HomeMy WebLinkAboutAgreement A-15-257 with Kings View Corporation.pdf1
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AGREEMENT
THIS AGREEMENT is made and entered into this I lJ ~
Agreement No. 15-257
'2015,
3 by and between the COUNTY OF FRESNO, a Political Subdivision of the State of California,
4 hereinafter referred to as "COUNTY", and KINGS VIEW CORPORATION, a private Non-profit,
5 501 (c) (3 ), Organization, whose address is 7170 N. Financial Drive, Suite 110, Fresno, CA 93 720,
6 hereinafter referred to as "CONTRACTOR".
7 W I T N E S S E T H:
8 WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), is in need of a
9 qualified agency to operate a Projects for Assistance in Transition from Homelessness (PATH)
1 0 program to deliver integrated mental health and supportive housing services to adults who are
11 homeless, or who are at imminent risk of becoming homeless, and have a severe mental illness and/or
12 co-occurring disorder, in an effort to enable this client population to live in the community and to avoid
13 homelessness, hospitalization and/or jail detention.
14 WHEREAS, COUNTY, through its Department ofBehavioral Health (DBH), is a Mental Health
15 Plan (MHP) as defined in Title 9 ofthe California Code of Regulations (C.C.R.), section 1810.226; and
16 WHEREAS, CONTRACTOR is qualified and willing to operate said PATH program and
1 7 provide PATH services pursuant to the terms and conditions of this Agreement.
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 as set
2 2 forth in Exhibit A, "Projects for Assistance in Transition from Homelessness (PATH) Program, Scope
2 3 of Work," attached hereto and by this reference incorporated herein and made part ofthis Agreement.
24 B. CONTRACTOR shall also perform all services and fulfill all responsibilities as
25 specified in COUNTY's Request for Proposal (RFP) No. 952-5327 dated January 15,2015, Addendum
26 No. One (1) to COUNTY'S RFP No. 952-5327 dated February 2, 2015 and Addendum No. Two (2) to
27 COUNTY's RFP NO. 952-5327 dated February 4, 2015, herein collectively referred to as COUNTY's
28 Revised RFP, and CONTRACTOR's Response to said Revised RFP dated February 12,2015, all
-1 -COUNTY OF FRESNO
Fresno, CA
incorporated herein by reference and made part of this Agreement.In the event of any inconsistency
among these documents,the inconsistency shall be resolved by giving precedence in the following
order of priority to:1)this Agreement,including all Exhibits.2)the Revised RFP,and 3)
CONTRACTOR'S Response to the Revised RFP.A copy of COUNTY'S Revised RFP No.952-5327
and CONTRACTOR'S Response thereto shall be retained and made available during the term of this
Agreement by COUNTY'S DBH Contracted Services Division.
C.Itis acknowledged by all parties hereto that COUNTY'S DBH Administrative
unit shall monitor PATH program operated by CONTRACTOR,in accordance with Section Fourteen
(14)of this Agreement.
D.CONTRACTOR shall participate in monthly,oras needed,workgroup meetings
consisting of staff from COUNTY'S DBH Administrative unit to discuss PATH requirements,data
reporting,training,policies and procedures,overall program operations and any problems or
foreseeable problems that may arise.
E.CONTRACTOR shall maintain requirements as an organizational provider
throughout the term of this Agreement,as described in Section Seventeen (17)of this Agreement.If
for any reason,this status is not maintained,COUNTY may terminate this Agreement pursuant to
Section Three (3)of this Agreement.
2.TERM
This Agreement shall become effective on the 1st day of July.2015 and shall terminate
on the 30th day of June,2018.
This Agreement,subject to satisfactory outcomes performance and subject to available
State funding each year,shall automatically be extended for two (2)additional twelve (12)month
periods upon the same terms and conditions herein set forth,unless written notice ofnon-renewal is
given by COUNTY or CONTRACTOR or COUNTY'S DBH Director or designee,not later than thirty
(30) days prior to the close of the current Agreement term.
3.TERMINATION
A. Non-Allocationof Funds - The terms of this Agreement,and the servicesto be
provided thereunder,are contingent on the approval of funds by the appropriating government agency.
COUNTY OF FRESNO
Fresno,CA
Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
terminatedat any time by giving CONTRACTORthirty (30) days advance writtennotice.
B.Breach of Contract -COUNTY may immediately suspend or terminate this
Agreementin wholeor in part, where in the determination of COUNTYthere is:
1) An illegal or improper use of funds;
2) A failure to comply with any term of this Agreement;
3) A substantially incorrect or incomplete report submitted to COUNTY;
4)Improperly performed service.
In no event shall any payment by COUNTY constitute a waiver by COUNTY of
anybreach of this Agreementor any default which maythen exist on the partof CONTRACTOR.
Neither shall such payment impair or prejudice any remedy available to COUNTY with respect to the
breach or default. The COUNTY shall have the right to demand of the CONTRACTOR the repayment
to the COUNTY of any funds disbursed to CONTRACTOR under this Agreement, which in the
judgmentof COUNTY werenot expended in accordance withthetermsof this Agreement.The
CONTRACTOR shall promptly refund any such funds upon demand or at COUNTY'S option, such
repayment shallbe deducted from future payments owingto CONTRACTOR underthis Agreement.
C.Without Cause -Under circumstances other than those set forth above,this
Agreement maybe terminated by COUNTY or CONTRACTOR uponthe givingof sixty(60)days
advance written notice of an intention to terminate.
4-COMPENSATION
The maximum amount of compensation paid to CONTRACTOR by COUNTY shall not
exceed FiveHundredThirty Thousandand No/100 Dollars ($530,000)during eachtwelve (12) month
period ofthis Agreement.Inno event shall total maximum compensation forthis Agreement paid to
CONTRACTOR by COUNTY exceed Two Million Six Hundred Fifty Thousand and No/100 Dollars
($2,650,000).
It is understoodby the CONTRACTORand COUNTYthat CONTRACTORestimatesto
generate Eighty Five Thousand Seven Hundred Twenty Seven and No/100 Dollars ($85,727)in Medi-
Cal Federal Financial Participation (FFP)and Twelve Thousand and No/100 Dollars ($12,000)inclient
COUNTY OF FRESNO
Fresno,CA
rentand transportation reimbursements tooffset CONTRACTOR'S program costsas set forth inthe
budget,attached hereto as ExhibitBand incorporated hereinby reference.
If CONTRACTORfails to generatethe Medi-Cal FFP reimbursementamountsset forth
hereinabove,andor fails to generate theclientrent and transportation reimbursement amounts set forth
above,the COUNTY shall not be obligated to pay the difference between these estimated amounts and
the actual amounts generated.
It is further understood by COUNTY and CONTRACTOR that any Medi-Cal FFP
reimbursement or client rent and transportation reimbursementabove the amounts statedhereinwill be
used to directly offsetthe COUNTY'S contribution of PATH and Mental Health Services Act (MHSA)
funds as identified in Exhibit B. The offset of funds will also be clearly identified in monthly invoices
received from CONTRACTOR as further described in Section Five (5)of this Agreement.
A. COUNTYagrees to pay CONTRACTORand CONTRACTORagreesto receive
compensation based uponactual expenditures incurredby CONTRACTORfor monthlyprogram costs,
in accordance withthe budget identified in ExhibitB.Travel shallbe reimbursed basedon actual
expenditures and mileage reimbursement shallbeat CONTRACTOR'S adopted rateper mile,notto
exceed the IRS published rate.It is understood that all expenses incidental to CONTRACTOR'S
performance of services under this Agreement shall be borne by CONTRACTOR.If CONTRACTOR
fails to comply with any provision ofthis Agreement.COUNTY shall be relieved of its obligation for
further compensation.
B. Paymentsshall be made by COUNTY to CONTRACTORin
arrears,for services provided during the preceding month,within forty-five (45)days after the date of
receipt by COUNTY ofthe monthly invoicing as described in Section Five (5)herein,it shall be
deemed sufficient cause for COUNTY to withhold payments until there is compliance, as further
describedin Section Five (5) herein. Paymentsshall be madeafter receipt and verificationof actual
expenditures incurred by CONTRACTOR inthe performance of this Agreement and shall be
documented to COUNTY on a monthly basis by the tenth (10th)of the month following the month of
said expenditures.
C. COUNTY shall not be obligated to make any payments under this
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Fresno,CA
Agreement if the request for payment is received by COUNTY more than sixty (60)days after this
Agreement has terminated or expired.All final claims and/or any final budget modification requests
shall be submitted by CONTRACTOR within sixty (60)days following the final month of service for
which payment is claimed.Any compensation not consumed by expenditures of CONTRACTOR by
the expiration or termination date of this Agreement shall be remitted to COUNTY within sixty (60)
days of expiration or termination.
D.The services provided by CONTRACTOR under this Agreement are funded in
whole orin part by the State of California.In the event that funding for these services is delayed by the
State Controller,COUNTY may defer payments to CONTRACTOR.The amount of the deferred
payment shall not exceed the amount of funding delayed by the State Controller to COUNTY.The
period of time of the deferral by COUNTY shall not exceed the period of time of the State Controller's
delay of payment to COUNTY plus forty five (45) days.
E.Contractor shall be held financially liable for any and all future
disallowances/audit exceptions dueto CONTRACTOR'S deficiency discovered through the State audit
process.At COUNTY'S election,the disallowed amount will be remitted within forty-five (45)days to
COUNTY upon notification or shall be withheld from subsequent payments to CONTRACTOR.
CONTRACTOR shall not receive reimbursement for any units of services rendered that are disallowed
or denied by the Fresno County Mental Flealth Plan (MHP)utilization review process or through the
Department of Health Care Services (DHCS)cost report audit settlement process for Medi-Cal eligible
clients.
F.COUNTY shallnot be obligated to makeany payments underthis Agreement for
employee morale or other staff expenses such as for food,drinks,picnics,and/or parties.The DBH
Director or Designee of may provide an exception to the aforementioned requirement in part orin its"
entirety as circumstances may warrant.
G. The CONTRACTOR agreesto limit administrative cost paid through this
agreement to a maximum of 15%of the total program budget and to limit employee benefits paid
through this Agreement toa maximum of 20%of total salaries for those employees working under this
Agreement during the term of this Agreement.Failure to conform to this provision will be grounds for
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Fresno,C/
contract termination atthe option ofthe County of Fresno or Director.Department of Behavioral
Health or designee.
5.INVOICING
CONTRACTOR shall invoice COUNTY in arrears by the tenth (10th)day of each month
for thepriormonth's expenditures rendered to DBH-Invoices(ia)co.fresno.ca.us.After CONTRACTOR
renders services to clients.CONTRACTOR will submit electronic claiming billing directly into
COUNTY'S billingsystem (AVATAR)for the DHCS reimbursements forall clients,including those
eligible for Medi-Cal as well as those thatare not eligible for Medi-Cal and including contracted cost
perunitand actual costper unit.COUNTY must pay CONTRACTOR before submitting a claim to
DHCS for Federal reimbursement for Medi-Cal eligible clients. A roster showing Medi-Cal and Non-
Medi-Cal clients shall be provided by CONTRACTOR each month to COUNTY.
A.Contractor shall submit monthly invoices and general ledgers that itemize the line
item charges for monthly program costsand provide monthlybudgetstatus report.The invoices and
general ledgers will serveas tracking toolsto determine if CONTRACTOR'S program costsarein
accordance withthe budget identified in ExhibitB. The monthly caseloadreport referenced in Section
Thirteen (13)must accompany the monthly invoicing.
B. At the discretion of COUNTY'S DBH Director, or designee,if an invoice is
incorrect or is otherwise not in properformor substance,COUNTY'S DBH Director,or designee,shall
have the right to withhold payment as toonlythat portion ofthe invoice that is incorrect or improper
after five (5)daysprior notice to CONTRACTOR.CONTRACTOR agrees to continue to provide
services fora period of ninety (90)days after notification ofan incorrect or improper invoice.If after
the ninety (90)day period,the invoice(s)is still not corrected to COUNTY DBH's satisfaction,
COUNTY'S DBH Director,or designee,mayelectto terminate this Agreement,pursuant to the
termination provisions stated in Section Three (3)ofthis Agreement.In addition,for invoices received
ninety (90)days afterthe expiration ofeach term of this Agreement or termination ofthis Agreement,
at the discretion of COUNTY'S DBH Director,or designee, COUNTY'S DBH shall have the right to
deny payment of any additional invoices received.
C.CONTRACTOR must report all third party collections from other funding
COUNTY
sourcessuchas Medicare,private insurance,client privatepay or any otherthird party.COUNTY
expects the invoice for reimbursement to equal the amount due CONTRACTOR less any funding
sources not eligible for federal reimbursement.
D.CONTRACTOR will remit annually within ninety (90) days from June 30. a
schedule to provide the required information on published charges (PC)forall authorized services.The
published charge listing will serve asa source document to determine the CONTRACTOR'S usual and
customary charge prevalent inthe public mental health sectorthatis used to billthe general public,
insurers or other non-Medi-Cal third party payers during the course of business operations.
E.CONTRACTOR shall submit monthly staffing reports that identify all direct
service and support staff,applicable licensure/certifications,and full time hours worked to be used asa
tracking tool to determine if CONTRACTOR'S program is staffed according to the Agreement
requirements.
F.CONTRACTOR must maintain such financial records for a period of seven (7)
years or until any dispute,audit or inspection is resolved,whichever is later.CONTRACTOR will be
responsible forany disallowances related to inadequate documentation.
G. CONTRACTOR is responsible for collection and managing data ina manner to
be determined by DHCS andthe Mental Health Planin accordance with applicable rules and
regulations.COUNTY electronic billing system isa critical source of information for purposes of
monitoring and obtaining reimbursement.
H.CONTRACTOR shall submit electronic billing for services directly into
COUNTY'S billing module (AVATAR)withinten (10)calendardays from thedate services were
rendered.DHCS' FFP reimbursementfor Medi-Cal specialtymentalhealth servicesis basedon public
expenditures certified by the CONTRACTOR.CONTRACTOR must submit a signed certified public
expenditure report,with each respective monthly invoice.DHCS expects the claim for reimbursement
to equal the amount the COUNTY paid the CONTRACTOR for the service rendered less any funding
sources not eligible for Federal reimbursement.
I.CONTRACTOR must provide all necessary data to allow the COUNTY to bill
Medi-Cal,and any other third-party source,for services and meet State and Federal reporting
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Fresno,CA
requirements.The necessary data canbe provided by a variety of means,including but not limited to:
1)direct dataentryinto COUNTY'S information system;2)providing an electronic file compatible
withCOUNTY'Sinformationsystem;or 3) integration betweenCOUNTY'S informationsystemand
CONTRACTOR'S information system(s).
J. If a Medi-Cal client has dual coverage,such as other health coverage (OHC) or
Medicare,the CONTRACTOR will be responsible for billing the carrier and obtaining a
payment/denial or have validation of claiming with no response ninety (90)daysafterthe claimwas
mailed before the service can be entered into AVATAR.CONTRACTOR must report all third party
collections for Medicare,third party or client pay or private pay in each monthly invoice and in the
cost reportthat is requiredto be submitted. A copy of explanationof benefitsor CSM 1500 is
required as documentation to be submitted in each monthly invoice.CONTRACTOR must comply
with all laws and regulations governing Medicare program, including, but not limited to:1)the
requirement of the Medicare Act.42 U.S.C.section 1395 et seq;and 2) the regulation and rules
promulgated bythe Centersfor Medicare and Medicaid Services as theyrelateto participation,
coverage andclaiming reimbursement.CONTRACTOR will be responsible for compliance as ofthe
effective date of each federal,state or local law or regulation specified.
K.Dataentry shall be the responsibilityof the CONTRACTOR. The data forbilling
must be reconciled by the CONTRACTORto the monthly invoices submitted for payment.COUNTY
shall monitor the number and dollar amount of services entered into AVATAR.Any and all audit
exceptions resulting from the provision and billing of Medi-Cal services by CONTRACTOR shall be
thesole responsibility of the CONTRACTOR.CONTRACTOR will comply withall applicable
policies,procedures,directives and guidelines regarding the use of COUNTY'S billing system.
L.Medi-Cal Certification and Mental Health Plan Compliance
CONTRACTOR will establish and maintain Medi-Cal certification or become
certifiedwithin ninety(90) days of the effective date of this Agreementthroughthe COUNTYto
provide reimbursable services to Medi-Cal eligible adult clients.In addition,CONTRACTOR shall
workwiththe COUNTY'S DBH Managed Careand Business Officeto executethe process if not
currently certified by COUNTY for credentialing of staff.During this process,the CONTRACTOR
Fresno,CA
will obtain a legal entity number established bythe DHCS,a requirement for maintaining
organizational provider status throughout the term of this Agreement.CONTRACTOR will be
required to become Medi-Cal certified prior to providing services to Medi-Cal eligible clients and
seeking reimbursement in COUNTY'S billing system.CONTRACTOR will not be reimbursed by
COUNTY for any Medi-Calservices rendered prior to certification.
Medi-Calbilling shall be inaccordancewith the Mental HealthPlan.
CONTRACTOR must comply withthe"Fresno County Mental Health Plan Compliance Program and
Code of Conduct"set forth in Exhibit J,attached hereto and incorporated herein by reference and made
part of this Agreement.
Medi-Cal can be billed for direct specialty mental health services of unlicensed
staffas long asthe individual is approved asan organizational provider by the Mental Health Plan,is
supervised by licensed staff,works within his/her scope and only bills Medi-Cal for allowable specialty
mental health services.
It is understood that each claim is subject to audit for compliance with Federal
and State regulations,and that COUNTY may be making payments in advance of said review.Inthe
eventthat a Medi-Calbillableservice is disapproved. COUNTY may,at its solediscretion,withhold
compensation orsetoff from other payments due the amount of said disapproved services.
CONTRACTOR shallbe responsible forauditexceptionsto ineligible datesof services or incorrect
application of utilization review requirements.
6.INDEPENDENT CONTRACTOR
In performance ofthe work,duties,and obligations assumed by CONTRACTOR under
this Agreement,it is mutually understood and agreed that CONTRACTOR,including any and all of
CONTRACTOR'S officers,agents,and employees willat all times be acting and performing as
independent CONTRACTOR,and shall act inan independent capacity and not asan officer,agent,
servant,employee,joint venturer,partner,or associate of COUNTY.Furthermore,COUNTY shall
have no right to control or supervise or direct the manner or method by which CON TRACTOR shall
perform its work and function.However,COUNTY shall retain the right to administer this Agreement
so asto verify that CONTRACTOR is performing their obligations in accordance with the terms and
COUNTY OF FRES>
Fresno,(
conditions thereof CONTRACTOR and COUNTY shall comply with all applicable provisions of law
and the rules and regulations,if any,of governmental authorities having jurisdiction over matters which
are directly or indirectly the subject of this Agreement.
Because of its statusas an independent contractor.CONTRACTOR shallhave absolutely
no right to employment rights and benefits available to COUNTY employees.CONTRACTOR shall
be solely liable and responsible for providing to.oronbehalfof,its employees all legally-required
employee benefits.In addition,CONTRACTOR shall be solely responsible and save COUNTY
harmless from all matters relatingto paymentof CONTRACTOR'S employees,including compliance
with Social Security,withholding,andallother regulations governing such matters.Itis acknowledged
that during the term of this Agreement,CONTRACTOR may be providing services to others unrelated
to COUNTY or to this Agreement.
7.MODIFICATION
Any matters ofthis Agreement may be modified from timeto timebythe written consent
of all the partieswithout, in any way,affecting the remainder.
Notwithstanding the above,changes to line items inthe budget,as set forth in Exhibit B,
that do notexceed 10%of the total maximumcompensation payableto CONTRACTOR,and changes
tothe volume of units of services/types of service units to be provided as set forth in Exhibit B,may be
made with the written approval of COUNTY'S DBH Director or designee and CONTRACTOR.Said
budget line item changes shall not result in any change to the maximum compensation amount payable
to CONTRACTOR,as stated herein.
8.NON-ASSIGNMENT
No party shall assign,transfer or subcontract this Agreement nor their rights or duties
under this Agreement without the prior written consent of COUNTY and CONTRACTOR.
9.HOLD-HARMLESS
CONTRACTOR agreesto indemnify,save,hold harmless,andat COUNTY'S request,
defend COUNTY,its officers,agents and employees from any and all costs and expenses,including
attorney fees and court costs,damages,liabilities,claims and losses occurring or resulting to COUNTY
in connection with the performance,or failure to perform,by CONTRACTOR,its officers,agents or
COUNTY OF FRESNO
Fresno,CA
employees under this Agreement,and from any and all costs and expenses,including attorney fees and
court costs,damages,liabilities,claims and losses occurring or resulting to any person,firm or
corporation who may be injured or damaged by the performance,or failure to perform,of
CONTRACTOR, their officers,agents or employees under this Agreement.
CONTRACTOR agrees to indemnify COUNTY for Federal and/or State of California
audit exceptions resulting from noncompliance herein onthe part of CONTRACTOR.
10.INSURANCE
Without limiting COUNTY'S right toobtain indemnification from CONTRACTOR or
any third parties,CONTRACTOR,at its sole expense,shall maintain in full force and effect the
following insurancepoliciesthroughoutthe term of this Agreement:
A.Commercial General Liability
CommercialGeneral Liability Insurancewith limits of not less than One Million
Dollars ($1,000,000)per occurrence andan annual aggregate ofTwo Million
Dollars ($2,000,000).This policy shall be issued ona per occurrence basis.
COUNTY may require specific coverage including completed operations,product
liability,contractual liability.Explosion,Collapse,and Underground (XCU),fire
legal liability or any other liability insurance deemed necessary because of the
nature of the Agreement.
B.Automobile Liability
Comprehensive Automobile Liability Insurance with limits for bodily injury of
not less than Two Hundred FiftyThousand Dollars($250,000)per person. Five
HundredThousand Dollars ($500,000) peraccidentand forpropertydamagesof
not less than Fifty Thousand Dollars ($50,000).or such coverage with a combined
single limit of One Million Dollars ($1,000,000).Coverage should include owned
and non-owned vehicles used in connection with this Agreement.
