HomeMy WebLinkAbout2019-636-E DSS - Charles House adult day care DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6 Contract468-2042
Charles liouse
Contract#68-2042 Fiscal Year Begins July 1, 2019 Ends June 30 , 2020
This contract is hereby entered into by and between the Orange County Department of Social Services (the "County") and
Charles House(the"Contractor")(referred to collectively as the"Parties"). The Contractor's federal tax identification number
or Social Security Number is 58-1582881 and County's DUNS Number is 09-157-5191,
1. Contract Documents: This Contract consists of the following documents:
(1) This contract
(2) The General Terms and Conditions (Attachment A)
(3) The Scope of Work, description of services, and rate (Attachment B)
(4) Federal Certification Regarding Drug-Free Workplace & Certification Regarding Nondiscrimination (Attachment C)
(5) Conflict of Interest(Attachment D)
(6) No Overdue Taxes (Attachment E)
(7) Certification Regarding Transportation (Attachment J)
(8) IRS federal tax exempt letter or 501 (c)(Attachment K) httr):Y/www.i rs.gov/pub/irs-fil Ilk 1023-pdf
(9) State Certification (Attachment M)
(10) Non-Discrimination, Clean Air, Clean Water (Attachment N)
(11) Outcomes and Reporting (Attachment O)
These documents constitute the entire agreement between the Parties and supersede all prior oral or written statements
or agreements.
2. Precedence among Contract Documents: In the event of a conflict between or among the terms of the Contract
Documents, the terms in the Contract Document with the highest relative precedence shall prevail. The order of
precedence shall be the order of documents as listed in Paragraph 1, above, with the first-listed document having the
highest precedence and the last-listed document having the lowest precedence. If there are multiple Contract
Amendments,the most recent amendment shall have the highest precedence and the oldest amendment shall have the
lowest precedence.
3. Effective Period: This contract shall be effective on July 1. 2019 and shall terminate on June 30, 2020.
This contract must be twelve months or less.
4. Contractor's Duties: The Contractor shall provide the services and in accordance with the approved rate as described in
Attachment B, Scope of Work, and shall meet the requirements set for in Attachment O, Outcomes and Reporting.
5. County's Duties: The County shall pay the Contractor in the manner and in the amounts specified in the Contract
Documents. The total amount paid by the County to the Contractor under this contract shall not exceed $24.000, This
amount consists of$24,000 in Federal funds(CFDA# ), $ 0 in State Funds, $0 in County funds
® a. There are no matching requirements from the Contractor.
❑ b. The Contractor's matching requirement is $ , which shall consist of:
❑ In-kind ❑ Cash
❑ Cash and In-kind ❑ Cash and/or In-kind
The contributions from the Contractor shall be sourced from non-federal funds.
The total contract amount including any Contractor match shall not exceed $24,000.
6. Reversion of Funds:
Any unexpended grant funds shall revert to the County Department of Social Services/Human Services upon
termination of this contract.
7. Reporting Requirements:
Contractor shall comply with audit requirements as described in N.C.G.S. § 143C-6-22&23 and OMB Circular-CFR Title
2 Grants and Agreements, Part 200, and shall disclose all information required by 42 U S C 455A 04, or 42 USC 455.105,
or 42 USC 455.106.
8. Payment Provisions:
Payment shall be made in accordance with the Contract Documents as described in the Scope of Work,
Contract-General (06119) Pagel of 4
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6 Contract#68-2042
Charles House
Attachment B.
9. Contract Administrators: All notices permitted or required to be given by one Party to the other and all questions about
the contract from one Party to the other shall be addressed and delivered to the other Party's Contract Administrator.
The name, post office address, street address, telephone number, fax number, and email address of the Parties'
respective initial Contract Administrators are set out below. Either Party may change the name, post office address,street
address, telephone number, fax number, or email address of its Contract Administrator by giving timely written notice to
the other Party.
For the County:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Kim Lassiter-Fisher, Adult Services Supervisor Kim Lassiter-Fisher, Adult Services Supervisor
Orange County Department of Social Services Orange County Department of Social Services
P❑ Box 8181 PO Box 8181
Hillsborough, NC 27278 Hillsborough, NC 27278
919-245-2880 919-245-2880
Lassiter@orangecountync.gov I Lassiter oran ecount nc. ov
For the Contractor:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Paul Klever Paul Klever
Charles House Association Charles House Association
7511 Sunrise Road 7511 Sunrise Road
Chapel Hill, NC 27514 Chapel Hill, NC 27514
919-967-7570 919-967-7570
10. Supplementation of Expenditure of Public Funds:
The Contractor assures that funds received pursuant to this contract shall be used only to supplement, not to
supplant, the total amount of federal, state and local public funds that the Contractor otherwise expends for contract
services and related programs. Funds received under this contract shall be used to provide additional public funding
for such services; the funds shall not be used to reduce the Contractor's total expenditure of other public funds for
such services.
11. Disbursements:
As a condition of this contract, the Contractor acknowledges and agrees to make disbursements in accordance with
the following requirements:
(a) Implement adequate internal controls over disbursements;
(b) Pre-audit all vouchers presented for payment to determine:
■ Validity and accuracy of payment
• Payment due date
• Adequacy of documentation supporting payment
■ Legality of disbursement
(c) Assure adequate control of signature stampslplates;
(d) Assure adequate control of negotiable instruments; and
(e) Implement procedures to insure that account balance is solvent and reconcile the account monthly.
12. Outsourcing to Other Countries:
The Contractor certifies that it has identified to the County all jobs related to the contract that have been outsourced
to other countries, if any. The Contractor further agrees that it will not outsource any such jobs during the term of
this contract without providing notice to the County.
13. Federal Certifications:
Contract-General (06/19) Page 2 of 4
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6 Contract468-2042
Charles House
Individuals and Organizations receiving federal funds must ensure compliance with certain certifications required by
federal laws and regulations. The contractor is hereby complying with Certifications regarding Nondiscrimination,
Drug-Free Workplace Requirements, Environmental Tobacco Smoke, Debarment, Suspension, Ineligibility and
Voluntary Exclusion Lower Tier Covered Transactions, and Lobbying. These assurances and certifications are to
be signed by the contractor's authorized representative.
14. Specific Language Not Previously Addressed:
( can be delted if not needed)
15. Signature Warranty: The undersigned represent and warrant that they are authorized to bind their principals to the
terms of this agreement.
The Contractor and the County have executed this contract in duplicate originals, with one original being retained by each
party.
DocuSilgn/ed by:
Pau Alt v�.t,y' 7/2/2019
Signature Date
Paul Klever Executive Director
Printed Name Title
tfNTi9 red by:
f jbin,IMt, �AaMtMt,VS�t 9/16/2019
Signature (must be legally authorized to sign contracts for County DSS) Date
Bonnie Hammersley County Manager
Printed Name Title
�°ftAT"Ient has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act.
('I-N 9/16/2019
Signature of County Finance Officer Date
Contract-General (06/19) Page 3 of 4
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
ATTACHM ENT A
GENERAL TERMS AND CONDITIONS
Orange County Department of Social Services
Relationships of the Parties the County or the Contractor,receiving services or benefits
under this contract shall be deemed an incidental
Independent Contractor: The Contractor is and shall be beneficiary only.
deemed to be an independent contractor in the performance
of this contract and as such shall be wholly responsible for Indemnity and Insurance
the work to be performed and for the supervision of its
employees. The Contractor represents that it has,or shall Indemnification: The Contractor agrees to indemnify and
secure at its own expense, ail personnel required in hold harmless the County and any of their officers,agents
performing the services under this agreement. Such and employees,from any claims of third parties arising out
employees shall not be employees of, or have any or any act or omission of the Contractor in connection with
individual contractual relationship with the County. the performance of this contract.
