Form Soc 2285 - In-Home Supportive Services Program Notice To Recipient Upholding Provider'S Fourth Violation (One-Year Period Of Ineligibility) For Exceeding Workweek And/or Travel Time Limits
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
NOTICE TO RECIPIENT UPHOLDING PROVIDER’S FOURTH VIOLATION (ONE-YEAR
PERIOD OF INELIGIBILITY) FOR EXCEEDING WORKWEEK AND/OR TRAVEL
TIME LIMITS
(ADDRESSEE)
COUNTY OF:
Notice Date:
Provider Name:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Recipient
This notice is to inform you that the Right to Dispute Violation form your provider,
_____________________________________________________________________
filed after the fourth violation he/she received for the month of ______________ has
been reviewed. As of the date of this notice, the violation is upheld. The reason for this
decision is based on our review of the information and/or documentation provided by your
provider on the Right to Dispute Violation form. We have determined there was not
enough information and/or documentation to show your provider met the criteria required
for him/her to work more than his/her workweek agreement allows for. Your provider will
continue to have a fourth violation for one or more of the following reason(s):
Worked more than 40 hours in a workweek for a recipient without the recipient
getting approval from the county when that recipient’s maximum weekly hours are
40 hours or less.
Worked more than a recipient’s maximum weekly hours without the recipient
getting approval from the county which caused your provider to work more
overtime hours in the month than your provider normally would.
Worked more than 66 hours in a workweek when your provider works for more
than one recipient.
Claimed more than 7 hours of travel time in a workweek.
If your provider requests a State Administrative Review, your provider may continue to
provide services until a final determination is made on his/her State Administrative
Review. If the outcome of the State Administrative Review is to uphold the violation
your provider will be terminated for a period of one year; 20 calendar days from the
date of that determination.
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SOC 2285 (7/16)
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