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Deficiency Form (20) DHR-DFC-1926 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type of ability: Home `❑,. Date off Visit: ]� �� lam° �✓ Q\0A Day Group ^ Night ❑ Center ❑ S.A.P. ❑ month/ day / year Facility Address: e: Telephone#: e 0a Ages: Director(f ap licable): Capacity: day / night day / night SECTION B-DEFICIENCY INFORMATION Column 1 Minimum Standard Column 2 Deficiency Date Corrected by Licensee 1 r 4\Nj no, �- INSTRUCTIONS TO LICENSEE: Column 2 Date Corrected b Licensee is to be completed by the facility representative after each deficiency is corrected The facility representative must put the date f c re ' nand his/her initials in Column 2. This form trust 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 inviolation;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' ompliance with Minimum Standards. Signature of Facility Representative Date -7 �o z, Signature of DHR Licensing Representative Date 1 COPI S TO: Page ' of I