Subcontracting: The Contractor shall not subcontract any Insurance: During the term ofthe contract,the Contractor
of the work contemplated under this contract without prior at its sole cost and expense shall provide commercial
written approval from the County. Any approved insurance of such type and with such terms and limits as
subcontract shall be subject to all conditions of this may be reasonably associated with the contract. As a
contract.Only the subcontractors specified in the contract minimum, the Contractor shall provide and maintain the
documents are to be considered approved upon award of following coverage and limits:
the contract. The County shall not be obligated to pay for (a) Worker's Compensation - The contractor shall
any work performed by any unapproved subcontractor. provide and maintain Worker's Compensation
The Contractor shall be responsible for the performance of Insurance as required by the laws of North
all of its subcontractors. Carolina,as well as employer's liability coverage
with minimum limits of$500,000.00,covering all
Assignment: No assignment of the Contractor's of Contractor's employees who are engaged in any
obligations or the Contractor's right to receive payment work under the contract. If any work is sublet,the
hereunder shall be permitted. However, upon written Contractor shall require the subcontractor to
request approved by the issuing purchasing authority,the provide the same coverage for any of his
County may: employees engaged in any work under the
(a) Forward the Contractor's payment check(s) contract.
directly to any person or entity designated by the (b) Commercial General Liability - General
Contractor,or Liability Coverage on a Comprehensive Broad
(b) Include any person or entity designated by Form on an occurrence basis in the minimum
Contractor as a joint payee on the Contractor's amount of$1,000,000.00 Combined Single Limit.
payment check(s). (Defense cost shall be in excess of the limit of
In no event shall such approval and action obligate the liability.)
County to anyone other than the Contractor and the (c)Automobile Liability Insurance: The Contractor
Contractor shall remain responsible for fulfillment of all shall provide automobile liability insurance with a
contract obligations. combined single limit of$500,000.00 for bodily
injury and property damage; a limit of
Beneficiaries: Except as herein specifically provided $500,000.00 for uninsured/under insured motorist
otherwise,this contract shall inure to the benefit of and be coverage; and a limit of$25,000.00 for medical
binding upon the parties hereto and their respective payment coverage. The Contractor shall provide
successors. It is expressly understood and agreed that the this insurance for all automobiles that are:
enforcement of the terms and conditions of this contract, (a) owned by the Contractor and used in the
and all rights of action relating to such enforcement,shall performance of this contract;
be strictly reserved to the County and the named (b) hired by the Contractor and used in the
Contractor.Nothing;contained in this document shall give performance of this contract; and
or allow any claim or right of action whatsoever by any (c) Owned by Contractor's employees and
other third person.It is the express intention ofthe County used in performance of this contract("non-
and Contractor that any such person or entity, other than owned vehicle insurance"). Non-owned
General Terms and Conditions-(06/16) Pagel of 5
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
vehicle insurance protects employers when
employees use their personal vehicles for Termination Without Cause: The County may terminate
work purposes. Non-owned vehicle this contract without cause by giving 30 days written
insurance supplements, but does not notice to the Contractor.
replace,the car-owner's liability insurance.
Termination for Cause: If, through any cause, the
The Contractor is not required to provide and maintain Contractor shall fail to fulfill its obligations under this
automobile liability insurance on any vehicle—owned, contract in a timely and proper manner,the County shall
hired,or non-owned--unless the vehicle is used in the have the right to terminate this contract by giving written
performance of this contract. notice to the Contractor and specifying the effective date
(d) The insurance coverage minimums specified in thereof. In that event,all finished or unfinished deliverable
subparagraph(a)are exclusive of defense costs. items prepared by the Contractor under this contract shall,
(e) The Contractor understands and agrees that the at the option of the County, become its property and the
insurance coverage minimums specified in Contractor shall be entitled to receive just and equitable
subparagraph (a) are not limits, or caps, on the compensation for any satisfactory work completed on such
Contractor's liability or obligations under this contract. materials,minus any payment or compensation previously
(f) The Contractor may obtain a waiver of any one or more made. Notwithstanding the foregoing provision, the
of the requirements in subparagraph (a) by Contractor shall not be relieved of liability to the County
demonstrating that it has insurance that provides for damages sustained by the County by virtue of the
protection that is equal to or greater than the coverage Contractor's breach of this agreement,and the County may
and limits specified in subparagraph(a). The County withhold any payment due the Contractor for the purpose
shall be the sole judge of whether such a waiver of setoff until such time as the exact amount of damages
should be granted. due the County from such breach can be determined. In
(g) The Contractor may obtain a waiver of any one or more case of default by the Contractor, without limiting any
of the requirements in paragraph(a)by demonstrating other remedies for breach available to it,the County may
that it is self-insured and that its self-insurance procure the contract services from other sources and hold
provides protection that is equal to or greater than the the Contractor responsible for any excess cost occasioned
coverage and limits specified in subparagraph(a). The thereby. The filing of a petition for bankruptcy by the
County shall be the sole judge of whether such a Contractor shall be an act of default under this contract.
waiver should be granted.
(h) Providing and maintaining the types and amounts of Waiver of Default: Waiver by the County of any default
insurance or self-insurance specified in this paragraph or breach in compliance with the terms of this contract by
is a material obligation of the Contractor and is of the the Provider shall not be deemed a waiver of any
essence of this contract. subsequent default or breach and shall not be construed to
(i) The Contractor shall only obtain insurance from be modification of the terms of this contract unless stated
companies that are authorized to provide such to be such in writing, signed by an authorized
coverage and that are authorized by the Commissioner representative of the County and the Contractor and
of Insurance to do business in the State of North attached to the contract.
Carolina.Ail such insurance shall meet all laws of the
State of North Carolina. Availability of Funds: The parties to this contract agree
(j} The Contractor shall comply at all times with all lawful and understand that the payment of the sums specified in
terms and conditions of its insurance policies and all this contract is dependent and contingent upon and subject
lawful requirements of its insurer. to the appropriation, allocation, and availability of funds
(k) The Contractor shall require its subcontractors to for this purpose to the County.
comply with the requirements of this paragraph.
(1) The Contractor shall demonstrate its compliance with Force Majeure: Neither party shall be deemed to be in
the requirements of this paragraph by submitting default of its obligations hereunder if and so long as it is
certificates of insurance to the County before the prevented from performing such obligations by any act of
Contractor begins work under this contract. war,hostile foreign action,nuclear explosion,riot,strikes,
civil insurrection,earthquake,hurricane,tornado,or other
Transportation of Clients by Contractor:The contractor catastrophic natural event or act of God.
will maintain Insurance requirements if required as noted
under Article 7 Rule R2-36 of the North Carolina Utilities Survival of Promises: All promises,requirements,terms,
Commission. conditions, provisions, representations, guarantees, and
warranties contained herein shall survive the contract
Default and Termination expiration or termination date unless specifically provided
General Terms and Conditions-(06/16) Page 2 of 5
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
otherwise herein, or unless superseded by applicable that comply with all applicable federal, state and
Federal or State statutes of limitation. local laws, regulations,and rules.
Intellectual Property Rights (b) Duty to Report: The Contractor shall report a
suspected or confirmed security breach to the
Copyrights and Ownership of Deliverables: All local Department of Social Services Contract
deliverable items produced pursuantto this contract are the Administrator within twenty-four(24)hours
exclusive property of the County. The Contractor shall not after the breach is first discovered,provided that
assert a claim of copyright or other property interest in the Contractor shall report a breach involving
such deliverables. Social Security Administration data or Internal
Revenue Service Data within one(1)hour after
Federal Intellectual Property Bankruptcy Protection the breach is first discovered.
Act:The Parties agree that the County shall be entitled to
all rights and benefits of the)Federal Intellectual Property (c) Cost Borne by Contractor: If any applicable
Bankruptcy Protection Act,Public Law 100-506,codified federal,state, or local law,regulation or rule
at 11 U.S.C. 365 (n)and any amendments thereto. requires the Contractor give written notice of a
security breach to affected persons,the Contract
Compliance with Applicable Laws shall bear the cost of the notice.
Compliance with Laws: The Contractor shall comply Trafficking Victims Protection Act of 2000:
with all laws, ordinances, codes, rules, regulations, and The Contractor will comply with the requirements of
licensing requirements that are applicable to the conduct of Section 106(g)of the Trafficking Victims Protection Act
its business, including those of federal, state, and local of 2000,as amended(22 U.S.C. 7104)
agencies having jurisdiction and/or authority. By
executing this Agreement Provider certifies that Executive Order#24: It is unlawful for any vendor,
Provider has not been identified, and has not utilized contractor, subcontractor or supplier of the state to make
the services of any agent or subcontractor, on the list gifts or to give favors to any state employee. For
created by the State Treasurer pursuant to G.S. 147- additional information regarding the specific
86.58. requirements and exemptions,contractors are
encouraged to review Executive Order 24 and G.S. Sec.
