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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: LITTLE EAGLE DAY CARE CENTER Day © Group ❑ Night ❑ Center ® Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 1954 COFFEEVILLE ROAD JACKSON ACADEMY (251)246-3262 JACKSON, AL 36545 INC Ages: Director (if applicable): Capacity: 2 1/2 Years through 12 Years LEEANN CHANCEY 60 -Day SECTION B -DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee Ore. l Y1® 1 U con+Ur ►1 (ACc + 1 op sa f c 4-- ! kk Cep, .���vxcuk dre-oavtdaa��5 ad U j I �,e spo n v� 9 Lcqn 1, s ri D r\co!�q 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 and his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before ZQ as verification that deficiencies have been corrected. �rf'�,c..k• `r},t��' S 4(cd(- NOTICE: Any misleading or any false statements or reports made to the Department and/or fai)a 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 D partment must meet Minimum Standards applicable to that facility at all times. It is the responsibility of the lice to operate in pliance _ith Minimum Stand�rnds. Signature of Facility Representative Dat ©�"' Q Signature of DHR Licensing Representative Date COPIES TO: Page of DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: LITTLE EAGLE DAY CARE CENTER Date of Visit: I& W ?o SECTION B -DEFICIENCY INFORMATION (Continued) Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee no pt a -Tkg- �tvkci, � 5 no+ a,+I-eu,54- fl. i n 6)?� o rt re- k- Pla ro"n� o r, f,�4- cortw X Sfa-4 ftGa44 oLrf- fro n co m I i (,,V-L-)0-0�CoJr. 1. C �. D ne- CWa cal, i t C44, INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee, is to be completed bythefacili representative after each deficiency is corrected. The facility representative must put the date of correcd n an his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before *.0 , as verification that deficiencies have been corrected. X/ C v' rY C- 1 (1 C,Za nPA S 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 Signature of DHR Licensing Representative Date L B ZU COPIES TOi ��V�. Page of