HomeMy WebLinkAbout2016-586-E Finance - Senior Care of Orange County, Inc. - Outside Agency Performance Agreement DocuSign Envelope ID:4FFDF545-B8C1-4ABF-A6A5-400656A36357
OUTSIDE AGENCY PERFORMANCE AGREEMENT
THIS AGREEMENT,made and entered into the first day of July 2016, ("Effective Date")by and between
the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street,
Hillsborough, North Carolina, 27278, ("County") and Senior Care of Orange County, Inc, a not-for-profit
corporation, located at 105 Meadowland Drive, Hillsborough,NC 27278 ("Provider").
WITNESSETH:
WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby
enhance its availability to residents of the County, and said program addresses an important community
human services need, as identified by the Board of Commissioners;
NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set
forth, the County and Senior Care of Orange County, Inc agree as follows:
1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1,
2016 to June 30, 2017.
2. Scope of Services.
a. Provider will provide services, as outlined in the attached Outside Agency Funding
Application and any amendments or revision thereto which is attached as Exhibit"A" and
incorporated by reference, to the residents of Orange County. The Scope of Services and
the Program Budget may be different from the original application based on County
appropriation; however, any revisions or amendments to this Agreement must be approved
in writing by the County and attached to this Agreement as Exhibit B.
b. The Provider shall be solely responsible for the means, methods, techniques, sequence,
safety program and procedures necessary to properly and fully complete the work set forth
in the Scope of Services.
3. Funding.
a. The County agrees to appropriate for the provision of services described in Exhibit A,
Scope of Services and more particularly described in the Revised Program Budget, the
maximum sum of 30000.
b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not
used for the purposes stated shall be returned to the County. Any changes in the use of
funds must be authorized in writing by the County prior to any expenditure of the funds by
the Provider. If the funds are expended not in accordance with the Scope of Services, at the
discretion of the County the Provider may be required to repay the funds to the County.
c. The Provider shall be paid in four equal installments in the amount of $7,500. The first
payment is contingent upon receipt of the agency's performance agreement; the remaining
payments are contingent upon receipt of the request for reimbursement and related
supporting documentation.
d. The County's obligation to make the quarterly payments is contingent upon receipt of
Progress Reports, which show satisfactory progress toward completion of performance
measures and an accounting of expenditures as detailed in the attached Scope of Services.
(Senior Care of Orange County,Inc)
Orange County Outside Agency Performance Agreement
Revised 8/2016
DocuSign Envelope ID:4FFDF545-B8C1-4ABF-A6A5-400656A36357
e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21
days after receipt of the Progress Report and Request for Reimbursement or 21 days after
due date of Progress Report whichever is later.
f. The County is not obligated to provide any other support to Provider in this or in
succeeding fiscal years.
4. Agency Reporting.
a. Provider will provide Orange County a Progress Report that includes a fiscal report and
updates on performance measures as outlined in the Scope of Services. Progress Report
dates are: July 1 —December 31; January 1 —March 31 and April 1 - June 30. Reports are
due on January 13,April 14, and July 14 of the program fiscal year.
b. Provider agrees to allow the County to inspect its financial books and records, which
document costs of those services,upon reasonable notice during normal working hours.
5. Termination.
a. In the event of any of the circumstances set forth below (hereinafter referred to as
"default"), the County may immediately terminate this Agreement, in whole or in part, and
from time to time. Notice of termination must be in writing, state the reason or reasons for
the termination, and specify the effective date of the termination:
i. In the event that Provider shall cease to exist as an organization or shall enter
bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all
of its assets, or significantly reduce its services or accessibility to Orange County
residents during the term of this Agreement; or
ii. In the event that Provider shall fail to render a satisfactory accounting as provided
section 4 above, the County may terminate this Agreement and Provider shall
return all payments already made to it by the County for services which have not
been provided or for which no satisfactory accounting has been rendered; or
iii. In the event of any fraudulent representation by the Provider in an invoice or other
verification required to obtain payment under this Agreement or other dishonesty
on a material matter relating to the performance of services under this Agreement.
iv. Nonperformance, incomplete service or performance, or failure to satisfactorily
perform any part of the work identified in the Scope of Services or to comply with
any provision of this Agreement, as determined by the County in its sole discretion.
v. Failure to adhere to the terms of applicable county, state or federal laws,
regulations, or stated public policy.
b. In the event of default by the Provider, the county may elect to terminate this Agreement, in
whole or in part and/or require the Provider to repay the funds within ten(10)business days
from written notice of default. The County may (but shall not be required to) grant the
Provider an opportunity to cure the default without termination of this Agreement. This
clause shall not be interpreted to limit the County's remedies in law or in equity.
(Senior Care of Orange County,Inc)
Orange County Outside Agency Performance Agreement
Rev. 8/16
DocuSign Envelope ID:4FFDF545-B8C1-4ABF-A6A5-400656A36357
c. Notwithstanding the foregoing, either party may terminate the agreement at any time
without penalty; provided that written notice of such termination is furnished to the other
party at least 30 days prior to termination. In the event of such termination, any payment
due shall be prorated to the date of termination and any unused funds shall be returned to
the County within 10 days of termination.
d. Any termination of this Agreement for default under this section that is later deemed to be
unjustified shall be deemed a termination for convenience.
6. Insurance.
a. General Requirements. The Provider shall purchase and maintain, during the period of
performance of this Agreement, insurance:
i. Worker's Compensation. For protection from claims under workers' or workmen's
compensation acts;
ii. Comprehensive General Liability Insurance covering claims arising out of or
relating to bodily injury, including bodily injury, sickness, disease or death of any
of the Consultant's employees or any other person and to real and personal property
including loss of use resulting thereof;
iii. Comprehensive Automobile Liability Insurance, including hired and non-owned
vehicles, if any, covering personal injury or death, and property damage; and
iv. Professional Liability Insurance, covering personal injury,bodily injury and
property damage and claims arising out of or related to the performance under this
Agreement by the Consultant or his agents, consultants and employees.
b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows:
INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE
• Worker's Compensation Limits for Coverage A- Statutory State
NC& Coverage B -Employers Liability
$500,000 each accident, disease policy limit and
disease each employee
• Commercial General $1,000,000 Each Occurrence
Liability $2,000,000 Aggregate
• Automobile Liability $500,000 Combined Single Limit
• Professional Liability $1,000,000 Each Occurrence
$2,000,000 Aggregate
c. All insurance policies (with the exception of Worker's Compensation and Professional
Liability)required under this Agreement shall name the County as an additional insured
party and as a certificate holder. Evidence of such insurance and all correspondence shall
be sent to:
Orange County Risk Manager
Post Office Box 8181
Hillsborough,NC 27278
d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity
defenses.
(Senior Care of Orange County,Inc)
Orange County Outside Agency Performance Agreement
Rev. 8/16
DocuSign Envelope ID:4FFDF545-B8C1-4ABF-A6A5-400656A36357
7. Relationship of the Parties. Provider is an independent contractor of the County. Provider
represents that they have or will secure, at his own expense, all personnel required in performing
the services under this Agreement. Such personnel shall not be employees or have any
contractual relationship with the County. All personnel engaged in work under this Agreement
shall be fully qualified and shall be authorized and permitted under federal, state and local law to
perform such services.
8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws,
ordinances, orders and regulations of the federal, state or local governments, as well as their
respective departments, commissions, boards, and officers, which are in effect at the time of
execution of this Agreement or are adopted at any time following execution of this agreement.
9. Subcontract. The County and Provider deem the services provided under this Agreement to be
personal in nature and Provider may not subcontract any rights or duties under this Agreement to
any other party without prior written consent from the County.
10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to
any other party without the prior written consent of the County.
