Los Angeles County
Department of Public Social Services
Resource Guide
2011
Public Social Services
Resource Guide
Table of Contents
General Information
• Contact Information Sheet
• Apply Online or Review Your Benefits Flyer
• Offices by Service Planning Area (SPA & Zip Code)
• Domestic Violence Referral Sheet
• Domestic Violence Brochure
• Toy Loan Program Fact Sheet
• Toy Loan Program Brochure
• Most Commonly Required Documents List for All Programs
CalWORKs
• CalWORKs Fact Sheet
• Applying for CalWORKs
• Homeless Program for Families with Eligible Children
• Rights, Responsibilities and Other Important Information Sample
Application for Cash Aid, CalFresh and Medi-Cal
• Statement of Fact for Cash Aid, CalFresh and Medi-Cal
General Relief
• General Relief Fact Sheet
• General Relief Restructuring Fact Sheet
• Veterans Projects
Cash Assistance Program for Immigrants (CAPI)
• Cash Assistance Program for Immigrants (CAPI) Fact Sheet
• Cash Assistance Program for Immigrants (CAPI) Brochure
CalFRESH
• CalFresh Program Fact Sheet
• Restaurant Meals Fact Sheet
• Restaurant Meals Participating Restaurants
• Sample Application for CalFresh Benefits
Medi-Cal
• Medi-Cal Program Quarterly Fact Sheet
• Sample Application for Medi-Cal
In-Home Supportive Services (IHSS)
• In-Home Supportive Services (IHSS) Fact Sheet
General Information
Contents
•
Contact Information Sheet
•
Apply Online or Review Your Benefits Flyer
•
Offices by Service Planning Areas (SPA & Zip Code)
•
Domestic Violence Referral Sheet
•
Domestic Violence Brochure
•
Toy Loan Program Fact Sheet
•
Toy Loan Program Brochure
•
Most Commonly Required Documents List for All Programs
Los Angeles County
Department of Public Social Services
PROGRAMS:
•
•
•
•
•
CALWORKS
CalFresh
MEDI-CAL
GENERAL RELIEF
REFUGEE SERVICES
•
•
•
•
•
IN-HOME SUPPORTIVE SERVICES
ADULT PROTECTIVE SERVICES
CASH ASSISTANCE PROGRAM FOR IMMIGRANTS
COMMUNITY SERVICES BLOCK GRANT PROGRAM
TOY LOAN
Contact Information
For help resolving individual constituent issues contact:
Anthony F. Morrone, Director of Governmental Inquiry and Response
Phone: (562) 908-6602
Fax: (562) 463-5396
Email: AnthonyFMorrone@dpss.lacounty.gov
For all other questions contact:
Bill Taylor, Director of Intergovernmental Relations
Phone: (562) 908-8517
Fax: (562) 699-3671
Email: BillTaylor@dpss.lacounty.gov
Did You Know
Now you can apply on-line or review
your benefits for the following
programs:
•
•
•
CalWORKs
CalFresh, or
Medi-Cal
Just visit us at
www.dpssbenefits.lacounty.gov.
COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC SOCIAL SERVICES
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 1 ANTELOPE VALLEY
DISTRICT / REGIONAL
OFFICES
Lancaster
349-B E. Ave. K-6
Lancaster, CA 93535
PROGRAMS ADMINISTERED
*CW/*GR/*FS/*MC
661-723-4001
Lancaster General
337 East Ave K-10
Lancaster, CA 93535
PROGRAMS ADMINISTERED
GR/GROW
661-723-4001
GAIN Region II
Palmdale Sub-Office
1050 E. Palmdale Blvd. Ste. 204
Palmdale, CA 93550
661-575-8901
DISTRICT / REGION NO.
ZIP CODES SERVED
91390, 93510, 93523,
93532, 93534, 93535,
93536, 93539, 93543,
93544, 93550, 93551,
93552, 93553, 93563,
93582, 93591,
34
91390, 93510, 93523,
93532, 93534, 93535,
93536, 93539, 93543,
93544, 93550, 93551,
93552, 93553, 93563,
93582, 93591,
67
Office served:
Santa Clarita – District #51
II
DIVISION
SUPERVISORIAL
DISTRICT
I
5
I
5
MAXIMUS
5
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 1 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 2 – SAN FERNANDO VALLEY
DISTRICT / REGIONAL
OFFICES
Glendale
4680 San Fernando Rd.
Glendale, CA 91204
PROGRAMS ADMINISTERED
CW/GR/FS/MC/REF
818-546-6460
East Valley
14545 Lanark St.
Panorama City, CA 91402
PROGRAMS ADMINISTERED
CW/FS/MC
818-901-4101
DISTRICT/ REGION NO.
ZIP CODES SERVED
90031, 90039, 90041,
90042, 90065, 91011,
91020, 91201, 91202,
91203, 91024, 91040,
91042, 91046, 91201,
91202, 91203, 91204,
91205, 91206, 91207,
91208, 91210, 91214,
91352, 91501, 91502,
91505, 91506, 91510,
91523, 91601, 91602,
02
91331, 91401, 91402,
91405, 91604, 91605,
91606, 91607,
11
DIVISION
SUPERVISORIAL
DISTRICT
I
5
I
3
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 2 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 2 – SAN FERNANDO VALLEY
DISTRICT / REGIONAL
OFFICES
San Fernando Branch
9188 Glenoaks Blvd.
Sun Valley, Ca 91352
PROGRAMS ADMINISTERED
GR/FS
818-394-3700
Santa Clarita Branch
27233 Camp Plenty Rd.
Canyon Country, CA 91351
PROGRAMS ADMINISTERED
CW/FS/MC
818-901-4371
West Valley
21415 Plummer St.
Chatsworth, CA 91311
PROGRAM ADMINISTERED
CW/FS/MC
818-718-5201
DISTRICT/ REGION NO.
ZIP CODES SERVED
91301, 91302, 91303,
91304, 91306, 91307,
91311, 91316, 91324,
91325, 91326, 91330,
91335, 91340, 91342,
91343, 91344, 91345,
91356, 91361, 91362,
91364, 91367, 91403,
91406, 91401, 91423,
91436, 93063, 91411,
32
91321, 91350, 91351,
91354, 91355, 91380,
91381, 91382, 91383,
91384, 91387, 91390,
51
91301, 91302, 91303,
91304, 91306, 91307,
91311, 91316, 91321,
91324, 91325, 91326,
91330, 91335, 91340,
91342, 91343, 91344,
91345, 91356, 91359,
91361, 91362, 91364,
91367, 91403, 91406,
91411, 91423, 91436,
82
DIVISION
SUPERVISORIAL
DISTRICT
I
3
I
5
I
3
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 3 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 2 – SAN FERNANDO VALLEY
DISTRICT / REGIONAL
OFFICES
DISTRICT/ REGION NO.
ZIP CODES SERVED
DIVISION
SUPERVISORIAL
DISTRICT
90
Countywide
I
3
Multi Year Funding
Northridge Medi-Cal
9451 Corbin Ave
Northridge, CA 91324
818-717-1508
94
Countywide
I
3
Northridge
Craig vs. Bonta
9451 Corbin Ave
Northridge, CA 91324
818-717-1507
96
Countywide
I
3
GAIN Region II
West San Fernando Valley
21415 Plummer St.
Chatsworth, CA 91311
818-718-4201
II
Office served:
Lancaster – District #34
MAXIMUS
3
Offices served:
East Valley – District #11
Glendale – District #02
MAXIMUS
5
Northridge Medi-Cal
9451 Corbin Ave
Northridge, CA 91324
818-717-1501
PROGRAM ADMINISTERED
MC/CRAIG vs BONITA
GAIN Region VII
East San Fernando Valley
3307 N. Glenoaks Ave
Burbank, CA 91504
818-729-8803
VII
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 4 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 3 SAN GABRIEL VALLEY
DISTRICT / REGIONAL
OFFICES
Pasadena
955 N. Lake Ave
Pasadena, CA 91104
PROGRAMS ADMINISTERED
CW/GR/FS/MC
626-791-6301
San Gabriel Valley
3352 Aerojet Ave
El Monte, CA 91731
PROGRAMS ADMINISTERED
CW/GR/FS/MC/CAPI/REF
626-569-3611
El Monte
3350 Aerojet Ave
El Monte, CA 91731
PROGRAMS ADMINISTERED
CW/FS/MC
626-569-3677
DISTRICT / REGION NO.
ZIP CODES SERVED
91001, 91101, 91103,
91104, 91105, 91106,
91107, 91108, 91011,
91016, 91006, 91023,
91030, 91125, 91126,
03
91007, 91731, 91732,
91733, 91744, 91754,
91770, 91776, 91780,
91801,
20
91006, 91007, 91016,
91748, 91010, 91706,
91731, 91732, 91733,
91744, 91745, 91746,
91754, 91770, 91776,
91780, 91789, 91801,
91803,
04
DIVISION
SUPERVISORIAL
DISTRICT
I
5
V
1
V
1
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 5 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 3 SAN GABRIEL VALLEY
DISTRICT / REGIONAL
OFFICES
Pomona
2040 W. Holt Ave
Pomona, CA 91768
PROGRAMS ADMINISTERED
CW/GR/FS/MC
909-397-7901
Medi-Cal Outreach (EAST)
3400 Aerojet Ave
El Monte, CA 91731
626-569-2901
PROGRAMS ADMINISTERED
FS/MC
Medi-Cal LTC Hospital
Certification
17171 E. Gale Ave,
City of Industry, CA 91745
626-854-4704
PROGRAMS ADMINISTERED
MC (IPW, CRAIG vs BONTA)
DISTRICT / REGION NO.
ZIP CODES SERVED
90631, 91010, 91702,
91706, 91709, 91710,
91711, 91722, 91723,
91724, 91733, 91740,
91741, 91744, 91745,
91746, 91748, 91750,
91763, 91765, 91766,
91767, 91768, 91773,
91789, 91790, 91791,
91792, 92621, 92821,
92823,
36
DIVISION
SUPERVISORIAL
DISTRICT
V
1
16
Countywide
II
1
80
Countywide
II
1
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 6 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 3 SAN GABRIEL VALLEY
DISTRICT / REGIONAL
OFFICES
Medi-Cal LTC IPW
17171 E. Gale Ave,
City of Industry, CA 91745
626-854-4704
Medi-Cal LTC Craig vs. Bonta
17171 E. Gale Ave,
City of Industry, CA 91745
626-854-4713
GAIN Region III
San Gabriel Valley
3216 Rosemead Blvd.
El Monte, CA 91731
626-927-2703
CAL-LEARN Branch
3216 Rosemead Blvd.
El Monte, CA 91731
909-392-3000
Pomona GAIN III
Pomona Sub-Office
2255 N. Garey Ave
Pomona, CA 91763
909-392-3000
DISTRICT / REGION NO.
ZIP CODES SERVED
DIVISION
SUPERVISORIAL
DISTRICT
81
Countywide
II
1
Countywide
II
1
V
1
V
1
V
1
97
Offices served:
El Monte – District #04
Pasadena – District #03
San Gabriel Valley –
District #20
III
Offices served:
El Monte – District #04
Lincoln Heights – District
#66
Pasadena – District #03
Pomona – District #36
San Gabriel Valley –
District #20
III
Offices served: Lincoln
Heights – District #66
Pomona – District #36
III
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 7 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 4 - METRO
DISTRICT / REGIONAL
OFFICES
Wilshire Special
2415 W. 6th St.
Los Angeles, CA 90057
PROGRAMS ADMINISTERED
GR/FS/MC/CAPI
213-738-4301
Metro North
2601 Wilshire Blvd.
Los Angeles, CA 90057
PROGRAMS ADMINISTERED
CW/FS/MC/REF
213-639-5401
Lincoln Heights
4077 N. Mission Rd.
Los Angeles, CA 90032
PROGRAMS ADMINISTERED
CW/FS/MC
323-342-8141
DISTRICT/ REGION NO.
ZIP CODES SERVED
90004, 90005, 90006,
90010, 90012, 90019,
90020, 90026, 90027,
90028, 90029, 90031,
90036, 90038, 90039,
90046, 90057, 90068,
90042, 90065, 91505,
91506, 91602, 91604,
91608,
10
90004, 90005, 90006,
90010, 90012, 90013,
90014, 90015, 90017,
90019, 90020, 90021,
90023, 90026, 90027,
90028, 90029, 90031,
90032, 90033, 90036,
90038, 90039, 90057,
90068, 90071,
38
90012, 90013, 90014,
90015, 90021, 90023,
90026, 90031, 90032,
90033, 90042, 90057,
90063, 90065,
66
DIVISION
SUPERVISORIAL
DISTRICT
II
2
II
2
III
2
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 8 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 5 - WEST
DISTRICT / REGIONAL
OFFICES
Rancho Park
11110 W. Pico Blvd.
Los Angeles, CA 90064
PROGRAMS ADMINISTERED
CW/GR/FS/MC
310-481-5300
DISTRICT / REGION NO.
ZIP CODES SERVED
90008, 90016, 90019,
90024, 90025, 90028,
90034, 90035, 90036,
90043, 90045, 90046,
90048, 90049, 90056,
90064, 90065, 90066,
90067, 90068, 90069,
90073, 90077, 90094,
90210, 90211, 90212,
90263, 90265, 90272,
90290, 90291, 90292,
90293, 90301, 90302,
90401, 90402, 90403,
90404, 90405, 91301,
91302, 91356, 91364,
91604,
60
DIVISION
SUPERVISORIAL
DISTRICT
II
2
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 9 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 6 - SOUTH
DISTRICT / REGIONAL
OFFICES
Metro Family
2615 S. Grand Ave
Los Angeles, CA 90007
PROGRAMS ADMINISTERED
CW/FS/MC
213-744-6601
Civic Center
813 E. Fourth Pl.
Los Angeles, CA 90013
PROGRAMS ADMINISTERED
GR/MC
213-974-0201
Exposition Park
3833 S. Vermont Ave 2nd Floor
Los Angeles, CA 90037
PROGRAMS ADMINISTERED
CW/MC
323-730-6101
Metro East
2855 E. Olympic Blvd.
Los Angeles, CA 90023
PROGRAMS ADMINISTERED
CW/GR
323-260-3501
DISTRICT / REGION NO.
ZIP CODES SERVED
90006, 90007, 90011,
90015, 90018, 90021,
90037, 90058,
13
90006, 90011, 90012,
90013, 90014, 90015,
90017, 90021, 90026,
90057, 90058, 90071,
14
90002, 90008, 90016,
90019, 90031, 90037,
90043, 90044, 90047,
90059, 90061, 90062,
12
90012, 90022, 90023,
90031, 90032, 90033,
90040, 90042, 90058,
90063, 90065, 90201,
90255, 90270, 90660,
91754,
15
DIVISION
SUPERVISORIAL
DISTRICT
III
2
II
2
II
2
III
2
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 10 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 6 - SOUTH
DISTRICT / REGIONAL
OFFICES
Florence
1740 E. Gage Ave
Los Angeles, CA 90001
PROGRAMS ADMINISTERED
CW/FS/MC
323-586-7001
Compton
211 E. Alondra Blvd.
Compton, CA 90220
PROGRAMS ADMINISTERED
CW/FS/MC
310-603-8401
South Central
10728 S. Central Ave
Los Angeles, CA 90059
PROGRAMS ADMINISTERED
CW/GR/FS/MC
323-563-4156
Metro Special
2707 S. Grand Ave
Los Angeles, CA 90007
PROGRAMS ADMINISTERED
GR/FS/MC
213-744-5601
DISTRICT / REGION NO.
ZIP CODES SERVED
DIVISION
SUPERVISORIAL
DISTRICT
III
2
17
90001, 90002, 90003,
90044,
26
90059, 90061, 90220,
90221, 90222, 90745,
90746, 90747,
IV
2
90002, 90003, 90059,
90061, 90220, 90222,
90262,
IV
2
III
2
27
90002, 90006, 90007,
90008, 90011, 90014,
90015, 90016, 90018,
90019, 90021, 90037,
90043, 90059, 90061,
90062, 90071, 90302,
70
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 11 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 6 - SOUTH
DISTRICT / REGIONAL
OFFICES
Medi-Cal Outreach (WEST)
2910 W. Beverly Blvd.
Los Angeles, CA 90057
213-351-5330
PROGRAMS ADMINISTERED
FS/MC
Medi-Cal Mail-In Application
2615 S. Grand Ave, 2nd floor
Los Angeles, CA 90007
213-741-8100
DISTRICT / REGION NO.
ZIP CODES SERVED
90004, 90011, 90012,
90015, 90021, 90022,
90026, 90027, 90029,
90033, 90037, 90044,
90230, 90262, 90291,
90301, 90303, 90304,
90405, 90502, 90505,
90640, 90710, 90712,
90723, 90732, 90744,
90806, 90813, 91007,
91103, 91105, 91204,
91331, 91340, 91343,
91345, 91355, 91356,
91402, 91404, 91405,
91505, 91605, 91606,
91722, 91731, 91733,
91740, 91766, 91767,
91773, 91790, 91801,
93534,
16
89
Countywide
DIVISION
SUPERVISORIAL
DISTRICT
II
2
II
2
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 12 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 6 - SOUTH
DISTRICT / REGIONAL
OFFICES
GAIN Region IV
Central County
3833 S. Vermont Ave 3rd floor
Los Angeles, CA 90037
323-730-6301
GAIN Region IV
Beverly Sub-Office
2910 W. Beverly Blvd.
Los Angeles, CA 90057
213-738-3154
DISTRICT / REGION NO.
ZIP CODES SERVED
Office served:
Exposition Park - District
#12
IV
Offices served:
Florence – District #17
Metro Family – District #13
Metro North – District #38
IV
DIVISION
SUPERVISORIAL
DISTRICT
V
2
V
2
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 13 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 7 – EAST
DISTRICT / REGIONAL
OFFICES
Belvedere
5445 Whittier Blvd.
Los Angeles, CA 90022
PROGRAMS ADMINISTERED
CW/FS/MC
323-727-4314
Cudahy
8130 S. Atlantic Ave
Cudahy, CA 90201
PROGRAMS ADMINISTERED
CW/FS/MC
323-560-5001
Norwalk
12727 Norwalk Blvd.
Norwalk, CA 90650
PROGRAMS ADMINISTERED
CW/FS/MC
562-807-7820
GAIN Region VI
Southeast County
5460 Bandini Blvd.
Bell, CA 90201
323-881-5312
DISTRICT / REGION NO.
ZIP CODES SERVED
90022, 90023, 90033,
90040, 90063, 90201,
90255, 90270, 90640,
90660,
05
90040, 90059, 90201,
90221, 90222, 90240,
90241, 90242, 90255,
90262, 90280, 90650,
90670, 90706, 90723,
06
90602, 90603, 90604,
90605, 90631, 90638,
90650, 90670, 90701,
90703, 90706,
40
Offices served:
Belvedere - District #05
Cudahy – District #06
Metro East – District #15
Norwalk – District #40
VI
DIVISION
SUPERVISORIAL
DISTRICT
III
1
III
1
III
4
V
1
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 14 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 7 – EAST
DISTRICT / REGIONAL
OFFICES
GAIN Region VI
Belvedere Sub-Office
5445 E. Whittier Blvd.
Los Angeles, CA 90022
323-260-3050
DISTRICT / REGION NO.
ZIP CODES SERVED
Offices served:
Belvedere - District #05
Cudahy – District #06
Metro East – District #15
Norwalk – District #40
VI
DIVISION
SUPERVISORIAL
DISTRICT
V
2
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 15 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 8 – SOUTH BAY / HARBOR
DISTRICT / REGIONAL
OFFICES
South Special
17600 “B” Santa Fe Ave
Rancho Dominguez, CA 90221
PROGRAMS ADMINISTERED
GR/FS
310-761-2030
DISTRICT / REGION NO.
ZIP CODES SERVED
90040, 90059, 90061,
90220, 90221, 90222,
90240, 90241, 90242,
90248, 90255, 90262,
90274, 90275, 90277,
90280, 90501, 90502,
90503, 90505, 90601,
90602, 90603, 90604,
90605, 90606, 90621,
90623, 90630, 90631,
90638, 90639, 90650,
90660, 90670, 90701,
90703, 90704, 90706,
90710, 90712, 90713,
90715, 90716, 90717,
90720, 90723, 90731,
90732, 90740, 90744,
90745, 90746, 90747,
90802, 90803, 90804,
90805, 90806, 90807,
90808, 90810, 90813,
90814, 90815, 90822,
90831, 90840, 90846,
07
DIVISION
SUPERVISORIAL
DISTRICT
IV
4
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 16 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 8 – SOUTH BAY / HARBOR
DISTRICT / REGIONAL
OFFICES
Southwest Special
1819 W. 120th St.
Los Angeles, CA 90047
PROGRAMS ADMINISTERED
GR/FS/MC
323-420-2918
Southwest Family
8300 S. Vermont Ave 3rd floor
Los Angeles, CA 90044
PROGRAMS ADMINISTERED
CW/FS/MC/REF
323-549-5674
DISTRICT / REGION NO.
ZIP CODES SERVED
90043, 90044,90045,
90245, 90047, 90201,
90230, 90249, 90250,
90260, 90266, 90277,
90278, 90303, 90304,
90504, 90505,
08
90001, 90002, 90003,
90037, 90043, 90044,
90230, 90043, 90044,
90045, 90047, 90056,
90059, 90061, 90094,
90222, 90230, 90245,
90247, 90248, 90249,
90250, 90254, 90255,
90260, 90261, 90262,
90266, 90277, 90278,
90280, 90292, 90293,
90301, 90302, 90303,
90304, 90305, 90501,
90502, 90503, 90504,
90505, 90506, 90710,
90745,
83
DIVISION
SUPERVISORIAL
DISTRICT
IV
2
IV
2
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 17 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 8 – SOUTH BAY / HARBOR
DISTRICT / REGIONAL
OFFICES
South Family
17600 “A” Santa Fe Ave
Rancho Dominguez, CA 90221
PROGRAMS ADMINISTERED
CW/FS/MC/REF
310-761-2000
Paramount
2961 E. Victoria St.
Rancho Dominguez, CA 90221
PROGRAMS ADMINISTERED
CW/FS/MC
310-603-5000
Hawthorne Medi-Cal Regional
12000 Hawthorne Blvd.
Hawthorne, CA 90250
310-349-47
PROGRAMS ADMINISTERED
MC
GAIN Region I
West County GAIN
5200 W. Century Blvd.
Los Angeles, CA 90045
310-665-7500
DISTRICT / REGION NO.
ZIP CODES SERVED
90220, 90221, 90704,
90712, 90720, 90731,
90740, 90744, 90745,
90802, 90803, 90804,
90806, 90807, 90708,
90810, 90813, 90814,
90815, 90822, 90831,
90840, 90846, 91760,
31
90712, 90713, 90715,
90716, 90723, 90805,
90806, 90807,
62
DIVISION
SUPERVISORIAL
DISTRICT
IV
2
IV
2
92
Countywide
II
2
I
Offices served:
Southwest Family – District
#83
West Los Angeles – District
#09
V
2
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 18 of 20
IAR/GPD – February 2011
DEPARMENT OF PUBLIC SOCIAL SERVICES
OFFICES BY SERVICE PLANNING AREA (SPA) & ZIP CODES
SPA 8 – SOUTH BAY / HARBOR
DISTRICT / REGIONAL
OFFICES
GAIN Region V
South County
2959 Victoria St.
Rancho Dominguez, CA 90221
310-603-8000
Harbor GAIN One Stop
1851 N. Gaffey St. Ste. F
San Pedro, CA 90731
310-519-6278/6279
DISTRICT / REGION NO.
ZIP CODES SERVED
DIVISION
SUPERVISORIAL
DISTRICT
V
2
V
2
Office served:
Compton – District #26
V
Offices served:
South Central – District #27
South Family – District #31
V
*CalWORKs (CW)
*General Relief (GR)
*Food Stamp (FS)
*Medi-Cal (MC)
*Refugee (REF)
*Cash Assistance for Immigrants (CAPI)
*Greater Avenue for Independence (GAIN)
Page 19 of 20
IAR/GPD – February 2011
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
DOMESTIC VIOLENCE REFERRAL SHEET
IF YOU ARE A VICTIM OF DOMESTIC VIOLENCE, THE FOLLOWING INFORMATION COULD SAVE YOUR LIFE
Violence in the family is a very serious problem. Many battered individuals suffer in silence and continue living with their abusers
for years. Without professional help, the problem rarely goes away. In fact, it usually gets worse, starting with insults and threats
and progressing to slaps, shoves and beatings. If the victim does NOT get professional help, the problem could end in serious
injury or death.
IN LOS ANGELES COUNTY, SERVICES ARE AVAILABLE TO HELP WITH THE FOLLOWING:
Emergency Residential Services
Law Enforcement
Individual/Group Counseling
Restraining Orders
Mental Health Services
Victims-Witness Assistance
Health & Medical Services
24-HOUR DOMESTIC VIOLENCE HOTLINE (800) 978-3600
IF YOU WANT TO TALK TO SOMEONE DIRECTLY ABOUT YOUR OPTIONS, YOU CAN CALL THE FOLLOWING
NUMBERS. UTILIZING THESE SERVICES DOES NOT REQUIRE YOU TO BE A SHELTER RESIDENT.
ANTELOPE VALLEY AND PALMDALE
CENTRAL AND WEST LOS ANGELES
Antelope Valley DV Council (Valley Oasis) ........... (800) 282-4808/
(661) 945-6736
Center for Pacific Asian Family..................... (800) 339-3940
Chicana Service Center ................................ (800) 548-2722
Children’s Institute International..................... (213) 385-5100
Community Counseling Services/Amanecer (213) 481-1792
Institute for Multicultural Counseling &........... (866) 604-6237/
Educational Services (IMCES)
(866) 444-6237
Prototypes...................................................... (323) 759-2466/
(323) 759-3094
SANTA CLARITA VALLEY
Child and Family Center ....................................... (661) 286-2562
SAN FERNANDO VALLEY
Domestic Abuse Center ........................................(818) 788-0117
Haven Hills............................................................(818) 887-6589
Institute for Multicultural Counseling & ..................(866) 604-6237/
Educational Services (IMCES)
(866) 444-6237
Jewish Family Service of LA .................................(818) 505-0900
San Fernando Valley Community Mental ..............(818) 838-1352
Health Center, Inc. (SFVCMHC)
Valley Women’s Center.........................................(800) 564-6600
YWCA of Glendale ................................................(818) 242-1106
SOUTH CENTRAL LOS ANGELES
1736 Family Crisis Center.............................. (213) 745-6434
Jenesse Center.............................................. (800) 479-7328
Legal Aid Foundation of LA............................ (213) 640-3911
Project: Peacemakers.................................... (323) 291-2525
SOUTH BAY
SAN GABRIEL VALLEY AND EAST LOS ANGELES
Bienvenidos Children’s Center, Inc. ......................(323) 726-9790
East L. A. Women’s Center...................................(800) 585-6231
Foothill Family Services ........................................(866) 304-4337
House of Ruth .......................................................(909) 988-5559
Santa Anita Family Services .................................(626) 359-9358
Southern California Alcohol & Drug.......................(562) 944-6144/
Program (SCADP)/Angel Step Inn ........................(323) 780-4357
YWCA of San Gabriel Valley.................................(626) 967-0658
SOUTH EAST LOS ANGELES
Cambodian Association ........................................(562) 424-0138
Helpline Youth Counseling ....................................(562) 484-3512
Human Services Association ................................(562) 806-5400
Interval House.......................................................(562) 594-4555
Legal Aid Foundation of LA...................................(213) 640-3911
National Council on Alcoholism/Drug ....................(562) 426-8262
Rainbow Services .................................................(310) 547-9343
South Asian Helpline & Referral Agency...............(562) 402-4132
Su Casa Domestic Abuse Network .......................(562) 402-4888
Women’s & Children’s Crisis Shelter.....................(562) 945-3939
Women’s Shelter of Long Beach...........................(562) 437-4663
PA 1914 - Rev. 09/15/08
1736 Family Crisis Center.............................. (310) 549-9910
Center for Pacific Asian Family...................... (800) 339-3940
Office of Samoan Affairs ................................ (310) 538-0555
LEGAL SERVICES
1736 Family Crisis Center.............................. (213) 745-6434/
(310) 549-9910
Antelope Valley DV Council (Valley Oasis) ... (800) 282-4808/
(661) 945-6736
Asian Pacific American Legal ........................ (213) 977-7500
Community Legal Services ............................ (800) 834-5001
Harriet Buhai Center for Family Law .............. (213) 388-7505
Institute for Multicultural Counseling &
(866) 604-6237/
Educational Services (IMCES)....................... (866) 444-6237
Jenesse Center.............................................. (800) 479-7328
Legal Aid Foundation of LA............................ (213) 640-3911
Los Angeles Center for Law & Justice ........... (323) 980-3500
Neighborhood Legal Services LA County ...... (800) 433-6251
Prototypes...................................................... (323) 759-2466
Su Casa Domestic Abuse Network ................ (562) 402-4888
YWCA of Glendale......................................... (818) 242-1106
What if I need help right away?
If someone is hurting you, or if you are afraid
and need help right away, call:
Domestic Violence Hotline
1-800-978-3600
If you are in immediate danger, please
call 911
How do I get CalWORKs
domestic violence help?
When you apply for cash aid, a worker will
review the available domestic violence services
with you.
You may ask for help at any time while you
are on or applying for cash aid; tell your
Eligibility or GAIN Services Worker right away.
We work with many agencies that can help
you, even when you are no longer receiving
cash aid because you used up your 60 months
of CalWORKs.
Department of Public Social Services
12860 Crossroads Parkway South
City of Industry, CA 91746
www.ladpss.gov
County of Los Angeles
Board of Supervisors
GLORIA MOLINA
First District
MARK RIDLEY-THOMAS
Second District
ZEV YAROSLAVSKY
Third District
DON KNABE
Fourth District
We are here to help you get on your feet and
keep your family safe.
Nothing
should stand between you and success!
CalWORKs Specialized
Supportive Services
for Victims of
Domestic Violence
MICHAEL D. ANTONOVICH
Fifth District
This brochure is available in Armenian, Cambodian,
Chinese, Korean, Russian, Spanish, Tagalog, and
Vietnamese. Please call 1-877-481-1044 for a copy.
CAL-3 Rev. 06/09
We Can Help You
Have The
Life You Want!
What is domestic violence?
Domestic abuse is any action or threat
against you by a spouse or ex-spouse,
boyfriend or ex-boyfriend, intimate partner.
How do I know if I’ve been
abused?
If you can identify any of these actions in your
life, you may be a victim of domestic violence.
We can help you!
We know that it can be hard enough to work
without having to worry about the abuse in
your home or family. You may be worried that
you will not be able to support yourself, if you
leave your abuser. You are not alone. It
is not your fault. DPSS can help.
What kind of help is available?
• Physical Abuse:
We have lots of help available to help you end
the abuse in your life and the lives of your
family. Some of these services include:
• Sexual Abuse: forcing you to have sex
• Emergency housing and safety
planning: help with leaving an abusive
hitting, punching,
shoving, throwing things, or using weapons.
against your will, or any sexual activity
involving a child.
• Emotional or Mental Abuse:
putting
you down, name calling, controlling what
you do, playing mind games, or threatening
to take away your children.
• Isolation: not letting you see your family
or friends; keeping you locked in the house.
• Economic Abuse:
controlling all the
money; keeping you from having or keeping
a job; not giving you money to buy things
you need.
• Stalking:
harassing, terrorizing, and
following you wherever you go; calling you
all the time.
How do I show abuse to get
DPSS’ help?
Your sworn statement is enough proof to
show abuse. You do not have to have any
police reports or other documents. Everything
you tell us will be kept secret to the extent of
the applicable law.
household, safety planning, free emergency
shelter, clothing, food, and health referrals.
What else should I know?
If you are working or are in GAIN or REP,
you may get extra money to help you pay
for childcare, transportation, tools, uniforms,
school books, and other supplies.
The County can waive some CalWORKs
program requirements for victims of
domestic violence, such as:
• Stop the 60-month clock on cash aid:
The 60-month time limit on cash aid can
be stopped or turned back.
• Waive out of GAIN: You can request to
waive the GAIN program requirements
and still get domestic violence help.
• Getting settled:
• Stop child support collections: You
can stop the County from going after the
father of your child for child support, if it is
dangerous for you or your child.
• Counseling:
• Waive the Maximum Family Grant rule:
If you are not getting cash for a child who
was born after you started receiving cash
aid, you can probably get your child’s
cash aid back.
help with transitional
housing, children’s activities, budgeting,
transportation, financial planning, and
setting and keeping schedules.
individual and group
counseling for adults and children, and
battered women’s support groups.
• Parenting classes:
child development
education, discipline, and developing
healthy parent-child relationships.
• Legal services: restraining orders, child
and spousal support, custody, visitation,
dependency court, property division, and
immigration issues.
What if I am not a U.S. citizen or
Legal Permanent Resident?
If you are not a U.S. citizen or legal
permanent resident and you or your child is
or was a victim of domestic violence, you
may be eligible to apply at the immigration
office to improve your immigration status so
that you can legally work or live in the
United States.
For more information, ask your Eligibility or
GAIN Services Worker for a referral, or call
any of the legal services offices for help and
advice.
TOY LOAN PROGRAM
FACT SHEET
BACKGROUND
In the summer of 1934, during the Great Depression, the manager of a dime store in
southwest Los Angeles noticed two young boys wandering around his store, and
discovered they were pocketing small toys and materials that could be used to construct
toys. The boys were apprehended and referred to the Probation Department. Probation
staff then spoke to the principal of the school they attended and found that the boys had
good records, but their families could not afford many toys. Together, the store manager,
school principal and Probation staff decided something must be done to prevent them from
becoming delinquents. From this, the idea of gathering toys and loaning them to children
was conceived.
The first Toy Loan Center opened May 6, 1935 in a garage near Manchester Park. The
basic ground rules were developed. Toys would be loaned on a weekly basis, and a record
would be kept of every toy borrowed. The children would be graded on the care of their
borrowed toy, receiving a satisfactory mark for returning their toy on time and in good
condition. After 20 good marks, s/he would attain the status of Honor Borrower, which
entitled the child to a gift from the Honor Cabinet. In addition, the Toy Loan Honor Code
was established to teach honesty, responsibility, courtesy, and integrity.
OVERVIEW
Individuals, groups and toy manufacturers donate toys and books to the Toy Loan
Program. Each Toy Loan Centers operates independently. The Toy Loan Centers are
located in parks, recreation facilities, children’s centers, housing projects and community
service buildings. Each center adheres to the basic tenets of the Toy Loan Program.
Currently, the Toy Loan Program supplies toys to over 50 centers throughout Los Angeles
County and is a resource for teachers and educators who borrow toys, books, and games
to enhance learning and stimulate communication. Over 35,000 children are served
annually by the various services offered by the program.
While the program depends on monetary, toy and book donations from the public and
private sectors, the County does provide other key supports such as a headquarters facility
and a delivery truck. Toys are sorted and sanitized at the headquarters, then distributed to
the various Toy Loan Centers as well as Domestic Violence and Homeless Shelters. At any
given time, there are approximately 45,000 toys in circulation.
ONGOING OBJECTIVES
Ź Continue to develop community partners and increase exposure
Ź Generate monetary and new toy donations
Ź Increase awareness of the Toy Loan Program
Ź Enhance support to existing Toy Loan sites
Ź Expand the number of Toy Loan sites
mbb 3/2011
ACCESSING HEALTH AND HUMAN SERVICES PROGRAMS
HEALTH
PROGRAM FEES/CO-PAYMENT
9
MENTAL HEALTH
(800) 854-7771
CHILD SUPPORT SERVICES
(323) 890-9800
WOMEN, INFANTS AND
CHILDREN (888) WIC-BABY
IN-HOME SUPPORTIVE
SERVICES (IHSS)
(888) 944-IHSS
GENERAL RELIEF
(877) 481-1044
FOOD STAMPS
(877) 597-4777
CASH ASSISTANCE PROGRAM
FOR IMMIGRANTS (CAPI)
(877) 481-1044
CALWORKS
(877) 481-1044
MEDICARE
(800) MEDICARE
MEDI-CAL
(877) 597-4777
HEALTHY FAMILIES
(888) 747-1222
HEALTHY KIDS
(888) 4LA-KIDS
CHILD HEALTH & DISABILITY
PREVENTION PROGRAM (CHDP)
(800) 993-2437
CALIFORNIA CHILDREN’S
SERVICES (CCS)
(800) 288-4584
MOST COMMONLY REQUESTED DOCUMENTS
OTHER
SERVICES
INCOME SUPPORT
9 9
Required Documents
Birth Certificate (for each applicant)
Resident Alien Card (If not a US
Citizen) or other residency documents
Proof of California Residency: Driver’s
License, State ID Card or current
letter mailed to you at your address
Social Security Card
9
Medicare Card or other health
insurance card
Marriage Certificate
9
9
9
9
9 9
9
9
9
9
Child/Spousal Support: child support
and/or spousal support award letter,
copies of check received or statement
from Child Support Services
Department for last month
Proof of Resources: all current bank
statements, property statements, auto
registrations, life and/or burial
insurance policies, life estate
agreement
Proof of Expenses/Proof of
Deductions: work clothing and
transportation costs, current taxes,
medical insurance, etc.
