Declaration CCP 585Cal. Super. - 6th Dist.June 22, 20211-11. 21 '1 1.2 .1 3' 1:4 .1 5 1 6 17 18- i9 20 2'1 22 .23 24 25' =26 2-? 23 AND REHABILITATION CENTER, ) ) Plaintiff, ) )1 vs, _) . . J MARGARET ANDAZOLA aka )__ 21 CV384568 Santa Clara - Civil REHASTE HARVEY WILSON =&- ”SAL-AMOFF,. LLP‘ A'DAM'L. S-ALAMOFF, ESQ, SBN. 193686 J, EDWARD WILSON,.ESQ.,SBN 1246710. 1221 E. Dyer Rd., Suite 200 Santa Ami CA 92705 Telspho'na: ('71'4)_289_-?D?0 Facsimile: (7'14) 289-7071- Electrohically Filed by Superior Court of CA, Countygof Santa Clara, on 12/772021 10:38 AM Reviewed By: A. Villanueva Case #21 CV384568 Attorney for Plaintiff COVENANT CARE CALIFORNIA, Ehfifldbdlmcfinted liability company, doing bugines's. as GRANT CUESTA SUB-ACUTE AND REHABILITATION CENTER SUSPERIoR CUURT'OE CALIFORNIA, COUNTY :0.F=-sANTA CLARA DOWNTOWN COURTHOUSE COVENANT.CARE CALIFORNIA LL-C, a __) California 1it‘11ited liability cemp'any, doing. ')' business as GRANT CUESTA SUB-ACUTE- ) MARGARET P. ANDAZOLA an individual j THOMAS ANDAZOLA akaTHOMAS M ANDAZOLA,'-an individual;- and DOES 1-20: inclu'sinie‘, ) ) J ) Defendants. J J ) ) ) I,_ Micah Almond, declare as.- follows: Case No. 21'CV384363 Assigfle‘d'to _ Judge Laurie Mikkeisen . Departmcnt 2 DECLARATION 0F MICAH ALMOND- IN SUPPORT 0F REQUEST TO-E-NTER JUDGMENT BY'DEFAULT BY COURT (CCP .§5825(d3') ComplaintsFiled: June- 22, 2021 Trial Date:- Not ISEt 1. I am-t‘heAdministra-mr ofGRANT CUESTA SUB-ACUTE AND 'REI-IABILIIIATION CENTER, 'a skilled nursing fagility-owned .and pperated by Plaintiff, COVENANTCARE CALIFORNIAILLC, the party-requasting-a Iudgment by'l'Default'by -424I-:,&_DECALMoND 1 Court. The fdllowing declaration-is-wi'thin my personal knowledge a_nd if sworn. as 'a DeCIa'rat'io'n of'Micali Aihi'ond . Jillanueva _ 1. .2. 1.3 14 15 16 .17 18 2'0 .21 22 23 24. 25 .26 '27 '28 'wi'tne'ssil could and. would competently testify thereto. 2. A's Administrammf-GMNT CUEs-TA SUB-ACUT-Ei-AND REHABILITATION CENTER (“Plaintiff’), I am responsible: for ovérseaiflg 'the'day-io- day operations of'the-facjlity including patient care andbusinass offiés-practicés and proceduras. 3. This declarationzis -in_ support 0f Plaintiff‘s Request-foéEntry 0f Judgmantby Default'by Court against.Defendant-MARGARET .ANDAZOLA akaéfMARGARET-P; ANDAZOL-A, an; individual (hereinafter ‘EDefendant'MARGARET”: and. Defendant. THOMASANDAZOLA aka THOMAS Mi. ANDAZOLA,,an individual (hereinafter- “Defendant THOMAS“); pursuant t_o CDdfi-Df Civil Procadure._ §538'5(€I)._ 4. With the excaptifln of an acuteparfe hospital'stay, Deféfldant Matgaretwflfa patient at Plaintiff“ s skilled nursing facility from 011 or-aboutSeptember-‘20, 2014 until her discharge‘from ille-facility on July'30, 2021. 5. On 01‘ about Sflptember 20', 201$ at Santa Clara, California, Defendant. MARGARET Entered into a written cOntract-(hereinaftar “the Cantract”) with Plaintiff.- D'efendant MARGARETS daughter, Ann Margaret Andazola,,. signed theiContract as. Dflfendant' .MARGARE'T’S “Resident‘s Representativef’ A true and correct capy 0f the, Contract-entitled "‘Califurnia Standard Admission Agreement for Skiflled-Nursing Facilities and-Intfirmadiate: Care'Facili‘ties‘g' is attached hereto as Exhibififlk.” ?Plaintiff i's unable to' submit the originalagreementbecauae i1: is Plaintiffsundarstandingthat StateanleEdEIaI. Iaw-fiand'the proyisi'nns 0f T-itlezZZ 0f 'the CaliforfiiaxCode 0f Regulations require. that .i'i: 'maintaiualll original contracts in its patiantirecordslo the. Complaint as Exhibit “A“ and by -this.-1‘e_f_erence:incorporated herein, 6. Pursuant t_o {ha terms ofthe Contract, Plaintiff agreedito' provide t0 'DeffindantjMARGARE-T, for a fee, rputine skilled nursing facility ._g:are, and SEWiCES, :as . 424: 1.6;DECaiLMOND 2- ch'claration 2:33 flMi'cah Almond m '11 1:2 . l3 1.4- .135:- 16 520 21 2'2 23 '24. 25. 26 2-? 23 more particuiarly describediin' the Contra'ct,_. and Defendants agreed tq'pa‘y for said skilled nursingcar'e and Samides'. I '7. At all times herein mcntionsd, Dafendant-_MARGARET Was a, Mgdi-Cal rscipient. Pursuantio"appl'ica'bia MEdi-Cal regulations (22'CCR $0690, §§2506551,___¢t.seq.), Defendant'MA-RGARET'waS- obligated'to pay a Shara 0f the cht 0f her medical care; (“Share 0f Cast“) at Plaintiff s skilled musing facility. The-‘amount 0f Defendant- MARGA-R-ET’S monthly Shat‘B-of'Cost obli-gation-was determined byith'e‘Santa Clara County WelfareDapartment, based] upon said Defén'dant?