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12/01/1981{ 1 , BAY SHORE MANOR A/KlA iiONROE COL;::TY HO:iE, AD 'LT CO:iGREGi��TE LIVING FACILITY FOR THE. ELDERLY - LEVEL II A G R E E LI E N T This Agreement entered into this 1st day of Decmeber 19 81 by and between the County of Monroe, State of Florida, hereinafter called "County", and Mary B. Herrick hereinafter called "Resident", and Donovan K. Herrick Party" , hereinafter called "Responsible 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 al to said home, now, therefore, IN CONSIDERATION of the mutual covenants, promises and premises herein contained, the parties agree as follows: A. SAY SHORE MANOR 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 long as personal belong- ings remain in the Resident's room. Refunds cannot be made as long as there are outstanding expenditures for services received by the.Resident. 4. Other: None 5. Other: None B. TT'F nrST F`:-7C :FT7T T` 1. To provic'e such rorsonal clothinc: and effects as neec'cci or c,e3irec, bvthe Resident. 2. To pay the monthly rate agreed upon and such charges as determined by the Monroe County Home to be necessary for the operation of the home. 3. That, upon certification by a physician or the Pcrministrator of the Home, that the Resident is no longer capable of meeting the requirements for occupancy in this facility, the Resident, next of kin, legal representative, or agency acting on the Resident's behalf, will be notified and the Resident will have to make arrangements for immediate transfer_ to an appropriate facility. In the event a Resident has no person to represent him/her, this facility shall assist Resident in contactina an appropriate social service agency for placement. Applicant agrees to vacate the facility within forty-eight (48) hours after disqualification. 4. To comply with all reauirements as set forth in the Ppplication made by the Resident. 5. To comply with all rules and regula- tions established by the County for operation and control of said home. 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. 7. Other: To be responsible for all hospital and medical costs. C. FINANCIAL ARPAINGFiAFNITS 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 $ 665.00 2. Responsible party will pay $ 3. Unearned income of Resident will pay: Social Security $ Civil Service P.nnuity $ VA Pension $ Other The Ccuntl'' thrOl.lC;n its has a,-'rc.eC_I to exercise such reasonable care toward the Resident as his or her known condition may require, however, this home is in no sense an insurer of his or her safety or welfare and assumes no liability as such. The Management of this home :aill not be respon- sible for any valuables or money left in the possession of this person while he or she is a resident of this home. E. TFRPIINATION If Resident is absent from the home in excess of fourteen (14) continuous days, such absence shall automa- tically terminate this Agreement and the Resident shall remove all of his or her property or belongings immediately. If Resident fails to remove same, the Resident does hereby authorize the County to remove said property or belongings and deliver same to Responsible Party. F. MEDICAL SERVICES 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 of service. G. DUPATIO',? OF AGRFF_*,TFNT Either party may terminate this agreement on five (5) days written notice. ethenAse, it will remain in effect until a different agreement is executed. However, this does not mean that a Resident wil. bc forced to remain in the facility against his/her will for any length of time. Witnesses as to Resident Witnesses as to Responsible Party Signatu of Resident Signature of Responsible Party DATE p� APPROVED: A 100A Signature of Pe esentative of Monroe County Home aka Bay Shore Manor Signature of Executive Director, Monroe County Social Services S' ture of County Administrator THIS IS TO CERTIFY THAT THIS ADMISSION AGPFFPIENT AS APPROVED BY THE COUNTY HOME AND THE COUNTY ADP4.INISTRATOR WAS RATIFIED BY THE MONROF COUNTY BOARD OF CO T�TTY CO�L%IISSIONFRS AT THEIR MEETING HELD ON THE Zq<_ DAY OF V4 LiiL C 19 -2 . L Si nature of the Chairman Monroe County Board of County Commissioners