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2017-476-E Finance - Charles House Association - Outside Agency Performance Agreement
DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2017, ("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 Charles House Association, a not-for-profit corporation, located at 7511 Sunrise Road, Chapel Hill,NC 27514 ("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 Charles House Association agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2017 to June 30, 2018. 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 B, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 22500 b. All funds appropriated shall be used for purposes described in Exhibit B. 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 5625. 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. (Charles House Association) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 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 12, April 13, and July 13 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. (Charles House Association) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 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. (Charles House Association) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 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 Non-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 $ 13.75 per hour. To the extent possible, Orange County recommends that Charles House Association 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: (Charles House Association) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 County: Finance &Administrative Services Provider: Charles House Association Orange County 7511 Sunrise Road Post Office Box 8181 Chapel Hill,NC 27514 Hillsborough,NC 27278 16. Entire 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. 18. 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. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php). Any violation of this requirement is a breach of the Agreement and County may immediately terminate this Agreement without further obligation on part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. 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. 19. 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 ��i�� �h�P Hof the Provider �u 8/31/2017 6F281 B385F664BB... Date (Charles House Association) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 Form Jf ►f Orange County Government botA lLi, A-cum144 (S 9/5/2017 oe270Q4az55.E47_z Bonnie Hammersley, County Manager Date (Charles House Association) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FOR OFFICE USE ONLY Agency Charles House Association Received By Program(s) jme Eldercao Date/Time Sbsectoj 1. Cover Page a. Applicant Contact Information b. Funding Requests C. Pr Signed Application Cover Page d. WSigned Disclosure of Conflicts of Interest and Clause 2. Agency Information a. 911 Agency's Years in operation b. A, Agency's PurposelMission c. IX Agency's Types of Services Provided d. V Agency's Experience with Programs e. 2 Other Pertinent Agency Information f. 2 Schedule of Positions g. 14 Living Wage h. 4 Agency Budget 3. Program Information a. ■41 Human Services Needs Priority b. Type of Program A separate Section 3 is c. NI Agency Collaboration required for each program. d. Summary of Program e. VI Description of Identified Need L 44 Description of Population to be Served g. 1,1 Program Staffing, Capacity, & Expertise Fr Program Implementation Timeline i. r4 Value of Investment j. Impact of Reduced/No Allocation k. 1 Other Pertinent Information I. 2 Target Population/Beneficiary Chart m. 14 Work Statement n. A Program Budget, Detail, & Cost per Individual 4. Attachments a. IL Audit: Organizations receiving $300,000 or more 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. IRS Federal Form 990 c. 4 NC Solicitation License d. II IRS Federal Tax-Exemption Letter e. 12 Certificate of Insurance f. List of Board of Directors g. Af Solid Waste Program Fee (SWPF)Verification Application Submittal Checklist 1/27/2017 4:52:00 PM Page "I of 1 6 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) A06licant Contact information Applicant Organization's Legal Name: Charles House Association Applicant Organization's Physical Address: 7511 Sunrise Road, Chapel Hill Applicant Organization's Mailing Address: 7511 Sunrise Road, Chapel Hill, NC 27514 Applicant Organization's Web Address: mw.charleshousporg Executive Director: Paul Klever Telephone Number: 919-967-7570 E-Mail: paul • charieshoum_ Tax ID Number: b) Funding Request List all FY17-18 Human Services (HS) Funding 1.;eing Requested — For Milo irca_yris) and the Proposed Use of Funds (2-3 lines or less) ErAgram Carrboro Chapel pranne Total HS Hill-HS ,,County-HS_ Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 Afterschool Program Coordinator salary and materials for youth activities and projects DAYTIME ELDERCARE PROGRAM $4000 $10,000 $25,000 $39,000 Totals $4000 $10,000 $25,000 $39,000 c) 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: JA V3e) ,2c))7 Executive Director Date SignatureA44-44 S. AV //.10/20/ 7 Board Chairperson Date AGENCY INFORMATION 1/27/2017 4:48:43 PM Page 2 of 1 7 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST ANI NON DISC*IMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO n a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? LI] E b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? 