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HomeMy WebLinkAboutDeficiency Form (21) j DHR-DFC-1926 f' ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A - IDENTIFYING INFORMATION Facility Name: Type of Facility: Home ❑ Date of Visit: KIDZ CAMP Day © Group ❑ Night ❑ Center ® Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 1256 HWY 43 AMANDA ROBERTSON (256)272-5060 KILLEN, AL 35645 Ages:I Director(if applicable): Capacity: 6 Weeks through 14,Years AMANDA ROBERTSON 46 - Day SECTION B - DEFICIENCY INFORMATION Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee i INSTR> CTIONS TO LICENSEE: Column 2, Date Corrected by Licensee, is to be completed by the facility representative after each deftciency is corrected. The facility representative must put the date ofem—fection an his/her 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 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 th ee to ope at i liance ith Minimum.Standards Signature of Facility Representative Dat Signatur;of DHR Licensing Represe W - Date 4 �( COPIES TO: Page lof-L