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Deficiency Form (5) 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: KATHY WILES' DAY CARE Day ❑x Group ❑ Night ❑ Center ❑ Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 302 GAYFER CT KATHY WILES (251)928-8518 FAIRHOPE, AL 36532 Ages: Director (if a p a le): Capacity: 6 Weeks through 6 Years 6 -Day SECTION B -DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee b tO)e, I l ee_ ,� VLF "/ ,rr-en ire, Jnsgg eAon w i r< i � '41 CAi 0 a INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee,ij tole completed by the facility representative after each deficiency is corrected. The facility representative must put the date of c a islNni�' in Column 2. This form must be returned to the Department of Human Resources on or before o"V dd /, 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 opipTance with Minimum Standards. Signature of Facility Representative —Date Signature of DHR Licensing RepresentativeyAM Dat S� COPIES TO: Page of DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: KATHY WILES' DAY CARE Date of Visit: ��"' Lq SECTION B -DEFICIENCY INFORMATION(Continued) Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee c� gem uje�rer,4- TiA I14,�b s medilcod andC, ap s� itt'd INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee, is to completed by the facility representative after each deficiency is corrected. The facility representative must put the date of c e Lion a i#0h in Column 2. This form must be returned to the Department of Human Resources of or before9j ", 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 T r Date Signature of DHR Licensing Represee ates'—3 COPIES TO: Pagl�:;I- oe=),