Any potential fiscal action will be calculated once the corrective action responses have been received and approved.

Administrative Review Summary and Corrective Actions SFA Name: Spring Garden Community Consolidated School District 178 Administrative Review Conducted on: Thursday, March 23, 2017 SFA Contact Name and Title: Stuart Parks, Superintendent CNR Reviewer: Rich Crandall The purpose of this spreadsheet is to inform you of the results of the Administrative Review that was conducted on March 23, 2017; an exit conference summarizing the findings took place on that same date. 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, 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 Thursday, June 9, 2017. 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 Thursday, June 9, 2017. Thank you,

3 10 SFA Name: Administrative Review Conducted on: Site(s) Selected for Review: Spring Garden Community Consolidated School District 178 Thursday, March 23, 2017 Spring Garden Elementary School Date Corrective Action Plan was provided to SFA: Due Date for Corrective Action Plan: Thursday, May 11, 2017 Thursday, June 9, 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 space provided. Finding #1- Meal Components and Quantities: Review Week For the week of menu review, the K-8 lunch menu did not meet the minimum weekly requirement of 1/2 cup other vegetable subgroup. During the review, the portion sizes required by the meal patterns were discussed with the SFA. The SFA must ensure that all meals counted for reimbursement contain the required components in the minimum portion size required for the specific grade group. This includes meeting the weekly requirements for the vegetables sub-groups. Over the course of the standard school week the SFA must at a minimum meet the required servings for each sub-group. The SFA should review all menus to ensure that at least the minimum serving for each sub-group is planned for the specific grade group. The SFA should also provide additional training to the kitchen staff on the requirements of a reimbursable meal. The training should include what to do if a certain planned menu item is not available or if the item runs out during service. The USDA FNS website can be used for training materials, resources and guidance on the meal pattern. http://healthymeals.nal.usda.gov/ 210.10(c)(iii) Vegetables component. Vegetable offerings at lunch over the course of the week must include the vegetable subgroups, as defined in this section in the quantities specified in the meal pattern in paragraph (c) of this section: K-8: 1/2 C other vegetable.

4 10 To come into compliance with meal pattern requirements, the SFA must provide a written plan that will be implemented to ensure future compliance. The plan should include; a statement that all menus will be reviewed to ensure that all weekly requirements for vegetable subgroups are met for the specific grade group, a process for sites to reference when they do not have one of the planned menu items or there is insufficient quantities, a statement that the serving line will be visually reviewed prior to service to confirm that all required components are available and that additional menu training for all SFA staff will be provided. Provide the outline and dates for the trainings that will be completed. 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 the menu from the week of review with the corrections that were made to the menu to bring it into compliance moving forward. Provide documentation to show that at least 1/2 cup of the other vegetable subgroup will be offered weekly. Documentation may include: menus, production records, recipes, and labels. On-site monitoring was not completed. Finding #2 - On-Site Monitoring During the review, the requirement for on-site monitoring was reviewed with the SFA. It was determined that the SFA did not complete on-site monitoring by February 1st and an extension was not requested. Since the SFA has multiple sites they are required to monitor the lunch counting and claiming system for each site in the SFA prior to February 1st of each year unless an extension was requested by the SFA and approved by the State Agency. 210.8(a)(1) On-site reviews. Every school year, each school food authority with more than one school shall perform no less than one on-site review of the lunch counting and claiming system employed by each school under its jurisdiction. The on-site review shall take place prior to February 1 of each school year. Further, if the review discloses problems with a school's meal counting and claiming procedures, the school food authority shall: ensure that the school implements corrective action; and, within 45 days of the review, conducts a follow-up on-site review to determine that the corrective action resolved the problems. Each on-site review shall ensure that the school's claim is based on the counting system authorized by the State agency under 210.7(c) of this part and that the counting system, as implemented, yields the actual number of reimbursable free, reduced price and paid lunches, respectively, served for each day of operation.

