Form Soc 2273 - In-Home Supportive Services Program State Administrative Review Request Of Third Or Fourth Violation For Exceeding Workweek And/or Travel Time Limits
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3STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
STATE ADMINISTRATIVE REVIEW REQUEST OF THIRD OR FOURTH VIOLATION
FOR EXCEEDING WORKWEEK AND/OR TRAVEL TIME LIMITS
(ADDRESSEE)
COUNTY OF:
Notice Date:
Recipient Name:
Recipient Case Number:
IHSS Office Address:
IHSS Office Telephone Number:
Violation Number:
To: In-Home Supportive Services (IHSS) Provider
The county has informed you that after reviewing your Right to Dispute Violation form,
it has been determined that your __________ violation for the month of ____________
for exceeding your workweek and/or travel time limits will be upheld.
If you disagree with this decision, you have the option to request a State Administrative
Review by submitting a State Administrative Review Request to:
California Department of Social Services
Systems and Administrative Branch
Claims, Certification and Appeals Bureau
Attn: Appeals Unit, MS 9-9-04
P.O. Box 944243
Sacramento, CA 94244-2430
• A request for a State Administrative Review must be received within ten calendar
days from the date on the SOC 2282 or SOC 2284 that the county mailed to you
indicating that your third or fourth violation has been upheld.
• If a request for a State Administrative Review is received within ten calendar days
from the date on the SOC 2282 or SOC 2284, you can continue to provide services
and be paid until a final decision is made on your State Administrative Review.
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SOC 2273 (8/16)
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