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Deficiency Form (5) ALAB kNLA DEPARTMENT OF HUNIAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELI`ES DEFICIENCY REPORT SECTION A-IDENTIFYING INFORALMON FFacilime: l Type of Faci ' y; • Day ' Dateof�utt.Night ❑Both ❑ \month/ day / ye3f ress:h--dQve . �• Telephone#: Staff in Charge i a licable/ e �� pp ) Capacity: d Y / night A � - D. Y�cv day / night SECTION B - DEFICIENCY INFORYLATION COIAmn 1 Health&Safety Guidelines Column Deficiency Date Corrected I I INSTRCCTIONS TO PERSON IN CHARGE: Column 2. Date Corrected is to be completed by the facility representative after each deficiency is corrected The facility representative ":list put the date orrection and hisAter initials in Column 2. returned to the Department of Human Resources on or before This form must be corrected , as verification that deficiencies have been 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 Health & Safety Guidelines. A facility approved b the Department must meet Health & Safety Guidelines applicable to that facility at all times. It is the responsibility of the'facility to p rate in co 'lance with Health&Safety Guidelines. Signature of Facility Representativ Date Signature of DHR Representativ �Da COPIES TO:- e� c ,� \ ` \\� Ol� l� ��� Page of