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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
COMPLAINT INVESTIGATION REPORT(Cont)Chico Residential, 620CohassetRoad
Suite s
Chico, CA 96926
FACILITY NAME: PIERCE GUEST HOME FACILITY NUMBER: 41374457
DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 07/31/2003
Deficiency Type
POC Due Date 1
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
1
FIRE SAFETY - Fire Safety - The licensee did not complete
1
Administrator agrees to submit a written
08/07/2003
2
deficiencies cited by the fire marshal in a timely manor. All
2
plan to the licensing agency advising how
Section Cited
3
facilities shall be maintained in conformity with the regulations
3
this deficiency will be avoided in the
87689
4
adopted by the state fire marshal for the protection of life and
4
future. Plan of correction will be due
7
5
property against fire and panic.
5
within one week.
6
6
7
7
1 1
2 2
3 3
4 4
5 5
6 6
7 7
1 1
2 2
3 3
4 4
5 5
6 6
7 7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result
in a civil penalty assessment.
SUPERVISOR'S NAME: Norma Soto-Nannery TELEPHONE: 530.895.5033
LICENSING EVALUATOR NAME: Donna Gurriere TELEPHONE: 530.895.5805
LICENSING EVALUATOR SIGNATURE: WE: 07/31/2003
I acknowledge receipt of this form and understand
FACILITY REPRESENTATIVE SIGNATUR&0;"'�-,
as explained and received.
DATE: 07/31/2003
LIC9099 (FAS) - (4196) Page: 2 of 2
Section Cited
2
2
3
3
4
4
5
5
6
6
7
7
1 1
2 2
3 3
4 4
5 5
6 6
7 7
1 1
2 2
3 3
4 4
5 5
6 6
7 7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result
in a civil penalty assessment.
SUPERVISOR'S NAME: Norma Soto-Nannery TELEPHONE: 530.895.5033
LICENSING EVALUATOR NAME: Donna Gurriere TELEPHONE: 530.895.5805
LICENSING EVALUATOR SIGNATURE: WE: 07/31/2003
I acknowledge receipt of this form and understand
FACILITY REPRESENTATIVE SIGNATUR&0;"'�-,
as explained and received.
DATE: 07/31/2003
LIC9099 (FAS) - (4196) Page: 2 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
COMPLAINT INVESTIGATION REPORT S��s esidentia1,620CohassetRoad
Chico, CA 96926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2003 and conducted by Evaluator Donna Gurriere
PUBLIC COMPLAINT CONTROL NUMBER: 253746
FACILITY
PIERCE GUEST HOME
NAME:
DIRECTOR:
RIKARD, CRYSTAL
ADDRESS:
589 OBERMEYER AVE.
CITY:
GRIDLEY
CAPACITY: 15
MET WITH: 6. Rl"RE) L : G
FACILITY
NUMBER:
FACILITY TYPE:
TELEPHONE:
STATE: CA ZIP CODE:
CENSUS: /j— DATE:
TIME BEGAN:
TIME COMPLETED:
41374457
740
(530)846-5037
95948
07/31/2003
ALLEGATIONIS):
1 Fire Safety - The licensee did not complete deficiencies cited by the fire marshal in a timely manor.
2
3
4
5
6
7
8
9
INVESTIGATION FINDINGS:
1 On 05/20/03, the fire marshal cited several deficiencies. The licensee did not make the appropriate corrections
2 until 07/15/03. Deficiencies included exit signs and emergency exit lights not in place, fire alarm system out of
3 service, electrical panel not covered and breakers to be labeled.
4
5 The preponderance of evidence standard has been met. Allegation is substantiated.
6
7
8
9
10
11
12
13
Substantiated Estimated Days of Completion:
SUPERVISOR'S NAME: Norma Soto-Nannery TELEPHONE: 530.895.5033
LICENSING EVALUATOR NAME: Donna Gurriere TELEPHONE: 530.895.5805
:
LICENSING EVALUATOR SIGNATURE(/i`11 �Gc — �8'ATE: 07/31/2003
I acknowledge receipt of this form and understand a p ri kts as explained and received.
FACILITY REPRESENTATIVE SIGNATUR DATE: 07/31/2003
LIC9099 (FAS) - (6/00) Page: 1 of 2
STATE OF CALIFORNIA - HEALTH ANL ..JMAN SERVICES AGENCY GRAY DAVIS, Govemor
DEPARTMENT OF SOCIAL SERVICES
Community Care Licensing
520 Cohasset Road, Suite 6
Chico, CA 95926
July 31, 2003
St,e.ve. Fowler. Fire Marshal
176 Nelson Ave.
Oroville, CA 95965
Please be advised that the complaint allegation findings have been completed at:
Pierce Guest Home and are attached for your review.
Donna Gurriere
Licensing Program Analyst
:dig
Attachments
Fire Prevention Bureau
176 Nelson Avenue
Oroville, CA 95965
Telephone 530-538-7888
F 530 538-2105
Butte County Fire Rescue
California Department of Forestry
and Fire Protection
Facility Inspection Report
White Copy - Business
Yellow Copy — Occupancy File
Pink Copy — Station File
Occ. Class.
ax -
Address: le-. Business Name:
Owner/Manager: , E ��.-R Bus:
Assistant Manager: Bus:
Hm:
Building Owner: Bus:
Hrn:
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.
