HomeMy WebLinkAbout _ 4.2(b) Shasta Community Health Center Contract Amendment � � �' � � �
� � � ' � �' � � ' � ` CITY OF REDDING
REPORT TO THE CITY COUNCIL
MEETING DATE: December 3, 2024 FROM: Steve Bade, Assistant City
ITElVI NO. 4.2(b) Manager
***APPROVED BY***
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sbade@cityofredding.org btippin@cityofredding.org
SUBJECT: 4.2(b)--Shasta Community Health Center Agreement - First Amendment
Recommendation
Authorize and approve the following:
(1) Authorize the City Manager, or designee, to execute the First Amendment to the
Encainpment Emergency Shelter Services Contract (C-10639) with the Shasta
Community Health Center thereby increasing the contract amount from $60,000 to
$165,000; and
(2) Find that amending a contract is considered an exempt activity under National
Environmental Policy Act, 24 CFR §58.34(a)(3) administrative activities.
Fiscal Impact
The Encampment Emergency Shelter Services Contract (Contract) is grant funded through the
City of Redding's (City) Encampment Resol�ution Funding Program Round 3-Lookback
allocation as well as other Housing Division budgeted funding sources necessary to fully fund
the contract. Increasing the contract from $60,000 to $165,000 will not impact the General Fund
or other Housing Division activities.
Alternative Action
The City Council (Council) could choose not to provide approval for the additional funding for
interim shelter services and provide staff an alternative direction. An alternative direction may
limit options for Shasta Community Health Center (SCHC) to provide shelter rooms to eligible
homeless individuals.
Background/Analysis
On November 6, 2024, the City terminated an agreement with a vendor who had been contracted
to provide interim shelter to unsheltered persons utilizing a local motel. In order to assist those
who were receiving interim shelter and were affected by the termination of the agreement, on
November 12, 2024, the City Manager signed a contract with SCHC to provide short-term,
Report to Redding City Council November 26,2024
Re: 4.2(b)Shasta Community Health Center ContractAmendment Page 2
interim shelter services for clients displaced from the interim shelter motel program. Although
the existing contract with SCTIC is in effect through March 31, 2025, increasing the contract
funding will allow uninterrupted interim shelter motel rooms for eligible persons displaced
through January 31, 2025.
It should be noted, under a separate, regular calendar staff report, staff has recommended that a
request for proposals be published so that the City can outreach to community service providers
that may be interested in partnering to create more long-term interim shelter contracts.
Envi�^onmental Review
Amending an agreement is not a project as de�ned under the California Environmental Quality
Act, and no further action is required.
Amending a current agreement is considered an exempt activity under National Environmental
Policy Act, 24 CFR §58.34(a)(3) administrative activities.
Council Pr�ioNity/City Manage� Goals
• Government of the 21St Century — "Be relevant and proactive to the opportunities
and challenges of today's residents and workforce. Anticipate the future to make
better decisions today."
• Economic Development — "Facilitate and become a catalyst for economic
development in Redding to create jobs, retain current businesses and attract new ones,
and encourage investment in the community."
Attachments
^First Amendment to C-10639
C-10639 - Encampment Emergency Shelter Services Contract - 2024 - Shasta Community
Health Center
Exhibit C-1
FIRST AMENDMENT TO THE
ENCAIVIPMENT EMERGENCY SI3ELTER SERVICES CONTRACT BETWEEN THE CITY
OF REDDING AND SHASTA COlVIMUNITY HEALTH CENTER(C-10639)
This First Amendment ("First Amendment") is made and entered into by and between the City of
Redding, a municipal corporation, ("City") and Shasta Community Health Center, a California
Nonprofit public benefit corporation ("Provider") (collectively the"Parties" and individually a"Party").
RECITALS
WHEREAS, the Parties have previously entered into the Encampment Emergency Shelter Services
Contract on November l, 2024 for the purpose of Encampment Emergency Shelter services (C-10639)
(referred herein as the "Contract"); and
WHEREAS, the Parties desire to amend the Contract to (1) Increase funding amount; and (2) Clarify
funding sources;
NOW, THEREFORE, the Parties for good and valuable consideration, the receipt and sufficiency of
which is hereby acknowledged, hereby agree as follows:
I. Subsection A of Section 2 of the Contract is hereby amended and replaced in its entirety to read
as follows:
Subsection 2(A). City shall pay Provider for services rendered pursuant to this Contract,
at times and in the manner set forth in Exhibit B, attached and incorporated herein, in a
total amount not to exceed One Hundred Sixty-Five Thousand Dollars and no/100 Cents
($165,000.00). This sum includes expenses incurred by Provider that are reasonably
associated with the provision of services under this Contract. The payments specified
herein shall be the only payments to be made to Provider for services rendered pursuant
to this Contract.
A11 other subsections of Section 2 of the Contract shall remain unchanged and in fu11
force and effect.
II. Subsec�ion L of Section 4 of the Contract is hereby amended and replaced in its entirety to read
as follows:
Subsection 4(L). This Agreement is funded by Encampment Resolution Funding 3-L or
any other grant funding available through the City Housing Department. Consultant
agrees to comply with all statutory,regulatory, and contractual requirements applicable to
this funding source. This may include both substantive restrictions on how funds may be
expended as well as various additional requirements, such as documentation, record
keeping, and reporting. In the event that any state or federal agency determines that the
City of Redding is required to repay any portion of the grant funds due, in whole or in
part, to Consultant's failure to comply with grant requirements, breach of this agreement,
or violation of law, Consultant agrees to make immediate payment to the City in the
First Amendment to Contract C-10639
Page 1
amount that agency has determined that the City must repay. This obligation is
cumulative and in addition to any remedies the City may have, whether in contract or in
tort
A11 other subsections of Section 4 of the Contract sha11 remain unchanged and in full
force and effect.
III. As of the effective date of this First Amendment, Exhibit B to the Contract is hereby deleted in
its entirety and replaced with Exhibit B-1 attached hereto and incorporated herein by reference,
each reference in the Contract to `Bxhibit B" shall mean and be a reference to "Exhibit B-1".
IV. The foregoing Recitals and all exhibits referenced therein are hereby incorporated by this
reference.
V. Except as expressly set forth herein, a11 of the terms and conditions of the Contract shall remain
in full farce and effect.
VL The effective date of this First Amendment sha11 be the date that it is signed by the City.
Remainder of page intentionally left blank
First Amendment to Contract C-10639
Page 2
IN WITNESS WHEREOF, City and Consultant have executed this First A�nendment on the days and
year set forth below:
CITY OF REDDING
A Municipal Corporation
Dated:
By: BARRY TIPPIN, CITY MANAGER
ATTEST: APPROVED AS TO FORM:
CHRISTIAN M. CURTIS
City Attorney
SHARLENE TIPTON, City Clerk By: CHRISTIAN M. CURTIS
City Attorney
PROVIDER
SHASTA COMMUNITY HEALTH CENTER
Dated: , 20
By: BRANDON THORNOCK,
Chief Executive Director
Tax ID No: 68-0165885
First Amendment to Contrac�C-10639
Page 3
Exhibit B-1.
SECTION 1. PAYMENT PROVISIONS
Summary cost reporting documentation must be submitted with invoices, and all backup
documentation must be retained for five (5) years.
Provider will be paid in accordance with the total budget stipulated as follows and subject to any
limitations and specifics contained in this Contract and specific regulations:
Pro'ect Cost Total
Motel Room Rental $ 156,750
dmin costs u to 5% $ 8,250
Total $ 165,000
Provider must demonstrate expenses are in alignment with the approved eligible expenditures
using the Monthly Repo�t and Teinplate (Exhibit C-1). Payments will not be made by the City on
an invoice unless the previous month's data has been submitted by the Provider into HMIS and
approved by the City.
Provider will be reimbursed for eligible expenses including Mote1 Room Rental costs and
Administration costs up to 5% of the total budget.
Motel room cost will be calculated by a daily rooin rate. It is acceptable to have two people share
a room if the room is an appropriate size and both people agree to share the room. Backup
documentation should identify the rooin number, room rate, and person(s) in the room.
This budget is subject to modification with the approval of the City Contract Representative, not
to exceed the total payment amount as indicated in Section 2 of this Contract.
Provider agrees to provide City with reports that may be required by County, State, or Federal
agencies for compliance with this Contract, including and not limited to:
1. Provider is required to enter each client served into the Homeless Management Information
System (HMIS) as shown in Exhibit D. This includes a completed valid Release of
Information from the program participant so that information may be inputted into HMIS
within three (3) days upon entry and exit. Failure to input or provide complete, accurate,
and timely client and program information into HMIS may result in payment delay.
Provider acknowledges and agrees to any training necessary to accurately enter data into
the HMIS and Coordinated Entry systems. The IIMIS and Coordinated Entry systems are
maintained by the United Way of Northern California. Their contact information is United
Way of Northern California, 3300 Churn Creek Rd., Redding, CA 96001, 530-241-7521.
CITY OF REDDING
ENCAMPMENT EMERGENCY SHELTER SERVICES CQNTRACT
THIS CONTRACT ("Contract')` is made at Redding, Calif'ornia, by and between the City of
Redding("City"), a municipal corporation,and The Shasta Community Health Center,a California
Nonprofit Public Benefit Corporation ("Provider") (collectively the "Parties", individualiy a
"Party")for the purpose of Encampment Emergency Shelter'services.
RECITALS
WHEREAS, City does not have sufficient personnel to perform the services required herein,
thereby necessitating this Contract for Encampment Emergency Shelter services.
WHEREAS,the California Department of Busine�s, Consumer Services and Housing Agency has
awarded City the encampment resolution funds for the purpose of ensuring the safety and weliness
o�people experiencing hornelessness in encampments, resolving critical encampment concerns
and transition individuals into safe and stable housing, and encouraging a data-inf'ormed,
coordinated approach to address encampment concerns ("Encampment Resolution Funding
Program{ERF-3-L)"); and
WHEREAS; City has entered in that certain Standard Agreement Number 23-ERF-3-L-00008,
Purchasing Authority Number 010725 with the California Departrnent of Business, Consumer
Services and Housing Agency dated October l2, 2023 under the authority of, and in furtherance
of, the purpose of the Encarnpmenf Resolution Funding Program (ERF-3-L) ("Standard
Agreement"); and
WI3EREAS, the California bepartment of Housing and Community Development ("HCD") has
assumed administration of the Encampment Resolution Funding Program(ERF-3-L)and currently
administrates the Encampment Resolution Funding Program {ERF-3-L}; and
WI�EREAS,Provider agrees to provide services related to the Encampment Resolution Funding
Prograrn set forth in the Contractand represents that it is capable of providing such services; and
WHEREAS,Pravider acknowledges and agrees that City shali utilize the Encampment Resolution
Funding Program to compensate Provider for the services provided pursuant to the Contract and
represents that it is willing and capable of complying with the Encampment Resalution Funding -
Program requirements;
NOW, TI�EREFORE, the Parties covenant and agree, for good consideration hereby
acknowledged, as f'ollows:
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Encampment Emergency Shelter Services Contract—Shasta Cammunity Health Center
SECTION 1. ENCAMPMENT EMERGENCY SHELTER SERVICES
A: Provider shall provide services outlined in Exhibit A, attached and incorporated herein.
Provider shalT provide the services at the time, place, and in the manner specified in
Exhibit A
B. Pravider shall provide services in campliance with all terms and conditions of the
Encampment Resolution Funding Program (ERF-3-L) set forth in the Standard
Agreemenf (as applicable) attached hereta as Exhibit E and incorparated herein by
reference: Provider sha11 notify City about any noncompliance by Provider with the
Encampment Resolution Funding Program (ERF-3-L) requirements either confirmed
or suspected.
SECTION 2. COMPENSATION AND REIMBURSEMENT OF COSTS
A. City shall pay Provider for services rendered pursuant ta this Cantract, at times and
in the manner set forth in Exhibit B, attached and incorporated herein, in a total
amounf not to exceed Sixty Thousand Dollars and nof l00 Cents ($60,00'0.00). This
sum includes expenses incurred by Provider that are reasonably associated with the
provisian of services under this Contract. The payments specified herein sha11 be the
anly payments to be made to Provider for services rendered pursuant to this Contract.
B. Provider shali submit monthly reports and invoices to the City for services completed
to the date of the invoice no later than the 15th of each month in the form set farth in
Exhibit C and Exhibit G1. Exhibit C and Exhibit C-1 are attached and incorporated
herein by reference. All invoices shall be itemized to reflect the activities completed,
'employees performing the requested tasks,the billing rate for each employee and the
hours worked. City shall not pay invoices submitted without manthly reports required
herein.
C. Drawdowns for the payment of eligible expenses shall be made against the lin�
budget items specified in Exhibit B and in accordance with performance. Reporting
of program expenses, including "zero" expenses, and drawdown requests will be
accompanied by program statistics as outlined on the Encampment EmeYgency
Shelter ProgYam Monthly Report (Exhibit C). This Exhibit shall be submitted along
with an invoice for project funds expended within the reporting periad and it must be
accompanied by documents that adequately justify the reported expenses.
Documentation may include, but is not limited to copies of receipts, bills, invoices,
payroll reports, paystubs'; timecards, and/or program financial statements as
appropriate. At its discretion, the City may request additionai supporting "
documentation for the purposes of accepting Exhibit C and approving any request for
reimbursement:
D. All correct, complete, and undisputed invoices sent by Provider to City that comply :
with requirements stated abave shall- be paid within thirty {30) calendar days of
receipt.
Encampment Emergency Shelter Services Contract—Shasta Community Health Center
SECTION 3. TERM AND TERMINATiQN
A: The Contract shall be effective on November l, 2024 (the "Effective Date") and
expires an March 3l, 2025, unless terminated earlier in accordance with the
termination provisions of this Contract
B. If Provider fails to (1}perform its duties ta the satisfaction of City, or(2) fulfill in a
timely and professinnal manner its obligatians under this Cantract; (3) comply with '
the requirements af the Encampment Resolution Funding Program(ERF-3-L), or(4)
ensure that each independent contractor or subcantractor haired by Provider ta
perfarm a partion of its obligations under this Contract camplies with the
Encampment Resolution Funding Program {ERF-3-L)'requirements,then City shall
have the right to terminate this Contract effective imrnediately upon City giving
written notice thereof'to Provider:
C. Either Party may terminate this Contract without cause an thirty (30) calendar days'
written notice.Notwithstanding the preceding�if the term set forth in Section 3:A. of
this Contract exceeds ninety (90) calendar days in duration, Provider's sole right to
terminate shall be limited to terminatian for cause.
D: In the event that City gives natice of termination,Provider shail pramptly provide to
City any and all finished and unfinished reports, data; studies, photographs; charts or
other work product prepared by Pravider pursuant to this Contract. City shall have
full ownership, including, but not limited to, intellectual property rights, and control
of all such finished and unfinished reports, data; studies, photographs, charts or other
work product.
E. In the event that City terminates the Contract,City shall pay Provider the reasonable
value of services rendered by Provider pursuant to this Contract;provided, however,
that City shall nat in any manner be liable for lost profits which might have been
made by Provider had Provider completed the services required by this Contract.
Provider shall;not later than ten (10) calendar days after terrnination of this Contract
by City, furnish to City such financial infarmatian as in the judgment of the City's
representative is necessary ta determine the reasanable value of the services rendered
by Provider.
F. In no event shall the terminatian or expiration of this Contract be construed as a
waiver of any right to seek remedies in law,equity or otherwise far a Party's failure
to perform each obligation required by this Contract.
SECTION 4. " MISCELLANEQUS TERMS AND CONDITIONS OF CONTRACT
A. All Provider records with respect to any matters covered'by this Contract shall be
made availabie to City, state, and/or federai authorities or any authorized
representatives, at any time during normal business hours, as aften as deemed
necessary, to audit, examine, and make excerpts or transcripts of ali relevant data.
Encampment Emergency Shelter Services Contract—Shasta Community Health Center
Any deficiencies noted in auditlmonitoring reports rnust be fu�1y cleared by Pravider
within 30 days after receipt of notice of deficiency or deficiencies by Provider.
Failure of Provider to comply with the above auditlmonitoring requirernents will
constitute a violation of this Contract and may result in the withholding of future
payments.
B. Pursuant to the City's business license ordinance, Provider sha11 obtain a City
business license prior to commencing work.
C. Provider represents and warrants to Citythat it has all licenses,permits,qualifications
and approvals of any nature whatsoever thaf are legally required for Provider to
practice its profession. Provider represents and warrants to City that Provider shall,
at its sale cost and expense, keep in effect or obtain at all times during the term of
this Contract any licenses,permits and approvals that are legally required for Provider
to practice its professian.
D. Provider shall, during the entire term of this Contract, be construed to be an
independent contractor and nothing in this Contract is intended, nar shaIl it be
construed, to create an employer/employee relatianship, assaciation, joint venture
relatianship,trust or partnership or to allow City to exercise discretion or contral over
the profe�sional manner in which Provider performs under this Contract.Any and all
taxes impased on Provider's income, imposed or assessed by reason of this Contract
or its performance, including but not limited ta sales or use taxes, shall be paid by
Provider. Pravider shall be responsible for any taxes or penalties assessed by reason
af any claims that Provider is an employee of City.-Pravider shall not be eligible for
coverage under City's workers' compensation insurance plan, benefits under the
Public Emplayee Retirement System or be eligible for any other City benefit.
E. No provision of this Contract is intended to, or shall be for the benefit of,or construed
to create rights in, or grant remedies to, any person or entity nt�t a party hereto:
F. No portion of the work ar services to be performed under this Contract shall be
assigned,transferred, conveyed or subcontracted without the prior written approval
of City. Pravider may use the services of independent contractors and subcontractors
to perfarm a portion-of its obligations under this Contract with the prior written
appro�al of City. Independent contractors and subcontractors shall be provided with
a copy of this Contract and Provider sha11 have an affirmative duty to assure that said
independent contractors and subcontractors comply with the same and agree to be
bound by its terms: Provider shall be the responsible party with respect to all actions
of its independent contractors and subcontractors, and shall obtain such insurance and
indemnity provisions from its contractors and subcontractors as City's Risk Manager
shall determine ta- be necessary: Provider shall ensure that each independent
cantractor or subcontractar haired by Provider to perform a portian of its obligations
under this Contract complies with the Encampment Resolution Funding Program
(ERF-3-L) requirements.
Encampment Emergency Shelter Services Contract—Shasta Comrnunity Health Genter
G. Provider,at such times and in such form as City may require, shall furnish City with
such periodic reports as it may request pertaining to the work or services undertaken
pursuant to this Contract, the costs or obligations incurred or to be incurred in
connection therewith, and any other matters covered by this Contract.
H. Pravider shall"maintain accounts and records, including personnel, property and
financial records, adequate to identify and account for all costs pertaining to this
Contract and such other records as may be deemed necessary by City to assure proper
accounting for a11 project funds. These records shall be made available for audit
purposes to state and federal authorities, or any authorized representative of City.
Provider shall xetain such records for five (5) years after the expiration of this
Contract, unless prior permission to destroy them is granted by City.
L Providef shall perform ai1 services required pursuant to this Contract in the manner
and according to the standards observed by a competent practitioner of Provider's
profession. A1T products of whatsoever nature which Provider delivers to City
pursuant to this Contract sha11 be prepared in a professional manner and conform to
the standards of quality normally observed by a person practicing the profession af
Provider and-its agents, emplayees and subcontractors assigned to perform the
services contemplated by this Contract.
J. A11 campleted repoi-ts and other data or documents, or computer media including
diskettes, and other materials provided or prepared by Provider in accordance with
this Contract are the property of City, and may be used by City. 'City shall have all
intellectual property rights including, but not limited to, copyright and patent rights,
in said documents, computer media, and other materials provided by Provider. City
shal� release, defend� indemnify and hold harmless Provider fxom all claims, costs,
expenses, damage or liability arising out of or resulting from City's use or
modification:of any reports, data, documents,drawings, specifications or other work
product prepared by Provider, except for use by City an tho'se portions of the City's
project for which such items were prepared.
K. Provider, including its employees, agents, and sub-providers, shall not maintain or
acquire any direct or indirect interest that conflicts with the performance of this
Contract. Provider sha11 comply with a11 requirements of the Political Reform Act
(Government Code § 8100 et seq.) and other laws relating to conflicts of interest,
including the following: 1)Provider shall not make or participate in a decision made
by City'if it is reasonably foreseeable that the decision may have a material effect on
Provider's economic interest, and2) if required by the City Attarney,Provider shall
file financial disclosure forms with the City C1erk.
L: This Agreement is funded by State and/or Federal grant funds. Consultant agrees to
comply with all statutory, regulatory, and contractual requirements applicable to this
funding source: This may include both substantive restrictions on how funds may be '
expended as we11 as various additional requirements� such as dacumentation, record
keeping, and reporting. In the event that any state or federal agency determines that
Encampment Emergency Shelter Services Contract—Shasta Community Health Center
the City of Redding is required to repay any portion of the grant funds due, in whole
or in part, to Consultant's failure to comply with grant re�uirements, breach of this -
agreement, or violation of law, Consultant agrees to make immediate payment to the
City in the amount that agency has determined that the City<must repay: This
obligation is cumulative and in additian to any remedies the City may have, whether
in contract or in tort.
SECTION 5. INSURANCE
A: Unless madified in writing by City's Risk Manager, Provider shall maintain the
following noted insurance during the duration of the Contract:
Coverage Re uired No#Re,guired
Colnmercial�'reneral Liability X
Comprehensive Vehicle Liabirity X
Workei•s' Cornpensation and Employers' Liability X
'Professional Liability(Errors and Otnissiozls) X
(Place an"x" in the appropriate box)
B. Coverage shall be at least as broad as:
L; Insurance Services Office form number CG-0001; Commercial Genera� :
Liability Insurance�in an amaunt not less than$1,000,OQ0 per accurrence and
$2,Q00,000 general"aggregate for bodily injury, persanal injury and property
damage;
2. Insurance Services Office form number CA-0001 (Ed. 1187), Comprehensive "
Automobile Liability Insurance, which pravides for total limits of nat less
than$1;000,000 combined single limits per aceident applicable to all owned,
non-owned and hired vehicles,
3. Statutory Workers' Compensation required by'the Labor Code of the State of
California and Employers' Liability Insurance in an amount not less than
$1,000,000 per occurrence: Both the Workers' Compensation and Employers"
Liability policies shall contain the insurer's waiver of subrogation in favor of
City, its elected officials, officers, employees, agents and volunteers;
4. Professional Liability (Errors and Omissions) Insurance, appropriate to
Provider's professian, against loss due to error or omissian or malpractice in
an amaunt not less than $1,000,000.
Encampment Emergency Shelter Services Contrack—Shasta Communiky Health Center
5. The City does nat accept insurance certificates or endorsements with the
wording "but only in the event of a named insured's sole negligence" ar any
other verbiage limiting the insured's insurance responsibi�ity.
C: Any deductibles ar self-insured retentions must be declared to and approved by City.
At the option of the City,either: the insurer shall reduce or el;irninate such deductib�es
or self-insured �etentions as respects the City, its elected afficials, offieers,
employees, agents and volunteers; or the Provider shall procure a bond guaranteeing
payment of losses and related investigations, claims administration and defense
expenses:
D: The General Liability shall cantain or be endorsed to contain the fallowing
provisions: _
L City, its elected officials, officers, employees,and agents are ta be covered as
additional insured as respects liability arising out of work ar operations
performed by or on behalf of Provider; premises owned, leased or used by
Provider; or automobiles owned,leased, hired or borrowed by Provider. The
coverage shall contain no special limitations on the scope af protectian
affarded to City, its eiected officials, officers, emplayees, agents and
volunteers.
2. The insurance coverage of Provider shall be primary insurance as respects
City, its elected officials, officers,-employees; agents and volunteers: Any
insurance or self-insurance maintained by City, its elected officials, officers,
employees, agents and volunteers, sha11 be in excess of Provider's insurance
and shall not cantribute with it.
3. Caverage shall state that the insurance of Provider shall apply separately ta
each insured against whom claim is made or suit is brought, except with
respect ta the limits of the insurer's liability.
4. Each insurance policy required by this Contract shall be endorsed to state that
caverage shali not be canceled except after thirty (30) calendar' days' prior
- written notice has been given to City. In addition,Pravider agrees that it shall
nat reduce its coverage or limits on any suchpolicy except after thirty(30)
calendar days' prior written natice has been given to City.
E'. Insurance is to be placed with insurers with a current A.M; Best's rating of no less
than A-V IL
F. Provider sha11 designate the City bf Redding, 777 Cypress Avenue, Redding, CA
96001 as a Certificate Holder of the insurance. Provider shall furnish City with
certificates of insurance and original endorsements effecting the caverages required
by this cl'ause. Certificates and endorseznents shall be subrnitted electronically via the
PINS Advantage system.A link wi11 be provided for the Provider, or their insurance
Encampment Bmergency Shelter Services Contract--Shasta Community Health Center
agent, to enter and upload documents directly to PINS Advantage. The certificates
and endorsements for each insurance policy are to be signed by a person authorized
by the insurer to bind coverage on its behalf.All endorsements are ta be received and -
approved in PINS Advantage by the City's Risk Manager prior to the commencement
of contracted services. City may withhold payments to Provider if adequate
- certificates of insurance and endorsements required have not been submitted as
described above ar provided in a timely manner.
G. The requirements as to the types and limits of insurance coverage to be maintained
by Provider as required by Section 5 of this Contract, and any approval of said
insurance by City; are not intended to and wi11 not in any manner limit or qualify the
liabiTities and obligations otherwise assumed by Provider pursuant ta this Contract,
including, without limitation, provisions cancerning indemnification.
H: If any policy of insurance required by this Section is a``claims made"policy,pursuant
to Code of Civi1 Procedure §342 and Government Code § 945.b,Provider shall keep
said insurance in effect for a period of eighteen (18) months after the termination of
this Contra�t.
I: If any damage, including death, personal injury ar property damage; occurs in
connection with the performance of this Contract, Provider shall immediately notify
City's Risk Manager by telephone at(530)225-4068.No later than three(3)calendar
days after the event, Pravider sha11 submit a written report to City's Risk Manager
containing the following infarmatian, as applicable:l) name and address of injured
or deceased person(s); 2) name and address of witnesses; 3) name and address of
Pravider's insura�ce company; and 4) a detailed description of'the damage and
whether any City property was involved; -
SECTION 6. INDEMNIFICATION AND HOLD HARMLESS
A. Consistent with California Civi1 Code § 2782:8, when the services to be provided
under this Cantract are design professional services to be'performed by a design
professional, as that term is defined under Section 2�82.8, Provider shall, ta the
fullest extent permitted by 1aw, indemnify pratect, defend and hoid harmless, City,
its elected officials,officers,employees,and agents,and each and every one ofthem,
from and against all actions, damages, costs, liability, claims, losses, penalties and
expenses (including, but not limited to, reasonable attorney's fees of the City
Attorney or legal counsel retained by City, expert fees, litigation costs, and
investigation costs) of every type and description to which any or all of them may be
subjected by reason of, or resulting from, directly or indirectly, the"negligence,
recklessness, or willful misconduct of Provider, its officers, employees or agents in
the performance of professional services under this Contract, except when liability
arises due to the sole negl'rgence;active negligence or misconduct of the City.
B: Other than in the performance of professional services by a design professional,
which is addressed solely by subdivision{A) of this'Section, and to the fullest extent
Encampment Emergency Shelter Services Contract—Shasta Community Health Center
permitted by law, Pravider shall indemnify protect, defend and hold harmless, City,
its elected officials,offcers, employees, and agents,and each and every one of them,
from and against all actions, damages, costs,liability, claims, losses, penalties and
expenses (including� but not limited to, reasonable attorney's- fees af the City
Attarney or legal counsel retained by City, expert fees, litigation costs; and
investigation costs)of every type and description to which any or all of them may be
subjected by reason of the performance of the services required under this Contract
by Provider its officers, employees or agents in the perfarmance af professional
services under this Contract, except when liability arises due ta the sole negligence,
active negligence or miscanduct of the City.
C. The Provider's obligation to defend, indemnify and hold harmless shall not be
excused because of the Provider's inability to evaluate liability. The Provider shall
respond within thirty (30} calendar days to the tender of any claim for defense and
indemnity by the City, unless this time has been extended in writing by the City. If
the Pravider fails to accept or reject a tender of defense'and indemnity in writing
delivered ta City within thirty (30) calendar days, in addition to any other remedy
authorized by law, the City may withhold such funds the City reasonably considers
necessary for its defense and indemnity until disposition has been made of the claim
or until the Provider accepts or rejects the tender of defense in writing delivered to
the City;whichever occurs first:This subdivision shall not be construed to excuse the
prompt and eontinued performance of the duties required of Provider herein.
D: The abligation to indemnify, pratect, defend, and hold harmless set forth in this
Sectian appiies to all claims and liability regardless of whether any insurance policies -
are applicable; The policy limits af said insurance policies da not act as a limitation
upon the amount of indemnifieation to be provided by Provider.
E: City shall have the right to approve or disapprove the legal counsel retained by
Provider pursuant to this Section to represent City's interests. City shall be
' reimbursed for ali costs and attorney"s fees incurred by City in enforcing the
obligations set forth in this Section.
SECTIUN 6. C4NTRACT INTERPRETATI4N, VENUE AND ATTORNEY FEES
A. This Contract shall be deemed to have been entered into in Redding, California. All
questions regarding the validity, interpretation; ar performance of any of its terms or
of any rights or abligations of the parties to this Contract sha11 be governed by
Califarnia law: If any claim, at law or atherwise, is made by either party to this
Contract, the prevailing party shall be entitled to its costs and reasonable attorneys'
fees.
Encampment Emergency Shelter Services Contract—Shasta Community Health Center
B: This document, including all exhibits, contains the entire agreement between the
parties and supersedes whatever oral or written understanding each may have had
prior to'the executian of this Contract. This Contractshall not be altered;amended or
modified'except by a writing signed by City and Provider:No verbal agreement ar
conversation with any official, officer, agent, or employee of City, either before,
during, or after the execution of this Contract, shall affect or modify any of the terms
or conditions contained in this Contract, nor shall any such verbal agreement or
conversation entitle Provider to any additional payment whatsoever under the terms
of this Contract.
C: No covenant or condition to be performed by Provider under this Contract can be
waived except by the written cansent of City.Farbearance or indulgence by City in
any regard whatsoever shall nat constitute a waiver of the covenant or condition in
question. Until performance by Provider of said covenant ar condition is complete,
City shall be entitled to invake any remedy available to-City under this Contract or
bylaw ar in ec�uity despite said forbearance or indulgence.
D: If any portion of this Contract or the application thereof to any person or circumstance -
shall be invalid or unenforceable to any extent, the remainder af this Contract shall
not be affected thereby and shall be enforced to the greatest extentpermitted by law.
E. The headings in this Contract are inserted for convenience only and shall not
constitute a part hereo£ A waiver of any party of any provision or a breach of this
Contract must be provided in writing and shall not be construed as a waiver of any
other provision or any succeeding breach of the same or any ather provisions herein.
F: Each Party hereto declares and represents that in entering into this Contract, it has
relied and is relying solely upon its own judgment, belief and knowledge of the
nature, extent, effect and consequence relating thereto. Each Party further declares
and represents that this Contract is made without reliance upon any statement or
representation not contained herein of any ather Party or any representative, agent,
or attorney of the other Party. The Parties agree that they are aware that they have the
right to be advised by counsel with respect ta the negatiations,terms; and conditions
of this Contract and that the decision of whether ar not to seek the advice of caunsel
with respect to this Cantracf is a decision which is the sole responsibility of each of
the Parties. Accordingly, no party shall be deemed to have been the drafter hereof,
and the principle of 1aw set farth in Civi1 Code § 1654 that contracts are construed
against the drafter shall not"apply.
G. Each of the Parties hereto hereby irrevocably waives any and all right to trial by jury
in any action, proceeding, claim ar counterclaim, whether in cantract or tort, at law
or in ec�uity, arising out of ar in any way related to this Agreement or the transactions
contemplated hereby. Each Party further waives any xight to consolidate any action
which a jury trial hasbeen waived with any ather action in which a jury trial cannot
be or has nat been waived. '
Encampment Emergency Shelter Services Contract—Shasta Community Health Center
H. In the event of a conflict between the term and conditions of the body of this Contract
and thase of any exhibit or attachment hereto; the terms and conditions set forth in
the body af this Contract proper sha11 prevail.In the event of a canflict between the
terms and canditions of any two or mare exhibits or attachments hereto, thase
prepared by City shall prevail over those prepared by Provider.
SECTION 7. SURVIVAL
The provisions set farth in Subsection 1(C} and Sectians 3 through 7, inclusive, of this
Contract shall survive the termination or expiration of the Contract.
SECTION 8. COMPLIANCE WiTH LAWS - NONDISCRIMINATTON
A. Provider shall comply with all applicable laws, ordinances and codes of federal,;state
and lacal governments.
B: In the performance of this Contract, Provider shall not discriminate against any
employee or applicant far employment because af race, color; ancestry, national
arigin,religious creed; sex, sexual arientation, disability, age, marital status, political
affiliation, or membership or non-membership in any organization. Provider sha�l
take affirmative action to ensure applicants are emplayed and that emplayees are
treated during their employment without regard to their race, color;ancestry,national
arigin,religious creed, sex, sexual orientation, disabiiity, age,marital status,political
affiliation,or membership or non-membership in any organization: Such actions shall
include, but not be limited to, the following: ernployment, upgrading, demotion or
transfer,recruitment or recruitment advertising, layoff or termination,rates of pay ar
ather forms of campensation,and selection for training.
SECTION 9. REPRESENTATIVES
A. City's representative for this Contract is Laura MeDuffey, Seniar Housing Specialist,
telephone number (530) 225-423b, fax number (530} 225-4126, email
ImcduffeY(�citvofi•eddin .g or�, 7'77 Cypress Avenue, Redding, California 96QO1. Al1 af
Provider's questions pertaining to this Contract shall be referred to the above-named
person, or to the representative's designee.
B. Provider's representative for this Contract is Brandon Tharnack, telephane number '
(530} 229-5074, email bthornock@shastahealth.org. All of City's c�uestions
pertaining to this Contract shall be referred to the above-named persan.
C. The representatives set farth herein shall have authority to give all notices required
herein.
Encampment Emergency Shelter Services Contract—Shasta Community Health Center
sEcrzoN �a. NaTICEs
A. All notices,requests,demands,and other cammunications hereunder shall be deemed -
- given anly if in writing signed by an authorized representative of the sender(may be
other than the representatives referred to in Section 10) and delivered by email ar
facsimile, with a hard copy mailed first class, postage prepaid; or when sent by a
courier ar an express service guaranteeing overnight delivery to the receiving party,
addressed to the respective parties as follows:
To City: To Provider:
Laura McDuffey Brandon Thornock
Senior Housing Specialist Chief Executive Director
City'of Redding Shasta Community Heaith Center
777 Cypress Ave. 1035 Placer St:
Redding, CA 960Q1 Redding,'CA 96001
lmcduffey@cityofredding:org bthornock@shastahealth.org
B. Either party may change its address for the purposes of this paragraph by giving
� � � ��written�notice of such�change to the other party in the�rnanner�provided in this Section. ���
C. Notice shall be deemed effective upon: l)personal service; 2)two calendar days after
mailing,emailing, or transmission by facsimile;whichever is earlier.
SECTION 11. AUTHORITY TO CONTRACT
A. Each of the undersigned signatories hereby represents and warrants that they are
authorized to execute this Contract on behalf of the respective parties to this Contract;
that they have fizll right, power, and Iawfizl authority to undertake all obligations as
provided in this Contract; and that the execution, performance, and delivery af this
Cantract by said signatories has been fizliy authorized by all requisite actions on the
part of the respective parties to this Contract.
B. �Vhen the Mayor is signatory to this Contract, the City Manager and/or the
Departrnent Director having direct responsibility for managing the services provided
herein shall have authority to execute any amendment to this Contract which does
not increase the amount of compensation allowable to Provider or otherwise
substantially change the scope of the services provided herein.
SECTION 12. INCORPORATION OF RECITALS;AND EXHIBITS
The foregoing Recitals and all exhibits referenced therein are hereby incorporated by this
reference and made part of this Contract.
Encampment Emergency Shelter Services Contract—Shasta Community Health Center
SECTION 13, EFFECTIVE DATE OF CONTRACT
The effective date af this Contract shall be the date it is signed by City.
Enclasures: '
Exhibit A—Scope of Work
Exhibit B —Payrnenf Provisions
Exhibit C=Monthly Report
Exhibit G l -Invoice Template
Exhibit D—HMIS Documents
Exhibit E—Executed Standard Agreement
[Remainder af Page Intentiona�ly Left Blank. Signature Page Follows.)
Encampment Emergency Shelter Services Contract—Shasta Community Health Center
IN WITNESS WHEREOF, City and Provider have executed this Contract on the days and year
set forth below:
CITY OF REDDING,
A Municipal Cor�oratior�
Dated: � � , 20 ,
B�: BAR�2� � tty lYlanager :�
ATTEST: APPROVED AS TO FORM:
� �CF1"1 ��7pt'�7V�d
�
��l � '� �
���� � � � �"� � talla ersol �
.
� �,,������,� "`���"•.�,�¥`� E '� �°��� Assistant City Attorne
� S�A E�E TIP"TC)l�T, C�ty +Clerk By: CHRISTIAN M. CURTIS,
City Attorney
PROVIDER: Shasta Community Health
Center
Dated: �� �? , 20 . .�--�''��.��-"°��.�..�,.a-
-�--
: BRANDON THQRNOCK,
Chief Executive`Director
Tax IDNo.: 68-0165885
Encampment Emeraency Shelter 5ervices Contract Shasta Community Health Center
Exhibit A;
Provider; Shasta Community Health Center wi11 be responsible for administering Encampment
Ernergency Shelter Services (Project) during the term of this Contract at the time, place, and
manner specified in this Exhibit.
SECTION L SCOPE OF WORK
Shasta Community Health Center will operate the Project as detailed in this Contract, obtaining a
black of hotel rooms for Emergency Shelter for eligible individuals as identified by the City in
accardance with the Encampment Resolutian Funding 3-L; and oversee shelter stays. Tasks will
include the following:
A. Work with the City's Crisis Intervention Response Team (CIRT) and Good News Rescue
Mission ERF Case Managers to pro�ide shelter rooms to identified homeless individuals.
Referrals will be accepted-through CIRT and other community providers and focus on ;
clients associated with the Linden Canyon or Progress Way encampments.
B. Coordinate with other funding sources that could provide emergency shelter and other
support:
C. Provide Emergency Shelter and support far client hauseholds as they adjust from living
outside ta living in temporary emergency housing.
D. Coordinate with available community case managers to assist clients with immediate
shelter fram the el'ements,establish stability, and connect to services with the intent of
permanent housing solutions.
E. `Collect data and information as required by the City; including enrolling clients into the
Coordinated Entry via Homeless Management Information System (HMIS) if they are not
enralled.
a. Provider wi11 set up and utilize a dedicated Emergency Shelter Program in HMIS
and"grant the City access for monitoring.
b. Provider will enroll clients in Coordinated Entry if they have not been previausly
enrolled or have expired Release of Infarmation forms, as indicated in Exhibit D.
c. Pravider will complete and upload a Hameless Certification document to HMIS for
each client; as indicated in Exhibit D.
F. Provider shall submit monthly reports to the Contract Representative using the required
City format and the Homeless Management Information System (HMIS). The Provider
will pro�ide monthly reports on requested data outcomes and demographics by the 15`I' of
each month.
G. Provider may be requested to provide reports from HMIS to Contract Representative.
Encampment Emergency Shelter Services Cantraet—Shasta Community HeaCth Center
H. Provider shall provide client-specific data as requested by the City.
SECTION 2. PERFORMANCE MEASUREMENT
The Project wi11 be monitored frequently using internal evaluations, data verification, and field
monitoring. The Provider wi1L•
A. Implement program evaluation tools to rneasure client satisfaction and program
effectiveness.
B. Submit monthly reports to the City of Redding;with additional reports and data as
requested.
G Receive periodic monitoring and evaluation by the City.
The following outcomes/outputs wiil be used to assess the performance of the Project. This data
will be reflected in HMIS reports along with monthly reports ta City:
A. Number of clients served.
B. Destinations of Clients when they exit the program.
C. Services pravided while in the program:
D. Data input to the HMIS is consistent and monitored monthly.
Encampment Emergency Shelter Services Contract—Shasta Community Heatth Center
Exhibit B;
SECTION L PAYMENT PROVISIQNS
Summary cost reporting documentation must be submitted with invoices, and atl backup
documentatian must be retained for five (5) years.
Provider will be paid in accordance with the total budget stipulated as follows and subject to any
limitations and specifics cantained in this Contract and specific regulations:
Praject Cost Total
Motel Room Rental $ 57,000
Admin costs (u to 5%) $ 3,000
Total $ b0,000
Provider must demonstrate expenses are in alignment with the approved eligible expenditures
using the Monthly Repor�t and Template (Exhibit C-l): Payments will not be made by'the City on
an invaice unless the previous month's data has been submitted by the Provider inta HMIS and
approved by the City:
Provider wi11 be reimbursed for eligible expenses including Motel Room `R�ntal costs and
Administration costs up to 5% of the total budget.
Motel room cost will be calculated by a daily room rate. It is acceptable to have two people share
a room if the room is an appropriate size and both people agree to share the room. Backup
documentation should identify the raorn number, room rate,and person(s) in the room.
This budget is subject to modification with the approval of the City Contract Representative, not '
to exceed the total payment amount as indicated in Sectian 2 af this Contract.
Provider agrees to provide City with reports that may be required by County, State, ar Federal
agencies for campliance with this`Contract, including and not limited to:
1. Provider is required to enter each client served into the Horneless Management Informatian
System (HMIS) as shown in Exhibit D. This includes a campleted valid Release of
Informatian from the program participant so that information may be inputted into HMIS
within three (3) days upon entry and exit. Failure ta input or provide camplete, accurate,
and timely client and program information into HMIS may result in payment delay.
Provider acknowledges and agrees to any training necessary to accurately enter data inta
the IIMIS and Coordinated Entry systems. The I-IMZS and Coordinated Entry systems are
maintained bythe United Way ofNorthern California. Their contact information is United
Way of Northern California, 3300 Churn Creek Rd.;Redding, CA 96001, 53Q-241-7521.
Encampment Emergency Shelter Services Contract—Shasta Cornmuniry Health Center
EXHIBIT C
ENCAMPMENT EMERGENCY SHELTER PRCIGRAM
MONTHLY REPORT
Provider: Shasta Community Health Center
Contact Person:
Accounting period for this report: thraugh
I.Financial Status
A;Total funds expended this accounting period:
B. Total funds expended in previous accounting periods:
C. Totat funds expended to date (A+B): _�_
II.Service Data
Number of unduplicated participants newly enralled this month:
Number of unduplicated participants newly into interim housing this month:
Location of interim housing; � _.._
Number of unduplicated participants finding permanent housing this manth: �
Total enrolled this month:
Number exited this month:
Reasons far exit:
III. HMIS Data
HNIIS CoC APR Report attached for the reporting period? ❑Yes ❑No ❑NIA
IV: Describe any successes or challenges during this reporting period:
Encampment Emergency Shelter Services Contract—Shasta Community Health Center
EX�-IIBIT C-1
ENCAMPIYIENT EMERGENCY SHELTER PROGRAM
INV4ICE TEMPLATE -
Date:
Provider fnformation Invoice Number:
Name:
Address:
GontactPerson:
Description of Reimbursement Amount
Tatai to be paid:
I hereby certifythe above to be true and correct,to the best of my knowledge:
5ignature Date
TYped or Printed Name Title
City Staff Appravaf Signature Date
Encampment Emergency Shelter Services Contract—Shasta Community Health Center
Exhibit D
o m -
1. Intake Summary
Agency Case No. Service Point Client No:
Intake Date Month �ay Year � Intake Staff Name
Case Manager StafF Direct Phone Line
Agency Name Notice of Privacy Practices Acknowledgernent signed
❑ Yes ❑ No
Program Name
Release of Information(ROI)Signed ❑Yes ❑No
2, Household Information �
❑ Couple(parent&friend}&chiid(ren} ❑ Foster Parent(s)with child(ren} ❑ Other
Household ❑ Gouple with no child(ren) ❑ Grandparent(s)with chiid(ren) ❑ Single Adult
Type ❑ Extended family unit ❑ Male Single Parent ❑ Two Parents with child{ren}
❑ Female Single Parent ❑Non-custodial Caregiver(s)w/child(ren}
3, Client Information
First Middle Last Suffix
Alias Email Rddress
Address Telephone �
SSN _ _ ❑ Yes
❑ Full Reported U.S.Military ❑ No
❑ Partial(Approx.Reported Veteran p elient doesn't know
SSN Data Quality p Client doesn'tknow (adu/tsonly) p Ciient refused
❑ Glient refused
Month Day Year ❑ Woman(Girl, if child) ❑Man (Bay,if child)
Date of Birth
❑ Cuituraliy SpeciFc Identity'(e.g.,Two-Spirit)
❑ Full DOB Reported Gender � Transgender
DOB Data Quality � Approximate or Partial DOB Reported ❑ Questioning
❑ Glient doesn't know ❑ Different Identity
❑ Ciient refused
❑American Indian,Alaska Native,or
indigenous
❑Asian,ar Asian America�
Race and Ethnicity � B�ack,African American,or African
❑ HispaniciLatina/e/o
❑ Middle Eastern or Narth African
❑ Native Nawaiin or Pacific Islander
❑White
❑ Self(Head of Nousehold}
Relationship to ❑ Head of Hausehoid's child ❑ Yes
Head of Househoid ❑ Head of Househoid's spouse or partner Disabling � No
(HoH) ❑ Head<of Nousehold`s other relation member �ondition? ❑ Client doesn't know
❑ Other{non-relation member) ❑ Ciient refused
2ip Code of Last ❑CA-516
Permanent ❑ DeI Norte
Address ❑ Lassen
Ciient Location ❑ Modoc
❑ Full Reported (CoC)& ❑ Plumas
Current
❑ Partia(/Approx.Reported ❑ Shasta
2ip Data quality County of
❑ Client doesn't know ❑ Sierra
❑ C[ient refused - Service ❑ Siskiyou
NOTES:
21
Z n k F -
4. Homeless Determination
--HOM�[Ess S�TuaT�oN--
❑ Place notmear�t far human habitation(car,abandoned building,bus or train station,etc.}
❑Emergeney shelter(incL hotel/motel ar campground paid for w/ES voucher,or RHY-funded Host Home Shelter)(ES)
❑Safe Haven(SH}
=-INSTITUTIONAL SITUATIONS--
❑ Foster care home or fosker care gro€�p home
❑Hospital or other residential non=psychiakric medical facility
❑Jail,prison,or juvenile detentionfacility
i ❑ Lang-term care facility ornursinghome
❑ Psychiatric hospitai or ather psychiatric Facility
❑Substance abuse treatment facilityjdetox
Priar Living' --��������B��HdUSING,�,�gj�g
❑Residential project or halfway hause w/no homelesscriteria
Situation p Notel or motel paid for without emergencyshelter voueher *If yes to TemporaryjPermanent Housing
❑Transitional housing for homeless persons(including homelessyouth) or Institutional Situations:
❑ Nost Home(non-crisis}
Where did you' � Staying ar I�ving in a friend's`room,apartmentor house On khe night before,did you stay on the
spend last nigltt? � Staying or living in a family member's room, apartmentor house streets, ES,or SH?
(alladulrc&= � Rental by client,wikh GPO TIP housing subsidy ❑ Yes ❑No
unaccampantedyouth) � Rental by client,with VASH subsidy
❑ Permanenk housing {other than RRH)for formerly homeless persons
❑ Rental by client,wikh RRH or equivalentsubsidy
❑ Rental by client,with HCV voucher(tenant ar projectbased)
❑ Rental by clienk in a public hausing uNt
❑ Re�tal by client, no ongoing housing subsidy
4 ❑ Rental by client,witl�other ongoing housing subsidy
'' ❑ Owned by client,+nrith ongoing housing subsidy
' ❑ Owned by client,no ongoing housing subsidy
--OTHER--
❑ Client doesn't k�ow
❑ G(ie�t refused
❑ Data Not Collected
ne rng or ess
❑Two to six nights Number af�me4 p 1 time
' ❑One week or more, but less than one month client has been ❑Z times
l.ength af stay in' ❑One monkh or more,but less than 90 days homeless(on the ' ❑3 t�mes
;previaus place ❑90 days or more,but less than one year streets,irt�S,or ❑Four or more times
❑Or�e year or longer SH)in past three ❑����nt doesn`t kr�ow
❑ Client doesn`t know years including p Client cefused
❑ Client refused ' today
Tota! number of' � 1 month (this time is the first mo�th)
APProximate date' Montfi Day Year ❑ 2 ❑3 ❑4 ❑ 5 ❑6
homelessness: months hameless , ❑ 7 ❑S ❑9 ❑ 10 ❑ l i
���� on the street in the p 12 ❑Ma�e than 12 months
past three years ; p ���ent doesn't know � Clienkrefused
5. Monthly Incorne
Income from any source. ❑Yes � No ❑Client daesn`t know ❑Glient refused
Receiving Income Amount Additional Nousehold
Source of Income: Saurce Received Members Nates
Alimony ar Other Spousal Support ❑Yes ❑No $ $
Child Support ❑Yes ❑No $ $
Eamed Tncortte(wages) ❑ Yes ❑No $ $
General Assistance;(GA) ❑Yes ❑ No $ , $
Other ❑ Yes ❑ No $ $
Pensit�n or retirement incnme from another jab ❑ Yes ❑ No $ $
Private Disability Insurance ❑Yes ❑ No $ $ �
RetirernentIncome from Soci�l Security ' ❑Yes ❑ No $ $
_ .
SSDI ❑Yes ❑No $ $
55I ❑Yes ❑ No $ $
TANF(including Ca1WURKs) ❑Yes ❑No $ $
Unempioymen#Insurance ❑Yes ❑ Na $ $
22
I In k F rm - 1
VA Non-Service-Connected Disability Pensian ❑Yes ❑No $ $
VA Service-Connected Disability Gompensation ❑Yes ❑ No � �
Worker's Gompensation ❑Yes ❑No � �
6. Non=Cash Benefits
Non=cash benefitfrom any source: ❑Yes ❑No ❑Glient doesn't know ❑Client refused
Source of Non-cash benefit: Receiving Benefit Type Received Additional Househoid Notes
Members
SNAP inciuding CaiFresh(Food Stamps) ❑Yes ❑No
Speciai Supplemental Nutrition Pragram{WIC) ; ❑Yes ❑ No
TANF Child Care Services ❑Yes ❑No
TANF Transportation Services ❑ Yes ❑ No
Other 7ANF Funded Services ❑ Yes ❑ No
Sec.8 Public Housing/Rent Assist}
OtherSource ❑Yes ❑ No
7: Health Insurance
Covered by Health Insurance: ❑Yes ❑ No ❑Client doesn't know - ❑Client`"refused
Heatkh Insurance type: Covered? Start date Insurance Notes
MEDICAIDJMEDI-GAL ❑Yes ❑ No
MEDICARE ❑ Yes ❑'No
Sta#e Chiidren's Nealth Insurance Program � Yes ❑ No
Veteran's Administratian(VA)Medical Services ' ❑ Yes ❑ No
Employer--Provided Health Insurance ❑ Yes ❑No
Health Insuranca obtained through COBRA ❑ Yes ❑No
Private Pay Heaith Insurance ❑ Yes ❑ No
State Wealth Insurance far Adui� ❑Yes ❑No
Indian Health Senrices Program ❑Yes ❑ No
Other ❑Yes ❑ No
8. Disabitities
if Yes,Expected to b�of long-
Disal�ility continued and indefnite duration
Disability Type: petermination and substantially impairs a6ility to Start date Disability Notes
live independentl ?
❑ Yes ❑ No ❑Yes ❑Clie�t doesn't know
Alcohol Use Disorder ❑ Client doesn't know p No ❑Clie�t refused
❑ Client refused
❑ Yes ❑No
Both Alcohol and Drug ❑ �lient doesn't know �Yes ❑Client doesn't know
Use Disorder ❑ Client refused � No ❑Glient refused
Chronic Health Condition ❑ Ceent daesn't k�ow �Yes ❑Client doesn't know
❑ Client refused � No ❑Gient refused
❑Yes ❑ No ❑ Yes ❑ Client doesn't know
Developmental ❑Client doesn't know
❑Client refused � No ❑£lient refused
❑Yes ❑ No ❑ Yes ❑Glient doesn't know
Drug Use aisorder ❑ Glient doesn't know
❑ Gientrefused � No ❑Client refused
❑Yes � N� ❑Yes ❑Client doesn't know
HIVjAIdS ❑Client doesn't know
❑ Glient refused � No ❑Client refused
Mental Health Problem �Yes ❑ No ❑Yes ❑Glient tloesn't know
❑ Client doesn't know ❑ No ❑Gient refused
Physical ❑Yes ❑ No ❑ Yes ❑Glient doeso't know
❑ Glient doesn't know ❑ No ❑Client refused
23
9:Domestic Violence Questions
Are you a Domestic ❑Yes ❑ No
Violence Victim/Survivor� � Client doesn't knaw
' ❑ Client refused
IF YES—When did the �Within past3 months ❑3-6 mo.Aga ❑6-12 ma.Ago ❑More than a year ago
Domestic Violence � Glient doesn't know ❑Ciient refusetl
experience occur? IF YES—Are you currently fieeing?
