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fy23 jcpc ATC Family Preservation agreement executedDocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 Wor"Ap- North Carolina Department of Public Safety Intensive Intervention - Program Agreement SECTION I A SPONSORING AGENCY AND PROGRAM INFORMATION FUNDING PERIOD: FY 22-23 DPS/JCPC FUNDING # (cont only) 865-XXXX COUNTY: New Hanover AREA: Eastern Area Multi -County: Yes Multi -Components No NAME OF PROGRAM: Alternatives to Committment: Family Preservation Program SPONSORING AGENCY: Coastal Horizons Center, Inc. SPONSORING AGENCY 615 Shipyard Blvd. PHYSICAL ADDRESS: Wilmington NC 28412 SPONSORING AGENCY 615 Shipyard Blvd. MAILING ADDRESS: Wilmington NC 28412 TYPE: Non -Profit (910) 515-1281 Fax: 1 (910) 202-5772 E-mail: niharris@coastalhorizons.org FEDERAL ID #156-0950370 Program Manager Name & Address (same person on signature page) Name: TOTAL COST OF COMPONENT ID # NAME OF PROGRAM COMPONENT PROGRAM TYPE Mailing Address: EACH COMPONENT 35291 Homebuilder's Family Preservation Home Based Family Counseling $ 81,108 Zip: Total cost of components: $ 81,108 Program Manager Name & Address (same person on signature page) Name: Nicole Harris Title: ATC Program Manager Mailing Address: 615 Shipyard Blvd. City: Wilmington Zip: 28412 Phone: (910) 515-1281 Fax: 1 (910) 202-5772 E-mail: niharris@coastalhorizons.org Contact Person (if different from program manager) Name: Joshua Main Title: IFPS State Consultant Mailing Address: 615 Shipyard Blvd. City: Wilmington Zip: 28412 Phone: (910) 524-6630 Fax: 1 (910) 202-5772 E-mail: jmain@coastalhorizons.org Program Fiscal Officer (cannot be program manager) Name: Jennifer Burns Title: Controller Mailing Address: 615 Shipyard Blvd. City: Wilmington Zip: 28412 Phone: (910) 343-0145 Fax: E-mail: jburns@coastalhorizons.org Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 SECTION I B PROGRAM COMPONENT DESCRIPTION COMPONENT ID # COMPONENT INFORMATION 35291 NAME OF COMPONENT: Homebuilder's Family Preservation BRIEF DESCRIPTION: Coastal Horizons provides intensive family preservation modeled off the Homebuilders Program that is highly successful at reducing out of home placement and providing support in times of crisis. This program eliminates existing service gaps in the continuum of care, while diversifying family centered treatment. The model requires caseloads to remain on average 3 families with ten hours of treatment per week completed by one professional. Services are rendered in the home for 4-6 weeks. Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 SECTION II COMPONENT STATISTICAL INFORMATION Multi -Components Yes Component Service Statistics PROGRAM COMPONENT INFORMATION - APPLICATION YEAR Component Name: Homebuilder's Family Preservation Component ID # 35291 What is this component's maximum client capacity at any given time? 3 Frequency of client contact per month: 12 Anticipated Average Length of Stay: 32 Days y Total Component Cost: $81,108 - by Estimated # to be served during funding period: 18 Estimated Average Cost Per Youth: $4,506 Actual number of youth admitted FY 20-21: 12 Applies to 12 Number of admissions Juvenile Justice Referred 100% of total admissions continuation 0 Number of admissions Law Enforcement Referred 0% of total admissions programs only. 0 Number of admissions District Court Referred 0% of total admissions Actual number served FY 20-21: 12 Form structure last revised 01/09/2012 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 SECTION III COMPONENT SUMMARY NAME OF COMPONENT: Homebuilder's Family Preservation 1. Statement of the Problem: In concise terminology, describe how the program will address continuum need(s) in the county. What are the Intensive Intervention needs the program intends to address? How will the program effectively serve juveniles at different levels of involvement with juvenile justice? Describe the gap in continuum of services for the population you will serve. Currently, in New Hanover and Pender County there are minimal evidence -based family counseling programs that are able to meet the network needs. New Hanover and Pender County's continuum of care for youth has gaps that keep youth and families from being safeguarded in their home communities. These gaps cause many Juvenile Justice involved families to be underserved or have behaviors that escalate until higher levels of care become needed. Many of these youth are disqualified from other enhanced levels of care for a myriad of reasons. The existing array of services is insufficient to meet the community-based family service needs of youth that do not qualify for mental services because they have not engaged in lower levels of care despite current high-risk behaviors or do not qualify based on sub -clinical mental health needs. Other gaps are families that need shorter periods of treatment. Most models of community-based services last for three to six months and employ models not supported by the Office of Juvenile Justice. A third, and critically impacted portion, are privately insured families. These families find themselves in a vulnerable position because their insurance companies do not cover the needed care or have deductibles that are too high for families to financially support their child's care. This leaves families being unable to comply with legal requirements because they are unable to meet their child's legal, behavioral, and mental health needs. This program has been able to meet youth on Post -Release and start engaging with the family prior to discharge. 2. Target Population: Describe the target population, including age, and the steps taken to insure that the target population is served. This program will serve youth from six to seventeen years old. The service will be open to male and female clients. The following clients will be appropriate for services: 1.Juvenile court referred youth, between the ages of 10 and 17, or older youth remaining under juvenile court jurisdiction, who have received a Level II disposition or Level III disposition, 2.Juvenile court referred youth that are high risk Level I adjudicated juveniles, with a Medium Risk or Medium/High Needs Score; 3.Juvenile court referred Level III youth re-entering the community on community placement or Post Release Supervision (PRS); 4.Juvenile court referred Level II youth who are most at -risk of a commitment to a YDC; 5. Juvenile court referred Level III or Level II youth re-entering the community from a residential or out of home placement. 3. Program Goal(s): Provide a brief statement to describe the overall purpose and effect of the program. The overarching goal of the program is to form an enhanced network of services to decrease delinquent and criminal behaviors, reduce unnecessary out -of -home placements, and offer concrete supports to families during time of needs. Coastal Horizons Center's mission is to promote choices for healthier lives and safer communities. This program will advance the mission of our organization by helping to ensure that some of the most marginalized juveniles have their mental health and behavioral health needs met. The developers of this model describe the goals as followed: HOMEBUILDERS® provides intensive, in-home crisis Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 SECTION III COMPONENT SUMMARY NAME OF COMPONENT: Homebuilder's Family Preservation intervention, counseling, and life -skills education for families who have children at imminent risk of placement in state - funded care. It is the oldest and best -documented Intensive Family Preservation Services (IFPS) program in the United States. Our goal is to prevent the unnecessary out -of -home placement of children through intensive, on-site intervention, and to teach families new problem -solving skills to prevent future crises. (Institute for Family Development, http://www.institutefamily.org/programs_IFPS.asp, 2015). 4. Measurable Objective(s): State in measurable terms (%) the intended effect of the program on specific undisciplined and/or delinquent behaviors. Example: anticipated reductions in court referrals, runaway behavior, disruptive behavior at school, anticipated improved school attendance and academic achievement. These objectives must include impact on participants. 80% Clients and families will demonstrate enhanced family functioning as a result of program services. 80% Clients will demonstrate improvement in replacement behaviors targeted in the individual service plan. 80% Clients will have no new adjudications for a complaint with an offense date after the admission date. 80% Clients will have no new complaints with an offense date after the admission date. 80% Clients successfully/satisfactorily completing the program will have no new adjudications in the 12 months following completion. 80% Clients successfully/satisfactorily completing the program will have no new complaints in the 12 months following completion. 80% Clients will reduce specific problem behaviors presented at referral and targeted in the individual service plan. 80% Clients will successfully or satisfactorily complete services as intended by the program design/service plan. 80% Clients will comply with the permanency plan as described in the individual service plan. 5. Elevated Risks and Needs: Describe how program services will address one or more of the elevated risk and needs listed in the most recent Intensive Intervention services Request for Proposals. Be sure to identify the specific risk and/or needs item(s) you will address. Per 2021 YASI Pre-screen: The most current Risk Comparison Data produced by the Division of Juvenile Justice shows New Hanover County trending higher than the state in many instances. For overall risk, New Hanover County is at 42.2% for moderate risk and 20.0% high risk in comparison to 38.9% and 16.7% respectively statewide. In reference to aggression, New Hanover County rates 12.6% with display of a weapon and 11.9% using a weapon, the state's rates are 9.1 % and 8.1 % respectively. Gang association is 13.3% for New Hanover County while the statewide rate is 8.5%. Alcohol/Drug Use in New Hanover County is almost 15% higher at 49.6% vs. 35.8% for the state. Family Mental Health and Juvenile Mental health rate 2-6% higher in New Hanover County with incidences of neglect, a youth being kicked out of their home, or running away ranging 5-6% higher than the state's rate. Per 2020 Risk Score Pre-screen: At 28.1 %, New Hanover County's rate of Risk Level V clients is almost 10% higher than the state's rate of 18.7%. New Hanover County's rate of Substance Abuse Needing Assistance/Treatment is 28.1 %, almost double the state's rate of 15.8%. Again, New Hanover County almost doubles the state's rate of Risk related to Peer Group with Gang Membership/Association at 13.7% vs. 7.5% statewide. Risk factors such as age of first complaint 12 years and over, referrals to court with 2-3 prior referrals, prior runaways, and prior assault range anywhere from 3% to 7% higher in New Hanover County than statewide. Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 SECTION III I COMPONENT SUMMARY NAME OF COMPONENT: I Homebuilder's Family Preservation These elevated risks can be addressed through the funding the Intensive Family Preservation model for this county. Programming will address risk and needs though Protective Factors such as concrete support in times of need, children's social and emotional competence, knowledge of parenting and child development, social connections and parent resiliency. The program focuses on stabilizing the crisis which put the family at risk. With a focus on making small but significant changes the ATC Program Manager uses the NCFAS assessment to address needs in the environment, parental capabilities, family interactions, family safety, child well-being, social/community life, and trauma. These factors affect risk related behaviors such as gang membership, alcohol and drug use, anger management and aggression. Specific strategies/intervention used are assessments, intensive family/individual counseling, client advocacy, case management, development/enhancement of parenting skills, referrals to other services and concrete services. This program will allow Court Counselors to have greater access to evidence -based treatment, with proven supports. Additionally, this program will give Court Counselors more access to an organization that they have an established partnership, and that has a wealth of resources housed in one agency. Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 SECTION IV COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: Homebuilder's Family Preservation 1. Location: List physical address(es) and describe where program services are delivered. The program is a community based program, and will primarily be delivered in the juvenile's home. Other acceptable service delivery places would include services delivered to meet the holistic needs of the child and/or family such as school, mental health facility, court, Division of Juvenile Justice facility, detention center, and other relevant collaborative services. The corporations physical address is 615 Shipyard Blvd, Wilmington, NC 28412. 2. Operation: Describe the daily/weekly schedule of program operation. The IFPS worker and their supervisor will adhere to the fidelity of the Homebuilders Model while providing routine and crisis care available twenty-four hours a day, seven days a week, 365 days per year. Each family will always receive minimally forty hours of face-to-face contact and have no less than on average three visits per week. The family will develop a service plan with their Child and Family team. The service plan will serve as the guiding mechanism for how their services will be tailored. Scheduled hours will be flexible to meet the needs of youth and families, and this will include night and weekend hours. For this reason, the worker will only carry two cases at a time per the fidelity of the model. 3. Staff Positions: Describe paid or volunteer position qualifications, (certifications, degrees, work experience) and position(s) responsibilities relative to this component. This time-limited service ultimately strives to help parents to have the skills to maintain their child in the home, and to develop the necessary skills to keep all parties safe. Our professionals are trained in ten hours of trauma focused Cognitive Behavioral Therapy, thirteen initial hours of North Carolina's System of Care Model, Motivational Interviewing, eleven hour of crisis intervention including eight hours of NCI, twelve hours of Person Centered Thinking, and multiple other related trainings for behavioral healthcare specialists. These trainings are intended to be the starting point of investment in the youth and families that we serve. The staff will additionally attend the first five day training offered through the state for the Homebuilders model. The funding will pay for .75 FTE time, dedicated ATC Program Manager position assigned to the program and another .25 FTE for an additional ATC Program Specialist in order to increase the number of clients served due to the level of need in the community. These staff members will have minimally a Bachelors, and preferably a Master's degree in a social services field and at least one year of relevant work or internship experience. The program will have an IFPS Supervisor and a IFPS State Consultant that are also trained in the model as well. Both the IFPS Supervisor and IFPS State Consultant will have a minimally a Bachelors degree, preferably a Master's degree along with three years experience working in the social service field. These positions will not be fully funded through this funding stream. Their responsibilities will be to assist the ATC Program Manager with on-call crisis situations, training needs, and supervision related to services, progress, issues, updates, and expectations of the program. Additionally, the department has a medical records and data collection administrative position that is connected to the program. This position is a High School Graduate with two years clerical experience or equivalent combination of education and experience along with experience with third party billing and the ability to work a flexible schedule. Responsibilities of this position include review of paperwork, filing of paperwork, and whenever needed other duties assigned. 4. Service Type SPEP: Describe implementation to include: Primary Service: Family Counseling; Secondary Service: None Evidence -Based Program Name: Homebuilder's Intensive Family Preservation Services Target Weeks: 4; Target Hours: 40 Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 SECTION IV I COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: I Homebuilder's Family Preservation 5. Admission Process: Describe the specific referral, screening, admission process (including timeline), the staff responsible for making decisions about admissions and reasons why a referral may not be accepted. Please describe: a) The specific referral, screening, and admission process, including at a minimum, the staff involved with the decision process. b) Interaction with Juvenile Court Counselors, other juvenile justice staff, and youth development centers, if applicable, including frequency, ongoing meetings, and other means of communication. Coastal Horizons Center values a collaborative process with referring youth that stresses the importance of timely admission, and to the correct level of care. Based on the Homebuilder's model, youth must be accepted into services and have their first appointment with a staff member within forty-eight hours of referral. If the program does not have any available positions then the referring Court Counselor will learn immediately that there are no available spaces, and when the next projected opening will occur. If a youth is being referred from Youth Development Center then the worker will attend the meeting and these youth will receive priority with spaces on the worker's caseload. Referrals are are given to the ATC Program Manager. The referral will consist of the NCDPS Juvenile Justice/JCPC Universal Referral Form, Family Data Sheet, YASI, and any assessments available that have been completed in the last 12 months. The screening process will ensure that the client is a level 2 or level 3 disposition and are within the ages of 12 to 18. ATC Program Manager will review referrals with IFPS State Consultant as received. Reasoning for why a referral is not accepted is if the youth in question is a level 1 or diversion contract, or under the age of 12 or over the age of 18. Coastal Horizons Center has been an active participant in local JJSAMHP committees as well as Juvenile Crime Prevention Councils. These meeting serve as a vehicle to continue communication with vested stakeholders, and understand the perception of services being offered. Our program intends to follow the expectations generally held by most JJSAMHP partnerships such as notifying the referring Court Counselor at time of referral, communication once an intake has been scheduled, providing any assessments or screens completed at intake within five days of intake, a pre -closure meeting is held one week from discharge, and termination and aftercare paperwork is shared within one week of discharge. 6. Termination Process: Describe the termination process, to include: a) The staff responsible for making decisions. b) The process for making the decision to terminate. c)The criteria for a successful termination, satisfactory termination, unsuccessful completion, and non-compliant termination. The Homebuilder's model requires a pre -closure meeting to occur on the week of the twenty-first day of service. This is the time when a determination to extend to six weeks typically occurs. At this time, the service plan will be updated to reflect progress made and aftercare recommendations. A discharge summary will be made available one week from the discharge date or sooner as requested. The specialist will maintain open communication with the court counselor regarding the family's progress with the service. During the Pre -Closure meeting, open conversation will be had with all parties involved regarding termination. Successful termination requires the minimum number of hours have been completed (40), progress has been made towards all goals developed at the start of services, and no new complaints have been received. Satisfactory termination will be considered when the minimum of hours have been completed (40), progress has been Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 SECTION IV COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: Homebuilder's Family Preservation made in only one goal of multiple goals developed at the start of services, and there are no new complaints have been received. Unsuccessful termination will be considered when the minimum number of hours have not been completed (40), no progress made towards goals that were developed at the start of services, or if there are new complaints that require additional adjudication. Non-compliant termination will be considered when client absconds from home, or refuses to meet with specialist after at least 2 interventions to address attendance/engagement concerns. How are the Juvenile Court Counselor and/or other juvenile justice staff involved in the termination process? The court counselor is actively involved in the termination process. The court counselor is invited to the termination meeting with the juvenile and their family. The court counselor is provided with a copy of the closing letter, case closure form (indicates goals and contact information for referrals) and weekly progress form (indicates weekly contact hours and areas addressed), and a discharge summary within seven days of discharge. 