0 c) Current beneficiaries of the program for which funds are being requested? 111 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. NON-DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to 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, gender identity/expression, 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. To the best of my knowledge and belief :II 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 program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. c1-7010ji 2e)/7 Signature: Executive Director Date Signature: /04e4 $c za 7 Board Chairperson Date ( AGENCY INFORMATION 1/27/2017 4:48:43 PM Page 3 of 1 7 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 2. AGENCY INFORMATION (Be Very Brief and Concise) Please provide the following information about your agency (2 pages OR LESS): a) Years in Operation, Date of Incorporation (Month/Year): Incorporated: 03/1984; 0_perations began: 06/1990 b) Agency's Purpose/Mission (no more than a few sentences): Charles House Association is a private, nonprofit organization whose mission is threefold: a) Enriching the lives of seniors b) Supporting families caring for aging family members c) Representing the community's commitment to its elders c) Types of Services the Agency Provides (bullet format): The Charles House Center for Community Eldercare includes: O Daytime Eldercare Program O Caregiver Orientation, Resources and Education—CORE Support Program O The Bradley Program in Learning & Service: opportunities for students and interns to be introduced to careers in aging and the positive Charles House approach to working with elders O Agency Administration, Community Outreach, Management of Eldercare Homes Charles House operates the pioneering residential care settings—neighborhood eldercare homes—in the Heritage Hills and the Winmore neighborhoods. d) Agency's History with Providing These Services: Since 1990, Charles House has been a leader in developing innovative, highly respected, services for elders and their caregiving families. Charles House's Daytime Eldercare Program is exemplary in bringing together community members, caregiving families, elders, other community resources, funders and donors, to support some of the most frail elders and the most challenged families in our community. Since 2011, Charles House has pioneered neighborhood Eldercare Homes as an innovative model of residential care and end-of-life care. e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? Is there a new Executive Director?Are there new initiatives?) Charles House celebrated its 25th Anniversary in October, 2016, with an event at The Friday Center featuring Jill McCorkle and Clyde Edgerton in conversation with D.G. Martin, plus musicians Carver, Hicks, Watson & Newberry. f) Schedule of Positions (For Entire Agency) • Full Time Equivalent(FTE) staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours =Volunteer FTE 2,080 # of FTE - Full-Time Paid Positions: 19.3 # of FTE - Paid Part-Time Positions: 8,25 # of Volunteers: 100+ # of FTE - Volunteers:10 g) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes/No) YES If yes, is this agency an Oran•le Count Livin. Wasle Certified Emslo er? NO If no, please explain. Since learning about the living wage determination in Orange County, the board of directors has been striving to move the entry pay rates to, and above, the living wage determination. All employees who are eligible for the employer sponsored health plan are at or above the living wage determination. As the organization moves to achieve 100% living wage designation, the board of directors will evaluate becoming a certified employer. Agency Information 1/27/2017 4:52:00 PM, Page 4 of 16 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION h) Agency Budget I. Is your agency currently receiving and/or requesting other (non-Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes/No) NO If yes, please list below: Include all programs that have funding requests/awards/totals from Carrboro Chapel Hill and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME I Program FY16-17 FY17-18 Source Award Request Ex: Affordable Rental 0 $20,000 Carrboro -Affordable Housing Rehabilitation Ex: Agency Administration $15,000 $15,000 Carrboro— Other Ex. Total $15,000 $35,000 Carrboro Total Funding *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate xis file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues o Private Donations o Program Generated Revenue o Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services Agency Information 1/27/2017 4:52;00 PM Page 5 of 16 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Orange County Other (DO NOT Include HOME funding here) O Other Government Grants • Triangle United Way • State Government Federal Government (CDBG/HOME/etc.) • Private Foundation Grants O Other Revenue Expenditures O Compensation O Rent & Utilities O Supplies & Equipment O Travel & Training O Other Expenses iii. Does your agency budget show a Surplus or Deficit? Surplus Is there a