROGRAM EXPENSES 430,000$
Other (Specify)
Other (Specify)
Assets over $5,000/unit (Specify)
Other (Specify)
Other (Specify)
Line Item Description
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
Leasehold/Tenant/Building Improvements
Other Assets over $500 with Lifespan of 2 Years +
ADMINISTRATIVE EXPENSES TOTAL
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Administrative Overhead
Professional Liability Insurance
Accounting/Bookkeeping
External Audit
Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
Payroll Services
Line Item Description
Insurance (Gen. Liab & Cyber-Security):
Exhibit C - 51 of 58
Acct #Amount
8101 Drug Medi-Cal -$
8102 SABG -$
-$
Acct #Amount
8201 Realignment -$
-$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports -$
8302 PEI - Prevention & Early Intervention 430,000
8303 INN - Innovations -
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
430,000$
Acct #Amount
8401 Client Fees -$
8402 Client Insurance -
8403 -
8404 -
8405 -
-$ OTHER REVENUE TOTAL
TOTAL PROGRAM FUNDING SOURCES:430,000$
NET PROGRAM COST: -$
MHSA TOTAL
8400 - OTHER REVENUE
Line Item Description
Grants (Specify)
Other (Specify)
Other (Specify)
Line Item Description
REALIGNMENT TOTAL
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
MHSA Program Name
Line Item Description
SUBSTANCE USE DISORDER FUNDS TOTAL
8200 - REALIGNMENT
Exhibit C - 52 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES & BENEFITS 288,127
Employee Salaries 242,584
1101 Rural Westside YEC Network Program Director 56,160 40 hrs./wk. @ $27/hr. - salaried position Luisa Avila - Direct based on timesheet.
responsible for financial and operational goals for the program, completes reporting to
the CEO
1102 Chief Education Director (YEC-CED)12,000 Chief Education Director, retired Principal Golden Plains, Mr. Espi Sandoval @ $23.08/hr -
Direct expense based on timesheet. Responsible for accomplishing the education goals of
the program such as activities and programs that direclty relate to education attainment
and progress
1103 Firebaugh/Kerman/Mendota YEC Site & mini-
centers Supervisor
41,600 Program Supervisor, 40 hrs./wk. @ $20/hr. Mr. Felipe Perez - Direct expense based on
timesheet. Reports to the Director and responsbilities include supporting youth council,
supervision of staff, program oversight at each location, works as a liason among
community partners and schools.
1104 Huron/Coalinga YEC Sites Supervisor 41,600 Program Supervisor, vacant @ $20.00/hr. - Direct expense based on timesheet. Reports
to the Director and responsbilities include supporting youth council, supervision of staff,
program oversight at each location, works as a liason among community partners and
schools.
1105 Youth & Family Resource Navigator - YEC
Resources and Referrals
14,144 Parent Partner, 20 hrs./wk. @ $17/hr. Ms. Nancy Peters - Direct expense based on
timesheet. Oversight on the referrals and resources available to the individuals and
families and coordinates the linkages including warm handoff.
1106 YEC Parent Partners: Firebaugh; Kerman;
Huron; Coalinga
24,960 Four part-time Parent Partner positions, one assigned to each YEC @ $15.00/hr. - Direct
expense based on timesheet. Provide support for the acitivies and services provided at
the centers.
