 - Child and Adult Care Food Program - Georgia (United States) Download Pdf){kind=small}
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5CHILD AND ADULT CARE FOOD PROGRAM
CHILD CARE CENTER REVIEW FORM
(Administrative and Center Sponsor Use Only)
st
nd
rd
Unannounced: YES
1
2
3
Date of Review:
Visit
NO
Arrival Time:
Departure Time:
Reviewer:
Sponsoring Org. Name:
Name of Center:
Licensed Capacity:
Address:
# Enrolled:
# Present on date of
visit:
County:
Eligibility Method:
Non-profit
Profit
Child Care Center
At Risk After School Care Program
Program Type:
Head Start
Emergency Shelter
(Check all applicable)
Outside School Hours Care
Licensing or Approval Type
Licensing Type:
Bright from the Start (DECAL)
Department of Defense (DOD)
Other Federal, State, or local authority
Approval Type:
Head Start Performance Standards
Indicate approving
authority:
Exempt from licensure/approval per CACFP
Alternate Licensure:
CACFP Child Care Standards
regulations
(At Risk, Outside School Hours, and
(
Emergency/Homeless shelters only)
Applicable to child care centers only)
Meal Types
Breakfast
PM Snack
Approved Meal
AM Snack
Supper
Type(s):
Lunch
Evening Snack
License
YES
NO
N/A
1) Is the center at or within licensed capacity at the time of the review?
2) If a Federal/State/Local Authority approved the center, is there verification of the approval
on file? (Not applicable to At Risk, Outside School Hours, or Emergency shelters)
3) If the CACFP Childcare Standards were used to meet the alternate licensure requirements,
does the center meet all of the standards?
a) Does the center have a copy of the food permit/food inspection and the certificate of
occupancy on file?
Civil Rights
YES
NO
N/A
4) Is the “And Justice for All” poster on display in a conspicuous location?
5) Are admission placement procedures nondiscriminatory?
6) Is there any separation by race, color, national origin, sex, age, or disability?
7) Is ethnic and racial data collected annually and maintained by the center?
Participant Information
YES
NO
N/A
8) Is current WIC information distributed to participant households (child care centers
excluding after school programs) per 7 CFR 226.15(n)?
9) Is the Building for the Future Flyer or applicable sponsor notice that contains the required
information distributed to participant’s households to inform them of the facility’s
participation in the CACFP per 7 CFR 226.16(b)(5)?
10) Is the site applying the approved free and reduced-price policy statement correctly?
(Pricing programs only)
Page 1 of 5
Sponsoring Organization Child Care Center Review Form (Revised 06/2018)
CHILD AND ADULT CARE FOOD PROGRAM
CHILD CARE CENTER REVIEW FORM
(Administrative and Center Sponsor Use Only)
st
nd
rd
Unannounced: YES
1
2
3
Date of Review:
Visit
NO
Arrival Time:
Departure Time:
Reviewer:
Sponsoring Org. Name:
Name of Center:
Licensed Capacity:
Address:
# Enrolled:
# Present on date of
visit:
County:
Eligibility Method:
Non-profit
Profit
Child Care Center
At Risk After School Care Program
Program Type:
Head Start
Emergency Shelter
(Check all applicable)
Outside School Hours Care
Licensing or Approval Type
Licensing Type:
Bright from the Start (DECAL)
Department of Defense (DOD)
Other Federal, State, or local authority
Approval Type:
Head Start Performance Standards
Indicate approving
authority:
Exempt from licensure/approval per CACFP
Alternate Licensure:
CACFP Child Care Standards
regulations
(At Risk, Outside School Hours, and
(
Emergency/Homeless shelters only)
Applicable to child care centers only)
Meal Types
Breakfast
PM Snack
Approved Meal
AM Snack
Supper
Type(s):
Lunch
Evening Snack
License
YES
NO
N/A
1) Is the center at or within licensed capacity at the time of the review?
2) If a Federal/State/Local Authority approved the center, is there verification of the approval
on file? (Not applicable to At Risk, Outside School Hours, or Emergency shelters)
3) If the CACFP Childcare Standards were used to meet the alternate licensure requirements,
does the center meet all of the standards?
a) Does the center have a copy of the food permit/food inspection and the certificate of
occupancy on file?
Civil Rights
YES
NO
N/A
4) Is the “And Justice for All” poster on display in a conspicuous location?
5) Are admission placement procedures nondiscriminatory?
6) Is there any separation by race, color, national origin, sex, age, or disability?
7) Is ethnic and racial data collected annually and maintained by the center?
Participant Information
YES
NO
N/A
8) Is current WIC information distributed to participant households (child care centers
excluding after school programs) per 7 CFR 226.15(n)?
9) Is the Building for the Future Flyer or applicable sponsor notice that contains the required
information distributed to participant’s households to inform them of the facility’s
participation in the CACFP per 7 CFR 226.16(b)(5)?
10) Is the site applying the approved free and reduced-price policy statement correctly?
(Pricing programs only)
Page 1 of 5
Sponsoring Organization Child Care Center Review Form (Revised 06/2018)
Claim for Reimbursement Verification
YES
NO
N/A
11) Are meals claimed only for enrolled participants?
12) Is the number of participants in care according to enrollment and attendance records for
the five-days reviewed comparable to the number of meals claimed? (Use the Meal Count
Reconciliation Page to document.)
13) Are meals claimed only for participants who are within regulatory age limits?
At Risk After School Care Snack Centers
YES
NO
N/A
14) Are enrichment or educational activities being offered during the At-Risk Program?
Document the activities
being conducted during
the visit:
Recordkeeping
YES
NO
N/A
15) Are annually updated enrollment forms on file for participants per 7 CFR 226.15(e)(2)?
16) Is the “Weekly Menu & Food Service Record” form used and up-to-date for all meals for
the current month?
17) Are records given to the sponsoring organization on a regular basis as provided for in the
agreement between the sponsoring organization and the center? (TA)
18) Does the center maintain all program records for three years after the date of submission of
the final claim for reimbursement for the fiscal year to which they pertain, or if an audit is
outstanding, until the audit is closed?
19) Are receipts and supporting documentation available to support both operating and
administrative costs charged to the CACFP?
20) Do the administrative costs claimed by the facility and the administrative fee charged by
the sponsor equal no more than 15% of the center’s monthly reimbursement?
21) Are all costs charged to the CACFP allowable costs?
22) Are shared costs prorated appropriately so that CACFP is charged only for the portion
used?
23) Are the following documents available to support labor costs charged to CACFP?
a) Time and attendance reports for all labor costs charged to the CACFP or combination
of forms based on Bright from the Start Labor Costs Policy Memo dated 5/23/05?
b) Time distribution reports for all labor costs charged or combination of forms based on
Bright from the Start Labor Costs Policy Memo dated 5/23/05?
Training
YES
NO
N/A
24) Has key center staff attended the sponsoring organization’s CACFP training within the last
12 months?
25) Has the center implemented ideas/information provided during training?
Other Requirements
YES
NO
N/A
26) Does the center have program guidance materials issued by the sponsor available for
reference? (TA)
27) Has effective action been achieved for all problem(s) noted during the last review?
Food Handling/Sanitation and Food Storage
YES
NO
N/A
28) Are disposable items discarded after each use?
29) Is the food service equipment free of dirt, dust, food, grease deposits and odor?
30) Is there evidence of good personal hygiene practices?
31) Is the food safely transferred from the kitchen/cafeteria to the classroom?
Observations:
32) Is a thermometer in use in refrigerator and freezer?
0
33) Is the refrigeration kept at 41
F degrees or below and the freezer temperature at zero
0
degrees (0
F) or below?
34) Is potentially hazardous food properly thawed?
Method used:
35) Does food appear to be in sound condition with no evidence of spoilage?
36) Is all food stored at least 6 inches above the floor?
37) Are storage areas and containers adequate to maintain food in sound condition?
38) Is food stored separately from cleaning items and other toxic material?
39) Are uncooked items, which are removed from original labeled package, which are in
refrigerator/freezer covered/sealed, labeled and dated?
40) Are leftovers properly labeled?
41) Are trash containers covered?
Page 2 of 5
Sponsoring Organization Child Care Center Review Form (Revised 06/2018)
42) Is the kitchen free of obvious fire, health and/or safety hazards?
43) Is food service conducted in compliance with generally accepted health and sanitation
practices (Staff refrains from use of tobacco products and use hair restraints)?
44) Are dishes sanitized correctly?
Method used:
45) Is the center free of rodent or insect infestation?
OBSERVATION OF MEAL SERVICE
Record the meal type observed, the total number of participants and food items served and the serving sizes for all
meals including infant meals, if applicable.
Indicate Meal Type
Infants
1-12 Yrs.
At Risk
Total Number of Participants
Observed:
Served on Date of Review:
Meal Components
Food Item
Serving Size
1 yrs.
2-5 yrs.
6-12 yrs.
At Risk
Fluid Milk
Meat/Meat Alternatives
Fruit
Vegetable
Grains
At least one serving a day must be WGR
Infants
Food Item / Serving Size
Meal Components
Birth through 5 Months
6 through 11 Months
Iron fortified Formula or
Breast Milk
Infant Cereal, Meat, Fish,
Poultry, Whole Egg, Cooked
Dry Beans or Peas, Yogurt,
Cottage Cheese or
Combination of the above.
Vegetable or Fruit or
Combination of Both
Sliced Bread or Crackers,
Infant Cereal, Ready-to-Eat
Cereal (Snack Only)
Meal Service for Date of Review
YES
NO
N/A
46) Does the posted menu correspond to the meal observed? (TA)
47) Are all components of the meal served on this date creditable?
48) Is unflavored low-fat or fat-free milk being served to children 2 through 5 years old; and
unflavored low-fat, unflavored fat-free, or flavored fat-free milk being served to children 6
years old and older? Children between 1 year and up to age 2 must be served whole-milk.
49) Was today’s meal served in appropriate quantities?
50) Was an accurate meal count taken at the point of service on the date of visit?
51) Was an accurate, daily meal count taken for program and non-program adults?
52) Does the observed meal provide a variety of colors, temperatures, textures, shapes, sizes,
and flavors? (TA)
53) Does the meal service occur in a positive/pleasant environment? (TA)
54) Does the center offer infant formula to applicable program participants?
55) Are only infant meals claimed that meet the USDA CACFP requirements?
56) Are medical statements on file for all substitutions related to medical, special dietary, or
religious needs?
57) Is potable drinking water being made available to children?
58) Is the number of participants in care at the time of the meal service consistent with the
number of participants being claimed for the previous five operating days?
a) If the answer to the previous question is no, can the Center Contact provide a valid and
reasonable explanation for the discrepancy? (Household Contacts may be required.)
b)
If the answer to the previous question is
yes, please list the explanation.
Page 3 of 5
Sponsoring Organization Child Care Center Review Form (Revised 06/2018)
MEAL COUNT RECONCILIATION
For the current or prior claiming period, for any five consecutive days, determine the number of participants in care
according to attendance and enrollment records. For At-Risk, Outside School Hours, and Emergency shelters which are not
required to maintain enrollment records, conduct reconciliation using attendance only. Record these numbers according to
these records. Record the facility meal counts documented on the Daily Menu and Food Service Record. Attach the Daily
Menu and Food Service Records and the attendance records for the five days reviewed to this form.
Breakfast Meal Service
Number according to attendance/enrollment
Meal Counts Documented by Facility
Date
1-12 yrs.
Infants
At Risk
1-12 yrs.
Infants
At Risk
/
/
/
/
/
/
/
/
/
/
AM Snack Service
Number according to attendance/enrollment
Meal Counts Documented by Facility
Date
1-12 yrs.
Infants
At Risk
1-12 yrs.
Infants
At Risk
/
/
/
/
/
/
/
/
/
/
Lunch Meal Service
Number according to attendance/enrollment
Meal Counts Documented by Facility
Date
1-12 yrs.
Infants
At Risk
1-12 yrs.
Infants
At Risk
/
/
/
/
/
/
/
/
/
/
PM Snack Service
Number according to attendance/enrollment
Meal Counts Documented by Facility
Date
1-12 yrs.
Infants
At Risk
1-12 yrs.
Infants
At Risk
/
/
/
/
/
/
/
/
/
/
Supper Meal Service
Number according to attendance/enrollment
Meal Counts Documented by Facility
Date
1-12 yrs.
Infants
At Risk
1-12 yrs.
Infants
At Risk
/
/
/
/
/
/
/
/
/
/
Evening Meal Service
Number according to attendance/enrollment
Meal Counts Documented by Facility
Date
1-12 yrs.
Infants
At Risk
1-12 yrs.
Infants
At Risk
/
/
/
/
/
/
/
/
/
/
Page 4 of 5
Sponsoring Organization Child Care Center Review Form (Revised 06/2018)
CHILD AND ADULT CARE FOOD PROGRAM
Center Name:
CENTER REVIEW FORM
Summary of Findings
Review
Brief Description of Finding
Corrective Action (C.A.) Needed
C.A.
Follow- up
Date
Item #
Due Date
Visit Date
Corrected
Center Staff Signature:
Date:
Reviewer Signature:
Date:
Page 5 of 5
Sponsoring Organization Center Review Form (Revised 06/2018)
 - Child and Adult Care Food Program - Georgia (United States).&description=Fill out, print and use this and thousands of other free templates at templateroller.com.&screenshot=https://data.templateroller.com/pdf_docs_html/1801/18016/1801603/child-care-center-review-form-administrative-and-center-sponsor-use-only-child-and-adult-care-food-program-georgia-united-states_big.png&pubid=ra-5bab7ed006800266&ct=1)
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