7500 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 SOLANO STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: 600 Union Avenue P.O. Caller 5000 Fairfield, CA 94533 IN RE THE CONSERVATORSHIP OF (Name): CASE NUMBER: PLACEMENT AND LEVEL OF CARE ASSESSMENT FOR CONSERVATEE (P.C. §2352.5) NOTICE TO CONSERVATOR OF THE PERSON You must complete, sign and return this form to the Court Investigators Office within 60 days of your appointment as conservator. You do not need to complete this form if the conservatorship is a "limited" conservatorship for a person with developmental disabilities. 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. If you need more space to answer any question, attach to this form a sheet of paper labeled with the case name and number at the top and the question number you are answering. I, named above and I declare as follows: , am the duly appointed conservator of the person 1. At the time of the commencement of the conservatorship, the conservatee was residing in: The conservatee's own home A skilled nursing facility Other (please describe): A residential care or assisted living facility A hospital . 2. The law presumes that the personal residence of the conservatee is the "least restrictive appropriate residence." (Probate Code §2352.5.) If the conservatee IS residing in their own home, what steps are necessary to keep them in their own home? PLACEMENT AND LEVEL OF CARE ASSESSMENT FOR CONSERVATEE Adopted for Mandatory Use Solano County Local Form no. 7500 Eff. 01/10 Prob. C. §2352.5 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 7500 IN RE CONSERVATORSHIP OF: CASE NUMBER: 3. If the conservatee IS NOT residing in his or her own home, what restrictions or limitations prevent the conservatee from residing in his or her own home? What steps would be necessary to return the conservatee to their home? What steps have been taken? If none, why not? 4. What are you doing to ensure the conservatee's safety and well-being? 5. Since your appointment as conservator, have there been any significant changes in the conservatee's circumstances affecting the conservatee's need for placement and care? No Yes (please explain): I declare under penalty of perjury of the laws of the State of California that the foregoing declaration and the information contained therein is true and correct. Date: (Signature of Conservator) PLACEMENT AND LEVEL OF CARE ASSESSMENT FOR CONSERVATEE Adopted for Mandatory Use Solano County Local Form no. 7500 Eff. 01/10 Prob. C. §2352.5 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com