Deficiency Form (14) ,/'\ DHR-DFC-1926
ALAB A DEPARTMENT OF HUMAN RL JURCES
CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT
SECTION A- IDENTIFYING INFORMATION
Facility Name: Type of Facility: Home Date of Visit:
FUN 4 KIDZ Day ® Group ❑ Q ��
Night ❑ Center ❑ J /Day/Night ❑ S.A.P ❑ month / 42y�// year
Facility Address: Licensee: Telephone#:
305 W COURTLAND AVE MELISSA GORMAN (256)248-4949
MUSCLE SHOALS, AL 35661
Ages: Director (if ap li ble): Capacity:
1 Weeks through 5 Years 6 - Day
SECTION B -DEFICIENCY INFORMATION
Column I Column 2
Minimum Standard Date Corrected by
Deficiency Licensee
INSTRU�STOENSEE: Column 2, Date Corrected by Licens e, is to be colVieted by the facility representative after
each deficiency is corrected The facility representative must put the date of correction nd hi er initials in Column 2. This
form must be returned to the Department of Human Resources on or before 8 , 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 license operate in carliance with Minimum Standards.
Signature of Facility Representative Dat 37/
Signature of DHR Licensing Representative 22! Dat
COPIES TO:
Page / of
^ DHR-DFC-1927
ALABAMti DEPARTMENT OF HUMAN RESG%)RCES
CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page)
Facility Name: FUN 4 KIDZ Date of Visit: .
SECTION B -DEFICIENCY INFORMATION (Continued)
Column 1 Column 2
Minimum Standard Date Corrected by
Deficiency Licensee
r
� � t
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 nd hi : r initials in Column 2. This
form must be returned to the Department of Human Resources on or before .3 a b' , 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 comp iance with Minimum Standaik rds./�
Signature of Facility Representative Date�� `/ /`�"7
Signature of DHR Licensing RepresentativC—Z Date
COPIES TO:
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