Backup Documents 04/28/2020 Item #16D 4 (Shifting Sands Adult Day Center, LLC)ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 1 6 D 4
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney
Office at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney
Office no later than Monday preceding the Board meeting.
**NEW** ROUTING SLIP
Complete routing lines # 1 through #2 as appropriate for additional signatures, dates, and/or information needed. If the document is already complete with
the exception of the Chairman's signature. draw a line through routine lines 41 through #2_ comnlete the checklist and forward to the C'nunty Attnrnev Off np.
Route to Addressees (List in routing order)
Office
Initials
Date
1. Risk
Risk Management
I G
1
2. County Attorney Office
County Attorney Office
4. BCC Office
Board of County
Commissioners
�cJ v�
4. Minutes and Records
Clerk of Court's Office
5 P90
5. Procurement Services
Procurement Services
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event
one of the addressees above, ma i need to contact staff for additional or missing information.
Name of Primary Staff
Ana Reynoso
Contact Information
239- 252-8950
Contact / Department
Agenda Date Item was
APRIL 28, 2020
Agenda Item Number
16.D.4.
Approved by the BCC
Type of Document
CONTRACT
Number of Original
2
Attached
Documents Attached
PO number or account
N/A
19-7596 (2 of 2)
Shifting Sands
number if document is
Shifting Sands
Adult Day Center,
to be recorded
_
Adult Day Center,
LLC
LLC
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark "N/A" in the Not Applicable column, whichever is
Yes
N/A (Not
aimromiate.
Initial
Applicable)
1.
Does the document require the chairman's original signature STAMP OK
AR
2.
Does the document need to be sent to another agency for additional signatures? If yes,
N/A
provide the Contact Information(Name; Agency; Address; Phone on an attached sheet.
3.
Original document has been signed/initialed for legal sufficiency. (All documents to be
AR
signed by the Chairman, with the exception of most letters, must be reviewed and signed
by the Office of the County Attorney.
4.
All handwritten strike -through and revisions have been initialed by the County Attorney's
N/A
Office and all other parties except the BCC Chairman and the Clerk to the Board
5.
The Chairman's signature line date has been entered as the date of BCC approval of the
AR
document or the final negotiated contract date whichever is applicable.
6.
"Sign here" tabs are placed on the appropriate pages indicating where the Chairman's
AR
signature and initials are required.
7.
In most cases (some contracts are an exception), the original document and this routing slip
N/A
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware of your deadlines!
8.
The document was approved by the BCC on 04/28/2020 and all changes made during
N/A is not
the meeting have been incorporated in the attached document. The County
an option for
Attorney' Office has reviewed the changes, if applicable.
I
Ois line.
9.
Initials of attorney verifying that the attached document is the versi
/A is not
BCC, all changes directed by the BCC have been made, and the dove
S
option for
Chairman's signature.
is line.
01
Risk Management
160 4
MEMORANDUM
Date: May 21, 2020
To: Ana Reynoso,
Procurement Services
From: Martha Vergara, Sr. Deputy Clerk
Minutes & Records Department
Re: Contract #19-7596 "General Service Agreement
(Non -Solicitation)"
Contractor: Shifting Sands Adult Day Center, LLC
Attached for your records is an original of the referenced document above,
(Item #16D4) adopted by the Board of County Commissioners on Tuesday,
April 28, 2020.
The Board's Minutes & Records Department has kept an original as part of
the Board's Official Records.
If you have any questions, please feel free to contact me at 252-7240.
Thank you.
Attachment
160 4
GENERAL SERVICE AGREEMENT (NON -SOLICITATION)
# 19-7596
for
Services for Seniors Program -Additional Services -Respite Facility & Adult Day Care
THIS AGREEMENT, made and entered into on this day of20,2:1 by and
between Shifting Sands Adult Day Center LLC ,
authorized to do business in the State of Florida, whose business address
is 28410 Bonita Crossinq Blvd, Suite 7, Bonita Springs, FL 34135 (the
"Contractor") and Collier County, a political subdivision of the State of Florida, (the "County"):
WITNESSETH:
AGREEMENT TERM. The Agreement shall be for a three (3 ) year period,
commencing ❑■ upon the date of Board approval OF E an and
terminating on threq_L) year(s) from that date or until all outstanding Purchase Order(s)
issued prior to the expiration of the Agreement period have been completed or
terminated.
The County may, at its discretion and with the consent of the Contractor, renew the
Agreement under all of the terms and conditions contained in this Agreement for
two (2 ) additional one (1 ) year(s) periods. The County shall give the
Contractor written notice of the County's intention to renew the Agreement term prior to
the end of the Agreement term then in effect.
The County Manager, or his designee, may, at his discretion, extend the Agreement
under all of the terms and conditions contained in this Agreement for up to one hundred
and eighty (180) days. The County Manager, or his designee, shall give the Contractor
written notice of the County's intention to extend the Agreement term prior to the end of
the Agreement term then in effect.
2. COMMENCEMENT OF SERVICES. The Contractor shall commence the work upon
issuance of a 0 Purchase Order ❑ j9ti6e te PFeeeed.
3. STATEMENT OF WORK. The Contractor shall provide services/products in accordance
with the terms and conditions of this Agreement, 0 Exhibit A — Scope of Services,
attached to this Agreement FE-1 Exhibit B — Fee Schedule, attached to this Agreement and
made an integral part of this Agreement.
Services/products acquired through this Agreement have been authorized through the
approval of a ❑ Single S06IFee WaffiyeF, ❑ , ❑ Exemption fFOFn the
0 Other: Collier County Procurement Ordinance No. 2017-08,
Section 12, Subsection 1: Reserved Riqhts
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General Service Agreement Non -Solicitation #2017-004 (Ver.2)
3.1 This Agreement contains the entire understanding between the parties and any
modifications to this Agreement shall be mutually agreed upon in writing by the Parties,
in compliance with the County's Procurement Ordinance, as amended, and Procurement
Procedures in effect at the time such services are authorized.
3.2 The execution of this Agreement shall not be a commitment to the Contractor to
order any minimum or maximum amount. The County shall order items/services as
required but makes no guarantee as to the quantity, number, type or distribution of
items/services that will be ordered or required by this Agreement.
4. THE AGREEMENT SUM.
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FO-1 The County shall pay the Contractor for the performance of this Agreement based on
Exhibit B- Fee Schedule, attached hereto and the price methodology as defined in
Section 4.1. Payment will be made upon receipt of a proper invoice and upon approval
by the County's Contract Administrative Agent/Project Manager, and in compliance with
Chapter 218, Fla. Stats., otherwise known as the "Local Government Prompt Payment
Act".
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-gy iR SeGtieR 4.1. Payment will be made 1-1—;—+
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4.1 Price Methodology (as selected below):
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❑■ Time and Materials: The County agrees to pay the contractor for the amount of labor
time spent by the contractor's employees and subcontractors to perform the work (number
of hours times hourly rate), and for materials and equipment used in the project (cost of
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General Service Agreement Non -Solicitation #2017-004 (Ver2)
160
EI
materials plus the contractor's markup). This methodology is generally used in projects in
which it is not possible to accurately estimate the size of the project, or when it is expected
that the project requirements would most likely change. As a general business practice,
these contracts include back-up documentation of costs; invoices would include number
of hours worked and billing rate by position (and not company (or subcontractor)
timekeeping or payroll records), material or equipment invoices, and other reimbursable
documentation for the project.
4.2 Any County agency may obtain services under this Agreement, provided
sufficient funds are included in their budget(s).
4.3 Payments will be made for services furnished, delivered, and accepted, upon
receipt and approval of invoices submitted on the date of services or within six (6) months
after completion of the Agreement. Any untimely submission of invoices beyond the
specified deadline period is subject to non-payment under the legal doctrine of "laches"
as untimely submitted. Time shall be deemed of the essence with respect to the timely
submission of invoices under this Agreement.
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General Service Agreement Non -Solicitation 42017-004 (Ver.2)
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5. SALES TAX. Contractor shall pay all sales, consumer, use and other similar taxes
associated with the Work or portions thereof, which are applicable during the performance
of the Work. Collier County, Florida as a political subdivision of the State of Florida, is
exempt from the payment of Florida sales tax to its vendors under Chapter 212, Florida
Statutes, Certificate of Exemption # 85-8015966531 C.
6. NOTICES. All notices from the County to the Contractor shall be deemed duly served if
mailed or emailed to the Contractor at the following:
Company Name: Shifting Sands Adult Day Center, LLC
Address: 28410 Bontia Brossing Blvd, Suite 7
Bonita Springs, Florida 34135
Authorized Agent:
Attention Name & Title:
Telephone:
E-Mail(s):
Tamatha Wilkinson. Administrator
(239) 405-7009
Tammy@shiftingsandsseniorservices.com
All Notices from the Contractor to the County shall be deemed duly served if mailed or
emailed to the County to:
Board of County Commissioners for Collier County, Florida
Division Director: Kristi Sonntag
Division Name: Community and Human Services Division
Address:
3339 Tamiami Trail East
Naples. Florida 34112
Administrative Agent/PM: Louise Pelletier
Telephone: (239) 252-2696
E-Mail(s): Louise.Pelletier@colliercountyfl.gov
The Contractor and the County may change the above mailing address at any time upon
giving the other party written notification. All notices under this Agreement must be in
writing.
7. NO PARTNERSHIP. Nothing herein contained shall create or be construed as creating a
partnership between the County and the Contractor or to constitute the Contractor as an
agent of the County.
8. PERMITS: LICENSES: TAXES. In compliance with Section 218.80, F.S., all permits
necessary for the prosecution of the Work shall be obtained by the Contractor. The County
will not be obligated to pay for any permits obtained by Subcontractors.
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General Service Agreement Non -Solicitation #2017-004 (Ver.2)
160 4
Payment for all such permits issued by the County shall be processed internally by the
County. All non -County permits necessary for the prosecution of the Work shall be
procured and paid for by the Contractor. The Contractor shall also be solely responsible
for payment of any and all taxes levied on the Contractor In addition. the Contractor shall
comply with all rules, regulations and laws of Collier County, the State of Florida, or the
U. S. Government now in force or hereafter adopted. The Contractor agrees to comply
with all laws governing the responsibility of an employer with respect to persons employed
by the Contractor.
9 NO IMPROPER USE. The Contractor will not use, nor suffer or permit any person to use
in any manner whatsoever. County facilities for any improper. immoral or offensive
purpose, or for any purpose in violation of any federal, state, county or municipal
ordinance. rule. order or regulation. or of any governmental rule or regulation now in effect
or hereafter enacted or adopted. In the event of such violation by the Contractor or if the
County or its authorized representative shall deem any conduct on the part of the
Contractor to be objectionable or improper, the County shall have the right to suspend the
Agreement of the Contractor. Should the Contractor fail to correct any such violation,
conduct. or practice to the satisfaction of the County within twenty-four (24) hours after
receiving notice of such violation, conduct. or practice, such suspension to continue until
the violation is cured. The Contractor further agrees not to commence operation during
the suspension period until the violation has been corrected to the satisfaction of the
County.
10. TERMINATION. Should the Contractor be found to have failed to perform his services in
a manner satisfactory to the County as per this Agreement, the County may terminate
said Agreement for cause: further the County may terminate this Agreement for
convenience with a thirty (30) day written notice. The County shall be the sole judge of
non-performance.
In the event that the County terminates this Agreement, Contractor's recovery against the
County shall be limited to that portion of the Agreement Amount earned through the date
of termination. The Contractor shall not be entitled to any other or further recovery against
the County. including. but not limited to, any damages or any anticipated profit on portions
of the services not performed.
11 NO DISCRIMINATION. The Contractor agrees that there shall be no discrimination as to
race. sex. color. creed or national origin.
12. INSURANCE. The Contractor shall provide insurance as follows:
A. * Commercial General Liability: Coverage shall have minimum limits of
$ 1.000,000 Per Occurrence. $ 2.000,000 aggregate for Bodily Injury Liability
and Property Damage Liability. This shall include Premises and Operations: Independent
Contractors; Products and Completed Operations and Contractual Liability.
