HomeMy WebLinkAboutA-22-230 - Board and Care revised 7.20.22.pdf Agreement No. 22-230
1 AGREEMENT
2 THIS AGREEMENT is made and entered into this 7th day of June, 2022,by and
3 between the COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter
4 referred to as "COUNTY", and each Contractor listed in Exhibit A"Specialized Supplemental Board
5 and Care Home Contractor List", attached hereto and by this reference incorporated herein, collectively
6 hereinafter referred to as "CONTRACTOR(S)" and such additional CONTRACTOR(S) as may, from
7 time to time during the term of this Agreement, be added by COUNTY. References in this Agreement
8 to "party" or"parties" shall be understood to refer to COUNTY and each CONTRACTOR,unless
9 otherwise specified.
10 WITNESSETH:
11 WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), has identified a
12 need for individuals with mental health conditions to be placed at licensed residential care facilities that
13 are able to provide Specialized Supplemental Board and Care Home services, in accordance with
14 various provisions of the California Welfare and Institutions Code; and
15 WHEREAS, certain CONTRACTOR(S)have the licensed residential care facilities, staff and
16 expertise, to provide Specialized Supplemental Board and Care Home services, for COUNTY placed
17 persons served with a mental health condition; and
18 NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties
19 hereto agree as follows:
20 1. SERVICES
21 A. CONTRACTOR shall perform all services and fulfill all responsibilities
22 providing Specialized Supplemental Board and Care Home services to persons served of Fresno
23 County, as identified in this Agreement, including all Exhibits, incorporated herein by reference and
24 made part of this Agreement.
25 B. It is understood that each CONTRACTOR shall provide Specialized
26 Supplemental Board and Care Home services at licensed residential care facilities as described in
27 Exhibit B "Specialized Supplemental Board and Care Homes Scope of Work", attached hereto and by
28 this reference incorporated herein.
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1 C. CONTRACTOR shall align program, services, and practices with the vision and
2 mission within Exhibit C, "DBH Guiding Principles of Care Delivery", attached hereto and by this
3 reference incorporated herein.
4 D. In the event that COUNTY persons served are away from the Specialized
5 Supplemental Board and Care Home due to special circumstances including, but not limited to,
6 attending a day program, court, AA/NA meeting, any other required service engagement, or are Away
7 With Out Leave (AWOL), the COUNTY's DBH placement staff will communicate with
8 CONTRACTOR to review whether a bed hold rate is authorized. Bed hold rates will be reimbursed as
9 stated in Exhibit D, "Fresno County DBH Specialized Supplemental Board and Care Homes Approved
10 Rates by Contractor". In the event a bed hold is authorized by COUNTY's DBH placement staff, the
11 bed hold rate shall be applied per each day the COUNTY person served is away from the facility, up to
12 seven(7) days. The COUNTY is required to review and approve all bed hold rate requests.
13 E. For COUNTY persons served that are determined not eligible for the Specialized
14 Supplemental Board and Care Home services described herein, as determined by designated
15 COUNTY's DBH staff, CONTRACTOR(S) shall still accept referred non-eligible COUNTY persons
16 served to live at the licensed residential care facilities, although they will not receive Specialized
17 Supplemental Board and Care Home services as described herein.
18 2. TERM
19 The initial term of this Agreement shall be for a period of three (3)years, commencing on
20 July 1, 2022 through and including June 30, 2025 ("Initial Term"). CONTRACTOR(S) added to this
21 agreement after July 1,2022, shall become part of this Agreement effective upon the date approved by the
22 COUNTY's DBH Director, or designee.
23 Upon the expiration of the Initial Term, the terms of this Agreement shall be
24 automatically extended for two (2) additional consecutive twelve (12)month periods upon the same
25 terms and conditions herein set forth, unless written notice of non-renewal is given no later than thirty
26 (30) days prior to the close of the current Agreement term by COUNTY's DBH Director, or designee,
27 or one (1) or more CONTRACTOR(S). A CONTRACTOR's written notice of non-renewal shall be
28 understood to effect renewal only to the extent of that CONTRACTOR's involvement in this
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1 Agreement.
2 The June 30 termination date specified herein shall be the termination date for all
3 CONTRACTORS,regardless of when CONTRACTOR is added to this Agreement. Any twelve(12)
4 month renewal period of this Agreement for any CONTRACTOR already providing services under this
5 Agreement shall commence on July 1, 2026 and 2027, as appropriate.
6 3. TERMINATION
7 A. Non-Allocation of Funds - The terms of this Agreement, and the services to be
8 provided thereunder, are contingent on the approval of funds by the appropriating government agency.
9 Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
10 terminated at any time by giving one (1) or all CONTRACTORS thirty(30) days advance written
11 notice.
12 B. Breach of Contract- COUNTY may immediately suspend or terminate this
13 Agreement in whole or in part, as to one (1) or all CONTRACTORS, where in the determination of the
14 COUNTY there is:
15 1) An illegal or improper use of funds;
16 2) A failure to comply with any term of this Agreement;
17 3) A substantially incorrect or incomplete report submitted to COUNTY;
18 4) Improperly performed service; or
19 5) Suspension or revocation of the license by any regulatory agency of the
20 State of California to operate the facility.
21 In no event shall any payment by the COUNTY constitute a waiver by the
22 COUNTY of any breach of this Agreement or any default which may then exist on the part of the
23 CONTRACTOR(S). Neither shall such payment impair or prejudice any remedy available to the
24 COUNTY with respect to the breach or default. The COUNTY shall have the right to demand of the
25 CONTRACTOR(S)the repayment to the COUNTY of any funds disbursed to the CONTRACTOR(S)
26 under this Agreement, which in the judgment of the COUNTY were not expended in accordance with
27 the terms of this Agreement. Each CONTRACTOR) shall promptly refund any such funds upon
28 demand or, at the COUNTY's option, such repayment shall be deducted from future payments owing to
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1 CONTRACTOR(S)under this Agreement. COUNTY shall provide notice to the CONTRACTOR(S) of
2 such a breach or default prior to taking any action to suspend payments or terminate the Agreement.
3 In addition, each CONTRACTOR shall have the right to terminate this
4 Agreement upon giving a written thirty(30) day notice to COUNTY, in the event COUNTY fails to
5 comply with the term of this Agreement or fails to perform its services as stated herein.
6 C. Without Cause -Under circumstances other than those set forth above, this
7 Agreement may be terminated by CONTRACTOR(S) or COUNTY upon the giving of thirty (30) days
8 advance written notice of an intention to terminate.
9 4. COMPENSATION
10 A. COUNTY agrees to pay and CONTRACTOR(S)agrees to receive compensation for
11 each day authorized persons served placed by COUNTY reside in the Specialized Supplemental Board and
12 Care Homes,whether or not the person served receives Supplemental Social Security Insurance
13 (SSI)/State Supplementary Payment(SSP)funds,has Medi-Cal,private insurance, or has no other
14 coverage, at the annually negotiated Supplemental Service reimbursement rates set within Exhibit D—
15 "Fresno County DBH Specialized Supplemental Board and Care Homes Approved Rates by Contractor",
16 attached hereto and by this reference incorporated herein. Rate setting for Supplemental Services shall
17 occur on an annual basis in a format provided by, and a deadline set by COUNTY. A day shall be defined
18 as any portion of a twenty-four(24)hour day beginning at 8:00 a.m. and ending at 7:59 a.m. the following
19 day.
20 B. The above Supplemental Service reimbursement rates identified within Exhibit D are
21 combined with a prorated/daily SSUSSP amount for Basic Services which includes the following
22 components: Room and Board, and Care and Supervision(Maximum)and shall be determined by the
23 Federal SSI Administration and the State of California Department of Health Care Services (DHCS) and
24 may be subject to adjustment by the SSI Administration or DHCS, as appropriate, during each term of this
25 Agreement. COUNTY shall reimburse CONTRACTOR(S)the uniform statewide daily reimbursement
26 rate as published annually by Federal SSI Administration and DHCS and incorporated in to Exhibit D.
27 COUNTY agrees to pay CONTRACTOR(S)the adjusted SSUSSP amount after the effective date of the
28 adjustment is authorized by the Federal SSI Administration or DHCS, as appropriate,and
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1 CONTRACTOR(S) agree to accept such reimbursement as of the effective date of such adjustment,
2 whether or not the cost of providing such services shall have exceeded the amount of the payments
3 hereunder. COUNTY shall notify CONTRACTOR(S) in writing of any rate change within thirty(30)days
4 of COUNTY receiving notice of any rate change from the SSI Administration or DHCS.All parties
5 acknowledge that no additional SSFSSP monies will be paid to the CONTRACTOR(S)by the COUNTY
6 Public Guardian Office(PGO), for authorized persons served placed in their facilities that are SSFSSP
7 recipients.
8 C. All parties agree that there will be no SSI payments whatsoever provided to
9 CONTRACTOR(S) from Department's PGO Division for any COUNTY person served who is eligible for
10 Specialized Supplemental Board and Care Home services, regardless of whether or not person served
11 receives SSI/SSP benefits. CONTRACTOR(S) shall seek payment of the equivalent of SSI for room and
12 board/care and supervision services through this Agreement. The parties acknowledge that said equivalent
13 SSI monies to be paid to the CONTRACTOR(S) for SSI recipients are not part of funds provided from the
14 Department's PGO Division.
15 D. In addition,the COUNTY agrees to pay and CONTRACTOR(S)agree to receive
16 compensation for delivering specialized services authorization(SSA) services to augment services under
17 this Agreement for persons served as authorized by COUNTY. An SSA Form must be used to request
18 services for persons served who require services above and beyond Exhibit B, "Specialized Supplemental
19 Board and Care Homes Scope of Work", of this Agreement. The SSA Form may be approved/denied on
20 a case-by-case basis by COUNTY when necessary and applicable,and is in addition to the approved rate
21 identified in Exhibit D. SSA Forms will be reviewed/approved up to a maximum of thirty(30) days with
22 justification. CONTRACTOR(S)must submit an authorization request in a format determined by
23 COUNTY,to COUNTY's DBH the day that a determination is made that SSA services are needed for an
24 authorized person served,but no later than two (2)business days after such determination is made.
25 CONTRACTOR(S) shall submit SSA Forms to COUNTY's DBH electronically via email to:
26 DBHLPSConservatorship@fresnocountyca.gov.
27 E. It is acknowledged by all parties hereto that any/all rates may be changed by the
28 Federal SSI Administration and/or DHCS during the term of this Agreement and such rate changes shall
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I become part of this Agreement as set forth in Subsection B above. Any/all rate adjustments shall not result
2 in an increase to the maximum compensation amount of this Agreement as stated herein.
3 F. If a CONTRACTOR is informed that an authorized person served placed in their
4 facility by COUNTY has access to a third-party source for reimbursement other than COUNTY, said
5 CONTRACTOR shall attempt to obtain payment for the services (rendered by said CONTRACTOR)
6 directly from the third-party source. In the event that CONTRACTOR(S)is paid from a third-party source
7 for any authorized person served placed in their facility by the COUNTY from a third-party source,
8 CONTRACTOR(S) shall deduct the amount collected from the third-parry source from the amount
9 invoiced to COUNTY for the services provided to any such person served. All amounts collected by
10 CONTRACTOR(S) shall be deducted from the amount otherwise payable to CONTRACTOR(S)pursuant
11 to this Agreement. CONTRACTOR(S) shall maintain and forward to COUNTY,monthly with their
12 invoice, a list of all persons served who have third-party resources.
13 G. CONTRACTOR(S)understand that COUNTY may seek reimbursement from
14 applicable third-party payors(e.g., Medicare,Medi-Cal or other insurance)for services rendered by
15 CONTRACTOR(S) and paid for by COUNTY. Upon request by COUNTY, CONTRACTOR(S) shall
16 prepare and submit information as it relates to authorized persons served placed by COUNTY for the
17 COUNTY to seek reimbursement from such third-parry payors.
18 H. In no event shall services performed under this Agreement for all
19 CONTRACTOR(S) combined be in excess of Ten Million,Eight Hundred Thousand and No/100 Dollars
20 ($10,800,000.00)for each fiscal year beginning with FY 2022-23 through FY 2026-27.
21 In no event shall the total maximum amount for the service provided by
22 CONTRACTOR(S) collectively under the terms and conditions of this Agreement for the entire five-year
23 term exceed Fifty-Four Million and No/100 Dollars ($54,000,000.00). It is understood that all expenses
24 incidental to CONTRACTOR(S)performance of services under this Agreement shall be borne by
25 CONTRACTOR(S).
26 I. Payment by COUNTY shall be in arrears,based on CONTRACTOR's monthly
27 invoice submitted for services provided during the preceding month,within forty-five (45) days after
28 receipt,verification and approval of CONTRACTOR's monthly invoices by COUNTY's DBH. In
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1 addition, it is understood by CONTRACTOR that at the discretion of COUNTY's DBH Director or
2 designee, COUNTY reserves the right to deny payment of any additional invoices received ninety(90)
3 days after the expiration of each term of this Agreement or termination of this Agreement. If
4 CONTRACTOR should fail to comply with any provision of this Agreement, COUNTY shall withhold
5 payment until such time as the non-compliance has been corrected, or COUNTY shall be relieved of its
6 obligation for further compensation.
