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Deficiency Form (14) �D — 1 ' 10 3.0 Io0 " 2. 1 0•2D ID l • r •2 a ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT . SECTION A- IDENTIFYING INFORiMATION Facility Name: Type of FaSiHty: Date of Visit`: Day ►� 1 M Night ❑ IZ Both ❑ month/ day / year Facility Address: Telephone#: �) 9 r� �8 a43 - a53D, v� 3b� � Ages: Staff in Charge(if applicable): Capacity: �W-Ys- I o o �_, X day / night 6UxM Q,�day / night SECTION B -DEFICIENCY INFORMATION Column I Health&Safety Guidelines Column 2 Deficiency Date Corrected CA INSTRUCTIONS TO ERSON IN CH_A RGE: olumn 2 Date Corrected is to be completed by the facility representative after each deficiency is corrected. The facility representative must put the date of corr�erion d his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before V C� , as verification that deficiencies have been corrected A. Co �2L-� NOTICE: Any misleading or any false statements or reports made to the Department a /or failure to correct the listed deficiencies can be the basis for adverse action. None of these requirements are to be interpreted to all 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 Signature of DHR Representative Cc Date ' 2 ! I COPIES TO: Page ` of ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT /� ' (Additional Page) Facility Name: C.7 T +'C 1(\0� J Date of Visit: SECTION B-DEFICIENCY INFORMATION Continued Column 1 Column 2 Health&Safety Guidelines Date Corrected Deficiency dr l Ch; l�r ns Its (WA oxy 1z r two C�nI �o�c�n� de., Icy 5 4 �C 1e-5 i n m \eA-C Ib ;J OD bne, cV end-Cr w1*41 )6+ N Psn 2 $ C ► v +��' e, nod Ulm 11 N �b�`2d �- ce )n 2 lz -� `bb�n l/ INSTRUICTIONS TO FACILITY: Column 2, Date Corrected is to be completed by the facility representative after eacl deficiency is corrected. The facility representative must put thf dale„f cor #Qn and his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before ` (� U ,as verification that deficiencies have been corrected. Ca�eL�- ;cam. NOTICE: Any mislea ing or any false statements or reports made to the epart ent 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 by the Department must meet Health&Safety Guidelines applicable to that facility at all times. It is the responsibility of the facility to o r to in compliance with the Health&Safety Guidelines Signature of Facility Representative Date — Signature of DHR Representative Date 12 %j 1 ' 19 ` COPIES TO: Page p+ of ALADAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT (Additional Page) Facility Name: 1 CA 01 (l�5 Date of Visit: 12 ' • I ! SECTION D -DEFICIENCY INFORMATION Continued Column I Column 2 Health&Safety Guidelines Date Corrected Deficiency 3 t V�0 t�)Q ly)ef)(-A 1 ,f) P05A-C-Ck 7COC "-,C� /6RaC)�S <S �nGr 2n� s o n 5 e. ire � Bess �l� u-Sk pc SG o-td D Cc > -� lie. o s�-e�1 • 2r no � rA- S► n ;r\ u (n r �� r1e�Q L� �► � ��- cow � ���, �sp� v,��1�, INSTRUaFIONS TO FACILITY: Column 2, Date Correckk is to be completed by the fac' ty 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� ,as verification that deficiencies have been corrected. ,0 � 1�0.� NOTICE: Any misle ding any false statements or reports made to t e Depa ent 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 & fety Guidelines applicable to that facility at all times. It is the responsibility of the facility pe ate in com nce ith the Health&Safe Guidelines Signature of Facility Representative Date A.-�� Signature of DHR Representative & Date COPIES TO: Pagev Of3 Vy 1 4 • r