Deficiency Form (14) ALABAMA DEPARTMENT OF HUMAN RESOURCES
CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT
SECTION A-IDENTIFYING INFORMATION
Facility Name: Type of Facility: Date of Visit:
Dy El
Night ❑ ago 1Z
Both month/ day 1 year
Facility Address:��,•1 � A�"�/ �e`�. Telephone#:
G
Ages: Staff in Charge(f applicable): Capacity:
day / night day / night
SECTION B -DEFICIENCY INFORMATION
Column 1 Column 2
Health&Safety Guidelines Date Corrected
Deficiency
P r _
r f
INST TIONS TO PERSON IN "GE: Column 2, Date Corrected is to be completeaO the facility representative after each
deficiency is corrected The facility representative must put the dgte.Qf correction qnd h' er 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 approveA by the Department must meet Health&Safety Guidelines applicable to that facility at all times.
It is the responsibility of the facility t o erate in compliance with Health&Safety Guidelines
Signature of Facility .
Re resentative "`"'' Date ,~ 0 b `c
ty p
Signature of DHR Representative Date
COPIES TO: Page Lof/