HomeMy WebLinkAbout2016-491-E DSS - Charles House Association for adult day care 000vSign Envelope ID: n1Ce00001185-4roA~^CrB-8C1rurr0013r
Contract#68'2009
Charles House Association
Contract# 68-2009 Fiscal Year Begins Jul '| 2016 Ends June 30, 20l7
This contract ia hereby entered into 6'� and between the Orange County Department o[Social Services(the ,Coun/y") and
Charles House Association (the "Contractor") (referred to collectively as the "Parties"). The Contractor's federal tax
identification number or Social Securi Number is
1. Contract Documents: This Contract consists of the following documents
(1) This contract
(2) The General Terms and Co odihons
(Attachment A)
(3) The Scope of or k, description of services, and rate
(Attachment B)
(4) Federal Certification Regarding Drug-Free Workplace&Certification
Regarding Nondiscrimination(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 or 50l(c)(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 $24,000. This
amount consists of$24,000 in Federal (CFDA # ), State and County funds, $0 (source of other funds if
applicable).
[X] a. There are no matching requirements from the Contractor.
| l b. The Contractor's matching requirement is $ , which shall consist of
[ ] 1o'kind [ ] Cash
| l Cash and In-kind [ ] Cash and/or in-kind
The coutrihu{iouo�orn the Cunto�torshall be sourced �unnnon-federal funds.
Thotctu|cno1ractan�o' t including any Contractor match shall not exceed$24,000.
6. Reporting Requirements: Contractor shall comply with audit requirements as described in N.C.G.S. § 143C-6-22&23
and OD]8 Circular&-l]3 and shall disclose all information required hy42[ISC455.l04`ur42USC455.l85,or42U5C
455.\06.
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000vSign Envelope ID: n1Ce00001185-4roA~^CrB-8C1rurr0013r
Contract#68-20P
Charles House Associatio
7. Payment Provisions: Payment shall be made in accordance vith the Contract Documents as described in the Scope of
Work, Attachment B.
8. Contract Administrators: All notices permitted or required to be given by one Party to the other and ail questions abotit
the contract from one Party to the other shall be addressed and delivered to the other Party's Contract Administrator. Ibr
nunnc`pnotoDOocuddrcas,ntroo\uddcesx,te1cphnoeuunuher,fbxuurnhcr,uodoruui|xddrrseofthePmtieu"o:apecdveinih+)
Contract Administrators are set out below. Either Party may change the name, post office address, street uddrca``
telephone number, fax number,or email address of its Contract Administrator by giving timely written notice to the oth;
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 Ser ices
P.O. Box 8181 2501 1-lornestead Road
Hillsborough, NC 27278 Chapel Hill, NC 27516
(919) 968-2000 ext.246
(919)
�
dsbuffer(Aco.orungc.00.us _
Program Contact:
Renee Bynum, Adult Services Supervisor
Orange County I)epartment of Social Services
P.O. Box 8181
113 Mayo Street
Hillsborough, NC 27278
(919)245-2881
kvognaoo.ucuo~e.nc.ua
For the Contractor:
.
IF DELIVERE D BY US POSTAL SERVICE IF DELIVERED �Y (IT-- MEANS
� - U
Paul
ruu Klever Paulklevcr
Charles House Association Charles House Association
109 Hillcrest Avenue 109 Hillcrest Avenue
Carrboro, NC 27510 Carrboro,NC 27510
(919)967-7570
,
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000vSign Envelope ID: n1Ce00001185-4roA~^CrB-8C1rurr0013r
Contract#68-2009
Charles House Association
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 The Cootrud�mrassures that funds received pursuant 10 this uonhuo
` 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 detetiiiine:
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 ter in of this contract without providing notice to the County.
Federal K�, ��orul Certifications: Individuals and Organizations receiving federal funds must ensure compliance `=�bccduln
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 own expense, all personnel required in performing the services under this Agreement. Such personnel
shafi 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 terutinated as specified in Attachment A, General Terms And Conditions.
