Form Soc 2290 - In-Home Supportive Services Program State Administrative Review Request Response Letter To Provider Upholding Fourth Violation

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
STATE ADMINISTRATIVE REVIEW REQUEST RESPONSE LETTER TO PROVIDER
UPHOLDING FOURTH VIOLATION (ONE-YEAR PERIOD OF INELIGIBILITY) FOR
EXCEEDING WORKWEEK AND/OR TRAVEL TIME LIMITS
(ADDRESSEE)
COUNTY OF:
Notice Date:
Recipient Name:
Recipient Case Number:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Provider
This notice is to inform you that we have reviewed the State Administrative Review
Request you filed after receiving a fourth violation for the month of ________________.
As of the date of this notice, the violation is upheld. This decision is based on our review
of the information and/or documentation you provided on the State Administrative
Review Request form. We have determined there was not enough evidence to
demonstrate you met the criteria required to work more hours than your workweek
agreement allows for. You will continue to have a fourth violation because you:
Worked more than 40 hours in a workweek for a recipient without the recipient
getting approval from the county when that recipient’s maximum weekly hours are
40 hours or less.
Worked more than a recipient’s maximum weekly hours without the recipient
getting approval from the county which caused you to work more overtime hours
in the month than you normally would.
Worked more than 66 hours in a workweek when you work for more than one recipient.
Claimed more than 7 hours of travel time in a workweek.
Your eligibility to provide IHSS services will be suspended 20 calendar days from the
date of this notice, for a period of one year. If you are unsure of the date that you are
eligible to resume providing services, please contact your IHSS office.
Before you may resume providing IHSS services, you will be required to complete all of
the provider enrollment requirements again, including the criminal background check,
provider orientation, and completion of all required forms.
If you have any questions about this notice, you may contact the California Department
of Social Services, Claims, Certification and Appeals Bureau, Appeals Unit at
(916) 651-3488.
SOC 2290 (6/16)

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