Agmt, Signature & Insurance - Harbor Interfaith Services, Inc. — Redondo Beach City Council, February 10, 2026

CITY OF REDONDO BEACH

COMMUNITY DEVELOPMENT BLOCK GRANT

PUBLIC SERVICE FUNDING AGREEMENT
Contractor: HARBOR INTERFAITH SERVICES, INC.

Project Title: STREET OUTREACH AND ENGAGEMENT PROGRAM
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TABLE OF CONTENTS
Section

ARTICLE I

INTRODUCTION AND CONDITIONS PRECEDENT
101. Parties to the Agreement
102. Representatives of the Parties and Service of Notices 103. Time of Performance
104. Conditions Precedent

ARTICLE II

DUTIES AND POWERS OF THE CONTRACTOR
201. Services to be Provided by the Contractor

ARTICLE III

DUTIES OF THE CITY
301. Compensation
302. Funding of the Agreement

ARTICLE IV

METHOD AND TIME OF PAYMENT
401. Payment to the Contractor
402. Withheld Payments
403. Receipt, Use and Accountability of Other Than Budgeted Funds 404. Utilization of Funds

ARTICLE V

REPORTS, RECORDS AND AUDITS
501. Reporting Requirement
502. Maintenance of Records
503. Audits and Inspections
504. Accounting Practices
505. Documentation of Expenditures
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Section

ARTICLE VI

GENERAL TERMS AND CONDITIONS
601. Indemnification and Insurance Requirements
602. Prohibition Against Assignment
603. Limitation of Expenditures
604 Limitation of Corporate Acts
605. Funding Reduction
606. Amendments to the Agreement
607. Compliance with Statutes and Regulations
608. Waivers
609. Independent Contractor
610. Attorney’s Fees
611. Nondiscrimination Provision
612 Program Income
613 Reversion of Assets
614. Anti-Lobbying
615 Conflict of Interest
616. Non-Liability of Officials and Employees of the City 617. Conflicting Provisions
618. Non-Exclusivity
619. Confidentiality
620. Third Parties
621. Governing Law and Venue
622. Claims
623. Interpretation
624. Severability
625. Authority

ARTICLE VII

DEFAULTS, SUSPENSION AND TERMINATION
701. Defaults
702. Suspension
703. Termination

ARTICLE VIII

ENTIRE AGREEMENT
801. Complete Agreement
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802. Number of Pages and Attachments

EXHIBITS
Exhibit I Program Budget
Exhibit II Job Descriptions
Exhibit III Income Level Guidelines
Exhibit IV Client Intake Sheet
Exhibit V Monthly Summary Sheet
Exhibit VI Public Service Agency Expenditure Report
Exhibit VII Insurance Requirements
1 AGREEMENT

BETWEEN

THE CITY OF REDONDO BEACH
AND
HARBOR INTERFAITH SERVICES, INC.

RELATING TO

STREET OUTREACH AND ENGAGEMENT PROGRAM
THIS AGREEMENT (“Agreement”) is entered into between the City of Redondo Beach, a chartered municipal corporation (“City”) and Harbor Interfaith Services, Inc., a California nonprofit corporation (“Contractor”), with reference to the following: Street Outreach and Engagement Program.

WITNESSETH
WHEREAS, the City has entered into a Grant Agreement with the United States Department of Housing and Urban Development, (“HUD”), pursuant to Title I of the Housing and Community Development Act of 1974, as amended, to address the community development needs of the City (the “HUD Grant Agreement”); WHEREAS, the City has received the Community Development Block Grant (“CDBG”) from HUD to administer City programs as described in the HUD Grant Agreement;
WHEREAS, the City Community Services Department has been designated by the City to provide for proper planning, coordination and administration of these programs;
WHEREAS, the City Community Services Department cooperates with private organizations, other agencies of the City and agencies of other governmental jurisdictions in carrying out these programs;
WHEREAS, the project which is the subject of this Agreement has been established by the City as one of the above described programs, and has been approved by the City Council and the Mayor of the City of Redondo Beach; and WHEREAS, the City wishes to engage the Contractor to provide the services described herein to carry out this project.

NOW, THEREFORE, the City and the Contractor agree as follows:
2 AGREEMENT

ARTICLE I

INTRODUCTION AND CONDITIONS PRECEDENT
101. Parties to the Agreement
The parties to this Agreement are:

1. The City of Redondo Beach, a chartered municipal corporation, having its principal office at 415 Diamond Street, Redondo Beach, California 90277.

2. Harbor Interfaith Services, Inc., a California nonprofit corporation organized under the laws of the State of California, having its principal offices at 670 West 9th Street, San Pedro, California 90731.
102. Representatives of the Parties and Service of Notices The representatives of the respective parties to whom formal notices, demands and communications shall be given are as follows:

1. The representative of the City shall be, unless otherwise stated in the Agreement:

Elizabeth Hause, Community Services Director
Community Services Department
1922 Artesia Boulevard
Redondo Beach, California 90278

2. The Administrative representative of the Contractor shall be:

Tahia Hayslet, Executive Director
Harbor Interfaith Services, Inc.
670 West 9th Street
San Pedro, California 90731

3. Formal notices, demands and communications to be given hereunder by either party shall be made in writing and may be effected by personal delivery or by mail. Notice by mail shall be deemed communicated as of the date of mailing.
103. Time of Performance
The term of this Agreement shall commence on July 1, 2025 and end June 30, 2026, which is subject to the provisions of sections 301, 302, and 701 herein. Performance shall not commence until the Contractor has obtained the City’s approval of the insurance required in section 601. 3 104. Conditions Precedent
A. Prior to the execution of this Agreement, the parties have cooperated in the preparation of the following:

1. Program Budget. A summary by cost category of the
projected annual expenditures for approved CDBG-funded
items and salaries. Budgets described herein shall be
adhered to unless modified and approved in writing as
provided by section 606 of this Agreement. The Program
Budget is attached hereto as Exhibit I, and by this reference incorporated herein.

2. Job Descriptions. A compilation of individual job
descriptions for all CDBG-funded personnel attached hereto as Exhibit II, and by this reference incorporated herein.

B. Prior to the execution of this Agreement, the Contractor shall provide the City with copies of the following documents:

1. Contractor’s Articles of Incorporation, and all amendments thereto, as filed with the Secretary of State.

2. Contractor’s By-Laws, and all amendments thereto, as adopted by the Contractor and properly attested.

3. Resolutions or other corporate actions of the Contractor’s Board of Directors, properly attested or certified, which specify the name(s) of the person(s) authorized to obligate the Contractor and execute contractual documents.

ARTICLE II

DUTIES AND POWERS OF THE CONTRACTOR
201. Services to be Provided by the Contractor
A. Client Eligibility

1. Fifty-one percent (51%) of the total persons served under this Agreement shall meet the low and moderate income guidelines as determined by HUD, as described in Exhibit III, attached hereto and by this reference incorporated herein.

2. The Contractor shall document income and residency for CDBGfunded outpatient clients as provided in Exhibit IV, attached hereto and by this reference incorporated herein. Income documentation is not required for shelter clients.

3. The Contractor shall submit a "Monthly Summary Sheet," as provided in Exhibit V, attached hereto and by this reference incorporated herein, with each request for payment. The City in its sole discretion, may withhold payment if Contractor does not submit 4 the Monthly Summary Sheet.

B. Services to be Provided

1. Contractor shall identify and engage to proactively locate unhoused individuals in Redondo Beach and offer pathways to housing and stability.

2. Contractor shall provide case management tailored to individual needs, including housing placement, job readiness, and access to mental health and substance use resources.

3. Contractor shall provide resource connections by assisting with securing vital documents, such as IDs and Social Security cards, offering life skills workshops, and connecting Pallet Shelter residents to employment opportunities.

4. Contractor shall work cooperatively with the City (and other nonprofit organizations at the City’s request) in its efforts to implement programs that reduce the impact of homelessness within the City. At City’s request, Contractor shall send a representative to attend (1) a one-day South Bay Homeless Summit and (2) a one-day training workshop on Los Angeles County’s Coordinated Entry System (including Coordinated Entry Assessment Tool training).

C. Intended Beneficiaries

1. Contractor shall ensure at least ten (10) City residents shall be served during the contract period.

ARTICLE III

DUTIES OF THE CITY
301. Compensation
A. The City shall pay to the Contractor an amount not to exceed $7,537 for complete and satisfactory performance of the terms of this Agreement; for the period July 1, 2025 through June 30, 2026 only; subject to the provisions of sections 302 and 605 of this Agreement.

B. Funding for the periods set forth by the foregoing Subsection A is subject to change in accordance with the availability of CDBG funds provided to the City by HUD. The City reserves the right to change the amount of Compensation set forth herein accordingly.

C. The City assumes no responsibilities to pay for salaries or other expenses not specifically enumerated in this Agreement and as understood by both parties that the City makes no commitment to fund this project beyond the term of this Agreement.
5 D. Contractor may be reimbursed for expenditures that exceed individual cost categories as outlined in Exhibit I, provided that the total amount requested for reimbursement does not exceed the total amount set forth in Section 301.A.
302. Funding of the Agreement
Notwithstanding the provision of section 103, Time of Performance, concerning the term of the Agreement, funding shall be provided according to the following provision:

Funding for the period July 1, 2025 through June 30, 2026 shall be as set forth by section 301, Compensation herein and is subject to changes set forth by the foregoing subsection 301.C.

ARTICLE IV

METHOD AND TIME OF PAYMENT
401. Payment to the Contractor
A. The Contractor shall be reimbursed for all expenses authorized under the terms and conditions of this Agreement, subject to the availability of funds for this project and subject to all other provisions of this Agreement.

B. Unless other arrangements are made, the City will issue reimbursement checks within 45 days of City’s receipt of Contractor’s “Public Service Agency Expenditure Report” (Exhibit VI) and the “Monthly Summary Sheet” (Exhibit V), which shall detail clients served to-date under this Agreement.
402. Withheld Payments
A. Unearned payments under this Agreement may be suspended or terminated if grant funds to the City are suspended or terminated, or if the Contractor refuses to accept additional conditions imposed on it by HUD under the HUD Grant Agreement or the City.

B. The City has the authority to withhold funds under this Agreement pending a final determination by the City of questioned expenditures or indebtedness to the City arising from past or present agreements between the City and the Contractor. Upon final determination by the City of disallowed expenditures or indebtedness, the City may deduct and retain the amount of the disallowance or indebtedness from the amount of the withheld funds.

C. Payments to the Contractor may be withheld by the City if the Contractor fails to comply with the provisions of this Agreement. 6 403. Receipt, Use, and Accountability of Other Than Budgeted Funds The Contractor agrees that income funds realized as a result of activities which are funded by this Agreement shall be reported in writing to the City along with the Contractor’s monthly reports. The Contractor further agrees that all such income funds shall: (1) constitute Program Income as described in section 612; (2) be the property of the City; (3) be used solely to offset the operating expenses of the activities funded by this Agreement; and (4) be subject to all of the provisions of this Agreement. 404. Utilization of Funds
Funds paid to the Contractor pursuant to this Agreement shall be used exclusively for the activities set forth by this Agreement.

ARTICLE V

REPORTS, RECORDS AND AUDITS
501. Reporting Requirement
A. At such times and in such forms as the City may require, Contractor shall furnish to the City such statements, records, reports, data and information as the City may request pertaining to matters covered by this Agreement.

B. On or before the fifteenth day of each month, the Contractor shall submit to the City a Public Service Agency Expenditure Report, including copies of invoices. A copy of the “Public Service Agency Expenditure Report” form is attached hereto as Exhibit VI, and by this reference incorporated herein.
502. Maintenance of Records
A. Records, in their original form, shall be maintained in accordance with requirements prescribed by HUD under the HUD Grant Agreement and the City with respect to all matters covered by this Agreement. Such records shall be retained for a period of five (5) years after termination of
this Agreement and all other pending matters are closed. “Pending matters” include, but are not limited to, audit, litigation, or other actions involving records. The City may, at its discretion, take possession and retain said records.

B. Records in their original form pertaining to matters covered by this Agreement shall at all times be retained within the Los Angeles Area unless authorization to remove them is granted in writing by the City.
503. Audits and Inspections
7 A. At any time during normal business hours and as often as HUD, the U.S. Comptroller General, or the City may deem necessary, the Contractor shall make available to the City for examination, all of its records with respect to all matters covered by this Agreement. The City and the U.S. Comptroller General shall have the authority to audit, examine and make excerpts or transcripts from records, including all contracts, invoices, materials, payrolls, records of personnel, conditions of employment and other data relating to all matters covered by this Agreement.

1. The City shall have the authority to examine the books and records used by the Contractor in accounting for expenses incurred under this Agreement. Should these books and
records not meet the minimum standards of the accepted
accounting practices of the City, the City reserves the right to withhold any or all of its funding to the Contractor until such time as they do meet these standards.

2. The City shall have the authority to examine all forms and documents used, including, but not limited to, client files, purchase requisitions, purchase orders, supply requisitions, invoices, journal vouchers, travel vouchers, payroll checks and other checks used by the Contractor. It further reserves the right to require that personnel forms and documents be pre-numbered and kept under accounting control.

3. The City may require the Contractor to use any or all of the City’s accounting or administrative procedures used in the planning, controlling, monitoring, and reporting of all fiscal matters relating to this Agreement.

4. The City reserves the right to dispatch auditors of its choosing to any site where any phase of the program is
being conducted. Such sites may include the home office, any branch office or other locations of the Contractor if such sites or the activities performed thereon have any
relationship to the program covered by this Agreement.

5. The City shall have the authority to make physical
inspections and to require such physical safeguarding
devices as locks, alarms, safes, fire extinguishers, sprinkler systems, etc., to safeguard property and/or equipment
authorized by this Agreement.

6. Subject to the discretion of the City, certain authorized members of the City shall have the right to be present at any and all of the Contractor staff meetings, Board of Directors meetings, Advisory Committee meetings and Advisory Board meetings if an item to be discussed is an item of this
8 Agreement.

B. When a fiscal or special audit determines that the Contractor has expended funds which are questioned under the criteria set forth herein, the Contractor shall be notified and given the opportunity to justify questioned expenditures prior to the City’s final determination of disallowed costs. The City shall determine any amount to be paid to the Contractor during the period of audit.
504. Accounting Practices
The Contractor shall maintain a system of internal control in accordance with accepted accounting practices as approved by the City. Internal control comprises the plan or organization and all of the coordinate methods and measures adopted within an organization to safeguard its assets, check the adequacy and the reliability of its accounting data, promote operating efficiency and assure adherence to prescribed management policies. 505. Documentation of Expenditures
Expenditures shall be supported by properly executed payrolls, time records, invoices, vouchers, or other official documentation evidencing in proper detail the nature and propriety of the charges. Checks, payrolls, invoices, vouchers, orders, or other accounting documents shall be clearly identified and readily accessible.

