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Deficiency Form (14) ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT SECTION A—IDENTIFYING INFORMATION Facili ame: Type of Facil' Date of Visit: Day Night ❑ �" Both ❑ month/ day / year Facility Address: OD Telephone#: Ages: Staff in Charge(if applicable): Capacity: w , G`�x*- - /V9 Jam'./� day / night day / night SECTION B—DEFICIENCY INFORMATION Column 1 Column 2 Health&Safety Guidelines Date Corrected Deficiency 1 r Poe— /W INSTRUCTIONS TO PERSON IN CH GE: olumn 2. Date Corrected to be completed by the facility representative after each deft ciency is corrected The facility representative must put the date oogrecA odwkis/her initials in Column 2. This form must be returned to the Department of Human Resources on or before sZI 7 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 approved by the Department must meet Health&Safety Guidelines applicable to that facility at all times. It is the responsibility of the facility to operate in compliance with Health&Safety Guidelines. Signature of Facility Representative Date Signature of DHR Representative Date el l COPIES TO: T Page ) of