C.Real and Personal Property
CONTRACTOR shall maintain a policy of insurance for all risk personal property
coverage which shall be endorsed naming the County of Fresno asan additional
loss payee.The personal property coverage shall be in an amount that will cover
thetotalof the County purchased and owned property,at a minimum,as
discussed in Section Twenty One (21)of this Agreement.
All Risk Personal Property
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CONTRACTOR will provide property coverage forthe full replacement value of
theCounty's Personal Property inthe possession of Contractor and/or used inthe
executionof this agreement.Countywill be identified on an appropriate
certificate of insurance as the certificate holder and will be named as an
Additional Loss Payee on the Property Insurance Policy.
D.Professional Liability
If CONTRACTOR employs licensed professional staff (e.g. Ph.D.,R.N..
L.C.S.W.,L.M.F.T.)in providing services,Professional Liability Insurance with
limits of not less than One Million Dollars ($1,000,000)per occurrence.Three
Million Dollars ($3,000,000) annual aggregate. This coverage shall be issued on a
perclaim basis.CONTRACTOR agrees that it shall maintain,at its sole expense,
in full force andeffectfor a period of three(3) years following the termination of
this Agreement,oneor more policies of professional liability insurance with
limits of coverage as specified herein.
E.Worker's Compensation
A policy of Worker's Compensation Insurance as may be required bythe
California Labor Code.
CONTRACTOR shall obtain endorsements to the Commercial General Liability
insurance naming the County of Fresno,its officers,agents,and employees,individually and
collectively,as additional insured,butonlyinsofaras the operations under this Agreement are
concerned.Such coverage for additional insured shall applyas primary insurance andanyother
insurance,or self-insurance,maintained by COUNTY,itsofficers,agentsand employees shall be
excess only and not contributing with insurance provided under CONTRACTOR'S policies herein.
This insurance shall not be cancelledor changed without a minimumof thirty(30) days advance
written notice given to COUNTY.
Within thirty (30) days from the date CONTRACTORsigns this Agreement.
CONTRACTOR shall provide certificates of insurance and endorsements as stated above for all of the
foregoing policies,as required herein,to the County of Fresno,Department of Behavioral Health.3133
N.Millbrook Ave. Fresno.California,93703.Attention:Contracts Division,stating that such insurance
coverages have been obtained and are in full force;that the County of Fresno,its officers,agents and
employees will not be responsible for any premiums on the policies;that such Commercial General
COUNTY OF FRESNC
Fresno,CI
1 Liability insurance names the County of Fresno,its officers,agents and employees,individually and
2 collectively,as additional insured,but only insofar asthe operations under this Agreement are
3 concerned;that such coverage for additional insured shall apply as primary insurance and any other
4 insurance,or self-insurance,maintained by COUNTY,its officers,agents and employees,shall be
5 excess only andnot contributing with insurance provided under CONTRACTOR'S policies herein;and
6 that this insurance shall notbe cancelled or changed without a minimum of thirty (30)days advance.
7 written notice given to COUNTY.
8 In the event CONTRACTOR fails to keep in effect at all times insurance coverage as
9 herein provided.COUNTY may,in addition to other remedies it may have,suspend or terminate this
10 Agreement upon the occurrence of such event.
11 All policies shall be with admitted insurers licensed to do business in the State of
12 California.Insurance purchased shall be from companies possessing a current A.M.Best,Inc.rating of
13 A FSC VII or better.
14 11.LICENSES/CERTIFICATES
15 Throughout each term of this Agreement,CONTRACTOR and CONTRACTOR'S staff
16 shall maintain all necessary licenses,permits,approvals,certificates,waivers and exemptions necessary
17 for the provision of the services hereunder and required by the laws and regulations of the United States
18 of America,State of California,the County of Fresno,and any other applicable governmental agencies.
19 CONTRACTOR shall notify COUNTY immediately in writing of its inability to obtain or maintain
20 such licenses,permits,approvals,certificates,waivers and exemptions irrespective of the pendency of
21 any appeal related thereto.Additionally,CONTRACTOR and CONTRACTOR'S staff shall comply
22 with all applicable laws,rules or regulations,as may now existor be hereafter changed.
23 12.RECORDS
24 CONTRACTOR shall maintain records in accordance with Exhibit C,"Documentation
25 Standards for Client Records",attached hereto and incorporated herein by reference.During site visits,
26 COUNTY shall be allowed to review records of services provided,including the goals and objectives
27 ofthe treatment plan,and how the therapy provided is achieving thegoalsand objectives.
2 8 13.REPORTS
A. Cost Report -CONTRACTOR agrees to submit a complete and accurate detailed
cost report on an annual basis for each fiscal year ending June 30th in the format prescribed by the
DHCS for the purposes of Short Doyle Medi-Cal reimbursements and total costs for programs.Each
cost report will be the source document for several phases of settlement with the DHCS for the
purposes of Short Doyle Medi-Cal reimbursement.CONTRACTOR shall report costs under their
approved legal entity number established during the Medi-Cal certification process.The information
provided applies to CONTRACTOR for program related costs for services rendered to Medi-Cal and
non Medi-Cal. The CONTRACTOR will remit a schedule to provide the required information on
published charges (PC)for all authorized services.The report will serve as a source document to
determine their usual and customary charge prevalent inthe public mental health sector that is used to
bill the general public,insurers or other non-Medi-Cal third party payers during the course of business
operations.CONTRACTOR must report all collections for Medi-Cal/Medicare services and
collections.The CONTRACTOR shall also submit with each cost report a copy of the
CONTRACTOR'S general ledger that supports revenues and expenditures for the specified Adult or
Youth CSC.CONTRACTOR must also include a reconciled detailed report of the total units of
services rendered under this Agreement compared tothe units of services entered by CONTRACTOR
into COUNTY'S data system.
Cost Reports must be submitted to the COUNTY asa hard copy with a signed
cover letter and electronic copy of the completed DHCS cost report form along with requested support
documents following each fiscal year ending June 30th.During the month of September of each year
this Agreement is effective.COUNTY will issue instructions of the annual cost report which indicates
the training session,DHCS cost report template worksheets,and deadlines to submit as determined by
the State annually.Remit the hard copies of the cost reports to County of Fresno.Attention:Cost
Report Team,P.O.Box 45003.Fresno,CA 93718.Remit the electronic copy or any inquiries to
DBHcostreportteam@co.fresno.ca.us.
All Cost Reports must be prepared in accordance with General Accepted
Accounting Principles (GAAP)and Welfare and Institutions Code §§5651(a)(4),5664(a),5705(b)(3)
and 5718(c).Unallowable costs such as lobby or political donations must be deducted on the cost
COUNTY OF FRESNC
report and invoice reimbursements.
If the CONTRACTOR does not submit the cost report(s) by the deadline,
including any extension period granted by the COUNTY,the COUNTY may withhold payments of
pending invoicing under compensation until the cost report(s)has been submitted and clears COUNTY
desk audit for completeness.
B.Settlements with State Department of Health Care Services (DHCS)
During thetermofthis Agreement and thereafter,COUNTY and
CONTRACTOR agree to settle dollar amounts disallowed or settled in accordance with DHCS and
COUNTY audit settlement findings relatedto the Medi-Cal and realignment reimbursements.
CONTRACTOR will participate inthe several phasesof settlements between
COUNTY/CONTRACTOR and DHCS.Thephasesof initial cost reporting for settlement according to
State reconciliation of records forpaid Medi-Cal services andaudit settlement-State DHCS audit:1)
initial cost reporting -after an internal review by COUNTY,the COUNTY files cost report with State
DHCSon behalfof the CONTRACTOR'Slegal entity forthe fiscal year; 2) Settlement -State
reconciliation of records for paid Medi-Cal services,approximately eighteen (18)to thirty-six (36)
months following the State close of the fiscal year,DHCS will send notice for any settlement under this
provision will be sent to the COUNTY;and 3)Audit Settlement-State DHCS audit.After final
reconciliation and settlement, COUNTY and/or DHCS may conduct a review of medical records, cost
report along with support documents submitted to COUNTY in initial submission to determine
accuracy and may disallow cost and/or unit of service reported on the CONTRACTOR'S legal entity
cost report.COUNTY may choose to appeal and therefore reserves the right to defer payback
settlement with CONTRACTOR until resolution of the appeal.DHCS Audits will follow federal
Medicaid procedures for managing overpayments.
If at the end of the Audit Settlement,the COUNTY determines that it overpaid
the CONTRACTOR,it will require the CONTRACTOR to repay the Medi-Cal related overpayment
back to the COUNTY.
Funds owed to COUNTY will be due within forty-five (45) days of notification
by the COUNTY,or COUNTY shall withhold future payments until all excess funds have been
COUNTY OF FRESNO
recouped by means of an offset against any payments then or thereafter owing to CONTRACTOR
under this or any other Agreement.
B.Quarterly Program Reports -CONTRACTOR shall submit to COUNTY'S DBH
Director or designee,quarterly reports of progress toward accomplishing the program objectives as
statedand described in Exhibit D,attached heretoand incorporatedherein by reference. Copiesof
progress reports shall be submitted to COUNTY'S DBHMental Health Contracted Services Division.
COUNTY will require an explanation of any deviation greater than 10%from the stated objective.
C. Monthly Caseload Reports-CONTRACTOR will submit a copy of enrolled
clients ona monthly basis to COUNTY'S DBH Director or designee identifying clients by DFICS
number.Social Security number.Date of Birth,Age,length of stay,housing status and financial status
such as Medi-Cal and/or general relief,identify client primary physician status,and identify dis-
enrolled or clients transitioned intoother agencies for additional services ina format acceptable to
COUNTY'S DBH Director or designee.Said monthly caseload reports shall accompany each monthly-
invoice submitted by CONTRACTOR.
D. PATH Annual Report- COUNTY is responsible for providing an annual report to
the State which will describe and evaluate the PATH program for essential planning purposes,
maintaining program accountability,and program monitoring.Therefore,CONTRACTOR is required
to submitto the COUNTY'SDBH Directoror designee data in accordance with Exhibit E,"PATH
Annual Report",attached hereto and incorporated herein by reference.
E. In addition,CONTRACTOR shall also furnish to COUNTY such statements,
records,reports,data,and other information as COUNTY may request pertaining to matters covered by
this Agreement.In the event that CONTRACTOR fails to provide such reports or other information
required hereunder,it shall be deemed sufficient cause for COUNTY to withhold monthly payments
until there is compliance.In addition,CONTRACTOR shall provide written notification and
explanation to COUNTY within five (5)days of any funds received from another source to conduct the
same services covered by this Agreement.
14.MONITORING
CONTRACTOR agrees to extend to COUNTY'S staff,COUNTY'S DBH Director and
COUNTY OF FR
DHCS.or their designees,the right to review and monitor records,programs or procedures,at any time,
in regard to clients,as well as the overall operation of CONTRACTOR'S programs,in order to ensure
compliance withthetermsand conditions of this Agreement.
15.REFERENCES TO LAWS AND RULES
In the event any law,regulation,or policy referred to in this Agreement is amended
during the term thereof,the parties hereto agree to comply with the amended provision asof the
effective date of such amendment.
16.COMPLIANCE WITH STATE REQUIREMENTS
CONTRACTOR recognizes that COUNTY operates its mental health programs under an
agreement with the State of California Department of Mental Health,and that under said agreement the
State imposes certain requirements on COUNTY and its subcontractors.CONTRACTOR shall adhere
to all State requirements,including those identified in Exhibit F "State Mental Health Requirements",
attached hereto and by this reference incorporated herein.
17.COMPLIANCE WITH STATE MEDICAL REQUIREMENTS
CONTRACTORshall be requiredto maintainorganizational providercertificationby
Fresno County.CONTRACTOR must meet Medi-Cal organization provider standards as listed in
Exhibit G,"Medi-Cal Organizational Provider Standards",attached hereto and incorporated herein.It
is acknowledged that all references to Organizational Provider and/or Provider in Exhibit G shall refer
to CONTRACTOR.In addition.CONTRACTOR shall inform every client of their rights under the
COUNTY'S Mental Health Plan as described in Exhibit H.attached hereto and by this reference
incorporated herein.CONTRACTOR shall also file an incident report for all incidents involving
clients,following the Protocol and using the Worksheet identified in Exhibit I,attached hereto and by
this reference incorporated herein,ora protocol and worksheet presented by CONTRACTOR that is
acceptedby COUNTY'SDBH Directoror designee.
18.CONFIDENTIALITY
All services performed by CONTRACTOR under this Agreement shall be in strict
conformance with all applicable Federal.State of California and/or local laws and regulations relating
to confidentiality.
COUNT'i
19.HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and CONTRACTOR each consider and represent themselves as covered
entities as defined by the U.S.Health Insurance Portability and Accountability Act of 1996,Public Law
104-191 (HIPAA)and agree to use and disclose Protected Health Information (PHI)as required by law.
COUNTY and CONTRACTOR acknowledge thatthe exchange of PHI between themisonlyfor
treatment, payment, and health care operations.
COUNTY and CONTRACTOR intend to protect the privacy and provide for the
security of PHI pursuant to the Agreement in compliance with HIPAA,the Health Information
Technology for Economic and Clinical Health Act,Public Law 111-005 (HITECH),and regulations
promulgated thereunder by the U.S.Department of Health and Human Services (HIPAA Regulations)
and other applicable laws.
As part of the HIPAA Regulations,the Privacy Rule and the Security Rule require
CONTRACTOR to enter intoa contract containing specific requirementsprior to the disclosureof PHI.
as set forth in, but not limited to.Title 45, Sections 164.314(a),164.502(e)and 164.504(e)of the Code
of Federal Regulations (CFR).
20.DATA SECURITY
Forthe purpose of preventing the potential loss,misappropriation or inadvertent access.
viewing,use or disclosure of COUNTY data including sensitive or personal client information;abuse
of COUNTY resources;and/or disruption to COUNTY operations,individuals and/or agencies that
enter into a contractual relationship with the COUNTY for the purpose of providing services under this
Agreement must employ adequate data security measures to protect the confidential information
provided to CONTRACTOR by the COUNTY,including but not limited to the following:
A.CONTRACTOR-Owned Mobile,Wireless,or Handheld Devices
CONTRACTOR may not connect to COUNTY networks via personally-owned
mobile,wireless or handheld devices,unless the following conditions are met:
1)CONTRACTOR has received authorization by COUNTY for
telecommuting purposes;
2) Current virus protection software is in place;
COUNTY OF FRE3:
3) Mobile device has the remote wipe feature enabled; and
4) A secure connection is used.
B.CONTRACTOR-Owned Computers or Computer Peripherals
CONTRACTOR may not bring CONTRACTOR-owned computers or computer
peripherals into the COUNTY for use without prior authorization from the COUNTY'S Chief
Information Officer,and/or designee(s),including butnot limited to mobile storage devices.Ifdatais
approved to be transferred,data must be stored on a secure server approved by the COUNTY and
transferred by means ofa Virtual Private Network (VPN)connection,or another type of secure
connection.Said data must be encrypted.
C.COUNTY-Owned Computer Equipment
CONTRACTORmaynot use COUNTYcomputersor computer peripheralson
non-COUNTY premises without prior authorization from the COUNTY'S Chief Information Officer,
and/or designee(s).
D. CONTRACTORmay not store COUNTY'S private,confidential or sensitivedata
on any hard-disk drive,portable storage device,or remote storage installation unless encrypted.
E. CONTRACTORshall be responsibleto employ strict controlsto ensurethe
integrity and security of COUNTY'S confidential information and to prevent unauthorized access,
viewing,use or disclosure ofdata maintained in computer files,program documentation,data
processing systems,data files and data processing equipment which stores or processes COUNTY data
internally and externally.
F. Confidential client information transmitted to one party by the other by means of
electronic transmissions must be encrypted according to Advanced Encryption Standards (AES)of 128
BITor higher.Additionally,a password or pass phrase must be utilized.
G. CONTRACTOR is responsible to immediately notify COUNTY of any
violations,breaches or potential breaches of security related to COUNTY'S confidential information,
data maintained in computer files,program documentation,data processing systems,data files and data
processing equipment which stores or processes COUNTY data internally or externally.
///
COUNTY OF
H.COUNTY shall provide oversight to CONTRACTOR'S response to all incidents arising
from a possible breach of security related to COUNTY'S confidential client information provided to
CONTRACTOR.CONTRACTOR will be responsible to issue any notification to affected individuals
as required by law or as deemed necessary by COUNTY in its sole discretion.CONTRACTOR will be
responsible for all costs incurred asa result of providing the required notification.
21.PROPERTY OF COUNTY
A. COUNTYand CONTRACTORrecognizesthat fixed assets aretangibleand
intangible property obtained or controlled under COUNTY'S Mental Health Plan for use in operational
capacity and will benefit COUNTY for a period more than one year.Depreciation of the qualified items
will be on a straight-line basis.
For COUNTY purposes,fixed assetsmust fulfill three qualifications:
1.Asset must have life span of over one year.
2.The asset is not a repair part.
3. Theasset mustbevaluedat or greaterthanthe capitalization thresholds for
the asset type:
Asset type Threshold
land $0
buildingsand improvements $100,000
infrastructure $100,000
• be tangible $5,000
o equipment
o vehicles
• or intangibleasset $100,000
o Internally generated software
o Purchased software
o Easements
o Patents
• and capital lease $5,000
Qualified fixed asset equipment isto be reported and approved by COUNTY.If
it is approved and identified as an asset it will be tagged with a COUNTY program number.A Fixed
asset log will be maintained by COUNTY'S Asset Management System and annual inventoried until
///
COUNTY OF FRE3NC
the asset is fully depreciated.During the terms of this Agreement,CONTRACTOR'S fixed assets may
be inventoried in comparison to COUNTY'S DBHAsset Inventory System.
B.Certain purchases less than Five Thousand and No/100 Dollars ($5,000.00)but
more thanOne Thousand andNo/100 Dollars ($1,000.00),withover one yearlifespan,andare mobile
and high risk of theft or loss are sensitive assets.Such sensitive items are not limited to computers,
copiers,televisions,cameras and other sensitive items as determined by COUNTY'S DBH Director or
designee.CONTRACTOR maintains a tracking system on the items and are not required to be
capitalize or depreciated.The items are subject to annual inventory for compliance.
C.Assets shall be retained by COUNTY,as COUNTY property,intheeventthis
Agreement is terminated or upon expiration of this Agreement.CONTRACTOR agrees to participate
in an annual inventory of all COUNTY fixed and inventoried assets.Upon termination or expiration of
this Agreement CONTRACTOR shall be physically present when fixed and inventoried assets are
returned to COUNTY possession.CONTRACTOR is responsible for returning to COUNTY all
COUNTY owned undepreciated fixed and inventoried assets,or the monetary value of said assets if
unable to produce the assets atthe expiration or termination ofthis Agreement.
CONTRACTOR further agrees to the following:
1.To maintain all items of equipment in good working orderand condition,
normal wear and tear is expected;
2. To label all items of equipment with COUNTY assigned program number,
to perform periodic inventories as required by COUNTY and to maintain an inventory list showing
where and how the equipment is being used,in accordance with procedures developed by COUNTY.
All such listsshall besubmitted to COUNTYwithin ten (10) days of any requesttherefore;and
3. To report in writing to COUNTY immediately after discovery,the lost or
theft of any items of equipment.For stolen items,the local law enforcement agency must be contacted
anda copyof the policereport submitted to COUNTY.
D.The purchase of any equipment by CONTRACTOR with funds provided
hereunder shall require the prior written approval of COUNTY'S DBH,shall fulfill the provisions of
this Agreement as appropriate,and must be directly related to CON TRACTOR'S services or activity
COUNTY OF FRESNO
Fresno,CA
under the terms of this Agreement.COUNTY'S DBH may refuse reimbursement for any costs
resulting from equipment purchased,which are incurred by CONTRACTOR,if prior written approval
has not been obtained from COUNTY.
E.CONTRACTOR must obtain prior written approval from COUNTY'S DBH
whenever there is any modification or change in the use of any property acquired or improved,in whole
or in part,using funds under this agreement.If any real or personal property acquired or improved with
said funds identified hereinis soldand/oris utilized by CONTRACTOR fora usewhichdoesnot
qualify under this program,CONTRACTOR shall reimburse COUNTY in an amount equal to the
current fair market value of the property,less any portion thereof attributable to expenditures of non-
program funds.These requirements shall continue in effect for the life of the property.In the event the
program is closed out,the requirements for this Section Twenty-One (21)shall remain in effect for
activities or property funded with said funds,unless action is taken by the State government to relieve
COUNTY of these obligations."
22.NON-DISCRIMINATION
During the performance of this Agreement,CONTRACTOR shall not unlawfully
discriminate against any employee or applicant for employment,or recipient of services,because of
race,religion,color,national origin,ancestry,physical handicap,medical condition,marital status,age
or sex.pursuant to all applicable State and Federal statutes and regulations.
23.CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence,CONTRACTOR shall comply with:
A.Title 6of the Civil Rights Act of 1964 (42 U.S.C.section 2000d.and 45 C.F.R.
Part 80)and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance
from discriminating against persons based on race,color,national origin,sex.disability or religion.
This is interpreted to mean that a limited English proficient (LEP)individual is entitled to equal access
and participation in federally funded programs through the provision ofcomprehensive and quality
bilingual services.
B.Policies and procedures for ensuring access and appropriate use of trained
interpreters and material translation services for all LEP clients,including,but not limited to,assessing
COUNTY OF FRESNO
the cultural and linguistic needs of its clients,training of staff on the policies and procedures,and
monitoring its language assistance program.The CONTRACTOR'S procedures must include ensuring
compliance of any sub-contracted providers with these requirements.
C.CONTRACTOR shall not use minors as interpreters.
