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Deficiency Form (17) 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: JULIE CARMACK Day ❑ Group 50 Night ❑ Center ❑ Day/Night ® S.A.P ❑ month / day ! year Facility Address: Licensee: Telephone#: 13000 FRANKFORT ROAD JULIE CARMACK 12561702-3600 TUSCUMBIA, AL 35674 Ages: Director (if applicable): Capacity: 6 Weeks through 13 Years 12 - Day 6 Weeks through 13 Years 8 - Day/Night SECTION B-DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee �Y eas MAL >1S8nS At2 r t 4 fe w—s ois M- See- INSTRUCTIONS TO LICENSEE: Colunin 2, Date Corrected bp Licensee,is to be completed by the facility representative after each deficiency is corrected The facilio,representative must put the date of co rection aixd his/her initials ir: Coltaum 2. This form must be returned to the Department of Human Resources ore or before=k-is " 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 Minimum Standards. A facility licensed by the Department must meet Minimum Standards applicable to that facility at all times. It is the responsibility of tine licensee to operate in compliance with Minimum Standards. Signature of Facility Representative _Date `1-30--m w Signature of DHR Licensing Representad Dal '-'V COPIES TO: J-tjl1e &Yww-y,- Page Eof