HomeMy WebLinkAbout32598SPECIALIZED ASSESSMENT SERVICES AGREEMENT 1 2 This Agreement is made and entered into this ___ day of ______ 2016, by and 3 between the COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter 4 referred to as "COUNTY", and FOSTER ASSESSMENT CENTER & TESTING SERVICE, INC, 5 an S Corporation, whose address is 516 Pennsfield Place, Suite 108, Thousand Oaks, CA 91360, 6 hereinafter referred to as "CONTRACTOR". 7 W I T NE S S E T H: 8 WHEREAS, pursuant to the California Work Opportunity and Responsibility to Kids Act 9 (Welfare and Institutions Code sections 11200 et seq. hereinafter called "CalWORKs") and 10 Temporary Assistance for Needy Families Block Grant ( 42 United State Code sections 601 et seq. 11 hereinafter called "TANF"), COUNTY is mandated and funded to deliver a time-limited structural 12 sequence of employment related activities and supportive services that are designed to maximize 13 unsubsidized employment opportunities to able-bodied, non-exempt CalWORKs public assistance 14 applicants and recipients; and 15 WHEREAS, COUNTY's Department of Social Services (DSS), has developed and submitted to 16 the State of California, a CalWORKs COUNTY Plan meeting the requirements of the CalWORKs Act 1 7 to deliver employment and training services to public assistance recipients; and 18 WHEREAS, COUNTY, is authorized to enter into an Agreement with CONTRACTOR for 19 such services pursuant to CalWORKs and the rules and regulations of the California Department of 2 0 Social Services; and 21 WHEREAS, CONTRACTOR, has submitted a Statement of Capability and Experience which 2 2 demonstrate qualifications to provide such services. 23 NOW, THEREFORE, in consideration of their mutual covenants and conditions, the 2 4 parties hereto agree as follows: 1. SERVICES 25 26 A. CONTRACTOR shall perform all services and fulfill all responsibilities as 2 7 identified in COUNTY' s Request for Proposal (RFP) No. 952-5425, dated January 13, 2016, and 28 Addendum No. One (1) to COUNTY's RFP No. 952-5425, dated February 10, 2016, collectively -1 -COUNTY OF FRESNO Fresno, CA
1 hereinafter referred to as COUNTY's Revised RFP No. 952-5425 and CONTRACTOR's response to 2 said Revised RFP, dated February 25, 2016. 3 B. CONTRACTOR shall be held responsible for all services and performance 4 outcome standards as set forth in Exhibit A, Summary of Services, attached hereto and by this 5 reference incorporated herein. 6 c. In the event of any inconsistency among the documents described in Paragraphs 7 I .A and 1.B hereinabove, the inconsistency shall be resolved by giving precedence in the following 8 order of priority; 1) to this Agreement, including all Exhibits attached hereto, 2) to COUNTY's 9 Revised RFP No. 952-5425, 3) to the response to Revised RFP. A copy of COUNTY's Revised RFP 10 No. 952-5425, and CONTRACTOR's response, shall be retained and made available during the term 11 of this Agreement by COUNTY's Department of Social Services. 12 D. Additionally, CONTRACTOR shall provide all services in accordance with the State 13 of California's Social Services Manual of Policies and Procedures, Eligibility and Assistance 14 Standards. The current manual can be viewed at: 15 http://www.dss.cahwnet.gov/ord/entres/getinfo/pdf/cws l .PDF 16 E. COUNTY shall be held responsible for services as set forth in the Summary of 1 7 Services, identified in Exhibit A. 18 2. TERM 19 The term of this Agreement shall be for a period of one (I) year, commencing on July l s1, 2016 2 0 through and including June 30, 2017. This agreement may be extended for two (2) additional 21 consecutive twelve ( 12) month periods upon the approval of both parties no later than thirty (30) days 2 2 prior to the first day of the next twelve month extension period. The Director of the Department of 2 3 Social Services or designee is authorized to execute such written approval on behalf of County based 24 on CONTRACTOR's satisfactory performance. The entire Agreement, including optional extension, 2 5 shall not exceed three (3) years. 26 3. TERMINATION 27 A. Non-Allocation of Funds -The terms of this Agreement, and the services to be 28 provided thereunder, are contingent on the approval of funds by the appropriating government agency. -2 -COUNTY OF FRESNO Fresno, CA
1 Should sufficient funds not be allocated, the services provided may be modified, or this Agreement 2 terminated at any time by giving CONTRACTOR thirty (30) days advance written notice. 3 B. Breach of Contract -COUNTY may immediately suspend or terminate this 4 Agreement in whole or in part, where in the determination of COUNTY there is: 5 1) An illegal or improper use of funds; 6 2) A failure to comply with any term of this Agreement; 7 3) A substantially incorrect or incomplete report submitted to COUNTY; 8 4) Improperly performed service. 9 In no event shall any payment by COUNTY constitute a waiver by COUNTY of 10 any breach of this Agreement or any default which may then exist on the part of CONTRACTOR. 11 Neither shall such payment impair or prejudice any remedy available to COUNTY with respect to the 12 breach or default. COUNTY shall have the right to demand of CONTRACTOR the repayment to 13 COUNTY of any funds disbursed to CONTRACTOR under this Agreement, which in the judgment of 14 COUNTY were not expended in accordance with the terms of this Agreement. CONTRACTOR shall 15 promptly refund any such funds upon demand or, at COUNTY's option, such repayment shall be 16 deducted from future payments owing to CONTRACTOR under this Agreement. 1 7 C. Without Cause -Under circumstances other than those set forth above, this 18 Agreement may be terminated by CONTRACTOR or COUNTY or COUNTY's DSS Director, or 19 designee, upon the giving of thirty (30) days advance written notice of an intention to terminate the 2 0 Agreement. 21 4. COMPENSATION 22 For actual services provided as identified in the terms and conditions of this Agreement, 2 3 COUNTY agrees to pay CONTRACTOR, and CONTRACTOR agrees to receive compensation in 2 4 accordance with Exhibit B, "Budget Summary", attached hereto and by this reference incorporated 2 5 herein. Mandated travel shall be reimbursed based on actual expenditures and mileage reimbursement 2 6 shall be at CONTRACTOR's adopted rate per mile, not to exceed the IRS published rate. 27 CONTRACTOR agrees to limit administrative cost to a maximum of 15% of the total program budget 28 and to limit employee benefits to a maximum of20% of total salaries for those employees working -3 -COUNTY OF FRESNO Fresno, CA