R B..C;nnirc AYIt� I ia��li+„• Cov-ragc shall have minimum limit of
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Gen:ral Scnice Agreement Non -Solicitation ;2017-004(Ver.)
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160 4
Propei-iy vuniuy� Liability. AAT/�h 11 .rihu!I �n�!uw�. lJw.�i.�, ��—i�v!�.ci. Hi -- -n K11 l.i ,...n
Vehicles and Employee Non Ov.mership
C. [M-1 Workers' Compensation: Insurance covering all employees meeting Statutory
Limits in compliance with the applicable state and federal laws.
The coverage must include Employers' Liability with a minimum limit of
$ 1.000.000 for each accident.
D. In Professional Liability/Abuse Liability: Shall be maintained by the Contractor
to ensure its legal liability for claims arising out of the performance of professional
services under this Agreement. Contractor waives its right of recovery against County
as to any claims under this insurance. Such insurance shall have limits of not less
than $ 1,000,000 each claim and aggregate.
E. FE] Coverage shall have minimum limits of W per claim.
F. ❑E Coverage sha!! have minimum !imits of $— --per
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vu.
Special Requirements: Collier County Board of County Commissioners, OR, Board of
County Commissioners in Collier County, OR. Collier County Government shall be listed
as the Certificate Holder and included as an "Additional Insured" on the Insurance
Certificate for Commercial General Liability where required. This insurance shall be
primary and non-contributory with respect to any other insurance maintained by, or
available for the benefit of, the Additional Insured and the Contractor's policy shall be
endorsed accordingly.
Current. valid insurance policies meeting the requirement herein identified shall be
maintained by Contractor during the duration of this Agreement. The Contractor shall
provide County with certificates of insurance meeting the required insurance provisions.
Renewal certificates shall be sent to the County thirty (30) days prior to any expiration
date. Coverage afforded under the policies will not be canceled or allowed to expire until
the greater of: thirty (30) days prior written notice. or in accordance with policy provisions.
Contractor shall also notify County, in a like manner, within twenty-four (24) hours after
receipt, of any notices of expiration, cancellation. non -renewal or material change in
coverage or limits received by Contractor from its insurer, and nothing contained herein
shall relieve Contractor of this requirement to provide notice.
Contractor shall ensure that all subcontractors comply with the same insurance
requirements that the Contractor is required to meet.
13. INDEMNIFICATION. To the maximum extent permitted by Florida law. the Contractor
shall defend, indemnify and hold harmless Collier County, its officers and employees from
any and all liabilities. damages. losses and costs, including, but not limited to, reasonable
attorneys' fees and paralegals' fees. whether resulting from any claimed breach of this
Agreement by Contractor, any statutory or regulatory violations, or from personal injury.
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Gencra1 Service Agreen,.n, loon -Solicitation P2017-(X)4 (Ver2)
160 4
property damage, direct or consequential damages, or economic loss, to the extent
caused by the negligence, recklessness, or intentionally wrongful conduct of the
Contractor or anyone employed or utilized by the Contractor in the performance of this
Agreement. This indemnification obligation shall not be construed to negate, abridge or
reduce any other rights or remedies which otherwise may be available to an indemnified
party or person described in this paragraph.
This section does not pertain to any incident arising from the sole negligence of Collier
County.
13.1 The duty to defend under this Article 13 is independent and separate from the duty to
indemnify, and the duty to defend exists regardless of any ultimate liability of the Contractor,
County and any indemnified party. The duty to defend arises immediately upon
presentation of a claim by any party and written notice of such claim being provided to
Contractor. Contractor's obligation to indemnify and defend under this Article 13 will survive
the expiration or earlier termination of this Agreement until it is determined by final judgment
that an action against the County or an indemnified party for the matter indemnified
hereunder is fully and finally barred by the applicable statute of limitations.
14. AGREEMENT ADMINISTRATION. This Agreement shall be administered on behalf of
the County by the Community and Human Services Division
15. CONFLICT OF INTEREST. Contractor represents that it presently has no interest and
shall acquire no interest, either direct or indirect, which would conflict in any manner with
the performance of services required hereunder. Contractor further represents that no
persons having any such interest shall be employed to perform those services.
16. COMPONENT PARTS OF THIS AGREEMENT. This Agreement consists of the following
component parts, all of which are as fully a part of the Agreement as if herein set out
verbatim: ❑ , ❑■ Insurance Certificate(s), * Exhibit A Scope of
Services, ❑■ Exhibit B Fee Schedule, ❑ subsequent quetes, and ❑■ Other
Exhibit/Attachment: Federal Contract Provisions, Grant Assurances and Certifications .
17. APPLICABILITY. Sections corresponding to any checked box (W expressly apply to the
terms of this Agreement.
18. SUBJECT TO APPROPRIATION. It is further understood and agreed by and between
the parties herein that this Agreement is subject to appropriation by the Board of County
Commissioners.
19. PROHIBITION OF GIFTS TO COUNTY EMPLOYEES. No organization or individual
shall offer or give, either directly or indirectly, any favor, gift, loan, fee, service or other
item of value to any County employee, as set forth in Chapter 112, Part III, Florida
Statutes, Collier County Ethics Ordinance No. 2004-05, as amended, and County
Administrative Procedure 5311. Violation of this provision may result in one or more of
the following consequences: a. Prohibition by the individual, firm, and/or any employee of
the firm from contact with County staff for a specified period of time; b. Prohibition by the
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General Service Agreement Non -Solicitation #2017-004 (Ver.2)
individual and/or firm from doing business with the County for a specified period of time,
including but not limited to: submitting bids, RFP, and/or quotes; and, c. immediate
termination of any Agreement held by the individual and/or firm for cause.
20. COMPLIANCE WITH LAWS. By executing and entering into this Agreement, the
Contractor is formally acknowledging without exception or stipulation that it agrees to
comply, at its own expense, with all federal, state and local laws, codes, statutes,
ordinances, rules, regulations and requirements applicable to this Agreement, including
but not limited to those dealing with the Immigration Reform and Control Act of 1986 as
located at 8 U.S.C. 1324, et seq. and regulations relating thereto, as either may be
amended; taxation, workers' compensation, equal employment and safety including, but
not limited to, the Trench Safety Act, Chapter 553, Florida Statutes, and the Florida Public
Records Law Chapter 119, including specifically those contractual requirements at F.S. §
119.0701(2)(a)-(b) as stated as follows:
IF THE CONTRACTOR HAS QUESTIONS REGARDING THE
APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE
CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO
THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC RECORDS
AT:
Communication and Customer Relations Division
3299 Tamiami Trail East, Suite 102
Naples, FL 34112-5746
Telephone: (239) 252-8383
The Contractor must specifically comply with the Florida Public Records Law to:
1. Keep and maintain public records required by the public agency to perform the
service.
2. Upon request from the public agency's custodian of public records, provide the
public agency with a copy of the requested records or allow the records to be
inspected or copied within a reasonable time at a cost that does not exceed the
cost provided in this chapter or as otherwise provided by law.
3. Ensure that public records that are exempt or confidential and exempt from public
records disclosure requirements are not disclosed except as authorized by law
for the duration of the contract term and following completion of the contract if the
Contractor does not transfer the records to the public agency.
4. Upon completion of the contract, transfer, at no cost, to the public agency all
public records in possession of the Contractor or keep and maintain public
records required by the public agency to perform the service. If the Contractor
transfers all public records to the public agency upon completion of the contract,
the Contractor shall destroy any duplicate public records that are exempt or
confidential and exempt from public records disclosure requirements. If the
Contractor keeps and maintains public records upon completion of the contract,
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the Contractor shall meet all applicable requirements for retaining public records.
All records stored electronically must be provided to the public agency, upon
request from the public agency's custodian of public records, in a format that is
compatible with the information technology systems of the public agency.
If Contractor observes that the Contract Documents are at variance therewith, it shall
promptly notify the County in writing. Failure by the Contractor to comply with the laws
referenced herein shall constitute a breach of this Agreement and the County shall have
the discretion to unilaterally terminate this Agreement immediately.
21. OFFER EXTENDED TO OTHER GOVERNMENTAL ENTITIES. Collier County
encourages and agrees to the successful Contractor extending the pricing, terms and
conditions of this solicitation or resultant Agreement to other governmental entities at the
discretion of the successful Contractor.
22. PAYMENTS WITHHELD. The County may decline to approve any Application for
Payment, or portions thereof, because of defective or incomplete work, subsequently
discovered evidence or subsequent inspections. The County may nullify the whole or any
part of any approval for payment previously issued and the County may withhold any
payments otherwise due to Contractor under this Agreement or any other Agreement
between the County and Contractor, to such extent as may be necessary in the County's
opinion to protect it from loss because of: (a) defective Work not remedied; (b) third party
claims failed or reasonable evidence indicating probable fling of such claims; (c) failure of
Contractor to make payment properly to subcontractors or for labor, materials or
equipment; (d) reasonable doubt that the Work can be completed for the unpaid balance
of the Contract Amount; (e) reasonable indication that the Work will not be completed
within the Contract Time; (f) unsatisfactory prosecution of the Work by the Contractor; or
(g) any other material breach of the Contract Documents.
If any conditions described above are not remedied or removed, the County may, after
three (3) days written notice, rectify the same at Contractor's expense. The County also
may offset against any sums due Contractor the amount of any liquidated or unliquidated
obligations of Contractor to the County, whether relating to or arising out of this Agreement
or any other Agreement between Contractor and the County.
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deems careless, incompetent, insubordinate or otherwise objectionable and whose
continued employment on Collier County projects is not in the best interest of the County.
wli
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160 4
28. SUBMITTALS AND SUBSTITUTIONS. Any substitution of products/materials form
specifications shall be approved in writing by the County in advance.
29. CHANGES IN THE WORK. The County shall have the right at any time during the
progress of the Work to increase or decrease the Work. Promptly after being notified of a
change, Contractor shall submit an estimate of any cost or time increases or savings it
foresees as a result of the change. Except in an emergency endangering life or property,
or as expressly set forth herein, no addition or changes to the Work shall be made except
upon modification of the Purchase Order by the County, and the County shall not be liable
to the Contractor for any increased compensation without such modification. No officer,
employee or agent of the County is authorized to direct any extra or changed work orally.
Any modifications to this Agreement shall be in compliance with the County Procurement
Ordinance and Procedures in effect at the time such modifications are authorized.
30. AGREEMENT TERMS. If any portion of this Agreement is held to be void, invalid, or
otherwise unenforceable, in whole or in part, the remaining portion of this Agreement shall
remain in effect.
31. ADDITIONAL ITEMS/SERVICES. Additional items and/or services may be added to this
Agreement in compliance with the Procurement Ordinance, as amended, and
Procurement Procedures.
32. DISPUTE RESOLUTION. Prior to the initiation of any action or proceeding permitted by
this Agreement to resolve disputes between the parties, the parties shall make a good
faith effort to resolve any such disputes by negotiation. The negotiation shall be attended
by representatives of Contractor with full decision -making authority and by County's staff
person who would make the presentation of any settlement reached during negotiations
to County for approval. Failing resolution, and prior to the commencement of depositions
in any litigation between the parties arising out of this Agreement, the parties shall attempt
to resolve the dispute through Mediation before an agreed -upon Circuit Court Mediator
certified by the State of Florida. The mediation shall be attended by representatives of
Contractor with full decision -making authority and by County's staff person who would
make the presentation of any settlement reached at mediation to County's board for
approval. Should either party fail to submit to mediation as required hereunder, the other
party may obtain a court order requiring mediation under section 44.102, Fla. Stat.
33. VENUE. Any suit or action brought by either party to this Agreement against the other
party relating to or arising out of this Agreement must be brought in the appropriate federal
or state courts in Collier County, Florida, which courts have sole and exclusive jurisdiction
on all such matters.
