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Deficiency Form (6) ALABAMA DEPARTMENT OF HUMAN RESOURCES DHR-DFC-1926 CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Facility: Home ❑ Date of Visit: BELLAMY HEAD START Day ® Group ❑ Night ❑ Center ® $ / / / Day/Night ❑ S.A.P ❑ /month / day �T year Facility Address: Licensee: 39 CEDAR ROAD Telephone#: BELLAMY, AL 36901 SUMTER COUNTY (205)392-4240 OPPORTUNITY, INC. Ages: Director (ifapplicable): Capacity: 12 Months through 5 Years LETHA MILLS 44 -Day SECTION B-DEFICIENCY INFORMATION Column I Minimum Standard Column 2 Date Corrected Deficiency Licensee Q 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 correcti n and his/her initials in Column Z This form must be returned to the Department of Human Resources on or before deficiencies have been corrected. , as verification that 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 le < Dat::� l �� Signature of DHR Licensing Representative Dat COPIES TO: OeA 14e ArQ9,ee Page of