September 1, 2023


8125 West Lancaster Avenue
Milwaukee, WI 53218


This Service Agreement is made in Milwaukee, Wisconsin, on date_________________________,
Hereinafter will be referred to as “Agreement “, between Light of Care Adult Family Home,
Hereinafter called “Light of Care LLC”, and __________________________________________hereinafter called
“RESIDENT” (may be or guardian), who agrees as follows:


The term of the Agreement shall begin on _______________and end on _____________.


Light of Care LLC shall pro vide RESIDENT with the following service as long as the RESIDENT
resides at its Light of Care LLC facility and uphold all the RESIDENT’S obligations under this

A. LIVING ACCOMMODATIONS: Living accommodation will be in a designated clean and safe
environment. Staff coverage and supervision will be available whenever residents are on
the premises. The staff will not be available on days/times when if all residents have
attended day care services. Light of Care LLC will maintain all interior and exterior areas,
according to its Light of Care LLC standards and maintenance schedule, and will provide a
central TV, all utilities, and landscaping.
B. FURNISHING: Furnishings in common areas will be provided by Light of Care LLC,
according to its Light of Care LLC standards. All residents will have privacy in their
unit/bedroom, with lockable bedroom doors, a choice of roommate, and freedom to furnish
and decorate their space.
C. MEAL: Light of Care LLC will provide 3 well balanced nutritious meals and snacks daily.
Menus will be posted in the common area for residents. Special dietary needs are provided
to each RESIDENT by doctor’s orders.


Personal cares include the following:
● Daily assistance with bathing, grooming, and dressing, toileting and walking.
● Assistance with medication and/or medicine administration.
● Continence care and management.
● Escorts and assistance with walking and transfer, if applicable.
● Daily meal preparation, including healthy snacks.
● Dining assistance and special diets.
● Assistance with reminders and redirections.
● Access to health and medical services.
● Health monitoring
● Social and recreational activities.
● Health promotion and exercise programs.
● Supervision.
E. HOUSEKEEPING: Bedroom wastebaskets will be emptied and the bathroom will be cleaned
daily. Daily housekeeping services include vacuuming of carpets, mopping of non-carpet
floors, cleaning of dishes and sinks, emptying of trash and weekly laundry for clothes and
linens which is also accessible to the RESIDENTS.
F. SOCIAL AND RECREATION FACILITIES: Light of Care LLC will provide or coordinate a
program of recreational, educational and cultural opportunities designed to enhance the
Resident’s stay at the facility. The planned activities will be posted in a common area for
residents and will be directed by a staff member. Some events such as tours, trips, concerts,
etc. may require an additional fee.

G. TRANSPORTATION: Light of Care LLC currently does not offer transportation, but will use
private companies to provide transportation services for recreational activities, and
community services for all RESIDENTS. In the event of a medical emergency, locate
ambulances services will be called for RESIDENTS. RESIDENTS are encouraged to utilize
transportation through insurance for medical appointments, and which Light of Care LLC,
will assist RESIDENTS with setting up the said transportation appointments.
H. LATE CHARGE FEE: Light of Care LLC, reserves the right to assess a late charge on past due
paymentsservice fees and charges. The late charges will be $5 per day, and will begin
accumulating on the 1 st days of each month to the end of each month; . If where fees are not
received by no later than 5:00 p.m. on the 10 th of each month. There will be no refunds for
any reason. The rates are inclusive of daily living skills, and supportive home care.


I. REDUCED RATE: In the event a RESIDENT is hospitalized for serious illness, a reduced rate
of $22.00 per day will be charged for room and board. After 30 consecutive days, the
resident or representative is required to provide notification as to the status of their
residence at Light of Care LLC. At the end of the 30 days, if we have not received notification
from the resident or their representative, the resident will be given an additional 30 days
letter of discharge.
J. If RESIDENT terminates services during hospitalization with Light of Care LLC, within the 1 st
month, fees will be prorated.

K. PAYMENTS BY RESIDENT: Light of Care LLC, will require the Resident to pay for items
not covered by the state; such payments include but are not limited to clothing.


A. PHYSICAL EXAMINATION: Prior to occupancy, RESIDENT agrees to obtain a standard
physical examination from RESIDENT’S primary care physician and provide a copy to
Light of Care LLC. Additional physical exams and reports may be requested, if needed, in
the opinion of Light of Care LLC management.
B. PHYSICALS: The RESIDENT should have a preferred physician licensed to practice in
Wisconsin. The name, address, and telephone number should be registered with Light of
Care LLC. The RESIDENT shall remain financially responsible for all medical services
provided to them.
C. MEDICAL TRANSFER: Within the opinion of Light of Care LLC management, if a
RESIDENT’S health has changed to the extent the RESIDENT requires in-patient medical
attention, the . RESIDENT agrees to transfer to an acute or long-term care facility
offering the appropriate level of health care under the circumstances. In the event
RESIDENT transfers to such facility, RESIDENT will be responsible for such transfer cost
and cost of care received in the facility. By signing this agreement, RESIDENTS
authorizes their his/her personal physician to release information concerning
RESIDENT’S health to Light of Care LLC. If, after consultation, that RESIDENT is unlikely
to return to Light of Care LLC facility. RESIDENTS agrees to be discharged at the end of
the thirty (30) day period at which the Agreement shall be terminated.


A. ADJUSTMENT PERIOD: Within (7) days from the date of admission, this agreement
may be terminated upon written notice by either party.
B. TERMINATION BY Light of Care, LLC: In the event RESIDENT ceases to satisfy the
health standards required by Light of Care LLC. Light of Care LLC shall have the right to
terminate this Agreement at any time and if not detrimental to health, safety or welfare
of RESIDENT, Light of Care LLC will provide thirty (30) days written notice. In the event
RESIDENT fails to pay their his/her service fees in a timely manner or fails to abide by
any of the other terms or conditions of this Service Agreement, or the policies and
procedures of Light of Care LLC, Light of Care LLC, has the right to terminate this
Agreement and the Resident may be given up to 90 days to find a new home .
Involuntary discharge will result in the above-mentioned 30 day written notice as well
as assistance in relocation to another facility.
C. TERMINATION BY RESIDENT: The RESIDENT may terminate the Service Agreement
only upon the giving of not less than thirty (30) days written notice (unless necessitated
by death or serious illness). RESIDENT shall be obligated to vacate the premises and
remove their his/her property by no later than the end of the thirty (30) days notice
Light of Care LLC will terminate the resident’s placement only after giving the
resident’s guardian, if any, the resident service coordinator, the placing agency, if any
and designated representative, if any 30 days written notice. However, in the event that
the RESIDENT may cause harm to other residents, an immediate termination will be in
place as a 30 days notice is not required (DHS 88.08 Termination of Placement).
D. PLACEMENT: An adult family home shall have a service agreement with each person to
be admitted to the home. The service agreement shall be completed prior to admission
and with revisions. RESIDENTS will be notified at least thirty (30) days prior to any
changes. The service agreement shall be dated and signed by the licensee or
management and the person being admitted or person’s guardian or designated
representative. Copies shall be provided to all parties and to all parties and to the
placing agency, if any.
E. RELOCATING: The RESIDENT has the right to relocate, as long as thirty (30) days
written notices isare given. Light of Care LLC will assist in relocating a RESIDENT to a
home or facility of their choice.
F. REFUND: The payment for services for the month in which discharge occurs shall be
prorated to the date of discharge. The balance shall be returned to the former resident,


or that person’s guardian, agent or designated representative within 10 working days
after the date of discharge.
G. FINANCIAL AFFAIRS: The RESIDENT has the right to manage their his/her own
financial affairs, including any personal allowances under federal or state programs.
Uunless the RESIDENT delegates, in writing, responsibility for financial management to
the licensee or someone else of RESIDENT’S choosing or the RESIDENT is adjudicated
incompetent in which case the guardian or guardian’s designee is responsible.
RESIDENTS may have a designated payee who will distribute their funds to them on a
monthly basis and /or an agency will contact Administrator staff to provide a monthly
check on behalf of residents. Funds will be made available to residents at their request.


