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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: •�5 Day Group P .C � Night. Center J J J S.A.P. month/day / year Facility Address: �� dqf,s4e,,j censee� Telephone #: _ �a ac,kIo A. 45 Qrolct ` (LSD 5si - I qq Ages: Director (if applicable): Capacity: _ �K5 • l3 q5 day / night Du -Or l* 15 f/ It day / night SECTION B - DEFICIENCY INFORMATION column 1 Column Z Minimum Standard Date Corrected Deficiency by Licensee ,5 5 l W.�1 C. S �'' GurSe. A.In (0 b0t � 1 a �U� slhom IDS � S 0 n. . l j0, (011j 1" 3 � , j'e COS 51pjrp ed4s INSTRUCtfONS TO LICENSEE: Column 2, Date Correctel ln/ Licensee, is to be completed by the facility representative after each deficiency is corrected. 77ie facility representative nuLst put the date of correction and his/her initials in Column 2. This form must be returned to the Department of Hunzan Resources oIn or before —1/ as ver ification that deficiencies have been corrected. NOTICE: Any misl�din�or any false statements or reports made to the Department a)d/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 �4inimum•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 ' omplianc with Minimum Standards. S,gnatur of Facility Representative Date Signature ofOHR LicensingyRepresentative Date Z COPIES TO:-Oa na Vr f S 1 Page-L—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 MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: J)I �5 5 Tf' �5 C.C.C. Date of Visit; fil(I 2i SECTION B - DEFICIENCY INFORMATION Continued Cclumn t Cc%mn 2 Minimum Standard Date Corrected Deficiency by Licensee S �� i�.cords a,VC �onro,,,r, 9�'an�, P�O� e� o�,c v�►lu�,¢�, i bu Q,�� (jiS GHQ c� n�n I ra&+ C', �W1111 tfA M re Jws cznd- rf 5eo 11 k .01a 0 f ��CO�11,P�1 (�( �� �G°l� la 6C a vr, Ixc,�6 '�'� . I t 1 �k2vL IS a V►' 1`11!a V �P- toil(eof / /j. I i I � . i i INSTRUCT IONS TO LICENSEE: Colunn! 2, Date Corrected bit Licensee is to be completed by the facility representative cV er earli deficiency is corrected The facility representative must put the date of correction and hi .i!er initials i�! Colu7711t n!ust be returned to the Department of Human Resources on or before__ (,' �- 2,() as t e;ificatioa! that d2ficie,zr.'es have been Corrected. 4 b r fe C� 4k2&rOLS ern rneA j'a.je( NOTICE: Any misleading or any false statements or reports made to the DepartmejancVor 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 !Nfinim= Standards. A facility licensed by the Department rnust meet Nfinimum Standards applicable to that facility at all times. It is the responsibility of the see to operate in compliance with Nfinimum`Standards. Signature of Facility t Is _ Da2 /0- Signature OfOHRLice:fsingRepresentatii Tr, � 20 .�COPIES TO: D&Aa Page d DlsznC!tier•. Orig,nal(15-0(rnit2i DHR file Ye'Icw CCCy P,3k CCp'/(3rd)-F301i;/cCCy