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Deficiency Form (5) b0 - 9D •2a ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT . SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Facility: Date of Visit:` NfDy ight ©❑ �2- I M l 5 Both ❑ month/ day / year Facility Address: Telephone#: 3 �)- 9 r) I l�Shw 3 tt 0 L4 - a53a Ages: Staff in Charge(if applicable): Capacity: day / night �U�(YZ �,f-5 day / night SECTION B -DEFICIENCY INFORMATION Column.I Column 2 Health&Safety Guidelines Date Corrected Deficiency A u e. c�.q ui re,Jme� C A N 1dm-) es 2- INSTRUCTIONS TO ERSON IN CHARGE: olumn 2 Date Corrected is to be completed by the facility representative after each deficiency is corrected. The facility representative must put the date of corr6on d his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before ' GCS , as verification that deficiencies have been corrected Co rrec+ 1 m m2�1\a NOTICE: Any misleading or any false statements or reports made to the Department a /or failure to correct the listed deficiencies can be the basis for adverse action. None of these requirements are to be interpreted to al 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 to operate in compliance with Health&Safety Guidelines. Signature of Facility Representative Date��� Signature of DHR Representative OL Date 12 ' •I I / COPIES TO: Page 1 of,:9— ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT C7 , (Additional Page) Facility Name: i Date of Visit: SECTION B-DEFICIENCY INFORMATION Continued Column I Column 2 Health&Safety Guidelines Date Corrected Deficiency 1 ce n ls i�e�s -� ohs o� c�.ni dl �i IPd h'l l C r n ' leI n m e s � S cd le, � U0Q Can i o�c�,n S ' �C6 Cam'& hr\t5 S 1 n -R�e-s i n m \e -c, Iti '1 Oo one, aV enA-c-F wi4,h �6+ P?, . (2' -5 �'oom �q Zo. `L+�rnonrc*r i n 2 Y2 _ �bbrn ( P�n2 +ierMDrNI�CA 11-� QAX\1-� ( ,Vo\ � �e In 2l2 -� `bbm %l2 ICU s�L i i : r1 6�v �o orn Co�ereA Com-4- f\e INSTRUICTIONS TO FACILITY: Column 2, Date Corrected is to be completed by the facility representative after each deficiency is corrected The facility representative must putt da�e,.,f cor tion and his/her initials in Column Z This form must be returned to the Department of Human Resources on or before (� V ,as verification that deficiencies have been corrected. NOTICE: Any mislea Ing or any false statements or reports made to the Depart ent and/or failure to correct the listed deficiencies can be the basis for adverse action. None of these requirements are to be interprete o 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 to r to in comp' nce with the Health&Safe Guidelines Signature of Facility Representative Date — — Signature of DHR Representative Date 12 COPIES TO: �— Page O► of v ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT (Additional Page) Facility Name: ► C CJI ► ll�5 Date of Visit: SECTION B-DEFICIENCY INFORMATION Continued Column I Column 2 Health&Safety Guidelines Date Corrected Deficiency 3 NO r-ODM V�o Inef)LA /6RCI&S - -ice e. os+ej • lolren in a ehoc� 4- C) rnN o� r INSTRU IONS TO FACILITY: Column 2, Date Correc is to be completed by the fac' ty representative after each deficiency is corrected. The facility representative must put the date o correction and his/her initials in,Column 2. This form must be returned to the Department of Human Resources on or before ZX) ,as verification that deficiencies have been corrected. -LAD NOTICE: Any misle ding any false statements or reports made to a D�)-eut and/or failure to correct the listed deficiencies can be the basis for adverse action. None of these requirements are to be interpo allow anyone to operate in violation of Health & Safety Guidelines. A facility approved by the Department must meet Health fty Guidelines applicable to that facility at all times. It is the responsibility of the facility, pe ate in com ' nce. ith the Health&Safety Guidelines Signature of Facility Representative Date fZ--2/— y Signature of DHR Representative & Date Z ' COPIES TO: Pagev of-3. Ir'rl S � ►�e�5