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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: CUBA HEAD START CENTER Day Y Group ❑ Night ❑ Center Y Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 5586 KINTERBISH 10 SUMTER COUNTY (205)392-5034 CUBA,AL 36907 OPPORTUNITY, INC. Ages: Director (if applicable): Capacity: 3 Years through 5 Years SHARON NELSON 57 -Day SECTION B -DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee _h-er e, .w eree,no dk 'e:%enc:%es cbseruecj In areas o-� U i zs 413111 r 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 corr�ef'ti n and his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before /V , 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 c mpliance with Minimum Standards. Signature of Facility Representative �.� Dat '� Signature of DHR Licensing Representati Date COPIES TO: b►rec.�ro � Page Lf