Los Angeles local probate form — Has the proposed conservatee been diagnosed with major or mild Neurocognitive Disorder (Dementia)? (LASC PRO 077)

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NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT STATE BAR NUMBER Reserved for Clerk’s File Stamp ATTORNEY:

SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES To keep other people from seeing what you entered on your form, please pr

COURTHOUSE ADDRESS: Click on the button to select the appropriate court address. IN THE CONSERVATORSHIP OF:

PROBATE COURT APPOINTED COUNSEL'S REPORT FOR CASE NUMBER:
DEVELOPMENTALLY DISABLED ADULTS WITH MAJOR OR MILD
NEUROCOGNITIVE DISORDER (DEMENTIA) ATTACHMENT

1. Has the proposed conservatee been diagnosed with major or mild Neurocognitive Disorder (Dementia)? Yes No Diagnosis confirmed by: Capacity Declaration on file in this proceeding Review of medical records Discussions with medical staff at facility where proposed conservatee resides Discussions with proposed conservatee’s physician Other:

2. I have considered, to the extent practicable, whether I believe that the proposed conservatee suffers from

   any of the mental deficits listed in subdivision(a) of Probate Code Section 811 that significantly impair the proposed conservatee’s ability to understand and appreciate the consequences of his/her action(s) in connection with the proposed conservatee’s ability to: Provide properly for his or her personal needs for physical health, food, clothing or shelter. Able Unable Manage his or her own financial resources or resist fraud or undue influence. Able Unable

3. Does the proposed conservatee currently reside in a locked skilled nursing facility which specializes in the care and treatment of people with dementia pursuant to subdivision (c) of Section 1569.691 of the Health and Safety Code and which has a care plan that meets the requirements of Section 87724 of Title 22 of the California Regulations? Yes No If yes, is this the least restrictive placement? Yes No Comments:

4. Is the proposed conservatee administered medications appropriate to the care of dementia?
   Yes No N/A (Cannot determine)

   Comments:

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Dated: Signature: SIGN Print Name:

SCLAC PRO 077 Rev. 04/26 For Mandatory Use Print This Form Clear This Form