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Agreement No. 20-102
AGREEMENT
THIS AGREEMENT is made and entered into this tenth day of March, 2020 , by and between the
COUNTY OF FRESNO , a Political Subdivision of the State of California , hereinafter referred to as
"COUNTY", and , Dreamcatchers Empowerment Network, a private , non-profit , 501 (c) (3), corporation ,
whose address is 1125 Missouri St. Ste . 302, Fairfield , CA, 94533 , hereinafter referred to as
"CONTRACTOR ," collectively , "the parties ."
WI T N E S S ET H:
WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), is in need of a qualified
agency to operate a Vocational and Educational Services (VES) program and provide Individual
Placement Services (IPS) for adult and older adult individuals with psychiatric disabilities living in Fresno
County and receiving specialty mental health services from DBH or other County contracted providers ;
WHEREAS , COUNTY, through its Department of Behavioral Health (DBH), is a Mental Health Plan
(MHP) as defined in Title 9 of the California Code of Regulations (C .C .R.), section 1810.226 ; and
WHEREAS, CONTRACTOR is qualified and willing to operate said VES Program in collaboration
with the State Department of Rehabilitation (DOR) 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. SERVICES
A. CONTRACTOR shall perform all services and fulfill all responsibilities as set forth in
Exhibit A , attached hereto and by this reference incorporated herein and made part of this Agreement.
B. CONTRACTOR shall also perform all services and fulfill all responsibilities as
specified in COUNTY's Request for Proposal (RFP) No. 19-066 dated April 5 , 2019 , and Addendum No .
One (1) to COUNTY's RFP No. 19-066 dated April 26 , 2019 , and CONTRACTOR's response to said
Revised RFP dated May 7 , 2019 all incorporated herein by reference and made part of this Agreement. In
the event of any inconsistency among these documents, the inconsistency shall be resolved by giving
precedence in the following order of priority: 1) to this Agreement , including all Exhibits; 2) to the Revised
RFP ; and 3) to the Response to the Revised RFP. A copy of COUNTY's Revised RFP No . 19-066 and
CONTRACTOR's response thereto shall be retained and made available during the term of this
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Agreement by COUNTY’s DBH Contracts Division.
C.It is acknowledged by all parties hereto that COUNTY's DBH shall monitor the
services provided by CONTRACTOR, in accordance with Section Fourteen (14) of this Agreement.
D.CONTRACTOR shall participate in monthly, or as needed, workgroup meetings
consisting of staff from COUNTY's DBH to discuss service requirements, data reporting, training, policies
and procedures, overall program operations and any problems or foreseeable problems that may arise.
E.CONTRACTOR shall maintain requirements as an organizational provider
throughout the term of this Agreement, as described in Section Seventeen (17) of this Agreement. If for
any reason, this status is not maintained, COUNTY may terminate this Agreement pursuant to Section
Three (3) of this Agreement.
F.CONTRACTOR agrees that prior to providing services under the terms and
conditions of this Agreement, it shall have appropriate staff hired and in place for program services and
operations, or COUNTY may, in addition to other remedies it may have, suspend referrals or terminate this
Agreement, in accordance with Section Three (3) of this Agreement.
2.TERM
This Agreement shall become effective upon execution and shall terminate on the 30th day
of June 2023 with an option to be extended for two (2) additional twelve (12) month periods upon the
written approval of both parties not later than sixty (60) days prior to the close of the then current
Agreement term. The COUNTY’s DBH Director or designee is authorized to execute such written approval
on behalf of COUNTY based on CONTRCTOR’s satisfactory performance.
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;
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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. The
COUNTY shall have the right to demand of the CONTRACTOR the repayment to the COUNTY of any
funds disbursed to CONTRACTOR under this Agreement, which in the judgment of COUNTY were not
expended in accordance with the terms of this Agreement. The 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.
C.Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by COUNTY, COUNTY’s DBH Director or designee, or CONTRACTOR
upon the giving of sixty (60) days advance written notice of an intention to terminate, with notice to the
COUNTY.
4.COMPENSATION
COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation in accordance with the budget set forth in Exhibit B, attached hereto and by this reference
incorporated herein and made part of this Agreement.
A.Maximum Contract Amount
The maximum amount payable to CONTRACTOR for the ramp up period of March
10, 2020 through May 31, 2020 shall not exceed Three Hundred Five Thousand Eleven and No/100
Dollars ($305,011.00).
The maximum amount payable to CONTRACTOR for the period of June 1, 2020
through June 30, 2020 shall not exceed Seventy-Six Thousand Seventy-Seven and No/100 Dollars
($76,077.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2020
through June 30, 2021 shall not exceed Eight Hundred Seventy-Six Thousand Six Hundred Eighty-Six and
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No/100 Dollars ($876,686.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2021
through June 30, 2022 shall not exceed Nine Hundred Twenty-Four Thousand Seventy-Eight and No/100
Dollars ($924,078.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2022
through June 30, 2023 shall not exceed Nine Hundred Fifty-One Thousand Seven Hundred Nineteen and
No/100 Dollars ($951,719.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2023
through June 30, 2024 shall not exceed Nine Hundred Eighty-Nine Thousand One Hundred Twenty-Seven
and No/100 Dollars ($989,127.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2024
through June 30, 2025 shall not exceed One Million Twenty Thousand One Hundred Twenty-Four and
No/100 Dollars ($1,020,124.00).
In no event shall the maximum contract amount for all the services provided by the
CONTRACTOR to COUNTY under the terms and conditions of this Agreement be in excess of Five Million
One Hundred Forty-Two Thousand Eight Hundred Twenty-Two and No/100 Dollars ($5,142,822.00) during
the total term of this Agreement.
Payment shall be made upon certification or other proof satisfactory to COUNTY’s
DBH that services have actually been performed by CONTRACTOR as specified in this Agreement.
B.Travel shall be reimbursed based on actual expenditures and mileage
reimbursement shall be at CONTRACTOR’s adopted rate per mile, not to exceed the Federal Internal
Revenue Services (IRS) published rate.
C.It is understood that all expenses incidental to CONTRACTOR’s performance of
services under this Agreement shall be borne by CONTRACTOR. If CONTRACTOR fails to comply with
any provision of this Agreement, COUNTY shall be relieved of its obligation for further compensation.
D.Payments shall be made by COUNTY to CONTRACTOR in arrears, for services
provided during the preceding month, within forty-five (45) days after the date of receipt and approval by
COUNTY of the monthly invoicing as described in Section Five (5) herein. Payments shall be made after
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receipt and verification of actual expenditures incurred by CONTRACTOR for monthly program costs, as
identified in Exhibit B, in the performance of this Agreement and shall be documented to COUNTY on a
monthly basis by the tenth (10th) of the month following the month of said expenditures. The parties
acknowledge that the CONTRACTOR will be performing hiring, training, and credentialing of staff, and the
COUNTY will be performing additional staff credentialing to ensure compliance with State and Federal
regulations.
E.COUNTY shall not be obligated to make any payments under this Agreement if the
request for payment is received by COUNTY more than sixty (60) days after this Agreement has
terminated or expired.
All final invoices shall be submitted by CONTRACTOR within sixty (60) days
following the final month of service for which payment is claimed. No action shall be taken by COUNTY on
invoices submitted beyond the sixty (60) day closeout period. Any compensation which is not expended
by CONTRACTOR pursuant to the terms and conditions of this Agreement shall automatically revert to
COUNTY.
F.The services provided by CONTRACTOR under this Agreement are funded in
whole or in part by the State of California. In the event that funding for these services is delayed by the
State Controller, COUNTY may defer payments to CONTRACTOR. The amount of the deferred payment
shall not exceed the amount of funding delayed by the State Controller to the COUNTY. The period of
time of the deferral by COUNTY shall not exceed the period of time of the State Controller’s delay of
payment to COUNTY plus forty-five (45) days.
G.It is understood by CONTRACTOR and COUNTY that this Agreement is funded
with mental health funds to serve adult individuals with Severely Mentally Ill (SMI) disorders, many of
whom have co-occurring substance use disorders. It is further understood by CONTRACTOR and
COUNTY that funds shall be used to support appropriately integrated and documented treatment services
for co-occurring mental health and substance use disorders.
5.INVOICING
A.CONTRACTOR shall invoice COUNTY in arrears by the tenth (10th) day of each
month for the prior month’s actual services rendered to DBH-Invoices@fresnocountyca.gov. After
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CONTRACTOR renders service to referred clients, CONTRACTOR will invoice COUNTY for payment,
certify the expenditure, and submit electronic claiming data into COUNTY’s electronic information system
for all clients, including those eligible for Medi-Cal as well as those that are not eligible for Medi-Cal,
including contracted cost per unit and actual cost per unit. COUNTY must pay CONTRACTOR before
submitting a claim to DHCS for Federal reimbursement for Medi-Cal eligible clients.
B. At the discretion of COUNTY’s DBH Director, or designee, if an invoice is incorrect
or is otherwise not in proper form or substance, COUNTY’s DBH Director, or designee, shall have the right
to withhold payment as to only that portion of the invoice that is incorrect or improper after five (5) days
prior notice to CONTRACTOR. CONTRACTOR agrees to continue to provide services for a period of
ninety (90) days after notification of an incorrect or improper invoice. If after the ninety (90) day period, the
invoice(s) is still not corrected to COUNTY DBH’s satisfaction, COUNTY’s DBH Director, or designee, may
elect to terminate this Agreement, pursuant to the termination provisions stated in Section Three (3) of this
Agreement. In addition, for invoices received ninety (90) days after the expiration of each term of this
Agreement or termination of this Agreement, at the discretion of COUNTY’s DBH Director, or designee,
COUNTY’s DBH shall have the right to deny payment of any additional invoices received.
C. Monthly invoices shall include a client roster, identifying volume reported by payer
group clients served (including third party payer of services) by month and year-to-date, including
percentages.
D. CONTRACTOR shall submit to the COUNTY by the tenth (10th) of each month a
detailed general ledger (GL), itemizing costs incurred in the previous month. Failure to submit GL reports
and supporting documentation shall be deemed sufficient cause for COUNTY to withhold payments until
there is compliance, as further described in Section Five (5) herein.
E. CONTRACTOR will remit annually within ninety (90) days from June 30, a schedule
to provide the required information on published charges for all authorized direct specialty mental health
services. The published charge listing will serve as a source document to determine the CONTRACTOR’s
usual and customary charge prevalent in the public mental health sector that is used to bill the general
public, insurers or other non-Medi-Cal third party payers during the course of business operations.
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F.CONTRACTOR shall submit monthly staffing reports that identify all direct service
and support staff, applicable licensure/certifications, and full time hours worked to be used as a tracking
tool to determine if CONTRACTOR’s program is staffed according to the services provided under this
Agreement.
G.CONTRACTOR must maintain financial records for a period of ten (10) years or
until any dispute, audit or inspection is resolved, whichever is later. CONTRACTOR will be responsible for
any disallowances related to inadequate documentation.
H.CONTRACTOR is responsible for collection and managing of data in a manner to
be determined by DHCS and the COUNTY’s Mental Health Plan in accordance with applicable rules and
regulations. COUNTY’s electronic information system is a critical source of information for purposes of
monitoring service volume and obtaining reimbursement.
I.CONTRACTOR shall submit service data into COUNTY’s electronic information
system according to COUNTY’s DBH documentation standards to allow the COUNTY to bill Medi-Cal, and
any other third-party source, for services and meet State and Federal reporting requirements.
J.CONTRACTOR must comply with all laws and regulations governing the Federal
Medicare program, including, but not limited to: 1) the requirement of the Medicare Act, 42 U.S.C. section
1395 et seq; and 2) the regulations and rules promulgated by the Federal Centers for Medicare and
Medicaid Services as they relate to participation, coverage and claiming reimbursement. CONTRACTOR
will be responsible for compliance as of the effective date of each Federal, State or local law or regulation
specified.
K.If a client has dual coverage, such as other health coverage (OHC) or Federal
Medicare, the CONTRACTOR will be responsible for billing the carrier and obtaining a payment/denial or
have validation of claiming with no response ninety (90) days after the claim was mailed before the service
can be entered into the COUNTY’s electronic information system. CONTRACTOR must report all third
party collections for Medicare, third party or client pay or private pay in each monthly invoice and in the
annual cost report that is required to be submitted. A copy of explanation of benefits or CMS 1500 form is
required as documentation. CONTRACTOR must report all revenue collected from OHC, third-party,
client-pay or private-pay in each monthly invoice and in the cost report that is required to be submitted.
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CONTRACTOR shall submit monthly invoices for reimbursement that equal the amount due
CONTRACTOR less any funding sources not eligible for Federal and State reimbursement.
CONTRACTOR must comply with all laws and regulations governing the Federal Medicare program,
including, but not limited to: 1) the requirement of the Medicare Act, 42 U.S.C. section 1395 et seq; and 2)
the regulation and rules promulgated by the Federal Centers for Medicare and Medicaid Services as they
relate to participation, coverage and claiming reimbursement. CONTRACTOR will be responsible for
compliance as of the effective date of each Federal, State or local law or regulation specified.
L.Data entry shall be the responsibility of the CONTRACTOR. COUNTY shall
monitor the volume of services and cost of services entered into the COUNTY’s electronic information
system. Any and all audit exceptions resulting from the provision and reporting of specialty mental health
services by CONTRACTOR shall be the sole responsibility of the CONTRACTOR. CONTRACTOR will
comply with all applicable policies, procedures, directives and guidelines regarding the use of COUNTY’s
electronic information system.
M.Medi-Cal Certification and Mental Health Plan Compliance
CONTRACTOR shall comply with any and all requests and directives associated
with COUNTY maintaining State Medi-Cal site certification. CONTRACTOR shall provide specialty mental
health services in accordance with the COUNTY’s Mental Health Plan. CONTRACTOR must comply with
the “Fresno County Mental Health Plan Compliance Program and Code of Conduct” set forth in Exhibit C,
attached hereto and incorporated herein by reference and made part of this Agreement. CONTRACTOR
shall comply with any and all requests associated with any State/Federal reviews or audits.
CONTRACTOR may provide direct specialty mental health services using pre-
licensed staff as long as the individual is approved as a provider by the Mental Health Plan, is supervised
by licensed staff, works within his/her scope and only delivers allowable direct specialty mental health
services. It is understood that each service is subject to audit for compliance with Federal and State
regulations, and that COUNTY may be making payments in advance of said review. In the event that a
service is disapproved, COUNTY may, at its sole discretion, withhold compensation or set off from other
payments due the amount of said disapproved services. CONTRACTOR shall be responsible for audit
exceptions to ineligible dates of services or incorrect application of utilization review requirements.
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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 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 their 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 the subject
thereof.
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 COUNTY or to this
Agreement.
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 services, staffing, and responsibilities of the
CONTRACTOR, as needed, to accommodate changes in the laws relating to mental health treatment, as
set forth in Exhibit A, may be made with the signed written approval of COUNTY’s DBH Director or
designee and CONTRACTOR through an amendment approved by COUNTY’s County Counsel and the
COUNTY’s Auditor-Controller’s Office.
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In addition, changes to line items in the budget, and changes to the volume of units of
services/types of service units to be provided attached as set forth in Exhibit B, that do exceed 10% of
maximum compensation payable to each CONTRACTOR may be made with the written approval of
COUNTY’s DBH Director or designee, with notice to the County. Said budget line item changes shall
not result in any change to the maximum compensation amount payable to each CONTRACTOR, as
stated herein.
Said modifications shall not result in any change to the annual maximum compensation
amount payable to CONTRACTOR, as stated in this Agreement.
8.NON-ASSIGNMENT
No party shall assign, transfer or subcontract this Agreement nor their rights or duties under
this Agreement without the prior written consent of COUNTY.
9.HOLD-HARMLESS
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request,
defend COUNTY, its officers, agents and employees from any and all costs and expenses, including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to COUNTY
in connection with the performance, or failure to perform, by CONTRACTOR, its officers, agents or
employees under this Agreement, and from any and all costs and expenses, including attorney fees
and court costs, damages, liabilities, claims and losses occurring or resulting to any person, firm or
corporation who may be injured or damaged by the performance, or failure to perform, of
CONTRACTOR, their officers, agents or employees under this Agreement.
CONTRACTOR agrees to indemnify COUNTY for Federal and/or State of California audit
exceptions resulting from noncompliance herein on the part of CONTRACTOR.
10.INSURANCE
Without limiting COUNTY's right to obtain indemnification from CONTRACTOR or any third
parties, CONTRACTOR, at its sole expense, shall maintain in full force and affect the following insurance
policies throughout the term of this Agreement:
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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 Three Million Dollars ($3,000,000). 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
Insurance Services Office Form Number CA 0001 covering, Code 1 (any auto), or if Consultant has no owned autos, Code 8 (hired) and 9 (non-owned).with limits of not less than) One Million Dollars ($1,000,000) per accident for bodily injury and property damage.
C. Real and Property Insurance
CONTRACTOR shall maintain a policy of insurance for all risk personal property coverage which shall be endorsed naming the County of Fresno as an additional loss payee. The personal property coverage shall be in an amount that will cover the total of the COUNTY purchase and owned property, at a minimum, as discussed in Section Twenty (21) of this Agreement.
All Risk Property Insurance
CONTRACTOR will provide property coverage for the full replacement value of the COUNTY’S personal property in possession of CONTRACTOR and/or used in the execution of this Agreement. COUNTY will be identified on an appropriate certificate of insurance as the certificate holder and will be named as an Additional Loss Payee on the Property Insurance Policy.
D. Professional Liability
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. CONTRACTOR agrees that it shall maintain, at its sole expense, in full force and effect for a period of three (3) years following the termination of this Agreement, one or more policies of professional liability insurance with limits of coverage as specified herein. E. Child Abuse/Molestation and Social Services Coverage
CONTRACTOR shall have either separate policies or an umbrella policy with endorsements covering Child Abuse/Molestation and Social Services Liability coverage or have a specific endorsement on their General Commercial liability policy covering Child Abuse/Molestation and Social Services Liability. The policy limits for these policies shall be One Million Dollars ($1,000,000) per occurrence
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with a Two Million Dollars ($2,000,000) annual aggregate. The policies are to be on a per occurrence basis.
F. Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the California Labor Code. G. Waiver of Subrogation CONTRACTOR hereby grants to COUNTY a waiver of any right to subrogation which any insurer of said CONTRACTOR may acquire against the COUNTY by virtue of the payment of any loss under insurance. CONTRACTOR agrees to obtain any endorsement that may be necessary to affect this waiver of subrogation, but this provision applies regardless of whether or not the COUNTY has received a waiver of subrogation endorsement from the insurer. Additional Requirements Relating to Insurance
CONTRACTOR shall obtain endorsements to the Commercial General Liability insurance naming
the County of Fresno, its officers, agents, and employees, individually and collectively, as additional
insured, 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 COUNTY, its officers, agents and employees shall be excess only and not contributing with insurance
provided under 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.
CONTRACTOR hereby waives its right to recover from COUNTY, its officers, agents, and
employees any amounts paid by the policy of worker’s compensation insurance required by this
Agreement. CONTRACTOR is solely responsible to obtain any endorsement to such policy that may be
necessary to accomplish such waiver of subrogation, but CONTRACTOR’s waiver of subrogation under
this paragraph is effective whether or not CONTRACTOR obtains such an endorsement.
Within Thirty (30) days from the date CONTRACTOR signs and executes this Agreement,
CONTRACTOR shall provide certificates of insurance and endorsement as stated above for all of the
foregoing policies, as required herein, to the County of Fresno, (Name and Address of the official who will
administer this contract), 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
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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 COUNTY, its officers, agents
and employees, shall be excess only and not contributing with insurance provided under 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 issued by admitted insurers licensed to do business in the State of California,
and such insurance shall be purchased from companies possessing a current A.M. Best, Inc. rating of A
FSC VII or better.
11.LICENSES/CERTIFICATES
Throughout each term of this Agreement, CONTRACTOR and CONTRACTOR’s staff shall
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, the County of Fresno, and any other applicable governmental 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. Additionally, CONTRACTOR and CONTRACTOR’s staff shall comply with all
applicable laws, rules or regulations, as may now exist or be hereafter changed.
12.RECORDS
CONTRACTOR shall maintain records in accordance with Exhibit D, "Documentation
Standards for Client Records", attached hereto and by this reference incorporated herein and made part of
this Agreement. COUNTY shall be allowed to review all records of services provided, including the goals
and objectives of the treatment plan, and how the therapy provided is achieving the goals and objectives.
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13. REPORTS
1. Outcome Reports
CONTRACTOR shall submit to COUNTY’s DBH service outcome reports as
reasonably requested by COUNTY’s DBH. Outcome reports and outcome requirements are subject to
change at COUNTY’s DBH discretion.
