HomeMy WebLinkAbout11-Parks and Recreation
CITY OF SAN B()INARDINO - REQUEC1 FOR COUNCIL ACTION
. -
From: Annie F. Ramos, Director '''~:'::.-Slibiect: AUTHORIZATION FOR APPLICATION AND
,,_ AIlMINISTRATION OF AN ACTION GRANT IN
Dept: Parks, Recreation & Community Ser~~cef " . THE 'AMOUNT OF $238,487 TO CONTINUE
tHE iADMINISTRATION ANO OPERATION OF THE
Date: March 25, 1992 SENIOR COMPANION PROGRAM FOR THE PERIOD
JULY 1, 1992 THROUGH JUNE 30, 1993.
Synopsis of Previous Council action:
The Mayor and Common Council has approved application and administration of ACTION
grants for the administration of the Retired Senior Volunteer Program and the
Senior Companion Program since 1975, the last approval being on June 17, 1992
for the RSVP.
Recommended motion:
That the Director of Parks, Recreation and Community Services be authorized to
apply for and administer an ACTION Grant in the amount of $238,487 to continue
the Senior Companion Program for period July 1, 1992 through June 30, 1993.
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Contact person:
Annie F. Ramos
Phone: 5030
Supporting data attached: Staff Report and App 1 kat ion
Ward:
City Wide
FUNDING REQUIREMENTS:
Amount: $48.620
Source: (Acct. No.) 001-381-53812
and volunteer expenses.
(Acct. Description) Grant Match - City Cash Match for salaries
Finance: ''/;I..-I''':/'.: / ,c'br,.
'J" ,4/1'(/
Council Notes:
75-0262
Agenda Item No / J
C~TY ~F SAN ~NARDINO - REQUECr FOR COUNCIL ACTION
STAFF REPORT
AUTHORIZATIOII FOR APPLICATIOII
UD ADMIIIISTRATIOII OF U ACTIOII
GRANT III TBB AMOUNT OF $238,487
TO COIITIIIUB TBB ADMIIIISTRATIOII
UD OORATIOII OF TBB SBIIIOR COKPUIOII
PROGRAM FOR TBB PBRIOD JULY 1, 1992
THROUGH JUIIB 30, 1993.
The Senior Companion Program is one in which low income
seniors serve as companions for frail elderly or disabled to
help them to remain in their own homes or return to their own
homes, thus avoiding institutionalization. The Senior
Companions are volunteers who, because they are low income,
receive an untaxed stipend of $2.45 per hour plus help with
lunch and transportation. This enables low income seniors to
serve as volunteers, thereby keeping them active and in their
own homes as well as the clients they serve.
The City will provide a total local match of $60,920 which
will include salaries for full and part time employees and
expenses for volunteers. This match is funded through the
General Fund budget for administrative services, in-kind city
contributions such as office space, utilities, custodial,
recognition, accounting, etc., and contributions from the
community for meals, services and donations.
This program has been renewed annually since 1975 and
currently has 60 companions who are providing 252 clients with
over 5,627 hours of service each month.
3/25/92
u
75-0264
. -0
APPUCATlONFOR
FEDERAL ASSISTANCE
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436-9017/11
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Cit of San r a
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300 North "0" Street
San Bernardino, CA 92418
County of San Bernardino
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Betty Lewison (909) 384-5100
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238,487.10
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48,620
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.. YES. TMS 'IlEAPI'UCA~TIClN WAlIoIADE AVAUILE TO THE
&TATE EXECUTIVE 0IlllEII Q:I7Z'1ID ,- PORIlEVIEW ON:
nlI WITli' '
DATE
b. NO. cJ: 'AOClMM IS NOT COVERED IV Eo O. Q:I7Z
.10
C 0Fl1'llOGlWol HAS NOT lEEN IILEC1ED IV &TATE l'OlIlIEVIEW
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22,442.
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g. TOTAL
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309,549.
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Annie F. Ramos Recreation & Comm. Svs. 0
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(1) VOLUNTEER SUPPORT EXPENSES
L 0JtANTEE PERSONNEL (1) (2) (3) (4) ~) (6)
EXPENSES Annual Is~~ Total Funds NOII-edcraJ .J~~
PIIsuioD Tide Salary .1011 Cost Requested Resources
Director S 100'" S S $ S
33,509. 29,67l. 3,707. 13l.
Clerk/Typist 70 12,462. -0- 12,462.
Coord. of Vols. 50 8,514. -0- 8,514.
Accountant 20 6,619. -0- 6,619.
TOTAl-PERSONNEL EXPENSES 5 lJI 562.355. 529.67l. 525 934. $ 6 750
b. FlUNGE BENEl'lTS 16 696. 3 000. 10.776. 2.920.
c. rn GRANTEE STAFF LOCAL 1'RA ~ 805. 405. 400.
c. (2) GRANTEE ST AFFLONG DlSTANCE 1'RA va 900. 900. -0-
d. EnUlPMEm
e. SUPPLIES 250. 100 1'iO. .
f. CQ!::!IR.a.~'AL SERVICE
I!. onB: Postaae 300. 200. 100.
Communications 720. 462. 258.
Priminl! 500. 300. 200.
Space 'i.4nn _n_ _n_ e; 4nn
h. INDIRECT COSTS
i. TOTAL VOL . SUPPORT EXpEN 58'7.926. lot "Ie;. 038. ot "17. R1 R. 115 . n'7n
(2) VOLUNTEER EXPENSES
a. PERSONNEL EXPE!-SES
Sti- ~.A14 1/;1I~ _n_
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b. FlUNG! BENEJ'rTS
Meals - 22 "72 ] A 11' 1.'7e;n 2.71n
fleA
Unifonns
J 263. 263. -o-
R-won 1 450. 660. 790.
Other: Phusica1 Exams 3 300. -0- 3.300.
c. 1'RA VEL 22 260. 15 600. 2 000. 4./;60
d.EQUIPMENT ". : . . ,',.;.":.,. . . ............... I..:............. ; .;'-.'. ... ^ "
e."SUPPLIES . .... . . .. ...-.-.-,-,.... .--'... ....... .. .....................
f.' S VICE .' ..... '-:';:'.:'. :;:.~::::..:.;.,.::;::::::~;.:'; .. ::.:::::::'::~::;-:K; .. .'.,- ',':-i~:': .,.'- . ,..,",~ ........ .
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h. TOTAL VOLUNTEER EXPENSES S221 62-3. S2n"lAAQ $ 1 0 8.n4 $ '7 "I'7n
i. TOTAL COSTS $309 549. $2311 4117 $ 48.622 $ ')? 4An
(3) PERCENTAGES 100'1> I 77% 16% 7%
Q PART I I -BUDGO
AcnOS PORM .2A.o\A (10.901
Page 2
Moddled Sf 424A (4~11
_bod'" OMS c:u...w A.Ill:
SENIOR COMPANION PROGRAM
BUDGET JUSTIFlCATlO~
Grant' 436-9017
July 1; 1992 tbru June 30. 1993
o
1.
VOLUNTEER SUPPORT EXPENSES:
A. Grantee Personnel Expenses:
Salaries and fringe benefi~s are
based on grantee's sslary scbedules
estabUsbed by resolution of tbe
Mayor and Common Council.
1. Project Director: (1001 time)
$16. i 1 per hr x BObra x 26 pay periods
2. Clerk/Typist:(701 time)
49.42 per hr x BOhrs x 26 pay periods
x 701
3. Coordinator of Volunteers:(501 time)
$8.186 per hr x BObra x 26 pay periods
x 501 .
