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 �
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