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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:15C000107012/28/2017FORM

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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?

The owner or manager of the establishment is required to file this visit.

How to fill out this visit was for?

The form can be filled out online on the health department's website or in person at their office.

What is the purpose of this visit was for?

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

What information must be reported on this visit was for?

The report must include details about cleanliness, food storage, employee hygiene, and sanitation practices.

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