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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 COPIES TO: Page of