Form SOC871 "Statement of Facts (Sof) Summary Sheet IHSS Program Caregiver Background Check Bureau (Cbcb), General Exception Unit (Geu)" - California

What Is Form SOC871?

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, 2012;
  • 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;

Download a fillable version of Form SOC871 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form SOC871 "Statement of Facts (Sof) Summary Sheet IHSS Program Caregiver Background Check Bureau (Cbcb), General Exception Unit (Geu)" - California

963 times
Rate (4.6 / 5) 58 votes
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF FACTS (SOF) SUMMARY SHEET
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
CAREGIVER BACKGROUND CHECK BUREAU (CBCB), GENERAL EXCEPTION UNIT (GEU)
A.
GENERAL EXCEPTION APPEAL INFORMATION
Legal Case #:
Appeal Request Received:
Acknowledgement Letter Sent:
SOF Due:
County:
County Contact:
B.
GENERAL EXCEPTION APPLICANT PROVIDER INFORMATION
Name (Last, First, MI):
General Exception ID#:
Address:
City:
ZIP Code:
Telephone: (
)
C.
TYPE OF ACTION REQUESTED
■ ■
■ ■
General Exception Denial:
General Exception Rescission:
D.
CBCB GEU INFORMATION
Analyst Name (Last, First):
Telephone: (
)
Mail Station:
Manager Name (Last, First):
Telephone: (
)
Mail Station:
Manager Signature:
Date:
Bureau Chief Signature:
Date:
E.
COMMENTS
PAGE 1 OF 2
SOC 871 (7/12)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF FACTS (SOF) SUMMARY SHEET
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
CAREGIVER BACKGROUND CHECK BUREAU (CBCB), GENERAL EXCEPTION UNIT (GEU)
A.
GENERAL EXCEPTION APPEAL INFORMATION
Legal Case #:
Appeal Request Received:
Acknowledgement Letter Sent:
SOF Due:
County:
County Contact:
B.
GENERAL EXCEPTION APPLICANT PROVIDER INFORMATION
Name (Last, First, MI):
General Exception ID#:
Address:
City:
ZIP Code:
Telephone: (
)
C.
TYPE OF ACTION REQUESTED
■ ■
■ ■
General Exception Denial:
General Exception Rescission:
D.
CBCB GEU INFORMATION
Analyst Name (Last, First):
Telephone: (
)
Mail Station:
Manager Name (Last, First):
Telephone: (
)
Mail Station:
Manager Signature:
Date:
Bureau Chief Signature:
Date:
E.
COMMENTS
PAGE 1 OF 2
SOC 871 (7/12)
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)
Page of 2