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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: Day i►' - Group ❑ Night ❑ Center Er' It f C'—a"( S.A.P. ❑ month/ day / year Facility Address: Licensee: Telephone#: el ,C , Ages: Director(ifapplicable): Capacity: 11:� A:�— —. 0 , -k I lec-) / )L VAn day / night day / night SECTION B-DEFICIENCY INFORMATION Column l Minimum Standard Column 2 Deficiency Date Corrected by Licensee r ,?X Owl 4 i CAAT�• o our a- Go per� 1�.ZC��C� Zy'l rl rOD 1S w % I'- # 4—0--W ok w,r�1:e,� ock "IA�n .-wo*or "�r J�tgAl&a\ j'nAon�5 gAes INSTRUCTIONS TO LICENSEE: Column 2. Date Corrected by Licensee, is to be completed by the facility representative after each deficiency is corrected The facility representative must put the 11 of co ection and h er initials in Column 2. This form must be returned to the Department of Human Resources on or before , as verificatlon that deficiencies have been corrected. *Hazards must be corrected immediately 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 arf to be interpreted to allow anyone to operate in violation of Minimum 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 in compliance with Minimum Standards. Signature of Facility Representative Date Signature of DHR Licensing Representative Date - COPIES TO: Page of