Borealis Care – Northridge
9337 Shoshone Ave, Northridge, CA 91325

This Admissions Agreement (“Agreement”) is made between Borealis Ventures, LLC dba Borealis Care – Northridge (“Facility”) located at 9337 Shoshone Ave, Northridge, CA 91325, and the undersigned Resident and/or Responsible Party.

• Facility Name: Borealis Care – Northridge
• Licensee: Borealis Ventures, LLC dba Borealis Care
• Facility Address: 9337 Shoshone Ave, Northridge, CA 91325
• License Number: 197610807
• Contact Information:
• Maria Camila Gutierrez
  (408) 613-0266
  gutierrez@borealiscare.com

• Lodging: Private rooms with an option for married couples to share a room ($500/month discount per resident, max 2 per room).
• Meals: Three nutritious meals per day, plus two snacks.
• Special Dietary Accommodations: Vegetarian, pescatarian, gluten-free, and diabetic-friendly options available or as prescribed by the resident’s physician
• Personal Care Assistance with Activities of Daily Living (ADLs):
• Bathing (twice per week)
• Daily dressing and bedtime readiness assistance
• Toileting
• Grooming
• Mobility help as needed
• Supervision & Monitoring: 24/7 staff oversight
• Medication Assistance: As needed, with taking prescribed medications in accordance with physician’s instructions unless prohibited by law or regulations.
• Medical Coordination: Scheduling and coordinating medical and dental visits
• Activities: On-site activities planned weekly, animal therapy
• Housekeeping & Laundry: Daily light cleaning & tidying of resident rooms and common areas. Deep Clean Weekly. Resident laundry performed by staff as needed
• TV, Internet & Phone Access: Included
• Planned recreational and social activities
• Transportation arrangements for medical and personal needs

• Provided for residents with dementia based upon the initial resident assessment performed prior to move-in. Depending on severity of the case, the service may include direct 1:1 supervision priced on a case by case basis according to need.

• Base Monthly Rate: $9,500/month
• Shared Room Discount: $500/month per resident
• Security Deposit: Equal to one month’s rent
• Admission Fee: $1,295 (includes assessment, paperwork processing, room preparation)
• Payment Methods:
• ACH transfer (no fee)
• Credit Card (3% surcharge applies)
• Due Date: Payment is due on the 1st of each month, in advance of services
• Late Payment Policy: Late after the 5th of the month, with a $50 late fee per occurrence.
• Third-Party Payers: Accepted, but the guarantor is responsible for any unpaid balances.

• A La Carte Services:
• Additional assisted showers: $150 per instance
• Hairdressing: $50 – $200 per instance
• Manicure/Pedicure: $50 per instance
• Procurement of Consumables (e.g., Clothing, Depends, special foods, special toiletry items, Online purchases, etc) available at an additional charge
• Off-site activities: Fees vary, communicated in advance
• Billing for Additional Services: Monthly, in arrears of the additional services rendered

• Rate Change Policy:

From time to time, it may be necessary to adjust our rates to reflect the increased costs associated with delivering high-quality care. In accordance with Title 22, Section 87507, we will provide at least 60 days’ written notice prior to any rate increase.

• Rate changes may be driven by a variety of factors, including but not limited to:
• Increases in staff wages and benefits, as required by California labor laws
• Rising costs of food, medical supplies, and daily living essentials
• Enhanced regulatory, licensing, and insurance requirements
• Inflation-related increases in utilities and facility maintenance
• We remain committed to transparency and fairness, and we will always communicate any changes clearly and in a timely manner to ensure families are fully informed.
• Refund Policy:
• Early Move-Out: Pro-rated refund for the unused portion of the month (except for disciplinary or non-payment evictions).
• Death of Resident: Pro-rated refund for the unused portion of the month.
• Notice for Voluntary Discharge: 30 days required.
• Grounds for Eviction/Relocation:
• Non-payment
• Aggressive, dangerous, or disruptive behavior (documented and unable to be corrected)
• Medical ineligibility (e.g., requiring IV medication without a private nurse)
• Assistance will be provided in transitioning to a skilled nursing facility if necessary.

• Resident Admission Criteria:
• Be 60 years of age or older (or 18–59 years with compatible needs under a waiver).
• Require only non-medical care and supervision.
• Be ambulatory or have an approved non-ambulatory fire clearance.
• Be free of active communicable tuberculosis (per Health & Safety Code §1569.69).
• Not require 24-hour skilled nursing care (with the exception of hospice or incidental medical services as permitted).
• Exhibit behavior that is not aggressive or dangerous to self/others.
• Have needs that fall within the facility’s approved services and staffing capabilities.

• Conditions That May Preclude Admission:
• Ongoing need for intravenous therapy, nasogastric feeding tubes, or other skilled medical interventions.
• Stage 3 or 4 pressure injuries (unless under hospice and permitted by waiver).
• Diagnosed infectious diseases that cannot be managed safely within the facility setting.
• Unmanaged serious psychiatric or behavioral conditions.
• Required Admission Documentation must be completed, reviewed, and filed before a resident is admitted:
• Pre-Admission Interview & Evaluation
• Completed by Administrator or Designee
• Evaluation of physical, cognitive, emotional, and behavioral needs
• LIC 602A – Physician’s Report
• Completed and signed by a licensed physician within 12 months of admission. Must indicate:
• Primary diagnosis and current medications
• Mental and functional status
• Ambulatory status
• TB clearance
• Resident Appraisal (LIC 603)
• Resident functional capabilities and social/emotional needs
• Immunization Record
• Proof of current influenza, COVID-19, and pneumococcal vaccines (or signed declination)
• Must comply with public health mandates during outbreaks
• Emergency Information Form (LIC 601)
• Includes emergency contacts, responsible party, physician info, and hospital preference
• Admission Agreement
• Executed by resident and/or responsible party
• Includes financial terms, rights, services provided, and policies
• Rules of Discipline & Personal Rights
• Signed acknowledgment of resident rights and grievance procedures
• Consent Forms
• Consent for basic care
• Consent for medical/dental treatment and release of information
• Pre-Admission Assessment:

Prior to being accepted into Borealis Care – Northridge, each resident and responsible party must complete a pre-admission assessment interview with staff to ensure suitability both for the resident as well as the facility to provide exceptional care. This appraisal includes:

• An evaluation of the prospective resident’s functional capabilities, mental condition, and social factors as specified in Title 22 Sections 87459 & 87462.
• Assess the person’s need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to:
• Bathing
• Dressing and Grooming: including the need for partial or complete assistance.
• Toileting, including the need for: Assistance equipment or the assistance of another person.
• Transferring: including the need for assistance in moving in and out of a bed or chair.
• Continence: Bowel and bladder control, and whether assistive devices such as a catheter are used.
• Eating: The need for adaptive devices or assistance from another person
• The resident’s physical condition, including: vision, hearing, speech, walking with or without equipment or other assistance, dietary limitations, review of medical history/ physician records, and the need for prescribed medications.
• Visitation:
• All visitors must sign in with staff before entry.
• Visiting hours: 10 AM – 5 PM daily.
• Quiet Hours: 9 PM – 7 AM.
• Pets: Not allowed, except for service animals and Borealis Care therapy animals.
• Leaving the Facility: Residents are free to leave the facility with their responsible parties/ family members with 24 hour advance notice so that staff may groom and dress the resident, and prepare any medications they may need while away from the facility.

• Resident Rights: Please refer to the attached “Rules of Discipline and Personal Rights” document in your packet for a complete list of all house rules.
• Filing Compaints:
• Must be submitted in writing using either the Borealis Care Complaint Form or via email.
• In the event that a resident cannot write the complaint themselves, a family member, conservator, or staff member can assist the resident to ensure all complaints are documented and addressed.
• Grievance Resolution Process:
• Internal review conducted.
• In-person/virtual meeting with resident, family, and administrator if needed.
• Written response provided if an in-person meeting is unnecessary.
• Advance Health Care Directive
• Making choices about one’s health and care is paramount to having a sense of control over one’s life. At Borealis Care, all residents have the right to make decisions concerning medical care, including the right to accept or refuse treatment, and the right to formulate an advance health care directive. Borealis Care will keep on file a copy of each residents POLST form in the event of an emergency so that the resident’s wishes will be respected. This form will be updated annually or upon the request of the resident.
• Access To Records
• In accordance with CA Title 22 regulations and in compliance with the CCLD and Dept of Social Services, the DSS has the authority to review resident records at any time as part of their evaluation of our facility. By entering into this agreement you are consenting to their ability to review your information.