11. Indemnification. Provider 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 the
negligence or willful misconduct of the Provider, except to the extent same are caused by the
negligence or willful misconduct of the County. It is the intent of this section to require Provider
to indemnify the County to the extent permitted under North Carolina law. Nothing in this
section is intended to affect or abrogate the County's sovereign immunity defenses.
12. Non-Appropriation. This Agreement is subject to the availability of funds to purchase the
specified services and may be terminated at any time if such funds become unavailable.
13. Non-Discrimination. Provider agrees as part of consideration of the granting of funds by Orange
County the parties hereto for themselves, their agents, officials, employees and servants agree not
to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap,
religion, sexual orientation, familial status or veterans status with reference to any activities
carried out by the grantee, no matter how remote. The parties hereto further agree in all respects
to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and
the Orange County Anti-discrimination Policy. This provision is enforced by action for specific
performance, injunctive relief, or other remedy as by law provided; this provision shall be
binding on the grantees, the successors and assigns of the parties hereto with reference to the
above subject manner.
14. Living Wage. Orange County is committed to providing its employees with a living wage and
encourages agencies if funds to pursue the same goal. The County's living wage is $ 13.15 per
hour. To the extent possible, Orange County recommends that Senior Care of Orange County,
Inc provide a living wage to its employees.
15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the
last known address shall constitute sufficient notice to the County and the Provider. All notices
required and/or made pursuant to this Agreement to be given to the County and the Provides shall
be in writing and mailed to the party addressed as follows:
(Senior Care of Orange County,Inc)
Orange County Outside Agency Performance Agreement
Rev. 8/16
DocuSign Envelope ID:4FFDF545-B8C1-4ABF-A6A5-400656A36357
County: Finance&Administrative Services Provider: Senior Care of Orange County,
Orange County Inc
Post Office Box 8181 105 Meadowland Drive
Hillsborough,NC 27278 Hillsborough,NC 27278
16. E
ntire Agreement. This Agreement, including any referenced attachments, constitutes the entire
Agreement between the parties and shall supersede, replace or nullify any and all prior
Agreements of understandings; written or oral, relating to the matters set forth herein, and any
such prior Agreements or understandings shall have no force or affect whatsoever on this
Agreement. The County and Provider have read this Agreement and agree to be bound by all of
its terms, and further agree that this Agreement constitutes the complete and exclusive statement
of the Agreement between the County and Provider.
17. Severability. All clauses found herein shall act independently of each other. If a clause is found
to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It
is understood by the parties hereto that if any part, term or provision of this Agreement is by the
Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United
States, the validity of the remaining portions or provisions shall not be affected, and the rights
and obligations of the parties shall be construed and enforced as if the Agreement did not contain
the particular part, term or provision held to be invalid.
a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of
respective parties hereunder shall be governed by the laws of the State of North Carolina.
By executing this Agreement Provider affirms that Provider and any subcontractors of
Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North
Carolina General Statutes. By executing this Agreement Provider certifies that Provider
has not been identified, and has not utilized the services of any agent or subcontractor, on
the list created by the State Treasurer pursuant to G.S. 147-86.58.
18. Signatures. This Agreement together with any amendments or modifications may be executed
electronically. All electronic signatures affixed hereto evidence the intent of the Parties to
comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66.
IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on
the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures
below.
For and R-, 111 ;aJ1he Provider
U _ 10/26/2016
-052B65BB443...
For and Date E ifrjhOrange County Government
6lA,Uttt, tka" tt-IrStt 10/26/2016
0617_924E75 F477
Bonnie Hammersley, County Manager Date
(Senior Care of Orange County,Inc)
Orange County Outside Agency Performance Agreement
Rev. 8/16
DocuSign Envelope ID:4FFDF545-B8C1-4ABF-A6A5-400656A36357
ATTACHMENT "A"
Orange County Certifications—FY 2016-17
Outside Agency Performance Agreement
Chief Contact,Administrators, Chief Executive Officer and Chief Financial Officer
I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief
financial officer for my agency with this Agreement and that I will keep it current to the County of Orange.
The list should be in writing with the name, title,residential address;phone and email address and if
possible, fax number.
Officers and Board of Directors
I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and
that we will continue to update the list as changes occur. The list should be in writing,with the name,
physical address,mailing address and if possible,phone, fax and email address.
Budget Submission
I certify that I have provided a budget for the period to be covered by funding Orange County, and that any
substantive changes made to this budget have been in advance authorized in writing by Orange County.
Annual Financial Review
I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget
adopted by the agency for the fiscal years encompassing this Agreement. If not,please explain on a
separate sheet of paper.
Alignment with Organization's Mission
I certify that the programs and services for which this funding is requested align with the mission of the
organization.
Intended Purpose
I certify that the funds provided to the agency under the terms of this Agreement will be used for a public
purpose and shall only be used for the purposes intended and any money not used for those purposes will be
promptly returned to Orange County.
DocuSigned by:
Di rector 10/26/2016
Certified by: LFlRO5?Bfi5BR44 3 Title: Date:
(Provider's Signature)
(Senior Care of Orange County,Inc)
Orange County Outside Agency Performance Agreement
Rev. 8/16
DocuSign Envelope ID:4FFDF545-B8C1-4ABF-A6A5-400656A36357 Exhibit A
Provider's Outside Agency Application
APPLICATION SUBMITTAL CHECKLIST
FOR OFFICE USE ONLY
Received By
Agency Senior Care of Orange County; Inc Date/Time I
Complete Y/N
Program(s) Florence Gray Soltys Adult Day Health Program
Section For CDBG & HOME -
Subsection
HUD Regulations
1. Cover Page a. XIII Applicant Contact Information
b. X[11 Project/Program Contact Information
C. XLI Funding Requests Identified
d. XIII Signed Application Cover Page
2. Agency a. Xrl Agency's Years in operation 24 CFR 570.506,
Information - b. XE Agency's Purpose/Mission 570.507, 570.610; 24
CFR Parts 84 or 85
c. XI—I Agency's Types of Services Provided
d. Xri Agency's Experience
e. XLI Other Pertinent Information
3. Program/ a. XL] Type of Application and Program Identified 24 CFR 570.200(a),
Project b. XL Summary of Program 570.201-570. 208,
Information - c. XE] Description of Identified Need 507.503
(for each d. xfl Description of Population to be Served
program/
e. XL Activity Manager and Location Description
project for
f. XEI Activity Implementation Timeline
which funding
is requested) g. XIII Agency Collaboration
h. XIII Describe Impact of Reduced/No Allocation
I. XIII Other Pertinent Information
j. XE Complete Target Population/Beneficiary Chart
k. XIII Complete Schedule of Positions
I. XE Signed Conflict of Interest Disclosure
m. XL Complete Work Statement
ilPage
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24 CFR 570.200(a),
4. Financial (for Program Budget Worksheet and Detail should reflect 570.201-570. 208,
each expenses for the entire program and ALL sources of 507.503
program/ funding. 24 CFR 570.506,
project for 570.507, 570.601,
which funding a. Xn Program Budget Worksheet 570.602, 570.607(b),
is requested) b. X111 Program Budget Detail 570.611
24 CFR
c. xri Cost Per Unit
570.502-570.504,
d. XI] Agency Operating Budget Worksheet 570.506,
570.507, 570.610; 24
CFR Parts 84 or 85, and
OMB Circulars A-87 or A-
122;
Treasury Circular 1075
5. Supplemental A. n Part A: CDBG & HOME
Sections (as B. El Part B: Construction/Rehab
applicable)
6. Attachments a, Lii Audit: Organizations receiving $300,000 or more OMB Circular A-133
in Federal financial assistance, and/or organizations
with more than $500,000 of receipts and
expenditures in a fiscal year, must secure an audit.
b. Xr1 IRS Federal Form 990
c. xn NC Solicitation License
d. xn IRS Federal Tax-Exemption Letter
e. xn Certificate of Insurance
f. xi List of Board of Directors 24 CFR Parts 84 or 85
g. xn Articles of Incorporation/Bylaws
24 CFR 570.208,
h. gi Authorization to Request Funds 570.500(c), 570.611
L Xn Authorized official designation
j. 41111 3-R Fee Verification
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.
