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Agreement No. 13-393-1
AMENDMENT I TO AGREEMENT
THIS AMENDMENT, hereinafter referred to as Amendment I, is made and entered into
this 16th day of June , 2015, by and between the COUNTY OF FRESNO, a
Political Subdivision ofthe State of California, hereinafter referred to as "COUNTY", and
TURNING POINT OF CENTRAL CALIFORNIA, INC., a private Non-profit Corporation,
whose address is P.O. Box 7447, Visalia, CA 93290, hereinafter referred to as
"CONTRACTOR" (collectively the "parties").
WHEREAS, the parties entered into that certain Agreement, identified as COUNTY
Agreement No. 13-393, effective June 18,2013, whereby, CONTRACTOR agreed to operate
Rural Full Service Partnership (FSP) program, an Intensive Case Management (ICM) program,
and an Outpatient (OP) mental health program for children, adult and older adult clients who
have serious emotional disturbance and/or serious and persistent mental illness in Pinedale,
Sanger, Reedley, Selma, Kerman, and Coalinga and other rural sites as may be needed; and
WHEREAS, the parties desire to amend COUNTY Agreement No. 13-393 effective upon
execution, regarding changes as stated below and restate the Agreement in its entirety.
NOW, THEREFORE, for good and valuable consideration, the receipt and adequacy of
which is hereby acknowledged, the parties agree as follows:
I. That the existing COUNTY Agreement No. 13-393, Section Four (4), Page Four
19 (4), Line Seven (7), beginning with the word "The" and ending on Page Five (5), Line
2 0 Seventeen (17) with the word "Exhibit C" be deleted and the following inserted in its place:
21 "The maximum amount under this Agreement for each fiscal year beginning FY
22 2013-14 and ending FY 2014-15, and for all three (3) rural programs (FSP, ICM, OP)
2 3 referenced in Section 1. SERVICES collectively, shall not exceed Four Million Nine Hundred
24 Thirty-Seven Thousand Three Hundred Ninety-Nine and No/100 Dollars ($4,937,399.00).
2 5 The maximum amount under this Agreement for each fiscal year beginning FY
26 2015-16 and ending FY 2017-18, and for all three (3) rural programs (FSP, ICM, OP)
27 referenced in Section 1. SERVICES collectively, shall not exceed Six Million Four Hundred
28 Seventy-Four Thousand Two Hundred Five and No/100 Dollars ($6,474,205.00).
-1 -
COUNTY OF FRESNO
Fresno, CA
1 The maximum amount under this Agreement for the entire five (5) year term for
2 all three (3) rural programs (FSP, ICM, OP) together shall not exceed Twenty-Nine Million
3 Two Hundred Ninety-Seven Thousand Four Hundred Thirteen and No/1 00 Dollars
4 ($29,297,413.00).
5 For fiscal year 2013-14, the Rural FSP program maximum amount under this
6 Agreement for all funding and revenue streams collectively shall not exceed One Million Five
7 Hundred Seventy-Three Thousand One Hundred Eighty-Seven and No/1 00 Dollars
8 ($1,573,187.00). The maximum amount ofMHSA funding for Rural FSP under this
9 Agreement, shall not exceed One Million One Hundred Ninety-Eight Thousand Three Hundred
10 Ninety-Seven and No/1 00 Dollars ($1, 198,397.00). In addition, it is understood by
11 CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Three Hundred
12 Sixty-Nine Thousand Seven Hundred Ninety and No/100 Dollars ($369,790.00) in Medi-Cal
13 Federal Financial Participation (FFP) and Five Thousand and Noll 00 Dollars ($5,000.00) in
14 client rents to offset CONTRACTOR's program costs as set forth in the budget, attached hereto
15 as Revised Exhibit C and incorporated herein by reference.
16 For fiscal year 2014-15, the Rural FSP program maximum amount under this
1 7 Agreement for all funding and revenue streams collectively shall not exceed One Million Fifty
18 Thousand Five Hundred Thirty-Eight and Noll 00 Dollars ($1 ,050,538.00). The maximum
19 amount of MHSA funding for Rural FSP under this Agreement, shall not exceed Seven
20 Hundred Twenty-Three Thousand Nine Hundred Twenty-Four and NollOO Dollars
21 ($723,924.00). In addition, it is understood by CONTRACTOR and COUNTY that
2 2 CONTRACTOR estimates to generate Three Hundred Twenty-One Thousand Six Hundred
2 3 Twelve and No/1 00 Dollars ($321 ,612.00) in Medi-Cal Federal Financial Participation (FFP)
2 4 and Five Thousand One and No/1 00 Dollars ($5,00 1.00) in client rents to offset
2 5 CONTRACTOR's program costs as set forth in the budget, attached hereto as Revised Exhibit
2 6 C and incorporated herein by reference.
2 7 For each fiscal year beginning FY 2015-16 and ending FY 2017-18, the Rural
2 8 FSP program maximum amount under this Amendment I to Agreement for all funding and
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COUNTY OF FRESNO
Fresno, CA
1 revenue streams collectively shall not exceed One Million Six Hundred Nineteen Thousand
2 Three Hundred Fifty-Eight and No/1 00 Dollars ($1 ,619,358.00). The maximum amount of
3 MHSA funding for Rural FSP under this Amendment I to Agreement, shall not exceed One
4 Million One Hundred Forty-Four Thousand Three Hundred Fifty-Three and Noll 00 Dollars
5 ($1,144,353.00). In addition, it is understood by CONTRACTOR and COUNTY that
6 CONTRACTOR estimates to generate Four Hundred Seventy Thousand Four and Noll 00
7 Dollars ($470,004.00) in Medi-Cal Federal Financial Participation (FFP) and Five Thousand
8 One and No/100 Dollars ($5,001.00) in client rents to offset CONTRACTOR's program costs
9 as set forth in the budget, attached hereto as Revised Exhibit C and incorporated herein by
1 0 reference.
11 For fiscal year FY 2013-14, the Rural ICM program maximum amount under this
12 Amendment I to Agreement for all funding and revenue streams collectively shall not exceed
13 Two Million Seven Hundred Seventy Thousand Three Hundred Twenty Seven and No/1 00
14 Dollars ($2,770,327.00). The maximum amount ofMHSA funding for Rural ICM under this
15 Amendment I to Agreement, shall not exceed Two Million One Hundred Sixty-Six Thousand
16 Nine Hundred Seventy-Seven and No/100 Dollars ($2,166,977.00). In addition, it is understood
1 7 by CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Six Hundred
18 Three Thousand Three Hundred Fifty and NollOO Dollars ($603,350.00) in Medi-Cal Federal
19 Financial Participation (FFP) to offset CONTRACTOR's program costs as set forth in the
2 0 budget, attached hereto as Revised Exhibit C and incorporated herein by reference.
21 For fiscal year FY 2014-15, the Rural ICM program maximum amount under this
2 2 Amendment I to Agreement for all funding and revenue streams collectively shall not exceed
2 3 Two Million Nine Hundred Ninety-Nine Thousand Three Hundred Seven and Noll 00 Dollars
24 ($2,999,307.00). The maximum amount ofMHSA funding for Rural ICM under this
2 5 Amendment I to Agreement, shall not exceed Two Million Three Hundred Ninety-Seven
26 Thousand Six Hundred Thirteen and No/100 Dollars ($2,397,613.00). In addition, it is
2 7 understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Six
2 8 Hundred One Thousand Six Hundred Ninety-Four and Noll 00 Dollars ($60 1 ,694.00) in Medi-
- 3 -
COUNTY OF FRESNO
Fresno, CA
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Cal Federal Financial Participation (FFP) to offset CONTRACTOR's program costs as set forth
in the budget, attached hereto as Revised Exhibit C and incorporated herein by reference.
For fiscal year beginning FY 2015-16 and ending FY 2017-18, the Rural ICM
program maximum amount under this Amendment I to Agreement for all funding and revenue
streams collectively shall not exceed Three Million Nine Hundred Seventy-One Thousand
Three Hundred Thirty-Five and NollOO Dollars ($3,971,335.00). The maximum amount of
MHSA funding for Rural ICM under this Amendment I to Agreement, shall not exceed Two
Million Two Hundred Fifty-Seven Thousand Three Hundred Fifty-Six and Noll 00 Dollars
($2,257,356.00). In addition, it is understood by CONTRACTOR and COUNTY that
CONTRACTOR estimates to generate One Million Seven Hundred Thirteen Thousand Nine
Hundred Seventy Eight and No/100 Dollars ($1,713,978.00) in Medi-Cal Federal Financial
Participation (FFP) to offset CONTRACTOR's program costs as set forth in the budget,
attached hereto as Revised Exhibit C and incorporated herein by reference.
For fiscal year 2013-14, the Rural OP program maximum amount under this
Amendment I to Agreement for all funding and revenue streams collectively shall not exceed
Five Hundred Ninety-Three Thousand Eight Hundred Eighty-Five and Noll 00 Dollars
($593,885.00). The maximum amount ofMHSA and Mental Health Realignment funding for
Rural OP under this Amendment I to Agreement, shall not exceed Three Hundred Ninety-Three
Thousand One Hundred Thirty-Six and No/100 Dollars ($393,136.00). In addition, it is
understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Two
Hundred Thousand Seven Hundred Forty-Nine and Noll 00 Dollars ($200, 749.00) in Medi-Cal
Federal Financial Participation (FFP) to offset CONTRACTOR's program costs as set forth in
the budget, attached hereto as Revised Exhibit C and incorporated herein by reference.
For fiscal year FY 2014-15, the Rural OP program maximum amount under this
Amendment I to Agreement for all funding and revenue streams collectively shall not exceed
Eight Hundred Eighty-Seven Thousand Five Hundred Fifty-Four and Noll 00 Dollars
($887,554.00). The maximum amount ofMHSA and Mental Health Realignment funding for
Rural OP under this Amendment I to Agreement shall not exceed Six Hundred Thirty-Six
- 4 -
COUNTY OF FRESNO
Fresno, CA
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Thousand Nine Hundred Seventy-Three and Noll 00 Dollars ($636,973 .00). In addition, it is
understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Two
Hundred Fifty Thousand Five Hundred Eighty-Two and No/1 00 Dollars ($250,582.00) in Medi-
Cal Federal Financial Participation (FFP) to offset CONTRACTOR's program costs as set forth
in the budget, attached hereto as Revised Exhibit C and incorporated herein by reference.
For each fiscal year beginning FY 2015-16 and ending FY 2017-2018, the Rural
OP program maximum amount under this Amendment I to Agreement for all funding and
revenue streams collectively shall not exceed Eight Hundred Eighty-Three Thousand Five
Hundred Twelve and No/100 Dollars ($883,512.00). The maximum amount ofMHSA and
Mental Health Realignment funding for Rural OP under this Amendment I to Agreement, shall
not exceed Five Hundred Fifty-Three Thousand Fifty-Six and Noll 00 Dollars ($553,056.00). In
addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to
generate Three Hundred Thirty Thousand Four Hundred Fifty-Five and Noll 00 Dollars
($330,455.00) in Medi-Cal Federal Financial Participation (FFP) to offset CONTRACTOR's
program costs as set forth in the budget, attached hereto as Revised Exhibit C and incorporated
herein by reference. "
2. That the existing COUNTY Agreement No. 13-393, Section Seven (7), Page
Eleven ( 11 ), Line Eighteen (18) beginning with the word "Notwithstanding" and ending on line
Twenty-Two (22) with the word "herein" be deleted and the following inserted in its place:
"Notwithstanding the above, changes to the line items in the individual program
budgets set forth in Revised Exhibit C, and movement of funds between the FSP, ICM and OP
program budgets, may be made with the written approval of COUNTY's DBH Director or
his/her designee and CONTRACTOR. All changes combined may not exceed ten percent
(10%) ofthe annual maximum compensation payable to CONTRACTOR, as stated herein."
