Georgia (United States) Child Care Center Review Form (Administrative and Center Sponsor Use Only) - Child and Adult Care Food Program Download Printable PDF

CHILD AND ADULT CARE FOOD PROGRAM

CHILD CARE CENTER REVIEW FORM

(Administrative and Center Sponsor Use Only)

Unannounced:  YES

Date of Review:

Visit

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

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

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

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)

Unannounced:  YES

Date of Review:

Visit

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

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

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

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

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

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

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

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

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

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?

33) Is the refrigeration kept at 41

F degrees or below and the freezer temperature at zero

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

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.)

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 Care Center Review Form (Administrative and Center Sponsor Use Only) - Child and Adult Care Food Program" - Georgia (United States)

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