Fillable IN-HOME SUPPORTIVE SERVICES (IHSS) APPLICANT PROVIDER REQUEST FOR (California)

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IN-HOME SUPPORTIVE SERVICES (IHSS) APPLICANT PROVIDER REQUEST FOR (California)

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IN-HOME SUPPORTIVE SERVICES (IHSS)
APPLICANT PROVIDER REQUEST FOR GENERAL EXCEPTION
To request a general exception, you must submit the items listed on this form to the address listed on
Page 3 within forty-five (45) calendar days of the date of your denial notice. If you request a general
exception, it may take at least seventy-five (75) calendar days to process after a complete exception
request and the applicant’s criminal offender record information (CORI) are received by the California
Department of Social Services (CDSS) Caregiver Background Check Bureau (CBCB). Once all the
documents are received, you will receive a written notice stating whether the request has been approved
or denied. You cannot be paid by the IHSS program for any work performed for an IHSS
recipient until the general exception request has been approved. (Please note that, if you are
currently working for an IHSS recipient because that recipient completed the individual waiver
process to hire you, you may continue to work for that recipient.)
I, ______________________________, am requesting a general exception to become an IHSS provider
and work for any IHSS recipient who wishes to hire me. I understand that, at this time, I am denied
eligibility to work as an IHSS provider, due to felony criminal conviction(s) listed on my CORI.
I am providing this information for the CBCB to evaluate my request for a general exception:
Applicant Provider Name:
Mailing Address:
Phone Number:
The CBCB will consider the following factors when considering whether to grant the general
exception:
A. The nature and seriousness of the crime(s) and the connection to the duties and
responsibilities of an IHSS provider.
B. Your activities since conviction, including (but not limited to) your employment, participation
in therapy education, or community service that would show your changed behavior.
C. The number of convictions and the time that has passed since the conviction(s).
D. The extent to which you have met the terms of parole, probation, restitution, or other
penalty imposed on you.
E. Any evidence of rehabilitation that you have submitted. This includes character references
submitted by others on your behalf.
F. Your employment history and current or past employer recommendations. Additional
consideration will be given to an employer recommendation from a person who has
received in the past or wants to receive personal care services from you.
G. Information about your involvement in the previous crimes(s) that would explain why it
is unlikely you would repeat such an offense.
H. The Governor’s full and unconditional pardon that was granted to you.
SOC 863 (1/11)
PAGE 1 OF 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS)
APPLICANT PROVIDER REQUEST FOR GENERAL EXCEPTION
Based on the CBCB factors A through H listed on the previous page, applicant providers must
enclose all of the following with this form:
1. A copy of the denial notice (SOC 852A) stating your ineligibility to be an IHSS provider.
2. A copy of form SOC 426 (IHSS Program Provider Enrollment Form), which you previously
completed and submitted to the county.
3. Documentation (Minute Order, Court-Issued Judgment of Conviction, or a letter from the
Probation Department) showing that your current or last probation period was informal,
if applicable.
4. A description of, and verification if available of, any completed training, classes, treatment,
counseling, or community service activities that would indicate rehabilitation or changed
behavior. Provide verification of completion (for example, certificates or diplomas), if applicable.
5. Evidence of an official pardon by the Governor, if applicable.
6. Employment history for the last 10 years.
7. Copies of all police reports involving the disqualifying crime(s) for which you were convicted
or a letter from law enforcement stating that a report no longer exists.
8. Three (3) signed character reference statements that include the following information:
a. How long the person has known you
b. How the person knows you (this could be a description of how this person came to know
you)
c. A statement of the person’s opinion of your character
d. A description of any interaction between you and a person who is elderly, blind, or disabled
who you have assisted
e. Other comments that would help describe your desire to work as an IHSS provider
The reference statements must be obtained and dated after the date of your denial notice. They
may be completed by current or former employers or other persons you choose. You are limited
to one reference from a family member.
9. A signed personal statement including the following information:
A. A description of the events surrounding the disqualifying crime(s) for which you were
convicted, including what happened, why it happened, how it happened, description of the
victim (if known, gender, approximate age, physical characteristics, relationship to victim),
and other relevant information about the disqualifying crime(s) or any other conviction(s).
The CBCB may compare your statement with police reports and court documents.
SOC 863 (1/11)
PAGE 2 OF 3
IN-HOME SUPPORTIVE SERVICES (IHSS)
APPLICANT PROVIDER REQUEST FOR GENERAL EXCEPTION
AND
B. A description of what you have done since the conviction(s) to ensure you will not be
involved in any criminal activity again.
Send this form and all requested documentation within forty-five (45) calendar days from the
date of your denial notice to the following address:
California Department of Social Services
Caregiver Background Check Bureau
744 P Street, MS 9-15-65
Sacramento, CA 95814
You must notify the CDSS within ten (10) calendar days of any change to your address or telephone
number at the contact information listed above.
__________________________________________________
Signature of Applicant Provider
__________________________________________________ ____________________
Print Name Date
SOC 863 (1/11) PAGE 3 OF 3
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Completed 12 March 2021

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