HomeMy WebLinkAboutAgreement A-17-303 with The Center.pdf
COUNTY OF FRESNO
Fresno, CA
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AGREEMENT
THIS AGREEMENT is made and entered into this _______ day of ________________, 2017,
by and between the COUNTY OF FRESNO, a Political Subdivision of the State of California,
hereinafter referred to as "COUNTY", and SIERRA HEALTH FOUNDATION: CENTER FOR
HEALTH PROGRAM MANAGEMENT, a California Nonprofit Organization, whose address is
1321 Garden Highway, Sacramento, California, 95833, hereinafter referred to as "CONTRACTOR".
W I T N E S S E T H:
WHEREAS, COUNTY, through its Department of Public Health, is in need of a qualified
agency to provide nutrition education in schools and afterschool programs; to provide a measurable
impact in target communities; and to provide integrated, layered, community-driven interventions
under the Department’s Nutrition Education and Obesity Prevention (NEOP) program; and
WHEREAS, CONTRACTOR, has the facilities, equipment and personnel skilled in the
provision of such services; and
WHEREAS, CONTRACTOR, is qualified and is willing to provide such services, pursuant to
the terms and conditions of this Agreement.
NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties
hereto agree as follows:
1. RESPONSIBILITIES
A. CONTRACTOR shall perform all services and fulfill all responsibilities as
identified in COUNTY’s Request for Proposal (RFP) No. 17-052 dated January 13, 2017, Addendum
No. One (1) to RFP No. 17-052 dated February 2, 2017, Addendum No. Two (2) to RFP No. 17-052
dated February 8, 2017 (collectively referred to herein as COUNTY’s Revised RFP), and
CONTRACTOR’s Response to COUNTY’s Revised RFP dated February 17, 2017, both incorporated
herein by reference and made part of this Agreement. In the event of any inconsistency among the
documents constituting this Agreement, the inconsistency shall be resolved by giving precedence in
the following order of priority: (1) to this Agreement, including Exhibits; (2) to COUNTY’s Revised
RFP; and (3) to the CONTRACTOR’s Response to RFP. A copy of COUNTY’s Revised RFP and
CONTRACTOR’s Response to RFP shall be retained and made available during the term of this
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Agreement by COUNTY’s General Services Department, Purchasing Division.
B. CONTRACTOR shall perform all services and fulfill all responsibilities
identified in Exhibit A, attached hereto and by this reference incorporated herein.
2. TERM
This Agreement shall become effective upon execution and shall terminate on the 30th
day of September, 2019. This Agreement may be extended for two (2) additional consecutive twelve
(12) month periods upon the same terms and conditions herein set forth upon written approval of both
parties no later than thirty (30) days prior to the first day of the next twelve (12) month extension
period.
3. TERMINATION
A. Non-Allocation of Funds - The terms of this Agreement, and the services to be
provided thereunder, are contingent on the approval of funds by the appropriating government agency.
Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
terminated at any time by giving CONTRACTOR thirty (30) days advance written notice.
B. Breach of Contract - COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of COUNTY there is:
1) An illegal or improper use of funds;
2) A failure to comply with any term of this Agreement;
3) A substantially incorrect or incomplete report submitted to COUNTY;
4) Improperly performed service.
In no event shall any payment by COUNTY constitute a waiver by COUNTY of any
breach of this Agreement or any default which may then exist on the part of CONTRACTOR. Neither
shall such payment impair or prejudice any remedy available to COUNTY with respect to the breach
or default. COUNTY shall have the right to demand of CONTRACTOR the repayment to COUNTY
of any funds disbursed to CONTRACTOR under this Agreement, which in the judgment of COUNTY
were not expended in accordance with the terms of this Agreement. CONTRACTOR shall promptly
refund any such funds upon demand or, at COUNTY’s option, such repayment shall be deducted from
future payments owing to CONTRACTOR under this Agreement.
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C. Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by COUNTY upon the giving of thirty (30) days advance written notice
of an intention to terminate to CONTRACTOR.
4. COMPENSATION
A. COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation at the rates as identified in Exhibit B, attached hereto and incorporated herein by this
reference. For the period of execution through and including September 30, 2017, in no event shall
actual services performed under this Agreement be in excess of Two Hundred Forty Thousand and
No/100 Dollars ($203,866.00). For the period of October 1, 2017 through and including September 30,
2018 and each subsequent 12 month period thereafter, in no event shall actual services performed
under this Agreement be in excess of Two Hundred Sixty Thousand and No/100 Dollars
($260,000.00). It is understood that all expenses incidental to CONTRACTOR's performance of actual
services under this Agreement shall be borne by CONTRACTOR.
B. Payments by COUNTY shall be in arrears, for services provided during the
preceding month, within forty-five (45) days after receipt and verification of CONTRACTOR's
invoices by COUNTY's Department of Public Health. If CONTRACTOR should fail to comply with
any provision of this Agreement, COUNTY shall be relieved of its obligation for further
compensation.
C. COUNTY shall not be obligated to make any payments under this Agreement if
the request for payment is received by the COUNTY more than forty-five (45) days after the end of
the Federal Fiscal Year.
D. COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation based on actual expenditures incurred by CONTRACTOR for monthly program costs in
accordance with the budget identified in Exhibit B.
E. CONTRACTOR shall be held financially liable for any and all future
disallowances/audit exceptions due to 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.
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5. INVOICING
CONTRACTOR shall invoice COUNTY monthly, by the thirtieth (30th) day of each
month for the prior month’s expenditures, addressed to the County of Fresno, Department of Public
Health, OPPC-NEOP, P.O. Box. 11867, Fresno, CA 93775, Attention: OPPC-NEOP Staff Analyst.
Invoices shall detail line items as specified in Exhibit B, including original budget amount(s), current
month’s expenses, year-to-date expenses, and budget balances. In addition, invoices shall also include
all relevant supporting documentation including but not limited to copies of original statements,
program expense receipts, payroll records and mileage claims.
6. INDEPENDENT CONTRACTOR
In performance of the work, duties, and obligations assumed by CONTRACTOR under
this Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of
CONTRACTOR's officers, agents, and employees will at all times be acting and performing as an
independent contractor, and shall act in an independent capacity and not as an officer, agent, servant,
employee, joint venturer, partner, or associate of the COUNTY. Furthermore, COUNTY shall have
no right to control or supervise or direct the manner or method by which CONTRACTOR shall
perform its work and function. However, COUNTY shall retain the right to administer this
Agreement so as to verify that CONTRACTOR is performing its obligations in accordance with the
terms and conditions thereof. CONTRACTOR and COUNTY shall comply with all applicable
provisions of law and the rules and regulations, if any, of governmental authorities having jurisdiction
over matters which are directly or indirectly the subject of this Agreement.
Because of its status as an independent contractor, CONTRACTOR shall have
absolutely no right to employment rights and benefits available to COUNTY employees.
CONTRACTOR shall be solely liable and responsible for providing to, or on behalf of, its employees
all legally-required employee benefits. In addition, CONTRACTOR shall be solely responsible and
save COUNTY harmless from all matters relating to payment of CONTRACTOR's employees,
including compliance with Social Security, withholding, and all other regulations governing such
matters. It is acknowledged that during the term of this Agreement, CONTRACTOR may be
providing services to others unrelated to the COUNTY or to this Agreement.
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7. MODIFICATION
Any matters of this Agreement may be modified from time to time by the written
consent of all the parties without, in any way, affecting the remainder. Notwithstanding the above,
changes to line items in the budget, attached hereto as Exhibit B, that do not exceed ten percent (10%)
of the maximum compensation payable to the CONTRACTOR may be made with written approval of
COUNTY’s Department of Public Health Director or designee and the designee of the California
Department of Public Health.
8. NON-ASSIGNMENT
Neither party shall assign, transfer or subcontract this Agreement nor their rights or
duties under this Agreement without the prior written consent of the other party.
9. HOLD-HARMLESS
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request,
defend the COUNTY, its officers, agents and employees from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
COUNTY in connection with the performance, or failure to perform, by CONTRACTOR, its officers,
agents or employees under this Agreement, and from any and all costs and expenses, including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to any
person, firm or corporation who may be injured or damaged by the performance, or failure to perform,
of CONTRACTOR, its officers, agents or employees under this Agreement.
COUNTY agrees to indemnify, save, hold harmless, and at CONTRACTOR’s request,
defend the CONTRACTOR, 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
CONTRACTOR in connection with the performance, or failure to perform, by COUNTY, its officers,
agents or employees under this Agreement, and from any and all costs and expenses, including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to any
person, firm or corporation who may be injured or damaged by the performance, or failure to perform,
of COUNTY, its officers, agents or employees under this Agreement.