1107 Rural Westside YEC Network Stress
Management & Mindfulness Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to build
and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct expense
based on timesheet
1108 Rural Westside YEC Network Nutrition &
fitness Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to build
and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct expense
based on timesheet
1109 Rural Westside YEC Network Restorative
Justice & conflict Mediation Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to build
and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct expense
based on timesheet
Youth Empowerment Centers
Westside Family Preservation Services Network - Huron
Fiscal Year (FY) 2025-26 Budget Narrative
PROGRAM EXPENSE
Exhibit C - 53 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
1110 Rural Westside YEC Network Dating Violence,
Homelessness & Bullying Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to build
and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct expense
based on timesheet
1111 Rural Westside YEC Network Employment, Job
Interviews, Dress for Success, Resume builder,
On-line Job applications & Workplace Skills
Coach/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to build
and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct expense
based on timesheet
1112 Rural Westside YEC Network Youth Navigator
for Positive Mental Health Resources &
Referrals/Intern
8,320 College student Internship: Mentor, role model & Coach to Program Participants to build
and deploy programs in this area of concentration 10 hrs./wk. @ $16/hr. - Direct expense
based on timesheet
1113 YEC Business Manager 2,200 YEC Business Manager, Mrs. Rose Spafford @ $21.00/hr. - Direct expense based on
timesheet. This position will ensure all expenses are collected and correct for financial
reporting.
1114 0 -
1115 0 -
1116 0 -
1117 0 -
1118 0 -
1119 0 -
1120 0 -
1121 0 -
1122 0 -
1123 0 -
1124 0 -
1125 0 -
1126 0 -
1127 0 -
1128 0 -
1129 0 -
1130 0 -
1131 0 -
1132 0 -
1133 0 -
1134 0 -
1135 0 -
Exhibit C - 54 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
Employee Benefits 23,100
1201 Retirement 4,181 3% Match of 1.0 FTE Personnel Salaries - Direct expense
1202 Worker's Compensation 1,819 0.75% of total Personnel Salaries & Wages - Direct expense
1203 Health Insurance 17,100 $450 mo. for 3.0 FTE Full Time Salaried Positions - Direct expense
1204 Other (Specify)-
1205 Other (Specify)-
1206 Other (Specify)-
Payroll Taxes & Expenses:22,443
1301 OASDI 15,043 6.2% - Direct expense
1302 MEDICARE 3,518 1.45% - Direct expense
1303 SUI 3,882 3.6% on the first $7000.00 of Salaries & Wages - Direct expense
1304 Other (Specify)-
1305 Other (Specify)-
1306 Other (Specify)-
2000: CLIENT SUPPORT 39,240
2001 Child Care 1,440 For community events for Transistion Aged Youth (TAY) - Direct expense
2002 Client Housing Support -
2003 Client Transportation & Support 5,000 Gas/Mileage to drivers for transportation program participants to technology classes at
Bitwise if ZOOM classes are not available. Estimated @ $333/mo - Direct expense
2004 Clothing, Food, & Hygiene 5,000 $105/mo. for snacks and water at two centers: Huron and Firebaugh sites - Direct
expense
2005 Education Support 13,200 $550/mo. for books and materials at two centers: Huron and Firebaugh - Direct expense
2006 Employment Support 2,600 $110/mo. For job readiness materials, including basic clothing to be distributed at two
centers: Huron and Firebaugh - Direct
2007 Household Items for Clients -
2008 Medication Supports -
2009 Program Supplies - Medical -
2010 Utility Vouchers -
2011 Participant Enrichment Trips 12,000 Trips for participants, where they choose, but to places like water amusement parks,
national parks, and/or aquariums - Direct expenses for admission and commercial
transportation
2012 Other (Specify)-
2013 Other (Specify)-
Exhibit C - 55 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
2014 Other (Specify)-
2015 Other (Specify)-
2016 Other (Specify)-
3000: OPERATING EXPENSES 36,800
3001 Telecommunications 9,100 $40/mo. Cell phone stipend for 13 paid positions and allocation of phone/internet
connection at four sites - Direct expenses
3002 Printing/Postage 3,800 $160/mo. for outside and inside printing, toner & copier maintenance at Huron and
Firebaugh YEC - Direct expense
3003 Office, Household & Program Supplies 2,400 $100/mo. for office, program supplies for activities for participants, like craft supplies,
etc. - Direct expense