1 under this Agreement during the term of this Agreement. Payment shall be made upon certification or 2 other proof satisfactory to COUNTY's DSS that services have actually been performed by 3 CONTRACTOR as specified in this Agreement. 4 For each twelve (12) month period of this Agreement, in no event shall services 5 performed under this Agreement be in excess of Three Hundred Eighty Five Thousand and Noll 00 6 Dollars ($385,000.00). The cumulative total of this Agreement shall not be in excess of One Million 7 One Hundred Fifty Five Thousand and No/100 Dollars ($1, 155,000.00). It is understood that all 8 expenses incidental to CONTRACTOR's performance of services under this Agreement shall be 9 borne by CONTRACTOR. 10 Except as provided below regarding State payment delays, payments by COUNTY shall 11 be in arrears, for services provided during the preceding month, within forty-five ( 45) days after 12 receipt, verification and approval of CONTRACTOR's invoices by COUNTY's DSS. If 13 CONTRACTOR should fail to comply with any provision of this Agreement, COUNTY shall be 14 relieved of its obligation for further compensation. All final claims shall be submitted by 15 CONTRACTOR within (60) days following the final month of service per contract year. No action 16 shall be taken by COUNTY on claims submitted beyond the sixty (60) day closeout period. Any 1 7 compensation which is not expended by CONTRACTOR pursuant to the terms and conditions of this 18 Agreement shall automatically revert to COUNTY. 19 The services provided by CONTRACTOR under this Agreement are funded in whole or 2 0 in part by the State of California. In the event that funding for these services is delayed by the State 21 Controller, COUNTY may defer payment to CONTRACTOR. The amount of the deferred payment 22 shall not exceed the amount of funding delayed by the State Controller to COUNTY. The period of 23 time of the deferral by COUNTY shall not exceed the period of time of the State Controller's delay of 2 4 payment to COUNTY plus forty-five ( 45) days. 2 5 COUNTY agrees to the extent permitted by State and Federal rules and regulations, 2 6 advanced payment of up to twenty percent (20%) of the compensation under this AGREEMENT if 2 7 requested by Contractor and approved by the DSS Director or designee. The amount of the advanced 2 8 payment shall be deducted in equal installments from claims submitted in the final three (3) months of - 4 -COUNTY OF FRESNO Fresno, CA
1 the term in which the advance was given. 2 5. INVOICING 3 CONTRACTOR shall invoice COUNTY in arrears by the tenth (101h) of each month for 4 actual expenses incurred and services rendered in the previous month to: 5 DSSinvoices@co.fresno.ca.us. A Monthly Activity Report (MAR) shall accompany the invoice, 6 reflecting services supported by the invoiced expenditures and be in a form and in such detail as 7 acceptable to COUNTY's DSS. Invoices shall include all corresponding documentation submitted 8 and identified by line item. Supporting documentation shall include but is not limited to receipts, 9 invoices received and documented administrative/overhead costs. No reimbursement for services 10 shall be made until invoices, MARs and outcomes are received, reviewed and approved by 11 COUNTY's DSS. 12 At the discretion of COUNTY's DSS Director or designee, if an invoice is incorrect or is 13 otherwise not in proper form or substance, COUNTY's DSS Director or designee shall have the right 14 to withhold payment as to only that portion of the invoice that is incorrect or improper after five (5) 15 days prior notice to CONTRACTOR. CONTRACTOR agrees to continue to provide services for a 16 period of ninety (90) days after notification of an incorrect or improper invoice. If after the ninety (90) 1 7 day period, the invoice(s) is still not corrected to COUNTY's DSS satisfaction, COUNTY's DSS 18 Director or designee may elect to terminate this Agreement, pursuant to the termination provisions 19 stated in Paragraph Three (3) of this Agreement. Invoices shall be submitted not later than (60) days 2 0 after the expiration of each term of this Agreement or termination of this Agreement. At the discretion 21 of COUNTY' s DSS Director or designee, COUNTY' s DSS shall have the right to deny payment of 22 any additional invoices received after sixty (60) days. 23 6. INDEPENDENT CONTRACTOR 24 In performance of the work, duties, and obligations assumed by CONTRACTOR under 2 5 this Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of 2 6 CONTRACTOR's officers, agents, and employees will at all times be acting and performing as an 2 7 independent contractor, and shall act in an independent capacity and not as an officer, agent, servant, 2 8 employee, joint venturer, partner, or associate of COUNTY. Furthermore, COUNTY shall have no -5 -COUNTY OF FRESNO Fresno, CA
1 right to control or supervise or direct the manner or method by which CONTRACTOR shall perform 2 its work and function. However, COUNTY shall retain the right to administer this Agreement so as to 3 verify that CONTRACTOR is performing its obligations in accordance with the terms and conditions 4 thereof. CONTRACTOR and COUNTY shall comply with all applicable provisions of law and the 5 rules and regulations, if any, of governmental authorities having jurisdiction over matters which are 6 directly or, indirectly the subject of this Agreement. 7 Because of its status as an independent contractor, CONTRACTOR shall have 8 absolutely no right to employment rights and benefits available to COUNTY employees. 9 CONTRACTOR shall be solely liable and responsible for providing to, or on behalf of, its employees 10 all legally-required employee benefits. In addition, CONTRACTOR shall be solely responsible and 11 save COUNTY harmless from all matters relating to payment ofCONTRACTOR's employees, 12 including compliance with Social Security, withholding, and all other regulations governing such 13 matters. It is acknowledged that during the term of this Agreement, CONTRACTOR may be 14 providing services to others unrelated to COUNTY or to this Agreement. 15 16 7. MODIFICATION A. Any matters of this Agreement may be modified from time to time by the written 1 7 consent of CONTRACTOR and COUNTY without, in any way, affecting the remainder. 