4. Accountant:(201 time)
$15.91 per br x BOhrs x 26 pay periods
x 201 - $6.619.00
TOTAL PERSONNEL EXPENSES
B.
Fringe Benefits:
1. Project Director:
2. Clerk/Typist:
3. Coordinator of Volunteers:
4. Accountant:
TOTAL FRINGE BENEFITS
C. Grantee Staff - Local Travel:
The Project Director will travel
an average of 150 mi. per month
x 12 mos. @ 25C per mi. - $450.00
The Coordinator of Volunteers will
travel an average of 125 mi. per
month x 12 mos. @ 25C per mi. - $375.00
D. Grantees Staff - Long Distance Travel:
The Project Director will attend
2 ACTION Training Conferences.
2 R.T. airfare @ $300.00
6 days @ $100.00 per diem - $600.00
(Includes room, meals and otber
related expenses.)
FEDERAL
NON-FEDERAL
EXCESS
NON-FEDERAl
*- INCLUDES $854.00 ADM. COST INCREASE
i
*$29,671.00 $ 3,707.00
-0-
13,713.00
-0-
8,514.00
-0-
-0-
6,750.00
$ 29,671.00 $ 25,934.00
$ 3.000.00 $
-0-
-0-
4,808.00
4,537.00
1,431.00
$ 131.00
-0-
-0-
6.619.00
$ -0-
-0-
1,464.00
1,456.00
$ 3.000.00 .$ 10,776.00
$ 2,920.00
$ 405.00 $ 25.00
-0- 375.00
$ 900.00
-0-
$ -0-
-0-
-0-
VOLUNTEER SUPPORT <:)ENSES (Continued) EXCESS
-~ NON-FEDERAL NON-FEDERAl
E. . Supplies:
Consumable desk-top supplies are
estimated to cost ~250.00 $ 100.00 $ 150.00 $ -0-
G. Other:
1. Postage:
Postage costs are estimated
at $300.00 200.00 100.00 -0-
2. Telephone:
Phone costs are estimated at
$600.00 per mo x 12 mo. . $720.00 462.00 258.00 -0-
3. Printina and Photocopying:
Based on actual cost:
834 pages @ 5C x 12 mo. . $500.00 300.00 200.00 -0-
4. Space: (Maintenance & Utilities)
SCP is housed in the City's Senior
Citizens Center and utilizes 1,032
sq. ft. of space, which is 8% of the
total building space of 13,000 sq. ft.
Custodial Service . $36,500.00
Utility Costs . 31,000.00
$67,500.00
$67,SOO.00 x S% . $5,400.00 -0- -0- 5,400.00
TOTAL VOLUNTEER SUPPORT EXPENSES: $35,038.00 $37.818.00 $15,070.00
VOLUNTEER EXPENSES:<=> ~ EXCESS
2. NON-FEDERAL NON-FEDERAL
A. Personnel Expenses:
1. Stipends:
66 volunteers x 1044 bra. @ $2.45
per br. $168.814.00 $ -0- $ -0-
B. Fringe Benefits:
1. Hesb
66 volunteers x 228 working
days @ $1.50 per day - $22,572.00 18,112.00 1,750.00 2,710.00
2. Insurance:
Accident: 66 volunteers x
$1.10 -72.60
P.L.: Hinumum premium - $45.00
Excess Auto: 53 vol. @ $2.75 -
$145.75 263.00 -0- -0-
3. Recognition:
66 volunteers @ $10.00, plus
sponsor and community donations
for additional meal costs, door
prizes, decorations, etc. in tbe
amount of $790.00 660.00 790.00 -0-
4. Pbysical Exams:
66 volunteers @ $50.00 -0- 3,300.00 -0-
C. Travel:
53 volunteers vill drive tbeir own
vebicles and are limited to $35.00
per montb - 53 x 12 x $35.00 - $22,260.00 15,600.00 2,000.00 4,660.00
13 volunteers use public trans-
portation @ $1.00 per day x 228
working days - 13 x $1.00 x 228
days -0- . 2,964.00 -0-
TOTAL VOLUNTEER EXPENSES $203,449.00 '$ 10.804.00 $ 7,310.00
TOTAL VOLUNTEER SUPPORT EXPENSES 35.038.00 37.818.00 15.070.00
TOTAL BUDGET $238.487.00 $ 48.622.00 $22.440.00
o
o
Date March 6. 1992
~11I!r!~~!!QtJ
OF
AUD IT
. City of San Bernardino Senior Companion Program
Grantee Na.e
bad it
accountinq systea audi ted by KPMG Peat Marwick
(Accountinq Firm)
725 South Figueroa St. Los Angeles.-Ca. 90017
(Address )
and the results are conuined in . repor't dated: December 31. 1991
Certified by
O-l) Or-
Signature
3/6;92
Date
City of San Bernardino
.
Sponsor IS Nlme
.. e:;.... 1';:<' ''"0
n~",~'I;l w::'~
MAR - U 1992
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SECTION B-PROJECT MANl't EMENT
1. (New Applications Only}-Attach the following d~ts:
a. A chart showing all ~or orpnizational components of the sponsoring orgjlni....riou. Include the
proposed project staff and its ~g relationship to the sponsoring organization. Show how the
proposed Advisory Council will function independendy of the sponsor's Board of Directors.
b. A list of the cunent Board of Directors showing name, address, and organizational or community
affiliation.
c. The cmrent resUllll! of the Director of the sponsoring agency or the project director if nominated and the
job description of the project director.
2. (Renewal Applications Only}-Attach the following documents ONLY IF there have been changes since
they were last submitted. (please check appropriate box).
Not Attached
(No Chanl!e)
Attached
a. Sponsor's organizational chart
b. Board of Directors
c. Project Director's cmrent re~ and job description
~
~
~
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o
o
3. a. (New Applications Only}-Describe plans for the daily supervision of volunteers. (Do not give,names
of persons).
b. (Renewal Applications Only}-Describe plans for daily supervision of volunteers ONLY IF there has
been a change since previous submission. Check box if no change. ..KI
Page 4
~
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4. L (New Applicalions Only)-Describe here, or attach, sponsor's plan for volunteer orientation.
b. (Renewal Applications Only)-Describe plan for volunteer orientation ONLY IF there has been a change
since previous submission. Check box if no change. gI
5. RSVP only:
L (New Applicalions Only) Describe plan for transpOrtation of volunteers to volunteer assignments.
b. (Renewal applications Only) Describe plan for volunteer transportartion ONLY IF there has been a
change since previous submission. Check box if no change: ~
Page 5
""'\
6. (New Applicadons Onl) ~How would your proposed project flw. "Y""ific need, one not being ~sed by
other organizations?
Clearly identify the proposed service area(s) in geographic terms, Le., city, town, county, etc.
Include information on appropriate senior population of project's service area. For FOP, also include
population information on children with special and exceptional needs.
7. L (New Applications Only)-List the names of public agencies and private nonprofit organizalions which
have expressed a willingness to utilize volunteer assistance. Attach a sample Memorandum of Under-
standing.
b. (Renewal Applications Only)-Attach a sample Memorandum of Understanding. AttaCh a list of
volunteer stations, specifying:
. Name and address of station (identify with an asterisk all proprietary health-care facilities).
. Type of station (e.g., school, hospital, etc.)
. Number of volunteers assigned.
. Brief description of volunteer services provided in each station.
. Date when Memorandum of Understanding was last reviewed and signed with each station.
. (FOP/SCP Only) Type(s) and number of special needs of children/adults served in each station.
