CITY OF RICHMOND
SHORT FORM CONTRACT
Department: Project Manager:
Project Manager E-mail: Project Manager Phone No:
PR No: Vendor No: P.O./Contract No:
Description of Services:
1. Parties. The parties to this Agreement are the City of Richmond (herein referred to as the “City”) and the
following named Contractor:
(Company)
(Street Address)
(City State, Zip Code)
(Contract Person)
(E-mail)
(Telephone)
(Fax Number)
Richmond Business License No.
Expiration Date:
2. Term. The effective date of this Agreement
is
and it terminates
unless sooner terminated as provided herein.
3. Payment Limit. City’s total payment to Contractor
under this Agreement shall not exceed ($10,000.00)
including expenses unless a contract amendment has
been approved by the City Council or City Manager.
4. City’s Obligations. City shall pay the Contractor a not to exceed amount of $
as total payment for all services rendered.
5. Location of Services. Contractor shall perform the
services set forth herein at the following location:
___________________________________________
6. Contractor’s Obligations.
To the satisfaction of the City’s Project
Manager, Contractor shall provide the
following services:
7. Supplemental Conditions. This
Contract is subject to the Supplemental
Conditions and Special Conditions (if
applicable) attached hereto, which are
incorporated herein by this reference.
8. Insurance Provisions. This Contract is
subject to the Insurance Provisions which
are attached hereto and are incorporated
herein by this reference.
9. Signatures. These signatures attest the
parties’ agreement hereto:
CITY:
CITY OF RICHMOND, CA
a municipal corporation
By:
City Manager or Designee Signature
CONTRACTOR:
By:
Signature Date:
Short Form Contract/EJ/TE 11-30-07
Community Development
Jesus Morales
[email protected]
(510) 620-6649
16064
/ 6649
Healing Spot Counseling Center, Inc. will provide mental health services to Castro encampment residents to support their well-being.
Healing Spot Counseling Center, Inc.
5179 Lone Tree Way
Antioch, CA 94531
Miya Moore-Felton
[email protected]
(925) 434-8506
4006-4844
December 31, 2023
August 1, 2023
June 30, 2024
10,000.00
Richmond, CA and on-line
Healing Spot Counseling Center, Inc. will
provide mental health services per scope
and budget attached.
DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129 8/21/2023
9/14/2023
1 PROPOSAL FOR SERVICES
CITY OF RICHMOND: CASTRO ENCAMPMENT RESOLUTION PROJECT
OVERVIEW
Healing Spot Counseling Center Inc. is pleased to submit this proposal for services to support the City of Richmond in supporting the Castro Encampment Resolution Project. The mental health support is designed to promote the physical and emotional safety of a population that is vulnerable to mental health challenges. The services outlined include crisis stabilization, mental health assessments, individual counseling, and group counseling.
The Objective
The objective is to train approximately six staff members to support the mental health needs of:
• Need #1: Crisis stabilization and psychological first aid for homeless residents • Need #2: Mental health assessments and interviewing for treatment planning • Need #3: Ongoing mental health support by licensed providers
OUR PROPOSAL
Healing Spot Counseling Center Inc. has a well-deserved reputation for quality mental health services and training for individuals, groups, and organizations. The City of Richmond provides food service and resource support to the Castro homeless encampment. Although many residents utilize the services offered, the staff reports that some encampment residents are experiencing mental health challenges. Many have experienced severe traumatic events (sexual assault, emotional and physical abuse, near-death experiences, etc.). These mental health challenges present a barrier to the resident’s utilization of community resources, as some residents have emotionally struggled after receiving housing placements, job referrals, and medical care. The assessment structure, individual counseling, and group sessions aim to help residents experiencing a mental health crisis, provide initial crisis stabilization and assessments, and connect them with additional mental health resources, if required, for continued care. Working with the homeless population can be grueling work that takes its toll on the staff's mental health.
DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129 2 Rationale
Providing mental health resources to homeless individuals can have several benefits, including:
Improved mental health: Homeless individuals often experience high-stress levels, trauma, and mental health conditions such as depression, anxiety, and post-traumatic stress disorder (PTSD). Access to mental health resources, such as therapy, counseling, and medication, can help alleviate symptoms and improve overall mental health.
Increased housing stability: Mental health issues can be a significant barrier to securing and maintaining stable housing. Homeless individuals may be better equipped to secure and maintain housing by addressing mental health concerns.
Reduced substance abuse: Homelessness and mental health issues are often associated with substance abuse.
Providing mental health resources can help address the underlying causes of substance abuse and support individuals in achieving and maintaining sobriety.
Reduced healthcare costs: Homeless individuals with untreated mental health conditions often utilize emergency rooms and other costly healthcare services at higher rates. By providing mental health resources, healthcare costs can be reduced by preventing the need for emergency care.
Improved overall well-being: Access to mental health resources can improve overall well-being, leading to increased engagement in education, work, and other meaningful activities.
Overall, providing mental health resources to homeless individuals can help address the complex and interconnected issues that contribute to homelessness and support individuals in achieving greater stability and well-being.
Execution Strategy
Our execution strategy incorporates proven methodologies, extremely qualified personnel, and a highly responsive approach to providing mental health services. Following is a description of the projected timeline and fees.
Resources Provided
Healing Spot Counseling Center has facilities to provide counseling services; however, services will be provided at the City of Richmond sites to facilitate accessibility to counseling services and the staff’s transportation system to and from the encampment.
Timeline for Execution
Key projected dates are outlined below to demonstrate the flow of service delivery. We can collaborate on dates that are best for the organization.
Description Start Date End Date Duration
Resident Assessments (Mon & Wed) 7/10/2023 7/12/2023 1.5 hours per client Resident Counseling Sessions (Mon & Wed) 7/17/2023 7/19/2023 1 hour per client Monthly Group Sessions 7/24/2023 1/8/2024 1 hour per group DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129 3 Mental Health Support Fees
These fees are based on the hours required to provide services to encampment residents weekly.
Mental Health Support Fees
Group Orientation (2 hours) $500
Resident Assessments x 15 persons $3000
Resident Counseling Sessions (1 x weekly) 6 months $5000 Monthly Group Sessions (6 months) $1400
Total $9900
It is recommended that training and mental health support be on different contracts. This will allow for a more customized approach to mental health support, which can be altered to fit the demand of encampment residents.
CONCLUSION
We look forward to working with the City of Richmond in supporting the Castro Encampment Resolution Project to help staff achieve its goal of safety and competency in working with a population vulnerable to mental health challenges. We are confident we can meet the challenges ahead and stand ready to partner with you to deliver effective mental health support. We are open to hearing any ideas you may have regarding the proposal and can customize the contract to meet your needs.
Please email Miya Moore-Felton at your convenience: [email protected] or by phone at (925) 434-8506. We will be in touch with you next week to arrange a follow-up conversation on the proposal.
I appreciate your consideration,
Miya Moore-Felton
Chief Executive Officer, Healing Spot Counseling Center, Inc.
DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129 For the Contract between the City of
Richmond and
Short Form Contract Supplemental Conditions/EJ/TE 11-30-07
SUPPLEMENTAL CONDITIONS
1. It is expressly agreed that Contractor is to perform the services described herein as an independent contractor pursuant to California Labor Code Section 3353, under the control of the City as to the result of his work only but not as to the means by which such result is accomplished. Nothing contained herein shall in any way be construed to make Contractor or any of its agents or employees, an agent, employee or representative of the City. Contractor shall be entirely responsible for the compensation of any assistants used by Contractor in providing said services.
2. This Contract shall automatically terminate when the total accumulated compensation paid or due to Contractor under this Contract reaches $10,000.00. The City shall not be responsible for compensating Contractor for any amounts in excess of $10,000.00.
