Form Soc 871 - Statement Of Facts (Sof) Summary Sheet In-Home Supportive Services (Ihss) Program Caregiver Background Check Bureau (Cbcb), General Exception Unit (Geu) Page 2

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STATEMENT OF FACTS (SOF) SUMMARY
INSTRUCTIONS
THE SOF SUMMARY SHEET PROVIDES BASIC INFORMATION TO BE ENTERED INTO THE LEGAL
CASE TRACKING SYSTEM (LCTS). THE LCTS PROVIDES A MECHANISM FOR TRACKING LEGAL
CASES THROUGHOUT THE GENERAL EXCEPTION (GE) PROCESS.
A. GENERAL EXCEPTION APPEAL INFORMATION
Legal Case #: Enter a 9 to 11 digit case number, which remains with the case throughout the
appeal process.
Appeal Request Received: Enter date CBCB received the appeal request.
Acknowledgement Letter Sent: Enter date acknowledgement letter was sent to applicant provider.
SOF Due: Enter date SOF is due from CBCB GEU analyst.
County: Enter the County in which the applicant applied to become an IHSS provider.
County Contact: Enter the name of the county contact.
B. GENERAL EXCEPTION APPLICANT PROVIDER INFORMATION
Name, Address, Telephone: Enter the applicant provider contact information.
General Exception ID #: Enter applicant provider General Exception ID #.
C. TYPE OF ACTION REQUESTED
General Exception Denial: Select if taking this action.
General Exception Rescission: Select if taking this action.
D. CBCB GEU INFORMATION
Analyst Name, Telephone, Mail Station: Enter contact information for the CBCB GEU analyst
Manager Name, Telephone, Mail Station:
Enter contact information for the CBCB GEU
analyst’s manager.
Manager Signature, Date: Obtain signature and date.
Bureau Chief Signature, Date: Obtain signature and date.
E. COMMENTS
Summarize reason(s) that support or clarify the denial of this GE request. State the factors
considered, per the “Evaluator Manual for General Exception” Section A-1115, and relevant
documentation submitted by the applicant provider. Documentation may include his/her concerted
rehabilitation efforts (such as education, employment, community service, therapy, etc.) and the
evaluation of his/her written statement regarding the circumstances of the commission of the crime.
PAGE 2 OF 2
SOC 871 (7/12)

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