CACFP Preoperational Visit Form Administrative and Center Sponsor

CACFP Preoperational Visit Form and Instructions Administrative and Center Sponsor Use Only
Date

MonthDayYear
Date
Time In:

Hour Minutes

AM/PM Option
Time Out:

Hour Minutes

AM/PM Option
Reviewer:
Reviewer:
Legal Name of Center
LLC, Inc, Partnership
DBA Name
Address (City, St, Zip)
County:
Licensed Capacity: (If applicable)
# Enrolled
Program Type

Child Care CenterAt Risk After School Care ProgramAdult Care CenterEmergency Shelter Head StartOutside School Hours Care:Head StartNon-ProfitProfitTitle XX or Title XIXFree or Reduced Meals (child)Self-preparationCentral KitchenSchool Food AuthorityFood Service Management Company
Licensing/Approval to Operate

Bright from the Start (DECAL)Department of DefenseHead Start Performance StandardsOther Federal, State, or local authority
Alternate Licensure

CACFP Child Care StandardsExempt from licensure/approval per CACFP regulations (At Risk, Outside School Hours, and Emergency/Homeless shelters only)

Rows	YES	NO	N/A
Are meals listed on the current menu creditable and contain all required components?
For child care centers that are not licensed or approved by a Federal, State, or local authority, has
a If using CACFP Child Care Standards to qualify, does the center have documentation of a current Certificate of Occupancy or satisfactory fire/building inspection within the last 12 months?
b If using CACFP Child Care Standards to qualify, does the center have documentation of a current health/sanitation permit or satisfactory inspection within the last 12 months?
Has the person in charge of CACFP operations and other key staff at the center received the
3. preapproval training provided by the sponsoring organization? 4. Does the center demonstrate knowledge of the sponsor’s procedures for submission of claim documentation at the end/beginning of each month?
Is center staff fully aware that all records pertaining to the CACFP must be maintained for a minimum of three years after the last claim submission?
6. allowable food program costs as determined by FNS Instruction 796-2 Rev. 3 and DECAL policies and memos?
If a pricing center, has the center developed a free and reduced written policy statement?
For child care centers, is the center aware that the enrollment information must be updated on an annual basis?
For child care centers that enroll infants, does the center have an acceptable plan to offer infant meals?
10. Determine if the center will use CACFP funds to pay for administrative costs other than those costs to be paid to the sponsoring organization. Does the center know that no more than 15% of the center’s reimbursement may go toward administrative costs, including fees paid to the sponsor?
11. Does the center demonstrate knowledge of recording all costs charged to the CACFP on the Monthly Record of Cost Form? Are receipts maintained?

Record the Meal Type and components served on date of visit:

Rows	YES	NO	N/A
12. Does the organization allow enrollment or participation regardless of race, color, national origin, sex, age, or disability?
13. During the visit, did it appear that discriminatory practices were avoided?
14. Were point of service meal counts correctly taken on this date?
15. Does center staff demonstrate appropriate knowledge of completing the Weekly Menu and Food Service Record?
16. If the center is applying for the At-Risk Afterschool Meals Program, review activities offered. Are enrichment and/or educational activities offered and actively delivered by staff?
17. Do serving areas have appropriately sized chairs and tables available for participant use?
18. Is the kitchen adequate to serve the number of children it proposes to serve?
19. Are food and food supplies stored at least six inches above the floor?
20. Are dishwashing/sanitizing methods accurate?
21. Is frozen food properly thawed?
22. Is the refrigerator at 45 degrees or below?
23. Is the freezer at 0 degrees or below?
24. Are cleaning supplies/pesticides stored separately from food items?
25. Are hair restraints and hygiene practices in place?
26. Is the kitchen free of insects and rodents?
27. Is the kitchen area and equipment clean?

Adult Centers

Complete the following questions only for programs that have an adult care program. Refer to DECAL CACFP Policy 33.

Rows	YES	NO	N/A
28. Does the center provide care for functionally impaired adults 18 yrs. of age or older?
29. Does the center have records that indicate the age of all enrolled adults?
30. Are those adults who are not functionally impaired 60 years of age or older?
31. Does the center have records that indicate that each adult under the age of 60 meets the functionally impaired criterion?
32. Does the center have records that indicate that participants reside in their own home or group living arrangements where the adult primarily has care for him/herself, which makes them eligible for CACFP meal reimbursement?
33. If the center enrolls participants with various living arrangements, does the center have a process in place to determine who is eligible for CACFP meals and meals are claimed only for eligible participants?
34. Does the center have individual plans of care for each functionally impaired adult?
35. Are individual plans of care reviewed and updated on a reasonable frequency (i.e., quarterly, or yearly)?
36. Does the center provide care for eligible adults less than 24 hours per day?
37. Does the center provide a structured comprehensive program that provides a variety of health, social and related support services to enrolled adults?
38. 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?
39. Does the center ensure that meals are not claimed for adults who come to the center only to participate in the following programs?
Workshops, single day, or series
b Substance abuse programs
Vocational or prevocational training
Social programs or events

Describe any technical assistance provided.
Describe any technical assistance provided.
Describe any technical assistance provided.
Center is eligible to participate in CACFP:

YesNo
Approval Recommended:

YesNo
Signature of Center Contact
Center Contact: Email
example@example.com
Date

MonthDayYear
Date
Signature of Sponsoring Organization Reviewer
Email: Organization Reviewer
example@example.com
Date

MonthDayYear
Date
Should be Empty:

CACFP Preoperational Visit Form and Instructions Administrative and Center Sponsor Use Only

Reviewer:

Adult Centers