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Home My WebLink About030-462-021 CF Archive..of. ANT PR( ANNEX B (!�:.0 ; 25-79 Main Drain Test Results: Inspection, Testing, and Maintenance Fire Sprinkler System NFPA 25, Chapter 5 as amended by CCR, Title 19 Page 1 of 4 Date of Inspection, Testing, Maintenance: System Riser ID: T = Test Property Information: M = Maintenance Type of System: OF.Cq�/ Name: �, ;--. c,_ •', ❑ Wet Pipe El Dry Pipe �` "�;` ".� Address: i 3 � f ❑Preaction P �, l Description NFPA 25 Reference ❑ Deluge g W ' OE City: �`j�t'7✓i 1 I WPP Preaction/Deluge Valves — Enclosure 12.4.3.1 Main Drain Test Results: Abbreviation Key: - I = Inspection Initial Static Pressure: (psi) T = Test M = Maintenance Residual Pressure: (psi) A -O = After Operation MI = Per Manufacturer's Instructions Restored Static Pressure: (psi) Item Activity Frequency Description NFPA 25 Reference Fail N/A Pass 1.1 I Daily Preaction/Deluge Valves — Enclosure 12.4.3.1 Weekly temperature 1.2 1 Daily Dry Pipe Valves — Enclosure 12.4.4.1.1 Weekly temperature 1.3 1 Quarterly Gauges (Dry, Preaction, Deluge 5.2.4.2 Systems) 5.2.4.3 1.4 1 Quarterly Control Valves 12.3.2.1 1.5 1 Quarterly Alarm Devices 5.2.6 1.6 1 Quarterly Gauges (Wet Pipe Systems) 5.2.4.1 1.7 1 Quarterly Hydraulic nameplate 5.2.7 1.8 1 Quarterly Pipe and Fittings 5.2.2 1.9 1 Quarterly Sprinklers 5.2.1 1.10 1 Quarterly Spare Sprinklers 5.2.1.3 1.11 1 Quarterly Fire Department Connections 12.7.1 1.12 1 Quarterly Alarm Valves — Exterior Inspection 12.4.1.1 1.13 1 QuarterlyPreaction/Deluge Valves — Exterior 12.4.3.1.6 Inspection 1.14 1 Quarterly Pressure Reducing Valves 12.5.1.1 1.15 1 Quarterly Dry Pipe Valves — Exterior Inspection 12.4.4.1.4 1.16 1 Quarterly Backflow Preventers 12.6.1 1.17 1 Annually Buildings 5.2.5 State Fire Marshal AES 2 March 21, 2006 Y ANNEX B 25-01 Inspection, Testing, and Maintenance Fire Sprinkler System Page 3 of 4 NFPA 25, Chapter 5 as amended by CCR, Title 19 Date of Inspection, Testing, Maintenance: System Riser ID: Property Information: 14pp e- �oF--cQ4,o Type of System:10 Name: 'r I ❑ Wet Pipe o'¢E ;2 El Dry Pipe "( - iv r Address: 1t.' El ��.`•�... ,1,,, }� le �-+t ��j `��'. ❑ Deluge ARE MP City: Item Activity Frequency Description NFPA 25 Reference Fail N/A Pass 2.10 T Annually Dry Pipe Valve — Priming Water 12.4.42.1 2.11 T AnnuallyDry Pipe Valve — Low Air Pressure 12.4.4.2.6 Alarm 2.12 T AnnuallyDry Pipe Valve — Quick -Opening 12.4.4.2.4 Device 2.13 T Annually Dry Pipe Valve — Trip Test 12.4.4.2.2 2.14 T Annually Backflow Preventer Assemblies 12.6.2 2.15 T 3 Years Dry Pipe Valve — Full Flow Trip Test 12.4.4.2.2.2 2.16 T 5 Years Gauges 5.3.2 2.17 T 5 Years Pressure Reducing Valve 12.5.1.2 2.18 T 5 Years Fire Department Connection Backflush 12.7.4 2.19 j T 5 Years Sprinklers — Extra High Temperature 5.3.1.1.1.3 2.20 T 5 Years Sprinklers — Corrosive environment or 5.3.1.1.2 corrosive water 2.21 T 10 Years Sprinklers - Dry 5.3.1.1.1.5 2.22 T 20 Years Sprinklers - Fast Response 5.3.1.1.1.2 2.23 T __ 50 Years Sprinklers 5.3.1.1.1 2.24 T 75 Years Sprinklers 75 years in service 5.3.1.1.1.4 2.25 T Sprinklers manufactured prior to 1920 5.3.1.1.1.1 — Replace 3.1 M Annually Control Valves 12.3.4 3.2 M Annually Preaction/Deluge Valves 12.4.3.3.2 3.3 M Annually y Dry Pipe Valves/Quick-Opening 12.4.4.3.2 Devices 3.4 M Annually Dry Pipe Valve — Low Point Drains 12.4.4.3.3 3.5 M 5 Years Obstruction Investigation Chapter 13 State Fire Marshal AES 2 March 21, 2006 `25-82 INSPECTION, TESTING, AND MAINTENANCE OF WATER-BASED FIRE PROTECTION SYSTEMS Inspection, Testing, and Maintenance Fire Sprinkler System NFPA 25, Chapter 5 as amended by CCR, Title 19 Page 4 of 4 Date of Inspection, Testing, Maintenance: r " n System Riser ID: Property Information: rn a[i,�ol Name: Type of System: El Wet Pipe El Dry Pipe ��oF-� Address: d � C iT Irl t4 ❑ Preaction ❑ Deluge 1 City: - Item Deficiencies and Comments: _ Deficiencies and Comments Item number must correspond to the Item number of the Activity listed above: i ❑ See Continuation Page(s) (Indicate the number of continuation pages) ❑ PASS ❑ FAIL' f..`..; Signature Date dr` State Fire Marshal AES 2 March 21, 2006 „_,..,�_:=-•� i. -... ,..= r _.,� ,� -,-..r.,..a-_J-::;-.�.ri--.++.-..-r_,.......�-.�.._—_ «.,.ew.a.�..,�-`,.rte...__ .... ��sy �•, s ��. � 9 a >ry j H m r . •vim .ik f �i � � - ii p��. 4 r %! t 4q"• . � � i � �F ,I � r � _: :•4 � k IIS: - r c � y M r . •vim .ik f �i � � - ii p��. 4 r %! t 4q"• . � � i � r � H t rY ,rub �4' � t ti.,. �t - -.14 � 'ft o- `t� •- c ,� I L - �Oi 1k.E `�t ..- �. i ^'X = ♦ �r .�. ,� ' .} a 3-1 �,, t 4� . 40 1 I � 'r Y �� 'i r� = c k %�y ' �� }�� [J �' �h - t 3 �• 1 '`' �T+r'�-• � r L � L��jlt i � ;- 7r, �y'1{� L J. i — � r � _: :•4 � k IIS: - r � H t rY ,rub �4' � t ti.,. �t - -.14 � 'ft o- `t� •- c ,� I L - �Oi 1k.E `�t ..- �. i ^'X = ♦ �r .�. ,� ' .} a 3-1 �,, t 4� . 40 1 I � 'r Y �� 'i r� = c k %�y ' �� }�� [J �' �h - t 3 �• 1 '`' �T+r'�-• � r L � L��jlt i � ;- 7r, �y'1{� L J. i r -LA0 0--0)0) Inspection, Testing, and Maintenance Cover Sheet NFPA 25 as amended by CCR. Title 19 1 Property Information: Name: Address; 7, City: w , ZIP: Contact: Telephone: Occupancy /Use: Construction Type: No. Stories: Year Constructed: e Contractor Information: Name: HAYDEN FIRE PROTECTION INC Address: 15108 JACK PINE WAY City: MAGALIA State: CALIFORNIA, 95954 Telephone: (800) 417-0440 CA License# C-16 827131 Job # Performed by: (Print) Note: Contractor information may be pre-printed Number of System Risers Copy sent to: ❑ Owner Date ❑ Fire AHJ Date - o Contractor Date NOTES: 1) For specific inspection, testing, and maintenance requirements and information, see NFPA 25, 2002 Edition as amended by California Code of Regulations, Title 19, §901 to §906. 2) Inspection Items may be performed by the Owner in accordance with California Code of Regulations Title 19 6904.1(a) Forms included with this report NFPA 25 Chapter Number of Forms NIA FAIL* PASS ❑ Automatic Sprinkler System 5 ❑ Standpipe and Hose Systems 6 ❑ Private Water Supply System 7 ❑ Fire Pump 8 ❑ Water Storage Tank 9 ❑ Water Spray System 10 ❑ Foam Water Sprinkler System 11 See "Deficiencies and Comments" section at end of each respective form. State Fire Marshal AES 1 March 21, 2006 v 1 T /• '�+ ��.J �Fr'S -'fi � .�`fti2 _ili"-C!N i' 1 l ^ e � - b 2I ; Tx Y•.� �' it Y�f.'"''"6�t1 S isi� 3 - - � < � �; _� # baa �, j� °�! �7 i t- � 7 � ^ ' aY X• x.r � z r ' dw 'i ,�i Je 3,.� n��! ♦ \4 �t if ��_C : psi r"`'''a. aY 2 - #; is.: e,{ --v1 -t -- W'�':!G^•"E�-il`,�]� kd-a"R• - �a�r 5 _-`r ri /Q; ea. a 7+ `t +i �'-: u, ii nor 'F�. � ;� -;� .;. tc :- -.,.,s �+ �}' L h+ +<� •� -'°'i.4: �-*s;�".r,*k 1 i{},��,yL::_r+a'83�a�Y��f 4 �� ` > �^'a� r \ 4 t''`"�9.�Q' ;� �, �t=t� F. I �"�`�,'"' 3�,! (� •p. � .�X, � � r k� v+z .r � J-_v..t'�-wr 1- �.r1' .,:.:q =,a.r.-.. \ .:-,-s fi ... Tc�+� �� ... �4•s�-.n�Pt-ueY�t v �l'''��''"n""4'�`r' i,�{Gs�' ..'h «�*S..H.F...-.a �..,..,�.. �, _ • 4 *"-'�'^+• aqg, :`.-^+�-sb+.+,«�*,--�.- .ti �...i'; �+-'c,`�"`�' t' 'r,�.'f�'c..g� p• d'� f . � - � ,.-�_-.��..�.r.,e-.�u'•j•c.,n..s.-w.=.•+-3-�.* .,�--53'�v"4,.:' -9,y - � --s6-`4a q�Ms ,r.«4• t.- `,.�-_ a t; ,A.�,z �n^.�.1 � '.ay. ”. 1s „wk lot—, �Cs v 1 T /• '�+ ��.J �Fr'S -'fi � .�`fti2 _ili"-C!N i' 1 l ^ e � - b 2I ; Tx Y•.� �' it Y�f.'"''"6�t1 S isi� 3 - - � < � �; _� # baa �, j� °�! �7 i t- � 7 � ^ ' aY X• x.r � z r ' dw 'i ,�i Je 3,.� n��! ♦ \4 �t if ��_C : psi r"`'''a. aY 2 - #; is.: e,{ --v1 -t -- W'�':!G^•"E�-il`,�]� kd-a"R• - �a�r 5 _-`r ri /Q; ea. a 7+ `t +i �'-: u, ii nor 'F�. � ;� -;� .;. tc :- -.,.,s �+ �}' L h+ +<� •� -'°'i.4: �-*s;�".r,*k 1 i{},��,yL::_r+a'83�a�Y��f 4 �� ` > �^'a� r \ 4 t''`"�9.�Q' ;� �, �t=t� F. I �"�`�,'"' 3�,! (� •p. � .�X, � � r k� v+z .r � J-_v..t'�-wr 1- �.r1' .,:.:q =,a.r.-.. \ .:-,-s fi ... Tc�+� �� ... �4•s�-.n�Pt-ueY�t v �l'''��''"n""4'�`r' i,�{Gs�' ..'h «�*S..H.F...-.a �..,..,�.. �, _ • 4 *"-'�'^+• aqg, :`.-^+�-sb+.+,«�*,--�.- .ti �...i'; �+-'c,`�"`�' t' 'r,�.'f�'c..g� p• d'� f . � - � ,.-�_-.��..�.r.,e-.�u'•j•c.,n..s.-w.=.•+-3-�.* .,�--53'�v"4,.:' -9,y - � --s6-`4a q�Ms ,r.«4• t.- `,.�-_ a t; ,A.�,z �n^.�.1 � '.ay. ”. 1s ATE OF CALIFORNIA Am, as IRE SAFETY INSPECTION REG. :ST 050(RIEV.10•94) See Instructions on reverse. A( ENCY CONTACTS NAME TELEPHONE NUMBER REQUEST DATE PROGRAM DSS/COMMUNITY CARE LICENSING 530 895-5033 6/7/06 RCFE AWATOR'S NAME REQUESTING MQENCY FACILITY NUMBER REQUEST CODE 207/DONNA GURRIERE 045001507 7A CODES 1. ORIGINAL A. FIRECLEARANCE LENSING DEPARTMENT OF SOCIAL SERVICES 2. RENEWAL B. LIFE SAFETY AGENCY NAMEAND COMMUNITY CARE LICENSING 3. CAPACITYCHANGE ADDRESS 520 COHASSET ROAD, SUITE 6 4. OWNERSHIP CHANGE CHICO, CA 95926 S. ADDRESSCHANGE ' L & NAME CHANGE FAX 1: ( 530) 895-5934 7. OTHER AMBULATORY NONAMBULATORY BEDRIDDEN TOTAL CAPACITY ACRY PREVIOUS CAPACRRY CAPACITY PREVIOUS CAPM' CAPACITY PSEVM CAPAWY 9 15 6 0 0 15 FAX=NAME LICENSE CATEGORY ERITAGE HOUSE RCFE ADDRESS (Aotua►Loeadw) NUMBEROFBUM MM 882 TEHAMA AVENUE 1 ROVILLE, CA 95965 RESTRAINT NO FA MM CONTACT PERSONS NAME HOURS ELLEN HENN 530 533-6060 or 530 533-5931 or 530 532-7 24 ST kTE OF CALIFORNIA FIRE SAFETY INSPECTION REQUEST WO (REV. law) See Instructions on reverse. AC ENCY CONTACTS NAME TELEPHONE NUMBER REQUEST DATE PROGRAM SS/COMMUNITY CARE LICENSING 530 895-5033 4/27/06 RCFE EV kLUATOn NAME REQUESTING AGENCY FACILITY NUMBER REQUEST CODE 207/DONNA GURRIERE 045001507 7A CODES 1. ORIGINAL A. FIRE CLEARANCE 2. RENEWAL B.UFESAFETY CENSING DEPARTMENT OF SOCIAL SERVICES AGENCY SAND COMMUNITY CARE LICENSING 3. CAPACITY CHANGE ADDRESS 520 COHASSET ROAD, SUITE 6 4. OWNERSHIP CHANGE CHICO, CA 95926 5. ADDRESSCHANGE L 6. NAME CHANGE 7. OTHER FAX # : ( 530) 895-5934 AMBULATORY NONAMBULATORY BEDRIDDEN TOTAL CAPACITY CA ACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY 9 6 6 0 0 15 FACIUTY NAME LICENSE CATEGORY HERITAGE HOUSE RCFE sn WET ADDRESS (Adwl Laadon) NUMBER OF BUILDINGS 1882 TEHAMA AVENUE 1 CIT Y RESTRAINT ROVILLE, CA 95965 NO FA 3LITY CONTACT PERSONS NAME ' ^N"' ELLEN HENN 530 533-6060 24 SP ;CLAL CONDITIONS ACILITY IS REQUESTING TO TAKE DEMENTIA RESIDENTS IN NON-AMBULATORY ROOMS #6, #9 AND #10. CLEARANCE MEN & CODE / CALIF. DEPT. OF FORESTRY -BUTTE C07 CODES FIRE "N FIRE CLEARANCE GRANTED A RKTY STEVE FOWLER, FIRE MARSHALL NAMEAND 176 NELSON AVENUE 2. FIRE CLEARANCE DENIED DDRESS TS OROVILLE, CA 95965-3425 A. B. CONSCONSTRUCTION C. FIRE ALARM D. SPRINKLERS 049 'ECTOR'S NAME (TyprdorPrigoo TELEPHONE NUMBER CFIRS NUMBER OCCUPANCY CLASS E HOUSEKEEPING 53€• 733 5 �C - (53c:.' ) es�(e3S- /Gn 2, 2 F. SPECIALHAZARD DATEINSPECTORS SIGNA d a E (Tyl Pri ed) G. OTHER 927 EXP JUN DENIAL OR UST SPECIAL CONDITIONS /.l v> > A -l" A 7,4-', 1� iii �> i�.a, ,�Li /-2 - -2/ - xi S/, FILE No.418 12/20 904 12:59 ID:CCL CHICO D.O. FAX:5,M. 895 5934 PAGE 1f 1 RAW OF QWMUA^ FIRE SAFETY INSPECTION REQUEST STD, 634 EV. f4M_� inst tedone OA rovem. 