Loading...
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: AMY ROBERTS Day ❑ Group Y Iq Night ❑ Center ❑ / 1�/ Day/Night ❑x S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 401 BRANDON AVENUE AMY ROBERTS (334)295-5103 LINDEN, AL 36748 Ages: Director(if appl able): Capacity: 6 Weeks through 12 Years 12 -Day 6 Weeks through 12 Years 12 -Day/Night SECTION B -DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee a h �Doe-. O'bi ) A 0/7 U.01 1 ►za e �� 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 oJ` ec don antyq. er�iitiall-An Colu n 2. This form must be returned to the Department of Human Resources on or befo e �r ff�� ''(6as 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 RmplJance with Minimum Standards. Signature of Facility Representative ate FP—Agp%'b � �J� Signature of DHR Licensing Representative DW COPIES TO: Page ! of DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: AMY ROBERTS Date of Visit:—�� SECTION B -DEFICIENCY INFORMATION (Continued) Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee 614 INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee, is to e completed by the facility representative after each deficiency is corrected. The facility representative must put the date c rection a r' rer ' itia s Column 2. This form must be returned to the Department of Human Resources on or be f re '9'�, 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 a Date Signature ofDHR Licensing Representative Date COPIES TO: Page�of