Form Ihss-E 005 - In-Home Supportive Services Program - Notice Of Ineligibility To Request Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) - Provider

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
NOTICE OF INELIGIBILITY TO REQUEST EXEMPTION
FROM WORKWEEK LIMITS FOR EXTRAORDINARY
CIRCUMSTANCES (EXEMPTION 2) - PROVIDER
COUNTY OF:
(ADDRESSEE)
Notice Date:
IHSS Office Address:
IHSS Office Telephone:
Provider Name:
Provider Number:
To: In-Home Supportive Services (IHSS) Provider
On __________, you requested an Exemption from the IHSS Program Workweek
Date
Limits for Extraordinary Circumstances (Exemption 2) for the following recipients.
Recipient Name: ____________________
Recipient Name: ____________________
Case Number: ______________________
Case Number: ______________________
Recipient Name: ____________________
Recipient Name: ____________________
Case Number: ______________________
Case Number: ______________________
We cannot forward your request for an Exemption 2 at this time. Here’s why:
You do not provide services for two or more IHSS recipients
One or all of the recipients you work for do not meet one of the following
conditions marked below:
The recipient(s) does/do not have complex medical and/or behavioral
needs that must be met by a provider who lives in the same home as
the recipient.
The recipient(s) does/do not live in the same home as the provider.
The recipient(s) does/do not live in a rural or remote area where available
providers are limited and as a result the recipient(s) is/are unable to hire
another provider.
IHSS-E 005 (1/17)
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