Title VI,Civil Rights Compliance: In accordance with
133-32.
Federal law and U.S.Department of Agriculture(USDA) Confidentiality
and U.S. Department of Health and Human Services
(HHS) policy, this institution is prohibited from Confidentiality: Any information, data, instruments,
discriminating on the basis of race,color,national origin, documents, studies or reports given to or prepared or
sex, age or disability. Under the Food Stamp Act and assembled by the Contractor under this agreement shall be
USDA policy, discrimination is prohibited also on the kept as confidential and not divulged or made available to
basis of religion or political beliefs. any individual or organization without the prior written
Equal Employment Opportunity: The Contractor shall approval of the County.The Contractor acknowledges that
comply with all federal and State laws relating to equal in receiving,storing,processing or otherwise dealing with
any confidential information it will safeguard and not
employment opportunity. further disclose the information except as otherwise
Health Insurance Portability and Accountability Act provided in this contract.
( I PAA): The Contractor agrees that, if the County Oversight
determines that some or all of the activities within the
scope of this contract are subject to the Health Insurance Access to Persons and Records: The State Auditor shall
Portability and Accountability Act of 1996,P.L. 104-91, have access to persons and records as a result of all
as amended("HIPAA"),or its implementing regulations, contracts or grants entered into by State agencies or
it will comply with the HIPAA requirements and will political subdivisions in accordance with General Statute
execute such agreements and practices as the County 147-64.7. Additionally,as the State funding authority,the
may require to ensure compliance. Department of Health and Human Services shall have
(a) Data Security: The Contractor shall adopt and access to persons and records as a result of all contracts or
apply data security standards and procedures grants entered into by State agencies or political
subdivisions.
General Terns and Conditions-(06/16) Page 3 of 5
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
subcontractors,complies with the requirements ofArticle 2
Record Retention: Records shall not be destroyed, of Chapter 64 of the NC General Statutes.
purged or disposed of without the express written consent
of the Division. State basic records retention policy Miscellaneous
requires all grant records to be retained for a minimum of
five years or until all audit exceptions have been resolved, Choice of Law: The validity ofthis contract and any of its
whichever is longer. If the contract is subject to federal terms or provisions,as well as the rights and duties of the
policy and regulations,record retention may be longerthan parties to this contract,are governed by the laws of North
five years since records must be retained for a period of Carolina.The Contractor,by signing this contract,agrees
three years following submission of the final Federal and submits,solely for matters concerning this Contract,to
Financial Status Report, if applicable, or three years the exclusive jurisdiction of the courts of North Carolina
following the submission of a revised final Federal and agrees, solely for such purpose, that the exclusive
Financial Status Report. Also, if any litigation, claim, venue for any legal proceedings shall be Orange County,
negotiation, audit, disallowance action, or other action North Carolina. The place of this contract and all
involving this Contract has been started before expiration transactions and agreements relating to it, and their situs
of the five-year retention period described above, the and forum,shall be Orange County,North Carolina,where
records must be retained until completion of the action and all matters,whether sounding in contract or tort,relating to
resolution of all issues which arise from it,or until the end the validity,construction,interpretation,and enforcement
of the regular five-year period described above,whichever shall be determined.
is later. The record retention period for Temporary
Assistance for Needy Families(TANF) and MEDICAID Amendment: This contract may not be amended orally or
and Medical Assistance grants and programs trust be by performance. Any amendment must be made in written
retained for a minimum of ten years. forth and executed by duly authorized representatives of
the County and the Contractor.
Warranties and Certifications
Severability: In the event that a court of competent
Date and Time Warranty: The Contractor warrants that jurisdiction holds that a provision or requirement of this
the product(s) and service(s) furnished pursuant to this contract violates any applicable law, each such provision
contract("product"includes,without limitation,any piece or requirement shall continue to be enforced to the extent it
of equipment,hardware,firmware,middleware,custom or is not in violation of law or is not otherwise unenforceable
commercial software,or internal components,subroutines, and all other provisions and requirements of this contract
and interfaces therein)that perform any date and/or time shall remain in full force and effect.
data recognition function,calculation, or sequencing will
support a four digit year format and will provide accurate Headings: The Section and Paragraph headings in these
date/time data and leap year calculations. This warranty General Terms and Conditions are not material parts ofthe
shall survive the termination or expiration of this contract. agreement and should not be used to construe the meaning
thereof.
Certification Regarding Collection of Taxes: G.S. 143-
59.1 bars the Secretary of Administration from entering Time of the Essence: Time is of the essence in the
into contracts with vendors that meet one of the conditions performance of this contract.
of G.S. 1 05-164.8(b)and yet refuse to collect use taxes on
sales of tangible personal property to purchasers in North Key Personnel: The Contractor shall not replace any of
Carolina. The conditions include: (a) maintenance of a the key personnel assigned to the performance of this
retail establishment or office; (b) presence of contract without the prior written approval of the County.
representatives in the State that solicit sales or transact The term "key personnel" includes any and all persons
business on behalf of the vendor; and (c) systematic identified as such in the contract documents and any other
exploitation of the market by media-assisted, media- persons subsequently identified as key personnel by the
facilitated, or media-solicited means. The Contractor written agreement of the parties.
certifies that it and all of its affiliates (if any) collect all
required taxes. Care of Property: The Contractor agrees that it shall be
responsible for the proper custody and care of any property
E-Verify furnished to it for use in connection with the performance
of this contract and will reimburse the County for loss of,
Pursuant to G.S. 143-48.5,the undersigned hereby certifies or damage to, such property. At the termination of this
that the Contractor named below, and the Contractor's contract, the Contractor shall contact the County for
General Terms and Conditions--(06/16) Page 4 of 5
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
instructions as to the disposition of such property and shall
comply with these instructions. Orange County Living Wage: Orange County is
committed to providing its employees with a living wage
Travel Expenses: Reimbursement, if provided in this and encourages agencies to which it provides funding to
Agreement, to the Contractor for travel mileage, meals, pursue the same goal. The County's living wage hourly
lodging and other travel expenses incurred in the standard, as adopted by the Orange County Board of
performance of this contract shall not exceed the rates County Commissioners annually, can be found in the
established in County policy. Orange County Budget Ordinance. To the extent possible,
Orange County recommends that the Contractor and all
SaleslUse Tax Refunds: If eligible,the Contractor and all subcontractors provide a living wage, as defined in this
subcontractors shall: (a) ask the North Carolina section,to their employees.
Department of Revenue for a refund of all sales and use
taxes paid by them in the performance of this contract, Signatures: This Agreement together with any
pursuant to G.S. 105-164.14; and (b) exclude all amendments or modifications may be executed
refundable sales and use taxes from all reportable electronically. All electronic signatures affixed hereto
expenditures before the expenses are entered in their evidence the intent of the Parties to comply with Article
reimbursement reports. 11A and Article 40 of North Carolina General Statute
Chapter 66.
Advertising: The Contractor shall not use the award of
this contract as a part of any news release or commercial
advertising.
General Terms and Conditions—(06/16) Page 5 of 5
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
ATTACHMENT B
SCOPE OF WORK
Orange County Department of Social Services
Federal Tax Id.or SSN 58-1582881
Contract# 68-2042
A. CONTRACTOR INFORMATION
1. Contractor Agency Name: Charles House Association
2. If dierent from Contract Administrator Information in General Contract:
Address
Telephone Number: Fax Number: Email:
3. Name of Program(s): Adult Dgy Care
4. Status: ( )Public (X)Private,Not for Profit { }Private, For Profit
5. Contractor's Financial Reporting Year July 1 2019 through June 30,2020
B. Explanation of Services to be provided and to whom(include SIS Service Code): The
Contractor will provide Adult Day Health Services SIS Code 030 and 155 to clients of the
Orange County Department of Social Services. These services will include assistance with
Activities of Daily Livin& health monitoring by an RN and therapeutic recreational progams.
