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MEMNON
i
INDEPENDENT CONTRACTOR AGREEMENT
This Agreement is made and entered into this 16th day of October, 2007
between the City of Redlands,a municipal corporation(hereinafter Aging Solutions with Heart, Inc., (hereinafter "Contractor'),after"Ci „ by and
sometimes individually referred to herein as a"paa )and Developing
City and Contractor are
"Party"and, together, as the"Parties."
RECITALS
WHEREAS, Contractor has expressed an interest in providing
management services, including
community resources for both depend nt adults with AI heimers and the, and access care
and their caregivers; and
WHEREAS,Contractor has represented to City that it has the requisite ex
special knowledge and expertise similar to others in the industryexperience,conducting these services;
NOW,THEREFORE in consideration of the mutual promises contained here'
and Contractor agree as follows:
m, City
AGREEMENT
Section 1. Sees
1.1 City hereby authorizes Contractor to provide v
services, includin P geriatric care management
Ing counseling, educational assistance, and access to
community resources for both dependent adults with Alhei
caregivers(the"Services"). mers and their
'
Services and shall advise City of the same prior to the performance�of the
e
Services. Contractor further agrees to perform such the Services to the best o
its ability and in an efficient, safe and competent manner.
1.2 Contractor shall determine the method, details and means of performing
f
1.3 As compensation for
Contractor in an amount not to exceed S 5,000.Services,the tY shall reimburse
Fede S
City laws governing reimbursement shall apply. tate, County and
1.4 Contractor shall submit to City a complete record of the Services
including, but not limited to: copies of invoices, agreements,erformed
expenses, administrative records, advertisements and backup materials.roll
A
detailed account of the Services performed, the names
ryPersons
Performing the Se ices and a cost breakdown shall also be of the of
to City.
Administration and Personnel records of Contractor shall be ty
examination by City• available for
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1.5 Contractor shall submit to Cit
documentation in compliance with the with
each
eq lest for reimbursement,
requirements including: Agreements with Subrecipients,StatemenR Records and
R 570.503
Reports; Program Income; Uniform Adminit Of
Requirements; Other
Program Requirements,Conditions for Religious Organizations; Suspension
and Termination and; Reversion of Assets.
1.6 Contractor shall submit to City, with each request for reimburse
documentation that at least 51% of the adult dependents served are from
ying households. In order to document the number of low and
income qualif
moderate income adult dependents benefiting from the Services, a
Beneficiary Qualification Statements form, a co
hereto and incorporated herein by reference as Exhibiy of hlcA is attached
completed by Contractor for each adult dependent that benefits from the
"A," shall be
Services. Using the Beneficiary Qualification Statements prepared for each
adult dependent, Contractor shall complete the Monthly Program Progress
Report form,a copy of which is attached hereto and incorporated herein b
� reference as Exhibit "B," for eve
and submit such Monthly program progress Reportmonth that CDBG s with Contnds are ractor's
monthly reimbursement request to Ci ractor's
be retained in Contractor's records for m nimum pleriod of submitted
(3) shall
from October 2, 2007. O years
1.7 Contractor shall submit all final claims for reimbursement to City no later
than June 30, 2008•
1.8 City will submit a final Request for Reimbursement for the Services no later
than July 21, 2008. After July 31, 2008 any balance remaining in City's
CD86 account for the Services will be reprogrammed. City's
Section 2. Independent Contractor. It is the express intention of the Parties
Contractor is an independent contractor and not an employee or agent of Ci
this Agreement shall be interpreted or construed as creating or establishin that
employer and employee between Contractor and Cit ty. Nothing in
Contractor is not n employee of Ci g a relationship of
City for State tax, Federal tax ora any other Purpose. that
Section 3, Contractor's Em Io ees. A listingof all o Purpose
agents who may participate in Contractor's performance of the Services is attached employees
and
Exhibit "C." No other employees or agents of Contractor shall participate
Performance of the Services without the prior written consent of City,
hereto as
P ctpate in the
Section 4. Te—
amination Cit},shall have the right to terminate this Agreement
twenty (20) days prior written notice to Contractor. City shall have no liability
claim for damages resulting to Contractor as a result of any exercise b C' upon
terminate this Agreement. for any
Y ty of its right to
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Section 5. Insurance and Indemnification
5.1 Contractor's Insurance to be Prima
All insurance required by this Agreement shall be maintained by Contractor for the
duration of its performance of the Services, and shall be primary with respect to Ci
non-contributing to any insurance or self-insurance maintained b Ci h'and
Y City. Contractor shall not
perform any Services unless and until all required insurance listed below is obtained
Contractor. Contractor shall provide City with Certificates of Insurance and endorsements b
evidencing such insurance and naming City as an additional insured (except for w Y
compensation and professional liability)
P workers
insurance policies shall include a Provision Prohibiting comIcancellatnon of thet of the Serv1ces. All
upon thirty(30) days prior written notice to City, policy except
5.2 Workers' Compensation and Employer's.Liability
A. Contractor shall secure and maintain Workers' Compensation and
Employer's Liability insurance throughout its performance of the Services in
amounts which meet statutory requirements with an insurance carrier
acceptable to City.
B. Contractor expressly waives all rights to subrogation against City, its
officers,employees and volunteers for losses arising from work performed by
Contractor for City by expressly waiving Contractor's immunity for injuries e obligation to indemnify,
to Contractor's employees and agrees that th
defend and hold harmless provided for in this Agreement extends to any
claim brought by or on behalf of any employee of Contractor.
5.3 comprehensive General Liabili Insurance.
Cntractor shall secure and
maintain in force throughout its performance of the Services co pr ehensive general liability
insurance with carriers acceptable to City. Minimum coverage of one million dol
($1,000,000) per occurrence and two dollars
liability, property damage and personal njutly i required.
equii 42'000,000) aggregate for public
5.4 Professional Liability Insurance.
Contractor shsecure and maintain
Professional liability insurance throughout the performance of the Slervices in the amount
one million dollars ($1,000,000)per occurrence. t of
5.5 Business Auto Liabil
liability coverage,with mini Insurance. Contractor shall have business auto
imum limits of one million dollars($1,000,000)per Occurrence,
combined single limit for bodily injury liability and property damage liability. This
coverage shall include all contractor owned vehicles used on the pro'ectg hiis
owned vehicles, and employee non ownership vehicles. ed and non-
5.6 Assi mment and Insurance Re
from Assigning any uirements. Contractor is expressly Prohibited
of the Services without the prior written consent of City. In the ev
mutual agreement between Parties to assign a portion of the Services,the Contractor will add
the subcontractor as an additional insured and provie insurance endorsements
City with thent of
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prior to any Services being performed by the assignee. Assignment does not include printing
or other customary reimbursable expenses that may be provided in this Agreement.
5.7 Hold Harmless and Indemnification. Contractor shall defend,indemnify and
hold harmless City,its elected officials,officers,employees and agents,from and against
and all actions, claims, demands, lawsuits, losses and liability for damages to persons or
Property, including costs and attorney fees,that may be asserted or claimed by any person,
firm, entity, corporation, political subdivision or other organization arising out of or in
connection with Contractor's negligent and/or intentionally wrongful acts or omissions under
this Agreement; but excluding such actions, claims, demands, lawsuits and liability for
damages to persons or property arising from the sole negligence or intentionally wrongful
acts of City, its officers, employees or agents.
Section 6. Health Insurance Portabili And Accountability Act of 1996,
to the Health Insurance Portability And Accountability Act of 1996(HIPAA), regulations t
have been promulgated governing the privacy of individually identifiable health information.
The HIPAA Privacy Regulations specify requirements with respect to contracts between
an
entity covered under the HIPAA Privacy Regulations and its Business Associates. A
Business Associate is defined as a party that performs certain services on behalf of, or
Provides certain services for,a Covered Entity and in conjunction therewith,gains access to
individually identifiable health information. Therefore, in accordance with the HIPAA
Privacy Regulations, Contractor shall comply with the terms and conditions as set forth in
fo
the attached Business Associate Agreement, Exhibit "D" hereby incorporated fo his
reference.
Section 7. Entire Agreement/Modification. This Agreement representsthe entire
Agreement of the Parties as to the matters contained herein. Any modification of this
Agreement will be effective only if it is in writing and signed by the Parties.
Section 8. Assignment. This Agreement shall not be assigned without the prior
written consent of City. Any assignment, or attempted assignment,
written consent, shall be null and void and, at the option of City, result in he immediaout such te
termination of this Agreement.
