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HomeMy WebLinkAbout13-2855 Supreme Co '� ' y ennsylvania For Pro thono ta ry Use On Ct)ll �:O OIIllYIO leas ry On � Docket No: *. � cu r County �3 018 5 �Ivl i Warp The information collected on this form is used solely for court administration purposes. This form does not supplement or replace the f ling and service ofpleadings or other papers as required by law or rules of court. Commencement of Action: S [D Complaint 0 Writ of Summons 0 Petition Transfer from Another Jurisdiction 0 Declaration of Taking E C Lead Plaintiffs Name: Lead Defendant's Name: ELMCROFT OF DILLSBURG JOANN SABOTCHICK T Dollar Amount Requested: Elwithin arbitration limits I Are money damages requested? S Yes 0 No (check one) []outside arbitration limits 0 N Is this a Class Action Suit? 0 Yes 0 No Is this an MDJAppeal? 0 Yes x! No f A Name of Plaintiff /Appellant's Attorney: MICHAEL J DOUGHERTY, PA ID# 76046 -j Check here if you have no attorney (area Self-Represented [Pro Se[ Litigant) Nature of the Case Place an "X" to the left of the ONE case category that most accurately describes your PRIMARY CASE. If you are making more than one type of claim, check the one that you consider most important. TORT (do not include Mass Tort) CONTRACT (do not include Judgments) CIVIL APPEALS Intentional Buyer Plaintiff Administrative Agencies Malicious Prosecution Debt Collection: Credit Card Board of Assessment O Motor Vehicle Xi Debt Collection: Other 0 Board of Elections Nuisance Dept. of Transportation Premises Liability Statutory Appeal: Other S C] Product Liability (does not include mass tort) 0 Employment Dispute: F ' Slander/Libel/ Defamation Discrimination C 0 Other: 0 Employment Dispute: Other Zoning Board , Other: I ® Other: O MASS TORT Asbestos N 0 Tobacco Toxic Tort -DES Toxic Tort -Implant REAL PROPERTY MISCELLANEOUS Toxic Waste Ejectment Emin J Common Law /Statutory Arbitration _ J B Other: 0 Declaratory Judgment Ground Mandamus 0 Landlord/Tenant Dispute Non - Domestic Relations 0 Mortgage Foreclosure: Residential Restraining Order PROFESSIONAL LIABLITY 0 Mortgage Foreclosure: Commercial 0 Quo Warranto 0 Dental 0 Partition ( Replevin 0 Legal 0 Quiet Title 0 Other: 0 Medical 0 Other: O Other Professional: Updated 1/1/2011 C PT1 W I"Ti 3 C:) �J <p "1 Cp N 'fi r, az IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION ELMCROFT OF DILLSBURG n Plaintiff No. 13 �iU�� VS. JOANN SABOTCHICK; and COMPLAINT IN CIVIL ACTION DONNA MCGAHEN Defendant FILED ON BEHALF OF ELMCROFT OF DILLSBURG COUNSEL OF RECORD OF THIS PARTY: Michael J. Dougherty, Esq. PA I.D # 76046 WELTMAN, WEINBERG & REIS CO., L.P.A. 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 215 -599 -1500 W WR# 09862279 O 103. �� Pa i100531�2) IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION ELMCROFT OF DILLSBURG Plaintiff(s) No. VS. COMPLAINT IN CIVIL ACTION JOANN SABOTCHICK; and DONNA MCGAHEN Defendant(s) NOTICE TO DEFEND NOTICE AVISO You have been sued in court. If you wish to defend Le han demandado a usted en la corte. Si usted quiere against the claims set forth in the following pages, you defenderse de estas demandas expuestas en las paginas must take action within twenty (20) days after this siguientes, usted tiene veinte (20) dias de plazo al partir complaint and notice are served, by entering a written de la fecha de la demanda y la notificacion. Hace falta appearance personally or by attorney and filing in ascentar una comparencia escrita o en persona o con un writing with the court your defenses or objections to the abogado y entregar a la corte en forma escrita sus claims set forth against you. You are warned that if you defensas o sus objeciones a las demandas en contra de su fail to do so the case may proceed without you and a persona. Sea avisado que si usted no se defiende, la corte judgment may be entered against you by the court tomara medidas y puede continuar la demanda en contra without further notice for any money claimed in the suya sin previo aviso o notificacion. Ademas, la corte complaint of for any other claim or relief requested by puede decider a favor del demandante y requiere que the plaintiff. You may lose money or property or other usted cumpla con todas las provisioner de esta demanda. rights important to you. Usted puede perder dinero o sus propiedades u otros derechos importantes para usted. You should take this paper to your lawyer at once. If you do not have a lawyer or cannot afford one, go to or Lleve esta demanda a un abogado immediatamente. Si no telephone the office set forth below to find out where tiene abogado o si no tiene el dinero suficiente de pagar you can get legal help. tal servicio. Vaya en persona o flame por telefono a la oficina cuya direccion se encuentra escrita abajo para averiguar donde se puede conseguir asistencia legal. CUMBERLAND COUNTY BAR ASSOCIATION 34 S BEDFORD ST CARLISLE, PA 17013 TEL: (717) 249 -3166 WELTMAN, WEINBERG & REIS CO., L.P.A. BY: Michael J. Dougherty, Esquire Attorney for Plaintiff(s) Pa. identification No. 76046 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 Phone: 215.599.1500 Fax: 215.599.1505 File #09862279 } ELMCROFT OF DILLSBURG } Court of Common Pleas } Cumberland County } } vs. } } JOANN SABOTCHICK and } NO. DONNA MCGAHEN } CIVIL ACTION — COMPLAINT 1. Plaintiff is a corporation licensed and authorized to conduct business in the Commonwealth of Pennsylvania with a place of business located in Dillsburg, Pennsylvania. 2. Defendants are adult individuals who at all times pertinent hereto resided at 16 Keefer Way, Mechanicsburg, Pennsylvania 17055. 3. On or around February 2011 Defendants entered into an Admission Agreement with Plaintiff in which Plaintiff agreed to provide certain services to and /or on behalf of Defendants as set forth in the Admission Agreement. See attached as Exhibit 1, a copy of the Admission Agreement. 4. Plaintiff fulfilled their obligations under the Admission Agreement, however, Defendants failed to fulfill their payment obligation. 5. Pursuant to the Admission Agreement, Defendant has an outstanding balance with Plaintiff in the amount of $12,747.29 for services provided. 6. Despite demand for payment, Defendants refuse to pay for the goods and services provided by Plaintiff. WHEREFORE, Plaintiff demands judgment be entered in its favor and against Defendants, jointly and severally, in the amount of $12,747.29 and costs. WELTMAN, WEINBERG AND REIS, CO. L.P.A. Michael J. D gherty, Esquire This law firm is a debt collector attempting to collect this debt for our client and any information obtained will be used for that purpose. Et lmeroft Senior Living AMENDMENT TO RESIDENCY AGREEMENT AND RESIDENT HANDBOOK Resident Name: Responsible Person Name: �0'r��,a. U Guarantor Name: t`�11� L. M C 6 a t l The Residency Agreement and the Resident Handbook are hereby amended as follows: All references to "assisted living" are deleted in entirety and replaced with "senior living." SIGNATURES c CONWUNITY: Resider a Director's Signature Date J do Q--- - ?<- r I Resid lifs Signature Date La- I t I R se po ible Person's Signature Date Guarantor 's Signature Date l Elrfiacroft of Dillsburg Personal Care Horne ,Residency Agreement PENNSYLVANIA TABLE OF CONTEN { RESIDENCYAGREBME NT ............... ............... ....................... I............ .......... ..N......1.... I r ( y R /yy} CYAGREZVENT ................................. ........I.......... ....... .............. .......... l •/ II I G 1 N\ TL/ YJ ................. ......... . .................... ... ............... I..I...........I............... 1................... i A . Community wu..ul............... NUPUU.... N1II.... NO... w.. N..... ....I ..... .....NLNN+»..N..N.1...• 1 B . Resident ........................ ... ........ . ......... .... .... ,.... ............................. ...... . ..... . .... . ........... 1 C . Responsible Person ...... w ... ........................................I...... ................. ............................. 1 M. Guarantor . . ..... . ............ ............I....... w.. .. ..... ... » .................... I .......... ....... ....... 1....x.... 1 M . SER ICE ...... ............................... 01.6..... .....1.............1..1 ....I ... . ........ ...........11..,.1.... 2 A . Accommodations .................... . .................... N .................... w............ .....1 ............ .. ... . 1. Apartment; Personal Property ..................»...»................................... ............................... 2 2. Inspection, Alterations .. .... » ................................».....»......».................. ............................... 2 3. Access ............................. ...............................11 ....._...........»........... .. ... .. . ..................... ........2 11.. .. 4. Common Areas .....................»...»......... ............................... »............»1111......... ,..... ..... .......... 3 B. Basic Services and Amenities . ............... .... N. ... .. ..... .. ......... .. ....... .... .............................. 3 1 . Staff... ................. ... .. ... ............»..................»..............................._..... ....I.........................3 2. Emergency Care and Emergency Transportation ...............»............... ............................... 3 3. Emergency Call Systein .............. »...... ........... ........ .. ............. .............. »............... ... — 3 4. Utilities ......... I ................................................. ..........._........... »....... ».. ................... »..........3 .5. lWaintenance ..................»....»...................................»........ ............................... ...... .......... 4 6 . Meals ...... » ................... ............................... ........................................ ....... »......................4 `_ .. .7 . Linens/ Laundry....... ............... .. ....... ....»»:..._.._....._........ .......... » »......... »......... 4 .8. Housekeeping ... ... .......... . ... ». .......... ..... ............ ..................................... ........... ... ...................... 4 9 . Activities ..............................................».................»... ............................... ....... ».................4 10. Appointments....... .................................. ......... ................................................ .. ............. 4 _11. Transportati on .................... .............................. ...... .... .. ........................... ........ ......... ......... 3 C . Personal Care Services......... u.......• ............. •Iwm•w........m....w.N•wNry..... 5 D. Additional Services....... .. .................... .. . ....... ................w..... 5 1, Private Telephone Service for Your Apartment...._ ..............»........._.... ............................... S 2. Cable Television Service for Your Apartment .....................1 ............ ........................ ».. »... 6 111. 3, Personai Transportation ......... » ................»...................»..»...»............... .........»..................... 6 4, Staff Escort to Appointment ................... .. ............ .. .. ......................... _ ............. ............ 6 5. Personal Funds Storage ............................................................. ............................... ........... 6 6 . Beauty and Barber Services .......... .. ......... ».... ...... ................................ .. ........ ...........0 .... ... 6 7. Guest Meal s ............. _ ..... » .... .. ...................................... ......................... ..... ............ .................. 7 8. Tray Service ................ ... ......................»................._........ .-........I.......».. ».....,... 7 9 . Pharmacy Selection; Medication Packaging ........................ ............................ .._............... 7 10. Other Ancillary Servi ces. ..........................................._............................ ............................... 7 E . Excluded Services; Third Party Services ... I...........» ....................... q... ........ I................ 8 1. Excluded Services ..................................................................................... ............................... 8 2 . Third Party Services ....».......... ....................»...................................... ............................... 8 Iv MEDICAL EYALUATI'ON; XMTIALAND ANNUAL ASSESSMENTS; SUPPORT ..................................... ................I.........I............... ............................... 9 A . IVIedicai Evaluation.......... ....................... 1.1.... 1N..........1................. ..................N............ 9 B. [nitial and Annual Assessments .............. . .... .... ..... .....,............................ .. .............. ...10 C. Support Plan .... w ......... ............ w.... ....... .. ........ ............... „..,.. I..,. ....... .. .,........................... 10 : LEVELS OF CAREAND LEVEL OF CARE ASSESSMENT ............... „............10 A . Levels of Care ......................................„.......... ......... ................,. „...« ..............1.1............10 L. Level of Care Assessment ... „ ..... „ ................... „........„....... w ........... ......... „.. „................10 C. Frequency of Completion .... „ ........ „ ........... .„ ... ........... I................ ................................ 11 D. Change in Level of Care .................. ..............................I .................11,1,1........ „1......._....11 VI. FIVANCIAL CONSI. DERATIONS ..............1.................1..... ........1. „..................12 A . Dally Rate.. w. w......„.........« ........................„...„.. w.„........................... .............................12 B . Adjustment to Daily Rate ................. w..»........... ..... „.... w ......... ... ................................ „.12 C. Adjustment to Range of Daily Rate ................. „ .......................... »....... „ „....I.w.w.......„ 12 D . - Additional Services Fees.....„ ................:........„............................... ........ „. „..................13 E . NewResidentFee. .......... w ....................„...............„.......„..........„..... ............. „...........,...13 F. New Respite Resident Fee......... ...................................................... .............................13 G . Pet Fee and Motorized Cart Fee .................... .............w..,.............. ........:........1.1.........13 H, Late Charges and Non - Sufficient Fund Charges ........„,......„.„... ...w ................... „.....13 1 . Third Party Insurance. ...........................„.... I........ I,........................ ...................w.........1d J. Absence from Community (Bed Hold Policy) ................. I.............. ........................... „.14 K . Refunds ........ w ........................................................................ w........... .............................14 L. Senior Citizens Rebate and Assistance Act .......... ............. „.......,......... „....,...............1.15 ivl Attorneys' Fees ......................................... ......................w..... „.. ....................1........15 VIZ RIGHTS AND RESPONSIBIMUES OF RESID.ENTAND RESPONSIBLE PERSON ...... „ ......................... ............................ .....................I......... .....1.......1...............15 A . Use of the Apartment...„ ..................... ........ I..,................... i 15 D. Conduct........ w. w......„... Y... w„..„„„ q.„ .... w..„ ..w„„... „. „. „.. /I..IY.w„I .......... 11....15 C . Services Performed by You ............................. ....... „....................... 1..............1:............16 D . Loss or Damage to Your Property......„ ........................................ ..............................w 16 E . Damage to Our Property ... w.. w ....................... ......................... „..... .....1.......................16 ' . F . Insurance....„ ................ ....... w ......................... ................ ......................... ... ................. 16 G . Complaint and Grievance Procedures ................ ........................I... „.. „......1................,16 VIII. TERMAND TEMINATION; TRANSFER AND DISCHARGE ...............17 A . Term yq u......... n........... w„„„„....„..., U„„..,....„...„ Y. w. b„........„ ...„.. ..... „.... ....... „ ... „....... 17 B . Termination by Yon on 30 - Days ' Advance Notice ..., .......... „ .... 1 .. ............1....,...., „ „,...17 C. Termination by the Community on 30 -Days' Advance Notice .................. .. ............. „ 17 D. Termination by the Community on less than 30 -Days' Advance Notice .................. IS E . Automatic Termination M.„uw„„I..U.„.. q,.. O.. 11. 1„. U... .IHII„..„ ...... w..N..„N „wHfO„.„w 18 f --A i jF. Your Right to Rescind» ................................................................... ............................... IS IX, .PARTIES' RIGHTS AND RCSPONSIMITIES IN CONNECTION 6VIT.II A TRANSFEROR DISCHARGE ............................................»............ ....................,........19 A . Transfer or Discharge; Alternative Setting ................................... .I....... »...................19 B. Removal of Personal Property .........» ......................».............»»». ..............................; 19 C. Existing Charges........„..„ ...........................»............».................. ........ »...................... 20 D. Right to Show Apartment .» ............................. ...........»............. ............................... 20 X . MEDICAL EMERGENCY.. ........................»........................... ............................... 20 XI. DISCLAIMER OF CERTAINDUTIES .............................. ............................... 20 XII. CONSERVATOR OR GUARDIAN ........ ................. .......... ............................... 21 X1II. MISCELLANEOUS PROVISIONS ................................ ............................... 21 A . Changes in Occupancy.».»...... N ......... .................... N...»..»........ ........................»......... 21 13. Ownership Rights » .......... . ................. ..................»..».................. ,.............. »............... 21 C. Assignment ............................. .» ............. » .......................... ........................ ......... ». ...... 21 D. Severabitity .................................................:»..............».....».....:.... ............................... 22 E Subordination » ......... »..........» n........ H» u»»..» ... .. .......................... »...»............. »u...o»» 22 F . Notices and Consents—..... ............. I . ............... I ....... . ...... . ... I .......................................... 22 _.- G.. Civil Rights ..... ....... » ......................:......................»........................ ............................... 22 H. Supplemental Security Income ( SSX) ...............................»........... ...........................,... 23 1 . Attachments; Entire Legal Agreement ...... ...» ............................. .............................. 23 J. Additional Information ................. ..............»...............»............... ........................ »....23 ATTACHMENTS AND EXHIBITS Attachment A —Rate Schedule Attachment B -- Acknowledgement and Consent Forms Attachment C -- Pharmacy Selection Attachment D — Complaint and Grievance Procedures Attachment E -• Addendum for Supplemental Security Income Residents Exhibit I —Resident Bill of Rights and Acknowledgement .Exhibit 2 — Residentt handbook and Acknowledgefnent Exhibit 3 — Support Plan r RESIDENCY AGREEMENT 1. RESIDENCY AGREENIENT This Residency Agreement describes our mutual rights and obligations related to your occupancy of an apartment at the Community, and the services that we will be providing you while you reside in the Community. I1. PARTIES A. Community The Community ( "we or us ") is AL Dillsburg Operations, LLC d/b /a Elmeroft of Dillsburg, located at 153 Logan Road, Dillsburg, Pennsylvania 17019 and licensed by the Pennsylvania Department of Public Welfare ( "DPNV "), as a Personal Care Rome. B. Resident The Resident is the person or persons ( "you ") who will reside in the apartment and will receive the services provided by us. If more than one person is signing this Residency Agreement as Resident, the word "you." refers to each person f individually and to both people together. - C. Responsible Person This iq the person chosen by you to be involved in decisions required for-your health, welfare and safety while at the dommunity. This person may also be responsible for handling your personal finances. The Responsible Person will be notified in case of an emergency if there are changes to or termination of services, and in other situations as required by law or the policies and procedures of the Community. In order to avoid confiision, you should be aware that the Pennsylvania Department of Public Welfare refers to your "Responsible. Person" as your "Designated Person" in the Personal Care Home regulations. D. Guarantor This person assumes personal financial responsibility for the payment of the charges incurred by you. This person voluntarily unconditionally and personally guarantees all of your financial obligations under this Residency Agreement. You are not required to select a Guarantor if you accept personal responsibility for your financial obligations under this Residency Agreement. Pennsylvania —PCH . Dillsburg (April 2069) ' I ill. SERVICES A. Accommodations 1, Apartment; Personal Property The apartment number listed on the Rate Schedule identifies your residence. You may move into your apartment on or after the date of occupancy also identified on the Rate Schedule. You may live in the apartment on a month -to -month basis, subject to the tenons of this Residency Agreement and the house rules, policies and procedures contained in the Community's Resident Handbook. You are encouraged to furnish your apartment with your own personal property. However,. in the event you are unable to provide your own Rimishings, the Community will provide the basic furniture we may be required to provide under applicable regulations or we may be able to rent certain items of furniture to you for the monthly rental fee identified on the Rate Schedule, Notwithstanding the foregoing, the Community will not charge you for any items of furniture we are required to provide to you by law. - 2. Inspection; Alterations You acknowledge you have had an opportunity to inspect the apartment and its condition meets your approval. You may not alter or change any part of the apartment without obtaining our prior consent.. You are responsible for the cost of any changes or alterations you may make and those changes or alternations become our property. 3. Access Although you have a right to your privacy in the apartment, we may enter - the apartment to provide you services under this Residency Agreement, to perform management functions on behalf of the Community, and to carry out our duties as the licensed operator of the Community. We may also enter the apartment to clean, inspect, repair, alter or conduct maintenance that we determine reasonably necessary for the care of the apartment. Whenever feasible, you will be provided reasonable notice before we (or any of our representatives) enter the apartment for these reasons; provided, however, no .notice is required in case of an emergency. For your safety, you will not change or add locks to any door or windrow of your apartment, 2 Pennsylvania -• PCH • Dillsbarg (April 2004) i 4. Common Areas While you are a resident in die Community, you may use our common areas and general purpose rooms such as lounges, activities rooms, the library, private dining rooms and the wellness center, to the extent they are available and subject to the provisions of the Resident Handbook. The Community may change or reconfigure common areas in the future in the Community's discretion. B. Basic Services and Amenities. - 1. Staff We offer 24 -hour staff supervision. You understand and agree the phrase "24- .hour staff supervision" does not require, and the Community does not provide, continuous, uninterrupted visual monitoring of you. 2. Emergency Care and Emergency Transportation Our staff will assist you in obtaining emergency medical care 24 hours a day by calling 9.1 -1, and you are responsible for the cost of the emergency transport and any emergency or. subsequent medical care you receive. 3: Emergency Call System The Community is equipped with an emergency call system to alert staff to emergencies. We will provide you with a pendant or your apartment will be • equipped with a pull cord that interacts with the.systew when activated in the event of an emergency. The Conununity will replace pendants due to normal wear and tear but replacement for other reasons such as loss or damage will be at your expense, as set forth on the Rate Schedule. 4. Utilities We will provide utilities for you, with the exception of telephone and cable services in your apartment. If you desire telephone and/or cable services in your apartment, you may arrange to have these provided at your own cost, and you will either be billed directly by the utility or by us as an additional charge if we have an arrangement with the provider. Pemsrtvania— PCH- Dltlsburg (April 2009) 3 S. Maintenance We will provide necessary maintenance and repairs to your apartment, at our expense. You will be responsible for any repairs not caused by normal wear and tear. 6. Meals We will provide you with three nutritionally balanced meals per day, and snacks each day. We may be able to accommodate special diets as prescribed by your physician, but because this additional service is included in your level of care assessment, this may result in a higher level of care and an increase in your daily rate. 7. Linens/Laundry We may provide bed and bath linens to you or, if you prefer, you may provide your own. All bed and bath linens provided by us will be laundered on a weekly basis. Personal laundry service is available, but because this additional service is included in your level of care assessment, this may result in a higher level of care and an increase in your daily rate. 8. Housekeeping We provide weekly housekeeping services. However, if you desire or require more frequent cleaning services, your needs will be'assessed as a part of your level of care assessment may result in a higher level of care and an increase in your daily rate. 9. Activities We offer a program of activities that are designed to meet the physical, spiritual, intellectual, emotional and social needs appropriate to the interests and capabilities of our residents, and we encourage you to participate in these activities. You, your Responsible Person and Guarantor each understand that you will be responsible for expenses incurred during outings from the Community, such as Burch, dinner, movie tickets, shopping, etc. 10. Appointments We will provide you with assistance in scheduling your personal appointments. Pexnsylvania-- PCH- Dillsburg(Apri12W) 4 11. Transportation f � We will assist you in arranging for your personal transportation. We will also provide transportation to limited local physician offices on limited days and times, based on scheduling and availability of staff and the Community's van. C. Personal Care Services We offer personal care services to assist you with the activities of daily living, including, but not limited to, the following: • Bathing, Grooming, Dressing • Communication: Hearing, Sight, Speech • Mobility Cueing, Escoit, Transfer o Toileting and Incontinence Management • Personal Laundry, Housekeeping Special Diets or Modified Diets 0 Mental Status; Social and Emotional Behavior • Stability/Falls • Pharmacy Selection; Management of Medication Packaging and Dispensing i • Medication Management The personal care services you need or desire will be determined by the Community through a level of care assessment more fully described in Section V of this Residency Agreement. D. Additional Services 1. Private Telephone Service for Your Apartment This service is optional. You will be responsible for arranging for this service with the telephone company, and you will be billed directly by the telephone company based on the services you choose. If you choose not to have telephone service in your apartment, you will have access to a'Community telephone for use in calling the local service area. We will also assist you with making Iong distance. telephone calls. You will be responsible for the cost of the icing distance calls by purchasing a long distance calling card or you Nvill be billed by us as.an additional charge in an amount equal to the vendor's charge. Pamsykate —PCH • Dillsburg (April 2009) 5 2. Cable Television Service for Your Apartment This service is optional. You will be responsible for arranging for this service. You will be billed directly by the cable company based on the services you choose unless we have an agreement with the cable company, in which case your cable services will be billed by us as an additional charge. 3. Personal Transportation We can provide transportation services to you for errands or appointments, both non. - medical and medical, based on the'availability of the Community van and our staff. The cost for this additional service is listed on the Rate Schedule. 4. Staff kscort to Appointment We can provide staff to escort you to your appointments, based on availability, and the cost for this service is noted on the Rate Schedule. 