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Deficiency Form (6) ALABA-MA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT . SECTION A- IDENTIFYING INFORMATION Facility blame: Type of Fa ity: Date of Visit: Day I-� Night [-I ► , 1 V / � 0 Both ❑ month/ day / year Facility Address: Telephone#: 201 ob NW`� 143 cz51 a75-- 3s94 r'o v e. Nr► 1 AL 3�v LI 51 Ages: Staff in Charge(if applicable): Capacity: - 1Z / X -1 -1 . x day 0. / night rqi:5bArl ` I day / night SECTION B -DEFICIENCY INFORMATION Column.I Column 2 Health&Safety Guidelines Date Corrected Deficiency r-\6 tApe Liis d 0 n -4h Urd 4r apprv< - 5 M nS A-ti r,rn out' on I • b ' 2.0 Ch ► 0ren under 2 2 CAr-5 nocrou edl INSTRUCTIONS TO PERSON IN CHARGE: Col mn 2, Date Corrected is to I& 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 1 -7 -2_- , as verbcation that deficiencies have been corrected . V Corctci iMMedia- 1 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 & Safetv 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 y Date Signature of DHR Representative A AA 0 ate. COPIES TO: Page of 5 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES-DEFICIENCY REPORT (Additional Page) Facility Name:('. Iff l(e l�r'C Date of Visit: ' z SECTION B - DEFICIENCY INFORMATION (Continued) Column i Column 2 Health&Safety Guidelines Date Corrected Deficiency i h cl-,Mlrern. nver 2. ' Z Pa t-S 0 n 2C). I l r c-�ur obi -t'i vf) n W aS o,,\\ 1 i �c 6 �—a.ve, n ben m e-� . fan i n i � W ► �rh � 11t�, 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 ,a�verification that deficiencies have been corrected. c r re L�r 1 cnm Qa NOTICE: Any misleading or any fallse statements or reports made to the Departnt 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 com lian t Health&Safety Guidelines Signature of Facility Representative. Date `a•� Signature of DHR Representative Date COPIES TO: Page—L—of