Addendum No. 1 Fillable Forms RFP 25-165.docx

Request For Proposals for

Substance Use Disorder and Recovery Services Perinatal Services

Joshua Dugas, Acting Director Department of Behavioral Health

San Bernardino County Department of Behavioral Health Contracts Administration 550 Hospitality Lane, 1st Floor San Bernardino, CA 92415-0026

RFP - DBH 25-165

ePro Bid ID # DBHE26-ADMN-6323

ATTACHMENT A

PROPOSAL SUBMISSION CHECKLIST

Use this checklist to ensure that all items have been included. This form is to be completed and included in the proposal.

Proposer Name:

Address:

Telephone No.: ( ) FAX No.: ( ) Email Address:

Federal Tax ID:

RFP Contact:

Name of Authorized Representative:

Title of Authorized Representative:

By signing below, the individual acknowledges that he/she has the authority to bind the Proposer to the terms of the Proposal. The individual further acknowledges that he/she has read and understands the RFP, the contents of the Proposal and the Attachments, and attests to the accuracy of the information submitted therein.

Signature of Authorized Representative:

Date:

ATTACHMENT B

TABLE OF CONTENTS

Item Page Number

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

ATTACHMENT C

STATEMENTS OF CERTIFICATION

(initial and explain in E- Exceptions)

Region(s) propose to serve: Central Valley ☐ West Valley ☐ East Valley ☐ Mountain Region ☐ Desert Region ☐ All ☐

Signature (Authorized Signer) Date

Print/Type Name

Company/Agency

Address

ATTACHMENT D

REPORTABLE CONDITIONS

(Initial and explain in Attachment E- Disclosures/Exceptions)

Does the Proposer or agency/organization have any former county administrative officials who are employees or representatives?

Has the Proposer or agency/organization had completed similar contracts or projects during the last five years?

Has the Proposer or agency/organization had any contracts terminated prior to the original termination date?

Does the Proposer or agency/organization have similar contracts currently in place?

Does the Proposer or agency/organization have controlling interest in any agencies providing equivalent or similar services?

Does the Proposer or agency/organization have any financial interest in other lines of business?

Does the Proposer or agency/organization have any pending litigation regarding crimes or offenses, financial misconduct, or fraud involving the Proposer’s business, or any of its officers, employees, and/or consultants thereof, in connection with contracts?

Does the Proposer or agency/organization have any convictions or adverse court rulings involving fraud and/or related acts of all officers, consultants, and employees?

Signature (Authorized Signer) Date

Print/Type Name

Company/Agency

Address

Address

ATTACHMENT E

DISCLOSURES, EXCEPTIONS, AND PUBLIC RECORDS ACT EXEMPTIONS TO RFP

DISCLOSURES

Proposer reports the following:

EXCEPTIONS

Proposer has reviewed the RFP and General Contract Terms in their entirety and has the following exceptions. (Please list your exceptions by indicating the section or paragraph number, and page number, as applicable. Be specific about your objections to content, language, or omissions. Add as many pages as required.)

PUBLIC RECORDS ACT EXEMPTIONS

Proposer requests that specific portions of the contents of this Proposal be held confidential and not subject to public disclosure pursuant to the Public Records Act. The specific portions are detailed below: (Please identify and list your exemptions by indicating the Section or Paragraph number, and Page number, of the Proposal where the content is contained.) Each stated exemption must include a citation to supporting legal authority, including statutory authority or case law, to support exemption from the Public Records Act. Requested exemptions that does not meet the requirements of this section will not be considered.

Name of Authorized Representative:

Signature of Authorized Representative:

Title: Date:

Name and Title of Proposer’s Contact Person:

Mailing Address:

Telephone Number:

Fax Number:

E-mail Address:

Federal Employer Identification Number:

Number of Years under Current Name:

Justification for Subcontracting: (Work)

Capacity to Perform the Required Services Statement:

Subcontractor’s Authorized Signature:

The undersigned hereby certifies that the information above is correct and agrees to serve as a subcontractor on and perform all work as indicated above and will comply with all items as indicated in Section IV of Substance Use Disorder Recovery Services Perinatal Services, RFP DBH 25-165.

I have attached an MOU with original signatures to this sheet for DBH review.

Signature: Date:

Print/Type Name: Title:

ATTACHMENT G

PROPOSER’S FINANCIAL CAPABILITY

Use this page as a cover sheet for financial documents.

Per Section XI, Sub-Section C, Item #8 of this RFP:

Proposer must provide the Company’s three most recent and complete annual audited financial statements; the most recent must be completed within the past 18 months.

If business has been in existence less than three years, and audited financial statements are not available, you must provide the most recent financial statements that have been audited by an independent, certified public accountant.

If you do not have audited financial statements, please submit unaudited financial statements for the three most current years (including balance sheet, income statement, and statement of cash flow).

You must also provide an unaudited financial statement to cover the period from the last audited statement to present, ending no more than 120 days prior to the date of submission of this Proposal.