2. Additional Reports
CONTRACTOR shall also furnish to COUNTY such statements, records, reports,
data, and other information as COUNTY’s DBH may reasonably request pertaining to matters covered by
this Agreement. In the event that CONTRACTOR fails to provide such reports or other information
required hereunder, it shall be deemed sufficient cause for COUNTY to withhold monthly payments until
there is compliance. In addition, CONTRACTOR shall provide written notification and explanation to
COUNTY within five (5) days of any funds received from another source to conduct the same services
covered by this Agreement.
3. Settlements with State Department of Health Care Services (DHCS)
During the term of this Agreement and thereafter, COUNTY and CONTRACTOR
agree to settle dollar amounts disallowed or settled in accordance with DHCS audit settlement findings
related to the reimbursement provided under this Agreement. CONTRACTOR will participate in the several
phases of settlements between COUNTY/CONTRACTOR and DHCS. The phases of initial cost reporting
for settlement according to State reconciliation of records for paid Medi-Cal services and audit settlement
are: State DHCS audit 1) initial cost reporting - after an internal review by COUNTY, the COUNTY files the
cost report with State DHCS on behalf of the CONTRACTOR’s legal entity for the fiscal year; 2) Settlement
–State reconciliation of records for paid Medi-Cal services, approximately 18 to 36 months following the
State close of the fiscal year, DHCS will send notice for any settlement under this provision to the
COUNTY; 3) Audit Settlement-State DHCS audit. After final reconciliation and settlement DHCS may
conduct a review of medical records, cost report along with support documents submitted to COUNTY in
initial submission to determine accuracy and may disallow costs and/or units of services. COUNTY may
choose to appeal and therefore reserves the right to defer payback settlement with CONTRACTOR until
resolution of the appeal. DHCS Audits will follow Federal Medicaid procedures for managing
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overpayments. If at the end of the Audit Settlement, the COUNTY determines that it overpaid the
CONTRACTOR, it will require the CONTRACTOR to repay the Medi-Cal related overpayment back to the
COUNTY.
Funds owed to COUNTY will be due within forty-five (45) days of notification by the
COUNTY, or COUNTY shall withhold future payments until all excess funds have been recouped by
means of an offset against any payments then or thereafter owing to COUNTY under this or any other
Agreement between the COUNTY and CONTRACTOR.
14.MONITORING
CONTRACTOR agrees to extend to COUNTY’s staff, COUNTY’s DBH Director and the
State Department of Health Care Services, or their designees, the right to review and monitor records,
services or procedures, at any time, in regard to clients, as well as the overall operation of
CONTRACTOR’s performance, in order to ensure compliance with the terms and conditions of this
Agreement.
15.REFERENCES TO LAWS AND RULES
In the event any law, regulation, or policy referred to in this Agreement is amended during
the term thereof, the parties hereto agree to comply with the amended provision as of the effective date of
such amendment.
16.COMPLIANCE WITH STATE REQUIREMENTS
CONTRACTOR recognizes that COUNTY operates its mental health programs under an
agreement with the State of California Department Health Care Services, and that under said agreement
the State imposes certain requirements on COUNTY and its subcontractors. CONTRACTOR shall adhere
to all State requirements, including those identified in Exhibit E “State Mental Health Requirements”,
attached hereto and by this reference incorporated herein and made part of this Agreement.
CONTRACTOR shall also file an incident report for all incidents involving clients, following the Protocol and
using the Worksheet identified in Exhibit F, attached hereto and by this reference incorporated herein and
made part of this Agreement or a protocol and worksheet presented by CONTRACTOR that is accepted
by COUNTY’s DBH Director or his or her designee.
///
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17.COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
CONTRACTOR shall inform every client of their rights under the COUNTY's Mental Health
Plan as described in Exhibit G, attached hereto and by this reference incorporated herein and made part of
this Agreement.
18.CONFIDENTIALITY
All services performed by CONTRACTOR under this Agreement shall be in strict
conformance with all applicable Federal, State of California and/or local laws and regulations relating to
confidentiality.
19.HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and CONTRACTOR each consider and represent themselves as covered
entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law 104-
191 (HIPAA) and agree to use and disclose Protected Health Information (PHI) as required by law.
COUNTY and CONTRACTOR acknowledge that the exchange of PHI between them is only for treatment,
payment, and health care operations.
COUNTY and CONTRACTOR intend to protect the privacy and provide for the security of
PHI pursuant to the Agreement in compliance with HIPAA, the Health Information Technology for
Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations promulgated thereunder
by the U.S. Department of Health and Human Services (HIPAA Regulations) and other applicable laws.
As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
CONTRACTOR to enter into a contract containing specific requirements prior to the disclosure of PHI, as
set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504€ of the Code of
Federal Regulations.
20.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
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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 his or her 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 may not use COUNTY computers or computer peripherals on non-
COUNTY premises without prior authorization from the COUNTY’s Chief Information Officer, and/or his or
her designee(s).
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
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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.
21. PROPERTY OF COUNTY
A. COUNTY and CONTRACTOR recognize that fixed assets are tangible and
intangible property obtained or controlled under COUNTY’s Mental Health Plan for use in operational
capacity and will benefit COUNTY for a period more than one year. Depreciation of the qualified items will
be on a straight-line basis.
For COUNTY purposes, fixed assets must fulfill three qualifications:
1. Asset must have life span of over one year.
2. The asset is not a repair part
3. The asset must be valued at or greater than the capitalization thresholds for
the asset type
Asset type Threshold
• land $0 • buildings and improvements $100,000
• infrastructure $100,000 • be tangible $5,000 o equipment o vehicles
• or intangible asset $100,000 o Internally generated software o Purchased software o Easements o Patents
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•and capital lease $5,000
Qualified fixed asset equipment is to be reported and approved by COUNTY. If it is
approved and identified as an asset it will be tagged with a COUNTY program number. A Fixed asset log
will be maintained by COUNTY’s Asset Management System and annual inventoried until the asset is fully
depreciated. During the terms of this Agreement, CONTRACTOR’s fixed assets may be inventoried in
comparison to COUNTY’s DBH Asset Inventory System.
B.Certain purchases less than Five Thousand and No/100 Dollars ($5,000.00) but
more than $1,000, with over one year life span, and are mobile and high risk of theft or loss are sensitive
assets. Such sensitive items are not limited to computers, copiers, televisions, cameras and other sensitive
items as determined by COUNTY’s DBH Director or designee. CONTRACTOR maintains a tracking
system on the items and are not required to be capitalize or depreciated. The items are subject to annual
inventory for compliance.
C.Assets shall be retained by COUNTY, as COUNTY property, 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 and inventoried assets. Upon termination or expiration of this
Agreement CONTRACTOR shall be physically present when fixed and inventoried assets are returned to
COUNTY possession. CONTRACTOR is responsible for returning to COUNTY all COUNTY owned
undepreciated fixed and inventoried assets, or the monetary value of said assets if unable to produce the
assets at the expiration or termination of this Agreement.
CONTRACTOR further agrees to the following:
1.To maintain all items of equipment in good working order and condition,
normal wear and tear is expected;
2.To label all items of equipment with COUNTY assigned program number, to
perform periodic inventories as required by COUNTY and to maintain an inventory list showing where and
how the equipment is being used, in accordance with procedures developed by COUNTY. All such lists
shall be submitted to COUNTY within ten (10) days of any request therefore; and
3.To report in writing to COUNTY immediately after discovery, the lost or theft
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of any items of equipment. For stolen items, the local law enforcement agency must be contacted and a
copy of the police report submitted to COUNTY.
D. The purchase of any equipment by CONTRACTOR with funds provided hereunder
shall require the prior written approval of COUNTY’s DBH, shall fulfill the provisions of this Agreement as
appropriate, and must be directly related to CONTRACTOR’s services or activity under the terms of this
Agreement. COUNTY’s DBH may refuse reimbursement for any costs resulting from equipment
purchased, which are incurred by CONTRACTOR, if prior written approval has not been obtained from
COUNTY.
E. CONTRACTOR must obtain prior written approval from COUNTY’s DBH whenever
there is any modification or change in the use of any property acquired or improved, in whole or in part,
using funds under this Agreement. If any real or personal property acquired or improved with said funds
identified herein is sold and/or is utilized by CONTRACTOR for a use which does not qualify under this
Agreement, CONTRACTOR shall reimburse COUNTY in an amount equal to the current fair market value
of the property, less any portion thereof attributable to expenditures of funds not provided under this
Agreement. These requirements shall continue in effect for the life of the property. In the event this
Agreement expires, or terminates, the requirements for this Section shall remain in effect for activities or
property funded with said funds, unless action is taken by the State government to relieve COUNTY of
these obligations
22. NON-DISCRIMINATION
During the performance of this Agreement, CONTRACTOR shall not unlawfully
discriminate against any employee or applicant for employment, or recipient of services, because of race,
religion, color, national origin, ancestry, physical handicap, medical condition, marital status, age or
gender, pursuant to all applicable State and Federal statutes and regulations.
23. CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence, CONTRACTOR shall comply with:
A. Title 6 of the Civil Rights Act of 1964 (42 U.S.C. section 2000d, and 45 C.F.R. Part
80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance from
discriminating against persons based on race, color, national origin, sex, disability or religion. This is
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interpreted to mean that a limited English proficient (LEP) individual is entitled to equal access and
participation in federally funded programs through the provision of comprehensive and quality bilingual
services.
B. Policies and procedures for ensuring access and appropriate use of trained
interpreters and material translation services for all LEP clients, including, but not limited to, assessing the
cultural and linguistic needs of its clients, training of staff on the policies and procedures, and monitoring its
language assistance program. The CONTRACTOR’s procedures must include ensuring compliance of any
sub-contracted providers with these requirements.
C. CONTRACTOR shall not use minors as interpreters.
D. CONTRACTOR shall provide and pay for interpreting and translation services to
persons participating in CONTRACTOR’s services who have limited or no English language proficiency,
including services to persons who are deaf or blind. Interpreter and translation services shall be provided
as necessary to allow such participants meaningful access to the programs, services and benefits provided
by CONTRACTOR. Interpreter and translation services, including translation of CONTRACTOR’s “vital
documents” (those documents that contain information that is critical for accessing CONTRACTOR’s
services or are required by law) shall be provided to participants at no cost to the participant.
CONTRACTOR shall ensure that any employees, agents, subcontractors, or partners who interpret or
translate for a program participant, or who directly communicate with a program participant in a language
other than English, demonstrate proficiency in the participant's language and can effectively communicate
any specialized terms and concepts peculiar to CONTRACTOR’s services.
E. In compliance with the State mandated Culturally and Linguistically Appropriate
standards as published by the Office of Minority Health, CONTRACTOR must submit to COUNTY for
approval, within sixty (60) days from date of contract execution, CONTRACTOR’s plan to address all
fifteen (15) national cultural competency standards as set forth in the “National Standards on Culturally and
Linguistically Appropriate Services (CLAS)”. COUNTY’s annual on-site review of CONTRACTOR shall
include collection of documentation to ensure all national standards are implemented. As the national
competency standards are updated, CONTRACTOR’s plan must be updated accordingly. Cultural
competency training for CONTRACTOR’s staff should be substantively integrated into health professions
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education and training at all levels, both academic and functional, including core curriculum, professional
licensure, and continuing professional development programs. CONTRACTOR on a monthly basis shall
provide COUNTY DBH a monthly monitoring tool/report that shows all CONTRACTOR’s staff cultural
competency trainings completed.
24.AMERICANS WITH DISABILITIES ACT
CONTRACTOR agrees to ensure that deliverables developed and produced, pursuant to
this Agreement shall comply with the accessibility requirements of Section 508 of the Rehabilitation Act
and the Americans with Disabilities Act of 1973 as amended (29 U.S.C. § 794 (d)), and regulations
implementing that Act as set forth in Part 1194 of Title 36 of the Code of Federal Regulations. In 1998,
Congress amended the Rehabilitation Act of 1973 to require Federal agencies to make their electronic and
information technology (EIT) accessible to people with disabilities. California Government Code section
11135 codifies section 508 of the Act requiring accessibility of electronic and information technology.
25.TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowance of reimbursement under section
1861(v)(1) (I) of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[I]), until the expiration of four (4)
years after the furnishing of services under this Agreement, CONTRACTOR shall make available, upon
written request to the Secretary of the United States Department of Health and Human Services, or upon
request to the Comptroller General of the United States General Accounting Office, or any of their duly
authorized representatives, a copy of this Agreement and such books, documents, and records as are
necessary to certify the nature and extent of the costs of these services provided by CONTRACTOR under
this Agreement. CONTRACTOR further agrees that in the event CONTRACTOR carries out any of its
duties under this Agreement through a subcontract, with a value or cost of Ten Thousand and No/100
Dollars ($10,000.00) or more over a twelve (12) month period, with a related organization, such Agreement
shall contain a clause to the effect that until the expiration of four (4) years after the furnishing of such
services pursuant to such subcontract, the related organizations shall make available, upon written request
to the Secretary of the United States Department of Health and Human Services, or upon request to the
Comptroller General of the United States General Accounting Office, or any of their duly authorized
representatives, a copy of such subcontract and such books, documents, and records of such organization
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as are necessary to verify the nature and extent of such costs.
26.SINGLE AUDIT CLAUSE
A.If CONTRACTOR expends Seven Hundred Fifty Thousand Dollars ($750,000.00)
or more in Federal and Federal flow-through monies, CONTRACTOR agrees to conduct an annual audit in
accordance with the requirements of the Single Audit Standards as set forth in Office of Management and
Budget (OMB) Circular A-133. CONTRACTOR shall submit said audit and management letter to
COUNTY. The audit must include a statement of findings or a statement that there were no findings. If
there were negative findings, CONTRACTOR must include a corrective action plan signed by an
authorized individual. CONTRACTOR agrees to take action to correct any material non-compliance or
weakness found as a result of such audit. Such audit shall be delivered to COUNTY’s DBH Business
Office, for review within nine (9) months of the end of any fiscal year in which funds were expended and/or
received for the program. Failure to perform the requisite audit functions as required by this Agreement
may result in COUNTY performing the necessary audit tasks, or at COUNTY’s option, contracting with a
public accountant to perform said audit, or, may result in the inability of COUNTY to enter into future
agreements with CONTRACTOR. All audit costs related to this Agreement are the sole responsibility of
CONTRACTOR.
B.A single audit report is not applicable if CONTRACTOR’s Federal contracts do not
exceed the Seven Hundred Fifty Thousand Dollars ($750,000.00) requirement or CONTRACTOR’s only
funding is through Drug related Medi-Cal. If a single audit is not applicable, a program audit must be
performed and a program audit report with management letter shall be submitted by CONTRACTOR to
COUNTY as a minimum requirement to attest to CONTRACTOR’s solvency. Said audit report shall be
delivered to COUNTY’s DBH Business Office, for review no later than nine (9) months after the close of
the fiscal year in which the funds supplied through this Agreement are expended. Failure to comply with
this Act may result in COUNTY performing the necessary audit tasks or contracting with a qualified
accountant to perform said audit. All audit costs related to this Agreement are the sole responsibility of
CONTRACTOR who agrees to take corrective action to eliminate any material noncompliance or
weakness found as a result of such audit. Audit work performed by COUNTY under this paragraph shall
be billed to the CONTRACTOR at COUNTY cost, as determined by COUNTY’s Auditor-
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Controller/Treasurer-Tax Collector.
C. CONTRACTOR shall make available all records and accounts for inspection by
COUNTY, the State of California, if applicable, the Comptroller General of the United States, the Federal
Grantor Agency, or any of their duly authorized representatives, at all reasonable times for a period of at
least three (3) years following final payment under this Agreement or the closure of all other pending
matters, whichever is later.
27. COMPLIANCE
CONTRACTOR agrees to comply with the COUNTY’s Contractor Code of Conduct and
Ethics and the COUNTY’s Compliance Program in accordance with Exhibit C, attached hereto and
incorporated herein by reference and made part of this Agreement. Within thirty (30) days of entering into
this Agreement with the COUNTY, CONTRACTOR shall have all of CONTRACTOR’s employees, agents
and subcontractors providing services under this Agreement certify in writing, that he or she has received,
read, understood, and shall abide by the Contractor Code of Conduct and Ethics. CONTRACTOR shall
ensure that within thirty (30) days of hire, all new employees, agents and subcontractors providing services
under this Agreement shall certify in writing that he or she has received, read, understood, and shall abide
by the Contractor Code of Conduct and Ethics. CONTRACTOR understands that the promotion of and
adherence to the Code of Conduct is an element in evaluating the performance of CONTRACTOR and its
employees, agents and subcontractors.
Within thirty (30) days of entering into this Agreement, and annually thereafter, all
employees, agents and subcontractors providing services under this Agreement shall complete general
compliance training and appropriate employees, agents and subcontractors shall complete documentation
and billing or billing/reimbursement training. All new employees, agents and subcontractors shall attend
the appropriate training within 30 days of hire. Each individual who is required to attend training shall
certify in writing that he or she has received the required training. The certification shall specify the type of
training received and the date received. The certification shall be provided to the COUNTY’s Compliance
Officer at 3133 N. Millbrook, Fresno, California 93703. CONTRACTOR agrees to reimburse COUNTY for
the entire cost of any penalty imposed upon COUNTY by the Federal Government as a result of
CONTRACTOR’s violation of the terms of this Agreement.
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28.ASSURANCES
In entering into this Agreement, CONTRACTOR certifies that neither it, nor any of its
officers, are currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal
Health Care Programs; that neither it, nor any of its officers, have been convicted of a criminal offense
related to the provision of health care items or services; nor has it, or any of its officers, been reinstated to
participate in the Federal Health Care Programs after a period of exclusion, suspension, debarment, or
ineligibility. If COUNTY learns, subsequent to entering into a contract, that CONTRACTOR is ineligible on
these grounds, COUNTY will remove CONTRACTOR from responsibility for, or involvement with,
COUNTY’s business operations related to the Federal Health Care Programs and shall remove such
CONTRACTOR from any position in which CONTRACTOR’s compensation, or the items or services
rendered, ordered or prescribed by CONTRACTOR may be paid in whole or part, directly or indirectly, by
Federal Health Care Programs or otherwise with Federal Funds at least until such time as CONTRACTOR
is reinstated into participation in the Federal Health Care Programs.
A.If COUNTY has notice that either CONTRACTOR, or its officers, has been charged
with a criminal offense related to any Federal Health Care Program, or is proposed for exclusion during the
term of any contract, CONTRACTOR and COUNTY shall take all appropriate actions to ensure the
accuracy of any claims submitted to any Federal Health Care Program. At its discretion given such
circumstances, COUNTY may request that CONTRACTOR cease providing services until resolution of the
charges or the proposed exclusion.
B.CONTRACTOR agrees that all potential new employees of CONTRACTOR or
subcontractors of CONTRACTOR who, in each case, are expected to perform professional services under
this Agreement, will be queried as to whether (1) they are now or ever have been excluded, suspended,
debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) they have been
convicted of a criminal offense related to the provision of health care items or services; and or (3) they
have been reinstated to participate in the Federal Health Care Programs after a period of exclusion,
suspension, debarment, or ineligibility.
1.In the event the potential employee or subcontractor informs
CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible, or has been
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convicted of a criminal offense relating to the provision of health care services, and CONTRACTOR hires
or engages such potential employee or subcontractor, CONTRACTOR will ensure that said employee or
subcontractor does no work, either directly or indirectly relating to services provided to COUNTY.
2.Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section Three (3) of this Agreement, or require adequate assurance (as
defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor of
CONTRACTOR will perform work, either directly or indirectly, relating to services provided to COUNTY.
Such demand for adequate assurance shall be effective upon a time frame to be determined by COUNTY
to protect the interests of COUNTY consumers.
C.CONTRACTOR shall verify (by asking the applicable employees and
subcontractors) that all current employees and existing subcontractors who, in each case, are expected to
perform professional services under this Agreement (1) are not currently excluded, suspended, debarred,
or otherwise ineligible to participate in the Federal Health Care Programs; (2) have not been convicted of a
criminal offense related to the provision of health care items or services; and (3) have not been reinstated
to participate in the Federal Health Care Program after a period of exclusion, suspension, debarment, or
ineligibility. In the event any existing employee or subcontractor informs CONTRACTOR that he or she is
excluded, suspended, debarred or otherwise ineligible to participate in the Federal Health Care Programs,
or has been convicted of a criminal offense relating to the provision of health care services,
CONTRACTOR will ensure that said employee or subcontractor does no work, either direct or indirect,
relating to services provided to COUNTY.
1.CONTRACTOR agrees to notify COUNTY immediately during the term of
this Agreement whenever CONTRACTOR learns that an employee or subcontractor who, in each case, is
providing professional services under this Agreement is excluded, suspended, debarred or otherwise
ineligible to participate in the Federal Health Care Programs, or is convicted of a criminal offense relating
to the provision of health care services.
