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Deficiency Form (10) ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT SECTION A -IDENTIFYING INFORMATION Facility Nam Type of Facility: Date of Visit: Day ❑ 26 2D)J / Night ❑ / / l Both month/ day / year Facility Address: 14 O+ -9Yan Y,-,- AVe n tA Lo Telephone#: Llylac,yAl AL 3 � 9 4? (33y 2a'-S I D,2 Ages: LO W k-- /a W,r Staff in Charge if applicable): Capacity: ) rS l ! j ecrS N ),�)— / 1 Z day / nip t day / night SECTION B - DEFICIENCY INFORMATION Column 1 Column 2 Health&Safety Guidelines Date Corrected Deficiency V-�nve-- )0ee-y-, INSTRUCTIONS TO PERSON IN CHARGE: Column 2 Date Correcte is 7and mpleted by the facility representative after each deficiency is corrected The facility representative must put the date of o r c Ater 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 & 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"". Signature of Facility Representative l/Date �y iTU1/ � Signature of DHR Representative ate (11 jQ — �C_ V COPIES TO: Page i—of