Form Rfa 09e - 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:
[Summarize facts that provide the basis for the exclusion including dates, locations, names, and what
happened. Identify children by initials only. This summary may be taken from RF visit, investigation,
or other reports. This is a summary only; do not include minute details that may be difficult to prove.
It should be no more than 1 short paragraph per factual allegation.]
RFA 09E (9/17) Non-Immediate (To individual)
Page ____ of ____
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