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Deficiency Form 41ENT DHR-DFC-1926 ALABAMAJL(%qT kaDNEFI AN CE�CY OURCES CHILDCARE REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Facility: Home ❑ Date of Visit: GIFTED MINDS Day © Group. ❑ 4 'to / Z'o Night ❑ Center 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 4vA . �c4 INSTRU TIONS 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 coff��e to n/2j initials in Column Z This form must be returned to the Department of Human Resources on or before Mg / o"�� , as verification that deficiencies have been corrected. / Cv rre-c+ " i la- *Any misleading or any false statements or reports. made to the Department /or failure to correct the listed deficiencies can be the basis for adverse action. None of these requirements are to be interp ed 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 icense t operate in compliance with Minimum Standards. Signature of Facility Representative Date Signature of DHR Licensing Representative Dat COPIES TO: C� Page f ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT (Additional Page) Facility Name: Date of Visit: Zi U zo SECTION B-DEFICIENCY INFORMATION Continued Column I Column 2 Health&Safety Guidelines Date Corrected Deficiency D F n INSTRUCTIONS TO FACILITY: Column 2 Date Corrected is to be completed by the facility representative after each deficiency is corrected. The facility representative must put th a c rre nion����z�-5�,his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before � l,�c�'� ,as verification that deficiencies have been corrected- "�a` ` p M �Q L NOTICE: Any misleading or ny fa se statements or repo s made tote epartment an r 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 & Safety Guidelines. A facility approveq by the Department must meet Health& Safety Guidelines applicable to that facility at all times. It is the responsibility of the facility to er e i m B ealth&Safe Guidelines Signature of Facility Representative p Date Signature of DHR Representative COPIES TO: Page C�2 of