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10. INSURANCE
Without limiting the COUNTY's right to obtain indemnification from CONTRACTOR
or any third parties, CONTRACTOR, at its sole expense, shall maintain in full force and effect the
following insurance policies throughout the term of this Agreement:
A. Commercial General Liability
Commercial General Liability Insurance with limits of not less than One Million
Dollars ($1,000,000) per occurrence and an annual aggregate of Two Million
Dollars ($2,000,000). This policy shall be issued on a 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 Fifty Thousand Dollars ($250,000) per person, Five
Hundred Thousand Dollars ($500,000) per accident and for property damages of
not less than Fifty Thousand Dollars ($50,000), or such coverage with a
combined single limit of Five Hundred Thousand Dollars ($500,000). Coverage
should include owned and non-owned vehicles used in connection with this
Agreement.
C. Professional Liability
If CONTRACTOR employs licensed professional staff (e.g. Ph.D., R.N.,
L.C.S.W., M.F.C.C.) 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.
D. Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
California Labor Code.
E. Child Abuse/Molestation and Social Services Liability
Sexual Abuse / Molestation Liability Insurance (including but not limited to
corporal punishment liability, sexual abuse and molestation liability, and child
abduction liability) with limits of not less than One Million Dollars
($1,000,000.00) per occurrence, Two Million Dollars ($2,000,000.00) annual
aggregate. This policy shall be issued on a per occurrence basis.
CONTRACTOR shall obtain endorsements to the Commercial General Liability
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insurance naming the County of Fresno, its officers, agents, and employees, individually and
collectively, as additional insured, but only insofar as the operations under this Agreement are
concerned. Such coverage for additional insured shall apply as primary insurance and any other
insurance, or self-insurance, maintained by the COUNTY, its officers, agents and employees shall be
excess only and not contributing with insurance provided under the CONTRACTOR's policies herein.
This insurance shall not be cancelled or changed without a minimum of thirty (30) days advance
written notice given to COUNTY.
Within thirty (30) days from the date CONTRACTOR executes 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 Public Health, P.O. Box
11867, Fresno, California, 93775, Attention: Contracts Section – 6th Floor, stating that such insurance
coverage have been obtained and are in full force; that the County of Fresno, its officers, agents and
employees will not be responsible for any premiums on the policies; that such Commercial General
Liability insurance names the County of Fresno, its officers, agents and employees, individually and
collectively, as additional insured, but only insofar as the operations under this Agreement are
concerned; that such coverage for additional insured shall apply as primary insurance and any other
insurance, or self-insurance, maintained by the COUNTY, its officers, agents and employees, shall be
excess only and not contributing with insurance provided under the CONTRACTOR’s policies herein;
and that this insurance shall not be cancelled or changed without a minimum of thirty (30) days
advance, written notice given to COUNTY.
In the event CONTRACTOR fails to keep in effect at all times insurance coverage as
herein provided, the COUNTY may, in addition to other remedies it may have, suspend or terminate
this Agreement upon the occurrence of such event.
All policies shall be with admitted insurers licensed to do business in the State of
California. Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating
of A FSC VII or better.
11. CONFIDENTIALITY
All services performed by CONTRACTOR under this Agreement shall be in strict
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conformance with all applicable Federal, State of California and/or local laws and regulations relating
to confidentiality.
12. DATA SECURITY
For the purpose of preventing the potential loss, misappropriation or inadvertent access,
viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse
of COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that
enter into a contractual relationship with 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;
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 but not limited to mobile storage devices. If data is
approved to be transferred, data must be stored on a secure server approved by the COUNTY and
transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
connection. Said data must be encrypted.
C. COUNTY-Owned Computer Equipment
CONTRACTOR or anyone having an employment relationship with the
COUNTY, may not use COUNTY computers or computer peripherals on non-COUNTY premises
without prior authorization from the COUNTY’s Chief Information Officer, and/or designee(s).
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D. CONTRACTOR may not store COUNTY’s private, confidential or sensitive
data on any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
E. CONTRACTOR shall be responsible to employ strict controls to ensure the
integrity and security of COUNTY’s confidential information and to prevent unauthorized access,
viewing, use or disclosure of data maintained in computer files, program documentation, data
processing systems, data files and data processing equipment which stores or processes COUNTY
data internally and externally.
F. Confidential client information transmitted to one party by the other by means of
electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of
128 BIT or higher. Additionally, a password or pass phrase must be utilized.
G. CONTRACTOR is responsible to immediately notify COUNTY of any
violations, breaches or potential breaches of security related to COUNTY’s confidential information,
data maintained in computer files, program documentation, data processing systems, data files and
data processing equipment which stores or processes COUNTY data internally or externally.
H. COUNTY shall provide oversight to CONTRACTOR’s response to all incidents
arising from a possible breach of security related to COUNTY’s confidential client information
provided to CONTRACTOR. CONTRACTOR will be responsible to issue any notification to
affected individuals as required by law or as deemed necessary by COUNTY in its sole discretion.
CONTRACTOR will be responsible for all costs incurred as a result of providing the required
notification.
13. 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, religious creed, color, national origin, ancestry, physical disability, mental disability, medical
condition, genetic information, marital status, sex, gender, gender identity, gender expression, age,
sexual orientation, or military or veteran status pursuant to all applicable State of California and
Federal statutes and regulations.
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14. LICENSES/CERTIFICATION
CONTRACTOR shall throughout the term of this Agreement maintain all necessary
licenses, permits, approvals, certificates, waivers and exemptions necessary for the provision of the
services hereunder and required by the laws and regulations of the United States of America, State of
California, Fresno County and any other applicable government agencies. CONTRACTOR shall
notify COUNTY immediately in writing of its inability to obtain or maintain such licenses, permits,
approvals, certificates, waivers and exemptions, irrespective of the pendency of any appeal related
thereto. In addition, CONTRACTOR shall comply with all other applicable laws, rules, or regulations,
as any may now exist or be hereafter changed.
15. COMPLIANCE WITH STATE REQUIREMENTS
CONTRACTOR recognizes that COUNTY operates is NEOP program under an
agreement with the State of California Department of Public Health, and that under said agreement the
State imposes certain requirements on the COUNTY and its subcontractors. CONTRACTOR shall
adhere to all State requirements, including those identified in Exhibit C, attached hereto and by this
reference incorporated herein. It is understood that Exhibit C also grants the COUNTY certain rights
which are reserved to the State; such rights are fully described therein.
16. PROPERTY OF COUNTY
All purchases over Five Thousand and No/100 Dollars ($5,000.00) and certain
purchases under Five Thousand and No/100 Dollars ($5,000.00) such as computers, printers, cameras
and other sensitive items made during the life of this Agreement shall be identified as fixed assets with
an assigned County of Fresno Accounting Inventory Number. These fixed assets shall be retained by
the COUNTY, as COUNTY property, in the event this Agreement is terminated or upon expiration of
this Agreement. CONTRACTOR agrees to participate in an annual inventory of all COUNTY fixed
assets and shall be physically present when fixed assets are returned to COUNTY possession at the
termination or expiration of this Agreement.
17. RECORDS
Financial and statistical data shall be kept and reports made as required by the
COUNTY’s Department of Public Health Director and the State. All such records shall be available
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for inspection by the designated Auditors of COUNTY or State at reasonable times during normal
business hours. All such records shall be maintained through the end of this Agreement. All records
shall be considered property of COUNTY and shall be retained by COUNTY at the termination or
expiration of this Agreement.
18. REPORTS
CONTRACTOR shall submit to COUNTY within ten (10) calendar days all program
reports for the preceding month. 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 the COUNTY within five (5) days of any fund received from another source to conduct
the same services covered by this Agreement.
19. PROHIBITION OF 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 (e.g.,
purchasing of tickets/tables, silent auction donations, media promotions) for the purpose of self-
promotion. Notwithstanding the above, publicity of the services described in Section One (1) of this
Agreement shall be allowed as necessary to raise public awareness about the availability of such
specific services when approved in advance in writing by COUNTY’s NEOP Project Coordinator and
the California Department of Public Health. Such items include but are not limited to written/printed
materials, materials posted on the Internet, or the use of media (e.g., radio, television, billboards,
newspapers), and any related expense. Documents prepared by CONTRACTOR using funding under
this Agreement for external release shall undergo appropriate review and approval prior to release.
Review may take up to thirty (30) business days. Materials, whether newly developed or reprinted,
shall include an appropriate acknowledgement/funding statement.
20. DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the CONTRACTOR is operating as a corporation (a
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for-profit or non-profit corporation) or if during the term of this Agreement, the CONTRACTOR
changes its status to operate as a corporation.
Members of the CONTRACTOR’s Board of Directors shall disclose any self-dealing
transactions that they are a party to while CONTRACTOR is providing goods or performing services
under this agreement. A self-dealing transaction shall mean a transaction to which the
CONTRACTOR is a party and in which one or more of its directors has a material financial interest.
