HomeMy WebLinkAbout2016-417-E DSS - Senior Care of Orange County - Adult Day Health DocuSign Envelope ID:� Contract#68-2014
Senior Care of Orange County, Inc.
Contract#_d8'20}4 Fiscal Year Begins_July 1, 2016 Ends June 30, 2017
This contract is hereby entered into by and between the Orange County Department of Social Services (the "County") and
Senior Care of Orange County,Inc.(the "Contractor")(referred to collectively as the"Parties"), The Contractor's federal tax
identification number or Social Security Number is
1. Contract Documents: This Contract consists of the following documents
(l) This contract
(2) The General Teiiiis and Conditions(Attachment A)
(3) The Scope of Work, description of services, and rate (Attachment B)
(4) Federal Certification Regarding Drug-Free Workplace&Certification Regarding Nondiscrim ination(Attachment C)
(5) Conflict of Interest(Attachment D)
(6) No Overdue Taxes (Attachment E)
(7) Certification of Transportation (Attachment J)
(8) IRS Federal Tax Exempt Letter wr5U1(o)(3}(Attachment K)
(9) State and Local Certifications(Attachment M)
(10) Outcomes and Reporting(Attachment N)
(11)Contract Determination Questionnaire
These documents constitute the entire agreement between the Parties and supersede all prior oral or written statements or
agreements.
2. Precedence Among Contract Documents: In the event of a conflict between or among the terms of the Contract
Documents and this Agreement,the terms of this Agreement shall control. In the event of a conflict between or among the
terms of the Contract Documents, then the Contract Documents with the highest relative precedence shall prevail. The
order of precedence shall be the order of documents as listed in Section 1,above,with Attachment A having precedence
over Attachment B and so forth. if there are multiple Contract Amendments, the most recent amendment shall have the
highest precedence and the oldest amendment shall have the lowest precedence.
3. Effective Period: This contract shall be effective on July 1, 2016 and shall terminate on June 30, 2017.
This contract must be twelve months or less.
4. Contractor's Duties: The Contractor shall provide the services and in accordance with the approved rate as described in
Attachment B, Scope of Work, and shall meet the requirements set forth in Attachment N, Outcomes and Reporting,
5, County's Duties: The County shall pay the Contractor in the manner and in the amounts specified in the Contract
Documents. The total amount paid by the County to the Contractor under this contract shall not exceed$20,000. This
amount consists of$20,000 in Federal (CFDA # ), State and County funds, $0 (source of other funds if
applicable).
[>[] a. There are no matching requirements from the Contractor.
[ 1 b. The Contractor's matching requirement is $ , which shall consist of:
| ] In-kind [ ] Cash
[ ] Cash and In-kind [ ] Cash and/or In-kind
The contributions from the Contractor shall be sourced from non-federal funds.
The total contract amount including any Contractor match shall not exceed $20,000.
6. RepnrtiogRegnirucoeots: Coonactorshu||connp}yvvi\hauditrcguircrueotxusdeoorihedinN.C.G.S. 8 143C'6-226t23
and 0MB Circular A-i33 and shall disclose all information required by 42 USC 455.104,or 42USC455.105,nr42D8C
455.106.
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DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
Contract/168-2014
Senior Care of Orange County, Inc
7. Payment Provisions: Payment shall be made in accordance with the Contract Documents as described in the Scope o
Work, Attachment B.
8. Contract Administrators: All notices permitted or required to be given by one Party to the other and all questions abou
the contract from one Party to the other shall be addressed and delivered to the other Party's Contract Administrator. Th4
name,post office address,street address,telephone number,fax number,and email address of the Parties'respective initia
Contract Administrators are set out below, Either Party may change the name, post office address, street address
telephone number,fax number,or email address of its Contract Administrator by giving timely written notice to the othe
Party.
For the County:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Denise Shaffer, Social Work Program Director Denise Shaffer, Social Work Program Director
Orange County Department of Social Services Orange County Department of Social Services
P.[). Box 8yDl 2501 Homestead Road
Hillsborough, Chapel-
(919)968-2000
` '
(919)968-2012
do runge.ne.us
Program Contact:
Renee Bynum, Adult Services Supervisor
Orange County Department of Social Services
P.0 Box 8\Bl
113 Mayo Street
Hillsborough,NC 27278
(919) 245-2881
hynunn@cuorungeoc.uo
For the Contractor:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Alvonia Baldwin Alvonia Baldwin
Florence Gray Soltys Adult Day Health Program Florence Gray Soltys Adult Day Health Program
P.O. Box 8181 105 Meadowland Drive
Ilillsborough,NC 27278 Hillsborough,NC 27278
(919) 245-2017
(919) 245-2018
a|b0|dwin(akoo,uou��ooux
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DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
Contract#68'2014
Senior Care of Orange County, Inc.
9. No Assignment or Sub-Contract: Contractor shall not sub-contract out any of the services provided for in this
Agreement or make any assignment of this Agreement(including rights to payments)without the prior written Consent of
the County as specified more fully in Attachment A, General Terms and Conditions.
10. Supplementation of Expenditure of Public Funds: The Contractor assures that funds received pursuant to this contract
shall be used only to supplement, not to supplant, the total amount of federal, state and local public funds that the
Contractor otherwise expends for contract services and related programs.Funds received under this contract shall be used
to provide additional public funding for such services; the funds shall not be used to reduce the Contractor's total
expenditure of other public funds for such services.
11. Disbursements: As a condition of this contract, the Contractor acknowledges and agrees to make disbursements in
accordance with the following requirements:
a. Implement adequate internal controls over disbursements;
b. Pre-audit all vouchers presented for payment to determine:
i. Validity and accuracy of payment
ii. Payment due date
iii. Adequacy of documentation supporting payment
iv. Legality of disbursement
c. Assure adequate control of signature stamps/plates;
d. Assure adequate control of negotiable instruments; and
e, Implement procedures to insure that account balance is solvent and reconcile the account monthly.
12. Outsourcing to Other Countries: The Contractor certifies that it has identified to the County all jobs related to the
contract that have been outsourced to other countries, if any. The Contractor further agrees that it will not outsource any
such jobs during the term of this contract without providing notice to the County.
13. Federal Certifications: Individuals and Organizations receiving federal funds must ensure compliance with certain
certifications required by federal laws and regulations. The contractor is hereby complying with Certifications regarding
Nondiscrimination, Drug-Free Workplace Requirements, Environmental Tobacco Smoke, Debarment, Suspension,
Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions, and Lobbying. These assurances and
certifications are to be signed by the contractor's authorized representative.
14. Relationship of the Parties: Contractor is an independent contractor of the County. Contractor represents that it has or
will secure,at its ow n expense,all personnel required in performing the services under this Agreement. Such personnel
shall not be employees of or have any contractual relationship with the County. All personnel engaged in work under this
Agreement shall be fully qualified and shall be authorized or permitted under state and local law to perform such services.
It is further agreed by Contractor that it shall obey all State and Federal statutes,rules and regulations which are applicable
to provisions of the services called for herein. Neither Contractor nor any employee of the Contractor shall be deemed an
officer, employee or agent of the County.
15. Termination: This Agreement may be terminated as specified in Attachment A, General Terms And Conditions.
10. Insurance Requirements:Contractor shall obtain,at its sole expense,all insurance as required in Attachment A,General
Terms And Conditions.
17. Indemnification: Contractor agrees to defend, indemnify,and hold harmless the County,for all loss, liability,claims or
expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any
person or persons caused in whole or in part by Contractor in accordance with Attachment A, General Terms And
Conditions. It is the intent of this Section that Contractor indemnify County to the full extent permitted by law.
18. Entire Agreement: The parties have read this Agreement, including the Contract Documents, and agree to be bound by
all of its terms,and further agree that it constitutes the complete and exclusive statement of the Agreement between the
parties.
19. Interpretation: When the context in which words are used in this Agreement indicates that such is the intent,words shall
in the singular number shall include the plural and vice versa. The masculine gender shall include the feminine and neuter.
Contract-General (07/10) Page 3 of5
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DocuSign Envelope ID:450Co831-88E2-408B-8r15~^r1C30u353*4
Contract 468-2014
Senior Care of Orange County, Inc
IN WITNESS WHEREOF,the County and the Contractor have been first duly authorized,have executed and entered into
this Agreement as of the day and year first above written.
SENTO Als14EgOPYORANGE COUNTY,INC.
7/29/2016
r
, ,
F7R5052R65RR443
Signature Date
Alvonia Baldwin Director
Printed Name Title
ORANGE COUNTY
DocuSigned by:
�� � �"° ^rL .
�/"kd^J� ``m»ww*�vu^.1 8/3/2015
[\onoioBam4i7 7(Mh Manager Date
Contract-General (07Y10) Page 4 of 5
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DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
a. The Contractor will provide participant files, reimbursement reques s, and all federal,
state, and county required documentation for financial assistance. Such documents
include but are not limited to |eonew, utility payment receipts, documentation of utilities
in the recipient's name, unit inspection reports, assurances of tenancy, and tracking of
financial assistance (amount and number of months) in a financial system and/or record
that allows the Contractor to comply with 0MB Circular A-133.
E. Use ESG funds only for approved eligible expenditures. For Housing Stability programs, these
expenditures include financial assistance (rental application fees, security deposits, last month's
rent, utility deposits, and utility payments), services(housing search and placement and housing
stability case management), and rent assistance. The Contractor may only spend funds in
categories that were applied for in the NC ES(J application that was submitted by the County to
the State prior to the contracting period June 1, 2015 lo December 3|, 20lj.
m°"vwnedby.
Di rector
e*B605-2e66eD443.' - �
Signature Title
senior care of orage county; Inc. 7/20/2016
&u� izuh"n Date
� -''� -�=-.�
(Certification signature should be same as Coiitract signature.)
