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Deficiency Form l ALABANIA DEPARTMENT OF HUNIAN RESOURCES CI4ILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT SECTION A -IDEtiTIFYING INFOI�ALMOI Facility Name: Type of Fac'•y: Date of Visit: Night Day Bath month/ day / year j Facility Acid ress: � Telephone#: 3(e5 S IAges: Staff in Charge(if applicable): Capacity: day / ni;lit �� i .�/C day night SECTION; B -DEFICIENCY INFOR.tiIATION Cotrrrrtrr I Colanrrr? Health &Safety Guidelines Date Corrected Deficiency VI IKUPA 5 INSTRUCTIONS TO PERSON IN CHARGE: Column 1, Date Corrected is to be completed b, the faciiu)• representative afrer each dr fciency- is eorrectetl. The f rcial. r•.preselliative uutsf Pitt the lrtte of correction and his/her tnhials it: 6(trnur 1. This form rttttsf he rentrized to eltc.D2paroneni of Flunrarr Resources an or bef re 10- I$�'Z as verifcation that deficiencies have been Corrected. Co" �.�ti�� ®y- � q9,nuo( cct4 C l NOTICE: Arty misleadingor any Use statements or reports made to the Department and/or failure'to correct the listed deficiencies can be the basis for adverse notion. None or these requirements are to be interpreted to allow anyone to operate in violation of Health & Safety Guideiiries. A facilir; approved by the Department must,meet:Health & Safety Guidelines applicahle to that facility at all times. It is the responsibilin`of t e facility to operate i c m liance��iti gait &Safety Guidetinzs. �n, i k V"79 q/ �0�-� \ Si;rtattrre of Fac•iliry Representative Date o� narrrre of DHR Rjprtsentadve Date 2 COPIESTO: Pau. [� or