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Deficiency Form (21) ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT SECTION A- IDENTIFYING INFORMATION Facility Name: Type of Fac' Night ❑ ity: Date of Visit: /l 1 I Day i g ! �V U To n n I p ^ � . / U (mil Both Elmonth/ day / year Facility Address: `c s D Telephone#: 119-b 3 � Ages: \ � Staff in Charge(fapplicable): Capacity: MA to ay / night day / night SECTION B - DEFICIENCY INFORMATION Cohin:n I Health&Safety Guidelines Date 2 Date Corrected Deficiency Y �Se INSTRUCTIONS TO PERSON IN CHARGE: Column 2, Date orrected is to be completed by the facility representative after each deficiency is corrected The facility representative must put the a e °n d l' initials in Column 2. This form must be returned to the Department of Human Resources on or beforer J 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 thl se requirements are to be interpreted to allow anyone to operate in violation of Health & Safety Guidelines. A facility approved by the Department must meet Health & Safety Guidelines applicable to that facility at all times. It is the responsibility of the facili to opera a in compliance—with Health&Safetv Guidelines. — Signature of Facility Representative t Date Signature of DHR Representative Date (f—M",[ b Z COPIES TO: Page i—of