16. Insurance Requirements: Contractor shall obtain,at its sole expense,all insurance as required in Attachment A,General
Tenns 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 oftbeAQreenuen1hetvcendbc
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.
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Contract#68-20
Charles House Associatio
IN WITNESS WHEREOF,the County and the Contractor have been first duly authorized,have executed and entered int
this Agreement as of the day and year first above written.
CHARLES itsksiB09SOCIATION
7
PAUL Wtmtr
8/24/2016
6F28113385F664B13
Signature Date
Paul Klever
Executive Di rector
Printed Name Title
ORANGE COUNTY
DocuSigned by:
j561/LtAdit, NAKAVAA.A1
8/26/2016
0637994E1755E477
Bonnie Hammersley, County Manager Date
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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 Contractor agrees to 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
individual 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) contract.
directly to any person or entity designated by the (b) Commercial General Liability - General
Contractor, or Liability Coverage on a Comprehensive Broad
(b) Include any person or entity designated by Form on an occurrence basis in the minimum
Contractor as a joint payee on the Contractor's amount of$1,000,000.00 Combined 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 of 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 in performance of this contract(-non-
and Contractor that any such person or entity, other than owned vehicle insurance"). Non-owned
General Terms and Conditions-(06/16) Page 1 of 5
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vehicle insurance protects 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 writte 1 '
insurance supplements, but does not notice to the Contractor.
replace,the car-owner's liability insurance.
Termination for Cause: If, through any cause, th".
The Contractor is not required to provide and maintain Contractor shall fail to fulfill its obligations under this
automobile liability insurance on any vehicle—owned, 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 tei minate this contract by giving writte
performance of this contract. notice to the Contractor and specifying the effective dat
(d) The insurance coverage minimums specified in thereof. In that event,all finished or unfinished del iverabl,
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 thr
insurance coverage minimums specified in Contractor shall be entitled to receive just and equitabl'
subparagraph (a) are not limits, or caps, on the compensation for any satisfactory work completed on suc
Contractor's liability or obligations under this contract. materials,minus any payment or compensation previous'
(0 The Contractor may obtain a waiver of any one or more made. Notwithstanding the foregoing provision, till.
of the requirements in subparagraph (a) by Contractor shall not be relieved of liability to the Coun
demonstrating that it has insurance that provides for damages sustained by the County by virtue of th
protection that is equal to or greater than the coverage Contractor's breach of this agreement,and the County ma '
and limits specified in subparagraph (a). The County withhold any payment due the Contractor for the purpos;,
shall be the sole judge of whether such a waiver of setoff until such time as the exact amount of damage.
should be granted. due the County from such breach can be determined. I
(g) The Contractor may obtain a waiver of any one or more case of default by the Contractor, without limiting an
of the requirements in paragraph(a)by demonstrating other remedies for breach available to it,the County ma
that it is self-insured and that its self-insurance procure the contract services from other sources and hol
provides protection that is equal to or greater than the the Contractor responsible for any excess cost occasione I,
coverage and limits specified in subparagraph(a). 'I he thereby. The filing of a petition for bankruptcy by th;
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 defaul
insurance or self-insurance specified in this paragraph or breach in compliance with the terms of this contract b
is a material obligation of the Contractor and is of the the Provider shall not be deemed a waiver of an 1
essence of this contract. subsequent default or breach and shall not be construed t
(i) The Contractor shall only obtain insurance from be modification of the terms of this contract unless state.
companies that are authorized to provide such to be such in writing, signed by an authorize
coverage and that are authorized by the Commissioner representative of the County and the Contractor an
of Insurance to do business in the State of North attached to the contract.
Carolina. All such insurance shall meet all laws of the
State of North Carolina. Availability of Funds: The parties to this contract agre:
(j) The Contractor shall comply at all times with all lawful and understand that the payment of the sums specified i
terms and conditions of its insurance policies and all this contract is dependent and contingent upon and subjec
lawful requirements of its insurer, to the appropriation, allocation, and availability of fund
(k) The Contractor shall require its subcontractors to for this purpose to the County. I
comply with the requirements of this paragraph.