3004 Advertising 1,200 $100/mo for a share of website and social media placements - Direct expense
3005 Staff Development & Training 2,200 Program budget for staff and participant training. Will vary depending upon program
emphasis. For instance, Michael J. Meade's Mosaic Multicultural Foundation programs on
education and cultural healing - Direct expense
3006 Staff Mileage 9,600 About 600 miles a month for each YEC @ $.50/mile for 8.0 FTE - Direct based on mileage
vouchers
3007 Subscriptions & Memberships -
3008 Vehicle Maintenance -
3009 Program Software - Apricot 360 8,500 Estimated yearly subscription cost - Direct for this program
3010 Other (Specify)-
3011 Other (Specify)-
3012 Other (Specify)-
4000: FACILITIES & EQUIPMENT 19,000
4001 Building Maintenance 1,000 Divided between two sites: Firebaugh and Huron - Direct
4002 Rent/Lease Building 18,000 $750/mo. X 10 mos. For Firebaugh YEC; $250/mo. X 10 mos. X 3 sites, For portion of
shared facilities costs in Huron and Coalinga and Kerman sites - Direct
4003 Rent/Lease Equipment -
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities -
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
Exhibit C - 56 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
5000: SPECIAL EXPENSES 5,500
5001 Consultant (Network & Data Management)5,500 $115/mo for four sites, Network management - Direct expense
5002 HMIS (Health Management Information
System)
-
5003 Contractual/Consulting Services (Specify)-
5004 Translation Services -
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
6000: ADMINISTRATIVE EXPENSES 41,333
6001 Administrative Overhead 27,569 Indirect costs cover additional health benefits to non-salaried staff such as vision, dental
also covers all contract expenses not otherwise included in a line item. Indirect allows for
the efficient use of staff time and effort in allocating direct expenses. Indirect expense
6002 Professional Liability Insurance -
6003 Accounting/Bookkeeping 7,200 $600/mo. For program bookkeeping, including the production of monthly invoices,
review timesheets, expenditure accounting and general ledger - Direct billed expense
6004 External Audit 2,400 Portion of annual A-133 Single Audit - indirect billed expense
6005 Insurance (Gen. Liab & Cyber-Security):3,384 Portion of liability, automotive insurance costs. We have no licensed professionals in this
program and therefore no professional liability insurance - Indirect expense
6006 Payroll Services 780 Weekly payroll processing at $5.00 per month x 13 paid employees - Intuit Payroll
Services - indirect expense
6007 Depreciation (Provider-Owned Equipment to
be Used for Program Purposes)
-
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
Exhibit C - 57 of 58
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
PROGRAM EXPENSE
7000: FIXED ASSETS -
7001 Computer Equipment & Software -
7002 Copiers, Cell Phones, Tablets, Devices to
Contain HIPAA Data
-
7003 Furniture & Fixtures -
7004 Leasehold/Tenant/Building Improvements -
7005 Other Assets over $500 with Lifespan of 2
Years +
-
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
ACCT #
PROVIDE DETAILS OF METHODOLOGY(IES) USED IN DETERMINING MEDI-CAL
SERVICE RATES AND/OR SERVICE UNITS, IF APPLICABLE AND/OR AS REQUIRED
BY THE RFP
8001
8002
8003
8004
8005
8006
8007
8008
8009
8010
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE:430,000
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE:430,000
BUDGET CHECK:-
PROGRAM FUNDING SOURCES
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
LINE ITEM
Mental Health Services
Case Management
Rehabilitation
Other (Specify)
Other (Specify)
Crisis Services
Medication Support
Collateral
Plan Development
Assessment
Exhibit C - 58 of 58
Exhibit D
Page 1 of 3
DOCUMENTATION STANDARDS FOR CLIENT RECORDS
The documentation standards are described below under key topics related to client care. All
standards must be addressed in the client record; however, there is no requirement that the
record have a specific document or section addressing these topics. All medical records shall
be maintained for a minimum of 10 years from the date of the end of the Agreement.
A.Assessments
1. The following areas will be included as appropriate as a part of a comprehensive client
record.
•Relevant physical health conditions reported by the client will be prominently
identified and updated as appropriate.
•Presenting problems and relevant conditions affecting the client’s physical health and
mental health status will be documented, for example: living situation, daily activities,
and social support.
