Dayle McIntosh - Rancho Santa Margarita

CITY OF RANCHO SANTA MARGARITA 2015‐2016 COMMUNITY DEVELOPMENT BLOCK GRANT PUBLIC SERVICE GRANT APPLICATION APPLICATION DUE DATE ‐ 12:00 PM JANUARY 23, 2015 Submit 1 original application to: Mike Linares City of Rancho Santa Margarita 22112 El Paseo Rancho Santa Margarita CA 92688 Also submit this Application Form (MS Word format) by the due date/time to: [email protected] Only complete applications will be considered. Use the check list below to ensure your application package is complete. Ensure all required text fields and applicable boxes are completed or checked. To complete the application, click on applicable box to insert text or check mark; “Tab” from field to field. Avoid hard returns within text box. Narrative text fields are limited in space so provide concise responses. PLEASE DO NOT MODIFIED THE APPLICATION FORM Organization Name: Dayle McIntosh Center for the Disabled
Program Name: DMC South
CDBG Amount Requested: $2,500
...... Application (including Attachment A: Proposed Budget & Attachment B: Proposed CDBG‐Funded Personnel) SUBMIT THE FOLLOWING MATERIALS AS PDF FILES COPIED TO A CD‐ROM
...... Proposed Program Application or Intake Sheet
...... IRS Tax Exempt Documentation
...... Current Board of Directors Roster
...... Most Recent 990 Tax Filing .......Most Recent Financial Audit (and A‐133 Single Audit if applicable) Please do not submit testimonials, letters of support, or program literature.
APPLICANT GENERAL INFORMATION A. Organization Legal Name: Dayle McIntosh Center for the Disabled
B. Mailing Address: 24031 El Toro Road, Suite 320, Laguna Hills, CA 92653
C. Program Name: DMC South
D. Check the ONE category that best describes the proposed program Youth
Senior
Disabled Adults
Low/Mod General
Homeless
Fair Housing
Housing
E. Is this application submitted by a faith‐based organization?
F. Is this request for a New
or Existing
Yes
No
program?
G. Location of where service will be provided (i.e., specify if program is citywide, a street address, a school site, etc.): Citywide
H. Person to contact regarding this application: Name: Paula Margeson
Email Address: [email protected]
Telephone: (714)621-3300 ext. 339
I. Federal Tax ID Number: 95-3313707 Fax: (714)663-2094
DUNS Number: 05528468
J. Official Authorized to Sign Contracts and Expend Funds: Name: Paula Margeson Title: Executive Director
G:\Applications\Dayle McIntosh 2015‐2016 Public Service Grant Application.docx 1 12/2014 2. COMMUNITY NEED FOR PROGRAM A. Summarize the proposed program and the nature/extent of Rancho Santa Margarita’s (RSM) need for the program. Include information regarding the characteristics of persons to be served (e.g., age, disability, income situation, other distinguishing characteristics), and data that supports the unmet need for the proposed program in RSM. According to the American Communities Survey conducted by
Cornell University, 10% of Californians have significant disabilities. In Rancho Santa Margarita, this means
that almost 5,000 residents are disabled. Living with a major disability is challenging at best. Usually
individuals need some assistance with information, resources, and support services to maximize their quality of
life. The Dayle McIntosh Center provides this type of assistance. Recently, the agency leased offices in
Laguna Hills in order to offer a wide range of services to area residents, who are disabled. Referred to as DMC
South, the program will provide these services: benefits counseling and advocacy, independent living skills
training, acquisition and use of assistive technology, peer support, housing referral, location of part and full time
caregivers, mobility training, sign language interpreter referral, disability-related information and referral, and
youth transition services. Although most people with disabilities can clearly benefit from such services, many
are unaware that agencies like the Dayle McIntosh Center exist. This is primarily because the center lacks the
resources to conduct marketing campaigns or pay for costly advertising. The center is requesting public service
funds from Rancho Santa Margarita to identify and serve local residents with disabilities. Of those to be
assisted with grant funds, it is expected that 30% will be twenty years of age or younger; 60% will be between
the ages of twenty-one and fifty-four; and 10% will be fifty-five years of age or older; 74% will be white, 2%
will be black or African American, 13% will be Latino or Hispanic, 7% will be of Asian origin, and 4% will be
from other races; 50% will be male and 50% will be female. 80% will be in the lower income range and 20%
will be in the moderate range. Since the Dayle McIntosh Center is a cross-disability organization, any RSM
resident, who is disabled, will be eligible for assistance regardless of the type or origin of his or her disability.
