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HomeMy WebLinkAboutDeficiency Form (12) ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type o F ility: Date Visit: Little Peoples Nursery School Day 0,71� Night i Both ❑ month/ day / year Facilit�� Address: Telephone#: 509 Alabama St. Kille;, AL 35645 ( 256 >757-4498 Ages: Staff in Charge(f applicable): Capacity: 5wks-12yrs / X Gail Johnson _ 37 -/—X— I ay / night day / night SECT�ON B-DEFICIENCY INFORMATION Column Health&Safety Guidelines Column 2 Deficiency Date Corrected I 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 a of correcdoj7 and his/her initials in Column 2. This form must be returnedto the Department of Human Resources on or before rG� �_ Zi9 mas 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. Signatureof Facility Representative Date Signatur of DHR Represen e Date��cJ ' a COPIES TO:Gail Johnson Page /of i r