Page 6
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SECTIONC-COMMUNITY INVOLVEMENT
1. (New Applications On1y~Attach three letters of supponreferencing knowledge of and suppon for proposed
project.
2. (New Applications On1y~Describe how potential volunteers, or persons to be served, or their representa-
tives, were involved in the development of this application.
3. a. (New Applications Only)-Specify your plan for establishing the project's Advisory Council. Member-
ship should reflect the population characteristics of the project service area and include volunteers, persons
served or their surrogates, representatives from ethnic and minority communities, the handicapped, and
community leaders.
b. (Renewal Applications Only~Attach a list of current members of the Advisory Council showing their
organizational or community affiliation.
4. a. (New Applications Only~Describe sponsor's plan for regular appraisal by the Advisory Council of
project management and the progress in meeting the project's goals and objectives.
b. (Renewal Applications Only~Attach a copy of current Advisory Council project evaluation.
Page 7
OENIOR COMPANION PROGRAM VOLUN'O STATIONS
1. Adult Day Health Care Center
3102 East Highland Avenue
Highland, CA 92346
This is a medical-model Day Care Center for adults with both physical and
mental problems. Six companions are assigned to twenty-one participants.
Services include assisting with eating, reading, taking for walks outside,
encouraging exercise, reality orientation, and listening. MOU signed 12-16-91
2. Casa Bernardine Retirement Home
1589 North Waterman Avenue
San Bernardino, CA 92404
This is a retirement home for adults who are ambulatory. One companion.
-is assigned to four. residents. Services include grooming, walking, reading,
listening, writing letters and reminiscing. MOU signed 12-05-91
3. Department of Public Social Service
494 North "E" Street
San Bernardino, CA 92401
DPSS utilizes nine companions to serve thirty- six homebound, isolated
clients. Services include grocery shopping, meal-preparation, reading mail,
assisting with money management, monitoring medications, and information &
referral. MOU signed 12-09-91
4. Family Services Agency
1669 North "E" Street
San Bernardino, CA 92405
FSA is multipurpose community service agency with two special services for
seniors. One is limited medical transportation and the other is a respite!
counseling service for family caregivers. Three tompanions are assigned to
twelve clients providing in-home respite care. MOU signed 12-11-91
5. Mental Health Association
600 South "-e" Street .
San Bernardino, CA 92408
MHA sponsors a mental health day-support center for adults who need assistance
structuring their time and activities on a daily basis. TareeCompanions are
assigned to ..~ine participants, encouraging them to participate in various
daily living experiences and assisting them in learning basic tasks to help
them be independent. MOU signed 12-12-91
6. National In-Home Health Care
(Now called Arrowhead )
1800 Western Avenue, Suite 302
San Bernardino, CA 92411
NIHH provides a variety of in-home health care services, utilizing nurses,
attendants, and companions. Three companions are assigned to eleven clients
providing respite care for family caregivers. MOU signed 12-16-91
,,..
SENQCOMPANION PROGIWI VOLUNTEER SOlONS - ~ase.2
7. Pacific Park Convalescent Hospital
1676 Medical Cen~er Drive
San Bernardino, CA 92411
This facility utilizes four companions assisned to sixteen patients.
Patients assisned are tbose needins extra personal attention and
encourasement to exercise, eat and socialize in order to return to
their homes. MOU sisned 12-11-91
8. Crestview Convalescent Hospital
1471 South Riverside Avenue
Rialto, CA 92376
This 200-bed facility utilizes two companions to serve six patients.
Activities include socialization, letter-writing, listening and
encouraging participation in group activities. MOU signed 07-25-91
9. Senior Home and Health Care
686 Eaat Mill Street
San Bernardino, CA 92415-0640
SHARC providea caae management services to the homebound, isolated
elderly. They utilize one companion to serve five clients.
Services include meal-preparation, grocery abopping, reality orientation,
housebold management, assistance witb mail and paying billa. and
companionship. MOU signed 12-13-91 .
10. Senior Services Center Outreach Program
600 West Fifth Street
San Bernardino. CA 92410
The Outreach Program aerves tbe homebound. isolated elderly population
by providiDs various aocial services through referral and networking.
Eight companions are assigned to thirty clients, providing companionship.
grocery sbopping, .eal-preparation. reading, wrUiDg. lIlonitoring .edicat-
ations, and iDformation/referral. MOU signed 02-26-92
11. Chateau Village Convalescent Hospital
620 East Highland Avenue
Redlands, CA 92374
This is a new site for us. At present one companion is assigned to three
residents, reading & writing for them, giving them personal attention and
encouragement to exercise, eat and join in the various activities.
MOU signed 02-26-92:
12. Valley Convalescent Hospital
1680 North Waterman. Avenue
San Bernardino, CA 92404
This facility utilizes one companion serving three residents, providing
friendship, attention, encouragement and hope. MOU signed 12-05-91
~
SENC:>COKPANION PROGRAM VOLUNTEER ~lONS - Page 3
13. Shea Convalescent Hospital
1335 North Waterman Avenue
San Bernardino, CA 92404
This facility has four companions serving sixteen patients. Patients
assigned are those needing extra personal attention and encouragement
to exercise, eat and socialize in order to return to thp.ir homes.
MOU signed .02-26-92
14. Medical Center Convalescent Hospital
467 East Gilbert
San Bernardino, CA 92404
Two companions are assigned to six patients in this convalescent
setting. Their duties include giving personal attention, encourage-
ment to eat, exercise and socialize with other patients, volunteers
and staff. MOU signed 06-21-91
15. VA Hospital Case Management Program
11201 Benton Street
Lama Linda, CA 92357
This unique outreach program links non-hospitalized veterans with
community resources. Two companions are assigned to six clients
providing services such as grocery shopping, meal-preparation, com-
panionship, walking, reading, etc. MOU signed 02-~-92
16. Visiting Nurses Association of Pomona - West End
636 Brier, #190
San Bernardino, CA 92408
The VNA provides in-home nursing services and case management for
people released from acute care hospitals. This agency has five
companions assigned to twenty. clients. Services include meal-
preparation, grocery shopping, assistance with walking, eating, and
exercising, and companionship. MOU signed 02-27-92
17. Westside Drop-In Center
1505 West Highland Avenue
San Bernardino, CA 92411
This center provides a variety of community services including
emergency food, housing and utility payments, job development,
insurance counseling, tax service and in-home services. The Beven
companions are assigned to twenty-eight clients and provide services
including grocery shopping, meal-preparation, companionship, reading
writing, household management, going for walks and information/referral.
MOU signed 12-09-91
.""
SENq COMPANION PROGRAM VOLUNTEER SOlONS
- Page 4
18. Senior Services Department
Community Center
First Street and Avenue B
Yucaipa, CA 92399
This station is a multi-purpose community center, with a special senior
services department. One companion is serving six frail elderly clients
in their homes, providing grocery shopping, paying bills, reading, writing,
reminiscing and trying to "protect" them from various frauds and schemes.
Yucaipa's population is 40% over 65, with many in their 80's & 90's,
leaving them very vulnerable. MOU signed 02-27-92
19. St. Bernardine Medical Center Home Health Care Agency
2101 North Waterman Avenue
San Bernardino, CA 92404
This agency provides in-home health care to patients recently released
from the hospital. Two companions are assigned to eight in-home clients
providing services such as meal-preparation, grocery shopping, household
management, encouraging exercise and promo~ing reality-orientation.
MOU signed 01-21-92
20. Riverside/San Bernardino Alzheimer's Association
11108 Anderson Street
Loma Linda, CA 92357
This Association provides information, assessments, education and
assistance to families who have members afflicted with Alzheimer's
Disease. Three companions are providing respite aervices to six families.
