Adult Protecitve Services (APS)

INTRODUCTION FOR APPLICANTS
Thank you for your interest in partnering with LA County to provide meals to our seniors in the County.

This application form has questions to confirm a restaurant’s eligibility to be considered for the program. For eligible restaurants, there are questions to capture operational information that will help us execute the order allocation most efficiently.

Nutritional Requirements: Food provider meals must meet the following nutritional requirements:
- Provide 3 meals a day
- Do not provide sugary drinks (see below definition) - allowable beverages include:
- All meals should be low in sodium (see below guidelines)
- Lunch and dinner must follow food group and serving guidelines (see below chart)

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NUTRITIONAL GUIDELINES - Please read before continuing

Food provider meals must meet the following nutritional requirements:

Restaurants need to provide 3 meals a day
Breakfast: low in sodium, no sugary drinks² (<24 grams /8 oz. and of fruit juice, must be only 100 percent fruit juice allowed); and
Lunch and dinner: a piece of fresh fruit or vegetable on each dish, and low in sodium³, no sugary drinks (<24 grams /8 oz. and of fruit juice, must be only 100 percent fruit juice allowed).

In addition to the FEMA defined nutritional requirements, the LA County Statement of Work includes further nutritional guidelines as per the definition from the Elder Nutrition Program:

TAG index

Food Group	Required Servings Per Meal	Dietary Guidelines Servings Per Meal
Protein	3 oz	3 oz servings whole or ground meats, chicken or fish. Limit ground meat three times per week.
	2 oz	2 oz meat or meat alternate used in salad entrée recipes. 2 oz meat or meat alternate used in sandwich recipes. Limit sandwiches to 3 times per week.
Vegetable/Fruit⁴	2-3 servings	Vegetables: For most vegetables, one serving is ½ cup; for salad greens, one serving 1 full cup Must be non-starchy; potatoes are counted in the grain/starch food group Should not be fried; okay to serve raw, steamed, baked, grilled, or cooked into the entree Fruit: ½ cup or 1 piece of fruit for dessert counts as 1 serving. If canned, should be packed in unsweetened juice or water (not syrup)
Grain/Starch	1 serving	1 serving per meal such as 1 slice whole grain bread or ½ cup rice or pasta. Frequently use brown rice, whole grain pasta, or half brown and white rice mixture. Try to incorporate grains like quinoa, bulgur, or barley. Should have 3 grams fiber/serving. Half of all grains must be whole grains.
Beverages	1 serving	6 to 8 oz water (for others, refer footnote #2)

Recommend food service providers purchase and serve locally grown and produced food when that option is available and affordable. Locally grown is defined by the Los Angeles Food Policy Council as within a 200-mile radius of Los Angeles.
The following beverages meet the Nutrition Guidelines for prepared meals:
- Fruit-based and vegetable-based drinks that are 100% juice (without added sweeteners) and no more than 230 mg sodium per serving
- Milk products, including 1%, nonfat, soy, rice, and other similar non-dairy milk without added sweeteners
- Beverages that do not exceed 25 calories per 8 ounces
Not recommended: All sodas, fruit drinks, sport drinks, low-calorie drinks and other beverages that contain added caloric sweeteners, such as sweetened tea, rice drinks, bean beverages, sugar cane beverages and nonalcoholic wines.
To maintain low sodium meals, following guidelines are recommended by LA County:
- Purchasing:
- Serving:
- To follow Nutrition Guidelines on allowable amount of sodium per meal (<800 mg), a restaurant would need to use no more than approx. 1/3 teaspoon of standard table salt per meal, if it is entirely prepared from fresh.
Vegetables & Fruits Dietary Recommendations

Vegetables Purchasing:

Require canned/frozen vegetables contain ≤ 290 mg sodium per serving
Require canned/frozen beans contain ≤ 290 mg sodium per serving

Vegetables Serving:

Require non-starchy vegetable options that are not fried
Require a raw, salad-type vegetable and/or steamed, baked, or grilled vegetables daily at lunch and dinner. Vegetables may be cooked into the entree and do not have to be served on the side.
Recommend seasonal vegetables whenever possible

Fruits Purchasing:

Require canned fruit is packaged in unsweetened 100% juice or water, not syrup
Recommend canned, dried, frozen, pureed, or whole fruits with no added sugars

Fruits Serving:

Require fresh fruit options
Recommend seasonal fruit whenever possible

Consent and Agreement*
YES, I MEET THESE REQUIREMENTS AND I WANT TO CONTINUE WITH MY APPLICATION
By checking "YES" you are indicating that you have read and understood this consent form and Nutritional Guidelines requirements.