❑Yes ❑ Na ❑Client doesn't know ❑C{ient refused
l0: Caordinated Entry Questions
Do you have a felony convictian? ❑Yes ❑ No Registered sex offender? ❑Yes ❑ No
Have you ever been denied housing p yes ❑ No Do you have any pets? ❑Yes ❑ No
because af criminal canvictions?
13. Residential Move=ln Date
Month Day Year
If Yes,Date of Move-In
12.'5treet Dutreach Only D�te of Engagement:
NOTES: �
I
�
Last Updated:11/Z02X
24
Homeless anagement Information System �H IS)
Authorization to Use or Disclose Confidential lnformation
- I hereby authorize use or disclosure of the named individuals' confidential information (Clj
collected in the Vulnerability lndex, as described below. I understand this authorization may
include the disclosure or exchange of information in written, verbal, ekectronic andjor other
forms. The named individuals' CI will not be made public and will only be used with strict
confidentiality.
Client:
Last Name-: First Name:
��—� _
Add ress:
City:------= State: __Zip.__
Telephone Number:
------
Date of Birth:
I ur�derstand that (Service Provider� collected information about
me and/or my dependents listed below to enter it into a database system called Homeless
Management Information System (HMIS). This database helps the Continuum of Care
(CoCj members and HUD to better understand homelessness, to'improve service delivery
to the homeless, and to evaluate the effectiveness ofservices provided tothe homeless in
the CoC. Participation in data collection and release, although optional, is a critical
component of our cammunity's ability to provide the most effective services and housing.
- The information that is collected in the NIVIIS database is protected by limiting access to
the database and by limiting with whom the information may be shared, in compliance
with the standards set forth by federal, state, and local regulations governing
confidentiality af client records. Every person and agency that is authorized to read or
enter information into the data'base has signed an agreement to maintain the security
and'confidentiality of the information.
The Cl gathered and prepared will be included in a HM1S database of participating
agencies who have entered into a Data Sharing Agreement and shall be used to:
a. Produce a client profile at intake that will be shared by collaborating agencies
b. Produce anonymous, aggregate=leve) reports regarding use of services
c. Track individual program=level outcomes
d. Identify unfilled service needs and plan for the provision of new services
e. Allocate resources among agencies engaged in the provision of new services
f. Disclose if required by court order or as required by law
g. Assess needs for housing, utility assistance,food,counseling andjor other services. :
25
The information may include, but is not limited fio the following Cl:
• FuI) Name • Residence prior to project entry • Domestic
• Date of Birth • HIVjAIDS status Vialence
• Social Security • Homeless history • Mental Health
Number • Zip Codes of last permanent • Disabling
• Gender address condition
• Ethnicity& Race • Family composition • Alcohol &drug
• Veteran Status • Empioyment status • Legal history
• Program entry date • Housing information • Photo (if
• Program exit date . Income and benefits information applicabJe)
• CINJinsurance
• The release of my information listed above does not guarantee that I will receive
assistance, and my refusal to authorize the use of my information does not
disqualify me from receiving assistance.
• J may revoke this authorization at any time by signing a "Revocation of Consent ta
Release lnformation form".
• I understand the revocation will not apply to information already released based
an this authorization, and all information about me already in the database will
remain but will become invisible to all ofthe participating agencies.
• My records are protected by federal, state, and local regulations governing
confidentialityofclient records and cannot be disclosed without mywritten consent
unless otherwise provided for in theregu1ations, law, or court order.
• Auditorsorfunderswfiohavelegalrightstoreviewtheworkofthisagency, including
the U.S. Department of Housing & Urban Development and Department of
Healthcare Services may see my information.
• People using HMIS information to write reports may see my information.
Researchers must sign an agreement to protect and deidentify G before seeing
HMIS data.
• I understand Imay inspect or obtain a copy of the Cl to be used or disclosed. I have
the right to receive a copy of this authorization.
• This authorization is valid for three (3} years from the date of my signature below or
the 18t" birthday of the minordependent,whichever occurs first:
Participating agencies: Agencies within the NorCal Continuum of Care HMIS are
authorized to use, disclose, and obtain information from the HMfS database are listed
below. These agencies may update periodically and can have retroactive effectiveness:
Del Norte:
County of Del Norte
27
Del Norte Mission Possible
Crescent City
Lassen:
`Lassen County HSS
Susanville lndian Rancheria
Modoc County:;
TERCN
Modoc County
Plumas:
Plumas Crisis Intervention Resource Center
Plumas County Behaviora) Health
Sierra County:
Sierra County
Shasta:
Fa ithworks
No Boundaries
Good News Rescue Mission
Nation's Finest
Pathways to Housing
Ready for Life
HiI) Country Community Clinic - -
Shasta Community Health Center
Access Homes
Shasta County H`HSA
Shasta County Housing Authority
City of Redding
Lutheran Social Services
North Valley catholic Social Services
Narthern California Youth and Family Programs
Shasta County Office of Education
United Way
Siskiyou County:
Siskiyou County HHSA
Karuk Tribe
Yauth Empowerment Siskiyou
Partnership Health Plan of California
29
Please �nitial one of the following levels of consent;
I give authorization for confidential information to be entered into HMIS and shared
between participating agencies.
C)R
I do not consent to the inclusion of confidential information in HMIS.
I, _(name of parent or legal guardian), am the parent or legal
guardian of child(ren} listed below) and have legal authority to execute this Release.
My signature on this document is intended to bind myself, rny child or any child whom I have
legal custody and control of and for whom I have the authority ta execute this release. The
undersigned expressly agrees fhat this Release is intended to be as broad and incl�sive as
permitted by California law,
List all Dependent ehildren under 18 in hausehold, if any (first and last names):
1. 2.
3. 4.
5. 6. �
7. 8.
Printed name Date
Signature Relationship to Client
3a
HMIS U date Exit Form
1. Exit Summary
Agency Name Staff Name
Program Name 5taff Pho�e Line
Date of entry into pragram Date of exit from program
2,Client Informatinn
Client Name Today's Date
_._:
SSN Street Address
Date of Birth City, State,Zip
Email Phone _
3. Reason For Leaving
❑ Completed program ❑ Non-compiiance with program
❑ Criminal activity/violence ❑ Non-paymenCof rent
❑ Death ❑ Other
❑ Disagreement with rules/persons ❑ Reached rnaximum time ailowed
❑ Left for housing opportunity before completing program p UnknownJDisappeared
❑ Needs could not be met
If other,specify:
4. Destination
❑ Place not meant for habitatian
❑ Emergency shelter, including hotel or motel paid for with emergency sheltervoucher
❑ Safe Haven
❑ Foster tare home or foster care group home
❑ Hospital or other residential non=psychiatric medical facility
❑ Jail,prison,or juvenile detention facility -
❑ Long-term care facility or nursing home
❑ Psychiatric hospital or other psychiatric faciliry
❑ Substance abuse treatme�t facility or detox ce�ter
❑Residential project or halfway house wJno homeless criteria
❑ Hotel or motel paid for without emergency shelter voucher
❑Transitional housing far homelesspersons(induding homeless youth}*
❑ Host Home(non-crisis}
❑ Staying or 3iving in a friend's room,apartment or house,temporary tenure
❑ Staying or living in a family member's room,apartment or house,temporary tenure
❑ Staying or living in a friend's room,apartment or house, permanent tenure
❑ Staying ar living in a family member's room,apartment or house,permanent tenure
❑ Moved from one HOPWA funded project to HOPWA PH
❑Moved from one HOPWA funded project to HOPWA TH
❑ RenCal by client,wfth GPD TIP housing subsidy
❑ Rental by client,with VASH housing subsidy
❑ Permanent housing (other than RRH}for formerly'homeless persons
❑ Rental by client,with RRH o�equivalent subsidy
❑Rental by client,with HCV voucher(tenant or project based}'
❑ Rental by client in a public housing unit
❑ Rental by clienY,no ongoing housing subsidy
❑ Rental by ciient,with other ongoing housing subsidy
❑ Owned by client,with angoing housing subsidy
❑ Owned by client, na ongoing housing subsidy
❑ No exit inter�iewcompieted -
❑ Other
❑ Deceased
❑ Client doesn't know
! ❑ Clierit refused
❑ Data Not Collected
If other,specify:
5. Residential Move-In Date �RRH 4n/y)
31
H I5 U date Exit Form
Month Day Year
ifYes,Date of Moue-In
6,Updates
Monthly Income Amaunt Non-Cash Benefits Amount
❑ NO CHANGE AT EXIT ❑NO CHANGE AT EXIT
❑Alimony or Other Spousal Support $ ❑SNAP'including�alFresh(Food Stamps) $
❑Child Support $ ❑Special Supptieme�tal Nutrition Program(WIC) $
❑Earned Income(wages) $ ❑TANFChild Gare Seivices , $
❑General Assistance(GA) $ ❑TANF Transportation Services $
❑Other � ❑Other TANF Funded Ser�rices �
Sec:B/Public Nousin /Rent Assist
' ❑ Pension or refirement income from another job $ ❑Other Source $
� Private Disability Insurance $
❑Retirement Incame from Social Security $
❑SSDI ' $
❑SSI , $
❑TANF(including Ca1WORKs} $
❑Unemployment Insurance $
❑VA Non-Service Gonnected Disability Pension , $
❑VA Service Connected Disability Compensation $
❑Worker's Compensatian ' $
Health Insurance: Notes Disabilities Notes
❑ NO CHANGE AT EXIT ❑ NO CHANGE AT EXIT
❑MEDICAIDJMEDI-CAL ❑Alcohol Abuse
❑MEDICARE ❑Both Alcohol and Drug Abuse
❑State Children's Health Insurance Program ❑Chronic Health Condition ----
❑Veteran's Administratio�(VA)Medical 5ervices ❑ Developmental
O Employer--Provided Health Insurance ❑ Drug Abuse
❑Health Insurance obtained through COBRA ❑HIV/AIDS
❑Private Pay Health Insurance ❑Mental Health Problem
❑State Health Insurance for Adults ❑Physical
a Indian Health Services Program
❑Other
***OPTIONAL EXIT QUESTIONS***
What supportive services did the client receive while in the program?
❑Outreach ' ❑Education
❑Drug or Alcohol abuse services ❑Child care
❑Employment assistance ❑ Domestic Violence services
❑Legal Services ❑ Life skills (outside of case management)
❑Credit repair ❑ Housing placement and search
❑Medi-Cal related services ❑Transportation
❑Gase management ❑Financial Assistance
❑Mental Health services ❑Other
❑Landlord engagement
Last Updated.•IOJ7/2019
33
NorCal GA 516 Continuum of'Care
Homeless Management Infornnatian System (HMIS)
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MA'Y BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMAT[ON. PLEASE REYIEW IT CAREFULLY.
If you have any questions about this Notice,you may contact either your service provider,or:
United Way of Northern California
3300 Churn Creek Road, Redding GA, 96002
(530)241-7521
Your information is personal, and the NorCa1 CA 5t6 Continuum of Care is cammitted to protecting it: Your
informatian is also very irnportant to our ability to provide you with quality services,and to comply with certain laws. '
This notice describes the privacy practices our employees and ather personnel are required to follow in handling your
information.
We are legally required to: Keep your informatian confidential; give you this notice of our legal duties and privacy
practices with respect to your information,and comply with this natice:
CHANGES TC3 THIS 1�10TIGE
We reserve the right to revise or change the terms of this Notice; and to apply those changes to aur policies and
procedures regarding your information. To obtain a copy of this notice,you can either ask any member of staff,ar go
to the United Way of Narthern California website at: https://www.norcalunitedwaY.ar�/hmis.
HOW WE MAY USE AND DISCLOSE YOUR INFORMATION
For Housing: We create a record af your information,including housing services you receive at our partner agencies.
We need this record to provide yau with quality services and to comply with certain legal requirements.
Participating agencies may use or disclose your information to other persannel who are involved in providing services
for you. For example, a housing navigator may need to know disability information to pravide appropriate hausing
resources:Your service team may share your information in order to coordinate the differentthin�s you need;such as
referrals and services.
Participating agencies may use and disclose your information to other participating HMIS a;encies.
We also may use and disclose yaur information to recommend service options or alternatives that may be of interest
to you. Additionally, we may use and disclase your information to tell'you about health-related benefits or services
that may be of interest to you for example,Medi-Cal eligibility or Social Security benefits.You have the right to refuse
this informatian,
For Service Coliaboration: We also may use and disclose your information about you so that you do not have provide
information more than once. This sharing; only when you access one of the participating agencies,;can help avoid
duplicatian of services and referrals that you are already receiving.
USES AND DISCT�QSURES THAT DO NOT REQUIRE YOUR AUTHORIZATIC?N
Research: Under`certain circumstances, we may use and disclose information about you for research purposes. For
example,a research project may involve comparing your service level and of a11 clients who received similar services.
A11 research projects, however, are subject to a special approval process. This process evaluates a proposed research
project and its use of informatian, trying to balance the research needs with clients' need for privacy of their
informatian. Before xhe use or disclosure of information for research purpases,any such research project must be
35
approved tl�rougl�an approval process. Aggregate information about you may be disclased to people conducting a
research project to help tl�em identify data for claents with specific needs:
As Required By Law: We will use and disclose information when required by federal or state law or regulation.
To Avert a Serious Ttireat to"Health or Safety: We may use and disclase your information when necessacy to
prevent a serious threat to your I�ealth and safety or the health;and safety of tlie'public or another person>
Public Healtt�Activities: We maydisclose your informatian for public health activities such as to report the abuse or
neglect of cl�ilclren, elders,and dependent adults
Abuse, Neglect, ar pomestic Violei�ce: We may disc(ose your inforEnation wl�en notifying tfie appropriate
government autharity if we believe you;have been the victiin af abuse, neg(ecE; or domestic vialence: We will anly
�nake tl�is disclosure if you agree or whenrequired or authorized by law:
Oversigl►t Activities: We may disclose your information to an oversigi�tagency;sucl�as the I3epartment of Housing
and Urban Development(I�UD)or the State af California, for activities auti�orized by law; Tl�ese oversigl�t activities
are necessary for the govern�nent to monitor government service prograins;and compliance with civil righYs Iaws.
OTHER USES OF YOUR INFORMATION
Other uses and disclosures of your inforsnation not covered by this Natice or tl7e laws that apply ta us wifl be iinade
only with your written authorization. If you provide us autharization to disclose your infarmation, yau may revoke '
that authorization; in wrifing, at ar�y ti�ne: if yau revoke your authorizaYion,we wi(i no longer use or disclose your
information for the reasons covered by the authorization,, except tl�at, we are unable ta take back any disclosures we
have already made wl�en tl�e autl�orization was in effect; and we are required to retain our records of tl�e services that
we provided to you,
YOUR RIGHTS RECARDING (NFORMAT[ON ABOUT YQU
Right to Inspect a�jd Obtair� Copies:
With certain exceptions, you have the right to inspect and obtain copies of your information frain our records.To
inspect and obtain copies of your infarmatian,you must submit a request in writing to your service provider where
you received services. T11e request will'bereviewed and responded to witl�in tf�ree(3)business days. We reserve the
right to deny yaur right ta inspect and abtain copies of your infacinatian: if yaur rec�uest is denied, you may
appeal this decision and request anather services professionai at United Way af Nortl�ern Califori�ia;wllo was
not involved in your provisian of services,review the deniaL
Right to RequesYan Amendme��t:
If you feel tl�at your infoc�natian in our records is incorrect or inco�nplete,you may ask us to ainend the information.
You 1�ave tl�e right to re�uest an a►nend�nent for as long as we keep the infarmatian. Ta request an amend�nent, yau
�nust subinit a rec�uest in w�-iting to your service provider: Yaur rec�aest wil( becoine part of your recard:
Riglit to Request Restrictions:
' You laave the right to request that'we follow additional, special restrictions wl7en disclosing your information. To
request restrictions; you tnust rnake your xequest in writing to your service provider. In your recluest, you�nust tell us
what inforination yau want to li�nit,the type of li�nitation;and ta whom you want the Iimitation to app[y.
Right to Request Conficlential Communications:
You I�ave ti�e right to request ti�at we communicate witli you about appointments or other matters related to your
service in a specific way or at a specific lacation: I'or example, you can ask that we on{y contact you at work;or by
�nai) af a post offce box: To re�uest canfidentia) communications, you must znake your request in writing to yaur
flgency case manager or tl�e persan in charge af your services:Your request must specify how or where you wish ta
be cantacted.
35
Right to a Paper Copy of This 1�Totice:
You may ask us for a paper copy of this Notice at any time: Even if you have abreed to receive this Notice
electronically,you are entitled to receive a paper copy of'this Notice:To obtain a paper copy of this Natice,ask any
member of staf£
You have the right to file a complaint if you believe that staffhas not camplied with the practices outlined in this
Notice.All complaints must be submitted in writinb.You will not be penalized in any way'for filing a complaint.
If you believe your privacy rights have been violated, you may file a complaint with the NorCal CA 516 Continuum
of Care System Administrator.
To fiie a camplaint with the Lead Agency,contact:
United WayofNorthern Califarnia
3300 Churn Creek Road,Redding CA 96002
Emai1:HMIS@NorCalUnitedWay.org
To file a compiaint with the State of California,contact:
www.privacy.ca.gov
866-785-9b63
sao-9sa-s21a
ACKNOWLEDGEIYIEIVT OF RECEIPT
By signing this form,you acknowledge receipt of the HMIS Notice of Privacy Practices: Our Notice ofPrivacy
Practices provides infarmation about how we may use and disclose your protected information:We encourage you to
read it in ful1:OurNotice of F'rivacy Practices is subjecf to change.If we chan;e our notice,you may obtain a copy
of the revised notice by accessing our web site:https:(Jwww.norcaiunitedway.or��hmis or by contacting any staff person
involved in your services
If you have any questions about ourNotice af Privacy Practices,please contact:
United Way of Northern Califarnia
3300 Churn Creek Raad, Redding CA 9b402
Email`. HMIS cr NorCalUnitedWay.orb
I acknowledge receipt of the HMIS Notice of Privacy Practices.
