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Deficiency Form (24) DBR-DFC-1926 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION JF�aciili�tyyN�aame: r � Type of Facility: Home ❑ Date of Visit: lam► �1 Day X Group A Night ❑ Center ❑ 4 / -� S.A.P. ❑ month/ day / year Facility Address: Licensee: Telephone#: , Sn M`�11 CJnc i eJcS - M6 Al 1ti �5� ` A Ed,t �' c � q . Ages: Director(if applicable): Capacity: / a /NIA day / night day / night SECTION B-DEFICIENCY INFORMATION CohannI Minimum Standard Colww2 Deficiency Date Corrected by Licensee I nalf*Azkel I 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 o corre.tion and his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before 1 a '� 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' compliance with Minimum Standards. Signature of Facility Representative Date 04112 1 Signature of DHR Licensing Representative 7 Date Adl�`A I COPIES TO: ��� Page f J