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HomeMy WebLinkAboutDeficiency Form DIR-DFC-1926 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARRMINIMUM STANDARDS DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Facility: Home . ❑ Date of Visit: Day UK Group 0 . Night ❑ Cenfer _/_ /�� K Z Y-n S.A.P. ❑ month/ day / year Facility Address: 12 SCv 44W u. Ll 3 Licensee: Telephone#:• , (2��)2'7 Z•So Co o `° =' ,'._ . Ages: Director(f a plicablg) man : Capacity: 1td a oloson � . / >C Aiet-�-rin _6LLrch*e1.l. Liu / day / night day night. SECTION B-DEFICIENCY INFORMATION Column 1 Minimum Standard Column2' Date Corrected by Deficiency' Licensee Th(-_ -Oddl�er_�t c ��1 c,�nct z.�� c�;e�Ssrno S e .�c� J e, Cii/1 xw C=c rl alo S in n Ic: in 7_0 o ct s dotes npf hcw•e, ljocxf ryl. W -•ear INSTRUCTIONS TO LICENSEE: Column 2, Date Corrected by Licensee, is Io lie.completed by the facility:representative after each deficiency is corrected The facility representative mustput 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 as verification, that deficiencies have been corrected ►f'f(QZ(�J►rds TY ul A bt czrr��'CCl I VY1lY1 IQ,Q�' � 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 m rompllance with Minimum Standards. I Signature of Facility Representative Date Signature of DHR Licensing Representative Date ZcD'ZD COPIES TO: Page of Distribution: Original(1st)(white)-DHR file Yellow copy(2nd)-Follow-up Pink copy(3rd)-Facility copy DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MIINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: K I d Z `�,� "cA w�+7- Date of Visit: �> •[5� 2(�Z L� SECTION B-DEFICIENCY INFORMATION Continued Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee 3 Tin�r•c, c�.�� o�c�-���. c�.k lor�s D►�—Nne,�.7. laygr��. C�,,rou nCj +h1e ICI. has ro 4ed l ---�,Dod cn P to,Cis N OLZ Les (art,nt,-o-b Q-pm�)VD nL� l °b dafGi,e,nC If-5 oUJ �Q20MOwnM, eju c) b e-0 ov-\ c jf-s . INSTRUCTIONS TO LICENSEE: Column Z 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 Z This form must be returned to the Department of Human Resources on or before l'_� Zq•'7Z.pL- , as verification that deficiencies have been corrected )(9amin S mu4 bt c-orrZ J_ _I�l ih'1ynAd 1te.� C� y 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 opWinp 'ance with Minimum Standards. n Signature of Facility Representative Date `0J / Do Signature of DHR Licensing Representativ Date �' 'GU(�J COPIES TO: Page-?---Of Distribution: Original(Ist)(white)-DHR file Yellow copy(2nd)-Follow-up Pink copy(3rd)-Facility copy ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD'CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Facility: Date_of Visit: LL Day Night ❑ ���/ �J /��� I_\1 d ZVYI Both ❑ month/ day / year Facility Address: 12� W' A . Ll 3 Telephone#: K-i,ll-itn, AL c2�C� lLrt'•SoLD0 Ages: Staff in Charge 1(if applicable): Capacity: LOIA57 l rs. / X �liresrksor, LI lo i . ir. Lr,a,I�tutcl-LOu- day / night day / 'night - SECTION B-DEFICIENCY INFORMATION Column 1 Column 2 Health&Safety Guidelines Date Corrected Deficiency Tht� -�o filar re: cboatccna << DO c�ssr rns Z T ho-J,e, Wwwofu-nnln:� w4u-' INSTRUCTIONS TO PERSON IN-CHARGE: .Column.2, Date Corrected 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 2This form must,be returned to the Department'of Human Resources on or before 'l O'2 Q•dim-1-D. , as verification that deficiencies have been corrected _ - -' " _' NOTICE:L 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 Health&. Safety`Guidelines. Afacility approved`by the Department must meet Health&Safety'Guidelines applicable to that facility at all times.' It is the responsibility of the facility to operate in compliance with Health&Safety Guidelines. Signature of Facility Representative Date Signature of DHR Representative YAW a—X,� Date b' 'S•�2[� COPIES TO: Page—c—of z ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT (Additional Page) Facility Name: I Date of Visit: SECTION B-DEFICIENCY INFORMATION Continued Column I Column 2 Health&Safety Guidelines Date Corrected Deficiency J Asnr)46-Z�wu r,6 1 Joe, LK)r) A �e nC g-, L-M A 4 - - "A A r L)Lin aAox 606 �2i membp-moL re up ft -tj,�IV% ApiL 4\f�C kir,N W, cL,,,J s INSTRUCTIONS TO FACILITY: Column 2, Date Corrected 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 t' ,as verification that deficiencies have been corrected it 1 NOTICE: Any misleading or any false statements or reports ma a to the Department an or failure to correct the listeel deficiencies can be the basis for adverse action. None of these requirements are to be interpreted to allow anyone to operate in violation of Health & Safety Guidelines. A facility approveWobD�!partmentt meet Health&Safety Guidelines applicable to that facility at all times. It is the responsibility of the facility t h the Health&Safety Guidelines Signature of Facility Representative t Date Signature of DHR Representative �Q ,l 6 4 Date ��' 15'2C)Zt COPIES TO: Page Z