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Deficiency Form (20) DBR-DFC-1926 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility NameC:� n r Type of Facility: Home ❑ Date of Visit: I Day 1�1 Group 3,4 1 Night ❑ Center ❑ S.A.P. ❑ month/ day / year Facility Address: Licensee: Telephone#: Hdi ��� �`I-7, 8`-c Ages: Director(if applicable): Capacity: / ici / day LightN /A --day ' night SECTION B-DEFICIENCY INFORMATION Column Minimum Standard Column Deficiency Date Corrected by Licensee 1 � �vM'C9-AQJ )1 17 )D J 11 I M--4d P19 as C� I I"L INSTRUCTIONS TO LICENSEE: Column 2, Date Corrected by Licensee, is to be completed'by the facility representative after each deficiency is corrected The facility representative must put the date of corr cdon ttnd his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before ( 6 'h , as verification that deficiencies have been corrected *Hazards must be corrected immediately NOTICE: Any misleading or any false statements or reports made to the Department and/or failure to correct the listed deficiencies can be the basis for adverse action. None of these requirements are to be interpreted to allow anyone to operate in violation of Minimum Standards. A facility licensed by the Department must meet Minimum Standards applicable to that facility at all times. It is the responsibility of the licensee to operate i compliance with Minimum Standards. Signature of Facility Representative Date 0 Signature of DHR Licensing Representative Date COPIES TO:j QgfjEe,-e Page�_ofc ALABAMA DEPARTMENT OF HUMAN RESOURCES DHR-DFC-1927 CHILD CARE MINIMUM STANDARDS� d � Date of Visit: ��DEFICIENCY REPORT (Additional Page) Facility Name: C m ��k)� -��_1 SECTION B—DEFICIENCY INFORMATION Continued Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee MUM /l 1 / 1 , OD A , a GM all t, INSTRUCTIONS TO LICENSEE: Column 2, Date Corrected by Licensee is to be completed by the facility representative after each deficiency is corrected The facility representative must put the date of correction and his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before as verification that deficiencies have been corrected *Hazards must be corrected immediately NOTICE: Any misleading or any false statements or reports made to the Department and/or failure to correct the listed deficiencies can be the basis for adverse action. None of these requirements are to be interpreted to allow anyone to operate in violation of Minimum Standards. A facility licensed by the Department must meet Minimum Standards applicable to that facility at all times. It is the responsibility of the licensee to operate in compliance with Minimum Standards. C < Signature of Facility Representative Date Signature of DHR Licensing Representative Date COPIES TO: I f w a J Page-a—of