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Deficiency Form (5) 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: GEIGER HEAD START Day ® Group ❑ Night ❑ Center ® 3 / 17- / Z� Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 187 COBY BROADWAY SUMTER COUNTY (205)455-2519 EMELLE, AL 35459 OPPORTUNITY, INC. Ages: Director (if applicable): Capacity: 3 Years through 5 Years DORIS LITTLE 40 -Day SECTION B-DEFICIENCY INFORMATION Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee There rue l o f ' i-Z Z0 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 must put the date of correct' .l nd 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 Department must meet Minimum Standards applicable to that facility at all times. It is the responsibility oft "licensee to operate in compliance with Minimum Standards. Signature of Facility Representative �1 ram `��+ Data Signature.of DHR Licensing Representative Il�rt 1t�1 eM Mt 1 Date COPIES TO: C ew<)JV mariA , T>o ri5 *tt Page ofJ