Adult Group Care Provider Information

Thank you for expressing an interest in becoming a contracted provider with Clark County Social Services for the Adult Group Care program. The original solicitation has closed. However, interested applicants are able to apply for funding consideration at any time for the duration of the program through this process. Please review the Scope of Work to gain an understanding of the scope of this project, its services and specific regulations. All applications will be submitted through a Smartsheet Application, the required attachments must be uploaded to the Smartsheet Application.

To submit a complete Application Package, the following components must be provided:

Adult Group Care Smartsheet Application

• Attachment 1: Application Narrative
• Attachment 2: Organizational Chart
• Attachment 3: Financial Statements
• Attachment 4: State of Nevada, Bureau of Health Care Quality Compliance (HCQC) Audit Results, if relevant
• Attachment 5: Disclosure of Ownership (County-issued template)
• Attachment 6: W-9 (County-issued template)
• Attachment 7: Business License
• Attachment 8: Supplier Maintenance Form (County-issued template)
• Attachment 9: Statement to Comply with County Contract

Additional Instructions:

To receive a copy of the application, when submitting the Smartsheet Application, please click “Send me a copy of my responses” and a copy of your application will be emailed to the “Applicant Point of Contact Email” provided in the application.

If you have any questions related to this application process, please contact the Project Development Team at SSPDT@ClarkCountyNV.gov.

Attachment 1: Application Narrative

Please download the application template from the “Reference Library.” All sections of the application must be completed. If a section does not apply, please indicate that it is not applicable. Provide detailed responses throughout. There is no page limit; however, responses should be concise while still addressing each section thoroughly.

Attachment 2: Organizational Chart

Provide your agency’s organizational chart.

Attachment 3: Financial Statement

Financial Statements for the past three years to demonstrate the agency’s financial ability to complete this project. Profit / loss or balance sheets would be acceptable.

Attachment 4: State of Nevada, Bureau of Health Care Quality Compliance Audit Results, if relevant

Provide current audit results from the State of Nevada, Bureau of Health Care Quality Compliance (BHCQC), if any.

Attachment 5: Disclosure of Ownership

See the “Reference Library” for the County-issued Disclosure of Ownership template. For step-by-step instructions, please see the Disclosure Form – Example.

Attachment 6: W-9

See the “Reference Library” for the County-issued W-9 template.

Attachment 7: Business License

A. Clark County Business License is required if:

• A business is physically located in unincorporated Clark County, Nevada.
• The work to be performed is located in unincorporated Clark County, Nevada.

B. Register as a Limited Vendor Business Registration if:

• A business is physically located outside of unincorporated Clark County, Nevada.
• A business is physically located outside the state of Nevada.

The Clark County Department of Business License can answer any questions concerning determination of which requirement is applicable to your firm. It is located at the Clark County Government Center, 500 South Grand Central Parkway, 3rd Floor, Las Vegas, NV or you can reach them via telephone at (702) 455-4340.

You may also obtain information on-line regarding Clark County Business Licenses by visiting the website.

Attachment 8: Supplier Maintenance Form

See the “Reference Library” for the County issued template.

Attachment 9: Statement to Comply with County Contract

Please review the standard County contract here. Do not submit a copy of this contract. To indicate that your agency accepts the terms and conditions laid out in the County contract, please submit the following signed statement on agency letterhead:

“[AGENCY NAME] has no exceptions to the sample contract.”

The letter must be signed by an authorized agency representative.