3. Either the City or Contractor may cancel this Contract at any time upon giving the other party ten (10) days' written notice of such cancellation. In the event of cancellation, the City shall be liable only to pay to the Contractor compensation for services rendered up to the date of the Contract's cancellation.
4. Contractor shall not assign th is Contract, or any part thereof, or any right of the Contractor hereunder without the prior written consent of the City.
5. Contractor shall indemnify , defend and hold the City harmless from and against all claims, demands and causes of action for injury, death or damage to any person or property which may arise or result from the contractor's performance of this Contract or from acts or omissions of any person(s) employed by Contractor.
6. Contractor agrees to observe a ll applicable laws including, but not limited to, the provisions of Section 2.28.030 of the Municipal Code of the City of Richmond obligating every contractor or subcontractor under a contract or subcontract to the City of Richmond for public works or for goods or service to refrain from discriminatory employment practices on the basis of the race, color, sex, sexual orientation, religious creed, national origin or ancestry of any employee of, or applicant for employment with, such contractor or subcontractor.
7. Pursuant to Chapter 7.04 and Section 7.04.160 (f) of the Municipal Code of the City of Richmond, if this Contract does not exceed five thousand dollars ($5,000.00) and if the Contractor does not make more than five thousand dollars ($5,000.00) within the City of Richmond during the fiscal year, then the Contractor shall be exempt from obtaining a City of Richmond business license.
8. If this Contract does exceed five thousand doll ars ($5,000.00), or if Contractor does make more than five thousand dollars ($5,000.00) within the City of Richmond during the fiscal year, then a City of Richmond business license shall be obtained before any payment under this Contract shall be authorized and the business license must be kept current during the term of this Contract for payments to continue to be authorized.
Healing Spot Counseling Center, Inc.
DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129 For the Contract between the City of
Richmond and
Short Form Contract Supplemental Conditions/EJ/TE 11-30-07
SPECIAL CONDITIONS
Healing Spot Counseling Center, Inc.
The Supplemental Conditions of the Short Form Contract are hereby amended to include the following modifications:
Sanctuary City Contracting Ordinance (SCCO). The Richmond Sanctuary City Contracting Ordinance No. 12-18 prohibits the City from granting and or retaining contracts with any person or entity that provides Data Broker or Extreme Vetting services to the U.S. Immigration and Customs Enforcement Division of the United States Department of Homeland Security (“ICE”). Contractor must submit the Sanctuary City Compliance Statement, attached hereto as Exhibit G, prior to the execution of this Agreement.
DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129 For the Contract between the City of
Richmond and
Short Form Contract Insurance Provisions/EJ/TE 11-30-07
INSURANCE PROVISIONS
During the entire term of this Contract and any extension or modification thereof, the CONTRACTOR shall keep in effect insurance policies meeting the insurance requirements specified in the insurance provisions which are attached hereto and incorporated herein by this reference.
Healing Spot Counseling Center, Inc.
DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129 ___ Exhibit F
___ Section 8
City of Richmond - Insurance Requirements - Type 2:
Professional Services
Type 2 – Page 1 of 3
Revised: September 2011
In all instances where CONTRACTOR or its representatives will provide professional services (architects, engineers, construction management, counselors, medical professionals, hospitals, clinics, attorneys, consultants, accountants, etc.) to the City of Richmond (City), the City requires the following MINIMUM insurance requirements and limits.
CONTRACTOR shall procure and maintain for the duration of the contract, agreement, or other order for work, services or supplies, 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 and the results of that work by the CONTRACTOR, its agents, representatives, employees or subcontractors. Maintenance of proper insurance coverage is a material element of the contract. Failure to maintain or renew coverage or to provide evidence of renewal may be treated by the City as a material breach of contract.
CONTRACTOR agrees that in the event of loss due to any of the perils for which it has agreed to provide Commercial General Liability insurance, CONTRACTOR shall look solely to its insurance for recovery.
