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08/08/1996 AgreementBAYSHORE MANOR A/K/A MONROE COUNTY HOME ASSISTED LIVING FACILITY FOR THE ELDERLY This agreement entered into this r day of ��6c!S 199 6 , by and between the County of Monroe, State of Florida, hereinafter called "COUNTY" and 4�Vi LY F•l ?FS {.th-r� , hereinafter called "RESIDENT", and JZ- ANNL-1 R-ARQt11J hereinafter called "RESPONSIBLE PARTY". W I T N E S S E T H: WHEREAS, RESIDENT desires to temporarily reside in the County facility known as Bayshore Manor, for a period of: � day(s) (NOT TO EXCEED THIRTY (30) DAYS) commencing on the g 711 day of A LI6 VST , 19 Q 6 , and terminating at day of 1I✓6 VJT .3 P•4 on the 19 (6 , and WHEREAS, COUNTY has reviewed RESIDENT'S application for admission to Bayshore Manor and has determined that RESIDENT is eligible for admission, now therefore, In consideration of the mutual covenants, promises and premises herein contained, the parties agree as follows: 1. Shall furnish room, board, linens and assistance with activities of daily living as may be required, based upon RESIDENT'S mental and/or physical limitations both at and subsequent to the time of admission. 2. Shall arrange for transportation of RESIDENT to his/her physician's office and/or arrange for RESIDENT'S transportation to hospital if such transportation is ordered by physician or if, in the opinion of the Director or his surrogate, RESIDENT'S condition so warrants. The RESPONSIBLE PARTY (as designated herein) will be immediately notified if RESIDENT requires hospitalization. 3. Shall make refunds on a per diem basis, commensurate with the date of discharge from Bayshore Manor, as detailed 2 2 2 in Section C of this AGREEMENT. Refunds will not be made for any days that personal belongings remain in RESIDENT'S room nor as long as there are outstanding expenditures for services received by RESIDENT. 4. Shall, in the event of closure of the facility for any reason, make a pro -rated per diem refund as of the date of such closure. Such applicable refund will be made within SEVEN (7) DAYS of closure, in compliance with Florida Statutes. S. Shall maintain no affiliation with any religious organization, except to provide assistance to RESIDENT in contacting such organization upon RESIDENT'S request. 6. Other Ph RIEWWWFITOWETIro Wow a WHO*) W1 I an mo -.jj 1. Shall provide all clothing, medication, and personal effects as required by RESIDENT during his/her residency at Bayshore Manor. 2. Shall pay the full amount due upon executing this AGREEMENT. 3. Shall comply with all requirements set forth in the application for admission. 4. Shall fully comply with all rules and regulations as now established by COUNTY or as may, in the future, be amended or established. 5. Shall make arrangements for RESIDENT'S immediate return to his/her home upon certification by either a physician or the Director of Bayshore Manor that RESIDENT is no longer capable of meeting the requirements for continued residence in or use of the facility. 6. Shall maintain on file with Bayshore Manor an up-to-date name, address and telephone number for RESPONSIBLE PARTY or next of kin. 7. Shall provide RESIDENT'S personal physician with written authorization to provide any medical care necessary while RESIDENT is residing at Bayshore Manor under terms of this AGREEMENT and provide Director of Bayshore Manor with a copy of such authorization. 8. Other: 0- RESIDENT and/or RESPONSIBLE PARTY agree to pay COUNTY the sum of SIXTY ONE ($61.00) DOLLARS per day, with the total amount due for 2 3 3 3 the entire term of AGREEMENT at the time the AGREEMENT is executed. :p .gu •k, COUNTY shall continually exercise such reasonable care as to maintain the health and safety of RESIDENT. However, COUNTY does not provide any assurance or guarantee for RESIDENT'S health and safety and shall have no liability for same. COUNTY shall have no liability or responsibility for cash or other valuables which RESIDENT may, at any time, have in his/her possession on the premises of Bayshore Manor. RESIDENT shall hold COUNTY harmless for any and all claims arising directly or indirectly from any negligent or intentional act of RESIDENT. •Q' RESIDENT shall at no time have in his/her possession on the premises personal cash in excess of ONE HUNDRED ($100.00) f9Z4)"R.11 � . NA + v WTI ORNA 5,15 ON COUNTY shall not be responsible for the payment of any medical, chiropractic, dental or hospital bill incurred by RESIDENT. Furthermore, COUNTY shall not be responsible for the payment of RESIDENT'S "over-the-counter" or prescription medications. RESIDENT'S perso nal physician is: NAME CA%A4tV4Y tu,l ADDRESS 3y1.? N. J ddSciV6:-, AJP 164y t,an Fin. 33()Y0 PHONE (3 0 d 1 q ►f - Wq 3 4 4 4 At the time that RESIDENT vacates Bayshore Manor this AGREEMENT shall automatically terminate, and RESIDENT or RESPONSIBLE PARTY shall remove all of RESIDENT'S personal property immediately. If property is not removed in a timely fashion, the parties agree that COUNTY is authorized to remove and dispose of such property after having