FSS Santa Ana Regional Center STATE OF CALIFORNIA
COUNTY OF ORANGE HEALTH AND WELFARE AGENCY
BLDG B
CALIFORNIA DEPARTMENT OF SOCIAL
1928 S GRAND AVE
SERVICES
SANTA ANA, CA 92705-4902
NOTICE DATE: June 12, 2024
CASE NAME: Shavon Pauni
CASE NUMBER: 1BH8973
WORKER NAME: S. Vijeila
WORKER ID: 30FS0AIB0E
TELEPHONE NUMBER: (714) 435-7309
CUSTOMER ID: 4019108632
NOTICE OF ACTION
CALWORKS DENIAL
Shavon Pauni
1928 S GRAND AVE
BLDG B
SANTA ANA, CA 92705-4902
Questions? Ask your worker.
The County has denied your application for cash aid State Hearing: If you think this action is wrong, you
dated 05/29/2024. can ask for a hearing. The back page tells you how.
Your benefits may not be changed if you ask for a
Here's why: hearing before this action takes place.
We asked you to complete and return the paperwork we
need to make a decision about your application or re-
evaluation of eligibility for aid. You did not return your
completed eligibility determination paperwork.
Even though you cannot get cash aid, you may still be
able to get child support from your child's other parent.
For help getting child support, call Child Support
Services Department at 1-866-901-3212.
Rules: These rules apply; you may review them at your welfare office:
MPP 40-105.1, 40-115, 40-157.2, 40-157.3, 40-181(k), 40-181.2
NOA 290 Page 1 of 1
0000000499452255
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: Hearing Rights Office
“Submit Appeal without Account” to file without an account 1928 S. Grand Ave Building C
OR Santa Ana, CA 92705
(800) 952-8349 / Fax: (833) 281-0905
• Call toll free (800) 743-8525 (or TDD (800) 952-8349 ) OR 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 ORANGE 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:
Community Legal Aid SoCal
2101 N. Tustin Ave
Santa Ana , CA 92705
8008345001
NA Back 9 (5/22) Required Form - No Substitute Permitted
0000000499452255
