03/12/1982 AgreementBAY SHORE MANOR A/K/A
e!O::ROE COL "'TY HO::E , AD LT CO::GREG .�\TE
LIVI:;G FACILITY FOR THE ELDERLY - LE%EL II
AGREEMENT
This Agreement entered into this _1� t_ day of
March 19 82 by and between the County of
Monroe, State of Florida, hereinafter called "County", and
Eloisa Park
hereinafter called "Resident", and Roldolfo Perez
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 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: To reimburse resident $10.00 per
month for personal spending funds.
t
1. To p-ovic?e suc'.: person: I clothin r nc
effect: as neec.!cd or desired by she
Resident.
2. To pay the monthly rate agreed ur_on 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 Administrator of the Dome, 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 ir,mediate
transfer_ to an appropriate facility.
In the event a Resident has no person
to represent him/her, this facility
shall assist Resident in contacting an
appropriate social service agency for
placement. Applicant agrees to vacate
the facility within forty-eight (48)
hours after discrualificati on.
4. To comply with all reguirernents 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 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. FINANCIA.L ARRANGE-MFAITS
The Resident and/or responsible party agrees to
pay to the County $ 592.30
rent for use of the facilities.
, per month as
Payment will be fromthe following sources:
1. Personal funds of Resident $
2. Responsible party will pay $ 400.00
3. Unearned income of Resident
will pay:
Social Security
Civil Service Annuity
VA Pension
Other Mortgage
$ 167.30
25.00
r, +
The Count%, t rOl1C; 1 its L ;C � C�'y' E'S 1 1S aC; rCed to
exercise such reasonable care to:aard the nesiCen.t 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 hom..e will 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. ITFRMINATION
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 ramove same, the Resident does hereby
authorize the County to remove said property or belongings
and deliver same to Responsible Party.
F. MF.I)TCA.T, SFRVT("F.
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? I OF AGRFE ,IFNT
Fither party may terminate this agreement on five
(5) days written notice. Othertaise, it will remain in
effect until a different agreement is executed. However,
this does not mean that a Resident wily b2 forced to remain
in the facility against his/her will for any lena,th of time.
L
d'e4e�/ewl2j
of
Signature of Resident
Witnesses as to Resident
Witnesses as to
Responsible Party
Siqnatu e of Responsible
Party
DATFlqeW o� �d 7
1
APPROVED:
6 1
J,X�-
Signature `Representative
of Monroe County Home aka
Bay Shore Manor
Signature of Fxecutive
Director_, Monroe County
Social Services
S g ature of County
Aeministrator
THIS IS TO CEP.2IFY THAT THIS ADMISSTO`T AGPFFMENT AS
APPROVFD BY THE COUNTY H07_1E AND THE COUNTY ADIIINISTPATOR
WAS RATIFIFD BY THE MONROF COUNTY BOARD OF COUNTY
COY,MISSIONERS `i' THEIR MEETING HELD ON THE ,z IJx,/ DAY
OFC�� c& -, 19 .
Siena re of the Chai7
Monroe County Board of
County Commissioners