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Deficiency Form (6) 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: WILL-N-HANDS Day ® Group ❑ Night ❑ Center ❑ I I/ ( n / Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: ' Telepho, : 1 120 PORTER ANDREWS ROAD CONNIE E. (334)774-9501 OZARK,AL 36360 WILLINGHAM Ages: Director (if applicable): Capacity: 0 Weeks through 12 Years 6 -Day SECTION B-DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee ON—pcot tic 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 correction and h' ear initials in Column 2. This fora: 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 Minimum Standards. A facility licensed by the Department must meet Minimum Standards applicable to that facility at all times. It is the responsibility of licensee$o o ep rate in compliance with Minimum St7ndar s. Signature of Facility Representative I�•C/� � ti Dot (/o Signature of DHR Licensing Representativof Dat COPIES TO: --���- 000 --t 04 L c etnS ems, Page—A—of j—