Form Rfa 09i - Notice Of Action And Exclusion Order Page 3
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5State of California – Health and Human Services Agency
California Department of Social Services
This exclusion order is effective IMMEDIATELY. If you wish to appeal this exclusion order you may do so by
submitting a written appeal and a copy of this notice to the address below. The appeal must be post marked
or delivered on or before the due date, which is twenty-five (25) calendar days from the date of this
notice. Add five (5) days to the due date for a total of 30 calendar days if this notice was mailed to you. If you
wish to use this form to appeal, you may do so by checking the appeal box and filling out the information
below, then sending the appeal and all pages of this notice to:
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
[DEPARTMENT ADDRESS, MS -
CITY, STATE, ZIP
ATTN: Contact Name, Title]
If you appeal, the Department will send you an acknowledgment of your appeal and you will be contacted and
provided additional information about the appeal process at a later date. If you appeal, it is also required that
you notify the Department in writing at the address listed above of your current address and any subsequent
change in your mailing address, until the administrative review process has been completed or terminated.
While the administrative review process is pending you must remain out of any resource family home or any
facility licensed by the Department or certified or approved by a Foster Family Agency, and may not have
contact with foster children, nonminor dependents or clients in a resource family home or licensed facility.
If you do not appeal this exclusion on or before the due date, or if you do appeal but the exclusion order is
affirmed after administrative review, you are excluded from all resource family homes and all facilities licensed
by the Department or certified or approved by a Foster Family Agency, for the remainder of your life. However,
you may petition for reinstatement to the Department one year after the effective date of the final exclusion
order pursuant to Government Code Section 11522 (attached).
You may call the Department at
if you have any questions regarding this notice.
________________________________________________
[Sign Above, Type In Name & Title]
I wish to appeal. (Submit this appeal request with a copy of this notice.)
________________________________________________
_____________________________
Print Name
Signature
________________________________________________
_____________________________
Address
Phone Number
Reasons for appeal (optional): _______________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
RFA 09I (9/17) Immediate (To individual)
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