•Documentation will describe client’s strengths in achieving client plan goals.
•Special status situations that present a risk to clients or others will be prominently
documented and updated as appropriate.
•Documentations will include medications that have been described by mental health
plan physicians, dosage of each medication, dates of initial prescriptions and refills,
and documentations of informed consent for medications.
•Client self report of allergies and adverse reactions to medications, or lack of known
allergies/sensitivities will be clearly documented.
•A mental health history will be documented, including: previous treatment dates,
providers, therapeutic interventions and responses, sources of clinical data, relevant
family information and relevant results of relevant lab tests and consultations reports.
•For children and adolescents, pre-natal and perinatal events and complete
developmental history will be documented.
•Documentations will include past and present use of tobacco, alcohol, and caffeine,
as well as illicit, prescribed and over-the-counter drugs.
•A relevant mental status examination will be documented.
•A DSM-5 diagnosis, or a diagnosis from the most current ICD, will be documented,
consistent with the presenting problems, history mental status evaluation and/or
other assessment data.
Exhibit D
Page 2 of 3
2.Timeliness/Frequency Standard for Assessment
•An assessment will be completed at intake and updated as needed to document
changes in the client’s condition.
•Client conditions will be assessed at least annually and, in most cases, at more
frequent intervals.
B.Client Plans
1.Client plans will:
•have specific observable and/or specific quantifiable goals
•identify the proposed type(s) of intervention
•have a proposed duration of intervention(s)
•be signed (or electronic equivalent) by:
the person providing the service(s), or
a person representing a team or program providing services, or
a person representing the MHP providing services
when the client plan is used to establish that the services are provided under the
direction of an approved category of staff, and if the below staff are not the
approved category,
a physician
a licensed/ “waivered” psychologist
a licensed/ “associate” social worker
a licensed/ registered/marriage and family therapist or
a registered nurse
•In addition,
Client plans will be consistent with the diagnosis, and the focus of intervention
will be consistent with the client plan goals, and there will be documentation of
the client’s participation in and agreement with the plan. Examples of the
documentation include, but are not limited to, reference to the client’s
participation and agreement in the body of the plan, client signature on the plan,
or a description of the client’s participation and agreement in progress notes.
Exhibit D
Page 3 of 3
Client signature on the plan will be used as the means by which the
CONTRACTOR documents the participation of the client.
When the client’s signature is required on the client plan and the client refuses or
is unavailable for signature, the client plan will include a written explanation of the
refusal or unavailability.
•The CONTRACTOR will give a copy of the client plan to the client on request.
2.Timeliness/Frequency of Client Plan:
•Will be updated at least annually.
•The CONTRACTOR(S) will establish standards for timeliness and frequency for the
individual elements of the client plan described in item 1.
C.Progress Notes
1.Items that must be contained in the client record related to the client’s progress in
treatment include:
•The client record will provide timely documentation of relevant aspects of client care.
•Mental health staff/practitioners will use client records to document client encounters,
including relevant clinical decisions and interventions.
•All entries in the client record will include the signature of the person providing the
service (or electronic equivalent); the person’s professional degree, licensure or job
title; and the relevant identification number, if applicable.
•All entries will include the date services were provided.
•The record will be legible.
•The client record will document follow-up care, or as appropriate, a discharge
summary.
2.Timeliness/Frequency of Progress Notes:
•Progress notes shall be documented at the frequency by type of service indicated
below:
a.Every Service Contact
•Mental Health Services
•Medication Support Services
•Crisis Intervention
Exhibit E
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 E
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.
Failure to comply with these requirements may result in suspension of payments
under this Agreement or termination of this Agreement or both and
Exhibit E
Page 3 of 6
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 E
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
Exhibit E
Page 5 of 6
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)
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.
Exhibit E
Page 6 of 6
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.