Members of the Board of Directors shall disclose any self-dealing transactions that they are a party to
by completing and signing a Self-Dealing Transaction Disclosure Form, attached hereto as Exhibit D
and incorporated herein by reference, and submitting it to the COUNTY prior to commencing with the
self-dealing transaction or immediately thereafter.
21. AUDITS AND INSPECTIONS
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 data with
respect to the matters covered by this Agreement. 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 with the terms of this Agreement.
If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
CONTRACTOR shall be subject to the examination and audit of the State Auditor for a period of
three (3) years after final payment under contract (Government Code Section 8546.7).
22. NOTICES
The persons and their addresses having authority to give and receive notices under this
Agreement include the following:
COUNTY CONTRACTOR
Director, County of Fresno Chief Executive Officer
Department of Public Health Sierra Health Foundation:
P.O. Box 11867 Center for Program Management
Fresno, CA 93775 1321 Garden Hwy.
Sacramento, CA 95833
Any and all notices between the COUNTY and the CONTRACTOR provided for or
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permitted under this Agreement or by law shall be in writing and shall be deemed duly served when
personally delivered to one of the parties, or in lieu of such personal service, when deposited in the
United States Mail, postage prepaid, addressed to such party.
23. GOVERNING LAW
The parties agree, that for the purposes of venue, performance under this Agreement is
to be 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.
24. SEVERABILITY
The provisions of this Agreement are severable. The invalidity or unenforceability of
any one provision in the Agreement shall not affect the other provisions.
25. ENTIRE AGREEMENT
This Agreement, including all Exhibits, constitutes the entire agreement between the
CONTRACTOR and COUNTY with respect to the subject matter hereof and supersedes all previous
Agreement negotiations, proposals, commitments, writings, advertisements, publications, and
understanding of any nature whatsoever unless expressly included in this Agreement.
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APPROVED AS TO LEGAL FORM:
DANIEL C.CEDERBORG,COUNTY COUNSEL
um
APPROVED AS TO ACCOUNTING FORM :
OSCAR J.GARCIA ,C.P.A.,AUDITOR-CONTROLLER/
TREASURER -TAX COLLECTOR
By .fiUU iL
REVIEWED AND RECOMMENDED FOR APPROVAL:
By /.OICQ.J/'
David Pomaville
Director
Department of Public Health
Fund /Subclass:0001 /10000
Organization:56201662
Account #:7295
/ET
15 COUNTY OF FRESNO
Fresno,CA
Exhibit A
Page 1 of 9
Activity
Number
Annual Activity Description Time Frame: Year &
Quarter**
Documentation
1.1 In collaboration with LHD, support and assist Champions with at least
two PSE related events annually to create awareness and support for
identified PSE reaching 225 community residents through facility logistics
and approved media promotion.
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
x x x x
Year 3
Q1 Q2 Q3 Q4
x x x x
Activity Tacking Form database (ATF), facility costs
documentation, approved media promotion
On file (LHD): Agenda, sign-in sheet, flyers, media articles,
pictures, Summary reports
*Contributes to objective 1.b, 2.b, 3.b
1.2 In collaboration with LHD, support 2 community forums to reassess
community priorities targeted communities through facility logistics and
approved media promotion, including the costs associated with logistics
and promotion.
Year 1
Q1 Q2 Q3 Q4
X X
Year 2
Q1 Q2 Q3 Q4
x x x x
Year 3
Q1 Q2 Q3 Q4
x x x x
ATF
On file: facility costs documentation, approved media promotion,
agenda, sign-in sheet, flyers, media articles, pictures, Summary
reports
*Contributes to objective 1.c, 2.c, 3.c
1.8 In collaboration with LHD, support at least 2 Youth-led events that are
promoting PSE work identified by youth leaders, in partnership with
adult ally, within the respective 6 targeted communities through facility
logistics and approved media promotion. Reaching at least 70 SNAP-Ed
eligible population (40 youth leaders, 30 adult participants).
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
x x x x
Year 3
Q1 Q2 Q3 Q4
x x x x
ATF
On file: facility costs documentation, approved media promotion,
agenda, sign-in sheet, flyers, posters, pictures, PowerPoint, media
stories
*Contributes to objective 1.b, 2.b, 3.b
1.9 Provide 102 single session nutrition and physical activity education (15
minutes or longer in duration) in year 1 (179 each in years 2 and 3) to at
least 2,171 unduplicated eligible individuals in year 1 (2,990 each in
years 2 and 3) at qualifying community centers, schools, afterschool’s,
churches, worksites, public housing locations, retail locations, and food
distributions. Taste-testing will be included. LHD will conduct education
activities in LHD six targeted communities only. UCCE will conduct
education activities in other communities throughout Fresno County.
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
x x x x
Year 3
Q1 Q2 Q3 Q4
x x x x
ATF, RTW, Sign-in sheets, evaluation tools
*Contributes to annual objective 1.e,2.d,3.e
Exhibit A
Page 2 of 9
1.10 Work with previously trained 30 SNAP-Ed eligible adults (Champions) to
provide 70 in year 1 (90 each in years 2 and 3) peer to peer single session
nutrition and physical activity education (15 minutes or longer in
duration) to at least 180 in year 1 (270 each in years 2 and 3)
unduplicated eligible adults at qualifying community centers, schools,
churches, worksites, public housing locations, retail locations. Support
includes up to $75 per champion covering time and offset travel
expenses or nutrition education expenses. Taste-testing will be
included. On-going support will be provided to Champions by LHD and
Nutrition Education Subcontractor, as needed.
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
x x x x
Year 3
Q1 Q2 Q3 Q4
x x x x
ATF, Sign-in Sheets, data cards, pictures, Champion Engagement
System tracking log, documentation to support champions
nutrition education efforts
*Contributes to annual objective 1.e,2.d,3.e
1.11 Recruit and engage at least 1 qualifying church annually in
predominately African-American and/or Latino communities to provide
culturally relevant nutrition education and physical activity promotion to
annually reach 60 unduplicated SNAP-Ed eligible individuals and to
influence organizational and systems changes in the church community.
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
x x x x
Year 3
Q1 Q2 Q3 Q4
x x x x
ATF, sign-in sheets, pictures, evaluation tools
*Contributes to annual objective 1.e,2.d,3.e
1.12 Provide indirect (i.e., less than 15 minutes in duration) nutrition
education and food tastings at qualifying church events reaching a
minimum of 50 annually SNAP-Ed eligible individuals annually at least 2
church sites.
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
x x x x
Year 3
Q1 Q2 Q3 Q4
x x x x
ATF, pictures, event flyers
*Contributes to annual objective 1.e,2.d,3.e
1.14 Utilize media, social media, blogs, and agency websites each year to
promote and cross-promote at least 20 in year 1 (30 each in years 2 and
3) SNAP-Ed activities, success stories, events, community forums, and/or
approved messaging.
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
x x x x
Year 3
Q1 Q2 Q3 Q4
x x x x
On file: Facebook analytics, blog analytics, copy of approved paid
media ads to promote town halls, and other C4C community
events.
*Contributes to all annual objectives as appropriate
Exhibit A
Page 3 of 9
1.15 Participate in at least 1 Fresno CHIP Quarterly meeting in year 1 (4
meetings in years 2 and 3) to align and leverage resources, provide
consistent messaging, and enhance impact of funded activities, as
appropriate.
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
x x x x
Year 3
Q1 Q2 Q3 Q4
x x x x
ATF
On file: Agenda, Notes
*Contributes to CNAP requirement
1.17 Provide referrals to partner agencies both SNAP-Ed and non-SNAP-Ed to
provide strategic coordinated nutrition and physical activity education to
eligible SNAP-Ed population.
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
x x x x
Year 3
Q1 Q2 Q3 Q4
x x x x
Referral Log, e-mails
*Contributes to annual objective 1.e,2.d,3.e
1.18 In collaboration with LHD, support trainings provided to at least 50 adult
and 15 youth champions to complete nutrition and physical activity PSE
projects through facility logistics and approved media promotion,
including the costs associated with logistics and promotion.
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
x x x x
Year 3
Q1 Q2 Q3 Q4
x x x x
ATF
On file: facility cost documentation, sign-in sheets, agendas,
evaluations, pictures, Champion Engagement System (tracking),
identified project documentation
*Contributes to objective 1.e,2.d,3.e
1.21 Participate and provide indirect (i.e., less than 15 minutes in duration)
education in at least 3 community events in year 1 (12 each in years 2
and 3) reaching at least 225 in year 1 (900 each in years 2 and 3) SNAP-
Ed eligible population.
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
x x x x
Year 3
Q1 Q2 Q3 Q4
x x x x
ATF, event flyer, event registration
*Contributes to annual objective 1.e,2.d,3.e
Exhibit A
Page 4 of 9
1.22 Provide indirect (i.e., less than 15 minutes in duration) nutrition
education that includes food tastings to a minimum of 2,000 in year 1
(6,000 each in years 2 and 3) SNAP-Ed eligible individuals annually at
food distributions.
