8.9.4.23 · B STAFF QUALIFICATIONS AND TRAINING

From the review of staff records, it was determined that 8 out of 8 new staff does/do not have documentation of orientation training. See Staff Records 8.9.4.23 form for staff with missing documentation. Immediate: CORRECTED ON SITE On 2/26/25 the director asked staff to sign the NEO forms. Preventative: The director will ensure that new staff complete the NEO forms at time of trainings. Monitoring: On 3/3/25 the director will monitor the staff files monthly for the next six months.

Corrected Corrected by Feb 26, 2025

Marked corrected in the state record.

8.9.4.23 · C STAFF/CHILD RATIOS AND GROUP SIZES

The center failed to post the capacity for each activity/interest area. 3 out of 4 classrooms failed to post the capacity for each activity/interest area. Immediate: CORRECTED ON SITE Preventative: 3/3/25 the director will check weekly that capacities are posted. Monitoring: The director will use a checklist to monitor for compliance twice a year through the next 12 months. Services and Care of Children in Centers:

Corrected Corrected by Feb 26, 2025

Marked corrected in the state record.

8.9.4.24 · B NAPS OR REST PERIOD

The center does not provide a clearly labeled individual bed, cot or mat for each child to ensure each child uses the same items between washing. Immediate: CORRECTED ON SITE Preventative: On 2/26/25 the director will meet with the staff to ensure cot are labeled at all times. Monitoring: The director will conduct walk throughs of classrooms monthly to ensure compliance.

Corrected Corrected by Feb 26, 2025

Marked corrected in the state record.

8.9.4.24 · G PHYSICAL ENVIRONMENT

Functional identifiable learning areas are not provided in the Preschool, School Age class room(s). Immediate: CORRECTED ON SITE Preventative: 3/3/25 the director will check weekly that learning areas are posted. Monitoring: The director will use a checklist to monitor for compliance twice a year through the next 12 months.

Corrected Corrected by Feb 26, 2025

Marked corrected in the state record.

8.9.4.24 · J OUTDOOR PLAY AREAS

The fall zone underneath the slide is not adequate as evidenced by the energy absorbent material is not uniformly spread over the fall zone area. Immediate: On 2/26/25 the director has informed maintenance that the fall zone needs to be uniformly spread under the slide. Preventative: On 3/3/25 the director will add to the weekly checklist for the maintenance to review fall zone material. Monitoring: The director will monitor the checklist monthly through the next 12 months. The director will provide document of correction. 02/26/2025 http://www.nmececd.org 4 of 6 Evangel Christian Academy 4000809 Services and Care of Children in Centers: (continued)

Corrected Corrected by Mar 26, 2025

Marked corrected in the state record.

8.9.4.29 · A HOUSEKEEPING

The fixtures are not in good repair as evidenced by School Age classroom: The girl's restroom, one toilet is not operable. the boy's restroom, tow toilets and two sinks are not operable or functioning properly. Immediate: On 2/26/25 the management met with maintenance to ensure the repair was scheduled. Preventative: On 3/3/25 the director will ensure the toilets and sinks in the restrooms are operable daily. Monitoring: The director will have maintenance check monthly for operational toilets and sinks through the next 12 months. The director will notify licensing when the corrections are made for a site visit. 02/26/2025 http://www.nmececd.org 5 of 6 Evangel Christian Academy 4000809 Building, Ground and Safety Requirements for Centers: (continued)

Corrected Corrected by Mar 25, 2025

Marked corrected in the state record.

8.9.4.29 · H SAFETY COMPLIANCE

The center failed to conduct a fire drill for the month(s) of October, December. Immediate: On 3/3/24 the director will create a tracking system to schedule fire drills and document on a log. Preventative: On 3/3/24 the director will log each fire drill monthly. Monitoring: The director will monitor the fire drill logs twice a year for compliance The director will provide a copy of the correction.

Corrected Corrected by Mar 26, 2025

Marked corrected in the state record.

8.9.4.22 · F PERSONNEL RECORDS

From the review of staff records, it was determined that 2 out of 6 staff records does/do not include a professional development plan based on seven areas of competency. See Staff Records 8.9.4.22 form for staff who need a current plan. Immediate Action: On 8/29/24 the director will meet with staff to complete Professional development plan. Preventative Action: 9/3/24 the director will utilize a checklist to monitor professional development plans quarterly. 08/22/2024 http://www.nmececd.org 2 of 5 Evangel Christian Academy 4000809 Administrative Requirements for Centers: (continued)

Corrected Corrected by Sep 23, 2024

Marked corrected in the state record.

8.9.4.23 · B STAFF QUALIFICATIONS AND TRAINING

Educators did not complete the following training within 3-months: first aid and cardiopulmonary resuscitation (CPR) certification; 1 out of 6 staff. Immediate Action: On 8/23/24 the director will meet with staff to schedule a training. Preventative Action: 9/3/24 the director will utilize a checklist to monitor required trainings quarterly.

Corrected Corrected by Sep 23, 2024

Marked corrected in the state record.

8.9.4.22 · A ADMINISTRATIVE RECORDS

The center failed to display in a prominent place that is readily visible to parents, staff and visitors the most recent environmental health inspection report. Expired 8/2023. Will reach out to Environmental Health.

Corrected Corrected by Oct 12, 2023

Marked corrected in the state record.

