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GC-355 DETERMINATION OF CONSERVATEE'S APPROPRIATE LEVEL OF CARE



With this form you are informing the court of the conservatee’s appropriate needed level of care from the start of your conservatorship and through the coming year (a year of your conservatorship not calendar year) when you will have to file this form again.

Your initial filing must be within 60 days of the date of the court’s order appointing you as conservator(s) which is the date stamped on GC-340 Order Appointing Probate Conservator. This is also the date used for line 1. This form is filed with Form P74 General Plan for Personal and Financial Needs of Conservatee.

The filling out of the form will vary between individuals and the level of care they need so read all of the form carefully. The Terry Morgan Doe example is filled out in the portions of the form that will need to be completed by most conservators. The degree will vary.

Form Links

Filled in Example GC-355 Form

- You can edit the example Doe forms to your situation, print, and file it at your local California Superior Court. The form is the same as the one you can get from a California Superior Court Website.

Blank GC-355 Form

http://www.courts.ca.gov/forms.htm?filter=GC California Probate Conservatorship Complete List Downloadable

Content

The each page notes are below the respective image of the form page.

GC-355 Page 1 Notes

GC-355 Page 2 Notes

GC-355 Page 3 Notes

GC-355 Page 4 Notes

GC-355 Form in HTML so it can be Translated

gc-355 page 1

Page 1 Notes:

Fill out form header.

Your name(s) and 1, 2a and b

Cal. Rules of Court, rule 7.1063 is on Page 3 Notes.

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gc-355 page 2

Page 2 Notes:

No specific notes.

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gc-355 page 3

Page 3 Notes:

No specific notes.

Rule 7.1063. Change of conservatee's residence

(a) Pre-move notice of change of personal residence required

Unless an emergency requires a shorter period of notice, the conservator of the person must mail copies of a notice of an intended change of the conservatee's personal residence to the persons listed below at least 15 days before the date of the proposed change, and file the original notice with proof of mailing with the court. Copies of the notice must be mailed to:

(1) The conservatee;

(2) The conservatee's attorney of record;

(3) The conservatee's spouse or registered domestic partner; and

(4) The conservatee's relatives named in the Petition for Appointment of Probate Conservator (form GC-310), including the conservatee's "deemed relatives" under Probate Code section 1821(b)(1)-(4) if the conservatee has no spouse or registered domestic partner and no second-degree relatives.

(b) Conservatee's personal residence

(1) The "conservatee's personal residence" under (a) is the residence the conservatee understands or believes, or reasonably appears to understand or believe, to be his or her permanent residence on the date the first petition for appointment of a conservator was filed in the proceeding, whether or not the conservatee is living in that residence on that date. A residential care facility, including a board and care, intermediate care, skilled nursing, or secured perimeter facility, may be the conservatee's personal residence under this rule.

(2) If the conservatee cannot form or communicate an understanding or belief concerning his or her permanent residence on the date the first petition for appointment of a conservator was filed in the proceeding, his or her personal residence under this rule is the residence he or she last previously understood or believed, or appeared to understand or believe, to be his or her permanent residence.

(3) For purposes of this rule, the following changes of residence are or are not changes of the conservatee's personal residence, as indicated:

(A) A move from the conservatee's personal residence under this rule to a residential care facility or other residence is a change of the conservatee's personal residence under (a).

(B) A move from a residential care facility or other residence to another residence that is not the conservatee's personal residence under this rule is a change of the conservatee's personal residence under (a).

(C) A move from a residential care facility or other residence to the conservatee's personal residence under this rule is not a change of the conservatee's personal residence under (a).

(c) Post-move notice of a change of residence required

The conservator of the person must file a notice of a change of the conservatee's residence with the court within 30 days of the date of the change. Unless waived by the court for good cause to prevent harm to the conservatee, the conservator must mail a copy of the notice to the persons named below and file a proof of mailing with the original notice filed with the court. Unless waived, the notice must be mailed to:

(1) The conservatee's attorney of record;

(2) The conservatee's spouse or registered domestic partner; and

(3) The conservatee's relatives named in the Petition for Appointment of Probate Conservator (form GC-310), including the conservatee's "deemed relatives" under Probate Code section 1821(b)(1)-(4) if the conservatee has no spouse or registered domestic partner and no second-degree relatives.

(d) Conservatee's residence

The "conservatee's residence" under (c) is the conservatee's residence at any time after appointment of a conservator.