D.CONTRACTOR shall provide and pay for interpreting and translation services to
persons participating in CONTRACTOR'S services who have limited or no English language
proficiency,including services to persons who are deaf or blind.Interpreter and translation services
shall be provided as necessary to allow such participants meaningful access to the programs,services
and benefits provided by CONTRACTOR.Interpreter and translation services,including translation of
CONTRACTOR'S "vital documents"(those documents that contain information thatis critical for
accessing CONTRACTOR'S services or are required by law)shall be provided to participants at no
cost to the participant.CONTRACTOR shall ensure that any employees,agents,subcontractors,or
partners who interpret or translate for a program participant,or who directly communicate with a
program participant in a language other than English,demonstrate proficiency in the participant's
language and can effectively communicate any specialized terms and concepts peculiar to
CONTRACTOR's services.
E.In compliance with the State mandated Culturally and Linguistically Appropriate
Services standards as published by the Office of Minority Health.CONTRACTOR must submit to
COUNTY for approval,within sixty (60)days from date of contract execution,CONTRACTOR'S plan
to address all fifteen national cultural competency standards as set forth in the "National Standards on
Culturally and Linguistically Appropriate Services (CLAS)"
http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf COUNTY'S annual on-site review of
CONTRACTOR shall includecollection of documentation to ensureall nationalstandardsare
implemented.As the national competency standards are updated,CONTRACTOR'S plan must be
updated accordingly.
24.TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowance of reimbursement under section 1861(v)
(1)(I)of the Social Security Act.(42 U.S.C.§1395x.subd.(v)(l)[I]),until the expiration of four (4)
COUNTY OF FRF3NC
years after the furnishing of services under this Agreement,CONTRACTOR shall make available,
upon written request ofthe Secretary ofthe United States Department of Health and Human Services,
or upon request of the Comptroller General of the United States General Accounting Office,or any of
their duly authorized representatives,a copy of this Agreement and such books,documents,and records
as are necessary to certify the nature and extent of the costs of these services provided by
CONTRACTOR under this Agreement.CONTRACTOR further agrees thatinthe event
CONTRACTOR carries out any of its duties under this Agreement through a subcontract,with a value
or costof Ten Thousand and No/100 Dollars ($10,000.00)or moreovera twelve(12)month period,
with a related organization,such Agreement shall contain a clause to the effect that until the expiration
of four (4)years after the furnishing of such services pursuant to such subcontract,the related
organizations shall make available,upon written request of the Secretary of the United States
Department of Health and Human Services,or upon request of the Comptroller General of the United
States General Accounting Office,or any of their duly authorized representatives,a copy of such
subcontract andsuch books,documents,and recordsof such organization as are necessary to verify the
nature and extent of such costs.
25.SINGLE AUDIT CLAUSE
A.IfCONTRACTOR expends Seven Hundred Fifty Thousand Dollars
($750,000.00)or more in Federal and Federal flow-through monies,CONTRACTOR agrees to conduct
an annual audit in accordance with the requirements of the Single Audit Standards as set forth in Office
of Management and Budget (OMB)Circular A-l 33.CONTRACTOR shall submit said audit and
management letter to COUNTY.The audit must include a statement of findings or a statement that
there were no findings.If there were negative findings,CONTRACTOR must include a corrective
action plan signed by an authorized individual.CONTRACTOR agrees to take action to correct any
material non-compliance or weakness found as a result of such audit.Such audit shall be delivered to
COUNTY'S Department of Behavioral Health.Business Office for review within nine (9)months of
the end of any fiscal year in which funds were expended and/or received for the program.Failure to
perform the requisite audit functions as required by this Agreement may result in COUNTY performing
the necessary audit tasks,or at COUNTY'S option,contracting with a public accountant to perform said
COUNTY OF FRES:
Fresno,:
audit,or,may result in the inability of COUNTY to enter into future agreements with CONTRACTOR.
All audit costs related to this Agreement are the sole responsibility of CONTRACTOR.
B.A single audit report is not applicable if CONTRACTOR'S Federal contracts do
not exceed the Seven Hundred Fifty Thousand Dollars ($750,000.00)requirement or
CONTRACTOR'S only funding is through Drug related Medi-Cal.Ifa single audit is not applicable,a
program audit must be performed and a program audit report with management letter shall be submitted
by CONTRACTOR to COUNTY as a minimum requirement to attest to CONTRACTOR'S solvency.
Said audit report shall be delivered to COUNTY'S Department of Behavioral Health,Business Office
for review,no later than nine (9)months after the close of the fiscal year in which the funds supplied
through this Agreement are expended.Failure to comply with this Act may result in COUNTY
performing the necessary audit tasks or contracting with a qualified accountant to perform said audit.
All audit costs related to this Agreement are the sole responsibility of CONTRACTOR who agrees to
take corrective action to eliminate any material noncompliance or weakness found as a result of such
audit.Audit work performed by COUNTY under this Section shall be billed to the CONTRACTOR at
COUNTY'S cost,as determined by COUNTY'S Auditor-Controller/Treasurer-Tax Collector.
C.CONTRACTOR shall make available all records and accounts for inspection by
COUNTY,the State of California,if applicable,the Comptroller General of the United States,the
Federal Grantor Agency,or any of their duly authorized representatives,at all reasonable times for a
period of at least three (3)years following final payment under this Agreement or the closure of all
other pending matters,whichever is later.
26.COMPLIANCE
CONTRACTOR agrees to comply with the COUNTY'S Contractor Code of Conduct and
Ethics and the COUNTY'S Compliance Program in accordance with Exhibit J,attached hereto and
incorporated herein by reference.Within thirty (30)days of entering into the agreement with the
COUNTY,CONTRACTOR shall have allof CONTRACTOR'S employees,agents and subcontractors
providing services under this Agreement certify in writing,that he or she has received,read,
understood,and shall abide by the Contractor Code of Conduct and Ethics.CONTRACTOR shall
ensure that within thirty (30)days of hire,all new employees,agents and subcontractors providing
COUNTY OF hRriN.
Fresno,CC
services under this Agreement shall certify in writing that he or she has received,read,understood,and
shall abide by the Contractor Code of Conduct and Ethics.CONTRACTOR understands that the
promotion of and adherence to the Code of Conduct is an element in evaluating the performance of
CONTRACTOR and its employees, agents and subcontractors.
Within thirty (30)days of entering into this Agreement,and annually thereafter,all employees.
agents and subcontractors providing services under this Agreement shall complete general compliance
training and appropriate employees,agents and subcontractors shall complete documentation and
billing or billing/reimbursement training.All new employees,agents and subcontractors shall attend the
appropriate training within 30 days of hire.Each individual who is required to attend training shall
certify in writing that he or she has received the required training.The certification shall specify the
type of training received and the date received.The certification shall be provided to the COUNTY'S
Compliance Officer at 3147 N.Millbrook.Fresno.CA 93703.CONTRACTOR agrees to reimburse
COUNTY for the entire cost of any penalty imposed upon COUNTY by the Federal Government asa
result of CONTRACTOR'S violation of the terms of this Agreement.
27.ASSURANCES
In entering into this Agreement,CONTRACTOR certifies that it is not currently
excluded,suspended,debarred,or otherwise ineligible to participate in the Federal Health Care
Programs:that it has not been convicted ofa criminal offense related to the provision of health care
items or services;nor has it been reinstated to participation in the Federal Health Care Programs after a
period of exclusion,suspension,debarment,or ineligibility.If COUNTY learns,subsequent to entering
into a contract,that CONTRACTOR is ineligible on these grounds,COUNTY will remove
CONTRACTOR from responsibility for,or involvement with,COUNTY'S business operations related
to the Federal Health Care Programs and shall remove such CONTRACTOR from any position in
which CONTRACTOR'S compensation,or the items or services rendered,ordered or prescribed by
CONTRACTOR may be paid in whole or part,directly or indirectly,by Federal Health Care Programs
or otherwise with Federal Funds at least until such time as CONTRACTOR is reinstated into
participation inthe Federal Health Care Programs.
A.If COUNTY has notice that CONTRACTOR has been charged with a criminal
COUNTY OF FRESN
offense related to any Federal Health Care Program,or is proposed for exclusion during the term on
any contract,CONTRACTOR and COUNTY shall take all appropriate actions to ensure the accuracy
of any claims submitted to any Federal Health Care Program.At its discretion given such
circumstances,COUNTY may request that CONTRACTOR cease providing services until resolution
of the chargesor the proposed exclusion.
B.CONTRACTOR agrees that all potential new employees of CONTRACTOR or
subcontractors of CONTRACTOR who,in each case,are expected to perform professional services
under this Agreement,will be queried as to whether (1)they are now or ever have been excluded,
suspended,debarred,or otherwise ineligible to participate in the Federal Health Care Programs;(2)
they have been convicted ofa criminal offense related to the provision ofhealth care items or services;
and or (3)they have been reinstated to participation in the Federal Health Care Programs after a period
of exclusion,suspension,debarment,or ineligibility.
1.In the event the potential employee or subcontractor informs
CONTRACTOR that he or she is excluded,suspended,debarred or otherwise ineligible,or has been
convicted ofa criminal offense relating to the provision of health care services,and CONTRACTOR
hires or engages such potential employee or subcontractor,CONTRACTOR will ensure that said
employee or subcontractor does no work,either directly or indirectly relating to services provided to
COUNTY.
2.Notwithstanding the above,COUNTY at its discretion may
terminate this Agreement in accordance with Section Three (3)of this Agreement,or require adequate
assurance (as defined by COUNTY)that no excluded,suspended or otherwise ineligible employee or
subcontractor of CONTRACTOR will perform work,either directly or indirectly,relating to services
provided to COUNTY.Such demand for adequate assurance shall be effective upon a time frame to
be determined by COUNTY to protect the interests of COUNTY clients.
C.CONTRACTOR shall verify (by asking the applicable employees and
subcontractors)that all current employees and existing subcontractors who.in each case,are expected
to perform professional services under this Agreement (1)are not currently excluded,suspended,
debarred,or otherwise ineligible to participate in the Federal Health Care Programs;(2)have not been
COUNTY OF F
convicted ofa criminal offense related to the provision of health care items or services;and (3)have
not been reinstated to participation in the Federal Health Care Program after a period of exclusion,
suspension,debarment,or ineligibility.In the event any existing employee or subcontractor informs
CONTRACTOR that he or she is excluded,suspended,debarred or otherwise ineligible to participate in
the Federal Health Care Programs,or has been convicted ofa criminal offense relating to the provision
of health care services.CONTRACTOR will ensure that said employee or subcontractor does no work,
eitherdirector indirect,relating to servicesprovidedto COUNTY.
1.CONTRACTOR agrees to notify COUNTY immediately during the term
of this Agreement whenever CONTRACTOR learns that an employee or subcontractor who,in each
case,is providing professional services under this Agreement is excluded,suspended,debarred or
otherwise ineligible to participate in the Federal Health Care Programs,or is convicted of a criminal
offense relating to the provision of health care services.
2.Notwithstanding the above,COUNTY at its discretion may terminate this
Agreement in accordance with the Termination Section ofthis Agreement,or require adequate
assurance (as defined by COUNTY)that no excluded,suspended or otherwise ineligible employee or
subcontractor of CONTRACTOR will perform work,either directly or indirectly,relating to services
provided to COUNTY.Such demand for adequate assurance shall be effective upon a time frame to be
determined by COUNTY to protect the interests of COUNTY clients.
D.CONTRACTOR agrees to cooperate fully with any reasonable requests for
information from COUNTY which may be necessary to complete any internal or external audits
relating to CONTRACTOR'S compliance with the provisions of this Section.
E.CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty
imposed upon COUNTY by the Federal Government as a result of CONTRACTOR'S violation of
CONTRACTOR'S obligations as described inthis Section.
28.DISCLOSURE -CRIMINAL HISTORY &CIVIL ACTIONS
CONTRACTOR is required to disclose if any of the following conditions apply to them,
their owners,officers,corporate managers and partners (hereinafter collectively referred to as
"CONTRACTOR"):
COUNTY OF t
Fresn
A.Within the three (3)year period preceding the Agreement award,they have been
convicted of.or hada civil judgment rendered against them for:
1.Fraud or a criminal offense in connection with obtaining, attempting to
obtain,or performing a public (federal,state,or local)transaction or contract
under a public transaction;
2.Violation of a federal or state antitrust statute;
3.Embezzlement,theft,forgery,bribery,falsification,or destruction of
records;or
4.False statements or receipt of stolen property.
B.Within a three (3)year period preceding their Agreement award,they have had a
public transaction (federal,state,or local)terminated for cause or default.
Disclosure of the above information will not automatically eliminate CONTRACTOR
from further business consideration.The information will be considered as part of the determination
of whether to continue and/or renew the Contract and any additional information or explanation that a
CONTRACTOR elects to submit with the disclosed information will be considered.Ifit is later
determined thatthe CONTRACTOR failed to disclose required information,any contract awarded to
such CONTRACTOR may be immediately voided and terminated for material failure to comply with
the terms and conditions of the award.
CONTRACTOR must sign a "Certification Regarding Debarment,Suspension,and Other
Responsibility Matters-Primary Covered Transactions"in the form set forth in Exhibit K,attached
hereto and by this reference incorporated herein.Additionally,CONTRACTOR must immediately
advise the County in writing if.during the term of this Agreement:(1)CONTRACTOR becomes
suspended,debarred,excluded or ineligible for participation in federal or state funded programs or
from receiving federal funds as listed in the excluded parties'list system (http://www.sam.gov);or (2)
any of the above listed conditions become applicable to CONTRACTOR.CONTRACTOR shall
indemnify,defend and hold the COUNTY harmless for any loss or damage resulting from a conviction,
debarment,exclusion,ineligibility or other matter listed in the signed Certification Regarding
Debarment,Suspension,and Other Responsibility Matters."
COUNTY OF FRESNO
29.DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the CONTRACTOR is operating as a corporation (a
for-profit or non-profit corporation)or if during the term of this agreement,the CONTRACTOR
changes its status to operate asa corporation.
Membersof the CONTRACTOR'SBoardof Directors shall discloseany self-dealing
transactions that they are a party to while CONTRACTOR is providing goods or performing services
under this agreement.A self-dealing transaction shall mean a transaction to which the CONTRACTOR
is a party and in which one or more of its directors has a material financial interest.Members ofthe
Board of Directors shall disclose any self-dealing transactions that they are a party to by completing
and signing a Self-Dealing Transaction Disclosure Form (Exhibit L)and submitting it to the COUNTY
prior to commencing with the self-dealing transaction or immediately thereafter.
30.DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST
INFORMATION
This provision is only applicable if CONTRACTOR is a disclosing entity,fiscal agent,or
managed care entity as defined in Code of Federal Regulations (C.F.R).Title 42 §455.101 455.104.
and455.106(a)(l),(2).
In accordance with C.F.R.,Title 42 §§455.101,455.104,455.105 and 455.106(a)(1).(2).
the following information must be disclosed by CONTRACTOR by completing Exhibit M,"Disclosure
ofOwnership and Control Interest Statement",attached hereto and by this reference incorporated
herein.CONTRACTOR shall submit this form to the Department of Behavioral Health within thirty
(30)days of the effective date of this Agreement.Additionally.CONTRACTOR shall report any
changes to this information within thirty five (35)days ofoccurrence by completing Exhibit M,
"Disclosure of Ownership and Control Interest Statement."Submissions shall be scanned pdf copies
and areto be sent via email to DIMlAdministration a co.fresno.ca.us attention:Contracts
Administration.
31.AUDITS AND INSPECTIONS
The CONTRACTOR shall at any time during business hours,and as often as the
COUNTY may deem necessary,make available to the COUNTY for examination all of its records and
r re
data with respect to the matters covered by this Agreement.The CONTRACTOR shall,upon request
by the COUNTY,permit the COUNTY to audit and inspect all such records and data necessary to
ensure CONTRACTOR'S compliance withthe termsof this Agreement.
If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
CONTRACTOR shall be subject to the examination and audit of the State Auditor General for a period
of three (3)years after final payment under contract (Government Code section 8546.7).
32.PROHIBITION ON PUBLICITY
None of the funds,materials,property or services provided directly or indirectly under
this Agreement shall be used for CONTRACTOR'S advertising,fundraising.or publicity (i.e..
purchasing of tickets/tables,silent auction donations,etc.)for the purpose of self-promotion.
Notwithstanding the above,publicity ofthe services described in Section One (1)of this Agreement
shall be allowed as necessary to raise public awareness about the availability of such specific services
when approved in advance by COUNTY'S DBH Director or designee and at a cost to be provided in a
Exhibit B for such items as written/printed materials,the use of media (i.e.,radio,television,
newspapers)and any other related expense(s).
33.COMPLAINTS
CONTRACTOR shall log complaints and the disposition of all complaints from a client
or a client's family.CONTRACTOR shall provide a summary of the complaint log entries concerning
COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (10th)day of the following
month,in a format that is mutually agreed upon.CONTRACTOR shall post signs informing client of
their right to file a complaint or grievance.PROVIDER shall notify COUNTY of all incidents
reportable to state licensing bodies that affect COUNTY clients within twenty-four (24)hours of
receipt of a complaint.
Within ten (10)days after each incident or complaint affecting COUNTY-sponsored
clients.CONTRACTOR shall provide COUNTY with information relevant to the complaint,
investigative details of the complaint,the complaint and CONTRACTOR'S disposition of,or corrective
action taken to resolve the complaint.In addition.CONTRACTOR shall inform every client of their
rights as set forth in Exhibit H.CONTRACTOR shall file an incident report for all incidents involving
COUNTY OF
clients,following the Protocol and using the Worksheet identified in Exhibit I.
34.NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CONTRACTOR
Director.Fresno County Chief Executive Officer
Department of Kings View Corporation
Behavioral Health PO Box 28923
4441 E.Kings Canyon Road Fresno.CA 93729
Fresno,CA 93702
Any and all notices between COUNTY and CON TRACTOR provided for or permitted
under this Agreement or by law shall be in writing and shall be deemed duly served when personally
delivered to one ofthe parties,or in lieu ofsuch personal service,when deposited in the United States
Mail,postage prepaid,addressed to such party.
35.GOVERNING LAW
The parties agree that for the purpose of venue,performance under this Agreement is in
Fresno County, California.
The rights and obligations of the parties and all interpretation and performance of this
Agreement shall be governed in all respects by the laws of the State of California.
36.ENTIRE AGREEMENT
This Agreement,including all Exhibits.COUNTY'S Revised RFP No.952-5327 and
CONTRACTOR's response thereto constitutes the entire agreement between CONTRACTOR and
COUNTY with respect to the subject matter hereof and supersedes all previous agreement negotiations,
proposals,commitments,writings,advertisements,publications,and understandings of any nature
whatsoever unless expressly included inthis Agreement.
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COUNTY OF FRESNO
Fresno,CA
1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as ofthe day and
2 year first hereinabove written.
3 ATTEST:
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KINGS VIEW CORPORATION
By:~~
Print Name: L e Q,{V l-loo v {"(
10 Title:. _ _.:;,.C.!...i.£"""'--'-0-L· _______ _
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Chairman of Board, or President
Or any Vice President
By~
Print Name: ::f V\ 5 /C.o:;IZ-1 4' d -?""
Title:._C~(b ______ _
Secretary of Corporation, or
Any Assistant Secretary, or
Chief Financial Officer, or
Any Assistant Treasurer
Mailing Address:
Kings View Corporation
PO Box 28923
Fresno, CA 93729
Phone No.: (559) 256-0100
Contact: Leon Hoover, CEO
COUNTY OF FRESNO
Chairman, Board of Supervisors
BERNICE E. SEIDEL, Clerk
Board of Supervisors
PLEASE SEE ADDITIONAL
SIGNATURE PAGE ATTACHED
-33 -COUNTY OF FRESNO
Fresno, CA
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APPROVED AS TO LEGAL FORM:
DANIEL C.CEDERBORG.COUNTY COUNSEL
Bv m±z
APPROVED AS TO ACCOUNTING FORM:
VICKI CROW,C.P.A..AUDITOR-CONTROLLER/
TREASURER-TAX COLLECTOR
By ilLk (_ADC
REVIEWED AND RECOMMENDED FOR
APPROVAL:
Dawan Utecht,Director
Department of Behavioral Health
Fund/Subclass:
Organization:
Account/Program:
Fiscal Year (FY)
FY 2015-16:
FY 2016-17:
FY 2017-18:
FY 2018-19:
FY 2019-20:
0001/10000
56302493
7294/0
Program Cost M/C FFP
$99,751
$99,751
$99,751
$99,751
$99,751
$530,000
$530,000
$530,000
$530,000
$530,000
Client Reimbursement
$12,000
$12,000
$12,000
$12,000
$12,000
COUNTY
Exhibit A
Page 1 of 7
PROJECTS FOR ASSISTANCE IN TRANSITION FROM HOMELESSNESS
(PATH)PROGRAM
Scope of Work
ORGANIZATION:
ADDRESS:
SITE ADDRESS:
SERVICES:
HOURS OF OPERATION:
PROJECT DIRECTOR:
Phone Number:
CONTRACT PERIOD:
CONTRACT AMOUNT:
Kings View Corporation
PO Box 28923,Fresno,CA 93729
1206 G Street,Suite 102,Fresno,CA 93706
Mental Health,Outreach,Case Management and Supportive Housing Services
8am to 5pm,Monday through Friday
Brenda Kent,Lie.LMFT
(559)459-0334
July 1,2015-June 30,2020
$530,000 FY 2015-16
$530,000 FY 2016-17
$530,000 FY 2017-18
$530,000 FY 2018-19
$530,000 FY 2019-20
TARGET POPULATION:
Participation inthe PATH Program is on a consumer voluntary basis.The target population to be served under this
Agreement are adult consumers (18 year and older) who are suffering from severe mental illness and substance
abuse (co-occurring disorders),and are homeless or at imminent risk of becoming homeless.