8.9.4.22 · F PERSONNEL RECORDS

From the review of staff records, it was determined that 2 out of 11 staff records does/do not include the staff's position. See Staff Records 8.9.4.22 form for staff with this missing information. Will add missing elements to staff files. 8.9.4.22.F.1.c.:current and past duties and responsibilities; Finding From the review of staff records, it was determined that 2 out of 11 staff records do/does not include the staff's current and past duties and responsibilities. See Staff Records 8.9.4.22 form for staff with this missing information. Corrective Action Plan Will add missing elements to staff files. 8.9.4.22.F.1.n.:written plan for ongoing professional development for each educator, including the director, that is based on the seven areas of competency, consistent with the career lattice, and based on the individual’s goals; and Finding From the review of staff records, it was determined that 11 out of 11 staff records does/do not include a professional development plan based on seven areas of competency. See Staff Records 8.9.4.22 form for staff who need a current plan. Corrective Action Plan Will complete professional development plans for each employee. 8.9.4.22.F.1.o.:signed acknowledgment that the staff have read and understand the personnel handbook; Finding From the review of staff records, it was determined that 3 out of 11 staff records does/do not include signed acknowledgement that the personnel handbook had been read and understood. See Staff Records 8.9.4.22 form for staff who need to complete the acknowledgement. Corrective Action Plan Will have staff complete missing acknowledgment. 8.9.4.22.F.1.p.:signed acknowledgement that all staff have reviewed and are aware of the center’s disaster preparedness plan, plan for care during a public health emergency, and evacuation plan. Finding From the review of staff records, it was determined that 3 out of 11 staff records does/do not include signed acknowledgement that the center's disaster preparedness plan, public health emergency plan, and fire evacuation plan were reviewed. Corrective Action Plan Will have staff complete missing acknowledgment. 09/12/2023 http://www.nmececd.org 3 of 8 Evangel Christian Academy 4000809 Personnel (continued) 8.9.4.22.F.1.k.:confidentiality form; Finding From the review of staff records, it was determined that 1 out of 11 staff records does/do not include a signed confidentiality form. See Staff Records 8.9.4.22 form for staff who need to complete a signed confidentiality form. Corrective Action Plan Will have staff complete missing acknowledgment. 8.9.4.22.F.1.f.:an annual signed statement that the staff member would or would not be disqualified as a direct provider of care under the most current version of the Background Checks and Employment History Verification provisions pursuant to 8.9.6 NMAC; Finding The center failed to have 1 out of 11 person(s) providing care to sign an annual statement that they have, or have never had, an arrest or substantiated referral to a child protective services agency. See Staff Records 8.9.4.22 form for staff with this missing information. Corrective Action Plan Will have staff complete missing acknowledgment. 8.9.4.22.F.1.j.:universal precaution acknowledgment form; Finding From the review of staff records, it was determined that 1 out of 11 staff records does/do not include a signed universal precaution acknowledgement form. See Staff Records 8.9.4.22 form for staff with missing documentation. Corrective Action Plan Will have staff complete missing acknowledgment.

Corrected Corrected by Oct 12, 2023

Marked corrected in the state record.

8.9.4.23 · B STAFF QUALIFICATIONS AND TRAINING

From the review of staff records, it was determined that 4 out of 11 staff does/do not have documentation of the 45-hour entry level course or an approved equivalent prior to or within six months of employment. Will obtain 45-hour or equivalent for each staff member. 09/12/2023 http://www.nmececd.org 4 of 8 Evangel Christian Academy 4000809 Personnel (continued) 8.9.4.23.B.2.b.:All new educators regardless of the number of hours per week will complete the following training within three (3) months of their date of hire. All current educators will have three months to comply with the following training from the date these regulations are promulgated: Finding Educators did not complete the following training within 3-months: CPR Training(2 out of 11 staff). Health and Safety Training (1 out of 11 staff). 8.9.4.23.B.2.a.:The director will develop and document an orientation and training plan for new staff members and volunteers and will provide information on training opportunities. The director will have on file a signed acknowledgment of completion of orientation by employees, volunteers and substitutes as well as the director. New staff members will participate in an orientation before working with children. Initial orientation will include training on the following: Finding From the review of staff records, it was determined that 3 out of 11 new staff does/do not have documentation of orientation training. See Staff Records 8.16.2.22 form for staff with missing documentation. Corrective Action Plan Will have staff complete missing NEO.

Corrected Corrected by Oct 12, 2023

Marked corrected in the state record.

8.9.4.23 · C STAFF/CHILD RATIOS AND GROUP SIZES

The center failed to post the capacity for each activity/interest area. 1 out of 4 classrooms failed to post the capacity for each activity/interest area. The educator will add center capacities for each area. Services and Care of Children in Centers:

Corrected Corrected by Oct 12, 2023

Marked corrected in the state record.

8.9.4.24 · A1 GUIDANCE

Of the 11 staff's records reviewed, 1 is/are missing a signed staff acknowledgement that the center's guidance policy had been read and understood. See the Children's Records 8.16.2.22 form for the child(ren) who have this missing. The Director will have staff complete missing acknowledgment.

Corrected Corrected by Oct 12, 2023

Marked corrected in the state record.

8.9.4.24 · B NAPS OR REST PERIOD

The center does not provide a clearly labeled individual bed, cot or mat for each child to ensure each child uses the same items between washing. The educator will add labels to cots.

Corrected Corrected by Oct 12, 2023

Marked corrected in the state record.

8.9.4.29 · H SAFETY COMPLIANCE

The center does not have verification of an annual fire inspection from the fire authority having jurisdiction. 8/2023 The Director will reach out to the Fire Authority. 09/12/2023 http://www.nmececd.org 7 of 8 Evangel Christian Academy 4000809 Building, Ground and Safety Requirements for Centers: (continued)

Corrected Corrected by Oct 12, 2023

Marked corrected in the state record.