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Deficiency Form (8) 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 ® iO Day/Night ❑ S.A.P ❑ month / day / 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 I Column 2 Minimum Standard Date Corrected by Deficiency Licensee T �A ' 06ser utrJ en 5 l! St b !D 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_/r1T,Ar , 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 t licenjef to o e ate•� cyrnpliance with Minimum Standards. w i � � Signature of Facility Representative ' Date + V Signature of DHR Licensing Representative '6CIM11r. mms-1 Date COPIES TO: C,ehkr mnaie,e' Page—t--of