HomeMy WebLinkAbout04945 - DESERT HEALTHCARE FOUNDATION SMILE FACTORY R 20302 Desert Healthcare Foundation
The Smile Factory
AGREEMENT #4945
SUBRECIPIENT AGREEMENT R 20302, 4-3-02
THIS AGREEMENT (herein "Agreement"), is made and entered into this 8rh day of June ,
2004, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and
charter city, and the Desert Healthcare Foundation . (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 at sec. ("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.
1.4 Financial Reporting. Any Provider receiving or due to receive or due to
receiver $20,000.00 or more from the City during the 2003 — 2004 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 3151 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 DOLLARS ($15,000.00) (the "Contract Sum")
in accordance with the Budget attached hereto in Exhibit B and incorporated herein by this reference;
and as herein provided. The budget cost categories set out in Exhibit B are general guidelines and if
mutually agreed by both parties, may be amended administratively by no more than 10%, without the
requirement of a formal amendment to this Agreement, but in no event shall such adjustments
increase the Contract Sum. The Provider shall submit to the City 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 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:
Samantha Prior
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 Subcontractino 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
-2 -
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 three 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:
(a) Submit to City through its Community and Economic Development
Department monthly 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;
(a) 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
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 sea.);
(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
-4 -
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
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
Contractors 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:
Aleshire &Wynder, LLP
18881 Von Karman Avenue, Suite 400
Irvine, CA 92612-6525
TO PROVIDER:
Desert Healthcare Foundation
1140 N Indian Canyon Dr
Palm Springs CA 92262-48
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 this Agreement on the date first above
written.
pp CITY OF PALM SPRINGS, CALIFORNIA
Dated: �t R ®q
City ManagerRev
Jla �
City Clerk e w r r opproved by
APPROVED AS TO FORM: a a,
Aleshire&Wynder, LLP
City AttorneyA-444444=-
PROVIDER:
Desert Healthcare Foundation
J
Dated: By:
Name: Mark Matthews
Title: President
By:
Name: Richard A. Grundy
Title: Treasurer
(Corporations require two NOTARIZED signatures by attaching a California All-Purpose
Acknowledgement; one from each of the following categories:
A. Chairman of Board, President or any Vice President;AND
B. Secretary,Assistant Secretary, Treasurer,Assistant Treasurer, or Chief Financial Officer.)
SubredpAg"n[
-6 -
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
FIOEY15
Cn L IFm Po % A
1 19�Qa S17 �a oy beforeme, E:Ri\5,ES7 X Sl?SS INNS f�C9 p, ppeu '
C e Name and Trio of Officer(e.g.,"Jane Coe,Nci�y Publw")
personally appeared 8 L N G-P- U N 7a y
Name(s)of sgner(s)
❑personally known to me-OR roved to me on the basis of satisfactory evidence to be the person(M
whose name(g) is/ate subscribed to the within instrument
and acknowledged to me that he/sheHl3ey executed the
same in his/he6gheir authorized capacity(ie€), and that by
his/hefftMeir signature(g)on the instrument the person(4§),
,� OFFICIAL SEAL or the entity upon behalf of which the person(S) acted,
��::r� ;..e ERNEST I.SUSSMAN
NOTARY PUBLIC-CALIFORNIA executed the instrument.
'g - COMMISSION#1303075
O, FOa RIVERSIDE COUNTY WITNESS my hand and official seal.
My Commission Exp.May 31,2005 y
CIS Signature of Notary Public
OPTIONAL
Though the information below is not required bylaw,it may prove valuable to persons relying on the document and could prevent
fraudulent removal and reattachment of this form to another document.
