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

Adult Center Review Form (Administrative and Center Sponsor Use Only) - Child and Adult Care Food Program is a legal document that was released by the Georgia Department of Early Care and Learning - a government authority operating within Georgia (United States).

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CHILD AND ADULT CARE FOOD PROGRAM
ADULT CENTER REVIEW FORM
(Administrative and Center Sponsor Use Only)
st
nd
rd
Unannounced:  YES
1
2
3
NO
Date of Review:
Visit
Arrival Time:
Departure Time:
Reviewer:
Institution Information
Name of Center:
Telephone #:
Address:
# Enrolled:
Non-profit
Eligibility Method:
County:
Profit
Medicaid or Medicaid Waiver Program
State Funded and Operated Facility
Recipient
Approval Type:
Indicate Authority below:
Approval granted by
Federal/State/Local Authority
Breakfast
PM Snack
Approved Meal Type(s):
AM Snack
Supper
Lunch
Evening Snack
Approval to Participate in CACFP
YES
NO
N/A
1) Is there verification on file documenting the approval to operate from a federal, state, or local
authority?
2) Is the approval documentation from a federal, state, or local authority current and/or valid?
3) Is there documentation to support the center receives funds from the Medicaid Program?
4) If the center is state funded/operated, are the workers state employees?
Civil Rights
YES
NO
N/A
5) Is the “And Justice for All” poster on display in a conspicuous location?
6) Are admission placement procedures nondiscriminatory?
7) Does the facility allow equal access and serve meals equally to all attending participants
regardless of their race, color, national origin, sex, age, or disability?
8) Is ethnic and racial data collected annually and maintained by the center?
Participant Information
YES
NO
N/A
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)?
11) Does the center have enrollment records indicating the age of each adult?
12) Does the center offer services to functionally impaired adults?
13) Are the functionally impaired adults age 18 years or older?
14) Are those adults who are not functionally impaired, age 60 or older?
15) Is there an Individual Plan of Care on file for adults determined functionally impaired?
16) Does the center have records that indicate that adult participants reside in their own home or
group living arrangements (in group living arrangements they must be primarily responsible
for themselves)?
17) Does the center provide care for participants less than 24 hours?
18) Does the center have documentation that support that it provides a comprehensive program
that offers a variety of health, social and related support services to enrolled adults?
Page 1 of 5
Sponsoring Organization Center Review Form (Rev. 6/2018)
CHILD AND ADULT CARE FOOD PROGRAM
ADULT CENTER REVIEW FORM
(Administrative and Center Sponsor Use Only)
st
nd
rd
Unannounced:  YES
1
2
3
NO
Date of Review:
Visit
Arrival Time:
Departure Time:
Reviewer:
Institution Information
Name of Center:
Telephone #:
Address:
# Enrolled:
Non-profit
Eligibility Method:
County:
Profit
Medicaid or Medicaid Waiver Program
State Funded and Operated Facility
Recipient
Approval Type:
Indicate Authority below:
Approval granted by
Federal/State/Local Authority
Breakfast
PM Snack
Approved Meal Type(s):
AM Snack
Supper
Lunch
Evening Snack
Approval to Participate in CACFP
YES
NO
N/A
1) Is there verification on file documenting the approval to operate from a federal, state, or local
authority?
2) Is the approval documentation from a federal, state, or local authority current and/or valid?
3) Is there documentation to support the center receives funds from the Medicaid Program?
4) If the center is state funded/operated, are the workers state employees?
Civil Rights
YES
NO
N/A
5) Is the “And Justice for All” poster on display in a conspicuous location?
6) Are admission placement procedures nondiscriminatory?
7) Does the facility allow equal access and serve meals equally to all attending participants
regardless of their race, color, national origin, sex, age, or disability?
8) Is ethnic and racial data collected annually and maintained by the center?
Participant Information
YES
NO
N/A
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)?
11) Does the center have enrollment records indicating the age of each adult?
12) Does the center offer services to functionally impaired adults?
13) Are the functionally impaired adults age 18 years or older?
14) Are those adults who are not functionally impaired, age 60 or older?
15) Is there an Individual Plan of Care on file for adults determined functionally impaired?
16) Does the center have records that indicate that adult participants reside in their own home or
group living arrangements (in group living arrangements they must be primarily responsible
for themselves)?
17) Does the center provide care for participants less than 24 hours?
18) Does the center have documentation that support that it provides a comprehensive program
that offers a variety of health, social and related support services to enrolled adults?
Page 1 of 5
Sponsoring Organization Center Review Form (Rev. 6/2018)
19) If the center operates multiple programs for which participants are not eligible for CACFP
meals, does the center have a process in place to determine which meal recipients are
CACFP eligible and that meals are claimed for only eligible participants’ meals?
Claim for Reimbursement Verification
YES
NO
N/A
20) Is the “Weekly Menu & Food Service Record” form used and up-to-date for all meals for the
current month?
21) Is the number of participants in care according to attendance and enrollment records for the
five-days reviewed comparable to the number of meals claimed? (Use the Meal Count
Reconciliation Page to document the number of participants in care according to attendance
records)
22) Are meals claimed only for participants who are within regulatory age limits?
23) Are meals claimed only for those eligible adults that are enrolled for comprehensive care?
