Form Soc 2263 - In-Home Supportive Services Program Notice To Provider Rescinding Violation

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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 RESCINDING VIOLATION
(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 the incident(s) of violation you received for the service
month of ____________, has been withdrawn as of the date of this notice. The reason
MONTH
for the withdrawal of the incident(s) of violation is:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Although this violation has been withdrawn, you could receive another violation at a
later time if you fail to follow the workweek and travel time limits for the IHSS program.
If you have any questions about this notice, you may contact your IHSS office at the
phone number above.
SOC 2263 (3/16)

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