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MINUTES - 02061996 - C57
To: BOARD OF SUPERVISORS Contra o FROM: JOAN V. SPARKS, DIRECTOR �' Costa COMMUNITY SERVICES DEPARTMENT oz � ��� . �. . STV DATE: January 12, 1996 County, SUBJECT: AUTHORIZATION TO EXECUTE FY 1995-96 CONTRACT #39-833 WITH THE CALIFORNIA DEPARTMENT OF EDUCATION. SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION I. RECOMIVIENDED ACTION: APPROVE and AUTHORIZE the Community Services Director or her designee to execute on behalf of the County, Contract #39-833 (State #GPRE-5292) with the California Department of Education in the amount of$48,692 for State preschool services for the period from January 2, 1996 through June 30, 1996. II. FINANCIAL IMPACT: This Contract is funded through the California Department of Education. Funds will be added by Appropriation Adjustment to the Department's 1995-96 County Budget. No County funding is required. III. REASONS FOR RECOMMENDATIONS/BACKGROUND: On November 28, 1995 the Community Services Department (Department) received Board approval to respond to the California Department of Education's (State) Request for Applications a center-based State Preschool Program within the County. Based upon the Department's application, the State has awarded the County this additional State Preschool contract. The County will also be awarded a one-time only start-up allowance of $11,019 which is not included in the contract's maximum reimbursable amount. This Contract will provide an additional 50 places for children of indigent families. State Preschool provides an opportunity for three- and four-year-old children of low-income families to receive developmentally appropriate education prior to enrollment in public school kindergarten classrooms. This Contract will be reviewed and approved as to form by County Counsel prior to submission to the State. CONTINUED ON ATTACHMENT: YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF SO D COMMITTEE APPROVE OTHER SIGNATURES: ACTION OF BOARD ON APPROVED AS RECOMMENDED OTHER VOTE OF SUPERVISORS / 1 HEREBY CERTIFY THAT THIS IS A TRUE IL__UNANIMOUS(ABSENT AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. CONTACT: Joan Sparks, 313-7350 CC: CAO ATTESTED 2 CSD PHIL BATCHELOR,CL <OF TH BOARD OF SUPERVISORS AND COUNTY ADMINISTRATOR (77 BY ,DEPUTY M382 (10/88) C•�� INCOMING FUNDS NARRATIVE STATEMENT FORMAT Approval to Provide State Preschool Program in Contra Costa County for Fiscal Year 1995-96 1. PROJECT/PROGRAM TITLE. Local Agreement for Child Development Services (additional State Preschool classes). 2. FUNDING AGENCY. California Department of Education/Child Development Division will provide 100 percent of the funding for this project. 3. SUBMITTAL STATUS. This contract is a result of a successful Request for Application (RFA) approved by the Board on November 28, 1995. The County will receive $48,692 during fiscal year 1995-96 and an annualized amount of $73,500 in each following year so long as the State Legislature continues to support State Preschool Programs in California and the County continues to meet the terms of the funding contract. State Preschool funding is under the protective umbrella of Proposition 98. 4. PROPOSED TERM. January 1, 1996 through June 30, 1996. The Contract will be renewed annually until either the County or the State decide to terminate it. The actual funding amount may be adjusted for growth and cost-of-living adjustments (COLA) annually. 5. CURRENT FUNDING. The total amount to be funded during 1995-96 is $48,692 with a start-up allowance of $11,019. 6. FUTURE FUNDING. The annualized amount of $73,500 for this Child Development Contract is under the Proposition 98 funding umbrella. It is part of the same legislation as the public school's K-12 programs. The County contract will be refunded annually contingent upon compliance with quality standards and contract funding terms and conditions. 7. BUDGET SUMMARY. See attachment. 8. STAFFING REQUIREMENTS. See attachment. 1 . / �e 57 9. PROGRAM NEED. Recent figures by the County's Child Care Task Force indicates that only 20 percent of the County's eligible State Preschool Children are being served. The addition of 50 places for children of indigent families is greatly needed in our low-income communities. State Preschool provides an opportunity for needy, three and four year old children to obtain developmentally appropriate education prior to enrollment in our public school kindergarten classrooms. Children who have the advantage of quality preschool programs are more successful in the early grades than children who do not. 10. RELATIONSHIP TO OTHER PROGRAMS. This new State Preschool will become part of the Community Services Department's Child Development Division which currently operates 28 General Child Care programs and 18 State Preschool classes funded through contracts with the California Department of Education, Child Development Division. The Community Services Department also collaborates with the Contra Costa Community College District and four delegate agencies to operate 16 of the State Preschool classes. Both of the two new classes formed under this funding will be located with three other Head Start classes and one General Child Care class at the Department's newest site, Balboa Child Development Center, 1001 57th Avenue, Richmond. 11. PROJECT GOALS. The goal of State Preschool projects is to provide funding for quality child care and development centers for young children that enable eligible parents to work or attend training, promoting family self-sufficiency and providing educationally appropriate child development activities which develops healthy children for success in later schooling. 12. STATED OBJECTIVES. • To implement the operation of two child development classes. • To provide opportunities for parents to positively participate in their children's early schooling. • To implement the structure that supports collaboration with Head Start and the General Child Development program at Balboa Child Development Center. • To implement the coordination, collaboration, and integration of services between Community Services Department, other County Departments, and other agencies in the County and State who also serve low-income families and children. 13. ACTIVITY SUMMARY. This contract will provide funds for the operation of two State Preschool sites. State Preschool provides child development services three hours per day, 175 days per year. Fifty children of income-eligible families will be served. The State Department of Education mandates that these programs provide an educational environment and be 2 staffed with trained instructors to assist the children's positive development and support the parents' efforts to provide for health development of their children. 14. EVALUATION METHOD(S). This program will be evaluated annually through Self-Review using the Exemplary Program Standard as required by the California Department of Education. Once every three years, the programs will be monitored by the State Department of Education for quality of service and contract compliance. Fiscal management and contract compliance is evaluated annually through an external audit conducted by an independent certified public accountant. 