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024-220-030 CF Archive
Palge.of. File No.:. 00 04 23 0 Office of the State Fire Marsnal INSPECTION REPORT 0070 _ 000 _ 555 ------------- 9 Name of Facility: GRIDLEY MIGRANT CHILDRENS CENTER Name of Building: Address: 1567 Booth Drive Gr i d l e , ' CAS.' 95948 scussed Wd oRm loll I IN Y ;Accompanied by. A n e 1 i t a Tid e. D`r e c t o r r �C14, FI STATE FIRE MA AL An annual inspection was conducted at the above faci 1ity. This was the last day of their seasonal program, No deficiencies were noted at this time. The facility maintains a reasonabl6 degree of fire and life safety, Fire clearance for 1 is-granted14 ambula- tory children, 74 ages 2-5 years old and 40 -ages 0-2 years old Go • 6 (Rev. 7/86) Office of the State Fire Marshal INSPECTION REPORT No.:. 00= 04_- 23 -A10a—_77--a00_-R35_---L of Facility: GRIDLEY HEAD START CENTER of Building: 850 E. Gridley Road Gridlev. CA 95948 Discussed with: Title: Accompanied by: Staff Title An annual inspection was conducted at the above facility. No deficiencies were noted. The facility maintians a reasonable degree of fire and life safety. Fire clearance is granted for 24 ambulatory children. FRE CLEARANCE GRANTED YET T-0ATE -91 12 STATUS DEPUTY STATE FRE MARSHAL i DATE OF NSPECTION 6 (Rev. 7/86) sof I"" Office of the State Fire Marshal INSPECTION REPORT oo _ 04 _ 2 3 ,. No.:. f— OQ14— --7�0� _ --Q35- _.._ --L of Facility: GR I DLEY HEAD START CENTER Nome of Building: rens: 850 E. Gridley Road Gridley, CA 95948 �f. ?r'Isdi .:. i .. .. •. ,( r� ri s' -`rA v .$ �> ► >s Y--- Y r fa- ♦ 7f .M M. ''.rA r4� :.t,•>.. .i(. 3.tk iG'. %4+.• F>•. `F •'•tAt a•.� .� '>~y'4* �..�.�: ._'.'�.,��v(y�•� ..i.: C td ..3• 3 r K f K6f'S.c". v.t/r.. ii ,�•� .G....b..- r ,s4. zYi''• .: �e ,�t�� .tier. f ` � �'�? �� nom" �{ .y{, �,,��M"• n �, ,y --t: -> ./. .Yi P "T \S �� »iii` ,>,. T •.iwj:`f . .S• 44++3' .•"C • •�� k^ -/�M .-aEt - A Y• 4Y : F•'•K'C,. SB . ^1. •S ''t� i►. �. 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An EN -12 was left at the door, r Office of the State Fire Marshal INSPECTION REPORT No.:. 00 — 04 23 0014 X00 - 035 — ime of Facility: GRIDLEY HEAD START CENTER Name of Building: ress: _ 850 E. Gridley Road- Gridley, oadGridley, Ca. 95948 r' v'. :. .. ... .... ... .... $ ..... ".- ... .,. %. :., Fs1„ f q -. .' y .,:^ { :.. ,. Paw= ... :. .: ... ,.. . ,: ..... ...,.. � .. tY .Fd. .. ard• ...x 'a'i•Y` <. », . 2�4.c . a,, : { a'z:•� S� "F� S .. ..Y 4) ..\r,-. .,.: fY. v. , J h.. \ f - 4 :A< ,• >. , . <y' p �4. i�" fr<.<. Yy': )' 1:. �,x• E r , ,� Rc•\. ,. #. .. ,r••)�.. °,F. .. .�:. .. .. .-.. �-e3.... r,. :•'„•. S..'�t �.: '.'f -...,c..:. ,:•. � .'C .sL'b. ... n 4. n' -:J - •. w.n .:i[�' .0 KW � -a`k.�f ' a • �'�+; : r• D. .:. • ) ... .f >^ y T. -,. _,., . .r.. < .. .. L... v >, .. ,. / , S .: .. : , ,X:-. v. ..>; A L. rf:+), :. �-f<• "Y` '4f .. ) .. ., �>- f ... ,. ..v.. ., .+ r? ..r 5^ 4.'�' ., /, :. f : -•Ss".. '•X-^• Y > ... .. .. w. .r. ,' ... ... .% .♦. .. ,. X� r. .. t t' ,r.:r. :-. ) .R. .. :.1 ... '.' :, i.':< ) fl f., a `+tt71 :!) YR„� C R„ � f A, f:•Y :. ... ,. \ ... r .1 'Y♦ .:,i<. ,. f..... .. c--> 53.<�-:._ .. .. , 2:: .. a%,: .. t. '�'d ♦• �L '✓ p Y(.. ... ....:.,., f.. ,»,. ., .. :. :,>. .<. ,♦ - � 1�. ..,. ....3 s .. c �;,• ... �y. �. t .Sw �<^s, . Fvb• � ...C` ,:L � f.,f,- �f"` '.S .eJ -,. :, r'- ... d't ...., .. ♦ <,�. . y,.. . � ,r . :. ra,, � x €>.;,.<, . .. 4 M „ J •,A;� t - .. ,.... - i:,.. R....: k .> .r .,. >. -.. ..✓',r sr J r..- . < :. ,. ... .: .. .. .. ,.. {�£ s:'�.r _ �f•.. y .s.L:. A, -,x. .: f , �a .R 3 :-n ter, i .. .: �,.. „ -.f.. •:: . +� { R.. x . , 3 Y. ::. ♦a' . --' - x•. -.. ..> _. ..:.. rt� ,. .,,. {.. .. . =v. ,,-,...w r-tr .:.. J .t. , -. .. .- a , d 1�'R z +t < n �^ <o � .... .... . .. r. .... . .. Y .. , Y1.. v.. %y: ti . ... Oa.. .. ,'f.. YS' SPJ L•' f 4 ., .!•..LV. .., ns-, .. .. .. ✓. .. 9r. L G:. .. .. s i- '. .. ,..: ... ..... :. .. .. r. .. .. ., .n 't": ..n.. An annual inspection was conducted at the above facility. No deficiencies were noted at this time. The facility maintains a reasonable degree of fire and life safety. Fire clearance is granted for 24 ambulatory children. �. '! �1R�11�iC.E: CR�4�1'1'E'D K s � � f yy y � > ( ::.. ••a: c. •.. +.'.�3' ..Z•. :?v',`R-j � s ed. >w L� S f.. 1 �f r Y f - UE'lJt1l STATE M MARSHAL E+ 't > .:') �,' Y s4 f c .'•Yv-:!'z <. F aw �s<:sLt,r 'i v: -T' r x +w i l ” ••2: 't x t , DAM 0 �VSKCWN Yg, e �n tii! y f 20 se er, 8 :.. U 03-6 (Rev. 7/86) STArE FIRE MARSHAL COPY DISTRIBUTION: SEE REVERSE OF COPIES 2 AND S FOR a�.wm"wa.w wf&w• rT•A&/ FIE SAFETY INSPECTION REOU. i 1 -3 --STATE FIRE MARSHAL V "" ""�` "' • •"�- _- 2 --FARE AUTHORITY _ 1. REQUEST DATE 2. PROGRAM STD 850 (REV. 8/86) 4 -5 --LICENSING AGENCY_.1 CONTACT 4. TELEPHONE NO. S. EVALUATOR 3. AGENCY �1.,S �f.JV= IA,. .1 :t 1 1 Y `. A:41%'i.' LlCr Ii1)1i1G Sa.J`5013 0111'"A 6. SFM REGION 7. SFM I.D. NO. A. REQUESTING AGENCY FACILITY NO. 9. REQUEST CODE 030�' 01413'71 /03 CODES 1. ORIGINAL A. FIRE CLEARANCE 2. RENEWAL B. LIFE SAFETY 3. CAPACITY CHANGE �� SOCIAL SERVICES 4. OWNERSHIP CHANGE 10. A ENCY DEPARTMENT COMM MITY CARE LICENSING S. ADDRESS CHANGE S. NAME CHANGE N AME 6 Cohasset Road* Suite PREVIOUS NAME A40 520 ADRESS Chico* CA 95928 7. OTHER ,.. , � .. -,fir. .-•., f-.•r� �„ ,.... .... ; i:, �..1 t�, 1 a.i�..a) 2-a t i'.�� f. I.r���, . -� L•� DATE OF ORIGINAL REQ. _ DATE OF LAST FIRE CLEARANCE 11. AMBULATORY NONAMBULATORY TOTAL CAP. CAPA CITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS 1 TO / 8 19 TO 65 AND CAPACITY f TO 1 A 1 A TO 6S AND CAPACITY 114 19. FACILITY _ •• 63 OVER 63 OVER CODE l 12. FACILITY NAME 13. NO. BLDGS CODES r, ., --_�� ��„�v • :"�' -•:�r , n-, r•r J T � r,y X1.1 t•. �..- •1.► -,n 7 1. GACH 7. ICF/OT 2. GACI••IR 8. ICF/DD 14. S REET ADDRESS (ACTUAL LOCATION) P.O. BOX 1S. RESTRAINT 3. SH 9. ADHC 4. APH 10. CLINIC CITY ZIP CODE 18. HOURS 59-48 5. PHF 11. JAIL 6. SNF 12. ICF /DDN 17. F CILITY CONTACT PERSON TELEPHONE NO. • 16A. SPECIAL CASTANEDA , ��1IGF TA o � r ( 91 -+ �{ �t . ,,_ / .i f� � '.. �. u 2 `'• C;kj'%j 13. OTHER TO BE COMPLETED BY INSPECTING AUTHORITY 26. CLEARANCE CODE 18. FRE i tiJ 1 A 1 i� �.` t i�E !'.i P%SS' 1,M j 1 A JTHOR 7 r�'''•►► •� �1ACJK PIRIva11 CODES N ME 4 WILL IS%I' �� L N'j E, ot,JI`.� 1, a 1. FIRE CLEAR, GRANTED AD CHCO2, CA 95926 2. FIRE CLEAR, DENIED AlDRESS II L 3. FIRE CLEAR, WITWELD 27. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 21. I SPECTOR'S NAME TELEPHONE NO. 22. CFIRS 23. T-19 OCC. ID NO. CLASS 1. EXITS SLAUGHTER 895-431 2 035 E_3 2. CONSTRUCTION 24. MSP. DATE 25. INSP S SIG U E 3. FIRE ALARM 9-20-89 1 4. SPRINKLERS 28. EXPLAIN 5. HOUSEKEEPING DENIAL OR LIST SPECIAL 426NDITIONS Fire clearance is granted for 114 ambulatory children, 2-5 years 6. SPECIAL HAZARD 7. OTHER old and 40 children, 0-2 years old. STATE FIRE MARSHAL USE ONLY F DEPARTMENT 07 SOCIAL SERVICES 20. RGION. COMMUNITY CARE LICENSING o FICE 520 Cohasset Road, Suite 6 A D Chico, CA 95926 ADDRESS I L� ENS C E Nov NOm C: REI NIt 'v -2A OFFICE OF STATE FIRE MARSHAL ANNUAL INSPECTION REPORT FILE#: 00--04-23-m0014-000-330-0 :ILITY . NAME : GRIDLEY HEAD START CENTER PHONE: am�4w_____ ;ILITY•. ADDRESS: 850 E GRIDLEY ROAD GRIDLEY CA 95948-0000 7ERVIEWED BY P F COTA ACCOMPANIED BY: gr _ 'm -.r r in , wme r .00 �,m r on an as Q0 r -r oft iii-#-r_i_ii-i•�__i-ir-i__-#i#-__ii,wftii__ii-i0Mlow ii_r�M.__-_mwiiiMi_--i-i__r_- INSP. OF INDIVIDUAL BUILDING - OCCUPANCY CLASS. ,_ (T24) E 3 HIGH RISE I INSP. OF ENTIRE FACILITY. CONSISTING OF 1 - BUILDINGS CLASSIFIED AS . FOLLOWS: BLDGS. 1 OCC. CLASS 23 NO.BLDGS. 0 OCC.CLASS N0s8LDGS. 0. OCC. CLASS ,BLDGS. 0 OCC.CLASS NO.BLDGS. 0 OCCOCLASS NO.BLDGS. 0 OCC.CLASS I GOi4* - UPDATE ON BLDG ( S) NOS ------_--__-_-------__--____-___.._--..-----------_ i�r�rrirrra�,w_mrrrrrr�dr_.i.rrir1 r�rAft..w�rrri�r.��s-rVr_rr�+�'MOO rrrrr� NONRATED BLDG. �-->#STOR3ES���lFLOOR PLAN: 4m an ATTACHEMENTS: M E N TS C ice.- �� - J--;jjlfu�o � - L3 GO -6 E 3 - GO -4* E 3 STD -850A E 3 DIAGRAM A C 3 . PHOTO S E 3 OTHER • � TOTAL#____.,____ -NO dM 00 f INSP TIME HRS LIST ! : DI .POSITION: CLEARED IEWED BY' :__�OW 4M 4W I=00_.�_a�r_--�----DATE_-- PECTED ---.-=_..-s._ DATE � __ � .3 NOT CLEARED ' T' DATE,_��- i .. r r -�. enr •v ao- .r rt a •.. •er. ..w rw a•. A► a.. • _ -� .� .- i• ' - ✓ r � _. '••� - -- - .. • - •� � � ..% y.. ,. -� I IS A •••• •.•. w• .n1 rn a.. rs. •r.• ... .♦ rw ..• .w. �w r .► Mir �. +•► res w- rr �► ss .f.. ii a.tt �C O o . - - •+ •.� •� •� Y4 w M ••.. �• rr► . �• �. •.. ref Y•• .w. .•.. r -• •� r• Aar 4. 7.► �M• A•• M• a- •� .•r ONO o ow •w� vow r •Y rR mmm a•a ar ••• aws- a� w .v or ... ri �,•• .p+ •1t _ ..-. 1'• i� k.. A. •� .► +. d .... q ._ i 1 • • 1 •. .• ... ,. - ••.. . ♦ .. . •. ..,4 1� ••► '! ♦,. .� L ..5 •}wL. ) -I. a _•t .� +T -.. r' / .r }� _. �-• •r _J .• Q r � .. . � .• _. 'V � - w a/ r i :J r � ./ � .. i. + -• .ri i. 0 •i'• _ r / V'' C 1 ,. ' wi V r% �1 •% ti Q .• • •r• i �� Jam• •' '•_ ;'1 , !- ,� I' _ ~ - i f. • i' ` s It .aeb rw r r.r .A w r tlY ! a.• am •A. - •r• .. ai d a n ae wo ... amp. r .w OP •rr 1 _ r . / � ..: _ ' � �' • L. •+ � �s t , �. r. Ae. M fa w• M •4• •••. N- n i r♦ OW qN. ar► 400 aw aY 0% ..a A o" r A� mow' •�. w� 010 •-- w, rr. ai _ r as .4 rr. .+ M END W -0. dM - OP ••y •e MID � SAL Y .s: rs •w rar y f p• .s• a As •A ar• s ..- - . r r w ... r r: ••r ry vn ... v.. a.- s. -. s. ... ..•F .471 aw. w ! 1•w .tM .r r• wr •.► r ... ••1. r 'M .w► •.. .,. Ars .Y w rs ••.• Or ._- r: r- .... rw, •,• r .a. «.. •... .._ w. .. r .... ao 4., w s w ! r•r. sa .•,n M. w' R• - - •� INS W 14 7+ r- f 1 •.• .. w a w .., u.. ef.- •.• w .r. a- w a•• .+. r.•. Wft ..r W. •e.. IM. sm .w• ra. w .•. am ••. qw m V. .... •.r - '- - .. -- s. �. .s •.. w K �. / r ... r •.•. s-• w. r• r - . -40. ... s., +., w. _ .� .. w . r ...06. rw OR ap ••• �. ty. .v w .. 4 f ..e. - STATIC FIRE MARSHAL FIR SAFETY INSPECTION REQUEST COPY DISTRIBITION; SEE REVERSE OF COPIES 2 AND 5 FOR 1 -3 - STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION STD 050 (REV. 7/80) - 2 - FIRE AUTHORITY 1. REQUEST DATE Z. PROGRAM 4-5 - LICENSING AGENCY 1-14-86 �3. AGENCY CONTACT 4. TELEPHONE NO. S. SIGNATURE ' D S COMMUNITY CARE LICENSING(916) 920-68 55 0/ .6. S M REGION 7. SPM I.D. NO. a. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR #o40300o89 040 _ 19. REQUEST CODE RESPONSE REQUIRED ' CODES 1:-ORIQTAL A. FIRE CLEARANCE ,• "'.-��^7'' 0 AGENCY �, ,... NAME '3.• 2. RENAL B. LIFE SAFETY 3. CA�NGE 1 ..,.,. AND; =- :� .• ,. ... , .. '- G E . ' ! 4. O W R;P.+C ADDRESS ,,�-,,.�;:..,-;. ._.^•.� ,,.._...-- _,�3��+1- • �,,ytr; J ":r ... `.� _..:..,.:. -� i 5. AI -MW i •'i°�'V GE t " �"' 3 s em'•'? ;Io u - 6. -'BATE OF ORIGINAL REQ. Ages 2--17 Years 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CAPACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS .TO 18 18 TO 65 AND CAPACITY TO 18 18 TO 65 AND CAPACITY , 20. FACILITYCODE 6S OVER 65 OVER 2 XX 24 12 12. FACILITY NAME 13. NO. BLDGS CODES GRIDLEY HEAD START CENTER 1 1 . G A C H 7. ICF/OT 2. GACH/R 8. ICF/DD 14. STREET ADDRESS 1S. RESTRAINT Gridley Farm Labor Camp 850 E. Gridley Road None 4. A PH 10. CLINIC S. PHF 11. JAIL CITY ZIP CODE 16. HOURS Gridley 95965 Days 6. SNF 12. OTH ER 17. ACILITY CONTACT PERSON TELEPHONE NO. 16A SPECIAL D tson, Diane (916) 534-4719 1 Child Care Center TO BE COMPLETED BY INSPECTING AUTHORITY 18. FIRE i 27. CLEARANCE '• AUTHOR. ( CODE ' 1 NAME CODES 1. FIRE CLEAR. GRANTED AND ADDRESS i 2. FIRE CLEAR. DENIED L- L WITHHELD 3. FIRE CLEAR. WIT 28. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. INSPECTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T-19 OCC. 10 NO. CLASS 1. EXITS John Woods 330 0 E3 2. CONSTRUCTION 3. FIRE ALARM 25. INSP. DATE 26. INSPECTOR `S SIGNATURE 10-01-85 4. SPRINKLERS S. HOUSEKEEPING 29. EXPLAIN DENIAL OR LIST SFWCIAL CONDITIONS .Fire clearance is granted for a capacity of 24 children for day 6. SPECIAL HAZARD 7. OTHER care only. STATE FIRE MARSHAL USE ONLY FIRE CLEARANCE GRANTER STATE FIRE MARSHAL 21 REGION. y A 21= ' OFFICE AND ADDRESS . - L� MILES NEXT INSP. (MO.DA-YR.) TIME STATE FIRE MARSHAL COPY DISTRIBUTION; SEE REVERSE OF COPIES 2 AND 3 FOR FIRE SAFETY INSPECTION REQUEST 1 - STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION STD 8 OA (NEW 6/80) 2 - FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM 3 - LICENSING AGENCY 084/154/85 ccf:l 09 3. AGE NCY CONTACT 4. TELEPHONE NO. 5. SIGNATURE E l;S0CLAk SVCS9 CUM LARE LIC 49161 920-6.855 ' 6. SFN REGION 7. SFM I.D. NO. I 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR jj0--. --23- 00- 3. 00 040370117 0-404 19. REQUEST CODE 2A CODES 1. ORIGINAL A. FIRE CLEARANCE 2. RENEWAL B. LIFE SAFETY AL �VCSv LUM CARE ' TO BE COMPLETED BY 10. GENCY�'; AME 2.400 GLENDALE LANE v SUITE E C 3. CAPACITY CHANGE ND 18. FIRE 4. OWNERSHIP CHANGE SAGRAMEklU 27. CLEARANCE CODE ; DDRESSA' AUTHOR. S. ADDRESS CHANGE L ' CODES 6. OTHER AJ4,4UhAT4GRV ONLYa CHILOREN AGES 2 THAWWi THAW6 YEARS,* DATE OF ORIGINAL REQ. 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE 12if 011,84 CAF ACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS 28. DENIAL TO 18 18 TO 65 AND CAPACITY TO 18 18 TO 65 AND CAPACITY CODE 65 OVER 65 OVER 15 20. CODE 20. i 12. FA CILITY NAME TELEPHONE NO. 13. NO. BLDGS. CODES :...kY HEAD START CENTE 1. GACH. 7. ICF/OT 2. GACH/R 8. ICF/DD 14. ST EET ADDRESS 15. RESTRAINT ....10LEY FARM LABOR CAMS 8 r 4. APH 10. CLINIC 5. PHF 11. JAIL C TY u ZIP CODE 16. HOURS 95965 UNDER 24 6. SNF 12. OTHER 17. FACILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL -OUENAS, ELISA, 916--S46-4559 CJiIL.D CARE CENTER TO BE COMPLETED BY INSPECTING AUTHORITY 18. FIRE 27. CLEARANCE CODE ; AUTHOR. ' CODES NAME 1. FIRE CLEAR. GRANTED AND ADDRESS 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. 1 SPECTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T-19 OCC. ID NO. CLASS 1. EXITS 2. CONSTRUCTION 3. FIRE ALARM 25. IIISP. DATE 26. INSPECTOR'S SIGNATURE 4. SPRINKLERS 5. HOUSEKEEPING 29.E PLAIN DENIAL OR LIST SPECIAL CONDITIONS 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY 21 REGION F OFFICE AND ADDRESS L J TIME MILES NEXT INSP. (MO. DA. YR.) COMMUNITY ACTION AGENCY I of Butte County, nco J Community Action (9 6) 534-4584 Head Start Program (9 6) 534-4719 x Programs 534-4719 June 19, 1985 State Fire Marshal Sacramento Region 4433 Florin Road, Suite 400 Sacramento, CA 95823 Dear Sir: 4.0 z6I Purchase Order #3922 is proof of purchase to comply with T-24 CAL Admin Code Sec 2-809(a) for the Gridley Head Start classrooms, 850 E Gridley Hwy, Gridley, CA. 95948. Purchase Order #4039 is proof of purchase to comply with T-24 CAL Admin Code Sec 2-809(a) for the Yuba, Head Start classroom, 719 Yuba Avenue, Oroville, CA. 95965. If any further information is needed please contact me at 534-4719. Sincerely, KD�u 'W NOEL MARTIN Interim Head Start Director Butte County Head Start 2255 - 2269 Del Oro Ave 0 Oroville, CA 95965 AIX _ Poi �. ,. JAI �,: F..-�.aC �'4!';!a !`r���r i�� .h.. ��n.. �j-1 �j1• '�C1 -r') f-17 - R-c�-ci �'''c-`7flai'��. Gt'�rP'i.� SQ - .r . i' �d H�TIT ,. �'�f? G^ ,?F,_ �,n? F ,�•�. it {f 3iT J �.r r ......L ♦ ' .Mat -s. �ri11� .-. def.- ,4 4q tr PURCHASE ORDER k 4039 5/16. 85 Req,* No. Date 19 -- To Smith's Security Systems For 170 Rio- Lindo Avenue -P.O. Box 372, Chico,- CA 95926 Ad ress Date Required Shi To Com unity Action Agency How Ship Ad ress .2255 Del Oro. 01oville, CA 95965 _—Terms S QUANTITY PLEASE SUPPLY ITEMS LISTED BELOW PRICE UNIT DRDERED RECEIVED - 10" fire alarm bell switch painted red, transformer 245 00 7 and and char Ler 21 - 0 3 -bettely 41 51 --6 a. 1 -7 I 1 -C "9-LWy.uba,,. Sm48 (*20 3" .7.0 X o 7 19 vow& ba" ! OR �4,. �? y: �y, - ,�.r:.�T.',t.>z�����r�"C., •c�,.�-. 'lti�;.'•i rte.. :7.,',±:-'• t••;, .. •'� I zX -7411-1--1 2 4� 1 ;3' R. 4N, -4- 2� 40V 4 ACCOUNTS PAYABLE DISTRIBUTION 'White. Orininal—Conerv. Office Canv—Pink. Receivina Deof. Coov SMITH'S SECURITY SYSTEMS P.O. BOX 372 CHICO, CA 95927 ALARM CO. LA000517 (918) 345-3411 DATE j DA I ACCOUNT NUMBER ACCOU,IT NUMBER I I �ia',-� # ll -5. o edit ��s PAGE NO. / nsure pr per, re please check those Items being paid In the."✓ " 'column and return this portion of the statement with your payment. 'REFERENCE c OAT ` < l�olE ` Q�8 �i1PTIQ Po 3�aa 3,a8,8�..i lo,, Po 39aa 95-.'510 - TkP,NSFor^rlex 0af�{ry 4 N)417�er pp��ga� r I �OS� '!8S-Doad ,3 CODES C- CR MEMO P - PAYMENT A- DISCOUNT F - FINANCE 0: DR MEMO I - INVOICE ALLOWED CHARGE PLEASE pAY a59.70 TOTAL a s 9.70 30 DAYS 60 DAYS , 9Q DAYS ! t� : r ,gt120 QAXS: - n i ..va SMITH'S SECURITY SYSTEMS REINSPECTION REPORT .• OFFICE OF STATE FIRE MARSHAL F LE N0. Date Reinspected N me of Facility Address S-0� . � -P Condi ti ons Discussed With F s A compani ed By r�(�.�.� ���s Title T)l I spection This Date -Discloses That Fire Safety Corrections Number l of Fire Safety Corrections Dilted oSi� 3 l oS� Have Been Complied With. F re Safety Corrections Number Were Discussed With and Disposition Will Be A Follows: R inspection Indicates That Neer - Fi re Safety . Correcti ons Shoul d Lie I sued. See Reverse Side or Comments and, New Firvaf ty Correc ions. GO -5 ` (3/70) REV 5/81r Deputy REINSPECTION REPORT • OFFICE OF STATE FIRE MARSHAL FLENO. 9 13 ED E D'Z �a a] FRI E Date Reinspected --65r N me of Facility, A dress C nditions Discussed With F s, Accompanied By r�����s Title Dj. yt� „� I sppction This Date Discloses That Fire Safety Corrections Number L of Fire Safety Corrections Dated t$ ., SS�o -S --1 —oS"�- Have Been Complied With. F i re Safety Corrections- Number • Were Di scus sed With and Disposition Will Be A F*o1 lows: Reinspection Indicates That New Fire Safety Corrections Should Be. Issued. See Reverse Side fiF.Comments.and New Fir of ty Correc ions. G -5 + (3/70) REV 5/81 Deputy 47 ...... a P.0. B 0 X 371 -- - -- - • CHICO. CA 95927 DATE UA � ® J ALARM CO. LA000517 -/ -S (916 345-3411 f I ACCOUNT NUMBER ACCOUNT NUMBER hCh fi--1k,&A--sLf-a -S-f A r-�f D �� s 1 C� o o Insure proper credit &-M � P P ��,n,A, �,(�", � �C. 1 Oj please check those items being paid in the "� " column and return this portion of the statement PAGE NO. / with your payment. REFERENCE DATE CODE DESCRIPTION AMOUNT BALANCE REFERENCE CODE AMOUNT -3 e- v- -Re ry 4 --Rery4 r��r a SqJb f DES C CR MEMO P PAYMENT A DISCOUNT F FINANCE PLEASE �� D - DR MEMO I - INVOICE ALLOWED CHARGE PAY C CJ DAYS 60 DAYS 90 DAYS 120 DAYS TOTAL cza :5 Is 76 SMITH'S SECURITY SYSTEMS -- --- - �s-- — z - - -- — — -- — _ _ .. --- -- - - - ----- — -- - - - - - - - -- s Please reply [] No reply necessary SIGNED 180.2 Available l(om rN Inc . Groton. Mass 01450 STATE FIRE MARSHAIL - - FIRE SAFETY CORRECTION NOTICE - STATE' -IRE MAR i4L FILE NUMBER Pig 9 KIN Q � Ell _H1 Fel opo Rill - - he above s - d e, zczencte are -o eorretec wzahn dais. Upon complete: please sgrn. ren return -the cert .zcc�t�on an the z e s� this ::, . I :t t State . : _ apo - t d o fore. f you have ary :questzQnsf cantae h. - Fire Marshal Office a (4t - ISS ED NBY (IPEPVTY _STATE FIRE MARSHAL) RECELVED BY JDATTE i ki i . EN -1 (REV. 7,r81)• YELCI W RCGtO►i5tILIiY .GREEN: "FSE - . ee701-355 a -ea ,� aa� TRIP OSP i 1 . A► , PURCHASE ORDER 3922, R. No. ` j Dote 3/28 e .� l • r .* t Vl To Smith s Security Systeme For ddress_ 170 Rio Lando Avenug, P.0, B= 372,, CA 95926 Date Required C0=nUr . ty • ,A►ction AgeiN Ship To How Ship_ - '• 2255 D81 4z�o 'x Ur �� �CA 95965 t- _ - - - - - Terms ., 985 610 INV PLEASE SUPPLY ted red Tax 7 ansformer kin EsauBattery and charger i*708-485-0020-2.3 classroom Gridley ACCOUNTS PAYABLE DISTRIBUTION DEPT. .& SUB. CLAIM INVOICE INVOICE GROSS SUB. PROJ. OBJ. N0. N0. DATE EPJCUM6. AMOUNT DISC. 7° x.59 �o 5��� -OFFICE OF THE STATE FIRE MARSHA INSPECTION LOG T i t ! e i 01.4F y t+f'A o s i` i t e U] R 510 H f5l F21 KI 2 Address f.��Q l� �2.t bt Date --�—�S Owner Q uTt E C IA "u ; -I �,,40 s rAo,-r 4 dcG 6 L N A D;N OT- v ,P4 W t rwNt r 5 t &Vk3 --t i T -a , L 1 -CA D U .i NA S xjOf,& Ctge, GG -6 (Rea. 5/81) t fS7*' c fq FToa. -e pi" ,4LAW.w►. S y S Mato1 IS I rv5 i e bb L L(FrD fltp "S E 'Tore A��A-Gds day �4-is y�v�e.we� FvUO tr uP �8-,LAa A4s4Jc. ry 7-'N+rL 1+1Z6 A w Y Q cc kd''r-, ot.1 s PLEA S L C.