2.Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section 3 of this Agreement, or require adequate assurance (as defined by
COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor of
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CONTRACTOR will perform work, either directly or indirectly, relating to services provided to COUNTY.
Such demand for adequate assurance shall be effective upon a time frame to be determined by COUNTY
to protect the interests of COUNTY consumers.
D. CONTRACTOR agrees to cooperate fully with any reasonable requests for
information from COUNTY which may be necessary to complete any internal or external audits relating to
CONTRACTOR’s compliance with the provisions of this Section.
E. CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty
imposed upon COUNTY by the Federal Government as a result of CONTRACTOR’s violation of
CONTRACTOR’s obligations as described in this Section.
29. PUBLICITY PROHIBITION
None of the funds, materials, property or services provided directly or indirectly under this
Agreement shall be used for CONTRACTOR’s advertising, fundraising, or publicity (i.e., purchasing of
tickets/tables, silent auction donations, etc.) for the purpose of self-promotion. Notwithstanding the above,
publicity 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 by
COUNTY’s DBH Director or designee and at a cost to be provided in Exhibit B for such items as
written/printed materials, the use of media (i.e., radio, television, newspapers) and any other related
expense(s).
30. COMPLAINTS
CONTRACTOR shall log complaints and the disposition of all complaints from a client or a
client's family. CONTRACTOR shall provide a copy of the detailed complaint log entries concerning
COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (l 0th) day of the following month,
in a format that is mutually agreed upon. In addition, CONTRACTOR shall provide details and attach
documentation of each complaint with the log. CONTRACTOR shall post signs informing clients of their
right to file a complaint or grievance. CONTRACTOR shall notify COUNTY of all incidents reportable to
State licensing bodies that affect COUNTY clients within twenty-four (24) hours of receipt of a complaint.
Within ten (10) days after each incident or complaint affecting COUNTY clients,
CONTRACTOR shall provide COUNTY with information relevant to the complaint, investigative details of
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the complaint, the complaint and CONTRACTOR's disposition of, or corrective action taken to resolve the
complaint. In addition, CONTRACTOR shall inform every client of their rights as set forth in Exhibit G.
CONTRACTOR shall file an incident report for all incidents involving clients, following the protocol and
using the worksheet identified in Exhibit F and incorporated herein by reference and made part of this
Agreement.
31. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION
This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent, or
managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101 455.104, and
455.106(a)(1),(2).
In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and 455.106(a)(1),(2),
the following information must be disclosed by CONTRACTOR by completing Exhibit H, “Disclosure of
Ownership and Control Interest Statement”, attached hereto and by this reference incorporated herein and
made part of this Agreement. CONTRACTOR shall submit this form to the COUNTY’s DBH within thirty
(30) days of the effective date of this Agreement. Additionally, CONTRACTOR shall report any changes to
this information within thirty-five (35) days of occurrence by completing Exhibit H, “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.
32. DISCLOSURE – CRIMINAL HISTORY AND CIVIL ACTIONS
CONTRACTOR is required to disclose if any of the following conditions apply to them, their
owners, officers, corporate managers and partners (hereinafter collectively referred to as
“CONTRACTOR”):
A. Within the three-year period preceding the Agreement award, they have been
convicted of, or had a civil judgment rendered against them for:
1. Fraud or a criminal offense in connection with obtaining, attempting to
obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction;
2. Violation of a federal or state antitrust statute;
3. Embezzlement, theft, forgery, bribery, falsification, or destruction of records;
or
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4.False statements or receipt of stolen property.
B.Within a three-year period preceding their Agreement award, they have had a
public transaction (federal, state, or local) terminated for cause or default.
Disclosure of the above information will not automatically eliminate CONTRACTOR from
further business consideration. The information will be considered as part of the determination of whether
to continue and/or renew this Agreement and any additional information or explanation that a
CONTRACTOR elects to submit with the disclosed information will be considered. If it is later determined
that the CONTRACTOR failed to disclose required information, any contract awarded to such
CONTRACTOR may be immediately voided and terminated for material failure to comply with the terms
and conditions of the award.
CONTRACTOR must sign a “Certification Regarding Debarment, Suspension, and Other
Responsibility Matters- Primary Covered Transactions” in the form set forth in Exhibit I, attached hereto
and by this reference incorporated herein and made part of this Agreement. Additionally, CONTRACTOR
must immediately advise the COUNTY’s DBH in writing if, during the term of this Agreement: (1)
CONTRACTOR becomes suspended, debarred, excluded or ineligible for participation in federal or state
funded programs or from receiving federal funds as listed in the excluded parties’ list system
(http://www.epls.gov); or (2) any of the above listed conditions become applicable to CONTRACTOR.
CONTRACTOR shall indemnify, defend and hold the COUNTY harmless for any loss or damage resulting
from a conviction, debarment, exclusion, ineligibility or other matter listed in the signed Certification
Regarding Debarment, Suspension, and Other Responsibility Matters.
33.DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the CONTRACTOR is operating as a corporation (a for-
profit or non-profit corporation) or if during the term of this Agreement, the CONTRACTOR changes its
status to operate 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
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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 J and incorporated herein by
reference and made part of this Agreement, and submitting it to the COUNTY prior to commencing with
the self-dealing transaction or immediately thereafter.
34. AUDITS AND INSPECTIONS
The CONTRACTOR shall at any time during business hours, and as often as the COUNTY
may deem necessary, make available to the COUNTY for examination all of its records and data with
respect to the matters covered by this Agreement. The CONTRACTOR shall, upon request by the
COUNTY, permit the COUNTY to audit and inspect all such records and data necessary to ensure
CONTRACTOR’s compliance 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 General for a period of
three (3) years after final payment under contract (California Government Code section 8546.7).
35. NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CONTRACTOR Director, Fresno County Executive Director Department of Behavioral Health Dreamcatchers Empowerment Network 3133 N. Millbrook Ave 1125 Missouri Street, Suite 302 Fresno, CA 93702 Fairfield, CA 94533 All notices between the COUNTY and CONTRACTOR provided for or permitted under this
Agreement must be in writing and delivered either by personal service, by first-class United States mail, by
an overnight commercial courier service, or by telephonic facsimile transmission. A notice delivered by
personal service is effective upon service to the recipient. A notice delivered by first-class United States
mail is effective three COUNTY business days after deposit in the United States mail, postage prepaid,
addressed to the recipient. A notice delivered by an overnight commercial courier service is effective one
COUNTY business day after deposit with the overnight commercial courier service, delivery fees prepaid,
with delivery instructions given for next day delivery, addressed to the recipient. A notice delivered by
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telephonic facsimile is effective when transmission to the recipient is completed (but, if such transmission
is completed outside of COUNTY business hours, then such delivery shall be deemed to be effective at
the next beginning of a COUNTY business day), provided that the sender maintains a machine record of
the completed transmission. For all claims arising out of or related to this Agreement, nothing in this
section establishes, waives, or modifies any claims presentation requirements or procedures provided by
law, including but not limited to the Government Claims Act (Division 3.6 of Title 1 of the Government
Code, beginning with section 810).
36. GOVERNING LAW
Venue for any action arising out of or related to the Agreement shall only 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.
37. ENTIRE AGREEMENT
This Agreement, including all Exhibits, constitutes the entire agreement between
CONTRACTOR and COUNTY with respect to the subject matter hereof and supersedes all previous
agreement negotiations, proposals, commitments, writings, advertisements, publications, and
understandings of any nature whatsoever unless expressly included in this Agreement.
///
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1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year
2 first hereinabove written .
3
4
5 DREAMCATCHERS EMPOWERMENT
10
11
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13
TWORK
ll&stJt:£,Du_~ &~~
lrtlef&, C3ta45??
14 Mailing Address
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20
FOR ACCOUNTING USE ONLY:
Fund/Subclass : 0001/10000 21 Org No .: 56304533 ($5,142,822)
22 Account No .: 7295
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y:
COUNTY OF FRESNO
Ernest Buddy Mendes,
Chairman of the Board of Supervisors
of the County of Fresno
ATTEST:
Bernice E. Seidel
Clerk of the Board of Supervisors
County of Fresno, State of California
32
Dreamcatchers Empowerment Network
Fresno County DBH Scope of Work
I.Introduction
This contract is intended for Dreamcatchers Empowerment Network (hereafter refers to
as Dreamcatchers) to provide services to clients of County of Fresno Department of
Behavioral Health (DBH). Services provided under this contract are designed to
prepare DBH clients with the necessary skills to obtain and retain competitive
employment using IPS Placement and Supports fidelity model.
The DBH agreement shall include Adults and Transitional Aged Youth defined as ages
16-24 (hereinafter know as TAY) who have current open cases within DBH or contract
provider.
All of the following conditions must be met for DBH clients referred to Dreamcatchers
and (potentially) through the Department of Rehabilitation:
•Individuals must have medical documentation of psychiatric diagnosis;
•Individual must be a legal resident of Fresno County;
•Individual must be at least 16 years of age;
•Individual must be receiving services from DBH or mental health contract
provider.
For each fiscal year, a minimum of 100 unduplicated DBH clients will receive services
through this contract.
Participants will benefit from the following array of services:
•Culturally competent community outreach and engagement to bring un-served,
diverse consumers into services that will open the door to success
•Wellness and Recovery Action Plan (WRAP) , Motivational Interviewing, and
Dialectical Behavioral Therapy (DBT)
•Peer Support groups, peer training, and supportive mentoring
•Connection to adult education and community college and other educational
services
•Assessment process including self-assessment, mental health and health history,
educational and vocational background completed by licensed clinician
•Individualized CARF accredited educational, employment, empowerment plan
addressing the person’s interests, goals, skills, abilities and needs
•Benefit planning assistance
•Job preparation, job seeking assistance, computer lab, placement services, and
coaching services
•Healthy relationships, harm reduction and life skills training
Participants will also have access to additional daily living supports at the center
including basic hygiene, food and clothing assistance when preparing for employment.
We will be able to provide monthly bus passes for 100 participants for 6-months while
job searching. Other employment supports such as flash drives for resumes and cover
letters to be maintained, portfolios for resume presentation, or items such as tool belts
or back braces needed when working will also be available limited basis. Educational
supports will be provided such as funds to cover the GED exam, the cost of textbooks
or enrollment into vocational training programs. These additional supports will be
available for those actively participating in services and will be closely monitored and
tracked in distribution.
Upon new receipt of referral from Behavioral Health, Dreamcatchers will contact the
client within 48 hours and schedule a time convenient to meet to complete an Intake,
including the IPS Career Profile, and develop a service plan. An individualized CARF
accredited educational, employment, empowerment plan addressing the person’s
developmental level, educational and employment history, interests, goals, skills,
special needs, and accommodation requirements. The plan is developed to help
eliminate their barriers to success is time oriented, attainable and developed by the
client and staff.
Employment and education services will be in accordance with the IPS model and
fidelity standards yet also in compliance with Department of Rehabilitation service
structures. The focus will be on competitive employment based upon client choice and
in alignment with their preferences. Job search will be provided within 30 days of intake
and will be a systematic approach by the Employment Specialist to visit employers in
alignment with the client preferences to develop opportunities for hire. Job supports will
be provided to each client while worked for the length of time of their choice. Clients will
receive personalized benefits counseling either directly through Dreamcatchers or
through community partner agencies such as the DOR Work Incentive Planner.
Employment and education services will be closely integrated with the clients’
behavioral health treatment team. The treatment team will meet on a weekly or regular
schedule to address wrap-around supports of the individual. Services provided may be
adapted to meet the needs of the populations being served while ensure fidelity to the
model. For example some individuals may not receive benefits or may now be
considering signing up for them. The approach to benefits counseling will vary.
Individual services customized to that individual are our philosophy in service delivery.
Although no direct behavior health services will be provided onsite at the center, we will
offer additional services to help support our clients such as WRAP, DBT, and
Motivational Interviewing. Dreamcatchers will work with community partners and
Behavioral Health treatment team to identify existing resources, services and supports
that clients can benefit from. Should a need arise to develop a formalized agreement
such as an MOU; Dreamcatchers is willing to negotiate with such partner to develop an
agreement feasible for both parties.
Staff providing direct client services through Dreamcatchers includes the following:
Employment Specialists will provide direct client services and develop job opportunities
within the community. The Employment Specialist will meet with the client upon initial
referral for DBH and begin the career planning process for rapid job search. The ES will
have a caseload of no more than 20 individuals at any given time to maintain the fidelity
standards. The primary functions include:
• Career Plan Development/Vocational Assessment
• Contact of employers to identify job openings
• Obtaining information detailing qualifications and work site requirements for
specific job opportunities to ensure applicant readiness and success on the job.
• Job site consultation to identify or modify barriers
• Negotiating job carving, work site analysis or other job accommodations
• Assisting job applicant in the interviewing process
• Assisting the job applicant in coordinating transportation needs
• Job coaching, once hired (may be on or off the work site)
• Incentive Planning assistance or referral
• Identify needs and supports for employment success (housing, education,
transportation, clothing, food, etc.)
• Work in partnership with the individual’s treatment team on all matters of care
and services
Education Specialists will help individuals enroll in or seek out education options based
upon the needs identified in the career planning process.
• Identify and seek education options
• Assist with enrollment
• Assist with financial aid, book purchase, etc.
• Assist with navigating the education system
• Identify needs and supports for education success (housing, financial aid,
transportation, clothing, food, etc.)
• Assist with access to any necessary tutoring services
Peer Specialist/Wellness Advocates will be located at the main office and well as
perform outreach into the community. Peers will be part of the employment team and
be available to support the clients throughout the employment services process.
• Assist with identifying and establishing meaningful life activities outside of
employment
• Provide wellness education including WRAP and DBT
• Assist with identifying individualized resources in the community
The Dreamcatchers onsite team will also consist of an IPS Team Lead/Supervisor and
an administrative support staff.
Reporting Requirements and Outcome Monitoring:
Throughout the process of services, Dreamcatchers will provide regular updates to the
DBH team summarizing how the service plan goals and objectives were met through
the provision of services. Recommendations of services or supports necessary to
ensure a successful employment outcome are included. Written documentation using
the IPS forms provided will be completed to ensure proper documentation is
maintained.
Review teams are instrumental for ensuring that the outcomes and objectives of the
contract are being met. Agency Coordination Meetings on a routine basis would include
the Supervisor/IPS Team Lead, Dreamcatchers Program Operations Director,
Employment Specialist, Peer Support, DBH Staff, DOR counselor, or anyone else
requested to be present. The routine meetings would address coordinated service
delivery, objective and outcomes of the program goals. Outcomes will be reported
monthly, or as needed or requested.
Dreamcatchers will collect data on a monthly bases beginning with the number of
referrals, the number of new services plans, the number of those engaged in each of
the various components of services, the number of those being hired and retaining
employment, and the number of those enrolled in education. Data collected includes
demographics such as age and race/ethnicity as well as referrals to other resources.
We also track where individuals are within their services plan goals, i.e. accomplishing
the goals established. Dreamcatchers current tracking systems identifies how many
hours are being spent in each of the services. Data will be collected on where the client
has been hired as well as the placement details including wages and if benefits are
available. Bi-annually satisfaction surveys are completed by clients participating in
services, and annually by stakeholders including employers, Department of
Rehabilitation and Behavioral Health.
Dreamcatchers expects to serve a minimum of 100 people per year and expects the
minimum of 40% will be hired each year and 75% maintain employment for a minimum
of 90-days. It is our anticipation that a minimum of 15% will be enrolled in higher
education or vocational training. Dreamcatchers, Behavioral Health and Department of
Rehabilitation will further review previous contract outcomes, MHSA requirements and
CARF standards to establish any further agreed upon outcomes to be tracked.
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Supervisor/IPS Team Lead 1.00 $10,560 $2,640 13,200$
1102 Employment Specialist 1.00 $8,320 $2,080 10,400
1103 Employment Specialist 1.00 $8,320 $2,080 10,400
1104 Employment Specialist 1.00 $8,320 $2,080 10,400
1105 Employment Specialist 1.00 $8,320 $2,080 10,400
1106 Employment Specialist 1.00 $8,320 $2,080 10,400
1107 Peer Specialist/Wellness Advocate 1.00 $7,488 $1,872 9,360
1108 Peer Specialist/Wellness Advocate 1.00 $7,488 $1,872 9,360
1109 Education Specialist 1.00 $8,320 $2,080 10,400
1110 Office Assistant 0.50 $4,420 - 4,420
1111 Executive Director 0.50 $12,500 - 12,500
1112 Program Operations Director 0.25 $3,330 - 3,330
1113 Records Clerk 0.25 $2,344 - 2,344
1114 - - -
1115 - - -
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
Personnel Salaries Subtotal 10.50 98,050$ 18,864$ 116,914$
Employee Benefits
Acct #Admin Direct Total
1101 $981 $189 1,170$
1102 $7,746 $1,490 9,236
1103 $7,033 $987 8,021
1104 - - -
1105 - - -
1106 - - -
15,760$ 2,666$ 18,427$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1201 -$ -$ -$
1202 $7,648 $1,471 9,119
1203 $1,265 $245 1,510
1204 - - -
1205 - - -
1206 - - -
8,913$ 1,717$ 10,629$
122,723$ 23,247$ 145,970$
Vocational and Educational Services
Dreamcatchers Empowerment Network
Ramp Up FY 2019-2020 (March 10 - May 31)
Description
Payroll Taxes & Expenses Subtotal:
Other (Specify)
Other (Specify)
EMPLOYEE SALARIES & BENEFITS TOTAL:
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Retirement
Worker's Compensation
Health Insurance
Other (Specify)
Other (Specify)
OASDI
FICA/MEDICARE
SUI
Other (Specify)
Other (Specify)
Employee Benefits Subtotal:
Description
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
2000: CLIENT SUPPORT
Acct #Amount
2001 -$
2002 -
2003 -
2004 -
2005 -
2006 -
2007 -
2008 -
2009 -
2010 -
2011 -
2012 -
2013 -
2014 -
2015 -
2016 -
-$
3000: OPERATING EXPENSES
Acct #Amount
3001 3,450$
3002 555
3003 2,000
3004 600
3005 480
3006 2,900
3007 -
3008 -
3009 588
3010 540
3011 6,435
3012 -
17,548$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001
4002 16,000
4003 2,000
4004 -
4005 -
4006 2,000
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
20,000$
5000: SPECIAL EXPENSES
Line Item Description
Line Item Description
Line Item Description
DIRECT CLIENT CARE TOTAL
Other (Specify)
Other (Specify)
Advertising
Rent/Lease Building
Building Maintenance
Education Support
Courier Service
FACILITIES/EQUIPMENT TOTAL:
OPERATING EXPENSES TOTAL:
Rent/Lease Vehicles
Security
Utilities
Rent/Lease Equipment
Fingerprints
Lodging
Other (Specify)
Telecommunications
Printing/Postage
Client Transportation & Support
Client Housing Support
Child Care
Other (Specify)
Other (Specify)
Clothing, Food, & Hygiene
Other (Specify)
Other (Specify)
Office, Household & Program Supplies
Utility Vouchers
Program Supplies - Medical
Medication Supports
Household Items for Clients
Employment Support
Staff Mileage
Subscriptions & Memberships
Vehicle Maintenance
Staff Development & Training
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Acct #Amount
5001 8,000$
5002 -
5003 -
5004 -
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
8,000$
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 39,784$
6002 -
6003 750
6004 -
6005 Insurance (Specify):225
6006 Payroll Services 900
6007 833
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
42,492$
7000: FIXED ASSETS
Acct #Amount
7001 19,000$
7002 12,000
7003 10,000
7004 15,000
7005 15,000
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
71,000$
Line Item Description
Professional Liability Insurance
Accounting/Bookkeeping
Leasehold/Tenant/Building Improvements
305,011$ TOTAL PROGRAM EXPENSES
FIXED ASSETS EXPENSES TOTAL
ADMINISTRATIVE EXPENSES TOTAL
SPECIAL EXPENSES TOTAL:
Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
External Audit
Commercial Liability
Line Item Description
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
Line Item Description
Administrative Overhead
Other Assets over $500 with Lifespan of 2 Years +
HMIS (Health Management Information System)
Consultant (Network & Data Management)
Contractual/Consulting Services (Specify)
Translation Services
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Acct #Service Units Rate Amount
8001 Mental Health Services 0 - -$
8002 Case Management 0 - -
8003 Crisis Services 0 - -
8004 Medication Support 0 - -
8005 Collateral 0 - -
8006 Plan Development 0 - -
8007 Assessment 0 - -
8008 Rehabilitation 0 - -
0 -$
0%
-
0%-
-$
Acct #Amount
8101 Drug Medi-Cal -$
8102 SABG -$
-$
Acct #Amount
8201 Realignment -$
-$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports 305,011$
8302 PEI - Prevention & Early Intervention -
8303 INN - Innovations -
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
305,011$
Acct #Amount
8401 Client Fees -$
8402 Client Insurance -
8403 Grants (Specify)-
8404 Other (Specify) -
8405 Other (Specify) -
-$
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
NET PROGRAM COST:
PROGRAM FUNDING SOURCES
TOTAL PROGRAM FUNDING SOURCES:305,011$
(0)$
SUBSTANCE USE DISORDER FUNDS TOTAL
MEDI-CAL FFP TOTAL
MHSA TOTAL
Line Item Description
Line Item Description
8100 - SUBSTANCE USE DISORDER FUNDS
OTHER REVENUE TOTAL
Line Item Description
8400 - OTHER REVENUE
Estimated Specialty Mental Health Services Billing Totals:
Estimated % of Clients who are Medi-Cal Beneficiaries
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries
Federal Financial Participation (FFP) %
MHSA Program Name
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
Line Item Description
REALIGNMENT TOTAL
8200 - REALIGNMENT
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
Budget Narrative
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES & BENEFITS 145,970
Employee Salaries 116,914
1101 Supervisor/IPS Team Lead 13,200 Onsite supervisor of team leading services in accordance with contract
1102 Employment Specialist 10,400 Direct staff providing IPS sevices to help clients become hired within the community
1103 Employment Specialist 10,400 Direct staff providing IPS sevices to help clients become hired within the community
1104 Employment Specialist 10,400 Direct staff providing IPS sevices to help clients become hired within the community
1105 Employment Specialist 10,400 Direct staff providing IPS sevices to help clients become hired within the community
1106 Employment Specialist 10,400 Direct staff providing IPS sevices to help clients become hired within the community
1107 Peer Specialist/Wellness Advocate 9,360 Peer staff with lived mental health experience to support clients receiving services
1108 Peer Specialist/Wellness Advocate 9,360 Peer staff with lived mental health experience to support clients receiving services
1109 Education Specialist 10,400 Direct staff providing IPS sevices to help clients reach their educational goals
1110 Office Assistant 4,420 Onsite clerical support staff to support IPS service delivery
1111 Executive Director 12,500 Responsible for hiring, training staff, new office set up and service implementation
as well as on going program services and outcomes
1112 Program Operations Director 3,330 Supports program implementation and on going support and guidance of the onsite
supervisor
1113 Records Clerk 2,344 Support staff to aid with training, set up and monitoring of client records
1114 0 -
1115 0 -
1116 0 -
1117 0 -
1118 0 -
1119 0 -
1120 0 -
Employee Benefits 18,427
1101 Retirement 1,170 1% of costs
1102 Worker's Compensation 9,236 7.9% of costs
1103 Health Insurance 8,021 15.7% of costs
1104 Other (Specify)-
1105 Other (Specify)-
1106 Other (Specify)-
Payroll Taxes & Expenses:10,629
1201 OASDI -
1202 FICA/MEDICARE 9,119 7.8% of Costs
1203 SUI 1,510 1.3% of Costs
1204 Other (Specify)-
1205 Other (Specify)-
1206 Other (Specify)-
2000: CLIENT SUPPORT -
2001 Child Care -
2002 Client Housing Support -
2003 Client Transportation & Support -
2004 Clothing, Food, & Hygiene -
2005 Education Support -
2006 Employment Support -
2007 Household Items for Clients -
2008 Medication Supports -
2009 Program Supplies - Medical -
2010 Utility Vouchers -
Dreamcatchers Empowerment Network
Vocational and Educational Services
Ramp Up FY 2019-2020 (March 10 - May 31)
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
2011 Other (Specify)-
2012 Other (Specify)-
2013 Other (Specify)-
2014 Other (Specify)-
2015 Other (Specify)-
2016 Other (Specify)-
3000: OPERATING EXPENSES 17,548
3001 Telecommunications 3,450 Office phone installation and monthly costs, plus monthly cell phone service costs
for staff providing services
3002 Printing/Postage 555 Cost for printing marketing materials to promote program and services. Also
includes postage stamps for client resumes or items to be mailed through postal
service.