18 B. Notwithstanding the above, changes to line items in the budget, attached hereto 19 as Exhibit B, in an amount not to exceed 10% of the total maximum compensation as identified in 20 Section Four (4) of this Agreement, may be made with the written approval ofCOUNTY's DSS 21 Director or designee and CONTRACTOR. Budget line item changes shall not result in any change to 2 2 the maximum compensation amount payable to CONTRACTOR, as stated herein. 23 c. CONTRACTOR hereby agrees that changes to the compensation under this 2 4 Agreement may be necessitated by a reduction in funding from State and/or Federal sources. 2 5 COUNTY's DSS Director or designee may modify the maximum compensation depending on State 2 6 and Federal funding availability, as stated in Section Four (4) in this Agreement. CONTRACTOR 2 7 further understands that this Agreement is subject to any restrictions, limitations or enactments of all 2 8 legislative bodies which affect the provisions, term or funding of this Agreement in any manner. - 6 -COUNTY OF FRESNO Fresno, CA
1 8. NON-ASSIGNMENT 2 Neither party shall assign, transfer or subcontract this Agreement nor their rights or 3 duties under this Agreement without the prior written consent of the other party. 4 9. HOLD-HARMLESS 5 CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request, 6 defend COUNTY, its officers, agents and employees from any and all costs and expenses, including 7 attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to 8 COUNTY in connection with the performance, or failure to perform, by CONTRACTOR, its officers, 9 agents or employees under this Agreement, and from any and all costs and expenses, including 10 attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to any 11 person, firm or corporation who may be injured or damaged by the performance, or failure to perform, 12 of CONTRACTOR, its officers, agents or employees under this Agreement. In addition, 13 CONTRACTOR agrees to indemnify COUNTY for Federal, State of California and/or local audit 14 exceptions resulting from noncompliance herein on the part of the CONTRACTOR. 15 10. INSURANCE 16 Without limiting COUNTY's right to obtain indemnification from CONTRACTOR or 1 7 any third parties, CONTRACTOR, at its sole expense, shall maintain in full force and effect the 18 following insurance policies throughout the term of this Agreement: 19 20 21 22 23 24 25 26 27 28 A. B. Commercial General Liability Commercial General Liability Insurance with limits of not less than One Million Dollars ($1,000,000) per occurrence and an annual aggregate of Two Million Dollars ($2,000,000). This policy shall be issued on a per occurrence basis. COUNTY may require specific coverage including completed operations, product liability, contractual liability, Explosion, Collapse, and Underground (XCU), fire legal liability or any other liability insurance deemed necessary because of the nature of the Agreement. Automobile Liability Comprehensive Automobile Liability Insurance with limits for bodily injury of not less than Two Hundred Fifty Thousand Dollars ($250,000) per person, Five Hundred Thousand Dollars ($500,000) per accident and for property damages of not less than Fifty Thousand Dollars ($50,000), or such coverage with a - 7 -COUNTY OF FRESNO Fresno, CA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 combined single limit of Five Hundred Thousand Dollars ($500,000). Coverage should include owned and non-owned vehicles used in connection with this Agreement. C. Professional Liability If CONTRACTOR employs licensed professional staff (e.g. Ph.D., R.N., L.C.S.W., M.F.C.T.) in providing services, Professional Liability Insurance with limits of not less than One Million Dollars ($1,000,000) per occurrence, Three Million Dollars ($3,000,000) annual aggregate. D. Worker's Compensation A policy of Worker's Compensation Insurance as may be required by the California Labor Code. CONTRACTOR shall obtain endorsements to the Commercial General Liability insurance naming the County of Fresno, its officers, agents, and employees, individually and collectively, as additional insured, 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. Within thirty (30) days from the date CONTRACTOR signs this Agreement, CONTRACTOR shall provide certificates of insurance and endorsements as stated above for all of the foregoing policies, as required herein, to the County of Fresno, DSS, PO BOX 1912, Fresno, California, 93718-1912, Attention: Contracts, stating that such insurance coverages have been obtained and are in full force; that the County of Fresno, its officers, agents and employees will not be responsible for any premiums on the policies; that such Commercial General 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 -8 -COUNTY OF FRESNO Fresno, Ci\
1 contributing with insurance provided under CONTRACTOR's policies herein; and that this insurance 2 shall not be cancelled or changed without a minimum of thirty (30) days advance, written notice given 3 to COUNTY. 4 In the event CONTRACTOR fails to keep in effect at all times insurance coverage as 5 herein provided, COUNTY may, in addition to other remedies it may have, suspend or terminate this 6 Agreement upon the occurrence of such event. 7 All policies shall be with admitted insurers licensed to do business in the State of 8 California. Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating 9 of A FSC VII or better. 10 11. CONFIDENTIALITY AND MEDI-CAL PRIVACY 11 All services performed by CONTRACTOR under this Agreement shall be in strict 12 conformance with all applicable Federal, State of California, and/or local laws and regulations relating 13 to confidentiality including, but not limited to: California Welfare and Institutions Code Sections 14 l 0850 and 14100.2; the COSS Manual of Policies and Procedures, Division 19-0000; and the 15 California Department of Health Care Services (DHCS) Medi-Cal Eligibility Procedures Manual, 16 Section 2H. In addition, all services performed by CONTRACTOR under this Agreement shall also 1 7 be in conformance with the Medi-Cal Data Privacy and Security Agreement between the California 18 DHCS and the County of Fresno (hereinafter referred to as "the Medi-Cal Data Agreement") that is 19 then in effect, which is by this reference incorporated herein. The current Medi-Cal Data Agreement 20 is available upon request or can be viewed at: http://www.co.fresno.ca.us/MediCalPrivacy/. The 21 purpose of this section is to assure that all applications and records concerning program recipients 2 2 shall be kept confidential and shall not be opened to examination, publicized, disclosed, or used for 23 any purpose not directly connected with the administration of the program. CONTRACTOR shall 2 4 inform all of its employees, agents, officers, and subcontractors of this provision; and that any person 2 5 knowingly and intentionally violating this provision is guilty of a misdemeanor. 26 12. DATA SECURITY 2 7 For the purpose of preventing the potential loss, misappropriation or inadvertent 28 disclosure of COUNTY data including sensitive or personal client information; abuse of COUNTY - 9 -COUNTY OF FRESNO Fresno, Ci\