+ALL yvA0cY F ig ,4.7' C916Jji2?— 2132S, . GGJ ST EMM A MARS NO&:t CORRECTION SAFETY NATE IBE MA.- - AL - N _ AIS 'RsS �f 1,L%n/ PAA.' FILE NUMBER K�ao a�o� ooa a • I c ^ rd - h r�_, co:, ante wi_ . tAe min standards: o 'ztle I9 C°alz orr a Adzn nes a zve `od a .� . f 0110wt torrect on., are req 2r d - e44 L III_ _ _ - _ - - - •. - -_ _ - a : -r: - - e Z.on-!eae :n a a e above c e� f o enures are to �� carr. ����d w t1��n, - da.�s. ��aon corr��� t �? - _� _ _ V. V s_c tt a ue 1 ' x �� s • e ,:� s or -fn : -I:. 'o -u a �e arx ons -.eo: �� he ce"icaa'zan o� the �ppos� � .�.� :of :� _ � - �_-.. _. _.. _ ,� .� h � '�_ B U'T STATE RS 1V RS_ HA L RE I BY DATE S - . - s _ YE IQif �AIFiC; ' aF+� � EES ;Ft - EN {REV. 7- o . �, _ io � _ , , �. _ :: se 01-a s e xMi'riar� cr - w y - .r^ Vic €ji ,V., i=`tG .�,- i "-� "1 ten. :�•, '4qL z^ � y.:a1 �T ' 3'� . 'Fa �'._'•�i ei' � �'+i��-+ �N ^�'i ��.� �FS •� � 'tom r_�i! �"�-��r,,r 'i .. .'� '3 •MSS.- . .s•� - s ' p ._ � ,.�� - � r �+' ,�- 3w i._� � i_' �,,,��i'2r�'F�� "-.1->�' A-•�-L�1`'w �r�,� ._. 5; �� ci _ a y, _ �r � � - x r. ;i � � � - '� -` K y _. � :;-��e �� �-. .�•r�+ '•�`�- � '� S' �i�-c��"' ^�� �`i`• �' � �� i � ;�" �� _ ` _ .ac'',e 5r ?� - - t -. ''s �k � ✓* 't:_ �-rs''ts =.'r sr.a.,.s. s o � - ,� <�;� 4•�Y �_�•' ''`�"�• _� - #�` '! rte-a.,�'` t{r� F z ' . �� - _ � �g i ' '>'�'�i �� "`:tl..y�$ � k a+ � � z �¢ �•9, ` _ ...�.5. _ �� .l' y.`% r '� #��s lR. YI 'a�` �_ +, Si 1' ''� s: _ � ���G I.3���` t 'S. �'rV � a --:>�T- ��"�k`+^ �' _ T^t': i � '�y'- . - at�`L�:.���--i�F �, -.�, .:+5 �- � _'��•n � � - a-s'X AM -_ �"t' � tea.- _ t^`'��'.'�_�•s`�`e�sf-x' c =.`��"� ik .,+ w �r-tot- 4 +�'"'t�r�_� _ : ,•x,�<_ �`✓,� �;,� ,�,,,�"`�'"-&f'^ �^-T. ` >--y._. 'r4 i��„+�„ -,{^� -' 4•' � „r•'•• Yy s��(bif �"t : �' � _u�4-w�,•-�� 3 -.� �+"z"+5' -� .as' .01 ` GJ�tc.''�•— w-�:'"F' '� � - ,e- f+� 1 ..��z� '`�`a' Z�:�f�� -� s" x" * �-`-.��� �'`� `_ �` * ��• i.•, 1����"�-� �• +`_.'" ,. ���• �, •'•4ra ,w �-- `-. �-�a�- :. z � � Y a `� -. �, -'°.fir K:_-.t,tS �z,e.. �., - x:.s:.;�'i`aF.`��' � '`F• b �`�i' ��-"� � . .,ry R "'��'�`��. F 4��. ���s'.��-= '�;� " „� �'�:. 4 er .: ^"q+ -.e -r _ �_ Tw.. F'"�,'.�'�"•r't'.^��"�-,i'�9^� _ aw.. _' �'_.�r- _ ^�-s-^,rr'w�-;t.f4`e�f+r.:-ti,.-..�=-*r-' �•�•�gc+>7 ��.� ,'r'Y. _ - .�` _"'.'-�. ' _ .. � .. _ , ;tc _ .... _ � a -�_ 'il �� .ter •n. ;�� _' A JON >•' a irk .u" +.-...Ji w ; k•�'': tom_ - S.V. i '� ` ��1�, � R-r-'l-Tf '-- „y-a.:ti-•MY'�' - ' � "71` a -,T Nv �- fid �� =<��_, _ 2.•. - � F.7, aS- VIE." EN -1 (REV. 7/81) YELLOW: REGION WHITE: FACILITY GREEN: FIELD 88701-355 3-84 12M TRIP OSP STATE FIREMARSHAL1E SAFETY CORRECTION NOTI,�AL ?^ AIREMAR JUIN 1985 , 'aece1at d E � ffamefft ,, Gf21A�-�y t��u4fo srr9Rr �Entt FILE NUMBER ® 0 0 R1 ®® " PS -0 ff. e fLIn ZEA' P -S, ®❑© �0 ©®© 0®© ❑° 10 u P- 10 Wq 4 y 8 NA ADDRESS In accordance with the minimum standards of Title 19, California Administrative Code, the following corrections are required: t, P/iv1110 P -Al s kM r- JLi &A L A 0 m Sf C - The above deficiencies are to be corrected within 30 days. Upon completion, please sign and return the certification on the opposite side of this form. If you have any questions, contact the State Fire Marshal's Office at ( q16 ) 4127— `t 32,r . ISSUED — BY EPUTY STATE FIRE MARSHAL) £ GJorVA t4 , RECEIVED BY 8. y pt+OA-�OE DATE /— EN -1 (REV. 7/81) YELLOW: REGION WHITE: FACILITY GREEN: FIELD 88701-355 3-84 12M TRIP OSP CERTIFICATION OF CORRECTIONS BY OWNER ' I certify that all items listed on the reverse of this form. have been corrected in accordance with the requirements of Title IJ, California Administrative Code. SIGNATURE DATE _ - (Folie -on -this lined - - -. - - - - (Fold on this dine) PLACE STAMP HERE STAVE ARE MARSI LAL Sacramento Region 4433 Florin Load, Suite 400 Sacramento, CA 95823 - - - CFf BUILDING SURVEY REPORT Date: STATE FIM All Fi le No: Q0 -6 q - I - C7o l y oo Q 0 -- 0 Nam of Facility:.. t s rIr Y.v a, Add ess .� 0 z�C1 . own r : u n- �. a s �- -�, ,...�., Telephone No. C 916 } X73 N of Building.: DESCRIPTION , Cart. le occu an Class E-3 .Use AY rt 1' Jr,. , ,Z Capacity 011 2 Construction 1, _Type. y r' _ N - Year Built Total ' . Largest Floor Basement No. High Rise Yes No +rrrrrlrrrrrrrr.r...� - 3 m : Area (Sq*'Ft&) 4 w Stories . Exterior Wall Construction 1pir'14a eujuiacm JgLaci< . opening Protection "or I&CO at ". 6. .Interior Wall Construction LAJUC I, t w4 av vz#q a k s , -tom. o,4 - P, Aj c. r 7. Floor Construction C MCrf A 9 r7 t cLjCO $z LP CZ: Roof Construction W000 z es . v`006 &A. rz. o . w Attic Draft Sto s No. &,er 2 oo u i Ma. Occ. Sep. mall Construction r �E b. Opening Protection No. Ivo r lzis 0 w I &Ad.... . 1 a. Area Sep. Wall Construction, yx Gm . b. opening Protection = No. _ 1 a . Smoke Barrier Wall Construct i bn b. Opening Protection 1 aw Corridor Wall . Construction PA A � Lj( ; ' le -vi � ,o r b. Opening . Protect i on T- &C a t,L,t 1.1a. Corridor Ceiling ` Construction 90A"V0 P" *V& b. -opening Protection GtaWW 1 a,* Shafts Number/T re O �+ b. Opening .. Protection DESCRIPTION Cama _ 16-1-0 Stair Enclosure opening Protection w' 17 Stairs No. 18.M R s No.,, 1910 Interior Finish Class ti Room IL.M0 ' #*Asu,4(. 1 w4 Corridor ��� � Exi t Encl. -- No.. Total Width 20 Exits 21D Exi t- Hardware 22 . Exit Sim/ • • I llumi nation * �•: -tet ' ti z v ..: IUoT RrL 0 wt � rz,0 . Emergency - Lighting 9 u s 23. Auto Sprink. Coverage - 24 . Standpipes Class/location ::... 25. Fire Alarm o�rera M4wk 4 L - Let) &4 C 2 Heatin &+Tf� u�. - Fuel dent ..: .:... - 270 Electrical Installation- :: 21* Stage/ Platform Hazardous Areas - - •.. .. . - . Ail 3 C other I pected By: Reviewed euTed By: U tec'i: No. Attachments: Date: •~ 97 t soft :i;t. Gam.[}ay! Nr •. 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C, Z r .c.e•.r•. .. •�.7 - - i. _ . c .r• • •r 1 - - .. r. _ :Y . HULTIPLE BUILDING FACILITY a . �.RECORID 40 .� FACILITY NAME: •� ... �� ��. ' ADDRESSO F, Az, 11 CiFV J r 0 FILE Vo a . [AE -o d �. • • -=Ufa" OCCUpA�cY BUILDING IDENTIFICATION CLASS N �"� 'FILE - � SUFFIX NO* U .�3r�� � • • (See Sec. ?40 31 • • • _ d • ���C/9 . • • lam s, �. 4V i i + • Rev. 3/81 STA s FIRE MARSHAL. COPY DISTRIBIT-ION; SEE REVERSE OF COPIES 2 ANCA 5 FOR FI S E SAFETY INSOE'CTION REQUEST 1-3 - STATEFIRE MARSHAL INSTRUCTIONS FOR COMPLETION STO 850 tREV. /80) 2 - FIR` AUTHORITY 1. REQUIEW DArE 2. PROGRAM 4--S - LICE=NSING AGENCY 10/25/84 3. GENCY CONTACT 4. TELEPHONE NO. S. SIGNATURE CMMMITY CARR LICZENSING (916) 920- 68 55 .6. FM REGION 7. SFM S.D. :10, 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR 00-6 -a„3- 0 0P' --c'. q ,fie ~to) 041370117 Chuck. Smith 19. REQUEST C0012 ' 3 RES PIs . ' .• f 1i•, J. 1 CODES. 1. ORIGIN.A L A. FIRK CLXA)VANCE 10. AGENCY 2. RENEWAL p, LIprE sAFETY NAME DEPA OF SQCUL SEMICES 3. CAPACITY CHANGE AND ADD R ESS COtOWi�Y CARE LICENSING 4. OWNERSHIP CHANGE, 520• Coh-asset Road, Suite 6 LChtco. CA 95926: . J 5. ADDRESS CHANGE 6.OTHER DATE OF ORIGINAL REQ. 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CA PACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS 9 TO I 18 TO SS AND 6S OVER CAPACITY 15 TO 18 18 TO 65 AND 6S - OVER CAPACITY 23 . 20. 20. FACILITY ' ' 12 12 FACILITY NAME 13. NO. BLDGS CODES GRIDLEY HEAD START CENTER 1 1. G A C H 7. ICF /OT 2. GACH/R S. ICF/DD 14 STREET ADDRESS 15. RESTRAINT • 850 $. Gridley Road None 4. A PH 10. CLINIC 5. PHF 11. JAIL CITY ZIP CODE 16. HOURS Gridley , CA 94948 Days 6. SNF 12. OTHER 17 FACILITY CONTACT PERSON TELEPHONE NO, 16A SPECIAL Elisa Duenas (316) 534-4719 Child Care Center TO BE COMPLETED BY INSPECTING AUTHORITY 1.' F i R E � --t •. 27. CLEARANCE ' AUTHOR. COOfs ; NAME CODES AND ADDRESS 1. FIRE CLEAR. GRANTED 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITH1.1'ELD 28. DENIAL COME TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. INSPECTOR S NAME TELEPHONE NO. _ 23. CFIRS 24. T-19 OCC. 10 NO. CLASS 1. EXITS 2. CONSTRUCTION 3. FIRE ALARM 2!. INSP. DATE 26. INSPECTOR'S SIGNATURE 4. SPRINKLERS 5. HOUSEKEEPING 29. EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY 1. REGION. OFFICE AND ADDRESS TIME MILES NEXT INSP. (MO.DA.YR'.) STATE FIRE MARSHAL FIRE SAFETY INSPECTION REQUEST .r COPY DISTRIBUTION; SEE REVERSE OF COPIES 2 AND 3 FOR 1 - STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION STD 8 OA (NEW 6/80) 2 - FIRE AUTHORITY 3 - LICENSING AGENCY 5f � 1. REQUEST DATE 07/14/83 2. PROGRAM CCF 109 3. AG NCV CONTACT 4. TELEPHONE NO.SIGNATURE 5. EPT SOCIAL SVCS. CCM CARE LIC 4916) 895-5033 6. SFh REGION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR 00-94-23-0"9--OCC-3300 041370117 0404 19. REQUEST CODE 2A CODES 1. ORIGINAL A. FIRE CLEARANCE F 2. RENEWAL B. LIFE SAFETY 10. AGENCY DEPT SOCIAL SVCSq CCM CARE LIC 3. CAPACITY CHANGE NAME AND 520 COHASSETT ROADS SUITE 6 4. OWNERSHIP CHANGE ADDRESS CHICO CA 95926 5. ADDRESS CHANGE L 6. OTHER Al" BULATORY ONLY. CHILDREN AGES 2 THROUGH 6 YEARS. DATE OF ORIGINAL REQ. - 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE 11/ 15$2 CA ACITY AGE RANGE (YEARS) TO 18 18 TO 65 AND PREVIOUS CAPACITY CAPACITY AGE RANGE (YEARS) 18 18 TO 65 AND PREVIOUS CAPACITY 65 OVER TTO 65 OVER 20. FACILITY 15 CODE 850 V 12. F CILITY NAME 13. NO. BLDGS. CODES G 1 DLEY HEAD START CENTER 1. GACH. 7. ICF/OT 2• GACH/R 8. ICF/DD 3. SH 9. ADHC 14. SREET ADDRESS 15. RESTRAINT G IDLEY FARM LABOR CAMP 4. APH 10. CLINIC 5. PHF 11. JAIL 6. SNF 12. OTHER 4IDLEY TY ZIP CODE 16. HOURS 95965 UNDER 2 17. FACILITY CONTACT PERSON7916-846-4559 ELEPHONE NO. 16A. SPECIAL DUENASs ELISA DAY CARE CTR CHLDN TO BE COMPLETED BY INSPECTING AUTHORITY 18 FIRE - 27. CLEARANCE CODE AUTHOR. CODES NAME 1. FIRE CLEAR. GRANTED AND ADDRESS J 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE - TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. NSPECTOR'S NAME TELEPHONE NO. 23. CFIRS ID NO. 24. T-19 OCC. CLASS 1. EXITS 2. CONSTRUCTION 3. FIRE ALARM 25. INSP. DATE 26. INSPECTOR'S SIGNATURE 4. SPRINKLERS 5. HOUSEKEEPING 29.�EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY 1. REGION, F OFFICE AND ADDRESS L TIME MILES NEXT INSP. (MO. DA. YR.) . IN, 3 U"l ' oTL T zi . • r .. .y41 1 1 COPY DISTRIBUTION; 2 AND 3 FOR STATE IRE 1!