PROJECT DESCRIPTION:
Withfunding through the Stewart B. McKinney Homeless Assistance Amendments Act of 1990,which authorizes
a Federal grant program (Projects for Assistance inTransition from Homelessness (PATH))to address the needs
of people who are homeless and have severe mental illnesses and/or co-occurring disorders,Kings View isable
to provide a PATH program for said target population. Kings View PATH program delivers services to
consumers who are suffering from severe mental illness and substance abuse (co-occurring disorders),and are
homeless or at imminent risk of becoming homeless.The goal of the PATH program is to enable consumers to
live in the community and to avoid homelessness,hospitalization and/or jail detention.The PATH program is
comprised oftwo components:1)PATH-Outreach,Engagement,and Linkage Services (OEL);and 2)PATH -
Specialty Mental Health Treatment Services (MH).Kings View's role is to provide outreach,engagement,and
linkage services to 500 consumers per year, of which 400 will be enrolled in the PATH-OEL where they will
receive case management,linkage,consultation,peer support services,and supportive interimor bridge housing
services.For consumers enrolled in ongoing mental health treatment (30 consumers at any given time) in
PATH-MH,consumer will receive intensive mental health treatment,case management,linkage,consultation,
peer support services,and supportive housing services (housing to a maximum of 10).Service goals are to help
stabilize and transition consumers into other County or community mental health programs.
The PATH program is a vital resource to the community as it seeks to reduce and end chronic homelessness.
The PATH program will serve as a front door for consumers into continuum of care services and mainstream
mental health,primary health care and the substance abuse services system.
Exhibit A
Page 2 of 7
Kings View shall provide:a partnership in whichthey committo "meet the consumer where they are' inorder to
assist the enrolled consumers achieve their personal recovery and wellness goals.Program will collaborate with
other agencies for provision of non-direct mental health services (Federal Qualified Health Clinics (FQHC),
Public Guardian,Fresno County etc.).Services will incorporate safety,emergency and crisis procedures inthe
field and in the organization's offices,personal services coordination, psychiatric services in the areas of
medication, prescription,administration,monitoring and documentation, mental health services, linkageservices,
and supportive housing services.COUNTY'S administrative staff shall monitorand oversee program outcomes,
coordinate reporting requirements,and execute contract.
King View's RESPONSIBILITY:
1 Shall providetwo program components;one component will consist ofan outreach/linkage program, where
consumers are enrolled and linked to other services based on the needs of the consumer.The second
component is mental health treatment services on an ongoing basis (upto 30 consumers at any giventime)
inclusive of supportive housing services (up to 10 consumers).
2 Provide a partnership inwhichthe service providercommits to "meet the consumer where they are" inorder
to assist the enrolled consumers achieve their personal recovery and wellness goals.
3 Collaborate withother agencies for provision of non-direct mental health services (FQHC, Public Guardian,
etc.).These services are particularly needed to reach people with co-occurring chronic or medical
conditions.Linkage must be provided for consumers to the full range of services.
4 For consumers enrolled in the mental health treatment component of the homeless program;consumer Plan
of Care must include and identifyat least,consumer current symptoms,treatment goals,and interventions.
5 Provide appropriate and as requested upon measurable outcomes,State Quarterly Performance Reports,
and PATH annual report.
Kings View PATH program will provide the following staffing components:
A. PATH outreach coordinator staff shall be available to provide crisis assessment and intervention,including
telephone and face-to-face contact during working hours Response to crisis shall be rapid and flexible.
Coordinators shall collaborate with facilities and designated staff to provide emergency placement should
crisishousing,short-termcare and inpatienttreatment (voluntary or involuntary)be needed. The vendor's
staff shall provide support to the maximum extent possible,including accompanying the consumer to the
County's Urgent Wellness Center and remain withthe consumer during the assessment.
B.The PATH -MH program will provide services for upto 30 consumers inan ongoing basis. Services include;
mental health individual/group therapy,case management linkage, referrals, education in the areas of
medication prescription, administration,monitoring and documentation.In addition, program shall:
•Assess each consumer's mental illness symptoms and behavior and prescribe appropriate
medication as necessary.Medication for consumers who do not have a third party payor will be
provided medicationvia Kings View's PATH programselected vendorand/orotherresources such as
samples,coupons and cost will be the responsibility of Kings View.
•Regularly review and document the consumer's mental illnesssymptoms as well as his/herresponse
to the prescribed medications;
•Educate the consumer and family members on the purpose of medication and any side effects; and
• Monitor,treat and document any medication side effects.
Exhibit A
Page 3 of 7
C.The PATH - MH program's consumer to staff ratio will be no more than 15 consumers to each staff.A ratio
of 1:15:or one staff serves no more than fifteen consumers.
D.Evaluate the staff's competency for performance purposes and establish medication policies and procedures
which identify processes to administer medications to consumers and train other staff and family mem bers
regarding medication education,medication delivery,medication side effects,observation of self
administration of medication and medication monitoring.
E.Assess and document the consumer's mental illness symptoms and behavior in response to medication and
monitor for medication side-effects during the provision of observed self-administration and during ongoing
face-to-face contacts.
F.Staff shall employ harm reduction and motivational interviewing techniques and principles.
G.Kings View program staff shall reflect the target population culturally (cultural,linguistic,ethnic,age,gender,
sexual orientation)and other social characteristics of the community which the program serves.
II.PATH program shall employ the following strategies:
A.Integrate physical and mental health services in collaboration with primary care physicians.
B.Collaborate with community law enforcement,probation and courts.
C.Provide education for consumers and family and/or to other caregivers as appropriate to maximize individual
choice about the nature of medications,the expected benefits and the potential side effects as well as
alternatives to medications.
D.Provide culturally competent evidence-based or promising clinical services that are integrated with overall
service planning,supportive housing,and employment support,and/or education goals.
E.Provide outreach to consumers in both the metropolitan and rural areas to reach out to at minimum 500
homeless mentally ill adults,of which,400 will be enrolled for outreach services.
F. Kings View Program Administrative staff will participate in the Fresno/Madera Continuum of Care (FMCoC)
as a member,COUNTY staff will provide technical assistance if needed.
G.The Program will participate and utilize the Homeless Management Information System (HMI S) to enter client
data.Through the FMCoC,the program will participate in accessing the HMIS to enroll all clients onto the
HMIS which is currently overseen by the Housing Authorities of the City and County of Fresno.
H.Incorporate the Supplemental Security Income/Social Security Disability Income (SSI/SSDI),SSI/SSDI
Outreach,Access.And Recovery (SOAR)as part of the case management services.SOAR provides the
program the tools to expedite access to Social Security disabilitybenefits that result in im proved housing and
treatment outcomes.
The PATH program shall provide the following specific services as it relates to mental health
treatment services:
A. Program will provide an outreach component,engaging homeless mentally ill and/or those at risk of
homelessness and provide appropriate linkage/referral as needed.Within the Outreach component,the
program will enroll at minimum 400 consumers within a twelve month period.
B.Program will provide a mental health treatment component,in which referrals will be approved by the
Department of Behavioral Health. The mental health treatment component will service up to 30 adult
Exhibit A
Page 4 of 7
consumers at any giventime,on an ongoing basis throughout the contract termwhoare seriously mentally
ill and who are homeless,or at risk of being homeless and/or have a co-occurring disorder.
C.CONTRACTOR shall have the flexibility to increase service intensity to a consumer in response to a
consumer's needs.Staff shall have the capacity to provide as many contacts as needed to consumers
experiencing significant problems in daily living.
D.Implement mental health service strategies to reduce the number of days a consumer experiences
hospitalization,incarceration and homelessness.
E. Provider shall operate a multidisciplinary treatment team including licensed/unlicensed mental health
professionals,case managers. Peer support specialist and other specialist to support consumer needs in
reaching his/her goals.
F. Staff will be available to provide symptom assessment,personal service coordination and supportive
counselingto assist consumers to cope with and gain mastery of symptomsand disabilities due to mental
illness and/or substance abuse.These services shall include,but not be limited to,the following:
• Ongoing assessment of the consumer's mental illness symptoms and response to treatment;
• Education ofthe consumer regarding his/her mental illness and the effects (including side effects)
of prescribed medications;
• Symptom management efforts directed to help the consumer identify the symptoms and their
occurrence patterns and development of methods (internal, behavioral, adaptive) to lessen their
effects;and
• Provision, both on a planned and on an "as needed"basis,of such psychological support as is
necessary to help consumers accomplish their personal goals and to cope with the stresses of
day-to-day living.
G.Provide training and instruction,including individual support,problem solving,skill development,modeling
and supervision,in home and community settings,to teach the consumer to:
Carry out personal hygiene tasks;
Perform household chores,including housekeeping,cooking,laundry and shopping;
Develop or improve money management skills;
Use community transportation;
Providing training and assistance to consumers in locating,securing,maintaining and financing
safe,clean and affordable housing which is appropriate to their levels of functioning; and
•Providing training and instruction,including individual support,problem solving,skill development,
modeling and supervision,in home and community settings.
H.Provide treatment services that is appropriate as it relates to age, culture,gender and language services
and when possible accommodations for physical disability(ies)to consumers.
I.Assign a case manager (Personal Services Coordinator)within 24 hours of accepting the case and the
development of a tentative consumer centered Plan ofCare to meet the consumer's needs.
J.Ensure that the team members are able to have on hand,in their possession,during regular working hours
(and when appropriate)an adequate amount of petty cash with which to make emergency purchasesof
food,shelter,clothing,prescriptions, transportation, or other items and services as needed forconsumers.
This may include security deposits,rent subsidy,and other itemsneeded by consumers.Kings View shall
provide policies andprocedures as to the handling ofpettycash.
K.Provide frequentcontacts,with consumers wherethey live orare most comfortable,in ordertoassist them
in accessing behavioral and physical health care,financial,education,vocational,rehabilitative,orother
needed community services,especially as these services relateto meeting the consumer's mental health
and housing needs.
Exhibit A
Page 5 of 7
L.Link consumers to appropriate social services,legal advocacy and other representation,provide
transportation as necessary and serve as a "representative payee"or refer consumer to other payee
services for consumer's SSI/SSD benefits.
M.Develop and support the consumer's participation in recreational and social activities and positive social
relationships and activities in a community setting.Staff shall provide support and help individual
consumers to establish positive social relationships and activities in community settings.Such services
shall include,but not to be limited to,assisting consumers in:
• Developing social skills and,where needed,the skills to develop meaningful personal
relationships;
•Planning appropriate and productive use of leisure time including familiarizing consumers with
available social and recreational opportunities and increasing their use of these activities;
•Interacting with landlords,neighbors and others effectively and appropriately;
•Developing assertiveness and self-esteem;and
• Using existing self-help centers,self-help groups and other social, church and recreational groups
to combat isolation and withdrawal experienced by many persons coping with severe and
persistent mental illness.
N.Provide alcohol,tobacco and drug abuse services as needed,this will include, but is not limitedto, individual
and group interventions to assist consumers in:
• Identifying alcohol,tobacco and drug abuse effects and patterns;
• Recognizing the interactive effects ofalcohol,tobacco and drug use, psychiatricsymptoms, and
psychotropic medications;
•Developing motivation for decreasing alcohol,tobacco and drug use;
•Developing coping skills and alternatives to minimize alcohol,tobacco and drug use;
•Achieving periods of abstinence and stability;
•Attending appropriate recovery or self-help meetings;and
•Achieving an alcohol and drug free lifestyle, ifat all possible.
O.Provide information,in an educational format,on the use of alcohol,tobacco,prescribed medications,and
other drugs of abuse and the impact that chemicals have on the ability to function in major life areas.
Information shall also include eating disorders,gambling,overspending,sexual and other addictions,as
appropriate.
P. Make appropriate referrals and linkages to addiction services that are beyond that ofthe Homeless program
to individuals with coexisting alcohol,tobacco and drug abuse and other addictive symptoms.
Q. Minimize consumer involvement with the criminal justice system,with services to include, but not be limited
to:
•Helping the consumer identify precipitants to the consumer's criminal involvement;
•Providing necessary treatment, support and education to helpeliminateany unlawful activities or
criminal involvement that may be a consequence of the consumer's mental illness; and
•Collaborating with police,court personnel and jail/prison officials and psychiatricstaffto ensure
appropriate use of legal and mental health services.
R.Assist consumer,family and other members of the consumer's social networkto relate ina positiveand
supportive manner through such means as:
•Education about the consumer's illness and their role in the therapeutic process;
•Supportive counseling;
•Intervention to resolve conflict;
• Referral,as appropriate,ofthe family to therapy, self-help and other family support services; and
Exhibit A
Page 6 of 7
•Provision to the consumer's other support systems with education and information about serious
mental illnesses and treatment services and supports.
S.Coordinate services with other community mental health and non-mental health providers,as well as other
medical professionals.Methods for service coordination and communication between program and other
service providers serving the same consumers shall be developed and implemented consistent with Fresno
County confidentiality rules.
T.Initiate voluntary commitment,should there be a need;program staff shall work with County staff within the
Adult Services Division.County staff will sign the involuntary commitment papers.
U.Provide appropriate consumer data,as required and requested by PATH grant,State,and County,such
data reports include quarterly performance reports,Behavioral Health Board annual update report and
quarterly reports,inclusive of demographics,caseload,and measureable outcomes.
V.Provide assistance and advocacy in obtaining available public assistance benefits,general relief,SSI/SSDI
and accessing needed behavioral health and physical health care for consumers.
W.Provide whatever direct assistance is reasonable and necessary to ensure that the consumer obtains the
basic necessities of daily life,including transportation.Program shall have vehicles available to staff to
transport consumers to appointments and social group activities.Bus token/passes will be made available
by the vendor to encourage and empower consumer to utilize public transportation to their scheduled
appointments.
X.Ensure billable Mental Health Specialty Services meet any/all County,State,Federal regulations including
any utilization review and quality assurance standards.
IV.The PATH program will provide specific services as it relates to housing:
Success in the community is critically enhanced by obtaining and retaining housing.For consumers enrolled
into the PATH program,for ongoing treatment services,will receive supported independent housing
opportunities and support services (minimum of 10) who accept housing.The program will empower
consumers to take an active role in the recovery process and provide housing options and maintain
consumers in independent living by providing needed services,accessing resources and encouraging
consumers to be independent,productive and responsible.The program will be responsible to negotiate
and establish relationships with apartment owners/landlords and/or utilize alternative housing resources
such as MHSA Housing Program residential facilities, Housing Authority programs such as the Shelter Plus
Care vouchers,and other available housing programs within the community.
A.The vendor shall provide whatever direct assistance is reasonable and necessary to ensure that the
consumer obtains the basic necessities of daily life,including but not limited to:
•Safe,clean,affordable housing;
•Food and clothing;
•Appropriate financial support,which may include housing deposits,Supplemental Security
Income,Social Security Disability Insurance,General Relief, and money management services.
B.Program shall have rapid access to consumer assistance funds for purchase of furniture, and other items
needed by consumers.
C.Ensure consumers maintain their respective housing and utilize supportive housing resources by providing
supportive and independent housing,as appropriate.
D.Assist consumers in coordinating rents,leases,general relief and work with housing owners/landlords.
Program staff shall send written notice to owners/landlords of housing facilities that explains the financial
Exhibit A
Page 7 of 7
responsibility program and the consumer (tenant)for payment of rent and utilities within 24 hours or the
following business day.
E. A completed consumer rental agreement shall document the amount of rent and the minimum utility expense
that a consumer is required to pay.Program staff shall also provide a monthly receipt to consumer of the
payment received and collected.
COUNTY RESPONSIBILITIES:
1.Provide oversight of the PATH program.In addition to contract monitoring of program,oversight includes,
but not limited to,coordination with the State Department of Health Care Services,Projects for Assistance in
Transition from Homelessness (PATH)program in regard to program administration and outcomes.The
PATH program administrative staff will meet with the Department liaison on a monthly basis to discuss
program consumer issues,concerns,measureable outcomes and reports,and any other items.
2.Assist the CONTRACTOR in making linkages with the total mental health system.This will be accomplished
through regularly scheduled meetings as well as formal and informal consultation
3.Participate in evaluating the progress of the overall program and the efficiency of collaboration with the
program administrative staff and will be available to the contractor for ongoing consultation.
4.Receive and analyze statistical data outcome information throughout the term of contract.DBH will notify
the program when additional participation is required.The performance outcome measurement process will
not be limited to survey instruments but will also include,as appropriate,client and staff interviews,chart
reviews,and other methods of obtaining required information.
5.Recognize that cultural competence is a goal toward which professionals,agencies,and systems should
strive.Becoming culturally competent is a developmental process and incorporates at all levels the
importance of culture,the assessment of cross-cultural relations,vigilance towards the dynamics that result
from cultural differences,the expansion of cultural knowledge,and the adaptation of services to meet
culturally-unique needs.Offering those services in a manner that fails to achieve its intended result due to
cultural and linguistic barriers is not cost effective.County will assist program towards cultural and linguistic
competency,DBH shall provide the following at no cost to vendor(s):
A.Technical assistance regarding cultural competency requirements and sexual orientation training.
B.Mandatory cultural competency training including sexual orientation and sensitivity training for program
personnel,at minimum once per year.County will provide mandatory training regarding the special
needs of this diverse population and will be included in the cultural competence training(s).Sexual
orientation and sensitivity to gender differences is a basic cultural competence principle and shall be
included in the cultural competency training.Literature suggests that the mental health needs of
lesbian,gay,bisexual,transgender (LGBT)individuals may be at increased risk for mental disorders
and mental health problems due to exposure to societal stressors such as stigmatization,prejudice and
anti-gay violence.Social support may be critical for this population.
C.Technical assistance for CONTRACTOR in translating behavioral health and substance abuse services
information into DBH's threshold languages (Spanish,Laotian,Cambodian and Hmong).Translation
services and costs associated will be the responsibility of the vendor.
Projects for Assistance Transitions from Homelessness(PATH)
Kings View Corporation
FISCAL YEAR 2015-2016
Exhibit B
Page 1 of 35
Budget Categories -Total Proposed Budget
OEL SMHS OEL SMHS
Line Item Description (Must be itemized)FTE %FTE %Admin OEL Admin SMHS Total
PERSONNEL SALARIES:
0001 Program Direction 0.05 0.01 4,271 1,068 $5,339
0002 Clinical Supervisor 0.64 0.16 43,680 10,920 $54,600
0003 Case Managers 1.45 0.35 61,139 15,285 $76,424
0004 Outreach Engagement Linkage (OEL)1.40 36,607 $36,607
0005 Psychiatric Services 0.21 27,040 $27,040
0006 Administrative Specialist 0.80 0.20 6,050 24,202 1,513 6,050 $37,815
0007 Title $0
SALARY TOTAL 4.55 0.72 $202,989 $34,836 $237,825
PAYROLL TAXES:
0031 FICA/MEDICARE 492 15,066 87 2,549 $18,194
0032 SUI 96 2,945 23 502 $3,566
0033 Workers Compensation 121 3,939 30 667 $4,757
PAYROLL TAX TOTAL $22,659 $3,858 $26,517
EMPLOYEE BENEFITS:
0041 Retirement 60 2,381 15 595 $3,051
0042 Health Insurance (medical,vision,life,dental)144 15,077 36 3,769 $19,026
EMPLOYEE BENEFITS TOTAL $17,662 $4,415 $22,077
SALARY &BENEFITS GRAND TOTAL $243,310 $43,109 $286,419
FACILITIES/EQUIPMENT EXPENSES:
OEL SMHS Total
1010 Rent/Lease Building 19,200 4,800 $24,000
1011 Rent/Lease Equipment 3,100 775 $3,875
1012 Utilities 7,200 1,800 $9,000
1013 Building Maintenance 2,800 700 $3,500
1015 Rent/Lease Vehicles 11,880 2,970 $14,850
FACILITY/EQUIPMENT TOTAL $44,180 $11,045 $55,225
OPERATING EXPENSES:
1060 Telephone 7,926 1,981 $9,907
1062 Postage 120 30 $150
1066 Office Supplies &Equipment 6,484 1,620 $8,104
1069 Program Supplies -Therapeutic 800 200 $1,000
1072 Staff Mileage/vehicle maintenance 4,000 1,000 $5,000
1076 Other -Program Supplies -Outreach 3,200 800 $4,000
1077 Other -Staff Recruitment/Background Checks 800 200 $1,000
OPERATING EXPENSES TOTAL $23,330 $5,831 $29,161
FINANCIAL SERVICES EXPENSES:
Exhibit B
Page 2 of 35
1082 Liability Insurance
1083 Administrative Overhead
1085 Professional Liability Insurance
2,595
25,022
2,713
753
23,160
787
$3,348
$48,182
$3,500
FINANCIAL SERVICES TOTAL $30,330 $24,700 $55,030
SPECIAL EXPENSES (Consultant/Etc.)