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 F
Page 1 of 2
Vendor:Contract#Contact Person Contact#
Item Make/Brand Model Serial #Fixed AssetSensitive ItemDate
Requested
(If Fixed
Asset)
Date
Approved (
If Fixed
Assset)
Purchase
Date Location Condition
Fresno
County
Inventory
Number
Cost
ExampleCopier Canon 27CRT 9YHJY65R x 3/27/2008 4/1/2008 4/10/2008 Heritage New $6,500.00
ExampleDVD Player Sony DV2230 PXC4356A x n/a n/a 4/1/2008 Heritage New $450.00
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:
Fixed Asset and Sensitive Item Tracking
EXHIBIT F
Page 2 of 2
Fi el d Number
Fi el d
Descri pt i on
I nst r uct i on or Comment s
Requi r ed or
Condi t i onal
Header Vendor I ndi cat e t he l egal name of t he agency cont r act ed t o
pr ovi de ser vi ces.
Requi r ed
Header Pr ogr am
I ndi cat e t he t i t l e of t he pr oj ect as descr i bed i n t he
cont r act wi t h t he Count y.
Requi r ed
Header Cont r act #
I ndi cat e t he assi gned Count y cont r act number . I f not
known, Count y st af f can pr ovi de.
Requi r ed
Header Cont act Per son
I ndi cat e t he f i r st and l ast name of t he pr i mar y agency
cont act f or t he cont r act .
Requi r ed
Header Cont act #
I ndi cat e t he most appr opr i at e t el ephone number of t he
pr i mar y agency cont act f or t he cont r act .
Requi r ed
Header Dat e Pr epar ed
I ndi cat e t he most cur r ent dat e t hat t he t r acki ng f or m
was compl et ed by t he vendor .
Requi r ed
a Item I dent i f y t he i t em by pr ovi di ng a commonl y r ecogni zed
descr i pt i on of t he i t em.
Requi r ed
b Make/ Br and I dent i f y t he company t hat manuf act ur ed t he i t em.Requi r ed
c Model I dent i f y t he model number f or t he i t em, i f appl i cabl e.Condi t i onal
d Ser i al #
I dent i f y t he ser i al number f or t he i t em, i f
appl i cabl e.
Condi t i onal
e Fi xed Asset
Mar k t he box wi t h an " X" i f t he cost of t he i t em i s
$5, 000 or mor e t o i ndi cat e t hat t he i t em i s a f i xed
asset .
Condi t i onal
f Sensi t i ve I t em
Mar k t he box wi t h an " X" i f t he i t em meet s t he
cr i t er i a of a sensi t i ve i t em as def i ned by t he Count y.
Condi t i onal
g Dat e Request ed
I ndi cat e t he dat e t hat t he agency submi t t ed a r equest
t o t he Count y t o pur chase t he i t em.
Requi r ed
h Dat e Appr oved
I ndi cat e t he dat e t hat t he Count y appr oved t he r equest
t o pur chase t he i t em.
Requi r ed
i Pur chase Dat e I ndi cat e t he dat e t he agency pur chased t he i t em.Requi r ed
j Locat i on I ndi cat e t he physi cal l ocat i on of t he i t em Requi r ed
k Condi t i on
I ndi cat e t he gener al condi t i on of t he i t em ( New, Good,
Wor n, Bad) .
Requi r ed
l
Fr esno Count y
I nvent or y
Number
I ndi cat e t he FR # pr ovi ded by t he Count y f or t he i t em.Condi t i onal
m Cos t
I ndi cat e t he t ot al pur chase pr i ce of t he i t em
i ncl udi ng sal es t ax and ot her cost s, such as shi ppi ng.
Requi r ed
FI XED ASSET AND SENSI TI VE I TEM TRACKI NG
1
National Standards for Culturally and Linguistically
Appropriate Services (CLAS) in Health and Health Care
The National CLAS Standards are intended to advance health equity, improve quality, and help
eliminate health care disparities by establishing a blueprint for health and health care organizations to:
Principal Standard:
1.Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and
practices, preferred languages, health literacy, and other communication needs.
Governance, Leadership, and Workforce:
2.Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and
allocated resources.