� ►RSHAL SEE REVERSE OF COPIES FIRE SAFETY INSPECTION REQUEST 1 - STATE FARE MARSHAL INSTRUCTIONS FOR COMPLETION STD 850A (NEW 6180) - 2 . FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM 3 . LICENSING AGENCY 04/13/83- CCF 1 Q9' r 3. AGNCY CONTACT 4. TELEPHONE NO. 5. SIGNATURE S ATE DEPT' OE EDUCATION - OCD ( 916) 322--624I. 6. SF REGION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR 00- - -- -000- 043 501156 0101 19. CODEEST0 ; Mole[] CODES 1. ORIGINAL A. FIRE CLEARANCE 10. GENCY F2. RENEWAL B. LIFE SAFETY AME STATE DEPT• . OF EDUCATION. o o 3. CAPACITY CHANGE ND 1500 5TH STREET, THIRD FLOOR 4. OWNERSHIP CHANGE DDR_ ESS SACRAMENTO 9 CA 95814 5. ADDRESS CHANGE J L t 6. OTHER LICENSEE PREFERS ACES D 14 DATE OF ORIGINAL REQ. - 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE 08/24/82 CAF ACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS TO 18 18 TO 65 AND CAPACITY TO 18 18 TO 65 AND CAPACITY 65 OVER 65 OVER 20. CODE FACILITY 850 12. FACILITY NAME 13. NO. BLDGS. CODES G I D:LE Y . N IGR ANT CC INF CTR (BUTT'ECO 1. GACH 7. ICP/OT 2. GACH/R 8. ICF/DD 14. S REET ADDRESS 15. RESTRAINT R UTE3 _. BOX 3250 3. SH 9. ADHC 4. APH 10. CLINIC 5. PHF 11. JAIL 6. SNF 12. OTHER C TY ZIP CODE 16. HOURS DL E Y 95948 UiER 24 17. F CILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL S I LLE 8,wAHOEL .I'TA 916-x•846--5147 AY- CARE CTR CHLON TO BE COMPLETED BY INSPECTING AUTHORITY 18 FIRE 27. CLEARANCE CODE ; AUTHOR. ' CODES NAME 1. FIRE CLEAR. GRANTED AND ADDRESS 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD c 28. DENIAL ; CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. NSPECTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T•19 OCC. ID NO. CLASS 1. EXITS 2. CONSTRUCTION 25. NSP. DATE 26. INSPECTOR'S SIGNATURE 3. FIRE ALARM 4. SPRINKLERS 29. EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS 5. HOUSEKEEPING 6. SPECIAL HAZARD 7. OTHER OFFICE OF STATE H_A'k'-i ' ARSH .,: Marina-Merceld Offle'e. Complen, . REGION, F_ l OFFICE 2-300 Merced Street AND ADDRESS San Leandro, CA 94677 t/L, LJ STATE FIRE MARSHAL USE ONLY TIME I MILES I NEXT INSP. (MO. DA. YR.) l ' r a g T i 0 7i ' r _. -3 GA 8.0P i STATE FIRE MARSHAL FIRE SAFETY INSPECTION REQUEST COPY DISTRIBUTION; 1 • STATE FIRE MARSHAL SEE REVERSE OF COPIES 2 AND 3 FOR INSTRUCTIONS FOR COMPLETION STD 851)A (NEW 6180) 2 FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM 3 LICENSING AGENCY ,,,3�A ENCY CONTACT 4. TELEPHONE NO. 5. SIGNATURE 6. SF REGION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR 19. REQUEST CODE U E � L;r. CODES Q 1ORIGINAL A. FIRE CLEARANCE 10.GENCY 2. RENEWAL B. LIFE SAFETY NAME 3. CAPACITY CHANGE AND ADDRESS 4. OWNERSHIP CHANGE 5. ADDRESS CHANGE L 6. OTHER DATE OF ORIGINAL REO. - 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CA ACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE( EARS) PREVIOUS CAPACITY CAPACITY TO 18 18 TO 65 AND TO 18 18 TO 1 65 AND 65 OVER65 1 OVER 1 20. FACILITY CODE 12. F CILITY NAME 13. NO. BLDGS. CODES 1. GACH 7. ICF/OT 2• GACHIR 8. ICF/DD 14. S REET ADDRESS 15. RESTRAINT 3. SH 9. ADHC 4. APH 10. CLINIC 5. PHF 11. JAIL C TY ZIP CODE 16. HOURS 6. SNF 12. OTHER ^F kCILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL TO BE COMPLETED BY INSPECTING AUTHORITY 18. r FIRE I 27. CLEARANCE CODE AUTHOR. CODES NAME 1. FIRE CLEAR. GRANTED AND ADDRESS 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE - TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. I SPECTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T•19 OCC. ID NO. CLASS 1. EXITS 2. CONSTRUCTION 3. FIRE ALARM 25. IsISP. DATE 26. INSPECTOR'S SIGNATURE 4. SPRINKLERS 5. HOUSEKEEPING 29. DENIAL OR LIST SPECIAL CONDITIONS �XPLAIN 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY ■► F J. REGION, OFFICE AND ADDRESS L TIME MILES NEXT INSP. (MO. DA. YR.) INSTRUCTIONS This form is designed for use with a window envelope. To use, fold at marks indicated in the left margin. Licensing or Requesting Agencies - Complete the following 21 sections on this form /�► before submitting it to the State Fire Marshal * Complete items marked with an asterisk only when Item 20 is not used. 1. REQUEST DATE. Enter the date risouest vas prepared. 2. PROGRAM. Licensing agency .use. 3. AGENCY CONTACT, 4. TELEPHONE NO., 5. SIGNATURE. Enter the name, telephone number, and signature of agency contact person. 6. SFM REGION. Insert one of the following 3 numbers for the SFM Regional Office in whose area the facility is located. 350 Coastal, 330 Northern, 370 Southern. 7. SFM ID NO. This is the SFM Identification Number and initially will be assigned by the State Fire Marshal. Licensing Agency - Insert this number on ail clearance requests subsequent to the initial request . 8. REQUESTING AGENCY FACILITY NO. This is the file number assigned by the licensing agency. 9. EVALUATOR. For licensing agency use. 10. AGENCY NAME AND ADDRESS. Enter the name and address of the licensing facility requesting the inspection. *11. AMBULATORY T- NON-AMBULATORY. Complete this section only when Item 20 dues not apply. Capacity: Insert, in the appropriate section, the capacity of licensed ambulatory or non-ambulatory oc- cupants covered by this request. Age Range: Indicate the age range of the licensed occupants. Previous If request is for renewal or capacity change, insert Capacity. capacity of previous clearance. Total Show total licensed capacity. If the Facility is Capacity: intended to house part ambulatory and part non- arnbulatory, show the total of the two types of occupants. 12. FACILITY NAME. Insert the name of the facility as it will appear on the license. 13. NO. BLD:S. Insert the total number of buildings to be used for housing of the occupants covered by the license. 14. ADDRESS. Insert street address and city only. >A post office box is not acceptable. * 15. RESTRAINT. Indicate if physicial restraint (locked in -a room or the building) is to be used in the housing of the occupants. Y= yes N = no. 16. HOURS. Indicate the number of hours the occupants are housed at the facility. (Less than 24 or 24+). 16a SPECIAL. Use to designate persons who are determined to be non-ambulatory for reasons other than a physical handicap. 17. FACILITY CONTACT PERSON - TELEPHONE NO. Indicate.the name and telephone number of the re- sponsible individual at the facility to be contacted by the fire authority. 18. FIRE AUTHOR. NAME AND ADDRESS. Insert the name and address of the fire authority in the vicinity where the facility is located. 19. REQUEST CODE. Use the six codes shown and insert theappropriate number in the box following "Request Code". Insert date of original request when request is other than an original. 20. FACILITY CODE. Mark this item only if the facility is a; (1) General Acute Care Hospital (GACH), (2) General Acute Care HospitalfRehab (GACHIR), (3) Special Hospital (SH), (4) Acute Psychiatric Hospital (APH), (5) Psychiatric Health Facility (PHF), (6) Skilled Nursing Facility (SNF), (7) Intermediate Care Facility/Other (ICF/07), (8) Intermediate Care Facility, 'Developmentally Disabled (ICFIDD), (9) Adult Day Health Care (ADHC), (10) Clinic, (11) Jail or (12) Other. When Item 20 is used , Item 11 does not need to be completed (except total cap). 21. REGION, OFFICE AND ADDRESS. Insert the name and address of the State Fire Marshal Regional Office in whose arei the facility is located. Fire Authority Conducting the Inspection - Complete the fallowing: 22. INSIPECTOR'S NAME= Print the initial of the in- spector's first name and full last name; insert the telephone number where the inspector may be contacted. 23. CFIRS ID.NO. Insert the fire department's number assigned by CFIRS. 24. TITLE 19 OCC. CLASS. Use Title 19 occupancy classifications and insert the occupancy deter- mined by the inspector. 25. INSP. DATE Enter the actual date of the in- spection. 26. INSPECTOR'S SIGNATURE. To be. signed by inspector conducting the inspection. 27: CLEARANCE CODE. Use the three codes shown and insert the appropriate number in the box following "Clearance Code". NOTE: If Code 2 (Denied) or Code 3 (Withheld) is used, explain. 28. DENIAL CODE. Use only the seven codes shown and insert the appropriate number in the box 000&1� following "Denial Code", If No, 7 "Other" is used. explain at Item 28. NOTE: Fire Clearance cannot be denied for other than lack of con- formance with the provisions of Title 19. 29. EXPLAIN DENIAL. If Clearance Code No. 2 or 3 is used, briefly explain reason. This space is also to be used to explain Denial Code item noted. STATE FIRE MARSHAL COPY DISTRIBUTION; FIR SAFETY INSPECTION REQUEST 1 - STATE FIRE MARSHAL .... SEE REVERSE OF COPIES 2 AND 3 FOR INSTRUCTIONS FOR COMPLETION STD 8 OA (NEW 6/80) 2 - FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM 3 - LICENSING AGENCY 3. AG NCY CONTACT 4. TELEPHONE NO. 5. SIGNATURE 6. SFIV REGION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR 19. REQUEST CODE CODES ORIGINAL A. FIRE CLEARANCE 211"RENEWAL B Y ry B. LIFE SAFETY 10. JAGENCY 3. CAPACITY CHANGE AME AND 4. OWNERSHIP CHANGE ADDRESS 5. ADDRESS CHANGE L 6. OTHER DATE OF ORIGINAL REQ. 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CAI ACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS CAPACITY CAPACITY TO 18 18 TO 65 AND TO 18 18 TO 65 AND 65 OVER 65 OVER 20. FACILITY CODE 12. Fi CILITY NAME 13. NO. BLDGS. CODES 1. GACH. 7. ICF/OT 2. GACH/R 8. ICF/DD 14. Sl REET ADDRESS 15. RESTRAINT 3. SH 9. ADHC 4. APH 10. CLINIC 5. PHF 11. JAIL CITY ZIP CODE 16. HOURS 6. SNF 12. OTHER 1�FACILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL TO BE COMPLETED BY INSPECTING AUTHORITY I 18. FIRE 27. CLEARANCE CODE AUTHOR. CODES NAME 1. FIRE CLEAR. GRANTED AND ADDRESS 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE - TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. I SPECTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T-19 OCC. ID NO. CLASS 1. EXITS 2. CONSTRUCTION 3. FIRE ALARM 25. I 4SP. DATE 26. INSPECTOR'S SIGNATURE 4. SPRINKLERS 5. HOUSEKEEPING 29. EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY .REGION, F OFFICE AND ADDRESS L J TIME MILES NEXT INSP. (MO. DA. YR.) This form is designed for use with a window envelope. To use, fold at marks indicated /n the km margin. Licensing or Requesting Agencies — Complete the following m sect/ons on this ^vnn before vvbninmg i/ to the State Fire Marshal +Complete items marked with unasterisk only when Item um/vnot used. 1. REQUEST DATE. Enter the date request was prepared. 