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Deficiency Form (6) i DHR-DFC 1 26 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Facility: Home Date of Visit: ! . I PHYLLIS DENNEY Day ® - Group• Q Nit /� / ❑ Center ❑ Day/Night ❑ S.A.P ❑ mon / day / ye Facility Address: Licensee:. Telephone#: 57 LEE ROAD 517 PHYLLIS DENNEY (706)575-5436 IX PHEN CITY,AL 36870 . 1 Ages: Director(if applicable): Capacity: 6 Weeks through 5 Years 6 -Day SECTION B-DEFICIENCY INFORMATION I. Column 1 Column 2 Minimum Standard Date Corrected by Deficiency o . g . �Sur � �AQS vd, ¢�► ►ca.l � C'J►��. �-1,rs�'�t �h tea. 'u , INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee,is to be completed by the facility represen at vel after each deficiency is corrected. The facility representative must put the date of corrects n and is er i Ysals in Column ;I, !�Is form must be returned to the Department-of Human Resources on or before as verificati in thll`t deficiencies have been corrected I l NOTICE: Any misleading or any false statements or reports made to.the Department and/or failure to cor ec the listed. deficiencies can be the basis for adverse action. None of these requirements are to be interpreted to allow anyon it operate in violation of Minimum Standards. A facility licensed by the Department must meet Minimum Standards applicable'` o hat facility at all times.'It is the responsibility of the licensee to operate in compliance with Minimum Standards. Signature of Facility Representative Dat ^� _'J Signature ofDHR Licensing Representative Dat oZ�O � COPIES TO: `�/�• Zq, "Z.I�Zl� Page of