Ade Form 718 - Permanent Agreement Page 15
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23ARIZONA DEPARTMENT OF EDUCATION
Child Nutrition Programs
1535 West Jefferson Street
Phoenix, Arizona 85007
CHILD AND ADULT CARE FOOD PROGRAM
PERMANENT AGREEMENT
Revised May 2011
CFDA# 10.558
A.G. Contract No. KR02-1170-ALS
THE ADULT CARE CENTER SPONSOR AGREES TO:
1.
Provide proof that all adult day care centers are appropriately licensed or approved.
2.
Provide a community-based group program designed to meet the needs of functionally impaired
adults or individuals sixty (60) years of age or older in a group setting outside of their homes or
group living arrangements on a less than 24-hour basis.
3.
Collect and maintain current family-size and income information of adult household members for
participants classified as eligible for free and reduced-price meals or collect and maintain food
stamp case numbers, Supplemental Security Income for the Aged, Blind and Disabled Program,
Food Distribution Program Indian Reservation or Arizona Health Care Cost Containment System
numbers in lieu of family size, income information and social security numbers.
4.
Maintain daily production records of food prepared and served until no longer required by ADE.
Records must be prepared one (1) week in advance of serve date.
5.
Maintain daily records indicating the number of adults in attendance (including time in and out) and
the number of meals by type (breakfast, lunch, supper and supplements) served to enrolled adults.
The SPONSOR shall not claim more than two (2) meals and one (1) snack or two (2) snacks and one
(1) meal or three (3) snacks for any adult in attendance during the designated meal times.
6.
Have an individual plan of care on file for each functionally impaired adult enrolled. Such plan
shall be structured and comprehensive and shall provide a variety of health, social and related
support services to enrolled adult participants.
7.
Abide by the administrative management plan/budget approved by ADE.
8.
Certify that each private for-profit adult day care center under its auspices receives compensation
from amounts granted to the State under Title XIX of the Social Security Act for at least 25% of
its enrolled adults during the month preceding application to the PROGRAM and for each month
the center receives reimbursement for meals served under the PROGRAM which are also claimed
under Title III(c), funded through the Older Americans Act. Such SPONSOR also certifies that
all centers under this agreement have the same legal identity as the SPONSOR.
9.
Certify that, with the exception of proprietary Title XIX centers, the PROGRAM is public or has
tax-exempt status under the IRS Code of 1986.
10.
Notify ADE in writing thirty (30) days in advance pending any change including, but not limited
to, ownership (i.e., status of sale, etc.), management status (i.e., sole proprietorship, partnership,
etc.) or tax-filing status. New owners or owners with a change of status must apply for
PROGRAM participation.
Certify that it is not on USDA’s National Disqualification List.
11.
ADE FORM 718 (799)
15
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