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HomeMy WebLinkAboutDeficiency Form (6) ALABAINLA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT SECTION A-IDENTIFYING INFOR:NLATION Facilitv`Nam\e: Type of Facil' Date of Visit: Q-01 10.h� Day Night ❑ Both ❑ month/ day / year Facility Address: Telephone M ()L5 Ages: Staff in Charge(if applicable): Capacity: C.cl / night day / night SECTION B -DEFICIENCY INFORNLATION Column I Health&Safety Guidelines Column Deficiency Date Corrected I INSTRUCTIONS TO PERSON IN CHARGE: Column 1. Date Corrected is to be completed by the facility representative after each deficiency is corrected The facility representative must put the date of c re ion and his/her initials in Column 1. This form must be returned to the Department of Human Resources on or before as verification tlrat deficiencies have been corrected NOTICE: Anv misleading or anv false statements or reports made to the Department and/or failure to correct the listed deficiencies can be the basis for adverse action. hone 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 operate in compliance with Health&Safety Guidelines. Signature of Facility Representative Date Signature of DHR Representative Date \—aq aQa,Q COPIES TO: \ Q�� 0.� {� `L R\ —+_'" � �' �^ 1v 1� Page of \