Client Signature Client Printed Name Date
Inability to Obtain Acknowiedgernent
' To be completed only if no si;nature is obtained. If it is not possible to obtain the client's acknowledgement,describe
the bood faith efforts made to obtain the client's acknowledgement,and the reasons why the acknpwledbement was not
obtained:
Staff Member's Signature Staff Narne and Title Date
Revs. 12I13/2023
37
���,���������r������-������������������r3�����;�����������r��������:������r���r�
58NG�E AD�li.�5 t��r1ER{CAP� t/�RS3C��Z,0�1
1 � �
Interviewer's Name Agency ❑Team'
❑Staff
❑Volur�teer
Survey Date Survey 7ime Survey Location
DDJMM/YYYY_.....) / _
1 �
Every assessor in yaur community regardless of organization completing the V1-5PDAT shauld use the
same introductory script. In thaf script you should highlight the following information:
� thenameoftheassessorandtheiraffiliation(arganizationthatemplaysthem,volunteeraspactafa
Point in Time Count,etc.}
< the purpose of the VI-SPDAT being completed
� thaC 'rt usually takes less than 7 minutes ta complete
� that only"Yes,""No,"or one-word answers are ibeing soug'ht
� that any question can be skipped or refused
� wherefhe information is gosng to be stared
� that ifthe participanfdoes not understand a question oxthe assessoc daes not understand the ques-
tian that clarification can be provided
x theimportanceofrelayingaccurateinfarmationtotheassessorandnotfeelingthatthereisacorrect
ar preferred answert°hatthey need to provide, nor information tl�eyneed to conceal
� � 1
First Name Nickname Last Name
In what language do yau feel best able to express yourself?
Date ofBirth Age SociaFSecurity Number Gonsentto participate
DD/MM/YYYY ( / ❑Yes ❑No
�@
� � � �� x . � � �. � �, � �o
0201 5 OrgCode Cansulting Mc.and Cammunity5olutions:All rights reserved. �
38
.... .... .... ���&:.C�YS;.1'SP1C3d?�a 1��3�1d�1'4":.a.�p���$lA�T"9"10l;dCEB S 9�......d�Po.6�S,a��4aH��i�,tl°9�r7�i�$riS^IRr� 8 1J4:d��Y#S'a7.3'�:,F�3� .... ..... .....
..... .... ��iIV1JL.��P'iR.�Ul�P� .��.. �� .... � .... � �... �1��4�}l..P't��V��JSV��L.UI .... .....
�.� � ����. � �.... ���� � � � . � .
1. Where do you sleep most frequently? {check one) ❑Shelters
�7ransitianaf Housing
O Safe Haven
� Outdoors
�Other(specify):
� Refused
� � � � a , � a � � . $ � g � � m
�� � � , ��,
2: How long has it been since you lived in permanent stable � Refused
housing�
3:'In the last three years, how manytimes have you been ❑ Refused
homeFess?
� � � , � � � �° �� � �� � � � �
� � �� � p �� � � ��
� �
4. in the past six months, how many times have you...
a) Received health care at an emergency department/room? �Refused
b} Taken an ambulance to the hospital? ❑Refused
c) Been hospitalized as an inpatient? O Refused
d) Used a crisis service, including sexual assault crisis, mental � Refused
health crisis,familyjintimate violence,distress centers and
suicide prevention hotlines?
' e) Talked to police because yau witnessed a crime,were the victim ❑ Refused
of a crime; or the alleged perpetrator of a crime or because the
police told you that you must move along?
f) Stayed ane or more nights in a hniding cell,jail or prison,whether � ❑ Refused
that was a short-term sta Iike the drunk tank a lon er sta tor a
5. Have you been attacked or beaten up since you've became ❑Y O N ❑Refused
hameless?
40
�°�5��������.��"'������.;���1I�����i��1�`���1"������������a�s"��`� ���°��L�"v`�-��[����
S�s�IG�.� ��tl�.€S ��ri��lCt�d� V�§�SI�,�I2.0�
7: Do you have any legal stuff going on right nowthat may resuit ❑Y ❑N ❑ Refused
in you 6eing locked up, having to pay fines, or that make it
more diffFcult ta rent a place to iive?
��
�A �� �
8. Daes anybody force or trick you to do tnings that you do not ❑Y ❑ N ❑Refused
wanfto do?
9: bo you ever do things that may be considered to be risky ❑Y ❑N ❑Refused
like exchange sex for money, ran drugs for someone,'have
unprotected sex with someone you don't know, share a
needle, ar anythingJike tfiat?
��
� � � � �� �� �� � � � � a �
� � � � � � �
10:!s there any person, past iandlord, business, bookie, dealer, ❑Y ❑ N ❑Refused
or governmentgroup Iike the IRS that thinks you owe them
' money?
11. Do you get any money from the government, a pension, ❑Y ❑ N ❑Refused
water and other things like that?
� � �
�
relatianship,or because famiiy or friends caused you to
become evicted?
42
���r���������°^������-�������������������c�r����s��c���s��s�������c��:���-s�����
sa�i'��� ;������s ����3r_�� �r����o�a�.o��
1S.Have you ever had to leave an apartment, shelter program, or ❑Y ❑ N ❑RefuSed
other place yau were staying because of yaur physical health?
16:Do you have any chronic health issues with your liver, kidneys, ❑Y ❑N ❑Refused
stamach, lungs or neart?
17. Ifthere was space"available in a program that specifically ❑Y ❑ N ❑Refused
assists people thatiive with H1V or AIDS;would that be of
interest to yaua
18:Da you have any physical disabilities that would limit the type ❑Y ❑ N ❑Refused
of housing you could access, or would make it hard to live
independently because you'd need help?`
19.When you are sick or not feeling well, do you avoid getting ❑Y ❑ N ❑Refused
help?
20. FOR FEMRiE R�5P0lVCtENTS ONLY: Are you currently pregnant? ❑Y ❑ N ❑ NJAOr
Refused
� � � ��� �. �� � . . a
��
21:Has your drinking or drug use led you to being kicked out of ❑Y ❑ N ❑RefuSed
an apartment or program where you were staying in the past?
22.Wi11 drinkin or dru' use make it difficult fc�r c�u tc� sta ❑1( I� N ❑RefUSEd
23:Have you ever had`trouble maintaining your housing, or been kicked out of an
apartrnent, shelter program ar ather piace you were staying, because of:
a) A mental health issue or concern? ❑Y ❑ N ❑Refused
b} A past head injury? ❑Y ❑`N ❑Reftased
c} A learning disability, developmental d'isability,or other ❑Y ❑ N ❑RefuSed
impairment?
24:Do you have any mental health or brain issues that would ❑Y ❑ N ❑Refused
�-- � � � � _�.. #a� � � . _�b � f � � �
44
�.�.. .�.. �... �",.ti�G`@����d�������V��.a^�a.•���7'�.�k6.sC:.Y"d"L��.i..Ag"i6 9 I�M5..4 Gf.64���h.a,�l���H't���5eb P N�E'��.m� 9�i.C.���N9^�:7�5"�M�� ... ...�. ..�.
�i�a�`wa� ,��1J�T5 ��e�E���AI�9 VER,S3�31��2.0�
25:Are there any medications that a doctor sa9d you should be ❑Y ❑ N ❑Refused
taking that,for whatever reason,you are nat taking?
26:Are there any medications like painkillers that you don't ❑Y ❑N ❑Refused
`take the way the doctor prescribed or where yau sell the
medication?
� � � ��� �� �� � � �
��
27. YES OR No; Has your current period of ❑Y ❑ N ❑ Refused
hamelessness been caused by an experience of
emational;,physical;
psycholagical,sexual, or ather type of abuse, or by any other
trauma you have experiertced?
��
�• �� x - B w - � a
� �
� � d � � s
� 5 �� Score: Recommendation:
� �� � � � � ° �� 0-3: no housing intervention
1� ' 4-7: an assessment for Rapid
� � . � � �� � ; /4 Re-Housing
� �6 8+: an assessment for Permanent
m � J�7 Supportive Housing/Housing First
� a
�
On a reg'ularday,where is iteasiesttofind place:
you and what time of day is easiest to do
so? time: :' or
Is there a phone number and/ar email phone: ( } -
where someone can safely get in touch with
you arleave you a message? email: �
Ok,now l'd like to take your picture so that ❑Yes ❑ No "❑ RefuSed
it is easier to find you and confirm your
identity in the future.May I do so?
Communities are encouraged to think of additional questions thatmay be relevant to the programs being
operated ar yaur specific local cantexx. This may include questions related to:
; militaryservice and nature of • mobility issues . �Qgal status in country
discharge = incame and source of if
� ageing out ofcare : currentrestrictionsonwhereapersancan
46
Documentation Checklist: Namelessness Verif�cation
Client Name:
� Date:
Current Residence:
(Night Before Above Date�
Staff Name;
Program'Name:
Companent Type:
(ES,TH, RRH, PSH,etc.}
��T`�o Written third-party documentation is aiwoys preferred to certify homelessness.
t , *^P"' . "m^�^p y �wm`e(�� ".�rws.*�;ry^� 4 � TM%"`
!���i��fiW���y l����� �I�������� I Ij i t � C7t 4( }�$} }i ( t�t �} 'i t J ' ( �}S i t i�t � 1f
( � . t i t f j��y7;��y�yi � � � �'�y,^� � }j� �i t r� � �J �` 1 � � t ° ;( 1 3
. s 3�.. tf � fY t 4 t 4 ,,�'i'C,,XNl��� � 4 tr,�X����t��,�#� 7 4. t }i F }ti � {}'� } ( � f {.. S t �. .
.. k, t„ t. „Y,,, „r.;t „�k,t r"!,, a,. r, ���,��.� �„f, .,f ..�t}'' �vP}us�t��d ;s ,4� 5 „st, ,r„ 1,. ,s ..
CATEGORY 1
PI.ACE NOT MEANT FOR HUMAN HABITATION, e.g., car,park, abandaned building, bus or
' train station,airport, camping ground (OK for CH-PSH, PSH, RRH,TH,SH,SS0)*
'❑ Written Third-Rarty(one or more of the following)dated within 14 daysprior to program entry:
❑ HMIS record of homeless street outreach contacts
❑ Signed letter on letterhead from a hameless street autreach provider
❑ Hamelessness Gertificatian (Form A)from a homeless street outreach provider
❑ YES OR
� ❑ Written Second-Party both of the followingj:
� �� ❑ Gertification Based anlntake Conversatian ar Intake Staff Observatian(Eocm G)AND-
❑ Staff Supplement to the Gertification Based on Intake Conuersation or intake Staff
Obse�vatian (Form G)describing attemptsto secure third party verification
OR
❑ Written First-Party both of the follawing):
❑ Cfient Self-Declaration of Hamelessness(Farm E)AN�,
❑ Staff Supplement to Self-Declaratian of Homelessness(Form E)describing attempts to
secure third-party verification
EMERGENCY SHE�TER, SAFE HAVEN, HOTEL/MC�TEL PAID BY CHARITABLE
� ORGANI'ZATION OR GOVERNMENT PROGRAM Ft)R COW-INCOME 1NDIVIDUALS (OK
#or CN-PSH, PSH, RRH,TH,SH, SSOj* k
, ❑ Written Third-Party(ane or more of the following)dated within 14 days priar to pragram entry:
; ❑ HMIS record of stay in emergency shelter;safe haven;ar hotelf motel paid for by
k
charitable organization or government program
❑Signed letter on letterhead from emergency sh'elter or safe haven provider or organization
paying fo�hatel/matel stay
❑ YES ❑ Hamelessness Certification (Form Aj from emergency shelter or safe haven provider or
� organization paying for hotel/motel stay
� �� OR
❑ Written Second-Party both of the following):
❑ Certification Based on Intake Conversation orintake Staff Observation(Farm Gj AND
❑ Staff 5upplement to the Certification Based on Intake Ganversatian or Intake Staff
Observation (Form G)describing attempts ta secure third partyverification �
OR
❑ Written First-Party both of the following).
❑ Client Self-Declaration of Homelessness(Form E)AND;
❑ Staff 5upplement to Self-Declaration af Homelessness{Form E)describing attempts to
secure third-party verification
*These are baseline eligibility rules based on project type.Vour grant may have additional eligibilityc�iteria.To determine applicable eligibility requi�ements:
1} Consult CoC NOFA under which project was firsEfunded for applicable new project eligibility requirementsANO
2) ConsultEoC NOFA that funded the particular grant year for applicable renewal project eligilaility requirementsAND
3) Consult HUDgrant agreement;including cammitments made in projecCapplication
' 48
Docutmentation Checklist: Hamelessness Verificat'ion
.. i il � y� t �.1 �.t Y k i} �t � 3 � 3t i t �
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f37. f i , r`�:t t t� :,.. u, �f..i .s ; ,, s 1 t, �,. :.� ,,: 2rt t ��l.{{k t7it.tY i5 it r...t}(1 i i �f, 3�{ it �...t 2 {.. 5s .t !
�s l�:.�t ti }ir S r ...t f t�.s, i,, . „S ..,,, . .,.... j�,.'.,.a , ,t{, _,,. c � .(Y:I 1t rrr�S{�a i`it it�41�.-.1 1 7 ) .(. t sr... t t { a.. i r 2:.: .
...... �rt.., r z:.. s �..t itt .r3,,t �,:-� ; , . .—�� ,' ,,�d < �. :: t � . 72r 4:�.:�71� '}i re s.: t rrt}stt �f f �.. t i7:,t. ta y }
tLa k„ �t.n ti�ro. >a�>Z4,�?��� nb.�l,.�r�' ,�t��, s:. i t,l+"�t: .�.4 ���s�(t;'��.�.,,:`t�„rt,r S t§,,;5>r��z�Ii�,�i,d(„� ik�.?i{I��mt} f����� ar,�t�,l, i� ,Elli4�tst,S»:�,itl
HOSPlTAL OR OTHER(N5TITUTION if client's stay was 90 days or fewer and client was in
emergency shelter or place not meant for human habitation prior to admission (OK for CH-PSH, PSH,
some RRH,TN, SH, SSO�*
� Documentation af institutional stay
� Written Third-Party(one ar more of the following):
� Discharge paperworkwith admission and discharge dates
� Written (or oral, but recorded in writing) referral from social worker,case
manager, or other official from institution with admissi'on and discharge dates
OR
�Written First-Party both of the foNowing):
� Client SeCf-Declaration of Homelessness(Form E}AND
� Staff Supplement to`Self-Declaratian of Nomelessness(Form E)describing
attempts to secure third-party verification
AND
� Documentatian of client's homeless status immediately prior to institutional stay
� YES � Written Third-Party(one or more of the following)dated within 14 days prior to
institutionalization:
� NO � HMIS record of shelter stay orhomeless street outreach contacts
� Signed letter on letterhead from emergency shelter or homeless street outreach
provider
� Homelessness Certification{Form A)fram emergency shelter or homeless street
outreach provider
dR'
� Written Secand-Party both of the fallowing):
� Certification Based on lntake Conversation or Intake Staff Observation (Form G)
AND
� Staff Supplement to the Certification Based on Intake Conversation or Intake Staff
Dbservation {Form G7 describing attempts to secure third party verification
dR
� Written First-Party both of the followingj:
� Client;Self-Declaration of Homelessness(Form E)AND
� StaffSupplementto Self-Dedaration of Homelessness(Form E}describing
attempts to secure third-party verification
TRANSITIONAC HOUSING ifgraduating from or timing out af TH and either in emergency shelter
orplace not meant for human habitation prior to admission or fleeing or attempting to flee domestic
violence including dating violence;sexual assault,stalking,human trafficking„and other
dangerous/life-threatening conditions that relate to violence aga'inst the individual or a family member
that make them afraid to return to primary nighttime residence (OK for PSH,some RRH,TH,SH,
ssOj*
� Written Third-Party(one or more of the following)dated within 14 days prior to program entry:
� YES ❑ � HMIS records of transitional housing stay and entry fram shelter or place not meant for
human habitation
❑ NO � Signed letteron letterhead from transitional housing provider certifying residency and
homeless living situation prior to admissian
❑ Homelessness Certification (Form A)signed by transitional housing provider
OR
❑Written First-Party both of the following):
❑ Client Self-Declaration of Homelessness(Form E)AND,
❑ Staff 5upplement to Self-Declaration of Homelessness(Form E)describing attempts to
secure third-party verification
*7hese are baseline eligibility rules based on project type.Your grant may have additionaPeligibility criteria;To determine applicable eligibility tequirements:
1) Cansuft CoGNOFA underwhicfi project was first funded for`applicable new praject el+gibility requirementsAND
2} tonsult CoC NOFA that funded tlie particular granf year for appficable renewal project eligibility requirementsAND
3} Gonsult HUD granYag�eement;including commitments made in projecYapplication
49
Documentation Checklist. Nomelessness Verification
� , f } J .
,,.t .,i.., , s„�r t,t�7{ +� i t,�45 t �. }a�;f r r�n rr t t a � r 4 S t ,. t t �t �s � ���jt t/ .
.... „H; S y' t { an:. j it !4 4 tti )}§t J 4 f .i � f � t :t 4� � h.:. t�t 1 fI t :slf b�)7 {�t}tt y ij $�4
�, ��f � ��:� �� 4 �. r i "{ 4=I f i t }� t jI}. f:i t t t�., t..� .s„�.s,
J ��' �..� �� 7 ¢� rc 7 4 Y.,tt t f 7a i{ ��..;: �t t .+� { :.r r .?., f ,<.
