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Deficiency Form DI-fft-DFC-192G ALABAMA DEPARTMENT OF I UMAN RESOURCES CIUL11 CARE MINIMUM STANDARDS DEFhCIENCY REPORT SECTION A-IDENTIFYING INFORMATION FacilityName: Type of Facility: Home. ❑ Date of Visit: Day Xg., Group 1A t Night ❑ Center 11 / E S.A.P.. ❑ rnonilr./ day / year Facility:Address: Licensee: Telephone k Ages:: Director(fapplicable): Capacity: day U Inight day / night .SECTION B-DEFICIENCY INFORMATION Colun+n;I Minimum Standard Colu=2 Deficiency Date Corrected by Licensee } te_��At) oxe-, INSTRUCTIQNS TO`LICENSEEr Column 2, Date Corrected by 'Licensee, is to be conipleted'by the facility representative after each deficiency is corrected. T/te factltty,representative must putllte date of,corre•tion.and Hs0er initials in Column 2. This forin»rust be returned to the:Department of Human Resources on or,before o as verification that deficiencies have been corrected. *Hazards must be corrected immediately NOTICE: Any misleading or any false stateuients.or reports made to the Department and/or failure to correct the listed dcticiciicies 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 t par ient:must meet Minimum Standards applicable to that facility at all times. It.is the responsibility of the licensee"to`opera it com tiancc,with Minimum Rthirds. Signature of Facility Representative A >tnA - Signature of D11R Licenrin�Represeigat„ ` I�otesa COPIES TO;- Page of a'. DHR DFC-I927 ALABAMA DEPARTMENT OF HUMAN RESOURCES LLD CARE MINIMUM STANDARDS.DEFICIENCY REPORT(Additional Page) rA e: l 11"I�Gt'. Vie, Date of Visit .r ON:B-DEFICIENCYINFORMATION Continued`: J= ' Coh m 2 M Onuim'Standard. Date Correcfed by Mracieacy e; i} .• " a,• , a � a , 1 1 1T'STRUCITONS TQ LICENSEE:. `Coluirrn<2,.Dale Carredeil bv'lleensee,1r 0 be COM PWl 4d by the jacUity..represe d1w alter each .. defuaiency is orrecded TheJacfllty representallve'nws/put the dale of corredlon and h&*er.kftM& n.Colam Z Thls form mast be, rawroed to The Deparin mf of-Xumiw Resources on or before as vedflcadon[hot'deficiencies have been correrled *Hawrds nu&be corrected fmmedlat* NOTICE: Anymisfeading or,vny.f2ise"statements or reports m�delo the Departmentaod/or hilarcto correct the listed de6cie'ncles can be:the basis for a'dyerscraction. None of theserequirements are to be'interpreted=to allow.anyoue to operate in violation of Minimum Standards A facrirty'licensed"by the Department must -Minimum,Standards applicable to that.facility all times. It'Is , the responsibility of the licensee to operate'm compliance'with Minimum Standards, SignalrrreofFacilflyl?epresenlalive Dbte iip=,rwe ojDHR,Uceesing Rep"resenralive Dole OPIES TO: 1,J C.e(�`' Page--a-0f �of +arp a co �V0,n\1 Obfy-\6 Out +0 60 lar`C�SCa � ino� SQaSohQll �. 2Sti mated ��iC� aUOn 0-11 C,.c) 11i � W � � � V�e trc�nsi � to n� n� to q cot Nt Ig rnor�lhS. ..q@o QSt1mGS1� C1LCt2 - Y1nK0 11 nor +ctrp a coy\r\var\\j comes out +c do lar�iScc�, � ng Scasonaiiy . wtSii mated (jGM, aUOn O'll CMOY-A V -t \ \ Yee to U Cot a� Ig rnor��hS. es-V\ npas+ecl date _ S � n certly , I'lixo n STn I d'ur a�a4 Sao