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Deficiency Form (23) DHR-DFC-1926 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION ��`F11a��Facility Name: Type of Facility: Home ❑ Date of Visit: lsC� Sick-, l�V��M� Day ❑ Group ❑ Q Night ❑ Center ❑ © S.A.P. ❑ month/ day / year Facility Address: , Licensee: Telephone#• Nc,p-K,I I Cha ie u Nod MSS. i 4h� Ages: 'Director(if applicable): Capacity: day / 'ght day / fight SECTION B-DEFICIENCY INFORMATION Column! Minimum Standard Cohan 2 Deficiency Date Corrected by Licensee 7--�afwkll age, rx (0.x u CxR e 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 correvtion and his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before Z , as verycation 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. Signature of Facility Representative L Date O Qa Signature of DHR Licensing Representative J Date COPIES TO: f B Can Page—L_of I