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Ng evaluator and reviewed by the licensing supervisor. The purpose of this form is to review staff coverage in large Residential Facilities for 24-hours per day covering a (3) three-week period to ensure sufficient staff coverage. CAREFULLY review split shifts, weekend coverage and irregular days off to ensure sufficient staff coverage. FACILITY NAME FACILITY NUMBER CLIENT/RESIDENT CENSUS LICENSING EVALUATOR For The Month(s) 2. Food Services (e.g, includes cook, dishwasher) Employee Name(s.

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