2. PROGRAM. Licensing agency use.. � 3L AGENCY CO��� 4.��E���'No.,� SIGNATURE. Enter the name, telephone number, and signature of agency contact person. 6. SFM REGION. Insert one ofthe following 3numbers for the SFM Regional Office in whose area the facility is located. 350 Coasto}, 830 Wortharn, 370 Southern. 7, SFh8ID NO. This iethe SFM Identification Number and initially will be assigned by the State Fire Marshal . Licensing Agency —Insert this number on all clearance requests subsequent to the initial request. G. REQUESTING AGENCY FACILITY NO. This iothe file number assigned by the licensing agency. S. EVALUATOR, For licensing agency use. 10. AGENCY NAME AND ADDRESS. Enter the name and address of the licensing facility requesting the inspection. *11. AMBULATORY --NOy4-Ak00ULATORY.Complete this section only when Item 20 does not apply. oa»uuuv: Insert, mthe appropriate section, the capacity oflicensed ambulatory o,non-ambulatory oc- cupants covered by this request. xoo Range: Indicate the age range mthe licensed occupants, pmvmva nrequest /cfor renewal orcapacity change, insert ounonxr. ovnxvuv o/ previous clearance, Total Show mto/ //nonveo capacity. If the raoonr is cmp^vnv: intended mhouse part ambulatory and part mm' omuu/aton.000wmntnm/ofmetwowvono/ occupants. 12' FACILITY NAME. Insert the name of the facility as it will appear on the license, 13' NO, BLDGS' Insert the total number of buildings tobeused for housing ofthe occupants covered by the license. . ^. 14. ADDRESS. Insert street address and city only. A post office box is not acceptable. . ` *15. RESTRAINT. Indicate ifh icial restraint (locked ^ in a room or the building) ia to be used in the housing of the occupants. Y = yes N = no. *16' HOURS. Indicate the number of hours the occupants are housed atthe facility. (Less than 24 or 24f). 16a SPECIAL Use to designate persons who are determined to be non-ambulatory for reasons other than a physical handicap. 17, FACILITY CONTACT PERSON —TELEPHONE NO. Indicate the name and telephone number ofthe re- sponsible individual a!the facility to be contacted by the fire authority. 18' FIRE AUTHOR. NAME AND ADDRESS. Insert the name and address of the fire authority in the vicinity where the facility is located. 19. REQUEST CODE. Use the six codes shown and insert the appropriate number inthe box following "Request Code"Insert date of original request when request is other than an original. 20. FACILITY CODE. Mark this item only ifthe facility i (U General ACare Hospital G (A01` General Acute Care Hospital/Rehab (GACH/R), (,, Special Hospital (SH), (4) Acute Psychiatric Hospital (APH), (5) Psychiatric Health Facility (PHF), (6) Skilled Nursing Facility (SNF), (7) Intermediate Care Facility/Other (ICF/OT), (8) Intermediate Care Facility/Developmentally Disabled (ICF ' /D D), (9) Adult Day Health Care (ADHC), (10) Clinic, (11) Jail or (12) Other. When Item 20 is used , Item 11 does not need to be completed (except total cap), 21' REGION, OFFICE AND ADDRESS. Insert the name and address ofthe State Fire Marshal Regional Office in vvh000 area the facility is located. Fire Authority Conducting the Inspection — Complete the following: 22. INSPECTOR'S NAME. Print the initial of the in- spector's first name and full last name; insert the telephone number where the inspector may ba contacted. 23. CF!RS 3D,NO. Insert the fire deportment's number auigned by CF|RS. 24. TITLE 1SOCC. CLASS. Use Title 18occupancy classifications and insert the occupancy deter- mined by the inspector, 25' INSP. DATE Enter the actual deh* of the in- spection. 26 INSPECTOR'S SIGNATURE. To be signed by inspector conducting the inspection. 27.CLEARANCE CODE. Use the three codes shown and insert the appropriate number in the box following "Clearance Codo" wors xCode 2(oanxm)mCode u(mmxem)isused, explain. 28' DENIAL CODE. Use only the seven codes shown and insert the appropriate number in the box following "Denial Code". If No. 7 "Other" is used, explain at item 28. wors: Fire Clearance cannot u*denied for other than lack n/con- formance wuo,xanm"/smnnof Title 19. 29. EXPLAIN 0|EP4IAk_ If Clearance Code No. 2 or is used, briefly explain reason. This space is also to be used to explain Oanio| Code item noted. D REINSFECTION REPORT OFFICE OF STATE JCe S HBiSr ML11;S,a1iLL File -_--------------- Date — ---'--------- Date Reinspected , . t. t.-4� -- - ---------- ------- --------- :name of Faeility_. _ -- j- _�_D_------7-�----------- `- a =-- ---------- .------------------------------ ----- ----- ------------------------------------- Address -_ ------------------ ConditionsWith -_lc._�----------------------------------------------------- ------------------ ------ Discussed With -------- Accompanied B ______-ccompanie y t 4� } . i Title_ Inspection This Date Discloses That Recommendations Number ------ .__.__ of Recommendations Dated----- -=--------•---- — p --------------------------------------------------------Have Been Complied With. t Recommendations Numbers---------- ------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------- Were Discussed ` and Disp sition Will Be o AsFollows:--------------._..------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------ -______._--------------------------------------------------------------------------------------------------------------------------------------------- ---------------- -~� A --------==-C-=---- -- ` - -= ------ -- f --- -----=--�---- ----------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- Reinspection Indicates That_________________ _ _________New Recommendations Should Be Issued. See Reverse Side for Comments and ' New Recommendations. GO— 5 -------------- --------- ------------------- --------.------------------------------ (3/70) Deputy -------------------------------------------------- -........------------------------------------------------------------� --- - ---------------------------------------------------------------------------------------------------------------------------------------------- -------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------- -------- ----- ------------------------ -------- ---------------- --------------- - ------ ----------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------- ------------- :suozjvpuazuuUoaaV MaN ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------- ---------------------•-------------------------------------------------------------------------------=--------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------ -------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- .------------------------------------------------------- - ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- :suoz;!puoo cnaN pun sluaUmoo s MINSPECTION REPORT - OFFICE of STATE FIRE MARSHA.. Date Reinspected Name of Facility....(-.�- �-� �� �-----_ �� � �_--- �- ---A � � - - --- C � �j 10't Address__ VM_h�q__ -• ---- C A / . _ __ -----_ - - } _ _ s_ _�__-__S. Conditions DiscussedWith ----------------------------------- -- Accompanied By... --------------- ---�" 5-----t 1►� ---- Title_----- o�ot_ - - ��___------------•-------_--------- ------------------ Inspection This Date Discloses That Recommendations Number __--- L - _ _`_-------- �. ---------------------------- - -------------- ---------------- - -------- ------ -------------------wwwwww..www_w-w__wr---.w_._www--__-.---__ww____s,__w-__r___w--___- w-w__------w__...-www------------------------------------------- - ------- — - — ----ww-----«------------------------------ N-------------- N ------ --- ---------------------------- N------------= - of Recommendations Dated.------ -------------------------------------- • ---�.----•----------------•--------Have Been Complied With. Recommendations - Numbers________ �A ----------------------- - N----- --------------------------------- - --------•--------------------------------------�Nw�_��--___�---__--- Were Discussed .--- ------------- -------- N-------------- ---------- --------- and Disposition Will Be As Follows: --------------._.------------------ ------------------ -------------------------------------------------------------- ------ ------------ --'-------- ------------------------------ '-------- -- ---- _www---__------------------------------- ---------------------------------- 11 C i, - N-------w---N_-—----- M---_------- _------------------------------------------------------------------------------------'----'--------------------r-----_-_-w--__----_--------_--------- - - ---__-_--__-__---M _-------------------------------------------------------------_-----------_---------w----------------------------------------------' y• Reinspection Indicates That_________________t& 4 ------- New Recommendations Should Be Issued. See Reverse Side for Comments and New. Recommendations. e r�1 j n- GO- 5 (3/70) D_-•_-- eputy F,jc•----------coo -- �� -- __ __-- o d o 00 4e t � : Z o: Dt n u z Y10 N. . e of Facility C, aqA r"T(�t�.i���• ----- LA 1%0 C AS Cft IDLe4 CA 951A vAdd M3n3gt:nenz ------ - Rcc m. and Cop es to P.cqutsted by - _ Tlit! e - A c oxr. -^a n; cd by. - t • Buirl.DI G P..EPORT. A B C I '_- zrre of Vdo. CIAI Te vo • e 2 T _ Occupancy- E; . 3.T-3eConst. A�� P Se 4. Ares of B�_ijdyng 0 L7.� �. Arce cr iaser:fCnt 6. v V• Floors � d CY'� t . F.cof Framing Uj ti �.5 1 3 A:., c SeparationF Ai nlP- 3 2 r • -S'h-�..fts � t_Ll:a1 ...: 13 S:jir Enclosures 14 No. and Loc. Exits 1 S Corridors ] E Exit Dcors & udws.- 1 . 1:,:eric: Finish 1 Au:U.1. Sgri-n!