09/13/1982► AAOO
BAY SHORE MAr• ,OR A/K/r.
EIC:..
,1C I -T'y . 0:. T:i:_ 1LC._..i.'Y' - LE'.'E . II
AG R E E '.E ;E T
This A;;ree::•:ent entered into tills 13th day of
Septanber 19 82 , by and between the County of
Monroe, State of Florida, hereinafter called "County", and
Dolores G. Cancino
herei^after called "Resider-", and Marita M. Knowles
hereinafter called "Responsible
Party"
W I T N E S S E T H:
WHEREAS, the Resident desires to use the facilities
of the County known as The Monroe County Home, aka Bay Shore Manor
and, -
WHEREAS, the County has reviewed the application
of the Resident for admission to The Monroe County Home and
has determined that the Resident is eligible for admission
to said home, now, therefore,
IN CONSIDERATION of the mutual covenants, promises
and premises herein contained, the parties agree as follows:
A. BAY SHORE MAN R
1. To furnish room, board, linens, prescribed
medicines and general personal care.
2. To arrange for the transfer of the
Resident to the hospital of Resident's
choice, when ordered by the attending
physician or the health of the Resi-
dent requires same, and immediately
notify any responsible party (as
designated herein) of such transfer.
3. To make refunds in accordance with the
policy of the Home. Refunds cannot
be made as lons as personal belong-
ings remain in the Resident's room.
Re ui, 's canr-ot be m<,cle as long as
there are cures
for servicC,,: re:l-riv��.' b-,- tlt_ ,Resi.dent.
To be resp-n,-Ah1 e for medical costs (after biedi.-
Yays .
S. Other: none
I
n
FESLC..r'nt.
2. To pair the monthly rate acr:�ed u_r_on r_inrl:
such char^es as c?ete-�.i:.ec'- by the :'onroa
County Home to be necessary for the
operation of the hoE-,e.
3. That, uron certificaticn b%' a ph%,sician
or th:_ ?c•ministrator of the Pome, that
the Resident is no loncer canaL'le of
meetinc the requirements for occupancy
in this facility, the Resident, neat of
kin, legal representative, or agency
acting on the Resident's behalf, will
be notified and the Resident will have
to make arrancements for immediate
transfer to an appropriate facility.
In the event a Resident has no person
to rec_resent him/her, this facility
shall assist Resident in conta_ctinc an
appropriate social service ac:ency fer
placement. Ppnlicant agrees to vacate
the facility within forty-eic_,ht (48)
hours after eiscuali fication.
4. To comply with all requirements as set
forth in the Application made by the
Resident.
5. To comply with all rules and regula-
tions established by the County for
operation and control of said horse.
6. -,Agrees, if not paying the maximum rate,
to pay any increases in in come during the
course of residency, up to the maximum rate.
To be responsible for all medical costs(after
7. Other, 'Ps ieF^Y all pkysiQiaia_ i4d Medicare)
C. FIN,;!.NCI: L AR_D'-2 G-:'.- _.`'S
The Resident and/or responsible party agrees to
pay to the County $ 665.00 , per month as
rent for use of the facilities.
Payment will be from the following sources:
1. Personal. funds of Resident $
2. Resnonsible party will p�,_,• $ 356.00
Social Security $ 309.00
Civil Service
VA. Pension
Other $
c,s :1,13 c?- r,-r,r? L o
exercise such reasonable care to::arr? tote ?esic?ert as his or
her known condition may require, howe•;er, this home is in no
sense an insurer of his or her SaEet%, or tjelfare and assumes
no liability as such.
The illanagement of this hope will not he respon-
sible for any valua}31'�s or :rorc-,; left in the POssl�'ssion Of
this person while he or she is a resident of this ho:�e.
F. T� RR'IN;2-^1C.t
L
If Resident is absent from the home in excess of
fourteen (14) continuous days, such absence shall autoraa-
tically terminate this Agreement and the Resident small
remove all of his or her property or belongings immediately.
If Resident fails to re_^ove same, the Resident does hereby
authorize the County to remove said property or belongings
and deliver same to Responsible Party.
F. bIFDICP_L SFRViCFS
The parties agree that Monroe County shall not be
or assume any responsibility for payment of any medical or
hospital services, unless specifically agreed to by the
parties or their representatives at the time of the render-
ing cf service.
G. DUP1 TIC`S OF RGPF_�:T,;T
Either party ray ter:'Linate this agree-ment on five
(5) days written notice. Other -•.rise, it will rer,ain in
effect until a different agre=.ient is executed. However,
this does not mean that a Resident wil b2 forced to rea:ain
in the facility against his/her will for any lenc,th of time.
C0 -,' -
Lditnesses as to P.esidont
Witnesses as to
Rest onsible Party,7
Signature of Residcn
--- Signature of ROSUOnSible
Party
DA l' F' 9/13/82
APPROVED: 9/10/82
�L.o � Lj
Sic nature of Peprc.sent-ative
of Monroe County E;ome aka
Bay Shore Manor
Si:;n tune o F::ecut�ve
Director, i•Ienroe Count-Z
Social. Ser_,i ces
S ature of County
Aeministrator
THIS IS TO CFP,7'IFY TF'AT THIS APMISSTO"T AGPFFNIFNT AS
APP::OVFD BY THE COUNTY HO.'TE A \TD THE COUNTY AD."'I�;ISTPrTOR
WAS P- TIFIFD BY TFT MONROr' COUNTY BOARD OF COUNTY
CO �•1TSSI0�3FRS AT THEIP. MEFTIL;G HELD ON THE t'�;e- DAY
OF-- 19 -
-Sena e of the Chairm
„ rr
Q tae -05unty. _�.Qarc of
County Commissioners