HomeMy WebLinkAbout007-550-028_7_3_90-4_9_04ire Prevention Bureau
76 Nelson Avenue
)roville, CA 95965
elephone 530-538-7888
ax 530-538-2105
Address:
Manager:
Owner.
,.+►
3utte County Fire Rescue
California Department of Forestry
and Fire Protection
Facility Inspection Report
Business Name:
Bus:
Bus:
Bus:
AM..
White Copy - Business
Yellow Copy — Occupancy File
Pink Copy — Station File
Occ. Class.
Hm:
Hm:
Hm:
Fax:
AN INCPF.C'TION OF VOITR FACILITY REVEALED THE FOLLOWING:
1.
Fire Extinguishers: Required, service due
10.
Exit(s) obstructed, inadequate
2.
Extension cords: Excess use, defective
11.
Exit sign(s) required, illumination
3.
Excessive rubbish, trash, debris
12.
Exit sign lights need replacing
4.
Fire alarm system defective
13.
Exit lighting: Required, defective
5.
Sprinkler system: Service required, defective
14.
Smoke detectors: Required, defective
6.
Kitchen hood extinguishing system service due
15.
Wiring: Exposed, damaged connectors, etc.
7.
Fire walls, ceilings, fire doors, draft stops
16. Heating system: Defective appliance, flue combustibles
8.
Knox Box keys
17.
Address posted and visible from road
9.
Fire Drill Witnessed Yes ❑ No ❑
18.
Other
DETAILED EXPLANATION AND CORRECTIONS: CORRECTED:
Date: Discussed with: Signed.
(Print)
Inspecting Officer:
Battalion 1 2 3 4 5 6 7 1 Station: FPB `
FIRE PREVENTION SAVES LIVES, PROPERTY, AND BUSINESS. YOUR COOPERATIO WITH
CORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATEt
A -0h, AIW
re Prevention Bureau utte County Fire Rescue White Copy - Business
76 Yelson Avenue California Department of Forestry Yellow Copy — Occupancy File
roville, CA 95965 and Fire Protection Pink Copy — Station File
1i01'. hn"A '530-538-78881V J,I,, -time action Re ort Occ. Class.
F
ax 530-538-2105
Address: 1-�jal Cky_j�Akva (j Business Name:
O"er/Manager: KATO'( BA,e Bus: Hm: Fax.
�ssistant Manager: 1 1 us: C., Hm: J
uilding Owner. AA Z4�1 C F A L r- Bus: Hm:
ddress:
A 1V YWQ1D1WC1rr7nV n1V VnIT12 FACn,lrrV 12-FV1FAJ.FD THE F( LLOWYNG:
1.
Fire Extinguishers: Required, service due
10.
Exit(s) obstructed, inadequate
2.
Extension cords: Excess use, defective
11.
Exit sign(s) required, illumination
3.
Excessive rubbish, trash, debris
12.
Exit sign lights need replacing
4.
Fire alarm system defective
13.
Exit lighting: Required, defective
5.
Sprinkler system: Service required, defective
14.
Smoke detectors: Required, defective
6.
Kitchen hood extinguishing system service due
15.
Wiring: Exposed, damaged connectors, etc.
7.
Fire walls, ceilings, fire doors, draft stops
16.
Heating system: Defective appliance, flue combustibles
8.
Knox Box keys
17.
Address posted and visible from road
9.
Fire Drill Witnessed Yes 0
18.
Other
DETAILED EXPLANATION AND CORREUTIONS: l VKttL1 I Eju:
ti , kc
Ac�c� I T
i:,x r t
TV& -Z c -6
v- I I
IDate:
Discussed with:
Signed:
(Print)
Inspecting Officer:
Battalion 1 2 3 4 '5 6 7
Station: FPB
FIRE PREVENTION SAVES LIVES, PROPERTY, AND BUSINESS. YOUR COOPERATION WHM
CORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE:
0
r.
