36C24418Q0128-002.docx

Community Residential Care Dietary Inspection Report

Date of Evaluation:____________________ Type of Evaluation: Initial________ Re-Evaluation________ Name of Home:_________________________________________________Phone:____________________ Address:___________________________________City:___________________State:______Zip:________

MENU

1. Facility has a planned menu

2. The menu is nutritionally adequate

3. Food preferences are accommodated

4. Modified diets are available with a physician order

5. Three meals are served at regular intervals, with no more than 14 hours between the last meal of one day and the first meal of the next day

6. Snacks are provided

7. Meals offer adequate variety in taste, color and texture

9. A dietitian prepares the menus Name license # expiration date

KITCHEN

1. There is adequate cooking and serving equipment

2. Kitchen work areas, range hood and equipment are clean and grease free

3. Refrigerator temperatures are at or below 40 degrees F

4 Freezer temperatures at or below 0 degrees F

5. Refrigerated food is properly covered, wrapped, labeled and dated

6. The dry storage area is clean

7. Food is stored above floor level and rotated to use oldest first

8. Hot water is maintained at proper temperatures and recorded on log

9. The dishwasher reaches sanitizing temperature or a ½ c bleach is added to the dishwasher to ensure proper sanitation

10. Window screens are clean and undamaged

11. Fans and /or incoming or exhaust vents are clean

12. Cleaning agents and chemicals are stored separate from food items

13. Garbage containers in kitchen and outside are adequately covered

14. Pest control is provided in-house or by contract

15. Medications are stored separately from food

16. Kitchen staff is trained in proper food handling methods

17. Kitchen staff training records with sign-in sheet and curriculum are available

DINING AREA

1. Dining area clean, pleasant, and properly furnished

3. Food is served at a proper temperature – hot food hot, cold food cold

EMERGENCY PREPAREDNESS

1. A fire extinguisher is located in the kitchen

2. Facility has a written plan for the safe provision of food in emergency

3. Facility maintains an adequate supply of paper products and equipment to safely serve meals in an emergency situation

4. Kitchen staff are trained in emergency procedures

5. At minimum, there is a 3-day supply of non-perishable food per resident

6. At minimum, there is a 3-day supply of water per resident

OVERALL ASSESSMENT

Rating: Excellent _______ Satisfactory:______ Marginal:______ Unsatisfactory:______

COMMENTS:

Signature:_________________________________________________ Date:_____________________