(1) The Contractor shall demonstrate its compliance with Force Majeure: Neither party shall be deemed to be i 1
the requirements of this paragraph by submitting default of its obligations hereunder if and so long as it i'..
certificates of insurance to the County before the prevented from performing such obligations by any act o'
Contractor begins work under this contract. war,hostile foreign action,nuclear explosion,riot,strikes,
civil insurrection,earthquake,hurricane,tornado, or othe
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,teims,
Commission. conditions, provisions, representations, guarantees, and
warranties contained herein shall survive the contract
Default and Termination expiration or termination date unless specifically provided
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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
requirements and exemptions, contractors are
86.58. 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
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1
subcontractors,complies with the requirements of Article 2
Record Retention: Records shall not be destroyed, of Chapter 64 of the NC General Statutes.
I
purged or disposed of without the express written consent 1
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 i is
whichever is longer. If the contract is subject to federal terms or provisions, as well as the rights and duties of th
policy and regulations,record retention may be longer than parties to this contract, are governed by the laws of Nort
five years since records must be retained for a period of Carolina. The Contractor, by signing this contract, agree.:
1
three years following submission of the final Federal and submits,solely for matters concerning this Contract,t
Financial Status Report, if applicable, or three years the exclusive jurisdiction of the courts of North Carol in.
following the submission of a revised final Federal and agrees, solely for such purpose, that the exclusiv-
Financial Status Report. Also, if any litigation, claim, venue for any legal proceedings shall be Orange Coun
negotiation, audit, disallowance action, or other action North Carolina. The place of this contract and a 1
involving this Contract has been started before expiration transact ions and agreements relating to it, and their situ.
of the five-year retention period described above, the and forum,shall be Orange County,North Carolina,wher
1
records must be retained until completion of the action and all matters,whether sounding in contract or tort,relating t
resolution of all issues which arise from it,or until the end the validity, construction,interpretation, and enforcemen
of the regular five-year period described above,whichever shall be determined,
is later. The record retention period for Temporary
Assistance for Needy Families (TAN F) and MEDICAID Amendment: This contract may not be amended orally o,
and Medical Assistance grants and programs must be by performance. Any amendment must be made in writte
retained for a minimum of ten years. form and executed by duly authorized representatives o
the County and the Contractor.
Warranties and Certifications
Severability: In the event that a court of competen
Date and Time Warranty: The Contractor warrants that jurisdiction holds that a provision or requirement of thi..
the product(s) and service(s) furnished pursuant to this contract violates any applicable law, each such provisio
contract("product"includes,without limitation,any piece or requirement shall continue to be enforced to the extent i
of equipment,hardware,firmware,middleware,custom or is not in violation of law or is not otherwise unenforceabl;
commercial software,or internal components,subroutines, and all other provisions and requirements of this contrac
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 thes!
date/time data and leap year calculations. This warranty General Terms and Conditions are not material parts of th i
shall survive the termination or expiration of this contract, agreement and should not be used to construe the meanin
thereof.
Certification Regarding Collection of Taxes: G.S. 143-
1
59.1 bars the Secretary of Administration from entering Time of the Essence: Time is of the essence in th.
