Form Soc 2248 - Ihss Complaint Of Suspected Fraud Form
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8STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IHSS COMPLAINT OF SUSPECTED FRAUD FORM
Please fill in as much Information as possible
Provider relationship to recipient:
County:
IHSS recipient name:
IHSS provider name:
IHSS recipient SSN:
IHSS provider SSN:
IHSS recipient DOB:
IHSS provider DOB:
IHSS recipient address:
IHSS provider address:
Complaint against recipient
Complaint against provider
A. REPORTING PARTY
Name:
Date:
Email:
Phone no.:
Relationship to IHSS participant:
No. in household:
How did you become aware of this information:
Name of person and Agency taking complaint:
B. REASON FOR COMPLAINT
Deceased
Recipient residing in a care facility or hospital
Name of facility:
Recipient
Provider
Date of death:
Dates of stay:
In Jail
Recipient
Provider
Dates:
Provider Issues
Being paid for services not
Stealing from
Abuse/neglect/maltreatment of recipient
provided
recipient
County employee is IHSS provider
Other (specify)
Recipient Issues
Does not appear to Need Services
Seen performing strenuous activities (such as yard work, sports, lifting heavy object, etc.)
Seen driving
If yes, where:
Seen working
Other (specify)
C. NARRATIVE DESCRIPTION (Actions observed, date observed, etc)
SOC 2248(3/13)
PAGE 1
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