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

FOR COURT USE ONLY

GC-355

FAX NO. (Optional):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

TELEPHONE NO.:

E-MAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

CONSERVATORSHIP OF THE PERSON
(Name):

AND ESTATE

OF 

DETERMINATION OF CONSERVATEE'S APPROPRIATE LEVEL OF CARE 

CONSERVATEE

CASE NUMBER:

Notice to Conservator of the Person

   You must prepare a written determination 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 may 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):

, declares as follows:
   

1.

I am conservator of the person of the above-named conservatee. I am determining the conservatee's appropriate level of care 
as of (date): 

, 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):

Telephone:

b.

The conservatee has been living in the above residence or facility since (date):

.

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

CONSERVATORSHIP OF 
(Name):

2.

c. The residence or facility identified in item 2a is described as follows (select all that apply):

CONSERVATEE

CASE NUMBER:

GC-355

Conservatee's single family home, condominium, or apartment

Relative's or friend's single family home, condominium, or apartment 
Acute care hospital

Acute psychiatric hospital

Licensed residential care facility
Board and care home (6 or fewer beds)

Assisted living facility (7 or more beds)

Continuing-care retirement community

Secured perimeter 

Intermediate-care facility

Skilled nursing facility

Congregate living health facility—terminal or life-threatening illness type (hospice)
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"):

No assistance is needed at this time.

Light housekeeping help required, 

hours per week.

Personal caregivers required, 

hours per week:

24-hour care

Part-time,

hours per day.

Assistance with daily living skills,

hours per week.

Nursing care required, 

hours per week.

Meal preparation assistance required,

hours per week.

Assistance with medication required,

hours per week:

Dispensing

Set-up only

Assistance with ambulation:

Maximum

Standby

In-home hospice services.

Other assistance required,

hours per week (describe):

Continued on Attachment 3a.

b.

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

CONSERVATORSHIP OF 

(Name):

CASE NUMBER:

GC-355

CONSERVATEE

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 the conservatee's personal residence.)

a.

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:

Continued on Attachment 4a.

b.

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

(1)

The conservator's plan to restore the conservatee to his or her personal residence is as follows:

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

CONSERVATORSHIP OF 

(Name):

CASE NUMBER:

GC-355

CONSERVATEE

4.

b.

(2)

The limitations or restrictions on the conservatee's return to his or her personal residence in the foreseeable 
future are as follows:

. 

Continued on Attachment 4b(2).

5. Number of pages attached:

Date:

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

(TYPE OR PRINT NAME OF CONSERVATOR OF THE PERSON)

(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