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Exhibit 14A: List of Subcontractors Region F FY / <br /> Provider: ('r"J't, �„tf S Provider Code: Oe 2- County C,cye,,r- J <br /> List each subcontractor in the chart below. A subcontractor is defined as an entity that has been contracted to do a job within the scope of the service provider's <br /> grant award. The subcontractor is accountable for the same requirements as the service provider, depending on the terms of the subcontract. Subcontractors <br /> must adhere to service standard requirements by the Division of Aging and Adult Services. Do not list vendors who provide services through a 'purchase of <br /> service'. These are services which do not follow prescribed service standards and are goods or services sold equally to all consumers. <br /> Subcontractor Type Agency Subcontracted Subcontractor Contact Name, Scope of the Subcontract(Briefly describe any service <br /> Name Non-Profit Service Name Address requirements that will be delegated to the subcontractor, e,g. <br /> For-Profit & Phone Number eligibility determination, service authorization, <br /> assessments/reassessments, preparation and delivery of <br /> Government meals, provision of a ride and driver/requirements, tasks on <br /> an In-Home Aide plan of care, aide competency testing, aide <br /> supervision,etc.) <br /> Aaron Jordan <br /> Punch s Diner For-Profit Congregate 550 Concord Parkway Concord, Preparation and delivery of meals to Congregate <br /> y Nutrition NC 28027 Nutrition sites <br /> 704-786-2222 <br /> Ruby Kumar <br /> University Adult Adult Day 1324 John Kirk Dr. <br /> Care, Inc. For-Profit Care/Health Charlotte, NC 28263 Provision of Adult Day Care/Health Services <br /> 704-510-0030 <br /> Susan Caudle <br /> Coltrane LIFE Adult Day 321 Corban Ave., SW <br /> Center, Inc. Non-Profit Care/Health Concord, NC 28025 Provision of Adult Day Care/Health Services <br /> 704-788-1215 <br /> Jule Conrad <br /> Interim Healthcare For-Profit In-Home 250 Branchview Dr. <br /> Provision of In-Home Aide Services Level II & III <br /> of the Triad, Inc. Services II & III Concord, NC 28025 <br /> 704-788-3483 <br /> Attest Statement: Providers utilizing subcontractors must provide assurance that both for profit and non-profit subcontractors are compliant with state and federal regulations. These assurances are <br /> the subcontractor:A)has not been suspended or debarred(G S. §143C-6-23:09NCAC03M), B)has not been barred from doing business at the federal level, C)is able to produce a notarized"State <br /> Grant Certification of No Overdue Tax Debts", D)has obtained all licenses,permit, bonds and insurance necessary for carrying out HCCBG Services. In addition, Non-Profit Subcontractors are <br /> registered as a charitable(501c3)organization with the federal government. <br /> 2 Provider Signature: - Title: Date: —_2 < <br /> Version 2016 Page of <br /> Attachment number 1 \n <br /> Version 2016 <br /> F-4 Page 117 <br />