Form Soc 852 - Notice To Applicant Provider Of Provider Ineligibility Tier I Crimes
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
NOTICE TO APPLICANT PROVIDER OF PROVIDER INELIGIBILITY
TIER I CRIMES (ELDER OR DEPENDENT ADULT ABUSE/CHILD ABUSE & FRAUD AGAINST A
GOVERNMENT HEALTH CARE OF SUPPORTIVE SERVICES PROGRAM)
[WELFARE & INSTITUTIONS CODE SECTION 12305.81]
(ADDRESSEE)
County of:
Notice Date:
Applicant Provider Name:
Recipient Name:
Recipient Case Number:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Applicant Provider
Due to a criminal conviction, the county/Public Authority/Non-Profit Consortium has denied your
eligibility to be an IHSS provider and to receive payment from the IHSS program for providing services.
■ ■
As part of the provider enrollment process, you submitted fingerprints for a California
Department of Justice criminal background check. The background check showed that
you had been convicted of a crime(s) that makes you ineligible to be an IHSS provider
and to receive payment from the IHSS Program for providing services based on Welfare
and Institutions Code (W&IC), Section 12305.81.
■ ■
The county/Public Authority/Non-Profit Consortium has learned that you have been
convicted of a crime(s) that makes you ineligible to be employed as an IHSS provider or
to receive payment from the IHSS program for providing services based on Welfare and
Institutions Code (W&IC), Section 12305.81. The conviction has been verified through
court documents.
The crime(s) which disqualified you is/are listed below:
SOC 852 (1/11)
PAGE 1 OF 2
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