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Deficiency Form (15) DHR-DFC-19.26 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 © Group ❑ Night ❑ Center ® _ Day/Night ❑ S.A.P ❑ month / ay / year Facility Address: Licensee: Telephone#: 3297 HIGHWAY 43 ANGEL BUMPERS (801)243-2532 JACKSON, AL 36545 Ages: Director (f 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 V2411� pAQ=, a-e, ,�L 1 - n 1 LA-'/_, "-1 r INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee, is to be completed by the facility representative after each deficiency is corrected., facility representative must put the date of co re ion a ed his/her initials.in Column Z This form must be returned to the Department of Human Resources on or before J �" ; as verification that deficiencies have been correcte.41 NOTICE: Any misleading or any false statements or reports made to t e Dep�nent 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 anyoneto 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 tooperate in compliance with Minimum Standards. Signature of Facility Representative "OD6Dat Signature ofDHR Licensing Representativ ' Dat COPIES TO: Page' of 6 DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: GIFTED MINDS Date of Visit: /2,02,o SECTION B -DEFICIENCY INFORMATION(Continued) Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee A )o Otto "Dn e_o:�5 tid rA 106- - * 6 INSTRUCTIONS TO LICENSE Colu 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 corre o ais/h initials in Column Z 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 the icensee to operate in compliance with Minimum Standards. AkVAAJJ��� Signature of Facility Representative Date ICD Signature of DHR Licensing Representative Date 1 J COPIES TO: Page of "' DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) �f Facility Name: GIFTED MINDS Date of Visit: .UO SECTION B-DEFICIENCY INFORMATION(Continued) Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee bezd ` rep ` MC01 , -F i sn -6 adi o r) L/n d A a rl 0 minu*;OT nji,ef re-,S �- 8L&rinc� I . - _j �anf a r� lbun(_k�r? INSTRUCTIOq TO` CENSEE: 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 corry n,a�ntfiislhrltiais 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 the licensee to operate in compliance with Minimum Standards. Signature of Facility Representative t °6"-av Signature ofDHR Licensing Representative D COPIES TO: PagOL—If_44�7 DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Q �J Facility Name: GIFTED MINDS Date'of Visit: j Z(1 "C�� SECTION B-DEFICIENCY INFORMATION (Continued) Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee reco Cj�3 V)0+ h � lC' be, s �- unoWe, 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 rr tion and his initials in Column 2. This form must be returned to the Department of Human Resources on or before G , 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 the li ensee to operate in compliance with Minimum Standards. Signature of Facility Representative �%dhDate Signature of DHR Licensing Representative Date 1 ?/ COPIES TO: �T Page,-of lV DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT(Additional Page) Facility Name: GIFTED MINDS Date of Visit:. � 2 v SECTION B-DEFICIENCY INFORMATION(Continued) Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee A& , V P l P O o d ® ra-�Lt-s- - b� o Igo Yn 0�w - I I INSTRUCTI NS 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 er 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 the censee to operate in compliance with Minimum Standards. Signature of Facility Representative Date Signature of DHR Licensing Representative COPIES TO: Pag� of V/ DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT(Additional Page) Q Facility Name: GIFTED MINDS Date of Visit: / �O SECTION B -DEFICIENCY INFORMATION(Continued) Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee -4rell of h;4 not corni F- V s V l 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 corr ctionAnd h* itials 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 the lic s e to operate in compliance wAk-Minimum Standards. Signature of Facility Representative Date y- C Signature of DHR Licensing Representative Da t c COPIES TO: Page of