AUTHORIZED REPRESENTATIVE DATE
5. EVICTION PROCEDURES: ADULT RESIDENTIAL CARE FACILITY
A. The licensee/administrator of the facility may, upon thirty (30) days written notice to the client/resident, evict the client/resident for one
or more of the following reasons:
1) Nonpayment of the rate for basic services within ten days of the due date;
2) Failure of the client/resident to comply with state or local law after receiving written notice of the alleged violation;
3) Failure of the client/resident to comply with the following written general policies of the facility which are for the purpose of
making if possible for clients/residents to live together.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
4) Inability of the licensee to meet the client's/resident's needs. Based upon a reassessment of the client's/resident's needs,
conducted pursuant to applicable regulations, the licensee/administrator of the facility and the person who performs the
assessment determine that the facility is not appropriate for the client/resident and the client/resident has been been given the
opportunity to relocate.
5) Change of use of the facility.
B. The licensee/administrator of the facility may, upon obtaining prior and/or documented telephone approval from the licensing agency,
evict the client/resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a
finding of good cause. Good cause exists if the client/resident is engaging in behavior which is a threat to the mental and/or physical
health or safety of himself/herself or to others in the facility.
C. The licensee/administrator of the facility shall, in addition to either serving thirty (30) days notice or seeking approval from the
Department and serving three (3) days notice on the client/resident, notify or mail a copy of the notice to quit to the client's/resident's
authorized representative, if any. Additionally, a written report of any eviction shall be sent to the licensing agency within five (5) days.
The licensee/administrator of the facility shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to
permit determination of the date, place, witnesses, and circumstances.
6. FACILITY VISITING POLICY:
The visiting policy for this facility is_
___________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
7. DISCHARGE/REMOVAL - GROUP HOMES:
The licensee/administrator is responsible for policies and procedures for the child's
discharge when he/she reaches age 18; after needs and services plan goals have been reached; when the needs and services plan has
proven to be ineffective; when it has been determined that the child's continued placement in the facility is detrimental to the child or other
children in the facility; or under other emergency circumstances when removed by an authorized representative.
8. NOTICE OF RATE CHANGE: If rates are increased, the client/resident or authorized representative will be given at least 30 days written
notice of the change. However, clients/residents whose care is funded at rates prescribed by government funded 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 client's/resident's
admission to or departure from the facility during the month.
10. REFUND POLICY: Refund policy for this facility is
_______________________________________________________________
_______________________________________________________________________________________________________
11. If client/resident leave the facility temporarily, the holding rate for his/her room is the same as Item 2 or
_per day.
12. 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.
13.
_________________________________________________________________________________
will:
NAME OF CLIENT/RESIDENT OR AUTHORIZED REPRESENTATIVE
A. Pay the basic monthly rate
in advance
in arrears.
B.
Will
will not purchase the above listed optional services.
C. Cooperate with the general policies of the facility that make it possible for clients/residents to live together.
D. Not bring medications, special foods, or beverages into the facility without the knowledge of the administrator.
E. Not be destructive of the property of the facility or other clients/residents.
F. Provide two weeks notice of intent to move from the facility unless the client's/resident's physical condition prevents this being done.
14. California Code of Regulations Section 80068(b)(6) - addresses the admission agreement requirement.
The right of the licensing agency to perform the inspection duties is contained in Section 80044(a)(b)(c) and (d).
15. The client's/resident's funding source* is
private source
SSI/SSP established rate
government funded.
(Response is optional).
16. The signature of the "Client/Resident or Authorized Representative: below indicates that he/she has read, or had read and explained to
him/her, the provisions of this agreement voluntarily.
17. PARTIES TO THIS AGREEMENT.
CLIENT/RESIDENT DATE
LICENSEE/ADMINISTRATOR DATE
*Admission agreements and any attachments shall be completed and signed in duplicate. Date client/resident was discharged_
*One copy to be retained by the residential facility.
*One copy to be given to the resident or resident's responsible person.
