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Deficiency Form (9) 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: AMY ROBERTS Day ❑ Group 91 cl Night ❑ Center ❑ Day/Night (I S.A.P ❑ month /day I year Facility Address: Licensee: Telephone#: 401 BRANDON AVENUE AMY ROBERTS (334)295-5103 LINDEN,AL 36748 Ages: Director(ifapplicable): Capacity: ' 6 Weeks through 12 Years MA 12-Day 6 Weeks through 12 Years f 12- Day/Night '1 SECTION B-DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee . l C ert 6L C LI..lien �I ov a vA J 12, 7LY-0 I Y1 I. Y l INSTRUCTIONS TO LICENSEE: olumn 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 r o an erf' Wal n��olumn 2. This form must be returned to the Department of Human Resources on or before vCJ dltiverification 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 of the licensee to.operate in com Hance with Minimum Standards. Signature of Facility Representative Date' Signature of DHR Licensing Representative Date ZX � COPIES TO: Page J_or y DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT(Additional Page) Facility Name: AMY ROBERTS Date of Visit: SECTION B-DEFICIENCY INFORMATION(Continued) i Column 1 Column 2 II Minimum Standard Date Corrected by Deficiency Licensee o Abu ky 12 . ra I1 �1 1 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 life date o co cn �djVr6?iqt6!qCa1unjn 2. This form must be returned to the Department of Human Resources on or befor 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 of the licensee to operate In compliance with Minimum Standards. Signature of Facility Representative t Dated Signature of DHR Licensing Representative Date C.O— L COPIES TO: Page u a