9
9
9
9
9 9
9
9
9
9
9 9
9
9
9
9
9 9
9
9
9
9
9 9
9
9
9
9
9
9
9
9
9
9
9 9
9
9
9 9
9
9
9
9
9
9
9
9
9
9 9
9
9 9
9
9
9
9
9
9
9
9
9
School Enrollment/Attendance Papers
If pregnant or applying for unborn
child, Proof of Pregnancy
Proof of Income
9
9
9
9
9
9
9
9
9
9
9
9
PROOF OF INCOME & EXPENSES: If you have any of the documents listed in the two sections below bring them with you.
INCOME
If employed: copy of most recent pay stub with name of employer and
person who worked OR
Signed statement from employer with gross monthly income stated and
dates received
If self-employed: copy of last year’s federal income tax return (with
Schedule C) or last 3 months’ profit and loss statements
If disabled or retired: copies of award letters or bank statements showing
direct deposits
If currently receiving benefits: proof of the amount (i.e. unemployment
insurance, Social Security, workers compensation, veteran income checks or
disability insurance)
If income from a loan: copy of loan papers with the name of person who is
receiving the loan, the amount and current balance
EXPENSES
For care of a child or disabled adult: receipts, bill or cancelled checks that show name
of the person cared for, cost of care, and the name of the person who paid for the
care
For housing and utility costs: receipts or bills that show user’s name and amount due
For medical costs for the disabled or persons age 60 or older: bills, receipts, medical
insurance premiums, or cancelled checks that show the name of the person who
incurred the expense, cost and name of person who paid for the care
For court ordered support payments: receipts, cancelled checks or money orders that
show who the payment was for and the amount paid
For self employed: signed receipts, cancelled checks or statements from whom you
get your supplies
This form is available at http://www.ladpss.org/dpss/mcrd_forms.cfm
rev. 5/10
DOCUMENT
WHERE TO ACCESS THE
MOST COMMONLY REQUESTED DOCUMENTS
DEPARTMENT
PHONE NO. & WEBSITE
Resident Alien Cards or other
Residency Documents
Proof of California Residency:
Driver’s License, State ID
Social Security Card
Registrar Recorder/County Clerk
Department Headquarters
12400 Imperial Highway
Norwalk, CA 90650
U.S. Citizenship and Immigration
Services
California Department of Motor Vehicles
(DMV)
Social Security Administration (SSA)
Copies of Income Tax Return
Internal Revenue Service (IRS)
Child Support Documents
Child Support Services Department
Birth, Death, and Marriage
Certificates
1-800-201-8999
www.lavote.net
1-800-375-5283
www.uscis.gov
1-800-777-0133
www.dmv.ca.gov
1-800-772-1213
www.ssa.gov
1-800-829-1040
www.irs.gov
1-800-615-8858 or
(323) 890-9800 in LA County
www.childsupport.co.la.ca.us
KEY COUNTY OF LOS ANGELES HEALTH & HUMAN SERVICES PROGRAMS
ƒ CALIFORNIA CHILDREN’S SERVICES (CCS)
(800) 288-4584
www.dhcs.ca.gov/services/ccs
ƒ CHILD HEALTH & DISABILITY PREVENTION PROGRAM (CHDP)
(800) 993-2437
LONG BEACH: (562) 570-4226
PASADENA: (626) 744-6016
www.dhcs.ca.gov/services/chdp
ƒ IN-HOME SUPPORTIVE SERVICES
(888) 944-IHSS (944-4477)
www.ladpss.org/dpss/ihss
ƒ WOMEN, INFANTS AND CHILDREN
(888) 942-2229
(888) 942-9675
www.wicworks.ca.gov
ƒ CHILD SUPPORT SERVICES
ƒ HEALTHY KIDS
(888) 4LA-KIDS (452-5437)
www.chigla.org
ƒ HEALTHY FAMILIES
(888) 747-1222
www.healthyfamilies.ca.gov
ƒ MEDI-CAL
(877) 597-4777
www.dhcs.ca.gov/services/medi-cal
www.ladpss.org/new_portal/dpss_medical.cfm
(800) 615-8858 OR (323) 890-9800
http://childsupport.co.la.ca.us
ƒ MENTAL HEALTH
(800) 854-7771
http://dmh.lacounty.gov
OTHER NUMBERS OF INTEREST
ƒ 211 LA COUNTY
www.211lacounty.org
ƒ MEDICARE
ƒ ACCESS
FOR
ƒ CALWORKS
ƒ COUNTY
OF
(800) MEDICARE (633-4227)
www.medicare.gov
(877) 481-1044
www.ladpss.org/dpss/calworks
ƒ CASH ASSISTANCE PROGRAM FOR IMMIGRANTS (CAPI)
(877) 481-1044
www.ladpss.org/dpss/capi
ƒ FOOD STAMPS
(877) 597-4777
www.ladpss.org/dpss/food_stamps
ƒ GENERAL RELIEF
(877) 481-1044
www.ladpss.org/dpss/general_relief
INFANTS AND MOTHERS
(800) 433-2611
www.aim.ca.gov
LOS ANGELES JOB HOTLINE
(800) 970-5478
http://dhr.lacounty.info
ƒ LOW INCOME HOUSING INFORMATION
(800) 731-HOME (731-4663)
www.hacola.org
ƒ LACOUNTYHELPS!
www.lacountyhelps.org
ƒ SUPPLEMENTAL SECURITY INCOME
(800) 772-1213
www.socialsecurity.gov/ssi
CalWORKs
The CalWORKs is a time-limited cash aid program for children and families
designed to provide temporary assistance for basic needs (shelter, food, and
clothing). The program establishes work requirements and provides a broad
spectrum
of
Welfare-to-Work (WtW) services that help remove barriers to employment
and help families become economically self-sufficient.
Contents
•
•
•
•
•
CalWORKs Fact Sheet
Applying for CalWORKs
Homeless Program for Families with Eligible Children
Rights, Responsibilities and Other Important Information Sample
Application for Cash Aid, CalFresh and Medi-Cal
Statement of Fact for Cash Aid, CalFresh and Medi-Cal
Additional information may be accessed through the websites listed below:
• www.ladpss.org
Department’s main website listing all departmental information, including
program-specific information, office locations and the community event’s
calendar.
•
www.lacountyhelps.org
Informs citizens of Los Angeles County of state and federal benefits
assistance. This website provides additional information about programs
available after completing a short online survey.
•
www.211LACounty.org
Provides information about human social services in the Los Angeles
County.
County of Los Angeles
Department of Public Social Services
Philip L. Browning,
Director
CALIFORNIA WORK OPPORTUNITY AND
RESPONSIBILITY TO KIDS (CalWORKs) PROGRAM
Fact Sheet
Requirements
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Deprivation must exist (unemployment, deceased, disabled or absent).
At application, the principle wage earner must not be employed more than 100 hours a month.
Once the case is approved, the principle wage earner may be employed over 100 hours per
month as long as there is financial eligibility.
Children must live with a parent or relative caretaker.
Children must be under 18 years of age or 18 years of age enrolled as a full-time student in high
school or a vocational/technical training program and:
• Expected to graduate/complete the training program before reaching age 19; or
• Not expected to graduate/complete the training before age 19 due to a disability.
Intend to reside in California.
Must be a U.S. Citizen, naturalized or lawful permanent immigrant.
Provide a Social Security Number (SSN).
Income Limits
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Gross income may include income from earnings, disability benefits, child/spousal support
payments, veterans, etc.
For Intake, the gross income (for earnings, deduct $90 from the gross income) must be under
Minimum Basic Standard of Adequate Care (MBSAC) for the family. If income is below
MBSAC, apply the $225/50% disregards to income from earnings or $225 disregard for specific
disability-based income. The remainder must be under the Maximum Aid Payment (MAP) for
the family.
For approved cases, the gross income (apply $225 plus 50% disregards to income from
earnings or $225 disregard for specific disability-based income) must be under MAP for the
family.
Property/Resource Limits
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$2,000 (cash on hand, savings, stocks, etc.).
$3,000 if someone in the Assistance Unit (AU) is 60 years or older.
Exempt Property/Resources may include:
• The home the applicant/participant resides in.
• Personal/household items (furniture, appliances, etc.)
• Tools used for trade/profession.
• Participants may hold special restricted savings accounts to be used for education/training,
business or to purchase a home.
• For the first car, deduct $4,650 from the Fair Market Value (FMV), the remainder is counted
towards the property limit.
-2-
Other Requirements
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Child Support cooperation.
Immunizations for all children under the age of 6 who are not enrolled in school.
Provide proof of regular school attendance for all school-age children.
Work and training is required for most parents.
Quarterly Eligibility/Status Reporting.
Participants who self-identify as either a fleeing/drug felon are ineligible for CalWORKs.
Maximum Family Grant (MFG) requires that cash benefits will not increase even if additional
children are born. There are exceptions to this rule, but in general, the MFG rule is invoked
when a child is born into an AU that has received CalWORKs for at least 10 months
immediately prior to the child’s birth. The MFG child is eligible to receive Food Stamps and
Medi-Cal benefits.
Time Limits
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Most adults can only receive 60 months of cash aid.
Exemptions may be applied to 20% of the CalWORKs population and to participants receiving
domestic violence services.
The months do not need to be consecutive.
Includes months in which aid was received from other states (after 1/1/98).
Aid received prior to January 1, 1998, is not counted.
MAP Levels
Exempt MAP (higher) is limited to families where each adult relative caretaker in the Assistance
Unit (AU) receives or meets one of the following conditions:
• SSI/SSP benefits;
• IHSS benefits;
• SDI, Temporary Workers’ Compensation (TWC), Temporary Disability (TDI) benefits; or
• Is a non-needy, non-parent caretaker relative who is not included in the AU.
Additional Benefits
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For Intake, a pregnant woman with no other children must be in her last trimester before she is
eligible for assistance. An applicant with other eligible children may receive the pregnancy
allowance from the date of application through the month of birth.
For Approved, the participant may receive the pregnancy allowance from the first of the month
in which medical verification is received through the month of birth.
The first $50 from a child support payment is disregarded.
A special need allowance may be allowed for diets, transportation, etc.
A special non-recurring allowance may be given to replace clothing, household equipment if the
loss was due to a sudden and unusual circumstance (fire, flood, earthquake, etc.).
There are a variety of homeless assistance programs available.
A Diversion payment may be available for applicants who need help to meet a one-time-only
expense that prevents current employment or who is likely to find employment in a short period
of time.
For detailed information, visit the DPSS website at http://www.ladpss.org/
CW Division Rev. 01/09
Attachment I
Applying for CalWORKs?
CalWORKs provides temporary financial aid and employment-focused services to families with
children. Families must meet basic eligibility rules to qualify for CalWORKs. For families with income
and property, the amounts must be below the State limits. For example, if your car is worth more than
$4,650, the amount over $4,650 will count towards the property limit. Your family size decides the aid
amount. For example, the monthly CalWORKs aid for two people without income is $561.
Basic Eligibility Rules:
Income Limits:
Based on your family size, your total gross income is at or below the income limit listed in the chart
below. (Note: If you are a relative caring for a child who is not your own, your income does not count
if you want aid for the child only.)
Family Size
2009-2010 Income Limits
Monthly Gross
Income Limit
Family Size
(add $90 for each
employed person)
1
2
3
4
5
$540
$885
$1,097
$1,302
$1,486
Monthly Gross
Income Limit
(add $90 for each
employed person)
6
7
8
9
10
$1,670
$1,835
$1,999
$2,168
$2,353
* Add $20 for each extra person
Resource/Property Limits:
Other Eligibility Rules:
Your family’s total resources/property (i.e.,
bank accounts, cash on hand, savings bonds,
other real property) is $2,000 or less ($3,000 if
the parent/caretaker is age 60 or older).
ƒ Your household must include a pregnant
woman or a child where at least one member
is either a U.S. citizen or a legal immigrant.
Some resources that do not count include:
ƒ A home, if family lives in it
ƒ Personal and household items
ƒ Motor vehicle valued at $4,650 or less
may be excluded
ƒ If both parents are in the home, one parent
must either be disabled or have worked less
than 100 hours in the four weeks before
applying for aid.
ƒ Other eligibility rules apply.
Even if your family is not eligible to CalWORKs, your family may apply and still be
eligible to receive Food Stamps and/or Medi-Cal.
You may apply for Food Stamps and/or Medi-Cal in-person or by mail. Please see the
District Customer Service Representative for an application and/or more information.
Please visit our website at www.ladpss.org for more information on County services and programs.
CalWORKs INFORMATION SHEET 02/10
DEPARTMENT OF PUBLIC SOCIAL SERVICES
HOMELESS PROGRAMS FOR FAMILIES
Temporary Homeless Assistance (HA) – A homeless CalWORKs family can receive from $65 up to $125
per night (depending on the Assistance Unit’s size) for temporary shelter in a hotel/motel or
commercial establishment for up to 16 consecutive days (receipts are required to verify the
hotel/motel expense). Payments are issued in increments of no more than seven days at a time.
Permanent Homeless Assistance (HA) – A homeless CalWORKs family can receive help with move-in
costs, such as last month’s rent, deposits, utility deposits, and cleaning fees, provided the family’s rent
costs do not exceed 80% of the total monthly household income.
HA Permanent Arrearage Payment – CalWORKs families who have received an eviction notice or
notice to pay or quit due to non-payment of rent because of a financial hardship, not a
lease/contract violation, may qualify to pay for up to two months in rent arrearages to prevent
eviction. The family’s monthly rent costs cannot exceed 80% of the total monthly household income.
Proof of financial hardship is required.
Moving Assistance (MA) for CalWORKs Families – CalWORKs families who are experiencing a financial
crisis, including homelessness or at-risk of homelessness (already received eviction notice or 3-day
notice to pay or quit) may receive funds to secure permanent housing. If the family is homeless, they
must have exhausted all other means of assistance including HA. If the family is not homeless, they
must demonstrate that they are experiencing a financial hardship that could result in homelessness.
Proof of financial hardship is required. MA provides funds for the last month’s rent, security deposits,
utility turn-on fees, and moving expenses (e.g., truck rental). The program also provides up to $405 for
a stove and/or refrigerator. A family may receive up to $2,000 in MA and MA can be used in
conjunction with permanent HA to purchase a stove/refrigerator or for truck rental only.
NOTE:
Effective October 1, 2010, this program is available only to families meeting their Welfareto-Work requirements (participating in the GAIN Program).
Emergency Assistance to Prevent Eviction (EAPE) - Helps CalWORKs families who are at risk of losing
their housing because of non-payment of rent due to a financial hardship (not for any other
lease/contract violations) to prevent eviction and remain in permanent housing. EAPE provides up
to $2,000 to help pay rent and/or utilities for up to two months in arrears to assist the family in
maintaining permanent housing. This program can be used “as needed” until the $2,000 limit has
been exhausted.
NOTE:
Effective October 1, 2010, this program is available only to families meeting their Welfareto-Work requirements (participating in the GAIN Program).
Housing Relocation Program - Provides a one-time-only relocation subsidy of up to $1,500 to eligible
CalWORKs participants working 20 hours or more per week or with a documented offer of
employment for 20 hours or more per week. In addition, the family may receive up to $405 to
purchase a stove/refrigerator if needed for the new place.
4-Month Rental Assistance (RA) Program for CalWORKs Families– Assists homeless CalWORKs Welfareto-Work families to remain in non-subsidized permanent housing by providing a short-term rental
subsidy. Families receiving HA Permanent Housing and/or MA may qualify for a rental subsidy of up
to $300 per family (based on the family size) for up to four consecutive months.
NOTE:
All of the above homeless programs are once-in-a-lifetime. Some programs may be
accessed again when certain exceptions are met (domestic violence, mental or physical
illness, prior residence becoming uninhabitable, or natural disaster).
HOMELESS SERVICES FOR FAMILIES
Homeless CalWORKs Families Project - This joint effort between DPSS, the Department of Mental
Health (DMH), and the Los Angeles Homeless Services Authority (LAHSA) connects homeless families
in which a parent has mental health problems with public benefits, including employment/supportive
services, and assists them in finding permanent housing. It also provides emergency housing
vouchers, transportation, and crisis intervention.
Emergency Shelter & Services – DPSS contracts with LAHSA to provide emergency housing and
shelter services for homeless CalWORKs Welfare-to-Work families. Eligible families may receive up to
120 days of emergency shelter.
The program also includes limited case management,
transportation, and assistance in finding permanent housing or moving the family into transitional
housing.
Homeless Case Management – Homeless Case Managers (HCMs) work with CalWORKs homeless
families to facilitate their access to services, initiate referrals, and move the family into permanent
housing. The services include crisis intervention, short-term stabilization, needs assessment,
employment services, advocacy, and an individualized housing plan.
Skid Row Access Team (SRAT) – A team comprised of staff from Departments of Public Social Services
(DPSS), Mental Health (DMH), Public Health (DPH) and Department of Children and Family Services
(DCFS) identifies homeless families in the Skid Row area and connects them with available benefits
and services.
District Access Team – CalWORKs district offices have designated Eligibility workers (EWs) from their
Housing Resources Unit as part of their access teams to connect families with CalWORKs and eligible
homeless programs and services. The EWs are placed on an “on-call” basis to accept potential
applications from access centers and shelters. If the family cannot travel to the district office and the
shelter/access center cannot provide transportation, the Access Team will travel to the
shelter/access center to assist the family as needed.
Homeless Programs & Services Fact Sheet - 10-14-2010.doc
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DEPARTMENT OF HEALTH SERVICES
RIGHTS, RESPONSIBILITIES AND OTHER IMPORTANT INFORMATION
For the Cash Aid and Food Stamp Programs, and/or Medi-Cal/34-County Medical Services Program (CMSP)
These pages give you your rights and responsibilities and other important information. The county needs your facts to see if
you are eligible for cash aid, food stamps, and/or Medi-Cal/34-County CMSP and to figure how much you will get if you are
eligible. If you need more information or have questions, ask your worker.
Cash Aid includes California Work Opportunity and Responsibility to Kids (CalWORKs) and Refugee Cash Assistance (RCA).
Medi-Cal/34-County CMSP includes Full Medi-Cal/34-County CMSP benefits and Restricted Medi-Cal/34-County CMSP
emergency and pregnancy related care only.
YOUR RIGHTS
1.
To be treated equally without regard to race, color,
national origin, religion, political affiliation, marital status,
sex, disability, or age. You may file a complaint of
discrimination if you feel you have been discriminated
against by first speaking with your county's designated
civil rights representative or by writing to the
State Civil Rights Bureau
744 P Street, MS 15-70
P.O. Box 944243
Sacramento, CA 94244-2430
or by calling toll free 1-866-741-6241 or for the hearing
impaired TDD 1-800-688-4486.
2.
3.
4.
5.
To get help applying for or continuing to receive cash
aid, benefits and services if you have a disability. If you
need help because of a disability, tell the county.
To ask for help to complete your application for any other
cash aid, food stamp, or Medi-Cal/34-County CMSP
form.
To ask for an interpreter and to have forms and notices
translated if you don't speak or read English.
To be treated with courtesy, consideration and respect.
14. To choose prepaid health plan (PHP), fee-for-service
coverage (if available), Health Maintenance
Organization (HMO), or Medi-Cal when eligible for
Medi-Cal.
15. To ask to have your Food Stamp I.D. or Medi-Cal
Benefits Identification Card (BIC), or EBT card replaced
if lost in the mail, damaged, or destroyed. The county
will tell you if you are eligible.
16. To ask for extra money if your income drops or stops
(cash aid only).
17. To ask for payments for clothing, housing or essential
household items which are lost, damaged or otherwise
unavailable due to sudden and unusual circumstances
(cash aid only).
18. To ask for payments for ongoing special needs like a
special diet, transportation for ongoing medical care,
special laundry service, telephone for the hard of
hearing, high utility bills, etc. (cash aid only).
19. To be notified in writing when your application is
approved, denied, or when your benefits change or stop.
20. To have your records kept confidential by the county and
state, unless you are getting cash aid or food stamps
and there is a felony arrest warrant issued for you, or as
otherwise provided by law.
6.
To be interviewed promptly by the county when you
apply and to have your eligibility determined within 45
days for cash aid and Medi-Cal/34-County CMSP (or 90
days for Medi-Cal if a determination of disability is
required) and within 30 days for food stamps.
21. To talk with someone from the county or file a formal
complaint with the state if you don’t agree with an action
taken by the county. You may call toll-free at
1-800-952-5253 or for the hearing impaired, TDD
1-800-952-8349.
7.
To discuss your case with the county and to review your
case yourself when you request to do so.
22. To ask for a State Hearing within 90 days of the county’s
action for cash aid, food stamps and Medi-Cal.
8.
To be told the rules for getting cash aid right away. If we
think you might be eligible, you will get an interview
within one day.
23. To ask for a State Hearing, you can write to your county
or call the State toll-free telephone numbers listed in
Item 21 above.
9.
To be told the rules for getting food stamps right away. If
we think you might be eligible to get them right away,
you will get an interview immediately and get food
stamps within three days.
24. To appeal all 34-County CMSP eligibility issues, you can
only write to your county.
10. To get Medi-Cal/34-County CMSP as soon as possible if
you have a medical emergency or are pregnant, if
eligible.
11. To continue getting cash aid and Medi-Cal benefits
without a break if you move from one county to another
if you stay eligible.
12. To be told the rules for retroactive Medi-Cal eligibility.
13. To lower any current Share of Cost you may have by
giving the county past unpaid medical bills you still owe,
when you apply for Medi-Cal/34-County CMSP.
25. To be represented at a State hearing by yourself, a
household member, friend, attorney, or other person of
your choice. NOTE: You may get free legal help at your
local legal aid office or welfare rights group.
26. To have reasonable access to a location where you can
withdraw your cash benefits with no or minimal costs.
27. To get a brochure that will tell you how to use your EBT
card and how to get your cash benefits at no or minimal
costs.
28. To get a list of surcharge-free ATMs and stores where
you can get cash back at no cost when you make a
purchase with your EBT card. You can get a list of these
locations from your county worker or at www.ebt.ca.gov.
SAWS 2A QR (11/10) (RIGHTS, RESPONSIBILITIES) CA 2/DFA 285-A2/MC210 (REQUIRED FORM - NO SUBSTITUTE PERMITTED)
Page 1 of 10
Page 2 of 10
YOUR RESPONSIBILITIES
Citizenship/Immigration Status
To sign under penalty of perjury that each member applying
for cash aid and food stamps is a U.S. citizen, U.S. national or
has lawful immigration status. Information you give us on
immigration status will be checked with the U.S. Citizenship and
Immigration Services (USCIS). Information we get from USCIS
may affect your eligibility. (Manual of Policies and Procedures
Section 42-433).
If you want Medi-Cal/34-County CMSP, you must provide a
declaration of citizenship/immigration status under penalty of
perjury. If you say you are an noncitizen with lawful permanent
residence (LPR) in the U.S., an amnesty alien with a valid and
current I-688 or an noncitizen permanently residing under color
of law (PRUCOL), your immigration status will be checked with
the USCIS. The information the USCIS receives to verify the
immigration status of the applicant can only be used to
determine Medi-Cal/34-County CMSP eligibility, and cannot be
used for immigration enforcement unless you are committing
fraud.
Fingerprint/Photo Imaging
All eligible adult household members for cash aid and/or
food stamps must be fingerprint/photo imaged. If anyone who is
required to cooperate with these rules does not get
fingerprint/photo imaged, no benefits will be issued to the entire
household. (Manual of Policies and Procedures Section
40-105.3).
The fingerprint/photo images are confidential and can only
be used to prevent or prosecute welfare fraud.
Social Security Number (SSN) Rules
The SSNs will be used in a computer match to check
income and resources with records from tax, welfare,
employment, the Social Security Administration and other
agencies. Differences may be checked out with employers,
banks or others. Making false statements or failing to report all
facts or situations which affect eligibility and aid payments for
cash aid, food stamp and Medi-Cal/34-County CMSP may result
in repayment of benefits and/or criminal or civil action.
Cash Aid and Food Stamps: You must give us the SSN for
each applicant or recipient of cash aid and/or food stamps. If
you refuse to give us either a SSN or proof of application for a
SSN, you will not be able to get cash aid or food stamps. For
cash aid, you must give proof of application for a SSN within 30
days of application for cash aid and give the SSN to the county
when you get it. (Manual of Policies and Procedures Section
40-105.2).
Each applicant for Medi-Cal/34-County CMSP, who says
he/she is a U.S. citizen, a U.S. national, LPR in the U.S., an
amnesty alien with a valid and current I-688, or PRUCOL, will be
disqualified from getting Medi-Cal if he/she refuses to give either
a SSN or proof of application for a SSN. Any noncitizen who
does not have a SSN and who is not an amnesty alien with a
valid and current I-688 or a LPR or PRUCOL, can still get
restricted Medi-Cal/34-County CMSP if he/she meets all
eligibility rules, including California residency.
CASH AID AND MEDI-CAL
To apply for any benefits or income anyone is eligible to get,
such as: Unemployment (UIB) or Disability benefits, Veterans
benefits, Social Security or Medicare, etc.
Child/Spousal and Medical Support
To cooperate with the county and the Local Child Support
Agency to:
•
identify and locate any absent parent in your case;
•
tell the county or the Local Child Support Agency anytime
you get information about the absent parent, such as place
of residence or work location;
•
determine the paternity of any child in your case when
needed;
•
obtain medical support money from any absent parent and,
if you get cash aid, obtain child support money;
•
give the Local Child Support Agency any medical support
money and, any child/spousal support money you get;
•
tell the county about medical coverage or money for
medical services paid by the absent parent.
Your cash aid will be lowered if you don’t cooperate. (Manual of
Policies and Procedures Sections 40-157.212; 40-157.213).
MEDI-CAL
Benefits Identification Card (BIC)
•
To sign your BIC when you get it and to use it only to get
necessary health care services.
•
To never throw your BIC away (unless we give you a new
BIC). You need to keep your BIC even if you stop getting
Medi-Cal. You can use the same BIC if you get cash aid or
Medi-Cal again.
•
To take the BIC to your medical provider when you or a
family member is sick or has an appointment.
•
To take the BIC to the medical provider who treated you or
your family member(s) in an emergency situation as soon
as possible after the emergency.
Health Care Coverage/Insurance
•
To tell the county and any health care provider of any health
care coverage/insurance you or a family member have.
•
To retain any health insurance available to you and your
family at no or reasonable cost.
•
To use any prepaid health plans, health maintenance
organization or health care insurance plans you have
before using Medi-Cal/34-County CMSP, unless the plan
does not offer the medical service needed. You need to
use them because Medi-Cal will not pay for any service
paid for and/or provided by these medical insurance plans.
•
To enroll and stay enrolled in an employment-related group
health plan when Medi-Cal approves payment of plan
premiums by the State of California.
Verification(s)
To give proof to support your eligibility. If you can't get
proof, you will need to give the name of some other person or
agency we may contact to get the proof. We will help you get
proof when you can't get it. (Manual of Policies and Procedures
Sections 40-105.1; 40-157.212; 40-157.213)
Cooperation
To cooperate with county, state and federal staff. For cash
aid, a county worker can come to your home at an arranged
time to check out your facts, including seeing each family
member. You may not get benefits or your benefits may be
stopped if you don't cooperate.
SAWS 2A QR (11/10) (RIGHTS, RESPONSIBILITIES) CA 2/DFA 285-A2/MC210 (REQUIRED FORM - NO SUBSTITUTE PERMITTED)
YOUR REPORTING RESPONSIBILITIES
You must report certain information to the county. If
you’re not sure how to report, what to report, or what proof
we need, ask your worker. If you get food stamps, your
worker will tell you if you are a quarterly or change reporting
household. If you get Medi-Cal/34-County CMSP, the
county will tell you when you must report. (Manual of
Policies and Procedures Section 40-181).
HOW YOU MUST REPORT
For Cash Aid and Food Stamp Quarterly Reporting, you
must turn in a Quarterly Eligibility Report (QR 7) by the fifth
day of the month following your report months and report all
required changes to the County within 10 days.
For Food Stamp Change Reporting, you must report all
changes within 10 days:
•
•
by mail, telephone, or in person at the County Food
Stamp office; OR
on a DFA 377.5, Food Stamp Household Change
Report
For Medi-Cal, you must report all changes within 10 days
AND turn in a complete Status Report by the 5th of the
month when the county sends or gives it to you.
WHEN YOU MUST REPORT
For Cash Aid and Food Stamp Quarterly Reporting
Quarterly reporting rules say that you must report things at
certain times. You will be assigned a “report month” for
each quarter (three month period). This will be the second
month of each quarter. For example, if your quarter is
January, February and March, February would be your
“report month” and your report would be due by the 5th day
of March. The report is always due by the 5th day of the
month following your “report month” and will be considered
late if not received by the 11th day of the month. If your
Quarterly Eligibility Report (QR 7) is late you will have to
pay back any Cash Aid or Food Stamps that you were not
supposed to get. You will have to report gross income,
changes in the number of people in your household,
property bought or sold by people in your household and
other information for that report month as well as any
changes in your gross income that you expect to happen in
the next quarter. If you do not turn in a completed
Quarterly Eligibility Report (QR 7) by the end of the first
working day of the month after the month your report is
due, your household’s benefits will be stopped.
What you must report on the Quarterly Report:
1. Earned Income: All gross earned income received by
you or anyone in your household in the report month.
This includes wages; tips; vacation pay; cash bonuses;
money from self employment or from a training
program; also any income in kind in exchange for work,
such as free rent, clothing or food.
2. Unearned or Disability Based Income: All other
income received by you or anyone in your household in
the report month. This includes Child/spousal support;
interest or dividends; gambling/lottery winnings;
insurance or legal settlements; strike benefits; cash,
gifts, loans scholarships; tax refunds; any government
benefits, like Social Security, Supplemental Security
Income/State Supplementary Payment (SSI/SSP),
unemployment, worker’s compensation, state disability
indemnity, veterans or railroad retirement, or other
private or government disability or retirement; rental
income and rental assistance; free housing/utilities/
clothing/food; or any other type of money received.
3. You must also report on your Quarterly Report any
changes in income that you expect to happen during the
next quarter. This includes earned, unearned and
disability based income changes.
4. Property: Any property including, motor vehicles; bank
accounts; savings bonds; insurance policies; a home or
land; trust; EBT cash balance, etc. that you or anyone in
your household has received since your last Quarterly
Report and still has, whether it was bought, obtained
through a trade or as a gift. The county will use this
information to determine if your household exceeds the
property limit. You must also report if you or anyone
sold, traded or gave away any property since your last
Quarterly Report.
5. If You Move or Someone Moves Into or Out of Your
Home: Anyone (including newborns) who moved into
your home since your last Quarterly Report and is still
there. You must also report anyone who moved out of
your home or who has died since your last Quarterly
Report.
6. Convicted Drug Felons, Fleeing Felons and
Probation/ Parole Violators: The name of anyone in
your household who is either avoiding or running from
the law to avoid a felony prosecution, custody or
confinement after conviction, or in violation of probation
or parole. You must also report any household member
who has been convicted of a drug felony for possession,
use, manufacturing sale or distribution, of a controlled
substance, or any activity in connection with these
unlawful acts, or harvesting, cultivating or processing
marijuana, or involving a minor in these activities. For
food stamps you must report felonies since August 22,
1996 and for Cash Aid list convictions that happened
after January 1, 1998.
7. Reduced Hours of Work: If you are an Able-Bodied
Adult Without Dependents (ABAWD), you must report
when your hours of work drop below 20 hours a week or
80 hours a month. You must also report if you expect
your work hours to drop below these limits during the
next three months.
For Medi-Cal/34-County CMSP, you must report when:
1. Anyone enters or leaves a nursing home or long term
care facility.
2. Anyone applies for disability benefits, such as SSI/SSP,
Social Security, Veterans, or Railroad Retirement.
3. Anyone gets health care services that result from an
accident or injury due to someone else’s action or failure
to act.
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YOUR REPORTING RESPONSIBILITIES (CONTINUED)
For Non-Assistance Food Stamps Quarterly Reporting
If you only get Food Stamps you must report when:
1. Anyone in the household moves to another address,
plans to move or gets a new mailing address.
2. Anyone who is an Able Bodied Adult Without
Dependents (ABAWD) Food Stamp recipient and the
number of hours they work or are in training drop to less
than 20 hours a week or 80 hours a month.
For CalWORKs you must report certain changes at other
times:
In certain circumstances you will be required to report things
(within ten days of the change) even if it is not your “report
month” such as:
1. Anytime that your family’s combined gross income (both
earned and unearned) is more than the Income
Reporting Threshold (IRT) for a family of your size.
Your county worker will tell you the IRT limit for a family
of your size. If your family only gets unearned income or
only gets Food Stamps, you will only be required
to report income on your Quarterly Eligibility Report
(QR 7).
2. Anytime that someone in your household is convicted of
a drug related felony, becomes a fleeing felon or is in
violation of probation or parole.
3. Anytime you move you must report your address change
so that the County will know where to send your
benefits, Quarterly Report forms and notices.
Reporting information voluntarily for CalWORKs and
Food Stamps Quarterly Reporting:
You may also report other information voluntarily even when
it is not your “report month.” Reporting information
voluntarily may cause your household’s benefits to go up. If
the information reported causes your benefits to go up, the
county will take action within ten days after you provide
verification. One exception is when the increase results
from adding another person to your case. In that situation,
the County will take action to increase benefits the first of the
month after you provide verification. Even if you have
already reported something to the County, you must also
report it on your next Quarterly Report (QR 7).
Some examples of voluntary reporting that may cause your
benefits to go up include:
●
Your income stops or drops.
●
Someone who has little or no income moves into your
home (including a newborn).
●
Someone who has income moves out of your home.
●
You believe that you or someone in your household is
eligible for a CalWORKs Special Needs payment, such
as pregnancy special needs or a qualifying special diet.
Additional examples for Food Stamps only:
●
A household member begins to pay court ordered child
support for a child not living in the home.
●
A household member is 60 or older.
●
Any member who is disabled or 60 years of age or older
has changes in or new medical expenses (if verified
your Food Stamps can be refigured).
Additional Information for Food Stamp Only Households
If you receive food stamp benefits and you voluntarily report
income that has increased, and it is above the gross income
level for your household size, your benefits may be
discontinued.
Note that if you receive only food stamp benefits: (1) you do
not have to report any increases in income during the
quarter; and, (2) when you report changes to the county or in
between written quarterly reports, you must also report the
change on your next QR 7.
At anytime you can ask the County to discontinue your entire
case or any individual person who has left the home or is not
required to be in the assistance unit. You can also ask the
County to discontinue certain benefits, such as: Medi-Cal or
Food Stamps. Receiving Medi-Cal/or Food Stamps only will
not count against your Cash Aid time limits.
Other changes for quarterly reporting:
There are other changes that will cause the County to
decrease or discontinue your benefits during the quarter in
which they happen. Here are some examples:
●
An adult in the household reaches the CalWORKs
60-month time limit;
●
A household member is sanctioned/penalized;
●
A child reaches the age of 18 (and will not graduate from
high school before the age of 19);
●
Someone in your household begins receiving benefits in
another household;
●
An eligible child is placed in Foster Care;
●
Anyone who is an Able Bodied Adult Without Dependents
(ABAWD) Food Stamp recipient and the number of hours
they work or are in training drop to less than 20 hours a
week or 80 hours a month.
FOOD STAMP CHANGE REPORTING
For Food Stamp Change Reporting, you must report
when:
1. Your total monthly income starts, stops, or changes by
more than $50.
2. Anyone’s source of income changes.
3. Anyone moves into or out of your home.
4. Anyone joins or leaves your household.
5. You move or you get a new address.
6. Your rent and utility costs only if you move.
7. Anyone buys, gets, sells, or gives away a licensed motor
vehicle.
8. The total of your household’s stocks, bonds, or other
money is or is more than $2000 (or $3000 if you have a
household member who is age 60 or older).
9. If there is a change in the amount of any court ordered
child support paid by a member of the household for a
child not living in the home.
10. Anyone who is an Able Bodied Adult Without Dependents
(ABAWD) Food Stamp recipient and the number of hours
they work or are in training drop to less than 20 hours a
week or 80 hours a month.
11. Any member of your household is avoiding or running
from the law to avoid any felony prosecution, custody or
confinement after conviction, or is in violation of probation
or parole.
12. Any household member convicted of a drug-related
felony after August 22, 1996, for manufacturing, sale or
distribution of a controlled substance(s), or any activity in
connection with these unlawful acts, or harvesting,
cultivating or processing marijuana, or involving a minor
in the above activities.
For Food Stamp Change Reporting, you may report
when:
1. Anyone’s physical or mental illness begins or ends.
2. Anyone’s citizenship/immigration status changes or
anyone gets a letter, form or new card from the USCIS.
3. You have changes in your dependent care costs.
4. Any member who is disabled or age 60 or older has
changes in or new medical expenses. If verified, your
allotment can be refigured.
5. Any household member starts to pay court ordered child
support for a child not living in the home.
SAWS 2A QR (11/10) (RIGHTS, RESPONSIBILITIES) CA 2/DFA 285-A2/MC210 (REQUIRED FORM - NO SUBSTITUTE PERMITTED)
YOUR REPORTING RESPONSIBILITIES (CONTINUED)
IMPORTANT INFORMATION CASH AID ONLY
Unemployed Parent
If you are applying for cash aid as an unemployed
parent, the principal earner (PE) must:
• be unemployed and not have worked in the
preceding 4 weeks
• apply for and accept any unemployment insurance
you are eligible to receive
The PE is the parent who has the most earnings in the
past 24 months.
