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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343622855
Report Date: 04/24/2025
Date Signed: 04/24/2025 12:54:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/21/2025 and conducted by Evaluator Dao Vang
COMPLAINT CONTROL NUMBER: 03-CC-20250421153939
FACILITY NAME:MINDFUL MIRACLE, INC.FACILITY NUMBER:
343622855
ADMINISTRATOR:ASHLEY TEENEYFACILITY TYPE:
850
ADDRESS:1001 I STREETTELEPHONE:
(916) 889-3443
CITY:SACRAMENTOSTATE: CAZIP CODE:
95814
CAPACITY:36CENSUS: 13DATE:
04/24/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kochelle (Tiffany) SimmonsTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff left child unsupervised on the playground.
INVESTIGATION FINDINGS:
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On 4/24/2025 at 10:00 AM, License Program Analyst (LPA) Pa Dao Vang conducted a complaint investigation inspection made to the regional office on 4/21/2025 and an Unusual Incident/Injury Report submitted on 4/23/2025. LPA met with the Director Kochelle (Tiffany) Simmons regarding the above allegation of staff left a child unsupervised on the playground. Upon arrival, LPA observed 13 children supervised by 3 staff.

During today's inspection, LPA made an observation, conducted interviews, and review a file. According the S1’s interview, on the day of the incident 4/21/2025, C1 ran off into the play structure as the group of children gathered by the teachers to transitioned inside. Another teacher brought C1 back with the group by the door. When they transitioned inside, they noticed that the C1 was missing. They check the door and notice C1 at the door outside. Director stated the incident occurred around 11:30 AM. LPA learned there was a absence of supervision as C1 was outside alone for a couple of minutes.
Continue report on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 03-CC-20250421153939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MINDFUL MIRACLE, INC.
FACILITY NUMBER: 343622855
VISIT DATE: 04/24/2025
NARRATIVE
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Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is founded to be substantiated. California Code of Regulations, (Title 22, Division 12 & Chapter 1), are being cited on the attached LIC9099-D.

A Title 22 deficiency is being cited on the subsequent pages of this report on LIC809-D page. Director Kochelle (Tiffany) Simmons acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809-D page with Type A deficiency for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the Licensee. Director's signature on this report acknowledges receipt of these rights. This report was reviewed with Director Kochelle (Tiffany) Simmons. A copy of this report, appeal rights, LIC9224, and a notice of site visit was provided to be posted for 30 consecutive days.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 03-CC-20250421153939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MINDFUL MIRACLE, INC.
FACILITY NUMBER: 343622855
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2025
Section Cited
CCR
101229(a)(1)
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Responsibility for Providing Care and Supervision
(1) No child(ren) shall be left without the supervison of a teacher at any time,...Supervision shall include visual observation.
This requirement is not met as evidenced by:
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 Director will also train staff on proper supervison of children. Director will email LPA Vang a copy of the signed agenda and daily cleaning list by the POC due date.
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Based on interviews and Uusual Incident/Injury Report, the licensee did not comply with the section cited above, as C1 was left outside for a couple of minutes alone with absence of supervision. This poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
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