CMS-07-021/023 - Los Angeles County Department of Children and ...

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NON-PROFIT ORGANIZATIONS NOT SUBJECT TO THIS CIRCULAR Advance Technology Institute (ATI), Charleston, South Carolina Aerospace Corporation, El Segundo, California American Institutes of Research (AIR), Washington D.C. Argonne National Laboratory, Chicago, Illinois Atomic Casualty Commission, Washington, D.C. Battelle Memorial Institute, Headquartered in Columbus, Ohio Brookhaven National Laboratory, Upton, New York ATTACHMENT C Circular No. A-122 Charles Stark Draper Laboratory, Incorporated, Cambridge, Massachusetts CNA Corporation (CNAC), Alexandria, Virginia Environmental Institute of Michigan, Ann Arbor, Michigan Georgia Institute of Technology/Georgia Tech Applied Research Corporation/ Georgia Tech Research Institute, Atlanta, Georgia Hanford Environmental Health Foundation, Richland, Washington IIT Research Institute, Chicago, Illinois Institute of Gas Technology, Chicago, Illinois Institute for Defense Analysis, Alexandria, Virginia LMI, McLean, Virginia Mitre Corporation, Bedford, Massachusetts Mitretek Systems, Inc., Falls Church, Virginia National Radiological Astronomy Observatory, Green Bank, West Virginia National Renewable Energy Laboratory, Golden, Colorado Oak Ridge Associated Universities, Oak Ridge, Tennessee Rand Corporation, Santa Monica, California Research Triangle Institute, Research Triangle Park, North Carolina Riverside Research Institute, New York, New York South Carolina Research Authority (SCRA), Charleston, South Carolina 54
Southern Research Institute, Birmingham, Alabama Southwest Research Institute, San Antonio, Texas SRI International, Menlo Park, California Syracuse Research Corporation, Syracuse, New York Universities Research Association, Incorporated (National Acceleration Lab), Argonne, Illinois Urban Institute, Washington D.C. Non-profit insurance companies, such as Blue Cross and Blue Shield Organizations Other non-profit organizations as negotiated with awarding agencies 55
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DEPARTMENT OF CHILDREN AND FAMILY S
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REQUEST FOR STATEMENT OF QUALIFICAT
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1.0 INTRODUCTION 1.1 Preamble For o
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COUNTY agencies and their partners
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1.3 DCFS Mission Statement DCFS wil
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2.0 GENERAL INFORMATION 2.0 Scope o
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2.4.1.2 Prospective Contractor must
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old for 30 days or less; (3) provid
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Contractor protest. In all cases, t
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2.19 Conflict of Interest No County
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submit evidence at that hearing. Af
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solicitation may result in the pros
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County’s contracting process by c
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2.33 Contractor’s Charitable Cont
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3.0 Instructions to Prospective Con
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The request for a Solicitation Requ
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3.7.1 Language The SOQ and all docu
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coverage should the prospective Con
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3.8.6 Please refer to Section 3.0 I
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4.0 SOQ REVIEW/SELECTION/QUALIFICAT
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The Department will execute Board o
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19 20 21 22 List of Required Forms
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CONTRACTOR’S ORGANIZATION QUESTIO
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CONTRACTOR’S ORGANIZATION QUESTIO
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VENDOR’S EEO CERTIFICATION REQUIR
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REQUIRED FORMS - FORM 5 FAMILIARITY
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PROSPECTIVE CONTRACTOR LIST OF TERM
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REQUIRED FORMS - FORM 9 COUNTY OF L
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REQUIRED FORMS - FORM 11 OFFER TO P
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CERTIFICATION OF FISCAL COMPLIANCE
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LIST OF COMMITMENTS Legal Name of A
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REQUIRED FORMS - FORM 17 CONTRACTOR
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CERTIFIED FOSTER PARENT CONFIDENTIA
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CONTRACTOR’S EMPLOYEE ACKNOWLEDGE
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Type of program: Foster Family Agen
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CONTRACTOR’S NAME: CONTRACT NO. N
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REQUEST FOR STATEMENT OF QUALIFICAT
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TRANSMITTAL FORM TO REQUEST A RFSQ
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APPENDIX E LISTING OF CONTRACTORS D
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SAMPLE CONTRACT COUNTY OF LOS ANGEL
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LIST OF EXHIBITS SAMPLE CONTRACT Ex
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SAMPLE CONTRACT Exhibit A-IX Requir
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as a single process. SAMPLE CONTRAC
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SAMPLE CONTRACT 2.27 “Foster Care
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SAMPLE CONTRACT written in accordan
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SAMPLE CONTRACT Such insurance shal
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SAMPLE CONTRACT 6.0 INSURANCE COVER
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SAMPLE CONTRACT partial, and supple
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SAMPLE CONTRACT 7.15 Provided that
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10.0 COUNTY’S RESPONSIBILITY SAMP
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SAMPLE CONTRACT 10.13 The CSWs shal
