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Deficiency Form ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: A&.. c!aA4_ Type of Facility: Date of Visit: . � Day �' wu^•�4 Night � 1�� Both month/ day / year Facility Address: Telephone#: Ma6CLA1 PaAzw o 12199 z4 11-0. Ages: Staff in Charge(if applicable): Capacity: JA*10-s- Sq day / night day SECTION B -DEFICIENCY INFORMATION Column I Health&Safety Guidelines Column 2 Deficiency Date Corrected A02 � . ID INSTRUCTIONS TO PERSON IN CHARGE: Column 2, Date Corrected is to be completed by the facility representative after each deficiency is corrected The facility representative must put the date of correction and his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before q L f °�Q , as verifzcadon 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 De ent must meet Health&Safety Guidelines applicable to that facility at all times. It is the responsibility of the facility Aerate i plian with Health&Safety Guidelines. • 77 Signature of FacilityRepresentati Date Signature of DHR Representati a ate COPIES TO:- Page 1 of j Lb, V i 64-vt.