36C26120Q0099-001.docx

B.3 Draft Statement of Work Surveying Community Nursing Homes, Community Residential Care Facilities, Adult Day Health Care Facilities, Grant and Per Diem Facilities and Vet Centers for Life Safety Code Compliance for SFVAHCS

SCOPE OF WORK

1. Overview

1.1 The contractor shall provide professional safety surveys at approximately 78 Community Nursing Homes, Community Residential Care Facilities, Adult Day Health Care (ADHC) Facilities, Grant and Per Diem Facilities and Vet Centers. The locations for these facilities are located throughout the area in Northern California extending as far north as Eureka, California to far south as Pacifica, California.

1.2 The Contracting Officer Representative (COR) will provide a list of the locations of the facilities and a POC (point of contact) (see attached list) San Francisco VA is the primary location of the COR at 4150 Clement, San Francisco, CA. COR for this contract will be Patrick Freeman.

1.3 The contractor must be a licensed registered Fire Protection Engineer shall have expertise in the Life Safety Code, National Fire Protection Association (NFPA 101) and the VA community veteran care program criteria for these types of facilities. The survey will be based on compliance with the applicable edition of the Life Safety Code (LSC), NFPA 101, including other NFPA standards as referenced by the LSC. The life safety code assessments will be completed using a provided check list from the COR and using NFPA standards and VA policies as guidelines. Local and State laws may also be taken into account when COR instructs contactor to use them.

The C&A requirements do not apply, and that a Security Accreditation Package is not required.

1.4 The contractor shall verify records of all sprinkler systems testing and fire drills conducted.

1.5 The contractor shall verify all City and County Fire and Health inspection records if available.

1.6 All payments for services performed will be invoiced through Austin, Texas for final payment.

Sizes of facilities range from 1,000-60,000 square feet and cover a 300 mile radius from San Francisco, CA to Eureka, CA and as far east as Rancho Cordova, CA.

2. Tasks

2.1 The contractor shall notify the facilities Director or persons responsible for the facility at least five business days prior to surveying the facility. The exception to this is when the need of the veteran is immediate.

2.2 The contractor shall provide the VA with the completed and signed checklist, along with a cover letter summarizing the survey results, significant findings and/or deficiencies.

2.3 The contractor shall provide recommendations for corrective action in writing. The report shall be delivered to the Facility Safety Office 14 days after the survey has been completed.

2.4 The contractor shall provide photos to clarify certain points in the final report. These photos shall NOT include staff or patients at the facility.

3. Travel Expense

3.1 All travel expenses will be the responsibility of the contactor and should be included in the estimated cost price as per GSA pricing for hotels and mileage.

.4. Hours of Work

4.1. These surveys shall be completed during business hours of 8:00 AM and 4:30 PM. Surveys should not be completed on Federal Holidays.

5. Time and duration

5.1. The Service of this contract will be 1 year from the award date of the contract with an option to renew every year for four years.

6. Contractor Performance

6.1. The COR will monitor the contractor’s performance using a Quality Assurance Surveillance Plan (QASP). The COR and the Contractor will coordinate and agree upon a QASP inspection plan within 30 days after the contract effective date.

7. Contractor Personnel Security Requirements:

Reference:

VHA Directive 0710, Personnel Security and Suitability Program/ May 18, 2007 VA Handbook 0710, Personnel Suitability and Security Program/ September 10, 2004

Upon contract award, all key personnel shall be subject to the appropriate type of background investigation or screening per VA/VHA directive 0710 and must receive a favorable adjudication from CCA Personnel Security Specialist or VA Security and Investigations Center (SIC) depending on investigation or screening required. This requirement is applicable to all subcontract personnel. If the investigation or screening is not completed prior to the start date of the contract, the Contractor will be responsible for the actions of those individuals they provide to perform work for VA.

Contract personnel who previously received a favorable adjudication as a result of a Government background investigation or screening may be exempt from this contract requirement. They must provide documentation to support the previous adjudication. Proof of previous adjudication must be submitted by the Contractor to the VA Contracting Officer. Proof of previous adjudication is subject to verification. Some positions maybe subject to periodic re-investigation/screening.

1. Position Risk/Sensitivity – For all positions required under this contract, the position risk/sensitivity has been designated as: Low Risk

2. Background Investigation/Screening – It is anticipated that the Contractor or contract personnel will be providing services at a VA facility(s) for MORE than 180 days under a single contract or series of contracts, or have access to VA computer data systems. The background investigation/screening commensurate with the requirements of this contract is: NACI

3. Contractor Responsibilities

a. The Contractor shall prescreen all personnel to ensure they are able to read, write, speak, and understand the English language.

b. The Contractor shall submit or have their contract personnel submit the following required forms to the Personnel Security Specialist or VA Contracting Officer, through the COR or Personnel Security Specialist, within five (5) business days of contract award.

4. Low Risk Investigative Requirements

a. All investigations must be completed through the Electronic Questionnaires for Investigations Process (e-QIP). All contractors must complete the Authorization for Investigation Worksheet before they can complete the online e-Qip.

b. Optional Form 306, Declaration for Federal Employment provide by VA point of contact.

c. Electronic Fingerprint Verification or FD 258, U.S. Department of Justice Fingerprint Applicant Chart.

d. Once the items requested are completed, the Contractor is authorized to provide services under the contract. As previously stated, if the investigation or screening is not completed prior to the start date of the contract, the Contractor will be responsible for the actions of those individuals they provide to perform work for VA.

e. The Contractor, when notified of an unfavorable determination by the Government, shall withdraw the contract person from consideration of working under the contract.

f. Failure to comply with these Contractor personnel security requirements may result in termination of the contract for default.

5. Government Responsibilities

a. The VA Contracting Officer will ensure a time for contract personnel to complete the fingerprint portion of this requirement, if any, and the COR will responsible for performing any duties assigned by the VA Contracting Officer with regard to fulfilling the Contractor personnel security requirements described herein.

b. Upon receipt, the local VA facility or VA SIC, depending on the type of investigation/screening required, will review the accuracy of the items requested in paragraph above, and forward these items to OPM to conduct their portion of the background investigation or screening, as applicable.

c. The requesting VA facility will pay for any portion of the investigation or screening conducted by OPM, if any.

d. Depending on the type of investigation/screening required, the Personnel Security Specialist, or VA SIC will notify the VA Contracting Officer of the adjudicating results of the background investigation or screening.

e. The VA Contracting Officer and Personnel Security Specialist will ensure that the required investigations or screening have been completed or are in the process of being requested.

Personnel Identity Verification (PIV) of Contractor Personnel

In accordance with FAR 52.204-9 and VA Directive 0735 – Personal Identity Verification of Federal Employees and Contractors, any contract person who requires routine physical access to a Federally-controlled facility and/or routine access to a Federally-controlled information system will be required to verify their identity prior to providing services under the contract. Prior to providing services under the contract, each contract person will be asked to provide two (2) forms of identification from the Accepted Identification Documentation List to the appropriate VA representative in order to obtain a proper VA-issued identification card. The COR, or designee, will be responsible for sponsoring each contract person that requires a VA-issued identification card.

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Facilities to be Inspected.xls Sheet1

Type Code County Code NFPA (Latest Edition) Fire Code Safety & Engineering Review Schedule for 2012 - 2014 Address Point of Contact Phone Last Review Sq. Ft. Contact

ADHC HUMBOLDT Ch.17 ADHC of Mad River 3800 Janes Road, Arcata, CA 95518 (707) 822-4866 3/3/11 w/ 2 Ds 4,800 Larimore

ADHC HUMBOLDT Ch.17 Eureka ADHC, 1901 California St., Eureka, CA 95501, 707-444-8254 3/3/11 w/ 1 D 5,200 Larimore

ADHC MARIN Ch.17 Marin ADHC, (Lifelong), 1905 Novato Blvd., Novato, CA 94947, 415-897-6884 4/12/11 w/ 0 Ds 9,500 Larimore

ADHC MENDOCINO Ch.17 Sherwood Oaks ADHC 130 Dana Street, Fort Bragg, CA 95437 415-489-3307 4/21/14 22,000 Larimore

ADHC NAPA Ch.17 Napa Valley Hospice & ADHC Services, 414 S. Jefferson, Napa, CA 94558 CEO: Linda, Pgm Dir: Celine Regalia, 707-258-9087 707-258-9087 4/5/11 w/ 0 Ds 9,700 Larimore

ADHC SF Ch.17 Stepping Stone, Mission Creek ADHC, 930 4th St., San Francisco, CA 94158 (& S. S. Admin Offcs) Moli Steinert, exec dir, St Stone 415-974-6785 3/3/11 - 0 Ds 1,500 Larimore

ADHC SF Ch.17 Ruth Anne Rosenberg ADHC 3600 Geary Blvd., San Francisco, CA 94118 415-489-3307 4/21/14 2,500 Dobbs/Brunner