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❑■ AGREEMENT STAFFING. The Contractor's personnel and management to be utilized
for this Agreement shall be knowledgeable in their areas of expertise. The County
reserves the right to perform investigations as may be deemed necessary to ensure that
competent persons will be utilized in the performance of the Agreement. The Contractor
shall assign as many people as necessary to complete required services on a timely basis,
and each person assigned shall be available for an amount of time adequate to meet
required services.
F■ ORDER OF PRECEDENCE (Grant Funded). In the event of any conflict between or
among the terms of any of the Contract Documents and/or the County's Board approved
Executive Summary, the terms of the Agreement shall take precedence over the terms of
all other Contract Documents, except the terms of any Supplemental Conditions shall take
precedence over the Agreement. To the extent any conflict in the terms of the Contract
Documents cannot be resolved by application of the Supplemental Conditions, if any, or
the Agreement, the conflict shall be resolved by imposing the more strict or costly
obligation under the Contract Documents upon the Contractor at County's discretion.
36. ASSIGNMENT. Contractor shall not assign this Agreement or any part thereof, without
the prior consent in writing of the County. Any attempt to assign or otherwise transfer this
Agreement, or any part herein, without the County's consent, shall be void. If Contractor
does, with approval, assign this Agreement or any part thereof, it shall require that its
assignee be bound to it and to assume toward Contractor all of the obligations and
responsibilities that Contractor has assumed toward the County.
37. SECURITY. The Contractor is required to comply with County Ordinance 2004-52, as
amended. Background checks are valid for five (5) years and the Contractor shall be
responsible for all associated costs. If required, Contractor shall be responsible for the
costs of providing background checks by the Collier County Facilities Management
Division for all employees that shall provide services to the County under this Agreement.
This may include, but not be limited to, checking federal, state and local law enforcement
records, including a state and FBI fingerprint check, credit reports, education, residence
and employment verifications and other related records. Contractor shall be required to
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General Service Agreement Non -Solicitation 42017-004 (Ver2)
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maintain records on each employee and make them available to the County for at least
four (4) years. All of Contractor's employees and subcontractors must wear Collier County
Government Identification badges at all times while performing services on County
facilities and properties. Contractor ID badges are valid for one (1) year from the date of
issuance and can be renewed each year at no cost to the Contractor during the time
period in which their background check is valid, as discussed below. All technicians shall
have on their shirts the name of the contractor's business.
The Contractor shall immediately notify the Collier County Facilities Management Division
via e-mail (DL-FMOPS@colliergov.net) whenever an employee assigned to Collier
County separates from their employment. This notification is critical to ensure the
continued security of Collier County facilities and systems. Failure to notify within four (4)
hours of separation may result in a deduction of $500 per incident.
(Intentionally left blank -signature page to follow)
Page 13 of 17
General Service Agreement Non -Solicitation #2017-004 (Ver.2)
IN WITNESS WHEREOF, the parties hereto, by an authorized person or agent, have executed
this Agreement on the date and year first written above.
ATTEST:
Crystal Kinzei, Clerk of Courts &
Comptroller
By:
Dated:
Attes,t WWJr nan'5�
ure only.
b ractor s Witnesses:
��Co-ntracto---
it t Witness
,s name i`
g1Ve55�`__
ess name!'
Approved ass`t�o� Farris and Legality:
_-_County Attorn
Print fame �
BOARD OF COUNTY COMMISSIONERS
COLLIER COUNTY, FLORIDA
BY:
Chairman
Shifting Sands Adult Care Center, LLC
Contractor
Sian re
TTypefprint signature and title'[
GU;er;f Service Agree+nent Non-SoHcitntinn 2fTI7-0(;4 (Ver.2)
160 4
Exhibit A
Scope of Services
❑■ following this page (pages 1 through 2 )
❑ this exhibit is not applicable
Page 15 of 17
General Service Agreement Non -Solicitation 42017-004 (Ver.2)
160 4
EXHIBIT A
SCOPE OF SERVICES
19-7596 "Respite Facility & Adult Day Care"
Collier County and CHS shall be used interchangeably.
Contractor, Provider, and Vendor Agency shall be used interchangeably.
The purpose of this award is for the provision of facility respite services and for the provision of adult day care to
be delivered to Collier County persons sixty years and older under CCE, OAA and to qualified persons eighteen
years or older under ADI. Unless otherwise stated, minimum hours of availability for adult day care are 8:00 am to
5:00 p.m. Monday through Friday, except for federal and state holidays. The hours for Respite Facility services and
emergency respite would be available 24 hours/day, 365 days/year.
Definitions, standards, and requirements of these services are included in the Department of Elder Affairs'
Handbook (DOEA Handbook).
The Contractor shall adhere to all requirements of Request for Proposal (RFP) # 19-7529, in addition to maintaining
adherence with the guidelines referenced in the current DOEA Handbook. Lack of knowledge of all requirements
of a service listed in the proposal SHALL NOT relieve the Contractor of liability and obligations under the
agreement.
Collier County Community & Human Services (CHS) division shall lead all service authorization and coordination.
To comply with the requirements of the ADI, CCE, and OAA Programs, clients entering the service system will be
assessed and prioritized by CHS. Upon determination of the service level to be provided, the CHS will offer the
client a listing of service vendors for the specific service(s) outlined within their care plan.
Upon the determination of the service, the service levels, and the selected Contractor, CHS will contact the vendor
agency, and authorize the service, number of hours, and frequency. In keeping with the state policy of client choice
of service providers, Collier County does not guarantee a minimum or maximum number of clients that will be
referred, nor a minimum or maximum number of service hours that will be requested during the contract period.
CHS shall send the agreed -upon Service Authorization to the chosen provider. These "service authorizations" or
"service orders" must contain necessary client information, such as street address, telephone number, and services
or items needed, as well as the name and telephone number of the CHS case manager authorizing the service.
The County may do so through a competitive and publicly announced selection process, which shall be coordinated
through the County's Procurement Division. Services shall be provided in the manner described in the then current
DOEA manual and outlined herein. Services covered by this agreement include, but are not limited to (should
funding for additional Senior Services be identified, the County reserves the right to add to the resultant agreements
the services, descriptions, rates, etc. by way of a contract addendum):
1. Adult Day Care: A day program of therapeutic social and health activities and day services provided to adults
who have functional impairments, in a Florida state licensed, protective environment that provides activities as a
non -institutional environment as possible. Provides a safe environment for seniors who need daily supervision and
can engage with other seniors. Monday -Friday, 8am-5pm
2. Facility Respite Services: a nursing facility that provides 24-hour care/365 days and is licensed as a State of
Florida Licensed Nursing home. The facility will provide 24/7 nursing care and supervision for days authorized by
CHS to assist the senior's caregiver with respite services.
3. Establish protocols for contacting CHS Case Managers in emergency or unusual circumstances and include
the documentation requirements (oral and written) in the Service Provider Application.
Page 1 of 2 ti
LJ
4. Provide disaster response protocols, plans and services: In the event of a natural disaster (hurricane, tropical
storm, tornado, flood, heat wave, etc.), the provider will have staff available to serve those clients in critical need of
services, as designated by the CHS Case Managers.
5. Establish a client grievance process: Each service provider agency must have a policy addressing client
grievances and/or complaints.
6. Establish and provide staff training: All services provided with funding from DOEA require service delivery
personnel to have general pre -service orientation and training specific to the service being provided. CHS is
responsible for provision of the pre -service training on program and billing requirements to the vendors who are
awarded the Proposal.
Pre -service orientation also must include:
• An overview of the aging process
• An overview of the aging network
• Communication techniques with the elderly
• Observation of abuse, neglect, exploitation and incident reporting
• Client confidentiality.
NOTE: All "hands-on" service personnel must receive training emphasizing the necessity of Universal Precautions.
Aides must have documentation of successful completion of 40 hours required training, and CNAs must have on
file a copy of their State of Florida certification. In-service training hours and topics are to be provided at the
discretion of the service provider agency and shall meet state requirements.
7. Compile and report program service delivery statistics and other data as identified by CHS. These are reported
to the Area Agency on Aging and Department of Elder Affairs in accordance with the reporting requirements
developed by the Department. CHS is responsible for entry of data in the Client Information and Registration
Tracking System (CIRTS), which generates payment to the service provider agency.
8. Maintain complete and accurate records: Service delivery logs, at a minimum, must be legible and contain the
name of client, type/s of services and date/s and hour/s of delivery. The client/caregiver must sign the log at the time
of each service visit. The service worker must sign and date the log upon completion and submit it to the service
provider agency.
9. Provide complete, clear and accurate invoices: Invoices must be submitted monthly by the following the week
once the services have been provided and shall include the services provided. The service week is defined as Monday
through Sunday.
Monthly invoices will include:
• Vendor name
• Vendor address
• Vendor telephone number
• Client name
• Services authorized and the service dates
• Number of service hours, cost per hour and total cost
• Person preparing the report and the date it was prepared
10. Prepare for annual on -site compliance audits by CHS Monitoring Unit team as directed by the CHS Division
and/or grant requirements.
Page 2 of 2
16D 4
Exhibit B
Fee Schedule
❑■ following this page (pages 1 through 1 )
❑ this exhibit is not applicable
Page 16 of 17
General Service Agreement Non -Solicitation #2017-004 (Ver.2)
160 4
EXHIBIT B-FEE SCHEDULE
#19-7596
"Services for Seniors Program -Additional Services -Respite Facility Services & Adult Day Care
SHIFTING SANDS ADULT DAY CENTER, LLC
Item
Services
Grant
Service
Cost Per Service
In -Kind 10%
Reimbursement Rate
Unit
Unit (Cost your
Service Unit (Cost
Per Unit (Amount
company charges
your company
the County will
for the service)
charges for the
reimburse your
service)
company for a given
service)
1
Adult Day Care
CCE
Per Hour
$13.89
$1.39
$12.50
ADI*
OAA
*The ADI program does not require an in -kind match contribution.
• Prices shall remain firm for the initial term of this contract.
• Skilled Nursing and Respite Services will not be provided under this Agreement.
160 4
Description:
Other Exhibit/Attachment
Federal Contract Provisions, Grant Assurances and Certifications
❑■ following this page (pages 1 through 24 )
❑ this exhibit is not applicable
Page 17 of 17
General Service Agreement Non -Solicitation 42017-004 (Ver2)
160 4
EXHIBIT I.A FEDERAL CONTRACT PROVISIONS
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
(ADMINISTRATION ON AGING)
AND
FLORIDA DEPARTMENT OF ELDER AFFAIRS
CFDA 93.OXX (CSFA 65.010)
The supplemental conditions contained in this section are intended to cooperate with, to supplement, and
to modify the general conditions and other specifications. In cases of disagreement with any other section
of this contract, the Supplemental Conditions shall govern.
Contractor means an entily that receives a contract.
The services performed by the awarded Contractor shall be in compliance with the provisions of Title 45
CFR Part 75; and/or, 2 CFR Part 200; and/or Title 45 Chapter XIII Part 1321 and/or other applicable
regulations. It shall be the awarded Contractor's responsibility to acquire and utilize the necessary manuals
and guidelines that apply to the work required to complete this project. In general,
1) The contractor (including all subcontractors) must insert these contract provisions in each lower
tier contracts (e.g. subcontract or sub -agreement);
2) The contractor (or subcontractor) must incorporate the applicable requirements of these contract
provisions by reference for work done under any purchase orders, rental agreements and other
agreements for supplies or services;
3) The prime contractor is responsible for compliance with these contract provisions by any
subcontractor, lower -tier subcontractor or service provider.