3003 Office, Household & Program Supplies 2,000 Includes office items such as client charts, copy paper, resume paper, pens, toner.
Also includes cleaning supplies, paper towels, toilet paper. A small food budget has
been included to have light snacks at the office for clients when needed.
3004 Advertising 600 Job postings to hire staff to deliver services under this contract
3005 Staff Development & Training 480 Intial fees for CPR training of all staff servicing contract
3006 Staff Mileage 2,900 Includes the cost to travel to/from outside of county for training and
implementation.
3007 Subscriptions & Memberships -
3008 Vehicle Maintenance -
3009 Courier Service 588 Inner office mail system between Fresno branch and DEN main office
3010 Fingerprints 540 Staff fingerprints required to deliver client services
3011 Lodging 6,435 Lodging for set up and implentation for out of county staff.
3012 Other (Specify)-
4000: FACILITIES & EQUIPMENT 20,000
4001 Building Maintenance -
4002 Rent/Lease Building 16,000 Monthly rent plus deposit
4003 Rent/Lease Equipment 2,000 Monthly cost plus installation/set up for copier service and water cooler
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities 2,000 Monthly utilities plus set up of PG&E
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
5000: SPECIAL EXPENSES 8,000
5001 Consultant (Network & Data Management)8,000 Monthly fee plus initial set up for ongoing network services
5002 HMIS (Health Management Information
System)
-
5003 Contractual/Consulting Services (Specify)-
5004 Translation Services -
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
6000: ADMINISTRATIVE EXPENSES 42,492
6001 Administrative Overhead 39,784 15% applied to total costs
6002 Professional Liability Insurance -
6003 Accounting/Bookkeeping 750 Costs for the added cost center established to monitor expenses and revenues
associated to contract
6004 External Audit -
6005 Insurance (Specify):225 Costs to add additional location to delivery contract services
6006 Payroll Services 900 Costs to add additional staffing to service contract
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
6007 Depreciation (Provider-Owned Equipment to
be Used for Program Purposes)
833 Costs for depreciation of furniture and server/network equipment over $5,000
divided by the 60 month contract
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
7000: FIXED ASSETS 71,000
7001 Computer Equipment & Software 19,000 Cost to purchase 3-desktop computers for the client computer lab plus a printer.
We also include 9-laptops computers and one desk top for staff use as well as the
cost of 3 additional printers for staff. All computer equipment will also include
Microsoft Office, thus the costs for licensing.
7002 Copiers, Cell Phones, Tablets, Devices to
Contain HIPAA Data
12,000 Purchase office phones, cell phones for each staff to be available when off-site as
well as mobile hot spots for internet access when away from the center.
7003 Furniture & Fixtures 10,000 To furnish office space where services providedf: desks, tables, chairs, filing
cabinets, etc.
7004 Leasehold/Tenant/Building Improvements 15,000 Improvements for office space including but not limited to updating/installing ADA
restroom, new laminate flooring, moving and removal of cabinetry, relocating front
office entry door.
7005 Other Assets over $500 with Lifespan of 2
Years +
15,000 Server and computer network equipment including router and switch
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE:305,011
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE:305,011
-
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Supervisor/IPS Team Lead 1.00 $3,520 $880 4,400$
1102 Employment Specialist 1.00 $693 $2,773 3,467
1103 Employment Specialist 1.00 $693 $2,773 3,467
1104 Employment Specialist 1.00 $693 $2,773 3,467
1105 Employment Specialist 1.00 $693 $2,773 3,467
1106 Employment Specialist 1.00 $693 $2,773 3,467
1107 Peer Specialist/Wellness Advocate 1.00 $624 $2,496 3,120
1108 Peer Specialist/Wellness Advocate 1.00 $624 $2,496 3,120
1109 Education Specialist 1.00 $693 $2,773 3,467
1110 Office Assistant 0.50 $1,473 - 1,473
1111 Executive Director 0.05 $417 - 417
1112 Program Operations Director 0.05 $264 - 264
1113 Records Clerk 0.05 $160 - 160
1114 - - -
1115 - - -
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
Personnel Salaries Subtotal 9.65 11,243$ 22,512$ 33,755$
Employee Benefits
Acct #Admin Direct Total
1101 $112 $225 338$
1102 888 $1,778 2,667
1103 $1,765 $3,534 5,300
1104 - - -
1105 - - -
1106 - - -
2,766$ 5,538$ 8,304$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1201 -$ -$ -$
1202 $877 $1,776 2,653
1203 $146 $293 439
1204 - - -
1205 - - -
1206 - - -
1,023$ 2,069$ 3,092$
15,031$ 30,119$ 45,150$
Retirement
Worker's Compensation
Health Insurance
Other (Specify)
Other (Specify)
Other (Specify)
Vocational and Educational Services
Dreamcatchers Empowerment Network
Fiscal Year 2019-2020 (June 1 - June 30)
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Description
Other (Specify)
Other (Specify)
Other (Specify)
Payroll Taxes & Expenses Subtotal:
EMPLOYEE SALARIES & BENEFITS TOTAL:
Employee Benefits Subtotal:
Description
OASDI
FICA/MEDICARE
SUI
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
2000: CLIENT SUPPORT
Acct #Amount
2001 -$
2002 -
2003 1,667
2004 1,667
2005 1,250
2006 1,250
2007 -
2008 -
2009 -
2010 -
2011 -
2012 -
2013 -
2014 -
2015 -
2016 -
5,833$
3000: OPERATING EXPENSES
Acct #Amount
3001 1,115$
3002 200
3003 250
3004 -
3005 267
3006 3,300
3007 -
3008 -
3009 96
3010 -
3011 585
3012 -
5,813$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 -$
4002 4,000
4003 500
4004 -
4005 -
4006 500
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
5,000$
5000: SPECIAL EXPENSES
Line Item Description
Household Items for Clients
Medication Supports
Program Supplies - Medical
Utility Vouchers
Other (Specify)
Other (Specify)
Child Care
Client Housing Support
Client Transportation & Support
Clothing, Food, & Hygiene
Education Support
Employment Support
Telecommunications
Printing/Postage
Office, Household & Program Supplies
Advertising
Staff Development & Training
Staff Mileage
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
DIRECT CLIENT CARE TOTAL
Line Item Description
OPERATING EXPENSES TOTAL:
Line Item Description
Building Maintenance
Rent/Lease Building
Rent/Lease Equipment
Rent/Lease Vehicles
Subscriptions & Memberships
Vehicle Maintenance
Courier
CARF Fees
Lodging
Other (Specify)
FACILITIES/EQUIPMENT TOTAL:
Security
Utilities
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Acct #Amount
5001 1,000$
5002 -
5003 -
5004 417
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
1,417$
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 9,923$
6002 -
6003 83
6004 67
6005 Insurance (Specify):75
6006 Payroll Services 300
6007 417
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
10,865$
7000: FIXED ASSETS
Acct #Amount
7001 -$
7002 -
7003 2,000
7004 -
7005 -
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
2,000$
Line Item Description
Consultant (Network & Data Management)
HMIS (Health Management Information System)
Contractual/Consulting Services (Specify)
Translation Services
Administrative Overhead
Professional Liability Insurance
Accounting/Bookkeeping
External Audit
Commerial Liability
Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
SPECIAL EXPENSES TOTAL:
Line Item Description
Line Item Description
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
Leasehold/Tenant/Building Improvements
Other Assets over $500 with Lifespan of 2 Years +
ADMINISTRATIVE EXPENSES TOTAL
FIXED ASSETS EXPENSES TOTAL
TOTAL PROGRAM EXPENSES 76,077$
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Acct #Service Units Rate Amount
8001 Mental Health Services 0 - -$
8002 Case Management 0 - -
8003 Crisis Services 0 - -
8004 Medication Support 0 - -
8005 Collateral 0 - -
8006 Plan Development 0 - -
8007 Assessment 0 - -
8008 Rehabilitation 0 - -
0 -$
0%
-
0%-
-$
Acct #Amount
8101 Drug Medi-Cal -$
8102 SABG -$
-$
Acct #Amount
8201 Realignment 0$
0$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports 76,077$
8302 PEI - Prevention & Early Intervention -
8303 INN - Innovations -
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
76,077$
Acct #Amount
8401 Client Fees -$
8402 Client Insurance -
8403 Grants (Specify)-
8404 Other (Specify) -
8405 Other (Specify) -
-$
PROGRAM FUNDING SOURCES
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
Line Item Description
Estimated Specialty Mental Health Services Billing Totals:
Estimated % of Clients who are Medi-Cal Beneficiaries
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries
Line Item Description
REALIGNMENT TOTAL
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
MHSA Program Name
Federal Financial Participation (FFP) %
MEDI-CAL FFP TOTAL
8100 - SUBSTANCE USE DISORDER FUNDS
Line Item Description
SUBSTANCE USE DISORDER FUNDS TOTAL
8200 - REALIGNMENT
OTHER REVENUE TOTAL
TOTAL PROGRAM FUNDING SOURCES:76,077$
NET PROGRAM COST: -$
MHSA TOTAL
8400 - OTHER REVENUE
Line Item Description
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
Budget Narrative
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES & BENEFITS 45,150
Employee Salaries 33,755
1101 Supervisor/IPS Team Lead 4,400 Onsite supervisor of team leading services in accordance with contract
1102 Employment Specialist 3,467 Direct staff providing IPS sevices to help clients become hired within the community
1103 Employment Specialist 3,467 Direct staff providing IPS sevices to help clients become hired within the community
1104 Employment Specialist 3,467 Direct staff providing IPS sevices to help clients become hired within the community
1105 Employment Specialist 3,467 Direct staff providing IPS sevices to help clients become hired within the community
1106 Employment Specialist 3,467 Direct staff providing IPS sevices to help clients become hired within the community
1107 Peer Specialist/Wellness Advocate 3,120 Peer staff with lived mental health experience to support clients receiving services
1108 Peer Specialist/Wellness Advocate 3,120 Peer staff with lived mental health experience to support clients receiving services
1109 Education Specialist 3,467 Direct staff providing IPS sevices to help clients reach their educational goals
1110 Office Assistant 1,473 Onsite clerical support staff to support IPS service delivery
1111 Executive Director 417 Responsible for hiring, training staff, new office set up and service implementation
as well as on going program services and outcomes
1112 Program Operations Director 264 Supports program implementation and on going support and guidance of the onsite
supervisor
1113 Records Clerk 160 Support staff to aid with training, set up and monitoring of client records
1114 0 -
1115 0 -
1116 0 -
1117 0 -
1118 0 -
1119 0 -
1120 0 -
Employee Benefits 8,304
1101 Retirement 338 1% of costs
1102 Worker's Compensation 2,667 7.9% of costs
1103 Health Insurance 5,300 15.7% of costs
1104 Other (Specify)-
1105 Other (Specify)-
1106 Other (Specify)-
Payroll Taxes & Expenses:3,092
1201 OASDI -
1202 FICA/MEDICARE 2,653 7.8% of Costs
1203 SUI 439 1.3% of Costs
1204 Other (Specify)-
1205 Other (Specify)-
1206 Other (Specify)-
2000: CLIENT SUPPORT 5,833
2001 Child Care -
2002 Client Housing Support -
2003 Client Transportation & Support 1,667 Dreamcatchers has included client support expenses such as bus passes for 150
clients.
2004 Clothing, Food, & Hygiene 1,667 Minimal food, clothing or hygiene items that our clients may need such as socks, a
belt, pants or shoes as well as shampoo, deodorant and razors to name a few.
2005 Education Support 1,250 Education supports may include the cost for books, GED exam fees, or the cost for
enrollment into a CNA course or take the Safe-Serve exam.
Vocational and Educational Services
Dreamcatchers Empowerment Network
Fiscal Year 2019-2020 (June 1 - June 30)
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
2006 Employment Support 1,250 Employment supplies may include a flash drive to hold a resume and cover letter, a
portfolio to maintain important documents, or other items such as tool belt for a
construction position or a back brace.
2007 Household Items for Clients -
2008 Medication Supports -
2009 Program Supplies - Medical -
2010 Utility Vouchers -
2011 Other (Specify)-
2012 Other (Specify)-
2013 Other (Specify)-
2014 Other (Specify)-
2015 Other (Specify)-
2016 Other (Specify)-
3000: OPERATING EXPENSES 5,813
3001 Telecommunications 1,115 Office phone installation monthly costs plus monthly cell phone service costs for
staff providing services
3002 Printing/Postage 200 Cost for printing marketing materials to promote program and services.
3003 Office, Household & Program Supplies 250 Includes office items such as client charts, copy paper, resume paper, pens, toner.
Also includes cleaning supplies, paper towels, toilet paper. A small food budget has
been included to have light snacks at the office for clients when needed.
3004 Advertising -
3005 Staff Development & Training 267 Intial fees for CPR training of all staff servicing contract
3006 Staff Mileage 3,300 Includes the cost to travel to/from outside of county for training and
implementation. Mileage to provide employment and education services to clients;
meeting with employers, education systems and clients in the community. Also
includes travel costs to meetings.
3007 Subscriptions & Memberships -
3008 Vehicle Maintenance -
3009 Courier 96 Inner office mail system between Fresno branch and DEN main office
3010 CARF Fees -
3011 Lodging 585 Lodging for set up and implentation of program during first month of services for
out of county staff travel
3012 Other (Specify)-
4000: FACILITIES & EQUIPMENT 5,000
4001 Building Maintenance -
4002 Rent/Lease Building 4,000 Monthly rent plus deposit
4003 Rent/Lease Equipment 500 Monthly cost plus installation/set up for copier service and water cooler
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities 500 Monthly utilities such as PG&E
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
5000: SPECIAL EXPENSES 1,417
5001 Consultant (Network & Data Management)1,000 Monthly fee plus initial set up for ongoing network services
5002 HMIS (Health Management Information
System)
-
5003 Contractual/Consulting Services (Specify)-
5004 Translation Services 417 ASL or Interpreting services that may be necessary for client communications
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
6000: ADMINISTRATIVE EXPENSES 10,865
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
6001 Administrative Overhead 9,923 15% applied to total costs
6002 Professional Liability Insurance -
6003 Accounting/Bookkeeping 83 Costs for the added cost center established to monitor expenses and revenues
associated to contract
6004 External Audit 67 Costs for additional location in Annual Financial Audit
6005 Insurance (Specify):75 Costs to add additional location to delivery contract services
6006 Payroll Services 300 Costs to add additional staffing to service contract
6007 Depreciation (Provider-Owned Equipment to
be Used for Program Purposes)
417 Costs for depreciation of furniture and server/network equipment over $5,000
divided by the 60 month contract
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
7000: FIXED ASSETS 2,000
7001 Computer Equipment & Software -
7002 Copiers, Cell Phones, Tablets, Devices to
Contain HIPAA Data
-
7003 Furniture & Fixtures 2,000 Additional funishing not originally obtained but needed for office space where
services provided: desks, tables, chairs, filing cabinets, etc.
