Administrative Review Summary Report

Date: 01-29-24

Name of Agency: Cristo Rey Oklahoma City Catholic High School (CROCHS)

Date of off-site review: 09-19-23

Reviewer: Matthew Smith Date of on-site review: 11-02-23,

11-07-23, 11-08-23, and 11-16-23

Fiscal Action: Yes, fiscal action amount will be assessed in the fiscal action and closure letter.

Persons interviewed: Lola Anaya and Date of exit conference: 01-25-24

Neal Snyder (Bench Mark)

Programs Operated by the School Food Authority (SFA): This SFA operates the National School Lunch Program.

The following areas were corrected prior to the On-Site Portion of this Administrative Review (AR):

Civil Rights – Written Procedure for Handling Civil Rights Complaints: Your Civil Rights Policy had personnel listed who were no longer employed by CROCHS. Federal regulation [7 CFR Part 210.23 (d)] and USDA FNS Instruction 113-1 requires School Food Authorities (SFA) to have a written procedure for handling civil rights complaints. Prior the completion of the on-site portion of this AR, CROCHS took corrective action by adopting a written procedure for handling civil rights complaints compliant with federal requirement.
Eligibility Certification – Eligibility Determination Error: A review of all household applications found one application approved for reduced priced meals when it should have been denied [as required by eligibility determination process required by federal regulation 7 CFR part 245.6 (c)]. Prior to the completion of the on-site portion of this AR, CROCHS took corrective action by issuing a notification of adverse action letter, waiting 10 days and then changing the household’s eligibility to paid meals. Fiscal action is required for this finding.
Eligibility Certification – Incomplete Household Applications: A review of all household applications found two applications without the Social Security Number (SSN) portion filled out [as required by federal regulation 7 CFR Part 245.6 (a) (6)]. Prior to the completion of the on-site portion of this AR, CROCHS contacted the households and had the applications completed.
Failure to Provide Requested Records: CROCHS failed to provide requested records during this AR [as required by federal regulation 7 CFR Part 210.9 (b) (17)]. Prior to the completion of the on-site portion of this AR, CROCHS provided the requested records.
HACCP Food Safety Plan: At the time of the on-site visit on 11/02/23, CROCHS did not have a HACCP food safety plan in place for the school as required by federal regulation [7 CFR Part 210.13 (c)]. Prior to the completion of the on-site portion of this AR, CROCHS adopted a HACCP food safety plan for their school.
Local Wellness Policy: The local wellness policy provided at the time of the off-site visit did not contain the following required areas:

Guidelines and standards for food and beverages served (not sold) on campus during the school day [as required by federal regulation 7 CFR Part 210.31 (c) (2)].

The policy also had personnel designated by name with responsibilities for ensuring the policy is implemented, as well as personnel designated by name with the responsibility for assessing the policy [7 CFR Part 210.31 (e) (1)]. The names listed were no longer employed by CROCHS. Prior to the completion of the on-site portion of this AR, CROCHS took corrective action and provided a local wellness policy compliant with federal requirements.

Meal Pattern – Menu Week Assessment: An assessment of the lunch menus for the week of 08/21/23 – 08/25/23, found systemic insufficient serving sizes [meal patterns required by 7 CFR Part 210.10 (c)]. Prior to the completion of the on-site portion of this AR, CROCHS took corrective action for all insufficient serving sizes.
Nutrient Analysis: As part of this AR, a nutrient analysis for the lunch menus for the week of 08/21/23 – 08/25/23 was conducted. The analysis found the average calories for the week exceed the average range of 750 – 850 calories [as required by the grades 9 – 12 meal pattern, required by federal regulation 7 CFR Part 210.10 (f) (1)]. Prior to the completion of the on-site portion of this AR, CROCHS took corrective action bringing the average calories into compliance with the meal patterns.
Professional Standards – Eight Hour Food Safety Training: The new school food services director for school year 2023 – 2024 failed to complete eight hours of food safety training within required timeframes as required by federal regulation [7 CFR Part 210.30 (b) (1) (v)]. Prior to the completion of the on-site portion of this AR, the director completed eight hours of food safety training.

