RFA_Foster_Family_Agency_Services_Appliation_Forms_063-2596903-WM.docx

REQUEST FOR APPLICATION

FOR

FOSTER FAMILY AGENCY SERVICES

County of Orange Social Services Agency

March 1, 2024

RFA#063-2596903-WM

APPLICANT FORMS

Applicants are responsible to manually insert and/or adjust page breaks so that the submitted application is formatted with each Form beginning at the top of a new page.

FORM A – APPLICATION COVER PAGE

Social Services Agency Request for Application (RFA) Title: Foster Family Agency Services

RFA # 063-2596903-WM

Application Due Date/Time: April 1, 2024, 4:00 p.m. (Pacific Time) Attention: William Mo

APPLICANT: [entered by Applicant]

Application for:

☐ FFA General Services (required) ☐ Temporary Evaluation Community Home (TECH) Services (optional)

☐ The undersigned read, understood, and agree to all statements, terms and conditions, Forms, and Attachments in the RFA referenced above. The signature(s) below are in accordance with RFA Subparagraph 2.1, Signature Requirements.

Applicant’s Name (as it appears on W-9 form)

An unsigned application may be subject to rejection.

FORM B - REQUIRED DOCUMENTS CHECKLIST

INSTRUCTIONS:

Submit the following documents in the order listed on this form, in accordance with Subparagraph 2.4, Application Package. Applicant will indicate on this checklist whether or not all items requested have been included.

Form A – Application Cover Page

Form B – Required Documents Checklist

Form C – Application

Form D – Statement of References

Form E – Organization Litigation

Form F – Applicant Certifications

Form G – Disabled Veteran Business Enterprise (DVBE) Certification

Form H - Levine Act Campaign Contribution Disclosure Form

FFA Program Statement /Plan of Operations

Certificates of Insurance

Current/valid copy(s) of organization license(s) to do business in California

CDSS FFA License

Board of Directors Resolution (if incorporated) / Authorized Representative Statement (if unincorporated)

Adoption Agency License (if available)

FORM C – APPLICATION

PART 1 OF 2

COUNTY OF ORANGE

SOCIAL SERVICES AGENCY

AGENCY APPLICATION

Foster Family Agency Services Request for Applications #063-2596903-WM July 1, 2024 – June 30, 2027

This form must be completed in its entirety. Applications received without authorized signature, and/or Board resolution for authorized signature, will NOT be evaluated.

Agency Information:

Name:

Address:

City:

State:

Zip:

Phone:

Fax:

Hours of Operation:

Holidays and other hours when business is closed:

Website:

FFA Contact Name and Title:

Phone:

Email:

Billing Contact Name and Title:

Phone:

Email:

Executive Contact Name and Title:

Phone:

Email:

ID Numbers:

Federal Employers Tax ID Number (TIN):

State Employers Tax ID Number (EIN):

DUNS Number:

SAM Unique Entity ID Number:

FFA Program Information:

FFA License Date:

FFA Program Statement State Approval Date:

If pending approval, provide date submitted and date is anticipated approval:

Summarize any changes in program statement since you were last awarded a contract:

Does your program statement include provisions for TFC (Yes/No):

Does your program statement include provisions for ISFC (Yes/No):

Adoption Agency License Date (if applicable):

Is your agency eligible to draw PAARP funds (Yes/No):

Emergency Contact Name and Title:

Phone:

Cell:

Email:

PART 2 OF 2

Optional TECH Service Information:

Each TECH bed must be available for sixty (60) days. Only include beds that meet this criterion below.

How many TECH beds can you provide in Orange County, California?

How many TECH homes can accommodate sibling sets of two (2) children?

How many TECH homes (not included in your answer to the previous question) can accommodate sibling sets of three (3) or more children?

How many TECH homes can you provide with bilingual Spanish capacity?

How many TECH homes can you provide with bilingual Vietnamese capacity?

Can your TECH homes accommodate children awaiting STRTP placements (Yes/No)?

Can your TECH homes accommodate children awaiting RCOC placements (Yes/No)?

