Maidstone Foundation, 1225 Broadway, New York, NY 10001

In-Home Residential Habilitation Plan Six Month Review April 28, 2008 NOD Date: 10/27/04 Service Initiated: 8/15/07 Effective Date: 11/01/07 Consumer: Margarita Yusupova Gender: Female Address: 97-22 57th Avenue, #7D Corona, NY 11368 Medicaid #: SC79551X SS#: 055-94-2272 TABS#: 309059 Advocate: Address: Telephone# Sara Yusupova (mother) same as above same as above D.O.B.: 8/18/69 Age: 39 Telephone: (718) 592-4723 ResHab Worker: Gulida Abdushakurova

Developmental Disability Diagnosis: Margarita has been diagnosed with moderate mental retardation. Appropriate Living Situation: Margarita lives in an apartment with her parents, and her brothers family in Queens. Location and Schedule of Services: Residential Habilitation Services will be delivered to Margarita by the Maidstone Foundation, located at 1225 Broadway, 9th Floor, New York, NY 10001. Residential Habilitation Services will be delivered to Margarita within her home and in the community for an average of 16 hours weekly. Residential Habilitation services are designed to complement Margaritas schedule and that of her family. Services are usually provided on weekdays, from 6PM to 10 PM, (4 hours daily) but these hours may vary, depending on Margaritas preferences, and may include some weekend hours. Background Information: Margaritas family emigrated from Uzbekistan. Margarita lives with her parents and her brothers family. The family has a good relationship with each other and all the members are supportive of Margarita.

Margaritas developmental milestones were delayed since birth, and she attended a special school for about one year. She was very frustrated with her academic work and refused to go to school. Her parents, then, decided to keep her at home collecting disability benefits. Margarita was married for about five years. The marriage was arranged, and after some time resolved in accordance with the wishes of the relatives of both parties. She had some gynecological problems in the past. Currently, she is appeared to be anxious, depressed, and somewhat lost. In the past, Margarita was medicated for depression and her mother is considering visiting a psychiatrist to determine if her daughter needs medication to improve her emotional condition. Upon arrival to the US, Margarita started attending a day program at YAI. She has also received Service Coordination and recreational services through the Maidstone Foundation and medication treatment and councelling. Margarita suffers from diabetes and takes somemedications for that, such as Avandia and Glucovance, and also Aspirin for blood thinning. Plan of Protective Oversight: Margarita cannot evacuate her apartment by herself in case of fire or other emergency. She needs to be escorted out of the building to safety. The apartment has one functional smoke detector. Margaritas parents would escort her out of the building if necessary. Margarita is not able to travel independently. Currently, the family is happy to have their ResHab worker, Gulida, provided by Maidstone. With Gulida, Margarita started to go out more often and she acquires new daily living skills, which improve her overall level. She understands the dangers posed by poisons and will stay away from them independently. Margarita likes to go shopping and to eat out in the local inexpensive restaurants.

Progress toward goals: Margarita and her family have a good relationship with her ResHab Worker. Margarita and her mother agreed that she would like to work on the valued outcomes which were developed to improve her performance in aspects of everyday activities, but she does not want to be forced to work on her valued outcomes (such as English) when she is feeling especially tired and frustrated. Margarita sometimes becomes irritable when she does not feel like performing the activities of daily living which a young woman of her age would normally perform, but Gulida is often able to initiate doing a task and she will then join in.

Margarita likes to go into the community, but does not like to go out when it is very cold. She wants to learn English but sometimes she can resist doing this activity as well; she becomes frustrated and tires easily. Margaritas Plan will be reviewed again in November of 2008.

Valued Outcomes: Margarita has chosen to continue to work on the following valued outcomes:

Margarita would like to improve her English so she can communicate with others who are not her immediate family members. Margarita would like to be able to visit various places in the community, for example, stores, the library, or to utilize occasional recreational or leisure opportunities. Margarita would like to practice her daily living activities.

Maidstone Foundation Residential Habilitation Plan Six Month Review April 28, 2008

Consumer: Margarita Yusupova Effective Date: 11/01/07 Program Site: In home and community Duration: Ongoing Valued Outcome Margarita would like to improve her English. Preference Margarita would like to improve her English. Activity/Service ResHab Worker will assist Margarita to learn English by speaking with her and using simple materials to teach functional English vocabulary. (Staff Action) ResHab Worker will accompany Margarita to various sites in the community which she and her mother choose. ResHab worker will accompany Margarita, and ResHab worker will suggest activities which Margarita might enjoy. (Staff Action) ResHab Worker will assist Margarita in learning how to keep her room neat. (Staff Action) Monitoring System ResHab Notes and Data Sheets Frequency 2-3 X per week.

Margarita would like to visit various places in the community, for example, stores, the library, or to explore recreational opportunities.

Margarita would like to know more about her neighborhood and what is available to her, and explore leisure activities. She could walk, but she also might like to use other forms of transportation.

ResHab Notes and Data Sheets

2-3 X week, weather permitting

Margarita would like to learn daily living activities.

Margarita would like to learn how to keep her room neat.

ResHab Notes and Data Sheets

2-3 times per week.

QMRP:__________________________________ Date: ___________________ Mariette J. Bates, Ph. D.