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HomeMy WebLinkAbout2020-870-E Aging - Charles House outside agency agreement DocuSign Envelope ID:2F348727-C96D-44CB-A423-F12561FB250C OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT,made and entered into the first day of July 2020, ("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., 7511 Sunrise Rd, Chapel Hill NC 27514, a not-for-profit corporation, located at ("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, 2020 to June 30,2021. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit "A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means,methods,techniques,sequence,safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of$23,363. b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of$5840.75. 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. (aAgencys_Name») Orange County Outside Agency Performance Agreement Revised 712018 Page 1 of 9 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F12561FB250C 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 11,April 12,and July 12 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. (aAgencys_Name») Orange County Outside Agency Performance Agreement Page 2 of 9 Rev. 7118 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F12561FB250C 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. (aAgencys_Name») Orange County Outside Agency Performance Agreement Page 3 of 9 Rev. 7118 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F12561FB250C 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 parry 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 $ 14.95 per hour. To the extent possible, Orange County recommends 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: (aAgencys_Name») Orange County Outside Agency Performance Agreement Page 4 of 9 Rev. 7118 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F12561FB250C 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. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified,and has not utilized the services of any agent or subcontractor,on the list created by the State Treasurer pursuant to G.S. 147-86.58. 18. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For and on behalf' * &Rwcmi4er V' 11/4/2020 Date al9anb0ehalf of Orange County Government 111512020 0627994R755F477... (aMgencys_Name») Orange County Outside Agency Performance Agreement Page 5 of 9 Rev. 7118 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F12561FB250C Bonnie Hammersley, County Manager Date (aAgencys_Name») Orange County Outside Agency Performance Agreement Page 6 of 9 Rev. 7118 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F12561FB250C ORANGE COUNTY—DEPARTMENT USE ONLY Department Party/Vendor Name: Charles House Association Party/Vendor Contact Person: Paul Klever Contact Phone: 919-967- 7570 Party/Vendor Address:7511 Sunrise Road City Chapel Hill State: NC Zip: 27514 Department: Finance & Administrative Services Amount:23,363 Purpose: FY 2020-21 Outside Agency/Human Services Performance Agreeement Budget Code(s): 10495050-710029 Vendor#vendor) 19446 Vendor is a BOCC consultant? Yes ❑ No❑ Contract Type: (Check one)New Renewal x❑ Amendment ❑ Effective Date 7/1/2020 Approved by Board Yes®No❑ Agenda Date: This agreement is approved as to techm ^ Vaff 'ontent: jav & ' �b_r 11/4/2020 Department Director's Signature Bz��s2oa_aFasaF�_. Date: Information Technoloizies (Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer Date: Risk Management This agreement is approved for sufficiency of'nsa w4weWandards,specifications,and requirements: aUSA, rbvvu,TTb 11/5/2020 Office of the Risk Management Officer Date: Financial Services This instrument has been pre-audited in wamisottwoquired by the Local Government Budget and Fiscal Control Act: Office of the Chief Financial Officer � a Date: 11/5/2020 Legal Services This agreement is approved as to F"Off":sufficiency: r_�, Office of the County Attorney Date: 11/5/2020 Clerk to the Board Received for record retention: All Docusign contracts must be copied to Sherri Ingersoll upon completion @ singersoll&oran e�ync.gov The following signature block is for hard copies only and is not required for Docusign contracts: Office of the Clerk to the Board Date: (aAgencys_Name») Orange County Outside Agency Performance Agreement Page 7 of 9 Rev. 7118 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F12561FB250C Exhibit A Provider's Outside Agency Application (aAgencys_Name») Orange County Outside Agency Performance Agreement Page 8 of 9 Rev. 7118 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F125131FB250C Exhibit B Provider's Revised Scope of Services and Program Budget (aAgencys_Name») Orange County Outside Agency Performance Agreement Page 9 of 9 Rev. 7118 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F12561FB250C ATTACHMENT "A" Orange County Certifications—FY 2018-19 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. Certified by: Title: Date: (Provider's Signature) (aAgencys—Name») Orange County Outside Agency Performance Agreement Page 10 of 9 Rev. 7118 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F125131FB250C COVERPAGE Applicant Contact Information Applicant Organization's Legal Name: Charles House Association Applicant Organization's Physical Address: 7511 Sunrise Road Chapel Hill NC 27514 Applicant Organization's Mailing Address: 7511 Sunrise Road Chapel Hill NC 27514 Applicant Organization's Web Address: www.charleshouse.or� Executive Director: Paul Klever Telephone Number: 919-967-7570 E-Mail: paul@charleshouse.org Tax ID Number: 58-1582881 Funding Request Please list all Fiscal Year 2021 Human Services (HS)funding requested for all programs and the proposed use of funds (please list program name only) Program Carrboro- Chapel Orange Total HS Hill-HS County-HS Ex. Youth�Iftemchool Program $10,000 $15,000 $5,000 $30,000 Operations o)�Personnel operations Personnel Operations Charles House Daytime Program $1500 $7000 $24,000 $32.500 Personnel Totals $1500 $7000 $24,000 $32.500 Briefly explain your proposed use of funds: The Outside Agency Funding is used to financially support families enrolled in the Daytime Eldercare Program at Charles House through scholarship funds and offsetting Orange County agencies (DSS, DoA) discounted purchase of services for specific clients. 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; !Z Executive Director Date Signature- /G� 1 UA Chairp erson erson Date p Uove Page P a g e 6 o 1 2 0 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F125131FB250C DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION 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 [] ® a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ® 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? ❑ ® c) Current beneficiaries of the program for which funds are being requested? ❑ ® 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 all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: Executive Director Date Signature: 3 Board Chairperson Date P a g e 7 o f 2 0 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F125131FB250C AGENCY INFORMATION Please provide the following information about your agency: 1. Date of Incorporation (Month/Year):03 1984 2. Agency's Purpose/Mission (no more than a few sentences); • Enriching the lives of seniors • Supporting families caring for aging family members • Representing the community's commitment to its elders 3. Please provide a brief description of your organization's past achievements in carrying out similar projects and evidence of successful record of meeting proposed budgets and timetables (no more than 100 words). Since 1990, Charles House has exemplified an innovative approach to serving and working with elders with frailty, challenges of aging, and their caregiving families. The Charles House Method has established a reputation for being vastly different than most settings for eldercare, a non-institutional approach that proves to be effectively therapeutic and supportive of families. Charles House has adapted its experience into creating the pioneering Neighborhood Eldercare Homes. Nearly thirty years later, Charles House continues to be a beacon for caregiving families and an exceptional learning experience for students and interns. 4. Living Wage: Does this agency pay permanent employees a minimum living wage? (Yes/No) Yes If yes, is this agency an Orange County Living Wage Certified Employe ?Yes if no, please briefly explain. Schedule of Positions: #of FTE—Full-Time Paid Positions: 17 #of FTE—Part-Time Paid Positions: 9 PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. 