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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:15G65202/21/2017FORM

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What is this visit was for?

This visit is for a routine inspection by the health department.

Who is required to file this visit was for?

All restaurant owners and managers are required to file this visit.

How to fill out this visit was for?

The visit should be recorded in the inspection log and any violations addressed.

What is the purpose of this visit was for?

The purpose of this visit is to ensure that the restaurant is in compliance with health regulations.

What information must be reported on this visit was for?

The visit must include details of any violations found, corrective actions taken, and follow-up plans.

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