To email this form do the foilowin :
1. Click on " Ft'ie rt
2. Click "Save"
3. Click on "File" again
4. Click on "Send To"
S. Click on "Mail recipient"
6. Address. to Cyndi Wilson
7. Click "Send this Sheet"
Business Nam
Bate of f 1 t /VD
ns 'on 3 �-I o.
Number of Violations
I ns or Narrte
Reins 'on Date AJS
I ft. 44: ?- -,o X
This form has been emailed to all stations.
the need to Vlil�en they complete the tnsp��ction
Y email or fax this for to me and then send our co •
copy of the inspection form.
Cyndi Wilson
> LAN
t
1
4
Fu•e Prevention Bureau Butte County Fire Rescue White Copy -Business
117§,Nelson Avenue California Department of Forestry Yellow Copy — Occupancy File
Oroville, CA 95965 and Fire Protection Pink Copy — Station File
Telephone 530-538-7888 Facility Inspection Report Occ. Class. l
Fax 530-538-2105
Address: -.-, Business Name: ".'
Q, wner/Mmger� 1 s 4F 4 +J {;�• �BuQ • ..• , MsiNm • FNf•
�siswit Manager: •. P, . , Bus: :: Hm:
..
ding Owner: /I Bus: Hm:
z t7"
Address:
AN INSPECTION OF YOUR FACILITY REVEALED THE FOLLOWING:
1.
Fire Extinguishers: Required, service due
10. Exit(s) obstructed, inadequate
2.
Extension cords: Excess use, defective
11. Exit sign(s) required, illumination
3.
Excessive rubbish, trash, debris
12. Exit sign lights need replacing
4.
Fire alarm system defective
13. Est lighting: Required, defective
115.
Sprinkler system: Service required, defective
14. Smoke detectors: Required, defective
�j 6.
Kitchen hood extinguishing system service due
15. Wiring: Exposed, damaged connectors, etc.
117.
Fire walls, ceilings, fire doors, draft stops
16. Heating system: Defective appliance, flue combustibles
118.
Knox Box keys
17. Address posted and visible from road
1-9.
Fire Drill Witnessed Yes ❑ No @�
18. Other
ETAILED EXPLANATION AND CORRECTIONS: CORRECTED:
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Date: _. �
• ,,
Discussed with:
Signed., .:'
♦.yAr} �.fir - ,i - ` "•7
(Print)JL.
Ins sm. Offic r:
J nation 1 2 3 •t5 6 7
Station: FPB
PREVENTION SAVES LIVES, PROPERTY, AND BUSINESS. YOUR COOPERATION7RE , WITH
ORRECTING TREE ABOVE LISTED ITEMS IS APPRECIATED. nE-wsmc oN DATE: � A
Office of the Slate Fire Marshal
� REGIONAL �
FACiLfTY FILE CHANGE NOTICE
Name Collection/Change Change—Fill Number
Address Correction/Change El Facility Discontinued
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STATE FIRE MA HAL
El Issue File Number
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Comments. -
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IN -13 (Rev. 7/86)
"400'LIFORNIA
AMIN /Ommw�
FIRR SAFETY INSPECTION REM 10'T
STD.` 50 REV. 10-94) See instructions on reverse.
AGEN Y CONTACTS NAME TELEPHONE NUMBER REQUEST DATE
S /C0 Wrff CAT -LICENSING (1130 895-5033 03/1.1/9
EVAL&IOR'S NAME
REQUESTING AGENCY FACILITY NUMBER
0• REQUESTING
GURRIERE 045000613
DEPARV EIR,
T -OF -
LI E SING M SOCSERVICES:
CY' C01P�JN =LICENSING
NA
ANQ 520: 00HASSET ROAD WITZ 6
A DRESS
CICO CA 95926:,-
PROGRAM -
8
REQUEST CODE.
