Form Cacfp 4118 – Fill Out and Use This PDF

INSTRUCTIONS FOR COMPLETING CACFP-4118

This form must be completed during the on-site monitoring visit to the Day Care Home Provider’s (Provider) home. Sponsoring Organizations (Sponsors) are required to conduct a minimum of three (3) monitoring visits per Provider for each twelve months of participation.

1.Provider Information

Provider – Enter the name of the Provider.

Address – Enter the physical address of the Provider, including city, state and zip code.

Phone – Enter the Provider’s telephone number.

CACFP Number – Enter the Provider’s ID number from the CACFP homes system.

2.Visit Information – Enter date/time of visit and type (announced or unannounced).

ｸTwo of the three required visits must be unannounced.

ｸIt is recommended that meals are observed at a minimum of two visits per year.

ｸA new Provider must have their initial monitoring visit within 28 days from beginning of participation (during the Provider’s first month of claiming).

3.Meal Service Observed

ｸA meal or snack must be observed on at least one of the unannounced visits for the year.

ｸIf meals are claimed on weekends (W/E) or in the evenings (supper or evening snack), monitoring visits should be scheduled during these times at least once per year.

Note: W/E means weekend meals approved.

4.Approval Year Begin Date – Enter the Provider's Approval Year Begin Date, which should correspond to the date that the Continuous Application and Agreement (DOH-3705) was signed.

5.License/Registration Information – Enter capacity information from license/registration and check if current or in renewal process.

6.Meal Components – List food items reported by component. Indicate if the meal was observed or reported. If monitor missed seeing meal, record what was served as reported by the Provider.

7.Evaluation Checklist – Sponsors are required to report violations in the health and safety of the child care home, including food preparation and service. Up-to-date enrollment, attendance, menus and meal count records must be available for review. Providers are required to keep copies of these records for 3 years. The previous 12 months must be kept on-site at the day care location; the additional previous two years of records may be kept off-site if necessary. The meal observed must meet required components as specified in the Child (CACFP-102)or Infant Meal Pattern (CACFP-103). The monitor should observe if kitchen, food preparation area and storage facilities appear clean and sanitary. The Provider must have a current DOH-4161 on file to claim their own/resident children and must notify the Sponsor whenever there is a change in household income or resident composition. Owners of multiple homes must ensure that the On-Site Provider Addendum (CACFP-160) is completed and submitted whenever the On-Site Provider changes.

8.Children In Attendance – List all children PRESENT at time of visit and their age. Review the Provider’s files for enrollment documentation. Check if children are enrolled in care. Enrollment information must be updated annually. Users of the NYS Local Homes System may attach the participant report to use it to check attendance and update enrollment information at the visit.

9.Children Expected – The monitor should ask the Provider if additional children are expected to arrive and consume the meal being observed. This will be useful to know when comparing observations of attendance to the Provider’s records.

10.Provider’s Own/Resident – Indicate the name, date of birth and enrollment status for Provider’s own or resident children present at time of review.

Note: All of the Provider’s children participating in CACFP must be enrolled. A Provider that is not eligible to claim their children in CACFP must still report their children on attendance records when they are under school age (not yet enrolled in kindergarten) as they count toward the licensed/registration capacity.

11.Enrolled Provider Information – The Enrolled Provider, Legally Exempt or Informal Family Day Care Provider must care for at least one non resident child for each month claimed. The Enrolled or Informal Provider cannot care for more than two non- resident/non-related children. There is a capacity of eight when the Provider cares for eligible resident (Provider’s own) and/or relative children while also caring for up to two non-resident, non-related children.

12.Corrective Action or Follow-up – The Sponsor should develop and implement a corrective action plan for a Provider to follow when CACFP program requirements are not met during monitoring visits; i.e., require the Provider to submit enrollment forms by a certain date, or disallow meals when meal count and attendance records were not up to date. If a previous visit found problems, indicate if they have been corrected by the Provider.

13.Provider Records Correspond To Observations – When the Provider submits the monthly menu, meal counts and attendance record, Sponsors must review what was recorded for the date of the visit. If there is a difference between what the monitor observed and what the Provider recorded for that date, meals should be disallowed accordingly. Corrective action should be taken to prevent such discrepancies in the future.

14.Local Homes System Update – The monitor should obtain updated information on enrollment, hours of operation, meals claimed, etc. If there are changes in the Provider's Tier status, meals, service times, days of operation, capacity, enrollment, income or household composition you must also update the system used to manage CACFP data.

CACFP-4118 (4/13)

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