"Family Child Care Learning Home (Fcclh) Monitoring Form" - Georgia (United States)

Family Child Care Learning Home (Fcclh) Monitoring Form 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 April 1, 2020;
  • The latest edition currently provided by the Georgia Department of Early Care and Learning;
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CHILD AND ADULT CARE FOOD PROGRAM
FAMILY CHILD CARE LEARNING HOME (FCCLH) MONITORING FORM
Date of Review:
Arrival Time:
AM/PM Departure Time:
AM/PM
Review Unannounced
Name of Sponsor:
Sponsor Agreement Number:
Name of Provider:
Address:
Provider Telephone Number:
Reviewer(s):
Tier I
Tier II
Tier II with Income Eligibility Applications
Family Child Care Learning
Approved License Capacity:
License #
Home (DCH)
Date of Last Inspection:
Expiration Date:
Informal Provider:
# of Children in Care:
Subsidy Verification from CAPS:
Form 58
Form 59
Form 62
Home Operation and
Holiday Care:
Attendance
Monday – Friday
Check Normal Days of Care:
Yes
No
Normal Hours of Operation:
Sun.
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Multiple Shifts
AM to
PM
Yes
No
Approved Meal Types:
Breakfast
AM Snack
Lunch
PM Snack
Supper
Evening
Snack
ATTENDANCE AND ELIGIBILITY DATA
Full Name of all Children listed on the
Child in
Age
Enrollment
Indicate
For
Not
Meal
Meal
Roster from all shifts
Attendance?
Form on
Relationship
Pay
for
Participant
Claimed
file?
to Provider
Pay
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Page 1 of 8
Revised 04/2020
CHILD AND ADULT CARE FOOD PROGRAM
FAMILY CHILD CARE LEARNING HOME (FCCLH) MONITORING FORM
Date of Review:
Arrival Time:
AM/PM Departure Time:
AM/PM
Review Unannounced
Name of Sponsor:
Sponsor Agreement Number:
Name of Provider:
Address:
Provider Telephone Number:
Reviewer(s):
Tier I
Tier II
Tier II with Income Eligibility Applications
Family Child Care Learning
Approved License Capacity:
License #
Home (DCH)
Date of Last Inspection:
Expiration Date:
Informal Provider:
# of Children in Care:
Subsidy Verification from CAPS:
Form 58
Form 59
Form 62
Home Operation and
Holiday Care:
Attendance
Monday – Friday
Check Normal Days of Care:
Yes
No
Normal Hours of Operation:
Sun.
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Multiple Shifts
AM to
PM
Yes
No
Approved Meal Types:
Breakfast
AM Snack
Lunch
PM Snack
Supper
Evening
Snack
ATTENDANCE AND ELIGIBILITY DATA
Full Name of all Children listed on the
Child in
Age
Enrollment
Indicate
For
Not
Meal
Meal
Roster from all shifts
Attendance?
Form on
Relationship
Pay
for
Participant
Claimed
file?
to Provider
Pay
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Page 1 of 8
Revised 04/2020
CHILD AND ADULT CARE FOOD PROGRAM
FAMILY CHILD CARE LEARNING HOME (FCCLH) MONITORING FORM
LICENSING REQUIREMENTS
YES
NO
NA
COMMENTS
1)
Is
the
Provider's
license current/valid at the time of the
visit?
2)
Does
the Provider meet license
capacity
at the time of the
visit?
a)
Does
the Provider have more than twelve (12) related
children or children that reside in the
home,
under the age
of
13,
present at one time?
3)
Does
the Provider have more than six (6) unrelated children,
under the age of 13, for pay or not for pay in care at one time?
4)
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?
5)
If an Informal
Provider,
are there no more than six (6) related
children in care for
pay?
If there
is
a combination of unrelated
and related children in
care,
does
the Informal Provider meet
requirements? Reference CAPS Policy –
the capacity
Participating Providers
https://caps.decal.ga.gov/en/Policy/
6) If an Informal
Provider,
are there no more than two
(2)
unrelated
children for pay in care at one
time?
a)
If an Informal
Provider,
are the following
requirements
met: At least 21
years
of
age?
b)
Have a successful CRC on
file?
c)
Eight (8)
hours
of approved training on Health and
Safety?
d)
Have CPR certification on file or within six
months
of
approval?
e)
Have a recent successful home inspection
by CCS?
f)
Have a working fire extinguisher and smoke detector where
children are
located?
PARTICIPANT ELIGIBILITY/MEAL COUNTS
YES
NO
NA
COMMENTS
7) Are the
meals
only served to children who meet age
requirements
claimed for
reimbursement?
8) 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
a)
for care?
When the Provider’s own or foster child(ren) meet
b)
eligibility requirements?
c)
When other enrolled child(ren) are present and participating
in the meal service?
9) Are the
meals counts
recorded on the DCH Weekly Meal Count
Record,
or an approved alternate
form?
10) 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.
records)
CIVIL RIGHTS
YES
NO
NA
COMMENTS
11) Based on
observation, does
the Provider allow all children
equal access to childcare services and facilities regardless of
race
race, color, sex, age, disability or national origin?
12)
Does
the Provider serve
meals
to all enrolled children
equally
regardless
of the
child's
race, color, sex, age,
disability or
national
origin?
13)
Is
current racial/ethnic data collected annually and maintained
on file by the
Provider?
HEALTH/SAFETY/SANITATION
YES
NO
NA
COMMENTS
14) Are the refrigeration and freezer
units
clean and maintained at
required
temperatures?
(41 and 0
degrees
respectively)
Page 2 of 8
Revised 04/2020
CHILD AND ADULT CARE FOOD PROGRAM
FAMILY CHILD CARE LEARNING HOME (FCCLH) MONITORING FORM
a)
Indicate the refrigerator temperature
Refrigerator Temp:
b)
Indicate the freezer temperature
Freezer Temp:
15)
Is
food properly
thawed?
Method
Used?
16)
Is
food properly stored in refrigeration/freezer
units
and in
dry
areas?
a)
Are storage areas adequate?
b)
Is all food off the floor?
c)
Is food stored separately from cleaning items and other
toxic materials?
17) Are trash
containers covered?
18) Are wiping
cloths
clean and replaced
often?
19)
Is
the home free of rodent or insect
infestation?
20)
Is
the home free from
any obvious
fire,
health and/or
safety
hazards?
21)
Is
food service conducted in compliance with generally accepted
health and sanitation
practices?
22)
Does
the Provider and children wash
hands
prior to food
handling and
eating?
TRAINING
YES
NO
NA
COMMENTS
23)
Has
the Provider attended the
sponsor's
training within the last
twelve
months?
24)
Has
the Provider implemented the information provided at
training?
25) If an Informal
Provider,
is
there written record of completing
the required Child Care and Parent
Services
(CAPS) 8-hour
Health/Safety
Training?
RECORDKEEPING
YES
NO
NA
COMMENTS
26)
Is
the monthly menu posted in accordance with
DECAL's
Child Care
Services requirements?
27) Are all
meals
and
snacks
on the monthly menu
creditable?
28) Are annually updated enrollment
forms,
with parent signature
and
date,
on file for all
participants?
Does
the Provider have
copies
of
previous
monitoring
reports?
29)
in
30)
Does
the Provider have notification of reimbursement
options
Tier I or Tier
II,
on
file?
31)
Does
the Provider have a copy of the current sponsor/provider
agreement on
file?
32) Does the Provider maintain documentation of the non-pay
status of related and unrelated children in care?
PARTICIPANT INFORMATION
YES
NO
NA
COMMENTS
Is
current WIC information distributed to participants
33)
households
per 7 CFR
226.15(n)?
34)
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
homes'
participation in the
CACFP per 7 CFR
226.16(b)(5)?
OTHER REQUIREMENTS
YES
NO
NA
COMMENTS
Has
effective corrective action been implemented for all
35)
findings
findings identified in the
previous review?
Page 3 of 8
Revised 04/2020
CHILD AND ADULT CARE FOOD PROGRAM
FAMILY CHILD CARE LEARNING HOME (FCCLH) MONITORING FORM
OBSERVATION OF MEAL SERVICE
36) Record the meal/snack observed, the total number of participants in attendance at the meal service, food items served, and the total
number of meals/snacks served to children in care and infant meals, if applicable.
Total Number of Participants
Meal/Snack Type Observed:
1-13 yrs.
Infants
Enrolled on Date of Visit:
Meal/Snack Time:
1-13 yrs.
Meal Components
Food Item(s)
Number of Meals/Snacks Served
1 yr.
2 yr.
3-5 yrs.
6-12 yrs.
13 yrs.
Milk
Meat/Meat Alternate
Fruits
Vegetables
Grains
WG
At least one serving a day
must be WGR
Infants
Meal Components
Food Item(s)
Number Meals/Snacks Served
Birth through 5 Months
6 through 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
37)
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?
38) Are
items
served consistent with the posted
menu?
39)
Does
the meal/snack observed contain all required
components?
40)
Was
unflavored whole milk served
to
children
ages
1
yr.
and up
to 2
years
old?
41)
Was
unflavored low-fat or
fat-free
milk served
to
children
ages 2-5?
42) Was
unflavored low-fat, unflavored
fat-free
milk, flavored low-fat or
flavored fat-free milk served
to children ages 6 or older?
43) Were the required serving
sizes
for each component/food
items
prepared,
available and
served?
44) Does
the observed meal/snack provide a variety of
colors,
temperatures,
textures, shapes, sizes
and
favor?
45)
Does
the meal service occur in a positive/pleasant
environment?
46) Are medical
statements
on file for all
substitutions
related to
disabilities
or medical needs?
47) Is the Provider suppling all but one (1) meal
component of the CACFP
meal pattern?
Is
the number of
participants
in care at the time of the meal service
48)
consistent
consistent with the number of
participants
being claimed for the
previous
days?
five operating
Page 4 of 8
Revised 04/2020
CHILD AND ADULT CARE FOOD PROGRAM
FAMILY CHILD CARE LEARNING HOME (FCCLH) MONITORING FORM
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
Weekly Meal Count Record, document the home’s meal counts numbers and attach the Weekly Meal
and enrollment
records. Using the
Count Records and the attendance records for the five days reviewed to this
form.
Check box if an
automated system was used to satisfy the 5-day meal count reconciliation requirement.
Breakfast Meal Service
Number According
to
Number According
to
Date
Meal Counts Documented
by
Provider
Attendance
Enrollment
AM Snack Service
Number According
to
Number According
to
Enrollment
Meal Counts Documented
by
Provider
Date
Attendance
Lunch Meal Service
Date
Number According
to
Number According
to
Meal Counts Documented
by
Provider
Enrollment
Attendance
PM Snack Service
Date
Number According
to
Number According
to
Enrollment
Meal Counts Documented
by
Provider
Attendance
Supper Meal Service
Date
Number According
to
Number According
to
Meal Counts Documented
by
Provider
Enrollment
Attendance
Evening Meal Service
Date
Number According
to
Number According
to
Meal Counts Documented
by Provider
Enrollment
Attendance
Page 5 of 8
Revised 04/2020
Page of 8