‘-s .anflfly iécome. =PursUant'to- the Contract, Defendant MARGARET agreadto pay her'SharB 0f'-Coét. 8. DefEndant THOMAS mad; payments .t'o. Plaintiff to peg}: for'Defendant" MARGARET? care and stay at PlaintifR-sxs'killad.nursing facility. Attacihedihereto as- Eihibit"‘B"’ is a true andborrect cfipy- 0f a check fmm Defendant THOMAS made payable t0."-"Grant Cué'sta.l”' Based'upon the forcgo'ing, Defendant THOMAS was tha-duly appo'intedTM'edi-Cal agent of'Defendant-MARGARET Aafin'g in the-‘course andrsmpfiflf said agéncy? Defendant- THOMAS'.m'anaged,. used andflbr contro’lledthe 'fImd's and a'SSEtS 0f. Defendant'MARGARETj which furids- and assets should have been LISed t'fi'pay Defendant MARGARET’S .Share-of'Co’st and othercharges not paid for by the MediFCal program, _p.'11rsuant..-to.- the tern'm' 0fthe written contract with Plaintiffand in accgrd'ancfizwith Welfare .andmstimtions Code {§141 10.8. 9-. A11 of tha-‘debt. owed fo-"Pla‘intiff‘consists 0ffDeféndant 'MARGARET’S unpaid M’edi'eCaIShara-of Cost obligation As Defiejndant MARGARET’S Me'di-Cal. agent,- D'efendant THOMAS} is: joihtly'andseverallyliable- for this debt. 1.0. Attached-to this declaration as Exhibit “CZ” is an 'iiemjzat-ibn 0f the‘unpaid chargesgi'ncurredfOr-thesaervicesrendered to Defendant MARGARET. 'Th'e-itemi'zation of unpaid. charges was prepared in the ordinary course 0f business at; or near the time of: the -424116_DEC:LILMOND 3' Déclarati'ofi o'f'NIicahAlmfind 1st 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 transactions it represents. This exhibit indicates there is a balance owing of $65,320 on the patient account of Defendant MARGARET as of June 17, 2021; said -sum is still due and owing on Defendant MARGARET's account. II. I am familiar with rates charged in the community for nursing facility services and the sum of $65,320 is a reasonable and customary charge for the services provided. 12. -Plaintiff hereby requests the entry of Judgment by Default by Court against Defendant MARGARET AND.AZOLA aka MARGARET P. ANDAZOLA, an individual; and Defendant THOMAS ANDAZOLA aka THOMAS M. ANDAZOLA, an individual, and in favor of Plaintiff, COVENANT CARE CALIFORNIA, LLC, a California limited liability company, doing business as GRANT CUESTA SUB-ACUTE AND REHABILITATION CENTER, in the principal sum of$65,320. Plaintiff further requests an award of attorney fees by the court in the sum of $960, pursuant to Civil Code § 1717 .5; plus, interest on the unpaid balance from July 31, 2021 (the day after Defendant MARGARET's discharge from Plaintiffs skilled nursing facility and for the purposes of this calculation, the "date of breach") through November 30, 2021, at the rate of 10% per annum, totaling $2,183.80; plus costs in the sum of$596, for a total judgment of $69,059.80. I declare under penalty of perjury pursuant to the laws of the State of California that the foregoing is true and correct. This declaration is executed this~_ day of December, 2021, at Mountain View, California. 4241 l6_DECALMOND 4 Declaration ofMicah Almond ( ( EXHIBIT ''A'' HI I “A” ¢f ‘xh Slale of California - Health and Human Services Agency Calliomia Department of Public Heaflh CALIFORNIA STANDARD ADMISSION AGREEMENT FOR SKILLED NURSING FACILITIES ANjD lNIERMggiATE CARE FACILITIES Resident Name: MARGARET ANDAZOLA Resident Number: l Admission Date: 912012014 Facitity Name: Grant Cuesta Sub-acute and Rehabilitation Center l. Preamble The California Standard Admission Agreement is an admission contract that this Facflity is required by state law and regulation to use. It is a legally binding agreement that defines the rights and obligations of each person (or party) signing the contact. Please read this Agreement carefully before you sign it. If you have any questions, please discuss them with Facility staff before you sign the agreement. You are encouraged to have this contract reviewed by your legal representative, or by any other adviser of your choice, before you sign it You may also call the Office of the State Long Term Care Ombudsman at 1-800-231-4024, for more information about this Faciiity. The report of the most recent state licensing visit t0 our facility is posted Next to the Consumer Information Board. and a copy of it or of reports of prior inspections may be obtained from the local office of the California Department of Public Health (CDPH), Licensing and Certification Division 150 North Hill Dr. Suite 22. Brisbane, 0a.. If our faciiity participates in the Medi-Cal or Medicare programs, we will keep survey certification and complaint investigation reports for the past three years and will make these reports availabie for anyone to review upon request. If you are able to do so, you are required to sign this Agreement in order to be admitted to this Facility. If you are not able to sign this Agreement, your representative may sign it for you. You shall not berequired to sign any other document at the time of. or as a condition of. admission to this Faciiity. ll. Identification of Parties to this Agreement DEFINITIONS In order to make the Agreement more easily understood, references to “wa,” “our." "us," “the Facility,” or “our Facility“ are references to: Grant Cuesta Sub-acute and Rehabilitation Center CDPP. 327 (05m) -1- 4"”\ i sme of California - Health and Human Services Agency Caiifomia Department of Pubita Healln Attachment A provides you with the name of the owner and iicensee of this faciliiy. and the name and contact information of a singie entity responsible for all aSpects of patient care and operation at this facility. References to "you,” “your.“ "Patient," or “Resident” are references to MARGARET ANDAZOLA. the person who will be receiving care- in this Facility. For purposes of this Agreement. “Resident“ has the same meaning as “Patient“ The parties to this agreement are the Resident. the Facility, and the Resident‘s Mbga(e’r Representative. References to the "Resident's Representative” are references to: , the person who will sign on your behalf to admit you to this Facility, andlor who is authorized to make decisions for you in the event that you are unable to. To the extent permitted by law. you may designate a person as your Representative at any time. Note: the person indicated as your “Resident’s Representative“ may be a fami|y member. or by law. any of the following: a conservator, a person designated under the Resident's Advance Health Care Directive or Power of Attorney for Health Care, the Resident's next of kin, any other person designated by the Resident consistent with State law. a perscm authorized by a court, or, if the Resident is a minor. a person authorized by haw to represent the minor. Signing this Agreement as a Resident‘s Representative does not, in and of itself. make the Resident's Representative liable for the Resident‘s debts. However. a Resident's Representative acting as the Resident's financial conservator or otherwise responsible for distribution of the Resident‘s monies shall provide reimbursements from the Resident's assets to the Facility in compliance with Section V. of the agreement. IF OUR FACILITY PARTICIPATES IN THE MEDI-CAL 0R MEDICARE PROGRAM, OUR FACILITY DOES NOT REQUIRE THAT YOU HAVE ANYONE GUARENTEE PAYMENT FOR YOUR CARE BY SIGNING 0R COSIGNING THIS ADMISSION AGREEMENT AS A CONDITION OF ADMISSION. The Parties to this Agreement are: Resident MARGARET ANDAZOLA fl areResident's Representative: {€- -’A”WM3r + Relationship: ‘ 32’?” Facility: Grant Cuesta Sub-acute and Rahabilltation Center copra 327 {05:11) -2. 1-. Stale of Cafiiomia - Hamil: and Human Services Agency Gallium Depanmem oi Pubfn: Health Ill. Consent to Treatment The Resident hereby consents to routine nursing care provided by the Facility, as well as emergency care that may be required. However, you have the right, to the extent permitted by law, to refuse any treatment and the right to be informed of pct-ential medical consequences should you refuse treatment. We win keep you informed about the routine nursing and emergency care we provide to you. and we will answer your questions about the care and services we provide you. If you are. or become‘ incapable of making your own medical decisions, we will follow the direction of a person with legal authority to make medical treatment decisions on your behalf. such as a guardian. conservator, next of kin, or a person designated in an Advance Health Care Directive or Power of Attorney for Health Care. Following admission. we encourage you to provide us with an Advance Health Care Directive specifying your wishes as to the care and services you want to receive in certain circumstances. However. you are not required to prepare one, or to provide us a copy of one. as a condition of admission to