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HomeMy WebLinkAboutA5639 - STROKE RECOVERY CENTER SUBRECIPIENT AGRSTROREC-01 EC RILL TIFICATE OF LIABILITY INSURANCE DATE 1/13/21312D/YYYY) 025 rER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ICE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED E CERTIFICATE HOLDER. ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. the terms and conditions of the policy, certain policies may require an endorsement. A statement on :ertificate holder in lieu of such endorsement(s). RECEIVED JAN 2 7 2025 CONTA NAME:CT Erika Carrillo PHONE FAX (AIC,No,Ext): (442) 282-4252 (A/C,No).' ADDRIESS: erika.carrillo@hubinternational.com IWSURERfS1 AFFORDING COVERAGE NAIC # INSURER A: Nonprofits' Insurance Alliance of California, Inc :E OF THE CITY C ro Vitality Center SURERB:State Compensation Insurance Fund of California 35076 c INSURER D : INSURER E: INSURER F : wry ur ure000. REVISION NUMBER: GVVtKAUtS kor-M r rrll rm r � "U"FI �+N. — - - - 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 NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR X X2024-06766 2/1/2024 2/1/2025 EACH OCCURRENCE 1 $ '000,000 DAMAGE TO RENTED PREMISES Ea occurrence 500,000 $ MED EXP An one person)$ 20,000 PERSONAL & ADV INJURY $ 1,000,000 A GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO LOC JECT El OTHER: AUTOMOBILE LIABILITY GENERAL AGGREGATE $ 3,000,U00 PRODUCTS - COMP/OP AGG $ 3,000,000 Liquor Liabilit Ea aBINED SINGLE LIMIT $ 1,000,000 $ 1,000,000 BODILY INJURY Per person)$ X ANY AUTO 2024-06766 2/1/2024 2/1/2025 BODILY INJURY Per accident $ OWNED SCHEDULED AUTOS ONLY AUTOS �( HIRED X NON -AWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ A4XEXCESS MBRELLA LIAB LIAB X OCCUR CLAIMS -MADE 2024-06766-UMB 2/1/2024 2/1/2025 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 21000,000ED X RETENTION $ 10,000 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A X 9121137-25 1/1/2025 1/1/2026 X PER OTH- STAT TE ER E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYE 1,000,000 $ E.L. DISEASE -POLICY LIMIT 1,000,000 $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of Palm Springs, it's officials, employees and agents are named as additional insureds per the attached endorsement. General Liability coverage is primary and non-contributory. Waiver of subrogation applies to General Liabilty and Workers Compensation. 30 day notice of cancellation, except 10 day notice of non-payment of premium. The City of Palm Springs 3200 E. Tahquitz Canyon Way Palm Springs, CA 92262 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE `� ACORD 25 (2016/03) v T cats-cu l o H�.vrtv vrcrvrw r rvr�. nu ++y++w +wc+ The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 2024-06766 COMMERCIAL GENERAL LIABILITY Named Insured: Stroke Recovery Center dba: Neuro Vitality Center CG 20 10 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- OWNERS, LESSEES OR CONTRACTORS SCHEDULED PERSON OR ORGANIZATION This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organlzation(s) Location(s) Of Covered Operations Any person or organization that you are required to All insured premises and operations, add as an additional Insured on this policy, under a written contract or agreement currently In effect, or becoming effective during the term of this policy. The additional insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization. I Information required to complete this Schedule, if not shown above, will be shown In the Declarations. i A. Section II —Who Is An insured is amended to Include as an additional insured the person(s) or organization(s) shown In the Schedule, but only with respect to liability for "bodily injury', "property damage" or "personal and advertising injury' caused, In whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; In the performance of your ongoing operations for the addifional Insured(s) at the locations) designated above. However: 1. The Insurance afforded to such additlonal Insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional Insured will not be broader than that which you are required by the contract or agreement to provide for such additional Insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This Insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or CG 20 10 12 19 0 Insurance Services Office, inc., 2012 Page 1 of 2 2. That portion of "your work" out of which the Injury or damage arises has been put to Its intended use by any person or organization other than another contractor or subcontractor engaged In performing operations for a principal as a part of the same project C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: if coverage provided to the additional Insured Is required by a contract or agreement, the most we will pay on behalf of the additional insured Is the amount of Insurance: 1. Required by the contractor agreement; or 2. Available under the applicable Limits of Insurance shown In the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of insurance shown in the Declarations. CG 20 1012 19 6 Insurance Services Office, Inc., 2012 Page 2 of 2 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 1, 2025 AT 12.01 A.M. AND EXPIRING JANUARY 1, 2026 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME STROKE RECOVERY CENTER PO BOX 1544 PALM SPRINGS, CA 92263 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 2.00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION 9121137-25 RENEWAL SP 0-78-65-49 PAGE 1 OF 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 SAN FRANCISCO: JANUARY 7, 2%02`15 2572 AUTHORIZED REPRESENT IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.4.2018) 1 OLD DP 217 NONPROFITS INSURANCE ALLIANCE OPCALIFORNIA A Huad/orInsurance, A Hoartlor Nonprofits. POLICY NUMBER:.2024-06766 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED PRIMARY AND NON-CONTRIBUTORY ENDORSEMENT FOR PUBLIC ENTITIES This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or organization: Per Certificate - As required by written contract A. Section it —WHO IS AN INSURED Is amended to Include: 4. Any public entity as an additional Insured, and the officers, officials, employees, agents and/or volunteers of that public entity, as applicable, who may be named In the Schedule above, when you have agreed In a written contract or written agreement presently In effect or becoming effective during the term of this policy, that such public entity and/or its officers, officials, employees, agents and/or volunteers be added as an additional insured(s) on your policy, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or In part, by: a. Your negligent acts or omissions; or b. The negligent acts or omissions of those acting on your behalf; in the performance of your ongoing operations. No such public entity or Individual Is an additional Insured for liability arising out of the soie negligence by that public entlty or Its designated individuals, The additional Insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization. B. Section III -- LIMITS OF INSURANCE Is amended to Include: 8, The limits of Insurance applicable to the public entity and applicable Individuals identified as an additional Insured(s) pursuant to Provision A.4, above, are those specified In the written contract between you and that public entlty, or the limits available under this policy, whichever are less. These limits are part of and not In addition to the limits of insurance under this policy. C. With respect to the Insurance provided to the additional insured(s), Condition 4. Other Insurance of SECTION IV COMMERCIAL GENERAL LIABILITY CONDITIONS Is replaced by the following: 4, Otherinsurance a. Primary Insurance This Insurance is primary if you have agreed In a written contract or written agreement: (1) That this Insurance be primary. If other Insurance is also primary, we will share with all that other insurance as described in c. below; or NIAC-E61 02 19 Page 1 of 2 IN NONPROFITS Q INSURANCE - ALLIANCE or CALIFORNIA ..��_ POLICY NUMBER: A Hoad forinsuranco. A Heart for Nonprofits. (2) The coverage afforded by this Insurance Is primary and non-contributory with the additional Insured(s)' own Insurance. Paragraphs (1) and (2) do not apply to other Insurance to which the additional insured(s) has been added as an additional insured or to other Insurance described In paragraph b. below. b. Excess insurance This insurance Is excess over; 1. Any of the other Insurance, whether primary, excess, contingent or on any other basis: (a) That Is Fire, Extended Coverage, Builder's Risk, installation Risk or similar coverage for "your work"; (b) That Is fire, lightning, or explosion insurance for premises rented to you or temporarily occupied by you with permission of the owner; (c) That Is insurance purchased by you to cover your liability as a tenant for "property damage" to premises temporarily occupied by you with permission of the owner; or (d) If the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to the extent not subject to Exclusion g. of SECTION I -- COVERAGE A-- BODILY INJURY AND PROPERTY DAMAGE. (e) Any other Insurance available to an additional Insured(s) under this Endorsement covering liability for damages which are subject to this endorsement and for which the additional Insured(s) has been added as an additional Insured by that other Insurance. (1) When this Insurance is excess, we will have no duty under Coverages A or B to defend the additional Insured(s) against any "suit" If any other Insurer has a duty to defend the additional Insured(s) against that "suit". If no other Insurer defends, we will undertake to do so, but we will be entitled to the additional insured(s)' rights against all those other Insurers. (2) When this Insurance is excess over other insurance, we will pay only our share of the amount of the loss, If any, that exceeds the sum of; (a) The total amount that all such other Insurance would pay for the loss In the absence of this Insurance; and (b) The total of all deductible and self -Insured amounts under all that other Insurance. (3) We will share the remaining loss, If any, with any other Insurance that Is not described In this Excess Insurance provision and was not bought specifically to apply In excess of the Limits of Insurance shown In the Declarations of this Coverage Part. c. Methods of Sharing If all of the other Insurance available to the additional Insured(s) permits contribution by equal shares, we will follow this method also. Under this approach each insurer contributes equal amounts until it has paid Its applicable limit of insurance or none of the loss remains, whichever comes first. If any other the other insurance available to the additional Insured(s) does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share Is based on the ratio of its applicable limit of Insurance to the total applicable limits of insurance of all Insurers. NIAC-E61 0219 Page 2 of 2 NONPROFITS POLICY NUMBER: 2024-06766 FORM: NIAC-E26 11 17 INSURANCE NAMED INSURED: Stroke Recovery Center dba: Neuro Vitality Center �F ALLIANCE OF CALIFORNIA A Head for Insurance, A Heart for Nonprofits. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIA131LITY COVERAGE PART SOCIAL SERVICE PROFESSIONAL. LIABILITY COVERAGE FORM SCHEDULE I Name of Person or Organization: Per Certificate - As required by written contract Where you are so required In a written contract or agreement currently in effect or becoming effective during the term of this policy, we waive any right of recovery we may have against that person or organization, who may be named in the schedule above, because of payments we make for Injury or damage. NIAC-E26 11 17 Page 1 of 1 STROREC-01 ECARRILLO . lll. R ' CERTIFICATE OF LIABILITY INSURANCE `� DAT/13/2D/YYYY) 1113/2025 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 License # 0757776 HUB International Insurance Services Inc. RECEIVED 75030 Gerald Ford Drive SuiteE-MAIL 201 CONTACT Erika Carrillo NAME: PHONE No, Ext): (442) 282-4252 (AIC, No); ADDRESS:erika.Carrillo@hubinternatlonal.Com m Palm Desert, CA 92211 J A N 2 7 2025 INSURERS AFFORDING COVERAGE NAIC # INSURER A: Nonprofits' Insurance Alliance of California, Inc INSURED OFFICE OF THE CITY LEIWuRER B:State Compensation Insurance Fund of California 35076 INSURER C : Stroke Recovery Center dba: Neuro Vitality Center INSURER D : 2800 E. Alejo Road Palm Springs, CA 92262 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: RFVI.RinN NIIMRFR- 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 NUMBER POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X 2024-06766 2/1/2024 2/1/2025 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence 500,000 $ MED EXP (Any oneperson) $ 20,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: X POLICY ❑ PRO- ❑ LOC JECT OTHER: GENERAL AGGREGATE $ 3,000,000 PRODUCTS -COMP/OP AGG 3,000,600 $ Liquor Liabilit 1$ 1,000,000 A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOSS AUTOS ONLY X AUOTOS ONLY 2024-06766 2/1/2024 2/1/2025 EO aBIiNdEED SINGLE LIMIT $ 1,000,000 BODILY INJURY Per erson $ Ix BODILY INJURY Per accident $ Peer acEcidentDAMAGE $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 2024-06766-LIMB 2/1/2024 2/1/2025 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 DED I X I RETENTION$ 10,000 B AND EMPLOY ERS COMPENSATION P N A TIOI N YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 9121137-25 1/1/2025 1/1/2026 PER OT X STATUTE EERH E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Village Fest City of Palm Springs is included as an Additional Insured as per the attached endorsement. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Palm Springs 3200 E. Tahquitz Canyon Way THE EXPTION DATE THEREOF, ACCORDANCE WITH THE POLICY P OVIS ONSCE WILL BE DELIVERED IN Palm Springs, CA 92262 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 2024-06766 COMMERCIAL GENERAL LIABILITY Named Insured_ Stroke Recovery Center dba: Neuro Vitality Center CG 20 10 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organlzation(s) Location(s) Of Covered Operations Any person or organization that you are required to All insured premises and operations. add as an additional Insured on this policy, under a written contract or agreement currently In effect, or becoming effective during the term of this policy. The additional insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization. I Information required to complete this Schedule, If not shown above, will be shown In the Declarations. I A. Section iI — Who Is An Insured Is amended to Include as an additional insured the person(s) or organization(s) shown In the Schedule, but only with respect to liability for "bodily injury', "property damage" or "personal and advertising injury" caused, In whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; In the performance of your ongoing operations for the additional Insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional Insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured Is required by a contract or agreement, the Insurance afforded to such additional Insured will not be broader than that which you are required by the contract or agreement to provide for such additional Insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply; This Insurance does not apply to "bodily injury" or "property damage" occurring after: All work, Including materlals, parts or equipment furnished In connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or CG 20 10 12 19 0 Insurance Services Office, Inc., 2012 Page 1 of 2 2. That portion of "your work" out of which the Injury or damage arises has been put to Its intended use by any person or organization other than another contractor or subcontractor engaged In performing operations for a principal as a part of the same project. C, With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured Is required by a contract or agreement, the most we will pay on behalf of the additional insured Is the amount of Insurance: 1. Required by the contractor agreement; or 2. Available under the applicable Limits of Insurance shown In the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 1012 19 0 Insurance Services Office, Inc,, 2012 Page 2 of 2 .�� STROREC-01 ECARRILLO ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY)2/5/2026 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 License # 0757776 HUB International Insurance Services Inc. RECEIVEPHONE 75030 Gerald Ford Drive Suite 201 Lpp Palm Desert, CA 92211 FEB 11 2025 NAMEACT Erika Carrillo (A/C, No, Ext): (44'2) 282-4252 jAAic, No): E-MAIL erika.carrillo@hubinternational.com ADDR S INSURERS AFFORDING COVERAGE NAIC q I A: Nonprofits' Insurance Alliance of California, Inc INSURED OFFICE O e : State Compensation Insurance Fund of California 35076 INSURERC: Stroke Recovery Center dba: Neuro Vitality Center INSURERD: 2800 E. Alejo Road Palm Springs, CA 92262 INSURER E INSURER F : 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 NUMBER POLICY EFF POLICLTRY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X X 01-CP-0006766-26 2/1/2025 2/1/2026 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence 500,000 $ MED EXP (Any oneperson) $ 20,000 PERSONAL & ADV INJURY $ 1,000,600 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO- JECT1-1LOC OTHER: GENERAL AGGREGATE $ 3,000,000 PRODUCTS - COMP/OP AGG $ 3,000,000 Liquor Liab. $ 1,000,000 A AUTOMOBILE LIABILITY X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS X HIRED X NOW WNED AUTOS ONLY AUTO ONLY 01-CP-0006766-26 2/1/2025 2/1/2026 COMBINED SINGLE LIMIT Ea ac ,d.nl 1,000,000 $ BODILYINJURY Per erson $ BODILY INJURY Per accident $ PPe�accRdenDAMAGE $ A UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 1 01-LIB-0006766-20 1 2/1/2025 2/1/2026 EACH OCCURRENCE $ 2,000,000 X AGGREGATE $ 2,000,000 DED X RETENTION $ 10,000 $ B WORKERS COMPENSATION ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A X 9121137-25 1/1/2025 1/1/2026 X TAT TE ER STATUTE E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of Palm Springs, it's officials, employees and agents are named as additional insureds per the attached endorsement. General Liability coverage is primary and non-contributory. Waiver of subrogation applies to General Liabilty and Workers Compensation. 30 day notice of cancellation, except 10 day notice of non-payment of premium. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City Of Palm Springs YACCORDANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN WITH THE POLICY PROVISIONS. 3200 E. Tahquitz Canyon Way Palm Springs, CA 92262 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 1, 2025 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING JANUARY 1, 2026 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME STROKE RECOVERY CENTER PO BOX 1544 PALM SPRINGS, CA 92263 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 2.00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION 9121137-25 RENEWAL SP 0-78-65-49 PAGE 1 OF 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 SArJNFRFRANCISCO: JANUARY 7, 2025 /�"- 'J/,"IL-4-1- 2572 AUTHORIZED REPRESENT IVE PRESIDENT AND CEO SCIF FORM 10217 IREV.4.2018) OLD OP 217 NONPROFITS POLICY NUMBER: 01-CP-0006766-26 FORM: NIAC-E26 11 17 INSURANCE NAMED INSURED: Stroke Recovery Center dba: Neuro Vitality Center �• ALLIANCE of CALIFORNIA A Head for lnsuranu, A He art for Nonprofits, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SOCIAL SERVICE PROFESSIONAL LIABILITY COVERAGE FORM SCHEDULE Name of Person or Organization: Per Certificate - As required by written contract Where you are so required In a written contract or agreement currently in effect or becoming effective during the term of this policy, we waive any right of recovery we may have against that person or organization, who may be named In the schedule above, because of payments we make for Injury or damage. NIAC-E26 11 17 Page 1 of 1 NONPROFITS INSURANCE �■ ALLIANCE OP CALIFORNIA A Noad forinsuranco, A Naar! forNonprof/ts, POLICY NUMBER: 01-CP-0006766-26 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED PRIMARY AND NON-CONTRIBUTORY ENDORSEMENT FOR PUBLIC ENTITIES This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Per Certificate - As required by written contract A, Section II —WHO IS AN INSURED is amended to Include: 4. Any public entity as an additional Insured, and the officers, officials, employees, agents and/or volunteers of that public entity, as applicable, who may be named In the Schedule above, when you have agreed In a written contract or written agreemont presently In effect or becoming effective during the term of this policy, that such public entity and/or Its officers, officials, employees, agents and/or volunteers be added as an additional Insured(s) on your policy, but only with respect to liability for "bodily Injury', "property damage" or "personal and advertising Injury"caused, In whole or In part, by: a. Your negligent acts or omissions; or b. The negllgent acts or omissions of those acting on your behalf; In the performance of your ongoing operations. No such public entity or Individual Is an additional Insured for liability arising out of the sole negligence by that public entity or Its designated individuals, The additional Insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization. B. Section III — LIMITS OF INSURANCE Is amended to Include: a. The limits of Insurance applicable to the public entity and applicable Individuals Identified as an additional Insured(s) pursuant to Provision AA, above, are those specified In the written contract between you and that public entity, or the limits available under this policy, whichever are less. These limits are part of and not In addition to the limits of insurance under this policy, C. With respect to the Insurance provided to the additional Insured(s), Condition 4. Other Insurance