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
x x x x
Year 3
Q1 Q2 Q3 Q4
x x x x
ATF, food distribution flyers, pictures
*Contributes to annual objective 1.e,2.d,3.e
1.24 Participate in meetings convened by LHD Community Coordinator in
each target community to strategically coordinate SNAP-Ed and non-
SNAP-Ed activities, align and leverage resources, provide consistent
messaging, and enhance impact of funded activities.
Year 1
Q1 Q2 Q3 Q4
X X
Year 2
Q1 Q2 Q3 Q4
x x x x
Year 3
Q1 Q2 Q3 Q4
x x x x
ATF, Agendas, meeting notes, sign in sheets
*Contributes to all annual objectives
1.25 Attend at least one (1) CDPH-sponsored CX3 trainings and meetings:
• CX3 orientation webinar
• Empowering & Facilitating Community Voices
• Geographic Information System (GIS) mapping
• Survey/Field Work
• Quarterly calls with CDPH
• Others as needed
The training shall prepare for the neighborhood assessment of the
nutrition and physical activity environment including:
• Walkability assessment around healthy food retail
• Access to healthy foods in retail and alternative food sources
(such as community gardens or farmers markets)
• Marketing of and availability of healthy and unhealthy foods in
retail and fast food outlets
• Opportunities for PA
• Identify food deserts in eligible
• communities
Assessment of food banks and emergency food outlets’ presence,
policies, and food offerings
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
Year 3
Q1 Q2 Q3 Q4
x x x x
ATF, training materials, agenda,
Webinar registration/agendas/recordings as available
*Contributes to objectives 1.d, 3.d
Exhibit A
Page 5 of 9
1.27 Field work/surveying
• Assist LHD staff and Evaluator subcontractor in conducting the
CX3 neighborhood data collection using CX3 tools and methods;
• Support training for local Champions who might participate in
data collection
CX3 assessments in Fresno County neighborhoods are being reassessed
in Year 1 and Year 3.
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
Year 3
Q1 Q2 Q3 Q4
x x
ATF, maps with data collector assignments, facility costs
documentation
*Contributes to objectives 1.d, 3.d
1.32 Participate in training provided by LHD to learn how to build Champion
capacity and support community-driven PSE. Throughout the training,
staff will learn how to apply community-driven PSE strategies and
techniques and how to deliver the training to Champions.
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
Year 3
Q1 Q2 Q3 Q4
ATF, Agenda, meeting notes
On file (LHD): curricula, training agenda and materials, sign in
sheet, pictures, evaluations
*Contributes to annual objectives 1.b,2.a, 2.b,3.a, 3.b
1.35 Promote the Champion Engagement opportunity (includes promoting
program messages, teaching nutrition education, participating in events,
working on PSE activities) to program participants. Identify and refer at
least 150 in year 1 (300 in each years 2 and 3) nutrition education
participants from the targeted communities that express interest in
becoming champions for the Champions for Change Program to LHD
Community Coordinators annually. Referral will be completed using a
Champion Interest Form completed by the program participant.
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
x x x x
Year 3
Q1 Q2 Q3 Q4
x x x x
Champion Interest Forms, e-mails
*Contributes to annual objective 1.b, 2.b, 3.b
2.7 Assist healthy retail subcontractor and provide indirect (i.e., less than 15
minutes in duration) nutrition education at least 2 Fruit and Veggie Fest
retail events reaching 100 eligible individuals annually.
Year 1
Q1 Q2 Q3 Q4
x x
Year 2
Q1 Q2 Q3 Q4
x x x x
Year 3
Q1 Q2 Q3 Q4
x x x x
ATF
On file: flyers, agendas, media articles, pictures
*Contributes to objective 1.c, 2.c, 3.c
Exhibit A
Page 6 of 9
Admin 1 Submit Monthly Invoices to LHD. Due 30 days after
the end of each
month in Year 1, 2,
& 3
Monthly invoices completed and submitted to LHD. Backup
documentation includes but not limited to, LHD Checklist,
Personnel Salaries and Benefits Costs Sheet, Summary
Spreadsheets, Bi-weekly Time Logs or timesheets as appropriate,
expenditure detail for travel, purchases and copies of respective
receipts, recipes
Admin 2 Enter program activity data entry into Activity Tracking Form (ATF)
NEOPB database.
Due the 15th after
each quarter ends
(4/15, 7/15, 10/15)
for Year 1, 2, & 3.
ATF is a NEOPB data base that collects data from each LHD and
subcontractors on each of their respective activities and
demographic data and participation in USDA programs data from
single sessions provided.
Admin 3 Work with LHD to complete the NEOPB Semi Annual Progress Report Due April 15 and
October 15 for Year
1, 2, & 3
All reporting to the state will accomplished by the County, with
information furnished by the successful bidders on the
appropriate NEOPB forms. This may include but not limited to:
back up documentation, pictures, evaluation reports, policies,
success stories, press releases, challenges encountered and
strategies to address them, and fiscal reports.
Admin 4 Submit LHD Quarterly Champions for Change Narrative Reports with
backup documentation on progress towards meeting subcontractors’
respective activities.
Due April 30, July 31
and October 31 for
Year 1, 2, & 3
Back up documentation includes Champions for Change Narrative
Report. Respective back up documentation for activity reporting
must be kept on file by activity number and quarter and readily
accessible if needed. This includes but not limited to:
• Nutrition and physical activity single session classes (sing
in sheets, agenda, data cards)
• Events (event flyer, pictures)
• Trainings/Meetings (agenda, Notes)
PSE (Meeting Agendas, e-mails, pictures)
Admin 5 Work with LHD contracted Evaluator to evaluator to comply with
required and PSE change evaluation activities
Ongoing Evaluation Reports, RE-AIM (PSE year-end reporting form) and
Success Stories
Admin 6 Participate in LHD and NEOPB periodic in person trainings and webinars
as appropriate
Ongoing ATF, LHD Quarterly Champions for Change Narrative Reports
Admin 7 Participate and engage in LHD Champions for Change Program Lead
meetings and Champions for Change All Team meetings as scheduled.
Ongoing Agenda, meeting notes
Admin 8 Participate and engage in FCHIP Work Groups, as appropriate, to
communicate, cross-promote, facilitate a coordinated approach that will
enhance the consistency of food and nutrition messaging and integrate
activities with subcontractors and community partners to improve
access to healthy foods, beverages and physical activity in the targeted
communities.