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SAMPLE CONTRACT and/or Certified Fo
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SAMPLE CONTRACT Investigation/Monit
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SAMPLE CONTRACT will also invite CO
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SAMPLE CONTRACT 18.4 The CONTRACTOR
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SAMPLE CONTRACT management review,
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SAMPLE CONTRACT 20.2 CONTRACTOR and
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SAMPLE CONTRACT 22.2 CONTRACTOR her
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SAMPLE CONTRACT notice by the CONTR
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SAMPLE CONTRACT COUNTY’s prior wr
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SAMPLE CONTRACT FOSTER FAMILY AGENC
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SAMPLE CONTRACT to the Contract, wh
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SAMPLE CONTRACT governing or impact
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8.0 GRIEVANCES SAMPLE CONTRACT term
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SAMPLE CONTRACT 11.1.2 For purposes
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SAMPLE CONTRACT CONTRACTOR will int
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SAMPLE CONTRACT conduct a hearing w
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SAMPLE CONTRACT CONTRACTOR warrants
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SAMPLE CONTRACT solely of CONTRACTO
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1015, attached hereto as Exhibit L.
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SAMPLE CONTRACT 30.1.3 CONTRACTOR m
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SAMPLE CONTRACT not limited to, the
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SAMPLE CONTRACT amounts COUNTY clai
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COUNTY OF LOS ANGELES DEPARMENTS OF
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PART A: INTRODUCTION 1.0 PREAMBLE E
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EXHIBIT A COUNTY agencies and thei
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EXHIBIT A (Health and Safety Code),
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PART B: TARGET DEMOGRAPHICS 1.0 TAR
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1.0 SAFETY EXHIBIT A PERFORMANCE OU
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1.1.7 Required Services by CONTRACT
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EXHIBIT A The CONTRACTOR shall Moni
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PROGRAM TARGET GROUP: Placed Childr
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EXHIBIT A the fullest extent possib
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EXHIBIT A Monitor for Compliance th
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3.0 WELL-BEING EXHIBIT A PERFORMANC
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EXHIBIT A participation in treatmen
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EXHIBIT A individuals to the extent
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EXHIBIT A 88068.2, 88068.3, and 880
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EXHIBIT A objectives appropriate to
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EXHIBIT A The CONTRACTOR shall prov
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3.7.4 Monetary Consequences EXHIBIT
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EXHIBIT A Days. After 14 Days, the
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EXHIBIT A The CONTRACTOR shall have
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EXHIBIT A for the Placed Child to r
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EXHIBIT A specified in the Needs an
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EXHIBIT A The CONTRACTOR shall Moni
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FOSTER YOUTH BILL OF RIGHTS EXHIBIT
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EXHIBIT A-I 19. Residents have the
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EXHIBIT A-I Reprise 25. Residents s
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INTENTIONALLY LEFT BLANK EXHIBIT A-
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EXHIBIT A-IVa STATE OF CALIFORNIA
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FOSTER CHILD’S NEEDS AND CASE PLA
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AGENCY - GROUP HOME AGREEMENT Child
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EXHIBIT A-VIII SPECIAL INCIDENT REP
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5. SERIOUS INJURY, ILLNESS OR ACCID
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EXHIBIT A-VIII 10. SIGNIFICANT INCI
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SCREENING REQUIREMENT PERIODICITY S
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Anticonvulsant medications, when pr
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Dr. faxes pages 1 & 2 of PMAF to th
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EXHIBIT A-X 2. Contact the physicia
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EXHIBIT A-X 1. Instruct the caregiv
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APPROVAL LEVELS Section Level Appro
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(CSW completes top section) Los Ang
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D. Please attach a list of the foll
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TO THE HEADS OF EXECUTIVE DEPARTMEN
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implementation of individual provis
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E. Negotiation and Approval of Indi
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. The restraints or requirements im
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objectives of the organization are
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distribution base. The result of th
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special cost studies (such as an en
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other activity. The bases must be e
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g. The results of each negotiation
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49. Training costs 50. Transportati
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e. Costs identified in subparagraph
