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07/09/2021- COMPLAINT HEALTH SURVEY- VILLAGE PARK MILTONPRINTED: 8/31/2021 FORM APPROVED State of GA, Healthcare Facility Regulation Division State of GA Inspection Report STATE FORM 6899 LN6011 If continuation sheet Page 1 of 2 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: ALC00675 (X2) MULTIPLE CONSTRUCTION A.BUILDING B.WING (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER VILLAGE PARK MILTON STREET ADDRESS, CITY, STATE, ZIP CODE 555 WILLIS ROAD ALPHARETTA, GA 30009 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {L 0000} >>>>The purpose of this visit was to investigate intake #GA00214653. No rule violations were cited as a result of this investigation. The investigation began 6/15/21 and was completed 7/9/21. PRINTED: 8/31/2021 FORM APPROVED State of GA, Healthcare Facility Regulation Division State of GA Inspection Report STATE FORM 6899 LN6011 If continuation sheet Page 2 of 2 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: ALC00675 (X2) MULTIPLE CONSTRUCTION A.BUILDING B.WING (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER VILLAGE PARK MILTON STREET ADDRESS, CITY, STATE, ZIP CODE 555 WILLIS ROAD ALPHARETTA, GA 30009 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)