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Deficiency Form (13) 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: GIFTED MINDS Day N Group ❑ Night 0 Center ® 2— Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 3297 HIGHWAY 43 ANGEL BUMPERS (801)243-2532 JACKSON, AL 36545 Ages: Director (if applicable): Capacity: 6 Weeks through 10 Years ANGEL BUMPERS 16 -Day SECTION B -DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee I ,� 9 o�ren �eI inu �vise� � -1 -t dC- s nod- OC c.n i Z OF 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 -Z L , as verification that deficiencies have been corrected. NOTICE: Any misleading or any false s atements or repgrts made to the Department nd/or failure to correct the listed deficiencies can be the basis for adverse action. None of these requirements are to be inte eted 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 licen see to operate in,com lance with Minimum Standards. Signature of Facility Representative Dat Signature of DHR Licensing Representative Qc Dat COPIES TO: I� r�1s� bArf)Pej� %l `� — Page Lof DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: GIFTED MINDS Date of Visit: 91 SECTION B -DEFICIENCY INFORMATION(Continued) Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee (p� 12) C1 C 0 rYl eT C,- . -]-woCb i td c- r\ is r) ° �eS 1nC n� 10 l�io�2 C P (Z CC-A a► 2}Z -6) A 02m 2NAA F-D� � eAe-A 01 2rhnC� � n 2 Y2 L,4 A - ,5LV\- INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee, is 4o 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- ' 19 -2-0 , as verification that deficiencies have been corrected. �o rr� t�,me R�pret NOTICE: Any misleading or any Ise sta ements or reports made to the D and r failure to correct the listed deficiencies can be the basis for adverse action. None of these requirements are 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 compliance with Minimum Standards. l Signature of Facility Representative y Date4 l� Signature of DHR Licensing Representative Date Z � � COPIES TO: er Page of DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: GIFTED MINDS Date of Visit:V2L� SECTION B -DEFICIENCY INFORMATION(Continued) Column I Column 2 Minimum Standard Date Corrected by ADeficiency Licensee ( �,n 2- I No wr as+e-A t 41 l� 1� s-VI G � m ems- i nemered 'Ale INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee, is to be completed by the facility representative each deficiency is corrected. The facility representative must put the date of co rr ctioll and his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before ' 2- Q , as verification that deficiencies have been corrected. .. NOTICE: Any misleading or any false statements or repo s made to the Department and/or fail to correct the listed deficiencies can be the basis for adverse action. None of these requirements are to be interpreted to al w 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 compliance with Minimum Standards. Signature of Facility Representative �' Date�.j2-- Signature of DHR Licensing Representative �—Dates G COPIES TO: '2— •� ' l 1 m� �j�lvl -ems Page 6 of DHR-DFC-1927 ALABAMA.DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) ' - Facility Name: GIFTED MINDS Date of Visit:12. 1 1 - 16) SECTION B-DEFICIENCY INFORMATION(Continued) Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee n) �A 1� menu o6�-ed1 v,tiCA, k s Co 2 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 co rre d n and 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. .Z O NOTICE: Any misleading or any false statements or reports made to the Departme 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 in compliance with Minimum Standards. Signature of Facility Representative Date Signature of DHR Licensing Representative ate Z COPIES TO: Page� of DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT(Additional Page) 1 Facility Name: GIFTED MINDS Date of Visit: 2 t SECTION B -DEFICIENCY INFORMATION(Continued) Column I Column 2 Minimum Standard Date Correeted by Deficiency Licens ZC -T)r)ecc ace, \j S CCInCA L n1C �C0CG orN Cen-der n o-Ir 0b1e, +D e n D 116 Q n -f j1- m i(1 i M u M Crop V 201 - ',) D 2- C �-- . 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 ' » • 2-D , as verification that deficiencies have been corrected. Y, �D r��� I �m� NOTICE: Any misleading or any false s atements or reports made to the Department d/or failure to correct the listed deficiencies can be the basis for adverse action. None of these requirements are to be interp feted 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 compliance with Minimum Standards. Signature of Facility Representative [�1 'L� Date Signature of DHR Licensing Representative Date COPIES TO: Page of