These services will be provided in accordance with provisions set forth in Volume IV of the
Adult and Family Services Manual Chapter II-Adult QLay Care Services. The Contractor is
required to meet all goals and outcomes listed in Attachment O.
C. Rate per unit of Service(define the unit):
1. If Standard Fixed Rate,Maximum Allowable,(See Rates for Services Chart)
Minimum daily rate: $33.071dgy per client
2.Negotiated County Rate.
D.Number of units to be provided:
E.Details of Billing process and Time Frames;The Coup will reimburse the Contractor for
services described in this contract up to the budget limits of the contract allotment. The
County will reimburse the Contractor at a rate of$33.07/day for approved services provided. For
reimbursement the Contractor must submit an on final and two copies of an invoice by the fifth
of the month for the preceding month's expenditures to the designated Coup Administrator.
The Couajy will reimburse the Contractor monthly upon receipt of a com lete and correctly filed
report.
Contract-Scope of Work(06/04) Page Iof 2
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
The services under contract with the Contractor are services for which a client mAY voluntaril
contribute to the cost. Policies regarding the solicitation and acceptance of voluntary
contributions are contained in Family Services Manual Volume VI Chapter III. If a client
voluntarily contributes to the cost of service the County will inform the Contractor of the amount
of the contribution and of any subs uent chan es. The Contractor will establish a plan with the
client for accepting the contribution on at least a monthly basis' and when contributions are not
received within ten days of the agreed upon date, will not' the client in writing and send a copy_
of the notification to the Coun . No other fees for services m4y be charged to the client. Client
contributions are to be reported monthly to the County.
F.Area to be served/Delivery site(s): Aran a Coun
DocuSigned by: DocuSigned by:
Nancy Coston Social Services Director {Signature of Contractor}
7/9/2019 7/2/2019
(Date Submitted) (Date Submitted)
Contract-Scope of Work(06/04) Page 2of 2
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
ATTACBTY ENT C
CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
AND CERTIFICATION REGARDING NONDISCRIMINATION
Orange County Department of Social Services
I, By execution of this Agreement the Contractor certifies that it will provide a drug-free workplace by:
A. Publishing a statement notifying employees that the unlawful manufacture,distribution,
dispensing,possession or use of a controlled substance is prohibited in the Contractor's
workplace and specifying the actions that will be taken against employees for violation of such
prohibition;
B. Establishing a drug-free awareness program to inform employees about:
(1)The dangers of drug abuse in the workplace;
(2)The Contractor's policy of maintaining a drug-free workplace;
(3)Any available drug counseling,rehabilitation,and employee assistance programs; and
(4)The penalties that may be imposed upon employees for drug abuse violations
occurring in the workplace;
C. Making it a requirement that each employee be engaged in the performance of the agreement be
given a copy of the statement required by paragraph(A);
D. Notifying the employee in the statement required by paragraph(A)that,as a condition of
employment under the agreement,the employee will:
(1)Abide by the terms of the statement; and
(2)Notify the employer of any criminal drug statute conviction for a violation occurring
in the workplace no later than five days after such conviction;
E. Notifying the County within ten days after receiving notice under subparagraph(D)(2)from an
employee or otherwise receiving actual notice of such conviction;
F. Taking one of the following actions,within 30 days of receiving notice under subparagraph
(D)(2),with respect to any employee who is so convicted:
(1)Taking appropriate personnel action against such an employee, up to and including
termination;or
(2)Requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State,or local health,
law enforcement,or other appropriate agency; and
Making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs(A),(B),(C),(D), (E),and(F).
Federal Certification-Drug-Free Workplace&Nondiscrimination rev.06-2015
Page 1 of 2
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
11. The site(s)for the performance of work done in connection with the specific agreement are listed
below:
1.
(Street address)
(City,county,state,zip code)
2.
(Street address)
(City,county, state,zip code)
Contractor will inform the County of any additional sites for performance of work under this agreement.
False certification or violation of the certification shall be grounds for suspension of payment,suspension
or termination of grants, or government-wide Federal suspension or debarment
45 C.F.R.Section 82.510. Section 4 CFR Part 85,Section 85.615 and 86.620.
CERTIFICATION REGARDING NONDISCRIMINATION
The Vendor certifies that it will comply with all Federal statutes relating to nondiscrimination. These
include but are not limited to: (a) Title VI of the Civil Rights Act of 1964(P.L. 88-352)which prohibits
discrimination on the basis of race,color or national origin;(b)Title IX of the Education Amendments of
1972, as amended (20 U.S.C. §§1681-1683, and 1685-1686),which prohibits discrimination on the basis
of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §794), which prohibits
discrimination on the basis of handicaps; (d)the Age Discrimination Act of 1975, as amended(42 U.S.C.
§§6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and
Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug
abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation
Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or
alcoholism; (g) Title VIH of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as amended,
relating to nondiscrimination in the sale, rental or financing of housing; (h) the Food Stamp Act and
USDA policy, which prohibit discrimination on the basis of religion and political beliefs; and (i) the
requirements of any other nondiscrimination statutes which may apply to this Agreement.
DocuSigned by:
i`4tVtV Executive Director
—e�za r��s 5e4s� —
Signature l it lc
Charles House Association 7/2/2019
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Federal Certification-Drug-Free Workplace&Nondiscrimination rev.06-2015
Page 2 of 2
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
Conb:aet#
(Charles House Association)
ATTACHMENT D
Conflict of Interest Policy
The Board of Directors or other governing persons, officers, employees or agents are to avoid any conflict,
of interest, even the appearance of a conflict of interest. The Organizations Board of Directors/Trustees
or'other governing body, officers, staff and agents are obligated to always act in the best interest of the
organization.This obligation requires that any Board member or other governing person, officer, employee
or agent, in the performance of Organization duties, seek only the furtherance of the Organization mission.
At.all times, Board. members or other governing persons, officers, employees or agents, are prohibited
from using their job title, the Organization's name or property,for private profit or benefit.
A. The. Board merribers or other governing persons, officers, empioyees, .or agents of the Organization
should neither solicit nor accept gratuities, favors, or anything of monetary value from current:or potential
contractors/vendors, persons receiving benefits from the Organization or persons who may benefit from
the actions of-any Board member or other governing person, officer, employee or agent This Is not
intended to preclude bona-fide Organization fund raising-activities. i
B. A Board or other governing body member may, with the approval of Board or other governing body,
receive honoraria for lectures and other such activities while not acting In any official capacity for the
Organization. Officers may, with the approval of.the Board or other governing body, receive honoraria for
lectures and other such activities while on personal days, compensatory time, annual leave, or leave.
without pay. Employees may, with the prior written approval of their supervisor, receive honoraria for
lectures and.other such activities while on personal days, compensatory time, annual leave, or leave
without pay. if a Board.or other governing body member, officer, erriployee or agent Is acting In any official
capacity, honoraria received in connection with activities relating to the Organization are to be paid to the
Organization.
C. No Board member or other governing person, officer, employee, or agent of the Organization shall
participate in the selection, award,.or administration of a purchase or contract with a vendor where, to his
knowledge,.any of the..folioVwing_has.a financial interest in that purchase or contract:
I, The Board member-or other governing person,.officer, employee,or agent;
2. Any member of their family by whole or half blood, step or personal relationship or relative-in-law;
3. An organization.in which any of the above Is.an officer,director, or employee;
4. A person or organization with whom any of the above individuals is negotiating or has any
.arrangement concerning prospective employment or contracts.
D. Duty to Disclosure, -- Any conflict of interest, potential conflict of interest; or the appearance of a
conflict of interest is to be reported to the Board or other governing body or one's supervisor immediately.