(e) Use of Judicial Council forms GC-079 and GC-080

(1) The Pre-Move Notice of Proposed Change of Personal Residence of Conservatee or Ward (form GC-079) must be used for the pre-move notice required under (a) and Probate Code section 2352(e)(3). The conservator, the conservator's attorney, or an employee of the attorney may complete the mailing and sign the Proof of Mailing on page 2 of the form. If the notice is mailed less than 15 days before the date of the move because an emergency requires a shorter period of notice, the basis for the emergency must be stated in the notice.

(2) The Post-Move Notice of Change of Residence of Conservatee or Ward (form GC-080) must be used for the post-move notice required under (c) and Probate Code section 2352(e)(1) and (2). The conservator, the conservator's attorney, or an employee of the attorney may complete the mailing and sign the Proof of Mailing on page 2 of the form.

(f) Prior court approval required to establish conservatee's residence outside California

Notwithstanding any other provision of this rule, prior court approval is required before a conservatee's residence may be established outside the state of California.

Rule 7.1063 adopted effective January 1, 2008.

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gc-355 page 4

Page 4 Notes:

Make sure you print and sign your name(s).

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GC-355 Form in HTML so it can be Translated

The GC-355 form is reproduced here in html so that it can easily be translated into multiple languages. You can not use this form to submit to court in any language. You have to use the GC-355 pdf form and English.

GC-335

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

 NAME: John Doe & Jane Doe
 FIRM NAME:
 STREET ADDRESS: 1234 ABC Street
 CITY: San Francisco           STATE: CA           ZIP CODE: 94102
 TELEPHONE NO.: 415-123-4567          FAX NO.:
 E-MAIL ADDRESS: info@raisingautism.net
 ATTORNEY FOR (name): In Pro Per
 SUPERIOR COURT OF CALIFORNIA, COUNTY OF
 San Francisco
 STREET ADDRESS: 400 MCALLISTER STREET
 MAILING ADDRESS: 400 MCALLISTER STREET
 CITY AND ZIP CODE: SAN FRANCISCO, CA 94102
 BRANCH NAME: PROBATE
 CONSERVATORSHIP OF THE PERSON   small form box AND ESTATE   OF
  (Name): Terry Morgan Doe
CONSERVATEE   
 DETERMINATION OF CONSERVATEE'S APPORPRIATE LEVEL OF CARE

FOR COURT USE ONLY



















 CASE NUMBER:
        PCN-16-123456

Notice to Conservator of the Person

You must prepare a written dtermination of the conservatee's appropriate level of care, sign it under penalty of perjury, and file it with the court within 60 days of the date of the court's order appointing you as conservator. You must use this form for that purpose. Your determination must include an evaluation of the conservatee's level of care on the date the conservatorship proceeding was started (the date the petition for the appointment of a conservator was filed with the court or, if more than one petition was filed, the date the first petition was filed), and the measures that would be necessary to keep the conservatee in his or her personal residence. If the conservatee was not living in that residence on the date the proceeding was started, your determination must include either a plan to return the conservatee to that residence or an explanation of the reasons why the conservatee cannot return to that residence in the foreseeable future. This determination is in addition to, not a replacement for, any written care or placement plan the court require. Check the court's local rules to see if a care or placement plan must also be filed.
The conservatee's personal residence is the residence he or she understood or believed, or appeared to understand or believe, was his or her permanent residence on the date the conservatorship proceeding was started, whether or not he or she was living there on that date. If the conservatee could not then form or communicate an understanding or belief about his or her permanent residence, the conservatee's personal residence is the residence he or she last previously understood or appeared to understand was his or her permanent residence. (See Cal. Rules of Court, rule 7.1063.)

(Name): John Doe & Jane Doe                                                                                               , declares as follows:

1. I am conservator of the person of the above-named conservatee. I am determining the consevatee's appropriate level of care
as of (date): date appointed     , the date of the order appointing me as conservator.

