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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343624251
Report Date: 12/10/2025
Date Signed: 12/10/2025 04:56:30 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
10/02/2025 and conducted by Evaluator Dao Vang
COMPLAINT CONTROL NUMBER: 03-CC-20251002120435
FACILITY NAME:MINDFUL MOMENTS, INC.FACILITY NUMBER:
343624251
ADMINISTRATOR:SIMMONS, TIFFANYFACILITY TYPE:
830
ADDRESS:750 N STREETTELEPHONE:
(916) 626-2739
CITY:SACRAMENTOSTATE: CAZIP CODE:
95814
CAPACITY:56CENSUS: 17DATE:
12/10/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ashely WinnTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility did not provide parents with licensing reports documenting Type A deficiencies.
The facility allows children to play with toys and equipment that are not age-appropriate.
INVESTIGATION FINDINGS:
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On 12/10/2025 at approximately 9:30 a.m., License Program Analyst (LPAs) Pa Dao Vang and Amanda Sutter conducted a complaint investigation inspection and met with the Director Ashely Winn. It was alleged the facility did not provide parents with licensing reports documenting Type A deficiencies and the facility allows children to play with toys and equipment that are not age-appropriate.

On 10/08/2025, 10/21/2025, 11/20/2025, and 12/10/2025, LPAs conducted an inspection, made observations, collected documentations, and conducted interviews.

The facility was cited two Type As on 6/17/2025 and LPA reviewed and provided the LIC9224 form to the Licensee.

Continue on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
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-20251002120435
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 MOMENTS, INC.
FACILITY NUMBER: 343624251
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
01/10/2026
Section Cited
CCR
101438.3(e)
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Indoor Activity Space for Infants
(e) The indoor activity space shall be equipped with a variety of age-appropriate washable toys and equipment.
This requirement is not met as evidenced by:
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The toys were removed immediately from the classoom by the staff.
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Based on LPA Vang's observation on several age-inappropriate toys accessible to children in the Toddler classroom on 11/20/2025. The toys were removed by the staff and Licensee immediately. This poses an immediate health, safety or personal rights risk to persons in care.
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LPA Vang received the signed LIC9224 forms for a list of children from Jared Winn via email on 10/17/2025 & 10/24/2025. These were forms from both the infant and toddler classrooms.
Request Denied
Type B
01/10/2026
Section Cited
HSC
1596.8595(c)(4)
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(c)(1) A licensed child day care facility shall provide... copies of any licensing report that documents any type A citation ... (4) The licensee shall keep verification of receipt in each child's file.
This requirement is not met as evidenced by:
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Based on observation, interview, record review, the licensee did not comply with the section cited above when new families were not given the LIC9224 forms unpon enrollment, which posed a potential 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: 12/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 03-CC-20251002120435
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 MOMENTS, INC.
FACILITY NUMBER: 343624251
VISIT DATE: 12/10/2025
NARRATIVE
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On 10/8/2025, the Licensee stated that they gave the LIC9224 forms to parents in the infant classroom to sign at the time of the citations were assessed. It was sent through Brightwheel to the parents. Licensee also stated that there were one to two children that started 30 days prior who didn’t sign an Acknowledgment of Receipt of Licensing Reports. LPA discussed the requirements with the Licensee and informed them that parents/guardians of children in currently enrolled and newly enrolled (within 12 months of the citation) must sign an Acknowledgment of Receipt of Licensing Reports, and the receipt notification must be kept with the children's forms as a receipt whenever any Type A documents are provided by the License. Through LPA’s file review, three infants enrolled in July 2025 and another child enrolled in September 2025. Licensee used the form LIC9224 as the Acknowledgment of Receipt of Licensing Reports. These forms for these 4 children were signed and dated on in October 2025 by the parents.

During the inspection on 11/20/2025, LPA Vang observed two containers of different age-inappropriate toys on the shelf of the Toddler classroom. It included a container of the wooden gem stone blocks (less than 2 inches) and colorful interlocking cubes (less than an inch each). Based on LPA’s search on the items, the wooden gem stone blocks and colorful interlocking cubes are designed for 3 years old or older. The Licensee and two other staff stated that the children in the toddler room are ages 1 to 2 years old.

Based on observations and interviews, the preponderance of evidence results in substantiating the allegations of the facility did not provide parents with licensing reports documenting Type A deficiencies and the facility allows children to play with toys and equipment that are not age-appropriate.

Based on LPA’s observations, interviews, and file reviews, there are Title 22 deficiencies being cited in accordance with California Code of Regulations, (Title 22, Division 12 & Chapter 1), are being cited on the attached LIC9099-D page. An exit interview, a copy of this report, and the appeal rights were provided to Director Ashely Winn. A Notice of Site Visit is also provided to the Director and remains posted for 30 consecutive days. Failure to comply with posting requirements can result in a $100 penalty.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC9099 (FAS) - (06/04)
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