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Deficiency Form (5) DHR-DFC-1926 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Facility: Home Date of Visit: THE BLESSED CHILDREN Day ® Group ❑ Night ❑ Center ❑ (o /4 / Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 7627 MELVIN LANE GLORIA MATTHEWS (251)391-0807 FAIRHOPE, AL 36532 Ages: Director(if applicable): Capacity: 2 Years through 12 Years A 6 -Day SECTION B -DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee 2Y ire, o�.r��nCS 1 1 o± Ir-IcLikre%WaA INSTRUCTIONS TO LICENSEE: Column 2, Date Corrected by Licensee, is to be completed by the facility representative after each deficiency is corrected. The facility representative must put the date of correcto and his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before c 1 TI-3//2,0 , 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 Minimum Standards. A facility licensed by the Department must meet Minimum Standards applicable to that facility at all times. It is the responsibility of th ' nsee to rate in compliance with Minimum Stand�arrds. Signature of Facility Representative 6����' Dap � 7 Signature of DHR Licensing Representativ Dat COPIES TO: Page ` of