HomeMy WebLinkAboutDeficiency Form (21) 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:
KIDZ CAMP Day ® Group ❑
Night ❑ Center ®
Day/Night ❑ S.A.P ❑ month / day T year
Facility Address: Licensee: Telephone#:
1256 HWY 43 AMANDA ROBERTSON (256)272-5060
KILLEN, AL 35645
Ages: Director(if applicable): Capacity:
6 Weeks through 14 Years AMANDA ROBERTSON 46 -Day
SECTION B-DEFICIENCY INFORMATION
Column 1 Column 2
Minimum Standard Date Corrected by
Deficiency Licensee
T{� - R I h t,"7 1 I
5 t l an, cx-& b--M �
evo0. an
INSTRUCTIONS TO LICENSEE: ColutiV2,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 correction and his/her initials in Column 2. This
form must be returned to the Department of Human Resources on or before 7' (-�1�t7 , 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 Minimum Standards. A facili y licensed by the epartment must meet Minimum Standards applicable to that facility at
all times. It is the responsibility of the lic to op ate i 1' with Minimum St nd ds.
F
Signature of Facility Representative Date—
Signature of DHR Licensing Representati Date l l'
COPIES TO:
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