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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343624252
Report Date: 06/17/2025
Date Signed: 07/01/2025 12:48:18 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
06/16/2025 and conducted by Evaluator Dao Vang
COMPLAINT CONTROL NUMBER: 03-CC-20250616131359
FACILITY NAME:MINDFUL MOMENTS, INC.FACILITY NUMBER:
343624252
ADMINISTRATOR:SIMMONS, TIFFANYFACILITY TYPE:
850
ADDRESS:750 N STREETTELEPHONE:
(916) 626-2739
CITY:SACRAMENTOSTATE: CAZIP CODE:
95814
CAPACITY:72CENSUS: 30DATE:
06/17/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Ashley Winn and Jared WinnTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff left child unsupervised on the playground.
INVESTIGATION FINDINGS:
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This is an amended report.

On 6/17/2025 at 8:45 AM, License Program Analyst (LPA) Pa Dao Vang and Licensing Program Manager (LPM) Seychelle De Luca conducted an unannounced complaint investigation inspection made to the regional office on 6/16/2025. LPA met with the Licensee Ashley and Jared Winn regarding the above allegation of staff left child unsupervised on the playground. Upon arrival, LPA and LPM observed 30 children supervised by 7 staff.

During today's inspection LPA and LPM made observation, conducted interviews,reviewed documents, and the electronic sign-in and out app. Based on interviews, LPA learned that a preschool child was left outside on the preschool ramp by themselves for about a minute. LPA learned staff saw the child through the window and went outside to bring them in immediately.

Continue on LIC9099-C...



Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
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-20250616131359
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: 343624252
VISIT DATE: 06/17/2025
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 LIC9099-D page. Licensee Ashley and Jared Winn acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 9099-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. Licensee's signature on this report acknowledges receipt of these rights. This report was reviewed with Licensee Ashley and Jared Winn. 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: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 03-CC-20250616131359
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: 343624252
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/18/2025
Section Cited
CCR
101299(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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Licensee will track name to face children through sign-in and out app. Licensee will include this in the one-on-one meeting with each staff and will email LPA a signed copy by the POC due date.
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Based on interviews, LPA learned that a preschool child was left outside on the preschool ramp by themselves for about a minute. 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: 06/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3