4A
CODES
1. ORIGINAL A. FIRE CLEARANCE
2. RENEWAL Bp_ LIFESAFETY
3. CAPACITY CHANGE'
4. OWNERSHIP CHANGE
5. ADDRESS CHANGE
6. NAME CHANGE
7. OTHER
SPEC AL CONDITIONS
AMBULATORY
NONAMBULATORY
BEDRIDDEN
TOTAL CAPACITY
CAPACITY
PREVIOUS CAPACITY
CAPACITY
PREVIOUS CAPACITY
CAPACITY
PREVIOUS CAPACITY
A -Ay.; �
r%
1 ------------------
6
CLEARANCE ./DENIAL CODE
-6
f a
0 1rrr1%% A All JKA
=OR
LICENSE CATEGORY
13RCF
STRE
DRESS (Actual Location)
NUMBER &"OUILDINWI
F' E #4 WIMIAMBURG UNESU A
2 i OAIK RANCH LANE
CITY
A j H RITY 9
U
RESTRAINT
CHI
CA 95973
NO
FACI
TY: CONTACT PERSON'S NAME
HOURS
A. D ESS
STAL RED (530) 343-2705 OR (530) 343-2565
24
SPEC AL CONDITIONS
ig: 1!X �1: R X.
IN,•�.. M, HE I ` N: i . 4 N MAN 0 rim
I I mo.-�
am, -m-W�. MKIM ea
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KIM
A W�m
:RK MIN ........•
�41 I
A -Ay.; �
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1 ------------------
CLEARANCE ./DENIAL CODE
JACK PIRISKY"
CODES.
1
F' E #4 WIMIAMBURG UNESU A
1. FIRE CLEARANCE GRANTED
A j H RITY 9
U
N:: AND MICO, CA 95926
2. FIRE CLEARANCE DENIED
A. D ESS
A. EXITS
L
B. CONSTRUCTION
C. FIRE ALARM
D. SPRINKLERS
INSPUCTOR'S NAME (Typed, or Printed?
KEPHONE NUMBER
CFIRS -NUMBER
OCCUPANCY CLASS
02, 2-.1
F. SPECIAL HAZARD
OUR
INS C—NIDATE
INSPECTOR'SSIGWAT
' d or Pri ted)
G. OTHER
J.
=4 . ......... ...
KA kINIAL'OR LIST SPECIAL CO UFFIUM
(L
Page—' of-
- _Cp
Of of the State Fire Marshal
INSPECTION REPORT
File NL.i.0
Name of Facility: _ (�� ,t , 9-c9-�� ` A Y,�L �
Nami? of Building:
CaAddres : (0 1
� �,k1 co 0 A o1 al
df ICE
�(i
STATE FIRE MAR HAL
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DATE -OF 111�MCVOW_•>;. ttt`3±.;i`�'', :t>r:' :':f►.T..w:r.�.<� ;.s.�''�4 . K, ...y`. ,•t:�, � :T�i ,.. �,(�� � �� ; .�'''«�'.?r:.j�;' .� -
Awnk�
!and return the certification on the opposite side of this form. If you have any questions,' contact the Office of the State
i ,
Fire Marshal at( } f
,'ISSUED BY (Deputy State Fire Marshal)
.An,
DATE
office of the State Fire Marshal
Fire Safety Correction Notice
ileNo:--------
— — — — --- --- —
Jame:
The California Health and Safety Code and the State Fire Marshal's regulations require the following fire safety
deficiencies be corrected.
i
I
IThe above deficiencies are to be corrected within days. When ALL deficiencies have been corrected, sign
!and return the certification on the opposite side of this form. If you have any questions,' contact the Office of the State
i ,
Fire Marshal at( } f
,'ISSUED BY (Deputy State Fire Marshal)
RECEIVED BY
DATE
I
IThe above deficiencies are to be corrected within days. When ALL deficiencies have been corrected, sign
!and return the certification on the opposite side of this form. If you have any questions,' contact the Office of the State
i ,
Fire Marshal at( } f
,'ISSUED BY (Deputy State Fire Marshal)
RECEIVED BY
DATE
EN -11 (Rev. 7/86) 86 96708 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field
O.y`,e of the State Fire Marshal
REINSPECTION REPOR'r
File o.: eC —
L2 --c Len
of Facility:
of Building:
CA�coo cz�'
VU
GO 5 (Rev. 7/86)
Discussed with: Title:
Accompanied
by: t- �..,:Q- Cid -00V `aTitle: 5--12-0
EPUTY STAT FIR
DATE OF REIN. EICTION
1 2
ire Safety Deficiencies Numbered noted on the Letter ❑
ire Safety Correction Notice (EN -11) ❑ dated "� " l�'-4ave been corrected.
ncorrected Deficiencies Numbered were re -issued as shown
n the Fire Safety Correction. Notice dated , which is attached to and made a part of this Report.
addition, new deficiencies were identified at the time of this reinspection, and are shown as Items
on the attached Fire Safety Correction Notice.
ire Clearance Instructions:
GO 5 (Rev. 7/86)
8tE GLEARANCE GRA
T -DATE
STATUS
EPUTY STAT FIR
DATE OF REIN. EICTION
1 2
GO 5 (Rev. 7/86)
STATE IN
E MARSHAL COPY DISTRIBUTION: SEE REVERSE OF COPIES 2 AND 5 FOR
FIRE -S FETY INSPECTION REQUEST 1 -3 -STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION
2 -FIRE AUTHORITY 1. REQUEST DATE 2- PROGRAM
STD 859(FEV. 8/86) 4--5-LICENSING AGENCY 8/24/94
3. AGENCY ;;CONTACT 4. TELEPHONE NO. 13.EVALUATOR
DS�/Community Care Licensing 1 (916) 895-5033 0207/Bob Caldwell
6. SFMA EG1ON
336
7. SFM I.D. NO.
& REQUESTING AGENCY FACILITY NO.
045000103
9. REQUEST CODE
7A
CODES
A AGORY CHANGE - FROM ADULT RES. TO ELDERLY
1. ORIGINAL A. FIRE CLEARANCE
2. RENEWAL B. LIFE SAFETY
RE ST FOR ONE CLIENT 65+*
3. CAPACITY CHANGE
4. OWNERSHIP CHANGE
10. AGEP IC Dept. of Social Services
S. ADDRESS CHANGE
NAME. Community Care Licensing
S. NAME CHANGE
AND 520 C o h a s s e t Rd. # 6
PREVIOUS NAME
ADD E S L Chico , CA 95926
7. OTHER
DATE OF ORIGINAL REQ.
11. AMB LKTORY
NONAMBULATORY
TOTAL CAP.
DATE OF LAST FIRE CLEARANCE
CAPACITY
AGE RANGE (YEARS)
PREVIOUS
CAPACITY
AGE RANGE (YEARS)
PREVIOUS
TO IS IS TO 65 AND
65 OVER
CAPACITY
6
TO IS IS TO 65 AND
65 OV X
CAPACITY
19. FACILITY
CODE
740/elderly
12. FACT ITY
NAME
13. NO. BLDGS
CODES
1. GACH 7. ICF / OT
2. GACH / R 8. ICF / DD
t
1
14. STREET
ADDRESS (ACTUAL LOCATION)
P.O. BOX
1 S. RESTRAINT
1*12C)l
Oak Ran ch Ln.
no
3. SH 9. ADHC
4. APH 10. CLINIC
CITY
ZIP CODE
16. HOURS
hi
CA
95926
4
5. PHF 11. JAIL
6. SNF 12. ICF / DDN
13. OTHER
17. FACI 17
athleen
CONTACT PERSON
Lockwood
TELEPHONE NO.
(916) 891-3591
16A. SPECIAL
TO BE COMPLETED BY
INSPECTING AUTHORITY
18. FIRECODE
Jack Pirisky
26. CLEARANCE
AUT OR #4 Williamsburg Ln. - Suite A
NAM Chico, CA 9.5926
AND
ADDRE s
I
CODES
1. FIRE CLEAR, GRANTED
2. FIRE CLEAR, DENTED
3. FIRE CLEAR, WITHHELD
27. DENIAL
CODE
TO BE COMPLETED BY INSPECTING AUTHORITY
CODES
21. INSPECTOR'S NAME
TELEPHONE NO.
22. CFIRS
23. T-19 OCC.
ID NO.
CLASS
. �
((��
PA G `t� �. Z'�
2 ZA
1. EXITS
2. CONSTRUCTION
3. FIRE ALARM
24. INS �TE 25. EC OR GN TUR
C �
r
r '
4. SPRINKLERS
5. HOUSEKEEPING
6. SPECIAL HAZARD
28. EXPLA DENIAL OR LIST SP IAL ONDITIONs
-n�a� L V ��
7. OTHER
NAAR L� �L
ETURN T0:
� F
20. REG ON.
OFF CE
AN
u
Dept. of Social Services
Community Care Licensing
520 Cohasset Rd.,#6`-
e o/
Uffice of the State Fire Marshal
� INSPECTION REPORT
Ln
of Facility:
of Building:
CA
..
�*
dEF qr
STATE FIRE MA AL
�.•t,� 7i
Accompanied
'scussed with:
by:
STATUS j
. , • , _ , .. ' - - ..
tz
ride,""......_alz��
�: .. .:� •_• '
C-50�� - /Z
t- - a �— I(4
rf
C, ( 2 A L
(1_
A
x, 25
I
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Y �
• 6 (Rev. 7/86)
Ctf1►RMlCE G'RAPtTm T -DAH
v
STATUS j
TATr
7 771
C-50�� - /Z
Y �
• 6 (Rev. 7/86)
Lei
la l�e of Facility:
arse of Building:
office of the State Fire Marshal
INSPECTION REPORT
01 O-Z:!-Pl
�fICE�
STATE FIRE MA AL
L
(Rev. 7/86)
V"
■,_/
(Rev. 7/86)
V"
STATE FIRE MARSHAL
FI A ETY INSPECTION C ON REQUE.
STD 85 EV. 8/86)
3. Ai
t
COPY DISTRIBUTION: SEE REVERSE OF COPIES 2 AND 5 FOR
1 -3 -STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION
2 -FIRE AUTHORITY 1. REQUEST DATE 12. PROGRAM
4^5 -LICENSING AGENCY 5-14,-92
CONTACT 4. TELEPHONE NO. a. EVALUATOR
,/COMMUNITY CARE LICENSING (916) 895-5033 0209/ECKERT
S. SPM REGION
7. SFM I.D. NO.
S. REQUESTING AGENCY FACILITY NO.
9. REQUEST CODE
041372999
3A
RESPONSE REQUIRED
CODES
1. ORIGINAL A. FIRE CLEARANCE
2. RENEWAL B. LIFE SAFETY
DEPARTMENT OF SOCIAL SERVIGE.S
3. CAPACITY CHANGE
4. OWNERSHIP CHANGE
10. AGE C
COA'Il MIY CARE LICENSING
a. ADDRESS CHANGE
NAME
520 COHASSET ROAD, SUITE 6
S. NAME CHANGE
AND
(NICD, CA 95926
PREVIOUS NAME
ADD E
S _
I
7. OTHER
- wi►.a- ti igct- -
-. .,w,•::If�„q. .. :`3�..'r'«' v.':;6.c.ti•itir
j},rY. `3 :« rt`. .
DATE OF ORIGINAL REQ.
11. AMB L
TORY
NONAMBULATORY
TOTAL CAP.
DATE OR LAST FIRE CLEARANCE
CAPACIT
6
AGE RANGE (YEARS)
TO 19 18 TO Sa AND
OVER
PREVIOUS
CAPACITY
CAPACITY
AGE RANGE YEARS)
TO 10 IS TO
as
63 AND
OVER
PREVIOUS
CAPACITY
4
6
19. FACILITY
CODE 735
12. FACT IT
NAME
13. NO. BLDGS
CODE'S
11
DS CARE HOME #2
1
1. GACH 7.1 ICF / OT
2. GACH/R 8. ICF lDD
14. STRT
ADDRESS (ACTUAL LOCATION)
P.O. BOX
13. RESTRAINT
13E 9
OAK RANCH LANE
NO
3. SH 9. ADHC
4. APH . 10. CLINIC
CITY
ZIP CODE
I& HOURS
CH CO.
CA
195926
24
6. PHF 11. JAIL
6. SNF 12. ICF /DDN
13. OTHER
17. FACI IT
KA] llll�,EEN
CONTACT PERSON
LO CKWOOD
TELEPHONE NO.
(916) 891-3591
16A. SPECIAL
TO BE COMPLETED BY
INSPECTING AUTHORITY
IS. FIRE
STATE FIRE MARSHALL
26. CLEARANCE
CODE
AUTi,
NAM R
NAM
AND
#4 WILLIAMSB ,, G LANE, SUITE A
CHICO, CA 95926
CODES
1. FIRE CLEAR, GRANTED
ADDR ES.
2. FIRE CLEAR, DENIED
3. FIRE CLEAR, WITHHELD
27. DENIAL
CODE
TO BE COMPLETED BY INSPECTING AUTHORITY
CODES '
21. INSPECTOR'S
NAM TELEPHONE NO.
22. CFIRS 23.
ID NO.
T-19 OCC.
CLASS
-
23.1 ECTOR SIGIA RE
ZA
1. EXITS
2. CONSTRUCTION
3. FIRE ALARM
24. INSP.
DENIAL OR LIST SPECIf CO9bITibNS
�..`
4. SPRINKLERS
rJ. HOUSEKEEPING
28. EXPL IN
yx�
&A.
T3
6. SPECIAL HAZARD
T. OTHER
STATE FIRE MARSHAL USE ONLY
20. REGI N.
DEPARTMENT' OF SOCIAL SERVICES
�
COMMUNITY CARE LICENSING
OFFIC E
520 COHASSET ROAD, - SUITE 6
AND
CHICO, CA 95926
ADDR S
Office of the State Fire Marshal
INSPECTION REPORT
File N1.:.'� 41
Name of Facility: %'-c ClL�,oi9f>-�S �l': � M
Name of Building:
Add
2 —2
L� CAcv L-0 cj-\
Ac otnwie
f
W
L-1
CSO -6 ev. 7/86) V
P
` sWy'`if�F#t�kZtYir
PDX
!
DEPI
TATE x3 1g" g DATE OF ►SPEGTION r. -
ts'3{{
tyy1Yr'�
CSO -6 ev. 7/86) V
N
rge R of
o../ .-
1
�,.,rfice of the State Fire Marshal
REINSPECTION REPORT
�.L
of Facility: �-�-�l,tl�d�'�S CjW:�� ��3L'��-C�
of Building:
&f'CE C'
STATE FIRE MA SHAL
A dress:L�z1
0 A cA
�j
Uscussed
4.
with:
ILI—
P Y 1'
•.�.•
.. ..^.._ , , tir . ',� •.rte„•ri*.�'�.i {'* .,� f .. '
Fie
Safety Deficiencies Numbered noted on the Letter ❑
Fief
_ ��7• _. C'� � .
Sa ety Correction Notice (EN 11) El dated - have been corrected.
Uncorrected
Deficiencies Numbered were re -issued as shown
the Fire Safety Correction. Notice dated , which is attached to and made a part of this Report.
n
addition, new deficiencies were identified at the time of this reinspection, and are shown as Items
on the attached Fire Safety Correction Notice.
Fire
Clearance Instructions:
L4 A&I
WS
suns
XM
ffY STATE
DATE OF
v
fJ
I
GO • S ev 7 /861
STAT FIRE MARSHAL
FIRE SAFETY INSPECTION REQUEST
STD 8 0 (REV. 8 / 86)
3. AGE C i CONTACT
DSS/ COMMUNITY CARE LICENSING
lPY DISTRIBUTION: SEE REVERSE OF COPIES 2 AND 5 FOR
3 -STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION
!-FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM
5 --LICENSING AGENCY 5/16 /
/16/
4. TELEPHONE NO. 5. EVALUATOR
(916) 895-5033 0103/BOB CALDWELL
S. SFM REGION
7. SPM I.D. NO.
S. REQUESTING AGENCY FACILITY NO.
9. REQUEST CODE
330
041372999
lA
CODES
1. ORIGINAL A. FIRE CLEARANCE
2. RENEWAL B. LIFE SAFETY
3. CAPACITY CHANGE
DEPT, OF SOCIAL SERVICES
4. OWNERSHIP CHANGE
10. AG N�Y - COMMUNITY CARE LICENSING
s. ADDRESS CHANGE
NAME 520 C O H A S S E T R D.,# 6
S. NAME CHANGE
AN C', H I C 0, CA 95926
PREVIOUS NAME
AD RSs L
7. OTHER
DATE OF ORIGINAL REO.
11. AM[ luliATORY
NONAMBULATORY
TOTAL CAP.
DATE OF LAST FIRE CLEARANCE
CAPACI TY
AGE RANGE (YEARS)
PREVIOUS
CAPACITY
AGE RANGE (YEARS)
PREVIOUS
TO 18 18 TO 65 AND
CAPACITY
TO 18 18 TO 65 AND
CAPACITY
19. FACILITY
4
15 OVER
0
65 OVER
4
CODE
735/ADULT RES,
12. FACILITY NAME
13. NO. BLDGS
CODES
LO WOODS CARE HOME #2
1 NO
1. GACH 7. ICF/OT
2. GACH/R 8. ICF/DD
14. ST ET ADDRESS (ACTUAL LOCATION)
P.O. BOX
15. RESTRAINT
13291 OAK RANCH N.
NO
3. SH 9. AQHC
4. APH 10. CLINIC
CITY I
ZIP CODE
16. HOURS
C H i 0 CA
195926
2 4
5. PHF 11. JAIL
6. SNF 12. ICF/DDN
17. FA ILI Y CONTACT PERSON
TELEPHONE NO.
16A. SPECIAL
KA LEEN LOCKWOOD
1(916) 891-3591
13. OTHER
TO BE COMPLETED BY
INSPECTING AUTHORITY
18. FIR4
F
26. CLEARANCE
CODE
JACK PIRISKY
AUT
AU dR
4 WILLIAMSBURG LN, , SUITE 3
CODES
NAN
CHIC 0, CA 95926
1. FIRE CLEAR, GRANTED
ANC
2. FIRE CLEAR, DENIED
A013RE5s
I
L-
3. FIRE CLEAR, WITHHELD
27. DENIAL
CODE
TO BE COMPLETED BY INSPECTING AUTHORITY
CODES
21. INSPECTOR'S
NAME
TELEPH NE NO.
22. CFIRS
23. T-19 OCC.
_
ID NO.
CLASS
.,/
1. EXITS
2. CONSTRUCTION
3. FIRE ALARM
2CA
4. S
TE
25. IAS ECTO S 1 ATU
r
V
4. SPRINKLERS
5. HO SEKEEPING •
2 . XP AiN
bENIAL OR LIST SPECT NDITIONS
�
HAZARD
7. OTHE
f
STATE FIRE MARSHAL USE ONLY
RETURN
'TO:
DEPT. OF SOCIAL SERVICES
20. REG ON.
COMMUNITY CARE LICENSING
OFFCEI
520 COHASSET RD.,#6
AN
/1 TT T !ti ^ !l A n c n#1 L
Office of the State Fire Marshal
Fire Safety Correction Notice HAL
*FIRE
File No:
Name:
Address:
I The California Health and Safety Code and the State Fire Marshal's regulations require the following fire safety
!deficiencies be corrected.
I
jhe above deficiencies are to be corrected within days. When ALL deficiencies have been corrected, sign
and return the certification on the opposite side of"this form. If you have any questions, contact the Office of the State
Fire Marshall at
ISSUED BY (Deputy State Fire Marshal)
RECEIVED BY
DATE
EN -11 (Rev. 7/86) 86 96708 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field
Mice of the State Fire Marshal
REGIONAL
FACILITY FILE CHANGE NOTICE
Name Collection/Change
Address Correction/Change
El Change File Number
El Facility Discontinued
�ftCf�
STATE FIRE MA HAL
"sue File Number
El Other
�.
OLD r
NEW
:4?
Name:
Address:
City:
Dunt(No.
t
Name: A Z,f�
Address: -
Cit •
y•
County: r �'
L
�
No.
Fi a No. • —
- - --
—
- - - - -- - -
File No.:
A
- - - - - - -
calpancy Class:
T-24 SFM FILE
Occupancy Class:
T-24
SFM FRE
Comments:
r -
P elol2
(Write of the State Fire Marshal
BUILDING SURVEY REPORT
a No.:
G-)
. CqC
e of Facility: '
e of Building:
7 -
cress:
►ner:
int:
aFFICf
STATE FIRE MA AL
Telephone No.:
Telephone No.: ( )
i
r
GO 4 (Rev. 7/86)
i
.r. e
1' Occupancy
TYPE USE
;� • �' -Z,
CAPACITY
3 C� -
2 Construction Type
. �'•
YEAR UIL
Bn
�T
(,
BASEMENT
0 0
3 Area (Sq. Ft.)
TOTAL f
LARGEST FLOOR
4 Stories
NO. !
HEIGHT
HIGH RISE
YES NO
5 3. Exterior Wall Construction
'Z Ltd
. Opening Protection
r
,J
6 Interior Wall Construction
i UL) �� ...- c� ._ 7 (2;,
7 Floor Construction
� ! � •., � � � , - ;. � U ; , 1L � . �
8 Roof Construction
91 Attic Draft Stops
-
NO.
PA
10. Occ. Sep. Wall Construction
No.
. Opening Protection
2. Area Sep. Wall Construction
NO.
. Opening Protection
12 . Smoke Barrier Wall Construction
NO.
. Opening Protection
13 . Corridor Wail Construction
. Opening Protection
14 . Corridor Ceiling Construction
. Opening Protection
15 Shafts
No.
TYPE
. Opening Protection
16 � . Stair Enclosure
No.
. Opening Protection
T
i
r
GO 4 (Rev. 7/86)
i
i
ar0e c--4 YVVI
F Ile No.:.
47-"BU6ildinArvey Report (GO -4)
Page 2of2
Rem
C ornm.
DEe fi"
1T. Stairs
• O.
1 . Ramps
NO.
1 . Interior Finish Class
ROOM
NO.
ORRDOR EX
TOTAL WIDTH
20. Exits
21. Exit Hardware Typevj�3
2 a. Exit Signs Alumination
b. Emergency Lighting
21. Auto Sprinkler Coverage
24. Standpipes Class/Location
25 Fire Alarm Type/Coverage,r-
26 Heating, Ventilation and
Air Conditioningj„iIMD-0
ffTIPE11L
27l Electrical Installation
,.r a ,
28 Stage/ Platform
Hazardous Areas
0. Other
MMENTS:
I
EM
YKI
P l e�of
�
F Office of the State fire Marshal � `�
INSPECTION REPORT STATE FIRE MAR AL
File No.:.6�0,,-- z04 .4 1
Ne of Facility: __���)C
Name �of Buildin
p,
A I
di @$S:
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