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HomeMy WebLinkAboutDeficiency Form (21) ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type of Facility: Date of Visit: II-- Day IV ,2 �Q� Night ❑ y /)_/ Z I �0 Both El month/ day / year Facility Address: Telephone#: Ages: Staff in Charge(rf applicable): Capacity: was • 3� / y _ day / night day / night SECTION B-DEFICIENCY INFORMATION Column 1 Health&Safety Guidelines Column 2Date Corrected Deficiency 01 cc tk IIV�� Ilk (Y,,-LA- ti e`T 1 Gi v y INSTRUCTIONS TO PERSON IN CHARGE: Column 2, Date Corrected is to be completed by the facility representative after each deficiency is corrected. The facility representative must put the date o correction and hisArer initials in Column 2. This form must be returned to the Department of Human Resources on or before� , as verification that deficiencies have been corrected. 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 operate in compliance with Health&Safety Guidelines. Signature of Facility Representative 6 Date Z Signature of DHR Representative Date f 0 COPIES TO: Page 1 of