1. COVER PAGE (Each program requires a separate application.)
a) Applicant Contact Information
Applicant Organization's Legal Name: Senior Care of Orange County; Inc.
Applicant Organization's Physical Address: 105 Meadowland Drive; HiUnbonough, NC 27278
Applicant Organization's Mailing Address: 105 Meadowland Drive; Hi||sb0n}UOh, N(} 27278
Applicant Organization's Web Address: vvvvvv.so|h/oodu|tdoyheolth.n[g
Executive Director: Alvonia Baldwin
Telephone Number: 913'245'2017 E'Mai|; m|ba|dvvinaoronAecnuntyncAov
DUNS Number: 123760520
(Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.)
b) Project/Program Contact Information
Project/Program Name: Florence Gray Soltys Adult Day Health Program
Project/Program Primary Contact and Title: Alvonia Baldwin, Executive Director
Telephone Number: 919-245-2017 E'Mai|: o|bgldvvinaorengacuuntync.gov
c) Funding Request Identification
Total P ject/Program Cost: $33.500 Total Amount of Funds Requested: $33.500
Proposed Use of Funds Requested (2-3 Line Maximum): Funding towards this one of a kind dual
model; Adult Day Care and Adult Day Health Program in Orange County will provide participant
scholarships for clients in need of a program that may be limited to the affordabili Caregiver respite is
needed due to the severely frail elderly and adults with special needs; program operational support with
purchase of program supplies, snacks, personnel and community resources for the continued sustainability of
the program and as a partnership with the county towards meeting the goals of the Master Aging Plan of
Orange County. Since 2011-2016; The Orange County amount has included up to$25,000 in participant
meal credits which continue to help wigntficumtKy. Below is not a reflection of the meal credit amount.
The in-kind donation is still needed for tbe /nculm. ($53,000ir,oimWunt6cmaawUwKox'OnanAmC000tv).
Please check all types, sources, and amounts of funding being requested. You must submit an
application package for each funding source, *The Particip ating Jurisdiction resetves the right to
fund projects from any funding source, subject to eligibility and funding constraints.
[— [—
CDBGNon-{�onatruotion (CH) $ . Grant .[— Loan
▪ [|DBG Construction (CH) F- Grant -- Loan
L MO��E {}MD{} � Grant Loan
F- HOME Other [l Grant -1 Loan
X Human Services: X Carrboro $1,500 X Chapel Hill $2,000 X Orange County $30,000
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d) To the best of my knowledge and belief all information and data in this application is
true and current. The document has been duly authorized by the governing board of the
applicant.
Signature:
Executive Director Date
7.21/267
Signature: A .
foard Chairperson Date
•
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2. AGENCY INFORMATION
•
Please provide the following information about your agency (Limit of 2 pages total):
a.Years in Operation:
The program began offering services on March 28, 2004, and through 2016 has served 251 participants and
their caregivers. The County of Commissioners passed a resolution of a name change to The Florence Gray
Soltys Adult Day Health Program on April 20,2010.
Date of Incorporation:
Senior Care of Orange County, Inc. was incorporated in March, 2004.
b. Agency's Purpose/Mission
The mission of the Florence Gray Soltys Adult Day Health Program remains the same, by providing social
and health services to frail, disabled and isolated adults 18 years and older with special needs that will benefit
from Adult Day Health programs. Stimulating activities, enriching programs, provision of nutritious meals
and snacks as well as rehabilitative services are offered. The program also provides respite and education for
family members and cure8ivora. The primary goal is to prevent or delay the onset of institutionalization of
participants.
The vision of Senior Care of Orange County, Inc. is to advocate, establish and operate programs that provide
services for frail or disabled older adults to remain in their homes with their family as long as possible. The
65 and older adult is the fastest growing population segment.
c. Types of Services the Agency Provides
The Florence Gray Soltys Adult Day Health Program is a therapeutic, health-focused program for adults and
xcuioothaioDe/avoddyofuervioesivabooue'}ikeneKiugtba1iuopuoiioom7:30mooto5:30pnu`Mooday-
Friday.
The relocation of the program,to a new and larger location in close relation with the Oi'ange County
Department on Aging has helped significantly. The need of this program is growing rapidly as more seniors
age in place with various diagnosis ranging from, but not limited to dementia, Parkinson's and diabetes. The
existing space allows more opportunities for families to feel reassured of the care and safety that their loved
one receives. From year to year, the number of participants enrolled in the program continues to grow,
Currently the program is averaging 24 participants per day, with a capacity for tip to 29 per day.
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d. Agency's Experience with Similar Programs as the Funding Request
Through the years, we have made great efforts and will continue to collaborate with the recruitment process to
assist participants from the Department of Social Services (Medicaid CAP/DA) and the Veteran's
Administration who will fmancially support the participants with low incomes and/or medical needs to utilize
the Day Health Program as an option to in-home care services. This option may also help with the social
interaction of each and every participant enrolled in the program. We will reapply for the Home Community
Care Block Grant from Triangle J Council of Governments for continued funding to help support days of
coverage for Adult Day Care and Health finding options.
e. Other Pertinent Agency Information
In 2003, Central Orange Adult Day Health Program (formally) was under the auspicious of the
Orange County Department on Aging. In 2004,the program assumed a non-profit 501 c-3 status under the
Governing Board of Senior Care of Orange County; Inc. Through the years the operation remained adjacent to
the Central Orange Senior Center and was licensed for 10 participants per day. As the need in the county
continued to grow,the program later expanded to hold a license of 29 participants per day on February 4,
2009 as a partnership with the county to continue to work towards meeting the goals of the Master Aging Plan
of Orange County.
The Senior Care Board continues to work toward building stronger relationships with the Veteran's
Administration Community referral program, and establishing a partnership with the local Veterans Affairs
Office, Discharge Planners at the local Hospitals to aid in the referral program. Additional In-kind support
still remains from Carol Woods Retirement Community with a representative which serves on the Senior Care
Board of Directors.
Additional In-kind support still remains from Carol Woods Retirement Community with a representative
which serves on the Senior Care Board of Directors. Efforts continue to recruit participants from the
Department of Social Services(Medicaid CAP/DA) and the Veteran's Administration who will financially
support the participants with low incomes and to encourage them to utilize the Day Health Program as an
option to home care. The program will reapply for the Home Community Care Block Grant from Triangle J
Council of Governments.
We have established the Florence Gray Soltys Memorial Scholarship fund where individuals can donate
throughout the year. The way we generate this fund is through newsletters, postings on our website, direct
mail lists,e-mail lists, phone lists, etc. We will also seek in kind gifts and work diligently on fundraising,
which will help develop these funding sources into a long-term support of the programs.
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3. PROJECT/PROGRAM INFORMATION
Agency & Program Name: Senior Care of Orange County; Inc.