our Facility. If you already have an Advance Health Care Directive, it is important that you provide us with a copy so that we may inform our staff. lf you do not know how to prepare an Advance Health Care Directive. and wish to prepare one. we will help you find someone to assist you in doing so. - IV. Your Rights as a Resident Residents of this Facility keep all their basic rights and liberties as a citizen or resident of the United States when. and after, they are admitted. Because these rights are so important. both federal and state laws and regulations describe them in detaii, and state law requires that a comprehensive Resident Bill of Rights be attached to this Agreement. Attachment F. entitled “Resident Bfli of Rights.” lists your rights, as set forth in State and Federal law. For your information. the attachment also provides the location of your rights in statute. Violations of state laws and regulations ident'rfied above may subject our Facility and our staff to civil or criminal proceedings. You have the right to voice grievances to us without fear of any reprisal. and you may submit complaints or any questions or concerns you may have about our- services or your rights to the local office of the California Department of Public Health, Licensing and Certification District Office 150 North HIII Dr. Suite 22, Brisbane. Ca.. or the State Long-Term Care Ombudsman (see page 1 for contact information) You shoutd review the attached “Resident Bill of Rights" very carefully. To acknowledge that yymave been infofi of the'Waiu of Rights." please sign here: /V\ _ V. Financlg] Ngnémenty’ \ cam»: 32? (car. 1 5 -3- i State of Calliorma - Health and human Servtces Agency Caufomfe Depamuem of Pubfia Health Beginning on 942012014, we will provide routine nursing and emergency care and other services to you in exchange for payment. Our Faculty has been approved to receive payment from the foliowing government insurance programs: ~/ Medi-Ca! ~/ Medicare At the time of admission, payment for the care we provide to you win be made by: E Resident (Private Pay) L: Medical Imedicare Part A Medicare Part e:l E Private Insurance: (Enter Insurance Company Name and Policy Number) E Managed Care Organization: l: Other: Resident's Share of Cost. Medi-Cal, Medicare, or private payer may require that the Resident pay a co-payment, co-insurance. or a deductible. all of which the Facility considers to be the Resident's share of cost. Failure by the Resident to pay his or her share of cost is grounds for involuntary discharge of the Resident. If you do not know whether your care in our Facility can be covered by Medi-Cal or Medicare. we will help you get the information you need. You should note that. if our Facility does not participate in Medi-Cai or Medicare and you later want these programs to cover the cost of your care, you may be required to heave our Facility. [APPLICABLE ONLY IF DATE ls ENTERED:] On (date) our Facility notified the Catifomia Department of Health Care Services of our intent to withdraw from the Medi-Cal Program. If you are admitted after that date, we cannot accept Medi-Ca‘l reimbursement on your behalf, and we wiII not be required to retain you as a Resident if you convert to Medi-Cal reimbursement during your stay here. If. on the other hand. you were a Resident here on that date. we are required to accept Medi-Cal reimbursement on your behalf. even if you become eligible for Medi-Cal reimbursement afier that date. YOU SHOULD BE AWARE THAT NO FACILITY THAT PARTICIPATES lN THE MEDl-CAL PROGRAM MAY REQUIRE ANY RESIDENT TO REMAIN IN PRIVATE PAY STATUS FOR ANY PERIOD 0F TIME BEFORE CONVERTING TO MEDI-CAL COVERAGE. NOR, AS A CONDiTION OF ADMISSION 0R CONTINUED STAY IN SUCH A FACILITY, MAY THE FACILITY REQUIRE ORAL OR WRITTEN ASSURANCE FROM A RESIDENT THAT HE OR SHE IS NOT ELIGIBLE FOR, OR WILL NOT APPLY FOR, MEDICARE OR MEm-CAL BENEFITS. CDFH 32710511 1} .4. \- i' State of Cafifomia - Heaith and Human Services Agency Cafiiornia Department of Pubic Health A. Chfies for Private Pay Residents Our Facility charges the following basic daily rates: $360.50 for a private, single bed morn $320.00 for a room with two beds $309.00 for a room with three beds $299.00 for The basic daily rate for private pay and privately insured Residents includes payment for the services and supplies descrlbed in Attachment B-‘l. The basic daily rate will