HomeMy WebLinkAboutAgreement A-16-193 with Maternal Child and Adolescent Health MCAH.pdf CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
MATERNAL, CHILD AND ADOLESCENT HEALTH (MCAH) DIVISION
FUNDING AGREEMENT PERIOD
FY 2015-16 (LHJs)/2012-13 to 2014-15 (CBOs)
AGREEMENT FUNDING APPLICATION (AFA)/UPDATE FORM
At the beginning of each fiscal year Agencies are required to submit this AFA Form along
with their AFA Package, which requires certification signatures (original signatures, no
stamps allowed). This form should also be used when submitting updates that occur during
the fiscal year. Update submissions do not require certification signatures.
The Agency Identification Information section must be completed each time this form is
submitted.
Note: A a reement refers to Allocations for LHJs or Grants for CBOs.
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Any pro-gram related information being sent from the CDPH MCAH Division
will be directed to the MCAH and/or AFLP Director.
Please check the applicable "Program" boxes below: changes being submitted:
❑ MCAH 0 AFLP E] BIH F-I FIMR Fj CHVP
Fiscal Year: 2015-16 Update Effective: _ (only required when submitting updates)
Agreement Number: 201510-2
Federal Employer 94-6000512
ID#:
Complete Official County of Fresno, Department of Social Services
Agency Name:
Business Office PO Box 1912,Fresno,CA 93718-1912
Address:
Agency Phone: 559-600-2346 Agency Fax: 559-600-2357
Agency Website I
Address: WWW.co.fresno.ca.us/DSS
A
Name: Delfino E.Neira
Title: Director
Mailing Address: I PO Box 1912
City: Fresno Zip: 1 93718-1912
Phone: 559-600-2300 Ext. FAX7, 559-600-23 10
E-Mail Address: dneira@co.fresno.ca.us
Page 1 of 7
Revised June 2014
Agency Name: County of Fresno, Department of Social Services
Agreement#: 201510-2 Fiscal Year: 2015-16
Clerk of the Board ❑ Chair Board of Supervisors
Title: County of Fresno Board of Supervisors
Mailing Address: 1 2281 Tulare Street,Room 301,Hall of Records
City: Fresno I Zip-, 93721-2198
Phone: 559-6003529 Ext. FAX: 559-600-2198
E-Mail Address: clerk/BOS@co.fresno.ca.us
Name: Ernest Budd Mendes
Title: Chairman,Board of Supervisors
Mailing Address: 1 2281 Tulare,Room#301
City: Fresno Zip: 93721-2198
Phone: 559-600-4000 Ext. FAX: 559-600-1609
E-Mail Address: district4@co.fresno.ca.us
7me: StaceySandoval
The County of Fresno, Department of Social Services Finance Division Chief
Mailing Address. PO Box 1912
City: Fresno Zi 93718-1912
Phone: 559-600-2823 Ext. FAX: 1 559-600-2882
E-Mail Address: Tstsandoval@co.fresno.ca.us
Name: Rose Mary Garrone,RN,BSN
Title: The County of Frenso, Department of Public Health, Division Manager
Mailing Address: I PO Box 118867
City: Fresno Zip: 93775
Phone: 559-600-3353 Ext. FAX: 559-600-7729
E-Mail Address: rgarrone@co.fresno.ca.us
Page 2 of 7
Revised June 2014
Agency Name: County of Fresno, Department of Social Services
Agreement#: 201510-2 Fiscal Year: 2015-16
0
Name:7me Jennifer Day,RN,BSN
Title. The County of Fresno, Department of Public Health, MCAH Coordinator
Mailing Address: I PO Box 11867
City: Fresno Zip: 93775
Phone: 559-600-6339 Ext. FAX: 1 559-600-7729
jday@co.fresno.ca.us
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Page 3 of 7
Revised June 2014
Agency Name: County of Fresno, Department of Social Services
Agreement#: 201510-2 Fiscal Year: 2015-16
Name: Laura Lopez
Title: County of Fresno, Department of Social Services,Program Manager 77
Mailing Address: 1 4455 E.Kings Canyon Road
City: Fresno Zip: 93702
Phone: 559-600-3251 Ext. FAX: 559-600-3256
E-Mail Address: lauralopez@co.fresno.ca.us
Name:
Title:
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me: August De La Cruz
CountV of Fresno, Department of Social Services, Financial Analyst
Mailing Address: I PO Box 1912
City: Fresno Zip: 93718-1912
Phone: 1 559-600-2846 Ext. FAX: 559-600-2846
E-Mail Address: adelacruz@co.fresno.ca.us
Name:
Title:
Mailing Address:
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Page 4 of 7
Revised June 2014
Agency Name: County of Fresno, Department of Social Services
Agreement#: 201510-2 Fiscal Year: 2015-16
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Page 5 of 7
Revised June 2014
Agency Name: County of Fresno, Department of Social Services
Agreement#: 201510-2 Fiscal Year: 2015-16
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Page 6 of 7
Revised June 2014
Agency Name: County of Fresno, Department of Social Services Agreement No. 16-193
Agreement#: 201510-2 Fiscal Year: 2015-16
APPLICATIONAGREEMENT FUNDING
POLICY COMPLIA-NCE. AND-CERTIFICATION
The undersigned hereby affirms that the statements contained in the Agreement Funding
Application (AFA) are true and complete to the best of the applicant's knowledge.
I certify that this Maternal, Child and Adolescent Health (MCAH) related program will comply
with all applicable provisions of Article 1, Chapter 1, Part 2, Division 106 of the Health and
Safety code (commencing with section 123225), Chapters 7 and 8 of the Welfare and
Institutions Code (commencing with Sections 14000 and 142), and any applicable rules or
regulations promulgated by CDPH pursuant to this article and these Chapters. I further certify
that this MCAH related program will comply with the MCAH Policies and Procedures Manual,
including but not limited to, Administration, Federal Financial Participation (FFP) Section. I
further certify that this MCAH related 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.) and recipients of funds
allotted to states for the Maternal and Child Health Service Block Grant pursuant to Title V of
the Social Security Act (42 U.S.C. section 701 et seq.). I further agree that this MCAH related
program may be subject to all sanctions or other remedies applicable if this MCAH related
program violates any of the above laws, regulations and policies with which it has certified it
will comply.
Chairman, Board of Supervisors
Original Signature of Official authorized to Title
commit the Agency to an MCAH Agreement
Ernest Buddy Mendes f`n C.l --A 10
Name (Type or Print) Date
Il
1
-- AFLP Director
Original Signa re o CA FLP Director Title
Laura Lopez
Name (Type or Print) Date !
ATTEST:
BERNICE E.SEIDEL,Clerk
Board of Supervisors
By Page 7 of 7 nIt &
Deputy�
Revised June 2014
1 APPLICATION FUNDING AGREEMENT BETWEEN THE COUNTY OF FRESNO AND
2 THE CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
3
4 No. 201510-2 Term: Fiscal Year 2015-16
5
6 APPROVED AS TO LEGAL FORM:
7
By �r
9 ie C. Cederborg, Count o nsel
10
11 APPROVED AS TO ACCOUNTING FORM:
12
13
14 By ,tea
Vicki Crow, C.P.A., itor-Controller/
15 Treasurer-Tax Collector
16
17 REVIEWED AND RECOMMENDED FOR
APPROVAL:
18
19
20 ByL X2_XN
Del mo E. ira, Director
21 Department of Social Services
22
23
Fund/Subclass: 0001/10000
24 Organization: 56107034
25 Account/Program: 4382
26
27
28 DEN:hh
1 - Fresno, CA