Outcomes (06/04) Page 2 of 2
DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
ATTACHMENT A
GENERAL TERMS AND CONDITIONS
Orange County Department of Social Services
Relationships of the Parties the County or the Contractor,receiving services or benefits
under this contract shall be deemed an incidental
Independent Contractor: The Contractor is and shall be beneficiary only.
deemed to be an independent contractor in the performance
of this contract and as such shall be wholly responsible for Indemnity and Insurance
the work to be performed and for the supervision of its
employees. The Contractor represents that it has, or shall Indemnification: The Contractoragreesto indemnify and
secure at its own expense, all personnel required in hold harmless the County and any of their officers, agents
performing the services under this agreement. Such and employees, from any claims of third parties arising out
employees shall not be employees of, or have any or any act or omission of the Contractor in connection with
individoul contractual relationship with the County. the performance of this contract.
Subcontracting: The Contractor shall not subcontract any Insurance: During the term of the contract,the Contractor
of the work contemplated under this contract without prior at its sole cost and expense shall provide commercial
written approval from the County. Any approved insurance of such type and with such terms and limits as
subcontract shall be subject to all conditions of this may be reasonably associated with the contract. As a
contract. Only the subcontractors specified in the contract minimum, the Contractor shall provide and maintain the
documents are to be considered approved upon award of following coverage and limits:
the contract. The County shall not be obligated to pay for (a) Worker's Compensation - The contractor shall
any work performed by any unapproved subcontractor. provide and maintain Worker's Compensation
The Contractor shall be responsible for the performance of Insurance as required by the laws of North
all of its subcontractors. Carolina,as well as employer's liability coverage
with minimum limits of$500,000.00,covering all
Assignment: No assignment of the Contractor's of Contractor's employees who are engaged in any
obligations or the Contractor's right to receive payment work under the contract. If any work is sublet,the
hereunder shall be permitted. However, upon written Contractor shall require the subcontractor to
request approved by the issuing purchasing authority, the provide the same coverage for any of his
County may: employees engaged in any work under the
(a) Forward the Contractor's payment check(s) contrucL
directly to any person or entity designated by the (b) Commercial General Liability - General
Contractor, or Liability Coverage on a Comprehensive Broad
(h) Include ally person or entity designated by Form on an occurrence basis in the minimum
Contractor as a joint payee on the Contractor's amount of$|,00O,000.O0Combined Single Limit.
payment check(s). (Defense cost shall be in excess of the limit of
In no event shall such approval and action obligate the liability.)
County to anyone other than the Contractor and the (c)Automobile Liability Insurance: The Contractor
Contractor shall remain responsible for fulfillment of all shall provide automobile liability insurance with a
contract obligations. combined single limit of$500,000.00 for bodily
injury and property damage; a limit of
Beneficiaries: Except as herein specifically provided $500,000.00 for uninsured/under insured motorist
otherwise,this contract shall inure to the benefit of and be coverage; and a limit of$25,000.00 for medical
binding upon the parties hereto and their respective payment coverage. The Contractor shall provide
successors. It is expressly understood and agreed that the this insurance for all automobiles that are:
enforcement of the terms and conditions o this contract, (a) owned by the Contractor and used in the
and all rights of action relating to such enforcement, shall performance of this contract;
be strictly reserved to the County and the named (b) hired by the Contractor and used in the
Contractor. Nothing contained in this document shall give performance of this contract; and
or allow any claim or right of action whatsoever by any (c) Owned by Contractor's employees and
other third person. It is the express intention of the County used ill performance of this contract( non-
and Contractor that any such person or entity, other than owned vehicle insurunoe` ). Non-owned
General Terms and Conditions—(U6/l6) Page I of 5
DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
vehicle insurance protect employers when
employees use their personal vehicles for Termination Without Cause: The County may terminat
work purposes. Non-owned vehicle this contract without cause by giving 30 days written
insurance supplements, but does not notice to the Contractor,
replace,the car-owner's liabil ity insurance.
Termination for Cause: |f, through any cause, the
The Contractor is not required to provide and maintain Contractor shall fail to fulfill its obligations under this
automobile liability insurance on any vehicle—owoed` contract in a timely and proper manner, the County shall
hired, or non-owned -- unless the vehicle is used in the have the right to terminate this contract by giving written
performance of this contract. notice to the Contractor and specifying the effective date
(d) The insurance coverage minimums specified in thereof. |n that event,u|\fioisbeduc unfinished deliverable
subparagraph(a) are exclusive of defense costs. items prepared by the Contractor under this contract shall,
(e) The Contractor understands and agrees that the at the option of the County, become its property and the
insurance coverage minimums specified in Contractor shall be entitled to receive just and equitable
subparagraph (a) are not limits, or caps, on the compensation for any satisfactory work completed on such
Contractor's liab ility or obligations under this contract. materials,minus any payment or compensation previously
(1) ThcContractor nnuyobtain uvvuivero[any one urmore made. Notwithstanding the foregoing provision, the
' � of the requirements in subparagraph (a) by Contractor shall not be relieved of liability to the County
demonstrating that it has insurance that provides for damages sustained by the County by virtue of the
protection that is equal to or greater than the coverage Contractor's breach of this agreement,and the County may
and limits specified in subparagraph (a). The County withhold any payment due the Contractor for the purpose
shall be the sole judge of whether such a waiver of setoff until such time as the exact amount of damages
should be granted. due the County from such breach can be determined. In
(g) The Contractor may obtain a waiver of any one or more case of default by the Contractor, without limiting any
,
of the requirements in paragraph(a)by demonstrating other remedies for breach available to it, the County may
that it is self-insured and that its self-insurance procure the contract services from other sources and hold
provides protection that iw equal to or greater than the the Contractor responsible for any excess cost occasioned
coverage and limits specified in subparagraph(a). The thereby. The filing of a petition for bankruptcy by the
County shall be the sole judge of whether such a Contractor shall be an act of default under this contract,
waiver should be granted.
(h) Providing and maintaining the types and amounts of Waiver of Default: Waiver by the County of any default
insurance or self-insurance specified in this paragraph or breach in compliance with the terms of this contract by
is a material obligation of the Contractor and is of the the Provider shall not be deemed a waiver of any
essence of this contract, subsequent default or breach and shall not be construed to
(i) The Contractor shall only obtain insurance from be modification of the terms of this contract unless stated
companies that are authorized to provide such to be such in writing, signed by an authorized
coverage and that are authorized by the Commissioner representative of the County and the Contractor and
of Insurance to do business in the State of North attached to the contract.
Carolina.All such insurance shall meet all laws ofthe
State of North Carolina. Availability of Funds: The parties to this contract agree
(j) The Contractor shall comply at all times with all lawful and understand that the payment of the sums specified in
terms and conditions of its insurance policies and all this contract ix dependent and contingent upon and subject
lawful requirements of its insurer. to the appropriation, allocation, and availability of funds
(k) The Contractor shall require its subcontractors to for this purpose to the County.
comply with the requirements of this paragraph.
(I) The Contractor shall demonstrate its compliance with Force Majeure: Neither party shall be deemed to be in
the requirements of this paragraph by submitting default of its obligations hereunder if and so long as it is
certificates of insurance to the County before the prevented from performing such obligations by any act of
Contractor begins work under this contract. war,hostile foreign action,nuclear explosion,riot,strikes,
civil insurrection, earthquake, hurricane,tornado,or other
Transportation of Clients by Contractor:The contractor catastrophic natural event or act of God.
will maintain Insurance requirements if required as noted
under Article 7 Rule R2-36 of the North Carolina Utilities Survival of Promises: All promises,requirements,terms,
Commission. conditions, provisions, representations, guarantees, and
, warranties contained herein shall survive the contract
Default and Termination expiration or termination date unless specifically provided
General Terms and Conditions—(06/16) Page 2 of 5
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
otherwise herein, or unless superseded by applicable that comply with all applicable federal, state and
Federal or State statutes of limitation. local laws, regulations, and rules.
Intellectual Property Rights (b) Duty to Report: The Contractor shall report a
suspected or confirmed security breach to the
Copyrights and Ownership of Deliverables: All local Department of Social Services Contract
deliverable items produced pursuant to this contract are the Administrator within twenty-four(24) hours
exclusive property of the County. The Contractor shall not after the breach is first discovered, provided that
assert a claim of copyright or other property interest in the Contractor shall report a breach involving
such deliverables. Social Security Administration data or Internal
Revenue Service Data within one(1) hour after
Federal Intellectual Property Bankruptcy Protection the breach is first discovered.
Act: The Parties agree that the County shall be entitled to
all rights and benefits of the Federal Intellectual Property (c) Cost Borne by Contractor: If any applicable
Bankruptcy Protection Act, Public Law 100-506,codified federal, state, or local law, regulation or rule
at 11 U.S.C. 365 (n) and any amendments thereto. requires the Contractor give written notice of a
security breach to affected persons, the Contract
Compliance with Applicable Laws shall bear the cost of the notice.
Compliance with Laws: The Contractor shall comply Trafficking Victims Protection Act of 2000:
with all laws, ordinances, codes, rules, regulations, and The Contractor will comply with the requirements of
licensing requirements that are applicable to the conduct of Section 106(g)of the Trafficking Victims Protection Act
its business, including those of federal, state, and local of 2000, as amended (22 U.S.C. 7104)
agencies having jurisdiction and/or authority. By
executing this Agreement Provider certifies that Executive Order#24: It is unlawful for any vendor,
Provider has not been identified, and has not utilized contractor, subcontractor or supplier of the state to make
the services of any agent or subcontractor, on the list gifts or to give favors to any state employee. For
created by the State Treasurer pursuant to G.S. 147- additional information regarding the specific
86.58. requirements and exemptions, contractors are
encouraged to review Executive Order 24 and G.S. Sec.
