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To the Waivers, Approval, Variances and Exceptions: Assisted Living webpage or contact the Division of Quality Assurance (DQA) Regional Office that serves the facility. • Return this completed and signed form to the appropriate DQA Regional Office email address. Name – Facility Type of Facility ADC AFH City Address - Street Type of Request: Waiver Approval Variance License No. CBRF Zip Code RCAC County Exception Time Period of Request Permanent To (MM/dd/yyyy): Temporary – From...
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