Administrative Review Summary Report
Administrative Review Summary Report
Date: 11-30-21
Name of Agency: Children’s Center Rehabilitation Hospital Date of off-site review: 09-23-20
Reviewer: Matthew Smith Date of on-site review: 10-28-21
Persons interviewed: Melissa Guzman and Date of exit conference: 11-19-21
Katy Zauner
This School Food Authority (SFA) operates the National School Lunch Program and the School Breakfast Program.
The following areas were corrected prior to the On-Site Portion of this Administrative Review (AR):
· Civil Rights – Procedure for Handling Civil Rights Complaints: Children’s Center Rehabilitation Hospital’s (CCRH) written procedure for handling civil rights complaints contained out of date contact information for the USDA for where to send complaints [FNS-Instruction 113-1]. Prior to the completion of the on-site portion of this AR, CCRH took corrective action by updating their written procedure for handling civil rights complaints with the current USDA contact information.
· Local Wellness Policy – Required Goal Areas: The local wellness policy provide during the off-site portion of this AR did not contain the goals for other school-based activities that promote student wellness [7 CFR Part 210.31 (c) (1)]. Prior to the on-site portion of this AR, CCRH provided an updated copy of their local wellness policy containing all the required goal areas.
· Professional Standards – Eight Hour Food Safety Training: The interim director (Melissa Guzman) had not completed eight hours of food safety within 30 days of becoming interim director, or within five years of assuming the duties [7 CFR Part 210.30 (b) (2)]. Prior to the on-site portion of this AR, a new interim director (Kati Zauner) completed eight hours of food safety within 30 days of assuming the duties of director.
Your staff took corrective actions for the above findings prior to the completion to the On-Site portion of this AR. No further action is required for the above.
Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted September 23, 2020:
Professional Standards: At the time of the off-site portion of this AR, CCRH could not locate records demonstrating staff members with duties within their school food services program were compliant with the annual training hour requirements for school year. Federal regulation [7 CFR Part 210.30 (g)] requires SFAs to maintain records demonstrating employees with duties within their school food services program are compliant with annual training hours. It is required these records to be retained for three school years plus the current school year.
Federal regulations have the following annual training hour requirements [7 CFR Part 210.30 (b) (3), 7 CFR Part 210.30 (c), 7 CFR Part 210.30 (d), and 7 CFR Part 210.30 (e)]:
Job Category |
Annual Training Hour Requirement |
School Food Services Director |
12 hours |
Employees with full-time duties within the school food services program (working an average of 20 hours or more a week within the school food services program) |
6 hours |
Employees with part-time duties within the school food services program (working an average of 19 hours or less a week within the school food services program) |
4 hours |
Mid-year hires in all categories (January 1st or later) |
One half of the required annual training hours. |
*Your SFA may not have all job categories listed above. All SFAs have a school food services director.
The above training requirements are required to be completed every school year (July 1st through June 30th). USDA Memo SP 39-2015 requires SFAs to use a State Agency [(SA) OKDHS School Nutrition Programs] approved training tracking tool. During this AR, the SA reviewer provided CCRH with an approved training tracking tool.
Trainings that can be credited toward the professional standards annual training requirements include [7 CFR Part 210.30 (b) (3), 7 CFR Part 210.30 (c), and 7 CFR Part 210.30 (d)]:
· Meal counting and the reimbursement claim procedures
· Identification of reimbursable meals at the point of service
· Annual civil rights training
· Nutrition
· Health and safety standards
To demonstrate compliance and understanding with Professional Standards requirements:
- Retain training records for employees with duties within CCRH’s school food services program.
- Provide CCRH’s corrective action plan to demonstrate compliance and understanding.
Findings and Recommendations Identified During the On-Site Portion of the Review Conducted October 28, 2021:
HACCP food safety Inspection: During school year 2020-2021, CCRH failed to request second health inspection for their single site. Federal regulation [7 CFR Part 210.13 (b)] requires School Food Authorities (SFA) to receive at least two health inspections during the school year. If two are not received, the SFA must call their local health department and request a second inspection. The SFA must document their local health department's response if they decline to conduct the second health inspection.
To demonstrate compliance with health inspection requirements:
- Provide CCRH's corrective action plan to demonstrate understanding and compliance with health inspection requirements.
Reviewer’s Comments: I want to thank the CCRH staff members involved with the school food services program who provided quick responses to my inquiries and provided requested documentation and information in a timely fashion.
Procurement Review Summary Report
Date: 11-30-21
Name of Agency: Children’s Center Rehabilitation Hospital Date of AR off-site review: 09-23-21
Reviewer: Matthew Smith Date of AR on-site review: 10-28-21
Persons interviewed: Melissa Guzman and Date of exit conference: 11-19-21
Kati Zauner
This School Food Authority (SFA) operates the National School Lunch Program and the School Breakfast Program.
There were no findings for the procurement review.
