Form FDACS-01926 "Summer Food Service Programs Sponsor Site Review" - Florida

What Is Form FDACS-01926?

This is a legal form that was released by the Florida Department of Agriculture and Consumer Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2018;
  • The latest edition provided by the Florida Department of Agriculture and Consumer Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form FDACS-01926 by clicking the link below or browse more documents and templates provided by the Florida Department of Agriculture and Consumer Services.

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Download Form FDACS-01926 "Summer Food Service Programs Sponsor Site Review" - Florida

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Florida Department of Agriculture and Consumer Services
Division of Food, Nutrition and Wellness
SUMMER FOOD SERVICE PROGRAMS
SPONSOR SITE REVIEW
NICOLE “NIKKI” FRIED
5P-3.002, F.A.C.
COMMISSIONER
Date:
Arrival Time:
Departure Time:
Sponsor Name:
Sponsor Number:
Site Name:
Site Number:
Site Phone Number:
Site Address:
City:
Zip:
Sponsor Monitor Name:
Approved Site Supervisor listed in FANS:
Alternate Site Supervisor listed in FANS (If applicable):
General Information
1. Type of Visit: Site Review_____ Follow-up Review_____
2. Food Preparation Type: Vended_____ Self-Preparation _____ Vended from Self-Preparation Central Kitchen _____
3. Eligibility Type: Open_____ Open Restricted_____ Closed Enrolled ______
Residential Camp_____ Nonresidential Camp_____
4. Period of Operation: Beginning Date_______________ Ending Date_______________
5. Is this site in close proximity (less than 0.25 miles) to another site? Yes ____________ No _____________
If Yes, what is the justification: ________________________________________________________________________
_________________________________________________________________________________________________
Is the justification confirmed? Yes _________ No __________
If No, what is the confirmed justification: _________________________________________________________________
_________________________________________________________________________________________________
6. Is this site designated as a day care in FANS? Yes _________ No __________
If Yes, is the daycare operating the CACFP during the summer? Yes _________ No __________
If Yes, does the site keep separate records for each program and serve different children? Yes _________ No __________
FDACS-01926 Rev. 06/18
Page 1 of 13
Florida Department of Agriculture and Consumer Services
Division of Food, Nutrition and Wellness
SUMMER FOOD SERVICE PROGRAMS
SPONSOR SITE REVIEW
NICOLE “NIKKI” FRIED
5P-3.002, F.A.C.
COMMISSIONER
Date:
Arrival Time:
Departure Time:
Sponsor Name:
Sponsor Number:
Site Name:
Site Number:
Site Phone Number:
Site Address:
City:
Zip:
Sponsor Monitor Name:
Approved Site Supervisor listed in FANS:
Alternate Site Supervisor listed in FANS (If applicable):
General Information
1. Type of Visit: Site Review_____ Follow-up Review_____
2. Food Preparation Type: Vended_____ Self-Preparation _____ Vended from Self-Preparation Central Kitchen _____
3. Eligibility Type: Open_____ Open Restricted_____ Closed Enrolled ______
Residential Camp_____ Nonresidential Camp_____
4. Period of Operation: Beginning Date_______________ Ending Date_______________
5. Is this site in close proximity (less than 0.25 miles) to another site? Yes ____________ No _____________
If Yes, what is the justification: ________________________________________________________________________
_________________________________________________________________________________________________
Is the justification confirmed? Yes _________ No __________
If No, what is the confirmed justification: _________________________________________________________________
_________________________________________________________________________________________________
6. Is this site designated as a day care in FANS? Yes _________ No __________
If Yes, is the daycare operating the CACFP during the summer? Yes _________ No __________
If Yes, does the site keep separate records for each program and serve different children? Yes _________ No __________
FDACS-01926 Rev. 06/18
Page 1 of 13
Meal Delivery/Preparation Observation
Yes
No
N/A
7. Does the site supervisor check all deliveries for completeness and spoilage?
8. Does the number of meals on the delivery receipt match the number received?
9. Does the site supervisor sign, date, and maintain a record of delivery receipts (5 days
minimum)?
10. Are sanitary procedures followed during the receiving, preparing, holding and serving of
meals?
11. Are the temperature requirements for potentially hazardous foods met at delivery?
(cold food ≤ 41°F and hot food ≥ 135°F)
12. Are the meals delivered or prepared within one hour of the meal service, or if not, were
adequate arrangements made to maintain proper temperatures?
13. Is food stored at proper temperatures? (cold food ≤ 41°F and hot food ≥ 135°F).
Meal Serving Times
Approved Serving Times
Actual Serving Times
Meal Service
14.
Observed
Begin Time
End Time
Begin Time
End Time
Breakfast
AM Snack
Lunch
PM Snack
Supper
Meal Components Served and Temperatures
Temperature (°F), if
Meal Components
Food Used
Serving Size
15.
applicable
Meat or Meat Alternate
Vegetables & Fruits
Vegetables & Fruits
Grains
Milk as a Beverage
Other foods
FDACS-01926 Rev. 06/18
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Meal Service Observation
Yes
No
N/A
16. Are all required components being served and are serving sizes meeting meal pattern
requirements?
17. If the site is using Offer Versus Serve, is it being implemented correctly?
18. Is the site using a tally sheet (i.e. daily meal count sheet) or a meal counting device?
19. Was the Site Supervisor on site during the entire meal service, including delivery and
clean up?
20. If the site is classified as an open or open-restricted eligibility type, are meals made
available to all children in the area on a first come, first serve basis?
Meal Count for Day of Review
Records Maintained
Monitor’s Counts
21.
Yes
No
N/A
Meals delivered or prepared
Meals leftover from previous day
+
Total meals available
=
First meals served
Second meals served
+
Total reimbursable meals
=
Program adult meals
Non-program adult meals
+
Other non-reimbursable meals
+
Unserved/ excess/ leftover meals
+
Total non-reimbursable meals
=
Disallowed Meals
Yes
No
22. Are any meals found to be ineligible? If Yes, indicate the number of ineligible meals by
reason below.
Reason
# of ineligible meals
If multiple reasons are shared, place an “X” in the # of ineligible meals box
N/A
Meals are being served to adults and counted as children’s meals.
N/A
Incomplete meals are being served (missing required components).
N/A
Deficient meals are being served (inadequate portion sizes).
N/A
Meals are not being served as a complete unit (note bulk meal waiver).
FDACS-01926 Rev. 06/18
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Disallowed Meals (Cont.)
Reason
# of ineligible meals
If multiple reasons are shared, place an “X” in the # of ineligible meals box.
N/A
More than one grain/bread, fruit or vegetable components is being consumed off site.
N/A
Meals are being served outside of the approved meal times.
N/A
The Site Supervisor is not present for the entire meal service.
N/A
The site is not using a tally sheet or a meal counting device.
Second meals are being served to a number of children before all children received their first
N/A
meal.
N/A
The site is counting second meals as first meals.
Meals are being delivered to the site more than one hour prior to the beginning of the meal
N/A
service, and there are no holding facilities to ensure adequate temperatures of hot and cold
meals.
Meals are being prepared or served that are inconsistent with temperatures required by state,
N/A
local health and safety regulations.
Meals are being served to infants one year or younger without prior approval from the state
N/A
agency.
N/A
Total meals disallowed
Site Recordkeeping
23.
Record the number of FIRST meals, of the same meal type, served on each of the five serving days prior to the day
of the review and calculate the average number of first meals served for days recorded:
Date
Total
st
Number of 1
Meals Served
Divide Total by # of Days Recorded = Average 1
st
Meals: ____________
st
Multiply the average 1
meals calculated above by 0.80 (80%): ____________
Are first meals on the day of review equal to or greater than this figure? YES_____ NO_____
If NO, note explanation for the decrease: ____________________________________________
FDACS-01926 Rev. 06/18
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Site Recordkeeping (cont
.)
24. Has the Site Supervisor received training in program requirements? Yes
No
25. Has the local health department visited the site yet this summer? Yes ______ No _______
If Yes, What is the date of the visit on the inspection form? _____________________
Please note any cited deficiencies and whether they have been corrected:
Civil Rights Data Collection
26. Review the site’s ethnic and racial data. Complete both charts below using numbers, not percentages.
Ethnicity (Total must be equal to the number of participating children)
Hispanic or Latino
Non-Hispanic or Latino
Total
Race (Total may be greater than or equal to number of participating children)
American Indian
Native Hawaiian
Black or African
or Alaskan
Asian
or Other Pacific
White
Total
American
Native
Islander
Civil Rights
Yes
No
27. Is the “And Justice For All” poster displayed in a prominent place for all to see?
28. Has staff been trained in Civil Rights?
FDACS-01926 Rev. 06/18
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