Form Soc 2257a - In-Home Supportive Services Program Notice To Recipient Of Provider'S First/second Violation 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 FIRST/SECOND VIOLATION
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
In the service month of _________________, your provider, ____________________,
MONTH
PROVIDER NAME
exceeded his/her workweek and/or travel time limits by doing one or more of the following:
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.
Because your provider exceeded his/her workweek and/or travel time limits, he/she
received his/her:
First Violation
Second Violation
Your provider has the one-time option of reviewing instructional materials and
•
submitting a verification notice to the IHSS office to avoid a second violation.
If he/she chooses not to review the instructional materials and submit a
•
verification notice within 14 calendar days, he/she will automatically be given
his/her second violation.
SOC 2257A (3/16)

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