Ongoing Agenda, meeting notes
**Time Frame: Year & Quarter:
Year 1 (FFY 2017); Year 2 (FFY 2018); Year 3 (FFY 2019)
Qtr. 1 (Oct. 1-Dec. 31); Qtr. 2 (Jan. 1-March 31); Qtr. 3 (Apr. 1-Jun. 30); Qtr. 4 (Jul. 1-Sept.30)
Exhibit A
Page 7 of 9
Educational Materials, Resources, and Curriculum
Activity Number Curriculum, Toolkit, Resource
Name
SNAP-Ed
Agency(ies)
Level of
Evidence Base
1.9, 1.10,
1.11, 1.12, 1.21,
1.22
My Plate Ten Tips Nutrition Education Series (Hmong, Spanish, English)
CWD
x LHD
AAA
UCCE
CCC
Research Tested
Practice Tested
Emerging
x N/A – Please describe below:
Approved SNAP-Ed resource materials
1.9,
1.11, 1.12, 1.22
Harvest of the Month handouts (California) CWD
x LHD
AAA
UCCE
CCC
Research Tested
x Practice Tested
Emerging
N/A - Please describe below:
1.9, 1.11, 1.22 NEOPB Cookbooks (Flavors of My Kitchen (Eng/Spa), Everyday Healthy Meals
(Eng/Spa), Healthy Latino Recipes (Eng/Spa), Soulful Recipes
CWD
x LHD
AAA
UCCE
CCC
Research Tested
Practice Tested
Emerging
x N/A – Please describe below:
Approved SNAP-Ed resource materials
1.9, 1.10,1.11,
1.12,1.21, 1.22
EatFresh.org CWD
x LHD
AAA
UCCE
CCC
Research Tested
Practice Tested
x Emerging
N/A - Please describe below:
1.10, 1.11 NEOPB, Power Play! Fit Deck Power Cards
CWD
x LHD
AAA
UCCE
CCC
Research Tested
Practice Tested
Emerging
x N/A - Please describe below:
Approved SNAP-Ed resource materials
1.9, 1.10, 1.11,
1.12,
1.21,1.22
USDA MyPlate Posters CWD
x LHD
AAA
UCCE
CCC
Research Tested
Practice Tested
Emerging
x N/A - Please describe below:
Approved SNAP-Ed Resource Materials
1.9, 1.10, 1.11,
1.12, 1.21, 1.22
Prevent Portion Distortion handout (Spanish, English)
http://food.unl.edu/freeprevent-portion-distortion-powerpoint
CWD
X LHD
AAA
UCCE
CCC
Research Tested
Practice Tested
Emerging
x N/A – Please describe below:
University of Nebraska Extension
Exhibit A
Page 8 of 9
1.9, 1.10, 1.11 Cooking Matters CWD
x LHD
AAA
UCCE
CCC
x Research Tested
Practice Tested
Emerging
N/A – Please describe below:
1.10, 1.11 Project Lean Parent Lesson Plans: Advocating for Healthier School Environments CWD
x LHD
AAA
UCCE
CCC
Research Tested
x Practice Tested
Emerging
N/A - Please describe below:
1.9, 1.10
1.11, 1.12, 1.21,
1.22
NEOPB Recipe Cards CWD
x LHD
AAA
UCCE
CCC
Research Tested
Practice Tested
Emerging
x N/A – Please describe below:
Approved SNAP-Ed Resource Materials
1.9, 1.10,
1.11,1.12
1.21, 1.22
Dairy Council Beverages: Make Every Sip Count CWD
x LHD
AAA
UCCE
CCC
Research Tested
Practice Tested
Emerging
x N/A - Please describe below:
Approved SNAP-Ed Resource Materials –
Dairy Council of California
1.9
1.10
Latino Campaign, Toolbox for Community Educators CWD
x LHD
AAA
UCCE
CCC
Research Tested
x Practice Tested
Emerging
N/A - Please describe below:
1.9
1.10
1.11
Body and Soul CWD
x LHD
AAA
UCCE
CCC
Research Tested
x Practice Tested
Emerging
N/A - Please describe below:
1.10, 1.24
CDPH Policy Systems and Environmental Change Resource Guide: Strategies for
Increased Access to Healthy Tools, Beverages and Physical Activity
CWD
x LHD
AAA
UCCE
CCC
Research Tested
Practice Tested
Emerging
x N/A - Please describe below:
Approved SNAP-Ed Resource Material
1.10, 1.11, 1.24 CDPH Physical Activity Resource Guide Implementing Physical Activity Programs for
SNAP-Ed Eligible Population
CWD
x LHD
AAA
UCCE
CCC
Research Tested
Practice Tested
Emerging
x N/A - Please describe below:
Approved SNAP-Ed Resource Material
Exhibit A
Page 9 of 9
1.24 Youth Participatory Action Research Project CWD
x LHD
AAA
UCCE
CCC
x Research Tested
Practice Tested
x Emerging
N/A - Please describe below:
1.9, 1.10, 1.11
1.14, 1.22
Champions for Change (CA) CWD
x LHD
AAA
UCCE
CCC
Research Tested
x Practice Tested
Emerging
N/A - Please describe below:
1.9
1.10
1.11
Eat Right When Money’s Tight CWD
x LHD
AAA
UCCE
CCC
Research Tested
x Practice Tested
Emerging
N/A - Please describe below:
YEAR 1JUN 6, 2017 ‐ SEP 30, 2017Organization Name:Contract/Sub‐Grant/Agreement: 1. Staffing: Salary/Benefits:Position #% of SNAP‐Ed Time spent on Mgmt/Admin Duties% of SNAP‐Ed Time spent on Direct SNAP‐Ed Delivery1TBD25.00% 75.00% 21,666.00$ 1.00$21,666.0035.00%$7,583.10 $7,312.28 $29,2492Lucia Navarro75.00% 25.00% 15,333.00$ 1.00$15,333.0035.00%$5,366.55 $15,524.66 $20,7003Brandie Banks‐Bey10.00% 90.00% 25,000.00$ 0.60$15,000.0035.00%$5,250.00 $2,025.00 $20,2504TBD20.00% 80.00% 11,666.00$ 0.45$5,249.7018.00%$944.95 $1,238.93 $6,1955TBD20.00% 80.00% 11,666.00$ 0.45$5,249.7018.00%$944.95 $1,238.93 $6,1956TBD20.00% 80.00% 11,666.00$ 0.45$5,249.7018.00%$944.95 $1,238.93 $6,1957TBD20.00% 80.00% 11,666.00$ 0.45$5,249.7018.00%$944.95 $1,238.93 $6,1958TBD20.00% 80.00% 11,666.00$ 0.45$5,249.7018.00%$944.95 $1,238.93 $6,1959TBD20.00% 80.00% 11,666.00$ 0.45$5,249.7018.00%$944.95 $1,238.93 $6,19510$0.00$0.00 $0.00 $011$0.00$0.00 $0.00 $021$0.00$0.00 $0.00 $0Total Staffing: Salary/Benefits:5.30 $83,497$23,869 $32,296 $107,367Definition and basis for calculations of benefit rate(s):Describe what is covered in the benefit rate for your agency.Retirement (10%), FICA (7.65%), medical/dental/vision (9.74%), long‐term disability/short‐term disability life/ADD (3.84%), workmen's compensation (2.77%), and California unemployment insurance (1.00%)*home‐based position; FTE not included in space/operating costs calculationsPromotora*Promotora*Promotora*Promotora*Promotora*Promotora*Communications ManagerFTETotal SNAP‐Ed SalaryBenefit RateTotal SNAP‐Ed BenefitsSNAP‐Ed Admin CostsTotal SNAP‐Ed Funded Salary and Benefits Annual SalaryBudget JustificationProject CoordinatorOffice Manager/Secretary/AdmAddDeleteReduceIncreaseLast Amount ApprovedPosition Title Position NameSNAP‐Ed Time SpentBudget AdjustmentCalifornia Department of Public HealthCounty/Jurisdiction:Fresno CountyThe Center/Cultiva La SaludBudget AdjustmentExhibit B Page 1 of 12
YEAR 1JUN 6, 2017 ‐ SEP 30, 2017Organization Name:County/Jurisidiction:Contract/Sub‐Grant/Agreement: 2. Non‐Capital Equipment/Supplies:AddDeleteReduceIncreaseLast Amount ApprovedFTE# of Items TotalBudget Justification15.34$2,12025.34$4,24035.34$6,36045.34$148134$7,2002$0$20,0683. Materials:AddDeleteReduceIncreaseLast Amount Approved# of Items Total Budget Justification12000$5,00022000$10,0003120$3,000430$2,25058$2806$07$0$20,530Total Materials: ServSafe Training Food handling training for all staff involved in food preparation. $35.00Small kitchen waresDurable kitchen items for taste testing activities, including but not limited to: electric skillet, spa water dispensers, cooking utensils, storage containers. These items will be acquired to the Project Coordinator and Promotoras.$25.00ChampionsSupport for Champions in providing peer to peer single session nutrition education. Calculated at $75 per Champion x 30$75.00Food & Beverage DemosMaterials & ingredients for healthy food and bevearge demonstrations. This includes cost of plates, napkins, utensils and cups.$2.50Nutrition Ed materialsPurchase of approved nutrition education materials. $5.00Total Non‐Capital Equipment/Supplies:Budget AdjustmentBudget AdjustmentBudget Item Description/Justification Cost per ItemTheft‐sensitive equipment/supplies that are less than $5,000 (Computers, printers, projectors, etc.)TabletTablets for each of the 6 Promotoras which will allow them to submit reports, email collegues and community residents and complete timesheets. The cost for each tablet is estimated at $600 x 6 = $3,600 and includes the cost of service at $150 per month x 6 x 4 months = $3,600. Total cost is $7,200.$600.00Postage & DeliveryPostage for mailing reminders to households without email or phone service. Postage is calculated by FTE x$7 a month x 4 months.$7.00Office SuppliesStandard office supplies for program operations and nutrition education sessions. Includes, paper, pens, rolling carts, storage carts, non consumible supplies for sugar savy trainings, ink, etc...This is calculated basedon FTE X $50 a month x 4 months$100.00CommunicationsCosts for telephone, email, internet, website and eNewsleter service. Cost are calculated based on FTE X $200 a month x 4 months$200.00California Department of Public HealthFresno CountyThe Center/Cultiva La SaludBudget AdjustmentBudget AdjustmentBudget Item Description/Justification Cost per ItemPrintingPrinting for office operations & nutrition eeucation sessions. This is calculated based on FTE x $200 x 4 months$300.00Exhibit B Page 2 of 12