-rIers 15. Fire A's arrr. 2 Static or P;atform 2 i rojectio^ Lr►oth 2 . Fi: st-r'%id Fire Equi?. 23. EX pc5ures 2 Norrrv.- and Actual Cap. 2 . A r:,SLla Lory 26. F.eszrz'mr 2 - SL'bt• y nfuJ�, o wE p K_ nlanle, dk Cor-: r-: o -s H.:.:: rIs: 1�' Le a lVcnc- He2tinsAuto. C.oncl oL i. T� dry �. F Clta rancc,c - EnOosur Rcrnarks: �Na �,( �� SE�t:ri•iCA Tj�t tv.r•_•nv-rtt*to Crc. Pro Ex•,C:>•Lon Cord APPLanccs Nal S:f e , - P�t:scle^141 ig and Stora�c• - ,, (N=7.—.I-2r Acc ordin s :o Front Page) f ' it • r 1 1 • �••�•� r,r •.•.r �•� _. .Y�•..� ��► _��• � r .. .+ter -•.�• rr�.r- -r -_� r � _ rr ••. .�. _�_� �-r -�•_ • �r-r �. �. r _� �•r �.��..-�•. �-. �. �. r�r _•..r��r �r _ •. r� - �. • ._�.•. � .� �. �ar..�r.�•��- � _ •ter wr .ter. _•. _. a« - �.• � - . ♦ �r rte• r•� - r 111 • . r r ■moo MEN mamosommumannoms MEN sssl�mmsmsmsnmn x NOMINEE SOMEONE RONNIE �����v���■immosm- F■yea� �������•�- oil Sussman ■■ 1t\��������<see■i����������r■r���1�������r����������// smorilhimmo-O , -_ ONUMEN q Oman No" 4NOMME No ON ON on smog OMENS sommimmm��on MEMO M SENSE 0 ommommum on. MEMNON 2200211, VMMMM Ems. -REN 01CAMIUMENE Emmmsommo� iii�i' Man�iui�iiii��siiis�iiiii iiiiiii�iiiii ■■■uu■■■■■�■e; �..� ----mss■ ■u■n�■■■■■ ■■■■■■■■r■■■-MENEM 01010111010010111 monomm MEN =1101 PINMENEWENEW1q, M mommoonMl PREEN ON al Sam - wMaimun, LUNIKENS."M mo-mm�MMMMMMKIM 2 WE 10111 mommosommUlm M_EEO amms so smaso INOME-0 min mm�mmviwmmIn son .0 sommommNNEOman ONEMo INS MOMMEMI ■ ■ ■l ■I ■l stmumm ARE lum- 0 11 �sA ■■ M: 1�ii�in Ems MEN OFrICE OF THE STATE FIRE MARSHAL INSPECTION LOG T i t I e kov inn go 0 El 0 0 M PI Rl a] iff] E Address ��/d%'� � �� . Date Owner ZZ �7f,64 Aa 0( 4oxi • �r ZwAk• p a GO -6 ( Rev. 5/81) ICE OF STATE: -IRE MAR AL STATE FIRE MARSHAL kiLRE SAFETY CORRECTION NOTICE FILE NUMBER El El 1:1 El [1 U El El F] F-1 El 1:1 El * 1:1 El 0 EJ In accordance with the minimum standards of Title 19, California Administratw-se Code, the following corrections are required: f X 4 Y, t 72. 'Ile Z ?e 7-r d 4 lit I _7of� .� ! J,r ,,,: A �`+"i f: ' r..� .. r'r r" }'. ' ., �: i e x� !' .. �r �f �'r - s : `4 �' 741e 10/71 Aj -7 r t� 27 .tom`'40 IleAfi de 20 Ile I J 7 The above deficiencies are to be corrected within days. Upon completion., please sign and return the certification on the opposite side of this form. If you have any questions, contact the State Fire Marshal's Office at ( ) ISSUED BY- (jPEPUTY STATE FIRE MARSHAL) RECEIVED BY DATE _0 EN -11 (REV. 7/81) YELLOW: REGION WHITE: FACILITY GREEN: FIELD 840,13-355 7-812,500 TRP cm&osp -, '"� b �����._.� �R�•• a 76� � ._ar- .5 -9'`S - c `wi'T�. ,F+.��rrti -ax� �k'N�' ��s-- }dam'_ '� �-.. s3. _ y • r*rk ..�.kc zj' -: � •. ��.--�' E-fir`'_ _ - r � _ •. <7. : ±+-r - Z. a r> ".�` -t . �� -� - j -�.. s•,*'xr<_ r s�''�cry,�-``9'� `��a. .-_e�rlR...r�k� �r��r'�i �>;.=- .sem-{•�'�M._��- -''�=^�•v^-.�.'-- e��� t: �r 57 ��� aeii -srfWs 1 �`f7ri_7y - _ _ - •;�-.'c - ,r. - ���rV�� - r � tic TI —. ��€ � ,Xr-- ��-.'+z.:r -""r-� �'_ ��a• '�- � '�" -r - # �. - s � .cg's` �-..'�'i:- � Vii. 3c '" � 'S' -_ w 4s - Y#t` r Afn ✓ . `.ten' 3" �� `s "sem s a- t� 77 R77� IFLN '� s"ri�, � 4 !T�_ - _. .-:`rF @.. -_d yy T `r r ,_ y - •rFk'+ Rr+ccY _ �5-. nk 41 MR :,?-•s 5.'.� d Ki'"�'_ _; s`�L- .'r' '5 .: ..�a,- � s� � „q_a. Cyt ._ _: �. '� t. �g ��;.� s -," � � �., . f �=--�.: .� _ •testi. � -- tiY: +< - _fix- r- ,a �k -- as•;.-'��'�€, - c �•:. mss. �. �- ` Jcs.r. '^ � f[.. :- _;� _ <!." er 1 •f.T ' _ sem^ i^ . 'AF- " � 4. - _ : i`T _ - `��' yy' �'_ r.. r tJ 4 ' W"vii �-� �� ,t v :�. . 4 Win• ~� � _• -y W-Wv,"? Y— ft ti .S e. CCUPANCY CLASS: OCCUPANCY CLASS: code proc . code proc . t 17) ORIGINATOR MSPECTION AUTHORITY 1"NSPECT t ON AUTHORITY 13) (� LOC. FACILITY -LOC, INSPECTION (0) � LOC. -FACILITY -LOC. INSPECTION (o) 14) � LOC. FACILITY-SFM INSPECTION (1) ❑ LOC. FACILITY -S FM INSPECTION (1) 15) SFM FACILITY (0) ❑ SFM FACILITY -(0) 16) COMMENTS: J4 ,e t 17) ORIGINATOR tot a , s l 1 Gl CE OF THE STATE FIRE MARSHAL INSPECTION LOG TifileFi le Address 109pki Date Owner GO -r6 (Rev. 5/81) �s- -•OtWE { 4 STATE IRE MAR Al STATE r.111 -LA 1"LA RSA } t L SAFETY CORRECTISN NOI�d FILE NUMBER AD or . 1• 0 1 r loop � lie - i' W r I s IL r 1- t r> . �/A 1.01 f.w l 010 6 ..a o42 A 0 f..LJ It 0900 r v �C-o--7.ar7o" 2010* 40 7.01,e lM 4djP1 -ems . The above deficiencies ars to be corrected within daps. Upon completion, please sign and return the certification on the opposite side of this form. If you have any questions, contact the State Fire l�larshal's Office at ( ) 1 . ED BY PUTY STATE FIRE MARSHAL) RECEIVED BY DATE R jFULJRVEY REPORT s/� OAR" OFFICE File�..�+.r�w...�r. Date "AOL"STATE FIS1 U HAL� Name of Facility 6-74tor A=. res ) . na�e'mec�t- Re om. and Copies to_�__., Insp. Requested by Accompanied y t j P BUILDING . rr.�.�...ir.�rw�..-i�w...�.r.�.■r..�■.. REPORT A B C 1 dame of Bids.. 2 Type Occupancy 3 Type Consr.---Age 4 Area of Building Area of Basement 6. Stories in Height 7. Exterior Walls R Interior Valls 9. Floors 1 Roof Framing 11. Attic Separation 12. Vertical Shafts 13. Stair Enclosures 1 No. and Loc. Exits . Corridors Exit Doors & Hdwe. 1 . Interior Finish . Autorn. Sprinklers . Fire Alarm 2. Stage or Platform 2 . Projection Booth 2 . First -Aid Fire Equip. Z . Exposures 24. Dorn:. and Actual Cap. 25. Ambulatory 2 Restraint 2 Surgery O-4 x d♦ /7d1y Nea �� t.I I f r L ,77 r 0 v .r . .f two let 0 r. a kzz _ l 1 rN V � o 3 u-kbl &KE f STATE AL NA E A DRESS .�, STATE FIRE MARSHAL ... FiRE SAFETY CORRECTION NOTIuE FILE NUMBER El 1:1 El El ❑❑ ❑❑❑❑ ❑❑❑ ❑❑❑ ❑ In accordance with the minimum standards of Title 19, California Administrative Code, the following corrections are required: The above deficiencies are to be corrected within days. Upon completion, please sign and return the certification on the opposite side of this form. If you have any questions, contact the State Fire Marshal's Office at ( ) I SUED BY (DEPUTY STATE FIRE MARSHAL) RECEIVED BY DATE -11 (REV. 7/81) YELLOW: REGION WHITE: FACILITY GREEN: FIELD 84013-3557-812,500 TRIP CAM Or OSP ' - _ - - _ - •i .. a .;mow-. _ CERTIFICATION OF CORRECTIONS BY OWNER - I certify -that all items listed on the reverse -of -this- for-m_ha.ve:heen. car -rested- in accordance - _ - k with the 'requiremen-ts -of Title � 9 California Administrative Code. SIGNATURE DATE - _- (F4o1d on- this= Ane)` • a (Fold'-oh-:--this-Ane) PLACE STAMP - - --- -- - _ - - --- _ •• -- - -- - - -- - HERE -.STATE _FIRE MARSHAL _ 23oQ Merced Street s San Leandro,-Californfa94577 II - _ It k ,,,,,SURVEY R-EPORT . � • OFFICE O.� STATE FIRE N AMHAL D2rc - jre& t Deputy Name of Facility- ew 2Ke Address 1 nagernent Rt GM. and Copies to Insp. Requested by Tst':e Accompanied by -.Tit e BU .DING REPORT - A$ B C 1 Name of Bldg..,old 2 Type Occupancy 3 Type Const. --Age t r bwr lax. 4 Area of Building#4 w f Area of Basement . - Stories in Height . Exterior Walls. . Interior Valls1 %virwd � �J_& -- X u . Floors I . Roof Framing aye' •.• je.. .9 ,.,a Ir 1 Attic SeparationJ, evv--" I 1j. Vertical Sh2f u __,d&Aa3fA Et. Stair Enclosures - �• 1 No. and Loc. Exits 1 Corridors --� • ••-- I Exit Doors Lit Hd ire. 1 . Interior Finish 1 Autorn. Sprinklers & Tft„a I e. v Fire Alarm 2 . Stage or Platform 2 . Pro j ec tion Booth Z . First -Aid Fire Equip. •.► -- 2 . Exposures . 2,41, Norms. and Actual Cap. 2 F. Ambulatory vAr e S 2 Restraint 224140rkc6 2 Surgery 0-40-70) 0 9 -kb I --R .S ,�'_"-�---.T;; ,- „r-,-:-_.. � .; _ _.-,7 ,,f7 '^?�'.-.z.:r �--,� .-.�,-..-•.s..,•.'v,r.�-.� •---..1-,.�.���t...;.s. �Y .-?.�Tr.;R. :rjFni4��`#�' v 3 `w�."��'�'T�.� �"r-7��wRiifiFi:�1 .�r�� � •'7�°'r'� t �• . ........... �: ;: "; _� �- ! � j �� � _) ! 1. -1 plat �! COPY DiSTRIPTim ., ,,ft SEE REVERSE OF COPIES 2 AND 3 FOR ,I SAF=ETY INSPECTION REQUEST 1 • STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLFTiON t A jl,EW 6160) 2 - FIRE AUTHORITY 1. REQUEST OATS 2. PROGRAM 3 LICENSING AGENCY A ENCY CONTACTTB-27-82 EPHONE NO. 5. SIGNATURE SS-Cow±unity Care Licensin(;'Ch�.co 6-89 -503i Sh41 REGION 7. SFM I.D. N0. S. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR New Application -041 370117 0404 f` TRUCTURED ENVIROti'1f2INT FOR CHILDREN" so, - 2_✓ _ 0X?d : Ot ' - 3 -�O19. REQUESTCODE 1 v CODES - �. 28. DENIAL 1. ORIGINAL A. FIRE CLEARANCE AME DEPAR .,r NT OF SOCIAL SERVICES NAME CODE CODES 2• RENEWAL S. LIFE SAFETY PIO COI.1111TITY CARE LICEPdSIi;G LTELEPHONENO. 3. CAPACITY CHANGE ADDRESS 520 COHASSET ROAD, SUITE 6 2. CONSTRUCTION SP. DATE 4. OWNERSHIP CHANGE 1 CHICO , CA 959206 3. FIRE ALARM S. ADDRESS CHANGE 4. SPRINKLERS .PLAIN DENIAL OR LST SPECIAL CONDITIONS - --- -- --- 6. OTHER S. HOUSEKEEPING 6. SPECIAL HAZARD DATE OF ORIGINAL REO. 11. AMBULATORY A ACITY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS TO 18 18 TO 65 AND CAPACITY CAPACITY TO 16 18 TO 85 AND 65 OVER =C 0 65 OVER 20. FACILITY FACILITY NAME 24 CODE 8 0 OR -II)QLD START CF,I;T R Y3. NO. BLOGS. CODE. 1. GACH 7. ICF/OT Oil S BEET ADDRESS GRIDLEY FARM L&BOR CAIN 15. RESTRAINT 2• GACHIR 8. ICFIDD 3. SH 9. AOHC Y NONE 4. APH 10. CLINIC 'CODE 16. HOURS 5. PHF 11, JAIL GRIDIZEY, CA (BLIT£ COUNTY) 6. SNF 12. OTHER DAYS CILITY CONTACT PERSON TTELEPHONE NO. 0116-pA�-�55� `�+``tt J i6A. SPECIAL Dl DOTSON OR ELISA Dtw'I.AS916-534-4719 AY CARE CENTER-CIP"LIREr TO BE COMPLETED BY INSPECTING AUTHORITY FIRE AUTHOR. 27. CLEARANCE CODE NAME CODES AND 1. FIRE CLEAR. GRANTED ADDRESS L t 2. FIRE CLEAR. DENIED REGION, S;'A.:: F IRZ 11-AR51ATI -7 OFFICE Fa_r oa-Merced Office CompleA I AND 2300 Merced Street ADDRESS San Leasadre, CA 94577 TIME MILES NEXT INSP. (MO, DA yR-j 3. FIRE CLEAR. WITHHELD 28. DENIAL -- - 70 BE GOIAP_LEIETLHY-CL�SPECT V,: Ai7TPftiFit7Y" _ CODE CODES SPECTOR'S NAME 27, CFrA$24: T-i50CC. ID MO'. CLASS LTELEPHONENO. 4. EXITS 2. CONSTRUCTION SP. DATE - --- ---- ----_-__ . 23. INSPECTOR'S SIGNATURE - ---- 3. FIRE ALARM 4. SPRINKLERS .PLAIN DENIAL OR LST SPECIAL CONDITIONS - --- -- --- S. HOUSEKEEPING 6. SPECIAL HAZARD 7. OTHER FIRE MARSHAL USE ONLY _ STATE REGION, S;'A.:: F IRZ 11-AR51ATI -7 OFFICE Fa_r oa-Merced Office CompleA I AND 2300 Merced Street ADDRESS San Leasadre, CA 94577 TIME MILES NEXT INSP. (MO, DA yR-j . ` COPY DISTRI u REVERSE OF COPIES 2 AND 3 FOR S MARSHAL ;SEE 1 FIRFETY INSPECTION REQUEST 1 - STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION .41JA 2 - FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM STDGEW 6180) 3 - LICENSING AGENCY . 