1 CONFIDENTIAL CONSERVATORSHIP CARE PLAN FCS-401-2017 Mandatory Rev. 7-10-2018 NOTICE TO CONSERVATOR/S You must complete, sign and return to the court on or before (date): . If you are conservator of the estate only, you must complete at least items 1,2, & 6-9. All other Conservators must complete the entire form. Print legibly or type. 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. An 223Attachment224 is one or more separate sheets of paper attached to this form. You may use any letter-sized paper for this purpose, including copies of Judicial Council form MC-025, Attachment, available from the court or located in .pdf format on the Judicial Council website, www.courts.ca.gov . Label each attachment with the items or question number you are answering. Before completing your Care Plan, please carefully read and review the 2016 Revised Edition of the Handbook for Conservators which you may obtain by downloading the handbook at: http://www.courts.ca.gov/documents/ handbook.pdf . If you are conservator of the estate, you must file regular accountings with the court in addition to this care plan. 1) Conservator (Continue on Attachment 1 if necessary. If there is more than one conservator, each must provide the information requested in items 1a-f, and each must sign this form): a) Conservator222s primary language: English Spanish Other: b) (Full Name): c) Present address (street address, including apartment number, city state and zip code of each conservator): d) Telephone of each conservator (home): (work): (cell): (Please circle the best number to reach you during court hours). e) Does the Conservatee reside with you? No Yes f) If the conservatee does not reside with you, how often do you visit? Daily Weekly Monthly Other: How often do you have contact with facility staff? Daily Weekly Monthly Other: g) Is this Care Plan a short or long term plan? If a short term plan, what is the long term plan? h) Do you have any significant health problems that would interfere with your ability to continue as conservator in the next two years? No Yes (If your answer is 223yes224, please explain in Attachment 1d) i) Since your appointment or your last report, have you been arrested for, charged with, or convicted of (1) any felony or misdemeanor; or (2) any other offense involving alcohol, illegal drugs, sexual misconduct or financial affairs? No Yes (If your answer is 223yes224, please explain in Attachment 1e. You need not report minor traffic offenses that do not involve alcohol or illegal drugs.) j) Are you a court-appointed guardian or conservator for any other child or adult under a different case number or court? No Yes (If your answer is 223yes224, please identify in Attachment 1f each other child or adult by name, court and case number.) Attorney or Party without Attorney (name and address) Email address: Attorney for (name): FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF TULARE Office of the Clerk, 221 S. Mooney Blvd, Room 201, Visalia, CA 93291 Office of the Clerk, 300 E. Olive Ave, Porterville, CA 93257 IN THE MATTER OF THE LIMITED CONS ERVATORSHIP OF THE PERSON ESTATE OF: CONSERVATEE CONFIDENTIAL CONSERVATORSHIP CARE PLAN Per Tulare County Superior Court Local Rule 1013 CASE NUMBER: American LegalNet, Inc. www.FormsWorkFlow.com 2 CONFIDENTIAL CONSERVATORSHIP CARE PLAN FCS-401-2017 Mandatory Rev. 7-10-2018 2) Personal Information of Conservatee (continue on Attachment 2 if necessary): a) Conservatee222s primary language: English Spanish Other: i) If the conservatee222s primary language is not English, who will interpret for the Conservatee, and how will conversation be provided to the Conservatee in his/her native language? b) (Full Name): c) (Birthdate): (Age): d) Present address if different from above (street address, including apartment number, city state and zip code of the conservatee): How long at this address: Date of admission: e) Telephone (home): (work): (cell): f) Type of Facility: private home board and care assisted living skilled nursing State Developmental Hospital Other: g) Name of Facility: h) Contact Person at the Facility: Contact Number at the Facility: 3) Current Level of Care (continue on Attachment 3 if necessary): a) requires total care requires assistance with care able to do own care ambulatory uses a walker/wheelchair has a catheter has feeding tube urinary/bowel incontinence Other: b) If residing in a facility or group home, attach a copy of the facility222s care plan. c) Do you plan to make any changes to the Conservatee222s residence in the next two years? No Yes ; If yes, explain: d) What is the plan to return the conservatee to his/her person residence if not now living at home? Why not? 4) Conservatee222s Physical and Emotional Health (continue on Attachment 4 if necessary): a) Please describe the Conservatee222s health, general well-being, and level of functioning: b) Please provide a brief description of the Conservatee222s adjustment, progress, and the reason(s) the conservatorship should continue: c) Please describe your feelings about the care and treatment the conservatee is receiving: d) Please Provide the names of the medical professionals providing services to the conservatee: i) Doctor(s): ii) Dentist: iii) Optician/Ohthalmologist: iv) Audiologist: v) Psychiatrist/Social Worker/therapist/Case Worker: American LegalNet, Inc. www.FormsWorkFlow.com 3 CONFIDENTIAL CONSERVATORSHIP CARE PLAN FCS-401-2017 Mandatory Rev. 7-10-2018 PLEASE NOTE THAT FAMILY COURT SERVICES MUST BE NOTIFIED OF ANY CHANGE OF ADDRESS FOR THE CONSERVATOR/S AND/OR CONSERVATEE (Judicial Council Forms GC-079, GC-080, or MC-040). e) Please list ALL current medical diagnoses for the Conservatee: Diagnosis Diagnosis Diagnosis f) Please list ALL current medications for the Conservatee and what they are used to treat: Medication Name: For Treatment of: Medication Name: For Treatment of: g) What type of health care insurance does the Conservatee receive? private insurance Tri-Care Medi-Cal Medicare Other: h) Who will arrange for, attend, and transport the conservatee for health and mental health appointments? i) Describe any emotional or behavioral issues that require treatment: j) Describe the Conservatee222s social activities/services including recreational, educational, spiritual, occupational or cultural activities: Who provides these activities/services? k) Who visits the conservatee other than the conservator? (1) How frequently? 5) Is the Conservatee a client of a Regional Center: No Yes (continue on Attachment 5 if necessary): a) Name of Regional Center: b) Name of the Case Manager: Telephone Number of Case Manager: c) Date of last Individual Program Plan review: a. Was the conservator present in-person by telephone Did not participate; If did not participate, why? 6) Does the conservatee attend an Employment/ Day Program/ Training Site: No Yes (continue on Attachment 6 if necessary): a) Name: b) Address: c) Usual Hours and Days of Attendance: d) Program/Employer Contact Person: Contact Telephone: 7) Financial Status of Conservatee (continue on Attachment 7 if necessary): a) What is the source of the conservatee222s income? SSA SSI VA Pensions Investments Rental Home Other: b) Who is payee of various types of income? e) Conservatee222s estimated monthly income (complete even if a conservatorship of the person only): f) Conservatee222s estimated monthly expenses (complete even if a conservatorship of the person only): g) If the Conservatee222s monthly expenses are greater than his/her income, explain how the shortfall will be met: American LegalNet, Inc. www.FormsWorkFlow.com 4 CONFIDENTIAL CONSERVATORSHIP CARE PLAN FCS-401-2017 Mandatory Rev. 7-10-2018 h) Who will pay board and care for the Conservatee? i) Amount of personal and incidental monies available to Conservatee per month: i) Who will monitor or assist use of funds? j) Does the conservatee have a trust or is s/he a beneficiary of a trust