HomeMy WebLinkAboutDeficiency Form (20) ALABAMA DEPARTMENT OF HUMAN RESOURCES
CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT
SECTION A-IDENTIFYING INFORMATION
Facility Name: Type of Fac'w. Date of Visit:
Day
CX ►&)7° V.-<'C)u c:;) Night ❑❑
1,�►Vn`V-1 Both ❑ month/ day / year
Facility Addre s:—� Telephone#:
NCXL- Z "AtN
Ages; Staff in Charge(rfapplicable): Capacity: /
3W •
V al / �Y MESA �U►v��5 dly % night
day / night
SECTION B-DEFICIENCY INFORMATION
Column 1 Column 2
Health&Safety Guidelines Date Corrected
Deficiency
O
INSTRUCTIONS TO PERSON IN CHARGE: Column 2, Date Corrected is to be completed by tl:e 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 3 -+�� as verification 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 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 op rate in compliance with Health&Safety Guidelines.
Signature ofFacility Representative Date %
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r
Signature of DHR Representative Date ��- �
COPIES TO: Page Lof
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