7 J. In the event the maximum compensation amount in any individual fiscal year as
8 noted above, is not fully expended, said remaining unspent funding amounts shall rollover to each
9 subsequent fiscal year's established maximum compensation.
10 5. INVOICING AND PAYMENTS
11 A. Invoicing
12 CONTRACTOR shall invoice COUNTY in arrears by the fifteenth(151h) day of
13 each month following the month in which services were rendered via email addressed to: 1)
14 dbhinvoicereview@fresnocountyca.gov, 2) dbh-invoices@fresnocountyca.gov; and 3)
15 dbhcontractedservicesdivision@fresnocountyca.gov and the assigned DBH Mental Health Contracts
16 Staff Analyst. CONTRACTOR(S) shall utilize an invoice template provided by COUNTY. All invoices
17 submitted should be completed in their entirety. In no event shall CONTRACTORS submit claims to
18 COUNTY for persons served that are not duly authorized by COUNTY to receive services.
19 B. Contract Payment Schedule
20 Payments by COUNTY shall be in arrears, within forty-five (45) days after
21 receipt and verification of CONTRACTOR(S)' invoices by COUNTY DBH in an amount equivalent to
22 the rates set in Exhibit D "Fresno County DBH Specialized Supplemental Board and Care Homes
23 Approved Rates by Contractor", including any rate adjustment provided for herein. However, if
24 invoice(s) is not received in proper form or substance as stated herein, COUNTY may withhold
25 subsequent payment(s)until such invoice(s) is received. No reimbursement for services shall be
26 made until invoices are received and reviewed by COUNTY's DBH. In addition, for invoices received
27 ninety (90) days after the expiration of each term of this Agreement or termination of this Agreement,
28
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1 at the discretion of COUNTY's DBH Director or designee, COUNTY reserves the right to deny
2 payment of any additional invoices received.
3 C. Reconciliation of Pam
4 COUNTY shall complete a reconciliation of payments made to costs invoiced.
5 If an adjustment to the payment is necessary, COUNTY shall notify CONTRACTOR(S) in writing
6 within five (5)working days after the completion of the reconciliation. Within forty-five (45) days
7 thereafter, COUNTY shall make payment to CONTRACTOR or CONTRACTOR shall reimburse
8 COUNTY as appropriate. In the event that CONTRACTOR(S)bills the COUNTY for supplemental
9 charges for a previous month's services, those charges shall be sent to the COUNTY for review via a
10 separate invoice and summarized statement and are not to be included within the next regular month's
11 invoice.
12 At the discretion of COUNTY's DBH Director or designee, if an invoice is
13 incorrect or is otherwise not in proper form or substance, COUNTY shall have the right to withhold
14 payment as to only that portion of the invoice that is incorrect or improper and CONTRACTOR agrees
15 to continue to provide services for a period of ninety(90) days and, if after the ninety(90) day period,
16 the invoice(s) is still not corrected to COUNTY's DBH satisfaction, COUNTY may elect to terminate
17 this Agreement with individual CONTRACTOR(S),pursuant to the termination provisions stated in
18 Section Three (3), TERMINATION, of this Agreement.
19 6. THIRD PARTY PAYMENTS
20 In the event any authorized COUNTY person served is a recipient of income from any
21 source, including Supplemental Security Income/State Supplemental Program(SSI/SSP),Veterans
22 Administration benefits, retirement benefits, or annuities, and the authorized COUNTY person's served
23 representative payee or the conservator of the person's served estate is the Fresno County Public
24 Guardian Office (PGO), COUNTY remains responsible to pay CONTRACTOR(S) the full amount for
25 services rendered under this Agreement. When PGO is the representative payee or conservator of the
26 estate, the authorized COUNTY persons served income shall be collected by PGO and utilized to
27 reimburse COUNTY for the costs of services provided hereunder.
28 CONTRACTOR(S) shall maintain and forward to COUNTY on a monthly basis a list of
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1 all persons served who have third-party payees or conservators of the estate, other than COUNTY's
2 PGO.
3 In the event CONTRACTOR(S) fails to comply with any provisions of this Agreement,
4 COUNTY shall withhold payment until such time as the non-compliance has been corrected.
5 7. INDEPENDENT CONTRACTOR
6 In performance of the work, duties, and obligations assumed by CONTRACTOR(S)
7 under this Agreement, it is mutually understood and agreed that CONTRACTOR(S), including any and
8 all of CONTRACTOR(S) officers, agents, and employees will at all times be acting and performing as
9 independent contractors, and shall act in an independent capacity and not as an officer, agent, servant,
10 employee,joint venturer,partner, or associate of the COUNTY. Furthermore, COUNTY shall have no
11 right to control or supervise or direct the manner or method by which CONTRACTOR(S) shall perform
12 their work and function. However, COUNTY shall retain the right to administer this Agreement so as
13 to verify that CONTRACTOR(S) is/are performing their obligations in accordance with the terms and
14 conditions thereof.
15 CONTRACTOR(S) and COUNTY shall comply with all applicable provisions of law
16 and the rules and regulations, if any, of governmental authorities having jurisdiction over matters the
17 subject thereof.
18 Because of their status as independent contractors, CONTRACTOR(S) shall have
19 absolutely no right to employment rights and benefits available to COUNTY employees.
20 CONTRACTOR(S) shall be solely liable and responsible for providing to, or on behalf of, their
21 employees all legally-required employee benefits. In addition, CONTRACTOR(S) shall be solely
22 responsible and save COUNTY harmless from all matters relating to payment of CONTRACTOR(S')
23 employees, including compliance with Social Security withholding and all other regulations governing
24 such matters. It is acknowledged that during the term of this Agreement, CONTRACTOR(S)may be
25 providing services to others unrelated to the COUNTY or to this Agreement.
26 8. MODIFICATION
27 Any matters of this Agreement may be modified from time to time by the written
2 8 consent of COUNTY and CONTRACTOR(S)without, in any way, affecting the remainder.
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I Notwithstanding the above, changes to the "Fresno County DBH Specialized Supplemental Board and
2 Care Homes Approved Rates by Contractor" (Exhibit D) for annual CONTRACTOR and Federal SSI
3 rate adjustments due to state-required facility rate increases for each of CONTRACTOR(S)' facilities
4 may be made with the written approval of the COUNTY's DBH Director, or designee, and the
5 individual CONTRACTOR.
6 In addition, non-material changes to the Specialized Supplemental Board and Care
7 Homes Scope of Work(Exhibit B) as needed to accommodate revisions in the law relating to mental
8 health treatment services may be made with the signed written approval of COUNTY's DBH Director,
9 or designee, and respective CONTRACTOR(S)through an amendment approved by COUNTY's
10 County Counsel and Auditor-Controller/Treasurer-Tax Collector. Said changes shall not result in any
11 change to the maximum compensation amount payable by COUNTY to CONTRACTOR(S), as stated
12 herein.
13 9. NON-ASSIGNMENT
14 COUNTY and CONTRACTOR(S) shall not assign, transfer or subcontract this
15 Agreement nor their rights or duties under this Agreement, without the prior written consent of
16 COUNTY and the individual CONTRACTOR seeking to make such assignment.
17 10. HOLD-HARMLESS
18 CONTRACTOR(S) agree to indemnify, save, hold harmless, and at COUNTY's request,
19 defend the COUNTY, its officers, agents and employees from any and all costs and expenses
20 (including attorney's fees and court costs), damages, liabilities, claims and losses occurring or resulting
21 to COUNTY in connection with the performance, or failure to perform, by CONTRACTOR(S), their
22 officers, agents or employees under this Agreement, and from any and all costs and expenses (including
23 attorney fees and court costs), damages, liabilities, claims and losses occurring or resulting to any
24 person, firm or corporation who may be injured or damaged by the performance, or failure to perform,
25 of CONTRACTOR(S), their officers, agents or employees under this Agreement. In addition,
26 CONTRACTOR(S) agree(s)to indemnify COUNTY for Federal, State of California and/or local audit
27 exceptions resulting from noncompliance herein on the part of the CONTRACTOR(S).
28 The provisions of this section 10 shall survive termination of this agreement.
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1 11. INSURANCE
2 Without limiting the COUNTY's right to obtain indemnification from
3 CONTRACTOR(S) or any third parties, CONTRACTOR(S), at its sole expense, shall maintain in full
4 force and effect, the following insurance policies or a program of self-insurance, including but not
5 limited to, an insurance pooling arrangement or Joint Powers Agreement QPA) throughout the term of
6 this Agreement:
7 A. Commercial General Liability
8 Commercial General Liability Insurance with limits of not less than Two Million
9 Dollars ($2,000,000.00)per occurrence and an annual aggregate of Four Million Dollars
10 ($4,000,000.00). This policy shall be issued on a per occurrence basis. COUNTY may require specific
11 coverage including completed operations,product liability, contractual liability, Explosion-Collapse-
12 Underground, fire legal liability or any other liability insurance deemed necessary because of the nature
13 of the Agreement.
14 B. Automobile Liability
15 Comprehensive Automobile Liability Insurance with limits of not less than One
16 Million Dollars ($1,000,000.00)per accident for bodily injury and property damages. Coverage should
17 include any auto used in connection with this Agreement.
18 C. Professional Liability
19 If CONTRACTOR(S) employs licensed professional staff(e.g. Ph.D., R.N.,
20 L.C.S.W., M.F.C.C.) in providing services, Professional Liability Insurance with limits of not less than
21 One Million Dollars ($1,000,000.00)per occurrence, Three Million Dollars ($3,000,000.00) annual
22 aggregate. CONTRACTOR agrees that it shall maintain, at its sole expense, in full force and effect for
23 a period of three (3) years following the termination of this Agreement, one or more policies of
24 professional liability insurance with limits of coverage as specified herein.
25 D. Worker's Compensation
26 A policy of Worker's Compensation Insurance as may be required by the
27 California Labor Code.
28 E. Sexual Abuse/Misconduct
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1 Sexual abuse/molestation liability insurance with limits of not less than One
2 Million Dollars ($1,000,000.00)per occurrence, Two Million Dollars ($2,000,000.00) annual
3 aggregate. This policy shall be issued on a per occurrence basis.
4 F. Cyber Liability
5 Cyber Liability Insurance,with limits not less than Two Million Dollars
6 ($2,000,000.00)per occurrence or claim, Two Million Dollars ($2,000,000.00) aggregate. Coverage shall
7 be sufficiently broad to respond to the duties and obligations as is undertaken by CONTRACTOR in this
8 Agreement and shall include,but not be limited to, claims involving infringement of intellectual property,
9 including but not limited to infringement of copyright,trademark,trade dress, invasion of privacy
10 violations, information theft, damage to or destruction of electronic information,release of private
11 information, alteration of electronic information, extortion and network security. The policy shall provide
12 coverage for breach response costs as well as regulatory fines and penalties as well as credit monitoring
13 expenses with limits sufficient to respond to these obligations
14 Additional Requirements Relating to Insurance
15 If CONTRACTOR maintains broader coverage and/or higher limits than the minimums
16 shown above, COUNTY requires and shall be entitled to the broader coverage and/or higher limits
17 maintained by CONTRACTOR. Any available insurance proceeds in excess of the specified minimum
18 limits of insurance and coverage shall be available to the County.
19 CONTRACTOR hereby waives its right to recover from COUNTY, its officers, agents,
20 and employees any amounts paid by the policy of worker's compensation insurance required by this
21 Agreement. CONTRACTOR is solely responsible to obtain any endorsement to such policy that may
22 be necessary to accomplish such waiver of subrogation, but CONTRACTOR's waiver of subrogation
23 under this section is effective whether or not CONTRACTOR obtains such an endorsement.
24 Within thirty (30) days from the date CONTRACTOR(S) signs this Agreement,
25 CONTRACTOR(S) shall provide certificates of insurance and endorsements as stated above for all of
26 the foregoing policies, as required herein, to the County of Fresno, Department of Behavioral Health,
27 Contracts Division at 3133 N. Millbrook Ave., Fresno, California, 93703, Attention: Contracts Unit,
28 stating that such insurance coverage have been obtained and are in full force; that the County of Fresno,
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1 its officers, agents and employees will not be responsible for any premiums on the policies; that such
2 worker's compensation insurance the CONTRACTOR has waived its right to recover from the
3 COUNTY, its officers, agents, and employees any amounts paid under the insurance policy and that
4 waiver does not invalidate the insurance policy; that such Commercial General Liability insurance
5 names the County of Fresno, its officers, agents and employees, individually and collectively, as
6 additional insured, but only insofar as the operations under this Agreement are concerned; that such
7 coverage for additional insured shall apply as primary insurance and any other insurance, or
8 self-insurance, maintained by COUNTY, its officers, agents and employees, shall be excess only and
9 not contributing with insurance provided under CONTRACTOR's policies herein; and that this
10 insurance shall not be cancelled or changed without a minimum of thirty (30) days advance,written
11 notice given to COUNTY.
