ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address): TELEPHONE NUMBER: FOR COURT USE ONLY Email Address: ATTORNEY FOR (Name): FAX NUMBER: SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA COURT ADDRESS: CITY AND ZIP CODE: 191 North First Street San Jose, California 95113 PHONE NUMBER: (408) 882-2761 FAX NUMBER: (408) 882-2797 BRANCH NAME: Downtown Courthouse – Court Investigator's Division Conservatorship of (Conservatee): PLACEMENT AND LEVEL OF CARE ASSESSMENT FOR CONSERVATEE (P.C. §2352.5) CASE NUMBER: 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__________________. 2. residential care or assisted living facility acute hospital 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? Continued on Attachment 2 PB-4025 REV 6/07 PLACEMENT AND LEVEL OF CARE ASSESSMENT FOR CONSERVATEE Page 1 of 8 American LegalNet, Inc. (P.C. §2352.5) www.FormsWorkflow.com CASE NAME: 3. CASE NUMBER If the conservatee is residing in their own home, what steps are necessary to keep them in their own home? Continued on Attachment 3 4. What services are in place to ensure the conservatee’s safety and well being? Continued on Attachment 4 5. Describe the limitations and / or restrictions for a plan to return the conservatee to their home. Continued on Attachment 5 PB-4025 REV 6/07 PLACEMENT AND LEVEL OF CARE ASSESSMENT FOR CONSERVATEE Page 2 of 8 (P.C. §2352.5) American LegalNet, Inc. www.FormsWorkflow.com CASE NAME: 6. CASE NUMBER 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: Continued 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 PB-4025 REV 6/07 PLACEMENT AND LEVEL OF CARE ASSESSMENT FOR CONSERVATEE Page 3 of 8 (P.C. §2352.5) American LegalNet, Inc. www.FormsWorkflow.com CASE NAME: CASE NUMBER ATTACHMENT 2 PB-4025 REV 6/07 PLACEMENT AND LEVEL OF CARE ASSESSMENT FOR CONSERVATEE Page 4 of 8 (P.C. §2352.5) American LegalNet, Inc. www.FormsWorkflow.com CASE NAME: CASE NUMBER ATTACHMENT 3 PB-4025 REV 6/07 PLACEMENT AND LEVEL OF CARE ASSESSMENT FOR CONSERVATEE Page 5 of 8 (P.C. §2352.5) American LegalNet, Inc. www.FormsWorkflow.com CASE NAME: CASE NUMBER ATTACHMENT 4 PB-4025 REV 6/07 PLACEMENT AND LEVEL OF CARE ASSESSMENT FOR CONSERVATEE Page 6 of 8 (P.C. §2352.5) American LegalNet, Inc. www.FormsWorkflow.com CASE NAME: CASE NUMBER ATTACHMENT 5 PB-4025 REV 6/07 PLACEMENT AND LEVEL OF CARE ASSESSMENT FOR CONSERVATEE Page 7 of 8 (P.C. §2352.5) American LegalNet, Inc. www.FormsWorkflow.com CASE NAME: CASE NUMBER ATTACHMENT 6 PB-4025 REV 6/07 PLACEMENT AND LEVEL OF CARE ASSESSMENT FOR CONSERVATEE Page 8 of 8 (P.C. §2352.5) American LegalNet, Inc. www.FormsWorkflow.com