7004 Leasehold/Tenant/Building Improvements -
7005 Other Assets over $500 with Lifespan of 2
Years +
-
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE:76,077
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE:76,077
-
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Supervisor/IPS Team Lead 1.00 $43,064 $10,766 53,830$
1102 Employment Specialist 1.00 $8,611 $34,445 43,056
1103 Employment Specialist 1.00 $8,611 $34,445 43,056
1104 Employment Specialist 1.00 $8,611 $34,445 43,056
1105 Employment Specialist 1.00 $8,611 $34,445 43,056
1106 Employment Specialist 1.00 $8,611 $34,445 43,056
1107 Peer Specialist/Wellness Advocate 1.00 $7,750 $31,000 38,750
1108 Peer Specialist/Wellness Advocate 1.00 $7,750 $31,000 38,750
1109 Education Specialist 1.00 $8,611 $34,445 43,056
1110 Office Assistant 0.50 $18,294 18,294
1111 Executive Director 0.05 $5,000 5,000
1112 Program Operations Director 0.05 $2,640 2,640
1113 Records Clerk 0.05 $1,951 1,951
1114 - - -
1115 - - -
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
Personnel Salaries Subtotal 9.65 138,116$ 279,436$ 417,552$
Employee Benefits
Acct #Admin Direct Total
1101 $1,381 $2,794 4,176$
1102 $10,911 $22,075 32,987
1103 $21,684 $43,871 65,556
1104 - - -
1105 - - -
1106 - - -
33,977$ 68,741$ 102,718$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1201 -$ -$ -$
1202 $10,773 $21,796 32,569
1203 $1,796 $3,633 5,428
1204 - - -
1205 - - -
1206 - - -
12,569$ 25,428.66$ 37,997.64$
184,662$ 373,605$ 558,267$
Retirement
Worker's Compensation
Health Insurance
Other (Specify)
Other (Specify)
Other (Specify)
Vocational and Educational Services
Dreamcatchers Empowerment Network
Fiscal Year 2020-2021
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Description
Other (Specify)
Other (Specify)
Other (Specify)
Payroll Taxes & Expenses Subtotal:
EMPLOYEE SALARIES & BENEFITS TOTAL:
Employee Benefits Subtotal:
Description
OASDI
FICA/MEDICARE
SUI
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
2000: CLIENT SUPPORT
Acct #Amount
2001 -$
2002 $15,000
2003 $15,000
2004 $7,500
2005 $7,500
2006 -
2007 -
2008 -
2009 -
2010 -
2011 -
2012 -
2013 -
2014 -
2015 -
2016 -
45,000$
3000: OPERATING EXPENSES
Acct #Amount
3001 13,380$
3002 610
3003 4,200
3004 250
3005 1,386
3006 40,590
3007 -
3008 -
3009 1,152
3010 1,000
3011 3,200
3012 -
65,768$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 5,000$
4002 48,000
4003 6,000
4004 -
4005 -
4006 6,000
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
65,000$
5000: SPECIAL EXPENSES
Line Item Description
Household Items for Clients
Medication Supports
Program Supplies - Medical
Utility Vouchers
Other (Specify)
Other (Specify)
Child Care
Client Housing Support
Client Transportation & Support
Clothing, Food, & Hygiene
Education Support
Employment Support
Telecommunications
Printing/Postage
Office, Household & Program Supplies
Advertising
Staff Development & Training
Staff Mileage
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
DIRECT CLIENT CARE TOTAL
Line Item Description
OPERATING EXPENSES TOTAL:
Line Item Description
Building Maintenance
Rent/Lease Building
Rent/Lease Equipment
Rent/Lease Vehicles
Subscriptions & Memberships
Vehicle Maintenance
Courier
CARF Fees
Lodging
Other (Specify)
FACILITIES/EQUIPMENT TOTAL:
Security
Utilities
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Acct #Amount
5001 12,000$
5002 -
5003 -
5004 5,000
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
17,000$
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 114,350$
6002 -
6003 1,000
6004 800
6005 Insurance (Specify):900
6006 Payroll Services 3,600
6007 5,000
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
125,650$
7000: FIXED ASSETS
Acct #Amount
7001 -$
7002 -
7003 -
7004 -
7005 -
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
-$
Line Item Description
Consultant (Network & Data Management)
HMIS (Health Management Information System)
Contractual/Consulting Services (Specify)
Translation Services
Administrative Overhead
Professional Liability Insurance
Accounting/Bookkeeping
External Audit
Commercial Liability
Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
SPECIAL EXPENSES TOTAL:
Line Item Description
Line Item Description
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
Leasehold/Tenant/Building Improvements
Other Assets over $500 with Lifespan of 2 Years +
ADMINISTRATIVE EXPENSES TOTAL
FIXED ASSETS EXPENSES TOTAL
TOTAL PROGRAM EXPENSES 876,686$
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Acct #Service Units Rate Amount
8001 Mental Health Services 0 - -$
8002 Case Management 0 - -
8003 Crisis Services 0 - -
8004 Medication Support 0 - -
8005 Collateral 0 - -
8006 Plan Development 0 - -
8007 Assessment 0 - -
8008 Rehabilitation 0 - -
0 -$
0%
-
0%-
-$
Acct #Amount
8101 Drug Medi-Cal -$
8102 SABG -$
-$
Acct #Amount
8201 Realignment (0)$
(0)$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports 876,686$
8302 PEI - Prevention & Early Intervention -
8303 INN - Innovations -
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
876,686$
Acct #Amount
8401 Client Fees -$
8402 Client Insurance -
8403 Grants (Specify)-
8404 Other (Specify) -
8405 Other (Specify) -
-$
PROGRAM FUNDING SOURCES
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
Line Item Description
Estimated Specialty Mental Health Services Billing Totals:
Estimated % of Clients who are Medi-Cal Beneficiaries
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries
Line Item Description
REALIGNMENT TOTAL
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
MHSA Program Name
Federal Financial Participation (FFP) %
MEDI-CAL FFP TOTAL
8100 - SUBSTANCE USE DISORDER FUNDS
Line Item Description
SUBSTANCE USE DISORDER FUNDS TOTAL
8200 - REALIGNMENT
OTHER REVENUE TOTAL
TOTAL PROGRAM FUNDING SOURCES:876,686$
NET PROGRAM COST: -$
MHSA TOTAL
8400 - OTHER REVENUE
Line Item Description
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
Budget Narrative
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES & BENEFITS 558,267
Employee Salaries 417,552
1101 Supervisor/IPS Team Lead 53,830 Onsite supervisor of team leading services in accordance with contract
1102 Employment Specialist 43,056 Direct staff providing IPS sevices to help clients become hired within the community
1103 Employment Specialist 43,056 Direct staff providing IPS sevices to help clients become hired within the community
1104 Employment Specialist 43,056 Direct staff providing IPS sevices to help clients become hired within the community
1105 Employment Specialist 43,056 Direct staff providing IPS sevices to help clients become hired within the community
1106 Employment Specialist 43,056 Direct staff providing IPS sevices to help clients become hired within the community
1107 Peer Specialist/Wellness Advocate 38,750 Peer staff with lived mental health experience to support clients receiving services
1108 Peer Specialist/Wellness Advocate 38,750 Peer staff with lived mental health experience to support clients receiving services
1109 Education Specialist 43,056 Direct staff providing IPS sevices to help clients reach their educational goals
1110 Office Assistant 18,294 Onsite clerical support staff to support IPS service delivery
1111 Executive Director 5,000 Responsible for hiring, training staff, new office set up and service implementation
as well as on going program services and outcomes
1112 Program Operations Director 2,640 Supports program implementation and on going support and guidance of the onsite
supervisor
1113 Records Clerk 1,951 Support staff to aid with training, set up and monitoring of client records
1114 0 -
1115 0 -
1116 0 -
1117 0 -
1118 0 -
1119 0 -
1120 0 -
Employee Benefits 102,718
1101 Retirement 4,176 1% of costs
1102 Worker's Compensation 32,987 7.9% of costs
1103 Health Insurance 65,556 15.7% of costs
1104 Other (Specify)-
1105 Other (Specify)-
1106 Other (Specify)-
Payroll Taxes & Expenses:37,998
1201 OASDI -
1202 FICA/MEDICARE 32,569 7.8% of Costs
1203 SUI 5,428 1.3% of Costs
1204 Other (Specify)-
1205 Other (Specify)-
1206 Other (Specify)-
2000: CLIENT SUPPORT 45,000
2001 Child Care -
2002 Client Housing Support 15,000 Dreamcatchers has included client support expenses such as bus passes for 150
clients.
2003 Client Transportation & Support 15,000 Minimal food, clothing or hygiene items that our clients may need such as socks, a
belt, pants or shoes as well as shampoo, deodorant and razors to name a few.
2004 Clothing, Food, & Hygiene 7,500 Education supports may include the cost for books, GED exam fees, or the cost for
enrollment into a CNA course or take the Safe-Serve exam.
Vocational and Educational Services
Dreamcatchers Empowerment Network
Fiscal Year 2020-2021
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
2005 Education Support 7,500 Employment supplies may include a flash drive to hold a resume and cover letter, a
portfolio to maintain important documents, or other items such as tool belt for a
construction position or a back brace.
2006 Employment Support -
2007 Household Items for Clients -
2008 Medication Supports -
2009 Program Supplies - Medical -
2010 Utility Vouchers -
2011 Other (Specify)-
2012 Other (Specify)-
2013 Other (Specify)-
2014 Other (Specify)-
2015 Other (Specify)-
2016 Other (Specify)-
3000: OPERATING EXPENSES 65,768
3001 Telecommunications 13,380 Office phone monthly costs plus monthly cell phone service costs for staff providing
services
3002 Printing/Postage 610 Annual cost for printing marketing materials to promote program and services. Also
includes postage stamps for client resumes or items to be mailed through postal
service.
3003 Office, Household & Program Supplies 4,200 Includes office items such as client charts, copy paper, resume paper, pens, toner.
Also includes cleaning supplies, paper towels, toilet paper. A small food budget has
been included to have light snacks at the office for clients when needed.
3004 Advertising 250 Job postings to hire staff to deliver services under this contract
3005 Staff Development & Training 1,386 Intial fees for CPR training of all staff servicing contract
3006 Staff Mileage 40,590 Mileage to provide employment and education services to clients; meeting with
employers, education systems and clients in the community. Also includes travel
costs to meetings.
3007 Subscriptions & Memberships -
3008 Vehicle Maintenance -
3009 Courier 1,152 Inner office mail system between Fresno branch and DEN main office
3010 CARF Fees 1,000 Staff fingerprints required to deliver client services
3011 Lodging 3,200 Lodging for set up and implentation for out of county staff.
3012 Other (Specify)-
4000: FACILITIES & EQUIPMENT 65,000
4001 Building Maintenance 5,000 Projected cost for any minor building maintenance that may be needed at office
where services are provided.
4002 Rent/Lease Building 48,000 Monthly rent
4003 Rent/Lease Equipment 6,000 Monthly cost for copier service and water cooler
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities 6,000 Monthly utilities such as PG&E
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
5000: SPECIAL EXPENSES 17,000
5001 Consultant (Network & Data Management)12,000 Monthly fee for ongoing network services
5002 HMIS (Health Management Information
System)
-
5003 Contractual/Consulting Services (Specify)-
5004 Translation Services 5,000 ASL or Interpreting services that may be necessary for client communications
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
6000: ADMINISTRATIVE EXPENSES 125,650
6001 Administrative Overhead 114,350 15% applied to total costs
6002 Professional Liability Insurance -
6003 Accounting/Bookkeeping 1,000 Costs for the added cost center established to monitor expenses and revenues
associated to contract
6004 External Audit 800 Costs for additional location in Annual Financial Audit
6005 Insurance (Specify):900 Costs to add additional location to delivery contract services
6006 Payroll Services 3,600 Costs to add additional staffing to service contract
6007 Depreciation (Provider-Owned Equipment to
be Used for Program Purposes)
5,000 Costs for depreciation of furniture and server/network equipment
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
7000: FIXED ASSETS -
7001 Computer Equipment & Software -
7002 Copiers, Cell Phones, Tablets, Devices to
Contain HIPAA Data
-
7003 Furniture & Fixtures -
7004 Leasehold/Tenant/Building Improvements -
7005 Other Assets over $500 with Lifespan of 2
Years +
-
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE:876,686
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE:876,686
-
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Supervisor/IPS Team Lead 1.00 44,579 11,145 55,723$
1102 Employment Specialist 1.00 8,911 35,643 44,554
1103 Employment Specialist 1.00 8,911 35,643 44,554
1104 Employment Specialist 1.00 8,911 35,643 44,554
1105 Employment Specialist 1.00 8,911 35,643 44,554
1106 Employment Specialist 1.00 8,911 35,643 44,554
1107 Peer Specialist/Wellness Advocate 1.00 8,020 32,082 40,102
1108 Peer Specialist/Wellness Advocate 1.00 8,020 32,082 40,102
1109 Education Specialist 1.00 8,911 35,643 44,554
1110 Office Assistant 0.50 20,010 20,010
1111 Executive Director 0.05 5,200 5,200
1112 Program Operations Director 0.05 2,732 2,732
1113 Records Clerk 0.05 2,019 2,019
1114 - - -
1115 - - -
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
Personnel Salaries Subtotal 9.65 144,045$ 289,166$ 433,211$
Employee Benefits
Acct #Admin Direct Total
1101 1440.45 $2,892 4,332$
1102 11379.55 $22,844 34,224
1103 $26,504 $53,207 79,711
1104 - - -
1105 - - -
1106 - - -
39,324$ 78,942$ 118,267$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1201 -$ -$ -$
1202 $11,236 $22,555 33,790
1203 $1,873 $3,759 5,632
1204 - - -
1205 - -
1206 - -
13,108$ 26,314$ 39,422$
196,478$ 394,422$ 590,900$
Retirement
Worker's Compensation
Health Insurance
Other (Specify)
Other (Specify)
Other (Specify)
Vocational and Educational Services
Dreamcatchers Empowerment Network
Fiscal Year 2021-2022
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Description
Other (Specify)
Other (Specify)
Other (Specify)
Payroll Taxes & Expenses Subtotal:
EMPLOYEE SALARIES & BENEFITS TOTAL:
Employee Benefits Subtotal:
Description
OASDI
FICA/MEDICARE
SUI
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
2000: CLIENT SUPPORT
Acct #Amount
2001 -$
2002 -
2003 $15,450
2004 $15,450
2005 $10,000
2006 $7,725
2007 -
2008 -
2009 -
2010 -
2011 -
2012 -
2013 -
2014 -
2015 -
2016 -
48,625$
3000: OPERATING EXPENSES
Acct #Amount
3001 13,380$
3002 610
3003 4,500
3004 250
3005 1,386
3006 45,800
3007 -
3008 -
3009 1,152
3010 -
3011 3,300
3012 -
70,378$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 5,000$
4002 48,000
4003 6,000
4004
4005 -
4006 6,000
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
65,000$
5000: SPECIAL EXPENSES
Line Item Description
Household Items for Clients
Medication Supports
Program Supplies - Medical
Utility Vouchers
Other (Specify)
Other (Specify)
Child Care
Client Housing Support
Client Transportation & Support
Clothing, Food, & Hygiene
Education Support
Employment Support
Telecommunications
Printing/Postage
Office, Household & Program Supplies
Advertising
Staff Development & Training
Staff Mileage
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
DIRECT CLIENT CARE TOTAL
Line Item Description
OPERATING EXPENSES TOTAL:
Line Item Description
Building Maintenance
Rent/Lease Building
Rent/Lease Equipment
Rent/Lease Vehicles
Subscriptions & Memberships
Vehicle Maintenance
Courier
CARF Fees
Lodging
Other (Specify)
FACILITIES/EQUIPMENT TOTAL:
Security
Utilities
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Acct #Amount
5001 12,000$
5002 -
5003 -
5004 5,000
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
17,000$
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 120,849$
6002 -
6003 1,000
6004 800
6005 Insurance (Specify):927
6006 Payroll Services 3,600
6007 5,000
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
132,176$
7000: FIXED ASSETS
Acct #Amount
7001 -$
7002 -
7003 -
7004 -
7005 -
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
-$
Line Item Description
Consultant (Network & Data Management)
HMIS (Health Management Information System)
Contractual/Consulting Services (Specify)
Translation Services
Administrative Overhead
Professional Liability Insurance
Accounting/Bookkeeping
External Audit
Commercial Liability
Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
SPECIAL EXPENSES TOTAL:
Line Item Description
Line Item Description
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
Leasehold/Tenant/Building Improvements
Other Assets over $500 with Lifespan of 2 Years +
ADMINISTRATIVE EXPENSES TOTAL
FIXED ASSETS EXPENSES TOTAL
TOTAL PROGRAM EXPENSES 924,078$
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Acct #Service Units Rate Amount
8001 Mental Health Services 0 - -$
8002 Case Management 0 - -
8003 Crisis Services 0 - -
8004 Medication Support 0 - -
8005 Collateral 0 - -
8006 Plan Development 0 - -
8007 Assessment 0 - -
8008 Rehabilitation 0 - -
0 -$
0%
-
0%-
-$
Acct #Amount
8101 Drug Medi-Cal -$
8102 SABG -$
-$
Acct #Amount
8201 Realignment 0$
0$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports 924,078$
8302 PEI - Prevention & Early Intervention -
8303 INN - Innovations -
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
924,078$
Acct #Amount
8401 Client Fees -$
8402 Client Insurance -
8403 Grants (Specify)-
8404 Other (Specify) -
8405 Other (Specify) -
-$
PROGRAM FUNDING SOURCES
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
Line Item Description
Estimated Specialty Mental Health Services Billing Totals:
Estimated % of Clients who are Medi-Cal Beneficiaries
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries
Line Item Description
REALIGNMENT TOTAL
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
MHSA Program Name
Federal Financial Participation (FFP) %
MEDI-CAL FFP TOTAL
8100 - SUBSTANCE USE DISORDER FUNDS
Line Item Description
SUBSTANCE USE DISORDER FUNDS TOTAL
8200 - REALIGNMENT
OTHER REVENUE TOTAL
TOTAL PROGRAM FUNDING SOURCES:924,078$
NET PROGRAM COST: -$
MHSA TOTAL
8400 - OTHER REVENUE
Line Item Description
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
Budget Narrative
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES & BENEFITS 590,900
Employee Salaries 433,211
1101 Supervisor/IPS Team Lead 55,723 Onsite supervisor of team leading services in accordance with contract
1102 Employment Specialist 44,554 Direct staff providing IPS sevices to help clients become hired within the community
1103 Employment Specialist 44,554 Direct staff providing IPS sevices to help clients become hired within the community
1104 Employment Specialist 44,554 Direct staff providing IPS sevices to help clients become hired within the community
1105 Employment Specialist 44,554 Direct staff providing IPS sevices to help clients become hired within the community
1106 Employment Specialist 44,554 Direct staff providing IPS sevices to help clients become hired within the community
1107 Peer Specialist/Wellness Advocate 40,102 Peer staff with lived mental health experience to support clients receiving services
1108 Peer Specialist/Wellness Advocate 40,102 Peer staff with lived mental health experience to support clients receiving services
1109 Education Specialist 44,554 Direct staff providing IPS sevices to help clients reach their educational goals
1110 Office Assistant 20,010 Onsite clerical support staff to support IPS service delivery
1111 Executive Director 5,200 Responsible for hiring, training staff, new office set up and service implementation
as well as on going program services and outcomes
1112 Program Operations Director 2,732 Supports program implementation and on going support and guidance of the onsite
supervisor
1113 Records Clerk 2,019 Support staff to aid with training, set up and monitoring of client records
1114 0 -
1115 0 -
1116 0 -
1117 0 -
1118 0 -
1119 0 -
1120 0 -
Employee Benefits 118,267
1101 Retirement 4,332 1% of costs
1102 Worker's Compensation 34,224 7.9% of costs
1103 Health Insurance 79,711 15.7% of costs
1104 Other (Specify)-
1105 Other (Specify)-
1106 Other (Specify)-
Payroll Taxes & Expenses:39,422
1201 OASDI -
1202 FICA/MEDICARE 33,790 7.8% of Costs
1203 SUI 5,632 1.3% of Costs
1204 Other (Specify)-
1205 Other (Specify)-
1206 Other (Specify)-
2000: CLIENT SUPPORT 48,625
2001 Child Care -
2002 Client Housing Support -
2003 Client Transportation & Support 15,450 Dreamcatchers has included client support expenses such as bus passes for 150
clients.
2004 Clothing, Food, & Hygiene 15,450 Minimal food, clothing or hygiene items that our clients may need such as socks, a
belt, pants or shoes as well as shampoo, deodorant and razors to name a few.
2005 Education Support 10,000 Education supports may include the cost for books, GED exam fees, or the cost for
enrollment into a CNA course or take the Safe-Serve exam.
Vocational and Educational Services
Dreamcatchers Empowerment Network
Fiscal Year 2021-2022
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
2006 Employment Support 7,725 Employment supplies may include a flash drive to hold a resume and cover letter, a
portfolio to maintain important documents, or other items such as tool belt for a
construction position or a back brace.
2007 Household Items for Clients -
2008 Medication Supports -
2009 Program Supplies - Medical -
2010 Utility Vouchers -
2011 Other (Specify)-
2012 Other (Specify)-
2013 Other (Specify)-
2014 Other (Specify)-
2015 Other (Specify)-
2016 Other (Specify)-
3000: OPERATING EXPENSES 70,378
3001 Telecommunications 13,380 Office phone installation monthly costs plus monthly cell phone service costs for
staff providing services
3002 Printing/Postage 610 Cost for printing marketing materials to promote program and services.
3003 Office, Household & Program Supplies 4,500 Includes office items such as client charts, copy paper, resume paper, pens, toner.
Also includes cleaning supplies, paper towels, toilet paper. A small food budget has
been included to have light snacks at the office for clients when needed.
3004 Advertising 250 Job postings to hire staff to deliver services under this contract
3005 Staff Development & Training 1,386 Intial fees for CPR training of all staff servicing contract
3006 Staff Mileage 45,800 Mileage to provide employment and education services to clients; meeting with
employers, education systems and clients in the community. Also includes travel
costs to meetings.
3007 Subscriptions & Memberships -
3008 Vehicle Maintenance -
3009 Courier 1,152 Inner office mail system between Fresno branch and DEN main office
3010 CARF Fees -
3011 Lodging 3,300 Lodging for set up and implentation of program during first month of services for
out of county staff travel
3012 Other (Specify)-
4000: FACILITIES & EQUIPMENT 65,000
4001 Building Maintenance 5,000 Projected cost for any minor building maintenance that may be needed at office
where services are provided.
