Form Soc 2259 - In-Home Supportive Services Program Notice To Provider Of 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
NOTICETO PROVIDER OF 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) Provider
Effective twenty (20) calendar days from the date of this notice, you are no longer
eligible to receive payment from the IHSS program for providing authorized services to
your current recipient(s) or to any other person for a period of one year.
In the service month of ____________, you exceeded your workweek and/or travel
MONTH
time limits by doing one or more of the following:
Working more than 40 hours in a workweek for a recipient without the recipient
getting approval from the county when that recipient’s maximum weekly hours
are 40 hours or less.
Working more than a recipient’s maximum weekly hours without the recipient
getting approval from the county which caused you to work more overtime hours
in the month than you normally would.
Working more than 66 hours in a workweek when you work for more than one
recipient.
Claiming more than seven (7) hours of travel time in a workweek.
After the one year ineligibility period, to become eligible to be paid by the IHSS
program for providing authorized services, you will have to complete all of the provider
enrollment requirements again, including the criminal background check, provider
orientation, and completion of all required forms.
If you disagree with this decision you may submit the attached county request form to
the IHSS office at the address above. You have ten (10) calendar days from the date of
this notice to request a county review. The county then has ten (10) business days to
review and investigate and make a decision.
SOC 2259 (3/16)

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