3.Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in
the service area.
4.Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.
Communication and Language Assistance:
5.Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate
timely access to all health care and services.
6.Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.
7.Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters
should be avoided.
8.Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.
Engagement, Continuous Improvement, and Accountability:
9.Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s
planning and operations.
10.Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into measurement and continuous
quality improvement activities.
11.Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to
inform service delivery.
12.Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the
cultural and linguistic diversity of populations in the service area.
13.Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.
14.Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts
or complaints.
15.Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.
Think Cultural Health
https://www.thinkculturalhealth.hhs.gov/
contact@thinkculturalhealth.hhs.gov
Exhibit G
Page 1 of 2
2
The Case for the National CLAS Standards
Health equity is the attainment of the highest level of health for all people.1 Currently, individuals across the United States from various cultural
backgrounds are unable to attain their highest level of health for several reasons, including the social determinants of health, or those conditions in which
individuals are born, grow, live, work, and age,2 such as socioeconomic status, education level, and the availability of health services.3
Though health inequities are directly related to the existence of historical and current discrimination
and social injustice, one of the most modifiable factors is the lack of culturally and linguistically
appropriate services, broadly defined as care and services that are respectful of and responsive to
the cultural and linguistic needs of all individuals.
Health inequities result in disparities that directly affect the quality of life for all individuals. Health
disparities adversely affect neighborhoods, communities, and the broader society, thus making
the issue not only an individual concern but also a public health concern. In the United States, it
has been estimated that the combined cost of health disparities and subsequent deaths due to
inadequate and/or inequitable care is $1.24 trillion.4
Culturally and linguistically appropriate services are increasingly recognized as effective in improving
the quality of care and services.5,6 By providing a structure to implement culturally and linguistically
appropriate services, the National CLAS Standards will improve an organization’s ability to address
health care disparities.
The National CLAS Standards align with the HHS Action Plan to Reduce Racial and Ethnic Health Disparities7 and the National Stakeholder Strategy for
Achieving Health Equity,8 which aim to promote health equity through providing clear plans and strategies to guide collaborative efforts that address racial
and ethnic health disparities across the country.
Similar to these initiatives, the National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities
by providing a blueprint for individuals and health and health care organizations to implement culturally and linguistically appropriate services. Adoption of
these Standards will help advance better health and health care in the United States.
Of all the forms of
inequality, injustice in
health care is the most
shocking and inhumane.
— Dr. Martin Luther King, Jr.
Bibliography
1. U.S. Department of Health and Human Services, Office of Minority Health (2011). National Partnership for Action to End Health Disparities. Retrieved from http://minorityhealth.hhs.gov/npa
2. World Health Organization. (2012). Social determinants of health. Retrieved from http://www.who.int/social_determinants/en/
3. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). Healthy people 2020: Social determinants of health. Retrieved from http://www.
healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=39
4. LaVeist, T. A., Gaskin, D. J., & Richard, P. (2009). The economic burden of health inequalities in the United States. Retrieved from the Joint Center for Political and Economic Studies website: http://www.
jointcenter.org/sites/default/files/upload/research/files/The%20Economic%2 0Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf
5. Beach, M. C., Cooper, L. A., Robinson, K. A., Price, E. G., Gary, T. L., Jenckes, M. W., Powe, N.R. (2004). Strategies for improving minority healthcare quality. (AHRQ Publication No. 04-E008-02). Retrieved
from the Agency of Healthcare Research and Quality website: http://www.ahrq.gov/downloads/pub/evidence/pdf/minqual/minqual.pdf
6. Goode, T. D., Dunne, M. C., & Bronheim, S. M. (2006). The evidence base for cultural and linguistic competency in health care. (Commonwealth Fund Publication No. 962). Retrieved from The
Commonwealth Fund website: http://www.commonwealthfund.org/usr_doc/Goode_evidencebasecultlinguisticcomp_962.pdf
7. U.S. Department of Health and Human Services. (2011). HHS action plan to reduce racial and ethnic health disparities: A nation free of disparities in health and health care. Retrieved from http://
minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf
8. National Partnership for Action to End Health Disparities. (2011). National stakeholder strategy for achieving health equity. Retrieved from U.S. Department of Health and Human Services, Office of
Minority Health website: http://www.minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286
Think Cultural Health
https://www.thinkculturalhealth.hhs.gov/
contact@thinkculturalhealth.hhs.gov
Exhibit G
Page 2 of 2
Exhibit H
Page 1 of 3
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(S) shall require its
employees and subcontractors to attend a compliance training that will be provided by Fresno
County. After completion of this training, CONTRACTOR(S), CONTRACTOR(S)’ employees and
subcontractors 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.
