03/28/1996BAYSHORE MANOR
A/K/A MONROE COUNTY HOME
ASSISTED LIVING FACILITY
FOR THE ELDERLY
This agreement entered into this .2r day of 41"tC4L 199
by and between the County of Monroe, State of Florida, hereinafter
called "COUNTY" and Li-plA ]S&rr4 A'yZ hereinafter
called "RESIDENT", and Ai-r R ltJA 3J-4,"` , 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:- 3 day(s)
(NOT TO EXCEED THIRTY (30) DAYS) commencing on the day of
NAkSA
day of
19 and terminating at ,. W P.m. on the
19 1 9 , 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:
� amm.(0) a No u ra k comp
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
r 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
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:
2
3
RESIDENT and/or RESPONSIBLE PARTY agree to pay COUNTY the sum of
SIXTY ($60.00) DOLLARS per day, with the total amount due for the
entire term of AGREEMENT at the time the AGREEMENT is executed.
A kip 9jr.110u •k a .'
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.
IMNIIWWb •�:
RESIDENT shall at no time have in his/her possession on the
premises personal cash in excess of ONE HUNDRED ($100.00)
DOLLARS.
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 personal physician is:
NAME , I 1f)C,0 vV A' <' 01, n) ( 7'0 N K4 N
ADDRESS (� Soy-rM7zb �Z__
Wd i C � -330yy
PHONE l_ 3y E) 1� � G
3
4
:u 0 4 Qa •kk4 • -13 21210
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.
NEWOURZEW• kk4 • u
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.
Any notice required by this agreement to be made by either party
shall be made as follows:
BAYSHORE MANOR
W Iao i- : u
:...
ra *111 a 1 ME a . -
RESPONSIBLE PARTY
Name: 4 L Fk.1.D/ tJ*4 &f L
Address: 2 01 3& f 14 V[
,KAY ,� ��, 330v c)
Phone: (3()Y� 6 `13
Parties may substitute the above by proper notice.
0
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.
L�
WITNESSES AS TO RESIDENT
WITNESSES AS TO RESPONSIBLE PARTY
DATE: t
DATE: 3 ' �'�' S i
APPROVED:
APPROVED AS TO FORM
AND AL SUF�FICY
AN E A. HUTTON
SIGNATURE OF RESIDENT
SIGNA E OF RESPONSIBLE PARTY
SIGNATURE ;OFDIRECT R, BAYSHORE MANOR
s
SIGNATURE OF EXECUTIVE DIRECTOR,
MONROE COUNTY SOCIAL SERVICES DEPARTMENT
5
COUNTY ADMINISTRATOR
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