'If C�ITACrS NAME TELEFHp[�iE� R��siA�1'E FAocpAN D"ARTM"Tr OF SOCIAL SERVICES 530 895-5805 _ _ 12/ :6/04 RCFE EVALIJATGR8lW4E �t34t�E8�INc3 JMi�IC1r PJ1Cti�7Yt+iiIMBER �_= Rlo0L�6TCODE 0207/DONNA OURRMU 045001507 ..«.w w..w....w......_._....._w_.+M�Yw...YM11.M.M1\...w....r.. u..«« ............ ........«....._.._..««.«_•___�.....�._.._._�.....«_..... ��_.. «.._....«..�.. 7A uCEla .DEPARTMENT OF SOC � UL S ERVICBS AGO NAS AMCO CAKE LfC�TSING Al 520 COHASSRT LOAD, SATE 6 CHICO, CA 95926 L_!" #: 530 895-5934 CCHM I. C"MNAL A. FIRE CLEARANCE 2 RENEWAL 8. LIM SAfk"7Y & CAPACM CHANGE 4. OWNeRSHIP CHANGE & ADDRESS CHANGE E. NAME CHANGE 7. OTf4ER I1�18t1�.ATORY Nou"BUL ATARY BIMRID004 TOTAL CAPACITY PE G:' 1V CAPPOrY PPAVKMCMACTr c crnr cAPAazY I 9 9 6 j6 0 0 FAC UTYWAM �.�..•�.�_ t�CE�14EG'I'EOOIRY ��Rrr�� tovsE RCM 1882 M"&U AVM4flZ RoF wut"s crry 1 �M OROV'iY lf, CA 93965 CRAW NO FACkmQmTAcrpWgK*MNAMe ELLEN HENN (530) 533.6060 O HOURSS g�w `,r.r. ww.....rN w.,._.... FMH. H...N.A..M.Y • _N.... M..M.N.If1W Y.... ...1 w.�.H�..«..... «. _.. «.._ «_..« __...• .� _« �. 7A: UPDATE FARE SAFETY INSPECTION REQUEST, INDICATING ROOMS APPRO' ) FOR NONAMBULATCRY. :ii: �i:•• :IEEE: :i::i:•:iiiiiiiii. •' •. :f: .•..111.1:. .1..................... ............... • •It.. 1. .. :i�j: • .. �i-'i: ..... ........ ... w r. �� ►•7.•11 �. •1• : N~•►•�•:wWw •.�._._. «.wr.__.ww_�.__w,.w _«w_.__r_��_•Iw_�w.�j.J. _.w.««�...:i �_...«_...... •. �RMCECOD`Futo / STEW FOWLER � Ct�ES AUTNQRITY FIRE 14IARSI�AL r- AMMU RE c��aE cwY� MAIM A 17b NELSON A'VE. OROVU.. A CA 95965 2 FIRE Ct EMUNCE DEMED A E)OTS i..... ; S. CONSTRUCTION +.J C. FM ALARM IWaPECTOIM9 K(r#1 W or I h * w 4 TE�I:!►+OkEI�uMdERcis a ..R.r oca.mANWcu►se 0. SPRINKLERS 9. HX1M INSPECr"DATE INSFECTOiZ'SSIGNATURE G. 4R'MER ._. 7 ...._.._..«.......�....___.ww.«_....._�._.._._....._.�w_.__.._.__...__..w._ww....._.._.r.«........._.w..w....w_.w_�.._...._._...r._.w._._w....._....._._..w.r......... _.._.. _._.... _._.. _............ . MAY 24 2004 09:04 FR CDSS .................... STATE 01:0LIFORNIA FIRE SAFETY INSPECTION REQUEST $TO, 889 (REV. 1 v-eo) - AGENCY CONTACT$ NAME DSS/COMMLJMTy CARE LICENSING EVALUATOR'S NAME —" 0207/DONNA GTIRRIERE 7075885080 TO 915305335931 P.02i02 See instructions on reverse. ILL I ==WIN TELEPHONE NUMBER REQUEST DATE PHOGF�AM t 530 ) 895-5033 1 5-18-04 RCFE REQUEVINGAGENCY FACILITY NUMBER REOUESTCODE -045001507 1A -_.•••-rww•vwrw,...,_ w....._.��.��. LICENSING DEPARTMENT OF SOCIAL SERVICES AGENCY COMMUNrry CARE LICENSING NAME AND 520 COHASSET RD., STE. 6 ADDRESS CHICO, CA 95926 in AMBULATORY NONAMBULATORY CAPACITY PREVIOUSCAPACITY I CApACI'I"Y I IPRE1fIOUSC J CODES 1. ORIGINAL A. FIRE CLEARANQE 2. RENEWAL B. LIFE SAFETY 3. CAPACITY CHANGE 4. OWNERSHIP CHANGE 5, ADDRESS CHANGE 6. NAME CHANGE 7, OTHER 8EDRIDDE N TOTAL CAPACITY CAPACi7Y PREVIOUS C.APACiTY 9 0 6 0 0 0 FA Gi LI TY NAME "'w' , -- •---••----- .-. HERITAGE HOUSE uccNSE CATEGORY EE AODRE88 (AC(iidILOcdlian) RCFE 1882 TE HAMA AVENUE CITY --•• • -» OROVYLLE, CA 95965 FACILITY CONTACT PERSON'S NAME----- ELLE,N HENN (530) 532-7815 SPECIAL CONDITIONS -- --.• ..._.— ....• .......____�__,__- __...._.. ... _ TO BE COMPLETED BY INSPECTING AUTHORITY I�w ORO , FARE , AUTHORITY l?35 yO DAME AND ADDRESS A A L L 0 l C -DT eti--tom �� • l� AJ E5—L_SzsxD A-V ce)ecV1��- SP5CTOR'SNAME(7ypodprft171ddj •r•-••—• _......._. T ........- _..._ .. - ELEPMONE NUMBER CFIRS NU161SER OCCUPANCY CLASS > L 3PE•C:TION,. (53c- )-53 1. �7 pA'TE lNSPFCTOR'f,$�CNAT )� • _. , fT dorPrinrgd� 11 NIALORUSTSPECIALCONDfTI N "' - --------=-•--•�.-•-•-•.,• ,... A NUMBER OF 8UILDINGS ONE RESTRAINT NONE HOURS 24 CLEARANCE0.2NIAL CODE • •. CODES Lot)IRE CLEARANCE GRANTED 2• FIRE CLEARANCE DENIED A. EXITS B. CONSTRUCTION r ] C. FIRS ALARM o • SPRINKLERS E. HOUSEKEEPING F. SPE I& HAZARD G.1 ER ........... kfh ** TOTAL PAGE. 02 ** Fire Prevention Bureau Butte County Fire Rescue White Copy - Business 176 Nelson Avenue California Department of Forestry Yellow Copy — Occupancy File Oroville, CA 95965 and Fire Protection Pink Copy — Station File Telephone 530-538-7888 Facility Inspection Report Occ. Class. Fax 530-538-2105 Fire Extinguishers: Required, service due Address: Business Name: Owner/Manager: Bus: Hm: Fax. Assistant Manager: Bus: Hm: 3. Building Owner: Bus: Hm: Exit sign lights need replacing Address: Fire alarm system defective AN INCPF.CTION nF VOI1R FACIIATV 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: t;uxx>!;c ILll: -7- 9 ^1V Date: Discussed with: Signed: (Print) Inspecting Officer - f Battalion 1 2 3 4 5 6 7 Station: FPB !f FIRE PREVENTION SAVES LIVES, PROPERTY, AND BUSINESS. YOUR COOPERATION WITH CORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE: Heritage House 1882 Tehama Ave Oroville, Ca. Bedroom Capacity Bedroom # Size Capacity Bedroom #1 11.5 X 14 1 Ambulatory Bedroom #2 14.4 X 13 1 Ambulatory Bedroom #3 11.4 X 13 1 Ambulatory Bedroom #4 14.2 X 11 2 Ambulatory Bedroom #5 11.4 X 10 1 Non Ambulatory Bedroom #6 14 X 13 Live- Quarters orl Non Ambulatory Bedroom #7 15 X 13 2 Ambulatory Bedroom #8 15X13 2 Non Ambulatory Bedroom #9 15X13 2 Ambulatory Bedroom #10 15X13 2 Non Ambulatory khan `mss NO ■er■■�e■■�■■■flr�r■�■1■Ie■e■■■■■ eee■1■ilrrlerrrll ■ ■■�1��lii�liiiVi■ r■fie■�■e■�r� ■r■� :�r�;Je■■e■ ■f■■►`,�■1!■fi�7i�ui■:■I.:�r�:ri■r�►��re■■!■'r■■!■�■ ■■.r■■■ewe■■■■■ ■■■erre■ erre■■ ��:.r■r■■ ■■■ ■e�11■e!�! erre■■ ■■■■■ret ■■eie� �►:�w: �!■■r■ ■!■ ��L�rIL';!'E!!!!■erre■■ ■r■■■r■!■■■■■e!■r■■■■■ �!a■ ri■1s•�i•i1i■■r■■■ ic�i�iCeZ�"iii■ i��l■�+1li!■ :.�i7��le!■■ ■■■■■■�+a ■e■■■■ �.:� ■rile■.. � ■®■rte■ tee■ r��r■f1 ■■■ ■■■■!■■■■ ■■■ff ■re!■■■■ee■m■■■M!i®r!■MAlI■■ ■■r■�■■rr■■1r■rle ■■■�■��r�r■■r,,,■,�.,,,� Iu■ ■■■e■■■■ ■reeel� ■r■1�■e■■ �r��■■r.�l�■■ ■r■ ■■■■■■r■■■1■■■r,M1 ■I. ;_ ,'!!CIS■!■■■■■■®■■ ■■■■ie ■■■■e■elriili�ia�:....■Ir■�:1�►��■�r��l�r::.��■�+� ��■i e■■■!■■mrr■Ir■1!■®: ,''C"!E Lri■■iMIU �I�r■11 ■�'�Z�E'!!\ �:Sli'.7ZTL� ■�■ der Q erre■ reel■■■ ■ reel ■i'i�iii�►��riJiii�ii�i�i!■■�'_�= r�lr�'�E�l�i■r■r■■r■� ■e■ i�rr�r■ erre■ ■■■!■■■ems■■ee �!�erle■��e ■ M ■■■ �M��1 erre■ ■r■Irrrr an ■!■1■■■■■ ■■i ■■■ _erre■■■■I■e■■■■r■■��r■�I■■■r■■■I■Ie� �r■iL. ��*r�MM��■■■■i��ii�l� i;�i��'i■■ ■■■■■e■■■■r■■1 t■■ i��lirl�lr■■■■■�!!i►l��r■■ ■e■■ME■■■■■■■1 ■■■r■1:%err■■ler■/rerr■■■err.rrr■■rrr■r■■r1 1r■iiili■ �l"EA■■ ■It■ ■L�le!!■■ e■I■�f1f1■fl■I■rfifif liioiimMUMM■■■■ IFere,"AIMME■Ilee ■lefl■Ire1■elr■r■I■ 1■■r■■■■■!�A!lei:r■■�■e■1��■. ■■err■ONE ■OEM ierlr�le■�Il�rr�ar■■■fieIeflle�rr�.�ew►�rr■1■e■1■r■1■r■ ■■el■■��:��y;� ■fie■■el■r�a NOISOME ilmom l■mom I ■■�■■ere■erre/r■r'■■!■■��■r■■e■■■r■■■■ I■■i�►.,i'ii7■1�e�lMA■/:�!■f!d!!e!■s/ s-:19. !�■1■II■elelllrer■ ■■i�!!!�vl��!II!!��lf� ■■r1l��!'1�� '■�'!!`:�■■!■■■■fir■ ■r■r■■■�7e■�!!1�1■ie■lrl�tll�!11�1■■!1!!lir■■■emom emom lI■■r■■Ir■rim■irl�]►�,rr,e�r ■►.i��i!!!!!■1■el■rr■1■ i■■e■■■■e■w ■ E ■!.;wrMMM ■■ammo■■■■err■■er mommo■eee■■r goosommom■■t■■■■■ ■■■i■■■■■�■■�■■■ISI■�r�J■I■■■■■■■r■■■■■■IIe■1�■I� ee■■le■■e■■■■■ ■r��i;,.�s■e■■e■flee■■■■■■rrri ■EEMMEI■■■■ ■■erre■e■■■■ !