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Public Authority Registry Provider Application



IP Characteristics:

Consumer Preference:

Geographic Preference:

Type of Work Desired:

Willing to Work With:


Years of Experience:

Employment References:

Personal Reference:

Do you give the Registry permission to conduct a background check?

Release of Information:

I give permission for the Public Authority to obtain references. I understand this release of information is valid for 90 days from the date indicated below. I agree to waive any and all claims against, and to hold harmless, the Public Authority and any predecessor employer in connection with release of all prior work history, regardless of form.

I also agree to waive my right to receive public records obtained by the Public Authority, as defined in Civil Code section 1786.53, and any other records received from a predecessor employer.

I agree to the forgoing waivers by providing my initials below.

Provider Criminal Record Check Policy and Procedure:

General Policy:

All registry applicants will be required to give written permission for the Public Authority to conduct a criminal record check.

All registry applicants will be required to disclose information on previous criminal convictions.

Staff will explain the Public Authority criminal record policy and procedure to all registry applicants; and all registry applicants will be given a copy of the Public Authority criminal record policy and procedure.

A DOJ live scan completed with the sheriff’s office or other accredited live scan vendor.

All consumers requesting providers from the registry will be clearly informed regarding the limited nature of the criminal record check.

Criminal Record Policy:

The following will not be eligible for inclusion on the Public Authority Registry:

1.  Providers who have failed to disclose any previous criminal conviction on their application to join the Registry.

2.  Providers who have been convicted, including pleas of no contest, at any time, of any of the following violations. (Note that references are made to California Penal Code sections; however, convictions for similar offenses may have occurred in other jurisdictions.)

A.  Sexual offenses against a minor.

B.  Violation of sexual battery (Penal Code 243-4); willful harm or injury to child, endangering person or health (Penal Code 273a); corporal punishment or injury of child (Penal Code 273d); infliction of pain or mental suffering or endangering health of elder or dependent adults; theft or embezzlement of property (Penal Code 368a, 368b)

C.  Offenses against property, including but not limited to, theft, robbery, burglary, embezzlement or extortion.

D.  Offenses where inclusion or continued participation in the Registry would, in the judgement of the Public Authority, subject an IHSS consumer to risk of harm, or otherwise undermine the functioning of the Registry.

Appeals Process for Being Excluded from the Registry Based on Criminal Convictions:

1.  An applicant may appeal the Registry's determination to exclude the provider from the Registry list only if one of the following applies:

A.  The Registry has determined (relative to item 2D above) that the applicant was convicted of an offense that would, in the judgement of the Public Authority, subject a consumer to risk of harm or otherwise undermine the functioning of the Registry.

B.  The applicant is not the defendant shown on the record of conviction.

2.  A written appeal shall be filed with the Public Authority Manager within 10 days of the mailing of the notice of determination. The appeal shall include a statement of the basis for the appeal, and whether an oral or written appeal is requested. The Public Authority has the sole discretion to determine whether the issue raised in the written appeal is a proper subject for appeal, as provided in subsection (1) above.

3.  The Public Authority Manager shall hear the appeal and review all documentary evidence and testimony provided by the applicant or the applicant's representative. Upon the conclusion of the appeals hearing, the Public Authority Manager shall provide a written decision within thirty days, which shall be final.

Confidentiality Statement:

As a Provider for the Calaveras County IHSS Public Authority, I agree to adhere to the laws concerning confidentiality as set forth in the California Welfare and Institutions Code (W&IC) Section 10850.

I understand that I am not to disclose any information about a Consumer and/or his/her records; except for the provision of information to “other public agencies to the extent required for verifying eligibility or for other purposes directly connected with the administration of public social services”.*

I understand that any violation of the confidentiality provision is subject to the penalty terms of W&IC 10850:  “Any person knowingly and intentionally violating this subdivision is guilty of a misdemeanor.”

Mandated Reporting Responsibilities for In-Home Supportive Services Providers:

As an In-Home Supportive Service Provider, YOU ARE A MANDATED REPORTER. This means you are required by law to report any known incident of elder and dependent adult abuse. Failure to report is a misdemeanor. The following explains the law as it pertains to In-Home Supportive Services.

California State Law, Section 15630 of the Welfare and Institutions Code, requires mandated reporters to report in his or her professional capacity, or within the scope of his or her employment while providing care has observed or has knowledge of an incident that appears to be Physical Abuse, Abandonment, Isolation, Financial Abuse, Abduction or Neglect. Reports are to be made to the Calaveras Works and Human Services Agency (Adult Protective Services) or to law enforcement by telephone immediately, followed by a written report within two working days. Suspected/Dependent Adult Elder Abuse form (soc341), may be obtained from the Calaveras Works and Human Services Agency (Adult Protective Services).