ARTICLE VI

GENERAL TERMS AND CONDITIONS
601. Indemnification and Insurance Requirements
A. Indemnification
To the maximum extent permitted by law, Contractor hereby agrees, at its sole cost and expense, to defend protect, indemnify, and hold harmless the City, its elected and appointed officials, officers, employees, volunteers, attorneys, and agents (collectively “Indemnitees”) from and against any and all claims, including, without limitation, claims for bodily injury, death or damage to property, demands, charges, obligations, damages, causes of action, proceedings, suits, losses, stop payment notices, judgments, fines, liens, penalties, liabilities, costs and expenses of every kind and nature whatsoever, in any manner arising out of, incident to, related to, in connection with or arising from any act, failure to act, error or omission of Contractor’s performance or work hereunder (including any of its officers, agents, employees, Subcontractors) or its failure to comply with any of its obligations contained in the Agreement, or its failure to comply with any current 9 or prospective law, except for such loss or damage which was caused by the sole negligence or willful misconduct of the City.

Contractor’s obligation to indemnify shall not be restricted to insurance proceeds, if any, received by Contractor or Indemnitees.

This indemnification obligation shall survive this Agreement and shall not be limited by any term of any insurance policy required under this Agreement.

1. Nonwaiver of Rights. Indemnitees do not and shall not waive any rights that they may possess against Contractor because the acceptance by City, or the deposit with City, of any insurance policy or certificate required pursuant to this Agreement.

2. Waiver of Right of Subrogation. Contractor, on behalf of itself and all parties claiming under or through it, hereby waives all rights of subrogation and contribution against the Indemnitees.

B. Insurance
Contractor shall comply with the requirements set forth in Exhibit VII.

Insurance requirements that are waived by the City's Risk Manager do not require amendments or revisions to this Agreement. 602. Prohibition Against Assignment
A. The Contractor shall not assign this Agreement, nor assign or transfer any interest or obligation in this Agreement (whether by assignment or novation) without prior written consent of the City, which may be withheld in the City’s sole discretion.

B. The Contractor shall not enter into any agreement with any other party under which such other party shall become the recipient of claims due or to become due to the Contractor from the City without prior written consent of the City, which may be withheld in the City’s sole discretion.

The sale, assignment, transfer or other disposition, on a cumulative basis, of twenty-five percent (25%) or more of the ownership interest in Contractor or twenty-five percent (25%) or more the voting control of Contractor (whether Contractor is a corporation, limited liability company, partnership, joint venture or otherwise) shall constitute an assignment for purposes of this Agreement.

Further, the involvement of Contractor or its assets in any transaction or series of transactions (by way of merger, sale, acquisition, financing, transfer, leveraged buyout or otherwise), whether or not a formal assignment or hypothecation of this Agreement or Contractor’s assets occurs, which reduces
Contractor’s assets or net worth by twenty-five percent (25%) or more shall also constitute an assignment for purposes of this 10 Agreement.
603. Limitation of Expenditures
A. The Contractor shall not expend funds provided under this Agreement subsequent to the suspension or termination of this Agreement in accordance with sections 702 and 703.

B. Expenditures shall be made in conformance with the Program Budget (Exhibit I).

C. Expenditures shall comply with 2 Code of Federal Regulations Part 200 (Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards), including Subpart D (Administrative Requirements), Subpart E (Cost Principles), and Subpart F (Audit Requirements), to the extent applicable to CDBG funded activities.

D. Expenditures shall be in direct support of the project which is the subject of this Agreement. The Contractor shall notify the City in writing of any expenditures for items jointly used for any other projects(s) and the expenditures shall be apportioned according to the percentage of direct use for this project.

E. Budget changes shall have the prior written approval of the City.

Unauthorized expenditures may result in withheld payments. 604. Limitation of Corporate Acts
The Contractor shall not amend its Articles of Incorporation or Bylaws, move to dissolve, transfer any assets derived from funds provided under section 301 herein or take any other steps which may materially affect the performance of this Agreement without first notifying the City in writing.

The Contractor shall notify the City immediately in writing of any change in the Contractor’s corporate name.
605. Funding Reduction
A. During the performance of this Agreement, the City shall have the authority to review the Contractor’s actual project expenditures and work performance. Should the City determine that the Contractor is in non-compliance with any contractual obligations, the City shall take appropriate action as provided by section 701 of this Agreement.

B. In the event that CDBG funds to the City are reduced, suspended or terminated by HUD, the City reserves the right to reduce, suspend or terminate the funds provided by this Agreement accordingly.
11 606. Amendment(s) to this Agreement
Either party may request an Amendment to this Agreement. Amendments to this Agreement must be in writing and properly executed by both parties and approved by the City Council.
607. Compliance with Statutes and Regulations
The Contractor warrants and certifies that in the performance of this Agreement, it shall comply with all applicable federal, state and local laws, statutes, ordinances, rules and regulations, and the orders and decrees of any courts or administrative bodies or tribunals, with respect to this Agreement, including without limitation laws and regulations pertaining to labor, wages, hours and other conditions of employment, and the City’s Affirmative Action Plan.

A. Examples of applicable statutes, rules, regulations, or requirements include, but are not limited to the following:

1. 2 Code of Federal Regulations Part 200 (Uniform
Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards);

2. 24 Code of Federal Regulations Part 570 (Community
Development Block Grant Regulations);

3. Copeland “Anti-Kickback” Act (18 U.S.C. § 874) (29
C.F.R., Part 3);

4. Contract Work Hours and Safety Standards Act (40
U.S.C. §§ 327-330) (29 C.F.R., Part 5);

5. Clean Air Act, as amended (42 U.S.C. § 7401, et seq.);

6. Federal Water Pollution Control Act, as amended (33 U.S.C. § 1251, et seq.);

7. Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d) and implementing regulations;

8. Title VII of the Civil Rights Act of 1964, as amended by the Equal Employment Opportunity Act of 1972, (42 U.S.C. §
2000e), and implementing regulations;

9. Section 3 of the Housing and Urban Development Act of 1968, as amended; and the implementing regulations at 24 C.F.R. Part 135;

10. Section 503, Affirmative Action for Handicapped Workers ($2,500+);
12 11. Section 402, Affirmative Action for Vietnam Era Veterans ($10,000+);

12. The Age Discrimination Act of 1975, as amended, 42
U.S.C. § 6101, et seq.) and implementing regulations;

13. Executive Order 11246, Non-Discrimination;

14. The assurances made by the City to the HUD in its
application for funds under Title I of the Housing and
Community Development Act of 1974, as amended; and

15. All applicable provisions, conditions, and assurances contained in

16. the HUD Grant Agreement between the City and HUD
(Provisions therein include, but are not limited to “Section 3” compliance, Flood Disaster Protection, Equal Employment Opportunity, Lead-Based paint Hazards, Compliance with Air and Water Acts, and Nondiscrimination).

17. HUD’s Equal Access Rule (24 C.F.R. §§ 5.105(a)(2), 5.403) to the extent applicable to the street outreach and
engagement services as described in this Agreement.

B. Religious organizations must comply with the following conditions:

1. It will not discriminate against any employee or applicant for employment on the basis of religion and will not limit
employment or give preference in employment to persons on the basis of religion;

2. It will not discriminate against any person applying for such public services on the basis of religion and will not limit such services or give preference to persons on the basis of
religion; and

3. It will provide no religious instruction or counseling, conduct no religious worship or services, engage in no religious proselytizing, and exert no other religious influence in the provision of such public services.
608. Waivers
A. Waivers of the provisions of this Agreement must be in writing and signed by the appropriate authorities of the City or the Contractor.

B. The waiver by the City of any breach of any term or provision of this Agreement shall not be construed as a waiver of any subsequent breach.
13 609. Independent Contractor
A. Contractor acknowledges, represents and warrants that Contractor is not a regular or temporary employee, officer, agent, joint venturer or partner of the City, but rather an independent contractor. This Agreement shall not be construed as a contract of employment.

Contractor understands and agrees that all persons furnishing services to City pursuant to this Agreement shall have no rights to any benefits which accrue to City employees unless otherwise expressly provided in this Agreement. Due to the independent contractor relationship created by this Agreement, the City shall not withhold state or federal income taxes, the reporting of which shall be Contractor's sole responsibility.

B. Contractor shall bear the sole responsibility and liability for furnishing Worker’s Compensation benefits to any person for injuries arising from or connected with services performed on behalf of Contractor pursuant to this Agreement.
610. Attorney’s Fees
In the event either party to this Agreement brings any action to enforce or interpret this Agreement, the prevailing party in such action shall be entitled to reasonable attorneys' fees (including expert witness fees) and costs. This provision shall survive the termination of this Agreement. 611. Nondiscrimination Provision
The Contractor, with regard to the work performed by it during the contract, shall not discriminate on the grounds of race, religion, creed, color, sex, age, disability, sexual orientation, gender identity or expression, or national origin in the selection and retention of subcontractors, in its employment practices, in the provision of services to clients, or in the selection and retention of subcontractors, including procurement of materials and leases of equipment, and shall comply with all applicable federal, state, and local nondiscrimination laws referenced in section 607. 612. Program Income
Any program income directly generated from total or partial use of City Community Development Block Grant funds shall be expended exclusively on the activities outlined in this Agreement. All terms of this Agreement shall apply to such expenditures.
613. Reversion of Assets
Upon expiration of this Agreement, Contractor shall transfer to the City any City granted CDBG funds on hand, and any accounts receivable attributable to the use of City granted CDBG funds.
614. Anti-Lobbying
Contractor certifies that no Federal appropriated funds have been paid or 14 will be paid, by or on behalf of it, to any person for influencing or attempting to influence an officer or employee of any Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment or modification of any Federal contract, grant, loan, or cooperative agreement.

Contractor certifies that if any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan or cooperative agreement, it will complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions. 615. Conflict of Interest
Contractor acknowledges, represents and warrants that Contractor shall avoid all conflicts of interest (as defined under any federal, state or local statute, rule or regulation, or at common law) with respect to this Agreement. Contractor further acknowledges, represents and warrants that Contractor has no business relationship or arrangement of any kind with any City official or employee with respect to this Agreement.

Contractor acknowledges that in the event that Contractor shall be found by any judicial or administrative body to have any conflict of interest (as defined above) with respect to this Agreement, all consideration received under this Agreement shall be forfeited and returned to City forthwith.

This provision shall survive the termination of this Agreement for one (1) year.
616. Non-Liability of Officials and Employees of the City No official or employee of the City shall be personally liable for any default or liability under this Agreement.
617. Conflicting Provisions
In the event of a conflict between the terms and conditions of this Agreement and those of any exhibit or attachment hereto, this Agreement proper shall prevail. In the event of a conflict between the terms and conditions of any two or more exhibits or attachments hereto, those prepared by the City shall prevail over those prepared by Contractor. 618. Non-Exclusivity
Notwithstanding any provision herein to the contrary, the services provided by Contractor hereunder shall be non-exclusive, and City reserves the right to provide funding to other contractors in connection with the project.
15 619. Confidentiality
To the extent permissible under law, Contractor shall keep confidential its obligations hereunder and the information acquired during the performance of the project or services hereunder, including but not limited to, personally identifiable client information.
620. Third Parties
Nothing herein shall be interpreted as creating any rights or benefits in any third parties. For purposes hereof, transferees or assignees as permitted under this Agreement shall not be considered "third parties." 621. Governing Law and Venue
This Agreement shall be construed in accordance with the laws of the State of California without regard to principles of conflicts of law. Venue for any litigation or other action arising hereunder shall reside exclusively in the Superior Court of the County of Los Angeles, Southwest Judicial District.
622. Claims
Any claim by Contractor against City hereunder shall be subject to Government Code §§ 810 et seq. The claims presentation provisions of said Act are hereby modified such that the presentation of all claims hereunder to the City shall be waived if not made within six (6) months after accrual of the cause of action.
623. Interpretation
Contractor acknowledges that it has had ample opportunity to seek legal advice with respect to the negotiation of this Agreement. This Agreement shall be interpreted as if drafted by both parties.
624. Severability
Any provision of this Agreement that is found invalid or unenforceable shall be deemed severed and all remaining provisions of this Agreement shall remain enforceable to the fullest extent permitted by law. 625. Authority
City warrants and represents that upon City Council approval, the Mayor of the City of Redondo Beach is duly authorized to enter into and execute this Agreement on behalf of City. The party signing on behalf of Contractor warrants and represents that he or she is duly authorized to enter into and execute this Agreement on behalf of Contractor, and shall be personally liable to City if he or she is not duly authorized to enter into and execute this Agreement on behalf of Contractor.
16 ARTICLE VII

DEFAULTS, SUSPENSION AND TERMINATION
701. Defaults
Should the Contractor fail for any reason to comply with the contractual obligations of this Agreement within the time specified by this Agreement, the City reserves the right to:

1. Reduce the total budget;

2. Make any changes in the general scope of this Agreement;

3. Suspend the Contractual Agreement in accordance with section 702; and

4. Terminate the Agreement in accordance with section 703. 702. Suspension
A. The City, by giving written notice, may suspend all or part of the project operations for failure of the Contractor to comply with the terms and conditions of this Agreement.

B. Said notice shall set forth the specific conditions of non-compliance and the period provided for corrective action.

C. Within five (5) working days the Contractor shall reply in writing setting forth the corrective actions which will be undertaken, subject to City approval in writing.

D. Failure to take necessary corrective actions will result in withheld funds. The City shall have final authority to determine whether or not Contractor is in full compliance.

E. Performance under this Agreement shall be automatically suspended without any notice from the City as of the date the Contractor is not fully insured in compliance with section 601.B.

Performance shall not resume without the prior written approval of City.
703. Termination
A. The parties agree that at any time during the term of the Agreement the City may terminate this Agreement or any part hereof upon giving the Contractor at least thirty (30) days written notice prior to the effective date of such termination, which date shall be specified in such notice.
17 B. All property, documents, data, studies, reports and records purchased or prepared by the Contractor under this Agreement shall be disposed of according to City directives.

C. In the event the Contractor goes out of existence, copies of all records relating to the project or activity that are the subject of this Agreement shall be furnished to the City.

D. Upon satisfactory completion of all termination activities, the City shall determine the total amount of compensation that shall be paid to the Contractor for any unreimbursed expenses reasonably and necessarily incurred in the satisfactory performance of this Agreement.

E. The foregoing Subsections B, C and D shall also apply if the Agreement terminates upon the date specified in section 103 or upon contractor’s completion of performance.

ARTICLE VIII

ENTIRE AGREEMENT
801. Complete Agreement
This Agreement contains the full and complete Agreement between the parties concerning the subject matter hereof and supersedes any previous oral or written agreement; provided, however, that correspondence or documents exchanged between Contractor and City may be used to assist in the interpretation of the exhibits to this Agreement. No verbal agreement or conversation with any officer or employee of either party shall affect or modify any of the terms and conditions of this Agreement. 802 Number of Pages and Attachments
This Agreement includes 18 pages and seven exhibits which constitute the entire understanding and agreement of the parties.
18 IN WITNESS WHEREOF, the parties have executed this Agreement in Redondo Beach, California, as of this 10th day of February, 2026.

