Form Soc 2247 - Ihss Uhv Findings Report Page 3

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
 
IHSS UHV FINDINGS REPORT INSTRUCTIONS
General Information
Enter the name of the recipient being visited.
IHSS recipient name:
Enter the IHSS case number.
Case no.:
Enter the phone number on file for the recipient.
Recipient phone no.:
Enter an alternate phone number for the recipient, if
Alt. phone no.:
there is one on file.
Select the county conducting the UHV.
County:
Enter the name of the person conducting the UHV.
UHV staff name:
Enter the phone number of the person conducting the
UHV staff phone no.:
UHV.
Enter the reason for the UHV. Please provide details
Reason for UHV:
in Section E as needed.
A.
Case File Information
Select the primary language of the recipient as listed
Primary language:
in the case file.
Enter the total number of people living in the
No. in household:
household including the recipient.
Enter the number of hours authorized for purchase.
Authorized no. hours:
Enter the number of eligible providers on file for this
No. of providers:
recipient.
Enter the date of the last recorded face-to-face
Date of last Face-to-Face
contact the county had with the recipient.
(F2F):
Enter the name of the person who conducted the
Who conducted the last F2F:
last face-to-face with the recipient.
Check if the recipient meets the Severely Impaired
Severely Impaired:
criteria.
Check if the recipient is currently authorized
Protective Supervision:
Protective Supervision.
SOC 2247 (1/14)
3

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