be charged for the day of admission, but not for any day beyond the day of discharge or death. However. if you are voluntarily discharged from the Facility less than 3 days after the date of admission. we may charge you for a maximum of 3 days at the basic daily rate. We will provide you with a 30-day written notice before increasing the basic daily rate. unless the increase is required because the State increases the Medi-Cal rate to a level higher than our regular rate. In this case. state law waives the 30-day notification. Attachment 3-2 lists for private pay and privately insured Residents optional supplies and services not included in our basic daily rate. and our charges for those supplies and services. We will only charge you for optional supplies and services that you specifically request, unless the supply or service was required in an emergency. We wfll provide you a 30-day written notice before any increase in charges for optional supplies and services. If you become eligible for Medi-Cal at any time after your admission. the services and supplies included in the dafly rate may change, and also the list of Optional supplies and services. At the time Medi-Cai confirms it will pay for your stay in this Facility. we will review and explain any changes in coverage. B. Sawfly Degogit lf- you are a private pay or privately insured Resident we require a security deposit of 5H WWW”) We will return the security deposit to you with no deductions for administration er handling charges within 14 days after you close your private account or we receive payment from Medi-Cat, whichever Is later If your care in our Faculty is covered by Medi-Cal or Medicare, no security defiosit is required. cnPH 327 (05:1 1} -D- State of California - Hean'n and Human Senfices Agensy California Department of auntie Heaath c. Charggs for Medi-ng. Medicare, or Insured Residents IF YOU ARE APPROVED FOR MEDI-CAL COVERAGE AFTER YOU ARE ADMITTED TO OUR FACILITY, YOU MAY BE ENTITLED TO A REFUND. WE WILL REFUND TO YOU ANY PAYMENTS YOU MADE FOR SERVICES AND SUPPLIES THAT ARE LATER PAID FOR BY MEDI-CAL, LESS ANY DEDUCTIBLE OR SHARE OF COST. WHEN OUR FACILITY RECEIVES PAYMENT FROM THE MEDI-CAL PROGRAM, WE WILL ISSUE A REFUND TO YOU. If you are entitled to benefits under Medi-Cal. Medicare. or private insurance, and if we are a participating Providar‘ we agree to accept payment from them for our basic daily rate. NEITHER YOU NOR YOUR REPRESENTATIVE SHALL BE REQUIRED T0 PAY PRWATELY FOR ANY MEDI-CAL COVERED SERVICES PROVIDED TD YOU DURING THE TIME YOUR STAY HAS BEEN APPROVED FOR PAYMENT BY MEDl-CAL. UPON PRESENTATION OF THE MEDl-CAL CARD OR OTHER PROOF OF ELIGIBILITY, THE FACILITY SHALL SUBMIT A MEDI-CAL CLAIM FOR REIMBURSEMENT. However, you are still responsible for paying all deductibles. copa-yments: coinsurance. and charges fro services and supplies that are not covered by Medi-Cal. Medicare. or your insurance. Please note that our Facility does not determine the amount of any deductible. copayment, or coinsurance you may be required to pay: rather, Medi-Cal, Medicare oryour insurance carrier determines these amounts. Attachments C-‘l . 0-2, and 0-3 describe the services covered by the Medi-Cal daily rate. services that are covered by Medi-Cal but are not included in the daily rate, and services that are not covered by Medi-Cal but are available ff you wish to pay for them. Attachment 0-1 and D-2 describe the services covered by Medicare, and services that are not covered by Medicare but are available If you wlsh to pay for them. You should note that Med-Cal will only pay for covered supplies and services if they are medicafly necessary. If Medi-Cal determines that a supply or service is not medicaliy necessary, we wiII ask whether you still want that supply or service and if you are willing to pay for it yourserf. We will only charge you for optional supplies and services that you specifically request. unless the SUpply or services was required in an emergency. We will provide you a 30-day written notice before any increase in charges for optional supplies and services. cow 32.7 {05:1 1:1 -6- i. State of California - Health and Human Services Agency Calfiornia Department oi Public haanl‘. D. Billing and Pment We will provide to you an itemized statement of charges that you must pay every month. You agree to pay the account monthly on the 1st (enter day of month). Payment is overdue 30 days after the due date. A late charge at n interest rate of 1O is charged on past due accounts and is calculated as follows: [6 fig . E. Payment of gthar Refgflds One to You As indicated in Section v.6. above, refunds may be due to you as a result of Medi-Cal paying for services and supplies you had purchased before your eiigibility for Medi-Cal was approved or for any security deposit you may have made. At the time of your discharge. you may also be due other refunds. such as unused advance payments you may have made for optional services not covered by the daily rate. We will refund any meney due to you within 14 days of your leaving our Facility. We will not deduct any administration or handling charges from any refund due to you. VI. Transfers and Discharges We will help arrange for your voluntary discharge or transfer to another facility. Except in an emergency. we will not transier you to another room within our Faciiity. or to another facility, and we will not discharge you from our Facility against your wishes, unless we give prior reasonable written notice to you, determined on a case by case basis. in accord with applicable state and federal requirements. For example, you have a right to refuse the transfer if the purpose of the transfer is to move you to or from a Medicare~certified bed. Our wrlflen notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance. However, we may provide less than 30 days notice if the reason for the transfer or discharge is to protect your health and safety or the health and safety of other individuals, if your improved health allows for a shorter notice, or if you have been in our Facility for less than 30 days. Our written notice will include the effective date, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reasons that we can transfer you to another facility or discharge you against your wishes are: 1). It is required to protect your weIl-being, because your needs cannot be met in our Facility; 2). It is appropriate because your health has improved enough that you no longer need the services of our Facility; cDPH 32? (05m; J- g L State of Calfiomia - Haanh and Human Semaes Agency California Department of Public Health 3). Your presence in our Facility endangers the health and safety of other individuals; 4). You have not paid for yOur stay in our Facility or have not arranged to have payment made under Medicare. Medi-Cal, or private insurance: 5). Our Facility ceases to operate; 6). Material or fraudulent misrepresentation of your finances to us. If we participate in Medi-Cal or Medicare, we will not transfer you from the Facility or discharge you solely because you change from prlvate pay or Medicare to Medi-Cal payment. in our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman. If you are transferred or discharged against your wishes. we will provide transfer and discharge planning as required by law. V11. Bed Holds ang Readrrlisgion If you must be transferred to an acute hospital for seven days or less, we will notify you or your representative that we are willing to hold your bed. You or your representative has 24 hours after receiving this notice to let us know whether you want us to hotd your bed for you. If Medi-Cal is paying for your care. then Medi-Cat will pay for up to seven days for us to hold the bed for you. If you are nut eligible for Medi-Cal a_pd the daiiy rate is not covered by your insurance. then you are responsible for paying sl K007“ /w for each day we hold the bed for you. You should be aware that Medicare does not cover costs related to holding a bed for you in these situations. If we do not follow the notification procedure described above, we are required by law (Title 22 California Code of Regulations Sections 7252mm and 73504{c)) to offer you the next availabie appropriate bed in our Facility. You should also note that, if our Facility participates in Medi-Cal and you are e!ig.ib|e for Medi- Cal, if you are away from our Facility for more than seven days due to hospitalization or other medical treatment, we will readmit you to the first available bed in a semi-private room if you need the care provided by our Facility and wish to be readmitted. CDPH 327 {95:11 y -B- t f State of Caiifomia - Heaflh and Human Services Agency Cambium Department of Pubkic Health VIII. Pergonal Progeny and Funds Our Facility has a theft and loss prevention program as required by state law. At the time you are admitted, we will give you a copy of our policies and procedures regarding protection of your personai property, as well as copies of the state laws that require us to have these policies and procedures. If our Facility participates in Medi-Cal or Medicare and you give us your written author'zation, we will agree to held personal funds for you in a manner consistent with all federal and state laws and regulations. If we are not certified for Medi-Cal or Medicare. we may offer these services but are not required to. You are not required to allow us to hold your personal funds for you as a condition of admission to our Facility. At your request. we will provide you with our policies, procedures. and authorization forms related to our holding your personal funds for you. IX. Photograghs You agree that we may take photographs of you for identification and health care purposes. We will not take a photograph of you for any other purpose. unless you give us your prior written permission to do so. X. Confidentiality of Your Medical Information You have a right to confidential treatment of your medical information. You may authorize us to disclose medical information about you to a family member or other person by completing the “Authorization for Disclosure of Medical Information" form in Attachment E. Xi. Facility Ruies and Grievance Procedure You agree to comply with reasonable rules, policies and procedures that we establish. When you are admitted, we wlll give you a ccpy of those rules. policies, and procedures. including a procedure for you to suggest changes lo them. A copy of the Facility grievance procedure, for resolution of resident complaints about Faclllty practices, is available; we will also give you a copy of our grievance procedure for resolution of any complaints you may have about our Facility. You may also contact the following agencies about any grievance or complaint you may have: California Department of Public Health Licensing and Certification Dlstrict Ofiioe Phone number: {415) 330-6353 (0R) State Long-Terrn ar Ombudsman Program Phone number: HQ-a/L/awlf CDPH 32? (05.11 1) -g- { a1 State 0‘ Calhomia - Health and Human Services Agency Cafifomia Department of Pubic Health XII. Entire Agreement This Agreement and the Attachments to It constitute the entire Agreement between you and us for the purposes of your admission to our Facility. There are no other agreements, understandings, restrictions, warranties, or representations between you and us as a condition of your admission to our Facility. This Agreement supersedes any prior agreements or understandings regarding your admission to our Facility. AH captions and headings are for convenience purposes only, and have no independent meaning. If any provision of this Agreement becomes invaiid. the remaining provisions shall remain in full force and effect. The Facility‘s acceptance of a partial payment on any occasion does not constitute a continuing waiver of the payment requirements of the Agreement. or otherwise limit the Facility’s rights under the Agreement. This Agreement shall be construed according to the iaws of the State of Califomia. Other than as noted for a duiy authorized Resident's Representative. the Resident may not assign or otherwise transfer his or her interests in this Agreement. Upon your request, we shall provide you or your Iegal representative with a copy of the signed agreement. all attachments and any other documents you sign at admission and shall provide you with a receipt for any payments you make at admission. By signing below, the Resident and the Facility agree to the terms of this Admission Agreem ' I “/47/ 7’7w/i Represefiivg'of the Facility Date Resident Date ago .ZQH t's epr sentative - if applicable Date CDPH 327 (W11 ; -1 o. Exhibit “B” {a Grant‘Cue‘sta Su b--Acute -& Rehab 19.49 Grant Street Me‘u n't_a_in View! Ca, 940,40 Bill To: Margargt A'ndazola 2546 Sierra Meadow Co‘urt San Jose. 'Ca. 95'116 Destriptio'n ' QJL' anl mcbmivfia‘mhl'n‘tJMm Hi'anuk H’Jvk ‘ . admit. IEQ-M M3.“ “:3!“ u fiM‘h'dde In "I G'v'nu‘dl H:"> ‘ vdfi¢ W1 l 'I- "l wnm-hi} I . MAW" - Hidla‘flmilfi- I I mm-I- 104% “344.1% M Q.“ ' AMA. ..-n.1|-.-. I ,__..n. ...._... p... .. fl..- ......._..... .___. _.. C“, oat'éfos/mzoz; 'Pa'tiefit Name: Margaretfimdazola _Pafl§h1; ID: 10410 65.32030