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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: �A4 Roo(C� Day Night 02 I ❑ �/ 0 J / Both ❑ month/ day / year Facility Address: Telephone#: VA,I,� �5 (��) 75 4g013 Ages: �✓pn Staff in Charge(if applicable): Capacity: \/ WN I / , o� / X day / ght day / night SECTION B -DEFICIENCY INFORMATION Column 1 Column 2 Health&Safety Guidelines Date Corrected Deficiency Q/ikj S LAI 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 ti 1 � C��