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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:15572505/18/2015FORM

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What is this visit was for?

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

Who is required to file this visit was for?

The restaurant owner or manager is required to file this visit.

How to fill out this visit was for?

The visit report form can be filled out online or submitted in person at the health department office.

What is the purpose of this visit was for?

The purpose of this visit was to ensure that the restaurant is following health and safety regulations.

What information must be reported on this visit was for?

The report must include details on food storage, cleanliness, temperature logs, and employee hygiene.

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