STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Provider Number__________________________
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
LIVE-IN FAMILY CARE PROVIDER OVERTIME EXEMPTION
PROVIDER NAME:
Part A: PROVIDER REQUIREMENTS
Beginning February 1, 2016, state law (Welfare and Institutions Code section 12300.4) limits the maximum weekly
number of hours an IHSS/Waiver Personal Care Services (WPCS) provider can work in a workweek. A provider in
the IHSS/WPCS program will be paid overtime if they work more than 40 hours a week, but providers shall not work
more than 66 hours a week for IHSS and WPCS recipients combined.
The IHSS program has created a family-member exemption to the workweek maximum of 66 hours for IHSS providers
to allow them to work up to a maximum of 90 hours per workweek and up to a maximum of 360 hours a month. In
order to be eligible for this exemption, you must meet the three (3) following conditions on or before January 31, 2016:
You must provide IHSS services to two or more IHSS recipients.
You must currently live in the same home as the IHSS recipients that you provide services to.
You must be related to the IHSS recipients to whom you provide services as his/her parent, stepparent, adoptive
parent or grandparent or be his/her legal guardian.
With this exemption, you cannot work more than 90 hours per workweek or more than 360 hours per month. If you
work up to these maximum hours for your recipients and your IHSS recipients still have IHSS hours left, then your
IHSS recipients will have to hire another IHSS provider to work the rest of their IHSS hours.
Please complete Part B of this form and provide all information to verify that you meet the three (3) requirements
above to qualify for this exemption as a Live-in Family Care Provider.
SOC 2279 (1/16)
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_________________________________________________________________________________________
__________________________________________________________________________________________
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Provider Number__________________________
Part B: PROVIDER & RECIPIENTS’ INFORMATION
INSTRUCTIONS: You must complete the information below about your residential and mailing addresses and then
complete the chart below for the recipients you provide services to.
1.Your residential address: _____________________________________________________________________
2.Your mailing address: _______________________________________________________________________
A
Recipient Information
Name Case Number
B
Relationship to Recipient
C
Does this recipient live with
you in the same residence?
Please answerYes or No
1.
1.
1.
2.
2.
2.
3.
3.
3.
4.
4.
4.
SOC 2279 (1/16)
PAGE 2 OF 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Provider Number__________________________
I declare that I meet all of the requirements to qualify for this exemption. I further declare that all of the
information I have provided on this form is true and correct to the best of my knowledge. I understand that
verification of this information will occur at the time of my IHSS recipient’s reassessment to determine if I
still qualify for this exemption. I agree to adhere to all requirements for overtime under this exemption. If I
no longer meet the three (3) requirements for this exemption I will no longer qualify for this exemption and I
must notify the county immediately. I understand that I will then be subject to the existing overtime limitation
restrictions.
PROVIDER SIGNATURE: DATE:
PROVIDER’S PRINTED NAME:
FOR STATE USE ONLY
STAFF NAME: DATE:
NOTES:
SOC 2279 (1/16)
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