significant change? Yes/No NO Please provide a brief explanation for Surplus or Deficit, and significant changes. iv. What is your agency's fiscal year? January 1 through December 31 (Example: July 1, 2016 through June 30, 2017) Agency Information 1/27/2017 4:52:00 PM Page 6 of 16 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: CHARLES HOUSE ASSOCIATION *based on Jan-Dec Fiscal Years Actual Estimated Projected Percent AGENCY REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 145,000 $ 150,000 I $ 50,000 -67% Agency Generated Revenue (fees) $ 1,185,725 $ 1,370,000 $ 1,441,600 5% Local Government Grants: Human Services -Town of Carrboro $ 3,500 $ 3,500 $ 4,000 14% Other--lown of Carrboro $ - $ - 0 Human Services -Town of Chapel Hill $ 9,000 $ 9,000 1 $ 10,000 11% Other-Town of Chapel Hill $ - $ - 1 $ 0 Human Services -Orange County $ 15,000 $ 20,000 $ 25,000 25% Other-Orange County $ - $ - $ 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOMEletc.) $ - $ - $ - 0 Private Foundation Grants $ 18,000 $ 60,500 $ 50,000 $ (0.17)1 Other Revenue $ 7,300 $ 1,250 $ 1,000 $ (0,20)1 $Total Agency Revenue 4) 1 1,383,525 $1,614,250 $1,581,600 -2% AGENCY EXPENSES Compensation/Personnel $ 990,000 $ 1,125,550 $ 1,140,000 1% Rent& Utilities $ 135,000 $ 133,100 $ 160,000 20% Supplies, Equipment, Program $ 80,000 $ 82,500 $ 82,000 -1% Development/Outreach $ 22,750 $ 32,000 $ 25,000 -22% Other Expenses: Administrative Exp. $ 31,500 $ 40,000 $ 37,000 -8% Other Expenses: Depreciaion $ 62,800 $ 64,150 $ 64,100 0% Total Agency Expenses $ 1,322,050 $1,477,300 $1,508,100 2% SURPLUS/(DEFICIT) FOR PERIOD: I $ 61,475 1 $ 136,950 1 $ 73,500 1 -46% FY 2015-16 Comparative Agency Budget Revised 9/2912014 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Charles House: Daytime Eldercare Program Program Primary Contact and Title: Paul Klever, Executive Director Telephone Number: 919-967-7570 E-Mail: paulRcharleshouse.org a) Indicate the type of Human Service Needs Priority, if program applicable: Di Priority Area #1: safety-net services for disadvantaged residents LI Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges Zi Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Public Housing Program Category Youth Adult Elderly Disabled Neighborhoods/Residents Affordable Housing Affordable Healthcare X X Education Family Resources Jobs/Jobs Training Food Transportation Other: Please specify Daytime Eldercare X X • Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated/collaborative efforts. • Orange County: Department on Aging—collaboration on various projects, including the Master Aging Plan, the Aging-in-Community series, sharing referrals for aging transitions, long-term care collaborative, contractually serve Orange County families/caregivers. • Orange County: Department of Social Services—collaboration on contractually serving Orange County families/caregivers, as well as with Adult Protective Services and regulatory oversite done by DSS. • UNC-Chapel Hill—collaborations with many of the schools and academic departments/programs on opportunities for learning & service for students/interns. • UNC Health Care—collaboration on clinical initiatives, volunteers and Charles House leadership • Duke University—collaboration with the Fuqua Business School, Medical School and Family Support Program. • Central Carolina University—collaboration with the school of social work. • Durham Technical—collaboration with the occupational therapy assistant program • Watts School of Nursing—collaboration on service learning PROGRAM INFORMATION 1/27/2017 4:52:00 PM Page 7 of 16 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION O Chapel Hill Transit E-Z Rider—collaboration on transportation Orange County Animal Shelter—collaboration on community service projects for sheltered animals. O Chapel Hill Library—collaboration on community service projects for children's library O Chapel Hill Service League—collaboration on community service projects for the League's Christmas House. • IFC's HomeStart Homeless Shelter---collaboration on community service projects, including flower arrangements for the HomeStart shelter. O Carol Woods Retirement Community—collaboration on community outreach and service to residents. O Carolina Meadows—collaboration through Carolina Meadows community agency funding program and service to residents. Various home health agencies; area assisted living and nursing care facilities—collaboration on service coordination, client referrals, etc. Various area schools—student groups, including music groups, volunteer at Charles House. • Area civic groups, churches—community outreach, church and group members often volunteer at Charles House. Program Description (3 pages OR LESS) Please provide the following information about the proposed program: c) Summarize the program services proposed and how the program will address a Town/County priority/goal? The Charles House Daytime Eldercare Program is a significant support to caregiving families in our community, families carrying the burdens of caring for aging and frail family members. The Daytime Program enriches the wellbeing of elders who participate in the program and provides significant support and respite to family caregivers. The Chapel