MOU signed 02-27-92
_ 0/A.""'f \ -e.--
M E90 RAN DUM ~F UN DE ROr AND 1 N-G
Between
.CITY OF SAN BERNARDINO'
SENIOR COMPANION PROGRAM
SENIOR CITIZENS SERVICE CENTER
600 West Fifth Street
San Bernardino, CA 92410
(714) 384-5100
AND
NAME
ADDRESS .
PHONE
1. The sponsor will:
a. Recruit, interview, select and enroll volunteers in the project.
b. Provide orientation to volunteer station staff prior to placement of volun-
teers, and at other times as the needs arise.
c. Refer volunteers to volunteer station for placement..
d. Designate a staff person to serve as liaison with volunteer station.
e. Furnish adequate accident and liability insurance coverages as required by
the program.
f. Retain full responsibility for the management and fiscal control of the
project.
g. In cooperation with the program Advisory Council, arrange for a volunteer's
appeals procedure to resolve problems arising between the volunteer, the sta-
tion and/or the sponsor.
h. Assign Senio~ Companions to serve adults between the
hours of ~.oo A I:l and r.;.OO PM' on the following days of the week:
Monday ~ru Frlaay
i. Specify activities to be performed by the volunteer under the direction of the
program staff, in cooperation with the volunteer station.
j. Approve individual written plans of care for each client.
2. The volunteer station will:
a. Designate to serve as liaison with the
sponsor.
b. Integrate Senior Companions into individual written care plans that address
the social and health needs of each client.
c. Where appropriate, assure adequate health and safety provisions for the pro-
tection of volunteers.
d. Collect and validate appropriate volunteer reports for submission to the
sponsor.
o
~/
0-
e. In consultation with the sponsor, make investigations and reports regarding
accidents and injuries involving volunteers. The volunteer station is not
liable for accidents involving the volunteers. .
f. Assist the program staff in the coordination of volunteer assignments, orien-
tation, in-service training and other pre. gram related activities.
g. Select and provide adults tG be served by the volunteers.
h. Designate service space for use by volunteers in their activities. (This
depends on the nature of the volunteer station.)
1. Provide the following meal arrangements f(lr volunteers chargeable to non-
federal support at $2.00 each day. (This depends on the nature of the volun-
teer sta t ion. )
j. Provide the following transportation arra'~ements for volunteers chargeable
to non-federal support at $2.00 a day. (This depends on the nature of the
volunteer station.)
k. Obtain a written agreement from person(s) to be served or from persons legally
responsible for the adult to be served by the volunteer in a private home. .
(The document authorizes volunteer service in the home, and requests specified
volunteer activities.)
THIS MEMORANDUM MAY BE AMENDED AT ANY TIME BY THE PARTIES INVOLVED.
SIGNATURE FOR VOLUNTEER STATION ~
TITLE
DATE
SIGNATURE FOR SENIOR COMPANION PROGRAM
TITLE
DATE
MEMORANDUM UPDATED
SIGNATURE FOR VOLUNTEER STATION
TITLE
DATE
SIGNATURE FOR SENIOR COMPANION PROGRAM
TITLE
DATE
",
b.t;1'4J.U~ \..V.lYU'I"U.,...V,", ~ ~....,~~...
~. VISORY COUNCIL MEMBERSO
, JANUARY, 1992 -
GARCIA, MADELINE
1415 West 16th Street
'San Bernardino, CA 92411
~KINS, JOSEPHINE
Senior companion
PO Box 1057
Rialto, CA 92377
AGUILAR, MAYELA
RSVP Director
600 West Fifth Street '. (
San Bernardino, CA 92410-3289
ANDERSON, GRACIE 823-7291
Senior Companion
7405 Laurel Avenue
Fontana, CA 92335
BROOKS CYNTHIA 384-5136
Senior' Affairs Coordinator
600 West Fifth Street
San Bernardino, CA 92410-3289
882-2575
CAMPBELL, FAIRFAX S.
7968 Cunningham, 12
Highland, CA 92346
CISMOWSKI, SHIRLEY
Water Dept., 5th Floor
Ci ty Ball
300 North "D" Street
San Bernardino, CA 92418
EARLY, GARDA 792-1909
Senior Companion
750 East Pioneer Avenue
Redlands, CA 92373
.
EWING, BOB
City Librarian
Feldheym Library
555 West 6th Street
San Bernardino, CA
BROWN, SHEILA
General Manager
KCKC/KBON Radio
PO Box 2565
. San Bernardino, CA
BUTLER, MONTE
ACTS
24949 Prospect
Lama Linda, CA
Avenue
92354
BYARS, R. WADE
congressional Asst. to
George E. Brown
657 N. LaCadena Dr.
Colton, CA 92324
887-1366.
384-5253
92406
796-8357
825-2472
9'1"1 -'~"'f(1\)
864-3522
384-5391
381-8211
8201
92410
889-7436
FISHER, EARLYNE
1325 Colorado Avenue
San Bernardino, CA 92411
885-4770
HOOF, HAL
P. O. Box 7083
Loma Linda, CA
92354
INLOES, DON. 886-6737
Vice President of Resource Development
Family Services Agency
1669 North "E" Street
San Bernardino, CA 92405
KIPP, DON . 1-800-564-9622
Chief Field Rep. to Senator Ruben Ayala.
9620 Center Avenue, Suite '100
Rancho Cucamonga, CA 91730
McKENNELL, MARY 825-7084 X 2281
Jerry L. Pettis Memorial Veterans Hosp.
11201 Benton Street
Loma Linda, CA 92357
MUKARRAM, AMEENAB 864-5197
Senior Compa~ion
2727 East Pacific Street, '92 ~
Highland, CA 92346
NEWMAN, VENNY 945-3860
Volunteer Coordinator DPSS
9638 7th Street
Rancho Cucamonga, CA 91730
O'NEAL, ED 783-1371 Bome
Special Field Rep to 387-4846 Work
Supervisor Barbara Cram Riordan
385 North Arrowhead, 5th Floor
San Bernardino, CA 92415-0110
POULOS, PHYLLIS 820-1902
Field Rep. to Assemblyman Jerry Eaves
224 North Riverside Avenue, Suite A
Ria1to, CA 92376
DES,
571
Hi
PTON,
Se' Com
5 rth" Sue
an Be ino,
>.
861 1441
-
...J.--,.., ~~u",l,
h...",("'
.88' 5834
"f\ '
'301 .:...;~CI!AS te
10 1-'fZ-
799-3212 Home
Ho~pital-882-~215
WILSON, BARBARA
Waterman Convalescant
PO Box 1737 .
Loma Linda, CA 92357
HOLCOMB, W.R. "BOB", MAYOR
City of San Bernardino
City Hall Plaza
300 North "D" Street
~__ ______A~~_ ~~ G?A1a
Ext. 5133
.
o 0
CITY OF
San Bernardino
PAIIKS, ItECREATIOII . CO..UNITY
IERVICE. DEP"RTMENT
SENIOR COMPANION PROGRAM
600 West Fifth Street
San Bernardino, CA 92410
March 2, 1992
PROGRAM EVALUATION SUMMARY
The Evaluation Committee of the Senior Companion Program's
Advisory Council has observed the program from several vantage
points. We have interviewed both Senior Companions and clients
of the program. We have heard ~omments about the double-edged
rewards of being involved---advantages to the giver and to the
receiver of services. We have helped with the training of new
Senior Companions. We have seen the involvement of the SCP staff
in other community organizations.
