ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address) Telephone Number E-MAIL ADDRESS ATTORNEY FOR (Name): FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF VENTURA Juvenile Courthouse 4353 Vineyard Ave Oxnard, CA 93036 IN THE MATTER OF: CONSERVATORSHIP CARE PLAN STATUS REPORT Ventura Superior Court Local Rule 10.02.I & J CASE NUMBER: , the conservator of the person/estate of hereby submits the conservator222s Care Plan Status Report in compliance with Ventura Superior Court Local Rules. 1. Conservatee222s curren t residence:* a . Address: b . Type of facility (i.e. own home, skilled nursing, hospital, etc.) : c . How long has the conservatee been in the present residence? d . Do you anticipate making any changes in the conservatee222s residence in the next year? No Yes (explain) e . W hat is the plan to return the conservatee to his/her personal residence if not now living at home? f . 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 has feeding tube able to do own care uses a wheelchair/walker has catheter ambulatory urinary/bowel incontinence Details: If residing in a facility or group home, attach copy of the facility222s care plan: If client of a regional center, identify regional center and social worker and telephone number as well as a complete copy of the most recent individual program planning (IPP) report : VN233 * Please note that the Probate Investigator222s Office, and Conservatee222s Counsel, must be notified of any change of address. Mandatory Form VN233 (0 7 / 1 9 ) CONSERVATORSHIP CARE PLAN / STATUS REPORT Page 1 of 3 CONFIDENTIAL American LegalNet, Inc. www.FormsWorkFlow.com CONSERVATORSHIP OF (Name): CONSERVATEE Case number: 3. Conservatee222s physical and medical condition: a. Please list health p roblems: b. Are any other health providers involved? No Yes visiting nurse social worker podiatrist dentist counselor physical therapist speech therapist other (specify): c. Medica tions: d. Activities conservatee is involved in? 4. How often do you expect to visit the conservatee? . Does the family visit? . 5 . Are there plans to give the conservator a rest? respite care adult day care other care takers In Home Su pport Services (IHSS) Names & relationships of relief caregivers : 6. Conservatee222s Estimated Monthly Income (complete even if a conservatorship of the person only): 7. Conservatee222s Estimated Monthly Expenses (complete even if a conservatorship of the person only): a. LIVING EXPENSES Rent/Mortgage $ Utilities $ Nursing/Care Home $ In - Home Care $ Food $ Clothing $ Medical/Dental $ Medications $ Transportation $ Entertainment $ Other (specify) $ Total Estimated Monthly Expenses $ b. OTHER EXPENSES TAXES Current Estimated Amount Income Tax $ $ Property $ $ Payroll $ $ c. INSURANCE Current Estimated Amount Homeowner $ $ Renters $ $ Automobile $ $ Worker222s Com p $ $ Health $ $ Life $ $ 8. What are the contents of any safe deposit boxes? Mandatory Form VN233 (0 7 / 1 9 ) CONSERVATORSHIP CARE PLAN / STATUS REPORT Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com CONSERVATORSHIP OF (Name): CONSERVATEE Case number: 9. Does the conservatee receive Medi - Cal benefits? No Yes $ share of cost 10. Do you expect to sell any of the conservatee222s real or personal property in the next year? No Y es If yes, what will be sold and explain reason why: 11. Does the conservatee own a home in which (s)he does not live in? No Yes If yes, is it rented? No Yes Amount of rent: $ If not rented, explain why: 12. If the Conservatee222s 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: 14. Do you anticipate any unusual activities related to the management of the conservatee222s estate during the next year? No Yes (explain): 15. Are there any special problems or needs raised by the Court Investigation, the Court, or other 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 acc urate, complete, and timely accountings. c. Carry out all mandatory usual and general duties of a conservator. d. Maintain periodic contact with the conservatee222s physician and other health care providers, if appointed conservator of the person. e . Maintain periodic contact with the conservatee222s 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. Upda te care plan as needed. l. Refer to the 223Conservator222s Handbook.224 I declare under penalty if perjury under the laws of the State of California that the foregoing is true and correct, and that I have retained a copy for my record. Dated Signature of Conservator Type or Print Name Mandatory Form VN233 (0 7 / 1 9 ) CONSERVATORSHIP CARE PLAN / STATUS REPORT Page 3 of 3 File the original Conservatorship Care Plan Status Report with the court and mail a copy to the Probate Investigations Office at: 800 S. Victoria Ave, Ventura, CA 93009 and Public Defender222s Office at: 800 S. Victoria Ave. Suite 207, Ventura, CA 93009. American LegalNet, Inc. www.FormsWorkFlow.com