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This form shall be used in conjunction with the Licensing Report (LIC 809) and is provided to the facility to verify the correction of deficiency(ies) cited in a licensing visit to your facility on . The use of this (DATE) form will not prohibit the Licensing Evaluator from conducting follow-up visits to ensure that deficiencies are corrected. (See instructions on back of this form). DEFICIENCY(IES) SECTION NUMBER PROOF OF CORRECTION PICTURE RECEIPT P.

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