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Deficiency Form (20) ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Aim Type of Facility: Date of Visit: Night ❑ _/ 4 ne Both ❑ month I day / year Facility Address: Telephone#: ® ` Ages: / Staff in Charge(if applicable): Capacity: x JOWCaS L1fWAQAVK day t� day di�/ m t / t SECTION B-DEFICIENCY INFORMATION Column 1 Column 2 Health&Safety Guidelines Date Corrected Deficiency 4. bAQ lei J 4 ` A a l 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 h' :er initials in Column 2. This form must be returned to the Department of Human Resources on or before Q 2b 00, 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 Health & Safety Guidelines. A facility approved by the De ment must meet Health&Safety Guidelines applicable.to that facility at all times. It is the responsibility of the facility perate i plian with Health&Safety Guidelines. Signature of FacilityRepresentati Date tzo a ' Signature of DHR Representati a_X ZhA 41 gn, COPIES TO: Page 6 of—L