3. That the following be inserted on Page Thirty-Four (34), Line Five (5) to the
existing COUNTY Agreement No. 13-393.
"31. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST
INFORMATION
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COUNTY OF FRESNO
Fresno, CA
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This provision is only applicable ifPROVIDER(s) 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, and 455.106(a)(1),(2).
In accordance with C.P.R., Title 42 §§ 455.101,455.104,455.105 and
455.106(a)(1),(2), the following information must be disclosed by PROVIDER(s) by
completing Exhibit K, "Disclosure of Ownership and Control Interest Statement", attached
hereto and by this reference incorporated herein and made part of this Agreement.
PROVIDER(s) shall submit this form to COUNTY's DBH within thirty (30) days of the
effective date of this Agreement. Additionally, PROVIDER(s) shall report any changes to this
information within thirty-five (35) days of occurrence by completing Exhibit J, "Disclosure of
Ownership and Control Interest Statement." Submissions shall be scanned pdf copies and are
to be sent via email to DBHAdministration@co.fresno.ca.us attention: Contracts
Administration.
4. That the existing COUNTY Agreement No. 13-393 Sections "31. Disclosure-
15 Criminal History & Civil Actions" through "34. Entire Agreement" be renumbered to read
16 Sections "32" through "35".
17 5. That a new "Exhibit K" is attached hereto and incorporated herein by this
18 reference.
19 6. That all references in existing COUNTY Agreement No. 13-393 to "Exhibit C,"
2 0 shall be changed to read "Revised Exhibit C," where appropriate, attached hereto and
21 incorporated herein by reference.
22 7. That all references in existing COUNTY Agreement No. 13-393 to "Exhibit
2 3 A-1, Exhibit A-2, and Exhibit A-3," shall be changed to read "Revised Exhibit A" where
2 4 appropriate, attached hereto and incorporated herein by reference.
25 8. COUNTY and CONTRACTOR agree that this Amendment I is sufficient to
2 6 amend the Agreement; and that upon execution of this Amendment I, the Agreement, and
2 7 Amendment I together shall be considered the Agreement.
2 8 The Agreement, as hereby amended, is ratified and continued. All provisions,
- 6 -
COUNTY OF FRESNO
Fresno, CA
1 terms, covenants, conditions and promises contained in the Agreement, and not amended herein,
2 shall remain in full force and effect. This Amendment I shall become effective upon execution
3 by all parties.
4 IN WITNESS WHEREOF, the parties hereto have executed this Amendment I to
5 Agreement No. 13-393 as of the day and year first hereinabove written.
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COUNTY OF FRESNO
Fresno, CA
1 ATTEST:
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CONTRACTOR:
TURNING POINT OF CENTRAL
CALIFORNIA, INC.
PrintName: ~.J7d-f~€J
Title: C/ZQ
Chairman of the Board, or
President, or any Vice President
COUNTY OF FRESNO
ByUJmwQ,
Deborah A. Poochigian
Chairman, Board of Supervisors
Date: ~nu lftr.W I 5
BERNICE E. SEIDEL, Clerk
Board of Supervisors
. By ~ By Sv,s,OyyV e:.i!llio,p
PrintName: f/tYOf/AJ£2 /3.~
Title: C£ D~ £L-ee-T Date: :.fu_.,NL, I LA 1 d-0 15
Secretary (of Corporation), oi
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer
Mailing Address:
P.O. BOX 7447
Visalia, CA 93290
Phone No.: (559) 732-8086 Ext. 140
Contact: Chief Executive Officer
-8 -
PLEASE SEE ADDITIONAL
SIGNATURE PAGE ATTACHED
COUNTY OF FRESNO
Fresno, CA
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APPROVED AS TO LEGAL FORM:
DANIEL C. CEDERBORG, COUNTY COUNSEL
By~~~ APPR ED AS TO COUNTING FORM:
VICKI CROW, C.P.A., AUDITOR-CONTROLLER/
TREASURER-TAX COLLECTOR
REVIEWED AND RECOMMENDED FOR
APPROVAL:
By~·~
Dawan Utecht, Director
Department of Behavioral Health
Fund/Subclass: 0001/10000
Organizations/Cost Centers: 56304527, 56304528, 56304529.
Accounts/Programs: 7294/0
FY 13-14 FY 14-15 FY 15-16 FY 16-17
OP 4527 $593,885 $887,555 $883,512 $883,512
ICM 4528 $2,770,327 $2,999,307 $3,971,335 $3,971,335
FSP 4529 $1,573,187 $1,050,538 $1,619,358 $1,619,358
Total-$4,937,399 $4,937,399 $6,474,205 $6,474,205
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FY 17-18 Total
$883,512 $4,131,976
$3,971,335 $17,683,639
$1,619,358 $7,481,799
$6,474,205 $29,297,413
COUNTY OF FRESNO
Fresno, CA
ORGANIZATION:
Mental Health Services Act (MHSA)
Rural Full Service Partnership (FSP) Services Program
Scope of Work
Turning Point of Central California, Inc.
CORPORATE ADDRESS: P.O. Box 7447, Visalia Ca 93290
SITE ADDRESSES: Pinedale:
Reedley:
Sanger:
Selma:
Kerman:
Coalinga:
34 & 40 East Minarets, Pinedale, CA 93650
1131 I Street, Reedley, CA 93654
225 Academy, Sanger, CA 93657
3800 & 3810 McCall Avenue, Selma, CA 93662
275 S. Madera Street, Suite 404, Kerman, CA 93630
311 Coalinga Plaza, Coalinga, CA 93210
Revised Exhibit A
Page 1 of 12
PROGRAMS & SERVICES: Programs are Full Service Partnership (FSP) Program, Intensive Case Management
(ICM) Program, and Outpatient (OP) Services Program. Services include mental
health services, intensive case management, crisis outreach services, medication
evaluation, peer support, and supported independent permanent housing for adults
with serious mental illness and children with severe emotional disturbance in rural
Fresno County. Services will be provided with a focus on recovery, resiliency and
well ness.
PROGRAM DIRECTOR: Veronica DeAlba; (559) 436-0482
CONTRACT PERIOD: July 1, 2013-June 30, 2018
CONTRACT FUNDING: $29,297,415-All5 Terms, All3 Programs and All6 Service Sites Combined
Full Service Partnership Program (all sites)
FY 2013-14
FY 2014-15
FY 2015-16
FY 2016-17
FY 2017-18
Total:
Total
$1,573,187
$1,050,538
$1,619,358
$1,619,358
$1,619,358
$7,481,799
CSS Realignment FFP
$1,198,397 0 $369,790
$ 723,924 0 $321,612
$1,144,353 0 $470,004
$1,144,353 0 $470,004
$1 I 144,353 Q $470,004
$5,355,380 0 $2,101,414
FULL SERVICE PARTNERSHIP
Client Rents
$5,000
$5,001
$5,001
$5,001
$5,001
$25,004
Mental Health Services in Reedley, Pinedale, Sanger, Selma, Kerman, and Coalinga
SCHEDULE OF SERVICES:
CONTRACTOR staff shall be available to provide services to clients 24 hours per day, seven (7) days per week.
TARGET POPULATION:
The target population includes adults and children that live in rural Fresno County and have been assessed and
determined to be in need of Full Service Partnership (FSP) level of mental health services. This population includes
adults with severe mental illness (schizophrenia, major depression with psychotic features or bi-polar disorders),
children with serious emotional disturbance, and those adults and/or children who have had recent admissions to
the county's crisis intervention services (CIS), acute inpatient or have been incarcerated. For those clients who have
0302adbh
Revised Exhibit A
Page 2 of 12
been assessed and determined in need of Rural Full Service Partnership (FSP) services, services will be provided
at six established rural service sites including: Reedley, Pinedale, Sanger, Selma, Kerman, and Coalinga. In
addition, those rural clients that do not reside in one of the rural service cities identified will be sought for delivery of
services and/or for transportation to services at one of the established rural sites. The FSP program will serve a
minimum of approximately 175 clients referred by the County annually in FY 2013-14, 120 clients in FY 2014-15 and
a total of 175 in FY 2015-16 and subsequent fiscal years.
CONTRACTOR'S RESPONSIBILITIES:
CONTRACTOR shall:
A. Provide case management and crisis outreach services will be available 24 hours a day/7 days a week both
telephonically and in person. There shall be a minimum of providing 3 person to person contacts a week
with each client. Services include, but may not be limited to: case management, crisis services, medication
support, collateral, plan development, assessment, and rehabilitation services as needed.
1. Provider shall adhere to the following:
• Staffing ratio of not more than 1 staff to 15 clients.
• Assist clients in accessing all entitlements or benefits for which they are eligible (i.e. Medi-Cal,
SSI, Section 8 vouchers etc.).
• Develop family support and involvement whenever possible
• Develop and maintenance access to supported education and employment opportunities.
• Develop and maintain a "representative payee" service to those clients who could benefit from this
service.
• Develop and provide transportation to enable clients to access health care, mental health services
and education, recreational or peer support services in the community.
2. Provide Medication Evaluation either in person or via tela-psychiatry.
3. Provide Peer Support services.
4. Provide Supported Independent Permanent Housing (including locating residences and assisting
clients to successfully live in the community).
5. Provide services for Co-Occurring substance abuse disorders.
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• Identify alcohol, tobacco and drug abuse effects and patterns.
• Education regarding the interaction of alcohol, tobacco and drug use with psychiatric symptoms
and medications.
• Developing motivation for deceasing alcohol, tobacco and drug use.
• Achieving periods of abstinence and stability.
• Use of clinical interventions and peer support recovery groups and activities.
• Assisting clients to achieve an alcohol, tobacco and drug free life style.
• Education regarding relapse prevention.
6. Develop client self-directed plan of care/wellness and recovery plan.
7. Provide Education and training in independent living skills to include.
• Carry out personal hygiene tasks.
• Perform household chores, including cooking, laundry and shopping.
• Development of money management skills.
• Use of community transportation.
8. Transport clients to and from rural service sites as needed.
Revised Exhibit A
Page 3 of 12
9. Collaborate with local communities to provide additional services at their locations, as well as
establishing new rural sites as circumstances and needs warrant.
10. Outreach to rural clients who are un-served and/or underserved to improve rural penetration rates,
with an emphasis on the penetration rates of rural Hispanics. Penetration rates should improve by a
minimum of 20% in the first term, and by at least 10% per subsequent term.
COUNTY RESPONSIBILITIES:
COUNTY shall:
1. Provide oversight (through the County Department of Behavioral Health (DBH), Adult System of Care, and
the Mental Health Services Act, Division Managers or designees) of the CONTRACTOR'S Rural FSP
program. In addition to contract monitoring of program, oversight includes, but not limited to, coordination
with the State Department of Mental Health, Mental Health Services Act in regard to program administration
and outcomes.
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
vendor staff and will be available to the contractor for ongoing consultation.
4. Receive and analyze statistical data outcome information from vendor throughout the term of contract on a
monthly basis. DBH will notify the vendor 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. To assist the vendor efforts towards cultural and
linguistic competency, DBH shall provide the following at no cost to vendor(s):
A Technical assistance to vendor regarding cultural competency requirements and sexual orientation
training.
B. Mandatory cultural competency training including sexual orientation and sensitivity training for DBH and
vendor 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
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Revised Exhibit A
Page 4 of 12
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. Access to care may be limited due
to concerns about providers' sensitivity to differences in sexual orientation.
C. Technical assistance for vendor 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.
PROGRAM OBJECTIVES AND Outcomes (FSP Program)
The following items listed below represent program goals to be tracked and achieved by the vendor during the
contract terms.