Homeless Assistance
You may be eligible for money to help pay for temporary
shelter, permanent housing or to prevent eviction. This is a
once-in-a-lifetime payment unless you meet an exemption.
If you have already received homeless assistance and need
it again, your worker will tell you if you are eligible.
School Attendance and Immunizations
You must provide proof when requested by the county that:
• all school-age children are attending school, and
• children under the age of 6 have received age
appropriate immunizations. (Manual of Policies and
Procedures Sections 40-105.4; 40-105.5).
Maximum Aid Payment (MAP)
There are two levels of Maximum Aid Payment (MAP). Most
families getting cash aid get the lower MAP level. Families
may get the higher MAP level if each parent or caretaker in
the Assistance Unit (AU):
• is disabled and getting Supplemental Security Income/
State Supplemental Payments (SSI/SSP), or In-Home
Supportive Services (IHSS), or State Disability
Insurance (SDI), or Temporary Workers Compensation
(TWC), or Temporary Disability Indemnity (TDI) benefits
• is caring for an aided child(ren) who is not their child and
the caretaker does not get cash aid.
Also eligible for the higher MAP:
• a family who gets Refugee Cash Assistance (RCA) if
each adult meets an exception.
If all the adults in the household meet at least one of these
exemptions, ask your worker about applying for an
exemption.
Treatment of Self-Employment
If you are self-employed, you will have a choice of figuring
your business expenses based on a standard deduction of 40
percent of gross income or using actual business expenses.
Once you choose a method of figuring your self-employed net
income, you can only change that way of figuring expenses at
redetermination or every six months whichever happens
sooner.
Maximum Family Grant (MFG) Rule
The MFG rule applies to any child born after August 31, 1997.
The MFG rule says that your maximum aid payment (MAP)
will not go up to include a child born to your family, if your
family got cash aid for the 10 months in a row right before the
child’s birth. There are exemptions to the rule. Your worker
will give you a copy of the MFG rules and answer your
questions. Then you will sign a copy that says you
understand the rules.
Proof of Facts
If you ask for cash aid within one year of the date it stopped,
the county must look at your prior case file to see if it already
has the proof needed to determine your eligibility when:
• you cannot get the proof, or
• there is a cost to you to get the proof, or
• processing your application would be delayed because it
would take too long for you to get the proof.
If you ask for cash aid within one year of the date it stopped
AND, if the county doesn’t have the proof it needs, then you
will have to provide proof.
If you have new changes since you last got cash aid, the
county will need new proof.
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You can work and still get cash aid:
✔ In most cases, when you work, your
gross earnings (earnings before
deductions) are not subtracted dollar
for dollar from your cash aid payment.
You may be eligible for work related
deductions. When you add it up, you
have more $$$$ for your family.
Here’s how Work Pays:
• Gives you more $$$$ to help support
your family
• Builds a better life for you and your
family
• Develops job skills
• Builds self-esteem
• Gives you personal satisfaction
✔ When you have a grant-based on the
job training (OJT) assignment, all or
part of your cash aid payment is used
by your employer to help pay your
wages. You do not get work related
deductions for grant based OJT
wages.
✔ Either way, you may be eligible for child
care costs that are paid to your
provider.
See page 7 for facts about work and
training rules, work incentives, including
child care programs. Ask your worker for
more facts about Work Pays and how
grant-based OJT can work for you.
Remember, you can work and still get cash aid as long as you
stay eligible and meet reporting rules in a timely manner.
SAWS 2A QR (11/10) (RIGHTS, RESPONSIBILITIES) CA 2/DFA 285-A2/MC210 (REQUIRED FORM - NO SUBSTITUTE PERMITTED)
Work and Training Rules
Your worker will tell you what cash aid and/or food stamp work
rules you need to follow before and after your application is
approved. You may be required to be in work, training or education
activities to keep getting your cash aid, food stamps, or both. More
than one member of a household can be required to follow cash
aid and/or food stamp work rules. If anyone becomes ineligible for
not following work or training rules, other members of their
household can still get cash aid or food stamps, as long as they
remain eligible. But, the amount of cash aid or food stamps they
get may change.
Cash Aid Work Rules
If you get cash aid and food stamps or just get cash aid, you will
need to take part in certain Welfare-to-Work activities to keep
getting your cash aid and food stamps. The county will tell you
how many hours a week you must take part in these activities or if
you are excused from these rules. Welfare-to-Work activities
include, but are not limited to, subsidized or unsubsidized work,
work experience, community service, adult basic education,
vocational training, and job search. Subsidized means that the
county or some other funding source pays your employer for part
of your wages.
The cash aid work rules also say you must:
•
Sign a Welfare-to-Work plan;
•
Take a suitable job that is offered to you;
•
Not quit a job or reduce your earnings.
Sanctions for Not Meeting Cash Aid Work Rules
Any time you don’t meet cash aid work rules for a good reason,
your cash aid will be stopped until you do what you should do.
After your cash aid is stopped or reduced, you can only get it back
again if you meet the work rules that you had stopped meeting or
you become excused. If your cash aid is stopped, your food
stamps may also be stopped or reduced.
Food Stamp Work Rules for Persons Not Receiving
Cash Aid
Work Requirement for Able-Bodied Adults Not Receiving
Cash Aid
If you only receive food stamps and you don’t have minor children,
there is another work rule which you also may need to meet. You
do not have to meet this work rule if you are under age 18, over age
49, pregnant, or you are part of a food stamp household with a
minor child. You may be excused for other reasons that your county
worker can explain. The work rule says that if you are an
able-bodied adult, you must work at least 20 hours a week or
80 hours a month in paid employment, take part in a workfare
project for the required number of hours, or take part in an
approved training activity for at least 20 hours per week or 80 hours
per month. During a period of 36 months, food stamps will stop if
there are three months in which you do not meet the work rule. If
you stop meeting the work rule a second time for reasons such as
being laid off, you may be able to get food stamps for three months
in a row without having to meet the rule. After that you can only get
food stamps if you meet the work rule or get excused.
Income Disregards
When you have income and are on cash aid, there are two income
disregards (deductions) that may be subtracted from certain types
of family income. When you or any of your family members receive
certain types of disability-based unearned income or you are
working and getting cash aid, you are eligible for an income
disregard of $225. The $225 is first deducted from certain disabilitybased unearned income. Any remainder of the $225 is then
deducted from earned income. If there is a remainder of earned
income, 50 percent of that remaining earned income will be
disregarded.
Treatment of Self-Employment
If you are self-employed, you will have a choice of figuring your
business expenses based on a standard deduction of 40 percent of
gross income or using actual business expenses. Once you
choose a method of figuring your self-employed net income, you
can only change that way of figuring expenses at redetermination
or every six months whichever happens sooner.
CalWORKs Child Care Program
If you only get food stamps, you may need to take part in certain
employment and training activities to keep getting your food
stamps. These activities include job search, workfare, adult basic
education, and vocational training. The county will tell you how
many hours a week you must take part in these activities or if you
are excused from these rules.
Child care benefits are available to recipients who need child care
to work or participate in county-approved welfare-to-work activities
such as attending education or job training programs.
The food stamp work rules also say you must:
•
Answer questions about your job experience and ability to
work;
•
Check on a possible job we tell you about and take a suitable
job that is offered to you;
•
Not quit a job or reduce the number of hours you work to less
than 30 hours per week.
Child care benefits are also available from CDE. Contact your local
Resource and Referral Agency for more information.
Food Stamp Only Penalties
California Department of Education (CDE)
Child Care
Transitional Medi-Cal (TMC)
You may get Medi-Cal for up to 24 months if you go off cash aid
because you are working. Your family must have gotten cash aid
for at least three of the last six months before cash aid stopped. To
get more than six months of TMC, your income must be under
certain limits and you must meet TMC reporting rules.
If you don’t meet food stamp work rules and you don’t have a good
reason, your food stamps will be denied or stopped for one, three,
or six months, depending on the number of times you stop meeting
the rules. After your food stamps are stopped, you can only get
them again at the end of the penalty or sooner if you become
excused.
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OTHER IMPORTANT INFORMATION
CASH AID AND FOOD STAMP QUARTERLY
REPORTING HOUSEHOLDS
Budgeting Rules
The amount of cash aid and/or food stamps you can get
depends on your income and allowable expenses. You will get
a Quarterly Eligibility Report (QR 7) to fill out every three
months. On the QR 7, you will need to report what income and
expenses you had in the last month and what income and
expenses you think you will have in the three months after you
turn in your report. The income and expenses you expect to
have in the next three months will be used to figure the amount
of cash aid and/or food stamps you can get for those three
months. Information that you put on the QR 7 about the past
month will be used for the next three months if you don’t expect
your income or expenses to change.
For example, if you turn in a QR 7 in March, you will report what
income you had in February. You will also report any income
changes you expect to have in April, May and June. If the
income from February will stay the same, your cash aid and/or
food stamps for April, May, and June will be figured using that
same income and expenses for each of those months. If your
income and expenses will change, your worker will use the new
income amounts you think you’ll get in April, May, and June to
figure your cash aid and/or food stamp amount for those
months. This method is called prospective budgeting.
FOOD STAMP ONLY
Utility Allowances
You will be allowed a Standard Utility Allowance (SUA) deduction if
you have heating and cooling costs. if you have utility costs other
than heating or cooling, such as water, sewer and garbage, you
will be given a Limited Utility Allowance (LUA) deduction. If you
only have a telephone cost, you will be given a Telephone Utility
Allowance (TUA) deduction. The SUA, LUA and TUA are used to
reduce your income, which helps you get more benefits.
MEDI-CAL/34-COUNTY CMSP ONLY
Spending Down Excess Property
•
•
If you get or apply for Medi-Cal/34-County CMSP Only and
you have more property than the rules allow, you may lower it
by the last day of any month, including the month of
application. For Medi-Cal you may spend your excess
property in any manner you want. But you may not be eligible
for nursing facility level of care for a period of time if you sell or
give away any property for less than its worth, and you apply
for or receive Medi-Cal nursing facility level of care within 30
months of the transfer.
You may not be eligible for 34-County CMSP if you sell or give
away any property for less than it is worth.
Property Limit
Resources And Property
There is a $2000.00 limit on the amount of property (e.g., bank
accounts, stocks, etc.) that your household can have and still
get cash aid or food stamps. If someone in your household is at
least 60 years old, the limit goes up to $3000.00. Your house
and furniture are not part of the total limit as long as you live in
your home. The individual vehicle value limit is $4650. If your
registered vehicle is worth more than $4650, anything over the
limit will be used as part of the total property limit unless the
vehicle is needed by the household for certain reasons. Ask
your worker what the reasons are. Any vehicle you have, that
cannot be sold for more than $1500, will not be used as part of
the total property limit to determine eligibility. Your worker can
tell you how to figure the value of any unregistered vehicles.
•
CASH AID ONLY
60-Month Time Limit
AVAILABLE SERVICES
As of January 1, 1998, a parent or caretaker relative is not
eligible for cash aid when he/she has received cash aid for a
total of 60 months. All aid received through CalWORKs
(California Work Opportunity and Responsibility to Kids) and/or
cash aid received from any other state counts toward the
60-month total. Only cash aid received on or after January 1,
1998, counts toward the 60-month total. There are exceptions to
this time limit and the limit does not apply to children.
Resources/Electronic Benefits Transfer (EBT)
Any balance remaining in the EBT account at the end of the
month will be considered an available resource and could make
your household ineligible for cash aid if your total countable
resources are more than the allowable resource limits.
•
All Medi-Cal benefits received after age 55 are subject to
recovery from a deceased Medi-Cal recipient’s estate.
However, recovery may not exceed the value of the estate.
Recovery may not occur if the beneficiary is survived by a
spouse. The state may not claim the proportionate share of an
estate left to a minor child or a totally disabled adult child. In
addition if recovery would cause an undue hardship for any
other heirs and that hardship can be demonstrated, recovery
may be waived in full or in part.
If you are institutionalized and your home or former home is
not exempt, the State may record a lien against your property
to repay the cost of medical care covered by Medi-Cal.
Women, Infants and Children (WIC) Supplemental Nutrition
Program: The WIC Program is only for pregnant and breast
feeding women, infants and children under age 5, who are at
medical-nutritional risk. For more facts about WIC, call your local
county health department or the phone number for “WIC” in the
telephone book.
Voter Registration: If you want to register to vote, ask your
worker to send you a registration form. If you need help filling it
out, ask your worker. You can mail the form yourself. Your
eligibility for aid will not be affected whether or not you register.
Your worker will not tell you how to vote.
Transfer of Assets Rule
Recipients can sell, exchange or change the form of their
property holdings, if they get fair market value for the property
(asset). If they do not get fair market value for the asset, the
family will get a period of ineligibility. The period of ineligibility is
figured by subtracting the amount received from the fair market
value of the asset and then dividing that amount by the need
standard for the family. The amount is rounded down to the
next lower whole number.
Cal-Learn
Cal-Learn helps pregnant and/or parenting teens under the age
of 20, who are getting cash aid and do not have a high school
diploma or its equivalent to stay in or return to school. Teens in
the Cal-Learn Program may get cash bonuses for good grades
and graduation from high school. Cal-Learn teens may get help
with child care, transportation, and other services. Cash
penalties may be subtracted from their family’s cash aid
payment for not going to school or for getting poor grades.
SAWS 2A QR (11/10) (RIGHTS, RESPONSIBILITIES) CA 2/DFA 285-A2/MC210 (REQUIRED FORM - NO SUBSTITUTE PERMITTED)
PENALTY WARNINGS
If on purpose you don’t report all facts or give wrong facts
to get or keep getting benefits, you can be legally
prosecuted, and can be charged with committing a felony if
more than $400 is wrongly paid out for cash aid, food
stamps, or Medi-Cal because you did not report all of your
facts or changes in income, property, or family status. And
you can be disqualified from getting cash aid or food
stamps.
Disqualification Penalties
Cash Aid and Food Stamps
Disqualification penalties start after a state hearing or court
of law finds that the individual has committed an Intentional
Program Violation (IPV). Also, anyone who is accused of
committing an IPV may agree to be disqualified by signing
an Administrative Disqualification Consent Agreement or
an Disqualification Hearing Waiver. Anyone who signs one
of these documents gives up any hearing rights and
accepts responsibility to repay any cash aid overpayment
and/or food stamp overissuance.
Cash Aid Penalties
If you do not follow cash aid rules, you may be fined up to
$10,000 and/or sent to jail/prison for 5 years.
And if you are found guilty by cour t of law or an
administrative hearing of committing certain types of fraud,
your cash aid can be stopped for 6 months, 12 months,
2 years, 4 years, 5 years or forever.
APPLICANT/RECIPIENT CERTIFICATION
•
•
•
•
•
I understand that one of the intended purposes for
the cash aid is to help meet the basic needs of my
family, including housing, food, clothing.
I understand my rights and responsibilities and agree
to comply with my responsibilities.
I also understand the penalties for giving incomplete
or wrong facts, or for failing to repor t facts or
situations that may affect my eligibility or benefit level
for cash aid or food stamps, and/or my
Medi-Cal/34-County CMSP share of cost.
I cer tify I was given a copy of The Rights,
Responsibilities, and Other Important Information
(SAWS 2A QR).
I also certify that, if I applied for or get cash aid, I got
a copy of the following:
■ Welfare to Work Informing Notice (WTW 5)
______________________
(APPLICANT/RECIPIENT’S INITIALS)
•
I also certify that if I applied for Medi-Cal/34-County
CMSP, I got a copy of the MC 219 /CMSP 219 and its
contents were explained to me.
Food Stamp Only
If your household receives food stamp benefits, it must
follow these rules:
•
Don’t give wrong or incomplete facts to get or keep
getting food stamp benefits.
•
Don’t trade or sell your EBT card.
•
Don’t alter EBT card to get food stamp benefits you are
not entitled to get.
•
Don’t use food stamp benefits to buy ineligible items
such as alcoholic drinks or tobacco, paper, or cleaning
products.
•
Don’t use someone else’s EBT card for your
household.
Food Stamps Penalties
If you do not follow food stamp rules, your benefits can be
stopped for 12 months for the first violation, 24 months for
the second, and forever for the third. And you may be fined
up to $250,000 and/or sent to jail/prison for 20 years. If you
are found guilty in any court of law or administrative
hearing because:
•
you traded or sold food stamp benefits for firearms,
ammunition, or explosives, your food stamp benefits
can be stopped forever for the first violation;
•
you traded or sold food stamp benefits for controlled
substance, your benefits can be stopped for 24 months
for the first violation and forever for the second;
•
you traded or sold food stamp benefits that were worth
$500 or more, your food stamp benefits can be stopped
forever;
•
you filed two or more applications for food stamp
benefits at the same time and gave the county false
identity or residence information, your food stamp
benefits can be stopped for 10 years.
ELIGIBILITY WORKER’S CERTIFICATION
I cer tify that the applicant/recipient appears to
understand:
• his/her rights and responsibilities and
• the penalties for giving incomplete or wrong facts, or for
failing to report facts or situations that may affect his/her
eligibility or benefit level for cash aid or food stamps,
and/or share of cost for Medi-Cal/34-County CMSP
I also certify that the applicant/recipient was given a
copy of:
• The Rights, Responsibilities, and Other Important
Information (SAWS 2A QR)
•
For cash aid:
■ Welfare to Work Informing Notice (WTW 5)
•
For Medi-Cal/34-County CMSP: the MC 219/CMSP 219
and that its contents were explained to him/her.
Signature (Parent or Caretaker Relative, Food Stamp Household Member or Authorized Representative, Medi-Cal/34-County CMSP
Applicant/Beneficiary)
Date
Signature (Other Parent Living in the Home)
Witness, if You Signed With An "X"
Date
Eligibility Worker's Signature
Eligibility Worker's Number
Date
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PENALTY WARNINGS
If on purpose you don’t report all facts or give wrong facts
to get or keep getting benefits, you can be legally
prosecuted, and can be charged with committing a felony if
more than $400 is wrongly paid out for cash aid, food
stamps, or Medi-Cal because you did not report all of your
facts or changes in income, property, or family status. And
you can be disqualified from getting cash aid or food
stamps.
Disqualification Penalties
Cash Aid and Food Stamps
Disqualification penalties start after a state hearing or court
of law finds that the individual has committed an Intentional
Program Violation (IPV). Also, anyone who is accused of
committing an IPV may agree to be disqualified by signing
an Administrative Disqualification Consent Agreement or
an Disqualification Hearing Waiver. Anyone who signs one
of these documents gives up any hearing rights and
accepts responsibility to repay any cash aid overpayment
and/or food stamp overissuance.
Cash Aid Penalties
If you do not follow cash aid rules, you may be fined up to
$10,000 and/or sent to jail/prison for 5 years.
And if you are found guilty by cour t of law or an
administrative hearing of committing certain types of fraud,
your cash aid can be stopped for 6 months, 12 months,
2 years, 4 years, 5 years or forever.
APPLICANT/RECIPIENT CERTIFICATION
•
•
•
•
•
I understand that one of the intended purposes for
the cash aid is to help meet the basic needs of my
family, including housing, food, clothing.
I understand my rights and responsibilities and agree
to comply with my responsibilities.
I also understand the penalties for giving incomplete
or wrong facts, or for failing to repor t facts or
situations that may affect my eligibility or benefit level
for cash aid or food stamps, and/or my
Medi-Cal/34-County CMSP share of cost.
I cer tify I was given a copy of The Rights,
Responsibilities, and Other Important Information
(SAWS 2A QR).
I also certify that, if I applied for or get cash aid, I got
a copy of the following:
■ Welfare to Work Informing Notice (WTW 5)
______________________
(APPLICANT/RECIPIENT’S INITIALS)
•
I also certify that if I applied for Medi-Cal/34-County
CMSP, I got a copy of the MC 219 /CMSP 219 and its
contents were explained to me.
Food Stamp Only
If your household receives food stamp benefits, it must
follow these rules:
•
Don’t give wrong or incomplete facts to get or keep
getting food stamp benefits.
•
Don’t trade or sell your EBT card.
•
Don’t alter EBT card to get food stamp benefits you are
not entitled to get.
•
Don’t use food stamp benefits to buy ineligible items
such as alcoholic drinks or tobacco, paper, or cleaning
products.
•
Don’t use someone else’s EBT card for your
household.
Food Stamps Penalties
If you do not follow food stamp rules, your benefits can be
stopped for 12 months for the first violation, 24 months for
the second, and forever for the third. And you may be fined
up to $250,000 and/or sent to jail/prison for 20 years. If you
are found guilty in any court of law or administrative
hearing because:
•
you traded or sold food stamp benefits for firearms,
ammunition, or explosives, your food stamp benefits
can be stopped forever for the first violation;
•
you traded or sold food stamp benefits for controlled
substance, your benefits can be stopped for 24 months
for the first violation and forever for the second;
•
you traded or sold food stamp benefits that were worth
$500 or more, your food stamp benefits can be stopped
forever;
•
you filed two or more applications for food stamp
benefits at the same time and gave the county false
identity or residence information, your food stamp
benefits can be stopped for 10 years.
ELIGIBILITY WORKER’S CERTIFICATION
I cer tify that the applicant/recipient appears to
understand:
• his/her rights and responsibilities and
• the penalties for giving incomplete or wrong facts, or for
failing to report facts or situations that may affect his/her
eligibility or benefit level for cash aid or food stamps,
and/or share of cost for Medi-Cal/34-County CMSP
I also certify that the applicant/recipient was given a
copy of:
• The Rights, Responsibilities, and Other Important
Information (SAWS 2A QR)
•
For cash aid:
■ Welfare to Work Informing Notice (WTW 5)
•
For Medi-Cal/34-County CMSP: the MC 219/CMSP 219
and that its contents were explained to him/her.
Signature (Parent or Caretaker Relative, Food Stamp Household Member or Authorized Representative, Medi-Cal/34-County CMSP
Applicant/Beneficiary)
Date
Signature (Other Parent Living in the Home)
Witness, if You Signed With An "X"
Date
Eligibility Worker's Signature
Eligibility Worker's Number
Date
SAWS 2A QR (11/10) (RIGHTS, RESPONSIBILITIES) CA 2/DFA 285-A2/MC210 (REQUIRED FORM - NO SUBSTITUTE PERMITTED)
General Relief
General Relief provides financial assistance to indigent adults who are not
eligible for any federal or State assistance programs. General Relief
applications are completed during the interview process and are generated via
the County’s automated computer system.
Contents
•
•
•
General Relief Fact Sheet
General Relief Restructuring Fact Sheet
Veterans Projects
Additional information may be accessed through the websites listed below:
•
www.ladpss.org
Department’s main website listing all departmental information, including
program-specific information, office locations and the community event’s
calendar.
•
www.lacountyhelps.org
Informs citizens of Los Angeles County of state and federal benefits
assistance. This website provides additional information about programs
available after completing a short online survey.
•
www.211LACounty.org
Provides information about human social services in the Los Angeles
County.
County of Los Angeles
Department of Public Social Services
Philip L. Browning
Director
GENERAL RELIEF FACT SHEET
DESCRIPTION
General Relief (GR) assists needy adults who are ineligible for State or federal assistance. An
average GR case consists of one person, living alone, with no income or resources. The
maximum monthly GR grant is $221.
ELIGIBILITY REQUIREMENTS
To be eligible for GR, an individual must be a resident of Los Angeles County. Non-needy
caretakers who are timed-off of CalWORKs are also eligible, if the following GR eligibility
requirements are met:
•
•
•
•
•
Monthly net income is lower than the maximum GR grant of $221 for one person.
Personal property has a combined value of $500 or less per adult.
Motor vehicle is valued at $4,500 or less. Only one motor vehicle may be retained.
Cash on hand or in a bank account is valued at $50 or less at application, or $1,500 or less
after approval.
Real Property (home) has an assessed value of $34,000 or less and signs a lien, allowing the
County to recover GR payments received under certain circumstances.
SUBSTANCE ABUSE PRE-SCREENING REQUIREMENT
Individuals are pre-screened at application for potential substance abuse. If determined to have a
substance abuse problem, individuals must attend a County-approved treatment program as a
condition of eligibility for GR.
SERVICES AVAILABLE:
Emergency Aid
If eligible to GR, the following aid may be available while GR is pending:
•
•
•
•
•
•
Aid to Prevent Eviction
Aid to Prevent Utility Shut-off or to Restore Utilities
Aid to First Paycheck
Meal and Housing Vouchers
Transportation to seek jobs/keep medical appointments, etc.
Expedited Food Stamps. Approximately 90% of GR participants also receive Food Stamp
benefits.
Ineligibles
An individual is ineligible to GR if he or she:
•
Was convicted of a drug felony after 12/31/97 and is an unaided member of a CalWORKs
Assistance Unit.
- 2SERVICES AVAILABLE: (Continued)
•
•
Is in violation of probation or parole.
Is fleeing to avoid prosecution or custody/confinement after a felony conviction.
Special Needs
Individuals may receive:
• A transportation allowance to look for work.
• A special/therapeutic diet allowance as verified by a doctor.
• An allowance for tools needed to begin a new job.
Health Care
County-approved GR Health Care providers offer a wide range of services, including primary
care, specialty physician visits, prescriptions, and emergency services. Applicants pending
approval of GR are referred to a County-administered clinic or hospital for health care services.
Supplemental Security Income Assistance Program (SSIAP)
Social Workers provide advocacy to help physically/mentally disabled individuals apply for SSI,
obtain early SSI approval, and become self-sufficient. If approved for SSI, the maximum monthly
grant is $845 versus the monthly GR grant of $221. In addition, SSI recipients receive full-scope
Medi-Cal.
GR CASELOAD TYPES
The GR caseload includes the following employability status classifications:
Employable (E)
Individuals are designated employable through self-declaration or through an employability
screening by contracted medical providers. Individuals determined to be employable are required
to participate in the General Relief Opportunities for Work (GROW) program, designed to help
them find employment. Employables may receive GR for nine months in any 12 month period,
provided they continue to comply with GROW requirements.
Unemployable (U)
Individuals are designated unemployable through an employability screening by contracted
medical providers. Time Limits: GR eligibility for unemployable individuals is not time limited, nor
are they required to participate in GROW. Severely disabled individuals must apply for SSI and
are referred to an SSI Advocate for assistance.
Needs Special Assistance (NSA)
Individuals with mental disabilities are designated as NSA. NSAs are given priority treatment in
the district office and are exempt from most GR requirements. GR for NSAs is not time limited,
nor are they required to participate in GROW. Evaluation of mental disability is conducted by
Department of Mental Health (DMH) or Adult Protective Services (APS) staff, who are co-located
in GR districts. Potentially SSI eligibles are referred to an SSI Advocate for assistance with their
SSI application.
Administratively Unemployable (AU)
Individuals with circumstances that prevent them from seeking employment, other than physical
or mental disabilities, may be designated AU. For example, an AU designation may be assigned
because an individual provides full time care to an incapacitated family member, is pregnant, or is
65 years of age or older. GR eligibility is not time limited for AUs, nor are they required to
participate in GROW.
(01/10)
County of Los Angeles
Department of Public Social Services
Philip L. Browning
Director
GENERAL RELIEF (GR) RESTRUCTURING
FACT SHEET
Why is the GR Restructuring Process Necessary?
GR Restructuring was mandated by a Board motion introduced by Supervisor Don Knabe on April 21, 2009, which
directed the Chief Executive Office (CEO), in collaboration with DPSS and in consultation with County Counsel, to
design a potential GR Program that will better assist participants towards self-sufficiency while controlling escalating
County costs.
Who Participated in the GR Restructuring Process?
In response to this motion, DPSS convened the GR Restructuring Workgroup. The purpose of the workgroup is to
discuss possible methods of redesigning the GR Program to enhance the lives of indigent adults and reduce County
costs. The GR Restructuring Workgroup consists of 11 County Departments and 10 Stakeholder organizations:
Chief Executive Office
DPSS
Dept. of Health Services
Dept. of Mental Health
Dept. of Public Health
Dept. of Community and Senior Services
Probation Department
Sheriff’s Department
Public Defender
Dept. of Children and Family Services
County Counsel
Legal Aid Foundation of Los Angeles
Hunger Action L.A.
Shelter Partnership
Mental Health Advocates
Commission for Public Social Services
SEIU Local 721
Weingart Center Association
Jewish Vocational Services
Neighborhood Legal Services
Public Counsel
Representatives from the BWS Integrated Services Section and Line Operations Development Section participated
in the Workgroup, as well as GR and General Relief Opportunity for Work (GROW) Program staff.
GR RESTRUCTURING ADOPTED RECOMMENDATIONS (PHASE I)
The GR Restructuring Workgroup members recommended 152 modifications to the GR Program. In Phase I, the
workgroup reached consensus to recommend 45 actions to the Board of Supervisors. Those 45 recommended
actions were consolidated into 27 recommendations and presented to the Board of Supervisors on October 6, 2009.
The Board of Supervisors unanimously approved the 27 Phase I recommended actions for GR Restructuring.
The 27 recommendations covered five important areas: Adult Linkages Project (ALP), Housing and Homelessness,
SSI Advocacy, Employment/Employability, and Other.
The ALP was a study conducted by the Chief Executive Office – Service Integration Branch that analyzed the costs
of GR to other County departments, such as Health Services, Sheriff and Mental Health. The study indicated that
for every $1 spent by DPSS in GR grants, other County departments spent over $4 on the same participant.
Page 1 of 4
GR RESTRUCTURING ADOPTED RECOMMENDATIONS (PHASE I) (continued)
Addressing Housing and Homelessness:
• Increase the number of housing subsidies to 10,000 by the year 2014 for homeless disabled GR
participants willing to pursue SSI/Veterans’ Benefits or for homeless employable GR participants;
• Increase the housing subsidy to $400 and reduce the participant contribution to $100;
• Pilot a master leasing project in an effort to make low-cost housing available; and
• Explore housing options for the mentally ill through the City and County Housing Authorities and smaller
Housing Authorities throughout the County.
Addressing SSI Advocacy:
• Replace the current Employability Screening with an extensive health assessment and medical/mental
health evaluation conducted by County health professionals or the public-private partnership facilities within
the County;
• Collaborate with the Sheriff, Mental Health, and Health Services Department to retrieve medical and mental
health records in support of GR participants’ SSI applications; and
• Integrate/combine SSI Advocacy services into the Public Defender’s services to GR participants who are
already clients of the Public Defender.
Addressing Employment/Employability:
• Replace the current Employability Screening with an extensive health assessment and medical/mental
health evaluation conducted by County health professionals or the public-private partnership facilities within
the County;
• Customize GROW services for youth age 18-24, veterans, and participants exiting Mandatory Substance
Abuse and Recovery Program (MSARP);
• Create a new voluntary category for NSA participants and GR participants who will be classified as
“employable with accommodations” and will be referred to a new GROW component designed to provide
employment services for individuals who can work with accommodations;
• Establish collaboration between DPSS and the Probation Department to reduce the number of youth age
18-24 applying for GR benefits;
• Establish collaboration with the Department of Community and Senior Services (CSS), L.A. City and all
other Workforce Investment Boards to provide job services and employment opportunities through the
WorkSource Centers, geared toward both youth and adult GROW participants; and
• Expand GROW to include GED preparation.
Lastly, the GR Restructuring approved recommended actions classified as Other are:
• Enhance the current jail match;
• Assess the effectiveness of the Jail Release Project; enhancing services for disabled participants exiting
jails to pave the way to SSI approvals or, in some cases, re-establishing SSI;
• Encourage police agencies to make social services referrals instead of issuing vagrant tickets;
• Evaluate the effectiveness of MSARP;
• Connect foster youth with County services through a pilot having the current Linkages GAIN Services
Workers at two or three small Department of Children and Family Services (DCFS) offices’ work with the
Children’s Social Workers;
• Improve screening for veterans, make better referrals for Veterans’ benefits, and strengthen DPSS case
management for veterans who are on GR to enable them to qualify faster for Veterans’ benefits;
• Assess and enhance the current mechanisms designed to enable former foster care youth, medically
indigent under 21 and probation youth to receive and retain Medi-Cal;
• Add positions in GR Offices to assist GR participants navigate the GR process. Positions may be filled with
GR Non-Custodial Parents (NCPs), CalWORKs participants and needy parents who qualify for ECF-funded
subsidized employment through September 30, 2010;
• Through the CEO, evaluation of GR Program mandates, rules, time limits, sanctions, operational processes,
and data limitations; and
• Increase GR participants’ resources by permitting GR participants to maintain a Restricted Savings Account
up to a pre-determined amount that would not be countable towards the property limit; help participants who
have child support obligations by assisting participants to lower child support payments and work with the
Child Support Services Department to reduce child support payments for participants after they leave GR,
for the first six-months they have a job, before resuming their original Child Support payments.
Page 2 of 4
GR RESTRUCTURING RECOMMENDATIONS PHASE II
The Workgroup reached a 100% consensus on the Implementation Plan for the 27 Phase I recommendations that
were approved by the Board on October 6, 2009.
The Workgroup reached consensus on 15 Phase II recommendations that were approved by the Board on
February 9, 2010.
The Workgroup reached consensus on a recommendation to reconstitute the GR Restructuring Workgroup as the
GR Restructuring Steering Committee, to meet quarterly, to do the following:
• Work together on the implementation process;
• Review evaluation data and make recommendations for any adjustments to processes or targets; and
• Identify and pursue opportunities for GR service integration.
Addressing Housing and Homelessness:
• Allow employable GR participants who reach the nine-month time limit to continue receiving the subsidy
during the three months that they are ineligible to GR.
Addressing SSI Advocacy:
• Improve DPSS’ GR SSI and Medi-Cal Advocacy Program by:
1. Customizing the approach to securing SSI based on available documentation for individual GR
participants by:
o
o
o
o
Better identifying GR participants who are potentially eligible for SSI through a more extensive
medical and/or mental health disability assessment (approved in Phase I);
Evaluate available medical treatment documentation and utilize the document retrieval process
(approved in Phase I), if necessary;
Evaluate whether a comprehensive medical/mental health evaluation (approved in Phase I), and the
resulting write-up would strengthen the SSI application, and if so, refer the participant for an
evaluation;
Make a decision about when to file the SSI application, in order to increase the chance of approval,
based on the participant’s situation and the results of any assessments, medical documentation,
and/or evaluation.
2. Seeking training from Social Security Administration for DPSS SSI Advocates on SSI medical disability
standards and case development.
•
•
•
•
•
Provide ancillary expenses for showers, shoes, clothes, etc., for those pursuing SSI, including a motel
voucher for the night before an SSI appointment with California Department of Social Services or Social
Security Administration, when needed to enable the participant to arrive on time.
Collaborate with private medical facilities to retrieve medical and mental health records on behalf of GR
participants to support their disability claim for SSI, as part of the current DPSS-DHS homeless release
project.
Assist GR participants applying for SSI benefits by:
1. Identifying GR participants who are in need of mental health treatment to secure medical
documentation needed to secure SSI;
2. Subject to funding, providing mental health treatment to those participants;
3. Documenting those who cannot be treated due to lack of funding;
4. Assessing current procedures for providing mental health treatment to GR participants; and
5. Recommending changes to better keep participant engaged in treatment.
Help GR SSI applicants keep track of appointments.
Strengthen current process to identify GR participants who were previously on SSI and prioritize SSI
advocacy for them.
Page 3 of 4
GR RESTRUCTURING RECOMMENDATIONS PHASE II (continued)
•
•
•
Establishing the following targets for SSI Approvals:
1. At least 50% at initial application in FY 10/11, at least 60% at initial application in FY 11/12, and to at
least 70% at initial application in FY 12/13.
2. Increase the overall number of SSI approvals to 6,400 in FY 10/11, 6,900 in FY 11/12, and 7,400 in FY
12/13;
Address/fix non-disability-related SSI eligibility issues, such as citizenship documentation, birth certificates,
etc.
Implement a transportation pilot project monthly bus passes to 200 GR participants receiving a housing
subsidy and pursuing SSI to determine whether providing bus passes increases their likelihood of approval
of SSI. Each participant will contribute $10 per month toward the cost of the bus pass.
Other recommendations:
• Assist GR participants in managing their money better by:
1. Formulating a list of banks that allow recipients to establish accounts with no minimum balances and
minimal overdraft fees;
2. Assembling training materials instructing clients about budgeting and money management, as well as
the security advantages of keeping their funds in a bank account, and focusing on providing this
information to GR participants securing SSI benefits;
3. Engaging with community organizations involved with assisting individuals with money management
issues; and
4. Seeking volunteer agencies who will offer training or assistance to GR participants on money
management.
•
Develop two pilot projects to contract with one or more community-based organizations to conduct SSI
advocacy for GR recipients in the areas served by the Rancho Park and South Special DPSS offices. The
two pilots will utilize different innovative strategies and will demonstrate new approaches to assisting GR
recipients to achieve SSI approval based on the initial application.
o
o
The Rancho Park pilot will utilize a competitive bidding process to select one or more community-based
contractor(s) to conduct all SSI advocacy work within the service area; and
The South Special pilot will utilize a competitive bidding process to select one or more communitybased contractors to augment the DPSS SSI Advocates in the South Special DPSS office.
Updated 02/16/10
Page 4 of 4
County of Los Angeles
Department of Public Social Services
Philip L. Browning
Director
SUMMARY OF DPSS VETERANS PROJECTS
The Department of Social Services (DPSS) in collaboration with the Department of Military and
Veteran Affairs (DMVA) implemented the DPSS/DMVA Veterans Project pilot in two of the
County’s largest General Relief (GR) Districts. Effective October 22, 2007, GR participants in the
Metro Special District (#70) and effective December 17, 2007, GR participants in the South
Special District (#07) who self declare that they have served in the U.S. military along with
participants who state that they have no military service but meet the veteran profile below will be
cleared for potential veterans benefits.