Exhibit H
Page 2 of 3
7.Bill only for eligible services actually rendered and fully documented. Use billing codes
that accurately describe the services provided.
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(S) 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.
Exhibit H
Page 3 of 3
Fresno County Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and
Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental
Health Compliance Program and understand the contents thereof. I further agree to abide by the
Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my
responsibilities as a mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement. I further understand that any
violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of
County policy and may also be a violation of applicable laws, regulations, rules or guidelines. I further
understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program
may result in termination of my agreement with Fresno County. I further understand that Fresno
County will report me to the appropriate Federal or State agency.
For Individual Providers
Name (print): _____________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Signature: _______________________________ Date: ___/____/___
For Group or Organizational Providers
Group/Org. Name (print): ______________________________________
Employee Name (print): _______________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Other:_________________________________________________
Job Title (if different from Discipline): ___________________________
Signature: _______________________________ Date: ___/____/___
Exhibit I
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
the individuals served 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.
Informal provider problem resolution process – the provider may first speak to a Provider
Relations Specialist (PRS) regarding his or her complaint or concern.
Exhibit I
Page 2 of 2
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.
INCIDENT REPORTING
PROTOCOL FOR COMPLETION OF INCIDENT REPORT
The Incident Report must be completed for all incidents involving individuals served through
DBH’s current incident reporting portal, Logic Manager, at
https://fresnodbh.logicmanager.com/incidents/?t=9&p=1&k=182be0c5cdcd5072bb1864cdee
4d3d6e
•The reporting portal is available 24 hours a day, every day.
•Any employee of the CONTRACTOR can submit an incident using the reporting
portal at any time. No login is required.
•The designated administrator of the CONTRACTOR can add information to the
follow up section of the report after submission.
•When an employee submits an incident within 24 hours from the time of the incident
or first knowledge of the incident, the CONTRACTOR’s designated administrator, the
assigned contract analyst and the Incident Reporting email inbox will be notified
immediately via email from the Logic Manager system that there is a new incident to
review.
•Meeting the 24 hour incident reporting requirements will be easier as there are no
signatures to collect.
•The user guide attached identifies the reporting process and the reviewer process,
and is subject to updates based on DBH’s selected incident reporting portal system.
Questions about incident reporting, how to use the incident reporting portal, or
designating/changing the name of the administrator who will review incidents for the
CONTRACTOR should be emailed to DBHIncidentReporting@fresnocountyca.gov and the
assigned contract analyst.
Exhibit J
Page 1 of 9
INCIDENT REVIEWER ROLE – User Guide
Fresno County Department of Behavioral Health (DBH) requires all of its county-operated and contracted
providers (through the Mental Health Plan (MHP) and Substance Use Disorder (SUD) services) to complete
a written report of any incidents compromising the health and safety of persons served, employees, or
community members.
Yes! Incident reports will now be made through an on online reporting portal hosted by Logic Manager. It’s
an easier way for any employee to report an incident at any time. A few highlights:
•No supervisor signature is immediately required.
•Additional information can be added to the report by the program supervisor/manager without
having to resubmit the incident.
•When an incident is submitted, the assigned contract analyst, program supervisor/manager,
clinical supervisor and the DBHIncidentReporting mailbox automatically receives an email
notification of a new incident and can log in any time to review the incident. Everything that
was on the original paper/electronic form matches the online form.
