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

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EXHIBIT Y THE TARGET POPULATION FOR NON-PROFIT GROUP HOMES VENDORED BY A REGIONAL CENTER ARE CHILDREN WHO: require a structured program and closer supervision than is usually provided in a relative or foster family home setting; or are Developmentally Disabled and: (1) have severe deficits in self-help skills and/or severe impairment in physical co-ordination and mobility; and/or (2) are severely disruptive or have self-injurious behavior; require extensive social work services and the program consultation services of a qualified mental retardation specialist; require frequent behavioral intervention; and require very intense supervision.
CHARITABLE CONTRIBUTIONS CERTIFICATION ________________________________________________________________________ Company Name ________________________________________________________________________ Address ________________________________________________________________________ Internal Revenue Service Employer Identification Number ________________________________________________________________________ California Registry of Charitable Trusts “CT” number (if applicable) EXHIBIT Z The Nonprofit Integrity Act (SB 1262, Chapter 919) added requirements to California’s Supervision of Trustees and Fundraisers for Charitable Purposes Act, which regulates those receiving and raising charitable contributions. Check the Certification below that is applicable to your company. Vendor or Contractor has examined its activities and determined that it does not now receive or raise charitable contributions regulated under California’s Supervision of Trustees and Fundraisers for Charitable Purposes Act. If Vendor engages in activities subjecting it to those laws during the term of a County contract, it will timely comply with them and provide County a copy of its initial registration with the California State Attorney General’s Registry of Charitable Trusts when filed. OR Vendor or Contractor is registered with the California Registry of Charitable Trusts under the CT number listed above and is in compliance with its registration and reporting requirements under California law. Attached is a copy of its most recent filing with the Registry of Charitable Trusts as required by Title 11 California Code of Regulations, sections 300-301 and Government Code sections 12585-12586. ___________________________________________ ________________________ Signature Date ________________________________________________________________________ Name and Title of Signer (please print)
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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
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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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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
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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
Page 699 and 700:
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
Page 745 and 746:
Southern Research Institute, Birmin
Page 747 and 748:
A-C Handbook Page 1 AUDITOR-CONTROL
Page 749 and 750:
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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EXHIBIT C-II circumstances, the ent
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EXHIBIT C-II At the pre-exit meetin
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EXHIBIT C-II will be provided with
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CONTRACTOR EMPLOYEE ACKNOWLEDGEMENT
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Group Home Semi-Annual Expenditure
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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
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
Page 833 and 834:
DCFS GROUP HOME CONTRACT INVESTIGAT
Page 835 and 836:
EXHIBIT N c) insufficient or poor f
Page 837 and 838: EXHIBIT N 5. The Division Chief or
Page 839 and 840: EXHIBIT O 1. The lesser number is a
Page 841 and 842: EXHIBIT O COUNTY OF LOS ANGELES CON
Page 843 and 844: CONTRACTOR’S CERTIFICATION OF COM
Page 845 and 846: F I F I F I F I EXHIBIT R F O R Y O
Page 847 and 848: 8. Does the child receive the sport
Page 849 and 850: EXHIBIT R 33. Is the child given th
Page 851 and 852: It is best that women seek help to
Page 853 and 854: Safely Surrendered Baby Hotline (87
Page 855 and 856: Cada recién nacido merece una opor
Page 857 and 858: DATE OF ISSUE: APPLICABLE TO: LEGAL
Page 859 and 860: TA/EW b) INVALID OVERPAYMENT EXHIBI
Page 861 and 862: WHO HOW following conditions exist:
Page 863 and 864: EXHIBIT T Deposit EW 3. Reconcile t
Page 865 and 866: O/P Collection EW b) Enter the stat
Page 867: c) FAD Exception Distribution d) Ov
Page 872 and 873: s mobility and independent function
Page 874 and 875: 1180.3. (a) This section shall appl
Page 876 and 877: (A) Obesity. (B) Pregnancy. (C) Agi
Page 878 and 879: PROBATION QUARTERLY REPORT FORMAT E
Page 880 and 881: Name of School: Address of School:
Page 882 and 883: Date Type Los Angeles County Probat
Page 884 and 885: Are there any SIRS to report? Yes N
Page 886 and 887: TARGET POPULATIONS WITH CORRESPONDI
Page 890 and 891: CONTRACT NO. COUNTY PROGRAM DIRECTO
Page 892 and 893: EXHIBIT CC LOS ANGELES COUNTY SUPER
Page 894 and 895: INTRODUCTION/SUMMARY In June, 2005,
Page 896 and 897: elatives) should reflect the unique
Page 898 and 899: Additionally, every effort should b
Page 900 and 901: DEPENDENCY CASE STAGES Stage 1: Pre
Page 902 and 903: The Pre-Disposition Family Visitati
Page 904 and 905: PRELIMINARY CONSIDERATIONS/FACTORS
Page 906 and 907: • Provide a drug/weapon/violence
Page 908 and 909: • Give parents suggestions for wh
Page 910 and 911: Visitation Objectives (reason for e
Page 912 and 913: issues specific to teen parents. Th
Page 914 and 915: Circumstance Team Response in FVP
Page 916 and 917: BIBLIOGRAPHY Casey Family Programs.
Page 918 and 919: Reporting Runaways A Guide for Care
Page 920 and 921: CONTRACTOR’S OBLIGATIONS UNDER HI
Page 922 and 923: 213-974-2166 EXHIBIT EE The initial
Page 924 and 925: 5.0 MISCELLANEOUS EXHIBIT EE agents
Page 926 and 927: CONTRACTOR’S NAME: CONTRACT NO. C
Page 928 and 929: BACKGROUND AND RESOURCES: CALIFORNI
Page 930 and 931: It is best that women seek help to
Page 932 and 933: Safely Surrendered Baby Hotline (87
Page 934 and 935: Cada recién nacido merece una opor
Page 936 and 937: 2.203.010 Findings. Chapter 2.203,
Page 938:
APPENDIX M following: 1. Has ten or
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