Facility Information

Name "
r Location Type
School of The Nativity > Telephone number
jComplaintPrivate Elementary
(703)455-2300
j School Food Service
Health Office
i Region — —

Primary Contact'Title "

Primary Contact First
Lunch Room Director Shannon Murphy
Primary Contact Last
Building #
Di Street Name
6398 :Type Suffix unit #
! Nativity Lane •
on!

Zip Code
| City
22015 : County
I Burke
Country Fairfax
USA

General Details
Complaint Type J Critical
Food Borne Illness j Date Received
Investigation Start Date* 21-Nov-2017 03:10 PM
| Date Closed
Received By ~ " ~
David Middlebrooks I Referred to ~
Confirmation** Rick Kurtz El
No ; Census Tract ""

Complainant information
Name —•­ xtAsked
_ to remair! j Verified
Christy Brennan, VDACS jPhone #1
: Phone #2
Address ' " 1(804)786-1581 1(804)382-0911
' Email ~ '
(Results Requested *
j christy. brennan@v ; O No O Yes
L_dacs. virginia.gov
State " Zip Code
Country VA
USA

|
Complaint Details and Actions*
Complaint Details" _ Tm Mo°Low Fa( Choco,a,e
_ ^ _

I
|i^ii^nTaken '
- -e
County hd help with this? )" Q 9 parents t0 he,P educate
«was
them on how to treat
j Foilow-Up Date

(Action Required By
Comments

Attachments

; t//7 (>
->/n
School of The Nativity

Food Safety Section

10777 Main Street, Suite 111
Fairfax, Virginia
22030
Phone: (703) 246-2444
Fax: (703) 653-9448
URL: Vyl7,Vy 7

FAIRFAX COUNTY Health Department

in cooperation with
VIRGINIA DEPARTMENT OF HEALTH

Foodservice Establishment Evaluation Report

Establishment Information
Establishment Name: School of The Nativity
Establishment Type: Private Elementary School Food Service
Address: 6398 Nativity Lane
Burke, VA 22015

Evaluation Information
Inspection Type: Complaint
Complaint Date: November 21, 2017
Evaluation Date/Time: November 21, 2017 03:55 PM to 06:45 PM
Evaluation Length: 2.83 hour(s)

Equipment Temperatures __
Description Temperature 0F
hotwater at handsink, 3-vat
Traulsen 2dr reach-in cooler

Person In Charge
Person In Charge: Maria E. Kelly, Principal
Food Certification: Certified Manager
Manager's Certificate Number:
Manager's Certificate Expiration:

Observations
Total Number:

Comments
The purpose of this visit was to investigate a complaint regarding adulterated food.

Received by. 7h^ 2v/Av/ EHS Page #1 of #2

tY\(kri*-- (J
 I
School of The Nativity

This Inspection Report sets forth the health department's observations, alleged violations, and recommendations for compliance,
but it is not a case decision as defined at Code of Virginia §2.2-4001. If you have additional facts you believe bear on this
inspection and would like to schedule an •informal-fact finding conference (IFFC) pursuant to Code of Virginia §2.2-4019, please
contact the Environmental Health Specialist referenced on this inspection report within fifteen days of receipt of this document.
Should an IFFC be scheduled and you fail to appear absent good cause, the Virginia Department of Health may issue an adverse
case decision as contemplated by Code of Virginia § 2.2-4020.2. This form corr s in formation that could be subject to disclosure
under Code of Virginia, §2.2-3700 '

AA. OCa J!JL

Received By: A Rick Kurtz
YY\p^r^t*— K^(y Environmental Health Specialist

Received by EHS Page #2 of #2

 County of Fairfax, Virginia
To protect and enrich the quality of life for the people, neighborhoods and diverse communities of Fairfax

HOLD ORDER
Establishment Name AjfV 1, ~C C ft'T' ^ —

Establishment Address A /^VT J U^" a3=~

Pursuant to: ^ ™
0 Fairfax County Code, Chapter 43.1 Q City of Falls Church Code, Chapter 12.1 0 City of Fairfax Code, Chapter 11.1

I. The food items listed below may not be used, sold, moved from the food establishment, or
destroyed without a written release from the Fairfax County Health Department.
II. The listed items are subject to a hold order due to • unapproved food source Q/J adulterated
food contamination Q not labeled according to law.
III. The food items subject to this Hold Order are listed below:

Common Name Label Information Container Quantity Location of Food

(description of contents) Description (starenopflb
(can, bottle, size) (refrigerate?,
— g ^ 2 etc.)
1 2
VXjOT Ki Kwr+uy ,
0./L mJuK
,K 1 sftff/* i/f f \A? Rr-v

This Hold Order may be appealed. A request for an appeal hearing may be made to the Director of
Environmental Health. The request for an appeal hearing must be received within 10 days of
receipt of this Hold Order. If no appeal hearing is requested, the listed items may be ordered
destroyed bytee regulatety authority. If you have any questions, please call 703-246-2444.

