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05.P- Parks, Recreation & Community Services
5.P RESOLUTION (ID # 4598) DOC ID: 4598 A CITY OF SAN BERNARDINO — REQUEST FOR COUNCIL ACTION Information/Report From: Jim Tickemyer M/CC Meeting Date: 09/06/2016 Prepared by: Mitch Assumma, (909) 384- 5233 Dept: Parks, Recreation & Community Ward(s): All Services Subject: Resolution of the Mayor and Common Council of the City of San Bernardino Ratifying the Submission of an Application for and Accepting a Contribution Sponsorship from Kaiser Permanente Operation Splash Fontana Community Benefit Grant Program, and Appropriating Additional General Fund Expenditures in the Amount of $15,000 for the 2016-17 Summer Aquatics Programs. (#4598) Current Business Registration Certificate: Not Applicable Financial Impact: Account Budgeted Amount: $286,979 Account No. 001-380-0069 Account Description: Aquatics Balance as of: July 1, 2016 Balance after approval of this item: $301,979 Although the Aquatics Season falls between two fiscal years, the total $15,000 will be made available for appropriation and expenditure in FY2016-2017. With the acceptance of this grant award, $15,000 in funds for this program will be appropriated into grant fund revenue Account No. 123-380-0000-4695 as a Contribution Sponsorship (non- Federal or State Grant) and an expenditure appropriation of$15,000 in Account No. 001-380-0069-5014-0979 per the attached FY2016-17 Object Code Budget. There is no City cash match requirement, though the funds may only be used per the grantor to subsidize the program and not replace full expenses. The Finance Director or designee is requested to incorporate the changes into the FY2016-2017 Budget as follows: FY2016-2017: $15,000 into line item 5014 (Salaries Temp/Part-time). Motion: Adopt the Resolution. Synopsis of Previous Council Action: June 15, 2016 Mayor and Common Council ratified the submission of an application for, accepted a Contribution Sponsorship from Kaiser Permanente Operation Splash Regional Community Benefit Grant Program for, and appropriated additional General Fund Expenditures in the Amount of $27,000 for the 2016 Summer Aquatics Program. June 15, 2015 Mayor and Common Council ratified the submission of an Updated: 8/30/2016 by Georgeann "Gigi" Hanna A Packet Pg.330 1 5.P 4598 application for, accepted a Contribution Sponsorship from Kaiser Permanente Operation Splash Regional Community Benefit Grant Program for, and appropriated additional General Fund Expenditures in the Amount of $27,000 for the 2015 Summer Aquatics Program. May 5, 2014 Mayor and Common Council accepted a $30,000 Grant Award (Contribution Sponsorship) from California Community Foundation and authorized the appropriation of $30,000 in additional grant expenditures for the parks, Recreation and Community Services Department's 2014 Summer Aquatics Program. April 29, 2014 Grant Committee approved the acceptance of a contribution sponsorship from Kaiser Permanente Operation Splash Regional Community Benefit Grant Program for funding in the amount of $30,000 for the 2014 Summer Aquatics Season. May 6, 2013 Mayor and Common Council accepted a grant award from Kaiser Permanente Operation Splash Regional Community Benefit Grant Program for funding in the amount of $30,000 and ratified the submittal of an on-line grant application upon invite to Kaiser Permanente Fontana and Ontario Medical Centers Community Benefit Grant Program for funding in the amount of $25,000 to provide for the Parks, Recreation and Community Services Department for the 2013 Summer Aquatics Season. March 19, 2012 Mayor and Common Council ratified the submittal of an on-line grant application to Kaiser Permanente Regional Operation Splash Community Benefit Grant Program in the amount of $30,000 for funding of aquatics programs in 2012 Season. Background: The Department continues to pursue other funding opportunities to supplement aquatics programming and provide greater access for the public to community pools as a means to improve overall fitness and health of the community residents. The Department recognizes the need to provide community services with as little impact to the General Fund as possible and continues to seek cash and in-kind contributions, volunteerism, and collaborative agreements in its mission of providing efficient and effective parks and recreation services. The Department has been awarded two grants from Kaiser Permanente Community Benefit Grants Programs in the past six fiscal years and one of those two the past nine years; one from the local Fontana & Ontario Medical Center and the second from the Kaiser Southern California Regional Headquarters. The Grants totaled $20,000 in 2009, $43,000 in 2010, $40,000 in 2011, $48,000 in 2012, $45,000 in 2013, $30,000 in 2014, and $27,000 in 2015. More recently, $27,000 for the 2016-17 Aquatics Seasons has been awarded and recognized at the June 6th Mayor & Council Meeting. Throughout the years, these grants have enabled the swimming pools at Updated: 8/30/2016 by Georgeann "Gigi" Hanna A Packet Pg.331 5.P 4598 Ruben Campos/Nunez, Meadowbrook/Hernandez, Mill, and Delmann Heights Parks to remain open throughout the traditional summer season at no cost to the patrons. The grants also provided for limited free swimming lessons for low-income youth at Ruben Campos/Nunez, Mill, Delmann Heights, and Hernandez pools and for the initiation and continuation of a Junior Lifeguard Program at the Jerry Lewis Family Swim Center at a reduced cost. The Department submitted a Grant Application with the Kaiser Permanente Fontana/Ontario Medical Centers that was due March 30, 2016, and the Department was notified of the award on July 12, 2016; a check followed shortly thereafter. The awarding of a Community Benefit Grant from Fontana Kaiser Permanente Operation Splash Program in the amount of$15,000 will allow the Department to offer low-income youth ages 6-17 years the opportunity to learn how to swim or to advance their swimming skills at no cost at Hernandez and Delmann Heights Pools. Furthermore, the Department will be able to provide greater access for low-income patrons to community pools by offering pool passes for those who cannot afford the regular fees at the Hernandez and Delmann Heights Pools. City Attorney Review: Supportinq Documents: RESOLUTION Kaiser Fontana Contribution - 2016-17 OpenSwim&LearnToSwim (DOC) Exhibit A - 2016-17 Grant Application Fontana Kaiser (PDF) Exhibit B - 2016-17 Ltr of Agreement&Award Fontana Kaiser Grant (PDF) Exhibit C - 2016-17 Object Code Budget Fontana Kaiser Grant (PDF) Updated: 8/30/2016 by Georgeann "Gigi" Hanna A Packet Pg.332 5.P.a c 0 1 RESOLUTION NO. s L 2 RESOLUTION OF THE MAYOR AND COMMON COUNCIL OF THE CITY c OF SAN BERNARDINO RATIFYING THE SUBMISSION OF AN APPLICATION r 3 FOR AND ACCEPTING A CONTRIBUTION SPONSORSHIP FROM KAISER L PERMANENTE OPERATION SPLASH FONTANA COMMUNITY BENEFIT GRANT 4 PROGRAM, AND APPROPRIATING ADDITIONAL GENERAL FUND 5 EXPENDITURES IN THE AMOUNT OF $15,000 FOR THE 2016-17 SUMMER o AQUATICS PROGRAMS. U- 6 ` Cn BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE Y CITY OF SAN BERNARDINO AS FOLLOWS: 8 T SECTION 1. That the Mayor and Common Council hereby ratify the N 9 submission of the grant application to the Kaiser Permanente Fontana/Ontario LO 10 11 Medical Centers Operation Splash Community Benefit Grants Program ("Kaiser 12 Grants Program"), marked Exhibit "A" and incorporated herein by reference as fully 0 13 as though set forth at length; and ca 14 E SECTION 2. That the Mayor and Common Council hereby accept the Kaiser cn 15 Grants Program award of $15,000 and authorize the City Manager , or his designee, 0 16 17 to execute the Letter of Agreement from the California Community Foundation, 0 N 18 marked as Exhibit "B" and incorporated herein by reference as fully as though set o .2 19 forth at length; and 20 SECTION 3. That the Director of Finance, or his designee, is authorized to coy 21 allocate the $15,000 in accepted grant funds to the FY 2016-2017 Object Codes in 22 U- 23 the amounts shown on the attachment marked as Exhibit "C" and incorporated herein y 24 by reference as fully as though set forth at length. Z 0 25 HI D J 0 co 26 /// w 28 1 y Q Packet Pg. 333 5.P.a 1 RESOLUTION OF THE MAYOR AND COMMON COUNCIL OF THE CITY OF SAN BERNARDINO RATIFYING THE SUBMISSION OF AN APPLICATION L 2 FOR AND ACCEPTING A CONTRIBUTION SPONSORSHIP FROM KAISER o PERMANENTE OPERATION SPLASH FONTANA COMMUNITY BENEFIT GRANT U 3 PROGRAM, AND APPROPRIATING ADDITIONAL GENERAL FUND L EXPENDITURES IN THE AMOUNT OF $15,000 FOR THE 2016-17 SUMMER 4 AQUATICS PROGRAMS. w 5 1 HEREBY CERTIFY that the foregoing Resolution was duly adopted by the U° 6 7 Mayor and Common Council of the City of San Bernardino at a joint regular meeting Y ti 8 thereof, held on the 6th day of September, 2016, by the following vote, to wit: o T C) N 9 Council Members: AYES NAYS ABSTAIN ABSENT LO 10 MARQUEZ 7t' E 11 BARRIOS vii 12 F- VALDIVIA o 13 14 SHORETT E n 15 NICKEL a. 0 16 RICHARD r 17 MULVIHILL N 18 0 w 19 Georgeann Hanna, City Clerk L 20 0 The foregoing resolution is hereby approved this day of 0 21 2016. c 22 U° 23 R. CAREY DAVIS, Mayor N City of San Bernardino Y 24 Approved as to Form: Z GARY D. SAENZ, City Attorney 0 25 Cn 26 By: W 27 CD 28 U fQ 2 Y Q Packet Pg. 334 EXHIBIT "A" Mitch Assumma From: Kaiser Permanente Online Application <mail @grantapplication.com> Sent: Friday, March 25,2016 3:33 PM To: Mitch Assumma Subject: Your Fontana & Ontario Medical Centers'Second Stage Grant Application Submission c Thank you for your submission. Your Fontana& Ontario Medical Centers' Second Stage Grant application has o been submitted successfully,and the tracking number is 143004. If you have questions about your application, .i please use the contact information designated in your application form. o U At.Kaiser Permanente,we are always looking for ways to improve our grant submission process. Your input can help us in that effort. We estimate it will take 15-20 minutes for you to complete. Please click on the link to the survey: https://www.gurveymonkey.com/r/KPGrantmaking = c For your records,here is a copy of the contents of your application. ,0 L a� Y Introduction Congratulations! _ 1...� x] f:. �: �°• :, .,' :;. - - _ r :S` - �1 !~;�rpI LGVI•,IQ - .r..,. I..v!,w...r. •- r.... ... Y - - .,� _ # ,.;, : :t �1.-•jl�f d������nt r�:,.C;orr��n::Unf : ::�eneft�'.'�:i��f�t�� . . .. .. ,: ._ . .. . . . ., - lC1 L Online Submission Process . �. P. - " Trill , :h � � i���, currdnt .i ► �4 : EJtfiis Y = s r . . . .......: . .:..:.-. :'v.>.�,�..-,�.>... •::1..:-,,:._,:,:.,�.$.._..2..,,.,...15_..: - - I� uP _ o rna ass arr :G:ar4 `i p lt*✓ Y.. Y a. ],. .iii.._..,...:._. _ - _ - �� ins u. ., :y, rfed.and/er:s.. ltad h 5 - r _ _ � e. ��is��. ::.-. '�`:ir~aE�ao yin' .. ...,:.,: ,:. ., - — i+:l, x _ °.1K�1IC�'1 r ... a..v,.•:.a:^+- ..v.r....' �c ,r........::y:Pi:ali;.' (� .� vim......,....-:..... 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' Is rcd re W The;0dll n" . h: ":. ....... ..... d...:•:_...0:.............., - - .,r:...!.....:._ ..,t., - .. a , s °this a kit I y,i I.t art eY� l ydd plan accof' Cp zf4; =.t l; Ip 9P Um ` '►'t :: fib : o.m lete a' licatts :s. =: i °iui' ltel = �1} : 1E i s ;- t `.. ; . : i �trnenfal7dot _. r �':` pf:Kaiser o .-.: •.tr::;..:•a._;:a.,�:�s•••:u...,c,i z „•,:�n•.0; .,dr .'@ 'Si'«.°i3i!`r;t�'c:•,,r,�;:e,R:!'i ' - 0 Contact Us = N. .... ._.. Please due""t;-an eo rit:related ' c AW "Id" C i r► i 1j l;B Y Benefit Health Mangy er, You rya send.; r e= Jf7 . x '� i 't. e 1,.,';9r. , "r:: F'--"i?�}r,.: ,m:�u'.�- "�i'.-t.'., ., .... 0 of this a e: .......::...:�;,,,_ L Es ,m 37� 3r-=i4 ., Plea9`ddirect any technical quei�ti 'regardfi`t � ication process to Kathl•Itte' N Murphy, Sr,,Data/Database Analyst, at KFrnrnunityrk p.org or (626} 405-599 .:In Y your message, please enter "O tl�r Apply t Question for Pontana & O�tbrio I�ledici� trs irt� h�,taelx .{: th bc�d of tie emall�, t �(41 c4` bstions or a A detail` 'E." .., ` r, > qty "Be seal N . L s, ......., Jra 7w,.r::n-c••",:rrnur,° ..,I.�-i. �:i-18�� a3 ..�t. , F� ,.•..".� �:;`..; where yt i '+ irk' e�actr d`: �i d, r? po d as s!ac J a t ,°._._3....;' K ;;:r�:, LO L Organization Information N ....................::...:. 141 �E� Q<. Tl � " �y(�� r, ,•. .Ify� ,. ! .:fl�.' !�.. Y I ...z, > :. ICU r 'a _ _;r a� l�I��I _ �.�:....__...._ _'�., L. Tax Status Information C 4 rplica� Or rzat an's L �. =".0 - - This is the name that appears on your IRS determination letter, other legal documentation, or Q Form 990. a City of San Bernardino - Parks, Recreation and Community Services Department c� F r O tzations Tax:II� Please enter your organization's Tax ID number as 12-3456789. N If you do not have a Tax ID number and are working with a fiscal agent, enter 'x' and complete the fiscal agent information below. a 95-6000772 X w Tax..StG.'tt�5r 'i ? , ... _.. ......... .. ... ... . •• Select your organization's tax status from the list below. If you use a fiscal agent, select "Other"and complete information requested later in this y application. a Government or Public Agency 2 Packet Pg. 336 Organization Documentation yl — ,.i..........:....... ... .... ...,. ,,, List of 0.._. �1�]fit �c t��._. ': in _ Please upload a current list of your board of directors, including those who hold officer positions and their affiliations. Your application will be considered incomplete without the affiliations. City of San Bernardino Board of Directors.pdf ..•........w7.. t' ,.,,;,r;,�:....:._r::•_.:.::r.•: r ..............._ , it:�'r'u3.•.^._..�,_°3....:•� ^_ r. l i�" _. -3W. ........ . O C Required for organizations not previously funded by Kaiser Permanente Please upload a signed copy of your (or that of your fiscal agent organization's) W9. A blank form can be found here. ° U City of San Bernardino W-9.pdf L 0 to - co IRS Form X30. _„ - Required for requests $25,004 and over o Please attach a copy of your organization's most recent IRS Form 990. U- L (Not required of government entities.) CityofSanBernardino IRS Tax Exempt Status VER 1,PDF Y ti Applicant Organization Information o Or. anxzatxon dame•.::.. .,... ,in . Please use the name as it a pp ears on your letterhead. LO City of San Bernardino - Parks, Recreation and Community Services Department L ° N_ Please enter a street address. Do not use a post office box. w 201 North E Street, Suite 301 ,0 San Bernardino CL ....,...:::. a �t ::,. .:.. .,... ..:::ec`rci•r i_i3:�;:�arr�c="°s sn`;�;.L.,,.;::a:?: ..s3!s CA LD -_. d ,.; . . ....... . .: N 92401 a w ... ................. ... . s .v...-... _... ,., r.:•,w::........,a..r,n.........._...y@::.:-..::.'.S_.!!4:�`"`3r::::.:_a�!1!t:", _ Q � o�i# i als>fa34 � ? 3Ya,: _ . .. . ., erF t , is s Please enter the phone number as shown; do not use punctuation: 1234567890 w (909) 384-5233 M Orgarttittnr `;Qe -umber Please enter the fax number as shown; do not use punctuation, 1234567890 a (909) 384-5160 3 1 Packet Pg. 337 1 assumma—mi@sbcity.org nations Well Address: LT .: . .... ( } Please use the following format: www.kaiserpermanente.org hftp:l/www.sbcity.org 2 Organization Budget Information Tofat Annual Organizatid But�gti :;?' ;.;;` c 204164694 r L :. ..• .-. ... _ r :: '..: dr,ieE�si�t�iztii�y .ss,••ii:.:..6,'`.E!! .�;�-,f.. QrganYZation$uctget �::: :w; s« a� , Required for requests $25,000 and over Please attach a copy of your organization's current itemized operating budget. �° City of San Bernardino - 2016 Budget & Narrative Rev 3-24-16.pddf N Audited Fan"ncral Statement Required for requests $25,000 and over Please attach a copy of your organization's (or the fiscal agent organization's) most recent N independent audited financial statement. 00 CD (Not required of government entities.) City of San Bernardino Single Audit Fiscal Year 2013-14.pdf i a� Organizational Capacity Y Date.the Organization Was Esta> lzshed c If you do not know the exact date, please use January 1 of the year the organization was �° established. 0 0 01/01/1854 .Q Limit statement to 50 words. L Creating Community through People, Parks, and Programs: The Department of Parks, Recreation and Community Services is committed to providing quality services, programs, and activities for all residents of the City of San Bernardino youth, adult, senior, and challenged populations, o N Organization's History Brief summary of your organization's history (Limit your answer to 950 words.) w The City of San Bernardino ("City") is one of Southern California's most historic communities. Incorporated in 1854, it is a city of 210,000 residents in 59.3 square miles at 1,049 feet above sea E level, As the county seat of San Bernardino County, it lies in the midst of the booming Inland Empire region. The City was founded early in California's history, and it had recently celebrated its a Bicentennial in 2010. Influences of Native Americans, Mexican settlers, Spanish missionaries, Mormon emigrants, and Railroads can still be seen throughout the City today. From 1910 when Franciscan missionary Father Dumetz named the area San Bernardino to the present, San 4 Packet Pg. 338 Bernardino has been recognized for its scenic beauty and strategic location, once a resort stop for movie stars and famous entertainers traveling from L.A. to Palm Springs. The City operates under a hybrid Mayor-Council-City Manager form of government. 2 Backgri IT3��rm ftin _..,,,...:::::.,. c „ ... Describe your organization's goal(s), communities/cities, and general target population served. 0 NOTE: Do not repeat content from "Organization's History"or "Current Services and Programs" sections. (Limit your answer to 150 words.) Creating Community through People, Parks, and Programs: The Department of Parks, Recreation and Community Services is committed to providing quality services, programs, and activities for all ,° residents of the City of San Bernardino youth, adult, senior, and challenged populations. Programs y include sports and fitness, after-school activities, recreational classes, open gym, nutrition Y programs, special events, aquatics, trips/tours, volunteer management and outdoor play. ti 0 N co d' L Current Setwzces an, Programs N Describe the organization's current services, programs, recent accomplishments and/or Y recognition received. (Limit your answer to 400 words.) The Parks, Recreation and Community Services Department's mission is to provide excellent ,° parks, recreation and cultural opportunities which enhance the quality of life within the San o Bernardino community. We create community through people, parks and programs and espouse the public leisure industry's mantra that"Parks Make Life Better". In the Aquatics division alone for Q the 2015 Season, we have successfully provided open swim to more than 26,793 visitors, taught a 361 youth in swim lessons and the Junior Lifeguard Program students at 18 workshops/class sessions, assisted 492 low-income family members through 87 family swim passes gain access to 2 pools, and offered 10 water safety and lifeguard certification classes. Through the partnership with Operation Splash Kaiser Regional Grants that funded summer aquatics programming (Jr. Lifeguard, Learn-to-Swim and free swim passes) our city pools improved physical fitness activity N for low-income members and provided safe and affordable relief to the summer heat for San a Bernardino residents. The City remains a Playful City, USA, despite a flat FY2014-2015 Budget. The Department also conducted a highly successful 2015 Operation SPLASH Opening/SwimFest with over 1,200 in attendance-In addition to pools and community centers, the department w continues to offer after-school programs, senior services, and therapeutic recreation to regional Q visitors. E a 5 Packet Pg. 339 � 4 Permane�ate k ontana b, �ntarl0 1VIedlcal Center . c If your organization has a current grant with either the Kaiser Permanente Fontana or Ontario 2 Medical Centers provide a brief statement on your year-to-date progress, including quantitative �L � measurements directly related to the grant objectives and outcomes. o (Limit your answer to 250 words.) None. o ' //Ln� V _ _ 0 LL L N ,R Y ti i �iMan�zatrQ� ro�ides direct medical services, please supply the following N co 0) LA Direct Medical Service Organizations d; Orgartzatzari Type Select the organization type that best describes your organization. The primary type should be Y selected first. If applicable, you may select more than one type, up to three types maximum. cc 0 Orgetixza xp 3 esr af79n 3 �... . . ... . _ •5 f+ Please select any designation your organization has received. If applicable, you may select more than one designation, up to three designations maximum. a a w _ L To ensure that Ka�ser Frtanenxe completes its due dgence, each organization aU s y r n requesting a'contribult i ti � st'1 h' f e: rlli wing questions, 0 N Organization Attestation a Col o�Irktexe�t' - Kaiser Permanente asks each organization requesting a contribution to disclose any relationships w with Kaiser Permanente that may be, or appear to be, a conflict of interest. Such relationships may not create actual conflicts of interest and do not necessarily prohibit your organization from E receiving a contribution. However, they must be disclosed in order for Kaiser Permanente to complete its due diligence. a Do any Kaiser Permanente executives, managers, directors, physicians, or other employees or their family members: 6 Packet Pg.340 • Serve as a board member, director, officer, manager, employee or fiduciary agent of your organization? Have a compensation arrangement or financial interest with your organization? Hold any position of substantial influence with respect to your organization? No 0 Conflict of Interest Details -„- • If you answered Yes above, in the text box below enter the name of the Kaiser Permanente o employee or their family member and describe the nature of the relationship with your organization. o • If you answered No above, enter"NIA" in the text box below. _ NA o U- L d N Y !f: ' . . s��'"llj,{'> Ltrshrp at fhrs �rn�Q/'but become aware of ane during the appliaafion , iy it � (f a tha relatlo sf tp 6y.cantactIng i4aiser: „a, a.:: ...... . .. ... Paxre ! ri' 8 to rnu enefrt'Grants Pro rare a ..:. -�/p-�j rr(r. {F�� t C14 5* J !�MSi�E�,. YF:� • 'lrR'lr/J 00 m nxule ram� ar:tlt ' „ r . . ..,, V. . .... .......... _ -:1.- .. .....r..: .......':a::.' ...:..i: ,. ! w.. .i.. zt{• •it: i1•r 7z` iii Pat iti �? #� Does a Member of Congress, Executive Branch Official, State Official, or their staff: Y • Serve as a board member, director, officer, manager, employee or fiduciary agent of your y organization? 0 LL • Have a compensation arrangement or financial interest with your organization? _ • Hold any position of substantial influence with respect to your organization? V Q No a Participation Details L9 • If you answered Yes above, in the text box below enter the name of the Member of Congress, Executive Branch Official, State Official, or their staff and describe the nature of the relationship with your organization. N • If you answered No above, enter"N/A" in the text box below. a ..r NA X Uj Reep k3 �e� F a..,fftd ,<.:... ..-,.E. -,., .._.. Will any portion of this contribution request be used to honor or recognize the achievements of a Member of Congress, Executive Branch Official, State Official, or their staff? Y a No JT„- Re 1 1 • If you answered Yes above, in the text box below enter the name, title, and affiliation of the official and provide a brief description of the honor. If you answered No above, enter"N/A' in the text box below. NA PAC•&CAPE Does your organization have a political action committee (PAC) or committee on political education (COPE)? L No 0 U Y V PAC&COPE Details. • If you answered Yes above, in the text box below enter whether or not any portion of this contribution request will be used to support the PAC or COPE or any program that will 2 _ support or oppose candidates for public office or political party. ,0 • If you answered No above, enter "N/A" in the text box below. .a Y NA .:......,r...... uv:.::::t..: Noncit r .. .. ......:k..:......;.:.::...... .. ..... ..............r................. 1MMU - N Does your organization have a policy or statement that prohibits discrimination on the basis of sex, co age, economic status, educational background, race, color, ancestry, national origin, sexual LO orientation, gender expression, gender identity, or marital status in your programs, services, L_ policies and administration? N Yes Y n- . . W..NoProsel 1zin g ..., - .r , .,..._:... r.d For a religious or faith-based organization, will the proceeds be used to support general = operations, services and programs of the congregation/membership/students, or to advance M religious doctrine or philosophy? 2 Q N/A a Fiscal Agent Information c7 If your organize#ion,will be using a fiscaa agent, please complete the f01.61WI lg Nnformation on behalf of the fscal agent If no#, Ike select y�xt (at the b`ottorn ryE FF N of ftie �age� ai E '.'._....E... ,.E,,'ai. ........ ..... .. . . a .. ...7.t:. .. ......, lY' .._.�.,iu, ._..._.!t ,•.n._.......... 'niRt ,...'i� ,i.......... -:...J..-.........t V.+ Fiscal Agent Memorandum of Understanding x :::.. ....:.:.. . ..:.. Fiscal ent MOU A Required if using a fiscal agent A memorandum of understanding/agreement between the fiscal agent and the requesting organization. t° Q IMPORTANT: All documents must be submitted in PDF format. s Packet Pg.342 Organization Information Fiscal:;A, is ,egal : As it appears on the IRS determination letter or Form 990 Fiscal Agent'S Tax t5r TIN} - 0 Please enter your organization's Tax ID number as 12-3456789. 0 U " 9sty...,it . F 3 S': !3na:i 9 ...a.: : - .....:r. s:5 ..y...........2:r_; � ! �;r'r?i ili,;::.ic. A j3t E�f``= ;'3"; is;° F.,:r L Fiscal.Agent.S M,41 ng d. ... :'<::,..:.,..:. ::.. ........:.:, �r_5,. ... c� Street Address, City, State, and ZIP Code 0 L E..:.... .... .::. .... .::••.:.-•rr.rn.. .rn::ea±mow., ..;. .....:::: ....:... `i;':i:3S;. _a,,..e _ .: r..�»:."::^."•'lz=2i.c.:M..cv�: ':.F an:,c ;:fir., �sca7 Agent Contact NamoE Prefix, first and last name of the chief executive of the fiscal agent. 0 N Fiscal Agenti`Contact Title: 00 L LO d Fiscal Agent Contad. fi1 Address _. c r F3 Agent'Contact Number 0 phone Please use the following format: (123) 456-7890 0 ca Q C. :: :: ization .......... n"""......re':..... :w;ir.l..,. ,.sE.-- ...2.E..:• lC tes its due del nc each organ.. riiislf illt?a ±€ !il : '' rr�r#fieollowr.ng questions about the fiscal ... .: ..E ,.....:. .,Li r 0 Fiscal Agent Organization Attestation `;' Conflict of:Inxexest(Fiscal Kaiser Permanente asks each fiscal agent organization requesting a contribution to disclose any relationships with Kaiser Permanente that may be, or appear to be, a conflict of interest. Such Ui relationships may not create actual conflicts of interest and do not necessarily prohibit the requesting organization from receiving a contribution. However, they must be disclosed in order for Kaiser Permanente to complete its due diligence. r Answer the following question as it pertains to the Fiscal Agent Organization: a Do any Kaiser Permanente executives, managers, directors, physicians, or other employees or their family members: 9 Packet Pg. 343 Serve as aboard member, director, officer, manager, employee or fiduciary agent? • Have a compensation arrangement or financial interest? Hold any position of substantial influence? • if Yes, in the text box below enter the name of the Kaiser Permanente employee or their family member and describe the nature of the relationship with the fiscal agent organization. • If No, enter"No" in the text box below. •L _ 0 U •.i....F:Y"�C.:Sy::Si:!::Fk_!:C.....:(:{:ir.iG.{.•A• .�:4pt..a.•.•••. L..IfIC L.:W.•,_fi.!_•. . ty•.• 20�P:' w.l.:...C( :S!. L 451 ?!:;..::s` 1(:.�... YID' !►cation: -t:r'_.:i_'.•. :. t.l.... �'�f::. :1!]1.��1�L,T�' F� ��.. .. � =.•.�:,�.!_Zi] !• ..P•_ Q/�� _..] t il!u?.t t iz,' =,:is. {�j/J'.�j;T'k.,_�„•.,•.:rI ..!;rrrtrw••• ...• .L.l;::... ��� . . .. .J_A! •�� �.i 4!!V •,Y. .:i{•.'�J,W.iG..: OF .� .» 'r • ri. •.r• a •':i.' '-{.. ].r._�_! �� !_ V x. t r .,, {1,. .r: :��T: �'. G41L- 1J96� ' i��t�r'•��..#f1=•�� �.. LL Participation by Government Official��fiscal Agent} Does a Member of Congress, Executive Branch Official, State Official, or their staff: Y ti • Serve as a board member, director, officer, manager, employee or fiduciary agent of the o fiscal agent organization? • Have a compensation arrangement or financial interest with the fiscal agent organization? co LO • Hold any position of substantial influence with respect to the fiscal agent organization? • If Yes, in the text box below, enter the name of the Member of Congress, Executive Branch Official, State Official, or their staff and describe the nature of the relationship A with the fiscal agent organization. Y • If No, enter "No" in the text box below. _ 0 U. C 0 AC,&COPE{Fiscal Agent) . Does the fiscal agent organization have a political action committee (PAC) or committee on a political education (COPE)? _ o L • If Yes, in the text box below, enter whether or not any portion of this contribution request will be used to support the PAC or COPE or any program that will support or oppose candidates for public office or political party. N • If No, enter "No" in the text box below. a w X w Nond*rzmmatioii 1h '(Fiscal Agen"t) a� Does the fiscal agent organization have a policy or statement that prohibits discrimination on the basis of sex, age, economic status, educational background, race, color, ancestry, national origin, M sexual orientation, gender expression, gender identity, or marital status in your programs, a services, policies and administration? fe Please enter Yes or No in the text box below. io Packet Pg.344 By answering "Yes," you affirm that your organization does have a nondiscrimination policy/statement and it does not discriminate. yes I� F'roscizrt�g P f t f If the fiscal agent is a religious or faith-based organization, will the proceeds be used to support . general operations, services and programs of the congregation/membership/students, or to 0 advance religious doctrine or philosophy? Please enter Yes, No, or Not Applicable in the text box below. 0 NA L 0 Key Contact Information .::...:::::.:r:-^..:.rote...-.:•.: ,,,,..-...,.,.1.,,.:t,•:.,",.:3:;:: - T� f` . '. _ _ kfi1 ur grant inqu�ry:VVill be re.peafed •:-.. G ,c:rr r.ra .. �1 i r�k: cl ' a t[�e �nform� �on.. !sl. N ,:.F:i':is+.y. :•s:-+:fr.;• -°�:— -'�: •::€ir;i .F�•'.:,ei - :�f:� � � c;! g � # ; n Y .yes .r�t�:. x ... ...:•, T N Chief Executive Information CO Pr X' r ..... Mr. Ftrst . Mickey 0 .. .. .......:,...:.: . ..... .. xe.. .........:....�Atk. ....<_S.,_..... ...p. ,}�:'.:'I".'..�:._.;:i.e::::l::c:.::iy._:.k'•r'.::,:<.:��:�.. ::.,.r „•r is a.:.=<4•.....L-.J=11...__-i.... 1 .iJvl t:..:. ........:v..._t.........,.—:.:,...:.i. .._ i ,. 1_. , ..1,<...e�T..S_.....,<•,•.-..... 1 t......,-: .;I J.....................I...I.SY.. 1 ,.r' •.. .._-. .3. 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Valdivia Q (�... :!r' J..:,r:.::-�,.:=!.�.:;.,. ..•........:'G:..... .... ..:..,....,L:... 7' :obi•.• _ !� ..+�►._:._-• •rt::.lt 7,. . .. .aa,�x t.-;:a;_:J:•r:,::ryr i",,..k-. :F�2 Q ..�. it�-.::: .'3T✓.:-• •-..x:•�� �. ... :. ::: ��' ,:+ _ <None> 10 L c� ... ....... .... ...... ............. <.>.:.._. .-...,:...:..:: .__............,...:..::::-..;s•r::•:,:;,.r::<. :t:..•rc.,�._.:..,:�.::.-. :;t,•^:::':'::•::t3'G`=:i'::-: r;;;:: •i.i.:': :•.:.:-.:—..... ........ ......,,.en.., «,.,.....ui..., ,. r r.n- .. ::.:.:r... x........:.......3,?:,::-._.... .,.....x_.f.- - i .................'� t.i._... .. ........._.s...... ..-......x:_x:r:. - c• ..,.m.._WCf......... ......<.n....:_�•... .. ..t t_... .. z. .........i1.L..F._.. .. ....,�s..tr._..4..... .c..Z....S.ux.,..a ,. ...r..,__:ct-....,-. _... ,.. .....3-,.,... ..,.cis - - - .............s.7.._.<. c.r..._.. .._:a%_ .......... .:!s>.:'� :i:.:ca:.:x:•".;:i,,:13!- .-_:...:..•:' ...:r... s.ia...............�.,., k., -.......r»Cs-.f_G.. ..e .i'._..._-.,,rrc:_:;::: r::-�_._.. :.r:::s:ek':FiLr.y-s;r.::a::::::; ::' i` - - - 4 �_., u.,e:a r A_._, ::..s:.:_.---<-'-_........i.xG:Y.Eu..�::;ci...K.,. .. , .. .._: _............. .. Director of Parks, Recreation and Community Services N Phone,. .. , ,.: _:,. .. •...:..... .... . _.....__ ...... . ._.,. • Please enter the phone number as shown; do not use punctuation: 1234567890 w (909) 384-5030 d ;. e lion - .. . ... .' ..... , ... ... .. If applicable. a i no ® MON11 Please enter the fax number as shown; do not use punctuation: 1234567890 (909) 384-5160 vaidivia_mi@sbcity.org aaee , crc 1 ,' d� itl�iosi„ . °. �'l, •, :` airiticQ ery e;as the.The k . �:':'•.::i''<,t.::t';,c. ,: '-;��l;r,..,t f.e t�''=�•i�„v<r•_r':f;�yien'.tre,n t -:€;. ',§:f:i ,r •r ..._ .:.•,:,::'_:..:::, •.•_:, ._ :•-� 'psi',iY.�;F;',r;',s;'.L�. i.� �ex•:' :r Flese:' hc_t11s bob 1�'thrjat cdn#act 1br thls proposal the"srne as the chief ekecutive;(above) No ''L^^ V .. ... ................ ... .. ......_................_..,.............,.._....._.._..-..._.....__........_..�-.:r..:eu:n:ar:.....::�::._;;..........�...t.i,::'-C,:i::t:ty;r.::ry::::r.•-r::.::�:;:::::d::�::'f^.: - .... ... ,._.....:..::.::�_.�..r.;}�:n_....-...........:::.•,..e:....:,te:z':'Lr'_r•..:r. s..�_.,.:::�...,.,...:...:;::...:._.a._.3_ ...i^..: _ xU:.i:.,':, ::[° - - o - u�ec .; ... .. ..R!r_:,:,;�. :_. ..:........... - �...:......-..........r....e....rz?T'3',�`}�7i' _.:a7vu.�. .t�.'Ji�� ��i.•� -„r.::•,.:a-. .u:ra:a,ellr.::L F (Sf ........ .-.,r:E_?�f fE ...R.. .,<tn..:.n .:Fi. :R:• f �:: ,}. . . q r.. n:rrrG':::-,,e:::.•:�ym3rn._e >.e•:u'�.:_C:-•�F.�:: :_.i_!:-�'1r-r,_i����T�ku:r..•.'r�'!''.,L''-F'.-'.:�I.-.. �..................i.....i, _r..t..m..?�e%-iT=.._...... Q U. L d Project Contact Information M Prefix. .. :., ,_ . ..,..-._ .....:...._- ... ..:..,. ..-. . . ti - T Mr. CD T N : ,,.....,S._...5. (::is-FI':r.w•..G•Lr._rG','.'a..t�.��it. I 11'rt 1'.I��i_i- o r':t�Ili(�E'jFiiif .. ..:.-•.^.a 1rstNam F V. �o LO Mitch L L.. .. :.....:....i_. ,i ..G_._ .. .... ,:.:._..:..:::.._._.:..::::. ast.Name Assumma ......:.:_,.�...i. ._t. w Suffix }r' x. <None> o .2 r ...t:......l..L.9.t... .:'t s .�.A e..W,.�.!:x...:....e...;:....c..:E....n........'.x..:.......s..rt..i._:r.'....ea:.#,._.#..f.�.s..v.7.:...r:•....:.'.:!.:�>.''i:nE.r i.:?.,.<!..w.t...'..--.Fs.,...i.r...dr....;,!.',.:..aJ:..1.,:t.1.:._::...:n 1,�m,#..r Y.,e.f.�.,..i.,..:....n...�..r..�n ny E¢�::-::3.•:[.^:.d:._f;,i.p,..:�^�.-.„..;.::.uii.n i...l..t.e...ni.u:...t......C:..:..a....._..,:c:..”..u_;::-e.i.c..:a.:G G:...:a,.E'_...u_.,::,1.i..-.=.7t.Psi.3S .t!n L m � r..:”;3aa _..k..:.i.i.':f. F;.r.`.�i<,st:-cr3 :. :..:2 �.r:e:.c«7i.if.i:r•.+.:F`_. -. I I _ ._.-__._....._._._..... Q Community Recreation Manager �o Phone _ ,: ..:..: .............._1, ,..,... . r ;.: _ -...... ........... , . ... .... .._. . Please enter the phone number as shown; do not use punctuation. 1234567890 T (909) 384-5132 N Extension :,-,n:;: P.If applicable. w Fax..,•'�. . ..... „ Please enter the fax number as shown; do not use punctuation. 1234567890 y (909) 384-5160 r .:.: .. ..:..Y: ....:.......is::..L"- ._1•.. ......•..•_: •- x S .::-•:�:..:. - 12 Packet Pg. 346 assumma_mi @sbcity.org Grant Request � f a is - Please attach a letter on the organization's letterhead that must include: • The legal name of the organization. 2 The organization's street address as listed earlier in the application. Do not use a post office box. r • Signature and date signed by the chief executive of the organization. o • Ensure that the letterhead includes updated address and telephone number as indicated on page 2 of this application. Cit y of San Bernardino Cover Ltr 2016-2017 Operation SPLASH 3-25-16. df I r- 0 ot�T'tf �; nformation you previously completed on.:your grant'inquiry will .be N repeated here:t4 provtde you with an :opportunity:to update fihe �nformtn Y ti Project Information Giant,Cycle..Start ? J j .,..... Al 07/01/2016 LO - , .. . .. . ....... .. .. 06/30/2017 Y e : .. ....:... .... Pr .ect.T1tl of :: .. ........ ... Please provide a descriptive title of the project you are proposing. (Limit your answer to 20 words.) 2 2016 Open Swim & Learn-To-Swim in Hernandez & Mill Neighborhoods .Q C. IS tlu&.pr:Jec new or caritlll ling y1�or)C�' '.. , -`--.. . _3= r r°:z r' r ; Continuing c� ti Whattype of funding are you,requesting;? tO General Operating Support N a T pe,ofundmg.(( :then) y If you selected "Other" please describe. w E Amount of: undingyou are requesting Below is the amount you applied for on your grant inquiry. If you were invited to apply for a a different amount, please enter the new amount now. 15000 13 Packet Pg.,347 I bta Pr et - Please enter the total cost of the project you are proposing. Project should not solely rely on this funding request. 64000 ;. .... - In the �e ai.ons below' Ieasedesc;r:,i•be,.the ne-etl or;probi `. Jthr + �'Fi" o ro ddresses' what ca acct our Qrganizatron 00 t�; lposed project or progr ,,and`chalinges and/or barriers that' �I / O ''Lnn V Proposal Narrative Funding Priority . : ..... .:: Visit our website at http://community.kp org/be-informed/service-area/fontana#grantmaking- ,° section for further details on the scope, descriptions, and priorities of Kaiser Permanente Fontana N and Ontario Medical Centers' grants. Y 2. Chronic Conditions (Southern California-Fontana) 6 Population IriformiCiop 0 N Describe the geographic area(s) and population(s) to be served. Specify the geographic areas 00 (e.g., specific cities or ZIP codes) where the project services/activities will be delivered. Proposed v services must be delivered within the Kaiser Permanente Fontana or Ontario Medical Centers service area. (Limit your answer to 250 words.) Y The population served include low to moderate income residents of the City of San Bernardino living or frequenting the neighborhoods of the Hernandez and Mill Pools in the 1st Ward (mid- 0 Central area of the City) and 3rd Ward (South). This population includes the broad community with U_ a diverse ethnic minority, especially a high concentration of Latinos and Blacks, of all ages, o primarily between the ages of 10-15 years, male and female. Sixty scholarship-qualifying families will be issued pool passes, learn-to-swim to accommodate 120 beginners ages 6-17 years, 5,000 Q open swim visitations, and distribution of thousands of copies of promotional materials. a �.a L c� ti �o 0 r PH Describe the needs, problems and/or issues to be addressed by this project. Include data used to w highlight and/or justify the need for this request and cite the references used. E (Limit your answer to 250 words.) City of San Bernardino FY2015-2016 Aquatics Budget remains under-funded. The City's r bankruptcy Plan of Adjustment calls for continued belt tightening. The aquatics facilities are in a threat of under-utilization. Regional Kaiser contributed $27,000 to the 2015 Season to supplement an aquatics program operational deficiency, which is half of prior years support. This allowed low- 14 Packet Pg.348 } •s - income residents access to local pools during the summer to promote physical activity in reducing chronic diseases and obesity and advance swim skills in preventing drowning and improving family unity.The City recruits, hires, trains, and retains each year approximately 50 certified aquatics personnel toward life-saving service directly at four pools, and it partners with the Boys & Girls Club to service an additional public pool. A large number of the City's at-risk youth and low- income housing are adjacent to these pools; access to pools within a walking distance is parameter to healthy living. The economy stills lags behind the Nation, and the recent Terrorist = Mass Shooting has created a community seeking comfort through unity and a sense of identity. ° Without supplemental funding, low income residents have few options to stay fit, seek relief from summer heat, learn swim skills to prevent drowning, and gain insight to the benefits of a healthy diet. The City has a large investment in pools that need to remian as beacons to support active living. Combined with hot summer months and a lack of in-home pools, our community lacks safe = water play opportunities and places in whcih to learn swim skills. 0 U_ m N Y ti T 0 LO N �ropds�d Request. Below is the proposed request as entered on the grant inquiry. You now have the opportunity to update and expand your answer. Describe the proposed request and how it directly supports the selected Kaiser Permanente Fontana or Ontario Medical Centers Priority Need this proposal is intended to meet. w (Limit your answer to 400 words.) c Provide a second safe swim session at the Hernandez and Mill Pools and allow a longer day's = access, which will increase the opportunity for longer physical activity through water play. Offer 2 no-cost swim lessons to beginner students ages 6-17 years of age at at the Hernandez and Mill Pools as a means to lower mortality in youth due to drowning and open opportunities to junior a lifeguard training and future employment. Promote the ReThink Your Drink branded message to Q low-income patrons in the Hernandez and Mill neighborhoods to encourage healthy and active L lifestyles. c� 0 N X W C d I_ t U R r Q Funding,Partners List other fenders supporting this project. Please describe type of monetary support provided (i.e., grants or sponsorships), number of years funding the project and when the funding term ends. 15 Packet Pg. 349 1 5.P.b Please list and describe briefly. Kaiser Permanente Regional Office annual application/award since 2009 Collabostl� , >�s _._ List key collaborative partners and clearly describe their role in the coordination, collaboration, o and/or implementation of this project. Please list and describe briefly. Boys & Girls Club of San Bernardino programs the City's pool at that same location. r c 0 U r c L Goal - 0 Briefly list the goal(s) of the proposal. Goals are broad, brief statements of about the long-term r intent or desired outcome of the program or project. �° L Example: To reduce obesity in adolescents in the San Gabriel School District. (Limit your answer to 35 words.) Y ti PRCSD's primary mission through the aquatics activities and facilities is to promote healthier lifestyles, water safety awareness,and a higher quality of life among community residents as one o means to reduce childhood obesity. N 00 ° bbj eeti es Briefly list three or fewer primary objectives for the proposed request. A Y Objectives: cc • Are key strategies that the project will undertake and intends to accomplish; �° • Are steps contributing to the goal; C • Must be tangible, specific, measureable, and achievable in a specified time period; and • Must be achievable within the requested budget. a CL Example: By May 31 (time), a minimum of 100 adults (target population, reach) will be recruited and trained on chronic self-management (activity/process) (Limit your answer to 35 words per objective.) Objective #1: By August 15, 2016, serve 3,400 visitors in open swim at the Hernandez and Mill Pools. ° Objective#2: By August 15, 2016, save lives through the provision of safe learn-to-swim activities N to 60 students that prevents drownings, especially among youth. a Objective#3: By August 15, 2016, offer swim play opportunities to 65 (260 family members) under-privileged families that promotes safe and healthy physical activity. w Objective #4: Throughout the 2016 Summer Aquatics Season, engage the low-income pool- r_ attending community at two under-served pool locations and through other community partners in E a ReThink Your Drink campaign. Project r a hes' 16 Packet Pg. 350 Describe the activities, tasks, and/or methods to undertake to successfully accomplish the objectives listed above. Examples: • Gather baseline data on diabetic population and average HbA1 c. • Partner with local organizations to recruit high-risk community members that could benefit from the program. ° r • Train the trainer on the chronic-care management L r (Limit your answer to 200 words.) This project proposes to meet the Need II of the KP Fontana Medical Center Needs Assessment to reduce obesity rates through physical activity. Open Swim and Learn-To-Swim programs are a part of the Parks, Recreation and Community Services Department mission in the municipal = recreation and leisure service delivery system. The community's access to these facilities promotes healthy physical fitness, which in return helps reduce obesity. Open swim is drop-in 0 water play, six days a week (M-Sat), from 1:00p.m.-3:00p.m. and 3:30p.m.-5:30p.m. where the N community can come and swim for their health, socialize with friends, and/or cool down from the hot summer weather. In the Learn-To-Swim program, low-income youth ages 6-16 years are Y taught basic swim skills and water safety awareness in a two-week session, 45-minute daily lesson in a small group setting. Hernandez Pool will be used to serve both the Mill and Hernandez o neighborhoods for free swim instruction for low-income recipients. A large portion of the City's at- N risk youth and low-income housing is situated in the Hernandez and Mill Pools service area. a) Ln Operating these two pools will promote a more fit community and build water skills in children, opportunities not available without this funding. N Y 0 c c 0 LL Expected Outcomes. . ... . Identify the expected outcomes to be achieved by successfully accomplishing your objectives. Q CL Outcomes: a • Describe a benefit or transformation that will result from your work, i.e., what will change in the lives of individuals, families, organizations, or the community as a result of the program. r • Are short and medium term results of the project or program; what you hope will be the c results of your activities. N • Are realistic, and tangible. a • Should include time frame, target population, and reach. X Example: By the end of the project(timeldate), at least 80% of program participants (population, w reach) will control blood sugar levels (HbA1 c control (Limit your answer to 35 words per outcome.) By August 15, 2016: Serve 3,400 visitors in Open Swim at Hernandez and Mill Pools. a Teach 60 youth in learn-to-swim classes at Hernandez and Mill Pools. Disperse 65 Family Pool Passes to the Hernandez and Mill Pool neighborhoods. Conduct a minimum of 10 RYD workshops at the Hernandez and Mill Pools, disperse 3,000 17 Packet Pg.351 copies of healthy living promotional materials, post RYD banners at pool facilities. Long-Term.Strafeges ° Describe long-term strategies for funding and sustaining this work. L (Limit your answer to 100 words.) 0 The Department will continue to lobby the City Council for full funding through the General Fund at Budget Development time each year of the fiscal year cycle. The City expects to complete the Plan of Adjustment activities by the close of the 2016 chronological year and would expect to see 0 more of the discretionary use of revenues expand to other non-public safety services in fiscal year I 2017-2018. However, partnerships/collaborations will continue to be used to supplement much of the mission of parks and recreation service delivery. i° L d Y p.:y7 F ti Describe how you will evaluate the success of the program. Describe how you will demonstrate N that you successfully achieved the objectives and outcomes. 00 LO 7 Example: Participants will monitor and report HbA 1 c levels which will be compared to baseline L data. All changes will be documented by program staff. N (Limit your answer to 200 words.) Y Open Swim:Attendance will be tracked daily, and safe, sanitary conditions will be provided by staff r_ on site. Swim pass issuance and attendance will be noted separately. Monthly Status Reports are a routine City policy and procedure. End of season totals can be provided upon request. Health u°_ and fitness improvement will be surveyed by personal opinion. o Learn-To-Swim Classes: Instructors will track attendance and assess the skills development of each student and recommend/encourage the appropriate advancement plan to the parents of Q each participant. By creating new habits and teaching purposeful swim lessons, participants will a leave with positive lifesaving skills and attributes to prepare them for other safe water play activities. Students will also be prepared to enter the City's Junior Lifeguard program through successful completion of a prerequisite swim test. Rethink Your Drink: Banners will be posted pre-season. All printed Rethink Your Drink literature 6 will get into the hands of swim patrons repeatedly over the hot summer months. A short N questionnaire will help us qualify the message effectiveness. Pledge Cards will track participation, a . including the Summer Reading Program participants and other youth-serving partners. A successful swim program with large attendance will maximize the audience to whom the campaign x is primarily intended. W w d E r Q is Packet Pg.352 3 i Key Staff and Responsibilities" List key project staff and volunteers on the project and describe their responsibilities. (Limit your answer to 100 words.) The Staff at the Hernandez and Mill Pools(1 Pool Manager,1 Senior Lifeguard,1 Lifeguard,1 Cashier) are budgeted to serve as the lifesaving services for the open swim program and as swim instructors. Pool staff is hired from a "pool` of qualified employees with varying work experience history. The Aquatics Recreation Supervisor has been employed in like capacity for over 27 years. o .2 Challenges and Oppo�rtixnities " ,: .. . Provide relevant information on challenges, both internal and external, confronting the proposed o project. Describe how you will mitigate those risks. The greatest challenge in the Aquatics Program is identifying and hiring enough qualified staff in iP lifeguard service. The City intends to offer certification classes in Lifeguarding and Water Safety Instruction in the Spring months in order to build a pool of respective candidates. A recent MOU with the San Bernardino City Unified School District has not only netted us the opportunity to 0 conduct certification classes in a heated pool but also to improve our recruitment efforts at the U_ high school level. A second challenge is maintaining equipment in operational order by y coordinating a comprehensive preventative maintenance plan and a capital replacement program; Y legislative changes and State-mandated health and safety codes must be adhered to on a daily/hourly basis. Staff training and supervision is key to this objective. The primary challenge in programming is to identify the needy patrons and motivate them to register into the activities. N Providing promotion materials in Spanish and aggressively marketing the target group through 00 existing programs especially will provide larger results in this effort. However, weather patterns to can greatly influence this interest and are not controllable. The scheduling of activities is already L based upon maximizing attendance during times of greatness availability and need (such as when N we offered swim classes at the 6p.m. hour instead of morning or noon times). As a reminder, the City is still immersed in a Recovery Plan as a condition of bankruptcy since 2012 with the FY2016- _ 2017 revenues expected to remain "flat". 0 U_ C 0 v .Q a a Involvement KaiserTermanente In*V6 vemerit List Kaiser Permanente physicians and/or employees affiliated with your organization and/or project. N None a w X W Pending Requests to Kaiser Pertrinente List other pending proposals submitted to Kaiser Permanente. (Indicate Kaiser Permanente E Medical Center location, amount, and proposed project.) None pending. Q 19 Packet Pg.353' 1 5.P.b Visibility Briefly describe any plans to communicate your progress and results to an external audience (e.g., newsletters, press releases, presentations) The City of San Bernardino will introduce and launch the Operation Splash Program on June 3, 2016 with the Operation Splash Kickoff& SwimFest event. We will partner with the County's First 5 Program in promoting water safety on this day. Open Swim and Learn-To-Swim classes will start the following Monday and continue throughout the summer months. Promotion of these activities o will take place no later than eight weeks prior and be on-going, allowing for sufficient time for service recipients to pre-register. Registration will be on-going. Marketing to the target group will be accomplished by production and distribution of fliers in both English and Spanish to students of o the San Bernardino City Unified School District (grades 5th-8th), local churches, Boy and Girl Y Scout Troops, Boys,& Girls Club of San Bernardino, the Public Safety Academy, Norton Space and Aeronautic Academy and other charter schools, Inland Empire American Red Cross, local EDD Office (SBETA), local doctorldentistry offices, resident youth sports groups organizations, neighborhood associations, and all community centers and libraries. Periodic press releases will be dispersed to a local and regional media list, on the City of San Bernardino Website, Public U. Cable Access Channel 3 (IEMG), and posted banners at public facilities. Announcements and N recognition will be provided at several televised City Council Meetings and at other City Y Commissions meetings. 0 N co LO ICI ase provide;,the following q ormati n about the groups( targeted by your,L praptosll v:. !G.. .... .. Y Population Demographics :0 V, India duals to be Directler,�ed ` _ ... ..... . .... . „ .. . .. `... . .. Num . ... . Y ,0 3,720 0 .2 Ya 7 ;r..,,.,•: ;5::,p;tE.:v.niEii:^:!.?_i: plllat o ...t.!- ? ...: •u . Q. Please select the top three populations served. a Broader Community Ethnic Minority Low-Moderate Income Age Crroup:of the Population Served _. N If your project will serve all ages listed, please select"All." Otherwise, please select up to three. a (0-12) Children (13-17) Teens x All Ages w Gender:of.tle Population Served: If your project will serve all genders listed, please select "All." Otherwise, please select all that apply. a All Ethnicity;of the Population Served _... .... 20 Please select all that apply. Please select "Other"if your project serves an ethnicity not listed. American Indian or Alaska Native Asian South Asian (Incl Indian, Pakistani, Afghani) Black -African-American Black- Other Black c Latino/Hispanic Middle Eastern Native Hawaiian = Pacific Islander White C Ethni& b marb pulat�dn Serucd If you selected "Other" because your project serves an ethnicity not listed, please enter the cc r ethnicity here: o LL L d 0 Y ti cfl 0 N 00 07 lA d' L Y R c m r _ 0 U. _ 0 CL a Q c co IIL^^ V T r N Q s x W m E t R r Q zi Packet Pg. 355 � 1 Mickey Valdivia Director of Parks,Recreation&Community Services 201 North"E"Street,Suite 301 i ; 6 San Bernardino,CA 92401 (909)384-5233 San liermar iflo •L March 25,2016 0 0 U c Community Benefit Grants Program P Kaiser Permanente Public Affairs Office Attn: Roberta Tinajero-Frankel R 393 E.Walnut Street,2"1 Floor �. c Pasadena,CA 91188 0 LL L Dear Ms.Tinajero-Frankel: N M The City of San Bernardino is pleased to be invited for stage two of the application for the Kaiser Permanente Fontana& Y Ontario Medical Centers funding for our 2016 Operation Splash program. The Department of Parks, Recreation and Community Services continues to emphasize its commitment to the reduction of the chronic diseases leading to an epidemic o of childhood obesity in our city.Our summer water play programming is a critical piece of the our overall community health N plan since this audience is so well connected to us in the summer months,starting with greater accessibility to our pools and swim play apparatus. Furthermore, we are very pleased with our progress in the branding of the Rethink Your Drink campaign and look forward to even greater things working alongside Kaiser Permanente for this Summer 2016. `O L The City of San Bernardino struggles with high poverty rate, low median family income levels, and a growth in the N Hispanic/Latino and African American populations, who are disproportionately affected by overweight and obesity. The recent mass shooting tragedy in San Bernardino will not delay our efforts to keep"SB STRONG". We will continue to be ever hardworking with such limited resources in a community we are proud to call"home"and hope that you will continue to share in that sentiment.As mentioned time and again,our summer aquatics programs are a focal point for healthy eating and active living. U. c The 2015 Operation Splash program's successes are well documented in the on-line application as we continue to apply o diminishing grant contributions into real-world successes, such as providing pools for 87 low-income families with 492 members the ONLY opportunity for water play and teaching 361 youth how to swim and stay alive while having fun in a Q water environment.Furthermore,the Rethink Your Drink promotion has really livened up many of the community members CL in making healthier food and beverage choices.Our greatest challenge this year will be to secure enough qualified part-time Q life-saving work force to do the things we do best, which is to Create Community through Parks, People and Programs, ca which is why the Junior Lifeguard Program is so important to us as well(Regional Kaiser funded program). r` Thank you for your past support.I look forward to our future successes in such a challenging community as San Bernardino. 0 Sincerely, `� UJI Q w c m Mitch Assumma on behalf of Mickey Valdivia Director Of Parks,Recreation and Community Services "Parks Make Life Better" Q cc: Mark Scott,City Manager Enclosures Packet Pg.356 5.P.b KAI5ER PE MANI tQfE. I ` . . o Organization Name:,City of San Bernardino- PRCSD Project Title:-nandez&Mill Pools Open Swim&Learn-To-Sk Date: 24-Mar-16 O Request from Other U In-Kind TOTAL Kaiser Foundation Sources BUDGET Hospitals Contribution of Income PERSONNELISTAFFING EXPENSES (List title and%on project) 1 10%-Aquatics Recreation Supervisor $ - $ 12,336.00 $ 5,000.00 $ 17,336.00 2 50%-Pool Manager $ 5,318.00 $ 5,318.00 $ 10,636.00 0 0 3 50%-Senior Lifeguard $ 4,792.00 $ 4,792.00 $ 9,584.00 u- I440%-Life Lifeguard $ 4,965.00 $ 6,193.00 $ 11,158.00 6 50%-Recreation Leader(Cashier) $ - S 6,600.00 $ 6,600.00 Y $ r` r Subtotal, Personnel/Staffing Expenses $ 15,075.00 $ 35,239.00 $ 5,000.00 $ 55,314.00 N Benefits( 7.5 %of Personnel) $ - $ 3,773.56 $ 3,773.56 00 LO TOTAL,PERSONNEL $ 15,075.00 $ 39,012.56 $ 5,000.00 $ 59,087.56 PROGRAMIOPERATING EXPENSES L m Office Supplies $ 100.00 $ 100.00 N Communications(e.g.,printing,cop in )-RYD $ 770.00 $ 770.00 c,s First Aid Supplies $ 200.00 $ 200.00 Y Custodial Supplies $ 400.00 $ 400.00 0 Swim Class Supplies $ 200.00 $ 200.00 L $ O w Other: $ TOTAL,PROGRAM EXPENSES $ - $ 4,846.00 $ - $ 4,846.00 Q- INDIRECTIOVERHEAD EXPENSE" Q ( 10 %of Expenses) $ $ ITOTAL EXPENSES t j (Personnel+Program+Indirect) $ 15,075.00 $ 43,858.56 $ 5,000.00 $ 63,933.56 T NARRATIVE:City pays all utilities cost(water,electric,gas),all pool chemical costs,licenses and fees for commercial pool operation, r and equipment maintenance and replacement(circulation system,chemical feed system,filtration,deck&grounds),NOT shown as In-Kind. CD CV PERSONNEL:The Staff atthe Hernandez and Mill Pcols(1 Pool Manager,l Senior Lifeguard,l Lifeguard,1 Cashier)are budgeted to serve as the lifesaving services for the open swim program and as swim instructors.Pool staff is hired from a"pool'of qualified employees Q with varying work experience history.The Aquatics Recreation Supervisor has been employed in like capacity for over 27 years.Two swim +r sessions are offered Monday through Saturday from 1:00pm-Toopm&3:30pm-5:30pm for a 10-week summer season only.Learn-to-swim t classes are taught B:OOpm-6:45pm on M-Th just after open swim.Five 2-week swim sessions are taught to one/two classes of B-10 students X each session.IN-KIND: Operating supplies include toiletries and sanitation supplies(staff also serve as custodians during daily use),routine LU first aid supplies needs,minor repair items(chemical tubing replacement or hardware for signs,etc.),and kickboards as teaching aids=lowks. 4. SUSTAINABILITY:General Fund(small%user fee cost recovery)and partnering to share costs and gain discounts/rebates,etc. d E L U fQ Q Packet Pg. 357 0 O uU, o ° o ° O O O N — O O O p % N ul 0 O kn M �--' O O O 0 .O O � ,_, N p 0 ¢ Q Q 0n ' N 00 O ° kn0NOOOOV � NMZ � N vl N y O O N O O 0 0 M U vin 00 I v'l M 00 00 0 M '" �o Q d Q Q M o _ 00 00 wi O 00 M 09 01 6 Y7 O M �r, of ,� _ NO U N�-. .-. M M �-. 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UU a 0 0 od a 0 ra fi COO z F� R, V] Vl Q x xZ Packet Pg.358 Mitch Assumma From: kp-community @kp.org Sent: Monday, March 14, 2016 4:28 PM To: SCAL.MC.Grants @nsnttp.kp.org Cc: Martha.R.Valencia @kp.org Subject: Kaiser Permanente Budget& Narrative c O r Hello, L You are receiving this email because you have hec;l,n a stage two application for the Kaiser Permanente Fontana& v Ontario Medical Centers. _ L We realized that the budget template and narrative were not included in the application. • ca c Attach a completed budget, based the Imidget template that you can download here: _ http:ilcommunity.kp.org/download,,/SCa iBudqetTemplate.xls 0 • If you prefer, you may upload an undated version of the budget you submitted during the first stage. • Items listed in the "In-Kind Conlribi lions"column of the budget template should list only non-cash support w for your project. For example, this is where you would list the value of donated office space, health Y education materials, or office equipment. • Attach a Word or PDF document describing how the requested funds will be used. N • Briefly describe the categories of 1.!-idinij you are requesting (e.g., personnel, program and/or operating co expenses). 0 v • Send the documents to scal.mc.grants(ii.'� noMc by March 31,2016 at 2:00 p.m. � N Y Please note: You have 3 additional days beyond W.;� original due date.Your new due date is March 31,2016 at 2:00 c>s .r p.m. o LL Please let me know if you need anything else, _ 0 ca Katherine Murphy 2 Technical Assistance a KP-Community a NOTICE TO RECIPIENT: If you are not the intended recipient of it a-mail,you arc prohibiled from sharing,copying,or otherwise using or disclosing its contents. If you have received this e-mail in error,please notif Ile::-..;rider immediately by mply e-mail and permanently delete this e-mail and any attachments (� without reading,forwarding or saving them. Thank you. r uj O N X W IE t V a i Packet Pg. 359 2016 GENERAL FUNDED PROGRAM PERSONNEL.BUDGET DRAFT WIREVENUE QECREATION SWIM: DAYS DAYS COST COST REVENUE OOL SITE POS.TITLE #OF EMPL. WAGE HRIDAY S-SUN HRIDAY MON-FRI S-SUN MON-FRI TOT.COST PROJECTED JERRY LEWIS PL MNGR.11 1 $15.90 6.3 28 6.3 56 $2 805 $5,610 $8,414 PL MNGR.I 1 $14.65 6.3 28 6.3 56 $2,584 $5,169 $7,753 SR.UG 2 $13.20 6.3 28 6.3 56 $4,657 $9,314 $13,971 UG 4 $11.55 6.31 28 6.31 56 $8,150 $16,299 $24,4 CASHIER 4 $10.00 61 28 6 56 $8,720 $13440 $20160 0 REC LDR 2 $10.50 5 28 2 56 $2 940 $2,352 $5,292 $80039 $41250 TOTAL POOL SITE POS.TITLE #OF EMPL. WAGE HFJDAY DAYS COST REV.PROJ. C Start:May 30-August 6,2016&Wknds Thru August U NUNEZ PL MNGR.1 1 $14.65 5,5 76 $6,124 (Thru Aug 12th&Wknds @ J.Lewis) SR.UG 2 $13.20 5.5 76 $11,035 Note:Revenue projections are based on the prior yews actuals. _ UG 2 $11.55 6.5 76 $9,656 L CASHIER 1 $10.00 5 76 $3 800 TOTAL $30 615 $4760 z_ POOL SITE POS.TITLE #OF EMPL. WAGE HRIDAY °DAYS COST REV.PROJ. O HERNANDEZ PL MNGR.1 1 $14.65 5.5 66 $5,318 LL SR.LIG 1 $13.20 5.5 66 $4,792 d UG 1 $11.55 5.5 66 $4193 uJ CASHIER 1 $10.00 5 66 $3 300 $17 602 $2100 TOTAL Y POOL SITE POS.TITLE #OF EMPL. WAGE HRIDAY DAYS COST W REV.PROJ. r DELMANN HTS PL MNGR.1 1 $14.65 5.5 66 $5 318 G N SR,UG 1 $13.20 5.5 66 $4792 UG 1 $11.55 5.5 66 $4193 00 CASHIER 1 $10.00 5 66 $3 300 0)LO TOTAL 17602 1200 � L SWIM CLASSES: a d POS.TITLE #OF EMPL. WAGE HRIDAY DAYS M-TH #SESSION COST REV.PROJ 4 :RNANDEZ UG 3 $11.55 1 B 5 $1,386 $0.00 ,NUNEZ UG 4 $11.55 1 8 5 $1848 $0.00 cT3 JERRY LEWIS UG 7 $11.55 1 8 5 $3,234 $5,000 G TOTAL _ 8 y x - .. It) mmt$ 4g8 O 5,000 SWIM RENTALS: LL POS.TITLE 1#OF EMPL. WAGE HRIDAY # RENTALS COST I REV.PROJ r_ JERRY LEWIS JUG 1 6 $11.55 21 20 $2,7721 $3,864 O a . JUNIOR LIFEGUARD PROGRAM: s v POS.TITLE OF EMPL. WAGE HRIWK #WEEKS ICOST IREV.PROJ p JERRY LEWIS Coord.11nstr.Train # 1 $17.53 4 10 5701 $300 Q Coord.11n5tcTrain 1 $17.53 2 10 $361 TOTAL $1052 $300 RETHINK YOUR DRINK: _ 0 POS.TITLE #OF EMPL. WAGE HRIWK #WEEKS COST R£V.PROJ II CITY-WIDE Su v. 1 $29.37 2 10 $587 $0 T POOL MGR. 3 $15.9D 1.5 5 $358 $945 $300 TOTAL C rm x _3 a. :_F'„a °�:.: >s �s.a u»._ a ...:"r.� 30 ".� ,. N Q w .fl s x LU c a� E J= co Q Packet Pg. 360 I ' Department of the Treasury O IRS Interwd Revenue Service P.O. Box 2508 In reply refer to : 0248221 Cincinnati OH 45201 Oct . 30 , 2009 LTR 4076C EO 95-6000772 000000 00 00014241 BODC: TE CITY OF SAN BERNARDINO CITY HALL o X MICHAEL GOMEZ 300 N D ST SN BERNRDNO CA 92418-0001 0 U c )03426 L C7 Federal Identification Number: 95-6000772 Person to Contact : April Howard Toll Free Telephone Number : 1-877-829-5500 0 LL m Dear Taxpayer : 'ca Y This responds to your request for information about your federal tax ti status. Our records do not specify your federal tax status. However , v; the following general information about the tax treatment of state N and local governments and affiliated organizations may be of interest 00 to you. 0) GOVERNMENTAL UNITS L Governmental units , such as States and their political subdivisions, vi are not generally subject to federal income tax. Political f° Y subdivisions of a State are entities with one or more of the co sovereign powers of the State such as the power to tax. Typically they include counties or municipalities and their agencies or 0 0 departments. Charitable contributions to governmental units are U_ tax-deductible under section 170 (c) ( 1) of the Internal Revenue Code o if made for a public purpose . ENTITIES MEETING THE REQUIREMENTS OF SECTION 115(1) Q An entity that is not a governmental unit but that performs an essential government function may not be subject to federal income = tax, pursuant to Code section 115( 1) . The income of such entities is (7 excluded from the definition of gross income as long as the income (1) is derived from a public utility or the exercise of an essential co government function , and (2) accrues to a State , a political N subdivision of a State , or the District of Columbia . Contributions made to entities whose income is excluded income under section 115 Q may not be tax deductible to contributors. X TAX-EXEMPT CHARITABLE ORGANIZATIONS w An organization affiliated with a State, county, or municipal government may qualify for exemption from federal income tax under E section 501 (c) (3) of the Code , if ( 1) it is not an integral part of U the government , and (2) it does not have governmental powers w inconsistent with exemption (such as the power to tax or to exercise Q enforcement or regulatory powers) . Note that entities may meet the requirements of both sections 501(c) (3) and 115 under certain circumstances . See Revenue Procedure 2003.12, 2003-1 C. B . 316 . Packet Pg. 361 0248221235 Oct . 30 , 2009 LTR 4076C EO 95-6000772 000000 00 00014242 CITY OF SAN BERNARDINO CITY HALL MICHAEL GOMEZ 300 N D ST SN BERNRDNO CA 92418-0001 0 .n L _ 0 U Most entities must file a Form 1023, Application for Recognition of Exemption Under Section 501(c) ) (3) of the Internal Revenue Code, P to request a determination that the organization is exempt from ca federal income tax under 501(c) (3) of the Code and that charitable contributions are tax deductible to contributors under section o 170(c) (2) . In addition, private foundations and other persons u. sometimes want assurance that their grants or contributions are made N to a governmental unit or a public charity. Generally, grantors and contributors may rely on the status of governmental units based on Y State or local law. Form 1023 and Publication 4220 , Applying for 501(c) (3) Tax-Exempt Status , are available online at www. irs.gov/eo. 0 N We hope this general information will be of assistance to you. This co letter , however , does not determine that you have any particular a' LO tax status. If you are unsure of your status as a governmental unit or state institution whose income is excluded under section 115(1) ' you may seek a private letter ruling by following the procedures •0 specified in Revenue Procedure 2007-1, 2007-1 I .R.B. I (updated Y annually) . c c� If you have any questions, please call us at the telephone number �o shown in the heading of this letter. _ 0 2 Sincerely yours , Q CL Q m Michele M. Sullivan , Oper. Mgr. co Accounts Management Operations I co14 Q .r s X w _ a� E s Q Packet Pg. 362 S.P.b Form W-9 Request for Taxpayer Give Forst to the (Rev.August 2013) requester.Do not Department of'he Treasury Identification Number and Certification send to the IRS. Internal Revenue Service Name(as shown on your income tax return) City of San Bernardino City Hall Business name/disregarded entity name.If different from above N N QI � ro Check appropriate box for federal tax classification: Exemptions(see instructions); O ❑Individual/sole proprietor ❑ C Corporation ❑S Corporation ❑ Partnership ❑ Trust/estate N Q a.o Exempt payee code(if any) 3 u� Limited liability company.Enter the tax classification(C=C corporation,S=S co rp oration,P=partnership)P) Exemption from FATCA reporting C ccode(if any) C V IL E] Other(see instructions)► _ u Address(number,street,and apt.or suite no.) Requester's name and address(optional) (L3 fl Soo N."Y Street City,state,and ZIP code C W San Bernardino CA,92418 List account number(s)here(optional) l0 L LM Taxpayer Identification Number(TIN) N Enter your TiN in the appropriate box.The TIN provided must match the name given on the"Name'line Social security number Y to avoid backup withholding.For individuals,this is your social security number(SSN).However,for a resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other —m entities,it is your employer identification number(EIN).If you do not have a number,see Now to get a �p TiN on page 3. o Note.If the account is in more than one name,see the chart on page 4 for guidelines on whose Empioyeridentificailon number tV number to enter. op 9 _ 6 0 4 0 7 7 2 rn LO Certification _ _ Under penalties of perjury,t certify that: y 1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and N 2. I am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue Y Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am C no longer subject to backup withholding,and tyo 3. 1 am a U.S.citizen or other U.S.person(defined below),and 0 O 4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct. Certification instructions.You must cross out Item 2 above,if you have been notified by the IRS that you are currently subject to backup withholding p because you have failed to report all interest and dividends on your tax return.For real estate transactions,Item 2 does not apply.For mortgage 'ia interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and v generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the Q instructions on page 3. Q sign Signature of / Community Recreation 1Manager = Here U.S.person t L .�� l I I L General Instructions withholding tax an forelgn partners'share of effectively connected income,and 0 4.Certify that FATCA codes)entered on this form(if any)Indicating that you are ti Section references are to the Internal Revenue Code unless otherwise noted. exempt from the FATCA reporting,Is correct. r Future developments.The IRS has created a page on IRS.gov for information Note.If you are a U.S.parson and a requester gives you a form other than Form about Form W-9,at www.trs.9ov 1w9.Information about any future developments W-9 to request your TIN,you must use the requester's form If it is substantially N affecting Form W-9(such as legisfation enacted after we release it)will be posted similar to this Form W9. on that page. Definition of a U.S.person.For federal tax purposes,you are considered a U.S. Q Purpose of Form person If you are: A person who is required to No an information return with the IRS must obtain your •An Individual who is a U.S.citizen or U.S.resident alien, correct taxpayer Identification number(TIN)to report,for example,Income paid to •A partnership,corporation,company,or association created or organized In the K you,payments made to you in settlement of payment card and third party network United States or under the laws of the United States, W transactions,real estate transactions,mortgage Interest you paid,acquisition or •An estate(other than a foreign estate),or abandonment of secured property,cancellation of debt,or contributions you made .A domestic trust(as defined In Regulations section 3D1.7701-7). to an IRA. Use Form W-9 only if you are a U.S.person(including a resident alien),to Special rules for partnerships.Partnerships that conduct a trade or business in E provide your correct TIN to the person requesting it(the requester)and,when the United States are generally required to pay a withholding tax under section 1446 on any foreign partners'sharp of effectively connected taxable income from v applicable,to: such business.Further,in certain cases where a Form W-9 has not been received, 1.Certify that the TIN you are giving Is correct(or you are waiting for a number the rules under section 1446 require a partnership to presume that a partner Is a Q to be issued), foreign person,and pay the section 1446 withholding tax,Therefore,if you are a 2.Certify that you are not subject to backup withholding,or U.S.person that is a partner in a partnership conducting a trade or business in the United States,provide Form W-9 to the partnership to establish your U.S,status S.Claim exemption from backup withholding iryou are a U.S,exempt payee.If and avoid section 1446 withholding on your share of partnership income. applicable,you are also certifying that as a U.S.person,your allocable share of any partnership income from a U.S.trade or business is not subject to the Get.No.10231X Form W-9(Rev.B-2013) Packet Pg. 363 EXHIBIT "B" L JETTER OF AGREEMENT KAISER FOUNDATION HOSPITALS,FONTANA COlVdMUNITY BENEFIT CHARITABLE CONTRIBUTIONS PROGRAM E 2 This Letter of Agreement(hereinafter"Agreement")is entered into by and between Kaiser Foundation Hospitals,a California nonprofit, public benefit corporation (hereinafter"KFH")and City of San Bernardino,a charter city organized in the State of California and not subject to federal or state income tax. L This Agreement sets forth the understanding of the parties hereto as to the terms and conditions under which KFH shall donate funds in the amount of$15,000.00 for a one year funding period beginning July 1,2016 through July 1,2017 for 2016 0 Open Swim&Learn-To-Swim in Hernandez& Delmann Heights Pools. Such terms u_ and conditions are as follows: N Y 1. Tax Exemption Status: Grantee represents that at all times relevant herein,it is a charter city organized in the State of California and not subject to federal or state income 0 tax. N 00 LO 2. Purpose of Grant. Grantee shall use entire Grant to support the specific goals, objectives,activities, and outcomes as stated in the Grant Summary. c L 3. Expenditure of Funds.This Grant(together with any income earned upon investment of grant funds) is made for the purpose outlined in the Grantee's Work Plan N and may not be expended for any other purpose without KFH's prior written approval. Y NMW c 4. Prohibited Uses. In no event shall Grantee use any of the funds from this Grant to (a) support a political campaign,(b)support or attempt to influence any government �° legislation, except making available the results of non-partisan analysis, study or research,or(c) grant an award to another party or for any purpose other than one 3 specified in Section 170(c)(2)(b)of the Internal Revenue Code of 1986 as amended. w Ca c 5. Return of Funds. KFH reserves the right to discontinue,modify or withhold d payments to be made under this Agreement or to require a total or partial return of any � funds, including any unexpended funds under the following conditions: Q (a) If KFH, in its sole discretion,determines that the Grantee has not performed in o accordance with this Agreement or has failed to comply with any terra or J condition of this Agreement. (b) If Grantee loses its status as an eligible Grantee under Paragraph 1 above. (c) Any portion of the funds is not used for the approved purpose . N (d) Such action is necessary to comply with the requirements of any law or regulation m applicable to Grantee or to KFH or to this Grant. 6. Records Audits and Site Visits. KFH is authorized to conduct audits,including W Ion-site audits,at any time during the term of this Grant and within four years after c completion of the Grant. Grantee shall allow KFH and its representatives,at its request, to have reasonable access during regular business hours to Grantee's files,records, accounts; personnel and client or other beneficiaries for the purpose of making such Q audits,verifications or program evaluations as KFH deems necessary or appropriate Community Benefit-Letter of Agreement Kaiser Tracking number for this grant/donation is 206=9586 1 of 4 Packet Pg.364_. s - concerning this Grant. Grantee shall maintain accounting records sufficient to identify the Grant and to whom and for what purpose such funds are expended for at least four(4) years after the Grant has been expended. ' 7. No Assignment or Delegation. Grantee may not assign, or otherwise transfer, any rights or delegates any of Grantee's obligations under this Agreement without prior written approval from KFH. L w 8. Records and Reports. Grantee shall submit written progress report(s)to KFH in �°� accordance with the due dates stated on the Grant Summary(Attachment). V Grantee shall be primarily responsible for the content of the evaluation report. If KFH determines IRB approval is necessary, as part of the evaluation process, Grantee shall follow KFH IRB approval processes and procedures. �° L d 9. Required Notification. Grantee is required to provide KFH with immediate 2 written notification of any change in Grantee's tax exempt status or when Grantee is Y unable to expend the grant funds for the approved purposes described in the Work Plan. T- 0 10. Identification of KFH. Grantee shall identify KFH as a supporting organization in all published material relating to the subject matter of this Grant. Whenever possible and rn appropriate,Grantee shall publicly acknowledge KFH for this Grant. v r c 11. Equal Employment Opportunity:Grantee agrees to comply with and be bound by CD the nondiscrimination and affirmative action clauses contained in: Executive Order 11246, as amended,relative to equal opportunity for all persons without regard to race, N color,religion, sex or national origin; the Vocational Rehabilitation Act of 1973, as Y amended, relative to the employment of qualified handicapped individuals without discrimination based upon their physical or mental handicaps;the Vietnam Era Veterans Readjustment Assistance Act of 1974,as amended,relative to the employment of disabled veterans and veterans of the Vietnam Era,and the implementing rules and regulations prescribed by the Secretary of Labor in Title 41,Part 60 of the Code of a Federal Regulations(CFR). 08 c a� 12. Immigration Act Requirements. Grantee shall comply during the term of this E Agreement with the provisions of the Immigration Reform and Control Act of 1986 and any regulations promulgated thereunder. Grantee hereby certifies that it has obtained a a properly completed Employment Eligibility Certificate(INS Form 1-9) for each worker ° performing services related to the program described in the Work Plan. -J ti 13. Licensing and Credentials. Grantee agrees to maintain, in full force and effect,all required governmental or professional licenses and credentials for itself, its facilities and N for its employees and all other persons engaged in work in conjunction with this Grant. m 14. Payment of Grant. First payment by KFH will be contingent upon a signed w Agreement between KFH and Grantee. Subsequent payments(if any) are contingent upon compliance with this Agreement,including timely receipt of reports as outlined in Paragraph 8 above. a Community Benefit-Letter of Agreement Kaiser Tracking number for this grant/donation is 20649586 2o 4 Packet Pg. 365 t IN WITNESS WHEREOF,the parties hereto have executed this Agreement as of the date first above written. Kaiser Foundation Hospitals X Trish Lopez Date Area Chief Financial Officer' 0 U Grantee SAM R Mic y V�xldivia '' Date Director of Parks, Recreation and Community Services �° City of San Bernardino Y C6 r 0 N co a) LO C O ''L^^ V L Y ca c R r c O W L 3 a 06 d E co L a M.. O L ti r 0 N S X w m E a Community Benefit-Letter of Agreement Kaiser Tracking number for this grant/donation is 20649586 3 of 4 Packet Pg.366 t LETTER OF AGREEMENT Attachment ' GRANT SUMMARY c 2 GRANT NUMBER: 20649586 DATE AUTHORIZED: June 15, 2016 GRANTEE NAME: City of San Bernardino- 0 Parks,Recreation and Community Services AMOUNT: $15,000.00 over 12 months Department c L CONTACT, TITLE: Mr. Mitch Assumma,Interim Recreation Division Manager c cts TELEPHONE: (909)384-5132 FAX: (909)384-5160 0 UL CB PROJECT MANAGER: Martha Valencia, Community Benefit Health Manager Phone: (909) 427-5269 Email: martha.r.valencia k .org Y ti GRANT PURPOSE: 2016 Open Swim&Learn-To-Swim in Hernandez&Delmann Heights Neighborhood Pools N GRANT OBJECTIVES: • To provide open swim to 3,400 visitors; swimming passes to 60 households(240 total 0 individuals); swimming lessons to 120 beginners ages 6-17 years;5,000 open swim visitations,a Hernandez and Delmann Heights Pool to 3,400. rLn V GRANT PERIOD: d Start date: 7/1/2016 End Date: 7/1/2017 Y NARRATIVE AND FINANCIAL REPORTS DUE: o Requirement Due Date t° Final Report August 1,2017 L a r d E d L a M- O L a+ J ti 7 tD r O N m w t X W C d E L V City of San Bernardino-Parks,Recreation and Community Services Department 2 CB Grant Summary Q Grant 4 20649586 4of4 Packet Pg. 367 IE Kaiser Foundation Hospitals July 14, 2016 Mitch Assumma Interim Recreation Division Manager c City of San Bernardino-Parks,Recreation and Community Services Department o 201 North E Street, Suite 301 San Bernardino,CA 92401 Dear Mr. Assumma, r It is with great pleasure that we at Kaiser Foundation Hospitals enclose a check to your organization in �° the amount of$15,000.00. These fun ss are for the support of your project,2016 Open Swim&Learn- y To-Swim in Hernandez&' leig 'borhoods. Y By endorsing, depositing,or cashing this check, you certify that: 0 There has been no change in your I.R.S. tax classification as an organization described in Internal V_ Revenue Service Code sections 501(c)(3), 501(c)(8),501(c)(10),or 501(c)(19); or the grantee is a N local, state,and federal government agency. 00 • The funds will be used as outlined in your grant proposal. LO • The organization will submit an Acknowledgment of Cash Contribution(see attachrnent)within five(5)business days of receipt of the check. 1a ® The organization will complete an online final grant report.A link will be sent to you at the end of the grant period. n For your reference,your tracking number is 20649586. (Please use this number in all � correspondence.) c c Sincerely, i° L Martha Valencia 3 Community Benefit Health Manager ca Fontana,Kaiser Foundation Hospitals E Q Enclosures: Check#9943400 Acknowledgment of Cash Contribution Instructions a Acknowledgment of Cash Contribution c cc: 0 N • t x w m E 9961 Sierra Avenue -nntana, CA 92335 Q Packet Pg.368' Instructions for Recipient Organizations to Complete 2016 Acknowledgement of Cash Contribution(s) from Kaiser Foundation Hospitals Your organization provides valuable services to the community and we are pleased to support your o work. In order for us to comply with the United States Department of the Treasury, Internal Revenue Service's rules regarding contribution documentation,we are requesting a Donation Receipt(enclosed) r from your organization for the 2016 cash contribution(s)you received from Kaiser Foundation v Hospitals, ("KFH"), listed in the attached document. We have enclosed the Acknowledgement of = Cash Contribution. Please follow the instructions below to finalize the process: o c 0 1. Review the pre-populated data(items 1-8)in column 2 for accuracy; d 2. If you have any changes to column 2,please make the updateslcorrections in column 3; Y ti 3. Complete item 9; 0 ■ If no Goods or Services(tangible benefit) were received by Kaiser Foundation Hospitals for the contribution listed, select `None' in 9a and continue to the signature a LO section. ■ If Goods and Services (tangible benefit)were received by Kaiser Foundation Hospitals far the contribution listed,complete 9a, 9b, and 9c before continuing to the signature section. a� 4. Sign,date and print or type the name and title of the Chief Executive or Officer from your Y organization; �o 5. Scan and email the signed Acknowledgement of Cash Contribution to Kaiser Foundation U_ Hospitals within, b sYnes days from receipt of the contribution to scal.mc.graiits@kp.org. 3 Please ernatl?scal.mc.grants @kp.org if you have questions, or if you would like an electronic version 06 of the receipt. E a� as L a 0 L r ti cc 0 N X W C E t U a Packet Pg. 369 Kaiser Foundation Hospitals 2016 Acknowled ement of Cash Contribution from Kaiser Foundation Nos itals Information Requested Records Show Corrections Y 1 Or anization's Legal Name: City f San Bernardino c y o 2 Organization's Tax ID: 95-6000772 3)Organization's Tax Exempt Government or Public Agency Status: 0 4)Fiscal Agents only:The name of the benefiting or g. o V//L�� ! 1 H AQMTR l I TION TR© .,K $ER FOEJ Q�T� N 1Q311TA1.S'. 5)Brief description of project: 2016 Open Swim&Learn-To-Swim in pen wim earn o Swim in Hernandez&Mill Neighborhoods Hernandez & Delmann Hei hts Neighbrr o 6 Check amount: $15,000.00 7 Check number: 9943400 8 Check date: 716/2016 Y ti GOODS AND SERVICES 9)Goods or services provided to Kaiser Foundation Hospitals and/or its representatives for the N contribution listed above. a) LO a)Type(s)of goods or services provided: ®NNi1 ❑ Meal ❑Advertisement ❑ Event Ticket ❑Booth ❑Other: c ca L b)Quantity of goods or services provided: (for example, 10 dinner seats) 0 L c)Fair market value of goods or services provided:(for example, $50 per seat,totaling$500) Y c c 0 U- 10)Signature(Item 9 above must be completed before signing) S interim 3 Jim TickemYer - Director of Parks, Recreation and Community Services Dept a Name&Title(type or print) °ia c m Signature a 4- 0 Date r J r INTERNAL USE ONLY 0 11)Tracking Number; 20649586 12)Payment Number: 90077 "' 13)Medical Center Service area: Fontana Document Rev: 12/112014 m :c Instructions: Please return the signed document within five (5) days of check receipt to W scal.mc.g >rlk . ;_ a \\cnndccbap003\Giftsdata\Template\09112345L.doc Packet Pg. 370 5.P.c ` + Check Date:Jul/0612016 Vendor Number:100011527 0009943400 Invoice Number Invoice Date Voucher ID Gross Amount Discount Taken Paid Amount 90077 Jun/30 12016 33277254 15,000.00 0.00 15,000.00 2016 OPEN SWIM LEARN-TO-SWIM IN HERNANDEZ MILL NEIGHBORHOODS C O O •L O U c R V R t. R C O LL L N Y f` 0 N 00 M to r C R V L N R Y R R c O LL 'O L Total Total Total R Check Number Date Gross Amount Discounts Paid Amount Q 0009943400 Jul/06/2016 $15,000.00 $0.00 $15,000.00 tv E W - a> L Q KP.FINAl�1CIAL S`TSrCS OPS . ;.;:::"t ? ::.. ::: :::......... ctTnaNlc,r1.a::::.... 0 0 0 9 x.4.3 4 0 A ;° o ::... . 75.N-Fair Oaks Aver ui.4th Fl .....; i .•f: ``"'' ..:c.:' ::Qne PeAU's,way b : - - New castle DE 1$720 '':.Date 2016 0.... PasadenaC6L91103r=::•:;; ;:'::' =_.;.' :, :,:°::,•: .. - ti .. ..,.. ti2r�Q13 i•l' ..... ..... :.._::. :::... ...... ... -.... :..,: :•:::: -.. :.;-::i•i:i• �::::Pay Amount $***15,000.00 ` N :: pay _' ****FkFTEFN TfiO AND.°N}a W-100 DOUAR _ :. m Tozhe GfT1�OF SAN BERNARDINQ �/� ' orderAe 2Q1•NORTH E,STREET.STE 30f : :..'.° W A 924i3�:. ::..:• :SAN.",sERNAFfiRINO, ;...:.;; Authorized ure :'• Autho' d Slgnat _ is ........... .R, :.: ....... Q �aatur ... a: 11'000994340011' 1:03 L it00 2091: 31378 100911, Packet Pg. 371 CITY OF SAN BERNARDINO, CALIFORNIA EXHIBIT "C" Schedu 5 E `' ", DEPARTMENT: Parks & Recreation PROJECT#: Fontana Kaiser Permanente Contribution - 2016-17 AW IL F 16 BUDGET Account Number Description ESTIMATES MATCH* TOTAL Grant Name' *NO MATCH REQUIRED-GRANTOR REQUESTED 00 TOTAL COSTS ++ Salaries 5011 Salaries perm/fulltime r 5013 Automobile allowance _ O 5014 Salaries temp/parttime 15,000 40,239 55,239 U 5015 Overtime - Total:Salaries 15,000 40,239 55,239 Benefits C7 5026 PERS retirement 3,774 3,774 C 5027 Health and life insurance - w 5028 Unemployment insurance _ O 5029 Medicare - LL Total:Benefits 3.774 3,774 N Total:Salaries&benefits 15,000 44,013 59-,013 N Maintenance and Operations ca Y 5111 Material and supplies 900 900 ti r 5112 Small tools&equip(consumables) - 5114 Raw foods 0 5122 Dues and subscriptions N 5131 Mileage 00 5132 Meetings and conferences rn Ln 5133 Education and training 73 5150 Utilities +- C 5172 Equipment maintenance - tL6 5174 Printing charges 770 770 (7 5175 Postage - O 5176 Copy machine charges N 5181 Other operating expense Y 5186 Civic and promotional cC 5193 Grant match - c�0 Total:Maintenance and Operations 1,670 1,670 O Contract Services LL 5502 Professional/contractual services - y 5505 Other professional services Total:Contractual Services - - - m Internal Service Charges N 5601 Garage charges '0 O 5602 Workers compensation U 5603 Liability 5604 IT charges in-house 5605 Telephone support 0 5606 Electric 5612 Fleet charges-fuel Total:Internal Service Charges - - Capital Outlay N 5703 Communications equipment ' Total:Capital Outlay Credit/billables 5910 Credit-federal and state program funding _ X Total:Credit/billables - W Total:Non-Personnel Expenses - 1,670 1,670 Grant Total 15,000 45,683 60,683 a) s m .r r Q 8/4/2016 Packet Pg. 372 5.P.d iA wus tf FERMANEfJfF., g� i........ 4Jf 1 r4'-s 1 riia"b^J 1�1 i{g�'.j sriY~ u r �Y £�yfIi "�fi. �., t r ?"T 3'`E.i f�t ^ ,++ -ir t �c _ x:,'�.#F —��,2f�yi'•'1�nE J.Lr�iJ•2 i,�nli.h it?; iSrcElfrgfa.li:i�iii?i_•T'r_,.i rtEr{at}(y£'t. ;:'��att�r r.y...,} ��Jt'�i��)'1';ft1'}� i . .'•.��.a li a�=r�l���,J;)a.rf£eiS�#��'`3�s�2,.�;a it Es�"1'";JET'�R��Jj+'�c r.!-� � Y^j���J�fa-� � � iii'!i Pia �iJC.{3t' to 1::-r' r.J t�:tt=.1 r' °f�r fr3r�'�t i.r z1 3friJi I sJlt it tt (t ffyN#1f cif' {J°3�rsf'_., e' H{arrt'?c�Y PrG'::Jar m S. 0 T_N; x 1 r C Organization Name: City of San Bernardino-PRCSD V Project Title:&Delmann hts or MITI Pools Open Swim&Lea Date: 2-Aug-16 = n3 Request from In-Kind Other TOTAL 0 Kaiser Foundation Contribution Sources BUDGET Hospitals of Income PERSONNELISTAFFING EXPENSES _ (List title and%on project) O 1 10%-Aquatics Recreation Supervisor $ - $ 12,336.00 $ 5,000.00 $ 17,336.00 LL 2 50%-Pool Manager $ 5,318.00 $ 5,318.00 $ 10,636.00 N 3 50%-Senior Lifeguard $ 4,717.00 $ 4,792.00 $ 9,509.00 A 440%-Lifeguard $ 4,965.00 $ 6,193.00 $ 11,158.00 Y ti 6 50%-Recreation Leader Cashier) $ - $ 6,600.00 $ 6,600.00 T $ co r $ N Subtotal, Person nel/Staff1n Expenses $ 15,000-00 $ 35,239.00 $ 5,000.00 $ 55,239.00 Benefits( 7.5 %of Personnel) $ - $ 3,773.56 $ 3,773.56 TOTAL,PERSONNEL $ 15,000.00 $ 39,012.56 $ 5,000.00 $ 59,012.56 M PROGRAM/OPERATING EXPENSES (7 Office Supplies $ 100.00 $ 100.00 N Communications(e.g.,printing,cop in )-RYD $ 770.00 $ 770.00 Y First Aid Supplies $ 200.00 $ 200.00 Custodial Supplies $ 400.00 $ 400.00 c Swim Class Supplies $ 200.00 $ 200.00 t0 Other: $ - TOTAL,PROGRAM EXPENSES $ $ 1,670.00 $ - $ 1,670.00 m d INDIRECT/OVERHEAD EXPENSE' ( 1Q of Expenses) $ $ - U TOTAL EXPENSES v Personnel+Program+Indirect) $ 15,000.00 $ 40,682.56 $ 5,000.00 $ 60,682.56 N .s= NARRATIVE:City pays all utilities cost(water,electric,gas),all pool chemical costs,licenses and fees for commercial pool operation, O and equipment maintenance and replacement(circulation system,chemical feed system,filtration,deck&grounds),NOT shown as In-Kind. ~ r PERSONNEL:The Staff at the Hernandez and D.H.or Mill Pools(1 Pool Manager,l Senior Lifeguard,t Lifeguard,l Cashier)are budgeted to r9 r serve as the lifesaving services for the open swim program and as swim instructors.Pool staff is hired from a"pool'of qualified employees p with varying work experience history.The Aquatics Recreation Supervisor has been employed in like capacity for over 27 years.Two swim fV sessions are offered Monday through Saturday from 1:00pm-3:00pm&3:30pm-5:30pm for a 10-week summer season only.Learn-to-swim U classes are taught 6:00pm-6:45pm on M-Th just after open swim.Five 2-week swim sessions are taught to oneltwo classes of 8-10 students each session.IN-KIND: Operating supplies include toiletries and sanitation supplies(staff also serve as custodians during daily use),routine first aid supplies needs,minor repair items(chemical tubing replacement or hardware for signs,etc.),and kickboards as teaching aids=lowks. X X SUSTAINABILITY:General Fund(small%user fee cost recovery)and partnering to share costs and gain discounts/rebates,etc. LV C d E L V t4 Q Packet Pg. 373