12 In the event CONTRACTOR(S) fails to keep in effect at all times insurance coverage as
13 herein provided, the COUNTY may, in addition to other remedies it may have, suspend or terminate
14 this Agreement upon the occurrence of such event.
15 All policies shall be with admitted insurers licensed to do business in the State of
16 California, and such insurance shall be purchased from companies possessing a current A.M. Best, Inc.
17 rating of A FSC VIII or better.
18 12. CONFIDENTIALITY
19 All services performed by CONTRACTOR under this Agreement shall be in strict
20 conformance with all applicable Federal, State of California and/or local laws and regulations relating
21 to confidentiality.
22 13. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
23 COUNTY and CONTRACTOR each consider and represent themselves as covered
24 entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law
25 104-19 1(HIPAA) and agree to use and disclose Protected Health Information (PHI) as required by law.
26 COUNTY and CONTRACTOR acknowledge that the exchange of PHI between them is
27 only for treatment, payment, and health care operations.
28 COUNTY and CONTRACTOR intend to protect the privacy and provide for the
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1 security of PHI pursuant to the Agreement in compliance with HIPAA, the Health Information
2 Technology for Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations
3 promulgated thereunder by the U.S. Department of Health and Human Services (HIPAA Regulations)
4 and other applicable laws.
5 As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
6 CONTRACTOR to enter into a contract containing specific requirements prior to the disclosure of PHI,
7 as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) of the Code of Federal
8 Regulations (CFR).
9 14. DATA SECURITY
10 For the purpose of preventing the potential loss, misappropriation or inadvertent access,
11 viewing,use or disclosure of COUNTY data including sensitive or personal person served information;
12 abuse of COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies
13 that enter into a contractual relationship with the COUNTY for the purpose of providing services under
14 this Agreement must employ adequate data security measures to protect the confidential information
15 provided to CONTRACTOR by the COUNTY, including but not limited to the following:
16 A. CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
17 CONTRACTOR may not connect to COUNTY networks via personally-owned
18 mobile, wireless or handheld devices, unless the following conditions are met:
19 1) CONTRACTOR has received authorization by COUNTY for
20 telecommuting purposes;
21 2) Current virus protection software is in place;
22 3) Mobile device has the remote wipe feature enabled; and
23 4) A secure connection is used.
24 B. CONTRACTOR-Owned Computers or Computer Peripherals
25 CONTRACTOR may not bring CONTRACTOR-owned computers or computer
26 peripherals into the COUNTY for use without prior authorization from the COUNTY's Chief
27 Information Officer, and/or designee(s), including but not limited to mobile storage devices. If data is
28 approved to be transferred, data must be stored on a secure server approved by the COUNTY and
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1 transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
2 connection. Said data must be encrypted.
3 C. COUNTY-Owned Computer Equipment
4 CONTRACTOR or anyone having an employment relationship with the
5 COUNTY may not use COUNTY computers or computer peripherals on non-COUNTY premises
6 without prior authorization from the COUNTY's Chief Information Officer, and/or designee(s).
7 D. CONTRACTOR may not store COUNTY's private, confidential or sensitive
8 data on any hard-disk drive,portable storage device, or remote storage installation unless encrypted.
9 E. CONTRACTOR shall be responsible to employ strict controls to ensure the
10 integrity and security of COUNTY's confidential information and to prevent unauthorized access,
11 viewing,use or disclosure of data maintained in computer files,program documentation, data
12 processing systems, data files and data processing equipment which stores or processes COUNTY data
13 internally and externally.
14 F. Confidential person served information transmitted to one party by the other by
15 means of electronic transmissions must be encrypted according to Advanced Encryption Standards
16 (AES) of 128 BIT or higher. Additionally, a password or pass phrase must be utilized.
17 G. CONTRACTOR is responsible to immediately notify COUNTY of any
18 violations, breaches or potential breaches of security related to COUNTY's confidential information,
19 data maintained in computer files,program documentation, data processing systems, data files and data
20 processing equipment which stores or processes COUNTY data internally or externally.
21 H. COUNTY shall provide oversight to CONTRACTOR's response to all incidents
22 arising from a possible breach of security related to COUNTY's confidential person served information
23 provided to CONTRACTOR. CONTRACTOR will be responsible to issue any notification to affected
24 individuals as required by law or as deemed necessary by COUNTY in its sole discretion.
25 CONTRACTOR will be responsible for all costs incurred as a result of providing the required
26 notification.
27 15. NON-DISCRIMINATION
28 During the performance of this Agreement CONTRACTOR shall not unlawfully
- 15 - COUNTY OF FRESNO
Fresno,CA
I discriminate in the provision of services because of sex, race, religion, color, national origin, ancestry,
2 ethnic group identification, physical disability, mental disability, medical condition, genetic
3 information, sexual orientation, marital status, age, gender, gender identity, gender expression, or
4 military or veteran status as provided by State of California and Federal law in accordance with Title VI
5 of the Civil Rights Act of 1964 (42 USC § 2000(d)); Age Discrimination Act of 1975 (42 USC § 1681);
6 Rehabilitation Act of 1973 (29 USC § 794); Education Amendments of 1972 (20 USC § 1681);
7 Americans with Disabilities Act of 1990 (42 USC § 12132); 45 CFR, Part 84; provisions of the Fair
8 Employment and Housing Act(California Government Code § 12900); and regulations promulgated
9 thereunder(CCR Title 2, § 7285.0); Title 2, Division 3, Article 9.5 of the California Government Code
10 commencing with section 11135; and CCR Title 9, Division 4, Chapter 6 commencing with section
11 10800.
12 16. TAX EQUITY AND FISCAL RESPONSIBILITY ACT
13 To the extent necessary to prevent disallowance of reimbursement under section 1861(v)
14 (1) (I) of the Social Security Act, (42 U.S.C. § 1395x, sub. (v)(1)[I]),until the expiration of ten(10)
15 years after the furnishing of services under this Agreement, CONTRACTOR(S) shall make available,
16 upon written request of the Secretary of the United States Department of Health and Human Services,
17 or upon request of the Comptroller General of the United States General Accounting Office, or any of
18 their duly authorized representatives, a copy of this Agreement and such books, documents, and
19 records as are necessary to certify the nature and extent of the costs of these services provided by
20 CONTRACTOR(S)under this Agreement. CONTRACTOR(S) further agrees that in the event
21 CONTRACTOR(S) carries out any of its duties under this Agreement through a subcontract, with a
22 value or cost of Ten Thousand and No/100 Dollars ($10,000.00) or more over a twelve (12)month
23 period, with a related organization, such Agreement shall contain a clause to the effect that until the
24 expiration of ten(10)years after the furnishing of such services pursuant to such subcontract, the
25 related organizations shall make available,upon written request of the Secretary of the United States
26 Department of Health and Human Services, or upon request of the Comptroller General of the United
27 States General Accounting Office, or any of their duly authorized representatives, a copy of such
28 subcontract and such books, documents, and records of such organization as are necessary to verify
- 16 - COUNTY OF FRESNO
Fresno,CA
1 the nature and extent of such costs.
2 17. ADDITIONS/DELETIONS OF CONTRACTORS
3 COUNTY's DBH Director, or designee, reserves the right at any time during the term of
4 this Agreement to add new CONTRACTOR(S) to those contained in Exhibit A. It is understood any
5 such additions will not affect compensation paid to the other CONTRACTOR(S), and therefore such
6 additions may be made by COUNTY without notice to or approval of other CONTRACTOR(S)under
7 this Agreement. These same provisions shall apply to the deletion of any CONTRACTOR(S)
8 contained in Exhibit A, except that deletions shall be by written mutual agreement between the
9 COUNTY's DBH Director, or designee, on behalf of COUNTY and the particular CONTRACTOR(S)
10 to be deleted, or shall be in accordance with the provisions of Section Three (3), TERMINATION, of
11 this Agreement.
12 18. COMPLAINTS
13 CONTRACTOR(S) shall log all complaints and the disposition of all complaints from a
14 person served or a person's served family. CONTRACTOR(S) shall provide a summary of the
15 complaint log entries concerning COUNTY sponsored persons served to COUNTY at monthly
16 intervals,by the fifteenth(15th) day of the following month, in a format that is mutually agreed upon.
17 In addition, CONTRACTORS shall provide details and attach documentation of each complaint with
18 the log CONTRACTOR(S) shall post signs informing persons served of their right to file a complaint
19 or grievance. CONTRACTOR(S) shall notify COUNTY of all incidents reportable to state licensing
20 bodies that affect COUNTY persons served within twenty-four(24)hours of receipt of a complaint.
21 Within fifteen(15) days after each incident or complaint affecting COUNTY sponsored
22 persons served, CONTRACTOR shall provide COUNTY with information relevant to the complaint,
23 investigate details of the complaint, the complaint and CONTRACTOR's disposition of, or, corrective
24 action taken to resolve the complaint.
25 19. CONFLICT OF INTEREST
26 No officer, agent, or employee of the COUNTY who exercises any function or
27 responsibility for planning and carrying out the services provided under this Agreement shall have any
28 direct or indirect personal financial interest in this Agreement. The CONTRACTOR(S) shall comply
- 17 - COUNTY OF FRESNO
Fresno,CA
1 with all Federal, State of California, and local conflict of interest laws, statutes, and regulations, which
2 shall be applicable to all parties and persons served under this Agreement and any officer, agent, or
3 employee of the COUNTY.
4 20. LICENSES/CERTIFICATES
5 CONTRACTOR(S) and CONTRACTOR(s)' staff, throughout the term of this
6 Agreement, shall maintain all necessary licenses, permits approvals, certificates, waivers and
7 exceptions necessary for the provision of the services hereunder and required by the laws and
8 regulations of the United States, State of California, County of Fresno, and any other applicable
9 governmental agencies.
10 CONTRACTOR(S) shall notify COUNTY immediately in writing of its inability to
11 obtain or maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions
12 irrespective of the pendency of any appeal related thereto. Additionally, CONTRACTOR(S) shall
13 comply with all other applicable laws, rules or regulations, as any may now exist or be hereafter
14 changed. CONTRACTOR(S) shall maintain copies of all licenses, certifications, etc., noted above and
15 shall allow COUNTY's DBH to review these documents upon request.
16 In the event of any change in CONTRACTOR name or Tax Identification Number,
17 CONTRACTOR shall provide written notice to COUNTY within ten(10) days from the date of the
18 change. Such notification shall include copies of revised W9 and CA590 forms.
19 21. REFERENCE TO LAWS AND RULES
20 CONTRACTOR(S) shall maintain in full force and effect and comply with any and all
21 licensing, local zoning, and State of California fire and safety ordinances and regulations.
22 22. RECORDS
23 A. Case Records: CONTRACTOR(S) shall maintain adequate case records on each
24 person served which shall include person served assessment, individual program plan, and records of
25 services provided by the various professional and para-professional personnel in sufficient detail to
26 make possible an evaluation of services, and contain all the data necessary in reporting to the State,
27 including records of person served interviews and progress notes. All such records shall be maintained
28 pursuant to applicable laws concerning confidentiality and, in the case of Mental Health records,
- 18 - COUNTY OF FRESNO
Fresno,CA
1 California Welfare and Institutions Code, section 5328, et al, and Title 45, Code of Federal
2 Regulations, section 205.50. All case management records shall be considered the property of
3 COUNTY and shall be retained by the COUNTY at the termination of this Agreement. The
4 CONTRACTOR(S)may retain copies of these records at the time of termination if they so choose. All
5 the terms and conditions of this Agreement concerning the confidentiality of such records shall survive
6 such termination of this Agreement and shall continue to apply to such copies of those records retained
7 by CONTRACTOR(S).
8 CONTRACTOR shall retain all records for a period of no less than ten(10) years
9 from the term end date of this Agreement or in the event the CONTRACTOR has been notified that an
10 audit or investigation of the Agreement has commenced, until such time as the matter under audit or
11 investigation has been revolved, including the exhaustion of all legal remedies, whichever is later.
12 B. Financial Records: Statistical data shall be retained and reports made as required
13 by COUNTY'S DBH Director and the State of California.
14 If COUNTY or CONTRACTOR(S) are requested to disclose any books,
15 documents or records relevant to this Agreement, for the purpose of an audit or investigation by an
16 entity authorized by law to conduct such an audit or investigation, COUNTY or CONTRACTOR(S)
17 shall notify the other party of the nature and scope of such request and shall make available to the other
18 party all such books, contracts, documents or records relating to this Agreement. By agreeing to the
19 aforementioned, COUNTY and CONTRACTORS do not waive any legal rights that they have with
20 regard to disclosure of documents or information.
21 CONTRACTORS shall maintain accurate accounting records of its costs and
22 operating expenses. Such records of costs and expenditures shall be maintained for at least ten(10)
23 years, or until audit findings are resolved, and shall be open to inspection by COUNTY's DBH
24 Director, COUNTY's Auditor-Controller/Treasurer-Tax Collector, the Grand Jury, the State Controller,
25 the State Director of the Department of Health Care Services, or any of their deputies.
26 C. COUNTY and State of California reserve the right to use and reproduce all
27 reports and data produced and delivered pursuant to this Agreement, and reserve the right to authorize
28 others to use or reproduce such materials,unless of a confidential nature.
