San Bernardino — SB-10120

Source: https://sanbernardino.courts.ca.gov/system/files/sb-10120.pdf

CONFIDENTIAL ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

TELEPHONE NO.: FAX NO. (Optional):

E-MAIL ADDRESS (Optional):

ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN BERNARDINO

STREET ADDRESS:

MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: CONSERVATORSHIP OF THE □ PERSON □ ESTATE OF (Name):

CASE NUMBER:

CONFIDENTIAL GENERAL CARE PLAN OF CONSERVATEE

All questions on this form must be completed and answered.

If the question or blank does not apply, write “not applicable” or “none”. If you need additional space to fully respond, please note on the form that a separate attachment is being provided and staple the attachment to the form.

PERSONAL NEEDS

Living Arrangements

Current address of Conservatee: Phone:

(Include name of facility if appropriate)

Current living arrangement: □ Personal residence □ Home of relative □ Board & care home □ Assisted living □ Skilled nursing facility

The Conservatee has been at the present residence since .

If the Conservatee is in his/her personal residence, what is the current level of care?
□ No assistance needed at this time.
Household help Hours per week □□ Personal caregivers Hours per week
What will be necessary to keep the Conservatee in his/her residence?

If the Conservatee is not living in his/her residence:
What is the plan to return Conservatee to his/her personal residence? If there are no plans to
return the Conservatee to his/her personal residence in the foreseeable future, explain the
limitations or restrictions:

Medical Information Is in good health □ Is developmentally disabled □□ Confusion / Disorientation □ Unable to read / write Memory loss □ Deaf or communication problem □ Other Name Purpose of Medication Name Purpose of Medication

Pr.C.§2352.5 GENERAL CARE PLAN FOR Local Form (Rev. 03/21/08)
Mandatory CONSERVATEE CONFIDENTIAL 1

CONFIDENTIAL CONSERVATORSHIP OF (Name): CASE NUMBER:

Provider Name Phone number Last visit

Physician

Dentist Other (e.g. visiting nurse, case worker)

Visitations

How often do you visit the Conservatee? How often does the Conservatee receive visits from family and friends? Are any visitations particularly valued or upsetting to the Conservatee?

Activities Describe□theOutingsnormal activities of Conservatee: □ Television / Radio □ Social □ Educational □ Recreational □ Unwilling to participate □ Unable to participate □ Other (i.e. reading material) Special Problems Explain how you have addressed any special needs or problems raised by the Court Investigator, the Court, or other interested persons:

FINANCIAL NEEDS

Estimated Monthly Income

Social Security $ Income - other sources $
Pension (type ) $ Dividends $
Veterans Benefits $ Rentals $
Supplemental Security Income $ Estimated Other $
Interest from Investment $ TOTAL Estimated Monthly Income $

Estimated Monthly Expenses TAXES Currently Paid? Next Due Date Estimated Monthly Payment Income □ Yes □ No $ Real Estate □ Yes □ No $

INSURANCE Company Premium Paid Coverage Amount Estimated Monthly Payment Homeowners Renters Yes No $ Automobile □ Yes □ No $ Workers Comp □ Yes □ No $ Health □ Yes □ No $ Life □ Yes □ No $ □ Yes □ No $ Other □ Yes □ No $ LIVING EXPENSES Rent or Mortgage $ Utilities $ Nursing Home or Telephone $ Board & Care Home $ Laundry and Cleaning $ Live-In Attendants $ Clothing $ Other Care Providers $ Entertainment / Recreation $ Medical and Transportation $ Dental Supplies $ Other $ Food $ TOTAL Estimated Monthly Expenses $

Pr.C.§2352.5 GENERAL CARE PLAN FOR CONSERVATEE Local Form (Rev. 4/1/08)
Mandatory CONFIDENTIAL 2

CONFIDENTIAL CONSERVATORSHIP OF (Name): CASE NUMBER:

If monthly expenses exceed monthly income, how do you plan to meet the shortfall a) for the present and b) for the long term?

Describe any planned changes in investments to be made and/or any major assets that may be sold in the coming year and the reason for these changes and/or sales:

Identify the contents of any safety deposit box.

Are there any valuable assets in the conservatee’s residence that need to be protected? If so, describe them and specify what steps have been take to protect these items from loss or theft:

Conservator believes it will be necessary to provide the following additional services to properly care for and maintain the personal and financial needs of the Conservatee:

The undersigned conservator will:

a. Carry out all mandatory duties of a conservator (refer to form GC-348);
b. Maintain periodic contact with the conservatee’s family and friends, if applicable;
c. Be available to the conservatee on a 24-hour basis for emergencies, or arrange for
such coverage by a qualified agent;

If appointed conservator of the estate
d. Inventory all assets in which the conservatee has any interest;
e. Render timely, accurate and complete accountings to the court;
f. Maintain accurate records related to the estate;
g. Maintain all estate assets in interest-bearing account, except as necessary for
everyday administration;
h. Maintain an adequate surety bond as required by law;

If appointed conservator of the person
i. Maintain periodic contact with the conservatee’s physician and other health care
providers.
j. Maintain conservatee in the least restrictive placement and, if moved, notice the
court and interested parties.

I declare under penalty of perjury under the laws of the State of California that the foregoing

is true and correct, and that I have retained a copy of this case plan for my records.

Date Attorney Date Conservator

Pr.C.§2352.5 GENERAL CARE PLAN FOR CONSERVATEE Local Form (Rev. 4/1/08)
Mandatory CONFIDENTIAL 3