E. Board Action--When a conflict of interest is relevant to:a matter requiring action by the Board of
DI rectors/Trustees or other governing body, the Board member or othergoverning pe.rsoh, officer,
employee,:or agent(person(s)J must disclose the existence of the conflict of interest and be given the
opportunity to.disclose all material facts to the Board and members of committees with governing board
delegated powers considering the possible conflict of interest.After disclosure of all material facts, and
after any discussion with the person, he/she shall leave the governing board or committee meeting while
the determination of a conflict of interest is discussed and voted upon. The remaining board or committee
members shall decide €f.a conflict of interest exists. In addition, the person(s)shall not participate In the
Final deliberation or decision regarding the matter under consideration and shall leave the meeting during
the discussion of and vote of the Board of DirectorslTrustees or other governing body.
F.Violations of the Conflicts of Interest Policy --If the Board of Directors or other governing body has
reasonable cause to believe a member, officer, employee or agent has failed to disclose actual or possible
conflicts of interest; it shall .inform the person of the basis for such belief and afford the person .an
opportunity to explain the alleged failure to disclose. If, after hearing the persons response and after
making further investigation as warranted by the circumstances, .the Board of Directors/Trustees or other
Rev. 46-07-2015 I
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
Contract#
(Charles House Association)
governing body determines the member, officer, employee or agent has failed to disclose an actual or
possible conflict of interest, it shall take appropriate disciplinary and corrective action.
G, Record of Conflict -- The minutes of the governing board and all committees with board delegated
powers shall contain:
1. The names of the persons who disclosed or otherwise were found to have an actual or possfble
conflict of interest, the nature of the conflict of interest, any action taken to determine whether a
conflict of interest was present, and the governing board's or committee's decision as to whether a
conflict of interest in fact existed.
2. The names of the persons who were present for discussions and votes relating to the transaction
or arrangement that presents a possible conflict of interest, the content of the discussion,
including any alternatives to the transaction or arrangement, and a record of any votes taken in
connection with the proceedings.
Approved by:
CHARLES HD SSOCIATION
e of Or n' tfon
—signature ofOr nization Offi i
al
a✓
Date
NOTARIZED CONFLICT OF INTEREST POLICY
State of North Carolina
County of Dy-rs
I, Notary Public for said County and State,certify
that
-13
t - k personally appeared before me this day and
acknowlediged
that he/she is of
CfM
D [eater name of entity/
and by that authority duly given and as the act of the Organization, affirmed that the foregoing Conflict of
Interest Policy was adopted by th Boar of Directors/Trustees or other governing body in a meeting
held on the 0_day ofJ, 20 0
Sworn to and subscribed before me this -Q5 day of �S 1 hug,ri _ r�Q019
G IlC Cp+}��o frr4
�itl lees
h
(Official Seal) = ca,)rDlS$ "�xpNo'gry Public
My Commission expires Jaxlc,-c-rUQrN C �p.``��•
Rev. 06-07-2015
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
CHARLES HOUS5 ASSOCIATION
�•�, Helping people age the way they have lived
June 25,2019
To: Orange County Department of Social Services
Serving Seniors and Their
Families Since 1990
Certification:
Enriching the!Ives ofsen1w We Certify that Charles House Association does not have any overdue tax
Supportingfam111es caring for debts, as defined by N.C.G, 105-243.1, at the federal, state, or local level. We
aging family members
further understand that any person who makes a false statement in violation of
Reprerentirrg the rommuniLy's
commitment to its elders N.C.G.S. 143-6-23(c) is guilty of a criminal offense punishable as provided by
N.C.G.S. 143C-1a-1.
130AHIJ OF DIRECTORS
Bradley Fox and Paul Klever,being duly sworn, say that we are tie Board
PRESIDENT Treasurer and Executive Director, respectively, of Charles House Association
Melvin Hurston of Chapel Hill, in the state of North Carolina; and that the foregoing
VICE PRESIDENT certification is tiue,accurate and complete to the best of our knowledge and
Beth'Fillman was made and subscribed by us, We also acknowledge and understand that any
;Board
suse of State fiord4wi be reported to the appropriate authorities for further
SECRETARY ion.
Sheana Futilchouser
TREASCIRER
Bradley Fox
Treasurer
Jesse Bassnight,Jr. (P �
Anna Beeber
Suzanne Kalbas Executive Director
Julia Lunsford
Joel Levy Sworn to and subscribed before me on the day of the date of said certification.
Nancy Jones
Mildred Witt L```1` tt1t9Hpt��f,
ay
EXECUTIVE Notary Signature grid Seaf Q; No1[3ty Public
DIRECTOR urban'G°unw
PaulItlever MY oromisslosr xPiSeS}
paul@charleshouse,org
My Commission Expires: 13 ,y
q CPS" �"N
G.S. 105-243.1 defines:overdue tax debt.—Any part of a tax debt that remains unpa€d 90 days or more
after the notice of final assessment was mailed to the taxpayer.The term does not include a lax debt,
however,.if the taxpayer entered into an Installment agreement for the tax debt under G.S. 105-237 within
90 days aQcr the notice of final assessment was mailed and has not failed to make any payments due
under the installment agreement. I
1
`s
1
7511 Sunrise Road, Chapel Hill, NC 275 i 4 (919) 967-7570
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
ATTACHMENT J
CERTIFICATION REGARDING TRANSPORTATION
Orange County Department of Social Services
By execution of this Agreement the Contractor certifies that it will provide safe client
transportation by:
1. Insuring that all drivers (including employees,contractors, contractor's employees, and
volunteers) shall be at least 18 years of age;
2. Insuring that all drivers(including employees,contractors,contractor's employees, and
volunteers)shall be licensed to operate the specific vehicle used in transporting clients in
accordance with Chapter 20-7 of the General Statutes of North Carolina and the Division
of Motor Vehicle requirements;
3. Insuring that all vehicles transporting clients shall have at least the minimum level of
liability insurance appropriate for the type of vehicle as defined by Article 7, Rule R2-36
of the North Carolina Utilities Commission;
4. Insuring that the contractor shall have written policies and procedures regarding how
drivers handle and report client emergencies and/or vehicle crashes involving clients to
contractor and how contractor notifies the Orange County Department of Social Services;
5. Insuring that no more than one quarter of one percent of all trips be missed by the
contractor during the course of the contract period; (Medicaid only)
6. Insuring that that no more than five percent(5%)of trips should be late for recipient drop
off to their appointment per month; (Medicaid only)
7. Contractor will maintain records documenting the following(County may require
contractor to provide):
a. Valid current copies of Drivers License for all drivers;
b. Current valid Vehicle Registration, for all vehicles transporting clients;
c. Driving records for all drivers for the past three years and with annual updates;
d. Criminal Background checks through North Carolina Law Enforcement or NCIC
prior to employment and every three years thereafter;
e. Alcohol and Drug Testing policy to meet the Federal Transit Authority guidelines.
8. Disclosing,at the outset of the contract,upon renewal and upon request, any criminal
convictions or other reasons for disqualifications from participation in Medicare,
Medicaid or Title XX programs(signature on this farm confirms this statement).
EP
DocuSilgn/ed��by:
�� ''__
�1�.���.V' Executive Director
Signature 'I itle
Charles House Association 7/2/2019
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Transportation Certification(06/16) Page 1 of 1
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
ATTACHMENT K
501(c)(3) and TAX EXEMPT STATUS
Orange County Department of Social Services
What is a Private Non Profit Agency?
Answer: A private non profit is an organization that is incorporated under State law and whose
purpose is not to make a profit, but rather to further a charitable, civic,religious, scientific,or
other lawful purpose. The Secretary of State's office grants corporate status to organizations in
North Carolina.
What is a 501(c)(3) designation.?
Answer: When the agency becomes a state private non profit corporation, it can then apply for
501(c)(3)designation through the IRS. Once the IRS grants 501(c)(3)status,the organization is
exempt from certain taxes and any donations to the charitable organization are tax deductible.
Many individuals and organizations prefer to make donations to 501(c)(3)private non profits.
Who can obtain a 501(c)(3) designation?
Answer:Any organization or group can apply for 501(c)(3) status, provided their charter or
mission focuses on the non profit's objective.
Another option is to apply for a 509(a)(1) status which falls under the 501(c)(3)umbrella. Being
a 509(a)(1)designates an organization as a tax-free public charity that receives most of its
support from a governmental unit or from the general public. Becoming a 509(a)(1) provides
public recognition of tax-exempt status, advance assurance to donors of deductibility of
contributions, exemption from certain State and federal taxes,and non profit mailing privileges.
Organizations that typically qualify are churches, educational institutions,hospitals, and
governmental units.
To learn more about non profits,visit www.irs.gov,or call the tax-exempt helpline at 877-829-
4933.
How does a Private Non Profit obtain Tax Exempt Status?
A private non profit must apply to the IRS for tax exempt status. To qualify,applicants must
complete and submit to the IRS Form 1023. Once federal tax exempt status is granted,the
private non profit applies for State tax exempt status by completing Form CD-435 and
submitting it to the N. C. Department of Revenue.
Please attach proof of 501(c)(3) or IRS tax-exempt status to this page.
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
Iriternal Revenue Service Department of the Treasury
District Director
F'.1). L>.:-_e;( 94 1 , Fal 1 i 1 :
Date : APR 1 ���� Ernp I dyer- Ident i f i cat i vri Nurnber :
r:ti-15:328:3 1
CorrL•act F'ers.srr:
BARBARA HARK 15
CHARLES FICUSE ASSOCIATION Contact Telephone Number.-
7r 9 W I LL I AM STREET (404] `3:31 --T4' -:i15
CHAPEL. HILL, NC 27514
Our Letter' Dated,
Addenderu App I i es :
Yes
--_Dear AppI icant:
Th 1 s rnOd i f I es cur- letter of the above date ire which we stated that you
would be treated as an organ i zat i ksn which Is not a private foundat i rsn un t i 1
the expiration of your advance ru I i re;3 Fier i cid .
-,Your "exempt status under- sect i ore 501 (a) - of the Internal Revenue Code as"ar
or-gan-1 zat i on described in sec t i r_ere 501 (c ) (3) Is st i l I in effect . Dased on the
information you submitted, we Have determined that you are not a private
Foundation within the meaning Of section 509( a) _,f the code because yr,u are an
or'ganlzation of the type described in section Fr7'? ( a) ( I ] and 170(b ) ( 1 ) (A) (vi ) .
(ar-antors and coritr- i taut t-s ina.y re t y on this de terra i nat i on un I ess the
Internal Revenue Service publishes root i cp t-) the contrary. However, if You
lase your section 5051(a) ( 1 ) status, a graretor Or ccontr-ibutor- may not rely on
this determination if he or she was in heart resp+:-rrs ih l e for- , rer was aware -of,
the act or failure to act, or the suhstarrt i al or rnater- i a l change rere the part o
the organ i gat i on that resu i ted in your 1055 of suCh s tatus r or if he Or she
acquired knowledge that the Internal Revenue Service had given notice that you
would no I orrger be classified as a section orgah l zat i *=err.
I f we have indicated ire the head i rqj of this letter that an addendum,
applies , the addendurn enclosed is an integral part Of this letter.
because this letter could help resolve any questions about your private
f�tiundat i on status , please keep it i n your per-rnanent records .
Letter- 1sr5fr(D1=s/CG)
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
ATTACfEWENT M
State and Local Certifications
Contractor Certifications Required by North Carolina Law
Orange County Department of Social Services
Instructions: The person who signs this document should read the text of the statutes and Executive Order listed below and consult
with counsel and other knowledgeable persons before signing.The text of each North Carolina General Statutes and of the Executive
Order can be found online at:
• Article 2 of Chapter 64: htt ://www.nc a.state.nc.usfEnactedLe is[ationIStatuteslPDF/B Artie]e/Cha ter 64/Article 2. df
■ G.S. 133-32: h :ii.....+.iic a.state.nc.usl ascri tsistatuteslstatutelooku . l?statute=l33-32
■ Executive Order No.24(Perdue,Gov.,Oct. 1,2009): h ://www,ethicscommission.nc. ov/1ibra 1 dfslLawsiF,'024. df
■ G.S. 105-164.8(b): htt ://www.nc a.state.nc.ui/FnactedLe is]ationJStatutes/PDF/B ySection/Cha ter 1051GS [05-164.8. df
■ G.S. 143-48.5: It ://w.vw.nc a.state.nc.usirnactedLe islation/StatuteslliTMUB SectionlCha ter 1431GS 143-48.5.htmi
■ G.S. 143-59.1: htt ;liwww.nc a.stale.n c.u s/Enac led Lep,islationlStatuteslPDFfB SectionlCha ter 143/GS 143-59.1. df
• G.S. 143-59.2: htt ://www.nc a.state.nc.us/EnactedLe islation/StatutesfPDFfB SectionlCha ter 1431GS 143-591. df
• G.S. 143-133.3: htt :/Iwww.nc a.state.nc.us/EnactedLe is]ation/Statute&MTMl,fB SectionlCha ter 1431GS 143-133.3.html
• G.S. 143B-139.6C: htt ://www.nc a.state.nc.usiE.nactedLe islation/Statutes/PDF/B SectionlCha ter 143BIGS 143B-139.6C. df
• The text of Orange County Living Wage Contractor Policy which is attached to this document.
Certifications
(1) Pursuant to G.S. 133-32 and Executive Order No. 24 ❑ Neither the Contractor nor any of its affiliates
(Perdue, Gov., Oct. 1, 2009), the undersigned hereby has incorporated or reincorporated in a "tax
certifies that the Contractor named below is in haven country" as set forth in G.S. 143-
compliance with,and has not violated,the provisions of 59.1(c)(2)after December 31,2401; or
either said statute or Executive Order.
(2) Pursuant to G.S. 143-48.5 and G.S. 143-133.3, the
undersigned hereby certifies that the Contractor named ® The Contractor or one of its affiliates has
below, and the Contractor's subcontractors, complies incorporated or reincorporated in a "tax haven
country" as set forth in G.S. 143-59.1(c)(2)
with the requirements of Article 2 of Chapter 64 of the
NC General Statutes, including the requirement for aver December 31, 2i141 but the United States
each employer with more than 25 employees in North is not the principal market for the public trading
Carolina to verify the work authorization of its of the stack of the corporation incorporated in
employees through the federal E-Verify system." E- the tax haven country.
Verify System Link: www.uscis.gov (4) Pursuant to G.S. 143-59.2(b), the undersigned hereby
certifies that none of the Contractor's officers,
Local government is specifically exempt from Article 2 directors, or owners (if the Contractor is an
of Chapter 64 of the North Carolina General unincorporated business entity) has been convicted of
Statutes. However, local government is subject to and any violation of Chapter 78A of the General Statutes or
must comply with North Carolina General Statute the Securities Act of 1933 or the Securities Exchange
153A-99.1, which states in part as follows: Act of 1934 within 10 years immediately prior to the
Counties Must Use E-Verify-Each county shall date of the bid solicitation.
register and participate in E-Verify to verify the work (5) Pursuant to G.S. 143B-139.6C, the undersigned
authorization of new employees hired to work in the hereby certifies that the Contractor will not use a
United States. former employee, as defined by G.S. 14313-
(3) Pursuant to G.S. 143-59.1(b), the undersigned hereby 139.6C(d)(2), of the North Carolina Department of
certifies that the Contractor named below is not an Health and Human Services in the administration of a
"ineligible Contractor" as set forth in G.S. 143-59.1(a) contract with the Department in violation of G.S.
because: 143B-139.6C and that a violation of that statute shall
void the Agreement.
(a) Neither the Contractor nor any of its affiliates has (6) The undersigned hereby certifies further that:
refused to collect the use tax levied under Article 5
of Chapter 105 of the General Statutes on its sales (a) He or she is a duly authorized representative of the
delivered to North Carolina when the sales met Contractor named below;
one or more of the conditions of G.S. 105-
164.8(b); and
(b) He or she is authorized to make, and does hereby
(b) (check one of the following boxes] make,the foregoing certifications on behalf of the
Contractor;and
Contractor Certifications Required by North Carolina Law(Rev.8/2016) Page] of 3
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
(c) He or she understands that any person who services under this contract a living wage (in
knowingly submits a false certification in response Orange County currently $14.95 per/hr.) Check
to the requirements of G.S. 143-59.1and -59.2 here ❑ if contractor pays employees performing
shall be guilty of a Class I felony. under this contract a living wage. If Contractor
does not pay employees a living wage, what is the
(1) Pursuant to the Orange County Living Wage wage that employees performing services under this
Contract's Policy, the undersigned certifies that contract paid?
the Contractor pays the employees who perform
Contractor's Name: Charles House Association
Dccusign
Contractor's rq W�"A y' 7/2/2019
Authorized Agent: Signature hate
Paul Klever Executive Director
Printed Na DocuSigned by: TitkL
Witness: Signature OCAV Fb�, Date 9/13/2019
Printed Name
Dean Fox Title Lead Program Director
The witness should be present when the Contractor's Authorized Agent signs this certificate and should sign and
date the document immediately thereafter.
