GC-355 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: CONSERVATORSHIP OF THE PERSON (Name): AND ESTATE OF CONSERVATEE CASE NUMBER: DETERMINATION OF CONSERVATEE'S APPROPRIATE LEVEL OF CARE Notice to Conservator of the Person You must prepare a written determination of the conservatee's appropriate level of care, sign it under penalty of perjury, and file it with the court within 60 days of the date of the court's order appointing you as conservator. You must use this form for that purpose. Your determination must include an evaluation of the conservatee's level of care on the date the conservatorship proceeding was started (the date the petition for the appointment of a conservator was filed with the court or, if more than one petition was filed, the date the first petition was filed), and the measures that would be necessary to keep the conservatee in his or her personal residence. If the conservatee was not living in that residence on the date the proceeding was started, your determination must include either a plan to return the conservatee to that residence or an explanation of the reasons why the conservatee cannot return to that residence in the foreseeable future. This determination is in addition to, not a replacement for, any written care or placement plan the court may require. Check the court's local rules to see if a care or placement plan must also be filed. The conservatee's personal residence is the residence he or she understood or believed, or appeared to understand or believe, was his or her permanent residence on the date the conservatorship proceeding was started, whether or not he or she was living there on that date. If the conservatee could not then form or communicate an understanding or belief about his or her permanent residence, the conservatee's personal residence is the residence he or she last previously understood or appeared to understand was his or her permanent residence. (See Cal. Rules of Court, rule 7.1063.) , declares as follows: (Name): 1. I am conservator of the person of the above-named conservatee. I am determining the conservatee's appropriate level of care as of (date): , the date of the order appointing me as conservator. 2. a. On the date stated in item 1, the conservatee was living at the following residence or facility (address and name of facility, if any): Telephone: b. The conservatee has been living in the above residence or facility since (date): Form Adopted for Mandatory Use Judicial Council of California GC-355 [New July 1, 2011] . Page 1 of 4 Probate Code, § 2352.5; Cal. Rules of Court, rule 7.1063 www.courts.ca.gov DETERMINATION OF CONSERVATEE'S APPROPRIATE LEVEL OF CARE (Probate--Guardianships and Conservatorships) American LegalNet, Inc. www.FormsWorkFlow.com GC-355 CONSERVATORSHIP OF (Name): CONSERVATEE 2. c. The residence or facility identified in item 2a is described as follows (select all that apply): Conservatee's single family home, condominium, or apartment Relative's or friend's single family home, condominium, or apartment Acute care hospital Acute psychiatric hospital Intermediate-care facility Assisted living facility (7 or more beds) Licensed residential care facility Board and care home (6 or fewer beds) Continuing-care retirement community Congregate living health facility--terminal or life-threatening illness type (hospice) Other (describe): Skilled nursing facility Secured perimeter CASE NUMBER: 3. a. The conservatee's care requirements as of the date given in item 1 are as follows (select all that apply; you may provide additional information concerning any items selected below under "other assistance required"): No assistance is needed at this time. Personal caregivers required, Assistance with daily living skills, Nursing care required, Assistance with ambulation: Other assistance required, Assistance with medication required, Light housekeeping help required, hours per week: hours per week. Meal preparation assistance required, Dispensing Set-up only Standby In-home hospice services. hours per week. hours per week: hours per week. Maximum 24-hour care hours per week. Part-time, hours per day. hours per week (describe): Continued on Attachment 3a. b. A professional assessment of the conservatee's care needs has been made. A copy of the assessment, including a statement of the professional's qualifications, is provided on Attachment 3b. (A professional assessment of the conservatee's care needs is not required, but is recommended if the conservatee's circumstances and condition warrant it and the conservatee can afford the expense. Include any written assessment performed by a professional fiduciary proposed for appointment or appointed as conservator.) GC-355 [New July 1, 2011] DETERMINATION OF CONSERVATEE'S APPROPRIATE LEVEL OF CARE (Probate--Guardianships and Conservatorships) Page 2 of 4 GC-355 CONSERVATORSHIP OF (Name): CONSERVATEE 4. (Complete item 4a if the residence identified in item 2 is the conservatee's personal residence as defined in Cal. Rules of Court, rule 7.1063. Complete item 4b if the residence identified in item 2 is not the conservatee's personal residence.) a. Conservatee living in personal residence The residence or facility described in item 2 is the conservatee's personal residence within the meaning of Cal. Rules of Court, rule 7.1063. The following measures are necessary to keep the conservatee in that residence: CASE NUMBER: Continued on Attachment 4a. b. Conservatee not living in personal residence The residence or facility described in item 2 is not the conservatee's personal residence within the meaning of Cal. Rules of Court, rule 7.1063. The conservatee's personal residence is (address and name of facility, if any): (Complete either item 4b(1) below or item 4b(2) on page 4. Complete item 4b(1) if you believe the conservatee can be returned to his or her personal residence in the foreseeable future. Complete item 4b(2) if you believe the conservatee cannot be returned to his or her personal residence in the foreseeable future.) (1) The conservator's plan to restore the conservatee to his or her personal residence is as follows: Continued on Attachment 4b(1). GC-355 [New July 1, 2011] DETERMINATION OF CONSERVATEE'S APPROPRIATE LEVEL OF CAR