■■■■■■e■ee■ ■ommo■I■I■r■■ MM1MMflMmMme■ ■e■e■■■■■ee ■ A rE OF CALIFORNIA RESOURCES AGENCY C LIFORNIA DEPARTMENT OF F RESTRY AND FIRE PROTECTION O FICE OF THE STATE FIRE MARSHAL C ICO BRANCH OFFICE 4 WILLIAMSBURG LANE, SUITE A C ICO, CALIFORNIA 95926 Benjamin Geneza 1216 Fulton Avenue Vallejo, California 94591 Dear Mr. Geneza, April 8, 1998 Comfort & Cheer Rest Home CSFM #00-04-42-0001-000-555-9 PETE WILSON, Governor (530) 895-4312 CALNET 8-459-4312 An inspection of the referenced facility was recently conducted in accordance with Section 13108(c) of the California Health and Safety Code. The purpose was to determine compliance with the minimum fire and life safety standards required by Titles 19 and 24 of the California Code of Regulations. The attached report is to advise you of the actions that are required to correct the noted deficiencies. To insure this facility is brought into compliance within a reasonable time, please submit your plan for accomplishing these corrections, to this office, within 30 days from receipt of this notice. Your current Fire Clearance is withdrawn and will be withheld until _these hazards are abated. If we can be of further assistance, or you desire additional information or clarification, please contact me at the Chico Branch office, (916) 895-4312. Deputy State Fire Marshal cc: Marie Smith, Supervisor, CC Licensing Robert Caldwell, Acting Supervisor, CC Licensing Donna Gurriere, Evaluator, CC Licensing CPt1F0AlyJ� '9,0ENT Of * RE PROt �l . y C ►ORTT a� . DF Comfort &Cheer CSFM #00-04-42-0001-000-555-9 ga 1. All fire alarm systems, fire detection systems, automatic sprinkler or extinguishing systems, and all other equipment, material or systems required by these regulations shall be maintained in an operable condition at all times. Upon disruption or diminishment of the fire protective qualities of such equipment, material or systems, immediate action shall be instituted to effect a reestablishment of such equipment material or system to their original normal and operational condition. [Title 19 CCR 3.24] . A. The fire alarm system was not operational at the time of this inspection and shall be repaired or replaced immediately. B. When the automatic sprinkler system was flow tested, the fire alarm system did not sound. It could not be determined if this was due to the fire alarm system being non -operational, or that the sprinkler system is not interconnected as required. C. Smoke detectors that cannot be maintained operational shall be replaced immediately. 2. Hoods shall be installed at or above all commercial -type cooking equipment. [1994 UMC 508.1] Provide an approved hood and duct system above the kitchen commercial stove. 3. Approved automatic fire -extinguishing systems shall be provided for the protection of commercial -type cooking equipment. [1994 UMC 509.21 Provide an approved pre-engineered automatic extinguishing system for the commercial hood and duct system described above in #2. 4. Buildings or parts of buildings classed in Group I, because of the use or character of the occupancy shall not be less than Type Vone-hour fire -rated construction. [1995 CBC 308.2, Table 5-B] The ceiling in the linen storage closet shall be repaired with an approved fire - rated material immediately. 5. Every building or occupancy within the scope of these regulations shall conform to the applicable provisions of Part 3, Title 24 CAC, which is hearby adopted by reference as the basic electrical regulations of the State Fire Marshal in matters relating to fire, panic and explosion safety. [Title 19 CCR 3.01] A. Remove and discontinue the use of extension/zip cords in lieu of permanent wiring. Remove the spliced extension cord running from an exterior outlet into the attic on the northwest side of the building. B. Repair the ceiling light fixture in the staff room #00. Comfort & Cheer CSFM #00-04-42-0001-000-555-9 6. Sprinklers shall be installed under exterior combustible roofs or canopies exceeding 4 feet. [1994 NFPA 13, 4.-5.7.2] Provide automatic sprinkler protection for the roofs covering the porches on the south, east and west side of the facility. 7. The storage of combustibles shall be kept at least 18 inches below sprinkler heads. [1994 NFPA 13, 4-4.1.6] Numerous storage violations were noted throughout the facility. 8. All drapes, hangings, curtains and all other decorative material that would tend to increase the fire and panic hazard shall be made from a nonflammable material, or shall . be treated and maintained in a flame-retardant condition by means of an approved flame retardant solution. Provide documentation that this has been done. TE OF CALIFORNIA • RESOURCES AGENCY CALIFORNIA DEPARTMENT OF F DRESTRY AND FIRE PROTECTION O FICE OF THE STATE FIRE MARSHAL C ICO BRANCH OFFICE 4 WILLIAMSBURG LANE, SUITE A C 1ICO, CALIFORNIA 95926 PETE WILSON, Governor (530) 895-4312 CALNET 8-459-4312 PLAN REVIEW TRANSMITTAL TO: Cki✓G k -cue t t( DATE: Mfg, CSFM# 66 -v -4-41-,-W -a) Iii Co , , C/" FACILITY NAME: 1 - FACILITY ADDRESS: TcI-ti )'nm AVE, Op—ok)t L_o PROJECT DESCRIPTION: As requested, we have reviewed 0 Plans f] Other: for the project listed above to determine conformance with the fire and life safety standards of Title 19 and 24, California Code Of Regulations. By copy of this transmittal we are: (I.IIr011M/,r utt�ot At PHO,([" h, h 1 C DF (] Advising you that the project listed above was found to be in accordance with the applicable provisions of Titles 19 an 24. Returning the items listed above to you for review. Consideration shall be given to all comments noted in red marks on the documents. D Requesting that you contact our office at the telephone number listed above for an appointment for our stamp of approval and/or back -check. Nothing in our review shall be construed as encompassing structural integrity. Approval of this plan does not authorize or approve any omission or deviation from applicable regulations. Final approval is subject to field inspection. Deputy State Fire Marshal cc: IAX (530) 895-4349 Chiefs Network - SFMCA S ATE OF CALIFORNIA - RESOURCES AGENCY PETE WILSON, Governor C LIFORNIA DEPARTMENT OF (530) 895.4312 F RESTRY AND FIRE PROTECTION CALNET 8-459-4312 O FICE OF THE STATE FIRE MARSHAL C ICO BRANCH OFFICE 4 WILLIAMSBURG LANE, SUITE A C ICO, CALIFORNIA 95926 PLAN REVIEW TRANSMITTAL CAMOAMI4 OIf0NE0��1 C '°l" D iJ F is TO: �iA-GrL�� SFCuet DATE: Q� �-300 � � C� 1, � csFM#00-4a40-0vel,o6o sss-q FACILITY NAME:_ FACILITY ADDRESS:(5pl8"6-AV6t C)Rouluig PROJECT DESCRIPTION: -_�a /)RCFC As requested, we have reviewed Plans kV Other: S►C,l6M ( %�"r/�-L for the project listed above to determine conformance with the fire and life safety standards of Title 19 and 24, California Code Of Regulations. By copy of this transmittal we are: Advising you that the project listed above was found to be in accordance with the applicable provisions of Titles 19 an 24. [] Returning the items listed above to you for review. Consideration shall be given to all comments noted in red marks on the documents. [] Requesting that you contact our office at the telephone number listed above for an appointment for our stamp of approval and/or back -check. Nothing in our review shall be construed as encompassing structural integrity. Approval of this plan does not authorize or approve any omission or deviation from applicable regulations. Final approval is subject to field inspection. De 50ty State F re Marshal cc: FAX (530) 895-4349 Which Network - SFMCA STA OFCAL06RNIA NONAMBULATORY BEDRIDDEN TOTAL CAPACITY FI E SAFETY INSPECTION REGI . ` T PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY CAPACITY _see instruck..ins on reverse. STD. 850 (REV. 10-94) CODES AGE14CY CONTACTS NAME TELEPHONE NUMBER FAC ILITY NAME REQUEST DATE PROGRAM �• tf ? r f+,• ""• -*�f 1 'ter; CL' l N �3.:)U), THORITY 4 2 %O RESTRAINT EVALUATOR'S NAME REQUESTING AGENCY FACILITY NUMBER REQUEST CODE A. 2. FIRE CLEARANCE DENIED GA. A. EXITS I L� CODES '� �i.%��t•�� a:��.�� t� �:-.� a; C., FIRE ALARM - - - '.---'�-..�: -_-.�..:....•.�.._....n.-...-...�_.-.ri..----.s.r::,:.,w..►....r....._�.�i:._�-.�._.�_..::,;:+--gE::�.Z,r. .. .. - 1_. ORIGINAL ,a., : A.. FIRE; CLEARANCE.:. ;a LI ENSING . �� .. � AR � If OF SOKI L bLRV I }_; -= CFIRS\IUMBER 2. RENEWAL B. LIFE SAFETY N ME AND t.t `k"WANI 1 Y RL �a.�.�ux E i�.3GENCY 3. CAPACITY CHANGE DRESS v u ..+ t SUI �.` E. HOUSEKEEPING 4. OWNERSHIP CHANGE F. SPECIAL HAZARD INSPECTION DATE S. ADDRESS CHANGE '�G THER �, 6. NAME CHANGE 7. OTHER AMBULATORY NONAMBULATORY BEDRIDDEN TOTAL CAPACITY CA ACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY CODES � FAC ILITY NAME LICENSE CATEGORY FIRE ..._.-.. STF EET ADDRESS (Actual Location) NUMBER OF BUILDINGS j ias �s •- E lil !A A V 310 U .Li THORITY cirr RESTRAINT FA IUTY CONTACT PERSON'S NAME HOURS JSP CIAL CONDITIONS -� e,_ �.A i..4, kit.. �.J'k, r Lt1 ►�' 9 �.. + �U ml..s? STATE OF CALIFORNIA FIRE SAFETY INSPECTION REe'�.--ST (100) STD. 850 (REV. 10-94) (REVERSE) INSTRUCTIONS This form is designed for use with a window envelope Licensing or Requesting Agencles—Complete the following 19 sections on this form before submitting It to the fire authority having jurisdiction. 1 AGENCY CONTACT, 2. TELEPHONE NUMBER, 5. EVALUATOR. Enter the name and telephone number of agency contact person. 3. PROGRAM. Licensing agency use. 6. REQUESTING AGENCY FACILITY NUMBER. This i the file number assigned by the licensing agency. I 7. REQUEST CODE. Use the seven codes shown an insert the appropriate number in the box following IfRe f quest Code i . If NAME CHANGE, please list previou name. Insert date of original request 'I's other than a original. 8. AGENCY NAME AND ADDRESS. Enterthenamean* I address of the licensing facility requesting the inspection. Capacity.- Insert in the appropriate section, the capacity of licensed ambulatory or nonambulatory oc- cupants covered by this request. Previous If request is for renewal or capacity change, Capacity: insert capacity of previous clearance. Total Show total licensed capacity. If the facility is Capacity: intended to house part ambulatory, nonambu- latory, and part bedridden, show the total of the three types of occupants. 18. FIRE AUTHORITY, NAME AND ADDRESS., Insert the name and address of the fire authority where the facility is located. 19. CLEARANCE/DENIAL CODE. Use the two #.: 1 for clearance granted, and 2 for clearance denied. If denied, also include the appropriate letter code. As an example, Denial based upon exiting would be coded 2A. 20. INS PECTO R'S NAME. Print the initial of the inspector's first name and full last name; insert the telephone number where the inspector may be contacted. 