1090 Consultant (network &data management)
1092 Medication Supports
1093 Other -One Time Emergency Housing
5,837
4,000
10,000
10,163 $16,000
$4,000
$10,000
SPECIAL EXPENSES TOTAL $19,837 $10,163 $30,000
FIXED ASSETS:
1190 Computers &Software 4,213 452 $4,665
FIXED ASSETS TOTAL $4,213 $452 $4,665
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)
2001 Client Housing Operating Expenditures (SFC 71)
2002.1 Clothing,Food &Hygiene (SFC 72)
2002.2 Client Transportation &Support (SFC 72)
2002.3 Education Support (SFC 72)
2002.4 Employment Support (SFC 72)
2002.7 Utility Vouchers (SFC 72)
2002.8 Child Care (SFC 72)
31,077
2,500
11,000
500
500
23,923 $55,000
$0
$2,500
$11,000
$500
$500
$0
$0
NON MEDI-CAL CLIENT SUPPORT TOTAL $45,577 $23,923 $69,500
TOTAL PROGRAM EXPENSES $410,777 $119,223 $530,000
77.51%22.49%
Exhibit B
Page 3 of 35
OEL SMHS Total
MEDI-CAL REVENUE:Service Rate $Amount $Amount Total
3000 Mental Health Services (Individual/Family/Group Therapy)0 $2.61 -$0
3100 Case Management 29,341 $2.04 59,856 $59,856
3200 Crisis Services 0 $0.00 -$0
3300 Medication Support 3,789 $4.82 18,263 $18,263
3400 Collateral 0 $2.61 -$0
3500 Plan Development 1,590 $2.61 4,150 $4,150
3600 Assessment 1,263 $2.61 3,296 $3,296
3700 Rehabilitation 41,285 $2.61 107,754 $107,754
Estimated Medi-Cal Billing Totals 77,268 $0 $193,319 $193,319
Estimated % of Federal Financial Participation Reimbursement 50.00%$96,659 $96,659
Estimated % of Clients Served that will be Medi-Cal Eligible 88.69%
MEDI-CAL REVENUE TOTAL $0 $85,727 $85,727
OTHER REVENUE:
4000 Other -PATH
4100 Other -Client Reimbursements
306,519
12,000
$306,519
$12,000
OTHER REVENUE TOTAL $306,519 $12,000 $318,519
MHSA FUNDS:
5100 Community Services &Supports Funds 104,258 21,496 $125,754
MHSA FUNDS TOTAL $104,258 $21,496 $125,754
TOTAL PROGRAM REVENUE 410,777 119,223 $530,000
Projects for Assistance Transitions from Homelessness(PATH)
Kings View Corporation
FISCAL YEAR 2016-2017
Exhibit B
Page 4 of 35
Budget Categories -Total Proposed Budget
OEL SMHS OEL SMHS
Line Item Description (Must be itemized)FTE %FTE %Admin OEL Admin SMHS Total
PERSONNEL SALARIES:
0001 Program Direction 0.05 0.01 4,378 1,094 $5,472
0002 Clinical Supervisor 0.64 0.16 44,772 11,193 $55,965
0003 Case Managers 1.45 0.35 62,667 15,667 $78,334
0004 Outreach Engagement Linkage (OEL)1.40 37,522 $37,522
0005 Psychiatric Services 0.21 27,040 $27,040
0006 Administrative Specialist 0.80 0.20 6,202 24,806 1,546 6,206 $38,760
0007 Title $0
SALARY TOTAL 4.55 0.72 $207,387 $35,706 $243,093
PAYROLL TAXES:
0031 FICA/MEDICARE 474 15,391 118 2,614 $18,597
0032 SUI 74 2,260 19 564 $2,917
0033 Workers Compensation 124 3,766 31 941 $4,862
PAYROLL TAX TOTAL $22,089 $4,287 $26,376
EMPLOYEE BENEFITS:
0041 Retirement 62 2,441 15 610 $3,128
0042 Health Insurance (medical,vision,life,dental)144 15,414 36 3,853 $19,447
EMPLOYEE BENEFITS TOTAL $18,061 $4,514 $22,575
SALARY &BENEFITS GRAND TOTAL $247,537 $44,507 $292,044
FACILITIES/EQUIPMENT EXPENSES:
OEL SMHS Total
1010 Rent/Lease Building 19,200 4,800 $24,000
1011 Rent/Lease Equipment 3,100 775 $3,875
1012 Utilities 7,200 1,800 $9,000
1013 Building Maintenance 2,860 715 $3,575
1015 Rent/Lease Vehicles 11,880 2,970 $14,850
FACILITY/EQUIPMENT TOTAL $44,240 $11,060 $55,300
OPERATING EXPENSES:
1060 Telephone 7,926 1,981 $9,907
1062 Postage 120 30 $150
1066 Office Supplies &Equipment 6,371 1,593 $7,964
1069 Program Supplies -Therapeutic 800 200 $1,000
1072 Staff Mileage/vehicle maintenance 4,000 1,000 $5,000
1076 Other -Program Supplies -Outreach 3,000 1,000 $4,000
1077 Other -Staff Recruitment/Background Checks 800 200 $1,000
OPERATING EXPENSES TOTAL $23,017 $6,004 $29,021
FINANCIAL SERVICES EXPENSES:
Exhibit B
Page 5 of 35
1082 Liability Insurance
1083 Administrative Overhead
1085 Professional Liability Insurance
2,595
25,022
2,884
753
23,160
721
$3,348
$48,182
$3,605
FINANCIAL SERVICES TOTAL $30,501 $24,634 $55,135
SPECIAL EXPENSES (Consultant/Etc.
1090 Consultant (network &data management)
1092 Medication Supports
1093 Other -One Time Emergency Housing
5,720
4,000
10,000
10,280 $16,000
$4,000
$10,000
SPECIAL EXPENSES TOTAL $19,720 $10,280 $30,000
FIXED ASSETS:
1190 Computers &Software 3,000 1,000 $4,000
FIXED ASSETS TOTAL $3,000 $1,000 $4,000
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)28,262 21,738 $50,000
2001 Client Housing Operating Expenditures (SFC 71)$0
2002.1 Clothing,Food &Hygiene (SFC 72)2,500 $2,500
2002.2 Client Transportation &Support (SFC 72)11,000 $11,000
2002.3 Education Support (SFC 72)500 $500
2002.4 Employment Support (SFC 72)500 $500
2002.7 Utility Vouchers (SFC 72)$0
2002.8 Child Care (SFC 72)$0
NON MEDI-CAL CLIENT SUPPORT TOTAL $42,762 $21,738 $64,500
TOTAL PROGRAM EXPENSES $410,777 $119,223 $530,000
77.51%22.49%
Exhibit B
Page 6 of 35
OEL SMHS Total
Units of
MEDI-CAL REVENUE:Service Rate $Amount $Amount Total
3000 Mental Health Services (Individual/Family/Group Therapy)0 $2.61 -$0
3100 Case Management 29,341 $2.04 59,856 $59,856
3200 Crisis Services 0 $0.00 -$0
3300 Medication Support 3,789 $4.82 18,263 $18,263
3400 Collateral 0 $2.61 -$0
3500 Plan Development 1,590 $2.61 4,150 $4,150
3600 Assessment 1,263 $2.61 3,296 $3,296
3700 Rehabilitation 41,285 $2.61 107,754 $107,754
Estimated Medi-Cal Billing Totals 77,268 $0 $193,319 $193,319
Estimated % of Federal Financial Participation Reimbursement 50.00%$96,659 $96,659
Estimated % of Clients Served that will be Medi-Cal Eligible 88.69%
MEDI-CAL REVENUE TOTAL $0 $85,727 $85,727
OTHER REVENUE:
4000 Other -PATH
4100 Other -Client Reimbursements
OTHER REVENUE TOTAL
306,519
$306,519
12,000
$12,000
$306,519
$12,000
$318,519
MHSA FUNDS:
5100 Community Services &Supports Funds 104,258 21,496 $125,754
MHSA FUNDS TOTAL $104,258 $21,496 $125,754
TOTAL PROGRAM REVENUE 410,777 119,223 $530,000
Projects for Assistance Transitions from Homelessness(PATH)
Kings View Corporation
FISCAL YEAR 2017-2018
Exhibit B
Page 7 of 35
Budget Categories -Total Proposed Budget
OEL SMHS OEL SMHS
Line Item Description (Must be itemized)FTE %FTE %Admin OEL Admin SMHS Total
PERSONNEL SALARIES:
0001 Program Direction 0.01 0.01
935 935 $1,870
0002 Clinical Supervisor 0.64 0.16 45,891 11,473 $57,364
0003 Case Managers 1.45 0.35 64,234 16,058 $80,292
0004 Outreach Engagement Linkage (OEL)1.40 38,460 $38,460
0005 Psychiatric Services 0.21 27,040 $27,040
0006 Administrative Specialist 0.80 0.20 6,356 25,427 1,589 6,356 $39,728
0007 Title $0
SALARY TOTAL 4.51 0.72 $208,343 $36,411 $244,754
PAYROLL TAXES:
0031 FICA/MEDICARE 485 15,453 122 2,664 $18,724
0032 SUI 91 3,010 24 546 $3,671
0033 Workers Compensation 121 4,014 32 728 $4,895
PAYROLL TAX TOTAL $23,174 $4,116 $27,290
EMPLOYEE BENEFITS:
0041 Retirement 62 2,441 15 610 $3,128
0042 Health Insurance (medical,vision,life,dental)144 15,414 36 3,853 $19,447
EMPLOYEE BENEFITS TOTAL $18,061 $4,514 $22,575
SALARY &BENEFITS GRAND TOTAL $249,578 $45,041 $294,619
FACILITIES/EQUIPMENT EXPENSES:
OEL SMHS Total
1010 Rent/Lease Building
1011 Rent/Lease Equipment
1012 Utilities
1013 Building Maintenance
1015 Rent/Lease Vehicles
19,200
2,640
7,200
2,860
11,880
4,800
660
1,800
715
2,970
$24,000
$3,300
$9,000
$3,575
$14,850
FACILITY/EQUIPMENT TOTAL $43,780 $10,945 $54,725
OPERATING EXPENSES:
1060 Telephone 7,926 1,981 $9,907
1062 Postage 120 30 $150
1066 Office Supplies &Equipment 6,371 1,593 $7,964
1069 Program Supplies -Therapeutic 800 200 $1,000
1072 Staff Mileage/vehicle maintenance 4,000 1,000 $5,000
1076 Other -Program Supplies -Outreach 3,000 1,000 $4,000
1077 Other -Staff Recruitment/Background Checks 800 200 $1,000
OPERATING EXPENSES TOTAL $23,017 $6,004 $29,021
FINANCIAL SERVICES EXPENSES:
1082 Liability Insurance
1083 Administrative Overhead
1085 Professional Liability Insurance
FINANCIAL SERVICES TOTAL
SPECIAL EXPENSES (Consultant/Etc):
1090 Consultant (network &data management)
1092 Medication Supports
1093 Other -One Time Emergency Housing
SPECIAL EXPENSES TOTAL
FIXED ASSETS:
1190 Computers &Software
FIXED ASSETS TOTAL
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)
2001 Client Housing Operating Expenditures (SFC 71)
2002.1 Clothing,Food &Hygiene (SFC 72)
2002.2 Client Transportation &Support (SFC 72)
2002.3 Education Support (SFC 72)
2002.4 Employment Support (SFC 72)
2002.7 Utility Vouchers (SFC 72)
2002.8 Child Care (SFC 72)
NON MEDI-CAL CLIENT SUPPORT TOTAL
TOTAL PROGRAM EXPENSES
2,595
25,022
2,884
$30,501
5,541
4,000
10,000
$19,541
1,500
$1,500
28,360
2,500
11,000
500
500
$42,860
$410,777
Exhibit B
Page 8 of 35
753
23,160
721
$24,634
10,459
$10,459
500
$500
21,640
$21,640
$119,223
$3,348
$48,182
$3,605
$55,135
$16,000
$4,000
$10,000
$30,000
$2,000
$2,000
$50,000
$0
$2,500
$11,000
$500
$500
$0
$0
$64,500
$530,000
77.51%22.49%
Exhibit B
Page 9 of 35
OEL SMHS Total
Units of
MEDI-CAL REVENUE:Service Rate $Amount $Amount Total
3000 Mental Health Services (Individual/Family/Group Therapy)0 $2.61 -$0
3100 Case Management 29,341 $2.04 59,856 $59,856
3200 Crisis Services 0 $0.00 -$0
3300 Medication Support 3,789 $4.82 18,263 $18,263
3400 Collateral 0 $2.61 -$0
3500 Plan Development 1,590 $2.61 4,150 $4,150
3600 Assessment 1,263 $2.61 3,296 $3,296
3700 Rehabilitation 41,285 $2.61 107,754 $107,754
Estimated Medi-Cal Billing Totals 77,268 $0 $193,319 $193,319
Estimated % of Federal Financial Participation Reimbursement 50.00%$96,659 $96,659
Estimated % of Clients Served that will be Medi-Cal Eligible 88.69%
MEDI-CAL REVENUE TOTAL $0 $85,727 $85,727
OTHER REVENUE:
4000 Other -PATH
4100 Other -Client Reimbursements
OTHER REVENUE TOTAL
MHSA FUNDS:
5100 Community Services &Supports Funds
MHSA FUNDS TOTAL
TOTAL PROGRAM REVENUE
306,519
$306,519
104,258
$104,258
410,777
12,000
$12,000
21,496
$21,496
119,223
$306,519
$12,000
$318,519
$125,754
$125,754
$530,000
Projects for Assistance Transitions from Homelessness(PATH)
Kings View Corporation
FISCAL YEAR 2018-2019
Exhibit B
Page 10 of 35
Budget Categories -
Line Item Description (Must be itemized)
Total Proposed Budget
OEL
FTE %
SMHS
FTE %
OEL
Admin OEL
SMHS
Admin SMHS Total
PERSONNEL SALARIES:
0001 Program Direction
0002 Clinical Supervisor
0003 Case Managers
0004 Outreach Engagement Linkage (OEL)
0005 Psychiatric Services
0006 Administrative Specialist
0007 Title
0.01
0.64
1.45
1.40
0.21
0.80
0.01
0.16
0.35
0.20 6,452
944
46,430
64,875
38,853
27,040
25,808 1,613
944
11,608
16,219
6,452
$1,888
$58,038
$81,094
$38,853
$27,040
$40,325
$0
SALARY TOTAL 4.51 0.72 $210,402 $36,836 $247,238
PAYROLL TAXES:
0031 FICA/MEDICARE
0032 SUI
0033 Workers Compensation
494
91
121
15,602
3,010
4,014
123
24
32
2,695
546
728
$18,914
$3,671
$4,895
PAYROLL TAX TOTAL $23,332 $4,148 $27,480
EMPLOYEE BENEFITS:
0041 Retirement
0042 Health Insurance (medical,vision,life,dental)
62
145
2,441
15,414
15
36
610
3,853
$3,128
$19,448
EMPLOYEE BENEFITS TOTAL $18,062 $4,514 $22,576
SALARY &BENEFITS GRAND TOTAL $251,796 $45,498 $297,294
FACILITIES/EQUIPMENT EXPENSES:
OEL SMHS Total
1010 Rent/Lease Building
1011 Rent/Lease Equipment
1012 Utilities
1013 Building Maintenance
1015 Rent/Lease Vehicles
19,200
2,640
7,200
2,640
11,880
4,800
660
1,800
660
2,970
$24,000
$3,300
$9,000
$3,300
$14,850
FACILITY/EQUIPMENT TOTAL $43,560 $10,890 $54,450
OPERATING EXPENSES:
1060 Telephone
1062 Postage
1066 Office Supplies &Equipment
1069 Program Supplies -Therapeutic
1072 Staff Mileage/vehicle maintenance
1076 Other -Program Supplies -Outreach
1077 Other -Staff Recruitment/Background Checks
7,605
120
6,371
800
4,000
3,000
800
1,902
30
1,593
200
1,000
1,000
200
$9,507
$150
$7,964
$1,000
$5,000
$4,000
$1,000
OPERATING EXPENSES TOTAL $22,696 $5,925 $28,621
FINANCIAL SERVICES EXPENSES:
1082 Liability Insurance
1083 Administrative Overhead
1085 Professional Liability Insurance
FINANCIAL SERVICES TOTAL
SPECIAL EXPENSES (Consultant/Etc.;
1090 Consultant (network &data management)
1092 Medication Supports
1093 Other -One Time Emergency Housing
SPECIAL EXPENSES TOTAL
FIXED ASSETS:
1190 Computers &Software
FIXED ASSETS TOTAL
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)
2001 Client Housing Operating Expenditures (SFC 71)
2002.1 Clothing,Food &Hygiene (SFC 72)
2002.2 Client Transportation &Support (SFC 72)
2002.3 Education Support (SFC 72)
2002.4 Employment Support (SFC 72)
2002.7 Utility Vouchers (SFC 72)
2002.8 Child Care (SFC 72)
NON MEDI-CAL CLIENT SUPPORT TOTAL
TOTAL PROGRAM EXPENSES
2,595
25,022
2,884
$30,501
5,435
4,000
10,000
$19,435
1,500
$1,500
26,789
2,500
11,000
500
500
$41,289
$410,777
77.51%
Exhibit B
Page 11 of 35
753
23,160
721
$24,634
10,565
$10,565
500
$500
21,211
$21,211
$119,223
22.49%
$3,348
$48,182
$3,605
$55,135
$16,000
$4,000
$10,000
$30,000
$2,000
$2,000
$48,000
$0
$2,500
$11,000
$500
$500
$0
$0
$62,500
$530,000
MEDI-CAL REVENUE:
3000 Mental Health Services (Individual/Family/Group Therapy)
3100 Case Management
3200 Crisis Services
3300 Medication Support
3400 Collateral
3500 Plan Development
3600 Assessment
3700 Rehabilitation
Estimated Medi-Cal Billing Totals
Estimated % of Federal Financial Participation Reimbursement
Estimated % of Clients Served that will be Medi-Cal Eligible
MEDI-CAL REVENUE TOTAL
OTHER REVENUE:
4000 Other -PATH
4100 Other -Client Reimbursements
OTHER REVENUE TOTAL
MHSA FUNDS:
5100 Community Services &Supports Funds
MHSA FUNDS TOTAL
Units of
Service
0
29,341
0
3,789
0
1,590
1,263
41,285
77,268
Rate
$2.61
$2.04
$0.00
$4.82
$2.61
$2.61
$2.61
$2.61
50.00%
88.69%
TOTAL PROGRAM REVENUE
OEL
$Amount
$0
$0
306,519
$306,519
104,258
$104,258
410,777
Exhibit B
Page 12 of 35
SMHS
$Amount
59,856
18,263
4,150
3,296
107,754
$193,319
$96,659
$85,727
12,000
$12,000
21,496
$21,496
119,223
Total
Total
$0
$59,856
$0
$18,263
$0
$4,150
$3,296
$107,754
$193,319
$96,659
$85,727
$306,519
$12,000
$318,519
$125,754
$125,754
$530,000
Projects for Assistance Transitions from Homelessness(PATH)
Kings View Corporation
FISCAL YEAR 2019-2020
Exhibit B
Page 13 of 35
Budget Categories -Total Proposed Budget
OEL SMHS OEL SMHS
Line Item Description (Must be itemized)FTE %FTE %Admin OEL Admin SMHS Total
PERSONNEL SALARIES:
0001 Program Direction 0.01 0.01 953 953 $1,906
0002 Clinical Supervisor 0.64 0.16 46,654 11,664 $58,318
0003 Case Managers 1.45 0.35 65,106 16,227 $81,333
0004 Outreach Engagement Linkage (OEL)1.40 39,042 $39,042
0005 Psychiatric Services 0.21 27,040 $27,040
0006 Administrative Specialist 0.80 0.20 6,485 25,937 1,621 6,485 $40,528
0007 Title $0
SALARY TOTAL 4.51 0.72 $211,217 $36,950 $248,167
PAYROLL TAXES:
0031 FICA/MEDICARE 496 15,662 124 2,703 $18,985
0032 SUI 91 3,010 24 546 $3,671
0033 Workers Compensation 121 4,014 32 728 $4,895
PAYROLL TAX TOTAL $23,394 $4,157 $27,551
EMPLOYEE BENEFITS:
0041 Retirement 62 2,441 15 610 $3,128
0042 Health Insurance (medical,vision,life,dental)145 15,414 36 3,853 $19,448
EMPLOYEE BENEFITS TOTAL $18,062 $4,514 $22,576
SALARY &BENEFITS GRAND TOTAL $252,673 $45,621 $298,294
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building
1011 Rent/Lease Equipment
1012 Utilities
1013 Building Maintenance
1015 Rent/Lease Vehicles
FACILITY/EQUIPMENT TOTAL
OPERATING EXPENSES:
1060 Telephone
1062 Postage
1066 Office Supplies &Equipment
1069 Program Supplies -Therapeutic
1072 Staff Mileage/vehicle maintenance
1076 Other -Program Supplies -Outreach
1077 Other -Staff Recruitment/Background Checks
OPERATING EXPENSES TOTAL
OEL
19,200
2,640
7,200
2,640
11,880
$43,560
7,605
120
6,371
800
4,000
3,000
800
$22,696
SMHS
4,800
660
1,800
660
2,970
$10,890
1,902
30
1,593
200
1,000
1,000
200
$5,925
Total
$24,000
$3,300
$9,000
$3,300
$14,850
$54,450
$9,507
$150
$7,964
$1,000
$5,000
$4,000
$1,000
$28,621
FINANCIAL SERVICES EXPENSES:
1082 Liability Insurance
1083 Administrative Overhead
1085 Professional Liability Insurance
FINANCIAL SERVICES TOTAL
SPECIAL EXPENSES (Consultant/Etc):
1090 Consultant (network &data management)
1092 Medication Supports
1093 Other -One Time Emergency Housing
SPECIAL EXPENSES TOTAL
FIXED ASSETS:
1190 Computers &Software
FIXED ASSETS TOTAL
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)
2001 Client Housing Operating Expenditures (SFC 71)
2002.1 Clothing, Food &Hygiene (SFC 72)
2002.2 Client Transportation &Support (SFC 72)
2002.3 Education Support (SFC 72)
2002.4 Employment Support (SFC 72)
2002.7 Utility Vouchers (SFC 72)
2002.8 Child Care (SFC 72)
NON MEDI-CAL CLIENT SUPPORT TOTAL
TOTAL PROGRAM EXPENSES
2,595
25,022
2,884
$30,501
5,400
4,000
10,000
$19,400
800
$800
26,647
2,500
11,000
500
500
$41,147
$410,777
77.51%
Exhibit B
Page 14 of 35
753
23,160
721
$24,634
10,600
$10,600
200
$200
21,353
$21,353
$119,223
22.49%
$3,348
$48,182
$3,605
$55,135
$16,000
$4,000
$10,000
$30,000
$1,000
$1,000
$48,000
$0
$2,500
$11,000
$500
$500
$0
$0
$62,500
$530,000
Exhibit B
Page 15 of 35
OEL SMHS Total
MEDI-CAL REVENUE:
Units of
Service Rate $Amount $Amount Total
3000 Mental Health Services (Individual/Family/Group Therapy)
3100 Case Management
3200 Crisis Services
3300 Medication Support
3400 Collateral
3500 Plan Development
3600 Assessment
3700 Rehabilitation
0
29,341
0
3,789
0
1,590
1,263
41,285
$2.61
$2.04
$0.00
$4.82
$2.61
$2.61
$2.61
$2.61
59,856
18,263
4,150
3,296
107,754
$0
$59,856
$0
$18,263
$0
$4,150
$3,296
$107,754
Estimated Medi-Cal Billing Totals 77,268 $0 $193,319 $193,319
Estimated % of Federal Financial Participation Reimbursement
Estimated % of Clients Served that will be Medi-Cal Eligible
50.00%
88.69%
$96,659 $96,659
MEDI-CAL REVENUE TOTAL $0 $85,727 $85,727
OTHER REVENUE:
4000 Other -PATH
4100 Other -Client Reimbursements
306,519
12,000
$306,519
$12,000
OTHER REVENUE TOTAL $306,519 $12,000 $318,519
MHSA FUNDS:
5100 Community Services &Supports Funds 104,258 21,496 $125,754
MHSA FUNDS TOTAL $104,258 $21,496 $125,754
TOTAL PROGRAM REVENUE 410,777 119,223 $530,000
Exhibit B
Page 16 of 35
Projects for Assistance Transition from Homelessness (PATH)
Kings View Corporation
Fiscal Year 2015-2016
PROGRAM EXPENSES
PERSONNEL SALARIES Annual Amount
Line 0001 ProgramDirection $5,339
0.06 FTE Provides program and clinical direction, maintains
collaborative relationships with other entities and agencies.