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CONTACT INFORMATION OF THE MEAL PROVIDER
Restaurant*
Name of the restaurant
https://
Website Link or Weblink to Restaurant, if available (https://)
Street Address*
Street Address
City*
City
Zip Code*
Zip Code
Type of cuisine*
Type of cuisine served by the restaurant
Other cuisine*
Other cuisine (please specify)
Last*
Restaurant’s contact name (First Name)
First*
Last Name
Phone*
Phone
Email*
Email
Enter Email Confirm Email

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MANDATORY REQUIREMENTS BY GREAT PLATES DELIVERED LA COUNTY PROGRAM
Restaurants must have a valid public health permit issued by the Department of Public Health. Restaurants should have an acceptable rating during their last inspection to be operational and participating in this program. Documentation should be submitted along with the contract submission. Acceptable ratings include Grade A or B as noted on the Retail Food Official Inspection Report. Do you meet this criterion?*
Restaurants must have a valid public health permit issued by the Department of Public Health. Restaurants should have an acceptable rating during their last inspection to be operational and participating in this program. Documentation should be submitted along with the contract submission. Acceptable ratings include Grade A or B as noted on the Retail Food Official Inspection Report. Do you meet this criterion?
Sorry, you do not qualify. Thank you for your interest.
Is your restaurant currently participating in a State or Federal meal service program (Ex. EBT)?*
Is your restaurant currently participating in a State or Federal meal service program (Ex. EBT)?
Sorry, you do not qualify. Thank you for your interest.

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FOOD HOME DELIVERY SERVICE
Overview: Great Plates delivered requires meals to be home delivered to seniors who are most vulnerable during the COVID-19 crisis. This is a requirement from the restaurants currently. The delivery staff MUST have valid background checks.
Will you be able to provide home delivery of meals to seniors and have delivery staff with valid background check?*
Will you be able to provide home delivery of meals to seniors and have delivery staff with valid background check?
If yes, what is your service area radius (i.e. 1-15 miles away from your restaurant location, etc.)?*
If yes, what is your service area radius (i.e. 1-15 miles away from your restaurant location, etc.)?
Zip Codes*
Please list the zip codes you can deliver to:
Zip Code

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OTHER REQUIREMENTS/ SELF ATTESTATIONS
Overview: The Great Plates Delivered Program would like to encourage restaurants who support LA County’s economy by sourcing local produce and hiring a local workforce. The criteria listed below are qualifiers for the program. Restaurants meeting these criteria will be given a preference.
Does your restaurant source local produce and meats? Local is defined as “grown within a 200-mile radius of Los Angeles County.”*
Does your restaurant source local produce and meats? Local is defined as “grown within a 200-mile radius of Los Angeles County.”
Has your business been certified by a Federal Source as either a Small Business, Disabled Veteran-Owned Business, or Social Enterprise**
Has your business been certified by a Federal Source as either a Small Business, Disabled Veteran-Owned Business, or Social Enterprise*?
*Examples of these certifications include:

i. by the federal Small Business Administration (SBA) or an active registration as a small business in the System for Aard Management (SAM) data base

ii. as a Service-Disabled Veteran-Owned Small Business (SDVOSB) by the Veterans Administration

iii. as a Social Enterprise
Will you: (select all that apply)*
Will you: (select all that apply)
- Select All
- Prioritize hiring local workers (those who live within 10 miles of your restaurant)?
- Prioritize job offers to workers who were employed at your restaurant prior to COVID-related layoffs?
- Ensure worker health and safety, including by following State-ordered protections for food workers?
- Maintain standards of equity and fairness in employment practices, wages, hiring, and promotion?