1.  Elder:  Any person over 65 years of age.

2.  Dependent Adult:  Any person 18 to 64 years old who has physical or mental limitations which restrict his or her ability to carry out normal activities or to protect his or her rights.

3.  Financial Abuse: Wrongfully taking, secreting, or appropriating an elder or dependent adult’s money or property, with intent to defraud.

4.  Neglect of Other:  The negligent failure of any person having the care or custody of an elder or dependent adult to exercise that degree of care which a reasonable person in a like position would exercise.

5.  Physical Abuse:  As characterized by bruises, injuries, burns, unreasonable physical or chemical restraints, sexual assault, unreasonable isolation, or deprivation of food and water.

6.  Abandonment: The desertion or willful forsaking of an elder or dependent adult by anyone have care or custody of that person under circumstances in which a reasonable person would continue to provide care and custody.

7.  Isolation: Acts intentionally committed for the purpose of preventing an elder or dependent adult from receiving mail, telephone calls or receiving visitors.

I certify that I have read the above reporting responsibilities and understand that I am a mandated reporter under the Welfare and Institutions Code Section 15630. I will comply with this code.

Workers' Compensation and Fraud Agreement:

Worker’s Compensation:

You need to report all IHSS work-related accidents and injuries immediately.

Within 24 hours of reporting a work-related accident or injury to the Social Worker, you will be provided with an “Employee Claim for Workers’ Compensation Benefits” (SOC-412). 

You should be aware that Workers’ Compensation will not pay if you are injured doing tasks that are not authorized for the Consumer (Recipient).  Always ask for a copy of the Consumer’s “Notice of Action” [NoA], so you will know exactly what tasks you should be doing for that particular Consumer.  If you have any questions about whether or not an activity or task is authorized for a Consumer, call a Public Authority staff member before doing it.

The following is a list of tasks that are not authorized for any Consumer:

1.  Washing windows, walls, ceilings, carpets, cupboards, yard work - unless specifically authorized as a one-time heavy cleaning or yard hazard abatement by an IHSS Social Worker.

2.  Moving heavy furniture, waxing floors, packing, unpacking from a move, painting, paneling walls, planting gardens, pet care or clean-up, cleaning up after Consumer’s friends or relatives.

3.  If the Consumer dies, goes into a hospital, skilled nursing facility, residential care facility, or is jailed, you need to call and report to IHSS staff immediately.  You may not claim hours while the Consumer is not in the home.


In-Home Supportive Services is a public welfare program funded by federal, state, and county funds.  Any false statement, claim, or concealment of information may be prosecuted under federal and state law.  Some examples of fraudulent behaviors include but are not limited to:

1.  Provider claiming hours that are not actually worked.

2.  Provider claiming hours for providing services that are not authorized by IHSS (see above examples).

3.  Provider/Consumer collude together to receive payment for services neither are eligible to receive.

4.  Forgery of signatures on the time sheet.

5.  Provider or Consumer misrepresents or exaggerates about the level of need for IHSS.

6.  Providers falsely reporting on-the-job injuries in an effort to collect Workers’ Compensation.

I have read the foregoing, and understand its terms or have had them explained to me, and acknowledge that IHSS time sheets are signed under penalty of perjury.

Registry Provider Agreement:

I will make sure to have a reliable phone and courteous voice mail message.

I will return all phone calls from Consumers and Public Authority staff.

I will show up to all interviews on time, and notify the involved party if I will be late.

I will always be professional, whether in person or on the telephone.

I will call the Consumer ahead of time if I am ill or unable to work for any reason.

I will perform all duties as agreed upon, based on the Consumer’s authorized services.

I will notify "PA" and give 2 weeks’ notice if I plan to terminate my employment with the Consumer.

I will give as much notice to Consumers and the "PA" Registry when planning vacations or time off.

I agree to update the Public Authority Registry once a month on my status of availability.

I understand that failure to abide by this agreement and all other duties and responsibilities as a Provider may result in my being placed on probation, de-activation or removal from the Registry.

Employment & Personal Reference Consent:

I hereby consent to your release of information relating to my job placement. I further consent to you or your designee to respond to written or telephone inquiries from the Calaveras County IHSS Public Authority.




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