7. Referring Agency Interaction: Describe the interaction with Juvenile Court Counselors and/or other juvenile justice staff, including how client progress will be communicated. During the duration of services the Court Counselor will receive at least weekly phone communication, all crisis or behaviors that impact probationary status will be communicated in a period not to exceed twenty-four hours, and face- to-face meetings will be accommodated as requested or as needed to coordinate care. 8. Intervention/Treatment: Describe specifically: What will the component do to address intensive intervention continuum needs and/or redirect inappropriate youth behavior? How will the component address the identified needs of the youth and family? What interventions will typically be utilized in this component? How will parents/guardians be involved? What is the therapeutic element within the service? The Institute for Family Development states "HOMEBUILDERS® also works with youth and their families to correct problems that contribute to delinquency, while allowing the youths to remain in the community. Staff help clients find the right school setting, attend classes regularly, adhere to curfews, comply with the court, participate in constructive activities with peers, and learn to manage anger and conflict without getting into trouble. Therapists also help parents learn to deal with the stress of raising a difficult adolescent (http://www.institutefamily.org/programs_lFPS.asp, 2015)." The model provides family and individual supportive counseling as appropriate to the education and licensure status of the staff. The model allows flexibility where to place emphasis between the child or caregiver, however, at least one caregiver must be actively involved in the services. The model's key elements are: Intervention at the crisis point: Services start when the families are in crisis. Client families are seen within 24-48 hours of referral. Treatment in the natural setting: Services take place in the client's home or the community where the problems are occurring and, ultimately, where they need to be resolved. Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 SECTION IV COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: Homebuilder's Family Preservation Accessibility and responsiveness: Specialists are on call to their clients 24 hours a day, 7 days a week. Families are given as much time as they need, when they need it. This accessibility also allows close monitoring of any dangerous situations. Intensity: Services are time-limited and concentrated in a period targeted at 4 weeks. The service is designed to resolve the immediate crisis, and teach the skills necessary for the family to remain together. Each family receives an average of 40 to 50 hours of direct service. Low caseloads: Maximum client capacity is 3 cases. This enables specialists to be accessible and provide intensive services. Low caseloads also allow therapists the time to work on specific psycho -educational interventions, as well as the basic hard service needs of the family. The services are concentrated to take advantage of the time when families are experiencing the most pain, and have the most motivation to change. Research -based interventions: Specialist utilize a range of research -based interventions, including crisis intervention, motivational interviewing, parent education, skill building, and cognitive/behavioral therapy. Flexibility: Services are provided when and where the clients wish. Specialists provide a wide range of services, from helping clients meet the basic needs of food, clothing, and shelter, to the most sophisticated therapeutic techniques. Specialists teach families basic skills such as using public transportation systems, budgeting, and where necessary, dealing with the social services system. They also educate families in areas commonly associated with counseling, such as child development, parenting skills, anger management, mood management skills, communications, and assertiveness. 9. Best Practice Model: Describe what evidence based/support model(s) or practice the program will use. North Carolina Child Welfare worked in partnership with Institute of Family Development to employ a state Intensive Family Preservation model based on the Homebuilders program. Our team works with Child Welfare to implement this program, and receive fidelity review with the child welfare state consultant. The Homebuilders model has stringent requirements that staff work with two families on average with the ability to only take a third family during the discharge week of an existing family. This heightened level of commitment to a small caseload ensures that families are creating strong therapeutic alliance, greater accessibility to their worker, and allow for progress at a much faster rate. The model is based on working with families for four weeks with the ability to extend to a maximum period of six weeks at the request of the referring agency in consultation with the worker. National Research has shown that this model is one of the most effective models to deliver home based family preservation services (Kirk, Raymond S., and Diane P. Griffith. 2003. "Intensive Family Preservation Services: Demonstrating Placement Prevention Using Event History Analysis." Social Work Research 28:5-18) and it is endorsed by the OJJDP website. Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 SECTION V Terms of Agreement This Agreement is entered into by and between Department of Public Safety (hereinafter referred to as DPS), and New Hanover County, (hereinafter referred to as the County), the County's Juvenile Crime Prevention Council (hereinafter referred to as the JCPC) and Coastal Horizons Center, Inc. (hereinafter referred to as the Sponsoring Agency). DPS, the County, the JCPC and the Sponsoring Agency do mutually agree as follows: Term of Agreement This Agreement shall become effective Jul 1, 2022 and shall terminate Jun 30, 2023. Payment to Sponsoring Agency All parties agree that services will be delivered as described in the approved Program Agreement and that funds will be disbursed in an amount not to exceed the amount $81108 for the term of this agreement, unless amended by an approved Program Agreement Revision. Availability of Funds: All parties to this Agreement agree and understand that the payment of the sums specified in this Program Agreement budget, or most recently approved Program Agreement Revision, is dependent and contingent upon and subject to the appropriation, allocation, and availability of funds for this purpose to DPS. Responsibilities of the Parties DPS shall: 1. Disburse funds monthly to County Governments, for payment to the Sponsoring Agency, from funds appropriated by the General Assembly; 2. Reserve the right to suspend payment to the County for any non-compliance of reporting requirements by the Sponsoring Agency set forth in the DPS JCPC Policy; 3. Immediately notify, in writing, the JCPC, County, and Sponsoring Agency (including the Board of Directors, if applicable), if payments are suspended and again once payments resume; 4. Pay only for work as described in the Program Agreement, or most recently approved Program Agreement Revision, provided by the Sponsoring Agency and approved subcontractors; 5. Provide technical assistance, orientation, and training to the Sponsoring Agency, the County and the JCPC; 6. Monitor the Sponsoring Agency's funded program(s) in accordance with DPS JCPC Policy 3. Operations: Program Oversight and Monitoring; and 7. Notify parties entering into this Agreement of all due dates in a timely manner in order for reports to be submitted by Form structure last revised 12/20/2013 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 the established due dates. The Sponsoring Agency shall: 1. Comply with all laws, ordinances, codes, rules, regulations, and licensing requirements that are applicable to the conduct of its business, including those of Federal, State, and local agencies having jurisdiction and/or authority; 2. Comply with all Federal and State laws relating to equal employment opportunity; 3. Keep as confidential and not divulge or make available to any individual or organization without the prior written approval of DPS any information, data, instruments, documents, studies or reports given to or prepared or assembled by the Sponsoring Agency under this Agreement; 4. Acknowledge that in receiving, storing, processing or otherwise dealing with any confidential information, it will safeguard and not redisclose the information, except as otherwise provided in this Agreement; 5. Comply with the DPS JCPC Policy and North Carolina Administrative Code procedures; 6. Secure local match, if applicable, pursuant to 14B NCAC 11 B.0105, for the approved DPS funds; 7. Create and adopt individualized written agency guidelines specific to the funded program, while also adhering to DPS JCPC Policy for the specific funded program type; 8. Ensure that state funds received are spent in accordance with the approved Program Agreement, or most recently approved Program Agreement Revision, and be accountable for the legal and appropriate expenditure of those state funds; 9. Maintain reports, records, and other information to properly document services rendered and outcomes; also maintain an ability to send and receive electronic communication; 10. Have the capacity to use the DPS