ATTACHMENT H

Indemnification and Insurance Requirements Affidavit

THE PROPOSER’S INSURANCE COMPANY(S) OR INSURANCE AGENT MUST COMPLETE THIS FORM

AND

THE PROPOSER MUST SUBMIT THIS COMPLETED AFFIDAVIT WITH THE PROPOSAL.

I, the undersigned (Please check one box) underwriter agent/broker, certify that I and the Proposer listed below have jointly reviewed the “Insurance Requirements” in this Request for Proposal (RFP). If the San Bernardino County (“County”) awards the Proposer the Contract for this project, I will be able—within fourteen (14) calendar days after the Proposer is notified of the Contract’s award—to furnish the County with all the required, insurance certificate(s) and endorsement(s) as specified in Section V, Paragraph B. Indemnification and Insurance Requirements.

Insurance Broker / Agency Name Date

Insurance Broker’s / Agent’s Name (Printed) Insurance Broker’s / Agent’s Name (signature)

Address City State Zip Code

Telephone Number FAX Number Email Address

Proposer’s Name County RFP Name and Number Below State the Name of Insurance Company Providing Coverage:

DO NOT write “Will Provide,” “To Be Determined,” “When required,” or similar phrases.

Commercial/General Liability Automobile Liability

Workers’ Compensation Liability Professional Liability

Cyber Liability

Sexual Abuse Liability

[NOTE TO PROPOSER: See Section V, Paragraph B. Indemnification and Insurance Requirements, for details on the basic requirements and types of insurance for this agreement.]

NOTE TO THE UNDERWRITER / AGENT-BROKER: If the insurance forms that the Proposer submits to the County do not fully comply with the Insurance Requirements, and/or if the Proposer fails to submit the forms within the 14-day time limit, the County may: (1) declare the Proposer’s Proposal non-responsive, and (2) award the Contract to the next highest ranked Proposer.

If you have any questions about the Insurance Requirements, please contact San Bernardino County - Risk Management Department via e-mail Insurance.Questions@RM.sbcounty.gov (Please provide name of RFP with your email question(s)).

Rev 08/01/19

ATTACHMENT I

Budget Proposal - Sample Budget Proposal – Sample TBD

ATTACHMENT J

BUDGETS

Use this page as a cover sheet when submitting budgets.

Submit complete Budgets (Schedule A’s and B’s) for each program, for each fiscal year and for each site (if applicable) for cost analysis purposes (see Attachment I - Sample). Electronic version will be e-mailed to each agency upon verification of mandatory proposal conference attendance or upon request, as appropriate.

NOTE: Failure to submit the Budget sheets for each program, for each year and for each proposed site as required WILL result in the elimination of the entire submitted proposal; it will not move forward in the evaluation process.

ATTACHMENT K

REFERENCES

Name/Address

Provide a minimum of three (3) customer references Proposer has contracted with, providing the same service as requested in this RFP.

*Enter “Present” if still providing the services (Example: 10/08/13 - present).

Name of Authorized Representative:

Signature of Authorized Representative:

Title: Date:

ATTACHMENT L

LICENSES, PERMITS, and/or CERTIFICATIONS

TYPE (ie: License, Permit, Certifications) EXPIRATION Include DIR Registration No. of Contractor and Subcontractors

ATTACHMENT M

ATTACHMENT N

PROVIDER INFORMATION REPORT

ORGANIZATIONAL INFORMATION

Today’s Date

DBH Contract Start Date

Administration Address

Administration Hours

E-mail Address Administrative Contact Phone Number

Title

E-mail Address Designated back-up Phone Number

Title

E-mail Address Fiscal Contact Phone Number

Title

FACILITY INFORMATION

Facility/Clinic Name

Facility/Clinic E-mail Address (if applicable)

Status of the Medical Director: ☐ Employee of the organization listed above ☐ Contracted Medical Director ☐ Memorandum of Understanding (MOU) between the Organization and the Medical Director

Facility/Clinic Hours

Are extended night/weekend and/or holiday clinic hours offered? ☐ Yes ☐ No (If yes, please list those hours above)

Drug Medi-Cal Certified? ☐ Yes ☐ No □ Pending, date Application Submitted:

If Yes, indicate Drug Medi-Cal Certification Effective Date (Attach copy of DMC Letter)

DHCS Residential License (If youth, CA Department of Public Health) (Attach copy of license)

Alcohol and other Drug (AOD) Certification ☐ Yes ☐ No □ Pending, date Application Submitted:

(Attach copy of AOD Certification)

Any other Accreditation (i.e. CARF, JACO, CCAPP) Enter they type of accreditation above and attach copy of most recent monitoring report

ASAM LEVEL OF CARE DESIGNATION AND POPULATION SERVED

Early Intervention/Outpatient/Intensive Outpatient/Recovery Services (check all that apply):

early Intervention ☐1.0 Outpatient

☐ 2.1 Intensive Outpatient

Residential Treatment Services (check all that apply):

☐ 3.1 Low – Intensity Residential ☐ 3.3 High – Intensity Residential (population specific) ☐ 3.5 High – Intensity Residential

Withdrawal Management (check all that apply):

☐ 1-WM

Evidenced Based Practices (EBPs)

Providers will implement at least two EBPs per service modality. Check the box for the specific EBPs your agency will provide for this contract.