YEAR 1JUN 6, 2017 ‐ SEP 30, 2017Organization Name:County/Jurisidiction:Contract/Sub‐Grant/Agreement: 4. Travel:AddDeleteReduceIncreaseLast Amount ApprovedLocation Description/Justification Trips FTE Days Nights Per Diem Lodging AirMiles($.540)Other Total Budget Justification1Lowell, West Fresno, Kerman, Sanger, Reedley, & ParlierTravel to target communities to deliver nutrition education sessons, peer to peer trainings and community meetings 72 1 1 0 $0.00 $0.00 $0.00 50 $0.00$1,9442Fresno Staff & Program meetings 108 3 1 0 $0.00 $0.00 $0.00 50 $0.00$2,9163$04$01$02$03$0$4,860* Lodging costs include taxes. Reimbursement at CalHR rates. 5. Building/Space:AddDeleteReduceIncreaseLast Amount ApprovedFTE# of Month(s)Total Budget Justification12.64$9,450214$600314$1,6004$0$11,6506. Maintenance:AddDeleteReduceIncreaseLast Amount ApprovedFTE# of Month(s)Total Budget Justification12.64$2,8003$04$05$0$2,800Total Maintenance:2409 Merced Street, Suite 101, Fresno, CA Janitorial services calculated by FTE x $269.23 per month x 4 months $269.23Total Building/Space:Budget AdjustmentBudget AdjustmentLocation Name/Address Calculation Description Cost per Month405 E. Belmont Ave, Fresno, CA Kitchen space for rental for food prep cost is based on $400/month $400.002409 Merced Street, Fresno, CA 93721Office space for project staff (based on rate per FTE) FTE x 150 sq ft x $6.06/ sq ft x 4 months. $908.653330 E Tulare Street, Fresno, CA Storage space for materials based on cost of $150/month $150.00Total Travel:Budget AdjustmentBudget AdjustmentLocation Name/Address Calculation Description Cost per MonthOut‐of‐StatePosition Title/NameRegistration FeeIn‐StateProject Coordinator$0.00Promotoras$0.00California Department of Public HealthFresno CountyThe Center/Cultiva La SaludBudget AdjustmentBudget AdjustmentExhibit B Page 3 of 12
YEAR 1JUN 6, 2017 ‐ SEP 30, 2017Organization Name:County/Jurisidiction:Contract/Sub‐Grant/Agreement: 7. Equipment and Other Capital Expenditures:AddDeleteReduceIncreaseLast Amount ApprovedFTE# ofItemsMisc. Total Budget Justification1$02$03$0$08. Contracts/Sub‐Grants/Agreements:AddDeleteReduceIncreaseLast Amount ApprovedTotal Grant Budget JustificationA$10,000B$0C$0D$0E$0F$10,0009. Indirect Costs:AddDeleteReduceIncreaseLast Amount ApprovedTotalBudget Justification1$26,5911$0$26,591Total Indirect Costs:Total Budget: $203,866Total Direct15.00% $177,274.88Program: [Please list the line items that are included in calculation]0.00%Budget AdjustmentCalculation MethodIndirect Cost RateTotal Admin/Program DollarsAdministration: [Please list the line items that are included in calculation]Total Contracts/Sub‐Grants/Agreements:Total Direct Costs: $177,275Budget AdjustmentOrganization Name Description of Service(s)Cultiva La Salud Adminstrator for Project in Year 1 ‐ Genoveva IslasTotal Equipment and Other Capital Expenditures:Budget AdjustmentBudget AdjustmentBudget Item Description/Justification Cost per ItemCalifornia Department of Public HealthFresno CountyThe Center/Cultiva La SaludBudget AdjustmentBudget AdjustmentExhibit B Page 4 of 12[
YEAR 2 OCT 1, 2017 ‐ SEP 30, 2018Organization Name:Contract/Sub‐Grant/Agreement: 1. Staffing: Salary/Benefits:Position #% of SNAP‐Ed Time spent on Mgmt/Admin Duties% of SNAP‐Ed Time spent on Direct SNAP‐Ed Delivery1TBD25.00% 75.00% 65,000.00$ 0.90$58,500.0035.00%$20,475.00 $19,743.75 $78,9752Lucia Navarro75.00% 25.00% 46,000.00$ 0.50$23,000.0035.00%$8,050.00 $23,287.50 $31,0503Brandie Banks‐Bey10.00% 90.00% 75,000.00$ 0.10$7,500.0018.00%$1,350.00 $885.00 $8,8504TBD20.00% 80.00% 32,000.00$ 0.25$8,000.0018.00%$1,440.00 $1,888.00 $9,4405TBD20.00% 80.00% 32,000.00$ 0.25$8,000.0018.00%$1,440.00 $1,888.00 $9,4406TBD20.00% 80.00% 32,000.00$ 0.25$8,000.0018.00%$1,440.00 $1,888.00 $9,4407TBD20.00% 80.00% 32,000.00$ 0.25$8,000.0018.00%$1,440.00 $1,888.00 $9,4408TBD20.00% 80.00% 32,000.00$ 0.25$8,000.0018.00%$1,440.00 $1,888.00 $9,4409TBD20.00% 80.00% 32,000.00$ 0.25$8,000.0018.00%$1,440.00 $1,888.00 $9,44010$0.00$0.00 $0.00 $011$0.00$0.00 $0.00 $021$0.00$0.00 $0.00 $0Total Staffing: Salary/Benefits:3.00 $137,000$38,515 $55,244 $175,515Definition and basis for calculations of benefit rate(s):Describe what is covered in the benefit rate for your agency.Retirement (10%), FICA (7.65%), medical/dental/vision (9.74%), long‐term disability/short‐term disability life/ADD (3.84%), workmen's compensation (2.77%), and California unemployment insurance (1.00%)*home‐based position; FTE not included in space/maintenance costs calculationsPromotora*Promotora*Promotora*Promotora*Promotora*Promotora*Communications ManagerFTETotal SNAP‐Ed SalaryBenefit RateTotal SNAP‐Ed BenefitsSNAP‐Ed Admin CostsTotal SNAP‐Ed Funded Salary and Benefits Annual SalaryBudget JustificationProject CoordinatorOffice Manager/Secretary/AdmAddDeleteReduceIncreaseLast Amount ApprovedPosition Title Position NameSNAP‐Ed Time SpentBudget AdjustmentCalifornia Department of Public HealthCounty/Jurisdiction:Fresno CountyThe Center/Cultiva La SaludBudget AdjustmentExhibit B Page 5 of 12
YEAR 2 OCT 1, 2017 ‐ SEP 30, 2018Organization Name:County/Jurisidiction:Contract/Sub‐Grant/Agreement: 2. Non‐Capital Equipment/Supplies:AddDeleteReduceIncreaseLast Amount ApprovedFTE# of Items TotalBudget Justification1212$1,2002212$3,6003212$3,6004212$1681$02$0$8,5683. Materials:AddDeleteReduceIncreaseLast Amount Approved# of Items Total Budget Justification11080$2,70021080$1,080330$2,2504$05$06$07$0$6,030Total Materials: Food & Beverage DemosMaterials & ingredients for healthy food and bevearge demonstrations. This includes cost of plates, napkins, utensils and cups.$2.50Nutrition Ed materials Purchase of approved nutrition education materials. $1.00Champions Support for Champions in providing peer to peer single session nutriotn education. Calculated at $75 per Champion $75.00Total Non‐Capital Equipment/Supplies:Budget AdjustmentBudget AdjustmentBudget Item Description/Justification Cost per ItemTheft‐sensitive equipment/supplies that are less than $5,000 (Computers, printers, projectors, etc.)Postage & DeliveryPostage for mailing reminders to households without email or phone service. Postage is calculated by FTE x$7 a month x 12 months.$7.00Office SuppliesStandard office supplies for program operations and nutrition education sessions. Includes, paper, pens, ink, etc...This is calculated basedon FTE X $50 a month x 12 months$50.00CommunicationsCosts for telephone, email, internet, website and eNewsleter service. Cost are calculated based on FTE X $150 a month x 12 months$150.00PrintingPrinting for office operations & nutrition education sessions. This is calculated based on FTE x $150 x 12 months$150.00California Department of Public HealthFresno CountyThe Center/Cultiva La SaludBudget AdjustmentBudget AdjustmentBudget Item Description/Justification Cost per ItemExhibit B Page 6 of 12
YEAR 2 OCT 1, 2017 ‐ SEP 30, 2018Organization Name:County/Jurisidiction:Contract/Sub‐Grant/Agreement: 4. Travel:AddDeleteReduceIncreaseLast Amount ApprovedLocation Description/Justification Trips FTE Days Nights Per Diem Lodging AirMiles($.540)Other Total Budget Justification1Lowell, West Fresno, Kerman, Sanger, Reedley, & ParlierTravel to target communities to deliver nutrition education sessons, peer to peer trainings and community meetings72 1 1 0 $0.00 $0.00 $0.00 50$0.00$1,9442Fresno Staff & Program meetings63 3 1 0 $0.00 $0.00 $0.00 50$0.00$1,7013$04$01$02$03$0$3,645* Lodging costs include taxes. Reimbursement at CalHR rates. 5. Building/Space:AddDeleteReduceIncreaseLast Amount ApprovedFTE# of Month(s)Total Budget Justification11.512$13,4882112$1,8003112$4,8004$0$20,0886. Maintenance:AddDeleteReduceIncreaseLast Amount ApprovedFTE# of Month(s)Total Budget Justification11.512$4,8004$05$0$4,800Total Maintenance:2409 Merced Street, Suite 101, Fresno, CA Janitorial services calculated by FTE x $266.67 per month x 12 months$266.67Total Building/Space:Budget AdjustmentBudget AdjustmentLocation Name/Address Calculation Description Cost per Month2409 Merced Street, Fresno, CA 93721Office space for project staff (based on rate per FTE) FTE x 150 sq ft x $5/ sq ft x 12 months. $749.333330 E Tulare Street, Fresno, CA Storage space for materials based on cost of $150/month$150.00405 E. Belmont Ave, Fresno, CA Kitchen space for rental for food prep cost is based on $400/month $400.00Total Travel:Budget AdjustmentBudget AdjustmentLocation Name/Address Calculation Description Cost per MonthOut‐of‐StatePosition Title/NameRegistration FeeIn‐StateProject Coordinator$0.00Promotoras$0.00California Department of Public HealthFresno CountyThe Center/Cultiva La SaludBudget AdjustmentBudget AdjustmentExhibit B Page 7 of 12
YEAR 2 OCT 1, 2017 ‐ SEP 30, 2018Organization Name:County/Jurisidiction:Contract/Sub‐Grant/Agreement: 7. Equipment and Other Capital Expenditures:AddDeleteReduceIncreaseLast Amount ApprovedFTE# ofItemsMisc. Total Budget Justification1$02$03$0$08. Contracts/Sub‐Grants/Agreements:AddDeleteReduceIncreaseLast Amount ApprovedTotal Grant Budget JustificationA$7,441BC$0D$0E$0F$7,4419. Indirect Costs:AddDeleteReduceIncreaseLast Amount ApprovedTotalBudget Justification1$33,9131$0$33,913Calculation MethodIndirect Cost RateTotal Admin/Program DollarsAdministration: [Please list the line items that are included in calculation]Total Indirect Costs:Total Budget: $260,000Total Direct15.00% $226,087.00Program: [Please list the line items that are included in calculation]0.00%Total Contracts/Sub‐Grants/Agreements:Total Direct Costs: $226,087Budget AdjustmentBudget AdjustmentOrganization Name Description of Service(s)Cultiva La Salud Adminstrator for Project ‐ Genoveva IslasTotal Equipment and Other Capital Expenditures:Budget AdjustmentBudget AdjustmentBudget Item Description/Justification Cost per ItemCalifornia Department of Public HealthFresno CountyThe Center/Cultiva La SaludBudget AdjustmentBudget AdjustmentExhibit B Page 8 of 12I
YEAR 3OCT 1, 2018 ‐ SEP 30, 2019Organization Name:Contract/Sub‐Grant/Agreement: 1. Staffing: Salary/Benefits:Position #% of SNAP‐Ed Time spent on Mgmt/Admin Duties% of SNAP‐Ed Time spent on Direct SNAP‐Ed Delivery1TBD25.00% 75.00% 65,000.00$ 0.90$58,500.0035.00%$20,475.00 $19,743.75 $78,9752Lucia Navarro75.00% 25.00% 46,000.00$ 0.50$23,000.0035.00%$8,050.00 $23,287.50 $31,0503Brandie Banks‐Bey10.00% 90.00% 75,000.00$ 0.10$7,500.0018.00%$1,350.00 $885.00 $8,8504TBD20.00% 80.00% 32,000.00$ 0.25$8,000.0018.00%$1,440.00 $1,888.00 $9,4405TBD20.00% 80.00% 32,000.00$ 0.25$8,000.0018.00%$1,440.00 $1,888.00 $9,4406TBD20.00% 80.00% 32,000.00$ 0.25$8,000.0018.00%$1,440.00 $1,888.00 $9,4407TBD20.00% 80.00% 32,000.00$ 0.25$8,000.0018.00%$1,440.00 $1,888.00 $9,4408TBD20.00% 80.00% 32,000.00$ 0.25$8,000.0018.00%$1,440.00 $1,888.00 $9,4409TBD20.00% 80.00% 32,000.00$ 0.25$8,000.0018.00%$1,440.00 $1,888.00 $9,44010$0.00$0.00 $0.00 $011$0.00$0.00 $0.00 $021$0.00$0.00 $0.00 $0Total Staffing: Salary/Benefits: 3.00 $137,000 $38,515 $55,244 $175,515Communications ManagerBudget AdjustmentCalifornia Department of Public HealthCounty/Jurisdiction:Fresno CountyThe Center/Cultiva La SaludBudget AdjustmentAddDeleteReduceIncreaseLast Amount ApprovedPosition Title Position NameSNAP‐Ed Time SpentFTETotal SNAP‐Ed SalaryBenefit RateTotal SNAP‐Ed BenefitsSNAP‐Ed Admin CostsTotal SNAP‐Ed Funded Salary and Benefits Annual SalaryBudget JustificationProject CoordinatorOffice Manager/Secretary/AdmPromotora*Promotora*Promotora*Promotora*Promotora*Promotora**home‐based position; FTE not included in space/maintenance costs calculationsDefinition and basis for calculations of benefit rate(s):Describe what is covered in the benefit rate for your agency.Retirement (10%), FICA (7.65%), medical/dental/vision (9.74%), long‐term disability/short‐term disability life/ADD (3.84%), workmen's compensation (2.77%), and California unemployment insurance (1.00%)Exhibit B Page 9 of 12
YEAR 3OCT 1, 2018 ‐ SEP 30, 2019Organization Name:County/Jurisidiction:Contract/Sub‐Grant/Agreement: 2. Non‐Capital Equipment/Supplies:AddDeleteReduceIncreaseLast Amount ApprovedFTE# of Items TotalBudget Justification1212$1,2002212$3,6003212$3,6004212$1681$02$0$8,5683. Materials:AddDeleteReduceIncreaseLast Amount Approved# of Items Total Budget Justification11080$2,70021080$1,080330$2,2504$05$06$07$0$6,030California Department of Public HealthFresno CountyThe Center/Cultiva La SaludBudget AdjustmentBudget AdjustmentBudget Item Description/Justification Cost per ItemOffice SuppliesStandard office supplies for program operations and nutrition education sessions. Includes, paper, pens, ink, etc...This is calculated basedon FTE X $50 a month x 12 months $50.00CommunicationsCosts for telephone, email, internet, website and eNewsleter service. Cost are calculated based on FTE X $150 a month x 12 months$150.00PrintingPrinting for office operations & nutrition education sessions. This is calculated based on FTE x $150 x 12 months$150.00Postage & DeliveryPostage for mailing reminders to households without email or phone service. Postage is calculated by FTE x$7 a month x 12 months.$7.00Theft‐sensitive equipment/supplies that are less than $5,000 (Computers, printers, projectors, etc.)Nutrition Ed materials Purchase of approved nutrition education materials. $1.00Total Non‐Capital Equipment/Supplies:Budget AdjustmentBudget AdjustmentBudget Item Description/Justification Cost per ItemFood & Beverage DemosMaterials & ingredients for healthy food and bevearge demonstrations. This includes cost of plates, napkins, utensils and cups.$2.50Champions Support for Champions in providing peer to peer single session nutriotn education. Calculated at $75 per Champion $75.00Total Materials: Exhibit B Page 10 of 12
YEAR 3OCT 1, 2018 ‐ SEP 30, 2019Organization Name:County/Jurisidiction:Contract/Sub‐Grant/Agreement: 4. Travel:AddDeleteReduceIncreaseLast Amount ApprovedLocation Description/Justification Trips FTE Days Nights Per Diem Lodging AirMiles($.540)Other Total Budget Justification1Lowell, West Fresno, Kerman, Sanger, Reedley, & ParlierTravel to target communities to deliver nutrition education sessons, peer to peer trainings and community meetings72 1 1 0 $0.00 $0.00 $0.00 50$0.00$1,9442Fresno Staff & Program meetings63 3 1 0 $0.00 $0.00 $0.00 50$0.00$1,7013$04$01$02$03$0$3,645* Lodging costs include taxes. Reimbursement at CalHR rates. 5. Building/Space:AddDeleteReduceIncreaseLast Amount ApprovedFTE# of Month(s)Total Budget Justification11.512$13,4882112$1,8003112$4,8004$0$20,0886. Maintenance:AddDeleteReduceIncreaseLast Amount ApprovedFTE# of Month(s)Total Budget Justification11.512$4,8002$03$0$4,800California Department of Public HealthFresno CountyThe Center/Cultiva La SaludBudget AdjustmentBudget AdjustmentPosition Title/NameRegistration FeeIn‐StateProject Coordinator$0.00Promotoras$0.00Out‐of‐StateTotal Travel:Budget AdjustmentBudget AdjustmentLocation Name/Address Calculation Description Cost per Month2409 Merced Street, Fresno, CA 93721Office space for project staff (based on rate per FTE) FTE x 150 sq ft x $5/ sq ft x 12 months. $749.333330 E Tulare Street, Fresno, CA Storage space for materials based on cost of $150/month$150.00405 E. Belmont Ave, Fresno, CA Kitchen space for rental for food prep cost is based on $400/month $400.00Budget AdjustmentBudget AdjustmentLocation Name/Address Calculation Description Cost per MonthTotal Building/Space:2409 Merced Street, Suite 101, Fresno, CA Janitorial services calculated by FTE x $266.67 per month x 12 months$266.67Total Maintenance:Exhibit B Page 11 of 12
YEAR 3OCT 1, 2018 ‐ SEP 30, 2019Organization Name:County/Jurisidiction:Contract/Sub‐Grant/Agreement: 7. Equipment and Other Capital Expenditures:AddDeleteReduceIncreaseLast Amount ApprovedFTE# ofItemsMisc. Total Budget Justification1$02$03$0$08. Contracts/Sub‐Grants/Agreements:AddDeleteReduceIncreaseLast Amount ApprovedTotal Grant Budget JustificationA$7,441BC$0D$0$7,4419. Indirect Costs:AddDeleteReduceIncreaseLast Amount ApprovedTotalBudget Justification1$33,9131$0$33,913Budget AdjustmentBudget AdjustmentCalifornia Department of Public HealthFresno CountyThe Center/Cultiva La SaludBudget ItemDescription/JustificationCost per ItemTotal Equipment and Other Capital Expenditures:Budget AdjustmentBudget AdjustmentAdministration: [Please list the line items that are included in calculation]Organization Name Description of Service(s)Cultiva La Salud Adminstrator for Project ‐ Genoveva IslasTotal Contracts/Sub‐Grants/Agreements:Total Direct Costs: $226,087Budget AdjustmentBudget AdjustmentCalculation MethodIndirect Cost RateTotal Admin/Program DollarsTotal Indirect Costs:Total Budget: $260,000Total Direct15.00% $226,087.00Program: [Please list the line items that are included in calculation]0.00%Exhibit B Page 12 of 12I
County of Fresno
16‐10139
Page 1 of 3
EXHIBIT C
STANDARD GRANT CONDITIONS
1. APPROVAL: This Grant is of no force or effect until signed by both parties and
approved by the Department of General Services, if required. The Grantee may not
commence performance until such approval has been obtained
2. AMENDMENT: No amendment or variation of the terms of this Grant shall be
valid unless made in writing, signed by the parties, and approved as required. No oral
understanding or Agreement not incorporated in the Grant is binding on any of the
parties. In no case shall the Department materially alter the scope of the Project set
forth in Exhibit A.
3. ASSIGNMENT: This Grant is not assignable by the Grantee, either in
whole or in part, without the written consent of the Grant Manager in the form
of a written amendment to the Grant.
4. AUDIT: Grantee agrees that the Department, the Bureau of State Audits,
or their designated representative shall have the right to review and to copy any
records and supporting documentation pertaining to this Grant. Grantee agrees
to maintain such records for a possible audit for a minimum of three (3) years
after final payment or completion of the project funded with this Grant, unless a
longer period of records retention is stipulated. Grantee agrees to allow the
auditor(s) access to such records during normal business hours and to allow
interviews of any employees who might reasonably have information related to
such records. Further, Grantee agrees to include a similar right of the State to
audit records and interview staff in any subcontract related to the project.
5. CONFLICT OF INTEREST: Grantee certifies that it is in compliance
with all applicable state and/or federal conflict of interest laws.
6. INDEMNIFICATION: Grantee agrees to indemnify, defend and save
harmless the State, its officers, agents and employees from any and all claims
and losses accruing or resulting to any and all contractors, subcontractors,
suppliers, laborers, and any other person, firm or corporation furnishing or
supplying work services, materials, or supplies in connection with the project,
and from any and all claims and losses accruing or resulting to any person, firm
or corporation who may be injured or damaged by Grantee in the performance
of any activities related to the Project.
County of Fresno
16‐10139
Page 2 of 3
7. FISCAL MANAGEMENT SYSTEMS AND ACCOUNTING STANDARDS:
Grantee agrees that, at a minimum, its fiscal control and accounting procedures will
be sufficient to permit tracing of all grant funds to a level of expenditure adequate to
establish that such funds have not been used in violation of any applicable state or
federal law, or the provisions of this Grant. Grantee further agrees that it will
maintain separate Project accounts in accordance with generally accepted
accounting principles.
8. GOVERNING LAW: This Grant is governed by and shall be interpreted in
accordance with the laws of the State of California.
9. INCOME RESTRICTIONS: Grantee agrees that any refunds, rebates,
credits, or other amounts (including any interest thereon) accruing to or
received by the Grantee under this Grant shall be paid by the Grantee to the
Department, to the extent that they are properly allocable to costs for which the
Grantee has been reimbursed by the Department under this Grant.
10. INDEPENDENT GRANTEE: Grantee, and its agents and employees of
Grantee, in the performance of the Project, shall act in an independent capacity
and not as officers, employees or agents of the Department.
11. MEDIA EVENTS: Grantee shall notify the Department’s Grant Manager
in writing at least twenty (20) working days before any public or media event
publicizing the accomplishments and/or results of the Project and provide the
opportunity for attendance and participation by Department’s representatives.
12. NO THIRD-PARTY RIGHTS: The Department and Grantee do not
intend to create any rights or remedies for any third- party as a beneficiary of
this Grant or the project.
13. NOTICE: Grantee shall promptly notify the Department’s Grant
Manager in writing of any events, developments or changes that could affect
the completion of the project or the budget approved for this Grant.
14. PROFESSIONALS: Grantee agrees that only licensed professionals
will be used to perform services under this Grant where such services are
called for.
County of Fresno
16‐10139
Page 3 of 3
15. RECORDS: Grantee certifies that it will maintain Project accounts in
accordance with generally accepted accounting principles. Grantee further
certifies that it will comply with the following conditions for a grant award as set
forth in the Request for Applications (Exhibit D) and the Grant Application
(Exhibit A).
Establish an official file for the Project which shall adequately document all
significant actions relative to the Project;
Establish separate accounts which will adequately and accurately depict all
amounts received and expended on this Project, including all grant funds
received under this Grant;
Establish separate accounts which will adequately depict all income
received which is attributable to the Project, especially including any income
attributable to grant funds disbursed under this Grant;
Establish an accounting system which will adequately depict final total
costs of the Project, including both direct and indirect costs; and,
Establish such accounts and maintain such records as may be necessary
for the state to fulfill federal reporting requirements, including any and all
reporting requirements under federal tax statutes or regulations.
16. RELATED LITIGATION: Under no circumstances may Grantee use funds from
any disbursement under this Grant to pay for costs associated with any litigation between
the Grantee and the Department.
17. RIGHTS IN DATA: Grantee and the Department agree that all data, plans,
drawings, specifications, reports, computer programs, operating manuals, notes,
and other written or graphic work submitted under Exhibit A in the performance of
the Project funded by this Grant shall be in the public domain. Grantee may
disclose, disseminate and use in whole or in part, any final form data and
information received, collected, and developed under this Project, subject to
appropriate acknowledgment of credit to the Department for financial support.
Grantee shall not utilize the materials submitted to the Department (except data) for
any profit making venture or sell or grant rights to a third-party who intends to do
so. The Department has the right to use submitted data for all governmental
purposes.
18. VENUE: The Department and Grantee agree that any action arising
out of this Grant shall be filed and maintained in the Superior Court, County of
Sacramento, California. Grantee waives any existing sovereign immunity for
the purposes of this Grant, if applicable.
Exhibit D
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “County”),
members of a contractor’s board of directors (hereinafter referred to as “County Contractor”), must
disclose any self-dealing transactions that they are a party to while providing goods, performing
services, or both for the County. A self-dealing transaction is defined below:
“A self-dealing transaction means a transaction to which the corpora tion is a party and in which one
or more of its directors has a material financial interest .”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member’s name, job title (if applicable), and dat e this disclosure is being made.
(2) Enter the board member’s company/agency name and address.
(3) Describe in detail the nature of the self -dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the Corporation has the transaction;
and
b. The nature of the material financial interest in the Corporation’s transaction that the
board member has.
(4) Describe in detail why the self -dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self -dealing transaction
described in Sections (3) and (4).
Exhibit D
Page 2 of 2
(1) Company Board Member Information:
Name: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a party to):
(4) Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233 (a):
(5) Authorized Signature
Signature: Date: