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CITY OF SAN BERNARDINO - REQUEST FOR COUNCIL ACTION
0RI6iNAL
Subject: RESOLUTION RATIFYING THE
SUBMITTAL OF A GRANT APPLICATION BY
THE DIRECTOR OF PARKS, RECREATION
AND COMMUNITY SERVICES FOR TITLE
moB GRANT APPLICATION TIIROUGH THE
COUNTY OF SAN BERNARDINO
DEPARTMENT OF ADULT AND AGING
SERVICES (DAAS) FOR ASSISTED
TRANSPORTATION FOR A PERIOD OF JULY
I, 1004 mROUGH JUNE 30, 1005.
MICC Meeting Date: May 3, 2004
From: Lemuel P. Randolph, Director
Dept: Parks, Recreation &
Community Services Dept.
Date: March 26, 2004 .." .,.
Synopsis of Previous Council Action:
April 13, 2004 - Grant Ad Hoc Committee heard and recommended for approval.
Recommended Motion:
Adopt resolution.
C/;('~/f/
Contact person: Aaliyah Harkley
Phone: 5231
Supporting data attached: Ward:
FUNDING REQUIREMENTS: Amount: NIA
Source: (Acct. No.)
(A~d nA!;~riptinn)
Finance:
Council Notes:
Z:<~Cl toI 2C04 -(2.2.
Agenda Item No.
dd.-
5/3/ f>!/
CITY OF SAN BERNARDINO - REQUEST FOR COUNCIL ACTION
Staff Report
Subject:
Resolution ratifying the submittal of a grant application by the Director of Parks, Recreation and
Community Services for Title III-B Grant application through the County of San Bernardino
Department of Adult and Aging Services (DAAS) for Assisted Transportation for a period of
July 1,2004 through June 30, 2005.
Background:
The Senior Companion Program (SCP) has received Title III-B funds for over 12 years. These
funds have helped to provide services to low-income, frail elderly clients in areas that are rura1
and sparsely populated. The SCP has existed since 1974. The Companions assist the clients
with grocery shopping, meal preparation, transportation to medical appointments, pharmacies,
banks, post offices, and etc. Many times the Companions are the only contact the clients have to
the outside world. These clients have no means of transportation and are at risk of early
institutionalization without this assistance.
Although the SCP has been involved with Title III-B funds for the past 12 years, staff was
informed on March 17, 2004 that the deadline for this year's grant was March 23, 2004 at 4 p.m.
(see attached letter). Staff verified with the County that the application could be ratified,
therefore, the application has already been submitted.
On April 5, 2004 the department was authorized by Council to apply and administer a grant for
SCP through Corporation of National and Community Services in the amount of $295,983. The
federal grant from the Corporation of National and Community Services for the SCP covers the
stipends and meal reimbursement costs, but only pays mileage to and from the client's home.
All of the miles the Companions drive, taking their clients to medical appointments, pharmacies,
grocery stores, banks, etc. are not allowable costs under that grant.
Since all Companions must meet the federal low-income guidelines, they are not able to absorb
the extra costs of fuel, maintenance, repairs and insurance for their vehicles. In order to continue
to serve the clients who have no other means of transportation, we must find a way to secure
these funds.
Since the Corporation of National and Community Services grant does not cover all
transportation cost, we are seeking this grant to supplement transportation cost for all of our
clients. The City operates the only SCP in the San Bernardino County, therefore, we are
required to serve outlying areas to receive the federal grant. Clients living in the Morongo Basin
and Victor Valley areas will benefit the most from this grant because their travel cost are higher.
This grant is in the amount of $27,698 and will fund services to 75 clients per week, utilizing 15
Companions. This grant will allow the City to provide more reimbursements for the
Companions for their transportation expenses that occur while assisting their clients.
Financial Impact:
There is no financial impact to the City. The matching funds required for this grant will be from
the Community Foundation for these areas. No matching funds from the City.
Recommendation:
Adopt Resolution.
Senior Companion Program
600 West Fifth Street
San Bernardino, CA 92410
March 23, 2004
County of San Bernardino HUJDIU1 Services System
Attn: Contract Administration RF A HSS 03-07
ISO South Lena Road
San Bernardino, CA 92415-05 IS
To Whom It May Concern:
The enclosed app1ication for Title moB funds is being sent for your perusal and
consideration for timding, We hope we haw included everytbiDg necessary.
When Nanci Sevelin ClIJD.C to monitor our current Title m program on Wecroe,d'ly,
March 17, she asked ifwe would be applying again this year. Ofcourse we said yes.
She then informed us that the app1ic~ were due by 4 p.rn. today! We bad not
received the RF A, which sbocked both of us. We remembered that our address on the
Monthly E ., Request Report was wrong at the Mginning of the
year. So we surmised that the RFA bad been m;",e'lt to P. O. Box 710, S.B. 92401.
(See attached example)
Luckily she bad a copy in her truDk. which she gaw to me. She said she would c:heck
with the contracts office to see iftbere could be any leeway. She did not call on
Thursday and when we tried to contact her on Friday, we were told she was off.
So, I called to talk with Regina, who was also o~ but did speak with Sandy, who
followed up on the problem. She called us beck and said that Regina told her ifwe got
the application in on time, that we could get the proper sign8tures later.
Therefore, we worked tirelessly to meet the deadline, which we have met!
Thanks for your patience and consideration. Jfyou haw any questions, please coutact us
at 384-5413 or f8x to 889-9801.
Very sincerely,
~
Betty A. Deal, Manager
City of San Bernardino Senior Companion Program
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R~L~~Y-
RESOLUTION OF THE MAYOR AND COMMON COUNCIL OF THE CITY
OF SAN BERNARDINO RATIFYING THE SUBMITTAL OF A GRANT
APPLICATION BY THE DIRECTOR OF PARKS, RECREATION AND
COMMUNITY SERVICES FOR TITLE III-B GRANT APPLICATION THROUGH
THE COUNTY OF SAN BERNARDINO DEPARTMENT OF ADlILT AND AGING
SERVICES (DAAS) FOR ASSISTED TRANSPORTATION FOR THE SENIOR
COMPANION PROGRAM FOR THE PERIOD OF JULY 1,2004 THROllGH JUNE 30,
2005.
BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE
CITY OF SAN BERNARDINO AS FOLLOWS:
SECTION I. The Mayor and Common Council of the City of San Bernardino hereby
ratify the submittal of a Title III-B grant application by the Director of Parks. Recreation and
Community Services Department through the Department of Adult and Aging Services
(DAAS) in the amount $27.698 for assisted transportation for the Senior Companion Program.
a copy of which is attached hereto. marked Exhibit "A" and incorporated herein by reference as
fully as though set forth at length.
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RESOLUTION OF THE MAYOR AND COMMON COUNCIL OF THE CITY
OF SAN BERNARDINO RATIFYING THE SUBMITTAL OF A GRANT
APPLICATION BY THE DIRECTOR OF PARKS, RECREATION AND
COMMUNITY SERVICES FOR TITLE III-B GRANT APPLICATION THROUGH
THE COUNTY OF SAN BERNARDINO DEPARTMENT OF ADULT AND AGING
SERVICES (DAAS) FOR ASSISTED TRANSPORTATION FOR THE SENIOR
COMP ANION PROGRAM FOR THE PERIOD OF JULY 1,2004 THROUGH JUNE 30,
2005.
I HEREBY CERTIFY that the foregoing Resolution was duly adopted by the Mayor
and Common Council of the City of San Bernardino at a
meeting thereoL held
davof
. 2004. by the following vote. to wit:
on the
Council Members:
AYES
NAYS
ABSTAIN ABSENT
ESTRADA
LIEN LONGVILLE
MCGINNIS
DERRY
KELLEY
JOHNSON
MCCAMMACK
Kache I (j. l'lark. l Ity llerk
day of
The foregoing resolution is hereby approved this
2004.
Judith Valles. Mayor
City of San Bernardino
Approved as to
Form and legal content:
JAMES F. PENMAN.
City Altom 'y
By:
f .:
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I ATTACHMENT C
,
I Application for Older American Act Title III B Funds
10. (Submit one aDDlieation for each service tvoe the aDDlvin!l oraanlzation wishes to Drovide.l
omplete the following:
1. Indicate the type of service for which funding is requested, and the area(s) to be served:
r Category Service Region
i
, Colorado North Morongo Victor Mountains East West
I
; River Desert Basin Vallev Vallev Vallev
I 01 Personal Care
, 02 Homemaker
I
I 03 Chore
05 Adult Day
Care/Health
, 09 Assisted
I T ransDortation x x
I 10 Transportation
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i 14 Outreach
I 15D 1) Medical
i Alert
I 2) Health
C15F
Screenina
Community
I Svs - Sr. Ctr.
I
I Manaoement
I 151 Friendly Visits
,
: 15K 11) Home
Modification
i 2) Home I
i Repair
2. For the regions checked above, specify if only specific cities will be served within the
region. and also specify any geographic boundaries, e.g., West Valley. from Rancho
Cucamonga to Rialto, excluding Fontana.
Region:
Morongo Basin: Joshua Tree, Twentynine Palms, Yucca Valley
Victor Valley: Adelanto, Apple Valley, Hesperia. Victorville
o Organization Name: City of San Bernardino Spnior r.ompanion PTngT~m
Page 4 of 18
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6.
7.
ATTACHMENT C
Mailing Address:
600 West Fifth Street
San Bernardino
City
92410
Zip
CA
State
Contact Person:
Betty Deal
Phone:
909-384-5413
Type of Organization:
o Private Non-Profit
o Private for Profit
[] GovernmenUPublic Agency
City of San Bernardino
Name of Government Unit
8. Federal (IRS) Taxpayer ID: 95-6000772
9.
10.
01.
12.
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Total Funds Requested: $ 27,698.00
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Number of clients to be served: 75 (by 15 CQlDPadons)
a. If applicant was in business anytime during the last two (2) years. enter the
number of clients served:
2002 # clients: 100 (by 20 Companions)
2003 # clients: 90 (by 18 Companions)
Cost per Unit of Service if awarded funding: $ .25 per mile x 25 miles.. $6.25 per trip
Total Program Income: $
-0-
13. Additional Funding Sources: (Provide a 2 year history, if applicable)
2002: Corporation for National Community Services. State. Communitv Foundation
2003: Same as above
14. Days and Hours of Operation: Monday throuRh Friday 7:30-4:30
Page 5 of 18
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15. Agency Background and Personnel
ATTACHMENT C
The City of San Bernardino has been the local grantee for the federal Senior Companion
Program and the Retired Senior Volunteer Program for 29 years. It has also been the
grantee for the Senior Nutrition Program for at least 26 years.
The City has a state, regional and national reputation for being one of the most insightful,
responsible, supportive and caring agencies in the whole country.
The Senior Companion Program staff consists of2 fulltime employees; Betty Deal, who
has directed the program for 18 years, and Program Specialist Penny Nelson who has 15
years experience with the program. OIafNeiiendam is the part time Coordinator of
Volunteers. He has been been employed for 3 Yo years and has proven to be a most
valuable addition to the staff.
Both Betty and Penny have been recipients of the "Woman of the Year" award. Betty
was also chosen "City Employee of the Quarter" several years ago.
The staff at the State office of the Corporation for National and Community Service often
refer new grantees and new program staff in other areas to the San Bernardino SCP for
guidance and technical assistance.
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16. Summary of Need of Program
ATTACHMENT C
At the present time, there are 200,000 senior citizens in San Bernardino County. By the
year 2020, the Department of Aging and Adult Services says that number should reach
600,000. In a survey of personal care participants conducted by DAAS , 57% were 75 +,
13% were minority and 72% wre functionally impaired. Of the minorites surveyed, 45%
were low-income. These are the populations the Senior Companion Program targets.
The federal grant from the Corporation of National and Community Services for the
Senior Companion Program covers the stipends and meal reimbursement costs, but only
pays mileage to and from the clients' homes. All of the miles the Companions drive
taking their clients to medical appointments, pharmacies, grocery stores, banks, etc. are
not allowable costs under that grant.
Since all Companions must meet the federal low-income guidelines, they are not able to
absorb the extra costs of fuel, maintenance, repairs and insurance. In order to continue
to serve the clients who have no other means of transportation, and in the process, allow
them to remain living in their own homes, we must fmd a way to secure these funds. We
are hopeful that this application will fill that need.
In the long run, this is much more cost-efficient than placing folks in nursing homes,
which cost upwards of$45,000.00 per year per resident. These costs would be borne by
the taxpayers due to the clients' inability to pay. (Most of them are on Medi-Cal.)
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17. Proposed Program
ATIACHMENTC
This program will follow DAAS client eligibility guideline by giving priority to seniors
with the greatest social and economic need. There is never a charge to the recipients of
the program's services.
Services provided by the Senior Companions include companionship, assistance with
ADL's, meal preparation, grocery shopping and transporting clients to their medical
appointments, pharmacies, post office, banks, etc.
Many of our elderly clients live in sparsely populated rura1 areas of the County and
have no means of transportation. They do not have cars or they are unable to drive
anymore. Their neighbors are few and fur between and most are in the same
circumstance. If the clients have family members, they reside in other areas ofthe state
or
country.
We can only use our federal funding from CNCS to pay mileage to the Companions
to and from their clients' homes. The extra miles that the Companions transport their
clients are not an allowable expense. Since all Companions must meet the federal Iow-
income guidelines, they cannot absorb these extra costs. Therefore, the clients
have no way to receive these necessary services.
Since there are no other programs available to provide these services, the frail-elderly
clients are forced into institutional care where they lose hope, dignity and, many times,
the will to live. Keeping them at home helps them to feel safe, retain their dignity and
highest level of independence. They know that their Senior Companion will always be
there on schedule to fill their needs.
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These services follow the DAAS belief that seniors hve the right to age in the least
restrictive environment and to maintain dignity, maintain home environment and avoid
institutional care.
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18. Budgetary Information ATTACHMENT C
The budgetary planning is a collaborative effort between the Senior Companion
Manager and her supervisor at the Parks, Recreation and Community Services
Department of the City of San Bernardino. This includes selection of the target
areas, target population and the number ofvolunteers (Companions) needed to
provide the best and most cost-efficient service to the seniors.
The City as an assigned Account Technician to handle all of the fiscal reports
and records for this program. The Senior Companion Program Manager works closely
with this person.
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ATTACHMENT C
h ..
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C1 ~ c2D III-B [i] III-FD VII OMB D VII ELD ABUSE D
Other
EXPENDITURE CATEGORY Funding Match
Less Match Cash In-Kind TOTAL
1. PERSONNEL
(Attach Schedule of Personnel) 4,680. 14,040. -0- 18,720
2. STAFF TRAVEL 518. 1.552. -0- 2,070.
! 3. STAFF TRAINING
4. EQUIPMENT
5. CONSULTANTS
6. FOOD COSl,S i . lunches -0- 6,300. -0- 6,300.
~- ompan ons
! 7. OTHER COST
--- ...._--- I
Q- Companion travel 22,500. -0- -0- 22,500.
Office Space -0- -0- 8,840. 8,840.
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ITotal Expenditure 27,698. 21,892 8,840. 58,430.
1------
LESS MATCH:
Match Cash 21,892. 21,892.
-- -----, -----~. -------------
, Match In-Kind 8,840. 8,840.
,
LESS FUNDING:
! Non Match USDA
i
Non Match Cash
Non Match In-Kind
! Program Income I
Deferred Income I
'TOTAL FUNDING REQUEST 27 698. 27 698. i
n;e of Phone No: 909-384-5413
_ bmission: 3-23-04
Prepared By: Betty A. Deal
Page 12 of 18
et Narrative
ATTACHMENT C
INITIAL BUDGET !JI
REVISED BUDGET 0
SAN BERNARDINO COUNTY - OMS 312111B - Revised 3/01
.;~';f"'t::'--' ..;-
Provide justification, rates, comments, descriptions, etc. for line items on the Budget
Summary Form-DAAS 312.
Line-Item Cost/Rate Descri tion/Justification
Personnel: $12 per hour 30 hrs. per wk @ $12. per hr x 52 wks x 25% time =$4,680.
Vol. Coordinat r (Coordinator will spend 25% of his time on this project)
Staff Travel 34.5c per mile 500 x 12 mos. @ 34.5c per mi.x 25% time _ $518.
Companion
Travel
25c per mi.
15 Companions x 500 per mo. @ 25c per mi. - $22,500.
(Companions take their clients to medicla appointments,
pharmacies, graocery shopping, and to banks, etc.,
which enables the clients to remain in their own homes
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Date
Submitted: 3-23-04
San Bernardino Countv-OAAS 320
Revised 03/06/2001 .
Provider Name
Betty Deal, Manager,
Senior Companion Proeram
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Page 13 of 18
!
I Bud> 'et lnJ~ind ftaaati~e
ATTACHMENT C
ovide justification, rates, comments, descriptions, etc. for line items on the Budget
Summary Form-OMS 312.
Line-Item CoSt/Rate Descif~ition/Justificatier'"
Office Space 65~ per sq. ft. Office space at 61607 Twentynine Palms Highway, Suite E,
x 50 sq. ft. X in Joshua Tree is donated;
260 days =$8,84
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'Qte
itted: 3-23-04
. ernardino County-OMS 322
Revised 03/06l200 1
Provider Name Betty Deal, Manager
Senior Comnanion PrQiTam
Page 14 of 18
ATTACHMENT C
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· Assurances
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---- - -- --- -- -- - - --
NOTE: All references given are for the Older Americans Act of 1965, as amended.
The Applicant Assures that they shall:
1.
2.
3.
o
4.
o
Set specific goals for providing services to older individuals with the greatest economic or
social needs, including specific objectives for providing services to low income minority
individuals. (306 (a}{5}{A}{i})
Include in each agreement made with a subcontractor a requirement that such service will-
(I) specify how the provider intends to satisfy the service needs of low income minority
individuals in the area served by the provider; (II) to the maximum extent feasible, provide
services to low-income minority individuals in accordance with their need for such services;
and (III) meet specific objectives established by the area agency on aging, for providing
services to low-income minority individuals within the planning and services areas. (306
{a}{5}{A}{ii} )
Use outreach efforts that will - (i) identify individuals eligible for assistance under this Act,
with special emphasis on (I) individuals residing in rural areas; (II) older individuals with
greatest economic need (with particular attention to low-income minority individuals); (III)
older individuals with greatest social need (with particular attention to low-income minority
indiViduals); (IV) older individuals with severe disabilities; (V) older individuals with limited
English-speaking ability; and (VI) older individuals with Alzheimer's disease or related
disorders with neurological and organic brain dysfunction (and caretakers of such
individuals); and (ii) inform the older individuals referred to in subclauses (I) through (IV) of
clause (i). and the caretakers of such individuals. of the availability of such assistance. (306
(a}{5}{B})
Assure that it will - (A) maintain the integrity and public purpose of services provided, and
service providers, under this title in all contractual and commercial relationships; (6)
disclose to the Commissioner and the State agency - (i) the identity of each non
governmental entity with which such agency has contract or commercial relationship relating
to providing any service to older individuals; and (ii) the nature of such contract or such
relationship: (C) demonstrate that a loss or diminution in the quantity or quality of the
services provided, under this title by such agency has not resulted and will not result from
such contract or such relationship; (0) demonstrate that the quantity or quality of the
services to be provided under this title by such agency will be enhanced as a result of such
contract or such relationship; and (E) on the request of the Commissioner or the State for
the purpose of monitoring compliance with this Act (including conduct an audit), disclose all
sources and expenditures of funds such agency receives or expends to provide services to
older individuals. (306 {a}{14} {A} through (E})
Assure that funds received under this title will not be used to pay any part of a cost
(including an administrative cost) incurred by the applicant to carry out a contract or
commercial relationship that is not carried out to implement this title. (306 (a}{15})
Pace 1:1 of 1R.
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13.
14.
15.
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6.
ATTACHMENT C
Assure that preference in receiving services under this title will not be given by the applicant
to particular older individuals as a result of a contract or commercial relationship that is not
carried out to implement this title. (306 (a}{16})
Assure that (A) the applicant will pursue activities to increase access by older individuals
who are Native Americans to all it's programs under this title.
8.
Assure that persons age 60 or over who are frail, homebound by reason of illness or
incapacitating disability, or otherwise isolated shall be given priority in the delivery of
services under this part. (!j1321.69 (a}).
9.
Such fiscal control and fund accounting procedures will be adopted as may be necessary to
assure proper disbursement of, and accounting for, Federal funds paid under this title to the
applicant. (307 (a}{7}{A))
10.
(i) No individual (appointed or otherwise) involved in the designation of the head of any
subdivision of an area agency on aging, is subject to a conflict of interest prohibited under
this Act; (ii) no officer, employee, or other representative of an area agency on aging is
subject to a conflict of interest prohibits under this Act; and (iii) mechanisms are in place to
identify and remove conflicts of interest prohibited under this Act. (307 (a}(7){B})
11.
(i) (It will) maintain the integrity and public purpose of services provided in all contractual
and commercial relationships; (ii) Demonstrate that a loss or diminution in the quantity or
quality of the services provided, or to be provided, under this Act by such applicant has not
resulted and will not result from such contract or such relationship; (iii) Demonstrate that the
quantity or quality of the services to be provided will be enhanced as a result of such
contract or such relationship. (307 (a}{7}(C})
Furnish assurances to the area agency that the applicant will maintain efforts to solicit
voluntary support and that the funds made available under this title to the applicant will not
be used to supplant funds from non-federal sources. (307 (a}{13}{H})
It shall establish procedures that will allow the option to offer a meal, on the same basis as
meals are provided to elderly participants, to individuals providing volunteer services dUring
the meal hours, and to individuals with disabilities who reside at home with and/or
accompany to meal sites older individuals who are eligible for meals. (307 (a){13}{I})
In the case of purchase or construction, that there are no existing facilities in the community
suitable for leasing as a multipurpose senior center, [and that the] plans and specifications
for the facility are in accordance with regulations relating to minimum standards of
construction promulgated with particular emphasis on securing compliance with the
requirements of the Act of August 12, 1968, commonly known as the Architectural Barriers
Act of 1968. (307 (a}(14){B){C})
Any laborer or mechanic employed by any applicant in the performance of work on the
[multipurpose senior center] facility will be paid wages at rates not less than those prevailing
for similar work in the locality as determined by the Secretary of Labor in accordance with
the Act of March 3, 1931 (40 use 276a-276a-5, commonly know as the Davis-Bacon Act),
and the Secretary of Labor shall have, with respect to the labor standards specified in this
clause, the authority and functions set forth in reorganization plan number 14 of 1950 (15
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Page 16 of 18
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18.
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ATTACHMENT C
FR 3176; 64 Stat. 1267), and Section 2 of the Act of June 13, 1934 (40 U.S.C. 276c). (307
(a){14){D})
If a substantial number of older individuals in the applicants service area are of limited
English-speaking ability, the applicant shall (A) utilize in the delivery of outreach services
under Sec. 306 (a) (2) (A) and 306 (a) (6) (P), the services of workers who are fluent in the
language spoken by a predominate number of elderly individuals who are of limited English-
speaking ability. (307 (a){20})
All services provided under Title III meet all existing state and local licensing, health, and
safety requirements for the provision of those services.
All staff hired by the program will be required to attend appropriate training sessions and
workshops sponsored by the Department of Aging & Adult Services and the Califomia
Department of Aging.
All materials, videotapes, and publicity will acknowledge the San Bemardino County
Department of Aging & Adult Services and indicate that the programs are made possible by
Older Americans Act funds.
Page 17 of 18
o Assurance #
List of Assurances
Reason for Non-Compliance
ATTACHMENT C
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THE CITY OF SAN BERNARDINO SENIOR COMPANION PROGRAM AGREES
TO ALL OF THESE ASSURANCES.
Oy exceptions to the assurances must be noted and fully explained and attached as an Appendix
the RFA.
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Regarding Item 4.c Audited and Unaudited Financial Statements under Application
Submission Item C: Guidelines for completing Application, the foIlowing explanation is
offered: The Account Technician who can supply this documentation is unavailable at
this time. This information wiIl be forthcoming as soon as possible.
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CIty of Sin Bernardino
Hvman Resource11 "Ialr Mal'\a".meF\1 OiVI$IOn
300 N. "0" St...t
Sfn Bernlrdlno. CD; 92'18
Dlfector. Human Ael;')urtps
J.r.d Wilton
City Administrator
CERTIFICATE OF INSURANCE
OR SELF.INSURANCE
In the event of c.nCf!II.tton of the salf'lnl"r3nce pro;',.", C( POllclClS dVJ1o""tad below. It is thl Intent of (h,
CIIV of San 8e,nardlF'lO to Mill 30 dlYs' prior "otice thereat la'
County of San Bernardino
Human Services System.. Contracts
150 S. Lena Road
SaD Bernardino. CA 92415-0515
Ttle City of San e.rn.,dlll(l r.ert,'ses tl1anhe rollow,no tolf.,nsur,o..:" 01\'(1' ttm~ en inSUI lInee ~olici.s ,ie In totCe:
City of San Bernardino - Senior Companion Program
The County and its officers. employees. aaents. and volunteers are named as
additional insured with respect to liabilities ariaing out of the performeDce
of services hereunder.
All riahts o[ subrogation against the County. tta officers, volunteers. employees.
o contractors and subcontractors are waived.
All policies are primary and non-contributory.
COMPANY AND l'OllCY UMITS OF uaarrv
TYI'E Of COvt:RAGI! POLICY NO. PEIlIOD aodlly Injury "&r-rtr DIl-~-
COr1'lpr.h."SIYO
GlIn'f,1 Liability 5.".10 !wred IfJd.f:nitt: $1.000,000 (:ornbil1.d $1t191. \',mlts
lOci, Auto Liabilrty
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General LlablhfY
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E Liability Sel [-insured Indefinite $1.000.000 per !ailll
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ThiS cartlrlc:~e is not vilod "'"'15S counttrslgned by In ai.lthoflled represel1l1\ive of the City Of S,n B.tn.rdInO. "i.k M,n,g.""t1! Divisiorl.
.:c Betty Deal. Parks (, Rec.
O 2-10-04 0,,".,0. Of Hum" R"OU'~ 6...:;.... - ~./" P
_ CttyllfS.lnletn.,dlno J-~~.~
Ol-te AIJ\ho,ized Reor..lntltlVI s.tMtlIIt
Risk Klnlt" Coord.
. For inhrmetio'l 'e4;lrd,ng l~e JlbOVE! 5flf,'~sul'lnce pollC!lIS, ple.n cont.ct RiSk M.n.gem.or DIVISIOn II (90"3".5308-
1tM21
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Addendum to Certificate of Self-Insurance
Acceptance of this application by the County shall constitute an agreement by the
County that a Certificate ofBonafide Program of Self-Insurance by the Contractor
shall satisfY all insurance requirements contained in this agreement.
17
The City of San Bernardino Senior Companion Program accepts these grievance
procedures.
~ Provider Name:
Betty Deal, SCP Manager
3-23-04
ATTACHMENT B
COMPLAINT AND GRIEVANCE PROCEDURES
(INSTRUCTIONS: THE PARTICIPANT IS TO READ AND RECEIVE THE TOP PORTION OF THIS FORM. THE BOTTOM
PORTION OF THE FORM IS TO BE SIGNED BY SERVICE RECIPIENT AND PLACED IN THE CONTRACTOR'S RECORDS.)
If you believe you have been discriminated against, or that there has been a violation of any laws or
regulations, or if you have a problem regarding services received, you have the right to file a grievance.
The following procedures are to be followed when filing a grievance:
1. Identify the complaint/grievance in writing and discuss it with the contractor/service provider.
Time frame: Within 1 week of discrimination/violation/problem.
If resolved at this level, no further action is required. If no resolution is apparent within 10
calendar days, proceed with Step 2.
Oard the written complaint/grievance to your Caseworker (whichever is applicable).
Time frame: Within 1 week of Step 1.
If resolved at this level, no further action is required. If no resolution is apparent within 20 calendar
days, proceed with Step 3.
3. Forward the written complaint/grievance to Program Manager at the following address:
Department of Aging and Adult Services
686 E. Mill Street
San Bernardino, CA 92415-0640
Time frame: Within 1 week of Step 2.
If resolved at this level, no further action is required.
4. If no solution is apparent after Steps 1-3 have been exhausted forward copy of written grievance to:
Human Services System, Contracts Manager
150 S. Lena Road
San Bernardino, CA 92415-0515
You will be contacted within 10 calendar days of any actions being taken. Please note: Each of these
O must be completed in the sequence shown.
.... ......... ........... ......-..... -........ :..... -..... ........... ..........
1 g
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ATTACHMENTC
Assurances: - Read "Assura.nces" (included in Attachment C) and submit reasons for any
Assurances that cannot be complied with. Failure to submit documentation may result in
the application not being considered.
20. Additional Information - Include Subcontractor Information, Former County Officials,
Audited Financial Statements, Insurance Information, Applicant Eligibility, and Complaint
and Grievance Procedures. Failure to submit these documents may result in the
application not being considered.
21. Submitted by:
23.
24.
Name: Betty A. Deal
(Typed)
Date: 3-22"'04
(Signature)
22. Title: Manager, Senior Companion Program
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