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Deficiency Form (20) Y ALABAMA DEPARTMENT OF HUMAN RESOURCES DHR-D C-1926 i CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION i Facility Name: Type of Facility: Home X Date of Visit: WILL-N-HANDS Day ® Group ❑ Night ❑ Center ❑ /-/ Day/Night ❑. S.A.P ❑ month / day / 77ear 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 SECTION B -DEFICIENCY INFORMATION i Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee � � �f r s� GUI • ��-e C.l�l.�-�_ 1 ao c5 Y, INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee, is to be completed by the facility represe tative after each deficiency is corrected The facility representative must put the date of correcdo an iis/her initials in Column 2. This form must be returned to the Department of Human Resources on or before 1 , as verifica 'on that deficiencies have been corrected. NOTICE: Any misleading or any false statements or reports made to the Department and/or failure to co rect the listed deficiencies can be the basis for adverse action. None of these requirements are to be interpreted to allow anyon to operate in violation of Minimum Standards. A facility licensed by the Department must meet Minimum Standards applicable o that facility at all times. It is the responsibility of tpq licensee to operate in comp iance with Minimum Stand rds. Signature of Facility Representative Dat 9 Signature of DHR Licensing Representative Dat COPIES TO: • I i Page tof 21— � � C-O'PL� Az DHR-D C-1927 ALsABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page). Facility Name: WILL-N-HANDS Date of Visit: 0(4 SECTION B -DEFICIENCY INFORMATION (Continued) Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee 5 �s�► ��rr, CIS. �� a i i i INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee, is to b co leted by the facility represen alive after each deficiency is corrected The facility representative must put the date of correct n a d his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before Lu , as verifica 'on that deficiencies have been corrected NOTICE: Any misleading or any false statements or reports made to the Department and/or failure to correct Ithe 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 jompliance with Minimum Standards. t Signature of Facility Representativ Date U Signature of DHR Licensing Representative Date COPIES TO: Page 2