5. Program Name: Charles House: Daytime Eldercare Program Program Primary Contact and Title: Paul I<lever, Executive Director Telephone Number: 919-967-7570 E-Mail: paul(@charleshouse.org 6. Please briefly describe the proposed program, including an explanation of how it aligns with the Town of Chapel Hill and Carrboro's Results Framework, and Orange County BOCC Goals and Priorities, and the target ..— population to benefit from the program. (100 words or less) Regarding Chapel Hill and Carrboro's Results Framework: Charles House Daytime Eldercare Program works primarily toward The Intermediate Result 3.2: Residents demonstrate new healthy lifestyle behaviors, particularly with performance indicators related to supporting independence, social skills, social connections and wellness (well-being) goals for both family caregivers and participant elders. Regarding Orange County BOCC Goals and Priorities: Charles House Daytime Eldercare Program relates primarily to the BOCC's priority of • Ensure a community network of basic human services and infrastructure that maintains, protects, and promotes the well-being of all county residents For Chapel Hill, Carrboro, and Orange County, Charles House Daytime Eldercare Program represents an exemplary municipal/county and nonprofit partnership, uniquely serving the wellbeing of some of the P a d e, 8 o f 2 0 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F125131FB250C most marginal residents (elders with frailty) and over-stretched families (their caregiving families members). 7. Target Population: Please complete the table below with numbers (not percentages) of individuals served and projected to be served. Program Target Population Demographics Projected Actual Projected Projected 2018-19 2018-19 2019-20 2020-21 Gender Men 55 44 55 57 Women 65 65 65 68 Non bin ary/Genderqueer Self Describe Total 1 170 109 120 125 Race and Ethnicity Black or African-American 12 11 12 13 American Indian or Alaska Native Asian 5 3 5 5 White 103 95 103 107 Native Hawaiian or other Pacific Islander Two or more races Some other race Total 120 109 12D 125 2 Of the above, how many Hispanic/Latino 3 1 2 123 Of the above, how many non-Hispanic/Latino 117 108 118 Total 120 109 120 125 Age 0-5 years 6-18 years 19-50 years 51+years 170 109 120 125 Total 120 109 120 125 Geographic Location Town of Chapel Hill 50 38 50 50 Town of Carrboro 12 11 12 12 Orange County(Outside of Chapel Hill/Carrboro) 7 9 7 10 Outside of Orange County 51 51 51 53 Total 120 109 120 125 Income Approx. 15-20%of Charles House enrolled families receive Low-income (80%of the Area Median Income and Below) Please see financial assistance,through Scholarship Funds,Orange Co.DSS, income table in the attachments Dept.on Aging. Total 0 0 0 0 Program information P a g e 9 o f 2 0 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F12561FB250C 8. Cost Per Individual This cost per individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2018-19 Projected 2019-20 Projected 2020-21 Total Cost of Program $633,000 $644,725 $668,700 Total # of Individuals 109 120 120 Cost Per Individual $5807 $5372 $5572 Total # Units of Service 7562 8100 8200 Cost Per Unit of Service $83.70 $79.60 $81.55 9. Performance Indicators For Chapel Hill and Carrboro applicants: Please complete the following chart with information about the Strategic Objective, Intermediate Result, and the Agency Performance Indicator for each program for which you are applying for funding. Please see the Results Framework in the Attachments section as a reference. Program Name: Strategic ❑ Children improve their educational outcomes Objective — (pleasechooseonefrom ❑ Residents Increase their livelihood security the Results Frarne►vor•k) LJ Residents improve their health outcomes Intermediate Insert Intermediate Result here. Result Intermediate Result 3.2: Residents demonstrate new healthy lifestyle behaviors (please choose one from the Results Frarne►vorlo RESULTS Actual Projected Projected 2018-19 2019-20 2020-21 Performance Inserl Performance Indicator here. 92%of the 90%of enrolled 50%of enrolled Family caregivers will observe survey participants(25 participants(25 Indicators improvements in the functioning of respondents of 50 of 50 (Please choose fit least their elder family member enrolled reported respondents to respondents to one perfor•manee in the Charles House program. improved the annual the annual indicator to report orr frorrr the Results. (in considering skills for healthy functioning in