191604061-3-2-2026-30-CC-TCHS-DRSW52-20260302155824

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191604061
Report Date: 03/02/2026
Date Signed: 03/02/2026 03:58:47 PM

Document Has Been Signed on 03/02/2026 03:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	HICKORY TREE PRESCHOOL		FACILITY NUMBER:	191604061
ADMINISTRATOR/ DIRECTOR:	JENNIFER WALLA		FACILITY TYPE:	850
ADDRESS:	21720 MADRONA AVENUE		TELEPHONE:	(310) 533-4830
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY: 100	TOTAL ENROLLED CHILDREN: 100	CENSUS: 52	DATE:	03/02/2026
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Sandy Hallworth		TIME VISIT/ INSPECTION COMPLETED:	04:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 03/02/2026 Licensing Program Analyst (LPA) Tyra Chavies, conducted an unannounced 3 Year Annual Required inspection at Hickory Tree Preschool. LPA met with administrator and toured the facility indoors and outdoors. Days and hours of operation are Monday through Friday 7:00 AM to 6:00 PM. LPA Chavies confirmed the phone number is: (310) 533- 4830 and email address is: dumpty12@aol.com. There were 52 children in care being supervised by 5 Staff members. This facility has 4 classrooms, MoonJumpers, Tigers, Sunshine, and Pre-Kindergarten and all classrooms are currently being used. This facility also has an Elementary school attached and is located behind the facility. The elementary school can not be accessed from the facility. Parents and elementary school children do enter through the front door of the facility and have a sign in sheet available on the front desk. Indoor furniture and equipment are in good condition, free of sharp, loose and/or pointed parts. LPA observed cots for sleeping and bedding will be taken home every Friday for parents to wash and bring back to the classroom. If a parent forgets a blanket, then there is an option to purchase one from the facility. LPA also observed age appropriate toys, books in primary care area and children's restrooms.

NAME OF LICENSING PROGRAM MANAGER: Karren Starks
NAME OF LICENSING PROGRAM ANALYST: Tyra Chavies
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: HICKORY TREE PRESCHOOL	FACILITY NUMBER: 191604061
	VISIT DATE: 03/02/2026

NARRATIVE

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The facility floors, bathroom and classrooms meet Title 22 Health and Safety regulations. If a child is not feeling well, the child will be seated in the front office with a staff member until a parent arrives. LPs inspected and verified that there is a fire system connected throughout the facility. The facility does have a fire extinguisher and has one or more functioning carbon monoxide detectors. The facility does have a First Aid kit and it is in good condition. LPA reviewed sign in and out sheet. LPA advised administrator that all children must be signed in/out and must provide time of day when entering the facility.

LPA inspected the outdoor activity space. Administrator advised LPA that the playground is shared with the elementary school but children always remind separate. This facility does have a play structure. LPA advised administrator that the surface of the outdoor activity space must be repaired and the play structure. Administrator advised LPA the facility is in the beginning stage of repairs and will have it done. All materials and surfaces accessible to children are toxic free. There are 3 places in the facility that contains heavy amounts of Sand. Administrator advised LPA, that the elementary teachers are supposed to check the sandbox in the morning and clean them if anything is found. LPA inspected toys and spading equipment. All are in good condition.

Facility has one or more functioning carbon monoxide detectors/ smoke alarms. Parents are required to provide lunch and the facility will provide AM/PM and a third snack. If parents do not bring their own meals, the facility will call parents and provided a food until the parents arrive. Drinking water is available both indoors and outdoors and upon request. On 09/12/2025, LPA Chavies conducted an inspection regarding Lead Testing. The facility is still in compliance.

NAME OF LICENSING PROGRAM MANAGER: Karren Starks
NAME OF LICENSING PROGRAM ANALYST: Tyra Chavies
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: HICKORY TREE PRESCHOOL	FACILITY NUMBER: 191604061
	VISIT DATE: 03/02/2026

NARRATIVE

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POSTING REQUIREMENTS: License and other relevant notices are visible for public view and correctly posted on the wall (Facility Sketch, PUB 394, LIC 9148, LIC 610A). Fire and disaster drills are being conducted as scheduled every six months.

CHILDREN'S RECORDS: LPA Chavies reviewed 10 children's files. All files are up to date and are in good condition. LPA advised administrator to update LIC 613 A.

STAFF'S RECORDS: LPA Chavies reviewed 6 staff files. All staff records are up to date and in good condition. All Mandated Reporter Training , Pediatric First Aid and CPR are valid.

The following were also discussed with the director:

LPA Tyra Chavies informed executive director, Lisa Hung, that this report dated 03/02/2026 document 1 Type A citation, which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Tyra Chavies informed the executive director to provide a copy of this licensing report dated 03/02/2026 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

NAME OF LICENSING PROGRAM MANAGER: Karren Starks
NAME OF LICENSING PROGRAM ANALYST: Tyra Chavies
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: HICKORY TREE PRESCHOOL	FACILITY NUMBER: 191604061
	VISIT DATE: 03/02/2026

NARRATIVE

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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Commencing September 1^st, 2016, prohibits a person from being employed or volunteering at a childcare facility or family day care if he or she has not been immunized against influenza, pertussis and measles.

Law enacted by SB 277, beginning January 1^st, 2016, personal beliefs exemptions will no longer be an option for the vaccines that are currently required for entry into childcare or school in California. Personal beliefs exemptions already on file will remain valid until the child reaches the next immunization checkpoint.
A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment.
When regulations are approved/changed/updated, providers will be notified through Provider Information Notice (PIN).

NAME OF LICENSING PROGRAM MANAGER: Karren Starks
NAME OF LICENSING PROGRAM ANALYST: Tyra Chavies
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: HICKORY TREE PRESCHOOL	FACILITY NUMBER: 191604061
	VISIT DATE: 03/02/2026

NARRATIVE

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Per Title 22 of the California Code of Regulations, this facilityis being cited a 1 Type A, a Technical Violation and a Technical Assistance. (Please see LIC 809-D and LIC 9102.)

An exit interview was conducted with Executive Director, Lisa Hung.

A copy of this report was read and given to Executive Director well as LIC 9213 (Notice of Site Visit form.) LIC 9213 is required to be posted for 30 days.

NAME OF LICENSING PROGRAM MANAGER: Karren Starks
NAME OF LICENSING PROGRAM ANALYST: Tyra Chavies
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/02/2026 03:58 PM - It Cannot Be Edited

Created By: Tyra Chavies On 03/02/2026 at 03:04 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: HICKORY TREE PRESCHOOL	FACILITY NUMBER: 191604061
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

101229(a)(1)

Responsibility for Providing Care and Supervision

(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, 1 child in restroom with no staff present, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/02/2026
	Plan of Correction
1 2 3 4	Executive Director will have training with staff to review CCLD Supervision Regulations.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Karren Starks
NAME OF LICENSING PROGRAM MANAGER:

	Tyra Chavies
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/02/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026

LIC809 (FAS) - (06/04)

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