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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 ate of Visit: WILL-N-HANDS Day ® Group ❑ Night ❑ Center ❑ D Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: ' Telepho a"#: 120 PORTER ANDREWS ROAD CONNIE E. (334)774-9501 OZARK, AL 36360 WILLINGHAM Ages: Director (f applicable): Capacity: 0 Weeks through 12 Years W 6 -Day SECTION B -DEFICIENCY INFORMATION Column I Column 2 Minimum Standard ,,- Date Corrected by Deficiency Licensee U OLAj c c ale Zcwtd anynue6 % 0 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 his/her initials in Column 2. This fora: must be returned to the Department of Human Resources on or before 11 ZI W l 9 , 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 compliance with Minimum Standards.d Signature of Facility Representative Dat _( Signature of DHR Licensing Representative If Date COPIES TO: Page of DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: WILL-N-HANDS Date of Visit: z Sd SECTION B-DEFICIENCY INFORMATION (Continued) Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee- Y 1AV i' 1 i LAA19 3W&= v v1+- l • G S + t/1eucuoawaddc Li ) . . l � lr I i V1 4-L-t t"10" 01',kechci 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 his/her initials in Column 2. This form 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 a'a 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 Representative414- Date C j) _jh Signature of DHR Licensing Representativ Date o l COPIES TO: Page Z,of --