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Deficiency Form (7) 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: CLARKE PREP DAYCARE&PRESCHOOL Day ® Group ❑ Night ❑ Center ® / I D / Z Q Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 20100 HIGHWAY 43 CLARKE SCHOOL (251)275-8594 GROVE HILL, AL 36451 FOUNDATION,INC. Ages: Director (if applicable): Capacity: 6 Weeks through 12 Years BONNIE SMITH 77 -Day SECTION B -DEFICIENCY INFORMATION Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee ` A 91 mun+h 01C1 chi 3 WaS e � �' n su r- Vi 5e.C1 On �h 1a and _0 irnat l min5 -to am h ur 0 n I - (o• 2.0 • . 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 form must be returned to the Department of Human Resources on or before I 1-7 ­2 0 , as verification that deficiencies have been corrected. - � NOTICE: Any misleading or any false statements or eports made to the Department and/or failurr 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 complia ce ith Minimum Standards. Signature of Facility Representative _ Date r' O a Signature of DHR Licensing Representative &5b Date 10- 7-0 COPIES TO: 5 , Page I of DHR-DFC-1927 y, ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: CLARKE PREP DAYCARE &PRESCHOOL Date of Visit: D -2 0 SECTION B -DEFICIENCY INFORMATION(Continued) Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee a CWdre(\ r\der 2 Vz e.acs otr rum e inn CkklaFen av C 202- 3 PM" Pcpoc-m4re-�sfs e� . J es c�nsc 1 a� is n -� 1 w�-kh �•� . 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 corrgction d h'/her in in Column 2. This form must be returned to the Department of Human Resources on or before ! ' 0 , as verification that deficiencies have been corrected CO rye C+ NOTICE: Any misleading or any false statements or reports made to the Depar, nt 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 mAon1pliance with Minimum Standards. Signature of Facility Representative Date Q— Signature of DHR Licensing Representative D"ate n• 2 O COPIES TO: Page of OL