Can your TECH homes accommodate children awaiting ISFC placements (Yes/No)?

Can your TECH homes accommodate children awaiting TFC placements (Yes/No)?

FORM D – STATEMENT OF REFERENCES

Name of Applicant: ________________________________________________________________________

INSTRUCTIONS: Applicant must provide names and addresses of three (3) current references. A minimum of two (2) of the references must be from organizations with whom the Applicant has had a contractual relationship for similar scope of services for some period during the past five (5) most recent years. NOTE: References from current or former SSA or Probation Department employees are not permitted.

Organization’s Name:

Address:

Contact Name and Title

Current Contact Phone and Email:

Brief Description of Contracted Services Provided or Nature of Relationship:

Organization’s Name:

Address:

Contact Name and Title

Current Contact Phone and Email:

Brief Description of Contracted Services Provided

Organization’s Name:

Address:

Contact Name and Title

Current Contact Phone and Email:

Brief Description of Contracted Services Provided

FORM E – ORGANIZATION LITIGATION

Name of Applicant: ___________________________________________________________

INSTRUCTIONS: Check YES or NO to the following questions. If a YES answer is checked, please explain fully the circumstances and include discussion of the type of program involved as well as the potential impact on this program, if funded. Include court jurisdiction and case number where applicable.

Response Section (Use extra pages, as necessary)

Applicant must specify any current and/or past litigation proceedings and indicate status.

Completed By: ___________________________________________

Name and Title: ___________________________________________

FORM F – APPLICANT CERTIFICATIONS

Model Contract

It is understood that the only contract terms and conditions that will be applicable to this solicitation and resultant contract(s) are those issued by the County of Orange, as they now exist or may be hereafter amended. Applicant acknowledges that she/he has read and agrees to all terms and conditions in the Model Contract and the requirements of this solicitation and indicates concurrence below. The County reserves the right to disqualify Applicants taking exception to the terms and conditions in the Model Contract. Applicants taking exception after notice of award may be disqualified from award of contract as determined by County.

☐ Organization acknowledges the terms and conditions as stated in the Model Contract to this RFA will be included in the resultant contract and does not take any exceptions.

(Signature Required) Printed Name Date

Certificates of Insurance

Applicant certifies, by signing below, its willingness and ability to provide the required insurance coverage, certificates, and endorsements as set forth in the terms and conditions of the Model Contract.

(Signature Required) Printed Name Date

Conflict of Interest

Disclose any financial, business, or other relationship with the County of Orange, any other entity that the Orange County Board of Supervisors governs*, or any Orange County board member, officer, or employee, which could affect or influence award of the contract for the services you propose to provide.

Applicant must certify either Option 1 or 2 below:

1. Applicant certifies current/past financial, business, or other relationship with the above exists/existed as follows:

Use Additional Pages as Necessary

(Signature Required) Printed Name Date

OR

2. Applicant certifies that no relationship with the above exists/existed as outlined above.

(Signature Required) Printed Name Date

*Orange County Board of Supervisors govern: All Assessment Districts, All Community Facilities Districts, All Reassessment Districts, Housing and Community Development Commission, Housing Successor Agency to the Orange County Development Agency, In-Home Supportive Services Public Authority, Industrial Development Authority For Orange County, Local Redevelopment Authority Marine Corp Air Station (MCAS) El Toro, Orange County Financing Authority, Orange County Flood Control District, Orange County Housing Authority, Orange County Housing Authority Acting As the Housing Successor Agency, Orange County Public Financing Authority, Orange County Special Financing Authority, South Orange County Public Financing Authority, and the Successor Agency to the Orange County Development Agency

Name/Ownership Changes

Applicant must certify either Option 1 or 2 below:

1. Applicant certifies past company name changes and/or ownership changes for Applicant’s firm and any proposed subcontractor firm, as follows:

a. Applicant shall provide detailed information regarding any company name changes (including legal business names) in the past seven (7) years.

b. Applicant shall provide detailed information regarding any company ownership changes (including legal business names) in the past seven (7) years.

(Signature Required) Printed Name Date

2. Applicant certifies that Applicant or any proposed subcontractors have not had any company name changes or ownership changes in the past seven (7) years.