Full Service Partnership
0302adbh
• Reduce frequency of hospitalization for each client served.
• Reduce frequency of access to crisis services provided by the Intensive Services Division.
• Reduce frequency of incarceration for each client.
• Vendor will conduct an assessment of each client and a plan of care
• Vendor will develop a satisfaction survey, approved by DBH that complies with the mandated
State performance outcome and quality improvement reports/outcomes. At a minimum, ninety
percent (90%) of clients will report satisfaction with the program services.
• Direct service productivity rate shall be a minimum of eighty percent (80%).
• Clients in independent housing will develop a plan for assisting in paying their own housing costs.
Clients will assume responsibility for housing costs when deemed ready and appropriate. Within
six months of enrollment, ninety-nine percent (99%) of clients without SSI will have made SSI
applications. Vendor shall provide a written report regarding these goals on a semi-annual basis.
• Vendor will identify services provided to each client and resulting outcome measurements as
requested.
• Comply with all MHSA Full Service Partnerships Data Reporting as referenced within Exhibit B.
Revised Exhibit A
Page 5 of 12
ORGANIZATION:
MENTAL HEALTH SERVICES ACT (MHSA)
RURAL INTENSIVE CASE MANAGEMENT PROGRAM
Scope of Work
Turning Point of Central California, Inc.
CORPORATE ADDRESS: P.O. Box 7447, Visalia Ca 93290
SITE ADDRESSES: Pinedale:
Reedley:
Sanger:
Selma:
Kerman:
Coalinga:
34 & 40 East Minarets, Pinedale, CA 93650
1131 I Street, Reedley, CA 93654
225 Academy, Sanger, CA 93657
3800 & 3810 McCall Avenue, Selma, CA 93662
275 S. Madera Street, Suite 404, Kerman, CA 93630
311 Coalinga Plaza, Coalinga, CA 93210
PROGRAMS & SERVICES: Programs are Full Service Partnership (FSP) Program, Intensive Case Management
(ICM) Program, and Outpatient (OP) Services Program. Services include mental
health services, intensive case management, crisis outreach services, medication
evaluation, peer support, and supported independent permanent housing for adults
with serious mental illness and children with severe emotional disturbance in rural
Fresno County.
PROGRAM DIRECTOR: Veronica DeAlba; (559) 436-0482
CONTRACT PERIOD: July 1, 2013-June 30, 2018
CONTRACT FUNDING: $29,297,415-All 5 Terms, All 3 Programs and All 6 Service Sites Combined
Intensive Case Management Program (all sites)
FY 2013-14
FY 2014-15
FY 2015-16
FY 2016-17
FY 2017-18
Total:
Total CSS Realignment FFP
$2,770,327 $2.166,977 0 $603,350
$2,999,307 $2,397,613 0 $601,694
$3,971,335 $2,257,356 0 $1,713,978
$3,971,335 $2,257,356 0 $1,713,978
$3,971.335 $2.257.356 Q $1.713.978
$17,683,639 $11,336,658 0 $6,346,978
INTENSIVE CASE MANAGEMENT
Client Rents
0
0
0
0
Q
0
ICM Mental Health Services in Reedley, Pinedale, Sanger, Selma, Kerman, and Coalinga
SCHEDULE OF SERVICES:
CONTRACTOR staff shall be available to provide services to clients 8 hours a day/ 5 days a week.
TARGET POPULATION:
The target population includes adults and children that live in rural Fresno County and have been assessed and
determined to be in need of Intensive Case Management (ICM) level of mental health services. This population
includes adults with severe mental illness (schizophrenia, major depression with psychotic features or bi-polar
disorders) and children with serious emotional disturbance who are in need of on-going community based services.
For those clients who have been assessed and determined in need of ICM services, services will be provided at six
established rural service sites including: Reedley, Pinedale, Sanger, Selma, Kerman, and Coalinga. In addition,
those rural clients that do not reside in one of the rural service cities identified will be sought for delivery of services
0302adbh
Revised Exhibit A
Page 6 of 12
and/or for transportation to services at one of the established rural sites. The ICM program will serve approximately
889 clients annually in FY 2013-14, 1,400 clients annually in FY 2014-15 and will serve approximately 1800 clients
annually in FY 2015-16 and each subsequent year.
CONTRACTOR'S RESPONSIBILITY:
B. Services include, but may not be limited to: case management, crisis services, medication support,
collateral, plan development, assessment, and rehabilitation services as needed.
CONTRACTOR shall:
1. Provide Case management and community based crisis intervention services will be available 8
hours a day/ 5 days a week. There shall be a minimum of 1 person to person contact a week with
clients. Services include, but may not be limited to: case management, crisis services, medication
support, collateral, plan development, assessment, and rehabilitation services as needed.
2. Provider shall:
• Assist clients with accessing all entitlements or benefits for which they are eligible (i.e. Medi-Cal,
SSI, Section 8 vouchers etc.).
• Develop family support and involvement whenever possible.
• Refer clients to supported education and employment opportunities.
• Provide transportation service when it is critical to initially access a support service or gain
entitlements or benefits.
• Provide and services to enable clients to access peer support activities.
3. Provide Medication Evaluation either in person or via tela-psychiatry.
4. Assist clients to locate appropriate housing in the community.
5. Refer or provide peer support activities.
6. Provide services for Co-Occurring substance abuse disorders.
• Identify alcohol, tobacco and drug abuse effects and patterns.
• Education regarding the interaction of alcohol, tobacco and drug use with psychiatric symptoms
and medications.
• Developing motivation for deceasing alcohol, tobacco and drug use.
• Achieving periods of abstinence and stability.
• Use of clinical interventions and peer support recovery groups and activities.
• Assisting clients to achieve an alcohol, tobacco and drug free life style.
• Education regarding relapse prevention.
7. Develop client self-directed plan of care.
8. Transport clients to and from rural service sites as needed.
0302adbh
Revised Exhibit A
Page 7 of 12
9. Collaborate with local communities to provide additional services at their locations, as well as
establishing new rural sites as circumstances and needs warrant.
10. Outreach to rural clients who are un-served and/or underserved to improve rural penetration rates,
with an emphasis on the penetration rates of rural Hispanics. Penetration rates should improve by a
minimum of 20% in the first term, and by'at least 10% per subsequent term.
COUNTY RESPONSIBILITIES:
COUNTY shall:
6. Provide oversight (through the County Department of Behavioral Health (DBH), Adult System of Care,
Division Manager or designee) of the CONTRACTOR'S Homeless ACT program. In addition to contract
monitoring of program(s), oversight includes, but not limited to, coordination with the State Department of
Mental Health, Projects for Assistance in Transition from Homelessness (PATH) program in regard to
program administration and outcomes.
7. 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
8. Participate in evaluating the progress of the overall program and the efficiency of collaboration with the
vendor staff and will be available to the contractor for ongoing consultation.
9. Receive and analyze statistical data outcome information from vendor throughout the term of contract on a
monthly basis. DBH will notify the vendor 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.
10. 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. To assist the vendor efforts towards cultural and
linguistic competency, DBH shall provide the following at no cost to vendor(s):
A. Technical assistance to vendor regarding cultural competency requirements and sexual orientation
training.
B. Mandatory cultural competency training including sexual orientation and sensitivity training for DBH and
vendor 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. Access to care may be limited due
to concerns about providers' sensitivity to differences in sexual orientation.
C. Technical assistance for vendor 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.
PROGRAM OBJECTIVES
The following items listed below represent program goals to be tracked and achieved by the vendor during the
contract terms.
0302adbh
Revised Exhibit A
Page 8 of 12
Intensive Case Management Services
0302adbh
• Reduce frequency of hospitalization for each client served. Department of Behavioral Health will
provide baseline data for each client enrolled in the program. Reports and data will be submitted
on a monthly basis.
• Reduce frequency of access to crisis services provided by the Intensive Services Division.
Department of Behavioral Health will provide baseline data for each client enrolled in the program.
Reports and data will be submitted on a monthly basis.
• Reduce frequency of incarceration for each client.
• Vendor will conduct an assessment of each client and a plan of care on an annual basis.
• Vendor will develop a satisfaction survey, approved by DBH that complies with the mandated
State performance outcome and quality improvement reports/outcomes. At a minimum, ninety
percent (90%) of clients will report satisfaction with the program services.
• Direct service productivity rate shall be a minimum of eighty Percent (80%).
• Within six months of enrollment, ninety percent (99%) of clients without SSI will have made SSI
applications.
• Vendor shall provide a written report of services provided and related outcome measurements as
requested.
ORGANIZATION:
Mental Health Services Act (MHSA)
Rural Outpatient Mental Health Services Program
Scope of Work
Turning Point of Central California, Inc.
CORPORATE ADDRESS: P.O. Box 7447, Visalia Ca 93290
SITE ADDRESSES: Pinedale:
Reedley:
Sanger:
Selma:
Kerman:
Coalinga:
34 & 40 East Minarets, Pinedale, CA 93650
1131 I Street, Reedley, CA 93654
225 Academy, Sanger, CA 93657
3800 & 3810 McCall Avenue, Selma, CA 93662
275 S. Madera Street, Suite 404, Kerman, CA 93630
311 Coalinga Plaza, Coalinga, CA 93210
KeVISea I:XniDit A
Page 9 of 12
PROGRAMS & SERVICES: Programs are Full Service Partnership (FSP) Program, Intensive Case Management
(ICM) Program, and Outpatient (OP) Services Program. Services include mental
health services, intensive case management, crisis outreach services, medication
evaluation, peer support, and supported independent permanent housing for adults
with serious mental illness and children with severe emotional disturbance in rural
Fresno County.
PROGRAM DIRECTOR: Veronica DeAlba; (559) 436-0482
CONTRACT PERIOD: July 1, 2013 -June 30, 2018
CONTRACT FUNDING: $29,297,415 -AilS Terms, A113 Programs and All6 Service Sites Combined
Outpatient Program (all sites)
FY 2013-14
FY 2014-15
FY 2015-16
FY 2016-17
FY 2017-18
Total:
Total CSS Realignment FFP
$593,885 $319,056 $74,080 $200,749
$887,554 $562,895 $74,080 $250,582
$883,512 $478,976 $74,080 $330,455
$883,512 $478,976 $74,080 $330,455
$883.512 $478,976 $74.080 $330.455
$4,131,975 $2,318,879 $370,400 $1,442,696
OUTPATIENT
Client Rents
0
0
0
0
Q
0
Mental Health Services in Reedley, Pinedale, Sanger, Selma, Kerman, and Coalinga
SCHEDULE OF SERVICES:
CONTRACTOR staff shall be available to provide rural outpatient mental health services to clients 8 hours a day/5
days a week.
TARGET POPULATION:
The target population includes adults and children that live in rural Fresno County and have been assessed and
determined to be in need of Outpatient (OP) level of mental health services. This population includes those who are
Medi-Cal eligible and meet the State Department of Mental Health's medical necessity criteria. For those clients
who have been assessed and determined in need of OP services, services will be provided at six established rural
service sites including: Reedley, Pinedale, Sanger, Selma, Kerman and Coalinga. In addition, those rural clients
that do not reside in one of the rural service cities identified will be sought for delivery of services and/or for
transportation to services at one of the established rural sites.
0302adbh
PROJECT DESCRIPTION:
Revised Exhibit A
Page 10 of 12
For clients who are Medi-Cal eligible and who meet the State Department of Mental Health's medical necessity
criteria, the vendor will provide office based outpatient mental services to include individual, group and family
therapy and medication support services. The outpatient mental health services will be accessed through the
County's managed care program and will require prior authorization for services. The vendor staff will provide
short-term psychotherapy and medication support services. For individuals, who need medications only and do
not require mental health specialty services, the vendor will work with United Health Center or other like agency
to develop a collaborative agreement for the provision of primary care services. CONTRACTOR will provide
rural outpatient mental health services to approximately 436 clients annually in FY 2013-14, and will serve
approximately 778 clients annually in FY 2014-15 and each subsequent year.
