San Joaquin — Conservatorship - Conservatee Status Report Form

Source: https://www.sjcourts.org/sites/default/files/forms/2026-02/Conservatorship_-_Conservatee_Status_Report_Form.pdf

SUPERIOR COURT INVESTIGATORS PHONE: (209) 992-5696 SUPERIOR COURT OF SAN JOAQUIN COUNTY

In The Conservatorship of:

CASE NUMBER

REPORT TO THE COURT ON THE STATUS OF CONSERVATEE

I, _____________________________am the Conservator of the above-named Conservatee and my status report is as follows:

1. Present age of the Conservatee: ____________ Conservatee’s Date of birth: ______________

2. Current Living arrangements of the Conservatee: A. Name of care facility/board and care: _________________________________________

   B. Current address: _________________________________________________________

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   C. Phone number of Conservatee: __________________________________________________ D. The Conservatee’s residence is own home/apartment Conservator’s home/apartment nursing home hospital or medical facility boarding home relative’s home (relationship) ________________ other (specify)__________ E. The Conservatee has been in the present residence since (date):. If moved within the past year, state reason(s) for change: ____________________________________________ F. I rate the Conservatee living arrangement as Excellent Average Below average (Explain)________________________________________________________ G. I believe the Conservatee is: content with the living situation unhappy with the living situation H. I recommend a more suitable living arrangement for the adult as follows: ________________________________________________________________________________ ________________________________________________________________________________

3. Physical Health A. I believe that the Conservatee’s current physical condition is Excellent Good Fair Poor B. During the past year the Conservatee’s physical condition has: remained about the same improved (Explain) _________________________________________________ worsened (Explain)_________________________________________________ C. During the past year the Conservatee received the following medical treatment; (Include check-ups and dental): Date Ailment Type of Treatment Doctor’s Name __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ STATUS REPORT ON CONSERVATEE

Form Adopted for Optional Use CONFIDENTIAL Superior Court of California, County of San Joaquin Form – CI-12 Effective 01/01/2011

4. Mental Health A. I believe the Conservatee’s current mental condition is Excellent Good Fair Poor B. During the past year the Conservatee’s mental condition has: remained about the same. improved (Explain) _________________________________________________________ worsened (Explain) ________________________________________________________ C. During the past year, treatment or evaluation by a psychologist or social worker: was provided was not provided __________________________________________________ D. IF conservatee is a client of Valley Mountain Regional Center please provide: (Case Manager Name): _________________________________ (Phone Number):___________________

5. Social Activities/Services A. The conservatee’s social condition is Excellent Good Fair Poor B. During the past year, the Conservatee’s social condition has: remained about the same improved (Explain) ______________________________________ C. IF conservatee participates in a day-program please provide Name of Program: ______________________________________________ Address: _____________________________________________________ Phone Number: ________________________________________________ D. During the past year, the Conservatee has participated in the following activities: Recreational _____________________________________________________________________ Educational ______________________________________________________________________ Social ___________________________________________________________________________ Occupational _____________________________________________________________________ Other organizations/programs the Conservatee participates in; describe: ______________________ ___________________________________________________________________________________ If the conservatee does not attend a day-program, please explain why: ________________________ ____________________________________________________________________________________

6. List of Visits Please check this box if the conservatee lives with the conservator. A. The last visit to the conservatee was on . During the past year, I visited the Conservatee as follows:___________________________________________________________________

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   B. The average amount of time I spent on each visit was: _______________________________________

7. I intend to change or I request the court to be able to change the following: A. The Conservatee’s living arrangement (describe);___________________________________________ ______________________________________________________________________________________

B. The current financial management of estate including the sale of any assets (describe);

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8. The conservatorship should be should not be continued because: ______________________________________________________________________________________

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9. A. I am the Conservator of the Person Only for the Conservatee. B. I am the Conservator of the Person and Estate and my accounting will be filed separately. ___________________________________ Address: ___________________________ Check if (Signature) new address _____________________________________

_________________________________________________ Phone: ___________________________ Check if (Date) new phone # STATUS REPORT ON CONSERVATEE CI-12 (01/11) CONFIDENTIAL