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: j
'
Battalion 1 2 3 4 5 b 7
Station:
Inspectips Officep,'
�.
FIRE PREVENTION SAVES LIVES, PROPERTY, AND BUSINESS. YOUR COOPERATION ITHI,
CORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE: /� '
F/L-,67
MEMORANDUM
To: Donna
From: Steve Fowler, Butte County Fire Department
Date: July 21, 2003
Re: Pierce Guest Home, 589 Obermeyer Ave. Gridley
On May 20, 2003 Fire Captain Sean Norman from our Gridley Fire Station made an annual
inspection at Pierce Guest Home. He noted the following deficiencies:
1. No exit signs in place.
2. Emergency exit fights required.
3. Fire alarm system out of service.
4. Need to completely cover electrical panel and label all breakers.
On July 1, 2003 Fire Apparatus Engineer Callie Zimmerlee made a re -inspection and found
that none of the corrections required by Captain Norman had been completed.
As per Butte County Fire protocol I was asked to accompany FC Norman on the 3'd re-
inspection. This was done on July 15th. All but the electrical panel violation had been
corrected. I also asked that they remove the many coats of paint from the alarm bell—it had
deadened the sound a bit.
In retrospect the station should have required the fire alarm to be repaired with a day or so—
but there's no excuse for it to be out of service for two months. That shows a complete lack
of respect for the safety of the guests.
I will mail copies of the inspection reports to you.
F- u
Fire Prevention Bureau
176 Nelsons Avenue
oroville, CA 95965
Telephone 530-538-7888
FAY 530-538-2105
owna'/Mwow,
Addm;.
FAX N0.
Butte County Fire Rescue
California Department of Forestry
and Fire Protection
Facigity inspection Report
Jul. 15 2803 11:53AM P1
White Copy - Busincss
fellow copy -- Occupancy File
Pink copy tation Fite
0cc. clan �
REVEAUD THE FULWWLNWw ,
xWs1 obsbucted, inadequate
ation .
i. .rite
17. Address p2!Lcd and visible from road .
Mw
S. �oX Bax keys• 9. Fire:wl Witnessed Yes D No 0 18. other .
toN AND c�RcTxoNS: CORRECTED*
D 'T'�l�II• D EX�'1�,A�tA &671
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Date: Discussed Sigma f
(Pnnt) (7,rFRJ2ft$
12-.0.. Ai.
Ins officer:
Battalion 1 2' 3. 4 5 6 L7)_ Station: FPB '�✓
Fn?,E P'REVENT'ION SAVES �S, PROPERTY, ,A.ND BUSINESS. YOUR COOPERATION WfTH
IS APPRECIATED. RE-INSMVI'1011 DA coR.RECNG THE ABOVE LISTED 1TE11�S ,
f Z
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|10DETAMED TION AND CORIIECTIONS*
' .
Fire Prevention Bureau White, Copy - Business
Mittr Conaty Fire Rescue
176 Nelson Avenue. Camfomia Department of For" Yellow Copy — Occummy filo
-1 ("A. fign(f aft"i 148 %e IPA
rIMMUq J1RSjkCft6U If-CLp6irl Um. U&SI.
Ffoi'120 53R 1,104 1
gle e.rf Home,
jin d Ao, Bus: 61 Hw Fax:
P/ Ti6 - _;3 *70
AssistantIM130ger-, Bus: HM:
Aftwe
AN INSPECnON OF YOUR FACELM REVEALED THE FOLLOWING*
1'. Fim)Exfi�00ers: Requir4mmicedue 10. Exit(s) obs"cwd� inadequze
'
. . . ..
. .
. .
. .
. .
. .
. .
. .
. . . ' .
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TAX
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it, all
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BUTTE COUNTY FIRE DEPARTMENT/CDF FIRE
TITLE 19/24
FACILITY INSPECTION
Ll
INSPECTION NO. eV 2 3
REINSPECT: 11 YES
Facility - Occupancy >/
Address E % - Inspector�a�/L
Phone Station
Contact Station Phone r`� '-
Compliance: Yes No = 0 Not applicable = N/A
ACCESS --All inspections ELECTRICAL --All inspections
Address correct/posted and visible from road (Butte Co. Code 32-9) Extension cords do not replace permanent wiring (CEC-400-8(1))
Access to public street or 20 ft. wide lane Cr19-3.05>
Extension cords do not pass through doors/walls (CEC-400-8 9,3))
Gates wide enough to admit fire apparatus (T19-3.16) 30 inch clearance around all electrical panels (CEC-110-16A)
Fire protection equipment visible/accessible (T19-3.14) All panels and breakers are marked (CEC-110-17 C)
Repair holes in fire -resistive construction CEC (300-21,22)
Mufti -plug power strips have circuit breaker (CEC 400-13)
PORTABLE FIRE EXTINGUISHERS -- All Inspections
Extinguishers have current annual service tag (T19-575 1A)
Maximum travel 75 ft. Cr19-567)
Provide clear access to fire extinguisher (r19-563.2)
Extinguishers mounted on wall/or in cabinet, visible and signed (T19-563.8)
EXITS -- All Inspections
Exits not obstructed Cris -3.11)
Exit signs in place (CBC 1003.2.9.1)
Doors operate without key or special knowledge (CFC 1207.3)
Rooms with Occupant Load of 50 Persons or More
Exit illumination and signs in place (CBC 1003.2.8.2)
Maximum occupancy sign in place (T19-3.30)
Two exit doors/panic hardware swing in direction of travel (CFC 2501 .8.2)
HOUSEKEEPING --All Inspections
No waste or rubbish accumulation inside or outside T19-3.14)
Reduce storage to at least _" below ceiling/ sprinklers (r19-3.14)
Remove combus. storage from heater, mech., elect. room (T19 -3.1m
Provide approved metal container for oily rag storage (T -19-3.19c)
Flammable liquids stored properly IT -19-3.15)
FIRE PROTECTION EQUIPMENT -- All Inspections
Hood system serviced/tagged every 6 mo. by cert. tech. (T19-904)
Clean filters, hood, and duct area over cooking appliances (CFC 1006.2.8)
Maintain extinguishing systems (r19-3:24)
Provide spare sprinkler heads (6 min.) and/or sprinkler wrench Cr19-904.5)
Replace damaged, corroded, or painted sprinkler heads (T19-904.5)
Identify sprinkler valves and secure in open position (r19-904.5)
Replace missing caps on fire department connection (r19-904.3)
Provide 5 -yr. certification test for sprinkler/standpipe (r19-904)
MECHANICAL EQUIPMENT -- All Inspections
Vents and chimneys -- No obvious hazards (CMC -Ch. 8)
SMOKE DETECTORS — Day Care Sr. Res., Hospitals, Apts.
Properly installed and tested (T19-749,754)
SCHOOLS, JAILS AND HOSPITALS
Decorations and curtains fire retardant (-r19-3.08)
LPG tanks fenced with locked gates (T19-3.22)
FIRE DRILLS -- School and Day Care (Title 19-3.13)
All systems operable/hooked to office
Held monthly (elementary schools)
Held semi-annually (high schools)
Evacuation plans posted in all rooms
Emergency procedures posted in office
Teachers take roll books
Corrections and Comments
The above deficiencies must be corrected within -r days.
Owner/Manager
Inspection Date:
AP #
�. MARDEL HOUSE c► s loses•
_ ..� G.A.-
Senior
iaoSenior Care Residence 9 i'� CIVIC
� J
s
Cleared for
�k :L 3 I piwellt ' ;Non-Amb. RL ransfer,DepTJ"
!# 7
-a
S
Lr
• • , • . • a"'t"" J ems.
l
P& °
#1 Bedroom for two clients 23 X 9 Ambulatory �••
#2 Bedroom for two clients 23' X: 9' "
2
#3 Bedroom for two clients 3' X: 9' "
� STEVE-- ! �
#4 Bedroom for one client 12' X 8' 9" HERE IS THE ORIGINAL
i
#5 Bedroom for two clients 19' X 18' 9" Non-Amb. FLOOR PLAN SUBMITTED.
6 Bedroom for one client 11' 10" X 10' PLEASE ADVISE IF THERE
5 Ambulatory ARE ANY AM-E)/NON AMB.
#7 Bedroom for two clients 14' X 13' 6"
CHANGES. WHEN I TALKED TO
(Bedroom. o T two
f.clients
Dependent) Non-Amb. LLOYD PIERCE LAST YEAR, I
#8 Bedroom for two clients 19' X 13' 911 Non-Amb. ADVISED THAT I WOULD TRY
AND SEE IF WE COULD
#9 Bedroom for two clients 19' X 14, 9" INCREASE H--,-S NON AMB STATUS.
Non-Amb. THANKS! DONNA GURRIERE
Recreation room for use by clients and visitors 23' 10" X 17' 895-5805
Living room a Tents 27' X 1Fi�
Dining room used for all meals by clients 10' 5" X 15' 6"
STA OF CJILJPORNIA
Fl SA --ET1( INSIA - 0
N>RE�U
T 0sm aw (REv. 10-94)
COF
See Instructions on reverse.
/ p'-- z
CONDITIONS
PLEASE ADVISE OF AMBULATORY/NONAMBULATORY STATUS OF EACH ROOM.
STEVE FOWLER
FIRE FIRE MARSHAL
rHORITY
MEAND 176 NELSON AVE.
CRESS OROVILLE, CA 95965
L_
NAME (Typed or Prialyd) TELEPHONE NUMBER CFIRS NUMBER OCCUPANCY CLASS
l'aA
TE INSPECTOR SSIGNATURE ypd or PAWS
DENIAL OR UST SPECIAL CONDITIONS
CLEARANCE /DENAAL CODE j
CODES
VFIRE CLEARANCE GRANTED
2 FIRE CLEARANCE DENIED
A. EATS
B. CONSTRUCTION
C. FIRE ALARM
D. SPRINKLERS
E HOUSEKEEPING
F. SPECIAL HAZARD
G. OTHER
TELEPHONE N
DATE
PROGRAM
D S/OMMU ITY CARE LICENSING
(0 895-5033
03/07/02
FE
EV TORS NAME
REQUESTING AGENCY FACILITY NUMBER
REQUEST CODE
02 7/GURRIERE
041374457
7A
CODES
1. ORIGINAL A. FIRE CLEARANCE
U SING F -DEPARTMENT
OF SOCIAL SERVICES
i RENEWAL B. LIFE SAFETY
GENCY,
NA.MSAND COMMUNITY CARE LICENSING"'
3. CAPACITY CHANGE
DRESS 520 COHASSET ROAD, SUITE 6
4. OWNERSHIP CHANGE
CHICO, CA 95928
S. ADDRESS CHANGE
L
6. NAME CHANGE
7. OTHER * *
SEE COMMENTS
AMBULATORY
NONAMBULATORY
BEDRIDDEN
TOTAL CAPACITY
CM ACITY
PREVMMS CAPACITY
CAPACITY
PREYMS CAPACITY
CAPACITY
PREVOW CAGY
9
6
15
FAC LITY NAME
LICENSE CATEGORY
PIERCE GUEST HOME
RCFE
STFJEET ADORF_SS (Actual Landon)
NUMBER OF BURMINGS
5$9 OBERMEYER AVENUE
1
RESTRAINT
G IDLEY, CA 95948
NO
FAC NJTY CONTACT PERSONS NAME
HOURS
LL.CYD PIERCE 530 846-5037
24
CONDITIONS
PLEASE ADVISE OF AMBULATORY/NONAMBULATORY STATUS OF EACH ROOM.
STEVE FOWLER
FIRE FIRE MARSHAL
rHORITY
MEAND 176 NELSON AVE.
CRESS OROVILLE, CA 95965
L_
NAME (Typed or Prialyd) TELEPHONE NUMBER CFIRS NUMBER OCCUPANCY CLASS
l'aA
TE INSPECTOR SSIGNATURE ypd or PAWS
DENIAL OR UST SPECIAL CONDITIONS
CLEARANCE /DENAAL CODE j
CODES
VFIRE CLEARANCE GRANTED
2 FIRE CLEARANCE DENIED
A. EATS
B. CONSTRUCTION
C. FIRE ALARM
D. SPRINKLERS
E HOUSEKEEPING
F. SPECIAL HAZARD
G. OTHER
6..1h,
BUTTE COUNTY FIRE DEPARTMENT/CDF FIRE
TITLE 19/24
FACILITY INSPECTION
INSPECTION NO. 1 2 3
REINSPECT: FV YES ,KNO
Facility %ffU_9!U kt&Yh& Occupancy
Address l3�ry1►'1y n Inspector _ n aJ
Phone Station T,T �}�i �f
Contact v D C%!ic-e Station Phone
Compliance: Yes =.4f
ACCESS --A inspections
Address cor ct/posted and visible from road (Butte Co. Code 32-9)
Access to publ street or 20 ft. wide lane (T19-3.05)
Gates wide enou to admit fire apparatus (T1s 3,16)
Fire protection equipl7ent visible/accessible (T19-3.14)
No = 0 Not applicable = N/A
ELECTRICAL --All inspections
xtension cords do not replace permanent wiring (CEC-400-8(1))
xtension cords do not pass through doors/walls (CEC-400-8 9.3))
p inch clearance around all electrical panels (CEC-110-16A)
AII panels and breakers are marked (CEC-110-17 C)
ORTABLE FIRE EXTINGUISHERS --All Inspections `
/ e
Extinguishers have current annual service tag (T19 -575.1A) / 1 IRE PR(
Maximum travel 75 ft. (T19-567) Z ZA H d
holes in fire -resistive construction CEC (300-21,22)
ug power strips have circuit breaker (CEC 400-13)
TECTION EQUIPMENT --All Inspections
oo r
ovide clear access to fire extinguisher (T19-563.2) 1e, � p( Clean 1
dinguishers mounted on wall/or in cabine i fan �Igned 1 �f� Maintain
Provide
--All Inspections -Replace
V Identify
i serviced/tagged every 6 mo. by cert. tech. (T1s-so4)
hood, and duct area over cooking appliances (CFC 1006.2.8)
nguishing systems (r19-3.24)
e sprinkler heads (6 min.) and/or sprinkler wrench (r19-904 5)
caged, corroded, or painted sprinkler heads (r19-904.5)
r_x s not obstructed (r19-3.11) n ikler valves and secure in open position (T19-904.5)
(7 t
Exit igns in place (CBC 1003.2.9.1) !) % Replace mi sing caps on fire department connection (r19-904.3)
V Provide 5 -yr. certification test for sprinkler/standpipe (Ti9-904)
Door operate without key or special knowledge (cFc 1 zo7. l'
Rooms wit Occupant Load of 50 Persons or More f v MECHANICAL QUIPMENT --All Inspections
Exit illum) ation and signs in place (CBC 1003.2.8.2) , Vents and chir#neys -- No obvious hazards (cMGcn. 8>
Maximum cupancy sign in place (T19 3.30) v i
SMOKE DETECTCiDS -- Day Care Sr. Res., Hospitals, Apts.
Two exit do s/panic hardware swing in direction of travel (CFC z5o1 8.z> properly installed and tested (r19-749, 7sa)
HOUSEKEEPING -All Inspections
No waste or rub h accumulation inside or outside T19-3.14)
Reduce storage t at least below ceiling/ sprinklers (1-19-3.14)
Remove combus. s rage from heater, mech., elect. room (r19-3.190
Provide approved
Flammable liquids
?dal container for oily rag storage (r -19-3.19c)
SCHOOLS, JAILS LAND HOSPITALS
Decorations and curtains fire retardant (r19-3.08)
LPG tanks fenced with locked gates (T19-3.22)
FIRE DRILLS -- School and Day Care (Title 19-3.13)
properly (r-19-3.15) ____All systems operable/hooked to office
Held monthly (elementary schools)
Held semi-annually (high schools)
Evacuation plans posted in all rooms
Emergency procedures posted in office
Teachers take roll books
The above deficiencies must be corrected within days
Inspection Date:
Owner/Manager AP
GRIDLEY FIRE DEPARTMENT � )"goo �
AZARDOUS TERIALS Ily.,SPECTION REPORT DATE
BUSINESS N
PHONE
ADDRESS !2
OCCUPANCY
pO. OF BLDGS.
NO. OF STORIES
MANAGER/OWNERgrjM
0v
PHONE
ADDRESS
5
BUILDING
APPROVED
APPROVED
YES
NO
NA
YES
NO
NA
1. EXIT
❑
❑
O
7. FIRE ASSEMBLIES/WALLS
❑
❑
D
2. EXIT SIGNS
❑
❑
D
8. AUTO SPRK. SYSTEM
O
❑
D
3. ELECTRICAL
D
❑
❑
9. FIRE EXTINGUISHER
❑
❑
D
4. OPENINGS (H&V)
❑
❑
❑
10. HOUSEKEEPIN
❑
❑
D
5. EMERGENCY LIGHTING
❑
❑
❑
O
❑
❑/
11 ADDRESS P
ADDRESSDt
D
❑
O
❑
O
❑
6. ALARM,SYSTEM
Aof
13. HAZMAT PLANS
❑
❑
2 W SIGNS
❑
❑
❑
14. COMPLYING WITH PLANS ❑
❑
5 RGENCY SHUT OFF
❑
❑
D
15. RECORDS/INVENT
❑
O
2 . DISPENSERS
❑
❑
O
16. PERMITS
❑
❑
27. REMOTE PRESET DEVICE
❑
❑
❑
17. TANKS IN USE
❑
O
❑
28. DETECTION/DEVICES
❑
D
❑
18. CONTAINMENT OK
❑
❑
❑
29. COMMLINICATION
❑
❑
❑
19. NO LEAKS
D
O
❑
30. PROPER STORAGE
❑
❑
❑
20. PETROLEUM WASTE
O
❑
❑
31. WASTE OIL
❑
❑
❑
21. FILL OPENING OK
❑
❑
❑
32. HANDLING ROOMS
D
❑
D
22. WELDING
O
❑
O
33. OILY RAGS
❑
❑
❑
23. ALARMS
❑
❑
❑
34. OTHER
❑
❑
❑
REMARKS ._
/%
� lsdD-ZN �1,o nl /� 7�M /�'d30V�
OIL
77v -wov�Jmow D
Alo v,49Y15) c ig
�G�n-
ALL EXCEPTIONS NOTED ABOVE MUST BE CORRECTED BEFORE CLEARANCE IS GRANTED
FIRST INSPECTION ❑ GRANTED ❑ FEE
SECOND INSPECTION D CONDITIONAL O
FINAL INSPECTION DENIED
yo
TIME INSP T N coo -z
rp
INSPECTOR
REPRESENTATIVE 'lbl�
1.01
�r
GRIDLEY FIRE DEPARTMENT
INSPECTION REPORT
L�
DATE
BUSINESS NA
ADDRESS
-- f
PHONE '' z"`
OCCUPANCY
NO. OF BLDGS.
NO. OF STORIES
MANAGER/OWNS
ADDRESS ,jla
.ti y ; ,�r ,., PHONE
Uii� trr.c v
EXITING
APPROVED
FIRE PROTECTION
APPROVED
YES NO NA
YES
NO
NA
1. EXIT
❑ ❑
7. FIRE EXTINGUESHERS
❑
jl
❑
2. EXIT SIGNS
❑ ❑
8. AUTO SPRK. SYSTEM
❑
CJ
3. EXIT CORRIDORS ❑ ❑
4. AISLE/SEATING ❑ ❑
5. OCCUPANT LOAD SIGN ❑ ❑
9. HOOD EXTING. SYSTEM
10. STANDPIPES
11. ALARM SYSTEMS
❑
❑
,!
❑
❑
11
E1
li
❑
6. OCCUPANT LOAD
❑ ❑
12. FIRE ASSEMB/WALLS
❑
❑
❑
BUILDING
APPROVED
SPECIAL CONDITIONS
APPROVED
YES NO NA
YES
NO
NA
13. ELECTRICAL
ld ❑ ❑
20. EMERGENCY LIGHTING
❑
❑
❑
14. HEATING EQUIP
❑ ❑ ❑
21. GREASE HOODS & DUCTS
❑
❑
0
15. COOKING EQUIP
❑ ❑ ❑
22. L.P.G.
❑
❑
0
16. DECORATIONS
❑ ❑ ❑
23. COMPRESSED GAS
❑
❑
0
17. OPENINGS
24. CHEMICALS
❑
❑
❑
VERTICAL
❑ ❑ ❑
25. SIGNS
❑
❑
0
HORIZONTAL
❑ ❑ ❑
26. HAZ MAT INSP.
❑
❑
0
18. HOUSEKEEPING
❑ ❑
27. OTHER
❑
❑
0
19. ADDRESS POSTED
❑ ❑
REMARKS
op
�1400t, 41 v
e
ALL EXCEPTIONS NOTED ABOVE MUST BE CORRECTED BEFORE CLEARANCE IS GRANTED
FIRST INSPECTION
GRANTED
❑
YEARLY FEE $20.00
SECOND INSPECTION
❑ CONDITIONAL
❑
FINAL INSPECTION
❑ DENIED
❑
TIME
NEXT INSPECTION
INSPECTOR P
REPRESENTATIVE
aDnxEss s
MANAGER/0
ADDRESS -
e i
GRIDLEY FIRE DEPARTMENT
.'kDOUS MATERIALS INSPECTION REPORT
0
NO. OF BLDGS.
NO.OF STORIES
BUILDING
APPROVED
GRANTED
I
APPROVED
CONDITIONAL
❑
YES
NO
NA
❑
YES
NO
NA
1. EXIT
45
❑
❑
7. FIRE ASSEMBLIES/WALLS
❑
❑
D .
2. EXIT SIGNS
D
❑
8. AUTO SPRK. SYSTEM
O
�
E33- ice' --fr6�
3. ELECTRICAL
D
O
9. FIRE EXTINGUISHERS
�
❑
4. OPENINGS (H&V)
❑
❑
10. HOUSEKEEPING
�
D
❑
5. EMERGENCY LIGHTING
O
❑
11. ADDRESS POSTED
,ate
O
O
6. ALARM SYSTEM
❑
❑
12. OTHER
❑
❑
13. HAZMAT PLANS
10
❑
24. WARNING SIGNS
❑
❑
14. COMPLYING WITH PLANS ❑
❑
25. EMERGENCY SHUT OFF
❑
❑
15. RECORDS/INVENT
❑
❑
26. DISPENSERS
❑
❑
16. PERMITS
D
❑
27. REMOTE PRESET DEVICE
❑
❑
17. TANKS IN USE
❑
❑
28. DETECTION/DEVICES
❑
❑
18. CONTAINMENT OK
❑
D
29. COMMUNICATION
❑
D
19. NO LEAKS
D
❑
30. PROPER STORAGE
❑
❑
20. PETROLEUM WASTE
❑
❑
31. WASTE OIL
❑
❑
21. FILL OPENING OK
❑
❑
32. HANDLING ROOMS
❑
❑
22. WELDING
p
❑
33. OILY RAGS
p
❑
23. ALARMS
X91
ol
❑
34. OTHER
❑
❑
'�; �',�' �'r' - �•_ �� tea.-• �� f/:r
IF �� ,�` .1, • �.
_ r �•' �_ -°;41
/ i/' 1 ; / l� F ...lid,
ALL EXCEPTIONS NOTED ABOVE MUST BE CORRECTED BEFORE CLEARANCE IS GRA200---
==7V
..............-... Yew GRANTED
n TT!T.
FIRST INSPECTION
GRANTED
❑ FEE
SECOND INSPECTION ❑
CONDITIONAL
❑
FINAL INSPECTION
❑
DENIED
❑
TIME
NEXT
INSPECTION
�
�'���°'��
INSPECTOR
REPRESENTATIVE -
�144-r
.-)GHES FIRE PROTECTION, INC.
1900 Park Avenue
800) 228-3473 Chico, CA 950,28 FAX (916)893-0466
DA. TE FIRE SPRINKLER SYSTEM INSPECTION REPORTy WET DRY
L 10
)V
0
CA -F19
T
0
N
.'HONE: PHONE:
PE5 Y R MI OTER�NT R
ACT NO:
j
(ES
NO
I. GENERAL:
A. Is occupancy the same?
B. Is building completely sprinklered?
C. Is building the same as 'Last inspected?
D. Does the exterior condition of piping, drain valves, check
valves, hangers, and strainers appear to be satisfactory?
E. What, is the water supply source? City tank
414Z
_K_Gravity
F. Has owner/occupant been advised of NFPA 13A inspection
requirements?
Il. CONTROL VALVES:
A. What is the location of control valves?
B. What type are the control valves?
C. Are control valves easily acces7sible"
D. Are signs for control valves, drains, and tests in proper
place?
E. Are all control valves open?
F. Are all control valves properly secured?
How? IC -Locked ---SUpervi sed
III. TANKS, PUMPS, AND FIRE DEPARTMENT CONNECTIONS:
per_
rG
A. Are tanks, pumps and reservoirs in good condition?
B. Are Fire Dept. connections in good condition, couplings
free, and caps or plugs in place".)
C. Are Fire Dept. connections visible and accessible?
D. Have fire pumps been tested to their full capacity through
hose streams or flow meters during the past twelve months?
E. Are gravity tanks at proper water level`'
IV. ALARMS:
A. What I is the location of inspector's test valve?
-Ae!5—f
VAL
B. Are alarm valves, water flow indicators, and retards in
good condition?
C. Did water motor and gongs operate satisfactorily?
D. Did electric alarms operate satisfactorily?
4
E. Did supervisory alarms operate satisfactorily?
I
V. SPRINKLERS:
A. Do sprinklers generally appear to be in good condition,
free of paint, corrosion, or loading obstructions?
HITE COPY - FILE
YELLOW COPY - FIRE DEPT, PINK COPY - CUSTOMER
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1:4
WHITE COPY — FILE YELLOW COPY FIRE DEPT. PINK COPY —,,'CUSTOMER
SPRINKLiWS7,.,� ontinued):
B. Does there appear to be proper clearance from spr,inkler
deflector?
C. Are guards installed where needed?
D. Are extra sprinkler heads and wrench of correct size and
type available?
LK
E. Are any sprinklers 50 years or older?
F. Are any extra high temperature solder, sprinklers regularly
_
exposed to temperatures near 300 degrees F?
VI. RISER AND PIPING:
A. Are all fittings tight and not leaking?
B. Are all fittings undamaged?
C. Are all fittings unobstructed?
D. Have the sprinkler systems been extended to all visible
areas of the building?
E. Ii_- exterior piping protected against freezing temperatures"
F. Have all antifreeze systems been tested"
VII. GAUGES:
A. -Are gauges in - -good condition?
P. Are gauge valves turned on?
VIII. TESTING:
A. System pressure � 9J-240 ---
B. Supply pressure
C. Residual pressure when main drain is open (:F-
D. Static pressure when main is closed _2<_�'
E, The alarm activates in seconds.
F. Was alarm received at supervised place?
G. Does alarm work under emergency power?
I )ISCREPANCIES NOTED:
L2j7= C, dc" i a k�a Ll lip, C
F,
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R-( P nrlF�,,o a, 1.�o P ri\teae
pr-�t,cp, epA G( Ahl'�irA4
10-jo
DATE, 7 ii
'USTOMER ACKNOWLEDGEMENT: V
STI MATE OF COSTS TO CORRECT DISCREPANCIES :6f --
Lad
t7nc 42� Cp
0
M/
INSPECTED BY:j )r DATE: 7 19'
WHITE COPY — FILE YELLOW COPY FIRE DEPT. PINK COPY —,,'CUSTOMER
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UAL P— -FIRE PLAN PESUR'v'EY
CHANGES
DATE
SIGNATURE
;'es NO
COMMENTS
G4'e
._
l
)Rflo►t1uN of (3�ORo�vh tsF�
N�� S� (�cAmRrri Ar►(3wLR'C��y �' NON /�►�13uLRTo+'-'/
/
LL
11 yo'®r
A v
b� ! Xiormwj /,fin n A---% �F chi t%s
t^
-716
CM
PRE- PLAN -
A -S T 6 z ( 1) LZZ 1-4
W
A
T
E
R
S
A
F
E
T
Y
P
E
R.
A
T
I
0
N
S
E
N
E
R
A
L
Bd-71 (8/83)
Type Location --
la 2" STANDPIPE ON PROPERTY WA-TER...OURCE 2 NEAR BY
2a SEASONAL CANAL 250' NORTH ON LARKIN RD.
SEA '
3., SEASONAL CANAL 1200 WEST ON OBERM.EYER
1. 6 AMBULATORY PERSONS NEED EVACUATION.
2. 6 NONAMBULATORY PERSONS
3. BOTH OWNERS LIVE ON SITE.
DOT #
1. ENTIRE BUILDING IS SPRINKLERED
2. F.D. CONNECTION LOCATED AT S.W. CORNER OF BUILDING.
3. 1750 G.P.M. AUTOMATIC PUMP SUPPLIES SPRINKLER SYSTEM
AND 2" STANDPIPES, y
Y
1. O.S & Y VALVE LOCATED ON WEST WALL OF BUILDING.
2. GAS SHUTOFF S.W. CORNER OF BUILDING
�
3. ELECT, SHUT OFF ON WEST WALL OF BUILDING
4. FIRE ALARM SHUT OFF BOXES LOCATED IN KITCHEN AND ON EXTERIOR
WALL ON NORTH SIDE OF BUILDING KEY TO BOX IN KITCHEN.
Date {
9-14-93
Name
PRE PLAN -*l
PIERCE GUEST HOUSE
A
St. Address
154
589 OBERMEYER AVE.
e
R
Cross St.
E
LARKIN RD.
S
Area
S
BUTTE CO. ATLAS—
43 D-3
—
GRIDLEY LOCADE 99 14 1
Phone No.
84.6-5037 OWNERS L lOYD
PIERCE/WAYNE LOCY i
Type Location --
la 2" STANDPIPE ON PROPERTY WA-TER...OURCE 2 NEAR BY
2a SEASONAL CANAL 250' NORTH ON LARKIN RD.
SEA '
3., SEASONAL CANAL 1200 WEST ON OBERM.EYER
1. 6 AMBULATORY PERSONS NEED EVACUATION.
2. 6 NONAMBULATORY PERSONS
3. BOTH OWNERS LIVE ON SITE.
DOT #
1. ENTIRE BUILDING IS SPRINKLERED
2. F.D. CONNECTION LOCATED AT S.W. CORNER OF BUILDING.
3. 1750 G.P.M. AUTOMATIC PUMP SUPPLIES SPRINKLER SYSTEM
AND 2" STANDPIPES, y
Y
1. O.S & Y VALVE LOCATED ON WEST WALL OF BUILDING.
2. GAS SHUTOFF S.W. CORNER OF BUILDING
�
3. ELECT, SHUT OFF ON WEST WALL OF BUILDING
4. FIRE ALARM SHUT OFF BOXES LOCATED IN KITCHEN AND ON EXTERIOR
WALL ON NORTH SIDE OF BUILDING KEY TO BOX IN KITCHEN.
Date {
9-14-93
L
.wrwd
' 2
•i
� PRE- PLAN' -
�-
Name All
P19RCE GUEST HOUSE
St. Address
589 OBERMEYER AVE.
Cross St.
LARKIN RD.
PREP _ *1
LAN
i
154 ;
f
Area
BUTTE CO. ATLAS 43-D-3 GRIDLEY LOCADE 99 14-11
N Phone No.
84.6-5037 OWNERS LlOY �
D PIERCE/WAYNE LOCY
W Type ocation
A 1s 2" STANDPIPE ON PRQ Y WATER SO �RC:F -A422-NEAR RBY
�t SEASONAL CANAL 250 NORTH ON LARKIN RD.
E__._,..
R 3, SEASONAL CANAL 1200' WEST ON OBERMEYER
S
A
F
E
T
y
0
P
E
R
A
T
1
O
wJ
1. 6 AMBULATORY PERSONS NEED EVACUATION,
2. 916L NONAMBULATORY PERSONS
3. BOTH OWNERS LIVE ON SITE.
DOT
I. ENTIRE BUILDING IS SPRINKLERED
r
2. F.D. CONNECTION LOCATED AT S.W. CORNER OF BUILDING.
3. 1750 G.P.M. AUTOMATIC PUMP SUPPLIES SPRINKLER SYSTEM
AND 2" STANDPIPES.
G I. O.S & Y VALVE LOCATED ON WEST WALL OF BUILDING.
E 2. GAS SHUTOFF S.W. CORNER OF BUILDING
N
E 3. ELECT. SHUT OFF
. ON WEST WALL OF BUILDING
R
A 4. FIRE ALARM SHUT OFF BOXES LOCATED IN KITCHEN AND ON EXTERIOR
WALL ON NORTH SIDE OF BUILDING KEY TO BOX IN KITCHEN.
L - ---
[Date
9-14-93
7d / 3, 4:7- 7 j r' C� c-00?2
q
R
O
�,
p
D
U
�
R
T
E
H
E
�
J
S
S
Name All
P19RCE GUEST HOUSE
St. Address
589 OBERMEYER AVE.
Cross St.
LARKIN RD.
PREP _ *1
LAN
i
154 ;
f
Area
BUTTE CO. ATLAS 43-D-3 GRIDLEY LOCADE 99 14-11
N Phone No.
84.6-5037 OWNERS LlOY �
D PIERCE/WAYNE LOCY
W Type ocation
A 1s 2" STANDPIPE ON PRQ Y WATER SO �RC:F -A422-NEAR RBY
�t SEASONAL CANAL 250 NORTH ON LARKIN RD.
E__._,..
R 3, SEASONAL CANAL 1200' WEST ON OBERMEYER
S
A
F
E
T
y
0
P
E
R
A
T
1
O
wJ
1. 6 AMBULATORY PERSONS NEED EVACUATION,
2. 916L NONAMBULATORY PERSONS
3. BOTH OWNERS LIVE ON SITE.
DOT
I. ENTIRE BUILDING IS SPRINKLERED
r
2. F.D. CONNECTION LOCATED AT S.W. CORNER OF BUILDING.
3. 1750 G.P.M. AUTOMATIC PUMP SUPPLIES SPRINKLER SYSTEM
AND 2" STANDPIPES.
G I. O.S & Y VALVE LOCATED ON WEST WALL OF BUILDING.
E 2. GAS SHUTOFF S.W. CORNER OF BUILDING
N
E 3. ELECT. SHUT OFF
. ON WEST WALL OF BUILDING
R
A 4. FIRE ALARM SHUT OFF BOXES LOCATED IN KITCHEN AND ON EXTERIOR
WALL ON NORTH SIDE OF BUILDING KEY TO BOX IN KITCHEN.
L - ---
[Date
9-14-93
7d / 3, 4:7- 7 j r' C� c-00?2