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:
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