made a reasonable effort to deliver it to RESIDENT or RESPONSIBLE PARTY, without success. Unless otherwise terminated, this agreement shall remain in full force and effect until such time as a new agreement is duly executed. This agreement may be amended at any time subsequent to its execution by both parties, or their legal representatives, by the parties or their legal representatives signing and executing such an amendment. J. NOTICE Any notice required by this agreement to be made by either party shall be made as follows: BAYSHORE MANOR ,— — f•e RESPONSIBLE PARTY Name ,1 Mtjtja AAP, pI'S Address: /il ViEd o'A LAivLe KA-1 wAV Ek• 330Y3 Phone :(30F) a 9 g _ ` 96-4 4 5 5 5 Parties may substitute the above by proper notice. Both parties shall at all times comply with the Laws of the State of Florida and Monroe County. Further, RESIDENT agrees that the proper jurisdiction and venue of any claims arising under this agreement shall be in Monroe County, Florida. COUNTY has no obligation to provide services except as stipulated herein. Should RESIDENT remain on the premises of Bayshore Manor after the expiration of the term, COUNTY may contact State Protective Services and relinquish custody of RESIDENT thereto. -4� WITNESSES AS TO RESIDENT WITNESSES AS TO RESPONSIBLE PARTY DATE: ID SIGNA DATE: / V SIGNA E OF RESIDENT L, SI ATURE OF RESPONSI LE PARTY F SECTOR, BAYSHORE MANOR SIGNATURE OF EXECUTIVE DIRECTOR, MONROE COUNTY SOCIAL SERVICES DEPARTMENT APPROVED AS TO FORM AND L SAL SUFFICIE BY 5 NE A. U DATE l APPROVED: SIGNATURE OF MONROE COUNTY ADMINISTRATOR APPROVED AS TO FOR AND LEGAL SUFFICIEN BY NE A. / 6 TE BAYSHORE MANOR A/K/A MONROE COUNTY HOME ASSISTED LIVING FACILITY FOR THE ELDERLY THIS AMENDMENT to AGREEMENT entered this day of J(yy-i 19 , by and between the County of Monroe, Florida, hereinafter called "COUNTY" and CV6LY11 PAS7R/c/' hereinafter called "RESIDENT" and J1,A l,4 Mk,AA RO1.S hereinafter called "RESPONSIBLE PARTY". WHEREAS, COUNTY has a primary responsibility for the safety of the residents of Bayshore Manor; and WHEREAS, there exists in Key West, Florida the possibility of a life threatening hurricane or other natural or man made disaster occurring which, in the sole discretion of County, will require the evacuation of the Bayshore Manor facility; and WHEREAS, either a natural or man made disaster might be of such a nature as to result in either a partial or complete destruction of the Bayshore Manor facility so as to render the structure uninhabitable and require alternative residential placement of RESIDENT on either a temporary or permanent basis; now, therefore IN CONSIDERATION of the mutual covenants herein contained, the parties agree as follows: The AGREEMENT entered on the gday of A06VI 19 U between the parties is hereby amended as follows: Paragraph M, DISASTER PLAN: is added to read: 1. If either a natural or man made disaster requires the evacuation of the Bayshore Manor facility; and 2. If, such a disaster causes such extensive damage to the Bayshore Manor facility as to render the structure uninhabitable, in the judgement of COUNTY; and 3. If, RESPONSIBLE PARTY has not evacuated RESIDENT from Bayshore Manor, for any reason; then 4. COUNTY has the absolute right to temporarily transfer RESIDENT to a shelter, either within or outside of Monroe County, until such time as the disaster requiring the evacuation has ended and County has assessed the extent of the damage to the Bayshore Manor facility. 5. If COUNTY determines that, as a result of the disaster, the Bayshore Manor facility is uninhabitable, COUNTY has the absolute right to transfer RESIDENT to an alternative Adult Congregate Living Facility of its choice within the State of Florida. 6. If County transfers RESIDENT to an alternative Adult Congregate Living Facility, County will make a reasonable effort to advise RESPONSIBLE PARTY of such a transfer. 7. If RESPONSIBLE PARTY removes RESIDENT from the ACLF in paragraph 6, except to return RESIDENT to a safely reconstructed Bayshore Manor, or enters into a separate agreement with said ACLF, this Agreement, as amended shall terminate immediately. 8. All other terms of the AGREEMENT, dated the To of ,gU�t4Tt , 199� , which are consistent herewith, shall remain full force d effect W WHNESSES AS TO RESIDENT WITNESSES AS TO R SPONSIBLE PARTY W104 •.RESIDENT SIONATURE OF RESPONSI E PARTY DATE: Im � V/ - 49& SI2GNATLBRE-TOR BA DATE: 0 SI ATURE OF EXECUTIVE DIRECTOR SOCIAL SERVICES DEPARTMENT APPROVED: SIGNATURE OF ADMINISTRATOR MONROE, COUNTY, FLORIDA APPROVED AS TOC FOR AND EN BY NNE DATE To Evelyn Pastuck Contract, dated August 8, 1996 From: Robert E. Lazarus, M.D., Director Bayshore Manor f Date: August 12, 1996 Re Early Discharge From Bayshore Manor - - - - - - - - - - - - - - - - - - - - - - - - - - - The above referenced agreement entered into on August 8, 1996 provided for Evelyn Pastuck to reside at Bayshore Manor from that date until 3:00 PM on August 15, 1996. Evelyn Pastuck only actually resided at Bayshore Manor from August 8, 1996 until 3:00 PM on August 12, 1996.