Administrative Review Summary and Corrective Actions Our Lady Queen of Peace Parish Administrative Review Conducted on:

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1 Administrative Review Summary and Corrective Actions SFA Name: Our Lady Queen of Peace Parish Administrative Review Conducted on: 17-Nov-16 SFA Contact Name and Title: Sharon Needham/Principal CNR Reviewer: Debbie Hawkins The purpose of this spreadsheet is to inform you of the results of the Administrative Review that was conducted on November 17, 2016 an exit conference summarizing the findings took place on November 17, The Administrative Review is a comprehensive evaluation of the Local Education Agency s (LEA s) National School Lunch Program (NSLP) and School Breakfast Program (SBP). The AR consists of two performance standards. While findings were identified, overall, the two performance standards reviewed were found to be satisfactory. During the Administrative Review, compliance with the new meal pattern requirements is also evaluated, at this time there are no menu findings that warrant the termination of the performance based reimbursement. This summary includes a comprehensive list of the technical assistance that was provided throughout the review as well as all findings that require a written response from the SFA. All items listed in the Corrective Action Plan must be submitted in writing to CN Resource, by Friday, February 10th, Please complete the chart, an electronic version or a hand written response will be acceptable. If any additional responses are needed, please respond on district letterhead. Failure to submit the required materials by the due date may result in the withholding of claims. Should corrective actions not be submitted, a follow-up review may take place to ensure all required corrective actions were completed and implemented system-wide as appropriate. Any potential fiscal action will be calculated once the corrective action responses have been received and approved. I appreciate the courtesies extended by you and your personnel during the review. If you have questions or need assistance concerning the school food service program, please call our office. Please respond to the AR Corrective Action Document by Friday, February 10th, Thank you,

2 Administrative Review Summary and Corrective Actions SFA Name: Our Lady Queen of Peace Parish Administrative Review Conducted on: 11/17/2016 SFA Contact Name and title: Sharon Needham/Principal CNR Reviewer: Debbie Hawkins Commendations & Suggestions Outstanding job meeting all of the requirements for the new meal pattern. All daily and weekly meal component and food quantity requirements were met. Menus reflect good variety, especially in fresh fruits offered during the week. The paperwork was completed accurately and was organized and very easy to review. Thank you for being so accommodating during the entire review process. Other areas of Technical Assistance (NOT requiring Corrective Action) During the on-site review, training requirements were discussed with the SFA. To be in compliance, the SFA must track the hours of training completed by all School Nutrition staff. The SFA has all the certificates showing the training. The SFA was informed to transfer that information onto a spreadsheet to make it easier for tracking.

3 3 8 SFA Name: Administrative Review Conducted on: Sites Selected for Review: Our Lady Queen of Peace Parish 11/17/2106 Our Lady Queen of Peace Parish Date Corrective Action Plan was provided to SFA: Wednesday, January 11th, 2017 Due Date for Corrective Action Plan: Friday, February 10th, 2017 The following pages address the findings that were identified during your Administrative Review. For each finding you will be presented with the following: The finding, and details specific to the SFA regarding the finding The Code of Federal Regulations citation number or alternate resource citation A summary of the regulation / requirement Suggested guidance for the SFA in order to achieve compliance SFA area for reply to state how, when and by whom corrections will be made Please provide a detailed response to each finding in the spaces provided. Finding #1- Civil Rights The SFA has a procedure in place for handling civil rights complaints, but the procedure does not identify the outside agency to which complaints are forwarded (i.e., SA, FNSRO, FNS Office of Civil Rights, or USDA Office of Civil Rights) During the review the requirement for the SFA to have a complaint procedure was discussed. The procedure must indicate: that any person or representative alleging discrimination based on a prohibited basis has the right to file a complaint; all complaints, written or verbal, must be forwarded to the appropriate Regional or FNS OCR Director, unless an approved State complaint procedure is in place; in the event a complainant makes the allegations verbally or in person and refuses or is not inclined to place such allegations in writing, the person to whom the allegations are made must write up the elements of the complaint for the complainant. The procedure must also identify the outside agency to which the complaints are forwarded. FNS Instruction Section XV All complaints, written or verbal, must be forwarded to the appropriate Regional or FNS OCR Director, unless an approved State complaint procedure is in place. A l i t ill b h dl d th l i t t th t t f ibl b d