Section 9. Attorney's Fees In the event any action is commenced to enforce or
interpret the terms or conditions of this Agreement,the prevailing party shall,in addition to
any costs or other relief, be entitled to recover its reasonable attorneys' fees, including fee
for use of in-house counsel by a Party,
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Executed this 16th day of October
2007.
City of Redlands
J Harrison, ayor Date: October 16 2007
Attest:
Lo e Poyze , ty le
rk
City of Redl s
Deve ing Aging Solutions with Heart, Inc.
Date
By: --
Za—
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EXHIBIT I (a) of 2
COUNTY OF SAN BERNARDINO DEPARTMENT OF COMMUNITY DEVELOPMENT AND HOUSING
P_ro'c—ct/Activit Title
� Case Number: 1 1 1-28127/2288
Redlands: Geriatric Care Services for Family Caregivers — DASH
_Name/Address of Contras toy ncy:
Developing Aging Solutions with Heart, Inc. Date ofItne:
306 West Calton Ave.
.--Original: 04/17/03
Redlands, CA 92374 X Amendment# 5 Beginning 07/01/07
BENEFICIARY QUALIFICATION STATEMENT
This fOrm has the purpose of providing information needed to qualify the use of federal Community Development Block
Grant (CD13G) funds for the project/activity described above. This statement must be completed and signed by the
person (or legal guardian of the person) requesting to receive benefits from the described project/activity. Only one
statement per person, per year is required.
Please answer each of the following questions.
1. This question helps you determine the size of your household. For this question a household is a group of related or
unrelated persons occupying the same house with at least one member being the head of the household. Renters,
roomers, or borders cannot be included as household members. How many persons are in your household?
2. This question asks if you are from a low- and moderate-income household. For this question a list of the 2007
t,OW-INCOME and LOW- AND MODERATE-INCOME categories* are presented below. Please add up the
combined gross annual income of all persons in your household from all sources of income. In the blank
provided, write yes or no, that your combined gross annual income is equal to or less than the LOW-
INCOME amount for the number of persons in your household:
In the blank provided, write,yes or no, if your combined gross annual income is equal to or less than the
LOW- AND MODERATE-INCOME amount for the number of persons in your household.
Number of Persons in Your Household
1 2 3 4
LOW-INCOME $20,700 $23,700 $26,650 $29,600
LOW- AND MODERATE- $33,150 $37,900 $42,600 $47,350
INCOME (COMBINED)
Number of Persons in Your Household
5 6 7 8
LOW-INCOME $31,950 $34,350 $36,700 $39,050
1.0W'- AND MODERATE- $51,150 $54,9.50 $58,700 $62,500
INCOME (COMBINED)
P.aoF I of
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EXHIBIT 1(a) of ?
COUNTY OF SAN BERNARDINO DEPARTMENT OF COMMUNITY DEVELOPMENT AND HOUSING
Project/Activity' Title:
Redlands: Geriatric Care Services for Family Caregivers— DASH Case Number: 1 1 1-28127/2288
Name/Address of Contractor Agency:
Developing Aging Solutions with Heart, Inc. Date of IS ue:
306 West Colton Ave. Original• 04/17/03
Redlands, CA 92374 X Amendment# 5 Beginning 07/01/07
3. Please indicate how you identity yourself by checking only one (1) of the following choices:
Non-
White Hispanic Hispanic
Black/African American ❑
Asian ❑ ❑
American Indian/Alaskan Native ❑ ❑
Native Hawaiian/Other Pacific Islander ❑ ❑
American Indian/Alaskan Native & White ❑ ❑
Asian & White ❑ ❑
Black/African American & White ❑ ❑
American Indian/Alaskan Native& Black/African American ❑ ❑
Balance/Other El El
❑ ❑
4. Please check whether you belong to a Female Headed Household:
❑Yes ❑No
5. Please describe the condition that would qualify you as being considered in ane Of the following presumed low-and
moderate-income categories:abused child, battered spouse,elderly person,homeless person,disabled adult,illiterate
person, or migrant farm worker:
(description)
ACKNOWLEDGMENT AND DISCLAIMER
I CER'T'IFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSEHOLD STATEMENTS
MADE ON THIS FORM ARE TRUE.
