Form Rfa 09i - Notice Of Action And Exclusion Order

Download a blank fillable Form Rfa 09i - Notice Of Action And Exclusion Order in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Rfa 09i - Notice Of Action And Exclusion Order with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

State of California – Health and Human Services Agency
California Department of Social Services
NOTICE OF ACTION AND EXCLUSION ORDER
Certified Mail Tracking Number:
Date:
Applicant(s) or RF Name(s):
County RF ID #:
PER ID#, if any:
To:
[Name of Individual]
[Address Line 1]
[Address Line 2]
[City/State/Zip]
ORDER TO INDIVIDUAL OF IMMEDIATE EXCLUSION
FROM RESOURCE FAMILY HOMES
AND DEPARTMENT LICENSED FACILITIES
The California Department of Social Services has determined that your continued or future contact with
dependent children (foster children), nonminor dependents, or clients of a facility licensed by the Department
or certified or approved by a Foster Family Agency, constitutes a threat to the health and safety of the
dependent children, nonminor dependents, and clients in care. Therefore, upon receipt of this notice, you
must remove yourself from any contact with dependent children, nonminor dependents, and clients in
care and not be physically present in any resource family home, care facility licensed by the
Department, or home certified or approved by a Foster Family Agency. You must also remove yourself
from being a board member, executive director or officer of any facility licensed by the Department.
This exclusion order is made pursuant to the authority in Welfare and Institutions Code section 16519.6,
subdivision (g), Health and Safety Code sections 1558, 1568.092, 1569.58, 1596.8897, and the RFA Written
Directives.
RFA 09I (9/17) Immediate (To individual)
Page ____ of ____

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 5