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MEAL TYPE AND CAPACITY OF RESTAURANTS
Overview: The Great Plates Delivered program requires restaurants to provide 3 fresh meals a day (Breakfast, Lunch and Dinner) to each senior client daily for 7 days a week.
Does your restaurant have the capacity to provide these services to clients for the next 12 weeks or more* (*FEMA funded Great Plates program may get extension beyond the current timeline of June 10th, 2020)*
Does your restaurant have the capacity to provide these services to clients for the next 12 weeks or more* (*FEMA funded Great Plates program may get extension beyond the current timeline of June 10th, 2020)
Please review the Nutritional Meal requirements for the Great Plates Delivered program for LA COUNTY and affirm that your establishment can meet the following requirements: (click here to read the requirements*
Please review the Nutritional Meal requirements for the Great Plates Delivered program for LA COUNTY and affirm that your establishment can meet the following requirements: (click here to read the requirements)
Do you certify that all of your workers are following government guidelines for safe food handling, preparation, and packaging during COVID-19? <a href="https://www.fda.gov/food/food-safety-during-emergencies/best-practices-retail-food-stores-restaurants-and-food-pick-updelivery-services-during-covid-19" target="_blank">(Ref: https://www.fda.gov/food/food-safety-during-emergencies/best-practices-retail-food-stores-restaurants-and-food-pick-updelivery-services-during-covid-19)*
Do you certify that all your workers are following government guidelines for safe food handling, preparation, and packaging during COVID-19? (Ref: https://www.fda.gov/food/food-safety-during-emergencies/best-practices-retail-food-stores-restaurants-and-food-pick-updelivery-services-during-covid-19)
In addition to ‘Regular Meals’ can your restaurant(s) prepare any of the following meals?*
In addition to ‘Regular Meals’ can your restaurant(s) prepare any of the following meals? (Select all that apply)
- Select All
- Gluten Free Meals
- Halal
- Kosher
- Vegan
- Vegetarian
What is the minimum number of clients required by your restaurant to make this as a viable option for your business? <em>We will do our best to not send you orders below the minimum viable quantity as stated by you below. (Note: 1 client= 3 meals a day; therefore, 10 clients= 30 meals a day)*
What is the minimum number of clients required by your restaurant to make this as a viable option for your business? We will do our best to not send you orders below the minimum viable quantity as stated by you below. (Note: 1 client= 3 meals a day; therefore, 10 clients= 30 meals a day)
Other, minimum # of clients per day
Other, minimum # of clients per day?
What is the maximum capacity of your restaurants for number of clients you can serve on a daily basis (each client gets 3 meals a day*
What is the maximum capacity of your restaurants for number of clients you can serve on a daily basis (each client gets 3 meals a day
Other, maximum # of clients per day*
Other, maximum # of clients per day?
If awarded, can you start providing meal and delivery services within 1 week?*
If awarded, can you start providing meal and delivery services within 1 week?

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OTHER QUESTIONS
Do you have more than 5 employees at your restaurant?*
Do you have more than 5 employees at your restaurant?
If you were to be selected for this program, how many employees would be employed / hired to provide these services?*
If you were to be selected for this program, how many employees would be employed / hired to provide these services?

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SELF ATTESTATION
Signature Attestation*
By submitting this form, I certify under penalty of perjury that the information provided in the application form is true and correct.
First and Last Name*
Executed On:
First and Last Name
Date*
Date
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

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Step 1 of 9 - Introduction

INTRODUCTION FOR APPLICANTS

NUTRITIONAL GUIDELINES - Please read before continuing

CONTACT INFORMATION OF THE MEAL PROVIDER

MANDATORY REQUIREMENTS BY GREAT PLATES DELIVERED LA COUNTY PROGRAM

FOOD HOME DELIVERY SERVICE

OTHER REQUIREMENTS/ SELF ATTESTATIONS

MEAL TYPE AND CAPACITY OF RESTAURANTS

OTHER QUESTIONS

SELF ATTESTATION

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County-Wide Resources

WDACS – LOS ANGELES COUNTY

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