Appendix C-Proposer's Questionnaire.docx
DOCX document 50 KB Posted
- Solicitation number
- RFP-BHS-FY26-0513
- Issued by
- Santa Clara County, California
About this file
This is a Proposer's Questionnaire for the County of Santa Clara Behavioral Health Services Department's RFP-BHS-FY26-0513: Independent Living Home Habitability Improvements Project. The questionnaire is a mandatory submission component requiring proposers to provide comprehensive organizational information including legal entity status, corporate governance details, capitalization structure, and authorized representatives. The project seeks to award forgivable loans to qualified operators of unlicensed independent living homes serving individuals with serious mental illness, with the overall objective of improving habitability conditions and safety standards in shared independent living homes to meet HUD housing quality standards. Habitability improvements encompass updating bathrooms for ADA compliance, renovations such as painting and flooring, repairing or replacing appliances including water heaters and air conditioning, fire system upgrades, bathroom and kitchen remodels, furniture and mattress replacement, and other improvements to expand bed capacity. The anticipated contract term commences upon execution of the agreement and remains in effect through June 30, 2027, allowing completion of County-approved improvements, inspections, and compliance verification for loan forgiveness. This RFP may result in multiple awards and represents a one-time funding opportunity.
The questionnaire requires proposers to disclose financial and operational history, including any bond denials or forfeitures, bankruptcy declarations, corrective action notices, contract cancellations, litigation, and audit or investigation participation. Proposers must provide references from at least two former customers with contact information, staffing data including local employment percentages and management-to-operational ratios, and details regarding employees directly servicing County accounts. Participation requires the operator's and home owner's willingness to grant the County first right of refusal for future vacancies, assurance that improvements will prevent closure and increase bed capacity, and confirmation that the home operates legally without providing the level of care and supervision required for licensure. All statements submitted in the questionnaire must be accurate and complete under penalty of perjury, with false or omitted information subject to proposal rejection.
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Text version
APPENDIX C
County of Santa Clara – Behavioral Health Services Department RFP-BHS-FY26-0513: Independent Living Home Habitability Improvements Project
PROPOSER’S QUESTIONNAIRE
All information requested in the Questionnaire shall be furnished by the Proposer, and shall be submitted with the proposal. Statements shall be complete, accurate, and in the form requested. Any omissions, inaccuracies, or misstatements may be cause for the rejection of a proposal in whole or part.
1. Name of Proposer exactly as it is to appear on a service agreement, and address at which Proposer would receive notice under the agreement:
2. Proposer, if selected, is ☐ An Individual;
☐ A Corporation; or ☐ Other: Click or tap here to enter text. If "Other", attach explanation.
3. If a corporation, answer the following:
A. When incorporated?
B. In what state?
C. Authorized to do business in California?
If so, what date?
| D. | Name, address, years in the corporation, and percentage of stock held by the following officers: |
| President: |
Years:
Stock
Vice President:
Years:
Stock
Secretary:
Years:
Stock
Treasurer:
Years:
Stock
Other:
Years:
Stock
| E. | Name, address, and percentage of stock held by each Member of the Board of Directors: |
| Chairman: |
Stock %:
Member:
Stock %:
Member:
Stock %:
Member:
Stock %:
F. Name, address and shares of stock held by other principal stockholders: (A Principal Stockholder is defined as a stockholder who holds 10% or more of standing stock of the corporation).
| Total Capitalization: |
| $ |
| Amount of capital stock subscribed: |
| $ |
| Amount paid in: |
| $ |
4. Has Proposer ever had a bond or surety denied, canceled, or forfeited?
YES ☐ NO ☐ If yes, state name of bonding company, date, amount of bond and reason for such cancellation or forfeiture in an attached statement.
5. Has Proposer ever declared bankruptcy or been declared bankrupt?
YES ☐ NO ☐ If yes, state date, court jurisdiction, docket number, amount of liabilities and amount of assets.
6. Has your organization ever received a “Notice of Intent to Consider Corrective Action” or “Notice of Corrective Action” letter due to non-compliance of contract provisions for services provided on behalf of the County?
YES ☐ NO ☐
7. Have any County Agreements held by Proposer for services similar to those listed in this RFP ever been canceled or terminated?
YES ☐ NO ☐
· If yes, please confirm the reason(cancelation, failure, or refusal to complete a contract, other) and
· indicate which organization/individual/entity initiated the process.
8. Has Proposer ever been sued for issues pertaining to fee payment, performance, or any other issues relating to the services listed in the RFP?
YES ☐ NO ☐ If yes, give details.
9. Is Proposer currently engaged or has been engaged in any litigation which will or could affect its ability to pay fees or perform the services required by a service agreement resulting from this RFP?
YES ☐ NO ☐ If yes, give details.
10. List any lawsuits filed against Proposer, Proposer’s subsidiaries, parent, other corporate affiliates, or subcontractors in the past five (5) years and the outcomes of those lawsuits. Identify the parties involved and circumstances. Also, describe any civil or criminal litigation or investigations pending against the Proposer.
11. List at least two persons, firms and/or governmental bodies with which Proposer has had agreements with that have since concluded, and thus are no longer active customers of Proposer. Provide a contact person’s name and phone number for each former customer.
12. State the number of persons employed by Proposer who are engaged in providing the services listed in this RFP. Indicate what percentages of these employees are employed locally and what percentage of those employees would directly service an account resulting from this RFP. Of the employees indicated, what percentage is management and what percentage are operational?
13. Please list and describe any audits and investigations in which the Proposer was or is the subject.
The undersigned hereby declares under penalty of perjury that all statements, answers and representations made in this questionnaire are true and accurate, including all supplementary statements hereto attached. In the case of a corporate Proposer, the signature of one duly authorized representative is sufficient.
Signature
(Please print or type name)
Title
Signature
(Please print or type name)
Title
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