Complete the form below for your facility. You may receive an email to clarify your request if there are further questions. Kitchen Sanitation Form Community Evaluator Date MM slash DD slash YYYY PercentageTotal points/Possible points = PercentageA: Storeroom Areas(Required) Proper ventilation/temperature Floor clean, no debris Shelving clean Dented cans stored separately Chemicals stored away from food Ingredient bins cleaned & covered Open packages sealed & dated Items stored> 18in from ceiling Check the box if points are awarded.CommentsB: Refrigerated Storage(Required) Temperature at <41 degrees Food stored off the floor, floor clean Surfaces clean & free of rust Gaskets clean & in good repair No expired food products All food labeled, dated, and sealed properly Temperature log maintained No spills on floor or shelving Outside walls, doors, top clean Raw meat stored in order top to bottom: seafood, whole cuts beef/pork, ground meat, poultry No staff food stored in resident refrigerator All lights in working order Interior fans clean, no dust Check the box if points are awarded.CommentsC: Frozen Storage(Required) Temperature <10 degrees to 0 degrees Food stored off the floor, floor is clean Shelves and walls clean, free of rust Gaskets clean and in good repair Raw meat on bottom shelf and separate Temperature log maintained No spills on floor or shelving Items stored greater than 18in from ceiling Outside walls and doors and top clean All lights in working order No ice buildup Check the box if points are awarded.CommentsD: Ware-Washing Areas(Required) Dish machine is clean inside & out Utensils & dishware air dried Temperature & PPM log current Off the floor stacking Work surfaces clean Service ware in good condition Floor & mats clean Sinks & areas clean Chemical containers off floor Garbage disposer per code Pot & pan area clean Manual washing procedure followed Sanitizing buckets PPM correct Check the box if points are awarded.CommentsE: Personal Hygiene(Required) Clean work clothing Clean hands and nails Nails without polish Wearing hair covering Appropriate jewelry Handwashing competency All staff wearing name badge Staff not eating or drinking in the kitchen Check the box if points are awarded.CommentsF: Dining Room(Required) Tables & chairs clean Floors & walls clean Areas cleaned between seatings Check the box if points are awarded.CommentsG: Service Checks(Required) Dish machine Juice dispenser Coffee makers Refrigerators & freezers Check the box if points are awarded.CommentsH: Food Preparation Area(Required) Range and oven clean inside/out Undersides of tables & equipment clean Hood and filters clean and free of dust Shelves and other surfaces clean Cabinets and drawers clean Can opener blade and bases clean Steamers and steam kettles clean Electrical food equipment and microwave clean Floors swept and mopped daily. Free of cracks Walls clean and free of cracks or chips or mold Dispensing equipment clean inside and out Ice scoop stored appropriately Ice maker clean and schedule or procedure followed Toaster clean Pots and pans free of grease and properly stored Shelves and drawers clean and orderly No signs of cross contamination All hood stickers updated with correct visit date Frozen meats thawed under refrigeration or running cold water Check the box if points are awarded.CommentsI: Tray Assembly & Tray Carts(Required) Steam table & wells clean & free of scale Steam table heats properly Food carts clean inside and out Plate warmers clean All items covered when delivered to room Check the box if points are awarded.CommentsJ: Miscellaneous Areas(Required) Trash cans washed routinely Trash removed timely and no odor Pests and vermin controlled no flies Trash container covered at all times Janitor closet clean no odor Cleaning agents stored off floor Floor drains clean no odor Mops and brooms hanging off floor Dumpster area clean with lids closed Check the box if points are awarded.CommentsK: Emergency Procedures(Required) Adequate water supply Menus available with mechanically altered spreadsheets Adequate supply of disposables Adequate food supply Water and food supplies rotated Check the box if points are awarded.CommentsL: Food handling(Required) Produce washed and out of delivery crates Gloves or utensils used to handle food Scoops not stored in food bins Cutting boards not excessively scratched Food maintained at proper temperature Food always covered Pasteurized eggs used No bare hands contact with food No signs of cross contamination Food temperature log maintained Working thermometer and unexpired probe wipes used correctly Staff able to calibrate thermometers Check the box if points are awarded.CommentsM: Equipment(Required) All equipment in working order Check the box if points are awarded.Total PointsAdditional NotesCAPTCHAEmailThis field is for validation purposes and should be left unchanged.