5 10 As the corrective action response the SFA must complete the monitoring review for all sites within the SFA. Submit copies of the monitoring forms with the response. Please submit a process that will be put in place moving forward to ensure that all on-site reviews are completed prior to February 1st of each year. Additionally, please submit a process that will be put in place should an extension need to be requested from the State Agency. Please identify the name(s) and title(s) of the person(s) who will be responsible for completing on-site monitoring. Finding #3 - Local School Wellness Policy The SFAs Local School Wellness Policy has not been reviewed or updated. During the on-site review, Local Wellness Policies were discussed with the SFA. The Local Wellness Policy is required to be reviewed and updated on a periodic basis to ensure that the policy reflects current requirements and SFA practices. 210.30 Local School Wellness Policy (e) Implementation assessments and updates. Each local educational agency must: (1) Designate one or more local educational agency officials or school officials to ensure that each participating school complies with the local school wellness policy; (2) At least once every three years, assess schools compliance with the local school wellness policy, and make assessment results available to the public. The assessment must measure the implementation of the local school wellness policy, and include: (i) The extent to which schools under the jurisdiction of the local educational agency are in compliance with the local school wellness policy; (ii) The extent to which the local educational agency s local school wellness policy compares to model local school wellness policies; and (iii) A description of the progress made in attaining the goals of the local school wellness policy. (3) Make appropriate updates or modifications to the local school wellness policy, based on the triennial assessment. To come into compliance with this requirement the SFA must submit a statement that the wellness policy will be reviewed and updated by the wellness committee. In addition to the statement the SFA must submit the minutes from the meeting that was held to determine the needed updates. If the policy has been updated by the corrective action due date, submit a copy of the revised wellness policy. If the due date is prior to the completion of the updates, submit a detailed timeline for the implementation of the changes. Once the revisions have been made a copy of the wellness policy should be submitted to for review.

6 10 Finding #4 - Local School Wellness Policy An assessment of the Local School Wellness Policy has not been completed. During the review, Local Wellness Policies were discussed with the SFA. The SFA is required to perform an assessment of the Local Wellness Policy at a minimum once every three years. The results of the assessment need to be made available to the public. The SFA should use the results of the assessment to determine any changes or updates that need to be made to the wellness policy. 210.30 Local School Wellness Policy (e) Implementation assessments and updates. Each local educational agency must: (1) Designate one or more local educational agency officials or school officials to ensure that each participating school complies with the local school wellness policy; (2) At least once every three years, assess schools compliance with the local school wellness policy, and make assessment results available to the public. The assessment must measure the implementation of the local school wellness policy, and include: (i) The extent to which schools under the jurisdiction of the local educational agency are in compliance with the local school wellness policy; (ii) The extent to which the local educational agency s local school wellness policy compares to model local school wellness policies; and (iii) A description of the progress made in attaining the goals of the local school wellness policy. (3) Make appropriate updates or modifications to the local school wellness policy, based on the triennial assessment. To come into compliance with this requirement the SFA must submit a statement that an assessment of the wellness policy will be completed by the wellness committee. In addition to the statement the SFA must submit the minutes from the meeting that was held to complete the assessment. If the assessment has been updated by the corrective action due date, submit a copy of the assessment report. If the due date is prior to the completion of the assessment, submit a detailed timeline for the completion of the assessment. Once it is completed copy of the assessment should be submitted to the for review. Finding #5 - Reporting and Recordkeeping Records are not being maintained for 3 years after the date of the fiscal year to which they pertain. The SFA only had one half of their CEP documentation available. When Ina and Dodds school districts consolidated two years ago to form Spring Garden, Ina was already on CEP. Dodds established their ISP in 2015-16 and has all of the paperwork to support it. Ina cannot find their paperwork from when they first established their ISP for CEP.

