Loading...
HomeMy WebLinkAboutA7247 - COUNCIL ON AGING - SO CA INC. (CDBG) SUBRECIPIENT AGREEMENT 19 THIS AGREEMENT(herein"Agreement'), is made.and entered into this eday of . 201 , by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city,and the Council on Aging—Southern California. Inc. , (herein"Provider"). WHEREAS, the City has entered into various funding agreements with the United States Department of Housing and Urban Development ("HUD"), which agreements provide funds ("CDBG Funds") to the City under the Federal Housing and Community Development Act of 1974 (42 U.S.C. Section 5301 et seg.), as amended from time to time (the "Act'), and the regulations promulgated thereunder(24 C.F.R. Section 570 et seg. ("Regulations");and WHEREAS, the Act provides that the City may grant the CDBG Funds to nonprofit organizations for certain purposes allowed under the Act; and WHEREAS,the Provider is a nonprofit organization which operates a program which is eligible for a grant of CDBG funds and the City desires to assist in the operation of the program by granting CDBG Funds to the Provider to pay for all or a portion of those costs incurred in operating the program permitted by the Act and the Regulations on terms and conditions more particularly set forth herein; NOW,THEREFORE, the parties hereto agree as follows: 1.0 SERVICES OF PROVIDER. 1.1 Scope of Services. Provider agrees to provide to City all of the services specified and detailed in its application for funding and Exhibit A. Provider represents and warrants to City that it is able to provide, and will use funds granted by the City to provide the services represented in the Provider's application for funding. City provided funds shall be used only for those purposes specified in such application and this Agreement. 1.2 Compliance with Law. All services rendered hereunder shall be provided in accordance with all ordinances, resolutions, statutes, rules, and regulations of the City and any Federal, State or local governmental agency of competent jurisdiction. 1.3 Reports. No later than ten (10) days prior to any payment date specified in Section 2.0, within ten (10) days following the termination of this Agreement, and at such other times as the Contract Officer shall request, Provider shall give the Contract Officer a written report describing the services provided during the period of time since the last report and accounting for the specific expenditures of contract funds hereunder, if applicable. At the times and in the manner required by law, the Provider shall provide to the City, the Department of Housing and Urban Development, the Comptroller General of the United States, any other individual or entity, and/or their duly authorized representatives, any and all reports and information required for compliance with the Act and the Regulations. 1.4 Financial Reporting. Any Provider receiving or due to receive $20,000.00 or more from the City during the 2018 —2019 Fiscal Year shall provide to City a financial statement prepared by a recognized accounting firm approved by or satisfactory to City's Finance Director completed within the most recent twelve (12) months showing the Provider's financial records to be kept in accordance with generally accepted accounting standards. The report shall include a general ledger balance sheet which identifies revenue sources and expenses in sufficient detail to demonstrate contract compliance and be balanced to bank statements. Any organization receiving or due to receive less than $20,000.00 in the current fiscal year from the City shall provide a copy of the organization's most recent charitable trust report to the Attorney General, or other financial information satisfactory to City's Finance Director. The financial information provided for in this paragraph shall be furnished not later than January 31"t of the current fiscal year. ORIGINAL BID AiNrV R AG REEM ENT 2.0 COMPENSATION. 2.1 Contract Sum. The City shall pay to the Provider on a reimbursable basis.for its services a sum not to exceed FIFTEEN THOUSAND DOLLARS ($15.000.00) (the "Contract Sum") in accordance with the Budget attached hereto in Exhibit B and incorporated herein by this reference; and as herein provided. The budget cost categories set out in Exhibit B are general guidelines and if mutually agreed by both parties, may be amended administratively by no more than 10%, without the requirement of a formal amendment to this Agreement, but in no event shall such adjustments increase the Contract Sum. The Provider shall submit to the City periodic statements, in the form of Exhibit F, on reimbursable expenditures pursuant to the attached Budget along with pertinent supporting documentation. The City shall promptly review the monthly expenditure statements and, upon approval, reimburse the Provider its authorized operating costs. 