•Do away with submitting a paper version with a signature.
•This online submission allows for timely action for the health and safety of the persons-served,
as well as compliance with state reporting timelines when necessary.
As an Incident Reviewer, the responsibility is to:
•Log in to Logic Manager and review incident submitted within 48 hours of notification of incident.
•Review incident for clarity, missing information and add in additional information deemed
appropriate.
•Notify DBHIncidentReporting@fresnocountyca.gov if there is additional information to be report
after initial submission
•Contact DBHIncidentReporting@fresnocountyca.gov if there are any concerns, questions or
comments with Logic Manager or incident reporting.
Below is the link to report incidents
https://fresnodbh.logicmanager.com/incidents/?t=9&p=1&k=182be0c5cdcd5072bb1864cdee4d3d6e
The link will take employees to the reporting screen to begin incident submission:
Mental Health Plan (MHP) and Substance Use Disorder (SUD) services
Incident Reporting System
Exhibit J
Page 2 of 9
Exhibit J
Page 3 of 9
Similar to the paper version, multiple incident categories can be selected
Exhibit J
Page 4 of 9
As another bonus feature, either drag files (such as a copy of a UOR, additional statements/document) or click on
Add File to upload a file.
Similar to the paper version, multiple Action Taken categories can be selected.
When done entering all the information, simply click submit.
Any fields that have a red asterisk, require information and will prevent submission of the form if left blank.
A “Thank you for your submission” statement will pop up if an incident is successfully submitted. Click “Reload the
Form” to submit another incident.
Exhibit J
Page 5 of 9
A Notification email will be received when a new incident is reported, or a new comment has been made regarding
an incident. Click on “Open this incident in Logic Manager” and the Logic Manager login screen will show.
Enter in email address and password. First time users will be prompted to set up a password.
Exhibit J
Page 6 of 9
Once logged in, the main screen will show reviewer task (incidents to review). Click on analyst/supervisor follow up
to view the incident.
This screen below will then pop up. There are 5 tabs to navigate through. Client information will show the client and
facility information. No edits can be made to this section.
The next tab is Summary: No edits can be made to this section.
Exhibit J
Page 7 of 9
The next tab is Follow up: This section can be edited. Add to the areas below or make corrections to these fields. Be
sure to click SAVE when edits are made. Then Cancel to Exit out of the incident.
The next tab is Documents: View and add attachments to the incident. Be sure to click SAVE when adding
documents. Then Cancel to Exit out of the incident.
If all tasks are followed up with and the incident no longer needs further review/information, click SUBMIT. Once
submitted, the incident will be removed from the task list and no further edits can be made. Notice the SUBMIT
button is on every tab. If further information needs to be included, email
DBHIncidentReporting@fresnocountyca.gov
Exhibit J
Page 8 of 9
To get back to the home view, click on the Logic Manager icon at any time. Any incidents that still need review will
show on this screen, click on the next incident and start the review process again.
Exhibit J
Page 9 of 9
Exhibit K
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 K
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 L
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 L
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 M
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “COUNTY”),
members of a CONTRACTOR’s board of directors (hereinafter referred to as “County
Contractor”), must disclose any self-dealing transactions that they are a party to while
providing goods, performing services, or both for the COUNTY. A self-dealing transaction is
defined below:
“A self-dealing transaction means a transaction to which the corporation is a party and in
which one or more of its directors has a material financial interest”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1)Enter board member’s name, job title (if applicable), and date this disclosure is being
made.
(2)Enter the board member’s company/agency name and address.
(3)Describe in detail the nature of the self-dealing transaction that is being disclosed to
the COUNTY. At a minimum, include a description of the following:
a.The name of the agency/company with which the corporation has the
transaction; and
b.The nature of the material financial interest in the corporation’s transaction that
the board member has.
(4)Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5)Form must be signed by the board member that is involved in the self-dealing
transaction described in Sections (3) and (4).
Exhibit M
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: