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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