FEDERAL STATUTORY AUTHORITY
Older Americans Act of 1965 (OAA), as amended (42 U.S.0 § 3001 et seq., as amended by Public Law
114-144; 106-501; Section 20.41)
OLDER AMERICANS ACT PROGRAM FUNDS
OAA, Title III, Section 307(a)(10)
OAA, Title III B - Supportive Services;
Title 45 Public Welfare (45 CFR 1321)
Chapter XIII Office of Human Development Services, Department of Health and Human Services
Part 1321.65 Grants to State and Community Programs on Aging; Part 1321.67 Service Contributions
FLORIDA STATUTORY AUTHORITY
TITLE XXX (Social Welfare); Chapter 430 (Elder Affairs)
CONTRACT COMPLIANCE OVERVIEW
Under the Florida Department of Elder Affairs Older Americans Act, the contractor must comply with the
contract documentation, conform to state and AAA policies, and comply with federal and state statutory
and regulatory requirements. (Ref. - Department of Elder Affairs Programs and Services Handbook,
Chapter 4, Page 22; July 2018: Older Americans Act.). The contractor will comply with the intent of Title
III to provide for formula grants to State agencies on aging to stimulate the development or enhancement of
comprehensive and coordinated community -based systems resulting in a continuum of services to older persons
with special emphasis on older individuals with the greatest economic or social need, with particular attention
to low-income minority individuals. (Ref. - Title 45 CFR 1321)
(Ref.: Florida Dept. of Elder Affairs' Home and Community -Based Services Handbook) FCP-1/Revised 01-14-19
160 4
EXHIBIT LA FEDERAL CONTRACT PROVISIONS
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
FEDERAL CONTRACT PROVISIONS
>$100,000
Administrative, Contractual, or Legal Remedies (Ref. 41 U.S.C. 1908, 2 CFR § 200 Appendix II (A)
Unless otherwise provided in this contract, all claims, counter -claims, disputes and other matters in question
between the local government and the contractor, arising out of or relating to this contract, or the breach of it,
will be decided by arbitration, if the parties mutually agree, or in a Florida court of competent jurisdiction.
Access to Records and Reports (Reference: 2 CFR § 200.333, 2 CFR § 200.336)
The contractor/vendor agrees to maintain all books, records, accounts and reports required under this contract
for a period of not less than three years after the date of termination or expiration of this contract, except in the
event of litigation or settlement of claims arising from the performance of this contract, in which case the
Contractor agrees to maintain same until the Purchaser, the Grantor Administrator, the Comptroller General, or
any of their duly authorized representatives, have disposed of all such litigation, appeals, claims or exceptions
related thereto. Furthermore, the County shall maintain written policies and procedures for computer system
backup and recovery and shall have the same requirement of its Contractors.
Byrd Anti -Lobbying Amendment (31 U.S.C. 1352) (Reference 2 CFR § 200 Appendix II (J)
Vendors must certify it will not and has not used Federal appropriated funds have been paid or will be paid, by
or to any person or organization for influencing or attempting to influence an officer or employee of an agency,
a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in
connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal
loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or
modification of any Federal contract, grant, loan, or cooperative agreement. The certification includes any
lobbying with non -Federal funds that takes place in connection with obtaining any Federal award.
Civil Rights
The contractor or a subcontractor who is the recipient of Federal funds (or assumes others with whom it arranges
to provide services or benefits in connection with any of its programs and activities or assures others with whom
it arranges to provide services or benefits to participants or employees) must comply with Title VI of the Civil
Rights Act of 1964, which prohibits discrimination on the basis of race, color, or national origin (45 CFR 80),
and Statutes and Regulations enforced by the Office of Civil Rights, U.S. Department of Health and Human
Services, as follow:
Section 504 of the Rehabilitation Act of 1973, as amended (29 USC § 794), prohibits discrimination
against otherwise qualified individuals on the basis of disability in programs and activities receiving
financial assistance from HHS 45 CFR 84 and/or programs or activities conducted by HHS 45 CFR 85 in
the provision of benefits and under the ADA that does not:
a. Exclude a person with a disability from a program or activity;
b. Deny a person with a disability the benefits of a program or activity;
c. Afford a person with a disability an opportunity to participate in or benefit from a benefit or
service that is not equal to what is afforded others;
d. Provide a benefit or service to a person with a disability that is not as effective as what is provided
others;
e. Provide different or separate benefits or services to a person with a disability unless necessary to
provide benefits or services that are as effective as what is provided others; or,
f. Apply eligibility criteria that tend to screen out persons with disabilities unless necessary for the
provision of the service, program or activity.
(Ref.: Florida Dept. of Elder Affairs' Home and Community -Based Services Handbook) FCP-2/Revised 01-14-19
160 4
EXHIBIT LA FEDERAL CONTRACT PROVISIONS
Section 508 of the Rehabilitation Act of 1973, as amended, (29 USC § 794(d)) prohibits discrimination
on the basis of disability in electronic and information technology as they relate to programs and activities
conducted by HHS.
The Age Discrimination Act of 1975, as amended (42 USC § 6101) prohibits discrimination on the basis
of age in programs or activities receiving Federal financial assistance 45 CFR 90; and/or programs or
services receiving HHS financial assistance 45 CFR 91;
Title II of the Americans with Disabilities Act (28 CFR Part 35), relating to Nondiscrimination on the
Basis of Disability in State and Local Government Services 2010 ADA Standards for Accessible Design;
The Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to
nondiscrimination on the basis of drug abuse;
The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act
of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or
alcoholism; (g) §523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. §290 dd-3 and 290 ee
3), as amended, as relating to confidentiality of alcohol and drug abuse patient records;
Section 1908 of the Public Health Service Act (42 USC § 300w-7) prohibits discrimination on the basis
of age, race, color, national origin, disability, sex (gender), or religion in programs, services, and activities
funded by Preventative Health and Health Services Block Grants.
Federal Health Care Conscience Protection Statutes (42 USC § 300a-7; 42 USC § 300a-7; 42 USC §
238n and the Weldon Amendment (Continuing Appropriations Resolution, Pub. L. No. 113-164, Sec.
101(a) (Sept. 19, 2015); Regulation for the Enforcement of Federal Health Care Provider Conscience
Protection Laws, which prohibit recipients of certain Federal funds from discriminating against certain
health care providers who refuse to participate in certain health care services on religious or moral
grounds.
Section 1557 of the Affordable Care Act prohibits discrimination on the basis of disability by entities
that operate a health program or activity.
45 CFR 80. The contractor must have on file an assurance that the program will be conducted in
compliance with all nondiscriminatory provisions as required in 45 CFR 80.
Clean Air Act and Federal Water Pollution Control Act
(Applicable to contracts containing federal funds and over $100, 000.)
The Contractor shall comply with all applicable standards, orders, or regulations issued under Section 306
of the Clean Air Act as amended (42 United States Code (U.S.C.) 7401, et seq.), Section 508 of the Federal
Water Pollution Control Act as amended (33 U.S.C. 1251, et seq.), Executive Order 11738, as amended,
and where applicable Environmental Protection Agency regulations, 2 CFR Part 1500. The Contractor shall
report any violations of the above to the Agency.
Computer Use and Social Media Policy
The Florida Department of Elder Affairs has implemented a Social Media Policy, in addition to its Computer
Use Policy, which applies to all employees, contracted employees, consultants, OPS and volunteers, including
all personnel affiliated with third parties, such as, but not limited to, contractors and subcontractors. Any entity
that uses the Department's computer resource systems must comply with the Department's policy regarding
social media. Social Media includes, but is not limited to blogs, podcasts, discussion forums, Wikis, RSS feeds,
video sharing, social networks like MySpace, Facebook and Twitter, as well as content sharing networks such
as flickr and YouTube. This policy is available on the Department's website at:
http://eIderaffairs.state.fl.us/doea/financial.vhp
Debarment and Suspension (Reference 2 CFR § 200 Appendix II (I)
Contract awards that exceed the small purchase threshold and certain other contract awards shall not be made to
parties listed on the government wide Excluded Parties List System in the System for Award Management
(SAM), in accordance with the OMB guidelines at 2 CFR 180 that implement Executive Orders 12549 (3 CFR
Part 1986 Comp., p. 189) and 12689 (3 CFR Part 1989 Comp., p. 235), "Debarment and Suspension." The
Excluded Parties List System in SAM contains the names of parties debarred, suspended, or otherwise excluded
(Ref.: Florida Dept. of Elder Affairs' Home and Community -Based Services Handbook) FCP-3/Revised 01-14-19
Q
U
160 4
EXHIBIT I.A FEDERAL CONTRACT PROVISIONS
by agencies, as well as parties declared ineligible under statutory or regulatory authority other than Executive
Order 12549. The successful bidder, by administering each lower tier subcontract that exceeds $25,000 as a
"covered transaction", must verify each lower tier participant of a "covered transaction" under the project is not
presently debarred or otherwise disqualified from participation in this federally assisted project. The Contractor
shall comply with these provisions before doing business or entering into subcontracts receiving federal funds
pursuant to this contract. The Contractor shall complete and sign the Certifications and Assurances Attachment
prior to the execution of this contract.
Diversity (Reference 2 CFR § 200.321)
The County is dedicated to fostering the continued development and economic growth of small, minority-,
women-, and service -disabled veteran business enterprises. All contracting and subcontracting opportunities
afforded by this solicitation/contract are strongly encouraged to contribute as both Contractors and Sub -
Contractors. Firms may be required to submit documentation addressing diversity and describing the efforts
being made to encourage the participation of small, minority-, women-, and service -disabled veteran business
enterprises. Information on Certified Minority Business Enterprises (CUBE) and Certified Service -Disabled
Veteran Business Enterprises (CSDVBE) is available from the Office of Supplier Diversity at:
hgp://dms.myflorida.com/other programs/office of supplier diversity osd/
Energy Policy and Conservation Act - (Reference 2 CFR § 200 Appendix II (H)
The contractor shall comply with any mandatory standards and policies relating to energy efficiency which are
contained in the F l o r i d a state energy conservation plan issued in compliance with the Energy Policy
and Conservation Act (Pub. L. 94-163, 89 Stat. 871, 42 U.S.0 Section 6201)
Equal Employment Opportunity (Appendix II, 2 CFR Part 200; Executive Order 11246, Equal Employment
Opportunity, as amended by Executive Order H 375 and others, and Department of Labor 41 CFR Part 60;
Dept. of Health and Human Services 45 CFR Part 80; 45 CFR Part 92, if applicable). The Contractor shall not
discriminate against any employee or applicant for employment because of race, age, creed, color, sex or national
origin. The Agency will take affirmative action to ensure that applicants are employed, and that employees are
treated during employment, without regard to their race, age, creed, color, sex, or national origin. Such action
shall include, but not be limited to, the following: Employment upgrading, demotion, or transfer; recruitment or
recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for
training, including apprenticeship. Contractors must insert a similar provision in all subcontracts, except
subcontracts for standard commercial supplies or raw materials.
E-verify, Presidential Executive Order 12989; Florida Executive Order Number 11-116
Vendors/Contractors/Subcontracts: 1. Agree to utilize the U.S. Department of Homeland Security's E-verify
system to verify the employment of all new employees hired by Contractor during the contract term; and 2.
Contractor shall include in related subcontracts a requirement that Subcontractors performing work or providing
services pursuant to the state contract utilize the E-verify system to verify employment eligibility of all new
employees hired by the Subcontractor during the contract term.
HIPAA Privacy Rules, 4 CFR Part 160 and Suparts A and E of part 164
The Third Party subrecipient will comply with HIPAA requirements to appropriate safeguards to protect the
privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be
made of such information without patient authorization.
Immigration and Nationality Act
The Contractor shall not employ an unauthorized alien. The Agency will consider the employment of un-
authorized aliens a violation of the Immigration and Nationality Act (8 U.S.C. 1324a) and the Immigration
Reform and Control Act of 1986 (8 U.S.C. 1101). Such violation will be cause for unilateral cancellation
of this contract by the Agency.
(Ref.: Florida Dept. of Elder Affairs' Home and Community -Based Services Handbook) FCP-4/Revised 01-14-19
160 4
EXHIBIT LA FEDERAL CONTRACT PROVISIONS
No Government Obligation to Third Parties - The Federal Government is not a party to this contract and is
not subject to any obligations or liabilities to the non -Federal entity, contractor, or any other party pertaining to
any matter resulting from the contract."
