Form Soc 2284 - In-Home Supportive Services Program Notice To Provider Upholding 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 PROVIDER UPHOLDING FOURTH VIOLATION (ONE-YEAR PERIOD
OF INELIGIBILITY) FOR EXCEEDING WORKWEEK AND/OR TRAVEL TIME LIMITS
(ADDRESSEE)
COUNTY OF:
Notice Date:
Recipient Name:
Recipient Case Number:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Provider
This notice is to inform you that we have reviewed the Right to Dispute Violation form
you filed after receiving a fourth violation for the month of ______________. 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 you provided on the Right to Dispute
Violation form. We have determined there was not enough information and/or
documentation to show you met the criteria required for you to work more hours than
your workweek agreement allows for. You will continue to have a fourth violation
for the following reason(s):
Working 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.
Working more than a recipient’s maximum weekly hours without the recipient
getting approval from the county which caused you to work more overtime hours
in the month than you normally would.
Working more than 66 hours in a workweek when you work for more than one recipient.
Claiming more than 7 hours of travel time in a workweek.
If you disagree with this determination and would like to request a State Administrative
Review, you have 10 calendar days from the date on this notice to submit the enclosed
State Administrative Review Request form. If you file a State Administrative Review
Request, you will be able to continue to provide services until a final decision has been
made on your request.
SOC 2284 (7/16)
PAGE 1 OF 2
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