Form Soc 2247 - Ihss Uhv Findings Report
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7STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IHSS UHV FINDINGS REPORT
GENERAL INFORMATION (Attach additional sheets if necessary)
IHSS recipient name:
County:
Case no.:
UHV staff name:
Recipient phone no.:
UHV staff phone no.:
Alt. phone no.:
Reason for UHV:
A. CASE FILE INFORMATION
Primary language:
No. of providers:
No. in household:
Date of last F2F:
Authorized no. hours:
Who conducted last F2F:
Severely Impaired
Minor
Protective Supervision
FI rank 5 service(s) (specify):
Case/Narrative notes reviewed
B. RECORD OF ATTEMPTS TO CONTACT THE RECIPIENT (Provide details in Section E)
Visits
Phone calls to recipient
Completed visit
(date)
(time)
(date)
(time)
Recipient ID verified
1st
1st
Provider present
2nd
2nd
Provider ID verified
3rd
Letter
NOA
(date)
(date)
Provider name:
C. FINDINGS OF THE UHV (Provide details in Section F)
Program Integrity concerns unsubstantiated (check ONLY if ALL statements below are correct)
It appears that all authorized services are being provided to the recipient
It appears that all authorized services are provided at an acceptable quality
It appears that the recipient is receiving adequate care
Program Integrity concerns appear valid
Services appear to be authorized beyond need
Services appear to be authorized below need
Authorized services appear to not be sufficiently provided
SOC 2247 (1/14)
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