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 o.1
Carolina. The conditions include: (a) maintenance of a the key personnel assigned to the performance of thi-
retail establishment or office; (b) presence of contract without the prior written approval of the County.1
representatives in the State that solicit sales or transact The term "key personnel" includes any and all person
business on behalf of the vendor; and (c) systematic identified as such in the contract documents and any othe
exploitation of the market by media-assisted, media- persons subsequently identified as key personnel by th
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
F-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
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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. 1 IA 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
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ATTACHMENT B
SCOPE OF WORK
Orange County Department of Social Services
Federal Tax Id. or SSN
Contract#
A. CONTRACTOR INFORMATION
1. Contractor Agency Name: Charles House Association
2. /foifferon/from Contract Administrator thformation in General Contract:
Address
__
Telephone Number: _ Fax Number: Email:
3. Name of Program (s):. Adult Day Care
4. Status: ( ) Public ( }{ ) Private, Not for Profit ( ) Private, For Profit
5. Contractor's Financial Reporting Year July l, 2O|6 through June 30, 2017
B. Explanation of Services to be provided and to whom (include SIS Service Code): The
Contractor will provide Adult Day Services(SIS Code 030)to clients of the Orange Countv
Department of Social Services. These services will be provided in accordance with provisions sct
forth in Volume IV of the Adult and Family Services Manual, Chapter lI-Adult Day Care
Services. The Contractor is required to meet all goals and outcomes listed in Attachment N.
C. Rate per unit of Service(define the unit):
I. If Standard Fixed Rate, Maximum Allowable, (See Rates for Services Chart)
Minjmum daily rate: $33.07/day per client
2.Negotiated County Rate.
D. Number of units to be provided:
E. Details of Billing process and Time Frames; The County will reimburse the Contractor for
services described in this contract up to the budgetary limits of the contract allotment. The
County will reimburse the Contra kxu1xrutco{$]3.U7/davOo,uppcovcdserviceuprovided. For
reimbursement.the Contractor must submjt an original and two copies of an invoice by the fifth
of the month for the preceding month's expenditures to the designated County Administrator.
The Count will reimburse the Contractor monthi ' u"ourcceivtpfacoun~|etc and uoorecU 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 lofl
DocuSign Envelope ID: 51CB0066-1185-4FDA-AC7B-8C1F27F6013F
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 will establish a plan with the
client for acce tine the contribution on at least a monthl basis. 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 to he served/Delivery site(s): Orange County
DocuSigned by: DocuSigned by:
KtAbil COSfOIA, P
AE4E46A84B466 1.8384F664B13
Nancy Coston, Social Services Director (Signature of Contractor)
8/25/2016 8/24/2016
(Date Submitted) (Date Submitted)
Contract-Scope of Work(06/04) Page 2of 2
000vSign Envelope ID: n1Ce00001185-4roA~^CrB-8C1rurr0013r
ATTACHMFNT C
CERTIFICATION RFGARDING DRUG FREE WORKPLACE REQUIREMENTS
AND CERTIFICATION REGARDING NONDISCRIMINATION
Orange County Department of Social Services
L 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 o[acootroUed substance io prohibited in the Conbootor'o
p/orko|occ'and specifying the actions that will be taken against employees for violation ofsuch
prohibition;
B. Establishing a drug-free awareness program to infoi in employees about:
(I)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. Nohfving 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 enop|oyerof any orino\ou| drug statute convicdonfor u violation 000uoing
` ' in the'workplace oo later than five days after such conviction;
E. Notifying the County within ten days u�erreceiving undcc under subparagraph(D)(2) from an
|' c� oro�hcrp/{aor�c�ivin�uctua| notioeofsucb 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;
(1) Taking appropriate personnel action against such an 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 1
000vSign Envelope ID: n1Ce00001185-4roA~^CrB-8C1rurr0013r
U. The site(s) for the performance of work done in connection vith the specific agreement are listed
below:
l.
(Street address)
(City, county, state, zip code)
2.
(Street
(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 be grounds for suspension of payment, suspension
or termination of grants, or government-wide Federal suspension or debarment
45 C.F.R. Section 02'51W 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 (Pi. 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 O.S.C. 001681-1683, and l685 l680), which prohibits discrimination on the basis
of sex; (c) Section 504 of the Rehabilitation Aotof |97], ao amended (29U.S.C. §794), which prohibits
discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C.