4 4 8 Anonymous complaints will be handled as any other complaints, to the extent feasible, based on available information. To come into compliance with civil rights requirements, the SFA must develop a procedure that will be put into place to handle any discrimination complaints and to forward them to an appropriate agency. The process must outline the steps that will be taken when a complaint is received, the name and contact information of the agency that the complaint will be forwarded to, and the name(s) and title(s) of the person(s) who will be responsible for forwarding complaints to the appropriate agency. Please submit the procedure to the State Agency. Finding #2- Food Safety Temperature logs are not being maintained for all food storage areas. During the on-site review, temperature logs were discussed with the SFA. The SFA must maintain temperature logs for all food storage areas, in accordance with the requirements of the local health department. The completed temperature logs must be kept on file for a minimum of 6 months (b)(5) The SFA must maintain records from the food safety program for a period of six months following a month's temperature records to demonstrate compliance with (c), and records from the most recent food safety inspection to demonstrate compliance with (b). To come into compliance with the requirements for food safety, the SFA must provide the State Agency with an assurance that the appropriate staff understand the requirements for food safety documentation. The assurance should include; a statement that the food safety plan will be implemented at each site, a statement that proper documentation practices will be established at each site, a statement that all temperature documents will be maintained for a minimum of 6 months, and that training will be completed for all appropriate SFA staff. Provide the agenda and sign-in sheets from the trainings. Finding #3- Food Safety Storage violations were observed on-site. The SFA had food that was not dated upon delivery.

5 5 8 During the review, storage requirements were discussed with the SFA. The SFA must ensure that all food is dated upon delivery (a) Health standards. The school food authority shall ensure that food storage, preparation and service is in accordance with the sanitation and health standards established under State and local law and regulations (d) (d) Storage. The school food authority shall ensure that the necessary facilities for storage, preparation and service of food are maintained. Facilities for the handling, storage, and distribution of purchased and donated foods shall be such as to properly safeguard against theft, spoilage and other loss. To come into compliance with this finding the SFA must submit an assurance that the SFA is aware of the requirements for food storage and holding within the food safety guidelines. The assurance must include: a statement that all food and chemicals will be kept separately; a statement that all food items will be dated with the delivery date as well as the date the product was opened; a statement that all food will be stored at least 6 inches off of the floor; and a statement that all storage areas including coolers, freezers and storage rooms will be kept within the allowable temperature ranges. The assurance should also include a statement that temperature logs will be maintained for all storage areas. Submit copies of completed temperature logs with the corrective action response. Finding #4- Food Safety The food safety plan did not include recipe categorized according to the process approach i.e. No Cook, Same Day Prep, Complex Prep. During the review, the food safety plan was discussed with the SFA. The SFA must have a complete food safety plan that includes all of the required sections as specified by USDA, including categorizing recipes according to the process approach. The SFA must have a food safety plan available at each site so that food service staff may stay in compliance with food safety requirements and procedures (c) Food safety program. The school food authority must develop a written food safety program th t f ilit t f f ilit h f d i t d d d Th f d f t