3. AGENCY CONTACT 4. TELEPHONE NO. 5. SIGNATURE ' 6. SFM REGION 7. SFM I.D. NO. 8. REQO STING AdENCY FACILITY NO. 9. EVALUATOR ..11ll ' moi '1 n �' i '� ' : �, t NAME _ - . 19. REQUEST CODE a c s-; ;- a-: i �'� , .i., f_� r,, �.., l ! �,�' CODES 1. ORIGINAL A. FIRE CLEARANCE I J 10 AGENCY 2. RENEWAL B. LIFE SAFETY =�- L . c -� ti NAME }'; f 1`11 t 13. �i_� l �.' ��'} C'(.: +... 2J_,. tij � � ,' , 3. CAPACITY CHANGE AND �� iii:. � ' �)1 i T �.I' '� �. _ ' � i... C1j" l �.� �F_'70 4. OWNERSHIP CHANGE ADDRESS CODE r� vOJ Lrl o _j 1 i�' 1�' 4 2��1.]�" 5. ADDRESS CHANGE irk �` () 9 C i 9 ) J 26 � 6. OTHER 22. L.- TELEPHONE NO. 23..CFIRS ID NO. 24. T-19 OCC. CLASS DATE OF ORIGINAL -REQ. 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE C kPACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS T018 18 TO 65 AND CAPACITY T018 18 TO 65 AND CAPACITY 4. SPRINKLERS . 26. ; EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS 65 OVER 65 OVER 20. FACILITY ' n• <_ _ Q (� 24, + CODE ' FACILITY NAME 13. NO. BLDGS. 12. CODES 1. REGION, OFFICE AND ADDRESS G LTJE A .!,) ;'.l.k.i:Lf1 1. GACH 7. ICF/OT 14. 2. GACHIR 8. ICFIDD STREET ADDRESS. 15. RESTRAINT 3. SH 9. ADHC ` E..:�. �' �'�/'li:i! ! .�j,l1.iI CAii' 1'J 4. APH 10. CLINIC 5. PHF 11. JAIL CITY ZIP CODE 16. HOURS 6. SNF 12. OTHER ,� �___. tom. ^� �� �F. ;fjl-. , CA D -t A. T r1 - y' FACILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL 17. �. p.� �'� s _ i;l :�ii.t� �'. ( 7+,1 -, r��,i.�Z7 ri, r,.� �' r.^+ ,r _ _ 1�'K... �i��., J �, �ifi;'•�r� . TO BE COMPLETED BY INSPECTING AUTHORITY 1 B. FIRE 27. CLEARANCE AUTHOR. CODE % CODES NAME 1. FIRE CLEAR. GRANTED AND ADDRESS I l� I J 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL . CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES` 22. INSPECTOR'S NAME TELEPHONE NO. 23..CFIRS ID NO. 24. T-19 OCC. CLASS 1. EXITS ' ; - ,'' '' '� �.,.. •'; 2. CONSTRUCTION 2%r. 3. FIRE ALARM INSP. DATE 26. INSPECTOR'S SIGNATURE 4. SPRINKLERS . 26. 5. HOUSEKEEPING EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY i 1. REGION, OFFICE AND ADDRESS OTATE VI Kest 14arina-Merced Office Complex 2'300 Merced Street San Leamdro. CA 9 5?? TIME MILES NEXT INSP. (MO. DA. YR.) J . INSTRUCTIONS � .. This form is designed for use with a window envelope.To use, fold at marks, indicated in the left margin. Licensing or Requesting Agencies — CoMpleW the t®iiuWIng 21 sections on this foram bore submitting. it to the State Fire Marshal Complete items -marked viith an asterisk only'When Item 20 °is not used. 1. REQUEST DATE. Enter the date request was 14, ADDRESS. Insert street address and city only. A prepared. post office box is not acceptable.- cceptable:2. 2.PROGRAM. Licensing agency use. * 15. RESTRAINT. Indicate if physicial restraint (locked 3. AGENCY CONTACT, 4. TELEPHONE NO., 5. in -a room or the building) is to be used in the SIGNATURE. inter the name, telephone number, housing of the occupants. Y= yes N = no.' and signature of agency contact person. 16. HOURS. Indicate the number of hours the - 6. SFM REGION. Inserf one of the following 3 numbers occupants are housed at the facility. (Less than for the SFM Regional Office in whose area the 24 or 24+). facility is located. 16a SPECIAL. Use to designate persons who are 3.5.0 Coastal, 330 Northern, 370 Southern. determined to be non-ambulatory for reasons other than a physical handicap. 7. SFM ID NO. This is the..SFM Identification Number and initially gill be `assigned. by the State dire 17: -FACILITY CONTACT PERSON --,-NO Marshal. Licensing Agency = Insert this number on Indicate the name and telephone number of the re - all clearance requests subsequent to the initial sponsible individual at ;the facility to be contacted request. by the fire authority. 5. -REQUESTING AGENCY FACILITY NO. This i -s the 16. FIRE AUTHOR. NAME AND ADDRESS. Insert- the fife number assigned by the licensing agency. name and address of the fire authority in the vicinity where the facility is located._ 90 EVALUATOR.- For licensing agency, use. 19. REQUEST CODE. Use the six codes shown and 10. AGENCY NAME AND ADDRESS. Enter the name _ insert the appropriate nu.rnbe-r in the box fiolloring and address of the licensing facilityrequesting =` Request Code". Insert date of original request g q the. inspection. � when request is -other than an original. *11. AMBULATORY Q NON -A OULAT®0Y. Complete y 2®o FACILITY CODE. Mark this item onlyif.the facility'' this section only. when Item 20 does not- apply. . • is a. (1) General. Acute Care Hospital (EACH), (2). Capacity: Insert, :_in the appropriate section, the capacity General Acute Care Hospital/Rehab (GACHIR), (3) of licensed ambulatory or non-ambulatory oc- Special Hospital (SH), (4) Acute Psychiatric Hospital cupants covered by this request. (ApH), (5) Psychiatric Health Facility (PH F), (6) Age Range: Indicate the age range of the licensed occupants. Skilled Nursing Facility (SNF), (7) Intermediate - Previous If request is for renewal or capacity change, insert Capacity: capacity of previous clearance. Care Facility/Other (ICF/OT), (3) Intermediate Care Total total licensed capacity. If the Facility is Facility/Developmentally Disabled (ICFIDD)-� (9) _show Capacity: intended to house part ambulatory and part non- Adult Day Health Care (A®HC}, (10) Clinic, (11) Jail ambulatory, show the total of the two types of or (12) Other. When item 20 is used , Item 1.1 does, occupants. not need to be completed (except total cap). 12. FACILITY NAME. Insert the name of the facility as 21. REGION, OFFICE AND ADDRESS. Insert the name it will appear on the license. and address of the State Fire Marshal Regional 13. NO. 9LDGS. Insert the total number of buildings - Off ice in whose area the faculty is located. to be used for housing of the occupants- covered _ by the license. Fire Authority Conducting the Inspection — Complete the following: 22. INSPECTORgS . NAME. Print the initial of the In- d 27. CLEARANCE CODE. Use the three codes* shown- spector's first name and full last- name; insert the and insert the appropriate number in the boxu telephone nmber where the inspector may -be - following "Clearance Code". contacted.' NOTE: If Code 2 (Denied) or Code 3 (Withheld) is used, explain. 23. CFIRS ID.NO. Insert the fire department's 2g, DENIAL CODE. Use only the seven codes shown number assigned by CFIRS. and insert the appropriate number in the box 24. TITLE 19 OCC. CLASS. Use Title 19 occupancy following "Denial.; Code", If No. 7 "Other" is used, classifications and insert the occupancy deter- -explain at Iter. .. mined by the inspector.8 ;.f;Lfte Oieamrjgq -car .nq OV- de��nl�ed t9.n.-other than lack of con - 25. INSP. DATE Enter the actual date of the in- formance withal pri - f T.itJQ. �;a. s ection. p 29, EXPEA . ,DE A •Af ieaTance. Code No. 2 or 3 -26o INSPECTOR9S SIGNATURE, To be signed by is used, briefly explain reason. This space is also . inspector conducting the inspection. -to be. used to explain Denial Code item noted. . STA E FIREMARSHAL' COPY,RN01C1; . SEE REVERSE OF COPIES 2 AND 3 FOR FIRE A�ETY INSPECTION REQUEST 1 STATE -FIRE MARSHAL .�� , : ,•:. INSTRt1CTlONS FOR COMPLETION STD 2- FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM 50A (NEW 6180) 3 • LICENSING AGENCY 1-29w-82 3. AGENCY CONTACT 4. TELEPHONE NO. S. SIGNATURE DSS-COTAMITY CARE LICENSING/CHICO 916 8{95-5033 6. SFM REGION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR 041300089 Stars Durr 19. REQUEST 2 CODE CODES 1. ORIGINAL A. FIRE CLEARANCE - 10 AGENCY 2. RENEWAL B. LIFE SAFETY NAME DSS --CO AMITY CARE LICENSING 3. CAPACITY CHANGE AND CO ASSE'TT SQUARE I 4. OWNERSHIP CHANGE ADDRESS 520 C014ASSETT ROAD 4 SUITE 6 � 5. ADDRESS CHANGE LCHIC09 CA 95926 6. OTHER ' (STRUCTURE.ENVIRONMENT IffOR CHIOREN) DATE OF ORIGINAL REQ. c•'-:--t•'y., ::�...^.r*+.»�---'..�. `3'�-w-"v.''t -Lw+ _ �. -_-�- - +`�. - - _ - - 'r._ -.. t, 1�• -.i„ - 1_.._; `•s.-.L`.f.- .1. _ -s»,- •' _ -- 11. AMBULATORY NONAMBI)LATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CAPACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANOElYEARS), PREVIOUS. ,. TO 18 18 TO 65 AND CAPACITY TO 18 18 TO 65 AND CAPACITY . 65 OVER 65 OVER 2 20- FACIL CODE ITY 12 20 xxx 12. FACILITY NAME 13. NO. BLDGS. CODES .BbTTE COUNTY HEAD START GRIDLEY CENTER 1 1. GACH 7' ICF/OT 14. 2• GACHIR 8. ICF/DD STREET ADDRESS 15. RESTRAINT 3. SH 9. ADHC A IA C;A " O O I E� ORAD E Hx���11 -none 4. APH 10.- CLINIC ` 5: PHF 11. JAIL ITY' ZIP CODE 16. HOURS ; CA 95 948 6. SNF 12. OTHER ACIL1,TY. CONTACT PERSON TELEPHONE NO. 16A. SPECIAL 17. l` JOAHNE SIE L0 916-846-5147 DAY CARE CE TER�CHILDN., ' TO BE COMPLETED BY ' INSPECTING AUTHORITY ' 1 FIRE � � 27. CLEARANCE CODE AUTHOR. ' CODES NAME 1. FIRE CLEAR. GRANTED AND ADDRESS 2., FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE • .�..�� �.:._ =��- ���-��•'COfill'p�.'�'TE�`�``11''`'�N���G'T A I�"i�l`i . .: e.. _ _ . _�• a � 'S. .aw''474";� cr1 �;" :'.4.r'•r,:' , .,..;; ,,.,;.:, ,r•t•?t- .•� �. •__T+a ll,lK. r i.� •_ - wt l .• ,�,`.. .Y :.,; airil... 22. NSPECTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T-19 OCC. ID NO. CLASS 1.. EXITS 2. CONSTRUCTION 25.' 3. FIRE ALARM NSP. DATE 26. INSPECTOR'S -SIGNATURE 4. SPRINKLERS 29. 5. HOUSEKEEPING - XPLAIN DENIAL OR LIST SPECIAL CONDITIONS 6. SPECIAL HAZARD 7. OTHER,' STATE FIRE MARSHAL -USE ONLY -' r 2'. REGION _ OFFICE ,AND - lt ADDRESS '�: TIME MILES NEXT INSP. (MO. DA. YR.) INSTRUCTIONS This form is designed for use with a window envelope. To use, fold at Licensing or Requesting Agencies — Complete the followini before submitting It to the state Fire Mi * Complete items marked with an asterisk only when Item 20 is not used. i�py�� a t aC IF 1. REQUEST DATE. Enter the date request was 14. ADDRSS. I r > ai' gs and Gity only. A prepared. post ti� X a -I Ise 2. PROGRAM. Licensing agency use. * 15. RESTRAINT. indicate if physicial restraint (locked 3. AGENCY CONTACT, 4. TELEPHONE NO., 5. in -a room or the building) is to be used in the SIGNATURE. Enter the name, telephone number, housing of the occupants. 