A( \ An AALzAr~clly/ t c h i /'' 7
Environmental Health Specialist Person In Charge (j Date

Fairfax County Health Department

Division of Environmental Health
Food Safety Section
10777 Main Street, Suite 111, Fairfax, VA 22030
Phone:703-246-2444 TTY:711 Fax:703-385-9568
www.fairfaxcounty.gov/hd
 INVOICE
LEHIGH VALLEY DAIRIES INVOICE#: 700703790
ROUTE#: 007007
DATE: 11/15/17 07:30
BOX # 3886' SALES REP: 7007 •
PREORDER#:'- 700703790
DUE DATE: 11/15/17 '
PO BOX 8600 AR TERMS: Net 15 Days
PREVBAL: 0.00

PHILADELPHIA PA 19178-3886

800 343-4982

SHIP TO#: 1202336 BILL TO#: 1202337

NATIVITY SCHOOL (3) NATIVITY SCHOOL
6398 NATIVITY LANE 6398 NATIVITY LANE
BURKE, VA.22015 BURKE, VA 22015
7034552300 00000 7034552300

SALES
CTL DEAN / CST ITEM UPC DESCRIPTION
UG UOM ORD-QTY INV-QTY J ITEM-PRICE NET-AMT
> 51858 004190007673 HP DPUR LEH 2% ECHO
50 HP 100 100 0.3650 36.50
45837 I004190007282 HP TM SKM AGH FREE CHO
50 HP 100 100 ' ' 0.3650 36.50

TOTAL SALES 200 73.00

TOTAL ITEMS: 2

PAYMENT TYPE: CHARGE TOTAL: 73 .00

> NON-RETURNABLE GL EQ 12.50 SR VAL 25.00 CM VAL 50.00

SIGNATURE / STORE STAMP

DUPLICATE
6-B2.26 PAGE' 1

LAST PAGE
Kurtz, Rick

From: Kurtz, Rick

Sent: Tuesday, November 21, 2017 6:25 PM
To: Yetman, John
Cc: Wastler, Kevin
Subject: Nativity Catholic School

SUPPLIER:
Leehigh Valley Dairies
P.O. Box 8500
Philadelphia, PA 19178-3886
# 800-343-4982L?

LOT #'s:
The following lot #'s were impounded:
42-046-1A, IB, 21, 22, 23, and 24 (All lot #s start 42-046-)

DATES: .
Most of the cartons of milk were dated 11/27, but a few were dated 11/28.

SCHOOL CONTACTS: _ "

Maria E. Kelly, Principal 703-455-2300^? xll8
M. Colleen Jarvis, RN School Nurse 703-455-2300^!? xl22 •
Email address: www.nativityschool.org

NOTE:
Both chocolate milk and 2% regular milk were included in the impoundment. All milk was in half pint
cartons. Both chocolate and regular milk share the same lot #'s. Some of the cartons were opened, and only
the chocolate milk was observed to be affected. It contained a clear liquid with a mild chemical odor. Some of
the school children drank the clear fluid before the problem was discovered, but no reports of illness have
been received by the school. All impounded milk was placed in containers (1 cardboard, 1clear plastic, and
one milk crate), then covered with plastic, labeled, and taped shut, so that tampering would be evident. Two
additional cartons discovered after sealing the other containers were placed in a zippered plastic bag that was
taped shut and labeled. All impounded milk was placed in a locked, 3 door upright refrigerator in the
kitchen. The church will be open tomorrow, and the refrigerator accessible, between 8AM and 12 noon.

l
To: Steven Kurtz November 27, 2017
Pennsylvania Department of Agriculture

From: James F. Macri

Plant Manager
Lehigh Valley Dairies
880 Allentown Road
Lansdale, Pa 19446

Subject: Milk Complaint-School of the Nativity, Burke Virginia

Mr Kurtz, per our conversation on Wednesday, November 22, 2017 regarding the complaint received
from Maria Kelly, principal at School of the Nativity.

Product: TruMoo 8oz Fat Free Chocolate Milk

Expiration Code: November 27th.

Production Time Stamp: 16:31(produced on Friday November 10th)

Complaint: Food Grade Sanitizer in the milk cartons.

Sanitizer: Ecolab - Vortexx food grade sanitizer. Diluted state.

Findings: I met with our production manager, Robert Dugan and QA manager, Amanda Beidler. The filler
operator was interviewed. We reviewed the production records from that day. We confirmed 16:31
military time (4:31 PM) was the start of the chocolate run that day. Operator stated he followed the
proper changeover protocol of pulsing the filler until the sanitizer was evacuated. This is followed by
two full cases of product (50 units per case) to be sent to dump. First off samples are brought to our
quality assurance lab for testing and flavoring. Moving forward we have tripled the amount to 6 cases
being sent to dump. Additionally, since this is a 4 lane filler, first off samples from all 4 lanes are now
being tested and flavored by our lab technicians.

Lehigh Valley Dairy takes food safety very seriously and we sincerely apologize for this occurring to our
valued customers. Please advise if you require any further information.

Regards,

James F. Macri
Plant Manager
Lehigh Valley Dairies