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Conservatorship Care Plan VN233 - California

Conservatorship Care Plan Form. This is a California form and can be used in Probate Ventura Local County .
 Fillable pdf Last Modified 2/21/2011
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CONFIDENTIAL ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address) Telephone Number FOR COURT USE ONLY VN233 E-MAIL ADDRESS ATTORNEY FOR (Name): 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 conservator's Care Plan Status Report in compliance with local court rules. 1. Conservatee's current residence address:* a. Type of facility (i.e. home, skilled nursing, hospital, etc.) : b. How long has the conservatee been in the present residence? c. Do you anticipate making any changes in the conservatee's residence in the next year? No Yes (explain) d. What is the plan to return the conservatee to his/her personal residence if not now living at home? e. 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 able to do own care uses a wheelchair/walker ambulatory urinary/bowel incontinence Other relevant information has feeding tube has catheter If residing in a facility or group home, attach copy of the facility's care plan: If client of a regional center, identify regional center and social worker and telephone number: * Please note that the Probate Investigator's Office must be notified of any change of address. Mandatory Form VN233 (01/11) CONSERVATORSHIP CARE PLAN/STATUS REPORT Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com CONSERVATORSHIP OF (Name): CONSERVATEE 3. Conservatee's physical and medical condition: a. Please list health problems: Case number: b. Are any other health providers involved? visiting nurse podiatrist counselor speech therapist c. Medications: d. Activities conservatee is involved in? 4. How often do you expect to visit the conservatee? No Yes social worker dentist physical therapist other (specify): . Does the family visit? other care takers . 5. Are there plans to give the conservator a rest? respite care adult day care In Home Support Services (IHSS) Names & relationships of relief caregivers: 6. Conservatee's Estimated Monthly Income (complete even if a conservatorship of the person only): 7. Conservatee's Estimated Monthly Expenses (complete even if a conservatorship of the person only): a. LIVING EXPENSES Rent/Mortgage Nursing/Care Home Food Medical/Dental Transportation $ $ $ $ $ Utilities In-Home Care Clothing Medications Entertainment Other (specify) Total Estimated Monthly Expenses $ $ $ $ $ $ $ b. OTHER EXPENSES TAXES Income Tax Property Payroll c. INSURANCE Current $ $ $ Current $ $ $ Estimated Amount Estimated Amount $ $ $ $ $ $ Homeowner Renters Automobile Worker's Comp Health Life $ $ $ $ $ $ 8. What are the contents of any safe deposit boxes? Mandatory Form VN233 (01/11) 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 No Yes 10. Do you expect to sell any of the conservatee's real or personal property in the next year? 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? If yes, is it rented? If not rented, explain why: No Yes Amount of rent: $ No Yes 12. If the Conservatee's 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 conservatee's 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 accurate, complete, and timely accountings. c. Carry out all mandatory usual and general duties of a conservator. d. Maintain periodic contact with the conservatee's physician and other health care providers, if appointed conservator of the person. e. Maintain periodic contact with the conservatee's 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. Update care plan as needed. l. Refer to the "Conservator's Handbook." 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 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 Mandatory Form VN233 (01/11) CONSERVATORSHIP CARE PLAN/STATUS REPORT Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com
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