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
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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