15. POTENTIAL CONTROVERSIAL ISSUES. In the past five and a half years of County operation, Child Development Division programs within the Community Services Department have raised no public controversy. The Department does not foresee any controversy. Four Children's Centers have been in continuous operation for over 50 years. The Department predicts controversy only if funding is discontinued. 3 1995-96 Budget for Contract #38-833 (California Department of Education GPRE-5292) Income CDE $49,692 CCFP 5,308 Total $54,000 Expense Certified Salaries $23,000 Classified Salaries 4,000 Benefits 2,000 Books and Supplies 3,000 Services and Operations 12,000 Capital Outlay 10,000 Total $54,000 New Staff to be Added for Contract #39-833 (California Department of Education Contract GPRE 52-92) Site Supervisor 0.5 $ 8,580 Head Teacher 1.0 10,900 Teacher 1.0 4,102 $23,582 4 CALIFORNIA DEPARTMENT OFED'UCATION > 721 Capitol Mall:P.O. Box 944272 F Y 9S - 96 Sacramento, CA 94244-2720 F. Y. DATE: January2, 1996 LOCAL AGREEMENT FOR CHILD DEVELOPMENT SERVICES CONTRACT NUMBER GPRE-5292 PROGRAM TYPE: Preschool PROJECT NUMBER:07-T687-01-03038-5 CONTRACTOR'S NAME: CONTRA COSTA COUNTY COMMUNITY SERVICES DEPARTMENT By signing this contract and returning it to the State,you are agreeing to provide services in accordance with the FUNDING TERMS and CONDITIONS(FT&C)and APPLICATION which are attached and by this reference incorporated into this contract. The FT&C and Requirements specify the contractual responsibilities of the State and the contractor. Funding of this contract is contingent upon appropriation and availability of funds. This contract is effective from January 2.1996 through June 301996. For satisfactory performance of the required services,the contractor shall be reimbursed in accordance with page 16 of the FT&C,at a rate not to exceed$13.87 per child per day of full-time enrollment and a Maximum Reimbursable Amount (MRA)of$48,692 . Any provision of this contract found to be in violation of Federal or State statute or regulation shall be invalid but such a finding shall not affect the remaining provisions of this contract. SERVICE REQUIREMENTS Minimum Child Days of Enrollment(CDE) Requirement 3.510.6 Minimum Days of Operation (MDO) Requirement 116 Up to$11.019 of the MRA maybe expended as one-time-only start-up costs in accordance with Education Code Section 8275 and the Funding Terms and Conditions. ..... . ....Q...................................................... ........:::::. ::: ::: .::::: :::::.::::.. ............. '...:....::::::::::::::::::..:.::::::::::::.:::::::.:::::: BY(AUTHORIZED SIGNATURE) BY(AUn10RI7ED SIGNATURE) PRINTED NAME OF PERSON SIGNING PRINTED NAME AND TTfLE OF PERSON SIGNING Joan V. Sparks, Director T"iE ADDRESS Martinez, C1 Cts 0ffice 11220 Morello Ave. , Ste 101 , 94553 AMOUNT ENCUMBERED BY THIS PROGRAMICATEOORY(CODE AND TTI1,E) FUND TITLE Department of General Services DOCUMENT Use Only 6 PRIOR AMOUNT ENCUMBERED'FOR TM (OPTIONAL USE) CONTRACT - 3010.010.000 ITEM CHAPTER STATUTE FISCAL YR TOTALAMOUNIENCUMBEREDTODATE 00-196-001 a 303 1995 1995/96 OBJECT OF EXPENDITURE(CODE AND TITLE) 709 T.BA NO. B.R.NO. I hereby catify upon my own personal larowledge that budgeted fimds we available for the period and purpose r Of the expenditure stated above. SIGNATURE OF ACCOUNTING OFFICER DATE California Departarcnt of Education Kebglont Bulletin- 2 Chad Development Division COWETITIVE APPLICATION (CD-3001 REV. 1/95) r,i I f l.0 D EV E L-0 P H EN T COYER PAGE (STATE PRESCHOOL) PART I COVERFA(J� t! 41 g LATE APPLICATIONS V4LL NOT BE ACCEPTED Return to: Legal Status of Agency Child Development Division check one: 560 7 Street, Suite 220 , Sacramento, CA 95814 —city or city agency college or university CDD use only x county or county agency () New (3)Competitive county office'of education O Revised- O Renewal (CDS# ) () Continuing _ private non-profit organization private profit organization PIease complete the following school district information: (CDS# ) Legal Mame of ApplicanrAgency .Amount Rcqucstcd Co—ntra-Costa County Community Services Department 71,506 Address City County , Zip, z- tra C6sta '94553- Projected Date of Operation Federal IdcntrficatlonNumbcr From.July 1 . 1995 to June 30 . I996 Contact Person for this application:• -•. Telephone 2�Iumba EXECUTIVE OFFICER/SUPERINTENDEI T .: Address, - _Tel cphon�:, 1220 Morello Avenue; Suite 101' (510'7.A3=-7350 --Joan V. Sparks City Martinez Zip 9455-3 PROGRAMS M=GER Address Telephone 2730 Maine.Avenue (510) 374-3994 Wilda Davisson city BOARD.CHAIRPERSON -Address Tcicohone =18 Crow-Canyon Ct., Suite 120 (510) 820-8683 Gayle Bishop City San Ramon Zip 94583 Certification: I hereby certify that all applicable State and federal rules.and regulations will be observed;that to the best of my knowledge,the information contained in this application.is cogect and complete. . Typed e Agent Title At P4i.nce, Adm.i.n.i,5t at-i..ve Seavicee 069-icm Octo r 12 1995 Signature of Authorized Agent Title i California Department of Education Contra Costa CountylCSD Child Development Division Legal Name of Applicant COMPETITIVE APPLICATION(CD-30021 REV. 1/95) PROGRAM INFORMATION(State Preschool) B. PROGRAM PHILOSOPHY AND OVERVIEW: Summarize the agency's philosophy regarding child development. Briefly describe the overall program provided to child and how it reflects the agency's philosophy for the target population. Note: This section affords the applicant an opportunity to share any philosophical or broad organizational features important to understanding the program described in the reminder of the application. Contra Costa County Community Services Department is dedicated to serving the communities of Contra Costa County by providing services to its low-income citizens. One of the services historically provided by the Department is quality,developmentally appropriate, educational programs for young children. These programs recognize the importance of the family as the child's primary nurturing unit and seek to support a partnership with the parents. We works with families to find and use the various support systems they need to produce healthy children who are ready to succeed in school and later community life. We believe in the developmentally approach to early childhood education derived from the work of Jean Piaget. We provide learning environments that nurture the children as they progress through the early childhood stages.. We train teachers to model appropriate strategies in working with children and help parents learn more about child development. We recognize that play is the child's work and that structured learning environments enhance opportunities for children to explore and create through a variety of age appropriate activities. Our daily activities are designed to meet children where they are developmentally and guide them thorough a variety