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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: JULIE CARMACK Day ❑ Group Night ❑ Center ❑ / Day/Night ❑x S'.A.P ❑ onth / day / year Facility Address: Licensee: Telephone#: 13000 FRANKFORT ROAD JULIE CARMACK (256)389-8214 TUSCUMBIA,AL 35674 Ages: Director (if applic ble)- Capacity: 0 Months through 13 Years 12 - Day 0 Months through 13 Years 8 - Day/Night SECTION B -DEFICIENCY INFORMATION Column I Column 2 Minimum Standard Date Corrected by Deficiency 'Licensee INSTRUCTIOA TO LICE SEE: Column 2,Date Cor ted by Licensee, is to be completed by the facility representative after each deficiency is corrected. The facility representative must put the date of correction and his per 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 the licensee to operate in compliance with Minimum( lStandards. Signature of Facility Representative Date _l J O Signature of DHR Licensing Representative Date. COPIES TO: Page—Lof J DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILDCARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: JULIE CARMACK Date of Visit: SECTION B -DEFICIENCY INFORMATION (Continued) Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee l 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 corre i n and l is/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 the licensee to operate in compliance with Minimum Standards. Signature of Facility Representative - ! Date I Signature of DHR Licensing Representative Date 0 COPIES TO: Page �f