NAME..:
DATE:
A D D R 1 S S: ------
_CI'I"Y: 7IP:
----- ----
.'1CiNA'I'[1RF :
PFI0NE: _
The information you provide on this form is for Community Development Block Grant (CDBG) Program
purposes only and will be kept confidential. p b
*Taken from1007 Section 8 Low-Income and Very Low-Income Limits,
Paec 2 of 2
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EXHIBIT 1(bL of 2_
COUNTY OF SAN BERNARDINO DEPARTMENT OF COMMUNITY DEVELOPMENT AND HOUSING
Pro'ectlActivi Title: Case Number: 111-28127/2288
Redlands: Geriatric Care Services for Family Caregivers— DASH
N<. /Address of Contractor n7en_
- — eX Date of Issue:
Developing Aging Solutions with Heart, Inc, _
306 West Colton Ave. _ _Original: 04/17/03
Redlands, CA 923'4 X Amendment # 5 Beginning 07/01/07
DECLARACI6N DE LA CALIFICACION DEL BENEFICIARIO
Esta forma tiene el prop6sito de proporcionar la informaci6n necesaria para calificar el use de los fondos federales del
bloque del desarrollo de la cornrnidad(CDBG)para el proyecto/actividad descrito arriba. Esta declaraci6n se debe Ilenar
y firmar por la persona(o la tutela legal de la persona)que solieita para recibir beneficios del proyecto/actividad descrito.
Solamente Lina declaraci6n por persona, por ano se requiere.
Conteste por favor a cads una de las preguntas siguientes.
I. Esta pregunta le ayuda a determinar el tamafio de su casa. En esta pregunta un hogar es un grupo de personas
relacionadas o sin relaci6n que ocupan la misma casa por to menos con un miembro que es la cabeza de la casa.
Los inquilinos no se pueden incluir como miembros de la casa. ZCuantas personas viven en su casa?
2. Esta pregunta explica si usted es de un hogar de ingresos bajos y moderados. Para esta pregunta la lista de 2007
de categorias de BAJOS-INGRESOS y del PUNTO BAJO Y de INGRESOS-MODERADOS*se presenta abajo.
Sume por favor para arriba los ingresos brutos anuales combinados de todas las personas en su hogary de todas
las fuentes de los ingresos. En el espacio en Blanco,escriba A o no,si su ingreso anual grueso combinado es
igual o menos que la cantidad de INGRESO-BAJO para el numero de personas en su casa.
En el espacio en blanco,escriba,si o no,si sus ingresos brutos anuales combinados son igual o menos que la
cantidad de INGRESOS BAJOS Y MODERADOS para el numero de personas en su casa.
Numero de Personas en su Hogar
1 2 3 4
[11N7J0S $20,700 $23,700 $26,650 $29,600
INGRESOS-BAJOS Y $$33,150 $37,900 $42,600 $47,35
0MODERADOS (COMBNADOS)
Numero de Personas en su Hogar
5 6 7 8
INGRESOS-BAJOS $31,950 $34,350 $36,700 $39,050
INGRESOS-BAJOS Y $51,150 $54,950 $58,700 $62,500
MODIRADOS (COMBINADOS)
r P3*P 1 of?
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EXHIBIT__- 1(b) of 2
COUNTY OF SAN BERNARDINO DEPARTMENT OF COMMUNITY DEVELOPMENT AND HOUSING
Protect/Activi Title:
Redlands: Geriatric Care ServiCaseces for Family Caregivers– DASH Number: 111-28127/2288
Name/Address Cor—of jtracter Agency:
Developing Aging Solutions with Heart, Inc, Date of Issue:
306 West Colton Ave. ________Original: 04/17/03
Redlands, CA 92374 X_ Amendment 4 5 Beginning 07/01/07
3. Indique por favor c61170 se identifica Listed, rnarcando solamente una (I) de las srg
o ciones i J
P urentes:
No-
Blanco Hispano Hispano
Negro/Afro A mericano ❑ ❑
Asiatico ❑ El
Ai nericanolNativo de Alaska ❑ ❑
Nativo Hawaiano/Otra Isla del Pacifica ❑ ❑
Indio Americano/Nativo de Alaska& Blanco ❑ ❑
Asiatico & Blanco ❑ ❑
Negro/Afro Americano& Blanco ❑ ❑
Indio Americano/Nativo de Alaska &Negro/Afro Americano ❑ ❑
Balance/Otro ❑ ❑
4. Marque por favor si Listed pertenece a un hogar encabeza ❑ F1do femenino: ❑Sr
5. Describa por favor la condieion que le calificarfa too siendo consi ONO
imderado en Lina de las categorfas de presumidos
ngresos bajos y moderados siguientes: nifio abusado,esposo estropeado,persona mpayor, ersona sin hogar,adulto
incapacitado, persona analfabeta, o trabajador ►nigratori
(description) o de granja:
--- ---�-
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RECONOCIMIENTO Y NEGACION
CERTIFICO BAJO PENA DE PERJURIO QUE LAS DECLARACIONES HECHASI✓N ESTA FORMA,
'
ACERCA DE LOS INGRESOS Y DE LAS CUENTAS DE LA CASA SON VERDADER
AS.
NOMBRF;
-----
_FECHA:
DOM IC 1 L IO: ----_--
- CIUDAD:
----..._-----------------CODIGO:
FIRMA: --------__.--
-- _ T'EI-EFONO:
La informacicin que usted proporciona en esta forma es para los propositus del pro rams
del desar'roik> de la comunidad (CI)BG)solamente y sera mantenida confidential.
g de fundus del Moque
*Tonrado de 2007 Seccibn 8 Inaresos bajos.
Paye 2 of 2
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EXHIBIT 2 of 2
COUNTY OF SAN BERNARDINO DEPARTMENT OF COMMUNITY DEVELOPMENT AND HOUSING
Project/Activi Title: Case Number: 1 11-28127/2288
Redlands: Geriatric Care Services for Family Caregivers--DASH
Name/Address of Contractor APi�ncy: nate of Issue:
Developing Aging SOIL16}t1S with Heart, Inc, Original: 04/17/03
306 West Colton Ave. X Amendment # 5 Beginning 07/01/07
Redlands, CA 92374
PROGRAM PROGRESS AND DIRECT BENEFIT REPORT For FY 200�-2008
PART 1: PROGRAM PROGRESS REPORT
A. Units of Service Provided and Description
Under each type of service listed below,summarize what your program has accomplished during this month. Include location,number of
persons served,services/benefits provided,and a description of the clients served. Also report the number of"Units ofService••provided,as
defined in the Project/Activity Description(Exhibit I of the agreement).
Type of service: Units of Service:
1. Geriatric Care Management Goal.; 10 Actual.:
(Each adult dependent participating in one(I)geriatric
care session equals one(I)unit of service.)
B. Beneficiary Count(may inchtde individual persons(P)or households(H)previously counted during this grant/program year)
Total number of beneficiaries(clients/patrticipants)served(choose one category only):
k of'Persons OR # of Households
PART 11: DIRECT BENEFIT REPORT
Direct Beucia Statistics(Unduplicated first-time client counts since start of contract;taken from Beneficiary Qualification Statement forms)
Enter the number of first-time program beneficiaries directly assisted
Count only as: ❑ individual Persons or ❑Households(check one box)
Low-income(orrir,) _ Low-and Moderate-income(combined): All Beneficiaries:
Racial Identity Categories Non-
Non-
Hispanic Hispanic Hispanic Hispanic
While
(a) (b) (c) (d)13 ackJrtfnr• American American Indian/Alaskan Native& White_-__ --
ui ut - -----.—
Asian&White
_ - ...—__. Black/African American&White
American Indian/Alaskan Native
--. —._ -_. .._ _ Amer. Indian/Alaskan Native&Atrican Amer,
Grand focal n n/other f'tcific Islander —. ------
Native f lawttir.tn,t, Balance/Other
tial (dcn[it} Categories Sum of coltunns a.b,c and d should equal the"All Benef iciaries••total above'
f cntalc I leadcd I louscholds —
S it;ncd 1"'itle
---------....---------------------- ate_
I'rmtcd Name Telephone No/Ext
pAop I of I
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EXHIBIT"C°
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DEVELOPING AGING SYSTEMS WITH HEART, INC. (D.A.S.H., INC)
THE OTHER PLACE ADULT DAY SUPPORT CENTER
EMPLOYEESLIST OF
COMMUNITY DEVELOPMENTBLOCK GRANTPROGRAM YEAR 2007-2008
Vicky Dickinson-Executive Director
2. Sandra Munoz-Health Services Coordinator/Activity Director
3. Larry Townend-Marketing Director/Office Manager
4. Annaliese Hogan-Program Aide
5. Melissa Tinoco-Program Aide