4002 Rent/Lease Building 48,000 Monthly rent
4003 Rent/Lease Equipment 6,000 Monthly cost for copier service and water cooler
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities 6,000 Monthly utilities such as PG&E
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
5000: SPECIAL EXPENSES 17,000
5001 Consultant (Network & Data Management)12,000 Monthly fee for ongoing network services
5002 HMIS (Health Management Information
System)
-
5003 Contractual/Consulting Services (Specify)-
5004 Translation Services 5,000 ASL or Interpreting services that may be necessary for client communications
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
6000: ADMINISTRATIVE EXPENSES 132,176
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
6001 Administrative Overhead 120,849 15% applied to total costs
6002 Professional Liability Insurance -
6003 Accounting/Bookkeeping 1,000 Costs for the added cost center established to monitor expenses and revenues
associated to contract
6004 External Audit 800 Costs for additional location in Annual Financial Audit
6005 Insurance (Specify):927 Costs to add additional location to delivery contract services
6006 Payroll Services 3,600 Costs to add additional staffing to service contract
6007 Depreciation (Provider-Owned Equipment to
be Used for Program Purposes)
5,000 Costs for depreciation of furniture and server/network equipment
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
7000: FIXED ASSETS -
7001 Computer Equipment & Software -
7002 Copiers, Cell Phones, Tablets, Devices to
Contain HIPAA Data
-
7003 Furniture & Fixtures -
7004 Leasehold/Tenant/Building Improvements -
7005 Other Assets over $500 with Lifespan of 2
Years +
-
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE:924,078
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE:924,078
-
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Supervisor/IPS Team Lead 1.00 46,126 11,532 57,658$
1102 Employment Specialist 1.00 9,223 36,891 46,114
1103 Employment Specialist 1.00 9,223 36,891 46,114
1104 Employment Specialist 1.00 9,223 36,891 46,114
1105 Employment Specialist 1.00 9,223 36,891 46,114
1106 Employment Specialist 1.00 9,223 36,891 46,114
1107 Peer Specialist/Wellness Advocate 1.00 8,299 33,197 41,496
1108 Peer Specialist/Wellness Advocate 1.00 8,299 33,197 41,496
1109 Education Specialist 1.00 9,223 36,891 46,114
1110 Office Assistant 0.50 20,710 20,710
1111 Executive Director 0.05 5,408 5,408
1112 Program Operations Director 0.05 2,828 2,828
1113 Records Clerk 0.05 2,090 2,090
1114 - - -
1115 - - -
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
Personnel Salaries Subtotal 9.65 149,096$ 299,270$ 448,367$
Employee Benefits
Acct #Admin Direct Total
1101 1,491 2,993 4,484$
1102 11,779 23,642 35,421
1103 27,434 55,066 82,499
1104 - - -
1105 - - -
1106 - - -
40,703$ 81,701$ 122,404$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1201 -$
1202 11,629 23,343 34,973
1203 1,938 3,891 5,829
1204 - - -
1205 - - -
1206 - - -
13,568$ 27,234$ 40,801$
203,367$ 408,205$ 611,572$
Retirement
Worker's Compensation
Health Insurance
Other (Specify)
Other (Specify)
Other (Specify)
Vocational and Educational Services
Dreamcatchers Empowerment Network
Fiscal Year 2022-2023
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Description
Other (Specify)
Other (Specify)
Other (Specify)
Payroll Taxes & Expenses Subtotal:
EMPLOYEE SALARIES & BENEFITS TOTAL:
Employee Benefits Subtotal:
Description
OASDI
FICA/MEDICARE
SUI
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
2000: CLIENT SUPPORT
Acct #Amount
2001 -$
2002 -
2003 15,913
2004 15,913
2005 10,300
2006 7,957
2007 -
2008 -
2009 -
2010 -
2011 -
2012 -
2013 -
2014 -
2015 -
2016 -
50,083$
3000: OPERATING EXPENSES
Acct #Amount
3001 13,781
3002 610
3003 4,800
3004 250
3005 1,386
3006 47,262
3007 -
3008 -
3009 1,187
3010 -
3011 3,296
3012 -
72,572$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 5,000
4002 48,000
4003 6,000
4004 -
4005 -
4006 6,000
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
65,000$
5000: SPECIAL EXPENSES
Line Item Description
Household Items for Clients
Medication Supports
Program Supplies - Medical
Utility Vouchers
Other (Specify)
Other (Specify)
Child Care
Client Housing Support
Client Transportation & Support
Clothing, Food, & Hygiene
Education Support
Employment Support
Telecommunications
Printing/Postage
Office, Household & Program Supplies
Advertising
Staff Development & Training
Staff Mileage
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
DIRECT CLIENT CARE TOTAL
Line Item Description
OPERATING EXPENSES TOTAL:
Line Item Description
Building Maintenance
Rent/Lease Building
Rent/Lease Equipment
Rent/Lease Vehicles
Subscriptions & Memberships
Vehicle Maintenance
Courier
CARF Fees
Lodging
Other (Specify)
FACILITIES/EQUIPMENT TOTAL:
Security
Utilities
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Acct #Amount
5001 12,000$
5002 -
5003 -
5004 5,000
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
17,000$
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 124,137
6002
6003 1,000
6004 800
6005 Insurance (Specify):liability 955
6006 Payroll Services 3,600
6007 5,000
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
135,492$
7000: FIXED ASSETS
Acct #Amount
7001 -$
7002 -
7003 -
7004 -
7005 -
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
-$
Line Item Description
Consultant (Network & Data Management)
HMIS (Health Management Information System)
Contractual/Consulting Services (Specify)
Translation Services
Administrative Overhead
Professional Liability Insurance
Accounting/Bookkeeping
External Audit
Commercial Liability
Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
SPECIAL EXPENSES TOTAL:
Line Item Description
Line Item Description
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
Leasehold/Tenant/Building Improvements
Other Assets over $500 with Lifespan of 2 Years +
ADMINISTRATIVE EXPENSES TOTAL
FIXED ASSETS EXPENSES TOTAL
TOTAL PROGRAM EXPENSES 951,719$
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Acct #Service Units Rate Amount
8001 Mental Health Services 0 - -$
8002 Case Management 0 - -
8003 Crisis Services 0 - -
8004 Medication Support 0 - -
8005 Collateral 0 - -
8006 Plan Development 0 - -
8007 Assessment 0 - -
8008 Rehabilitation 0 - -
0 -$
0%
-
0%-
-$
Acct #Amount
8101 Drug Medi-Cal -$
8102 SABG -$
-$
Acct #Amount
8201 Realignment (0)$
(0)$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports 951,719$
8302 PEI - Prevention & Early Intervention -
8303 INN - Innovations -
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
951,719$
Acct #Amount
8401 Client Fees -$
8402 Client Insurance -
8403 Grants (Specify)-
8404 Other (Specify) -
8405 Other (Specify) -
-$
PROGRAM FUNDING SOURCES
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
Line Item Description
Estimated Specialty Mental Health Services Billing Totals:
Estimated % of Clients who are Medi-Cal Beneficiaries
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries
Line Item Description
REALIGNMENT TOTAL
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
MHSA Program Name
Federal Financial Participation (FFP) %
MEDI-CAL FFP TOTAL
8100 - SUBSTANCE USE DISORDER FUNDS
Line Item Description
SUBSTANCE USE DISORDER FUNDS TOTAL
8200 - REALIGNMENT
OTHER REVENUE TOTAL
TOTAL PROGRAM FUNDING SOURCES:951,719$
NET PROGRAM COST: -$
MHSA TOTAL
8400 - OTHER REVENUE
Line Item Description
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
Budget Narrative
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES & BENEFITS 611,572
Employee Salaries 448,367
1101 Supervisor/IPS Team Lead 57,658 Onsite supervisor of team leading services in accordance with contract
1102 Employment Specialist 46,114 Direct staff providing IPS sevices to help clients become hired within the community
1103 Employment Specialist 46,114 Direct staff providing IPS sevices to help clients become hired within the community
1104 Employment Specialist 46,114 Direct staff providing IPS sevices to help clients become hired within the community
1105 Employment Specialist 46,114 Direct staff providing IPS sevices to help clients become hired within the community
1106 Employment Specialist 46,114 Direct staff providing IPS sevices to help clients become hired within the community
1107 Peer Specialist/Wellness Advocate 41,496 Peer staff with lived mental health experience to support clients receiving services
1108 Peer Specialist/Wellness Advocate 41,496 Peer staff with lived mental health experience to support clients receiving services
1109 Education Specialist 46,114 Direct staff providing IPS sevices to help clients reach their educational goals
1110 Office Assistant 20,710 Onsite clerical support staff to support IPS service delivery
1111 Executive Director 5,408 Responsible for hiring, training staff, new office set up and service implementation
as well as on going program services and outcomes
1112 Program Operations Director 2,828 Supports program implementation and on going support and guidance of the onsite
supervisor
1113 Records Clerk 2,090 Support staff to aid with training, set up and monitoring of client records
1114 0 -
1115 0 -
1116 0 -
1117 0 -
1118 0 -
1119 0 -
1120 0 -
Employee Benefits 122,404
1101 Retirement 4,484 1% of costs
1102 Worker's Compensation 35,421 7.9% of costs
1103 Health Insurance 82,499 15.7% of costs
1104 Other (Specify)-
1105 Other (Specify)-
1106 Other (Specify)-
Payroll Taxes & Expenses:40,801
1201 OASDI -
1202 FICA/MEDICARE 34,973 7.8% of Costs
1203 SUI 5,829 1.3% of Costs
1204 Other (Specify)-
1205 Other (Specify)-
1206 Other (Specify)-
2000: CLIENT SUPPORT 50,083
2001 Child Care -
2002 Client Housing Support -
2003 Client Transportation & Support 15,913 Dreamcatchers has included client support expenses such as bus passes for 150
clients.
2004 Clothing, Food, & Hygiene 15,913 Minimal food, clothing or hygiene items that our clients may need such as socks, a
belt, pants or shoes as well as shampoo, deodorant and razors to name a few.
2005 Education Support 10,300 Education supports may include the cost for books, GED exam fees, or the cost for
enrollment into a CNA course or take the Safe-Serve exam.
Vocational and Educational Services
Dreamcatchers Empowerment Network
Fiscal Year 2022-2023
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
2006 Employment Support 7,957 Employment supplies may include a flash drive to hold a resume and cover letter, a
portfolio to maintain important documents, or other items such as tool belt for a
construction position or a back brace.
2007 Household Items for Clients -
2008 Medication Supports -
2009 Program Supplies - Medical -
2010 Utility Vouchers -
2011 Other (Specify)-
2012 Other (Specify)-
2013 Other (Specify)-
2014 Other (Specify)-
2015 Other (Specify)-
2016 Other (Specify)-
3000: OPERATING EXPENSES 72,572
3001 Telecommunications 13,781 Office phone monthly costs plus monthly cell phone service costs for staff providing
services
3002 Printing/Postage 610 Cost for printing marketing materials to promote program and services.
3003 Office, Household & Program Supplies 4,800 Includes office items such as client charts, copy paper, resume paper, pens, toner.
Also includes cleaning supplies, paper towels, toilet paper. A small food budget has
been included to have light snacks at the office for clients when needed.
3004 Advertising 250 Job postings to hire staff to deliver services under this contract
3005 Staff Development & Training 1,386 Intial fees for CPR training of all staff servicing contract
3006 Staff Mileage 47,262 Mileage to provide employment and education services to clients; meeting with
employers, education systems and clients in the community. Also includes travel
costs to meetings.
3007 Subscriptions & Memberships -
3008 Vehicle Maintenance -
3009 Courier 1,187 Inner office mail system between Fresno branch and DEN main office
3010 CARF Fees -
3011 Lodging 3,296 Lodging for set up and implentation for out of county staff.
3012 Other (Specify)-
4000: FACILITIES & EQUIPMENT 65,000
4001 Building Maintenance 5,000 Projected cost for any minor building maintenance that may be needed at office
where services are provided.
4002 Rent/Lease Building 48,000 Monthly rent
4003 Rent/Lease Equipment 6,000 Monthly cost for copier service and water cooler
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities 6,000 Monthly utilities such as PG&E
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
5000: SPECIAL EXPENSES 17,000
5001 Consultant (Network & Data Management)12,000 Monthly fee plus for ongoing network services
5002 HMIS (Health Management Information
System)
-
5003 Contractual/Consulting Services (Specify)-
5004 Translation Services 5,000 ASL or Interpreting services that may be necessary for client communications
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
6000: ADMINISTRATIVE EXPENSES 135,492
6001 Administrative Overhead 124,137 15% applied to total costs
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
6002 Professional Liability Insurance -
6003 Accounting/Bookkeeping 1,000 Costs for the added cost center established to monitor expenses and revenues
associated to contract
6004 External Audit 800 Costs for additional location in Annual Financial Audit
6005 Insurance (Specify):liability 955 Costs to add additional location to delivery contract services
6006 Payroll Services 3,600 Costs to add additional staffing to service contract
6007 Depreciation (Provider-Owned Equipment to
be Used for Program Purposes)
5,000 Costs for depreciation of furniture and server/network equipment
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
7000: FIXED ASSETS -
7001 Computer Equipment & Software -
7002 Copiers, Cell Phones, Tablets, Devices to
Contain HIPAA Data
-
7003 Furniture & Fixtures -
7004 Leasehold/Tenant/Building Improvements -
7005 Other Assets over $500 with Lifespan of 2
Years +
-
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE:951,719
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE:951,719
-
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Supervisor/IPS Team Lead 1.00 47,740$ 11,935$ 59,675$
1102 Employment Specialist 1.00 9,547 38,189 47,736
1103 Employment Specialist 1.00 9,547 38,189 47,736
1104 Employment Specialist 1.00 9,547 38,189 47,736
1105 Employment Specialist 1.00 9,547 38,189 47,736
1106 Employment Specialist 1.00 9,547 38,189 47,736
1107 Peer Specialist/Wellness Advocate 1.00 8,590 34,362 42,952
1108 Peer Specialist/Wellness Advocate 1.00 8,590 34,362 42,952
1109 Education Specialist 1.00 9,547 38,189 47,736
1110 Office Assistant 0.50 21,435 21,435
1111 Executive Director 0.05 5,624 5,624
1112 Program Operations Director 0.05 2,927 2,927
1113 Records Clerk 0.05 2,163 2,163
1114 - - -
1115 - - -
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
Personnel Salaries Subtotal 9.65 154,353$ 309,791$ 464,144$
Employee Benefits
Acct #Admin Direct Total
1101 1,544$ 3,098$ 4,641$
1102 12,194 24,473 36,667
1103 30,871 61,958 92,829
1104 - - -
1105 - - -
1106 - - -
44,608$ 89,530$ 134,138$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1201 -$ -$ -$
1202 12,040 24,164 36,203
1203 2,007 4,027 6,034
1204 - - -
1205 - - -
1206 - - -
14,046$ 28,191$ 42,237$
213,008$ 427,512$ 640,519$
Retirement
Worker's Compensation
Health Insurance
Other (Specify)
Other (Specify)
Other (Specify)
Vocational and Educational Services
Dreamcatchers Empowerment Network
Fiscal Year 2023-2024
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Description
Other (Specify)
Other (Specify)
Other (Specify)
Payroll Taxes & Expenses Subtotal:
EMPLOYEE SALARIES & BENEFITS TOTAL:
Employee Benefits Subtotal:
Description
OASDI
FICA/MEDICARE
SUI
2000: CLIENT SUPPORT
Acct #Amount
2001 -$
2002 -
2003 16,390
2004 16,390
2005 10,609
2006 8,195
2007 -
2008 -
2009 -
2010 -
2011 -
2012 -
2013 -
2014 -
2015 -
2016 -
51,584$
3000: OPERATING EXPENSES
Acct #Amount
3001 14,195$
3002 610
3003 5,100
3004 250
3005 1,386
3006 47,464
3007 -
3008 -
3009 1,223
3010 1,000
3011 3,395
3012 -
74,623$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 5,000$
4002 48,000
4003 6,000
4004 -
4005 -
4006 6,000
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
65,000$
5000: SPECIAL EXPENSES
Line Item Description
Household Items for Clients
Medication Supports
Program Supplies - Medical
Utility Vouchers
Other (Specify)
Other (Specify)
Child Care
Client Housing Support
Client Transportation & Support
Clothing, Food, & Hygiene
Education Support
Employment Support
Telecommunications
Printing/Postage
Office, Household & Program Supplies
Advertising
Staff Development & Training
Staff Mileage
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
DIRECT CLIENT CARE TOTAL
Line Item Description
OPERATING EXPENSES TOTAL:
Line Item Description
Building Maintenance
Rent/Lease Building
Rent/Lease Equipment
Rent/Lease Vehicles
Subscriptions & Memberships
Vehicle Maintenance
Courier
CARF Fees
Lodging
Other (Specify)
FACILITIES/EQUIPMENT TOTAL:
Security
Utilities
Acct #Amount
5001 12,000$
5002 -
5003 -
5004 5,000
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
17,000$
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 129,017$
6002 -
6003 1,000
6004 800
6005 Insurance (Specify): 984
6006 Payroll Services 3,600
6007 5,000
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
140,401$
7000: FIXED ASSETS
Acct #Amount
7001 -$
7002 -
7003 -
7004 -
7005 -
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
-$
Acct #Service Units Rate Amount
8001 Mental Health Services 0 - -$
8002 Case Management 0 - -
8003 Crisis Services 0 - -
8004 Medication Support 0 - -
8005 Collateral 0 - -
8006 Plan Development 0 - -
Line Item Description
Consultant (Network & Data Management)
HMIS (Health Management Information System)
Contractual/Consulting Services (Specify)
Translation Services
Administrative Overhead
Professional Liability Insurance
Accounting/Bookkeeping
External Audit
Commercial Liability
Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
SPECIAL EXPENSES TOTAL:
Line Item Description
Line Item Description
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
Leasehold/Tenant/Building Improvements
Other Assets over $500 with Lifespan of 2 Years +
ADMINISTRATIVE EXPENSES TOTAL
PROGRAM FUNDING SOURCES
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
Line Item Description
FIXED ASSETS EXPENSES TOTAL
TOTAL PROGRAM EXPENSES 989,127$
8007 Assessment 0 - -
8008 Rehabilitation 0 - -
0 -$
0%
-
0%-
-$
Acct #Amount
8101 Drug Medi-Cal -$
8102 SABG -$
-$
Acct #Amount
8201 Realignment (0)$
(0)$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports 989,127$
8302 PEI - Prevention & Early Intervention -
8303 INN - Innovations -
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
989,127$
Acct #Amount
8401 -$
8402 -
8403 Grants (Specify)-
8404 Other (Specify) -
8405 Other (Specify) -
-$
Estimated Specialty Mental Health Services Billing Totals:
Estimated % of Clients who are Medi-Cal Beneficiaries
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries
Line Item Description
REALIGNMENT TOTAL
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
MHSA Program Name
Federal Financial Participation (FFP) %
MEDI-CAL FFP TOTAL
8100 - SUBSTANCE USE DISORDER FUNDS
Line Item Description
SUBSTANCE USE DISORDER FUNDS TOTAL
8200 - REALIGNMENT
OTHER REVENUE TOTAL
TOTAL PROGRAM FUNDING SOURCES:989,127$
NET PROGRAM COST: -$
MHSA TOTAL
8400 - OTHER REVENUE
Line Item Description
Client Fees
Client Insurance
Budget Narrative
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES & BENEFITS 640,519
Employee Salaries 464,144
1101 Supervisor/IPS Team Lead 59,675 Onsite supervisor of team leading services in accordance with contract
1102 Employment Specialist 47,736 Direct staff providing IPS sevices to help clients become hired within the community
1103 Employment Specialist 47,736 Direct staff providing IPS sevices to help clients become hired within the community
1104 Employment Specialist 47,736 Direct staff providing IPS sevices to help clients become hired within the community
1105 Employment Specialist 47,736 Direct staff providing IPS sevices to help clients become hired within the community
1106 Employment Specialist 47,736 Direct staff providing IPS sevices to help clients become hired within the community
1107 Peer Specialist/Wellness Advocate 42,952 Peer staff with lived mental health experience to support clients receiving services
1108 Peer Specialist/Wellness Advocate 42,952 Peer staff with lived mental health experience to support clients receiving services
1109 Education Specialist 47,736 Direct staff providing IPS sevices to help clients reach their educational goals
1110 Office Assistant 21,435 Onsite clerical support staff to support IPS service delivery
1111 Executive Director 5,624 Responsible for hiring, training staff, new office set up and service implementation
as well as on going program services and outcomes
1112 Program Operations Director 2,927 Supports program implementation and on going support and guidance of the onsite
supervisor
1113 Records Clerk 2,163 Support staff to aid with training, set up and monitoring of client records
1114 0 -
1115 0 -
1116 0 -
1117 0 -
1118 0 -
1119 0 -
1120 0 -
Employee Benefits 134,138
1101 Retirement 4,641 1% of costs
1102 Worker's Compensation 36,667 7.9% of costs
1103 Health Insurance 92,829 15.7% of costs
1104 Other (Specify)-
1105 Other (Specify)-
1106 Other (Specify)-
Payroll Taxes & Expenses:42,237
1201 OASDI -
1202 FICA/MEDICARE 36,203 7.8% of Costs
1203 SUI 6,034 1.3% of Costs
1204 Other (Specify)-
1205 Other (Specify)-
1206 Other (Specify)-
2000: CLIENT SUPPORT 51,584
2001 Child Care -
2002 Client Housing Support -
2003 Client Transportation & Support 16,390 Dreamcatchers has included client support expenses such as bus passes for 150
clients.