CITY OF REDONDO BEACH, HARBOR INTERFAITH SERVICES, INC., a chartered municipal corporation a California nonprofit corporation __________________________ By: ________________________ James A. Light, Mayor Name:________________________
Title: ________________________
ATTEST: APPROVED:
__________________________ __________________________
Eleanor Manzano, City Clerk Diane Strickfaden, Risk Manager APPROVED AS TO FORM:
_________________________
Joy A. Ford, City Attorney
Executive Director/CEO
2/4/2026 | 9:46 AM PST
Tahia Hayslet
I-1

EXHIBIT I

PROGRAM BUDGET
JULY 1, 2025 - JUNE 30, 2026
Agency Name: Harbor Interfaith Services, Inc.

Program Title: Street Outreach and Engagement Program
Cost
Category
CDBG
Share
Agency
Share
Total
Cost
Personnel $6,037 $148,163 $154,200
Lease/Rent - - -
Equipment $1,000 $2,500 $3,500
Supplies - - -
Professional
Services
- $25,000 $25,000
Other* $500 $2,500 $3,000
Total $7,537 $178,163 $185,700
Please indicate whether you will bill on a monthly _ X or quarterly basis. *Other includes travel and insurance costs
II-1

EXHIBIT II

JOB DESCRIPTIONS
Harbor Interfaith Services, Inc. | Outreach/Housing Navigator | Job Description Harbor Interfaith Services (HIS) is a non-profit organization based in San Pedro, with a mission to provide food, shelter, transitional housing, childcare, and support services to the homeless and working poor in the South Bay area of Los Angeles, Service Planning Area.

Harbor Interfaith Services is looking to add a full-time Housing Navigator to our team. This position is a full-time role with a set schedule of 7:30am to 4:30pm Monday through Friday. The Housing Navigator assists individuals to stabilize permanent housing by providing location assistance, retention services, and financial support. Team member benefits include medical, dental, vision, and life insurance covered by HIS, a 403(b) retirement plan, sick leave, vacation leave and eleven paid holidays.

Key responsibilities:
• Ensuring individuals have the resources and documentation needed to secure permanent housing
• Completing the comprehensive standardized assessment
• Providing case management to SPA 8 individuals
• Developing and implementing the housing and supportive service plan • Making referrals to community-based supportive services as appropriate • Tracking financial assistance benefits through HMIS
• Inputting information into HMIS as required
• Ensuring case files are accurate and up to date
• Answering phones, greeting clients, and troubleshooting as needed • Attending staff meetings, case conferences, trainings, and workshops as required and completing other duties as assigned.

We would like to speak with you if:
• You have a Bachelor’s degree in social work or a related field, or 4 years of equivalent social services experience with an emphasis on case management. • You have a background in substance abuse and recovery. • You are familiar with the Harm Reduction and Housing First models of service delivery. • You are bilingual (English/Spanish) – preferred but not required. • You have a valid California driver’s license, a clean driving record with no more than two driving infraction points, and adequate auto insurance.

About Harbor Interfaith
We offer an inclusive environment where all are empowered to share their diverse perspectives and experiences so we can ultimately be better together. Our policies, practices, programs, activities and decisions regarding employment, hiring, assignment, compensation, and volunteerism are not based on a person’s race, color, sex, age, religion, national origin, mental or physical disability, ancestry, military discharge status, sexual orientation, gender identity or expression, marital status, parental status, housing status, or other protected status.

If you are interested in this position, please send your resume and contact information to the attention of Human Resources at [email protected].

II-2
Harbor Interfaith Services is an at-will employer, meaning we or our employees have the right to terminate the employment relationship at any time, for any reason, with or without cause.

Harbor Interfaith participates in the E-Verify program.

Harbor Interfaith Services, Inc. | Program Manager | Job Description Harbor Interfaith Services (HIS) is a non-profit organization based in San Pedro, with a mission to provide food, shelter, transitional housing, childcare, and support services to the homeless and working poor in the South Bay area of Los Angeles, Service Planning Area (SPA) 8.

Harbor Interfaith Services is looking to add a full time Program Manager to our team. This position will be responsible for the oversight of the Interim Housing program. This is a full-time role and will primarily work Monday through Friday, 8:30am to 5:30pm. We are recruiting people who are top performers with excellent interpersonal and critical thinking skills and a fierce passion for serving the community.

Key responsibilities:
• Oversight of the overall operation of the interim Housing program and ensuring compliance with outcomes.
• Supervising Interim Housing staff, up to and including case managers, resident aides, custodians and security.
• Creating an efficient model for screening applicants, minimizing turnover and ensuring collaboration with the SPA Coordinated Entry System (CES). • Completing program reporting in an accurate and timely manner. • Ensuring achievement of program performance measures and compliance with all fudnigng contracts.
• Supervising staff to ensure documentation of services provided to program residents.

Documentation may include quarterly goal statements, progress towards goal achievement, maintenance of resident case files, and ensuring HMIS data entry and compliance. • Assisting with presentations, tours, and community awareness to increase knowledge of Harbor Interfaith programs and the Interim Housing site.
• Ensuring upkeep and safety of the facility and reporting concerns immediately to the Facilities Manager.
• Working with onsite security, custodial staff, and resident aides to ensure resident compliance and facility upkeep.
• Attending staff meetings, case conferences, and other required meetings as schedule, as well as completing other duties as assigned.

We would like to speak with you if:
• You have a minimum of three years’ experience in staff supervision and administration of a housing program.
• You have extensive experience working with at risk populations • You have demonstrated ability to design, implement, and evaluate housing programs. • You have a working knowledge of San Pedro and the South Bay education, employment, housing, and counseling resources.
• You have a management style characterized by initiative, flexibility, creativity, and strong organizational skills.

II-3
• You have a valid California driver’s license, a clean driving record with no more than two driving infraction points, and adequate auto insurance.

If you are interested in this position, please send your resume and contact information to the attention of Human Resources at [email protected].

Harbor Interfaith Services is an at-will employer, meaning we or our employees have the right to terminate the employment relationship at any time, for any reason, with or without cause.

Harbor Interfaith participates in the E-Verify program.

III-1

EXHIBIT III
INCOME LEVEL GUIDELINES*
NO. IN
FAMILY
LOW
INCOME

VERY LOW
INCOME

EXTREMELY

LOW INCOME
1 84,850 53,000 31,850
2 96,950 60,600 36,400
3 109,050 68,150 40,950
4 121,150 75,750 45,450
5 130,850 81,800 49,100
6 140,550 87,850 52,750
7 150,250 93,900 56,400
8 159,950 100,000 60,000
*U.S. Department of Housing and Urban Development. Effective 6/1/2025.

Income Level Guidelines includes gross income from all sources for all members in the household who are 18 years of age or older and not full-time students. Income from household members under 18 years of age who are more than half-time students is not included in gross income unless regular payment is received, such as child support, social security, or aid to dependent children.

IV-1

EXHIBIT IV

CLIENT INTAKE SHEET
See attached.

DHS INTERIM HOUSING
Verified by:________
SECTION I: CLIENT INFORMATION / AUTHORIZATION FORMS
Client Intake Form
HFH Referral Form
Emergency Contact
Client Identification Card (If Applicable)
Client Social Security Card (If Applicable)
Client Medical Card (If Applicable)
Client Proof of Income
Authorization for the Use and Disclosure of Health and Social Service Information Notice of Privacy Practices

INTAKE FORM
All information collected is geared to housing and resources. The information is to help your case manager focus on resources and housing that you qualify for.

There are several different sources one may qualify for but without the information we may be limited, so we ask you to try to be open and honest so we can best help you.

Basic Information
First: Middle: Last:

DOB: Age: Social Security:

Years of Homelessness: Location of Homelessness:

Notes:

Contact Information
Phone Number: Email:

Emergency Contact: Waiver signed: Yes or No
Notes:

Medical/ Mental Health Information
Medical history health conditions? (Diabetes, Cancer, Liver conditions) Medication: Medication Log: Yes or No
Mental Health Dx: Currently on Medication: Yes or No
Medications: Medication Log: Yes or No
Covid Vaccine: Yes or No Date of 1st: Date of 2nd:

Last PositiveTtest:

HIV/ AIDS: Yes or No If Yes, Do you receive services?
NOTES:

Employment, Education/ Learning Disabilities
Years of Employment? Can You Work? Yes or No
Type of Work Experience?
NOTES:

Higest grade completed: Currently in School? Yes or No
Degrees or Certificates:

NOTES:

Housing Related and/or Resources Questions
Do you have a history of drug use? Yes or No Drug of choice:

If in recovery how long? Do you want resources: Yes or No Are you a Veteran? Year? Honorable: Yes or No
Do you have an: Service Animal or Pet Shots and Vet care up to date: Yes or No IF yes above: Where does the animal receive services? Type of animal? Behavior? Have you ever lived is subsdized housing? Yes or No
Do you have a felony and if so would it prevent you from some housing: Yes or No If Yes above, make notes if additional information is given.

Addition Information Shared :

Date:

Alternate Staff: Office/Pager #:

IDENTIFYING INFORMATION
First Name: Middle Name: Last Name:

HOUSING FOR HEALTH (HFH) HOUSING

REFERRAL FORM
Referring Agency/DHS Facility: Staff Name/Title:

Office #: Cell/Pager #:
□ Female □ Client Doesn't know □ Never Married □ Living Together □ Transgender (F to M) □ Client Refused □ Divorced □ Widowed Gender: Marital Status:
□ Male □ Other □ Single □ Common Law
Know Aliases: SSN# Mother's Maiden Name: Place of Birth:

DOB: Client ID#
□ Son □ Guardian □ Other Caretaker
□ Daughter □ Spouse

FAMILY INFORMATION
Relationship to Head of Household:
□ Self □ Dependent Child □ Other Family Member
□ Parent □ Grandparent □ Other Non-Family
□ Transgender (M to F) □ Data Not Collected □ Married & Living with Spouse □ Other □ Married & Not Living with Spouse □ Civil Union

DEMOGRAPHIC INFORMATION
Ethnicity Race
□ Hispanic/Latino □ American Indian or Alaska Native □ White Service Planning Area: Different Residential Address:

Primary Phone: Alternate Phone: Email Address:

Frequent Client Location : Other Contact Information:

Contact Information: If you do not enter a phone number of email address, you willl be required to provide a contact plan during the application process.

Mailing Address:

Address 2:

City State Zip Code
□ Yes □ Client doesn't know □ Data not collected
□ No □ Client refused
Primary Language
□ Client Refused □ Native Hawaiian or Other Pacific Islander □ Data not Collected □ Data Not Collected
Have you served in the US armed forces?
□ Non-Hispanic/Latino □ Asian □ Client Doesn't Know
□ Client Doesn't Know □ Black or African American □ Client Refused First Name: Last Name Gender DOB DOB Quality Relationship to Head of Household □ Eligible Non-Citizen Alien Number:
□ Ineligible Non-Citizen Entry Date:

APPLICATION

FAMILY COMPOSITION
English Other: Can communicate in English? □ Yes □ No

CITIZENSHIP INFORMATION
Citizenship Status:
□ U.S. Citizen Country of Origin:

02.2017 1 of 4

MULTIPLE INTERESTED OTHERS
Type Relationship Name Primary Phone Email Address Note

SERVICE ANIMALS
Name Animal Type Weight (in lbs.) Need Type History of Aggression Vaccination Additional Information Date Signed: Date Signed:

HOUSING DOCUMENTS
Verification Date:

Method of Verification: □ Scanned Uploaded Method of Verification: □ Scanned Uploaded Comment: Comment:

REQUIRED DOCUMENTS
Authorization to Release/Share information Authorization for Use and Disclosure of PHI □ Signed Document □ Signed Document
Valid Government ID □ CA State ID □ Scanned Uploaded
Birth Certificate □ Birth Certificate □ Scanned Uploaded Verification Item Acceptable Document Method of Verification Issuance Date Expiration Date Comment □ Military Identitfication
□ Driver's License
□ Consulate/International ID
□ Permanent Resident Card
□ Passport
□ Other State ID
□ Paystub
Proof of Income □ None
Social Security Card □ Social Security Card □ Scanned Uploaded □ W2
□ Tax Return
□ Social Services/Income Verification
Geographic Preferences Geographic Restrictions
□ Antelope Valley (SPA 1) □ Antelope Valley (SPA 1)
□ Countywide (SPA 1 - 8) □ Countywide (SPA 1 - 8)

HOMELESS STATUS
Assessment Date: Current Location:

Service Planning Area: Years Homeless: Months Homeless:

Proof of Residency □ Document □ Scanned Uploaded
□ Southeast (SPA 7) □ Southeast (SPA 7)
□ South L.A. (SPA 6) □ South L.A. (SPA 6)
□ West L.A. (SPA 5) □ West L.A. (SPA 5)
□ San Fernando Valley (SPA 2) □ San Fernando Valley (SPA 2) □ San Gabriel Valley (SPA 3) □ San Gabriel Valley (SPA 3) □ South Bay/Long Beach (SPA 8) □ South Bay/Long Beach (SPA 8) □ Downtown (SPA 4) □ Downtown (SPA 4)
□ Hollywood (SPA 4) □ Hollywood (SPA 4)
□ East L.A. (SPA 4) □ East L.A. (SPA 4)
CES Package Completed? □ Yes □ No CES Package Score:
□ Los Angeles (SPA 4 - 7) □ Los Angeles (SPA 4 - 7)
Willing to Reside in Communal Living for Permanent Housing: □ Yes □ No Willing to Reside in Skid Row for Permanent Housing: □ Yes □ No History of Aggression: □ Yes □ No History of Domestic Violence: □ Yes □ No

02.2017 2 of 4
Is Primary
□ The client is an individual who is exiting an institution where he/she resided 90 days or less and who resided in an emergency shelter or place not meant for human habitation immediately before entering that institution. □ The client is an individual or family who will imminently lose their primary nighttime residence within 14 days and no subsequent residence has been identified and the individual or family lacks the resources and support networks needed to obtain housing. □ The client is an individual or family who is fleeing, or is attempting to flee, domestic violence, has no other residence; and lacks the resources or support networks to obtain other permanent housing.

HOMELESS QUESTIONNAIRE - Check the box next to each true statement □ The client is an individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning: Has a primary nighttime residence that is a public or private place not meant for human habitation; OR is living in a publicly or privately operated shelter designated to provide temporary living arrangements (including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state and local government programs). □ Employment
□ Unemployment
* Occasions are separated by a break of at least seven nights that an individual is not residing in an emergency shelter, safe haven, or a place meant for human habitation (e.g., staying with a friend, in a hotel/motel paid for by the program participant). Institutional stays of less than 90 days do not constitute a break.