Contractor Certifications Required by North Carolina Law(Rev.8/2016) Page 2 of 3
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
Section 1: General Government and Administration
Policy 10.0: Living Wage Contractor Policy
Reviewed by: County Attorney/County Manager
Approved by: County Manager
Original Effective Date: April 21,2016
Revisions:
Policy Statement
It is the policy of Orange County to ensure its employees, and all individuals who provide services for Orange County,are
paid a living wage.
Purpose
To encourage all vendors and contractors to pay a living wage to all employees who perform work pursuant to a contract
with Orange County.
Applicability
Applies to all Orange County contracts and purchases.
Policy
10.1 Living Wage
10.1.1 Orange County is committed to providing its employees with a living wage and encourages all contractors
and vendors doing business with Orange County to pursue the same goal. Orange County's living wage is$14.95
per hour. To the extent possible,Orange County recommends that contractors and vendors seeking to do business
with Orange County provide a living wage to their employees.
10,1.2 Prior to final execution of a contract with Orange County all contractors and vendors seeking to do
business with Orange County shall submit to the County's representative a statement indicating whether those
employees who will perform work on the Orange County contract are paid at least the living wage amount set out
above. If such employees do not make at least the living wage amount set out above the contractor or vendor
shall indicate in the statement the actual amount paid to such employees. For bid projects this statement should
be submitted as part of the bid packet.
This policy may be reviewed annually and updated as needed by the Manager's Office
Contractor Certifications Required by Orange County and North Carolina Law
Revised 6119 Page 3 of 3
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
Contract#68-2042
Charles House
ATTACHMENT N
Orange County Department of Social Services/Human Services
CERTIFICATION REGARDING NONDISCRIMINATION,CLEAN AIR ACT,CLEAN
WATER ACT
Certification Regarding Nondiscrimination
The Contractor certifies that it will comply with all Federal statutes relating to
nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of
1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or national origin;
(b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §§1681-1683, and
1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the
Rehabilitation Act of 1973, as amended (29 U.S.C. §794),which prohibits discrimination on the
basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §§6101-
6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and
Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of
drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and
Rehabilitation Act of 1970(P.L. 91-616), as amended, relating to nondiscrimination on the basis
of alcohol abuse or alcoholism; (g)Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601
et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (h)
the Food Stamp Act and USDA policy,which prohibit discrimination on the basis of religion and
political beliefs; and (i) the requirements of any other nondiscrimination statutes which may
apply to this Agreement.
The Contractor must comply with Executive Order 11246, entitled "Equal Employment
Opportunity,"as amended by Executive Order 11375,and as supplemented by the Department of
Labor Regulations (41 CFR Part 60): The Executive Order prohibits federal contractors and
federally-assisted construction contractors and subcontractors who do over $10,000 in
Government business in one year from discriminating in employment decisions on the basis of
race, color, religion, sex, or national origin. The Executive Order also requires Government
contractors to take affirmative action to ensure that equal opportunity is provided in all aspects of
their employment.
Meanin 1 Access for LEP Individuals: The Contractor that participate in the SNAP must take
reasonable steps to ensure that LEP persons have meaningful access to programs, services, and
benefits. This includes the requirement to provide bilingual program information and
certification materials and interpretation services to single language minorities in certain project
areas. SNAP Contractors that do not provide meaningful access for LEP individuals risk
violating prohibitions against discrimination based on National Origin in the Food and Nutrition
Act of 2008, as amended, Title VI of the Civil Rights Act of 1964(Title VI)and SNAP program
regulations at 7 CFR 272A(b). They also risk noncompliance with the USDA policy guidance
titled, "Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition
Against National Origin Discrimination Affecting Limited English Proficient Persons",
published in 79 FR 70771 -70784(November 28, 2014).
The Contractor should develop an implementing plan to address the language assistance needs
of the LEP population served. This may include contracting for oral interpretation services,
hiring bilingual staff, arranging telephone interpreters and/or language lines, coordinating
community volunteers, translating vital documents, and providing written notice that language
services are available in appropriate languages. Quality and accuracy of the language service is
(Federal Certification-Non-Discrimination, Clean Air, Clean Water) (01/2018)Page I of 4
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
Contract 468-2042
Charles House
critical in order to avoid serious consequences to the LEP person and to the recipient. LEP needs
should be considered in developing budgets and front line staff should understand how to obtain
language assistance services. For additional assistance and information regarding LEP matters,
please also visit littp://www.Iep.gov.
Ensuring Equal Opportunity Access for Persons with Disabilities: The Contractor must also
ensure equal opportunity access for persons with disabilities. This includes ensuring that
communications with applicants, participants, members of the public, and companions with
disabilities are as effective as communications with people without disabilities. Contractors that
do not provide persons with disabilities equal opportunity access to programs may risk violating
prohibitions against disability discrimination in the Rehabilitation Act of 1978, the American
with Disabilities Act(ADA)of 1990,as amended,and SNAP program regulations.
DO7 published revised final regulations implementing Title Il and Title III of the ADA on
September 15, 2010. These regulations are codified at 28 CFR Part 35 "Nondiscrimination on
the Basis of Disability in State and Local Government Services" and at 28 CFR Part 36
"Nondiscrimination on the Basis of Disability in Public Accommodations and Commercial
Facilities". In accordance with the implementing regulations, Contractors must provide auxiliary
aids and services where necessary to ensure effective communication and equal opportunity
access to program benefits for individuals with disabilities. The type of auxiliary aids and
services required will vary, but a Contractor may not require an individual with a disability to
bring another individual to interpret, and may rely on a person accompanying a disabled
individual only in limited circumstances. When a Contractor communicates with applicants and
beneficiaries by telephone, it must provide text telephone services (ITY) or have access to an
equally effective electronic telecommunications system to communicate with individuals who are
deaf, hard of hearing, or hearing impaired. Contractors must also ensure that interested persons,
including persons with impaired vision or hearing,can obtain information as to the existence and
location of accessible services, activities, and facilities. For more information, please visit the
ADA website: http://www.ada.gov.
IV.The Clean Air Act,Section 306; 42 U.S.C.§7401 et seq.(1970)
a. No Federal agency may enter into any contract with any person who is convicted of any
offense under section 113(c) for the procurement of goods, materials, and services to
perform such contract at any facility at which the violation which gave rise to such
conviction occurred if such facility is owned, leased, or supervised by such person. The
prohibition in the preceding sentence shall continue until the Administrator certifies that
the condition giving rise to such a conviction has been corrected. For convictions arising
under section 113(c)(2), the condition giving rise to the conviction also shall be
considered to include any substantive violation of this Act associated with the violation
of 113(c)(2). The Administrator may extend this prohibition to other facilities owned or
operated by the convicted person.
b. The Administrator shall establish procedures to provide all Federal agencies with the
notification necessary for the purposes of subsection(a).
c. In order to implement the purposes and policy of this Act to protect and enhance the
quality of the Nation's air,the President shall,not more than 180 days after enactment of
the CIean Air Amendments of 1970 cause to be issued an order (1) requiring each
Federal agency authorized to enter into contracts and each Federal agency which is
empowered to extend Federal assistance by way of grant, loan, or contract to effectuate
the purpose and policy of this Act in such contracting or assistance activities, and (2)
(Federal Certification-Non-Discrimination, Clean Air, Clean Water) (0112018)Page 2 of 4
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
Contract 468-2042
Charles House
setting forth procedures, sanctions, penalties, and such other provisions, as the President
determines necessary to carry out such requirement.
