Form Soc 2259a - In-Home Supportive Services Program Notice To Recipient Of Provider'S Fourth Violation (One-Year Period Of Ineligibility) 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 RECIPIENT OF PROVIDER’S FOURTH VIOLATION
(ONE-YEAR PERIOD OF INELIGIBILITY)
FOR EXCEEDING WORKWEEK AND/OR TRAVEL TIME LIMITS
(ADDRESSEE)
COUNTY OF:
Notice Date:
Provider Name:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Recipient
Your Provider, _____________________________, has received a fourth violation for
PROVIDER NAME
the service month of _______________ by doing one or more of the following:
MONTH
Working more than 40 hours in a workweek for you without you getting approval
from the county when your maximum weekly hours are 40 hours or less.
Working more than your maximum weekly hours without you getting approval
from the county which caused him/her to work more overtime hours in the month
than he/she normally would.
Working more than 66 hours in a workweek when he/she works for more than
one recipient.
Claiming more than seven (7) hours of travel time in a workweek.
As a result, your provider will be ineligible to be paid by the IHSS program for providing
authorized IHSS services to you or any other IHSS recipients for one year.
You must find a new provider within twenty (20) calendar days of the date of this notice.
During this twenty-day period your current provider will still be able to continue to
provide you services. If you need assistance finding a new provider, please contact
your IHSS office at the number listed above.
SOC 2259A (3/16)

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