Hill Human Human Service Needs Assessment identified priorities: Affordable Healthcare and in the priority of Education and Family Resources a sub-priority identified is Family supports and resources— The Charles House Daytime Eldercare Program addresses both these priority areas. Charles House is a primary support for families dealing with the challenges of caring for a frail elder family member. The Daytime Eldercare Program is an affordable care option for families and supports their caregiving. The Orange County BOCC Goal 1: Ensure a community network of basic human services and infrastructure that maintains, protects, and promotes the well-being of all county residents. The Charles House Daytime Eldercare Program provides significant support to the health and wellbeing of some of the most frail citizens in our community and supports the wellbeing of their family caregivers. The Carrboro Board Priorities include: Create public/private partnerships for various special programs..., Offer diversified programs reflective of citizen needs and promotes sensitivity to cultural diversity., and The Charles House Daytime Eldercare Program provides significant support to the health and wellbeing of some of the most frail citizens in our community and supports the wellbeing of their family caregivers. d) Describe the community need or problem to be addressed in relation to the Chapel Hill PROGRAM INFORMATION 1/27/2017 4:52:00 PM Page 8 of 16 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Human Services Needs Asses§:rhent, Qrapag County BOCC Goals and Pnorities, Town of Chapel 0-11111 Council Goals, Carrboro goals, or other community priorities (i.e. Council/Board Goals), Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. See description is a). in addition, Charles House is a significant community resource, as well as one of the very few established nonprofit organizations, serving the quickly growing eider population. Our community is experiencing a population "explosion," of sorts, with some of the fastest growth rates for the 65+ population in the state. While Orange County is notably progressive in addressing aging issues, the needs for supportive services to enhance the quality of life and wellbeing for these—and all residents—will increase with this population growth. This is especially true for those families and individuals facing some of the most difficult challenges of aging—as people move into frailty. Charles House is an exceptional community resource for these families. e) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? The target population for Charles House services is families and individuals who are dealing with challenges of aging, including cognitive decline, dementia, Alzheimer's, Parkinson's, neuro-muscular disorders, stroke, vision and hearing loss, ambulation and balance concerns, social engagement decline, etc. t) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Staff credentials: Chuck Fleming, Program Administrator, MSW, experience in aging services. Dean Fox, Program Director, MSW, 5 years Charles House experience. Fiona Allen, Program Director, Masters Recreation Therapy. The Program Team of Directors and Facilitators bring varying levels of experience, working as a collaborative team. Training is an ongoing process of orientation, peer instruction and in-service training. Volunteers who are part of the Program Team also receive orientation, peer instruction and will participate in in-service training. g) Describe the specific period over which the activities will be carried out and include an implementation timeline. The Charles House Daytime Program is an ongoing service. The program operates Monday through Friday, 7:30-5:30. h) Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) As stated in d), Charles House is an exceptional community resource addressing the challenging issues caregiving families face with aging family members. The resources and support services provided to these families is vital to our community being a welcoming and attractive place to live, work, and age. 0 Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. The Human Services Funding is critical to the Charles House Scholarship Fund, which allows services to be made available to families across the socio-economic spectrum, families of need and to accommodate the significant agency discounts for the Orange County Department on Aging and Dept. of Social Services. Without this funding, there would be severe reduction in the level of services available to PROGRAM INFORMATION 1/27/2017 4:52:00 PM Page 9 of 16 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Orange County agencies clients and other families of need. j) include any other pertinent information. PROGRAM INFORMATION 1/2712017 4:52:00 PM Page 10 of 16 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 I EXHIBIT A I PROVIDER'S OUTSIDE AGENCY APPLICATION Additional piro ram Information k) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male 43 45 48 Female 61 65 70 Total 104 110 118 Ethnicity African-American 8 10 12 American Indian or Alaska Native Asian 2 3 4 Caucasian 93 95 99 , — , Native Hawaiian or other Pacific Islander Other: specify Hispanic 1 2 3 Total 104 110 118 Of the above, how many