☐ Motivational Interviewing: A patient-centered, empathic, but directive counseling strategy designed to explore and reduce a person’s ambivalence toward treatment. This approach frequently includes other problem solving or solution-focused strategies that build on patients’ past successes.

☐ Cognitive-Behavioral Therapy: Based on the theory that most emotional and behavioral reactions are learned and that new ways of reacting and behaving can be learned.

☐ Relapse Prevention: A behavioral self-control program that teaches individuals with substance addiction how to anticipate and cope with the potential for relapse. Relapse prevention can be used as a stand-alone substance use treatment program or as an aftercare program to sustain gains achieved during initial substance use treatment.

☐ Trauma-Informed Treatment: Services shall take into account and understanding of trauma, and place priority on trauma survivors’ safety, choice and control.

☐ Psycho-Education: Psycho-educational groups are designed to educate patients about substance use, and related behaviors and consequences. Psycho-educational groups provide information designed to have a direct application to patients’ lives, to instill self-awareness, suggest options for growth and change, identify community resources that can assist patients in recovery, develop an understanding of the process of recovery, and prompt people using substances to take action on their own behalf.

Evidenced-Based (EB) curriculum(s) utilized within your Program. (Specify name and author of the EB curriculum)

Do you provide curriculum in any other language? ☐ Yes ☐ No [If yes, specify language(s)]

Does your organization have a current Cultural Competency Plan? ☐ Yes ☐ No (If yes, please provide a copy of the plan image2.emf

TO BE CERTIFIED AS A LOCAL VENDOR, eligible for Local Vendor Preference (any vendor, contractor or consultant, hereafter “vendor” ) I certify under penalty of perjury that����������������������������������������� meets all of the following requirements:

• The main office (headquarters) or a major regional office is located within the boundaries of San Bernardino County;

• Twenty-five percent (25%) of full-time management employees and twenty-five percent (25%) of full-time regular employees work from locations in the County;

• Employ at least one full-time or two part-time employees with primary residence in the County;

• “Point of sale” for purposes of reporting sales tax to the State Board of Equalization (if applicable) is within the boundaries of the County and payment of any local share of sales tax goes to the County or a city within the County. ( If the local business has more than one sales office in the State of California, the office located in the County shall be the point of sale for sales tax calculation);

• Not delinquent in any taxes or other payments to the County;

• Possess a valid and verifiable business license in��������������������������������������������������������� (if required);

• Have been open and established since _________________ ;

• Have had on-going business activity in the field of ___________________________________________ since_________________ (which is at least six months prior to the issuance of the solicitation);

• Have not, within five years prior to the date this form is signed, admitted guilt or been found guilty by any court or state or federal regulatory enforcement agency of violation of any criminal law or any law or regulation regarding fraud and not federally debarred; and

• Not suspended or debarred from participation in the County, in the scope of work that is the subject of the solicitation.

FURTHER, I acknowledge by initialing the following boxes that I understand:

–If any time after being certified as a local vendor, a change in status occurs rendering a vendor no longer eligible for such status, the vendor must notify the Purchasing Agent prior to responding to a solicitation or accepting an award.

Self certification is good for a period of five years, then must be renewed.

–False certifications shall be immediate grounds for rejection of any proposal or bid or if the proposal or bid is awarded, grounds for voiding the proposal or bid, terminating any agreement, and seeking damages thereto. Failure to certify the above information shall result in the proposal or bid being considered by the County without any adjustment for a local vendor.

–Self-certification provided by the vendor requesting a local preference shall be submitted to the Purchasing Agent under penalty of perjury. No person or business shall make a false representation to a County official or employee for the purpose of influencing the certification or denial of certification of any local vendor.

–Any vendor that falsely obtains certification shall be ineligible to transact business with the County for not less than one year and not more than three years, at the discretion of the Purchasing Agent. This penalty shall also apply to any vendor that previously obtained proper certification and, because of a change in its status would no longer be eligible for certification, and fails to notify the County of this information prior to responding to a solicitation or accepting an award.

Purchasing

LOCAL VENDOR PREFERENCE

SELF-CERTIFICATION

Vendor Legal Name______________________________________

Vendor Representative __________________________________

Vendor Address_________________________________________

City, State, Zip__________________________________________

Phone__________________________________________________

Email___________________________________________________

Federal Tax ID #___________________________________________

Reviewed By:

Location(s)

Date

DateNature of Business

I am an authorized representative of_____________________________________________and can legally bind the company.

Date Name Position

Vendor Representative:

City State Zip:

Vendor Name:

Vendor Address:

Phone:

Location(s):

Date 2:

Nature of Business:

Position:

Initial 2:

Initial 1:

Initial 3:

Initial 4:

Date:

Date3:

Email:

Federal Tax ID #:

Signed:

Reviewed By:

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