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.In-Home Aide.Home Care (home health).Housing and Home Improvement.Adult Day Care or Adult Day Health Care <br />• <br />• <br />• <br />• <br />• <br />• <br />Agency Name: <br />Name of Agency Administrator: <br />Signature: <br />Client Rights will be distributed to, and discussed with, each new client receiving one or more of the above <br />listed services prior to the onset of service. For all existing clients, the above information will be provided no <br />later than the next regularly scheduled service reassessment. <br />ORANGE COUNTY <br />(Please return this form to your Area Agency on Aging and retain a copy for your files.) <br />Standard Assurance To Comply with Older Americans Act <br />Requirements Regarding Clients Rights <br />For <br />Agencies Providing In-Home Services through the <br />Home and Community Care Block Grant for Older Adults <br />be fully informed both orally and in writing, in advance of receiving an in-home service, of <br />the individual’s rights and obligations. <br />As a provider of one or more of the services listed below, our agency agrees to notify all Home and <br />Community Care Block Grant clients receiving any of the below listed services provided by this agency of their <br />rights as a service recipient. Services in this assurance include: <br />Notification will include, at a minimum, an oral review of the information outlined below as well as providing <br />each service recipient with a copy of the information in written form. In addition, providers of in-home <br />services will establish a procedure to document that client rights information has been discussed with in- <br />home services clients (e.g. copy of signed Client Bill of Rights statement). <br />Clients Rights information to be communicated to service recipients will include, at a minimum, the right to: <br />be fully informed, in advance, about each in-home service to be provided and any change <br />in service(s) that may affect the wellbeing of the participant; <br />participate in planning and changing any in-home service provided unless the client is <br />adjudicated incompetent; <br />voice a grievance with respect to service that is or fails to be provided, without <br />discrimination or reprisal as a result of voicing a grievance; <br />confidentiality of records relating to the individual; <br />have property treated with respect; and <br />DocuSign Envelope ID: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22 <br />Janice Tyler