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Deficiency Form (13) 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: AIv1Y ROBERTS Day � Group ® Night Center ❑ Day/Night © S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 401 BRANDON AVENUE AMY ROBERTS (334)295-5103 LINDEN, AL 36748 Ages: Director(if ap licable): Capacity: 6 Weeks through 12 Years 12 -Day 6 Weeks through 12 Years 12 - Day/Night SECTION B -DEFICIENCY INFORMATION Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee e-no, 0 rreefl-�4' 0A r6 J 1-")nz rt r I �; W rM doej k wwy) 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 correcti 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 of thticensee too eratein compliance with Minimum Standards. Signature of Facility Representative, Datel—;LOSignature ofDHR Licensing Representa Dat COPIES TO: Page Tof