5. Personal Funds Storage We may offer storage of a small amount of personal funds. This service is optional, and at no charge. We limit the amount of fiends we will store for you, as more fillly explained in the house rules. We will store your funds in a locked area in the business office. You or your Responsible Person will have access to your funds and financial records during normal business hours. Funds will be disbursed during normal business hours within 24 hours of your request.. We will keep a record of your transactions, including dates, amouuts of deposits, amounts of withdrawals and current balance. We will provide you or your Responsible Person with an itemized accounting of your transactions on a quarterly basis. Upon your discharge or transfer, any funds stored for you will be returned to you or your Responsible person within two (2) business days from the date the room is cleared of your personal belongings, assuming there is no balance due. 6. Beauty and Barber Services We have an on -site salon, and beauty and barber services are provided based on the availability of the stylist and/or barber. Depending on the Community's arrangement with the stylist and barber, (i) if the vendor is responsible for billing, you will be billed by and will pay the vendor directly in accordance with the ' vendor's rates, or (ii) if the Community is responsible for billing on behalf of the vendor, you will be billed by the Community for an additional charge in an amount equal to the vendor's rates. ` Pennsylvania — PCH- DipsbLn (April M09) d 1 f 7. Guest Meals We request at least a 24 hour advance notice if a guest will be joining you at meal time; however, we will try to accommodate your guests with less notification. Guest meals are billed to you as an additional charge, and the costs of guest meals are included in the Rate Schedule. 8. Tray Service We encourage you to socialize in our dining area during meals; however, in the ' event of illness, you may wish to have meals served in your apartment. If this is the case, we will deliver a me'ai tray to you during meal time. The cost for this service is included in the Rate Schedule, and will be billed by the Community as an additional charge. 9. Pharmacy Selection; Medication Packaging The Community contracts with one or more designated pharmacies (each, a 'Designated Pharmacy") tor provide prescription and over - the - counter medications and supplies to our residents in accordance with the Community's packaging and dispensing requirements. You have the right to use a Designated Pharmacy or to select another pharmacy of your choice. If you elect not to use a Designated t.... Pharnacy, the pharmacy you choose must comply with the Community's packaging and • dispensing requirements. Information on the Community's Designated Pharmacies and the Community's packaging and dispensing requirements will be provided on or prior to move -in. You must make your pharmacy selection upon move -in, which you will do by completing Attachment C to this Residency Agreement. You may change your pharmacy selection at any time during your stay by notifying the Community in' advance and executing a new Attachment C to your Residency Agreement. 10. Other Anciila;t'y Services The Community may provide other ancillary services to you, either directly or through a vendor, such as dry cleaning, catering, etc. If these ancillary services are available and are provided to you directly by the Community, they will be billed to you as an additional charge for the costs noted on the Rate Schedule. If these ancillary services are available and are provided to you by a vendor, they will be billed to you in accordance with the ondor's rates. Peansy[vania —PCH • Dillsburg (Apri12009p 7 } I I f ,. E, Excluded Services; Third Party Services 1. Excluded Services Subject to the rights and obligations you and the Community have with respect to your assessment, discharge and transfer, the Community cannot admit or retain you if you require or desire services or accommodations beyond that which the Community is authorized to provide tinder (i) the Community's rules, policies and procedures, (ii) the Community's license as a Personal Care Horne and (iii) applicable federal, state and local laws, rules and regulations. Services that are not permitted under the foregoing will not be provided by the Community. 2, Third Party Services Except as otherwise expressly provided in this Residency Agreement, you or your Responsible Person are rosponsible for arranging for any of your personal and health care services, including, without limitation, any care or services not provided at the Community; hospital services; physicians' services; nursing services; skilled nursing services; private duty personnel services; home health services; pharmacy services; dental, hearing and eye care services; orthopedic services; laboratory and x -ray services; or any rehabilitative therapies. If *the Community does not provide a personal or health care service you require or desire, you or your Responsible Person may arrange for such personal or health care service to be provided to you at the Community by a third party provider (a 'Third Party Provider") subject to compliance with the following terms and conditions: (a) Delivery of the personal or health care service to you must be permitted under the laws, rules and regulations governing the Community's licensure as a Personal Care Dome, including those pertaining to admission and continued residency at the Community. (b) Delivery of the personal or health care service to you must be permitted under the Community's rules, policies and procedures, including those regarding admission or continued residency at the Community. (c) Delivery of the personal or health care service to you must not interfere with your ability or the Community's ability to meet the uniform fire safety standards applicable to the Community. (d) if you need or desire a health care service, such health care service must be supported by a valid order from a physician, registered PennsyNanta -PCH • Difturg (AprD 2009) L - t ` t nurse or other health care professional, to the extent required under { applicable law and the Community's rules, policies and procedures. (e) For personal or health care services required to be provided to you by a licensed Third Party Provider, including but not limited to a home health agency or private duty nurse, such Third Party Provider must (i) provide evidence of valid credentials to the Community, and (ii) agree in writing to comply with the Community's rules, policies and procedures. (0 For personal or health care services permitted to be provided to you by an unlicensed Third Party Provider, such as a private duty aide, such Third Party Provider must (i) provide evidence of a satisfactory criminal background check to the Community, and (ii) agree in writing to comply with the Community's rules, policies mid procedures. (g) You, your. Responsible Person or Guarantor is solely responsible for paying all costs and expenses in connection with any personal or . health care services rendered to you by a Third Party Provider. If you, your Responsible Person, your Guarantor or the Third Party Provider does i not comply with the requirements set forth in this Section III E, depending on the circumstances, the Community may either take steps to deny access to the Third Party Provider or discharge you and terminate this Residency Agreement as described in Sections VIII C and D. IV.>YIEDICAL EVALUATION; INITIAL AND ANNUAL ASSESSMENTS; SUPPORT PLAN A. Medical Evaluation ' As a resident of this Community, you must agree to a medical evaluation completed by a physician, a physician's assistant or a certified registered nurse practitioner, as follows: 1. Within sixty (60) days prior to or within thirty (30) days after your admission; 2, Annually following admission; and 3, Upon any change in your medical condition. Pay Wivanto — PCH - Dillsburg (Apnl 2009) 9 The Resident also agrees to provide to the Community a copy of the Resident's annual medical evaluation on Form MA. -51 designated by DPW. B. Initial and Annual Assessments As a resident of this Community, you must agree to a written initial assessment that is documented on a form prescribed by DPW within fifteen (15) days of your admission, and you agree to have additional assessments completed, as follows: 1. Annually; 2. Upon any significant change in your condition.; and 3. At the request of DPW upon cause to believe that an update is required. C. Support Plan Your support plan will be completed within thirty (30) days of your admission, and documented on a form prescribed by DPW. Your support plan will be revised within thirty (30) days of completion of your annual assessment or upon a change in your condition. The support plan will describe the care, service and treatment needs you require. You or your Responsible Person may participate in the development of your support plan. Your current support plani will be attached to this Agreement as Exhibit 3. If any medical evaluation or assessment indicates that you need another, more appropriate level of care than the care provided by our Community, you will be discharged in accordance Avith Section VIII D or E of this Residency Agreement. V. LEVELS OF CARE AND LEVEL OF CARE ASSESSMENT A. Levels of Care We offer four customized levels of care. The level of care you will receive is based on your physical and cognitive abilities and your desires. The four levels of care are: Level B, Level L, Level M, and Level M +. B. Level of Care Assessment To detennine your level of care, we assess your health and mental condition using a level of care assessment, together with the other assessments described in Section IV above. A level of care assessment consists of the general categories of personal acid health care services the Community provides. Each general category is subdivided into one or more acuity levels. Each acuity level is assigned a Penmykrania— PCS.Dillsbuq (April 2009) .10 specific number of service points. To complete your assessment, the Community compares your needs and desires against the acuity levels in each category of the assessment, and adds up the number of assigned service points. Your total number of service points determines your level of care, and is classified based on the following ranges: Level E Minimum Assistance 0 -58 Service Points Level L Moderate Assistance 59 -117 Service Points Level M Greatest Assistance 115 -210 Service Points Level M+ Additional Set vices 211- 300Service Points beyond level M C. Frequency of Completion Except as may otherwise be required under applicable regulations, a level of care assessment is completed on or prior to your residency and again within thirty (30) days after you move -in. Thereafter, you will be reassessed and a new level of care assessment will be completed at least quarterly or more frequently as needed in connection with one of the following events: (i) upon a change in your condition, (ii) upon your return from a hospital or other health or mental care facility, (iii) at the request of you or your Responsible Person or (iv) as may otherwise be required under applicable regulations. D. Change In Level of Care ' When a new level of care assessment is completed, if your total service points falls within a new range, your level of care will be changed. Concurrent with a change in your level of care, your daily rate will be adjusted in accordance with the Rate Schedule attached to this Residency Agreement. We will provide you, your Responsible Person and Guarantor with notification that your level of care has changed, and you, your Responsible Person and Guarantor will be required to sign an Amendment to the Rate Schedule as more fully explained in the amendment - portion of the Rate Schedule attached to this Residency Agreement. Penasyl"nla PCH • Dillsbur0 (April 2009) i VI. FINANCIAL CONSIDERATIONS A. Daily Rate Your daily rate is based on the apartment you choose and the total service points associated with your level of care during your stay at the Community. Unless otherwise provided, the daily rate includes: • The Accommodations described in Section III A; • The Basic Services and Amenities described in Section III B; and • The Personal Care Services described in Section III C. Your daily rate is listed on the Rate Schedule attached to this Residency Agreement as Attachment A. We will begin charging you your daily rate on the date of occupancy referenced on the Rate Schedule. The daily rate is calculated on a per day basis, and is billed monthly in advance. Upon move -in, you are required to pay the following: (i) your daily rate for the month in which you move in, on a prorated basis and (ii) your daily rate for the next following month. As discussed . in Section VI r below, we charge the daily rate on days when you are absent from the Community, such as when you are on vacation, visiting family or friends, or hospitalized. B. Adjustment to Daily Rate The range of daily rates you may be charged for your apartment and the Community's four levels of care are disclosed on the Rate Schedule attached to this Residency Agreement. After you move in, if you choose a different apartment, your daily rate will change. Also, if your health or mental status changes and a new level of care assessment indicates you require a different level of care based on your total service points, your daily rate will change, Promptly following*a change in your daily rate, we will notify you in writing and make the new level of care assessment available to you. We are not required to provide you with advance notice of a change in your daily rate so long as the new daily rate falls within one of the four ranges disclosed to you on the Rate Schedule attached to this Residency Agreement. However, the Community and you, your Responsible Person. and Guarantor will be required to sign an Amendment to the Rate Schedule to document the new daily rate. C. Adjustment to Range of Daily Rate We reserve the right to adjust the range of our daily rates associated with the four levels of care presented on the Rate Schedule. Any adjustment in this range of rates will be effective only after we give you thirty (30) days' advance written ' 12 Pennsylvania — PCH - DiiSahurg (April 2009) r • Notice of the change. In addition, the Community and you, your Responsible f f Person and Guarantor will be required to sign an Amendment to the Rate Schedule to document the new range of rates. D. Additional Services Fees If you have requested any of the additional services described in Section III D of this Residency Agreement, there are additional charges for these services and you agree to pay the associated fees, We will bill you monthly in arrears for these services. We reserve the right to change these fees from time to time during your stay with us. We will provide you with thirty (30) days' advance written notice of these changes. E. New Resident Fee You will owe us on the date of occupancy the resident fee listed on the Rate Schedule. This fee is an application and administrative fee. It is a one -time fee that is refundable but only on a prorated basis within the first thirty (30) days following the date of occupancy. After expiration of the thirty (30) day period, the resident fee is non- refiuidable. F. New Respite Resident Fee For a respite stay, you'will owe us on the date of occupancy the respite resident fee listed on the Rate Schedule. This is an administrative fee that we charge one time during each six -month period. The respite resident fee is non- refundable. G. Pet Fee and Motorized Cart Fee We reserve the right to approve any pet you wish to have (which pet must have current vaccinations), and there is a pet fee as stated on the Rate Schedule. This pet fee is a one -time fee and is non - refundable. We also reserve Gtte light to approve your use of a motorized cart, and in the event you use such a cart, we will charge you a motorized cart fee in the amount stated on the Rate Schedule. This motorized cart fee is a one -time, non - refundable fee. H. Late Charges and Non - Sufficient Fund Charges All fees are due and payable on the first day of the month (or the due date listed on the monthly invoice). If payment is not reeelved within ten (70) days of tl :e due date on the invoice, we will assess a• late charge of one and one -half per cent (1.5 %) of the outstanding balance that is late for each month or portion of the month your fees reinaln unpaid. If any check is not honored for payment, we Pennsylvania — PCS . Dlllelwrg (April W09) ' 13 S i i �j will assess a seMce fee of $25 in addition to any late charge that may be assessed. If payments are routinely late, or if any check is returned for non- sufficient funds, we reserve the right to determine an alternate method of payment: You are strongly encouraged to use direct draft service for the payment of charges. I. Third Party Insurance If your stay is covered by long -term care or other third party insurance or benefits, you must still submit payment to us when payment is due. You will then apply for reimbursement directly from your insurance company. To the extent permitted under applicable privacy laws, we agree to cooperate with you and any third party payor in providing reasonable information they may require to process benefits to which you inay be entitled. J. Absence from Community (Bed Hold Policy) If you leave the Community for medical or personal reasons, the Community Nvill reserve your apartment for up to 100 days (subject to extension at the sole discretion of the Community) so long as all fees continue to be paid under this Residency Agreement. You, your Responsible Person or your Guarantor are t responsible for paying the daily rate even when you are absent, including, but not limited to, time when you are on - vacation or when you have been transferred temporarily to a skilled nursing facility, inpatient hospital, mental facility, rehab facility or other health care facility. You or your Responsible Person must notify, the Community in writing of any - change in status that would prevent you from • Returning to the Community. Unless and until the Community receives the foregoing written notice, and you have vacated your belongings from your apartment, you wW continue to be assessed your daily rate even during your absence.. K. Refunds As a result of your transfer, discharge, or upon closure of the Community, we will refund on a pro- rated 'basis, based on your daily rate, any unused portion of amounts paid to us beyond the date your apartment is vacated and cleared of all personal belongings, after deducting the cost of any damages to the apartment resulting from circumstances other than normal use, unpaid bills, charges, etc, The Community will pay any refiind that is due within - thirty (30)•days after your transfer, discharge, or upon closure of the Community. As a result of your death, the Community will issue refunds in accordance with the Elder Care Payment Restitution Act. Your personal representative or guardian PenmyArenia - PCH.11illsbuTs(Aprit2009) 1 ' will be refunded die daily rate paid in advance and unused by you. The refund ( will be paid to your personal representative or guardian within thirty (30) days of the date your personal belongings are cleared from the apartment. L. Senior Citizens Rebate and Assistance Act Under the Senior Citizens Rebate and Assistance Act, dte Community may not seek or accept payment from you in excess of one -half of any funds you receive under the Act. The Community may assist you with filling out the paperwork to apply for your rent rebate, but Nye will not seek to retain any of the rent rebate monies you receive. X Attorneys' Fees In the event you, your Responsible Person or Guarantor fails to pay any fees due under this Residency Agreement, we are entitled to recover all costs incurred in order to collect the fees, including reasonable attorneys' fees to the extent allowed under applicable. state law. V11. RIGHTS AND RESPONSIBILITIES OF RESIDENT AND RESPONSIBLE PERSON { A. Use of the Apartment You will use the apartment as your private residence and will maintain it in a clean, sanitary and orderly condition. While you remain a resident in the Community, you will not act in any manner that will interfere with our other residents' quiet enjoyment of the Community or their apartments. B. Conduct You agree to conduct yourself in a socially acceptable manner, consistent with the peace and harmony of the Community. You agree to observe and abide by our rules, policies and procedures contained in the Resident Handbook. A copy of the Resident Handbook is printed on Exhibit 2 following the end of this Residency Agreement. We reserve the right to change or otherwise modify the Resident Handbook from time to time, If we do so, we will provide you with a copy of the revised Resident Handbook thirty (30) days in advance of the effective date of the changes. If we determine you are not complying with the provisions of the Resident Handbook, we will ask you to discontinue the actions we believe are not in compliance. Depending on the circumstances, refusal to diseontimte such actions and failure to comply with the Resident Handbook may be grounds for discharge or transfer from the Community as described in Sections VIII C and D. Pennsylvania — PCH • Biilsbnrg (April 2009) 15 I i 1. Smoldng Policy. In accordance with the Pennsylvania Clean Air Act, you are advised that ours is a smoke -free building. You are not permitted to smoke in your apartment, or anywhere inside of the building. Smoking is permitted outside of the building in the designated area(s) set forth in the house rules. You agree to abide by our smoking policy, C. Services Performed by You You may not be required to perform any services for us, except as provided for in this Residency Agreement or a subsequent written agreement. We may agree, in writing„ that you will perform certain activities or services in the Community if you volunteer OR if you are compensated at or above prevailing rates. If you are compensated for performance of certain activities to which we agree, you must undergo acid receive a satisfactory criminal records check. D. Loss or Damage to Your Property We recommend that you not keep valuables, such as jewelry or more than minimal cash, in your apartment. You are responsible for the loss, damage or theft or any other loss of your personal property. { E. Damage to Our Property If you or any of your visitors damage any of our furnishings or fixtures beyond normal wear and tear, you are obligated to reimburse us for the cost of repair or replacement. F. Insurance You are responsible for insuring any personal property that you may keep in the apartment and for any liability insurance for you or your visitors. The insurance carried by this Community does not apply to or cover the personal possessions you keep in your apartment. G. Complaint and Grievance Procedures You and your Responsible Person have the right to lodge formal complaints and informal grievances without intimidation, retaliation or threats of retaliation from our Community or staff against the individual who reported the complaint or grievance. Retaliation includes discharge or transfer from the home. Peaasylvank —PCH - Drlkburg (Apri12009) 16 1. Formal Complaint Procedure. You and your Responsible Person may ( file a formal complaint in accordance with the procedure outlined in Pant 1 of Attachment D with the Community and/or one or more of the following third party agencies: DPW's personal care home regional office, the local ombudsman or protective services unit in the area agency on aging, Pennsylvania Protection & Advocacy, Inc. or law enforcement. 2. Informal Grievance Procedure. You and your Responsible Person may file an informal grievance with the Community in accordance with the procedure outlined in Part 2 of Attachment D. You and your Responsible Person will be required to acknowledge receipt of Attachment D. VIII. TERM AND TERI IINATION; TRANSFER AND DISCHARGE. A. Term This Residency Agreement shall commence on the date of occupancy identified on the Rate Schedule and shall be in effect on a month -to -month basis unless and until it is terminated in accordance with the following provisions. B. Tennination by You on 30 -Days' Advance Notice You or your Responsible Person may terminate this Residency Agreement for any 'reason by giving the Community thirty (30) days' advance written notice. C. Termination by the Community on 30 -Days' Advance Notice Except as otherwise provided in Section VIII D below, the Community may transfer or discharge you and terminate this Residency Agreement for one or more of the following reasons by giving thirty (30) days' advance written notice to you, your Responsible Person and any applicable referral agency: • 1. if you are a danger to yourself or others; 2. If the Community chooses to voluntarily close, or close a potion of the Community; 3. If it is determined by your physician, an appropriate assessment agency or the Community that your functional level had advanced or declined so that your needs cannot be met by the Community; Pennsylvania —PCH - Diltsburg (April 2009) 17 f t 4. If meeting your needs would require a fundamental alteration in our Community programming or building site, or would create an undue financial or programmatic burden on our Community; S. If you have failed to pay your obligations under this Residency Agreement after reasonable documented efforts by us to obtain payment; 6. If the closure of our Community is initiated by DPW; or 7. If you repeatedly violate our rules, including the Resident Handbook, and we have documented such violations. D. Termination by the Community on less than 30 -Days' Advance Notice The Community may transfer or discharge you and terminate this Residency Agreement if a delay in discharge or transfer Would jeopardize the health, safety or welfare of you or others In the Community, as certified by a physician, DPW, or both, and the Community shall give only such notice as is reasonable and practicable under the circumstances, i' K Automatic Termination This Residency Agreement will automatically terminate without any notice from the Community in connection with the following: 1. You pags away; or 2. You are absent from the Community for medical or personal reasons and the Community receives a written notice from you of a change Mi status that prevents you from returning to the Community as contemplated under Section VI 7 of this Residency Agreement. R Your Right to Rescind For a seventy -two (72) hour period beginning on the date of occupancy, you have the fright to rescind any contractual obligation to which you have entered into with the Community, including this Residency Agreement, and to pay only for the services received during that period. Your rescission must be in writing and addressed to the Community - Attention: Residence Director. Pannsytvanla— KH- Ddlsburg(Aprit1009) 18 IX.PARTIES' RIGHTS AND RESPONSIBILITIES IN CONNECTION i WITH A TRANSFER OR DISCHARGE A. Transfer or Discharge; Alternative Setting Upon receipt of a notice of transfer or discharge, you and your Responsible Person will make arrangements to relocate you to an appropriate alternative setting. The Community will provide reasonable assistance to you and your Responsible Person in connection with your relocation efforts, including; 1. Identifying altemative facilities commensurate with your current needs; Z. Preparing you and your personal belongings for transfer, including your medications; 3. Documenting your transfer in your resident record, including the reason(s) therefor; and 4. Subject to applicable privacy laws, providing such information and documentation that may be required by the new facility relative to your condition and stay at the Conummity. I If you or your Responsible Person does not cooperate to effect the transfer or discharge, we may call Adult Protective Services or other appropriate agencies in the county in which the Community is located for assistance. .B. Removal of Personal Property You or your Responsible Person must remove your personal property from the apartment on or prior to the termination date. If this Residency Agreement is terminated other than as a result of your death, we will continue to assess fees at your current daily rate until you or your Responsible Person has removed your personal property from your apartment. If you or your Responsible Person fails to remove your personal property as of the termination date, upon seven (7) days' prior written notice, the Community may elect to remove your personal property and place it in storage at your expense at a charge equal to your daily rate for each day your property remaini in storage. If your personal property is not claimed within seven (7) days-after we provide such written notification, the Community may dispose of it in its discretion. If this Residency Agreement is terminated as a result of your death, in accordance with the Elder Care Payment Restitution Act, the Community will contact your hm*ylvaria— PCH- Dillsburg(April2M9) 19 + I personal representative or guardian within 24 hours to arrange for an inventory of your personal property, and your personal representative or guardian is responsible for removing your belongings. If your personal property is not removed from the apartment after the completion of the inventory, the Community may elect to remove and store it for a period of thirty (30) days at the Community's expense. If following such thirty (30) day period your personal property is still not claimed, the Community wi send your personal representative or guardian a written notice by certified mail that unless your personal property is claimed within the next fourteen (14) days, the Community may dispose of it in its discretion. C. Existing Charges You, your Responsible Person or your Guarantor is responsible for any charges incurred by you up through and including the date of termination of this Residency Agreement. This payment obligation shall expressly survive any