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Deficiency Form (7) ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Facility: Date of Visit: -)q l o � Day ❑ �, Day o �/ Both � month/ day / year Facility Address: 140 ) Erandon aven L(e Telephone#: ), � nJe, 9� Ages: i lR W U UC W Staff in Charge(if applicable): Capacity: l day / ni t /V +4 day / night SECTION B -DEFICIENCY INFORMATION Column 1 Health&Safety Guidelines Column 1 Date Corrected Deficiency r-a+,' 0 IMCA,5' v n1t due, 4--� e tio -� hay, I d e r,V Ir C e, -�Y-a i Y? " P )c �q INSTRUCTIONS TO PERSON IN CHARGE: Co 2, Date Corrected is to be completed by the facility representative after each deficiency is corrected. The facility representative must put tit of Corr t'on gild fli initials in Column 1. This form must be returned to the Department of Human Resources on or befor �( , 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 Health & Safetv Guidelines. A facility approved by the Department must meet Health & Safety Guidelines applicable to that facility at all times. It is the responsibility of the facility to operate in compliance with Health&Safety Guidelines. Signature of Facility Representative Date v��ll✓ — I� Signature of DHR Representative to COPIES TO: Page Lof 2 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT (Additional Page) Facility Name: , V b Date of Visit: SECTION B-DEFICIENCY INFORMATION Continued Column I Column 2 Health&Safety Guidelines Date Corrected Deficiencyre,19 U re naDp ay-ea� , INSTRUCTIONS_TO FACILITY: Column 2. Date Corrected is,to be completed by the facility representative after.each deficiency is corrected. The facility representative must put the date of correction and his1her 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 Health & Safety Guidelines. A facility approved by the Department must meet Health &Safety Guidelines applicable to that facility at all times. It is the responsibility of the facility o opera a in co liance with the Health&Safety Guidelines Signature of facility Representative A rrDate ) —JIS Signature of DHR Representative Date l V 7' rl COPIES TO: Page 2, of 2,