Nondiscrimination
The Contractor will 1. not discriminate against any person in the provision of services or benefits under this
contract or in employment because of age, race, religion, color, disability, national origin, marital status or
sex in compliance with state and federal law and regulations. 2. Assumes others with whom it arranges to
provide services or benefits in connection with any of its programs and activities are not discriminating
against clients or employees because of age, race, religion, color, disability, national origin, marital status
or sex. And 3. Assures others with whom it arranges to provide services or benefits to participants or
employees in connection with any of its programs and activities are not discriminating against those
participants or employees in violation of the above statutes, regulations, guidelines, and standards.
Pension Protection Act of 2006
If the Contractor is a non-profit provider and is subject to Internal Revenue Service (IRS) tax exempt
organization reporting requirements (filing a Form 990 or Form 990-N) and has its tax exempt status
revoked for failing to comply with the filing requirements of the Pension Protection Act of 2006 or for any
other reason, the Contractor must notify the Agency in writing within thirty (30) days of receiving the IRS
notice of revocation.
Procurement of Recovered Materials (Reference 2 CFR § 200.322)
Contractor and subcontractor agree to comply with Section 6002 of the Solid Waste Disposal Act, as amended
by the Resource Conservation and Recovery Act, and the regulatory provisions of 40 CFR Part 247. (1) In the
performance of this contract, the Contractor shall make maximum use of products containing recovered materials
that are EPA designated items unless the product cannot be acquired (i) Competitively within a timeframe
providing for compliance with the contract performance schedule; (ii) Meeting contract performance
requirements; or (iii) At a reasonable price. (2) Information about this requirement is available at EPA's
Comprehensive Procurement Guidelines web sitehttp://www.epa.gov/. The list of EPA -designate items is
available at https://www.epa.gov/smm/comprehensive-procurement-guideline-cpg-program.
Program Fraud and False or Fraudulent Statements of Related Acts
The contractor acknowledges that 31 U.S.C. Chap. 38 (Administrative Remedies for False Claims and
Statements) applies to the contractor's actions pertaining to this contract.
Termination for Cause and Convenience
See County's Standard Terms and Conditions.
Trafficking in Persons
The Contractor and subcontractors shall comply with Title 2 CFR Part 175 and 2 CFR §175.15 provisions
applicable to a private entity, as defined in 2 CFR 175.25.
Transparency Act
Unless exempt under 2 CFR § 170.11 O(b), the Contractor shall comply with the reporting requirements of the
Transparency Act as expressed in 2 CFR Part 170.
(Ref.: Florida Dept. of Elder Affairs' Home and Community -Based Services Handbook) FCP-5/Revised 01-14-19
160
EXHIBIT I.A FEDERAL CONTRACT PROVISIONS
STATE CONTRACT PROVISIONS
Administrative Procedures Act, Section 120.57(2), F.S.
Additional procedures for particular cases.
In a matter initiated as a result of agency action proposing to determine the substantial interests of a party, the
party's timely petition for hearing may challenge the proposed agency action based on a rule that is an invalid
exercise of delegated legislative authority or based on an alleged unadopted rule.
Data Integrity and Safeguarding Information, Uniform Electronic Transaction Act, Section 668.50, F.S.;
Public Records Law, Chapter 119, Section 29, F.S
The Contractor shall ensure an appropriate level of data security for the information the Contractor is collecting or
using in the performance of this contract. An appropriate level of security includes approving and tracking all
Contractor employees that request system or information access and ensuring that user access has been removed
from all terminated employees. The Contractor, among other requirements, must anticipate and prepare for the
loss of information processing capabilities. All data and software shall be routinely backed up to ensure recovery
from losses or outages of the computer system. The security over the backed -up data is to be as stringent as the
protection required of the primary systems. The Contractor shall ensure all Subcontractors maintain written
procedures for computer system backup and recovery. The Contractor shall complete and sign the Certification
Regarding Data Integrity Compliance for Agreements, Grants, Loans, and Cooperative Agreements prior to the
execution of this contract.
Discriminatory Vendors List, Section 287.134, F.S.
In accordance with Section 287.134, Florida Statutes, an entity or affiliate who has been placed on the
discriminatory vendor list may not submit a bid on a contract to provide any goods or services to a public entity,
may not submit a bid on a contract with a public entity for the construction or repair of a public building or
public work, may not submit bids on leases of real property to a public entity, may not be awarded or perform
work as a contractor, supplier, subcontractor, or consultant under a contract with any public entity, and may not
transact business with any public entity.
Equal Employment Opportunity
The Contractor shall not discriminate against any employee or applicant for employment because of race, age,
creed, color, sex or national origin. The Agency will take affirmative action to ensure that applicants are
employed, and that employees are treated during employment, without regard to their race, age, creed, color,
sex, or national origin. Such action shall include, but not be limited to, the following: Employment upgrading,
demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms
of compensation; and selection for training, including apprenticeship. Contractors must insert a similar provision
in all subcontracts, except subcontracts for standard commercial supplies or raw materials.
Inspections (Meals)
The Contractor must agree to notify the Nutrition Provider within 24 hours of any sanitation inspection and
provide a copy of the report.
Inspector General Cooperation, Section 20.055(5), F.S.
The Parties agree to comply with Section 20.055(5), Florida Statutes, for the inspector general to have access to
any records, data and other information deemed necessary to carry out his or her duties and incorporate into all
subcontracts the obligation to comply with Section 20.055(5), Florida Statutes.
Interest of Members of Congress
No member of or delegate to the Congress of the United States shall be admitted to any share or part of this
contract or to any benefit arising therefrom.
(Ref: Florida Dept. of Elder Affairs' Home and Community -Based Services Handbook) FCP-6/Revised 01-14-19
160 4
EXHIBIT I.A FEDERAL CONTRACT PROVISIONS
Interest of Public Officials
No member, officer, or employee of the public body or of a local public body during his tenure or for two years
thereafter shall have any interest, direct or indirect, in this contract or the proceeds thereof. For purposes of this
provision, public body shall include municipalities and other political subdivisions of States; and public
corporations, boards, and commissions established under the laws of any State. No member, officer, or employee
of the MPO or of a local public body during his tenure or for two years thereafter shall have any interest, direct
or indirect, in this contract or the proceeds thereof.
Lobbying
No funds received pursuant to this Agreement may be expended for lobbying the Legislature, the judicial branch
or a state agency.
(Ref.: Florida Dept. of Elder Affairs'Home and Community -Based Services Handbook) FCP-7/Revised 01-14-19
160 4
l :' HIBI"i 1.13 GRANT CER 1`1FIC;ATIONS AND ASSURANCES
GRANT CERTIFICATIONS AND ASSURANCES
THE FOLLOWING DOCUMENTS NEED TO BE RETURNED WITH SOLICITATION DOCUMENTS
BY DEADLINE TO BE CONSIDERED RESPONSIVE.
Page
GCA 2-6
GCA - 7-9
Certification and Form
Attachment III - Certifications and Assurances (A-,n
A. Debarment and Suspension Certification (29 CFR Part 95 and 45 CFR Part 75)
B. Certification Regarding Lobbying (29 CFR Part 93 and 45 CFR Part 93)
C. Nondiscrimination & Equal Opportunity Assurance (29 CFR Part 37 and 45 CFR Part 80)
D. Certification Regarding Public Entity Crimes, section 287.133. F.S.
E. Association of Community Organizations for Reform Now (ACORN) Funding Restrictions
Assurances (Pub. L. I I 1-117)
F. Scrutinized Companies Lists and No Boycott of Israel Certification, section 287.135. F.S.
G. Certification Regarding Data Integrity Compliance for Contracts, Agreements, Grants, Loans
and Cooperative Agreements
H. Verification of Employment Status Certification
I. Records and Documentation
J. Certification Regarding Inspection of Public Records
Attachment IV — Assurances Non -Construction Programs
GCA - 10-13 Attachment V — Civil Rights Compliance Checklist
GCA - 14 Attachment VII — Background Screening Affidavit of Compliance - Employer
GCA - 15 Conflict of Interest Certification
GCA - 16 Anticipated DBE, MIWBE or VETERAN Participation Statement
GCA - 17 Bid Opportunity List for Commodities and Contractual Services and Professional
Consultant Services
160 4
EXB. 1.13 GRANT ASSURANCES AND CERTIFICATIONS
ATTACHMENT III
CERTIFICATIONS AND ASSURANCES
Agency will not award this Contract unless Contractor completes this CERTIFICATIONS AND ASSURANCES. In
performance of this contract, Contractor provides the following certifications and assurances:
A. Debarment and Suspension Certification (29 CFR Part 95 and 45 CFR Part 751
B. Certification RegardingLobbying (29 CFR Part 93 and 45 CFR Part 93)
C. Nondiscrimination & Eaual Opportunity Assurance (29 CFR Part 37 and 45 CFR Part80)
D. Certification Regarding Public Entity Crimes. section 287,133. F.S.
E. Association of Community Organizations for Reform Now _(ACORN) Funding Restrictions Assurance
F. Scrutinized Companies Lists and No Boycott of Israel Certification section 287,135. F.S.
G. Certification Regarding Data Integrity ComUliance for Contracts. Agreements, Grants. Loans, and
Cooperative Agreements
H. Verification of Emwment Status Certification
1. Records and Documentation
J. Certification Regarding lnnnection of Public Records
A. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY
MATTERS — PRIMARY COVERED TRANSACTION.
The undersigned Contractor certifies, to the best of its knowledge and belief, that it and its principals:
1. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
covered transactions by a Federal department or agency;
2. Have not within a three-year period preceding this Contract been convicted or had a civil judgment rendered against
them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing
a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State
antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records,
making false statements, or receiving stolen property;
3. Are not presently indicted or otherwise criminally or civilly charged by a government entity (Federal, State, or
local) with commission of any of the offenses enumerated in paragraph A.2. of this certification; and/or
4. Have not within a three-year period preceding this application/proposal had one or more public transactions
(Federal, State, or local) terminated for cause of default.
The undersigned shall require that language of this certification be included in the documents for all subcontracts atall
tiers (including subcontracts, sub -grants, and contracts under grants, loans, and cooperative agreements) and that all
sub -recipients and contractors shall provide this certification accordingly.
GCA-2
160 4
GRANT ASSURANCES AND CERTIFICATIONS
B. CERTIFICATION REGARDING LOBBYING — CERTIFICATION FOR CONTRACTS, GRANTS, LOANS,
AND COOPERATIVE AGREEMENTS.
The undersigned Contractor certifies, to the best of its knowledge and belief, that:
No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for
influencing or attempting to influence an officer or employee of Congress or an employee of a Member of Congress in
connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the
entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any
Federal contract, grant, loan, or cooperative agreement.
If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of
Congress, or employee of a Member of Congress in connection with a Federal contract, grant, loan, or cooperative
agreement, the undersigned shall also complete and submit Standard Form — LLL, "Disclosure Form to Report
Lobbying," in accordance with its instructions.
The undersigned shall require that language of this certification be included in the documents for all subcontracts at all
tiers (including subcontracts, sub -grants, and contracts under grants, loans, and cooperative agreements) and that all
sub -recipients and contractors shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this Contract was made or
entered into. Submission of this certification is a prerequisite for making or entering into this Contract imposed by 31
U.S.C. 1352. Any person who fails to file the required certification shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.
C. NON- DISCRIMINATION & EQUAL OPPORTUNITY ASSURANCE (29 CFR PART 37 AND 45 CFR PART
80). - As a condition of the Contract, Contractor assures that it will comply fully with the nondiscrimination and equal
opportunity provisions of the following laws:
1. Section 188 of the Workforce Investment Act of 1998 (WIA), (Pub. L. 105-220), which prohibits discrimination
against all individuals in the United States on the basis of race, color, religion, sex, national origin, age, disability,
political affiliation, or belief, and against beneficiaries on the basis of either citizenship/status as a lawfully admitted
immigrant authorized to work in the United States or participation in any WIA Title I -financially assisted program
or activity.