•
•
•
•
Age 22 or older;
Unemployable (Permanently Unemployable or Unemployable for 1 year or longer) or Needs
Special Assistance (Temporary or Permanent NSA);
Male; and
Primary Language is English.
Participants will be referred with the use of a CW 5 to the DMVA Representative located in the
pilot Districts. The DMVA Representative will clear the participants’ information on the Veteran
Affairs (VA) database for potential eligibility to veterans benefits. If the VA clearance finds that the
participant is potentially eligible to veterans benefits the DMVA Representative will assist the
participant with the application process including appeals and/or referrals to attorneys for appeals
at the highest level.
In addition, DPSS and the Legal Aid Foundation of Los Angeles (LAFLA) have a similar pilot in the
planning stages. The DPSS/LAFLA Veterans Project Pilot is schedule to be implemented in one
GR District Office. GR participants will be asked at the time of application (Intake) and at the
yearly redetermination if they have prior military service. If the participant states that they have
served in the military, they will be asked if they would like assistance from the LAFLA Veterans
Advocate, to assist them in applying for veterans benefits. Once the participant agrees to accept
the assistance in applying for veterans benefits, DPSS will initiate a referral to the LAFLA Veterans
Advocate. The LAFLA Advocate will contact the participant; schedule an appointment to assist the
participant with the application for veterans benefits, which would include all levels of appeals, if
necessary.
The participant’s involvement in both Veteran Projects is voluntary and no adverse action will
be taken if he/she refuses or fails to comply with the application process.
Veterans Projects Summary - 02-10
Cash Assistance Program
for Immigrants (CAPI)
The Cash Assistance Program for Immigrants (CAPI) was implemented on November 1, 1998,
and is a State-administered, County-operated program. CAPI provides cash assistance to
aged, blind, or disabled legal immigrants who meet the Supplemental Security Income/State
Supplemental Payments (SSI/SSP) immigration status requirements, in effect as of August 21,
1996, and all other SSI/SSP eligibility requirements but cannot receive SSI/SSP benefits due
to a change in federal law regarding legal immigrant eligibility to SSI.
Contents
•
•
Cash Assistance Program for Immigrants (CAPI) Fact Sheet
Cash Assistance Program for Immigrants (CAPI) Brochure
Additional information may be accessed through the websites listed below:
•
www.ladpss.org
Department’s main website listing all departmental information, including
program-specific information, office locations and the community event’s
calendar.
•
www.lacountyhelps.org
Informs citizens of Los Angeles County of state and federal benefits
assistance. This website provides additional information about programs
available after completing a short online survey.
•
www.211LACounty.org
Provides information about human social services in the Los Angeles
County.
County of Los Angeles
Department of Public Social Services
Philip L. Browning
Director
CASH ASSISTANCE PROGRAM FOR IMMIGRANTS (CAPI)
FACT SHEET
BACKGROUND
The State Legislature approved and the Governor signed Assembly Bill (AB) 2779 authorizing
a State-only program to provide cash assistance to certain aged, blind, and disabled legal
non-citizens who are not eligible for Supplemental Security Income/State Supplemental
Payment (SSI/SSP). CAPI was implemented on November 1, 1998.
ELIGIBLE POPULATION
If otherwise eligible, the following legal non-citizens will qualify for CAPI:
< Qualified aliens 65 years or older (aged) who lawfully entered the U.S. on or before
August 21, 1996. If aged individuals are disabled or blind, they may be eligible to
SSI/SSP. However, they may receive CAPI benefits until SSI/SSP is approved; or,
< Individuals who are disabled, blind or aged, and entered the U.S. on or before August
21, 1996 (these individuals must provide proof of their Permanent Residence Under Color
of Law [PRUCOL] status); or,
< Qualified aliens who are disabled, blind or aged, lawfully entered the U.S. on or after
August 22, 1996 and have a sponsor, but the sponsor is deceased, disabled or abusive
(or the sponsor’s spouse is abusive to the immigrant).
< Qualified aliens or PRUCOLs who are disabled, blind or aged, entered the U.S. on or
after August 22, 1996, and do not have a sponsor or have a sponsor who is not
deceased, disabled or abusive.
Federal SSI/SSP was restored for the aged/disabled legal non-citizens (PRUCOLs) who had
been slated for discontinuance on September 30, 1998.
BASIC ELIGIBILITY REQUIREMENTS
To be eligible for CAPI, individuals must successfully complete the application process,
including the following:
< Apply for SSI/SSP - This is necessary to determine if an individual is ineligible for SSI/SSP
solely due to their immigrant status.
-2< Meet the income criteria - The individual’s monthly income, after certain amounts are
disregarded, cannot be greater than the maximum monthly CAPI benefit amount.
Income is anything the person receives in cash or in-kind that can be used or sold to
meet their needs for food, clothing and shelter. In-kind income is food, clothing or
shelter, or something that can be used to get any of these items.
< Meet the resource criteria - The resources a person may own cannot be greater than
$2,000 for an individual or $3,000 for a couple.
Resources are cash or other property that the person can convert into cash for support.
For example: stocks, bonds, mutual funds, mortgages, bank accounts, household goods,
boats and vehicles, or land. Some resources are not counted in determining eligibility,
such as the principal place of residence (regardless of value), one car (used to provide
necessary transportation or does not exceed a certain value), and household goods and
personal effects of reasonable value.
< Meet CAPI living arrangements and residency requirements - Any individual living in a
public institution, such as jail, for an entire month is not eligible for CAPI. Individuals who
are not California residents are not eligible for CAPI. California residence is determined
by physical presence in California with the intent to remain in the State.
BENEFITS
By law, CAPI payment amounts are $10 less for an individual or $20 less for a couple
than the SSI/SSP payment standards. CAPI participants will receive these payment amounts
if no other income is received by the household.
CAPI participants may be eligible for Medi-Cal, In-Home Supportive Services (IHSS) and/or
Food Stamp benefits. Individuals requesting such benefits must file the appropriate
application for the other program.
OUTREACH EFFORTS
DPSS posts flyers in district offices to advise individuals about CAPI. Flyers are also shared
with community representatives, General Relief (GR) participants and other interested
agencies or individuals. CAPI presentations were given at District Community meetings and
other community agency meetings. CAPI brochures are available at all District Offices for
applicants of all aids.
APPLICATION PROCESSING
CAPI applications may be filed at any DPSS GR office. Homebound applicants may call the
toll-free Hotline Number 1-877-481-1044 to receive an application by mail. CAPI applications
are processed centrally in the Wilshire CAPI District.
CAPI FS (1/10)
WHAT ARE MY RIGHTS? (continued)
■
If you receive a written notice saying your application for CAPI is denied, you or
your authorized representative have the right to appeal the action and to request a
State hearing.
■
If your CAPI application is approved and you do not agree with a decision to
reduce or discontinue your aid, you or your representative have a right to appeal
the action and request a State hearing. You will receive a written notice regarding
the proposed action, as well as one showing the result of any hearing.
WHAT ARE MY RESPONSIBILITIES?
■
Cooperate with the County on the processing of your application
■
Report all of your and your sponsor’s income/resources
Any changes that might occur in the following categories must be reported within 10
days to your Eligibility Worker:
■
Where you live - Did you move or leave your household for more than one month?
■
How you live - Have there been changes in your household? Did the amount of
money that you pay for your household expenses change?
■
Your income - Has the amount of money you receive from someone or some place
increased or decreased?
■
Help you get from others - Has the amount of help (money, food, clothing, or
payment of household expenses) you receive increased or decreased?
■
Things of value that you own- Has the value of your resources increased over
$2,000 when you add them all together ($3,000 for couples) or have you bought or
given any things of value away?
■
Immigration Status – Has your Immigration and Naturalization Status changed?
CENTRAL HELPLINE NUMBER
1-877-481-1044
CAPI 105 (03/2010)
Cash Assistance
Program for Immigrants
(C A P I)
WHAT IS THE CASH ASSISTANCE PROGRAM FOR IMMIGRATNTS (CAPI)?
INCOME (continued)
CAPI is a California program that provides cash assistance to certain aged, blind and
disabled legal non-citizen who are not eligible for federal supplemental Security
Income/ State Supplemental Payment (SSI/SSP).
■
WHICH IMMIGRANTS ARE ELIGIBLE?
Income is anything you receive in cash or in-kind that can be used or sold to meet
your needs for food, clothing and shelter. In-kind income is not cash but it is
food, clothing, shelter, or something that can be used to get any of these (e.g. a
second car or coin collection that can be sold for cash, which then could be used
to purchase food or shelter).
■
“Qualified” immigrants, or
RESOURCES
■
Persons who are Permanently Residing Under Color of Law [PRUCOL]
■
An individual may have up to $2,000 in resources and a couple may have up to
$3,000.
■
Resources are cash or other property that you can convert into cash for support,
some resources are not counted in determining eligibility, such as your principle
place of residence (regardless of value) and one car (used to provide necessary
transportation or does not exceed $4,500).
WHO IS A “QUALIFIED” IMMIGRANT?
Qualified immigrants include: lawful permanent resident, refugees, asylees, persons
granted withholding of deportation or withholding of removal, conditional entry,
paroled into the U.S. for at least a year, Cuban/ Haitian entrants, and certain battered
spouses and children.
WHAT ARE THE BENEFITS?
WHO IS A “PRUCOL” IMMIGRANT?
■
CAPI payments are $10 less for an individual or $20 less for a couple than the
SSI/SSP payment standards.
PRUCOL is a term that generally describes immigrants living in the United States
without a permanent residence status, but who are known to the USCIS and the USCIS
is not taking steps to deport or remove from the country.
HOW CAN I APPLY FOR CAPI?
WHO IS NOT ELIGIBLE?
■
You may apply in person at any General Relief (GR) District Office.
You are not eligible for CAPI if:
■
You may call the toll free Central Helpline Number 1-877-481-1044 to receive an
application by mail if you are homebound or in residential care.
■ You are a U.S citizen
■ You are a fleeing felon
AM I ELIGIBLE FOR FOOD STAMPS OR MEDI-CAL?
■ You are in a public institution
■ You are not a California resident
CAN IMMIGRANTS WITH SPONSORS GET CAPI?
You may be eligible; however you must apply for each program separately.
Yes. Immigrants with sponsors can get CAPI if their income, combined with their
sponsor(s)’s income, meets the income requirement for CAPI. There are some
exceptions to this rule.
WHAT ARE MY RIGHTS?
■
You have the right to apply for CAPI even if you have been informed that you
are not eligible.
■
You have the right to apply for CAPI even if you have been informed that
you are not eligible.
■
You have the right to apply for Food Stamps or Medi-Cal.
WHAT ARE THE ELIGIBILITY REQUIREMENTS?
In addition to immigration status, you must meet all of the following:
INCOME
■
Your monthly income after certain amount is disregarded cannot be greater than
the maximum CAPI benefit amount.
CalFRESH
The Food Stamp program was established to improve the nutrition of people in
low-income households by increasing their food buying power.
Contents
•
•
•
•
CalFresh Program Fact Sheet
Restaurant Meals Fact Sheet
Restaurant Meals Participating Restaurants
Sample Application for CalFresh Benefits
•
www.ladpss.org
Department’s main website listing all departmental information, including
program-specific information, office locations and the community event’s
calendar.
•
www.lacountyhelps.org
Informs citizens of Los Angeles County of state and federal benefits
assistance. This website provides additional information about programs
available after completing a short online survey.
•
www.211LACounty.org
Provides information about human social services in the Los Angeles
County.
CALFRESH PROGRAM
FACT SHEET
The CalFresh Program is a federal program. The purpose of this program is to promote and safeguard
the health and well-being of low-income households by raising their levels of nutrition and increasing
their food purchasing power.
ELIGIBILITY REQUIREMENTS
Categorical Eligibility
Households in which all CalFresh-eligible members are authorized to receive CalWORKs or General
Relief (GR) are "categorically eligible" to receive CalFresh benefits and are automatically eligible to a
benefit determination without applying the resource or income limits.
Effective February 1, 2011, households not receiving CalWORKs or GR are “categorically eligible”
through access to the Temporary Assistance for Needy Family (TANF) brochure PUB 275. These
households with limited gross and adjusted net income, that do not exceed the limits, may also be
eligible for CalFresh benefits. Eligibility requirements for these non-categorically eligible households
are as follows:
Income
A two-step determination is done to compute income eligibility for non-categorically eligible households.
The gross and net income tests do not apply to categorically eligible households.
1. Gross Income
All non-categorically eligible households, except those containing an aged or disabled member,
must first meet a Gross Income Test and then, if eligible, the Net Income Test. Gross income is
defined as all non-excluded income from any source. The maximum allowed is 130% of the poverty
level as established by the federal government. Effective October 1, 2010, the gross income
maximum for non-categorically eligible households is as follows:
NO.
IN HOUSEHOLD
GROSS
INCOME
1
2
3
4
5
6
7
$1174 $1579 $1984 $2389 $2794 $3200 $3605
8*
$4010
* Each additional member + $406
If the gross income for the non-categorically eligible household is the same or less than shown in the
chart above, then the adjusted net income is computed.
2. Adjusted Net Income
All non-categorically eligible households, including those containing an aged or disabled member, must
meet the Net Income Test.
Adjusted net income is defined as all earned income, less 20% for work-related expenses, plus any
unearned income received minus allowable deductions.
CalFresh Fact Sheet
Page 2
ELIGIBILITY REQUIREMENTS (Continued)
These amounts are effective October 1, 2010 and are subject to change yearly. The allowable
deductions include:
¾
¾
¾
¾
¾
$142 standard deduction for household size of 1,2,3,
$153 standard deduction for household size of 4,
$179 standard deduction for household size of 5,
$205 standard deduction for household size of 6 or more,
$143 homeless standard shelter allowance for homeless households,
In addition, a deduction is allowed for the cost of housing and utilities that exceed 50% of the net
income. The maximum excess shelter allowance is $458.
Standard Utility Allowance (SUA)
SUA amount increased from $287 to 320 FFY 2010 – 11, effective October 1, 2010. A household
that does not qualify for the SUA, but incurs expenses for at least two separate utilities other than
heating and cooling is eligible for a LUA.
Limited Utility Allowance (LUA)
LUA amount increased from $88 to $94 FFY 2010 – 11, effective October 1, 2010. A household
that does not qualify for the SUA, but incurs expenses for at least two separate utilities other than
heating and cooling is eligible for a LUA.
Telephone Utility Allowance (TUA)
The TUA amount is unchanged and remains at $20 for FFY 2010 – 11. a household that is not
eligible for SUA or LUA, but incurs a telephone expense, or an expense for an equivalent form of
communication is eligible to receive a TUA.
Households containing a member 60 or older or a disabled member have no maximum on the cost of
housing and utilities exceeding 50% of their net income. These elderly/disabled households may also
qualify for special medical deductions.
This adjusted net income is used to compute the household's coupon allotment. Effective October 1,
2010, the adjusted income maximum for all eligible households is as follows:
NO. IN HOUSEHOLD
1
NET
INCOME
$903
2
1215
3
1526
4
5
6
1838
2150
2461
Each additional member + $312
7
2773
8*
3085
CalFresh Fact Sheet
Page 3
ELIGIBILITY REQUIREMENTS (Continued)
Resources
Resources are assets that are readily converted into cash or available for support of the household;
e.g., cash on hand or in a checking or savings account, United States savings bonds, stocks, and
funds in individual retirement accounts (IRA), etc. The total value of non-exempt resources is limited
to $2,000 for households in which all members are under age 60.
For households which include a member disabled or aged 60 or older, the limit is $3,000 per
household.
Effective January 1, 2004, all vehicles are exempt from resource consideration for the purpose of
determining eligibility to the CalFresh Program.
Effective February 1, 2011, households will no longer be required to meet the resource limit for the
purposes of determining eligibility to the CalFresh Program. Households must still meet other eligibility
requirements.
Eligibility for Immigrants
Legal non-citizens are ineligible to federal CalFresh benefits unless they meet the following conditions:
¾
¾
¾
Legally residing in the United States for five years or more;
Under the age of 18 regardless of the date of entry into the United States;
Disabled regardless of the date of entry into the United States and they (1) meet the definition of
disability in accordance to the California Department of Social Services (CDSS) and (2) are
receiving blind or disabled benefits, but not receiving SSI/SSP.
Effective April 1, 2003, federal eligibility was restored to legal non-citizens who have lived in the United
States as a qualified alien for five years from the date of entry.
Effective October 1, 2003, federal eligibility was restored to all legal non-citizen children under the age
of 18 years old regardless of their date of entry to the United States if otherwise eligible. Additionally
this regulation eliminates the deeming requirements for non-citizen children that count the income and
resources of the non-citizen’s sponsor when determining CalFresh eligibility and benefit amounts for the
non-citizen child.
The California Food Assistance Program (CFAP) provides CalFresh benefits to legal adult non-citizens
who are not eligible to the federal program because they have resided in the United States less than 5
years.
Eligibility for Drug Felons
Effective January 1, 2005, individuals convicted of felony use or possession for personal use of a
controlled substance may be eligible to receive CalFresh benefits if they can provide proof of one of
the following:
¾
¾
¾
¾
¾
Completion of a government-recognized drug treatment program;
Participation in a government-recognized drug treatment program;
Enrollment in a government-recognized drug treatment program;
Placement on a waiting list for a governmental-recognized drug treatment program: or
Other evidence that the illegal use of controlled substances has ceased.
CalFresh Fact Sheet
Page 4
ELIGIBILITY REQUIREMENTS (Continued)
Individuals will remain ineligible for CalFresh benefits if convicted of any drug felony offenses which
include: unlawfully transporting, importing into this state, selling, furnishing, administering, giving away,
possessing for sale, purchasing for purposes of sale, manufacturing, possessing precursors with the
intent to manufacture a controlled substance, or cultivating, harvesting, or processing marijuana.
Note: ALL DRUG FELONS CONVICTED AFTER AUGUST 22,1996, CONTINUE TO BE
INELIGIBLE TO RECEIVE CALWORKS BENEFITS
CalFresh Households
Eligibility is determined on a household by household basis. A "household" is an individual or a group
of individuals living together who customarily purchase and prepare food in common. Parents and their
children under 22 years of age living together are considered one household. Persons receiving
SSI/SSP, boarders, certain non-citizens and most persons residing in institutions are not eligible to
receive CalFresh benefits.
Certain types of institutions do qualify for CalFresh benefits. Residents of Food and Nutrition Service
(FNS) approved drug and alcoholic rehabilitation facilities, disabled persons, or persons age 60 or over
who live in FNS-approved group living arrangements, homeless individuals in shelters, and women with
children who are temporary residents of a shelter for battered women and children, may be eligible to
participate in the program.
Employable CalFresh participants who do not have a child less than 18 years of age in the home must
either be working 20 hours a week, performing workfare, or in an approved education/training program,
to receive CalFresh benefits for more than 3 out of any 36-month period.
APPLICATION PROCESSING AND EXPEDITED SERVICE
CalFresh applications are processed within 30 days. In emergency situations, an individual may
receive CalFresh benefits within three days of the date of their CalFresh application. It is our
department’s policy to issue expedited CalFresh benefits on the day of application, whenever possible.
The household must meet specified conditions which would render the household's situation as
emergent (e.g., monthly gross income is less than $150).
CALFRESH ISSUANCE AND USE
Los Angeles County uses a method of issuing CalFresh benefits called Electronic Benefit Transfer
(EBT). EBT is an issuance system in which benefits are stored in a central computer database and
electronically accessed by cardholders at a Point of Sale (POS) device in authorized food retailers
utilizing a reusable plastic card. When the participant is determined eligible, their benefit information is
electronically loaded each month into a central computer account.
Any domestic or imported food produced for human consumption may be purchased with CalFresh
benefits. Garden seeds and plants sold by retail grocery stores and grown for food may also be
purchased with CalFresh benefits. Effective July 25, 2005, homeless, elderly, and disabled households
may purchase prepared meals at United States Department of Agriculture – Food and Nutrition Service
authorized restaurants with CalFresh benefits.
Tobacco and alcohol may not be purchased with CalFresh benefits. The United States Department of
Agriculture (USDA) is responsible for authorizing retail food stores to accept CalFresh benefits.
Currently over 8,000 food retailers in Los Angeles County accept CalFresh benefits.
CalFresh Fact Sheet
Page 5
ELIGIBILITY REQUIREMENTS (Continued)
As a result of the American Recovery and Reinvestment Act (ARRA) of 2009, HR 1 of 2009 (Stimulus
Act of 2009), CalFresh benefits were increased by raising maximum benefit allotments by 13.6 percent
of the June 2008 value of the Thrifty Food Plan. The increase was effective April 1, 2009.
The total dollar amount of CalFresh benefits a household is entitled to receive is determined by the
number of eligible household members and their total adjusted net income. Examples effective
October 1, 2010 are as follows:
Maximum
CalFresh
Allotment
Persons in
Adjusted
CalFresh
If Zero
Household
Net Income
Coupons
Income
1
3
6
10
14
$ 90
$170
$300
$300
$350
$ 173
$ 475
$ 862
$1,412
$1,997
$ 200
$ 526
$ 952
$1,502
$2,102
CALFRESH EMPLOYMENT AND TRAINING REQUIREMENTS
The CalFresh Employment and Training (E&T) Program provides employment and training activities to
CalFresh participants not exempt from work registration. The goal of the program is to assist
participants in obtaining employment and avoiding long-term dependency on assistance.
The CalFresh Security Act of 1985 directed the States to develop CalFresh employment and training
programs. Counties were authorized to design programs which best fit their needs within the
parameters of the federal requirements. The Los Angeles County FSET Program consists of the
following components:
Non-Assistance CalFresh benefits
¾
Workfare
General Relief CalFresh benefits
¾
¾
¾
Job Search Workfare
Education/Vocational Training
Substance Abuse Recovery Program
Workfare
¾
The objective of the Workfare Program is to provide non-assistance ABAWD participants with work
activities that may lead to self-sufficiency. Participants gain job skills and work experience which
may assist them in obtaining entry level employment.
¾ Participants are required to perform workfare if participation level in another ABAWD component is
less than 20 hours a week. Sponsor organizations and agencies utilizing this program benefit from
client services, as well as play an important role in providing work skills and training experience to
the participants.
¾ There are approximately 217 workfare project sites located throughout Los Angeles County.
CalFresh Fact Sheet (Continued)
Page 6
CALFRESH EMPLOYMENT AND TRAINING REQUIREMENTS (Continued)
Currently we have workfare projects with 20 other Los Angeles County departments; incorporated
cities; State, Federal, and private non-profit agencies; and the Los Angeles and Inglewood Unified
School Districts.
Education/Vocational Training
DPSS has contracted with the Los Angeles County Community and Senior Services (CSS) and the Los
Angeles County Office of Education (LACOE) to conduct a full service employment program based on
the successful GAIN model. The employment services available to GR participants mirror those
provided to CalWORKs participants as follows:
¾
Orientation/appraisal provides motivation and self-esteem building skills. Participants not
already in education/training programs are scheduled for Job Club.
¾ A three-week Job Club teaches participants the skills they need to obtain a job. The first week
in a classroom setting, with the following two weeks focusing on supervised job search
activities.
¾ Upon completion of Job Club, a vocational assessment results in an agreed upon employment
plan to go into one of four components: (1) education, (2) vocational training, (3) workfare, (4)
job search/workfare.
CALFRESH EMPLOYMENT AND TRAINING REQUIREMENTS
Education/Vocational Training
¾
Supportive service screening/referrals assist participants in overcoming any substance abuse,
domestic violence and/or mental health barriers to employment.
¾ Post employment services offered assist participants in retaining employment, becoming
re-employed, and improving skills and earnings potential for better paying jobs.
Substance Abuse Recovery Program
¾
Participants in the Substance Abuse Recovery Program are provided a continuum of services,
starting out in residential and moving to outpatient treatment during the program.
¾ Once in outpatient treatment, the participants may be involved in any of the other program
components, for example, vocational training, and concurrent with their substance abuse recovery
treatment.
3-16-11
LRL:LE:rr
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
FACT SHEET FOR RESTAURANT MEALS PROGRAM
The Restaurant Meals Program is an extension of the Federal Food Stamp Act of 1977
and is established under the communal dining provision. The program is only available to
CalFresh households that are homeless, or contain members who are elderly (age 60 and
older), or disabled (receiving Social Security Disability, Railroad Retirement, or CAPI
benefits). Eligible participants may purchase prepared meals from restaurants that have
entered into a Memorandum of Understanding (MOU) with the County of Los Angeles.
California Department of Social Services (CDSS) elected to participate in the Restaurant
Meals program by piloting the program in the City/County of San Francisco in March 2003,
with the implementation of the Electronic Benefit Transfer System.
Los Angeles County was approved to participate in the Restaurant Meals Program by
CDSS in March of 2005, and on July 25, 2005, the Restaurant Meals Program was
implemented in Los Angeles County with 39 Subway Restaurants. Since that time, we
have been actively recruiting restaurants serving a variety of cuisines throughout the
county.
We believe that the Restaurant Meals Program can make a difference in the lives of
homeless, elderly, and disabled CalFresh participants. Many of the homeless CalFresh
participants are unable to prepare hot meals because they do not have a stove or a place
where they can prepare meals, and traditional CalFresh does not allow participants to
purchase prepared or hot meals. Perishable items often spoil, and for the homeless, this
limits the types of food that can be purchased and consumed. Many of the elderly and
disabled can no longer prepare their own meals, and depend on others for assistance.
Also, the homeless, elderly and disabled may have difficulty with carrying and storage of
food preparation items.
The Restaurants Meal Program provides greater independence to homeless, elderly, and
disabled CalFresh households. They now have the option to use their monthly CalFresh
benefits at the grocery store and/or at participating restaurants. This provides healthier food
choices.
There is no application process. CalFresh participants meeting the eligibility criterion have
been electronically coded and are automatically identified as eligible participants of the
Restaurant Meals Program when the Golden State Advantage Card is swiped. Program
participants can purchase breakfast, lunch and dinner from participating restaurants. A list
of participating restaurants is available at DPSS district offices and from the Restaurant
Meals website www.dpss.lacounty.gov/dpss/restaurant__meals/default.cfm.
It is the Department’s goal to provide Restaurant Meals Program participants with a variety
of low-cost meal choices.
03/11
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
Caroyln's Kitchen
853 East Manchester Avenue
Los Angeles, 90001
(323) 585-1660
Domino's Pizza
2025 East Florence Avenue
Los Angeles, 90001
(323) 587-0300
La Pizza Loca
1401 Gage Avenue, Suite A
Los Angeles, 90001
(323) 589-9150
Panda Chef
1901 East Gage Avenue
Los Angeles, 90001
(323) 585-2228
Pizza Hut
1457 East Florence Avenue, #109
Los Angeles, 90001
(323) 582-9200
Subway
1657 East 103rd Street
Los Angeles, 90001
(323) 566-1722
Tam's Burgers
6620 South Central Avenue
Los Angeles, 90001
(323) 585-8267
Subway
3300 South Central Avenue
Los Angeles, 90001
(323) 232-2211
Tam's Burgers
904 East Manchester Boulevard
Los Angeles, 90001
(323) 583-7076
Wimpy's Burger
8328 Compton Avenue
Los Angeles, 90001
(323) 584-4132
B D Burger
10203 Central Avenue
Los Angeles, 90002
(323) 563-3297
Burger King
1202 East Firestone Boulevard
Los Angeles, 90002
(323) 588-5988
Burger King
1673 East 103rd. Street
Los Angeles, 90002
(323) 564-8594
Jack in the Box
10307 South Central Avenue
Los Angeles, 90002
(323) 564-7156
Subway
NEW
10317 South Avalon Boulevard
Los Angeles, 90003
(323) 755-7200
A & T Burgers
9401 South Avalon Boulevard
Los Angeles, 90003
(323) 754-0709
Burger King
304 West Century Boulevard
Los Angeles, 90003
(323) 779-3684
El Pollo Loco
101 E. Manchester Boulevard
Los Angeles, 90003
(323) 759-7009
Jack in the Box
7120 South Broadway
Los Angeles, 90003
(323) 751-5083
Los Gordos Investments, Inc.
10425 Avalon Boulevard
Los Angeles, 90003
(323) 779-3474
Pizza Hut
7229 South Figueroa Street
Los Angeles, 90003
(323) 753-8800
Progresso Restaurant
6500 South Broadway
Los Angeles, 90003
(323) 751-8503
Subway
8565 South Broadway, #2
Los Angeles, 90003
(323) 451-0122
Tam's Burgers
10023 South Figueroa Street
Los Angeles, 90003
(323) 418-0951
Yoshinoya Beef Bowl
539 East Florence Avenue
Los Angeles, 90003
(323) 971-4560
Domino's Pizza
244 South Oxford Avenue, #T
Los Angeles, 90004
(213) 385-3888
Kentucky Fried Chicken
126 Vermont Avenue, #112
Los Angeles, 90004
(213) 487-4503
Kentucky Fried Chicken
240 North Virgil Avenue
Los Angeles, 90004
(213) 385-5380
Kentucky Fried Chicken
340 North Western Avenue
Los Angeles, 90004
(323) 464-9637
Pizza Hut
4251 West Beverly Boulevard
Los Angeles, 90004
(323) 660-1498
Subway
198 South Vermont Avenue
Los Angeles, 90004
(213) 380-1485
Subway
4206 Beverly Boulevard
Los Angeles, 90004
(213) 383-8400
Yoshinoya Beef Bowl
4202 Beverly Boulevard
Los Angeles, 90004
(213) 384-1557
Subway
NEW
1728 South Western Avenue
Los Angeles, 90006
(323) 731-3592
Chinatown Express
1001 South Alvarado Street
Los Angeles, 90006
(213) 384-9211
Domino's Pizza
1740 South Hoover Street, #D
Los Angeles, 90006
(213) 748-7774
El Pollo Loco
1934 West Olympic Boulevard
Los Angeles, 90006
(213) 380-2772
El Pollo Loco
986 South Vermont Avenue
Los Angeles, 90006
(213) 380-7721
Jack in the Box
2120 West Pico Boulevard
Los Angeles, 90006
(213) 252-8209
Kentucky Fried Chicken
2801 West Olympic Boulevvard
Los Angeles, 90006
(213) 386-7222
Pizza Hut
1555 South Western Avenue
Los Angeles, 90006
(323) 734-7713
Subway
1013 South Alvarado Street
Los Angeles, 90006
(213) 388-3040
Yoshinoya Beef Bowl
2897 Olympic Boulevard
Los Angeles, 90006
(213) 382-0184
Chano's
3000 South Figueroa Street
Los Angeles, 90007
(213) 747-3944
Domino's Pizza
2803 South Figueroa Street
Los Angeles, 90007
(213) 746-9999
El Pollo Loco
2904 South Figueroa Boulevard
Los Angeles, 90007
(213) 746-4232
Jack in the Box
2511 South Vermont Avenue
Los Angeles, 90007
(323) 735-7124
Lucy's Bakery
1330 West Washington Boulevard
Los Angeles, 90007
(213) 747-8919
Pizza Hut
1107 West Adams Boulevard
Los Angeles, 90007
(213) 746-2900
Subway
1625 West Washington Boulevard
Los Angeles, 90007
(323) 735-7218
Taco Bell
3629 South Vermont Avenue
Los Angeles, 90007
(323) 737-4717
Wendy's
3019 South Hoover Street
Los Angeles, 90007
(213) 746-8072
Wing Stop
2280 South Figueroa Street
Los Angeles, 90007
(213) 745-9464
Yoshinoya
2215 South Vermont Avenue, #106
Los Angeles, 90007
(323) 732-1516
Yoshinoya Beef Bowl
4000 South Vermont Avenue
Los Angeles, 90007
(323) 231-4378
Daddy Dave & Big Mama's
4287 S. Crenshaw Boulevard
Los Angeles, 90008
(323) 294-3019
El Pollo Loco
3350 West Vernon Avenue
Los Angeles, 90008
(323) 295-8122
M & M Soul Food
3552 W. Martin Luther King Jr., Blvd.
Los Angeles, 90008
(323) 299-1302
O'So Juicy N' Tasty
3347 West 43rd Place
Los Angeles, 90008
(323) 293-6348
Pizza Hut
4356 Leimert Boulevard
Los Angeles, 90008
(323) 291-4000
Rally's Hamburger
3650 W. Martin Luther King Jr., Blvd.
Los Angeles, 90008
(323) 299-8510
Subway
3939-C Crenshaw Boulevard
Los Angeles, 90008
(323) 293-7771
Wing N Stuff
West Martin Luther King Jr., Blvd.
Los Angeles, 90008
(323) 295-2928
Wing Stop
3825 South Crenshaw Boulevard
Los Angeles, 90008
(323) 296-9464
Page 1
NEW
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
El Pollo Loco
3959 Wilshire Boulevard
Los Angeles, 90010
(213) 383-3351
Pizza Hut
3959 Wilshire Boulevard
Los Angeles, 90010
(213) 380-5900
Burger King
NEW
2511 South San Pedro Street
Los Angeles, 90011
(213) 748-2821
El Pollo Loco
408 East Washington Boulevard
Los Angeles, 90011
(213) 748-7616
El Pollo Loco
4405 Avalon Boulevard
Los Angeles, 90011
(323) 846-8488
El Pollo Loco
5800 South Vermont Avenue
Los Angeles, 90011
(323) 751-1556
Jack in the Box
4407 South Central Avenue
Los Angeles, 90011
(323) 233-4440
Louisiana Fried Chicken & Chinese
4400 South Central Avenue
Los Angeles, 90011
(323) 232-2005
Pizza Hut
4351 South Central Avenue
Los Angeles, 90011
(323) 233-1444
Tam's Burger
2801 South Central Avenue
Los Angeles, 90011
(323) 234-5630
Tam's Burger
5023 South Central Avenue
Los Angeles, 90011
(323) 233-1320
Yoshinoya Beef Bowl
1900 South San Pedro Street
Los Angeles, 90011
(213) 748-1908
La Pizza Loca
250 E. Martin Luther King Jr., Blvd.
Los Angeles, 90011
(323) 231-1288
Subway
370 East 2nd Street
Los Angeles, 90012
(213) 613-0741
Broadway Food Corner
315 West 5th Street
Los Angeles, 90013
(213) 629-1244
Domino's Pizza
545 South Olive Street
Los Angeles, 90013
(213) 623-2424
Martha's Kitchen
507 East 4th Street
Los Angeles, 90013
(213) 625-8341
People Market
500 South San Pedro Street
Los Angeles, 90013
(213) 817-8700
Richie's Café & Grill
965 North Vignes Street, #6
Los Angeles, 90012
Unlisted
Corner Kafe
301 East 7th Street
Los Angeles, 90014
(213) 622-5202
Downtown Catch 21
441 South Central Avenue
Los Angeles, 90013
(213) 485-1614
Food for Life, Inc.