Line0002 Clinical Supervisor:$54,600
0.80 FTE Provides clinical supervision of all staff including
interns.
Line0003 Case managers $76,424
1.75 FTE Provides case management services
Line0004 OutreachEngagement Linkage:$36,607
1.40 FTE Provides Outreach and engagement services,provides
linkage to needed services
Line0005 Psychiatric Services $27,040
0.21 FTE Provides Medication services for consumers
Line 0006 Administrative Specialist $37,815
1.0 FTE provides reception, medical records and other
needed support tasks for the program and consumers
SALARY TOTAL $237,825
PAYROLL TAXES :
Line 0031 FICA/MEDICARE - Employer share $18,194
Line 0032 SUI $3,566
Line 0033 Workers Compensation $4,757
PAYROLL TAX TOTAL $26,517
EMPLOYEE BENEFITS
Line 0041 Retirement -Employer shareof 401 (K)$3,051
Line0042 Medical,Dental, Vision,Life - Employershare $19,026
Calculated on actual plans chosen by current employees
assumes continued employment of existing staff
Employee Benefits equal 9.3%of Salary Total (Lines 0001 through 0006)
EMPLOYEE BENEFITS TOTAL:$22,077
SALARY &BENEFITS GRAND TOTAL $286,419
FACILITIES/EQUIPMENT EXPENSES
Exhibit B
Page 17 of 35
Line 1010 Rent/Lease Building $24,000
This amount is calculated at 2,500 square feet at 0.80 per
Sq.foot.The current location ofthe PATH program will
be demolished for the High Speed Rail. We are currently
working with realtors to find a new location.
Line 1011 Rent/Lease Equipment $3,875
The annual cost to lease a copier.
Line 1012 Utilities $9,000
The annual cost of gas and electric
Line 1013 Building Maintenance $3,500
The annual cost of janitorial services and minor building
repairs.
Line 1015 Rent/Lease Vehicles $14,850
The annual cost to lease 2 cars and one van,this line
includes license and registration fees.
FACILITIES/EQUIPMENT TOTAL $55,225
OPERATING EXPENSES
Line 1060 Telephone $9,907
The annual cost of telephone services, land lines, long
distance, cell phones and data connectivity
Line 1062 Postage $150
Line 1066 Office Supplies &Equipment $8,104
This includes all supplies used by staff in the course of
providing service to consumers
Line 1069 Program Supplies -Therapeutic $1,000
Supplies used consumers suchas workbooks,journals and
art supplies
Line 1072 Staff Mileage/vehicle maintenance $5,000
This includes vehicle maintenance costs,fuel costs and
Staff reimbursement for using a personal vehicle paid at
The IRS rate of 0.575 per mile.
Line 1076 Other -Program Supplies -Outreach $4,000
Supplies provided to homeless consumers bythe Outreach
Engagement Linkage Team
Line 1077 Other -Staff Recruitment/Intern Background Checks $1,000
Thoroughbackgroundchecks are required,this amount
will fund 20-25 checks
OPERATING EXPENSES TOTAL $29,161
FINANCIAL SERVICES
Line 1082 Liability Insurance $3,348
Includes general liability and auto insurance
Line 1083 Administrative Overhead (Corporate Indirect)$48,182
10%on all other expenses, provides HR,Payroll, Fiscal
17
Exhibit B
Page 18 of 35
Management, Accounts Payable and other administrative
functions.
Line 1085 Professional Liability $3,500
Includes the annual cost of Professional liability insurance
FINANCIAL SERVICES TOTAL $55,030
SPECIAL EXPENSES
Line 1090 Network & Data Management $16,000
Information Services provides the following:
Managed InternetService Provider
SPAM, virus,content filtering of e-mail & web services.
HIPAA compliant configuration of firewall & intrusion
detection systems. Quality of service controls.
Network & Desktop Management
Installation,maintenance &administration of servers,routers,
switches, wiring/cables & other related equipment. Installation,
maintenance & repair of desktop PCs, laptops, printers & other
related equipment. Online, onsite, phone-based & emergency
support-24/7 support
Project Management
For both application& technology;managementof the planning,
design,development,implementation,maintenance& support
phases of a project.Post implementationqualityassurance
Technology Procurement
Purchaseequipment, software& other services from approved
&authorized vendors
Telecommunications Management
Installation/maintenance/management of international, national,
state, metro, campus & local area networks. High definition
video systems for bothIP,Traditional &ISDN networks
Strategic TechnologyPlanning
Budgetprojections,technologyassessment& risk management
System Documentation
Network diagrams,policies,procedures,floorplans,manuals&
desktop configurations
Application/Data Hosting
Access to applications suchas Office Professional,Adobe Reader,
WinZip.Data files and documents storedin secured data center,
daily/weekly backups.Encryption (256 bit)of email for sensitive
information.Access to data/documents 24/7.
Line 1092 Medication Supports $4,000
This includesthe purchaseof medicationsfor consumerswith
no other ability to pay. Consumersare enrolled in Patient
Assistance Program until they obtain Medi-Cal
Line 1093 Other- Onetime Emergency Housing $10,000
18
Exhibit B
Page 19 of 35
SPECIAL EXPENSES TOTAL $30,000
FIXED ASSETS
Line 1190 Computers &Software $4,665
Replacementcost for anticipatedequipmentfailure, many
Computersystems forthis programare 5 or more yearsold,
the costs for HMIS enrollment and user licenses are included
here
FIXED ASSETS TOTAL $4,665
NON MEDICAL CLIENT SUPPORT EXPENSES
Line 2000 Client Housing Support Expenditures $55,000
Cost of non-emergency housing for consumers
Line 2002.1 Clothing,Food&Hygiene $2,500
Purchase of food, clothing and hygiene items for consumers
Line 2002.2 Client Transportation &Support $11,000
Monthly bus passes and tokens for consumers
Line 2002.3 Education Support $500
Assist with education expenses such as books and
registration
Line 2002.4 Employment Support $500
Costof employment assistance suchas DMV records,ID
Cards or birth certificates
NON MEDI-CAL CLIENT SUPPORT EXPENSES TOTAL $69,500
TOTAL PROGRAM EXPENSES $530,000
PROGRAM REVENUE
Line 3000-3700 Medi-Cal Revenue Total $85,727
Based ona report ofthe last 5 years of actual services provided and adjusted
for changes in staff,clinical supervision and program goals.30 expected clients.
Line 4000 Other - PATH $306,519
Based on last year's allocation
Line 4100 Other -ClientRent&Transportation Reimbursements $12,000
Based on current program collection practices
Line 5000 MHSA CSS Funds $125,756
TOTAL PROGRAM REVENUE $530,000
Exhibit B
Page 20 of 35
Projects for Assistance Transition from Homelessness (PATH)
Kings View Corporation
Fiscal Year 2016-2017
PROGRAM EXPENSES
PERSONNEL SALARIES Annual Amount
Line 0001 Program Direction $5,472
0.06 FTE Provides program and clinical direction, maintains
collaborative relationships with other entities and agencies.
Line 0002 Clinical Supervisor:$55,965
0.80 FTE Provides supervision of all staff including interns.
Line 0003 Case managers $78,334
1.75 FTE Provides case management services
Line 0004 Outreach Engagement Linkage:$37,522
1.40 FTE Provides Outreach and engagement services, provides
linkage to needed services
Line 0005 Psychiatric Services $27,040
0.21 FTE Provides Medication services for consumers
Line 0006 Administrative Specialist $38,760
1.0FTEprovides reception,medical recordsand other
neededsupporttasks for the programand consumers
SALARY TOTAL $243,093
PAYROLL TAXES :
Line 0031 FICA/MEDICARE -Employer share $18,597
Line 0032 SUI $2,917
Line 0033 Workers Compensation $4,862
PAYROLL TAX TOTAL $26,376
EMPLOYEE BENEFITS
Line 0041 Retirement -Employer share of 401 (K)$3,128
Line 0042 Medical,Dental,Vision,Life-Employer share $19,447
Calculated on actual plans chosen by current employees
assumes continued employment of existing staff
Employee Benefits equal 9.3%of Salary Total (Lines 0001 through 0006)
EMPLOYEE BENEFITS TOTAL:$22,575
SALARY &BENEFITS GRAND TOTAL $292,044
20
Exhibit B
Page 21 of 35
FACILITIES/EQUIPMENT EXPENSES
Line 1010 Rent/Lease Building $24,000
This amount is calculated at 2,500 square feet at 0.80 per
Sq.foot.The current location ofthe PATH program will
be demolished forthe High SpeedRail. We are currently
workingwith realtorsto find a new location.
Line 1011 Rent/Lease Equipment $3,875
The annual cost to lease a copier.
Line 1012 Utilities $9,000
The annual cost of gas and electric
Line 1013 Building Maintenance $3,575
The annual cost of janitorial services and minor building
repairs.
Line 1015 Rent/Lease Vehicles $14,850
The annual cost to lease 2 cars and one van,this line
includes license and registration fees.
FACILITIES/EQUIPMENT TOTAL $55,300
OPERATING EXPENSES
Line 1060 Telephone $9,907
The annual cost of telephone services, land lines, long
distance,cell phones and data connectivity
Line 1062 Postage $150
Line 1066 Office Supplies &Equipment $7,964
This includes all suppliesusedby staffinthe courseof
providing service to consumers
Line 1069 Program Supplies -Therapeutic $1,000
Supplies used consumers such as workbooks,journals and
art supplies
Line 1072 StaffMileage/vehicle maintenance $5,000
This includes vehicle maintenance costs,fuel costs and
Staff reimbursement for using a personal vehicle paid at
The IRS rate of 0.575 per mile.
Line 1076 Other -Program Supplies -Outreach $4,000
Supplies provided to homeless consumers by the Outreach
Engagement Linkage Team
Line 1077 Other -StaffRecruitment/InternBackgroundChecks $1,000
Thorough background checksare required,this amount
will fund 20-25 checks
OPERATING EXPENSES TOTAL $29,021
FINANCIAL SERVICES
Line 1082 Liability Insurance $3,348
21
Exhibit B
Page 22 of 35
Includes general liability and auto insurance
Line 1083 Administrative Overhead (Corporate Indirect)$48,182
10%on all other expenses,provides HR,Payroll,Fiscal
Management,Accounts Payable andother administrative
functions.
Line 1085 Professional Liability $3,605
Includes the annual cost of Professional liability insurance
FINANCIAL SERVICES TOTAL $55,135
SPECIAL EXPENSES
Line 1090 Network &Data Management $16,000
Information Services provides the following:
Managed Internet Service Provider
SPAM, virus, content filtering of e-mail & web services.
HIPAAcompliantconfigurationof firewall & intrusion
detection systems. Quality of service controls.
Network & Desktop Management
Installation, maintenance &administration of servers, routers,
switches,wiring/cables &other related equipment.Installation,
maintenance & repairof desktop PCs,laptops,printers & other
relatedequipment. Online, onsite, phone-based& emergency
support-24/7 support
Project Management
For both application &technology;management ofthe planning,
design,development,implementation,maintenance &support
phases of a project.Post implementation quality assurance
Technology Procurement
Purchase equipment,software &other services from approved
&authorized vendors
Telecommunications Management
Installation/maintenance/management of international,national,
state,metro,campus &local area networks.Fligh definition
video systems for both IP,Traditional &ISDN networks
Strategic Technology Planning
Budget projections,technology assessment &risk management
System Documentation
Network diagrams,policies,procedures,floor plans,manuals &
desktop configurations
Application/Data Hosting
Access to applications such as Office Professional,Adobe Reader,
WinZip.Data files and documents stored in secured data center,
daily/weekly backups.Encryption (256 bit)of email for sensitive
information.Access to data/documents 24/7.
Line 1092 Medication Supports $4,000
This includes the purchase of medications for consumers with
22
Exhibit B
Page 23 of 35
no other ability to pay.Consumers are enrolled in Patient
Assistance Program untiltheyobtain Medi-Cal
Line 1093 Other -One time Emergency Housing $10,000
SPECIALEXPENSESTOTAL $30,000
FIXED ASSETS
Line 1190 Computers &Software $4,000
Replacement costfor anticipated equipment failure,many
Computer systems for this program are 5or more years old
the costs for HMIS enrollment and user licenses are included
here
FIXED ASSETS TOTAL $4,000
NON MEDI-CAL CLIENT SUPPORT EXPENSES
Line 2000 Client Housing Support Expenditures $50,000
Cost of non-emergency housing for consumers
Line 2002.1 Clothing,Food &Hygiene $2,500
Purchase of food, clothing and hygiene items for consumers
Line 2002.2 Client Transportation &Support $11,000
Monthly bus passes and tokens for consumers
Line 2002.3 Education Support $500
Assist with education expenses such as books and
registration
Line 2002.4 Employment Support $500
Cost of employment assistance suchas DMV records,ID
Cards or birth certificates
NON MEDI-CAL CLIENT SUPPORT EXPENSES TOTAL $64,500
TOTAL PROGRAM EXPENSES $530,000
PROGRAM REVENUE
Line 3000-3700 Medi-Cal Revenue Total $85,727
Based on a report of the last 5 years of actual services provided and adjusted
for changes in staff,clinical supervision and program goals.30 expected clients.
Line 4000 Other-PATH $306,519
Based on last year's allocation
Line 4100 Other -Client Rent &Transportation Reimbursements $12,000
Basedon current program collectionpractices
Line 5000 MHSA CSS Funds $125,756
TOTAL PROGRAM REVENUE $530,000
Exhibit B
Page 24 of 35
Projects for Assistance Transition from Homelessness (PATH)
Kings View Corporation
Fiscal Year 2017-2018
PROGRAM EXPENSES
PERSONNEL SALARIES Annual Amount
Line 0001 Program Direction $1,870
0.02FTE Provides program andclinical direction,maintains
collaborative relationships withotherentitiesand agencies.
Line 0002 Clinical Supervisor:$57,364
0.80FTE Provides supervision of all staff including interns.
Line 0003 Case managers $80,292
1.75 FTE Provides case management services
Line 0004 Outreach Engagement Linkage:$38,460
1.40 FTE Provides Outreach and engagement services, provides
linkage to needed services
Line 0005 Psychiatric Services $27,040
0.21 FTE Provides Medication services for consumers
Line 0006 Administrative Specialist $39,728
1.0 FTE provides reception,medical recordsand other
needed support tasks for the program and consumers
SALARY TOTAL $244,754
PAYROLL TAXES :
Line 0031 FICA/MEDICARE -Employer share $18,724
Line0032 SUI $3,671
Line 0033 Workers Compensation $4,895
PAYROLL TAX TOTAL $27,290
EMPLOYEE BENEFITS
Line 0041 Retirement -Employer share of 401 (K)$3,128
Line 0042 Medical,Dental,Vision,Life -Employer share $19,447
Calculatedon actual plans chosenby current employees
assumescontinuedemploymentof existing staff
Employee Benefits equal 9.7%of Salary Total (Lines 0001 through 0006)
EMPLOYEE BENEFITS TOTAL:$22,575
SALARY &BENEFITS GRAND TOTAL $294,619
FACILITIES/EQUIPMENT EXPENSES
Line 1010 Rent/Lease Building $24,000
24
Exhibit B
Page 25 of 35
This amount is calculated at 2,500 square feet at 0.80 per
Sq.foot.The current location of the PATH program will
be demolished for the High Speed Rail. We are currently
workingwith realtorsto find a new location.
Line 1011 Rent/Lease Equipment $3,300
The annual cost to lease a copier.
Line 1012 Utilities $9,000
The annual cost of gas and electric
Line 1013 Building Maintenance $3,575
The annualcost ofjanitorial servicesand minor building
repairs.
Line 1015 Rent/Lease Vehicles $14,850
The annual cost to lease 2 cars and one van,this line
includes license and registration fees.
FACILITIES/EQUIPMENT TOTAL $54,725
OPERATING EXPENSES
Line 1060 Telephone $9,907
The annualcost of telephone services,land lines, long
distance, cell phones and data connectivity
Line 1062 Postage $150
Line 1066 Office Supplies &Equipment $7,964
This includes all supplies usedby staff inthe courseof
providing service to consumers
Line 1069 Program Supplies -Therapeutic $1,000
Supplies used consumers such as workbooks,journals and
art supplies
Line 1072 Staff Mileage/vehicle maintenance $5,000
This includes vehicle maintenance costs,fuel costs and
Staff reimbursement for using a personal vehicle paid at
The IRS rate of 0.575 per mile.
Line 1076 Other -Program Supplies -Outreach $4,000
Supplies provided to homeless consumers by the Outreach
Engagement Linkage Team
Line 1077 Other- Staff Recruitment/Intern Background Checks $1,000
Thorough background checks are required,this amount
will fund 20-25 checks
OPERATING EXPENSES TOTAL $29,021
FINANCIAL SERVICES
Line 1082 Liability Insurance $3,348
Includes general liability and auto insurance
Line 1083 Administrative Overhead (Corporate Indirect)$48,182
10%on all other expenses,provides HR,Payroll,Fiscal
Management,Accounts Payable and other administrative
25
Exhibit B
Page 26 of 35
functions.
Line 1085 Professional Liability $3,605
Includes the annual cost of Professional liability insurance
FINANCIAL SERVICES TOTAL $55,135
SPECIAL EXPENSES
Line 1090 Network & Data Management $16.000
Information Services provides the following:
Managed Internet Service Provider
SPAM,virus,content filtering of e-mail & web services.
HIPAAcompliantconfigurationof firewall & intrusion
detection systems. Quality of service controls.
Network & Desktop Management
Installation,maintenance &administration of servers,routers,
switches,wiring/cables & other related equipment.Installation,
maintenance & repairof desktop PCs,laptops,printers & other
relatedequipment. Online, onsite, phone-based& emergency
support-24/7 support
Project Management
Forboth application &technology;management ofthe planning,
design,development,implementation,maintenance &support
phasesof a project.Post implementation quality assurance
Technology Procurement
Purchase equipment,software &other services from approved
&authorized vendors
Telecommunications Management
Installation/maintenance/management of international, national,
state,metro,campus& localarea networks.High definition
video systems forboth IP,Traditional &ISDN networks
Strategic TechnologyPlanning
Budget projections,technology assessment &risk management
System Documentation
Network diagrams,policies,procedures,floor plans,manuals &
desktop configurations
Application/Data Hosting
Access to applications such as Office Professional,Adobe Reader.
WinZip.Data files and documents stored in secured data center,
daily/weekly backups.Encryption (256 bit)of email for sensitive
information.Access to data/documents 24/7.
Line 1092 Medication Supports $4,000
This includes the purchase of medications for consumers with
noother ability to pay.Consumers are enrolled in Patient
Assistance Program until they obtain Medi-Cal
Line 1093 Other -One time Emergency Housing $10,000
26
Exhibit B
Page 27 of 35
SPECIAL EXPENSES TOTAL $30,000
FIXED ASSETS
Line 1190 Computers &Software $2,000
Replacement costfor anticipated equipment failure,many
Computer systems for this program are 5or more years old
the costs for HMIS enrollment and user licenses are included
here
FIXED ASSETS TOTAL $2,000
NON MEDICAL CLIENT SUPPORT EXPENSES
Line 2000 Client Housing Support Expenditures $50,000
Cost of non-emergency housing for consumers
Line 2002.1 Clothing,Food &Hygiene $2,500
Purchase of food, clothing and hygiene items for consumers
Line 2002.2 Client Transportation &Support $11,000
Monthly bus passes and tokens for consumers
Line 2002.3 Education Support $500
Assist with education expenses such as books and
registration
Line 2002.4 Employment Support $500
Costof employment assistance suchas DMV records,ID
Cards or birth certificates
NON MEDI-CAL CLIENT SUPPORT EXPENSES TOTAL $64,500
TOTAL PROGRAM EXPENSES $530,000
PROGRAM REVENUE
Line 3000-3700 Medi-Cal Revenue Total $85,727
Based on a report of the last 5 years of actual services provided and adjusted
for changes in staff,clinical supervision and program goals.30 expected clients.
