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Page 1 Corporation: NAME and Title of Person completing this form: TITLE Local Facility/Unit/Group Home NPI Number: Name: License Number: Director: Physical Address: Mailing Address: City: Zip Code:
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Local facilityunitgroup home is a type of residential care facility that provides housing and care services.
Local facilityunitgroup home operators are required to file.
Local facilityunitgroup home information can be filled out on specific forms provided by the regulatory agency.
The purpose of local facilityunitgroup home is to ensure residents receive proper care and supervision in a residential setting.
Information such as resident demographics, care services provided, and any incidents or complaints must be reported.
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