Loading...
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 % � �1- r Signature of DHR Representative Date ��- � COPIES TO: Page Lof \'&� 0Zx ce'V•� VDIM\\ - �a4c-a