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Deficiency Form (20) 1 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: KATHY WILES' DAY CARE Day ® Group ❑ Night ❑ Center ❑ Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 302 GAYFER CT KATHY WILES (251)928-8518 FAIRHOPE, AL 36532 Ages: Director(if applicable): Capacity: 6 Weeks through 4 Years 6 -Day SECTION B -DEFICIENCY INFORMATION Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee Ca r hunr o nc4 haxe, � irnm i Dvi -R'k. i r1 e- h me 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 corn�jcti n and his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before '-1 Z 2.1 ZZ , 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 Signature of DHR Licensing Representative at 's 2 COPIES TO: Page I of DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: KATHY WILES' DAY CARE Date of Visit: .I L-C) SECTION B -DEFICIENCY INFORMATION (Continued) Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee M CS min •e— .( , 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 correction and his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before 2� , 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 Date O� Signature of DHR Licensing Representative Date COPIES TO: Page 2,of r