21. CFIRS I.D. NUMBER. Insert the fire department's num berassigned by California Fire Incident Reporting Systel 10. FACILITY NAME. Insert the name of the facility as:� it appear on the license. List identifying sub name if I known (i.e., Hacienda Corp/Medina Lodge). 11. LICENSE CATEGORY. Insertthe category of license being sought as it will appear on the license certificatu. 11ADDRESS. Insert street address and city only. A post office box is not acceptable as only location. 13. NUMBER OF BUILDINGS. Insert the total number 61 buildings to be used for housing of the occupants covered by the license. 14. RESTRAINT. Indicate if physical restraint (locked in a room or the building) is to be used in the housing of the occupants. FACILITY CONTACT PERSON—TELEPHONE NUfd- BEfill . Indicate the name and telephone number of the responsible individual at the facility to be contacted by the fire authority. 16.HOURS. Indicate the number of hours the occupants , are housed at the facility (less than 24 or 24+). 17, SPECIAL CONDITIONS, Indicate any conditions a a unique to this request. As an example, if the inspection request is for one building in a multi -building facility. 22. OCCUPANCY CLASSIFICATION. Use Californica Building Code occupancy classifications and insert thE', occupancy determined by the inspector. 23. INSPECTION DATE. Enter the actual date of the! #I inspection. 94 8531 91 e-oof the State Fire Marshal � REINSPECTION REPORT C 4 r Fil No.: ..— ._- of Facility. Name of Building: Address: P,�'1� CL �, l p�FKc� STATE FIRE MA SHAL , .>: X ....,�' ..; .... -: � c ':: •. ✓ ' .. .+f. �+1°i-�-{;.,• ','q'.-1! ' .;t.•�4 . u•R •i .w! i,v , t. r- i .y • t• ao-s< fI�T • �r 1.r K - a -r 'Y � �. •a it yr.. 3' w , 1 1 ? :. �S Y • �1pa 't : % ai, i' • C•' x SI Vey, • • .,� •'C K:•' �i � ' to • ! . M. ,�,.., �, -�•*> „vc ..3' . 1. u;4 .%+•�-Ya ;i �,>.d �{ �` 7i K . iE > 'i:jt kY . : }.•a 1 .,�' IA: .!. <:. t, - ;�: 'a+.: •�,` .G•� 'Q3 .. .y>. 13Y:. .�5 .A { .4. >,� > .. .9 R �, AA raw e.' r 0.Y ..w.`�F1: T / i/ 'jx, -y :�i' .-'iG-• �,y :.f� r:7 ; w f .� '.. •<o. .,, . .. ' �. •• �... . -j, ..^ :+w'�..^i�'.Aa-'.'Z 4 . 1F�' �i•. ;,Y'^.i .� ..�Ni" .�- •' .�0.,( t't•• w..w .. ,. .^l Y•y:11\'i"�..�•. if. .1 `- ✓,h } Y•. ! ::ii �.^.f• :>. �~ 3. •k 1 7. '.r >rj y,,.: c.. 1� ,�q J!..., '7v: •'fir ��. 'ri•.sN. s - X:�, - •.n {:;. 1j. �. ';f. •y 7K'�' .�oaY . w,� ,tsvK • t<+ •Y.. .'y�'k r -:G- ...p� ,•t S 1' #•.... �i'' �►'�• T w l�S+,P,. ....3' 4'. j#..., + wK T.. Vt :•! ,.j -c r. r ..� .7, k. :' 'a. P.'r _�.. •r Y. i �.1 't. x ''L y •�`�r•i. �l,t„^ 'Y[t •2 •} .•.r .Y; �.�.Y>�.. ♦:�'.'3!,�" }. ►t .....,r�4:: .r 1 r.. t .•;c: 4i Yy. J. '9f .t'i . 3. '•• :A�G.i=' i's^' �: AY. .Y`• :.: `:Y •' �A�� .�S+t(� G • tiT..� `'.be '�� i :,t.. .•s. irnr `�^. wE tr, V3' :.G1 .. )'V Y�, •'y.•r �;w ,� 3 ,#� `;-'.,. wy,�'�` +11'z. 1�+' i'.- • wG�4.Rv. �* . Fire Safety Deficiencies Numbered t 7, noted on the Letter ❑ Fire Safety Correction Notice (EN -11) ❑ dated' have been corrected. Uncorrected Deficiencies Numbered were re -issued as shown on the Fire Safety Correction. Notice dated , which is attached to and made a part of this Report. In addition, new deficiencies were identified at the time of this reinspection, and are shown AN Items on the attached Fire Safety Correction Notice. % �, '\.. C_ .:- (, : • _ � --�C' till-. Fire Clearance% Instructions. V- k, u U t C' iA nc�L-t-/ „•;.s -.,,r .:?• i�W;. -w �r'�. 'kr �f Iii < :4 �r ��w .. v1 �._,f �!`- Fl�,.r :w'1 ,� `� ��►y.• -FIM CLEARANCE :.:1i r-. AA::;?•113 •.��`•. C ,yw .. .. C .. 7'f .�, Y. J, 'A•'E• f rta• t• .r' "',.tip• t.< Vi.. : `- Y.. .. it .. h,. 4 t qy a N <. s �( w Ik.+ ••..yy.�.�••.� ST FK -:. .> . �� -•; v f�*J? i. .g' f,. .-' k. _tfp�.' ;-_fir \:� K �� ♦.. t. /IMiI•„'Y1 S. 'F .27''�,f:Yf,H 1P .;� ^It .�s ..> "k. : �Ai�;:e - �4. �+� �1''�'-:: 'moi .t.:.+i'`: �ga`• RAM it or ♦ .'��. � g Y 1 2 5 (Rev. 7/86) Page of *FIRE 'Office of the State Fire Marsh INSPECTION REPORT HAL File No.:. s�'�) Name of Facility: - of Building: r, 7 b [ 1 'Title STATUS Title ;. DEPUTY ATE FIRE WpSFLIL �.} DATE OF. INSPECTION I I � «er',' �-r,�� -- FIRE FIRE CLEARANCE GRANTED'T-DATE STATUS DEPUTY ATE FIRE WpSFLIL DATE OF. INSPECTION 1 GO -6 (Rev. 7/86) STATE F!.R*E- M9RSHAL COPY DISTRIBUTION: REE REVERSE OF COPIES 2 AND 5 FOR FIRE SAFETY INSPECTION REQUEST 1-3 - STATE FIRE MARSHAL STRUCTIONS FOR COMPLETION 2 - FIRE AUTHORITY STD 850 (REV. 8/86) (Continuous) 4-5 - LICENSING AGENCY 1. REQUEST DATE 2. PROGRAM 1 11z22z93 3. AGE 4CY CONTACT 4. TELEPHONE NO. S. EVALUATOR DSS Community Care Licensing (916 )895-5033 Bob Caldwell/0207 6. SFM REGION 7. SFM ID. NO. 8. REQUESTING AGENCY FACILITY NO. 9. REQUEST CODE 041374777 4A CODES 1. ORIGINAL A. FIRE CLEARANCE • 2. RENEWAL B. LIFE SAFETY 3. CAPACITY CHANGE 4. OWNERSHIP CHANGE 10. AGENCY Dept. of Social Services S. ADDRESS CHANGE AME Community Care Licensing 6. NAME CHANGE ND 5 2 0 C o h a s s e t R d.,# 6 PREVIOUS NAME DDRESSI Chico, CA 95926 7. OTHER DATE OF ORIGINAL REQ. 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CAPAi ITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS TO 18 18 TO 65 AND 65 OVER CAPACITY TO 18 18 TO 65 AND CAPACITY 19. FACILITY 12 1 x 6 65 OVER x 18 CODE 740/RCFE 12. FACILITY NAME 13. NO. BLDGS. CODES COMFORT & CHEER REST HOME 1 1. GACH 7. ICF/OT 2. GACH / R S. ICF/DD 14. STREET ADDRESS P.O. BOX 15. RESTRAINT 1882 Tehama Ave, no 3. SH 9. ADHC 4. APH 10. CLINIC 5. PHF 11. JAIL CIT Y ZIP CODE 16. HOURS Oroville CA 95965 24 6. SNF 12. ICF/DDN 13. OTHER 17. FACILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL Ben Geneza (916) 533-5469 or 707) 557--9426 TO BE COMPLETED BY INSPECTING AUTHORITY 18. FIRE 26. CLEARANCE AUTHCODE Jack Pirisky, State Fire Marshal AME AME #4 Williamsburg Ln., Suite .A CODES ND Chico, C A 95926 DDRESSL I 1. FIRE CLEAR, GRANTED 2. FIRE CLEAR, DENIED J 3. FIRE CLEAR, WITHHELD 27. DENIAL CODE TO BE COMPLETED- BY INSPECTING AUTHORITY CODES 21. INSPECTOR'S NAME TELEPHONE NO. 22. CFIRS 23. T-19 OCC. ID. NO. CLASS 1. EXITS ---.-'l� ,` �, > -� �� 2. CONSTRUCTION 3. FIRE ALARM 24. IN DATE 25. INSPECTOR'S S URE �l 4. SPRINKLERS 5. HOUSEKEEPING 21f. EXPLAIN DENIAL OR LIST SPECIAL CONDITIO S 6. SPECIAL HAZARD 7. OTHER 0�1 V STATE FIRE MARSHAL USE ONLY RETURN TO: 20. REGION, Dept. of Social Services OFFICE Community Care Licensing AND 520 Cohasset Rd.,#6 ADDRESS Chico, CA 95926 I I J A.., ,.... Office of the State Fire Marsha, Fire Safety Correction Notice File No: - - - - - — — Name: Address: The California Health and deficiencies be corrected. Safety Code and the State Fire Marshal's regulations require the following fire safety CI y The above deficiencies are to be corrected within -` days. When ALL deficiencies have been corrected, sign and return the certification on the opposite side of this form. If you have any questions, contact the Office of the State Fire Marshal at ( ) ISSUED BY (Deputy State Fire Marshall RECEIVED BY DATE EN -11 (Rev. 7/86) 86 96708 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field No.: of Facility: of Building: Nice of the State Fire Marshal REINSPECTION REPORT 0 Discussed with: Title: Accompanied by: Title: Fire Safety Deficiencies Numbered l noted on the Letter ❑ Fire Safety Correction Notice (EN -11) ❑ dated have been corrected. Uncorrected Deficiencies Numbered were re -issued as shown on the Fire Safety Correction. Notice dated which is attached to and made a part of this Report. In addition, new deficiencies were identified at the time of this reinspection, and are shown as Items on the attached Fire Safety Correction Notice. GPAFire Clearance Instructions:—1 FIRE CLEARANCE GRANTED T -DATE 0� STATUS DE DATE OF REINSPECTION ') V W-5 (Rev. 7/86) Office of the State Fire Marshal Fire Safety Correction Notice File No: Name: Address: SF OF I I CALIFORNIA STATE FIRE MARSHAL The California Health and Safety Code and the State Fire Marshal's regulations require the following fire safety deficiencies be corrected. The above deficiencies are to be corrected within days. When ALL deficiencies have been corrected, sign and return the certification on the opposite side of this form. If you have any questions, contact the Office of the State Fire Marshal at ( _ ) ISSUED BY (Deputy Stale Fire Marshal) RECEIVED BY DATE EN -I I (Rev. 7/86) 89 88751 DISTRIBUTION: GREEN—Facility J� WHITEIRegion YELLOW—Field .-•.rF•,.'•'�"'Y:''4 '�.yw•.f.r. �'^.. ( Cj�y r. ,r '+r r --,w.� :�;'. �'.�.'R1P� f'?/'..- .^1'�,.w .rr 3:•r('/�!'Ffv-. f. rr-j ?M Vp` "•r'•': ^tfdtYiiA�.t fi -fi'" •`♦ •nt _,5... ,r.•;✓',,,....•'' ... 7.. :[•+.f- '"''.,fy'; ,rrt=�• ; Y. y 7 f • 1.� - _ :o; t .' . -.• I!'J •... '��. .. r... ."'Sit!' I. M�{Wl. Ii��ii%'r •v'• .^ '1s� �. fr.• • r'rKlrriA..: .iSr-M 1f••n .'.i : .. ,age of Office of the State Fire Marshal INSPECTIONREPORT'' . 1 , STATE FIRE MA AL 0001 000 555 _. 9 Jame of Facility: Jame of Building: ' Wdress: 1882 Tehsm St Qrov -Ue CA 95965 . t r rL �iL Yf.A�rf.2t!`^ �-'•'`�°,t..�•' vr` .9�! 1. "'lr,,�ll�rf�:•v i� ffrrl.,�t :�tii{�.�♦�i'.'•jtt 1 r•��`i'IR'�';�:n•.•��.,�i;.,i� :r .r �, '/. 1- 7.. a. r. .V : ir[!1 �•� .1,, .u%..,�,f .lair �'• ip• � !f' r''�' -i'1'r Y,•'; .`, 'A\ .♦.. .�:, .'} .�•'.R•.f�'f .�, ••!�•••:•. �� ..� '�•. V:•1. ':'�y .� ,F k.. '.' �'`+r: f • rt. : • .. ,. .�! � i, r , .�j.. !Vt. �'. ,.i•1:',^� i' ;. ;' t� rr fj. � i�r (.s " � `! : t,. �f"a�" t. ,� .��. r r i • l /.. '} r . •�S :a.. i'' •f�•' t". !j r: IL ��•:. 4,7. :y.'2'• ✓�t.r � �l♦�', ��►:;��`r� 1• .•f ♦'.ifs ��.i •• `! �. fr�''� a' i •::,. '• f •f '••, lj�•u 1':�1 :rt f, "O x1111 �N �• .l1• iVr.� �f. y� r .pt • r 4,;�� Discussed with: • _. r •... ♦. �' .�. r' } r. ,,J' C r .