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Deficiency Form (20) DHR-DFC-1926 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Facility: Home Date of Visit: JONNY'S DAYCARE Day a Group .❑ F / J 1 n /�D�V Night ❑Center am/ Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 60 GROSS ROAD JONNY SMITH (251)862-2643 FRISCO CITY, AL 36445 Ages: Director (if app is ble): Capacity: 0 Months through 12 Years Al 6 -Day SECTION B-DEFICIENCY INFORMATION Column I Column 2 Minimum Standard Date Corrected.by Deficiency Licensee L r4ff &1exAmbe Y& 0 ons 1 . INSTRUCTIONS TO LICENSEE: Coltann 2.Date Corrected by Licensee, is be completed by the facility representative after each deficiency is corrected The facility representative must put the date:of ection a is rr�n' 'a in Column 2. This form must be returned to the Department of Human Resources on or before UAd , 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 1ction. 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 o e lice see to opera in emmliance wit Minimum Standards. Signature of Facility Representative Datr� Signature of DHR Licensing Representativ at U D COPIES TO: Page / of 1