FACILITY VISIT SUMMARY
Location__________________________________ Date__________________
Licensed Manager's Name_____________________________________________________________________
Purpose of Visit:______________________________________________________________________________
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Licensed Manager's Comments:__________________________________________________________________
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Recommendations:____________________________________________________________________________
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Time and Length of Visit:_______________________________________________________________________
Licensed Manager's Signature____________________________________________________________________
BEP Staff Signature____________________________________________________________________________
Distribution: White-Manager, Yellow-BEP Staff, Pink-Facility File
N.M. Admin. Code § 9.4.7.28