Form Soc 863 - In-Home Supportive Services (Ihss) Applicant Provider Request For General Exception

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS)
APPLICANT PROVIDER REQUEST FOR GENERAL EXCEPTION
To request a general exception, you must submit the items listed on this form to the address listed on
Page 3 within forty-five (45) calendar days of the date of your denial notice. If you request a general
exception, it may take at least seventy-five (75) calendar days to process after a complete exception
request and the applicant’s criminal offender record information (CORI) are received by the California
Department of Social Services (CDSS) Caregiver Background Check Bureau (CBCB). Once all the
documents are received, you will receive a written notice stating whether the request has been approved
or denied. You cannot be paid by the IHSS program for any work performed for an IHSS
recipient until the general exception request has been approved. (Please note that, if you are
currently working for an IHSS recipient because that recipient completed the individual waiver
process to hire you, you may continue to work for that recipient.)
I, ______________________________, am requesting a general exception to become an IHSS provider
and work for any IHSS recipient who wishes to hire me. I understand that, at this time, I am denied
eligibility to work as an IHSS provider, due to felony criminal conviction(s) listed on my CORI.
I am providing this information for the CBCB to evaluate my request for a general exception:
Applicant Provider Name:
Mailing Address:
Phone Number:
The CBCB will consider the following factors when considering whether to grant the general
exception:
A. The nature and seriousness of the crime(s) and the connection to the duties and
responsibilities of an IHSS provider.
B. Your activities since conviction, including (but not limited to) your employment, participation
in therapy education, or community service that would show your changed behavior.
C. The number of convictions and the time that has passed since the conviction(s).
D. The extent to which you have met the terms of parole, probation, restitution, or other
penalty imposed on you.
E. Any evidence of rehabilitation that you have submitted. This includes character references
submitted by others on your behalf.
F. Your employment history and current or past employer recommendations. Additional
consideration will be given to an employer recommendation from a person who has
received in the past or wants to receive personal care services from you.
G. Information about your involvement in the previous crimes(s) that would explain why it
is unlikely you would repeat such an offense.
H. The Governor’s full and unconditional pardon that was granted to you.
SOC 863 (1/11)
PAGE 1 OF 3

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