••r ♦, r ,I jf •L A• F,. tical ..�-'f'F`'t }►y= ' .�► "jtr, •N a.. fj f, i j• r r. '� •• i.I,•` •;•� r . +/f• S' ♦�. �7. 'z .i ''1"i .•+} i .r � 'r!.�.' 'i.•f;•.}.fA. '•k: :T, ♦.�,i;...L tj�'r, �; ,q•,�.f.r.•.•1 •i1irji•t,i:t.f .i�.f:. ''-��.�.a , .•!.TseC• :{.•'..'',ri (',:♦!' r••.1: .C;��•• �� .".rrvtah474 .-Y:�'` ..��'� j�, •-? . .• .� �.♦'�•►1N1'- a.� .�. f 1. .'!�' •,�+..-•1. •, �i,t.�`yr"r," ..:/♦� ,i`JJ,' fFZ itAccompanied b • �j.r.♦.{,. . ;�r'•S.•• 1Ax"� •.:.:.J'�•..ttS� w.-YW._� �� I�.�•y .��• �yt ,•, , i • � t �. r.•r'it• i V 'it � r �. .f •I" '•'}. :�4 .!'�t't,.}'�; ,(.. 1'r 5.. �.• f An MI tion was conducted at the above facility. A ginde def icienc was noted on the attached FN-11. 00 • 6 ltev. 786) %iffice of the State Fire Marshal INSPECTION REPORT No.:. -OO --O/— ---4 2_ --909.1 — _ --909- ---555__ — ---7-_q_ Name of Facility: COMFORT & CHEER REST HOME Name of Building: Address: 1882 Tehama Street Oroville, CA 95965 At the request of Community Care Licensing, a fire and life safety inspection was conducted at the above facility. One deficiency, a phone shelf protruding into the corridor was removed. Licensing request ask to designate which rooms were cleared for six nonambulatory clients. In the I-2 facility all rooms can be used to egress ambulatory and nonambulatory clients The facility maintains a reasonable degree of fire and life safety. Fire clearance is granted for 12 ambulatory and six nonambulatory clients FRE `UFARMKE GRMITFO T bAIEStATUS G - chars DEPUFY STATE FRE MARSHAL i n' q �,�T^"X�4 YT�Y }�{ t Si._ iry: ASA 1 i' n t�`£ t{ i r i€„ r DATE of NSPFtTK)N f A ., SL AUG$TE�tr��ry,�,.;',��;�f,:Lt'�.��'�,'"Spf•'�;t.`�`L�f.r GO -6 (Rev. 7/86) 71, 'ql � kr- Jl �� eRc. - `^r � k�"i+''"w �'�o- =='� :��J��'a� �_ g� � `tom _`� � 'a � lei• k - t k ...... ...... t� te oz-itwo T! TAME kMyT - imp vjFj;jmR-. um SATE FIRE MARSHALCO�r', �SQi3UTION: SEE REVERSE OF COPIES 2 AND 5 FOR IRE SAMTY INSPECTION REOL 1-3-STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION .jT 2-FIRE AUTHORITY 1. REQUEST DATE 2. PROGR;An S D 850 (REV. 8/86) 4-5--LICENSING AGENCY 9/19/9,11 3. AGENCY; CONTACT 4. TELEPHONE NO. S. EVALUATOR DSS/COMMUNITY CARE LICENSING(916) 895-5� ( 033 0210 MARIE SMITH 6. SFM REGION 7. SFM I.D. NO. S. REQUESTING AGENCY FACILITY NO. 9. REQUEST CODE 330 00-04-42-0001-000-555-9 041371384 7 PLEASE DESIGNATE ROOMS CLEARED FOR THE SIX NONAMBULATORY CODES 1. ORIGINAL A. FIRE CLEARANCE CLIENTS• 2. RENEWAL B. LIFE SAFETY • �= • 3. CAPACITY CHANGE DEPT• OF SOCIAL SERVICES 4. OWNERSHIP CHANGE 10. AGENCY , ; � COMMUNITY CARE LICENSING - _ . a. ADDRESS CHANGE NAME 520 C O H A S S E T RD, ,# 6 6. NAME CHANGE AND � � CHIC 0, C A 95926 � PREVIOUS NAME ADDRESS � � 7. OTHER DATE OF ORIGINAL REQ. 1 AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE C PACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS TO 19 18 TO 63 AND 65 CAPACITY 18 18 TO 65 AND 65 OVER CAPACITYTO 19. FACILITY 12 ITR 6 X 18 CODE 740/RCFE T2. FACILITY NAME 13. NO. BLDGS CODES COMFORT & CHEER REST HOME 1 1: GACH 7. ICF/OT 2. GACH/R 8. lCF/DD 141. STREET ADDRESS (ACTUAL LOCATION) ' P.O. BOX' 15. RESTRAINT 1882 TEHAMA AVE • NO 3. SH s. ADHC 4. APH 10. CLINIC CITY ZIP CODE 16. HOURS OROVILLE, CA 95965 24 s. PHF 11. JAIL 6. SNF 12. lCF /DDN 117. FACILITY CONTACT PERSON TEL EPHONE NO. 16A. SPECIAL MARINA OR JAIME FERRER (916) 533-5469 OR 33-2913 13. OTHER TO BE COMPLETED BY INSPECTING AUTHORITY • 1 . FIRE 26. CLEARANCE CODE AUTHOR JACK PIRISKY CODES NAME #4 WILLIAMSBURG LN • - SUITE A 1. FIRE CLEAR, GRANTED AND CHIC 0, CA 95926.. ADDRESS II 2. FIRE CLEAR, DENIED • J 3. FIRE CLEAR WITHHELD - - 27. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 21. INSPECTOR'S NAME TELEPHONE NO. 22. CFIRS 23. T-19 OCC. ' ID NO. CLASS 1. EXITS Slaughter 1 895-4312 035 1 I-2 2. CONSTRUCTION 2 INSP. DATE 25. INSPECTOR'S SIGNATURE 3. FIRE ALARM 2 Se t . 91 4. SPRINKLERS 2 EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS 5. HOUSEKEEPING _ 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY RETURN TO: REGION. DEPT. OF SOCIAL SERVICES OFFICE COMMUNITY CARE LICENSING AND 520 COHASSET RD,,#6 ADDRESS CHICO, CA 95926 Page of Office of the State Fire Marshal 0111cDI REINSPECTION REPORT STATE Fj IRF MA�2SHAt �.--�- File No. 00 04 42-- ()()()1 '-- OOO1 _ OOO _ 035 — 1 Name of Facility COMFORT & CHEER REST HOME Name of Building Address: 1882 Tehama St. Oroville. CA 95965 Discussed with: Accompanied by: Staf f 1 -We: Y)de: Fire Safety Deficiencies Numbered one noted on the Letter ❑ Fire Safety Correction Notice (EN -11) ® dated 2 .Tan 91 have been corrected. Uncorrected Deficiencies Numbered none were re -issued as shown on the Fire Safety Correction. Notice dated which is attached to and made a part of this Report. In addition, no new deficiencies were identified at the time of this reinspection, and are shown as Items on the attached Fire Safety Correction Notice. Fire Clearance Instructions: Fire sprinkler system was repaired and is operational Facility maintains a reasonable degree of fire and life safety. Fire clear— ance is gran ed for 18 aged clients, six of which maybe nonamhulatory YDS I-21 DMM STATE DATE Or RF:,6PKTI3H FRE CLEARANCE T -DATE STATEIS 7kNM YDS I-21 DMM STATE DATE Or RF:,6PKTI3H 19 F'eb 91 GO. 5 (Re. 7 86) Office of the State Fire Marshal Fire Safety Correction Notice File No:Q �`� - U 4- _7 Name• � J v � , _ � -t., ! J Address: 31 SF I I CALIFORNIA STATE FIRE MARSHAL The California Health and Safety Code and the State Fire Marshal's regulations require the following fire safety deficiencies be corrected. The above deficiencies are to be corrected within days. When ALL deficiencies have been corrected, sign and return the certification on the opposite side of this form. If you have any questions, contact the Office of the State Fire Marshal at ( ) ISSUED BY (Deputy State Fire Marshal) RECEIVED BY �I t DATE EN -1I (Rev. 7/86) 89 88751 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field Page of Office of the State Fire Marshal INSPECTION REPORT File No.:. 00 ---0 4 =42 Q0Q-L-- Oa ----035 ---1 Name of Facility: COMFORT & CHEER Name of Building: Address: 1882 Tehama Oroville, CA 95965 OR Discussed with: Marina Ferrer Accompanied by: Title: Owner/Operator Title: An annual inspection was conducted at the above facility. One deficiency was noted on an EN -11. The sprinkler system frooze during the December freeze. The owner have contacted a sprinkler repair company and parts are on back- order. FRE OSARANCE GRANTED T -DATE STATUS DEPUTY STATE FIRE MARSHAL. DATE OF INSPECTION 2 Jan 91 GO -6 (Rev. 7/86) Page—of Office of the State Fire Marshal INSPECTION REPORT File No.:. �� -� (-/ — � Z— Name of Facility: Name of Building: Address: l � Sz ' �� "47C -A -A &)U) L) i l(V*,e C,;O, r Sy6 � AS '�:, t��. ,a✓T-��Vi `1> CG.. R1 TY} 1 G�7yYy 1�'� r... c« , � �r '•tn'��3„Ces'`t � � k 4 � �•� �vaYx� � Asa ♦ � � � q� • .✓R `��>d �llM,`�' a �"� i} Y} fi� s Z�� Y � c�• b i}� a„ kF� ��''_ }s� $ .� s 3 ,>,�j, s' ty�eH,a.{'ygr iuf _.. � �• �,r.Y,� �'+a,i< s � %D�'v3'M'�` ^tw�,�?'.T•�$ o s': s £ ,tp `?.. 1 k• � "'� � �. � i v 8o, �J = ,r1 �jj ,bi jog GO.6 (Rev. 7/86) 11 _ e of File No Name of Facility: �ame of Building l69 Z�� Address Office of the State Fire Marshal INSPECTION REPORT / - Com- c^_�5s _,/ Discussed with: Title: Accompanied by: ,Q��tifi .0 Title: I FUZE CLEARANCE CRANED I -0ATE STATUS 'SPATE FlR DATE of INNIFCTION O - 6 (Rev. 7/86) P+se-of- Office of the State Fire Marsha, REINSPECTION REPORT File No.: 1�z of Facility: of Building: 5s: ,. .f .. .:: :6.. f:... .. .: ., �:,:... ... ;tf�..w. ;».- ':2: • .a.. 'r. n'•MMR. :7'•R �: .. J•f. ..so, S� S".]„f, ..t-7n�e!'w: R�,, ;5'+s�...: v A •'v Y o. S?F N i 11 Y. v 3",e” �>.. .mac , r... _Y• t . •r2. t •{ K : L r•'>W a !.' � �F.`..�,• t '•i . ++1 .w',F' �"E. ii�' •S`' 4C+��-^.NF1'>•. 1�-' •++ .. , S S.. •ice. <. .i :. tx. I_.: .a. .> t ..� tt '•aJ >. z '.♦ �� fi 4 �.. .t .J f �.>.,�'� .r.. .y-. 31,4. .>�.'Y^� TT 4.�: (l '. Y C � �. Y:.•: -. .. .:. .:..'.. .. :vW u.. � ... ..<.• r o:: .'?. .....;. w.r.., ...#f. ..y -.>. ,i '' .r x, sS r. 2 2.4 F' .f 4 '�/'!IM 1',1f�il�'�_.�E+f�l'�" . .. ��.ru+ !+.� C �, e�R�� ...- ,� .. , . � .... ��.��+ � '�� •.�.�.w�� r„ ...��IA�:�.�: .. .l� . .. •. i Fire Safety Deficiencies Numbered noted on the Letter ❑ r � . Fire SafetyCorrection Notice EN -11 ❑ dated � have been corrected. ( ) Uncorrected Deficiencies Numbered were re -issued as shown on the Fire Safety Correction. Notice dated , which is attached to and made a part of this Report. In addition, new deficiencies were identified at the time of this reinspection, and are shown as Items on the attached Fire Safety Correction .Notice. Fire Clearance Instructions: —.._.. _ .—. r ,r.�. ♦{:i; �� N fir'•" � '{ � n>w'•-�� tf +f ),, f. f �< j":F e�. n.. .•;7t ,6:; •', 'v (> k' o is T d K. aR- 'ry ry t a +±M .0 r Y f- ef'u"...��'.R`t*°;4�' a+�x^'+2T` - 5 otev. 7/86) 5W , t f< f < `�eh�,t9K !• ',r n V ' h A. }� \ =Y• (t �.Y{fi ,> i ••i�i�f, 4. a twF ,. „�y♦ 6. y�"� F t, y.. jjY �� ?�q STA! 1FIRE MARSHAL COPY DISTRIBITION; SEE REVERSE OF COPIES 2 AND 5 FOR FIR SAFETmftbY INSPECTION REQUEST 1-3 - STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION STO 850 (REV. 7/80) ` 2 - FIRE AUTHORITY. 1. REQUEST DATE 2. PROGRAM 4-5 - LICENSING AGENCY1/03/87 S. GtNCY CONTACT 4. TiLEPHONE NO. 5. SIGNATURE S/Co ity Care Incensing (916)895-5033 0000 S. FM RtGiON 7. SFM I.D. NO. •. REQUESTING AGENCY FACILITY NO. f. !VALUATOR 34 •_ . 441371384 /� 0103/Laurel Eckert 71 Is_ 9. RKQU6$T REQ COD! 7A .y CODES IGINAL A.FIRE CLEARANCE ,J�� ,� .10. "•'��' AGENCY �, �- `.t,,�-�'� DEPARTMENT OF SOCIAL SERVICES NEWAL S. LIR! SAFETY NAME �?� '''��•''tl AND COMMUNITY CARE LICENSING 14 �� ApDRESSg2p PACITY CHANGE NERSHIP CHANGE P.ADORESS Cok�aSSet Road. Suite.Q '� •C�CQs CA . 195928 ~�`v� .->'�,I�•�' l_ CHANGE 6.OTHER y DATE OF ORIGINAL. REQ. 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CAP CITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS TQ f0 10 TO 65 AND 45 OV CAPACITY TO 10 1d TO 6b AND 65 Olin CAPACITY �� 20. FACILITY 2 . CODE 40 7 12. ACILITY NAME 13. NO. BLDGS CODES r�fort and Cheer Rest Brow 1 1. G A C H 7. ICF /OT 2. GACH/R S. ICF/DD 14. TRK9T ADDRESS 15. RESTRAINT 882 mm Avenue 310 3. SH 9. ADH C • 4. APH 10. CLINIC 5. PHF 11. JAIL ITY ZIP CODE 16. HOURS 0:ille i California 95965 24 6. S NF 12. OTHER 17. IT; CONTACT PERSON TELEPHONE NO. 16A SPECIAL Ferrer (916)533m5-69. TO BE COMPLETED BY INSPECTING AUTHORITY 10. IRE r 27. CLEARANCE UTHOR. I CODE AME _. CODES NO 1. FIRE CLEAR. GRANTED QOR ESS L 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL. CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22.INSPECTORS NAME TELEPHONE NO. 23. CFIRS 24. T-19 OCC. ID NO. CLASS ...tom �� '�► \J 1. EXITS 2. CONSTRUCTION 25.1 SP. DATE 24. INSPECT GNA R 3. FIRE ALARM 1 4. SPRINKLERS S. HOUSEKEEPING ,jXPLL,,AIN DENIAL OR LIST SP IAL CONDITIONS � / �/%ar4�=7 6 /V A. SPECIAL HAZARD OTHER' 17. STATE FIRE ARSHAL USE ONLY 21. EGION. :OFFICE State Fire Marshal 940 X33 (Marie Read, Suite 4W OCR ESS emosdo' C*Iifornia 95823 L TIME MILES NEXT INSP. (MO.DA. YR.� -M-� f. Jffice of the State Fire Marsha Fire Safety Correction Notice File No: 1�7/0-rz Name:!/=P�/� Address: L The California Health and Safety deficiencies be corrected. Code and the State Fire Marshal's regulations require the following fire safety S/z �� z 7 fi t-- �' %_) �' • -rfl& Z9 7L) -:5 r The above deficiencies are to be corrected within t days. When ALL deficiencies have been corrected, sign' and return the certification on the opposite side of this form. If you have any questions,contact the Office of the State Fire Marsha,! -at (�) ISSUED BY (Deputy State Fire Marshal) RECEIVED BY DATE EN -11 (Rev. 7/86) 86 96708 DISTRIBUTION: GREEN—Facility WHITE—R�gion YELLOW—Field Aak, Aft, -)ffice of the State Fire Marshak Fire Safety Correction Notice File No:iea 2 - Name: Address: Z, Z_ The California Health and Safety Code and the State Fire Marshal's regulations require the following fire safety deficiencies be corrected. 2 3), A,162 71 /41 C -T -1-7 / > 7 The above deficiencies are to be corrected within,,,'" days. When ALL deficiencies have been corrected, sign and return the certificationon the opposite -side,of this form. If you have any questions, contact the Office of the State Fire, Marshal at ISSUED BY (Deputy State EN -71 (Rev. 7/86) 86 96708 DISTRIBUTION GREEN—Facility RECEIVED BY WHITE—Regi DATE YELLOW—Field _Z) Af Ace of the State Fire Marsha' INSPECTION REPORT File No.: A510 — &etl— 4z z Name of Facility: Name of Building:--- Address:---- 1 Title:... 3 ,%�.� /� = �.i7d-�-✓ C-t/.�. �' C�8'�r/v�.��..;�c�-->� ,.per--• ----- eri+ F¢{tkT,GATf DATE—Of IMSPECI uER[d�Y SI AT¢ fr�?�6RSFi U / _ GO -6 (Rev. 7186) t9Y 1� t �' -:5; Y ,ti * ,;•.i +F is I j ! { 1 i , ir: 1r ?: :t:fi� E++. „' �{ E • } 3 :..� ,, i' " , I i; 1, N - .. d ?._,k. (T ' �' •t t, t ,, ; 'y ,,Y 'r .: I� i j} f ` 1 t t s Ir. ,.j ` `a{ (.r k' Y i. �iIt 7I :J �`; :'i rr .; 1I i:. ) ,-:�..i 0t �..1 '"I `�; , ,• - r � - - _ r, i 'm,. .i :IZ I k -2 Jr 1 ' 1i Ii1.,.Fi �.1 !. 1 ,. 0 t �i ' (�. 4t r: t� -,�,t tt .) 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NO,il�r�1�1111D Aa V� l'�rv►KL.. ;,f=:; F,i'p. 11 IIS +i , I.4, i 'tit ri{."1 +1 i.l i i r 4 ,Y, l' liJS :) f.i{ '1 1 !il 1" U I { 1, j i • i s t I' Iii. I i 1 if t J I 1:1 ( i IY�i:1': l ` 41.,kb'.i�1,1F _'_i 1. 1 .I 1 .i :i: 1.' 1 1,', .{ -. 'i I._ - . — ;, ) r I 'I: A.,i •r ,- +'. ,v..,1 ,I i'. :9'�".Z e Page -of Office of the State Fire Mars7`1- REINSPECTION REPORT !e No.: ._._ .._._ Name of . FacilitY Marne of Building: Address: K: 11i• !F .r .d -: � �. k. '.e Ya : { �• ,?fi�. ,f i. it !.-�" 3-. i :i':, a+�� •t)... .�. ..r 5-C' �� L. B' S- o�:� ,.g �:1 F �y j 1: •1!� f—, _t:. ..vt':•yF ••yn... � 4 It #b.. S '� :'t'.) �?. y F'2r %. �.� F :'l ��": SSrr ':f. i. vj r'a} a�i'.�'t :' ,�C:�• L� "s r,,. r +5._ �:� x .� n �:� 77 }x� 3 # _.r. x '� �1f; "'TR.2:. I �� .t i. ..'Txl• f .1. ::� a i. , ,1...�.; t bi� •�. r ii Y:�t }.<��' O - ..�_�-y.': .fig •rF �.�.� �.-: '��I��i .'e.00wr.Mr-s6id�-�z/z }°. M { . 4 i � ��' c; . � �1 •k r e aB.Str�i �-` � � � i Fire Safety Deficiencies Numbered /5 -- noted on the letter Fire Safety Correction Notice (EN -11) dated _._ I'F have been corrected. Pmorrewel DO *encies Nupberec� were pzrpsued as sown on the Fire Sa f cty Correction. Notice dated , which is attacPed to and mad, a of Fppoq. 1 In addition, newleficiencios were identified at the tir a of tb.i� rOnspectim end rp shoWp 4s �erps on the axtached Fire Safety Cc recd, on Notice• Fire Clearance Instructions: ZC1 - �.��CL—,�-.-� i� � -GO - 5 (Rev. 7/86) Q -0 PACIFIC VALLEY FIRE. -PROTECTION INC. ` 7500 ran Joaquin St. Sacramento, CA 95820 Lic#493314 (916) 451.7342 REPORT OF INSPECTION WET FIRE SPRINKLER SYSTEM CCNTRACT#:. "06! . CONTROL VALVES N0. OF VALVES TYPE - - CITY CONNECTION TANK PUMP .)LCT I ONAL 3 STF,A Y / ID B. EXSIc- pg 2 of 2 Inspection and suggested ire. ovement s were discussed with the undersigned owner or owner' re/presen ive? SIGNATURE : /' DATE: CON REP STR CIT INS PACIFIC .ALLEY FIRE PROTEG..40N INC. 7500 San Joaquin St, Sacramento CA 95820 Lid*493314 (816) 4517342 REPORT OF INSPECTION WET FIRE SPRINKLER SYSTEM pg 1 of 2 CRACT : DATE, ..• -46• )RT TO . -- LOCATION INSPECTED: w SET : STREET: STATE �'"--� IP : %t:.M�.: [. ..,.-,q C T • r I Y o STATE , ZIP . ?ECTOR s--►rf� -� • .- PHONL'�` : ANNUAL SEMI-ANNUAL QUARTERLY OTHER OF INSPECTION: Pnrequired ES NO • Has 5YR. ins ecti by California Aaministra ion Code Title 19 AB250 been and performed? Date: - -3- S"? Has owner/occupant been advised of SYB. requirement of California Administration Code Title 19 and AB2504? Are Fire Dept.Connections in good condition, couplings free, and 47e01-0- V00 caps or plugs in place? Are Fire Dept. Connections visible and accessible? Dosprinklersgenerally appear to be in good condition, free of paint, corrosion or loading obstructions? Have the sprinkler systems been extended to all visible areas of the building? Does there appear to be proper clearance from sprinkler deflector? Are extra sprinklers available on premises? Does the exterior condition of piping, drain valves, check valves, hangers, and strainers appear to be satisfactory? Are i signs for control valves, drains, and tests n proper pla'ce? . Are all control valves in proper open or closed position? Are control valves easily accessible? Are control valves properly secured? --.,Haw. ,� ' j Il Did water motor and gongs operate satisfactor'y'? Did electric alarms operate satisfactory? Did supervisory alarms operate satisfactory? Are any sprinklers 50 years or older?. Are any extra high temperature solder sprinklers regularly exposed to temperatures near 300 degrees F? Have fire pumps been tested to their full capacity through hose � streams or flow meters in the past 12 months?. Do fire pumps, gravity, surface of pressure tanks appear to be in good external external condition? Are gravity tanks at proper water lever? 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"- •. •a.: !jt t .. .._... .•i.«��_..1.'.•.•i•_.• •r•�L � • ......_ •M�'•.._.. •L•..� •• .. dr •waiar ww�.w••.•www ••+�w.wel.r.w+iri..ww..w.wr.wraw•++ ...�.w.w�w�+w.w •e F • r afe Correct ons StIoul ci BeReinspection Indicates That New r . .• ��omi��ents and flew 1 r Safet rrecti on . -- Issued. ----See -Reverse -Side for-��---=-��•=--- . .. G0-5 .. � -'• «.....`. Sti .:.�.f..+L.:J_•:L •• i .. •. A•....•_ q.:.:w..•r�-.Av.w_r.•_ •.. -_..« •...+r•rr. �:_-._. • !�.• » . • ..• . r.r:ri- .•. .• •.» .. .. - •.•. :� �• .. � . -. �- De u ti Office of the State Fire Marsha Fire Safety Correction Notice File No: 0 Name:'"1; Address: L The California Health and Safety Code and the State Fire Marshal's regulations require the following fire safety deficiencies be corrected. 7'� 9 c ate/ %j The above deficiencies are to be corrected within ='`F days. When ALL deficiencies have been corrected, sign and return the certification on the opposite side of this form. If, you have any questions, contact the Office of the State Fire Marshal at ( } ISSUED BY (Deputy State Fire Marshall RECEIVED BY DATE EN -17 (Rev. 7/86) 86 96708 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field EN -77 JREV. 71E1) - YELLOW: REGION WHITE: FACILITY GREEN: FIELD 88701-355 3-04 12M TRIP OSP dCSTATE FIRE MARSHAL rIRE SAFETY CORRECTION NOT im;E STATE AL ME FILE NUMBER sin F to ' C' ZCk 5 i K-0/t1 ®0 0❑ y❑ 0 ` tf �4u 1F ?� ❑❑❑❑ ❑ El ❑ ❑❑❑ NA ADDRESS In accordance with the minimum standards of Title 19, California Administrative Code, the following corrections are required: l �2 1AV10 P SAI-41( /3dq, PSM A t_ L LJ t o f: sjrC Lt t r L QC' t i�lE �r ►J % lF ! t 2 C Y ✓i L' f 2-i' _ f •i- rtl + O r c. L e. 9 0 1 3 TkZ Ptaf AlAai,4.4ti-. i Iu io -U � cJ %r jrS ivL19Lt y 1 i� ,. ✓It/� r IQLAf2gs L2'-1 LA4 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 ( ; �, ) - c, ; ISSUED BY (DEPUTY STATE FIRE MARSHAL) RECEIVED BY DATE EN -77 JREV. 71E1) - YELLOW: REGION WHITE: FACILITY GREEN: FIELD 88701-355 3-04 12M TRIP OSP kc _..yam y _<:- T - «tom ' r•f.C:. Trr f,. � " k_,r-_- , , _�w .;...