Fresno — Confidential Conservatorship Care Plan – Part 1

Source: https://www.fresno.courts.ca.gov/system/files/forms-and-filings/gc-355-confidential-conservatorship-care-plan-part-1.pdf

GC-355 ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: FOR COURT USE ONLY NAME:

FIRM NAME:

STREET ADDRESS:

CITY: STATE: ZIP CODE:

TELEPHONE NO.: FAX NO.:

EMAIL ADDRESS:

ATTORNEY FOR (name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

CONSERVATORSHIP OF THE PERSON AND ESTATE OF (name): CONSERVATEE CONFIDENTIAL CONSERVATORSHIP CARE PLAN—PART 1 CASE NUMBER: Initial Update Limited Conservatorship

To the Conservator of the Person

Use this form and Confidential Conservatorship Care Plan—Part 2 (Medical Information) (form GC-356) to prepare a care plan for the conservatee. Complete each item on this form and items 1–4 on form GC-356 unless one of the following two exceptions applies: If you are a limited conservator who is the conservatee's parent or child, you are required to complete this form once, within 120 days of your appointment, and only items 1–4. The other items are optional unless the court ordered you to complete one or more. If you are the Director of Developmental Services or the director's designee and the conservatee has developmental disabilities and is a regional center consumer, you must complete items 1, 3a–3f, and 5–12 on this form and items 1–4 on form GC-356. Note: If you are a limited conservator who is not the conservatee's parent or child and is not the state Director of Developmental Services or the director's designee, you must complete each item on this form and items 1–4 on form GC-356. Do not discuss confidential medical information on this form. Discuss confidential medical information only on Confidential Conservatorship Care Plan—Part 2 (Medical Information) (form GC-356); deliver form GC-356 with this form only to the conservatee, the conservatee's attorney, the conservator of the estate, if any, and that conservator's attorney as instructed on page 6. When you have completed Part 1 and Part 2 of the care plan: Sign page 4 of this form and page 2 of Confidential Conservatorship Care Plan—Part 2 (Medical Information) (form GC-356); Deliver the care plan to the persons and in the manner described in the instructions on page 6; and File both parts of the care plan and a completed Proof of Delivery by Mail (page 5 of this form) or other proof with the court: no later than 120 days after the date of the court order appointing you conservator (initial plan); no later than 10 days before a hearing to consider whether to continue or terminate the conservatorship (updated plan); or as directed by the court. For more information about developing, completing, and filing a care plan, see chapters 4 and 6 of the Handbook for Conservators.

WARNING: If you do not file a completed care plan by the applicable deadline, the court can remove you as conservator, order you to pay a penalty of up to $500, and, if you are a professional fiduciary, refer you to the Professional Fiduciaries Bureau for investigation.

1. I, (name): am the conservator of the person of the conservatee named above. I was appointed on (date of order): .

2. a. These conservatorship proceedings began on (date of filing of first petition for appointment of conservator): . b. The conservatee's care on that date was was not sufficient to meet the conservatee's needs for the reasons given below on Attachment 2b.

3. a. The conservatee is currently living at the following address (street, city, state, and zip code; if it is a care facility, give the name):

   Telephone number: Email address: b. The conservatee has been living at this location since (date):

Form Adopted for Mandatory Use Prob. Code, §§ 2351.2, 2352.5; Judicial Council of California CONFIDENTIAL CONSERVATORSHIP CARE PLAN—PART 1 Cal. Rules of Court, rule 7.1063 GC-355 [Rev. January 1, 2025] www.courts.ca.gov

GC-355 CONSERVATORSHIP OF CASE NUMBER: (name): CONSERVATEE

3. c. The location in item 3a is (check all that apply): (1) The conservatee's single family home, condominium, or apartment. (2) A relative's or friend's single family home, condominium, or apartment. (3) An acute care (a) hospital (b) psychiatric hospital. (4) A skilled nursing facility. (5) A licensed unlicensed care facility that provides (if you know): (a) intermediate care for adults with developmental disabilities. (b) residential care for older adults. (c) assisted-living services (with 7 or more beds). (d) board and care (with 6 or fewer beds). (6) Another type of residence described below. on Attachment 3c.

   d. The location in item 3a uses a secured (locked) perimeter delayed egress system to regulate the departure of residents. e. The location in item 3a is is not the least restrictive residence appropriate for the conservatee for the reasons given below. on Attachment 3e.

   f. I plan do not plan to move the conservatee or change the conservatee's residence within the next 12 months for the reasons given below. on Attachment 3f.

   g. The location in item 3a (1) is the conservatee's personal residence because the conservatee understands or believes, or appears to understand or believe, that it was their permanent residence on the date in item 2; or the conservatee cannot form or communicate an understanding or belief about their permanent residence, and it is the residence they last understood or believed, or appeared to understand or believe, to be their permanent residence. (2) is not the conservatee's personal residence because the conservatee understands or believes, or last understood or believed, that a different home or care facility was their permanent residence on the date in item 2. The conservatee's personal residence is located at (street, city, state, and zip code, and, if a care facility, name): (3) is not the conservatee's personal residence because the conservatee does not understand or believe, and has never understood or believed, that they had a permanent residence on the date in item 2.

4. a. The conservatee is living in their personal residence. The measures necessary to allow the conservatee to stay in that residence are described (check all that apply): below on Attachment 4a in item 5 in item 6 Ii‘COnftilnttli.COn1l7VltO71sti.Cl7l.Piln|Pl7t.2.((lit[li.InfO7rlttOn1‘((fIm‘Giy356)=

b. (1) The conservatee is not living in their personal residence but will be able to return to live in that residence in the foreseeable future. My plan to help the conservatee return to live in their personal residence is described (check all that apply): below in Attachment 4b(1) in item 5 in item 6 Ii‘COnftilnttli.COn1l7VltO71sti.Cl7l.Piln|Pl7t.2.((lit[li.InfO7rlttOn1‘((fIm‘Giy356)=

(2) The conservatee is not living in their personal residence and will not be able to return to live in that residence in the
foreseeable future for the reasons described below. on Attachment 4b(2).

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GC-355 CONSERVATORSHIP OF CASE NUMBER: (name): CONSERVATEE

5. The conservatee is currently receiving the following care or assistance. (Check all that apply; you may provide additional information about any item in the space after "other care or assistance" or on Attachment 5j. Note: Do not discuss confidential medical information on this form. Discuss that information only in Part 2 (form GC-356).)

   a. No care or assistance. b. Light housekeeping help. c. Personal caregivers for hours per day. 24-hour care. d. Assistance with daily living skills. e. Nursing care. f. Meal preparation assistance. g. Assistance with medication: Administering. Setup only. h. Assistance with mobility: Hands-on. Standby only. i. In-home hospice services. j. Other care or assistance, as described below. on Attachment 5j.

6. a. The conservatee's current care and treatment are sufficient to meet the conservatee's needs. I plan to continue the care and treatment described in item 5 and Confidential Conservatorship Care Plan—Part 2 (Medical Information) (form GC-356).

   b. The conservatee's current care and treatment are not sufficient to meet the conservatee's needs. I have arranged or plan to arrange the care described (check all that apply): below on Attachment 6b in item 3b of Confidential Conservatorship Care Plan—Part 2 (Medical Information) (form GC-356) to meet those needs. (Note: Do not discuss confidential medical information on this form. Discuss that information only in form GC-356.)

7. The conservatee's care needs have been evaluated by a professional. A copy of the evaluation, including a description of the professional's qualifications, is included as Attachment 7. IMPORTANT: You must complete and file Part 2 of the care plan (form GC-356) even if you attach a professional evaluation. If the professional evaluation includes confidential medical information, make sure to redact (block out so no one can read) that information from all copies except the copy filed with the court and the copies delivered to the conservatee, the conservatee's attorney, the conservator of the estate, and the conservator of the estate's attorney.

