Deficiency Form DHR-DFC-1926
ALABAMA DEPARTMENT OF HUMAN RESOURCES
CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT
SECTION A-IDENTIFYING INFORMATION
Facility Name: Type of Facility: Home ❑ Date of Visit:
ACHR CDP KING CENTER Day . ® Group ❑ q
Night ❑ Center ® 09 /6115 , 19
Day/Night ❑ S.A.P ❑ month / day / year
Facility Address: Licensee: Telephone#;
950 SHELTON MILL ROAD A C H R, INC. (ACHR (334)821-8336
AUBURN, AL 36830 CDP)
Ages: Director (if applicable): Capacity:
3 Years through 5 Years DEBORAH CHISM 120 -Day
SECTION B.-DEFICIENCY INFORMATION
Column 1 Column 2
Minimum Standard Date Corrected by
Deficiency Licensee
in6bA LO vet
INSTRUCTIONS 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 correction and 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
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 the licensee to operate in compliance with Minimum Standards.
Signature of Facility Representative Date �`'� -�
Signature of DHR Licensing Representative p-�Date M S
COPIES TO:
Page of
i