2.2 Payroll Records. In cases where the contract sum will reimburse payroll expenses as part of operations, the Provider will establish a system of maintaining accurate payroll records which will track daily hours charged to the project by the Provider's respective employees, as set forth in OMB Circular A-122 Attachment B.6. 2.3 Draw Downs. Failure by Provider to request reimbursement or encumbrance of at least 25%of the total grant by the end of each fiscal year quarter(September 30, December 30, March 31,and June 30)shall result in the immediate forfeiture of 25%of the total grant. 3.0 COORDINATION OF WORK. 3.1 Representative of Provider. The following principals of Providers are hereby designated as being the principals and representatives of Provider authorized to act in its behalf with respect to the work specified herein and make all decisions in connection therewith: Elizabeth(Libby)Anderson, Long-Term Care Ombudsman Program Director 3.2 Contract Officer. The Contract Officer shall be such person as may be designated by the City Manager of City. 3.3 Prohibition Against Subcontracting or Assignment. Provider shall not contract with any other entity to perform in whole or in part the services required hereunder without the express written approval of the City. Neither this Agreement nor any interest herein may be assigned or transferred,voluntarily or by operation of law,without the prior written approval of the City. 3.4 Independent Contractor. Neither the City nor any of its employees shall have any control over the manner, mode or means by which Provider, its agents or employees, perform the services required herein, except as otherwise set forth herein. Provider shall perform all services required herein as an independent contractor of City and shall remain at all times as to City a wholly independent contractor with only such obligations as are consistent with that role. Provider shall not at any time or in any manner represent that it or any of its agents or employees are agents or employees of City. 4.0 COMPLIANCE WITH FEDERAL REGULATIONS. 4.1 The Provider shall maintain records of its operations and financial activities in accordance with the requirements of the Housing and Community Development Act and the regulations promulgated thereunder, which records shall be open to inspection and audit by the authorized representatives of the City, the Department of Housing and Urban Development and the Comptroller General during regular working hours. Said records shall be maintained for such time as may be required by the regulations of the Housing and Community Development Act, but in no case for less than five years after the close of the program. -2- 4.2 The Provider certifies it shall adhere to and comply with the following as they may be applicable, and as may be amended from time to time: (a) Submit to City through its Community and Economic Development Department semi-annual reports on program status; (b) Section 109 of the Housing and Community Development Act of 1974, as amended and the regulations issued pursuant thereto; (c) Section 3 of the Housing and Urban Development Act of 1968, as amended; (d) Executive Order 11246, as amended by Executive Orders 11375 and 12086, and implementing regulations at 41 CFR Chapter 60; (e) Executive Order 11063, as amended by Executive Order 12259, and implementing regulations at 24 CFR Part 107; (f) Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112), as amended,and implementing regulations; (g) The Age Discrimination Act of 1975 (P.L. 94-135, as amended, and implementing regulations; (h) The relocation requirements of Title If and the acquisition requirements of Title III of the Uniform Relocation Assistance and Real Property Acquisition at 24 CFR Part 42; (i) The restrictions prohibiting use of funds for the benefit of a religious organization or activity as set forth in 24 CFR 570.200 0); (j) The labor standard requirements as set forth in 24 CFR Part 570, Subpart K and HUD regulations issued to implement and requirements; (k) The Program Income requirements as set forth in 24 C.F.R. 570.504(c)and 570.503(b)(8); (1) The Provider is to carry out each activity in compliance with all Federal laws and regulations described in 24 C.F.R. 570, Subpart K, except that the Provider does not assume the City's environmental responsibilities described at 24 C.F.R. 570.604; nor does the Provider assume the City's responsibility for initiating the review process under the provisions of 24 C.F.R. Part 52; (m) Executive Order 11988 relating to the evaluation of flood hazards and Executive Order 11288 relating to the prevention, control and abatement of water pollution; (n) The flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973(P.L. 93-234); (o) The regulations, policies, guidelines and requirements of 24 CFR 570; the"Common Rule", 24 CFR Part 85 and subpart J; OMB Super Circular 2 CFR 200 as they relate to the acceptance and use of federal funds under the federally-assisted program; -3- (p) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) and implementing regulations issued at 24 CFR Part.1; (q) Title VIII of the Civil Rights Act of 1968(P.L. 90-284)as amended; (r) The lead-based paint requirements of 24 CFR Part 35 issued pursuant to the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seg.); (s) Procure, use, manage and dispose of personal property in accordance with 2 CFR 200.310 and 2 CFR 200.312 through 2 CFR 200.316; t Reversion of asset. Upon the Expiration of the agreement, the () p P , 9 subrecipient shall transfer to the City any CDBG funds on hand at the time of expiration and any accounts receivable attributable to the use of CDBG funds. Additionally, any real property under the subrecipient's control that was acquired or improved in whole or in part with CDBG funds (including CDBG funds provided to the subrecipient in the form of a loan)in excess of$25,000 is either. (i) Used to meet one of the national objectives in Section 570.208 (formerly Section 570.901) until five years after expiration of the agreement, or for such longer period of time as determined to be appropriate by the City; or (ii) Not used in accordance with paragraph (t)(i) above, in which event the subrecipient shall pay to the City an amount equal to the current market value of the property less any portion of the value attributable to expenditures of non-CDBG funds for the acquisition of, or improvement to, the property. The payment is program income to the City. (No payment is required after the period of time specified in paragraph (t) of this section.) (u) Conflict of Interest. The Provider is required to disclose to the City in writing any potential conflict in accordance with 24 CFR Part 570.611; and (v) Such other City, County, State, or Federal laws, rules, and regulations, executive orders or similar requirements which might be applicable. 4.3 The City shall have the right to periodically monitor the program operations of the Provider under this Agreement. 5.0 INSURANCE AND INDEMNIFICATION. 5.1 Insurance. The Provider shall procure and maintain, at its cost, and submit concurrently with its execution of this Agreement, public liability and property damage insurance against claims for injuries against persons or damages to property resulting from Providers acts or omissions arising out of or related to Provider's performance under this Agreement. Provider shall also cant'Workers'Compensation Insurance in accordance with State Workers'Compensation laws. Such insurance shall be kept in effect during the term of this Agreement and shall not be cancelable without thirty (30) days' prior written notice of the proposed cancellation to City. A certificate evidencing the foregoing and naming the City as an additional insured shall be delivered to and approved by the City prior to commencement of the services hereunder. The procuring of such insurance or the delivery of -4- policies or certificates evidencing the same shall not be construed as a limitation of Provider's obligation to indemnify the City, its officers, or employees. The amount of insurance required hereunder shall be as.required by the Contract Officer not exceeding One Million Dollars($1,000,000). 5.2 Indemnification. The Provider shall defend, indemnify and hold harmless the City, its officers and employees, from and against any and all actions, suits, proceedings, claims, demands, losses, costs, and expenses, including legal costs and attorneys'fees, for injury to or death of person(s), for damage to property (including property owned by the City) arising out of or related to Contractor's performance under this Agreement, except for such loss as may be caused by City's own negligence or that of its officers or employees. 6.0 CITY OFFICERS AND EMPLOYEES: NON-DISCRIMINATION, TERMINATION, AND ENFORCEMENT. 6.1 Non-Liability of City Officers and Employees. No officer or employee of City shall be personally liable to the Provider, or any successor-in-interest, in the event of any default or breach by City or for any amount which may become due to the Provider or its successor, or for breach of any obligation of the terms of this Agreement. 6.2 Conflict of Interest. Provider acknowledges that no officer or employee of the City has or shall have any direct or indirect financial interest in this Agreement nor shall Provider enter into any agreement of any kind with any such officer or employee during the term of this Agreement and for one year thereafter. Provider warrants that Contractor has not paid or given,and will not pay or give, any third party any money or other consideration in exchange for obtaining this Agreement. 6.3 Covenant Against Discrimination. In connection with its performance under this Agreement, Provider shall not discriminate against any employee or applicant for employment because of actual or perceived race, religion, color, sex, age, marital status, ancestry, national origin ( i.e., place of origin, immigration status, cultural or linguistic characteristics, or ethnicity), sexual orientation, gender identity, gender expression, physical or mental disability, or medical condition (each a "prohibited basis"). Provider shall ensure that applicants are employed, and that employees are treated during their employment, without regard to any prohibited basis. As a condition precedent to City's lawful capacity to enter this Agreement, and in executing this Agreement, Provider certifies that its actions and omissions hereunder shall not incorporate any discrimination arising from or related to any prohibited basis in any Provider activity, including but not limited to the following: employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship; and further, that Provider is in full compliance with the provisions of Palm Springs Municipal Code Section 7.09.040, including without limitation the provision of benefits, relating to non-discrimination in city contracting. 6.4 Term. Unless earlier terminated in accordance with Section 6.5 of this Agreement, this Agreement shall continue in full force and effect until completion of the services, but not exceeding one(1)year from the date hereof. 6.5 Termination Prior to Expiration of Term. a. In accordance with 2 CFR 200.339, the City may suspend or terminate, in whole or in part, this Agreement if Provider fails to comply with any term of this Agreement or the terms and conditions of the subaward; b. In accordance with 2 CFR 200.339, the City may terminate this Agreement with the consent of the Provider after both parties have agreed upon the termination conditions, including the effective date and, in the case of a partial termination,the portion to be terminated; and -5- C. The Provider may terminate this Agreement at any time, with or without cause, upon thirty (30) days' notification setting forth the reason(s) for such termination, the effective date and, in the case of partial termination, the portion to be terminated. Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder except as may be specifically approved by the Contract Officer. However, if the City determines in the case of partial termination that the reduced or modified portion of the subaward will not accomplish the purposes for which the subaward was made, the City may terminate the subaward in its entirety. Provider shall be entitled to compensation for all services rendered prior to receipt of the notice of termination and City shall be entitled to reimbursement for any services which have been paid for but not rendered. 7.0 MISCELLANEOUS PROVISIONS. 7.1 Notice. Any notice, demand, request, consent, approval, or communication that either party desires, or is required to give to the other party or any other person shall be in writing and either served personally or sent by pre-paid, first-class mail to the address set forth below. Notice shall be deemed communicated seventy-two (72) hours from the time of mailing if mailed as provided in this Section. Either party may change its address by notifying the other party of the change of address in writing. TO CITY: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Manager WITH COPY TO: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Attorney TO PROVIDER: Council on Aging—Southern California. Inc. 2 Executive Cir, Ste 175 Irvine, CA 92614-6773 7.2 Amendment. This Agreement may be amended at any time by the mutual consent of the parties by an instrument in writing. IN WITNESS WHEREOF, the parties have executed and entered into this Agreement as of the date first written above. [End—Signatures on Next Page j -6- sill CITY OF PALM SPRINGS ATTES corporation By: 7� all . Ci lerk City Manager APPR VE AS TO F M: APPROVED BY CITY COUNCIL AIXI City Attorney 04341 PROVIDER: Check one: _Indivi ual _Partnership / Corporation (Corporations require two notarized signatures: One signature must be from the Chairman of Board, President, or any Vice President. The second signature must be from the Secretary, Assista t S cr ,Treasurer,Assistant Treasurer, or Chief Financial Officer). By: By: �k J C —jFotariz d Si n re of Chairman of Board, Notarized Sig natu a etary,Asst Secretary, President any Vice President Treasurer,Asst Treasurer or Chief Financial Officer Name: bf`� VVrLgk+20: 1ra4 Name: 0 d i'� Title: Cam) Title: SJ2-(5 Q— State of State of fri ) County of )ss County of )SS A notary public or other officer completing this certificate A notary public or ther officer completing this certificate verifies only the identity of the individual who signed the verifies only the identity of the individual who signed the document to which this certificate is attached, and not document to which this certificate is attached, and not the truthfulness,accuracy,or validity of that document. the truthfulness,accuracy,or validity of that document. State of "'1Vr l a ) State of WM1 ) '1' I ) County of lcnwv )SS. County of 0 rel )SS.1 On \ u l before me, On before me, e�wfh `l; , Ik ly appeared 62hoffov 14.p�tonally appeared JQ WI7 '� �n who proved to who proved to me on the b(sf atisfa ory evidence to be the person(:) me on the b(sipf satis cto evidence to be the person(:) whose name 1 are subscri to the within instrument and whose name slis re sub bed to the within instrument and a ledged o me that h he hey executed the a in nowledged me the he hetthey executedfie ame in hi heir authorized capacl les),and that by hi he heir i er/their authorized ca city(ies),and that berltheir slgna re(s) on the instrument the person(:), or th entity nature(:) on the instrument the person(s), entity upon behalf of which the person(s) acted, executed the upon behalf of which the person(s) acted, executed the instrument. instrument. I certify under PENALTY OF PERJURY under the laws of the I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and State of California that the foregoing paragraph is true and correct. correct. WITNESS my hand a d official Real WITNESS my hand and cial seal. Notary Signatur Notary Signature: Notary Seal: Notary Seal: JANET NAVIDAD JANET NAVIDAD Commission NO. 2204135 � Commission No. 2204135 NOTARY PM1c-M1F0 " NOTA11��RppYR�P��U��E1�L{II fC/�-�yAILIFrOvvOMuAA CoUiM •M'IxeBClCT7l16'T W cvles TX--1 .Oetl8 Comm.Expires AUGUST 1.2021 M►y Comm.Expins AUGUST 1.2021 -7- CITY OF PALM SPRINGS EXHIBIT A Scope of Services Proiect/Activity Title: Proiect Number: Council on Aging—Southern California, Inc. 0005 Long-Term Care Ombudsman Name/Address of Provider: Council on Aging—Southern California, Inc. 2 Executive Cir, Ste 175 Irvine,CA 92614-6773 Objectives/Activities The intent of this program is to expand their existing services by providing protection and advocacy for all frail, elderly and disabled adult residents living-in Palm Springs skilled nursing and residential care facilities which totals twenty-six(26)Palm Springs low income residents. The Provider shall be responsible for the completion of the following objectives/activities in a manner acceptable and satisfactory to the City and consistent with the standards required as a condition of providing these CDBG funds. Objective 1: Assist the City by timely providing any additional information requested. TARGET DATE ACTIVITY#1 On-Going Make readily available any information relative to the successful implementation of the activity. Objective 2: Establish and maintain a programmatic and financial record keeping process. TARGET DATE ACTIVITY#1 On-Going Establish and maintain an efficient program process/procedure for proper record keeping. Set-up a filing system for CDBG files only. Document and maintain all records related to this program in a stable and secure location. Objective 3: Advertise, market and publicize the program to facilitate positive promotion for all parties (i.e., Provider, City, CDBG, etc.). TARGET DATE ACTIVITY#1 On-Going Draft a promotional piece and submit to City for approval. Advertise in the Desert Sun. Submit final publication to City. Objective 4: Enroll and income qualifies at least an approximately twenty-six (26) low income Palm Springs residents in accordance with Exhibit D for new access to services. TARGET DATE ACTIVITY#1 On-Going Provide Long-Term Care Ombudsman services to twenty-six (26) City-wide clients. Maintain records of names, addresses, demographics and service dates for all assistance. Objective 5: Maintain records for all CDBG activities related to this program. TARGET DATE ACTIVITY#1 On-Going Document and maintain all records related to this program, including those required, in accordance with HUD Regulations, in a stable and secure location. ACTIVITY#2 On-Going Submit Semi-Annual reports — referenced Exhibit E within fifteen (15) calendar days of the program mid-year, December 31st,and program completion,June 30th Objective 6: Manage/monitor program activities. TARGET DATE ACTIVITY#1 On-Going Perform monitoring activities necessary to ensure that the program is being conducted in compliance with the CDBG policies, federal regulations, and local statues, including Davis-Bacon Act, Copeland Act, and Non-discrimination/EEO requirements. Objective 7: Establish New and/or Expanded Services for Seniors, At-Risk Youth, Severely Disabled Adults, and Special need Population. TARGET DATE ACTIVITY#1 On-Going Conduct program activities to improve availability/accessibility, as stipulated in this Agreement. Objective 8: Provide an evaluation within fifteen (15)calendar days of the program completion or final reimbursement. TARGET DATE ACTIVITY#1 07/15/19 Provide an evaluation and final report on all programmatic and financial activities. General Administration Provide the management oversight and leadership to address specific operational tasks in meeting the established performance levels,as well as perform supportive activities(i.e., clerical, monitoring,etc.) CITY OF PALM SPRINGS EXHIBIT B Budget Summary Project/Activity Title: Project Number: Council on Aging—Southern California, Inc. 0005 Long-Term Care Ombudsman Name/Address of Provider: Council on Aging—Southern California, Inc. 2 Executive Cir,Ste 175 Irvine, CA 92614-6773 I, , COST CATEGORY CDBG OTHER TOTAL SHARE SOURCES COST 1 3ersonnel Costs— $13,500. - 0- $13,500. Wa es Benefits&Employers Taxes 2 Indirect Administration Costs— 1,500. -0- 1,500. Per the de minimis rules TOALS $1s�df4 . ' 3 x If costs are to be shared by other sources of funding, including CDBG funds from other jurisdictions, identify the source of funding,grantor/lending agency,and cost category information. The Subrecipient shall submit Request for Reimbursements in accordance with the aforementioned cost categories and line items. The Subrecipient recognizes that the CDBG Funds are received from the HUD, and that the obligation of the City to make payment to Subrecipient is contingent upon receipt of such funds from HUD. In the event that said funds, or any part thereof, are, or become, unavailable, then the City may immediately terminate or amend this Agreement. Services are to be performed over a twelve month period of July 1, 2018 through June 30, 2019 with funds allocated from 2018—19 Program Year. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory Proiect/Activity Title: Project Number: Council on Aging—Southern California, Inc. 0005 Long-Term Care Ombudsman Name/Address of Provider: Council on Aging—Southern California, Inc. 2 Executive Cir, Ste 175 Irvine, CA 92614-6773 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company GuideOne Mutual Insurance Company Effective Dates of Policy 07/01/18 to 07/01/19 Claims Made Policy / / Per Occurrence Policy Limits of Liability $2M General Aggregate Deductibles: Per Occurrence Annual Aggregate Additional Insured Endorsement (Certificate Holder) 21 Yes ❑ No Original Certificate of Insurance Attached ❑ Yes 0 No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company State Compensation Insurance Fund Effective Dates 01/01/19 to 01/19/20 Limits of Liability $1 M Per Occurrence Underlying Coverage Limits Original Certificate of Insurance Attached ❑ Yes 2 No DATE(MMIDD/YYYY) ACORN® CERTIFICATE OF LIABILITY INSURANCE ��. 12/18/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER CONTACT NAME: Ted Worrell Buckler Insurance Agency,LLC PHONE Ext): (800)995-5396 FAX NO: (800)995-5396 2743 Toume Ln E-MAIL tedworrell bucklera enc .com Y ADDRESS: C 9 Y INSURERS AFFORDING COVERAGE NAIC# Corona CA 92881 INSURER A: GUIDEONE MUTUAL INSURANCE COMPANY 15032 INSURED INSURER B: Council on Aging-Southern California,Inc INSURER C: 2 Executive Circle INSURER D: Ste 175 INSURER E: Irvine CA 92614 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED 1,000,000 PREMISES Ea occurrence) $ MED EXP(Any one person) $ 15,000 A X 01449400 07/01/2018 07/01/2019 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY 7 JECTPRO ❑ LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED X 01789892 07/01/2018 07/01/2019 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A X EXCESS LIAB CLAIMS-MADE 01449401 07/01/2018 07/01/2019 AGGREGATE $ 2,000,000 DED X I RETENTION$ 2,500 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY y/N STATUTE I JER ANY PROPRIETOR/PARTNER/EXECUTI— E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ Employee Dishonesty Employee Dishonesty 300,000 A Incl.Forgery 01449401 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) See Attached Endorsement D �O ey READ CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLE EFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Palm Springs ACCORDANCE WITH THE POLICY PROVISIONS. Attn:City Clerk AUTHORIZED REPRESENTATIVE PO Box 2743 0 p n Palm Springs CA 92262 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commercial General Liability Endorsement Example POLICY NUMBER: 01449400 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: City of Palm Springs PO Box 2743 Palm Springs,CA 92262 Attn: City Clerk (If no entry appears above, the information required to complete this endorsement will be shown in the Declaration as applicable to this endorsement.) WHO IS AN INSURED (Section II)is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. a. The City of Palm Springs,its officers,officials,employees and volunteers are to be covered as additional insureds. b. For any claims related to this project,named insured's insurance coverage shall be primary and non-contributory to any insurance maintained by the certificate holder. C. Each insurance policy required shall be endorsed that a thirty(30)day notice be given to CITY in the event of cancellation or modification to the stipulated insurance coverage. 41v CG 20 10 10 93 e1' RFCQ ACORIDO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `„/ 01/14/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME:NTACT Cindy Hales Milestone Risk Management&Insurance Services PHONE (949)852-0909 F0'X (949)852-1131 A/ No Ext: A/C No): License No.0872766 E-MAIL chales@milestonepromise.com ADDRESS: 8 Corporate Park,Suite 130 INSURER(S)AFFORDING COVERAGE NAIC# Irvine CA 92606 INSURERA: State Compensation Ins.Fund 35076 INSURED INSURER B Council on Aging-Southern California,Inc. INSURER C: 2 Executive Circle,Suite 175 INSURER D: INSURER E: Irvine CA 92614 INSURERF: COVERAGES CERTIFICATE NUMBER: 2019-20 WC ONLY REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBK POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDIYYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMACLAIMS-MADE OCCUR PREM E T RE PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X ST YIN ATUTE ER A ANY PROPRIETOR/PARTNEIRIEXECUTIVE 1,000,000 OFFICER/MEMBEREXCLUDED? N NIA 92429872019 01/01/2019 01/01/2020 E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) WC Waiver of Subgrogation included per the attached endorsement. 4?0� /5 0 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED B RE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Palm Springs ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 2743 AUTHORIZED REPRESENTATIVE Palm Springs CA 92262 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ENDORSEMENT AGREEMENT _A WAIVER OF SUBROGATION REP C2 INSURANCE • ENSATION BLANKET BASIS 9242987-19 FUND NEW SP HOME OFFICE 0-64--29-25 SAN FRANCISCO EFFECTIVE JANUAR.Y 1, 2019 AT 12 .01 A.M. PAGE 1 OF 1 ALLEFFECTIVE DATESARE AND EXPIRING JANUARY 1, 2020 AT 12 .01 A.M. AT 12 01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME COUNCIL ON AGING - SOUTHERN CALIFO 2 EXECUTIVE CIRCLE IRVINE, CA 91739 WE HAVE THE RIGHT TO RECOVER OUR PAYMENTS FROM ANYONE LIABLE FOR AN INJURY COVERED BY THIS POLICY. WE WILL NOT ENFORCE OUR RIGHT AGAINST THE PERSON OR ORGANIZATION NAMED IN THE SCHEDULE. THIS AGREEMENT APPLIES ONLY TO THE EXTENT THAT YOU PERFORM WORK UNDER A'WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT FROM US. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00W OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION BLANKET WAIVER OF FOR WHOM THE NAMED INSURED SUBROGATION HAS AGREED BY WRITTEN D CONTRACT TO FURNISH THIS WAIVER �S ✓qN NOTHING IN THIS ENDORSEMENT SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS IN THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAANF/R/ANCISCO: DECEMBER 27, 2//018 J/ AUTHORIZED REPRESENT IVE PRESIDENT AND CEO 2572 , l CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Proiect/Activity Title: Project Number: Council on Aging—Southern California, Inc. 0005 Long-Term Care Ombudsman Name/Address of Provider: Council on Aging—Southern California, Inc. 2 Executive Cir, Ste 175 Irvine, CA 92614-6773 BENEFICIARY QUALIFICATION STATEMENT This statement must be completed and signed by each person or head of household (legal guardian)receiving benefits form the described project/activity. Please answer each of the following questions. 1. How many persons are In your household? For this question a household is a group of related or unrelated persons occupying the same house with at least one member being the head of the household. Renters,roomers,or borders cannot be included as household members. 2. Circle your combined gross annual income(Riverside-San Bernardino-Ontario,CA MSA—04101/18) AREA MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME(AMI) 1 2 3 4 5 6 7 8 LEVEL-$65 800 EXTREMELY LO INCOME $14,150 $16,460 $20,780 $25,100 $29,420 $33,740 $38,060 $42,380 0-30%of AMI LOW INCOME $23,600 $27,000 $30,350 $33,700 $36,400 $39,100 $41,800 $44,500 30-50%of AMI MODERATE INCOME $37,750 $43,150 $48,550 $53,900 $58,250 $62,550 $66,850 $71,150 50-80%of AMI NON LOW&MOD INCOME $37,751+ $43,151+ $48,551+ 53,901+ $58,251+ $62,551+ $66,851+ $71,151+ >80% 3. What race/ethnicity do you identify yourself as;please note that this self-identification Is voluntary in accordance with equal opportunity laws? ❑ White ❑ American Indian or Alaska Native AND White ❑ Black/African American ❑ Asian AND White ❑ Asian ❑ Black/African American AND White ❑ American Indian or Alaskan Native ❑ American Indian/Alaska Native AND Black/African American ❑ Native Hawaiian or Other Pacific Islander ❑ Other: HISPANIC/LATINO ETHNICITY ❑ Yes ❑ No If yes,check one:❑ Mexican/Chicano ❑ Puerto Rican ❑ Cuban ❑ Other: 4. Are you female Head of Household? ❑ YES ❑ NO 5. Do you have a disability? ❑ YES ❑ NO If YES,please describe: ACKNOWLEDGEMENT AND DISCLAIMER 1 CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSHOLD STATEMENTS MADE ON THIS FORM ARE TRUE. NAME: DATE; ADDRESS: PHONE NO: SIGNATURE: The information you provide on this form is confidential and is only utilized for Community Development Block Grant(CDBG)program purposes,a Federally-funded program,governmental reporting purposes to monitor compliance. CITY OF PALM SPRINGS EXHIBIT E Semi-Annual Program Progress Report Proiect/Activity Title: Project Number: Council on Aging—Southern California, Inc. 0005 Long-Term Care Ombudsman Name/Address of Provider: Council on Aging—Southern California, Inc. 2 Executive Cir, Ste 175 Irvine,CA 92614-6773 PROGRAM PROGRESS REPORT Period: DIRECT BENEFIT REPORT ♦ Number of First-Time Program Beneficiaries Serviced: #of Households #of Persons <or=30%: 30-50%: 50-80%: >80%: ♦ Number of First-Time Female Headed Households: ♦ Counts by Race/Ethnicity: White American Indian or Alaska Native AND White Black/African American Asian AND White Asian Black/African American AND White American Indian or Alaskan Native American Indian/Alaska Native AND Black/African American Native Hawaiian or Other Pacific Islander Other: HISPANIC/LATINO ETHNICITY: Mexican/Chicano Puerto Rican Cuban Other: ♦ Number of Disabled: ♦ Number of Homeless Persons Given Overnight Shelter: ACCOMPLISHMENT NARRATIVE LEVERAGING RESOURCES NARRATIVE Signed Title Date CITY OF PALM SPRINGS EXHIBIT F Request for Reimbursement Project/Activity Title: Project Number: Council on Aging—Southern California, Inc. 0005 Long-Term Care Ombudsman Name/Address of Provider: Council on Aging—Southern California, Inc. 2 Executive Cir, Ste 175 Irvine, CA 92614-6773 BENEFICIARY QUALIFICATION STATEMENT Personnel Costs— $13,500. Wages,Benefits&Employers Taxes Indirect Administration Costs— 1,500. Per the de minimis rules lfflml� $15,000.00. 1 CERTIFY THAT, (a) the City of PALM SPRINGS, as grantee of the CDBG, has not previously been billed for the costs covered by this invoice, (b)funds have not been received from the Federal Government or expended for such costs under the terms of the Agreement or grant pursuant to FMC-74-4 &24 CFR Part 58;(c)this agency is in full compliance with all applicable provisions under the terms of the Contractor grant; and (d) this agency is in full compliance with all applicable tax laws and hereby affix original signatures. PREPARED BY: APPROVED BY: Name,Title, Date Name,Title, Date City of PALM SPRINGS Use Only Audited by: Examined by: Approved by: If necessary,additional sheet(s)must be attached detailing cost breakdowns,and verified by original signatures.