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 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 the effective date of this
order as identified in 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 non-immediate 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 09E (9/17) Non-Immediate (To individual)
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