Description of Attached Document � '� Y cm F t wLll-L Spf�lw S
Title or Type of Document: SLJ t' ff�EG)�l � 1 �CT� d1�N r
Document Date: 'bJ(E 1-7 1 "ate Number of Pages: S C7 1 t7
Signer(s) Other Than Named Above: l✓bus
Capacity(ies) Claimed by Signer(s)
Signer's Name: Signer's Name:
❑ Individual ❑ Individual
,]Corporate Officer ❑ Corporate Officer
Title(s): �4kCnStaRC—:la, Title(s):
❑ Partner—❑ Limited ❑ General ❑ Partner—❑ Limited ❑ General
❑ Attorney-in-Fact ❑ Attorney-in-Fact
❑ Trustee ❑ Trustee
❑ Guardian or Conservator ❑ Guardian or Conservator
❑ Other: Top of thumb here ❑ Other. Top of thumb here
I
Signer Is Representing: Signer Is Representing:
1
,I
1
01995 Natural Notary Association•8236 Remmet Ave.,P.O Box 7184•Canoga Park,CA 91309-7184 V Prod.No.5907 v Reorder:Call Tall-Free 1-800-876-6827
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
- - I
State of SO R �j
County of la l 17 R S 1 C
On :Tu"E l'7 before me, R1�7(�S/ �. SI�SSMFIN - 1 7�19�� �'{�5
ilt
Dale Name and Title of Officer(a.g.."Jane Doe,Nol ry Public")
personally appeared 11 FI1a M�ut�' < ,
Names)of Signer(s)
personally known to me—OR—❑proved to me on the basis of satisfactory evidence to be the person(g)
whose name(S) is/afe subscribed to the within instrument
and acknowledged to me that he/slaaghay executed the
same in his/-Iq�authorized capacity(iea),and that by
-- ----- --"�"' his/herl`M signature(s) on the instrument the person(s'),
OFFICIAL SEAL
ev , ERNESTI.SUSSMANqor the entity upon behalf of which the person(s) acted,
NOTARY PUSL.SUSSMFORNIA executed the instrument.
COMMISSION#1303075
RIVERSIDE COUNTY
My Commission Exp.May 31,2005 WITNESS my hand and official seal.
�r r
Signature of Notary Public _
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent
fraudulent removal and reattachment of this form to another document.
Description of Attached Document
ctTy aF %Pgl-M sl'P
Rffvo�
Title or Type of Document: i C 1 2?167(0 R6.7E I.9�NT
Document Date: Number of Pages: SL�1
Signer(s) Other Than Named Above: 1 (� I� �b V LP N GL R U Ul9 lJ
Capacity(ies) Claimed by Signer(s)
Signer's Name: �� Signer's Name:
❑ Individual ❑ Individual
Corporate Officer ❑ Corporate Officer
Title(s): G i Title(s):
❑ Partner—❑ Limited ❑ General ❑ Partner—❑ Limited ❑ General
❑ Attorney-in-Fact ❑ Attorney-in-Fact
❑ Trustee ❑ Trustee
❑ Guardian or Conservator O Guardian or Conservator
❑ Other: Top of thumb here ❑ Other: Top of thumb here
Signer Is Representing: Signer Is Representing:
0 1995 National Notary Assoclation•8236 Remmet Ave.,P.O.Box 7184,Canoga Park,CA RI309-7184 Prof.No 5907 Reorder.Call Toll-Free 1-600-876-6827
CITY OF PALM SPRINGS
EXHIBIT A
Scope of Services
Project/Activity Title: Project Number:
Desert Healthcare Foundation/Smile Factory Operations 0019
Name/Address of Provider:
Desert Healthcare Foundation
1140 N Indian Canyon Dr
Palm Springs, CA 92262-4872
O b i ectives/Activities
The intent of this program is to provide funds for the operation of The Smile Factory, a mobile dental
clinic, which visits elementary schools, providing free oral screening and dental health care services to
very low / low-income children qualified for the National School Lunch and School Breakfast Programs,
often referred to the School Free or Reduced Lunch Program. Each qualifying child will receive a basic
dental examination (i.e., x-rays, fluoride cleaning, and sealants on non-decayed teeth). In addition, some
of those children receiving basic dental care may need more extensive dental treatment (i.e., cavities,
infection, gum disease and other dental problems). This will be accomplished through dental scholarship
funding for very low to low income Palm Springs school-age children attending the Palm Springs Unified
School District who are not covered under a public insurance program. The Smile Factory will serve
2,536 children District-wide of which 634 are expected to be Palm Springs residents and 80 very low to
low income youth will receive scholarship assistance.
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 aprogrammatic and financial record keeping process.
TARGET
DATE ACTIVITY#1
On-Going Establish and maintain an efficient program process/procedure for proper record keeping.
Set-up a filing system for CDBG files only. Document and maintain all records related to
this program in a stable and secure location.
Objective 3: Advertise, market and publicize the Program to facilitate Positive promotion for all parties
(i.e. Provider. City, CDBG. etc.)_;
TARGET
DATE ACTIVITY#1
On-Going Draft a promotional piece and submit to City for approval. Advertise in the Desert Sun.