006101'6107)` which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and
Treatment Act of 1972 (Pl. 92-255), as amended, relating to nondiscrimination on the basis of drug
abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation
Act of 1970 (P1. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or
alcoholism; (g) Title \/|D of the Civil Rights Act of 1968 (42 U.S.C. 683601 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:
PAUL
v ��.p^�
Executive Di rector
.F28-1�-3g5. 664B13
3i a1urc Title
charles House Association 8/24/2016
_ -
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Federal Certification Drug-Free Workplace &Nondiscrimination rev. 06-2015
Page 2 o[2
000vSign Envelope ID: n1Ce00001185-4roA~^CrB-8C1rurr0013r
ATTACHMENT D
CONFLICT OF INTEREST POLICY
Orange County Department of Social Services
The Board of Directors/Trustees or other governing persons, officers, employees or agents are to
avoid any conflict 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 governing person, officer, employee or agent, in the performance 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 their job title, the
Organization's name or property, for private profit or benefit.
A. The Board members or other governing persons, officers, employees, or agents of the
Organization should neither solicit nor accept gratuities, favors, or anything of monetary value
from cunent or potential contractors/vendors, persons receiving benefits from the Organization or
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 bona-fide Organization fund raising-
activities.
B. A Board or other governi body member may, with the approval of Board or other governing
body, receive honoraria for lectures and other such activities while 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 on personal days,
compensatory time, annual leave, or leave without pey. 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 puy. If a Board or other
governing body member, 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 perouo, 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 contrac :
1. The Board member or other governing person, officer,employee, or agent;
2. Any member of their family by whole or half blood, step or personal relationship or
relative-in-law;
3. An organization in which any of the above is an officer,director, or employee;
4. A person or organization with whom any of the above individuals is negotiating or has
any arrangement concerning prospective employment or contracts.
D. Duty to Disclosure -- Any conflict of interest, potential conflict of interest, or the appearance
of a conflict of interest is to be reported to the 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 Directors/Trustees or other governing body, the Board member or other governing
person, officer,employee, or agent(person( )) must disclose the existence of the conflict of
interest and be given th opportunity to disclose all material facts to the Board and members of
Conflict of Interes Policy(06 |5) Page l of
000vSign Envelope ID: n1Ce00001185-4roA~^CrB-8C1rurr0013r
committees with governing board delegated powers considering 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 and voted upon. The remaining board orcornniittee members shall decide if a conflict
of interest exists. In addition,the person(s)shall not participate in the final deliberation or
decision regarding the matter under consideration arid shall leave the meeting during the
discussion of and vote of the Board of Directors/Trustees or other governing body.
F. Violations of the Conflicts of Interest Policy -- If thc Board of Directors/Trustees or other
governing body has reasonable cause to believe a member, of6uer, employee or agent has failed
to disclose actual or possible conflicts of interest, it shall inform the person of the basis for such
belief and afford the person an opportunity to explain the alleged failure to disclose. lf, after
hearing the person's response and after making further investigation as warranted by the
circumstances, the Board nfDbec(ors/Inwtens or other governing body determines the member,
officer, employee or agent has failed to disclose an actual or possible confict of interest, it shall
take appropriate disciplinary and corrective 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 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 a conflict of interest was present, and the governing board's or
committee's decision as to whether a conflict of interest in fact 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 transaction or arrangement, and a record of
any votes taken in connection with the proocnd|ngu.
