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Deficiency Form (8) e ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT . SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Faj)iiity: Date of Visit: Day [� ^ Night 20 AU 14�11 Both ❑ month/ day 7-year Facility Address: Telephone#: 20.I 0b I- L`A143 (asi 975- 9594 6 (-D\)e, 4; kl AL Ages: Staff in Charge(if applicable): Capacity: day / night day / night SECTION B -DEFICIENCY INFORMATION Column_I Column 2 Health&Safety Guidelines Date Corrected Deficiency oUnA 4 apipQroX rni r�5 . - '-b ur on 1 • b ` 2-0 C h i l d rein u n der- 2 A Q ca r-,5 n P c cou e of INSTRUCTIONS TO PERSON IN CHARGE: Col mn 2. Date Corrected is to 4 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 •2,.D , as verification that deficiencies have been corrected Corce ci lMMeANaA6 NOTICE: Any misleading or any false statements or reports made to the Departme a d/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 Representative 1 Date Signature of DHR Representative Q A A AA te 1 - J« COPIES TO: a Page I of l5 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT (Additional Page) Facility Name:[ Cyr ke, ('T Gyc are. Date of Visit: SECTION B -DEFICIENCY INFORMATION Continued Column 1 Column 2 Health&Safety Guidelines Date Corrected Deficiency i h h I I ren 2 c'5 o n L 0. N C-�Or Ob► van n 1e� OL 0, 1 I i f�c ts n o ITb e-�n. Mel . U "�ImerarncLi Prejoarpdne:56 and m6por6el. Aar\ i6 on I, le With -b1-1 INSTRUCTIONS TO FACILITY: 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 ,as verification that deficiencies have been corrected -le r reC,-� 1 i�nrn a NOTICE: Any misleading or any false statements or reports made to the Depa nt and/or failure to correct the listed deficiencies can be the basis for adverse action. None of these requirements are to be interprete 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 corn is t Health&Safety Guidelines Signature of Facility Representative Date Signature of DHR Representative Date I • 2 COPIES TO: Pagel---Of 2—