-.+...��'.� �..�...��" s.... -g '--_..._ �,y _'L.tr4•e.�� C ,re4___''-.��"' �,�.` t'`u� 1y3�� ,�� FE?iY;s� V �—— T , — xr ter, et t L ' aoYi '� �..._,,�.- � � .-�"•--_-c-� y —�--•_ �'�' •.� .�s_ t ; ' �`�� _�:�...�'.#�x a�P-` 't'}�� r�- .'�� ` ill' _ kall c !� ly .. r _.ri-_ k .�--, � = - r t = � �s�- ��" - t+"� r -s .�' � . -5`.��s+•�� s'�t�- x"3 .F.. - �':~s �.-Iw'7r:,• -+,yam yN •+ -Y c4 ` '.. �. x - r' d ply .--��ALIL -.-.A�- v. - ice" T M �� 1� .gin•-,iry,�-?' ,.r��,-..�.,..�- �{ �- �r -� -Y 1 r .Pe` -..»r 1 - _ _ �-. �'!!i'-*�'�-+? "•c.�a _4r�i.'�.i- :,3irl�;:ca4-r i1.1Lw..�L f�\1. 2.-i t-�iit3_m ,� •� ,ems '4- 3''r-.��, .G i�i� �Sii!`� r"-fi i llE►ia � '�i[ - �- � t - , t .. �°'f. �—"a�_._x r•'4�'!x„ti � _.r, _ ��'s�. � -.i��,�y_.. 'r "� S� �...' -! +Z"��. �fa.c'y�- A � z .t^'y..�.-=--�a+dr... `-�---�-m=ar-.�."�"4. "� '��' � tx fE.1��' ' i.. -.�'i� ,�► t�.i � "e �� ."• �� _ �7 .'�.s. >�-.L i r --I - Jsl 4 -v � �.+fF.s„�s'•"'. ._tom a_ �� "-:' � �;[g_ -.3 N o -:- r< .� .:� � ;. IWAI- 4 � : � _ _ '. .FVJf�-}�„�'. �, 'y`n Y__� ..��: Sy3��EE•aaafggr N ? � .,€•' -v''�.'k1's . jrte' -` )V. IV_ i =Y _ �� 5�'cZ3 �,.' 3.+�'' i y. _• t' ta` 't E - =�4- *1RE AL STATE FIRE MARSHAL ;�.. -v1RE SAFETY CORRECTION NOI -to-,'E NAME � M AOK-1- ca WX4 (E S lT s OuE FILE NUMBER ❑ ❑❑❑ ❑❑0 1:1❑0 `LTJ A DDRESS In accordance with the minimum standards of Title 19, California Administrative Code, the following corrections are required: M. Su a 2%_..J vd71qicLXL f ,,f MIA 6) 18 Tl -x 4pyzx A 0UfG Cts L V Z -, l4' r �r� S tsi4e OW PgzLiuoiro A cAe s io a.( 1r.� LL 1Att AX IJ�QI�ir%:Cv i0 i� 1.l J J SE L . The above deficiencies are to be corrected within 6o 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 ( '_'/L ) - g ,, z ISSUED BY (DEPUTY STATE FIRE MARSHAL) RECEIVED BY DATE EN -1 (REV. 7/81) YELLOW: REGION WHITE: FACILITY GREEN: FIELD 88701-355 3-84 12M TRIP OSP IT-1(11rz nvws� 7, 0 --zs- —� -7 --7 44V aAkia A64" EL--' JAL .r..+rn,.� ay�- J,.. lad . Me -a I IONA 34 A6%04 ........... IA., v r 7 -a - lam" n AAW A bob aib Au I �tk Z7. 4F'.. zma J� mixii - AigT ws - Am —W 7 - -7� 7 44 EN -I1 (REV. 7791) - YELLOW: REGION WHITE: FACILITY GREEN: FIELD BB7o 1-3553-8412M TRIP OSP cwcl of i•� STATE FIRE MARSHAL r IRE SAFETY CORRECTION N01 akE STATE IRE MAR AL FILE NUMBER El El E! FI 0 'eX E ❑ El 0l El E (n re ov, NAME ADDRESS In accordance with the minimum standards of Title 19, California Administrative Code, the following corrections are required: o) ,v —,ovZ, 1 0 — iQ ,C'.. ,n r ) S fD" C oYf. �.f t d i -J C4-4, iFL Z ✓L iJ -72-J—C "Q C-1 t -4 L7 yt L t EF v iC LOSSI- Avo94 A 413-2-0 n c ,". The above deficiencies are to be corrected within G�� 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 ( 9) r_, ) --i ,r z ' ISSUED BY (DEPUTY STATE FIRE MARSHAL) RECEIVED BY DATE EN -I1 (REV. 7791) - YELLOW: REGION WHITE: FACILITY GREEN: FIELD BB7o 1-3553-8412M TRIP OSP .:l73woj;jxllAl , - a -am AAa� -A aii �u -An- lad& Msaa -77-7r, -37- �`Al `7' _7N, U 771- -zv K7 4 Ai, 2 -awe Fll Tr, Z- ;7 -1 .:l73woj;jxllAl , - STATE FIRE MARSHAL'IRE SAFETY CORRECTION NOI,i ;E AIREAL ME FILE NUMBER Lco S -S' t ❑ ❑ ❑❑ ❑ F1 IrPz t A r+,A AVX ❑ ❑ ❑ ❑ El ❑ ❑ ❑ ❑ ❑ ADDRESS In accordance with the minimum standards of Title 19, California Administrative Code, the following corrections are required: 9FK 1 c® trLX ! sX 1 �1 iloucio lax 0dryal. Ce,21-zier-nea—) t- S wS d r 4XA XT t 1,0 ` i Z-cE" The above deficiencies are to be corrected within f'_'`{ 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 ( ,f`/ ) S'7:- - - ? L'- . ISSUED BY (DEPUTY STATE FIRE MARSHAL) RECEIVED BY DATE EN -1 (REV. 7/81) YELLOW: REGION WHITE: FACILITY GREEN: FIELD 88701-3553-8412M TRIP OSP ': � �k � �^�' � 'X-x'� - _ - • � .- � III ,�... 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'� • F - M 2c. f•.:-_. � -4'r` - •":"' a - � � >�+, a�`t-� - ti s= '� b��. L�. _ � .s +.s �-�"^u�-c � i � r .' a f �� ^�'-g��.rr'�."� � R _ Ss' y mi �r��-�'2�'a_•'_�C.�s � v'' _ �'` J- _ �' �tF'..M.�""`: � ... r•y.. �- " � � -.fir � � �^f9+�s^ -� `i,-=� fay �r :r -�'_ :� � 't�' i.� �- 1 a� .1:u E'�'�3 � r - � � � T _ �-_- - ':.� r� ��b >a�..� r-�.: �,� � Fes' "_� � =-� s"-{ '�``' - � �•� - ;•X .- � t � -s0.. z .$ :.'.� h#tr ae�e= � - • � � ._ 4 _ �E"��;�d'S"-��'� 7�sz � .rte 3�+^`" �'"_ �T ' $�+�,��• �afre�...-;_.• .•+rf-hu+.•.•� y - ~� �_y•'u y `tom 4.- +j .. + ,�`- �- -2- �•� alis .�,�� "`2' ' � Y '�:� � w .,. "�'-c-" --T--�--�'� �, <-"�•�•.'' We Az � __ y'7_,.> F - - � _ i �.�'"�•w *'..m,.��'� �-' it �"'� a"Y'"�,��. '�i ��'� ,d�.. "� •au_ £, _vim. T y!^-'# cr`wwc..�ay .__�--• +�. _-_tS T _ y Y-. �' J:,- f % dam• �` al 61- awn;i J•£' s��_.-vim . �y •-,S _i. _+y��_ - - S 4r . Y fir_ �i7 .-AS OFFICE OF THE STATE FIRE MARSHAL INSPECTION LOG File Address i �� T-6144 :4A ,,4u ��,t , 1 'a ��'' Date _ - A—A Owner L u&C jr'J.,r- "'' - �►+ � : ~ cr ; Rif � -� .� '^^� r S Ur Z Rub- MCI- 116,46 GO --6 (Rev._ 5/81) NE STA BUILDING SURVEY REPORT Date: I I- h- -6 File No: e)6-cU-42-c�+.>,�I- v� of Facility: 2 As-- dreSS: I f"P^ ZJF, t4A,LiA AVIZ 6,L -vi - 4 4A Qr i C', S'• Tier: u Telephone No. ( 916) irre of Building: • LL' JL.L�1r 11vty Comm. 1. Occupancv Class Use (2,E „p r, �n,A` C✓�� '�'�� `% Capacity Ig 4 1 Ivo 2. Construction Tvpe wr)v - «- -- _ Year Built ttiMv Area (Sq. Ft.) i3. Total qq kq Largest Floor 4q r, 3y Basenent AO,-Jx 4. Stories No. �_ High Rise Yes No )c - 5a. Exterior Wall Construction Si%4ct. 0 LtA��f wps b. Opening Protection .A_ r c; s,aetrAA-no,) ota Ai.c S14#Ff -9 -.interior Wall /7 ( Construction Lid P,) . e 4 S71.;af GW�'t.>✓�to OA.. P,,A: xf' 7. Floor Construction ... .. WtL✓j arc heK _iX + �^wZ A%0 -4-4c:7 f�.k oxcfl.J, 4 � L�� bv 8. .Roof Construction A ria �+;✓�s A s«cu,��l s�►c'rry s�,�� (�o„/J -- ----......:......._.._. ___.. _ No. F nth.,; vvA '�.}.� 06 C, o ►: r. 4�c 9. Attic_ Draft Stops ___..... ._..- -_-- Oa. Occ. Sep. Wall Construction -1 b.. Opening Protection No. a -.,A 1a. Area Sep. Wall Construction b. Opening Protection No. ,A 2a. Smoke Barrier Wall Construction b. Opening Protection 3a. Corridor Wall Construction _ b . Opening Protection AA A 4a. Corridor Ceiling Construction ..b. Opening _. Protection 5a. Shafts .:._ ,., - r�.� � --• . ...:..:'' .. �_ - - .. .: �._ - .... � DESCRIPTION . �� _. _ ... ... Comm. 16a. Stair Enclosure A 0- b. opening• ' Protects on --f n 1... ; 18. Ramps No. f 19,_ Interior 20. Exl is 21, Exit Hardware 1 Type 22a. Exit -Signs/ Illumination b. r Error gency Lighting 23. Auto Spri nk - Coverage 24. Standpipes i Class/Location 25. Fire Alarm Tvpe/Cove race 2.7 . Electrical t Platform 29: Hazardous Room -,... Corridor — Exit Encl. No. �� Total width j;.. Type --jra= e. Ea A Fuel ^ Vent COUMENTS : �• � ti w • e MT respected By: No. Attachments: �--%viewed By: Date: r Jpdated: 4 1 O • roluLTIPLEi BUILDING FAC, `lTY RECORD • • FACILITY NAME: 4 FM?s "ADDRESS: _ tiAVLF LD V i LT FILE NO3 � I - cl • ' • Sm'R1A -• r t,� • • '• OCCUPANCY , • FILE' • BUILDING IDENTIFICATION .ION • . ate,-, SUFFIX . CLASS � T �?`3raR (See. Scc..Vc. 3 ) 17113 -Amar , ,,iNP�la�. 1-1411% yy 4sfCA n - q 1v i.�- 3'IV. HALF Llasfp/A}M. j25TIy /lso�yys^�reFM .,,� fMAti3 AfAwMD N � N 4/.41,jll CbM left � ChGeE �pS�Ne ^2e 1:10 4 N P- F 1 LE N0o El nnD no 0 12 0 Fol REINSPECTION REPORT OFFICE OF STATE FIRE MARSHAL ame of Fac i 1 i ty� M r " ddress :, - -, rM U,j, 0 v LL s onditions Discussed With L0e- /J ,ccompani ed By ; Ti tl e 0 nspection This Date Discloses That Fire Safety Correction L 0�- Fire Safety Corrections Dated- _ _ Have Been Complied With. Fire Safety Corrections ; } Were Discussed With and Disposition Will Be As Follows: �rr-S .` , tj, New Fire Safety Corrections Should Be Reinspection Indicates That ,�� } • Issued. See Reverse Side for Comments an New ire Safety Corrections. w GO -5 W1 7 REV 5/81 Deputy (3/0) Comnents and New Conditions: New Fire Safety Corrections. i 0-1 FI ICE CE OF STATE IRE MAR AL STATE FIRE MARSHAL RE SAFETY CORRECTION NOS p'E AME - --FILE NUMBER ADDRESS .• El EJ El 0 El El =.1 1:111oo aF]o':aoa 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 ( ) ISS ED BY (DEPUTY STATE FIRE.- MARSHAL) RECEIVED BY DATE EN -1 I (REV. 7/81). YEUOW: REGION WHOTE*- FACOUTY GREEN: IFIELD: 840,13-365 7-61 2,500TRIP CAM OT OSP "YY `-' -•• -v - +=+ vv:u� i Lcuit,c v�� = v�ti c4lr1Ji1 1VCCC1 (1 1. Zsi = uor action Noted C-0-.4 Item No. S� E TIO; TIME: INSPEC'1 D BY REVIEWED BY DATE DATE OFFICE For Office Use Only OF -Z -TATE FIRE MARSHAL FIRE & PANIC SAFETY NOARDS - INSPECTION REPORT NEW � DELET ANNUAL FOLLOW-UP PREY. INSP. DATE: F1 c p A 000 330 6 FACILITY NAME: _(0at �orT A,VD CCN -w ke5T ?cake. . PHONE. FACILITY ADDRESS: -' INTERVIEWED `�L e, S ,~ eet) W Affe i ty _ (zip) ACCOMPANIED BY INSPECTION OF INDIVIDUAL BUILDING - OCCUPANCY CLASSIFICATION I (T-24) NIGH RISE 1El INSPECTION OF ENTIRE FACILITY CONSISTING OF THE FOLLOWING BUILDINGS: FILE I.D. FILE I.D. FILE I.D. NO.BLDGS. OCC.CLASS. NO.BLDGS. OCC.CLASS. NO.BLDGS. OCC.CLASS. FILE I.D. FILE I.D. FILE I.D. NO.BLDGS. , OCC-CLASS. NO.BLDGS. OCC.CLASS. NO.BLDGS. OCC.CLASS. CHEC!C LIS _EM REF* N" I C ITEM REF N.N Iq CN. CFN !. ctua apathy 9,58 16. Housekeeping 52 . Basement 22 17. Pre -Fire Plan 53 i rine Protection Systems 23 18. Supervision/Staffing 56 _Exposures ;. Attics 24 19. Portable Fire Ext. 57 f of. 28 20.- 6. Interior Construction 29,30,31 21. ' Fire Assemblies 0,31,34 2 . I terior finish 32 23. H zardous Areas 40 24. _. c sting 30,43 25. __. F re Protective Sig- Sys. 44 26. . H(AC 45 27. :-17—E ect ri ca 46 28. D conative Materia s —ra 50 29.