d. The President may exempt any contract, loan, or grant from all or part of-the provisions
of this section where he determines such exemption is necessary in the paramount
interest of the United States and he shall notify the Congress of such exemption.
e. The President shall annually report to the Congress on measures taken toward
implementing the purpose and intent of this section, including but not limited to the
progress and problems associated with implementation of this section. [42 U.S.C. 7606]
V.The Clean Water Act;33 U.S.C.§1251 et seq. (1972)
a. No Federal agency may enter into any contract with any person who has been convicted
of any offense under Section 309(c) of this Act for the procurement of goods, materials,
and services if such contract is to be performed at any facility at which the violation
which gave rise to such conviction occurred, and if such facility is owned, leased, or
supervised by such person. The prohibition in preceding sentence shall continue until
the Administrator certifies that the condition giving rise to such conviction has been
corrected.
b. The Administrator shall establish procedures to provide all Federal agencies with the
notification necessary for the purposes of subsection(a)of this section.
c. In order to implement the purposes and policy of this Act to protect and enhance the
quality of the Nation's water, the President shall, not more than 180 days after the
enactment of this Act,cause to be issued an order:
(i) requiring each Federal agency authorized to enter into contracts and each Federal
agency which is empowered to extend Federal assistance by way of grant, loan, or
contract to effectuate the purpose and policy of this Act in such contracting or assistance
activities,and
(ii) setting forth procedures, sanctions, penalties, and such other provisions, as the
President determines necessary to carry out such requirement.
d. The President may exempt any contract, loan, or grant from all or part of the provisions
of this section where he determines such exemption is necessary in the paramount
interest of the United States and he shall notify the Congress of such exemption.
e. The President shall annually report to the Congress on measures taken in compliance
with the purpose and intent of this section, including, but not limited to, the progress and
problems associated with such compliance.
f. No certification by a contractor, and no contract clause, may be required in the case of a
contract for the acquisition of commercial items in order to implement a prohibition or
requirement of this section or a prohibition or requirement issued in the implementation
of this section.
g. In paragraph(1), the term"commercial item"has the meaning given such term in section
4(12)of the Office of Federal Procurement Policy Act(41 U.S.C. 403(12)).
(Federal Certification-Nan-Discrimination, Clean Air, Clean Water)(0112018)Page 3 of 4
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
Contract#69-2042
LDocuSiglgnl/etd,byy:1� Charles House
Pau V ""' "' Executive Director
g-lB385F46ASS—
Signature Title
Charles House Association 7/2/2019
Agency/Organization Date
(Certification signature should be same as Contract signature.)
(Federal Certification-Nan-Discrimination, Clean Air, Clean Water) (01/2018)Page 4 of 4
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
ATTACHMENT U
OUTCOMES AND REPORTING
Orange County Department of Social Services
By signing and submitting this document,the Contractor certifies that it agrees to the following:
1.The Contractor agrees to participate in program,fiscal and administrative monitoring and/or audits,
making records and staff time available to Federal, State and County staff.
2.The Contractor agrees to take necessary steps for corrective action,as negotiated within a corrective
action plan,for any items found to be out of compliance with Federal, State,and County laws,regulations,
standards and/or terms of the Contract.
3. The Contractor agrees that continuation of and/or renewal of this Contract is contingent on meeting the
following requirements. The Contractor agrees to:
A. Provide Adult Day Health Care Services,according to the North Carolina State Standards for
Certification,to clients referred by the County.
B. CompIy with all State licensing standards,all applicable accrediting standards and any other
standards or criteria established by the North Carolina Department of Health and Human
Services to assure quality of services
C. Maintain all financial and program records for a period of three years from the date of final
payment under this agreement for inspection by the County,the Area Agency on Aging and the
Comptroller General of the United States,or any of their duly authorized representatives. If any
claim, litigation,negotiation, audit or other action involving the Contractor's records has been
started before the expiration of the three-year period,the records must be retained until
completion of the action and resolution of all issues that arise from it.
D. Maintain appropriate program records,client case files which document the provision of the
agreed upon service(s); and maintain a valid authorization for services for each client
determined to be eligible by the County and authorized by the County for service(s)provided
under this agreement.
E. Furnish financial and program data as required to document the basis for the reimbursement rate
and to document that applicable standards have been met.
F. Be responsible for compliance with the audit requirements of the Department of Health and
Human Services.
a. An annual audit is to be performed in accordance with OMB Circular A-110 by an
"independent auditor." "Independent auditor"means either:
i. A state government auditor for the Department of Human Resources or the
Department of Administration,Office of the State Auditor;or
ii. A certified public accountant.
b. Upon completion of the audit, a copy of the audit report must be forwarded to the
County.
G. Notify the County of participant absences of more than 5 days.
H. Notify the County,in a timely manner,of significant changes in the clients' conditions or
situations.
Outcomes (06/04) Page I of 2
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
LDocuSiggn'ed`b'y: I^
�"�"`^ Executive Director
$B386F-6641111
Signature Title
Charles House Association 7/2/2019
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Outcomes (06/04) Page 2 of 2
DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6
DATE(MMIDDrYYYY)
CERTIFICATE OF LIABILITY INSURANCE
061201201 s
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 INSURERjS), 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 an
this certificate does not confer rights to the certificate holder in lieu of such endorsements.
PRODUCER CONTACT Michael Riggabee,Jr.
Me
Carolina National Insurance Agency PHONE (919)636-3252 FAX Ore
PO Box 1028 ADoRL • luke cnia enc .cam
INSURERS AFFORDING COVERAGE NAIC#
Carrboro NC 27510 INSURER A: Philadelphia 18058
INSURED INSURER B: Carolina Mutual Insurance Company 14090
Charles House Association INSURER C:
7511 Sunrise Road INSURER D:
INSURER E:
Chapel Hill NC 27514 1NSURERF:
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 SEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF IN AODLISU9R Mfqn POLiCYN11MeER MPOLICY EFF PCLIICDY EXP LJMITS
X COMMERCIALGENERALLIABLLITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE 19 OCCUR ❑PFZr
ISESO REaNcaTED fEance $ 100,000
MEP EXP(Any one arson) $ 5,000
A Y PHPK1958555 05110/2019 05/1012020 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 3.000,000
X POLICY PRO LOC PRODUCTS-COMPICFAGG $ 3,000,000
JECT
$
OTHER: COMBINED
AUTOMOBILE LIABILITY Ee accAden SINGLE LIMIT $ 1,000.000
ANY AUTO BODILY INJURY(Per person) S
A AWNED SCHEDULED PHPK1958555 05110/2019 0511012020 BODILY INJURY(Paraccldanl] $
AUTOS ONLY AUTOS
X HIRED NON-0WNE❑ PROPERTY DAMAGE S
AUTOS ONLY AUTOS ONLY Per accide l
S
UMBRELLA LIAB M OCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS LIIIB CLAIMS-MADE PHUB669036 05/1012019 05110/2020 AGGREGATE $ 1,000,000
DE❑ I X I RETENTION$ 10,000 $
WORKERS COMPENSATION PaTERIUT
E ERH
AND EMPLOYERS'LIABILITY
ANY P ROP RIETO RIPARTN ERIEX ECUTIVE YIN E.L.EACH ACCIDENT $ 500,000
B OFFICERIMEMBER EXCLUDEDP ❑ NIA N WC23000-2019 06/25/2019 06/2512020
(Mandatory In NH E.L.DISEASE-EA EMPLOYEE S 500.000
"yes,describe under 500,000
DESCRIPTION OF OPERATIONS ba I I E.L.DISEASE-POLICY LIMIT S
Each Claim $1,000,000
Professional Liability TI I
q PHPK1958555 05/10/2019 0611012020 Aggregate $3,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (A CORD 1al,Additional Remarks Schedule,may be attached Ir mare space Is required]
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBES]POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Orange County Government ACCORDANCE WITH THE POLICY PROVISIONS.
PO Box 8181 AUTHORIZED REPRESENTATIVE
Hillsbarou h NC 27278
Fax: Email, @ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD