HomeMy WebLinkAbout09-07-11ANNUAL REPORT OF
GUARDIAN OF THE PERSON
COURT OF COMMON PLEAS OF
Cumberland COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
Estate of Nicole Hlavac
No. 06-0608
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an Incapacitated Person
I. INTRODUCTION
Dana and Rose Hlavac ,was appointed
~ Plenary ^Limited Guardian of the Person by Decree of J. Oler , J„
dated 8131 /2006
A. This is the Annual Report for the period from Sept 1 , 2010
to Auk 31 2011 (the "Report Period"); or
^ B. This is the Final Report for the period from _
to (the "Report Period"), and is filed
for the following reason:
1. The death of the Incapacitated Person. Date of death:
2. The Guardianship was terminated by the Court by Decree of
J., dated
For a Final Report, omit Sections II through IV.
Form G-03 rev. 10.13.06
Page 1 of 4
n
/ ~~~
Estate of Nicole Hlavac
II. PERSONAL DATA
Age of the Incapacitated Person: 23
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
905 Charleston Green
Malvern, PA 19355
an Incapacitated Person
Date of Birth: 6/28/88
B. The Incapacitated Person's residence is:
~ own home /apartment
0 nursing home
^ boarding home /personal care home
Guardian's home 1 apartment
0 hospital or medical facility
relative's home (name, relationship and address)
mother:
Group Home
C. The Incapacitated Person has been in the present residence since July 10, 2009
. If the Incapacitated Person has moved within the
past year, state prior residence and reason(s) for move:
Form G-03 rev. 10.13.06 Page 2 of 4
Estate of Nicole Hlavac , an Incapacitated Person
D. Name and address of the Incapacitated Person's primary cazegiver:
Melmark
2600 Wayland Rd
Berwyn, PA 19312
IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person aze as fol{ows:
Nicole has profound intellectual disabilities including: ADD/ADHD, CP, Autism
and OCD due to a rare genetic defect.
B. Specify what, if any, social, medical, psychological and support services the
Incapacitated Person is receiving:
In addition to support services through her group home provider, Nicole is in a
vocational program at Melmark. The program includes supports for Nicole's speech
and behavioral needs.
V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian of the Person that the guazdianship should:
® continue
[~ be modified
^ be terminated
Form C-03 rev. lOJ3.06 Pale 3 of 4
Estate of Nicole Hlavac an Incapacitated Person
The reasons for the foregoing opinion are:
While Nicole is learning self care and job skills, she remains unable to care for
herself and is dependent on others for her care and safety.
B. During the past year, the Guardian of the Person has visited the Incapacitated Person
~ times with the average visit lasting 25 hours, 0 minutes.
The report of a social service organization employed by the Guardlan to oversee and
coordinate the care of the Incapacitated Person for the period covered by this Report may be
attached to supplement this Report.
I verify that the foregoing information is correct to the best of my knowledge,
information and belief; and that this Verification is subject to the penalties of 18 Pa. C.S.A. § 4904
relative to unsworn falsification to authorities.
9/3/2011 ~~
Date i~nature ajGuardian ofthe Person
Rose Hlavac
Name ofGttardian ofthe Person (type arprint)
9 Oak Ridge Rd
Address
Cazlisle, PA 17015
City, State, Zip Y
717-258-5665
Telephone
Form G-03 rev. 10.13.06 Page 4 of 4
Supplement to Annual Report of Guardian of the Person
Person: Nicole Hlavac; Docket Nbr: 06-0608
Following are the details regarding visits to Niki during the September 1, 2010 to August
31, 201 i timeframe.
Trip
Number
Visit Start
Visit
End Durati
on
Hrs _~
Notes
1 9/19/10 9/19/10 4.10 Visit, hair cut, sho in
2 11/24/10 11/28/10 87.05 Niki home for Thanks 'vin ~
3
12/23/10
12/26/10
68.12 _
Niki home for Christmas
4 4/24/11 4/24/11 6.10 Visit Niki for Easter
5
6/5/11
6/5/11
2.92 _
Take Niki Tomato Plants for self and staff
6 6/11/11 6/11/11 4.42 Celebrate Niki's Birthda a bit earl
7
8/13/11
8/13/11
2.28 _
Lunch with Niki after RS meetin _
Total visits = 7
Total hours =174.98
Average Per Visit:
25 hours 0 minutes