All of the above listed involvements confirm that the program
is effectively and efficiently administered, develops and maintains
high morale and, most importantly, serves those who need to be
served. The most moving conversations have been with recipients
of Companion services, as they talk about the joy, practical ad-
vice and genuine friendship their Companions bring to their lives.
Program Director, Betty Lewison, shows great skill in know-
ing how to work well with her staff, volunteers, referring agencies
and Advisory Council members. The meetings for the Council are
well-organized. As members of the Council, we know what is going
on and we are asked for advice and assistance in many areas when-
ever the need arises.
We have great praise and admiration for the Senior Companion
Program. Our community is fortunate to have this resource, and
we are indeed fortunate to have the outstanding leadership exhib-
ited by the program staff.
i~
Campbell, Chairman
&47 N. SIERRA WAY, SAN BERNARDINO.
CALIFORNIA 924'0.4816 7t./........
PRIDE .f
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OMB Appvv.JNo.03CI~
ASSURANCZS-NON.c:oNSBUCUOOGRAMS
ClInaInof........ll _..._...~. .,.......,................If,........ ~...,a-_lIIo"""',-"
............r.IaIl.~oIlI- I~"'nq*c~." -.aalIfjlll-~~~_ ....If...lIlIIo-.,.wiII...-m.s.
.....:
A1111a6dy..t..a -.11..... r -=wollbe....../:-' ..-Ify1bat1he1lJlP1k-l:
I. .... ...1opI...., .....J .........ai -..-..... .........
--""P'"' - lNl.'''-.:w...,-~OMl''''''''''''
.....,., .... .. III fIR' .... or.... _) .. _ ......
r...." -- J . .. 11_/ . · of... .... ........... ......
."Ii ~I
:a. WiII.......~- -....,....- ... lIoro-atof..w.t
..... _"...,. . '- .. s-........,.................. ~
..... _. ad"liIlI& ....... all -*. ..... .......
.1 ~ .......... awIIII; ad will.............. . ..
.,..... . . - trida ..-DJ . .....1IIIlOaIIIbIJ ........
1pIlC)'6.C1i_ .
,. WiD ealIIlab .... .. ....liIaploJwl..... ... dIdr poIi-
liaDs Ior.JIIIIPOIC'" OOlISIiMUorpueall_.......-"rpalOllll
........_I-aicl.,iIaIeIl,.pcnDIII! pia.
4. WiD laiIiIIe ad -.- _ woII< wiIIIiD _ IppIicolllo IilIlo .....
..... noIipl or lIpJIIII'lI .,.... ...riDa 1pIlC)'.
5. WiD ....IJ wiIh .... ........,_ -I PonoIll101 Act or 1970 (42
u.s.C.'1 ~"')ftIIIIlI& toplUCllbod aDdInIs formalllJllOllll
lor JIIOJlOIIlI faDdoIIlIIdor _ or.... iii-. - . np\IIiau
v..""" . AppeaoII. A or OPM'. SIIDdInIs far . Mail SJSICIIl .,
Par ,_I U.... 1 I Aio& (5 c.F.R. lMlO. Sobpln F).
6. WiD -plJ willi III FeoIaII _ R1aIiIt& .. -'" . "'""-
",..iodadc..... Mllimllllll to: (0) TII1& VI or.... ad...... Act
or 1964 cPJ. '~S52) wIddI po\lIIiII d;.........w""- _ .... .... or
-.coIororlllliaM1 oriIia: (II) 1lI1o lXor....Ed........ A.-' k
orl972.......... (2lI u.s.c. '116'1-1613. ...IAS-16I6), wIddI
r"""'" ...........w""- OD .... ... or Ia; (c) SllClioa 504 or..
'."-~OII Act ., 1m. . . ~ (29 u.s.c. . 19C), wIIicII
pobiIIiIs lIis J.." "OII08dIe buis oBediolfS; (d)dleApDilc:dmi-
__ Act or 1m. . , .-. (42 u.s.c. H 610106107). wIIicII
,""",1iIIdiI~' i ~ _lIIo...orlp;(c)..Dna........OIIioe
ad T_ Act or 1972 cPJ. ~5). . . . 1IIIIiIt&..
aoa..&.-4..1 --!- _die ... of" .... (t)... C-. ... ;c
A1colaat AbaIe ad AJr"Gt-1l%- Fi~~-Ai~ T..... ad """"HI&.
IioD Aa oum cP.L '10616),. omrr"-l. ftIIIIlI& III -...........-
IioD _ die... or 1Icol!DI-- or .,-_... (a) .1523... m or
.... PaWi. HoIIdl s.mcc Aa or 1912 (42 u.s.c. 290 """, ODd 290.
S), . . ........ III _"...........,. or.Jocballlld ...... ....
pIIiclII.......; (b)1idc vm or. ad IlialuAct "U961 (42 u.s.c.
. 5601 . 181I.),. III1r "..1daIia& to n.............w....... i111he .....
n:DIa1 _ 1;--"':.. .r......; 6) .Y ...... p-...........1IIIiDa provi-
.... .Ihe IpOCiIc ....-.(I) ..... wIIicb IppIiCllioa for I'e-.I
, '-. -il.....8IlIc;0Dd(j)dlcRll.a. . "UJlIIbor-
...._.~....) wIIic:Ia..y 8pPIy ID 1bc ......r:...
7. WaD anp\J. or ....budJ ClOIIIpIied. trida _ nqaitelD_ "mdes D
ad m.,.... umr- bIocIriOll ........-- ODd Roo1I'n1pody Aoqai-
IiIion Policies Aa or 1m cP.L '14t6) wIIicb pnMdc far foir IIId
oqaiIallI. _.,....... d;'P"-' or...... JII'IIl'I'J illlllIuiIed
..lU1Ikofl'e-.l...r....I1JauiIIed""........ "'nq-
8ppIJ ... all ~ ill nil ........J ooquiled for pn>jeCl '1IlJIOICI
......... or I'e-.I plllic:ipllioo in pan:\lueI.
L WlllllllllplJwIIIa .."....lIhuor........Aa C$ u.s.c. H ISIlI-I..
... 7>>1-'7321) .....1iIIIIl.... fOIl1I-I ....of .1,.. .....
,a.IpII .....,.Jo, - ..Ai." _ ...... . ..... -. .. .-
,... .....
to WiDIIIIIIpIJ,.w-~.........."bd"of"~...~' -All
(40U.s.c. H 276&... ~7),'" ......-- Aa (40u.s.c..~"
I.U.s.C.HI74)......c:.-Wodd....ODdSarelJI- .~ All
(40 u.s.c. II S27-3SS), ......1IIa ._A-o. for fodIn11J....
till 1'- ... ~.
10. WiII.....,.,.If...r....... wIIIlII...II..._ .........,4. ---' or
SectIoalll2(o)or..RocoI~1\. 1 ~ AaorlmcPJ.9S-2M)
......nq..... ". .......IoolIIluInI_...J*IidPIIailldle
J'IOIIOID ... III r- '-- lIooII ~ If... IDIaI - of........
0Il0III1ICli0Il ad ooqllililioo II 510.000 or -. .
