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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