of activities which will nurture their self-esteem,promote their physical well-being,enhance their cognitive skills,and release their creative capacity. C. GOALS AND OBJECTIVES: Describe the agency's major goals and objectives for the program in accordance with the following instructions. goals for the children to be served and objectives should be developmentally,culturally and linguistically appropriate for the children to be served. Goals should be broad and comprehensive and should encompass overall program operation including administration,staffing,program activities, support services, family and community involvement,and program evaluation. Objectives must be specific and indicter a subject(child, staff, parent,etc.)and an outcome(expected learning or experience). Objectives should indicate a timeline and method of measurement without excluding individuals or groups of children. The goals of Contra Costa County Community Services Department, Child Development Division are as follows: • Institute a quality State Preschool program at a licensed site that is responsive to the needs of the community,families,and children to be served by January 2, 1996. • Establish a children's,program that provides a safe,healthful,reliable and stimulating environment for the nurturing of young children from multi-ethnic, low-income families by January 2, 1996. • Maintain a reliable fiscal and organizational structure to accommodate the smooth operation of this program throughout the life of the contract. • Employ culturally diverse and competent staff to implement and sustain a quality children's program and to encourage the growth and advancement of these employees by January 2,1996. • Meet the culture, linguistic and developmental needs of preschool children by June 1996. • Coordinate with the Department's and County's other programs to reduce the cost of program overhead by sharing training purchasing,fun8-raising,and support services to the staff,parents,and children by June 1996. • Establish a parent/teacher advisory group to empower the parents and staff to affect changes in the programs based on an annual self-evaluation by March 1996. • Evaluate the growth of the children and the effectiveness of the program as required by the terms of the contract 3 California Department of Education Contra Costa County/CSD Child Development Division Legal Name of Applicant COMPETITIVE APPLICATION(CD-30021 REV. 1195) PROGRAM INFORMATION(State Preschool) D. PROGRAM EVALUATION: Describe how the program will be evaluated. The evaluation plan should include the processes for annually assessing the agency's progress in meeting the goals and objectives and/or policies and procedures on an annual basis, in relation to the provisions of activities and services. Describe how the results of the evaluations will be used to modify the goals,objectives,curriculum, instruction or other program components on an annual basis. • Contra Costa County Community Services Department,Child Development Division will monitor the program to insure eligibility for enrollment,staffing requirements and ratios,parent involvement,food service quality,licensing compliance and fiscal accountability as required by the contract. • Required reports will be accurately prepared and submitted to CDE in a timely manner. • Fiscal records will be submitted for an annual independent audit and reports submitted to CDE as required. • Probationary and annual evaluation based on performance standards are required on agency staff. • The program will monitor contract compliance used the CDE Contract Monitoring Review protocol. • The program will engage in an annual self-review using CDE's Exemplary Program Standards to devise plans for improvement • Plans for improvement generated during the self review are submitted for approval to the County Board of Supervisors annually. • An advisory committee,comprised of representatives of staff and parents will meet regularly to provide opportunities for input toward program improvement. • The program will conduct annual needs assessments for parent and staff and plan workshops and in-service training to meet those need. • The agency belongs to and is active in a County Child Care Consortium that provides on-going opportunities for program quality improvement through peer reviews and materials and training for staff. • We employ an Education Specialist who visits classrooms and provides teachers with quality improvement support on an as needed basis. • Teacher assess the children's need within the fust month of enrollment and hold conference with parents to develop plans for the developmental program for the child. • Teachers keep portfolios of children's work and meet with parents to review the progress of their child as needed but at least two time per school year. • Teaching and administrative staff meet weekly to plan for and carry out the sites program. • Parents meet at least fnonthly for planning and information exchange. • Center administrative staff meet at least twice monthly with management staff to coordinate the program with it goals and objectives. • Management meets with the Department director at least twice per month to coordinate the child development programs with the other divisions in the department and the other departments in County government 5 California Department of Education Contra Costa County/CSD Child Development Division Legal Name of Applicant COMPETITIVE APPLICATION(CD-30021 REV.1/95) PROGRAM INFORMATION(State Pre$chool) G. DEVELOPMENTAL PROGRAM: Describe how the program will address the following developmental areas: - Social/Emotional development(self-awareness,emotions, interaction with peers/adults, etc.) -Physical Development(large and small muscle activities,eye/hand coordination,etc.) -Cognitive Development(conceptualization,classification, serration, problem solving,etc.) -Language Development(understanding and use of words and sentences) -Creative Development(art,music,dramatic play,etc.) Include major activities,strategies or approaches,and curriculum materials utilized in each of the developmental areas to demonstrate that he program will be developmentally,culturally and linguistically appropriate. Under "language development"describe how you propose to support language acquisition and the development of each child's home language. Specify theoretical basis and instructional methodology. 