133-32.
Title VI, Civil Rights Compliance: In accordance with
Federal law and U.S. Department of Agriculture(USDA)
Confidentiality
and U.S. Department of Health and Human Services
(HHS) policy, this institution is prohibited from
Confidentiality: Any information, data, instruments,
discriminating on the basis of race, color, national origin,
documents, studies or reports given to or prepared or
sex, age or disability. Under the Food Stamp Act and
assembled by the Contractor under this agreement shall be
USDA policy, discrimination is prohibited also on the
kept as confidential and not divulged or made available to
basis of religion or political beliefs.
any individual or organization without the prior written
approval of the County.The Contractor acknowledges that
Equal Employment Opportunity: The Contractor shall
in receiving, storing, processing or otherwise dealing with
comply with all federal and State laws relating to equal
any confidential information it will safeguard and not
employment opportunity.
further disclose the information except as otherwise
provided in this contract.
Health Insurance Portability and Accountability Act
(HIPAA): The Contractor agrees that, if the County
Oversight
determines that some or all of the activities within the
scope of this contract are subject to the Health Insurance
Access to Persons and Records: The State Auditor shall
Portability and Accountability Act of 1996, P.L. 104-91,
have access to persons and records as a result of all
as amended ("HIPAA"), or its implementing regulations,
contracts or grants entered into by State agencies or
it will comply with the HIPAA requirements and will
political subdivisions in accordance with General Statute
execute such agreements and practices as the County
147-64.7. Additionally,as the State funding authority,the
may require to ensure compliance.
Department of Health and Human Services shall have
access to persons and records as a result of all contracts or
(a) Data Security: The Contractor shall adopt and
grants entered into by State agencies or political
apply data security standards and procedures
subdivisions.
General Terms and Conditions—(06/16) Page 3 of 5
Docu Sig n Envelope I D:456CB831-89E2-409B-8715-A71C362353A4
subcontractors,complies with the requirements of Article 2
Record Retention: Records shall not be destroyed, of Chapter 64 of the NC General Statutes.
purged or disposed of without the express written consent
of the Division. State basic records retention policy Miscellaneous
requires all grant records to be retained for a minimum of
five years or until all audit exceptions have been resolved, Choice of Law: The validity of this contract and any of its
whichever is longer. If the contract is subject to federal terms or provisions, as well as the rights and duties of the
policy and regulations,record retention may be longer than parties to this contract, are governed by the laws of North
five years since records must be retained for a period of Carolina. The Contractor, by signing this contract, agrees
three years following submission of the final Federal and submits,solely for matters concerning this Contract,to
Financial Status Report, if applicable, or three years the exclusive jurisdiction of the courts of North Carolina
following the submission of a revised final Federal and agrees, solely for such purpose, that the exclusive
Financial Status Report. Also, if any litigation, claim, venue for any legal proceedings shall be Orange County,
negotiation, audit, disallowance action, or other action North Carolina. The place of this contract and all
involving this Contract has been started before expiration transactions and agreements relating to it, and their situs
of the five-year retention period described above, the and forum,shall be Orange County,North Carolina,where
records must be retained until completion of the action and all matters,whether sounding in contract or tort,relating to
resolution of all issues which arise from it,or until the end the validity,construction, interpretation,and enforcement
of the regular five-year period described above,whichever shall be determined.
is later. The record retention period for Temporary
Assistance for Needy Families (TANF) and MEDICAID Amendment: This contract may not be amended orally or
and Medical Assistance grants and programs must be by performance. Any amendment must be made in written
retained for a minimum of ten years. form and executed by duly authorized representatives of
the County and the Contractor.
Warranties and Certifications
Severability: In the event that a court of competent
Date and Time Warranty: The Contractor warrants that jurisdiction holds that a provision or requirement of this
the product(s) and service(s) furnished pursuant to this contract violates any applicable law, each such provision
contract("product"includes,without limitation,any piece or requirement shall continue to be enforced to the extent it
of equipment,hardware,firmware,middleware,custom or is not in violation of law or is not otherwise unenforceable
commercial software,or internal components,subroutines, and all other provisions and requirements of this contract
and interfaces therein) that perform any date and/or time shall remain in full force and effect.
data recognition function, calculation, or sequencing will
support a four digit year format and will provide accurate Headings: The Section and Paragraph headings in these
date/time data and leap year calculations. This warranty General Terms and Conditions are not material parts of the
shall survive the termination or expiration of this contract. agreement and should not he used to construe the meaning
thereof
Certification Regarding Collection of Taxes: G.S. 143-
59.1 bars the Secretary of Administration from entering Time of the Essence: Time is of the essence in the
into contracts with vendors that meet one of the conditions performance of this contract.
of G.S. 105-164.8(b)and yet refuse to collect use taxes on
sales of tangible personal property to purchasers in North Key Personnel: The Contractor shall not replace any of
Carolina. The conditions include: (a) maintenance of a the key personnel assigned to the performance of this
retail establishment or office; (b) presence of contract without the prior written approval of the County.
representatives in the State that solicit sales or transact The term "key personnel" includes any and all persons
business on behalf of the vendor; and (c) systematic identified as such in the contract documents and any other
exploitation of the market by media-assisted, media- persons subsequently identified as key personnel by the
facilitated, or media-solicited means. The Contractor written agreement of the parties.
certifies that it and all of its affiliates (if any) collect all
required taxes. Care of Property: The Contractor agrees that it shall be
responsible for the proper custody and care of any property
E-Verify furnished to it for use in connection with the performance
of this contract and will reimburse the County for loss of,
Pursuant to G.S. 143-48.5,the undersigned hereby certifies or damage to, such property. At the termination of this
that the Contractor named below, and the Contractor's contract, the Contractor shall contact the County for
General Terms and Conditions--(06/16) Page 4 of 5
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
instructions as to the disposition of such property and shall
comply with these instructions. Orange County Living Wage: Orange County is
committed to providing its employees with a living wage
Travel Expenses: Reimbursement, if provided in this and encourages agencies to which it provides funding to
Agreement, to the Contractor for travel mileage, meals, pursue the same goal. The County's living wage hourly
lodging and other travel expenses incurred in the standard, as adopted by the Orange County Board of
performance of this contract shall not exceed the rates County Commissioners annually, can be found in the
established in County policy. Orange County Budget Ordinance. To the extent possible,
Orange County recommends that the Contractor and all
Sales/Use Tax Refunds: If eligible,the Contractor and all subcontractors provide a living wage, as defined in this
subcontractors shall: (a) ask the North Carolina section, to their employees.
Department of Revenue for a refund of all sales and use
taxes paid by them in the performance of this contract, Signatures: This Agreement together with any
pursuant to G.S. 105-164.14; and (b) exclude all amendments or modifications may be executed
refundable sales and use taxes from all reportable electronically. All electronic signatures affixed hereto
expenditures before the expenses are entered in their evidence the intent of the Parties to comply with Article
reimbursement reports. 11A and Article 40 of North Carolina General Statute
Chapter 66.
Advertising: The Contractor shall not use the award of
this contract as a part of any news release or commercial
advertising.
General Terms and Conditions—(06/16) Page 5 of 5
DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
ATTACHMENT B
SCOPE OF WORK
Orange County Department of Social Services
Federal Tax Id. or SSN
Contract# _68'2814
A. CONTRACTOR INFORMATION
I. Contractor Agency Name: Senior Care of Orange County, Inc.
2. If clUfereni from Contract Administrator Information in General Contract:
Address
Telephone Number: _ Fax Number: ______£nnoil:_
3. Name of Program (s): Adult Day Health Service
4. Status: ( ) Public ( ){ ) Private, Not for Profit ( ) Private, For Profit
5. Contractor's Financial Reporting Year July ], 2Ol6 through June 30, 2017
B. Explanation of Services to be provided and to whom (include SIS Service Code): _The
Contractor wilLprovide Adult Day Health Servic (SIS Code 091)to clients of the Orange
County Department of Social Services. These services will include assistance with Activities of
Daily Living, health monitoring by an Ky4- and therapeutic recreational programs. The
Contractor is required to meet ajj goals and outcomes listed in Attachment N.
C. Rate per unit of Service (define the unit):
1. If Standard Fixed Rate, Maximum Allowable, (See Rates for Services Chart)
Minimum daily rate: $38.42/duy per client_
2. Negotiated County Rate.
D. Number of units to be provided:
E. I)etails of Billing process and Time Frames; The County will reimburse the Contractor for
services described in this contract up to the budgetary limits of the contract allotment. The
County will reimburse the Controrat a rate of$38.92/daylor approved services provided. For
reimbursement,the Contractor niust submit an original and two copies of an invoice by the fifth
of the month for the preceding month's expenditEes to the designated County Administrator.
The County will reimburse the Contractor monthly upon receipt of a complete and correctly filed
report.
The service(s) under contract with the Contractor are services for which a client may voluntarily
contribute to the cost. Policies regarding the solicitation and acceptance of voluntary
contributions are contained in Family Services Manual, Volume VI, Chapter III. If a client
Contract-Scope of Work(06/04) Page |of|
DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
voluntarily contributes to the cost of service,the County will inform the Contractor of the amount
of the contribution and of any subsequent changes. The Contractor vill establish a plan with the
client for accepting the contribution on at least a monthly hasis and when contributions are not
received within ten days of the agreed upon date, will notify the client in writing and send a copy
of the notification to the County. No other fees for services may be charged to the client. Client
contributions are to be reported monthly to the County.