2004 Clothing, Food, & Hygiene 16,390 Minimal food, clothing or hygiene items that our clients may need such as socks, a
belt, pants or shoes as well as shampoo, deodorant and razors to name a few.
2005 Education Support 10,609 Education supports may include the cost for books, GED exam fees, or the cost for
enrollment into a CNA course or take the Safe-Serve exam.
Vocational and Educational Services
Dreamcatchers Empowerment Network
Fiscal Year 2023-2024
2006 Employment Support 8,195 Employment supplies may include a flash drive to hold a resume and cover letter, a
portfolio to maintain important documents, or other items such as tool belt for a
construction position or a back brace.
2007 Household Items for Clients -
2008 Medication Supports -
2009 Program Supplies - Medical -
2010 Utility Vouchers -
2011 Other (Specify)-
2012 Other (Specify)-
2013 Other (Specify)-
2014 Other (Specify)-
2015 Other (Specify)-
2016 Other (Specify)-
3000: OPERATING EXPENSES 74,623
3001 Telecommunications 14,195 Office phone monthly costs plus monthly cell phone service costs for staff providing
services
3002 Printing/Postage 610 Cost for printing marketing materials to promote program and services.
3003 Office, Household & Program Supplies 5,100 Includes office items such as client charts, copy paper, resume paper, pens, toner.
Also includes cleaning supplies, paper towels, toilet paper. A small food budget has
been included to have light snacks at the office for clients when needed.
3004 Advertising 250 Job postings to hire staff to deliver services under this contract
3005 Staff Development & Training 1,386 Intial fees for CPR training of all staff servicing contract
3006 Staff Mileage 47,464 Mileage to provide employment and education services to clients; meeting with
employers, education systems and clients in the community. Also includes travel
costs to meetings.
3007 Subscriptions & Memberships -
3008 Vehicle Maintenance -
3009 Courier 1,223 Inner office mail system between Fresno branch and DEN main office
3010 CARF Fees 1,000 Staff fingerprints required to deliver client services
3011 Lodging 3,395 Lodging for set up and implentation for out of county staff.
3012 Other (Specify)-
4000: FACILITIES & EQUIPMENT 65,000
4001 Building Maintenance 5,000 Projected cost for any minor building maintenance that may be needed at office
where services are provided.
4002 Rent/Lease Building 48,000 Monthly rent
4003 Rent/Lease Equipment 6,000 Monthly cost for copier service and water cooler
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities 6,000 Monthly utilities such as PG&E
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
5000: SPECIAL EXPENSES 17,000
5001 Consultant (Network & Data Management)12,000 Monthly fee for ongoing network services
5002 HMIS (Health Management Information
System)
-
5003 Contractual/Consulting Services (Specify)-
5004 Translation Services 5,000 ASL or Interpreting services that may be necessary for client communications
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
6000: ADMINISTRATIVE EXPENSES 140,401
6001 Administrative Overhead 129,017 15% applied to total costs
6002 Professional Liability Insurance -
6003 Accounting/Bookkeeping 1,000 Costs for the added cost center established to monitor expenses and revenues
associated to contract
6004 External Audit 800 Costs for additional location in Annual Financial Audit
6005 Insurance (Specify): 984 Costs to add additional location to delivery contract services
6006 Payroll Services 3,600 Costs to add additional staffing to service contract
6007 Depreciation (Provider-Owned Equipment to
be Used for Program Purposes)
5,000 Costs for depreciation of furniture and server/network equipment
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
7000: FIXED ASSETS -
7001 Computer Equipment & Software -
7002 Copiers, Cell Phones, Tablets, Devices to
Contain HIPAA Data
-
7003 Furniture & Fixtures -
7004 Leasehold/Tenant/Building Improvements -
7005 Other Assets over $500 with Lifespan of 2
Years +
-
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE:989,127
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE:989,127
-
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Supervisor/IPS Team Lead 1.00 49,650$ 12,412$ 62,062$
1102 Employment Specialist 1.00 9,881 39,526 49,407
1103 Employment Specialist 1.00 9,881 39,526 49,407
1104 Employment Specialist 1.00 9,881 39,526 49,407
1105 Employment Specialist 1.00 9,881 39,526 49,407
1106 Employment Specialist 1.00 9,881 39,526 49,407
1107 Peer Specialist/Wellness Advocate 1.00 8,891 35,565 44,455
1108 Peer Specialist/Wellness Advocate 1.00 8,891 35,565 44,455
1109 Education Specialist 1.00 9,881 39,526 49,407
1110 Office Assistant 0.50 22,185 22,185
1111 Executive Director 0.05 5,849 5,849
1112 Program Operations Director 0.05 3,044 3,044
1113 Records Clerk 0.05 2,239 2,239
1114 - - -
1115 - - -
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
Personnel Salaries Subtotal 9.65 160,035$ 320,695$ 480,730$
Employee Benefits
Acct #Admin Direct Total
1101 1,600$ 3,207$ 4,807$
1102 12,643 25,335 37,978
1103 32,007 64,139 96,146
1104 - - -
1105 - - -
1106 - - -
46,250$ 92,681$ 138,931$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1201 -$ -$ -$
1202 12,483 25,014 37,497
1203 2,080 4,169 6,249
1204 - - -
1205 - - -
1206 - - -
14,563$ 29,183$ 43,746$
220,848$ 442,560$ 663,408$
Retirement
Worker's Compensation
Health Insurance
Other (Specify)
Other (Specify)
Other (Specify)
Vocational and Educational Services
Dreamcatchers Empowerment Network
Fiscal Year 2024-2025
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Description
Other (Specify)
Other (Specify)
Other (Specify)
Payroll Taxes & Expenses Subtotal:
EMPLOYEE SALARIES & BENEFITS TOTAL:
Employee Benefits Subtotal:
Description
OASDI
FICA/MEDICARE
SUI
2000: CLIENT SUPPORT
Acct #Amount
2001 -$
2002 -
2003 16,882
2004 16,882
2005 10,927
2006 10,927
2007
2008 -
2009 -
2010 -
2011 -
2012 -
2013 -
2014 -
2015 -
2016 -
55,617$
3000: OPERATING EXPENSES
Acct #Amount
3001 14,621$
3002 610
3003 5,300
3004 250
3005 1,386
3006 47,702
3007 -
3008 -
3009 1,260
3010 -
3011 3,497
3012 -
74,626$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 5,000$
4002 48,000
4003 6,000
4004 -
4005 -
4006 6,000
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
65,000$
5000: SPECIAL EXPENSES
Line Item Description
Household Items for Clients
Medication Supports
Program Supplies - Medical
Utility Vouchers
Other (Specify)
Other (Specify)
Child Care
Client Housing Support
Client Transportation & Support
Clothing, Food, & Hygiene
Education Support
Employment Support
Telecommunications
Printing/Postage
Office, Household & Program Supplies
Advertising
Staff Development & Training
Staff Mileage
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
DIRECT CLIENT CARE TOTAL
Line Item Description
OPERATING EXPENSES TOTAL:
Line Item Description
Building Maintenance
Rent/Lease Building
Rent/Lease Equipment
Rent/Lease Vehicles
Subscriptions & Memberships
Vehicle Maintenance
Courier
CARF Fees
Lodging
Other (Specify)
FACILITIES/EQUIPMENT TOTAL:
Security
Utilities
Acct #Amount
5001 12,000$
5002 -
5003 -
5004 5,000
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
17,000$
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 133,060$
6002 -
6003 1,000
6004 800
6005 Insurance (Specify): 1,014
6006 Payroll Services 3,600
6007 5,000
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
144,474$
7000: FIXED ASSETS
Acct #Amount
7001 -$
7002 -
7003 -
7004 -
7005 -
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
-$
Acct #Service Units Rate Amount
8001 Mental Health Services 0 - -$
8002 Case Management 0 - -
8003 Crisis Services 0 - -
8004 Medication Support 0 - -
8005 Collateral 0 - -
8006 Plan Development 0 - -
Line Item Description
Consultant (Network & Data Management)
HMIS (Health Management Information System)
Contractual/Consulting Services (Specify)
Translation Services
Administrative Overhead
Professional Liability Insurance
Accounting/Bookkeeping
External Audit
Commercial Liability
Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
SPECIAL EXPENSES TOTAL:
Line Item Description
Line Item Description
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
Leasehold/Tenant/Building Improvements
Other Assets over $500 with Lifespan of 2 Years +
ADMINISTRATIVE EXPENSES TOTAL
PROGRAM FUNDING SOURCES
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
Line Item Description
FIXED ASSETS EXPENSES TOTAL
TOTAL PROGRAM EXPENSES 1,020,124$
8007 Assessment 0 - -
8008 Rehabilitation 0 - -
0 -$
0%
-
0%-
-$
Acct #Amount
8101 Drug Medi-Cal -$
8102 SABG -$
-$
Acct #Amount
8201 Realignment 0$
0$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports 1,020,124$
8302 PEI - Prevention & Early Intervention -
8303 INN - Innovations -
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
1,020,124$
Acct #Amount
8401 -$
8402 -
8403 Grants (Specify)-
8404 Other (Specify) -
8405 Other (Specify) -
-$
Estimated Specialty Mental Health Services Billing Totals:
Estimated % of Clients who are Medi-Cal Beneficiaries
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries
Line Item Description
REALIGNMENT TOTAL
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
MHSA Program Name
Federal Financial Participation (FFP) %
MEDI-CAL FFP TOTAL
8100 - SUBSTANCE USE DISORDER FUNDS
Line Item Description
SUBSTANCE USE DISORDER FUNDS TOTAL
8200 - REALIGNMENT
OTHER REVENUE TOTAL
TOTAL PROGRAM FUNDING SOURCES:1,020,124$
NET PROGRAM COST: -$
MHSA TOTAL
8400 - OTHER REVENUE
Line Item Description
Client Fees
Client Insurance
Budget Narrative
ACCT #LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES & BENEFITS 663,408
Employee Salaries 480,730
1101 Supervisor/IPS Team Lead 62,062 Onsite supervisor of team leading services in accordance with contract
1102 Employment Specialist 49,407 Direct staff providing IPS sevices to help clients become hired within the community
1103 Employment Specialist 49,407 Direct staff providing IPS sevices to help clients become hired within the community
1104 Employment Specialist 49,407 Direct staff providing IPS sevices to help clients become hired within the community
1105 Employment Specialist 49,407 Direct staff providing IPS sevices to help clients become hired within the community
1106 Employment Specialist 49,407 Direct staff providing IPS sevices to help clients become hired within the community
1107 Peer Specialist/Wellness Advocate 44,455 Peer staff with lived mental health experience to support clients receiving services
1108 Peer Specialist/Wellness Advocate 44,455 Peer staff with lived mental health experience to support clients receiving services
1109 Education Specialist 49,407 Direct staff providing IPS sevices to help clients reach their educational goals
1110 Office Assistant 22,185 Onsite clerical support staff to support IPS service delivery
1111 Executive Director 5,849 Responsible for hiring, training staff, new office set up and service implementation
as well as on going program services and outcomes
1112 Program Operations Director 3,044 Supports program implementation and on going support and guidance of the onsite
supervisor
1113 Records Clerk 2,239 Support staff to aid with training, set up and monitoring of client records
1114 0 -
1115 0 -
1116 0 -
1117 0 -
1118 0 -
1119 0 -
1120 0 -
Employee Benefits 138,931
1101 Retirement 4,807 1% of costs
1102 Worker's Compensation 37,978 7.9% of costs
1103 Health Insurance 96,146 15.7% of costs
1104 Other (Specify)-
1105 Other (Specify)-
1106 Other (Specify)-
Payroll Taxes & Expenses:43,746
1201 OASDI -
1202 FICA/MEDICARE 37,497 7.8% of Costs
1203 SUI 6,249 1.3% of Costs
1204 Other (Specify)-
1205 Other (Specify)-
1206 Other (Specify)-
2000: CLIENT SUPPORT 55,617
2001 Child Care -
2002 Client Housing Support -
2003 Client Transportation & Support 16,882 Dreamcatchers has included client support expenses such as bus passes for 150
clients.
2004 Clothing, Food, & Hygiene 16,882 Minimal food, clothing or hygiene items that our clients may need such as socks, a
belt, pants or shoes as well as shampoo, deodorant and razors to name a few.
2005 Education Support 10,927 Education supports may include the cost for books, GED exam fees, or the cost for
enrollment into a CNA course or take the Safe-Serve exam.
Vocational and Educational Services
Dreamcatchers Empowerment Network
Fiscal Year 2024-2025
2006 Employment Support 10,927 Employment supplies may include a flash drive to hold a resume and cover letter, a
portfolio to maintain important documents, or other items such as tool belt for a
construction position or a back brace.
2007 Household Items for Clients -
2008 Medication Supports -
2009 Program Supplies - Medical -
2010 Utility Vouchers -
2011 Other (Specify)-
2012 Other (Specify)-
2013 Other (Specify)-
2014 Other (Specify)-
2015 Other (Specify)-
2016 Other (Specify)-
3000: OPERATING EXPENSES 74,626
3001 Telecommunications 14,621 Office phone and monthly costs plus monthly cell phone service costs for staff
providing services
3002 Printing/Postage 610 Cost for printing marketing materials to promote program and services.
3003 Office, Household & Program Supplies 5,300 Includes office items such as client charts, copy paper, resume paper, pens, toner.
Also includes cleaning supplies, paper towels, toilet paper. A small food budget has
been included to have light snacks at the office for clients when needed.
3004 Advertising 250 Job postings to hire staff to deliver services under this contract
3005 Staff Development & Training 1,386 Intial fees for CPR training of all staff servicing contract
3006 Staff Mileage 47,702 Mileage to provide employment and education services to clients; meeting with
employers, education systems and clients in the community. Also includes travel
costs to meetings.
3007 Subscriptions & Memberships -
3008 Vehicle Maintenance -
3009 Courier 1,260 Inner office mail system between Fresno branch and DEN main office
3010 CARF Fees -
3011 Lodging 3,497 Lodging for set up and implentation for out of county staff.
3012 Other (Specify)-
4000: FACILITIES & EQUIPMENT 65,000
4001 Building Maintenance 5,000 Projected cost for any minor building maintenance that may be needed at office
where services are provided.
4002 Rent/Lease Building 48,000 Monthly rent
4003 Rent/Lease Equipment 6,000 Monthly cost for copier service and water cooler
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities 6,000 Monthly utilities such as PG&E
4007 Other (Specify)-
4008 Other (Specify)-
4009 Other (Specify)-
4010 Other (Specify)-
5000: SPECIAL EXPENSES 17,000
5001 Consultant (Network & Data Management)12,000 Monthly fee for ongoing network services
5002 HMIS (Health Management Information
System)
-
5003 Contractual/Consulting Services (Specify)-
5004 Translation Services 5,000 ASL or Interpreting services that may be necessary for client communications
5005 Other (Specify)-
5006 Other (Specify)-
5007 Other (Specify)-
5008 Other (Specify)-
6000: ADMINISTRATIVE EXPENSES 144,474
6001 Administrative Overhead 133,060 15% applied to total costs
6002 Professional Liability Insurance -
6003 Accounting/Bookkeeping 1,000 Costs for the added cost center established to monitor expenses and revenues
associated to contract
6004 External Audit 800 Costs for additional location in Annual Financial Audit
6005 Insurance (Specify): 1,014 Costs to add additional location to delivery contract services
6006 Payroll Services 3,600 Costs to add additional staffing to service contract
6007 Depreciation (Provider-Owned Equipment to
be Used for Program Purposes)
5,000 Costs for depreciation of furniture and server/network equipment over $5,000
divided by the 60 month contract
6008 Other (Specify)-
6009 Other (Specify)-
6010 Other (Specify)-
6011 Other (Specify)-
6012 Other (Specify)-
7000: FIXED ASSETS -
7001 Computer Equipment & Software -
7002 Copiers, Cell Phones, Tablets, Devices to
Contain HIPAA Data
-
7003 Furniture & Fixtures -
7004 Leasehold/Tenant/Building Improvements -
7005 Other Assets over $500 with Lifespan of 2
Years +
-
7006 Assets over $5,000/unit (Specify)-
7007 Other (Specify)-
7008 Other (Specify)-
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE:1,020,124
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE:1,020,124
-
Exhibit E
Page 1 of 3
FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable laws,
regulations, rules and guidelines that apply to the provision and payment of mental health services.
Mental health contractors and the manner in which they conduct themselves are a vital part of this
commitment.
Fresno County has established this Contractor Code of Conduct and Ethics with which
contractor and its employees and subcontractors shall comply. Contractor shall require its employees
and subcontractors to attend a compliance training that will be provided by Fresno County. After
completion of this training, each contractor, contractor’s employee and subcontractor must sign the
Contractor Acknowledgment and Agreement form and return this form to the Compliance officer or
designee.
Contractor and its employees and subcontractor shall:
1. Comply with all applicable laws, regulations, rules or guidelines when providing and billing
for mental health services.
2. Conduct themselves honestly, fairly, courteously and with a high degree of integrity in their
professional dealing related to their contract with the County and avoid any conduct that could
reasonably be expected to reflect adversely upon the integrity of the County.
3. Treat County employees, consumers, and other mental health contractors fairly and with
respect.
4. NOT engage in any activity in violation of the County’s Compliance Program, nor engage in
any other conduct which violates any applicable law, regulation, rule or guideline
5. Take precautions to ensure that claims are prepared and submitted accurately, timely and are
consistent with all applicable laws, regulations, rules or guidelines.
6. Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or reimbursement
of any kind are submitted.
7. Bill only for eligible services actually rendered and fully documented. Use billing codes that
accurately describe the services provided.
Exhibit E
Page 2 of 3
8. Act promptly to investigate and correct problems if errors in claims or billing are discovered.
9. Promptly report to the Compliance Officer any suspected violation(s) of this Code of Conduct
and Ethics by County employees or other mental health contractors, or report any activity that
they believe may violate the standards of the Compliance Program, or any other applicable
law, regulation, rule or guideline. Fresno County prohibits retaliation against any person
making a report. Any person engaging in any form of retaliation will be subject to disciplinary
or other appropriate action by the County. Contractor may report anonymously.
10. Consult with the Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law, regulation, rule or guideline.
11. Immediately notify the Compliance Officer if they become or may become an Ineligible person
and therefore excluded from participation in the Federal Health Care Programs.
Exhibit E
Page 3 of 3
Fresno County Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and
Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental
Health Compliance Program and understand the contents thereof. I further agree to abide by the
Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my
responsibilities as a mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement. I further understand that any
violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of
County policy and may also be a violation of applicable laws, regulations, rules or guidelines. I further
understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program
may result in termination of my agreement with Fresno County. I further understand that Fresno
County will report me to the appropriate Federal or State agency.
For Individual Providers
Name (print): _____________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Signature :________________________________ Date : ___/____/___
For Group or Organizational Providers
Group/Org. Name (print): _______________________________________
Employee Name (print): ________________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Other:___________________________________________
Job Title (if different from Discipline): ___________________________
Signature: _________________________________ Date: ____/___/____
Exhibit F
Page 1 of 3
Documentation Standards For Client Records
The documentation standards are described below under key topics related to client care. All
standards must be addressed in the client record; however, there is no requirement that the record
have a specific document or section addressing these topics. All medical records shall be
maintained for a minimum of 10 years from the date of the end of the Agreement.
A. Assessments
1. The following areas will be included as appropriate as a part of a comprehensive client record.
• Relevant physical health conditions reported by the client will be prominently identified
and updated as appropriate.
• Presenting problems and relevant conditions affecting the client’s physical health and
mental health status will be documented, for example: living situation, daily activities,
and social support.
• Documentation will describe client’s strengths in achieving client plan goals.
• Special status situations that present a risk to clients or others will be prominently
documented and updated as appropriate.
• Documentations will include medications that have been described by mental health plan
physicians, dosage of each medication, dates of initial prescriptions and refills, and
documentations of informed consent for medications.
• Client self report of allergies and adverse reactions to medications, or lack of known
allergies/sensitivities will be clearly documented.
• A mental health history will be documented, including: previous treatment dates,
providers, therapeutic interventions and responses, sources of clinical data, relevant
family information and relevant results of relevant lab tests and consultations reports.
• For children and adolescents, pre-natal and perinatal events and complete developmental
history will be documented.
• Documentations will include past and present use of tobacco, alcohol, and caffeine, as
well as illicit, prescribed and over-the-counter drugs.