1 resources; and/or disruption to COUNTY operations, individuals and/or agencies that enter into a 2 contractual relationship with COUNTY for the purpose of providing services under this Agreement 3 must employ adequate data security measures to protect the confidential information provided to 4 CONTRACTOR by COUNTY, including but not limited to the following: 5 A. Contractor-Owned Mobile/Wireless/Handheld Devices may not be connected to 6 COUNTY networks via personally owned mobile, wireless or handheld devices, except when 7 authorized by COUNTY for telecommuting and then only if virus protection software currency 8 agreements are in place, and if a secure connection is used. 9 B. Contractor-Owned Computers or Computer Peripherals may not brought into 10 COUNTY for use, including and not limited to mobile storage devices, without prior authorization 11 from COUNTY' s Chief Information Officer or her designee. Data must be stored on a secure server 12 approved by COUNTY and transferred by means of a VPN (Virtual Private Network) connection, or 13 another type of secure connection of this type if any data is approved to be transferred. 14 c. County-Owned Computer Equipment -CONTRACTOR or anyone having an 15 employment relationship with COUNTY may not use COUNTY computers or computer peripherals 16 on non-COUNTY premises without prior authorization from COUNTY' s Chief Information Officer or 1 7 her designee. 18 D. CONTRACTOR may not store COUNTY's private, confidential or sensitive 19 data on any hard-disk drive. 20 E. CONTRACTOR is responsible to employ strict controls to insure the integrity 21 and security of COUNTY's confidential information and to prevent unauthorized access to data 2 2 maintained in computer files, program documentation, data processing systems, data files and data 2 3 processing equipment which stores or processes COUNTY data internally and externally. 24 F. Confidential client information transmitted to one party by the other by means of 2 5 electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of 2 6 128 BIT or higher. Additionally, a password or pass phrase must be utilized. 27 G. CONTRACTOR is responsible to immediately notify COUNTY of any breaches 2 8 or potential breaches of security related to COUNTY' s confidential information, data maintained in -10 -COUNTY OF FRESNO Fresno, Ci\
1 computer files, program documentation, data processing systems, data files and data processing 2 equipment which stores or processes COUNTY data internally or externally. 3 H. In the event of a breach of security related to COUNTY' s confidential client 4 information provided to CONTRACTOR, COUNTY will manage the response to the incident, 5 however, CONTRACTOR will be responsible to issue any notification to affected individuals as 6 required by law or as deemed necessary by COUNTY in its sole discretion. CONTRACTOR will be 7 responsible for all costs incurred as a result of providing the required notification. When no longer 8 needed, all Medi-Cal Personally Identifiable Information, as defined in the Medi-Cal Data Privacy and 9 Security Agreement between the California DHCS and the County of Fresno (hereinafter referred to as 10 "the Medi-Cal Data Agreement"), whether stored in print or electronic format, must be destroyed or 11 disposed of through confidential means, as described in the Medi-Cal Data Agreement. The current 12 Medi-Cal Data Agreement is available upon request or can be viewed at: 13 http://www.co.fresno.ca.us/MediCalPrivacy/. 14 I. The requirements in this Data Security provision shall apply to 15 CONTRACTOR's subcontractors, if any. 16 13. NON-DISCRIMINATION 1 7 During the performance of this Agreement CONTRACTOR shall not unlawfully 18 discriminate against any employee or applicant for employment, or recipient of services, because of 19 ethnic group identification, gender, gender identity, gender expression, sexual orientation, color, 2 0 physical disability, mental disability, medical condition, national origin, race, ancestry, marital status, 21 religion, or religious creed, pursuant to all applicable State of California and Federal statutes and 2 2 regulations. 23 14. CONFLICT OF INTEREST 2 4 No officer, agent, or employee of COUNTY who exercises any function or 2 5 responsibility for planning and carrying out the services provided under this Agreement shall have any 2 6 direct or indirect personal financial interest in this Agreement. In addition, no employee of COUNTY 2 7 shall be employed by CONTRACTOR to fulfill any contractual obligations with COUNTY. 2 8 CONTRACTOR shall also comply with all Federal, State of California, and local conflict of interest -11 -COUNTY OF FRESNO Fresno, CA
1 laws, statutes, and regulations, which shall be applicable to all parties and beneficiaries under this 2 Agreement and any officer, agent, or employee of COUNTY. 3 15. CHARITABLE CHOICE 4 CONTRACTOR may not discriminate in its program delivery against a client or 5 potential client on the basis of religion or religious belief, a refusal to hold a religious belief, or a 6 refusal to actively participate in a religious practice. Any specifically religious activity or service made 7 available to individuals by CONTRACTOR must be voluntary as well as separate in time and location 8 from County funded activities and services. CONTRACTOR shall inform COUNTY as to whether it 9 is faith-based. If CONTRACTOR identifies as faith-based it must submit to DSS a copy of its policy 10 on referring individuals to an alternate treatment provider, and include a copy of this policy in its 11 client admission forms. The policy must inform individuals that they may be referred to an alternative 12 provider if they object to the religious nature of the program, and include a notice to DSS. Adherence 13 to this policy will be monitored during annual site reviews, and a review of client files. If 14 CONTRACTOR identifies as faith-based, by July 1 of each year CONTRACTOR will be required to 15 report to DSS the number of individuals who requested referrals to alternate providers based on 16 religious objection. 17 16. PROHIBITION ON PUBLICITY 18 None of the funds, materials, property or services provided directly or indirectly under 19 this Agreement shall be used for CONTRACTOR's advertising, fundraising, or publicity (i.e., 2 0 purchasing of tickets/tables, silent auction donations, etc.) for the purpose of self-promotion. 21 Notwithstanding the above, publicity of the services described in Paragraph One (I) of this Agreement 2 2 shall be allowed as necessary to raise public awareness about the availability of such specific services 2 3 when approved in advance by the Director or designee and at a cost as provided in Exhibit B for such 2 4 items as written/printed materials, the use of media (i.e., radio, television, newspapers) and any other 25 related expense(s). 26 17. DISCLOSURE OF SELF-DEALING TRANSACTIONS 2 7 This provision is only applicable if CONTRACTOR is operating as a corporation (a for-2 8 profit or non-profit corporation) or if during the term of this Agreement, CONTRACTOR changes its -12 -COUNTY OF FRESNO Fresno, CJ\
1 status to operate as a corporation. 2 Members of CONTRACTOR's Board of Directors shall disclose any self-dealing 3 transactions that they are a party to while CONTRACTOR is providing goods or performing services 4 under this Agreement. A self-dealing transaction shall mean a transaction to which CONTRACTOR 5 is a party and in which one or more of its directors has a material financial interest. Members of the 6 Board of Directors shall disclose any self-dealing transactions that they are a party to by completing 7 and signing a Self-Dealing Transaction Disclosure Form, attached hereto as Exhibit C and by this 8 reference incorporated herein, and submitting it to COUNTY prior to commencing with the self-9 dealing transaction or immediately thereafter. 10 18. AUDITS AND INSPECTIONS 11 CONTRACTOR shall at any time during business hours, and as often as COUNTY may 12 deem necessary, make available to COUNTY for examination all of its records and data with respect 13 to the matters covered by this Agreement. CONTRACTOR shall, upon request by COUNTY, permit 14 COUNTY to audit and inspect all such records and data necessary to ensure CONTRACTOR's 15 compliance with the terms of this Agreement. 16 If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00), 1 7 CONTRACTOR shall be subject to the examination and audit of the State of California Auditor 18 General for a period of three (3) years after final payment under contract (California Government 19 Code section 8546. 7). 20 In addition, CONTRACTOR shall cooperate and participate with COUNTY's fiscal 21 review process and comply with all final determinations rendered by the COUNTY's fiscal review 22 process. If COUNTY reaches an adverse decision regarding CONTRACTOR's services to 2 3 consumers, it may result in the disallowance of payment for services rendered; or in additional 2 4 controls to the delivery of services, or in the termination of this Agreement, at the discretion of 25 COUNTY's DSS Director or designee. If as a result of COUNTY's fiscal review process a 2 6 disallowance is discovered due to CONTRACTOR's deficiency, CONTRACTOR shall be financially 2 7 liable for the amount previously paid by COUNTY to CONTRACTOR and this disallowance will be 28 adjusted from CONTRACTOR's future payments, at the discretion of COUNTY's DSS Director or -13 -COUNTY OF FRESNO Fresno, CA
1 designee. In addition, COUNTY shall have the sole discretion in the determination of fiscal review 2 outcomes, decisions and actions. 3 19. NOTICES 4 The persons having authority to give and receive notices under this Agreement and their 5 addresses include the following: 6 7 8 9 COUNTY Director, County of Fresno Department of Social Services PO BOX 1912 Fresno, CA 93718-1912 CONTRACTOR CEO Foster Assessment Center & Testing Service, Inc 516 Pennsfield Place, Suite 108 Thousand Oaks, CA 91360 10 20. CHANGE OF LEADERSHIP I MANAGEMENT 11 Any and all notices between COUNTY and CONTRACTOR provided for or permitted 12 under this Agreement or by law, shall be in writing and shall be deemed duly served when personally 13 delivered to one of the parties, or in lieu of such personal service, when deposited in the United States 14 Mail, postage prepaid, addressed to such party. 15 In the event of any change in the status of CONTRACTOR'S leadership or 16 management, CONTRACTOR shall provide written notice to COUNTY within thirty (30) days from 1 7 the date of change. Such notification shall include any new leader or manager's name, address and 18 qualifications. "Leadership or management" shall include any employee, member, or owner of 19 CONTRACTOR who either a) directs individuals providing services pursuant to this Agreement, b) 2 0 exercises control over the manner in which services are provided, or c) has authority over 21 CONTRACTOR's finances. 22 21. GOVERNING LAW 2 3 The parties agree, that for the purposes of venue, performance under this Agreement is 2 4 to be in Fresno County, California. 2 5 The rights and obligations of the parties and all interpretation and performance of this 2 6 Agreement shall be governed in all respects by the laws of the State of California. 27 28 22. ENTIRE AGREEMENT This Agreement, including all Exhibits, COUNTY's Revised RFP 952-5425 and -14 -COUNTY OF FRESNO Fresno, CA
1 CONTRACTOR's response thereto, constitutes the entire agreement between CONTRACTOR and 2 COUNTY with respect to the subject matter hereof and supersedes all previous agreement 3 negotiations, proposals, commitments, writings, advertisements, publications and understandings of 4 any nature whatsoever unless expressly included in this Agreement. 5 Ill 6 Ill 7 Ill 8 Ill 9 Ill 10 Ill 11 Ill 12 Ill 13 Ill 14 Ill 15 Ill 16 Ill 1 7 Ill 18 Ill 19 Ill 20 Ill 21 Ill 22 Ill 23 Ill 24 Ill 25 Ill 2 6 Ill 27 Ill 28 Ill -15 -COUNTY OF FRESNO Fresno, CA
1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year first
2 hereinabove written.
3
4 ATTEST:
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CONTRACTOR:
~~Testing Service,
By~~
Print Name: A V\l>...'f.e.tt... !Z;i e.r-
Title: LED
Chainnan of the Board, or
President, or any Vice President
Print Name: R .Lra..ta ~t.e..r
Title: ~{=D J
Secretary (of Corporation), or
any Assistant Secretary, or
ChiefFinancial Officer, or
any Assistant Treasurer
Mailing Address:
516 Pennfield Place, Ste 108
Thousand Oaks, CA 91360
Phone No.: (805) 497-1685
Contact: Andrea Foster, CEO
Ill
Ill
COUNTY OF FRESNO
By<c'"' 7'-~
Ernest BuddYM~ and/or
Brian Pacheco, Vice-Chairman
Board of Supervisors
BERNICE E. SEIDEL, Clerk
Board of Supervisors
PLEASE SEE ADDITIONAL
SIGNATURE PAGE ATTACHED
-16 -COUNTY OF FRESNO
FCCl!no,CA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 APPROVED AS TO LEGAL FORM: DANIEL C. CEDERBORG, COUNTY COUNSEL By~~~~'-J,!.->.L.l,.L!-,-c-Jl.L-'.,£.....1_.j""'-4--.$.-+-JL!':l,~-(,4/, ti APPRO~ED AS TO ACCOUNTING FQRT\;'. . VICKI dROW, C.P.A., AUDITOR-CO&ROLLER/ TREASURER-TAX COLLECTOR By 0f4. £ (-cJ! "9" J= REVIEWED AND RECOMMENDED FOR APPROVAL: E. N · a, Director Department o Social Services Fund/Subclass: 0001/10000 Organization: 56107001 Account/Program: 7870/0 DEN: It -17 -COUNTY OF FRESNO Fresno, C1\
SUMMARY OF SERVICES Exhibit A Page 1 of 7 ORGANIZATION: Foster Assessment Center & Testing Service, Inc. ADDRESS: 516 Pennsfield Place, Ste 108, Thousand Oaks, CA 91360 SERVICE ADDRESS: Fresno County SERVICES: CalWORKs Assessment Services TELEPHONE: (805) 497-1685 CONTACT: Andrea Foster EMAIL: andreafoster@fosterassessment.com CONTRACT PERIOD: July 1, 2016 -June 30, 2017, with the option to renew for (2) additional years AMOUNT: $385,000 (per 12 month period) A. SUMMARY OF SERVICES: CONTRACTOR shall provide specialized assessment services for referred CalWORKs participants, residing in Fresno County, who have limited English speaking ability, potential learning disabilities, potential trauma symptoms, and other unique needs. The period of activity for this Agreement is July 1, 2016 through June 30, 2017, with the option to renew for (2) additional years. The CalWORKs participants to be assessed will be identified and referred by Fresno County's Department of Social Services (DSS). Additionally, DSS will identify and determine appropriate types of assessments for each CalWORKs participant. CONTRACTOR shall administer assessments based on DSS' determination. DSS will use the assessments for the following purposes: 1. Provide an evaluation of the CalWORKs participants' interest, academic abilities, aptitudes, and work history. 2. Develop a Welfare to Work Plan (WTW) as appropriate and/or Learning Disabilities Profile (DP) for each CalWORKs participant based on test results and information obtained in client interviews. 3. Provide a Learning Disabilities Evaluation in accordance with the rules and regulations of the California Department of Social Services, Manual of Policies and Procedures, Eligibility and Assistance Standards, Chapter 42-700, Section 42-722, Learning Disabilities Protocols and Standards, inclusive of DSS policy and procedure guidelines.
Exhibit A Page 2 of7 4. Provide a third party review of assessment plans written by DSS as requested and determine if the plan is appropriate. Additionally, if review of the COUNTY plan requires a new assessment, testing will be completed, and a new plan will be developed by CONTRACTOR. 5. Screen referred clients for potential trauma symptoms (anxiety, panic episodes, traumatic events, psychotic episodes) during the intake interview process using the Trauma Symptom Inventory (TSI). This will be included in the WTW Plan submitted to the DSS Case Manager. The scheduling of assessments will be coordinated with DSS. CONTRACTOR agrees to provide services according to the CalWORKs Assessment Procedures. CONTRACTOR shall also ensure that LEP clients have meaningful, effective, and equal access at every point of contact with project services. B. TARGET POPULATION: Services will be restricted to only CalWORKs recipients referred through DSS. C. CONTRACTOR's RESPONSIBILITIES: 1. FACILITY DEVELOPMENT and TESTING CENTERS CONTRACTOR will open a centrally located main facility in Fresno County, to provide LOE, LE and third party assessments. The facility shall be consistent with the Commission on Accreditation of Rehabilitation Facilities (CARF) standards. CONTRACTOR will provide testing services on West Hills Community College Campuses of Firebaugh and Coalinga two times per month. Contractor will take full advantage of other community colleges and community centers to provide the widest coverage of assessment services throughout Fresno County. 2. SPECIALIZED ASSESSMENTS In the event that a participant requires a specialized assessment that cannot be completed by DSS staff, the participant will be scheduled for the specialized assessment with the CONTRACTOR. Once provided CASAS data by DSS Program Staff, CONTRACTOR shall take into consideration the following information gathered from the assessment to develop the WTWPlan: • Detailed information on any past or present employment history and an inventory of the client's employment skills, knowledge, and abilities. • Detailed information regarding the client's current attendance in vocational/educational type training should be discussed and included in the
Exhibit A Page 3 of 7 plan. (i.e. school, date of enrollment, type of training, hours per week, degree or certification program, etc.) If applicable, any past education/training should also be included in the development of the plan. • The participant's needs, including the need for supportive services (i.e. child care, transportation, ancillary costs, etc.) • An evaluation of the chances of employment, given the current skills of the participant and the local labor market conditions. • Local labor market information. The information referenced above must be included in the packet provided to DSS. NOTE: At any time, if the participant does not agree with the results of the assessment, or the WTW Plan from CONTRACTOR, the client will be referred to DSS for an impartial Third Party Review. DSS will follow established guidelines for Third Party Reviews. 3. LIMITED ENGLISH PROFICIENT ASSESSMENTS (includes WTW Plan) CalWORKs participants exhibiting limited or non-English speaking ability will be referred to contractor for LEP Assessments. The majority of participants will have a primary language of Spanish or Southeast Asian (Hmong, Lao, and Cambodian). However, additional language barriers are anticipated. CONTRACTOR will provide assessments services to all referred CalWORKs WTW participants in a timely manner. The expected length of time for completion of each assessment is as follows: CONTRACTOR will provide LEP assessments as a one-day process (five to eight hours) that will be completed on the same day of assessment in both rural and urban areas. However, if extenuating circumstances arise, CONTRACTOR may extend the assessment to two days for those participants requiring such. 4. LEARNING DISABILITY EVALUATION (LDE) a. Referral Process: Counties are required to offer learning disabilities screening to CalWORKs WTW individuals upon entering the program or when certain events occur, indicating that the participant may have a potential learning disability. These events may include, but are not limited to any of the following: • Individuals that have a suspected learning disability, as identified by the County, outside service provider, or the participant • Individuals that are in good cause determination, compliance, or sanction processes, and
