HomeMy WebLinkAboutDeficiency Form (22) ALABAMA DEPARTMENT OF HUMAN RESOURCES
CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT
SECTION A-IDENTIFYING INFORMATION
Facility Name: Type of Facility: Date of Visit:
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❑ �/ 0 J /
Both ❑ month/ day / year
Facility Address: Telephone#:
VA,I,� �5 (��) 75 4g013
Ages:
�✓pn Staff in Charge(if applicable): Capacity: \/
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day / ght day / night
SECTION B -DEFICIENCY INFORMATION
Column 1 Column 2
Health&Safety Guidelines Date Corrected
Deficiency
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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 of come tin and his/her 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.
1
Signature of Facility Representative L4U
(�Date I — Ca l ~ 1
Signature of DHR Representative T Date
COPIES TO: Page 1 of
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