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Form Soc 2268a - In-Home Supportive Services Program Notice To Provider Approval To Work Alternate Schedule Due To Recurring Event

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

IN-HOME SUPPORTIVE SERVICES PROGRAM

NOTICE TO PROVIDER

APPROVAL TO WORK ALTERNATE SCHEDULE DUE TO RECURRING EVENT

(ADDRESSEE)

County of:

Notice Date:

Provider Name:

IHSS Office Address:

IHSS Office Telephone Number:

To: In-Home Supportive Services (IHSS) Provider

This notice is to inform you that your recipient’s request to adjust his/her maximum

weekly hours for a specified week of the month due to a monthly recurring event has

been approved. You may work the additional hours during the specified week of each

month. Do not work these hours without first obtaining permission from your recipient.

This means that your maximum weekly hours for one week of each month will be different

from the other weeks of the month.

You may continue to work this weekly schedule in all later months as long as your recipient

continues to have the need for the adjustment resulting from a recurring event. Your

recipient must notify the county immediately if the situation changes and he/she no

longer has the need for this adjustment.

Also, please note that if you work for more than one recipient, you cannot work more

than 66 hours in a workweek. Therefore, if the adjustment to your recipient’s maximum

weekly hours would result in you working more than 66 hours in a workweek, you will

not be able to work those additional hours or you may have to adjust the hours you

work for another recipient.

If you have any further questions about this notice, you may contact your county IHSS

office at the phone number above.

SOC 2268A (1/16)

Form Soc 2268a - In-Home Supportive Services Program Notice To Provider Approval To Work Alternate Schedule Due To Recurring Event