7 10 During the review, record retention requirements were discussed with the SFA. The SFA must maintain documentation substantiating eligibility determinations on file for 3 years after the date of the fiscal year to which they pertain, except that if audit findings have not been resolved, the documentation must be maintained as long as required for resolution of the issues raised by the audit. A link was provided to the ISBE site on CEP that includes the application form and directions on how to reapply. 246.6(e) Recordkeeping. The local educational agency must maintain documentation substantiating eligibility determinations on file for 3 years after the date of the fiscal year to which they pertain, except that if audit findings have not been resolved, the documentation must be maintained as long as required for resolution of the issues raised by the audit. To come into compliance with recordkeeping requirements, the SFA must provide a written assurance that staff administering the Community Eligibility Program understand these requirements, include a statement that all records will be retained for three years after the fiscal year they pertain or until all audit findings have been resolved. Please submit the written assurance. Finding #6 - Civil Rights The SFA must use the current and full civil rights statement on all Program materials. The SFA is not using the civil rights statement on all Program materials. During the review the requirement for the most current civil rights statement to appear on all Program material was discussed with the SFA. The SFA must use the most current statement on all Program material. Per USDA requirements the new Non-discrimination statement must be on all program materials no later than September 30, 2016. The SFA was provided with the USDA link to the new non-discrimination statement. http://www.fns.usda.gov/fns-nondiscrimination-statement FNS Instruction 113-1 IX A 3 Nondiscrimination Statement. All information materials and sources, including Web sites, used by FNS, State agencies, local agencies, or other sub recipients to inform the public about FNS programs must contain a nondiscrimination statement. It is not required that the nondiscrimination statement be included on every page of the program information Web site. At the minimum, the nondiscrimination statement, or a link to it, must be included on the homepage of the program information. To come into compliance with civil rights requirements, the SFA must submit an assurance that the current non-discrimination statement has been added to all program materials. In addition, the SFA must submit a sample of program materials, such as a menu or letter to households with the statement added.

8 10 Finding #7 - Food Safety The SFA does not have a food safety plan. They have temperature logs and certain HACCP procedures but they do not have a comprehensive plan in place. 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. 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. 210.13(c) Food safety program. The school food authority must develop a written food safety program 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 210.15(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 an assurance that the appropriate staff understand the requirements for a food safety plan. The assurance should include; a statement that the food safety plan will contain all required fields, that the food safety plan will be available at each site within the SFA, and that training will be completed for all appropriate SFA staff. In addition to the assurance an electronic copy of the food safety plan must be submitted for review. Finding #8 - Civil Rights

9 10 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 113-1 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. 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. Finding #9 - Civil Rights The SFA is not accommodating life-threatening allergies when a medical statement has been provided. The student is required to drink soy milk the family is providing it instead of the school. During the review the requirement for the SFA to accommodate students with life-threatening allergies when a medical statement has been provided was discussed. When a medical statement is provided the SFA is required to accommodate physical and mental disabilities which substantially limit one or more major life activities including severe food allergies that result in anaphylaxis. This includes providing component substitutions if necessary. I provided TA about purchasing the soy milk for the student and the school agreed and will immediately change their practice. 210.10(m)(1) Exceptions and variations allowed in reimbursable meals (1) Exceptions for disability reasons. Schools must make substitutions in lunches and afterschool snacks for students who are

10 10 reasons. Schools must make substitutions in lunches and afterschool snacks for students who are considered to have a disability under 7 CFR 15b.3 and whose disability restricts their diet. Substitutions must be made on a case by case basis only when supported by a written statement of the need for substitution(s) that includes recommended alternate foods, unless otherwise exempted by FNS. Such statement must be signed by a licensed physician. To come into compliance with this requirements for special dietary needs, the SFA must provide an assurance that appropriate staff understand the requirement, and the SFA must put a plan in place to ensure future compliance. The plan must include the SFA's process for students that have life threatening allergies and the SFA's process for student with special dietary needs that do not rise to a level of a disability. Each process should include; the type of documentation that must be maintained on file, how the sites will be informed of the child's specific needs, the process that will be used to ensure that the SFA is meeting the requirements for both groups of dietary needs, and the name and title of the SFA representative that will oversee compliance. Signature of Reviewer: Rich Crandall Date: 3/23/2017 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 31060 Mesa, AZ 85275 866-941-6368 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.