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Deficiency Form (8) ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility-Name: Type of Facli'ty Date of Visit: Day PQ Night ❑ ` l / 2�j /� . C Both ❑ month/ day / year Facility Address: Telephone#: Pnc , A-. 36 1, 10 a5► > 51 -5 559 IA�ges:y�� Staff in Charge(ifapplicable): Capacity: X 61 day / night day / night SECTION B-DEFICIENCY INFORMATION - Column 1 Health&Safetv.Guidelines Column 2 Deficiency Date Corrected JJ 7 -L�n INSTRUCTIONS TO PERSON IN CHARGE: 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 his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before _ ' �D 2 Q , as verbcation 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 to operate in compliance with Health&Safety Guidelines. Signature of Facility Representat�Ke Date Signature of DHR Representative Date COPIES TO: Page I of