B. Discuss if other organizations provide a similar service to RSM residents and how the proposed program differs or augments these similar services? Explain why you consider this program to be costs effective when compared to similar services provided by another agency. The Dayle McIntosh
Center is the only agency of its type in Orange County. Referred to as a center for independent living, the
agency is staffed and directed primarily by individuals with disabilities. While other organizations in the area
provide similar functions, the focus of the center is to aid people, who are disabled, to become and remain selfsufficient. DMC collaborates with other public and private entities to assure that a broad continuum of services
is available to the disability community and to avoid needless duplication of services. The center receives core
funding through the state and the U.S. Department of Education and conducts fund raising activities. Other
contracts and grants are also sought by the organization. These diverse funding sources make it possible for the
Dayle McIntosh Center to spread the cost of services among the various contributors. This practice will make
the provision of assistance in Rancho Santa Margarita extremely cost effective. Consumers are not charged a
fee for services
G:\Applications\Dayle McIntosh 2015‐2016 Public Service Grant Application.docx 2 12/2014 C. Provide the following information regarding the anticipated number of individuals to be served by the proposed program from 7/1/2015 - 6/30/2016:
1. How many unduplicated individuals regardless of city of residence will benefit from the proposed activity? 2000 Individuals
2. How many of the individuals listed above will be unduplicated RSM residents? 50 Individuals
3. Of the RSM residents listed above, how many will be assisted with requested CDBG funds? 50
Individuals
D. From the list below, select one HUD‐required “Objective” and one HUD‐required “Outcome” that will be addressed by the proposed activity. HUD Objectives Create a Suitable Living Environment: Activity designed to benefit the community, families, or individuals by addressing living environment issues. Provide Decent Affordable Housing: Housing activity designed to meet individual family or community housing needs. Create Economic Opportunities: Activity such as economic development or commercial revitalization that creates or expands job opportunities. HUD Outcomes Availability/Accessibility: Services, infrastructure, housing or shelter will be made available/accessible to Low‐ & Moderate‐Income people, including the disabled. Affordability: The activity will provide affordability for Low‐ & Moderate‐Income people including creation/maintenance of affordable housing, basic infrastructure or services. Sustainability (Promoting Livable or Viable Communities): The program/project will improve the community or neighborhoods by making them livable or viable by providing benefits to Low‐ and Moderate‐Income people. E. Regarding the “Outcome” selected above, describe how success & effectiveness of proposed services will be measured. Include definition of success/effectiveness, tools to measure program success/effectiveness, the % of individuals served that will met the success/effectiveness threshold & how clients will be tracked after they leave the program to measure outcome. If outcome measurements are not in place discuss steps to be taken to implement performance measurements.
DMC South will work toward the achievement of the HUD outcome to make Services, infrastructure, housing
or shelter available to Low & Moderate-Income people, who are disabled. This outcome will be accomplished
by offering information, resources, and direct assistance to RSM residents. At the time of initial contact, the
specific needs of consumers will be identified and a plan of action formulated. Often individuals will require
disability-related information and referral or assistance understanding laws, regulations, benefits, and services.
Others will require one or more services to reach desired goals. In such instances, an independent living plan
will be developed, which will structure the provision of assistance. The plan will define targeted goals, desired
outcomes, steps to be taken to reach goals and outcomes, time lines, and staff and consumer responsibilities.
