HomeMy WebLinkAboutTime for a Change Foundation-2012-20 i INDEPENDENT CONTRACTOR AGREEMENT
2 FOR FY 2011/2012
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4 THIS AGREEMENT is made and entered into as of this 14th day August 2012, by and between the
s City of Grand Terrace, a municipal corporation(hereinafter"City")and Time for a Change Foundation
6 (hereinafter"Foundation"),a California non-profit Corporation.
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e RECITALS
9 WHEREAS, Foundation has expressed an interest in providing a program for low-and-moderate income
10 persons or households for the City of Grand Terrace. The program provides housing and case-
11 management to homeless children and their parents to assist them into self-sufficiency, including
12 education and counseling.
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14 WHEREAS,Foundation has represented to City that it has the requisite experience, special knowledge
is and expertise similar to others in the industry to oversee.
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17 WHEREAS,on August ,2012,the City agreed to accept, but has not yet received, Community
18 Development Block Grant funding from the County of San Bernardino("County") in the amount of
19 $6,000.00 for the purpose of contracting with Foundation for the time period of July 1, 2012 to June 30,
20 2012 and for the provision of an"Housing and Case-Management Program", in accordance with Exhibit
21 "A", Scope of Services, incorporated herein.
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23 WHEREAS, Foundation will complete performance of the services described in Exhibit"A",titled
24 Scope of Services,which is incorporated herein by this Agreement, for the time period of July 1,2012 to
25 June 30,2013.
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2 WHEREAS, in order for the City to receive reimbursement in the amount of$6,000.00 of CDBG funds,
3 as described above, from the County of San Bernardino,the County requires City submit an Agreement
4 between the City and Foundation to the County.
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6 WHEREAS,the parties enter into this agreement to allow City to comply with the County's CDBG
7 funding requirements.
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9 NOW THEREFORE, in consideration of the mutual promises contained herein,the City of Grand
to Terrace and Foundation hereby agree as follows:
11 AGREEMENT
12 Section 1: Services.
13 A. City and Foundation mutually agree that payment of Foundation for performance of the
19 services more specifically described in Exhibit`A",titled Scope of Services,
1s incorporated herein by this reference,("Services") shall be in the maximum amount of
16 $6,000.00 in Community Development Block Grant("CDBG") funds reimbursed to the
19 City from the County related to the services as described by Exhibit"A", Scope of
18 Services, incorporated herein.
19 B. City hereby agrees to reimburse Foundation, in a maximum amount of$6,000.00,for
20 staffing costs,mileage, insurance,rent,audit expense,consultant services,and other
21 related office supplies necessary for Foundation to administer the"Housing and Case-
22 Management Program", in accordance with Exhibit"A", Scope of Services, incorporated
23 herein.
24 C. Prior to City's reimbursement to Foundation, Foundation shall deliver receipts for all
25 eligible expenditures to the City.
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1 D. Foundation shall further submit to the City a completed County of San Bernardino
2 Department of Economic and Community Development Monthly Program Progress
3 Report/Direct Benefit Reportand Beneficiary Qualification Statements reflecting program
4 activity for the term wherein Services were performed.
5 Section 2. Independent Contractor. It is the express intention and understanding of the
6 parties hereto that Foundation acted as an independent contractor and not an employee or agent of
7 City.Nothing in this Agreement shall be interpreted or construed as creating or establishing a
8 relationship of employer or employee between Foundation and City. Both parties acknowledge
9 that Foundation is not an employee for State tax, Federal tax,or any other purpose.
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11 Section 3. Term. The term of this Agreement shall be one(I)year starting July 1,2012
12 and ending June 30, 2013.
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14 Section 4. Termination. City shall have the right to terminate this Agreement,with or
15 without cause,upon twenty(20)days prior written notice to Foundation. City shall have no
16 liability for any claims or damages resulting to Foundation as a result of any exercise by City of
17 its right to terminate this Agreement.
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19 Section 5. Compliance with Laws and Regulations. Foundation shall comply with all
20 applicable federal, state and local laws,regulations and ordinances. By executing this Agreement,
21 Foundation hereby certifies that it will adhere to and comply with the following as they may be
22 applicable to a subrecipient of funds granted pursuant to the Housing and Community
23 Development Act of 1974,as amended(the"Act"):
24 A. The Housing and Community Development Act of 1974,as amended,and the regulations
25 issued thereto;
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t B. Section 3 of the Housing and Urban Development Act of 1968,as amended;
2 C. Executive Order 11246, as amended by Executive Orders 11375 and 12086, and
3 implementing regulations at 41 CFR Chapter 60;
4 D. Executive Order 11063,as amended by Executive Order 12259,and implementing
5 regulations at 24 CFR Part 107;
6 E. Section 504 of the Rehabilitation Act of 1973 (PL 93-112),as amended, and
7 implementing regulations;
s F. The Age Discrimination Act of 1975 (PL 94-135), as amended, and implementing
9 regulations;
to G. The relocation requirements of Title II and the acquisition requirements of Title III of the
11 Uniform Relocation Assistance and Real Property Acquisitions Policies Act of 1970,and
12 the implementing regulations at 24 CFR Part 42;
13 H. The labor standard requirements as set forth in 24 CFR Part 570, Subpart K and 1-IUD
14 regulations issued to implement such requirements;
15 I. Executive Order 11988 relating to the evaluation of flood hazards and Executive Order
16 11288 relating to the prevention,control and abatement of water pollution;
17 J. The flood insurance purchase requirements of Section 102(a)of the Flood Disaster
18 Protection Act of 1973 (PL 93-234);
19 K. The regulations,policies,guidelines and requirements of 24 CFR Part 85 "Common
20 Rule,"OMB Circular Nos.A-87, A-21,A-110,A-I 22 and A-133 as they relate to the
21 acceptance and use of federal funds under the federally-assigned program;
22 L. Title VI of the Civil Rights Act of 1964(PL 88-352)and implementing regulations issued
23 at 24 CFR Part I;
24 M. Title VIII of the Civil Rights Act of 1968(PL-90-284)as amended;and
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1 N. The lead based paint requirements of 24 CFR Part 35 issued pursuant to the Lead-based
2 Paint Poisoning Prevention Act(42 USC 4801,et seq.);
3 O. Uniform Administration Requirements pursuant to 24 CFR 570.502.
4 P. The Foundation shall carry out its activity pursuant to this Agreement in compliance with
5 all federal laws and regulations described in Subpart K of Title 24 of the Code of Federal
6 Regulations,except that:
7 1. Foundation does not assume the City's or COUNTY'S environmental
8 responsibilities described at §570.604; and
9 2. Foundation does not assume the City's or COUNTY'S responsibility for
10 initiating the review process under the provisions of 24 CFR Pmt 52.
11 Q. All Uniform Administrative Requirements pursuant to 24 CFR 570.502.
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13 Section 6. Federal Requirements. Foundation shall comply with the provisions of the
14 Act and any amendments thereto and the federal regulations and guidelines now or hereafter
15 enacted pursuant to the Act. More particularly, Foundation is to comply with those regulations
16 found in 24 CFR 570, Part 84 and Part 85. Foundation is to comply with OMB Circular Nos. A-
17 110,A-87. A-122, and A-133 as applicable,as they relate to the acceptance and use of federal
18 funds under this Agreement.
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20 Section 7. Community Development Block Grant Manual. Foundation certifies that the
21 staff assigned to the CDBG-funded activities have received,reviewed,and will follow the County
22 of San Bemardino's Community Development Block Grant Policy Manual,as applicable, which
23 is incorporated herein by this reference and made a part hereof
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1 Section S. Program Income. Foundation,who is a subrecipient as defined in Section
2 570.500(c),shall not retain any program income as defined in Section 570.500 of Title 24 of the
3 Federal Code of Regulations.
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5 Section 9. Insurance. Without limiting or diminishing Foundation's obligations to defend,
6 indemnify,or hold the City harmless, Foundation shall procure and maintain or cause to be
7 maintained,at its sole cost and expense, the following insurance coverage's during the term of the
8 Agreement.
9 A. Workers' Compensation:
10 If Foundation has employees as defined by the State of California, Foundation shall
11 maintain statutory Workers' Compensation Insurance(Coverage A)as prescribed by the laws of
12 the State of California. Policy shall include Employers' Liability(Coverage B) including
13 Occupational Disease with limits not less than $1,000,000 per person per accident. The policy
14 shall be endorsed to waive subrogation in favor of the CITY OF GRAND TERRACE.
