Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

GENERAL INFORMATION

  • Date and Time audit began

  • Name(s) of PIC/person(s) in charge (ServSafe certification or equal)

  • ServSafe certifications appropriately displayed

  • Employee health poster available

  • Most recent resident satisfaction score:

  • % of food prepared from fresh ingredients:

  • Describe how choice and preferences are handled:

  • Comments:

PROCUREMENT and RECEIVING FOOD

  • Food items are purchased from approved source. (licensed by the county, state, or federal government). List primary Vendor Names

  • Deliveries are accepted at non peak times (Record normal delivery day and approximate time)

  • Food is inspected before placed into storage (free from damage, contamination, adulteration and spoilage)

  • Food deliveries are kept 6" off the floor before being stored

  • Potentially Hazardous Food (PHF) received at temperature 41° F or below

  • Frozen food received at temperature 0° F or below

  • Comments:

PERSONNEL HYGIENE PRACTICES

  • Employees wear proper uniform including proper shoes

  • Hair restraint is worn

  • Fingernails are short, unpolished and clean

  • Jewelry is limited to watch, simple earrings and plain rings

  • Hands are washed or gloves are changed at critical points

  • Open sores, cuts, or splints and bandages on hands are completely covered while handling food

  • Hands are washed thoroughly using proper hand-washing procedures at critical points

  • Eating, Drinking or chewing gum are observed only in designated areas away from work areas

  • Staff beverages are covered with a lid and straw and stored away from food preparation area

  • Staff take appropriate action when coughing or sneezing

  • Disposal tissues are used and disposed of when coughing/blowing nose

  • Comments:

HANDWASHING

  • Hand sinks accessible and stocked with soap and paper towels

  • Staff wash hands in hand-washing sinks only

  • Staff observed washing hands between tasks (handling raw meat, seafood, mops, garbage, ect...

  • Employees wash hands before starting work and returning from break

  • Comments:

DRY FOOD STORAGE

  • Temperature is appropriate <br>between 50° F and 70° F

  • Evidence that temperatures are monitored and recorded

  • Record temperature

  • Food is stored at least 18" below sprinkler head(s)

  • Is storage area well lit

  • Protective light shields cover all light sources

  • All food is labeled with name and delivery date

  • All food and paper supplies are 6" off the floor

  • Bulk foods are labeled with common name if not in original container<br>(Flour, rice, sugar, ect)

  • There is no bulging, dented or leaking canned goods in storage

  • Food is protected from contamination

  • All surfaces and floor are clean

  • Chemicals are stored away from food and other food related supplies

  • Comments:

COLD FOOD STORAGE

  • Walk In Freezer

  • Thermometer is conspicuous and accurate

  • Evidence that temperatures are monitored and recorded

  • Record temperature here. (must be < 0° F)

  • Food is stored 6" off floor

  • All food is properly wrapped, labeled and dated

  • Unit is clean inside and out

  • Interior safety release is installed and functioning to prevent accidental entrapment.

  • Walk In Refrigerator

  • Thermometer is conspicuous and accurate

  • Evidence that temperatures are monitored and recorded

  • Record temperature here. (must be < 41° F)

  • Food is stored 6" off floor

  • All food is properly wrapped, labeled and dated

  • Food being thawed is on lowest shelf(s)

  • Unit is clean inside and out

  • Interior safety release is installed and functioning to prevent accidental entrapment.

  • Reach In Freezer

  • Thermometer is conspicuous and accurate

  • Record temperature here. (must be < 0° F)

  • Evidence that temperatures are monitored and recorded

  • All food is properly wrapped, labeled and dated

  • Unit is clean inside and out

  • Reach In Refrigerator

  • Thermometer is conspicuous and accurate

  • Evidence that temperatures are monitored and recorded

  • Record temperature here. (must be < 41° F)

  • All food is properly wrapped, labeled and dated

  • Food being thawed is on lowest shelf(s)

  • Unit is clean inside and out

  • Milk Refrigerator

  • Thermometer is conspicuous and accurate<br>

  • Evidence that temperatures are monitored and recorded

  • Record temperature here. (must be < 41° F)

  • Unit is clean inside and out

  • Comments:

FOOD HANDLING

  • Frozen food is thawed under refrigeration or in cold running water

  • Food is not allowed to become cross contaminated

  • Food is handled with utensils, clean gloved hands or clean hands

  • Utensils are handled to avoid touching parts that will be in direct contact with food

  • Reusable towels are used only for sanitizing equipment surfaces and not for drying hands, utensils, floors and ect...

  • Comments:

UTENSILS and EQUIPMENT

  • Drawer(s) are clean

  • Rack(s) are clean

  • Equipment is covered when clean and not in use

  • Ice scoops are stored in appropriate container and not in ice machine

  • Dishes are free of stains and food debris

  • EQUIPMENT OPERATION

  • Inoperative equipment has been repaired, replaced or removed from the community

  • Pots and pans are free of carbon build up, stains and food debris

  • Only approved equipment (NSF or equivalent with the exception of toasters, mixers, microwave ovens) are installed in an approved manner

  • Comments:

CLEANING and SANITIZING

  • Is can opener clean

  • Wiping cloths are stored in sanitizing solution while in use Sanitizing solution <br>100 ppm Chlorine OR 25 ppm OR 200 ppm quat

  • Is toaster clean

  • Is slicer clean

  • Slicer unplugged when not in use

  • Is mixer clean

  • Is coffee machine clean

  • Is juice machine clean

  • Is soda machine clean

  • Is microwave clean

  • Is convection oven clean

  • Is range/oven clean

  • Is char broiler clean

  • Is steamer clean, free of lime build up

  • Is range hood and filters clean

  • Note Date of last professional cleaning of range hood and vendo

  • Is deep fryer clean and properly aligned under fire suppression nozzle

  • Is steam table clean and free of lime build up

  • Are carts clean and wheels free of rust and debris

  • Three Compartment Sink

  • Three compartment sink is used

  • Three compartment sink WASH hot, soapy water

  • Three compartment sink RINSE clean, warm water to remove detergents

  • Three compartment sink SANITIZE one minute in clean, warm (at least 75° F) water at:<br>50ppm chlorine OR 12.5 ppm iodine OR 200 ppm quat

  • Three compartment sink AIR DRY on drainboard/sink

  • Dishmachine Chemical Type

  • Dishmachine High Temperature

  • Comments:

GARBAGE STORAGE and DISPOSAL

  • Kitchen garbage cans are clean and covered when not in use

  • Garbage cans are emptied as necessary

  • Boxes and containers are removed from site

  • Dumpster lid(s) are closed

  • Dumpster area is clean

  • Comments:

INTEGRATED PEST CONTROL

  • Screens are on open windows and doors are in good repair

  • Door sweeps restrict the passage of light

  • No evidence of insect or pests is present

  • Comments:

SIGNATURES

  • Signature of PIC

  • Signature of Auditor

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.