Form Soc 872 - Statement Of Facts (Sof) Preparation Checklist In-Home Supportive Services (Ihss) Program Caregiver Background Check Bureau (Cbcb), General Exception Unit (Geu)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF FACTS (SOF) PREPARATION CHECKLIST
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
CAREGIVER BACKGROUND CHECK BUREAU (CBCB), GENERAL EXCEPTION UNIT (GEU)
•
Check the appropriate box [YES, NO, or N/A (Not Applicable)] in the right-hand column for each
item.
•
Attach checklist to the SOF Summary.
CHECK SOF SUMMARY FOR THE FOLLOWING:
■ ■
■ ■
■ ■
1.
Has all identifying information on Page 1 of the SOF Summary
YES
NO
N/A
been completed?
2.
Have copies of the following documents (submitted by the
applicant provider) and the CBCB analyst’s evaluation of those
documents (if applicable) been included in the case file?
a. IHSS Program Notice to Applicant Provider of Provider
■ ■
■ ■
■ ■
YES
NO
N/A
Ineligibility - Tier 2 Crimes (SOC 852A)
■ ■
■ ■
■ ■
YES
NO
N/A
b. IHSS Program Provider Enrollment Form (SOC 426)
■ ■
■ ■
■ ■
c. Documentation of informal probation, if applicable
YES
NO
N/A
d. Description and verification of completed training classes,
■ ■
■ ■
■ ■
treatment, counseling, or community services activities
YES
NO
N/A
indicating rehabilitation or changed behavior
■ ■
■ ■
■ ■
YES
NO
N/A
e. Evidence of an official pardon by the Governor, if applicable
■ ■
■ ■
■ ■
YES
NO
N/A
f. Employment history for the last 10 years
g. Copies of police reports involving the disqualifying crime(s) or a
■ ■
■ ■
■ ■
YES
NO
N/A
letter from law enforcement stating the reports no longer exist
■ ■
■ ■
■ ■
YES
NO
N/A
h. Three (3) signed character reference statements
■ ■
■ ■
■ ■
i. Signed personal statement
YES
NO
N/A
3.
Has a copy of the Criminal Offender Record Information (CORI)
■ ■
■ ■
■ ■
YES
NO
N/A
been included in the case file?
■ ■
■ ■
■ ■
YES
NO
N/A
4.
Has a copy of the “Triage” form been included in the case file?
SOC 872 (7/12)

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