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Deficiency Form (11) i DHR-DFC-1926 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A-IDENTIFYING IN k ORMATION Facility Name: Type of Facility: Home ❑ Date of Visit: CLARKE PREP DAYCARE &PRESCHOOL Day Group ❑ Night ❑ Center [ / ( () / Z C) Day/Night ❑ SAP ❑ month / day / year Facility Address: Licensee: Telephone #: 20100 HIGHWAY 43 CLARKE SCHOOL (251)275-8594 GROVE HILL, AL 36451 FOUNDATION, INC. Ages: Director (if applicable): Capacity: 6 Weeks through 12 Years BONNIE SMITH 77 -Day SECTION B-DEFICIENCY INFORMATION Column 1 Column 2 Mi imum Standard Date Corrected by Deficiency Licensee Aa mun+h 01 chlAd Was - n npp r-o i ma�- 1 5 M n 5- -t o a n ho u r n 1 - 620 . INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee, is to be completed by the facility representative after each deficiency is corrected. The facility r resentative must put the.date of correction and his/her initials in Column 2. This form must be returned to the Department Human Resources on or before I - 1-1 . 2 C�. , as verification that deficiencies have been corrected. -1� 1 z�r- 1/eports �O r-�-e 1 NOTICE: Any misleading or any false statements or made to the Department and/or failur'e'to correct the listed deficiencies can be the basis for adverse cdon. None of these requirements are to be interpreted to allow anyone to operate in violation of Minimum Standards. A facili licensed by the Department must meet Minimum Standards applicable to that facility at all times. It is the responsibility of the fficei see to operate in complia ce ith Minimum)Standards. Signature of Facility Representative _ Date `^ D _c-)-O Signature of DHR Licensing Representative Date ' 10• 2-0 COPIES TO: 5 Page I of i DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT(Additional Page) Facility Name: CLARKE PREP AWARE & PRESCHOOL Date of Visit: D 'ZD SECTION B-DEFICIENCY INF RMATION(Continued) Column 1 Colztmn 2 Minimum Standard Date Corrected by Deficiency Licensee h i I e n nd e Z Vz eq <-s a r rum ecoiktn cklIaren av r 2 '/ n ( • (o , J�)WeCj-()f-_ 06kAlor, r_�O 11ed as [ - tuc, i c`ti S �G ve r \o b e n rn es Dnsc. g1cLn INSTRUCTIONS TO LICENSEE: Column 2 Date Corrected bv Licensee, is to be-completed by the facility representative after each deficiency is corrected. The facility representative must put the date of corrfcdol id h'A initials in Column 2. This of form must be returned to the Department Human Resources on or before LL , as verification that deficiencies have been corrected. Co��eC+ ►mi�ned��}e l� NOTICE: Any misleading or any false statements or reports made to the Depar nt 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 facilitV licensed by the Department must meet Minimum Standards applicable to that facility at all times. It is the responsibility of the like see to operat eliance with Minimum Standards. Signature of Facility Representative 9 ' Date `�C)—��Signature ofDHR Licensing Representative Date 1 10. 2 COPIES TO: Page 9 of O`