Deficiency Form (6) 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:
Day Group x
Night Center ❑
S.A.P. ❑ month/ day / year
Facility Address: /�j /� Li nsee: Telephone#:
Ages: Director(if applicable): Capacity:
day / night e`ddaayy / night
SECTION B -DEFICIENCY INFORMATION
Column I
Minimum Standard Column 2
DeficiencyDate Corrected by
Licensee
Zia,
alt f
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 mast put the date of c r cti n and his/her initials in.Column 2. This form must be
returned to the Department of Human Resources on or before 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 epartment must meet Minimum Standards applicable to that facility at all times. It is the
responsibility of the licensee to operate ompliance with Mini Standards.
Signature of Facility Representative Date
Signature ofDHR Licensing Re / Date
COPIES TO: Page of
i
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