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Deficiency Form (21) DHR-DFC-1926 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Facility: Home ❑ Date of Visit: Day -h Group 3R Night ❑ Center ❑ 0_/ / � S.A.P. ❑ month/ day / year Facility Address: Licensee: Telephone#: Nal ��b TP5 Hd, W) 07, Ages: Director(if applicable): Capacity: / day Aight day / ni-gh�t,//A — SECTION B-DEFICIENCY INFORMATION Column Minimum Standard Column Deficiency Date Corrected by Licensee ch 1 (1 CL r A� ,l , �Iaa Lan--� Z I)ek M�Abela�mm mur4px.Oak I e,<--) M 3La,11d2PnS &'L�5 ake, Im de,66"'01 k am),s t 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 Corr ction nd 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 i compliance with Minimum Standards. Signature of Facility Representative Date 1,141 Signature of DHR Licensing Representative J' }, Date COPIES TO: Q?-1 Page�_of ALABAMA DEPARTMENT OF HUMAN RESOURCES DHR-DFC-1927 CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: P� � } ���� � Date of Visit: AA SECTION B—DEFICIENCY INFORMATION Continued Column I column 2 Minimum Standard Date Corrected by Deficiency Licensee a�pvn Lam)-- MA Ao+ =� a � a 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 o as verication 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 : ` t J Date ? Signature of DHR Licensing Representative Date*j&03J COPIES TO: UV Lc`_!� Page-a—of