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PRINTED: 05/17/2022 FORM APPROVEDDivision of Health Service Regulation STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:SOUTHERN LIVING FOR SENIORS

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Individuals who wish to provide adult care services in a licensed facility or as a caregiver in a private home may need to fill out a form for adult care licensure.

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What is form adult care licensure?

Form adult care licensure is a document that must be filled out by facilities providing care for adults.

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Facilities providing care for adults are required to file form adult care licensure.

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The purpose of form adult care licensure is to ensure that facilities providing care for adults meet certain standards and regulations.

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Information about the facility, staff, services provided, and compliance with regulations must be reported on form adult care licensure.

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