HomeMy WebLinkAbout09-04-15 (2) i
�...J
� 1-�-a `,�
ANNUAL REPORT OF � Q � � R,
�
GUARDIAN OF THE PERSON ,�-�; � �.y �� `'�' `;
_,. _._ . _,
, .
, r__. �..
�' --s= :_�
- �
COURT OF COMMON PLEAS OF _—�-_3 '." -�;
Ctttnber�anc� CQUNT�,PENNS�'L�ANIA c., "�LL'
��r
ORPHANS' COURT DIVISION ►-- �5 a
c� _;�
Estate of Nicole Hlavac , an Incapacitated Person
No. 06-0608
I. INTRODUCTION
Dana and Rose Hlavac ,was appointed
�Plenary QLimited Guardian of the Person by Decree of J• Oler ,J.�
dated 8f3 2/2Qf16
0 A. This is the Annual Report for the period from �eptember 1 2014
t6 August 3 t , 20�5 ftfs�"Re�rt P�t i6d"�;or�
� B. This is the Final Report for the period from
to , (t�"Report Pe�iod"}, a��s f led
f6r the fatiawing reasan:
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 IT!
Form G-03 rev.10.13.06 Page 1 of 4
�
�
[
Estate of Nicole Hlavac an Incapacitated Person
II. PERSONAL DATA
Age of the Incapacitated Person: 27 Date of Birth: 6/28/1988
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
314 Chaxleston Green
Malverr�,PA �9355
B. The Incapacitated Person's residence is:
�own home/apartment
�nursing home
�boarding home/personal care home
0 Guazdian's home/apartment
�hospital or medical facility
❑relative's home(name,relationship and address)
0 other:
Group Home
C. The Incapacitated Person has been in the present residence since September 2012
. If the Incapacitated Person has moved within the
past year, state prior residence and reason(s)for move:
Farm G-03 rev.10.13.06 Page 2 of 4
a
Estate of Nicole Hlavac an Incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
Melmark
2600 Wayland Rd
Berwyn,PA 19312
IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person are as follows:
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 supparts for Nicole's speech
and behavioral needs.
V. GUARDIAN'S OPIlVION
A. It is the opinion of the Guardian of the Person that the guardianship should:
�continue
�be modified
�be terminated
Form G-03 rev.10.13.06 Page 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 other for her care and safety.
B. During the past year,the Guardian of the Person has visited the Incapacitated Person
5 times with the average visit lasting 42 hours, 30 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.
9/1/2015
Date tgnature ofGuardian ofthe Person
Rose Hlavac
Nmne ofGuardirat ofthe Perswr(tyy�e orpriruJ
42 Keswick Dr
AadreSs
Mechanicsburg,PA 17050
City.State,Zip
717-258-5666
Telephone
Form G-03 rev.10.13.06 Page 4 of 4
►
Supplement to Annual Report of Guardian of the Person
Person: Nicole HIavac; Docket Nbr: 06-0608
Following are the details regarding visits to Niki during the September 1, 2014 to August
31,2015 timeframe.
Trip Durati
# Visit Start Visit Eed o� No�es
rs
1 12/15/2Q14 lI/1�/2Q15 3.75 Lunch
2 11/25/2014 11/30/2014 111.25 Thanks ivin
3 12/23/2014 12/26/2014 79 Christmas
4 4/5/2015 4/5/2015 8.5 Easter
5 6/28/2015 6/28/2015 10 Niki's Birthda
Total visits=5
Total hours=212.5
Average Per Visit: 42.5 hrs (42 hours 30 minutes)