(Signature Required) Printed Name Date

FORM G - DISABLED VETERAN BUSINESS ENTERPRISE (DVBE) CERTIFICATION REQUIREMENTS

1) To participate as a DVBE the following requirements must be met:

A. A business must be certified with DGS as a DVBE - https://caleprocure.ca.gov/pages/sbdvbe-index.aspx

B. DVBE Certification must be valid at the date/time solicitation is closed, and it shall remain in effect at the time of contract award. County reserves the right to verify and/or reject incomplete documents.

C. Complete and sign the Affirmation form attached herein. The signed Affirmation form and the DVBE Certification are required and must be returned with the solicitation response in order to compete as a DVBE.

County of Orange Disabled Veteran Business Enterprise (DVBE) Affirmation

DVBE Certification Requirements: To be certified as a Disabled Veteran Business Enterprise, a business must meet the following requirements:

1) Must be certified as a DVBE by the State of California Department of General Services (DGS); and

2) DGS DVBE requirements must be valid at the time of application submittal.

I, certify that ______________________, (legal company/business name) is certified as a DVBE and currently meets the respective Certification Requirements set forth above.

_____________________________ Print Name

_____________________________ Authorized Signature

___________________ Title

___________________ Date

Please check the following:

☐ State of California DVBE Certification attached.

County Use Only

Solicitation Number:

Solicitation Description:

File Folder Number:

FORM H – LEVINE ACT

CAMPAIGN CONTRIBUTION DISCLOSURE FORM

Application or Solicitation Number:

Application or Solicitation Title:

Was a campaign contribution, regardless of the dollar amount, made to any member of the Orange County Board of Supervisors or to any County Agency Officer within the preceding 12 months by the applicant, or, if applicable, any of the applicant’s proposed subcontractors or the applicant’s agent or lobbyist?

Yes ____ No_____

If no, please sign and date below.

If yes, please provide the following information:

Applicant’s Name:

Contributor or Contributor Firm’s Name:

Contributor or Contributor Firm’s Address:

Is the Contributor:

Note: Under California law as implemented by the Fair Political Practices Commission, campaign contributions made by the Applicant and the Applicant’s agent/lobbyist who is representing the Applicant in this application or solicitation must be aggregated together to determine the total campaign contribution made by the Applicant.

Identify the Board of Supervisors Member(s) and County Agency Officer(s) to whom you, your subcontractors, and/or agent/lobbyist made campaign contributions, the name of the contributor, the dates of contribution(s) in the preceding 12 months and dollar amount of the contribution. Each date must include the exact month, day, and year of the contribution.

Name of Board of Supervisors Member or County Agency Officer:

Name of Contributor:

Date(s) of Contribution(s):

Amount(s):

(Please add an additional sheet(s) to identify additional Board Members or County Agency Officer to whom you, your subconsultants, and/or agent/lobbyist made campaign contributions)

By signing below, I certify that the statements made herein are true and correct. I also agree to disclose to the County any future contributions made to Board Members or County Agency Officers by the applicant, or, if applicable, any of the applicant’s proposed subcontractors or the applicant’s agent or lobbyist after the date of signing this disclosure form, and within 12 months prior to and following the approval, renewal, or extension of the requested license, permit, or entitlement to use.

Date Signature of Applicant

ORANGE COUNTY BOARD OF SUPERVISORS

AND COUNTY AGENCY OFFICERS

Board of Supervisors

Donald P. Wagner, Chairman, Third District Andrew Do, Vice Chairman, First District Vicente Sarmiento, Second District Doug Chaffee, Fourth District Katrina Foley, Fifth District

County Agency Officers

Claude Parrish, Assessor Andrew Hamilton, Auditor-Controller Hugh Nguyen, Clerk-Recorder Todd Spitzer, District Attorney-Public Administrator Don Barnes, Sheriff-Coroner Shari L. Freidenrich, Treasurer-Tax Collector Foster Family Agency Services Page 56 of 73 RFA #063-2596903-WM, February 16, 2024 image1.png