ADHC SF Ch.17 Bayview/Hunter's Point ADHC, , 1250 LaSalle, San Francisco, CA 94124 Shiela Hembry, Pgm Director 415-826-4774 3/3/11 w/ 1 D 5,200 Larimore

ADHC SF Ch.17 IOA Ruth A Rosenberg AD Svcs Pgm, 3575 Geary Blvd., San Francisco, CA 94118, Tracy McCloud, ADC Director 415-750-4180 4/12/11 w/ 0 Ds 9,700 Larimore

ADHC SF Ch.33 Jewish Home, 302 Silver Ave., San Francisco, CA 94112, William T. Foster, Cmty Liaison Dir, 415-706-0256 415-334-2500 7/14/11? 9,700 Larimore

ADHC SF Ch.17 Stepping Stone, Mabini ADHC Center, 55 Mabini St., San Francisco, CA 94107, 415-882-7301 4/5/11 - 0 Ds 49,000 Larimore

ADHC SF Ch.17 Stepping Stone, Golden Gate ADHC Ctr, 350 Golden Gate Ave., San Francisco, CA 94102, 415-359-9210 4/5/11 - 0 Ds 51,000 Larimore

ADHC SONOMA Ch.17 Southwest ADHC, 684 Benecia Drive, Santa Rosa, CA 95409, Susan Beer, dir. 707-573-4522 4/12/11 w/ 0 Ds 8,700 Larimore

BC HUMBOLDT Ch.33 North Coast Veterans Resource Center 919 “E” St. Eureka, CA 95501 Ben Ferrell, (707) 442-5852 4,500 Dobbs/Brunner

BC HUMBOLDT Ch.33 North Coast Veterans Resource Center 121 4th Street, Eureka, CA 95501 Bickerstaff 415-489-3307 4/21/14 9,500 Dobbs/Brunner

BC HUMBOLDT Ch.33 North Coast Veterans Resource Center 109 4th Street, Eureka, CA 95501 Bickerstaff 415-489-3307 4/21/14 10,000 Dobbs/Brunner

BC HUMBOLDT Ch.33 Homeward Bound 199 North Hamilton Parkway, Novato, CA 94945 (415) 382-3532 12,000 Dobbs/Brunner

BC MARIN Ch.33 Homeward Bound New Beginnings 199 North Hamilton Parkway, Novato, CA 94949 Bickerstaff (415) 382-3532 4/21/14 1,500 Dobbs/Brunner

BC MARIN Ch.33 Center Point, Inc. (Mens) 603 D Street, San Raphael, CA 94901 Miller 415-456-6655 4/21/14 10,000 Dobbs/Brunner

BC MARIN Ch.33 Center Point, Inc. (Womens) 1477 Lincoln Avenue, San Raphael, CA 94901 Miller 415-349-4390 4/21/14 12,000 Dobbs/Brunner

BC SF Ch.33 Salvation Army Harbor House 407 9th Street, San Francisco, CA Bickerstaff 415-489-3307 4/21/14 1,500 Dobbs/Brunner

BC SF Ch.33 Walden House 890 Hayes Street, San Francisco, CCA 94117 Loza 415-725-1986 4/21/14 1,500 Brunner

BC SF Ch.33 Salvation Army Railton Place 242 Turk Street, San Francisco, CA Bickerstaff 415-489-3307 4/21/14 2,000 Dobbs/Brunner

BC SF Ch.33 Swords to Plowshares 27 DeMont Fort, San Francisco, CA 94112 Lennon 415-349-4390 4/21/14 2,000 Dobbs/Brunner

BC SF Ch.33 Walden House 815 Buena Vista Avenue, San Francisco, CA 94117 Lim 415-298-5016 4/21/14 2,000 Brunner

BC SF Ch.33 Swords to Ploughshares 42 DeMont Fort, San Francisco, CA 94112 Lennon 415-349-4390 4/21/14 2,500 Dobbs/Brunner

BC SF Ch.33 MSC South 525 5th Street, San Francisco, CA 94103 4/21/14 2,500 Dobbs/Brunner

BC SF Ch.33 The Sanctuary 201 8th Street, San Francisco, CA 94103 4/21/14 3,000 Dobbs/Brunner

BC SF Ch.33 Walden House 214 Haight Street, San Francisco, CA 94117 Miller 415-558-4202 4/21/14 3,500 Dobbs/Brunner

