HomeMy WebLinkAboutDeficiency Form (20) ALABAMA DEPARTMENT OF HUMAN RESOURCES
CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT
SECTION A-IDENTIFYING INFORMATION
Facility Name: Type of Facility: Date of Visit:
Kidz Camp Day Z
Night El El _/ JMLD
Both ❑ month/ day / year
Facility Address: 1256 Hwy. 43 Telephone#:
Killen,AL 35645
(256)272-5060
Ages: Staff in Charge(if applicable): Capacity:
6 weeks- 14 years x 46 X
/ Amanda Robertson /
day / night day / night
SECTION B-DEFICIENCY INFORMATION
Column 1 Column 2
Health&Safety Guidelines Date Corrected
Deficiency
C
e�
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 2. This form must be
returned to the Department of Human Resources on or before 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 Health &
Safety Guidelines. A facility approved by the Department must meet Health&Safety Guidelines applicable to that facility at all times.
It is the responsibility of the facility to erate in comp lianc with Health&Safety Guidelines.
Signature of Facility Representative Date
Signature of DHR Representative Date 0' l - Gu 0
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