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Deficiency Form (6) 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: TINY TOTS CHILD DEVELOPMENT Day ® Group ❑ CENTER Night ❑ Center ® / jzm Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 803 2ND AVENUE, SE T &T CHILD (205)932-7908 FAYETTE, AL 35555 DEVELOPMENT CENTER, INC. Ages: Director (if applicable): Capacity: 3 Weeks through 12 Years CONNIE HATHCOCK 79 -Day SECTION B -DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee , 10_ . e✓ INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected bV Licensee,is to be completed by the facility representative after each deficiency is corrected. Thel/acility representative must put the date of correcti n nd 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. 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 Minimum Standards. A facility licensed by the Department must meet Minimum Standards applicable to that facility at all times. It is the responsibility of th nsee to op rate' omp a ce with Minimum Standards. Signature of Facility Representati Date Signature of DHR Licensing Representativ Date�`-��an COPIES TO: _ GI?N C- PageLof