F. Area<ohcxen/�d/D�h�oryai�c/$� Orange E
o"cuom�*^':
KtAbil COSfOIA, co..______,Nancy Coston, Social Services Director (Signature of Contractor)
8/2/2016 7/20/2016
' — —
(Date Submitted) (Date Submitted)
Contract-Scope of Work(06/04) Page 2of 2
DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
ATTACHMENT C
CERTIHCATION REGARDING DRUG [REF WORKPLACE REQUIRFMFNTS
AND CERTIFICATION REGARDING NONDISCRIMINATION
Orange County Department of Social Services
I. By execution of this Agreement the Contractor certifies that it will provide a drug-free workplace by:
A. Publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance is prohibited in the Contractor's
workplace and specifying the actions that will be taken against employees for violation of such
prohibition;
R. Establishing a drug-free awareness program to inform employees about:
(1) The dangers of drug abuse in the workplace;
(2) The Contractor's policy of maintaining a drug-free workplace:
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon employees for drug abuse violations
occurring in the workplace:
C. Making it a requirement that each employee be engaged in the performance of the agreement be
given a copy of the statement required by paragraph (A);
D. Notifying the employee in the statement required by paragraph (A) that, as a condition of
employment under the agreement, the employee will:
(1) Abide by the terms of the statement; and
(2) Notify the employer of any criminal drug statute conviction for a violation occurring
in the workplace no later than five days after such conviction;
E. Notifying the County within ten days after receiving notice under subparagraph (D)(2) from an
employee or otherwise receiving actual notice of such conviction;
F. Taking one of the following actions, within 30 days of receiving notice under subparagraph
(D)(2), with respect to any employee who is so convicted:
(I) Taking appropriate personnel action against such art employee, up to and including
termination; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or local health,
law enforcement, or other appropriate agency; and
Making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs(A), (B), (C), (D), (E), and (F).
Federal Certification - Drug-Free Workplace&Nondiscrimination rev. 06-2015
Page 1 of
DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
U. The site(s for the performance o[work done in connection with the mpecifioagreement are listed
below:
(Street address)
(City, county, state, zip code)
(Street address)
(City, county, state, zip code)
Contractor will inform the County of any additional sites for performance of work under this agreement.
False certification or violation of the certification shall he grounds for suspension of payment, suspension
or termination of grants, or government-wide Federal suspension or debarment
45 C.F.R. Section 02.5111 Section 4 CFR Part 85, Section 85.615 and 86.620.
CERTIFICATION REGARDING NONDISCRIMINATION
The Vendor certifies that it will comply with all Federal statutes relating to nondiscrimination. These
include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits
discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of
1972, as amended (20 D.S.C. §§1681-1683, and 1085'1686), which prohibits discrimination on the basis
of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.0 §794), which prohibits
discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C.
§§6l0l-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and
Treatment Act of 1972 (P.L 92-255), as amended, relating to nondiscrimination on the basis of drug
abuse; (0 the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation
Act of 1970 (P.L. 9}'616), as amended, relating to nondiscrimination on the basis of alcohol abuse or
alcoholism; (g) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. O83601 et seq.), as amended,
relating to nondiscrimination in the sale, rental or financing of housing; (h) the Food Stamp Act and
USDA policy, which prohibit discrimination on the basis of religion and political beliefs; and (i) the
requirements of any other nondiscrimination statutes which may apply to this Agreement.
DocuSigned by:
��---^ Di rector
Signature ` »�ew� x
^^ ' Title — -
senior care of orage county; Inc. 7/20/2016
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Federal Certification - Drug-Free Workplace&Nondiscrimination rev. 06-2015
Page 2 of 2
DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
~~~'' � ^—"'_`
cmcuaIgnEnvel^n m:s^A1000s-42un-45Aw-8m8-Anono7en0000
Contract WI-2014
Suicr Care of Onmge County,Inc
ATTACHMENT D
CONFLIcT OF INTEREST POLICY
Orange County Depaitnicul of Social Services
The Board nfDirectors/Trustees or other governing persons,officers, employees or agents are to
avoid any confliot of interest, even the appearance of a conflict of interest The Organization's
Board of Directors/Trustees or other governing body, officers, staff and agents are obligated to
always act in the best interest of the organization.This obligation requires that any Board member
or other gove o/ngyomon. ofUcer, employee ct agent, in the perforutance of Organization duties,
seek only the furtherance of the Organization mission. At all times, Board members or other
governing persons, officers, employees or agents, are prohibited from using thoi,jnb title, the
Orgnniaatioifs nemC or property,for private profit or iefrt
A. The Board members or other governing persons, officers, vmp|oyeex, or agents of the
Organization should neither solicit nor accept gratuities, favors, or anything of monetary value
from current or potential contractors/vendors,pomou receiving benefits from the Organization oi'
persons who may benefit from the actions of any Board member or other governing person,
officer,employee or agent.This is not intended to preclude horia-fide Organization fund roising raising-
activities.
B.A Board or other governing bndymom6e'mxy^viUh the approval of Boar or other governing
body, receive honoraria for lectures and tlier such activities wliile not acting in any official
capacity for the Organization, Officers may,with the approval of the Board or other governing
body,
receive honoraria for lectures and other such activities while oil personal days,
compensatory time, annual leave, or leave without pay. Employees may, with the prior written
approval of their supervisor, receive honoraria for lectures and other such activities while on
personal days, compensatory time, annual leave, or leave without pay. If a Board or other
governing body mombcr, officer,employee or agent is acting in any official capacity, honoraria
received in connection with activities relating to the Organization are to be paid to the
Organization,
C.No Board member or other governing person,officer,employee,or agent of the Organization
shall participate in the selection,award, or administration of a purchase or contract with a vendor
where,to his knowledge any of the following has a financial interest in that purchase or contract:
1. The Board member m other governing person,vffio:r,employee,oragent;
2. Any member of their family by whole or half b)ood, step or personal relationship or
relative-in-law;
3. An organization iii which any of the above is an officer,director,or employee;
4. A pern or organization with whom any of the above individuals is negotiating or has
)
any arrangement concerning prospective employmsiit or contructs,
D.Ditty to Diaclesure—Aisy conflict of interest,potential conflict of interestb or the appearance
of^conflict oFinterest is to be reported to tim Board or other governing body or one's supervisor
immediately.
E.Board Action--When a conflict of interest is relevant to a matter requiring action by the
Board of Direetorilfrustees or other goveening body,the Board member or other governing
person,effect',employee,or agent(person(s))must disclose the existence of the conflict of
b`tereutmndh*8|v*odmoppormnityuudionluooul\mu«teriul facts to the Board and members of
Conflict of(merest Policy(Oti/04) Page of 3
U �
DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
ovmSignsnmmn /mc^a1B0ms-4cun-4u^*-81an*ooaornooyoc
Contract 068-2014
Senior Care of'Orange County,inc.
committees with governing board delegated powers considerin the possible conflict of interest.
After disclosure of all material facts,and after any discussion with the person,he/she shall leave
the governing board or committee meeting while the determination of a conflict of interest is
discussed amid voted upon. The remaining board orcotnirmitlee nietnbors shall decide if a conflict
ol'interest exists. In addition,the person(s)shell not participate in the final deliberation or
decision regarding the matter under consideration and shrill leave the meeting during the
discussion of and vote of the Board of DireutorsiThistees or other governing body,
F. Violations of the Conflicts of Interest Policy -- If the Board of Directors/Trustees or other
governing body has reasonable cause to believe a member, officer, employee or agent has failed
to disclose actual or possible conflicts of interest, it shall inform the parson of the basis for such
belief and afford the person an opportunity to explain the alleged failure to disclose, If, after
hearing the person's response and after making further investigation as warranted by the
circumstances, the Board of Dirootors/Trustees or other governing body determines the member,
officer, employee or agent has failed to disclose an actual or possible conflict of inteicit, it shall
take appropriate disciplinary arid coriective action
G. Record of Conflict -- The minutes of the governing board and all committees with board
delegated powers shall contain:
1. The names of the i ' °of the persons who disclosed or otherwise were found to have an actual or
possible conflict of interest, the nature of the conflict of interest, any action taken to
determine whether conflict of interest was present, and the governing board's or
oommitteeodovisionnwmnbothouoonOlctufbunmminfao existed.
2. The names of the persons who were present for discussions and votes relating to the
transaction or arrangement that presents a possible conflict of interest,the content of'the
discussion, including any alternatives to the ttaiisection ce arrangement, and a record of
any votes taken in connection with the proceedings.
. /
� \
Approved by:
�\,
u�^ u~' a*
"pwr ` �/,
Name of Organisation
��
��
Signature of Organization Official
/��
10 '���
^ —
Date
` |
9navcvr]
CvnOkxoflm�ot Policy(06/04)
_ >
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
DocuSign Envelope ID:EAA1BOSE-4226-45M-815B-A3513979DD9OC
Contract 068.2014
Senior Care of Orange County,Inc.
NOTARIZED CONFLICT OF INTEREST POLICY
State of North Carolina
County of Orange
I, . , a , Notary Public for said County and Slate,
certify that _ E. , personally appeared before me this
day and acknowledged that he/she is A 1.12A-1- of
_ — and by that authority duly given and as the
— a —
act of the corporation, affirmed that the foregoing Conflict of Interest Policy was adopted by the
Board of Directors in a meeting held on the •5 day of oft -V-11
Sworn to and subscribed before me this 3 Cl day of afaLS7
1-eo-v,A4 CK" (Official Seal)
Notary Public
My Commission expires k 20 I' I
I r?t
E
01.A
r. e.
t.‘'S
E
Conflict o Interest Policy(06/01) Page 3 of 3
DocuSign Envelope ID:456CB831-89E2-409B-871 5-A71 C362353A4
DocuSign Envelope ID:EAA1B08E-4226-45A4-818B-A3569790090C
Contract 1/68-2014
Senior Care of Orange County.Inc,
ATTACHMENT it
OVERDUE TAXES
Orange County Deportment of Social Services
Instructions: Grantee/Provider should complete this certification for all funds received.Entity
should enter appropriate data in the yellow highlighted areas., The completed and signed form
must be provided to the County Department of Social Services.