401 East 6th Street
Los Angeles, 90014
(213) 896-0200
Food For You Market & Restaurant
653 South San Pedro Street
Los Angeles, 90014
(213) 327-1107
Margarita's Place
660 South Main Street
Los Angeles, 90014
Unlisted
Pizza Hut
718 South Los Angeles Street
Los Angeles, 90014
(213) 489-3863
Pizza Xpress
303 East 7th Street
Los Angeles, 90014
(213) 489-3863
Tony's Burger
649 South Wall Street, #1
Los Angeles, 90014
(213) 627-2768
Hong Kong Express
155 West Washington Boulevard
Los Angeles, 90015
(213) 765-3318
La Pizza Loca
1563 West Pico Boulevard
Los Angeles, 90015
(213) 380-2190
Pizza Hut
1562 West Pico Boulevard
Los Angeles, 90015
(213) 388-6111
Pollo Campero
1605 West Olympic Boulevard
Los Angeles, 90015
(213) 251-8594
Subway
1400 West Pico Boulevard
Los Angeles, 90015
(213) 477-8411
Subway
308 South Broadway
Los Angeles, 90015
(213) 626-1605
Yoshinoya
NEW
1570 South Western Avenue, Suite 100
Los Angeles, 90016
(323) 733-3317
Burger King
1662 West Martin Luther King Jr., Blvd.
Los Angeles, 90016
(323) 296-1159
Burger King
3036 South Crenshaw Boulevard
Los Angeles, 90016
(323) 737-2622
California Steak & Fries
3745 South La Brea Avenue
Los Angeles, 90016
Unlisted
Domino's Pizza
3631 Crenshaw Boulevard, #113
Los Angeles, 90016
(323) 737-7700
El Pollo Loco
2801 Crenshaw Boulevard
Los Angeles, 90016
(323) 734-3373
Subway
2817 South Crenshaw Boulevard
Los Angeles, 90016
(323) 735-6962
Taco Bell
2800 South Crenshaw Boulevard
Los Angeles, 90016
(323) 737-5700
Taurus Flavors Deli
5012 West 21st Street
Los Angeles, 90016
(323) 937-4252
Kentucky Fried Chicken
1501 West 6th Street
Los Angeles, 90017
(213) 483-9412
Subway
801-A South Flower Street
Los Angeles, 90017
(213) 892-0926
Burger King
3533 South Western Avenue
Los Angeles, 90018
(323) 732-2197
Haven Burgers
3515 Rodeo Road
Los Angeles, 90018
(323) 299-5271
Master Burger
4366 West Adams Boulevard
Los Angeles, 90018
(323) 734-8021
Domino's Pizza
3309 West Pico Boulevard
Los Angeles, 90019
(323) 735-8008
Domino's Pizza
5151 West Pico Boulevard, #B
Los Angeles, 90019
(323) 934-3030
El Pollo Loco
1545 South Western Avenue
Los Angeles, 90019
(323) 732-5626
Pizza Hut
5101 Venice Boulevard
Los Angeles, 90019
(323) 938-6111
Yoshinoya Beef Bowl
4846 West Pico Boulevard
Los Angeles, 90019
(323) 931-9972
Burger King
833 South Central Avenue
Los Angeles, 90021
(213) 622-2755
Jack in the Box
1415 South Alameda Street
Los Angeles, 90021
(213) 746-8827
Pop's Foodmart and Restaurant
810 East 7th Street
Los Angeles, 90021
(213) 689-4311
Subway
1000 East Washington Boulevard
Los Angeles, 90021
(213) 765-9579
Domino's Pizza
4746 East Cesar Chavez Avenue
Los Angeles, 90022
(323) 268-3030
El Pollo Loco
5160 East Olympic Boulevard
Los Angeles, 90022
(323) 981-9196
Jack in the Box
5075 East Whittier Boulevard
Los Angeles, 90022
(323) 266-2449
John's Burgers
6537 Whittier Boulevard
Los Angeles, 90022
(323) 721-1524
La Pizza Loca
5040 Whittier Boulevard
Los Angeles, 90022
(323) 261-7744
Pizza Hut
5213 Whittier Boulevard
Los Angeles, 90022
(323) 267-0300
Subway
289 South Atlantic Boulevard
Los Angeles, 90022
(323) 264-8885
Subway
5536 East Whittier Boulevard
Commerce, 90022
(323) 720-1573
NEW
Page 2
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
Yoshinoya Beef Bowl
701 South Atlantic Boulevard
Los Angeles, 90022
(323) 268-3636
Burger King
2675 East Olympic Boulevard
Los Angeles, 90023
(323) 262-6002
Carnitas Michoacan
741 South Soto Street
Los Angeles, 90023
(323) 266-7188
Domino's Pizza
2193 Whittier Boulevard
Los Angeles, 90023
(323) 268-2000
El Pollo Loco
1224 South Soto Street
Los Angeles, 90023
(323) 261-4671
Jack in the Box
1335 South Soto Street
Los Angeles, 90023
(323) 263-1450
Sam's Tacos
715 South Soto Street
Los Angeles, 90023
(323) 263-7858
TV Café
1777 East Olympic Boulevard
Los Angeles, 90023
(213) 624-1155
Yoshinoya Beef Bowl
1201 South Soto Street
Los Angeles, 90023
(323) 269-3575
Burger King
900 Westwood Boulevard
Los Angeles, 90024
(310) 208-6781
Domino's Pizza
1371 Westwood Boulevard
Los Angeles, 90024
(310) 824-5000
Domino's Pizza
12237 Santa Monica Boulevard
Los Angeles, 90025
(310) 826-3030
El Pollo Loco
11870 Santa Monica Boulevard
Los Angeles, 90025
(310) 820-7924
Pizza Hut
12217 Santa Monica Boulevard
Los Angeles, 90025
(310) 207-7748
Subway
11819 Wilshire Boulevard, Unit #105
Los Angeles, 90025
(310) 444-1813
Subway
11275 Santa Monica Boulevard
Los Angeles, 90025
(310) 966-1650
Burger King
1301 Glendale Boulevard
Los Angeles, 90026
(213) 413-8655
Domino's Pizza
1311-G Glendale Boulevard
Los Angeles, 90026
(213) 413-8444
Domino's Pizza
3502 Sunset Boulevard
Los Angeles, 90026
(323) 667-2323
El Pollo Loco
1260 North Vine Boulevard
Hollywood, 90026
(323) 464-0860
El Pollo Loco
330 North Alvarado Street
Los Angeles, 90026
(213) 353-0084
Jack in the Box
1710 Glendale Boulevard
Echo Park, 90026
(323) 661-7225
Patra Burgers
1524 Sunset Boulevard
Los Angeles, 90026
(213) 250-0301
Pizza Hut
2542 West Temple Street
Los Angeles, 90026
(213) 387-7711
Domino Pizza
5065 Hollywood Boulevard, #101
Los Angeles, 90027
(323) 662-6666
El Pollo Loco
5319 Sunset Boulevard
Los Angeles, 90027
(323) 462-2644
Pizza Hut
2724 Hyperion Avenue
Los Angeles, 90027
(323) 663-1200
Wendy's Restaurant
1305 North Vermont Avenue
Los Angeles, 90027
(323) 663-7387
Domino's Pizza
4815-H Valley Boulevard
Los Angeles, 90028
(323) 222-7722
Domino's Pizza
6051 Hollywood Boulevard, #106
Los Angeles, 90028
(323) 463-7044
Pizza Hut
6660 West Sunset Boulevard
Los Angeles, 90028
(323) 467-4466
El Pollo Loco
912 North Vermont Avenue
Los Angeles, 90029
(323) 660-7900
El Pollo Loco
3925 Sunset Boulevard
Los Angeles, 90029
(323) 665-1333
Pizza Hut
4629 W. Santa Monica Boulevard
Hollywood, 90029
(323) 663-0400
Subway
1018 North Vermont Avenue
Los Angeles, 90029
(323) 664-6035
Yoshinoya Beef Bowl
700 North Vermont Avenue
Los Angeles, 90029
(323) 668-1935
Dino's Burgers
2817 North Main Street
Los Angeles, 90031
(323) 223-1843
Jack in the Box
2521 North Pasadena Avenue
Los Angeles, 90031
(323) 223-6094
Yoshinoya Beef Bowl
2500 Pasadena Avenue
Los Angeles, 90031
(323) 222-9705
El Pollo Loco
5151 State University Drive
Los Angeles, 90032
(323) 343- 6728
Pizza Hut
5130 South Huntington Drive
El Sereno, 90032
(323) 221-3100
Rally's Hamburger
9829 Venice Boulevard
Los Angeles, 90034
(323) 753-5033
La Pizza Loca
2924 East Cesar Chavez Avenue
Los Angeles, 90033
(323) 263-9949
Tom's Burgers
320 South Soto Street
Los Angeles, 90033
(323) 264-4422
Burger King
3520 South Sepulveda Boulevard
Los Angeles, 90034
(310) 390-2891
Domino's Pizza
2815 South Robertson Boulevard
Los Angeles, 90034
(310) 559-3030
El Pollo Loco
3008 South Sepulveda Boulevard
Los Angeles, 90034
(310) 444-0010
Jack in the Box
10701 Venice Boulevard
Los Angeles, 90034
(310) 836-2385
Pizza Hut
3002 South Sepulveda Boulevard
Los Angeles, 90034
(310) 473-1133
Subway
10401 Venice Boulevard
Los Angeles, 90034
(310) 204-2730
Subway
8511 Venice Boulevard
Los Angeles, 90034
(310) 558-4222
Pizza Hut
8947 West Pico Boulevard
Los Angeles, 90035
(310) 888-0070
Domino's Pizza
7125 Beverly Boulevard
Los Angeles, 90036
(323) 936-1140
El Pollo Loco
5001 Wilshire Boulevard, Suite 101
Los Angeles, 90036
(323) 937-7171
Jack in the Box
465 South Fairfax Avenue
Los Angeles, 90036
(323) 936-7709
Jack in the Box
5201 Wilshire Boulevard
Los Angeles, 90036
(323) 965-8102
Kentucky Fried Chicken
5925 West Third Street
Los Angeles, 90036
(323) 931-4861
Louisiana Fried Chicken
NEW
1030 West Martin Luther King Jr., Blvd.
Los Angeles, 90037
(323) 233-8728
Burger King
4410 South Figueroa Street
Los Angeles, 90037
(323) 846-9404
Carl's Jr
1001 W. Martin Luther King Jr., Blvd.
Los Angeles, 90037
(323) 766-8290
Chano's
3850 South Figueroa Street
Los Angeles, 90037
(213) 748-0397
Domino's Pizza
5401 South Figueroa Street, #8
Los Angeles, 90037
(323) 753-6888
Jack in the Box
4353 South Figueroa Street
Los Angeles, 90037
(323) 235-4345
Kentucky Fried Chicken
1425 Martin Luther King Jr., Blvd.
Los Angeles, 90037
(323) 291-4322
Page 3
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
Kentucky Fried Chicken
2809 South Figueroa Street
Los Angeles, 90037
(213)748-5632
Pizza Hut
1014 W. Martin Luther King Jr., Blvd.
Los Angeles, 90037
(323) 231-8000
Subway
3974 South Figueroa Street
Los Angeles, 90037
(213) 747-9779
Subway
1030 Martin Luther King Blvd., #106B
Los Angeles, 90037
(323) 231-4200
Taco Bell
5801 South Vermont Avenue
Los Angeles, 90037
(323) 759-1891
The BBQ Pit Stop
5103 South Figueroa Street
Los Angeles, 90037
(323) 232-5776
China Lee Chinese Fast Food
5920 Santa Monica Boulevard
Los Angeles, 90038
(323) 871-2838
Jack in the Box
1243 North Highland
Los Angeles, 90038
(323) 461-7605
Subway
6115 West San Monica Blvd, Unit D
Los Angeles, 90038
(323) 463-6115
Subway
750 North Vine Street
Los Angeles, 90038
(323) 465-1025
Tam's Burger
4419 South Normandie Avenue
Los Angeles, 90037
(323) 290-9821
Wok & Roll China
1050 Vine Street
Los Angeles, 90038
(323) 464-5799
Yoshinoya Beef Bowl
1075 North Western Avenue, # 109
Los Angeles, 90038
(323) 871-0877
Yoshinoya Beef Bowl
6300 Santa Monica Boulevard
Los Angeles, 90038
(323) 467-8875
Domino's Pizza
5742 Olympic Boulevard
Commerce, 90040
(323) 888-1555
Jack in the Box
7503 East Slauson Avenue
Commerce, 90040
(323) 890-2945
Subway
6130 East Washington Boulevard
Commerce, 90040
(323) 721-8200
Burger King
4959 Eagle Rock Boulevard
Los Angeles, 90041
(213) 258-2040
Domino's Pizza
1759 Colorado Boulevard
Los Angeles, 90041
(323) 256-5991
Jack in the Box
4470 Eagle Rock Boulevard
Los Angeles, 90041
(323) 259-3154
Pizza Hut
2930 East Colorado Boulevard
Los Angeles, 90041
(818) 552-2277
Domino's Pizza
5524 York Boulevard
Los Angeles, 90042
(323) 255-5999
Pizza Hut
5839 York Boulevard
Highland Park, 90042
(323) 256-5700
R & J Family Restaurant
8852 Rosecrans Avenue
Downey, 90042
(562) 408-2960
Fred Down Home Burger
2524 West Slauson Avenue
Los Angeles, 90043
(323) 298-7762
Fresh and Meaty Burgers
3016 West Florence Avenue
Los Angeles, 90043
(323) 751-2247
Jack in the Box
2220 West Slauson Avenue
Los Angeles, 90043
(323) 298-0653
Jack in the Box
4210 South Crenshaw Boulevard
Los Angeles, 90043
(323) 293-0034
Mama's Chicken
2510 West Slauson Avenue
Los Angeles, 90043
(323) 292-9777
Pioneer Pizza
3272 West Slauson Avenue
Los Angeles, 90043
(323) 299-4444
Popeye's Chicken & Biscuit
3268 West Slauson Avenue
Los Angeles, 90043
(323) 294-8116
Subway
3274 W. Slauson Ave., #202-203
Los Angeles, 90043
(323) 296-0996
The Flavor Table
2812 West Florence Avenue
Los Angeles, 90043
(323) 751-6000
Bobo's Hamburgers
1220 Firestone Boulevard
Los Angeles, 90044
(323) 582-9978
Chris Burger
4444 Crenshaw Boulevard
Los Angeles, 90044
(323) 295-4004
Domino's Pizza
950 West Manchester Avenue
Los Angeles, 90044
(323) 758-5500
Dragon Loco
1011 West Florence Avenue
Los Angeles, 90044
(323) 565-4060
El Pollo Loco
1360 West Imperial Highway
Los Angeles, 90044
(323) 757-8229
House of Edaw
9000 South Vermont Avenue
Los Angeles, 90044
(323) 777-1614
Jack in the Box
1000 West Slauson Avenue
Los Angeles, 90044
(323) 834-0199
Mc Donald's
501 West Imperial Highway
Los Angeles, 90044
(323) 756-9006
Pizza Hut
1001 West Century Boulevard
Los Angeles, 90044
(323) 757-9000
Subway
5864 South Vermont Avenue
Los Angeles, 90044
(323) 758-5700
Subway
8310 South Vermont Avenue
Los Angeles, 90044
(323) 750-8965
Tam's Burger
500 West Manchester Avenue
Los Angeles, 90044
(323) 735-6962
Yoshinoya Beef Bowl
1004 West Slauson Avenue
Los Angeles, 90044
(213) 565-3506
Burger King
5228 West Centinela Avenue
Los Angeles, 90045
(310) 649-2146
El Pollo Loco
5300 Centinela Avenue
Los Angeles, 90045
(310) 645-2080
Pizza Hut
6312 West 89th Street
Los Angeles, 90045
(310) 641-1114
Subway
5339 West Centinela Avenue, #A
Los Angeles, 90045
(310) 670-7092
Subway
1111 North Fairflex Avenue
West Hollywood, 90046
(323) 650-2888
Subway
7353 Melrose Avenue
Los Angeles, 90046
(323) 951-9266
Wendy's Restaurant
7135 West Sunset Boulevard
Los Angeles, 90046
(323) 876-1925
Aunt Rosa Lee's Mississippi Soulfood
10336 South Western Avenue
Los Angeles, 90047
Unlisted
Best Burger
7730 South Western Avenue
Los Angeles, 90047
(323) 752-2205
Burger King
1453 W. Manchester Boulevard
Los Angeles, 90047
(323) 751-6292
Carl's Jr.
