014 Civic Center STATE OF CALIFORNIA
COUNTY OF LOS ANGELES HEALTH AND WELFARE AGENCY
813 E 4TH PL
CALIFORNIA DEPARTMENT OF SOCIAL
LOS ANGELES, CA 90013-1805
SERVICES
NOTICE DATE: January 17, 2025
CASE NAME: Shylene Rodriguez
CASE NUMBER: L1B7494
WORKER NAME: Customer Service
WORKER ID: 19DP141V37
TELEPHONE NUMBER: (866) 613-3777
CUSTOMER ID: 4013188459
CALFRESH NOTICE OF
RESTORATION APPROVAL
Shylene Rodriguez
506 S SPRING ST UNIT 13308
LOS ANGELES, CA 90013-3215
Questions? Ask your worker.
YOUR CALFRESH BENEFITS HAVE BEEN State Hearing: If you think this action is wrong, you
RESTORED EFFECTIVE 01/17/2025. can ask for a hearing. The back page tells you how.
Your benefits may not be changed if you ask for a
This is the date we got the needed information to hearing before this action takes place.
restore your benefits. Your certification remains the
same and ends on 06/30/2025.
If nothing changes you will get: CalFresh Budget
$141.00 for 01/2025 for 1 person(s).
Report Month 01/2025
For CalFresh, your family size is 1. Your IRT is
$1,632.00. Household Size 1
IF YOU ALSO APPLIED FOR CASH AID, and it has not
Total Countable Earned Income $0.00
yet been approved, your CalFresh benefits may be
Adjusted Countable Earned Income $0.00
lowered or stopped without another notice if your cash
Total Countable Unearned Income $221.00
aid is approved.
Net Countable Income $221.00
Your CalFresh benefits will be available through
Electronic Benefit Transfer- EBT on the 4th of each Standard Deduction $204.00
month. Dependent Care $0.00
Homeless Shelter Deduction $0.00
The amounts used to figure your CalFresh are shown Excess Medical Expense for Aged/Disabled $0.00
on this notice. If your case contains a disqualified Total Deductions $204.00
person(s) and that/those person(s) has/have income, all
of their income is used to compute your CalFresh Preliminary Adjusted Income $17.00
allotment. Housing Expenses $8.50
Utility Expenses $645.00
EBT: Keep your plastic Golden State Advantage card, Adjusted Net Income $0.00
even if your aid is terminated. Please do not throw it
Rules: These rules apply; you may review them at your welfare office: CalFresh Allotment $141.00
ACL 10-32 Less Overissuance -$0.00
Total CalFresh Allotment =$141.00
CF 388 (8/13) Page 1 of 2
0000000574391266
California Health & Human Services Agency California Department of Social Services
YOUR HEARING RIGHTS
YOUR HEARING RIGHTS (See also PUB 412 at www.cdss.ca.gov/inforesources/state-hearings )
You can ask for a hearing if you disagree with a county/agency action or failure to act. You have 90 days to do so,
starting the day after the date of the notice. After 90 days, you must prove you had a good reason for asking late. You
can also ask for a hearing to review your benefits for the past 90 days. If you ask for a hearing before the date of the
change, your benefits will continue unchanged. CalFresh will end if you don’t recertify when due.
• Online at acms.dss.ca.gov Click "Create an account" to • Fill out this page, and deliver it by one of the following:
have an ACMS account and get documents online; or click o In-person: Appeals and State Hearings Section
“Submit Appeal without Account” to file without an account 3833 S. Vermont Ave.
OR 4th Floor
Los Angeles, CA 90037
• Call toll free (800) 743-8525 (or TDD (800) 952-8349 ) OR (800) 952-8349 / Fax: (833) 281-0905
Toll Free: (800) 743-8525
• Fax fill out this page/fax to (833) 281-0905 OR
o Mail to: CDSS State Hearings Division, PO Box 944243,
MS 21-37 Sacramento CA 94244-2430
o Email to: SHDCSU@DSS.ca.gov
HEARING REQUEST
1. My hearing issue involves (benefit program)
and LOS ANGELES County/Agency.
2. I want a hearing because:
3. Print name of person who needs a hearing: Birthdate:
4. Mailing Address: Phone number:
I want to get hearing notices from the State Hearing Division by email. Email Address:
5. Name/Signature: Date Signed
6. Interpreter: I want a free interpreter for the language or dialect.
7. Disability Accommodation for hearing? No Yes (explain):
8. Your Hearing will be scheduled by phone. If you want your hearing conducted by a different method, tell us how:
By Telephone By Video (you see judge on your phone/computer) In person at the county hearing site
I have no phone or internet access. I want to go and use the phone or video at hearing site for my hearing.
9. I need a faster scheduled hearing due to Denial of CalWORKs or CalFresh emergency benefits
Medical Emergency Eviction/homelessness Other (explain):
10. If you timely appeal before the action listed in the notice takes place, your aid may stay the same. For CalWORKs
(including Child Care) and CalFresh, if the county action was correct, you have to pay back any extra aid.
Check to have your aid lowered or stopped pending the hearing for: CalWORKs Childcare CalFresh
11. You can have a friend, relative, legal counsel or other person help with your hearing. If they have agreed:
NAME: Email:
Address: Phone:
12. To Get Help: These groups below may be able to give you legal advice or represent you at the hearing:
Legal Aid Foundation of Los Angeles (LAFLA) Welfare Rights Office
(800) 399-4529 4513 E. Compton Blvd.
Compton, CA 90221
(310) 603-3341
NA Back 9 (5/22) Required Form - No Substitute Permitted
0000000574391266
STATE OF CALIFORNIA
COUNTY OF LOS ANGELES
NOTICE OF ACTION HEALTH AND WELFARE AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL
Continuation Page SERVICES
NOTICE DATE: January 17, 2025
CASE NAME: Shylene Rodriguez
CASE NUMBER: L1B7494
WORKER NAME: Customer Service
WORKER ID: 19DP141V37
TELEPHONE NUMBER: (866) 613-3777
CUSTOMER ID: 4013188459
away.
Medi-Cal: This Notice of Action does not change or
stop Medi-Cal benefits. If there is any change in your
Medi-Cal benefits, you will receive another Notice of
Action. Keep your plastic Benefits Identification Card(s).
CF 388 (8/13) Page 2 of 2
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