Form Soc 855a - In-Home Supportive Services Program Notice To Recipient Of Provider Ineligibility Tier I Crimes

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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 INELIGIBILITY
TIER I CRIMES(ELDER OR DEPENDENT ADULT ABUSE/CHILD ABUSE & FRAUD
AGAINST A GOVERNMENT HEALTH CARE OR SUPPORTIVE SERVICES PROGRAM)
[WELFARE & INSTITUTIONS CODE SECTION 12305.81]
(ADDRESSEE)
County of:
Notice Date:
Applicant Provider Name:
Recipient Name:
Recipient Case Number:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Recipient
Due to a criminal conviction, the person you have chosen to employ to provide IHSS services for you,
___________________________, has been denied eligibility. He/she cannot receive payment from the
IHSS program for providing services to you or to any other person.
As part of the provider enrollment process, this person submitted fingerprints for a California Department
of Justice criminal background check. This background check or a court document showed that he/she
had been convicted of a crime(s) that makes him/her ineligible to be an IHSS provider and to
receive payment from the IHSS Program for providing services based on Welfare and Institutions Code,
Section 12305.81. The crime(s) which disqualified him/her is/are one or more of the crimes listed below:
Abuse of an elder or dependent adult; and/or
●
Specified abuse of a child; and/or
●
Fraud against a government health care or supportive services program.
●
This information regarding the applicant provider’s convictions is highly sensitive and must be kept strictly
confidential. You are prohibited by law from sharing any part of this information with any other
individual or entity.
Because this applicant provider has been determined to be ineligible to provide services through the
IHSS program, you must choose a different person to provide services. If you choose to continue
receiving services from this person, you will be responsible for paying him/her with your own money for
any services provided.
If you need help finding a different provider, call ______________________________ .
SOC 855A (1/11)

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