Form Soc 2272 - In-Home Supportive Services Program Notice To Provider Of Right To Dispute Violation For Exceeding Workweek And/or Travel Time Limits

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
NOTICE TO PROVIDER OF RIGHT TO DISPUTE 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:
To: In-Home Supportive Services (IHSS) Provider
You received a violation because you exceeded your workweek and/or travel time limits.
If you believe you should not have been issued a violation because the additional hours
you worked met all 3 of the criteria listed below, please review and respond to the
questions on the following pages.
If you provide services to only 1 recipient, you must answer questions 1 through 5 and
questions 9 through 11. If you provide services to 2 or more recipients, you must answer
questions 6 through 11.
You have 10 calendar days from the date indicated on the violation notice to submit this
form to the county requesting an official county review of the circumstances surrounding
the additional hours you worked which led to the violation.
Criteria:
1. The need for additional hours was necessary to meet an unanticipated need;
2. The additional hours were related to an immediate need that could not be
postponed until the arrival of a back-up provider as designated on the IHSS
Program Individual Emergency Back-Up Plan (SOC 827) form; and
3. The additional hours were related to a need that would have had a direct impact
on the IHSS recipient and were needed to ensure his/her health and/or safety.
PAGE 1 OF 4
SOC 2272 (7/16)

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