Approved by:
CHARLES HOUSE ASSOCIATION
Name of Organizati
/mi./
Signature of Organization Official
V_ah�_-__ �
~.^~
Conflict of Interest Policy(06/15) Page 2 of 3
DocuSign Envelope ID: 51CB0066-1185-4FDA-AC7B-8C1F27F6013F
NOTARIZED CONFLICT OF INTEREST POLICY
State of North Carolina
County of Orange
ece-t, , Notary Public for said County and State,
certify that P-taj,■i" . Li personally appeared before me this•
day and acknowledged that he/she is } e r of
C
L -- 2J) 1-(040 and by that authority duly given and as the
act of the corporation, affirmed that the foregoing Conflict of Interest Policy was adopted by the
Board of Directors/Trustees or other governing body in a meeting held on the (3 /- ---day of
Sworn to and subscribed before me this 12 day of 1.4-k 2- b(
KESHA PATEL
(Official Seal) Notary Public
Durham Co.,North Carolina
Notary Public My Commission Expires Aug.09,2020
My Commission expires A e")7 202-4,
Conflict of Interest Policy(06/15) Page 3 of 3
DocuSign Envelope ID: 51CB0066-1185-4FDA-AC7B-8C1F27F6013F
1 ) 4, CHARLES HOUSE ASSOCIATION
' -,,,,:f - Yi,
Helping people age the way they have lived
4 i, '6'''0'4' ""''(''0 July 13, 2016
,r'hiu i 1
To: Orange County Department of Social Services
Serving Seniors and Their
Families Since 1990
Certification:
Enriching the lives of senioi s
We certify that Charles House Association does not have any overdue tax
Supporting families caring for
debts, as defined by N.C.G. 105-243.1, at the federal, state, or local level. We
aging family member
further understand that any person who makes a false statement in violation of
Representing the community's
commitment to its elder N.C.G.S. 143-6-23(e) is guilty of a criminal offense punishable as provided by
N.C.G.S. 143C-10-1.
BOARD OF DIRECTORS
Melvin liurston and Paul Klever, being duly sworn, say that we are the Board
PRESIDENT President and Executive Director, respectively, of Charles House Association
Melvin Flurston of Carrboro, in the state of North Carolina; and that the foregoing certification
VICE PRESIDENT is true, accurate and complete to the best of our knowledge and was made and
Sheryl Zimmerman subscribed by us. We also acknowledge and understand that any misuse of
State funds will be reported to the appropriate authorities for further action.
SECRETARY
Sheana Funkhouser
TREASURER
Bradley Fox Board President
Jesse Bassnight,Jr. Executive Director
Michael Hill
Suzanne Kalbas
Joel Levy Sworn to and subscribed before me on the day of the date of said certification.
Nancy Jones
Cindy Skocik ..._
Mildred Witt — :1'P-0,D '-"C"–:::):1-, KESHA PATEL
Notary Public
Notary Signature and Seal
EXECUTIVE Durham Co,North Carolina
DIRECTOR My Commission Expires Aug.09,2020
Paul Klever
My Commission Expires: 11.314 (L 2c 2 C)
paul@charleshouse.org
GS, 105-2431 defines:Overdue tax debt.—Any part of a tax debt that remains unpaid 90 days or more
alter the notice of final assessment was mailed 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 G,S, 105-237 within
90 days after the notice of final assessment was mailed and has not failed to make any payments due
under the installment agreement.
7 511 :Sunrise Road, Chapel 1)111, NC 27514 (919) 967-7570
DocuSign Envelope ID: 51CB0066-1185-4FDA-AC7B-8C1F27F6013F
ATTACHMENT J
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 NCIC
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,
Medicaid or Tiby:tle XX programs (signature on this form confirms this statement).
DocuSigned
PAUL Uumx
Executive Director
‘`-b1-26113.3t45 •.■
Signature Title
Charles House Association 8/24/2016
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Transportation Certification(06/16) Page 1 of 1
DocuSign Envelope ID: 51CB0066-1185-4FDA-AC7B-8C1F27F6013F
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.