- 19 - COUNTY OF FRESNO
Fresno,CA
1 D. Other: CONTRACTOR(S) shall maintain and provide to COUNTY, with prior
2 notice,person served information for purposes of trend studies conducted by COUNTY's Quality
3 Assurance Coordinator and other staff as appropriate, as authorized by COUNTY's DBH Director, or
4 designee.
5 23. COMPLIANCE WITH STATE REQUIREMENTS
6 Each CONTRACTOR shall recognize that COUNTY operates its Department of
7 Behavioral Health under an agreement with the State of California DHCS, and that under said
8 agreement the State imposes certain requirements on the COUNTY and its subcontractors.
9 CONTRACTOR(S) shall adhere to all State of California requirements, including those identified in
10 Exhibit E "State Mental Health Requirements", attached hereto and by this reference incorporated
11 herein.
12 24. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST
13 INFORMATION
14 This provision is only applicable if CONTRACTOR(S) is a disclosing entity, fiscal
15 agent, or managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101
16 455.104, and 455.106(a)(1),(2).
17 In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and 455.106(a)(1),(2),
18 the following information must be disclosed by CONTRACTOR(S)by completing Exhibit F
19 "Disclosure of Ownership and Control Interest Statement", attached hereto and by this reference
20 incorporated herein and made part of this Agreement. CONTRACTOR(S) shall submit this form to
21 COUNTY's DBH within thirty(30) days of the effective date of this Agreement. Additionally,
22 CONTRACTOR(S) shall report any changes to this information within thirty-five (35) days of
23 occurrence by completing Exhibit F. Submissions shall be scanned pdf copies and are to be sent via
24 email to COUNTY's DBH Contracted Services at dbhcontractedservicesdivision@fresnocountyca.gov.
25 25. DISCLOSURE—CRIMINAL HISTORY AND CIVIL ACTIONS
26 CONTRACTOR(S) is required to disclose if any of the following conditions apply to
27 them, their owners, officers, corporate managers and partners (hereinafter collectively referred to as
28 "CONTRACTOR(S)"):
- 20 - COUNTY OF FRESNO
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1 A. Within the three (3)year period preceding the Agreement award, they have been
2 convicted of, or had a civil judgment rendered against them for:
3 1) Fraud or a criminal offense in connection with obtaining, attempting to
4 obtain, or performing a public (federal, state, or local) transaction or contract under a public
5 transaction;
6 2) Violation of a federal or state antitrust statute;
7 3) Embezzlement, theft, forgery, bribery, falsification, or destruction of
8 records; or
9 4) False statements or receipt of stolen property.
10 B. Within a three (3)year period preceding their Agreement award, they have had
11 a public transaction (federal, state, or local)terminated for cause or default.
12 Disclosure of the above information will not automatically eliminate
13 CONTRACTOR(S) from further business consideration. The information will be considered as
14 part of the determination of whether to continue and/or renew the Agreement and any additional
15 information or explanation that a CONTRACTOR(S) elects to submit with the disclosed
16 information will be considered. If it is later determined that the CONTRACTOR(S) failed to
17 disclose required information, any contract awarded to such CONTRACTOR(S) may be
18 immediately voided and terminated for material failure to comply with the terms and conditions of
19 the award.
20 CONTRACTOR(S)must sign a"Certification Regarding Debarment,
21 Suspension, and Other Responsibility Matters - Primary Covered Transactions" in the form set forth
22 in Exhibit G, attached hereto and by this reference incorporated herein. Additionally,
23 CONTRACTOR(S) must immediately advise the COUNTY in writing if, during the term of this
24 Agreement: (1) CONTRACTOR(S)becomes suspended, debarred, excluded or ineligible for
25 participation in federal or state funded programs or from receiving federal funds as listed in the
26 excluded parties' list system (hqp://www.sam.gov); or(2) any of the above listed conditions become
27 applicable to CONTRACTOR(S). CONTRACTOR(S) shall indemnify, defend and hold the
28 COUNTY harmless for any loss or damage resulting from a conviction, debarment, exclusion,
- 21 - COUNTY OF FRESNO
Fresno,CA
1 ineligibility or other matter listed in the signed Certification Regarding Debarment, Suspension, and
2 Other Responsibility Matters.
3 26. DISCLOSURE OF SELF-DEALING TRANSACTIONS
4 This provision is only applicable if the CONTRACTOR(S) is operating as a corporation
5 (a for-profit or non-profit corporation) or if during the term of this Agreement, the CONTRACTOR(S)
6 changes its status to operate as a corporation.
7 Members of the CONTRACTOR(S)' Board of Directors shall disclose any self-dealing
8 transactions that they are a party to while CONTRACTOR(S) is providing goods or performing
9 services under this Agreement. A self-dealing transaction shall mean a transaction to which the
10 CONTRACTOR(S) is a party and in which one or more of its directors has a material financial interest.
11 Members of the Board of Directors shall disclose any self-dealing transactions that they are a party to
12 by completing and signing a"Self-Dealing Transaction Disclosure Form", attached hereto as Exhibit H
13 and incorporated herein by reference and made part of this Agreement, and submitting it to the
14 COUNTY prior to commencing with the self-dealing transaction or immediately thereafter.
15 27. AUDITS AND INSPECTIONS
16 The CONTRACTOR(S) shall at any time during business hours, and as often as the
17 COUNTY may deem necessary, make available to the COUNTY for examination all of their records
18 and data with respect to the matters covered by this Agreement. The CONTRACTOR(S) shall, upon
19 request by the COUNTY, permit the COUNTY to audit and inspect all such records and data necessary
20 to ensure CONTRACTOR(S') compliance with the terms of this Agreement.
21 If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
22 CONTRACTOR(S) shall be subject to the examination and audit of the State Auditor General for a
23 period of three (3)years after final payment under contract(California Government Code section
24 8546.7).
25 28. REPORTING
26 CONTRACTOR shall provide at COUNTY's request, any required reports to COUNTY
2 7 which may include performance outcome measurement reports as communicated by the COUNTY to
28 CONTRACTOR.
- 22 - COUNTY OF FRESNO
Fresno,CA
1 29. MONITORING
2 CONTRACTOR(S) agree to extend to COUNTY's staff, COUNTY's DBH Director,
3 and the State Department of Health Care Services, or their respective designees, the right to review and
4 monitor records, programs or procedures, at any time, in regard to persons served, as well as the overall
5 operation of CONTRACTOR(S)' programs in order to ensure compliance with the terms and
6 conditions of this Agreement.
7 30. PROHIBITION ON PUBLICITY
8 None of the funds, materials,property or services provided directly or indirectly under
9 this Agreement shall be used for CONTRACTOR(S)' advertising, fundraising, or publicity(i.e.,
10 purchasing of tickets/tables, silent auction donations, etc.) for the purpose of self-promotion.
11 Notwithstanding the above, publicity of the services described in Section One (1), SERVICES, of this
12 Agreement shall be allowed as necessary to raise public awareness about the availability of such
13 specific services when approved in advance by COUNTY's DBH Director, or designee and at a cost to
14 be provided in writing for such items as written/printed materials, the use of media(i.e., radio,
15 television, newspapers) and any other related expense(s). Communication products must follow DBH
16 graphic standards, including typefaces and colors, to communicate our authority and project a unified
17 brand. This includes all media types and channels and all materials on and offline that are created as
18 part of DBH's efforts to provide information to the public.
19 31. CULTURAL COMPETENCY
20 As related to Cultural and Linguistic Competence,CONTRATOR(S) shall comply with:
21 A. Title 6 of the Civil Rights Act of 1964 (42 U.S.C. § 2000d,and 45 CFR Part 80)
22 and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance from
23 discriminating against persons based on race, color,national origin, sex, disability or religion. This is
24 interpreted to mean that a limited English proficient(LEP)person served is entitled to equal access and
25 participation in federally funded programs through the provision of comprehensive and quality bilingual
26 services.
27 B. Policies and procedures for ensuring access and appropriate use of trained
28 interpreters and material translation services for all LEP persons served,including,but not limited to,
- 23 - COUNTY OF FRESNO
Fresno,CA
I assessing the cultural and linguistic needs of its persons served,training of staff on the policies and
2 procedures, and monitoring its language assistance program. The CONTRACTOR's procedures must
3 include ensuring compliance of any sub-contracted providers with these requirements.
4 C. CONTRACTOR assurance that minors shall not be used as interpreters.
5 D. CONTRACTOR shall provide and pay for interpreting and translation services to
6 persons participating in CONTRACTOR's services who have limited or no English language proficiency,
7 including services to persons who are deaf or blind. Interpreter and translation services shall be provided as
8 necessary to allow such persons served meaningful access to the programs, services and benefits provided
9 by CONTRACTOR(S). Interpreter and translation services, including translation of CONTRACTOR's
10 "vital documents"(those documents that contain information that is critical for accessing
11 CONTRACTOR's services or are required by law)shall be provided to persons served at no cost to the
12 person. CONTRACTOR shall ensure that any employees, agents, subcontractors, or partners who interpret
13 or translate for a program person served, or who directly communicate with a program person served in a
14 language other than English, demonstrate proficiency in the person's served language and can effectively
15 communicate any specialized terms and concepts peculiar to CONTRACTOR's services.
16 E. In compliance with the State-mandated Culturally and Linguistically Appropriate
17 Services standards as published by the Office of Minority Health,new CONTRACTOR must submit to
18 COUNTY for approval,within sixty(60) days from date of contract execution, CONTRACTOR's plan to
19 address all fifteen(15)national cultural competency standards as set forth in the"National Standards on
20 Culturally and Linguistically Appropriate Services"(CLAS),
21 http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf. County's annual on-site review of
22 CONTRACTOR shall include collection of documentation to ensure all national standards are
23 implemented. As the national competency standards are updated, CONTRACTOR's plan must be updated
24 accordingly.
25 32. NOTICES
26 The persons and their addresses having authority to give and receive notices under this
27 Agreement include the following:
28
- 24 - COUNTY OF FRESNO
Fresno,CA
1 COUNTY CONTRACTOR(S)
2 Director, Fresno County SEE EXHIBIT A
Department of Behavioral Health
3 1925 E Dakota Ave
Fresno, CA 93726
4
5 Any and all notices between the COUNTY and the CONTRACTOR(S)provided for or
6 permitted under this Agreement or by law shall be in writing and delivered either by personal service,
7 by first-class United States mail,by an overnight commercial courier service, or by telephonic facsimile
8 transmission. A notice delivered by personal service is effective upon service to the recipient. A notice
9 delivered by first-class United States mail is effective three (3) COUNTY business days after deposit in
10 the United States mail,postage prepaid, addressed to the recipient. A notice delivered by an overnight
11 commercial courier service is effective one (1) COUNTY business day after deposit with the overnight
12 commercial courier service, delivery fees prepaid, with delivery instructions given for next day
13 delivery, addressed to the recipient. A notice delivered by telephonic facsimile is effective when
14 transmission to the recipient is completed(but, if such transmission is completed outside of COUNTY
15 business hours, then such delivery shall be deemed to be effective at the next beginning of a COUNTY
16 business day), provided that the sender maintains a machine record of the completed transmission. For
17 all claims arising out of or related to this Agreement, nothing in this section establishes, waives, or
18 modifies any claims presentation requirements or procedures provided by law, including but not limited
19 to the Government Claims Act (Division 3.6 of Title 1 of the Government Code,beginning with section
20 810).
33. SEVERABILITY
21
22 If any non-material term,provision, covenant, or condition of this Agreement is held by
23 a court of competent jurisdiction to be invalid, void or unenforceable, the remainder of the provisions
24 shall remain in full force and effect, and shall in no way be affected, impaired or invalidated.
34. SEPARATE AGREEMENT
25
26 It is mutually understood by the parties that this Agreement does not, in any way, create
27 a joint venture among the individual CONTRACTORS. By execution of the Agreement,
28 CONTRACTORS understand that a separate Agreement is formed between each individual
CONTRACTOR and COUNTY.
- 25 - COUNTY OF FRESNO
Fresno,CA
1 35. GOVERNING LAW
2 The parties agree that for the purposes of venue,performance under this Agreement is to
3 be in Fresno County, California. The rights and obligations of the parties and all interpretation and
4 performance of this Agreement shall be governed in all respects by the laws of the State of California.
5 36. ELECTRONIC SIGNATURE
6 The parties agree that this Agreement may be executed by electronic signature as
7 provided in this section. An"electronic signature"means any symbol or process intended by an
8 individual signing this Agreement to represent their signature, including but not limited to (1) a digital
9 signature; (2) a faxed version of an original handwritten signature; or(3) an electronically scanned and
10 transmitted(for example by PDF document) of a handwritten signature. Each electronic signature
11 affixed or attached to this Agreement(1) is deemed equivalent to a valid original handwritten signature
12 of the person signing this Agreement for all purposes, including but not limited to evidentiary proof in
13 any administrative or judicial proceeding, and(2) has the same force and effect as the valid original
14 handwritten signature of that person. The provisions of this section satisfy the requirements of Civil
15 Code section 1633.5, subdivision (b), in the Uniform Electronic Transaction Act(Civil Code, Division
16 3, Part 2, Title 2.5, beginning with section 1633.1). Each party using a digital signature represents that
17 it has undertaken and satisfied the requirements of Government Code section 16.5, subdivision(a),
18 paragraphs (1)through (5), and agrees that each other party may rely upon that representation. This
19 Agreement is not conditioned upon the parties conducting the transactions under it by electronic means
20 and either party may sign this Agreement with an original handwritten signature.
