RESIDENT PERSONAL INFORMATION APPLICATION

Phone (Home/Work/Cell):
Format: (000) 000-0000.
E-mail:
example@example.com
Health Insurance:
Secondary Insurance:
Policy Holder:
Policy/Group #:
Phone:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctors
1. Name:
Type:
Phone:
Format: (000) 000-0000.
Hospital:
Address:
2. Name:
Type:
Phone:
Format: (000) 000-0000.
Hospital:
Address:
3. Name:
Type:
Phone:
Format: (000) 000-0000.
Hospital:
Address:
Full Disclosure
The information provided is true and accurate. Changes will be communicated to the Executive Director.
Signatures:
Resident:
Date:

MonthDayYear
Date
Responsible Party:
Date:

MonthDayYear
Date
Page of 3

SUNRISE
Resident Agreement Form:
Name of Facility Sunrise Care LLC, Class 2 Residential Facility, agrees to provide room and board, accommodation, supervision, and personal care services, as stated in this agreement, effective on the date of admission to the facility, for the residents listed below.
for
the resident.
Admission Date

MonthDayYear
Date
The monthly charge for these provisions in a: Private Room is $
Double Occupancy is $
Payment is due on the 1^st Month Day of each month.
Provisions for exceptions, late payments, security deposits, if any, are as follows:
No charges, fines, or penalties will be assessed against the residents other than those stipulated in this agreement. Should an increase in the charge for provided services become necessary, the operator shall give the resident and/or responsible party at least 30 days' verbal and written advance notice.
For a resident receiving RSS, the monthly charge for room and board, supervision and personal care services shall not exceed the amount specified in Chapter 5122-36 of the Administrative Code. The allowable fee paid by the residents is $1,100.00. This is only for RSS, not for private pay, private client or any other Medicaid client.
At no time shall the staff or operator of a facility assume payee ship for a resident's income, require income checks to be signed over to or be cashed by facility staff, nor in any manner establish controls over the handling of any resident's funds.
The operator may not charge an additional fee beyond the standard monthly charges for room and board (sleeping and living space, meals or meal preparation, laundry services, housekeeping services or any combination there of), provision of personal care services, if applicable to the residents, and basic cable service if offered.
The resident is responsible for providing the following items:
In the event of the resident's absence, discharge or transfer from the facility, the facility will refund the monthly charges and security deposit, if applicable, as follows;
Refund Process:
Resident Initials
DMHAS-7083 (4/19)
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Agreement Roommate Policy
Facility Name: Sunrise Care LLC
Residents are informed of the roommate policy at the time of admission, and this information is provided with the resident agreement. Check one:
The facility has 1 single room and 2 double rooms.
Residents are informed of the bedrooms available prior to admission to the facility and if they are single or double rooms.
If a resident wishes to move to a different available bedroom while in the facility, the process is as follows: Open approval from manager /owner.
Signatures:
Resident:
Date:

MonthDayYear
Date
AFH/Manager:
Date:

MonthDayYear
Date
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SUNRISECARE LLC-
Locked Storage Space Policy & procedures
Facility Name: SUNRISE CARE LLC.
Each adult has upon request an individual locked storage space provided.
by the facility freely available within the facility. Each facility shall develop a policy regarding the
facility's access to the residents locked storage space and inform.
the resident of this policy upon admission to the facility. The locked storage in this facility is
located: common are Residents can access the locked storage area as needed.
Residents can access the locked storage area on the following days and times: 7 days of week.
Staff may need to access the residents locked storage space for the following reasons: in case of
emergency or to assist residents.
In addition, the following procedures apply to the locked storage (Restriction may only be in
according with instruction from a guardian, if application.
Signatures:
Resident:
Date:

MonthDayYear
Date
AFH/ Manager:
Date:

MonthDayYear
Date
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SUNRISECARE LLC—
Sign/Sign-Out Policy for Sunrise Care LLC:
VISITORS HOURS:
1. Purpose: To ensure the safety, security, and accountability of all visitors, staff, and residents by
tracking facility entry and exit.
2. Policy Statement: All visitors, staff, and vendors are required to sign upon arrival and sign out
upon departure. This procedure helps maintain a secure and controlled environment.
3. • Sign-In: All visitors must report to the reception desk upon arrival. They will provide their name,
contact information, purpose of visit, and time of arrival.
•Sign-Out Before leaving the facility, all visitors are required to sign out by indicating their
departure time.
• Verification: Facility staff may periodically check the sign-in logs to ensure compliance with this
policy.
4. Visitation Hours: Visitors are allowed between 8:00 AM and 5:00 PM. Any exceptions require
prior authorization from facility management.
5. Conduct and Privacy: Visitors must adhere to all facility rules and respect the privacy of all
residents. Unauthorized access to private areas is strictly prohibited.
6. Enforcement: Failure to comply with this sign-in/sign-out policy may result in restricted
visitation privileges or additional measures as deemed necessary by management.
This policy ensures that all visitors and staff entering or leaving the facility are properly recorded,
contributing to the overall safety and security of the facility's environment. Contact details for
Narad Bastola and Sunrise Care LLC are provided at the end of the policy.
Narad Bastola. Owner/Facility Manager
Sunriseare2054@gmail.comP. (614)-302-4089 F. (614)-604-7280
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Full Name Resident