Florence Gray Sottys Adult Day Health Program
Operated by: Senior core of Orange Coimty,Inc.
105 Meadowland Drive
Hillsborough,North Carolina 27278
06/24/2015
To Orange County Department of Social Services
Certification:
We certify that the Senior Core of Orange County'b;c does not have any overdue tax debts,as
defined by N.C.0.5, I 05-243,1E,at the federal, State,or local level. We further understand that
any person who makes a false statement in violation of N.C,G.S. 143C-4-23(c)is guilty of a
criminal offense punishable as provided by N.C.O.S, 143C-10-1(b),
Sworn Statement:
John Hammond and David Wilkerson]being duly sworn,say that we are the Board Chair and
Treasurer,respectively,of Seuior Care of Orange County; Inc of Hillsborough in the State of
North Carolina;and that the foregoing certification is true,accurate ancicoinplete to the best of
our knowledge and was made and subscribed by us. We also acknowledge and understand that
any misuse of State funds will be reported to the appropriate authorities for further action.
//c/i66. )144-te4,7451x
a, 'd Chi
• .1 • :7
0g
re; rer
94
Sworn to and subscribed before me on the day of the date of said certification. vv•
''',0111111111 L"'''
.416, 1.-1.KAA'.•1/4 My Commission Expires:Fe ) 84
otary ignature and Seal)
a;odivni
G.S. 105-243.1 defines:Overdue tax debt.—Any part of a tax debt that manilas unpaid 90 days or mere alter the
notice of tinal assessment was nailed to the taxpayer.The term does not include a tax debt,however,if the taxpayer
entered Into an installment agreement for the tax debt under a& 105-237 within 90 days after the native of ling
assessment was mailed and hes not tailed to make any payments due under the installment agreement,"
Overdue Taxes—(07/08) Page 1 of
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
POMMMMMIIIMM■W A MP....
DocuSIgn Envelope ID: EAA1B08E-4226-45A4-818B-A35B979DD90C
11/10/2000 99:53 9197328173 RC NE/GHBOURS CO INC PAGE 02
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'W. O. ADX 2500 .
cumnumx, OH 49201 . .
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'reployer Identifitationthsnbert
Date' JUL 22 26% .
MN: .
.t;
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'. ,.. ,. . ... 1703159003034
. . =TOE. MRS OF ORS COUNTY MC Coutaot Ferzont— ,
EIS /CAMILA= VA ATE 400 v.sWXA MK lip 31522
RILLSOORMOR, SC 272/0 Contact Telephone Number:
. ' (077) 029-550o
Aceolint-ine Period Rnding:
. . qtEE 30
POblic Charity St-et-est
:4 1.70(3) (1) IA) (vi,
Form 990 Requiredr
YE
gffective Date of Exemptionl
04 MRCS 29, 2004 .
, att71,1;LIYAG,' K.,:taue, TliAl . Q , Conti/1=11i= Deductibility:
, .
xtmv.er7,
.'tr. Iffm: :: Y.,::.,r,z ' hdvance Ruling Ending DOet . .
■':'1”ii" f'. " .: . ' mum 30, 2005
•, .
, near Applicant:
• ,P.,,
:,,,... 0: ,wel 474, ,,-1404169, teljhform you that upon review of your application for tax.
4Jo ark, 'ev, omempr OntuivoiAhave.detarmined that you are exempt from Eaderal inoometax •
(ANYtt-rut r .,,.. neth.lea-S132(001 ,of the Internal nevecue Code. Contributions to you urn :
. 'e0v : dednatible:'under cootie-a l7o a; the Code. You are also qualified to woceive ,
61.■';*
v Fir taledadeestblettbaguestail-clevieve transfere or gifts under section 205, 2106
!,kr vrUe ' arT2522'breftamerlx6db.r:q8acaueo this letter could help resolve any questions
-.roalwrituxqurene...exlmeptk.stetes, you shOuld keep it in your permanent recede.
. ..!. 1:4; 0; 4.4010egenisationaexempL under erection 150110431 0Z tas Code aro further elesoified
as,Joithbr quhlic charities or private fonadationa. During your adianos ruling
'period, you will be treated en a publics charity. Your advance ruling period i..
,le - begins with the effective date of your exemption and engin edth advance ruling
ending date shown du the heading of the letter.
. .
Shortly before the.end of your advance ruling period, we will Amid you poxm ..
0734„ Support Schedule tor Advanne Poling Period. You will hAvo 90 days atter -
. the end of your Advance ruling'pOriod to return the completed farm. We will
them metity 'M ,A in writing, about your public obnrity otatun. .
:
.pleazia see enclosed Tntormation fox Exempt Organizations Under Section .
g01(c) (3) for soma belpful information about youx responsibilities as an exempt
organisation.
. . .
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Dotter 104S (DO/02)
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DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
Florence Gray 5oltys Adult Day Health Program
(Operated,* 5erilor Care of Orange Caufity, /Re)
105 fileadowland Drive
Hillsborough, North Carolina 2 7278k
Jahn Harnmand, President
Wavy Fspersen Wee President
Dowd aMerssnP, Treasurer
Karen Dania4 Secretary
(9119)2-95-2017
Fax(919)2q5-207,5'
Date: June 28,2016
To: Orange County Department of Social Services
r°m: Alvonia.Baldwin,
. ,
Executive Director
Re: Overdue Taxes Statement and Conflict of Interest Policy
The Florence Gray Soltys Adult Day Health Program, operated by the Senior Care of Orange
County, Inc., is a non profit agency. Senior Care of Orange County Inc; does not have any overdue tax
debts. We are waiting for Orange County DSS to send their"Overdue Tax Statement"for the new
fiscal year of 2016-2017 no later than July 5, 2016 for the Board Chair and Treasurers signatures and a
notary's stamp as the sworn statement. In the meantime, please accept this letter, last year's copy of
attachment E along with Senior's 990 indicating last year's taxes were filed.
If additional information is needed, please contact me at 919-245-2017 and in my absence, please
contact the Director Substitutes, Kristin Price and or Tamara Griffin.
Thank you.
• Couitlielty tAACtn,c-Q,
••••••
ConwearaviallhiStaie of
The foregoing ic4ShgricA*IR acknowledged bare
meths 11 ettv 20/c' '
by, A erc\ cK,
(nirlis of wson seeking ecknowiedgemet)
6 ,
Cc ASHLEYLAYNE H.BELL
Nary
Noteiy
Dave Wilkerson My Commbeen V--1
Atamanoe Co Public Egibek 0
North Cantina
Kristin Price My Commission Expires Feb.22,2021
Tamara Griffin
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
ATTACHMENT
CERTIFICATION REGARDING TRANSPORTATION
Orange County Department of Social Services
By execution of this Agreement the Contractor certifies that it will provide safe client
transportation by:
1. Insuring that all drivers (including employees, contractors, contractor's employees, and
volunteers) shall be at least 18 years of age;
2. Insuring that all drivers (including employees, contractors, contractor's employees, and
volunteers) shall be licensed to operate the specific vehicle used in transporting clients in
accordance with Chapter 20-7 of the General Statutes of North Carolina and the Division
of Motor Vehicle requirements;
3. Insuring that all vehicles transporting clients shall have at least the minimum level of
liability insurance appropriate for the type of vehicle as defined by Article 7, Rule R2-36
of the North Carolina Utilities Commission;
4. Insuring that the contractor shall have written policies and procedures regarding how
drivers handle and report client emergencies and/or vehicle crashes involving clients to
contractor and how contractor notifies the County Department of Social
Services;
5. Insuring that no more than one quarter of one percent of all trips be missed by the
contractor during the course of the contract period; (Medicaid only)
6. Insuring that that no more than five percent (5%) of trips should be late for recipient drop
off to their appointment per month; (Medicaid only)
7. Contractor will maintain records documenting the following (County may require
contractor to provide)."
a. Valid current copies of Drivers License for all drivers;
b. Current valid Vehicle Registration, for all vehicles transporting clients;
c. Driving records for all drivers for the past three years and with annual updates;
d. Criminal Background checks through North Carolina Law Enforcement or NC1C
prior to employment and every three years thereafter;
e. Alcohol and Drug Testing policy to meet the Federal Transit Authority guidelines.
8. Disclosing, at the outset of the contract, upon renewal and upon request, any criminal
convictions or other reasons for disqualifications from participation in Medicare,
MedioidgperdiTitle XX programs (signature on this form confirms this statement).
Di rector
Bt7052B15-5B&W37
Signature Title
senior care of orage county; Inc. 7/29/2016
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Transportation Certification(06/16) Page 1 of 1
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
ATTACHMENT K
501(c)(3) and TAX EXEMPT STATUS
Orange County Department of Social Services
What is a Private Non Profit Agency?
Answer: A private non profit is an organization that is incorporated under State law and whose
purpose is not to make a profit, but rather to further a charitable, civic, religious, scientific, or
other lawful purpose. The Secretary of State's office grants corporate status to organizations in
North Carolina.
What is a 501(c)(3) designation?
Answer: When the agency becomes a state private non profit corporation, it can then apply for
501(c)(3) designation through the IRS. Once the IRS grants 501(c)(3) status, the organization is
exempt from certain taxes and any donations to the charitable organization are tax deductible.
Many individuals and organizations prefer to make donations to 501(c)(3) private non profits.
Who can obtain a 501(c)(3) designation?
Answer: Any organization or group can apply for 501(c)(3) status, provided their charter or
mission focuses on the non profit's objective.
