Inspection Reports for
Foulkeways at Gwynedd

1120 MEETING HOUSE ROAD,, GWYNEDD, PA, 19436

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21 Reports

2016–2026

Inspection Report — Jul 15, 2026

Renewal
Date: Jul 15, 2026

Visit Reason
The inspection was a renewal visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 07/15/2026 and 07/16/2026 to review compliance and verify the submitted plan of correction.

Findings
The facility was found to have multiple deficiencies related primarily to medication management, emergency procedures, resident assessments, and support plans. All deficiencies had accepted plans of correction which were reported as implemented by 08/24/2026.

Citations (25)
25a - Written Contract and Review: Resident 1 did not have a resident-home contract completed prior to or within 24 hours after admission.
91 - Telephone Numbers: Emergency telephone numbers for hospital, police, fire, ambulance, poison control, and complaint hotline were not posted by telephones #71 and #83.
107d - Procedure Emergency Management Agency Submission: The home’s written emergency procedures had not been submitted to the local emergency management agency since 2/13/2024.
121a - Unobstructed Egress: A long red strap blocked egress from the home’s emergency exit in the dining area on 7/16/2026.
123b - Emergency Procedures Posted: Emergency procedures were not posted in a conspicuous and public place in the home.
132b - Safety Inspection/Fire Drill: The last fire drill observed by a fire safety expert was conducted on 12/4/2025, missing the annual requirement.
132e - Fire Drill Sleeping Hours: The home failed to conduct an overnight fire drill during sleeping hours within the required 6-month interval.
141b1 - Annual Medical Evaluation: Resident 1 and Resident 2 had incomplete or missing annual medical evaluations including medication lists and self-administration ability.
181c - Self-administration Assessment: Resident 2 self-administers medications but was not assessed by a licensed practitioner regarding ability and need for reminders.
181d - Storing Medication: Residents 1 and 3 had unlocked, unattended medications in their rooms, posing safety risks.
181f - Record of Medication: Resident 3’s medication record did not include a current list of all medications being taken.
183b - Meds and Syringes Locked: Resident 2 had expired and unsecured medications accessible in their room without assessment for self-administration.
183d - Prescription Current: Discontinued medications for residents 4 and 5 were found in the medication cart.
183e - Storing Medications: Several medications in the medication cart were undated, improperly labeled, or had compromised packaging.
184a - Resident's Meds Labeled: Resident 11’s medications had pharmacy labels with incorrect administration instructions.
184b - Labeling OTC/CAM: Acetaminophen suppositories belonging to Resident 12 were not labeled with the resident’s name.
185a - Implement Storage Procedures: Resident 13’s prescribed eye drops were not available; Resident 14’s glucometer was not calibrated; controlled substance logs for Resident 15 lacked time documentation.
187a - Medication Record: Residents 11 and 14’s medication administration records lacked diagnosis or purpose for prescribed medications.
187b - Date/Time of Medication Admin.: Staff documented administration of medications not given; missing staff initials on medication records; repeated violations noted.
187d - Follow Prescriber's Orders: Residents 14 and 17 were not administered prescribed medications as ordered.
225a - Assessment 15 Days: Resident 1 did not have an initial assessment completed within 15 days of admission.
225c - Additional Assessment: Resident 18’s assessment lacked description of need for assistance with transportation, appointments, and caring for possessions.
227a - Support Plan 30 Days: Resident 1 did not have an assessment and support plan completed within 30 days of admission, and the plan lacked description of need or support.
227d - Support Plan Medical/Dental: Residents 14, 16, and 18’s support plans lacked documentation of supervision needs, wander guard use, and bedside mobility device details.
251b - Record Entries Legible: Controlled substance logs for residents 13 and 15 contained illegible dates due to overwritten numbers.
Report Facts
Residents Served: 76 Staff: 82 Waking Staff: 62

Inspection Report — Oct 30, 2025

Complaint Investigation
Date: Oct 30, 2025

Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 10/30/2025.

Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.

Report Facts
Total Daily Staff: 82 Waking Staff: 62 Residents Served: 76 Residents Age 60 or Older: 76 Residents with Mobility Need: 6 Residents with Physical Disability: 1

Inspection Report — Jul 21, 2025

Renewal
Date: Jul 21, 2025

Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.

Findings
The inspection found multiple deficiencies including delayed access to resident and staff lists, missing annual fire safety training for a staff member, uncovered food in the kitchen, incomplete fire drill records, residents not evacuating to designated meeting places during fire drills, incomplete or untimely medical evaluations, unsecured medications in resident rooms, discontinued medications still present in the medication cart, missing medication administration documentation, and unsigned support plans.

Citations (11)
Delayed access to resident and staff lists requested by Department agents.
Staff Person B did not receive required annual fire safety training during 2024.
Uncovered fruit tray stored in the main kitchen refrigerator.
Fire drill record for 4/12/25 missing actual time of drill; 6/10/25 drill missing number of residents evacuated.
Residents did not evacuate to designated meeting places during fire drills on 6/11/25, 6/10/25, and 5/23/25.
Medical evaluation not completed within required timeframe for Resident #2.
Resident #3's medical evaluation did not accurately indicate ability to self-administer medications; Resident #4's evaluation missing medication addendum.
Unsecured medications found in Resident #3's bedroom; resident does not lock medications or bedroom door.
Discontinued medications (erythromycin and acetaminophen) still present in medication cart for Resident #2.
Medication administration records for Resident #5 missing staff initials for administration of Calcium Carbonate and Pregabalin on 7/8/25.
Resident #6 participated in support plan development but did not sign the support plan.
Report Facts
Residents Served: 76 Total Daily Staff: 82 Waking Staff: 62 Residents with Mobility Need: 6 Residents with Physical Disability: 1 Residents 60 Years or Older: 76 Residents Present During Fire Drill: 81 Residents Evacuated During Fire Drill: 50 Residents Evacuated During Fire Drill: 31 Residents Evacuated During Fire Drill: 48

Inspection Report — Oct 1, 2024

Renewal
Date: Oct 1, 2024

Visit Reason
The inspection was a renewal inspection conducted as an unannounced full review of the facility on 10/01/2024 and 10/02/2024.

Findings
The facility was found to have multiple deficiencies including issues with record confidentiality, fee schedule omissions in resident contracts, staff training deficiencies, exit door security, fire department notification, fire drill record keeping, annual medical evaluations, medication storage and administration, additional resident assessments, and support plan documentation. Plans of correction were accepted and implemented by 12/02/2024.

Citations (17)
Resident records were unlocked, unattended, and accessible in the Abington House North care base.
Resident-home contracts for residents #1 and #2 did not include a fee schedule of actual amounts charged for available services.
Staff person B did not complete training in emergency medical plan within 40 scheduled working hours.
Direct care staff person A received only 11.83 hours of annual training in training year 2023.
Direct care staff persons A and C did not receive required training on several annual training topics including medication self-administration and meeting residents' needs.
Exit door between resident apartments #65 and #66 requires a security card to open; residents are not provided a security card.
The home lacked documentation of written notification to the local fire department regarding address, bedroom locations, and evacuation assistance.
Fire drill records did not include the amount of time it took for evacuation, recording time in minutes only.
Resident #3’s most recent medical evaluation was not current.
Resident #4 self-administers medications stored unsecured in their apartment.
Resident #5 had a non-current prescription medication in the medication cart.
Resident #5's glucometer was not displaying correct time; Resident #6 was missing a prescribed medication.
Medication administration records (MAR) for residents #4 and #5 lacked required information including diagnosis/purpose and documentation space.
Medication administration records for residents #4 and #6 lacked initials of staff administering medications.
Resident #6 missed administration of prescribed medications without documentation of reason.
Residents #3 and #7 had outdated additional assessments.
Resident #8's support plan conflicted with medical evaluation regarding ability to self-administer medications; residents #4 and #9 had bedside mobility devices not addressed in support plans.
Report Facts
Residents Served: 79 Total Daily Staff: 92 Waking Staff: 69

Inspection Report — Apr 19, 2023

Renewal
Date: Apr 19, 2023

Visit Reason
The inspection was conducted as a renewal inspection of the FOULKEWAYS AT GWYNEDD facility on 04/19/2023 and 04/20/2023.

Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies were noted related to the presence of a portable space heater, evacuation drill timing, annual medical evaluations, and preadmission screening forms, all of which have directed plans of correction with completion dates and have been implemented.

Citations (4)
A portable space heater was found in the conference room next to the director of health services office, which is prohibited.
The home exceeded the safe evacuation time of 12 minutes during a monthly fire drill, completing it in 14 minutes.
Resident #1's most recent medical evaluation was not completed as required annually.
Preadmission screening forms for residents #2 and #3 did not indicate the date of completion.
Report Facts
Residents Served: 75 Safe Evacuation Time: 12 Evacuation Drill Time: 14 Total Daily Staff: 77 Waking Staff: 58

Employees mentioned
NameTitleContext
Mary KnappDirector of Health ServicesRemoved the portable space heater from the conference room as of 5/11/2023.

Inspection Report — Aug 1, 2022

Date: Aug 1, 2022

Visit Reason
The inspection was conducted as a licensing inspection due to an incident, with unannounced partial inspection on 08/01/2022 and off-site review on 08/02/2022.

Findings
No regulatory citations or deficiencies were identified as a result of this inspection.

Report Facts
Residents Served: 76 Total Daily Staff: 76 Waking Staff: 57

Inspection Report — Sep 21, 2021

Complaint Investigation
Date: Sep 21, 2021

Visit Reason
The inspection was conducted as a complaint investigation due to an incident involving staff-resident interactions.

Complaint Details
The complaint involved allegations of disrespectful and aggressive behavior by Staff Person A towards residents during medication administration. The investigation confirmed the residents were not treated with dignity and respect. Staff Person A was terminated and the incident was reported to DHS and Montgomery County AAA as suspected abuse.
Findings
The investigation found that Staff Person A was argumentative and disrespectful towards residents during medication administration, causing residents to feel disrespected and uncomfortable. The facility confirmed the residents were not treated with dignity and respect and took corrective action by terminating the staff member and implementing ongoing training.

Citations (2)
Staff Person A argued with Resident 1 over medication administration and was aggressive, causing the resident to feel disrespected and uncomfortable.
Staff Person A arrived late to administer eye drops to Resident 2 and made demeaning and disrespectful comments, making the resident feel unimportant.
Report Facts
Residents Served: 79 Total Daily Staff: 80 Waking Staff: 60

Employees mentioned
NameTitleContext
Staff Person ANamed in findings related to disrespectful and aggressive behavior towards residents

Inspection Report — Sep 21, 2021

Plan of Correction
Date: Sep 21, 2021

Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident involving resident treatment and medication administration.

Findings
The investigation confirmed that residents were not treated with respect and dignity, involving a staff member who argued with residents and administered medication improperly. The staff member was terminated and corrective actions including training were implemented.

Citations (1)
Staff Person A argued with Resident 1 over medication administration and was aggressive and demeaning. Resident 2 was disrespected by Staff Person A who arrived late and made inappropriate comments about the resident's personal history and other residents' medications.
Report Facts
Residents Served: 79 Total Daily Staff: 80 Waking Staff: 60

Employees mentioned
NameTitleContext
Mia JohnsonSigned letter confirming plan of correction implementation

Inspection Report — Aug 27, 2021

Renewal
Date: Aug 27, 2021

Visit Reason
The document is a renewal license issued in response to the May 13, 2021 renewal application to operate the Personal Care Home, Foulkeways at Gwynedd. The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation.

Findings
The license renewal was granted and a regular license issued. The Department will conduct an inspection within the next twelve months and take enforcement action if non-compliance is found.

Report Facts

Employees mentioned
NameTitleContext
Jamie L. BuchenauerDeputy SecretarySigned letter regarding license renewal and inspection requirements

Inspection Report — Aug 26, 2021

Renewal
Date: Aug 26, 2021

Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 08/26/2021 and 08/27/2021 to assess compliance with Department of Human Services regulations.

Findings
Multiple deficiencies were found related to resident funds refunds, direct care staff training, food safety, medical evaluations, medication storage and administration, resident assessments, and record content. Plans of correction were accepted for all violations with specified completion dates.

Citations (16)
Resident #11 was discharged but refund to estate was delayed beyond 30 days.
Direct care staff person A did not complete DHS-approved direct care training before providing unsupervised ADL services.
Staff training plan lacked names, positions, duties, and scheduled training details for direct care staff.
Leftover food (piece of cake) was undated and unlabeled in a community refrigerator.
Outdated or unlabeled food (bag of squash zucchinis) found in kitchen area.
Resident #1's medical evaluation was not completed within required timeframe.
Resident #1's medical evaluation did not include dietary needs.
Resident #10's medications were stored unlocked and unattended in resident's room.
Discontinued medication for Resident #2 was found in medication room.
Glucometer readings for residents #1 and #2 were inaccurately documented in medication records.
Medications prescribed as needed for Resident #3 were unavailable at time of inspection.
Medication records lacked diagnosis or purpose for medications for residents #2 and #3.
Resident #1 and #2 had discrepancies between blood glucose levels and insulin units administered.
Preadmission screening form was not completed for Resident #4.
Resident #8's initial assessment and support plan were not completed within required timeframes.
Resident records for multiple residents lacked color of hair, color of eyes, and identifying marks.
Report Facts
Residents Served: 76 Total Daily Staff: 78 Waking Staff: 59 Completion Dates: 16

Inspection Report — Aug 10, 2021

Monitoring
Date: Aug 10, 2021

Visit Reason
The inspection was an unannounced monitoring visit to review the facility's compliance and implementation of the submitted plan of correction.

Findings
The submitted plan of correction was determined to be fully implemented with continued compliance required. Several deficiencies were identified related to medication management, preadmission screening, and resident assessments, all of which had corrective plans accepted and implemented.

Citations (5)
Expired/discontinued medication (Eardrops 6.5% soln.) was found in the home's medication cart.
Resident #2 was administered medication beyond the prescribed period.
Resident #3's preadmission screening form was not completed prior to admission.
Resident #4's initial assessment was not completed within 15 days of admission.
Resident #5's most recent annual assessment was not current.
Report Facts
Residents Served: 79 Total Daily Staff: 79 Waking Staff: 59

Inspection Report — Nov 17, 2020

Renewal
Date: Nov 17, 2020

Visit Reason
The inspection was conducted as a renewal inspection of the personal care home facility.

Findings
The inspection identified multiple deficiencies including failure to post the current license inspection summary, incomplete resident-home contracts, staff orientation issues, training deficiencies, food safety violations, fire safety concerns, medical evaluation delays, and medication storage problems. Plans of correction were accepted or disputed with corrective actions and completion dates provided.

Citations (18)
3c - Post Current License: The home's license inspection summary dated 5/13/19 was not posted in a conspicuous and public place on 11/17/2020.
25a - Written Contract and Review: Resident #1 did not have a resident-home contract completed until 11/17/2020.
25b - Contract Signatures: Resident-home contracts for Residents #2 and #3 were not signed by the residents, though signed by their designated persons.
65a - FS Orientation 1st Day: Staff Person A did not receive fire safety orientation on the first day of work as required.
65f - Training Topics: Direct care Staff Person B did not receive required medication self-administration and personal care services training during 2019.
85d - Trash Receptacles: Uncovered, unattended trash cans were found in the main kitchen and first floor north serving kitchen on 11/17/2020.
91 - Telephone Numbers: Emergency telephone numbers were not posted by the telephone in the Alice Paul activities room.
103e - Left Overs: Unlabeled and undated leftover salad and rice were found in the upstairs country kitchen refrigerator.
103i - Outdated Food: Unlabeled, undated open food items including hamburgers, orange juice, rolls, and mustard were found in various kitchen locations.
105g - Lint Removal and Duct Cleaning: Approximately 1 inch of lint was accumulated in the lint trap of the first floor north laundry room dryer on 11/17/2020.
121a - Unobstructed Egress: A table and chairs blocked egress from the home's courtyard east wing exit on 11/17/2020.
133.2 - Exit Signs Direction: The exit sign in the courtyard east wing pointed left, but the exit was to the right.
141a - Medical Evaluation: Resident #1's medical evaluation was not completed until 7/6/2020, after admission.
141b1 - Annual Medical Evaluation: Resident #3's medical evaluation for 2019 was not completed; last evaluation was 11/14/18.
171b5 - First Aid Kit: The first aid kits in vehicles used for resident transport lacked eye coverings and contained expired antiseptic.
181d - Storing Medication: Resident #4 self-administered medications but did not lock medications in the provided lockbox or lock the bedroom when leaving.
224a - Preadmission Screen Form: Residents #2 and #3's preadmission screening forms did not include a determination that their needs could be met by the home.
225c - Additional Assessment: Resident #3's 2019 assessment was not completed; last assessment was 12/10/18.
Report Facts
Residents Served: 76 Staff: 76 Waking Staff: 57 Completion Date: Nov 17, 2020

