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Deficiency Form (18) DHR-DF -19 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Facility: Home X Date of Visit: WILL-N-HANDS Day ❑x Group ❑ Night ❑ Center ❑ Day/Night ❑ S.A.P ❑ month / day / y ar Facility Address: Licensee: Telephone#: 120 PORTER ANDREWS ROAD CONNIE E. (334)726-4672 OZARK,AL 36360 WILLINGHAM Ages: Director(if applicable): Capacity: 0 Weeks through 12 Years 6 - Day i SECTION B -DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee 1 �5 In Up 4� ccv yxD+ INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee, is to be completed by the facility represent five f r each deficiency is corrected. The facility representative must put the date of correctio am :is/her initials in Column 2 Th's form must be returned to the Department of Human Resources on or before , as veriflcati n th at ' 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 opler ate in violation of Minimum Standards. A facility licensed by the Department must meet Minimum Standards applicable t that facility at all times. It is the responsibility of th licensee to operate in comp iance with Minimum St*rds6. , Signature of Facility Representative Dat 9 Signature of DHR Licensing Representative Dat O COPIES TO: Page 0