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Get CA HS 215A 2008-2021

DD-N Intermediate Care Facility Pediatric Day Health & Respite Care Residential Care Facility for the Elderly Skilled Nursing Facility Other Have you ever held a 5 percent or more beneficial ownership interest in any of the facility types above? Yes No If YES, complete Section F (below) and the “Facility Information Sheet” (attached). F. Adverse Actions Have you been affiliated with any facility, either past or present, that has been identified as having one or more of the No If YES, check.

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