of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS Is replaced by the following: 4. Other Insurance a. Primary Insurance This insurance Is primary If you have agreed In a written contract or written agreement: (1) That this Insurance be primary, if other Insurance Is also primary, we will share with all that other Insurance as described In c. below; or NIAC-E61 02 19 Page 1 of 2 NONPROFITS INSURANCE �P ALLIANCE OF CALIFORNIA A Haad for /nsuranca, A Naart for Nonprofits, POLICY NUMBER: (2) The coverage afforded by this Insurance Is primary and non-contrlbutory with the additional Insured(s)' own Insurance. Paragraphs (1) and (2) do not apply to other Insurance to which the additional Insured(s) has been added as an additional insured or to other Insurance described In paragraph b. below. b, Excess Insurance This Insurance Is excess over: 1. Any of the other Insurance, whether primary, excess, contingent or on any other basis: (a) That Is Fire, Extended Coverage, Bulkier's Risk, installation Risk or similar coverage for "your work" ; (b) That is fire, lightning, or explosion Insurance for premises rented to you or temporarily occupied by you with permission of the owner; (c) That Is insurance purchased by you to cover your liability as a tenant for "property damage" to premises temporarily occupied by you with permission of the owner; or (d) If the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to the extent not subject to Exclusion g. of SECTION I — COVERAGE A— BODILY INJURY AND PROPERTY DAMAGE. (e) Any other Insurance available to an additional Insured(s) under this Endorsement covering liability for damages which are subject to this endorsement and for which the additional insureds) has been added as an additional insured by that other Insurance. (1) When this insurance Is excess, we vdiit have no duty under Coverages A or B to defend the additional Insured(s) against any "suit" if any other Insurer has a duty to defend the additional Insured(s) against that "suit". if no other Insurer defends, we will undertake to do so, but we will be entitled to the additional Insured(s)' rights against all those other Insurers. (2) When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of: (a) The total amount that all such other insurance would pay for the loss In the absence of this Insurance; and (b) The total of all deductible and self -Insured amounts under all that other insurance. (3) We will share the remaining loss, if any, with any other Insurance that Is not described In this Excess insurance provision and was not bought specifically to apply In excess of the Limits of Insurance shown In the Declarations of this Coverage Part. c. Methods of Sharing If all of the other Insurance available to the additional Insured(s) permits contribution by equal shares, we will follow this method also, Under this approach each Insurer contributes equal amounts until It has paid Its applicable limit of Insurance or none of the loss remains, whichever comes first. If any other the other insurance available to the additional Insured(s) does not permit contribution by equal shares, we will contribute by limits. Under this method, each Insurer's share is based on the ratio of its applicable limit of Insurance to the total applicable limits of Insurance of all Insurers. NIAC-E61 0219 Page 2 of 2 POLICY NUMBER: 01-CP-0006766-26 COMMERCIAL GENERAL LIABILITY Named Insured: Stroke Recovery Center dba: Neuro Vitality Center CG 20 10 12 19 THiS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Persons) Or Organizations) Location(s) Of Covered Operations Any person or organization that you are required to All insured premises and operations. add as an additional Insured on this policy, under a written contract or agreement currently In effect, or becoming effective during the term of this policy. The additional insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization. I Information required to complete this Schedule, If not shown above, will be shown In the Declarations, j A. Section II —Who Is An Insured Is amended to include as an additional insured the person(s) or organization(s) shown In the Schedule, but only with respect to liability for "bodily injury', "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; In the performance of your ongoing operations for the additional Ensured(s) at the location(s) designated above. However: 1. The Insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured Is required by a contract or agreement, the Insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional Insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This Insurance does not apply to "bodily Injury" or "property damage" occurring after: All work, Including materials, parts or equipment furnished In connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or CG 20 10 12 19 OO Insurance Services Office, inc., 2012 Page 1 of 2 2. That portion of "your work" out of which the Injury or damage arises has been put to Its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C, With respect to the insurance afforded to these additional insureds, the following is added to Section III —Limits Of Insurance: If coverage provided to the additional Insured Is required by a contract or agreement, the most we will pay on behalf of the additional insured Is the amount of Insurance: 1. Required by the contractor agreement; or 2. Available under the applicable Limits of Insurance shown In the Declarations; whichever is less, This endorsement shall not increase the applicable Limits of Insurance shown In the Declarations. CG 20 10 12 19 ® Insurance Services Office, Inc,, 2012 Page 2 of 2 STROREC-01 tL:AKKIL / 7 DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 2/5/2026 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). License # 0757776 CONTNAME:A PRODUCER CT Erika Carrillo HUB International Insurance Services Inc. RECEIVED PHExt): (442) 282-4252 (A/C, No): ONE FAX 75030 Gerald Ford Drive lac, No, E-MAIL erika.carrillo hubinternational.com Suite 201 ADDRE S: Palm Desert, CA 92211 F 2025 INSURERS AFFORDING COVERAGE NAIC # L L INSURER A: Nonprofits' Insurance Alliance of California, Inc INSURED ''((���� ��� rrITY CL ERB:State Compensation Insurance Fund of California 35076 Stroke Recovery CenterQFaFN�ifrbPtalit�i�t5f ER c 2800 E. Alejo Road INSURER D : Palm Springs, CA 92262 INSURER E: REVISION NUMRFR! COVERAGES GtK l It -ILA I t_ rvumaMrc: REVISION — -- 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. INN -SR I TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF 2/1/2025 2/1/2025 POLICY EXP 2/1/2026 2/1/2026 LIMITS A laY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR X 01-CP-0006766-26 01-CP-0006766-26 EACH OCCURRENCE $ 1,DAMAG000,000 TO RENTED PREMISES Ea occurrence PREMIS 500,000 $ MED EXP (Any oneperson) $ 20,000 BADVINJURY $ 1,000,000 -PERSONAL GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO-- LOC R: LE LIABILITY UTO D SCHEDULED S ONLY AUTOS X NON WNED S ONLY AUTO ONLY PRODUCTS - COMP/OP AGG 3,000,000 $ Liquor Liab. COMBINED SINGLE LIMIT Ea accident $ 1,000,000 1,000,000 $ BODILY INJURY Per person)$ BODILY INJURY Per accident $ PPe�PER DAMAGE $ B ELLA LIAB SS LIAR X OCCUR CLAIMS -MADE N / A 01-UB-0006766-20 9121137-25 2/1/2025 1/112025 2/1/2026 111/20261,000,000ANY EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 EERHAND X RETENTION $ 10,000 WORKERS COMPENSATION EMPLOYERS'LIABILITY PROPRIETOR/PARTNER/EXECUTIVE Y❑ in NH) EXCLUDED? describe under DESCRIPTION OF OPERATIONS below T $(Mandatory EMPLOYE $ 1,000,000Ifyes, "LIMIT$ ICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Village Fest City of Palm Springs is included as an Additional Insured as per the attached endorsement. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Palm Springs ACCORDANCE WITH THE POLICY PROVISIONS. 3200 E. Tahquitz Canyon Way Palm Springs, CA 92262 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) \l ID00YV IJ v,w vv.v The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 01-CP-0006766-26 COMMERCIAL GENERAL LIABILITY Named Insured: Stroke Recovery Center dba: Neuro Vitality Center CG 20 W 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- OWNERS, LESSEES OR CONTRACTORS SCHEDULED PERSON OR ORGANIZATION This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organlzation(s) Location(s) Of Covered Operations rw ny person or organization that you are required to All insured premises and operations. dd as an additional Insured on this policy, under a ritten contract or agreement currently in effect, or ecoming effective during the term of this policy. The dditional insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization. information required to complete this Schedule, If not shown above, will be shown In the Declarations. A. Section II — Who Is An insured Is amended to Include as an additional insured the person(s) or organization(s) shown In the Schedule, but only with respect to liability for "bodily injury', "property damage" or "personal and advertising injury" caused, In whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; In the performance of your ongoing operations for the additional Insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional Insured only applies to the extent permitted by law; and 2. If coverage provided to the additional Insured is required by a contract or agreement, the Insurance afforded to such additional Insured will not be broader than that which you are required by the contract or agreement to provide for such additional Insured. S. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This Insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, Including materials, parts or equipment furnished In connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or CG 20 10 12 19 © Insurance Services Office, Inc., 2012 Page 1 of 2 2. That portion of "your work" out of which the injury or damage arises has been put to Its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project C. With respect to the insurance afforded to these additional insureds, the following is added to section III -- Limits Of Insurance: if coverage provided to the additional Insured Is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of Insurance: 1. Required by the contractor agreement; or 2. Available under the applicable Limits of Insurance shown In the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 10 12 19 © Insurance Services Office, Inc., 2012 page 2 of 2 SUBRECIPIENT AGREEMENT THIS AGREEMENT (herein "Agreement"), is made and entered into this;At day of fC�, 2019, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city, and the Stroke Recovery Center / Neuro Vitality Center , (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 sea.), as amended from time to time (the "Act"), and the regulations promulgated thereunder (24 C.F.R. Section 570 et seq. ("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 2019 — 2020 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 sc of the current fiscal year. 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 AND SIXTY-SEVEN DOLLARS ($15,067.00) (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: Beverly Greer, Chief Executive Officer 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. -2- 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. 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 II 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; -3- (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; (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 sue.); (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 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. -4- 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 Provider's acts or omissions arising out of or related to Provider's performance under this Agreement. Provider shall also carry 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 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 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: Stroke Recovery Center / Neuro Vitality Center 2800 East Aleio Road Palm Springs, CA 92262-6253 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. A 0 APPROVED AS TO FORM: City Attorney [ End - Signatures on Next Page ] CITY OF PALM SPRINGS I corppration By: City Manager AAPPROVED BY CRY COUNC#. PROVIDER: Check one: _ Individual _ Partnership ZCorporation (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, Assistant Secret , rer, Assist nt Treasurer, or Chief Financial Of ii r). By: By: Notarized Sign ure of dhirm'q of Board;, Notarized Signa6ure Secretary, Asst Secretary, sirieri or any Vice "President 1+ Treasurer, Asst Treasurer or Chief Financial Officer Name: O him-ti Name:ic�c Title: _ C �� �� Title: State of ) County of ) ss A notary public or other officer completing this ficate State of ) County of ) ss A notary public or other officer completing this certificate verifies only the identity of the individual who signed the verifies only the identity of the indiv=aftached, 'fie` document to which this certificate is attached, and not document to which this certificatenot the truthfulness, accuracy, or validity of that document. the truthfulness, accuracy, or validity of that document. State of ) Countypf ) ss. State of MM -7- '461 1AA kx�e17&1 c-^) i r CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE g 1050 A notary public or other officer completing this certificate verifies only the identity of the individual Nfiio signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of RIVERSIDE O n 10/24/2019 a notary public personally appeared M, 'FE , who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is'/are subscribed to the within instrument and acknowledged to me that lie/they executed the same in hisNe-Wtheir authorized capacity(ies), and that by lamer/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. before me, D.G. DRISKILL l certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and Signat ial seal. ------------- D. G. DRISKILL NotaryPublic- California Riverside County Commission # 2200325 My Comm, Expires Jul 2, 2021 (Seal) DRISKILL bhc- California Z ,ide County lion 8 2200325 Expires Jul 2, 2021 County of 7 7 ss. On before me, On personally appeared _ who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. before me, personally appeared who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the 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 and official seal. WITNESS my hand and official seal. Notary Signature: Notary Signature: Notary Seal: Notary Seal: AnnieR/CDBG19-20StrokeRecovery_NVC_SubredpAgr nt.SEPT1 WE CITY OF PALM SPRINGS EXHIBIT A Scope of Services Proiect/Activity Title: Project Number: Stroke Recovery Center / Neuro Vitality Center 0005 Protective Shade Structure Name/Address of Provider: Stroke Recovery Center / Neuro Vitality Center 2800 East Alejo Road Palm Springs, CA 92262 Objectives/Activities The intent of this program is to provide the most comprehensive direct client services and advocacy to help individuals and their families living with stroke and related chronic neurological conditions through community -centered care, rehabilitation services, behavioral health support, wellness education, nutrition and research. This will be accomplished through the facility upgrades to provide expansion and access to essential services to enhance quality of life and well-being of patients served. The upgrades will be a purchase and installation of an outdoor shade structure in conjunction with the new campus layout that allows for expansion of their disabled neurological patient rehabilitation programs and group support networks. The Stroke Recover Center / Neuro Vitality Center covers the City of Palm Springs, and the adjacent four communities of Cathedral City, Desert Hot Springs, Rancho Mirage, and Palm Desert serving 350 clients West Valley of which 100 are Palm Springs 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's daily general circulation. Submit final publication to City. Objective 4: Enroll and income qualify at least a total of one hundred (100) extremely low income to moderate -income Palm Springs residents in accordance with Exhibit D for improved access to the facility. TARGET DATE ACTIVITY #1 On -Going Provide direct client services and advocacy to help 350 Valley -wide residents living with neurological conditions manage their chronic disease. 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 30t'' 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: Make improvements through Architectural & Engineering Services (A&E) and associated installation costs to install an outdoor shade structure that will be a usable area to expand the disabled neurological patient rehabilitation programs and group support networks. DATE ACTIVITY #1 On -Going Conduct activities to improve availability/accessibility in accordance with an 'open competitive' procurement process as stipulated in this Agreement and in consultation with the City. Objective 8: Provide an evaluation within fifteen (15) calendar days of the program completion or final reimbursement. TARGET DATE ACTIVITY #1 07/15/20 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: Stroke Recovery Center / Neuro Vitality Center 0005 Protective Shade Structure Name/Address of Provider: Stroke Recovery Center / Neuro Vitality Center 2800 East Alejo Road Palm Springs, CA 92262 BUDGET SUMMAR COST CATEGORY CDBG SHARE OTHER SOURCES TOTAL COST 1 Personnel -0- -0- -0- 2 Consultant/Contract Services -0- -0- -0- 3 Travel -0- -0- -0- 4 Space Rental -0- -0- -0- 5 Consumable Supplies -0- -0- -0- 6 Rental, Lease or Purchase of Equipment -0- -0- -0- 7 Insurance -0- -0- -0- 8 Other— Construction/Rehabilitation $15,067. -0- $15,067. Landscaping, Irrigation Control, Side Walks and Demolition Costs -0- $33,780 $33,780. TOTALS $15,067. $33,780. $48,847. * 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. Other funding sources may include Stroke Recovery Foundation contribution of $33,780. Progress payments, approved by the Subrecipient and based upon the percentage of completion of the work with a 10% retention, shall be paid by the 30"' day of each month, provided that the payment application has been submitted to the City on or before the first working day of the month. The Subrecipient shall receive reimbursements and/or its suppliers/vendors shall receive direct payments by way of a two-party check, in accordance with the aforementioned cost categories and line items which are subject to receipt of an acceptable requisition in the form of a monthly Request for Reimbursement. 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, 2019 through June 30, 2020 with funds allocated from 2019 - 20 Program Year. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory Project/Activity Title: Project Number: 0005 Stroke Recovery Center / Neuro Vitality Center Protective Shade Structure Name/Address of Provider: Stroke Recovery Center / Neuro Vitality Center 2800 East Alejo Road Palm Springs, CA 92262 LIABILITY INSURANCE POLICY Name of Provider's Insurance Company Effective Dates of Policy Claims Made Policy Limits of Liability 2; &VV.,vwr� Deductibles: INSURANCE INVENTORY .ti��/ p/L aFi i s 1'�'Scc f�st's�G-F Per Occurrence Policy $3,000,000 Per Occurrence Annual Aggregate 07-V an a -a p Additional Insured Endorsement (Certificate Holder) 0 Yes ❑ No Original Certificate of Insurance Attached ❑ Yes 0 No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Companc'-a.-cOO -z-A S </1-t° 4-E' Effective At N .0 PAC 1 1 vial Dates Limits of Liability Underlying Coverage Limits Original Certificate of Insurance Attached $2M Per Occurrence ❑ Yes 0 No CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Proiect/Activity Title: Project Number: Stroke Recovery Center / Neuro Vitality Center 0005 Protective Shade Structure Name/Address of Provider: Stroke Recovery Center / Neuro Vitality Center 2800 East Alejo Road Palm Springs, CA 92262 BENEFICIARY QUALIFICATION STATEMENT This statement must be completed and signed by each person or head of household (legal guardian) receiving benefits form the described projectlactivity. 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 — 06/28/19) AREA MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME (AMI) 1 2 3 4 5 6 7 8 LEVEL - $65,800 EXTREMELY LOW $15,100 $17,250 $21,330 $25,750 $30,170 $34,590 $39,010 $43,430 INCOME 0 - 30% of AMI LOW INCOME $25,150 $28,750 $32,350 $35,900 $38,800 $41,650 $44,550, $47,400 30 - 50% of AMI MODERATE INCOME $40,250 $46,000 $51,750 $57,450 $62,050 $66,650 $71,250 $75,850 50 - 80% of AMI NON LOW & MOD INCOME $40,250+ $46,000+ $51,750+ $57,450+ $62,050+ $66,650+ $71,250+ $75,850+ > 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 I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSHOLD STATEMENTS MADE ON THIS FORM ARE TRUE. NAME: ADDRESS: SIGNATURE: UL•V11114 PHONE NO: 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 Pr_oiect/Activity Title: Project Number: Stroke Recovery Center / Neuro Vitality Center 0005 Protective Shade Structure Name/Address of Provider: Stroke Recovery Center / Neuro Vitality Center 2800 East Alejo Road Palm Springs, CA 92262 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 Black/African American Asian American Indian or Alaskan Native American Indian or Alaska Native AND White Asian AND White Black/African American AND White American Indian/Alaska Native AND Black/African American Native Hawaiian or Other Pacific Islander Other: HISPANIC/t_ATINO ETHNICITY: Mexican/Chicano Cuban ❑ Number of Disabled: 0 Number of Homeless Persons Given Overnight Shelter: Puerto Rican Other: ACCOMPLISHMENT NARRATIVE LEVERAGING RESOURCES NARRATIVE Signed Title Date CITY OF PALM SPRINGS EXHIBIT F Request for Reimbursement Project/Activity Title: Project Number: Stroke Recovery Center / Neuro Vitality Center 0005 Protective Shade Structure Name/Address of Provider: Stroke Recovery Center / Neuro Vitality Center 2800 East Alejo Road Palm Springs, CA 92262 BENEFICIARY QUALIFICATION STATEMENT Description Approved Grant Amount Current Reimbursement Period Prior Reimbursement Period(s) Total YTD Reimbursement Grant Balance (Over/ Under) Other — Construction/Rehabilitation $15,067 TOTAL $15,067 I 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. CITY OF PALM SPRINGS EXHIBIT G Employment Restrictions 1. Labor Standards The PROVIDER agrees to comply with the requirements of the Secretary of Labor in accordance with the Davis -Bacon Act as amended, the provisions of Contract Work Hours and Safety Standards Act, the Copeland "Anti -Kickback" Act (40 U.S.C. 276a- 276a-5; 40 USC 327 and 40 USC 276c) and all other applicable Federal, state and local laws and regulations pertaining to labor standards insofar as those acts apply to the performance of this contract. The PROVIDER shall agree to submit documentation provide by the CITY which demonstrates compliance with hour and wage requirements of this part. The PROVIDER agrees that, all general contractors or subcontractors engaged under contracts in excess of $2,000.00 for construction, renovation or repair work financed in whole or in part with assistance provided under this contract, shall comply with Federal requirements adopted by the CITY pertaining to such contracts and with the applicable requirements of the regulations of the Department of labor, under 29 CFR Parts 1, 3, 5 and 7 governing the payment of wages and ratio of apprentices and trainees to journeyworkers; provided, that if wage rates higher than those required under the regulations are imposed by state and local law, nothing hereunder is intended to relieve the PROVIDER of its obligation, if any, to require payment of the higher wage. The PROVIDER shall cause or require to be inserted in full, in all such contracts subject to such regulations, provisions meeting the requirements of this paragraph. 2. "Section 3 Clause' a. Compliance Compliance with the provisions of Section 3, the regulations set forth in 24 CFR 135, and all applicable rules and orders issued hereunder prior to the execution of this contract, shall be a condition of the Federal financial assistance provided under this Contract and binding upon the CITY, the PROVIDER and any of the PROVIDER'S subrecipients and subcontractors. Failure to fulfill these requirements shall subject the CITY, the PROVIDER and any of the PROVIDER'S subrecipients and subcontractors, their successors and assigns, to those sanctions specified by the Agreement through which Federal assistance is provided. The PROVIDER certifies and agrees that no contractual or other disability exists which would prevent compliance with these requirements. The PROVIDER further agrees to comply with these "Section 3" requirements and to include the following language in all subcontracts executed under this Agreement: "The work to be performed under this contract is a project assisted under a program providing direct Federal financial assistance from HUD and is subject to the requirements of Section 3 of the Housing and Urban Development Act of 1968, as amended, 12 U.S.0 1701. Section 3 requires that to the greatest extent feasible opportunities for training and employment be given to low- and very low-income residents of the project area and contracts for work in connection with the project be awarded to business concerns that provide economic opportunities for low- and very low-income persons residing in the metropolitan area in which the project is located." The PROVIDER further agrees to ensure that opportunities for training and employment arising in connection with a housing rehabilitation (including reduction and abatement of lead -based paint hazards), housing construction, or other public construction project are given to low- and very low-income persons residing within the metropolitan area in which the CDBGfunded project is located; where feasible, priority should be given to low- and very low-income persons within the service area of the project or the neighborhood in which the project is located, and to low- and very low-income participants in other HUD programs; and award contracts for work undertaken in connection with a housing rehabilitation (including reduction and abatement of lead -based paint hazards), housing construction, or other public construction project are given to business concerns that provide economic opportunities for low- and very low-income persons residing within the metropolitan area in which the CDBG-funded project is located; where feasible, priority should be given to business concerns which provide economic opportunities to low- and very low-income residents within the service area or the neighborhood in which the project is located, and to low- and very low-income participants in other HUD programs. The PROVIDER certifies and agrees that no contractual or other legal incapacity exists which would prevent compliance with these requirements. C b. Notifications The PROVIDER agrees to send to each labor organization or representative of workers with which it has a collective bargaining agreement or other contract or understanding, if any, a notice advising said labor organization or worker's representative of its commitments under this Section 3 clause and shall post copies of the notice in conspicuous places available to employees and applicants for employment or training. DOCUMENT TRACKING Page:1 Report: One Document Detail October 14,2010 Condition: Document Number a5639, Document# Description Approval Date Expiration Date Closed Date A5639 CDBG 08-09 Energy Conservation Improvements $44,018 04/02/2008 .ompany Name: Stroke Activity Center Wdress: )roup: COMMUNITY&ECONOMIC Contract Amt. Total Paid Balance iervice: In File $44,018.00 $44 018,00 ;Ref: COMMUNITY&ECONOMIC ns.Status: New Entry.Inactive Document Tracking Items: Due Completed Tracking Amount Amount Code Item Description Date Date Date Added Paid kdh Res 22193 Ite, 1A 04/02/2008 $44,018.00 kdh to CM for sig IN FILE 11/24/2008 ******ENDOFREPORT****** `O SUBRECIPIENT AGREEMENT THIS AGREEMENT (herein "Agreement"), is made and entered Into this 30t' day of October, 2008, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city, and the Stroke Recovery Center, (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 sec.), as amended from time to time (the "Act"), and the regulations promulgated thereunder(24 C.F.R. Section 570 et seq. ("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, and to conduct all programs specified therein in a manner to reflect credit upon the City and Provider. 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. 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 2.2, 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 A Financial Reporting. Any Provider receiving or due to receive or due to receiver$20,000.00 or more from the City during the 2008 —2009 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 312'of the current fiscal year. 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 FORTY-THREE THOUSAND NINE HUNDRED NINETY-EIGHT DOLLARS ($43.998.00) (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 monthly statements 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 Reoresentative 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.- Beverly Greer, Administrator 3.2 Contract Officer. The Contract Officer shall be such person as may be designated by the chief administrative officer 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 -2 - may be required by the regulations of the Housing and Community Development Act, but in no case for less than three years after the close of the program. 42 The Provider certifies it shall adhere to and comply with the following as they may be applicable: (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 II and the acquisition requirements of Title III of the Uniform Relocation Assistance and Real Property Acquisition at 24 CFR Part 42; (1) The restrictions prohibiting use of funds for the benefit of a religious organization or activity as set forth in 24 CFR 570200 a); Q) 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 G.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); - 3- (o) The regulations, policies, guidelines and requirements of 24 CFR 570; the "Common Rule", 24 CFR Part 85 and subpart J; OMB Circular Nos. A-102, Revised, A-87, A-110 and A-122 as they relate to the acceptance and use of federal funds under the federally- assisted program; (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 seeq_); (s) Maintain property inventory system to numerically identify HUD purchased property and document its acquisition date as is set forth in OMB Circular A-110 Attachment N Property Management Standard 6d; and (t) Reversion of asset. Upon the Expiration of the agreement, the 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 (s)(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 (s) of this section.) (u) 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 Provider's acts or omissions arising out of or related to Providers performance under this Agreement. Provider shall also carry 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 -4 - 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 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 Five Hundred Thousand Dollars ($500,000). 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 DISCRIMINATION, TERMINATION, AND ENFORCEMENT. 6.1 Covenant Against Discrimination. Provider covenants that, by and for itself, its heirs, executors, assigns, and all persons claiming under or through them that there shall be no discrimination against or segregation of any person or group of persons on account of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, pregnancy, marital status, age, sex, sexual orientation, or any other basis Protected Characteristic by applicable federal, state or local law in the performance of this Agreement. Provider shall take affirmative action to insure that applicants are employed and that employees are treated during employment without regard to their race, color, creed, religion, sex, marital status, physical or mental disability, national origin, ancestry or any other basis Protected Characteristic by applicable federal, state or local law. 6.2 Term. Unless earlier terminated in accordance with Section 6.3 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. 6.3 Termination Prior to Expiration of Term. Either party may terminate this Agreement at any time, with or without cause, upon thirty (30) days' written notice to the other party. 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. 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, document, consent, approval, or communication either party desires or is required to give to the other party shall be in writing and either served personally or sent by prepaid, first-class mail to the address set forth below, or such other addresses as may from time to time be designated by mail. TO CITY: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Manager - 5 - WITH COPY TO' City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Attorney TO PROVIDER: Stroke Recovery Center 2800 E Alejo Rd Palm Springs, CA 92262-6253 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] - 6- CITY OF PALM SPRINGS ATTEST: � a municipal corporation By: FEU City Clerk City Manager APPR ETAS T APPROVED BY CITY COUNCIL ity�ey PROVIDER: Check one: _Individual _ Partnership T 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, Assistant Secretary, Treasurer,Assistant Treasurer, or Chief Financial Officer). Notarized Signature of Chairman of Board, Notarized Signature Secretary,Asst Secretary, President or any Vice President Treasurer,Asst Treasurer or Chief Financial C0c4—r Name: �h 1� 1'1' r Name: /,�5v c V Title: Ij Yr_ i ;rG.r.11� Title: $Ez-/L2r /f- Slate of h�-f state of } County os County of �ss before ree, on before me, personally appeared ,personally appeared Na �— personalty known personally known o me(o d-Id e o e`6aal factory eyideneu)` to me(or proved to me on the basis of satisfactory,evidence) to be the person whose nama( ) are sub to the to be the person(s)whose name(s) Ware subscribed to the within instrument and acknowledged me the bell within instrument and acknowledged to me that he/sbeRhey executed the dame in,21 entheir authorized adty(f[b), execulad the same In hlrfiedtlrelr authorized capac ty(ies), end that by I rlthelr s nalum(o on the InsbumefiI the and that by hisrheMhelr signatum(s) on the instrument the persooK, or the entity upon behalf of which the personty person(s), or the entity upon behalf of which the person(s) acted,executed�the� enC. acted.executed the instrument. WITNESS my ah nd a d b I t IMTNES$my hand and niBcial swi. Notary Signature' 1 Notary Signature: ZNZ�.CaQ T�h('A aa� Notary Seal: Notary Seal: .......... u.u.nrr.................0 "�"' �' C,,#1769539 �+ F Noial ersic c-Calif y .b Ires -lip hlv mmj County s Commission fx 11 -1 11 o sepicrn4e.21.2 �i.n.' $WkeRamveryCr& SubtdpAgrmnLOdae -7- ACKNOWLEDGMENT State of California County of RIVERSIDE On 10/30/08 before me, MARCELLA SPEARMAN, NOTARY PUBLIC, personally appeared BEVERLY GREER - SECRETARY who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her authorized capacity, and that by her signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. 1� Signature "O )V 'a I LLI 1— P U (Seal) MARCELIA WARMAN ComMRllpll# 15-',c72 r' Nolgry public- Carttofnla Rlversloe County My Comm.EYcuGs Mart,2010 'r -lo - film_.!\Ova �'-.... CITY OF PALM SPRINGS EXHIBIT A Scope of Services Proiect/Activity Title: Pro ec� t Number: Stroke Recovery Center! 0005 Energy Conservation Improvements Name/Address of Provider: Stroke Recovery Center 2800 E Alejo Rd Palm Springs, CA 92262-6253 Obl ectives/_Activities The intent of this program is to provide programming, services and therapies for stroke survivors. This will be accomplished through the continued renovation of their facility that will upgrade of the building's interior lighting systems for greater energy-efficiencies. These improvements will replace the current high energy interior lighting fixtures with more energy-saving T-8 style fluorescent lamps and LED lamps which will reduce operational expenses enabling those savings to be redirect to program and service operations. The Stroke Recovery Center covers the entire Coachella Valley, serving 115 clients of which 41 are Palm Springs' 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 rovidin an 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 Qrogrammatic and financial record keeping recess. 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. Objective4: Enrol_I_nand_-income qualify at least a total of forty-one (41) extremely-low income to moderate-income Palm Springs residents. TARGET DATE ACTIVITY#1 On-Going Provide direct client programming for Palm Springs residents. 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 Monthly Submit Semi-Annual reports--referenced Exhibit E. 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: Upgrade and improve the building's interior lighting systems for greater energy_ efficiencies in accordance with an 'open competitive' procurement process as outlined in proposal TARGET DATE ACTIVITY#1 On-Going Conduct program activities, as stipulated in the proposal and in consultation with the City Objective 8: Provide an evaluation_within fifteen (15) calendar days of the program completion or final reimbursement. TARGET DATE ACTIVITY#1 07/15/09 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. Proiect Number. Stroke Recovery Center/ 0005 Energy Conservation Improvements Name/Address of Provider Stroke Recovery Center 2800 E Alejo Rd Palm Springs, CA 92262-6253 BUDGET SUMMARY _ CAST CATEGORY CDBG OTHER TOTAL SHARE SOURCES COST 1 Personnel $ - 0 - $ - 0 - $ - 0 - 2 Consultant/Contract Services $ - 0 - $ - 0 - $ - 0 - 3 Travel $ - 0 - $ - 0 - $ - 0 - 4 Space Rental $ - 0 - $ - 0 - $ - 0 - 5 Consumable Supplies $ - 0 - $ - 0 - $ - 0 - 6 Rental, Lease or Purchase of $ - 0 - $ . 0 - $ - 0 - Equipment 7 Insurance $ - 0 - $ - 0 - $ - 0 - 8 Other $43,998. $ - 0 - $43,998. Contractor Contract $ - 0 - $ - 0 - $ - 0 - $43,998. $ - 0 - $43,998. TOTALS 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 Reimbursement in accordance with the aforementioned cost categories. In no quarter shall the Subrecipient submit for reimbursement more than % of the total annual budget. Payments, approved by the Subrecipient, shall be paid by the 30th day of each month, provided that the payment application has been submitted to the City on or before the first working day of the month. Services are to be performed over the twelve-month period of this 2008-09 Program Year — July 1, 2008 through June 30, 2009. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory Project/Activity Title: Project Number- Stroke Recovery Center/ 0005 Energy Conservation Improvements Name/Address of Provider. Stroke Recovery Center 2800 E Alejo Rd Palm Springs, CA 92262-6253 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance NIAC Effective Dates of Policy 02/01/08 to 02/01/09 Claims Made Policy_ / / Per Occurrence Policy / / Limits of Liability $2,000,000 General Aggregate Deductibles,- Per Occurrence $1,000,00000 Annual Aggregate $1,000,000,00 Additional Insured Endorsement (Certificate Holder) R1 Yes ❑ No Original Certificate of Insurance Attached ❑ Yes Z No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company____Tower_Select Insurance Company_ _ Effective Dates 01/01/08 to 01/01/09 Limits of Liability Statutory Requirements Underlying Coverage Limits Original Certificate of Insurance Attached ❑ Yes Z No Client#:8492 2STROREC ACORD,„ CERTIFICATE OF LIABILITY INSURANCE 10`6Ni2008 rr' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Desert Empire Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Services,inc. LIC7t OP09643 HOLDER,THIS CERTIFICATE DOES NOT AMEND,ExTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. T7.564 Country Club Drive Palm Desert,CA 92211 INSURERS AFFORDING COVERAGE NAIC# INSURED tNGURERA NIAC 136684 Stroke Recovery Center INSURER B. Tower Select Insurance Company 2800 F,Alejo Road INSURER C. Palm Springs,CA 92262 INSURER D lh URER E COVERAGES 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 SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS Or SUCH POLICIES AGGREGATE LIMITS SHQWN MAY HAVE BEEN REOUOEO BY PAID CLAIMS ICY UMNSR TYPE OF INSUIlMCE POUCINUMaER CATEYMMODCTNE PDDATE MMMPIYYN UNITS A GENERAL LIABILITY 20086766NPO 02101108 07J01I09 EACH OCCURRENCE 51006000 X CGLWERCALG'NERALLIARILITY DAnrGF TG REM1TEn 51UU 66D 4aC CLAIMSMAC"e 7X OCCUR LIED EYP(Any one Prrmnl S10.000 FER50NAL&AOVmURY 21000000 GENERAL AGGREGATE $2 000 000 G=NLAGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AEG 52000000 POLICY jRT Lac A AUTOMOBILE UAEILITY 20086766NPO 02/01/06 02/01/09 COMBINED SINGLE LIMIT 51,000,000 X ANY AUTO (`A PCDecnO ALL OWNED ALTOS ?DOILY INJURY 5CHEOULF.n AUTOS (Per pe=s i 5 X HIRED AUTOS BODILY INJJRY X NONOMMI ALTOS ;Par a.nnant� I5 PROPERTY DAMAGE 5 (Pef JECOANJ GA RAGE LIABILITY AUTD ONLY-eA ACEMENT $ ANY AUTO OTHER THAN SAACC s AUTO ONLY AGC 5 A IXLESSIUMBRELLA LIABILTIY 200806766UMBNPO 02/01/08 02O1109 EACH OCCURRENCE 12009000 CC=R X❑CL:1!•15 MADE AGGREGATE S DEDUCIBLE 5 X R3T4NTICN S 19000 I S B WORKERS COMPENSATION AND TSIWD7080102400 01/01108 01/01109 g r c5TAly- DTH• EMPLOYERS LIABILITY EL EACHACCIDENT si,000,000 ANY PRDPRIETMPARTNERI EXECUTIVE CFFICEt MENIBER EXCLUDED? EL OISBAGE-SA EMPLOYEE1 51,000,000 II c: e bem+ee' EL D15EASE-PO4ICY4IMIY 51,000,000 S I AL PRON151ONS Cn,ow CTNFR DESCMPTION OF OPERATIONS I LOCATIONS 1 VEHICLES I EXcLusIONs ADDED GY ENDORGDMENT1 SPECIAL PROVISIONS Certificate Holder i5 named as Additional Insured to include Primary and Non-contributory wording. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE PESCRiesn FvuclEs aB LANCCLL[D BEFORE THE EXPIRATION The City of Palm Springs,it's DATE THEREOF,TILE ISSUING INSURER WILL ENDEAVOR TO MAIL -4W DAYSWRITTEN officials,employees and agents NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAJLDRB TO DO SO SHALL P.O.Box 2743 IMPOSE NO OSUGATIDN OR LIABRJTY OF ANY KIND UPON THE INSURER nS AGENTS OR Palm Springs,CA 92262 REPRESENTATNEs. AUTHORISED REFRESENTATIVE ACORD 25(2001108)1 Of 2 #91260191M726018 2TEAD 0 ACORD CORPORATION 1858 POLICY NUMBER: 20086766NPO COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s), Or Or anlzation s : Locations Of Covered Operations City of Palm Springs P.O. Box 2743 Palm Springs, CA 92262 Attn: City Cleric Information required to complete this Schedule, if not shown above, will be shown in the peelarations. A. Section II -- Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or addrtional insureds, the following additional exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for"bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" .,property damage"occurring after, caused, in whole or in part,by. 1. All work, including materials, parts or equip- 1. Your acts or omissions; or ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project(other than service, maintenance behalf- or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed;or nated above. 2, That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a princi- pal as a part of the same project. CG 20 10 07 04 0 ISO Properties, Inc,2004 Pagel of 1 I7 -, n 1 Enduuomcnl No ,:•:ur Get,(PAIN❑17 1Y1 11/U4/20D8 d Desert Empire Insurance Svcs, Inc. „IIIt;r NLAC LIC flOF09643 "' 36684 77-564 Country Club Drive ;°IrL,°r;r,l,.rl 200806776NP0 � Palm Springs, CA92262 02/01/2008 -- 02/01/2009 I �c.n,rlr.l,;c � pn 1,� (760) 360--4 700 W>.rti,]p lrh•1•-nr l'eul:ll,u a,,rluaud In L nnlL. III,dJalon to Lwii', El iStroke Recovery Center 2800 E. Alejo Road Palm Springs, CA 92262 ---- -- ---- - �'•'.h un A'.,,,.=,;a'. 'It s J AdN1•u�b1. , ..e „ nr'I,.,q • „„1 ,Ja ,[ • In ., [ I IT' 11 U 1:Iy1'r,xn• f :"., n l I.n.. I .,., ••y. n , II. I19r IT �t•t_ _,tin_ Cdy A:,rn,ITT... Pv'n,es VyCu oral Llohdny l x IL.)1111 dl(h"[:IeI L.,.Id11y 1 Ll:iup ^a;1I„I,r Fnr 11 . rcqdg n Tnnli:a•In,9 1 UCCUIMMOO PR;,91gC5)l(l[rdilhnti �� '1 l„II ,u Llrllll•^:-,P^ r reF`5+'I'l'.f , LaY1 +rPa,.,.1d L .:(h, a: m l•, ..,d- e J, ur.l our ml S r:UtLrpI,.I•'at.n1 $1,000,000 $2,000,000 $1,000,000 $2,000,000 I n on 1L'I,.'L., nl tL,,l II ,I,II!;,.il .Ind Ia,..vil1,Lw,llny any llcen.'I:ilunl 41dlpinuul ,•1 Ihu I...d_t lu whicl, :his cndcr.urn_pl i, ow'd 1 -n.l,n,VIIII nvl.I Il M 1111.I,111LIJ 111a 1I;,IJ1(1 DI ICL6'd5 12 A414411orwl ln:urcU TII,;CIIynf Ptll 1,SpcogS and as atfcmis umpiDycLs-and acenls dra mcluuod dE.uP.nlluncl,Irts1 rUUZ mlh IL!JZII.1 lU 1LIIA11y'I'Id bUIUP•,' [1. jt I•111 l]:. 'd.v,[I la bd Ud'Lob Cl 10(1gll{ubUfv:'1�]:10OV,v pn!pna burl l»1,;qx;r'�L n:ZI I ld I s,51.lu1 t,-i wJ l.yo a 11;,o'1'.:of 14 u eA r rn.l � III,111:h1 n CIVI?IS,nlyn L.,[d,r(nl n.;l 0 T1 'e(•=I,,,rnmry nIt-rLspl:cl t[ :•n ,n•,.u:Irv=C mn nt II C 11,J„IT,'.r.(,•Pah` S,.ml ;'In.' II I11 rot L.fl:,,I Ill;, It ' 14 Cdtl cml P:Uwt IQ.I.v A I!I ,, ^,q.l hI IIII, ntuf1;St I,[ It Cn} o' .,In•I?,,nay.Ins'III q 11n: ,ho•I I U'bu on nc cl I, dI I,q,;l r[Aly IuIILC;o I b%rmg:,nrIllnits meo],'ullltr 1:IIYy(70I IAoy.'•Pnp1 srp(un n.,,tlg,,Gy l,.e,^II,I ec t l.,: ,er•,•tL d�I:n InC C1:,f-It F'dl 19punI,-.Itlr1u_g;ra I'll. Ily I NnId1,i P,.j Kj,' AtII N,!ik N1,I1,19,1 :10(]E Lah,1wL'C.Iu"un 1'..�v rdc 'Spu n,,s CP Or...: ' I n.:9 11 11i11vd l;wl l•nut1111,I;I m rin.J oll bu IT,h,I(I NI:IL,\JIIUI(11 011e 11d.1111 Cf Il rU lnt,m l„n'Ju,rl9 :r p r„gt 1,11!p OF e.(to•Iol ly,l[I m puh�,to pn'rry iltl%1 nw U5i Ltgl ii I•:.L'[1"1.^." Ci ty Pn•vTIO41 .ucnuM, ^. C AL'n:,nZL`dRr-r),U•.I:n in, o7IC11n,,r,P.g:m Y�U ldl I wilr�����,..._.,,......,�..,.,...�.,,,.,.1 f Van Tanner 'I Ciq)of Palm Springs _ __ I{�nIILr;,L •I,I,IIUI t•.,I,I,III ul,,: 1•,.,.,, ; i 3200 f ahC ut:iCc tiVOil Way durnUnlj iP f[u,[I the IJLA:1•'I,i1" Iluuallw cu•Ir,.Iny.I•d:ly III) K;I!,AIWI,In.Ii ur1 Ju ywd Pu y`nlnp�ny n)19,::,p1 tln lITI Palm Springs, CA 92232 (760.)_360-4700 cl1u 11/04/2008 °y r - - I I ::FI Ill IQU 2 Gat,:Irc M,DD;YY; 7' 5' PJjw,�F-Ill, 11/04/2008 NIAC 36684 Desert Empire Insurance Svcs, Inc. 200806776NP0 LIC #01709643 2/01/2008 — 02/01/2009 77-564 Country Club Drive Tf.op A41j1j I'I"t,I kr"ll 3U ITI if I IllItIF I--, IT t1IJIjllI1NfL[pill ll,'I ........M --m--D (1,A q9911 (76n) Un—� l . ,L Stroke Recovery Center ;AA, 2800 E. Alejo Road ❑ if,, rriw Palm Springs, CA 92262 AII,1,,lI'lJIL t,l I,, if if u,pr .l. 1.1, 1, .1 m!l Lj.,r1I I, I,I,,_ IT I"III', I"Ilk LrNIUD )III t,I I. ,,I, Lhe brr IT oz; r,, ,;I, I i i r r ily AgIrt'LT'u-lL 11PI r I L,'Once I C I;,o5)...... x— J II IT IN I CSL- $1,000,000 A,IG, 10-CIwIT-t 'kil't x I,I.,J,Ijiur, ,t III- -ILMM,IT, il,(l;,t] III, I,L I t n.it I lh,p pd,C1 l,IT, uJI liIIII LI1dOeLIl1F,11 1. zilLcOiQ I IF ,I rr,,.I IL I I V 11 11. 1 il, I,..„ I'i,T,I I I I I" I 11 A[I Ll i t On il I I I I S I I I e r-,I I y,:F-IFIT-I sprinct;.10f-11,:XfOlplin li"O 2"at'll"Z,I I;Jl It,kAdeO'J5 0(101t[Ori'l I I 5i IF UJ%,•-,;It,iLDZIFIJ U lIdbilllyond I I 1, I ,I I 1 11 f F!,elf Of I I,I I US IF t III I I q IS le'I L I ii llg I I U I L j p um I I u 11,zfn ki if U r 111111 V.I I I I V[A if 11 It 11 t I Z.I I L t the C 11.I I I I t U Xr T 2 Contriuutiu.i Not RI I is miI =rfiih rospeci In al rI5LIFiML,-: ki I I I tJ I I I ,I fy I t I L Clly L,r P.I I'S,j;I r n,a II J ,T I I II nu;t I I II,I I L 1',111 111;,-Iv r ,,,j 11,LjU DU IJ, 1O1CLI41110il NOIACC. :l,1111 IL 10 OIL' IIII I.11 UID City W P1111M 311 this FiFI shalt jD1 )e L�rit;Li ad, T o,,LII t LIP Ill luvls 11V.ept art(If 11hil m):j;I 91 or wI IVUU:Cy'l(:Ur:1„1aLll,gllyly t)ftY 1pl,,oT I ljjvcn to in,%City Lit i'ar i: 0, 1,11,5 uIri F,ritb 01 L XCILI'tf"i)s'U lh,� lf)llCV Ill WI I ILI I --------- 14. CilfiDepaw -I MF1'JIC3Lf 1,, If 4_;I r I. j...1, Cily of Ftalr.i Springs f r Van Tanner prlwl-EI-,Nj liar in) wIlI!hit I ill 3200 E.Taf-Lqu",z Canyon Way 11)n I I j to'ljn d thi-&Bl5o tC,MI I IF I;7U f T)IT I i)a riy a n.t hj 11 5 fir1q:I Oil,51) PaIrri5prings, CA 92262 -.�. ...... 760 360-47Q2 CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Proiect/Activity Title, Project Number Stroke Recovery Center/ 0005 Energy Conservation Improvements Name/Address of Provider: Stroke Recovery Center 2800 E Alejo Rd Palm Springs, CA 92262-6253 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--021131108) AREA MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME(AMI) 1 2 3 4 5 6 7 8 LEVEL EXTREMELY LO INCOME $14,000 S16 000 S18 000 $20 000 $21 600 $23 200 $24,800 $26 400 0.30%of AMI VERY LOW INCOME $23,300 $26.650 $29,950 $33,300 S35,950 $38,650 $41,300 $43,950 31-50%of AMI LOW INCOME S371300 $42,650 $47 950 $53,300 $57 550 $61 850 $66,100 $70,350 5T-80%OfAMI MODERATE INCOME $52,100 $59.500 367.000 $74,400 $80.400 $86,300 $92,300 $98,200 61-120% 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 0 Asian ❑ Black/African American AND White ❑ American Indian or Alaskan Native 0 American Indian/Alaska Native AND Black/African American ❑ Native Hawaiian or Other Pacific Islander ❑ Other: HISPANIC/LATINO ETHNICITY ❑ Yes ❑ No If yes,check one: 0 Mexican/Chicano ❑ Puerto Rican ❑ Cuban ❑ Other 4. Please check,for no, if you are a female Head of Household? ❑ YES ❑ NO 5. Do you have a disability? ❑ YES ❑ NO If YES,please describe: ACKNOWLEDGEMENT AND DISCLAIMER I 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 farm Is confidential and Is only utilized for Commumry 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: Stroke Recovery Center/ 0005 Energy Conservation Improvements Name/Address of Provider: Stroke Recovery Center 2800 E Alejo Rd Palm Springs, CA 92262-6253 PROGRAM PROGRESS REPORT Period: DIRECT BENEFIT REPORT ♦ Number of First-Time Program Beneficiaries Serviced: #of Households #of Persons 0-30% below 31-50% below: 51-80%below 120%below ♦ Number of First-Time Female Headed Households: ♦ Counts by Race/Ethnicity- White American Indian or Alaska Native AND While Black/African Amencan Asian AND White_ Asian Black/Africen 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: ACCOMPLISHMENT NARRATIVE LEVERAGING RESOURCES NARRATIVE Signed Title Date CITY OF PALM SPRINGS EXHIBIT F Request for Reimbursement Proiect/Activity Title: Project Number: Stroke Recovery Center/ 0005 Energy Conservation Improvements Name/Address of Provider: Stroke Recovery Center 2800 E Alejo Rd Palm Springs, CA 92262-6253 BENEFICIARY QUALIFICATION STATEMENT Approved Currant Pribr Total Lnt PP Descrlpdon Grant Re 'ant Relmbursomont ,YTD ncaAmount Porlod Parlod(s) RalmbursomontUndar) Other $43,998 Contractor Contract TOTAL I 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 CITY OF PALM SPRINGS EXHIBIT G Employment Restrictions 1, Labor Standards The PROVIDER agrees to comply with the requirements of the Secretary of Labor in accordance with the Davis-Bacon Art as amended, the provisions of Contract Work Hours and Safety Standards Act, the Copeland "Anti-Kickback" Act (40 U.S C 276a-276a-5,40 USC 327 and 40 USC 276c)and all other applicable Federal, state and local laws and regulations pertaining to labor standards insofar as those acts apply to the performance of this contract The PROVIDER shall agree to submit documentation provide by the CITY which demonstrates compliance with hour and wage requirements of this part. The PROVIDER agrees that, all general contractors or subcontractors engaged under contracts in excess of$2,000 00 for construction, renovation or repair work financed in whole or in part with assistance provided under this contract, shall comply with Federal requirements adopted by the CITY pertaining to such contracts and with the applicable requirements of the regulations of the Department of labor, under 29 CFR Parts 1, 3, 5 and 7 governing the payment of wages and ratio of apprentices and trainees to journeyworkers, provided, that if wage rates higher than those required under the regulations are imposed by state and local law, nothing hereunder is intended to relieve the PROVIDER of its obligation, if any, to require payment of the higher wage. The PROVIDER shall cause or require to be inserted in full, in all such contracts subject to such regulations,provisions meeting the requirements of this paragraph. 2. "Section 3 Clause„ a. Compliance Compliance with the provisions of Section 3,the regulations set forth in 24 CPR 135, and all applicable rules and orders issued hereunder prior to the execution of this Contract, shall be a condition of the Federal financial assistance provided under this Contract and binding upon the CITY, the PROVIDER and any of the PROVIDER'S subrecipients and subcontractors Failure to fulfill these requirements shall subject the CITY, the PROVIDER and any of the PROVIDER'S subreeipients and subcontractors, their successors and assigns, to those sanctions specified by the Agreement through which Federal assistance is provided. The PROVIDER certifies and agrees that no contractual or other disability exists which would prevent compliance with these requirements. The PROVIDER further agrees to comply with these "Section 3" requirements and to Include the following language in all subcontracts executed under this Agreement 'The work to be performed under this contract is a project assisted under a program providing direct Federal financial assistance from HUD and is subject to the requirements of Section 3 of the Housing and Urban Development Act of 1968 as amended, 12 U.S.0 1701. Section 3 requires that to the greatest extent feasible opportunities for training and employment be given to low- and very low-Income residents of the project area and contracts for work in connection with the project be awarded to business concerns that provide economic opportunities for low-and very low-income persons residing in the metropolitan area in which the project is located:' The PROVIDER further agrees to ensure that opportunities for training and employment arising in connection with a housing rehabilitation (including reduction and abatement of lead-based paint hazards) housing construction, or other public construction project are given to low-and very low-income persons residing within the metropolitan area in which the CDeG- funded project is located;where feasible, priority should be given to low-and very low-income persons within the service area of the project or the neighborhood in which the project is located, and to low- and very low-income participants in other HUD programs; and award contracts for work undertaken in connection with a housing rehabilitation (including reduction and abatement of lead-based paint hazards), housing construction, or other public construction project are given to business concerns that provide economic opportunities for low- and very low-income persons residing within the metropolitan area in which the CDBG-funded project is located; where feasible, priority should be given to business concerns which provide economic opportunities to low-and very law-income residents within the service area or the neighborhood in which the project is located and to low-and very low-income participants in other HUD programs. The PROVIDER certifies and agrees that no contractual or other legal incapacity exists which would prevent compliance with these requirements. b. Notifications The PROVIDER agrees to send to each labor organization or representative of workers with which it has a collective bargaining agreement or other contract or understanding, if any, a notice advising said labor organization or worker's representative of its commitments under this Section 3 Clause and shall post copies of the notice in conspicuous places available to employees and applicants for employment or training. /_M44111 ACORO" v �SrROREC-01 CERTIFICATE OF LIABILITY INSURANCE ft-7.Ao DATE iMMIODM(YY) 12/16/2022 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 License # 0757776 c TACT Virginia Ramirez (PH/cON , Etl: (760) 360-4700 4252 1 F ,No:(760) 200-5841 HUB International Insurance Services Inc. 75030 Gerald Ford Drive Suite 201 A% L . virginia.ramirez@hubintLrnational.com Palm Desert, CA 92211 INSURERS) AFFORDING COVERAGE NAIC 71 INSURERA: Nonprofits' Insurance Alliance of California Inc 01184 INSURED INSURER B: State Compensation Insurance Fund Of California 35076 INSURER C: Stroke Recovery Center dba: Neuro Vitality Center INSURER D: 2800 E. Alejo Road Palm Springs, CA 92262 INSURER E : INSURER F: COVERAGES CFRTIFICATF NUMRER' 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 16LINSn TYPE OF INSURANCE ADDLSUB MD POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 CLAIMS -MADE �X OCCUR X X 2022-06766 211/2022 2/1/2023 DAMAGETO RENTED S 500,000 MED EXP (Any one $ 20,000 PERSONALS ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY LOG GENERAL AGGREGATE 3'000'000 PRODUCTS -COMP/OPAGGr 3,000,000 LICIOUR LIABILIT1,000,000 OTHER: A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,Qgg,000X BODILY INJURY PerOWNED ANY AUTO 2022-06766 2/1/2022 211/2023 INJURY Per accidentX SCHEDULEDAlgn'�O�S ONLY AU��TNNOppSWWNN��ppBODILY �t-EI�n1GE AUTOS ONLY AUT09w A UMBRELLA LIAR X OCCUR EACH OCCURRENCE2,000,000 EXCESSUAB CLNMSAIADE 2022-06766-UMB 2H/2022 2/1/2023 X AGGREGATE 21000,000 LIED I X J RETENTIONS 10,000 B WORKERSCOMPENSATON AND EMPLOYERS' UABILITY YIN Ap�andelM'NY PROPRIETgOERIPARTNER/EXECUTIVE IM'in NH)pEXCLUDEDT ,M N/A X 9121137-23 U1/2023 1/1/2024 X PER OTH- TE ER E.L. EACH ACCIDENT 1,000,000 E.L. DISEASE - EA EMPLOYE S 1'g00'000 DrSRIPTdscIONOFOlok, under DESCRIPTION OF OPERATIONS be. E.L. DISEASE -POLICY LIMB 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) The City of Palm Springs, its officials, employees and agents are named as additional insureds per the attached endorsement a -Li 7lloverage is primary and non-contributory. Waiver of subrogation applies to General Liabilty and Workers Compensation. 30 day notice of n, except 10 day notice of non-payment of premium. DEC 19 2022 City Hall Reception Desk CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The Cityof Palm Springs THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 3200 E. Tahquitz Canyon Way Palm Springs, CA 92262 AUTHORIZED REPRESENTATIVE omy_ _ '-_ ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NONPROFITS POLICY NUMBER: 2022-06766 FORM: NIAC-E26 11 17 INSURANCE NAMED INSURED: Stroke Recovery Center dba: Neuro Vitality Center ALLIANCE OF CALIFORNIA A Head for Insurance. A Heart for Nonprofits. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SOCIAL SERVICE PROFESSIONAL LIABILITY COVERAGE FORM SCHEDULE Name of Person or organization: Per Certificate - As required by written contract Where you are so required in a written contract or agreement currently in effect or becoming effective during the term of this policy, we waive any right of recovery we may have against that person or organization, who may be named in the schedule above, because of payments we make for injury or damage. NIAC-E26 11 17 Page 1 of 1 0 NONPROFITS INSURANCE ALLIANCE OF CALIFORN IA A Head for Insurance. AHeart for Nonprallts. POLICY NUMBER:. 2022-06766 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED PRIMARY AND NON-CONTRIBUTORY ENDORSEMENT FOR PUBLIC ENTITIES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Per Certificate - As required by written contract A. Section II —WHO IS AN INSURED is amended to include: 4. Any public entity as an additional insured, and the officers, officials, employees, agents and/or volunteers of that public entity, as applicable, who may be named in the Schedule above, when you have agreed in a written contract or written agreement presently in effect or becoming effective during the term of this policy, that such public entity and/or Its officers, officials, employees, agents and/or volunteers be added as an additional insured(s) on your policy, but only with respect to liability for "bodily injury', "property damage" or "personal and advertising injury' caused, in whole or in part, by: a. Your negligent acts or omissions; or b. The negligent acts or omissions of those acting on your behalf; in the performance of your ongoing operations. No such public entity or individual is an additional Insured for liability arising out of the sole negligence by that public entity or its designated individuals. The additional insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization. B. Section III — LIMITS OF INSURANCE is amended to include: S. The limits of insurance applicable to the public entity and applicable individuals identified as an additional insured(s) pursuant to Provision A.4. above, are those specified in the written contract between you and that public entity, or the limits available under this policy, whichever are less. These limits are part of and not in addition to the limits of insurance under this policy. C. With respect to the insurance provided to the additional insured(s), Condition 4. Other Insurance of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS is replaced by the following: 4. Other Insurance a. Primary Insurance This insurance is primary if you have agreed in a written contract or written agreement: (1) That this insurance be primary. If other insurance is also primary, we will share with all that other insurance as described in c. below; or NIAC-E61 02 19 Page 1 of 2 NONPROFITS INSURANCE ALLIANCE OF CALIFORNIA A Head Jor Insurance. A Heart Jor Nonprofits. POLICY NUMBER: (2) The coverage afforded by this insurance is primary and non-contributory with the additional insured(s)' own Insurance. Paragraphs (1) and (2) do not apply to other insurance to which the additional insured(s) has been added as an additional insured or to other Insurance described in paragraph b. below. b. Excess Insurance This Insurance is excess over: 1. Any of the other Insurance, whether primary, excess, contingent or on any other basis: (a) That is Fire, Extended Coverage, Builder's Risk, Installation Risk or similar coverage for .your work": (b) That is fire, lightning, or explosion insurance for premises rented to you or temporarily occupied by you with permission of the owner; (c) That is insurance purchased by you to cover your liability as a tenant for "property damage" to premises temporarily occupied by you with permission of the owner; or (d) If the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to the extent not subject to Exclusion g. of SECTION I — COVERAGE A— BODILY INJURY AND PROPERTY DAMAGE. (e) Any other insurance available to an additional insured(s) under this Endorsement covering liability for damages which are subject to this endorsement and for which the additional insured(s) has been added as an additional insured by that other insurance. (1) When this insurance is excess, we will have no duty under Coverages A or B to defend the additional Insured(s) against any "suit" if any other insurer has a duty to defend the additional insured(s) against that "suit". If no other insurer defends, we will undertake to do so, but we will be entitled to the additional insured(s)' rights against all those other insurers. (2) When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of: (a) The total amount that all such other insurance would pay for the loss in the absence of this insurance; and (b) The total of all deductible and self -insured amounts under all that other insurance. (3) We will share the remaining loss, if any, with any other insurance that is not described in this Excess Insurance provision and was not bought specifically to apply in excess of the Limits of Insurance shown in the Declarations of this Coverage Part. c. Methods of Sharing If all of the other insurance available to the additional insured(s) permits contribution by equal shares, we will follow this method also. Under this approach each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. If any other the other insurance available to the additional Insured(s) does not permit contribution by equal shares, we will contribute by limits. Under this method, each Insurers share is based on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers. NIAC-E61 02 19 Page 2 of 2 POLICY NUMBER: 2022-06766 COMMERCIAL GENERAL LIABILITY Named Insured: Stroke Recovery Center dba: Neuro Vitality Center CG 20 10 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Oraanization(s) Any person or organization that you are required to add as an additional insured on this policy, under a written contract or agreement currently in effect, or becoming effective during the term of this policy. The additional insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization. Location(s) Of Covered All insured premises and operations. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury' caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or CG 20 10 12 19 © Insurance Services Office, Inc., 2012 Page 1 of 2 2. That portion of "your work' out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 10 12 19 © Insurance Services Office, Inc., 2012 Page 2 of 2 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 1, 2023 AT 12:01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING JANUARY 1, 2024 AT 12:01 A.M. AT 1E:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME STROKE RECOVERY CENTER 2800 E ALEJO RD PALM SPRINGS, CA 92262 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 2200$ OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION 9121137-23 RENEWAL SP 0-78-65-49 PAGE 1 OF 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 S'IqIS,.SSUUEE-D�AATT�SjAANFRFRANCISCO: DECEMBER 16, 200222 /'ly"w"^' , �V4. I/of.-�i'•-� ,'V7 �oree.v`. AUTHORIZED REPRESEN/T PRESIDENT AND CEO SCIF FORM 10217 (REV.4-2010) 1 2572 OLD OP 217