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Deficiency Form (20) DHR-DFC:-1926 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT i SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Facility: Home T(1 Date of Visit: Day '� Group ❑ Night ❑ Center ❑ h l l►s Lynne S.A.P. ❑ month/ day / year Facility Address: 57 k.ee Rad 517 Licensee: Telephone#: Phenix Clay, A6876 ( 1W5rE -5436 Age : Director(ifopplicable): Capacity: Weel var5 gars / to l NIA day / night day / night SECTION B-DEFICIENCY INFORMATION Column 1 Minimum Standard Column2 Deficiency Date Corrected by . O }� ` an heretlrtd_ (' Licensee Coh�d.InerS �n not under lock and keu. 2-There, are a 'r oP hedae 5tiro a la roam 1 i e. 3 . There 1-5 a 5 all +Wo y, Pour UX4) piece Lk-�" d wood on4 the la rov►.nd. I O� 1-her i 5ng soi 1 ba on I round rie � 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 hislher 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 inust be corrected lnunediately / 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 Date •����^ Signature of DNR Licensing Representative Date a[�J� f COPIES TO: Page ` of DHR-DFC-1927 ALABAIVIA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: "� ben n e Date of Visit: SECTION B—DEFICIENCY INFORMATION Continued Column 2 Column l Minimum Standard Date Corrected by (eOn*-i nu ec� Deficiency Licensee under It)& arl K,% e , 5 . Them !s a l air e. l h �bGot on a �f, 1� ba . Th�r s a buc o n -ho w s .rdi�n r an i siJe Where. art ev 1 arder, o s a' 1 b Duna on r en hbe h r Q.nd d� i -+-aal� all n o+ tender lock aynd Ke $. �1 cen5le� doesr�- Ve 0. bib n rnan Cbi+ai n er . 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 d o Corr tion an hismer initials in Column 2. This form must be returned to the Department of Human Resources on or before 20 , as verification that deficiencies have been corrected. *Hazards nrust 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 S Date J Signature of DHR Licensing Representative Dare 23 2.42t COPIES TO: Page-,of A