No further action is required for the above findings.

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted September 19, 2023:

Civil Rights – Public Release: CROCHS did not conduct the public release process prior to, or at the beginning of the school year 2023 – 2024. USDA FNS Instruction 113-1 requires SFAs to notify the public of the SFA’s participation in USDA programs. To be compliant with this requirement, the public release is required to include the following:

Program availability
Income eligibility guidelines
Information on how and where participants can file civil rights complaints
The full nondiscrimination statement

Federal regulation [7 CFR Part 210.15 (b)] requires documentation of this process to be kept for at least three school years after the last reimbursement claim has been received for the school year.

To demonstrate compliance with civil rights requirements or the public release:

Provide CROCHS’ plan for corrective action demonstrating understanding and compliance.

Professional Standards – Training Hours: During school year 2022 – 2023, four employees with part-time duties (average of 19 hours or less per week) in CROCHS school food services program failed to complete four hours of training crediting toward the annual training hours [as required by federal regulation 7 CFR Part 210.30 (d)].

To demonstrate compliance with training hour requirements:

Provide CROCHS’ plan for corrective action demonstrating understanding and compliance.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted November 2, 2023, November 7, 2023, November 8, 2023, and November 16, 2023:

Offer versus Serve: Meal service observation on October 2, 2023, found students were only given the option to not take the fresh fruit, or to not take the milk. Federal regulation [7 CFR Part 210.10 (e)] requires offer versus serve to be used with grades 9 -12. For lunch meals to be reimbursable under offer versus serve students must be offered all five lunch meal components. The students then must take at least three of the components one of which must be the fruit or vegetable with a serving size of at least ½ cup.

To demonstrate compliance with offer versus serve requirements:

Train staff members with duties serving the food, and those with recording meal counts regarding offer versus serve.
Provide CROCHS’ plan for corrective action to demonstrate understanding and compliance.

Review Period Production Records: During a review of the remaining (one week was reviewed as part of the menu week assessment for this AR) production records for the review period (August 2023) systemic insufficient serving sizes were discovered. The following insufficient serving sizes [not compliant with the meal pattern for grades 9 – 12 required by federal regulation 7 CFR Part 210.10 (c)] were discovered:

08/11/23, there was insufficient daily serving size for the vegetable component. The menu for the day only credited ½ cup toward the daily serving. The minimum required serving is 1 cup for grades 9-12 [7 CFR Part 210.10 (c)].
08/14/23, there were insufficient daily servings for the fruit component, as well as the vegetable component. The menu for the day only credited 5/8 cup toward the fruit component and the romaine lettuce credited ½ cup toward the daily serving. The minimum required serving is 1 cup for grades 9-12 [7 CFR Part 210.10 (c)].
08/16/23, there was an insufficient daily serving for the vegetable component. The menu for the day only credited ½ cup toward the daily serving.
08/17/23, there was an insufficient daily serving for the vegetable component. The menu for the day only credited 5/8 cup of vegetables toward the daily serving.
08/28/23, there was insufficient daily servings for the fruit component and the vegetable component. The menu credited 5/8cup toward the fruit component daily serving and ½ cup (romaine lettuce) toward the vegetable component daily serving.
08/29/23, had a non-creditable pasta salad product used to meet the vegetable component. Federal regulation [Appendix C 7 CFR Part 210] requires a product such as this pasta salad to have either a Child Nutrition (CN) label issued by the USDA, or a product formulation statement issued by the manufacturer.

To demonstrate compliance with meal pattern requirements:

Bring all insufficient serving sizes into compliance with the meal pattern for grades 9 – 12.
Replace the non-creditable pasta salad product for the lunch menu for 08/29/23.
Provide documentation of the above actions, along with CROCHS’ plan for corrective actions to demonstrate understanding and compliance.
Verification – Documentation of Income: During the verification process for school year 2022 – 2023, CROCHS used tax documentation providing documentation of income from the previous calendar year. Federal regulation [7 CFR Part 245.6a (d) (5)] requires documentation of income for a household to be no older than 180 days when being used as part of the verification process.

To demonstrate compliance with documentation of income requirement:

Provide CROCHS’ plan for corrective action to demonstrate understanding and compliance.

Reviewer’s Comments: Overall, CROCHS is doing a good job with running their school nutrition program. The findings contained in this report in no way reflect on the good work being done by employees of CROCHS in the school’s school nutrition program. These employees are commended on a job well done

Procurement Review Summary Report

Date: 01-29-24

Name of Agency: Cristo Rey Oklahoma City Catholic High School

Date of AR off-site review: 09-19-23

Reviewer: Matthew Smith Date of AR on-site review: 11-02-23,

11-07-23, 11-08-23, and 11-16-23

Persons interviewed: Lola Anaya Date of exit conference: 01-25-24

Programs Operated by the School Food Authority (SFA): This SFA operates the National School Lunch Program.

The following areas were corrected during the Procurement Review (PR):

Procurement Plan: The procurement plan on file at the time of the PR was commenced did not address the use of the micro-purchase method of procurement. Federal regulations [2 CFR Part 200.318 (a) and 7 CFR Part 210.21 (c)] requires School Food Authorities (SFA) to have documented procurement procedures that could be used by the school food services program. Prior to the completion of this PR, CROCHS took corrective action by adopting an amendment to their procurement plan addressing the use of the micro-purchase method of procurement.
Vended Meal Contract – Civil Rights Attestation: The vended meal contract for school year 2022 – 2023, did not have the full civil rights attestation as required by USDA FNS Instruction 113-1. Prior to this PR, CROCHS took corrective action by having the full civil rights attestation in their vended meal contract for school year 2023 – 2024.
Vended Meal Contract – Required Disbarment/Suspension Language: The vended

meal contract for school year 2022 – 2023, did not have the required language for disbarment/suspension as required by federal regulation [7 CFR Part 3016.35]. Prior to this PR, CROCHS took corrective action adding the required language to their vended meal contract for school year 2023 – 2024.

No further action is required for the above findings.

Findings for the Procurement Review (PR)

Code of Conduct: Your code of conduct had a typo. In one area of the document where “Cristo Rey Oklahoma City Catholic High School” should have been entered someone typed “finance director.” Federal regulations [2 CFR Part 200.318 (c) (1) and 7 CFR Part 210.21 (c)] require School Food Authorities (SFA) to have a written standards of conduct covering conflicts of interest and governing actions of its employees engaged in procurement activities.

To demonstrate compliance with the code of conduct requirement:

Correct the code of conduct’s language for the typo discovered during this PR.
Provide a copy of the corrected code of conduct along with CROCHS’ plan for corrective action to demonstrate understanding and compliance.

Record Keeping – Failure to Maintain Sufficient Documentation: CROCHS failed to keep sufficient documentation of the procurement process for their vended meal contract for school year 2022 – 2023. Federal regulation [2 CFR Part 200.318 (i)] requires SFAs “…to maintain records sufficient to detail the history of procurement.” CROCHS must maintain records of procurement process sufficient to demonstrate compliance with federal procurement requirements.

To demonstrate compliance with procurement record keeping requirements:

Provide CROCHS’ plan for corrective action to demonstrate understanding and compliance.

Vended Meal Contract – Failure to Obtain State Agency Approval: CROCHS signed the vended meal contract without getting the prior approval of their state agency (Oklahoma Human Services) as required by federal regulations [7 CFR Part 210.19 (a) (3) and 7 CFR Part 210.19 (a) (5)].

To demonstrate compliance with state agency approval of vended meal contracts:

Provide CROCHS’ plan for corrective action to demonstrate understanding and compliance.

Last Modified on Feb 29, 2024