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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: MS. TIFFANY'S DAY CARE Day ® Group Night ❑ Center ❑ / 2 / Zo Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 11880C CO RD 48 TIFFANY VILLANOVA (251)591-0045 FAIRHOPE, AL 36532 Ages: Director (if applicable): Capacity: 2 Weeks through 5 Years 12 - Day SECTION B -DEFICIENCY INFORMATION Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee >j QkACLn6 S .i ' 2 r On 4-he, +ztblf, bw 441c,;Mnk Amr i s t ode- + keq z -5her-e, i sec-Ho � ncno;s5inq in 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 an 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. V � �r r p� ' / ,�r� NOTICE: Any misleading or any faL�esz%,,L4- ts or repor`fs mace' to"the Deeplartment tan'ilVor 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 facilit licensed b t e Department must meet Minimum Standards applicable to that facility at all times. It is the responsibility of the li e o oper incco pliance with Minimum/- Stan ards. Signature of Facility Representative D 1 Ga 71P Signature of DHR Licensing Representative 46 Dat Zc) COPIES TO: Page 1 of 3 DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: MS. TIFFANY'S DAY CARE Date of Visit: it) SECTION B -DEFICIENCY INFORMATION(Continued) Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee ty- ou�,Si de da-v anea is res+r;c4ed/1(Mi+ej a alle -ram M Sin Eli^n of 4me uniii -R.r41cr ncki ue . Once e c) A ' e )o %Is correc;W,- 4�xmus� be Acffified visa MiA5f be mo Ae bu 4 denar4mcrrf r e (.' onn k ',or +D L(5r, . qre koj-\ oeS b+ i n e. aL� r ' r f %Is L t uth5ee, i c� not' nobN -F�lroe. c1unr4meM 6� 2 2� W housetiold mtmbex . 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 ande his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before In /(&/ .?® , 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 li ns a to op r e`in compliance with Minimum Standards. Signature of Facility Representative Date Signature of DHR Licensing Representative G.Q•+^' Date ®COPIES TO: TO: Page a of DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) I Facility Name: MS. TIFFANY'S DAY CARE Date of Visit: Jfl 212A SECTION B-DEFICIENCY INFORMATION(Continued) Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee ®m houl5e�)old mtmber ckoes not howe. We A,cod o rf e5t Jak anct rc-suR5, 4c,+ w ces c>r- CA Clearance 5qrrn on r% -vhe ywre. - ne. s L b�+W t, ®es howe rre,n+ ecl i co.J r or-+ o 'le- i VI +h e hom e ® ; ►dre'n 5 r or . Se L 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 correcto and his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before 0 710/Za , 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 operat ill compliance with Minimu m Standards. Signature of Facility Representative Date Signature of DHR Licensing Representative Date 1 O M COPIES TO: Page 2) of