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DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 <br />EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION <br />ameliorate symptoms, lower dependence on tax dollars and improve quality of life for the person and the <br />family. Its chronic nature means life -long treatment and vigilance. People living with serious mental illness <br />need trusting relationships, social connections, supports, and opportunities to avert isolation, unnecessary <br />hospitalizations, homelessness, and involvement with the legal system. Assistance in navigating the complex <br />healthcare and benefits systems is essential. People living with serious mental illness need opportunities for <br />education and employment to mitigate the social and economic impact of mental illness. <br />In order to have quality staff, Club Nova is seeking to ensure even our part -time transportation staff have a <br />living wage. <br />f) Who is your target population of individuals to benefit from this program and how will they <br />be identified and connected with the program? <br />Club Nova works with Orange County adults living with serious mental illness (SMI), primarily <br />schizophrenia and bipolar disorder. All members are beneficiaries. Beneficiaries are identified <br />through outreach, community education, other providers and organizations, families, and members <br />of the community. Our referral process ensures that Club Nova is preserved for the intended <br />beneficiaries — adults living with serious mental illness. <br />g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program <br />Manager and credentials, describe training provided to volunteers, etc.) <br />All staff must have the following trainings in order to maintain our Mental Health License, be <br />accredited by CARF, and in order to bill for Medicaid services: <br />• CPR and First Aid —Annually <br />• Client Rights <br />• Confidentiality <br />• HIPAA <br />• Infectious Diseases and Bloodborne Pathogens <br />• Alternatives to Restrictive Intervention and Crisis Management <br />The following are our key staff related to the program and their credentials: <br />• Karen Kincaid Dunn, Executive Director, BA, QP, 32 years of direct mental health <br />experience <br />• Steven Warnock, Associate Director of Program, MDiv, QP, 10 years of direct <br />mental health experience <br />Volunteers go through a Club Nova orientation, and are trained directly by an Associate Director <br />and members. They are required to have confidentiality and Clubhouse Model trainings. <br />h) Describe the specific period over which the activities will be carried out and include an <br />implementation timeline. <br />Implementation Timeline: Club Nova has been fully operational for 29 years. <br />• We are open six days per week and all major holidays on the holiday. We are open 54 + hours per <br />week. <br />• Community Supports are provided on a daily, ongoing, and as needed basis. <br />PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 15 of 26 <br />