Adult Family Home Disclosure of Charges
Home Name: Sunrise Care LLC
License Number: 03-8510
Note:
The term "the home" refers to Sunrise Care LLC, an assisted living family home listed above. This form provides information to help individuals select a home that suits their needs. This document is not exhaustive or binding and is subject to update with 30 days written notice. Contact Sunrise Care LLC directly at 614-302-4089 or sunrisecare2054@gmail.com for further details.
Admission Fee: N/A
Additional Comments: Sunrise Care LLC does not charge an admission fee for RSS or private-pay residents.
Deposit: N/A
Additional Comments: Sunrise Care LLC does not require deposits.
Prepaid Charges
Prepaid Charges: N/A
Additional Comments: Sunrise Care LLC does not require prepayment for services.
Daily and Monthly Rates
Daily Rate/Monthly Rate ____________ Included services:
Personal care (eating, bathing, toileting, transferring, hygiene, dressing)
Medication management
Basic activities and social events
Meals and snacks
Boarding
Additional Fees
Optional Services:
Haircuts: At cost
Special outings/events: At cost
Cable/Internet/WI-FI for Phone: Included
Premium personal care products (e.g., shampoo, soaps): At cost
Disposable supplies (e.g., incontinence products): At cost
Activities
Basic activities: Included in monthly rate
Special trips (e.g., shopping, events): At cost
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Full Name Resident

DIETARY SERVICES
DIETARY SERVICES

We will provide three meals daily that are balanced, nourishing, and appetizing.

There will be a four-hour interval between scheduled meals.

There will not be more than fourteen hours between the evening meal and breakfast. Snacks are always available.

Residents involved in vocational or therapeutic day programs will be provided with a snack lunch.

Our policy is to provide special dietary needs. Special dietary needs include, but are not limited to low or no salt acid foods, reduced fat foods, reduced cholesterol foods, reduced or no sugar added

foods, frequency and/or protein size of meals, liquid only or clear liquids only for a period designated by a physician or dietician; and simple modification of food textures, such as pureeing.

In order to special diet requirements, we will need the following as a written prescription from a physician or dietician:

A list of permitted and excluded foods.

Recommended meal Patterns and technique where they are applicable. A list of resources to consult for additional guidance.

We will ensure that all! food shall be stored, prepared, and meals distributed in a manner that protects against contamination and spoilage.

We will provide hand-washing facilities, hot water, cold water, hand soap, and single use towels in the kitchen.

We will maintain the kitchen area free of poisonous and toxic materials other than those necessary for maintaining cleaning operation and sanitizing of kitchen equipment or controlling insect and rodents. However, these materials will be separated from all food and beverages.

We will supervise and assist a resident in consuming food if this service is needed.
Full Name of Resident

Ohio Department of Mental Health andAddiction ServicesResident Rights/Policy/Procedure Acknowledgement D The Resident'sRights PolicyD Transfer andDischarge Rights and ProceduresD House RulesD FacilitySmoking PolicyD FacilityGrievance ProcedureD Mental HealthEvaluation and Services Referral PolicyD Special DietProceduresD FacilityVisitation PolicyD FacilityRoommate PolicyI have also received a copy of theResident Agreement. The contents of these documents have been explained to me,and I understand my rights set forth therein._________________________________________Signature of Resident_________________________________________Signature of Guardian or Legal Representative_________________________________________Signature of Case Manager (optional)____________________Date
Signature of Resident
Signature of Case Manager (Optional)
Date

MonthDayYear
Date
Should be Empty:

DEMOGRAPHIC & PERSONAL INFORMATION

MARITAL STATUS

PARKING

LEGAL DOCUMENTS:

FINANCES:

FUNERAL ARRANGEMENTS:

SIGNIFICANT OTHER / EMERGENCY CONTACTS:

Doctors

Full Disclosure

Signatures:

SUNRISE

Resident Agreement Form:

RESIDENT AGREEMENT

Health Assessments:

Skilled Nursing Care and Changes in a Resident's Health:

Central Locked Storage Space:

Staffing Requirements and Supervision:

Personal Care Services:

RESIDENT AGREEMENT

Transportation

Sleeping and Living Space

Social, Recreation and Leisure Activities

Nutrition and Food Safety

Medication

Agreement Roommate Policy

Signatures:

SUNRISECARE LLC-

Locked Storage Space Policy & procedures

Signatures:

Release of Information (ROI) Form

SUNRISECARE LLC—

Sign/Sign-Out Policy for Sunrise Care LLC:

Adult Family Home Disclosure of Charges

Note:

Prepaid Charges

Daily and Monthly Rates

Additional Fees

Activities

DIETARY SERVICES