Florence Gray Soltys Adult Day Health Program
As you complete your application, complete only those sections that pertain to the type of
application you are submitting. The application is divided into several sections and not all sections
apply to every project. Every applicant MUST complete the main application.
a) Check the type of funding request for this application package submittal and complete the
application and supplemental application sections as specified below:
X Human Services (Main Application Only)
AH Non-Construction (Main Application Only)
AH Construction —(Main Application AND Part B)
• AHDR Non-Construction (Main Application Only)
n AHDR Construction — (Main Application AND Part B)
I I CDBG Non-Construction — (Main Application AND Part A)
El CDBG Construction — (Main Application AND Part A AND Part B)
El HOME CHDO Set-aside — (Main Application AND Part A)
n HOME Other —(Main Application AND Parts A AND Part B)
Indicate the type of program for which you are requesting funding:
Disabled Public Housing
Program Category Youth Adult Elderly (not Neighborhoods/Resid
elderly) ents
Education
Health and Nutrition X X X
Job Training
Sports and Arts
Activities
Pre-School Activities
After-School
Activities
Mentoring
Transportation
Housing
Other: Please
specify Adult Day
Care/Health Program
_ X X X
Program/Project Description (Label your responses as outlined below; not to exceed 3
pages.)
Please provide the following information about the proposed program/project:
b) Summarize the program services proposed and how the program will address the
chosen Town/County priority? This is a request to continue with the financial support provided to
the Florence Gray Soltys Adult Day Health Program under the auspices of Senior Care of Orange County,
Inc. This program originally started by the County Department on Aging as a major Master Aging Plan
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funded initiative. County and Town funds are critical for the continuation of this one of a kind program
that serves the severely frail elderly and adults with special needs in Orange County. We have seen
growth from residents of Chapel Hill and Carrboro needing Adult Day Health services since 2014. The
program expanded on February 4, 2009 as a partnership with the county to continue to work towards
meeting the goals of the Master Aging Plan of Oratige County. The request for funding from each
participating jurisdiction is a huge priority with helping to prolong and/or prevent institutionalization.
This would allow the individual to age in place within their home and community as statistics show that
adults are living longer. This program will continue to provide quality of care; with dignity and respect
to all individuals in which we serve ages 18 and up. (Please note that the crverage age is 80 years old.)
c) Describe the local need or problem to be addressed in relation to the Consolidated
Plan or other community priorities (i.e. Council/Board Goals). Cite local data to support
the need for this program and the population being served. Not applicable to our Agency
d) Describe the population to be served or the area to benefit and indicate how you will
identify beneficiaries. The population being served is more of the adults ages 65 and older. The need of
this program is growing rapidly as more seniors age in place with various diagnosis ranging from,but not
limited to dementia, Parkinson's disease, CVA and Diabetes. The existing space continues to allow more
opportunities for families to feel reassured of the care and safety that their loved one receives with health
monitoring by registered nurses, contracts with occupational and physical therapy services, certified nursing
assistants to aid and assist in ADL care (activities of daily living), along with a social worker and activities
staff to ensure that physical, social emotional and cognitive domains are being met. From year to year,the
numbers enrolled continues to grow. Currently the program is averaging 24 participants per day, which
allows for part-time and full-time enrollment with a licenses capacity for up to 29 on any given day.
Affordability along with flexibility in participant's schedules helps to determine and identify funding for
qualifying individuals. A weekly attendance and revenue form is used to track participants under an
additional and/or supplemental funding source.
e) Who specifically will carry out the activities and in what location will they be carried out?
The Florence Gray Soltys Adult Day Health Program; operated by Senior Care of Orange County; Inc.; is a
therapeutic,health-focused program model for adults and seniors which offers a variety of services in a
home-like setting based in the community. The hours of operation are from 7:30um to 5:30pm" Monday-
Friday. As a team effort,the interdisciplinary team will specifically carry out daily day health services at
the Soltys Adult Day Health Program.
f) Describe specifically the period over which the activities will be carried out, the
frequency with which the activities will be carried out, and the frequency with which
services will be delivered. Include an implementation timeline. The activities carried out for
providing funding for adult day health services and continued program operations will transpire through the
July |`2Di0-]uuoJ0, 20l7 fiscal year. The funding will help the continuation of services for families in
need of Adult Day Health programming and additional days as needed along with program operations that
would include but not limited to medical,office and activity supplies, some food cost with am and pm
snacks,training(i.e. staff development on a quarterly basis and new staff orientation.) The services for the
participants would vary on each individual need base. (i.e. one—two days per week, short-term and/or long-
term.)
g) Provide a bulleted list of other agencies, if any, with which your agency
coordinateo/co||ab#ratemto accomplish or enhance the Projected Results in the Program(s)
to be funded. For each, give specific examples of the coordinated/collaborative efforts.
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• Continued collaboration with the Vet mnu` Admbdxtroiioo (bompkWbaoodiuI}urbuno,NC). We
have a VA contract that is negotiated each year. This continues to become a stronger referral base for
us as we focus on our Aging Veterans in the community.
• We also work closely with the Department on Aging- Eldercare Respite Program; support for
caregivers needing services for their loved ones. This funding source offers Day Health services as
an alternative to a couple of hours per day of in home aid services. This also allows the client to
remain connected with the community through socialization with their peers.
• Collaborate with NC Alzheimer's Association which is ongoing through resources for staff and
caregivers and at times are able to temporally provide short-term funding based on certain diagnosis
and financial needs.
• Contract with a community based physical and occupational therapy organization.
• We continue to seek volunteers throughout the community—often being met through our relationship
with other human service agencies (i.e. Central Orange Senior Center, Seymour Center and other non-
profit and for profit agencies and member organizations).
• We periodically work with interns in various human service fields provided through UNC Hospital
and the University(i.e. occupational therapy, social work, and nursing students.)
* We have a continued relationship with the Orange County Department of Social Services and the
Health Department in monitoring our program for quality assurance to maintain state certification.
* Continued support with Triangle J of Governments with the Home and Community Care Block Grant
(HCCBG)funding for adults 65 and older in need of Adult Day Health Services. This funding is used
to provide a day (unit) of service for qualified individuals that meet the criteria.
h)
Describe what would happen if requested funding is not awarded at all or if a reduced
allocation is recommended. If funding was a reduced allocation; hopefully the program would continue
to serve as many participants and their families as possible which may reduce the daily average of
individuals enrolled in the program due to limited funding sources. We would hate to fathom if funding was
not awarded. If this scenario were to happen to Orange Counties one of a kind Adult Day Health model;this
would be a huge impact for all the families that we serve. This unique program is committed to the health
and well being of adults with physical and mental impairments that come along with the aging process. As
Orange County continues to grow, with the new UNC hospital and new residential communities this shows a
need of Adult Day Health services. Again, this program is able to provide a safe, stimulating, friendly
environment to meet the quality of life for frail individuals that may need a bit more of structure in their day
to day activities along with health care monitoring. Funding not awarded would also impact working
caregivers and veterans of Orange County. Working caregivers may need to retire early or leave a position
to care for their loved ones and with the Veterans,unable to provide the contracted services for the men and
women that have served our country due to the lack of financial sustainability. Our program fees are based
on a sliding scale of the individual in need of our program. This program was designed to meet the needs of
all families that we serve. Majority of our population about 90% have at least a dementia diagnosis which is
growing rapidly in this age group and the need for Adult Day Health services. Without the towns and
County support, our program would be very difficult for the program to continue for more than one or
possibly two years. Please consider the continuation of funding to help out our Orange County Residents.
The Orange County Aging profile shows by 2034, the over age 60` 65 and 85 population will increase by
76.2%, 109%and 167%respectively. The Demographer of the Division of Aging and Adult Services of the
NC Department of Health and Human Services provided this data. (see included in the pertinent information
section (i) of this application)
i) Include any other pertinent information.
• A 2 page document on"North Carolina is Aging!";prepared by Swarna Reddy, NC DAAS,
l)ece///be/'2O1J
• Two informational brochures about The Florence Gray Soltys Adult Day Health Program.