1. CONTRACTOR shall provide the following specific services as it relates to mental health:
C. CONTRACTOR will provide mental health outpatient services (individual, group and family therapy, and
medication support) to approximately 436 (FY 2013-14-FY 2014-15) and 778 (FY 2015-16-2017-18)
adult clients annually throughout the contract term. Services include, but may not be limited to: case
management, crisis services, medication support, collateral, plan development, assessment, and
rehabilitation services as needed.
D. Ensure CONTRACTOR staff provides appropriate age, culture, gender and language services and
accommodations for physical disability (ies) to clients.
E. Make appropriate referrals and linkages to addiction services that are beyond that of the Rural Outpatient
Mental Health services program to individuals with coexisting alcohol, tobacco and drug abuse and other
addictive symptoms.
F. Provide support to the client's family and other members of the client's social network to help them manage
the symptoms and illness of the client and reduce the level of family and social stress associated with the
illness.
G. 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 vendor and other
service providers serving the same clients shall be developed and implemented consistent with Fresno
County confidentiality rules.
H. Selected Vendor shall maintain an up to date caseload record of all clients enrolled in services, and provide
client, programmatic, and other demographic information to the County. Reports are to be submitted to the
DBH Mental Health Services Act Division Manager or MHSA Staff Analyst on a monthly basis.
1. Selected bidder(s) shall compile quarterly reports indicating the total number of clients served in a particular
Fiscal Year.
J. Ensure billable Mental Health Specialty Services meet any/all County, State, Federal regulations
including any utilization review and quality assurance standards. Provide all pertinent and
appropriate information in a timely manner to County to bill Medi-Cal for services rendered.
K. Transport clients to and from rural service sites as needed.
L. Collaborate with local communities to provide additional services at their locations, as well as establishing
new rural sites as circumstances and needs warrant.
M. Outreach to rural clients who are un-served and/or underserved to improve rural penetration rates, with an
emphasis on the penetration rates of rural Hispanics. Penetration rates should improve by a minimum of
20% in the first term, and by at least 10% per subsequent term.
0302adbh
COUNTY RESPONSIBILITIES:
COUNTY shall:
Revised Exhibit A
Page 11 of 12
11. Provide oversight (through the County Department of Behavioral Health (DBH), Adult System of Care, and
Mental Health Services Act Division Managers or designees) of the CONTRACTOR'S Rural Outpatient
Mental Health Services program. In addition to contract monitoring of program, oversight includes, but not
limited to, coordination with the State Department of Mental Health, Mental Health Services Act in regard to
program administration and outcomes.
12. 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
13. Participate in evaluating the progress of the overall program and the efficiency of collaboration with the
vendor staff and will be available to the contractor for ongoing consultation.
14. Receive and analyze statistical data outcome information from vendor throughout the term of contract on a
monthly basis. DBH will notify the vendor 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.
15. 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. To assist the vendor efforts towards cultural and
linguistic competency, DBH shall provide the following at no cost to vendor(s):
A. Technical assistance to vendor regarding cultural competency requirements and sexual orientation
training.
B. Mandatory cultural competency training including sexual orientation and sensitivity training for DBH and
vendor 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. Access to care may be limited due
to concerns about providers' sensitivity to differences in sexual orientation.
C. Technical assistance for vendor 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.
PROGRAM OBJECTIVES
The following items listed below represent program goals to be tracked and achieved by the vendor during the
contract terms.
Rural Mental Health Outpatient Services
0302adbh
0302adbh
Revised Exhibit A
Page 12 of 12
• Vendor will develop a satisfaction survey, approved by DBH that complies with the mandated
State performance outcome and quality improvement reports/outcomes. At a minimum, ninety
percent (90%) of clients will report satisfaction with the program services.
• Direct service productivity rate shall be a minimum of eighty Percent (80%).
• Vender will comply with all requirements of the Department of Behavioral Health Managed Care
Organizational Provider Manual.
• Vender will comply with the County's Quality Assurance and Improvement Project.
• Vendor will identify services provided to each client and resulting outcome measurements as
requested.
Rural Mental Health-FSP
Turning Point of Central CA, Inc.
Fiscal Year 2013-2014
Budget Categories -
Line Item Description (Must be itemized) FTE% Admin.
PERSONNEL SALARIES:
0001 Program Director 27%
0002 Assistant Program Director 27%
0003 Mental Health Professionalrfeam Leader 100%
0004 Supervising Personal Services Coordinator 54%
0005 Case Managers 600%
0006 Driver 54%
0007 Nurse 95%
0008 Peer Support 41%
0009 Secretary 101%
0010 Billing Clerk 54%
0011 Psychiatrist 22%
0012
SALARY TOTAL 12.02
PAYROLL TAXES:
0030 OASDI
0031 FICA/MEDICARE
0032 SUI
PAYROLL TAX TOTAL
EMPLOYEE BENEFITS:
0040 Retirement
0041 Workers Compensation
0042 Health Insurance (medical, vision, life, dental)
EMPLOYEE BENEFITS TOTAL
SALARY & BENEFITS GRAND TOTAL
FACILITIES/EQUIPMENT EXPENSES·
1010 RenULease Building
1011 RenULease Equipment
1012 Utilities
1013 Building Maintenance
1014 Equipment Maintenance
FACILITY/EQUIPMENT TOTAL
$0
$0
$0
Revised Exhibit C
Page 1 of21
Total Proposed Budget
Direct Total
26,094 $26,094
21,793 $21,793
75,681 $75,681
28,674 $28,674
252,689 $252,689
15,783 $15,783
50,503 $50,503
11,837 $11,837
33,673 $33,673
23,524 $23,524
81,993 $81,993
$622 244 $622,244
$411193
$9,023
$11,761
$0 $61,977
$18,668
$41,131
$105,781
$0 $165,580
$849,801
$50,194
$3,271
$12,656
$3,325
$6,558
$76,004
OPERATING EXPENSES·
1060 Telephone
1061 Answering Service
1062 Postage
1063 Printing/Reproduction
1064 Publications
1065 Legal Notices/Advertising
1066 Office Supplies & Equipment
1067 Household Supplies
1068 Food-(Under Flexible)
1069 Program Supplies -Therapeutic
1070 Program Supplies -Medical
1071 Transportation of Clients (Under Flexible)
1072 Staff Mileage/vehicle maintenance
1073 Staff Travel (Out of County)
1074 Staff Training/Registration
1075 Lodging -Per Diem
1076 Other-(Vehicle Lease, Vehicle Insurance)
Other -(Licenses, Security, Recruitment,
1077 taxes, Client Activities, bank charges)
OPERATING EXPENSES TOTAL
FINANCIAL SERVICES EXPENSES·
1080 Accounting/Bookkeeping
1081 External Audit
1082 Liability Insurance
1083 Administrative Overhead
1084 Payroll Services
1085 Professional Liability Insurance
FINANCIAL SERVICES TOTAL
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management)
1091 Translation Services
1092 Medication Supports
SPECIAL EXPENSES TOTAL
FIXED ASSETS·
1190 Computers & Software
1191 Furniture & Fixtures
1192 Other -(Identify)
FIXED ASSETS TOTAL
Revised Exhibit C
Page 2 of21
$9,653
$0
$617
$912
$858
$0
$3,164
$1,287
$0
$3,378
$1,000
$0
$33,785
$0
$1,260
$429
$8,748
$2 859
$67,950
$0
$885
$1,377
$205,198
$0
$0
$207,460
$0
$1,500
$60,000
$61,500
$3,486
$3,486
$0
$6,972
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)
2002.5 Respite Care (SFC 72)
2002.6 Household Items
2002.7 Utility Vouchers (SFC 72)
2002.8 Child Care (SFC 72)
NON MEDI-CAL CLIENT SUPPORT TOTAL
TOTAL FY 2013-14 FSP PROGRAM EXPENSES
Units of
MEDI-CAL REVENUE: Service Rate
3000 Mental Health Services (lndividuaVFamily/Group Therapy) 16,443 $2.20
3100 Case Management 198,167 $1.80
3200 Crisis Services 9,965 $2.95
3300 Medication Support 46,028 $3.75
3400 Collateral 822 $2.20
3500 Plan Development 822 $2.20
3600 Assessment 2,466 $2.20
3700 Rehabilitation 61,663 $2.20
Estimated Medi-Cal Billing Totals 336,376
% of Federal Financial Participation Reimbursement 0.50%
% of Early and Periodic Screening, Diagnostic, and Treatment Reimbursement 0%
MEDI-CAL REVENUE TOTAL
OTHER REVENUE·
4000 Other-(Client Fees)
4100 Other-(Client Insurance)
OTHER REVENUE TOTAL
MHSA FUNDS·
5000 Prevention & Early Intervention Funds
5100 Community Services & Supports Funds
5200 Innovation Funds
5300 Workforce Education & Training Funds
MHSA FUNDS TOTAL
TOTAL FY 2013-14 FSP REVENUE
Revised Exhibit C
Page 3 of21
$274,000
$0
$14,000
$8,000
$5,000
$1,500
$0
$0
$500
$500
$303,500
$1,573,187
$Amount
$36,175
$356,701
$29,397
$172,605
$1,809
$1,809
$5,426
$135,659
$739,581
$369,790
$
$369,790
$5,000
$0
$5,000
$0
$11198,397
$0
$0
$1,198,397
$1,573,187
Rural Mental Health-ICM
Turning Point of Central CA, Inc.
Fiscal Year 2013-14
Budget Categories -
line Item Description (Must be itemized) FTE% Admin.
