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HomeMy WebLinkAboutDeficiency Form ALAB AZNL�k DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT SECTIOti A-IDENTIFITNG INFORILATION Facility Name: Type of Fac' 'ty: Date of Visit: Yl� ��-�,, \\ Day Fer l v C Y1 �`r Ou 5 �C�l(1 N �j Night ❑ —�k /�-� v Both El month/ day / year Facility Address: Telephone M Ages: Staff in Charge(if applicable): Capacity: dayx / night day / night i SECTION B -DEFICIENCY INFORTNIATION Column 1 Health&Safety Guidelines Column Deficiency Date Corrected l'rR y\ I q INSTRUCTIONS TO PERSON IN CHARGE: Column 2, Date Corrected is to be completed by the facility representative after each deficiency is corrected The facility representative must put the date of correction and his1her initials in Column 2 This form must be returned to the Department of Human Resources on or before ')-_ �1— .C) , 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 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 COPIES TO: �.� G� ��h K' ��� �" �a 1"�� 7 page \ of 1