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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 l