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Deficiency Form (21) 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: BELLAMY HEAD START Day ® Group ❑ Night ❑ Center ® 1 I Z. 17-0 Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 39 CEDAR ROAD SUMTER COUNTY (205)392-4240 BELLAMY, AL 36901 OPPORTUNITY, INC. Ages: Director (if applicable): Capacity: 12 Months through 5 Years TYRONE THOMAS 44 -Day SECTION B-DEFICIENCY INFORMATION Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee eA ca er.,8 es- r U I 'r 4- DI 2 So - INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee, is to he 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 lY�� , 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 Dep ent must meet Minimum Standards applicable to that facility at all times. It is the responsibility of the licensee to ope to in co p 'ance with Minimum Sta5dar s. Signature of Facility Representative Dat 0010 Signature of DHR Licensing Represen e DatP ®-Z." COPIES TO: Page of i