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Deficiency Form (17) DHR-DFC-1926 ALABA.,_.i DEPARTMENT OF HUMAN RE; JRCES BRECENEa CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A- IDENTIFYING INFORMATION MAY 16 Z Facility Name: Type of Facility: Home pT"' Date of Visjif:Care services p ision FUN 4 KIDZ Day ® Group ❑ Night ❑ Center ❑ / Q/ Day/Night ❑ S.A.P ❑ in nth / day4yar Facility Address: Licensee: Telephone#: 305 W COURTLAND AVE MELISSA GORMAN (256)248-4949 MUSCLE SHOALS, AL 35661 Ages: Director (if a icable): Capacity: 1 Weeks through 5 Years 6 - Day SECTION B - DEFICIENCY INFORMATION Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee �FJ 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 correction and hi 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 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 licensSq to operate in comp ' nce with Minimum Standards. Signature of Facility Representative �^'Dat Signature of DHR Licensing Representative Date COPIES TO: Page�of