6 6 8 that covers any facility or part of a facility where food is stored, prepared, or served. The food safety program must meet the requirements in paragraph (c)(1) or paragraph (c)(2) of this section, and the requirements in (b)(5). (1) A school food authority with a food safety program based on traditional hazard analysis and critical control point (HACCP) principles must: (i) Perform a hazard analysis; (ii) Decide on critical control points; (iii) Determine the critical limits; (iv) Establish procedures to monitor critical control points; (v) Establish corrective actions; (vi) Establish verification procedures; and (vii) Establish a recordkeeping system. (2) A school food authority with a food safety program based on the process approach to HACCP must ensure that its program includes: (i) Standard operating procedures to provide a food safety foundation; (ii) Menu items grouped according to process categories; (iii) Critical control points and critical limits; (iv) Monitoring procedures; (v) Corrective action procedures; (vi) Recordkeeping procedures; and (vii) Periodic program review and revision. To come into compliance with the requirements for food safety, the SFA must provide the State Agency with an assurance that the appropriate staff understand the requirements for a food safety plan. The assurance must include a statement of assurance that all recipes will be categorized appropriately. Submit copies of the recipes served on the day of review including: Orange Chicken and Fried Rice, Meatball Sub Sandwich, Caesar Salad and PBJ Sandwich, that have been categorized according to the process approach. Finding #5- Meal Components and Quantities The production records are incorrect. The production record was missing an area for the recipe or product number, the projected number of student and total meals, and the number of leftovers. In addition, the alternate menu options of Caesar Salad and Uncrustables should include the same information as the main menu items. During the review, production records were discussed with the SFA. The SFA must ensure that all sites are keeping accurate and complete production records for the meals they produce. The records must be completed throughout meal service and maintained everyday. At a minimum the production records should include the name of the item, the recipe or item number, the portion size, the number of planned portions, the component contribution amount and the number of actual servings. All kitchen staff should be trained on completing productions records so that everyone can complete the records (a)(3)Production and menu records. Schools or school food authorities, as applicable, must keep d ti d d f th l th d Th d t h h th l

7 7 8 production and menu records for the meals they produce. These records must show how the meals offered contribute to the required food components and food quantities for each age/grade group every day. Labels or manufacturer specifications for food products and ingredients used to prepare school meals must indicate zero grams of trans fat per serving (less than 0.5 grams). Schools or school food authorities must maintain records of the latest nutritional analysis of the school menus conducted by the State agency. Production and menu records must be maintained in accordance with FNS guidance. To bring this area into compliance the SFA must submit a written assurance that includes; a statement that the SFA is aware of the production records requirement, a statement that production records will be maintained for all meals produced, a process for completing the productions records, and a statement that additional training will be provided to the SFA staff, include the training outline and the dates that the trainings will be held. In addition please submit the name(s) and title(s) of the SFA representative(s) that will oversee this area and ensure future compliance. Submit a week of completed production records for review. Finding #8- SBP and SFSP Outreach The SFA has not performed SFSP outreach. It was determined during the review that the SFA has not performed SFSP outreach. The SFA must perform SFSP outreach before the end of the school year. Methods of outreach such as posting SFSP information on the SFA's website, parent newsletters and district-wide s were discussed with the SFA (d)(2) School food authorities must cooperate with Summer Food Service Program sponsors to distribute materials to inform families of the availability and location of free Summer Food Service Program meals for students when school is not in session. To come into compliance with this requirement, the SFA must submit an assurance to the State Agency that the SFA will cooperate with Summer Food Service Program sponsors to conduct outreach on the availability of the Summer Food Service Program. A poster has been attached that should be used. Additionally, please state the name and position of the person who will oversee compliance in this area. Finding #9- School Breakfast and Summer Food Service Program Outreach

8 8 8 The SFA has not performed SFSP outreach. It was determined during the review that the SFA has not performed SFSP outreach. The SFA must perform SFSP outreach before the end of the school year. Methods of outreach such as posting SFSP information on the SFA's website, parent newsletters and district-wide s were discussed with the SFA. A flyer has been attached for your use (d)(2) School food authorities must cooperate with Summer Food Service Program sponsors to distribute materials to inform families of the availability and location of free Summer Food Service Program meals for students when school is not in session. To come into compliance with this requirement, the SFA must submit an assurance to the State Agency that the SFA will cooperate with Summer Food Service Program sponsors to conduct outreach on the availability of the Summer Food Service Program. A poster has been attached that should be used. Additionally, please state the name and position of the person who will oversee compliance in this area. Signature of Reviewer: Date: 11/17/2016 Signature of SFA Representative: Date: If you have any questions, feel free to contact CN Resource at your convenience. Thank you. Administrative Review Team CN Resource P.O. Box Mesa, AZ adminreview@cnresource.com Please insert your detailed responses, save, print, sign, scan and upload the signed copy to cnrsupport.com by the due date indicated. Thank you.