CONTRACTOR hereby grants to CITY, on behalf of any insurer providing Commercial General Liability insurance to either CONTRACTOR or CITY with respect to the services of CONSULTANT herein, a waiver of any right to subrogation which any such insurer of said CONTRACTOR may acquire against the CITY by virtue of the payment of any loss under such insurance.
Original, signed certificates and original, separate policy endorsements, naming the City as an additional insured for general liability coverage, as well as a waiver of subrogation for Workers’ Compensation insurance, shall be received and approved by the City before any work may begin. However, failure to do so shall not operate as a waiver of these insurance requirements.
City reserves the right to modify or require additional coverages for specific risk exposures depending on scope of CONTRACTORS work.
Minimum coverage is detailed below. The policy limits of coverage shall be made available to the full limits of the policy. The minimum limits stated herein shall not serve to reduce the policy limits of coverage of CONTRACTOR.
Minimum Scope of Insurance – the following forms shall be provided and coverage shall be at least as broad as the following:
1. Insurance Services Office Commercial General Liability coverage (ISO Occurrence Form CG 0001), and including coverage for bodily and personal injury, property damage, and products and completed operations (if applicable).
2. Insurance Services Office Automobile Liability coverage (ISO Form CA 0001, Code 1, Any Auto).
3. Original and Separate Additional Insured Endorsement for General Liability (ISO Form CG 20 10 11/85 or its equivalent) with primary and non-contributory language.
4. Workers’ Compensation Insurance as required by the State of California including Employer’s Liability coverage.
5. Original and Separate Waiver of Subrogation for Workers’ Compensation insurance.
6. Professional Liability or Errors & Omissions Liability Insurance appropriate to the CONTRACTOR’s profession (if required.)
Required Coverage Minimum Limits
Workers’ Compensation and
Employers’ Liability
Statutory limits as required by the State of California including $1 million Employers’ Liability per accident, per employee for bodily injury or disease.
If CONTRACTOR is self-insured, provide a certificate of Permission to Self- Insure, signed by the California Department of Industrial Relations and Self- Insurance. If contractor is a sole proprietor (has no employees) than contractor must sign “Contractor Release of Liability” found at:
http://www.ci.richmond.ca.us/index.aspx?nid=61.
General Liability
(primary and excess limits
combined)
$2,000,000 per occurrence for bodily injury, personal injury and property damage. If the policy includes a general aggregate, either the general aggregate shall apply separately to this project, service or location or the minimum required aggregate limit shall be twice the per occurrence limit ($4 million aggregate limit).
Policy shall be endorsed to name the City of Richmond as an additional insured per the conditions detailed below.
DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129 ___ Exhibit F
___ Section 8
City of Richmond - Insurance Requirements - Type 2:
Professional Services
Type 2 – Page 2 of 3
Revised: September 2011
Automobile Liability $1,000,000 per occurrence for bodily injury and property damage.
PROJECT COST R EQUIRED LIMIT
$0 - $1 million $1 million p/o
$1 million - $5 million $2 million p/o
Over $5 million $5 million p/o
Professional Liability or Errors &
Omissions Liability –
Required for all professionals
including architects, engineers,
consultants, construction
management, counselors, medical
professionals, hospitals, clinics,
attorneys and accountants, & other
consultants as may be required by
the City.
Required Policy Conditions
Additional Insured Endorsement
Applicable to General Liability coverage.
The City of Richmond, its officers, officials, employees, agents and volunteers are to be named as additional insureds for all liability arising out of the operations by or on behalf of the named insured including bodily injury, deaths and property damage or destruction arising in any respect directly or indirectly in the performance of this contract.
ISO form CG 20 10 (11/85) or its equivalent is required. If the Contractor is supplying their product or providing a service then the endorsement must not
exclude products and completed operations
coverage. If it does, then CG 20 37 (10/01) is also required.
SAMPLE Endorsements can be found at
http://www.ci.richmond.ca.us/index.aspx?nid=61
.
Primary and Noncontributory The contractor’s insurance coverage must be primary coverage as it pertains to the City, its officers, officials, employees, agents and volunteers. Any insurance or self insurance maintained by the City is wholly separate from the insurance of the contractor and in no way relieves the contractor from its responsibility to provide insurance.
Waiver of Subrogation
Endorsement Form
Contractor’s insurer will provide a Waiver of Subrogation in favor of the City for Workers’ Compensation Insurance during the life of this contract.
SAMPLE Endorsements can be found at
http://www.ci.richmond.ca.us/index.aspx?nid=61.
Deductibles and Self-Insured
Retentions
Any deductible or self-insured retention must be declared to and approved by the City. At the option of the City either the insurer shall reduce or eliminate such deductibles or self-insured retention as respects the City or the CONTRACTOR shall procure a financial guarantee in an amount equal to the deductible or self-insured retention guaranteeing payment of losses and related investigations, claims administration and defense expenses.
Contractor is responsible for satisfaction of the deductible and/or self-insured retention for each loss.
A. M. Best Rating A:VII or Better. If the A.M. Best Rating falls below the required rating, CONTRACTOR must replace coverage immediately and provide notice to City.
Umbrella/Excess Liability Policies
If an Umbrella or Excess Liability Policy is used to meet the liability limits, coverage shall be as broad as specified for underlying coverage’s and cover those insured in the underlying policies.
DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129 ___ Exhibit F
___ Section 8
City of Richmond - Insurance Requirements - Type 2:
Professional Services
Type 2 – Page 3 of 3
Revised: September 2011
Claims-Made Policies
If any insurance policy is written on a claims-made form: 1) the retroactive date must be shown, and must be before the date of the contract or the beginning of contract work. 2) Insurance must be maintained and evidence of insurance must be provided for at least five (5) years after completion of the contract of work. 3) If coverage is canceled or non-renewed, and not replaced with another claims-made policy form with a retroactive date prior to the contract effective date, the Contractor must purchase an extended period coverage for a minimum of five (5) years after completion of contract work.
Subcontractors
CONTRACTOR
shall include all subcontractors as insured under its policies or shall furnish to the City for review and approval, separate certificates and endorsements for each subcontractor. All coverage for subcontractors shall be subject to all of the requirements stated herein.
CONTRACTOR agrees to defend and indemnify the City of Richmond for any damage resulting to it from failure of either CONTRACTOR or any subcontractor to take out or maintain the required insurance policies.
The fact that
insurance is obtained by CONTRACTOR, and/or CONTRACTOR’s subcontractors, will not be deemed to release or diminish the liability of CONTRACTOR, including, without limitation, liability under the indemnity provisions of this contract. Damages recoverable by CITY from CONTRACTOR or any third party will not be limited by the amount of the required insurance coverage.
Verification of Coverage
All original certificates and endorsements shall be received and approved by the City before work may begin .
The City of Richmond reserves the right to require complete, certified copies of all required insurance policies including endorsements affecting the coverage at any time.
Original insurance certificates and required policy endorsements shall be mailed or delivered to the Designated Project Manager for the City of Richmond.
Insurance certificates and endorsements may be faxed to the Designated Project Manger. However, CONTRACTOR must mail the original certificates and endorsements to Designated Project Manager once faxed.
Continuous Coverage
CONTRACTOR shall maintain the required insurance for the life of the contract. Should the CONTRACTOR cease to have insurance as required during this time, all work by the CONTRACTOR pursuant to this agreement shall cease until insurance acceptable to the City is provided. In the event that CONTRACTOR fails to comply with the City’s insurance requirements, the City may take such action as it deems necessary to protect the City’s interests. Such action may include but is not limited to termination of the contract, withholding of payments, or other actions as the City deems appropriate.
If services or the scope of work extend beyond the expiration dates of the required insurance policies initially approved by the City, CONTRACTOR must provide updated certificates and endorsements indicating that the required coverage, terms and conditions are still in place. Renewal certificates and updated endorsements shall be mailed to the Designated Project Manager.
Cancellation
CONTRACTOR shall ensure that coverage shall not be cancelled, reduced or otherwise materially changed except after thirty (30) days’ prior written notice has been given to the City.
Reporting Requirements
Any failure to comply with reporting or other provisions of the policies including breaches of warranties shall not affect coverage provided to the City, its officers, officials, employees or volunteers.
Consistent with Public Policy
The insuring provisions, insofar as they may be judged to be against public policy shall be void and unenforceable only to the minimum extent necessary so that the remaining terms and provisions herein may be consistent with public policy and thus enforceable.
DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129 Hiscox Insurance Company Inc.
Your Insurance Documents
Enclosed you will find the policy documents that make up your insurance contract with us.
Please read through all of these documents. If you have any questions or need to update any of your information please call us at 844-357-0840 (Mon-Fri, 7am-10pm ET).
Your insurance documents
Declarations Page
This contains specific policy information, such as the limits and deductibles you have selected.
Policy Wording
This details the terms and conditions of your coverage, subject to policy endorsements.
Endorsements
These documents modify the Policy Wording or Declarations Page. These include relevant terms and conditions as required by your state and are part of your policy.
Notices
These documents provide information that may affect your coverage such as optional terrorism coverage (if purchased) and other important items required by your state.
Application Summary
This is a summary of the information that you provided to us as part of your application. Please review this document and let us know if any of the information is incorrect.
Reporting a claim
Please inform us immediately if you have a claim or loss to report. Please have your policy number available, which can be found on the declarations page, so we can handle your call quickly. Contact us via the methods below or file a claim using our online form at https://www.hiscox.com/manage-your-policy/claims-center.
Email: [email protected]
Phone: 866-424-8508
Mail: Hiscox Claims Center
5 Concourse Parkway
Suite 2150
Atlanta, GA 30328
DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129 Declarations Page
DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129 HISCOX INSURANCE COMPANY INC. (A Stock Company)
104 South Michigan Avenue, Suite 600, Chicago, Illinois 60603 CGL D001 10 18 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © ISO Properties, Inc., 2000
Commercial General Liability Declarations
In return for the payment of the premium, and subject to all the terms of this Policy, we agree with you to provide the insurance as stated in this Policy.
Declaration effective from: July 28, 2023
Policy No.: P102.176.827.1
Named Insured: Healing Spot Counseling Center Inc.
Address: 5065 Deer Valley Road
Antioch, CA 94531
Email Address: [email protected]
Policy period: From: July 28, 2023 To: July 28, 2024
At 12:01 A.M. (Standard Time) at the address shown above.
Form of Business: Not for profit Corporation
Each Occurrence Limit: $2,000,000
Damage to Premises Rented to You Limit: $100,000 Any one premises Medical Expense Limit: $5,000 Any one person
Personal & Advertising Injury Limit: $2,000,000 Any one person or organization General Aggregate Limit: $2,000,000
Products/Completed Operations
Aggregate Limit:
Products-completed operations are subject to the General Aggregate Limit Supplemental Business Personal Property Floater
Coverage Limit:
$0
Supplemental Business Personal Property Floater
Coverage Deductible:
Not Applicable
All Premises You Own, Rent or Occupy
Premises Number:
1 Address: 5065 Deer Valley Road
Antioch, CA 94531
Total Premium: 381.00
Attachments: See attached Forms and Endorsements Schedule.
DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129 HISCOX INSURANCE COMPANY INC. (A Stock Company)
104 South Michigan Avenue, Suite 600, Chicago, Illinois 60603 CGL D001 10 18 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © ISO Properties, Inc., 2000
IN WITNESS WHEREOF, the Insurer indicated above has caused this Policy to be signed by its President and Secretary, but this Policy shall not be effective unless also signed by the Insurer's duly authorized representative.
President
Secretary
Authorized Representative
DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129 HISCOX INSURANCE COMPANY INC. (A Stock Company)
104 South Michigan Avenue, Suite 600, Chicago, Illinois 60603 INT D001 01 10 Page 1 of 1
Forms and Endorsements Schedule
Forms and Endorsements made part of this policy at time of issue:
CGL D001 10 18 - Commercial General Liability Declarations INT D001 01 10 - Forms and Endorsements Schedule
CG 00 01 12 07 - General Liability Coverage Form
CGL E5401 CW (03/10) - Definition of Employee
CGL E5403 CW (03/10) - Notice Information
CGL E5404 CW (03/10) - Exclusion - Personal Information CGL E5407 CW (03/10) - Exclusion - Professional Services CGL E5408 CW (03/10) - Cancellation Provision (14 Day Full Refund) CGL E5409 CW (03/10) - Right and Duty to Select Defense Counsel CGL E5421 CW (02/14) - Additional Insured - Automatic Status IL 00 17 11 98 - Common Policy Conditions
IL 00 21 09 08 - Nuclear Energy Liability Exclusion Endorsement (Broad Form) CG 00 68 05 09 - Recording and Distribution of Material or Information in Violation of Law Exclusion CG 21 41 11 85 - Exclusion - Intercompany Products Suits CG 21 46 07 98 - Abuse or Molestation Exclusion
CG 22 44 07 98 - Exclusion - Services Furnished By Health Care Providers Endorsement CG 21 57 07 98 - Exclusion - Counseling Services
IL 02 70 09 08 - California Changes - Cancellation and Nonrenewal CG 32 34 01 05 - California Changes
CGL E5402 CW (03/10) - Modified Waiver of Transfer of Rights of Recovery Against Others To Us CG 21 73 01 15 - Exclusion Of Certified Acts Of Terrorism CGL E1954 CW (05/20) - Asbestos - Exclusion
CGL E1975 CW (05/20) - Limitation of Coverage to Business Operations CG 21 32 05 09 - Communicable Disease Exclusion
INT N003 CW (01/19) - Policyholder Notice Electronic Delivery INT N001 CW (01/09) - Economic And Trade Sanctions Policyholder Notice DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129 Contractor Release of Liability
For Workers’ Compensation Coverage
TO: City of Richmond
City Department: _______________________________________ Contractor’sName: _______________________________________ Scope of Services: _______________________________________ I, ________________________, declare under penalty of perjury, that I am a sole proprietor, doing business as Healing Spot Counseling Center Inc. As such, I do not employ any employees.
I fully understand that if I hire any employees during the term of this contract, that I must abide by the laws and regulations of the State of California regarding Workers’ Compensation insurance. At such time, I will provide the City of Richmond evidence of such Workers’ Compensation coverage in compliance with the terms of this contract.
Should I fail to secure Workers’ Compensation coverage as required by the State of California, I will defend and indemnify the City of Richmond for any damage resulting to it from my failure to take out or maintain such insurance.
It is further understood and agreed that this release and assumption of risk is to be binding on my heirs and assigns.
Print Name:________________________________________________ Signature:______________________________ Date:________________ Healing Spot Counseling Center Inc.
Mental Health Services
Miya Moore-Felton
Miya Moore-Felton
6/24/2023
DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129 Letter 947 (Rev. 2-2020)
Catalog Number 35152P
Department of the Treasury Internal Revenue ServiceTax Exempt and Government EntitiesP.O. Box 2508Cincinnati, OH45201 THE HEALING SPOT COUNSELING CENTER INC5179 LONE TREE WAYANTIOCH, CA94531 Date:
03/21/2023
Employer ID number:
92-2866360
Person to contact:
Name: Customer Service
ID number: 31954
Telephone: 877-829-5500
Accounting period ending:
December 31
Public charity status:
170(b)(1)(A)(vi)
Form 990 / 990-EZ / 990-N required:
Yes
Effective date of exemption:
March 7, 2023
Contribution deductibility:
Yes
Addendum applies:
No
DLN:
26053476003733
DearApplicant:
We're pleased to tell you we determined you're exempt from federal income tax under Internal Revenue Code (IRC) Section 501(c)(3). Donors can deduct contributions they make to you under IRC Section 170. You're also qualified to receive tax deductible bequests, devises, transfers or gifts under Section 2055, 2106, or 2522. This letter could help resolve questions on your exempt status. Please keep it for your records.
Organizations exempt under IRC Section 501(c)(3) are further classified as either public charities or private foundations. We determined you're a public charity under the IRC Section listed at the top of this letter.
If we indicated at the top of this letter that you're required to file Form 990/990-EZ/990-N, our records show you're required to file an annual information return (Form 990 or Form 990-EZ) or electronic notice (Form 990-N, the e-Postcard). If you don't file a required return or notice for three consecutive years, your exempt status will be automatically revoked.
If we indicated at the top of this letter that an addendum applies, the enclosed addendum is an integral part of this letter.
For important information about your responsibilities as a tax-exempt organization, go to www.irs.gov/charities.
Enter "4221-PC" in the search bar to view Publication 4221-PC, Compliance Guide for 501(c)(3) Public Charities, which describes your recordkeeping, reporting, and disclosure requirements.
Sincerely,
Stephen A. Martin
Director, Exempt Organizations
Rulings and Agreements
DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129
CITY OF RICHMOND
Sanctuary City Compliance Statement
The undersigned, an authorized agent of Healing Spot Counseling Center Inc. _ (hereafter "Contractor"), has had an opportunity to review the requirements of City of Richmond Ordinance 12-18 (hereafter " Sanctuary City Contracting Ordinance " or "SCCO"). Contractor understands and agrees that the City may choose with whom it will maintain business relations and may refrain from contracting with any person or entity that provides Data Broker or Extreme Vetting services to the U.S. Immigration and Customs Enforcement Division of the United States Department of Homeland Security ("ICE"). Contractor understands the meaning of the following terms used in the SCCO:
a. " Data Broker" means either of the following:
i. The collection of information, including personal information about consumers, from a wide variety of sources for the purposes of reselling such information to their customers, which include both private-sector busmess and government agencies;
ii. The aggregation of data that was collected for another purpose from that for which it is ultimately used.
b. "Extreme Vetting" means data mining, threat modeling, predictive risk analysis, or other similar services."
Contractor understands that it is not eligible to receive or retain a City contract if at the time the Contract is executed, or at any time during the term of the Contract, it provides Data Broker or Extreme Vetting services to ICE.
Contractor further understands and agrees that Contractor' s failure to comply with the SCCO shall constitute a material default of the Contract and the City Manager may terminate the Contract and bar Contractor from bidding on future contracts with the City for five (5) years from the effective date of the contract termination.
By executing this Statement, Contractor certifies that it complies with the requirements of the SCCO and that if at any time during the term of the Contract it ceases to comply, Contractor will promptly notify the City Manager in writing.
Any person or entity who knowingly or willingly supplies false information in violation of the SCCO shall be guilty of a misdemeanor and subject to a $1,000 fine.
Based on the foregoing, the undersigned declares under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed this 26 _day of June _, 2023, at _, California.
Printed Name: MiYa Moore-Felton Title: chief Executive Offlcer/Director Signed: 'M^O. 'Mffff^&.-^eA^^ Date: 6/28/2023
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Business Entity: Healing Spot CounsHjing Center Inc.
Vendor SCCO Compliance Statement (Augt2020)
DocuSign Envelope ID: 98BFCADC-DCEA-45C3-A987-A97AA1785129