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ANNUAL REPORT OF Co a
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GUARDIAN OF THE PERSON ter' m N rr," r
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COURT OF COMMON PLEAS OF r ' rti
CUMBERLAND t
COUNTY, b
ORPHANS' COURT DIVISION
Estate of AT HUA CHEN an Incapacitated Person
No. 11-1184
I. INTRODUCTION
KONG Ji CHEN was appointed
0 Plenary[ Limited Guardian of the Person by Decree of Hon. Albert H. Masland, J
dated November 28,2011
A. This is the Annual Report for the period from November 28 2012
to November 27 , 2013 (the "Report Period"); or
C] 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 11 through IV.
Fnrm G-03 rev.10.13.06 Page 1 of 4
�/J
Estate of Al HUA CHEN an Incapacitated Person
Ii. PERSONAL DATA
Age of the Incapacitated Person: 60 Date of Birth: 08/03/1953
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
Select Specialty Hospital
503 North 21st Street
Camp Hill, PA 17011
B. The Incapacitated Person's residence is:
own home/apartment
®nursing home
®boarding home/personal care home
0 Guardian's home/apartment
®✓ hospital or medical facility
n relative's home(name, relationship and address)
n other:
C. The Incapacitated Person has been in the present residence since on or about
December 10, 2011** . If the Incapacitated Person has moved within the
past year, state prior residence and reason(s) for move:
** He was moved to another nursing and rehabilitation facility In Harrisburg, PA,
known as Spring Creek, for two months. However, a deterioration in his condition
required his return to Select Specialty Hospital where he remains at present.
Form G-03 rev. 10.13,06 Page 2 of 4
Estate of Al HUA CHEN an incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
Kong Ji Chen,the Guardian,residing at 7 Hedge Row Lane, Carlisle,PA 17015.
Actual day to day care is provided by the staff at Select Specialty Hospital,where
the Incapacitated Person resides.
IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person are as follows:
He remains essentially comatose from traumatic brain injuries suffered in a fall
from a ladder at his place of employment. Although there has been very slow
minimal improvement since the date of the adjudication on November 28, 2011, in
that he has times of being visibly awake,but he is still unable to move or
communicate.
B. Specify what, if any, social, medical,psychological and support services the
Incapacitated Person is receiving:
His care and treatment are directed by the staff at Select Specialty Hospital where he
resides, and he receives full-time nursing care 24 hours a day, 7 days a week.
V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian of the Person that the guardianship should:
R continue
®be modified
rl be terminated
Farm G-03 rev. 10.13.06 Page 3 of 4
Estate of Al HUA CHEN an Incapacitated Person
The reasons for the foregoing opinion are:
The fact that the Incapacitated Person is confined to a nursing hospital facility,
cannot move or communicate, and is in essentially the same comatose state that he
was in when the Guardian was appointed in 2011.
B. During the past year,the Guardian of the Person has visited the Incapacitated Person
200 times with the average visit lasting 4 hours, minutes.
The report of a social service organization employed by the Guardian 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.
November 2 a, 2013 —Q
Date Signature of Guardian of the Perron
Kong Ji Chen
Name of Guardian of the Person(nine or print)
7 Hedge Row Lane
Address
Carlisle,PA 17015
City,State,Zip
(717) 218-8989
Telephone
Form G-03 rev.10.13.06 Page 4 of 4