VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Open Door Learning Center
601 Catoctin Circle NE
Leesburg, VA 20176
(703) 777-6010

Current Inspector: Sarah Marbert (703) 479-4678

Inspection Date: Jan. 18, 2023

Complaint Related: No

Areas Reviewed:

8VAC20-780 Administration. 8VAC20-780 Staff Qualifications and Training. 8VAC20-780 Physical Plant. 8VAC20-780 Staffing and Supervision. 8VAC20-780 Programs. 8VAC20-780 Special Care Provisions and Emergencies 8VAC20-780 Special Services. 8VAC20-820 THE LICENSE 8VAC20-820 THE LICENSING PROCESS 8VAC20-820 HEARINGS PROCEDURES 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect

Technical Assistance:

Discussed with Director: Attendance sheet documentation for children leaving the facility and returning, returning outdated medication to parents

Comments:

An in person renewal study was conducted today. All rooms are in ratio during the inspection. Emergency evacuation drills, shelter-in-place drills, emergency supplies, lunches labeled and dated, injury reports, injury prevention plan update and playground are all in compliance. Violations discussed with Director during the exit interview. See Violation notice for non-compliances. If you have any questions regarding this inspection you may contact me at (703) 479-4678 or at Sarah.Marbert@doe.virginia.gov. LI was present today from 9:23AM - 11:10 PM.

Violations:

Standard #:	22.1-289.036-B-2
Description:	Based on a review of records, one applicant did not have an completed Sworn Disclosure Statement (SDS) on file prior to becoming a Board Officer. Evidence: No SDS document was available for review for a Board Member dated when they became a Board Member. (Member A)
Plan of Correction:	I will maintain close contact with HR to make sure all required documents are maintained.
Standard #:	8VAC20-780-130-A
Description:	Based on a review of records, one child record does not contain documentation of an immunization record prior to attending the center. Evidence: 1 of 2 records reviewed did not contain any documentation of an immunization record. (Child 1: DOE 10/24/22)
Plan of Correction:	I have contacted the parent to ask that they retrieve the form from the doctor as soon as possible.
Standard #:	8VAC20-780-140-A
Description:	Based on a review of records, one child record did not contain documentation of a completed physical past 30 days of enrollment. Evidence: 1 of 2 records reviewed did not contain a completed physical. (Child 1: Date of Enrollment: 10/24/22)
Plan of Correction:	I will contact parent to ask that they retrieve the form from the doctor as soon as possible.
Standard #:	8VAC20-780-60-A-8
Description:	Based on a review of records, one child record does not contained documentation of an allergy action plan with physician's instructions for a diagnosed food allergy. Evidence: 1of 2 child records reviewed did not contain documentation of an allergy action plan for a food allergy to nuts, peanuts. (Child 1)
Plan of Correction:	I will reach out to the parents to ask that they provide an allergy action plan signed by the doctor.
Standard #:	8VAC20-780-70
Description:	Based on a review of records, one staff record does not contain all required components. Evidence: 1 of 3 staff records reviewed was missing documentation of education to qualify them for a lead teacher position. (Staff A)
Plan of Correction:	I will obtain staff's education documents from HR as soon as possible.
Standard #:	8VAC20-780-245-A
Description:	Based on a review of records, staff records do not include documentation of 16 hours of annual training. Evidence: The training record for 1 staff member does not include 16 hours of annual training for 2021. 5 hours were documented. (Staff B)
Plan of Correction:	I will have all documentation for staff recorded on the training form with certificates.
Standard #:	8VAC20-780-245-M
Description:	Based on a review of records, staff records do not contain acceptable documentation of on-going training. Evidence: Documentation requirements for on-going training include: training method delivery, evidence that training on the topic required was completed (ie. certificate).
Plan of Correction:	I will have all documentation of trainings recorded on the log as well as method.
Standard #:	8VAC20-780-270-A
Description:	Based on observation, a door in a classroom is not maintained in a safe manner. Evidence: The 1/2 door in the Starfish room has exposed edges at the top of the door exposing the interior of the door.
Plan of Correction:	I will reaxh out to maintenance and have them fix the door.
Standard #:	8VAC20-780-340-A
Description:	Based on multiple staff statements, the center is not ensuring care and protection to a child in care. Evidence: Staff were unable to locate an EpiPen for a child in care that has a diagnosed food allergy. Staff stated the medication was in the office, the office stated the medication was in the classroom. The medication could not be located during the inspection. (Child 2)
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-440-F
Description:	Based on direct observation, rest mats used are not able to be cleaned and sanitized. Evidence: Multiple rest mats, in multiple rooms have holes or tears exposing the inside foam. The mats cannot be sanitized with exposed foam.
Plan of Correction:	I will obtain new rest mats for all children.
Standard #:	8VAC20-780-440-F
Description:	Based on direct observation, rest mats used are not able to be cleaned and sanitized. Evidence: Multiple rest mats, in multiple rooms have holes or tears exposing the inside foam. The mats cannot be sanitized with exposed foam.
Plan of Correction:	I will designate a desired area to keep student's Epi-pen in, and assure that parents provide a new one if it expires.
Standard #:	8VAC20-780-510-F
Description:	Based on a review of documentation, one medication does not have an authorization available for review. Evidence: 1 child's Epi-pen at the facility does not have an authorization available for review. (Child 1)
Plan of Correction:	I will ask the parent to complete the authorization as soon as possible.
Standard #:	8VAC20-780-510-I
Description:	Based on a review of medication, one medication is not maintained in the original, labeled container. Evidence: Based on observation, on Epi-pen at the facility is not in the original box with a prescription label attached. (Child 1).
Plan of Correction:	I have contacted the parents to ask that they provide the original label (box).