Form Soc 2320 - In-Home Supportive Services (Ihss) And Waiver Personal Care Services (Wpcs) Cdss Violation Removal Request Page 2

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State of California – Health and Human Services Agency
California Department of Social Services
IN-HOME SUPPORTIVE SERVICES (IHSS) AND WAIVER PERSONAL
CARE SERVICES (WPCS) CDSS VIOLATION REMOVAL REQUEST
NOTE: This form is for use by the county only for requesting CDSS review of an overtime violation.
SECTION A: PROVIDER/VIOLATION INFORMATION
1. Provider Name:
2. Provider Number:
3. Violation Count Number:
4. Violation Number:
5. Violation Notice Date:
6. Violation Dispute Received Date:
SECTION B: COUNTY REQUESTOR INFORMATION
7. County/District Office (CO/DO):
8. Date of Request:
9. CO Requestor Name:
10. CO Requestor Phone Number:
11. CO Requestor Email:
SECTION C: JUSTIFICATION FOR OVERRIDE
12. Why the dispute was not entered timely:
13. Why the violation should be removed (per ACL 16-46):
SECTION D: COUNTY SUPERVISOR APPROVAL
14. Supervisor Name:
15. Supervisor Phone Number:
16. Supervisor Email Address:
17. Supervisor Signature:
SOC 2320 (10/17)
Page 2 of 2

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