Texas Department of Agriculture / Adult Day Care Food Program
Facility Pre-Approval Visit / Form H1602-P
April 2010
Name of Sponsoring Organization / Program (TX) No.
TX –
Date of Pre-Approval Visit / Time of Arrival / Time of Departure
AM PM / AM PM
Center Type
Public or Private Non-Profit For-Profit (Title XIX/XX)
Child and Adult Care Food Program (CACFP) Status:
Currently Active: Sponsor ______ Previous Participation: Sponsor ______
Never Participated
Facility Name / Email Address
Facility Address
Affiliated Unaffiliated
Person Interviewed at Facility / Title of Person Interviewed
Program Elements / Discussed / Comments
1. Enrollment
Review the facility’s methods and the documents used to enroll adults to ensure all information required by CACFP regulations is obtained. /
c
2. Eligibility Determination
Review completed Forms; if available. If not, ensure the applicant has adequate knowledge of the eligibility determination process. /
c
3. Meal Count/Attendance
Review Form H1535 to ensure the facility understands how to complete the form. Ensure the count is obtained at the "point of service". Ensure the facility understands that these forms must be completed daily and that the totals are used to complete their monthly claim.
If possible, conduct the pre-approval visit during a meal service to observe the point of service meal count. /
c
4. For-Profit Sites
Ensure that the facility understands how to calculate the 25% Title XIX/XX to determine the eligibility of for-profit centers. /
c
Form H1602-P
Page 2/04-2010
5. Menu Records
Review the menus that have been developed or completed to date. Ensure that all components for the meal types being claimed are included. /
c
6. Meal Production Records
Review meal production records, if any have been completed. Ensure that these forms are completed on a daily basis. Ensure that the facility understands the documentation requirements for processed foods, i.e., CN label. Review the use of the Food Buying Guide (FBG) with the applicant. Ensure special diet meals are documented. If contracting with a vendor, ensure that vendor has had appropriate training from the facility and is completing meal production records as indicated in the contract. /
c
7. Non-profit Food Service
Ensure the facility understands that they must maintain a non-profit food service and that these funds must be kept in a separate account or as a separate ledger item in their accounting system. CACFP funds help defray the cost of the food program and are not intended to pay for all of the food program operations. Ensure the facility understands the documentation required to claim budgeted costs. Ensure that time distribution records are maintained, if required. /
c
8. Claims
Review the procedures for filing claims. Emphasize the due date requirements for submittal of claim documentation to your office. Explain late claims and disallowances. /
c
9.  Training Requirements
Discuss the mandatory training requirements and the consequences for failure to attend. /
c
Form H1602-P
Page 3/04-2010
10. Monitoring Requirements
Discuss monitoring requirements. Explain announced and unannounced reviews. Review Form H1602 with the facility and explain corrective action requirements. /
c
11. Procurement
Discuss the procurement process outlined in the handbook. Explain the documentation that must be maintained to demonstrate compliance with procurement requirements. /
c
12. Record Retention Requirements Inform the facility that they must maintain their records for 3 yrs., or until audit findings, claims, or litigation have been resolved. Ensure the facility maintains records on-site according to CACFP record-keeping requirements. /
c
13. Civil Rights Requirements
Discuss civil rights requirements with the facility as well as the required poster that must be displayed. Ensure the facility has the poster. Ensure the facility has a process for handling complaints and can explain the complaint procedure. /
c
14. Health and Sanitation
Look for any obvious health, sanitation, or safety concerns. Review the most recent sanitation inspection report to assist you with this observation. /
c
Form H1602-P
Page 4/04-2010
15. Other
Use this space to document other topics reviewed, your observations and commendations. /
c
Is this facility eligible to participate in the CACFP? c Yes c No
If no, explain.
Sponsoring Organization Representative Name: ______
Sponsoring Organization Representative Title: ______
Sponsoring Organization Representative Signature: ______
Date of Signature: ______
Facility Representative Name: ______
Facility Representative Title: ______
Facility Representative Signature: ______
Date of Signature: ______