Loading...
Deficiency Form (13) z • � � � 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 ❑ enter ❑ '� / ;eg/ Day/Night El S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 309 W. HIGHLAND AVE. SUSAN BALL l (256)381-2074 MUSCLE SHOALS,AL 35661 Ages: ,2 �� Director(if is le): Capacity: af fT SECTION B -DEFICIENCY INFORMATION Column 1 Column 2 Minim-um Standard Date Corrected by Deficiency Licensee ?-fie 56 de V5l' INSTRU IONS TO LICENSEE: Column Z Date Corrected Licensee,is to be comp let by the facility representative after each deficiency is corrected. he facility.-rep�reentative:must putahe ddte_of corm ctionared titer znifials zn Column 2. Thz y -- f as verification that Lfornz must:be returned•' oF� tlieDepartmen;�of Human Resources_o_n or be ore 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 1 censee to operat zn mpliance with Minimum Standards. Signature of Facility Representative Dal "_._ v V Signature of DHR Licensing Rep ve Dal COPIES TO: Page of '�7sn �n