II. W......lJ willa ....._A.-..I aDdInIs wIIicIl .J .. ,....abed
...-..._.........: (0) luIIloliOJlof ....v0." ... .-JiIJ-.a
- _.....dIe Nllillllll E..\L ...11II1 PoIiC)' Aa .,1969 cP.L ,.-
19O).1IId Eaac:oIivc Order (EO) 11514; (II) ............... or wioIIliDa
facIIiIieI"..-...EO 117S1;(c)... ~.D"r.........'_...EO
11990; (II) avI1ua1ioaorllood .......1100""....... '-- widl
EO 11911; (c) __ orpnljoCl_lIil'"":r.,,- willa_ ~r....d S1a
-. '1 .. .....- devcIopoiI ..... die CDI&II Zaoe ..-. 1
Aa orl97206 U.s.c. .11451.181I'); (I)_-"""I'e-.I ""-
... SIII& (Qcu ~..... v . -.-....1IIdor SllClioa 1'76(.) or..
CuD AIr Aa or 1955. . ~. (42 U.s.c. . 7401 . ....); (&)
r 1 ~- of . r I _ or dIinIdDa - ..... .... We
1lrillIIIIlI'W...Acton974.....-~.(PJ.9S-523);...(b)r ~
or v'- _ .A............. En' -..... SpocieI Aa or 1973. .
III .~ (PJ. 93-a5).
12. Will ClllllJllJtrida die Wild udScaic ItiYIII Aa oU96I 06 U.s.C. H
1:Z71.....)...... 1 hili""" l.orpalallialllllDJ -or
.. DIIioM1 wlId...... dwn.,...
13. W............~'W.-JilI........ oampIionae wilIlSllClioa 106
ordlc NIIiDDI1 HillDlid\..... .....Act oU966.. .~ (16 U.s.c.
4'10), EO 11593 (idelllilCIIiao ad,.... OIl... orbilloJi. JII"IIClIieI),ODd
. ItrJo ",pal ad IIiIloIic .......... Aa or 1974 06 u.s.c.
469&-1 . ....).
14. W.._plJwilhP.L93-S4...........IheI".. .-,0r...........~
iavoI....in.-dl.deYCIop-.andtelamlCliviliesl1lpJlClllCdll)'lIIis
aWII'II of -.;--
15. W.. -.IJ wlllallle~ AIIiIIIII W.u-Act or 1966 cP.L 19-
544..- . ~.7U.s.C.:l131.",,)""".dIe....kmuO\;..
ad - -_ or __ lIIoadod IlllilDlllIIeId for........~. or
lIIbor octiwidellllJlllClllOd II)' 1IIis._ or ......-
16. W.. -.IJ trida ... '-d-1Iued PainI .......... ~ Aa (42
U.s.C. .1 4101 . ....) ,,1Iil:b pnIbIlIiII.... .. or Ica/I ......... poilIl in
CIIIIIItI'III:I. ~'-"'it";'OD oflidealill____
17. WIII_..... JI'If.....s Ihe nqaind ......... and CIOIIIp1iInao udiIs
in __ wiIh.... 5ina1e Ad Aa or 1914.
I'. Will anp\J wilIlalllpJllic:obl. ~ .r aIIl11bor Federal.....
CUClIlive...... lIIa1oIioas and paIicieI......,m, IIIis J'IOIIOID.
SIGNATURE OF AUTIfORIZED CERTIFYING OfFICIAL 1TILE Director ,
Parks Recreation & COIlUll. Svs.
APPUCANTORGANlZATION' DA'IE SUBMI'ITED
Citv of San Bernarn;no
Page 9
Authorized for Local Reproduction
SI8IIdard Form 42AB (4-88)
Prescribed by OMB Ciradar A-I02
0'.,
-
CD AnONS REGARDING (A) DEB~NT,SUSPENSlON
. AND 011lER RESPONSmlUTY MAnERS;
(8) DRUG-FREE WORKPLACE REQUIREMENTS; AND (C) LOBBYING
App1ic-'" should refer to Ihe ~1',1.riOllS cited below to determine which certification(s) apply to their pant, IIId
~view Ihe instructions included in the ~gu1ations. Signing this fonn complies with certification requiremenlS under
"Government-wide Debarment IIId Suspension (Nonprocurement)" and "Government-wide RequirementS for Dlug-
Free Workplace (GranlS)" (under 45 CPR Part 1229),1IId "New Restrictions CII Lobbying" (under 45 CPR Part 1230).
The cenifi,.atiOll(S) shall be treated as a material ~presentation of fact upon which ~liance will be placed wben
ACTION determines to award the covered ttlIIISaction. pant, or cooperative agreement.
A. DEBARMENT, SUSPENSION, AND 011lER
RESPONSIBILITY MAnERS
As required by Executive Order 12549, Debarment 8IId
Suspension, and implemented It 45 CPR Part 1229, for
prospective panicipanlS in primary covered transaCtions.
as defined It 45 CPR Part 1229, Sections 1229.105 8IId
1229.11G-
1. The applic8llt certifies that it 8IId its principals:
(a) ~ not presently debmed, suspended, proposed
for debarment, declaJed ineligible, or voluntarily
excluded from cove~ ttansactions by 8IIY Fed-
eral depanment or agency;
(b) Have nOt, within a three-year period preceding
this application, been convicted of or bad a civU
judgment ~ against them for commission
of fraud or a criminal offense in COMection with
obtaining, attempting to obtain, or peIforming a
public (Federal, State or local) ttlIIISaction or
contract under a public transaction; violation of
Federal or Swe 8lltitruSt swutes or commission
of embezzlement, theft, forgery , bribery, falsifi-
cation or destruction of ~cords, making false
SWemenlS, or receiving stolen propery;
(c) Are not presently indicted for or otherwise crimi-
nally or civilly charged by aFederal.State orlocal
government entity with commission of any of the
offenses enumerated in paragraph 1 (b) of this
certification;
(d) Have not, within a three-year period preceding
this application. had one or more public transaC-
tions (Federal, State orlocal)terminated for cause
or default; 8IId
2. Where the applicant is unable to cenify to 8IIY of the
statements in this cenification, he or she shall anach
an explanation to this application.
B. DRUG-FREEWORKPLACE
(GRANTEES OTHER THAN INDMDUALS) .
As requ~ by the Dlug-Free Workplace Act of 1988,
and implemented at 45 CPR Part 1229, Subpan F, for
pantees. as defined It 45 CPR Part 1229, Sections
1229.605 8IId 1229.61G-
1. The applicant certifies that it will or will continue to
provide a drug-free workplace, 8IId will:
(a) Publish a statement notifying employees that the
unlawful manufacture. distribution, dispensing.
possession or use of a controlled subst8llte is
prohibited in the panlee'S workplace 8IId speci-
fying the actions that will be taken against em-
ployees for violation of such prohibition;
(b) Establish 811 on-going drug-free awareness pr0-
gram to inform ernployees about-
(1) The d8l\gers of drug abuse in the workplace;
(2) The pantee's policy of maintaining a drug-
free workplace;
(3) Any available drug counseling, rehabilita-
tion, 8IId employee assist8l\te programs; 81\d
(4) The penalties that may be imposed upon
employees for drug abuse violations occur:
ring in the workplace.
(c) Make it a requirement that each employee to be
engaged in the performance of the grant be given
a copy of the swement ~qu~ by paragraph
1(a);
(d) Notify the employee in the statement ~quired by
subparagraph 1(a) that. as a condition of employ-
ment under the grant, the employee will--
(1) Abide by the terms of the swement; 81\d
(2) Notify the employer in writing of 8IIY convic-
tion for a violation of a criminal drug statUte
which occurred in the workplace, no later
than five calendar days after such conviction;
ACTION Form 424.E,F,G (1191)
Page 10
...
(e) Nodfy die CTlON Grants Officer
within teD ep1_".wdays afterJeCeivingnOlice of
such convicticll UDder subpmpapb (d)(2) from
the employee. or otherwise JeCeiving ICtUIlIlO-
nce. The n~ shall iDclucle die title of die
employee's position and the identification
number(s) of each affected pant;
(t) Take one of the following actions, within 30
calendu days of receiving notice under
subparagraph 4b. with mpect to lilY employee
who is so convicted-
(1) Take appropriate personnel action apinst
such an employee up to and including termi-
nanon consistent with the requirements of the
Rehabilitation Act of 1973. as amended; or
(2) Require such employee to participate satis-
factorily in a drug abuse assistance or reha-
bilitationprogramapprovedforsuchpmpoJeS
by a Federal, SWe or local health. law en-
forcement, or other appropriate agency;
(g) Make a good faith effort to continue to maintain
a drug-me workplace through implementation
of paragraphs I(a) through I(t).
2. The grantee shall insen in the space provided below
the site(s) for die perfortDlllCC of wort done in
connecdon with the specific grant:
Place ofPerfonnance (Street addIess, city, county, &We.
zip code):
Senior Companion Proqram
600 West Fifth Street
San Bernardino. CA 92410-3289
o Check here if there are grantee workplaces that are
not identified above.
C. LOBB NG
As required by Secdon 13S2. Title 31 of the U. S. Code.
and implemented It 4S CFJl Pan 1230. fororpnizations
entering into a grant or coopemive agreement over
5100.000. as defined at 4S CFJl Part 1230. Sections
1230.IOS and 1230.110. the app1iclllt c:enifies thIt:
1. No Federal appropriated fundshave been paid or will
be paid. by or on behalf of me undersigned. to lilY
person for influencing or attempting to int1uence III
officer or emplOyee of any qency, a Member of
Congress. an officer or employee of Congress. or III
employee of a Member of Congress in ccmnec:tion
with the awarding of any Federal contract, the making
of any Federal pant, the making of any Federal 10lIl.
the entering into of any cooperative agreement, or the
extepsion. continuation, renewal. amendment, or
modification of any Federal conttact. grant, 10lIl. or
cooperative agreement.
2. If lilY funds other than Federal appropriated funds
have been paid or will be paid to any person for
influencing or attempting to inftuence an officer or
employee of any 1pIC)'. a Member of Congress. an
officer or employee of Congress. or III employee of a
Member of Congress in c:onnection with this Federal
CODttact. grant, 10111. or cooperative agreement, the
undersigned shall complete and submit Standard
Form-LLL, "Disclosure FOrm to Report Lobbying,"
in accordance with its instructions.
3. The undersigned shall require thIt the language of
this certification be included in the award documents
for all subconttacts It all tiers (including subcon-
uacts. subgrants, and contraclS under pants. loans.
IIId cooperative agreements)1IId thatallsublecipients
shall certify and disclose accordingly.
As the duly authorized represenwive of the applicant, I hereby certify that the applicant will comply with the above
certification(s). (A copy of the governing body's authorization for me to sign this certificanon as official represen-
tative is on file in the applicant's office.)
City of San Bernardino
. . .
Applicant Org811lZ8tlon
Annie F. Ramos, Director
Parks. Recreation and rnmmnnii-y
Printed Name and Title of Authorized Representative
Signature of Authorized Cenifying Official
~pr'tTi"'&:I
Date
Page 11
'-..
Y739-9300
CERTIFICATE
o
March 12. 19111
ReNEWAL
THE_CIMA COMPANIES INC
216 S-PEYTON STREET
ALEXANDRIA VA 2231'1 AGENCY CODE
2.115228
INSURANCE COMPANY OF
NORTH AMERICA
PO BOX 30390
TAMPA FL 33630-0390
SENIOR COMPANION PROG
(CASA51)
600 W 5TH 5T
SAN BERNARDINO CA 92'110
LICY NUMBER
G1180'l056
POLICY PERIOD
POLICY TYPE
OAVP
HAM
AlL A DR S OF INSURED
(EXPIRATION)
TO Julv 1. 1992
--------------------------------------------------------------------------------
1. OAVP PERSONAL LIABILITY
------------------------------------------------------------------------------
VOLUNTEERS INSURANCE SERVICE POLICY I
DECLARATIONS
------------------------------.------------------------------------------------
Thi~ policy, ~ubiEct to all it~ tErffi~' condition~ and liffiitation~. i~
continl,~d in force for .3 fUT.tt,:?T' p~riod of Tw~l,,~ (12) ffionth~ .?r..j shall
expirE on Julv 1, 1992, 12:01 d.n" Starld.3t,~ Tin.E at the plaCE or placE~
d~si~nat~d in said policy.
------------------------------------------------------------------------------
PERSONAL LIABILITY - LIMITS OF LIABILITY
PEr~onal Injury Liabilitv Dr
Property Da~a8~ Liabilitv or
bott. con,t,inEd
$1,000.000 Each occurrEnce
$3.000,000 annual a98re8at~
PREMIUM COMPUTATION
ESTIMATED NUMBER
OF VOLUNTEERS PER YEAR
RATE PER VOLUNTEER
PER YEAR OR PART THEREOF
ADVANCE
PF:EMIUM
----------------------
------------------------
65
A~ p~T tt.5 r~coTd of
the insured or~anlz3tiorl
MINIMUM
, . '10
'$ '15.0('
F'F:EMIUM: ., '15.00
------------------------------------------------------------------------------
508 RICHMOND, VAS
( CASA51-3 C'B
CDhM 15%
3/12/<,'1\
SIC83229/MHC=2
LD4787 & GL-1a1~
SCl
AAt G~//;
-A- )
".".,
~~~~~~ili~~~~:~~~~;:l~T~v:- --- -~:~ :~.
"'.
o
POLICY
CHANGE
o
All9 23, 1991
l'
NAME
THE CIMA COMPANIES INC
216 S PEYTON STREET
ALEXANDraA VA 223141 AGENCY CODE
215228
IL A ESS F INSURED
SENIOR COMPANION PROGRAM
( CASA51>
600 WEST 5TH STREET
SAN BERNARDINO CA 92~10
INSURANCE CD OF NORTH AMERICA
PO E:OX 30390
TAMPA FL 33630-0390
OLley TYPE
OAVP
POLICY PERIOD CINCEPTION) (EXPIRATION)
July 1, 1991 ro July 1, 1992
Change effective July 1, 1991
--------------------------------------------------------------------------------
1. OAVP EXCESS AUTO LIABILIT
------------------------------------------------------------------------------
VOLUNTEERS INSURANCE SERVICE POLICY
------------------------------------------------------------------------------
AUTOMOBILE ENDORSEMENT - GENERAL PURPOSE
------------------------------------------------------------------------------
t
This for., effective July 1, 1991, becomes part of this policy.
The endorsement number for this policy is 00010.
------------------------------------------------------------------------------
I ITEM ONE - POLICY ENDORSEMENT SUMMARY I
-----------------------------------------
It is agreed that the policy is hereby amended in the following
~.articlllars:
Total Pre.ium Change for this endorsement is: $ 2~.75.
------------------------------------------------------------------------------
DESCRIPTION OF CHANGE
-----------------------------------------
The premiu. has been amended due to a change in the number of
volunteers. Total Number of Volunteers is now shown as 53.
------------------.------------------------------------------------------------
-------------------------------------------------------------------------------
50S RICHMOND, VAS
( CASA51-4I LC
COMM 15% SICB3229/MHC=2 LD17B7 & GL-1Slb
8/23/~1) PRODUCER BILLED: 241522B
SCl
.' < c--)'~:7
/\1 L. .-,. )
(A~th~~i~{~i8~~t~~;)------------
Hi.~~\u.fe J~&;:J;~ED REPRESENTATIVE LC (;'.:
o
o
INSURANCE CO"PANY OF NORTH A"ERICA
A STeCK I~SURANCE CO~PANY-
EXPIRING POLICY NO. SA~E
.----------------------------------------------------------------------------
USINESS AUTO DECLARATIONS
POLICY NO. CALB15167
.----------------------------------------------------------------------------
EFERENCE 10:
PRODUCER tILLED
PRODUCER NO. OAVP - 2~5228
INDUSTRY CODE: TF
PIIC CODE: 8322q filAP-KET HAZARD CODE: 2
.------------------------------------------.---------------------------------
TE'" ONE -
VAS- RICHr.OND, VA.
._---------------------------------------------------------------------------
AfilED INSURED: SENIOR COf'lPANION PROC (CASA511
DDRESS: 600 W 5TH ST SA'" BERNARDINO CA q2~10
OR~ OF BUSI~ESS: NON-prOFIT ORGANIZATION
AMED INSU~ED'S BUSINESS: SOCIAL SERVICE AGENCY
, OLICY PERIOD: POLICY COVERS FROfil 7/01/Ql TO 7/01/Q2 12:01 A~ STANDARD
TIME AT THE NA~ED INSUREO'S ADDRESS STATED ABOVE
STIMATEO TOTAL rRE~IUr.: S 121.00
AUDIT PERIOD: NOT APPLICABLE
N RETURN FOR THE PAYMENT OF PREfilIU~ AND SUBJECT TO ALL THE TERMS OF THIS
OLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.
----------------------------------------------------------------------------
TEfiI TWC - Sr~EOULE OF COVERAGES AND COVERED AUTOS
----------------------------------------------------------------------------
HIS POLICY PROVIDES ONLY THOSE COVERAGES SPECIFIED BELOW. EACH OF THESE
OVERAGES ~ILl APPLY ONLY TO THOSE -AUTOS" SHOWN AS COVERED -AUTOS" ey THE
NTRY OF ONE OR ~ORE OF THE SYMBOLS FROM THE COVERED AUTO SECTION OF THE
USINESS AUTO COVEP.ACE FORM AND FOR WHICH A PRE~IUM IS SHOWN IN THE SCHEDULE
F COVERED AuTOS YOU OWN.
OVHAGES
COVERED
AUTOS
LJI'!JT
THE MOST WE WILL PAY FOR
A~Y ONE ACCIDE~T OR LOSS
PR E'" JUM
lABILITY INSURANCE
1
S 500,000
$ 121.00
-----------------------------------------------------------------------------
~-30387 (ED. 01/B71
:PIES OF THIS D~CU~ENT HAVE erEN SE~T TO:
'0 508 C AU-3~280 VAS (
PAGE 1 OF
INSURED PRODUCER
3/121'H DB
2
S /0 AUDIT
CASA51-~ I
o
o
.-------------------------~---------------------------~----------------------
USINESS AUTO DECLARATIONS - (CONTINUEDI
POLICY NO. CAL815167
.----------------------------------------------------------------------------
TEM THREE - F(lRMS AND ENO(lRSE~EtlTS ATTACHED TO POLICY AT INCEPTION
----------------------------------------------------------------------------
CA00010187 - BUSINESS AUTO COVERAGE FORM
CA002901S8 - BUSINESS AUTO COVERAGE FORM - INSURED CONTRACT
CA217101S8 - PUNITIVE DA~AG[S EXCLUSION
IL00171185 - COMMON POLICY CONDITIONS
IL002111S5 - NUCLEAR ENrRGY LIABILITY EXCLUSION ENDORSE~ENT (BROAD FORMI
DABE810a - VOLUNTEERS INSURANCE SERVICE ENDORSEMENT (EXCESSI
DA9F28 - MRETAINED LIMIT" REDEFINED
CA01~30187 - CALIFOr.NIA CHANGES
IL0270038P - CALIFORNIA CHANGES
----------------------------------------------------------------------------
TEM FOU~ - SCHEDULE OF ~IREC OR 8nR~0~E~ AUTO COVERAGES ANn PREMIUMS
----------------------------------------------------------------------------
IA~ILITY INSURANCE - RATING ~ASIS: N~M8ER OF VOLUNTEERS
STATE
NU~PER OF
VOLUNTfERS
RATE PER
VOLUUEER
PREMIUM
CA
PER APPLICATION ON
FILE WITH THE CO~PANY
INCLUDED
MOECl"
----------------------------------------------------------------------------
TE" FIVE - SCHEDULE OF NON-Dw~Er.SH!P LIABILITY
----------------------------------------------------------------------------
AMEP INSURED'S BUSINESS
lUTING BASIS
NUMEER PRE~IUM
OCIAl SERVICE AGENCY
NUl':llER OF
VOlU~T[ERS
PER APPLICATIPN MDECL"
ON FILE WITH THE
C01'lPANY
----------------------------------------------------------------------------
HIS DECLARATION ANO THE BUSINESS ALTO POLICY AND ENDO~SF~ENTS, IF ANY,
SSUED TO ForM A PART THEREOF, COMPLETE THE A80VE NU~BEREC POLICY.
----------------------------------------------------------------------------
C'JUNTEI!S I GNED
A /'7
, "
BY: ; Ie.. _':::--'
/ \ '--... .,'- .~./,. ,
-----------------~~---------------------
AU'f-HORH ED A GENT
JPYRIGHT, INSURANCE SERVICES PFFICE, I~S. 19878
PAGE: 2 CF 2
~-30387 (fD. 011871
JPJES OF THIS DCCU"IENT HAVE HEN SEtn T(1: INSURED prODUCH' SID AUCIT
'0 508 CAU-33280 VAS ( CASA51-~ Dll 3/12191 I
.
~~.
o
. ilIloSSOCtA'hON ~tl,ICl MAN4GlMlNT
~~MANAGlMtN'l'
"~~I""Jrr&AQfMlNT
~IC""~
IIICM~I MAfrrItAGlMENT
.... CQlN'nltOL IIlWCU
t.' .
"'...;; .;. -.
THE CIMA COMPANIES. INC.
,..IOUT"PlnQflj 1TJIf11 "LI~ C~l 738 8300
Al........... ~:r:r3W:r.,) ....1703.'3.07.,
SENIOR ~OMPANION PROGRAM
(CASA51)
600 WEST 5TH STREET
SAN BERNARDINO CA 92110
DATE
ACCOUNT
PHONE
Al'gllst 23. 1991
A CASA51-2 NA
(711) 383-5100
THIS IS YOUR RECElrT/ (A)
DO NOT PAY
PLEASE DETACH AND RETURN TOP STUB W!TH ~"YMENT
OAVP ACCIDENT
Renewal
82.50
K Total prE.'~ill~ dlle
.82.50
PREMIUM PAID IN ULL THANK YOU
"POIITMT: .........amine the policies Iiaed.bow 8ftd notify imrnedi81e1y if.ny changes or COf',ecboh." nece...ry. Art., policy not....ed rnuI1 be munwd~'
tor C8ftCeIIation; otherwise en .~ '""""'" will be charged bv the CompIny for the time it ... in farce. .
K..... ...... oil -. _ to THE CtMA COMPANIES. INC.. 216 South ........ S'IOOl. _. VA 223U-2813, INVOICE
___..__.__ _____.__. ----------____.-0_". _. _._
. .
"
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