FINANCIAL PROFILE
Assessment Date:

Type Description Monthly Amount
□ The client has a disability, including but not limited to, a diagnosable substance use disorder, serious mental illness, severe chronic health condition (including AIDS), or the co-occurrence of two or more of these conditions. □ The client has been homeless CONTINUOUSLY for at least twelve (12) months □ OR on at least four (4) separate occasions* in the last three (3) years where the combined occasions must total at least twelve (12) months. □ Food Stamps/Cal FRESH
□ Other
□ Social Security Disability Insurance (SSDI)
□ Veteran's Administration Benefits
□ General Relief (GR)
□ Supplemental Security Income
□ Medicare □
□ Pending
/Applied □
Active
□ Medi-Cal □
□ Pending
/Applied □
Active

MEDICAL PROFILE
Assessment Date:

Insurance Information
Type Insurance Provider Name Status Date Applied Start date End date □ Healthy Families □
□ Pending
/Applied □
Active
□ VA □
□ Pending
/Applied □
Active
□ Medi-Cal/Medicare □
□ Pending
/Applied □
Active
□ Other □
□ Pending
/Applied □
Active
□ Private □
□ Pending
/Applied □
Active
Physical Health Information
Primary Care Provider
Medical Facility/Clinic: Medical Last Visit Date:

Chronic Conditions:
□ Unknown □
□ Pending
/Applied □
Active
□ None □
□ Pending
/Applied □
Active

02.2017 3 of 4
Mobility/Accessibility Needs
□ Cannot Climb Stairs □ Needs Ramp Access
□ Has Manual Wheelchair □ Uses Manual Wheelchair
□ Has Motorized Wheelchair □ Uses Motorized Wheelchair
□ None
Mental Health Information
Mental Health Clinician Name:

Medical Health Agency/Clinic: Mental Health Last Visit Date:

Medical Needs
□ Activities of Dailiy Living (hygiene/grooming, etc.) □ Independent Living Skills (cleaning, cooking, etc.) □ Breathing (supplemental oxygen) □ Taking Medications
□ Incontinent Issues □ Other
□ Needs Assistance Transferring In/Out of Wheelchair □ Uses Walker/Cane/Crutches □ Other
□ None
□ None
Cognitive Impairments
□ Dementia □ Mutiple Issues
□ Developmental Disability □ Traumatic Brain Injury
□ Mood Disorder □ Schizophrenia
□ Personality Disorder(Axis II) □ Suicidal Ideation/Attemped Suicide □ Other
Mental Health Diagnoses
□ Anxiety Disorder □ Post-Traumatic Stress Disorder
□ Bipolar Disorder □ Psychosis
□ Depression □ Schizoaffective Disorder
□ Alcohol □ Yes □ No □ Yes □ No
□ Benzodiazepines □ Yes □ No □ Yes □ No
Substance Use Profile
Substance Other Substance Past Use Current Use Date Last Use □ If Other, Please Explain:

Mental Health Diagnoses Details:
□ None
□ Injectable Drug Use □ Yes □ No □ Yes □ No
□ Marijuana □ Yes □ No □ Yes □ No
□ Cocaine/Crack Cocaine □ Yes □ No □ Yes □ No
□ Heroin/Opiates □ Yes □ No □ Yes □ No
□ Other □ Yes □ No □ Yes □ No
Legal Profile
□ Prescription Narcotics □ Yes □ No □ Yes □ No
□ Synthetic Marijuana/Spice □ Yes □ No □ Yes □ No
□ Methadone □ Yes □ No □ Yes □ No
□ Metamphetamines □ Yes □ No □ Yes □ No
□ Production Metamphetamines
□ Arson
Conviction/Legal Issue Other Issue County Date Arrest
Date
Conviction Date
□ Warrants
□ Violent Crime
□ Sex Offender
□ Other 3
□ Other 2
□ Other 1

02.2017 4 of 4

DHS INTERIM HOUSING
Emergency Contact Form
Participant First and Last Name
Phone Number
Alternate Phone Number
Email Address
Please list person(s) to contact in case of an emergency:

First Name Last Name Relation Phone Number

AUTHORIZATION FOR THE USE AND DISCLOSURE

OF HEALTH AND SOCIAL SERVICE INFORMATION (ADULT)

APPROVED FOR USE AT ALL DHS FACILITIES

SCAN INTO ELECTRONIC HEALTH RECORD

AUTHORIZATION FOR THE USE AND DISCLOSURE

OF HEALTH AND SOCIAL SERVICE INFORMATION (ADULT)

Page 1 of 6 ends

NAME
DOB
FIN#
MR#
SEX on ID

PATIENT HIM LABEL
________________________________________________________ _____________________________ ___________________ CLIENT NAME CLIENT ID DATE OF BIRTH:

The County of Los Angeles (“County”) operates and engages in health information exchanges to allow your information to be shared among and between County Programs and their partners to help you get resources and social services that can improve your health. A health information exchange is an electronic system that allows organizations to share information. “County Programs” are programs that provide services to you or obtain benefits for you through the following County Departments:
• Department of Health Services (DHS)
• Department of Mental Health (DMH)
• Department of Public Health (DPH), including the Substance Abuse Prevention and Control (DPH-SAPC)
• Department of Public Social Services (DPSS)
• Justice, Care and Opportunities Department, only for re-entry services Many types of organizations work as partners of County Programs, some as contractors or subcontractors, to provide, coordinate, or pay for these services or benefits, including:
• Health care providers
• Mental health providers
• Substance use disorder providers
• Social service providers
• Managed care plans
• Housing and assisted living providers
• Meal service providers
• Legal providers who assist you in obtaining benefits or services • Community organizations that provide or coordinate services, including to persons involved with the justice system
These organizations may need to share your health and/or social services information to:
• See if you are eligible for services or benefits provided by County Programs or through other resources and/or for Medi-Cal enrollment and benefits
• Coordinate your health care and community supports
• Communicate with your treating providers and organizations and social service providers • Provide you with treatment and related services
• Receive payment for services
• Conduct quality improvement, reporting, and evaluation activities
• Carry out related County Program activities

AUTHORIZATION FOR THE USE AND DISCLOSURE

OF HEALTH AND SOCIAL SERVICE INFORMATION (ADULT)

APPROVED FOR USE AT ALL DHS FACILITIES

SCAN INTO ELECTRONIC HEALTH RECORD

AUTHORIZATION FOR THE USE AND DISCLOSURE

OF HEALTH AND SOCIAL SERVICE INFORMATION (ADULT)

Page 2 of 6 ends

NAME
DOB
FIN#
MR#
SEX on ID

PATIENT HIM LABEL
By signing my name below, I agree that my current, past, and future treating providers, non-treating providers listed in Attachment A, and County Programs may disclose my health information, records, social services information, and related data to any County health information exchange. Such data may be used and shared among and between the County Programs. I also agree that County Programs may disclose this information to my current, past, and future treating providers (including County Program subcontractors), and the managed care plans and other organizations that work with County Programs that are listed in Attachment A for the purposes described above. • I authorize my health and social service information to be shared through any health information exchange operated by or with participation from the County. • Information that may be shared will include:
o My general information, such as my age and gender;
o My medical, mental health, or substance use history;
o My social service information (including CalFresh, Special Supplemental Nutrition Program for Women, Infants, and Children (“WIC”), General Relief, CalWorks, Cash Assistance Program for Immigrants, Medi-Cal, Homeless Management Information System/Housing Records, and other public benefits that I may apply for and/or receive); and o Treatment and/or services I receive.
• I understand that this Authorization will apply to data related to services I receive from County Programs (including their subcontractors).
• I understand that my information will be shared in electronic formats, including through a health information exchange, as described above. My information may also be shared in verbal and written formats.

I specifically authorize my current, past, and future treating providers and County Programs to share the following sensitive information (check as appropriate):
 Information from health care providers about my mental health diagnosis or treatment that is protected under Welfare and Institutions Code § 5328 _________ (initial) (excluding psychotherapy notes)
 Information from substance use disorder programs (includes substance use disorder diagnoses and medications, inpatient stays and outpatient visits or residential treatment, provider names and contact information, and names of the treatment programs) that is protected under 42 C.F.R. Part 2 or State law _________ (initial)
I may ask for a list of providers and organizations that have received my substance use disorder information by contacting my care manager.

AUTHORIZATION FOR THE USE AND DISCLOSURE

OF HEALTH AND SOCIAL SERVICE INFORMATION (ADULT)

APPROVED FOR USE AT ALL DHS FACILITIES

SCAN INTO ELECTRONIC HEALTH RECORD

AUTHORIZATION FOR THE USE AND DISCLOSURE

OF HEALTH AND SOCIAL SERVICE INFORMATION (ADULT)

Page 3 of 6 ends

NAME
DOB
FIN#
MR#
SEX on ID

PATIENT HIM LABEL
I also authorize County Programs to share my health and social service information with the following family members or other persons so that they may assist in coordinating or paying for my care:
________________________________________________________ ______________________________________________

NAME RELATIONSHIP
________________________________________________________ ______________________________________________

NAME RELATIONSHIP
(Please continue on back of form if more room is needed.) I understand:
• This Authorization will be valid for as long as I receive services from County Programs. • I have the right to cancel or change this Authorization at any time. I can start this process by talking to my service provider or case/care manager. At that time, I will either cancel my Authorization or complete a new Authorization to reflect the change(s) to the sensitive information that I want to share. If I limit my information sharing, my sensitive information will not be shared from that date forward. Any sensitive information previously shared cannot be recalled. Should I elect not to share any sensitive information, certain care coordination, case management, benefits advocacy or other services may be limited, if my authorization is required by Federal law. • State and Federal laws already allow health care organizations to share some of my health information (including sensitive information) to treat me, obtain payment, and run their operations without my consent. I understand that this Authorization does not change the information that can be shared under these laws. I also understand that my authorization is required to share my substance use disorder information, if applicable.
• When my information is shared, Federal law or California privacy law may not protect the resharing of my information, except for substance use disorder information that is specially protected and may not be re-shared with others.
• My ability to receive medical services, treatment, or public social services does not depend upon whether I sign this Authorization. However, if I choose not to sign this Authorization, County Programs may not be able to share data to coordinate the services I receive, and I may not be able to receive full care coordination, case management, benefits advocacy or related services. • I have the right to:
o Inspect or obtain a copy of my health information and social services information that is shared by this Authorization.
o Refuse to sign this Authorization.
o Receive a copy of this Authorization.
[signature on following page]

AUTHORIZATION FOR THE USE AND DISCLOSURE

OF HEALTH AND SOCIAL SERVICE INFORMATION (ADULT)

APPROVED FOR USE AT ALL DHS FACILITIES

SCAN INTO ELECTRONIC HEALTH RECORD

AUTHORIZATION FOR THE USE AND DISCLOSURE

OF HEALTH AND SOCIAL SERVICE INFORMATION (ADULT)

Page 4 of 6 ends

NAME
DOB
FIN#
MR#
SEX on ID

PATIENT HIM LABEL
I have read this Authorization or it has been read to me. I authorize the use and sharing of my health and social services information as described above.
_________________________________________________________________________________________________

CLIENT NAME
_________________________________________________________________________________________________

CLIENT OR RESPONSIBLE PERSON SIGNATURE DATE
If this Authorization is signed by a person other than the client, please indicate the relationship:
___________________________________________________________________________________________________________

NAME RELATIONSHIP TO CLIENT

AUTHORIZATION FOR THE USE AND DISCLOSURE

OF HEALTH AND SOCIAL SERVICE INFORMATION (ADULT)

APPROVED FOR USE AT ALL DHS FACILITIES

SCAN INTO ELECTRONIC HEALTH RECORD

AUTHORIZATION FOR THE USE AND DISCLOSURE

OF HEALTH AND SOCIAL SERVICE INFORMATION (ADULT)

Page 5 of 6 ends

NAME
DOB
FIN#
MR#
SEX on ID

PATIENT HIM LABEL
Attachment A
Non-Treating Providers (for Payment, Benefits Advocacy, etc.) Health Plans, Federal, State and Local Organizations
Anthem Blue Cross/Care
Health Net
Blue Shield Promise
LA Care
Molina Health Care
Kaiser Permanente
Senior Care Action Network (SCAN)
U.S. Social Security Administration Disability Determination Services U.S. Veteran’s Administration
Centers for Medicare and Medicaid Services
California Department of Health Care Services
California Department of Social Services
California Department of Developmental Services
LA Homeless Services Authority
LA County Department of Children and Family Services
LA County Department of Military and Veterans Affair
LA Cash Assistance for Immigrants Program (CAPI)
CBEST Participant Organizations (Benefits Advocacy)
Inner City Law Center
Legal Aid Foundation of Los Angeles (LAFLA)
Health Advocates
Lutheran Social Services
Los Angeles County Department of Consumer and Business Affairs Special Services for Groups
St. Joseph’s Center
Tarzana Treatment Center
The Catalyst Foundation
Volunteers of America
Watts Community Action Labor Committee (WLCAC)

AUTHORIZATION FOR THE USE AND DISCLOSURE

OF HEALTH AND SOCIAL SERVICE INFORMATION (ADULT)

APPROVED FOR USE AT ALL DHS FACILITIES

SCAN INTO ELECTRONIC HEALTH RECORD

AUTHORIZATION FOR THE USE AND DISCLOSURE

OF HEALTH AND SOCIAL SERVICE INFORMATION (ADULT)

Page 6 of 6 ends

NAME
DOB
FIN#
MR#
SEX on ID

PATIENT HIM LABEL
I revoke the Authorization submitted to County Programs as ___________________________________ DATE
This Revocation does not affect any disclosures made prior to receiving this Revocation. This Revocation does not change the information that may be shared under State or federal laws without my consent.
_______________________________________________________________________________________________________

CLIENT NAME
______________________________________________________________________________________________

NAME RELATIONSHIP TO CLIENT
1051 (5-17)

T1050 File in Medical Record
Los Angeles County Health Agency

ACKNOWLEDGEMENT OF RECEIPT

NOTICE OF PRIVACY PRACTICES

HEALTH AGENCY NOTICE OF PRIVACY PRACTICES

Effective Date: May 30, 2017

ACKNOWLEDGEMENT OF RECEIPT
By signing this form, you acknowledge receipt of the Notice of Privacy Practices of the Los Angeles County (LAC-Health Agency) Departments of Health Services, Mental Health, and Public Health, collectively referred to as the Health Agency. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to review it carefully.

I acknowledge receipt of the Notice of Privacy Practices of LAC-Health Agency.

Signature: Date: __________________
(patient/parent/conservator/guardian)

INABILITY TO OBTAIN ACKNOWLEDGEMENT
To be completed only if no signature is obtained. If it is not possible to obtain the individual’s acknowledgement, describe the good faith efforts made to obtain the individual’s acknowledgement, and the reasons why the acknowledgement was not obtained:

Signature of Workforce Member: _______________________________ Date: ______________ Reasons why the acknowledgement was not obtained:
☐ Patient refused to sign.
☐ Other Reason or Comments:
____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

DHS INTERIM HOUSING
Verified by:________
SECTION II: INTAKE DOCUMENTATION
 IH Handout
 House Rules
 Case Management Agreement
 Grievance Policy
 Mandated Reporter
 Mail Agreement
 Service Animal Consent
 Photo Release
 Property Release
 Transportation Release
 HMIS Consent
 Termination Policy

DHS INTERIM HOUSING

PROGRAM HANDOUT
What is Interim Housing (IH)?
Interim Housing (IH) serves individuals with complex health and/or behavioral health conditions who need a higher level of support services than is available in most shelter settings. IH offers temporary housing in a stable environment to assist participants in increasing independence and completing housing goals.

