Form Rfa 09i - Notice Of Action And Exclusion Order Page 2
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5State of California – Health and Human Services Agency
California Department of Social Services
Specifically, it has been determined that you have violated an applicable law or the Written Directives, including
the following:
[Select one or more causes of action from the Cause of Action reference page and paste here below
the statutory citation. You may add the applicable subsection (a, b, c, d, e, or f) to the statutory
reference. If there are additional causes of action not listed, insert here. Identify the WDs versions
you are citing.]
Welfare and Institutions Code section 16519.61.
This action and order are based on the evidence set forth in the reports, statements, papers, and other
documentary evidence contained in the official files of the department, which information and records
are hereby incorporated by this reference. Details regarding the reasons for this exclusion order are
included below:
RFA 09I (9/17) Immediate (To individual)
Page ____ of ____
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