Form RFA09B "Notice of Action to Individual Regarding Resource Family Approval Criminal Record Exemption Decision" - California

What Is Form RFA09B?

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 April 1, 2018;
  • 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 RFA09B 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 RFA09B "Notice of Action to Individual Regarding Resource Family Approval Criminal Record Exemption Decision" - California

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State of California – Health and Human Services Agency
California Department of Social Services
NOTICE OF ACTION TO INDIVIDUAL
REGARDING RESOURCE FAMILY APPROVAL
CRIMINAL RECORD CLEARANCE OR EXEMPTION
County:
Date:
Applicant(s) or RF Name(s):
County RF ID#:
RF Address:
Individual’s Name:
PER ID#:
To:
[Insert individual's address]
This notice is to inform you that
on
A rescinded exemption, a denied
exemption request, or a denied exemption due to a non-exemptible conviction means that you may
not reside or be regularly present in an approved Resource Family home, and you may not have
contact with children or nonminor dependents placed in the home. If you applied for Resource Family
approval, this means your application must be denied. If you are currently approved as a Resource
Family, this means the approval will be referred for rescission. A similar notice (excluding your
convictions) has been sent to the resource family or applicant.
If this is a denial of a criminal record exemption request or an exemption rescission, it is based upon
your failure to provide satisfactory evidence that you can meet or conform to all Resource Family
Approval background check requirements. If you have a non-exemptible conviction you are not
eligible for exemption. The criminal record clearance and exemption requirements are set forth in
Welfare and Institutions Code Section 16519.5 et seq., Health and Safety Code section 1522, other
applicable law and RFA Written Directives, Version(s)
sections 6-03A, 6-03B, and 10-01.
Specifically, it has been determined that you:
[Check one only.]
Have a criminal conviction or convictions for which you have failed to provide substantial and
convincing evidence that you are rehabilitated and of present good character.
Have a non-exemptible criminal conviction or convictions for which we are prohibited by law from
granting a criminal record exemption.
RFA 09B (4/18)
Page ___ of ___
State of California – Health and Human Services Agency
California Department of Social Services
NOTICE OF ACTION TO INDIVIDUAL
REGARDING RESOURCE FAMILY APPROVAL
CRIMINAL RECORD CLEARANCE OR EXEMPTION
County:
Date:
Applicant(s) or RF Name(s):
County RF ID#:
RF Address:
Individual’s Name:
PER ID#:
To:
[Insert individual's address]
This notice is to inform you that
on
A rescinded exemption, a denied
exemption request, or a denied exemption due to a non-exemptible conviction means that you may
not reside or be regularly present in an approved Resource Family home, and you may not have
contact with children or nonminor dependents placed in the home. If you applied for Resource Family
approval, this means your application must be denied. If you are currently approved as a Resource
Family, this means the approval will be referred for rescission. A similar notice (excluding your
convictions) has been sent to the resource family or applicant.
If this is a denial of a criminal record exemption request or an exemption rescission, it is based upon
your failure to provide satisfactory evidence that you can meet or conform to all Resource Family
Approval background check requirements. If you have a non-exemptible conviction you are not
eligible for exemption. The criminal record clearance and exemption requirements are set forth in
Welfare and Institutions Code Section 16519.5 et seq., Health and Safety Code section 1522, other
applicable law and RFA Written Directives, Version(s)
sections 6-03A, 6-03B, and 10-01.
Specifically, it has been determined that you:
[Check one only.]
Have a criminal conviction or convictions for which you have failed to provide substantial and
convincing evidence that you are rehabilitated and of present good character.
Have a non-exemptible criminal conviction or convictions for which we are prohibited by law from
granting a criminal record exemption.
RFA 09B (4/18)
Page ___ of ___
State of California – Health and Human Services Agency
California Department of Social Services
This decision is based on the evidence set forth in the court and law enforcement records, reports,
statements, papers, and other documentary evidence contained in the official files compiled by the
county or department, which information and records are hereby incorporated by this reference. This
decision is based on the criminal convictions listed below which occurred on or about the dates listed
as follows:
[Instructions: List conviction(s) in this format: June 5, 2016, Vehicle Code Section 23152 (a), driving under the influence of
alcohol or drugs, a misdemeanor, in Los Angeles, CA.” If a conviction is a federal 5 year non-exemptible, include a sentence
stating: “Health and Safety Code section 1522(g) prohibits the granting of an exemption to a foster care provider with a felony
conviction within the last five years for physical assault, battery, or a drug or alcohol related offense.” If non-exemptible,
attach copy of individual’s CORI to this RFA 09B NOA as required by WDs 6-03B(b)(1) and list only the non-exemptible
conviction(s) below. Use a separate sheet of paper if additional space is needed.]
The following was considered in reviewing your request for an exemption:
[Instructions: List here the relevant specific reasons for denial or rescission using the exemption factors from Written
Directives version 5, section 6-03B (h), (i), or (k). If this is an exemption rescission, use factors in 6-03B(I); add factors from
(h), (i), or (k) if applicable. If non-exemptible, insert ‘Not applicable’.]
RFA 09B (4/18)
Page ___ of ___
State of California – Health and Human Services Agency
California Department of Social Services
If you disagree with this action, you may appeal by submitting a written request and a copy of this
notice to the address below. Be advised that if you appeal and it is established that the conviction is
non-exemptible, the Administrative Law Judge who handles the appeal is also prohibited by law from
granting an exemption. If you wish to use this form to appeal, you may do so by checking the box and
filling out the information below, then sending all pages of this notice to the address listed below.
[COUNTY ADDRESS:
CITY, STATE, ZIP:
ATTN: County Contact, Title]
[Appeal due dates effective 1/1/18: Exemption Denial = 90 days. Exemption rescission = 25 days.]
The due date for this appeal is
from the date of this notice.
If this decision is not appealed on or before the due date, the action will be final. The appeal
must be post marked or delivered on or before the due date.
If you appeal, you
continue to reside in the home until completion of the administrative
review of your appeal. You will be contacted and provided additional information about the appeal
process at a later date. If you appeal it is required that you notify the county, in writing, of any change
in your address. Please call the approval worker at
if you have any questions
regarding this notice.
_________________________________________________
[Sign above the line, then type name & title here]
I wish to appeal. (Submit this request with a copy of this notice)
______________________________________
__________________________________
Print Name
Signature
______________________________________
__________________________________
Address
Phone Number
Reasons for appeal (optional): _______________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
[For County use only. Do not write in this box.]
County: ______________________________ County RF ID#: ________________
Exemptible
Non-exemptible
Both
Forum: SHD
OAH
RFA 09B (4/18)
Page ___ of ___
State of California – Health and Human Services Agency
California Department of Social Services
[This page to be kept attached only for appeals that will go to SHD. For OAH cases, please detach before serving.]
[For County use only. Do not write in this box.]
County: ______________________________ County RF ID#: ________________
Exemptible
Non-exemptible
Both
Forum: SHD
OAH
RFA 09B (4/18)
Page ___ of ___