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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 ❑ Date of Visit: BELLAMY HEAD START Day © Group ❑ Night ❑ Center ® Day/Night ❑ S.A.P ❑ month / dhy / year Facility Address: Licensee: Telephone#: 39 CEDAR ROAD SUMTER COUNTY (205)392-4240 BELLAMY,AL 36901 OPPORTUNITY, INC. 'Ages: Director(if applicable): Capacity: 12 Months through 5 Years LETHA MILLS 44 -Day SECTION B -DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee • re nal aahidme e ` 2 A OU o We. 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 correc 'on at&d 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.* zcC kurjS �I17�'�K/4 y1C NOTICE: Any misleading or any false statements or reports made to the D partment 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 a licensee too erlte in compliance with Minimum and rds. Signature of Facility Representative ��►► Dat g Signature of DHR Licensing Represe talive/T[�tJYd✓{� C,CIMs4k> Dat g COPIES TO: Page—[of