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PRINTED: 02/19/2020 FORM APPROVEDDivision of Health Service Regulation STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION A.

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Information such as property value, income generated, expenses incurred, and other relevant financial details need to be reported on the Graceland Manor DDA 3 form.

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