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Deficiency Form (6) ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Facility: Date of Visit: G )i Idre►-, 59 Night ElLlt 0 Both ❑ month/ day / year Facility Address: Telephone#: "1b0 Mei,vin Lam F&r hD(fie, , A4. 21443 2 Ages: Staff in Charge(rf applicable): Capacity: 45 - ILWie3 / N1A 6 / N/A �— day —' / night day / night SECTION B -DEFICIENCY INFORMATION Column l Health&Safety Guidelines Column 2 Date Corrected Deficiency oeak k sodgL4 GVdALUkQ5 haws bew INSTRUCTIONS TO PERSON IN CHARGE: Column 2, Date Corrected is to be completed by the facility representative after each deficiency is corrected The facility representative must put the date of corr ction and his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before I , 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 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 of Facility Representative Date 'g Signature of DHR Representativea�)" COPIES TO: Page I of /