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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: CLARKE PREP DAYCARE AND PRE- Day W Group ❑ SCHOOL Night ❑ Center ® C� Day/Night ❑ ' S.A.P ❑ mont / day / year Facility Address: Licensee: Telephone#: 20100 HWY 43 CLARKE SCHOOL (251)275-8594 GROVE HILL,AL 36451 FOUNDATION Ages: Director (if applicable): Capacity: 6 YVeeks through 12 Years BONNIE SMITH 106 -Day SECTION B-DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee V0 - 2Y'2- Vr. 60 olm &n '6"Dws o ' l fi mom' i5dim re a -ve af&bit on -Fhc r- I ll r Old plambard . I�S sl 1 INST UCTIONS TO LICENSEE: Col n 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 a d his/her initials in Column 2. This form must be returned to the Departmen�of Human Resources on or before_ S 71 l I q , as verification that deficiencies have been corrected. I�n�l/p�r�-` Offed n a, NOTICE: Any misleading or any false sta-tle lments or reports made to th(eu iDlelp�rtment 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 i to in compliance with Minimum St ndards. Signature of Facility Representative Date Q ' o l 11 Signature of DHR Licensing Representative Date. �9 COPIES TO: WI 1 �I rI� uM Page I of DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) 9 Facility Name: CLARKE PREP DAYCARE AND PRE-SCHOOL Date of Visit: SECTION B-DEFICIENCY INFORMATION(Continued) Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee lh �5 nb sb on i initc b�& h ho a Mrc0_fi`_6r N446 Ooc 1fl60M0&-4_�Tw5 )*1w 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 cor�nrectio and his/her initials in Column 2. This form must be returned to the Department o Human Resources on or before 8'1 ' —I , as verification that deficiencies have been corrected. �UrrP 'ha�nrdg rmme��a . NOTICE: Any misleading or any false statements or reports made to the Depattment 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 thS41censee to operate in compliance with Minimum Standards. Signature of Facility Representative Date Signature of DLCT+ HRLicensing Representative Date 1•G 1 COPIES TO: w&hl�.rl. wo Page f