1. Social/Emotional Development The program will reflect the belief that positive self-esteem is the essence of wholesome social development. To that end, materials,activities,staff-training and inter-relationships will be directed toward developing positive self-concept in children and their parents. To insure this: • Staff will be recruited to reflect the ethnic/cultural make-up of the community. • Children and parents will be welcomed by name(preferably in their primary language)daily. • Children will have their own cubbies identified by their pictures and names. • Daily communications between program staff and parents will emphasize the positive activities of the children with discussion about problems being reserved for parent/teacher conferences. • Parent and children will be involved in making decisions about program activities as much as possible. • Staff will seek creative methods to secure greater parent involvement. • The services of support staff well be enlisted to assist teachers and parents develop strategies for dealing with"behavior problems." • The children will be organized in small groups of no more than eight children with a primary care giver to develop a sense of belonging to a"family"during meals and activities whenever possible. • The environment will be structured so that children can make many choices about their daily activities and solve many of their own problems. • Teacher will model for children positive problem solving strategies. • Teacher will help children learn to follow a few simple"rules"for respecting the rights of others. • Teachers will assist children in working out problem and getting their needs met by using conflict resolution. • Parent workshops and materials to reinforce positive self-concept will be provided. • Teachers will make a point of providing positive feed back to children and assisting them to control their negative behavior by redirecting them to more acceptable choices. • Classroom staff will coordinate their approach to providing a safe and non-violent environment for children. 7 California Department of Education Contra Costa County/CSD Child Development Division Legal Name of Applicant COMPETITIVE APPLICATION(CD-30021 REV. 1/95) PROGRAM INFORMATION(State Preschool) _ H. NUTRITION: Describe how nutritional services will be provided which meet the requirements of the Federal Child Care Food Program for the ages of the children to be served. Including funding sources and strategies or approaches to nutrition education with the children. Describe how the nutrition program will a developmentally and culturally appropriate for the children. ATTACH SAMPLE MENU FOR ON MONTH O TO EACH COPY OF THE APPLICATION. Indicate if menu is used on a rotating basis. The children's meals,meeting the Federal Child Care Food Program guidelines,will be prepared by the Martinez Unified School District in their central kitchen.. Under a contract that we currently have with them for another child development program operating in their district,meals are delivered daily in bulk and served family style by-our child development staff. Our Department's Food Service Manager and our nutritionists have met with school district food personnel to plan menus appropriate to preschool children form multi-cultural families. Although the menu is generated monthly,the district offers a six week cycle men. Adjustment are made seasonally to take of the availability of fresh vegetables and fruits. The Department nutritionists provides training to the staff and parents regarding healthy food choices. The staff and parents are encouraged to attend our Department Food Service Advisory committee meeting to have input into menu planning and to make suggesting for improvement in the delivery of nutrition education and food services to children. The nurse weighs and measures the children at the beginning of service to identify low or above weight children. Individual conference are held with parents where the child's growth or weight appear to be a problem. We coordinate with the WIC program to enroll eligible children for supplementary food income. Our nutrition division has ordered software to go on line with both"Nutra- Kid"and"Shape". WE collaborate with Head Start to spread the cost of the nutritionist services between funding sources. I. ETHNIC AND CULTURAL RECOGNITION: Describe how the program will support ethnic and cultural recognition and multi-cultural education of children in a developmentally appropriate manner. Include major strategies or approaches,activities,materials and planned staff development activities. Describe plans to recruit and employ staff that reflect the linguistic and cultural background of the children, families and local community to be served. • The program will enroll income and age eligible children without regard for race,religion,or national origin. Children with special needs will be welcome into the program if reasonable accommodations can be provide to meat their health and safety needs. • The program will employ staff representative of the cultural diversity of the community who are trained to be sensitive to culmral/ethnic difference. The County subscribes to an affirmative action plan for hiring. Our program more that meets the minimum requirements. • The County's Training Institute offers training for our staff in cultural and gender sensitivity. • The program will provide workshops and materials for staff and parents to learn more about their own and other cultures. • Staff will be required to model respect for the ethnic/cultural background of all children. • Teacher will use pictures,books,recording,games,etc.reflecting the ethnic/cultural diversity of our society. They will provide opportunity for children to display family pictures as well. • Parent and community members will be invited to share their cultural arts/crafts,songs,stories,customs and foods with the children. • Pot luck dinners will be held to encourage families to meet each other and to share the foods of their culture with others. • The children's food menus will include foods prepared in the style of a variety of cultures • Opportunity will be provided for parents to meet and work with parent on various projects. • Staff will be trained to teach"The Multi-Cultural Curriculum". 10 Califorimia Department of Education Contra Costa County/CSD Child Development Division Legal Name of Applicant COMPETITIVE APPLICATION(CD-30021 REV. 1/95) PROGRAM INFORMATION(State Preschool) L. SPECIAL NEEDS: Describe major activities and strategies planned to address the special needs of limited English proficient children, children with exceptional needs, and children receiving Child Protective Services,. Strategies should address instructional activities and methodologies, learning environment,assessment, materials staff behavior, staff qualifications, staff development,and support services. • Prior to enrollment the site administrator meets with all parents to complete the enrollment and entrance documentation. Some special needs are identified at this time. The site administrator reviews all children's enrollment information to determine if a child has an identified special need. It appears that that a child will need special accommodation the administrator call upon the support service team of nurse,education specialists,mental health counselor,parent and teacher to develop an individual training plan(ITP)for the child. The plan is followed after enrollment. If,however, the program is unable to make reasonable accommodations for the child's health,safety or training,the family is referred to another agency for more intensive service. • All enrolled children are initially observed in the classroom environment. The teacher may request a