• A relevant mental status examination will be documented.
• A DSM-5 diagnosis, or a diagnosis from the most current ICD, will be documented,
consistent with the presenting problems, history mental status evaluation and/or other
assessment data.
2. Timeliness/Frequency Standard for Assessment
• An assessment will be completed at intake and updated as needed to document changes in
the client’s condition.
• Client conditions will be assessed at least annually and, in most cases, at more frequent
intervals.
B. Client Plans
Exhibit F
Page 2 of 3
1. Client plans will:
• have specific observable and/or specific quantifiable goals
• identify the proposed type(s) of intervention
• have a proposed duration of intervention(s)
• be signed (or electronic equivalent) by:
the person providing the service(s), or
a person representing a team or program providing services, or
a person representing the MHP providing services
when the client plan is used to establish that the services are provided under the
direction of an approved category of staff, and if the below staff are not the approved
category,
a physician
a licensed/ “waivered” psychologist
a licensed/ “associate” social worker
a licensed/ registered/marriage and family therapist or
a registered nurse
• In addition,
client plans will be consistent with the diagnosis, and the focus of intervention will be
consistent with the client plan goals, and there will be documentation of the client’s
participation in and agreement with the plan. Examples of the documentation include,
but are not limited to, reference to the client’s participation and agreement in the body
of the plan, client signature on the plan, or a description of the client’s participation
and agreement in progress notes.
client signature on the plan will be used as the means by which the
CONTRACTOR(S) documents the participation of the client
when the client’s signature is required on the client plan and the client refuses or is
unavailable for signature, the client plan will include a written explanation of the
refusal or unavailability.
• The CONTRACTOR(S) will give a copy of the client plan to the client on request.
2. Timeliness/Frequency of Client Plan:
• Will be updated at least annually
• The CONTRACTOR(S) will establish standards for timeliness and frequency for the
individual elements of the client plan described in item 1.
C. Progress Notes
1. Items that must be contained in the client record related to the client’s progress in treatment
include:
• The client record will provide timely documentation of relevant aspects of client care
• Mental health staff/practitioners will use client records to document client encounters,
including relevant clinical decisions and interventions
Exhibit F
Page 3 of 3
• All entries in the client record will include the signature of the person providing the
service (or electronic equivalent); the person’s professional degree, licensure or job title;
and the relevant identification number, if applicable
• All entries will include the date services were provided
• The record will be legible
• The client record will document follow-up care, or as appropriate, a discharge summary
2. Timeliness/Frequency of Progress Notes:
Progress notes shall be documented at the frequency by type of service indicated below:
A. Every Service Contact
• Mental Health Services
• Medication Support Services
• Crisis Intervention
Exhibit G
Page 1 of 6
STATE MENTAL HEALTH REQUIREMENTS
1. CONTROL REQUIREMENTS
The COUNTY and its subcontractors shall provide services in accordance with all
applicable Federal and State statutes and regulations.
2. PROFESSIONAL LICENSURE
All (professional level) persons employed by the COUNTY Mental Health
Program (directly or through contract) providing Short-Doyle/Medi-Cal services
have met applicable professional licensure requirements pursuant to Business and
Professions and Welfare and Institutions Codes.
3. CONFIDENTIALITY
CONTRACTOR shall conform to and COUNTY shall monitor compliance with
all State of California and Federal statutes and regulations regarding
confidentiality, including but not limited to confidentiality of information
requirements at 42, Code of Federal Regulations sections 2.1 et seq; California
Welfare and Institutions Code, sections 14100.2, 11977, 11812, 5328; Division
10.5 and 10.6 of the California Health and Safety Code; Title 22, California Code
of Regulations, section 51009; and Division 1, Part 2.6, Chapters 1-7 of the
California Civil Code.
4. NON-DISCRIMINATION
A. Eligibility for Services
CONTRACTOR shall prepare and make available to COUNTY and to the
public all eligibility requirements to participate in the program plan set
forth in the Agreement. No person shall, because of ethnic group
identification, age, gender, color, disability, medical condition, national
origin, race, ancestry, marital status, religion, religious creed, political
belief or sexual preference be excluded from participation, be denied
benefits of, or be subject to discrimination under any program or activity
receiving Federal or State of California assistance.
B. Employment Opportunity
CONTRACTOR shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices. Such practices include retirement, recruitment
advertising, hiring, layoff, termination, upgrading, demotion, transfer,
Exhibit G
Page 2 of 6
rates of pay or other forms of compensation, use of facilities, and other
terms and conditions of employment.
C. Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all
further funds, until CONTRACTOR can show clear and convincing
evidence to the satisfaction of COUNTY that funds provided under this
Agreement were not used in connection with the alleged discrimination.
D. Nepotism
Except by consent of COUNTY’s Department of Behavioral Health
Director, or designee, no person shall be employed by CONTRACTOR
who is related by blood or marriage to, or who is a member of the Board
of Directors or an officer of CONTRACTOR.
5. PATIENTS' RIGHTS
CONTRACTOR shall comply with applicable laws and regulations, including but
not limited to, laws, regulations, and State policies relating to patients' rights.
STATE CONTRACTOR CERTIFICATION CLAUSES
1. STATEMENT OF COMPLIANCE: Contractor has, unless exempted, complied with
the non-discrimination program requirements. (Gov. Code§ 12990 (a-f) and CCR, Title 2,
Section 111 02) (Not applicable to public entities.)
2. DRUG-FREE WORKPLACE REQUIREMENTS: Contractor will comply with the
requirements of the Drug-Free Workplace Act of 1990 and will provide a drug-free
workplace by taking the following actions:
a. Publish a statement notifying employees that unlawful manufacture, distribution,
dispensation, possession or use of a controlled substance is prohibited and specifying
actions to be taken against employees for violations.
b. Establish a Drug-Free Awareness Program to inform employees about:
1) the dangers of drug abuse in the workplace;
2) the person's or organization's policy of maintaining a drug-free workplace;
3) any available counseling, rehabilitation and employee assistance programs; and,
4) penalties that may be imposed upon employees for drug abuse violations.
c. Every employee who works on the proposed Agreement will:
1) receive a copy of the company's drug-free workplace policy statement; and,
Exhibit G
Page 3 of 6
2) agree to abide by the terms of the company's statement as a condition of employment
on the Agreement.
Failure to comply with these requirements may result in suspension of payments under
the Agreement or termination of the Agreement or both and Contractor may be ineligible
for award of any future State agreements if the department determines that any of the
following has occurred: the Contractor has made false certification, or violated the
certification by failing to carry out the requirements as noted above. (Gov. Code §8350 et
seq.)
3. NATIONAL LABOR RELATIONS BOARD CERTIFICATION: Contractor certifies
that no more than one (1) final unappealable finding of contempt of court by a Federal
court has been issued against Contractor within the immediately preceding two-year
period because of Contractor's failure to comply with an order of a Federal court, which
orders Contractor to comply with an order of the National Labor Relations Board. (Pub.
Contract Code §10296) (Not applicable to public entities.)
4. CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO
REQUIREMENT: Contractor hereby certifies that Contractor will comply with the
requirements of Section 6072 of the Business and Professions Code, effective January 1,
2003.
Contractor agrees to make a good faith effort to provide a minimum number of hours of
pro bono legal services during each year of the contract equal to the lessor of 30
multiplied by the number of full time attorneys in the firm’s offices in the State, with the
number of hours prorated on an actual day basis for any contract period of less than a full
year or 10% of its contract with the State.
Failure to make a good faith effort may be cause for non-renewal of a state contract for
legal services, and may be taken into account when determining the award of future
contracts with the State for legal services.
5. EXPATRIATE CORPORATIONS: Contractor hereby declares that it is not an
expatriate corporation or subsidiary of an expatriate corporation within the meaning of
Public Contract Code Section 10286 and 10286.1, and is eligible to contract with the
State of California.
6. SWEATFREE CODE OF CONDUCT:
a. All Contractors contracting for the procurement or laundering of apparel, garments or
corresponding accessories, or the procurement of equipment, materials, or supplies, other
than procurement related to a public works contract, declare under penalty of perjury that
no apparel, garments or corresponding accessories, equipment, materials, or supplies
furnished to the state pursuant to the contract have been laundered or produced in whole
or in part by sweatshop labor, forced labor, convict labor, indentured labor under penal
sanction, abusive forms of child labor or exploitation of children in sweatshop labor, or
with the benefit of sweatshop labor, forced labor, convict labor, indentured labor under
Exhibit G
Page 4 of 6
penal sanction, abusive forms of child labor or exploitation of children in sweatshop
labor. The contractor further declares under penalty of perjury that they adhere to the
Sweatfree Code of Conduct as set forth on the California Department of Industrial
Relations website located at www.dir.ca.gov, and Public Contract Code Section 6108.
b. The contractor agrees to cooperate fully in providing reasonable access to the
contractor’s records, documents, agents or employees, or premises if reasonably required
by authorized officials of the contracting agency, the Department of Industrial Relations,
or the Department of Justice to determine the contractor’s compliance with the
requirements under paragraph (a).
7. DOMESTIC PARTNERS: For contracts of $100,000 or more, Contractor certifies that
Contractor is in compliance with Public Contract Code section 10295.3.
8. GENDER IDENTITY: For contracts of $100,000 or more, Contractor certifies that
Contractor is in compliance with Public Contract Code section 10295.35.
DOING BUSINESS WITH THE STATE OF CALIFORNIA
The following laws apply to persons or entities doing business with the State of
California.
1. CONFLICT OF INTEREST: Contractor needs to be aware of the following provisions
regarding current or former state employees. If Contractor has any questions on the
status of any person rendering services or involved with the Agreement, the awarding
agency must be contacted immediately for clarification.
Current State Employees (Pub. Contract Code §10410):
1). No officer or employee shall engage in any employment, activity or enterprise from
which the officer or employee receives compensation or has a financial interest and
which is sponsored or funded by any state agency, unless the employment, activity or
enterprise is required as a condition of regular state employment.
2). No officer or employee shall contract on his or her own behalf as an independent
contractor with any state agency to provide goods or services.
Former State Employees (Pub. Contract Code §10411):
1). For the two-year period from the date he or she left state employment, no former state
officer or employee may enter into a contract in which he or she engaged in any of the
negotiations, transactions, planning, arrangements or any part of the decision-making
process relevant to the contract while employed in any capacity by any state agency.
2). For the twelve-month period from the date he or she left state employment, no former
state officer or employee may enter into a contract with any state agency if he or she was
Exhibit G
Page 5 of 6
employed by that state agency in a policy-making position in the same general subject
area as the proposed contract within the 12-month period prior to his or her leaving state
service.
If Contractor violates any provisions of above paragraphs, such action by Contractor shall
render this Agreement void. (Pub. Contract Code §10420)
Members of boards and commissions are exempt from this section if they do not receive
payment other than payment of each meeting of the board or commission, payment for
preparatory time and payment for per diem. (Pub. Contract Code §10430 (e))
2. LABOR CODE/WORKERS' COMPENSATION: Contractor needs to be aware of the
provisions which require every employer to be insured against liability for Worker's
Compensation or to undertake self-insurance in accordance with the provisions, and
Contractor affirms to comply with such provisions before commencing the performance
of the work of this Agreement. (Labor Code Section 3700)
3. AMERICANS WITH DISABILITIES ACT: Contractor assures the State that it
complies with the Americans with Disabilities Act (ADA) of 1990, which prohibits
discrimination on the basis of disability, as well as all applicable regulations and
guidelines issued pursuant to the ADA. (42 U.S.C. 12101 et seq.)
4. CONTRACTOR NAME CHANGE: An amendment is required to change the
Contractor's name as listed on this Agreement. Upon receipt of legal documentation of
the name change the State will process the amendment. Payment of invoices presented
with a new name cannot be paid prior to approval of said amendment.
5. CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA:
a. When agreements are to be performed in the state by corporations, the contracting
agencies will be verifying that the contractor is currently qualified to do business in
California in order to ensure that all obligations due to the state are fulfilled.
b. "Doing business" is defined in R&TC Section 23101 as actively engaging in any
transaction for the purpose of financial or pecuniary gain or profit. Although there are
some statutory exceptions to taxation, rarely will a corporate contractor performing
within the state not be subject to the franchise tax.
c. Both domestic and foreign corporations (those incorporated outside of California) must
be in good standing in order to be qualified to do business in California. Agencies will
determine whether a corporation is in good standing by calling the Office of the Secretary
of State.
6. RESOLUTION: A county, city, district, or other local public body must provide the
State with a copy of a resolution, order, motion, or ordinance of the local governing body
Exhibit G
Page 6 of 6
which by law has authority to enter into an agreement, authorizing execution of the
agreement.
7. AIR OR WATER POLLUTION VIOLATION: Under the State laws, the Contractor
shall not be: (1) in violation of any order or resolution not subject to review promulgated
by the State Air Resources Board or an air pollution control district; (2) subject to cease
and desist order not subject to review issued pursuant to Section 13301 of the Water
Code for violation of waste discharge requirements or discharge prohibitions; or (3)
finally determined to be in violation of provisions of federal law relating to air or water
pollution.
8. PAYEE DATA RECORD FORM STD. 204: This form must be completed by all
contractors that are not another state agency or other governmental entity.
9. INSPECTION and Audit of Records and access to Facilities.
The State, CMS, the Office of the Inspector General, the Comptroller General, and their
designees may, at any time, inspect and audit any records or documents of
CONTRACTOR or its subcontractors, and may, at any time, inspect the premises,
physical facilities, and equipment where Medicaid-related activities or work is conducted.
The right to audit under this section exists for 10 years from the final date of the contract
period or from the date of completion of any audit, whichever is later.
Federal database checks. Consistent with the requirements at § 455.436 of this chapter,
the State must confirm the identity and determine the exclusion status of
CONTRACTOR, any subcontractor, as well as any person with an ownership or control
interest, or who is an agent or managing employee of CONTRACTOR through routine
checks of Federal databases. This includes the Social Security Administration's Death
Master File, the National Plan and Provider Enumeration System (NPPES), the List of
Excluded Individuals/Entities (LEIE), the System for Award Management (SAM), and
any other databases as the State or Secretary may prescribe. These databases must be
consulted upon contracting and no less frequently than monthly thereafter. If the State
finds a party that is excluded, it must promptly notify the CONTRACTOR and take
action consistent with § 438.610(c).
The State must ensure that CONTRACTOR with which the State contracts under this part
is not located outside of the United States and that no claims paid by a CONTRACTOR
to a network provider, out-of-network provider, subcontractor or financial institution
located outside of the U.S. are considered in the development of actuarially sound
capitation rates.
Exhibit I
Page 1 of 2
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• The Incident Report must be completed for all incidents involving clients. The staff person
who becomes aware of the incident completes this form, and the supervisor co-signs it.
• When more than one client is involved in an incident, a separate form must be completed
for each client.
Where the forms should be sent - within 24 hours from the time of the incident
• Incident Report should be sent to:
DBH Program Supervisor
Exhibit I
Page 2 of 2
INCIDENT REPORT WORKSHEET
When did this happen? (date/time) Where did this happen?
Name/DMH #
1. Background information of the incident:
2. Method of investigation: (chart review, face-to-face interview, etc.)
Who was affected? (If other than consumer)
List key people involved. (witnesses, visitors, physicians, employees)
3. Preliminary findings: How did it happen? Sequence of events. Be specific. If attachments are needed write
comments on an 8 1/2 sheet of paper and attach to worksheet.
Outcome severity: Nonexistent inconsequential consequential death not applicable unknown
4. Response: a) corrective action, b) Plan of Action, c) other
Completed by (print name)
Completed by (signature) Date completed
Reviewed by Supervisor (print name)
Supervisor Signature Date
Exhibit I
Page 1 of 2
Fresno County Mental Health Plan
Grievances
Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance
and appeal process and an expedited appeal process to resolve grievances and
disputes at the earliest and the lowest possible level.
Title 9 of the California Code of Regulations requires that the MHP and its fee-
for-service providers give verbal and written information to Medi-Cal beneficiaries
regarding the following:
• How to access specialty mental health services
• How to file a grievance about services
• How to file for a State Fair Hearing
The MHP has developed a Consumer Guide, a beneficiary rights poster, a
grievance form, an appeal form, and Request for Change of Provider Form. All
of these beneficiary materials must be posted in prominent locations where Medi-
Cal beneficiaries receive outpatient specialty mental health services, including
the waiting rooms of providers’ offices of service.
Please note that all fee-for-service providers and contract agencies are required
to give their clients copies of all current beneficiary information annually at the
time their treatment plans are updated and at intake.
Beneficiaries have the right to use the grievance and/or appeal process without
any penalty, change in mental health services, or any form of retaliation. All
Medi-Cal beneficiaries can file an appeal or state hearing.
Grievances and appeals forms and self addressed envelopes must be available
for beneficiaries to pick up at all provider sites without having to make a verbal or
written request. Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 45003
Fresno, CA 93718-9886
(800) 654-3937 (for more information)
(559) 488-3055 (TTY)
Provider Problem Resolution and Appeals Process
The MHP uses a simple, informal procedure in identifying and resolving provider
concerns and problems regarding payment authorization issues, other
complaints and concerns.
Exhibit I
Page 2 of 2
Informal provider problem resolution process – the provider may first speak to a
Provider Relations Specialist (PRS) regarding his or her complaint or concern.
The PRS will attempt to settle the complaint or concern with the provider. If the
attempt is unsuccessful and the provider chooses to forego the informal
grievance process, the provider will be advised to file a written complaint to the
MHP address (listed above).
Formal provider appeal process – the provider has the right to access the
provider appeal process at any time before, during, or after the provider problem
resolution process has begun, when the complaint concerns a denied or modified
request for MHP payment authorization, or the process or payment of a
provider’s claim to the MHP.
Payment authorization issues – the provider may appeal a denied or modified
request for payment authorization or a dispute with the MHP regarding the
processing or payment of a provider’s claim to the MHP. The written appeal
must be submitted to the MHP within 90 calendar days of the date of the receipt
of the non-approval of payment.
The MHP shall have 60 calendar days from its receipt of the appeal to inform the
provider in writing of the decision, including a statement of the reasons for the
decision that addresses each issue raised by the provider, and any action
required by the provider to implement the decision.
If the appeal concerns a denial or modification of payment authorization request,
the MHP utilizes a Managed Care staff who was not involved in the initial denial
or modification decision to determine the appeal decision.
If the Managed Care staff reverses the appealed decision, the provider will be
asked to submit a revised request for payment within 30 calendar days of receipt
of the decision
Other complaints – if there are other issues or complaints, which are not related
to payment authorization issues, providers are encouraged to send a letter of
complaint to the MHP. The provider will receive a written response from the
MHP within 60 calendar days of receipt of the complaint. The decision rendered
buy the MHP is final.
Exhibit J
Page 1 of 2
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identifying Information
Name of entity D/B/A
Address (number, street) City State ZIP code
CLIA number Taxpayer ID number (EIN) Telephone number
( )
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
YES NO
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) ........... ❒ ❒
III. 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: ❒ Sole proprietorship ❒ Partnership ❒ Corporation
❒ Unincorporated Associations ❒ 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. ..........................................................................................................
❒ ❒
NAME ADDRESS PROVIDER NUMBER
Exhibit J
Page 2 of 2
YES NO
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?....................................................... ❒ ❒
If yes, 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 yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
B. If the answer to question VII.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
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
Signature Date Remarks
Exhibit K
Page 1 of 2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below.
2. The inability of a person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction. The prospective
participant shall submit an explanation of why it cannot provide the certification set out
below. The certification or explanation will be considered in connection with the
department or agency's determination whether to enter into this transaction. However,
failure of the prospective primary participant to furnish a certification or an explanation
shall disqualify such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which
reliance was placed when the department or agency determined to enter into this
transaction. If it is later determined that the prospective primary participant knowingly
rendered an erroneous certification, in addition to other remedies available to the
Federal Government, the department or agency may terminate this transaction for
cause or default.
4. The prospective primary participant shall provide immediate written notice to
the department or agency to which this proposal is submitted if at any time the
prospective primary participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, participant,
person, primary covered transaction, principal, proposal, and voluntarily excluded, as
used in this clause, have the meanings set out in the Definitions and Coverage
sections of the rules implementing Executive Order 12549. You may contact the
department or agency to which this proposal is being submitted for assistance in
obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment
of a system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
Exhibit K
Page 2 of 2
CERTIFICATION
(1) The prospective primary participant certifies to the best of its knowledge and belief,
that it, its owners, officers, corporate managers and partners:
(a) Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of
or had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(Federal, State or local) transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, or receiving
stolen property;
(c) (d) Have not within a three-year period preceding this application/proposal
had one or more public transactions (Federal, State or local) terminated for cause or
default.
(2) Where the prospective primary participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an explanation
to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or
Company)
Exhibit L
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 corporation 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 date 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 L
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: