HomeMy WebLinkAboutDeficiency Form (23) DHR-DFC-1926
ALABAMA DEPARTMENT OF HUMAN RESOURCES
CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT
SECTION A-IDENTIFYING INFORMATION
Facility Name: Type of Facility: Home ❑ Date of Visit:
LITTLE PEOPLES NURSERY SCHOOL Day ❑x Group ❑
Night ❑ Center ® mth // - dIa�y // 4ear
Day/Night ❑ ❑Facility Address: Licensee: Telephone#:
509 ALABAMA STREET LITTLE PEOPLE'S 12561757-4498
KILLEN,AL 35645 NURSERY SCHOOL,
INC.
Ages: Director(if applicable): Capacity:
5 Weeks through 12 Years GAIL JOHNSON 37 - Day
SECTION B -DEFICIENCY INFORMATION
Column I Column 2
Minimum Standard Date Corrected by
Deficiency Licensee
UA
a a s
WA021. 1
INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee, is to be completed by the facility representative after
each deficiency is corrected. The facility representative must put the date of correction of d 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 Minimum Standards. A facility licensed by the.Department must meet Minimum Standards applicable to that facility at
all times. It is the responsibility of the licensee to operate in compliance with Minimum Standards.
r
Signature of Facility Representative MLA Date
Signature of DHR Licensing Representative Date
1
COPIES TO:
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