Submit final publication to City.
Objective 4: Enroll and income qualify at least a total of ei hc� tv (80) very low to low income Palm
Springs Elementary School-age children.
TARGET
DATE ACTIVITY#1
On-Going Provide The Smile Factory program opportunities and services to eligible Palm Springs
children living within the Palm Spring Unified School District. Applicants must meet
criteria in Exhibit D. 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 quarterly 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: Provide The Smile Factory program opportunities and services to eligible Palm Springs
children living within the Palm Spring Unified School District 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
07/15/02 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:
Desert Healthcare Foundation/Smile Factory Operations 0019
Name/Address of Provider:
Desert Healthcare Foundation
1140 N Indian Canyon Dr
Palm Springs, CA 92262-4872
BUDGETSUMMARY '
COST CATEGORY CDBG OTHER TOTAL
SHARE SOURCES COST
1 Personnel $ $214,225. $214,225.
2 Consultant/Contract Services $ $ $
3 Travel $ $ $
4 Space Rental $ $ $
5 Consumable Supplies— $ $36,560. $36,560.
Dental and Office
6 Rental, Lease or Purchase of $ $2,470. $2,470.
Equipment
7 Insurance $ $14,000. $14,000.
8 Other- $ $1,500. $1,500.
Telephone
$ $7,500. $7,500.
Trailer Expenses
$ $29,305. $29,305.
Allocated M mnt& General
Other- $15,000. $ $15,000.
Dental Scholarships
$16,000. $305,560. $320,560.
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.
Other funding sources include fundraising activities conducted by Denti-Cal and Healthy Families
Public Insurance Programs($50,000), Indian Wells Tennis Masters($60,000),Tour de Palm Springs
Bike Ride($30,000),Coachella Valley Classic Car Rally($10,000), and private donations.
The Subreciplent shall receive reimbursements in accordance with the aforementioned cost categories and
line items. The program will pay for 80 dental scholarships, including Basic Dental Exams at $129.00 per
child and Extensive Dental Treatment at an amount not to exceed $600 per child, both in accordance with
Dent!-Cal and Healthy Families preset amounts. Payments, approved by the Subrecipient and based upon
the actual number of income eligible scholarships awarded in the prior period,shall be paid by the 301h 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 2002 — 03 Program Year—July 1, 2002
through June 30,2003.
CITY OF PALM SPRINGS
EXHIBIT C
Insurance Inventory
Proiect/Activity Title: Project Number:
Desert Healthcare Foundation/Smile Factory Operations 0019
Name/Address of Provider:
Desert Healthcare Foundation
1140 N Indian Canyon Dr
Palm Springs, CA 92262-4872
INSURANCE INVENTORY
LIABILITY INSURANCE POLICY
Name of Provider's Insurance Company Special District Risk Authority
Effective Dates of Policy August 18 2004 to June 30 2005
Claims Made Policy / / Per Occurrence Policy
Limits of Liability $2.5 Million General Aggregate
Deductibles:
Per Occurrence $1 000.00
Annual Aggregate $2,500,000400
Additional Insured Endorsement (Certificate Holder) V/Yes ❑ No
Original Certificate of Insurance Attached VI
Yes ❑ No
WORKER'S COMPENSATION POLICY
Name of Provider's Insurance Company State Compensation Insurance Fund
Effective Dates 07/01/04 through 06/01/05
Limits of Liability $1,000,000 Per Occurrence
Underlying Coverage Limits
Original Certificate of Insurance Attached ❑ Yes VNo
ORIGINAL
SIM
•:::::
'• °""' SPECIAL DISTRICT RISK
., s .....
I�;_N
€ EN s MANAGEMENT AUTHORITY
SDRMA
1481 River Park Drive Suite 110 Sacramento, CA 95815-4501
Wednesday, August 18, 2004
Insured/Participant Certificate of Coverages
SDRMA/Desert Healthcare District This certificate is issued as a matter of
1140 North Indian Canyon Drib k,� �` '� V information only and confers no rights upon the
jc k ; certificate holder. This certificate does not
Palm Springs, Ca 92
amend, extend or alter the coverage afforded by
Certificate Holder �� `� li9 the policies listed below.
