Form Soc 859a - In-Home Supportive Services Program Notice To Recipient Of Provider Ineligibility Tier I Crimes Ineligibility - Subsequent Conviction

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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 INELIGIBILITY - SUBSEQUENT CONVICTION
[WELFARE AND INSTITUTIONS CODE SECTION 12305.81]
(ADDRESSEE)
County of:
Notice Date:
Provider Name:
Recipient Name:
Recipient Case Number:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Recipient
Effective twenty (20) days from the date of this notice, the person you have chosen to provide IHSS
services to you, _____________________, is not eligible to receive payment from the IHSS program for
providing services to you or to any other person. If this person has been providing services for you,
he/she can only be paid for services he/she provides for you through _________________.
Since this person’s initial enrollment, the county/Public Authority/Non-Profit Consortium has learned
through certified court documents or through a criminal background check that he/she has been
convicted of a crime(s) that makes him/her ineligible to serve as an IHSS provider or to receive payments
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 child; and/or
●
Fraud against a government health care or supportive services program.
●
The information regarding the provider’s criminal 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 provider has been determined to be ineligible to provide services through the IHSS
program, you must choose a different individual to act as your IHSS provider. If you choose to continue
receiving services from this individual, you will be responsible for paying him/her with your own money
for any services provided.
If you have any questions about this notice or need help finding a different provider, you may call
________________________ .
SOC 859A (1/11)

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