2. Title VI of the Civil Rights Act of 1964 (Pub. L. 88-352), as amended, and all requirements imposed by or pursuant
to the Regulation of the Department of Health and Human Services (45 CFR Part 80), to the end that, in accordance
with Title VI of that Act and the Regulation, no person in the United States shall, on the ground of race, color, or
national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to
discrimination under any program or activity for which the Applicant receives Federal financial assistance from the
Agency.
3. Section 504 of the Rehabilitation Act of 1973 (Pub. L. 93-112), as amended, and all requirements imposed by or
pursuant to the Regulation of the Department of Health and Human Services (45 CFR Part 84), to the end that, in
accordance with Section 504 of that Act and the Regulation, no otherwise qualified handicapped individual in the
United States shall, solely by reason of his handicap, be excluded from participation in, be denied the benefits of,
or be subjected to discrimination under any program or activity for which the Applicant receives Federal financial
assistance from the Agency.
GCA-3
160 4
EXB. LB
GRANT ASSURANCES AND CERTIFICATIONS
4. The Age Discrimination Act of 1975 (Pub. L. 94-135), as amended, and all requirements imposed by or pursuant
to the Regulation of the Department of Health and Human Services (45 CFR Part 91), to the end that, in accordance
with the Act and the Regulation, no person in the United States shall, on the basis of age, be denied the benefits of,
be excluded from participation in, or be subjected to discrimination under any program or activity for which the
Applicant receives Federal financial assistance from the Agency.
5. Title IX of the Education Amendments of 1972 (Pub. L. 92-318), as amended, and all requirements imposed by or
pursuant to the Regulation of the Department of Health and Human Services (45 CFR Part 86), to the end that, in
accordance with Title IX and the Regulation, no person in the United States shall, on the basis of sex, be excluded
from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any education
program or activity for which the Applicant receives Federal financial assistance from the Agency.
6. The American with Disabilities Act of 1990 (Pub. L. 101-336), which prohibits discrimination in all employment
practices, including job application procedures, hiring, firing, advancement, compensation, training, and other
terms, conditions, and privileges of employment. It applies to recruitment, advertising, tenure, layoff, leave, fringe
benefits, and all other employment -related activities.
7. Contractor also assures that it will comply with 29 CFR Part 37 and all other regulations implementing the laws
listed above. This assurance applies to Contractor's operation of the WIA Title I — financially assisted program or
activity, and to all contracts Contractor makes to carry out the WIA Title I — financially assisted program or activity.
Contractor understands that the Agency and/or DOEA and the United States have the right to seek judicial
enforcement of the assurance.
The undersigned shall require that language of this assurance be included in the documents for all subcontracts at all
tiers (including subcontracts, sub -grants, and contracts under grants, loans, and cooperative agreements) and that all
sub -recipients and contractors shall provide this assurance accordingly.
D. CERTIFICATION REGARDING PUBLIC ENTITY CRIMES, SECTION 287.133, F.S.
Contractor hereby certifies that neither it, nor any person or affiliate of Contractor, has been convicted of a Public Entity
Crime as defined in section 287.133, F.S., nor placed on the convicted vendor list.
Contractor understands and agrees that it is required to inform Agency immediately upon any change of circumstances
regarding this status.
E. ASSOCIATION OF COMMUNITY ORGANIZATIONS FOR REFORM NOW (ACORN) FUNDING
RESTRICTIONS ASSURANCE (Pub. L. 111-117).
As a condition of the Contract, Contractor assures that it will comply fully with the federal funding restrictions
pertaining to ACORN and its subsidiaries per the Consolidated Appropriations Act, 2010, Division E, Section 511 (Pub.
L. 111-117). The Continuing Appropriations Act, 2011, Sections 101 and 103 (Pub. L. 111-242), provides that
appropriations made under Pub. L. I I 1-117 are available under the conditions provided by Pub. L. I I 1-117.
The undersigned shall require that language of this assurance be included in the documents for all subcontracts at all
tiers (including subcontracts, sub -grants and contracts under grants, loans and cooperative agreements) and that all sub -
recipients and contractors shall provide this assurance accordingly.
F. SCRUTINIZED COMPANIES LISTS AND NO BOYCOTT OF ISRAEL CERTIFICATION, SECTION
287.135, F.S.
In accordance with section 287.135, F.S., Contractor hereby certifies that it has not been placed on the Scrutinized
Companies that Boycott Israel List and that it is not participating in a boycott of Israel.
GCA-4
160 4
GRANT ASSURANCES AND CERTIFICATIONS
If this Contract is in the amount of $1 million or more, in accordance with the requirements of section 287.135, F.S.,
Contractor hereby certifies that it is not listed on either the Scrutinized Companies with Activities in Sudan List or the
Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List and that it does not have business
operations in Cuba or Syria.
Contractor understands that pursuant to section 287.135, F.S., the submission of a false certification may result in the
Agency terminating this contract and the submission of a false certification may subject Contractor to civil penalties and
attorney fees and costs, including any costs for investigations that led to the finding of false certification.
GCA-3
If Contractor is unable to certify any of the statements in this certification, Contractor shall attach an explanation to
this Contract.
G. CERTIFICATION REGARDING DATA INTEGRITY COMPLIANCE FOR CONTRACTS, AGREEMENTS,
GRANTS, LOANS, AND COOPERATIVE AGREEMENTS
1. The Contractor and any Subcontractors of services under this contract have financial management systems
capable of providing certain information, including: (1) accurate, current, and complete disclosure of the financial
results of each grant -funded project or program in accordance with the prescribed reporting requirements; (2) the
source and application of funds for all contract supported activities; and (3) the comparison of outlays with
budgeted amounts for each award. The inability to process information in accordance with these requirements
could result in a return of grant funds that have not been accounted for properly.
2. Management Information Systems used by the Contractor, Subcontractors, or any outside entity on which the
Contractor is dependent for data that is to be reported, transmitted, or calculated have been assessed and verified
to be capable of processing data accurately, including year -date dependent data. For those systems identified to be
non -compliant, Contractors will take immediate action to assure data integrity.
3. If this contract includes the provision of hardware, software, firmware, microcode, or imbedded chiptechnology,
the undersigned warrants that these products are capable of processing year -date dependent data accurately. All
versions of these products offered by the Contractor (represented by the undersigned) and purchased by the state
will be verified for accuracy and integrity of data prior to transfer.
4. In the event of any decrease in functionality related to time and date related codes and internal subroutines that
impede the hardware or software programs from operating properly, the Contractor agrees to immediatelymake
required corrections to restore hardware and software programs to the same level of functionality as warranted
herein, at no charge to the state, and without interruption to the ongoing business of the state, time being of the
essence.
5. The Contractor and any Subcontractors of services under this contract warrant that their policies and procedures
include a disaster plan to provide for service delivery to continue in case of an emergency, including emergencies
arising from data integrity compliance issues.
H. VERIFICATION OF EMPLOYMENT STATUS CERTIFICATION
As a condition of contracting with the Agency, Contractor certifies the use of the U.S. Department of Homeland
Security's E-verify system to verify the employment eligibility of all new employees hired by Contractor during the
contract term to perform employment duties pursuant to this contract, and that any subcontracts include an express
requirement that Subcontractors performing work or providing services pursuant to this Contract utilize the E-verify
system to verify the employment eligibility of all new employees hired by the Subcontractor during the entire contract
term.
GCA-5
160 4
EXB. 1.13 GRANT ASSURANCES AND CERTIFICATIONS
The Contractor shall require that the language of this certification be included in all sub -agreements, sub -grants, and
other agreements/contracts and that all Subcontractors shall certify compliance accordingly.
This certification,is a material representation of fact upon which reliance was placed when this Contract was made or
entered into. Submission of this certification is a prerequisite for making or entering into this Contract imposed by
Circulars A-102 and 2 CFR Part 200 and 215 (formerly OMB Circular A-110).
I. RECORDS AND DOCUMENTATION
The Contractor agrees to make available to Agency staff and/or any party designated by the Agency any and all
contract related records and documentation. The Contractor shall ensure the collection and maintenance of all program
related information and documentation on any such system designated by the Agency. Maintenance includes valid
exports and backups of all data and systems according to Agency standards.
J. CERTIFICATION REGARDING INSPECTION OF PUBLIC RECORDS
In addition to the requirements of sections 10.1 and 10.2 of the Standard Contract, sections 119.0701(3) and (4) F.S.,
and any other applicable law, if a civil action is commenced as contemplated by section 119.0701(4), F.S., and the
Agency is named in the civil action, Contractor agrees to indemnify and hold harmless the Agency for any costs
incurred by the Agency and any attorneys' fees assessed or awarded against the Agency from A Public Records
Request made pursuant to Chapter 119, F.S., concerning this contract or services performed thereunder.
a. Notwithstanding section 119.0701, F.S., or other Florida law, this section is not applicable to contracts executed
between the Agency and state agencies or subdivisions defined in section 768.28(2), F.S.
2. Section 119.01(3), F.S., states if public funds are expended by an agency in payment of dues or membership
contributions for any person, corporation, foundation, trust, association, group, or other organization, all the financial,
business, and membership records of such an entity which pertain to the public agency (Area Agency on Aging
for Southwest Florida, Inc.) are public records. Section 119.07, F.S, states that every person who has custody of such
a public record shall permit the record to be inspected and copied by any person desiring to do so, under reasonable
circumstances.
Additionally, I certify this organization does does not provide for institutional memberships.
Contractor's signature below attests that records pertaining to the dues or membership application by the Agency are
available for inspection if applicable, as stated above.
By execution of this contract, Contractor must include these provisions (A-J) in all related subcontract agreements (if
applicable).
By signing below, Contractor certifies that the representations outlined in parts A through J above are true and correct.
ignature d Title of AuthorizedRepresentative
Street Address
Ao,7 tilp
Contrastto
City, State, Zip code
GCA-6
160 4
EXHIBIT 1.13
GRANT CERTIFICATIONS AND ASSURANCES
ATTACHMENT IV
ASSURANCES--NON-CONSTRUCTION PROGRAMS
Public reporting burden for this collection of information is estimated to average forty-five (45) minutes per response, including time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing
the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the Office of Management and Budget. Paperwork Reduction Project (0348-0043),
Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND
BUDGET, SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
Note: Certain of these assurances may not be applicable to your project or program. If you have questions please
contact the awarding agency. Further, certain federal awarding agencies may require applicants to certify to
additional assurances. If such is the case, you will be notified.
1. Has the legal authority to apply for federal assistance, and the institutional, managerial and financial capability
(including funds sufficient to pay the non-federal share of project cost) to ensure proper planning, management, and
completion of the project described in this application.
2. Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the state, throughany
authorized representative, access to and the right to examine all records, books, papers, or documents related to the
award; and will establish a proper accounting system in accordance with generally accepted accounting standards or
agency directives.
3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the
appearance of personal or organizational conflict of interest, or personal gain.
4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency.
5. Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. §4728-4763) relating to prescribed standards
for merit systems for programs funded under one of the 19 statutes or regulations specified in Appendix A of OPM's
Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F).
6. Will comply with all federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of
the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or national origin;
(b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §1681-1683, and 1685-1686), which
prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C.
§794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended
(42 U.S.C. §6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment
Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive
Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended,
relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) §523 and 527 of the Public Health Service
Act of 1912 (42 U.S.C. §290 dd-3 and 290 ee 3), as amended, relating to confidentiality of alcohol and drug abuse
patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §3601 et seq.), as amended, relating to
nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provisions in the specific
statute(s) under which application for federal assistance is being made; and 0) the requirements of any other
nondiscrimination statute(s) which may apply to the application.
GCA-7
160 4
EXHIBIT 1.13
GRANT CERTIFICATIONS AND ASSURANCES
7. Will comply, or has already complied, with the requirements of Titles II and III of the uniform Relocation Assistance
and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable treatment of
persons displaced or whose property is acquired as a result of federal or federally assisted programs. These requirements
apply to all interests in real property acquired for project purposes regardless of federal participation inpurchases.
8. Will comply, as applicable, with the provisions of the Hatch Act (5 U.S.C. §1501-1508 and 7324-7328), which limit
the political activities of employees whose principal employment activities are funded in whole or in part with federal
funds.
9. Will comply, as applicable, with the provisions of the Davis -Bacon Act (40 U.S.C. §276a to 276a-7), the Copeland Act
(40 U.S.C. 276c and 18 U.S.C. §874) and the Contract Work Hours and Safety Standards Act (40 U.S.C. §327-333),
regarding labor standards for federally assisted construction sub -contracts.
10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster
Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the
program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000.00 or
more.
11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of
environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and
Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands
pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of
project consistency with the approved State management program developed under the Coastal Zone Management Act
of 1972 (16 U.S.C. § 1451 et seq.); (f) conformity of federal actions to State (Clear Air) Implementation Plans under
Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C. §7401 et seq.); (g) protection of underground
sources of drinking water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and (h) protection
of endangered species under the Endangered Species Act of 1973, as amended, (P.L. 93-205).
12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. §1721 et seq.) related to protecting components
or potential components of the national wild and scenic rivers system.
13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of
1966, as amended (16 U.S.C. §470), EO 11593 (identification and protection of historic properties), and the
Archaeological and Historic Preservation Act of 1974 (16 U.S.C. §469a-1 et seq.).
14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development, and related
activities supported by this award of assistance.
15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. §2131 et seq.)
pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities
supported by this award of assistance.
16. Will comply with the Lead -Based Paint Poisoning Prevention Act (42 U.S.C. §4801 et seq.), which prohibits the use of
lead- based paint in construction or rehabilitation of residence structures.
GCA-8
160 4
EXHIBIT 1.13
GRANT CERTIFICATIONS AND ASSURANCES
17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act
Amendments of 1996 and 2 CFR Part 200.
18. Will comply with all applicable requirements of all other federal laws, executive orders, regulations and policies
governing this program.
SIGN TURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE
APPLICANT ORGANIZATION DATE SUBMITTED
<1b,41 �, 7/3,1/a-o,17
GCA-9
160 4
STATE, OF FLORIDA DEPARTMIRNT OF F.T.iIF.R AFFATRC rivii i?iCu re rn&4 i iAyd-v r-ilyi-w7 iQT
Program/Facility Name:
County:
AAA/Contractor
Aess: � 7
Completed By:
City State, Zip Code: V
13,1
rz_&z1
Date:
7 3/l-0l9
TelephvDD
�9- V -
rhi 1 1: rkrlA" Inr, Al IA�.17-C.0 L14.71KU1.l1V1`I3 rvK ri,LUJ IKAIiVL 11VrOKMAIMIN WHIUH WILL HELY YOU COMYLE'I'E
THIS FORM.
1. Briefly describe the geographic area served by the program/facility and the type of service provided:
7
For questions 2-5, please indicate the following:
Total I
White
Black
Hispanic
%
Other
Female
Disabled
Over 40
2.Population of area served
Source of data
�qp
L3
Jr
oZ
S�
3.Staff currently employed
Source of data
S
/s-
U
U
�D
4.Clients currently enrolled/registered
Source of dataIaVLO
9
U
�s
By
7
d 4)
5.Advisory/Governing Board if applicable
Source of data
rAni it. Uor, A ar.rAmA i L Jnr.r, i Vr rArL' K r VK AIN Y r.1SrLA1vA I IUfNb KLVUIKENu MUKL SYAC,L.
1. Is an Assurance of Compliance on file with DOEA?
2. Compare the staff composition to the population. Is staff representative of the population?
3. Are eligibility requirements for services applied to clients and applicants without regard to race, color,
national origin, sex, age, religion or disability?
N/A
❑
N/A
N/A
❑
YES
El
YES
YES
1
NO
❑
NO
NO
❑
4. Are all benefits, services and facilities available to applicants and participants in an equally effective -
manner regardless of race, sex, color, age, national origin, religion or disability?
N/A
❑
YES
1
NO
❑
5. For in -patient services, are room assignments made without regard to race, color, national origin
or disability?
N/A
4
YES
❑
NO
❑
6. Is the program/facility accessible to non-English speaking clients?
N/A
❑
YES
113-11
NO
❑
7. Are employees, applicants aioparticip s informed of their protection against discrimination? If YES,
how? Verbal Written RrPoster U01,
N/A
❑
YES
V
NO
El
8. Give the number and current status of any discrimination complaints regarding services or employment filed
against the program/facility.
N/A
V
NUMBER
1 6 D 4
9. Is the program/facility physically accessible to mobility, hearing, and sight -impaired individuals?
N/A
❑
YI4 NO
❑
PART III: THE FOLLOWING QUESTIONS APPLY TO PROGRAMS AND FACILITIES WITH 15 OR MORE EMPLOYEES. IF NO
EXPLAIN
10. Has a self -evaluation been conducted to identify any barriers to serving disabled individuals, and to make
any necessary modifications? YES NO
❑ ❑
11. Is there an established grievance procedure that incorporates due process in the resolution of complaints?
YES
❑
NO
❑
12. Has a person been designated to coordinate Section 504 compliance activities?
YES
❑
NO
❑
13. Do recruitment and notification materials advise applicants, employees and participants of nondiscrimination
on the basis of disability?
YES
❑
NO
❑
14. Are auxiliary aids available to assure accessibility of services to hearing and sight -impaired individuals?
YES
NO
PART IV: FOR PROGRAMS OR FACILITIES WITH 50 OR MORE EMPLOYEES AND FEDERAL CONTRACTS OF $50,000.00 OR
MORE.
15. Do you have a written affirmative action plan? If NO, explain. YES NO
❑ ❑
DOEA
USE ONLY
Reviewed B7
In Compliance: YES NO* ❑
Program Office
*Notice of Corrective Action Sent
Date
Telephone
Response Due
On -Site ❑ Desk Review ❑
Response Received
Revised August 2010, Page 2 of 2
GCA - 11
2
160 4
INSTRUCTIONS FOR THE CIVIL RIGHTS COMPLIANCE CHECKLIST
Describe the geographic service area such as a district, county, city or other locality. If the program/facility serves a
specific target population such as adolescents, describe the target population. Also, define the type of service
provided.
2. Enter the percent of the population served by race and sex. The population served includes persons in the
geographical area for which services are provided such as a city, county or other regional area. Population statistics
can be obtained from local chambers of commerce, libraries, or any publication from the 1980 Census containing
Florida population statistics. Include the source of your population statistics. ("Other" races include Asian/Pacific
Islanders and American Indian/Alaskan Natives.)
3. Enter the total number of full-time staff and their percent by race, sex and disability. Include the effective date of
your summary.
4. Enter the total number of clients who are enrolled, registered or currently served by the program or facility, and list
their percent by race, sex and disability. Include the date that enrollment was counted.
5. Enter the total number of advisory board members and their percent by race, sex, and disability. If there is no
advisory or governing board, leave this section blank.
6. Each recipient of federal financial assistance must have on file an assurance that the program will be conducted in
compliance with all nondiscriminatory provisions as required in 45 CFR 80. This is usually a standard part of the
contract language for DOEA recipients and their sub -grantees, 45 CFR 80.4 (a).
7. Is the race, sex, and national origin of the staff reflective of the general population? For example, if 10% of the
population is Hispanic, is there a comparable percentage of Hispanic staff.
8. Where there is a significant variation between the race, sex or ethnic composition of the clients and their availability
in the population, the program/facility has the responsibility to determine the reasons for such variation and take
whatever action may be necessary to correct any discrimination. Some legitimate disparities may exist when
programs are sanctioned to serve target populations such as elderly or disabled persons, 45 CFR 80.3 (b) (6).
9. Do eligibility requirements unlawfully exclude persons in protected groups from the provision of services or
employment? Evidence of such may be indicated in staff and client representation (Questions 3 and 4) and also
through on -site record analysis of persons who applied but were denied services or employment, 45 CFR 80.3 (a) and
45 CFR 80.1 (b) (2).
10. Participants or clients must be provided services such as medical, nursing and dental care, laboratory services,
physical and recreational therapies, counseling and social services without regard to race, sex, color, national origin,
religion, age or disability. Courtesy titles, appointment scheduling and accuracy of record keeping must be applied
uniformly and without regard to race, sex, color, national origin, religion, age or disability. Entrances, waiting
rooms, reception areas, restrooms and other facilities must also be equally available to all clients, 45 CFR 80.3 (b).
1 ] . For in -patient services, residents must be assigned to rooms, wards, etc., without regard to race, color, national origin
or disability. Also, residents must not be asked whether they are willing to share accommodations with persons of a
different race, color, national origin, or disability, 45 CFR 80.3 (a).
12. The program/facility and all services must be accessible to participants and applicants, including those persons who
may not speak English. In geographic areas where a significant population of non-English speaking people live,
program accessibility may include the employment of bilingual staff. In other areas, it is sufficient to have a policy
or plan for service, such as a current list of names and telephone numbers of bilingual individuals who will assist in
the provision of services, 45 CFR 80.3 (a).
GCA - 12
I bD 4
13. Programs/facilities must make information regarding the nondiscriminatory provisions of Title VI available to their
participants, beneficiaries or any other interested parties. This should include information on their right to file a
complaint of discrimination with either the Florida Department of Elder Affairs or the U.S. Department of HHS. The
information may be supplied verbally or in writing to every individual, or may be supplied through the use of an
equal opportunity policy poster displayed in a public area of the facility, 45 CFR 80.6 (d).
14. Report number of discrimination complaints filed against the program/facility. Indicate the basis, e.g., race, color,
creed, sex, age, national origin, disability, retaliation; the issues involved, e.g., services or employment, placement,
termination, etc. Indicate the civil rights law or policy alleged to have been violated along with the name and address
of the local, state or federal agency with whom the complaint has been filed. Indicate the current status, e.g., settled,
no reasonable cause found, failure to conciliate, failure to cooperate, under review, etc.
15. The program/facility must be physically accessible to disabled individuals. Physical accessibility includes designated
parking areas, curb cuts or level approaches, ramps and adequate widths to entrances. The lobby, public telephone,
restroom facilities, water fountains, information and admissions offices should be accessible. Door widths and traffic
areas of administrative offices, cafeterias, restrooms, recreation areas, counters and serving lines should be observed
for accessibility. Elevators should be observed for door width, and Braille or raised numbers. Switches and controls
for light, heat, ventilation, fire alarms, and other essentials should be installed at an appropriate height for mobility
impaired individuals.
16. Section 504 of the Rehabilitation Act of 1973 requires that a recipient of federal financial assistance conduct a self -
evaluation to identify any accessibility barriers. Self -evaluation is a four step process:
a. With the assistance of a disabled individual/organization, evaluate current practices and policies which do not
comply with Section 504.
b. Modify policies and practices that do not meet Section 504 requirements.
c. Take remedial steps to eliminate any discrimination that has been identified.
d. Maintain self -evaluation on file. (This checklist may be used to satisfy this requirement if these four steps have
been followed.), 45 CFR 84.6.
17. Programs or facilities that employ 15 or more persons must adopt grievance procedures that incorporate appropriate
due process standards and provide for the prompt and equitable resolution of complaints alleging any action
prohibited by Section 504.45 CFR 84.7 (b).
18. Programs or facilities that employ 15 or more persons must designate at least one person to coordinate efforts to
comply with Section 504.45 CFR 84.7 (a).
19. Continuing steps must be taken to notify employees and the public of the program/facility's policy of
nondiscrimination on the basis of disability. This includes recruitment material, notices for hearings, newspaper ads,
and other appropriate written communication, 45 CFR 84.8 (a).