2 a. On the date stated in item 1, the conservatee was living at the following residence or facility (address and name of facility, if
any):

1234 ABC Street
San Francisco, CA 94102



Telephone: 415-123-4567


b. The conservatee has been living in the above residence or facility since (date): 1/2/1998

Page 1 of 4
Form Adopted for Mandatory Use
Judicial Council of California
GC-355 [New July 1, 2011]
DETERMINATION OF CONSERVATEE'S APPROPRIATE LEVEL OF CARE
(Probate-Guardianships and Conservatorships)
Probate Code, § 2352.5;
Cal. Rules of Court, rule 7.1063
www.courts.ca.gov
www.courts.ca.gov


 

GC-355
  CONSERVATORSHIP OF
  (name):   Terry Morgan Doe
CONSERVATEE   
  CASE NUMBER:
        PCN-16-123456


2. c. The residence or facility identified in item 2a is described as follows (select all that apply):
small form box check Conservatee's single family home, condominium, or apartment
small form box Relative's or friend's single family home, condominium, or apartment
small form box Acute care hospital small form box Acute psychiatric hospital small form box Intermediate-care facility small form box Skilled nursing facility
small form box Licensed residential care facility small form box Assisted living facility (7 or more beds)
small form box Board and care home (6 or fewer beds) small form box Continuing-care retirement community small form box Secured preimeter
small form box Congregate living health facility -- terminal or life-threatening illness type (hospice)
small form box Other (describe):







3. a. The conservatee's care requirements as of the date given in item 1 are as follows (select all that apply; you may provide
additional information concerning any items selected below under "other assistance required"):
small form box No assitance is needed at this time. small form box Light housekeeping help required,        hors per week.
small form box check Personal caregivers required,   70   hours per week: small form box 24-hour care small form box check Part-time,   10   hours per day.
small form box check Assistance with daily living skills,   15   hours per week.
small form box Nursing care required,        hours per week.  small form box check Meal preparation assistance required,   14   hours per week.
small form box check Assistance with medication required,    5   hours per week: small form box check Dispensing small form box Set-up only
small form box check Assistance with ambulation: small form box Maximum small form box Standby  small form box In-home hospiced services.
small form box Other assistance required,       hours per week (describe):











      small form box Continued on Attachment 3a.
b. small form box A professional assessment of the conservatee's care needs has been made. A copy of the assessment, including a
statement of the professional's qualifications, is provided on Attachment 3b. (A professional assessment of the conservatee's care needs is not required, but is recommended if the conservatee's circumstances and condition warrant it and the conservatee can afford the expense. Include any written assessment performed by a professional fiduciary proposed for appointment or appointed as conservator.)


GC-355 [New July 1, 2011]


DETERMINATION OF CONSERVATEE'S APPROPRIATE LEVEL OF CARE
(Probate-Guardianships and Conservatorships)
Page 2 of 4





 

GC-355
  CONSERVATORSHIP OF
  (name):   Terry Morgan Doe
CONSERVATEE   
  CASE NUMBER:
        PCN-16-123456


4. (Complete item 4a if the residence identified in item 2 is the conservatee's personal residence as defined in Cal. Rules of
Court, rule 7.1063. Complete item 4b if the residence identified in item 2 is not conservatee's personal residence.)
a small form box check Conservatee living in personal residence
The residence or facility described in item 2 is the conservatee's personal residence within the meaning of
Cal. Rules of Court, rule 7.1063. The following measures are necessary to keep the conservatee in that residence:











     small form box Continued on Attachment 4a.
b. small form box Conservatee not living in personal residence
The residence or facility described in item 2 is not the conservatee's personal residence within the meaning of Cal. Rules of Court rule 7.1063. The conservatee's personal residence is (address and name of facility, if any):





(Complete either item 4b(1) below or item 4b(2) on page 4. Complete item 4b(1) if you believe the conservatee cannot be returned to his or her personal residence in the foreseeable future.)

(1) small form box The conservator's plan to restore the conservatee to his or her personal residence is as follows:














small form box Continued on Attachment 4b(1).
GC-355 [New July 1, 2011]


DETERMINATION OF CONSERVATEE'S APPROPRIATE LEVEL OF CARE
(Probate-Guardianships and Conservatorships)
Page 3 of 4





 

GC-355
  CONSERVATORSHIP OF
  (name):   Terry Morgan Doe
CONSERVATEE   
  CASE NUMBER:
        PCN-16-123456


4.  b.   (2)  small form box The limitations or restrictions on the conservatee's return to his or her personal residence in the foreseeable
future are as follows:












small form box Continued on Attachment 4b(2).

5. Number of pages attached:       
I declare under penalty of pe ury under the laws of the State of California that the foregoing is true and conrect.

Date:


   John Doe & Jane Doe                                            
(TYPE OR PRINT NAME OF CONSERVATOR OF THE PERSON)
Signature arrow
   (SIGNATURE OF CONSERVATOR OF THE PERSON)   


GC-355 [New July 1, 2011]


DETERMINATION OF CONSERVATEE'S APPROPRIATE LEVEL OF CARE
(Probate-Guardianships and Conservatorships)
Page 4 of 4






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