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Deficiency Form (13) DHR-DFC-1926. A.LABAMA DEPARTMENT OF HIJMI A1V RESOURCES CHILD CARE VI INIMUIVI STANDARDS DEFICIENCY REPORT .SECTION A-,IDENTIFYIi IG.INTFORIVIATION, Facility Name: Type of=Facility: 17ioriie ❑ Date.(if Visit: CLARKE.PREP DAYCARE.&PRESCHOOL Day p Grvuj 0 Cu Night ❑ Center 0 / `Q / Day/Night Q S.A P p -,month L day '1, year, Facility Address: Licensee: Telephone`#: 20100 HIGHWAY43 CLARKE:SCHOOL (251)275-8594 GROVE HILL,AL 36451 FOUNDATION, INC. Ages: Director(if applicable); Capacity: 6 Wuks through 12 Years MISTY KNIGHT '77 -D.ay, SECTION B -DEFICIENCY INFORMATION Column 1 Cohimn 2 Minimum:Standard Date Corrected by. Def ciency Licensee. 00 INSTRUCTIONS TO LICENSGEt. Column 2j Dale.Corrected bit Licensee, is.tb be cq ipleted:by Ike facility r'epreserrtafivc after each deficiency is corrected. Tite facility represeirtrrtzvc nurst,prrt the date of corrc o t'and It 's//rer initials;in Colrruli:2: This form must be returned to the Department of Human Resources on or before �;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 It be interpreted to allow anyone to opera to in violation of Mini huni.stflndards. A facility licensed by'the Department must.meet Ntinirnum Standards:applicable to that facility at all times. 1t is:the respbnsibility of tlrc liceiiseeto operntc,in complian e with Minimum:Standards; Signature'of Facility Representative 6 Data �,"' �8 � Signature ofDHR Licerrsing.Represeriteitive ' Dah, Co Q 7 °40io COPIES TO: Page of f