electronic, internet-based system for tracking clients served; also maintain an ability to electronically sign required DPS documents; 11. Use generally accepted accounting procedures that guarantee the integrity of the expenditure of funds, and maintain reports, records, and other information to properly account for the expenditure of all State funds provided to the Sponsoring Agency; 12. When refunds are requested from the North Carolina Department of Revenue for sales and/or use taxes paid by the agency in the performance of the Program Agreement, or most recently approved Program Agreement Revision, as allowed by NCGS § 105-164.14(c), the agency shall exclude all refundable sales and use taxes from reportable expenditures submitted to the County and DPS; 13. Submit Program Agreement Revisions, Third Quarter Accounting, Final Accounting, and annual detailed expenditures through NCALLIES. These reports must be in accordance with the submission process as outlined in the DPS JCPC Policy and with the due dates established by DPS; 14. Make personnel, reports, records and other information available to DPS, the County, the JCPC, and/or the State Auditor for oversight, monitoring and evaluation purposes; Form structure last revised 12/20/2013 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 15. Submit any other information requested by DPS, the County, the JCPC, and/or the State Auditor; 16. Be responsible for the performance of all subcontractors as described in the Program Agreement or most recently approved Program Agreement Revision; 17. Indemnify, defend, and hold harmless DPS, the State of North Carolina, the County, the JCPC and any of their officers, agents and employees, from any claims of third parties arising out of any act or omission of the Sponsoring Agency in connection with the performance of the Program Agreement or most recently approved Program Agreement Revision; 18. Receive written permission and budgetary approval from DPS prior to using the Program Agreement, or most recently approved Program Agreement Revision, as a part of any news release or commercial advertising, and acknowledge DPS funding in partnership with the County; 19. Comply with DPS JCPC Policy 6: Operations: Program Eligibility for Funding regarding any trainings and requirements for the United States Department of Justice national standards to prevent, detect, and respond to prison rape under the Prison Rape Elimination Act (PREA) and any additional requirements in 14B NCAC 11 C 20. Be deemed an independent contractor in the performance of services described in the Program Agreement, or most recently approved Program Agreement Revision, and as such shall be wholly responsible for the services to be performed and for the supervision of its employees, interns, volunteers and subcontractors; and 21. Represent that it has, or shall secure at its own expense, all personnel required in performing the services as described in the Program Agreement, or most recently approved Program Agreement Revision. Such personnel shall not be employees of or have any individual contractual relationship with DPS. Sponsoring Agency and Use of Contractor(s)/Subcontractors The Sponsoring Agency may engage with independent contractors as needed to perform services or support services described in line item 190 the Program Agreement, or most recently approved Program Agreement Revision. When independent contractors are providing services the Sponsoring Agency must: 22. Upload a signed Contract for Professional Services (Form JCPC/PO 001 Contract for Professional Services Template) into NCALLIES once the Program Agreement or Program Agreement Revision is approved by DPS; 23. Be responsible for the performance of all contractors or subcontractors as described in the Program Agreement, or most recently approved Program Agreement Revision; 24. Hold any contractor or subcontractor to which the Sponsoring Agency provides State funds accountable for the legal and appropriate expenditure of State funds and require compliance with all applicable laws and DPS JCPC Policy; and 25. Ensure that all contractors or subcontractors provide all information necessary to comply with the standards set forth in the Program Agreement, or most recently approved Program Agreement Revision. The JCPC shall: Form structure last revised 12/20/2013 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 1. Ensure the Sponsoring Agency uses JCPC funds only for the purposes approved by DPS in the JCPC Program Agreement or most recently approved JCPC Program Agreement Revision; 2. Comply with the DPS JCPC Policy, the North Carolina Administrative Code procedures (14B NCAC 11 B), and N.C. G.S. §§ 1436-845 to 851; 3. Review and locally approve Program Agreements, Program Agreement Revision(s), and Third Quarter Accounting and submit information to the County in a timely manner to meet due dates established by DPS; 4. Submit any other information requested by the County or DPS; and 5. Monitor the Sponsoring Agency's currently funded JCPC program(s) in accordance with DPS JCPC Policy 3. Operations: Program Oversight and Monitoring. Reference: 14B NCAC 118.0202 and DPS JCPC Policy (policies 1, 3, 7, 8, 9, 10 and 11). The County shall: 1. Ensure the Sponsoring Agency is appropriately licensed when applicable, and either a local public agency, a 501(c) 3 nonprofit corporation or local housing authority (applicable only to the JCPC funding process); 2. Use funds only for the purposes approved by DPS in the Program Agreement, or most recently approved Program Agreement Revision; 3. Disburse funds monthly and oversee funds to the Sponsoring Agency in accordance with 14B NCAC 11 B.0108; 4. Comply with the DPS JCPC Policy and North Carolina Administrative Code procedures (14B NCAC 11 B); 5. Review and locally approve Program Agreement Revisions received from the Sponsoring Agency for final approval from DPS; and 6. Review and locally approve Third Quarter and Final Accounting forms for the JCPC and all funded programs according to the procedures and due dates established by DPS. Reference: 14B NCAC 11 B.0108; DPS JCPC Policy (policies 8 and 9). Headings: The Section and Paragraph headings in these General Terms and Conditions are not material parts of the agreement and should not be used to construe the meaning thereof. Choice of Law: The validity of this Program Agreement and any of its terms or provisions, as well as the rights and duties of the parties to this Program Agreement, are governed by the laws of North Carolina, including the relevant provisions of G.S. Chapter 143B, Article 13, Part 3, Subpart F, and the Rules of 14B NCAC Chapter 11. The parties, by signing this Program Agreement, agree and submit, solely for matters concerning this Program Agreement, to the exclusive jurisdiction of the courts of North Carolina and agree, solely for such purpose, that the exclusive venue for any legal proceedings shall be Wake County, North Carolina. The place of this Program Agreement and all transactions and agreements relating to it, and their situs and forum, shall be Wake County, North Carolina, where all Form structure last revised 12/20/2013 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 matters, whether sounding in Program Agreement or tort, relating to the validity, construction, interpretation, and enforcement shall be determined. Assignment: No assignment of the Sponsoring Agency's obligations or the Sponsoring Agency's right to receive payment hereunder shall be permitted. However, upon written request approved by the issuing purchasing authority, DPS may: (a) Forward the Sponsoring Agency's payment check(s) directly to any person or entity designated by the Program Manager, or (b) Include any person or entity designated by the Sponsoring Agency as a joint payee on the Sponsoring Agency's payment check(s). In no event shall such approval and action obligate DPS or County Government to anyone other than the Sponsoring Agency, and the Sponsoring Agency shall remain responsible for fulfillment of all Program Agreement, or the most recently approved Program Agreement Revision, obligations. Beneficiaries: Except as herein specifically provided otherwise, this Program Agreement shall inure to the benefit of and be binding upon the parties hereto and their respective successors. It is expressly understood and agreed that the enforcement of the terms and conditions of this Program Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to DPS, the County Government, and the Sponsoring Agency. Nothing contained in this document shall give or allow any claim or right of action whatsoever by any third person. It is the express intention of DPS and County Government that any such person or entity, other than DPS or the County Government or the Sponsoring Agency receiving services or benefits under this Program Agreement shall be deemed an incidental beneficiary only. Property Rights Intellectual Property: All deliverable items produced pursuant to this Program Agreement are the exclusive property of DPS. The Sponsoring Agency shall not assert a claim of copyright or other property interest in such deliverables. Physical Property The Sponsoring Agency agrees that it shall be responsible for the proper custody and care of any property purchased for or furnished to it for use in connection with the performance of this Program Agreement, or the most recently approved Program Agreement Revision, and will reimburse DPS for loss of, or damage to, such property. At the termination of this Program Agreement, the Sponsoring Agency, County Government, and JCPC shall follow the guidelines for disposition of property set forth in the North Carolina Administrative Code and DPS JCPC Policy 1. Operations: JCPC Operations. Reference: 14B NCAC 118.0110. Disbursements and Internal Controls Reversion of Unexpended Funds Any remaining unexpended funds disbursed by DPS to the County for the Sponsoring Agency must be refunded/ reverted back to DPS at the close of the fiscal year or upon termination of this Agreement. Accountability for Funds Form structure last revised 12/20/2013 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 Audit Requirement - Local Government or Public Authority Requirements Local Government or Public Authorities in accordance with N.C.G.S. § 159-34 must have an audit performed in conformity with generally accepted auditing standards. The audit shall evaluate the performance of a unit of local government or public authority regarding compliance with all applicable Federal and State agency regulations. This audit, combined with the audit of financial accounts, shall be deemed to be the single audit described by the "Federal Single Audit Act of 1984". Oversight Access to Persons and Records The State Auditor shall have access to persons and records related to all Program Agreements entered into by State agencies or political subdivisions in accordance with N.C.G.S. § 147-64.7. Additionally, as the State funding authority, DPS shall have access to persons and records related to all Program Agreements entered into by State agencies or political subdivisions. Record Retention Records shall not be destroyed, purged, or disposed of without the express written consent of DPS. State basic records retention policy requires all records to be retained for a minimum of five (5) years or until all audit exceptions have been resolved, whichever is longer. If the Program Agreement is subject to Federal policy and regulations, record retention may be longer than five (5) years since records must be retained for a period of three (3) years following submission of the final Federal Financial Status Report, if applicable, or three (3) years following the submission of a revised final Federal Financial Status Report. Also, if any litigation, claim, negotiation, audit, disallowance action, or other action involving this Program Agreement has been started before expiration of the five- year retention period described above, the records must be retained until completion of the action and resolution of all issues which arise from it, or until the end of the regular five-year period described above, whichever is later. No Overdue Tax Debt Not for profit organizations ONLY must comply with this section. This form must be uploaded in NCALLIES when submitting a Program Agreement. The Sponsoring Agency shall be responsible for the payment of all State, local, and Federal taxes. Consistent with N. C.G.S. § 143C -6-23(c), not for profit organizations shall file with DPS and the County a written statement completed by that Sponsoring Agency's Board of Directors or other governing body, stating whether or not the Sponsoring Agency has any overdue tax debts, as defined by N.C.G.S. § 105-243.1, at the Federal, State, or local level. This written statement, No Overdue Tax Debts, shall be completed by the Sponsoring Agency to certify when there are no overdue taxes. If the agency has overdue taxes, the Sponsoring Agency must notify DPS at the time a Program Agreement is submitted. Conflict of Interest Not for profit organizations ONLY must comply with this section. This form must be uploaded in NCALLIES when submitting a Program Agreement. Consistent with the N.C.G.S. § 143C -6-23(b), not for profit organizations shall file with DPS and the County, a copy of that Sponsoring Agency's policy addressing conflicts of interest that may arise involving the Sponsoring Agency's management employees and the members of its Board of Directors or other governing body. The policy shall address situations in which any of these individuals may directly or indirectly benefit, except as the Sponsoring Agency's employees or members of its Board or other governing body, from the Sponsoring Agency's disbursing of State funds and shall include actions to be taken by the Sponsoring Agency or the individual, or both to avoid conflicts of interest and the appearance of impropriety. The policy shall be filed before the County or DPS will disburse any funds. The Sponsoring Agency shall also complete the DPS Conflict of Interest Policy Statement (Form DPS 13 001) and upload the statement in NCALLIES along with and the Sponsoring Agency's policy addressing conflicts of interests. Form structure last revised 12/20/2013 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 Proof of 501(c)(3) Not for profit organizations ONLY must comply with this section. This form must be uploaded in NCALLIES when submitting a Program Agreement. Not for profit organizations must upload proof of the agency's 501(c)(3) status when submitting a program agreement in NCALLIES. Amendment: This Agreement may not be amended orally or by performance. Any amendment must be requested by the Sponsoring Agency through submission of a Program Agreement Revision and executed by duly authorized representatives of DPS, the County Government, JCPC, and Sponsoring Agency. Severability: In the event that a court of competent jurisdiction holds that a provision or requirement of this Program Agreement violates any applicable law, each such provision or requirement shall continue to be enforced to the extent it is not in violation of law or is not otherwise unenforceable and all other provisions and requirements of this Program Agreement shall remain in full force and effect. Termination for Cause: If, through any cause, the Sponsoring Agency shall fail to fulfill its obligations under this Program Agreement in a timely and proper manner, DPS shall have the right to terminate this Program Agreement by giving written notice to the Sponsoring Agency and specifying the effective date thereof. In that event, all finished or unfinished deliverable items prepared by the Sponsoring Agency under this Program Agreement shall, at the option of DPS, become its property and the Sponsoring Agency shall be entitled to receive just and equitable compensation for any satisfactory work completed on such materials, minus any payment or compensation previously made. Notwithstanding the foregoing provision, the Sponsoring Agency shall not be relieved of liability to DPS for damages sustained by DPS by virtue of the Sponsoring Agency's breach of this agreement, and DPS may withhold any payment due the Sponsoring Agency for the purpose of setoff until such time as the exact amount of damages due DPS from such breach can be determined. The filing of a petition for bankruptcy by the Sponsoring Agency shall be an act of default under this Program Agreement. Termination without Cause: DPS, the County Government, or the Sponsoring Agency may terminate this Agreement at any time and without cause by giving at least thirty (30) days advance written notice to the other parties. If this Program Agreement is terminated by DPS as provided herein, the Sponsoring Agency shall be reimbursed on a pro rata basis for services satisfactorily provided to DPS under this Program Agreement, or the most recently approved Program Agreement Revision, prior to Program Agreement termination. Waiver of Default: Waiver by DPS of any default or breach in compliance with the terms of this Program Agreement, or the most recently approved Program Agreement Revision, by the Sponsoring Agency shall not be deemed a waiver of any subsequent default or breach and shall not be construed to be modification of the terms of this Program Agreement unless stated to be such in writing, signed by an authorized representative of DPS, County Government, the JCPC, and the Sponsoring Agency. Force Majeure: Neither party shall be deemed to be in default of its obligations hereunder if and so long as it is prevented from performing such obligations as a result of events beyond its reasonable control, including, without limitation, fire, power failures, any act of war, hostile foreign action, nuclear explosion, riot, strikes, civil insurrection, earthquake, hurricane, tornado, or other catastrophic natural event, pandemic, or act of God. Survival of Promises: All promises, requirements, terms, conditions, provisions, representations, guarantees, and warranties contained herein shall survive the Program Agreement expiration or termination date unless specifically provided otherwise herein, or unless superseded by applicable Federal or State statutes of limitation. Entire Agreement: This Program Agreement (including any documents mutually incorporated specifically herein) represents the entire agreement between the parties and supersedes all prior oral or written statements or Form structure last revised 12/20/2013 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 agreements. END OF SECTION V — Terms of Agreement Form structure last revised 12/20/2013 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 SECTION VI: BUDGET NARRATIVE Alternatives to Committment: Family Preservation Program Fiscal Year FY 22-23 $35,256 Intensive Family Preservation Supervisor Item # Justification Expense In Kind Expense 120 IFPS Worker (1) ($22.60 per hour, 30 hours per week) $35,256 120 IFPS Supervisor ($25 per hour, 4 hours per week) $5,200 120 IFPS Worker (2) ($22.60 per hour, 10 hours per week) $11,752 180 IFPS Worker (1) fringe benefits (75% of their benefit package) $8,814 180 IFPS Supervisor's fringe benefits $1,500 180 IFPS Worker (2) fringe benefits (25% of their benefits package) $2,938 220 Flex funding spending averaging $300 per family as indicated by Homebuilder's model $5,400 260 Work supplies $1,000 310 Mileage reimbursement (38 cents for worker's personal vehicle) $1,750 320 Cell phone and WiFi expenses for staff specialist $2,300 390 5100 Administration Cost, Fair Share Portion, Program Assigned Cost (IFPS portion) $3,948 390 Initial and on-going professional development training $1,250 TOTAL $81,108 Job Title Annual Expense Wages Annual In Kind Wages Intensive Family Preservation Specialist (1) $35,256 Intensive Family Preservation Supervisor $5,200 Intensive Family Preservation Specialist (2) $11,752 TOTAL $52,208 Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 SECTION VII Program: Alternatives to Committment: Family Preservation Program Fiscal Year: FY 22-23 Number of Months: 12 I. Personnel Services 120 Salaries & Wages 180 Fringe Benefits 190 Professional Services" *Contracts MUST be attached Cash $65,460 $52,208 $13,252 In Kind Total $65,460 $52,208 $13,252 $0 II. Supplies & Materials $6,400 $6,400 210 Household & Cleaning 220 Food & Provisions 230 Education & Medical 240 Construction & Repair 250 Vehicle Supplies & Materials 260 Office Supplies and Materials 280 Heating & Utility Supplies 290 Other Supplies and Materials $5,400 $1,000 $0 $5,400 $0 $0 $0 $1,000 $0 $0 III. Current Obligations & Services $9,248 $9,248 310 Travel & Transportation $1,750 $1,750 320 Communications $2,300 $2,300 330 Utilities $0 340 Printing & Binding $0 350 Repairs & Maintenance $0 370 Advertising $0 380 Data Processing $0 390 Other Services $5,198 $5,198 IV. Fixed Charges & Other Expenses $0 410 Rental or Real Property $0 430 Equipment Rental $0 440 Service and Maint. Contracts $0 450 Insurance & Bonding $0 490 Other Fixed Charges $0 V. Capital Outlay $0 [This Section Requires Cash Match] 510 Office Furniture & Equipment $0 530 Educational Equipment $0 540 Motor Vehicle $0 550 Other Equipment $0 580 Buildings, Structure & Improv. $0 Total $81,108 $81,108 Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 SECTION VIII SOURCES OF PROGRAM REVENUE (ALL SOURCES) FY 22-23 New Hanover County Funding ID: 865-XXXX Sponsoring Agency: Coastal Horizons Center, Inc. Program: Alternatives to Committment: Family Preservation Program $81,108 DPS/JCPC Funds * This is the amount approved in your application 0% Local Match Rate Is the Local Match Rate 10%, 20% or 30%? County Cash (Specify Source) Local Cash (Specify Source) Local Cash (Specify Source) Local In -Kind (Specify Source) Other (Specify Source) Other (Specify Source) Other (Specify Source) Other (Specify Source) $81,108 TOTAL $0 $0 Required Local Match Match Provided by: gqDocuSigned 6/$/2022 798FE7A4BD9F419... Authorizing Official, Department of Public Safety Date Thefollowing signature certifies that this program agreement has been locally approved by the Board of County Commissioners. by: EDocuSigned olv�ItA wa�lnt) lln�, YR ('FOL 68/2022 / 9507FA3F06164E9... Chair, County Board of Commissioners or County Finance Director Date The following signature certifies that this program agreement has been locally approved by the Juvenile Crime Prevention Council. DocuSigned by: (� (hVr Itt.*" if 6/2/2022 4A2540C 3DDSE15D... Chair, Juvenile Crime Prevention Council Date Doc'u•Signed %t7l.L NMSC\ EN 6/2/2022 25A0561AAFD7453... Program Manager Date Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 PDepartment of the Treasury Wit S internal Revenue Service In reply refer to: 0248288031 CINCINNATI OH 45999-0038 Feb. 06, 2019 LTR 4168C 0 56-0950370 000000 00 00008433 in BODC: TE 035456 COASTAL HORIZONS CENTER INC 615 SHIPYARD BLVD WILMINGTON NC 28412 Employer ID number: 56-0950370 Form 990 required: Yes Dear Taxpayer: We're responding to your request dated Jan. 28, 2019, about your tax—exempt status. We issued you a determination letter in March 1971, recognizing you as tax-exempt under Internal Revenue Code (IRC) Section 501(c) (3). We also show you're not a private foundation as defined under IRC Section 509(a) because you're described in IRC Sections 509(a)(1) and 170(b)(1)(A)(vi). Donors can deduct contributions they make to you as provided in IRC Section 170. You're also qualified to receive tax deductible bequests, legacies, devises, transfers, or gifts under IRC Sections 2055, 2106, and 2522. In the heading of this letter, we indicated whether you must file an annual information return. If you're required to file a return, you must file one of the following by the 15th day of the 5th month after the end of your annual accounting period: - Form 990, Return of Organization Exempt From Income Tax - Form 990EZ, Short Form Return of Organization Exempt From Income Tax - Form 990-N, Electronic Notice (e -Postcard) for Tax -Exempt Organizations Not Required to File Form 990 or Form 990 -EZ - Form 990 -PF, Return of Private Foundation or Section 4947(a)(1) Trust Treated as Private Foundation According to IRC Section 6033(j), if you don't file a required annual information return or notice for 3 consecutive years, we'll revoke your tax-exempt status on the due date of the 3rd required return or notice. You can get IRS forms or publications you need from our website at www.irs.gov/forms-pubs or by calling 800 -TAX -FORM (800-829-3676). If you have questions, call 877-829-5500 between 8 a.m. and 5 p.m., DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 0248288031 Feb. 06, 2019 LTR 4168C 0 56-0950370 000000 00 00008434 COASTAL HORIZONS CENTER INC 615 SHIPYARD BLVD WILMINGTON NC 28412 local time, Monday through.Friday (Alaska and Hawaii follow Pacific time). Thank you for your cooperation. Sincerely yours, 1�9 Kim A. Billups, Operations Manager Accounts Management Operations 1 DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 New kianoverCourty NnRTHaCARO I -INA March 18, 2022 NEW HANOVER COUNTY JUVENILE CRIME PREVENTION COUNCIL 230 Government Center Drive Suite 195 Wilmington, North Carolina 28403 Ms. Pamela Stokes Lead Area Consultant Department of Public Safety 2241 Dickinson Avenue Greenville, NC 27834 Dear Ms. Stokes: The New Hanover County Juvenile Crime Prevention Council is pleased to commit to the Homebuilders Grant, submitted by Coastal Horizons Center. Inc., for an eighth year. Coastal Horizons is a leader in providing family counseling services. The agency offers a variety of mental health and wellness supports in the community. They are and have been a vital partner of the Division of Juvenile Justice. Historically the partnership between Coastal Horizons and the New Hanover County Juvenile Crime Prevention Council (JCPC) has been significant and productive. The agency has demonstrated the ability to initiate new programs through good leadership and collaborative partnerships with various agencies. The Alternatives to Commitment program provides Intensive Family Preservation Services that align with the mission of the JCPC. The mission of this service is to deliver immediate interventions for at- risk, adjudicated youth upon their return to the community in an effort to prevent their return to a Youth Development Center or another out -of -home placement. Involving and supporting the family is a crucial component of the program. Connections to community resources, goal setting, problem solving, skill building, and teaching replacement behaviors are a few of the strategies implemented. Coastal Horizons' Homebuilders Alternatives to Commitment program meets all the qualifications as outlined in the county Plan of Action. Without programs such as Homebuilders, many of the youth and their families would not have the opportunity or skills to successfully remain in the community and become productive citizens. Sin rely, HWbI trpening II Chief District Court Judge Chairman, New Hanover County Juvenile Crime Prevention Council DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 PENDER COUNTY JUVENILE CRIME PREVENTION COUNCIL March 14, 2022 Ms. Pamela Stokes Eastern Area Lead Consultant Department of Public Safety 2241 Dickinson Avenue Greenville, NC 27834 Dear Ms. Stokes: The Pender County Juvenile Crime Prevention Council is pleased to commit to the Homebuilders Grant, submitted by Coastal Horizons Center, Inc. Coastal Horizons is a leader in providing family counseling services. The agency offers a variety of mental health and wellness supports in the community. They are and have been a vital partner of the Division of Juvenile Justice. Historically the partnership between Coastal Horizons and the Pender County Juvenile Crime Prevention Council (JCPC) has been significant and productive. The agency has demonstrated the ability to initiate new programs through good leadership and collaborative partnerships with various agencies. The Alternatives to Commitment program provides Intensive Family Preservation Services that align with the mission of the JCPC. The mission of this service is to deliver immediate interventions for at -risk, adjudicated youth upon their return to the community in an effort to prevent their return to a Youth Development Center or another out -of -home placement. Involving and supporting the family is a crucial component of the program. Connections to community resources, goal setting, problem solving, skill building, and teaching replacement behaviors are a few of the strategies implemented. Coastal Horizons' Homebuilders Alternatives to Commitment program meets all the qualification as outlined in the county Plan of Action. Without programs such as Homebuilders, many of the youth and their families would not have the opportunity or skills to successfully remain in the community and become productive citizens. Respectfully submitted, Dee Turner Chairman, Pender County JCPC DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 COASTAL HORIZONS CENTER, INC. Pr-omotiogcLoiceslorltealduei-E es vldsafer•commuruties" Board of Trustees Conflict of Interest Policy A. Statement of Policy No board member shall use his or her position, or the knowledge gained there from, in such a manner that a conflict between the interest of Coastal Horizons Center, Inc. or any of its affiliates and the board member may arise. Each board member has a duty to place the interest of Coastal Horizons Center, Inc. foremost in any dealings pertaining to Coastal Horizons Center, Inc. and has a continuing responsibility to comply with the requirements of this policy. Board or committee members may not obtain for themselves, their relatives, or their friends a material interest of any kind from their association with Coastal Horizons Center, Inc.. If a board member has an interest in a proposed transaction with Coastal Horizons Center, Inc, in the form of a significant personal financial interest or in any organization involved in the transaction, or holds a position as trustee, director, or officer in any involved organization, he or she must make full disclosure of such interest before any discussion or negotiation of such transaction. Any board or committee member who is aware of a potential conflict of interest with respect to any matter coming before the board or committee shall not be present for any discussion of or vote in connection with the matter. B. Disclosure To ensure that the decision making process of the Board of Trustees of Coastal Horizons Center, Inc. is free from conflict of interest and appearances of conflict, the following procedures will be followed: 1) All Board members will file with the Administrative Office of the Corporation a statement(s) listing any person, firm, or organization by which they are employed or associated and through which a conflict of interest might reasonably be expected as a possibility. Such statements will be filed no later than 60 days after the board member takes office and will be reviewed annually by the Executive Committee of the board. 2) Any board member who perceives a potential conflict of interest, or the appearance of a conflict of interest regarding any issue before the board of Coastal Horizons Center, Inc., shall declare a conflict of interest and disqualify themselves from participation in discussion or voting of the issue in question. These reports will be reviewed by the Executive Committee, which will attempt to resolve any actual or potential conflict(s) and, in the absence of resolution, refer the matter to the Board of Trustees. C. Potential Conflict of Interest Statement I have read the statement of policy regarding conflicts of interest. To the best of my knowledge and belief, except as disclosed herewith, neither I nor any person with whom I have or had a personal or business relationship is engaged in any transaction or activity or has any relationship that may represent a potential competing or conflicting interest, as defined in the statement of policy. Further, to the best of my knowledge and belief, except as disclosed herewith, neither I nor any person with whom I have or had a personal, business, or compensated professional relationship intends to engage in any transaction, to acquire any interest in any organization or entity, or to become the recipient of any substantial gifts or favors that might be covered by the statement of policy regarding conflicts of interest. L,,w Pria e �' '. (� � " I '11� � /n / I , Sig aVlv tDate Board of Trustees Conflict of Interest Policy. doc//2/20/18 DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 Coastal Horizons Margaret Weller Stargell, January 19, 2022 President and CEO To: State Agency Head and Chief Fiscal Officer Corporate Headquarters Willie Stargell Office Park 615 Shipyard Blvd. Wilmington, NC 28412 Administration 910-790.0187 910.790.0189 Fax Open House Youth Shelter (920)39Z 6916 Rape Crisis Center (910)392-7185 New Hanover (910) 754.7949 Brunswick Om patient Treatment (Boo) 672-2903 (910) 343 014 5 New Hanover (910) 754-4515 Brunswick (9ro) 259-o668 PenJer Community Based FamilyScrvices (910) 202 3155 Horizons Health Primary Care {910) 202-3860 WHAT (910)790 9949 Colltinatim ofCare (9to) 216.6080 Prevention Services (910) 202.0840 Outdoor Adventure (910)392.7306 TASC (910) 762-5333 New Hanover TASC RCE, (2sz) 638-3909 Region 1 (910) 321 6793 Region z NC TASC Training Institute. (910) ].02-SSOo Our Children's Place (919) 904-4286 Recidivists Reduction Services (910) 202.5125 RESET (910) 762-5333 Certification: We certify that Coastal Horizons Center, Inc. does not have any overdue tax debts, as defined by N. C. G. S. 105-243.1, at the federal, State, or local level. We further understand that any person who makes a false statement in violation of N. C. G. S. 143C -6-23(c) is guilty of a criminal offense punishable as provided by N.C.G.S.) 143C -10-1b. Sworn Statement: Brad Hudson and Margaret Weller-Stargell being duly sworn, say that we are the Board Chair and President and CEO respectively, of Coastal Horizons Center of Wilmington in the State of North Carolina; and that the foregoing certification is true, accurate and complete to the best of our knowledge and was made and subscribed by us. We also acknowledge and understand that any misuse of State funds will be reported to the appropriate authorities for further action. Board Chair + R} W President and CEO Sworn to and subscribed before me on the day of the date of said certification. (Notary Signature and Seal) My Commission Expires: A�-3 ' G.S. 105-243.1 defines: Overdue tax debt. — Any part of a tax debt that remains unpaid 90 days or more after the notice of final assessment was mailed to the taxpayer. The term does not include a tax debt, however, if the taxpayer entered into an installment agreement for the tax debt under G.S. 105-237 within 90 days after the notice of final assessment was mailed and has not failed to make any payments due under the installment agreement." to rice/, C ar " e CARF - Internationai Accreditation for Quality wi1nv,Coastalhorizons.Org * CABHA -Critical Access Behavioral Health Agency — DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 D Moot � o_er►n_ .u�Nr of PVe WM NOT FOR PROFIT DPS CONFLICT OF INTEREST POLICY STATEMENT This document is only required from not for profit organizations ONLY: lir accordance with the N.C.G.S. 143C-6-23 (b), every Grantee shall f le with the State agency/Grantor a copy of the Grantee's agency policy addressing conflicts of interest that Wray arise involving the Grantee's rnanagenrent errrployees and the members of its board of directors or other governing body. The policy shall address situations in which any of these individuals Wray directly or indirectly benefit, except as the Grantee's employees or nrenrbers of its board or other governing body, from the Grantee's disbursing of State funds and shall include actions to be taken by the Grantee or the individual, or both to avoid conflicts of interest and the appearance of impropriety. Agency conflict of interest policy shall be submitted to the Department of Public Safety (DPS) to avoid any delay with the disbursement of DPS JCPC funds. The Grantee shall submit this form (Not for Profit DPS Conflict of Interest Policy Statement Form DPS 13 001) along with the agency's conflict of interest policy when applying for f rnding. Accordingly, no member or board member of the private, nonprofit entity may receive directly or indirectly, any funds received from the State of North Carolina, except for duly, authorized staff compensation and benefits, and reimbursement for expenses actually incurred in connection with the private, nonprofit entity's business and in accordance with final approved grant agreements. WHEREAS, (Name of entity) Coastal Horizons Center, Inc. desires to require its Board of Directors and managing employees to avoid conflicts of interest or the appearance of impropriety in the disbursement of State funds; THEREFORE, no member of the Board of Directors or staff members of said private, nonprofit entity shall participate in the solicitation, negotiation, formation, award, arbitration, modification, or settlement of any contract or grant funded in whole or in part by State funds or of any dispute arising under such contract or grant when the director or staff members stands to benefit, either directly or indirectly, from such grant or contract; PROVIDED, no member of the Board of Directors or staff members shall be deemed to benefit directly or indirectly from any contract or grant funded in whole or in part by State funds if he/she receives only the salary or stipend due to him/her in the normal course of employment with, or service to, said private, nonprofit entity. FURTHERMORE, said private, nonprofit entity has written conflict of interest policies and reporting procedures applicable to board members, staff members and volunteers who have any interest or any authority regarding the resources of the private, nonprofit entity. These policies have been communicated to board members, staff members and volunteers and full disclosure has been provided for any possible appearance of conflict of interest that may exist. Form DPS 13 001 Not for Profit DPS Conflict of Interest Policy Statement Form stricture last revised July 2020 NC Department of Public Safety Page I of 3 DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 DPS EWYMWEM OF PUBLIC SAFETY NOT FOR PROFIT" " DPS CONFLICT OF INTEREST POLICY STATEMENT The following serves to identify and document any personal interest staff members, officers, and members of the Board of Directors may have. This document is also to be used to disclose any transactions that may result in personal, financial, professional and/or political gain at the expense of DPS. The statement requires that all personal relationships that may inappropriately influence (bias) actions be disclosed. Relationships, be it personal, financial, professional acrd/or political are required to be disclosed to DPS. Conflict means a conflict or the appearance of a conflict betiveen the private interests and official responsibilities of a person in a position of trust. Persons in a position of trust include staff members or the Board of Directors. Private, nonprofit entities shall make full disclosure by notice in writing to the full Governing Board/Council all conflicts of interest, if "yes" is answered to ally of the following, see page 3: (Check all that apply) Form DPS 13 001 Not for Profit DPS Conflict of Interest Policy Statement Form structure last revised July 2020 NC Department of Public Safety Page 2 of 3 YES NO 1. A Board member is related to a staff member. ❑ 2. A staff member in a supervisory capacity is related to another staff member whom he/she supervises. ❑ X❑ 3. A staff member is related to another staff member. ❑ FX 4. A board member or staff member has or may have personal, financial, professional, and/or political gain at the expense or ❑ KI benefit of the private, nonprofit entity, 5. There is a business entity in which a staff, board, or family member participates that may be viewed as Laving direct or indirect ❑ KI influence over the private, nonprofit entity's business. 6. A staff, board, or family member may be viewed as having direct or indirect financial gain from personal or business ❑ ❑X investments/interest in real property held by that staff, board, or family member. 7. A staff or board member received honorarium or other compensation outside of the scope of employment/operations with ❑ the private, nonprofit entity that creates or appears to create bias. 8. A staff or board member secured employment with a competitor or other similar private, nonprofit entity. ❑ K 9. Ongoing, paid consulting work outside of the staff member's current employment or board member's with your private, ❑ [� nonprofit entity exists. Form DPS 13 001 Not for Profit DPS Conflict of Interest Policy Statement Form structure last revised July 2020 NC Department of Public Safety Page 2 of 3 DocuSign Envelope ID: 61447D32-9E3F-4AD5-AFEB-B12DC4C9B014 CWSJ MPARTMEMCW�8"� NOT FOR PROFIT DPS CONFLICT OF INTEREST POLICY STATEMENT 1. If "yes" is checked to any of the aforementioned items, the JCPC Program Manager and Board Chair must ensure details for any transaction that exists are described and attached to this form. 2. If this statement fails to list a transaction that may exist that is non-financial in nature, please attach details. 