000vSign Envelope ID: n1Ce00001185-4roA~^CrB-8C1rurr0013r
ATTACHMENT M
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:
htLp://p/w,v.ncgu.stakc.nc.us/EguctedLegisiation/Stututeo/PDF/Rv/\rdc|c/Chup1or 64/Article 2.pdf
• The text of G.S. 105 164.8(b) can be found online at:
http://v/x/*.nogo.uta\c.nc.ox/Enuu(edLerio|ogion/Stu1uteo/YDF/By3cotion/Chuptec_l05/G5 105-154.0.pdf
• The text of G.S. 143-48.5 (S.L. 2013'418, s. 2.(d))cuubefbundon|incu\:
http://wv/v/.ncgu.$utc.oc.ux/Seosiono/20I3/E6)\o/Houxe/PDF/1-1786v6odf
• The text of G.S. 143-59.1 can be found online at:
http://v/vnx.ncgu.stute.no.us/Boactcd[egio|utioo/Stoiu1es/PDF/BySeotion/Chapicr 143/(}S_143 59.l.pd[
• The text of G.S. 143-59.2 can be found online at:
bttp://wvw.ncgu.state.nc.uu/Eoortud[cgis\o1ion/StatuLex/P[}F/DyScction/Cbupter_l43/{35_i43'59.2.pdf
• The text ofG.S. 147'33.95(g)(SI. 2013'410, s. (e))can be found online at:
http:Yvvvv*'.ncgu.guTcoo.us/3eosions/20l3/BU\x/Houae/9DF/R7X6v6.0f
• The text of Orange County Living Wage Contractor Policy which is attached to this document.
Certifications
(1) Pursuant to G.S. 143-48.5, 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:
"^vW.unoix 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 0153A'99.l.,
which states in part as follows:
Counties Must Use E-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(h), 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 1 of 3
����
000vSign Envelope ID: n1Ce00001185-4roA~^CrB-8C1rurr0013r
more of the conditions of G.S. 105-164.8(h); and
(b) [check one of the foll i boxes]
�
Neither the Contractor nor any of its affiliates has incorporated or re inu"tax have
country" as set forth iu143-59.1(c)<2) u��rl)�o�mbcr3l 200L� pr
G.S.� ` ,
The Contractor or one of its affiliates has incorporated or reincorporated in a"tax haven country'
as set forth in G.S. 143'59.l(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 la,.
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{b� (�ou�nxctoriaouuoiuuorporu1�dbuuiu�yu �nl�k/) huoh��u000vic�c� o�nnyvinla1inun�(�hup��
(if entity)
78A of the General Statutes or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 year
immediately prior to the date of the bid solicitation.
(4) The undersigned hereby certifies further that:
(a) I-Ic 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
,
(o) He or she understands that any person who knowingly submits a false certification in response to the
requirements oyG.8. 143'59.luud 59.2 shall hc guilty wfa Class lfelony.
(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 ~�
living wage (in Orange County currently $13.l5 per/hr.) Check here if contractor pays employee,
' j
performing under this contract u living vva#e. l[Con�uotmr does not pay employees u living vxagc,v�bat 'sth~
wage that employees performing services under this contract pale
charles House Association
- -- '
Contractor's HY ^/ u^
PAUL 8/24/2016
��
Signature nf`"..tf-sarig-TrT7TdtborizedAgent Date
Paul nl eve r Executive Director
Printed N"C77~°`�^ Authorized Agent Title
` °A ,0 Program Administrator
ww+2C-
Signature of Witness Title
chuck Fleming 8/24/2016
Printed Name of Witness Date
The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and dal
this document immediately thereafter.
Contractor Certificatio s Required by North Carolina Law Page 2 of
000vSign Envelope ID: n1Ce00001185-4roA~^CrB-8C1rurr0013r
Section I: General Government and Administration
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
To encourage all vendors and contractors to pay a living wage to all employees who perform work pursuant to a contract
with Orange County.
Applicability
Applies to all Orange County contracts and purchases.
Policy
10.1 Living Wage
lO.l.| Orange County is committed to providing its employees with a living wage and encourages all contra toru
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 projects 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
000vSign Envelope ID: n1Ce00001185-4roA~^CrB-8C1rurr0013r
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:
1. 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 Care 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
Services 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, oogodudon, 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
deteiiiiined 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 Department 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 1
000wSWn Envelope ID: 51Co0000 1185-4roA~^C7B-8C1r27r0013r
DocuSigned by:
PAUL r~^°`°` Executive Di rector
�--"r28n�8'5•rwmBB- -- ---'
Signature Title
Charles House Association on 8/24/2016
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Outcomes (O6/04) Page 2 of 2
DocuSign Envelope ID: 51 CB0066-1185-4FDA-AC7B-8C1 F27F6013F
____,.......4p CHARL-1 OP ID: MR
ACC3R0" CERTIFICATE OF LIABILITY INSURANCE DATE(MMroDrcYYYI
` / 08/11/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must 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 NAMEACT Margo G. Roberts,AAI,CISR
Summers Thompson Lowry,Inc. PHONE FAX
100 Europa Drive,Suite 571 (A/C,No,_Extl 919-969-5300 (A!c Nol 919.942-4221
Chapel Hill,NC 27517 E-MAIL
p ADDRESS:margoestlinsure.com
C.Duke Thompson CPCU ARM
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:Philadelphia Ins Co
INSURED Charles House Association INSURER B:*ISurity
Paul Klever
751 Sunrise Road INSURER C;
Chapel Hill, NC 27514 INSURER D:
INSURER E
INSURER F: ;
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VNTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IR TYPE OF INSURANCE_ ADDL StiHR POLICY NUMBER POUCY (MM!D
LTR D!YYYY) LIMITS
LT INSD WVD
A X COMMERCIAL GENERAL LIABILITY '. EACH OCCURRENCE '..$ 1,000,000
DAMAGE"T2J R-ELATED �
X PHPK1466031 05/10/2016 05/10/2017 100,000
CLAIMS-MADE OCCUR PREMISES(EaoccurrenceJ..._.,-,. $
MED EXIP(Any one person) $ 5,000
'..
PERSONAL&ADV INJURY $ 1,000,000
GEN"L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 3,000,000..
POLICY PRO JECT LOC PRODUCTS-COMP/OPAGG $ 3,000 000
OTHER Emp Ben. $ 1,000,000
AUTOMOBILE LIABILITY $ 1,000,000'.
COMBINED SONGLE LIMIT
(Ea accidentj__
A ANY AUTO PHPK1466031 05/10/2016 05/10/2017 BODILY(INJURY(Per person) $
ALL OWNED --_..__.. SCHEDULED -. _,_-_,......_._.- _ . .....__._....
AUTOS AUTOS BODILY INJURY Y(Per cderi)r $
.... NON-OWNED PROPERTY DAMAGE $
X X
HIRED AUTOS AUTOS (Per accHent)..._
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS LIAB CLAIMS-MADE PHUB533292 05/10/2016 05/10/2017 AGGREGATE 1 $ 1,000,000
....... ....
l RETENTION$ 10000 __._...... .... . ._,.. s
DED I X I
WORKERS COMPENSATION X PER 0TH-
AND EMPLOYERS'LIABILITY STATUTE ER
B ANY PROPRIETORPARTNER/EXECUTIVE !N
` I N r a WC19056-2015 06/25/2016 06/25/2017 EL EACH ACCIDENT S 500,000
OFFICER/VEMBER EXCLUDED? — - ---
(Mandatory in NH) E L DISEASE EA EMPLOYEE S 500,000
If yes,describe under
DESORPTION OF OPERATIONS below E L DISEASE•POLICY LVMVT S 500,000
A Molestation/Sexual PHPK1466031 05/10/2016 05/10/2017 Agg 1,000,000
Misconduct Occ 1,000,000
DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES (ACORD 101,Addttlonal Remarks Schedule,may be attached If more space Is required)
For Information Purposes
CERTIFICATE HOLDER CANCELLATION
ORANGSS
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Orange County Social Services ACCORDANCE WITH THE POLICY PROVISIONS,
Adult Services -
PO Box 8181 AUTHORIZED REPRESENTATIVE
Hillsborough, NC 27278 C 21,4-3,446--,
1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD