Pine Residential Villa

Type of visit: Prelicensing

On 11/13/25 Licensing Program Analysts (LPA) Alfonso Iniguez conducted a pre-licensing evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with Michelle Porca/Administrator. The licensee has applied for a license to serve (6) elderly residents ages 59 and older. The fire clearance is approved for (6) residents or which (5) can be non-ambulatory and (1) Bedridden in bedrooms: #2 or #5. The facility is located on a residential neighborhood, it consists of (6) bedrooms, (4) bathrooms, living room, dining room, kitchen, backyard with shaded area, office area, closet, employee’s lounge and an attached garage on the back. The following was observed during this visit: MEDICATIONS There is a locked centralized storage area for Resident medications. The evaluation Report continues on the next page, LIC 809-C PHYSICAL PLANT Facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68 degrees and 85 degrees. Open porches, and areas of potential hazard are well-lit and equipped with sturdy hand railings. Smoke alarms operate properly. Carbon monoxide detectors operate properly. BEDROOMS No client bedroom is a passageway to another room, bath or toilet. There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair. Mattresses and pillows are flame-retardant. There is dresser and closet space for each client that includes at least two (2) drawers or eight (8) cubic feet of dresser space per client. There is a chair and lamp for each client and at least one (1) nightstand per two (2) clients. BATHROOMS There is at least one (1) toilet and washbasin per six (6) clients, family, and personnel. There is at least one (1) shower or bathtub per ten (10) clients, family, and personnel. Hot water temperature is between 105-120 degrees Fahrenheit. Bathroom is located near client bedrooms. There are nightlights in the hallways outside non-private bathrooms. SUPPLIES There are client personal hygiene supplies to include soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths. The evaluation Report continues on the next page, LIC 809-C FOOD SERVICE Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0 degrees Fahrenheit. Refrigerator is a maximum of 45 degrees Fahrenheit. A seven (7) day supply of non-perishable food is present. There are sufficient amounts of tableware, tables, dishes, and utensils. There are sufficient amounts of equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. RECORDS There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility. ADMINISTRATION The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings. ACTIVITIES There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors. There are activity supplies to include board games and electronic gaming systems. The evaluation Report continues on the next page, LIC 809-C MISCELLANEOUS There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries. During this pre-licensing inspection, LPA did not find corrections are needed. LPA conducted the Component III Orientation with the Licensee and copy of this report was provided. A copy of the facility evaluation report will be available to the Central Applications Unit (CAU) for review.the state’s words, verbatim · CDSS document, Nov 13, 2025