Facility Personnel Roster Completed Form Examples and Samples

To: Licensing Division, Dept of Health. From: Sarah Jenkins, HR Director, Sunnyvale Health Center. Date: May 14, 2026. Regarding the licensure renewal for our new branch located at 4500 Oakwood Drive, Sunnyvale, CA 94086, please find the required personnel documentation for our expansion project (Provider ID: SHC-99201). We have finalized the staffing team. Our primary contact for this facility is Marcus Thorne (Age: 42, SSN: 000-11-2233), who serves as the Director of Operations. Working under him, we have Elena Rodriguez (Age: 38, SSN: 444-55-6677), our Lead Nurse. Administrative support is provided by David Kim (Age: 29, SSN: 777-88-9900) and Susan Miller (Age: 34, SSN: 111-22-3344), who handle admissions. For facility maintenance, we have hired James O'Connell (Age: 51, SSN: 555-66-7788). We also have two dietary specialists on staff: Beatrice Thorne (Age: 45, SSN: 888-99-0011) and Raj Patel (Age: 31, SSN: 222-33-4455). Finally, our night shift supervisors are Linda Garris (Age: 53, SSN: 666-77-8899) and Thomas Wright (Age: 48, SSN: 333-44-5566). Please let me know if you require additional proof of certification for these individuals, as we have those stored internally. The entire roster has been reviewed by our compliance officer, Michael Henderson, who confirms that all background checks were cleared as of last Tuesday. Please ensure the final filing is processed before the state inspection window opens next month.