Who will be working with me and what do they do?
IH Case Managers
The IH case manager shall serve as the central point of contact and coordinator of critical services access for each of the participants assigned to their caseload IH Program Managers
Providing oversight and support to IH case managers.

What services will I receive?
Case Management, housing resources, linkages to resources, and helping achieve your goals to maintain independence and stability
Can anyone that is homeless be a part of this program?
If you know someone else in need, notify your case manager and they will direct them through the right process. IH is specific to whom it serves, but Habor Interfaith Services is able to link all homeless individuals to a proper service.

Client Signature: Date:

Case Manager Signature: Date:

Client was offered a copy of this document: Yes No
Client: Accepted Declined
If the client declined the acceptance of this form, please provide a brief explanation below:

No Expiration Date REV 06/10/2024
Section 5: Use of your Unit
HARBOR INTERFAITH SERVICES INC. (HIS)
Pallet Shelter Program Participant Agreement
Welcome to the Redondo “Pallet Shelter” Program. Your presence here is a step on your journey towards health, housing, and community. Your stay here is important to us and your participation in the community is valuable. The policies below are in place to ensure the safety and comfort of our residents.

The Redondo Pallet Shelter (“Program”) is a temporary shelter program. A central goal of the Program is to connect you with permanent housing and end your experience of homelessness.

Therefore, we encourage you to work closely with staff to develop a housing plan. The goal of the Program is to identify housing for you within ninety (90) days of your enrollment in the Program. The Program location is not a permanent housing option for you.

Each adult enrolled in the Program must sign or acknowledge receipt of this Program Participant Agreement (“Agreement”) at enrollment. If you do not sign this agreement or acknowledge receipt of this agreement, you cannot participate in the Program. In this Program, you are considered a “Shelter Program Participant.” As a “Shelter Program Participant” your right to stay at the Redondo Pallet Shelter location is due to your participation in the Program.

Section 1: Meals
Three meals a day (i.e., breakfast, lunch, and dinner) will be available seven days a week, including holidays, at no cost to you.

Section 2: Personal Belongings and Vehicle
You are responsible for your own personal belongings. You acknowledge and agree that Harbor Interfaith Services (including Staff) is not responsible for any loss or damage to your personal belongings or other personal property. Storage of belongings for anyone but yourself is not permitted.

Section 3: Removal of Personal Belongings and Vehicles
If you exit the program, you must take all your belongings and your vehicle (if applicable) with you upon leaving.

If you are exited from the Program pursuant to a direct threat made by you, you will have 30 days after your immediate exit to retrieve your personal belongings and vehicle.

If you are exited with a 30-Day Notice, you will have 30 days from the date of the notice issuance to retrieve your personal belongings and vehicles (if applicable).

Personal belongings that are on-site beyond the timelines above may be disposed of without liability to Harbor Interfaith Services.

Section 4: Religious Participation or Charging of Fees
Harbor Interfaith Services does not require participation in any religious activities, and there are no fees to enter or stay in the Program
You may use your assigned unit only for a temporary stay for yourself. You may not use the unit for a home business (such as babysitting, childcare, preparation of tax returns, the sale of goods, or the sale of personal services). You may not keep or use any hazardous or toxic substances or flammable liquids in your unit or around the property. You may not do anything that is illegal in or around the unit or anywhere on the property. You may not store anything outside of your unit.

You are expected to respect the privacy of all other participants. You are expected to keep your unit neat and orderly. Shower facilities are to be used individually. Couple Showers are not allowed.

Section 6: Entry and Inspection.

Harbor Interfaith staff reserve the right to enter and inspect your room on a regular basis to make sure you are complying with this Agreement, to make repairs, perform maintenance, conduct routine or enhanced cleaning, or conduct health screenings.

Section 7:No Illicit Drugs or Alcohol.

Sobriety is supported. Possession or use of alcohol or drugs is not allowed on the premises at any time. Any drugs, alcohol, or drug paraphernalia found during the searching of property will not be returned to residents.

Section 8: Consent to Search Personal Belongings
By signing this Agreement, you give consent to Harbor Interfaith staff to search your room (including all personal items that you arrived with) for illegal drugs or weapons. Program Staff may search your room for illegal drugs or weapons anytime.

Pallet units are subject to inspection at any time, especially when there is an indication that contraband has been brought onsite and in a resident’s unit. This is done to protect the health and safety of all residents and staff at this site. Individual unit search will only be conducted after consulting with the Program Manager.

All residents will submit to a search by onsite Security before entering site. This includes all personal belongings and will include metal detector wand to search for any contraband including weapons, drugs/alcohol and paraphernalia. Security will also request each person to empty the contents of their pockets, backpacks or any other packages brought on site.

Section 9: No Weapons, Violence, Abuse or Damage
You may not possess or use any weapons (real or replica), threaten violence, or use violent or abusive language against anyone in or around your unit or on site, against staff members, other Participants or others on the property. Tampering with or disabling of smoke detectors is prohibited and may result in your immediate termination/exit. You also may not abuse or damage your unit or any other property. Respect for site property as well as the property of others is expected. This includes but is not limited to; not stealing or borrowing items that do not belong to you and avoiding damages of site property like showers, toilets, and other onsite equipment/fixtures.

Section 10: Crimes
You may not commit any crime in or around your unit. If you do commit a crime, Program Staff may report the crime to law enforcement and you may be terminated/exited from the Program and removed from the location.

Section 20: Termination Policy
Section 11: Noise and Nuisance
You may not use or do anything inside or outside of your room that disturbs your fellow Program participants or others on the property, including making or causing loud noises or creating a nuisance.

Section 12: Safety and Housekeeping.

You must keep your unit in a neat, clean, and safe condition. When your Program participation ends, you must return the unit in the same condition that the room was in when you moved in, excepting normal wear and tear. Also, urinating, defecating, or dumping waste or trash anywhere in your unit is not permitted. Always utilize appropriate facilities to dispose of all waste and trash.

Section 13: No Visitors
Visitors are not allowed on site under any circumstances. You must meet visitors off premises.

No participant shall enter another participant’s unit. L.A. County Dept. of Health Services COVID guidelines require 6 foot social distancing, wearing Personal Protective Equipment (masks) and washing hands frequently. Pallet units are single occupancy units and do not allow for 6-foot social distancing in compliance with DPH guidelines.

Section 14: Assistance Animals and Pets.

All pets are under the control of their owner and must always remain on a leash. Pets are not allowed to be left alone in the rooms, beds, or site. Any messes created by pets are the responsibility of the owner.

Section 15: Medication
All medications will be kept in a secure area and available to you as needed.

Section 16: Smoking
Smoking is only allowed outside of the building and within designated areas.

Section 17: No Tenancy
I acknowledge and agree that as Program Participant in an interim housing shelter program, I have no tenancy rights. By agreeing to participate in the Program and being enrolled into the program, I acknowledge and agree that no tenancy rights will be created.

Section 18: Violence and Bullying
This site has a zero-tolerance policy against violence and bullying. Under no circumstances are residents allowed to assault other residents or staff; physically or verbally.

Section 19: Site Hours
The site is open 24 hours. All residents are expected to return to the site by 10:00 p.m. for nightly bed check. To request an accommodation, please contact the Program Director.

This section sets out the Termination/Exit Policy. Harbor Interfaith Services reserves the right to exit you from the Program based upon the terms of this Agreement. The Harbor Interfaith Services Inc. Termination Policy and Procedure will be given to all Participants at intake/enrollment.

Reasons for immediate termination/exit:

You may be exited and removed immediately from the program location if your conduct is deemed by program staff to rise to the level of a “direct threat.” You are hereby notified that you have the right to initiate the grievance process, as described in at the time of your removal from the program location or at any time thereafter. Please note: participation in the grievance process does not delay immediate exits or removals from the program location.

Your participation in the Program and your stay at the Redondo Pallet Shelter location may be terminated if you engage in any behaviors described below:
• Any conduct that constitutes a “direct threat,” defined as a substantiated threat to the health or safety of others (i.e., significant risk of bodily harm or would cause substantial physical damage to the property of others, and such risk cannot be sufficiently mitigated or eliminated by a reasonable accommodation)
o Possession of or use of weapons
o Theft or destruction of agency property
• Sexual assault or verbally or physically threatening behavior that rises to the level of a “direct threat” to persons or property.
• Threats or actual acts of physical violence to staff or other program participants.

Reasons for termination/exit with 30-day notice
The following reasons for termination/exit have been approved by the Shelter Program. If you are terminated/exited for any of the reasons stated below, you will receive a 30-day written Notice of Termination (Exit from the Program). The written notice of termination/exit will state the reason(s) for your termination/exit and will advise you of your right to a reasonable accommodation if you are a qualified person with a disability and of your right to utilize the grievance process.
• Participant chooses to not participate in programs and or services • Participant is using drugs or alcohol on-site
• Participant is no longer eligible for the program in which they are enrolled based on program guidelines of the funders
• Participant successfully secures permanent housing
• Reunification services are utilized or the participant self resolves their housing crisis • Participant relocates outside of Los Angeles County
• Participant is enrolled in another Interim Housing program (Crisis, Bridge, Recuperative Care, Stabilization, etc.) or Transitional Housing Program • Participant will be hospitalized for seven days or incarcerated for seven consecutive days or more
• Participant misses three consecutive nights without approved absence: If you are absent from your bed or room for three (3) or more consecutive calendar days for any reason without prior approval you may be exited from the Program. If this occurs, a 30-Day Notice of Termination (Exit from the Program) will be posted on the door of your room and/or on a community notice board and your personal belongings will be stored for the 30-day period. At the end of the 30-Day Notice period, your personal belongings will be disposed of. If you return within the 30-day period, best efforts will be used to rehouse you, subject to availability.

Termination Process
If a Participant fails to comply with the program rules, a Participant conference will be held to discuss the specifics of the situation. The conference will include a review of all facts, a review of the alleged violation. The assigned staff member, Program Manager and Director will attend the meeting with the Participant. If it is determined that the violation stands and the Participant will be terminated from the program, the following process will be applied.

All terminations will be documented in the client file and updated in HMIS (or applicable program database) in accordance with funding requirements and HIS documentation procedures. The client will be given written statement with the reasons for termination within 72 business hours.

The 30-Day Notice of Termination (Exit from the Program) will be served on you within 72 hours by one of the following methods: (1) by personal delivery; (2) by affixing a copy of the notice to the front door of your unit, or in a common area within the program where such notices are posted; or (3) if applicable, by mailing a copy by USPS mail to an address associated with your name in the Homeless Management Information System (“HMIS”).

Service of notices sent by US mail is deemed complete upon deposit of the notice with the mail carrier.

Participants have the right to receive competent, considerate and respectful care by the agency’s staff. If a Participant requests a review of the termination, he/she may proceed as follows:

1. The request must be submitted in writing to the appropriate department as identified below.
(310) 831-9123 (Martha Flecha-Raza, Family Resource Center) (310) 831-0603 (Shari Weaver, SPA 8 CES Adults, Families and Youth) (310) 831-5729 (Iran Guzman, Family Shelter and Accelerated Learning & Living Program)
(310) 547-3762 (Isabel Lopez, Caulder Center & HIS Kids Club)

2. After reviewing the document, an appointment will be made with the Director specified above and the Executive Director and if necessary, the assigned case manager. The entire process will be addressed within 72 business hours of the request in writing.

3. If the terminations stand, the Participant will receive a written Termination Notice that contains the reason(s) for termination within 72 business hours.

4. All written documents will also be submitted to the Grievance Coordinator at the Los Angeles Homeless Services Authority (LAHSA) 707 Wilshire Blvd., 10th Floor Los Angeles, California 90017. LAHSA Fax Number: (213) 892-0093 The termination will be in effect until all procedures have been followed and a final resolution has been made. Participant may be eligible to access services at a later date upon case review and discussion with the Participant.

Section 21: Grievance Procedure
Harbor Interfaith Services has a written grievance procedure for you to follow if you disagree with any program action (e.g., exit notice/termination), program decision (e.g., individual housing plan disagreement or room move), or if you have a problem with a staff member. In addition to any other rights that you may have to initiate and use the grievance process, you may initiate the grievance process when you receive a 30-day Notice of Termination (Exit from the Program) or at any time thereafter. If you are immediately removed based on findings that you present a “direct threat,” you may initiate the grievance process at the time of removal or at any time thereafter.

Section 22: Absences
It is your responsibility to notify staff if you are going to be sleeping off site and sign out accordingly. If you are observed to be absent from your bed for 3 consecutive nights, staff will consider you for immediate discharge. All absences are reviewed by shelter team to determine if this is the appropriate housing for your case.

Section 23: Accommodations
Participants may contact the Program Manager to request any ADA accommodations.

HARBOR INTERFAITH STAFF
Print Name:

Signature: Date:

PARTICIPANT(S)
I have read and understand the terms of this Agreement and I agree to abide by it. I understand that violations of this Agreement may result in immediate exit/termination from the Program.

I understand that NO TENANCY IS CREATED by my participation in the Program.

Print Name:

Signature: Date:

HARBOR INTERFAITH SERVICES INC. (HIS)

CASE MANAGEMENT AGREEMENT
Case Management is a collaborative process in which both the participant and case manager will assess, plan, implement, coordinate, monitor, and evaluate options and services to meet the participant’s needs. Case management is available for the duration of a participant’s stay. To produce the best possible outcome, both case manager and participant should commit to the following expectations:

Participant’s Role:

1. I am the expert of my life and I will be an active participant by attending scheduled appointments so that I many review of my goals and my required services can be consistent.

2. I will follow the Policies and Procedures of Harbor Interfaith Services and the Torrance Pallet Shelter.

3. I will be respectful to all staff at Harbor Interfaith Services at Torrance Pallet Shelter.

4. I will provide requested documentation that will help me to achieve my goals. (Examples: Identification and TB test and any other documents , which are both required to work towards permanent or emergency housing placement).

Case Manager’s Role:

1. To provide participants with follow-up case management appointments to discuss goals and progress.

2. To provide participants with options and resources they can choose from including housing, mental health, substance use services, life skills, domestic violence services, medical care, and income services. Available housing options are limited and may be outside of the area.

3. I will respond to phone messages within 24 hours. Please allow me to return your call before leaving additional messages. *If you are experiencing a medical emergency, please call 911, or go to the nearest hospital*

4. I will strive to empower you and motivate your own self-determination at each meeting.

Participant/Case Manager Team Role:

1. It is important for both participant and case manager to be present at scheduled meetings and appointments. If either party is unable to make an appointment, it is imperative to notify the other party as soon as possible to reschedule. It is understood that emergencies do happen and notifying each other may be impossible. However, we are expected to communicate as soon as we can.

2. Reassess each participants progress toward meeting their outlined Housing Plan goals every 30 days.

Note: Due to the high demand for case management, participant case management appointments may be limited or reduced for the following reasons (this is not an exhaustive list):

1. If you are not ready to actively work on housing goals.

If you are part of Shelter Program and are inactive toward meeting your goals, case managers will assess whether an extension for services can be granted, or you may be terminated for not participating in case management services.
________________________________________________ __________________________________ Participant Signature Date
________________________________________________ __________________________________ Case Manager Signature Date
HARBOR INTERFAITH SERVICES, INC.

PARTICIPANT RIGHTS AND GRIEVANCE POLICY

NON DISCRIMINATION STATEMENT
Clients shall not be discriminated against in the provision of services because of race, color, religion, national origin, ethnic identification, ancestry, sex, age, condition of physical or mental handicap, in accordance with requirements of federal and state laws, or in any manner on the basis of the client’s sexual orientation.

CONFIDENTIALITY OF RECORDS
Clients have the right to view his/her own records, to confidential handling of all communications and records pertaining to his/her participation in the program. This agency will not report that a person is a client of this agency to anyone outside the program unless the client consents in writing, the disclosure is allowed by court order, or the disclosure is made to medical personnel in a medical emergency or to a qualified person for research, audit, or program evaluation. Limits to confidentiality are: child abuse, elder abuse, dependent adult abuse, danger to others (duty to warn), danger to self (right to warn), and danger to property (right to warn).

PROGRAM RULES AND REGULATIONS
Clients must adhere to the program rules and regulations in order to preserve every program participant’s right and opportunity to benefit fully from program services.

GRIEVANCE PROCEDURES
Clients have the right to receive competent, considerate and respectful care by the agency’s staff. If a client is dissatisfied with the services, he/she is receiving, he/she may proceed as follows:

1. Speak with his/her assigned case manager:

If the client does not feel the staff response was satisfactory, they may bring the concerns to the supervisor.

2. Speak with the identified staff supervisor.
• (310) 547-3762 ( Isabel Lopez, Children’s Center)
• (310) 831-9123 (, Family Resource Center-FRC)
• (310) 770-1241 (Lisa Gray, Interim Housing & ICMS)
• (310) 770-0371 (Ramon Rendon, Beach Cities Programs & Redondo Beach Pallet Shelter) • (310) 766-4201 (Aaron Street, Torrance Pallet Shelter) • (562) 549-5911 (Cheryl Townsend-Hartdige, 26 point 2) Every effort will be made to resolve the matter at this level. However, if dissatisfaction is still evident, the client may be referred to the VP of Housing, VP of Programs or VP of Coordinated Entry System (CES) and/or the Executive Director/CEO at (310) 831-0603.

3. The grievance must be in writing and can be sent to or dropped off in person to the Executive Director/CEO at 670 W. 9
th Street, San Pedro, CA 90731. After review of the grievance, an appointment will be made with the Executive Director/CEO, Director of the Coordinated Entry System, Program Director, and if necessary, the assigned case manager, for the purpose of conflict resolution. The entire process will be addressed within 72 business hours of receipt of the complaint in writing. Review of grievance will take place in a confidential meeting area. A notice of the provider’s decision will be in writing and issued to the client within 48 hours of the formal meeting.

4. The funder will be notified in writing of all unresolved grievances that are referred to an outside agency. All completed forms will be submitted to the Grievance Coordinator of that specific funder.

The above-referenced grievance procedures must be followed as written above. All grievances in writing will be kept on file in the designated program for up to five years.

APPEAL PROCESS FOR DISCHARGE
I have read and understand the client rights and grievance procedure and acknowledge this by my signature:

Client Signature: __________________________________________________________________ Date: ___________________________________________________________________________ Staff Signature: ___________________________________________________________________ Date: ___________________________________________________________________________ REV 6.10.24
. Confidentiality and Mandated Reporting
WHAT IS CONFIDENTIALITY?
Confidentiality is defined as the assurance that the access to information regarding a client utilizing shelter/program advocacy shall be strictly controlled and that any violation is not only a breach of faith but has the potential to threaten the safety and life of the client and their children.

In providing service, there are some limits to confidentiality. Information about you is held in confidence.

However, we are required or permitted by law to release information to appropriate authorities including the Department of Children and Family Services, law enforcement, or mental health evaluators under one or more of the following circumstances

1. When you waive your privilege of confidentiality.

2. When contemplating a harmful act to self or others.

3. Following a court order.

4. In cases of suspected child abuse, dependent adult abuse, elder abuse or if a child is a witness to domestic violence. A suspicion of child abuse can occur through direct observation, past or present reports of abuse; verbal or written statements or other information provided by the parent/guardian, the client or other family members.

If a HIS staff person has reason to suspect, based on their professional judgment that a child is or has been abused, staff are required to report their suspicions to the authority or government agency vested to conduct child abuse investigations. Staff are required to make such reports even if they do not see the child in any professional capacity. HIS staff are mandated to report suspected child abuse if anyone aged 14 or older tells them that he or she committed child abuse, even if the victim is no longer in danger. HIS staff are also mandated to report suspected child abuse if anyone tells them that he or she knows of any child who is currently being abused. _____________________ ___________ _______________________ Case Manager Name Case Manager Signature Date
_______________________
Client Name
_____________________ ___________
Client Signature Date
Rev 06/05/2024
Interim Housing Service Animal Policy
Purpose
The purpose of this policy is to set forth guidance regarding adherence to the Americans with Disabilities Act (ADA) as it relates to ensuring people with disabilities have equal access to participate in programs and services at Harbor Interfaith Services, ABH.

The ADA prohibits discrimination against people by entities and guarantees that people with disabilities have equal access to services, programs and facilities offered by Harbor Interfaith Services, ABH. Harbor Interfaith Services will ensure that persons with disabilities are not discriminated against or excluded from receiving services based on their disability.

Definitions
For purposes of this policy, these terms are defined as follow:

A. Handler – a person with a disability using a service animal. The terms “guide animal” and “signal animal” have the same meaning as “service animal.”
B. Person or individual with a disability – A person who has a sensory, physical or mental impairment that limits one or more major live activities, including but not limited to walking, talking, seeing, breathing, hearing, or living independently.

C. Service animals are working animals, NOT PETS.

D. Service Animal – Any dog or other common domestic animal individually trained to do work for or perform tasks for the benefit of a qualified person with a disability. The “training” of a service animal need not be formal or professional, nor result in any special license or certification.

Policy
Harbor Interfaith Services is committed to complying with both the intent and spirit of the ADA and does not discriminate on the basis of disability in admission to, access to, or operations of its programs, facilities or services.

Unless specifically noted otherwise, for the purposes of this policy, the term “service animal” shall also include emotional support animals that help individuals with psychiatric disabilities manage or alleviate the symptoms of those disabilities, by providing therapeutic nurture, comfort and support.

Facilities & Accommodations
HIS will make every effort to accommodate any animal onsite that contributes to an individual’s well-being as long as HIS participant abides by the below policy: If a participant is approved to have an animal onsite, the handler agrees to the following terms and conditions:

1. Participant agrees to and is capable of keeping his/her animal under control at all times. This includes accepting responsibility for the following:
a. Handler must minimize barking
b. Handler must prevent biting, or other aggressive behaviors c. Handler must provide daily food and water to their animal, which is kept near the participants area/ space.

2. Participant agrees the animal will at all times be harnessed, leashed, unless these devices interfere with the service animal’s work or the individual’s disability prevents use of such devises.

3. Participant agrees to never leave animal unattended.

Rev 06/05/2024

4. Participant confirms the animal is housebroken and the guest is capable of taking the animal to an appropriate location to relieve itself regularly as needed.

5. Participant agrees to immediately dispose of their animal’s droppings properly, both in front of ABH -San Pedro and in the neighborhood.

6. Participant agrees to keep animal from causing discomfort or annoyance to others and will immediately remedy any complaints made through HIS staff or security.

7. Participant agrees to pay for any damages, loss, or expense caused by their animal.

8. Participant agrees and understands that this agreement and terms permit them to keep ONLY the one animal named and described below.

9. Participant agrees to provide proof of vaccination within seven (7) days of initial entry to HIS ABH housing program. If you need help identifying a low-cost veterinarian clinic to provide these required vaccinations, please inform HIS staff, who can provide some resources.

10. Participant understands that HIS reserves the right to dismiss individuals and their animals who do not follow the above outlined expectations.

Animal Name: Description (Color/Breed):

Tasks Service Animal Performs:
___________________________________________________________________________________________ Participant Name Participant Signature Date
_____________________ ______________________________ ____________ Case Manager Name Case Manager’s Signature Date
When a person with a service animal enters any Harbor Interfaith facility, the person cannot be asked about the nature or extent of his/her disability. Only two questions may be asked:

I. Is the animal required because of a disability?
II. What work or task has the animal been trained to perform? REV 06/05/2024

PHOTO CONSENT
I understand that in agreeing to an interview or photo shoot with Harbor Interfaith Services that I give Harbor Interfaith Services (together with its affiliates and subsidiaries) the right and permission to copyright and/or use, reuse and/or publish, and republish any story or article written from material in the interview. Likewise, I give similar permission for publication of any photographs, audio or videos of myself taken as part of this interview.

I hereby waive any right to inspect or approve the written copy, photography or video that may be used in conjunction therewith or to the eventual use that it might be applied.

I hereby release, discharge and agree to hold harmless Harbor Interfaith Services and its representatives acting under its authority from any liability resulting from publication or distribution of the same.

Likewise, I hereby release and agree to hold Harbor Interfaith Services harmless from any liability resulting from the publication of these materials by a third party. Harbor Interfaith Services has no control over such publication and if published the material is accurate.

I hereby warrant that I am over twenty-one years of age and competent to contract in my own name insofar as the above is concerned.

I have read the foregoing release, authorization and agreement, before affixing my signature below and warrant that I fully understand the contents thereof. _____________________________________________________________________________ Client Name Client Signature Date
Minor children (if any)
_________________________
_________________________
__________________________
___________________ _______________________________ ______________ Case Manager Name Case Manager Signature Date

AUTHORIZATION FOR RELEASE OF PROPERTY
I , hereby authorize the following individuals to
obtain my personal belongings in the event of my death:

1. Name Relationship Phone#

2. Name Relationship Phone#
• I understand that this authorization only applies to my personal belongings and does not grant access to any financial or legal documents or assets. • I also understand that this authorization can be revoked or amended at any time by me, provided that I am of sound mind and able to make such decisions. • Upon the receipt of the property from Harbor Interfaith Services a photo ID will need to be provided by the person listed above.
• I release and hold harmless Habor Interfaith Services from all liability relating to the release of said property to the person listed above.

Date:

Client Name: Signature

PROPERTY RELEASE UPON DEATH OF PARTICIPANT
I,
property of
, am the authorized representative to obtain the upon
death. I hereby release Harbor Interfaith Servicesfrom
and all liability related to obtaining personal property located at . any I understand that I am obtaining this property at my own risk, and that Harbor interfaith Services makes no representations or warranties as to the condition or suitability of the property for any particular purpose. By signing this statement, I acknowledge that I hold no liability for any injuries, damages, or other consequences that may arise from my obtaining or using this property.

Date:

Printed Name Signature

HARBOR INTERFAIRTH SERVICES (HIS)
670 W 9TH Street, San Pedro, CA 90731
Tel:(310) 831-0603 Fax:(310) 831‐0791/ website: www.harborinterfaith.org

TRANSPORTATIONFORM
I, , agree to be transported in an HIS vehicle under Agency supervision.

Print Name
Permission is granted for agency transportation from___ / ___/____ to ____/____/_____. Permission is also granted for my children to be transported in an HIS vehicle. The children’s names are:

1.______________________________ _______ 2.______________________________ _______ 3.______________________________ _______ Print Name of Child Age Print Name of Child Age Print Name of Child Age

4.______________________________ _______ 5.______________________________ _______ 6.______________________________ _______ Print Name of Child Age Print Name of Child Age Print Name of Child Age “All persons named above making trips in Agency vehicles are deemed to have waived all claims against Habor Interfaith Services and its employees for personal injury, accident, illness, or death occurring during or by reason of the trip.” I agree to cooperate and conform to directions and instructions of the Agency transportation staff and personnel in charge of the activity.

Client Signature: ____________________________________________________________________________ Date ___/____/_____ Must be signed by an adult 18 or older
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MEDICAL AUTHORIZATION
Date: ___________________________________
Client Name: ________________________________________ List known Allergies/Medication if any: ______________________________________________________ Additional Allergies/Medication if any: ______________________________________________________ Additional Allergies/Medication if any: ______________________________________________________ Additional Allergies/Medication if any: ______________________________________________________ Client Address: __________________________________________________________________City ______________________________Zip Code: _______________ Client Contact Phone Number:______________________________________________________________Email Address:________________________________ Name of Emergency Contact person:__________________________________________________Relationship: _________________________________________________ Emergency Home Phone Number:_____________________________________________________Cell Phone:____________________________________________________ The signature above certifies that I agree to the following statements. Should it be necessary for myself to have medical treatment during HIS vehicle transported trips, I hereby give the Agency personnel permission to use their judgment in obtaining emergency medical service for myself and I give my permission to the physician selected by the Agency personnel to render medical treatment deemed necessary and appropriate by the physician. I understand that medical or hospital cost incurred for treatment shall be my sole responsibility.

Rev: 06/05/2024

MAIL AGREEMENT FORM
Date:

Participants Name: UNIQUE IDENTIFIER:

State Issued ID: DOB:

Case Manager: Program:

I _____________________________ agree to receive my mail at Harbor Interfaith Services at (Full name as appeared in State Issued ID)
670 W. 9th Street. San Pedro CA, 90731 and must follow the below mentioned guidelines to receive my mail. (please initial all guidelines)
____ Provide State Issued ID when checking mail (Mail will not be issued without photo ID) ____ Check mail during regular business hours: Monday –Friday from 9 am to 5 pm (Office Closed Saturday & Sunday, Holidays and/ or special events)
____ All mail should have full first and last name.
____ Mail will be returned to sender after two weeks
____ No packages (with the exception of prescription medication), magazines or inappropriate material will NOT be accepted.
____ Mail can only be checked in person with State Issued ID, mail will not be checked over the telephone. (No exceptions)
____ Mail requiring signature will not be accepted
____ Mail Agreement Form is to be updated quarterly
I ______________________________ understand that I must follow this guidelines stated above in order to receive my mail at Harbor Interfaith Services. ________________________________
(Full Name)
________________________________ ________
(Signature) (Date)
Notes:

Office use only

Page 1 of 3 ends

GREATER LOS ANGELES

HOMELESS MANAGEMENT INFORMATION SYSTEM (LA HMIS)

CONSENT TO SHARE PROTECTED PERSONAL INFORMATION
_____________________________________________________________________________________ The LA HMIS is a local electronic database that securely record information (data) about clients accessing housing and homeless services within the Greater Los Angeles County. This organization participates in the HMIS database and shares information with other organizations that use this database. This information is utilized to provide supportive services to you and your household members.

What information is shared in the HMIS database?
We share both Protected Personal Information (PPI) and general information obtained during your intake and assessment, which may include but is not limited to:
• Your name and your contact information
• Your social security number
• Your birthdate
• Your basic demographic information such as gender and race/ethnicity • Your history of homelessness and housing (including your current housing status, and where and when you have accessed services)
• Your self-reported medical history, including any mental health and substance abuse issues • Your case notes and services
• Your case manager's contact information
• Your income sources and amounts; and non-cash benefits • Your veteran status
• Your disability status
• Your household composition
• Your emergency contact information
• Any history of domestic violence
• Your photo (optional)
How do you benefit from providing your information?
The information you provide for the HMIS database helps us coordinate the most effective services for you and your household members. By sharing your information, you may be able to avoid being screened more than once, get faster services, and minimize how many times you tell your ‘story.’ Collecting this information also gives us a better understanding of homelessness and the effectiveness of services in your local area.

Who can have access to your information?
Organizations that participate in the HMIS database can have access to your data. These organizations may include homeless service providers, housing groups, healthcare providers, and other appropriate service providers.

Page 2 of 3 ends

How is your personal information protected?
Your information is protected by the federal HMIS Privacy Standards and is secured by passwords and encryption technology. In addition, each participating organization has signed an agreement to maintain the security and confidentiality of the information. In some instances, when the participating organization is a health care organization, your information may be protected by the privacy standards of the Health Insurance Portability and Accountability Act (HIPAA).

By signing below, you understand and agree that:
• You have the right to receive services, even if you do not sign this consent form. • You have the right to receive a copy of this consent form. • Your consent permits any participating organization to add to or update your information in HMIS, without asking you to sign another consent form.
• This consent is valid for seven (7) years from the date the PPI was created or last changed. • You may revoke your consent at any time, but your revocation must be provided either in writing or by completing the Revocation of Consent form. Each Participating Organization that entered information into HMIS will continue to have access to your PPI, but the information will no longer be available to any other Participating Organization. • The Privacy Notice for the LA HMIS contains more detailed information about how your information may be used and disclosed. A copy of this notice is available upon request. • No later than five (5) business days of your written request, we will provide you with:
o A correction of inaccurate or incomplete PPI
o A copy of your consent form
o A copy of your HMIS records; and
o A current list of participating organizations that have access to your HMIS data. • Aggregate or statistical data that is released from the HMIS database will not disclose any of your PPI.
• You have the right to file a grievance against any organization whether or not you sign this consent.
• You are not waiving any rights protected under Federal and/or California law.

Right to Make Corrections
If you believe that your PPI in HMIS is incorrect or incomplete, you have the right to request a correction. To ask for either of these changes, send a written request, including the reason why you believe the information is incorrect or incomplete, to the HMIS Administrator of the organization that entered the information into HMIS. The organization may turn down your request if the information:
• Was not created by the organization you are requesting the change from; • Is not part of the information that you would be allowed to look at and copy; • Is related to another individual;
• Is found to be correct and complete.
• Is otherwise protected by law.

However, if your request for correction is denied, you have the right to request that the following language is entered next to a particular entry: “The participant disputes the accuracy of this entry.”

Page 3 of 3 ends

SIGNATURE AND ACKNOWLEDGEMENT
Your signature below indicates that you have read (or been read) this client consent form, have received answers to your questions, and you freely consent to have your information, and that of your minor children (if any), entered into the HMIS database. You also consent to share your information with other participating organizations as described in this consent form.  I consent to sharing my photograph. (Check here)
Client Name: ________________________________________ DOB: _____________ Last 4 digits of SS_________ Signature ____________________________________________________________Date _____________________  Head of Household (Check here)
Minor Children (if any):

Client Name: _____________________ DOB: ___________ Last 4 digits of SS _________ Living with you? (Y/N) Client Name: _____________________ DOB: ___________ Last 4 digits of SS _________ Living with you? (Y/N) Client Name: _____________________ DOB: ___________ Last 4 digits of SS _________ Living with you? (Y/N) ___________________________________________ _______________________________ Print Name of Organization Staff Print Name of Organization ____________________________________________ _______________________________ Signature of Organization Staff Date

HARBOR INTERFAITH SERVICES, INC (HIS)
Termination Policy and Procedure
Termination from Harbor Interfaith (HIS) programs may include but are not limited to:
• Client choice to not participate in a HIS program and/or service. • Client is no longer eligible for the program in which they are enrolled, based on program guidelines and eligibility of the funders.
• Violation of program requirements as listed below:

1. Acts of threat or violence against another participant and/or staff.

2. Drug and/or alcohol use on-site.

3. Theft or destruction of agency property.

4. Possession of, or use of a weapon.

If a client is terminated as a result of one of the above rules, a client conference will be held to discuss the specifics of the termination. The conference will include a review of all facts, and a review of the alleged reason that led to the termination. The assigned staff member and program director will attend the meeting with the client. If it is determined that the violation stands and the client will be terminated from the program, the following process will be applied:

Termination Process
Clients have the right to receive competent, considerate and respectful care by the agency’s staff. If a client requests a review of the termination, he/she may proceed as follows:

1. The request must be submitted in writing to the appropriate department as identified below.
• (310) 547-3762 ( Isabel Lopez, Children’s Center)
• (310) 831-9123 (, Family Resource Center-FRC)
• (310) 770-1241 (Lisa Gray, Interim Housing & ICMS)
• (310) 770-0371 (Ramon Rendon, Beach Cities Programs & Redondo Beach Pallet Shelter) • (310) 766-4201 (Aaron Street, Torrance Pallet Shelter) • (562) 549-5911 (Cheryl Townsend-Hartdige, 26 point 2)

2. After reviewing the document, an appointment will be made with the Director as specified above and the Executive Director/CEO, and if necessary, the assigned Case Manager. The entire process will be addressed within 72 business hours of receipt of the request, in writing.

3. If the termination stands, the client will receive a written Termination Notice that contains the reason(s) for the termination within 72 business hours.

4. All written documents will be submitted to the Grievance Coordinator at the Los Angeles Homeless Services Authority (LAHSA) 811 Wilshire Blvd., Suite 600 Los Angeles, California 90017. LAHSA Fax Number: (213) 892-0093
The termination will be in effect until all procedures have been followed and a final resolution has been made. Client may be eligible to access services at a later date, upon case review and discussion with the client.

Documenting a Termination
All terminations from a HIS program will be documented in the client file and updated in HMIS (or applicable program database) in accordance with funding requirements and HIS documentation procedures. The client will be given a written statement with the reason/s for termination within 72 business hours.

LAHSA will be notified in writing of all unresolved terminations. All completed forms will be submitted to the Grievance Coordinator at the Los Angeles Homeless Services Authority (LAHSA) 811 Wilshire Blvd., Suite 600 Los Angeles, California 90017, Fax (213) 892-0093.

The above-referenced termination procedures must be followed as written above. All program terminations will be kept on file in the designated program for up to five years.

Harbor Interfaith Services Inc. (HIS) Termination Policy and Procedure will be given to all clients at Intake/enrollment.

I ________________________________have read and understand the HIS termination policy and procedure and acknowledge this by my signature below.

Client Signature: ________________________________________________________________ Date: _________________________________________________________________________ Staff Signature: ________________________________________________________________ Date: _________________________________________________________________________

DHS- INTERIM HOUSING
Verified by:________
SECTION III: HOUSING DOCUMENTATION
Please select the housing subsidy that applies (Select one)  HACLA
 LACDA
 DHS -PSH
Housing Information (Check all that apply)
 Voucher (If Applicable)
 Current Lease
 Rental Application (If Applicable)
 Move in Assistance/Furniture Request
 Recertification Application
Brilliant Corners Housing Documents (Check all that apply)  Unit Identification form (If Applicable)
 Move in Assistance/Furniture Request
 General Assistance Request (If Applicable)
 Recertification Application

DHS-INTERIM HOUSING
Verified by:________
SECTION IV: ASSESSMENTS AND PLANNING
Housing Services Log
Initial Assessment
Goals and Plans for Success (GPS)
Budget

HOUSING SERVICES LOG
Participant’s Name: CHAMP ID #:

Housing Services Log: Form should be completed on a weekly basis. A minimum of 3 Housing leads should be discussed each week.

Date Unit Address &
Phone Number
Phone number Client
Accepted
(Y/N)
Client Response Outcome
___________________________ __________________________________ ________________________ Client Name Client Signature Date
___________________________ __________________________________ ________________________ Case Manager Name Case Manager Signature Date
___________________________ __________________________________ ________________________ Supervisor Name Supervisor Signature Date

INITIAL ASSESSMENT

DEMOGRAPHIC INFORMATION
First Name: Middle Name: Last Name:

AKA (alias): Height:

Weight:

Date of Birth:

Age:

Gender:

Male
Female
Transgender
Place of Birth:

City:

State:

Country:

Residency Status:

US Citizen
Legal Resident
Race:

Caucasian Latino/a
Black/African American
Other:

Primary Language:

English
Spanish
Other:

Marital Status:

Single Significant Other Married Divorced Separated
Widowed
Do you want to live with your partner? Yes No
Explain:

Religious Preference:

Christianity Catholicism
Baptist Judaism Muslim/Islam
Buddhism None Other:

EDUCATION
What is the highest level of education that you have completed? Were you ever in special education classes as a minor (under 18)? YES NO

EMPLOYMENT
If employed:

Where are you employed?
How long have you been employed?
What is your current job title?
If NOT employed, what are your reasons for not being employed:

Medical Substance Abuse Psychiatric Other
Do you have a job you currently do not report?
If YES, what type of work do you do? How much is your income from this work? YES NO When was the last time you worked?
What did you do at your last place of employment?
What was your longest full time job?
Assessment Date:

Interviewed by:

Client contact number:

CLIENT ID:

Revised 03/2017
2 MEDICAL HISTORY
Do you have health insurance?
If YES, what kind: YES NO
Do you have any allergies to medications or food?
If YES, what are they: YES NO
Does patient have any of the following medical conditions that impact their independent living? YES NO

1. Colostomy bag 4. Feeding tube 7. Incontinent of urine or feces

2. Urinary catheter 5. Ongoing intravenous therapy 8. Evidence of active TB

3. Tracheotomy 6. Wounds that require wound care 9. At risk for alcohol withdrawal seizures/DTs and need detox Does patient you have any health or medical conditions? YES NO If YES, what are they:

1. 4. 7.

2. 5. 8.

3. 6. 9.

Are you receiving treatment for those conditions? YES NO If NO, why not?
If YES, complete section below:

CURRENT MEDICAL PROVIDER

PRIMARY CARE

PROVIDER NAME OF DOCTOR ADDRESS PHONE NUMBER

TYPE OF

SPECIALIST(S)

NAME OF DOCTOR ADDRESS PHONE NUMBER

HISTORY OF EMERGENCY ROOM VISIT(S)

DATE HOSPITAL NAME CITY, STATE REASON FOR ER VISIT

HISTORY OF INPATIENT ADMISSION(S)

DATE HOSPITAL NAME CITY, STATE REASON FOR ADMISSION

HISTORY OF SURGERIES
DATE TYPE OF SURGERY CITY, STATE OUTPATIENT or

INPATIENT
(Revised 8. 2015)
3 FUNCTIONAL ASSESSMENT & SPECIAL NEEDS ASSESSMENT

PHYSICAL CHALLENGES
Assistive Device/Machine YES NO Assistive Device/Machine YES NO Cane Walker
Limb Braces Wheel Chair
Talking Devices Other:

ACTIVITIES OF DAILY LIVING (ADLs)
Walk Self Partial assistance Complete assistance
Bathing / Shower: Self Partial assistance Complete assistance Brush teeth: Self Partial assistance Complete assistance Use toilet: Self Partial assistance Complete assistance Cooking: Self Partial assistance Complete assistance
Cleaning: Self Partial assistance Complete assistance
Wash clothes: Self Partial assistance Complete assistance Use public transportation: Self Partial assistance Complete assistance CASE MANAGER: Does client have awareness of medical condition? YES NO CASE MANAGER: Did Case Manager observe client demonstrate appropriate mobility/functioning?
YES NO

PSYCHIATRIC HISTORY
Have you ever been diagnosed with a mental health illness or received mental health services? YES NO If YES, what is your diagnosis or what have you received services for? When were you diagnosed and where (clinic/facility)?
Where other places have you received services before?
DATES IN TREATMENT MENTAL HEALTH AGENCY Individual
Therapy
Group
Counseling
Psychiatry

YES NO YES NO YES NO

YES NO YES NO YES NO
Are you currently enrolled in mental health services? (NOTE: If YES, sign consent to release information)
YES NO
If YES, where:

If YES, what kind of services are you receiving? (i.e. therapy, psychiatry, group counseling, life skills, housing, etc) Are you taking any medications for mental health? YES NO If YES, names of medications, dose, and side effects:

MEDICATION DOSE SIDE EFFECTS
a) Have you ever been hospitalized for mental health reasons? YES NO If YES, what for and how many times?
What is voluntary or involuntary?
b) Do you have a family history of mental health illness? YES NO If YES, who and what type of illness:

CURRENT RISK AND SAFETY CONCERNS
Have you ever had thoughts of hurting yourself/suicide? YES NO Have you ever attempted to hurt yourself/commit suicide? YES NO (Revised 8. 2015)
4 If YES to above, number of attempts and method(s):

Most recent attempt:

Do you currently experience thoughts about hurting yourself/committing suicide? YES NO If YES to above, does client have intent, a plan, and means? Does client have safety plan?
Have you ever thought about injuring or causing harm to someone else? YES NO Have you ever injured or caused harm to someone else? YES NO If YES to any of the above, explain these feelings:

Would you be interested in individual therapy? YES NO

TRAUMA/ABUSE HISTORY
Have you ever been physically, emotionally, or sexually abused? YES NO Have you recently been a victim of violence/abuse? YES NO Are there any other traumatic experiences that you feel would be important for me to know? If YES, explain:

YES NO
If YES to any of the above, do you want to work through these issues? YES NO

THOUGHT DISORDER QUESTIONNAIRE
Are there ever thoughts/voices that you cannot get out of your head? YES NO Have you ever felt like someone was reading your mind or making you think things? YES NO Have you ever felt that your mind was playing tricks on you? YES NO Do you hear voices?
If YES, what do the voices say?
How long have you been hearing voices?
Are the voices female or male?
What do they tell you to do?
Are they inside or outside of your head?
YES NO
Do you ever feel like someone is following you or out to get you? If YES, who?
YES NO

DRUG/ALCOHOL/ADDICTION
Have you ever used drugs and alcohol in your lifetime? YES NO Substance Age first used Last time used Frequency
Substance Age first used Last time used Frequency
Substance Age first used Last time used Frequency
If YES, drug of choice:

Do you think that you have a drug or alcohol problem? Or has anyone ever suggested that you have a drug or alcohol problem?
If YES, explain:

YES NO
Have you ever tried to quit on your own or cut down on your drug or alcohol use? If YES, explain:

YES NO
Have you ever received help in the past for substance use issues? If YES, Detox Outpatient or Residential treatment program? Name of Program:

Dates:

Was it beneficial? How?
YES NO
Would you be interested in treatment? (CASE MANAGER: If YES, make referral to CASC) YES NO Do you think you have any other Addictive Behaviors such as eating, gambling, sex, shopping, video games, etc.?
YES NO
Family history of alcohol and/or substance abuse:
(Revised 8. 2015)
5 FAMILY/SOCIAL RELATIONSHIPS
Whom do you have support from?
Family Friends Other No one
Do you socialize with others?
If YES, what do you do for socialization? YES NO
Do you have family or friends you can confide in? YES NO What do you do to manage your feelings?
Have you ever participated in Case Management/Supportive Services before? If YES:

Where (name of clinic/facility/agency):

Name of last case manager:

What services where you assisted with?
How long:

YES NO

CHILDREN
Do you have any children?
If YES, name(s) and age(s): YES NO
Do you have any children?
If YES, name(s) and age(s): YES NO
Name: Age:

Name: Age:

If children are under the age of 18, do you have legal custody of your children? YES NO If NO, what are the reasons you do not have custody?
Do you owe child support? YES NO
Have you ever been involved with DCFS?
If YES, explain: YES NO
Do you have an open DCFS case?
If YES, explain:

If YES, do you have a court-ordered case plan and what is it? If YES, name and contact information for DCFS case worker:
(NOTE: If client agrees, sign release of information to coordinate treatment) YES NO
SIGNATURE_________________________________________________________________________ (Case Manager) (Date)
(Revised 8. 2015)
    
    
    

GOALS AND SERVICE PLAN
Objective: Client Participation:

Intervention: Outcome:

Outcome Date:

Client Signature: Date:

Staff Signature: Date:

Revised 06/07/2024
Goal 1
Housing Physical/
Mental Health
Substance Use/
Medication Management
Life Negotiation Skills/
Employment/ Benefits
ADLs/ IADLs (Independent/
Activities of Daily Living)
Objective: Client Participation:

Intervention: Outcome:

Outcome Date:

Housing Physical/
Mental Health
Substance Use/
Medication Management
Life Negotiation Skills/
Employment/ Benefits
ADLs/ IADLs (Independent/
Activities of Daily Living)
Goal 2
Client Name: CID: Date:

Please choose 3 goals to address per Individual Service Plan. Case management will be aligned with the following for 3 months with intent to accomplish goal. Re-assessment will be conducted and documented in CHAMP.

Goal 3
Objective: Client Participation:

Intervention: Outcome:

Outcome Date:

ADLs/ IADLs (Independent/
Activities of Daily Living)
Life Negotiation Skills/
Employment/ Benefits
Substance Use/
Medication Management
Physical/
Mental Health
Housing
1 of 2

CLIENT BUDGET WORKSHEET
CLIENT NAME: DATE:

Current housing situation:

Number in household:

Total monthly income: * Total monthly expenses:

Income Sources Household Member’s Name Amount Month/Year AFDC (TANF)* $ per
General Relief $ Per
Employment PT/FT* $ Per
VA Benefits $ Per
S.S.I./S.S.A $ Per
Disability $ Per
Unemployment $ Per
Foster Care $ Per
Disabled Family Member $ Per
Educational Assistance $ Per
Child Support $ per
Military $ per
Pension $ Per
Business Income $ per
Other Income $ per
Vehicle Information
Do you or any household member own a vehicle(s)? Yes No If YES and the vehicle is financed, how much is owed $ What is the monthly payment? $ Do you have car insurance? Yes No If Yes, How much do you pay per month/quarter? $ Medical Information
Do you have medical/health insurance? Yes No Payment per month/quarter/year? $ If Yes, What type of coverage do you have?
Do you pay for medicines or other out-of-pocket medical expenses? Yes No If Yes, what are they?
How much do you pay out of pocket per month (on average)? $ 2 of 2
EXPENSES for NEXT 3 MONTHS
#1 Current Monthly Expenses
Rent $ Medical Insurance $ Clothing $
Gas $ Out of pocket Medical $ Life Insurance Policy $
Electric $ Public Transportation $ Furniture Payment $
Water $ Automobile Payment $ Credit Card Payments $
Trash $ Car Insurance Payment $ Childcare $
Telephone $ Gasoline/Care Repairs $ Cable/DTV Other $
Pager $ Household Supplies $ Other $
Cell Phone $ Food $ Other $
#2 Next Month’s Expenses
Rent $ Medical Insurance $ Clothing $
Gas $ Out of pocket Medical $ Life Insurance Policy $
Electric $ Public Transportation $ Furniture Payment $
Water $ Automobile Payment $ Credit Card Payments $
Trash $ Car Insurance Payment $ Childcare $
Telephone $ Gasoline/Care Repairs $ Cable/DTV Other $
Pager $ Household Supplies $ Other $
Cell Phone $ Food $ Other $
#3 Third Month Expenses
Rent $ Medical Insurance $ Clothing $
Gas $ Out of pocket Medical $ Life Insurance Policy $
Electric $ Public Transportation $ Furniture Payment $
Water $ Automobile Payment $ Credit Card Payments $
Trash $ Car Insurance Payment $ Childcare $
Telephone $ Gasoline/Care Repairs $ Cable/DTV Other $
Pager $ Household Supplies $ Other $
Cell Phone $ Food $ Other $

1. Do you need budget counseling, money management, or how to consolidate your debts? ( )Yes ( ) No

2. Are you currently enrolled in job training/employment services that may lead to increased income? ( )Yes ( ) No

3. Are you currently applying for government benefits? ( )Yes ( ) No Plan to Increase Income and Reduce Expenses:

Action Target Date:

1. 2.

3. 4.

Client’s Signature: Date:

Case Manager Signature: Date:

DHS INTERIM HOUSING
Verified by:________
SECTION V: SUPPORTIVE SERVICES
Medical Questionnaire
Case Notes
Copies of Receipts
Medical History Questionnaire
1 of 3
Rev. 6.14.24
Client Name:

Age
List All Known Allergies (If
applicable)
Please check Yes or No Yes No

1. Do you have a chronic health condition such as: Diabetes, Congestive Heart Failure, or Uncontrolled high blood pressure?

2. Do you have a primary care provider?
2a. If you do not have a medical provider, would you like to be connect to one and receive treatment?

3. Do you have any memory problems?

4. Do you have a physical disability?

5. Does your health condition(s) prevent you from doing things that you would like to do, such as daily activities, walking around, physical activity, or employment?

6. Do you think you need a denist?
6a. If yes, would like help arranging this?

7. Do you have trouble seeing?
7a. If yes, do you think you need new or updated pair of glasses? 7b. If yes, have you been told that you have vision problem that glasses will not fix?

8. Do you have difficulty hearing?
8a. If yes, does it interfere with your daily activities? 8b. If yes, would you like help addressing this?
Medical History Questionnaire
2 of 3
Rev. 6.14.24
Please check Yes or No Yes No

9. Are you taking any prescribed medication?

10. Have you ever had issues with any of the following mental health conditions? Check all that apply. If no, skip to next question.

Depression Hallucinations
Anxiety Delusions
Schizophrenia Sucidal Thoughts
Manic Episodes Self-Harning
PTSD/Flashbacks/Nightmares Anger Management
Homicidal ideation Other:

11. Do you currently see a mental health provider?
11a. If no, would you like one?
Primary Care Information
Name of Provider
Address
Phone Number
Medications
Complete if currently taking medication
Name of Medication Dosage Reason(s) Side Effects if any Example: Seroquel 10mg/3x a
day
Bipolar disorder Sleepiness, drymouth,
forgetfulness.

Medical History Questionnaire
3 of 3
Rev. 6.14.24
Mental Health Care Information
Name of Provider
Address
Phone Number
Please provide any other information regarding your health that you feel it is important for us to know such as any dietry restrictions, medication that needs to be stored in a refrigerator, etc.

DHS INTERIM HOUSING
Verified by:________
SECTION VI: EXIT FORMS
Exit Form
Incident Reports
Miscellaneous
Effective 07/01/2024

Exit Summary Form
Participant Name: CHAMP ID:

Program Name: Program Start Date:

HOUSING STATUS
Participant Housing Status at Exit:
☐ Transitional Housing for homeless persons (including homeless youth) ☐ Permanent Housing
☐ Remained in Permanent Housing (Only for Prevention Program) ☐ Exited to a Rapid Re-Housing Program
☐ Exited to another program that provides housing search and placement assistance ☐ Other:

PERMANENT HOUSING DESTINATION ADDRESS
(Only complete if participant has moved into permanent housing or youth has moved into transitional housing placement)
Move-In Date:

Street Address: Unit/Apt #:

City: State: Zip Code:

CHAMP EXIT REPORTING
☐ CHAMP Exit Destination reported:
☐ Move-In Date reported for permanent housing

REASON FOR PROGRAM EXIT
☐ Completed Program Goals ☐ Linked to Another Program
☐ Self-Resolved Housing Crisis ☐ Duly enrolled in another program ☐ Refused contact for 90 Days or more ☐ Hospitalized or Incarcerated for 90 Days or more ☐ Relocated to Another CoC ☐ No longer eligible for services ☐ Other
Effective 07/01/2024

EXIT QUESTIONS
I. What progress and achievements were made towards goals defined in the Care Plan? II. What supports or services are needed for the participant to retain permanent housing? III. Does the participant have access to the needed supports or services?

SIGNATURES
Participant Name
______________________________
Participant Signature
Date
Staff Name Staff Signature Date
Supervisor Name Supervisor Signature Date
V-1

EXHIBIT V

MONTHLY SUMMARY SHEET

RACE/ETHNICITY
# White
# Black/African American
# Asian
# American Indian or Alaskan Native
# Native Hawaiian or Other Pacific Islander
# American Indian or Alaska Native AND White #
Asian AND White
# Hispanic/Latino
# Black/African American AND White
# American Indian/Alaska Native AND Black/African American # Other:

SEX
# Female Head of Household (i.e., female with dependent child) INCOME
Total Redondo Beach Clients
Total Low Income (51%-80% Area Median Income)
Total Very Low Income (31%-50% Area Median Income)
Total Extremely Low Income (Equal to or less than 30%)
Total Non-Low Income
Agency Director Agency Name
VI-1

EXHIBIT VI

PUBLIC SERVICE AGENCY EXPENDITURE REPORT

CITY OF REDONDO BEACH

DEPARTMENT OF COMMUNITY SERVICE

1. Contractor’s Name: 2. Address of Contractor:

3. Fiscal Year Report No. 4. Report Period
Month or Quarter

5. Contact Person: 6. Telephone No.:

I. REQUEST FOR PAYMENT

1. Total Cumulative Expenditures (Section II, Column C-2, Line 5) $

2. Reimbursements to Date $

3. Amount Requested for Payment $

CITY USE ONLY
Date Report Received
Amount
Authorized
Date Report Reviewed Reviewed By
II. CITY FUNDED EXPENDITURES
A. LINE ITEM COSTS B. PROGRAM BUDGET C. EXPENDITURES D. AVAILABLE

BALANCE

1. Current 2. Cumulative

1. Staff Salary: wages

2. Equipment

3. Rent/Lease Costs

4. Other

5. Total Costs
VII-1

EXHIBIT VII

INSURANCE REQUIREMENTS FOR CONTRACTORS
Without limiting Contractor’s indemnification obligations under this Agreement, Contractor shall procure and maintain for the duration of the contract insurance against claims for injuries to persons or damages to property which may arise from or in connection with the performance of the work hereunder by the Contractor, its agents, representatives, or employees.

Minimum Scope of Insurance
Coverage shall be at least as broad as:

Insurance Services Office Commercial General Liability coverage (occurrence form CG0001).

Insurance Services Office form number CA 0001 (Ed. 1/87) covering Automobile Liability, code 1 (any auto).

Workers’ Compensation insurance as required by the State of California.

Employer’s Liability Insurance.

Minimum Limits of Insurance
Contractor shall maintain limits no less than:

General Liability: $2,000,000 per occurrence for bodily injury, personal injury and property damage. The general aggregate limit shall apply separately to this project. An umbrella policy may be used to provide additional liability coverage, so long as the combined General Liability coverage (General Liability and umbrella) is at least $2,000,000.

Automobile Liability: $1,000,000 per accident for bodily injury and property damage.

Employer’s Liability: $1,000,000 per accident for bodily injury or disease.

Deductibles and Self-Insured Retentions
Any deductibles or self-insured retentions must be declared to and approved by the City.

At the option of the City, either: (1) the insurer shall reduce or eliminate such deductibles or self-insured retentions as respects the City, its officers, officials, employees and volunteers or (2) the Contractor shall provide a financial guarantee satisfactory to the City guaranteeing payment of losses and related investigations, claim administration and defense expenses.

Other Insurance Provisions
The general liability and automobile liability policies are to contain, or be endorsed to contain, the following provisions:

Additional Insured Endorsement:

General Liability: The City, its officers, elected and appointed officials, employees, and VII-2
volunteers shall be covered as insureds with respect to liability arising out of work performed by or on behalf of the Contractor. General liability coverage can be provided in the form of an endorsement to the Contractor’s insurance, or as a separate owner’s policy.

Automobile Liability: The City, its officers, elected and appointed officials, employees, and volunteers shall be covered as insureds with respect to liability arising out of automobiles owned, leased, hired or borrowed by or on behalf of the Contractor.

For any claims related to this project, the Contractor’s insurance coverage shall be primary insurance as respects the City, its officers, elected and appointed officials, employees, and volunteers. Any insurance or self-insurance maintained by the City, its officers, officials, employees, or volunteers shall be excess of the Contractor’s insurance and shall not contribute with it.

Each insurance policy required by this clause shall be endorsed to state that coverage shall not be canceled by either party, except after thirty (30) days prior written notice by certified mail, return receipt requested, has been given to the City.

Each insurance policy shall be endorsed to state that the inclusion of more than one insured shall not operate to impair the rights of one insured against another insured, and the coverages afforded shall apply as though separate policies had been issued to each insured.

Each insurance policy shall be in effect prior to awarding the contract and each insurance policy or a successor policy shall be in effect for the duration of the project. The maintenance of proper insurance coverage is a material element of the contract and failure to maintain or renew coverage or to provide evidence of renewal may be treated by the City as a material breach of contract on the Contractor’s part.

Acceptability of Insurers
Insurance shall be placed with insurers with a current A.M. Best’s rating of no less than A:VII and which are authorized to transact insurance business in the State of California by the Department of Insurance.

Verification of Coverage
Contractor shall furnish the City with original certificates and amendatory endorsements effecting coverage required by this clause. The endorsements should be on the City authorized forms provided with the contract specifications. Standard ISO forms which shall be subject to City approval and amended to conform to the City’s requirements may be acceptable in lieu of City authorized forms. All certificates and endorsements shall be received and approved by the City before the contract is awarded. The City reserves the right to require complete, certified copies of all required insurance policies, including endorsements effecting the coverage required by these specifications at any time.

Subcontractors
Contractor shall include all subcontractors as insured under its policies or shall furnish separate certificates and endorsements for each subcontractor. All coverages for VII-3
subcontractors shall be subject to all of the requirements stated herein.

Risk Management
Contractor acknowledges that insurance underwriting standards and practices are subject to change, and the City reserves the right to make changes to these provisions in the reasonable discretion of its Risk Manager.

Redondo Beach City CouncilFebruary 10, 2026

Redondo Beach City Council
February 10, 2026