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Deficiency Form ALABAMA DEPARTMENT OF HUMAN RESOURCES DHR FC:'1926 CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT ' SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Facility: Home X Date of Visit: PHYLLIS DENNEY Day ® Group ❑ Night ❑ Center ❑ Day/Night ❑ S.A.P ❑ mont / da / y Y Y Facility Address: Licensee: Telephone#: 57 LEE ROAD 517 PHENIX CITY,AL 36870 PHYLLIS DENNEY (7061575-5436 I E. Ages: Director (if applicable): Capacity: 6 Weeks through 5 Years 6 - Day SECTION B -DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected b Deficiency Licensee 01 tire-CL Coe d Cyr v c , e,�► �c�.l CPe. �� ' �►,� �i ca. 'gin 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 correcti n and k Aer gi Is in Colum 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 facility licensed by the Department must meet Minimum Standards applicable to that facility at .;all times. It is the responsibility of the licensee to operate in compliance with Minimum Standards. Signature of Facility Representative Dat 0 .Z0 I Signature of DHR Licensing Representative Date (a COPIES TO: i 11 C, Z.I�ZJ� P Page of TA