11224 South Western Avenue
Los Angeles, 90047
(323) 242-0011
Domino's Pizza
2101 West Century Boulevard
Los Angeles, 90047
(323) 756-0080
D's Original Take Out Grill
7873 South Western Avenue
Los Angeles, 90047
(323) 971-3663
El Pollo Loco
1714 West Century Boulevard
Los Angeles, 90047
Unlisted
Golden Bird
8300 South Western Avenue
Los Angeles, 90047
(323) 750-0705
Master Burger
3420 West Slauson Avenue, #A
Los Angeles, 90047
(323) 293-0890
Pizza Hut
1851 West Slauson Avenue
Los Angeles, 90047
(323) 290-2290
Subway
1810 West Slauson Avenue
Los Angeles, 90047
(323) 292-8788
Page 4
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
Wing Stop
1754 West Slauson Avenue, #A
Los Angeles, 90047
(323) 293-9464
Zelma's Soul Food & More
1561 West Florence Avenue
Los Angeles, 90047
(323) 751-4688
Subway
4949 West Slauson Avenue, A-3
Los Angeles, 90056
(323) 299-7991
Burger King
2025 West 3rd Street
Los Angeles, 90057
(213) 484-9803
El Pollo Loco
503 South Alvarado Street
Los Angeles, 90057
(213) 413-1811
La Pizza Loca
610 South Rampart Avenue
Los Angeles, 90057
(310) 677-1117
Subway
610 South Rampart Boulevard
Los Angeles, 90057
(213) 388-2078
Subway
2112 Beverly Boulevard
Los Angeles, 90057
(213) 353-0043
Subway
712 South Los Angeles Street
Los Angeles, 90057
(213) 624-6490
Yoshinoya Beef Bowl
642 South Alvarado Street
Los Angeles, 90057
(213) 483-2455
China Express & Louisiana Fried Chicken
1601 East Imperial Highway, #101
Los Angeles, 90059
(323) 563-8838
Domino's Pizza
417 West El Segundo Boulevard
Los Angeles, 90059
(323) 756-3030
Golden Seafood Express & Hamburger
1601 East Imperial Highway
Los Angeles, 90059
(323) 566-6119
James Fish Market
625 East El Segundo Boulevard
Los Angeles, 90059
(323) 754-5558
Jordan's Hot Dogs
1330 East Imperial Highway
Los Angeles, 90059
(323) 569-6165
Mc Donald's
11800 Wilmington Avenue
Los Angeles, 90059
(323) 564-3448
NY Express Donuts & Chinese
10727 South Central Avenue
Los Angeles, 90059
(323) 566-1626
Pizza Hut
11710 South Wilmington Avenue
Los Angeles, 90059
(323) 563-9100
Pizza Hut
611 East Imperial Highway
Los Angeles, 90059
(323) 820-9629
Slater Market/House of Burger
11603 1/2 South Slater Street
Los Angeles, 90059
(323) 563-1129
Subway
11812 Wilmington Avenue
Los Angeles, 90059
(323) 567-7009
Taco Pete
12007 South Central Avenue
Los Angeles, 90059
(323) 569-5164
A & T Burgers
11318 Avalon Boulevard
Los Angeles, 90061
(323) 757-0710
Burger King
12736 South Avalon Boulevard
Los Angeles, 90061
(323) 754-1373
El Pollo Loco
12800 Avalon Boulevard
Los Angeles, 90061
(310) 532-0060
Jack in the Box
12735 South Main Street
Los Angeles, 90061
(323) 820-1865
Jack in the Box
1441 West Martin Luther King Jr., Blvd.
Los Angeles, 90062
(323) 290-2520
Pizza King
3993 South Western Avenue
Los Angeles, 90062
(323) 299-9838
Taco Bell
1401 W. Martin Luther King Jr., Blvd.
Los Angeles, 90062
(323) 296-5505
Mel's Bakery & Café
1977 West 48th. Street
Los Angeles, 90062
(323) 293-0193
Subway
3991 South Western Avenue
Los Angeles, 90062
(323) 294-3300
Burger King
1540 North Eastern Avenue
Los Angeles, 90063
(323) 262-4200
Burger King
1540 North Eastern Avenue
Los Angeles, 90063
(323) 262-4200
Pizza Hut
3400 East First Street
Los Angeles, 90063
(323) 265-0800
Pizza Hut
4209 Cesar Chavez Boulevard
Los Angeles, 90063
(323) 260-7100
Troy's Burger
4260 East Cesar Chavez Avenue
Los Angeles, 90063
(323) 269-9950
Domino's Pizza
10616 West Pico Boulevard
Los Angeles, 90064
(310) 839-0800
Subway
2408 South Barrington Avenue
Los Angeles, 90064
(310) 479-7827
Burger King
NEW
3241 North Figueroa Street
Los Angeles, 90065
(323) 342-9948
La Pizza Loca
3109 San Fernando Road
Los Angeles, 90065
(323) 256-4710
Cypress Best Burgers
3240 North Figueroa Street
Los Angeles, 90065
(323) 223-1505
Domino's Pizza
520 West Avenue 26
Los Angeles, 90065
(323) 225-1080
Pizza Hut
4329 North Figueroa Street
Highland Park, 90065
(323) 221-2700
Subway
3105 San Fernando Road
Los Angeles, 90065
(323) 256-0466
El Pollo Loco
3070 San Fernando Road
Los Angeles, 90065
(323) 256-1938
Yoshinoya
NEW
3081 North San Fernando Road
Los Angeles, 90065
(323) 258-4142
Domino's Pizza
902 North La Cienega Boulevard
Los Angeles, 90069
(310) 855-1899
Burger King
7900 Atlantic Avenue
Cudahy, 90201
(213) 560-4424
El Pollo Loco
6929 Eastern Avenue
Bell Gardens, 90201
(323) 771-5544
El Pollo Loco
7519 South Atlantic Avenue
Cudahy, 90201
(323) 560-0758
El Zunzal Pupuseria
6311 South Atlantic Avenue
Bell, 90201
(323) 562-2776
Jack in the Box
4525 Florence Avenue
Bell, 90201
(323) 771-9439
Kentucky Fried Chicken
5735 East Florence Avenue
Bell Gardens, 90201
(323) 773-3323
La Pizza Loca
7296 Atlantic Boulevard
Cudahy, 90201
(323) 773-5755
Perry Burger
6402 East Florence Avenue
Bell Gardens, 90201
(562) 928-2466
Pizza Hut
7000 Atlantic Avenue
Bell, 90201
(323) 771-4000
Sam's Burgers & Fast Food
6007 East Florence Avenue
Bell Gardens, 90201
(323) 560-4011
Tacos Don Chente
6377 Florence Avenue
Bell, 90201
(562) 928-5000
Tom's Burger
6484 East Florence Avenue
Bell Gardens, 90201
(562) 927-3984
Yoshinoya Beef Bowl
6801 S. Eastern Avenue
Bell Gardens, 90201
(323) 771-8568
Domino's Pizza
371 South Doheny Drive
Beverly Hills, 90212
(310) 273-8600
Pizza Hut
5736 Gage Avenue
Bell Gardens, 90201
(323) 560-5500
China Star Express
918 South Central Avenue
Compton, 90220
(310) 632-6829
Del Taco
1641 South Alameda Street
Compton, 90220
(310) 608-2325
Page 5
NEW
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
El Pollo Loco
101 East Compton Boulevard
Compton, 90220
(310) 631-7691
Ichibang Teriyaki
116 East Compton Boulevard
Compton, 90220
(310) 898-2175
Jack in the Box
115 North Central Avenue
Compton, 90220
(310) 603-8728
Louisiana Fried Chicken
734 West Alondra Boulevard
Compton, 90220
(310) 764-2110
Pizza Hut
153 East Compton Boulevard
Compton, 90220
(310) 635-5900
Popeye's Chicken
300 West Compton Boulevard
Compton, 90220
(310) 669-8830
Subway
159 East Compton Boulevard
Compton, 90220
(310) 632-9642
Subway
1720 West Rosecrans Avenue
Compton, 90220
(310) 639-2585
Burger King
290 East Compton Boulevard
Compton, 90221
(310) 635-6345
Chinatown Express & Louisiana Fried Chicken
1900 North Long Beach Boulevard
Compton, 90221
(310) 639-2888
Domino's Pizza
821 South Long Beach Boulevard
Compton, 90221
(310) 635-1212
Jack in the Box
701 East Rosecrans Avenue
Compton, 90221
(310) 608-1083
Southern Wok
1110 South Long Beach Blvd., #1
Compton, 90221
(310) 604-3868
California Steak & Fries
6000 Sepulveda Boulevard
Culver City, 90230
(310) 398-2575
Domino's Pizza
4238 South Sepulveda Boulevard
Culver City, 90230
(310) 839-0999
Pizza Hut
10702 Jefferson Avenue
Culver City, 90230
(310) 838-9600
Subway
3817 Sepulveda Boulevard
Culver City, 90230
(310) 397-1515
Subway
4730 South Inglewood Boulevard
Culver City, 90230
(310) 398-1515
Subway
3895 Overland Avenue
Culver City, 90232
(310) 287-0790
Wendy's
9036 West Venice Boulevard
Culver City, 90232
(310) 837-7736
Domino's Pizza
7433-A Florence Avenue
Downey, 90240
(562) 806-4631
Jack in the Box
8136 Telegraph Road
Downey, 90240
(562) 776-6038
Kentucky Fried Chicken
7865 East Florence Avenue
Downey, 90240
(562) 928-2916
Pizza Hut
7936 Florence Avenue
Downey, 90240
(562) 927-4090
Yoshinoya Beef Bowl
7910 Florence Avenue
Downey, 90240
(562) 928-1603
El Pollo Loco
14329 Lakewood Boulevard
Downey, 90241
(562) 602-1550
El Pollo Loco
9341 East Firestone Boulevard
Downey, 90241
(562) 862-3139
Subway
251 Stonewood Street
Downey, 90241
(562) 923-1300
Domino's Pizza
7840 Imperial Highway
Downey, 90242
(562) 861-3030
Pizza Hut
9111 East Imperial Highway
Downey, 90242
(562) 862-0727
Subway
13541 Lakewood Boulevard
Downey, 90242
(562) 633-3377
Wendy's
14305 Lakewood Boulevard
Downey, 90242
(562) 630-0875
Domino's Pizza
130 East Grand Avenue
El Segundo, 90245
(310) 322-6733
Burger King
1701 West Artesia Boulevard
Gardena, 90247
(310) 808-2209
Cici Pizza
1050 West Rosecrans Avenue
Gardena, 90247
(310) 532-2229
Domino's Pizza
1544 West Redondo Beach Blvd.
Gardena, 90247
(310) 327-0444
El Pollo Loco
15329 Normandie Avenue
Gardena, 90247
(310) 515-7562
Jack in the Box
1000 Rosecrans Avenue
Gardena, 90247
(310) 538-3149
Kentucky Fried Chicken
1078 West Rosecrans Avenue, #B
Gardena, 90247
(310)324-9153
Pizza Hut
1336 West Rosecrans Avenue
Gardena, 90247
(310) 329-9100
Popeye's Chicken
1150 Rosecrans Avenue
Gardena, 90247
(310) 323-7708
Subway
1096 Rosecrans Avenue
Gardena, 90247
(310) 329-8458
Jack in the Box
1099 West Artesia Boulevard
Gardena, 90248
(310) 532-3528
Wendy's
17420 South Western Avenue
Gardena, 90248
(310) 327-7707
Domino's Pizza
15900 Crenshaw Boulevard, #A
Gardena, 90249
(310) 327-7266
Golden Bird
14905 Western Avenue
Gardena, 90249
(310) 715-6774
Jack in the Box
13510 Western Avenue
Gardena, 90249
(310) 538-5561
Subway
15900 Crenshaw Boulevard, #E
Gardena, 90249
(310) 523-3390
Tottino's Pizza & Louisiana Fried Chicken
2216 El Segundo Boulevard
Gardena, 90249
(310) 327-4002
B & R's Old Fashion Burger
3512 Rosecrans Avenue
Hawthorne, 90250
(310) 679-4774
Domino's Pizza
4285 El Segundo Boulevard
Hawthorne, 90250
(310) 219-0008
El Pollo Loco
14300 Prairie Avenue
Hawthorne, 90250
(310) 644-1956
Jack in the Box
5016 El Segundo Boulevard
Hawthorne, 90250
(310) 644-0027
Pizza Hut
12203 Hawthorne Boulevard
Hawthorne, 90250
(310) 219-3000
Pizza Hut
3109 Rosecrans Avenue
Hawthorne, 90250
(310) 355-0300
Pizza Hut
4830 West Rosecrans Avenue
Hawthorne, 90250
(310) 978-8100
Rally's Hamburger
12812 Hawthorne Boulevard
Hawthorne, 90250
(310) 219-0013
Subway
12811 Crenshaw Boulevard
Hawthorne, 90250
(310) 675-4447
Subway
11808 Hawthorne Boulevard
Hawthorne, 90250
(310) 978-4030
Subway
12770-B Hawthorne Boulevard
Hawthorne, 90250
(310) 675-3050
Subway
14304 Ocean Gate Avenue
Hawthorne, 90250
(310) 675-4070
Yoshinoya Beef Bowl
14308 Prairie Avenue
Hawthorne, 90250
(310) 978-3074
El Pollo Loco
719 Pier Avenue
Hermosa Beach, 90254
(310) 406-2824
Page 6
NEW
Domino's Pizza
201 Pacific Highway
Hermosa Beach, 90254
(310) 318-3344
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
Jack in the Box
1160 Aviation Boulevard
Hermosa Beach, 90254
(310) 379-9173
Bobo's Hamburgers
7300 Pacific Boulevard
Huntington Park, 90255
(323) 856-2020
Domino's Pizza
2717 Slauson Avenue
Huntington Park, 90255
(323) 589-7374
El Pollo Loco
2501 Slauson Avenue
Huntington Park, 90255
(323) 588-5009
Pizza Hut
3176 Florence Avenue
Huntington Park, 90255
(323) 587-2454
Pizza Hut
6048 Pacific Boulevard
Huntington Park, 90255
(323) 585-2500
Subway
2501 Florence Boulevard
Huntington Park, 90255
(323) 588-1800
Subway
3126 Florence Avenue
Huntington Park, 90255
(323) 583-5300
Yoshinoya Beef Bowl
2667 East Florence Avenue, #G
Huntington Park, 90255
(323) 583-8025
Domino's Pizza
15114 Inglewood Avenue
Lawndale, 90260
(310) 676-0017
Jack in the Box
15025 Hawthorne Boulevard
Lawndale, 90260
(310) 644-3584
Subway
16129 Hawthorne Boulevard
Lawndale, 90260
(310) 371-1264
Wendy's
14502 Hawthorne Boulevard
Lawndale, 90260
(310) 679-6009
Domino's Pizza
11391 Long Beach Boulevard
Lynwood, 90262
(310) 604-1299
El Pollo Loco
11118 Long Beach Boulevard
Lynwood, 90262
(310) 632-7446
Jack in the Box
11390 Atlantic Boulevard
Lynwood, 90262
(310) 631-6933
La Pizza Loca
12630 Long Beach Boulevard
Lynwood, 90262
(310) 764-1600
Pizza Hut
3601 Martin Luther King Jr., Blvd.
Lynwood, 90262
(310) 761-1000
Subway
10921 Atlantic Avenue
Lynwood, 90262
(310) 608-0688
Subway
3180 Imperial Highway
Lynwood, 90262
(310) 763-8001
Subway
3628 Martin Luther King Jr., Blvd.
Lynwood, 90262
(310) 632-6808
Domino's Pizza
3001 Sepulveda Boulevard
Manhattan Beach, 90266
(310) 546-5833
El Pollo Loco
800 North Sepulveda Boulevard
Manhattan Beach, 90266
(310) 376-4143
Jack in the Box
815 North Sepulveda Boulevard
Manhattan Beach, 90266
(310) 318-3014
Pizza Hut
400 North Sepulveda Boulevard
Manhattan Beach, 90266
(310) 318-8549
El Pollo Loco
4501 East Slauson Avenue
Maywood, 90270
(323) 771-1199
Jack in the Box
3700 East Slauson Avenue
Maywood, 90270
(323) 582-6622
Jack in the Box
17346 West Sunset Boulevard
Pacific Palisades, 90272
(310) 459-9470
Burger King
27400 Hawthorne Boulevard
Rolling Hills Estates, 90274
(310) 377-6991
El Pollo Loco
28901 Western Avenue
Rancho Palos Verdes, 90274
(310) 832-6157
Domino's Pizza
29221 South Western Avenue
Rancho Palos Verdes, 90275
(310) 832-0911
Domino's Pizza
730 S. Pacific Coast Hwy.
Redondo Beach, 90277
(310) 316-6172
Subway
3613 Inglewood Avenue
Redondo Beach, 90278
(310) 536-9527
Yoshinoya
3506 Tweedy Boulevard
South Gate, 90280
(323) 564-9934
Bobo's Hamburgers
2709 Firestone Boulevard
South Gate, 90280
(323) 249-6711
Domino's Pizza
3538 Tweedy Boulevard
South Gate, 90280
(323) 563-3030
El Pollo Loco
4058 Tweedy Boulevard
South Gate, 90280
(323) 564-5042
El Pollo Loco
5740 Imperial Highway
South Gate, 90280
(562) 862-7575
Jack in the Box
8920 Atlantic Boulevard
South Gate, 90280
(323) 569-2335
La Pizza Loca
3320 Tweedy Boulevard
South Gate, 90280
(323) 563-1183
Pizza Hut
3255 Tweedy Boulevard
South Gate, 90280
(323) 566-6600
Subway
3522 Tweedy Boulevard
South Gate, 90280
(323) 563-6600
Subway
4070-A Tweedy Boulevard
South Gate, 90280
(323) 566-2100
Big Daddy and Sons
1809 Ocean Front Walk
Venice, 90291
(323) 314-6194
Big Daddy's Restaurant
1425 Ocean Front Walk
Venice, 90291
(310) 508-2793
Pizza Hut
1411 Lincoln Boulevard
Venice, 90291
(310) 577-9697
Subway
1411 Lincoln Boulevard
Venice, 90291
(310) 827-0322
Domino's Pizza
2484 Lincoln Boulevard
Venice, 90292
(310) 763-8001
Domino's Pizza
901 South La Brea Avenue
Inglewood, 90301
(310) 677-1900
El Pollo Loco
11331 Hawthorne Boulevard
Inglewood, 90301
(310) 412-0303
El Pollo Loco
1200 West Manchester Boulevard
Inglewood, 90301
(310) 645-2491
El Pollo Loco
3125 West Century Boulevard
Inglewood, 90301
(310) 674-7924
Jack in the Box
1127 Manchester Avenue
Inglewood, 90301
(310) 337-0864
Jack in the Box
4069 West Century Boulevard
Inglewood, 90301
(310) 419-8153
Pizza Hut
11115 Crenshaw Boulevard
Inglewood, 90301
(310) 695-9838
Pizza Hut
1275 South La Brea Avenue
Inglewood, 90301
(310) 419-4900
Subway
300 West Manchester Boulevard
Inglewood, 90301
(310) 674-7827
Golden Bird
902 North La Brea Avenue
Inglewood, 90302
(310) 671-0604
Bayou Grille
1400 North La Brea Avenue
Inglewood, 90302
(310) 673-0824
Domino's Pizza
955 North La Brea Avenue
Inglewood, 90302
(310) 639-2585
El Pollo Loco
426 North La Brea Avenue
Inglewood, 90302
(310) 677-7182
Pizza Hut
1000 North La Brea Avenue
Inglewood, 90302
(310) 674-7400
Subway
947 North La Brea Avenue
Inglewood, 90302
(310) 330-1116
The Serving Spoon Restaurant
1403 Centinela Avenue
Inglewood, 90302
(310) 412-3927
NEW
Page 7
NEW
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
Wok on the Wild Side
929 North La Brea Avenue
Inglewood, 90302
(310) 671-8988
Burger King
3104 West Century Boulevard
Inglewood, 90303
(310) 671-4208
Jack in the Box
11306 Crenshaw Boulevard
Inglewood, 90303
(323) 242-9499
King Fish Market
10901 Crenshaw Boulevard
Inglewood, 90303
(310) 677-0425
M & M Cali
2638 Imperial Highway
Inglewood, 90303
(323) 777-7979
Shabazz Good Foods
2636 West Imperial Highway
Inglewood, 90303
(323) 590-5574
Subway
2782 West Imperial Highway
Inglewood, 90303
(323) 755-1199
Subway
3561 West Century Boulevard, #C
Inglewood, 90303
(310) 674-3588
Wendy's
3504 West Century Boulevard
Inglewood, 90303
(310) 673-5382
Burger King
4350 West Century Boulevard
Inglewood, 90304
(310) 412-1049
El Pollo Loco
4954 West Century Boulevard
Inglewood, 90304
(310) 674-8110
Jack in the Box
4069 West Century Boulevard
Inglewood, 90304
(310) 419-8153
Jack in the Box
4737 Imperial Highway
Inglewood, 90304
(310) 673-5025
La Pizza Loca
10731 Hawthorne Boulevard
Lennox, 90304
(310) 677-1117
Melo Burgers
10003 South Inglewood Avenue
Inglewood, 90304
(310) 672-3164
Yoshinoya Beef Bowl
10025 Hawthorne Boulevard
Inglewood, 90304
(310) 677-9543
Louisiana Fried Chicken
8409 South 8th Avenue, #B
Inglewood, 90305
(323) 541-0533
Domino's Pizza
1865 Lincoln Boulevard
Santa Monica, 90404
(310) 396-9696
Burger King
1919 Pico Boulevard
Santa Monica, 90405
(310) 450-1227
Jack in the Box
2025 Lincoln Boulevard
Santa Monica, 90405
(310) 450-2927
Pizza Hut
2029 Pico Boulevard
Santa Monica, 90405
(310) 399-6767
Domino's Pizza
1640 West Carson Street, Suite B
Torrance, 90501
(310) 533-1174
El Pollo Loco
1565 Sepulveda Boulevard
Torrance, 90501
(310) 539-9347
Jack in the Box
2760 Cabillo Avenue
Torrance, 90501
(310) 212-0967
Subway
2396 Crenshaw Boulevard
Torrance, 90501
(310) 320-3366
Burger King
831 Sepulveda Boulevard
Torrance, 90502
(310) 539-0180
Pizza Hut
1173 West Carson Street
Torrance, 90502
(310) 320-1590
Pizza Hut
2208 West Artesia Boulevard
Torrance, 90502
(310) 329-9900
Burger King
5326 Torrance Boulevard
Torrance, 90503
(310) 540-3005
Domino's Pizza
3556 Torrance Boulevard
Torrance, 90503
(310) 316-8199
Jack in the Box
4911 Torrance Boulevard
Torrance, 90503
(310) 371-8306
Pizza Hut
20305 Anza Avenue, #D
Torrance, 90503
(310) 370-3531
Subway
20208 Anza Avenue
Torrance, 90503
(310) 214-0634
Burger King
18201 Crenshaw Boulevard
Torrance, 90504
(310) 538-2549
El Pollo Loco
17307 Crenshaw Boulevard
Torrance, 90504
(310) 538-4308
El Pollo Loco
18200 Hawthorne Boulevard
Torrance, 90504
(310) 542-4006
Jack in the Box
3940 Redondo Beach Boulevard
Torrance, 90504
(310) 715-6494
Jack in the Box
17916 Hawthorne Boulevard
Torrance, 90504
(310) 370-9262
Jack in the Box
2186 Redondo Beach Boulevard
Torrance, 90504
(310) 538-1459
Kentucky Fried Chicken
16502 Crenshaw Boulevard
Torrance, 90504
(310) 324-9153
Subway
18910 Crenshaw Boulevard
Torrance, 90504
(310) 516-7258
Domino's Pizza
24404 Hawthorne Boulevard
Torrance, 90505
(310) 373-3372
Jack in the Box
2705 Pacific Coast Highway
Torrance, 90505
(310) 534-0220
Kentucky Fried Chicken
3777 Pacific Coast Highway
Torrance, 90505
(310) 373-1222
Pizza Hut
3848 Sepulveda Boulevard
Torrance, 90505
(310) 373-1616
Subway
3902 Pacific Coast Hwy, Suite C
Torrance, 90505
(310) 375-3885
Domino's Pizza
10807 Beverly Boulevard, #C
Whittier, 90601
(562) 695-2600
Pizza Hut
11550 Whittier Boulevard
Whittier, 90601
(562) 699-4000
Subway
5416 Norwalk Boulevard, #B-7
Whittier, 90601
(562) 908-3082
Domino's Pizza
13205 Whittier Boulevard, #A
Whittier, 90602
(562) 945-7691
Kentucky Fried Chicken
13106 Whitter Boulevard
Whittier, 90602
(562) 698-4105
La Pizza Loca
13022 Whittier Boulevard
Whittier, 90602
(562) 693-3535
Subway
12548 Washington Boulevard, #108
Whittier, 90602
(562) 698 7545
Kentucky Fried Chicken
16161 Leffingwell Road
Whittier, 90603
(562) 929-6531
Jack in the Box
14437 Telegraph Road
Whittier, 90604
(562) 204-0614
Pizza Hut
13525 Telegraph Road
Whittier, 90605
(562) 944-7700
Denny's Restaurant
8425 Pioneer Boulevard
Whittier, 90606
(562) 695-4464
El Pollo Loco
11624 Washington Boulevard
Whittier, 90606
(562) 695-4822
Michael's Burgers
11506 Slauson Avenue
Whittier, 90606
(562) 699-8783
Burger King
16610 Valley View Boulevard
La Mirada, 90638
(714) 443-3090
Kentucky Fried Chicken
13970 East Imperial Highway
La Mirada, 90638
(562) 926-7670
Paraiso
13914 East Imperial Highway
La Mirada, 90638
(562) 407-1894
Sam's Burgers & Fast Food
14525 Telegraph Road
La Mirada, 90638
(562) 944-3192
Domino's Pizza
803 West Whittier Boulevard
Montebello, 90640
(323) 262-3030
Page 8
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
El Pollo Loco
712 West Beverly Boulevard
Montebello, 90640
(323) 722-0420
Jack in the Box
706 West Beverly Boulevard
Montebello, 90640
(323) 722-0211
Jack in the Box
892 North Garfield Avenue
Montebello, 90640
(323) 724-3462
Jack in the Box
108 North Garfield Avenue
Montebello, 90640
(323) 724-3764
The Daily Brew
137 North Montebello Boulevard
Montebello, 90640
(323) 888-4201
The Daily Brew
137 North Montebello Boulevard
Montebello, 90640
(323) 888-4201
Burger King
13400 East Rosecrans Avenue
Norwalk, 90650
(562) 623-0724
Domino's Pizza
10948 East Imperial Highway
Norwalk, 90650
(562) 864-9951
El Pollo Loco
12551 Rosecrans Avenue
Norwalk, 90650
(562) 802-2294
Jack in the Box
11353 Firestone Boulevard
Norwalk, 90650
(562) 929-0132
Jack in the Box
12060 Rosecrans Avenue
Norwalk, 90650
(562) 929-6531
Kentucky Fried Chicken
10905 Imperial Highway
Norwalk, 90650
(562) 929-1122
Kentucky Fried Chicken
12209 Norwalk Boulevard
Norwalk, 90650
(213) 868-1783
Kentucky Fried Chicken
12959 Rosecrans Avenue
Norwalk, 90650
(562) 926-1914
La Pizza Loca
12619 Pioneer Boulevard
Norwalk, 90650
(562) 406-3840
Pizza Hut
11006 East Rosecrans Avenue
Norwalk, 90650
(562) 863-4466
Pizza Hut
12628 South Pioneer Boulevard
Norwalk, 90650
(562) 864-5226
Rally's Hamburger
11750 East Imperial Highway
Norwalk, 90650
(562) 807-0036
Sam's Burgers & Fast Food
10961 Firestone Boulevard
Norwalk, 90650
(562) 863-8851
Sam's Burgers & Fast Food
14041 Pioneer Boulevard
Norwalk, 90650
(562) 929-4699
Subway
11782 Firestone Boulevard
Norwalk, 90650
(562) 864-5242
Subway
10710 Alondra Boulevard
Norwalk, 90650
(562) 402-7765
Subway
11729 Imperial Highway
Norwalk, 90650
(562) 864-5242
Subway
12301 Imperial Highway
Norwalk, 90650
(562) 929-1687
Domino's Pizza
4500 Rosemead Blvd., Suite B
Pico Rivera, 90660
(562) 692-9591
Pizza Hut
9338 East Whittier Boulevard
Pico Rivera, 90660
(562) 948-1191
Sam's Burgers
8505 East Telegraph Road
Pico Rivera, 90660
(562) 869-1482
Subway
9002 East Slauson Avenue
Pico Rivera, 90660
(562) 948-3140
Wendy's Hamburgers
8450 East Washington Boulevard
Pico Rivera, 90660
(562) 801-2521
Domino's Pizza
12610 Leffingwell Avenue
Santa Fe Springs, 90670
(562) 229-3070
Jack in the Box
13400 Telegraph Road
Santa Fe Springs, 90670
(562) 941-6480
Jack in the Box
13402 Imperial Highway
Santa Fe Springs, 90670
(562) 407-2069
Subway
13238 Imperial Highway
Santa Fe Springs, 90670
(562) 483-8338
Subway
15911 Valley View Boulevard
Santa Fe Springs, 90670
(562) 926-1705
El Pollo Loco
16707 Pioneer Boulevard
Artesia, 90701
(562) 924-6918
Kentucky Fried Chicken
19015 South Pioneer Boulevard
Artesia, 90701
(562) 860-4616
Pizza Hut
18325 South Pioneer Boulevard
Artesia, 90701
(562) 809-8811
Kentucky Fried Chicken
13313 Artesia Boulevard
Cerritos, 90703
(562) 926-7676
Kentucky Fried Chicken
15925 Studebaker Road
Cerritos, 90703
(562) 865-7020
Domino's Pizza
9353 East Alondra Boulevard
Bellflower, 90706
(562) 920-8353
Grandma's Chicken
9886 Alondra Boulevard
Bellflower, 90706
(562) 920-1797
Pizza Hut
9118 East Alondra Boulevard
Bellflower, 90706
(562) 866-3000
Subway
15794 Bellflower Boulevard
Bellflower, 90706
(562) 461-0171
Subway
16607 Bellflower Boulevard
Bellflower, 90706
(562) 804-7212
Subway
17222 1/2 South Lakewood Blvd.
Bellflower, 90706
(562) 866-4415
Yoshinoya Beef Bowl
15794 Bellflower Boulevard, # A
Bellflower, 90706
(562) 867-3733
El Pollo Loco
1141 West Pacific Coast Highway
Harbor City, 90710
(310) 530-0534
Subway
1664 West Sepulveda Boulevard
Harbor City, 90710
(310) 534-5466
Tandoori Bistro
970 Sepulveda Boulevard
Harbor City, 90710
(310) 530-2245
Jack in the Box
5747 Lakewood Boulevard
Lakewood, 90712
(562) 602-1100
Subway
2706 Carson Street
Lakewood, 90712
(562) 429-7801
Subway
4836 Paramount Boulevard
Lakewood, 90712
(562) 423-2900
Wendy's
4314 South Street
Lakewood, 90712
(562) 531-0345
Subway
5517 Del Amo Boulevard
Lakewood, 90713
(562) 866-6909
Domino's Pizza
5538 Del Amo Boulevard
Lakewood, 90713
(562) 804-4637
Goody's Pizza
5695 Woodruff Avenue
Lakewood, 90713
(562) 867-3555
Kentucky Fried Chicken
12161 East Carson Street
Hawaiian Gardens, 90713
(562) 402-3425
Kentucky Fried Chicken
4917 Bellflower Boulevard
Lakewood, 90713
(562) 925-1983
Laventina's Pizza
5806 Bellflower Boulevard
Lakewood, 90713
(562) 804-6490
Pizza Hut
5917 East South Street
Lakewood, 90713
(562) 866-6611
El Pollo Loco
11601 Carson Street
Lakewood, 90715
(562) 924-2250
Goody's Pizza
20161 South Pioneer Boulevard
Lakewood, 90715
(562) 924-0588
Pizza Hut
12602 Del Amo Boulevard
Lakewood, 90715
(562) 809-5000
Jack in the Box
12150 Carson Street
Hawaiian Gardens, 90716
(562) 496-0540
NEW
Page 9
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
Jack in the Box
2101 North Palos Verdes Drive
Lomita, 90717
(310) 325-4552
Jack in the Box
1724 West Pacific Coast Highway
Lomita, 90717
(310) 326-5225
Little Caesar's Pizza
1846 Lomita Boulevard
Lomita, 90717
(310) 534-4888
Pizza Hut
1901 Pacific Coast Highway
Lomita, 90717
(310) 325-2300
Quizno's Subs
2169 Pacific Coast Highway, #A
Lomita, 90717
(310) 530-0441
Domino's Pizza
15500 South Paramount Boulevard
Paramount, 90723
(562) 408-1531
Jack in the Box
7930 Rosecrans Avenue
Paramount, 90723
(562) 633-6232
La Pizza Loca
14150 Paramount Boulevard
Paramount, 90723
(562) 408-0023
Pizza Hut
8029 Alondra Boulevard
Paramount, 90723
(562) 529-3900
Subway
16289-3 Paramount Boulevard
Paramount, 90723
(562) 531-4947
Subway
8809 Alondra Boulevard
Paramount, 90723
(562) 531-9909
Burger King
215 North Gaffey Street
San Pedro, 90731
(310) 833-1550
City Hall Market
1043 South Palos Verdes Street
San Pedro, 90731
(310) 548-1171
Domino's Pizza
1510 South Gaffey Street
San Pedro, 90731
(310) 832-4521
La Pizza Loca
1306 South Gaffey Street
San Pedro, 90731
(310) 521-3000
Pizza Hut
650 South Gaffey Street
San Pedro, 90731
(310) 521-0500
Wienerschnitel
230 North Gaffey Street
San Pedro, 90731
(310) 831-4486
Jack in the Box
29317 South Western Avenue
Rancho Palos Verdes, 90732
(310) 831-3509
Domino's Pizza
1360 Avalon Boulevard
Wilmington, 90744
(310) 513-8040
El Pollo Loco
1380 Avalon Boulevard
Wilmington, 90744
(310) 834-1000
Jack in the Box
1010 West Pacific Coast Highway
Wilmington, 90744
(310) 835-5308
Pizza Hut
909 West Pacific Coast Hwy.
Wilmington, 90744
(310) 513-1700
Subway
1356 Avalon Boulevard
Wilmington, 90744
(310) 513-9600
Taco Bell
100 Pacific Coast Highway
Wilmington, 90744
(310) 549-2599
Domino's Pizza
23565 South Avalon Boulevard, #E
Carson, 90745
(310) 549-1600
El Pollo Loco
111 East Carson Street
Carson, 90745
(310) 830-3491
Jack in the Box
23813 South Avalon Boulevard
Carson, 90745
(310) 830-2621
Jack in the Box
111 East 223rd Street
Carson, 90745
(310) 518-3025
Jack in the Box
22220 Wilmington Avenue
Carson, 90745
(310) 522-0725
Jack in the Box
939 East Carson Street
Carson, 90745
(310) 522-5696
Kentucky Fried Chicken
545 East Sepulveda Boulevard
Carson, 90745
(310) 835-0012
Little Caesar's Pizza
243 West Carson Street
Carson, 90745
(310) 834-1223
Pizza Hut
20377 South Avalon Boulevard
Carson, 90745
(310) 324-1102
Pizza Hut
23301 South Main Street
Carson, 90745
(310) 549-5000
Popeye's Chicken
154 West Carson Street
Carson, 90745
(310) 549-3271
Subway
156 East Sepulveda Boulevard
Carson, 90745
(310) 549-7198
Subway
22232 Wilmington Street
Carson, 90745
(310) 513-9028
Subway
860 East Carson Street, Suite 101
Carson, 90745
(310) 518-6595
Domino's Pizza
633 East University Drive
Carson, 90746
(310) 516-9800
Jack in the Box
319 East Albertoni Street
Carson, 90746
(310) 217-0882
Kentucky Fried Chicken
18401 South Avalon Boulevard
Carson, 90746
(310) 532-2970
Subway
17401 South Avalon Blvd, Suite D-2
Carson, 90746
(310) 516-9222
Jack in the Box
3399 East Pacific Coast Highway
Signal Hills, 90755
Unlisted
Subway
3225 East Pacific Coast Highway
Signal Hills, 90755
(562) 961-1994
Jack in the Box
801 East Spring Street
Signal Hills, 90755
Unlisted
El Pollo Loco
631 Long Beach Boulevard
Long Beach, 90802
(562) 437-5689
Pizza Hut
1200 East 4th Street
Long Beach, 90802
(562) 983-1177
Subway
100 Broadway, #170
Long Beach, 90802
(562) 436-9977
Subway
265 East 5th Street
Long Beach, 90802
(562) 436-0455
Burger King
4542 East Pacific Coast Highway
Long Beach, 90804
(562) 498-6331
China Kitchen Express
3429 East Anaheim Street
Long Beach, 90804
(562) 498-9516
Jack in the Box
2101 East Anaheim Street
Long Beach, 90804
(562) 439-8958
Kentucky Fried Chicken
4001 East Anaheim Street
Long Beach, 90804
(562) 498-0446
Pelayo's Burgers
2300 E. Pacific Coast Hwy.
Long Beach, 90804
(562) 961-1994
Pizza Hut
3498 East 7th Street
Long Beach, 90804
(562) 438-6161
Terri's Kitchen
2015 East Anaheim Street
Long Beach, 90804
(562) 343-5243
Wienerschnitel
3012 Artesia Boulevard
Long Beach, 90804
(562) 423-9609
China Beauty Food Express
6588 Atlantic Avenue
Long Beach, 90805
(562) 984-6388
El Pollo Loco
3463 Artesia Boulevard
Long Beach, 90805
(562) 531-0476
El Pollo Loco
5386 Cherry Avenue
Long Beach, 90805
(562) 422-5050
Jack in the Box
2001 East Artesia Boulevard
Long Beach, 90805
(562) 531-6894
Jack in the Box
5150 Atlantic Avenue
Long Beach, 90805
(562) 423-2164
Kentucky Fried Chicken
3430 East Artesia Bouleard
Long Beach, 90805
(562) 422-4417
Louis Place Burgers
5990 Atlantic Avenue
Long Beach, 90805
(562) 423-3511
Page 10
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
Louisiana Fried Chicken
5184 Atlantic Avenue
Long Beach, 90805
(562) 984-8450
Mc Donald's
6595 Atlantic Avenue
Long Beach, 90805
(562) 423-3758
Pizza Hut
1171 East Market Street
Long Beach, 90805
(562) 422-1313
Subway
2183 East South Street, Suite B
Long Beach, 90805
(562) 984-5355
Subway
3713 East South Street
Long Beach, 90805
(562) 634-2469
Uncle Val's Pizza
5806 Downey Avenue
Long Beach, 90805
(562) 633-4700
Yoshinoya
6598 Cherry Boulevard, #B
Long Beach, 90805
(562) 984-4884
El Pollo Loco
2525 Long Beach Boulevard
Long Beach, 90806
(562) 426-5006
Jack in the Box
1190 East Pacific Coast Highway
Long Beach, 90806
(562) 591-3868
Jack in the Box
3980 Ocean Avenue
Long Beach, 90806
(562) 439-6798
Kentucky Fried Chicken
209 East Pacific Coast Highway
Long Beach, 90806
(562) 599-6218
Mc Donald's
1830 Long Beach Boulevard
Long Beach, 90806
(562) 591-1137
Pizza Hut
300 West Willow Street
Long Beach, 90806
(562) 988-1711
Wing Stop
2000 Long Beach Boulevard
Long Beach, 90806
(562) 218-9464
Yoshinoya Beef Bowl
590 East Willow Street
Long Beach, 90806
(562) 427-5818
Domino's Pizza
4227 Atlantic Avenue
Long Beach, 90807
(562) 492-1323
Kentucky Fried Chicken
4528 Atlantic Avenue
Long Beach, 90807
(562) 428-5459
Subway
3400 Long Beach Boulevard
Long Beach, 90807
(562) 989-9733
Subway
3401 Cherry Avenue
Long Beach, 90807
(562) 595-4240
Subway
4267 Atlantic Avenue
Long Beach, 90807
(562) 426-2678
Jack in the Box
4170 Lakewood Boulevard
Long Beach, 90808
(562) 496-4565
Pizza Hut
4110 Lakewood Boulevard
Long Beach, 90808
(562) 425-8887
Pizza Hut
4558 Atlantic Avenue
Bixby Knolls, 90808
(562) 422-9005
Jack in the Box
1720 West Pacific Coast Highway
Long Beach, 90810
(562) 436-6850
Kentucky Fried Chicken
1601 West Willow Steet
Long Beach, 90810
(562) 424-3861
Domino's Pizza
1158 East 7th Street
Long Beach, 90813
(562) 437-4868
Kentucky Fried Chicken
1601 East 7th Street
Long Beach, 90813
(562) 599-2547
Pizza Hut
1702 Long Beach Boulevard
Long Beach, 90813
(562) 591-2333
Domino's Pizza
393 Redondo Avenue
Long Beach, 90814
(562) 434-9971
El Pollo Loco
3425 East Anaheim Street
Long Beach, 90814
(562) 494-1343
Domino's Pizza
2221 Palo Verde Avenue, #B
Long Beach, 90815
(562) 594-4506
El Pollo Loco
2200 Clark Avenue
Long Beach, 90815
(562) 494-9691
Kentucky Fried Chicken
2970 Bellflower Boulevard
Long Beach, 90815
(562) 496-1321
Pizza Hut
4502 Los Coyotes Diagonal
Long Beach, 90815
(562) 597-2900
Jack in the Box
2305 North Lake Avenue
Altadena, 91001
(626) 791-5402
Pizza Hut
2211 North Lake Avenue
Altadena, 91001
(626) 791-0800
Kentucky Fried Chicken
119 East Foothill Boulevard
Arcadia, 91006
(626) 357-2202
Pizza Hut
121 East Foothill Boulevard
Arcadia, 91006
(626) 303-5888
Pizza Hut
161 East Live Oak Avenue
Arcadia, 91006
(626) 445-5599
Subway
411 East Huntington Drive
Arcadia, 91006
(626) 821-9865
Subway
160 East Duarte Road, Unit D
Arcadia, 91006
(626) 446-5375
Subway
288 East Live Oak Avenue, #B
Arcadia, 91006
(626) 446-5464
Subway
733 North Naomi Avenue, Unit G
Arcadia, 91007
(626) 446-3120
Domino's Pizza
1802 East Huntington Drive, #B
Duarte, 91010
(626) 359-3030
El Pollo Loco
1212 East Huntington Drive
Duarte, 91010
(626) 358-5005
Kentucky Fried Chicken
1128 Huntington Drive
Duarte, 91010
(818) 357-5113
Subway
2225 East Huntington Drive
Duarte, 91010
(626) 303-2320
El Pollo Loco
2230 Foothill Boulevard
La Canada, 91011
(818) 249-3538
Jack in the Box
2225 Foothill Boulevard
La Canada, 91011
(818) 957-1963
Pizza Hut
942 West Foothill Boulevard
La Canada, 91011
(818) 952-8700
Domino's Pizza
404 West Huntington Drive
Monrovia, 91016
(626) 303-2655
Popeye's Chicken
300 West Huntington Drive
Monrovia, 91016
(626) 358-9001
Burger King
8241 Foothill Boulevard
Sunland, 91040
(818) 353-7779
Pizza Hut
8337 Foothill Boulevard
Sunland, 91040
(818) 352-8868
Kentucky Fried Chicken
6585 Foothill Boulevard
Tujunga, 91042
(818) 352-3283
Kentucky Fried Chicken
2050 North Fair Oaks Avenue
Pasadena, 91103
(626) 797-1127
Bonnie B's Smokin
1280 North Lake Avenue
Pasadena, 91104
(626) 794-0132
Domino's Pizza
1802 East Washington Boulevard
Pasadena, 91104
(626) 794-3030
Domino's Pizza
2057 North Los Robles Avenue
Pasadena, 91104
(626) 791-9285
Pizza Hut
1269 North Lake Avenue
Pasadena, 91104
(626) 398-3700
Domino's Pizza
633 South Arroyo Parkway
Pasadena, 91105
(626) 584-1976
Pizza Hut
777 South Arroyo Parkway
Pasadena, 91105
(626) 792-2800
Jack in the Box
1415 East Colorado Boulevard
Pasadena, 91106
(626) 792-7076
Domino's Pizza
2363 East Colorado Boulevard
Pasadena, 91107
(626) 584-0866
Page 11
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
El Pollo Loco
262 South Rosemead Boulevard
Pasadena, 91107
(626) 584-0261
Jack in the Box
30 North Rosemead Boulevard
Pasadena, 91107
(626) 304-9356
Pizza Hut
203 South Rosemead
Pasadena, 91107
(626) 405-9100
Burger King
1635 West Glenoaks Boulevard
Glendale, 91201
(818) 241-1857
Jack in the Box
1200 West Glenoak Boulevard
Glendale, 91201
(818) 956-0470
Pizza Hut
1428 West Glenoaks Boulevard
Glendale, 91201
(818) 241-1900
Subway
6340 San Fernando Road
Glendale, 91201
(818) 291-0805
Burger King
523 North Central Avenue
Glendale, 91203
(818) 247-1914
Subway
110 North Brand Boulevard
Glendale, 91203
(818) 244-0411
Pizza Hut
1261 South Central Avenue
Glendale, 91204
(818) 244-4477
Yoshinoya Beef Bowl
4000 San Fernando Boulevard
Glendale, 91204
(818) 545-0112
Burger King
1200 East Colorado Street
Glendale, 91205
(818) 247-6965
China Food Express
1139 East Colorado Street
Glendale, 91205
(818) 507-8868
Domino's Pizza
1244 West Glenoaks Boulevard
Glendale, 91205
(818) 247-3340
Domino's Pizza
1428 East Colorado Boulevard
Glendale, 91205
(818) 247-9500
Domino's Pizza
723 South Central Avenue
Glendale, 91205
(818) 246-3850
El Pollo Loco
235 South Glendale Avenue
Glendale, 91205
(818) 545-0700
Jack in the Box
1131 Colorado Boulevard
Glendale, 91205
(818) 240-0450
Subway
1136 East Broadway Avenue
Glendale, 91205
(818) 546-2685
Domino's Pizza
3430 Ocean View Boulevard, Unit H
Glendale, 91208
(818) 249-5530
Burger King
3517 Foothill Boulevard
Glendale, 91214
(818) 249-8869
Pizza Hut
3437 Foothill Boulevard
La Crescenta, 91214
(818) 957-2600
Pizza Hut
5146 Kanan Road
Agoura Hills, 91301
(818) 991-7508
Domino's Pizza
26500 West Agoura Road
Calabasas, 91302
(818) 880-0550
Jack in the Box
26510 Agoura Road
Calabasas, 91302
(818) 880-9253
Burger King
21227 Sherman Way
Canoga Park, 91303
(818) 883-3018
Jack in the Box
6800 De Soto Avenue
Canoga Park, 91303
(818) 313-9459
Jack in the Box
7264 Topanga Canyon Boulevard
Canoga Park, 91303
(818) 347-8353
Papa John's Pizza
22330 Sherman Way
Canoga Park, 91303
(818) 888-8000
Pizza Hut
22323 Sherman Way
Canoga Park, 91303
(818) 348-6900
El Pollo Loco
8239 Topanga Canyon Boulevard
Canoga Park, 91304
(818) 887-0346
Vallarta Supermarket & Deli
21555 Roscoe Boulevard
Canoga Park, 91304
(818) 704-1717
Wendy's Restaurant
8232 De Soto Avenue
Canoga Park, 91304
(818) 700-1578
Burger King
20056 Sherman Way
Canoga Park, 91306
(818) 346-3660
Church's Chicken
7635 Winnetka Avenue
Winnetka, 91306
(818) 576-0490
Domino's Pizza
21001 Sherman Way
Canoga Park, 91306
(818) 347-6600
El Pollo Loco
7211 Winnetka Avenue
Canoga Park, 91306
(818) 773-9603
Jack in the Box
20840 Roscoe Boulevard
Canoga Park, 91306
(818) 998-4295
Jack in the Box
20840 Roscoe Boulevard
Canoga Park, 91306
(818) 998-4295
Kentucky Fried Chicken
20101 Sherman Way
Canoga Park, 91306
(818) 882-1160
Pizza Hut
23717 Victory Boulevard
West Hills, 91307
(818) 703-6700
Burger King
20838 Devonshire Street
Chatsworth, 91311
(818) 718-6366
Domino's Pizza
9874 De Soto Avenue
Chatsworth, 91311
(818) 882-2200
Papa John's Pizza
10316 De Soto Avenue
Chatsworth, 91311
(818) 725-2600
Papa John's Pizza
20422 Sherman Way
Canoga Park, 91306
(818) 610-8300
Pizza Hut
20901 Lassen Street
Chatsworth, 91311
(818) 772-0700
Domino's Pizza
17020 Ventura Boulevard
Tarzana, 91316
(818) 981-5811
El Pollo Loco
17660 Ventura Boulevard
Encino, 91316
(818) 345-5507
Subway
17261 Ventura Boulevard
Encino, 91316
(818) 906-3376
Wendy's Restaurant
18507 Devonshire Street
Northridge, 91320
(818) 366-4561
Ameci Pizza
24268 Lyons Avenue
Newhall, 91321
(661) 255-3500
El Pollo Loco
24805 Pico Canyon Road
Newhall, 91321
(661) 222-7150
El Pollo Loco
26930 Sierra Highway
Santa Clarita, 91321
(661) 299-2236
Jack in the Box
22908 Lyons Avenue
Newhall, 91321
(661) 254-3330
Papa John's Pizza
23120 Lyons Avenue, Suite 1 & 2
Santa Clarita, 91321
(661) 254-2100
Pizza Hut
23430 Lyons Avenue
Newhall, 91321
(661) 259-8983
El Pollo Loco
8301 Reseda Boulevard
Northridge, 91324
(818) 886-3157
Jack in the Box
9433 Reseda Avenue
Northridge, 91324
(818) 885-8261
Pizza Hut
10231 Reseda Boulevard
Northridge, 91324
(818) 998-4700
Jack in the Box
19322 Roscoe Boulevard
Northridge, 91325
(818) 885-8149
Jack in the Box
19322 Roscoe Boulevard
Northridge, 91325
(818) 885-8149
Jack in the Box
11216 Tampa Avenue
Northridge, 91326
(818) 368-9941
Burger King
8500 Reseda Boulevard
Northridge, 91324
(818) 349-1985
Domino's Pizza
8662 Lindley Avenue
Northridge, 91325
(818) 349-0995
NEW
Page 12
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
Domino's Pizza
13931 Van Nuys Boulevard
Pacoima, 91331
(818) 897-0355
El Pollo Loco
9800 Laurel Canyon Boulevard
Pacoima, 91331
(818) 897-8968
La Pizza Loca
9792 Laurel Canyon Boulevard
Pacoima, 91331
(818) 899-6828
Pizza Hut
10365 Laurel Canyon Boulevard
Pacoima, 91331
(818) 890-8000
Subway
9724 Woodman Avenue
Arleta, 91331
(818) 897-0165
Jack in the Box
6820 Reseda Boulevard
Reseda, 91335
(818) 708-3501
JC's Famous Pizza
6756 Tampa Avenue
Reseda, 91335
(818) 343-3308
Pizza Hut
19417 3/4 Victory Boulevard
Reseda, 91335
(818) 343-3600
Pizza Hut
19731-A Saticoy, Unit C
Reseda, 91335
(818) 998-5600
Popeye's Chicken
18300 Van Owen Street, #1
Reseda, 91335
(818) 774-9581
Wendy's Restaurant
19309 Sherman Way
Reseda, 91335
(818) 882-1530
Yoshinoya
12902 Foothill Boulevard
Sylmar, 91340
(818) 365-7444
Burger King
2008 Glenoaks Boulevard
San Fernando, 91340
(818) 898-1171
El Pollo Loco
1125 Truman Street, #C2
San Fernando, 91340
(818) 557-0683
Pizza Hut
551 North Maclay
San Fernando, 91340
(818) 898-3737
Subway
11220 Laurel Canyon
Mission Hills, 91340
(818) 838-3532
Taste of Soul
2035 Glenoaks Boulevard
San Fernando, 91340
(818) 361-5023
Yoshinoya Beef Bowl
317 San Fernando Mission Road
San Fernando, 91340
(818) 361-0122
El Pollo Loco
12930 Foothill Boulevard
San Fernando, 91342
(818) 365-2840
Pizza Hut
12737 Glenoaks Bouelvard
Sylmar, 91342
(818) 362-6741
Popeye's Chicken
12659 Glenoak Boulevard
Sylmar, 91342
(818) 367-5110
Kentucky Fried Chicken
NEW
8800 Sepulveda Boulevard
North Hollywood, 91343
(818) 894-4500
El Pollo Loco
16940 Nordhoff Boulevard
Northridge, 91343
(818) 895-1680
El Pollo Loco
9522 Sepulveda Boulevard
North Hills, 91343
(818) 891-8383
Jack in the Box
15651 Nordhoff Street
North Hills, 91343
(818) 893-9919
Pizza Hut
15650 Nordhoff Street, #101
North Hills, 91343
(818) 895-0944
Popeye's Chicken
16159 Parthenia Street
North Hills, 91343
(818) 891-9948
Yum Yum Sandwiches
8332 Sepulveda Boulevard, #5
North Hills, 91343
(818) 892-7091
Domino Pizza
16215 Devonshire Street
Granada Hills, 91344
(818) 363-2020
Domino's Pizza
17650 Chatsworth Street
Granada Hills, 91344
(818) 368-1157
El Pollo Loco
10651 Balboa Boulevard
Granada Hills, 91344
(818) 831-4044
Pizza Hut
16923 Devonshire Street
Granada Hills, 91344
(818) 831-0055
Subway
10680 Balboa Boulevard
Granada Hills, 91344
(818) 366-2422
Good Day Donuts & Mini Mart
11110 Sepulveda Boulevard, #10
Mission Hills, 91345
(818) 365-7409
Kentucky Fried Chicken
10865 Sepulveda Boulevard
Mission Hills, 91345
(818) 361-6466
Pizza Hut
10719 Sepulveda Boulevard
Mission Hills, 91345
(818) 895-2478
Papa John's Pizza
27911 Seco Canyon Rd., E-1
Santa Clarita, 91350
(661) 513-0900
Pizza Hut
27984 Seco Canyon Road, #301
Santa Clarita, 91350
(661) 513-0600
Papa John's Pizza
18934-B Soledad Canyon Road
Canyon Country, 91351
(661) 298-2411
Pizza Hut
18520 West Soledad Canyon
Canyon Country, 91351
(661) 298-4000
Domino Pizza
8126 Sunland Boulevard
Sun Valley, 91352
(818) 768-8833
Domino's Pizza
8313 Laurel Canyon Boulevard
Sun Valley, 91352
(818) 768-7888
El Pollo Loco
8351 Sunland Boulevard
Sun Valley, 91352
(818) 767-1257
Jack in the Box
7955 Vineland Avenue
Sun Valley, 91352
(818) 764-0359
La Pizza Loca
7608 Vineland Avenue
Sun Valley, 91352
(818) 503-0600
El Pollo Loco
24365 Magic Mountain Parkway
Valencia, 91355
(661) 254-6627
Domino's Pizza
18957 Ventura Boulevard
Tarzana, 91356
(818) 996-9690
Kentucky Fried Chicken
19256 Ventura Boulevard
Tarzana, 91356
(818) 881-2131
Wendy's Restaurant
5788 North Lindero-Canyon Road
West Lake Village, 91362
(818) 879-9416
Ameci Pizza
4861 Topanga Canyon Boulevard
Woodland Hills, 91364
818) 346-1500
Jack in the Box
20037 Ventura Boulevard
Woodland Hills, 91364
(818) 887-9339
Papa John's Pizza
19907 Ventura Boulevard
Woodland Hills, 91364
(818) 226-9200
Papa John's Pizza
23305 Mulholland Drive, Suite 7D
Woodland Hills, 91364
(818) 888-8000
Jack in the Box
22664 Ventura Boulevard
Woodland Hills, 91367
(818) 224-3460
Jack in the Box
22730 Victory Boulevard
Woodland Hills, 91367
(818) 715-0550
Ameci Pizza
27305 Live Oak Road, Suite E
Castaic, 91381
(661) 257-3855
El Pollo Loco
31783 Castaic Road
Castic, 91384
(661) 294-5221
El Pollo Loco
6568 Van Nuys Boulevard
Van Nuys, 91401
(818) 786-2516
Jack in the Box
6416 Woodman Avenue
Van Nuys, 91401
(818) 909-0066
Vallarta Supermarket & Deli
16107 Victory Boulevard
Van Nuys, 91401
(818) 781-9007
Burger King
8030 Van Nuys Boulevard
Panorama City, 91402
(818) 780-4176
Domino Pizza
15245 Roscoe Boulevard
Panorama City, 91402
(818) 893-7777
Domino's Pizza
14550 Chase Avenue, 78A
Panorama City, 91402
(818) 891-7991
Good Day Donut
8245 Sepulveda Boulevard
Panorama City, 91402
(818) 893-0251
Page 13
NEW
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
Jack in the Box
15342 Roscoe Avenue
Panorama City, 91402
(818) 892-7059
Pizza Hut
14500 Nordhoff
Panorama City, 91402
(818) 893-3333
Wendy's Restaurant
14645 Roscoe Boulevard
Panorama City, 91402
(818) 894-0659
Yoshinoya Beef Bowl
8267 Sepulveda Boulevard
Panorama City, 91402
(818) 894-9108
Burger King
5109 Van Nuys Boulevard
Sherman Oaks, 91403
(818) 789-6876
El Pollo Loco
4544 Saugus Avenue
Sherman Oaks, 91403
(818) 990-7655
Domino's Pizza
6805 Sepulveda Boulevard
Van Nuys, 91405
(818) 909-0088
El Pollo Loco
14429 Roscoe Boulevard
Panorama City, 91402
(818) 895-1925
Jack in the Box
6847 Van Nuys Boulevard
Van Nuys, 91405
(818) 782-1823
Pizza Hut
7136 Van Nuys Boulevard
Van Nuys, 91405
(818) 779-0400
Taco Bell
13641 Sherman Way
Van Nuys, 91405
(818) 997-8495
El Pollo Loco
17240 Saticoy Street
Van Nuys, 91406
(818) 774-1173
Jack in the Box
16860 Vanowen Street
Reseda, 91406
(818) 779-1350
Pizza Hut
17630 Van Owen Boulevard
Van Nuys, 91406
(818) 343-7070
Wendy's Restaurant
16930 Roscoe Boulevard
Van Nuys, 91406
(818) 705-0224
Wendy's Restaurant
17648 Sherman Way
Van Nuys, 91406
(818) 342-3975
El Pollo Loco
6411 North Sepulveda Boulevard
Van Nuys, 91411
(818) 785-8008
Jack in the Box
6351 Sepulveda Boulevard
Van Nuys, 91411
(818) 988-4049
Pizza Hut
14900 Burbank Boulevard
Sherman Oaks, 91411
(818) 784-3400
Wendy's Restaurant
6181 Sepulveda Boulevard
Van Nuys, 91411
(818) 787-2072
El Pollo Loco
13357 Riverside Drive
Sherman Oaks, 91423
(818) 995-7361
Burger King
545 North Victory Boulevard
Burbank, 91502
(818) 848-3668
Domino's Pizza
433 North Glenoaks Boulevard
Burbank, 91502
(818) 841-3337
El Pollo Loco
521 North First Street
Burbank, 91502
(818) 846-4022
Pizza Factory
101 N. Victory Boulevard, #K8
Burbank, 91502
(818) 840-8805
Subway
124 E. Magnolia Boulevard, #H1
Burbank, 91502
(818) 953-2972
Wendy's Restaurant
1575 North Victory Boulevard
Burbank, 91502
(818) 729-8320
Pizza Hut
1212-A N. San Fernando Road
Burbank, 91504
(818) 845-3400
Yoshinoya Beef Bowl
1215 North San Fernando Boulevard
Burbank, 91504
(818) 556-5623
Domino's Pizza
2015 North Hollywood Way
Burbank, 91505
(818) 954-9600
Pizza Hut
3311 West Magnolia
Burbank, 91505
(818) 559-6500
Subway
10970 Sherman Way, #101
Burbank, 91505
(818) 847-2579
Domino's Pizza
1600 West Olive Avenue
Burbank, 91506
(818) 841-8433
El Pollo Loco
1150 West Alameda Street
Burbank, 91506
(818) 557-0683
Jack in the Box
3830 West Sierra Highway
Acton, 93510
(661) 269-2635
Pizza Hut
44836 10th Street West
Lancaster, 93534
(661) 949-8383
Pizza Hut
1876 East Avenue J
Lancaster, 93535
(661) 948-8993
Big Al's Pizza
8714 E. Avenue T, Unit M
Littlerock, 93543
(661) 944-0827
El Pollo Loco
2221 East Palmdale Boulevard
Palmdale, 93550
(661) 265-1615
Subway
1823-A East Palmdale Boulevard
Palmdale, 93550
(661) 274-1355
Subway
39904 West 10th Street, #B
Palmdale, 93551
(661) 265-0955
Big Al's Pizza
40340 East 170th Street, Unit A
Palmdale, 93591
(661) 264-4662
Domino's Pizza
5166 Lankershim Boulevard, #B
North Hollywood, 91601
(818) 769-3733
El Pollo Loco
10944 Magnolia Boulevard
North Hollywood, 91601
(818) 763-6592
Pizza Hut
5948 Lankershim Boulevard
North Hollywood, 91601
(818) 509-9555
Subway
10942 Magnolia Boulevard
North Hollywood, 91601
(818) 766-9991
Domino's Pizza
10652 Riverside Drive
North Hollywood, 91602
(818) 769-2800
Pizza Hut
4408 Vineland Avenue
North Hollywood, 91602
(818) 769-2400
Domino Pizza
11674 Ventura Boulevard
Studio City, 91604
(818) 980-1999
Domino's Pizza
12901 Sherman Way, #C
North Hollywood, 91605
(818) 759-0000
El Pollo Loco
12643 Sherman Way
North Hollywood, 91605
(818) 765-7603
Jack in the Box
12900 Sherman Way
North Hollywood, 91605
(818) 982-5225
Pizza Hut
8023 Lankershim Boulevard
North Hollywood, 91605
(818) 771-0800
El Pollo Loco
6400 Lankershim Boulevard
North Hollywood, 91606
(818) 763-7945
Jack in the Box
6551 Lankershim Boulevard
North Hollywood, 91606
(818) 763-3818
Pizza Hut
12447 Victory Boulevard
North Hollywood, 91606
(818) 505-8000
Subway
6006 Lankershim Boulevard
North Hollywood, 91606
(818) 506-7870
Pizza Hut
5212 Witsett Avenue
North Hollywood, 91607
(818) 509-9300
Wienerschnitel
5135 Laurel Canyon Boulevard
North Hollywood, 91607
(818) 506-9086
La Pizza Loca
493 South Citrus Avenue
Azusa, 91702
(626) 915-2929
Pizza Hut
331 North Citrus Avenue
Azusa, 91702
(626) 334-8855
Subway
1195 West Foothill Boulevard
Azusa, 91702
(626) 334-2477
Burger King
3101 Baldwin Park Boulevard
Baldwin Park, 91706
(626) 337-1648
Domino's Pizza
14604 Ramona Boulevard
Baldwin Park, 91706
(626) 960-5002
Page 14
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
La Pizza Loca
13020 Francisquito Avenue, #18
Baldwin Park, 91706
(626) 337-9900
Long John Silver's
14400 Merced Avenue
Baldwin Park, 91706
(626) 851-3718
Paraiso
4303 Maine Avenue, Unit 104
Baldwin Park, 91706
(626) 856-1674
Pizza Hut
13926 Ramona Boulevard
Baldwin Park, 91706
(626) 337-8200
Subway
16012 East Arrow Highway
Irwindale, 91706
(626) 960-0058
Subway
14417 Ramona Boulevard
Baldwin Park, 91706
(626) 851-9200
Subway
3127-A Baldwin Park Boulevard
Baldwin Park, 91706
(626) 851-2404
El Pollo Loco
14455 East Ramona Boulevard
Baldwin Park, 91706
(626) 960-8861
Subway
NEW
1404 North Azusa Avenue, Unit G
Covina, 91722
(626) 967-4040
Burger King
1681 West San Bernardino Road
Covina, 91722
(626) 915-5439
Kentucky Fried Chicken
1405 North Azusa Avenue
Covina, 91722
(626) 969-9437
Pizza Hut
1665 West San Bernandino Road
Covina, 91722
(626) 339-5000
Pizza Hut
468 East San Bernandino Road
Covina, 91723
(626) 331-9800
Kentucky Fried Chicken
1057 North Grand Avenue
Covina, 91724
(626) 966-2239
Wendy's
970 East Badillo Street
Covina, 91724
(626) 858-1956
El Pollo Loco
10612 Valley Mall
El Monte, 91731
Unlisted
Flames X-Press Charbroiled Burgers
11003 Lower Azusa Road
El Monte, 91731
(626) 350-7500
Jack in the Box
9220 Flair Drive
El Monte, 91731
(626) 571-5462
Jack in the Box
10699 East Valley Boulevard
El Monte, 91731
(626) 444-3629
Subway
10697 Valley Boulevard
El Monte, 91731
(626) 454-4077
El Pollo Loco
4794 North Peck Road
El Monte, 91732
(626) 448-6767
El Pollo Loco
11928 Garvey Avenue
El Monte, 91732
(626) 442-8682
Jack in the Box
11780 Ramona Boulevard
El Monte, 91732
(626) 279-7549
Kentucky Fried Chicken
3814 Peck Road
El Monte, 91732
(626) 443-1367
La Pizza Loca
11806 East Valley Boulevard
El Monte, 91732
(626) 448-5944
Pizza Hut
11910 East Garvey Avenue
El Monte, 91732
(626) 448-8300
Subway
11990 Garvey Avenue
El Monte, 91732
(626) 279-1860
Domino's Pizza
1937 Tyler Avenue
South El Monte, 91733
(626) 579-3030
Flames Burgers
9847 Rush Street
El Monte, 91733
(626) 448-2316
Foody Goody Restaurant
10472 Garvey Avenue
El Monte, 91733
(626) 329-0588
Jack in the Box
1933 Durfee Avenue
El Monte, 91733
(626) 444-8029
Jim's Burger
10159 East Garvey Avenue
El Monte, 91733
(626) 443-4018
Kentucky Fried Chicken
1927 North Durfee Avenue
El Monte, 91733
(626) 579-0374
Subway
1130 Peck Boulevard
South El Monte, 91733
(626) 279-6307
Subway
9328 Garvey Avenue, #B
South El Monte, 91733
(626) 350-1415
Yoshinoya Beef Bowl
10534 Garvey Avenue, # 101
El Monte, 91733
(626) 401-0132
El Pollo Loco
750 South Grand Avenue
Glendora, 91740
(626) 914-3344
Pizza Hut
1433 East Route 66
Glendora, 91740
(626) 335-4500
El Pollo Loco
1341 Hacienda Boulevard
La Puente, 91744
(626) 917-9407
Jack in the Box
14304 Amar Road
La Puente, 91744
(626) 918-7569
Pizza Hut
14316 Amar Road
La Puente, 91744
(626) 917-6464
Pizza Hut
15495 East Valley Boulevard
Industry, 91744
(626) 333-0041
Pizza Hut
1599 North Hacienda Boulevard
La Puente, 91744
(626) 918-2892
Domino's Pizza
15908 Halliburton Road
Hacienda Heights, 91745
(626) 369-0999
El Pollo Loco
17182 Colima Road
Hacienda Heights, 91745
(626) 912-8111
Jack in the Box
1159 South Hacienda Boulevard
Hacienda Heights, 91745
(626) 330-3608
Kentucky Fried Chicken
1135 South Hacienda Boulevard
Hacienda Heights, 91745
(626) 330-7421
Pizza Hut
2133 Hacienda Boulevard
Hacienda Heights, 91745
(626) 369-4433
Domino's Pizza
4561 North Peck Road
El Monte, 91746
(626) 448-3030
Subway
13129 Valley Boulevard
La Puente, 91746
(562) 695-6700
Domino's Pizza
1725 South Nogales, Suite 110
Rowland Heights, 91748
(626) 912-1130
Jack in the Box
18721 Gale Avenue
Industry, 91748
(626) 810-7963
Kentucky Fried Chicken
17901 South Colima Road
Industry, 91748
(626) 839-7414
Pizza Hut
1758 South Nogales Street
Rowland Heights, 91748
(626) 912-9292
El Pollo Loco
2360 Foothill Boulevard
La Verne, 91750
(909) 596-3206
Pizza Hut
2208 Foothill Boulevard
La Verne, 91750
(909) 596-9444
Yoshinoya
NEW
2121 South Atlantic Boulevard
Monterey Park, 91754
(323) 780-8288
Domino's Pizza
829 South Atlantic Boulevard
Monterey Park, 91754
(626) 576-2000
El Pollo Loco
2258 South Atlantic Boulevard
Monterey Park, 91754
(323) 278-9021
Pizza Hut
2212 South Atlantic Boulevard
Monterey Park, 91754
(323) 725-6400
Subway
2250 South Atlantic Boulevard
Monetery Park, 91754
(323) 721-8037
Kentucky Fried Chicken
2709 Diamond Bar Boulevard
Diamond Bar, 91765
(909) 598-5100
Pizza Hut
1241 South Grand Avenue, A
Diamond Bar, 91765
(909) 396-1600
Burger King
1908 South Garey Avenue
Pomona, 91766
(909) 627-5200
Page 15
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
Pizza Hut
2301 North Garey Avenue
Pomona, 91766
(909) 593-2000
Kentucky Fried Chicken
2294 North Garey Avenue
Pomona, 91766
(909) 593-2568
Kentucky Fried Chicken
375 East Mission Boulevard
Pomona, 91766
(909) 623-2549
Pizza Hut
2218 South Garey Avenue
Pomona, 91766
(909) 465-9200
Subway
291 East Second Street
Pomona, 91766
(909) 622-3408
Yoshinoya Beef Bowl
2102 South Garey Avenue
Pomona, 91766
(909) 591-3183
Subway
1760 East Arrow Highway
Pomona, 91767
(909) 621-6840
Classic 66 Burger
504 East Foothill Boulevard
Pomona, 91767
(909) 621-7493
Subway
NEW
101 East Foothill Boulevard, Unit #37
Pomona, 91767
(909) 593-1750
El Pollo Loco
729 West Las Tunas Boulevard
San Gabriel, 91767
(626) 576-5438
J & J BBQ Fish
751 Indian Hill Boulevard
Pomona, 91767
(909) 865-6700
Bravo's Burger
1215 North White Avenue
Pomona, 91768
(909) 622-0855
Burger King
2085 West Holt Avenue
Pomona, 91768
909) 620-7206
La Pizza Loca
937 West Holt Avenue
Pomona, 91768
(909) 469-1200
Domino's Pizza
8350 Garvey Avenue, #B
Rosemead, 91770
(626) 288-3030
Jack in the Box
820 San Gabriel Boulevard
Rosemead, 91770
(626) 569-0363
Jack in the Box
3038 North San Gabriel Boulevard
Rosemead, 91770
(626) 569-0663
Jack in the Box
4216 North Rosemead Boulevard
Rosemead, 91770
(626) 285-7984
Pizza Hut
7779 Garvey Avenue
Rosemead, 91770
(626) 307-5533
El Pollo Loco
1006 West Arrow Highway
San Dimas, 91773
(909) 592-6832
Pizza Hut
1059 West Arrow Highway
San Dimas, 91773
(909) 599-0444
Domino's Pizza
1001 East Las Tunas Drive
San Gabriel, 91776
(626) 287-0901
Jack in the Box
901 West Las Tunas Drive
San Gabriel, 91776
(626) 570-6131
Kentucky Fried Chicken
518 East Las Tunas Drive
San Gabriel, 91776
626) 285-1227
Pizza Hut
927 East Las Tunas Drive
San Gabriel, 91776
(626) 451-5900
Domino's Pizza
9443 Las Tunas Drive
Temple City, 91780
(626) 285-0033
Jack in the Box
9965 Lower Azusa Road
Temple City, 91780
(626) 401-9730
Subway
9441 Las Tunas Drive
Temple City, 91780
(626) 285-7280
Domino's Pizza
18870 Amar Road
Walnut, 91789
(909) 594-5533
El Pollo Loco
21610 Valley Boulevard
City of Industry, 91789
(909) 594-8656
Jack in the Box
20965 Golden Springs Drive
Diamond Bar, 91789
(909) 595-1414
Jack in the Box
1245 North Grand Avenue
Walnut, 91789
(909) 595-9856
Kentucky Fried Chicken
555 South Glendora Avenue
West Covina, 91790
(626) 338-6922
Pizza Hut
504 South Vincent Avenue
West Covina, 91790
(626) 962-8300
El Pollo Loco
2312 South Azusa Avenue
West Covina, 91792
(626) 965-8119
Kentucky Fried Chicken
19080 La Puente Road
Walnut, 91792
(626) 964-1145
Kentucky Fried Chicken
2301 South Azusa Avenue
West Covina, 91792
(626) 965-1712
Pizza Hut
3646 Nogales Street, #C
West Covina, 91792
(626) 854-0022
Kentucky Fried Chicken
1425 New Avenue
Alhambra, 91801
(818) 282-3177
Kentucky Fried Chicken
151 North Garfield Avenue
Alhambra, 91801
(626) 289-4463
Pizza Hut
1219 North Atlantic Boulevard
Alhambra, 91801
(626) 458-1313
Pizza Hut
1224 South Atlantic Boulevard
Alhambra, 91801
(626) 284-8200
Subway
1701 West Main Street
Alhambra, 91801
(626) 458-5543
Subway
2 South Garfield, #1
Alhambra, 91801
(626) 293-8603
Domino's Pizza
703 South Atlantic Boulevard
Alhambra, 91803
(626) 289-5694
El Pollo Loco
2528 W. Commonwealth Avenue
Alhambra, 91803
(626) 289-9882
Kentucky Fried Chicken
2970 West Valley Boulevard
Alhambra, 91803
(626) 282-1193
Burger King
43627 North 15th Street West
Lancaster, 93534
(661) 942-2477
Burger King
1202 West Avenue I
Lancaster, 93534
(661) 948-4417
Jack in the Box
43628 10th Street West
Lancaster, 93534
(661) 942-0522
Nick's Café & Pizzeria
43755 N. 15th Street West
Lancaster, 93534
(661) 951-1035
Pizza Hut
1979 West Avenue L
Lancaster, 93534
(661) 723-3313
Captain Tony's Pizza
135 East Avenue J
Lancaster, 93535
(661) 942-3000
Domino's Pizza
1007 East Avenue J
Lancaster, 93535
(661) 945-9456
Domino's Pizza
2072 West Avenue J
Lancaster, 93535
(661) 948-0991
Jack in the Box
1799 East Avenue J
Lancaster, 93535
(661) 949-8975
Burger King
4107 West Avenue L
Lancaster, 93536
(661) 722-0340
Domino's Pizza
42056 50th Street West
Quartz Hill, 93536
(661) 943-2456
Jack in the Box
2030 West Avenue K
Lancaster, 93536
(661) 945-4244
Burger King
8314 Pearblossom Highway
Littlerock, 93543
(661) 944-4175
Domino's Pizza
8201 Pearblossom Highway
Littlerock, 93543
(661) 944-0404
Jack in the Box
2443 West Avenue I
Lancaster, 93543
(661) 726-3626
Church's
810 West Avenue I
Lancaster, 93534
(661) 949-8962
NEW
Page 16
NEW
El Pollo Loco
123 East Holt Boulevard
Pomona, 91767
(909) 622-2275
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
RESTAURANT MEALS PARTICIPATING RESTAURANTS
February 2011
Domino's Pizza
4604 East Avenue S, #G
Palmdale, 93550
(661) 274-1355
Domino's Pizza
602 East Palmdale Boulevard
Palmdale, 93550
(661) 272-0033
Jack in the Box
564 Palmdale Boulevard
Palmdale, 93550
(661) 947-2729
Pizza Hut
220 East Palmdale Boulevard
Palmdale, 93550
(661) 273-5877
Pizza Hut
37244 47th Street, Suite C-3
Palmdale, 93550
(661) 285-9595
Burger King
2606 East Palmdale Boulevard
Palmdale, 93551
(661) 272-9126
Burger King
3045 Rancho Vista Boulevard
Palmdale, 93551
(661) 722-0340
El Pollo Loco
3051 Rancho Vista Boulevard
Palmdale, 93551
(661) 274-0463
Jack in the Box
570 West Avenue P
Palmdale, 93551
(661) 273-8261
Revised 01/24/11
Burger King
38137 47th Street East
Palmdale, 93552
(661) 259-9955
El Pollo Loco
38007 47th Street
Palmdale, 93552
(661) 285-0402
Jack in the Box
37070 47th Street East
Palmdale, 93552
(661) 285-7382
Page 17
Medi-Cal
The Medi-Cal program provides health care services to CalWORKs and
SSI/SSP recipients. Other low-income persons (primarily families with
children and the elderly, blind, and disabled) who meet the program’s eligibility
criteria can also receive Medi-Cal benefits.
Applicants can receive a mail-in application by calling 1-877-597-4777.
Contents
•
•
Medi-Cal Program Quarterly Fact Sheet
Sample Application for Medi-Cal
•
www.ladpss.org
Department’s main website listing all departmental information, including
program-specific information, office locations and the community event’s
calendar.
•
www.lacountyhelps.org
Informs citizens of Los Angeles County of state and federal benefits
assistance. This website provides additional information about programs
available after completing a short online survey.
•
www.211LACounty.org
Provides information about human social services in the Los Angeles
County.
County of Los Angeles
Department of Public Social Services
PHILIP L. BROWNING
Director
SHERYL L. SPILLER
Chief Deputy
MEDI-CAL PROGRAM
FACT SHEET
October 2010 - December 2010
Overview
The Medi-Cal Program provides comprehensive medical benefits to certain public assistance
recipients and other eligible persons who are unable to afford the cost of their medical care.
Individuals receiving public assistance from Supplemental Security Income/State Supplementary
Payment (SSI/SSP), Foster Care and CalWORKs (CW) are automatically eligible for Medi-Cal
benefits. Other aged, disabled, family-linked individuals, children up to age 21, pregnant women
and adults in a skilled nursing facility may be eligible for benefits under the Medi-Cal
Assistance Only (MAO) programs. Other adults between the ages of 21 and 65 who are not
blind or disabled, pregnant, in a skilled nursing facility, or are not members of families with minor
children who meet federal deprivation requirements, are identified as Medically Indigent Adults
(MIA) and are not eligible for Medi-Cal. MIAs may receive medical care from County public
health facilities. Medi-Cal is under the jurisdiction of the California Department of Health Care
Services (CDHCS).
Requirements for Medi-Cal Eligibility
The following basic requirements must be met for Medi-Cal eligibility:
ƒ
Residency
The person must be a California resident; however, there is no durational
residency requirement.
ƒ
Citizenship/Immigration Status
To receive full-scope coverage, an individual must be a U.S. citizen or a noncitizen with
satisfactory immigration status. The Deficit Reduction Act (DRA) of 2005 requires that
persons declaring U.S. citizenship or U.S. national status must provide original or certified
copies of documents that verify their U.S. citizenship and identity. As of January 2010,
this requirement may also be met by matching a person's information with Social Security
Administration records. Noncitizens without satisfactory immigration status and citizens
with no proof of citizenship and identity may receive coverage limited to emergency,
skilled nursing and pregnancy related care.
Requirements for Medi-Cal Eligibility (Continued)
ƒ
Resources
An applicant’s non-excluded resources must not exceed the limits, based on
family size, as shown below:
1 person
2 persons
3 persons
4 persons
$2,000*
3,000
3,150
3,300
5 persons
6 persons
7 persons
8 persons
$ 3,450
3,600
3,750
3,900
9 persons
$ 4,050
10 or more persons
4,200
*The property limit for one person for the 1931(b) Program is $3,000. Other property limits may vary based on specific
program requirements.
The person’s principal residence is not considered in determining resources and
eligibility. The individual may also exempt real property, other than his/her own home if it
is utilized and the net market value (assessed value less encumbrances) does not
exceed $6,000. The value of other real property that exceeds $6,000 is applied to the
family’s total resources. Other personal property, such as cash, bank accounts, and
non-exempt vehicles are also included in the total resource valuation. For 1931(b), a
vehicle may be exempt if it is used for self-employment, transportation of a disabled
person living in the home, transportation of the primary supply of fuel or water for the
home, or used as a home. For MAO, the family may choose one vehicle for exemption,
regardless of its use. A vehicle used as a home is also exempt for this program.
Individuals with resources valued in excess of the limit for their household size are not
eligible. For some qualifying children and pregnant women, resources are not counted
(see details in Special Programs).
For married persons who need Medi-Cal because one spouse receives long-term
inpatient care, the law allows the spouse at home to retain a portion of the combined
community and separate property. The 2010 Community Spouse Resource Allowance
(CSRA) is $109,560. The CSRA is adjusted annually based on the Consumer Price
Index, however, the limit was not increased in 2010 and remains at the 2009 level.
What is the Cost of Medical Care?
The amount that a family or an individual has to pay for Medi-Cal benefits is determined by the
amount of available income that remains after appropriate exclusions and deductions are
allowed. While there are no income limits for Medi-Cal eligibility, income that remains after all
State-allowed deductions are applied must be paid or obligated toward the individual or family
monthly medical expense before Medi-Cal coverage is utilized. This amount that must be paid
or obligated is called a Share of Cost (SOC).
Unlike a monthly medical premium, the SOC must only be met if Medi-Cal coverage is needed
during the month. Each time a beneficiary receives medical services, the service provider will
use the Benefits Identification Card (BIC) to determine how much, if any, is obligated to be
paid.
Medi-Cal Program Section
Page 2 of 10
01/03/11
What is the Cost of Medical Care? (Continued)
In certain cases where a third party may be responsible for an individual’s injury or illness, the
CDHCS will try to recover the cost of Medi-Cal treatment from the responsible party.
Which Services are Covered?
Individuals who are eligible to receive full-scope Medi-Cal benefits are entitled to a
comprehensive range of health care services, dental care (for ages 0 up to 21 years) and
prescription drugs (both in and out of a hospital or nursing home) from health care providers who
participate in the program. This includes hospice care to alleviate pain and suffering of
individuals with a diagnosis of illness with a life expectancy of six months or less.
Pregnant women may be entitled to benefits that include pregnancy-related services and 60
days of postpartum services at no SOC. In most instances, newborns may continue to be
covered at the same SOC as their mothers until their first birthday.
Medi-Cal benefits for pregnancy-related services and for emergency medical services only,
which include labor and delivery of an infant, are available to noncitizens who do not have
satisfactory immigration status and citizens with unverified proof of citizenship and identity, if
otherwise eligible.
CDHCS establishes which services are authorized. Before providing and billing for certain
benefits, providers of Medi-Cal services may need to obtain authorization from the
Medi-Cal Consultant at CDHCS. Prior authorization is required for such things as dental
services, prescription drugs not on the State-approved list, hearing aids, some sickroom
equipment, prosthetic and orthodontic appliances, non-emergency hospitalization, nursing home
services and intermediate facility care.
An applicant may be eligible for Medi-Cal coverage for services received in any of the three
months immediately preceding the month of application or re-application if all requirements are
met for those past months. A beneficiary who is eligible for benefits on the first day of the month
is entitled to services for the entire month.
How are Services Received?
A plastic BIC is provided to each beneficiary. The BIC must be shown to the provider each time
medical services are received. The provider will use the BIC to determine the individual’s
Medi-Cal eligibility status and SOC obligation. The BIC should be retained even if benefits are
subsequently discontinued. In the event that benefits are restored at a later date or upon
reapplication, the BIC is reactivated for the beneficiary’s use.
Certain persons entitled to zero SOC Medi-Cal are now required to enroll in a managed care
plan. These are private health organizations under contract with the State to provide
comprehensive health services to Medi-Cal enrollees. Once enrolled in a managed care plan, a
recipient must obtain his/her medical care through the plan except for any medical services that
are not covered (e.g., dental care). Certain other groups or persons who have a monthly SOC
obligation may receive fee-for-service care from a qualified Medi-Cal provider.
Medi-Cal Program Section
Page 3 of 10
01/03/11
SPECIAL PROGRAMS FOR FAMILIES, WOMEN AND CHILDREN
The following programs provide Medi-Cal at zero SOC to certain eligible women, families, and
children.
1931(b) Program - Provides no cost Medi-Cal benefits to families receiving CW payments and
families who do not receive CW, but meet the eligibility requirements which were in force for
the Aid to Families with Dependent Children (AFDC) Program based on the passage of welfare
reform legislation on July 16, 1996. Eligibility staff must first determine if eligibility can be
granted under the 1931(b) Program, and if not, then, determine if eligibility can be established
for other Medi-Cal programs. Verification of resources is required.
100% Program - Provides Medi-Cal benefits with no SOC to children age 6 to 19 if the family’s
net nonexempt income is at or below 100% of the Federal Poverty Level (FPL). Family
resources are not counted for this program.
133% Program - Provides Medi-Cal benefits with no SOC to children age 1 to 6 if the family’s
net nonexempt income is not more than 133% of the FPL. Family resources are not counted
for this program.
200% Program - Provides Medi-Cal benefits with no SOC to pregnant women and infants
under age one who do not meet the no share of cost criteria under other programs. The
adjusted net income can be no more than 200% of the FPL. The benefits for women are
limited to pregnancy-related and postpartum medical care. Infants receive full-scope Medi-Cal
services. Family resources are not counted for the pregnant woman or infant.
Continuous Eligibility for Children (CEC) - Establishes eligibility with no SOC for up to
twelve consecutive months and ends at the child’s 19th birthday, or twelve months from the
initial month of application or annual redetermination, whichever occurs first. During the CEC
guarantee period, any changes in the family’s income or resources which would cause the
child to have a SOC or be totally ineligible are disregarded until the next annual
redetermination or the child’s 19th birthday. CEC will protect the child from discontinuance,
even if resource changes affect the other family members.
Presumptive Eligibility (PE) for Pregnant Women - Allows certain qualified health care
providers to extend zero SOC prenatal Medi-Cal coverage to eligible pregnant women with
income up to 200% of the FPL at the first clinic/office visit. This coverage ends either at the
end of the second month of PE or upon approval or denial of the regular Medi-Cal application
filed by the pregnant woman. Family resources are not counted for the pregnant woman’s
eligibility to pregnancy-related-only services.
Deemed Eligibility (DE) - Provides that infants born to women eligible for and receiving
Medi-Cal at the time of the child's birth are automatically deemed eligible for one year without
a separate Medi-Cal application. Birth verification is not required and a Social Security
Number (SSN) is not required for the child until age one. This program also provides that such
infants shall remain eligible, regardless of any increases in the family's income until the child
reaches age one.
Medi-Cal Program Section
Page 4 of 10
01/03/11
SPECIAL PROGRAMS FOR FAMILIES, WOMEN AND CHILDREN (Continued)
Transitional Medi-Cal (TMC) Program - Provides up to 12 months of no SOC benefits to
families who have lost eligibility to CW or 1931(b) benefits due to increased hours of
employment or increased earnings of the caretaker/relative or primary wage earner. Certain
eligibility requirements must be met.
Four-Month Continuing Medi-Cal - Allows families who have lost eligibility to CW or 1931(b)
Medi-Cal due to receipt of, or an increase in child support or alimony, to receive no-cost,
full- scope benefits, under certain conditions, for four additional months.
Medi-Cal/Healthy Families Bridging - Extends one month of no-cost eligibility to children under
age 19 who are moving from no-cost coverage to a SOC, or who have lost eligibility due to
increased resources. The additional month allows referral to the Healthy Families program for a
determination of eligibility. Children must be U. S. citizens or legal permanent residents with
income under 250% of the FPL.
Former Foster Care Children (FFCC) Program - Provides for automatic, continuing, no-cost,
full-scope Medi-Cal coverage for children who were in foster care on their 18th birthday and who
were subsequently released from the foster care system due to age. There is an annual
redetermination requirement which involves no income or resource verification. Medi-Cal
coverage continues until the FFCC’s 21st birthday as long as he/she remains in the State.
SPECIAL PROGRAMS FOR ADULTS
The following programs provide Medi-Cal at zero SOC to certain eligible adults:
Aged & Disabled Federal Poverty Level (A&D FPL) Program - Provides zero SOC Medi-Cal
to income-eligible aged and disabled persons. To be eligible for this program, the individual
must be at or over 65 years of age or be considered disabled by Social Security criteria, have
resources below the MAO limits (see Resources, page 2), and have net countable income at or
below 100% of the FPL.
Pickle Amendment Benefits - Under the Pickle Amendment to the Social Security Act,
Medi-Cal benefits, at no SOC, are available to persons who have lost their eligibility for SSI cash
benefits due to cost-of-living adjustments in their regular Social Security disability or retirement
benefits. To be eligible, an individual’s countable income must be less than the current SSI
payment level, after all cost of living adjustments subsequent to SSI ineligibility due to increased
SSA benefits have been disregarded. This program was expanded to include Disabled Adult
Children and Disabled Widow(er)s.
OTHER SPECIAL PROGRAMS
The programs listed below provide financial or medical assistance to persons who may or may
not otherwise be eligible for Medi-Cal benefits.
Child Health and Disability Prevention Program (CHDP) - CHDP is a federally and State
mandated program which provides preventive health care to children ages 0-20 who receive
Medi-Cal. Eligible children receive services that include periodic assessments and referrals for
diagnosis and treatment of suspected health care problems. Non-Medi-Cal eligible children,
Medi-Cal Program Section
Page 5 of 10
01/03/11
OTHER SPECIAL PROGRAMS (Continued)
ages 0-19, whose family income is equal to or less than 200% of the FPL, are also eligible for
these services. The primary goal of the program is to keep children and teens healthy through
regular check-ups and to find health problems before they become more serious. In Los
Angeles County, CHDP services are provided by CHDP certified fee-for-service providers,
Medi-Cal Managed Care providers, County Public Health Centers, and certain prepaid health
plans. In Long Beach and Pasadena, the City of Long Beach Health and Human Services and
the City of Pasadena Public Health Department also provide these services.
Minor Consent Services - This program provides confidential services to minors related to
sexual assault, pregnancy and pregnancy-related services, family planning, sexually
transmitted diseases, drug and alcohol abuse, and outpatient mental health treatment and
counseling.
250% Working Disabled Program - This program expands Medi-Cal zero SOC eligibility to
working, disabled individuals, subject to payment of a monthly premium. Applicants must meet
SSI eligibility rules, although their countable net income can be as high as 250% of the FPL.
The county determines eligibility and premiums are collected by the State. The monthly
premium is set using a sliding scale, based on individual income.
Dialysis and Related Services - Limited Medi-Cal coverage is provided to property ineligible
persons who need life-sustaining dialysis and related services. Eligible persons may be
obligated to pay a percentage of the treatment costs for services not covered by other health
insurance or government programs.
Health Insurance Premium Payment (HIPP) Program - Under the HIPP Program, the
CDHCS will pay health insurance premiums on behalf of certain MAO beneficiaries who have
high-cost medical conditions. The County Department of Public Social Services (DPSS) refers
potentially eligible clients to CDHCS for possible participation in the program.
Medicare Savings Programs (MSP) - The Medicare Catastrophic Coverage Act (MCCA) of
1988 requires that states pay the Medicare Part A and Part B cost-sharing expenses of
qualified low-income Medicare beneficiaries that include premiums, deductibles and
coinsurance fees.
Under the Qualified Medicare Beneficiary Program (QMB), Medi-Cal will help pay monthly
Medicare Part A and Part B premiums plus deductible and coinsurance fees for certain aged
and disabled persons. For Part A Medicare premium coverage under the QMB Program,
eligible persons may have income up to 100% of the FPL. Under the Specified Low Income
Medicare Beneficiary (SLMB) Program, individuals may have income above 100% but less
than 120% of the FPL. Coverage under SLMB is limited to the payment of Medicare Part B
premium, not payment of Medicare Part A premium or the Part B deductibles or coinsurance
fees.
The Qualifying Individual-1 (QI-1) Program is limited to the payment of the Medicare Part B
premium. It does not pay the Medicare Part A premium or the Part B deductibles or
coinsurance fees. To be eligible, a QI-1 person must have income at or above 120% of the
FPL and up to but not including 135% of the FPL. This program sunset date has been
extended to December 2010.
Medi-Cal Program Section
Page 6 of 10
01/03/11
OTHER SPECIAL PROGRAMS (Continued)
Medicare Buy-In is the payment of Medicare Part B premiums by CDHCS for certain
eligible aged, blind or disabled beneficiaries under the Medicare Buy-In agreement with the
Social Security Administration. Effective December 2008, a Medi-Cal/Medicare beneficiary must
be a full-scope Medi-Cal beneficiary with no SOC, a beneficiary with a SOC at or below $500 or
a beneficiary with a certified SOC over $500.
Tuberculosis Program - This is an optional program for persons infected with tuberculosis who
do not qualify for federally funded Medi-Cal programs. To be eligible, income and resource
requirements are applied.
Breast and Cervical Cancer Treatment Program (BCCTP) - This program is administered by
CDHCS for affected individuals who do not meet the requirements for full-scope, no-cost MediCal. County staff refers potentially eligible persons to BCCTP for evaluation. The State refers
persons who are no longer eligible for BCCTP benefits to DPSS for eligibility under other
Medi-Cal programs. For enrollment information, individuals should call the toll-free number
1-800-824-0088.
Assisted Living Waiver Pilot Project (ALWPP) - ALWPP is a three-year pilot project created
by State law (AB 499) in 2000 to test the efficacy of assisted living as an alternative to long-term
care nursing provider site placement. The ALWPP is intended to provide options for older adults
and individuals with disabilities who want to remain in a community-based setting. The waiver
was renewed in March 2009 to extend the project for an additional five years.
OTHER PATHS TO MEDI-CAL
Several programs have been developed by CDHCS to facilitate children’s access to Medi-Cal
benefits and expedite the application process. These programs offer either no-cost Medi-Cal
benefits for certain apparently eligible children for a period of 60 days or until a determination of
eligibility has been completed OR use alternate application methods to expedite the eligibility
determination. The programs that offer expedited access to Medi-Cal benefits are:
Accelerated Enrollment - Allows apparently eligible children under age 19 to receive temporary
(up to 60 days) no-cost, fee-for-service Medi-Cal benefits. During this time, the Healthy Families
Program makes a determination of eligibility after receiving a Joint Medi-Cal/Healthy Families
application (MC 321 HFP) via Single Point of Entry. If the family appears eligible to Medi-Cal,
the application is forwarded to the county of residence.
CHDP Gateway - Allows apparently eligible children, age 0 to 19 years, to enroll into temporary,
no-cost Medi-Cal benefits through providers at the time of the CHDP examination. Applications
must be submitted during the 60-day temporary enrollment period if benefits are to continue. If
an application is not returned, the temporary benefit stops at the end of the 60-day period. The
exception to this CHDP Gateway process rule is: No application is required for a CHDP
Gateway enrolled infant born to a mother who was eligible to and receiving Medi-Cal in the
infant’s birth month. The infant remains eligible to receive the temporary benefits until age one
or until eligibility under regular Medi-Cal programs has been completed.
Medi-Cal Program Section
Page 7 of 10
01/03/11
OTHER PATHS TO MEDI-CAL (Continued)
Express Lane Enrollment - A pilot program in collaboration with Los Angeles Unified School
District (LAUSD) and the Department of Public Social Services (DPSS) that allows staff
enrollment of uninsured students into Medi-Cal using the National School Lunch Program
(NSLP) application as an application for Medi-Cal.
Healthy Families to Medi-Cal Presumptive Eligibility Program - This program replaced the
Healthy Families to Medi-Cal Bridging Program effective July 1, 2007. The program gives
full-scope no SOC Medi-Cal benefits to children who were receiving Healthy Families benefits
but who appear to be eligible for Medi-Cal. The Presumptive Eligibility period continues until a
Medi-Cal eligibility determination has been completed.
Other Paths to Medi-Cal for Adults
The "Medicare Improvements for Patients and Providers Act of 2008” (MIPPA) Eliminating
Barriers to Medicare Savings Programs Enrollment requires the State to treat the Low Income
Subsidy (LIS) application (Medicare Part D) as an application for the Medicare Savings
Programs (MSP). California has elected to also treat the LIS application as an application for
Medi-Cal for which an eligibility determination is required.
Based on an agreement between CDHCS and the Department of Corrections and
Rehabilitation (CDCR), applications for adult inmates who are granted parole will be processed
prior to their release. If the inmate is determined to be eligible, the CDCR is notified and a
temporary BIC is issued in order to access health care upon release.
What's New in 2010
Suspension of Medi-Cal Benefits for Incarcerated Juveniles
Beginning January 2010, Assembly Bill 1147 was implemented for individuals under age 21
who are beneficiaries at the time of incarceration. The bill allows for a suspension of benefits
from the date of incarceration that ends on 1) the date the individual is no longer an inmate of
a public institution; 2) at the end of the year he or she became an inmate of the public
institution; 3) at the end of the month that the juvenile turns 21; or, 4) at the end of the month
that the juvenile has become otherwise ineligible for Medi-Cal, whichever is sooner. This
allows the juvenile to access Medi-Cal benefits at the end of incarceration, if eligibility
requirements are met at the time of release.
Health Care Reform
The Patient Protection and Affordable Care Act and the Health Care and Education
Reconciliation Act were approved in March 2010. More commonly referred to as the Health
Care Reform Act, the federal law will be evaluated by State legislators and the CDHCS for
impact on Medi-Cal programs eligibility and methodology. The California Health Care Initiative
“California Bridge to Reform” was approved by the Centers for Medicare and Medicaid
Services (CMS) in November 2010. This will allow the state to implement coverage and
improvements for a seamless transition to reform mandates effective 2014.
