Form SOC2272 "In-home Supportive Services Program Notice to Provider of Right to Dispute Violation for Exceeding Workweek and/or Travel Time Limits" - California

What Is Form SOC2272?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2016;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SOC2272 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form SOC2272 "In-home Supportive Services Program Notice to Provider of Right to Dispute Violation for Exceeding Workweek and/or Travel Time Limits" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
NOTICE TO PROVIDER OF RIGHT TO DISPUTE VIOLATION 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
You received a violation because you exceeded your workweek and/or travel time limits.
If you believe you should not have been issued a violation because the additional hours
you worked met all 3 of the criteria listed below, please review and respond to the
questions on the following pages.
If you provide services to only 1 recipient, you must answer questions 1 through 5 and
questions 9 through 11. If you provide services to 2 or more recipients, you must answer
questions 6 through 11.
You have 10 calendar days from the date indicated on the violation notice to submit this
form to the county requesting an official county review of the circumstances surrounding
the additional hours you worked which led to the violation.
Criteria:
1. The need for additional hours was necessary to meet an unanticipated need;
2. The additional hours were related to an immediate need that could not be
postponed until the arrival of a back-up provider as designated on the IHSS
Program Individual Emergency Back-Up Plan (SOC 827) form; and
3. The additional hours were related to a need that would have had a direct impact
on the IHSS recipient and were needed to ensure his/her health and/or safety.
PAGE 1 OF 4
SOC 2272 (7/16)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
NOTICE TO PROVIDER OF RIGHT TO DISPUTE VIOLATION 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
You received a violation because you exceeded your workweek and/or travel time limits.
If you believe you should not have been issued a violation because the additional hours
you worked met all 3 of the criteria listed below, please review and respond to the
questions on the following pages.
If you provide services to only 1 recipient, you must answer questions 1 through 5 and
questions 9 through 11. If you provide services to 2 or more recipients, you must answer
questions 6 through 11.
You have 10 calendar days from the date indicated on the violation notice to submit this
form to the county requesting an official county review of the circumstances surrounding
the additional hours you worked which led to the violation.
Criteria:
1. The need for additional hours was necessary to meet an unanticipated need;
2. The additional hours were related to an immediate need that could not be
postponed until the arrival of a back-up provider as designated on the IHSS
Program Individual Emergency Back-Up Plan (SOC 827) form; and
3. The additional hours were related to a need that would have had a direct impact
on the IHSS recipient and were needed to ensure his/her health and/or safety.
PAGE 1 OF 4
SOC 2272 (7/16)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Questions for Providers with Only One Recipient:
1. If you received a violation for exceeding your workweek limits, please state the
reason(s) your recipient requested you to work more than your regular hours.
________________________________________________________________
________________________________________________________________
________________________________________________________________
2. Did your recipient obtain approval from the county so you could work the additional
hours? Please check the box:
Yes
No.
• If yes, was the approval received before or after you worked the additional
hours? ________________________________________________________
• What was the date(s) your recipient requested approval from the county?
______________________________________________________________
• If known, what was the name of the county staff that granted your recipient
approval to allow you to work the additional hours? _____________________
_______________________________________________________________
3. If your recipient did not request approval from the county so you could work the
additional hours, please explain the reason why an approval was not requested
prior to the submission of your timesheet.
________________________________________________________________
________________________________________________________________
________________________________________________________________
4. Please describe the reason(s) why you worked the additional hours for your
recipient that caused you to receive this violation and why you believe the
additional hours worked met all of the criteria listed on page 1.
________________________________________________________________
________________________________________________________________
________________________________________________________________
5. Please provide any additional information and attach any documentation that you
believe will help the county determine whether to rescind your violation.
________________________________________________________________
________________________________________________________________
PAGE 2 OF 4
SOC 2272 (7/16)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Questions for Providers with 2 or More Recipients:
6. If you received a violation for exceeding your workweek limits, please state the
reason(s) your recipient requested you to work more than your regular hours.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
7. Did your recipient obtain approval from the county so you could work the additional
hours? Please check the box:
Yes
No.
• If yes, was the approval received before or after you worked the additional
hours? ________________________________________________________
• What was the date(s) your recipient requested approval from the county?
______________________________________________________________
• If known, what was the name of the county staff that granted your recipient
approval to allow you to work the additional hours? _____________________
_______________________________________________________________
8. If your recipient did not request approval from the county so you could work the
additional hours, please explain the reason why an approval was not requested
prior to the submission of your timesheet.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Questions for All Providers:
9. Please describe the reason(s) why you worked the additional hours for your
recipient(s) that caused you to receive this violation and why you believe the
additional hours worked met all of the criteria listed on page 1.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
PAGE 3 OF 4
SOC 2272 (7/16)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
10. If the violation was issued because you traveled more than 7 hours in a workweek,
please explain the reason why you exceeded the 7 hour limitation on travel time
and why the violation should be rescinded based on the criteria listed on page 1.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
11. Please provide any additional information and attach any documentation that you
believe will help the county determine whether to rescind your violation.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
If you need more space, check the box to the left and attach additional page(s) as
needed.
Provider’s Signature: _________________________________________________
Provider’s Telephone No.: ___________________________ Date: _____________
I agree with the above information and believe it to be true and correct.
Recipient’s Signature: ________________________________________________
Date: ___________________________
PAGE 4 OF 4
SOC 2272 (7/16)
Page of 4