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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/