15 B. Commercial General Liability:
16 Commercial General Liability insurance coverage, including but not limited to,premises
17 liability,contractual liability, products and completed operations liability, personal and
18 advertising injury,and cross liability coverage,covering claims which may arise from or out of
19 Foundation's performance of its obligation hereunder. Policy shall name the CITY OF GRAND
20 TERRACE, its Agencies, Districts, Special Districts,and Department,their respective directors,
21 officers,employees, elected or appointed officials,agents or representatives as Additional
22 Insureds. Policy's limit of liability shall not be less than $1,000,000 per occurrence combined
23 single limit. If such insurance contains a general aggregate limit, it shall apply separately to this
24 agreement or be no less than two(2)times the occurrence limit.
25 C. Vehicle Liability:
1 If vehicles or mobile equipment are used in the performance of the obligations under this
2 Agreement,then Foundation shall maintain liability insurance for all owned, non-owned or hired
3 vehicles so use in any amount not less than $1,000,000 per occurrence combined single limit. If
4 such insurance contains a general aggregate limit, it shall apply separately to this agreement or be
5 no less than two(2)times the occurrence limit. Policy shall name the CITY OF GRAND
6 TERRACE, its Agencies, Districts, Special Districts, and Departments,their respective directors,
officers,employees,elected or appointed officials,agents or representatives as Additional
8 Insureds.
9 D. General Insurance Provisions—All Lines:
10 1. Any insurance carrier providing insurance coverage hereunder shall be
11 admitted to the State of California and have a A M BEST rating of not
12 less than A: VIII (A:S)unless such requirements are waived, in writing,
13 by the City Attorney. If the City Attorney waives a requirement for a
14 particular insurer such waiver is only valid for that specific insurer and
15 only for one policy term.
16 2. Foundation shall cause Foundation's insurance carrier(s)to furnish the
19 City with either 1)a properly executed original Certificate(s)of
18 Insurance and certified original copies of Endorsements effecting
19 coverage as required herein,and 2) if requested to do so orally or in
20 writing by the City, provide original Certified copies of policies
21 including all Endorsements and all attachments thereto, showing such
22 insurance is in full force and effect. Further, said Certificate(s)and
23 policies of insurance shall contain the covenant of the insurance
24 carriers(s)that thirty(30)days written notice shall be given to the City
25 prior to any material modification, cancellation,expiration or reduction
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1 in coverage of such insurance. In the event of a material modification,
2 cancellation,expiration,or reduction in coverage,this Agreement shall
3 terminate forthwith, unless the City receives, prior to such effective date,
4 another properly executed original Certificate of Insurance and original
s copies of endorsements or certified original policies, including all
6 endorsements and attachments thereto evidencing coverage's set forth
7 herein and the insurance required herein is in full force and effect.
8 Foundation shall not commence operations until the City has been
9 furnished original Certificate(s) of Insurance and certified original
10 copies of endorsements and if requested, certified original policies of
11 insurance including all endorsements and any and all other attachments
12 as required in this Section. An individual authorized by the insurance
13 carrier to do so on its behalf shall sign the original endorsements for each
14 policy and the Certificate of Insurance.
15 3. If, during the term of this Agreement or any extension thereof,there is a
16 material change in the scope of services;or,there is a material change in
17 the equipment to be used in the performance of the scope of work which
18 will add additional exposures(such as the use of)aircraft,watercraft,
19 cranes,etc.);or,the term of this Agreement, including any extensions
20 thereof, exceeds five(5)years the City reserves the right to adjust the
21 types of insurance required under this Agreement and the monetary
22 limits of liability for the insurance coverage's currently required herein,
23 if; in the City Attorney's reasonable judgment,the amount or type of
24 insurance carried by the sponsor has become inadequate.
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1 4. Foundation shall pass down the insurance obligations contained herein to
2 all tiers of subcontractors working under this Agreement.
3 5. The insurance requirements contained in this Agreement may be met
4 with a program(s)of self-insurance acceptable to the City.
5 6. Foundation agrees to notify City of any claim by a third party of any
6 incident or event that may give rise to claim arising from the
7 performance of this Agreement.
8 Section 10. HUD Indemnity. Foundation shall defend, indemnify,and hold harmless the
9 County of San Bernardino and City against any liability, claims, losses,demands, and actions
10 incurred by the County of San Bernardino and City as a result of the determination by HUD or its
u successor that activities undertaken by Foundation under the program(s)fail to comply with any
12 laws, regulations or policies applicable thereto or that any funds billed by and disbursed to
13 Foundation under this Agreement were improperly expended.This indemnity shall survive and
14 extend beyond the term or termination of this Agreement.