Exhibit A Page4 of 7 • Individuals that are failing to maintain satisfactory progress in their wrw activities, including employment Upon determination that a learning disability evaluation is necessary, the CONTRACTOR Case Manager will complete the Learning Disability Screening with the participant. Participants are not required to be evaluated for a suspected leaning disability and may choose to decline the screening and evaluation. If the participant agrees to an evaluation, they will be referred to CONTRACTOR. When accommodations are required, for either testing or vocational activity, recommendations will be made regarding resources for persons with such disabilities and specific referrals suggested for various compensatory or support services that will be included in the wrw Plan. CONTRACTOR will complete the LOE in one day provided there are three or less participants per assessor. If four or more participants are expected, and the assessor is off-site (from the Fresno assessment center) and working on their own, the assessment may take up to two days. b. Testing and Evaluation Process: In addition to an initial interview and wrap-up session, several tests will be administered. Testing will be individualized and tailored to meet the particular needs of each client. All of the tests listed below are multi-purpose and wide-ranging in scope and designed to identify many different challenges. Test selection and administration will be done with caution and according to the needs and capabilities of the participant. These tests will be used, as they are relatively free of culture bias and can be modified to suit the needs of limited English speakers. The Center Director/Lead Assessor will assist professional staff in the administration of the tests. The following tests may be used to complete the assessments: • WJ-IIIR Tests of Cognitive and/or Achievement • WJ-IVR Tests of Cognitive and/or Achievement • Trauma Symptom Inventory • Gates-MacGinitie Reading Test • TABE-Test of Adult Basic Skills(To be used only if CASAS is not used) • Revised BET A 111 • Raven Standard Progressive Matrices • TONI 4 -Test of Non-Verbal Ability • COPS -Career Occupational Preference System • MPFB -Minnesota Paper Form Board • GCT -General Clerical Test • Bennett Mechanical Comprehension Test • Purdue Pegboard • Myers-Briggs Type Indicator • SkillCheck • WRAT IV
Exhibit A Page 5 of? For the purpose of identifying interest and skill set, work sample assessments may include, but are not limited to VALPAR, TOWERS, and JEVS tests. c. Reporting Process: For all assessments, a separate written participation profile will be developed based on individual interviews, discovery, and assessment results. The profile will provide a brief discussion of the test implications and conclude with recommendations for further action and/or referrals for needed services. The report will also include a WTW Plan, if requested by DSS. All test results, including the WTW Plan will be submitted to DSS within five business days of the date of assessment. 5. TRAUMA SYMPTOM INVENTORY (TSI} The TSI will be administered along with the LOS testing when determined necessary by the tester at any time during the intake interview, testing, or post-test interview for clients who disclose a reported history of depression, anxiety, panic episodes, psychotic episodes and/or traumatic events. Additionally, CONTRACTOR shall administer the TSI upon DSS specific request and referral. Although, TSI is not a diagnostic tool, CONTRACTOR shall identify clients that may have serious issues dealing with past or present traumatic events where further psychological assessment and treatment are necessary. All LDEs that include a TSI must be clearly identified when sent to DSS. TSls must be submitted to DSS within five business days form the date of the test. 6. THIRD PARTY ASSESSMENT REFERRAL PROCESS: Upon specific request and referral from DSS, CONTRACTOR will provide an impartial third party review of WTW Plan(s) developed by DSS staff. CalWORKs participants have the right to be automatically referred to a third party assessment when the participants do not agree with the results of their DSS assessments. EVALUATION PROCESS: DSS will meet with CONTRACTOR and provide all testing used to develop the participant's WTW Plan. Upon receipt of the WTW Plan, the CONTRACTOR will perform a thorough review of the test(s) administered by DSS and review the developed WTW Plan. CONTRACTOR must complete the Third Party Review within 30 days from the original date of request. Extensions may be given, but must be obtained from DSS. Based on this review, a determination will be made as to whether or not the test results and plan are valid or a new plan is needed. If it is deemed appropriate to assess the participant, the CONTRACTOR will complete another assessment and develop a new plan for the participant. The results of the third party assessment are binding between the COUNTY and the participant.
D. STAFFING LEVELS: Exhibit A Page 6 of 7 CONTRACTOR will establish assessment services by staffing the following positions: Lead Assessor/Center Director, 2nd Assessor (Rural Travel/Bilingual/Spanish-Speaking), Secretary and/or Test Technician, (Bilingual-Spanish and/or Hmong), and a part-time Quality Assurance Supervisor. E. COUNTY RESPONSIBILITIES : COUNTY shall be responsible for the following activities: 1. Provide the CONTRACTOR CalWORKs referrals determined appropriate for LEP, LDE, Third Party Assessment, or TSI assessment. 2. Provide current information and/or training to CONTRACTOR's staff on specific areas/functions of the CalWORKs Employment Services Program when determined helpful and/or needed for the successful delivery of the specialized assessments. 3. Provide all needed and appropriate supportive services for participants including child care, transportation, and ancillaries. 4. Work with CONTRACTOR's staff for compliance resolution including good cause determination and sanction. 5. Meet with CONTRACTOR's staff as often as needed to monitor services, exchange pertinent information, resolve problems, and work together to coordinate services. F. REPORTS AND OUTCOMES DSS will consider CONTRACTOR performance levels when determining funding recommendations for future Agreements. For the contract period, CONTRACTOR shall provide specialized assessment testing to assist CalWORKs recipients in the development of Welfare to Work Plans. The plan will be used to assist the recipients in obtaining new skills that will lead to higher wages and self-sufficiency. (See the following page for specific performance measurements.)
