Attorney or party without attorney (Name, State Bar number, and address) FOR COURT USE ONLY TELEPHONE NUMBER: Email Address: FAX NUMBER: ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE Riverside: 4050 Main St. (P.O. Box 431), Riverside, CA 92502-0431 Palm Springs: 3255 E. Tahquitz Canyon Way, Palm Springs, CA 92262 Hemet: 880 N State St., Hemet, CA 92543 Case Number: Conservatorship of (Conservatee): PLACEMENT AND LEVEL OF CARE ASSESSMENT FOR CONSERVATEE (PrC §2352.5) NOTICE TO CONSERVATOR You must complete, sign and return this form to the Court Investigator within 60 days of your appointment. Failure to complete, sign and return this form will result in further court action, possibly including your removal as conservator. A conservator who willfully submits any material information required by this form that he or she knows to be false is guilty of a misdemeanor. Pursuant to Probate Code §2352.5, which states that the personal residence of the conservatee is presumed to be the least restrictive appropriate residence, the conservator declares as follows: 1. At the time of the commencement of the conservatorship, the conservatee was residing in: own home skilled nursing facility other residential care or assisted living facility acute hospital . 2. If not residing in their own home, what steps would be necessary to return the conservatee to their home? What steps have been taken? If none, why not? Continue on Attachment 2 Form #RI-P28A Revised 4/5/10 PLACEMENT AND LEVEL OF CARE ASSESSMENT FOR CONSERVATEE (P.C. §2352.5) Page 1 of 3 RI-P28A American LegalNet, Inc. www.FormsWorkFlow.com CASE NUMBER CASE NAME: 3. If the conservatee is residing in their own home, what steps are necessary to keep them in their own home? Continue on Attachment 3 4. What services are in place to ensure the conservatee’s safety and well being? Continue on Attachment 4 5. Describe the limitations and/or restrictions for a plan to return the conservatee to their home. Continue on Attachment 5 Form #RI-P28A Revised 4/5/10 PLACEMENT AND LEVEL OF CARE ASSESSMENT FOR CONSERVATEE (P.C. §2352.5) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com CASE NUMBER CASE NAME: 6. Since your appointment, has there been a material change in the conservatee’s circumstances affecting the conservatee’s need for placement and care? If yes, explain: Continue on Attachment 6 I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Signature of Conservator Form #RI-P28A Revised 4/5/10 PLACEMENT AND LEVEL OF CARE ASSESSMENT FOR CONSERVATEE (P.C. §2352.5) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com