STATE OF CALIFORNIA − HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SOC 2255 (11/15)
PAGE 1 OF 7
PROVIDER NAME: PROVIDER NUMBER:
• State law (Welfare and Institutions Code section 12300.4) limits providers in the IHSS and Waiver Personal Care
Services (WPCS) programs to working a maximum weekly number of hours providing IHSS and WPCS. A
provider who works for multiple recipients is limited to providing 66 hours per workweek.
• The maximum weekly workweek does not include travel time as described in Part B of this form. The workweek
starts on Sunday at 12:00 a.m. (midnight) and ends at 11:59 p.m. on the following Saturday.
• Recipients are authorized services on a monthly basis and, based on state law, are limited to receiving a set
amount of those services on a weekly basis. You will get a notice telling you how many authorized service hours
each of your recipients gets weekly and monthly. You may never work more than a recipient’s monthly authorized
hours for that recipient. However, you may work more than a recipient’s weekly authorized hours in certain
circumstances. A recipient may adjust his or her weekly authorized hours, but he/she must get approval from the
county if the adjustment will result in either a provider working more overtime hours in the month than the provider
would normally work or working over 40 hours in any workweek for him/her (when, he/she is authorized to receive
40 hours or less in services in a workweek).
• It is your responsibility as a provider to:
Make sure that the total combined hours you work providing authorized services for all the recipients you
work for in one workweek do not total more than the 66 hours in a workweek.
Make sure that the hours you work providing services to any one of your recipients are not more than that
recipient’s weekly authorized hours, unless the hours are correctly adjusted.
PART A. WORKWEEK SCHEDULE
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
PROVIDER WORKWEEK & TRAVEL TIME AGREEMENT
(To be completed by a provider who provides authorized services to multiple recipients)
PROVIDER NUMBER ______________________