PERSONNEL SALARIES:
0001 Program Director 61%
0002 Assistant Program Director 61%
0003 Mental Health Professionalrream Leader 626%
0004 Supervising Personal Services Coordinator 123%
0005 Case Managers 1117%
0006 Driver 123%
0007 Nurse 387%
0008 Peer Support 93%
0009 Secretary 402%
0010 Billing Clerk 123%
0011 Psychiatrist 41%
SALARY TOTAL 31.57
PAYROLL TAXES:
0030 OASDI
0031 FICA/MEDICARE
0032 SUI
PAYROLL TAX TOTAL
EMPLOYEE BENEFITS:
0040 Retirement
0041 Workers Compensation
0042 Health Insurance (medical, vision, life, dental)
EMPLOYEE BENEFITS TOTAL
SALARY & BENEFITS GRAND TOTAL
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building
1011 Rent/Lease Equipment
1012 Utilities
1013 Building Maintenance
1014 Equipment Maintenance
$0
$0
$0
Revised Exhibit C
Page 4 of21
Total Proposed Budget
Direct Total
55,000 $55,000
50,000 $50,000
312,500 $312,500
53,100 $53,100
330,000 $330,000
31,000 $31,000
115,000 $115,000
21,921 $21,921
81,000 $81,000
55,000 $55,000
337,000 $337,000
$1,441,521 $1,441,521
$77,402
$16,875
$21,995
$0 $116,272
$34,912
$48,923
$200,036
$0 $283,871
$1,841,664
$103,980
$557
$11,822
$21,258
$17,288
FACILITY/EQUIPMENT TOTAL
OPERATING EXPENSES·
1060 Telephone
1061 Answering Service
1062 Postage
1063 Printing/Reproduction
1064 Publications
1065 legal Notices/Advertising
1066 Office Supplies & Equipment
1067 Household Supplies
1068 Food
1069 Program Supplies -Therapeutic
1070 Program Supplies -Medical
1071 Transportation of Clients (Under Flexible)
1072 Staff Mileage/vehicle maintenance
1073 Staff Travel (Out of County)
1074 Staff Training/Registration
1075 Lodging-Staff Per Diem
1076 Other-(Vehicle Lease, Vehicle Insurance)
Other-(Licenses, Security, Recruitment,
1077 taxes, Client Activities, bank charges)
OPERATING EXPENSES TOTAL
FINANCIAL SERVICES EXPENSES·
1080 Accounting/Bookkeeping
1081 External Audit
1082 Liability Insurance
1083 Administrative Overhead
1084 Payroll Services
1085 Professional Liability Insurance
FINANCIAL SERVICES TOTAL
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management)
1091 Translation Services
1092 Medication Supports
SPECIAL EXPENSES TOTAL
FIXED ASSETS:
1190 Computers & Software
1191 Furniture & Fixtures
FIXED ASSETS TOTAL
Revised Exhibit C
Page 5 of21
$154,9051
$43,000
$0
$1,100
$516
$800
$0
$30,608
$2,873
$0
$15,409
$11,225
$0
$80,992
$0
$3,522
$8
$23,065
$23,479
$236,597
$0
$3,766
$1,592
$415,241
$0
$0
$420,599
$0
$7,100
$52,100
$59,200
$15,861
$4,261 ----
$20,122
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)
2002.5 Respite Care (SFC 72)
2002.6 Household Items
2002.7 Utility Vouchers (SFC 72)
2002.8 Child Care (SFC 72)
NON MEDI-CAL CLIENT SUPPORT TOTAL
TOTAL ICM FY 2013-14 PROGRAM EXPENSES
Units of
MEDI-CAL REVENUE: Service Rate
3000 Mental Health Services (Individual/Family/Group Therapy) 31,283 $2.20
3100 Case Management 250,698 $1.80
3200 Crisis Services 16,661 $2.95
3300 Medication Support 96,580 $3.75
3400 Collateral 1,566 $2.20
3500 Plan Development 1,564 $2.20
3600 Assessment 4,692 $2.20
3700 Rehabilitation 117,313 $2.20
Estimated Medi-Cal Billing Totals 520,357
% of Federal Financial Participation Reimbursement 0.50%
% of Early and Periodic Screening, Diagnostic, and Treatment Reimbursement 0%
MEDI-CAL REVENUE TOTAL
OTHER REVENUE·
4000 Other-(Client Fees)
4100 Other-(Client Insurance)
OTHER REVENUE TOTAL
MHSAFUNDS·
5000 Prevention & Early Intervention Funds
5100 Community Services & Supports Funds
5200 Innovation Funds
MHSA FUNDS TOTAL
TOTAL ICM FY 2013-14
Revised Exhibit C
Page 6 of21
$10,000
$5,000
$400
$11,700
$70
$70
$0
$10,000
$0
$0
$37,240
$2,770,327
$Amount
$68,823
$451,256
$49,150
$362,175
$3,445
$3,441
$10,322
$258,089
$1,206,701
$603,350
$
$603,350
$0
$0
$0
$0
$2,166,977
$0
$2,166,977
$2,770,327
Rural Mental Health-OP
Turning Point of Central CA, Inc.
Fiscal Year 2013-2014
Budget Categories -
Line Item Description (Must be itemized) FTE%
PERSONNEL SALARIES:
0001 Program Director 10%
0002 Assistant Program Director 10%
0003 Mental Health Professionalrream Leader 101%
0004 Supervising Personal Services Coordinator 20%
0005 Case Managers 179%
0006 Driver 20%
0007 Nurse 62%
0008 Peer Support 15%
0009 Secretary 65%
0010 Billing Clerk 20%
0011 Psychiatrist 101%
0012
SALARY TOTAL 6.03
PAYROLL TAXES:
0030 OASDI
0031 FICA/MEDICARE
0032 SUI
PAYROLL TAX TOTAL
EMPLOYEE BENEFITS:
0040 Retirement
0041 Workers Compensation
0042 Health Insurance (medical, vision, life, dental)
EMPLOYEE BENEFITS TOTAL
SALARY & BENEFITS GRAND TOTAL
FACILITIES/EQUIPMENT EXPENSES:
1010 RenULease Building
1011 RenULease Equipment
1012 Utilities
1013 Building Maintenance
1014 Equipment Purchase/Maintenance
Admin.
$0
$0
$0
Revised Exhibit C
Page 7 of21
Total Proposed Budget
Direct Total
8,100 $8,100
7,500 $7,500
56,371 $56,371
4,459 $4,459
42,666 $42,666
5,441 $5,441
23,000 $23,000
500 $500
12,000 $12,000
8,000 $8,000
107,000 $107,000
$275,037 $275,037
$7,740
$4,867
$4,775
$0 $17,382
$4,500
$7,000
$33,589
$0 $45 089
$337,508
$17,000
$2,771
$2,722
$3,817
$5,556
FACILITY/EQUIPMENT TOTAL
OPERATING EXPENSES·
1060 Telephone
1061 Answering Service
1062 Postage
1063 Printing/Reproduction
1064 Publications
1065 Legal Notices/Advertising
1066 Office Supplies & Equipment
1067 Household Supplies
1068 Food
1069 Program Supplies -Therapeutic
1070 Program Supplies -Medical
1071 Transportation of Clients (Under Flexible)
1072 Staff Mileage/vehicle maintenance
1073 Staff Travel (Out of County)
1074 Staff Training/Registration
1075 Lodging
1076 Other-(Vehicle Lease, Vehicle Insurance)
Other-(Licenses, Security, Recruitment,
1077 taxes, Client Activities, bank charges)
OPERATING EXPENSES TOTAL
FINANCIAL SERVICES EXPENSES·
1080 Accounting/Bookkeeping
1081 External Audit
1082 Liability Insurance
1083 Administrative Overhead
1084 Payroll Services
1085 Professional Liability Insurance
FINANCIAL SERVICES TOTAL
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management)
1091 Translation Services
1092 Medication Supports
SPECIAL EXPENSES TOTAL
FIXED ASSETS·
1190 Computers & Software
1191 Furniture & Fixtures
FIXED ASSETS TOTAL
Revised Exhibit C
Page 8 of21
$31,8661
$8,178
$0
$522
$773
$727
$0
$4,281
$1,091
$0
$2,862
$500
$0
$14,623
$0
$1,068
$363
$4,811
$5,422
$45,221
$0
$750
$1,167
$86,467
$0
$0
$88,384
$0
$1,500
$79,000
$80,500
$2,953
$?,953
$5,906
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)
2002.5 Respite Care (SFC 72)
2002.6 Household Items
2002.7 Utility Vouchers (SFC 72)
2002.8 Child Care (SFC 72)
NON MEDI-CAL CLIENT SUPPORT TOTAL
TOTAL OP FY 2013-14 PROGRAM EXPENSES
Units of
MEDI-CAL REVENUE: Service Rate
3000 Mental Health Services (Individual/Family/Group Therapy) 18,095 $2.20
3100 Case Management 61,205 $1.80
3200 Crisis Services 8,131 $2.95
3300 Medication Support 18,212 $3.75
3400 Collateral 904 $2.20
3500 Plan Development 904 $2.20
3600 Assessment 2,714 $2.20
3700 Rehabilitation 67,858 $2.20
'. :::·. ; . Estimated Medi-Cal Billing Totals 178,023
% of Federal Financial Participation Reimbursement 0.50%
% of Early and Periodic Screening, Diagnostic, and Treatment Reimbursement 0.00%
MEDI-CAL REVENUE TOTAL
OTHER REVENUE·
4000 Other -(Client Fees)
OTHER REVENUE TOTAL
MHSAFUNDS:
5000 Prevention & Early Intervention Funds
5100 Community Services & Supports Funds
5200 Realignment Funds
5300 Workforce Education & Training Funds
MHSA FUNDS TOTAL
TOTAL OP FY 2013-14
Revised Exhibit C
Page 9 of 21
$0
$0
$1,000
$2,000
$1,000
$500
$0
$0
$0
$0
$4,500
$593 885
$Amount
$39,809
$110,169
$23,987
$68,295
$1,989
$1,989
$5,971
$149,288
$401,497
200,749
$
$200,749
$0
$0
$0
$319,056
$74,080
$0
$393,136
$593,885
Rural Mental Health -FSP
Turning Point of Central CA, Inc.
Mental Health Services
Fiscal Year 2014-2015
Budget Categories -FINAL Total Proposed Budget-CurrenUOriginal
Line Item Description (Must be itemized) FTE Admin. Direct Original
PERSONNEL SALARIES:
0001 Program Director 0.20 $17,784 $26,094
0002 Assistant Program Director 0.20 $14,397 $21,793
0003 Mental Health ProfessionaVTeam Leader 2.20 $124,568 $75,681
0004 Supervising Personal Service Coordinator 0.40 $15,111 $28,674
0005 Case Managers 3.60 $138,099 $252,689
0006 Driver 0.40 $10,792 $15,783
0007 Nurse 1.15 $52,555 $50,503
0008 Peer Support 0.30 $7,410 $11,837
0009 Secretary 1.20 $34,803 $33,673
0010 Billing Clerk/Records Tech 0.60 $24,782 $23,524
0011 Psychiatrist 0.24 $90,000 $61,993
0012
SALARY TOTAL 10.49 $0 $530,301 $622,244
PAYROLL TAXES:
0030 OASDI $6,164 $41,193
0031 FICA/MEDICARE $27,217 $9,023
0032 S.U.I $6,078 $11,761
PAYROLL TAX TOTAL $0 $39,459 $61,977
EMPLOYEE BENEFITS:
0040 Retirement $9,441 $18,668
0041 Workers Compensation $3,588 $41,131
0042 Health Insurance (medical, vision, life. dental) $67,393 $105.761
EMPLOYEE BENEFITS TOTAL $0 $80,422 $165,580
SALARY & BENEFITS GRAND TOTAL $650,181 $849,801
FACILITIES/EQUIPMENT EXPENSES
1010 RenULease Building $36,452 $50,194
1011 RenULease Equipment $0 $3,271
1012 Utilities $8,455 $12,656
1013 Building Maintenance $5,468 $3,325
1014 Equipment Maintenance $1,515 $6,558
FACILITY/EQUIPMENT TOTAL $51,890 $76,004
OPERATING EXPENSES·
1060 Telephone $19,528 $9,653
1061 Answering Service $0 $0
1062 Postage $494 $617
1063 Printing/Reproduction $903 $912
1064 Publications $275 $856
1065 Legal Notices/Advertising/Recruitment $804 $0
