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Deficiency Form (12) 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: SUSAN BALL Day ❑ Group Night ❑/ month Center ❑ Y g Da /Ni ht �T S.A.P ❑ nth / day / /y-ear Facility Address: Licensee: Telephone#: '309 W. HIGHLAND AVE. SUSAN BALL (256)381-2074 MUSCLE SHOALS, AL 35661 Ages: 02 � Director (if a p c ble): Capacity: 2 SECTION B -DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee r r , INSTRU IONS TO LICENSEE: Column 2 Date Corrected Licensee, is to be complet by the facility representative after each deficiency is corrected. The facility representative must put the date'of correction and hjs/her initials in Column 2. This form must be returned to the Department of Hunan 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 f ility licensed by the Department must meet Minimum Standards applicable to that facility at all times. It is the responsibility oft e 1 c`enseeee to operat in mpliance with Minimum Standards. Signature of Facility Representative / Dat v V J f Signature of DHR Licensing Reprmenta ve Dat ly COPIES TO: Page of