survey)will be survey)will be Framework,and add lifestyle and well-being for elders their observed by observed by adtitional performance with frailty, a myriad of"skills"are participant their families as their families as indicators thatiporr important, i.e. ambulation, verbal family member, having improved having improved would like to report to and language processing, appetite. including social functioning, functioning, the Towrrs. Please insert)vns.tior:rrl rows as Therefore, this performance functioning including social including social needed,listing one per indicator, limited to the improved "skills" functioning functioning ,ow). "social skills,"indicates a bias toward "skills" "skills" citizens who are "developing"and valued for their"independence.") Program information P a g e 1 0 o f 2 0 I DocuSign Envelope ID:2F348727-C96D-44CB-A423-F125131FB250C ORANGE COUNTY i1oRn l CAROLINA Outside Agencies/Human Services Please use the drop down menu below to select which function area best aligns with your agency and program(s) in which you are requesting funding. Please select only one from the drop down menu below. Senior Services If you selected other, please tell us what function area best aligns with your organization: Please indicate three program goals/performance measures below. A few notes: • If you use percentages, please put the actual number equivalence. • Please ensure your performance measures are outcome based and not outputs. Program Goal # 1 The Program will meet/exceed state standards The Program will continue to meet the requirements for NC State Performance Measure Certification (Hory will you accomplish your goal?) Charles House was successfully re-certificated in July, 2018 Actual Results (Outcome) Ending F118-19 Projected Results Charles House was successfully re-certificated in July, 2019 (Outcome) Enclirt FY202U Projected Results Charles House will be successfully re-certificated in July, 2020 (Outcome) Ew in FY2021 Families are supported in their caregiving of family members with frailty Program Goal# 2 and challenges of aging, 50%of enrolled fconilies in the f nding year will have the calmeily to Performance Measure continue providing care in the home and not require, or delcq', (Hon)vill,you accomplish yourgoal?) residential care placement_for their participant/enrolled fancily member, 56.7%(38 of 67)of the families enrolled at the beginning of the grant Actual Results year continued caregiving with Charles House support at the end of the (Outcome) grant year Ending FY18-19 Projected Results 60%of enrolled families in the finding year will have the capacity to (Outcome) continue providing care ill the home and not require,or delay,residential Ending FY2020 care piacement for their participant/enrolled family member. Program informatics P a g e :I. 1 0 1 ). 0 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F12561FB250C ORANGE COUNTY NOW11 ii C ROLI NA Outside Agencies/Human Services es R d Projccteults (Outcome)Res 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 Endnzg F):2021 care placement for their participant/enrolled family ineinber. Families will observe positive effects of the Daytime Program for their Program Goal 3 family member. Family caregiver-s ivill report in the annual evaluation szu•vey Performance Measure satisfaction with the Charles House program and will report positive (Hoiv will you acconyplislr yoru•gnrrl?) elfects of the program for their enrolled fcanily members, szzch as improvement irr their participant/enrollee's behavior, emotional status, physical and/or co nitive inctionin Actual Results 92%of reporting families(46 of 50)indicated observing improvements (Outcome) in their family member's (Charles House participants')functioning. Ending FY18-19 Projected Results 90%of reporting families(38 of 41) indicated observing improvements (Outcome) in their family member's (Charles House participants')functioning. Ditfing FY2020 Projected Results 80%of reporting families will indicate observing improvements in their (Outcome) family member's(Charles House participants)functioning, Ending FY2021 Program information P a g e 1 2 o f 2 0 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F1 25B1 FB250C Agency Budget Operating Budget for Entire Agency AGENCY NAME: CHARLES HOUSE ASSOCIATION Actual Estimated 2019 Projected 2020, Percent AGENCY REVENUE 2018-19 20 21 