conference to discussions or screening results based on a Behavioral Concerns Checklist with Support Service Consultants. The Behavioral Check list is submitted to the site administrator for review. A copy is kept in the child's folder. • All concerns are documented and discussed with the administrator and forwarded to the appropriate Support Services consultant for follow-up. • A parent conference is scheduled to discuss results of the child's assessment. Parent's consent for referral and further screening/diagnosis is obtained. (any child for whom concerns exist may be referred to the nurse,mental health counselor,or the local school district's multi-disciplinary support team. Children may also be referred to the County Health Department and eventually to the local regional center for disabled children. For limited English speaking children we collaborate with the local school districts consultation team. • The consultants will discuss with teachers and parents information about a child in an ITP conference. The site administrator, teacher,parent and supporting consultants will plan strategies for appropriate activities to meet the child's needs. The ITP is implemented and a copy is placed in the child's folder. • A child with special need may be served on site or transported to another program. • If a child needs a smaller group setting and the State Preschool classroom is not an appropriate place for him/her,there will be a follow up conference. The parents will be provided with a listing of other local resources to more appropriately meet the child's needs. The child may be removed from the State Preschool only after due process has been followed. Parents have the right to appeal decisions made by the local agency and are informed of that right. 12 C,JirorniaDcputtncntocEducation Contra Costa County Community Services Dept. Auld D6vcl0pmart Division Legrl Name or Applicant CoMPETTTWE APPLICATION(CD30021 REV.1/95) ADM NISTRATION INFORMATION(State Preschool) PART III ADMINISTRATION NARRATIVE SECTION A. ADMINISTRATIVE STRUCTURE AND FUNCTION: 1. Board Composition List the titles, names, addresses and telephone numbers of all members of the agency's Board of Directors. If the applicant is not a corporation, identify the sole proprietor, partners, or officers of the organization by title. APPLICANTS MAY ATTACH ONE SEPARATE PAGE to list all board members or to list members in addition to the spaces provided below. *Please refer to list below. (#2) Title Name Address Phone Chairperson Vice Chair Secretary Treasurer Member Member Member 2. Organizational Structure and Function Describe the organizational process by which policies will be set. Describe how the proposed program will. function within the existing organizational structure and process, including the roles of the Board (or sole proprietor or partners) , administrative and program staff. ATTACH AN ORGANIZATION CHART TO EACH COPY OF THE APPLICATION. Family child care applicants must also attach an organization chart that reflects the relationship of the provider to assistants, -substitutes and the administering agency as appropriate for the provider's situation. The Contra Costa County, Community Services Department (CCC/CSD) functions under a five member publicly elected governing board. The Board of Supervisors is responsible for developing Board Policy for CCC/CSD, and the Department Director reports directly to the Board of Supervisors. She is responsible for implementing Board Policy. The contract will be subject to approval by the Board of Supervisors. BOARD OF SUPERVISORS JIM ROGERS DISTRICT 1 . . . . . . . . 6-3231 374-3231 MARK DE SAULNIER DISTRICT 4 . . 6-5763 . . . 646-576: t t m i mond 94805 Stanwell r ncor 95 Move to FAX# . . . . . . . . . . . . . . . . . 6-3429 . . . 374-3429 2425 Blsso Lane Ste 110 Concord 94520 Chief Assistant, Helen Freeman FAX# . . . . . . . . . . . . . . . . . . . . . . 6- 767 . . - 646-576; Assistant, Kathleen Nimr Chief Assistant, Karen S Mitchoff Assistant, Trevor Norman JEFF SMITH DISTRICT 2 . . . . . . . - . 6-2080 . . . 646-2080 Assistant, Valerie Brandt Ine bt Hm 108A Martinez 94553 TOM TORLAKSON DISTRICT 5 . . . . 6-8138 . . . 427-8131 300 E FAX# 6-1396 . . . 646-1396 Leland Ave to ltts urg 94565 Chief Assistant, Nancy Hobert - - . 427-814, Assistant, Mark Hughes FAX# . . . . . 6 8142 ia Assistant, Pam Pagnl Sawyer Chief Assistant, Gloria Oma. . Assistant, Sharon Haynes-Creswell GAYLE BISHOP DISTRICT 3 . . . . . . . . . . . . . . . . 820-8683 Assistant, Kathi Bala ad 18 Grow Uanyon Ut bte 120 ban Ramon 94583 Assistant, Lori Haywood FAX# . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 820-6627 Chief Assistant, Patricia A Rosenberg Assistant, Jane Ellen Korsick 13 Assistant, Janet L Brown uuuocnu Ucpanmcm«cc� Child DcvcloM as Division Lc&d Name of Applican, •-comrETrrrvE APPLlCATlOK(C'D30021 REV.1/95) ADMINIK ISTRATION FORMATION(State Preschool) C. FINANCIAL STATUS: 1. Financial Statement If a certified financial audit has been completed on the agency for the prior fiscal year, INCLUDE ONLY ONE COPY OF THE AUDIT. Describe any steps the agency is taking to address any management recommendations, qualified or adverse opinion, or negative fund balance presented in the audit. If the agency was not audited, attach a copy of a balance sheet and a revenue and expenditure statement which reflects the agency's financial status as of the end of the past month for the agency's current fiscal year. Describe any management or financial issues the agency is currently experiencing and what steps are being taken to address these issues. Attached please find a copy of the Divisions annual contracts audit that cover FY 1993-94. There were no significant findings.The auditor noted one instance in a sampling of twenty-five children's attendance where one absence for one pupil on one day had not been signed by a parent or staff person. Staff have subsequently been instructed to double check signatures for absences and to count as unexcused any notation that is not signed. This clerical error had no affect on the CDE count for the year since the agency was well within the allowance for unexcused absences. 2. Existing Programs and Sources of Funds List all existing contracts, agreements, grants, parent fees, and other fund sources. Briefly describe the services provided, the funding source(s) , and the amount of funding for each. The Child Development Division of CCGCSD operates as a separate budget organization within the Department. It has its own organization code for the Child Development Fund within in the County's financial structure. The table below shows the Division funding during FY 1994-95. FY 1994-5 CHILD DEVELOPMENT DIVISION INCOME SOURCE AMOUNT CDE TITLE IV-A CONTRACT $541,104 CDE CONTRACT FOR TRACKING AFDC FAMILIES $10,350 CDE GENERAL CHILD CARE CONTRACT $2,664,694 CDE STATE PRESCHOOL CONTRACT $106,519 COLLEGE DIST. STATE PRESCHOOL CONTRACT $718,135 CHILD CARE FOOD REIMBURSEMENT (EST) $315,000 PARENT FEES (EST) $92,945 ONE-TIME-ONLY CONTRACT $292,000 COMMUNITY DEVELOPMENT BLOCK GRANT $75,000 SH COWELL FOUNDATION $250,000 COUNTY CHILD CARE AFFORDABLILITY FUND $50,000 MISC. GRANTS AND FUNDS $8,000 TOTAL $5,123,747 15 CW0r;,.iaDcpartmentofEducation W11LLa UU.JLa WLUILY k,"IHuulLLLy ouLvices Dept Child Dcvdopmcut Misioa Legal Name of Applicant COMPETITIVE APPLICATION(CD3002I REV.1/93) AbmimsTRATION INFORMATION(State Prcschool) C. FINANCIAL STATUS (CONTINUED) : _ S. Adverse Actions Have any funding source agencies, other than the Child Development Division, California Department of Education, taken adverse actions, such as termination of funds or stipulation of conditional/probationary funding, against the applicant agency? X No Yes, Adverse actions If yes, indicate the number of adverse actions. For each yes response, ATTACH AN EXPLANATION TO EACH COPY OF THE APPLICATION of the situation not to exceed one page. Indicate if the adverse action was based on any finding that the agency's fiscal management system was inadequate. For all explanations, describe steps taken by the applicant to examine and modify agency policies, procedures and practices to prevent similar situations from occurring again. D. INTERNAL FISCAL PROCEDURES AND CONTROLS: Describe the following internal fiscal procedures and controls to be employed by the proposed program to safeguard public and other funds. Indicate by position title who will be responsible for each function described. 1. Accounting system The County's accounting system,which conforms to generally accepted accounting principals as applicable to governmental entities, is operated under the direction of the County Auditor-Controller's Office. A modified accrual system of fund accounting is employed. Using an automated accounting system, the Auditor-Controller restricts each Department's expenditures to the amount appropriated by the Board of Supervisors for the-year. Increases in budget appropriations must be approved by the Board. No Department.is permitted to-spend more than its available appropriations. An encumbrance accounting system is used to facilitate effective budgetary control., The Director of each Department is responsible for ensuring that proper internal procedures and controls are in effect at all times for all programs under the Director's review. Program expenditures and revenues from each funding source are properly segregated by organization account units. The Child Development Division Accountant has the responsibility to insure that program income and expenses are allocated to the appropriate accounts and in accordance with the Funding Terms and Conditions of our various contracts. The Auditor-Controller's Office has an Internal Audit staff that routinely reviews/audits Departmental accounting procedures, systems and controls to ensure compliance with County standards. Child Development Division contracts are audited by an outside, independent auditor. 17 California.Department of Education Child Development Division Legal Name of Applicant COMPETITIVE APPLICATION(CD-30021 REV.1/95) PROGRAM INFORMATION(State Preschool) E. COMMUNITY RESOURCES AND INVOLVEMENT: Describe any anticipated community resources or involvement such as in-kind contributions,donated goods or services and referrals. Indicate how these services will contribute to the cost-effectiveness of the proposed program, enrich the program,or expend services to children and families. Indicate how the agency will generate community awareness of an involvement in the program. Describe any in-kink services to be provided by the applicant agency to the proposed program. • Community Services Department is the grantee for the County's Head Start Program. We share materials,staff training,sites and personnel wherever it is appropriate to do so on a prorated basis. • Community Services Department,Child Development Division directly operates nine child care and development centers with 27 General child Care classes and 6 State Preschool classes. In addition,we subcontract nine State Preschool classes to five community based child development agencies through a contract we have the College District. We provide training and technical assistance to these delegate agencies and our own direct programs by sharing the cost of additional personnel such as:a nurse,an LVN,a mental health consultant,five mental health interns,a fiscal consultants,outside trainers and internal educational specialists. • Administrative expenses are allocated over the multiple contracts for greater cost savings. • The County's Social Services and Health Services Departments provide us with referrals and we access-their economic support and medical services for needy families. We are able to help families access AFDC,Medi-Cal,Food Stamps,Housing Certificates, Counseling and Job Training. • All eligible are referred to Child Health and Disability Prevention(CHDP)for enrollment physicals and medical and dental follow- up. • The County provides coverage for Worker's Compensation,Liability Insure and Fire and Theft Insurance through a County self- insurance program operated by the Risk Management Division at a cost lower than the market rate. • The County Payroll Division,Purchasing Division,and Auditor Controller's Office insure the safe keeping of contract funds. • We will seek to continue our relationship to the Martinez Unified School District for the leasing of an additional room for the operation of this program and to coordinate with the local schools for a smooth transition of students. • We will continue our relationship with the Martinez Unified School District for a food service contract. • Parents from our program will-be referred to the Martinez Unified School District's Adult Education Program for the continuation of their education. • We will continue our collaboration with other child development agencies to share information to improve the quality of our program. • We will continue to provide copies of our newsletter and fliers about our program to the school district and the local media. • We are able to use the County's welfare check distribution system to inform eligible parent about our State Preschool programs. • We have access to public service announcements on Contra Costa TV to announce important events at our sites. • We are active participants in the Contra Costa Child Care Task Force,a local planning committee for County Services and the Policy Academy that makes recommendations to the Board of Supervisors regarding children and family services. • Our program administrators belong to the Contra Costa Child Care Director's Association and the California Child Development Administrators Association. • Our Manager is a representative to the Child Care Committee for the Child Welfare League of America and the Department Director is the Western Regional Representative to CWLA. • Our staff is actively involve in the Child Care Consortium and participates in peer reviews of other agencies. 19 California Department of Education Contra Costa Cnunr)r Cnmrmrni tyrServices Dept. Child Development Division Legal Name of Applicant COMPETITIVE APPLICATION(CD-30021 REV. 1/95) PROGRAM INFORMATION(State Preschool) G. FACILITY INFORMATION: Describe all actions the agency has taken and/or will take to ensure the availability of an adequate number of licensed child care facilities for the proposed program in the designated service delivery area by the first day of operation: 1. Describe the location(s)of proposed facilities. Is the facility to be acquired through lease or purchase? Indicate any necessary renovations and the estimated time-line for completion of same. The County has a lease for one classroom at a school that is no longer being used for elementary classes for a back-to-back State Preschool classroom. The District's Board President has already indicated to our Director that she will assist us in acquiring another room at this site. We have already begun to develop the licensing packaged to add a room to our existing program. Should we be successful in our proposal for funding,we will work through the County's Lease Management Division to adjust the rental arrangement we now have to include another classroom and bathrooms for the enlarged program. 2. Describe the actions taken to obtain the licensure of the facilities. Please see the answer to the above question. The Licensing Division in our area has helped to obtain"Fast Track Licensing"on other projects. We expect to have a site for the children by the start-up date of January 2, 1996. 21 _ ^ N I I I I o O � N-..{{{{ N N O O I I Co O P w N N - C F u r •- O 1 O Y VC) C) (DQ t ! t l O ! ' u L T B O O tri N O N I GO I -T N N u y u o I I O N I I r-4j l Co O O ` rq 00 00 O Cl) I I "D O- (3-, (,o I 1 1 1 M a . 4 o- 5 it I I I I I I I I I i I L L y O O o O O O O O I O O O ✓ ✓ N J I N u 2 au u L O ✓ O O O O 0 0 'O, O I O O O N 3 t V L 2Q z o N 0 UO rtO r -( 1J O CO a Cl) n oO o c 0 o c . -T C m a N �'O 00 1� W aH ~ O U W .. c o I p Cl) R. to q q L V 0 z U) u C a N .u+ u H a O H Qo a0 0V =0 VOI i I I OI 0 1 C:); ; OI (I 0 1 OI O I O W VUP zle lull) I I 1 I I I 1 1 1 1 I �j i N �" 5 Z O — LL. L O O O Co O+ O i I O O O 0 0�rl K y q p 1 I 1 1 I 1 I t 1 NI i I W ✓ N c I I O 0 0 L c C N tb to I O v r-+ 00 O 0 CO ! I I N Cl t\ to 7•. - °-`= is cC14 -I Cc 1 1 ' 1 to I 1 - Lf') r--t o u url I i r I O m ✓ V O N I N _ N \ x CC M ►- -, a N O W L C L C a L a 0 r. � I J O � OC a v u o � •, . a _ ° in w O O V V > L V u O C u ° A p N lJ ✓ m p ? u ° L K U 1 V O40 wk u O cwc i } o Ly a r- > .- C E . to O y p _ U V N W m N O U — i W Z o L, G u x ` 2 S O o o O po g Y = 4 N M V� O O I f` a Z o f — -- ,t T M J N •O CO P I O ^ N 0- lzP w a c = w C x m 7 V P v .. lu K a - C u O r V V V eC CEKTER-BASED L FMILT CHILD CARE 110ftE (FCCK) APPLICATIt}( FOR fixon(c FIKAXCIAL SCREDULE-8 PACE 1 Of 2 Instruction for Conpleting Financial Seheddite B (CO-3002A Rev, 2/91) ►inarcial Sehedute.8 (CD-3002A) details the agency's planned expenditures for specific object classifications. I( the applican n9 planned expenditures in the items detailed on this form write "not applicable" in the first line, Co(Lrrns (A) - (F) in cotum (A), report planned Child OevclopTcnt contract expenditures for each specified object classification. in colurns (8) th. (E), report planned expenditures that will be used to support the child developncnt program: eotum (8) subsidized parent fees non-subsidized parent fees; (D) other restricted funds; and (E) other tnrestrictcd funds. The total of all planned cxperditur, reported in eolLxm (F). Description Explain in detail expenditures planned for each specified object classification, Approval of the application and budget docs constitute approval of any subcontract, equipment, travel, or renovation and repair expenditures for which prior written approval be required from the Child Development Division. If an object classification or funding icvrce is not applicable. leave the aooropr eolutns and description blank, CONTRA COM COUNTY funding Source Legal Rame of Applicant Agency—CO)`4IUNITY SERVCIES DEPARTTiII1T Ch i(d Deve l opment I CHILD DEVELOPMENT DIVISION _ I II I Child Line f Acct. Oevelopment (Subsidized Konsubstdizedl Other I Other Un- I Ko. l No. Classification Division parent fees I parent f"s restricted restricted TOTAL I (A) I (8) (C) I (D) j (E) I (F) 3 3900 Other employee I I I benefits IS is i ,S IS IS Description: 5 5100 Personal services I I of consultants, I etc. I s- 4000.00 is - 0 - 1 s - 0 - is— 0 - i - 0 - Is 4000.00 j I Description: $2000.00 for the School Nurse $2000.00 for the Mental Health Consultant 5 1 5200 Travel and I conference I expenses, etc. Is 200.00 Is - O - 1S- 0 - 1 - IS - 0 - Is 200.00 Description: Annual Child Development Conference I 5 j 5610- Contracts i IS Is I S i is Description: I 5 ( 5620 Rents, teases (S10000.00 is - 0 - s - 0 - ` s - 0 - li - 0 - IS10000.00 I Description: Rent includes custodial, heating, electric, water and garbage col- lection. Site will be shared with L.atckey program. 'Indicate payu�cnts to FCCH providers, if applicable, 25 1 � uti o N 0 ON r� v G .✓ go � � n h O C v Y � O ✓ u • � N O N a ✓ p ✓ .�. � tt'� M v o a00 u = C f- ° lop u o o CAN O • O '° r c^3 M � N �• yW. 0 r , q a '° G O u a F ✓ U u qk 03N Y r ° y u 0 0` c i N a o Q & u u✓ G 6 0 u N ttt� A u O V ✓ Y ^ (�A � � r uN ° � � • � guy app � Ct? A C �. ✓p N ✓ O ij C W90 ¢ t7 ✓ L p uto C tJ C3 f G G OD v � V ia i u § u c O F+ c- cJ� 0 $ � � �' � a a s o to -4 3 N do o ✓ v " L. . A j O QQ _ ON O W N A W. O O S 6 0 �"'O L t p C ON U L O a r. Y at = 1 0 � a o+✓ ` � u t o u a "� � , tri a G ° � W ✓9 130 0, aswN u � � •3 r ✓ `` u. C G 1 :) V o — N ✓ ,y QY� N a N 7 ii n r N Tp ✓ •p t, Y V Y 0 M •'' , O ✓ `"4 N 'c 1 D Y A ✓ 0 0 C ✓ Y .p G .�. N • u .� ,t 4 u W N r vcc ap C M o ° �' ✓ v O�Q a ✓ Y Y G .n tl fc �, � C/� lf1 p " t it O a ✓ '� it G. M O p �' i Y g n ✓ ^ .cel ^ r A T✓ y9A � �' ✓ 4 N i � � cp 07, O' 4 � O '~ tl ✓ C A 6 p ✓ ✓ 8 $ O G F. N a UA C6 V" N v Y O N ✓ T N ° to cc N Y ° C 9 ~� e+ a✓•J� w ygu0 y �, ✓4p ~ 1 Ot N Cl Is O V' Ua Ir at � � G u"" ✓ q ° � < N t� g �' u " ✓ t4 G nN ..- r, -O p -u � e A � ✓ 7""� O ✓ ✓ a N✓ u C N w' N Q G N = a U N d v y r G G v G :n O ^ U x G v CA r+ N .9 c-U tA vN Q 43 c-4 s N .140 -1 W co PA tJl W V l r •a. ` M A z ° VA QO P N N N O y cl �,, U� o-� N r► � � v G '� G a ,, x N f � U �O p1 v L ••- m WA C d US D ) 05 G 7 ON p1 C O o U V C O i I I I C0 00 00 ' 00I 00! 1 ^ ' O O o; O 14I ' � � c o I —4 1 I I v v p I N N N N N N N N N ` u M u -- O O Ln .. ` v OI O 1-+ H r+ to c cyll n I « T 1 1 04 I x $ fib} u OOrI1 �' y � a, O O co 0o co 010 co! m I I N t1 — 10 II O C) W W .. ° M M 111 M M I co . U H c ..` i r O O �7 �7 -It 0. 0: -,t -t I 40 CL Y I u (Qto c O N In u •- v 0 O O O O O O OI O O o cA v o A I x N •+ N A V 1 y I I 9 ti u ! I J Y I �w A o o .o .o .fl o o �o •o I I V W — '• 1 c W 0 f L ✓ co C o -' 0 O O N N N O O� N N � _ H I I I H 'A 5 ,0 i O o AC U u) 4-) tai N I s a ''-3 M L Q) r L y.l O Y O O N N N O O N N 9 Ql o « « : O i O — W U « 4-J 00 0 : : : a a I a m a a a N M SO I► b P .0 N " N M J ✓� p A < ! E E E E E 8 E E E E E E E r+ u5 8 < I Y 4u u tr.::a �...,oc..�: �:.r,:o� 1995-yo --.• CALENDAR ;u:u xaaa o. aax-cr /n? ►RCJsc? raou C-O✓Ij-rCc. CID—� a0 . i Im%= ax •x• as ayssx au rocs raocaux w= s: o►rx roa alxvics. JULY 1995 AUGUST 1995 SEPTEMBER 1995 Su N I TV Y TH F SV I H TV y = F SVI H I TV I y TR r 1 1 2 3 4 S 2 2 3 •1 S 7 t 6V1'4 t 10 11 12 3 •4 S 6 7 t 9 FIRST 9 30 11 13 14 15 13 16 17 It 119 10 11 1 1;,K3 14 15 16 QCARTER 16 18 22 24 26 128 20 r22 23 24 2S 126 17 Ijr19 20N29 22 23 17 t21 23 25 27 29 28 -29 30 31 25 : 26 27 29 30 0 131 Days Of operation: Days o: Operation: Days of Operation:_ HI OCTOBER 1995 NOVEMBER 1995 DECEMBER 1995 I SJ : H nj v I TH S F SU I H T it y 17w 1 F S-j H I TV' 1I 7 F I l I 2 : 3 4 i S E 7 1 2 3 4 2 SECCt�� 8 '•9 110 11 12 r 13 114 1 5 1 6 7 1 8 9 I•10111 3 4 1 S 1 6 I e 1 9 r Q�AR:z R 15 1 1E 1 18 19 : 20 2: 1 12 '13 ; 1 is 116 117 lie 10 111 112 ! 14 , is . 161, 122 24 25 126 2-1 126 19 . 21 22 •23. 24 25 17 ' 18 120 ( 21 • Z2 23 I 30 ' 31 i Z'. l 27 128 129 130 1 24 S' 26 121 126 Days o: operation: cat's o: Operation: Days Of Ope:a:ic:.:_ TC-.>-' 151A JANUARY 1996 FEBRUARY 1996 MARCH 1996 SU H TJ I le i rX; F I SA SV r x I TU' V , TR 1 F SA S'' H TV I Y I TH: F I SA : I.1 I i i 6 ><1 3 D--K2' 7 . 13 4 110 735<I X 9 TH:pJ : 14 •is 2: 11 X. 17 10 :x *1 �I 116 QUARTER 21 j � ,� 27 18 •19� �� � 24 17 !fir ( �' iX23 29 XI 25 ;< 24 ' ZK ,><I 30 3: Days of Ope:ation:� Days of Operation: -20 Days c: Operatics:_?, APRIL 1996 MAY 1996 JUNE 1996 SU x Tv Y TH r SA sv x Tv Y T8 r SA sv m 2V Y. T8 F SA `,>K 6 XX >91 >Q 4 1 7 13 S A 11 2 ?� d MURTH 14 0 tw 20 12 IV Ix 1 11 9 �Q X 15 QUARTER 21 I 7,aY 2)< 0 24 27 19 y� 1� 25 16 ' 17. 18119 20 21 22 29 '• I 26 •23F 1 23 2; 25 25 27 128 29 3: �-4 Days Of Operation:- Days of operation: .- Days of Cperatior.:1Q '=OTA' • Legal Holiday o'.,ZPA:-L TOS'!-- 33 Chitd Ocvc(opmCnt Division - stato"cnt of Co-p((ence (m-3002D Rcv. 3/93) STATEMENT OF COMPLIANCE CONTRA COSTA COUNTY COyWMNY NAME—COA1I`1UNITY SERVICES DEPARTtM — CHILD DEVELOPPM DIVISION The company named above (hereinafter referred to as "prospective contrac(or") hereby certifies, unless specif(cal exempted, compliance with Government Code Section 12990 and California Administrative Code, Title 2, Divisi, 4, Chapter 5 in matters relating to the development, implementation and maintenance of a nondiscriminatie program, of nondiscrimination program. Prospective contractor agrees not to unlawfully discriminate against any employ( or applicant for employment because of race, religion, color, national origin, ancestry, physical handicap, medic condition (cancer related), marital status, sex or age (over forty). CERTIFICATION I, the official named below, hereby swear that I am duly authorized to legally bind the prospective contractor i the above certification, executed on the date and in the county below, is made under penalty of perjury under t. laws of the State of California. `(AME OF OFFICIAL .Joan V. Sparks _ DATE EXECUTED 6/26/95 I EXECUTED LN THE COUNTY bF Contra Costa PROSPECTIVE CONTRACTOR SIGNATURE PROSPECTIVE CONTRACTOR TTTLE y Services 4epartnent Director PROSPECTIVE CONTRACTOR FEDERAL EMPLOYEE I.D.NUMBER ATTACH ONE COMPLETED COPY INCLUDING AN ORIGINAL SIGNATURE TO THE APPLICATI N CHECKLIST. 35 18NDOR DATA RECORD 'required in lieu of IRS W-9 when doing business with the State of California) TD.204(REV.6-92) DEPARTMENT/OFFICE PURPOSE: Information contained in this form CA. Dept. of Education Child Develo ent Div. will be used by State agencies to prepare Infor- RETURN PLEASE STREET ADDRESS mation Returns(Form 1099)and forwithholding To: 560 J Street Suite 220 on payments to nonresident vendors. CI STATE,ZIP CODE (See Privacy Statement on reverse.) Sacramento, CA 95814-2322 ENDOR'S BUSINESS NAME OWNERS FULL NAME (Last,First,ACL) Contra Costa County, Community Service Department TREET ADDRESS ARE YOU SUBJECT TO FEDERAL BACKUP WITHHOLDING, 1220 Morello Avenue Suite 101 (see insftc6oft for IRS Form W-9) ITY,STATE,AND ZIP CODE Martinez CA 94553 ❑ YES [� No INSTRUCTIONS: (1). Check box indicating type of business entity and provide taxpayer Identification number. (2). Check box indicating resident or nonresident. (See reverse for additional information). (3). Check one or more VENDOR ACTIVITY boxes specifying vendor activity type. . ::::<::?;:::::>\(ENDOR::::: -7: StDE -: ATU <...:...:..::.' _....__.....-.....TYPE...--_ .__....................5............................................................:.........._..... ..._.........................-._........-.._.............-.-......._...... ❑ CORPORATION ❑ MEDICAL SERVICES(Inc/udmgdentistry. (Enter Federal Empbyerldentification Number) podiatry.Psychotherapy.optometry, a SERVICES(NON MEDICAL) chiropractic,etc) 1 4 6 1 0 1 0 1 0 L9 EOUIPMENT/SUPPLIES I - 11 5 10 1 9 ❑ (Exempt from State mdtho/din9) Resident-Qualified to do business in CA/® ❑ RENT Permanent place of business in CA OTHER ❑ Non Resident (See Reverse) ❑ (sve�hl ❑ INDIVIDUAL/SOLE PROPRIETOR ❑ NON EMPLOYEE COMPENSATION(Including ❑ EOUm tfromState w S (Enter Socia/securify Account Number only,NOT FEIN) repairs and maintenance,construction,efa) (Exempt from State rvithhoking) MEDICAL SERVICES(Including dentistry, L I I I - I I ( — ( I I I I ❑ podiatry,psychothwrapr optometry. chiropractic,etc) ❑ Resident ❑ Non Resident (See Reverse) ❑ INTEREST(Exempt from State withholding) ❑ PARTNERSHIP ❑ RENT (Enter Federal Ernployer Identification Number) L ( I - I I I I I I I I ❑ ROYALTIES ❑ Resident ❑ Non Resident (See Reverse) ❑ PRIZES AND AWARDS ❑ ESTATE OR TRUST (Enter Federal Employer Identification Number) ❑ OTHER(Speoi/yJ - L . I I I I I l l ❑ Resident (Estate) Decedent was a CA resident at the time of death ❑ Resident (Trust) -At least one trustee is a CA resident ❑ Non Resident (See Reverse) I hereby certify under penalty of perjury that the Information provided on this document Is true and correct. N my residency status should change,I will promptly Inform you. IUTHORIZED VENDOR REPRESENTATNES NAME(Type or print) TITLE Joan V. Sparks Department Director SIGNATURE DATE TELEPHONE NUMBER .......................... .........:.::. June 26, 1995 510 313-7350 .::::.::::::: : :: .::.::.::.:..:::._:.:.::.::::::::::::::::::. -............ ':=' :,.. :.:'!`>r`tJSEJIEY ........... _. CONT /LEASE NUMBER (specify) NONRESIDENT WITHHOLDING ❑ NONEMPLOYEE ❑ MEDICALSERVICES ❑ RENT F] OTHER COMPENSATION ❑ STANDARD RATE IEPORTABLE INCOME CODE PER STATE ADMINISTRATIVE MANUAL SECTION 9422.19(Check One) INITNLS DATE INITIALED' ❑ WAIVED ❑ t ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 ❑ 7 ❑ REDUCED RATE % 77 N 7� v O G O C� -c � N , �. C) O '` r op m n cv A GCD Lo moa x D . n N CopOI� G d O G > -* G CD N p 00 cD O N a=� O N G r• •" CD CD n 7 0 .O 1 o- 3 O CD o co3 w � 0(P 0 4 G m O a.CD )3tlD O 3 � O G ° � O @ C) C,A cr o ..c r CQ a 4 N N CD 0 n P1 �' It � W � CID A � O Lp G N Q 4 o J . cT cT CD CD CD --------- m 0 � 1 D ID N O 4' C, O 0c CD 1 9r n � a n n s � _ .. .. . . . . .. . . .. � \ . )� o� w ®{ . {| �} k � IL 2 `■ ° • |# | i j W ra /k fR r ' | _ �o • !£2 ! U-1{} )\ �{ �) \� ~ ' ..] \k !\ =z L[/ f« \7 \ k\ !! © ; ?� 5% ; . �i L _] . §{ ; Lfj.- - ki _ 2i 2i ki 9i \ §ick \ j �\ /§ {{ - \�� \ : , ){ !Ik cc 3){