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HomeMy WebLinkAboutDeficiency Form (23) DHR-DFC-1926 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A- IDENTIFYING INFORMATION a Facility Name: Type of Facility: Home ❑ Date of Visit: KIDZ�CAMP Day © Group ❑ Night ❑ Center ® Day/Night ❑ S.A.P ❑ month / day / year Facili� Address: Licensee: Telephone#: 1256 H; WY 43 AMANDA ROBERTSON (256)272-5060 KILLEN, AL 35645 Ages:I Director (if applicable): Capacity: 6 Weeks through 14 Years AMANDA ROBERTSON 46 - Day SECTII N B - DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee gx d+tL� . rs d �N 1• L�/V (Cf . i�IR y INSTROCTiblKS TO LICENSEE: Column 2, Date Corrected by Licensee, is to be completed by the facility representative after each defciency is corrected The facility representative must put the date of c r ction nd his/h initials in Column 2. This form in be returned to the Department of Human Resources on or before ,4 �, � 621, as verification that deficien•ies have been corrected *Hazards must be corrected immediately NOTIC : Any misleading or any false statements or reports made to the Department and/or failure to correct the listed deficien ies can be the basis for adverse action. None of these requirements are to be interpreted to allow anyone to operate in violatio►l of Minimum Standards. A facility licensed by the Department must meet Minimum Standards applicable to that facility at all timed. It is the responsibility of the 1 ensee tooperate i com Tian a with Minimum Standards. Signatur i of Facility Representative Date am- l' Signature of DHR Licensing Represent Dat\ Q!; COPIES TO: Page 1 of DHR-DFC-1927 I ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: KIDZ CAMP Date of Visit:._ I SECTION B -DEFICIENCY INFORMATION(Continued) Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee I � 'ESf��-cam- V) P � 'C� �d C �- LIST/a �• L,�-Iaf d �aG( d. !�5 I I a V' ft�— Gam, l ( i , I INSTR CTIONS 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 co hon and his/her initials in Column 2. This form must be returned to the Department of.Human Resources on or beforej�� '.Zb , as verification that deficiencies have been corrected *Hazards must be corrected immediately NOTIC�: Any misleading or any false statements or reports made to the Department and/or failure to correct the listed deficien ies can be the basis for adverse action. None of these requirements are to be interpreted to allow anyone to operate in violationl,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 icensee to operate in compliance with Minimum Standards.. Signature of Facility Representative Date L Signature of DHR Licensing Represent Date COPIES TO: Page