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compensation for employees on feder
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(3) Excise taxes on accumulated fun
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with certainty as to time, intensit
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appeals, antitrust suits, or the pr
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(1) Donated or volunteer services m
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(1) Capital expenditures for genera
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(2) "Idle facilities" means complet
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enovations, alterations, equipment,
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. For non-profit organizations subj
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already required or maintained. Als
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see paragraphs 37., Professional se
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41. Recruiting costs. a. Subject to
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continued to own the property. This
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48. Termination costs applicable to
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(3) Fees charges by the educational
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e. Foreign travel. Direct charges f
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Southern Research Institute, Birmin
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A-C Handbook Page 1 AUDITOR-CONTROL
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A-C Handbook Page 3 2.2 Cash Receip
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A-C Handbook Page 5 If a Payroll Re
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A-C Handbook Page 7 Outside Meals -
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A-C Handbook Page 9 CONTRACTOR shal
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A-C Handbook Page 11 2.3 Petty Cash
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A-C Handbook Page 13 Salaried emplo
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A-C Handbook Page 15 Indirect Cost
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A-C Handbook Page 17 2.3 Acceptable
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A-C Handbook Page 19 D. UNALLOWABLE
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EXHIBIT C-II AUDITOR-CONTROLLER/DEP
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• California Code of Regulations,
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If CONTRACTOR and A-C/DCFS hold a p
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XIV. Final Report to the Board of S
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EXHIBIT D Cont. I understand that I
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EXHIBIT D-I Cont. I understand that
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24. Equipment Leases 25. Depreciati
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Report all costs related to telepho
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EXHIBIT E D. Total Un-Expended AFDC
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EXHIBIT F (D) If the State Departme
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EXHIBIT F (C) Individuals who are e
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EXHIBIT F subdivision (g). The Stat
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EXHIBIT F processing. (B) Upon requ
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EXHIBIT F self-addressed envelope f
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EXHIBIT F shall disclose that clien
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EXHIBIT F state, would have been pu
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statement, fingerprints and photogr
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Name, Address and Telephone Number
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EXHIBIT G If a CSW or SCSW has any
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EXHIBIT G 10) minute orders and cou
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0500-501.20 (Rev 12/02) EXHIBIT G 4
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EXHIBIT G See Procedural Guide 0200
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EXHIBIT G that the research will no
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EXHIBIT G detrimental to the safety
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EXHIBIT G Procedural Guide 0500-504
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EXHIBIT H of changes to the plan. (
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EXHIBIT I (e) The child's caretaker
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EXHIBIT I CSW in Concurrent Plannin
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Procedures A. WHEN: A CHILD IS DETA
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B. WHEN: A CHILD IS IN OUT-OF-HOME
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Dependency Investigator CSW Respons
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EXHIBIT I For offices who have impl
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EXHIBIT I FB1 Addendum, Family Back
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CHILD WELFARE SERVICES PROGRAM 31-4
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Department of the Treasury Internal
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DCFS FOSTER FAMILY AGENCY CONTRACT
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EXHIBIT N medication authorizations
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EXHIBIT N 5. The DCFS Division Chie
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EXHIBIT O 1. The lesser number is a
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EXHIBIT O COUNTY OF LOS ANGELES CON
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CONTRACTOR’S CERTIFICATION OF COM
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F I F I F I F I EXHIBIT R F O R Y O
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8. Does the child receive the sport
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EXHIBIT R 33. Is the child given th
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Every baby deserves a chance for a
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Es mejor que las mujeres busquen ay
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• Llámenos para recibir informac
