08/23/1994BAYSHORE MANOR
A/K/A MONROE COUNTY HOME
ADULT CONGREGATE LIVING FACILITY
FOR THE ELDERLY
SHORT TERM RESIDENTIAL
A G R E E M E N T
This agreement entered into this �3? day of AV6-KIT , 19gy ,
by and between the County of Monroe, State of Florida,
hereinafter called "COUNTY" and A:1!2669114 64804
hereinafter called "RESIDENT", and ROBE iii PAIAO&I
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: 30 day(s)
(NOT TO EXCEED THIRTY (30) DAYS) commencing on the 13 -4 day of
1%CVdi , 199Y , and terminating at -3 • on the
04 MAdayof 5ZP166 14 Q4t R 19 Q Y 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:
A. BAYSHORE MANOR:
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
in Section C of this AGREEMENT. Refunds will not be
made for any days that personal belongings remain in
1
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.
5. Shall maintain no affiliation with any religious
organization, except to provide assistance to RESIDENT
in contacting such organization upon RESIDENT'S request.
6. Other WA
B. RESIDENT and/or RESPONSIBLE PARTY
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: AM
C. FINANCIAL RESPONSIBILITY
RESIDENT and/or RESPONSIBLE PARTY agree to pay COUNTY the sum of
FIFTY FIVE ($55.00) DOLLARS per day, with the total amount due
for the entire term of AGREEMENT at the time the AGREEMENT is
executed.
D. STANDARD ADMISSION WAIVER
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.
E. RESIDENT PERSONAL CASH
RESIDENT shall at no time have in his/her possession on the
premises personal cash in excess of ONE HUNDRED ($100.00)
DOLLARS.
F. MEDICAL AND DENTAL SERVICES
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 LL STA84p IKdRGo�/!a/ . KID.
ADDRESS 1/// /Z f� 11'. it Dh/
ATY watt Ft. 33DyP
PHONE
G. TERMINATION OF AGREEMENT
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
3
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.
H. DURATION OF AGREEMENT
Unless otherwise terminated, this agreement shall remain in full
force and effect until such time as a new agreement is duly
executed.
I. AMENDMENTS TO AGREEMENT
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
Name �QeDtR7 g �AIARJI. U�. D
Address: 520o COLt Gif fiom
May wzrr. FL, 33 0t40
Phone : (3qr 2 9 N-Y96 6
RESPONSIBLE PARTY
Name: 0ar2-; P-40got/
Address:. /6 2 6 Ivan ST.
di k)W. F4. 3301/0
Phone : &DS) :1 Q6 "3%92.
Parties may substitute the above by proper notice.
K. FLORIDA LAW
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.
4
L. POST -TERMINATION PRESENCE
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.
WITNESSES AS RESIDENT
. dA.M-- ( --
WITNESSES AS T RESPONSIBLE PARTY
DATE • ? ZL31
7
DATE •
APPROVED:
SI
SIGNATURE OF RESIDENT
SIGNATURE OF RESPONSIBLE PARTY
OF DIRECTOR, BAYSHORE MANOR
SIGNATURE OF EXECUTIVE DIRECTOR,
MONROE COUNTY SOCIAL SERVICES DEPARTMENT
SIGNATURE OF MONROE COUNTY ADMINISTRATOR
APPROVED AS TO F^^..',g
AND GAL SUFFIC
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5
,Qa sore, Manor
BAYSHORE MANOR
A/K/A MONROE COUNTY HOME
ADULT CONGREGATE LIVING FACILITY
FOR THE ELDERLY
A G R E E M E N T
00
This agreement entered into this arday of ,��yf7 1991/,
by and between the County of Monroe, State of Florida,
hereinafter called "COUNTY" and ,4QZ464T♦1 9ARCA ,
hereinafter called "RESIDENT", and Rolgagy Pi-lpod ,
hereinafter called "RESPONSIBLE PARTY".
W I T N E S S E T H:
WHEREAS, RESIDENT desires to live in the County facility known as
Bayshore Manor, 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:
A. BAYSHORE MANOR:
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. Refunds will not be made for any days that
personal belongings remain in RESIDENT'S room.
Refunds will not be made 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
1
Florida Statutes.
5. Shall notify RESIDENT and/or RESPONSIBLE PARTY in
writing THIRTY (30) DAYS in advance of any rate change.
6. Shall maintain no affiliation with any religious
organization, except to provide assistance to RESIDENT
in contacting such organization upon RESIDENT'S request.
7. Subject to the availability of funds, shall pay for such
medications as may be prescribed for RESIDENT by his/her
physician, as well as necessary non-prescription medical
supplies, provided that RESIDENT'S monthly rate under
this agreement is less than maximum rate and RESIDENT has
insufficient medical insurance to cover such expenses,
or in the event that RESIDENT'S monthly rate under this
agreement is the maximum rate but RESIDENT has neither
sufficient additional funds nor sufficient medical
insurance to pay for the above.
8. Shall provide to RESIDENT whose monthly rate is less than
the maximum rate, or who is paying the maximum rate and
has no additional funds, on a monthly basis, TWENTY
($20.00) DOLLARS for his/her personal use.
Such monthly reimbursements will be skipped or reduced
any month when full payment would result in RESIDENT
having more than ONE HUNDRED ($100.00) DOLLARS in
his/her possession; or any month that RESIDENT receives
funds for personal use of up to TWENTY ($20.00) DOLLARS,
from any source, such as OSS, etc., to the extent
necessary to assure RESIDENT of at least TWENTY ($20.00)
DOLLARS for personal use.
9. Other: N%
B. RESIDENT and/or RESPONSIBLE PARTY
1. Shall provide all clothing and personal effects as
required by RESIDENT.
2. Shall pay the agreed upon monthly rate no later than the
third day of each calendar month.
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
transfer to an alternative, appropriate facility upon
certification by either a physician or the Director of
Bayshore Manor that RESIDENT is no longer capable of
meeting the requirements for residence in the facility.
In the event that RESIDENT has no person or agency,
whether RESPONSIBLE PARTY, next of kin or other person
or agency appointed to act on RESIDENTS behalf to
represent him/her, Bayshore Manor shall assist RESIDENT
in contacting an appropriate social service agency for
placement. RESIDENT agrees to vacate the facility
within SEVEN (7) DAYS after disqualification.
6. Shall, if RESIDENT is not paying the maximum rate, pay
any increase in RESIDENT'S income (from any source) to
COUNTY during his/her stay at Bayshore Manor, up to but
2
not exceeding the maximum rate as may from time to time
be adjusted by COUNTY.
7. Shall, if funds for medication expenditures become
unavailable, make arrangements for payment of medication
expenses which Bayshore Manor cannot pay or arrange for
RESIDENT'S transfer to an alternative, appropriate
facility.
8. Shall maintain on file with Bayshore Manor an up-to-date
name, address and telephone number for RESPONSIBLE PARTY
or next of kin.
9. Other: d) Rrjigfi YT fmotL. Da As 0,gT9.6 do saftum-i 21, 711H• Q LMAL- PAY 5o4 Act
F944#kAC4vncat,1 Ngaic..t&& I&rMJtAD nva,ai. R12si-01r,14y ® CgaL-L MAI#k ld Id � U
F✓u- F04a .0•1.0 WrAret 'F l'�► 1PARDIFNcy 4" 14"4rN A9J L/FS /VJJVlr{rt%cd /d
0 atr As DF 7t1L-1 t /114 tE►Atc. NW;jpE Apgrr i)I#VFR1 At MAY aga RtW_W�)
D,pRto6, RdiI'Virw iy,
C. FINANCIAL RESPONSIBILITY
RESIDENT and/or RESPONSIBLE PARTY agree to pay COUNTY
$ / b 9a do per month for use of COUNTY' S Bayshore Manor
facility.
Monthly payment shall be derived from the following sources:
1.
Personal funds of
RESIDENT
$ ..0'
2.
RESPONSIBLE. PARTY
will pay
$ 100- d o
3. Monthly income of RESIDENT:
Social Security income $ $
Supplemental Security Income $ -0'
Railroad Retirement income $ I&
Civil Service income $
V.A. Pension $ -b
Other $ .4
D. STANDARD ADMISSION WAIVER
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
3
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.
E. RESIDENT PERSONAL CASH
RESIDENT shall at no time have in his/her possession on the
premises personal cash in excess of ONE HUNDRED ($100.00)
DOLLARS.
F. MEDICAL AND DENTAL SERVICES
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 except
as detailed in paragraph A-7, above.
G. TERMINATION OF AGREEMENT
In the event that RESIDENT vacates Bayshore Manor for more than
FOURTEEN (14) consecutive days, except for hospitalization, 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. In addition to the methods of terminating this
agreement, detailed in Paragraphs B-5 and G, above, it may be
terminated by RESIDENT upon written notice to COUNTY at any
time. Additionally, COUNTY may terminate the agreement upon
THIRTY (30) DAYS written notice to RESIDENT of RESPONSIBLE PARTY,
certified mail, return receipt requested.
H. DURATION OF AGREEMENT
4
Unless otherwise terminated, this agreement shall remain in full
.force and effect until such time as a new agreement is duly
executed.
I. AMENDMENTS TO AGREEMENT
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
RESIDENT/RESPONSIBLE PARTY
Name: 900,64 4. LAZAAVJ. t+-0. Name: ApeaQ7 PAOROd
Address : 106 CcoLLCs64f P,6 4d
49-4 WsS;M EL. 33040
Phone bor) .19 4- 11 t
Address: 1126 SOVTN ff,
Y�y� Q., 330y v
Phone : L3o J- -296-37 9 �
Parties may substitute the above by proper notice.
K. FLORIDA LAW
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.
It
WITNESSES AS RESIDENT
6')
WITNESSES AS O RESPONSIBLE PARTY
DATE • 23
DATE • S 1
APPROVED:
SIGNATURE OF RESIDENT
SIGNATURE OF RESPONSIBLE PARTY
SIGNATURE OF D CTOR, BAYSHORE MANOR
SIGNATURE OF EXECUTIVE DIRECTOR,
MONROE COUNTY SOCIAL SERVICES DEPARTMENT
SIGNATURE OF MONROE COUNTY ADMINISTRATOR
r,
APPROVED AS TO FORM
BAYSHORE MANOR
A/K/A MONROE COUNTY HOME
ADULT CONGREGATE LIVING FACILITY
FOR THE ELDERLY
AMENDMENT TO AGREEMENT
THIS AMENDMENT to AGREEMENT entered this J3 t day of / &VJT ,
19_t�L, by and between the County of Monroe, Florida, hereinafter
called "COUNTY" and ELl +'!i AB4'Y'H CARCt#4 hereinafter
called "RESIDENT" and J{DdlrtT PA,1RD& 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 —21 day of All&fjj`f ,
191q, between the parties is hereby amended as follows:
Paragraph L, 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 3�day of
/1c16.Vj-r , lgly—, which are consistent herewith, shall
remain in full force and effect.
1
jt-o'-m��
WITNES ES AYTO RESIDENT
WITNES S AS rRESPONSIBLE
PARTY
DATE: Z�
DATE •
SIGNAT E OF RESIDENT
-6�0-palj�
SIGNATU E OF RESPONSIBLE PARTY
SIGAkTURE OF PIRECTOR
BAYSHORE —
SIGNATURE OF VMCUTIVE DIRECTOR
SOCIAL SERVICES DEPARTMENT
APPROVED: —
SIGNATURE OF ADMIWI—STRATOR
MONROE, COUNTY, FLORIDA
APPROVED AST"
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