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0 Quarterly Caregiver Newsletters for the families that we serve and prospective families.
Program/Project Information
C. Complete the Target Population and Program Beneficiary Demographics Chart
D. Complete the Schedule of Positions Chart for Program Staff
E. Disclosure of Potential Conflicts of Interested must be signed
F. Complete the Work Statement Chart to describe the work to be performed, and be sure to
attach copies of all data collection tools that will be used to verify achievement of program
goals and objectives. Describe who will be responsible for monitoring progress.
Information to Complete
j.) Target Population
Complete the following tables to the best of your ability. Show numbers of participants and
percentages, as applicable, in each category.
Please indicate whether this project/program will serve: X Persons 111 Households - Units
Program:
Program Beneficiary Demographics
Actual Estimated Projected
2014'15 201546 2016-17
Gender
Male 46 48 50
Female 36 38 42
Total 82 86 92
Of the fema|eo, how many are single-
female Head of Households (Omit for
Human Services) n/a n/a n/a
Ethnicity
African-American 24 25 30
American Indian or Alaska Native 2 1 3
Asian 2 4 5
Caucasian 54 54 50
Native Hawaiian or other Pacific
Islander 0 0 1
Other 0 2 3
Total 82 88 92
Of the above, how many
Hispanic/Latino 0 2 3
Of the above, how many non-
H|opanio/LaUno 82 84 89
Total 82 86 92
Agm'` ��'` ``'^ `
0-5 years
6-18 years
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19-50 years 2 1 1
51-61 years 2 6 8
62+ years 78 79 83
Total 82 86 92
�Geographic Location
�'` `'' � �`'`' ' �`
Durham City
Durham County 8 8 8
Carrboro 5 6 7
Chapel Hill 9 12 13
Chapel Hill Public Housing Residents
Orange County 53 54 56
Raleigh 1 1 1
Wake County & Other Counties-
Alamance & Person 6 5 7
Total 82 86 92
nco ' foll sr ``�``�
([ i }-S �!���``��|�'.`��`'{'!�, `'�`� ```�
< 3UY6 Area Median Income 25 27 28
31-50% Area Median Income 36 35 37
51-80% Area Median Income 17 19 22
> 80% Area Median Income 4 5 5
Total 82 80 92
Special Needs (Omit for HS)
Elderly(Over 62) 78 80 85
Disabled (not elderly) 4 6 7
Homeless
People with HIV/Aids
Total 82 86 92
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CDBG & HOME ONLY - Area Benefit Activities (Infrastructure and Public Facilities)
Street Census Tract Block Group Total Persons #LMI Persons
2015 Area Median Family income Limits
U.S. Department of Housing & Urban Development (HUD)
2015 Area Median Family Income Limits
Effective March 15, 2015
Income 1 2 3 4 5 6 7 8
Level person people people people people people people people
30% AMI $14,150 $16,200 $20,090 $24,250 $28,410 $32,570 $36,730 $40,890
50% AMI $23,600 $27,000 $30,350 $33,700 $36,400 $39,100 $41,800 $44,500
80% AMI $37,750 $43,150 $48,550 $53,900 $58,250 $62,550 $66,850 $71,150
100% AMI $47,188 $53,938 $60,688 $67,375 $72,813 $78,188 $83,563 $88,937
115%AMI $54,266 $62,028 $69,791 $77,481 $83,734 $89,916 $96,097 $102,278
http://www.huduser.org/portal/datasets/i1/1115/FY2015 IL nc.pdf
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k) Schedule of Positions
Please include program staff positions followed by volunteer positions; these financial figures
should match the personnel figures in your Agency Comparative Budget Excel Form. Similar
positions can be combined. (i.e., 8 Occupational Therapists can be inserted as one line item).
If provided
indicate:
lox
Position Titles FTE* % Actual Estimated Projected °A Total rztirement
Vacant Staff+ - Plan
(H) Health
Plan
Program Director 180 1.0 64,888 64,888 64,888 n/m
Office Manager 1.00 .75 n/a 28,000 28,000 n/a
Registered Nurses 1.00 1.0 38,000 38,000 38,000 n/a
Certified Nursing
Assistants 3.50 I50 81,850 81,050 81,050 n/a
Activity Coordinator 1.00 1.0 17,000 17,000 17,000 nia
Social Worker .50 .50 28/000 23,000 23/000 n/a
$223,938 $251,938 $251,938
Notes:
= Similar positions can be combined: i.e. 8 Occupational Therapists can be inserted as one line item.
• ^" Full Time Equivalent staff will be noted as 1.00; half time as .50; quarter time as .25, etc.
• + Denotes the percentage of staff time involved with this program.
o Calculate a Full Time Equivalent for all recorded volunteer hours using the following:
Total Volunteer Hours=Volunteer FTE
1,960
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I.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST
Are any of the Board Members or employees of the agency which will be carrying out this project, or
members of their immediate families, or their business associates:
YES NO
a) Employees of or closely related to employees of the Town of Chapel Hill, Orange
County, Carrboro, or Hillsborough?
X b) Members of or closely related to members of the governing bodies of Chapel Hill,
Carrboro, Hillsborough, or Orange County?
X c) Current beneficiaries of the project/program for which funds are requested?
LI X d) Paid providers of goods or services to the program or having other financial interest in
the program?
If you have answered YES to any question, please provide a full explanation below.
To the best of my knowledge and belief all of the above information is true and
current. I acknowledge and understand that the existence of a potential conflict of interest
does not necessarily make the project ineligible for funding, but the existence of an
undisclosed conflict may result in the termination of any grant awarded.
Signature: V9///&
Executive Director Date
Signature: f tc_0, /MO //21/4_0/
ard Chairperson Date
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m.) Work Statement
This form is used to document program activities, program goals, performance measures,
and actual results. (Add more rows as needed) If this is a new program, you will only
document the projected information.
• Program Activities should outline major activities the agency implements to accomplish its
program goals.
e Program Goal should explain what the program is trying to achieve/accomplish. Goals are
statements about what the program should accomplish. SMART Goals
o Performance Measures describe how you will evaluate the degree in which you achieved
the stated goals.
o Actual Program Results use program results to indicate the actual measureable
achievement of goals. If goals were not met, please explain.
Actual Estimated Projected
2014-15 2015-16 2016-17
Program Activity 1
Program Goal Maintain Adult Day Health Maintain Adult Day Health Maintain Adult Day Health
1 "I -I I I III -# I • II-I -I
Increase marketing
Peilormance Measures
Strategies Increase marketing Strategies Increase marketing Strategies
Program Results Monthly Marketing resulted in Monthly Marketing resulted in an Monthly Marketing resulted in an
.1 I 0-I I I I • II-# ". ". 11 -I It III
Program Activity 2 Prevent and/or Delay Prevent and for Delay Prevent and for Delay
Institutionalionalization Institutionalionalization Institutionalionalintion
Program Goal rTesoopurrocveilti7navn:ioaflcooamarrilcuioniatynts rTesoopurrocvesidetof financial oa fl cooamitrincumniatynts To provide financial community
resources to 85%of oarticivants
Performance Measures Assist with supplemental Assist with supplemental funding Assist with supplemental funding
.11-0 +11 I •I
Program Results
25°0 of families resulted in 20%of families resulted in 15%of families resulted in
I *O. .1 *zation, institutionalization
Program Activity 3
Program Goal
Performance Measures
Program Results
Program Activity 4
Program Goal
Performance Measures
Program Results
Activity 5
Program Goal
Performance Measures
Program Results
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4. FINANCIAL INFORMATION FOR SERVICE PROGRAMS
a.) Program Budget
Please complete a Program Budget Excel Form for each requested program. The
Program Budget should reflect only figures and amounts associated with the Program(s) for
which you are seeking funding and not the total agency budget.
If the program's finances experienced significant changes that you would like to explain,
please use the space below.
It is required that your Excel budget worksheet be embedded on the next page. You must
also submit an electronic copy of the MS Excel file with your application, as a separate file.
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Program Budget Worksheet
AGENCY NAME: Senior Care of Orange County; Inc.
Actual Estimated Projected Percent
PROGRAM REVENUE 2014-15 2015-16 2016-17 Change
Private Donations $ 150 $ 550 $ 250 -55%
Program Generated Revenue (fees) $ 297,933 $ 318,951 $ 335,000 5%
Local Government Grants: .
Orange County $ 25,000 $ 25,000 $ 25,000 0%
Town of Chapel Hill $ 750 $ 1,500 $ 1,500 0%
Town of Carrboro $ 1,000 $ 1,000 $ 1,000 0%
Other Local: IIIIIIII 0
Other Local: Mill.111 .111.111111111 0
Other Local: 111111M11111.111 0
If more than 3 sources,please
provide a separate list.
Non-Local Government Grants
Triangle United Way $ 928 1311111.1M 0
State Government IIIIMIllill. 0
Federal Government 11111M110. 0
Other Grants: 11111111111111=111.11 0
Other Grants: .1 .111=11111 0
Miscellaneous/Other Revenue 111=M11 0
!lease list 3 largest rViscellanous sources:
$ _
$ _
$ _
Total Program Revenue $ 325,761 $ 347,001 $ 362,750 M!!
PROGRAM EXPENSES
Compensation $ 295,014 $ 312,000 $ 310,000 -1%
Rent&Utilities $ 1,561 $ 1,561 $ 1,561 0%
Supplies&Equipment $ 13,423 $ 11,000 $ 12,500 14%
Travel &Training $ 1,964 $ 1,430 $ 1,500 5%
Other Expenses: $ 36,885 $ 38,000 $ 37,000 -3%
Flease list 3 largest"Other Expenses":
Insurance $ 20,943.00
Snacks $ 6,324.00
Copier Lease $ 3,465.00
Total Program Expenses $ 348,847 MIMI 0%
SURPLUS/(DEFICIT)FOR PERIOD: I $ (23,086) $ (16,990)1 $ 189 1 1011
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b.) Program Budget Detail
What is the cost to deliver your project/program? List each project/program element in the table below,
including the cost of each element, the quantity and unit of measure, and the subtotal for each element.
Where necessary, allocate costs to the use of shared space, vehicles or equipment.
Example Program: Credit Counseling Class
Cost Elements Cost($) Quantity/Unit of Measure Subtotal ($)
Credit Counseling Teacher-in class $25 96 hours (8 hrsImth x 12 months) $2,400
Credit Counseling Teacher—class prep $25 48 hours (4hrslmth x 12 mths) $1,200
Credit Counselor—one-on-one $20 120 hours(10 hrstinth x12 mths $2,400
Materials $25 120 course packets/credit reports $3,000
Total $9,000
Complete the table below for the project/program for which you are requesting funds.
Attach additional rows/pages, as needed.
Program: Supplemental Funding for client enrollment and program operations
Cost Elements Cost($) Quantity/Unit of measure Subtotal($)
Client cost per day $44.00 -I unit/day ( 240 days) $10,560
Program Cost(supplies&personnel) $90.00 Average cost per day for operabons(253) $22,770
Total $33,330
c.) Cost per Unit
Actual 2014-15 Estimated 2015-16 Projected 2016-17
Total Cost of Program $348,847 $363,991 $362,561
Total # of Units 6024 6072 6072
Cost Per Unit $57.90 $59.94 $5911
This Cost Per Unit must reflect the total program budget and the total number of
program beneficiaries (households or persons) in this application and must be
consistent with report submittals from previous years (if applicable).
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cl.) Agency Operating Budget
Please show all sources and amounts of funding for your entire current fiscal year. What is your
agency's fiscal year? Example: July 1, 2016 through June 30, 2017. Submit operating budget in
your own format.
Senior Care of Orange County Inc.'s annual fiscal year is July 1, 2016 through June 30, 2017
Do not include funds that have been applied for but not yet awarded: If the total revenue is not
the same amount as the budget for any fiscal year, please attach a statement explaining the deficit
or surplus.
It is required that your Excel budget worksheet be embedded on the next page. You must
also submit an electronic copy of the MS Excel file with your application, as a separate file.
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Section Vl. Financial Data
Operating Budget for Entire Agency
AGENCY NAME: Senior Care of Orange County;Inc,
Actual Estimated Projected Percent
PROGRAM REVENUE 2014-15 2015-16 2016-17 Change
Private Donations $ 150 $ 550 $ 250 MI
Program Generated Revenue (fees) $ 297,933 $ 318,951 $ 335,000 5%
Local Government Grants:
Orange County $ 25,000 $ 25,000 $ 25,000 0%
Town of Chapel Hill $ 750 $ 1,500 $ 1,500 0%
Town of Carrboro $ 1,000 $ 1,000 $ 1,000 0%
Other Local: IMME 0
Other Local: = 11=.1111111111111111111111111 0
Other Local: 0
It rnore than 3 sources,please
provide a separate list.
Non-Local Government Grants
Triangle United Way $ 928 $ - 0
State Government IMIIIIIIIIIIIIIII 0
Federal Gmernment 0
Other Grants: 111111.11111•11111 0
Other Grants: 11.1111111111MEMMINIMII 0
Miscellaneous/Other Revenue 0
Reese list 3 largest Miscellanous sources:
$ -
$ _
$ -
Total Program Revenue IMI $ 347,001 $ 362,750 .1111
PROGRAM EXPENSES
Compensation $ 295,014 $ 312,000 $ 310,000 -1%
Rent&Utilities $ 1,561 $ 1,561 $ 1,561 0%
Supplies&Equipment " $ 11,000 $ 12,500 MN
Travel &Training $ 1,964 $ 1,430 $ 1,500 MI
Other Expenses: $ 36,885 $ 38,000 $ 37,000 MI
Reese list 3 largest"Other Expenses":
Insurance $ 20,943.00 •
Snacks $ 6,324 00
Copier Lease $ 3,465.00
Total Program Expenses $ 348 847 $ 363 991 IIPEI 0%
SURPLUS/(DEFICIT)FOR PERIOD: $ (23,086)1 $ (16,990)1 $ 189 1 iotycl
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Florence Gray Soltys Adult Day Health Program
("Operated 6y. Sem;ar Care of Orange Coemty, //7c)
705 fileadowland Drive
Hillsborough, North Carolina 27278'
• 1/ammona; Pres/de
• ESperse,7 President
eailferson, Treasurer
Karen Daniet Secretary
TeA (979)21'5,2077
Far(9W)2.95-2078'
Main Application: Program/Project Description
i. Other pertinent information included:
Please see attached forms:
• 2 page document on "North Carolina is Aging"
• 2 program brochures
• Caregiver's Corner Quarterly Newsletter
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North Carolina is ��x�^ K��
" ~~°. = = ~�~°^ ~~,." "~° .= Aging!
.��.
The number of adults 65 and older will increase dramatically over the next 15 years.
Here are a few facts:
* North Carolina ranks gth nationally,both in total l population and in the
number of people 65 and older
�
In 2025,one in five North Carolinians will be 65 and older.
�
Our 65 and older population will almost double in the next 20 years from
1.5tv2.5million.
^
The number of people age 85 and older will be the fastes growing
segment beginning in 2030 when the oldest of 2.4 million baby hoomers
near their 85:k birthday.
Population Change 2OI4'2O34
VlaPge
Ages :1611...1";,,, 201,0-g0340
Total 9,953,687 12,020298 20.8%
60+ 2,033,282 20.4% �lI63O37 26.3% 55.6%
65+ 1455,043�`� 14.6% 3,459532 20.5% 69.0%
85+ 169,4 13% 325,964 2.7% 92.3%
Status of North Caroli i 65 and ONe 2014
Living alone 28% 28%
Veterans 21% 22%
Have a disability 38Y6 36%
Have less than high school education 22% 20%
In labor force 16% 17%
Own their homes 82% 79%
Income is below poverty level ` 10% 10%
Income is between 100%-199%of the poverty leve 24% 22%
Median household income $35,204 $37,945
4 2%of individuals 65 and over speak English less than"very well".
*
An estimated 20,191 people 65 and over migrated from other states
and abroad to North Carolina.
+ 100,472 grandparents age 30 and over are responsible for grandchildren
under 1Oin the state. 1.4%of them are age 65 and over.
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�
20%of persons age 65 and over are members of racial or ethnic
minority populations, 16%of them are African-Americans.
Race d Hi i Latino Origin, 65 and older, 2014
White 81.4% 84.5%
Black or African American 15.8% 8.7%
American Indian and Alaska Native 0.8y6 0.5%
1.1% 3
Asian ' '8%
Native Hawaiian and Other Pacific Islander 0.0% 0.1%
Some other race 0.3Y6 1.5%
Two or more races 0,6% 1.0%
Hispanic or Latino origin(of any race 1.5%'SY6 7'3%
White alone, not Hispanic or Latino 80.3% 79.1%
Health Facts:
* North Carolina currently(2015)has 160,000 adults 65 and over with
Alzheimer's disease and this number is projected to rise to 210,000 by
2025.This disease is the fifth leading cause of death among people 65
and over.
• Ofthepeop|e6Sandnvcr,amcopd|ngtothe8ehaviora| RiskFaotor
Surveillance System(BRFSS)survey for 2014:
o 82%had at least one chronic disease.54%of them had 2 or
more chronic diseases;
o
Diseases of the heart(22.1%)and cancer(21.6%)were the
leading causes of death;
o 69%had an adult flu treatment,71%had a pneumonia shot
and 36%either had shingles or the zoster vaccine;
u 72%reported that they had not fallen in the past year;
o 68%reported exercising in the past 30 days.
Sources
1. Alzhelmer's AssocIation,2015 Altheimer's disease Facts and Figures.htto://www.aisarg/facts/
2. North Carolina Office of State Budget and Management,population estimates and projections. http://www^sumoc.xvvitacts-
ngvresWom«m'^n»icu
3. North Carolina State Center for Health Statistics,BREsS. °ww.scx`.state.ocus4ata brfss 2014
4. Census Bureau.American Community Survey,2014 one year estimate and 2010-2014 five year estimates.https:fiwww.census.govi
*prepared by Swarna Reddy,NC DAAS,December 2015
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Ault Day Services Association. An Enriching Day Health Program
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For more information or to make referral.
CD Sir M (Phone) 919®245-2017 (Fax) 919-245-2018 for Adults and Se °ors
U-)Misoltysaayhealth.org
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Florence Gray Soltys Affordable Transportation mailable Our, Benefidial ° . s
Adult Day Health Program for Orange County Residents.
The lives of adults who have
certain physical disabilities and/or
Strongly committed tote ealt
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a being f adults struggling
enriched thorough:
with e entia. The services
offered ° c ude: * Exercise
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Florence Gray Solty
Our program is open
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as well as veterans. - ADULT DAY HEALTH ,
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Florence Gray Soltys There is no need fora veteran to have
Adult Day Health Program
is strongly committed committed to the health � _ to remain home alone, or insituionaIized
and well-being of Veterans with {' `£ � because of minor Health needs.
physical or mental health needs.
Our services to our participants
can enrich
and their families include: Why our program
` A safe, friendly environment a Veterans life.
Qualified nurses & therapists Our participants experience comradery,
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* Assistance bathing m a self fulfillment and the feeling of
Nutritious Meals r I l �al � r aC giving back to the community as well
.Q Caregiver respite as to each other. They are encouraged
Q Socialization to follow their own interests, and
>' The unique needs of each veteran to make as many choices as possible.
Stimulating activities
connection with the community are respected, and their goals for
Our program includes:
<t A focus on each individual's needs personal fulfillment are supported by:
1'o elpfulness in reching the height Exercise recreation
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of thei
DocuSign Envelope ID:4FFDF545-B8C1-4ABF-A6A5-400656A36357 t A - continued
Provider's Outside Agency Application
Florence G. Soltys Adult Day Health Program
105 Meadow land Drive Hillsborough, North Carolina 27278 919-245-2017
Caregaivers Co ,, er
Quarterly Newsletter January— March 2016
"Things that bothered you this week, ten years from now, look entirely different, or fifty years from now. People have
themes in their lives that they like to go back to and emphasize, which are always, I think, very important to listen to."
-Florence Gray Soltys
- s
FREE LEGAL ADVICE provided all day by the Young Lawyers Division of the NC Bar Association!
Caregiver Educar, fl. 2016 Ask-A-Lawyer Dav
Saturday, Feb. 6 The Young Lawyers Division of the North Carolina Bar Association(YLD NCBA) is pleased to provide free
legal advice to citizens through the annual Ask-A-Lawyer Day.
Ask-A-Lawyer Day 2016 will take place Saturday,Feb. 6,at 10 locations across the state.This is a public service event at
which volunteer attorneys provide free legal advice to North Carolina citizens. No business relationship may be established
between the volunteer attorneys and the citizens. It's all completely free.
Attorneys will be on hand to answer questions in the following cities and towns: Asheville, Burlington,Burnsville,Chapel
Hill, Charlotte, Durham,Greensboro, Raleigh, Wilmington and Winston-Salem.
To avoid confusion,please note that this event is different than the NCEIA's 4ALL Statewide Service Day,which is conducted entirely by
phone.That event is conducted annually on the first Friday in March and will he held this year on March 4.
Ask-A-Lawyer Day is coordinated by the YLD's Civic Education and Community Relations Committee,which is chaired by
Andrew R.Jones of Rountree Losee LLP in Wilmington.
Caregiver Chat: Valuable Resource, and It's Free!
Healthy Ti
Thanks YLD NCBA I The Soltys Program was informed of this valuable resource being
offered in our local and surrounding areas by NC-DHHS Division of
Aging&Adult Services in Raleigh, NC via the Young Lawyers Division
of the NC Bar Association.Their statement reads as follows:
0 0 "This is a free, in-person legal program by the Young Lawyers Division
, of the NC Bar Association that will be held in 10 different locations
across the state on Saturday. February 6, 2016. This is open to any
North Carolina citizen of any age,"
• -
list The list of locations and times is on the back of this News Flash.
Please consider the resource. As always, I am available to discuss, in
1,woavi.wow b0,,,aid beta live irt.those stit*mktras detail, how you as a caregiver will benefit from this valuable and free
wlvext our hear ts.trro corkoiotx Omr froo-Vofo&." service!
'fitorrifo.sa Wilder
Call mel
luttrgam,ratawaars-cc xv.
Tamara Griffin, MSW at 919 245 2017.
DocuSign Envelope ID 4FFDF545-B8C1-4ABF-A6A5-400656A36357 i A - continued
Provider's Outside
Florence G. Soltys Adult Day Health Program
105 Meadow land Drive Hillsborough, North Carolina 27278 919,245'2027
�����r��� �� mr ers '
C r
Quarterly NeVVsletterJaDuary— March 2016
Details regarding times, locations, event coordinators and contact information follows:
Asheville Location: Pack Memorial Library, 67 Haywood Street, Asheville, NC 28801 Time: 10 a.m.to 1 p.m. Event
Coordinator: Shannan Barclay Tuorto Contact Information for Event Coordinator: Ingrid Friesen, P.A., 77 Church St.,
Asheville, NC 28801, shannanbarclay@charter.net
Burlington Location: May Memorial Library, 342 S. Spring St., Burlington, NC 27215 Time: 9:30 a.m. to 12 p.m. Event
Coordinator: Nick Bakatsias Contact Information for Event Coordinator: Carruthers& Roth, P.A, 23S N. Edgeworth St.,
Greensboro, NC 27401; njb@crlaw.com; 336-478-1121
Burnsville Location: United Community Bank, 603 E. Bypass, Burnsville, NC 28714 Time: 10 a.m. to 1 p.m. Event
Coordinator: Morgan Peterson Contact Information for Event Coordinator: Roberts &Stevens, P.A., 1 West Pack Square,
Suite 1100, Asheville, NC 28801, mpetenon@prOberbs-stevens.com
Chapel Hill Location:Town of Chapel Hill Public Library, 100 Library Drive, Chapel Hill, NC 27514 Time: 1U am.to 1 p.m.
Event Coordinator:James (Jim) Baker Contact Information for Event Coordinator: Hedrick Gardner Kincheloe & Garofalo
LLP, 4131 Parklake Avenue, Suite 300, Raleigh, NC 27612,919J19.3712, 919.832.9425,jbaker@hedrickgardner.com
Charlotte Location: Legal Services of Southern Piedmont, 1431 Elizabeth Avenue, Charlotte, NC 28204 Time: 10 a.m. to 1
p.m. Event Coordinator: Parker Moore Contact Information for Event Coordinator:Johnston Allison & Hord, 1065 East
Morehead Street, Charlotte, NC 28204; pmoore@jahlaw.com; 704'998'2237
Durham Location: The Cookery-1101 West Chapel Hill Street, Durham, NC 27701 Time: 10 a.m. to 1 p,m. Event
Coordinator: Cohn Shive Contact Information for Event Coordinator:Tharrington Smith LLP, 150 Fayetteville Street, Suite
1800, Raleigh, North Carolina 27602, 919-821-4711, cshive@tsmithlaw.com
Greensboro Location: Greensboro Public Library–219 N. Church St., Greensboro, NC 27401 Time: 10 a.m.to 2 p.m. Event
Coordinator:Jonathan Massell Contact Information for Event Coordinator: Nexsen Pruet, PLLC, 701 Green Valley Road,
Suite 100, Greensboro, NC 27408; JMassell@nexsenpruet.com; 336'387'5159
Raleigh Location: Cameron Village Regional Library, 1A30 Clark Avenue, Raleigh, NC27605 Time: lU:30a.m.ho1:3Up.m.
Event Coordinator: Laura Forrest Contact Information for Event Coordinator: Hedrick Gardner Kincheloe &Garofalo LLP,
4131 Parklake Avenue, Suite 300, Raleigh, NC27612, 919.719.S711, |fmrrext@hedrickXardner.mom
Wilmington Location: Independence Mall, 3500 Oleander Drive, Wilmington, NCl84O3 Time: 11p.nn.toZp.m. Event
Coordinator: Pamela Carter Contact Information for Event Coordinator: Hedrick Gardner Kincheloe & Garofalo LLP, 6770
Parker Farm Drive,Suite 300, Wilmington, NC 28405 pcarter@hedrickgardner.com
Winston-Salem Location: Carver School Road Branch of Forsy h County Public Library, 4915 Lansing Drive,Winston Salem,
NC 27105 Time: 10 a.m.to 12 p.m. Event Coordinator:Toni Grace Contact Information for Event Coordinator: Blanco
Tackabery& Matamoros, P.A., 110 South Stratford Road, Suite 500, VVinston'Sa|em, NC271O4-4299, tjg@blancolaw.com
DocuSign Envelope ID:4FFDF545-B8C1-4ABF-A6A5-400656A36357
EXHIBIT `B"
Scope of Services—FY 2016-17
Outside Agency Performance Agreement
Agency Name: Senior Care of Orange County, Inc
Funding Award: $30,000
Outline how the agency will spend Orange County's funding award.
Expense Description Amount
Personnel—Salaries 30,000
Programmatic Expenses—Supplies,Transportation, Staff Development,and Outreach
Program Services
For assistance with this or the following section, please reference the Exhibit A instructions and example, located within the
contract and reporting memorandum. Outline the major activities the agency will employ to attain the Anticipated Outcomes
below,by June 30,2016.
• To conitnue to provide a therapuetic health model focus to the participants by promoting
independence,wellness, socialization and emotional well being in a community based setting.
• Provide additional respite support services and resources for the families that we serve through
quarterly trainings and inservices.
• To support the conitnuation of additional program supplies when census increases.
Anticipated Outcomes
The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange
County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants
within that measure's description or for an earlier performance measure.
Performance Measures Anticipated
Results
Provide financial community resources to participants 85 %
Prevent families from resulting in institutionalization 15 %
FL:e:Signed u by:
Director 10/26/2016
Certified by: _ Title: Date:
60,52B65B6443...
(Provider's Signature)
DocuSign Envelope ID:4FFDF545-B8C1-4ABF-A6A5-400656A36357
Client#:955852 04SENIOCARI
ACORDTM CERTIFICATE OF UAB L[TY INSURA• NCE DATE(MWDDNYYY)
9!02!2916
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 CONTICCT
NAME:
BB&T Insurance Services,Inc. PHONE 888 743-2217 FAX 8888279861
(AIC,No ExI): (FUG,No):
414 Gallimore Dairy Road E-MAIL
Suite F
ADDRESS:
Greensboro,NC 27409
INSURER(S)AFFORDING COVERAGE NAIL#
INSURER A:Evanston Insurance Company 35378
INSURED INSURERB:Riverport Insurance Company 36684
Senior Care of Orange County Inc
Attn Day Health Cent INSURER C:
INSURER D:
105 Meadowland Dr.
Hillsborough,NC 27278-8181 INSURERE:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY FEE
LTR INSR,WVD POLICY NUMBER (MMIDDNYYY) IMMIODNYYY) LIMITS
A X COMMERCIAL GENERALLIABIUTY SM914951 07/13/2016 07/13/2017 EACH OCCURRENCE 51,000,000
X CLAIMS-MADE OCCUR
PREMISES(Eaccccurrence) 550,060
X BIIPD Ded:5,000 MED EXP(Any one person) 55,000
PERSONAL&ADVINJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s3,000,000
PRO-
POLICY -JECT LOC PRODUCTS-COMP/OP AGG $
OTHER: $
AUTOMOBILE UABILITY COMBINED SINGLE LIMIT
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE
HIRED AUTOS AUTOS (Per accident)
• 5
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE
DED 1 RETENTION$ _ _ $
pci B WORKERS COMPENSATION NCARP305328 02/08/2016 02/0812017 X ISr.MUTE I OTH-
ER
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE YlN
E.L.EACH ACCIDENT $500,000
OFFICEWMEMBEREXCLUDED? [ Yl NIA
(Mandatory In NH) EL.DISEASE-EA EMPLOYEE 5500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below F.L.DISEASE-POLICY LIMIT $500,000
A Sexual Acts SM914951 07/13/2016 07/13/2017 $100,000 occurence
Liablity $300,000 aggregate
DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
Professional Liability-Pol.#SM914951
Professional Liability Limit#1:1,000,000 Ded.#1:$5,000.00
Limit#2:3,000,000
Retroactive Date:July 13,2005 for GL and PRO
(See Attached Descriptions)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
1Uf>1t.Cui
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