HomeMy WebLinkAbout001-104-014 CF ArchiveST TE OF CALIFORNIA
FIRE SAFETY INSPECTION REt,%.jEST
ST . 850 (REV. 10-94)
See instructions on reverse.
AGENCY CONTACT'S NAME TELEPHONE NUMBER REQUEST DATE PROGRAM
CRSS/COMMUNITY CARE LICENSING 530 595-5033 5/29/01
EVA LUATOR'S NAME REQUESTING AGENCY FACILITY NUMBER REQUEST CODE
0101 m Po SEXTON 045402767 A
- - - - _ CODES
RkSPONSE RE TIRED
�' F1. ORIGINAL A. FIRE CLEARANCE
Lt(GENCY
ENSING 2. RENEWAL B. LIFE SAFETY
COMMUNITY CARE LICENSING
- NAME AND 3. CAPACITY CHANGE
ADDRESS 520 C OHASSET ROAD, SUITE 6
4. OWNERSHIP CHANGE
C N I C 0 9 CA 95926 5. ADDRESS CHANGE
L 6. NAME CHANGE
7. OTHER
AMBULATORY
NONAMBULATORY
BEDRIDDEN
TOTAL CAPACITY
CAF ACITY
PREVIOUS CAPACITY
CAPACITY
PREVIOUS CAPACITY
CAPACITY
PREVIOUS CAPACITY
FIRE P I G G S. F -T E DEPT °
S
0
0
0
0
�.
FAC LITY NAME -
CA 95965
LICENSE CATEGORY
T ALAS9 NICOLE FAdILY GRIND CARE ROME
A. EXITS
FGCR 810
STR ET ADDRESS (Actual Location)
NUMBER OF BUILDINGS
291.4 SIXTSR
.
CITY
RESTRAINT
D GGSA CA 95917
110NE
FAC[ TY CONTACT PERSON'S NAME PHONE
� � � � � $ 6 8 �. 5 3 4 4 MvuHs -
T OCAS, NICOLE- � DABS
SPE lAL CONDITIONS
CLEARANCE /DENIAL CODE
CODES
FIRE P I G G S. F -T E DEPT °
1)FIRE CLEARANCE GRANTED
AU HORITY 176 HELSON AVENUE
N ME AND
2. FIRE CLEARANCE DENIED
ADDRESS 'OROVILLE9
CA 95965
A. EXITS
LATTENTIONO
STEVE FOWLER
B. CONSTRUCTION
.
C. FIRE ALARM
D. SPRINKLERS
E:^ HOUSEKEEPING
INSEtf GTOR'S NAME_ (Typedlor Printed) 4
TELEPHONE NUMBER
CFIRS NUMBER
`OCCUPANCY CLASS
�- V
F. SPECIAL HAZARD
DATE
CTO IGNATR
d r rpfedjINSPECTION
,
G. OTHER
i
EXPU JN DENIAL OR LIST SPECIAL CONDITIONS
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