NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NUMBER Reserved for Clerk's File Stamp ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES Name of Court: Branch Name: Street Address: City and Zip Code: In the Matter of: CONSERVATORSHIP CARE PLAN CASE NUMBER: , the conservator of the person/estate of hereby submits the conservator's General Plan in compliance with local court rules. 1. Conservatee's current residence address:* a Type of facility (i.e. home, skilled nursing, hospital, etc.) b. How long has the conservatee been in the present residence? c. Do you anticipate making any changes in the conservatee's residence in the next year? No Yes (explain) d. What is the plan to return the conservatee to his/her personal residence if not now living at home? e. If there are no plans to return the conservatee to his/her personal residence in the foreseeable future, explain the limitations or restrictions for not doing so? 2. Current level of care (mark all that apply): requires total care requires assistance with care able to do own care ambulatory Other relevant information If residing in a facility or group home, attach copy of the facility's care plan: If client of a regional center, identify regional center and social worker and telephone number: has feeding tube has a catheter uses wheelchair/walker urinary/bowel incontinence *Please note that the Probate Investigator's Office must be notified of any change of address by using the Notification to Court of Address form number PRO 003. PRO-023 ADMIN Approved (Rev. 07/08) Conservatorship Care Plan Page 1 of 4 PC Section 2352.5 (c) American LegalNet, Inc. www.FormsWorkflow.com CONSERVATORSHIP OF (Name): _ CONSERVATEE CASE NUMBER: 3. Conservatee's physical and medical condition: a. Please list health problems: b. Are any other health providers involved? visiting nurse podiatrist counselor speech therapist c. Medications: d. Activities conservatee is involved in? 4. How often do you expect to visit the conservatee? 5. Are there plans to give the conservator a rest? respite care adult day care other care takers In Home Supportive Services (IHSS) Names & relationships of relief caregivers: 6. Conservatee's Estimated Monthly Income (complete even if a conservatorship of the person only): 7. Conservatee's Estimated Monthly Expenses (complete even if a conservatorship of the person only): a. LIVING EXPENSES Rent/Mortgage Nursing/Care Home Food Medical/Dental Transportation $ $ $ $ $ Utilities In-Home Care Clothing Medications Entertainment Other (specify) $ $ $ $ $ $ $ . Does the family visit? . No social worker dentist physical therapist other (specify) Yes Total Estimated Monthly Expenses: PRO-023 ADMIN Approved (Rev. 07/08) Conservatorship Care Plan Page 2 of 4 PC Section 2352.5 (c) American LegalNet, Inc. www.FormsWorkflow.com CONSERVATORSHIP OF (Name): _ CONSERVATEE CASE NUMBER: b. OTHER EXPENSES TAXES Income Tax Property Payroll c. INSURANCE Homeowner Renters Automobile Worker's Comp Health Life Coverage Amount $ $ $ $ $ $ Estimated Premiums $ $ $ $ $ $ Current $ $ $ Estimated Amount $ $ $ 8. What are the contents of any safety deposit boxes? 9. Does the conservatee receive Medi-Cal benefits? No Yes $ share of cost 10. Do you expect to sell any of the conservatee's real or personal property in the next year? No Yes If yes, what will be sold and explain reasons: 11. Does the conservatee own a home in which s/he does not live? If so, is it rented? Amount of rent: $__________ If not rented, explain why: 12. If the Conservatee's monthly expenses are greater than his/her income explain how the shortfall will be met: 13. Does the conservatee have a trust or is s/he a beneficiary of a trust and entitled to receive income from the trust? If so, please provide an attachment with the name of the trust, the name(s) of the trustee(s) and their contact information, and if applicable court case number for the trust: PRO-023 ADMIN Approved (Rev. 07/08) Conservatorship Care Plan Page 3 of 4 PC Section 2352.5 (c) American LegalNet, Inc. www.FormsWorkflow.com CONSERVATORSHIP OF (Name): _ CONSERVATEE CASE NUMBER 14. Do you anticipate any unusual activities related to the management of the conservatee's estate during the next year? No Yes (explain) 15. Are there any special problems or needs raised by the Court Investigation, the Court, or others interested? If yes, how have you addressed them? The undersigned conservator will: a. Inventory all assets in which the conservatee has any interest. b. Submit accurate, complete, and timely accountings. c. Carry out all mandatory usual and general duties of a conservator. d. Maintain periodic contact with the conservatee's physician and other health care providers, if appointed conservator of the person. e. Maintain periodic contact with the conservatee's family and friends, if applicable. f. Be available to the conservatee on a 24 hour basis for emergencies, or arrange for such coverage by a qualified agent. g. Maintain accurate records related to the estate. h. Maintain all estate assets in a separate identifiable manner. i. Maintain estate cash assets in interest-bearing accounts, except as necessary for every day administration. j. Maintain an adequate surety bond as required by law. k. Update care plan as needed. l. Refer to the "Conservator's Handbook." File stamp the original Conservatorship Care Plan with the court and mail a copy to the Probate Investigations Office at: 111 N. Hill Street, Room 208, Los Angeles, CA 90012. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that I have retained a copy of this case plan for my record. Dated: Signature of Conservator Type or Print Name PRO-023 ADMIN Approved (Rev. 07/08) Conservatorship Care Plan Page 4 of 4 PC Section 2352.5 (c) American LegalNet, Inc. www.FormsWorkflow.com