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Please provide the following information about your agency: <br />1. Date of Incorporation (Month/Year): August I 2014 <br />2. Agency's Purpose/Mission (no more than a few sentences): <br />Club Nova provides opportunities for individuals living with serious mental illness <br />(predominately schizophrenia, bipolar disorder, and major depression) to lead meaningful <br />lives of their choice in the community. Club Nova is an intentional, caring community <br />comprised of members and staff who work together as colleagues to directly address the <br />risks of serious mental illness and improve the health, education, housing, economic <br />stability, and quality of life of each member. Club Nova focuses on members' strengths <br />and potential rather than their illness. <br />3. Please provide a brief description of your organization's past achievements in carrying out similar <br />projects and evidence of successful record of meeting proposed budgets and timetables (no more than <br />100 words). <br />Club Nova has 32 years of experience providing the full range of Clubhouse Model <br />supports and opportunities. We are accredited through a rigorous process assuring <br />fidelity to the Model. This Model operates on proven standards and is replicated in 300 <br />communities worldwide. The Model is included in the SAMHSA registry for Evidence- <br />Based Practices and received the Conrad N. Hilton Foundation award for humanitarian <br />work alleviating human suffering. Club Nova recently received the GSK Impact Award for <br />outstanding achievement in improving community health. <br />We have a long-established record meeting budgets and timetables amidst perpetual <br />changes in the NC mental health system. <br />4. Living Wage: Does this agency pay permanent employees a minimum living wage? {Yes/ No) No <br />If yes, is this agency an Orange County Living Wage Certified Employer? __ <br />If no, please briefly explain. <br />Club Nova strives to pay our employees the living wage rate. All our full-time employees <br />are paid above the living wage. Additionally, Club Nova provides excellent health <br />insurance coverage for full-time employees with Club Nova paying 70% of the premium <br />and employees paying 30%. <br />We have four transportation positions that are .25 FTE ( -10 hours per week). The rates <br />of pay are $12.00 and $13.63. These rates of pay fall short of the living wage. With the <br />low Medicaid reimbursement rates and exclusions of services, it is a challenge to keep <br />all positions paid the living wage. <br />Schedule of Positions: #of FTE-Full-Time Paid Positons: 10 #of FTE-Part-Time Paid Positions: 2 <br />#of FTE-Full-Time Vacant Positons: 2 #of FTE-Part-Time Vacant Positions: 2 <br />ProgrClrn information Page 9 of 35 <br />I <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2