Medi-Cal Program Section
Page 8 of 10
01/03/11
County of Los Angeles
Department of Public Social Services
PHILIP L. BROWNING
Director
SHERYL L. SPILLER
Chief Deputy
MEDI-CAL PROGRAM
STATISTICAL FACT SHEET
October - December 2010
MEDI-CAL CASELOAD
¾
Average Caseload
Cases
Persons
710,368
1,675,005
AGE
¾
¾
¾
¾
¾
¾
ETHNICITY
Under 1
1–5
6 – 18
19 – 20
21 – 65
Over 65
3.16%
15.15%
30.36%
4.33%
34.35%
12.66%
¾
¾
¾
¾
¾
¾
WHITE
HISPANIC
BLACK
ASIAN/PACIFIC ISLANDER
AMERICAN INDIAN/ALASKAN NATIVE
OTHER
GENDER
¾
¾
Adults
Children
MALE
FEMALE
16.19%
26.64%
30.81%
26.35%
9.04%
72.23%
7.12%
8.59%
0.08%
2.94%
LANGUAGE
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
ENGLISH
SPANISH
ARMENIAN
CHINESE
RUSSIAN
KOREAN
VIETNAMESE
CAMBODIAN
FARSI
TAGALOG
OTHER
45.28%
43.22%
2.62%
3.26%
0.58%
1.53%
1.26%
0.29%
0.51%
0.76%
0.68%
CITIZENSHIP STATUS OF AIDED PERSONS
¾
¾
¾
¾
US CITIZENS
LEGAL IMMIGRANTS
OTHER
UNDOCUMENTED IMMIGRANTS
68.81%
11.33%
0.10%
19.76%
* Report includes statistical data from September through November 2010. Data for December 2010 was not
yet available.
Medi-Cal Program Section
Page 9 of 10
01/03/11
Medi-Cal Program Staffing By Classification
HSA III
HSA II
HSA I
PA
Acting Sec IV
Sec II
IC
EW
1
2
9
4
1
2
2
1
“To Enrich Lives Through Effective And Caring Service”
Bureau of Special Operations
Medi-Cal Program Section
12900 Crossroads Parkway South
City of Industry, California 91746
Medi-Cal Program Section
Page 10 of 10
01/03/11
HEALTH CARE COVERAGE
FOR PEOPLE WITH LIMITED INCOME OR RESOURCES
MAIL-IN APPLICATION AND INSTRUCTIONS
Physical
Therapy
Pharmacy
Services
Pregnant
Women
Nursing
Home Care
Disabled
Infants/
Children
Elder Care
Vision Care
Families
Dental Care
Emergency
Medical
Transportation
Working
Parents
For FREE help to apply for Medi-Cal,
contact your local social services office.
What is Medi-Cal?
• Health care coverage for qualifying persons who live in California, who have income
and resources below established limits
Who can get Medi-Cal?
• Persons 65 or older
• Persons who are under 21 years of age
• Certain adults between 21 and 65 years of age,
if they have minor children living with them
• Persons who are blind or disabled
• Pregnant women
• Persons receiving nursing home care
• Certain Refugees, Asylees, Cuban/Haitian Entrants
Do I have to be a U.S. citizen to get Medi-Cal?
• No, documented and undocumented aliens may be eligible for Medi-Cal. Some persons
may receive pregnancy related and emergency services only; others are eligible for full
Medi-Cal benefits depending on their alien status
When Medi-Cal says “a minor child,” what does it mean?
• A child married or unmarried under 21 years of age living in your home or away at school
What do I do to get Medi-Cal coverage?
• Complete and send in the enclosed application
• Send copies of any required documentation (See instructions)
How can my family and I qualify for Medi-Cal coverage?
If you are in one of the groups listed in “Who can get Medi-Cal?”
above:
• We look at your income and subtract some expenses you pay to
decide your family’s countable income for Medi-Cal
• We look at things you and your family own (bank accounts,
vehicles, etc.) to see if you meet the resource limit. Please Note:
Not all the things you or your family own are counted; your local
social services office can give you more information
If I do not fall into one of the covered groups,
how can I get coverage?
• Contact your local social services office for information about medical services in your county
MC 210 2/10
INSTRUCTIONS
When Applying For Medi-Cal Health Coverage
What Should I Do If...
I have an immediate need for health
care services, such as severe illness
or pregnancy.
• Take this application directly to the nearest social
services office to start the application process.
I have the application,
but need help.
• Read Instructions carefully.
• Contact your local social services office for help.
• Ask a friend or relative to help you.
My spouse or I are entering
a nursing home and applying
for Medi-Cal.
• Immediately contact your local social
services office for a copy of the notice
regarding standards for Medi-Cal eligibility
form (DHCS 7077). This form will explain
certain exempt resources, certain protections
against spousal impoverishment, and certain
circumstances under which an interest in a
home may be transferred without affecting
Medi-Cal eligibility.
I filled out the application
and want to mail it.
• Mail the completed application and
documentation to your local social
services office.
NOTE: Medi-Cal will only pay for the covered services you get from
an enrolled Medi-Cal provider after you apply. If you want Medi-Cal
to pay, make sure your provider is an enrolled Medi-Cal provider.
I’m homeless or do not
have a mailing address.
DO NOT MAIL THIS APPLICATION.
• Go to the nearest local social services office
to turn in this application.
I’m a minor/teenager and want
confidential Minor Consent Services, for
family planning, pregnancy
related care, mental health, drug
and alcohol abuse treatment/
counseling, sexually transmitted
diseases (STD) or sexual assault.
• To maintain confidentiality, you must take
this application to the local social services
office or eligibility worker site.
DO NOT MAIL IT.
I want to ask for Medi-Cal
in person. I do not want
to mail the application.
• Contact your local social services office and
ask for an interview to apply in person.
Remember, whether you take your application to the local social services office or
you mail it, you should not pay anyone to help you with this application.
www.dhcs.ca.gov
For FREE help to apply for Medi-Cal,
contact your local social services office.
MC 210 2/10
INSTRUCTIONS
INSTRUCTIONS
How to fill out the application
• Tear out the application
• Read the instructions completely
• Fill out as much of the application
as you can
• Include requested documentation
(See instructions)
• If help is needed contact
the local social services
office
• Do not delay in sending
in your application
Whose information should you put on this application?
• If you are an adult not living with a spouse, and you have no children,
enter your own information.
• If you are legally married and living together, enter your and your
spouse’s information.
• If you are legally married but one or both of you are living in a nursing
home or board and care facility, enter your and your spouse’s information.
• If your children are under 21 years of age and living with you and their
other parent, enter your own information, your children’s and the other parent’s.
• If you are under 21 years of age and not living with your parents, enter your
own information.
• If you are an unmarried minor under 21 years of age living with your parent(s) and
asking for Minor Consent confidential services, enter your own information.
What will happen after I send in my application?
• The local social services office will notify you within 10 working days that they received
your application. They will give you the name of someone you can contact for more
information about your application.
• You will receive a packet from the county with additional program information.
• You may receive a request for additional information that the county will need in order
to determine your eligibility.
• In most instances the local social services office will determine your eligibility within
45 days and notify you in writing of that decision. An eligibility determination based on
disability may take up to 90 days.
• If you are determined eligible, depending on what county you live in, you may
be able to choose a health plan. Even before you know if you qualify for Medi-Cal, you can
call 1-800-430-4263 (the call is free), to find out about health plans that are available in your
area and to ask for an informing packet with enrollment forms.
• If you do not qualify for no-cost Medi-Cal and you wish to apply for the Healthy Families
program, the local social services office will forward this application to that program.
MC 210 2/10
INSTRUCTIONS
INSTRUCTIONS
SECTION 1
Please read before beginning application.
• Persons in an institution
• Children in a family, if identity of one parent
Identity proof is not needed for
Tell us about the person who wants
Medi-Cal for themselves, their
family or children in their care.
has been established
• Children requesting Medi-Cal for Minor
Consent services
• The spouse of a person whose identity has
Questions 1-8:
Enter the name, home address
and telephone numbers of the
person who wants Medi-Cal
or the parent/caretaker of
the children who
want Medi-Cal.
been verified
SECTION 2
Tell us about the person listed in
Section 1, his or her family and the
children they care for, even if they
don’t want coverage.
Questions 9-13:
Enter the phone number and
mailing address (if different than
home address provided in #2) of the
person who wants Medi-Cal. This is the address
where all information regarding the application
and health benefits will be mailed.
If you are applying for
more than 5 people,
use a separate piece of
paper or a photocopy
of pages A1, A 2, A3 and
A4 of the application,
to give us information
about the additional
persons.
Question 14A-B:
Enter the language you speak and/or read best.
Send proof of identity. Only one person
(a parent or caretaker) in a family needs to provide
an identity document. Send a photocopy of one
of the following identity items:
• California driver license
• Identification card issued by the Department
Who counts as an adult?
• Persons 21 years of age or older
• Persons under 21 years of age who are not
of Motor Vehicles
• U.S. citizenship or alien status documents
living in the home of their parent or caretaker
relative and are not claimed as tax dependents
(passport)
• School identification card
• Birth certificate
• Marriage record
• Social Security card or document containing
• All natural and adoptive children under 21
Who counts as children?
living in the home
• All natural and adoptive children between
a Social Security number
• Divorce decree
• Work badge, building pass
• Adoption record
• Court order for name change
• Church membership or baptismal
18 and 21 years of age, away from home and
claimed as tax dependents
• All stepchildren under age 21 living in the home
Question 15:
confirmation certificate
MC 210 2/10
INSTRUCTIONS
1
Write the last, first and middle name of each person
in the house.
GO TO PAGE 2
SECTION 2
Question 25:
If you have ever received Medi-Cal, tell us your
Medi-Cal Benefits Identification Card (BIC)
number if you have it.
Continued
Question 16:
How is each person related to the person in
Section 1. Example: self, wife, husband,
grandparents, friend, daughter, stepchild,
nephew, etc.
Your Medi-Cal
Benefits Identification
Card (BIC) number
can be found here.
Question 17:
Write the complete address, if different from the
address in Section 1. Example: child is in college
and living at school.
Question 26:
Check “Yes,” if you are
asking for medical benefits for this person.
Question 18:
Indicate gender of each person.
Question 27:
Tell us if you own or are buying a home outside
California. Your answer helps us determine your
residency.
Question 19:
Indicate the marital status of each person listed.
Question 20:
Write the name of the spouse of any married minors
living in the home. Any income of the spouse must
be listed in Section 4.
Send proof of California residency. You can
use your proof of income as proof of residency.
If your income is not from California, send other
proof of residence. For example: rent receipts,
utility bill or a child’s school records.
Question 21:
Write month, day and year of birth for each person.
Question 22:
Tell us if this person is pregnant. If “Yes,” tell us
the due date.
SECTION 3
Answer for all children in Section 2.
Send proof of pregnancy from a doctor’s
office or a clinic within 60 days of applying
to continue receiving full Medi-Cal benefits.
You do not need to send verification if you
only want pregnancy related services.
Question 28:
Write the name of the natural or adoptive mother of
each child. Check the box to tell us if the mother is
employed, disabled, unemployed, deceased or
absent from the home.
Question 29:
Write the name of the natural or adoptive father of
each child. Check the box to tell us if the father is
employed, disabled, unemployed, deceased or
absent from the home.
Question 23:
Check “Yes,” if person is blind or has a physical or
mental illness that is expected to last at least 30
days. If person is unable to work, check “Yes,” and
check the box that best describes how long the
person will be unable to work if declared disabled.
This will help us decide if you are eligible for
Medi-Cal based on disability.
Question 24:
Tell us if anyone has ever had cash aid, SSI, Food
Stamps or Medi-Cal. This will help the local social
services office check for needed information before
asking you to give it. If you checked “Yes,” tell us the
name you received benefits under.
MC 210 2/10
INSTRUCTIONS
2
GO TO PAGE 3
SECTION 4
List all income/money received by
persons listed in Section 2.
Questions 30 and 31:
Use a separate line for each person who receives
money. If a person receives money from two
different places, use two lines.
Example: if the applicant has
two jobs, use one line for
each job to report
her/his earnings.
Question 32:
Write the amount of
money you receive
each time.
Documentation of Income
• Send proof of income. Send a copy of the
Example:
if you get money
once a week, write
the weekly amounts
in the box.
most recent pay stub you have. If a pay stub
is not available, get a signed statement from
your employer. Gross monthly income and the
dates received should be on the statement.
If the money amount
changes from time to time,
put the average amount you
get on a regular basis. We use
pay stubs or other documents you
give us to figure out the correct monthly income.
• A copy of last year’s federal income tax return.
OR
OR
• If a person is self-employed, send last year’s
Other proof of income you may need to send:
If you know your family’s income will go up or down
in the next few months due to overtime, promotion,
raises in pay, expected increases in child support/
alimony, layoffs, furloughs, etc., explain on a
separate sheet of paper.
federal income tax return, include Schedule C
or F, or the last 3 months’ profit and
loss statements.
• If a person has income such as disability or
Example: Maria’s gross income from her job on this
check is $1000 but her regular monthly pay
is only $800. Explain on the paper that Maria’s
paycheck included $200 overtime pay, or a cash
bonus and how long the overtime will last or how
often she gets bonuses.
retirement, send copies of award letters or
bank statements showing the direct deposits.
• If anyone gets child support and/or alimony
or spousal support, send copies of the
checks received or statements from the
District Attorney’s Family Support Division
for the last month.
Question 33:
How often do you receive this money?
• If anyone gets student loans or grants, send
Example: Monthly (once a month); weekly
(once-a-week); biweekly (every other week);
bimonthly (twice a month); or daily (every day).
MC 210 2/10
INSTRUCTIONS
in copies of award letters or loan papers.
3
GO TO PAGE 4
SECTION 6
SECTION 5
Skip this section if you are only
applying for Children under 19 and/or
pregnant women applying for
pregnancy related services only.
Otherwise answer for all persons
listed in Section 2.
Give information about the listed
expenses/costs paid by all persons
listed in Section 2.
Tell us if you pay court-ordered child support,
or alimony, or have other health insurance or
Medicare premium costs.
If you have questions or concerns
about completing Section 6,
leave it blank and contact the local
social services office for help.
Medi-Cal will pay your medicare premiums and
deduct the cost of any other insurance premium
from your countable income.
Question 34:
Write the name of the person who pays the cost.
The value of the home you are living in is
not counted for Medi-Cal.
Question 35:
Write in the total amount paid each month.
Question 40:
Tell us the amount of all cash you have on hand
and the amount of any checks you have received
but not cashed.
Question 36:
Write in the costs paid for child care and/or
disabled dependent care.
Question 41:
If anyone listed has a checking and/or savings
account or life insurance policy, please send
copies of the following documents:
Question 37:
List the age of the child
or disabled dependent.
• Account statements showing current balances
•
Question 38:
Write the name
of the person who
pays the cost.
Question 42:
If you checked “Yes,” send us a copy of the
vehicle registration(s) or pink slip(s) or estimate(s)
of value from a qualified source, such as a dealer
or mechanic.
Question 39:
List the total amount
paid monthly for
each child or
disabled dependent.
Question 43:
If you check “Yes,” send us copies of all court
orders, documents and agreements.
Send proof of expenses (costs)
listed in Section 5. Send in proof
of child support or alimony costs.
For childcare and dependent care,
send receipts or cancelled checks.
MC 210 2/10
INSTRUCTIONS
in accounts.
Copies of all life insurance policies.
Question 44:
4
If you check “Yes,” send us copies of your policies,
contracts and purchase agreements. If your
policy is certified by the California Partnership
for Long-Term Care, give us a copy of your most
recent benefit statement.
GO TO PAGE 5
Questions 45-47:
If you check “Yes,” you may be asked to provide
additional information. You may also have to fill out
a property supplement form.
SECTION 7
Answer only for persons who
want Medi-Cal.
Question 48:
A Social Security number for each person applying
for full Medi-Cal benefits is required. If you do
not have a Social Security number, do not delay
sending in this application. You can apply now
and give us the number within the next 60 days.
Send proof of immigration status or a
USCIS receipt showing that you applied to
replace a lost document. Many immigrants may
get full Medi-Cal even if they do not have a
green card or immigration document. Copy both
sides and send proof now or within 30 days
of application. If you do not send this proof,
you may still be eligible for emergency or
pregnancy related services.
Pregnancy and emergency
care services may be
available to persons who
are unable to get a
Social Security number.
Do not give immigration information about
people who are not asking for Medi-Cal.
Information about immigration is private
and confidential.
For information on how to apply for a Social Security
number, call Social Security Administration toll-free,
1-800-772-1213.
Question 51:
Tell us if the person is in a nursing facility,
residential, or board and
care facility. If you
check “Yes,” tell
us the name of
the facility.
Question 49:
Write the place of birth for each person. If born in
the United States, write the name of the state. If
born outside the U.S., write the name of the country.
Question 50:
Check “Yes” or “No,” telling us if the person is a
Citizen or U.S. National.
Question 52:
Check box to
show if each
person has other
health insurance
coverage.
Give immigration information only for people
applying for health coverage. Do not give
information for people not applying. The State will
use this information only for eligibility determination.
Information about immigration is private and
confidential.
Immigrants who meet all immigration requirements
may get full Medi-Cal benefits. Undocumented
immigrants can get pregnancy related and
emergency services.
MC 210 2/10
INSTRUCTIONS
5
You can get
Medi-Cal and
still have other
health coverage.
Medi-Cal may cover
what your other health
coverage does not.
GO TO PAGE 6
SECTION 7
SECTION 8
Continued
Information Release (Optional).
Question 53:
If you check “Yes,” Medi-Cal may be able to help
pay some or all of the paid or unpaid medical costs
you have had in the 3 months before you applied.
Question 59:
If a child does not qualify for the Medi-Cal program,
the local social services office will send this
application to the Healthy Families program.
If you do not want your application to be sent
to Healthy Families, check this box.
Question 54:
Check “Yes,” if any
person has filed a
lawsuit because of
an accident or injury,
workers compensation,
or car accident.
The Healthy Families Program provides
comprehensive health, dental, and vision coverage.
For further information call 1-800-880-5305 or visit
their website at www.healthyfamilies.ca.gov
Question 55:
Question 60:
Check box(es) to show
if individual, spouse or
parent of individual is
or was in the U.S.
Military. We are asking
for this information to see if you can get other
services or benefits.
If you fill out this item you are telling the local social
services office it is okay to give information about
your application to the person you have named.
SECTION 9
Signature and Certification.
Question 56 (Optional):
You can choose to enter the Ethnicity (race)
for each person. This information is used for
statistics only and has no effect on your eligibility
for Medi-Cal.
Who can sign this application?
• The person who wants Medi-Cal, or the
spouse of the person who wants Medi-Cal
• The conservator, guardian executor, or
caretaker of a child who wants Medi-Cal
• Someone acting for the person who
wants Medi-Cal when the person is
incompetent, in a comatose condition, or
suffering from amnesia and there is no
spouse, conservator, guardian or executor
• Persons 14 to 21 years old if they are
not living with a parent, caretaker relative,
or foster parent
• Persons 14 to 21 requesting Minor
Consent Services
Question 57:
Check box to show if person is in school. The
earnings of a person under 21 years may not be
counted if the person is attending school.
Question 61:
Question 58:
Tell us if the person is living away from home, is
away at school, or out of town working.
MC 210 2/10
INSTRUCTIONS
6
State and federal laws require your signature
on this application form. Your signature in this
section indicates that your declarations and
answers are truthful and the documents
you submit are true and correct.
GO TO PAGE 7
Medi-Cal Rights, Responsibilities
and Declarations
I declare that each person I am applying for:
• Lives in California.
• Is not getting public assistance from outside California.
• Is not in jail, prison or any other correctional facility.
I have the right to:
• Be treated fairly and equally regardless of my race,
color, religion, national origin, sex, age, or political
beliefs.
• Ask for an interpreter.
• Ask for a fair hearing if I think a decision on my
Medi-Cal case is unfair or wrong. I must ask for a
hearing within 90 days after the notice of action is
mailed to me. To find out about Medi-Cal fair hearings,
call toll-free, 1-800-952-5253.
• A face-to-face interview.
• Review Medi-Cal program rules and manuals.
Medi-Cal Confidentiality Notice
The information given in this application is private and
confidential under Welfare and Institutions Code 14100.2.
The information will be disclosed only if required by law.
Medi-Cal Privacy Notice
The Information Practices Act of 1977 and the Federal
Privacy Act require the Department of Health Care
Services to provide the following information: Welfare
and Institutions Code Section 14011 and regulations in
Title 22, CCR, require applicants for the Medi-Cal
program to provide the eligibility information requested
in this application.
I have the responsibility to:
• Report any changes in the information I give on this
application within 10 days.
• Let the local social services office know if a family
member applies for disability benefits; is in a public
institution; or gets medical care for any accident or
injury caused by another person.
• Cooperate if my case is reviewed.
• Apply for available income.
• Cooperate with appropriate paternity determinations
and medical support enforcement efforts.
• Assign rights to medical support to the State of
California.
• Assign rights to third party medical support to the
State of California.
This information may be shared with federal, state, and
local agencies for purposes of verifying eligibility and
for other purposes related to the administration of the
Medi-Cal program, including confirmation with the
USCIS of the immigration status of only those persons
seeking full scope Medi-Cal benefits. (Federal law says
the USCIS cannot use the information for anything else
except cases of fraud.) The information will used to
process claims and make Benefits Identification Cards
(BICs). Failure to provide the required information may
result in denial of the application.
Information required by this form is mandatory, with the
exception of ethnicity information, and any other item
marked voluntary or optional.
I understand that:
• As a condition of Medi-Cal eligibility, all rights to
medical support are automatically assigned to the
State of California.
• If I purposely do not give needed facts, or if I give
false facts, I understand benefits may be denied or
ended and repayment may be required. I may also
be investigated for fraud.
• After my death, the State has the right to seek
repayment from my estate for all Medi-Cal benefits I
receive after age 55 unless I have a surviving spouse,
minor child(ren), blind or permanently and totally
disabled child(ren).
• If I am admitted to a nursing facility and I have no
intention of returning to my home, the State may
impose a lien against my property.
MC 210 2/10
INSTRUCTIONS
Social Security Numbers
Unless you are applying for emergency or pregnancyrelated benefits only, you must provide your Social
Security Number. (Welfare and Institutions Code
section 14011.2 and Social Security Act section
1137(a)(1)).
Access to Records
You have the right to access records maintained by the
Department of Health Care Services that contain your
personal information.
Contact your local social services office to request your
records.
7
Provided by the State of California
MC 210 2/10
English
TEAR HERE
State of California - Health and Human Services Agency
Department of Health Care Services
APPLICATION FOR MEDI-CAL
To complete this form, use the instructions. Print clearly. Use black or blue ink only.
SECTION 1
1
2
5
LAST NAME
Tell us about the person who wants Medi-Cal for themselves, their family or children in
their care.
FIRST NAME
HOME ADDRESS (NUMBER AND STREET). DO NOT LIST A P.O. BOX UNLESS HOMELESS
6 COUNTY
CITY/STATE
3 APARTMENT NUMBER
4 HOME PHONE #
12 CITY
14A WHAT LANGUAGE/DIALECT DO YOU SPEAK BEST?
(
)
(
)
(
)
8 WORK PHONE #
7 ZIP CODE
10 APARTMENT NUMBER
9 MAILING ADDRESS (IF DIFFERENT FROM ABOVE) OR P.O. BOX
SECTION 2
MIDDLE INITIAL
11 MESSAGE PHONE #
13 ZIP CODE
14B WHAT LANGUAGE DO YOU READ BEST?
Tell us about the person listed in Section 1, his or her family and the children they care for,
even if they don’t want coverage.
Adult 1/Self
15 Name:
Adult 2
Child 1
Child 3
Child 2
Last
First
Middle
16 Relationship to person
in Section 1.
17 If address where living
is not the same as
listed in Section 1, put
address where living:
18 Gender:
19 Marital Status:
20 Name of spouse(s)
Male Female Male Female Male Female Male Female Male Female
Single
Married
Divorced
Separated
Widowed
of married minors in
the home.
21 Date of Birth:
22 Pregnant:
Due Date:
TEAR HERE
23 Has a physical, mental
or emotional disability?
Disability expected
to last:
MC 210 2/10
APPLICATION
MO
/
DAY
/
YR
Yes No
MO
/
DAY
/
YR
Yes No
Single
Married
Divorced
Separated
Widowed
MO
/
DAY
/
YR
Yes No
MO
/
DAY
/
YR
Yes No
Single
Married
Divorced
Separated
Widowed
MO
/
DAY
/
YR
Yes No
MO
/
DAY
/
YR
Yes No
Single
Married
Divorced
Separated
Widowed
MO
/
DAY
/
YR
MO
YR
MO
Yes No
MO
/
DAY
/
Single
Married
Divorced
Separated
Widowed
Yes No
/
DAY
/
YR
Yes No
/
DAY
/
YR
Yes No
30 Days or More 30 Days or More 30 Days or More 30 Days or More 30 Days or More
12 Months or More 12 Months or More 12 Months or More 12 Months or More 12 Months or More
A1
CONTINUED
SECTION 2 Continued
24 Has any one ever received
cash aid, SSI, Food
Stamps or Medi-Cal?
Adult 1/Self
Adult 2
Child 1
Child 2
Child 3
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If “Yes,” under
what name?
25 Medi-Cal benefits card
number (BIC), if you have it:
26 Wants medical benefits?
27 Do you own or are
you buying a home
outside California?
SECTION 3
28
Mother’s Name:
Disabled
Deceased
Is Mother:
Employed
Unemployed
Absent
Is Father:
Disabled
Deceased
Father’s Name:
Is Father:
Disabled
Deceased
SECTION 4
30
Mother’s Name:
Employed
Unemployed
Absent
Employed
Unemployed
Absent
Is Mother:
Employed
Unemployed
Absent
Is Father:
Is Mother:
Employed
Unemployed
Absent
Is Father:
31
Disabled
Father’s Name:
Disabled
Deceased
SOURCE OF INCOME/
MONEY RECEIVED
(Employment, social security)
32
HOW MUCH
INCOME/MONEY
IS RECEIVED
Employed
Unemployed
Father’s Name:
Employed
Disabled Unemployed
Deceased Absent
33
HOW OFTEN INCOME/
MONEY RECEIVED
(Monthly, bimonthly, weekly, biweekly, daily)
Give information about the listed expenses/cost paid by all persons listed in Section 2.
TYPE OF PAYMENT
YOUR FAMILY MAKES
34
NAME OF
PERSON WHO PAYS
35 MONTHLY
AMOUNT PAID
36
1.
Other Health
Insurance Premium
3.
Alimony
Medicare Premium
CHILD CARE OR
DEPENDENT CARE
(List child’s or dependent’s name)
Child Support
MC 210 2/10
APPLICATION
Disabled
Deceased
Mother’s Name:
Employed
Unemployed
Absent
List all income/money received by persons listed in Section 2.
NAME OF PERSON RECEIVING
INCOME/MONEY
SECTION 5
Mother’s Name:
Father’s Name:
Disabled
Deceased
Unborn
Child 3
Child 2
Child 1
Is Mother:
29
Answer for all children in Section 2.
2.
4.
A2
37 AGE
38
NAME OF
PERSON WHO PAYS
39 MONTHLY
AMOUNT PAID
TEAR HERE
SECTION 6
Skip this Section if you are only applying for children under 19 and/or pregnant women
(pregnancy related services only).
Otherwise answer for all persons listed in Section 2.
40 Does anyone have cash or uncashed checks?
If “Yes,” list amount here
Yes No
(See instructions)
41 Does anyone have a checking, savings account, or life insurance? (See instructions)
45 Does anyone own any items such as stocks, bonds, retirement funds, trusts, real estate,
Yes
Yes
Yes
Yes
Yes
46 Has anyone listed on this form transferred, sold, traded or given away any items such as those
Yes No
42 Is there one car or more in the household? (See instructions)
43 Does anyone have a court ordered settlement or judgement? (See instructions)
44 Does anyone have Long-Term Care insurance? (See instructions)
motor vehicles for a business, business accounts, promissory notes, mortgages, deeds of trust,
recreational vehicles, burial trusts or funds, annuities, jewelry (not heirloom or wedding), oil or
mineral rights? (See instructions)
listed above in the last 30 months? (See instructions)
47 Have any items listed in this section been spent or used as security for medical costs?
(See instructions)
SECTION 7
Yes No
Answer only for persons who want Medi-Cal.
48 Social Security #:
Adult 1/Self
49 Place of Birth:
50 U.S. Citizen or National?
State or Country.
If “No,” write in date of
entry into U.S.
51 Living in a Long-Term
Care or Board and
Care Facility?
Adult 2
Child 1
Child 3
Child 2
You may be able to receive Medi-Cal even if you do not have a Social Security Number.
Yes No
MO
/
DAY
/
YR
Yes No
MO
/
DAY
/
YR
Yes No
MO
/
DAY
/
YR
Yes No
MO
/
DAY
/
YR
Yes No
MO
/
DAY
/
YR
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
vision coverage?
Yes No
Yes No
Yes No
Yes No
Yes No
within the 3 months
before the month you
applied and want MediCal for those expenses.
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If “Yes,” name of
facility:
Do you intend to
return home?
Do you intend to
return home within
six months?
52 Has health/dental or
53 Had medical expenses
TEAR HERE
No
No
No
No
No
54 Lawsuit pending due
to accident or injury?
MC 210 2/10
APPLICATION
A3
CONTINUED
SECTION 7 Continued
55 Current or past
U.S. Military Service
for adults, spouse or
child’s parents?
56 Ethnicity (race):
(optional)
57 In school full time?
58 Living away from
home?
SECTION 8
Adult 1/Self
Adult 2
Child 1
Child 2
Child 3
Yes No
Self
Spouse
Parent
Yes No
Self
Spouse
Parent
Yes No
Self
Spouse
Parent
Yes No
Self
Spouse
Parent
Yes No
Self
Spouse
Parent
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Information Release (Optional).
59 Check this box if you do not want Medi-Cal to share your child’s application with the low-cost
60
Healthy Families if your child does not qualify for no-cost Medi-Cal.
I got help from (give name of person)
when I
filled out this application. I agree that the local social services office may give them information about the status of this
application. Applicant please initial
SECTION 9
Signature and Certification.
61 I declare under penalty of perjury under the laws of the State of California that the answers I have given in this
application, and the documents given are correct and true to the best of my knowledge and belief.
I declare that I have read and understand the application instructions, the declarations, and all information printed
on this application.
Signature
Date
Witness Signature (If person signed with a mark)
Date
Signature of person helping Applicant fill out the form
Telephone Number
Relationship to Applicant
Date
Signature of person acting for Applicant/Beneficiary
Telephone Number
Relationship to Applicant
Date
For information about any of the following programs, check the box(es) below and
information will be sent to you. Visit our website, www.dhcs.ca.gov
Personal Care Service Program (PCSP). A program for in-home care.
Access for Infants, and Mothers (AIM). A program to help pregnant women with moderate income
obtain health care.
Woman, Infants and Children Nutrition Program (WIC). A nutrition program for pregnant and
postpartum women and children under 5.
Family Planning
Child Health and Disability Prevention (CHDP) program. Preventive healthcare for children and youth.
Do you want your children or youth referred to the CHDP program for follow-up?
Yes No
MC 210 2/10
APPLICATION
A4
In-Home Supportive
Services (IHSS)
The IHSS program provides supportive services to aged, blind, or disabled
persons who are unable to perform all of the personal and household services
needed to maintain independent living and who cannot remain safely in their
own home unless such services are provided.
Applicants can receive a mail-in application by calling
1-888-944 IHSS (4477)
or
1-213-744-4477
Contents:
•
In-Home Supportive Services (IHSS) Fact Sheet
Additional information may be accessed through the websites listed below:
• www.ladpss.org
Department’s main website listing all departmental information, including
program-specific information, of+fice locations and the community
event’s calendar.
•
www.lacountyhelps.org
Informs citizens of Los Angeles County of state and federal benefits
assistance. This website provides additional information about programs
available after completing a short online survey.
•
www.211LACounty.org
Provides information about human social services in the Los Angeles
County.
County of Los Angeles
Department of Public Social Services
PHILIP L. BROWNING
Director
SHERYL L. SPILLER
Chief Deputy
IN-HOME SUPPORTIVE SERVICES PROGRAM
FACT SHEET
PURPOSE
The In-Home Supportive Services (IHSS) Program helps
disabled individuals so that they may remain safely in
alternative to out-of-home care such as nursing homes or
one must be 65 years of age or older or disabled or
IHSS.
pay for services provided to aged, blind or
their own home. IHSS is considered an
board and care facilities. To receive IHSS,
blind. Disabled children may also receive
IHSS authorized services can include: housecleaning, meal preparation, laundry, grocery shopping,
personal care services (such as bowel and bladder care, bathing, grooming, protective supervision and
paramedical services), and accompaniment to medical appointments.
ELIGIBILITY CRITERIA
Income
• Receiving Supplemental Security Income/State Supplemental Payments (SSI/SSP); or
•
Meeting all SSI/SSP eligibility criteria except for income or citizenship/immigration status (includes
Cash Assistance Program for Immigrants (CAPI) recipients) and are Medi-Cal eligible; or
•
Meeting all SSI/SSP eligibility criteria including income, but do not receive SSI/SSP (includes
CalWORKs participants or Medi-Cal Medically Needy (MN) beneficiaries who have a chronic
disability lasting at least 12 continuous months).
•
Paying the share of cost for Medi-Cal and IHSS benefits if income is above the SSI/SSP payment
limits.
Property
• Personal property may not exceed $2,000 for an individual or $3,000 for a couple.
•
Countable property includes: cash on hand, checking and savings accounts, the value of stocks,
bonds, trust deeds, real property (other than the home owned and lived in), automobiles and
recreational vehicles, promissory notes and loans.
•
Property not counted includes: the home owned and lived in, one automobile needed for
transportation to medical appointments or work, and all life insurance policies if the combined face
value is $1,500 or less.
Residency
• United States citizenship or an alien lawfully admitted for permanent residence.
• California residency.
• Living in own home that is not a nursing home or other out-of-home care facility (licensed or not).
ELIGIBILITY CRITERIA; (CONTINUED)
APPLICATION PROCESS
Applications for IHSS are made by calling (888) 944-IHSS [4477] or (213) 744-IHSS [4477]. The call
can be made by the applicant or someone calling on his/her behalf. Applicants receiving SSI/SSP
payments from the Social Security Administration will be interviewed by an IHSS Social Worker (SW)
during a home visit to determine eligibility and need for IHSS. Applicants who do not receive SSI/SSP
payments or Medi-Cal benefits must first be determined eligible to receive Medi-Cal benefits under
Medi-Cal rules and regulations. The IHSS application is automatically sent to a Medi-Cal Eligibility
Worker for this determination. Once Medi-Cal eligibility is determined, an IHSS SW will conduct a
home visit to determine eligibility and need for IHSS.
During the home visit, the IHSS SW will assess the types of IHSS services needed and authorize an
amount of time for each one based on the applicant’s/consumer’s functional ability to safely perform
certain tasks. The assessment of need includes information given by the applicant, and if appropriate,
family, friends, physician, or other health care practitioners.
Notices are mailed for the approval or denial of Medi-Cal benefits and IHSS. If denied for IHSS, the
reason for denial is stated on the notice. If approved for IHSS, the services and number of hours per
month that have been authorized are listed on the notice. All notification regarding approval or denial
will be in writing.
IHSS consumers must hire someone (the IHSS service provider) to perform the authorized services.
The IHSS consumer is considered the provider’s employer. It is the responsibility of the IHSS
consumer to hire, train, supervise and, if necessary, fire this individual.
All IHSS providers must complete all of the following enrollment requirements:
•
Complete and sign the IHSS Provider Enrollment Form (SOC 426). The form must be submitted to
the county in person and original documentation verifying provider’s identity (e.g. current photo
identification and social security card) must be provided for photocopying by the county;
•
Attend an on-site provider orientation to obtain information about IHSS rules and requirements for
being a provider;
•
Complete and sign the Provider Enrollment Agreement, SOC 846. The SOC 846 states that the
provider understands and agrees to the rules of the IHSS program and the responsibilities of being
an IHSS provider; and
•
Submit fingerprints and pass a Criminal Background Investigation from the Department of Justice.
IHSS PROVIDER PAYMENTS
The State issues the paychecks for IHSS provider payments and withholds the applicable amounts for
disability insurance coverage and Social Security. The IHSS provider may choose to have federal and
State income taxes withheld. IHSS providers are covered by Workers Compensation insurance.
IHSS consumers and providers must complete, sign, date, and mail timesheets verifying the delivery of
authorized services for each pay period.
MEDI-CAL BENEFITS
Individuals receiving SSI/SSP payments automatically receive Medi-Cal through the Social Security
Administration. Those who do not receive SSI/SSP benefits must be determined eligible to receive
Medi-Cal benefits under Medi-Cal rules and regulations. If eligible to receive Medi-Cal, there may be a
share of cost for benefits.
IHSS QUESTIONS
For questions or concerns
(888) 678-IHSS [4477].
IN-HOME SUPPORTIVE SERVICES PROGRAM FACT SHEET
REVISED JANUARY 2011
about
the
IHSS
program
call
the
IHSS
Ombudsman
at