Line4000 Other-PATH $306,518
Based on last year's allocation
Line 4100 Other -Client Rent &Transportation Reimbursements $12,000
Based on current program collection practices
Line5000 MHSA CSSFunds $125,755
TOTAL PROGRAM REVENUE $530,000
27
Exhibit B
Page 28 of 35
Projects for Assistance Transition from Homelessness (PATH)
Kings View Corporation
Fiscal Year 2018-2019
PROGRAM EXPENSES
PERSONNEL SALARIES Annual Amount
Line 0001 Program Direction $1,888
0.02FTE Provides program andclinical direction,maintains
collaborative relationships with other entities and agencies.
Line 0002 Clinical Supervisor:$58,038
0.80 FTE Provides supervision of all staff including interns.
Line 0003 Case managers $81,094
1.75 FTE Provides case management services
Line 0004 Outreach Engagement Linkage:$38,853
1.40 FTE Provides Outreach and engagement services, provides
linkage to needed services
Line 0005 Psychiatric Services $27,040
0.21 FTE Provides Medication services for consumers
Line 0006 Administrative Specialist $40,325
1.0 FTE provides reception,medical recordsand other
needed support tasks for the program and consumers
SALARY TOTAL $247,238
PAYROLL TAXES :
Line 0031 FICA/MEDICARE -Employer share $18,914
Line 0032 SUI $3,671
Line 0033 Workers Compensation $4,895
PAYROLL TAX TOTAL $27,480
EMPLOYEE BENEFITS
Line 0041 Retirement -Employer share of 401 (K)$3,128
Line 0042 Medical,Dental,Vision,Life -Employer share $19,448
Calculatedon actual plans chosen by current employees
assumes continued employment of existing staff
Employee Benefits equal 9.3%of Salary Total (Lines 0001 through 0006)
EMPLOYEE BENEFITS TOTAL:$22,576
SALARY &BENEFITS GRAND TOTAL $297,294
FACILITIES/EQUIPMENT EXPENSES
Line 1010 Rent/Lease Building $24,000
28
Exhibit B
Page 29 of 35
This amount is calculated at 2,500 square feet at 0.80 per
Sq.foot.The current location of the PATH program will
be demolishedfor the High Speed Rail. We are currently
workingwith realtors to finda new location.
Line 1011 Rent/Lease Equipment $3,300
The annual cost to lease a copier.
Line 1012 Utilities $9,000
The annual cost of gas and electric
Line 1013 Building Maintenance $3,300
The annual costofjanitorialservicesandminorbuilding
repairs.
Line 1015 Rent/Lease Vehicles $14,850
The annual cost to lease 2 cars and one van,this line
includes license and registration fees.
FACILITIES/EQUIPMENT TOTAL $54,450
OPERATING EXPENSES
Line 1060 Telephone $9,507
The annual cost of telephone services, land lines, long
distance,cell phones and data connectivity
Line 1062 Postage $150
Line 1066 Office Supplies &Equipment $7,964
This includes all supplies used bystaffinthe course of
providing service to consumers
Line 1069 Program Supplies -Therapeutic $1,000
Supplies used consumers such as workbooks,journals and
art supplies
Line 1072 Staff Mileage/vehicle maintenance $5,000
This includes vehicle maintenance costs,fuel costs and
Staffreimbursementfor usinga personal vehicle paid at
The IRS rate of 0.575 per mile.
Line 1076 Other -Program Supplies -Outreach $4,000
Supplies provided to homeless consumers by the Outreach
Engagement Linkage Team
Line 1077 Other- Staff Recruitment/Intern Background Checks $1,000
Thorough background checks are required,this amount
will fund 20-25 checks
OPERATING EXPENSES TOTAL $28,621
FINANCIAL SERVICES
Line 1082 Liability Insurance $3,348
Includesgeneral liabilityand auto insurance
Line 1083 Administrative Overhead (Corporate Indirect)$48,182
10%o onallother expenses,provides HR,Payroll,Fiscal
Management,Accounts Payable and other administrative
29
Exhibit B
Page 30 of 35
functions.
Line 1085 Professional Liability $3,605
Includes the annual cost of Professional liability insurance
FINANCIAL SERVICES TOTAL $55,135
SPECIAL EXPENSES
Line 1090 Network &Data Management $16,000
Information Services provides the following:
Managed Internet Service Provider
SPAM, virus, content filtering of e-mail & web services.
HIPAA compliant configuration of firewall &intrusion
detectionsystems. Qualityof service controls.
Network & Desktop Management
Installation,maintenance &administration of servers, routers,
switches,wiring/cables &other related equipment.Installation,
maintenance &repairof desktop PCs,laptops,printers &other
related equipment.Online,onsite,phone-based &emergency
support-24/7 support
Project Management
For both application &technology;management of the planning,
design,development, implementation,maintenance &support
phases ofa project.Post implementation quality assurance
Technology Procurement
Purchase equipment,software &other services from approved
&authorized vendors
Telecommunications Management
Installation/maintenance/management of international,national,
state,metro,campus &local area networks.High definition
video systems for both IP,Traditional &ISDN networks
Strategic Technology Planning
Budget projections,technology assessment &risk management
System Documentation
Network diagrams,policies,procedures,floor plans,manuals &
desktop configurations
Application/Data Hosting
Access to applications such as Office Professional,Adobe Reader,
WinZip.Data files and documents stored in secured data center,
daily/weekly backups.Encryption (256 bit)of email for sensitive
information.Access to data/documents 24/7.
Line 1092 Medication Supports $4,000
This includes the purchase of medications for consumers with
no other ability to pay.Consumers are enrolled in Patient
AssistanceProgramuntil they obtain Medi-Cal
Line 1093 Other -One time Emergency Housing $10,000
30
Exhibit B
Page 31 of 35
SPECIALEXPENSESTOTAL $30,000
FIXED ASSETS
Line 1190 Computers &Software $2,000
Replacement costfor anticipated equipment failure,many
Computer systems for this program are5or more years old
the costs for HMIS enrollment and user licenses are included
here
FIXED ASSETS TOTAL $2,000
NON MEDI-CAL CLIENT SUPPORT EXPENSES
Line 2000 Client Housing Support Expenditures $48,000
Cost of non-emergency housing for consumers
Line 2002.1 Clothing,Food &Hygiene $2,500
Purchase of food, clothing and hygiene items for consumers
Line 2002.2 Client Transportation &Support $11,000
Monthly bus passes and tokens for consumers
Line 2002.3 Education Support $500
Assist with education expenses such as books and
registration
Line 2002.4 Employment Support $500
Costof employment assistance suchas DMV records,ID
Cards or birth certificates
NON MEDI-CAL CLIENT SUPPORT EXPENSES TOTAL $62,500
TOTAL PROGRAM EXPENSES $530,000
PROGRAM REVENUE
Line 3000-3700 Medi-Cal Revenue Total $85,727
Based on a report of the last 5 years of actual services provided and adjusted
for changes in staff,clinical supervision and program goals.30 expected clients.
Line4000 Other-PATH $306,519
Based on last year's allocation
Line 4100 Other -Client Rent &Transportation Reimbursements $12,000
Based on current program collection practices
Line 5000 MHSA CSS Funds $125,756
TOTAL PROGRAM REVENUE $530,000
31
Exhibit B
Page 32 of 35
Projects for Assistance Transition from Homelessness (PATH)
Kings View Corporation
Fiscal Year 2019 -2020
PROGRAM EXPENSES
PERSONNEL SALARIES Annual Amount
Line 0001 Program Direction $1,906
0.02FTE Provides programandclinical direction,maintains
collaborativerelationshipswith other entities and agencies.
Line 0002 Clinical Supervisor:$58,318
0.80FTE provides supervision of all staff including interns.
Line 0003 Case managers $81,333
1.75 FTE Provides case management services
Line 0004 Outreach Engagement Linkage:$39,042
1.40 FTE Provides Outreach and engagement services, provides
linkage to needed services
Line 0005 Psychiatric Services $27,040
0.21 FTE Provides Medication services for consumers
Line 0006 Administrative Specialist $40,528
1.0 FTEprovides reception,medical recordsandother
neededsupport tasks for the programand consumers
SALARY TOTAL $248,167
PAYROLL TAXES :
Line 0031 FICA/MEDICARE -Employer share $18,985
Line 0032 SUI $3,671
Line 0033 Workers Compensation $4,895
PAYROLL TAX TOTAL $27,551
EMPLOYEE BENEFITS
Line 0041 Retirement -Employer share of 401 (K)$3,128
Line 0042 Medical,Dental,Vision,Life -Employer share $19,448
Calculatedon actual plans chosen by current employees
assumescontinuedemploymentof existing staff
Employee Benefits equal 9.3%of Salary Total (Lines 0001 through 0006)
EMPLOYEE BENEFITS TOTAL:$22,576
SALARY &BENEFITS GRAND TOTAL $298,294
FACILITIES/EQUIPMENT EXPENSES
Line 1010 Rent/Lease Building $24,000
32
Exhibit B
Page 33 of 35
This amount is calculated at 2,500 square feet at 0.80 per
Sq.foot.The current location of the PATH program will
be demolished forthe HighSpeedRail. Weare currently
workingwithrealtorsto finda new location.
Line 1011 Rent/Lease Equipment $3,300
The annual cost to lease a copier.
Line 1012 Utilities $9,000
The annual cost of gas and electric
Line 1013 Building Maintenance $3,300
The annual costofjanitorial services andminorbuilding
repairs.
Line 1015 Rent/LeaseVehicles $14,850
The annual cost to lease 2 cars and one van,this line
includes license and registration fees.
FACILITIES/EQUIPMENT TOTAL $54,450
OPERATING EXPENSES
Line 1060 Telephone $9,507
The annual cost of telephone services,land lines, long
distance,cell phones and data connectivity
Line 1062 Postage $150
Line 1066 Office Supplies &Equipment $7,964
This includes all supplies usedbystaffinthe course of
providing service to consumers
Line 1069 Program Supplies -Therapeutic $1-000
Supplies used consumers such as workbooks,journals and
art supplies
Line 1072 Staff Mileage/vehicle maintenance $5,000
This includes vehicle maintenance costs,fuel costs and
Staff reimbursement for using a personal vehicle paid at
The IRS rate of 0.575 per mile.
Line 1076 Other -Program Supplies -Outreach $4,000
Supplies provided to homeless consumers by the Outreach
Engagement Linkage Team
Line 1077 Other -Staff Recruitment/Intern Background Checks
Thorough background checks are required,this amount
will fund 20-25 checks
000
OPERATINGEXPENSESTOTAL $28,621
FINANCIAL SERVICES
Line 1082 Liability Insurance $3,348
Includes generalliabilityand auto insurance
Line 1083 Administrative Overhead (Corporate Indirect)$48,182
10%>onallother expenses,provides HR,Payroll,Fiscal
Management,Accounts Payable and other administrative
Exhibit B
Page 34 of 35
functions.
Line 1085 Professional Liability $3,605
Includes the annual cost of Professional liability insurance
FINANCIAL SERVICES TOTAL $55,135
SPECIAL EXPENSES
Line 1090 Network & Data Management $16,000
Information Services provides the following:
Managed Internet Service Provider
SPAM, virus,content filtering of e-mail & web services.
HIPAA compliant configuration of firewall & intrusion
detection systems. Quality of service controls.
Network & Desktop Management
Installation,maintenance &administration of servers,routers,
switches,wiring/cables & otherrelated equipment.Installation,
maintenance & repairof desktop PCs,laptops,printers & other
relatedequipment.Online, onsite, phone-based& emergency
support-24/7 support
Project Management
Forboth application &technology;management ofthe planning,
design,development,implementation,maintenance & support
phases of a project.Post implementation quality assurance
Technology Procurement
Purchase equipment,software &other services from approved
&authorized vendors
Telecommunications Management
Installation/maintenance/management of international,national,
state,metro,campus& localarea networks.High definition
video systems for both IP,Traditional &ISDN networks
Strategic Technology Planning
Budget projections,technology assessment & risk management
System Documentation
Network diagrams,policies,procedures,floor plans,manuals &
desktop configurations
Application/Data Hosting
Access to applications such as Office Professional,Adobe Reader,
WinZip.Data files and documents stored in secured data center,
daily/weekly backups.Encryption (256 bit)of email for sensitive
information.Access to data/documents 24/7.
Line 1092 Medication Supports $4,000
This includes the purchase of medications for consumers with
noother ability to pay.Consumers are enrolled in Patient
Assistance Program untiltheyobtain Medi-Cal
Line 1093 Other -One time Emergency Housing $10,000
34
Exhibit B
Page 35 of 35
SPECIALEXPENSESTOTAL $30,000
FIXED ASSETS
Line 1190 Computers &Software -the costs for HMIS enrollment $1,000
and user licenses are included
FIXEDASSETS TOTAL $1,000
NON MEDI-CAL CLIENT SUPPORT EXPENSES
Line 2000 Client Housing Support Expenditures $48,000
Cost of non-emergency housing for consumers
Line 2002.1 Clothing,Food &Hygiene $2,500
Purchase of food, clothing and hygiene items for consumers
Line 2002.2 Client Transportation &Support $11 -000
Monthlybus passes and tokens for consumers
Line 2002.3 Education Support $500
Assist with education expenses such as books and
registration
Line 2002.4 Employment Support $500
Costof employment assistance suchas DMV records,ID
Cards or birth certificates
NON MEDI-CALCLIENT SUPPORT EXPENSES TOTAL $62,500
TOTAL PROGRAM EXPENSES $530,000
PROGRAM REVENUE
Line 3000-3700 Medi-Cal Revenue Total $85,727
Based on a report of the last 5 years of actual services provided and adjusted
for changes in staff,clinical supervision and program goals.30 expected clients.
Line 4000 Other -PATH $306,519
Based on last year's allocation
Line 4100 Other -Client Rent &Transportation Reimbursements $12,000
Based on current program collection practices
Line 5000 MHSA CSS Funds $125,756
TOTAL PROGRAM REVENUE $530,000
35
Exhibit C
Page 1 of 3
Documentation Standards For Client Records
The documentation standards are described below under key topics related to client care. All
standards must be addressed in the client record;however,there is no requirement that the record
have a specific document or section addressing these topics.
A.Assessments
1.fhe following areas will be included as appropriate as a part of a comprehensive client record.
• Relevant physical health conditions reported by the client will be prominently identified
and updated as appropriate.
•Presenting problems and relevant conditions affecting the client's physical health and
mental health status will be documented,for example:living situation,daily activities,and
social support.
•Documentation will describe client's strengths in achieving client plan goals.
• Special status situations that present a risk to clients or others will be prominently
documented and updated as appropriate.
•Documentations will include medications that have been described by mental health plan
physicians, dosage of each medication, dates of initial prescriptions and refills,and
documentations of informed consent for medications.
• Client self report of allergies and adverse reactions to medications, or lack of known
allergies/sensitivities will be clearly documented.
• A mental health history will be documented, including: previous treatment dates, providers,
therapeutic interventions and responses, sources of clinical data, relevant family information
and relevant results of relevant lab tests and consultations reports.
• For children and adolescents, pre-natal and perinatal events and complete developmental
history will be documented.
•Documentations will include past and present use of tobacco, alcohol, and caffeine, as well
as illicit,prescribed and over-the-counter drugs.
• A relevant mental status examination will be documented.
• A five axis diagnosis from the most current DSM, or a diagnosis from the most current
ICD,will be documented,consistent with the presenting problems,history mental status
evaluation and/or other assessment data.
2.Timeliness/Frequency Standard for Assessment
• An assessment will be completed at intake and updated as needed to document changes in
the client's condition.
• Client conditions will be assessed at least annually and. in most cases,at more frequent
intervals.
0374 ddbh
Exhibit C
Page 2 of 3
B.Client Plans
1.Client plans will:
• have specific observable and/or specific quantifiable goals
•identify the proposed type(s)of intervention
•have a proposed duration of intervention(s)
• be signed (or electronic equivalent)by:
* the person providing the service(s).or
* a person representing a team or program providing services,or
* a person representing the MHP providing services
*when the client plan is used to establish that the services are provided under the
direction of an approved category of staff, and if the below staff are not the approved
category.
* a physician
* a licensed/"waivered"psychologist
* a licensed/"associate"social worker
* a licensed/registered/marriage and family therapist or
* a registered nurse
•In addition.
*client plans will be consistent with the diagnosis,and the focus of intervention will
be consistent with the client plan goals,and there will be documentation of the
client's participation in and agreement with the plan.Examples of the documentation
include,but are not limited to,reference to the client's participation and agreement in
the body of the plan,client signature on the plan, or a description of the client's
participation and agreement in progress notes.
*client signature on the plan will be used as the means by which the
CONTRACTOR(S)documents the participation of the client
*when the client's signature is required on the client plan and the client refuses or is
unavailable for signature,the client plan will include a written explanation of the
refusal or unavailability.
• The CONTRACTOR(S)will give a copy of the client plan to the client on request.
2.Timeliness/Frequency of Client Plan:
• Will be updated at least annually
•The CONTRACTOR(S)will establish standards for timeliness and frequency for the
individual elements of the client plan described in item 1.
C.Progress Notes
1.Items that must be contained in the client record related to the client's progress in
treatment include:
• The client record will provide timely documentation of relevant aspects of client care
0374 ddbh
Exhibit C
Page 3 of 3
•Mental health staff/practitioners will use client records to document client encounters,
including relevant clinical decisions and interventions
• All entries in the client record will include the signature of the person providing the
service (or electronic equivalent);the person's professional degree,licensure or job title;
and the relevant identification number,if applicable
• All entries will include the date services were provided
• The record will be legible
• The client record will document follow-up care,or as appropriate,a discharge summary
2.Timeliness/Frequency of Progress Notes:
Progress notes shall be documented at the frequency by type of service indicated below:
A.Every Service Contact
•Mental Health Services
•Medication Support Services
•Crisis Intervention
0374 d dbh
PROGRAM OBJECTIVES
Exhibit D
Page 1 of 2
The following items listed below represent program goals to be tracked and achieved
by vendor during the contract term. The programs success will be based on the
number of goals itcan achieve,resulting from performance outcomes.The selected
vendor will utilize a computerized tracking system with which outcome measures and
other relevant client data,such as demographics,will be maintained and reports
provided to the County on a quarterly and as requested basis. Program objectives are
as follows:
1.Reduce frequency of homelessness for each client.Vendor will provide most
recent 12 month history for each client which will be used as baseline data.
Reports and data will be submitted on a monthly basis.
2.Reduce frequency of hospitalizations for each client.DBH will provide most recent
12 month history as it relates to Managed Care for each client which will be used
as baseline data.Reports and data will be submitted on a monthly basis.
3.Reduce frequency of access to crisis services as provided by the Intensive
Services Division for each client.DBH will provide most recent 12 month history
for each client which will be used as baseline data.Reports and data will be
submitted by Vendor on a monthly basis.
4.Reduce frequency of incarceration for each client. Vendor will provide, through
client self-reporting, or notification by the Jail Psychiatric team,most recent 12
month historyfor each client which will be used as baseline data. Reports and
data will be submitted on a monthly basis.
5. Vendor will make an objective assessment of each client and develop a Plan of
Care and provide a summary report inwritten form monthlyto designated Division
Manager.
6. Vendor will develop a satisfaction survey,approved by DBH designated Division
Manager, that will comply with mandated State performance outcomes and quality
improvement reports/outcomes (www.dmh.ca.gov/POQI/).At a minimum,fifty
percent (50%) of those surveyed,will report their satisfaction with program
services through MHSIP Client Oriented Report Card overallscore, semi-annually.
7. Direct services productivity rate is expected to be at a minimum of eighty percent
(80%)and reported in writing at regularly scheduled meetings with the
Department.
8. Clients in independent supportive housing and lower levels of care will develop a
planforassisting with their own housing cost. Clients will assume responsibility
for housing cost, when ready and as appropriate. Vendor will work with clientsfor
payments.Within sixmonths of enrollment,ninety percent (90%)of clients without
SSI will have made SSI applications,establish benefits or have developed an
alternative planfor eventually assuming their own housing costs. Said report will
be submitted on a semi-annual basis.
Exhibit D
Page 2 of 2
9.Vendor will identify services provided to each client on a monthly basis,including
recreational and social activities and linkages provided to clients such as the
County's E&TA,General Relief Program.This information will be provided to the
designated Division Manager in a monthly report.
10.The Vendor's PATH program will establish collaborative relationships with
agencies and individuals who have frequent contact with homeless adults target
population within the first three months of operation.Collaborative relationships
will include local law enforcement agencies,Veterans Administration,Marjoree
Mason Center,Fresno County Human Services Departments,churches,acute
psychiatric facilities,schools,community centers,etc.Letters of introduction,
including description of services and how to contact the PATH program shall be
distributed to potential partners.Initial referrals to this program will be facilitated
by the Department of Behavioral Health.
€=xh'i bi-\-£Expiration Date:01/31/2016
PATH Annual Report-Budget Information Reporting Period
1.Federal PATH funds received this year:$
2. Matching funds from State,local, or other sources used in support of PATH
received this year:$
3.Total funds dedicated this year,agency wide,to persons who have serious
mental illness and are homeless or at risk of homelessness (include PATH,
matching,and non-PATH funds): $
4.Number of staff supported by PATH and matching funds:
5. Full-time equivalent (FTE)of staff supported by PATH and matching funds:
6.Type of organization in which your PATH program operates:
•Community mental health center
•Consumer-run mental health agency
•Other mental health agency
•Social service agency
• Health Care for the Homeless/other health agency
O Substance use treatment agency
•Shelter or other temporary housing resource
O Other housing agency
•Other (please specify)
„•*::".,
:!..;^.v><><-jis-.'...--•.••Page 1 of 6
PATH Annual Report-Data Information niirtrtiiililite:.