Inspection Report — May 13, 2019

Renewal
Date: May 13, 2019

Visit Reason
The inspection was a renewal inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.

Findings
Multiple violations were found related to staff training records, safety equipment, resident contracts, and documentation. Plans of correction were submitted with varying implementation statuses.

Citations (24)
2600 5.a The home failed to provide requested annual staff training records for the training year August 2017 through July 2018 in a timely manner.
2600 18 There is no carbon monoxide detector within 15 feet of the boiler room in the home's basement.
2600 25.b The resident-home contract dated 08/20/2018 for resident #1 was not signed by the resident.
2600 41.e Resident #1's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures.
2600 65.e The home could not provide the total number of hours of annual training for direct care staff member A in training year August 2017 through July 2018.
2600 65.f Direct care staff person A did not receive training in medication self-administration during training year August 2017 through July 2018.
2600 65.g Staff person A did not receive training in Resident Rights during training year August 2017 through July 2018.
2600 65.i The home's record of direct care staff training does not include the length of each course.
2600 85.a On 05/14/2019, a glucometer with a label saying 'stock glucometer for temporary resident use' was found with several readings on it.
2600 101.j Resident #1 does not have access to a source of light that can be turned on/off at bedside.
2600 107.d The home's written emergency procedures have not been submitted to the local emergency management agency since 2015.
2600 123.b The home's emergency procedures are not posted in a conspicuous and public place in the home.
2600 141.a Resident #2 was admitted on 04/11/2019 and her medical evaluation was completed on 05/29/2019, outside the required timeframe.
2600 141.b.1 Resident #1's medical evaluation dated 08/23/2018 did not include medication regimen, contraindicated medications, medication side effects, or ability to self-administer medications.
2600 183.d Several residents had discontinued medications still in the home's medication cart.
2600 187.a Resident #4's medication administration record did not indicate diagnoses for prescribed medications.
2600 187.b On 05/14/2019, staff #8 was witnessed entering signatures for residents who administered morning medications without the residents' signatures at the time of administration.
2600 187.c Resident #8 refused to take scheduled medications on 05/08/2019 and the home did not notify the prescriber of the refusal.
2600 187.d Resident #5 was ordered a vital sign check daily for a week but vital signs were only checked 2 days that week.
2600 191 Resident #1 has not been educated on the right to refuse medication if a medication error is believed.
2600 224.a Resident #9's preadmission screening form dated 12/11/2018 does not include Personal Care and Medical Needs.
2600 225.c Resident #4's most recent assessment was completed on 02/03/2018 and was not completed annually nor was the support plan revised annually.
2600 227.a Resident #1's initial support plan finalization date is missing, making it impossible to determine if it was completed timely.
2600 227.c Resident #4's annual RASP assessment was not completed in a timely manner.
Report Facts
Residents Served: 78 Residents Served: 84

Inspection Report — May 10, 2019

Renewal
Date: May 10, 2019

Visit Reason
The document is a renewal application and license issuance for Foulkeways at Gwynedd Personal Care Home. The Department of Human Services will conduct an onsite inspection within the next twelve months as required by regulation.

Findings
This document does not contain inspection findings but confirms the issuance of a regular license following the renewal application for the Personal Care Home.

Notice — May 15, 2018

Date: May 15, 2018

Visit Reason
This document serves as a renewal notification for the Personal Care Home license at Foulkeways at Gwynedd and informs that an annual onsite inspection will be conducted within the next twelve months as required by state regulations.

Findings
No inspection findings are reported in this document. It is a license renewal notice with an attached certificate of operation.

Report Facts

Notice — Dec 22, 2017

Date: Dec 22, 2017

Visit Reason
Issuance of a revised license due to a recent adjustment of the use of physical space at the facility.

Findings
The document includes a certificate of compliance granting a maximum capacity of 112 residents and a letter confirming the revised licensed capacity. No inspection findings or deficiencies are reported.

Report Facts
Number of Residents Served: 59 Staffing Hours - Resident Support: 59 Staffing Hours - Total Daily Staff: 120 Staffing Hours - Waking Staff: 90

Employees mentioned
NameTitleContext
Mary T. KnappDirector of Health ServicesRecipient of the license adjustment letter (page 2).
Sandy SheardAdministratorNamed in the violation report header (page 3).
Jacqueline L. RoweDirectorSigned the license adjustment letter (page 2).
Robert E. RobinsonIssuing OfficerSigned the certificate of compliance (page 1).

Inspection Report — Oct 23, 2017

Annual Inspection
Date: Oct 23, 2017

Visit Reason
The visit was an annual licensing inspection conducted by the Department's Bureau of Human Services Licensing on October 23 and 24, 2017.

Findings
No violations were found during the inspection, and a determination was made not to issue any violations in the license inspection summary. Continued compliance with 55 Pa. Code Ch. 2600 must be maintained.

Notice — Jun 15, 2017

Date: Jun 15, 2017

Visit Reason
This document serves as a renewal notification for the Personal Care Home license of Foulkeways at Gwynedd, confirming receipt of the renewal application and informing about the requirement for an annual onsite inspection within the next twelve months.

Findings
No inspection findings are reported in this document. It is an administrative notice regarding licensing and inspection requirements.

Report Facts

Inspection Report — Jul 1, 2016

Renewal
Date: Jul 1, 2016

Visit Reason
The inspection was conducted as an annual licensing renewal inspection of the personal care home facility.

Findings
Violations related to food storage, medication administration records, and medication documentation were found and detailed in the License Inspection Summary. Plans of correction were submitted and partially implemented as of August 2016.

Citations (3)
55 Pa.Code §2600.103(g): Food was not stored in closed or sealed containers; an ice cream container in the kitchen freezer was partially opened and dented.
55 Pa.Code §2600.187(a): The medication administration record for resident #1 lacked PRN Q-Tussin cough syrup; resident #2 had orders for Folic Acid 1mg and 1000mcg but the MAR did not reflect this correctly.
55 Pa.Code §2600.187(b): On 7/11/16, resident #3 was administered Oxycodone ER 20mg at 9am but staff incorrectly initialed the narcotic count sheet for Oxycodone 5mg PRN instead of 20mg ER.
Report Facts
Number of Residents Served: 58 Total Daily Staff: 64 Walking Staff: 48 Number of Current Hospice Residents: 1 Number of Hospice Residents in Past Year: 11 Number of Residents 80 Years or Older: 58 Number of Residents with Mental Illness: 2 Number of Residents with Mobility Need: 6

Employees mentioned
NameTitleContext
Mary T. KnappDirector of Health ServicesNamed as legal entity representative signing plans of correction.
Lauren KazimerOn-site inspector conducting the inspection.
Sabrina FreemanOn-site inspector conducting the inspection.

Notice — May 17, 2016

Date: May 17, 2016

Visit Reason
This document serves as a renewal notification for the Personal Care Home license and informs the facility of the requirement for an annual onsite inspection within the next twelve months.

Findings
No inspection findings are reported in this document; it is a license renewal notice confirming the issuance of a regular license.

Report Facts

Inspection Report — June 23, 2020

Renewal
Date: June 23, 2020

Visit Reason
The document is a renewal license issued in response to the May 29, 2020 renewal application to operate the Personal Care Home. The Department advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.

Findings
No inspection findings are reported in this document. It serves as a certificate of compliance and license renewal notification.

Report Facts

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