RAINBOW VALLEY GROUP HOME
ADMISSION AGREEMENT
Mailing Address: 2835 G Street, Merced, CA 95340
1. FACILITY INFORMATION______
NAME OF FACILITY TYPE OF FACILITY
RAINBOW VALLEY GROUP HOME
ADDRESS CITY STATE ZIP CODE TELEPHONE
1227 Cavalaire MERCED CA 95348 209-385-9917
Is a residential care facility licensed by the State Department of Social Services. This is a non-medical care facility.
2. BASIC SERVICES
The licensee shall provide the following basic services for:
NAME OF CLIENT/RESIDENT SOCIAL SECURITY NUMBER BIRTHDATE
1. BASIC GENERAL SERVICES
(a) Lodging ( ) single room (X) double room
(b) Food Services:
a. three nutritious meals daily and between meal snacks.
b. special diets if prescribed by a doctor.
(c) Laundry Facility.
(d) Client Room Maintenance.
(e) Comfortable bed including adequate linen for changes weekly or as needed.
(f) Plan, arrange and/or provide for transportation to medical/dental appointments.
(g) Planned recreational activities and utilization of community resources.
(h) Notification to family and other appropriate person/agency of resident’s needs.
2. BASIC PERSONAL SERVICES
(a) Continuous observation, care and supervision as required.
(b) Assistance/instruction with bathing and personal needs, as required
(c) Assistance in meeting necessary medical and dental needs.
(d) Assistance with taking prescribed medications in accordance with physician’s instructions unless prohibited by law or regulations.
(e) Bedside care for minor temporary illnesses.
(f) Maintenance or supervision of client/resident cash resources or property.
The monthly established rate for basic services is $_5234_____per month.
Basic services are paid in arrears.
The basic monthly rate, as stated above, does not include additional charges for additional services provided by this facility. There is no obligation to purchase additional services.
3. ADDITIONAL SERVICES REQUESTED
SERVICE TO BE PROVIDED COST OF SERVICE
4. TOTAL COST OF BASIC AND ADITIONAL SERVICES $______
5. EVICTION PROCEDURES: The facility may request a resident be moved from the facility with 10 days written notice for one or more of the following reasons:
1. Nonpayment of established rate.
2. Failure of the resident to comply with general household rules and policies which are for the purpose of making it possible for residents to live together.
3. If the client’s needs change significantly to the point that the facility can no longer meet their needs.
4. If a client’s behavior becomes a threat to themselves or others in the facility.
6. FACILITY VISITING POLICY: All visits concerning residents placed in this facility with be at the direction and approval of the placing agency.
7. DISCHARGE/REMOVAL: The licensee is responsible for the policies and procedures for the discharge of the resident when they reach the age of emancipation, when needs and services goals are met, when the program can no longer meet the needs of the child, if the child is determined to be a threat to themselves or others, or other emergency circumstances where a child is removed by an authorized representative.
8. NOTICE OF RATE CHANGE: If rates are increased, the authorized representative will be given written notice of the change. Resident’s whose care is funded at rates prescribed by government funding programs may have the basic rate change effective on the operative date of any rate change made in that program without notice.
9. MONTHLY RATE: The total monthly rate set forth in the admission agreement will be prorated on a daily basis upon the resident’s admission/departure from the facility during the month.
If a client leaves the facility temporarily the holding rate for his/her room will be the prorated daily rate.
10. REFUND POLICY: If an overpayment is established the refund of this overpayment will be negotiated with the placing agency and paid with an agreed amount on a monthly basis.
11. The licensee will not be responsible for any cash resources, valuables or personal property brought into the facility unless these items are delivered to the licensee/administrator for safeguarding.
12. ______will do the following:
a. Pay the basic monthly rate including optional services if purchased.
b. Cooperate with the general policies of the facility that make it possible for residents to live together.
c. Not bring medications, special foods, or beverages into the facility without the knowledge of the administrator.
d. Not be destructive of the property of the facility or other residents.
e. Provide 7 days notice of intent to move a resident from this facility.
13. California Code of Regulations Sections 87568 and 80068(b)(6) – address the admission agreement requirement. Right of the licensing agency to perform the inspection duties are contained in Sections 80044(b)(c) and 87344.
14. The Client’s Funding Source is: Private SSI/SSP established rate Government
15. The signature of the Resident/Authorized Representative below indicates that they have read and understood the provisions of this agreement.
16. PERMISSION TO MOVE: Rainbow Valley may may not move the resident to another Rainbow Valley Group Home facility if the resident’s needs can be better met in the other group home. I understand that I will be informed at least 24 hours prior to such a move and that I can decline permission at that time.
17. PARTIES TO THIS AGREEMENT
PLACING AGENCY PLACING AGENCY ADDRESS
PLACING AGENCY REPRESENTATIVE SIGNATURE PLACING AGENCY PHONE NUMBER
GROUP HOME REPRESENTATIVE SIGNATURE DATE OF PLACEMENT