1.Total number of persons who received any PATH-funded service during the
current reporting period:
2.Total number of persons who were Outreached/Contacted during the
current reporting period:
3.Total number of persons who were Outreached/Contacted that became
Enrolled during the current reporting period:
4.Total number of persons who could not be Enrolled because they were
ineligible:
5.Total number of persons currently Enrolled in PATH:
6.Total number of contacts made this reporting period:
7.Total number of services provided during this reporting time period:
8.Total number of referrals given during this reporting time period:
9.Housing Status
Total Number of
Persons who were
Outreached/Contacted
During the Current
Reporting Period with
this Status
Literally homeless
Imminently losing their housing
Unstably housed and at-risk oflosing their
housing
Stably housed
Don't know
Refused
Total
.;•;:•.".f...:;.*'•''.WvJ*3*a*Wi!Bs>;(.;Page 2 of 6
PATH Annual Report-Data Information \Reporting Period
10.Services Provided
Total Number
of Times this
Service was
Provided
Number of
Persons
Receiving this
Service
Outreach
Screening/Assessment
Habilitation/Rehabilitation
Community Mental Health
Substance Use Treatment
Case Management
Residential Supportive Services
Housing Minor Renovation
Housing Moving Assistance
Housing Technical Assistance
Security Deposits
One-time Rent for Eviction Prevention
Other
Total
11.Referrals Provided
Total Number
of Times this
Type of
Referral was
Made
Number of
Persons
Receiving this
Type of Referral
(Assisted)
Number of
Persons that
Attained this
Type of Referral
Community Mental Health
Substance Use Treatment
Primary Health Services
Job Training
Educational Services
Relevant Housing Services
Housing Placement Assistance
Income Assistance
Employment Assistance
Medical Assistance
Total
Si.^SJfr •£.•$£>'•Page 3 of 6
:^&ly^-:
PATH Annual Report-Data Information
12.Demographics
Persons
Contacted
Persons
Enrolled
DC
UJ
Q
Z
UJ
Female
Male
Transgendered Male to Female
Transgendered Female to Male
Other
Don't Know
Refused
Total
UJ
<
17 and Under
18-23
24-30
31-50
51-61
62 and over
Don't Know
Refused
Total
UJ
U
<
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific
Islander
White
Two or More Races
Don't Know
Refused
Total
>-
i-
u
z
X
H
UJ
Non-Hispanic/Non-Latino
Hispanic/Latino
Don't Know
Refused
Total
Reporting Period ..
Page 4 of 6
PATH Annual Report-Data Information
VETERANSTATUSVeteranNon-VeteranUnknownTotale?Co-OccurringSubstanceUseDisorder—ccDCujNoCo-OccurringSubstanceUseCO-OCCUDISORDDisorderUnknownTotalEmergencyshelter,includinghotelormotelpaidforwithemergencysheltervoucher(ShortTermShelter)Transitionalhousingforhomelesspersons(includinghomelessyouth)Permanenthousingforformerlyhomelesspersons(suchasSHP,S+C,orSROModRehab)PsychiatrichospitalorotherHZUl5psychiatricfacilitySubstanceusetreatmentfacilityor-j-jODC2detoxcenterHospital(non-psychiatric)orphysicalUJO1-rehabilitationfacilityJail,prisonorjuveniledetentionHXS2facilityLongtermcarefacility(e.g.boardingzDCoornursinghome)Stayingorlivinginafamilymember'sDCQ.UlUroom,apartmentorhouseStayingorlivinginafriend'sroom,zUJoapartmentorhouseHotelormotelpaidforwithoutUJDCemergencysheltervoucherFostercarehomeorfostercaregrouphomePlacenotmeantforhabitation(e.g.,avehicle,anabandonedbuilding,bus/train/subwaystation/airportoranywhereoutside);inclusiveof"non-housingservicesite(outreachprogramsonly)"Other"•JS-8v^SSs%';;:Kh^:*•*.*
Reporting Period
Page 5 of 6
PATH Annual Report-Data Information
Safe Haven
Rental by client,with VASH housing
subsidy
Rental by client,with other (non-
VASH)ongoing housing subsidy
Owned by client,with ongoing
housing subsidy
Rental by client,no ongoing housing
subsidy
Owned by client,no ongoing housing
subsidy
Don't Know
Refused
Total
LENGTHOFTIMELIVINGOUTDOORSOR INSHORTTERMSHELTER
Less than 2 days
2 -30 days
31-90 days
91 days to lyear
Over 1 year
Unknown
Total
Reporting Period
Public Burden Statement:An agency may not conduct or sponsor,and a person isnot required to respond to.a
collection of information unless it displays a currently valid OMB control number.The OMB control number for
this project is 0930-0205.Public reporting burden for this collection of information is estimated to average 27 hours
per respondent,per year,including the time for reviewing instructions,searching existing data sources,gathering and
maintaining the data needed,and completing and reviewing the collection of information.Send comments regarding
this burden estimate or any other aspect of this collection of information,including suggestions for reducing this
burden,to SAMHSA Reports Clearance Officer,1 Choke Cherry Road,Room 2-1057.Rockville,Maryland,20857.
S5SSS?":•...*•••.:K-gi.V.^:•._;•:"I :;;|S::.".?••*fy-;/••%;:.•;••;*..*fe/y i^jj^&jjjjpj Page 6 of 6
Exhibit F
Page 1 of 2
STATE MENTAL HEALTH REQUIREMENTS
CONTROL REQUIREMENTS
The COUNTY and its subcontractors shall provide services in accordance with all
applicable Federaland State statutesand regulations.
PROFESSIONAL LICENSURE
All (professional level)personsemployedbythe COUNTY Mental Health
Program (directly or through contract)providing Short-Doyle/Medi-Cal services
havemet applicable professional licensure requirements pursuant to Business and
Professions and Welfare and Institutions Codes.
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 confidentialityof information
requirements at 42.Codeof 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,Part2.6,Chapters 1-7 ofthe
California Civil Code.
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 planset
forth in the Agreement. No person shall, because of ethnic group
identification,age, gender, color, disability, medicalcondition, national
origin,race,ancestry,marital status,religion,religious creed,political
beliefor sexual preferencebe excluded from participation,be denied
benefitsof, 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
discriminationagainst any person on the groundsof race, color, national
origin,sex,religion,age,disability status,or sexual preference in
employment practices.Suchpractices include retirement,recruitment
advertising,hiring,layoff,termination,upgrading,demotion,transfer,
Exhibit F
Page 2 of 2
rates of pay or other forms of compensation,use of facilities, and other
terms and conditions of employment.
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
Medi-Cal Organizational Provider Standards
Exhibit G
Page 1 of 2
1.The organizational provider possesses the necessary license to operate,if applicable,and any
required certification.
2.The space owned,leased or operated bythe provider and used for services orstaff meets
local fire codes.
3.The physical plant ofany site owned,leased,or operated bythe provider and used for
services or staff is clean,sanitary and in good repair.
4. The organizational provider establishes and implements maintenance policies for anysite
owned,leased,or operated bythe provider andusedfor services or staffto ensure the safety
and well being of beneficiaries and staff.
5.The organizational provider hasa current administrative manual which includes:personnel
policies and procedures,general operating procedures,service delivery policies,and
procedures for reporting unusual occurrences relating to health and safety issues.
6.The organizational provider maintains client records ina manner that meets applicable state
and federal standards.
7.The organization provider has staffing adequate to allow the County to claim federal
financial participation for the services the Provider delivers to beneficiaries,as described in
Division 1,Chapter 11,Subchapter 4 of Title9, CCR,when applicable.
8.The organizational provider has written procedures for referring individuals toa psychiatrist
when necessary,or to a physician, ifa psychiatrist is not available.
9.The organizational provider has as head of service a licensed mental health professional of
other appropriate individual as described in Title 9,CCR,Sections 622 through 630.
10.For organizational providers that provide or store medications,the provider stores and
dispenses medications in compliance with all pertinent state and federal standards.In
particular:
A.All drugs obtained by prescription are labeled in compliance with federal and state laws.
Prescription labels are altered onlyby persons legally authorized todo so.
B.Drugs intended for external use only or food stuffs are stored separately from drugs for
internal use.
C.All drugs are stored at proper temperatures,room temperature drugs at 59-86 degrees F
and refrigerated drugs at 36-46 degrees F.
Exhibit G
Page 2 of 2
D.Drugs are stored ina locked area with access limited to those medical personnel
authorizedto prescribe,dispenseor administer medication.
E.Drugs arenot retained afterthe expiration date.IM multi-dose vials are dated and
initialed when opened.
F.A drug log is maintained to ensure the provider disposes of expired,contaminated,
deterioratedand abandoneddrugs ina mannerconsistent with state and federal laws.
G.Policies and procedures are inplacefor dispensing,administering and storing
medications.
11.For organizational providers that provide day treatment intensive or day rehabilitation,the
provider must have a written description oftheday treatment intensive and/or day treatment
rehabilitation program that complieswith State Department of Mental Health's day
treatment requirements.The COUNTYshall review the provider's written program
description for compliance withthe State Department of Mental Health's day treatment
requirements.
12.The COUNTY mayacceptthehostcounty's site certification and reserves the right to
conduct an on-site certification review at least every three years. The COUNTY may also
conduct additional certification reviews when:
• The provider makes major staffing changes.
• The provider makes organizational and/or corporate structure changes (example:
conversion from a non-profit status).
•The provider adds day treatment or medication support services when medications
shall be administered or dispensed from the provider site.
• Thereare significant changesinthe physical plantof the providersite(some
physical plant changes could requirea new fireclearance).
• There is change of ownership or location.
• There are complaints against the provider.
• There are unusual events,accidents, or injuries requiring medical treatment for
clients,staff or members of the community.
Exhibit H
Page 1 of 2
Fresno County Mental Health Plan
Grievances
Fresno County Mental Health Plan (MHP)provides beneficiaries with a grievance
and appeal process and an expedited appeal process to resolve grievances and
disputes at the earliest and the lowest possible level.
Title 9 of the California Code of Regulations requires that the MHP and its fee-
for-service providers give verbal and written information to Medi-Cal beneficiaries
regarding the following:
• How to access specialty mental health services
• How to file a grievance about services
•How to file for a State Fair Hearing
The MHP has developed a Consumer Guide,a beneficiary rights poster,a
grievance form,an appeal form,and Request for Change of Provider Form.All
of these beneficiary materials must be posted in prominent locations where Medi-
Cal beneficiaries receive outpatient specialty mental health services,including
the waiting rooms of providers'offices of service.
Please note that all fee-for-service providers and contract agencies are required
to givetheirclients copies of all current beneficiary information annuallyat the
time their treatment plans are updated and at intake.
Beneficiaries have the right to use the grievance and/or appeal process without
any penalty,change in mental health services, or any form of retaliation.All
Medi-Cal beneficiaries can file an appeal or state hearing.
Grievances and appeals forms and self addressed envelopes must be available
for beneficiaries to pick up at allprovider sites without having to make a verbal or
written request.Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O.Box 45003
Fresno,CA 93718-9886
(800)654-3937 (for more information)
(559)488-3055 (TTY)
Provider Problem Resolution and Appeals Process
The MHP uses a simple,informal procedure in identifying and resolving provider
concerns and problems regarding payment authorization issues,other
complaints and concerns.
Exhibit H
Page 2 of 2
Informalprovider problem resolution process -the provider may first speak to a
Provider Relations Specialist (PRS)regarding his or her complaint or concern.
The PRS will attempt to settle the complaint or concern with the provider.If the
attempt is unsuccessful and the provider chooses to forego the informal
grievanceprocess, the provider will be advised to file a written complaint to the
MHP address (listed above).
Formalprovider appeal process -the provider has the right to access the
provider appeal process at any time before,during,or afterthe provider problem
resolution process has begun, when the complaint concerns a denied or modified
request for MHP payment authorization, or the process or payment of a
provider's claim to the MHP.
Payment authorization issues -the provider may appeal a denied or modified
request for payment authorization or a dispute with the MHP regarding the
processing or payment ofa provider's claim to the MHP.The written appeal
must be submitted to the MHP within 90 calendar days of the date of the receipt
of the non-approval of payment.
The MHPshall have 60 calendar days from its receipt of the appeal to informthe
provider in writing ofthe decision,including a statement ofthe reasons forthe
decision that addresses each issue raised by the provider,and any action
required by the provider to implement the decision.
If the appeal concerns a denial or modification of payment authorization request,
the MHP utilizesa Managed Care staff who was not involved inthe initial denial
or modification decision to determine the appeal decision.
If the Managed Care staff reverses the appealed decision, the provider will be
asked to submit a revised request for payment within 30 calendar days of receipt
of the decision
Other complaints - if there are other issues or complaints,which are not related
to payment authorization issues,providers are encouraged to send a letterof
complaint to the MHP.The provider will receive a written response from the
MHP within 60 calendar days of receipt ofthe complaint. The decision rendered
buy the MHP is final.
Exhibit 1
Page 1 of 2
PROTOCOL FOR COMPLETION OF INCIDENT REPORT
• The Incident Report must be completed for all incidents involving clients. The staff
person who becomes aware ofthe incident completes this form,and the supervisor co-
signs it.
•When more than one client is involved in an incident,a separate form must be
completed for each client.
Where should the forms be sent -within 24 hours from the time of the incident
•Incident Report should be sent to:
• DBH Division Manager
•Copy to DBH Housing Coordinator or designee
0263kdbh
Exhibit I
Page 2 of 2
INCIDENT REPORT WORKSHEET
When did this happen?(date/time)Where didthis happen?
Name/DMH #
1.Background information of the incident:
2.Method of investigation:(chart review,face-to-face interview, etc.;
Who was affected?(If other than consumer)
Listkey people involved,(witnesses,visitors, physicians,employees)
3.Preliminary findings:How did it happen?Sequenceofevents. Be specific.If attachments are needed write comments
on an 8 1/2 sheet of paper and attach to worksheet.
Outcome severity:Nonexistent inconsequential consequential death not applicable unknown_
4.Response:a) corrective action, b) Plan of Action,c) other
Completed by (print name)
Completed by (signature)Date completed
Reviewed by Supervisor (print name).
Supervisor Signature Date
0263kdbh
Exhibit J
Page 1 of 3
Fresno County Mental Health Compliance Program
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable laws,
regulations,rules and guidelines that apply to the provision and paymentof mental
health services.Mental health contractors and the manner in which they conduct
themselves are a vital part of this commitment.
Fresno County has established this Contractor Code of Conduct and Ethics with
which contractor and its employees and subcontractors shall comply.Contractor
shall require its employees and subcontractors to attend a compliance training that
will be provided by Fresno County. Aftercompletion of this training,each contractor,
contractor's employee and subcontractor must sign the Contractor Acknowledgment
and Agreement form and return this formto the Compliance Officeror designee.
Contractor and its employees and subcontractors shall:
1.Comply with all applicable laws, regulations, rules or guidelines when providing
and billingfor mental health services.
2. Conduct themselves honestly,fairly,courteously and with a high degree of
integrity in their professional dealings related to their contract with the County
and avoid any conduct that could reasonably be expected to reflect adversely
upon the integrity of the County.
3. Treat County employees, consumers and other mental health contractors fairly
and with respect.
4.NOT engage in any activity in violation of the County's Compliance Program, nor
engage in any other conduct which violates any applicable law,regulation,rule
or guideline.
5. Take precautions to ensure that claims are prepared and submitted accurately,
timely and are consistent with all applicable laws,regulations,rules or
guidelines.
6.Ensure that no false,fraudulent,inaccurate or fictitious claims for payment or
reimbursement of any kind are submitted.
7.Bill only for eligible services actually rendered and fully documented.Use billing
codes that accurately describe the services provided.
8.Act promptly to investigate and correct problems if errors in claims or billings are
discovered.
Exhibit J
Page 2 of 3
9.Promptly report to the Compliance Officer any suspected violation(s)ofthis Code
of Conductand Ethics byCountyemployees or other mental health contractors,
or report any activity that they believe may violate the standards of the
Compliance Program,or any other applicable law,regulation,rule or guideline.
Fresno County prohibits retaliation against any person making a report.Any
person engaging in any form of retaliation will be subject to disciplinary or other
appropriateaction bythe County.Contractormay report anonymously.
10.Consult with the Compliance Officer if you have any questions or are uncertain of
any Compliance Program standard or any other applicable law,regulation,rule
or guideline.
11.Immediately notify the Compliance Officer if they become or may become an
Ineligible Person and therefore excluded from participation in the Federal health
care programs.
Rev Effec:7/14/05
Exhibit J
Page 3 of 3
Fresno County
Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received, read and understand the Contractor Code of
Conduct and Ethics.I hereby acknowledge that I have received training and information
on the Fresno County Mental Health Compliance Program and the Integrity Agreement
and understand the contents thereof.I further agree to abide by the Contractor Code of
Conduct and Ethics,and all Compliance Program and Integrity Agreement requirements
as they applyto my responsibilities as a mental health contractorfor Fresno County.
I understand and accept my responsibilities under this agreement.I further understand
that any violation of the Contractor Code of Conduct and Ethics or the Compliance
Program is a violation of County policy and may also be a violation of applicable laws,
regulations,rules or guidelines.I further understand that violation ofthe Contractor Code
of Conduct and Ethics or the Compliance Program may result in termination of my
agreement with Fresno County.I further understand that Fresno County will report me to
the appropriate Federal or State agency.
Agency Name /^.,
(If applicable):,/|/M?.f 1/'/'<=•^J
Provider or
Employee Name
(Printed):/e o/o ^/no i/fr
Discipline (Indicate below ifapplicable):
Licensed : []Psychiatrist []Psychologist [] LCSW[]LMFT
UnLicensed:[]Psychologist [ ] ASW []IMF
Other fliXiD ^yylqtvCt,
Job Title
(If different from Discipline):(\f-f9)
Signature:
Date:S~/ /?/2-^Q"
New Contr Ack Rev:2/06
Exhibit K
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 ofa 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 ofwhyitcannot providethe certification set out below.The
certification or explanation will be considered in connection with the department or
agency's determination whetherto enter into this transaction.However,failure ofthe
prospective primary participant to furnish a certification oran explanation shall disqualify
such person from participation inthis transaction.
3.The certification in this clause is a material representation of fact upon which reliance was
placed when the departmentor agency determined to enter into this transaction.If it is
later determined that the prospective primary participant knowingly rendered an erroneous
certification,inaddition to other remedies available to the Federal Government, the
department or agency mayterminatethistransaction for cause or default.
4. The prospective primary participant shall provide immediate written notice to the
department or agencyto which this proposal is submitted if at any time the prospective
primary participant learnsthat 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 ofthe 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 ofthose regulations.
6.Nothing contained in the foregoing shall be construed to require establishment ofa system
of records in order to render ingood faith the certification required bythis clause. The
knowledge and information ofa participant is not required toexceed that which is normally
possessed bya prudentperson in the ordinary course ofbusiness dealings.
CiMH Agreement
Exhibit K
Page 2 of 2
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;
(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:^^C^„/-j^n/--*-—Date:Sf/£~/Xo/S~
(Printed Name &Title)(Name oftAgency or Company)
CiMH Agreement
Exhibit L
Page 1 of 2
SELF-DEAUNG 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 meansa transaction to which the corporation isa party and in which one
or more of its directors has a materialfinancial interest"
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1)Enter board member's name, job title (ifapplicable),and date this disclosure isbeingmade.
(2) Enter the board member's company/agency name and address.
(3)Describe indetail the nature ofthe self-dealingtransaction that isbeing disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with whichthe 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 indetail whythe self-dealing transaction isappropriate basedon applicable
provisions of the Corporations Code.
(5)Form must be signed by the board member that is involved inthe self-dealing transaction
described in Sections (3)and (4).
(1J Company Board Member Information:
Name:Date:
Job Title:
(2)Company/Agency Name and Address:
(3)Disclosure (Please describe the nature ofthe self-dealing transaction you are a party to)
Exhibit L
Page 2 of 2
(4)Explain why this self-dealing transaction is consistent with the requirements ofCorporations Code 5233 (a)
(5)Authorized Signature
Signature:Date:
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
Exhibit M
Page 1 of 2
I.Identifying Information
Name of entity D/B/A
Address (number,street)City State ZIP code
CLIA number Taxpayer ID number (EIN)Telephone number
1 1
NAME ADDRESS
List the names,addresses,date of b rth,SSN,and EIN if applicable for any person(s)whether it be an individual or corporation withanownershiporcontrollinginterestinthedisclosingentityormanagedcareentity.If a person(s)with an ownership or controlling
interest of the disclosing entity is related to another person having ownership or controlling interest as a parent,spouse,sibling orchildIncludingwhethertheperson(s)with ownership or controlling interest of the disclosing entity is related to a person (parent,spouse,sibling or child)with ownership or has five (5)percent or more interest in any of its subcontractors please list under
Remarks section.
EIN/SSN DOB
B.List the names,addresses,and EIN if applicable for any subcontractor(s)in which the disclosing entity has five (5)percent or more
interest.
NAME ADDRESS EIN
C.List the names,addresses,and EIN of any other disclosing entity in which an owner of the disclosing entity has an ownership or
control interest.
NAME ADDRESS EIN
D List the names,addresses,date of birth,SSN of Any person(s)with an ownership or control interest in the provider,or agent or
managing employee of the provider;and has been convicted of a criminal offense related to that person's involvement in any
program under Medicare,Medicaid,or the title XX services program since the inception of those programs.
NAME ADDRESS EIN/SSN DOB
List any significant business transactions between the provider and any wholly owned supplier or between the provider-andI anysubcontractor,during the 5-year period ending on the date of the request.If additional space is needed,attach additional sheets of
paper and indicate the question being answered.
Name of Supplier:
Explain:
NAME
List each person including corporate officers and directors for corporations and all partners in partnerships with an ownership orcontrolinterest.in any subcontractor with whom the applicant or provider has had business transactions totaling more than
$25,000 during the 12-month period preceding the date ofthe request.
ADDRESS EIN/SSN DOB
Exhibit M
Page 2 of 2
its agreement or contract with the agency,as appropriate.
Name of authorized representative (typed)
Title
Date
Signature
Remarks