HomeMy WebLinkAboutDeficiency Form (2) DHR-DFC-1926
ALABAMA DEPARTMENT OF HUMAN RESOURCES
CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT
SECTION A-IDENTIFYING INFORMATION
Facility Name: Type of Facility: Home ❑ Date of Visit:
ADVENTUROUS BEGINNINGS, INC. Day ❑x Group ❑
Night ❑ Center ® 2L / /
Day/Night ❑ S.A.P ❑ —month / day / year�
Facility Address: Licensee: Telephone#:
3064TH AVENUE ADVENTUROUS 12051221-5273
JASPER, AL 35501 BEGINNINGS, INC.
Ages: Director (if applicable): Capacity:
3 Weeks through 6 Years THERESA BANKS 60 -Day
SECTION B -DEFICIENCY INFORMATION
Column I Column 2
Minimum Standard Date Corrected by
Deficiency Licensee
• U r4 rA\ . I I
INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by License , is to be completed by the facility 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 — Q—aoao , 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 1'censee to operate in compliance with Minimum Standards. .
Signature of Facility Representative 14A ( Date aO
Signature of DHR Licensing Representative 1,� T Date
1r ��—
COPIES TO:
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