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HomeMy WebLinkAboutDeficiency Form Mar02 21 12:44p Adventurous Beginnings 2052215273 p.1 DNR DFC-1926 AL.ABAMA DEPARTMENT OF HUMAN RESOURCES CHMD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Facility: Home Q Date of Visit: {�,� Day ❑ Group 1] `'"'•"'v im Qu _ Night ❑ Center O � /� !�� `� �nLCk'z S.A.P. O month/ day`l year Facility Address.., Licensee: Telephone#: �-- 'y Ord. _v-'c�, AT ^� Director(Ifapplkable): Capacity: d / night Y1 - day l night SECTION B-DEFICIENCY INFORMATION C*fW,,,l Minimum Standard eolum2 Deficiency Date Corrected by Licensee INSTRUCTIONS TO LICENSEE: Column 2. Date Corrected by llcenree.Is to be completed by the faaafty representative after each defrcfency is corrected The fadifty representative must put the date of correction and his/her infilals in Column 2. nir form must be returrfed to die Department of Hrrrnan Resources on or before � v r , as verlflcallon that deftdeneies have been rnrracted %tHaxards must be corrected inrrnediately NOTICE: Any misleading or any false statements or'reports made to the Department and/or failure to correct the listed deficiencies can be the hasis for adverse action. None of these requirements are to be interpreted to allow anyone to operate in violation of i�1 nimum Stagdarl A facility licensed by the Department most meet�4finimam Standards appticabie to that facility at all bates. It is the responsibility of the Uceosee to operate in compliance with Minimum Standards. SI afore o f acffi Re resentative '1 ' �' �1#`�)9, Date ;xi- i I -?i Sri f• ,}' p �,�..,•. Signature of DHR Idwaksg Representative :` .r° Date v � COPIESTO: CC ,3f �' �'�,`��� •�p,Y.�� _ Page of