Form Soc 2264 - In-Home Supportive Services Program Notice To Recipient Rescinding Provider 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 RECIPIENT
RESCINDING PROVIDER VIOLATION
(ADDRESSEE)
COUNTY OF:
Notice Date:
Provider Name:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Recipient
This notice is to inform you that the incident(s) of violation your provider,
_______________________, received for the service month of ___________ has
MONTH
PROVIDER NAME
been withdrawn as of the date of this notice.
Although this incident(s) of violation has been withdrawn, your provider could receive
another violation at a later time if he/she fails 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 2264 (3/16)

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Parent category: Legal
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