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PRINTED: 06/19/2019 FORM APPROVEDDivision of Health Service Regulation STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:A. BUILDING: ___ B. WING ___MHL029024

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Start by writing the number '509' in the first space provided for the street address.

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Next, write 'Shoaf' in the second space for the street name.

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