20. Programs/facilities that employ 15 or more persons must provide appropriate auxiliary aids to persons with impaired
sensory, manual or speaking skills where necessary. Auxiliary aids may include, but are not limited to, interpreters
for hearing impaired individuals, taped or Braille materials, or any alternative resources that can be used to provide
equally effective services, 45 CFR 84.52 (d).
21. Programs/facilities with 50 or more employees and $50,000.00 in federal contracts must develop, implement and
maintain a written affirmative action compliance program in accordance with Executive Order 11246, 41 CFR 60 and
Title VI of the Civil Rights Act of 1964, as amended.
DOEA Form 101-13, Revised August 2010
GCA - 13
160 4
BACKGROUND SCREENING
Affidavit of Compliance - Employer
AUTHORITY: This form is required annually of all employers to comply with the attestation
requirements set forth in section 435.05(3), Florida Statutes.
➢ The term "employer" means any person or entity required by law to conduct background screening,
including but not limited to, Area Agencies on Aging, Aging Resource Centers, Aging and Disability
Resource Centers, Lead Agencies, Long -Term Care Ombudsman Program, Serving Health Insurance Needs
of Elders Program, Service Providers, Diversion Providers, and any other person or entity which hires
employees or has volunteers in service who meet the definition of a direct service provider. See §§
435.02, 430.0402, Fla. Stat.
➢ A direct service provider is "a person 18 years of age or older who, pursuant to a program to provide
services to the elderly, has direct, face-to-face contact with a client while providing services to the client
and has access to the client's living area, funds, personal property, or personal identification information
as defined in s. 817.568. The term includes coordinators, managers, and supervisors of residential
facilities; and volunteers." § 430.0402(1)(b), Fla. Stat.
ATTESTATION: ca
As the duly authorized representative of
{ ,p� Employer Name U
located at c l���O A62,71k � �ji >y/ 1,c�
Street Address City St a ZIP code
I' �� do hereby affirm under penalty of perjury.. l Name of Representative
that the above named employer is in compliance with the provisions of Chapter 435 and section
430.0402, Florida Statutes, regarding level 2 background screening.
�f' .
Signature of Representative Date ���
STATE OF FLORIDA, COUNTY OF
Sworn to (or affirmed) and subscribed before me this ° day of yl 20 61 . by �<
(Name of Representative) who is personally known 7
to me or produced
as proof of identification.�r.
n r a. c.r, ,
.9
Print, Type, or Stamp Commissioned Name of Notary Public Notarv.Ptibllc — — — — — — — — —
T R I N A W CAR80NNEAU
EA Form 235, Affidavit of Compliance -Employer, Effective April 2012 _ ' '�' Commission s GG$MQjn
Form available at:http://eideraffairs.state.flus/english/backgroundscreeninep>� `per. P. My Comm. Expires Jul13,2021
16D 4
EXHIBIT I.13 GRANTCERTIFICATIONS AND ASSURANCES
/9-7.rf&-D/- of
Collier County Solicitation No.
I, / 'L-n� �i /�O � , hereby certify that to the best of my knowledge,
neither I norm spouse, dependent child, general partner, or any organization for which I am serving as
an officer, director, trustee, general partner or employee, or any person or organization with whom I am
negotiating or have an arrangement concerning prospective employment has a financial interest in this
matter.
I further certify to the best of my knowledge that this matter will not affect the financial interests of any
member of my household. Also, to the best of my knowledge, no member of my household; no relative
with whom I have a close relationship; no one with whom my spouse, parent or dependent child has or
seeks employment; and no organization with which I am seeking a business relationship nor which I now
serve actively or have served within the last year are parties or represent a party to the matter.
I also acknowledge my responsibility to disclose the acquisition of any financial or personal interest as
described above that would be affected by the matter, and to disclose any interest I, or anyone noted
above, has in any person or organization that does become involved in, or is affected at a later date by, the
conduct of this matter.
C0
Name
Signatu
Position Date
Privacy Act Statement
Title I of the Ethics in Government Act of 1978 (5 U.S.C. App.), Executive Order 12674 and 5 CFR Part
2634, Subpart I require the reporting of this information. The primary use of the information on this form
is for review by officials of The Justice Department to determine compliance with applicable federal
conflict of interest laws and regulations. Additional disclosures of the information on this report may be
made: (1) to a federal, state or local law enforcement agency if the Justice Department becomes aware of
a violation or potential violation of law or regulations; (2) to a court or party in a court or federal
administrative proceeding if the government is a party or in order to comply with a judge -issued
subpoena; (3) to a source when necessary to obtain information relevant to a conflict of interest
investigation or decision; (4) to the National Archives and Records Administration or the General
Services Administration in records management inspections; (5) to the Office of Management and Budget
during legislative coordination on private relief legislation; and (6) in response to a request for discovery
or for the appearance of a witness in a judicial or administrative proceeding, if the information is relevant
to the subject matter. This confidential certification will not be disclosed to any requesting person unless
authorized by law. See also the OGE/GOVT-2 executive branch -wide Privacy Act system of records.
GCA - 15
160
EXIIIBITLB
GjlANTCERTIFICATIONS AND ASSURANCES
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GCA - 16
160 4
EXHIBITLB GRANT" CERTIFICATIONS AND ASSURANCES
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GCA - 17
160 4
ACORO® CERTIFICATE OF LIABILITY INSURANCE
Ill
DATE(MM/DD/YYYY)
1 05/08/2020
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT Joan Randolph
NAME:
Comegys Insurance Agency
PHONE (727) 521-2100 FAX (727) 528-0626
A/C No EXt : A/C, No
E-MAIL joan.randolph@comegys.com
ADDRESS:
One Beach Drive S. E. Ste. 230
INSURER(S) AFFORDING COVERAGE
NAIC #
Saint Petersburg FL 33701
INSURERA: Lloyds of London
INSURED
INSURER B
Shifting Sands Adult Day Care, LLC
INSURER C :
28410 Bonita Crossings Blvd.
INSURER D :
Unit B7
INSURER E
Bonita Springs FL 34134
INSURER F :
COVERAGES CERTIFICATE NUMBER: 20/21 GL/PL REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
INSD
WVD
POLICYNUMBER
POLICY EFF
MMIDD/YYYY
POLICY EXP
MM/DD/YYYY
LIMITS
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE X OCCUR
A A N
PREMISES Ea occurrence
50,000
$
MED EXP (Any one person)
$ 5,000
PERSONAL&ADV INJURY
$ 1,000,000
A
Y
1135200
05/01/2020
05/01/2021
GEN'LAGGREGATE LIMITAPPLIES PER:
GENERAL AGGREGATE
$ 3,000,000
X POLICY ❑ PRO- ❑ LOC
JECT
PRODUCTS - COMP/OPAGG
$ 1,000,000
Professional Liability
s 1,000,000
OTHER
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
Ea accident
$
BODILY INJURY (Per person)
$
ANYAUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
$
HCLAIMS-MADE
AGGREGATE
$
EXCESS LAB
DIED I I RETENTION $
$
WORKERS COMPENSATION
ANDEMPLOYERS'LIABILITY YIN
PER OTH-
STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT
$
OFFICER/MEMBER EXCLUDED? ❑
NIA
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE
$
If yes, describe under
DESCRIPTION OF OPERATIONS below
I
E.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The Certificate Holder is included as additional insured per written contract with respect to General Liability.
07_111 f PaR a 9G10da[I
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Muriel Court, L.P c/oAJS Realty Group ACCORDANCE WITH THE POLICY PROVISIONS.
4980 Tamiami Trail North
AUTHORIZED REPRESENTATIVE
Suite 201
Naples FL 34103
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
ACORO® CERTIFICATE OF LIABILITY INSURANCE
16. �
DATE(MM/DD/YYYY)
05/08/2020
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT Joan Randolph
NAME:
Comegys Insurance Agency
PHONE (727) 521-2100 FAX (727) 528-0626
A/C No Et : AIC, No
E-MAIL joan.randolph@comegys.com
ADDRESS:
One Beach Drive S. E. Ste. 230
INSURER(S) AFFORDING COVERAGE
NAIC #
Saint Petersburg FL 33701
INSURERA: Lloyds of London
INSURED
INSURER B
Shifting Sands Adult Day Care, LLC
INSURER C :
28410 Bonita Crossings Blvd.
INSURER D :
Unit B7
INSURER E
Bonita Springs FL 34134
INSURER F
COVERAGES CERTIFICATE NUMBER: 20/21 GL/PL REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
AUUL
INSD
bIJUK
WVD
POLICY NUMBER
POLICY EFF
MM/DD/YYYY
POLICY EXP
MM/DD/YYYY
LIMITS
X
COMMERCIAL GENERALLIABILITY
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE X OCCUR
A ^ T17-50,000
PREMISES Ea occurrence
$
MED EXP (Any one person)
$ 5,000
PERSONAL &ADV INJURY
$ 1,000,000
A
Y
1135200
05/01/2020
05/01/2021
GEN'L AGGREGATE LIMITAPPLIES PER:
GENERALAGGREGATE
$ 3,000,000
X POLICY ❑JECT PRO ❑ LOC
PRODUCTS - COMP/OPAGG
$ 1,000,000
Professional Liability
$ 1.000,000
OTHER:
AUTOMOBILE
LIABILITY
COEa accMBidentINED SINGLE LIMIT
$
BODILY INJURY (Per person)
$
ANYAUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
$
HCLAIMS-MADE
AGGREGATE
$
EXCESS LIAB
DED I I RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
PER OTH-
STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑
OFFICER/MEMBER EXCLUDED?
N/A
E.L. EACH ACCIDENT
$
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE
$
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Collier County Board of County Commissioners is included as additional insured with respect to General Liability on a primary and non-contributory basis if
and to the extent required by written contract.
(:LKI IFIUAI L HULULK (.ANL LLLAI IUN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Collier County Board of County Commissioners ACCORDANCE WITH THE POLICY PROVISIONS.
3295 Tamiami Trail E.
AUTHORIZED REPRESENTATIVE (�
Naples FL 34112 x
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
16D 4
A� Or CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
05/14/2020
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
"Marsh USA, Inc.
1166 Avenue of the Americas
New York, NY 10036
Attn: Atlanta.Certrequest@marsh.com
CONTACT
NAME:
PHONE FAX
A/c No):
E-MAIL
ADDRESS:
INSURERS AFFORDING COVERAGE
NAIC #
INSURER A: Illinois National Insurance Company
23817
CN103161462-FL-WC-20-21 815021
INSURED
DecisionHR, Inc.
INSURER B :
INSURER C :
11101 Roosevelt Blvd N
St. Petersburg, FL 33716
INSURER D
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: ATL-005066360-02 REVISION N1IMRFR• 1
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INTR
R
TYPE OF INSURANCE
INSO
WVD
POLICY NUMBER
MM DDfYYYY
EXP
MM/DDY
/YYYY
LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE OCCUR
EACH OCCURRENCE
$
DAMAGETO
PREMISES Ea occurrence)
ccurrence)$
GEN'L
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
AGGREGATE LIMIT APPLIES PER:
PRO-
JECT POLICY LOC
OTHER:
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
$
$
AUTOMOBILE
LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
COMBINED SINGLE LIMIT
Ea accident
$
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
UMBRELLA LIAB
EXCESS LAB
OCCUR
EACH OCCURRENCE
$
HCLAIMS-MADE
AGGREGATE
$
DED I I RETENTION $
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N
OFFICER/MEMBEREXCLUDED?
(Mandatoryin NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
WC 048425874
/ /
06/01/2 221
X PER OTH-
STATUTE ER
E.L. EACH ACCIDENT
$ 1,000,000
E.L. DISEASE - EA EMPLOYEE
$ 1,000.000
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Coverage is provided for only those employees leased to but not subcontractors of Shifting Sands Adult Day Center, LLC
Collier County Board of County
Commissioners
3295 Tamiami Trail E.
Naples, FL 34112
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Henry L. Whiting z.. _ y
@ 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD