HomeMy WebLinkAbout040-200-071 CF Archive (2)"=IRE SAFETY INSPECTION REPO' --
Butte County Fire Department
California Department of Forestry and Fire Protection
Orovilfe, California 95965 • (530) 538-7888
Business Address: CRY. Inspection Date:
Business Name: Business Phone:
Owner/PropertylManagement: _"'k.
7 AP#:
NO.
CORRECTIONS REQUIRED
NOL
LOCATION IREMARKS
CLEMM
LOCATION
I Rmq& address numbersiWicling I.D. visbe from street
I EXITING
2 Remove obstructions at exits, doors, aisles, stairways, etc.
3
Exit door to open without a key or any special krmledgd effort.
4 Repair non-cperable exit door hardware.
5
Remove obstructions from door regized to be closed.
6 Remove loclellatches from doors with panic hardware.
7
Provide sign over main exit door - 'This door to remain unlocked cli.&g
business hours".
8
Remove sta-age from under unprotected starrivay.
9 ProvkWimaintain exit sigrVemergericy loting.
FIRE EXTWGUISHERS
10
Have fire ediTuisher(s) serviced and tagged.
RE -INSPECTION DATES
INSPECTOR
11
PrcvideJmount fire adinguisher as ideated.
1st
/ /
12 Post a sign inclicating fire edinguisher location.
13
Provide clear access to fire adnguisher.
2nd
/ /
FIRE PROTECTION ECAMI)IIIIIENT
14
Maintain, repair, paint inspect, andAor test spcinkleftn*ipe
systemftdranVFDC/PIV.
Refer to FPB
/ /
15
Maintain 3 feet minimum clearance for access/use of fire
appliances/equipment.
District Attorney
/ 1
16
Replace damagedfMinted(missing sprinkler heads/FDC caps.
Final Cleararim
I /
17
Provide 5 -year certification test for spdnklerk1an4*e system.
I Oce"J""WCIM
0 Check Pre -Fire Plan for accuracy.
18
Provide spare sprinkler heads (min. q ardor conpitible 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 reinspection will be conducted
on . Willful failure to comply with this notice is a
misdemeanor. Violations that are not corrected immediately arid/or remain
I after the reinspection may be processed as a criminal offense. Thank you
for your assistance and cooperation in minimt!hg the fire and life loss in
your community.
19 Hoodduct extiNuishing system to be serves tagged every 6 mo.
20 Remove grease from hood, duct, and filters. (KEEP CLEAN)
FIRE ALARM SYSTEMS
21 Maintain, repair, inspect, ardor test fire alarm system.
FIRE SEPARATIONS I
-
22 Repair holes in required fire resistive construction.
23 Providetrepair self or automatic closing fire rated assemblies.
24 Keep attic access and scuttle openings closed.
ELECTRICAL
Signature of Recipient:
25 Discontinue use of adension cards.
26Install
permanent wiring for fixed and stationary appliances.
0 Owner 13 Manager 0 Employee 0 Other
27
Provide cover plates for all junction boxes.
Inspecting Officer.
28 Remove exposed wiring or protect in approved conduit
29
Provide a 3Nnch clear space to and in front of electrical panel.
FPB- Engine Company:
30
Maintain vAring in good condition and protect from damage.
0 NO VIOLATIONS NOTED THIS DATE
THANK YOU FOR BEING FIRE SAFEI
I I FLAMMABLE ]LIQUIDS - COMPRESSED GASES
31
Provide a flammable liquid storage cabinet or reduce storage to 10 gallons or
less.
Addbonal Comments:
tP,0 L
U I G uvT
Page_ of
32 Remove all flammable liquids not used for maintenance purposes.
33 Store flammable liquids away from exits, stairs, or corridors.
34 Secure compressed gas cylinders.
STORAGE * HOUSEKWW
35 Arrange storage in an orderly mariner to provicle
36 Remove combustible storage from water heater and electrical room.
37 Remove storage to 24 inches below ceiling or 18 inches below sonkler heads.
38 Remove lintbebris from behind washers and dryers.
39 Remove waste/rubbish materials from the premises.
40 Keep ckimpsters 5 feet away from combustible walls, eaves, or opening.
MISCELLANEOUS.
41 Other violations ardor comments.
ire Prevention Bureau
76 Nelson Avenue
lroville, CA 95965
telephone 530-538-7888
ax 530-538-2105
Address: I
Manager:
.-NW
Butte County Fire Rescue
California Department of Forestry
and Fire Protection
Facility Inspection Report
Business Name:
Bus:
Bus:
Bus:
Hm:
Hm:
Hm:
White Copy - Business
Yellow Copy — Occupancy File
Pink Copy — Station File
Occ. Class.
Fax:
I AN 7NQPF.CTinN nF VnITR FAf'HYFV RF,VF,ALED TAE 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: UGHKEU1EIR
Date:
Discussed with:
Signed:
(Print)
Inspecting Officer:
Battalion 1 2 3 4 5 6 7
Station: FPB
FIRE PREVENTION SAVES LIVES, PROPERTY, AND BUSINESS. YOUR COOPERATION WI'T'H
CORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE:
'ire Prevention Bureau
76 Nelson Avenue
)roville, CA 95965
'elephone 530-538-7888
'ax 530-538-2105
Address: I
Manager:
Owner.
3utte County Fire Rescue
California Department of Forestry
and Fire Protection
Facility Inspection Report
Business Name:
Bus:
Bus:
Bus:
A060.
White Copy - Business
Yellow Copy — Occupancy File
Pink Copy — Station File
Occ. Class.
Hm:
Hm:
Hm:
Fax:
AN TNC1PFCT1rnx nF VnITR FiACYLITV RF,VFAI,F,D TRF. 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 0'
18.
Other
DETAILED EXPLANATION AND CORRECTIONS: UU1W U I hU:
Date:
Discussed with:
Signed:
(Print)
Inspecting Officer -
Battalion 1 2 3 4 5 6 7
Station: FPB
FIRE PREVENTION SAVES LIVES, PROPERTY, AND BUSINESS. YOUR COOPERATION W11'H
CORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE:
v
,.► Page 1 of 2
Fowler, Steve
From: BTU Durham Stn
Sent: May 06, 2005 7:00 AM
To: Fowler, Steve
Subject: RE: Inspection Completion Notification.xls
Not sure if some replied to this or not Steve our computer hard drive crashed, but yes it is complete.
G/Sjolund
From: Fowler, Steve
Sent: Sunday, April 24, 2005 10:38 AM
To: BTU Durham Stn
Subject: RE: Inspection Completion Notification.xls
is this one done for this year?
Steve Fowler
Life Safety Officer/Asst. Fire Prot. Planner
Butte County Fire Rescue/CDF Fire
office (530) 538-6837, Ext. 166
Cell (530) 521-8768
Fax (530) 538-2105
steve.fowler@fire.ca.gov
www.buttefire.com
-----Original Message -----
From: BTU Durham Stn
Sent: April 21, 2005 1:39 PM
To: Fowler, Steve
Subject: RE: Inspection Completion Notification.xls
To email this form do the following:
1. Click on "File"
2. Click "Save"
3. Click on "File" again
4. Click on "Send To"
5. Click on "Mail Recipient"
6. Address to Cyndi Wilson
7. Click "Send this Sheet"
Business Name Walden Farm
Date of Inspection 3/31/05, final on 4/21/05
Number of Violations 2
Inspector Name Joe Flagg, G/Sjolund on reinspect
05-08-2005
1 -
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ire Prevention Bureau
76 Nelson Avenue
)roville, CA 95965
telephone 530-538-7888
ax 530-538-2105
Address: TO
Manager:
Owner:
"6'3utte County Eire Rescue
California Department of Forestry
and Fire Protection
---- Facility Inspection Report
S u j, Busine Name: (�
_62 Bus: 2 . / Z
Bus:
Bus:
"` White Copy - Business
Yellow Copy — Occupancy File
Pink Copy — Station File
Occ. Class.
t-OAZVA
Hm: Fax.
Hirt:
Hm:
—I AN rNCPFf TTnN nF VnITR FACH.ITV 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
Knox Box keys
17.
Address posted and visible from road
+8.
9.
Fire Drill Witnessed Yes ❑ No ❑
18.
Other
(DETAILED EXPLANATION AND CORRECTIONS: UUMMc:rhli:
s
■IL�t►lel':�L93/IJ'1[��lYl.�►y��r�i►zi
r
Date: Discussed, with: i Signed: �
S- � ' 0 j (Print)' t � `�
Inspecting Oil er-
attalion 1 2 4 5 6 7 Station: F�� FPB rj
PREVENTION SAVES LIVES, PROPERTY, AND BUSINESS. YOUR COOP TION WITH
CORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE:
,t.�tG�""�;�'►� �-• -�, . j �Ll LX1-X 2rr �, c.. -vu �frr�a-�-7 C.: r, �� c �� �`
BUTTE COUNTY FIRE DEPARTMENT/CDF FIRE
TITLE 19/24 INSPECTION NO.z 3
FACILITY INSPECTION
REINSPECT: -iYES FY NO
Facility "Irn 5 fa ril'1 n i 'S+ Occupancy . IA
Address 1�P,ixon -Rd tu..-K m q593$ Inspector S1-t.annen Ga.rrGtt'
Phone _ "' Station `-S
Contact PjitrjAl 1n OLLCIQn Station Phone o0q I 2'18$
Compliance: Yes =.4f
ACCESS --All inspections
�i Address correct/posted and visible from road (Burse Co. Code 32-9)
1f Access to public street or 20 ft. wide lane (T19-3.05)
t Gates wide enough to admit fire apparatus Cr19-3.16)
tf Fire protection equipment visible/accessible (T19-3.14)
PORTABLE FIRE EXTINGUISHERS --All Inspections
V Extinguishers have current annual service tag (T19 -575.1A)
No = 0 Not applicable = N/A
ELECTRICAL --All inspections
f
V Extension cords do not replace permanent wiring (CEC-400-8(1))
i` Extension cords do not pass through doors/walls (CEC-400-8 9,3))
M 30 inch clearance around all electrical panels (CEC-110-16A)
All panels and breakers are marked (CEC-110-17 C)
V Repair holes in fire -resistive construction CEC (300-21,22)
Multi -plug power strips have circuit breaker (CEC 400-13)
FIRE PROTECTION EQUIPMENT --All Inspections
Maximum travel 75 ft. Cr19-567) N/r Hood system serviced/tagged every 6 mo. by cert. tech. (T19-904)
Provide clear access to fire extinguisher (x19-563.2) /I I Clean filters, hood, and duct area over cooking appliances (CFC 1006.2.8)
Extinguishers mounted on wall/or in cabinet, visible and signed (rig -563.8) • `a, I, ! Maintain extinguishing systems (x19-3.24)
Provide spare sprinkler heads (6 min.) and/or sprinkler wrench (T19-904.5)
EXITS --All Inspections 11 Replace damaged, corroded, or painted sprinkler heads (T19-904.5)
V Exits not obstructed Cris -3.11)
Identify sprinkler valves and secure in open position Cris -904.5)
7
Exit signs in place (cec 1003.2.9.1) / ,
'e rReplace missing caps on fire department connection (T19-904.3)
®
/V r Provide 5 -yr. certification test for sprinkler/standpipe (T19-904)
V 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)
,gIL4 Maximum occupancy sign in place (r19-3.30)
/1/�Two exit doors/panic hardware swing in direction of travel (CFC 2501 8.2)
HOUSEKEEPING — All Inspections
f No waste or rubbish accumulation inside or outside T19-3.14)
Reduce storage to at least _" below ceiling/ sprinklers Cris -3.14)
A f Remove combus. storage from heater, mech., elect. room Cr19-3.19f)
Provide approved metal container for oily rag storage (T-19-3.190)
Flammable liquids stored properly (T-19-3.15)
OF
Corrections and Comments 1, SrU
311
21
bf ✓: ilaS f C aC[ t a
The above d6fici ncies mube corrected within
MECHANICAL EQUIPMENT --All Inspections
_Vents and chimneys -- No obvious hazards (CMC -Ch. 8)
SMOKE DETECTORS -- Day Care Sr. Res., Hospitals, Apts.
V 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 (x19-3.22)
FIRE DRILLS -- School and Day Care (Title 19-3.13)
All systems operable/hooked to office
/vHeld monthly (elementary schools)
�4Ield semi-annually (high schools)
Evacuation plans posted in all rooms
Emergency procedures posted in office
OJTeachers take roll books
1-171-74
days. Inspection Date:
AP #
BUTTE COUNTY FIRE DEPARTMENT/CDF FIRE
TITLE 19/24
FACILITY INSPECTION
INSPECTION NO. 1 2 3
REINSPECT: FV YES -1 NO
Facility `Y4a We r, `� r—a i" t'3 ; Occupancy
Address -1f),4 0 � ��)rGr� ; i Inspector , f r t— it
Phone, Station
Contact 0hP-vzStation Phone
compiiance: res =-f
ACCESS --All inspections
Y Address correct/posted and visible from road (Butte Co. Code 32-9)
Access to public street or 20 ft. wide lane (r19-3.05)
Gates wide enough to admit fire apparatus (T19-3.16)
Fire protection equipment visible/accessible (T19-3.14)
PORTABLE FIRE EXTINGUISHERS -- All Inspections
Extinguishers have current annual service tag (T19 -575.1A)
No = u ivoi appncame = [VIA
Maximum travel 75 ft. (r19-567)
Provide clear access to fire extinguisher Cr19-563.2)
Extinguishers mounted on wall/or in cabinet, visible and signed (T19-563.8)
EXITS -- All Inspections
Exits not obstructed Cr19-3.11)
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
r Exit illumination and signs in place (CBC 1003.2.8.2)
' j''Maximum occupancy sign in place (T19-3.30)
",j 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 (T19-3.14)
Remove combus. storage from heater, mech., elect. room Cr19-3.19f)
Provide approved metal container for oily rag storage (r -19-3.19c)
Flammable liquids stored properly (r-19-3.19)
Corrections and Comments
ELECTRICAL --All inspections
Extension cords do not replace permanent wiring (CEC-400-8(1))
Extension cords do not pass through doors/walls (CEC-4008 9,3))
30 inch clearance around all electrical panels (CEC-110-16A)
All panels and breakers are marked (CEC-110-1 7 C)
Repair holes in fire -resistive construction CEC (30021,22)
Multi -plug power strips have circuit breaker (CEC 40013)
FIRE PROTECTION EQUIPMENT --All Inspections
Hood system serviced/tagged every 6 mo. by cert. tech. Cr19-904)
Clean filters, hood, and duct area over cooking appliances (CFC 1006.2.8)
Maintain extinguishing systems Cn9-3.24)
Provide spare sprinkler heads (6 min.) and/or sprinkler wrench Cr19-904.5)
Replace damaged, corroded, or painted sprinkler heads Cr19-904.5)
Identify sprinkler valves and secure in open position (r19-904.5)
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 (r19-3.08)
LPG tanks fenced with locked gates (T19-3.22)
FIRE DRILLS -- School and Day Care (Title 19-3.13)
All systems operable/hooked to office
Held monthly (elementary schools)
Held semi-annually (high schools)
Evacuation plans posted in all rooms
Emergency procedures posted in office
�',• / Teachers take roll books r
The above deficiencies must be corrected within days.
Owner/Manager
Inspection Date: f ( C'
AP #
STATE OF CALIFORNIA
FIRSAFETY INSPECTION RE �T
STD. (REV. 10-94)
See mastrumeorts on reverse.
T
AGENCY CONTACTS NAME TELEPHONE -NUMBER REQUEST DATE PROGRAM
0/
rj� jq/C0jjMUp.TTy CARR LIGRENSING 5_30) 89.5-51103.33
EVALUATOR'S NAME REQUESTING AGENCY FACILITY NUMBER REQUEST CODE
05'- C A1,.jTDT4,TP.1T,L 0 5 0 10 2 6 6
CODES
1. ORIGINAL A. FIRE CLEARANCE
LICNSING
!Z.'PA1RTM1F*TT OF 43-011 Al B R V I G E; S7
2. RENEWAL B. LIFE SAFETY
AqENCY C 0 Xi 1,11 TN I T, Y 0 A R 'E" 14 T C E TT S I IT G 3. CAPACITY CHANGE
NARPE AND
ADDRESS 59 0 COTTAOSST RDe STI -ITE 4. OWNERSHIP CHANGE
T7 T i-1 .' C 2..;
A C-' 26
5. ADDRESS CHANGE
L 6.NAME CHANGE
7. OTHER
AMBULATORY
NONAMBULATORY
BEDRIDDEN
TOTAL CAPACITY
CAPACITY
PREVIOUS CAPACITY
CAPACITY. -
PREVIOUS CAPACITY
CAPACITY
PREVIOUS CAPACITY
7.
JNAM
I L1
CODES
FIRE
LICENSE CATEGORY
a T1 - C -If I
#4,
0 z
STREET ADDRESS (Actual Location)'
WILLTA"ISDURG LANE9 .5
1-
1-
NUMBER OF BUILDINGS
C�9 0 S C) T -T, 0 INT R 0 A'C)
N EAND
`TTTC05 tr';& P 5 / .4
CITY
2. FIRE CLEARANCE DENIED
A DRESS
RESTRAINT
0A
A. EXITS
FACIIJ TY CONTACT PERSON'S NAME muumb
VIAL -1 C H F R YX .5., 3 0 4) 4 15"
SPECT 4L CONDITIONS
Al' WILT, P..� Jq0NA'j -,T!" �1'110R'f
Ur'
.1-1 0 rV �,j R TTrATORV STAn
CLEARANCE /DENIAL CODE
7.
CODES
FIRE
--ALL
STATE FTR-T4A , il I 4 "D .
1. FIRE CLEARANCE GRANTED
AU HORI
WILLTA"ISDURG LANE9 .5
1-
1-
N EAND
`TTTC05 tr';& P 5 / .4
2. FIRE CLEARANCE DENIED
A DRESS
A. EXITS
L
B. CONSTRUCTION
C. FIRE ALARM
D. SPRINKLERS
El:
INSP CTOR'S NAME (Typed or Printed)
TELEPHONE NUMBER
CFIRS NUMBER
OCCUPANCY CLASS
E. HOUSEKEEPING
F. SPECIAL HAZARD
NS CTIONJ DATE
I pi:
INSPECTOR'S-SIGN`,TURE (Typed or Pti4fed)
G. OTHER
EXP IN DENIAL OR LIST SPECIAL CONDITIONS
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REGIONAL OV
FACILITY FILE CHANGE NOTICE
Name Correction/Change ❑ Change File Number A Issue File Number
Address Correction/Change ❑ Facility Discontinued ❑ Other
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Address:
City:
County:
(No.
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Name: �1� ply"ll S—►'�Li1J1 JJ �C��
Address: 3.01, L1 Ct qu � Vb
City: I)Ua4. 4144 Cd\ of Sa 3
County: (No. )
File No.: _ —
---
File No.: — —
Occupancy Class:
T-24 SFM FILE
Occupancy Class:
T-24 SFM FILE
Comments:
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INSPECTION REPORT
le No.:. _
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ame of Facility:
ame of Building:
dress:u.6`oJ 0-0b
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ST43 ALIFORNIA'SEE
DOPY DISTRIBUTION: REVERSE OF COPIES 2 AND 5 FOR
FIRE SAFETY` INSPECTInN Rpni ["� :.. _ _ __ _ __ ___ _ INSTRUCTIONS FOR COMPLETION
STD 50 (REV. 3-93) .-v-..�I„IV_ u_Inc mnnan/%�
2 --FIRE AUTHORITY
1. REQUEST DATE
2. PROGRAM
.4 -5 --LICENSING AGENCY
09/21/95
3. AG NCY CONTACT
4. TELEPHONE NO.
S. EVALUATOR
SS/COMMUNITY CARE LICENSINGf
(916) 895-5033
•0205/SALGADO ��--
G. SFF I REGION
7. SFM I.D.--N �..
6. REQUESTING AGENCY FACILITY NO.
9. REQUEST CODE
045000266
1A
CODES
RESPONSE RE UIRED
I. ORIGINAL A. FIRE CLEARANCE
RENEWAL B. LIFE SAFETY
•DEAPRTMENT'OF SOCIAL•. SERVICES
�
"
3. CAPACITY CHANGE
14. A ENCY -
COMMUNITY CARE LICENSING
t
4. OWNERSHIP CHANGE
" ME • - .: -• 520 COHASSET ROAD SUITE 6 � � ... • � • a .. � . � • � ' �
-
S. ADDRESS CHANGE
- •CHICO I}.. CA 95926.
G. NAME CHANGE
PREVIOUS NAME
ADDRESS
7. OTHER
,. • k �:
DATE OF ORIGINAL REQ.
11. Ah BULATORY
NONAMBULATORY
TOTAL CAP.
DATE OF LAST FIRE CLEARANCE
CAPAC tTY
MEDICAL, CARE- , ''
'"' PREVIOUS
CAPACITY
MEDICAL CARE'
PREVIOUS
CAPACITY,-
_
CAPACITY
C&NO. [] YES
5
ElNO YES'
19. FACILITY
:-. .
12. FA{LITY NAME
W LDEN' S FARM • -' N•' REST STOP•'
.. - -
13. NO. BLDGS.
1
CODES
1. GACH 9. ADHC
2. GACH/R 10. CLINIC
14. ST EET ADDRESS (ACTUAL LOCATION)
9 49 ESQUON ROAD
P.O. BOX
115. RESTRAINT
'
NO
3. SH 11. JAIL
4. APH 12. ICF/DDN
CITY
DURHAM,
ZIP CODE
• 16. HOURS
CA
95938
24
S. PHF 13. RCF
G. SNF 14. CCF
17. FACILITY CONTACT. PERSON
TELEPHONE NO.
16A. SPECIAL
C ERYL • WALDEN
�Z��X� (916) 343-6215
7. {CF/OT 1 S. DAF
S. ICF/DD 16. OTHER
• a. .. /; ., , - . _ - ' - .- -
=
TO BE COMPLETED BY
• •,
'tom • + "' - i -
INSPECTING AUTHORITY
{
18. FIR STATE FIRE MARSHALL s
26. CLEARANCE
CODE
AU- -HoR. 4 WILLIAMSBURG LANE , - SUITE A
cODEs
NAE_ • - - CHICO • QA-*.-- 9.59.2,6.:..•• -• i. • . . _ . -
' •.
1. FIRE CLEAR. GRANTED
AN ; i, •
AD RESS ~' `
2. FIRE CLEAR, DENIED
FIRE CLEAR WITHHELD
27. DENIAL
CODE
TO BE COMPLETED BY INSPECTING AUTHORITY-
CODES
21. INSI 2ECTOR'S NAME TELEPHONE- NO.�;-} _ M CF IRS '
�'
23. T-19 OCC:
1. EXITS
ID NO '
CLASS
v
AL
Z
2. CONSTRUCTION
3. FIRE ALARM
24. INS ATE 25., IN ECTOR' GN R -
4. SPRINKLERS
IL HOUSEKEEPING
28. EXP IN DENIAL OR LIST SPECIAL ONDITION
G. SPECIAL HAZARD
7. OTHER
'LJu 111
STATE FIRE MARSHAL USE ONLY
A-DEAPRTMENT`OF SOCIAL SERVICES-..,
�
20. REG ON @.
. COMMUNITY CARE , LICENSING ' �,•. _
r
.
.
OFF E --...-520 COHASSET- ROAD SUITE
-6:
AND CHICO,� CA 9592b.
ADD ESS