Recordkeeping
YES
NO
N/A
24) 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)
25) 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?
26) Are receipts and supporting documentation available to support both operating and
administrative costs charged to the CACFP?
27) 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?
28) Are all costs charged to the CACFP allowable costs?
29) Are shared costs prorated appropriately so that CACFP is charged only for the portion used?
30) 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
31) Has key center staff attended the sponsoring organization’s CACFP training within the last 12
months?
32) Has the center implemented ideas/information provided during training?
Other Requirements
YES
NO
N/A
33) Does the center have program guidance materials issued by the sponsor available for
reference? (TA)
34) Has effective action been achieved for all problem(s) noted during the last review?
Food Handling/Sanitation and Food Storage
YES
NO
N/A
35) Are disposable items discarded after each use?
36) Is the food service equipment free of dirt, dust, food, grease deposits and odor?
37) Is there evidence of good personal hygiene practices?
38) Is the food safely transferred from the kitchen/cafeteria to the classroom?
Observations:
39) Is a thermometer in use in refrigerator and freezer?
0
0
40) Is the refrigeration kept at 41
degrees or below and the freezer temperature at zero (0
)
degrees or below?
41) Is potentially hazardous food properly thawed?
Method used:
42) Does food appear to be in sound condition with no evidence of spoilage?
43) Is all food stored at least 6 inches above the floor?
44) Are storage areas and containers adequate to maintain food in sound condition?
45) Is food stored separately from cleaning items and other toxic material?
46) Are uncooked items, which are removed from original labeled package, which are in
refrigerator/freezer covered/sealed, labeled and dated?
47) Are leftovers properly labeled?
48) Are trash containers covered?
Page 2 of 5
Sponsoring Organization Center Review Form (Rev. 6/2018)
49) Is the kitchen free of obvious fire, health and/or safety hazards?
50) Is food service conducted in compliance with generally accepted health and sanitation
practices (Staff refrains from use of tobacco products and use hair restraints)?
51) Are dishes sanitized correctly?
Method used:
52) Is the center free of rodent or insect infestation?
OBSERVATION OF MEAL SERVICE
Record the food items served and serving sizes for all meals applicable.
Indicate the Meal Type
Indicate the number of
Observed:
participants served:
Meal Components
Food Item
Serving Size
1,2,3
Milk
Meat/Meat Alternates
4
Fruit
Vegetable
 WGR
5
Grains
At least one daily serving of grains must
be served whole grain-rich (WGR)
Other
1
Unflavored low-fat, unflavored or flavored fat-free
2
Yogurt may be used to meet the equivalent of 8
ounces of fluid milk once per day when yogurt is not
served as a meat alternate in the same meal.
3
Fluid milk is optional for supper served to adults.
4
Fruit Juice is limited to once per day
5
Grain-based desserts no longer count towards the
grain component
Meal Service for Date of Review
YES
NO
N/A
53) Does the posted menu correspond to the meal observed? (TA)
54) Are all components of the meal served on this date creditable?
55) Was today’s meal served in appropriate quantities?
56) Was an accurate meal count taken at the point of service on the date of visit?
57) Was an accurate, daily meal count taken for program and non-program adults?
58) Does the observed meal provide a variety of colors, temperatures, textures, shapes, sizes,
and flavors? (TA)
59) Does the meal service occur in a positive/pleasant environment? (TA)
60) Are medical statements on file for all substitutions related to medical, special dietary, or
religious needs?
61) If implementing Offer vs. Serve, is the center accurately applying this option?
62) 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?
b) If the answer to the previous
question is yes, please list the
explanation.
Most items answered as “NO” will require a finding and corrective action. Some items answered as a
“NO” will only require technical assistance. Both should be documented on the Summary of Findings
– page 5. Separate technical assistance items from the findings at the bottom of the form.
Page 3 of 5
Sponsoring Organization Center Review Form (Rev. 6/2018)
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. Record these numbers according to these records. Record the facility meal
counts documented on the Weekly Menu and Food Service Record. Attach the Weekly Menu and Food Service Records and
the attendance records for the five days reviewed to this form.
Date
Breakfast Meal Service
# of Adults in
# of Adults
# of Adults Claimed
Attendance
Enrolled
for Reimbursement
1
2
3
4
5
Date
AM Snack Meal Service
# of Adults in
# of Adults
# of Adults Claimed
Attendance
Enrolled
for Reimbursement
1
2
3
4
5
Date
Lunch Meal Service
# of Adults in
# of Adults
# of Adults Claimed
Attendance
Enrolled
for Reimbursement
1
2
3
4
5
Date
PM Snack Meal Service
# of Adults in
# of Adults
# of Adults Claimed
Attendance
Enrolled
for Reimbursement
1
2
3
4
5
Date
Supper Meal Service
# of Adults in
# of Adults
# of Adults Claimed
Attendance
Enrolled
for Reimbursement
1
2
3
4
5
Page 4 of 5
Sponsoring Organization Center Review Form (Rev. 6/2018)
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-
Date
Item #
Due Date
up
Corrected
Visit
Date
Center Staff Signature:
Date:
Reviewer Signature:
Date:
Page 5 of 5
Sponsoring Organization Center Review Form (Revised 12/2014)
Page of 5