'Y= yes N = no. and signature of agency contact person. _ - * 16. HOURS. Indicate the number of hours the 6. SFM REGION. Inser't one of the following 3 � cumbers occupants are housed at the facility. (Less than for the SFM Regional Office in whose_area_th6e 24 or 24+). facility is located. aha SPECIAL. Use to designate persons who are 350 Coastal, 330 Northern, 370 Stbe n. determined to be non-ambulatory for reasons other 1 ` than a physical handicap. 7. SFM ID X10. This is the AFM Ideion N er � FACILITY CONTACT PERSON ®TELEPHONE NO. and initially will be assigned NIAR AL indicate the name and tele hone number of the reMarshal. Licensing Agency —inRREtG pail clearance requests subseqthe initial sponsible individual at the facility to be contacted request . by the fire authority. 3. REQUESTING AGENCY FACILITY NO. This is the 16. FIRE AUTHUR. 14IAME. AND ADDRES& insert the file number assigned by the licensing agency. name and address of the fire authority in the vicinity where the facility is located. 9. EVALUATOR. For licensing agency use. 19. REQUEST CODE. Use the six codes shown and 10. AGENCY NAME AND ADDRESS. Enter the name insert the appropriate number in the box following and address of the licensing facility requesting "Request Code". Insert date of original request the inspection. when request is other than an original. *11. AMBULATORY — NON-AMBULATORY. Complete this section only when Item 20 does not apply. Capacity: insert, in the appropriate section, the capacity of licensed ambulatory or non-ambulatory oc- cupants covered by this request. Age Range: Indicate the age range of the licensed occupants. Previous If request is for renewal or capacity change, insert Capacity: capacity of previous clearance. Total Show total licensed capacity. If the Facility is Capacity: intended to house part ambulatory and part non- ambulatory, show the total of the two types of occupants. 12. FACILITY NAME. insert the name of the facility as it will appear on the license. 13 qO SLOGS. insert the total number of buildings to be used for housing of the occupants covered by the license. 20. FACILITY CODE. Mark this item only if the facility is a: (1) General Acute Care Hospital (GACH), (2) General Acute Care HospitallRehab (GACHIR), (3) Special Hospital (SH), (4) Acute Psychiatric Hospital (APH), (5) Psychiatric Health Facility (PHF), (b) Skilled Nursing Facility (SNF), (7) Intermediate Care Facility/Other (ICF/OT), (8) Intermediate Care Facilitymevelopmentally Disabled (ICF/DD), (9) Adult Day Health Care (ADHC), (10) Clinic, (11) Jail or (12) Other. When Item 20 is used , Item 11 does not need to be completed (except total cap). 21. REGION, OFFICE AND ADDRESS. insert the name and address of the State Fire Marshal Regional Office in whose area the facility is located. Fire Authority Conducting the Inspection — Complete the following.- 22. ollowing:22. INSPECTOR'S NAME. Print the initial of the in- 27. CLEARANCE CODE. Use the three codes shown spector's first Dame and full fast name; insert the and 'insert the appropriate number in the box #el number where the inspector may be following "Clearance Code". a.,.vaaaQa.+calif �lyt:' n' �i•�; �1N � .. 23.. I `�►dlert,i, the f re department's f'nr assigned by CFtIS - j a' 24 ;5 E i 5,b=. CLASS. Use Title 19 occupancy J sification$ and insert the occupancy deter- tUal date of the in- spection. 26. INSPECTOR'S SIGNATURE. To be signed by inspector conducting the inspection. NOTE: If Code 2 (Denied) or Code 3 (Withheld) is used, explain. Zit. DENIAL ;®DE. Use only the seven codes shown and insert the appropriate number in the box following "Denial Code". If No. 7 "Other" is used, explain at Item 26. NOTE: Fire Clearance cannot be, denied for other than lack of con- formance with the provisions of Title 19. 29. EXPLAIN DENIAL.. if Clearance Code No. 2 or 3 is used, briefly explain reason. This space is also to be used to explain Denial Code item noted. STA FIRE MARSHAL FIRE SAFETY INSPECTION REQUEST COPY Dk%TRIBUTION; 1 - STATE FIRE MARSHAL S. VERSE OF COPIES 2 AND 3 FOR IN$T!?q{CTIONS FOR COMPLETION STD 50A (NEW fi180) 2 - FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM 3 -LICENSING AGENCY 1-29-82 3. AGENCY CONTACT 4. TELEPHONE NO. 5. SIGNATURE DSS- COM4UNITY CARE LICENSING/CHICO 916-895-5033 6. SFM REGION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR A , 041300089 Stan Durr 19. REQUEST 2 CODE CODES 1. ORIGINAL A. FIRE CLEARANCE 10. AGENCY F 2. RENEWAL B. LIFE SAFETY NAME DSS -COMMUNITY CARE LICENSING 3. CAPACITY CHANGE AND ADDRESS COHASSETT SQUARE I 4. OWNERSHIP CHANGE 520 COHASSETT ROAD $ SUITE 6 S. ADDRESS CHANGE Lmico, CA 95926 6. OTHER (STRUCTURE ENVIRONMENT WOR CHILDREN) DATE OF ORIGINAL REQ. -- 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CAPACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS TO 18 18 TO 65 AND CAPACITY TO 18 18 TO 65 AND CAPACITY 65 OVER 65 OVER' 20. FACILITY CODE 12 20 lxxx 20 ' 12. FACILITY NAME 13. NO. BLDGS. CODES BUTTE COUNTY HEAD START - GRIDLEY CENTER 1 1. GACH 7. ICF/OT 12. GACHIR 8. ICFIDD 14. STREET ADDRESS 15. RESTRAINT 3. SH 9. ADHC FARM LABOR CAMPs OROVILLE- GRIDLEY HIGHWAY none 4. APH 10. CLINIC. 5. PHF 11. JAIL ITY ZIP CODE 16. HOURS . 6. SNF 12. OTHER GRIDLEYCA 95 948 17. FACILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL JOANNEAIELLO 916-846-5147 DAY CARE CENTER- CHILDR] TO BE COMPLETED BY INSPECTING AUTHORITY 18. FIRE 27. CLEARANCE ; CODE AUTHOR. ' CODES NAME 1. FIRE CLEAR. GRANTED AND ADDRESS 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE -' TO BE COMPLETED BY INSPECTING AUTHORITY - CODES 22. I SPECTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T-19 OCC. ID NO. CLASS 1. EXITS Z CONSTRUCTION 1 3. FIRE ALARM 25. 1SP. DATE 26. INSPECTOR'S SIGNATURE -4. SPRINKLERS S. HOUSEKEEPING 29. E PLAIN DENIAL OR LIST SPECIAL CONDITIONS 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY OFFICE OF STATE FIRE ARSHAL 21. REGION, Marina -Merced Office Complex f , f OFFICE 2300 Merced Street AND ADDRESS Sen Leandro, CA 94577r TIME MILES NEXT INSP. (M0' i -�y-- t K � � 5��,'� c >� •T ��y# � r�Y �� � �>�-f:<-' �' *3�_ 4 • 't Fh 1 i t t -_M lei— ZT AN $a LTM �? � � tri' ., -.r _. �,. �. ✓ 4� �! - �: Pik S , - 11 u Gt� rte.`: y jr - 1I7 1 �.-,.9.,..�nrr -.t a. .,. � R, ' •+c ( jL. " . ._. „T-. . 7741 41. Ma T l(nT 71.0 ��..�) 'a'•,d _ 1 ` t r t :,t yam, ct �'': sFy.. r, f`., p.�.. ,yf' �" t d}r �. :1�rt, .s.- W.� �'.. 3� ��-.� '�w- .I, a��"i x's3 .-,-...-.�a,� - ; �•1 _ �r x+c a . 4 y-c.S' � _ �, h rd° *C - " �." a r •' '�' 1.�. h a N. h-• # . _ S K ,f$' Fc s q � } �. q .nom, .• ♦ � r 7. t Y': 5.+�� r - '� �``$ art`^ d u J. v7 'r: �7�•e s n• C - f i n r9 r �. _ 4 - yi�'• i ` �t<i '�+�'kfiyc 3+`� r! 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"•�µ"�"?�x,.� �i `' � T+ aw �-'��r�r o n� �ir+� - �_ .�k'.f 7' .-`J^' 4..Ysi�)z•'e-Tj '."2 i' !.+ _: * .�i ., � 7 n C , . f` k i�Ni^rY t ¢p lg .4 -�• 'ems-`L.' . � For Office Use CnI.• OFF, OF STATE FIRE MARSHAL L]NEJA Z�:7DELET£ FIRE 2, PANIC ,.�,FETY STANDARDS — INSPECT .JN REPORT 'v-NUAL DATE: FHE: �Oolfq 00,j 33O 0 FA ILITY NAME: t,07 -Ie Co,JAlI`� MOADS—,Ar FA ILITY ADDRESS: ( `i U'l �a--4 1 {`t S -F (Street) BUILDINO NA -',f--7: A.L1 OV, i-3 LE CA-ACITY:� KIM: -2-0 NO.:-AJS: SYSTE.%i (Y,N) L%PO Leri yDP DP=V._INSP.DiP.T=.. Ii - cT, 7D (Deputy) 814 (City) (Zip) NO.O_= B-7 DGS. I OCC?TPANCY: 3 11 PE CONST: A''.EA(SCl.ft.). IT NC. S _ ==5: `- HIGH ?ISE (Y,N): rJ 'I -,W? z S,C,0) \ CCVYP�GE(C,P) C� -'_S_ I.-iM E=' `;' �' :i ''` I^� 1 F. = * NiA IC aa, Cr:; �52 �2. Ease.T: r.v 22 F ---_r= Pl-=n 53 23 �= F{pCS--'45 24 - - - - -- i-- - 57 i `a e7i Finish j 32 S. Arc -as 40 D Exiting 1 30, -"?2= 127. 2SJAC 45 �_ 1' �- !3 Electrical 45 er ralive iti`�`_ ialS 5G i I il5 Ste-ag� 51 i - X35- i IBSPECTION T_VE; EXCLUDI'_: 1 .-ri'.•�L (�':?c=los !G1 h c= F`:):ir) . A—plicaLie/IC=In Co=l rection First 1;,3ted _-efe_ GG -4 1l_:,.S C_`.C_-L— -,3�c @:.`_�._� C , I 7�Cs_=El .`will Gu -6 SilerOf-3, the this v- c; _ y (Su_e disc:) D.1 T'E' 2nd Ccr;-K7D_ 3rd Copy -Fief" i pM P t a r tD 10-0 IN m i r J- 1 • - i i ' I �.•I= 1? � . E I ! � , i � � I � ' � f i_ l l i I Certificate of Slame ktoiqtanre G�STF�4 REGISTERED pf �Citi,. ,sC APPLICATION ISSUED BY o Date treated or CONCERN No. COIT DRAPERY CLEANERS manufactured 164.East 2nd. Avenue ".I.^?t 1• 1932 93F•�R.vp� A233Chico, California 95926 aESP Norvi I Ie R. Weiss This is to certify that {{t,,��he materials described on the reverse side hereof have been flame- FOarda�tuhiett�r.°e'Ztqift�t�ienflammaAIDDRESS 1567 Booth Dr. — CITY ri ey STAB a Certification is hereby made that: (Check "a" or "b") (a) The articles described on the reverse side of this Certificate have been treated with a flame-retardant chemical approved and registered by the State Fire Marshal and that the application of said chemical was done in conformance with the laws of the State of California and the Rules and Regulations of the State Fire Marshal. F1aruort f U c +.7 Name of chemical used......................................................................Chem. Reg. No ........................... Method of application------------------------------- �p � ❑ (b) The articles described on the reverse side hereof are made from a flame -resistant fabric or material registered and approved by the State Fire Marshal for such use. Trade name of flame -resistant fabric or material used..................................Reg. No ......................... The Flame Retardant Process Used ... .-.will.......-_-. Be Removed By Washing (will or, will not) Nol-Ville A. Wr:i.,s Name of Applicator or Production Superintendent By .44W 46 Title CONTROL NO CUSTOMER ORDER NO. 76711 CUSTOMER INVOICE NO. fir.. YARDS OR QUANTITY 7 tin print, 6 green, Z6 white blue gi: eaD pcint •� COLOR di -apes STYLE DATE PROCESSED iP._^Gh 13, 982