The plan will be monitored by staff and activity will be detailed in ongoing case notes. The percentage of goals
and outcomes achieved will be tracked to determine levels of success and effectiveness. At the conclusion of
services, consumers will receive a satisfaction survey in which they will indicate the degree to which their needs
were met and their capacity for self-sufficiency increased.
G:\Applications\Dayle McIntosh 2015‐2016 Public Service Grant Application.docx 3 12/2014 3. ORGANIZATION CAPACITY AND EXPERIENCE A. Summarize your organization’s experience to carry out the proposed program. Include information regarding length of time providing service, professional qualification of staff (include license, academic credentials, etc.), and other relevant information. The Dayle McIntosh Center for the
Disabled was established in 1977 and obtained 501(3)© tax exempt status the next year. The service area of the
organization is all of Orange County. Two sites are maintained by DMC to promote access for consumers
countywide. One office is in Anaheim and the other is in Laguna Hills. The Dayle McIntosh Center meets the
standards and indicators set forth in the Rehabilitation Act of 1973, as amended, for the operation of centers for
independent living. Two primary purposes drive the organization: 1) To provide services that empower people
with disabilities to recognize options available to them, make informed choices, and control their own lives, and
2) To educate the general public about disability-related topics in order to promote the full integration of
individuals, who are disabled into the mainstream of society. Numerous programs have been developed by the
center to address identified needs in the disability population of Orange County. The guiding principle of the
organization is that any person with a disability, who has determination and resilience, and the opportunity to
obtain needed resources and skills, can become a success story. Seventy-five percent of the agency’s employees
have post-secondary degrees, however, licensing and certification are not required.
B. Has your agency received CDBG funding from the City of RSM in the past? Yes
No
C. Summarize your organization’s experience administering CDBG public service grant funds. Name of City or County Providing Prior CDBG $ Laguna Woods
Tustin
County of Orange
Year Funds Received CDBG Grant Amount 2010-2015
$5-10,000
Aging with Vision Loss
Prior to 2006
$unknown
Housing Assistance
Prior to 2006
$10-20,000
Annually
Homeless Prevention
Program Funded D. Are you requesting CDBG funding for this program from any other City or the County? Yes
No
If “Yes,” from whom and how much?
City/County CDBG Amount Requested Laguna Niguel
$TBD
Newport Beach
$TBD
$
E. Will volunteers, donated good/services, and/or fundraising activities be used to supplement the proposed program? Yes
No
Summarize these efforts. The Dayle McIntosh Center uses
volunteers in various functions dependent upon individual skills and experience. Examples include clerical
functions, internship in conjunction with specific course work, community outreach and education, and fund
raising. The board of directors is composed of community leaders, who donate their time and expertise in
governance of the organization. Occasionally, the center receives in-kind donations such as office supplies or
items for use in various program areas such as durable medical equipment recycling. G:\Applications\Dayle McIntosh 2015‐2016 Public Service Grant Application.docx 4 12/2014 F. Compliance with OMB Circular A‐133 (Single Audit): 1. In any one of the past 3 years, has your agency expended more than $500,000 in federal funds during a fiscal year? Yes No 2. During this year(s), did your agency prepare a Single Audit compliant with OMB Circular A‐133? Yes No If “Yes,” provide a copy of most recent Single Audit. If “No” explain why a Single Audit was not prepared. G:\Applications\Dayle McIntosh 2015‐2016 Public Service Grant Application.docx 5 12/2014 4. PROGRAM INFORMATION AND BUDGET A. Complete the following budget summary for the proposed program. 1. 2015‐2016 CDBG Grant Funds Requested: 2. Total 2015‐2016 Program Budget: 3. Total 2015‐2016 Budget for ALL programs offered by your agency:
$2,500
$194,762
$2,318,350
B. Outline how requested CDBG funds will be utilized (e.g., staff salaries, benefits; program supplies; insurance; direct client assistance, etc.). Ensure that Attachment A “Proposed Program Budget” is reflective of this outline. Rancho Santa Margarita, CDBG funds will be used for program infrastructure and
supplies, and to provide outreach to residents within their city.
C. Provide the following information regarding full‐time, part‐time, contract and volunteer staff that will be utilized to provide the proposed service. (If CDBG funds are requested for personnel costs, Attachment B “CDBG Funded Personnel” must be completed.) Full‐Time staff:
Contract staff:
3
n/a
G:\Applications\Dayle McIntosh 2015‐2016 Public Service Grant Application.docx Part‐Time staff:
Program volunteers: 6 5
2 part-time
12/2014 5. CLIENT INTAKE INFORMATION A. HUD requires that each organization providing services to individuals with CDBG public service grant funds document the size, race/ethnicity, and income of assisted households. Does the proposed program application/intake form collect this information? Yes
No
If “Yes,” how is the information documented? 1. Self‐Certification:
2. Analysis of household income documents such as tax returns/pay checks:
If “No,” how will this information be collected and/or reported to the City? Note: Income documentation is not required but requested for “presumed beneficiary” category clients. Per HUD regulations, presumed beneficiaries include: abused children, seniors (over 62 years of age), battered spouses, severely disabled adults, homeless persons, illiterate persons, persons with HIV/AIDS, and migrant farm workers. Documentation of “presumed beneficiary” status is required. B. Will the proposed program exclusively serve presumed beneficiaries? Yes
No If “Yes,” list the category Disabled
C. Submit a copy of the proposed program application/intake form with your original application submission package. G:\Applications\Dayle McIntosh 2015‐2016 Public Service Grant Application.docx 7 12/2014 6. CERTIFICATION I hereby certify that I am authorized to submit this application for CDBG public service grant funding provided by the City of Rancho Santa Margarita (“City”) by the Board of Directors of Dayle McIntosh
Center for the Disabled (“Agency”). If grant funds are granted, funds will be used solely to benefit low‐ and moderate‐income Rancho Santa Margarita residents. Agency understands that general liability, auto liability insurance, and workers compensation insurance are required and will be provided per terms of a grant agreement to be executed between the City and the Agency. Agency understands that grant funds are provided on a reimbursement basis and will provide appropriate documentation to substantiate expenditures submitted for reimbursement. Grant funds will be administered pursuant to this agreement and consistent with applicable federal regulations. If the Agency fails to serve eligible Rancho Santa Margarita residents during the term of the contract, or fails to substantially attain projected accomplishments (defined as at least 75% of projected number of persons to be served), Agency may be required to repay all or a portion of funds already disbursed to the Agency by the City and/or forego receipt of additional grant funds. Agency also certifies that it is in compliance with all local zoning/land use regulations and possesses all required licenses and permits to operate/provide program. Name: Paula Margeson
Title:
Executive Director
Original signature and date on file
Signature G:\Applications\Dayle McIntosh 2015‐2016 Public Service Grant Application.docx Date 8 12/2014 ATTACHMENT A PROPOSED 2015‐2016 PROGRAM BUDGET BUDGET CATEGORY Agency Administration Staff Salaries & Benefits Program Staff Salaries & Benefits Program Supplies Rent/Lease Communications Utilities Insurance Professional Services (Specify) expertise not found on staff
Other (Specify) Equipment Lease/Maintenance
Other (Specify) Printing/Postage
Other (Specify) Travel/Mileage
Other (Specify) Staff Development
Other Audit/Accounting TOTAL
CDBG $ OTHER $ TOTAL $ $0
$19,743
$19,743
$0
$111,877
$111,877
$200
$1,600
$1,800
$1,000
$28,232
$29,232
$300
$8,100
$8,400
$0
$400
$400
$300
$3,130
$3,430
$300
$4,200
$4,500
$0
$2,980
$2,980
$100
$1,100
$1,200
$200
$2,800
$3,000
$100
$1,100
$1,200
0
$7,000
$7,000
$2,500 $192,262 $194,762 List Source of “Other” Program Funds AMOUNT OF OTHER PROGRAM FUNDS SOURCE OF OTHER PROGRAM FUNDS ARE FUNDS ALREADY SECURED VIA CONTRACT? Federal
$154,000
Yes
No
Laguna Woods
$10,000
Yes
No
Other Cities
$7,500
Yes
No
State of California
$20,000
Yes
No
Fee for service/Fund raising
$4,762
Yes
No
TOTAL G:\Applications\Dayle McIntosh 2015‐2016 Public Service Grant Application.docx 9 $196,262 12/2014 ATTACHMENT B PROPOSED CDBG FUNDED PERSONNEL (Only list staff for which CDBG funding is requested) Not Applicable AGENCY ADMINISTRATION STAFF POSITION TITLE ANNUAL SALARY $
$
$
$
$
ANNUAL BENEFITS $
$
$
$
$
TOTAL COMPENSATION $
$
$
$
$
CDBG FUNDS REQUESTED $
$
$
$
$
% OF TIME POSITION IS DEDICATED TO RSM CDBG ACTIVITY %
%
%
%
%
PROGRAM STAFF POSITION TITLE ANNUAL SALARY $
$
$
$
$
ANNUAL BENEFITS $
$
$
$
$
TOTAL COMPENSATION $
$
$
$
$
CDBG FUNDS REQUESTED $
$
$
$
$
% OF TIME POSITION IS DEDICATED TO RSM CDBG ACTIVITY %
%
%
%
%
PROGRAM CONTRACT STAFF POSITION TITLE ANNUAL SALARY $
$
$
12/2014 ANNUAL BENEFITS $
$
$
10
TOTAL COMPENSATION $
$
$
CDBG FUNDS REQUESTED $
$
$
% OF TIME POSITION IS DEDICATED TO RSM CDBG ACTIVITY %
%
%
PDF 1
DMC Intake Form
Date
Primary Staff
Funding Source
Older Individuals Who Are Blind (OIB - consumer 55+ with vision loss):  Yes  No
First Name
Middle Initial ____
Last Name
Parent/Guardian Name
Relationship
Phone/Video Phone (VP) (
)
Phone 2 (
)
State
Zip
County
Address
City
Living arrangement (OIB consumers only):  Lives Alone  Lives with Others  Not Applicable
Email
EMERGENCY INFORMATION
Emergency Contact
Relationship
Phone
Cell
Email
Pertinent Medical
Medications
Allergies
Exclude from Mailing Lists? (If checked, will exclude consumer from receiving newsletter, event flyers, etc.)
Head of Household (Head of Household (HOH) filing status on your tax return if you are unmarried, have
cared for a dependent for over half the year, and paid more than half the cost of maintaining a home.)
PERSONAL INFORMATION
Date of Birth:
Veteran:
 No  Yes
If yes, Branch
DMC Intake Forms Updated 12.16.14
Years of Service
1
Independent Living Plan Status:  Signed  Waived
Gender:  Male  Female
ILP Target Date _________________
 Other
US Citizen:  Yes  No
Resident:  Yes  No
Ethnicity:  Hispanic/Latino
Card #
 Other (If Hispanic/Latino is checked, a race does not have to be selected)
Race: (mark all that apply):  Asian  Black or African American  Native Hawaiian or other Pacific
Islander  White  Unknown/Decline to respond
Marital Status:  Single  Married  Divorced  Widowed  Separated  Partner  Unknown
Housing Status:  Assisted Living  Dependent Family/Friend  Homeless  Independent
 Institution/Skilled Nursing Facility (SNF)  Group Home Transitional  Rent – Un-subsidized
 Rent - Subsidized (Subsidized - government sponsored assistance with housing costs)
Employment Status:  Unemployed  Not Employed, Seeking  Not Employed, Not Seeking
 Full Time  Part Time  Sheltered  Supported  Internship (paid)  Internship (unpaid)
 Transitional  Retired
Education Level:
 Below 8th Grade  9th – 11th Grade  High School Diploma Trade/Vocational  License/Certification
 Special Education  Some College  Bachelor’s Degree  Some Graduate  Master’s Degree
 Doctorate Degree  Outside of the U.S.  G.E.D.  High School Certificate of Completion
Contact Method:
 Standard
 Videophone
 Large Print
 E-Mail
Registered Voter:  Yes
No
 Braille
 Telephone or Text Message
 Decline to respond
Primary Language:
 English  Spanish  Vietnamese  American Sign Language (ASL)  Other
Income Source(s):  Employment  Unemployment  Family/Friend/Child Support
 Supplemental Security Income (SSI)  Social Security Disability Insurance (SSDI)
 Veterans Benefits  Social Security Retirement
 TANIF (Temporary Assistance for Needy Families Formerly ‘Welfare’)
 Aid to Families with Dependent Children (AFDC)  Pension  Unknown
Amount per Month: $
DMC Intake Forms Updated 12.16.14
2
Income Level (Yearly):  $0-5,000  $5,001 - $10,000  $10,001 - $20,000  $20,001 - $30,000
 $30,001 - $40,000  $40,001 - $50,000  $50,001 - $60,000  $60,001 +
DISABILITY RELATED INFORMATION
Primary Disability
Onset Date:
Disability Type:  Cognitive  Hearing  Mental/Emotional  Physical  Visual  Other
Additional Disability
Onset Date:
Disability Type:  Cognitive  Hearing  Mental/Emotional  Physical  Visual  Other
Additional Disability
Onset Date:
Disability Type:  Cognitive  Hearing  Mental/Emotional  Physical  Visual  Other
Additional Disability
Onset Date:
Disability Type:  Cognitive  Hearing  Mental/Emotional  Physical  Visual  Other
Visual Impairment Severity (OIB consumers only):  Not Applicable
 Totally Blind  Legally Blind  Severe Visual Impairment
Visual Impairment Major Cause (OIB consumers only):  Not Applicable
 Macular Degeneration  Diabetic Retinopathy  Glaucoma  Cataracts  Other
OTHER INFORMATION
Referred by
Referral Contact
DOR Counselor (if applicable)
Office:
DOR Authorization Number
Dates of Service
PROGRAM
 AB204  AB204 Assistive Technology Services (AT)  California Community Transitions (CCT/MFP)
 Fee for Service (FFS)  ILS Fee for Service (FFS)  OIB  RSA/710 South County
 Grant(s):
 Other
Increased Access Area (The lack of transportation, health care services or assistive technology as barriers to
independence may be identified by the consumer and/or by the service provider):
 Transportation  Health Care Services  Assistive Technology  No Increased Access Area
DMC Intake Forms Updated 12.16.14
3
Assistive Technology:
Is AT equipment needed?  No  Yes
If yes, please explain
The following has been completed:
a) Consumer Orientation ...........................................................................
 Yes  No
b) Clients Rights Agreement .......................................................................
 Yes  No
c) Consumer Grievance and Appeal Process .............................................
 Yes  No
d) Client Assistance Program (CAP)
........................................................
 Yes  No
e) Voter Preference Form ............................................................................
 Yes  No
f) Explanation of DMC Mandated and Confidentiality Reporting Requirements
 Yes  No
Notes:
DMC Intake Forms Updated 12.16.14
4
Consumer
I certify that the information I have provided regarding my disability and eligibility to receive DMC services
is true and accurate to the best of my knowledge, and that if requested by DMC staff, I will be able to
furnish documents supporting such eligibility.
_____
Date
Signature of Consumer
Parent/ Guardian (if consumer under 18yrs)
/
/
/
/
Date
It has been explained to me that all personal information that I provide to the Dayle McIntosh Center will
be kept confidential and may not be shared with anyone outside of DMC or our partner service agencies
without my written permission. However, if I reveal to DMC staff that I will hurt others, or myself I
understand that the staff person has a legal duty to report this to the appropriate authorities.
/
Signature of Consumer
/
Date
I have determined that this Consumer’s disability significantly impedes the Consumer’s functioning in the
community and that the Consumer can benefit from Independent Living services provided by DMC.
/
Signature of DMC staff
Date
Supervisor Signature
DMC Intake Forms Updated 12.16.14
5
/
Independent Living Plan (ILP)
Consumer Name
Date
Staff Member
Funding Source
ILP will be re-evaluated after 90 days if consumer’s case remains open.
Goal Type: Communication  Health Care Access  Residential  Vocational  Mobility
 Self-Care  Financial  Other:
Consumer Goal
Target date for completion
Service Provider
Target date for completion
Outcome:  Goal Met  Goal Continued  Goal Canceled
Outcome Date
Goal Type: Communication  Health Care Access  Residential  Vocational  Mobility
 Self-Care  Financial  Other:
Consumer Goal
Target date for completion
Service Provider
Target date for completion
Outcome:  Goal Met  Goal Continued  Goal Canceled
Outcome Date
Goal Type: Communication  Health Care Access  Residential  Vocational  Mobility
 Self-Care  Financial  Other:
Consumer Goal
Target date for completion
Service Provider
Target date for completion
Outcome:  Goal Met  Goal Continued  Goal Canceled
DMC Intake Forms Updated 12.16.14
6
Outcome Date
Review will be scheduled for (90 days from date of intake):
Consumer Status
 Completed Goals  Moved  Died  Withdrew  Other:
Consumer Signature:
Date:
DMC Staff Signature:
Date:
Supervisor Signature:
Date:
DMC Intake Forms Updated 12.16.14
7
Waiver of Independent Living Plan
I, _____________________understand that I have the right to develop an Independent Living Plan with
the help of a DMC Service Provider. I have chosen not to develop an Independent Living Plan at this
time.
Consumer Signature
Date
DMC Staff Signature
Date
DMC Intake Forms Updated 12.16.14
8
Consumer Grievance and Appeal Process and Procedure
As a Consumer of Dayle McIntosh Center, you have a right to appeal any decisions made
regarding the handling or closure of your case. If you disagree with the way in which your case is
being handled by any service provider, please follow these procedures to resolve your complaint:
1. Discuss the problem or grievance directly with the service provider with whom you have the
problem, to make sure that service provider is aware of the problem
2. If your problem or grievance remains unresolved after Step One, you can request a meeting
with the person’s immediate supervisor, to be held within five business days of receiving
your request.
3. If you are still dissatisfied after taking the first two steps, ask for an appointment with the
Program Manager to present a grievance, to be held within five business days of receiving
your request. It is helpful, but not required, to write your complaint down to be presented to
the Program Manager before your appointment.
4. If you are still dissatisfied after taking the first three steps, ask for an appointment with the
Executive Director to present your grievance, to be held within 15 business days of receiving
your request.
5. If you are still not satisfied with the outcome, you may request an appeals meeting with the
Personnel Committee of the DMC Board of Directors, to be held within 15 business days of
receiving your request. An appeals decision will be made within 30 days of meeting.
•
If you need assistance in writing your grievance due to a motor, visual, learning or other
disability, please contact Dayle McIntosh Center at (714) 621-3300.
If you prefer to make a complaint via an outside organization, you may call the Client
Assistance Program at 1- 800-776-5746 or 1-800-719-5798 TTY
Note: The Client Assistance program (CAP) was established in 1973 by Congress as an independent
advocacy service to advise clients and applicants of the benefits available under the Rehabilitation Act
and Title I of the ADA.
CAP can answer questions, help resolve issues and provide advocacy for clients and applicants of
Department of Rehabilitation and other disability agencies.
I have received and understand the above grievance procedure.
Consumer/Parent Guardian Signature
DMC Intake Forms Updated 12.16.14
Date
9
Clients Rights Agreement
As a consumer of Dayle McIntosh Center, you have the right to:
o Be treated with courtesy, dignity, and respect.
o Be served without verbal, emotional, sexual or physical abuse or harassment.
o Served without discrimination on the basis of race, religion, age, gender, national origin, sexual
orientation, disability, or any other basis prohibited by law.
o Given a full and complete explanation of all appropriate service options
o Provided services expeditiously, as permitted by DMC’s current workload.
o View your individual service file record.
o Appeal any decision DMC has made on your behalf
o Terminate services with DMC at any time.
As a consumer of Dayle McIntosh Center, you also have the responsibility to:
o Treat DMC staff with courtesy, dignity and respect.
o Refrain from any verbal, emotional, sexual or physical abuse or harassment of DMC staff.
o Demonstrate appropriate behavior at all times.
o Provide complete and accurate information.
o Keep DMC informed of changes to address, phone number, and any other relevant personal
information.
o Schedule and keep appointments.
o Cancel or reschedule appointments at least 24 hours in advance when conflicts occur.
o Follow through with all objectives in the ILP unless waived.
Signature of Consumer:
Date:
Signature of DMC Staff:
Supervisor Signature:
DMC Intake Forms Updated 12.16.14
10
CONSENT FOR RELEASE OF INFORMATION
Consumer’s Full Name:
Alternate Name(s): ___________________________________________________________
Address: ____________________________________________________________________
Phone: (
) ___________________
NOTICE: Under state law and state regulations, all information that you supply to the Dayle McIntosh
Center is maintained in files that are subject to inspection by the applicant/client/ consumer.
I, the undersigned, hereby consent to, request and authorize Dayle McIntosh Center staff to release to
applicable designated information regarding the above named person. I am aware that this information is
for the purpose of independent living services. I authorize the release of any or all medical, social,
psychological, educational information as specifically listed below. I consent to, request, and authorize
said Dayle McIntosh Center to release/receive the said information to organization/agency:
Agency/Person Name:
Address:
Contact Person(s)/Relationship:
Phone Number:
I hereby consent to and authorize Dayle McIntosh Center to:
☐ Obtain from you the following information:
☐ Release to you the following information:
☐ Name, Date of Birth, Age, Address, phone number
☐ Diversity or Ethnic data
☐ Financial information
☐ Medical or disability information
This Consent shall be Valid for (Choose One):
☐ 6 months for Independent Living Services
☐ 1 year for Vocational Services
Date of Expiration:
Consumer/Guardian Signature
Date
DMC Staff Signature
Date
DMC Intake Forms Updated 12.16.14
11
PDF 3
Dayle McIntosh Center for the Disabled
Board of Directors 2014/2015
Name
Richard Devylder
Office
President
Paula Dunn
Vice President
Michael Ryan
Eva Casas-Sarmiento
Treasurer
Secretary
Cindy McLeroy
Member at Large
Art Blaser
Member at Large
Daniel Holder
Member at Large
Ariel Martinez
Member at Large
Klye McIntosh
Member at Large
Outside Affiliation
Advisor, California Governor’s
Office of Emergency Services
Sign Language Interpreter,
California State Department of
Rehabilitation
Independent Financial Advisor
Disability Rights Attorney at
Law
Medically Retired – Former
Logistics Systems Manager for
ConAgra
Professor Of Political Science,
Chapman University
Consumer
Computer Instructor, Blind
Children’s Organization
Finance Director is with Amgen
Inc.