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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: SUSAN BALL Day ❑ Group Night ❑ Center ❑ Day/Night ® S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 309 W. HIGHLAND AVE. SUSAN BALL (256)381-2074 MUSCLE SHOALS, AL 35661 Ages: Director(if applicable): Capacity: 2 Weeks through 8 Years 12 -Day 2 Weeks through 8 Years �`-- i` 6 -Day/Night SECTION B -DEFICIENCY INFORMATION Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee c� C�t�� � • '� � lQ -av INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee, is to be completed by the facility representative after each deficiency is corrected The facility representative must put the date of c°� ion and his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before ' ` , 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 'lity licensed by the partment must meet Minimum Standards applicable to that facility at all times. It is the responsibility of th li ensee to operate i m�pli, ce ith Minimum Standards. Signature of Facility Representative \ 1,1 Dat Signature of DHR)Licensing Representativ Date COPIES TO:S r� Page-of