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
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