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Deficiency Form (22) DHR-DFC-1926 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A-IDENTIFYINGIIN ORMATION I Facility Name: Type of Facility: Home Date of Visit: JONNY'S DAYCARE Day © Group ❑ Night ❑ Center ❑ J 9 / 2 Day/Night ❑ S.A.P ❑ month / 'day / year Facility Address: Licensee: Telephone#: 60 GROSS ROAD FRISCO CITY, AL 36445 JONNY SMITH (251)862-2643 Ages: Director (if app is ble): Capacity: 0 Months through 12 Years 6 - Day SECTION B -DEFICIENCY INF, RMATION Column 1 Column 2 1 M' imum Standard Date Corrected by �nA� Deficiency LicenseeAt 1 1nse6 n -i an�js a ev k-rev yt anda I I INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee is to be completed by the facility representative after each deficiency is corrected. The facility iepresentative mustput the date of co 1 ection a!p is/ r nifa .in Column 2. This form must be returned to the Department f Human Resources on or before' UA d, , as verification that deficiencies have been corrected IJ NOTICE: Any misleading or any fals 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 Minimum Standards. A facil�ty licensed by the Department must meet Minimum Standards applicable to that facility at all times. It is the responsibility of a licensee to operas in c liance wit 'Minimum Standards. Signature of Facility Representative Date Signature of DHR Licensing Representativ at ` COPIES TO: i Page 8 of 4