BC SF Ch.33 Swords to Plowshares 1432 Halibut Court, Treasure Island, SF, CA 94130 (415) 834-0341 15,000 Dobbs/Brunner

BC SF Ch.33 Salvation Army Harbor Light and DETOX Center 1275 Harrison St. San Francisco, CA 94103 (415) 503-3044 Dobbs/Brunner

BC SONOMA Ch.33 North Bay Resource Center 3 Rocca Dr. Petaluma CA : Att: Lauralyn Castle 707-578.2784 1,500 Dobbs/Brunner

BC SONOMA Ch.33 Interfaith Shelter Network 1635 Mariposa Drive, Santa Rosa, CA 95405 Bickerstaff 415-489-3307 4/21/14 1,500 Dobbs/Brunner

BC SONOMA Ch.33 Santa Rosa Council Chambers 2149 West Hearn Avenue, Santa Rosa, CA 95405 Bickerstaff 415-489-3307 4/21/14 5,500 Dobbs/Brunner

BC SONOMA Ch.33 Turning Point 440 Arrowood Avenue, Santa Rosa, CA 95407 Bickerstaff 415-489-3307 4/21/14 15,000 Dobbs/Brunner

GP LAKE Ch.33 Hilltop Recovery (Women's) 3937 Foothill Drive, Lucerne, CA 95458 Bickerstaff 415-489-3307 2/21/14 2,000 Dobbs/Brunner

GP MENDOCINO Ch.33 Ford Street Project 139 Ford Street, Ukiah, CA 95482 Bickerstaff 415.410.1721 2/21/14 5,000 Dobbs/Brunner

GP NAPA Ch.33 Hilltop Recovery (Men's) 10155 Socrates Mine Road, Middleton, CA 95461 Bickerstaff 415-489-3307 2/21/14 6,000 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 38 Williams #A San Francisco CA 94124 Bickerstaff 415.410.1721 2/21/14 1,500 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 38 Williams Ave #B San Francisco CA 94124 Bickerstaff 415.410.1721 2/21/14 1,500 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 625 LaSalle Avenue, San Francisco, CA 94124 Bickerstaff 415.410.1721 2/21/14 1,500 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 1224 Revere Street #B San Francisco, CA 94124 Bickerstaff 415.410.1721 2/21/14 1,500 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 1224 Revere Street #C San Francisco, CA 94124 Bickerstaff 415.410.1721 2/21/14 1,500 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 1239 Quesada Avenue, San Francisco, CA 94124 Bickerstaff 415.410.1721 2/21/14 1,500 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 1276 Palou Avenue, San Francisco, CA 94124 Bickerstaff 415.410.1721 2/21/14 1,500 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 1315 Newhall Street, San Francisco, CA 94124 Bickerstaff 415.410.1721 2/21/14 1,500 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 1730 LaSalle Avenue, San Francisco, CA 94124 Bickerstaff 415.410.1721 2/21/14 1,500 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 1732 LaSalle Avenue, San Francisco, CA 94124 Bickerstaff 415.410.1721 2/21/14 1,500 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 1780 McKinnon Street #B, San Francisco, CA 94124 Bickerstaff 415.410.1721 2/21/14 1,500 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 1780 McKinnon Street #C, San Francisco, CA 94124 Bickerstaff 415.410.1721 2/21/14 1,500 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 1784 McKinnon Street #B, San Francisco, CA 94124 Bickerstaff 415.410.1721 2/21/14 1,500 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 1784 McKinnon Street #A, San Francisco, CA 94124 Bickerstaff 415.410.1721 2/21/14 1,500 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 1784 McKinnon Street #C, San Francisco, CA 94124 Bickerstaff 415.410.1721 2/21/14 1,500 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 1911 Jennings Street, San Francisco, CA 94124 Bickerstaff 415.410.1721 2/21/14 1,500 Dobbs/Brunner

GP SF Ch.33 Hope House for Veterans 4502 3rd Street, San Francisco, CA 94124 Bickerstaff 415.410.1721 2/21/14 10,000 Dobbs/Brunner

GP SF Ch.33 SafeHaven Facility 420 Eddy Street, San Francisco, CA 94109 Bickerstaff 415.410.1721 2/21/14 15,000 Dobbs/Brunner

GP SF Ch.33 Next Door Shelter 1001 Polk Street, San Francisco, CA 94109 Blake 415-292-2180 4/21/14 20,000 Brunner

NH HUMBOLDT Ch.18/19 Fortuna Rehab & Wellness Ctr (was St. Luke's), 2321 Newburg Road, Fortuna, CA 95540, Samantha L'Allier, Administrator 707-725-4467 707-725-2441 3/3/2011 correx needed 36,000 Larimore

NH HUMBOLDT Ch.18/19 Pacific Rehab & Wellness Center, 2211 Harrison Ave., Eureka, CA 95501, Lorena Smith 707-443-9767 5/23/11 - correx needed 37,000 Larimore

NH LAKE Ch.18/19 Cloverdale Health Care, 300 Cherry Creek Road, Cloverdale, CA 95425, 707-894-5201 3/2/11 - correx needed 36,500 Larimore

NH LAKE Ch.18/19 Meadowood Nursing Center, 3805 Dexter Lane, Clearlake, CA 95422, Renate Fassbinder, Adm 707-994-7769 Mar-12 38,000 Larimore

NH LAKE Ch.18/19 Evergreen Healthcare, Lakeport, 1291 Craig Ave., Lakeport, CA 95653, Mary Johnson, Adm 707-263-6382 5/23/11 - correx needed 45,000 Larimore

NH MARIN Ch.18/19 5th Ave HC, 1601 5th Ave., San Rafael, CA 94901, 415-456-7170 415-456-7170 4/12/2011 - 0 defcs 35,000 Larimore

NH MARIN Ch.18/19 Care Meridian 2390 Sir Francis Drake Blvd., Fairfax, CA 94930, DON & Adminstr: Shauna 415-256-8007 5/31/11 - correx needed 40,000 Larimore

NH MARIN Ch.18/19 Canyon Manor, 655 Canyon Road, Novato, CA 94947, Alan Jamison 415-892-1628 4/12/11 - 0 defcs 48,000 Larimore

NH MENDOCINO Ch.18/19 Sherwood Oaks Health Center, 1330 Dana St., Fort Bragg, CA 95437 707-964-6333 3/3/2011 - correx needed 42,000 Larimore

NH NAPA Ch.18/19 Golden Living Sierra Vista, 705 Trancas St., Napa, CA 94558, Administrator: Bryan Adams (acting) 707-255-6060 707-255-6060 4/12/2011 - 0 defcs 56,000 Larimore

NH SAN MATEO Ch.18/19 Linda Mar Care Center, 751 San Pedro Terrace Rd., Pacifica, CA 94044, 650-359-4800 650-359-4800 3/23/11 - 0 defcs 48,000 Larimore

NH SF Ch.18/19 19th Avenue HC (ref: Kindred 415-544-3500), 2403 19th Ave., San Francisco, CA 94116, 415-661-8787 4/12/2011 - 0 defcs 40,000 Larimore

NH SF Ch.18/19 Tunnell Center, 1359 Pine Street, San Francisco, CA 94109, Murial Han 415-673-8405 ?? 45,000 Larimore

NH SONOMA Ch.17 Park View Gardens, 3751 Montgomery Dr., Santa Rosa, CA 95405, 707-525-1250 Eric Moessing, admin, 707-525-1250 8,700 Larimore

NH SONOMA ch.18/19 Empres Post Acute (Skilled Nursing Facility) 300 Douglas Street, Petaluma, CA 94952 Bickerstaff 415-489-3307 2/21/14 22,000 Dobbs/Brunner

NH SONOMA Ch.18/19 Sonoma Healthcare, 1250 Broadway, Sonoma CA 95476, 707-938-8406 4/12/11 - 0 defcs, but recommdns 30,000 Larimore

NH SONOMA Ch.18/19 Petaluma Healthcare & Rehab / Evergreen, 300 Douglas Street, Petaluma, CA 94952, 707-763-6887 4/12/2011 - 0 defcs 37,500 Larimore

NH SONOMA Ch.18/19 Golden Living London Hse, 678 2nd St. West, Sonoma, CA 95476 707-938-1096 707-938-1643 4/12/2011 - 0 defcs 60,000 Larimore

VET SF Vet Center 2830 G Street, Suite A , Eureka, CA 95501 Vet Center 8/8/10 1,200

VET SF Vet Center 505 Polk St, San Francisco Vet Center 8/8/10 1,500

VET SONOMA Vet Center 6225 State Farm Drive Suite 101, Rohnert Park, CA 94928 Vet Center 6/8/14 2,000

&C&"Arial,Regular"&14APPENDIX A

FACILITIES TO BE INSPECTED

(SORTED BY COUNTY CODE)

&C&"Arial,Regular"&12Page &P of &N

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