HomeMy WebLinkAboutAgreement A-22-499 FY 2022-23 CHDP Plan and Budget.pdf Agreement No. 22-499
DHCS State of California—Health and Human Services Agency
Department of Health Care Services +
MICHELLE BAASS GAVIN NEWSOM
DIRECTOR GOVERNOR
Child Health and Disability Prevention Program
Plan and Budget Reporting Checklist
County/City: Fresno Fiscal Year: 2022-23 Page Number
1. CHDP Plan and Budget Reporting Checklist 1
2. CHDP Certification Statement 2
3. CHDP Organizational Chart Retain Loc
4. CHDP New or Revise Memorandum of Understanding and
Inter-agency Agreements N/A
5. If Applicable:
a. Contractor Equipment Purchased with DHCS Funds Form
(DHCS1203) N/A
b. Inventory/Disposition of DHCS Funded Equipment Form
(DHCS1204) N/A
c. Property Survey Report Form (STD 152) N/A
6. CHDP Plan and Budget Reporting Spreadsheet
a. Agency Information Sheet 3
b. CHDP Memorandum of Understanding and Inter-agency
Agreement List 4
c. CHDP Incumbent List 5
d. CHDP Budget
i. CHDP Administrative Budget
— Summary and Worksheet 6 - 7
— Budget Narrative 8
ii. Optional County/City- Federal Match Budget
— Summary and Worksheet N/A
— Budget Narrative N/A
All items listed here should be submitted to the ISCD Budget Portal as one signed PDF
document. In addition, Excel worksheet components of this reporting package should
also be submitted as one document. Detailed instruction for each item listed can be
found in the Integrated Systems of Care Division Plan and Fiscal Guidelines.
Systems of Care Division 1515 K Street, Suite 400, Sacramento, CA 95814
P.O. Box 997413, MS 8100 Sacramento, CA 95899-7413
(916)327-1400
Internet Address:www.dhcs.ca.gov
DHCS State of California—Health and Human Services Agency
YIIy e
Department of Health Care Services `
MICHELLE SAASS GAVIN NEWSOM
DIRECTOR GOVERNOR
Child Health and Disability Prevention Program
Certification Statement
County/City: Fresno Fiscal Year: 2022-23
1 certify that the CHDP Program will comply with all applicable provisions of Health and
Safety Code, Division 106, Part 2, Chapter 3, Article 6 (commencing with Section
124025), Welfare and Institutions Code, Division 9, Part 3, Chapters 7 and 8
(commencing with Section 14000 and 14200), Welfare and Institutions Code Section
16970, and any applicable rules or regulations promulgated by DHCS pursuant to that
Article, those Chapters, and that section. I further certify that this CHDP Program
will comply with the Integrated Systems of Care Plan and Fiscal Guidelines Manual,
including but not limited to, Section 9 Federal Financial Participation. I further certify that
this CHDP Program will comply with all federal laws and regulations governing and
regulating recipients of funds granted to states for medical assistance pursuant to Title
XIX of the Social Security Act (42 U.S.C. Section 1396 et seq.). I further agree that
this CHDP Program may be subject to all sanctions or other remedies applicable if
this CHDP Program violates any of the above laws, regulations and policies with which it
has certified it will comply.
J �-Ad � 4M0, MrH `� �zgIzz
Signature f CHDP Director/Deputy Director Date Signed
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ature and Titl er—Optional Date Signed
I certify that this plan has been approved by the local governing body.
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Signature of Local Governing Body Chairperson Date Signed
ATTEST:
BERNICE E.SEIDEL
Clerk of the Board of Supervisors
County of Fresno;State of California
By Deputy
Systems of Care Division 1515 K Street,Suite 400,Sacramento,CA 95814
P.O. Box 997413,MS 8100 Sacramento,CA 95899-7413
(916)327-1400
Internet Address:www.dhcs.ca.gov
DHCS State of California—Health and Human Services Agency,Iqp
Department of Health Care Services
Child Health and Disability Prevention ",
MICHELLE BAASS Agency Information GAVIN NEWSOM
DIRECTOR GOVERNOR
County/City: JlFresno Fiscal Year: 2022-23
Official Agency
Street Address:1221 Fulton Street Health Officer: Dr. Rais Vohra (Interim)
City: Fresno Local CHDP
Zip Code: 93721 Central Inbox:
CMS Director(if applicable)
Name: Street Address:
Phone: City:
Email: Zip Code:
CHDP Director
Name: Trinidad Solis, MD Street Address: 1221 Fulton Street
Phone: 559-600-6412 City: Fresno
Email: tsolis@fresnocountyca.gov Zip Code: 93619
CHDP Deputy Director
Name: Ankara Lee Street Address: 380 W Ashlan Ave
Phone: 559-600-6591 City: Clovis
Email: alee@fresnocountyca.gov Zip Code: 93612
Clerk of the Board of Supervisors or City Council
Name: Bernice Seidel Street Address: 2281 Tulare St., 3rd Floor
Phone: 559-600-3529 City: Fresno
Email: bseidel@fresnocountyca.gov Zip Code: 93721
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DHCS State of California—Health and Human Services Agency4ROO
Department of Health Care Services -:
Child Health and Disability Prevention
MICHELLE BAASS Budget Narrative GAVIN NEWSOM
DIRECTOR GOVERNOR
State/Federal Funding Source: Base
County/City Namej Fresno IFiscal Year 2022-23
I. Personnel Expenses
Identify and Explain Any Changes in Personnel/Personnel Expenses
Salary and Benefits for 7 positions,total of 6.60 FTE. Benefits rate calculated with estimated average of
total benefits for the positions. Includes retirement, health insurance, Unemployment Insurance, and
Benefits Administration.
II. Operating Expenses
Identify and Explain All Operating Expense Line Items
Private mileage reimbursement at$0.625/mile and costs for usage of County cars
Travel: associated with provider visits and travel to State-sponsored meetings and conferences.
Cost of tuition and registration fees for program staff to attend State-sponsored training
Training: and other trainings to enhance knowledge and skills.
III. Capital Expenses
Identify and Explain All Capital Expense Line Items
IV. Indirect Expenses
Identify and Explain All Indirect Expense Line Items
Fresno County Department of Public Health's indirect rate is 18.816% of personnel costs
Internal: approved reviewed for metholody, accounting standards, and data used by Fresno
External:
V. Other Expenses
Identify and Explain All Other Expense Line Items
Prepared By: Sign Print Title Date Email
' 0 0 0
Authorized CHDP Program Representative: Sign Print Title Date Email