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A. WHEN: A FAD INDICATES A POTENTIA
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EXHIBIT T O/P Collection EW 4. INVA
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EXHIBIT T NOTE: Overpayment recover
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Reconciliation EW 3. Receive the Ba
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Overpayment Recovery Unit ES WHO HO
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CHARITABLE CONTRIBUTIONS CERTIFICAT
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SERVICE DELIVERY SITES Foster Famil
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TABLE OF CONTENTS INTRODUCTION/SUMM
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PURPOSE/PHILOSOPHY STATEMENT These
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TEAMING PROCESS Family-Centered Tea
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COURT ORDERS Oftentimes, the judici
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First 24 Hours Child removed from p
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FAMILY VISITATION PLAN Prior to the
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• Whether or not the parent is a
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• Maintain objectivity, and remai
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Judicial Officers Judicial Officers
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Unless the FVP specifically states
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the visitation objectives. In addit
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Sexual Abuse Permanency Transportat
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SUBCOMMITTEE MEMBERS The Drafting S
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EXHIBIT Y of information, including
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EXHIBIT Y accounting of Disclosures
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DISCHARGE SUMMARY FOR DCFS: FOSTER
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INTENTIONALLY LEFT BLANK EXHIBIT BB
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10.0 COMPLIANCE WITH CIVIL RIGHTS L
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Exhibit T Overpayments Exhibit U Gr
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WHEREAS, CONTRACTOR warrants that i
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2.0 DEFINITIONS Exhibit T Overpayme
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2.16 “Do Not Refer Status” or
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2.31 “Pool Rate” - means the ra
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notify COUNTY of such change. COUNT
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equivalent providing the CONTRACTOR
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a bed open for a Placed Child, CONT
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7.14 CONTRACTOR may appeal the fina
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9.2 If CONTRACTOR’s staff qualify
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10.11 COUNTY Workers shall provide
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13.0 FEES 12.1 CONTRACTOR shall mai
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Exhibit N, DCFS/Probation Group Hom
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16.0 FINANCIAL REPORTING 16.1 CONTR
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closing summary of CONTRACTOR's rec
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including but not limited to, the U
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19.6 Nothing herein precludes COUNT
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entirety; or (2) reduced in accorda
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accounted for and that unspent fund
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omissions, resulting from its perfo
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County of Los Angeles - Department
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4.0 BUDGET REDUCTIONS In the event
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6.2.3 The assurance that all employ
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CONTRACTOR hereby assures that it w
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12.3 CONTRACTOR shall comply with a
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modify, deny or adopt the proposed
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minimum waiting time for clearance.
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County of Los Angeles Department of
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eject children for placement consis
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30.0 DISCLOSURE OF INFORMATION 30.1
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33.7 CONTRACTOR shall obtain the fo
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35.0 TERMINATION FOR CONVENIENCE 35
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CONTRACTOR receives, has access to,
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COUNTY OF LOS ANGELES DEPARTMENT OF
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COUNTY OF LOS ANGELES DEPARTMENTS O
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• Safety and Survival; • Emotio
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Service Access Service providers wi
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The CONTRACTOR shall request approv
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Plan/Quarterly Reports in cooperati
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6.4 The CONTRACTOR’S Treatment Te
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PART C: SERVICE TASKS TO ACHIEVE PE
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1.0: SAFETY PERFORMANCE OUTCOME GOA
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Placed Children; and (2) abide by a
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(b) The CONTRACTOR shall use seclus
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PERFORMANCE OUTCOME SUMMARY 2.0 PER
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2.0: REUNIFICATION/PERMANENCY PERFO
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2.2 Visitation Plan: modification i
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(a) For infants from birth to 6 mon
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PERFORMANCE OUTCOME SUMMARY 3.0 WEL