1066 Office Supplies & Equipment $9,547 $3,164
1067 Household Supplies $770 $1,287
1068 Food-UNDER FLEX $0 $0
1069 Program Supplies -Therapeutic $2,689 $3,378
1070 Program Supplies -Medical $653 $1,000
1071 Transportation of Clients • UNDER FLEX $0 $0
1072 Staff Mileage/vehicle maintenance $23,015 $33,785
1073 Staff Travel (Out of County) $0 $0
1074 Staff Training/Registration $1,124 $1,260
1075 Lodging $179 $429
1076 Other-Vehicle Lease, Vehicle Insurance $7,014 $8,748
1077 Taxes, Client Activities, Bank Charges $1,845 $2,859
OPERATING EXPENSES TOTAL $66,839 $67,950
FINANCIAL SERVICES EXPENSES
1080 Accounting/Bookkeeping $0 $0
1081 External Audit $700 $865
1082 Liability Insurance $1,567 $1,377
1083 Administrative Overhead 15% $137,026 $205,198
1084 Payroll Services $0 $0
1085 Professional Liability Insurance $0 $0
FINANCIAL SERVICES TOTAL $139,314 $207,460
Revised Exhibit C
Page 10 of21
FINAL BUDGET
AMENDMENT ONE
$17,784
$14,397
$124,568
$15,11]
$138,099
$10,792
$52.555
$7,410
$34,803
$24,782
$90,000
$0
$530,301
$6,164
$27,217
$6,078
$39,459
$9,441
$3,588
$67,393
$80,422
$650,181
$36,452
$0
$8,455
$5,468
$1,515
$51,890
$19,528
$0
$494
$903
$275
$804
$9,547
$770
$0
$2,689
$653
$0
$23,015
$0
$1,124
$179
$7,014
$1,845
$68,839
$0
$700
$1,587
$137,026
$0
$0
$139,314
SPECIAL EXPENSES (ConsultanVEtc. :
1 090 Consultant (network & data management)
1091 Translation Services
1092 Medication Supports
$3,854
$2,702
$3,000
SPECIAL EXPENSES TOTAL
FIXED ASSETS:
$9,556
1190 Computers & Software $0
1191 F umiture & Fix1ures $1,698
FIXED ASSETS TOTAL $1,698
NON MEDI-CAL CLIENT SUPPORT EXPENSES·
2000 Client Housing Support Expenditures (SFC 70) $120,000
2001 Client Housing Operating Expenditures (SFC 71) $0
2002.1 Clothing, Food & Hygiene (SFC 72) $7,290
2002.2 Client Transportation & Support (SFC 72) $1,604
2002.3 Education Support (SFC 72) $140
2002.4 Employment Support (SFC 72) $0
2002.5 Respite Care (SFC 72) $0
2002.6 Household Items $0
2002.7 Utility Vouchers (SFC 72) $25
2002.8 Child Care (SFC 72) $0
NON MEDI-CAL CLIENT SUPPORT TOTAL $129,059
TOTAL FSP PROGRAM l
UNITS OF
MEDI-CAL REVENUE: SERVICE Rate
Mental Health Services (Individual/Family/Group
3000 Therapy) 59% 71,250 $ 2.20
3100 Case Management 17% 35,698 $ 1.80
3200 Crisis Services 3% 6,546 $ 2.95
3300 Medication Support 21% 45,585 $ 3.75
3400 Collateral 1,273 $ 2.20
3500 Plen Development 1,273 $ 2.20
3600 Assessment 12,856 $ 2.20
3700 Rehabilitative 39,895 $ 2.20
Est1mateo MeCIH::;al t!llllng 1 otals ALL MEDI-CAL TYPES 214,375
Estimated MAGI Billing Totals (23% of total)
NET NON-MAGI MEDICAL
% of Federal Financial Participation Reimbursement 50%
% MAGI Federal Financial Participation Reimbursement 95%
I MEDI-CAL REVENUE TOTAL
OTHER REVENUE·
4000 Other-Client Fees 0
4100 Other-Clientlnsuranca 0
OTHER REVENUE TOTAL 0
MHSAFUNDS·
5000 Prevention & Early Intervention Funds 0
5100 Community Services & Supports Funels 1198397
5200 Realignment Funds
5100 EXPANSION CSS FUNDS
5300 Workforce Education & Training Funds 0
MHSA FUNDS TOTAL 1198397
TOTAL FSP PROGRAM
$0
$1,500
$60,000
$61,500
$3,486
$3,486
$6,972
$274,000
$0
$14,000
$8,000
$5,000
$1,500
$0
$0
$500
$500
$303,500
$1,573,187
ORIGINAL
CONTRACT$
Amount
$36,174.60
$356,700.60
$29,397.75
$172,605.00
$1,808.40
$1,808.40
$5,425.20
$135,658.60
$739,579
$369,789
$0
$369,789
$5,001
$0
$5,001
$0
$1,198,397
$0
$0
$0
$1,198,397
$1,573,187
$3,854
$2,702
$3,000
$9,556
$0
$1,698
$1,698
$120,000
so
$7,290
Sl,604
$140
so
so
$0
S25
$0
$129,059
$1,050,537
Revised Exhibit C
Page 11 of21
J
FINAL BUDGET
AMENDMENT ONE
$156,750
$64,256
$19.310
$170,944
$2,800
$2,800
$28,283
$87,769
$532,912
$122,570
$410,342
$205,171.05
$116,441.23
$321,612
$5,001
$0
$5,001
$0
$723,924
$0
$0
$0
$723,924
$1,050,537
Budget Categories -
Rural Mental Health -ICM
Turning Point of Central CA, Inc.
Rural Mental Health Services-ICM
Fiscal Year 2014-2015
FINAL Total Proposed Budget-Current/Original
Line Item Description (Must be itemized) FTE Admin. Direct Original
PERSONNEL SALARIES:
0001 Program Director 0.63 $56.019 $47,862
0002 Assistant Program Director 0.63 $45,351 $40,357
0003 Mental Health ProfessionaVTeam Leader 6.93 $392.388 $231.961
0004 Supervising Personal Service Coordinator 1.26 $47,601 $53,100
0005 Case Managers-PSC 11.34 $435,013 $290,464
0006 Driver 1.26 $33,995 $29,228
0007 Nurse 3.61 $165,549 $92,924
0008 Peer Support 0.95 $23,340 $21,921
0009 Secretary 3.78 $109,630 $62,357
0010 Billing Technician/Records Clerk 1.89 $78,062 $43,562
0011 Psychiatrist 1.11 $415,000 $250,000
0012
SALARY TOTAL 33.38 $0 $1,801,947 $1,163,736
PAYROLL TAXES:
0030 OASDI $19,417 $72,152
0031 FICA/MEDICARE $85,734 $16,875
0032 S.U.I $19,146 $21,995
PAYROLL TAX TOTAL $0 $124,297 $111,022
EMPLOYEE BENEFITS:
0040 Retirement $29,738 $34,912
0041 Workers Compensation $11,303 $76,923
0042 Health Insurance (medical, vision, life, dental) $212,288 $197,836
EMPLOYEE BENEFITS TOTAL $0 $253,328 $309,671
SALARY & BENEFITS GRAND TOTAL $2,179,572 $1,584,429
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $114,825 $94,480
1011 Rent/Lease Equipment $0 $6,157
1012 Utilities $26,632 $23,822
1013 Building Maintenance $17,224 $6,258
1014 Equipment Maintenance $4,771 $10,988
FACILITY/EQUIPMENT TOTAL $163,453 $141,705
OPERATING EXPENSES:
1060 Telephone $61,513 $18,169
1061 Answering Service $0 $0
1062 Postage $1,555 $1,400
1063 Printing/Reproduction $2,845 $1,716
1064 Publications $866 $1,615
1065 Legal Notices/Advertising/Recruitment $2,534 $0
1066 Office Supplies & Equipment $30,072 $11,658
1067 Household Supplies $2.425 $2,423
1068 Food-UNDER FLEX $0 $0
1069 Program Supplies -Therapeutic $8,470 $6,359
1070 Program Supplies -Medical $2,057 $1,000
1071 Transportation of Clients -UNDER FLEX $0 $0
1072 Staff Mileage/vehicle maintenance $72,496 $63,592
1073 Staff Travel (Out of County) $0 $0
1074 Staff Training/Registration $3,539 $2,372
1075 Lodging $565 $808
1076 Other-Vehicle Lease, Vehicle Insurance $22,093 $16,465
1077 Taxes, Client Activities, Bank Charges $5,812 $5,679
OPERATING EXPENSES TOTAL $216,842 $133,256
FINANCIAL SERVICES EXPENSES:
1080 AccounUng/Bookkeeping $0 $0
1081 External Audit $2,205 $1,666
1082 Liability Insurance $4,999 $2,592
1083 Administrative Overhead 15% $391,214 $289,841
1084 Payroll Services $0 $0
1085 Professional Liability Insurance $0 $0
FINANCIAL SERVICES TOTAL $398,418 $294,099
Revised Exhibit C
Page 12of21
FINAL BUDGET
AMENDMENT
ONE
$56,019
$45,351
$392,388
$47,601
$435,013
$33,995
$165,549
$23,340
$109,630
$78,062
$415,000
$0
$1,801,947
$19,417
$85,734
$19,146
$124,297
$29,738
$11,303
$212,288
$253,328
$2,179,572
$114,825
$0
$26,632
$17,224
$4,771
$163,453
$61,513
$0
$1,555
$2,845
$866
$2,534
$30,072
$2,425
$0
$8,470
$2,057
$0
$72,496
$0
$3,539
$565
$22,093
$5,812
$216,842
$0
$2,205
$4,999
$391,214
$0
$0
$398,418
SPECIAL EXPENSES (Consu~anVEtc )· ..
1090 Consultant (network & data management) $12,139
1091 Translation Services $6,512
1092 Medication Supports $9,450
SPECIAL EXPENSES TOTAL $30,101
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $5,349
I FIXED ASSETS TOTAL $5,349
I
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70) $0
2001 Client Housing Operating Expenditures (SFC 71) $0
2002.1 Clothing, Food & Hygiene (SFC 72) $0
2002.2 Client Transportation & Support (SFC 72) $5,053
2002.3 Education Support (SFC 72) $441
2002.4 Employment Support (SFC 72) $0
2002.5 Respite Care (SFC 72) $0
2002.6 Household Items $0
2002.7 Utility Vouchers (SFC 72) $79
2002.6 Child Care (SFC 72) $0
NON MEDI-CAL CLIENT SUPPORT TOTAL $5,573
TOTAL ICM PROGRAM EXPENSES
UNITS OF
MEDI-CAL REVENUE: SERVICE
Mental Health Services (lndividuaVF amily/Group
3000 Therapy) 61% 126,366
3100 Case Management 6% 32,070
3200 Crisis Services 3% 12,648
3300 Medication Support 26% 105,896
3400 Collateral 2.273
3500 Plan Development 2,265
3600 Assessment -55,880
3700 Rehabilitative 42,698
I:Stomatea Meat-(.;al t:lllllng I Otats ALL Mt:UI-I.;AL I T t"t::> 360,096
Estimated MAGI Billing Totals (23% of total)
NET NON-MAGI MEDICAL
%of Federal Financial Participation Reimbursement
% of MAGI Federal Financial Participation Reimbursement
MEDI-CAL REVENUE TOTAL
OTHER REVENUE:
4000
4100
Other-Client Fees
Other-Client Insurance
OTHER REVENUE TOTAL
MHSAFUNDS·
5000 Prevention & Earty Intervention Funds
5100 Community Services & Supports Funds
5200 Realignment Funds
5100 EXPANSION CSS FUNDS
5300 Workforce Education & Training Funds
MHSA FUNDS TOTAL
$
$
$
$
$
$
$
$
Rate
50%
95%
0
0
0
2.20
1.60
2.95
3.75
2.20
2.20
2.20
2.20
1657761
0
0
TOTAL ICM PROGRAM REV
$0
$1,500
$45,000
$46,500
$6,561
$6,561
$13,122
$0
$0
$2,000
$5,000
$1,000
$1,000
$0
$0
$0
$0
$9,000
$2,222,111
c~~~~;2~s
Amount
$68,822.60
$451,256.40
$49,149.95
$284,175.00
$3,444.80
$3,440.80
$10,322.40
$258,088.60
1,126,701
$564,350
$0
I $564,350 I
$0
$1,657,761
$0
$0
$1,657,761
$2,222,111
Revised Exhibit C
Pagel3of21
$12,139
$8,512
$9,450
$30,101
$0
$5,349
$5,349
$0
so
$0
$5,053
$441
$0
$0
$0
$79
so
$5,573
$2,999,307
FINAL BUDGET
AMENDMENT ONE
$278,005
$57,726
$37,312
$397,110
$5,000
$4,983
$122,936
$93,936
$997,006
$229,312
$767,696
$383,848
$217,846
$601,694
$0
$2,397,613
$0
$0
so
$2,397,613
$2,999,307
I
Rural Mental Health -OP
Turning Point of Central CA, Inc:.