-- 9.oraae o g e 51 30. --D 4 UPDATE ON BLDGS NO. "ONME TS : VN DISPOSITION: GO -6 Attached CLEAR -REINSPECTION DATE CORRECTION NOTICE ESN -11 :attached AMBULATORY NONAMBULATORY TOTAL CAPACITY CAPACITY AGE RANGE (YEARS) CAPACITY AGE RANGE YEARS) PREVIOUS 'To 1E 18.to 65 65 &,Over To 1 18 to 65 65 & Over LP C ITY _. r, LE. RED :'P CITY A' -.L A__Z "YY `-' -•• -v - +=+ vv:u� i Lcuit,c v�� = v�ti c4lr1Ji1 1VCCC1 (1 1. Zsi = uor action Noted C-0-.4 Item No. S� E TIO; TIME: INSPEC'1 D BY REVIEWED BY DATE DATE j r �1 Oct .k �•� N n ; Sf• •1t r-•. .a- W �' Lt. Q Lo , •k w Lo .k - ..-� V,,, OG •jc U. ^ N Uj v LL. N W d• ._.• t!1 t.�.J CSC Cl G �✓ 4c E Ce •r- * U.. cn o • LL w C. o �-• in to a9 • W Q: QJL- m M E r LL •t— 4-3 � CL � r-- C d- tU C7 LLJ to •r.. . to of -- ♦C 4-3 C}" Lti L_ C to rd -k to `✓ IU 4-3 • r- a1 4-J U- Li., � G aU C c._ U L LLJ A cU .-- ^ (v ro L 4J a. u =3 LAG LU M 4-a M C71 0. L. ro > to u •.... 4A cap a u (a wry �/ ~� • V W •r- � �(1) i'w� V / CIJ Gnr-- c.t_ t- a) L V R 4a w u C. u o 0 Cf C) O r--• (U 0 •r-• u w Q1 Cl 4- 4-- 4-- 4-• 4--- vi r•- C3 i._ ;� QJ �--► �„) C l'... •r-• -0 4-3 •1--1 4-3 4-3 +-) •�~" -L? r•••- •r••• CT r-- •r-• •r-- •1--� 4-3 C M m res ro ro 4— rrs 41 (1) 4..3 r. 4 -a v ro r-- r-- I--- r--- I C: .la ru cv U 0 V) Cl- r L Lt- C.1_ CA- Cn E >) >-) • r- - n3 Q) r••-- 0 t.,.. L j � 1. `� � c m [... t- c- E. m 4-- _tom tU r-•- C?f dj cv •r.• r-• Qj M, CU (V E. ..--1 rn Cn M M L.n 4-1 4-- M Cn C n C n 4-J 4, 4J 4.3 -N rn fu m res r ra ro C Lr [.. i_ t.., to C C C C C 4-) •N 4, 4-) 4-J CV :5 = N tU CU (U (U QJ w v) cn c) cn c) v') � V) to V) V) w �-- }--• �-... �--- �. Ln C) i t t r i I F3- � M d• Ln to h+ 00 C�•' t0 C% C3 U C\t CSI Clq N (fit F-- N N N " N N CV 01 C\l --t E E E E E E 1••-• E F E E E E m E E E E E m (U a) cu W a cv cv cu Q.t aJ cli ai (U a a) cv �.1. H F-1 e...� 1--1 w �•-4 1'--1 H i• --i 1--� M p-•1 '�-1 - vfFICE OF THE STATE FIRE MARSHAL INSPECTION LOG Title File Address ��r�� 1.�.- Date Owner GO -6 (Rev. 5/81) J TIME I MILES I NEXT INSP. (MO. DA. YR.) 21. T "t- COPY DISTRIBUTION; ,: ,,,.SEE REVERSE OF COPIES 2 AND 3 FOR , .ARE MARSHAL /SAFETY INSPECTION REQ'UESTi1�.....STATE FIRE MARSHAL _r INSTRUCTIONS FOR COMPLETION - f )AT ' U . 2 • FIRE AUTHORITY' :' � 1. REQUEST DATE 2. PROGRAM i AND (NEW 6180) _ 1 3 LICENSING AGENCY A. 1../ 3. A 31ENCY CONTACT 4. TELEPHONE NO. 5. SIGNATURE 6. S FM REGION 7. SFM I.D. NO. 8. REQUESTING -AGENCY FACILITY NO. 9. EVALUATOR 19. REQUEST :. CODE t CODES 1. ORIGINAL A. FIRE CLEARANCE 2. RENEWAL B. LIFE SAFETY 10. AGENCY NAME ;' _-� '_Y' .l ` L 1�1i` `; t ; ` .;. ._:.- '., 3. CAPACITY CHANGE AND ;;, ; : t- ,; T T 4. OWNERSHIP CHANGE � ADDRESS 5. ADDRESS CHANGE 6. OTHER p°: ' �_ '` ._ '� i`'y .f `` ►_ '�' :j. ;_. �,t �' ` ` . J DATE OF ORIGINAL REQ. 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CA DACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS . - TO 18 18 TO 65 AND CAPACITY T018 18 TO 65 AND CAPACITY ; .65 OVER 65 OVER 20. FACILITY CODE ' 12. F CILITY NAME 13. NO. BLDG$. CODES 1. GACH 7. ICF/OT `-� j. 14. S 2- GACHIR 8. ICF/DD t REET ADDRESS 15. RESTRAINT 3. SH 9. ADHC N '...:, ;► ��" ._.1' ; v r - 4. APH 10. CLINIC CITY 5. PHF 11. JAIL ZIP CODE 16. HOURS 6. SNF 12. OTHER - 17. FACILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL v.. TO BE COMPLETED BY INSPECTING AUTHORITY FIRE 27. CLEARANCE 18. 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. INSPECTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T-19 OCC. ID NO. CLASS 1. EXITS Z. CONSTRUCTION 25.1 3. FIRE ALARM SP. DATE 26. INSPECTOR'S SIGNATURE ;, 4. SPRINKLERS 29. EXPLAIN 5. HOUSEKEEPING DENIAL OR LIST SPECIAL CONDITIONS ,,, - • 't\ t 1 1 "U I / 7 !I L•�� /1 Il 3 �^ < >t ! - 4. / ro_ ii : �. 1 6. SPECIAL HAZARD - 7. OTHER STATE FIRE MARSHAL USE ONLY J TIME I MILES I NEXT INSP. (MO. DA. YR.) 21. REGION, OFFICE AND ADDRESS J TIME I MILES I NEXT INSP. (MO. DA. YR.) ...... .... INSTRUCTIONS i This form is designed for use with a window envelope. To use, fold at marks ,.indicated in the left margin. , Licensing or Requesting Agencies m- 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 request was prepared. 2. PROGRAK, 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 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 = REINSPECTION REPORT OFFICE OF STATE FIRE Ib1t1]E3SHAI. 44'. 0(� 000 336 0 File-------------------------------- - ------ Date Reinspected -- � Px Name of Facility.... -- Cdr Far - ?" � e 4�E��C-ST �Jo4ij,& ------------------------ ---------------------------------------------------- - ---------------------------------------------------------------- -fC- k A M 4 C) r o P (1j. Address.--------------------------------------------------------------------------------------------- ---------'-------------------`- - 5------�'-�-----------�----------------------- C D I UJ V\q ot To A Conditions Discussed With ----------- ------------�----\--------�---------------------- Accom anied By_.---------------------------------------W------------�----P----h--. -,_---d.----"---T---i-t-l-e-------------------------'--�---- ---��---------------------t- ----------.------ -C---------- Inspection -i-�---`---' % Inspection --� -----�---�-f----�------- - This Date Discloses That Recommendations Number__._______�.1__Z_/.___�___��_/__�___�__b__________._�� L�) .................----------------------------------------------------------------------------------------------------------------------------------------------- of Recommendations Dated*--------- )- .-.- � � ---�- � 0 - Been Complied With. Recommendations Numbers A/ U ---------------C---,--j-------------------------------------------------------'--------------------------------------------------------------------------------- Were Discussed �VPAWith------------------ ((� � , ! 2 �' S � a1 t 4� w q r� Q With Disposition Will Be AsFollows---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- C) Nr k I � 6e; 4t,11) O�D-Qr - -- - ------------------------------------------------------------------------------------- ---- � X11 U N � �---� � �_ ,�}__ � � �----� ------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------- - --------------------------------------------------------------------------------------------- - --- -- - -------------------- ------- --------------- 40 -- ------------------------ -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ----------------------------------------------------------------- ---- ------ ------------ --- -----------------------------------------------------------------------.----- -- Reinspection Indicates That- _______�----------------------- New Recommendations Should Be Issued. See Reverse Side for Comments and New Recommendations. di. ej VrtAl-) GO- 5 _--------------------------------------------------------------------------------------------------- (3/ 7 4) Deputy Comm emtsand New Conditions: --'--- ---'------ -----------'-------- ----' ------------ ------' ---'---- ________ ---_-__--'�_----' ` - ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Nem ---------------------- _ ---'---------------------------------------- ------------------------------------------- _--- ----- ' 0 P SURVEY REPORT OFFICE OF STATE FIRE MARSHAL File Date Mau 21. 1 Q63 Deputy Ska-rai nk Name of Facility- Comfort and Cher Res _How Address 1882 Tehama Avenue u Ornv 11V IWO ww "so a .. _._-. IMF - Management dc's• Ada Lana Recom. and Copies to Bu •Rlitts- Countu Wa3 f2ras w w - & -{shied' Sharp, O rosins Fire DAD I . Insp. Requested by B=te Cor Weanaria Title Accompanied by Pelf Title BUILDING REPORT A B 1. Name of Bldg.Residence 2. Type Occupancy 3. Type Const. -Age 4.. Area of Building 5. Area of Basement 6. Stories in Height 7. Exterior Walls 8. Interior Walls 9. Floors 10. Roof Framing 11. Attic Separation 12. Vertical Shafts 13. Stair Enclosures 14. No. and Loc. Exits 15 . Corridors 16. Exit Doors & Hdwe. 17. Interior Finish 18. Autom. Sprinklers 19. Fire Alarm 20. Stage or Platform 21. Projection Booth. 22. First -Aid Fire Equip. 23. Exposures 24. Norm. and Actual Cap. 25. Ambulatory 26. Restraint 27. Surgery V N.H. 21 yzaarA 1340 go, fto - N _ On a "dFswWSowGB WFwGLPm-GLP W qn WD aw 2_ `i'., 6 O 0 K O . OAe 0*K0 SIR O OKS S/R Kone ,gee SA None Q * K O * K 6 o* 6 N o emn on ewamb None Common Hazards: Heating: Type 11n it Fue —Vent 0..,K.—Auto. Contro Clearances S 11 R Enclosure N Remarks: Electrical: Type Wiring Romax Circ. Prot. S /R Extension Cords O- K• Appliances OAKS Remarks: Housekeeping and Storage: • • General Comments: ( Number According to Front Page) T -h -a -a- is an existinw- fac-1111- Id hia s haen 1. iefmSa Welfare for vaars .. Q.tharwi ne .hs would be lj 19. rA"an"51_ mr.a _ an -q in phi iae ,qhn"-nt a IA_. Incorrect exit door hardware r 19, This facil-ity haa been licenned hr the welfar dp-nartmant --as foll 4 ambs In the mna n building 2 ambs in what they have called Cottace 1. This is a trailer -with the wheels . removed. Two men who do not want to be in the m& house have occupied this unit for some time. If no other arrangements can be made for these men to occuny a room in the main house Another unit--,, Cottage 2 is occupied by Mrs. Owens mother and fattier who are not considered as ffuests bar the waifara nsnsrt,mpnt _ '9i Electrical panel is over fused. '28. Space beater in livine room does not have suffic�.ent clearance front rux directly beneath. Enclosed hot water heater does hot ' have proper combustion air. Bed in east room used as a bedroom blocks the front exit . (agvd juo.cd o f Suspto.7oV .taquinN) : suoilquauiuioaalf