HomeMy WebLinkAboutDeficiency Form (22) ALABAMA DEPARTMENT OF HUMAN RESOURCES
CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT
SECTION A-IDENTIFYING INFORMATION
Facility Name: Type of F lity: Date of Visit:
Kidz�Cam Day `
P Night ❑❑ b / 1
Both ❑ month/ day F year
Facility Address: 1256 HWY 43 Telephone#:
Killen, AL 35645 (256) 272-5060
Ages: Staff in Charge(if applicable): Capacity:
6 wks-14 yrs / X Amanda Robertson
day, / night 46 / X
day / night
SECTION B-DEFICIENCY INFORMATION
Column 1 Column 2
Health&Safety Guidelines
Deficiency Date Corrected
4Lt
I
r � R
INSTRUCTIONS TO PERSON IN CHARGE: Column 2, Date Corrected is to be completed by the facility representative after each
deficiency is corrected. The facility representative must put the,jj&of correcd n and his/her initials in Column 2This form must be
returned to the Department of Human Resources on or befored &,e, �4_ 'Zr.,Lt , as verification that deficiencies have been
corrected
I *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 Health &
Safety Guidelines. A facility approved by the Department must meet Health&Safety Guidelines applicable to that facility at all times.
It is the responsibility of the facility operate in mpl'ance with Health&Safe Guidelines. r
Signatureof Facility Representative Date 1
Signature of DHR Represe Date �l
COPIES TO:Amanda Robertson Page—[Of