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Deficiency Form i DID-DFC-1926 ALABAMA DEPARTMENT OF 14UMAN RESOORCE,S CI ILD-CARE MINIMUM STANDARDS.DEFICIENCY REPORT SECTION A-IDEA ENTIFYING INFORMATION 'Facili_ty'N'zame: t O Type.of Facility: Home ❑ Date of Visit: se i 1 si& O V IC7�.-� Day PL Group A Night ❑ Center ❑ t�/ f S,A 1': ❑ month/ day / year FacilityAddress: Licensee: Telephone#;. Al Ages: Director(if applicable): Capacity: day Inight, day / /night SECTION B DEFICIENCY INFORMATION Cokrmn7 Minimum Standard Colunuf2 Deficiency Date Corrected by Licensee C2 -1fQ j INSTRUCTIONS TO'LICENSEE-, Column 2, Date Corrected by Licensee,:is to be cotgpleted by the facility representative after each deficiency is corrected. Tlie facility,reprisenla#ve must put the date of corre•tion and hMter initials in Column 2. This form must be ,returned to the Department of Himidn Resources on or before I r o as verification that deficiencies have been corrected *Hazards must be corrected hninediately NOTICE: Any misleading or any false statements.or reports made to,.tlte Department and/or failure to correct the listed deficiencies can be.the basis for adverse action. None of these requirements are.to be interpreted Wallow anyone to operate in violation of Minimum Standards. A facility aicenscd by tVlvpar fticntmmst meet Minimum Standards applicable to that facility at all tunes. It,is the responsibility of the licensee to operate inf0ornbliance,with.Minimum SVMthirds. Signature ofFacility Representative M S� Signature of DIM Licensing Rej.treseniat Date I COPIES TO: Page of I DHR DFC-1927 ' ALABAMA DEPARTMENT OF,HUMAN RESOURCES �r CH><LD CARE NflMMUNI STANDARDS DEFICIENCY REPORT(Additional Page) Illstme: 11r�, grC Date of Visit:. ON B:-DEFICIENCY INFORMATION Con tin aed CO&MI §' a Minimum_Standard. Date Corrected by Deficiency Licensee aiv �n a � x K at INSTRUCTIONS TO I:ICENSEE: "Column,2.:Dale Correded by is to be comlpleled by the faeft.repremniolve after each defile, y.is correded The fadlltyv represemlative nmust put the dale of cotredion and h4vher hddad's im Cohumn Z This form anus!be meurned to the Depdr&wd of Hum=Resources on or before o as verification that deficiencies have been corrected *Hazards must be corrected immediately N0,77CM,Any misleadIag:'or anyfalse'sfatcments or reports made to theDepartment and/or failure.:to correct the listed deficiencies-can be the'iia for adverse action. None of theserequiremetits are to be interpreted:to allow.anyone to operate in violation:of Minimum Standards :AAiciiity jI.ccused by thjc,Depsrtmcut must meet Minimum Standards applicable to that.facility�at all times: It.is the responsibilityof the licensee to operate in:compliance with Minimum Standards: Signature ofFaci/iry Represeritoti►de' Dote UgnaftweofDHRLicensingRepreseiiiative: LIo7e l OPIF.S TO; :ten- Page-a—of for the mu� �h and � np� sed +orp a Covnvcm\j out +0 do la�'YaSCc�{� � n9 SfQSOhQII �. N\�q)n ot CSti mct�fC1 C��1� �o � lin w � � 1 be transi � i oni ng to q CC)t at rn or�i�S. .-qlo eStirvGS� C��{e YV\6JA S ; n cerc,ly , {-tp� n-sx o n STn I � u,,pi. w9j uoXrU Y \ y� �uow g� A)o �-m b C)4 u�01 1X�anNA ?v0pp?)Vw '� i jnuosbaS Gwk�SDOC op o+ ArO SaWO� I\U-Q(AV\AQ� V dam Du)o uo \r.m auk a0