Exhibit A Page 7 of? Specific Performance Measurements PERFORMANCE MEASURE Performance Measure 1: Completion Rate of Assessments -the length of time allowed for development and completion of Assessments Reports from the date the participant completes the activity. Third Party Assessments will be an exception. Measurement Parameters: Length of time between Assessment Test and date the Welfare to Work Plan is sent to DSS Universal Engagement staff. Data Sources: Dates entered on activity rosters submitted with invoice. Performance Measure 2: Outreach Activities -the number of outreach activities conducted to promote Specialized Assessment services by the end of the contract term. 50% of the outreach activities must be completed within the first three months of the contract period. Thereafter, a minimum of one outreach activity is required each month, until goal is reached. Measurement Parameters: • Activities include presentations at designated DSS locations • Presentations to specialized DSS units on a quarterly basis • Assessment process and test review training for DSS staff and • Publications for the DSS PS Newsletter Data Sources: The primary data sources are invites from DSS. Activities should be coordinated with DSS. EXPECTED LEVEL OF PERFORMANCE The Assessment Report will be completed within five (5) working days from the time completed assessment. The CalWORKs WTW staff makes the initial referral for assessment, unless otherwise directed. A 95% rate of completion is expected. Third Party Assessments will be an exception. 12 outreach activities are to be performed by the end of the contract term. It is expected that 570 participants will be assessed in fiscal year 2016-17. Annually, CONTRACTOR will provide staff development to ensure DSS Program Staff are familiar with the type of test given and how to read assessment results.
NAME OF ORGANIZATION: NAME OF PROJECT: Exhibit B 1 of 3 Foster Assessment Center & Testing Services, Inc Specialized Assessment BUDGET SUMMARY • 12 month Budget Categories Account Number TOTAL BUDGET SALARIES & BENEFITS Personnel Salaries 0100 $ 228,800 Payroll Taxes 0150 $ 23,000 Benefits 0175 $ 20,400 Subtotal ....... . $ 272,200 SERVICES & SUPPLIES Budgeted Amount Insurance 0200 $ 4,000 Communications 0250 $ 7,000 Office Expense 0300 $ 42,000 Equipment 0350 $ 7,200 Utilities 0400 $ 4,000 Travel Costs 0500 $ 11,030 Program Supplies 0550 $ 16,000 Indirect Costs 0700 $ 21,570 Subtotal.. ...... $ 112,800 TOTAL (Salaries/Benefits & Services/Supplies) $ 385,000
NAME OF ORGANIZATION: NAME OF PROJECT: PERSONNEUSALARIES: Title/Position Lead Assessor/Center Director 2nd Assessor (Rural Travel/Bilingual/Spanish) Secretary Test Technician (Bilinqual-Hmonq) Quality Assurance Supervisor SALARIES TOT AL PAYROLL TAXES No.of FTE 1 1 1 1 0.8 Months Employed 0175 Federal Unemployment Tax FICA/Medicare SDI SUI/SDI EMPLOYEE BENEFITS: Health Insurance and Dental 401 K Pension Plan 12 12 12 12 4 Exhibit B 2 of 3 Foster Assessment Center & Testing Services, Inc Specialized Assessment Funds Requested $ 80,000 $ 65,000 $ 32,200 $ 26,000 $ 25,600 $ 228,800 $ 2,100 $ 17,546 $ 2,059 $ 1,295 $ 23,000 $ 11,800 $ 8,600 $ 20,400 TOTAL (Personnel Salaries, Payroll Taxes & Benefits) $ 272,200
BUDGET EXPENSE CATEGORY DESCRIPTIONS Julv 1,2016 · June 30,2017 Exhibit B 3 of 3 NAME OF ORGANIZATION: Foster Assessment Center & Testing Service,lnc NAME OF PROJECT: Specialized Assessments Account Account Total Number Expense Category Descriptions {Rounded to nearest 100) 0100 Salaries $228,800 Lead Assessor/Center Director $ 80,000 Travel/Bilingual/Spanish) $ 65,000 Secretary $ 32,200 Test Technician (Bilinoual-Hmono) $ 26,000 Qualitv Assurance Supervisor $ 25,600 0150 Benefits $20,400 Health/Dental $ 11,800 401K $ 8,600 0175 Pavroll Taxes $23,000 Federal Unemployment Tax $ 2,100 FICA/Medicare $ 17,546 SDI $ 2,059 SUI/SDI $ 1,295 0200 Insurance $4,000 Workers Compensation $ 2,000 Professional Liability $ 500 General Liability $ 1,500 0250 Communications $7,000 Postaoe $ 1,200 Phone/fax/internet $ 4,800 Translation Services $ 1,000 0300 Office Expense $42,000 Rent $ 29,000 ADA Tenant Improvements $ 4,000 PC/Back up Storaqe/MS User Licens 8,000 Movino Expenses $ 1,000 0350 Equipment $7,200 Copier/Fax/Scanner $ 7,200 0400 Utilities $4,000 Total utility cost $ 4,000 0500 Travel Costs $11,030 Rural Assessments Firebauoh/Coalinoa $ 1,936 Quarterly mtgs in Reseda, CA $ 1, 181 Quality Assurance Supervisor Visits $ 1,368 Lodqino I QA Supervisor $ 4,080 Per Diem Meals/ QA Supervisor $ 2,465 0550 Proqram Suoolies $16,000 Testina Suoolies $ 12,000 Office Suoolies $ 4,000 0600 Indirect Costs $21,570 Equipment Decpreciation $ 2,500 CARF Accreditation $ 3,000 Accountina/ Auditina $ 2,500 Administration Expenses $ 9,000 Administration Waaes $ 4,570 Budget Total $385,000
Exhibit C 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 C (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: I Date: I