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Deficiency Form (4) 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: MS. TIFFANY'S DAY CARE Day ® Group Eil Night ❑ Center ❑ Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#:. 11880C CORD 48 TIFFANY VILLANOVA (251)591-0045 FAIRHOPE,AL 36532 Ages: Director(if applicable): Capacity: 2-Weeks through 5 Years N A 12-Day SECTION B-DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiene Licensee Q rolp e_.vGL u Y 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 correca n a d his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before )��i 1 �� ,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 llkenseeioi operate in compliance with Minimum Standards. Signature of Facility Representative JU77MV Dat Z� Signature of DHR Licensing Representativ ..-DateQ a COPIES TO: Page J_of DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN.RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: MS.TIFFANY'S DAY CARE Date of Visit: f (� SECTION B-DEFICIENCY INFORMATION(Continued) Column 1 Column 2 Minimum Standard Date corrected by Deficiency Licensee Y c t Lis S 5 15 l r�1 i 61 Zj 1q d� -`I T� � 1 V &�r Y S t ZCi.) ai' .C..� - (� C�Z L. l C 1v\ 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 r�li �� , 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 Representat t tC. ' (e _4, Date l41 COPIES TO: Page of