.. i �r �, t� , s... t i t s { { t
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7 i
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't t .f.. 3 tr .f t: �(.
t t-.; .F.. .t.�
s 5, .� t .'s s ��k .'t t'.. r i:7� c
J ���t =zstj t t,�y ,:(.:} Sr 2 �„ot f,��,.yr,f,ri ?� ,,�� u tt�F�t It,�I�Ji i �/4t ,zt r( � .Y 3ss,t � r:t t jli}{�?z}t�{ +4Y . � ritat��r a�t �jy;y�sittl�l� .i}{ t �,
$ 1�����a���"'f`,+���z�,���`�����i��{�r�t�.�.{i �,i},.t } }i£ '. }i � j.. { � 4 `� �
r4, �<.;4 c �{,. 5 5�,. }., ;s, ,�#„b i.:
TRANSlTIC}NAL NQUSING if graduating from or timing out of TH and neither in emergency shelter
o'r piace not meant for human habitation prior to admission nor fleeing or attempting to flee domestic
violence including datingvialence,sexual assault,stalking, human trafficking,and other
dangerous/life-threatening eonditions that relate to violenee against the individual or a family member
that make them afraid to return toprimary nighttime residence (OK for some RRH,TH,SSO}*
� Written Third-Party(one of the fallowing)dated within 14 days prior to program entry:
� YES � �MIS records of transitianal housing stay and hameless living situation prior to admission
� � Signed letter on letterhead from transitional housing provider certifyi'ng residency and
� �'� homeless living situation prior to admission
� Hamelessness Gertification (Form A)signed by transitional housing provider
aR
� Written First-Party both of the following):
[� Glient Self-Declaratian of Hamelessness(Form Ej AND
� StaffSupplement to Self-Declaratian of Homeiessness(Form E)describing attempts to
secure third-party'verification
ca�r��o�v 2
IMMINENTLY LOSING PRIMARY NIGHTTIMf RESIDENCE, i.e., primary nighttime residence
F will be lost within 14 days,and no subsequent residence has been identified, and the househoid lacks
� the resources and support netwarks needed to abtain other permanent housing(OK for some RRH,
i � TH, SSO)*
��� � � ���At least one��of the��following: ��� ���
' � Court arder resulting from an eviction notice or equivalent, or farma!eviction notice
� For clients in hotelsJmotels not falling under Category 1, evidence that hausehold lacks
�YES the financial resources necessary to stay far more than 14 days
[] Oral statement 6y individual or head of household that the owner ar Yenter of the
� �� , � residence will not allow them to stay for more than 14 days and documentation by staff of
the statement client made to staffand
� Written verification from the owner ar renter of the residence verifying client's
statement or
�Staff Supplement to Self-Declaration of Homelessness(Form E)describing
� attempts to secure verification from the owner ar renter of the residence
AND
Corraborating Client Self-Declaratian of Homelessness(Form E)
*These are baseline eligibility rules based bn projecttype.Your grant may have additional eligibilitycriteria.To deterrnineapplicableeligibility requirements
1) Consult CoC NOFA under which project wasfirst funded fo�applicable new project eligibility requirementsAND
2} Consult CoC NOFA that funded the particulargrant year for applicable rersewa[project eiigif�ility requirementsANO
3) Consult HUD grant agreement;including commitments made in projectapplication
50
Documentation Checklist: Homelessness Verification
CATEGORY 4
FLEEING OR ATTEMPTING T!� FLEE DOMESTIC Vf(JLENCE,induding dating violence,sexual
' assault,stalking, human trafficking, and other dangerous/life-threatening cond'itions that relate to
violence against the individual or a family memberthat;make them afraid to return to primary
nighttirne residence{"the condition"} (OK for PSH, some RRH,TH, SS0)*
� The following:
� YES ❑ Client Self-Declaration of Hornelessness (form E)
AND FOR NON-VICTIM SERUICE PROVIDERS
� NO � If safety wauid not be jeopardi2ed,written third-party certification with minimum amount
of infarmation necessary to document fleeing or attempting to flee the condition (one or
more of the following):
� Written observation by intake workerverifying the condition
� Signed letter on letterhead from by a housing or service provider,social warker, health-care
provider, law enforcemenf agency, legal assistance provider, pastoral counselor, or any oth�r
' organization from whom the individual or head afhousehold hassought assistance farthe condition
*7hese are baseline eligibility rules based on project type.Your grant may have additiona(eligibility criteria:To determine appiicable eligi6ility requirementsi
1) Consult CoG NOFA underwhich project-was first funded for applicable new project eligibility requirementsRNd
2j Consult CoG NOFA that fundedthe particulargrant yearfor applicable renewal project eligibilityrequirementsAND
3) Consuit HllD granf agreement;inclading commitments made in projectapplication
51 '
Homelessness Certification (Form Aj
Client(s)Name(s):__� ---
❑ Housel�old without dependent children ❑ Houset�old with dependent cnildren Number in the household:�
This'form is to certify that the above-named individual or household is currently homeless based on the check mark,other
indicaYed information,and signature indicating their current living situation. By signing this form,you are certifying tfiis
infa�mationto be t�ue.Check onlv one box and complete only that section.
Living Situation: Ptace not meant for human habitation
❑ The persan(s} named above wasjwere living in a public or private place not designed for, or ardinarily used as a regular sleeping
accommodation for humans,incPuding a car, park,abandoned building,bus station,airport,or camp graund on the date{s) below.
Description of livingsituation(please provide tfie location and detailed description of living conditions):
Homeless Street OutreachjReferraf Pragram Name: _, . _,�,�
Date(s)af Gontact:_
Authorized Agency Representative Name:_� —.,.�:
Authorized Agency Representative Signature:_ �Date:��A�
living Situation: Emergency Shelter
❑ The person(s) nacned above was/were living in a supervised publicly or privately aperated shelter on the date(s} below:
Emergency Shelter Program Name:�^
Date(sj of Night(sj in the Sheiter:�
Authorized Agency Represerrtative Name: —.__
Authorized Agency Representative Signature: � Date:
Living Situation:Transitiona) Housing
[NOTE: USE ONLY FOR PURPOSES QF DOCUMENTING ELIGIBiUTY FOR TRANSlTIONAL HOUSING PROGRAMS]
❑ The person{s) named above isjare currently living in a transitional housing program for persans who are homeless.The
persans(s)named above isjare gcaduating from or timong aut af the transitional housing pragram:
Transitional Housing Program Name:__ --- �—�
Immediately priar to entering transitional haasing the person(s}named above wasfwere residing in:
❑ emergency shelter OR ❑ a place unfit for human habitation OR ❑ � :
Authorized Agency Representative Name:� —�:�.—
Authorized Agency Representative 5ignature:_ _,�, Date:
Page 1 af 1 Homelessness Certification -NorCal GoC 2022
52
NorGal CaC
SECOND-PARTY CERtIFICATION Of NOMELESSNESS BASED ON INTAKE CONVERSATION C)R lNTAKE
STAFF OBSERVATION (Form B)
Applicant Name: Intake Date: �lic'� E��a�,=a �c� va$��r� c��r�.
Note;This form does nof constitute third-party documentation and should be used only ifthird-party documentation is not
available:
Instructions:If third-party documentation is not available, a housing program intake worker may pravide second-party
documentation of the applicant's homelessness by one of'two methods:
• The intake worker may go out and physically observe the applicant's place of residence.
• The intake worker may certify the applicant's homelessness in the intake worker's professional capacity based on their
intake conversation with tne applicant.
iNFORMATION REQIiESTED: PLEASE COMPLETE ONE OF THE TWO TABLES BELOW
(i"a be compteted by the intake workerJ
If the intake worker physically observed the applicant's place of residence:
Approxirnate date Location (address, ' Description of living conditions observed (sleeping in a car, in a tent,in
observed: narne of public ' the open, etc.):
space,street name, -
landmark, etc�:
If the intake worker is certifying the applicartt's homelessness in the intake worker's professiona!capacity based on their
intake conversation with the app'licant:
Approximate Location,where applicant Description of intake conversation with applicant and reason you
date when was living: believe they were living in a homelesssituation:
applicant
experienced
homelessness:
❑ Place not meant for
human habitation
❑ Emergency Shelter
❑ Safe Haven
❑ Hatel/matel paid by
charitable organization or
'government program for
low-income individuals
Page 1 of 2 Certification Based on Intake Conversation-NorCal CoG 2022
53 "
I certify that based on my physical observation ar to the best of my knowledge and in my professionai apinion,that
the Applicant was living in a place not rrteant for human habitation, emergency shelter,safe haven,or hotel/motel
paid by charitable organization or government program for low=income individuals during the above time:
Printed Name Qrganization Title
Signature Date Phone Number
Staff Supplement to Certification Based on Intake Conversation
I understand that thi�d-party verification is the preferred method of certifying homelessness for an individual or household who is
applying for assistance. I understand my declaration at intake is only permitted when I have attempted ta but cannat abtain third
party verification.
Documentation of attempt(s�made for third-party verificatron:
Date of Cantact Individual/Organization Contacted Method of Cantact Outcome of Contact
Stafif Signature: T� __ Date: �
Page 2 of 2 Certification Based on Intake Conversation-Nor�al CoC 2022
54
Clier�t Self-Declaration of Homelessness (Form Cj
Instructions`. If third-party documentation is not available, individuals or households may self-certify their current homeless status.
Please initial the line below next to your current living situation and provide the details requested.
Applicant Name: ._d., .._,.
My current living situation is:
__Place not meant for human habitation(e:g:such as cars, parks,sidewalks)
(ocation and Dates: :
_Emergency shelter
Emergency She/ter Name, tocation and Dates of Residency__,,�
Transitional Housing
Transitional Nousing Program Name, Locatian and Dates of Residency
AND
Previous Homeless Living Situation(Name,LocationJ and Dates
__Discharging from a Hospital or other Institution
Hospital or lnstitution Name, Location, Date of Entry, and Expected Discharge bate:
AND
Previous HomeJess Living Situation Details and Dates:
' Fleeing a domestic violence, including dating violence,sexual assault,stalking,human trafficking,and other dangerous/life-
threatening conditionsthat relate to vialence against me ar a family member that make me afraid'to return to my primary
residence and (initial all that are true)
Have no other place to live
Do not have the financial resources and su'pport networks ta obtain other housing
Being evicted from the housing we are presentlystaying in and (initial all that are true)
[NOTE: SUCH INDIVtDUALS ARE ELIGIBLE FOR A LIMI7ED SUBSET OF PROGRAMS—CONSUIT DOCUMENTATION CHEGKLIST]
Must leave this housing within the next days
__Nave not identified other housing
_Do not have the'financial resaurces and support networks to obtain other housing
I certify the above-stated information to be true.
Applicant 5ignature: Date:
Page 1 of 2 Client Self-Declaration of Homelessness-NorCal CoC 2022
55
Staff Supplement to Self-Declaration of Homelessness
I understandthatth'srd-partyverification isthe preferred method of certifying homelessness faran individual or household who is
applying'far assistance. l understand self-declaration is oniy permitted when I have attempfied to but cannot obtain third party
verificatian:
Documentation of attempts made for third-party verificatron:
........
Date of Cantact IndividualJOrganizatian Cantacted Methad of Contact �' Outcome of Contact
,
C
,
�
Staff Signature: �. �ate:
Page 2 of 2 Client Self-Declaration of Homelessness= NarCal CoC 2022
56
5C0 ID, ���i�$ h`L`:
STATE OF GALIFOf2NlA-OEPARTMEN7 0F GENERALSERVtCES ______ — _-------�
STANDARDAGREEMENT AGREEMENTNUMBER PURCHASINGAUTHO;RlTYNUMBERi�FApplica6le}
57o zt3 cRev.oatzozo� 23-ERF-3-L-00008 010725
1.This Agreement is entered into between the Contracting Agency and the Contractor named be{ow:
CON7RACTING AGENCY NAME
6usiness,Consumer Services and Housing Agency
CONTRA�TOR NAME
City of Redding
2:The term of this Agreement is:
START DATE
10/12/2023
TNROUGH END OATE
31311�027
3.The maximum amount of this Agreement is:
58,354,955.00 (Eight Million Three Hundred Fifty Four Thousand Nine Hundred FiftyFive Dollars and No Cents)
4.The parties agree to comply with the terms and co�ditions of the foliawing exhibits,which are by this reference rnade a part of the Agreement.
Exhibits Title Pages
Exhibit A Autho�ity, Purpose and Scope of Work 6
Exhibit B Budget Detail and Disbursement Provisions 4
Exhibit C State of California General Terms and Conditions ' 1
+
Exhibit D General Te�ms and Conditions 10
+
Exhibit E Special Terms and Conditions 2
'tems s own with an asferis (J,are eie y intorpoiated by teterence an made pa�t o this agreement as i ottache ereto.
These documents con be viewed at httes./Iwww:dqs:ta.gavfOLSlResou�ces
'N W/TNE55"WHEREOF,TNlS AGREE11r1ENT HAS BEEN EXECEITEQ BYTNE PART/ES HERETO.
CONTRACTOR
CONTRACT'OR NAME(if other than an individual,state whether a corporation,partnership,ett.)
City afRedding
CONTRACTOR BUSINE55 ADDRESS CITY STATE 21P
777 Cypress Ave Redding CA 96001
PRINTED NAME OF PERSON SIGNING TI7lE
8arry Tippin City Manager
Ct7h1TR t7R AUTFt�ktiZEC}�iGtVATURE QAT�SiGPl�
�
�
�
� �arr�`sr: ��, ,� � -� �
.. . . .. � . E �VC.� .
rwvnn
. . i.i}:,F!f C'i}�i�.Y� .a' 4 �.'„'y
1. .... . � ,��
ffi ��.. �+ �{ }# .. �... �
.... e ��✓"� �Y �4 U T �..5 .. . ay� . �m a..:,..,. :
sM��L����r��rc��, c��y cEe�c � � xt, r � � :, -
� � e s�� �
�����F,.�....� w,,.���..,�. �__�.,..��.�.�
� . ��
SCO1D.
Si'ATE OF CAUFORNIA-DEPARTMENT C7F GENERAL SERVlCES _��
STANDARDAGREEMENT AGREEMENTNUMBER PUR�HASINGAUTHORI7YNUMSER{lfAppycab3e)
sTo zi�tR�v:o4no�o� 23-ERF-3-L-00008 010725
STATE OF CAtlFORNIA
CONi'RACTWG AGENCY NAME
Business,Consumer Services and Nousing Agency
CQNTRACTING AGENCY ADORESS CITY S3ATE t{P
500 Capitof Mall,Suite 1850 Sacramento CA 95814
PRINTED NAME dF PERSON 53GNING TITLE
Lourdes Castro Ramirez Secretary
CONTRACTiNG AGENGY AUTHORI2E0 SlGNATURE DATE SiGNED
'?✓).�.� „c�., Oct 12,2023
/
CAlIFORNIA DEPARTtNENT OF GENERAL SERVICES APPROVAI EXEMP7ION(!f Appticabte)
City of Redding
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Encampment Resolutian Funding Program
Round 3, �ookback Disbursement (ERF�3-�)
Standard Agreement
EXHIBIT A
AUTHORITY,PURPOSE, AND SCOPE OF WORK
1} Authority
The State of California has established the Encampment Resolution Funding
Program (°ERF" or "Program") pursuant to Chapter 7 (commencing with Section
50250) of Part 1 of Divisian 31 of the Health and Safety Code: Amended by SB 197
(Statutes of 2022; Chapter 70, Sec;3-8;effective June 30, 2022}:
The Program is administered by the California lnteragency Council on
Homelessness ("CaI ICH") in#he Business, Consumer Services and Housing
Agency ("Ageney"). ERF provides one-time, competitive grant funds to Continuums
of Care and / or Local Jurisdictions as defined beiow: To date, there have been two
previaus rounds of the Encamprnent Resolution Funding Pragram. This Standard
Agreement governs the Lookback Disbursement in Round 3 of the ERF Program
{"ERF=3-L"). Fa�this Standard Rgreement, ERF-3-L is synonymous with "ERF° or
"Program"." and refers#o programs and grantees under Health and Safety Code
section 50252,1(b).
This Standard Agreement along with all its exhibits ("Agreement"} is entered into by
Cal 1CH and a Continuum of Care or a �ocal d�risdiction ("Grantee") underthe
authority of, and in furtherance of, the purpose ofthe Program. ln signing this
Agreement and thereby accepting#his award of funds, the Grantee agrees to comply
with the terms and conditions af this Agreement, the Notice of Funding Availability
("NOFA"} under which the Grantee applied, the representations contained in
the Grantee's application, CaI ICH guidance or directives; and the requirements :
appearing"in the statutory authority for the Pragram cited above:
2) Purpose
As stated in the NOFA, the Pragram's objective is to fund actionable, person-
centered local proposals that resolve the experience of unsheltered hamelessness
for people residing in encampments. Resolving these experiences of homelessness
will necessarily address the safety and wellness of people within encampments, :
resolve critical encampment concerns, and transition individuals into interim shelter
with clear pathways to permanent housing or directly inta permaneni housing, using
data informed, non-punitive, low-barrie�, person-centered, Housing First, and
caordinated approaches. These projects must comply with the principles of Housing
First as defined in Welfare and Institutians Code Section 8255. Propasals may
balster existing, successful models andJar support new approaches that pravide safe
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stable; and ultimately permanent hausing for people experier�cing hamelessness in
encampments. Expenditures shall be consistent with the legislative intent of the
authorizing statute to ensure'the safety and wellness of peaple experiencing
hamelessness in encampments.
3) Definitions
The following Encampment Resolution Funding Program terms are defined in
accordance with Health and Safety Code Section 50250,Subdivisians (ai -(I);
(a) "Additianal funding round moneys" means moneys appropriated for the program in
or after fiscal year 2022-23.
(b) "`Agency" means the Business, Consumer Services, and Housing Agency:
(c) "`Applicant°' means a continuum of care ar local jurisdiction
{d) "Continuum of Care° has the same meaning as in Section 578.3 of Title 24 of the
Code of Federal Regulations:
(e) "Cauncil" means the Califomia lnteragency Cauncil an Hamelessness, previously
known as the Homeless Caardinating and Financing Council created pursuant to
Section 8257 of th�Welfare and Institutions Cade.
(f) "County" includes, b�t is not limited to, a city and county:
(g} "Funding round 1 moneys" means moneys apprapriated for the program in fiscal
year 2021-22.