   A professional evaluation of the conservatee's care needs is not required, but is recommended if the circumstances and the conservatee's condition warrant it and the conservatee can afford it. Note: Include any written evaluation by a professional fiduciary appointed as conservator or proposed for appointment.

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GC-355 CONSERVATORSHIP OF CASE NUMBER: (name): CONSERVATEE

8. a. (1) I live with the conservatee. (2) I plan to visit the conservatee on the schedule described below. on Attachment 8a.

   b. The steps that I plan to take to ensure that the conservatee is able to visit and communicate with family and friends, consistent with the conservatee's preferences, are described below. on Attachment 8b.

9. a. The conservatee engages in the social or recreational activities described, including location, below. on Attachment 9a.

   b. The conservatee is not able to engage in social or recreational activities for the reasons explained below. on Attachment 9b.

10. a. Any problems brought to my attention by the court, the investigator, or an interested person and my plans to address each of those problems are described below. on Attachment 10a.

    b. No specific problems have been brought to my attention.

11. a. The conservatee's estimated monthly expenses, to the extent I have access to the information needed to estimate them, in each category listed in Probate Code section 2351.2(b)(7), are stated below. on Attachment 11a.

    b. Except for the expenses stated in item 11a, I do not have access to the information needed to estimate the conservatee's monthly expenses.

12. Number of pages attached:

Date:

(TYPE OR PRINT NAME OF CONSERVATOR OF THE PERSON) (SIGNATURE OF CONSERVATOR OF THE PERSON )

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GC-355 CONSERVATORSHIP OF CASE NUMBER: (name): CONSERVATEE PROOF OF DELIVERY BY MAIL

1. I am over the age of 18. I am the appointed conservator of the conservatee named above, the conservator's attorney, or an employee of the conservator's attorney. I am a resident of or employed in the county where the mailing occurred.

2. My residence or business address is (specify):

3. I delivered a copy of this form (GC-355) and a copy of Confidential Conservatorship Care Plan—Part 2 (Medical Information) (form GC-356) to each person in items 1 to 4 below the signature line. I delivered a copy of this form without form GC-356 to the persons in items 5 to 9 below and on any attachment. I enclosed each copy in an envelope addressed as shown below and a. deposited the sealed envelope on the date and at the place shown in item 4 with the United States Postal Service with the postage fully prepaid.

b. placed the envelope for collection and mailing on the date and at the place shown in item 4 following our ordinary business
practices. I am readily familiar with this business's practice for collecting and processing correspondence for mailing. On
the same day that correspondence is placed for collection and mailing, it is deposited in the ordinary course of business
with the United States Postal Service in a sealed envelope with postage fully prepaid.

4. a. Date mailed: b. Place mailed (city, state):

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date:

(TYPE OR PRINT NAME OF PERSON COMPLETING THIS FORM) (SIGNATURE OF PERSON COMPLETING THIS FORM)

NAME AND ADDRESS OF EACH PERSON TO WHOM A COPY OF THE PLAN WAS MAILED
Name and relationship Address
to conservatee (number, street, city, state, and zip code)

1. The conservatee

2. The conservatee's attorney

3. The conservator of the estate (if not you)

4. The attorney for the conservator of the estate

ALERT: Do not deliver a copy of the care plan to any person if the court found that delivery to that person would pose a risk of harm to the conservatee. Do not, under any circumstances, deliver a copy of form GC-356 to anyone except the persons in 1–4. 5. The conservatee's spouse or registered domestic partner 6. Relationship:

7. Relationship:

8. Relationship:

9. Relationship:

   Continued on an attachment. (List the name, mailing address, and relationship to the conservatee of each additional person.)

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GC-355 CONSERVATORSHIP OF CASE NUMBER: (name): CONSERVATEE

INSTRUCTIONS FOR DELIVERING COPIES OF CONFIDENTIAL CONSERVATORSHIP CARE PLAN—PART 1 AND CONFIDENTIAL CONSERVATORSHIP CARE PLAN—PART 2 (MEDICAL INFORMATION) BY MAIL

You (the conservator, your attorney, or an employee of your attorney) must deliver a copy of Confidential Conservatorship Care Plan— Part 1 (this form) and Confidential Conservatorship Care Plan—Part 2 (Medical Information) (form GC-356) to each person in item 1, below. You must also deliver a copy of this form without form GC-356 to each living person in item 2, below, as applicable. You may send each copy of the care plan by mail; these instructions describe how to do that. Alternatively, you may deliver a copy to someone in person or send a copy electronically to someone who has consented to receive electronic service and provided an electronic service address on Consent to Electronic Service and Notice of Electronic Service Address (form EFS-005-CV).

1. Who must receive the mailing: You must mail a copy of this form (GC-355) and Confidential Conservatorship Care Plan—Part 2 (Medical Information) (form GC-356) to each of the following persons: a. The conservatee; b. The conservatee's attorney; c. The conservator of the estate (if the court appointed one); and d. The attorney for the conservator of the estate.

2. You must also mail a copy of this form without form GC-356 to each of the persons in the following categories. But if the court found that delivery of the care plan to one or more of those persons would result in harm to the conservatee, do not mail a copy of either Part 1 (form GC-355) or Part 2 (form GC-356) to that person or those persons.

   a. The conservatee's spouse or domestic partner; b. All the conservatee's relatives in the first degree (parents and children 12 years of age and older); c. If the conservatee has no spouse or registered domestic partner and no relatives in the first degree, then all the relatives in the second degree (siblings, grandchildren 12 years of age and older, grandparents); d. If the conservatee has a child, sibling, or grandchild under 12 years of age, then a parent, guardian, or other person having legal custody of the child, sibling, or grandchild with whom the child, sibling, or grandchild resides.

3. When the mailing must be completed: If the care plan is an initial plan, you must complete the mailing described above no later than the end of the 120th day after the filing date of the Order Appointing Probate Conservator (form GC-340) issued in your case. If the care plan is an update, you must complete the mailing no later than the end of the 10th day before the hearing to consider terminating the conservatorship or no later than the date the court orders.

4. Before you mail: Make enough copies of pages 1–4 of this form to be able to send one to each person in the categories in items 1 and 2, above. Make enough copies of form GC-356 to be able to send one to each person in item 1, above. IMPORTANT: Do not send Confidential Conservatorship Care Plan—Part 2 (Medical Information) (form GC-356) to anyone except the persons in item 1.

5. Fill out Proof of Delivery by Mail: You (the conservator) or your attorney must fill out the Proof of Delivery by Mail on page 5 of this form, including the names, relationships to the conservatee, and mailing addresses of the persons in the categories in items 1 and 2, above, who are entitled to receive to receive a copy of the plan. If the Proof of Delivery by Mail does not have enough space for the names, relationships, and addresses of all the persons who will receive a copy of the plan, you must show the additional names, relationships, and addresses on one or more additional pages and attach those pages to the Proof of Delivery. After completing the mailing as described in item 6 below, you or your attorney must date and sign the Proof of Delivery by Mail on page 5 of this form.

6. How to mail: You (the conservator), your attorney, or an employee of the attorney, must do the following: a. Place copies of this form and—only to the persons listed in item 1 above—form GC-356 in sealed envelopes with postage fully prepaid addressed to each person at the address shown for that person on the Proof of Delivery by Mail on page 5 of this form or on attached additional pages.

   b. Deposit (mail) the sealed envelope(s) with the United States Postal Service on the date and from the place (city and state) shown in item 4 at the top of the Proof of Delivery by Mail on page 5 of this form.

7. File the care plan: You (the conservator or your attorney) must file with the court the original Confidential Conservatorship Care Plan—Part 1 (this form) and Confidential Conservatorship Care Plan—Part 2 (Medical Information) (form GC-356) and a signed and dated Proof of Delivery by Mail (page 5 of this form) with any additional address pages attached.

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