City of Palm Springs � Coverage Period
3200 E. Tahquitz Can r^VVa,/`' 8/18/2004 to 6/3012005
Palm Springs, CA 92262-6959
This is to certify that the coverages listed below have been issued to the participant named above for the 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 coverage afforded by the policies described herein is
subject to all the terms, exclusions and conditions of such policies.
Policy Dates: 7/1/2004 to 6/30/2005 LIMITS
Personal IniurV and Property Damage Liability Coverage-General
Company: Special District Risk Management Authority, Cov. $2,500,000 per occurrence/aggregate where
No. CVA0405V06E03-GL applicable
Personal Injury and Property Damage Liability Coverage-Auto
Company: Special District Risk Management Authority, Cov. $2,500,000 per accident
No. CVA0405VO6E03-AL
Public Officials and Employees Errors and Omissions Liability
Company: Special District Risk Management Authority, Cov. $2,500,000 per wrongful act/annual member
No. CVA0405VO6E03-EO aggregate
Property Coverage
Company: PEPIP Primary Carrier- Lexington, Policy No. $750,000,000 per occurrence
RKM103900348
Company: Special District Risk Management Authority Replacement cost for Scheduled Property
Description:
The City of Palm Springs, its officers and employees are hereby named as addtionally insured members with
respect to Desert Healthcare District's City Grant Application for CDBG Funds.
Cancellation
Should any of the above described policies be canceled before the expiration date thereof, the issuing company
will endeavor to mail thirty(30) days written notice to the certificate holder. But failure to mail such notice shall
impose no obligation or liability of any kind upon the company its agents or representatives.
Authorn d Signature v/
CITY OF PALM SPRINGS
EXHIBIT D
Beneficiary Qualification Statement
Project/Activity Title: Project Number:
Desert Healthcare Foundation/Smile Factory Operations 0019
Name/Address of Provider:
Desert Healthcare Foundation
1140 N Indian Canyon Dr
Palm Springs, CA 92262-4872
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 Gannet be included as household members.
2. Circle your combined gross annual income(Riverside-San Bernardino,CA-12110/01)
MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD:
INCOME 1 2 3 4 5 6 7 8
LEVEL
VERY LOW
INCOME $17,600 $20,100 $22,650 $25,150 $27,150 $50,150 $31,200 $33,200
Below 50%
LOW INCOME $28,150 $32,200 $36,200 $40,250 $43,450 $46,700 $49,900 $53,100
51—80%
MODERATE
INCOME $42,300 $48,350 $54,400 $60,400 $65,250 $70,100 $74,900 $79,750
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
❑ 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. Please check,for no,if you are a female Head of Household? ❑ YES ❑ NO
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 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
Quarterly Program Progress Report
Proiect/Activity Title: Project Number:
Desert Healthcare Foundation/Smile Factory Operations 0019
Name/Address of Provider:
Desert Healthcare Foundation
1140 N Indian Canyon Dr
Palm Springs, CA 92262-4872
PROGRAM PROGRESS REPORT Period:
DIRECT BENEFIT REPORT
• Number of First-Time Program Beneficiaries Serviced:
#of Households #of Persons
0-50%below 51-80%below 120%below
♦ Number of First-Time Female Headed Households:
♦ Counts by Race/Ethnicity:
White _ American Indian or Alaska Native AND White _
Black/AfdGan American Asian AND White_
Asian Black/African American AND White_
American Indian or Alaskan Native American Indian/Alaska Native AND Black/African American
Native Hawaiian or Other Pacific Islander Other:
HISPANIC/LATINO ETHNICITY: Mexican/Chicano Puerto Rican
Cuban Other:
ACCOMPLISHMENT NARRATIVE
LEVERAGING RESOURCES NARRATIVE
Signed Title Date
CITY OF PALM SPRINGS
EXHIBIT F
Request for Reimbursement
Project/Activity Title: Project Number:
Desert Healthcare Foundation/Smile Factory Operations 0019
Name/Address of Provider:
Desert Healthcare Foundation
1140 N Indian Canyon Dr
Palm Springs, CA 92262-4872
BENEFICIARY QUALIFICATION STATEMENT
AppFbvetl Currgnt Prior Total - Grant
Description GrantReimbursement Reimbursement- Y7D Balance
Amount - Perlod P.eriod(s) - Reimbursement .(Over/Under):_
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 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 50 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 furtheragrees 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 CDBG-
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 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.
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.