3. Details must include at least the name, and, address, or persons involved, and a description of the relationship and the transaction. Note: Failure to disclose any conflict of interest transaction that exists or is potential within your private, nonprofit entity may result in the cessation of any further DPS JCPC State funds. County: New Hanover County Agency's Name: (Legal Applicant) NIA Federal Tax ID #: 56-0950370 Private, Nonprofit Entity Name: Executive Director's Print Name: Sign Board Chair's Name: I Horizons Center, Inc. (Date of M© Sworn to and subscribed before me on the y of the date of said certification M. Cj Signature -Notary Public CHRISTINA M CARTER NOTARY PUBLIC NEW HANOVER COUNTY STATE OF NORTH CAROLINA MY COMMISSION EXPIRES O4-12- .0 oat ��4zz Date Forth DPS 13 001 Not for Profit DPS Conflict of Interest Policy Statement form structure last revised July 2020 NC Department of Public Safety Page 3 of 3 DocuSign Certificate Of Completion Envelope Id: 61447D329E3F4AD5AFEBB12DC4C9B014 Status: Completed Subject: DPS eSignature Request for New Hanover 865-12425 Alternatives to Committment: Family Preservation Pr Source Envelope: Document Pages: 30 Signatures: 4 Envelope Originator: Certificate Pages: 5 Initials: 0 DPS-DJJ Community Programs AutoNav: Enabled 3040 Hammond Business PI Envelopeld Stamping: Enabled Raleigh, NC 27603 Time Zone: (UTC -05:00) Eastern Time (US & Canada) djjdp.applicationsupport@ncdps.gov IP Address: 207.4.107.7 Record Tracking Status: Original Holder: DPS-DJJ Community Programs Location: DocuSign 6/2/2022 10:47:00 AM djjdp.applicationsupport@ncdps.gov Signer Events Signature Timestamp Nicole Harris [D—Si,"edly: Sent: 6/2/202210:47:02AM niharris@coastalhorizons.org (A N yvts Viewed: 6/2/2022 10:48:01 AM Security Level: Email, Account Authentication 25AO561AAFD7453 Signed: 6/2/2022 10:48:39 AM (None) Signature Adoption: Pre -selected Style Signed by link sent to niharris@coastalhorizons.org Using IP Address: 173.93.140.85 Electronic Record and Signature Disclosure: Accepted: 6/2/2022 10:48:01 AM ID:c9e45653-896d-4bda-8824-60e2d68004f9 J H Corpening II 11: Sent: 6/2/2022 10:48:41 AM julius.h.corpening@nccourts.org [D­Si,n1d R (tvFt,ln.tlni� N Viewed: 6/2/2022 6:08:52 PM Securit Level: Email Account Authentication 3DDSE15D4A2540C... Signed: 6/2/2022 6:09:02 PM Y 9 (None) Signature Adoption: Pre -selected Style Signed by link sent to julius.h.corpening@nccourts.org Using IP Address: 204.152.3.37 Electronic Record and Signature Disclosure: Accepted: 6/2/2022 6:08:52 PM ID: e4f30b2f-9f2b-4a87-9bOf-d95c06b73b89 Martha Wayne, Interim CFO a DOC"S'9netlbl Sent: 6/2/2022 6:09:04 PM mwayne@nhcgov.com C (�a+ IAX, �In VA l,r Viewed: 6/3/2022 8:24:25 AM Security Level: Email, Account Authentication 9507FA3F°6164E9... Signed: 6/8/2022 1:58:08 PM (None) Signature Adoption: Pre -selected Style Signed by link sent to mwayne@nhcgov.com Using IP Address: 70.63.86.17 Electronic Record and Signature Disclosure: Accepted: 6/3/2022 8:24:25 AM ID: 3e7a4f60-a039-456e-a297-5738beba714e Signer Events Signature Timestamp Cindy Porterfield sy dby: Sent: 6/8/2022 1:58:10 PM cindy.porterfield@ncdps.gov OED ""'� �'' Viewed: 6/8/2022 8:21:23 PM Director of Juvenile Community Programs 798FE7A4ED9F419.. Signed: 6/8/2022 8:21:34 PM NC Dept of Public Safety Signature Adoption: Pre -selected Style Security Level: Email, Account Authentication (None) Signed by link sent to cindy.porterfield@ncdps.gov Using IP Address: 45.37.201.178 Electronic Record and Signature Disclosure: Not Offered via DocuSign In Person Signer Events Signature Timestamp Editor Delivery Events Status Timestamp Agent Delivery Events Status Timestamp Intermediary Delivery Events Status Timestamp Certified Delivery Events Status Timestamp Carbon Copy Events Status Timestamp Witness Events Signature Timestamp Notary Events Signature Timestamp Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 6/2/2022 10:47:02 AM Certified Delivered Security Checked 6/8/2022 8:21:23 PM Signing Complete Security Checked 6/8/2022 8:21:34 PM Completed Security Checked 6/8/2022 8:21:34 PM Payment Events Status Timestamps Electronic Record and Signature Disclosure Electronic Record and Signature Disclosure created on: 4/3/2018 2:57:43 PM Parties agreed to: Nicole Harris, J H Corpening II, Martha Wayne, Interim CFO CONSUMER DISCLOSURE From time to time, NC Dept of Public Safety (we, us or Company) may be required by law to provide to you certain written notices or disclosures. Described below are the terms and conditions for providing to you such notices and disclosures electronically through the DocuSign, Inc. (DocuSign) electronic signing system. Please read the information below carefully and thoroughly, and if you can access this information electronically to your satisfaction and agree to these terms and conditions, please confirm your agreement by clicking the a€ -I agreea€TM button at the bottom of this document. Getting paper copies At any time, you may request from us a paper copy of any record provided or made available electronically to you by us. You will have the ability to download and print documents we send to you through the DocuSign system during and immediately after signing session and, if you elect to create a DocuSign signer account, you may access them for a limited period of time (usually 30 days) after such documents are first sent to you. After such time, if you wish for us to send you paper copies of any such documents from our office to you, you will be charged a $0.00 per -page fee. You may request delivery of such paper copies from us by following the procedure described below. Withdrawing your consent If you decide to receive notices and disclosures from us electronically, you may at any time change your mind and tell us that thereafter you want to receive required notices and disclosures only in paper format. How you must inform us of your decision to receive future notices and disclosure in paper format and withdraw your consent to receive notices and disclosures electronically is described below. Consequences of changing your mind If you elect to receive required notices and disclosures only in paper format, it will slow the speed at which we can complete certain steps in transactions with you and delivering services to you because we will need first to send the required notices or disclosures to you in paper format, and then wait until we receive back from you your acknowledgment of your receipt of such paper notices or disclosures. To indicate to us that you are changing your mind, you must withdraw your consent using the DocuSign a€ -Withdraw Consenta€TM form on the signing page of a DocuSign envelope instead of signing it. This will indicate to us that you have withdrawn your consent to receive required notices and disclosures electronically from us and you will no longer be able to use the DocuSign system to receive required notices and consents electronically from us or to sign electronically documents from us. All notices and disclosures will be sent to you electronically Unless you tell us otherwise in accordance with the procedures described herein, we will provide electronically to you through the DocuSign system all required notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you during the course of our relationship with you. To reduce the chance of you inadvertently not receiving any notice or disclosure, we prefer to provide all of the required notices and disclosures to you by the same method and to the same address that you have given us. Thus, you can receive all the disclosures and notices electronically or in paper format through the paper mail delivery system. If you do not agree with this process, please let us know as described below. Please also see the paragraph immediately above that describes the consequences of your electing not to receive delivery of the notices and disclosures electronically from us. How to contact NC Dept of Public Safety: You may contact us to let us know of your changes as to how we may contact you electronically, to request paper copies of certain information from us, and to withdraw your prior consent to receive notices and disclosures electronically as follows: To contact us by email send messages to: david.pozun@ncdps.gov To advise NC Dept of Public Safety of your new e-mail address To let us know of a change in your e-mail address where we should send notices and disclosures electronically to you, you must send an email message to us at david.pozun@ncdps.gov and in the body of such request you must state: your previous e-mail address, your new e-mail address. We do not require any other information from you to change your email address.. In addition, you must notify DocuSign, Inc. to arrange for your new email address to be reflected in your DocuSign account by following the process for changing e-mail in the DocuSign system. To request paper copies from NC Dept of Public Safety To request delivery from us of paper copies of the notices and disclosures previously provided by us to you electronically, you must send us an e-mail to david.pozun@ncdps.gov and in the body of such request you must state your e-mail address, full name, US Postal address, and telephone number. We will bill you for any fees at that time, if any. To withdraw your consent with NC Dept of Public Safety To inform us that you no longer want to receive future notices and disclosures in electronic format you may: i. decline to sign a document from within your DocuSign session, and on the subsequent page, select the check -box indicating you wish to withdraw your consent, or you may; ii. send us an e-mail to david.pozun@ncdps.gov and in the body of such request you must state your e-mail, full name, US Postal Address, and telephone number. We do not need any other information from you to withdraw consent.. The consequences of your withdrawing consent for online documents will be that transactions may take a longer time to process.. 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By checking the a€ -I agreea€TM box, I confirm that: • I can access and read this Electronic CONSENT TO ELECTRONIC RECEIPT OF ELECTRONIC CONSUMER DISCLOSURES document; and • I can print on paper the disclosure or save or send the disclosure to a place where I can print it, for future reference and access; and • Until or unless I notify NC Dept of Public Safety as described above, I consent to receive from exclusively through electronic means all notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to me by NC Dept of Public Safety during the course of my relationship with you.