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Deficiency Form (5) ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT SECTION A - IDENTIFYING INFORMATION Facility Name: Type of F ility: Date of Visit Day Ni-ht �vl &v ! Both month/ day / year Facility Address:&,? �, // Telephone#: -�O/.5 Acres: Staff in Charge(if applicable): Capacity: �5 4q l lv day / night day / night SECTION B - DEFICIENCY INFORMATION Column I Column 2 Health&Safety Guidelines Date Corrected Deficiency INSTRUCTIONS TO PERSON IN CHARGE: Cohrntn 2, Date Corrected is to be completed by the facility representative after each deficiency is corrected The facility representative must put the date of c e t' it and hisAter 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 Health & Safetv 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 erate in compliance wj h Health&Safety Guidelines. Signature of Facility Representative Date -�-a� Signature of DHR Representative Date COPIES TO: PageLof l