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16 Section 11. Indemnity. Foundation shall defend, indemnify, and hold harmless the County
19 of San Bernardino and the City, its elected officials, officers, employees and agents from and
18 against any and all actions,damages, losses,causes of action and liability imposed or claimed
19 relating to the injury or death of any person or damage to any property, including attorney's fees,
20 costs,and other legal expenses,arising directly or indirectly from any act or omission of
21 Foundation in performing services hereunder. This indemnity shall survive and extend beyond th•
22 term or termination of this Agreement.
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24 Section 12. Prohibition Against Conflicts of Interest.
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1 A. Foundation and its assigns,employees,agents,consultants, officers and elected and
2 appointed officials shall become familiar with and shall comply with the CDBG
3 regulations prohibiting conflicts of interest contained in 24 CFR 570.611, by this
4 reference incorporated herein.
5 B. Foundation understands and agrees that no waiver or exception can be granted to the
6 prohibition against conflict of interest except upon written approval HUD pursuant to 24
7 CFR 570.611(d). Any request by Foundation for any exception shall first be reviewed by
e City to determine whether such request is appropriate for submission to HUD.
9 C. Prior to any funding under this Agreement, Foundation shall provide City with a list of all
10 employees, agents, consultants, officers and elected and appointed officials who are in a
11 position to participate in a decision-making process,exercise any functions or
12 responsibilities, or gain inside information with respect to the CDBG activities funded
13 under this Agreement. Foundation shall also promptly disclose to City any potential
14 conflict, including even the appearance of conflict,that may arise with respect to the
15 CDBG activities funded under this agreement.
16 D. Any violation of this section shall be deemed a material breach of this Agreement, and
17 the Agreement shall be ground for immediate termination by the City.
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19 Section 13. Religious Activities. Under federal regulations, CDBG assistance may not be
20 used for inherently religious activities or provided to primarily religious entities for any activities
21 including secular activities. Foundation shall adhere to the restrictions set forth in 24 CFR
22 570.200(j), by this reference is incorporated herein.
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24 Section 14. Lobbying. Foundation certifies to the best of it knowledge and belief,that:
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1 A. No federally appropriated funds have been paid or will be paid, by or on behalf of the
2 undersigned,to any person for influencing or attempting to influence an officer or
3 employee of any agency, a member of Congress,an officer or employee of Congress,or
4 an employee of a member of Congress in connection with the awarding of any federal
5 contract,the making of any federal grant,the making of any federal loan,the entering
6 into of any cooperative agreement,and the extension,continuation, renewal, amendment,
7 or modification of any federal contract, grant, loan,or cooperative agreement.
8 B. If any funds other than federally appropriated funds have been paid or will be paid to any
9 person for influencing or attempting to influence an officer to employee of any agency,a
10 member of Congress,an officer or employee of Congress,or an employee of a member
11 of Congress in connection with this federal contract,grant, loan,or cooperative
12 agreement,the undersigned shall complete and submit Standard Form-LLL,"Disclosure
13 Form to Report Lobbying," in accordance with it instructions.
14 C. The undersigned shall require that the language of this certification be included in the
15 award document for all subawards at all tier(including subcontracts, subgrants,and
16 contracts under grants, loans,and cooperative agreements)and that all subrecipients shall
19 certify and disclose accordingly. This certification is a material representation of fact
18 upon which reliance was placed when this transaction was made or entered into.
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20 Section 15. Entire Agreement/Modification. This Agreement represents the entire
21 Agreement of the parties hereto as to the matters contained herein.Any modification of this
22 Agreement will be effective only if it is in writing and signed by the parties hereto.
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1 Section 16. Assinnment. This Agreement shall not be assigned without the prior written
2 consent of City. Any assignment,or attempted assignment,without such prior consent, shall be
3 null and void and, at the option of City, result in the immediate termination of this Agreement.
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s Section 17. Attorney's Fees and Governing Law. In the event any action is commenced
6 to enforce or interpret the terms or conditions of the Agreement the prevailing party shall, in
7 addition to any costs or other relief, be entitled to recover its reasonable attorney's fees. This
8 Agreement and any dispute arising hereunder shall be governed by and interpreted in accordance
9 with the laws of the State of California. This Agreement shall be construed as a whole according
10 to its fair language and common meaning to achieve the objectives and purposed of the parties
11 hereto, and the rule of construction to the effect that ambiguities are to be resolved against the
12 drafting party shall not be employed in interpreting this Agreement,all parties having been
13 represented by counsel in the negotiation and preparation hereof.
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1s Section 18. Jurisdiction and Venue. Any action at law or in equity arising under this
16 Agreement or brought by a party hereto for the purpose of enforcing, construing or determining
17 the validity of any provision of this Agreement shall be filed in a court of competent jurisdiction
18 in the County of San Bernardino, State of California,and the parties hereto waive all provisions
19 of law providing for the filing, removal or change of venue to any other court or jurisdiction.
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21 Section 19. Program Reportinn. Foundation agrees to prepare and submit financial,
22 program progress,and other reports as required by HUD or the County of San Bernardino and/or
23 City accounts as are considered necessary by HUD or the County of San Bernardino and/or City
24 to assure proper accounting for all Agreement funds.All Foundation records, with the exception
25 of confidential client information, shall be made available to representatives of the County of San
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1 Bernardino and/or City and the appropriate federal agencies. Foundation is required to submit
2 data necessary to complete the Annual Grantee Performance Report in accordance with HUD
3 regulations in the format and at the time designated by the Community Development Director or
4 his/her designee. By the 30th of each month, Foundation shall submit a completed"Monthly
5 Program Progress Report"Foundation shall also provide the Monthly Progress Program Report/
6 Direct Benefit Report included as Exhibit"B",as necessary for completion of the Annual Grantee
7 Performance Report.
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9 Section 20. Applicability of Agreement. In consideration of the intent of the parties to
to memorialize the parties understanding of the terms of their agreement,all uses of the present
11 tense shall be interpreted to apply to the term of the Agreement. With the exceptions of Sections
12 9, 10, 11,and any other section of this Agreement expressly stating otherwise,which obligations
13 shall not terminate,the terms and conditions of this Agreement shall only apply during the term
14 of this Agreement.
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16 Section 21. Waiver. Failure by a party to insist upon the strict performance of any of the
17 provisions of this Agreement by the other party,or the failure by a party to exercise its rights
18 upon the default of the other party, shall not constitute a waiver of such parry's right to insist and
19 demand strict compliance by the other party with the terms of this Agreement thereafter.
20 Section 22. Severability. Each section and provision of this Agreement is severable from
21 each other provision,and if any provision or part thereof is declared invalid,the remaining
22 provisions shall nevertheless remain in full force and effect.
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1 Section 23. Counterparts. This Agreement may be signed by the different parties hereto
2 in counterparts,each of which shall be an original but all of which together shall constitute one
3 and the same agreement.
4 CITY OF GRAND TERRACE ,, ,
5 ra7.17a)0 �./ -/e
6 Manager Date
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APPROVED A T :
SIPC9 �l
Richard L. Adams, City Attorney Date
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ATTEST:
12 %J Y A-L-41 A
13 Tracey Martinez, City
Clerk
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TIME FOR CHANGE FOUNDATION
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16 ' 17I24 I��
17 Kim Carter, Executive Director Date ff
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1 EXHIBIT A
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Exhibit "A"
Time for Change Foundation
Scope of Work
Mission: To provide essential resources, through our programs and services, to women and children who
desire to change the course of their lives by making the transition from homelessness and recidivism to
self-sufficiency.
Vision: Time For Change Foundation is the model of excellence in the Inland Empire for empowering
disenfranchised women who are making the transition from homelessness and recidivism.
Core Values: Time for Change Foundation is built on the belief that any woman who desires to change
the course of her life deserves an opportunity to do so. Our programs and services are built on the
following core values.
• Everyone deserves a home that is nurturing and supportive
• Spirituality is essential to growth
• Respect and altruistic concern for others
• Have an open mind to invest in the potential of the human spirit
• Empower women to break the cycles of recidivism and homelessness.
Our project encompasses two components in alignment with your charism. To address
the critical and unmet needs of homeless women and their children we provide housing
and supportive services listed below as well as our affordable housing project:
Housing (Emergency Shelter 10 -60 days) - (Transitional Housing 2 -- 18 months)
and (Phoenix Square —affordable housing 7 unit apartment building)
We currently have 3 facilities located in San Bernardino. Mt. View shelter for single
women provides necessary structure and support for women to reestablish themselves
in a positive lifestyle. Our second facility titled "Sweet Dreams" was established in 2005
for homeless women with their children. We provide a safe and nurturing environment
conducive to proper parenting, education, and positive social development for the
children.
Our Target area is San Bernardino County
Our Services include:
1. Case management -- Clients' individual case plans are developed in order to identify
and achieve their goals. We assist with: legal issues, referrals to physical and mental
health assessment, substance abuse, build activities of daily living skills, socialization
and recreational activities and provide support.
2. Parenting- Clients are taught how to raise a child to be respectful, self reliant, happy,
healthy, confident, cooperative, and responsible.
3. Family Resilience - Maximize self-sufficiency through making the parent a model for
education.
4. Mommy & Me - Mothers and their children are taught how to bond in order to create
an environment that will instill socializing skills, and confidence in a child.
5. Family re-unification --families are destroyed by separation, incarceration of mothers
hence children are put in foster care system, mothers have been absent in their
children's lives and seeking reunification. We work to ensure that children are the
priority in assessing their parent's custody.
6. Transportation --We provide our clients and their children with transportation as
needed to and from classes, doctor appointments, community events, social activities,
schools, court, and grocery stores.
7. Anger management- Clients are taught to raise self-esteem while reducing
symptoms of depression, anxiety and hostility.
8. Financial education and money management- Clients and community members are
taught how to manage their resources, create a budget and develop savings.
9. Employment readiness- clients' skills are identified, referred to resume writing
centers, assisted with internet access, transported to employment readiness workshops
and referred to career colleges to advance their education
10. Leadership Development—Clients are taught to recognize their self-worth, identify
their inner strength to advocate for themselves, take an active role in creating a healthy
community for themselves and their families and participate in civic engagement.
Affordable Housing Project: Our third facility's name is "The Phoenix Square" and is
our first affordable housing project whereby clients who matriculate through our
emergency and transitional housing program will have access to affordable housing
despite their criminal and financial background. Currently under construction, this
apartment building will be the model of low income housing for San Bernardino and it is
our goal to demonstrate that poor people do desire to live in a clean and healthy
environment, engage in community pride and take high priority in their children's well-
being. Residents of the project will have access to our supportive services and
community networks. Because the women and children will be transitioning from our
existing shelter they will need basic furnishings in order to start their new lives and
remain in compliance with Child Protective Laws.
Locations of the facilities are not listed to protect our clients.
Our mailing address is:
P 0 BOX 25040
San Bernardino CA 92406
COUNTY OF; BERNARDINO ECONOMIC DEVELOPA T AGENCY
Project'Activity Title: Case Number: 300-34127/3194
Grand Terrace: Senior Services, Grant Subsistence for Emergency Needs-
And Transportation Services for Seniors
Name/Address of Contract Agency: Date of Issue.
Family Service Association X Original: Beginning. 07/01/11
21250 Box Springs Rd., Ste. 212, Moreno Valley, CA 92557 _Amendment No:
MONTHLY PROGRAM PROGRESS AND DIRECT BENEFIT REPORT For the Month of ,20
PART I: MONTHLY PROGRAM PROGRESS REPORT
A. Units of Service Provided and Description
In the space provided 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 of Service' provided, as defined in the Project/Activity Description (Exhibit 1 of the
agreement). Attach additional pages if needed.
Type of Service: Anticipated Units of Service
1. Basic subsistence and transportation services. Goat/mo.:>4 Actual/mo.:
(Each service provided to a service citizen will count
as one(1)unit service)
2. Goal/mo.: Actual/mo.
3. GoaVmo Actual/mo.:
B. Monthly Beneficiary Count (may Include individual persons or households previously counted during this
grsntprogram year)
Total number of beneficiaries(ClienWparticipants)served this month(choose one category only)'
Number of Persons OR Number of Households
PART II: DIRECT BENEFIT REPORT
Direct Benefit 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 this month
Count only as: ❑Individual Persona Qr ❑Households(check one box)
Extremely Low-Income(only):_ Low-Income only). Low-egg Moderate-Income(combined):
All Beneficiaries.
Racial Identity Categories
Non- Non-
Hispanic Hispanic Hispanic Hispanic
(a) (b) (d (d)
White American Indian/Alaskan Native&White
Black/African American Asian&White —
Asian _ Bleck/African American&White _
Amencan Indian/Alaskan Native Amer.Indian/Alaskan Native&African Amer. _
Native Hawaiian/Other Pacific Islander _ Balance/Other _
Grand Moral of Racial Identity Categores Sum of columns a.b.c.and d should equal the'All Beneficiaries'total above. _
Female Headed Households.
Signed Title Date
Printed Name Telephone No/Ext.
Exhibit 2 Page 1 of 1