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HomeMy WebLinkAboutDeficiency Form (5) Mar 04 20 02:07p Adventurous Beginnings 2062215273 p.2 ALAB A_tiLA DEPARTMENT OF HU1LA`RESOURCES CHILD CARE HEALTH R: SAFETY GUIDELINES DEFICIENCY REPORT SECTION A-IDENTTFU G INTOR`ZA.TIO` Facility tiame: Type of Fae' ty: Date oE,/ d3y ` ,yy Day (�,CV�N 1��OU� w�. �.f1 Y1�111 �j 14ight ❑ v Both C] month / yeat FacilityAddress: Teleph Ages: Staff in Charge(Vapplfcable): Capacity: 0.Y�F-Co K day I nightday I night SECTION B-DEFICIENCY L`'FOR UTIO` Colson l Health&Safety Guidelines Cotman2 Deficiency Date Corrected I�LZ1n _ era' Y\ cl r `prAna rP 5'A 5 A INSTRUCTIO`S TO PERSON IN CHARGE: Casa;; 2. Date Corrected is to be completed by the facif o representafive apes each defrcfency it corrected The facing,representative nutst put the date of correction and his/her laidafs in Cohimtr 2 I'lris form must be retrtmed to the Department of Hunan Resources on or before c'1—�c[3 , ar verycatiort that defidendes 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& Saretv 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 comp;fance with Health&Safety Guidelines. Signature of Facility Representative T \ DGoG�f�S Signature of DHR Representative Dare l 1 COPIES T0: C� -r Gar �• \�t1 ]a��Cj . Page , of 1 �- �v