termination 'of this Residency Agreement. D. Right to Show Apartment During the time between delivery of notice of termination and the termination date, you and your Responsible Person grant us permission to show the apartment r' to prospective residents upon reasonable notice and during reasonable hours. X. MEDICAL EMERGENCY In the event of a medical emergency, 'as solely determined by our staff, we will call 9 -1 -1 to summon emergency medical services for you and to transport you to the appropriate medical facility to provide medical care and treatment, as determined by the emergency medical personnel. You understand and agree that payment for the costs of emergency services and transport, and any medical care and services received during hospitalization, will be your responsibility. XI. DISCLAIMER OF CERTAIN DUTIES As a resident of our Community, you retain your independence and may cone and go from the Community or the apartment at your pleasure, except to the extent that your actions interfere with the quiet enjoyment, welfare, health or safety of our other residents or staff. We assume no duty to limit or otherwise control your ingress or egress from the Community, You and your Responsible Person.under this Resident Agreement expressly waive any right to claim that we have a duty to limit or otherwise control your ingress and egress. You and your Responsible Person discharge and release us from such duty should it be found at law. Pennsylvania — PCH- D�7lsburg(Api%2009) 20 i I X11. CONSERVATOR OR GUARDIAN t If you become legally incompetent or are unable to care for yourself or your property properly and have failed to designate a person to serve as your guardian or conservator, you grant us the authority to apply on your behalf to a court for the appointment of a guardian or conservator. Neither this Community nor any of its employees can be appointed as your guardian or conservator. XIII. MSCELLANEOUS PROVISIONS A. Changes in Occupancy If the apartment is occupied by two related persons and one surrenders the apartment to the other, the remaining Resident's obligation under this Residency Agreement will continue in full legal force and effect, and the daily rate will be adjusted to reflect the single occupancy rate then in effect for the apartment. You, your Responsible Person and Guarantor will be required to sign an Amendumetrt to the Rate Schedule to document the new daily rate. B. Ownership Rights Except for your personal property, you have no ownership rights to or interest in ( the apartment, our personal property, the land, buildings and other improvements located at the Community. This Residency Agreement is not a lease nor does it confer on you any right of tenancy or ownership. C. Assignment The rights and obligations of the Resident, the Responsible Person and the Guarantor, if awry, under this Residency Agreement may not be assigned. The Resident may not sublet the apartment. In connection with the transfer of our interest in the Community, we may assign all of our rights and obligations under this Residency Agreement to an assignee who agrees to assume the rights and obligations arising under this Residency Agreement. Upon such an assignment, we will be released from all further obligations arising under this Residency } Agreement and you agree to look solely to the assignee for enforcement of any of your rights under this Residency Agreement on and after the effective date of such assignment. Peansylmia — PCH . Dillsburg (Ayll 2004) 2 t I � I D. Severability If a court holds any provision of this Residency Agreement or the application to any circumstance or person to be invalid or unenforceable, the remainder of this Residency Agreement or the application of such provision to persons or circumstances other than those to which it is held invalid or unenforceable will not be affected E. Subordination Your rights wider this Residency Agreement are subject and subordinate to any lease, mortgage or security instrument secured by the Community's assets. F. Notices and Consents Unless otherwise provided elsewhere in this Residency Agreement, all notices, consents or waivers will be in writing. Except as may otherwise be required under the laws and regulations applicable to the Community, we will deliver.our notices to you at your apartment with a copy to your Responsible Person and Guarantor at their last known addresses. Your Responsible Person and Guarantor are responsible for providing the Community with their current address information, and any changes that may occur while you reside in the Community. You will deliver your notices to us at the Community's address to the attention of the Residence Director. All written notices under this Residency Agreement shall be delivered by one or more of the following methods: (i) by personal delivery, in which case such notice shall' bd deemed received by the intended recipient upon delivery or, if delivery is refirsed, uppn the date of attempted delivery; (ii) by U.S. mail (regular, first class), in which case such notice shall be deemed received by the intended recipient five (5) business days after the notice is deposited in the U.S. mail; (iii) by U.S. mail (registered or certified mail, return receipt requested, in which case such notice shall be deemed received by the intended recipient three (3) business days after the notice ,is deposited in the U.S. mail; or (iv) by a reputable nationally recognized overnight courier service, in which case such notice shall be deemed received by the intended recipient on the next business day after the notice is deposited with the courier service. G. Civil Rights We are in compliance with Title VI of the Civil Rights Act of 1964 and applicable requirerneats imposed by and pursuant to the regulations of the United States Department of Health and Human Services. Pennsylvania — PCH - Dalaburg (April 2009) 22 E r H. Supplemental Security Income (SSI) � PF Recipients of, or eligible applicants for, SSI should refer to and sign the SSI Addendum attached to this Residency Agreement as Attachment E. If you are eligible and receive SSI, the amount you are required to contribute towards your obligations under this Residency Agreement shall automatically increase to reflect any increases in Social Security and Supplemental Security Income payments you receive, minus the then current personal needs allowance you are entitled to retain for personal expenditure. I. Attachments; Entire Legal Agreement Attachments A through E listed below are attached to this Residency Agreement. • Attachment A - Rate Schedule • Attachment B - Acknowledgement and Consent Forms Photo Release Medical Information and Release A Medication Refusal • Attachment C — Pharmacy Selection. • Attachment D —Complaint Procedures ( + Attachment E —Addendum for Supplemental Security Income Residents Attachments A through E are incorporated by reference and are made a part of this Residency Agreement. This Residency Agreement and Attachments A through E constitute the entire legal agreement between the Community and you, your Responsible Person and Guarantor regarding your stay in the Community and supersede any prior agreements regarding your residency. J. Additional Information For your convenience and easy reference, the following information appears at the end of this Residency Agreement but it is not part of the legal agreement: (i) a copy of your current Resident's Rights, which are provided to you under Pennsylvania law, (ii) a copy of the Community's current Resident Handbook, which contains the house rules, and (iii) your current support plan Your current Resident's Rights under state law are printed on Exhibit 1. The current Resident Handbook is printed on Exhibit 2. In order to document that your Resident's Rights under state law and the Community's Resident Handbook were provided and explained to you, you will sign an acknowledgment on Exhibit l and Exhibit 2. PannsyNaaia— PCS•Dilist.. (A012409) 23 If the State of Pennsylvania elects to change our Resident's Rights a g Y g s they appear (' on Exhibit 1, the Community will provide you with a new copy. We reserve the right to change or otherwise modify the Resident Handbook as it appears on Exhibit 2 from time to time. If we do so, we will provide you with a copy of the revised Resident Handbook thirty (30) days in advance of the effective date of the changes, Your current support plan will be Exhibit 3 and will be signed by you and your Responsible Person or documented as to the reason signatures do not appear. Your support plan will be updated as set forth in this Agreement. The Resident's Rights, Resident Handbook and the current Support plan are being provided to you for informational purposes only. They are not incorporated into and do not form a pail of this Residency Agreement, and they do not give you, your Responsible Person or Guarantor any rights of any kind against the Community. [this portion of the page is intentionally left blank] { (the next two fallowing pages are the signature pages) t f Pennsylvania — PCK- Diillaburg (April 2009) 24 i I Residency Agreement Signature Page(s) Having read and understood this Residency Agreement and each of the Attachments A -E that follow this signature page and the rights and obligations created by such documents, the undersigned acknowledge that they understand the rights and obligations created by this Residency Agreement and the Attachments and, by signing below, agree to all the terns and conditions of this Residency Agreement. COMMUNITY: AL Dillsbur Operati , LLC d/b/ croft of Dillsburg By: Date: ( signature) PrintedName: Title: RESIDEN By: Date: /� a (signature) (' Printed Na ��• C_ By: Date: (j 149 (signatur Pri ted Name: Having read and understood this Residency Agreement and each of the Attachments A -E that follow this signature page and the rights and obligations created by such documents, the Responsible Person(s) signs) this Residency Agreement and agrees to such rights and obligations, and to be involved in decisions required for the Resident's welfare while at the munity. The Responsible Person(s) acknowledges that he/she is is not responsible for managing the Resident's personal funds. c � Pennsylvania — PCH.DOlsburg (April 200) s-1 1 RESPO SIBLE PERS�O�T:� s0. f' B y : Date: g> Printed Name: (si Lure ---1 By Date, 3 b (signature) Printed Name: Having read and understood this Residency Agreement and each of the Attachments A -E that follow this signature page and the rights and obligations created by such documents, the Guarantor voluntarily signs this Residency Agreement to personally. guarantee the financial obligations of the Resident, including the personal liability for payment of all fees that the Resident may owe the Community, GUARANTOR: By: , x�di,�b'L� --_.� Date: Q �•(,'� /�-' (si rat re) ( Punted Name; i Pennsylvania -PCS- DillsWr& (Apr 20" 5'_2 i I � 4 Attachment A - Rate Schedule ( t EImcroft of Dlllsburg D9llsburg, Pennsylvania Resident Name: Responsible Person Name: Guarantor Name: Residency:' Assisted Living ermanent Respite Private Semi - Private Related Resident Date of Occupancy: Apartment Number: Enter the level of care at lime of move - in, and the daily rate and fees at time of ' move - in, or enter MA if not applicable. Level of Care: 1— Daily Rate: $ A 0' New Resident Service Fee: $–W� New Respite Resident Service Fee: $ Pet Fee: $ Motorized Cart Fee: $ _ Furniture Rental Fee: $ • I (per month, if applicable) { f Peimsyhrenia— PCN- 171lkburg(Apt112009) A -1 i I • I ACCOMMODATIOAULEVEL OF CARE CkIANGE: If there is a change in your accommodations and/or your level of care, you will begin to pay an adjusted daily rate as set forth below: _Apartment Number Level E Level L I Level mbi Levelly+ NOTE: The daily rate is not reduced during hospitalization or other absences from the Community except as otherwise provided in the Residency Agreement. Additional Services GuestMeal Breakfast ......................... ............................... ..............:...... $4.00 /meal GuestMeal - Lunch ................................................... ............................... $5.00 /meal GuestMeal - Dinner .................................................. ............................... $6.00 /meal GuestMeal - Holiday ............................................. ............................... $10.00 /meal Tray. Service .................................... ............................... ..........................$3.00 /meal Basic Cable Television (if billed directly by Community) .................. $30.00 /month Pendant Replacement (if applicable) ........ ............................Per Conununity Charge KeyReplacement ............ ..................... ............................... ..................... $5.00 /each Catering ............................. .....:.....:................... ............................Per Vendor Charge ( Dry Cleaning ..................... ......................... ............................Per Vendor Charge Personal and Medical Supplies ........................ .........:.:................Per Vendor Charge Telephone Services (including long distance. calls) ....................Per Vendor Charge Cable Television (if billed directly to Resident) .........................Per Vendor Charge Beautyand Barber ........................................ ............................... Pek Vend ' or Charge Pharmacy ........................... ............................... ............................Per Vendor Charge Activities ............................... Per Vendor charge for general admission, lunch, etc. Personal Transportation Transportation of 20 miles or less on designated days ........................... 10.00 Transportation on non - designated days ............ $20.00 per .hour plus $0.75 per mile Transportation in excess of 20 miles ................ $20.00 per hour plus $0.75 per mile Escort Services ................................................... ............................... $20.00 per hour Invoices are due on the 0 day of each month. If the invoice is not paid by the 10 day of the month, late charges will be applied. A compounding late fee of 1.5% will be applied monthly to any balance due. i POOMY OMA — PCH - Dilisburg (April 200P) A -2 I t - ACICNOWLEDGEMENTS Understanding and Receipt of Rate Schedule. The patties acknowledge and agree that they understand all rates and fees they are responsible for paying to the Community, as set forth in this Rate Schedule attached to the Residency Agreement as Attachment A. The Resident, the Responsible Person and Guarantor each acknowledges receipt of the foregoing. Rate Changes; Amendment to Rate Schedule; Notice, The parties understand, acknowledge and agree that (i) the original Rate Schedule is determined at the time of move -in, (ii) the Rate Schedule is subject to change by the Community from tithe to time, (iii) any change to the Rate Schedule will be reflected in an Amendment to Rate Schedule executed by the Community, the Resident, the Responsible Person and the Guarantor, (iv) the Community is not required to provide advance notice of any change in the Daily Rate made pursuant to Section VI 13 of the Residency Agreement, and (v) the Community is required to provide thirty (30) days' advance notice of any change in the Rate Schedule made pursuant to Section VI C of the Residency Agreement. f Xf this is an Amendment to the Rate Schedule, check the box below, and indicate the Amendient number and the effective date of the Amendment. o Amendment 0 to Rage Schedule, effective on the day of 20 You are being provided with an Amendment to the Rate Schedule. The effective date of the Amendment Is indicated above. .except as expressly stated in this Amendment, (i) you- ratify and confirm all the terms, conditions and provisions of your Residency Agreement, and (ii) you acknowledge and agree that your Residency Agreement remains in full force and effect in accordance with its terms. All references to your Residency Ags eenrent shall mean your Residency Agreement as amended by this Amendment. [SIGNATURES TO "A'TTACHME NT A - RATE SCHEDULE" ARE ON TRVNEXT FOLLOWING PAGE] 1 Pemsylvala -PCH • D8lsbhtg (Apd12009) A -3 The parties hereto, intending to be legally bound, execute this Rate Schedule, l effective as of the date referenced. Resi nt's Signature Date 6 r - R nsible Person's Signature - Date Gu ntoes i " nature — � f � -- $ Date COMMUNITY: Name Date Residence Director or Designee r i P"mylvania— PGE- Dilbburs(Aprd2M A -4 1 Attachment B - AcknowIedgement and Consent Forms Elmeroft of Dillsburg Dillsburg, Pennsylvania PHOTO} RELEASE Part A I understand that for safety and security reasons it is the policy of the Community to maintain a photograph of me in the resident files, and I consent to being photographed for this purpose. 110 R i nt's Si t Date Resp Bible Person's Signature Date ,, 6lr r Gu ntoes Signature Date Part B: I understand that my photograph may be taken in connection Mth activities and may be posted within the Community. I also understand that my photograph may be used for marketing purposes: including printed materials or published articles about the Community-for the purposes of advertising, product information, publicity, public and corporate information and that these photos are not produced for sale to the public at large. I give my consent to be photographed for these reasons, and . release the photographs to the Community for these purposes, and in the event the photographs of me are released to the media, or in . any printed form through the Community for any media use, I willingly give my consent to such uses without remuneration. I agree to hold the Community, its assigns and its agents harmless in the use of such photographs, materials and articles. a.� �l o ji d Re dent's Si re Date OA 0/1� . R nsib a erson's Signature bate A ►: �tiC�2. c�f 0 �l g AA Gu tor's Signature Date • i Pannsylvanin— PCH- Dillsburg (APn72009) B - ' t MEDICAL INFORMATION and RELEASE I give pennission to the Community to obtain, review and hold any medical information and records relating to my medical and physical condition and medical care I have received, and to release such medical information to persons and facilities providing medical care to me. o.[1 Re 'dent's Signatur Date 2� R nsible Person's Signature Date G i antoes Signature Date MEDICATION REFUSAL In accordance with Section 2600.191 of the Pennsylvania Code, I have the right to question or refuse medication if I believe there may be an error, and I hereby acknowledge that I have been informed of this right, and I understand I have this right. - 66&"Sj�m4dL Resgdeffs Signature - Date R ponsible Person's Signature Date i%wgAJ iL _ N/6 Gu antor's Signature Date Prnasylwnia— PCH- Dilisyrrg (April 2009) B -2 ti i Attachment C – Pharmacy Selection !� Elmeroft of Dillsburg Dillsburg, Pennsylvania I understand I have the right to select a pharmacy of my choice to provide my prescription and over - the - counter medications and supplies. I may use one •of the Community's Designated Pharmacies or I may select another pharmacy. However, if I do not use one of the Designated Pharmacies, the pharmacy of my choice must comply with the Community's packaging and dispensing requirements. yl I elect to use one of the Community's Designated Pharmacies. I elect to use a pharmacy of my choice that is willing and able to provide my prescription and over- the - counter medications and supplies in accordance with the Community's packaging and dispensing requirements. The parties understand, acknowledge and agree that (i) the original Pharmacy Selection is made by the Resident or Responsible Person at the time of move -in, (ii) the Resident or Responsible Person may change the Pharmacy Selectia:tt from time time on advance notice to the Community, and (iii) any change to the Pharmacy Selection will be reflected in an Amendment to Pharmacy Selection executed by the Community, the Resident and the Responsible Person. If this is an Amendment to the Pharmacy Selection, check the box below, and indicate the Amendment number and the effective date of theAmeitdrnen4 o Amendment # to Pharmacy Selection, effective on the day of _ 20 —. You are being provided with an Amendment to the Pharmacy Selection, The effective date of the Amendment is indicated above. Except as expressly stated In this Amendment, (i) you ratify and confir all the terms, conditions and provisions of your Residency Agr eement, and (ii) you acknowledge and agree That your Residency Agreement remains in full farce and effect in accordance with its terms. All references to your Residency Agreement shall mean your Residency Agreement as amended by this Amendment Pcnmy Ivanis— PCfI - Dillst1urg(Apill2009) L'—� i The parties hereto, intending to be legally bound, execute this Pharmacy Selection l attachment effective as of the date referenced. n,f\ RMA& L4AMtk Re nt's Si a Date �lV�. 31�0(�0 R onsible Person's lgna Date C01 MITY- C-1" ame Date Residence Director or Designee f Pennsylvania — PCH- Dillsburg(April 2009) C -2 f � Attachment D -- Complaint and Grievance Procedures Elmcroft of Dillsburg Dillsburg, Pennsylvania Part 1— Formal Complaints Every Resident or Resident's Responsible Person has the right to file a formal complaint with the Community, the Department of Public Welfare's personal care home regional office, the local ombudsman or the protective services unit in the area agency on aging, Pennsylvania Protection & Advocacy, Inc. or law enforcement agency. Chapter 2600.44 of DPW's regulations establishes the following formal complaint procedure: ! (a) Prior to admission, the home shall inform the resident and the resident's designated person of the right to file and the procedure for filing a complaint with the home or the Department of Public Welfare's personal cAre home regional office, local ombudsman or protective. services unit in the area agency on aging, Pennsylvania protection & Advocacy, Inc. or law enforcement agency. (b) The home shall permit and respond to oral and written complaints from any ( source regarding an alleged violation of resident rights, duality of care or other matter without retaliation or the threat of retaliation. (c) If a resident indicates that he /she wishes to make a written complaint, but needs, assistance in reducing the complaint to writing, the home shall assist the resident in writing the complaunt. (d) The home shall ensure investigation and resolution of complaints. The home shall designate the staff person responsible for receiving complaints and determining the outcome of the complaint. (e) Within 2 business days after the submission of a written complaint, a status report shall be provided by the home to the complainant. If the resident is not the complainant, the resident and the resident's designated person shall receive the status report unless contraindicated by the support plan. The status report must indicate the steps that the home is taking to investigate and address the complaint. (f) Within 7 days after the submission of a written complaint, the home shall give the complainant and, if applicable, the designated person, a written decision explaining the home's investigation findings and the action the home plans to take to resolve the complaint. If the resident is not the complainant, the affected Pennsylvania —PCH - Dlitsburg (Ap412009) D -1 j t I resident shall receive a copy of the decision unless contraindicated by the support (' plan. If the home's investigation validates the complaint allegadons, a resident who could potentially be harmed or his/her designated person shall receive a copy of the decision, with the name of the affected resident removed, unless contraindicated by the support plan. (g) The telephone number of the Department's personal care home regional office, the local ombudsman or protective services unit in the area agency on aging, Pennsylvania Protection & .Advocacy, Inc., the local law enforcement agency, the Commonwealth Information Center and the personal care home complaint hotline shall be posted in large print in a conspicuous and public place in the home. NOTE: At any time during this process, the Resident or the Resident's Responsible Person may also file an informal grievance with the Community as outlined in Part 2 below. Part 2 -- Informal Grfcyances Every Resident or Resident's Responsible Person has the right to file an informal grievance with the Community. The procedure is as follows: ( (a) Discuss the concern or grievance with the staff member directly responsible. (b) If you are not satisfied with the result, please discuss the concern or grievance with the department supervisor. (c)'If you are not satisfied with the result, please bring the matter to the attention of the Residence Director, Please allow seven days for a response. This time may be necessary in the event the Residence Director. needs to complete an investigation. (d) If the matter still is not resolved to your satisfaction, we ask that you contact the Regional Director of Operations to make your concern known. (e) If you have exhausted all of above, and are still unsatisfied, please contact the Operations Department at the Support Center, NOTE: At any time during this process, the Resident or the Resident's Responsible Person may also file a formal complaint as outlined in Part i above. , FOLLOWING IS THE CONTACT INFORMATION NEEDED IN ORDER TO FILE A FORIMAL COMPLAINT OR AN INFORMAL GRIEVANCE: 1 I J Pennsylvania— PCH.Dillsburg(ApU 2004) D-2 + t �.. Pennsylvania Department of Public Welfare Personal Care Homes Central Field Office Counties ReRrresented: Adams, Bedford, Blair, Cambria, Cameron, Centre, Chester, CIearfield, Clinton, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lancaster, Lebanon, Mifflin, Perry, Potter, Snyder, Somerset, York Ron Melusky, Licensing Director Address: 1401 North 7th Street, Bertolino Building - 4th Floor, P.O. Box 2675, Harrisburg, FA 17105 -2675 Telephone Number: 717- 772 -4673 Toll-Free Number: 1- 800 - 882 -1885 Fax Number: 717 - 783 -3956 Pennsylvania Department of Public NVelfare Complaint Hotline: 1 -800- 254 -5164 Pennsylvania Department of Aging — County Area on Aging Office (Ombudsman Program and Adult Protective Services Program) York County Area Agency on Aging 100 Nest Market Street, Suite 102 York, PA 17401 -1341 Tel: (717) 771 -9610 Toll free: (800) 632 -9073 ( Fax: (717) 771 -9044 Web site: www,ycaaa -qg E-mail: aging @ york- countyorg Services: Apprise: (800) 632 -9073 or (717) 771 -9610 Ombudsmen: (717) 771 -9610 Protective Services: (800) 632 -9073 Pennsylvania Protection and Advocacy, Inc. 1414 N. Cameron Street, Suite C Harrisburg, PA 17103 Tel: 800 - 692 -7443 TTY: 877 - 375 -7139 FAX: 717 - 236 -0192 Website: www.ppainc.orR E -mail: ppa ftpainc.org t Patim ylvania -PCH - Ailisbtiag (April 2009) D -3 Local Law Enforcement Agency (' Carroll Township Police Department 555 Chestnut Grove Road Dillsburg, PA 17019 Phone: (717) 432 -3317 Fax: (717) 432 -9883 Pennsylvania Department of General Services — Commonwealth Information Center 402A Finance Building Harrisburg, PA 17125 Telephone: (717) 787- 2121(voice) Toll Free: 1- 800-932 -0784 (voice) TDWITY number for the hearing impaired: 1- 800324 -8040 Monday through Friday, 8:00 AM to 5:00 PM. Community Contact Information The staff members are identified by their name tags. The names of supervisors of specific departments are included in the Resident Handbook, as well as the name of the Residence Director. For contact information on the name, address and ' telephone number of the Regional Director of Operations, or the Senior Vice President of Operations, please contact the Support Center at the address and telephone number listed below: • Senior Care, Inc. 9510 Ormsby Station Road, Suite 101 Louisville, KY 40223 Telephone: 502-753-6000 Fax: 502 -753 -6100 I acknowledge receipt of the Complaint and Grievance Procedures outlined in Attachment D. (Re dent signature) esponlsible. Person signature) I Pennsylvania— PCH - Aiilsburg(April 2009) D4 ' t ' Attachment E Addendum for t Supplemental Security 3Lucome Residents Elmeroft of Dillsburg Dillsburg, Pennsylvania CHECK ONE: his Addendum does apply Xdoes not apply. If the Addendum does a y, you must obtain signatures on the signature page. This Adden for Supplemental Security Income Residents to the Residency Agreement (the `SSI Addendum'') applies to residents Nvho receive or are eligible for SSI benefits. n the event of any conflict between the provisions of this Addendum and the p visions of your Residency Agreement, the provisions of this Addendum shall be doe ed to be controlling. E -1. Services. The Community will pro ' e to the Resident necessary personal hygiene items such as a comb, tootbbrush, othpaste, soap and 'shampoo at no additional t cost to the Resident. Additionally, th Community will provide personal laundry services, bed linens, towels and perso 1 care services to the Resident, which services are included in the Daily Rate. smetic items, dry cleaning and other specialized services are not included in the D ' y Rate. Financial Obligations. The Daily Rate for actual rent and other se ices will not exceed the Resident's actual current monthly income reduced by a then current personal needs allowance, as determined by DPW. The Daily to will automatically increase to coincide with increases in Social Security and S lemental Security Income payments to the Resident, minus the current persona eeds allowance, which the Resident will retain for personal expenditure. The Community will not charge a finance charge to the Resi t for any balance that is overdue because of processing by the Social ecurity Administration. Pennsylvania— PCH•Dillsbucg(Apri12009) -1 r. . i i Payment for rent and other services m not include funds received as lump r �` sum awards, gifts or inheritances, gains from the sale of property, or retroactive gove ent benefits. The Community may seek and accept payments from