Another option is to apply for a 509(a)(1) status which falls under the 501(c)(3) umbrella. Being
a 509(a)(1) designates an organization as a tax-free public charity that receives most of its
support from a governmental unit or from the general public. Becoming a 509(a)(1) provides
public recognition of tax-exempt status, advance assurance to donors of deductibility of
contributions, exemption from certain State and federal taxes, and non profit mailing privileges.
Organizations that typically qualify are churches, educational institutions, hospitals, and
governmental units.
To learn more about non profits, visit www,irs.gov, or call the tax-exempt helpline at 877-829-
4933.
How does a Private Non Profit obtain Tax Exempt Status?
A private non profit must apply to the IRS for tax exempt status. To qualify, applicants must
complete and submit to the IRS Form 1023. Once federal tax exempt status is granted, the
private non profit applies for State tax exempt status by completing Form CD-435 and
submitting it to the N. C. Department of Revenue.
Please attach proof of 501(c)(3) or IRS tax-exempt status to this page.
DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
°` .^..^. ,.E^,T ~.
STATE AND LOCAL CERTIFICATION
Contractor Certifications Required by North Carolina Law
Orange County Department of Social Services
Instructions
The person who signs this document should read the text of the statutes listed below and consult with counsel and other
knowledgeable persons before Signing.
• The text of Article 2 of Chapter 64 of the North Carolina General Statutes can be found online at:
• The text of6.8. |05'l64.8(h)can be found online at:
hm//www.ncta.state,nc us/E:nac ted tnslation/Statutes/PDF/By$eaion/C haver I 05/GS j 05-164 8,01
• The text of6.6. l43-48.5 (8.L. 20\3'4l8, s. 2.(d))can ho found online at:
• The text of G.S. 143'59.1 can be found online at:
• The text ofG.8. 143-59.2 can be found online at:
4 ' D
• The text of G,S. 147-33.95(g) (S.L. 2013-418, s. 2. (e))can be found online at:
• The text of Orange County Living Wage Cont actor Policy which is attached to this document.
Certifications
(1) Pursuant to G.S. 143-40,5, the undersigned hereby certifies that the Contractor named below, and the
Contractor's subcontractors, complies with the requirements of Article 2 of Chapter 64 of the NC General
Statutes, including the requirement for each employer with more than 25 employees in North Carolina to verify
the work authorization of its employees through the federal E-Verify system." E-Verify System Link:
www,uscis,gov
Local government is specifically exempt from Article 2 of Chapter 64 of the North Carolina General Statutes.
However, local government is subject to and must comply with North Carolina General Statute O153A'99.1.,
which states in part as follows:
Counties Must Use 6-Verify. -Each county shall register and participate in E-Verify to verify the work
authorization of new employees hired to work in the United States.
(2) Pursuant to G.S. 143-59.1(b), the undersigned hereby certifies that the Contractor named below is not an
"ineligible Contractor"as set forth in G.S. 143-59.1(a)because:
(a) Neither the Contractor nor any of its affiliates has refused to collect the use tax levied under Article 5 of
Chapter 105 of the General Statutes on its sales delivered to North Carolina when the sales met one or
Contractor Certifications Required by North Carolina Law Page I of
ENE&
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
more of the conditions of G.S. 105-164.8(b); and
(b) [check one of the following boxes]
*
Neither the Contractor nor any of its affiliates has incorporated or reincorporated in a "tax haven
country" as set forth in G.S. 143-59.1(c)(2)after December 31, 2001; or
_
The Contractor or one of its affiliates has incorporated or reincorporated in a "tax haven country"
_
as set forth in G.S. 143-59.1(c)(2) after December 31, 2001 but the United States is not the
principal market for the public trading of the stock of the corporation incorporated in the tax
haven country,
[
(3) Pursuant to G.S. 143-59.2(b), the undersigned hereby certifies that none of the Contractor's officers, directors,
or owners (if the Contractor is an unincorporated business entity) has been convicted of any violation of Chapter
78A of the General Statutes or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 years
immediately prior to the date of the bid solicitation, .
(4) The undersigned hereby certifies further that:
(a) He or she is a duly authorized representative of the Contractor named below;
(b) He or she is authorized to make, and does hereby make, the foregoing certifications on behalf of the
Contractor; and
(c) He or she understands that any person who knowingly submits a false certification in response to the
requirements of G.S. 143-59.land -59,2 shall be guilty of a Class 1 felony.
(5) Pursuant to the Orange County Living Wage Contractor's Policy:
(a) The undersigned certifies that the Contractor pays the employees who perform services under this contract a
living wage (in Orange County currently $13.15 perfhr.) Check here * if contractor pays employees
performing under this contract a living wage. If Contractor does not pay employees a living wage, what is the
wage that employees performing services under this contract paid
senior care of orage county; Inc.
Contract or sDIktlicl'Ud bY:
7/29/2016
236-5Er44 .
Signature o ,ontrac or s Authorized Agent Date
Al voni a Baldwin Director
DocuSiomed by:
Printed a.me ol uontractor's Authorized Agent
r
Title
office Manager
Signature 7 Witness i r
E il 9 447 .
Title
Kristin Price 7/29/2016
Printed Name of Witness Date
The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and date
this document immediately thereafter,
Contractor Certifications Required by North Carolina Law Page 2 of 2
DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
Section 1: General Government and Administra oo
Policy 10.0: Living Wage Contractor Policy
Reviewed by: County Attorney/County Manager
Approved by: County Manager
Original Effective Date: April 21, 2016
Revisions:
Policy Statement
It is the policy of Orange County to ensure its employees, and all individuals who provide services for Orange County, are
paid a living wage.
Purpose
- all vendors and contractors pay living wage to all employees who work pursuant to a contract
To encourage v perform
with Orange County.
Applicability
Applies to all Orange County contracts and purchases.
Policy
1111 Living Wage
lU.|.) Orange County is committed to providing its employees with a living wage and encourages all contractors
and vendors doing business with Orange County to pursue the same goal. Orange County's living wage is $13.15
per hour. To the extent possible, Orange County recommends that contractors and vendors seeking to do business
with Orange County provide a living wage to their employees.
10.1.2 Prior to final execution of a contract with Orange County all contractors and vendors seeking to do
business with Orange County shall submit to the County's representative a statement indicating whether those
employees who will perform work on the Orange County contract are paid at least the living wage amount set out
above. If such employees do not make at least the living wage amount set out above the contractor or vendor
shall indicate in the statement the actual amount paid to such employees. For bid pr jects this statement should
be submitted as part of the bid packet.
This policy may be reviewed annually and updated as needed by the Manager's Office
Contractor Certifications Required by North Carolina Law Page 3 of 3
����'
DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
Contract#68-2014
Senior Care of Orange County, inc.
ATTACHMENT N
OUTCOMES AND REPORTING
Orange County Department of Social Services
By signing and submitting this document,the Contractor certifies that it agrees to the following:
|. The Contractor agrees to participate in program, fiscal and administrative monitoring and/or audits,
making records and staff time available to Federal, State and County staff.
2. The Contractor agrees to take necessary steps for corrective action, as negotiated within a corrective
action plan, for any items found to be out of compliance with Federal, State, and County laws, regulations,
standards and/or terms of the Contract.
3. The Contractor agrees that continuation of and/or renewal of this Contract is contingent on meeting the
following requirements. The Contractor agrees to:
A. Provide Adult Day Health Services, according to the North Carolina State Standards for
Certification, to clients referred by the County.
B. Comply with all State licensing standards, all applicable accrediting standards and any other
standards or criteria established by the North Carolina Department of Health and Human
ervices to assure quality of services
C. Maintain all financial and program records for a period of three years from the date of final
payment under this agreement for inspection by the County,the Area Agency on Aging and the
Comptroller General of the United States, or any of their duly authorized representatives. If any
claim, litigation, negotiation, audit or other action involving the Contractor's records has been
started before the expiration of the three-year period, the records must be retained until
completion of the action and resolution of all issues that arise from it
.
D. Maintain appropriate program records, client case files which document the provision of the
agreed upon service(s); and maintain a valid authorization for services for each client
determined to be eligible by the County and authorized by the County for service(s) provided
under this agreement.
E. Furnish financial and program data as required to document the basis for the reimbursement rate
and to document that applicable standards have been met.
F. Be responsible for compliance with the audit requirements of the Department of Health and
Human Services.
a. An annual audit is to be performed in accordance with OMB Circular A-110 by an
"independent auditor." "Independent auditor" means either:
i. A state government auditor for the I)epartment of Human Resources or the
Department of Administration, Office of the State Auditor; or
ii. A certified public accountant.
b. Upon completion of the audit,a copy of the audit report must be forwarded to the
County.
G. Notify the County of participant absences of more than 5 days.
H. Notify the County, in a timely manner, of significant changes in the clients' conditions or
situations.
Outcomes (06/04) Page 1 of
DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
Contract#68'20|4
Docu»m°ed^,: Senior Care of Orange County, Inc.
Di rector
`^—=7*s052136.5aB44,
Signature Title
senior care of orage county; Inc. 7/29/2016
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Outcomes (06/04) Page 2 of 2
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
North Carolina
Department of Health and Human Services
Division of Aging and Adult Services
This is to Certify that a Certificate is hereby granted to operate an:
Adult Day Care/Day Health Center
known as
Florence Gray Soltys Adult Day
Health Program
located in the County of
Orange, North Carolina.
This Certificate is issued subject to the statutes of North Carolina and the Rules
adopted by the North Carolina Social Services Commission, is not transferable, and
shall expire January 31, 2017 unless revoked before that date.
Capacity: 29 Certification Status: Full
.,,,,'' ,i. STATE c;0' 4.■,‘
opyX).
t‘
1,.. ,tr ) 4. _ ,.ii.
