DSHS Form 10-577 Attachment R "Revisits" - Washington

What Is DSHS Form 10-577 Attachment R?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2021;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSHS Form 10-577 Attachment R by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 10-577 Attachment R "Revisits" - Washington

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Attachment R
Revisits
ASSISTED LIVING FACILITY NAME
LICENSE NUMBER
FACILITY / LICENSEE’S NAME
DATE OF VISIT
LICENSOR’S NAME
DATE OF ORIGINAL
DATE OF PLAN OF
INTAKE NUMBER
INSPECTION
CORRECTION
Follow-up Type:
Full inspection
Complaint Investigation
On-Site
Document Review
Issue(s) from Prior Visit
WAC / RCW
Summary of Findings
Page 1 of 2
REVISITS
DSHS 10-577 (REV. 10/2021)
Attachment R
Revisits
ASSISTED LIVING FACILITY NAME
LICENSE NUMBER
FACILITY / LICENSEE’S NAME
DATE OF VISIT
LICENSOR’S NAME
DATE OF ORIGINAL
DATE OF PLAN OF
INTAKE NUMBER
INSPECTION
CORRECTION
Follow-up Type:
Full inspection
Complaint Investigation
On-Site
Document Review
Issue(s) from Prior Visit
WAC / RCW
Summary of Findings
Page 1 of 2
REVISITS
DSHS 10-577 (REV. 10/2021)
Additional Comments
Attachment R
Page 2 of 2
REVISITS
DSHS 10-577 (REV. 10/2021)
Page of 2