21 37. ENTIRE AGREEMENT
22 This Agreement, including all Exhibits, constitutes the entire agreement between the
23 CONTRACTOR(S) and COUNTY with respect to the subject matter hereof and supersedes all
24 previous agreement negotiations,proposals, commitments, writings, advertisements, publications, and
25 understandings of any nature whatsoever unless expressly included in this Agreement.
26 ///
27
28
- 26 - COUNTY OF FRESNO
Fresno,CA
I IN WITNESS WHEREOF,the parties hereto have executed this Agreement as of the day
2 and year first hereinabove written.
3
4 CONTRACTOR C UN OF FRESNO
5
6 SEE EXHIBIT A Brian Pacheco, Chairman of the Board of
Supervisors of the County of Fresno
7
8
9
10 ATTEST:
11 Bernice E. Seidel
Clerk of the Board of Supervisors
12 County of Fresno, State of California
13 By:-
14 De uty
15
16
17 FOR ACCOUNTING USE ONLY:
18
19 ORG No.: 56302175
Account No.: 7295/0
20 Fund/Subclass: 0001/10000
Reauisition No.: N/A
21
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— 27 — COUNTY OF FRESNO
Fresno,CA
1 CONTRACTOR: "'S $OME OF BLESSING AND JOB'' INC.
2
3 By
_. 4A kw
5 Print Name:
6
7 Title: pre-31*d
Chairman of the Board, President or Vice President
8 ?
9 Date:
10
11
12 By
13
14 Print Name: 4l�/�
15
16 Title:
Setary (of Co a io Assistant Secretary,
17 Chief Financial Officer, or Assistant Treasurer
18
19 Date: ✓�lJ 7
20
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28 COUNTY OF FRESNO
Fresno,CA
y.
IM
CamScanner
1 CONTRACTOR: A]" HOME OF CARE,LLC.
2
3 By
9 .
5 Print Name: �kALHT
6
Title: yl(0— QC-to-S l C -
7 Chairman of the Board, President, or Vice President
8
9 Date: �j j
10
11 II
12 By
13
14 Print Name: nn r
15
16 Title:
ecretary (of Corporation Assistant Secretary,
17 Chief Financia ice , or Assistant Treasurer
18
19 Date: (C)
20
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— 29 —
COUNTY OF FRESNO
Fresno,CA
CamScanner
I CONTRACTOR: ANJALEONI ENTERPRISE,INC.
2 dba LEONIE HOUSE
3
4 By
5
6 Print Name: Sundari Susan Kendakur
7
8 Title: Chief Executive Officer
Chairman of the Board, President, or Vice President
9
10 Date: May 15, 2022
11
12
13 By ��—�/
14
15 Print Name: Anjali Sabrina Kendakur
16
17 Title: Secretary
Secretary(of Corporation), Assistant Secretary,
18 Chief Financial Officer, or Assistant Treasurer
19
20 Date: May 18, 2022
21
22
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- 30 - COUNTY OF FRESNO
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1 CONTRACTOR: BENEVOLENT RESIDENTIAL CARE HOME,LLC
2 dba DAILEY'S HAVEN
3
4 By
6 Print Name: Estelle Dailey
7
8 Title: President/Administrator
Chairman of the Board, President, or Vice President
9
10 Date: 05/10/2022
11
12
13 By
14
15 Print Name:
16
17 Title:
Secretary (of Corporation), Assistant Secretary,
18 Chief Financial Officer, or Assistant Treasurer
19
20 Date:
21
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— 31 — COUNTY OF FRESNO
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I CONTRACTOR: BK HOUSE OF GRACE, LLC.
2 pp p
3 By 0wt)�'+ a�t Kau
4
5 Print Name: Balwinder Kaur
6
Title: Owner/ CEO
7 Chairman of the Board, President, or Vice President
8
9 Date: 05/11/2022
10
11
12 By ZWiiJc;Id&, Kazi,
13
14 Print Name: Balwinder Kaur
15
16
Title: Owner/ CEO
Secretary(of Corporation), Assistant Secretary,
17 Chief Financial Officer, or Assistant Treasurer
18
19
Date: 05/11/2022
20
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- 32 - COUNTY OF FRESNO
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I CONTRACTOR: BONAVENTE HOME FOR THE ELDERLY 11
2
3 By
4
5 Print Name:
6 /
Title: w h S l D W c?.Ff2 I Ce 6
7 �E Chairman of the Board, President, or Vice President
8
9 Date: �J f G t -2-0 2 ?�
10
11 /J
12 By
13
14 Print Name: I ►DA A - Go nclj eVl-4-e—
15
16 Title: See Y�-y /6 w�
Secretary (of Corporation), Assistant Se retary, l
17 Chief Financial Officer, or Assistant Treasurer
18
19 Date:
20
21
22
23
24
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26
27
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— 33 — COUNTY OF FRESNO
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I CONTRACTOR: THE CHIMES HOME
2
3 By '
4
5 Print Name: A m o y. h . A L6 61
6 ( f
Title: My-yx ty r Av�'4vr- 1 L-i 6&�
7 Chairman of the Board, President, or Vice President
8
9 Date: 5
10
11
12 By
13
14 Print Name:
15
16 Title:
Secretary(of Corporation), Assistant Secretary,
17 Chief Financial Officer, or Assistant Treasurer
18
19 Date:
20
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— 34 — COUNTY OF FRESNO
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- 35 - COUNTY OF FRESNO
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1 CONTRACTOR: GARDEN MANOR
2 �
3 Byti
4
Print Name: Joan Black
5
6 Title: President, Owner
7 Chairman of the Board, President, or Vice President
8
9 Date: 5/19/2022
10
11
12 By
13
Print Name:
14
15
Title:
16 Secretary(of Corporation),Assistant Secretary,
17 Chief Financial Officer, or Assistant Treasurer
18
Date:
19
20
21
22
23
24
25
26
27
28
- 36 - COUNTY OF FRESNO
Fresno,CA
I CONTRACTOR: GAREM ASSISTED LIVING, INC.
2
3 By
4
5 Print Name: Maxima S Dionisio
6
7 Title: Chief Executive Officer
Chairman of the Board, President, or Vice President
8
9 Date: 05/16/2022
10
11
12 By
13
14 Print Name: Joycelyn Bare Hopper
15
16
Title: Chief Financial Officer
Secretary(of Corporation), Assistant Secretary,
17 Chief Financial Officer, or Assistant Treasurer
18
19 Date: 05/16/2022
20
21
22
23
24
25
26
27
28
- 37 - COUNTY OF FRESNO
Fresno,CA
1 CONTRACTOR: HASKINS RESIDENTIAL CARE
2
3 B
y
4
5 Print Name:
6
Title: ObWK-ZlQknt'l( E��41,4—
Chairm of the Board, President, or Vice President
8
9 Date: s
10
11
12 By
13
14 Print Name:
15
16 Title:
Secretary (of Corporation),Assistant Secretary,
17 Chief Financial Officer,or Assistant Treasurer
18
19 Date:
20
2,
22
23
24
25
26
27
28
- 38 - COUNTY OF FRESNO
Fresno,CA
I CONTRACTOR: JAN-ROY PLACE OF FRESNO
2
3 By 99 '
It
5 Print Name: Joycelyn Bare Hopper
6
Title: Chief Executive Officer
7 Chairman of the Board, President, or Vice President
8
9 Date: 5/15/2022
10
11
12 By
13
14 Print Name: Kir Gilroy B Mendoza
15
16
Title: Secretary
Secretary(of Corporation), Assistant Secretary,
17 Chief Financial Officer, or Assistant Treasurer
18
19 Date: 5/15/2022
20
21
22
23
24
25
26
27
28
- 39 - COUNTY OF FRESNO
Fresno,CA
1 CONTRACTOR: MARIAN HOMES, INC.
2 dba SIERRA VILLA REST HOME
3
4 By
5
6 Print Name: Sundari Susan Kendakur
7
8 Title: Chief Executive Officer
Chairman of the Board, President, or Vice President
9
10 Date: May 15, 2022
11
12
13 By
14
15 Print Name: Samuel Leone Kendakur
16
17 Title: Chief Financial Officer
Secretary(of Corporation), Assistant Secretary,
18 Chief Financial Officer, or Assistant Treasurer
19
20 Date: May 18, 2022
21
22
23
24
25
26
27
28
- 40 - COUNTY OF FRESNO
Fresno,CA
1 CONTRACTOR: MARK A GISLER
2 dba RUBY'S VALLEY CARE HOME
3
4 By
5
6 Print Name: Mark A. Gisler
7
8 Title: Owner/Licensee
Chairman of the Board, President,or Vice President
9 G
10 Date: S- 1 ' Lo 2--L
11
12
13 By
14
15 Print Name: Mary P. Gisler
16
17 Title: Owner/Licensee
Secretary (of Corporation),Assistant Secretary,
18 Chief Financial Officer,or Assistant Treasurer
19 7
/�
20 Date:
21
22
23
24
25
26
27
28
41 — COUNTY OF FRESNO
Fresno,CA
1 CONTRACTOR: MODESTO RESIDENTIAL LIVING CENTER
2
3 BY
40L==--
4
5 Print Name: De m S A,
6
Title:
7 Chairman of the Board, President, or Vice President
8 /
9 Date: i�i/l 61!21,7
10
11
12 By
13
14 Print Name: po;ffi
15
16 Title:
Secretary (of Corporation), Assistant Secretary,
17 Chief Financial Officer, or Assistant Treasurer
18
Date:
