12/01/1981 AgreementBAY SHORE MANOR A/K/A
i i0, 0 COUNT Y HO: E , ADULT CO:+G ;FGR��TE
LIVING FACILITY FOR THE. ELDERLY - LEVEL II
A G R E E 'I E N T
This Agreement entered into this lst day of
December, 19 81 by and between the County of
Monroe, State of Florida, hereinafter called "County", and
Mary Schoneck ,
hereinafter called "Resident", and Ray A. Schoneck
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
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: None
B. T1TF me j.•F., nn : c �,.,c T- T _
1. To c rcvide suc': rersona i clothinc anci
effects as neeor desired by
Resident.
2. To pay the monthly rate agreed u-pon and
such charges as determined by the Yonroe
County Home to be necessary for the
operation of the home.
3. That, upon certification by a physician
or the P.dministrator 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 contacting an
appropriate social service agency for _
placement. Applicant agrees to vacate
the facility within forty-eight (48)
hours after disaualification.
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 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 medical
and hospital costs.
C. FINANCIA.L ARRANGEMFNITS
The Resident and/or responsible party agrees to
pay to the County $ 665.00
rent for use of the facilities.
, per month as
Payment will be from. the following sources:
1. Personal funds of Resident S
2. Responsible party will pay $ 272.60
3. Unearned income of Resident
will pay:
Social Security $
Civil Service Annuit, $
VA Pension $ 50.40
Other $ 342.00
CSA- Federal lighthouse service
Thr? (fount`_ ti:ro�lc;'; _ is `' r,r_ l.oes has agrc'er1 to
exercise such reasonable care toward the Resident as his or
her knot -in 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 10anacement of this home will not be respon-
sible for any valuables or money left in the TDossession of
this person while he or she is a resident of this home.
E. TFRMINATION
If Resident is absent from the home in excess of
fourteen (14) continuous days, such absence stall automa-
tically terminate this Agre=ent 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 SFRVICES
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. DUR_Z�TIOTT OF AGRFF'AFN71
Either party may terminate this agreement on five
(5) days written notice. Otherwise, it will remain in
effect until a different agree -meat is executed. However,
this does not mean that a Resident wil' b2 forced to remain
in the facility against his/her will for any length of time.
PJitnesses as to Resident
Witnesses as to
Responsible Party
T r
Sig ure of Resident
r
Si.canature of Responsible
Pj.rty
DATE
APPROVED: S .- 3- r ;k--
�L" Leaj
Signature of, Representative
of Monroe County Home aka
Bay Shore Manor
�e-7��.
Signature of Executive
Director, Monroe County
Social Services
Sic ature of County
A .inistrator
THIS IS TO CERTIFY THAT THIS ADMISSIO`T AGREFMENT F>S
APPROVED BY THE COUNTY HOME AND THE COUNTY AD2-^.INISTRATOR
WAS RATIFIFD BY THE MONROE COUNTY BOARD OF COUNTY
COMMISSIONERS AT THEIR. MEFTING HELD ON THE _ DAY
OF 19
��
'anatu e of the Ch rman
M nroe County Board f
County Commissioners