Hispanic/Latino Of the above, how many non-Hispanic/Latino . .......... Total 0 0 0 Age 0-5 years 6-18 years 19-50 years 51+ years 110 118 .... .. Total j 0 0 0 Geographic Location Alamance County 2 3 3 Chatham County 15 16 18 Durham County 27 28 30 Wake County 2 2 2 Orange County Breakdown Chapel Hill Public Housing _ Town of Chapel Hill (Non-Public Housing) 46 48 50 Town of Carrboro 5 6 7 Town of Hillsborough 1 1 1 City of Mebane (Orange County) Orange County (Outside Municipalities) 6 6 7 Total 104 110 118 PROGRAM INFORMATION 1/27/2017 4:52:00 PM Page 11 of 1 6 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement I) Complete the Work. Statement. Chart to describe the work to be performed. This chart 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. Every program is required to have AT LEAST 1 Program Activity, which should be SMART( ecific, Measurable, Achievable, Relevant, and Time-bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) e Program Goal should explain what the program is trying to achievefaccomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday-Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day,) e Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program Charles House Daytime Eldercare Program 1. Program Activity Name Family Caregiver Support: The Charles House Daytime Program supports family caregivers by offering respite from the ongoing concerns of caring for a loved one and by supporting the best functioning of their loved ones through participation in the therapeutic program Program Goal Enrollment in the program allows caregiving families to continue their caregiving as they wish. Performance Measures 50% of enrolled families in the funding year will have the capacity to continue providing care in the home and not require, or delay, residential care placement for their participant/enrolled family member. Previous Year Program Results At the end of the FY, 66%of the families enrolled at the beginning of the FY were still engaged in caring for their loved ones. Current Year Estimated Results Estimating 65%of the enrolled families at the beginning of the grant year will continue family caregiving throughout the year. Next Year Projected Results Projecting 70% of the enrolled families at the beginning of the grant year will continue family caregiving throughout the year. 2. Program Activity Name Enriching the lives of elders, enhancing well-being and supporting functioning: The relationship Charles House maintains with enrolled families is the basis for the collaboration in caring. The daytime program works to support a variety of functioning abilities for participants: including self-esteem,gross and fine motor skills, social skills, verbal skills, ambulation, memory and reminiscence, activities of daily living. Program Goal The Charles House program thrives to enhance the functioning and quality of life for participants. Performance Measures Over 75% of families will report in the annual evaluation survey satisfaction with the Charles House program and will report positive effects of the program for their enrolled family members, such as improvement in their participant/enrollee's behavior, emotional status, physical and/or cognitive functioning PROGRAM I C FORMATION 1/27/2017 4:52:00 PM P a g e 12 of 16 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Previous Year Program Results The 2015 Caregiver Survey showed 100%of repotting families observing improvements in their family member's functioning. Current Year Estimated Results The 2016 Caregiver Survey also showed 100% of reporting families observing improvements in their family member's functioning. Next Year Projected Results It is projected that the 2017 Caregiver Survey will show over 90% of reporting families observing improvements in their family member's functioning. 3. Program Activity Name Maintain Program Standards: Program administration assures that all aspects of the program are in compliance with the state rules for annual certification Program Goal The program strives for a level of excellence and maintains standards required by the State Division of Aging and Adult Services Performance Measures (While the annual caregiver survey is a good tool for measuring qualitative standards of the program, state licensure is also a measurable marker.) Charles House Association will continue to surpass the NC Standards and maintain state certification to operate as an adult day program. Previous Year Program Results Charles House received recertification by the State Division of Aging and Adult Services in July,2015 Current Year Estimated Results Charles House received recertification by the State Division of Aging and Adult Services in June,2016 Next Year Projected Results It is projected that Charles House will successfully complete recertification by the State Division of Aging and Adult Services in summer,2017 4. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results PROGRAM INFORMATION 1/27/2017 4:52:00 PM Page 13 of 16 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME: CHARLES HOUSE: Daytime Eldercare Program *based on Jan-Dec Fiscal Years Actual Estimated Projected Percent PROGRAM REVENUE 2015-16* 2016-17 201748 Change Private Donations $ $ - $ 0 Program Generated Revenue $ 375,725 $ 545,000 $ 590,000 8% Local Government Grants: Human Services-Town of Carrboro $ 3,500 $ 3,500 $ 4,000 14% Other-Town of Carrboro $ - $ $ - 0 Human Services-Town of Chapel Hill $ 9,000 $ 9,000 $ 10,000 11% Other-Town of Chapel Hill $ $ $ - 0 Human Services - Orange County $ 15,000 $ 20,000 $ 25,000 25% Other- Orange County $ $ - $ - 0 Other-Town of Hillsborough $ $ $ - 0 Other Government Grants Triangle United Way $ $ $ - 0 State Government $ $ $ 0 Federal Government (CDBG/HOME/etc) $ $ - $ 0 Private Foundation Grants $ $ - $ 0 Other Revenue $ $ - $ - 0 Total Program Revenue $ 403,225 $ 577,500 $ 629,000 9% PROGRAM EXPENSES Compensation $ 350,000 $ 365,000 $ 448,500 23% Rent& Utilities $ 53,500 $ 73,000 $ 89,000 22% Supplies, Equipment, Program $ 32,725 $ 32,000 $ 34,000 6% Travel & Training $ $ $ 0 Other Expenses: Administrative Exp. $ 5,500 $ 7,000 $ 6,500 -7% Other Expenses: Depreciation Exp. $ 17,300 $ 23,000 $ 23,000 0% $ 459,025 $ 500,000 $ 601,000 20%, SURPLUSI(DEFICIT) FOR PERIOD: $ (55,800)1 $ 77,500 1 $ 28,000 1 -64% DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 EXHIBIT "B" Scope of Services— FY 2017-18 Outside Agency Performance Agreement Agency Name: CIIARLES HOUSE ASSOCIATION Program Name: DAYTIME ELDERCARE PROGRAM Funding Award: $22,500 Outline how the agency will spend Orange County's funding award. Expense Description Amount Personnel support; payroll $22,,500 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. « The Daytime Eldercare Program provides therapeutic social engagement, care and activity for elders and respite for their family caregivers. Family Caregiver Support:The Charles House Daytime Program supports family caregivers by offering respite from the ongoing concerns of caring for a loved one and by supporting the best functioning of their loved ones through. participation in the therapeutic program Enriching the lives of elders, enhancing well-being and supporting functioning: • The relationship Charles House maintains with enrolled families is the basis for the collaboration in caring. The daytime program works to support a variety of functioning abilities for participants: including self-esteem, gross and fine motor skills, social skills, verbal skills, ambulation, memory and reminiscence, activities of daily living. Maintain Program Standards: o Program administration assures that all aspects of the program are in compliance with the state rules for annual certification 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 50% of enrolled families in the funding year will have the capacity to continue providing care in the home and not require, or delay, residential care placement for their partici ant/enrolled family member. Over 75% of families will report in the annual evaluation survey satisfaction with the Charles House program and will report positive effects of the program for their enrolled family members, such as improvement in their participant/enrollee's behavior, emotional status, physical and/or cognitive functioning (While the annual caregiver survey is a good tool for measuring qualitative standards of the program, state licensure is also a measurable marker.) Charles House Association will continue to surpass the NC Standards and maintain state certification to operate as an adult day rogram. DocuSigned by: PAUL . Executive Di rector $/31/2017 lob 6F 8 e 5F6 4BB_. Certified by i , 4. :' 'a Title: e toe Date: 1-7 5. 17 (Provider's Signature) DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 ATTACHMENT "A" Orange County Certifications—FY 2017-18 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 PAUL µhr Executive Director 8/31/2017 Certified by: 6F281B385F664BB_. Title: Date: (Provider's Signature) (Charles House Association) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 CHARHOU-01 DMASON ACORO"° CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 07/07 �.... 07/07/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Summers Thompson Lowry,Inc. PHONE FAX 100 Europa Drive (A/C,No,Ext): (919)968-4472 (A/C,No):(919)942-4221 Suite 571 ADDRESS:info @STLinsure.com Chapel Hill,NC 27517-2393 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Philadelphia Ins Co INSURED INSURER B:Carolina Mutual Insurance Inc. Charles House Association INSURER C Paul Klever 7511 Sunrise Road INSURER D: Chapel Hill,NC 27514 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 SUBR W POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD VD (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X PREMIS P PHPK1650069 05/10/2017 05/10/2018 REMI EES S(Ea( RENTED occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY PRO LOC PRODUCTS-COMP/OPAGG $ 3,000,000 PRO- OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO PHPK1650069 05/10/2017 05/10/2018 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ X AUTOS ONLY X AUUTOS ONLYY PROPERTY DAMAGE (Per PROPERTY A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE PHUB582933 05/10/2017 05/10/2018 AGGREGATE $ 1,000,000 DED X RETENTION$ 10,000 $ B WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N WC19056-2017 06/25/2017 06/25/2018 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 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