Mental Health Services
Fiscal Year 2014-16
Revised Exhibit C
Page 14 of21
Budget Categories -FINAL Total Proposed Budget-CurrenVOriglnal FINAL BUDGET Line Item Description (Must be itemized) FTE Admin. Direct Original AMENDMENT ONE
PERSONNEL SALARIES:
0001 Program Director 0.17 15,116 21,768 s 15,116
0002 Assistant Program Director 0.17 12,238 18,564 $ 12,238
0003 Mental Health Professionai!Team Leader 1.87 105,882 159,671 s 105,882
0004 Supervising Personal Service Coordinator 0.34 12,845 24,426 $ 12,845
0005 Case Managers 3.06 117,384 42,666 s 117,384
0006 Driver 0.34 9,173 13,441 s 9,173
0007 Nurse 0.97 44,672 42,745 $ 44,672
0008 Peer Support 0.26 6,298 10,084 s 6,298
0009 Secretary 1.02 29,583 26,684 s 29,583
0010 Billing Clerk/Records Tech 0.51 21,064 20,039 s 21,064
0011 Psychiatrist (28 hours per week) 0.48 180,000 186,000 s 180,000
0012 0 0 s
SALARY TOTAL 9.19 $0 554,255 570,088 554,255
PAYROLL TAXES:
0030 OASDI 3,743 37,740 $ 3,743
0031 FICAIM EDICARE 24,632 8,887 s 24,632
0032 S.U.I 5,166 10,775 s 5,166
PAYROLL TAX TOTAL $0 33,540 57,382 33,540
EMPLOYEE BENEFITS:
0040 Retirement 8,024 17,105 s 8,024
0041 Workers Compensation 3,050 37,683 $ 3,050
0042 Health Insurance (medical, vision, life, dental) 57,264 96,915 s 57,284
EMPLOYEE BENEFITS TOTAL $0 68,358 151,703 68,358
SALARY & BENEFITS GRAND TOTAL 779,173 656,154
FACILITIES/EQUIPMENT EXPENSES:
1010 RenVLease Building 30,984 42,526 s 30,984
1011 RenVLease Equipment 0 2,771 $
1012 Utilities 7,186 10,722 s 7,186
1013 Building Maintenance 4,648 2,817 s 4,648
1014 Equipment Maintenance 1,288 5,556 s 1,288
FACILITY/EQUIPMENT TOTAL 44,106 64,392 44,106
OPERATING EXPENSES:
1060 Telephone 16,599 8,178 $ 16,599
1061 Answering Service 0 0 s
1062 Postage 420 522 s 420
1063 Printing/Reproduction 768 773 s 768
1064 Publications 234 727 s 234
1065 Legal Notices/Advertising/Recruitment 684 0 s 684
1066 Office Supplies & Equipment 6,115 2,681 s 8,115
1067 Household Supplies 654 1,091 s 654
1068 Food-UNDER FLEX 0 0 $
1069 Program Supplies -Therapeutic 1,550 2,662 s 1,550
1070 Program Supplies -Medical 1,272 500 $ 1,272
1071 Transportation of Clients -UNDER FLEX 0 0 s
1072 Staff Mileage/vehicle maintenance 19,562 28,623 s 19,562
1073 Staff Travel (Out of County) 0 0 $ -
1074 Staff Training/Registration 955 1,068 s 955
1075 Lodging 152 363 $ 152
1076 Other-Vehicle Lease, Vehicle Insurance 5,962 7,411 $ 5,962
1077 Taxes, Client Activities, Bank Charges 1,568 5,422 s 1,568
OPERATING EXPENSES TOTAL 58,494 60,221 58.494
FINANCIAL SERVICES EXPENSES
1080 Accounting/Bookkeeping 0 0 s -
1081 Ex1emal Audit 595 750 s 595
1082 Liability Insurance 1,349 1,167 $ 1,349
1083 Administrative Overhead 15% 115,768 145,492 $ 115,768
1084 Payroll Services 0 0 s
1085 Professional Liability Insurance 0 0 $
FINANCIAL SERVICES TOTAL 117,712 147,409 117,712
Client Housing Operating Expenditures (SFC 71)
Clothing, Food & Hygiene (SFC 72)
Client Transportation & Support (SFC 72)
Education Support (SFC 72)
Employment Support (SFC 72)
Respite Care (SFC 72)
Household Items
Utility Vouchers (SFC 72)
Child Care
MEDI-CAL REVENUE:
3000 Therapy) 65%
Case Management 2%
Crisis Services 1%
Medication Support 32%
Collateral
Budget Units
of Service Rate
Revised Exhibit C
Page 15 of21
1,363
138
21
Rural Mental Health • FSP
Turning Point of Central CA, Inc.
Mental Health Services
Fiscal Year 2015·2016through 2017·2018
Budget Categories • FINAL Total Pro osed Budget-Curreni/Origlnal
line Item Description (Must be Itemized) FTE Admin. Direct Original
PERSONNEL SALARIES:
0001 Program Director 0.24 23,428 26,094
0002 Assistant Program Director 0.48 39,960 21,793
0003 Mental Heallh Professionai!Team Leader 3.48 232,901 75,681
0004 Supervising Personal Service Coordinator 0.72 36,363 28,674
0005 Case Managers 4.32 181,850 252,689
0006 Driver 0.72 20,408 15,783
0007 Nurse 1.65 83,563 50,503
0008 Peer Support 0.36 9,844 11,837
0009 Secretary 1.68 53,923 33,673
0010 Billing Clerk 0.72 30,592 23,524
0011 Psychiatrist (12 hours per week) 0.30 145,472 81,993
0012 0
SALARY TOTAL 14.67 so 858,306 622,244
PAYROLL TAXES:
0030 OASOI 9,980 41,193
0031 FICNMEDICARE 44,552 9,023
0032 S.U.I 12,176 11.761
PAYROLL TAX TOTAL $0 66,708 61,977
EMPLOYEE BENEFITS:
0040 Retirement 10,670 18,668
0041 Workers Compensation 6,426 41,131
0042 Health Insurance (medical, vision, life, denial) 133,587 105,761
EMPLOYEE BENEFITS TOTAL 50 150,683 165,580
SALARY & BENEFITS GRAND TOTAL 1.075,696 849,801
FACILITIES/EQUIPMENT EXPENSES·
1010 Rent/lease Building 47,638 50,194
1011 Rent/lease Equipment 217 3,271
1012 Utilities 6.605 12,656
1013 Building Maintenance 8.087 3,325
1014 EQuipment Maintenance 2.231 6,558
FACILITY/EQUIPMENT TOTAL 64.778 76.004
OPERATING EXPENSES
1060 Telephone 10,181 9,653
1061 Answering Service 864 0
1062 Postage 521 617
1063 Printing/Reproduction 906 912
1064 Publications 321 658
1065 Legal NoticesiAdVertislng/Recruitmenl 470 0
1066 Office Supplies & Equipment 16,624 3,164
1067 Household Supplies 1,438 1,267
1066 Food· UNDER FLEX 0 0
1069 Program SuppHes • Therapeutic 2,791 3,378
1070 Program Supplies • Medical 735 1,000
1071 Transportation of Clients • UNDER FLEX 0 0
1072 Staff Mileage/vehicle maintenance 36,859 33.765
1073 Staff Travel (Out of County) 0 0
1074 Staff Training/Registration 1,146 1,260
1075 lodging 360 429
1076 Other· Vehicle Lease, Vehicle Insurance 9,713 6,748
1077 Taxes, Client Activities. Bank Charges 1,433 2.859
OPERATING EXPENSES TOTAL 86,363 67.950
FINANCIAL SERVICES EXPENSES·
1080 Accounting/Bookkeeping 0 0
1061 External Audit 1,532 665
1082 Liability Insurance 715 1,377
1083 Administrative Overhead 15% 211.206 205,196
1064 Payroll Services 0 0
1085 Proresslonal Liability Insurance 0 0
FINANCIAL SERVICES TOTAL 213,452 207.460
SPECIAL EXPENSES (ConsultanUEtc.):
11ogo Consultant (network & data management) 6.40~1 1.50~1 1091 Translation Services 2,010
FSP 12·22·14
FINAL BUDGET
AMENDMENT ONE
$23,428
$39,960
$232,901
$36,363
$181,850
$20,408
$83,563
$9,844
$53,923
$30,592
$145.472
$0
$858,306
$9,960
$44,552
$12.176
66,708
$10,670
$6,426
$133.587
150,683
1,075,696
$47,636
$217
$6,605
$8,087
$2.231
64,778
$10,161
$864
$521
$906
$321
$470
$18,624
$1,438
$0
$2,791
$735
so
$36,859
$0
$1,146
$360
$9,713
$1,433
66.363
$0
$1,532
$715
$211,206
$0
$0
213.452
$6,40~1 $2,010
Revised Exhibit C
Page 16 of21
I
Rural Mental Health • FSP
Turning Point of Central CA, Inc:.
Mental Health Services
Flac:al Year 2015·2016 through 2017·2018
Client Housing Operating Expenditures (SFC 71)
Clothing, Food & Hygiene (SFC 72)
Client Transportation & Support (SFC 72)
Educ:alion Support (SFC 72)
Employment Support (SFC 72)
Respite Care (SFC 72)
Household Items
Utility Vouc:hers (SFC 72)
Original
Budget Units
MEDI·CAL REVENUE: of Service
Mental Health Services (lndivlduaVFamiiy!Group
3000 Therapy) 69.21% il0,698
3100 Case Management10.56% 63,229
3200 Crisis Services 1. 79% 6,546
3300 Medication Support 16.45% 53,077
3400 Collateral 1,273
3500 Plan Development 1,273
3600 Assessment 21,591
3700 Rehabilitative 68,182
eStimated M8dl-cat Hilling IOIBIS AL.L. MEUI·CAL. rYPt:.ll 325,869
Estimated MAGI Bll~ng Totals (23% of total)
NET NON·MAGI MEDICAL
% of Federal Financial Participation Reimbun;ement
% MAGI Federal Financial Pertlclpatlon Reimbursement
MEDI"9AL REVENUE TOTAL
OTHER REVENUE.
4000 Other-Client Fees
4100 Other-Client Insurance
OTHER REVENUE TOTAL
MHSAFUNOS·
5000 Prevention & Early Intervention Funds
5100 Community Services & Supports Funds
5200 Realignment Funds
5100 EXPANSION CSS FUNDS
5300 Workforca Educ:ation & Training Funds
MHSA FUNDS TOTAL
Rate
$ 2.20
s 1.60
$ 2.95
$ 3.75
$ 2.20
$ 2.20
$ 2.20
$ 2.20
50%
95%
0
0
1198397
0
1198397
TOTAL FSP PROGRAM REVENUE
FSP 12·22·14
ORIGINAL
CONTRACT$
Amount
$36,174.60
$~6.700.60
$29,397.75
$172,605.QO
$1,808.40
$1,808.40
$5,425.20
$135,658.60
$739,579
$369,769 so
$369,789
$0
$1,198,397
$0
$0
$0
$1,198,397
$1,573,167
FINAL BUDGET
AMENDMENT ONE
$243,536
$113,813
$19,310
$199,038
$2,800
$2,800
$47,500
$150,000
$778,797
$179,123
$599,674
$299,837
$170,167
$470,004
$5,001
$0
$5,001
$0
$1,144,353
$0
$0
$0
$1.144.353
$1,619,358
Revised Exhibit C
Page 17 of21
Rural Mental Health • ICM
Turning Point of Central CA, Inc.
Mental Health Services
Fiscal Year 2015-2016 through 2017·2018
Budget Categories • FINAL Total Pro osed Budget·Current/OriJ!inal
Line Item Description (Must be Hemlzed) FTE Admin. Dfrect Original
PERSONNEL SALARIES:
0001 Program Director 0.63 $61,499 $47,862
0002 Assistant Program Director 1.26 $104,896 $40,357
0003 Mental Health Professional/Team Leader 9.14 $611,365 $231,961
0004 Supetvlslng Personal Setvice Coordinator 1.89 $95,454 $53,100
0005 Case Managers·PSC 11.34 $477,355 $290,464
0006 Driver 1.89 $53,572 $29,228
0007 Nurse 4.31 $219,353 $92,924
0008 Peer Support 0.95 $25,840 $21,921
0009 Secretary 4.41 $141,546 $62,357
0010 Billing Technicians 1.89 $80,305 $43,562
0011 Psychiatrist 45 hrs. per week 1.12 $493,273 $250,000
0012 $0
SALARY TOTAL 38.82 so $2,364.461 $1.163,736
PAYROLL TAXES:
0030 OASDI $26,197 $72,152
0031 FICA/MEDICARE $116,949 $16,875
0032 S.U.I $31.962 $21,995
PAYROLL TAX TOTAL $0 $175,107 $111,022
EMPLOYEE BENEFITS:
0040 Relirement $28,009 $34,912
0041 Workers Compensation $16,868 $76,923
0042 Health Insurance (medical, viSion, Rfe, dental) $350,665 $197,836
EMPLOYEE BENEFITS TOTAL so $395.543 $309,671
SALARY & BENEFITS GRAND TOTAL $1,584,429
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $125,050 $94,480
1011 Rent/Lease Equipment $569 $6,157
1012 UUiilies $17,337 $23,822
1013 Building Maintenance $21.229 $6,258
1014 Equipment Maintenance $5.857 $10,g88
FACILITY/EQUIPMENT TOTAL $170.042 $141,705
OPERATING EXPENSES:
1060 Telephone $26.725 $18,169
1061 Answering Setvice $2,266 $0
1062 Postage $1.367 $1,400
1063 Printing/Reproduction $2.376 $1,716
1064 Publications $644 $1,615
1065 Legal Noticas/Advertising/Recruitment $1.234 $0
1086 Office Supplies & Equipment $48.686 $11,658
1067 Household Supplies $3,774 $2,423
1068 Food· UNDER FLEX $0 $0
1069 Program Supplies • Therapeutic $7.326 $6,359
1070 Program Supplies -Medical $1,930 $1,000
1071 Transportation of Clients ·UNDER FLEX $0 $0
1072 Staff Mileage/vehicle maintenance $96,755 $63,592
1073 Staff Travel (Out of County) $0 $0
1074 Staff Training/Registration $3,008 $2,372
1075 Lodging $945 $808
1076 Other· Vehicle Lease, Vehicle Insurance S25,497 $16,465
1077 Taxes, Client Activities. Bank Charges $3.763 $5,67g
OPERATING EXPENSES TOTAL $226.704 $133,256
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0 $0
1081 External Audit $4,020 $1,666
1082 Liability Insurance $1,877 $2,592
1063 Administrative Overhead 15o/o $517.970 $289,841
1084 Payroll Services $0 $0
1085 Professional Liability insurance $0 $0
FINANCIAL SERVICES TOTAL $623.867 $294,099
ICM 12·22-14
Revised Exhibit C
Page 18 of21
FINAL BUDGET
AMENDMENT
ONE
$61,499
$104,896
$611,365
$95,454
S4n.355
$53,572
$219,353
$25,640
$141,548
$80,305
$493,273
so
$2,364,460
$26,197
$116,949
$31,962
$175,107
$28,009
$16,868
$350,665
$395,543
$2,935,110
$125,050
$569
$17,337
$21,229
$5,657
$170.042
$26,725
$2,268
$1,367
$2,378
$844
$1,234
$48,888
$3,774
$0
$7,326
$1,930
$0
$96,755
$0
$3,008
$945
$25,497
$3,763
$226,704
$0
$4,020
$1,877
$517,970
$0
$0
$523,867
Rural Mental Health • ICM
Turning Point of Central CA, Inc:.
Mental Health Services
Fiscal Year 2015·2016 through 2017-2018
Client Housing Operating Expenditures (SFC 71)
Clothing, Food & Hygiene (SFC 72)
Client Transportation & Support (SFC 72)
Education Support (SFC 72)
Employment Support (SFC 72)
Respite Care (SFC 72)
Household Items
Utility Vouchers (SFC 72)
Child
Therapy) 60.76%-
C11se Management 2.46%
Crisis Services 1.59%
Medication Support 35.20%
Collateral
ICM 12·22-14
Revised Exhibit C
Page 19 of21
Rural Mental Health· OP
Tumlng Point of Central CA, Inc.
Mental Health Services
Fiscal Year 2015-2016through 2017·2018
Revised Exhibit C
Page 20 of21
Budget Categories -FINAL Total Proposed Budget-CurrenVOriglnel FINAL BUDGET
Line ltam Description (Must be itemized) FTE Admin. Direct Original AMENDMENT ONE
PERSONNEL SALARIES:
0001 Program Director 0.13 12,690 21,768 s 12,690
0002 Assistant Program Director 0.26 21,645 16,564 $ 21,645
0003 Mental Health Professional/Teem Leader 1.68 126,155 159,671 s 126,155
0004 Supervising Personal Service Coordinator 0.39 19,697 24,426 $ 19,697
0005 Case Managers 2.34 98,502 42,666 s 98,502
0006 Driver 0.39 11,055 13,441 $ 11,055
0007 Nurse 0.89 45,263 42,745 s 45,263
0008 Peer Support 0.20 5,332 10,084 $ 5,332
0009 Seastary 0.91 29,208 28,684 $ 29,206
0010 Billing Cieri\ 0.39 16,571 20,039 $ 16,571
0011 Psychiatrist (28 hours per week) 0.70 156,856 188,000 $ 156,856
0012 0 0 $ -
SALARY TOTAL 8.48 $0 570,068 570,088 542,974
PAYROLL TAXES:
0030 OASDI 5,406 37,740 $ 5,406
0031 FICA/MEDICARE 25,098 8,867 $ 25,098
0032 S.U.I 6,595 10,775 $ 6.595
PAYROLL TAXTOTAL so 57,382 57.382 37,099
EMPLOYEE BENEFITS:
0040 Retirement 5,780 17,105 $ 5,760
0041 Workers CompensaUon 3,461 37,683 $ 3,481
0042 Health Insurance (medical, vision, life, dental) 72,124 96.915 s 72,124
EMPLOYEE BENEFITS TOTAL $0 81,385 151,703 81,385
SALARY & BENEFITS GRAND TOTAL 661,457 779.173 661,457
FACILITIES/EQUIPMENT EXPENSES:
1010 RenVLease Building 25,804 42,526 $ 25,804
1011 RenVLease Equipment 117 2,771 $ 117
1012 Uti lilies 3,578 10,722 s 3.576
1013 Building Maintenance 4,381 2,617 $ 4,381
1014 Equipment Maintenance 1,209 5,556 s 1,209
FACILITY/EQUIPMENT TOTAL 64,392 64,392 35.088
OPERATING EXPENSES:
1060 Telephone 5,515 8,178 s 5,515
1061 Answering Service 468 0 s 468
1062 Postage 282 522 $ 282
1063 Printing/Reproduction 491 773 s 491
1064 Publications 174 727 $ 174
1065 Legal Notices/Advertising/Recruitment 255 0 s 255
1066 Office Supplies & Equipment 10,068 2,681 $ 10,088
1067 Household Supplies 779 1,091 s 779
1068 Food-UNDER FLEX 0 0 $ -
1069 Program Supplies -Therapeutic 1,512 2,662 $ 1,512
1070 Program Supplies -Medical 355 500 $ 355
1071 Transportation of Clients -UNDER FLEX 0 0 s
1072 Staff Mileage/vehicle maintenance 19,965 26,623 $ 19,965
1073 Staff Travel (Out of County) 0 0 s
1074 Staff Training/Registration 621 1,068 $ 621
1075 Lodging 195 363 $ 195
1076 Other· Vehicle Lease, Vehicle Insurance 5,261 7,411 $ 5,261
1077 Taxes. Client Activities, Bank Charges 776 5,422 $ 776
OPERATING EXPENSES TOTAL 46,736 60,221 46,736
FINANCIAL SERVICES EXPENSES
1080 Accounting/Bookkeeping 0 0 $ -
1081 External Audit 630 750 $ 830
1082 Liability Insurance 387 1,167 $ 387
1083 Administrative Overhead 15% 115.143 145,492 $ 116,143
1084 Payroll Services 0 0 s -
1085 Professional UabllitY Insurance 0 0 $
FINANCIAL SERVICES TOTAL 116.360 147,409 116,360
OP 12-22-14
Rural Mental Health • OP
Turning Point of Central CA, Inc.
Mental Health Servlc;es
Flac:al Year 2D15·2016through 2017·2018
Client Houslrig Operating Expenditures (SFC 71)
Clothing, Food & Hygiene (SFC 72)
Client Transportation & Support (SFC 72)
Education Support (SFC 72)
Employment Support (SFC 72)
Respite Cera (SFC 72)
Household Items
Utility Vouchers (SFC 72)
Therapy) 33.19%
Case Management 1.27%
Crisis Services .64%
Medication Support 64.9%
Collateral
OP 12·22·14
Revised Exhibit C
Page 21 of21
FINAL BUDGET
AMENDMENT ONE
479
50
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. ldenti in Information
Name of entity D/8/A
Address (number. street)
CLIA number Taxpayer tD number (EIN) Telephone number
ZIP code
Exhibit K
Page 1 of 2
II. Answer the following questions by checking "Yes" or "No." If any of the questions are answered "Yes," list names and
addresses of individuals or corporations under "Remarks" on page 2. Identify each item number to be continued.
A Are there any individuals or organizations having a direct or indirect ownership or control interest
of five percent or more in the institution, organizations, or agency that have been convicted of a criminal
offense related to the involvement of such persons or organizations in any of the programs established
by Titles XVIII, XIX, or XX? ........................................................................................................................ .
B. Are there any directors, officers, agents, or managing employees of the institution, agency, or
organization who have ever been convicted of a criminal offense related to their involvement in such
programs established by Titles XVIII, XIX, or XX? .................................................................................... ..
C. Are there any individuals currently employed by the institution, agency, or organization in a managerial,
accounting, auditing, or similar capacity who were employed by the institution's, organization's, or
agency's fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only) ......... ..
YES NO
0 0
0 0
0 0
Ill. A List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling
interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names
and addresses under "Remarks" on page 2. If more than one individual is reported and any of these persons are
related to each other, this must be reported under "Remarks."
NAME ADDRESS EIN
B. Type of entity: o Sole proprietorship o Partnership o Corporation
o Unincorporated Associations o Other (specify)---------
C. If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations
under "Remarks."
D. Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities?
(Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses
of individuals, and provider numbers ......................................................................................................... .. 0 0
NAME ADDRESS PROVIDER NUMBER
IV. A. Has there been a change in ownership or control within the last year? ...................................................... .
If yes, give date.
B. Do you anticipate any change of ownership or control within the year? ...................................................... .
lfyes,when? ________________________ __
C. Do you anticipate filing for bankruptcy within the year? .............................................................................. ..
If yes, when?--------------------
V. Is the facility operated by a management company or leased in whole or part by another organization? ..........
If yes, give date of change in operations.
VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year? .........
VII. A. Is this facility chain affiliated? ..................................................................................................................... .
If es, list name, address of cor oration, and EIN.
Name EIN
Address (number. name) State
B. If the answer to question VI I.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State
ZIP code
ZIP code
Exhibit K
Page 2 of2
YES NO
t:J t:J
t:J t:J
t:J t:J
t:J t:J
t:J t:J
t:J t:J
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative (typed) Title
S1gnature Date
Remarks