Suzanne P.Merrill,Division Director,Division of Aging&Adult
Ik...t. ti Services
i
:I
...0 .."
AI
•; • I , ...:. •■•0; . ;..e,
if February 1, 2016
111 if.A...._41PRIt 12.ITS 4,. x Date Issued
‘•,, ,-7 QUAM
''—"..........,...:;.------
This Certificate Remains the Property of the State
DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
Client#: 955852 04SEmKOCAR1
ACORD= CERTIFICATE OF LIABILITY INSURANCE DATE(MM/nD/Yr n
'
O7/1W2416
TillS 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 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
BB&T Insurance Services, Inc. PHONE 888 743-2217 °°.w*.888V%7g881
414 Gallimore Dairy Road E-MAIL
ADDRESS:��~�__
Suite INSURER(S)AFFORDING COVERAGE NAIC»
Greensboro, NC 37409 ����^.Evanaton|nsurancoCnmpany 35378
INSURED --- --- --- --- -- �i��po,�|nmu,enoe���`pany ---- 36684
���!"a.
Senior Care of Orange County Inc
INSURER C; __
Attn Day Health Cent
INSURER o.____
105 Meadowland Dr.
INSURER s.
Hillsborough, NC 27270'0181
INSURER,. ---
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 rEwmo,
EXCLUSIONS AND SUCH POLICIES. LIMITS SHOWN MAY REDUCED o, pmo CLAIMS.
___
pSvr--- -------' ---�v�Svam' ------- u��
LTR �Psm,woun^pCE /NmamVD POLICY M�mo�'v` MMme, ,
A COMMERCIAL SM914951 `+7/1�/�V1� 07/1�/2V1 EACH� OCCURRENCE
X CLAIMS-MADE � OCCUR B���_� �� $50�oo
) |gyPuDed:5.V00 MED EXp(Any one person) l$5,000
pExS�A.ummINJURY $1,000,000
srwL^oencamcum�mppussPER; , GENERAL AGGREGATE $3.00�000
.....
PRO-
_
pnucr mn pnoouCTI-cm*pmp^GG $
�
OTHER:
--- --- — --- --- --- SINGLE ���
AUTOMOBILE LIABILITY � 'r^aymeno »
ANY AUTO / EDGILY INJURY(Per person) $
1 ALL OWNED i I SCHEDULED accident) 5 _______
AUTOS AUTOS
HIRED AUTOS | NON-OWNED PROPERTY DAMAGE p_AUTOS
s
UMBRELLA ��N OCCUR EACH OCCURRENCE
— |
EXCESS u�� CLAIMS-MADE � AGGREGATE
_
--� , |�
--- ----- ---- -- . � ---- or�' ---
B WORKERS COMPENSATION NCARp305328 ^2/0g0016 O2/U0201� �_����
^wo EMPLOYERS'LIABILITY ,� |
'" s'�����cposwr $500,000
/�������������[�nc��srunvs�~| u/^ �
* ^ ' . c.L.o/Sc^Sr-EA EMPLOYEE $509,000_
���"�� ERATIONS below � � E.L.DISEASE-POLICY LIMIT $500,000
A Sexual Acts SM914951 "7/13/2016 07/13Q01 $100,000 occurence
Liablity $300,000 aggregate
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACOpo`o,.Additional Remarks Schedule,may be attached if more space is required)
Professional Liability'Po|.#SMg14951
Professional Liability Limit#1: 1.800.000 Ded.#1: $5.000.00
Limit#2: 3,000,000
Retroactive Date:July 13, 2005 for GL and PRO
(See Attached Descriptions)
.
CERTIFICATE CANCELLATION
` .
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
'
Senior Care o Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Attn: Day Health Center ACCORDANCE WITH THE POLICY PROVISIONS.
For Information Only ,
105 Meadowland Drive AUTHORIZED REPRESENTATIV
Hillsborough, NC 27378'8181 ��
. � _ m �
@1yov-2v1*Aoono CORPORATION,All rights reserved.
Acunoes(2v4/o1) 1 of 2 The ACORD name and logo are registered marks of ACORD
#S16521611/M16521526 SO5
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
DESCRIPTIONS (Continued from Page 1)
**Workers Comp Information**
Proprietors/Partners/Executive Officers/Members Excluded:
Jack Chestnut, president
Jerry Passmore,secretary
Ed Flowers
Mary Ann Peter
Food and Beverages consumed on insured's premises are covered under the operations coverage of the General
Liability policy.
SAGITTA 25,3(2014/01) 2 of 2
#S16521611/M16521526
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
North Carolina Workers' Compensation Insurance Plan
B Riverport Insurance Co MCCI Carrier Code 27995
Administered by Berkley Assigned Risk Services
P.O.Box 59143,Minneapolis,Minnesota 55459-0143
ASSIGNED RISK SERVICES Toll Free(88B)548-7431 Fax(866)215-8118
www.berkleyassignedrisk.com poticyservices@berkleyrisk,com
ENTITY AND LOCATION SCHEDULE
1. The Insured: Policy Number: NCARP305328
Tax ID#:
Senior Care of Orange County Policy Period: From: 02/0812016
105 Meadowlands Drive To: 02/0812017
Hillsborough, NC 27278 Endorsement Date 02/08/2016
Date of Mailing: 01/08/2016
Entity Information Effective Expiration
Insured Name: Senior Care of Orange County February 8,2016 February 8, 2017
Federal ID Number: February 8, 2016 February 8, 2017
Entity Type: Corporation February 8, 2016 February 8, 2017
Location No, Location Address Effective Expiration
1 105 Meadow land Dr February 8,2016 February 8, 2017
Hillsborough, NC 27278
Agency Name and Address
BB&T Ins Services inc
414 Gallimore Dairy RD Ste F
Greensboro, NC 27409 WC990601
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
ii
klite
(:(- 410.AtliMbaft
40/14P4
N 0 R T II C A R 0 I, I N A NCACC Risk Management Pools
ASSOCIATION 01, COUNTY COMMISSIONERS Liability and Property
NCACC LIABILITY AND PROPERTY POOL
COVERAGE CONTRACT
GENERAL DECLARATIONS
Participant SENIOR CARE OF ORANGE COUNTY, INC.
Address 105 MEADOWLAND DRIVE
HILLSBOROUGH,NC 27278
Contract number LP-SE-525-16
Contract Period July 1, 2016 to July 1, 2017
Effective Time 12:01 A.M., Eastern Daylight Time
Pool Sponsored by North Carolina Association of County Commissioners
215 North Dawson Street
Raleigh, North Carolina 27603
Pool Adminstered by North Carolina Association of County Commissioners
215 North Dawson Street
Raleigh, North Carolina 27603
Claims Administrator Sedgwick Claims Management Services, Inc.
5260 Parkway Plaza Boulevard, Suite 190
Charlotte, North Carolina 28217
NCACC RMP General Declarations Page
Edition 7/1/2014 Issued
6/27/2016
DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
NORTH� ■~~ (— m u n L I m A NCACC Risk Manag
ement Pools
Liability and Property
ASSOCIATION OF COUNTY COMMISSIONERS
SECTION 1
PROPERTY & INLAND MARINE COVERAGE
CONTRACT DECLARATIONS
Participant SENIOR CARE OF ORANGE COUNTY, INC.
Contract Number LP'SE'526'16
Contract Period July 1, 2016 to July 1, 2017
Effective Time 12:01 A.M., Eastern Daylight Time
SCHEDULE OF PROPERTY AND INLAND MARINE LIMITS
Real and Personal Property coverage: Blanket Limit $0
Inland Marine coverage: Blanket Limit $0
(including, but no limited to: Mobile equipment, voting machines,
mobile radios, telephone equipment, communications towers,
landfill equipment, and miscellaneous equipment)
Dogs or Horses: Declared and Schedule values) $0
DEDUCTIBLES
Real and Personal Property per Occurrence &1.000
,Inland Marine per Occurrence $1,000
Flood per Occurrence $25.000
Earthquake per Occurrence $25.000
Terrorism per Occurrence $10.000
Mold per Occurrence $10.008
-29&Wind Deductible NO
The following conditions apply to certain property and inland marine:
Any building over$1.000'000 in value and over fifty(50) years old requires an appraisal if
replacement cost is to apply. Othorwioe, coverage shall be mado on an actual cash value basis.
With regard to Law Enforcement Dogs& Horses, values must be declared for coverage to apply.
If a new exposure is acquired by the Participant/Member during the year, such new exposure
must be reported for coverage to apply. This applies to exposures for which a limit is not already
shown on this Property and Inland Marine Contract Declarations page of automatically covered in the
Property Coverage document.
Any single item of Fine Arts valued over$250,000 must be scheduled and have a recent appraisal.
NCACC AMP Property and Inland Marine Declarations Page
Edition 7/1/2016 Issued
3 6/27/2016
DocuSign Envelope ID:4n0Ce831-88Eu-408B-8r1n~^r1C30u3n3*4
Coverage Extensions
The following Sub limits apply on a per occurrence basis, unless otherwise stated. Any
Sub limit shown as an annual aggregate applies per occurrence and to all losses for that
peril/coverage in the aggregate during the contract term.
For additional coverages and sub-limits are found in the Property Coverage document, under 7. Limits
of Liability and a description of the coverage is found under the PROPERTY DAMAGE -SECTION 6,3,
ADDITIONAL COVEFRAGES section of the PROPERTY COVERAGE document.
