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HomeMy WebLinkAboutDeficiency Form (22) Mar 0521 12:22p Adventurous Beginnings 2052215273 p.1 ALABAMA DEPARTMENT OF EWMAN RESOURCES CHILD CARE HEALTH&SAFETY GUIDELINES DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Fac'i Date of Visit. Day C3tit�t3 i V►Y Chu Night ❑❑ / L`r�'r+t'r► Both ❑ -month 4 day /-year Fatility Addre �. Telephone#: �� Cs: Staff` l Staff in Charge(if Caps L d yY I night �nGY'1C;S0. U.v11(.-�J day I night SECTION B-DEFICIENCY INFORMATION cdrum„l Health&Safety Guidelines Corxw 2 Deficiency Date Corrected d INSTRUCTIONS TO PERSON IN CHARGE: Column 2 Date Corrected is to he completed by the facility representative after each defrdency is corrected The faeillty represenmtive must put the date of correction and his/her initials in Column 2. 77tis form must he returned to the Deparbneni of Human Resources on or before -�i . 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 andlor failure to correct the fisted 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 operate in compliance with Health&Safety Guidelines. Signature of facility Represenrarrve ��� i,)' C�fit.. Date Signature of DHR Representative a` Date `1 f}, COPIES TO: `� V�,,� >� � .� fj►t�,�� PageLof 1