(h) "Homel�ss° has the same meaning as in Section 57$.3 of Title 24 of th� Cade of
Federal Regulations.
(i) "�ocal Jurisdiction° means a city, including a charte� city, a county, including a
charter caunty, or a city-and county, including a charter city and county.
(j) "Program" means the Encampment Resolutian Funding pragram established
pursuant to this chapter.
(k) "Recipient" means an applicanf that receives grant funds fram the council for the
purposes af the program.
(I) "State right-af-way" means real property held in title by the State of Califarnia
Additional definifions for the purposes of ERF program:
"Grantee" is "a Continuum of Care or a Lacal Jurisdiction that receives grant`funds
frorn the Cauncil for the purpases of the pragram. Grantee is synonymous with
"Recipient"
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"Subrecipients" or "Subgrantees° are entities tnat receive subawards from
"Recipients" or"Grantees" to carry out part of the Program:
"Expended" means aII ERF funds obligated under contract-or subcontract that have
been fully paid and receipted, and no invoices remain outstanding.
"Obligate" means that the Grantee has placed orders, awarded contracts, received
services, or entered into simitar transactions that require payment using ERF
funding. Grantees rnust obligate the funds by the statutory deadlines set forth in this
Exhibit A.
"CaI ICH° is synonymous with "Council".
4) ,Scope af Work
This Scope of Work identifies the terms and conditions necessary to accomplish the
Pragram's intended abjectives.
As detailed in Exhibit A.2, the Program's objective is to fund grantees to implement
actionable, person-centered local proposals that resolve the experience of
unsheltered homelessness for people residing in encarnpments:
Grantees will implement their ERF funded local proposals in cornpliance with the
terms and conditions of this Rgreement, the NQFR under which the Grantee applied,
the representatians contained in the Grantee's application, Ca( ICH guidance and
directives, and the requirements p�r the authorizing statute.
Expenditures shall be consistent with the legislative intent of the authorizing statute
to ensure the safety and wellness of people experiencing homelessness in
encampments.Permissible eligible uses and activities are detailed belaw in Exhibit
B, Budget Details and DisbursementProvisians. Prior to fully executing this
agreement, Grantees must standardize their budget using a CaI ICH provided
budget template.
Grantees are expected to be close partners with CaI ICN. This rneans timely and
accurate reporting, candid communication of'successes and challenges, and
availability of persons, informatian, or materials.
Quarterly reporting requirements are detailed below in Exhibit Q:4. Reporting,
Evaluation; and Audits.
Fiscal deadlines are detailed below in Exhibit A.6. Effective Date; Term of
Agreement, and D'eadlines.
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Grantees shall camplete a Final 1Nork Praduct (As detailed below in Exhibit A.6.d.�
and participate in a program evaluation regarding their implementation af ERf
awards. To suppart this effort,-Cal 1CH will make Technicai Assistance available.
Cal ICH maintains sole authority to determine if`a Grantee is acting in compliance
with #he program objectives-and may direct Grantees'to take specified actions ar risk
breach of this Agreement. Grantees wili be provided reasonable notice and
CaI ICH's discretion in making th�se det�rminations are absoiute and final.
5) Cal ICH Contract Coordinator
Cal ICH"s Contract Coordinatar for this Agreement is the Council's Grant
Development Section Chief ar the Grant Development Section Chief's designee.
Unless athe�wise instructed, any cammunication sha(I be conducted thraugh email to
the Cal ICH Cantractor Coordinatar or their designee> lf documents require an
origir�al signature, the strongly preferred fnrm is an e-Signature in accordance with
the Uniform Electronic Transactions Rct (UETA): If an Awardee is unwilling ar unable
to sign a document electranically,Agency shall accept wet or original signed
documents: These documents containing wet signatures should be both mailed ta
CaI ICH and scanned and emailed as instructed. State law or policy may require the
use of wet signatures for specific documents.The Represer�tatives duri�g th� term
of this Agreement will be:
PROGRRM GRANTEE
ENTITY: gusiness, Cansurner Services City of Redding
and Housing Agency
California lnteragency Council on
SECTItJN/UNIT: Homelessness
Cal ICH
ADDRESS: $Q1 Capital Ma11, 6rn floor 777 Cypress Ave
5acramento, CR, 95814 Redding; CA 96001
CONTRACT Jeannie McKendry Steve Bade
COORDINATOR
PHONE
NUMBER: (�16) 51Q-9446 (530) 245-7129
EMAIL Jeannie.McKendry@bcsh.ca.gov sbade a�cityofredding.org
ADDRESS: and calichgrants a�bcsh.ca.gov
The Council reserves the righf to change their Cal ICH Contractar Coardinator,
designee, and 1 or contact information at any time with reasonable notice ta the
Grantee.
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All requests to update the Grantee informationlisted within this Agreement shail be
emailed to CaI ICH grant's general email box at calichgrants(c�bcsh.ca.qov.
Notice to either party may be given by emaiL Such notice shall`be effective when
received as indicated on email. Changes to Cal ICH Contractor Coordinator,
designee, and /or contact information or grantee information can be made without
a farmal amendment, approved by DGS, if necessary.
6) Effective Date, Term of Aqreement, and Deadlines
a) This Agreement is effective upon executian by Cal ICH, which ineludes signature
from the Grantee and CaI ICH. This is indicated by the Cal ICH provided
signature and date on the second page of the accampanying STD: 213, Standard
Rgreement.
b) Performance shall start no later than 30 days, or on the express date set by Cal
ICH and the Grantees, after all approvals have been obtained and the Grant
Agreement is fully executed. Should the Grantee fail to commence work at the
agreed upon time, CaI tCH, upon five (5) days written notice to the grantee,
reserves the right to terminate the Agreement.
c) Grantees will continue ta perform until the Agreement is terminated, including
data reporting and participation in program evaluation activities, as needed.
d} This Agreement will terminate on March 31,2027:
Grantees shall submit a Final Work Product by September 30, 2026. The Final
Work Product will include programmafic and fiscal data and a narrative on the
outputs and outcomes of the program on a reporting template to be pravided by
"CaI ICH.
Cal ICH will review submitted Final Work Products and collaborate with Grantees
to cure any deficiencies by March 31, 2027.
Grantees are expected ta continue performing until March 31, 2027. This means
timely and accurate reporting, candid communication of success ar
shortcomings, and availability of persons, information, or materials.
e) Expenditure and Obligation Deadlines:
i. Grantees shall expend no less than 50 percent and obligate 100 percent of
Program funds by June 30,2D25.
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ii. Grantees that have not expended 50 percent of their Program funds by
June"30, 2025, shall ret�arn the unspent portion to Cal ICH, in a form and
manner determined by Cal ICH.
iii, Grantees that have not abligated 100 percent of their Pragram funds by
June-30, 2D25, shall submit an alternative disbursementplan to GaI ICH for
approval na Iater than July 3Q,"2025. This alternative disbursement plan
should detail the explanation for the delay and plans for all future obligations
and expenditures.
iv. Grantees not meeting the requirements outlined in {i) may be subject to
additional corrective action, as determined by CaI ICH.
v. All Program funds (100 percent} shall be expended by June 30, 2026. Any
funds not expend`ed by this date shall revert to the fund of origin pursuantto
HSC Section 50253(d)(5).
7) S ecial Conditions
Cal ICH maintains sole authority to determine if a Grantee is acting in compliance
with the pragram objectives and may direct Grantees to take specified actions or risk �
breach of this Agreem�nt. Grantees wiil be provided reasonable notic�and Cal
TCH's discretion in making these determinations are absolute and final.
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Encarnpment Resolutian Funding Program (ERF-3-L)
Standard Agreement
EXHIBIT B
BUDGET DETAIL and DISBURSEMENT PRC}VISfONS
1} General Conditions Prior to Disbursement
All Grantees must submit the following completed forms prior to ERF being
released:
• Request for Funds Farm ("RFF"}
• STD 213 Standard Agreement form and initialed Exhibits A thraugh E
• STD 204 Payee bata Record or Government Agency Taxpayer ID Farm
2) Disbursement of Funds
ERF will be disbursed to the Grantee upon receipt, review and approval of the
completed Standard Agreement and RFF by Cal ICH.
The RFF must include the total amount of Program funds prapased to be expended.
The ERF will be disbursed in one allocation via mailed check once the RFF has
been received by the SCO, Checks will be mailed to the address and contact name
Gsted on the RFF.
3) Budqet Details and Expenditure of Funds
The Grantee shall expend Program funds on eligible uses and activities
as detailed in the submitted standardized budgef. CaI ICH reserves the right to direct
specific line-item changes in the originally submitted Application budget or
subsequently submitted standardized budgets.
a) Budget Changes
i} Process
Budget modification requests should be made as part of the quarterly report
process. These requests will be reviewed in the first week after quarterly
repo�ts are received. CaI ICH may consider budget change requests outside
of this process, thraugh email as needed due to dacumented, exigent
circumstances. Grantees carry the burden to anticipate foreseeable budget
change requests and should plan accordingly.
CaI tCH reserves the right to amend or adjust this process as necessary.
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ii} Conditions requiring a budget modificatian request:
Changes may be made to the timing (e.g., fiscal year) of eligible use
expenditures w'rthout prior approval by Cal ICH sa long as the total
expenditures (actual`and projected) for each eligible use category remain the
same as approved in the standardized b�dget.
Any decrease or increase to the total expenditures for any eligible use
categ'ory must be approved by Ca1 1CH's Grant Development Section Chief or
- their designee, in writing, before the Grantee may expen,d Pragram funds
according;to an alternative standardized budget. The Grant Development
Section Chief will respond to Grantee with approval or denial of
request. Failure ta obtain written approval from CaI ICN as required by this
sectian may be considered a breach of this Agreement. R breach af this
agreemenf may result in remedies listed belaw in Exhibit D.6. Breach and
'Remedies;
Regardless of an increase or decrease of an expenditure amount, any
significanf or material programmatic or fiscal change as consid�red by a
reasonable project manager should be submitted to Cal' ICH fo�approvaL
b) Eligible Uses
Eligible uses and activities must be consistent with NSC Sections 50250 -
50254, other applicable laws, the terms and conditians of this Agreement, Cal
IC'H guidance or directives, the NOFA under which the Grantee applied, -
representations contained in the Grantee"s applicafion, and the Pu�pose of the
Pragram as detailed'in Exhibit A:2. Purpose,
Eligible uses and activities include, but are not limited ta, the fallowing:
Rapid Rehousing: Rapid rehousing, including housing identification services,
rental subsidies, security deposits, incentives to landlortls, and holding fees for
eligible persons, housing search assistance, case management and facilitate
access to other community-based services.
Operating Subsidies: Operating subsidies in new and existing affordable or
suppartive housing units, emergency shelters, and navigatian centers. Operating
subsidies may include operating reserves.
Street Uutreach: Street autreach ta assist eligible persons ta access crisis
services, interim housing aptions, and permanent housing and services> Services
Coordination Services caardination, which may include access to warkforce,
education, and training programs, or other services needed ta improve and
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pramote housing stability for eligible persons, as well as direct case management
services being pravided to persons.
Systems Support: Systems support far activities that improve, strengthen,
augment, complement, andlor are necessary to create regional partnerships and
a homeless services and housing delivery system that reso(ves persons'
experiences of unsheltered homelessness.
Delivery of Permanent Nousing: Delivery of permanent housing and innovative
hausing solutions, such as unit conversions that are well suited for eligible
persons:
Prevention and Shelter Diversion: Prevention and shelter diversion to -
permanent hausing, including flexible farms of financial assistance, problem
solving assistance,-and other services to prevent people that have been placed
into permanent housing from losing their housing and falling back into
unsheltered homelessness. This category`is only available to serve people wha
were formerly residing in the prioritized ERF encampment site.
Interim Sheltering: lnterim sheltering, limited to newly developed clinically
enhanced congregate shelters, new or existing non-congregate shelters, and
aperatians af existing navigation centers and'si�elters based on demonstrated
need that are well suited for eiigible persons.
Improvements to Existing Emergency Shelters: Improvements to existing
emergency shelters to lower barriers, 'increase privacy,better address the needs
of eligible persans, and improve outcomes and exits to permanent housing.
Administration: up to 5% of awarded Program funds may be applied to
administrative costs.
N4TE:Program funds shall not be expended an Site Restoration ar ather
Ineligible Costs as detailed immediately below.
4} Ineli�g,ible Costs
ERF shall not be used for costs associated with activities in violation, conflict, or
inconsistent with HSC Sections 50250 = 50254, other applicable iaws, the terms and
conditions of this Agreement, Cai ICH guidance or directives, the NOFA under which
the Grantee applied, representations cantained in the Grantee's application, and the
Purpose of the Program as detailed in Exhibit A.2. Purpose:
Costs shall not be used for any use or acfi�ity that is in violation, conflict, or
inconsistent with the legislative intent of the authorizing statute to ensure the safety
and wellness of people experiencing homelessness in encampments. ;
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Moreover, no parfies to this contract nor fiheir agents shall directly or indirectly use
ERF awards for any use or activity that is in violatian, confiict, or inconsistent with
the legisiative intent of the authorizing statute to ensure the safety and wellness of
peopie experiencing homelessness in encampments. This prohibition includes using
ERF funds in connectiQn ta or in suppart af activities-that cause a traumatic effect an
those experiencing homelessness.
Cal ICH, at its sale and absalute discretian, shall make the final dete�minatian
regarding the allowability of ERF expenditures.
Cal IGN reserves the right to request additional clarifying information to determine
the reasonableness and eligibility of all uses of the funds made available by this
Agreement: If the Grantee ar its funded subrecipients use ERF funds to pay
for ineligible activifies, the Grantee shall be required to reimburse these funds to Cal
ICH at an amount and#imeframe determined by Ca1 ICH.
Rn expenditure which is nat authorized by this Agreement, ar by written approval of
Cai ICH, or which cannot be adeq�aately documented, sha1i be disallowed, and
musf be reimbursed to CaI IGH by the Grantee at an amount and timeframe
determined by CalJGN.
Program funds shall nat be used to supplant existing loca!funds for homeless
housing, assistance, prevention, ar encampment resolutian.
Unless expressly appraved by Cai ICH in writing reimbursements are not permifted
for any Program expenditures priar to this Agreement's date of execution.
__.----
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Encampment Resalution Funding Program (ERF-3=L)
Standard Agreernen#
EXHIBIT C
5TATE t3F CA�iFt�RN1A GENERAL TERMS AND CONDITIONS
This exhibit is incorporated by reference and made part of this agreement: The General
Terms and Gonditions (GTC 04/2017) can be viewed at the fallowing link:
h, ttps:llwww.dqs.ca.qovl-lmedia/Divisions/U�S/Resources/GTC-April-2Q17-
FINR�a�ri12017,pdf?la=en&hash=3A64979F777D5B9D35309433EE81969FD69052D2.
In the interpretation of this Agreement, any inconsistencies between the State af
California General Terms and Conditians (GTC = 04J2017) and the terms of this
Agreement and its exhibitstattachments shall be resolved in favor of this Agreement and
its exhibitslattachrnents.
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Encampment Resolution Funding Program {ERF=3-L)
Standard Agreement
EXHIBIT D
GENERAL TERM� AND CONDITIONS
1) Term�nation and Sufficiencv of Funds
a) Termination of Agreement
Gal ICH may terminate this Agreement at any time for cause by giuing a
minimum of 14 days' notice of termination, in writing, to the Grantee. Cause shall
consist of violations af any conditions of this Agreement, any breach of contract
as described in paraqraph ��of this Exhibit D; violation of any federal
or state 1aws; or withdrawal of Cal 1CH's expenditure authority. Upan terminatian
of this Agreement, unless otherwise approved in writing by GaI ICH, any
unexpended funds received by the Grantee shall be returned to Cal ICH
within 30 days of Cal ICH's specified date of terminatior�.
b} Sufficiency of Funds
This Agreement is valid and enforceable only if sufficient funds are rnade
available to Cal ICH by legislative appropriatian. ln addition, this Agreement is
subject to any additional restrictions,'limitations or conditians, or statutes,
regulations c�r any other laws, whether federal or#hose of the State of California,
or of any agency, department, or any political subdivision of the federal ar State
of Califarnia gavernments, which may affect theprovisions, terms or funding of
this Agreement in any manner.
2) Transfers
Grantee may not transfer or assign 6y su6contract ac novatian, ar by any other
means, the rights, duties, or performance of this Agreement ar any part thereof,
except as allowed within Exhibit D.12. (Special Canditions-- GranteeslSub Grantee)
or with the priorwritten approval of CaI ICH and a farmal amendment to this
Agreement to affec#such subcontract or novation.
3) Grantee's Application for Funds
Grantee submitted a standardized budget to Cal ICH as part of their application for
the Pragram.
Grantee warrants that all information, facts, assertions and representatians
cantained in the application and approved modifications and additions thereto are
true, correct, and camplete ta the best of Grantee's knowledge. In the event that any
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part of the application and any approved modification and addition thereto is untrue,
incarrect, incomplete, or misleading in such a manner that wauld substantially affect
CaI iCN appraval, disbursement,or manitoring of the funding and the grants or
activities governed by this Agreement, then Caf ICN may declare a breach of this
Rgreement and take such action or pursue such remedies as are legally available.
4) Repartinq,:Evaluation1 and Audits
a} Reporting Requirements
i, Timing and Format of Reports.
Grantee is required to provide Cal 1CH or its agents with all data and
outcomes that may inform an assessment of the funded proposaL Grantees
shall report quarterly and have one Final Work Product subrnitted priorto
this Agreement's termination.
The quarterly reports shall be su6mitted on a template to be provided by Cal
I'CN at least 90 days prior to the first reporting deadline: CaI ICH may
request interirn reports as needed and will provide no less than 30 days'
notice to Grantees.
ii; Required Data
Grantees will be required to provide:
• Outreach and service path data at the anonymized, individual level;
• Current housing status of persons served in the aggregate;
• Status of funding as presented in the GaI ICH appraved, standardized
budget; and
• Continued confirmatian that prajects receiving ERF funds are populated
timely inta HMIS and use CaI JCH supplied funding cades.
Cal ICH's discretion in identifying which information shall be included in
these reports is final. Grantees shall also report information in the farm and
manner required by Cal ICH. Failure ta comply will be considered a breach.
Pursuant to HSC Section 50254, grantees shall provide data elements,
including, but not limited to; health informatian, in a manner consistent with
state and federal law, to their local Hameless Management Information
System for tracking in the statewide Homeless Data Integration System.
Pursuant to HSC Section 50254(b){3), Grantees shall report individual,
client-level data far persons served by grant funding to the cauncil, in
addition to any data reported through focal Homeless Management
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Informatian System, as required by the council for the purposes af research
and evaluatian of grant perfarmance, service pathways, and outcomes for
peaple served.
Grantees shall comply with the data entry requirements'af AB 977, lacated
at Welfare and institutions Code section 8256(d).
iii. CaI ICH usage of Reports
Pursuanf ta HSC Sectian 50254(b){4), Council staff may use information
reported directly fram grantees and through statewide Homeless Data
Integration System for the purposes af research and evaluation of grant
perfarmance, service pathways, and outcomes for pec�ple served.
iv. Failure to Repart
If the Grantee fails to provide any such repart, Ca1 ICH may recapture any
portion of the amount authorized by this Agreement with a 14-day written
notificatian.
b) Evaluation
i. Af Cal ICN's discretion, Grantees shall participate in a program evaivation
regarding their implementation of ERF awards.To support this effort, Cal
I`CH will can#ract a third party to comple#e the evaluation.
ii: �rantees are expected ta be close partners with Gal ICH far this program
: evaluation and for all evaluative aspects ofthis Program. This means timely
and accurate reporting, candid communication of success ar challenges,
and availability of persons, information, or materials. More sp�cificaily,
Granteesm�st cooperate with Cal ICH ar its designee as reasonably
required to implement an evaluation plan. This includes providing or
facili#atir�g the collection of data and materials as reasonably requested by
CaI ICH or its designee.
iii, For the purpose of evaluation, Cal ICH or its designee may visit sites related
ta the project and film, tape, photagraph, int�rview, and othen�vise document
Grantee's operations during normal business hours and with reasonable
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advance nofice. CaI ICH will comply with Grantee's site visit terms during
any site visits.
iv. Grantees should maintain active data, documents; and filings in anticipation
of this evaluation. Special care should be taken to organize and preserve
internal work products that guided implementatian by the Grantee or
subgrantee.
v: Grantees shall notify CaI ICH and provide copies of any reparts ar findings if
Grantee conducts or cammissians any third-party research or evaluation
regarding their funded project.
vi. All terms and canditions that apply to reparting similarly applyto evaluation.
c) Auditing
• Cal ICH reserves the right to perform or cause to be performed a financial
audit♦At CaI 1GH request, the Grantee shall provide, at its awn expense, a
financial audit prepared by a certified public accountant. Shauld an audit
be required, the Grantee shall adhere to the fol)owing canditions:
i) The audit shall be perfarmed by an independent certified public accountant.
ii) The Grantee shall notify Cal IGH of the auditar's name and address
immediately after the selection has been made. The contracf for the audit
shall a11ow access by CaI ICH to the independent auditor's working papers:
iii) The Grantee is respansible for the completion of audits and all casts of
preparing audits.
iv) If there are audit findings, the Grantee must submit a detailed r�sponse
acceptable to Gal IGH for each audit finding within 90 days from the date of
the audit finding report.
5} ,Inspection and Retentian of Records
a) Record Inspectian
; Cal ICH or its designee shall have the right to review, abtain, and copy all
records and supporting documentation pertaining to performance under this
Agreement. The Grantee agrees to provide CaI ICN, or its designee, with any
relevant information requested. The Grantee agrees ta give Cal ICH or its
d�signee access to its premises, upon reasanable natice and during normal
business hours, for#he purpose of interviewing employees who might reasonabiy
have informatian related to such records, and of inspecting and copying such
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baaks, records, accounts, and other materials that may be relevant to
an inves#igation of compliance with the ERF Iaws, CaI ICH guidance or
directives, and this Agreement.
b} Record Retention
The Grantee further agrees to retain all r�cards described in subparagraph A for
a minimum period of five (5)years after the termination of this Agreement.
If any litigation, claim, negotiation, audit, monitaring, inspection, or other action
has been commenced before#he expiration of the required record retention
period, all records must be retained until completion af the action and resolution
of ail issues which arise from it.
c) Public Records Act
The grantees' applicatian, this contract, and other dacuments related to the grant
are considered public records, which are available for pnblic viewing pursuant to
the Califarnia Public Records Rct.
6) Breach and Remedies
a} Breach ofi Agreement
Breach of this Ag�eement includes, but is not limited to, the following events:
i. Grantee's failure to comply with the terms or conditians of this Agreement
ii. Use of, ar permitting the use af, Program funds provided under this
Rgreement far any ineligible activities.
iii. Any failure ta comply with the deadlines set forth in this Agreement. _
b) Remedies for Breach of Agreement
In addition ta any other remedies that may be available ta CaI ICH in law or
equity for breach of this Agreement, Cal lCN may, in a form and manner
determined by CaI ICH:
i. Conduct a program m�nitoring which will include a corrective action pian
{CAP) with findings, remedies, and timelines for resolving the findings.
ii. Bar the Grantee fram applying for future ERF funds;
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iii; Revoke any ather existing ERF award(s) to the Grantee;
iv. Require the return of any ur�expended ERF funds disbucsed under this
Agreement;
v: Require repayment af ERF funds disbursed and expended under this
Agreement;
vi. Require the immediate return to Cal fCH af all funtls derived from the use of
ERF
vii. Seek, in a court of competent jurisdictian, an order for specific performance
of the defaulted obligation or participation in the technical assistance in
accordance with ERF;requirements.
c) A( remedies available to Cal ICH are cumulative and not exclusive.
d) Cal ICH may give written notice to the Grantee to cure the breach ar
violation within a period of nof less than 14 days.
7} Waivers
No waiver of any breach of this Agreement shall be held to be a waiver af any prior
or subsequent breach. The failure of Cal JCH to enforce at any time the pravisions of
this Rgreement, or to require at any time,perfarmance by the Grantee of these
provisions, shall in no way be construed to be a waiver of such pravisions nor to
affect the validity of this Agreement or the right of CaI ICH to enforce
these provisions.
8) Nondiscriminatian
During the perfarmance of this Agreement, Grantee and its subrecipients shall not
unlawfully discriminate, harass, or allow harassment against any employee or
applicant for employment because of sex (gender), sexuai orientation, gender
identity, gender expressian, race, color, ancestry, religion, creed, national origin
(including language use restriction), pregnancy, physical disability (including HIV and
AIDS), mental disability, medical condition (cancer/genetic characteristics), age
(over 40}, genetic information, marital status, military and veteran status, denial af
medical and family care leave ar pregnancy disability leave, or any other
characteristic protected by state orfederal Iaw: Grantees and Sub grantees shall
ensure thaf the evaluation and treatment of their employees and applicants for
employment are free frorn such discrimination and harassment.Grantee and
its subrecipients shall comply'with#he provisians of California's laws against
discriminatary practices relating to specific groups the California Fair Employment
and Nousing Act {FEHA) {Gov. Code, Section 12900 et seq.), the regulatians
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promulgated thereunder (CaI. Cade Regs., tif. 2, Section 11 OOO et seq.); and the
provisions of Article 9.5, Chapter 1, Part 1, Diuision 3, Title 2 of the Gouernment
Code (GoV: Cade, Sec#ion 11135 - 1�139.5). Grantee and its subrecipients shall
give written notice of their abligafions under this claus� to labor arganizatians with
which they have a collective bargaining or ather agreement
9) Canflict of Interest
All Grantees are subject ta state ar�d federal conflict of interest laws. Failure to
comply with these laws, including business and financial disclasure provisions, will
result in the application being rejected and any subsequent eontract being declared
void. Other legal action may also be taken. Additional applicable statutes include,
but are not Iimited to, Government Code �ection 1090 andPublic Cantract Code
Sections 10410 and 10411.
a) Current State Employees: No State officer or employee shall engage in any
employment, activity, or enterprise from which#he afficer or employee receives
compensation or has a financiai interest, and which is sponsored ar funded by
any State agency, unless the employment, activity, or enterprise is required as a
candition of regular State employment. Na state-officer ar�mployee sha11-
contract onhis or her awn behalf as an independent Grantee with any �tate
agency ta provide goods or services. ;
b) Former State Employees: For the two-year period from khe date he or she left
State employment, no form�r State officer or employee may enter inta a contract
in which he or she engaged in any af the negotiations, transactions; planning, -
arrangements, or any part of the decision-making process relevant to the
contract while employed in any eapacity by any State agency. For the twelve-
month period fram the date he or she left State employment, na former State
officer or employee may enter i'nto a cantract with any State agency if he or she-
was employed by that State agency in a palicy-making posifian in the same
general subject area as the propased contract within the twelve-manth period
prior to his or her leaving State service:
c) Emplayees of the Grantee: Employees of the Grantee shall comply with all
applicable provisians ofJaw pertaining to canflicts of interest, including but not
limited to any applicable conflict of interest provisions Qf the PoliticalReform
Rct of 1974 (Gov. Code, Sectian 81000 et seq.).
d) Representatives of a County: A representative of a caunty serving on a boartl,
committee, or bady with the primary purpose of administering funds or making
funding recommendatior�s for applicatians pursuant to this chapter shall have no
financial interest in any contract, program, or project voted on by the board,
committee, ar bady on the basis of the receipt of campensation for hoiding public
office or public employment as a representative of the caunty_
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10)>,Druq-Free Workplace Certification
Certification of Cornpliance: By signing this Agreement, Grantee hereby certifies,
under penalty of perjury under the laws of State of Califomia, that it and its
subrecipients will comply with the requirements of the Drug-Free Workplace Act of
1990 (Gov. Code, Section 8350 et seq.} and have or will provide a drug-free
worKplace by taking the following actions:
Publish a statement notifying employees and subrecipients that unlawful
manufacture distribution, dispensation, possession, or use of a controlled substance
is prohibited and specifying actions to be taken againsf employees, Grantees, or -
subrecipients far violations, as required by GovemmenY Code Section 8355,
subdivision (a){1),
a) Establish a Drug-Free Awareness Prograrn, as required by Governmenf Code
Sectian 8355, subdivisian{a){2) to inform employees, Grantees, or
subrecipients about all of the following:
i. The dangers of drug abuse in the workplace;
ii. Grantee's policy of maintaining a drug-free workplac�;
iii. Any available counseling, rehabilitation, and employee assistance pragram;
- and
iv. Penalties that may be imposed upon employees, Grantees, and
subrecipients fordrug abuse violations. _
b) Provide, as required by Government Code Section 8355, subdivision (a)(3),that
every employee and/or subrecipient that works under this Agreement:
i. Will receive a copy of Grantee's drug-free policy statement, and
ii. Will agree to abide by terms of Grantee`s condition of employment or
subcontract.
11) ,Child Support Com�liance-Act
For any Contracf Agreement in excess of$100,000, the Grantee acknowledges in
accordance with Public Contract Cade 719 0, that
a) The Grantee recognizes the importance of child and family support obligations
and shall fully comply with all applicable state and federal laws relating ta child
and family support enforcement, including,but not limited to, disclosure of
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information and compliance with earnings assignment orders, as provided in
Chapter 8 (commencing with Section 5200) of Part 5 of Division 9 of the Family
Code; and
b) The Grantee, to the best of its knowledge is fully complyir�g with the earnings
assignment arders of all employees and is prouidir�g the names of al! new
emplayees to the New Hire Registry maintained by the California Employment
Developmenf Department.
12) Special Conditions —Grantees/Subqrantee
The Grantee agrees to comply with all conditions of this Agreement including
the Special Conditions set forth in Exhibit"E. These conditions shall be met to the
satisfaction of CaI ICH priar to disbursement of funds: The Grantee shall ensure that
all Subgrantees a`re rnade aware of and agree to camply with all the conditions of
this Agreement and the applieable State requirements governing the use of ERF.
Failure ta comply with these conditions may result in termination of this Agreement
a) The Agreemenf between the Grantee and any Subgrantee shall require
the Grantee and its Subgrantees, if any, to:
i. Perform the wark in accordance with Federal, State and Laca! housing and
building codes, as applicable.
ii. Maintain at least the minimum State-required worker's compensation for
thase employees who will perform the work or any part of'it.
iii. Maintain, as required by law, unemployment insurance, disability insurance,
and liability insuranc� in an amount that is reasonable to compensate any
persan, firm or corporation who may be injured or damaged by the Grantee or
any Subg�antee in performing the WorK or any part of it.
iv. Agree to include and enforce all the terms of this Agreement in each
subcontract.
13) Compliance with"State and Federal LawsLRutes, Guidelines and Requtations
The �rantee agrees to comply with al! state and federal laws, rules and regulations
that pertain to construction; health and safety, labor, fair emp)oyment practices,
environmental protectian, equal opportunity, fair housing, and all other m�tte�s
applicable andlor related to the ERF program, the Grantee, its subrecipients, and a!I
eligi6le activities.
G�antee shall alsa be responsible for obtaining any and all permits, licenses, and
approvals required forperforming any activities under this Agreement, including
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- those necessary to perform design, construction, or operation and maintenance of
the activities. Grantee shall be responsible for observing and complying with any
applicable federal, state, and local laws,-rules or regulations affecting any such work,
specifically those including, but not limited to, environmental protection,
procurement, and safety laws, rules, regalations, and ordinances. Gtantee shall
pravide copies of permits and approvals to CaJ 1CH upon request.
14) Inspections
a) Gr�ntee shall inspect any work performed hereunder to ensure that the work is
being and has been performed in accordance with the applicable federal, state
and/or local requirements, and this Agreement -
b) Cal JCH reserves the right to inspect any work performed hereunder, including
site visits, to ensure that the work is being and has been performed in
accordance with the applicable federal, state and/or local requirements, and this
Agreement.
c) Grantee agrees to require that all work that is determined based an such
inspections nat to conform to the applicable requirements be corrected and to
withhold payments to the subrecipient until it is corrected.
15) Litigation
a) If any provision of this Agreement, or an underlying obligation, is held invalid by
a court of competent jurisdiction, such invalidity, at the sale discretion of Cal
ICH, shall not affect any other provisions of this Agreement and the remainder of
this Agreement shall remain in full force and effect; Therefore, the provisions of
this Agreement are and shall be deemed severable.
b) The Grantee shall notify Cal ICH immediately of any claim or action undertaken
by or against it, which affects or may affect this Agreement or CaI ICH, and shall
take such action with respect to the claim or action as is consistent with the -
terms of this Agreement and the interests of CaI ICH.
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Encampment Resolutian Funding Program (ERF=3-L)
Standard Agreement
EXHIBIT E
SPECIAL TERMS AND CONDITIONS
1) All proceeds from any interest-bearing account established by the Grantee for the
depasit of'funds, aiang with any i�terest-bearing accounts opened by subrecipients
to#he Grantee for the deposit of fu�ds, must be used for eligible activities; Grantees
mus# maintain recards af all expenditures ofithe proceeds from these interest- -
bearing accounts for five (5}years: Cal !CH reserves'the right ta per�orm or cause to
be performed a financial audit on the use of praceeds from interest bearing
accounts.
2} Grantee shall utilize its local Homeless Management Information System (HMIS) ta
frack ERF projects, services, and clients served: Grantee will ensure that HMIS data
are collect�d in accardance with applicable laws and in such a way as to identify
individual projects, services, and clients that are supparted by
funding (e.g:, by creating appropriate - ERF specific funding sources and project
codes in HM15).
3} Grantee shall participate in and provide data elements, including, but not limited to,
health infarmation, in a manner consistent with federai law, to the statewide
Homeless Management lnfarmatian System (known as the Homeless Data
lntegration System or"HDIS"'}, in accardance with their existing Data Use
Rgreement entered into with the Council, if any, and as required by Health and
Safety Cade Section 50254: Any health information provided to, or maintained
within, the statewide Homeless Management Infarmatian System shall not be
subject to public inspection or disclosure under the California Public Records Act
{Ghapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the
Government Code). Forpurposes af this paragraph, "health infarmation" means
"pratected health informatian," as defined in Part 160.1 Q3 of Title 45 of`the Cade of
Federai Regulations, and "medical information,° as defined 'in subdivision {j) of
Section 56_05 of the Civil Code. The Council may, as required by aperational
necessity, amend or madify required data elements, disclosure formats, or
disclosure frequency. Additionally, the Council, at its discretion, may provide
Grantee with aggregate reports and analytics of the data Gcantee submits to HDIS in
support of'the Purpose of this Agr��ment and the existing Data use Agreement.
4} Grantee agrees to accept teehnical assistance as directed by Ca11CH or by a
cantracted technical assistance provider acting an behalf of CaI:ICH. Grantee will
report'to CaI ICH on programmatic changes the Grantee wiil make as a result of the
technical assistance and in suppart of their grant goals,
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5) Grantee shouid establish a mechanism for people with lived experience of
homelessness to have mean"sngful and purposeful opportunities #o inform and shape
all levels of planning and implementation, including through opportunities to nire
people with lived experience.
6} Cal ICH maintains sole authority to determine if a Grantee is acting in compliance
with the pragram objectives and may direct grantees to take specified actians or risk
breach af'this Agreement. Grantees will be provided reasonable natice and Cal
ICH's discretion in making these determinations are absolute and final.
Initial Here �,�,�,,,
EX�IIBIT C-1
ENCAMPMENT EMERGENCY SHELTER PROGRAM
INVOICE TEMPLATE
Date:
Providerinformation Invoice Number:
Name:
Address:
Gontact Person:
Descriptio.n of Reimbursement: Amount
Totai to be paid:
I hereby certify the above to be true and correct,to the best of my knowledge:
Signature Date
Typed or Printed Name Title
City Staff Approval Signature Date
Encampment Emergency Shelter Services Contract—Shasta Community Health Center