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3.0 WELL-BEING PERFORMANCE OUTCOME
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(b) Two children’s rights recentl
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their responsibilities to pupils in
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3.2.8 Educational Assessments by th
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information such as immunizations g
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The CONTRACTOR shall have an emerge
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assistance with homework; (5) daily
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3.11.5 Clothing Fit, Appropriatenes
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placed with a minor parent if the C
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PART D - PERFORMANCE REQUIREMENT SU
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FOSTER YOUTH BILL OF RIGHTS EXHIBIT
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19. Residents have the right to con
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not prohibited by the resident's ne
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TABLE OF CONTENTS ii EXHIBIT A-II I
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OUT-OF-HOME CARE EXHIBIT A-II What
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EXHIBIT A-II What is a juvenile cou
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EXHIBIT A-II care still exist, if y
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EXHIBIT A-II Can I have an attorney
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TYPES OF PLACEMENTS EXHIBIT A-II Wh
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GUARDIANSHIP EXHIBIT A-II What is t
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INDEPENDENT LIVING EXHIBIT A-II Wha
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CONFIDENTIALITY AND YOUR RECORDS EX
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WHEN RECORDS ARE DESTROYED Juvenile
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MONEY EXHIBIT A-II Do I have a righ
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RELIGION Can my foster parents or N
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EXHIBIT A-II What if I can't get a
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EMANCIPATION EXHIBIT A-II What does
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EXHIBIT A-II What are the disadvant
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KNOW YOUR RIGHTS EXHIBIT A-II With
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DEFINITION INDEX The number refers
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ENDNOTES 1. The following abbreviat
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35. WIC 317(c) 36. WIC 317(d),(e) E
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84. VC 12814.6 85. VC 17701 86. FC
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PROBATION CASE PLAN FORM (PROB 1385
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EXHIBIT A-V 1. Describe Circumstanc
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EXHIBIT A-V Probation Officer’s R
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EXHIBIT A-V _______________________
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SIGNATURES: EXHIBIT A-V MINOR: THIS
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FOSTER CHILD’S NEEDS AND CASE PLA
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cc: to group home, child’s(ren’
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SPECIAL INCIDENT REPORTING GUIDE FO
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4 EXHIBIT A-VIII 5. SERIOUS INJURY,
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6 EXHIBIT A-VIII 10. SIGNIFICANT IN
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SCREENING REQUIREMENT PERIODICITY S
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Anticonvulsant medications, when pr
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Dr. faxes pages 1 & 2 of PMAF to th
Page 677 and 678:
EXHIBIT A-X 2. Contact the physicia
Page 679 and 680:
EXHIBIT A-X 1. Instruct the caregiv
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APPROVAL LEVELS Section Level Appro
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Group Home Organization: FORMAT FOR
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Exhibit A-XIIIa COUNTY OF LOS ANGEL
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Exhibit A-XIIIb COUNTY OF LOS ANGEL
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GROUP HOME PROGRAM STATEMENT EXHIBI
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TO THE HEADS OF EXECUTIVE DEPARTMEN
Page 693 and 694: implementation of individual provis
Page 695 and 696: E. Negotiation and Approval of Indi
Page 697 and 698: . The restraints or requirements im
Page 699 and 700: objectives of the organization are
Page 701 and 702: distribution base. The result of th
Page 703 and 704: special cost studies (such as an en
Page 705 and 706: other activity. The bases must be e
Page 707 and 708: g. The results of each negotiation
Page 709 and 710: 49. Training costs 50. Transportati
Page 711 and 712: e. Costs identified in subparagraph
Page 713 and 714: compensation for employees on feder
Page 715 and 716: (3) Excise taxes on accumulated fun
Page 717 and 718: with certainty as to time, intensit
Page 719 and 720: appeals, antitrust suits, or the pr
Page 721 and 722: (1) Donated or volunteer services m
Page 723 and 724: (1) Capital expenditures for genera
Page 725 and 726: (2) "Idle facilities" means complet
Page 727 and 728: enovations, alterations, equipment,
Page 729 and 730: . For non-profit organizations subj
Page 731 and 732: already required or maintained. Als
Page 733 and 734: see paragraphs 37., Professional se
Page 735 and 736: 41. Recruiting costs. a. Subject to
Page 737 and 738: continued to own the property. This
Page 739 and 740: 48. Termination costs applicable to
Page 741 and 742: (3) Fees charges by the educational
Page 743: e. Foreign travel. Direct charges f
Page 747 and 748: A-C Handbook Page 1 AUDITOR-CONTROL
Page 749 and 750: A-C Handbook Page 3 2.2 Cash Receip
Page 751 and 752: A-C Handbook Page 5 If a Payroll Re
Page 753 and 754: A-C Handbook Page 7 Outside Meals -
Page 755 and 756: A-C Handbook Page 9 CONTRACTOR shal
Page 757 and 758: A-C Handbook Page 11 2.3 Petty Cash
Page 759 and 760: A-C Handbook Page 13 Salaried emplo
Page 761 and 762: A-C Handbook Page 15 Indirect Cost
Page 763 and 764: A-C Handbook Page 17 2.3 Acceptable
Page 765 and 766: A-C Handbook Page 19 D. UNALLOWABLE
Page 767 and 768: EXHIBIT C-II AUDITOR-CONTROLLER/DEP
Page 769 and 770: EXHIBIT C-II circumstances, the ent
Page 771 and 772: EXHIBIT C-II At the pre-exit meetin
Page 773 and 774: EXHIBIT C-II will be provided with
Page 775 and 776: CONTRACTOR EMPLOYEE ACKNOWLEDGEMENT
Page 777 and 778: Group Home Semi-Annual Expenditure
Page 779 and 780: EXHIBIT F (D) If the State Departme
Page 781 and 782: EXHIBIT F (C) Individuals who are e
Page 783 and 784: EXHIBIT F subdivision (g). The Stat
Page 785 and 786: EXHIBIT F processing. (B) Upon requ
Page 787 and 788: EXHIBIT F self-addressed envelope f
Page 789 and 790: EXHIBIT F shall disclose that clien
Page 791 and 792: EXHIBIT F state, would have been pu
Page 793 and 794: statement, fingerprints and photogr
Page 795 and 796:
Name, Address and Telephone Number
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EXHIBIT G If a CSW or SCSW has any
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EXHIBIT G 10) minute orders and cou
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0500-501.20 (Rev 12/02) EXHIBIT G 4
Page 803 and 804:
EXHIBIT G See Procedural Guide 0200
Page 805 and 806:
EXHIBIT G that the research will no
Page 807 and 808:
EXHIBIT G detrimental to the safety
Page 809 and 810:
EXHIBIT G Procedural Guide 0500-504
Page 811 and 812:
EXHIBIT H of changes to the plan. (
Page 813 and 814:
EXHIBIT I (e) The child's caretaker
Page 815 and 816:
EXHIBIT I CSW in Concurrent Plannin
Page 817 and 818:
Procedures A. WHEN: A CHILD IS DETA
Page 819 and 820:
B. WHEN: A CHILD IS IN OUT-OF-HOME
Page 821 and 822:
Dependency Investigator CSW Respons
Page 823 and 824:
EXHIBIT I For offices who have impl
Page 825 and 826:
EXHIBIT I FB1 Addendum, Family Back
Page 827 and 828:
Page 829 and 830:
Page 831 and 832:
Department of the Treasury Internal
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DCFS GROUP HOME CONTRACT INVESTIGAT
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EXHIBIT N c) insufficient or poor f
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EXHIBIT N 5. The Division Chief or
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EXHIBIT O 1. The lesser number is a
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EXHIBIT O COUNTY OF LOS ANGELES CON
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CONTRACTOR’S CERTIFICATION OF COM
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F I F I F I F I EXHIBIT R F O R Y O
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8. Does the child receive the sport
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EXHIBIT R 33. Is the child given th
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It is best that women seek help to
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Safely Surrendered Baby Hotline (87
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Cada recién nacido merece una opor
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DATE OF ISSUE: APPLICABLE TO: LEGAL
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TA/EW b) INVALID OVERPAYMENT EXHIBI
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WHO HOW following conditions exist:
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EXHIBIT T Deposit EW 3. Reconcile t
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O/P Collection EW b) Enter the stat
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c) FAD Exception Distribution d) Ov
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s mobility and independent function
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1180.3. (a) This section shall appl
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(A) Obesity. (B) Pregnancy. (C) Agi
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PROBATION QUARTERLY REPORT FORMAT E
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Name of School: Address of School:
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Date Type Los Angeles County Probat
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Are there any SIRS to report? Yes N
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TARGET POPULATIONS WITH CORRESPONDI
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EXHIBIT Y THE TARGET POPULATION FOR
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CONTRACT NO. COUNTY PROGRAM DIRECTO
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EXHIBIT CC LOS ANGELES COUNTY SUPER
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INTRODUCTION/SUMMARY In June, 2005,
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elatives) should reflect the unique
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Additionally, every effort should b
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DEPENDENCY CASE STAGES Stage 1: Pre
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The Pre-Disposition Family Visitati
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PRELIMINARY CONSIDERATIONS/FACTORS
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• Provide a drug/weapon/violence
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• Give parents suggestions for wh
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Visitation Objectives (reason for e
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issues specific to teen parents. Th
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Circumstance Team Response in FVP
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BIBLIOGRAPHY Casey Family Programs.
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Reporting Runaways A Guide for Care
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CONTRACTOR’S OBLIGATIONS UNDER HI
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213-974-2166 EXHIBIT EE The initial
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5.0 MISCELLANEOUS EXHIBIT EE agents
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CONTRACTOR’S NAME: CONTRACT NO. C
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BACKGROUND AND RESOURCES: CALIFORNI
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It is best that women seek help to
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Safely Surrendered Baby Hotline (87
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Cada recién nacido merece una opor
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2.203.010 Findings. Chapter 2.203,
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APPENDIX M following: 1. Has ten or
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