Coverage Limits '
Animal Mortality Coverage applies if
scheduled and endorsed
Landfill fires: �254OOOmnn�u| agUregod '
~ - '
� ••••• TIME LIMITS OR LIMITATIONS
In Addition to the time limits shown elsewhere in this Contract, the following appl :
Automatic Coverage 90 Day Period
Interruption by Civil Authorities 30 Day Period
Ingress/Egress 30 Day Period
Extended Period of Indemnity ] 180 Day Period
NCACC RMP Property and Inland Marine Declarations Page •
Edition 7/1/2016 Issued
4 6/27/2016
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
04* r ritity#
.1:fk 4 w•
NoRT W CAROLINA NCACC Risk Management Pools
ASSOCIATION OF COUNTY COMMISSIONERS Liability and Property
SECTION III
BUSINESS AUTOMOBILE COVERAGE
CONTRACT DECLARATIONS
Participant SENIOR CARE OF ORANGE COUNTY, INC.
Contract Number LP-SE-525-16
Contract Period July 1,2016 to July 1,2017
Effective Time 12:01 A.M., Eastern Daylight Time
SCHEDULE OF COVERAGES AND COVERED AUTOMOBILES
COVERAGE COVERED AUTOMOBILES LIMIT (per accident)
Automobile Liability Any Covered Automobile $2,000,000
Out of State No-Fault Any Covered Automobile State Law Minimum
Physical Damage coverage:
Comprehensive and Collision Automobiles shown on schedule Actual Cash Value of Vehicle
of vehicles to include Automobile unless otherwise indicated
Physical Damage coverage
Comprehensive and Collision Fire Trucks, Ambulances and other $0
Specialized Vehicles where a
Replacment Cost value is shown
on the Schedule of Vehicles
DEDUCTIBLES
-Automobile Liability $0
Out of State No-Fault $1,000
Comprehensive and Collision $1,000
NCACC RMP Business Automobile Declarations Page Issued
Edition 7/1/2016 6/27/2016
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
17
Igtte a .
- :6
NoRTII vi--r CARO 1. INA NCACC Risk Management Pools
ASSOCIATION OF COUNTY COMMISSIONERS Liability and Property
SECTION IV
CRIME COVERAGE
CONTRACT DECLARATIONS
Participant SENIOR CARE OF ORANGE COUNTY, INC.
Contract Number LP-SE-525-16
Contract Period July 1, 2016 to July 1,2017
Effective Time 12:01 A.M., Eastern Daylight Time
SCHEDULE OF COVERAGS AND LIMITS
COVERAGE LIMIT
Employee Theft (per Loss Coverage) $250,000
Forgery or Alteration (per Contract Period) $250,000
Inside the Premises Theft of Money and Securities (per Contract Period) $250,000
Inside the Premises Robbery or Safe Burglary(per Contract Period) $250000
Outside the Premises (per Contract Period) $250,000
Computer Fraud (per Contract Period) $250,000
Money Orders and Counterfeit Paper Currency(per Contract Period) $250,000
DEDUCTIBLE
Employee Theft(per Loss Coverat e) $1,000
Forgery or Alteration $1,000
- -
Inside the Premises Theft of Money and Securities $1,000
Inside the Premises Robbery or Safe Burglary $1,000
Outside the Premises $1,000
Computer Fraud $1,000
Money Orders and Counterfeit Paper Currency $1,000
NCACC RMP Crime Declarations Page Issued
Edition 7/1/2016 6/27/2016
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
„ A .4-00,745 „at
/Ili way
N O R T II 4 CAROLINA NCACC Risk Management Pool
ASSOCIATION OP COUNTY COMMISSIONERS Liability and Property
SECTION V
PUBLIC OFFICIALS LIABILITY
CONTRACT DECLARATIONS
Participant SENIOR CARE OF ORANGE COUNTY, INC.
Contract Number LP-SE-525-16
Contract Period July 1,2016 to July 1,2017
Effective Time 12:01 A.M., Eastern Daylight Time
SCHEDULE OF COVERAGES AND LIMITS
COVERAGE LIMIT
Coverage Agreement A(per Public Officials Wrongful Act) $2,000,000
Coverage Agreement B (Sexual Misconduct, each person) $1,000,000
Coverage Agreement B (Sexual Misconduct, Contract Period aggregate) $1,000,000
$250,000 per
Coverage Agreement C (per Public Officials Wrongful Act) Wrongful Act
Coverage Agreement C (Public Officials Wrongful Act, Contract Period Aggregate) $500,000 aggregate
DEDUCTIBLE
Coverage Agreement A (per Public Officials Wrongful Act) $5,000
Coverage Agreement B (Sexual Misconduct, each person) $5,000
Coverage Agreement C (per Public Officials Wrongful Act) $5,000
NCACC RMP Public Officials Liability Declarations Page Issued
Edition 7/1/2016 6/27/2016
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
rsaL-TriektiAgs*
- - .40
N 0 K T Ii dr r— ARC) LINA NCACC Risk Management Pools
ASSOCIATION OF COUNTY COMMISSIONERS Liability and Property
SECTION VII
EMPLOYMENT PRACTICES LIABILITY
CONTRACT DECLARATIONS
Participant SENIOR CARE OF ORANGE COUNTY, INC.
Contract Number LP-SE-525-16
Contract Period July 1,2016 to July 1,2017
Effective Time 12:01 A.M., Eastern Daylight Time
SCHEDULE OF COVERAGES AND LIMITS
COVERAGE LIMIT
_..„
( Coverage Agreement A (per Employment Practices Wrongful Act) $2,000,000
Coverage Agreement B (per Employee Benefits Negligent Act, Error or Omission) $2,000,000
DEDUCTIBLE
Coverage Agreement A (per Employment Practices Wrongful Act) $5,000
Coverage Agreement B (per Employee Benefits Negligent Act, Error or Omission) $5,000
. .
,
NCACC RMP Employment Practices Liability Declarations Page Issued
Edition 7/1/2016 6/27/2016
,
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
O. -et .t•ky
N 0 R T Ii r C A R 0 I. 1 N A NCACC Risk Management Pools
ASSOCIATION OF COUNTY COMMISSIONERS Liability and Property
1
1
SECTION VIII
ENVIRONMENTAL IMPAIRMENT LIABILITY COVERAGE
CONTRACT DECLARATIONS
Participant SENIOR CARE OF ORANGE COUNTY, INC.
Contract Number LP-SE-525-16
Contract Period July 1,2016 to July 1,2017
Effective Time 12:01 A.M., Eastern Daylight Time
Amount of Coverage $250,000 aggregate for the entire Contract Period.
This coverage is written on a claims made basis.
Pool Sponsored by North Carolina Association of County Commissioners
215 North Dawson Street
Raleigh, North Carolina 27603
Pool Adminstered by North Carolina Association of County Commissioners
215 North Dawson Street
Raleigh,North Carolina 27603
Claims Administrator Sedgwick Claims Management Services, Inc.
5260 Parkway Plaza Boulevard, Suite 190
Charlotte, North Carolina 28217
(
NCACC AMP Environmental Impairment Liability Declarations Page Issued
Edition 7/1/2016 6/27/2016
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
rtirthOer
N 0 R T II ilPr* C A R 0 i. I N A NCACC Risk Management Pools
a
ASSOCIATION OF COUNTY COMMISSIONERS Liability nd Properly
SECTION IX
CYBER LIABILITY & EXPENSE COVERAGE
CONTRACT DECLARATIONS
Participant SENIOR CARE OF ORANGE COUNTY, INC.
Contract Number LP-SE-525-16
Contract Period July 1, 2016 to July 1,2017
Effective Time 12:01 A.M., Eastern Daylight Time
SCHEDULE OF COVERAGES AND LIMITS
COVERAGE LIMIT
Cyber Liability Section A(1) $1,000,000 per claim
Cyber Liability Section A(1) $1,000,000 General Aggregate
Sublimit: Privacy Response Expenses Section A(2) $500,000 per claim
Subilmit: Privacy Response Expenses Section A(2) $500,000 Aggregate
Submit: Regultory Penalties Section A(3) $250,000 per claim
Submit: Regultory Penalties Section A(3) $250,000 Aggregate
Submit: Limited Cost of Recovery of Information Protection A(4) $10,000 per Extortion
- Submit: Limited Cost of Recovery of Information Protection A(4) $20,000 Aggregate
DEDUCTIBLE
Each Cyber Liability Wrongful Act $5,000
Each Extortion $5,000
This coverage is written on a claims made basis.
RETROACTIVE DATE: 7/1/2014.
NCACC RMP Employment Practices Liability Declarations Page Issued
Edition 7/1/2014 6/27/2016
DocuSign Envelope ID:456CB831-89E2-409B-8715-A71C362353A4
North Carolina Workers' Compensation Insurance Plan
Berkley Riverport Insurance Co NCCI Carrier Code 27995
Administered by Berkley Assigned Risk Services
P.O,Box 59143, Minneapolis,Minnesota 55459-0143
ASSIGNED RISK SERVICES Toll Froc(888)548-7431 Fax(866)215-8118
vvww.berkleyassignedrisk,COrn policyservices@borkleyrIsk,com
ENTITY AND LOCATION SCHEDULE
1. The Insured: Policy Number: NCARP305328
Tax ID#:
Senior Care of Orange County Policy Period: From: 02/08/2016
105 Meadowlands Drive To: 02/08/2017
Hillsborough, NC 27278 Endorsement Date 02/08/2016
Date of Mailing: 01/08/2016
Entity information Effective Expiration
Insured Name: Senior Care of Orange County February 8, 2016 February 8,2017
Federal ID Number: February 8, 2016 February 8, 2017
Entity Type: Corporation February 8, 2016 February 8, 2017
Location No. Location Address Effective Expiration
1 105 Meadowland Dr February 8, 2016 February 8,2017
Hillsborough, NC 27278
Agency Name and Address
BB&T Ins Services Inc
414 Gallimore Dairy RD Ste F
Greensboro, NC 27409 WC990601