19
20
21
22
23
24
25
26
27
28
— 42 — COUNTY OF FRESNO
Fresno,CA
1 CONTRACTOR: PROVIDIAN RESIDENTIAL CARE SERVICES, INC.
2 dba FILLMORE CHRISTIAN GARDENS
3
4 By
5
6 Print Name:
7
8 Title:
Chairman of the Board, President, or Vice President
9
10 Date:
11
12
13 BY ',a'"e i� /-t4
14
15 Print Name: Inthone Milly
16
17
Title: Chief Executive Officer
Secretary(of Corporation), Assistant Secretary,
18 Chief Financial Officer, or Assistant Treasurer
19
20
Date: May 19, 2022
21
22
23
24
25
26
27
28
- 43 - COUNTY OF FRESNO
Fresno,CA
I CONTRACTOR: ROYAL BOARD AND CARE HOME FOR THE ELDERLY
2
3 By
4
5 Print Name: Rudy G Rigon
6
Title: Administrator
7 Chairman of the Board, President, or Vice President
8
9 Date: May 18, 2022
10
11
12 By
13
14 Print Name: Rudy Rigon
15
16 Title: Licensee
Secretary(of Corporation), Assistant Secretary,
17 Chief Financial Officer, or Assistant Treasurer
18
19 Date: May 18, 2022
20
21
22
23
24
25
26
27
28
- 44 - COUNTY OF FRESNO
Fresno,CA
I CONTRACTOR: SUNSHINE BOARD AND CARE II
2
3 By�
4
5 Print Name: Aurora A Rigon
6
7 Title: Administrator
Chairman of the Board, President, or Vice President
8
9 Date: May 18, 2022
10
11
12 By�
13
14 Print Name: Aurora A R i g o n
15
16 Title: Licensee
Secretary(of Corporation), Assistant Secretary,
17 Chief Financial Officer, or Assistant Treasurer
18
19 Date: May 18, 2022
20
21
22
23
24
25
26
27
28
- 45 - COUNTY OF FRESNO
Fresno,CA
Specialized Supplemental Board and Care Home Contractor List Exhibit A
VENDOR FACILITY LOCATION CONTACT PERSON
AK's Home of Blessing and Joy, Inc. Akwant Malhi
Remit to: 6631 E Cetti Ave 559-708-3485
6631 E. Cetti Ave Fresno Ca, 93727 jchatha1983@hotmail.com
Fresno, Ca 93727
AK's Home of Care, LLC Akwant Malhi
Remit to: 122 W San Gabriel 559-708-3485
122 W San Gabriel Clovis, Ca 93612 jchatha1983@hotmail.com
Clovis, CA 93612
Anjaleoni Enterprise, Inc. Sundari Susan Kendakur
dba Leonie House 2931 Caesar Ave 559-347-9900 or 559-779-4071
Remit to: Clovis, Ca 93611 anjaleoni@me.com
3086 Armstrong Ave
Clovis, Ca 93611
Benevolent Residential Care Service, LLC. Estelle Dailey
dba Dailey's Haven 4479 N. Eddy Ave 559-456-9440 or 559-970-1536
Remit to: Fresno, Ca 93727 estelle.daileyl@comcast.net
5261 E McKenzie
Fresno, Ca 93727
BK House of Grace, LLC Rosemarie Riemer
Remit to: 1463 N Archie Ave 559-708-2877
813 S Douglas Ave. Fresno, Ca 93703 roseriemer@gmail.com
Fresno, Ca 93727
Bonavente Home for the Elderly II Rosemarie Riemer
Remit to: 6097 Harrison 559-708-2877
2788 W Fir Ave. Fresno, Ca 93711 roseriemer@gmail.com
Fresno, Ca 93711
The Chimes Home Amor Alegre
Remit to: 3041 E Clinton 559-244-0479 or 559-369-9949
2845 N Armstrong Ave Fresno, Ca 93703 amoralegre122@gmail.com
Fresno, Ca 93727
Garden Manor Joan Black
Remit to: 4983 E Olive Ave 559-255-8650 x201
4983 E Olive Ave. Fresno, Ca 93727 gardenmanor4983@yahoo.com
Fresno, Ca 93727
Garem Assisted Living, Inc Joycelyn Hopper
Remit to: 4266 N 9th St 559-940-9708 or 559-797-9284
4266 N. 9th St Fresno, Ca 93726 garem816@gmail.com
Fresno, Ca 93726
Haskins Residential Care Donald Haskins
Remit to: 1037 S Chestnut Ave 559-453-6832 or 559-352-5240
1037 S Chestnut Ave Fresno, Ca 93702 natalieh@haskinsrescare.com
Fresno, Ca 93702
Jan-Roy Place of Fresno Joycelyn Hopper
Remit to: 4766 E Illinois Ave 559-940-9708 or 559-890-0839
4766 E Illinois Ave Fresno, Ca 93702 janroy8693@gmail.com
Fresno, Ca 93702
Marian Homes Sundari Susan Kendakur
dba Sierra Villa Rest Home 175 W Sierra Ave 559-347-9900 or 559-779-4071
Remit to: Clovis, Ca 93612 anjaleoni@me.com
3086 Armstrong Ave
Clovis, Ca 93611
Mark A Gisler Mark Gisler
dba Ruby's Valley Care Home 9919 S Elm Ave 209-329-1159
Remit to: Fresno, Ca 93706 marebot@aol.com
9919 S Elm Ave.
Fresno, Ca 93706
Revised 7/20/22 Page 1 of 2
Specialized Supplemental Board and Care Home Contractor List Exhibit A
VENDOR FACILITY LOCATION CONTACT PERSON
Modesto Residential Living Center Lena Baldwin
Remit to: 1932 Evergreen Ave 209-530-9300
1932 Evergreen Ave Modesto, Ca 95350 modestorlc@yahoo.com
Modesto, Ca 95350
Providian Residential Care Services, Inc. Inthone Milly
dba Fillmore Christian Gardens 4826 E Fillmore 559-307-4170
Remit to: Fresno, Ca 93727 Inthonemilly@providianres.com
4826 E Fillmore
Fresno, Ca 93727
Royal Board and Care Home for the Elderly Rudy Rigon
Remit to: 3407 N Fresno 559-903-6846
3407 N Fresno St Fresno, Ca 93726 rudygrigon@gmail.com
Fresno, Ca 93726
Sunshine Board and Care II Aurora Rigon
Remit to: 1642 W Robinson Ave 559-903-2401
1642 W Robinson Ave Fresno, Ca 93705 auroraarigon@gmail.com
Fresno, Ca 93705
Valley Comfort Home, Inc. Priscilla Quinto
Remit to: 6579 E Fillmore Ave 559-495-8273 or 559-454-0704
6579 E Fillmore Ave. Fresno, Ca 93727 precydquinto@yahoo.com
Fresno, Ca 93727
Revised 7/20/22 Page 2 of 2
Exhibit B
Page 1 of 15
SPECIALIZED SUPPLEMENTAL BOARD AND CARE HOMES
SCOPE OF WORK
I. QUALITY ASSURANCE STANDARDS FOR LICENSED RESIDENTIAL CARE FACILITIES -
BASIC CARE AND SUPERVISION
SECTION I - PROGRAM
1.1 Each facility has a written Program Design (Title 22, Plan of Operation) approved by the
Department of Behavioral Health (DBH) which contains a statement of purpose, a statement of
goals, a description of program methods and a staff training plan.
1.2 The activities and opportunities provided to each person served are consistent with the written
Program Design.
1.3 The facility administrator, person served and agency referral person/authorized representatives
are involved in the development of the person's served "Appraisal/ Needs and Services Plan."
1.4 The facility ensures continuity in each person's served planned activities by having staff
communicate and participate with other agencies in case conferences and in the development
of a plan of care or educational plan.
1.5 The supervision and training provided to each person served follows the objectives and plans
written in the "Needs and Appraisal Plan."
1.6 The facility provides supervision and training seven days per week with a staff ratio adequate to
implement the "Appraisal/Needs and Services Plan."
1.7 The facility has a written monthly Activity Schedule posted for all hours that persons served are
awake and under the supervision of the facility, seven days per week. The Activity Schedule
reflects the time and place of usual person served activities. The Activity Schedule reflects at
least one recreational activity each day and at least one activity in the community each week.
1.8 The facility teaches and enables persons served to practice skills and behaviors that are
necessary for attaining greater independence in the home and in the community in accordance
with the "Appraisal/Needs and Services Plan." The facility encourages use of leisure time in a
constructive manner.
1.9 Daily activities are age appropriate.
1.10 Natural environments and materials are used in teaching skills to persons served.
1.11 Training techniques are individualized in accordance with the "Appraisal/Needs and Services
Plan."
1.12 Training techniques are consistent with the principles of least restrictive method.
Exhibit B
Page 2 of 15
1.13 All staff responsible for carrying out a person's served "Training/Treatment" are familiar with its
objectives and methods of implementation.
1.14 There is a continuity, through staff changes, in training provided to persons served, as
evidenced by either oral or written communications between staff on different shifts.
1.15 Every twelve (12) months the "Appraisal/Needs and Services Plan" is reviewed by the case
manager/authorized representative, person served and facility staff to measure and document
progress of set objectives and/or the need to modify.
1.15.1 Every six (6) months the person served is assessed by case manager with input from
the CONTRACTOR.
1.16 When the "Needs Service Plan" needs to be updated, facility staff bring this to the attention of
the case manager. The facility staff, case manager and resident
participate in the revision, as appropriate.
1.17 Staff shall keep daily progress notes of activities and participation in milieu.
SECTION 2 - RIGHTS
2.1 A statement of person served rights is posted where it is easily accessible to persons served
and visitors. The statement includes a description of procedures to be followed and whom to
contact if the person has questions or complaints regarding rights.
2.2 Upon admission, each person served shall receive instruction on his or her rights via
communication methods which are appropriate for that person.
2.3 There is no denial of person's served rights unless the facility follows the procedures specified
by law.
2.4 House rules must be writing and posted and are appropriate for the persons served.
2.5 The facility's house rules shall be explained to each person served via communication methods
which are appropriate for that person.
2.6 Facility shall have a complaint procedure which persons served may use to appeal a decision
made by a staff member.
2.7 The complaint procedure must be written and posted and, upon admission, explained to each
person served via communication methods which are appropriate for that person.
2.8 All persons served shall have access to the facility 24 hours a day.
SECTION 3 - COMMUNITY INTEGRATION
Exhibit B
Page 3 of 15
3.1 If the facility is located in a residential neighborhood, it must be physically compatible with
residences in that neighborhood.
3.2 Persons served shall have access to resources available to other members of the local
community and are given regular opportunities to use those resources.
3.3 Persons served must be given opportunities to practice community and independent living skills
in their local community.
3.4 The facility shall provide group activities which include activities involving six (6) or fewer
persons served.
3.5 The facility shall offer at least one recreational activity a week in the community appropriate to
the interests or development of interests of the persons served. (Refer to Section 1 - 1.7)
SECTION 4 - SOCIAL - PSYCHOLOGICAL ENVIRONMENT
4.1 The physical aspects of the facility must be appropriate to the age and physical abilities of the
persons served.
4.2 Persons served shall eat in the dining room or eating areas typically used by family and/or staff
members.
4.3 Each person served shall wear/have properly fitting clothing.
4.4 Each person served shall receive training, or be assisted, in selecting clothing which is
appropriate to his or her age, sex and the season.
4.5 Each person served shall be allowed to wear his or her own clothing.
4.6 There shall be recognition and acceptance by staff of persons' served cultural and ethnic
differences.
4.7 Communication and interaction between staff and persons served shall reflect respect and
caring.
4.8 Staff shall make an effort to establish positive relationships with persons served via
communication methods which are appropriate for those persons.
4.9 Staff shall make an effort to establish positive relationships with person's served family
members.
4.10 Persons served shall share in facility decision-making through weekly house meetings designed
to encourage participation.
4.11 Persons served shall be encouraged to pursue individual interests and schedules.
Exhibit B
Page 4 of 15
4.12 The facility shall be furnished, decorated, and arranged to provide a home-like, non- institutional
atmosphere.
4.13 Bathroom facilities must be designed and equipped to afford privacy.
4.14 No more than two (2) persons served shall share a bedroom.
4.15 Bedrooms shall not be used as passageways to other rooms.
4.16 Persons served must be allowed to use bedrooms as places to be alone.
4.17 Persons served shall have access to all common areas of the residence, except controlled
storage areas and staff designated areas.
SECTION 5 - HEALTH
5.1 Within sixty (60) days of admission, each person served shall complete an appointment with a
primary care doctor for a physical exam and regular appointments once a year thereafter.
5.2 Within six (6) months of admission, each person served shall:
5.2.1 Complete a dentist appointment for a dental cleaning, any needed follow up care and
regular appointments once a year thereafter;
5.2.2 Complete an Optometrist/Ophthalmologist appointment and follow up care once each
two (2) years thereafter;
5.2.3 For persons served 45 years and older, complete a colonoscopy and endoscopy and as
ordered by a doctor;
5.2.4 For women persons served 45 years and older, complete a mammogram and every two
(2) years thereafter;
5.2.5 For women persons served 18 years old and older, receive a gynecological exam with
an OBGYN and annually thereafter; and
5.2.6 Provider staff shall obtain a copy of any doctor's note the same day as the appointment
and submit to the conservator for all doctor's visits as described above.
5.3 Staff shall provide a copy of the person's served most recent medical/psychiatric notes from the
doctor to the DBH RISE Conservatorship Office.
5.4 Telehealth support—All persons served shall have access to a computer (with sound) and be
allowed privacy to attend psychiatry appointments and court evaluations with a doctor.
5.5 Facilities that have an onsite doctor, board certified psychiatrist or psychiatric nurse practitioner
shall provide medical services for all psychiatric medications.
Exhibit B
Page 5 of 15
5.6 Persons served who require adaptive devices (eyeglasses, hearing aids, dentures, wheelchairs,
etc.) shall be given assistance in securing and maintaining these devices.
5.7 Staff must present a copy of person's served medication log to health professionals prior to
treatment.
5.8 Staff shall complete requests for packets prior to doctor evaluation appointments for court when
requested by DBH.
5.9 Staff shall ensure each person served displays good personal hygiene with regard to skin, nails,
teeth, hair and clothing and the facility shall provide personal grooming supplies. Staff shall
encourage each person served to maintain adequate grooming.
5.5 The facility shall have a method for ensuring that the nutritional needs of all persons served are
satisfied. Monthly menus must be posted and corrected as served.
5.6 The food served in the facility must provide a variety, must be presented in an appetizing
manner and when possible reflect the ethnicity of the persons served.
5.7 Notice of any unusual incident (AWOL, hospital admission, abuse), accident or death shall be
immediately reported to the Case Manager, Specialized Supplemental Board and Care
Coordinator, Conservator/Guardian (as appropriate), and State Community Care Licensing. A
copy of the incident report shall be provided to the Department of Behavioral Health Case
Manager by the end of the next business day.
SECTION 6 - PHYSICAL ENVIRONMENT AND SAFETY
6.1 The facility shall be safe, clean and well maintained, both inside and out.
6.2 Each person served shall be provided with a comfortable bed with clean linens, warm blankets
and a pillow.
6.3 Each person served shall be provided closet space and a dresser or drawer space for the
exclusive use of the person.
6.4 All person's served medications must be stored in a centrally located, locked storage area. All
medications received and dispensed shall be entered in the medication log.
6.5 All potentially dangerous non-edible or toxic items shall be clearly labeled and stored away from
food supplies.
6.6 The facility must be equipped with first aid supplies and a first aid manual.
6.7 The facility shall provide fire/disaster plan training for staff and persons served and shall
conduct and document at least one drill each quarter.
6.8 Vehicles used for transporting persons served shall be properly maintained and equipped with
seat belts. Persons served must use seat belts when vehicle is in motion.
Exhibit B
Page 6 of 15
SECTION 7 -ADMINISTRATION
7.1 Relevant chapters of Title 22 shall be maintained in the administrative offices of the facility and
available to all staff and persons served upon request.
7.2 A notice shall be posted stating that the results of State Licensing evaluations are available
upon request to persons served or other persons with a legitimate need to know.
7.3 The facility shall operate within the limitations of its license.
7.4 The facility shall maintain a record of any person's served money handled by the facility,
documenting each person's served income, disbursements made to the person served and
expenditures made on behalf of them by facility staff.
7.5 When cash is given to a person served, he/she must sign or place his/her mark on a receipt or
log specifying the cash amount.
7.6 Receipts shall be retained for expenditures made on behalf of the person served by facility staff.
7.7 A person's served funds shall be only be used by themselves or for their expenditures.
7.8 Persons' served funds shall be kept separate from facility funds.
7.9 The facility shall have procedures for protecting persons' served personal property from loss or
abuse and which also allows each person served easy access to his/her own property.
7.10 The facility shall have established screening procedures to evaluate a potential employee's
character and his/her employment history. The facility shall comply with any and all State
Department of Social Services, Community Care Licensing Division's requirements for
screening and fingerprinting.
7.11 The facility administrator or designee shall be available at all hours to respond to any needs
from staff or persons served. There shall be a notice posted with the administrator's 24-hour
contact number.
7.12 The facility shall provide or arranges for local transportation and/or training in use of public
transportation in order for persons served to:
❖ participate in programs and services outside the facility.
❖ engage in activities of daily living and leisure activities/events as cited in each person's
served "Appraisal/Needs and Services Plan."
7.13 The facility will encourage persons' served use of public transportation. The facility shall be
responsible to ensure the person's served safety regardless of the mode of transportation
chosen.
Exhibit B
Page 7 of 15
7.14 The facility shall provide transportation and supervision to get persons served safely to and from
medical/dental appointments and communicates adequately with the medical/dental provider.
7.15 All staff shall have knowledge about legal requirements for reporting person served abuse.
SECTION 8 — PERSON SERVED RECORDS
8.1 A document file of person's served records shall be maintained at the facility for each person.
Each person's served file shall include, but is not limited to, the following information:
❖ Person served rights
❖ Person's served social security number
❖ Name, address and phone numbers of conservator or family member
❖ Dates of major illnesses
❖ Record of psychiatric/medical/dental treatments
❖ Admission physical and diagnosis
❖ Record of allergies
❖ TB clearance
❖ Funeral arrangements
❖ Weight record
❖ Person's served personal property list
❖ Current admission agreement
❖ Current "Facility Service Plan"
❖ Weekly progress notes and monthly summary
8.2 All treatment services to be provided to the person served, except emergency services, are
noted in "Facility Service Plan."
8.3 The facility shall maintain a medical log for each person served: type of medication, dosage,
frequency of administration, time of each administration, and initials of staff supervising
administration of medication. The facility shall make clear on the medication log which
medications are psychotropic medications. Psychotropic medications shall indicate: name of
medication, reason for its use and possible side effects.
8.4 Person served records are confidential in accordance with California Welfare and Institutions
Code provisions.
8.5 Any consent for release of information provided by the person served, or their conservator shall
specify:
❖ Information to be released
❖ Purpose of the release
❖ Agency or person to whom release is to be made
❖ The time period for which the release is valid
8.6 Consents for Release of Information are maintained permanently in the person's served record.
Exhibit B
Page 8 of 15
8.7 Person served records shall contain monthly summary notes addressing all needs/services in
the "Facility Service Plan" and other significant events/observations affecting the person.
SECTION 9 -TRAINING
9.1 Direct-care staffs shall complete on-the-job training by the facility within one (1) month following
employment. At a minimum, the subjects covered in the training include: Special Incident
Reports, health and emergency procedures, medications, person served rights and abuse
reporting.
9.2 Direct-care staff shall complete orientation within one (1) month from start date of employment.
The orientation includes at least the following topics: awareness of mental health programs,
review of quality assurance standards, and the placement packet.
9.3 All direct-care staff shall have a current first aid training and CPR certification from an
appropriate agency, such as the Red Cross.
9.4 The facility administrator shall complete at least 20 hours per year of continuing education or in
service training. Topics of education or training are chosen from those approved by the State
Community Care Licensing Division.
9.5 Direct-care staff shall complete at least nine (9) hours of continuing education or in service
training in mental health issues or related topics. Topics of education or training are chosen
from those approved by the State Community Care Licensing Division.
II. CERTIFICATION REQUIREMENTS
A. Facilities eligible to be certified for payment for Specialized Supplemental Board and Care
Home services from Fresno County Department of Behavioral Health SHALL:
1. Be a licensed Adult Residential Care Facility or licensed Residential Care Facility for the
Elderly, authorized by the California State Department of Social Services, Community
Care Licensing Division, to provide care and supervision to mentally disabled adults.
2. Ensure the facility administrator has completed 20 hours per year of the continuing
education or in-service training in mental health issues or related topics, in accordance
with the education or training specifications of the California State Department of Social
Services, Community Care Licensing Division.
3. Ensure all direct care staff employed by the facility participate in the training activities
specified in the "Fresno County Department of Behavioral Health, Quality Assurance
Standards for Licensed Adult Residential Care Facilities, and Residential Care Facilities,
Section 9."
4. Provide information for monthly billing and other data, as required by the County's
management information system.
Exhibit B
Page 9 of 15
5. Provide a monthly statement of all persons served living in the facility.
B. Facilities SHALL be certified for participation by the COUNTY and services SHALL be provided
through written agreement. THESE FACILITIES SHALL:
1. Cooperate with County staff, subsequent to referral and with authorization by the
County, in completing the "Appraisal/Needs and Services Plan," as indicated by the
California Department of Social Services, Adult Residential Facilities, Division 6, Chapter
1, Section 80068.2, to meet the goals, objectives, and activities appropriate to the
person served. This plan shall be completed and placed in the person's served record on
or before the first day of placement and kept current.
2. Complete a "Facility Service Plan" indicating the specific services to be provided to
address the needs identified in the "Appraisal/Needs and Services Plan." This plan shall
be completed and placed in the person's served record on or before the first day of
placement.
3. Maintain individual person served records, on the premises, in accordance with "Fresno
County Department of Behavioral Health, Quality Assurance Standards for Licensed
Adult Residential Care Facilities and Residential Care Facilities, Section 8 - Person
Served Records" to promote the services to each individual. These records SHALL
include:
a. The "Appraisal/Needs and Services Plan" specifying the needs to be addressed.
b. Weekly progress notes and monthly summary notes and maintain in person's
served record.
C. Weekly notes SHALL:
i. Address all needs, objectives, and services provided by facility staff to
implement the "Facility Service Plan" for each person served.
ii. Address significant occurrences affecting the person served (incidents,
illness. exacerbation of symptoms, signs of improved functioning, etc.), as
appropriate.
iii. Describe behavioral observations and symptoms.
iv. Be written by staff having direct supervision/observation of the person
served.
d. Monthly summary notes SHALL reflect all needs and services addressed in the
"Needs/Appraisal Plan." (Refer to "Fresno County Department of Behavioral
Health, Quality Assurance Standards for Licensed Adult Residential Care
Facilities and Residential Care Facilities, Section 8 - Person Served Records.").
Exhibit B
Page 10 of 15
e. All other documents/information as required by State Community Care Licensing
Division.
4. Allow access to the facility, to the extent authorized by law, by County and State staff for
assessment of consumer(s), monitoring of the contract, record review, consultation with
staff, and evaluation of the facility and services.
5. Maintain the capability to provide the services required to meet the specialized needs of
person's served, as identified in their' "Appraisal/Needs and Services Plans."
6. Cooperate and consult with County staff to improve/enhance/modify program services to
meet the need of persons served as indicated in their "Appraisal/Needs and Services
Plans."
7. Inform COUNTY's Case Manager and Specialized Supplemental Board and Care Home
Services Coordinator immediately and provide a written report within 24 hours of all
incidents necessitating an incident report to State Licensing Division. Incidents to be
reported include, but are not limited to, death, accident/injury, abuse, and absence
without leave (AWOL).
8. Inform the Coordinator within 24 hours of all person served movements (i.e. admissions
to a general hospital, acute psychiatric facility, and/or AWOL).
9. As persons served increase ability to function in particular areas, increase persons
served responsibilities for own care/activities in those areas, as specified in their
"Appraisal/Needs and Services Plan."
10. Offer persons served opportunities to function/perform in those areas where they are
competent or are learning new life skills.
11. Encourage consumers to take increased responsibility for own treatment by setting self-
established goals.
12. Provide scheduled and posted activities to encourage the development of activities
satisfying to persons served, as specified in their"Appraisal/Needs and Services Plans."
The posted monthly schedules SHALL reflect the interests of persons served, expose
them to and develop a variety of leisure interests, and develop interpersonal skills and
relationships.
C. Specialized Supplemental Board and Care Home services may consist of, but not limited to, all
of the components listed below. They are to be provided to each person served as specified in
their "Appraisal/Needs and Services Plan," or as the need arises.
1. Training in grooming and hygiene and supervision to ensure grooming/hygiene is
maintained at an adequate level.
2. Training in activities of daily living: These may include, but are not limited to:
Exhibit B
Page 11 of 15
a. Budgeting: Developing a spending plan for necessities/personal shopping, how
to plan for larger purchases, how to make economical purchases, where to shop,
credit buying, opening a savings account, etc.
b. Use of money: Paying bills, making change, getting receipts, keeping money
safe, opening an account, etc.
C. Menu planning, shopping for and preparing individual/family sized/balanced
meals, reading instructions/recipes, kitchen hygiene/cleanliness, use of kitchen
utensils and appliances.
d. Housekeeping/cleaning/making own bed.
e. Laundry and maintenance of clothing.
f. Education on the following topics:
i. Maintaining good health and eating wholesome and nutritious diet
ii. Basic disease prevention concepts
iii. Importance of regular exercise and adequate sleep
iv. Proper use of over-the-counter medication
V. Dangers of excessive use of alcohol, tobacco and street drugs
vi. Proper use of the transportation system
3. Assistance with personal shopping, as appropriate. Assistance with coordinating clothing
and making purchases to complete/supplement wardrobe.
4. Training to develop adequate medication management skills including, but not limited to:
a. When and how much of each medication to take
b. How to read instructions on medication containers
C. How to relate and talk with the doctor about symptoms, complaints and side
effects of medications.
5. Working with persons served to express feelings appropriately including, but not limited
to:
a. Dealing with conflict
b. Dealing with anger
C. Dealing with loss or grief
d. Expressing a variety of feelings, including positive feelings
6. Working with persons served to develop skills including, but not limited to:
Exhibit B
Page 12 of 15
a. Starting and maintaining conversations
b. Dealing with family, and significant others
C. Talking with persons of either gender
d. Asserting own needs/desires/choices
7. Encouraging observations of culturally appropriate holidays, events, and traditions, in
accordance with the ethnic background of persons served and their wishes. This may
include, but not be limited to, offering activities, foods, and decorations appropriate to the
person served.
8. Providing close supervision of and interactions with persons served who require
management of difficult behavioral problems consistent with the "Appraisal/ Needs and
Services Plan." This may include, but not be limited to:
a. Providing support and encouragement
b. Providing specific individualized directions
C. Providing alternative activities
d. Setting specific behavioral limitations
e. Allowing for the appropriate expression of feelings
f. Separating the person served from others, when interactions tend to exacerbate
behaviors
g. Establishing a behavioral contract with the person served
III. SPECIALIZED TRANSITIONAL RESIDENTIAL SERVICES PROGRAM REQUIREMENTS
In the event persons served fall under more than one category as set forth below, COUNTY shall pay
only one rate which is to be mutually agreed upon by COUNTY'S Department of Behavioral Health
(DBH) and CONTRACTOR(S). Please note: possession of care exemptions approved by Community
Care Licensing (CCL) will be required to provide services to persons served with specialized medical
needs.
PERSON SERVED CATEGORIES:
A. CHRONIC INEBRIATES: dual diagnosis persons served needing controlled community access.
Services provided will include:
1. 15-minute visuals, 24/7, 365 days
Exhibit B
Page 13 of 15
2. In-house psychiatrist with assessments done on site
3. On call 24/7 psychiatrist with standing orders for PRN & injectables
4. Prevocational job training on site with a community re-entry based philosophy
5. On-site Drug &Alcohol counselors
6. Day Treatment: Recovery models: WRAP &Wellness
7. On-site dietician to provide healthy diets
B. SPECIAL NEEDS
1. Diabetic—trained staff (incl. LVN, dietary) available to meet CCL Title 22 Section
80092.8. Services provided will include:
a. Insulin shots
b. Diabetes maintenance including, but not limited to insulin injections and blood
sugar monitoring
C. On-site dietician to provide special diet (sugar free menu)
d. Blood sugar monitoring by licensed, qualified staff
e. 50% of staff shall be certified Medical Assistants
f. 15-minute visuals, 24/7, 365 days a year
g. On call 24/7 psychiatrist with standing orders for PRN & injectables
h. Prevocational job training on site with a community re-entry-based philosophy
i. Day Treatment: Recovery models: WRAP &Wellness
2. Conditions of Life —facility upgrades &trained staff available to meet CCL Title 22
Section 80077.2-3, 80001d.(2) for persons served who rely on others to assist with most
activities of daily living, persons served with lack of hazard awareness/impulse control
orwith medical conditions for which they need assistance/observation;
Services provided will include:
a. 15-minute visuals 24/7 365 days a year
b. On-site dietician to provide special diets as required
C. 50% staff are certified Medical Assistants to monitor health conditions
Exhibit B
Page 14 of 15
d. On call 24/7 Psychiatrist with standing orders for PRN & injectables
e. Prevocational job training on-site with a community re-entry based philosophy
f. Day Treatment: Recovery models: WRAP &Wellness
g. CCL waiver for persons served needing oxygen
3. Non-Ambulatory: all the above facility services shall be available to non-ambulatory
persons served. In addition to diabetic, dual-diagnosis and other conditions of life
services, the facility shall provide:
a. Trained staff available to assist non-ambulatory persons served with ADL's.
Facility-wide training shall be rendered to ensure the safety of non-ambulatory
persons served with regards to egress, mobility and emergency procedures
b. Transportation to allow non-ambulatory persons served to participate in
community outings
4. Ambulatory Issues - trained staff(incl. LVN, dietary) available to meet CCL Title 22
Section 80010.
a. Amputee
b. Wheelchair dependent (for mobility)
C. Walkers/Other Walking Assistance Devices
d. Visual Impairment/Including Legal Blindness
5. Medical —trained staff to provide care for persons served who have any of the following
restricted health conditions, or who require any of the following health services:
a. Colostomy bags — as specified in CCL Title 22, Section 87621
b. Oxygen dependent persons served - as specified in CCL Title 22, Section 87618
C. Catheter services - as specified in CCL Title 22, Section 87623.
C. CONTRACTOR(S) should have trained staff available to provide care within a facility intended
for individuals with mental health disorders, specific characteristics, and a history of additional
behaviors/legal status including, but not limited to the following:
1. Behavioral/Legal Status
2. LPS Conservatorship:
Exhibit B
Page 15 of 15
a. Accept persons served moving from locked and out of town (possible) Institute of
Mental Disease (IMD)
b. Accept persons served from acute inpatient psychiatric facilities
3. Aggressive Behaviors:
a. Recent physical aggressive episode toward a person (general)
b. History of physical assault on a Staff
4. Fire Setting
5. Elopement
a. Elopement is considered not returning by curfew.
6. Sexual Assault or Sex Offender status
7. Young Adults
a. Young adults considered to be between the ages of 18—24 years old
8. Individuals with mild developmental delays
a. "Mild developmental delay" defined as borderline intellectual functioning with an
IQ of just below 80.
Exhibit C
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
2. Principle Two - Strengths-based
1
rev 01-02-2020
Exhibit C
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
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
2
rev 01-02-2020
Exhibit C
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
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
3
rev 01-02-2020
Exhibit C
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
4
rev 01-02-2020
Exhibit D
Fresno County Department of Behavioral Health
Specialized Supplemental Board and Care Homes
Approved Rates by Provider
Fiscal Year 2022-23
Social Security Income
County Approved Daily Services Daily Room and
Contract Provider Total Daily Rate
Supplemental Services Rate Board and Care and
Supervision Rate
AK's Home of Blessing and Joy, Inc. $89.00 $39.84 $128.84
AK's Home of Care, LLC $66.00 $39.84 $105.84
Anjaleoni Enterprises, Inc. -dba Leonie House $120.00 $39.84 $159.84
Benevolent Residential Care Services LLC- dba Dailey's Haven $125.00 $39.84 $164.84
BK House of Grace, LLC $91.10 $39.84 $130.94
Bonavente Home for the Elderly II $95.16 $39.84 $135.00
The Chimes Home $112.00 $39.84 $151.84
Garden Manor $83.54 $39.84 $123.38
Garem Assisted Living, Inc. $110.00 $39.84 $149.84
Haskins Residential Care $190.24 $39.84 $230.08
Jan-Roy Place of Fresno, Inc. $120.00 $39.84 $159.84
Marian Homes, Inc. - dba Sierra Villa Rest Home $120.00 $39.84 $159.84
Mark A Gisler- dba Ruby's Valley Care Home $154.11 $39.84 $193.95
Modesto Residential Living Center, Inc. $80.16 $39.84 $120.00
Providian Residential Care Services Inc. - dba Fillmore Christian Gardens $125.00 $39.84 $164.84
Royal Board and Care Home for the Elderly $90.00 $39.84 $129.84
Sunshine Board and Care II $90.00 $39.84 $129.84
Valley Comfort Home, Inc. $100.00 $39.84 $139.84
** Bed holds shall be paid for a period of seven (7) calendar days at a rate that is reimbursed at 50%of the daily rate per contracted provider.
Revised 7/20/2022
Exhibit D
Non-Medical Out-of-Home Care (NMOHC)
Payment Standard for Individuals-Licensed Facility or
Without In-Kind Room and Board
Effective January 1, 2022
Source Amount
Supplemental Security Income (SSI) $ 841.00
State Supplementary Payment (SSP) 524.77
Total NMOHC Payment Standard $1,365.77*
The NMOHC Payment Standard includes the following components:
J Component
Room and Board $ 590.77
Care and Supervision (maximum) $ 621.00
Amount Payable for Basic Services $1,211.771
Personal and Incidental Needs Allowance (minimum) $ 154.00
(Must be provided to the recipient)
Total NMOHC Payment Standard $1,365.77*
*This total NMOHC payment standard is doubled for SSI/SSP couples.
'NOTE: Recipients who have income in addition to their SSI/SSP check (for example, a
pension, Social Security retirement, or disability benefits) can be charged the $1,211.77
amount for basic services plus an additional $20. Because federal rules do not count
the first $20 of a recipient's income against his/her SSI/SSP grant, an SSI/SSP recipient
with other income has an extra $20 that people who receive only an SSI/SSP check do
not have. Neither federal nor state law restricts the recipient in how this additional $20
amount is spent. Thus, if the recipient agrees in the admission agreement to pay the
additional $20 for basic services, the facility may charge the additional amount.
Exhibit E
Page 1 of 7
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 7
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,
Exhibit E
Page 3 of 7
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
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
Exhibit E
Page 4 of 7
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.
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.
Exhibit E
Page 5 of 7
b). No officer or employee shall contract on his or her own behalf as an
independent contractor with any state agency to provide goods or services.
Former State Employees (Pub. Contract Code §10411):
a). For the two (2)year period from the date he or she left state employment,
no former state officer or employee may enter into a contract in which he
or she engaged in any of the negotiations, transactions, planning,
arrangements or any part of the decision-making process relevant to the
contract while employed in any capacity by any state agency.
b). For the twelve (12) month period from the date he or she left state
employment, no former state officer or employee may enter into a contract
with any state agency if he or she was employed by that state agency in a
policy-making position in the same general subject area as the proposed
contract within the twelve (12) month period prior to his or her leaving
state service.
If CONTRACTOR violates any provisions of above paragraphs, such action by
CONTRACTOR shall render this Agreement void. (Pub. Contract Code §10420)
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:
Exhibit E
Page 6 of 7
a. When agreements are to be performed in the state by corporations, the
contracting agencies will be verifying that the CONTRACTOR is
currently qualified to do business in California in order to ensure that all
obligations due to the state are fulfilled.
b. "Doing business" is defined in R&TC Section 23101 as actively engaging
in any transaction for the purpose of financial or pecuniary gain or profit.
Although there are some statutory exceptions to taxation, rarely will a
corporate contractor performing within the state not be subject to the
franchise tax.
C. Both domestic and foreign corporations (those incorporated outside of
California)must be in good standing in order to be qualified to do
business in California. Agencies will determine whether a corporation is
in good standing by calling the Office of the Secretary of State.
6. RESOLUTION: A county, city, district, or other local public body must provide
the State with a copy of a resolution, order, motion, or ordinance of the local
governing body, which by law has authority to enter into an agreement,
authorizing execution of the agreement.
7. AIR OR WATER POLLUTION VIOLATION: Under the State laws, the
CONTRACTOR shall not be: (1) in violation of any order or resolution not
subject to review promulgated by the State Air Resources Board or an air
pollution control district; (2) subject to cease and desist order not subject to
review issued pursuant to Section 13301 of the Water Code for violation of waste
discharge requirements or discharge prohibitions; or(3) finally determined to be
in violation of provisions of federal law relating to air or water pollution.
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
Exhibit E
Page 7 of 7
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 parry 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 3
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.
YES NO
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
by Titles XVI I I, XIX, or XX? ......................................................................................................................... o 0
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 XVI 11, XIX, or XX?...................................................................................... o 0
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 XVI II providers only)........... o 0
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: o Sole proprietorship o Partnership o Corporation
o Unincorporated Associations o 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........................................................................................................... n n
NAME ADDRESS PROVIDER NUMBER
Exhibit F
Page 2 of 3
YES NO
IV. A. Has there been a change in ownership or control within the last year? ....................................................... o 0
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... o 0
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................ o 0
If yes, when?
V. Is the facility operated by a management company or leased in whole or part by another organization?.......... o 0
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?......... o 0
VII. A. Is this facility chain affiliated? ...................................................................................................................... o 0
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 F
Page 3 of 3
INSTRUCTIONS FOR COMPLETING DISCLOSURE OF CONTROL AND INTEREST STATEMENT
Please answer all questions as of the current date. If the yes block for any item is checked,list requested additional information under
the Remarks Section on page 2,referencing the item number to be continued.If additional space is needed use an attached sheet.
DETAILED INSTRUCTIONS
These instructions are designed to clarify certain questions on the form.Instructions are listed in question order for easy reference.No
instructions have been given for questions considered self-explanatory.
IT IS ESSENTIAL THAT ALL APPLICABLE QUESTIONS BE ANSWERED ACCURATELY AND THAT ALL INFORMATION
BE CURRENT.
Item I-Under"Identifying Information"specify in what capacity the entity is doing business as(DBA)(e.g.name of trade or
corporation).
Item II-Self-explanatory
Item III-List the names of all individuals and organizations having direct or indirect ownership interests,or controlling interest
separately or in combination amounting to an ownership interest of 5 percent or more in the disclosing entity.
Direct ownership interest-is defined as the possession of stock,equity in capital or any interest in the profits of the disclosing entity.
A disclosing entity is defined as a Medicare provider or supplier,or other entity that furnishes services or arranges for furnishing
services under Medicaid or the Maternal and Child Health program,or health related services under the social services program.
Indirect ownership interest-is defined as ownership interest in an entity that has direct or hospital-based home health agencies,are not
indirect ownership interest in the disclosing entity.The amount of indirect ownership in the disclosing entity that is held by any other
entity is determined by multiplying the percentage of ownership interest at each level.An indirect ownership interest must beds in the
facility now and the previous be reported if it equates to an ownership interest of 5 percent or more in the disclosing entity.Example:
if A owns 10 percent of the stock in a corporation that owns 80 percent of the stock of the disclosing entity,A's interest equates to an 8
percent indirect ownership and must be reported.
Controlling interest-is defined as the operational direction or management of disclosing entity which may be maintained by any or all
of the following devices:the ability or authority,expressed or reserved,to amend or change the corporate identity(i.e.,joint venture
agreement,unincorporated business status)of the disclosing entity;the ability or authority to nominate or name members of the Board
of Directors or Trustees of the disclosing entity;the ability or authority,expressed or reserved,to amend or change the by-laws,
constitution,or other operating or management direction of the disclosing entity;the right to control any or all of the assets or other
property of the disclosing entity upon the sale or dissolution of that entity;the ability or authority,expressed or reserved,to control the
sale of any or all of the assets,to encumber such assets by way of mortgage or other indebtedness,to dissolve the entity or to arrange
for the sale or transfer of the disclosing entity to new ownership or control.
Item IV-VII-(Changes in Provider Status)For Items IV-VII,if the yes box is checked,list additional information requested under
Remarks. Clearly identify which item is being continued.
Change in provider status-is defined as any change in management control.Examples of such changes would include;a change in
Medical or Nursing Director,a new Administrator,contracting the operation of the facility to a management corporation,a change in
the composition of the owning partnership which under applicable State law is not considered a change in ownership,or the hiring or
dismissing of any employees with 5 percent or more financial interest in the facility or in an owning corporation,or any change of
ownership.
Item IV-(A&B)If there has been a change in ownership within the last year or if you anticipate a change,indicate the date in the
appropriate space.
Item V-If the answer is yes,list name of the management firm and employer identification number(EIN),or the name of the leasing
organization.A management company is defined as any organization that operates and manages a business on behalf of the owner of
that business,with the owner retaining ultimate legal responsibility for operation of the facility.
Item VI-If the answer is yes,identify which has changed(Administrator,Medical Director,or Director of Nursing)and the date the
change was made.Be sure to include name of the new Administrator,Director of Nursing or Medical Director,as appropriate.
Item VII-A chain affiliate is any free-standing health care facility that is either owned,controlled,or operated under lease or contract
by an organization consisting of two or more free-standing health care facilities organized within or across State lines which is under
the ownership or through any other device,control and direction of a common party.Chain affiliates include such facilities whether
public,private,charitable or proprietary.They also include subsidiary organizations and holding corporations.Provider-based
facilities,such as hospital-based home health agencies,are not considered to be chain affiliates.
Exhibit G
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 G
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 H
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 H
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: