HomeMy WebLinkAbout039-460-017 CF Archive=IRE SAFETY INSPECTION REPO
Butte County Fire Department
California Department of Forestry and Fire Protection
_ _ Oroville, Caldomia 95965 • (530) 538-7888
Inspection Date: "--!5 -t)7
Business Phone: '1147 — O / a
NO.
CORRECTIONS REQUIRED
NQ
LOCATION / REMARKS
CLEAR®
UXATION
1 Provide address number&building I.D. visible from street
EXITING
`stairways,
2 Remove obstructions at exits, doors, aisles, etc.
3
Exit door to open without a key or any special Imowledgel effort.
4 Repair exit door hardware.
5
Remove obstructions from door required to be closed.
6 Remove lock&Wches from doors with panic hardware.
7
Provide sign over main e<it door - `This door to remain unlocked during
business hours".
/ J
8
Remove storage from under unprotected staff
9 Providelmaintain? � em lighting.
`FIRE EX WGUMHERS
10
Have fore s serviced and tagged.
REaNSPECTION DATES
INSPECTOR
11
Provide/mount fire adinguisher as indicated.
1st
Z //V p
J
oS ' Cie 11 -J
12 Post a sign indicating fire extinguisher location.
13
Provide dear access to fire ednguisher.
2nd
FIRE PROTECTION EQUIPMENT
14
Maintain, repair, paint, mspect, andADr test sprinkterfshandpipe
systemftdrant/FDC/PIV.
Refer to FPB
15
Maintain 3 feet minimum clearance for access/use of fire
appliances/equipment.
District Attorney
16
Replace damagedrpaintedrmssing sprinkler heads/FDC raps.
Final Clearance
17
Provide 5 -year certification test for inkler/sha em.
I Occwxwclws ' _
❑ Check Pre -Fire Plan for accuracy.
18
Provide spare sprinklerbeads min. ardor compatible wrench.
BY ORDER OF THE FIRE CHIEF
You are hereby notified to correct all violations immediately or show cause
why you should not be required to do so. A reg ion will be conducted
on Willful failure to comply with this notice is a
misdemeanor. Violations that are not corrected immediately and/or remain
after the re -inspection may be processed as a criminal offense. Thank you
for your assistance and cooperation in minim¢rrrg the fire and Tile loss in
your community.
19 Hoodrduct edinguishing system to be serviced/ tagged every 6 mo.
20 Remove grease from hood, dud, and filters. KEEP CLEAN)
FIREALARM SYSTEMS
21 Maintain, repair, inspect, ardor test fire alarm system.
FIRE SEPARATIONS
22 Repair holes in required fire resistive construction.
23 Provide! it self or automatic closing fire rated assemblies.
24 Keep attic access and scuttle openings closed.
ELECTRICAL
Signature of Recipient
25 Discontinue use of extension cords.
26
Installpermanent wiri for fixed and stationary appliances.
❑ Owner ❑ Ma r OEmployee ❑ Other
27
Provide cover plates for all junction boxes.
Inspecting Officer,
? -SO L ---A fib
28 Remove exposed wiring or protect in approved conduit.
29
Provide a 30 -inch clear space to and in front of electrical panel.
FPB: Engine Com
30
Maintain wiring in good condtion and protect from damage.
❑ NO VIOLATIONS NOTED THIS DATE
THANK YOU FOR BEING FIRE SAFE!
FLAMNABLE LIQUIDS • COMPRESSED GASES
31
Provide a flammable liquid storage cabinet or reduce storage to 10 gallons or
less.
Additional Comments:
// `
C G 11 o vt h/l 0. 2) 1Z v37
Page of
32 Remove all flammable licluids not used for maintenance purposes.
33 Store flammable liquids away from exits, stairs, or corridors.
34 Secure compressed inders.
STORAGE + HOLMEKEEPW
36 Arrange s in an orderly manner to provide access/
36 Remove combustible storage from water heater and electrical room.
37 Remove storage to 24 inches below ceiling or 18 inches below sprinkler herds.
38 Remove linf/debrs from behind washers and dryers -
39 Remove waste/rubbish materials from the premises.
40 Keep dumpsters 5 feet away from combustible wails, eaves, or openings.
MISCELLANEOUS
41 Other violations ardor comments.
Business Addre
Busir>ess Name.
Owner/Property,
`IRE SAFETY INSPECTION REPOT*-*
Butte County Fire Department
Ca6fomia Department of Forestry and Fire Protection
Oroville, California 95965 • (530) 538-7888
OA•?CJ _ Cffy:
Inspection Date: 17-- t.. ` ".:
Business Phone: kq 41 Orlq
AP#:
NO.
CORRECTIONS REQURED
N4
LOCATION I REMAM
CLEAR®
LOCATION_
ri-�l A C ryL't U y� i ��C.
. ALL li rJ
1 Provide address num I.D. visible from street
EXff1ihIG
VA LN,,aC:*14
2 Remove obstructions at exits, doors, aisles, , etc.
3
Exit door to open without a key or any special krrowledgel effort.
;-em-c' , rt
4 Repair exit doorhardw-&e.
5
Remove obstiutions from door required to be closed.
! !
6 Remove bcksllatches from doors with panic hardware.
7
Provide sign over main exit door -'Ths door to remain unlocked during
business hours".
�(,A',{ q
.. y
t7r l L
8
Remove StWdge from under unprotected stairhW.
r,? ti l c.. :'�?. +r -Y ++ "� • a�
Z
9 ,i Providelmalntain eds
EXTINGLISHERS
10
Have fire s serviced and
RUNSPECfION DATES
INSPECTOR
11
r' Providelmount fire eKtinguisher as indicated.
1st
Z zol u C
12 Past a s n indicating fire extinguisher location.
13
Provide dear access to fire esti fisher.
2nd
2/�-/G 7
FIRE PROTECTION EQLMWM
14
Maintain, repair, paint, inspect, anchor test spnnklerMarx*gpe
systemlhydranNFDC/PIV.
Refer to FPB
15
Maintain 3 feet minimum clearance for access/use of fire
appliances/equipment.
District Attorney
/ !
16
Replace damaged/paintedlmissing sprinkler hea&.4-M caps.
Final Clearance
17
Provide 5- ear certification test for nkkc!dsha em.
Cfess `.
❑ Check Pre -Fire Plan for accu
18
Provide spare spilinkler heads min. q ardor oornpatiole wrench.
BY ORDER O F THE FIRE CHIEF
You are hereby notified to correct all violations immediately or show cause
why you should not be required to do so. A reinspection will be conducted
on . Willful failure to comply with this notice is a
misdemeanor. Violations that are not corrected immediately and/or remain
after the reinspection may be processed as a criminal offense. Thank you
for your assistance and cooperation in minimizing the fire and life loss in
your community.
19 Hood/duct eDdinguishing system to be serviced/ tagged every 6 mo.
20 Remove rease from hood, duct, and filters. KEEP CLEA
FIREALARM SYSTEMS
21 Maintain, repair, inspect, ands test fire alarm system.
FIRE SEPARATIONS
22 Repair holes in required fire resistive construction.
23 Provide) it self or automatic closing fire rated assemblies.
24 Keep attic access and scuttle openings closed.
ELECTRICAL
Signature of Recipient
25 Discontinue use of edersion cords.
26
Install permanent wiring for fixed and stationary appliances.
❑ Owner ❑ Manager ❑ Employee ❑ Other
27
j_/1 Provide cover plates for all junction boxes.
Inspecting Officer:
28 Remove exposed wiring or protect in approved conduit.
29
Provide a 3Nnch dear space to and in front of electrical panel.
FPB: Engine Com
30
Maintain wiring in good condfion and protect from damage.
❑ NO VIOLATIONS NOTED THIS DATE
THANK YOU FOR BEING FIRE SAFE!
FLAMUABLE LIQUIDS - COM PREM GASES
31
Provide a flammable liquid storage cabinet or reduce storage to 10 gallons or
less.
Additional Comments:
Z
!Jr f Q� v UCEAT j7J
30
Ut SILAF7 LA APso.,5
Page of
32 Remove all flammable liquids not used for maintenance purposes.
33 Store flammable liquids from exits, stairs, or corridors.
34 Secure compressed gas qinders.
STORAGE r HOUSEKEEPING
35 Arrange storage in an orderly manner to provide access/
36 Remove combustible storage from water heater and electrical room.
37 Remove storage to 24 inches below oeilrg or 18 inches below sprinkler heads.
38 Remove lint/debris from behind washers and dryers.
39 Remove waste/nbbish materols from the premises.
40 Keep cumpsters 5 feet away from combustible walls, eaves, or openings.
41 Other violations and/or comments.
U
Fire Prevention Bureau 3utte 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
Address:
t�4rahiiQrve /ii�i3 Business Name: '1�02r0r.:': ALr`,
Owner/Manager: O_T.Cxc N� Y Nanta Bus: , c; ( Hm: �q L./ -Z7 7_& Fax:
Assistant Manager: Bus: Hm:
Building Owner: Bus: Hm:
Address: <!� s; s s Z •,' 2:� r 3 I I:. ,r,
AN UVQPF.f T1nN nF vnITR FAC H.ITY RF,VEALFI) 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.
Fire walls, ceilings, fire doors, draft stops
16.
Heating system: Defective appliance, flue combustibles
4 �8Knox
Box keys
17.
Address posted and visible from road
9.
Fire Drill Witnessed Yes No 0
18.
Other
DETAILED EXPLANATION AND CORRECTIONS: I:VKKi4.l.IEM:
�, - ,yJ��r-f E �::;� F � r�t�,��, �� �,�� ��R _ ro SG.1�,�i�b �W;�. p•- p �
-POST J`1-i2G_>i
�7--cc_ 17
13
X471. � •'f � Gi'lii I�GoJL h/f�;�JZ F� a�.-Ui. l� C:'•11 /�H K LCIL IC -i F1'i1 �:'ti P� �'il�/�JZs�
Ai
Date: Discussed with: Signed:
V S(Print) Clrl1L (
Inspecting Officer:
Battalion 1 23 4 5 6 7 Station: FPB
FIRE PREVENTION SAVES LIVES, PROPERTY, AND BUSINESS. YOUR COOPERATION WITH
CORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE:
Fire Prevention Bureau
176 Nelson Avenue
Oroville, CA 95965
Telephone 530-538-7888
Fax 530-538-2105
Address: c. S
Owner/Manager:
Assistant Manager:
Building Owner.
wak
Butte County Fire Rescue
California Department of Forestry—
and Fire Protection
Facility Inspection Report
Business Name:
Bus: = q 4 L
Bus:
Bus:
White Copy - Business
Yellow Copy — Occupancy File
Pink Copy — Station File
Occ. Class. 17= - . I, ',
°r6g1q-
Hm:
Hm:
Z Lo I Fax:
Address: �1 Y.. a : h ) + A� ZAA \"I A", � -A
AN TA1Qp11!`9PTl1N nF V(1TT12 FACTLITV RFVFAI.FD 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 tl
18.
Other
I DETAILED EXPLANATION AND COKKEUTWIN J: U"I KL' U 11 rim:
Date:
Discussed with:
Signed:
U
rint p
_
n
Inspecting Officer:
Battalion 1 2,113'; 4 5 6 7
Station: FPB
7,
FIRE PREVENTION SAVES LIVES, PROPERTY, AND BUSINESS. YUUK UOUrtHATMIN Wlltt
CORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE:
BUTTE COUNTY FIRE DEPARTMENT/CDF FIRE
TITLE 19/24
INSPECTION NO. 1 2 ,,
FACILITY INSPECTION _
REINSPECT: YES L NO
/, if
Facility (fdQ,/ ,*1P- C,,�.2 ;,e Occupancy -.-
Address� !�""Doe-band pv Inspector
PhoneStation
Contact 77-44V, IV,. 155on/ 47, .:ai -/42.6+ Station Phone
Compliance: Yes =.4f
ACCESS --All inspections
`r�Address correct/posted and visible from road (Butte Co. Code 32-9)
JZ Access to public street or 20 ft. wide lane (T19 -3.o5)
Gates wide enough to admit fire apparatus (r19-3.16)
(\J,, t' Fire protection equipment visible/accessible (r19-3.14)
PORTABLE FIRE EXTINGUISHERS -- All Inspections
Extinguishers have current annual service tag (r19 -575.1A)
No = 0 Not applicable = N/A
ELECTRICAL --All inspections
Extension cords do not replace permanent wiring (CEC-40o-8(1))
Extension cords do not pass through doors/wails (CEC-400-8 (2,3))
30 inch clearance around all electrical panels (CEC-110-16A)
._ All panels and breakers are marked (CEC-110-17 C)�� i
1� Repair holes in fire -resistive construction CEC (300-21,22) 4;
77"
_Multi -plug power strips have circuit breaker (CEC 400-13)
Maximum travel 75 ft. (r19-567)
Provide clear access to fire extinguisher (r19-563.2)
Extinguishers mounted on wall/or in cabinet, visible and signed (T19-563.8)
EXITS --All Inspections
Exits not obstructed (r19-3.11) bG
LlExit signs in place (CBC 1003.2.9.1) ,, eej- L)^., cp--e, r' c�vt
13 Doors operate without key or special knowledge (CFC 1207.3)
Rooms with Occupant Load of 50 Persons or More
Exit illumination and signs in place (CBC 1003.2.8.2)
Maximum occupancy sign in place (r19-3.30)
Two exit doors/panic hardware swing in direction of travel (CFC 2501.8.2)
HOUSEKEEPING --All Inspections
No waste or rubbish accumulation inside or outside T19-3.14)
�7t 6a Reduce storage to at least _" below ceiling/ sprinklers (r19-3.14)
` Remove combus. storage from heater, mech., elect. room (r19-3.190
Loof' Provide approved metal container for oily rag storage (T-19-3.190)
Flammable liquids stored properly (T-19-3.15)
FIRE PROTECTION EQUIPMENT -- All Inspections
� -Hood system serviced/tagged every 6 mo. by cert. tech. (r19-904)
Clean filters, hood, and duct area over cooking appliances (CFC 1006.2.8)
)
Maintain extinguishing systems (r19-3.24)
Provide spare sprinkler heads (6 min.) and/or sprinkler wrench (T19-904.5)
Replace damaged, corroded, or painted sprinkler heads (T19-904.5)
Identify sprinkler valves and secure in open position (r19-904.5)
Replace missing caps on fire department connection (r19-904.3)
Provide 5 -yr. certification test for sprinkler/standpipe (r19-904)
MECHANICAL EQUIPMENT -- All Inspections
,-' Vents and chimneys -- No obvious hazards (CMC -Ch. 8)
SMOKE DETECTORS -- Day Care Sr. Res., Hospitals, Apts.
Properly installed and tested (r19-749, 754)
Pleed r'we ham!/
SCHOOLS, JAILS AND HOSPITALS
Decorations and curtains fire retardant (T19-3.08)
LPG tanks fenced with locked gates (r19-3.22)
FIRE DRILLS -- School and Day Care (Title 19-3.13)
All systems operable/hooked to office
Held monthly (elementary schools)
Held semi-annually (high schools)
Ief Evacuation plans posted in all rooms
Emergency procedures posted in office
AJ`6k`Teachers take roll books
Corrections and Comments Th gr4r- ry--s. S
116
The above deficiencies must be corrected within �f ays. Inspection Date:
,ner/Manager AIS #
31
l
BUTTE COUNTY FIRE DEPARTMENT/CDF FIRE
TITLE 19/24
FACILITY INSPECTION
INSPECTION NO. 1 2 3
REINSPECT- /' YES L] NO
Facility Occupancy
Address Inspector
Phone Station_', — .w
Contact Station Phone
Compliance: Yes =-It
ACCESS --All inspections q
U tAddress correct/posted and visible from road (Butte co. Code 32-9)
' Access to public street or 20 ft. wide lane (T19-3.05)
Gates wide enough to admit fire apparatus (T19-3.16)
Fire protection equipment visible/accessible (r19-3.14)
PORTABLE FIRE EXTINGUISHERS --All Inspections
No = 0 Not applicable = N/A
ELECTRICAL --All inspections
Extension cords do not replace permanent wiring (CEC-400-8(1))
V=—Extension cords do not pass through doors/walls (CEC-400-8 {2,3))
30 inch clearance around all electrical panels (CEC-110-16A)
r3 All panels and breakers are marked (CEC-1 ) 0-'17 C)
Repair holes in fire -resistive construction CEC (300-21,22)
Multi -plug power strips have circuit breaker (CEC 400-13)
Extinguishers have current annual service tag (T19 -575.1A)
Maximum travel 75 ft. (T19-567)
Provide clear access to fire extinguisher (r19-563.2)
Extinguishers mounted on walUor in cabinet, visible and signed (T19-563.8)
EXITS -- All Inspections
Exits not obstructed (T19-3.11)
Exit signs in place (CBC 1003.2.9.1)
Doors operate without key or special knowledge (CFC 1207.3)
Rooms with Occupant Load of 50 Persons or More
Exit illumination and signs in place (CBC 1003.2.8.2)
Maximum occupancy sign in place (r19-3.30)
Two exit doors/panic hardware swing in direction of travel (CFC 2501.8.2)
HOUSEKEEPING —All Inspections
No waste or rubbish accumulation inside or outside T19-3.14)
Reduce storage to at least "below ceiling/ sprinklers (r19-3.14)
Remove corrmbus. storage from heater, mech., elect. room (T193.19f)
Provide approved metal container for oily rag storage (r -19-3.19c)
Flammable liquids stored properly (T-19-3.15)
Corrections and Comments
FIRE PROTECTION EQUIPMENT --All Inspections
Hood system serviced/tagged every 6 mo. by cert. tech. (T19-904)
Clean filters, hood, and duct area over cooking appliances (CFC 1006.2.8)
Maintain extinguishing systems (T19-3.24)
Provide spare sprinkler heads (6 min.) and/or sprinkler wrench (T19-904.5)
Replace damaged, corroded, or painted sprinkler heads (T19-904.5)
Identify sprinkler valves and secure in open position (T19-904.5)
Replace missing caps on fire department connection (T19-904.3)
Provide 5 -yr. certification test for sprinkler/standpipe (T19-904)
MECHANICAL EQUIPMENT -- All Inspections
Vents and chimneys -- No obvious hazards (CMC -Ch. 8)
SMOKE DETECTORS -- Day Care Sr. Res., Hospitals, Apts.
Properly installed and tested (T19-749,754)
SCHOOLS, JAILS AND HOSPITALS
Decorations and curtains fire retardant (r19-3.08)
LPG tanks fenced with locked gates (r19-3.22)
FIRE DRILLS -- School and Day Care (Title 19-3.13)
__.All systems operable/hooked to office
Held monthly (elementary schools)
Held semi-annually (high schools)
Evacuation plans posted in all rooms
Emergency procedures posted in office
Teachers take roll books
The above deficiencies must be corrected within days. Inspection Date:
Owner/Manager AP #,
0.1
' BUTTE COUN TY FIRE DEPARTMENT/CIT; FIRL.
TITLE 19/24
FACILITY INSPECTION
Facility ., r --� rl'�/:; C:. <,t ••- `w'► '�. -u •�'
! rim
r
Address "2�, �• it'' �i;fir ► -->�o �-� �-! :�t
Phone 'i le'
ContactI c�-f J�1 1 �s �.^ �.•, / o .e. l�
l�•�SP C,T10N N0 2 3
............
RE -INSPECT. YE -•'' NO
Occupancy --
Inspector
Station 1
Station Phone L� f ''"' - �'�-•"�
Compliance: Yes =44f No = 0 Not applicable = NSA
ACCESS --All inspections � 1 j
Nee /�'S _r o be- r2ar-� a
Address correcposted and visible from road (Butte co Code
V Access to public street or 20 ft. wide lane (r19-3.05)
1�Gates wide enough to admit fire apparatus (T19-3 16)
jV - Fire protection equipment visible/accessible (T19-3 14)
ELECTRICAL --All inspection p ;.� - �•— o r ' f
!+ �_ , ,-; ,_� t- ,��• �. ' ; ,, • � CJ's r C. f � .
. L��✓ �7
` Extension cords d10 not replace permanent .wiring (CEC-46C-8(1) '
•�' Extension cords do not pass through doors/walls (CEC-400-8 (2.3))
30 inch clearance around all electrical panels cc cc -110. 16A) L C`- ro�'�
All panels and breakers are marked (c.t:c_110-'S I c)
Repair holes in fire -resistive construction CEC ;300-21.22) O le 'J ir -
P 4 -
Multi -plug power strips have circuit breaker (CEC 4ea-13)
✓
PORTABLE FIRE EXTINGUISHERS -- All inspections
Extinguishers have current annual service tag (T19-5751 A)
Maximum travel 75 ft. (T19-567)
1/ Provide clear access to fire extinguisher (T1C9-563.2)
_Extinguishers mounted on wall/or in cabinet, visible and signed (T15-563 8)
EXITS --All inspections
Exits not obstructed (T123.11) _`� ✓� ' � 1 .� '
Exit signs in place (CSC 1003 2.9.1)t.!:.G1 1% t.tiff "t
Doors opera a without key or special knowledge (CFC 1207 3)
'
�' -✓ 0 G 1 C,,1J C COY
Rooms with Occupant Load of 50 Persons or More
Exit illumination and signs in place (CBC 1003.42.8.2)
FIRE PROTECT ION EQUIPMENT -- All Inspections
Hood system serviced/tagged every 6 mo. by cert. tech. (T19-904)
_Clean filters, h*od, and duct area over cooking appliances (CFC 1006.2 81
fMaintain extinguishing systems ; n9-':. -a)
i Provide spare sprinkler heads (6 min.) and/or sprinkler wrench (1-1q-904 5)
�L Replace damaged, corroded, or painted sprinkler heads (T19-904.5)
Identify sprinkler valves and secure in open position (T19-904.5)
Replace missing caps on fire department connection (T19-904.3)
„Provide 5 -yr. certification test for sprinkler/standpipe (T19-904)
MECHANICAL EQUIPMENT -- All Inspections �
Vents and chimneys -- No obvious hazards (CMC -Ch. 8)
Maximum occupancy sign in place (T19-3.30) SMOKE DETECTORS -- Day Care Sr. Res., Hospitals, Apts.
7Two exit doors/panic hardware swing in direction of travel (CFC 2501 8.2) -1 !.
Properly installed and tested 8,19- 49. 754) . N.A.. V
1 • � . 1. , / � � • ~� / � /•/••• •.. ,'^
HOUSEKEEPING -- All Inspections
No waste or rubbish accumulation inside or outside T19-3.14)
-1/4 Reduce storage to at least " below ceiling/ sprinklers (T19-314)
Remove combus. storage from heater, mech., elect. room (T19 -3.19f)
Provide approved metal container for oily rag storage J -19-3.19c)
Flammable liquids stored properly (T-19-3.15) C�JeC-;;i r ,;;� I.r
�5to
�oG1 � !off GLr E �• � /-oG 1 � � �-.{�.-.
N -C6 t � Ov off-
U
SCHOOLS, ,TAILS AND HOSPITALS
i
Decorations and curtains fire retardant (T13-3 08)
LPG tanks fenced with locked gates (T-19-3.22)
FIRE DRILLS -- School and Day Care (Title '19-3.13)"
All systems operable/hooked to office
Held monthly (elementary schools)
Held semi-annually (high schools)
Evacuation plans posted in al! rooms
Emergency procedures posted in office
Teachers take roll books
-��
Corrections and Comm751010 rn rr� ; jo C_�'' !fir -r7•' �- t ; �': ,� • ••r:. ; ,._� , .,.: j ... ��,
& ee
G 1
Q /� Q
•,w l �� /� �i� �� I {` I + }� ;4 tL01
,.! l / •�r f ��' i ,, i r�("S�" %r`f i' T i : r: •' 1
r 1
4no- A10 / f� • .i '•'""• 'f ��1.�'r r` / i�-,'�''• r " �J�' f 1� r 1 1 l , , �. :.,�,•� pt I
rid
Th6 above deficiencies must be corrected within days. Inspection Date- 02 -/. -'a 7
Owner!Manager ��l �� / AP #
r
Bill Orthel
To: Fowler, Steve
Cc: BTU Durham Stn; orthel, Bill
Subject: Title 19 inspections
Steve, The Clear Creek facility is done.
The Northern Cailf. adaptive living has a few more items to be corrected. I have a couple of
questions.
1. They removed the dead bolts on the regular exit doors but they still have the regular knobs with
the lock knob in the center. Do these need to be replaced? The sliding glass door has regular locks.
Is their something special for sliders?
2. They have an outside freezer where the cord runs through the equipment room door to an inside
outlet. I advised them this should be replaced with an outside gfi outlet. Just checking for a second
opinion?
I'll put the folders in your box.
gn v e,* "
wg/.Aaffe ('a.. 9 /.r/i'eacue
..l?altafrooiz Y&M
1
i'
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BUTTE COUNTY FIRE DEPARTMENT/CDF FIRE
TITLE 19/24
FACILITY INSPECTION
INSPECTION NQ..;�1 ,� 2 3
REINSPECT. :YES NO
n r 1
Fa ci I ity -/' - r�J':,'.�.,' ,'-�'` fir Occupancy
Address �= �r.?^-1 L' , --�-o +� ,�A to " Inspector ;; .'
Phone �,-,;r, f G '. Qi 4� - Station 1,, %
Contact ��,.• i`l,' ! 5-S4:�Pnj 4, 9-� /ate h Station Phone
Compliance: Yes =crf
ACCESS --All insFp
ctions
Ivece
6e re -P V
Address correc sted and visible from road (Butte Co. Code 32-9)
Access to public street or 20 ft. wide lane (T19-3.05)
10' Gates wide enough to admit fire apparatus (T19-3.16)
4�. Fire protection equipment visible/accessible (T19-3-14)
PORTABLE FIRE EXTINGUISHERS --All inspections
Extinguishers have current annual service tag (r19 -5751A)
No = 4 Not applicable = NIA
ELECTRICAL. --All inspection
0 r -k
40 Extension cords do not re�ace permanent wiring (CEC-40-8(1)
Extension cords do not pass through doorstwalls (CEC-400-8 �,3))
9 r. �
30 inch clearance around all electricalp anels (CF -C.1
CEC.•110-16A d L �'�- �d c'
t '��� f CJ CJ J'• � � t..i f V
..i All panels and breakers are marked (CEC-110-17 C) r
Repair holes in fire -resistive construction CEC (300-21,22) k O ti r
_Multi -plug power strips have circuit breaker (cEc 4e0-13)
_Pr a&,
Maximum travel 75 ft. (T19-567)
l/ Provide clear access to fire extinguisher (T1;9-563.2)
_Extinguishers mounted on wall/or in cabinet, visible and signed (T19-563 8)
EXITS -- All Inspections
Exits not obstructed fr19-3.11) _`14:d ril- C;
j .,.�
Exit signs in place (CBC 1003.2.9.1)�'�t��'-6" �c�''� ��� �l ('J`� tj
Doors opera;e without key or special knowledge (CFC 1207.3) of.j 4
I #
0 ov,--
Rooms with Occupant Load of 50 Persons or More
Exit illumination and signs in place (CBC 1003.2.8.2)
Maximum occu anc si n in lace 19-1212
0
FIRE PROTECTION EQUIPMENT -- All Inspections
Hood system serviced/tagged every 6 mo. by cert. tech. (T19-904)
-Clean filters, hood, and duct area over cooking appliances (CFC 1006.2.8)
Maintain extinguishing systems j14 -4)
Provides aresprinkler heads (6 min.) and/orsprinkler wrench R19-904 5
)
Replace damaged, corroded, orP
ainted sprinkler heads (r19-904.5)
P
i Identify sprinkler valves and secure in open position CT19-904.5)
Replace missing caps on fire department connection R19-904.3
)
Provide 5 -yr. certification test for sprinkler/standpipe (T19-904)
MECHANICAL EQUIPMENT -- All Inspections
C
� Vents and chimneys -- No obvious hazards (CMC -Ch. 8)'; . .,
I�.
P y to P R) SMOKE DETECTORS -- Day Care Sr. Res., Hospitals, Apts.
Two exit doors/panic hardware swing in direction of travel (CFC 2501 8.2) , � c��
Properly installed and tested (T19-749.754) ; �,..�; C ,
1't .--r i r�•C, 0), f �• j rl f,
�•; r:
-a
HOUSEKEEPING --All Inspections
No waste or rubbish accumulation inside or outside T19-3.14)
-�\J/Q- Reduce storage to at least " below ceiling/ sprinklers (T19-314)
Remove combus. storage from heater, mech., elect. room (T19 -3.19f)
r pp Provide approved metal container for oily rag storage (T -19-3.19c)
SCHOOLS, .TAILS AND HOSPITALS
Decorations and curtains fire retardant (T19-3.08)
LPG tanks fenced with locked gates (T19-3.22)
FIRE DRILLS -- School and Day Care (Title 19-3.13)'
Flammable liquids stored properly (r-19-3.15) IV All systems operable/hooked to office
w -00 r )/V A) Held monthly (elementary schools)
Held semi-annually (high schools)
Evacuation plans posted in all rooms
14 5.. Emergency procedures posted in office
Teachers take roll books
Corrections and Comme ,5,43 M A + 0 r-:?
e0l �j d�
jts
Tht above deficiencies must be corre
4 )CX ", (
ed within /Z/ days.
It
Owner/Manager Al 1 1..f�oj
os~�ikA?
i'
�Aq Z"e-ple :"7
Inspection Date: / A "/,"-~ a G
AP #
;X�
BUTTE COUNTY FIRE DEPARTMENT/CDF FIRE
TITLE 19/24
t =YFACILITY INSPECTION
V
INSPECTION NO. 1 2 3
REINSPECT: YES NO
_ I e 1 ��,1, '1*Ve Occupancy lik
Address 4te),' ,,?;.- f. 1�� InspectorJI
`
Phone f? 0 Station �-
Contact j e .�
"-`, rp.."Station Phone
. �
Compliance: Yes =14t
ACCESS -- All inspections _
Address, correct/posted and visible from road (Butte Co. Code 32-9)
Access to public street or 20 -ft. wide lane '(T1 9-3.05)
Gates -wide enough to admit fire apparatus (T19-3.16)
!- 'Fire protection equipment visible/accessible (T19-3.14)
,r•
PORTABLE FIRE EXTINGUISHERS -- All Inspections
No = 0 Not applicable = N/A
_r0Extinguishers have current annual service tag (T19 -575.1A)
11-Z •Maximum travel 75 ft. (T19-567)
.. Provide clear access to fire extinguisher (T19-563.2)
1 extinguishers mounted on wall/or in cabinet, visible and signed (T19-563.8)
EXITS -- All Inspections
Exits not obstructed (T19-3.11)
'=Exit signs in place (CBC 1003.2.9.1)
Doors operate without key or special `knowledge (CFC 1207.3)
Rooms with Occupant Load of 50 Persons or More
./Exit illumination and signs in place (CBC 1003.2.8.2)
l Maximum occupancy sign in place (T19-3.30)
3l
Two exit doors/panic hardware swing in direction of travel (CFC 2501.8.2)
f '•
HOUSEKEEPING -- All Inspections
4
1No waste or rubbish accumulation inside or outside T19-3.14}
t°J Reduce storage to at least _" below ceiling/ sprinklers (T19-3.14)
It
r Remove combus. storage from heater, mech., elect. room (T19 -3.19q
Provide approved metal container for oily rag storage (T -19-3.19c)
—Flammable liquids stored properly (T-19-3.15)
ELECTRICAL --All inspections
Extension cords do not replace permanent wiring (CEC-400-8(1))
Extension cords do not pass through doors/walls (CEC-400-8 (2,3))
ti f.
.� " 30 inch clearance around all electrical panels (CEC-110-16A)
_ Allpanels.aneaer�`are marked �cEd-ilo-rrc` •
•; ,..._
a =• :v ; : •.,.f ,r ice,.%: r:i. /
V" Repair holes in fire -resistive construction CEC (300-21,22)
V`0 Multi -plug power strips have circuit breaker (CEC 400-13)
FIRE PROTECTION EQUIPMENT —All Inspections
�Hood system servicedltagged every 6 mo. by cert. tech. (T19 -9o4)
_Clean filters, hood, and duct area over cooking appliances. (CFC 1006.2.8)
+Maintain extinguishing systems R19-3.24)
s
Provide spare sprinkler heads (6 min.) and/or sprinkler wrench (T19-904.5)
Replace damaged, corroded, or painted sprinkler heads (T19-904.5)
.-i-Identify sprinkler valves and secure in open position . (T19-904.5)
s'
Replace missing caps on fire department connection Cr19-904.3)
Provide 5 -yr. certification test for sprinkler/standpipe (T19-904)
MECHANICAL EQUIPMENT -- All Inspections
/Vents and chimneys -- No obvious hazards (CMC -Ch. 8)
SMOKE DETECTORS -- Day Care Sr. Res., Hospitals, Apts.
.�� Properly installed and tested (T19-749,754)
SCHOOLS, JAILS AND HOSPITALS
Decorations and curtains fire retardant (T19-3.08)
LPG tanks fenced with locked gates (T19-3.22)
f
FIRE DRILLS -- School and Day Care (Title 19-3.13)
All systems operable/hooked to office
-..---,Held monthly (elementary- schools):
Held semi-annually (high schools)
Evacuation plans posted in all rooms
Emergency procedures posted in office
'Teachers take roll books
?0000"
� J`` .. • ,� r.I'�_ {r �,y.4� f J t � �„�,�,ld.�-'�•Ms�' ,:�' I�, • �� �', j ���,' f '����• .- —.«. ••l . f � 1
Corrections and Comments 4 �v
is
The above deficiencies must be corrected within I - l days.
Owner/Manager .;::� �`.� :� �_, •.f -
Inspection Date:
AP #
STJE
FI F
OF CALIFORNIA
CAFFTV lhlQPPPTIANI DGBL ir- r
COPY DISTRIBUTION: �+- SEE REVERSE OF COPIES 2 AND 5 FOR
INSTRUCTIONS FOR COMPLETION
STD
1-3-OIAIt I-IHt MAHZ511AL
850 (REV. 3-93) 2 -FIRE AUTHORITY
1. REQUEST DATE
2. PROGRAM
4 -5 -LICENSING AGENCY
3. AGENCY
CONTACT
14. TELEPHONE NO.
5. EVALUATOR
SS/COMMUNITY CARE LICENSING
(916)895-5033
207/CALDWELL
6. 5
M REGION
7. SFM I.D. NO. -
8. REQUESTING AGENCY FACILITY NO.
9. REQUEST CODE
041370178
2
CODES
1. ORIGINAL A. FIRE CLEARANCE
2. RENEWAL B. LIFE SAFETY
10.
GENCY DEPARTMENT OF SOCIAL SERVICES
3. CAPACITY CHANGE
4. OWNERSHIP CHANGE
AME COMMUNITY CARE LICENSING
S. ADDRESS CHANGE
AND
520 COHASSET ROAD, SUITE 6
6. NAME CHANGE
DDRESS L CHICO, CA 95926
PREVIOUS NAME
7. OTHER
DATE OF ORIGINAL REQ.
11. P
MBULATORY NONAMBULATORY
TOTAL CAP.
DATE OF LAST FIRE CLEARANCE
CAPACITY
MEDICAL CARE
PREVIOUS CAPACITY
MEDICAL CARE
PREVIOUS
CAPACITY
CAPACITY
1
1 e. CODIEITM L 3
❑ YES El NO
r]YES El NO
6
06
740
12. FACILITY
NAME
13. NO. BLDGS.
CODES
N
RTHERN CALIFORNIA ADAPTIVE LIVING CENTER INC
1
1. GACH 9. ADHC
2. GACH/R 10. CLINIC
14. E
rREET ADDRESS (ACTUAL LOCATION)
P.O. BOX
15. RESTRAINT
265
DURHAM DAYTON HIGHWAY
0
3. SH 11. JAIL
4. APH 12. ICF/DDN
CITY
ZIP CODE
16. HOURS
D
JRM
95938
24
S. PHF 13. RCF
6. SNF 14. CCF
7, ICF/OT 15. DAF
17. F
CILITY CONTACT PERSON
TELEPHONE NO.� qK
16A. SPECIAL
JIM
HAYES
(916)894-2726,
8. ICF/DD 16. OTHER
TO BE COMPLETED BY
18. F
IK ' �^ C f
RE J Ad< I 1 I �J �, /
_f
INSPECTING AUTHORITY
26. CLEARANCE
CODE
A
NAME
THOR v `.rL�
LL is � S bury L�
CODES
FIRE CLEAR, GRANTED
2. FIRE CLEAR, DENIED
A
14D1.
/l .I `�I
�0
3. FIRE CLEAR WITHHELD
27. DENIAL
CODE
TO BE COMPLETED BY INSPECTING AUTHORITY
CODES
21. INSPECTOR'S
NAME
TELEPHONE NO.
22. CFIRS
ID NO.
23. T-19 OCC.
CLASS
1. EXITS
2. CONSTRUCTION
3. FIRE ALARM
4. SPRINKLERS
24. IN
SP. DATE
25. INSPECTOR'S SIGNATURE
5. HOUSEKEEPING
6. SPECIAL HAZARD
28.E
PLAIN DENIAL OR LIST SPECIAL CONDITIONS
7. OTHER
STATE FIRE MARSHAL USE ONLY
20. REGION,
OFFICE
AND
ADDRESS
age of L . � ice of the State Fire Marshal
INSPECTION REPORT
ile No.:. L" : -LS
ame of Facility: NC'i2Cl{V L-� �L�.�`'> l/)(`
Jame of Building:
ddress Z S� �U ti
*FIREHAL
`xqL
I l
ofc,
f�iscussed with: ��_" :�� Title:
Accompanied by. Title:
CLEARANCE GRANTED
J
V
T -DATE .. !';.?
STATUS
EPUTY TATE FIRE RS
DATE OF I. PECTI
i
t t
GO
6 (Rev. 7/86)
Page -.—of-...
Office of the State Fire Marshal
INSPECTION REPORT
rile No.:. 00= 04 _ 47
A021 �551.
Name of Facility: IHM CALUUWA ADAPTIVE IZVBC OTTER
Name of Building:
Addiess: 2455 An%an7I fUm
v
Dai on, CA 95938
STATE IAL
&irk
q't"I �•i�d•�'A. � *' 'ryr , tti••jl• •/'� ��•'Ci j)rSre { •, _�1•j .!T1�' +' Ii,!�`I:.�y�'� I t**I tt -••.�r ci �L i,YYQyTs , l ti11j,�+�.,-�t � . .��,. •+�,. 3- �-,rAJ�.. • ��Ii�l) 1`l•�/`,'�t,+ij` '��r,�:tif.yY�/r. ✓�i`. ,/ ..I�,, !r .„•i - •i �.�11�1 �{''I1f .,1t,:•`a,.1:.: t {r1 '.'' ,.:�W' �,, �1,1,/'e ••.�i1��(!,!�{��t��•r'r (c•tirf-!, �: .Lt'�i�2/ i#•S °�li'tl• `s ie {r�•�• ��.(�i�. �.'+11 ..•lt.?i'l .�•'�i�1.��" l. tA�•{!, iXfl•�++-�.. ,.Ii�"�F�: 1•. s11 -'1j , r•t! r.r �'i• ....<.•`"A� /t�.r}'�{'.�•. �1a..�.�i�•'tY`+�1 �� jN:•. . Iij.t11 i,+ '��.%:�.%��1/�•11t.'�y.••
4.
Discussed
wllh:L
4-i V4111,71" .44
11b
ILI I
tit
'rf-
Accompanied
6y
44
n
MM VIA Q02110 Z14 VAR
50t
Aq— A
)a al y1. Fill z 1 96" 11 FIA I I" x0fff# 111111, k4 D � I
•
GO.6 Ptev. 7/66)
r.V'r, -_0r____
Office of tine Slate U're Marshal
INSI'ECII0N IMPORT
I He ou.: . 00 04 47
Name- of J'atility: NORTHERN CALIFORNIA ADAPTIVE LIVING CENTER
hl.,ri a of 1101cling:
A& r cc, r,: 2455 Durham -Dayton Hw
r
0
Durham CA 95938
�IKtG,
St/1tE' FIRE MAR IIAI
` rr
/ !',•S"����il • i i ±4'= 1 �. %•/� 1 i•• 1 rrf<`•/t• 'i•- }.•}i+� ♦., i ! 1� { �.• i ,.1"•' �i 1 li '/ 1•, �1•r ) f / •fRIP
"ISCUSSed •i/'\lta
IT r •. r;�♦ •! • t i •J/ • ,[ : ,~ : t •� t' .; •'.,, r�' l� }' �•
• 1 r• �. •• �j'�• sit-�"�•� •!• ; yy'� '�,i•, f•r�,. .+ �• ,,*r !' ••• •f •
r . r;� *,�••.� 'f S•:l/� f .fir ��i�T'..1 �•••j'�1.. .w \1 •1 �'!!�� 'i � • .•• ''i•r ''1•' • f, .•�•S•� • • • �• t, • ••� � •
rr •1• '� i M 1 i.i 1 • t. • ••1 ,
�.L���1 •� [� l■■��/ 1 , r r, f �• r'• +. 1• 1; • t• (,fh If '1 • •:.�••, •x.1,,1• ,; � �3 t • ,• �� f� ••• •••) � 1 '�, l •, .►: 1• � �. :r••, •
���1l�et� V ■ • 1 •• 1 4 1'• � l •! r� •'1 S f I •• � t.,:. �••. '� t
An annual inspection was conducted. at the above facility, no deficiencies were
at this time. The facility maintains a reasonable degree of fire and life saf etv .
Fire clearance is granted for six ambulator
y children to aQe la,
7 .• ,1
yea
11 Y S III IE FAtE AV1RSi W, '• •� , "� .
�LAHTER
UG . .
i
r•n - 61 qp*v. 7/04
i • r••�►�� -sem
• '' ti , bAlt CX RNjcjK)N
9 Oct •91'
e of ,rice of the State Fire Marshal
REINSPECTION REPORT
File No.: Q a
Nme of Facility: �(A,-f�'�Ic
I APTI
i5� A-,�) L)o
0oFCC1'
C�
STATE FIRE MA SHAL
Name of Building -
Ac dress:
Q �Sq -15
A�Ssed with: Me:
:,. • 'ccompan�ed by:
ire SafetyDeficiencies s Numbered noted on the Letter ❑
ire Safety Correction Notice (EN -11) dated have been corrected.
ncorrected Deficiencies Numbered were re -issued as shown
in the Fire Safety Correction. Notice dated , which is attached to and made a part of this Report.
n addition, new deficiencies were identified at the time of this reinspection, and are shown as Items
on the attached Fire Safety Correction Notice.
Fire Clearance Instructions: -—
&2
L&LA &AL, -A Vl-� ed V J .�
C -f C15,
TiE SCAM
STATE - DATE OF RENW1 N
-- L� 1;c
GO - A (Rev 7/86)
office of the State Fire Marsha.
Fire Safety Correction Notice
File No: — — - — —`
Name: ' /�
Address: _
4, 01A
The California Health and Safety
deficiencies be corrected.
Code and the State Fire Marshal's regulations require the following fire safety
i
1
G
C4 0 C
c� j c� �� `-c) �l
The above deficiencies are to be corrected within .y i' �- 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 DATE
EN -I I (Rev. 7/86) -86 96708 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field
No.:.
ne of Facility: L
office of the State Fire Marshal
INSPECTION REPORT
of Building:
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GO - 6 (Rev. 7/86)
STAT FIRE MARSHAL COPY DISTRIBUTION:
1
•--
SAFETY INSPECTION REQUE-3-STATE FIRE MARSHAL
2 -FIRE AUTHORITY
STD 8 0 (REV. 8 / 86) 4 -5 -LICENSING AGENCY
3. AGE CY CONTACT 4. TELEPHONE NO.
SS/COMMUNITY CARE LICENSING 1 (916) 895-5033
SEE REVERSE OF COPIES 2 AND 5 FOR
INSTRUCTIONS FOR COMPLETION
1. REQUEST DATE 12. PROGRAM
4/5/90
S. EVALUATOR
0113/BETHELL
S. SFM REGION
7. SFM I.D. NO.
S. REQUESTING AGENCY FACILITY NO.
9. REQUEST CODE
041370178
2A
CODES
SECOND REQUEST RESPONSE REQUIRED
1. ORIGINAL A. FIRE CLEARANCE
2. RENEWAL B. LIFE SAFETY
10. AGENCY DEPARTMENT OF SOCIAL SERVICES
NAME COMMUNITY CARE LICENSING
AND 520 COHASSET ROAD, SUITE 6
AD11RESsCHICO, CALIF. 95926 I
J
3. CAPACITY CHANGE
4. OWNERSHIP CHANGE
S. ADDRESS CHANGE
S. NAME CHANGE
PREVIOUS NAME
7. OTHER
'
DATE OF ORIGINAL REQ.
11. AMI 3ULATORY
NONAMBULATORY
TOTAL CAP.
DATE OF LAST FIRE CLEARANCE
CAPAC TY
AGE RANGE (YEARS)
PREVIOUS
CAPACITY
AGE RANGE (YEARS)
PREVIOUS
6
TO 18 18 TO 65 AND
1 3-17 65 OVER
CAPACITY
0
TO 18 18 TO 65 AND
65 OVER
CAPACITY
6
19. FACILITY
CODE 730
12. FA ILITY NAME
JORTHERN CALIFORNIA ADAPTIVE LIVING CENTER
13. NO. BLDGS
1
CODES
1. GACH 7. ICF / OT
2. GACH/R 8. ICF/DD
3. SH 9. ADHC
4. APH 10. CLINIC
14. STEET ADDRESS (ACTUAL LOCATION)
1455 DURHAM DAYTON HWY
P.O. BOX
15. RESTRAINT
NO
CITY
ZIP CODE
16. HOURS
URHAM, CALIF.
95938
24
5. PHF 11. JAIL
6. SNF 12. ICF/DDN
13. OTHER
17. FA ILITY CONTACT PERSON
ICHARD BROWNE
TELEPHONE NO.
(916) 894--2726
16A. SPECIAL
TO BE COMPLETED BY
INSPECTING AUTHORITY
18. FIR
26. CLEARANCE
CODE
AUTHOR JACK PIRISKY
CODES
NAE #4 WILLIAMSBERG LANE SUITE 3
�
1. FIRE CLEAR, GRANTED
AND CHICO, CALIF. 95926
ADORESS
2. FIRE CLEAR, DENIED
3. FIRE CLEAR, WITHHELD
27. DENIAL
CODE
TO BE COMPLETED BY INSPECTING AUTHORITY
CODES
21. IN ECTOR'S NAME
TELEPHONE NO.
22. CFIRS
23. T-19 OCC.
ID NO.
CLASS
�-
1. EXITS
2. CONSTRUCTION
3. FIRE ALARM
4. SPRINKLERS
5. HOUSEKEEPING
AL HAZARD
7.0 ER
24. INSP. DATE S. INSP TjR't SIGNATUR
28. EXPLAIN DENIAL OR LIST ECI L CONDITIONS
�A-C ' Instil.
to
F
20. RE ION. DEPARTMENT OF SOCIAL SERVICES
OFFICE
AN CONQZ[1NITY CARE LICENSING
AD RESS 520 COHASSET ROAD, SUITE 6
L CHCIO, CALIF. 95926
J
STATE FIRE MARSHAL USE ONLY
y r
l3 .
tTJt-ti ttxj
tmlj
STATE FIRE MARSHAL ra"
Iri G CAI ffIry lklclr%of%"rlrVU
COPY DISTRIBUTION: - SEE REVERSE OF COPIES 2 AND 5 FOR
i_Q-QTATC GIDG nAADQWAI INSTRUCTIONS FOR COMPLETION
r1
G �J/°1f G i i 11\Jr Gtr 116!1• f1Gd .J 1
_ 2 -FIRE AUTHORITY
i. REQUEST DATE
2. PROGRAM
ST
850 (REV. 8/86) 4 -5 -LICENSING AGENCY
4 590
+
3. AGENCY
CONTACT
4. TELEPHONE NO.
i 3NI'TY CARE LICENSING
�5.EVALUATOR
VBEWR�L
6. SFM
REGION
7. SFM I.D. NO.
S. REQUESTING AGENCY FACILITY NO.
9. REQUEST CODE
041370178
2A
CODES
SECIM REQUEST nESPIME R DED
1.ORIGINAL A. FIRE CLEARANCE
2. RENEWALS. LIFE SAFETY
3. CAPACITY CHANGE
4. CHANGE
OF AL SMICES
1�I
D�� `X
OWNERSHIP
10.
AGENCY
% OMMITY CM LICEMING
5. ADDRESS CHANGE
NAME
C�WO, SUM 6
6. NAME CHANGE
NAME
AND (520
taliICO, CALM. 9-%26
PREVIOUS
7. OTHER
ADDRESS
L �
DATE OF ORIGINAL REQ.
-
- -
--
DATE OF LAST FIRE CLEARANCE
11.
MBULATORY
NONAMBULATORY
TOTAL CAP.
CA
ACITY
AGE RANGE (YEARS)
PREVIOUS
CAPACITY
AGE RANGE (YEARS)
PREVIOUS
CAPACITY
CAPACITY
19. FACILITY
TO 18 18 TO AND
TO 18 18 TO 165 AND
�65
65 OVER
I
65 OVERj
_
CODE
12.
FACILITY NAME
13. NO. BLDGS
CODES
! uALIFORNIA ADAPTIVE Ll@ CENTER
1. GACH 7. ICF/OT
2. GACH/R 8. ICF/DD
..
14.
STREET ADDRESS (ACTUAL LOCATION)
P.O. BOX
15. RESTRAINT
2455 WFJIM DAYM flNY
' -
3. SH 9. ADHC
4. APH 10. CLINIC
CIT
ZIP CODE
16. HOURS
__ _
D�$,
95938
_
5. PHF 11. JAIL
6. SNF 12. ICF/DDN
17.
ACILITY CONTACT PERSON
TELEPHONE NO.
16A. SPECIAL
(416) 844-2726
13. OTHER
TO BE COMPLETED BY
INSPECTING AUTHORITY
F
26. CLEARANCE
CODE
18.
IRE I
UTHOR JAa PIRIM
CODES
AME $4 HLIA�OtSdeCG IME, SUITE! J
If
1. FIRE CLEAR, GRANTED
ND CHI00, CAL". 9592b
2. FIRE CLEAR, DENIED
DDRESS
3. FIRE CLEAR, WITHHELD
27. DENIAL
CODE
- - - TO -BE COMPLETED BY INSPECTING AUTHORITY - - - -
- CODES -
21.
NSPECTOR'S NAME
TELEPHONE NO.
22. CFI RS
23. T-19 OCC.
ID NO.
CLASS
1. EXITS
2. CONSTRUCTION
3. FIRE ALARM
24.
NSP. DATE
25. INSPECTOR'S SIGNATURE
4. SPRINKLERS
5. HOUSEKEEPING
28.
EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS
G:'SPE CIAL HAZARD
7. OTHER
(
STATE FIRE MARSHAL USE ONLY
20.
REGION. DZ,tpWDMT OF @MIA SERVICES
FFICE o*mT M1J�67:/ cmnw
■
AND 520 008ASSET ROAD, SUIT 6
ADDRESS L CBCIO, CUIF. 95926
ens
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Office of the State Fire Marshal
ge of *FIRE
INSPECTION REPORT HAL
F e No.:. 00 - 04= 47_
0023 _ _- 000 _- 035 _ _- 1
Name of Facility: NORTHERN CALIFORNIA ADOPTIVE LIVING CENTER
Name of Building:
Address: 2455 Durham -Dayton Road
Durham, Calif. 95938
biscussed with: Meg CastropTitle:
Accompanied by:
Staff.
Title:
An annual inspection was conducted at the above
facility. No deficiencies
were noted at this time. Facility maintains a
reasonable degree of fire and
life safety, fire clearance is granted for six
ambulatory children to 18 years.
FRE CLEARANCE GRANTED
es
T -DATE
I -
STATUS
DEPUTY STATE ME MARSHAL
SLAUGHTER
DATE OF INSPECTION
7 A112ust 89
G -6 (Rev. 7/86)
Page of dice of the State fare Mars[ 00CF�`
REINSPECTION REPORT STATE FIRE MA SHAL
File No.: .� 0 _ Q4.,7
_.t..._
7
.� v fD
Name of Facility: (. - �� `� "zo �
Name of Building -
Address: 5'� SauL/t&Jan — 645E0_.nj
,t.
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s>:
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r
Fire Safety Deficiencies Numbered __b .. .1_..t..,.
noted on the Letter
Fire Safety Correction Notice (EN -11) [V 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, ..A)-2) ... ._,1 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: �- t - r- 6::a d rf A
. F .CUARANa CRANTgJ 5
^ At. • i
T -DATE
< • . < < t
'.„ Y� I
STATUS i • r 1.
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e 'y
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K A•• V s'
1• _
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i�.§H
DEPUTY STA MAAL
DATE DF"REWSPECTlOPi
�a
t .r t
• r.•1� r
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•F � t
(yy'to-1•
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GO - 5 (Rev. 7/86)
Office of the State Fire Marsnal
Fire Safety Correction Notice
File No:--------
Name:
Address:
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 (�' r. )
ISSUED BY (Deputy Stale Fire Marshal) RECEIVED BY DATE
_;
L
EN -11 (Rev. 7/86) 86 96708 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field
�
. .
~ REINSPECTION -
^
OFFICEOF
'
STATE FIRE
.`"",L
.
1�1 F21 0"� FLI �� �� IE �� .
FILE NO. ' '
Date Reinspected Or
'
. .
Name of Facility
' . .
'
Address
Conditions Discussed With
Accompanied By Title
'
Inspection This ~ Date Discloses That Fire Safety Corrections Number '
of QFire Safety Corrections
. ' . .
' — ' Have Been Complied With '
' Dated ^ .
Fire Safety- Corrections Number'
Were Discussed
-
With 0 and Di
si ti on. Will Be
As Follows: Z>"
' . . .' .. �-
' .
- _.
'
*7"
'
77
New Fire Safety Corrections Stiould Be
Reinspection Indicates'That
Issued --See Reverse --Side -f�or "Commenfs -and 14ew Fi E=!afety. Correctionse..
7k
16
Mice of the State Fire Marsh: —
REINSPECTION REPORT
No.. `—� Z
of Facility: tL4�.� (?" t' `� Z'�U�i�jGr
of Building:
Building:
Address: z`fSS ,z�li ,OgyTos/J Nov
A-115 Owl'
Fire Safety Deficiencies Numbered TLj noted on the Letter ❑
Fire Safety Correction Notice (EN -11) Vdated '5�— /Z have been corrected.
Uncorrected Deficiencies Numbered
were re -issued as shown
on the Fire Safety Correction. Notice dated 2-(d S , which is attached to and made a part of this Report.
In addition, A) 0 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:�f�--
n U .11 it
GO - 5 (Rev. 7/86)
AWMW ..
Office of the State Fire Marsht.
Fire Safety Correction Notice
IFile No: — - - —
I Name:
I Address:
*FIRE
HAL
The California Health and Safety Code and the State Fire Marshal's regulations requirethe 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 DATE
EN -11 (Rev. 7/86) 86 96708 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field
P6ge_,,�—of�
Office of the State Fire Mar: 1
INSPECTION REPORT
File No.:.0 Q
L) -C� ? a --
Name of Facility: N(,10-H�iLn� �r4 (�' r= 11 I /) i,y L =
Name of Building:
Address: •z < /J," -,L- 4,,4•^1 —A+ TJ�J H j Z
Discussed with: _ _ _ _____— Title:
Accompanied by: Title:
A/J;'Ut,kf+( /jf-P L^ il'cyU LIZ 6y3yd�_-
�}�L1/� D/�'ni�r '1 � �i /"f� �'L C'_ "� j.,'i%Lr�_„ lJ�=• f=-�j%�n� �f3 1 ..=iL�� n,��--T"i! Gl
o ,.1 /}.o
FIRE CLEARANCE GRANTED I T -DATE
STATUS
DEPUTY STATE jvuRSllAi. DATE OF INSPECT Nv
_ `sia...�-' 7./t,.^i� ..r � . G i.-.•�{r � Vis.
GO - 6 (Rev. 7/86)
Office of the State Fire Marsi.-Ill
Fire Safety Correction Notice
File No:
Name:
Address
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
a. z
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
tLE No: [A
919911
REINSPECTION REPORT
OFFICE OF
STATE FIRE MARSHAL
Date Reinspected ' -�,�-
ame of Facility w, x 4 o c , rig.A gA ex., w
ddress0 U C t ,,,,�, �� ,r 0"
onditions Discussed With �
ccompani ed By Ti tl e
nspecti on This Date Discloses That Fire Safety Corrections Number_
■Y•Y1
29 ------
ated Y6 Have Been Complied With.
ire Safety Corrections Number
of Fire Safety Corrections
Were Discussed
ith and Disposition Will Be
Ri nspecti on Indicates That New Fire Safety Corrections Should Be
I suede See Reverse Side or omments and --New" Fire afety Corrections,
G -5
/70) REV 5/81
Deputy
Comments and New Condition .
M
M
New Fire Safety Corrections:
w.�
�r
'VICE
STATE IRE MAR AL
STATE FIRE MARSHAL
Fl.kiE SAFETY CORRECTION NOTIUA -
a
NAME
FILE NUMBER
-1
k91 Fol 0 ® ET F7
0 ®[-a] F3-1'- ® Fr-]> [9' F31 [-31 Fol 9
a '
ADDRESS
In accordance with the minimum standards of y Title 19, California Administrative Code, the
following corrections are required:
A I !A -e
71rLff --1 CI MC homo..) 4PV
d.
QCs %t4�A&DLU P-riow4cn
rimi: a o e -44L o s 9 0 re.
o _
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. I f you have any questions, contact the State
Fire Marshal's Office at W& 143 t 2 ,
ISSUED
BY (DEPUTY STATE FIRE MARSHAL) RECEIVED BY
0.
CQ4��-WLeAl
DATE
c; = —
EN -11 EV. 7/81) YELLOW: REGION WHOTE: FACULITY GREEN: FOES,®
88701-355 3-84 12M Tc
1 ��
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 19, California Administrative Code.
SIGNATURE: y. DATE
0
e-
- — — — — — — — — — — -- -- — — — — — — — — — — — — --
-- 71
(Fold on this line)
PMj
LXAJ-0.x0 qS -'s
STATE FIRE MARSHAL
4 WILLIAMSBURG LANE, SUITE 3
CHICO, CA 95926
F(CE OF THE STATE FIRE MARSHAL
INSPECTION LOG
Title �nT���w� 0rLu..)! A App 7-1ubF EE
EF21
Q
Address "'ur
-� �ro� 4�q dux.l 9,513 Date. --j
�f—
Owner
OouuLA. r'co A pu1u A s r�o v 5 �tcx t foo.
�J'vgroeAL
n
A."
V -
Od-O U Y VWX., Fly MA A Sl y'
UML
r. •
(Rev. 5/a1 ] . .
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• -- -' -'- r. _ ::L_ .�_ . _ _ _ _ ..-_ _ •• �,,,ri •:.••_,;sr.• ' i�we. � '�h ��.? �..r+.a�.�,� -� :'t. :.d- ..� - -... _. .. _ .. .. - - .��_:� ' - _ ... _ ... .'........• •« . r �..., .. ',
.a.•_. _ _ .. __ - - c.. •.v.i'..:•_ _•� :t =r.. :_r.,� ' ...:� • - `�_=•�a.rrs �e-t _ .4:..' �..�w.., j-
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... _ ....
:... :. ....
PAGE IL of
'ULTIPLE FUILDING FACILiTY
RECORD
FACILITY
NAMES
�_lllo+�r�+�'�e � dAO(F. Aode ri u C c., VIA-6- 9&4wot
.
ADDRESSO
' ELLE ATO.�p
��L=EU UU�GO[AD �'110 � Ono � 3 ElEl
• SERIAL
BUILDING iDEhTI�ICA�I��T
OCCUPANCY� � ' � FILE"
IX
NOW�.
� '.
CLASS N JML £R
iSe2 Sec.Nc.3�
i�-►GCS 6(��cd�WG Fr4ci`iT-{• _
� ?.*4 �
fi
BUILDING SUF:VEY REPORT
Date: _. cls 6
STATE FIRE MA AL
File No.
N of Facility:
Address: 04
Owner: MA Telephone. No. (qj ,
Narre of Building:
• DESCRIPTION
Carni.
1
Class - Use 00dod wicam Capacity
a4: lit— Year Built
TotalLargest Floor M Basement
No. High Rise Yes No �.
? 41
-Floor
Occupancy.
2
Construction
Type
8
3
Area (Sq. Ft.)
Construction
.
4
Stories
Exterior Wall
No. ,� ,.,;,
lo
Construction
. Opening
Protection
... .. _ _. _ ... � ....:._... ......�. ..._. -
. 6
Interior Wall -
t
Construction
Class - Use 00dod wicam Capacity
a4: lit— Year Built
TotalLargest Floor M Basement
No. High Rise Yes No �.
? 41
-Floor
-
Cons truct i on
8
Roof
Construction
09 61, 0 6&6N" ,a
9
Attic
Draft Stops
No. ,� ,.,;,
lo
. Occ. Sep. Wall
Construction
.. Opening .._.._....
... .. _ _. _ ... � ....:._... ......�. ..._. -
Protection
No.
ll
. Area Sep. Wall
Construction
A 44-
. Opening
Protection
No.
12a.
Smoke Barrier
. Wall Construction
b.
Opening
Protection
13
. Corridor Wall
Construction
b.
Opening
Protection
14
Corridor Ceiling
Construction
. Opening .
' Protection
l5a, Shafts -
Number/T . -
.&DOW, D, Opening
Protection
.1.. R06-_. �Rg y
_ _ .w.•T- ^``w rte_ w _ ."Ci•-- - � �• - •�. �' - r�_-_...r.._
i - r .oar -_ ... .»-_'_.... __ .. ----- _..� -- -- s-'--- • : -j.� Y.. -
' __ - - _. _" y` _ - - ....`-.fir.. - sr.- . - _ . �� - .r•.•� � .. a:..«a.�.. _ +liil�l�'��i-.sar - ..'a,.�y�y
i+Y^: a.Y ?+sem- • �,R«, : - • - - - . _..c,IM
,`ii..3,i: � _ - Y • � _ r_1y�-. . _ _ rte, - -.-
t:.� .r+.+�rM � .�'..T__". ___.:.:' �--'r ,�,�iSCCt."5�:.. u� _ - _-:.-��. ...�..�..+.+:+:�.+:..`+n�+......r....w.+rw`.ur✓w._�. .........-r.. .. .� .� N.ew
. DESCRI PTIOt�
77
Conn.
16a. Stair
-- .
. Enclosure
b. Opening
� Protection
17. Stairs No.
18 : Rates No.
Oft IT s Aaf 4r ( 4*f .
19. Interior
Finish Class
Room ' ' Corridor Exit Encl.40
20. Exits •
No. Total Width 11, Pr
21.. Exit Hardware*
22a. Exit -Signs/
Illumination
b. Emergency
Di htin
23. -Auto Sprink.
Covera e4A.
24. Standpipes
Class/ ,ocation
AA -
25a Fire Alarm
Type/Coverage
Si I t&f *5 #o,.► 5 -M
6 . Heating
Type 1AMM 1 b Fuel X -4 L 4.A - f Ven -I.-
27. Electrical
InstallationV_
All�'TACAG SA 7i�o � atz `��L�� ��
28. Stage/
,
Platform
4*v>AAZ
%9 . Hazardous
Areas
30. Other
.�NjMEi�TTS : Fn -O Y. it • A tojD Tri - int X M 1r.V#T 0
Inspected By: #4u7f S .)I`7A' M41U 94L No. Attachmnts:
?vi ewed By:
ti Date.
:1,.dated:
-1
1 „ f $'
STATFIRE MARSHAL COPY DISTRIBUTION:-----.- SEE REVERSE OF COPIES :2 AND 3 FOR
FIR SAFETY INSPECTION REQUEST 1 - STATE F1 -RE -MARSH INSTRUCTIONS FOR COMPLETION
STD 81 OA (NEW 6180) 2 - FIRE AUTHORITY": 1. REQUEST DATE 2. PROGRAM
3 - LICENSING AGENCY
3. A ENCY CONTACT 4. TELEPHONE NO. S. SIGNATURE
(;01-r:aunit~ Gare L ceps _nz 916-335Mr,0i3
6. S M REGION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO.
N e fin.' C u t on 7 0 17 8
a
9. EVALUATOR
1N . .^% r
i
19. REQUEST c
CODE
-' TO BE COMPLETED BY INSPECTING AUTHORITY
22. IN PECTOR'S NAME TELEPHONE NO. 23. CFIRS
ID NO.
25. IN P. DATE 26. INSPECTOR'S SIGNATURE
29. EX 2LAIN DENIAL OR LIST SPECIAL CONDITIONS
21. EGION, F t
FFIce guTE FIRE I+FARSHAti
No Maring..p48xQeg Office Complex
ADDRESS 2300 Merced Street
$M Leandro, CA, 9459?
28. DENIAL ;
CODE
CODES
24. T-19 OCC.
CLASS
-wl 1. EXITS
2. CONSTRUCTION
3. FIRE ALARM
4. SPRINKLERS
5. HOUSEKEEPING
6. SPECIAL HAZARD
7. OTHER
STATE FIRE MARSHAL USE ONLY
TIME I -MILES { NEXT INSP. (MO. DA. YR.)
.. b aSC -Lo-
Chi �.c�ren
1. ORIGINAL A. FIRE CLEARANCE
10.
GENCY F -De pa r iv�.le �:• C = �� a a :: w' Cl e
2. RENEWAL B. LIFE SAFETY
AMEM
3. CAPACITY CHANGE
ND
DDRESS 520 CiDha R se t 4ad ;
C-01 s se t Square I
'4. OWNERSHIP CHANGE
a to 1�: . � �; c,;
5. ADDRESS CHANGE
I
6. OTHER`
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
6
�1p
CODE
12..FACILITY
NAME
13. NO. BLDGS.
CODES -
Northern
Ca l i forn .a Ada , t j v e
L. Lx. inenLe i
one
1. GACH 7. ICF/OT
2. GACHIR 8. ICF/DD
14. ST IEET ADDRESS
15. RESTRAINT
3. SH 9. ADHC
14.
2453
Du r ha a Dayton Highway
none
APH 10. CLINIC
5. PHF 11. JAIL
CITY
ZIP CODE
16. HOURS
6. SNF 12. OTHER
Durha ?, CA.
91)
24 �
17. FACILITY CONTACT -PERSON
TELEPHONE NO.
16A. SPECIAL
John
' :am.e S e g916-877-5`,00
none
'v0u "love
TO BE COMPLETED BY
INSPECTING AUTHORITY
18.
IRE
27. CLEARANCE
CODE
UTHOR.
CODES
AME
1. FIRE CLEAR. GRANTED
ND
DDRESS
2. FIRE CLEAR.. DENIED
.-1
3. FIRE CLEAR. WITHHELD
-' TO BE COMPLETED BY INSPECTING AUTHORITY
22. IN PECTOR'S NAME TELEPHONE NO. 23. CFIRS
ID NO.
25. IN P. DATE 26. INSPECTOR'S SIGNATURE
29. EX 2LAIN DENIAL OR LIST SPECIAL CONDITIONS
21. EGION, F t
FFIce guTE FIRE I+FARSHAti
No Maring..p48xQeg Office Complex
ADDRESS 2300 Merced Street
$M Leandro, CA, 9459?
28. DENIAL ;
CODE
CODES
24. T-19 OCC.
CLASS
-wl 1. EXITS
2. CONSTRUCTION
3. FIRE ALARM
4. SPRINKLERS
5. HOUSEKEEPING
6. SPECIAL HAZARD
7. OTHER
STATE FIRE MARSHAL USE ONLY
TIME I -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 0ATEe Enter the date request was
prepared.
a 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.
t 7. SFM 10 NO. This is the SFM Identification Number
and initially will be assigned by the State r -ire
Marshal. Licensing Agency -- Inseit this,number on
all clearance requests,su sequen°t to the initial
ti
request
3: REQUESTING AGENCY FACILITY NO. This- is the
file number assigned by th licensing agency.
9. EVALUATOR. For licenncy use.
10,, AGENCY NAME AND ADDRESS. Enter the name
and ,address of the licensing -facility requesting
the inspection.
*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. No. SLOGS. Insert the- total number of buildings
to be' used for housing of the .occupants covered-
by the license.
140 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.
13. 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 in the box following
"Request Code". Insert date of original request
when request is other than an original.
20. FACILITY CODE. Dark this item only if the facility
is a: (1) General Acute Care Hospital (GACH), (2)
General Acute Care Hospital/Rehab (EACH/R), (3)
Special Hospital (SH), (4) Acute Psychiatric Hospital
(APH), (5) Psychiatric Health Facility (PHF), (6).
Skilled Nursing Facility (SNF), (7) Inte.rmedi.ate
Care Facility/other (ICF/OT), (8) Intermediate Care
Facility/Developmentally 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 lis 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 • be
contacted.
23. CFIRS ID.NO. Insert the fire department's
number assigned by GF1RS.
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.
26e- INSPECTOR'S SIGNATURE. URE. To be signed by
inspector conducting the inspection.
4
-27. CLEARANCE CCDE..Use the three codesshown
and insert the appropriate number in the box
following "Clearance Code".- -
NOTE: If Code 2 (Denied) or Code 3 (Withheld) is used, explain.
26. 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.
..NOTE: Fire Cie'aCra ice na ti o#-� etlenf�� � o 'other than lack of con-
. t. •.� � .. _:..� y
fdrmande Wifk`thb;0rovisdhs:of Tftle.19.
29. EXPLAIN 13I'AL: 1t Ciearanee Code No. 2 or 3
is used; -b''iefly e*Wftrreason. This space is also
to be used to explain Denial Code item noted.
1
OFFICE OF THE STATE FIRE MARSHAL
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