"Monitoring Review Form for Family Child Care Learning Home (Day Care Home) Provider - Child and Adult Care Food Program" - Georgia (United States)

Monitoring Review Form for Family Child Care Learning Home (Day Care Home) Provider - 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).

Form Details:

  • Released on January 1, 2018;
  • The latest edition currently provided by the Georgia Department of Early Care and Learning;
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Download "Monitoring Review Form for Family Child Care Learning Home (Day Care Home) Provider - Child and Adult Care Food Program" - Georgia (United States)

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CHILD AND ADULT CARE FOOD PROGRAM
MONITORING REVIEW FORM FOR
FAMILY CHILD CARE LEARNING HOME (DAY CARE HOME) PROVIDER
Review Unannounced
Date of Review:_________________
Arrival Time:
Departure Time: _______
1. Name of Sponsor:
Sponsor Agreement Number:
2. Name of Provider:
Address:
Telephone Number:
Tier I
Tier II
3. Reviewer(s):
Tier II with Income Eligibility Applications
Group DCH
4.
Family Child Care Learning Home (DCH)
Child Care Learning Center (
)
Approved License Capacity: ________ License #_________Date of Last Inspection: ______ Expiration Date: ___________
# of children in care: ________ Subsidy Verification from CAPS: Form 58 Form 59 Form 62
Informal Provider:
5.
Home Operations and Attendance.
Holiday Care:
Check Normal Days of Care:  Monday-Friday
Normal Hours of Operation:
 Yes
 No
 Sun.  Mon. Tues. Wed. Thurs.  Fri.  Sat.
Multiple Shifts
____ AM - _____ PM
 Yes
 No
Approved Meal
 Breakfast
 AM Snack
 Lunch
 PM Snack
 Supper
Types:
ATTENDANCE AND ELIGIBILITY DATA
For
Full Name of All Children listed
Child in
Enrollment
Indicate
Meal
Meal
Pay
Attendance?
Form on
Relationship to
Participant
Claimed
on the Roster from all shifts
Age
file?
Provider
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Page 1 of 8
Rev’d 1/2018
CHILD AND ADULT CARE FOOD PROGRAM
MONITORING REVIEW FORM FOR
FAMILY CHILD CARE LEARNING HOME (DAY CARE HOME) PROVIDER
Review Unannounced
Date of Review:_________________
Arrival Time:
Departure Time: _______
1. Name of Sponsor:
Sponsor Agreement Number:
2. Name of Provider:
Address:
Telephone Number:
Tier I
Tier II
3. Reviewer(s):
Tier II with Income Eligibility Applications
Group DCH
4.
Family Child Care Learning Home (DCH)
Child Care Learning Center (
)
Approved License Capacity: ________ License #_________Date of Last Inspection: ______ Expiration Date: ___________
# of children in care: ________ Subsidy Verification from CAPS: Form 58 Form 59 Form 62
Informal Provider:
5.
Home Operations and Attendance.
Holiday Care:
Check Normal Days of Care:  Monday-Friday
Normal Hours of Operation:
 Yes
 No
 Sun.  Mon. Tues. Wed. Thurs.  Fri.  Sat.
Multiple Shifts
____ AM - _____ PM
 Yes
 No
Approved Meal
 Breakfast
 AM Snack
 Lunch
 PM Snack
 Supper
Types:
ATTENDANCE AND ELIGIBILITY DATA
For
Full Name of All Children listed
Child in
Enrollment
Indicate
Meal
Meal
Pay
Attendance?
Form on
Relationship to
Participant
Claimed
on the Roster from all shifts
Age
file?
Provider
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Page 1 of 8
Rev’d 1/2018
LICENSING REQUIREMENTS
YES
NO
N/A
COMMENTS
Is the Provider’s license current/valid at the time of the visit?
6)
7)
Does the Provider meet license capacity at the time of the visit?
Does the Provider have more than 12 total children, under the
age of 13, in care at one time?
8)
Does the Provider have more than six (6) unrelated children in
care for pay at one time; regardless of relationship to the
Provider?
9)
Does the Family (Group) Child Care Learning Home Provider
have documentation on file for those children in care for no pay?
10) Does the Provider have written approval from DECAL’s CCS
Unit to care for an additional two (2) unrelated children, for pay
or not for pay, for up to two (2) hours per day?
11) If an Informal Provider, are there no more than six (6) related
children in care for pay or not for pay? If there is a combination
of unrelated and related children in care, does the Informal
Provider meet the capacity requirements?
12) If an Informal Provider, are there no more than two (2) unrelated
children for pay in care at one time?
If an Informal Provider, are the following requirements met:
At least 21 years of age?
Have a successful CRC on file?
Eight (8) hours of approved training on Health and Safety?
Have CPR certification on file or within six months of
approval?
Have a recent successful home inspection by CCS?
Have a working fire extinguisher and smoke detector where
children are cared located?
PARTICIPANT ELIGIBILITY/ MEAL COUNTS
YES
NO
N/A
COMMENTS
13) Are the meals only served to children who meet age
requirements claimed for reimbursement?
14) Are meals served to the Provider’s own children or foster
children in the Provider’s care? If so, are the meals/snacks
claimed for reimbursement when the following requirements
met:
When the Provider’s own or foster child(ren)
are enrolled for care?
When the Provider’s own or foster child(ren)
meet eligibility requirements?
When other enrolled children are present and
participating in the meal service?
15) Are the meals counts recorded on DCH Weekly Meal Count
Record, or an approved alternate form?
16) Are meal counts consistent with enrollment and attendance for
children in care? (Use the Meal Reconciliation page to document
the number of participants in care according to attendance
records)
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Rev’d 1/2018
CIVIL RIGHTS
YES
NO
N/A
COMMENTS
17) Based on observation, does the Provider allow all children equal
access to childcare services and facilities regardless of race,
color, sex, age, disability or national origin?
18) Does the Provider serve meals to all enrolled children equally
regardless of the child’s race, color, sex, age, disability or
national origin?
19) Is current racial/ethnic data collected annually and maintained on
file by the Provider?
HEALTH/SAFETY/SANITATION
YES
NO
N/A
COMMENTS
20) Are the refrigeration and freezer units clean and maintained at
required temperatures? (40 and 0 degrees respectively)
Indicate the refrigerator temperature.
Refrigerator Temp: _____ Freezer Temp: ______
Indicate the freezer temperature.
21) Is food properly thawed?
Method Used? _______________________________________
22) Is food properly stored in refrigeration/freezer units and in dry
areas:
Are storage areas adequate?
Is all food off the floor?
Is food stored separately from cleaning items and other toxic
materials?
23) Are trash containers covered?
24) Are wiping cloths clean and replaced often?
25) Is the home free of rodent or insect infestation?
26) Is the home free from any obvious fire, health and/or safety
hazards?
27) Is food service conducted in compliance with generally accepted
health and sanitation practices?
28) Does the Provider and children wash hands prior to food
handling and eating?
TRAINING
YES
NO
N/A
COMMENTS
29) Has the Provider attended the sponsor’s training within the last
twelve months?
30) Has the Provider implemented the information provided at
training?
31) If an Informal Provider, is there written record of completing the
required Child Care and Parent Services (CAPS) 8-hour training?
RECORDINGKEEPING
YES
NO
N/A
COMMENTS
32) Is the monthly menu posted in accordance with DECAL’s Child
Care Services requirements?
33) Are all meals and snacks on the monthly menu creditable?
34) Are annually updated enrollment forms, with parent signature
and date, on file for all participants?
35) Does the Provider have copies of previous monitoring reports in
her/his files?
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Rev’d 1/2018
36) Does the provider have notification of reimbursement options,
Tier I or Tier II, on file?
37) Does the provider have a copy of the current sponsor/provider
agreement on file?
PARTICIPANT INFORMATION
YES
NO
N/A
COMMENTS
38) Is current WIC information distributed to participant households
per 7 CFR 226.15(n)?
39) Is the Building for the Future Flyer or applicable sponsor notice
that contains the required information distributed to participant
households to inform them of the facilities’ participation in the
CACFP per 7 CFR 226.16(b)(5)?
OTHER REQUIREMENTS
YES
NO
N/A
COMMENTS
40) Has effective corrective action been implemented for all findings
identified in the previous review?
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Rev’d 1/2018
OBSERVATION OF MEAL SERVICE
41) Record the meal/snack type observed, the total number of participants in attendance at the meal service, food items served, and
the total number of meal/snacks served to children in care, including infant meals, if applicable.
Meal/Snack Type Observed:
Total Number of Participants
1-12 yrs.
Infants
Enrolled on Date of Visit:
Meal/Snack Time:
1-12 yrs.
Meal Components
Food Item
Number of Meals/Snacks Served
1 yr.
2-5 yrs.
6-12 yrs.
Milk
Meat/Meat Alternate
Fruit
Vegetable
Grain (whole grain required once
WG
per day)
Infants
Meal Components
Food Item
Number Meals/Snacks Served
Birth - 5 Months
6-11 Months
Iron-fortified Formula/Breast Milk
Infant Cereal, Bread, Crackers
Fruit/Vegetable
Meat/Meat Alternate
Sliced Bread or Crackers
Observed Meal Service on Date of Review
YES
NO
N/A
COMMENTS
42) Was the meal/snack served at the approved, scheduled time?
a) If “NO”, does the provider have documentation that the sponsor was
notified of the change?
43) Are items served consistent with the posted menu?
44) Does the meal/snack observed contain all required components?
45) Was unflavored whole milk served to children ages 1 yr. and up to 2 years old?
46) Was unflavored low-fat or fat-free milk served to children ages 2-5?
47) Was unflavored low fat or flavored or unflavored fat-free milk served to
children ages 6 or older?
48) Were the required serving sizes for each component/food items prepared,
available and served?
49) Does the observed meal/snack provide a variety of colors, temperatures,
textures, shapes, sizes and flavor?
50) Does the meal service occur in a positive/pleasant environment?
51) Are medical statements on file for all substitutions related to disabilities or
medical needs?
52) Is at least one component of the infant meal pattern supplied by the provider for
claimed infant meals?
53) 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?
Describe required corrective action for any item that was answered as a “NO” on the Summary of Findings – page
Page 5 of 8
Rev’d 1/2018
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