11/02/1992 AgreementBAYSHORE 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 2nd day of
NOVEMBER
by and between the County of Monroe, State of Florida,
hereinafter called "COUNTY" and MAXINE M. LOMAX
19 92
hereinafter called "RESIDENT", and BILL GILLETTE
hereinafter called "RESPONSIBLE PARTY". w
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W I T N E S S E T H:
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WHEREAS, RESIDENT desires to temporarily reside in the=`County
facility known as Bayshore Manor, for a period of: 11 day(s)
(NOT TO EXCEED THIRTY (30) DAYS) commencing on the 19th day of
NOVEMBER , 19 92 , and terminating at
30t1day of NOVFIIBFR 19
92
3 PM on the
, 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
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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 NONE
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• NONE
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.
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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 IAN L. GARRIQUES , M.D.
ADDRESS 1111 12th Street (Ste) 104
Key west, Fla, 33040
PHONE (305)294-5259
G. TERMINATION OF AGREEMENT
At the time that RESIDENT vacates Bayshore Manor this AGREEMENT
shall automatically terminate, and RESIDENT or RESPONSIBLE PARTY
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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.
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 ROBEFT E, LAZARUS, M.D,
Address: 5200 College Road
Key West, Fla. 33040
Phone: (305)294-4966
RESPONSIBLE PARTY
Name • BILL GILLETTE
Address: 1415 Truman Avenue
Key West, Fla, 33040
Phone: (305)296-2060
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
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proper jurisdiction and venue of any claims arising under this
agreement shall be in Monroe County, Florida.
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.
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WITNESSES AS TO RESIDENT
WITNESSES AS TO ESPONSIBLE PARTY
DATE: //4 2—
-7b-
DATE:
DATE: to -5 �/
APPROVED:
SIGNATURE OF RESIDENT
SIGNATURE OF RESPONSIBLE PARTY
SIGNATURE OF DIR�CTOR, BAYSHORE MANOR
SIGNATURE OF EXECUTIVE DIRECTOR,
MONROE COUNTY SOCIAL SERVICES DEPARTMENT
SIGNATURE
COMMUNITY
ION DIRECTOR,
DIVISION
N 0 V 12 1992
N0
SIGNATURE OF MONROE COUNTY ADMINISTRATOR
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This is to certify that this AGREEMENT as approved by Bayshore
Manor and the Monroe County Administrator was ratified by the
Monroe County Board of Commissioners at it's meeting held on the
9th day of December 19 92
NATURE OF THE CHAIRPERSON
MONROE COUNTY BOARD OF
COUNTY COMMISSIONERS
(SEAL)
ATTEST: DANNY L. KOLHAGE, CLERK
By C. Q)V•
Deputy Clerk
By —
Date
APPROVED AS 70 FORM
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