HomeMy WebLinkAboutDeficiency Form (6) ALABAMA DEPARTMENT OF HUMAN RESOURCES -
CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT
SECT ON A-IDENTIFYING INFORMATION
Facility Name: Type ty: Datefif Visit:
Little Peoples Nursery School Nay t
Both ❑ month/ day / year
Facility Address: Telephone#:
509 Alabama St.
Killen, AL 35645 ( 256 >757-4498
Ages: Staff in Charge(f applicable): Capacity:
_5wki-12yrs i X Gail Johnson _ 37 _/ X
flay / night day / night
SECTION B -DEFICIENCY INFORMATION
Column 1; Column 2
li Health&Safety Guidelines Date Corrected
Deficiency
� r
INSTRUCTIONS TO PERSON IN CHARGE: Column 2, Date Corrected is to be completed by the facility representative after each
deficienej is corrected The facility representative must put the a of correctio+J and his/her initials in Column Z This form must be
returned o the Department of Human Resources on or before r4—l�. ?.Q' was 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 lo f Facility Representative ) Date
Signatureof DHR Represen e Date c�---92r—t ab
j
COPIES TO:Gail Johnson Page of
I