A. CLOTHING AND POSSESSION: Resident may To retain and use personal clothing
and effects and to retain, as space permits, other personal possession in a reasonably
secure manner.
B. CARE OF PERSONAL PROPERTY: In the event of RESIDENT’S absence, Light of Care
LLC will make a reasonable effort to safeguard RESIDENT’S property until RESIDENT
returns. If RESIDENT does not return and if RESIDENT’S property is not claimed
within thirty (30) days, Light of Care LLC reserves the right to dispose of the
property. If RESIDENT moves in with personal funds, the RESIDENT will be given the
option to open a personal account which the RESIDENT will have 24 hours access to.
C. RIGHT OF ENTRY: Light of Care LLC reserves the right to enter the RESIDENT’S
bedroom at reasonable times for the purpose of inspection, pest control,
maintenance, and service cares. In the event of a suspected medical emergency, Light
of Care LLC reserves the right to enter RESIDENT’S bedroom at any time. RESIDENTS
shall use door locks to lock the room at anytime.
D. HOUSE RULES: During the term of this Service Agreement and as a condition to
RESIDENT’S continuing right to use and occupy the premises, RESIDENTS agree to
the following:

  1. Pets are not allowed in or on the premises unless specifically authorized as a
    special condition on the Agreement.
  2. Hazardous substances or illegal drugs are not allowed on or in the premises.
  3. RESIDENTS will not make excessive noise or engage in activities, which would
    unduly disturb other residents at the premises and will respect the rights and
    property of other residents and staff occupying and/or working at the facility.


  1. Visitors and guests are allowed at the resident’s request, guests are not allowed
    to stay overnight on the premises. Guests must abide by all house rules during
    their visitation.
  2. Smoking is prohibited in the facility, smoking may only be done at the (Outside
    designated areas outside the premises.)
  3. RESIDENTS or guests are not allowed to have weapons on the premises.
    RESIDENT shall further comply with all additional house rules, which will be
    posted at the facility where the RESIDENTS reside and Light of Care LLC
    reserves the right to make such reasonable house rules governing the premises
    and make changes to such rules from time to time and RESIDENT agrees to
    observe and comply with all such rules. RESIDENTS will be given a 30 days’
    notice informing them on any changes.

E. SOLE AGREEMENT: This Agreement may not be amended or modified in any aspect
except by instrument in writing signed by both parties. This Agreement constitutes
the entire Agreement between the parties and supersedes all negotiations,
discussion, writing and Agreement between them.
F. ASSIGNMENTS: RESIDENTS may not assign or sublease theirhis/her rights provided
by this Service Agreement.
G. GOVERNING LAW: This Agreement shall be governed by and constructed in
accordance with the law of the State of Wisconsin.
Type of Private Funds: ____________

Manage Care Organization/ Contract:
Manage Care Organization/ Contract Company Name: ___________

The resident and resident’s representative agree to pay the operator and accept the
following payment in full satisfaction of the services which the operator must
provide according to law and regulations.
$___________Security Deposit (Refundable) – With the exception of any loss, damage or
repairs needed to be made to unit/room (i.e. carpet, painting etc.) The cost of these
repairs shall be deducted from the security deposit and in some cases money may be
owed to Light of Care Adult Family Home by Residents.


Payment of Monthly Fee: The monthly fee payable by the Resident/contract under
this Agreement is initially $___________ per month for one person. The monthly fee
begins, which is calculated on a prorated daily basis, on the day the Resident moves
into Light of Care Care Adult Family Home. The payment for the initial month or
partial month of occupancy is due on the first day of occupancy when Resident
moves into Light of Care Adult Family Home. Monthly bills for the following month
will be mailed to the Resident’s designee. All charges are due and payable on the 1 st of
every month. A late charge of $5 per day will be assessed if housing and services fees
are not received by the 10 th of the month. Resident shall pay all costs of collection of
any past due sums owed to Light of Care Family Home, including a reasonable
attorney’s fee for service rendered by suit or otherwise.

ALL RESIDENT’S rights and grievance procedure have been explained, and
given to resident and responsible party.

Light of Care Adult Family Home

Director/Manager Date

Resident Date

P.O.A. (Power of Attorney) If applicable Date

Guardian (If applicable) Date

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