funds receive as retroactive awards of SSI benefits, but only to the extent that the retroacti awards cover periods of time during which the Resident actually resided in Community fbr which full payment has not been received. (this portion of the page is intentionally left blank) the next following page is the signature pages) i 1 Prnnsyl- nnia —FCH - DIRSUarg (April 2009) �,` -� The parties, intending to be legally bound, eXecute this SSI Addendum, effective as of the day of , 20 Resident's ignature Date (lf unable t sign, mark below) Guarantor's Signature Date (if other than Resident) Responsible Party's Signature Date (at the option of the Resident) Resident's Mark Date (if unable to sign) FOR THE COMMUNITY: Name Date Community Director or Designee ` - -END OF RESIDENCY AGREE A1ENT -- Pennsylvania — PCH - Dillsburg (April 209) Era i -- INFORIMATIONAL MATERIALS— Exhibit 1— Resident Bill of Rights'and AcIonowledgement Pennsylvania Code — Chapter 2600.42 - Resident Rights. (a) A resident may not be discriminated against because of race, color, religious creed, disability, handicap, ancestry, sexual orientation, national origin, age or sex. (b) A resident may not be neglected, intimidated, physically or verbally abused, mistreated, subjected to corporal punishment or disciplined in any tvay. (c) A resident shall be treated with dignity and respect. (d) A resident shall be informed of the rules of the home and given 30 days' written notice prior to the effective date of a new home rule. (e) A resident shall have access to a telephone in the home to make calls in privacy, Nontoll calls shall be without charge to the resident. (0 A resident has the right to receive and send mail. (1) Outgoing mail may not be opened or read by staff persons unless the resident requests. (2) Incoming mail may not be opened or read by staff persons unless upon the request of the resident or the resident's designated person. (g) A resident has the right to communicate privately with and access the local ombudsman. (h) A resident has the right to practice the religion or faith of the resident's choice, or not to practice any religion or faith. (i) A resident shall receive assistance in accessing health services. (j) A resident shall receive assistance in obtaining andkeeping clean, seasonal clothing, A resident's clothing may not be shared with other residents. (k) A resident and the resident's designated person, and other individuals upon the resident's written approval shall have the right to access, review and request corrections to the resident's record. S (1) A resident has the right to furnish his room and purchase, receive, use and r retain personal clothing and possessions, (m) A resident has the right to leave and return to the home at times consistent with the home rules and the resident's support plan. (n) A resident has the right to relocate and to request and receive assistance, from the home, in relocating to another facility. The assistance shall include helping the resident get information about living arrangements, making telephone calls and transferring records. (o) A resident has the right to freely associate, organize and communicate with others privately. (p) A resident shall be free from restraints. (q) A resident shall be compensated in accordance with State and Federal labor laws for labor performed on belialf of the home. Residents may voluntarily and without coercion perform tasks related directly to the resident's personal space or common areas of the home. (r) A resident has the right to receive visitors for a minimum of 12 hours daily, 7 { days per week, (s) A resident has the right to privacy of self and possessions. Privacy shall be provided to the resident during bathing, dressing, changing and medical procedures. . (t) A resident has the right to file complaints with any individual or agency and recommend changes in policies, home rules and services of the home without intimidation, retaliation or threat of discharge. (u) A resident has the right to remain in the home, as long as it is operating with a license, except as specified in § 2000.228 (relating to notification of termination). (v) A resident has the right to receive services contracted for in the resident -home contract. (w) A resident has the right to use both the home's procedures and external procedures, if any, to appeal involuntary discharge. (x) A resident has the right to a system to safeguard a resident's money and property. {. I 1 i 1 r (y) A resident has the right to choose his own health care providers without limitation by the home. This includes the right to select the resident's own pharmacist provided that the pharmacy agrees to supply medications in a way that is compatible with the home's system for handling and assisting with the self - administration of resident medications. I acknowledge receipt of the Resident Bill of Rights, (R den i ( ponsib a Person signature) , t (G actor signature) t Run Date 11/19/2012 SENIOR CARE ALF Run Time 11:55:33 AM System Date 11/19/2012 : 9510 ORMSBY STATION RD STE 101 Page No. : 1 JOANN LOUISVILLE KY 40223 Patient: 349 SABOTCHICK + Detail Inquiry ------------------------------- - - - - -- _ _______ _ _ _ ________ BillNum Proc Description ServDate Bto Pln Pry Fac Units Charge - - -- -- _ _ Payment# PmtCode PmtDate Payment Adjustment Balance ------- ------------------------ -------- --- 0138283 RB -ALL AL LEVEL L SER 5/1/2012 PVT PVTAL NODOC 126 31.00 3548.88 ---------------------------------- 0084384 200 2 PMT PRIVATE 9/14/2012 001 2403.95 0199680 BBFEE BB BARBER /BEAU 5/3/2012 PVT PVT NODOC 126 1.00 12.65 1195.93 0144680 BBFEE BB BARBER /BEAU 5/7/2012 PVT PVT NODOC 126 1.00 46.00 12.65 0144680 BBFEE BB BARBER /BEAU 5/11/2012 PVT PVT NODOC 126 1.00 12.65 46.65 0149997 BBFEE BB BARBER /BEAU 5/17/2012 PVT PVT NODOC 126 1.00 12.65 12.65 0149997 BBFEE BB BARBER /BEAU 5/24/2012 PVT PVT NODOC 126 1.00 12.65 12.65 0149997 BBFEE BB BARBER /BEAU 5/31/2012 PVT PVT NODOC 126 1.00 12.65 12.65 0145151 RB -ALL AL LEVEL L SER 6/1/2012 PVT PVTAL NODOC 126 30.00 3434.40 12.65 0153239 BBFEE BB BARBER /BEAU 6/7/2012 PVT PVT NODOC 126 1,00 12.65 3434.40 0160117 BBFEE BB BARBER /BEAU 6/15/2012 PVT PVT NODOC 126 1.00 12.65 12.65 0160117 BBFEE BB BARBER /BEAU 6/21/2012 PVT PVT NODOC 126 1.00 12.65 12.65 0160117 BBFEE BB BARBER /BEAU 6/29/2012 PVT PVT NODOC 126 1.00 12.65 12.65 0169999 RB -ALL AL LEVEL L SER 7/1/2012 PVT PVTAL NODOC 126 23,00 2633.04 12.65 0161992 BBFEE BB BARBER /BEAU 7/6/2012 PVT PVT NODOC 126 1.00 12.65 2633.04 0163539 BBFEE BB BARBER /BEAU 7/13/2012 PVT PVT NODOC 126 1.00 12.65 12.65 0168689 BBFEE BB BARBER /BEAU 7/20/2012 PVT PVT NODOC 126 1.00 12.65 12.65 0169999 R13 AL LEVEL M SER 7/24/2012 PVT PVTAL NODOC 126 8.00 1067.89 12.65 0170510 BBFEE BB BARBER /BEAU 7/27/2012 PVT PVT NODOC 126 1.00 12.65 1067.64 0170022 RB -ALM AL LEVEL M SER 8/1/2012 PVT PVTAL NODOC 126 31.00 4137.88 12.65 0178360 MEALTRAY TRAY SERVICE T 8/1/2012 PVT PVT NODOC 126 3.00 9.00 4137.68 0172568 BBFEE BB BARBER /BEAU 8/2/2012 PVT PVT NODOC 126 1.00 12.65 9.00 0172568 BBFEE BB BARBER /BEAU 8/6/2012 PVT PVT NODOC 126 1.00 46.00 12.65 0178360 BBFEE BB BARBER /BEAU 8/9/2012 PVT PVT NODOC 126 1.00 12.65 46.00 0178360 BBFEE BB BARBER /BEAU 8/16/2012 PVT PVT NODOC 126 1.00 12.65 12.65 0178360 BBFEE BB BARBER /BEAU 8/23/2012 PVT PVT NODOC 126 1.00 12.65 12.65 0179334 BBFEE BB BARBER /BEAU 8/30/2012 PVT PVT NODOC 126 1.00 12.65 12.65 12,65 ------ - - - - -- ------ - - - - -- ----- - - - - -- ----- - - - - -- Patient Total: 15150.74 2403.45 0.00 12747.29 VERIFICATION PAGE The undersigned does hereby verify subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities, that l she is Director of Accounting Plaintiff herein, and that /she is duly authorized to make this Verification, and that the facts set forth in the foregoing Complaint are true and correct to the best of M /her knowledge, information and belief. Date l �� (Signature) Elizabeth Butler SHERIFF'S OFFICE OF CUMBERLAND CO,UINTY_ .. , Ronny RAnderson 4; ` i}��. fia�iE�'i Plt� ;�"A ;`f Sheriff crt 4;nrrairc U14, 3 Jody S Smith t:13 � 1 L Chief Deputy n • � cJe BElA�� �� T` f Richard W Stewart i Solicitor UPC OF-H-1- kERIF�;5 PENNSYLVANIA Elmcroft of Dillsburg Case Number vs. Joann Sabotchick(et al.) 2013-2855 SHERIFF'S RETURN OF SERVICE 05/24/2013 07:06 PM- Deputy Ryan Burgett, being duly sworn according to law, served the requested Complaint& Notice by handing a true copy to a person representing themselves to be Donna McGahen, daughter of defendant, who accepted as"Adult Person in Charge"for Joann Sabotchick at 16 Keefer Way, Upper Allen, Mechanicsburg, PA 17055. RYAN BURGETT, DE 05/24/2013 07:06 PM - Deputy Ryan Burgett, being duly sworn according to law, served the requested Complaint& Notice by"personally" handing a true copy to a person representing themselves to be the Defendant, to wit: Donna McGahen at 16 Keefer Way, Upper Allen, Mechanicsburg, PA 17055. RYAN BURGETT, DEPUTY SHERIFF COST: $55.30 SO ANSWERS, X. 6a � May 29, 2013 RbNW R ANDERSON, SHERIFF (c)CountySuito Sheriff,Teleosoft,Inc. t, TILE J-� :'I ICE T :4- 1°r`tiOTi;OIdOTAf ?01 AL 15 Pt l 2: U 3 CUMBERLAND COUNTY PENNSYLVANIA IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION ELMCROFT OF DILLSBURG Plaintiff No: 2013-02855 VS. PRAECIPE FOR DEFAULT JUDGMENT JOANN SABOTCHICK DONNA MCGAHEN Defendants FILED ON BEHALF OF Plaintiff COUNSEL OF RECORD OF THIS PARTY: Michael J. Dougherty, 76046 WELTMAN, WEINBERG & REIS CO. , L.P.A. 325 CHESTNUT STREET SUITE 501 PHILADELPHIA, PA 19106-2614 215-599-1500 FAX: 215-599-1505 09862279 C i Jer TWI Judgment Amount $12747 . 2.9 /'��(,' "'�Ip•��cal �O oct C) G IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION ELMCROFT OF DILLSBURG Plaintiff VS . Civil Action No. 2013-02855 JOANN SABOTCHICK DONNA MCGAHEN PRAECIPE FOR DEFAULT JUDGMENT TO THE PROTHONTARY: Kindly enter Judgment against the Defendants JOANN SABOTCHICK, DONNA MCGAHEN, above named, in the default of an Answer, in the amount of $12747 . 29 computed as follows: Amount claimed in Complaint $12747 . 29 Less payments / adjustments made $0 . 00 Attorney' s fees $0 . 00 TOTAL $12747 . 29 I hereby certify that appropriate Notices of Default, as attached have been mailed in accordance with PA R.C.P. 237 . 1 on the dates indicated on the Notices . WELTMAN, WEINBERG & RE CO. , L.P.A. By:, 76046 Michael J. Do g e y, 09862279 C i Jer TWI Plaintiff ' s address is : c/o WELTMAN, WEINBERG & REIS CO. , L.P.A. , 325 CHESTNUT STREET SUITE 501 PHILADELPHIA, PA 19106-2614 And that the last known address of the Defendants are JOANN SABOTCHICK 16 KEEFER WAY MECHANICSBURG, PA 17055 DONNA MCGAHEN 16 KEEFER WAY MECHANICSBURG, PA 17055 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION ELMCROFT OF DILLSBURG Plaintiff vs. Civil Action No. 2013-02855 JOANN SABOTCHICK DONNA MCGAHEN NOTICE OF JUDGMENT OR ORDER TO: ( ) Plaintiff (xx) Defendant Garnishee You are hereby notified that the foljow�nq Order of Judgment was entered against you on - ­716A9 (xx) Assumpsit Judgment in the amount of $12747 .29 plus costs . Trespass Judgment in the amount of $ plus costs. If not satisfied within sixty (60) days, your motor vehicle operator' s license and/or registration will be suspended by the Department of Transportation, Bureau of Traffic Safety, Harrisburg, PA. (xx) Entry of Judgment of Court order Non-Pros Confession (xx) Default ( ) Verdict A Arbitration A d Prothonotary -By: PROTHONOTARY Ir4ft-DEPUTY) JOANN SABOTCHICK 16 KEEFER WAY MECHANICSBURG, PA 17055 DONNA MCGAHEN 16 KEEFER WAY MECHANICSBURG, PA 17055 Plaintiff ' s address is: c/o WELTMAN, WEINBERG & REIS CO. , L.P.A. , 325 CHESTNUT STREET SUITE 501 PHILADELPHIA, PA 19106-2614 215-599-1500 IN THE-COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION ELMCROFT OF DILLSBURG Plaintiff Case No. 2013-02855 vs. DONNA MCGAHEN JOANN SABOTCHICK Defendant IMPORTANT NOTICE TO: DONNA MCGAHIEN 16 KEEFER WAY MECHANICSBURG, PA 17055 Date of Notice: IN .2 0,20 YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE,COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE, IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT-AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION 32 SOUTH BEDFORD STREET CARLISLE, PA. 17013 (717)249-3166 WELTMAN WE & REIS CO., L.P.A. By: Michael Dougherty P.A.1.D.#76046 WELTMAN,WEINBERG&REIS CO., L.P.A. 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 (215) 599-1500 (215) 599-1505 9862279 1 PHI IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION ELMCROFT OF DILLSBURG Plaintiff Case No. 2013-02855 VS. DONNA MCGAHEN JOANN SABOTCHICK Defendant IMPORTANT NOTICE TO: JOANN SABOTCHICK 1jum 6 16 KEEFER WAY MECHANICSBURG, PA 17055 Date of Notice: YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE, IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, TH18 OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE, CUMBERLAND COUNTY BAR ASSOCIATION 32 SOUTH BEDFORD STREET CARLISLE, PA. 17013 (717)249-3166 WELTMAN, WEINBERG & REIS CO., L.P.A. By: Michael Do4herty P.A.I.D-#76 46 WELTMAN,� EINBERG & REIS CO., L.P.A. 325 Chestnu Street, Suite 501 Philadelphia, PA 19106 (215) 699-1500 (215)599-1505 9862279 1 PHI IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION ELMCROFT OF DILLSBURG Plaintiff VS. Civil Action No. 2013-02855 NON-MILITARY AFFIDAVIT JOANN SABOTCHICK DONNA MCGAHEN The undersigned is the- duly authorized agent and/or attorney for the Plaintiff in the within matter and states as follows: Affiant states that the within Affidavit is made pursuant to and in accordance with the Servicemembers , Civil Relief Act (SCRA) , 50 U.S.C. App. 521. Affiant further states that based upon investigation it is the affiant ' s belief that the Defendants, JOANN SABOTCHICK, DONNA MCGAHEN, are not in military service. Affiant further states that this belief is supported by the attached certificate from the Defense Manpower Data Center (DMDC) , which states that the DMDC does not possess any information indicating that the below individual is in the military service: JOANN SABOTCHICK 16 KEEFER WAY MECHANICSBURG, PA 17055 DONNA MCGAHEN 16 KEEFER WAY MECHANICSBURG, PA 17055 Affiant further states that the averments contained herein are true and correct to the best of Affiant ' s knowledge, information and belief and that these averments are made subject to the penalties of 18 Pa C.S.A. Section 4904 relating to unsworn falsification to authorities . AFFIANT Department of Defense Manpower Data Center Results as of:JuWB-201310:00:16 SCRA 3.0 ,► " Status Report rr t; Pursuant to Servicemembers Civil Relief Act Last Name: SABOTCHICK First Name: JOANN Middle Name: Active Duty Status As Of: Jul-08-2013 On Active Duty On Active Duty Status Date Active Duty Start Date Active Duty End Date Status Service Component NA NA No NA This response reflects the Individuals'active duty status based on the Active Duty Status Date Left Active Duty Within 367 Days of Active Duty Status Date Active Duty Start Date Active Duty End Date Status Service Component NA NA - - - No NA This response reflects where the Individual left active duty status within 367 days preceding the Active Duty Status Date r } The Member or His/Her Unit Was Notified of a Future Call-Up to Active Duty on Active Duty Status Date Order Notification Start Data Order Notification End Date Status Service Component NA NA "* No NA This response reflects whether the individual or hialher Zink has received early notification to report for active duty Upon searching the data banks of the Department of Defense Manpower Data Center,based on the information that you provided,the above is the status of the individual on the active duty status date as to all branches of the Uniformed Services(Army,Navy,Marine Corps,Air Force,NOAA,Public Health,and Coast Guard). This status includes information on a Servicemember or his/her unit receiving notification of future orders to report for Active Duty. HOWEVER,WITHOUT A SOCIAL SECURITY NUMBER,THE DEPARTMENT OF DEFENSE MANPOWER DATA CENTER CANNOT AUTHORITATIVELY ASSERT THAT THIS IS THE SAME INDIVIDUAL THAT YOUR QUERY REFERS TO.NAME AND DATE OF BIRTH ALONE DO NOT UNIQUELY IDENTIFY AN INDIVIDUAL. lot �s 'p Mary M.Snavely-Dixon,Director Department of Defense-Manpower Data Center 4800 Mark Center Drive,Suite 04E25 Arlington,VA 22350 it The Defense Manpower Data Center(DMDC)is an organization of the Department of Defense(DoD)that maintains the Defense Enrollment and Eligibility ' Reporting System(DEERS)database which is the official source of data on eligibility for military medical care and other eligibility systems. The DoD strongly supports the enforcement of the Servicemembers Civil Relief Act(50 USC App.§501 at seq,as amended)(SCRA)(formerly known as the Soldiers'and Sailors'Civil Relief Act of 1940). DMDC has issued hundreds of thousands of"does not possess any information indicating that the individual is currently on active duty"responses,and has experienced only a small error rate. In the event the individual referenced above,or any family member,friend,or representative asserts in any manner that the individual was on active duty for the active duty status date,or is otherwise entitled to the protections of the SCRA,you are strongly encouraged to obtain further verification of the person's status by contacting that person's Service via the "defenselink.mil"URL:http://www.defenselink.mil/faq/pis/PC09SLDR.htmi. If you have evidence the person was on active duty for the active duty status date and you fail to obtain this additional Service verification,punitive provisions of the SCRA maybe invoked against you. See 50 USC App.§521(c). This response reflects the following information: (1)The individual's Active Duty status on the Active Duty Status Date(2)Whether the individual left Active Duty status within 367 days preceding the Active Duty Status Date(3)Whether the individual or his/her unit received early notification to report for active duty on the Active Duty Status Date. More information on "Active Duty Status" Active duty status as reported in this certificate is defined in accordance with 10 USC§101(d)(1). Prior to 2010 only some of the active duty periods less than 30 consecutive days in length were available. In the case of a member of the National Guard,this includes service under a call to active service authorized by the President or the Secretary of Defense under 32 USC§502(f)for purposes of responding to a national emergency declared by the President and supported by Federal funds. All Active Guard Reserve(AGR)members must be assigned against an authorized mobilization position in the unit they support. This includes Navy Training and Administration of the Reserves(TARS),Marine Corps Active Reserve(ARs)and Coast Guard Reserve Program Administrator(RPAs). Active Duty status also applies to a Uniformed Service member who is an active duty commissioned officer of the U.S. Public Health Service or the National Oceanic and Atmospheric Administration(NOAA Commissioned Corps). Coverage Under the SCRA is Broader in Some Cases Coverage under the SCRA is broader in some cases and includes some categories of persons on active duty for purposes of the SCRA who would not be reported as on Active Duty under this certificate. SCRA protections are for Title 10 and Title 14 active duty records for all the Uniformed Services periods. Title 32 periods of Active Duty are not covered by SCRA,as defined in accordance with 10 USC§101(d)(1). Many times orders are amended to extend the period of active duty,which would extend SCRA protections.Persons seeking to rely on this website certification should check to make sure the orders on which SCRA protections are based have not been amended to extend the inclusive dates of service. Furthermore,some protections of the SCRA may extend to persons who have received orders to report for active duty or to be inducted,but who have not actually begun active duty or actually reported for induction. The Last Date on Active Duty entry is important because a number of protections of the SCRA extend beyond the last dates of active duty. Those who could rely on this certificate are urged to seek qualified legal counsel to ensure that all rights guaranteed to Service members under the SCRA are protected WARNING: This certificate was provided based on a last name,SSN/date of birth,and active duty status date provided by the requester. Providing erroneous information will cause an erroneous certificate to be provided. Certificate ID: 238AJB3AVOF0460 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION ELMCROFT OF DILLSBURG Plaintiff vs. Civil Action No. 2013-02855 JOANN SABOTCHICK i t�.� (Q(,h , M 1-o SS DONNA MCGAHEN Keel `� ` j; Defendant(s) `\\`1 IN 1/O 1( FULTON BANK j 33N� e✓� L� AMERICHOICE FCU , DO : . n�' &1�'-1 —i l4 I us9 z- "!' ORRSTOWN BANK •-� `/ i c.. , 51M-1'Q '�v_ '�jSS 1 . ri� G Garnishee(s) �, .• PRAECIPE FOR WRIT OF EXECUTION -e TO THE PROTHONOTARY: Kindly issue a Writ of Execution in the above matter... 1. directed to the Sheriff of CUMBERLAND County: 2. against JOANN SABOTCHICK DONNA DONNA , Defendant 3. against FULTON BANK, AMERICHOICE FCU, ORRSTOWN BANK, Garnishee 4. Judgment Amount $ $12,747.29 Less Payments/credits received $ $0.00 Interest $ $402.33 Costs $ SUBTOTAL: $ $13,149.62 Costs(to be added by Prothonotary): $ WELTMAN, WEINBERG & REIS CO., L.P.A. ava By: �1 James . 196 Esquire PA 6 ` r W I.D. #7 596 r ,� C' WELTMAN, WEINBERG& REIS CO., L.P.A. ss•�� ``3� 436 7`"Avenue, Suite 1400 1��.'�j Pittsburgh, PA 15219 l� t� (412)434-7955 c� ,s5 s .a )1A..1 d fret , b c,/. ("-' I' so/ S a WWR No. 9862279 WI' IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION ELMCROFT OF DILLSBURG Plaintiff No. 2013-02855 vs. PRAECIPE FOR WRIT OF EXECUTION (BANK ATTACHMENT ONLY) JOANN SABOTCHICK DONNA MCGAHEN Defendant(s) FULTON BANK AMERICHOICE FCU ORRSTOWN BANK, Garnishee(s) FILED ON BEHALF OF Plaintiff COUNSEL OF RECORD OF THIS PARTY: James P. Valecko, Esquire PA I.D. #79596 WELTMAN, WEINBERG & REIS CO., L.P.A. 436 7th Avenue, Suite 1400 Pittsburgh, PA 15219 (412)434-7955 WWR No. 9862279 WRIT OF EXECUTION and/or ATTACHMENT COMMONWEALTH OF PENNSYLVANIA) NO 13-2855 Civil COUNTY OF CUMBERLAND) CIVIL ACTION—LAW TO THE SHERIFF OF CUMBERLAND COUNTY: To satisfy the debt, interest and costs due ELMCROFT OF DILLSBURG Plaintiff(s) From JOANN SABOTCHICK,DONNA MCGAHEN, 16 KEEFER WAY,MECHANICSBURG, PA 17055 (1) You are directed to levy upon the property of the defendant(s)and to sell You are also directed to attach the property of the defendant(s)not levied upon in the possession of GARNISHEE(S)as follows: FULTON BANK,3344 TRINDLE ROAD,CAMP HILL,PA 17011 AMERICHOICE FCU,20 SPORTING GREEN DRIVE,MECHANICSBURG,PA 17050 ORRSTOWN BANK,77 E. KING STREET,SHIPPENSBURG,PA 17257 and to notify the garnishee(s)that: (a)an attachment has been issued; (b)the garnishee(s) is enjoined from paying any debt to or for the account of the defendant(s) and from delivering any property of the defendant(s)or otherwise disposing thereof; (2) If property of the defendant(s)not levied upon an subject to attachment is found in the possession of anyone other than a named garnishee, you are directed to notify him/her that he/she has been added as a garnishee and is enjoined as above stated. Amount Due$12,747.29 Plaintiff Paid$ Interest$402.33 Attorney's Comm. % Law Library$.50 Attorney Paid$204.55 Due Prothonotary$2.25 Other Costs$ Date:3/3/14 I i . David D.Buell,Prothonotary • Deputy REQUESTING PARTY: Name : JAMES P.VALECKO,ESQ. Address: WELTMAN,WEINBERG &REIS CO.,L.P.A. 436 7TH AVENUE, SUITE 1400 PITTSBURGH,PA 15219 Attorney for: PLAINTIFF Telephone: 412-434-7955 Supreme Court ID No. 79596 Ronny R Anderson Sheriff Jody S Smith Chief Deputy Richard W Stewart Solicitor SHERIFF'S OFFICE OF CUMBERLAND �������� ��" "~�"~"" " ~� ��" " "�~�� ��" ��~�"°"��~�"~��"°�� COUNTY " F/ .� '«W/N6/�]�� '' /AP 20111 19 PH � / R/ 6 ` "oB `" PFtv'N_ .^,*m/A y Elmcroft of Dillsburg vs. Joann Sabotchick (et al.) Case Number 2U13'2855 SHERIFF'S RETURN OF SERVICE 03/12/2014 11:43 AM - Dennis Fry, Deputy, who being duly sworn according to law, attached as herein commanded all goods, chattels, rights, debts, credits, and monies uf the Defendant, inthehando.posaossinn.orconhn|of the within named garnishee, Orrstown Bank, 22 S Hanover Street, Carlisle Borough, Carlisle, PA 17013, Cumberland County, by handing to Chastity Bucher, head teller, personally three copies of interrogatories together with three true and attested copies of the Writ of Execution and made the contents there of known to her. DENN RY, DEPUTY SO ANSWERS, March 13, 2014 RON R ANDERSON, SHERIFF Ronny R Anderson Sheriff Jody S Smith Chief Deputy Richard W Stewart Solicitor SHERIFF'S OFFICE OF CUMBERLAND COUNTY ~°" "~~"~"" " ~° =°" " "~°~~ ~~" wn �«�. PROTHONu��K 2011i MAR PM �; \/ '` ����UNTy [U��BERL ~~'`' PENNSYLVANIA Elmcroft of Dillsburg vs. Joann Sabotchick (et al) Case Number 2013-2855 SHERIFF'S RETURN OF SERVICE 03/12/2014 11:26 AM - Noah Cline, Deputy, who bei law, attached as herein commanded all guodo, chatte|a, hghtn, debto, crodiha, and monies of the Dohsndan\, in the hondm, pouoession, or control of the within named garnishee, AmeriChoice Federal Credit Union, 20 Sporting Green Drive, Silver Spring Township, N1ocheniosburg, PA 17050. Cumberland County, by handing to Carrie Dehert, Head Member Service Representative, personally three copies of interrogatories together with three true and attested copies of the Wri of Execution and made the contents there of known to her. NOAH C NE, DEPUTY SO ANSWERS, March 13, 2014 RONNYR ANDERSON, SHERIFF (c) CountySifite Sheriff: Teleoccit. inc. Ronny R Anderson Sheriff Jody S Smith Chief Deputy Richard W Stewart Solicitor SHERIFF'S OFFICE OF CUMBERLAND COUNTY 9 of Cum r�_ v / r MAR 19 PM �:|7 CUMBERLAND COUNTY PENNSYLVANIA Elmcroft of Dillsburg vs. Joann Sabotchick (et al.) Case Number SHERIFF'S RETURN OF SERVICE 03/12/2014 02:54 PM - Noah Cline, Deputy, who bein duly ccording to law, attached as herein commanded all goods, chattels, rights, debts, credits, and monies of the Defendant, in the hands, possession, or control of the within named garnishee, Fulton Bank, 3344 Trindle Road, Camp Hill Borough, Camp Hill, PA 17011, Cumberland County, by handing to M Rosenbloom, Teller, personally three copies of interrogatories together with three true and attested copies of the Writ of Execution and made the contents there of known to him/her. The wri of execution and notice to defendant was mailed on March 13, 2014 to Donna McGahen at 16 Keefer Way, Mechanicsburg, PA 17055 and to Joann Sabotchick at 16 Keefer Way, Mechanicsburg, PA 17055. y7 NOAH CLINE, DEPUTY SO ANSWERS, March 13, 2014 R ONNYR ANDERSON, SHERIFF WELTMAN, WEINBERG & REIS BY: James P Valecko, Esquire I.D. No. 79596 436 Seventh Avenue, Suite 1400 Pittsburgh, PA 15219 Phone: 412.434.7955 Fax: 412.434.7959 File # 9862279 f• .,.. to { it; :- CO., L.P.A. Attorney for Plaintiff(s) hpg _8 Ali 8t 21 CUMBERLAND COUNTY PENNSYLVANIA ELMCROFT OF DILLSBURG Cumberland County Court of Common Pleas vs. JOANN SABOTCHICK DONNA MCGAHEN and FULTON BANK, AMERICHOICE FCU AND ORRSTOWN BANK Garnishee(s) PRAECIPE TO DISCONTINUE ATTACHMENT EXECUTION NO. 2013 -02855 TO THE PROTHONOTARY: Kindly marked the above matter discontinued and ended as to Garnishee(s), FULTON BANK, AMERICHOICE FCU AND ORRSTOWN BANK, only. WELTMAN, WEINBERG & REIS CO., L.P.A. By James Valecko Esquire Atto y for Plaintiff 011/14 '56/Del Ck.I 11.sLiss L '?.4- Wick � SHERIFF'S OFFICE OF CUMBERLAND COUNTY Ronny RAnderson F| E Sheriff OF THE PRQTRONOARY Jody S Smith Chief Deputy Richard W Stewart Solicitor opr IcE OF THE SHERIFF �A����� N���4� ~~,^°~" �"°�^,v'�� CUMBERLAND COUNTY PENNSYLVANIA Elmcroft of Dillsburg vs_ Joann Sabotchick (et al.) Case Number 2013-2855 SHERIFF'S RN OF SERVICE 03/12/2014 11:26 AM - Noah Cline, Deputy, who being duly sworn accordto law, attached as herein commanded all goods, chattels, rights, debts, credits, and monies of the Defendant, in the hands, possession, or control of the within named garnishee, AmeriChoice Federal Credit Union, 20 Sporting Green Drive, Silver Spring Township, Mechanicsburg, PA 17050, Cumberland County, by handing to Carrie Dehart, Head Member Service Representative, personally three copies of interrogatories together with three true and attested copies of the Writ of Execution and made the contents there of known to her. 03/12/2014 11:43 AM - Dennis Fry, Deputy, who being duly sworn according to law, attached as herein commanded all goods, chattels, rights, debts, credits, and monies of the Defendant, in the hands, possession, or control of the within named garnishee, Orrstown Bank, 22 S Hanover Street, Carlisle Borough, Carlisle, PA 17013, Cumberland County, by handing to Chastity Bucher, head teller, personally three copies of interrogatories together with three true and attested copies of the Writ of Execution and made the contents there of known to her. 03/12/2014 02:54 PM - Noah Cline, Deputy, who being duly sworn according to law, attached as herein commanded all goods, chattels, rights, debts, credits, and monies of the Defendant, in the hands, possession, or control of the within named garnishee, Fulton Bank, 3344 Trindle Road, Camp Hill Borough, Camp Hill, PA 17011, Cumberland County, by handing to Marty Rosenbloom, Teller, personally three copies of interrogatories together with three true and attested copies of the Writ of Execution and made the contents there of known to him/her. The writ of execution ar,d notice to defendant was maUed on March 13, 2014 to Donna McGahen at 16 Keefer Way, Mechanicsburg, PA 17055 and to Joann Sabotchick at 16 KeefeWay, Mechanicsburg, PA 17055. 10/07/2014 Ronny R. Anderson, Sheriff, who being duly sworn according to law, states this writ of execution is returned as ABANDONED. No action on writ in over 6 months. SHERIFF COST: $227.73 SO ANSWERS, October 07, 2014 RbN R ANDERSON, SHERIFF CountySuile Sheriff, Teleosott, Inc, pet .�«�� )' . �� ^�= ��/^�� ������.3S V �/��e7/-� ��� ��,=