Change Private Donations $ 94,000 $ 110,000 $ 35,000 -68% Agency Generated Revenue (fees) $ 1,464,400 $ 1,527,800 $ 1,612,600 6% Local Government Grants: Human Services-Town of Carrboro $ 1,500 $ 900 $ 1,500 67% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ 6,500 $ 6,000 $ 7,000 17% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 23,250 $ 23,363 $ 24,000 3% Other-Orange County $ - 1 $ - 1 $ - 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 $ 15,000 $ 95,000 $ 35,000 $ (0.63) Other Revenue $ - $ - $ - 0 Total Agency Revenue $ 1,604,650 $ 1,763,063 $ 1,715,100 -040%. AGENCY EXPENSES Compensation $ 1,220,000 $ 1,270,000 $ 1,325,000 Rent& Utilities $ 162,000 $ 156,000 $ 158,000 1% Program Supplies&Equipment $ 89,000 $ 82,000 $ 95,300 16% Development $ 12,000 $ 18,500 $ 13,200 -29% Administration $ 38,200 $ 35,000 $ 37,800 8% Other Expenses--Depreciation: $ 66,000 $ 64,200 $ 64,200 1 0% Other Expenses: $ - $ - $ - 0 Total Agency Expenses $ 1,587,200 $ 1,625,700 $ 1,693,500 $ 0 SURPLUS/(DEFICIT) FOR PERIOD: $ 17,450 $ 137,363 $ 21,600 -84% FY 2018-19 Agency Budget DocuSign Envelope ID:2F348727-C96D-44CB-A423-F125131FB250C Program Budget Operating Budget for Program PROGRAM NAME: Charles House Daytime Eldercare Program Actual Estimated Projected Percent PROGRAM REVENUE 2018-19 2019-20 2020-21 Change Private Donations $ - $ - $ - 0 Program Generated Revenue $ 587,500 $ 662,000 $ 660,000 0% Local Government Grants: Human Services-Town of Carrboro $ 1,500 $ 900 $ 1,500 67% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ 6,500 $ 6,000 $ 7,000 17% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 23,250 $ 23,363 $ 24,000 3% 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 $ 618,750 $ 692,263 $ 692,500 0% PROGRAM EXPENSES Compensation $ 479,000 $ 496,000 $ 515,000 4% Rent, Utilities, Property $ 88,400 $ 86,400 $ 86,500 0% Program Supplies&Equipment $ 36,600 $ 34,225 $ 39,500 15% Administration &Outreach $ 6,000 $ 5,100 $ 4,700 -8% Other Expenses-Depreciation: $ 23,000 $ 23,000 $ 23,000 0% Total Program Expenses $ 633,000 $ 644,725 1 $ 668,700 1 4% SURPLUS/(DEFICIT) FOR PERIOD: 1 $ (14,250)1 $ 47,538 $ 23,800 1 -50% FY 2018-19 Program Budget DocuSign Envelope ID:2F348727-C96D-44CB-A423-F125131FB250C EXHIBIT `B" Scope of Services—FY 2020-21 Outside Agency Performance Agreement Agency Name: Charles House Program Name: Daytime Eldercare Program Funding Award: 23,363 Outline how the agency will spend Orange County's funding award. Expense Description Amount Personnel Expense 23,363 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2021. • The Daytime Eldercare Program supports the well-being of participant elders through a therapeutic social program. • The Program supports family caregivers by providing respite,engaging family members in a high quality program. • Family Caregivers are also supported by the program with knowledge, informatio and participation in the group program Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Oran e County,only(all Towns and municipalities). If you use yercentaees,you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results The Program will continue to meet the requirements for NC State Charles House Certification will be successfully re-certificated in July, 2020 50%of enrolled families in the funding year will have the capacity to continue Families are supported in their caregiving of family members with frailty providing care in the home and not require,or delay, and challenges of aging. for residential careplacement lA for their participant/ enrolled family member. of Families will observe positive effects of the Daytime Program for their will dicaeorting ob ervingies improvements in their family member. familymember's (Charles House participants)functioning. Certified by: Title: Date: (Provider's Electronic Signature) "You will sign this document electronically with your performance agreement. DocuSign Envelope ID:2F348727-C96D-44CB-A423-F125131FB250C ORANGE COUNTY NORTH CAROLINA FY 2020-21 Outside Agency Contact Information Congratulations on being awarded Outside Agency Funding for FY 2020-21! Please provide the below information regarding your agencies' contacts for fiscal year 21. Please complete and sign this form electronically and submit to Allen Coleman at outsideagencies@orangecountync.gov by Friday,August 14, 2020. Section A: Agency Information: Agency Legal Name Charles House Association Agency DBA (If Applicable) Physical Address 7511 Sunrise Rd Mailing Address Chapel Hill, NC 27514 Agency's Telephone Number 919-967-7570 Agency Website www.charleshouse.org Section B: Executive Director's Information Executive Director's Name Paul kl eve r Executive Director's Telephone Number 919-967-7570 Executive Director's Email Address paul@charleshouse.org Will the Executive Director Sign the YES NO Performance Agreement? 0 0 If no,please tell us who?-Name: Email Address F71 Application Orientation & What type of Communications should this Training Opportunities individual receive? II Financial Reporting Please select check all that apply: 0 Performance Reporting 0 Performance Agreement Execution 1 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F125131FB250C ORANGE COUNTY NORTH CAROLINA FY 2020-21 Outside Agency Contact Information Section C: Program Contact Information Program Director's Name Same Program Director's Telephone Number Program Director's Email Address ❑ Application Orientation & What type of Communications should this Training Opportunities individual receive? [] Financial Reporting Please select check all that apply: 0 Performance Reporting ❑ Performance Agreement Execution Section D: Financial Contact Information Finance Director's Name Same Finance Director's Telephone Number Finance Director's Email Address 0 Application Orientation & What type of Communications should this Training Opportunities individual receive? ❑ Financial Reporting Please select check all that apply: ❑ Performance Reporting 0 Performance Agreement Execution Section E: Administrative/Office Manager Contact Information Administrative Contact Name Same Administrative Telephone Number Administrative Email Address 0 Application Orientation & What type of communications should this Training Opportunities individual receive? ❑ Financial Reporting Please select check all that apply: 0 Performance Reporting 0 Performance Agreement Execution 2 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F125131FB250C ORANGE COUNTY NORTH CAROLINA FY 2020-21 Outside Agency Contact Information Existing Agencies: Has your agencies banking information changed? [E] YES M NO Has your federal ID number changed? 0 YES FW11NO New Agencies: Please submit a W9 and EFT Authorization Form. Both documents are required. DigitPaul Klever Paul KI ever Datea1ly 2020.08.18signedy13 24 24-04'00' Signature Date 3 DocuSign Envelope ID:2F348727-C96D-44CB-A423-F125131FB250C 76/23/2020 E(MM/DDIYYYY) ACaRf> CERTIFICATE OF LIABILITY INSURANCE 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 endorsements . PRODUCER CONTACT Victoria DeCamp,CISR NAME:TITAN Rlsk Consultants LLC PHONE 919 969 3252 x 2 FAX No): (888)615 4260 107 Conner Drive,Suite 225 E-MAIL-ADDRESS: -MAILADDRESS: v.decamp@titanriskconsultants.com titanriskconsultants.com INSURERS AFFORDING COVERAGE NAIC# Chapel Hill NC 27514 INSURER A: Philadelphia Insurance Company 18058 INSURED INSURERB: Carolina Mutual Insurance Company 14090 Charles House Association INSURER C: 7511 Sunrise Road INSURERD: INSURER E: Chapel Hill NC 27514 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 POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 \/ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 A Y PHPK1958555 05/10/2020 05/10/2021 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY PRO ❑ PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ AUTOMOBILE LIABILITY COEaMBINED accidentS INGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED PHPK1958555 05/10/2020 05/10/2021 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESSLLIAB CLAIMS-MADE PHUB669036 05/10/2020 05/10/2021 AGGREGATE $ 1,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION PER Y/N OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 B OFFICER/MEMBER EXCLUDED? N/A N WC23000-2020 06/25/2020 06/25/2021 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 Professional Liability Each Claim $1,000,000 A PHPK1958555 05/10/2020 06/10/2021 Aggregate $3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate holder is added as Additional Insured as respects General Liability as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED 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 Hillsborough, NC 27278 'Fax: Email:Email: ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD