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041-480-002_11_12_82-11_27_06.2 (2)
Page of -)ffice of the State Fire Marsha' INSPECTION REPORT File No.:. C/ d Name of Facility: Name of Building: �J Address: Busse w)th Tit1�, lccomprnesl byTtT)t k 4., a •,a, i FRE; gLov a GRANTED T•DATE STAII S �-o ATE ft DATE OF W KO)ON I� ~ GO -6 (Rev. 7/86) rr ..� Office of the State Fire Marsha. Fire Safety Correction Notice File No: — - — I name: _ Address: <- _-- L The California Health and Safety Code deficiencies be corrected. i and the State Fire Marshal's regulations require the following 'fire safety 216 17 S The above deficiencies are to be. corrected within r' days. When ALL deficiencies have been corrected, sign and return the certificatidn ,on the opposite side of,this form. If you have any questions, contact the Office of the State Fire Marshal at C�t) ISSUED BY (Deputy State Fire Marshal) RECEIVED BY DATE EN -11 (Rev. 7/86) 86 96708 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field i STATI _FIRE MARSHAL COPY DISTRIBUTION: SEE REVERSE OF COPIES 2 AND 5 FOR FIS APETY INSPECTION REQI,. 1 -3 -STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION 2 -FIRE AUTHORITY STD 8 0 REV. 8/ 86� 1. REQUEST DATE 2. PROGRAM 4 -5 -LICENSING AGENCY 6-13-89 3. AG NGY CONTACT 4. TELEPHONE NO. 5. EVALUATOR DOSS/COMMUNITY CARE LICENSING (9160 895-5033 0113 BETHELL S. SFIV REGION 7. SFM I.D. NO. S. REQUESTING AGENCY FACILITY NO. 9. REQUEST CODE 041304029 3A IS REQUEST REPLACES ONE DATED 5-24-89. PLEASE CLEAR FOR ONE CODES B DRIDDEN CLIENT 1. ORIGINAL A. FIRE CLEARANCE 2. RENEWAL B. LIFE SAFETY 1 F 3. CAPACITY CHANGE DEPARTMENT OF SOCIAL SERVICES 4. OWNERSHIP CHANGE 10. AGE CY COMMUNITY CARE LICENSING S. ADDRESS CHANGE NAM 520 COHASSET ROAD SUITE 6 6. NAME CHANGE AND CHICO, CA, 95926 PREVIOUS NAME All DR ESS I J 7. OTHER ' DATE OF ORIGINAL REQ. 11. A BI LATORY NONAMBULATORY DATE OF LAST FIRE CLEARANCE TOTAL CAP. CAPACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS CAPACITY TO 18 18 TO 65 AND CAPACITY TO 18 18 TO 65 AND 65 OVER 65 OVER 19. FACILITY 118-5 6 41 118-5 CODE 12 12. Ffi C11.1 Y NAME OMASSON FAMILY HOME 13. NO. BLDGS CODES 14.5 RT ADDRESS (ACTUAL LOCATION) P.O. BOX 1 1. GACH 7. ICF / OT 3E 30 CHEROKEE ROAD 15. RESTRAINT 2. GACH/ R 8. ICF / DD NO CITY 3. SH 9. ADHC ZIP CODE O'OVILLE, CA 16. HOURS 4. APH 10. CLINIC 95965 24 17. FACILITY CONTACT PERSON 5. PHF 11. JAIL TELEPHONE NO. LLA THOMASSON (916) 533-6830 16A. SPECIAL s. SNF 12. ICFIDDN 13. OTHER TO BE COMPLETED BY I � 18. FIEF26.JACK INSPECTING AUTHORITY CLEARANCE PIRISKI � CODE AUTHOR #4 WILLIAMSBERG LANE SUITE ./� NAM 't/' 3 CHICO, CALIF. 95926 CODES AP ID 1. FIRE CLEAR, GRANTED At 10 Ess L 2. FIRE CLEAR, DENIED 3. FIRE CLEAR WITHHELD 27. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY 21. IN P CTOR'S NAME TELEPHONE NO. 22. CFIRS CODES 23. T-19 OCC. ' ID NO. CLASS 1. EXITS j ��24. 2. CONSTRUCTION P ATE 25. I PEC 'S G - �' 3. FIRE ALARM 2 E AI DENIAL OR LISTS E AL CONDI 10 4. . SPRINKLERS 5. HOUSEKEEPING j kca6sPECIAL HAZARD ` 7. OTHER jONLYTATE l E 900 FI E MARSHAL USE .i r 20. R EGION. DEPARTMENT OF SOCIAL SERVICES -I o FIFE COMMUNITY CARE LICENSING A D, 520 COHASSET ROAD SUITE 6 A DRESS CHICO, CALIF. 95926 J Age -of uo.: 0 %-,ffice of the State fire Marshal REINSPECTION REPORT Nrr�e of Facility: M&!�V� gL� 74-1 Nm' a of Building: A ress. �. e rtict 4r STATE FIRE MA SNAL Uscussed with: Me: Accompanied try: Zr ire Safety Deficiencies Numbered noted on the Letter ❑ ire Safety Correction Notice (EN -11) El dated eT WE'As have been corrected. ncorrected Deficiencies Numbered were re -issued as shown the Fire Safety Correction. Notice dated I , which is attached to and made a part of this Report. addition, e Clearance Instructions: i new deficiencies were identified at the time of this reinspection, and are shown as Items on the attached Fire Safety Correction Notice. r +V 11J1d / L INV, 1�� r r co - 5 (ORte /86) CkHCEr-j, of— Office of the State Fire Marsh CfCE REINSPECTION REPORT STATE FIRE MA HAL No...Q� s2 � � � 0 0 .3,-0 —0 cL—D 3- �--L neof Facility: �N b,� �►' �Sv 1 Fi9� �'•t i l y /'�o� E ne of Building: Tress: � � 3U C�+-< <,tid Kew 20 +,0 QAJ �scussed 414 & -e Title: .-77 a d --b -77 _nie YA: Fire Safety Deficiencies Numbered noted on the Letter D Fire Safety Correction Notice (EN -11) [dated A)O have been corrected. Uncorrected Deficiencies Numbered were re -issued as shown on the Fire Safety Correction. Notice dated I . which is attached to and made a part of this Report. In addition., /AS42 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: _.40=--= 4/ CJ - Ao-t Pic, (A I 16P 6 x GO -5 (Rev. 7/86) Mt r. ;STATEjk��At .04 TE 1(X. K���4 % x GO -5 (Rev. 7/86) off CE 04, P,ag& 01. Office of the State Fire Marst 'k 0 INSPECTION REPORT STATE FIRE MA AL 00 04 42 �ile No.: 0003 000 035 ame of Facility- Thomasson Family Home Name of Building: Address: 3530 Cherokee Road Oroville, Calif. 95965 141 D erl ona , 4kit cus MOT! An annual inspection was conducted at the above facility. The owners were requesting fire clearance for one ambulatory client, who at the time of placement is 17 years old. One deficiency was noted on an EN -11. the facility maintains a reasonable degree of fire and life safety, a. c a3 F -w8812 a. ryr s. OV 4 GO - 6 (Rev. 7/86) V J 20, REGION. F Dept. of Social Services OFFICE Community Care Licensing AND 520 Cohasset Rd., #6 TATE FIRE MARSHAL COPY DISTRIBUTION: SEE REVERSE OF COPIES 2 AND 5 FOR IRE SAFETY INSPECTION REQUEST 1 -3 -STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION 2 -FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM TO 850 (REV. 8 / 86) 4 -5 -LICENSING AGENCY 11_3_88 . AGENCY CONTACT TELEPHONE NO. 5. EVALUATOR 14. DSS/CommunitAr fare Licensing (916) 895-5033 0105/Laurel Eckert . SFM REGION SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO. 9. REQUEST CODE 330 17. 041304029 7A# CODES 'REQUESTING CLEARANCE FOR ONE CLIENT UNDER THE AGE OF 18. 1. ORIGINAL A. FIRE CLEARANCE 2. RENEWAL B. LIFE SAFETY 3. CAPACITY CHANGE CHANGE Dept. of Social Services 4. OWNERSHIP O. AGENCY Community Care Licensing 5. ADDRESS CHANGE NAME 520 Cohasset Rd., #6 6. NAME CHANGE AND Chico, CA 95926 PREVIOUS NAME - ADDRESS 7. OTHER DATE OF ORIGINAL REQ. DATE OF LAST FIRE CLEARANCE 1. AMBULATORY NONAMBULATORY TOTAL CAP. APACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS TO 18 18 TO AND CAPACITY TO 18 I8 TO AND CAPACITY 19. FACILITY 6 165 6 X OVER 4 165 X OVER 10 CODE 735/adult res. 2. FACILITY NAME 13. NO. BLDGS CODES THOMASSON FAMILY HOME 1 1. GACH 7. ICF/OT 2. GACH/R 6. ICF/DD 4. STREET ADDRESS (ACTUAL LOCATION) 7 P.O. BOX 15. RESTRAINT 3530 Cherokee Rd. no 3. SH 9. ADHC 4. APH 10. CLINIC ITYZIP CODE 16. HOURS Oroville CA 195965 24 5. PHF 11. JAIL 6. SNF 12. ICF/DDN 7. FACILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL Lula Thomasson 916 533-6830 13. OTHER TO BE COMPLETED BY INSPECTING AUTHORITY 26. CLEARANCE CODE r� 8. FIRE Jack Piriski 11 AUTHOR #4 Williamsberg, Suite 3 NAME Chico, CA 95926 FIRE CLEAR, GRANTED AND 2. FIRE CLEAR, DENIED ADDRESS 3. FIRE CLEAR, WITHHELD 27. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 1. INSPECTOR'S NAME TELEPHONE NO. 22. CFIRS 23. T-19 OCC. ID NO. CLASS Ann C , // %L 4-31 .2- Z 1. EXITS h�a 2. CONSTRUCTION 3. FIRE ALARM 4. INSP. DATE INSPECT S SIGNAT R Wy ---_N 4. SPRINKLERS 5. HOUSEKEEPING 8. EXPLAIN DENIAL OR LIST SPECIAL WNDITIONS A-- C�� /� IQ G/L. p, (,Iti-toy, A" il jQof�4*t,6 4,+-rvrLq 6. SPECIAL HAZARD 7. OTHER � J 20, REGION. F Dept. of Social Services OFFICE Community Care Licensing AND 520 Cohasset Rd., #6 '�" /0""'Jffice of the State Fire Marsh?, Fire Safety Correction Notice 1/�-. He No: o -Aw �� j � l �����r rte.,y.r,� l` � � • �. � ,� % ' � �� ` � Jame: iddress: LO lot, L < A L �� 1 1ti J r , � � / .;- �/ � `: -'� � V �-- Vic:- �c ,r ,(J� -�-_,.eoj N-11 (Rev. 7/86) w VD/W lJlblKlt$UllUN: LACEIN—rdClIlly VV III I L-gw5pul I ST TE FIRE MARSHAL •� COPY DISTRIBUTION: SEE REVERSE OF COPIES 2 AND 5 FOR INSTRUCTIONS FOR COMPLETION 1-IJAF't I T IIVJYtko I IVIV 1 r_u J 1 '-J-J'^"` ' 2 -FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM rt ST 850 (REV. 8/86) 4 -5 -LICENSING AGENCY 3. GENCY CONTACT 4. TELEPHONE NO. 5. EVALUATOR n >>/Comlk�un yL are Licersin,, _ , - }- '• . `. 6. FM REGIONI.D. 7. SFM NO. S. REQUESTING AGENCY FACILITY NO. 9. REQUEST CODE 330 041304029 CODES *REQUESTING CLEARANCE FOR ONE CLIENT UNDER THE AGE OF; 18. 1. ORIGINAL A. FIRE CLEARANCE 2. RENEWAL B. LIFE SAFETY 3. CAPACITY CHANGE Dept. of Social Services 4. OWNERSHIP CHANGE 10 AGENCY Community Care Licensing 5. ADDRESS CHANGE NAME 520 Cohasset Rd., #6 6. NAME CHANGE ANDV 592 Chico, CA 95926 C 11111 7J i US ADDRESS L 7. OTHER DATE OF ORIGINAL REO. DATE OF LAST FIRE CLEARANCE 11. AMBULATORY NONAMBULATORY TOTAL CAP. CAPACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS TO 18 18 TO AND CAPACITY TO 18 18 TO 165 AND CAPACITY 19. FACILITY 165 65 1 OVER 1 65 OVER CODE 1 FACIL,iY 13. NO. BLDGS CODES i /� 7 MSP 1. GACH 7. ICF/OT p. GACHlR 8. ICF/DD 1 . STREET ADDRESS (ACTUAL LOCATION) P.O. BOX 15. RESTRAINT 3530 Cherokee Rd. - 3. SH 9. ADHC 4. APH 10. CLINIC C TY ZIP CODE 16. H1,1''RS 1396* 5 5. PHF 11. JAIL 6. SNF 12. ICF/DDN I .FACILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL Lula Thomasson 916 533-6830 13. OTHER TO BE COMPLETED BY INSPECTING AUTHORITY 1 FIRE 26. CLEARANCE CODE t- IPiriski AUTHOR ,(Jack #4 William8berg, Suite 3 CODES NAME Chico, CA 95926 1. FIRE GRANTED AND -CLEAR, 2. FIRE CLEAR, DENIED ADDRESS 3. FIRE CLEAR, WITHHELD 27. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 1. INSPECTOR'S NAME TELEPHONE NO. 22. CFIRS 23. T-19 OCC. ID NO. CLASS �/S' 431 Z 1. EXITS 2. CONSTRUCTION 3. FIRE ALARM 4. INSP. DATE --L 25. INSPECTOR'S SIGNAT RE /j�� c�_ Tt� y 4. SPRINKLERS 5. HOUSEKEEPING 8. EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS vlt n vv. c 17 ff J� /hi: 6. SPECIAL HAZARD 7. OTHER ! i STATE FIRE MARSHAL USE ONLY RE'r TO: F O. REGION. Dept. of Social Services - OFFICE Community Care Licensin.a AND 520 Cohasset , #6 )Rd. ADDRESS Chico, CA 95926 L CTIOAS 4(0�1� 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 20 sections on this form before submitting It to the State Fire Marshal 1 -REQUEST DATE. Enter the date request was 12. FACILITY NAME. Insert the name of the facility as prepared. it will appear on the license. List identifying sub ncame 2. PROGRAM. Licensing agency use. if known- (i.e., Hacienda Corp/Medina Lodge)., 3. AGENCY CONTACT, 4. TELEPHONE' NO. 13., WO. BL.DGS.- Insert the total number of buildings to 5. EVALUATOR. Enterthe name and telephone be used for housing of the occupants covered by the mimhar of nnannvr nnnfat-f ckronn license. 86 966.5-0 6. SFM REGION. Insert one of the following 3 numbers 14.- ADDRESS. --Insert street address and city only. A for the SFM Regional office in whose area the facility post office box Js not -acceptable as only location. is located: 350 Coastal, 330 -Northern, 370.Southern. 15. RESTRAINT. Indicate if Physical restraint (locked in a room or -the building is -to be used in the houtssing 7. SFM ID NO. This is the SIT Identification Number of the occupants. and initially will be assigned by the State Fire Marshal. Licensing- ppy—Insert this number on all 1.6. HOURS Indicate the number of hours the clearance requests subsequent to the initial request. I SS occupants are housed at the facility (le than 24 or 24+). 8. REQUESTING AGENCY' FACILITY NO. This is the - file number assigned by the licensing agency. 6 1a. SPECIAL. Use -to designate persons who are 46'tier*mfined to be non-ambulatory for reasons other 9. REQUEST CODE. Use the seven codes shown and than a physical handicap. insert the appropriate number in the box following .."Request Code""'. If -NAME CHANGE, please -list 17. FACILITY CONTACT PERSON—TELEPHOINE previous name. Insert date of ' original request when NO. Indicate' the name and telephone number ofthe request is other than an original. responsible individual .at the.facility to be contacted loot AGENCY NAME AND ADDRESS. Enter -the name by the fire authority - and address of the licensing facility requesting the 18. FIRE AUTHOR, NAME AND ADDRESS.'. Insert the inspection. name and address of the fire -authority where the 110 AMBULATORY—NON-AMBULATORY. facility is located. Capacity. Insert, in, the appropriate section, --the 19. FACILITY CODE. - (1) General Acute Care -Hospital 'Hospital/Rehab capacity of licensed ambulatory or non- (GACH), (2) General Acute -Care ambulatory occupants covered by 'thi's - (GACH/13). (3) Special Hospital. -(SH),'-..(4) Acute •ing request. Psychiatric -Hospital- (APH), (5)'Psythiatric, Health Facility (PHF), (6) Skilled NursFacility (SNF-),' Age Indicate the age range of the licensed (7) Intermediate Care Facility/Other (ICF/0T), Range', occupants- (8) Intermediate Care Facility/ Developmentally Previous request is for renewal or capacity Disabled Hab-ilitative (IGF IDDI-1), (9) Adult Day ..If Capaci.tyl—change., insert capacity of previous Health Care (A HC), (10) Clinic, (11) Jail, learance. (1 0Z) Intermediate .-Ca'r'e -Facility /Developmentally 'rotal Disabled Nursing (ICF /DDN), or (13) Other. Show total licensed capacity. If the facile Capaqit,y,.-ty is intended to house part ambulatory 20. REGION, OFFICE AND AD -DRESS. Insert the name and. part non-ambulatory, show the total and address of the State Fire Marshal Regional of the two types of occupants. Office in whose area the facility is located. FIRE AUTHORITY CONDUCTING THE INSPECTION09=0=0000MPLETE THE FOLLOWING. 2 1. INSPECTOWS 'NAME. Print the initial of the in-. the three codes shon -26CLEARANCE Co g __jJ-sV_ w spector's first narne ,and full last name; insert the and insert the a-ppedpriate number in the box follow - telephone... number where, the inspector may be con- ing "Clearance Code"'. tacted. NOTE, If Code 2 (Denied) or Code 5_(Witfiheld) is used. explain, $.2. CFIRS P. NO.. --Insert the fire department's number assigned. by CIIS. 27.DENIAL CODE. Use only the seven codes shown and insert the appropriate number in the box follow- 3 19 ,. . TITLE OCC. CLASS. Use Title 19 occupancy ing "Denial Code"'. If No. 7 "Other"' is used, explain classifications and insert' the occupancycletern-flned at Item 28. by the inspector. NOTE: Fire Ciearance cannot be denied for other than Jack of confa.r- 24. INSP. DATE. Enter' actual date of the in- mance with the provisions of Title 19, spection. 28. EXPLAW:DENIAL. If Clearance Code No. 2 or 3 is 25. INSPECTOR'S -SIGNATURE. To be signed by used, briefly explain. reason. -This space is also to be inspector conducting the inspection. used to explain Denial Code item noted. 86 966.5-0 v A .` Office of the State Fire Marsh. Fire Safety Correction Notice File No: Name: Address: *FIRE HAL The California Health and Safety Code and the State Fire Marshal's regulations require the following fire safety deficiencies be corrected': I ` 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. 7/85) 86 96708 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field STATE OF CALIFORNIA—STATE AND CONSUMER SERVICES AGENCY STATE FIRE MARSHAL NORTHERN REGION 4�,33 FLORIN ROAD, SUITE 400 SACRAMENTO, CA 95823 July 9, 1986 Harley & Lula Thomasson Rt 1 Box 307G - Cherokee Rd. Oroville, CA 95965 SUBJECT: THOMASSON FAMILY HOME SFM FILE #: 00-04-84-0022-000-330-0 Dear Mr. & Mrs. Thomasson: GEORGE DEUKMEIIAN, Governor (916) 427-4325 ATSS 466-4325 TDD (916) 427-4186 . , ..,• During our recent meeting you asked that we reconsider our response to your pending fire clearance request for a capacity increase from six to ten full time care ..._severely....:hand,. capp.ed_.. people. Your request was prompted by our letter of November 22, 1985 which listed the modifications required in order for your home to be eligible for fire clearance. You indicated that, when plans to convert the garage into bedrooms were approved by the State Fire Marshal on March 4, 1985, you assumed the building would qualify for the capacity increase that you applied for on June 24, 19850 The requirements impacting your home are contained in Section 13143.6 of the California Health and Safety .Code and Titles 19 and 24 of the California Administrative Code. These standards, our records and the information you provided were used in our review of your case. There are some important differences in the fire safety requirements governing housing of six or less persons and homes caring for more than six people. Two requirements are significant i n the case of your home. Section 2-1403 of Title 24, California Administrative Code specifies that a building used for the full time care of more than six people between the ages of 18 and 64 shall be of not less than one-hour f i.-r.e--r-e i-,s„t.-i-ve--co.n,s-tr__u_c.t_i on . A home used for similar care of six or less may be of non fire -rated construction. Health and Safety Code, Section 13143.6 and Section 2-1409 of Title 24, California Administrative Code stipulates that an approved automatic fire alarm system be installed in a building used for full time care of more than six persons if any of them are physically or mentally handicapped or non-ambulatory. Plans for your garage conversion into two bedrooms and support space were received on February 14, 1985. (Please refer to enclosed Plan Review Transmittal) The transmittal indicates that the review is for"garage i conversion for group I -1A occupancy." A group I -1A occupancy s one that W, Harley & Lula Thomasson -2- July 9, 1985 accomodates six or less persons. The Plan Review Approval dated March 4, 1985 for the 720 square foot bedroom addition (copy enclosed) was granted on the basis of a capacity of s i x or less persons . Our records indicate that you and Deputy State Fire Marshal John Woods discussed the requirements for full time care of more than six persons. During one of these discussions Deputy Woods indicated that your building could meet fire safety design and construction requirements for the full time care of more than six persons without being of one-hour fire -rated construction as a "Group D, Division 3 Occupancy". A "Group D, Division 3 Occupancy_', risa home for full time _care of more than six ambulatory porr-oma �i9,6 -'18 through 64 .. not -.-, inc - 1 udi ng employees or relatives. Bui 1 di ngs----h,ou!ssijng Group D-; D i v`iion 3-OC'ufp`aht'i es need--n-o"be' of" one'hour fire -resistive construction when not more than two stories in height and not more than 3,000 square feet. .--Your home --meets .-th.i..s...-cr-. eri a as� it is not more than two siories '-and"i s less than. 3,000.._sq.uare feet. in d -der for it to qualify as a Group D, Division 3 Occupancy with a capacity of 10, at least s i x persons would have to be ambulatory and not more than four people could be non- ambulatory. on- ambulatory. In summation, the requirements noted in our letter of November 22, 1985 are correct and apply to your request for a capacity increase from s i x to ten people, six of whom are non-ambulatory. I suggest that you contact Community Care L -i cens i ng about revising your application if you wish to have your home qualify as a Group D, Division 3 Occupancy. We are requesting that Deputy Woods visit you to answer any questions prompted by this letter or -about th,e applicable requirements. Sincerely, JAMES F. McMULLEN State Fire Marshal WALTER McDERMOTT Deputy Director Field Operations WM:JCH:ca cc: John Woods, Deputy Enclosures: 2 Photos of Thomasson Home Plans - 2 Sheets (2/3 & 3/3/85) Plan Review Transmittal dated 2/14/85 Plan Review Approval dated 3/4/85 Application for Community Care License dated 6/24/85 i STAIRE MARSHAL COPY DISTRIBUTION; SEE REVERSE OF COPIES 2 AND 3 FOR �" FIR AFETY INSPECTION REQUEST 1 - STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION STD 50 (NEW 6/80) 2 - FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM 3 - LICENSING AGENCY 02/14186 CC F109 3. AN Y CONTACT 4. TELEPHONE NO. 5. SIGNATURE � PT SOCIAL SVCS* COM CARE LIC 4-9161 1" 895m-5033.. 6. SF EGION 7. SFM I.D. NO. 0077-- 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR 00 t04vA-84=w000m*3300 041304029 0103 19. REQUEST CODE 2A CODES 1. ORIGINAL A. FIRE CLEARANCE F 2. RENEWAL B. LIFE SAFETY 10. A ENCY OE PT SOCIAL S%fCSt CON.CARE LIC 3. CAPACITY CHANGE N ME .520 COHASSETT ROAD, SUITE 6 4. OWNERSHIP CHANGE A DRESS C H ICO ! CA 95926 5. ADDRESS CHANGE L 6. OTHER A NAMSULATORY ADULTS AGES 18 THROUGH A1 DATE OF ORIGINAL REGI. v 11ATORVIFOUR 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FAIRE CLEARANCE 06/28/8.5 CAA ITY 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 6CODE 20. FACILITY 735 12. F CI ITY NAME 13. NO. BLDGS. CODES T S I FAMILY NOME 1. GACH. 7. ICF/OT 2. GACH/R 8. ICF/DD 3. SH 9. ADHC 14. ST E T ADDRESS 15. RESTRAINT RT I BOAC 307 G 4. APH 10. CLINIC 5. PHF 11. JAIL CY ZIP CODE 16. HOURS OVILLifi 95965 24+ 6. SNF 12. OTHER 17. FACILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL H & L THONASSON 916533-830 ADULT RESI BENT IAL. TO BE COMPLETED BY INSPECTING AUTHORITY 18. IRE 27. CLEARANCE � CODE ; U HOR. CODES AME 1. FIRE CLEAR. GRANTED N 2. FIRE CLEAR. DENIED D DRESS 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. IN P CTOR'S NAME TELEPHONE NO. 23. CFIRS ID NO. 24. T-19 OCC. CLASS 1. EXITS 2. CONSTRUCTION 3. FIRE ALARM 25. IN P. DATE 26. INSPECTOR'S SIGNATURE 4. SPRINKLERS 5. HOUSEKEEPING 29. EX L IN DENIAL OR LIST SPECIAL CONDITIONS 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY 21. IEION, F FICE N D DRESS L J TIME MILES NEXT INSP. (MO. DA. YR.) OFFICE OF THE STATE FIRE MARSHAL INSPECTION LOG Title Mw :U:i AA, 4 U ro o 1__JAC4 _.a�J- _ r.m r:M m EPA v [on Address a Date GO -6 (Rev. 5/81) ICE' - 6F RE �SA► CREIN N(3T1 STA"i`E .'IRE MAR At - ATE FIRE MARSHAL CO!!',Y DISTRIBITION; F RE SAFETY INSPECTION REQUEST 1-3 -STATE FIRE MARSHAL A~ SEE REVERSE OF COPIES 2 AND 5 FOR INSTRUCTIONS FOR COMPLETION S1 D 850 (REV. 7/80) 2 - FIRE AUTHORITY, 1. REQUEST DATE 2, PROGRAM 4-5 - LICENSING AGENCY . AGENCY CONTACT 4, TELEPHONE NO. SIGNATURE 'are Ucensin 15. • SFM REGION 7. SFM I.D. NO, 9. REQUESTING AGENCY FACILITY NO, 9. EVALUATOR - 19. REQUEST PESPONSF.', CODE CODES (.ORIGINAL AFIRE CLEARANCE O. AGENCY F- DL'PARTMENT OF SOCIAL SERVICES 2.RENEWAL B. LIFE SAFETY . NAME COMMUNITY CARE LICENSING •AND ADDRESS 520 CobasSet Road. Suite 6 3.CAPACITY CHANGE 4.OWNERSHIP CHANGE Chico, CA 959.26• "`,'.' S.A DDRESS CHANGE DATE OF ORIGINAL REO. 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE _ C kPACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS TO 10 IB TO 165 AND 65 OVER CAPACITY TO 18 IB TO 65 AND 65 OVER CAPACITY - CILIT� . `'1,I�CODE 4�6- --- 1 It. FACILITY NAME 13. NO. BL CODES �a,� '� ICF 1T Z. G Cx� Re 8. ICF/bK IS. ADDRESS 15. REST I$TREET C 7,-, It 4 t Box ✓7J 4... Cher{ kee 1ti.Q`ad ._ �:�t4NT N 3. S . ((�Vj• 9. AOHC 4. APR G� � 10. CLINIC 5. PHFjL 11. JAIL 6. SNF 12. Q1-1 ER O CITY t' ,Jro L Le 9 �.1- -95 ZIP CODE 16. HOURS �4 �f1 I FACILITY CONTACT PERSON _ TE LE PFIO NE NO, � i6A SPECIAL TO BE COMPLETED BY INSPECTING AUTHORITY 18. FIRE 27. CLEARANCE AUTHOR. CODE NAME CODES AND I -FIRE CLEAR. GRANTED 2. ADDRESS J FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE - TO BE COMPLETED BY INSPECTING AUTHORITY CODES 2 . INSPECTOR'S NAME TELEPHONE NO. 23, CFIRS Z4, T-19 OCC, ID NO -L .t `� _- --. CLASS 1. EXITS 2. CONSTRUCTION 3. FIRE ALARM 4. SPRINKLERS 25. INSP. DATE26. { a INS)PE CYOR'S SIGNATURE .�.. 5. HOUSEKEEPING 21. EXPLAIN DENIAL OR. LIST SPECIAL CONDITIONS rL, 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY 1. REGION. OFFICE Ftr t(- F'..r r- Marshal AND 4433 Florin !*t-.ite ZKY-) �Reg�y^ 8nd ADDRESS Sacrai1.s=•`i to, LN. 23 J TIME MILES NEXT INSP. (MO.DA.YR.' , INSTRUCTIONS This form is designed for use with a window envelope. To use, fold at marks indicated in the left margin. Licensing or Requesting Agencies - Complete the following 21 sections on this form before submitting it to the State Fire Marshal *Complete items marked with an asterisk only when Item 20 is not used. 1. REQUEST DATE. Enter the date request was prepared. 2. PROGRAM. Licensing agency use. 3. AGENCY CONTACT, 4. TELEPHONE NO., 5. SIGNATURE. Enter the name, telephone number, and signature of agency contact person. 6. SFM REGION. Insert one of the following 3 numbers for the SFM Regional Office in whose area the facility is located. 350 Coastal, 330 Northern, 370 Southern. 7. SFM ID NO. This is the SFM Identification Number and initially will be assigned by the State Fire Marshal. Licensing Agency - Insert this number on all clearance requests subsequent to the initial request. 8. REQUESTING AGENCY FACILITY NO. This is the file number assigned by the licensing agency. 9. EVALUATOR. For licensing agency use. 10. AGENCY NAME AND ADDRESS. Enter the name and address of the licensing facility requesting the inspection. *11. AMBULATORY - NON-AMBULATORY. Complete this section only when Item 20 does not apply. Capacity: Insert, in the appropriate section, the capac ty of licensed ambulatory or non-ambulatory occupants covered by this request. Age Range: Indicate the age range of the licensed occu- pants Previous If request is for renewal or capacity change, Capacity: insert capacity of previous clearance. Total Show total licensed capacity. If the Facility Capacity: is 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 as it will appear on the license. 13. NO. BLDGS. Insert the total number of buildings to be used for housing of the occupants covered by the license. 14. ADDRESS. Insert street address and city only. A post office box is not acceptable. * 15. RESTRAINT. Indicate if physical restraint (locked in -a room or .the_bujld.ing), is to be used in the housing of the-occuparits.' Y = yes N = no. * 16. HOURS. -Indi.cate<the number of hours the occupants are housed at the .facility, (less than 24 or 24 +). 16a SPECIAL. Use to designate persons who are determined to be non-ambulatory for reasons other than a physical handicap. 17. FACILITY CONTACT PERSON - TELEPHONE NO. Indicate the name and telephone number of the re- sponsible individual at the facility to be contacted by the fire authority. 18. FIRE AUTHOR. NAME AND ADDRESS. Insert the name and address of the fire authority in the vicinity where the facility is located. 19. REQUEST CODE. Use the six codes shown and insert the appropriate number in the box following "Request Code". Insert date of original request when request is other than an original. 20. FACILITY CODE. Mark this item only if the facility is a: (1) General Acute Care Hospital (GACH), (2) General Acute Care Hospital/Rehab (GACH/R), (3) Special Hospital (SH), (4) Acute Psychiatric Hospital (APH), (5) Psychiatric Health Facility (PHF), (6) Skilled Nursing Facility (SNF'), (7) Intermediate Care Facility/Other (ICF/OT), (8) Intermediate Care Facility/Developmental- ly Disabled (ICF/DD), (9) Adult Day Health Care (ADHC), (10) Clinic, (11) Jailor (12) Other. When Item 20 is used, Item 11 does not need to be completed (except total cap). 21. REGION, OFFICE AND ADDRESS. Insert the name and address of the State Fire Marshal Regional Office in whose area the facility is located. Fire Authority Conducting the Inspection - Complete the following: 22. INSPECTOR'S NAME. Print the initial of the inspec- tor's first name and full lastname; insert the tele- phone number where the inspector may be contacted. 23. CFIRS ID. NO. Insert the fire department's number assigned by CFIRS. 24. TITLE 19 OCC. CLASS. Use Title 19 occupancy classifications and insert the occupancy determined by the inspector. 25. INSP. DATE. Enter the actual date of the inspection. 26. INSPECTOR'S SIGNATURE. To be signed by inspec- tor conducting the inspection. 27. CLEARANCE CODE. Use the three codes shown and insert the appropriate number in the box following "Clearance Code". NOTE: If Code 2 (Denied) or Code 3 (Withheld) is used, explain. 28. DENIAL CODE. Use only the seven codes shown and insert the appropriate number in the box fol- lowing "Denial Code". If No. 7 "Other" is used, ex- plain at Item 28. NOTE: Fire Clearance cannot be denied for other than lack of conformance with the provisions of Title 19. 29. EXPLAIN DENIAL. If Clearance Code No, 2 or 3 is used, briefly explain reason. This space is also to be used to explain Denial Code item noted. 85 94333 STATE FIRE MARSHAL REGIONAL ROUTE TO. (1) 7- FACILITY CHANGE ANGE NOTICE SUPERVISOR (2) DATE: /I - RECORDS CONTROL CLERICAL (3) QNAME CORRECTION/CHANGE DEPUTY (4) ADDRESS CORRECTION= initials (5) OCCUPANCY CORRECT (6) INSPECTION AUTHORITY CORRECTION/CHANGE (7) FACILITY DISCONTINUED (8) ISSUE OR CHANGE IN FILE NUMBER (9) OTHER (10) 0 L D N E W -t 104 if NAPE. 0'4A'A.s NAME: rZ-t ADDRESSe,.�,j.,r (.X ry 1,� ADDRESS COUNTA' (No. COUNTY: (No. FILE IDENTIFICATION NO. �� L �Q I DO 11) FILE IDENTIF N NO. In Ef 11 E1110ff nlo[j II[Iff 0 0 -,pq 02) OCCUPANCY CLASS:. OCCUPANCY CL code proc. INSPECTION AUTHORITY .-'INSPECTION AUTHORITY (13) LOC.',FACILITY-LOC. INSPECTION (0) LOC. FACILITY -LOC. INSPECTION (0) (14) LOC. FACILITY-SFM INSPECTION (1) LOC. FACILITY-SFM INSPECTION (I (15) E] STM FAC I L I TY.. (0) SFIVI FACILITY (0).- A �. Atw* INSTRUCTIONS This form is intended to relay the information shown between clerical, field and supervisory personnel. 1. ROUTE TO: The originator of the form shall check, in the appropriate square, the individuals who are to receive the form. Upon receipt of the form, the recipient is to initial it in the space provided adjacent to the checked box. 2. DATE: Enter the date when the form is originated. 3. NAME CORRECTION/CHANGE: Check this box only when there is a -correction or change in the name of the facility. 4. ADDRESS CORRECTION/CHANGE: Check this box only when there is a correction or change in the address of the facility. 5. OCCUPANCY CORRECTION/CHANGE: Check this box only when there is a correc- tion or change in the occupancy classification of the facility. 6. INSPECTION AUTHORITY CORRECTION/CHANGE: Check this box only when there is a correction or change in the inspection authority for the facility. 7. FACILITY DISCONTINUED: Check this box only when the facility has been dis- continued. 8. ISSUE OR CHANGE IN FILE NUMBER: Check this box whenever boxes 5 or 6 are checked. 9. OTHER: Check this box and write in purpose if not covered by. boxes 1 thru 8. 10.- NAME AND ADDRESS: Print name, address and county where facility is' Iocated...:.(No.-. ) shall be the county -number -.assigned by. the Regional File Procedures. 11. FILE IDENTIFICATION NO.: Insert all of known file identification numbers in accordance with Regional File Procedures. 12. OCCUPANCY CLASS: Insert occupancy classification as determined by T-19 in sect i.on marked "Code" and occupancy number as determined by Regional F i le Procedures - in.section marked "Proc. 13. LOC. FACILITY - LOC. INSPECTIONS: Check this box only. if the facility is within the jurisdiction of and inspected by the Local Enforcing Agency. 14. LOC. FACILITY - SFM INSPECTION: Check this.box only if..the.local_.enforcing agency is the legal authority and the SFM conducts the inspections. 15. SFM FACILITY: Check this box only if the SFM is -the legal authority and is conducting required inspections. .16. COMMENTS: This space is to be used only to relate special circumstances relating to the facility file not covered by items 3.thru 9. 17. ORIGINATOR: Insert the name of the originator of the form._ NOTE: 1. ,This form is NOT to be used. in lieu of a required inspection form. y.. 2.., _This form is to- be filed-. in a.. separate file by-. month, ---county,: and.- facility name (alphabetically) and retained for one year. OFFICE OF THE STATE FIRE MARSHAL INSPECTION LOG DR 9N 22 File 01:1111:1 DDD Address c tl`� 4 Date Owner - to c,a p TO f4.- t.,O int i Dp--? fit C u11 4X12 V at X�C 4tpP-C:Ao� it ytJ KJ C, Not tc S -o f at !&.!A�-eg f /L)v a AGO t c,4 j'k:� A") ''z T t W, i'` � sc cs✓J i uco" t Z .. vJ✓� tvi� �.9v- ;�-4 kC"ir,9 66-" oxy-,CXTY 3 �A icle A14(li vAc AVT- Qtr G0-6 ( Rev. .5/8 t) _ OFFICE OF THE STATE FIRE MARSHAL INSPECTION LOG Title J:homAsroo prv;o4ftY c4rm,,S File Address ,,,� i 6.,)< .�Q 1 6 (CAiuFAoKtFAf 00vrccF C4 Date Owner I-tAtGf't A� L-�L r10e1,,4SSyAJ .�. �''t �c4' GJ i/i C �', t,(� W - E.{ l �" -I.� 3 4'� G (Z�i•� Z# .� If u j. AEC ! 4-A C (L t r (r /Lov &&A s % 1-e!µ tC A lJo r%' �'L' X;/4 vdi' Ll c, �u a�� vett ►�../ c.�ptc �� �Uc? G .S l� �C�,C'�� �4 �t � CX4 tom' &a� GO -6 (Rev. 5/81) STAT F CALIFORNIA—STATE AND CONSUMER SERVICES AGENCY TE FIRE MARSHAL `�`` `'"" GEORGE DEUKMEJIAN, Cx6yernor Date q- 000 sow Name of Facility SFH # Vow -- T "Z ' r✓I y� 0_ A.)�rl 00 04 A I L% sf Address of Facility. Owner/Operator- 14 A 4, An attempt was made to inspect the above facility this date. Please, notify the office listed below by mail or phone, so� that an Inspection can be scheduled FIRE CLEARANCE MAY BE DENIED IF NOTIFICATION IS NOT RECEVED WITHIN 15 DAYS. Office of the State Fire Marshal.. Office of the State Fire Marshal 4433 Florin Road, Suite 400. 429 Red Cliff Drive, Suite 205 Sacramento, CA 95823 Redding, CA - 96QO2 (916)427-.4325 (916) 225-2222 [lop! fice of the State Fire Marshal Office of the State Fire Marshal 4..Williamsburg Lane, Suite 3 1500 West Shaw, Suite 301 Chico., CA 95926 Fresno, CA 93704 (916) 895-4312 (209) 445-6117 Office of the*State Fire Marshal 2937 Veneman Avenue, Suite B Rm. 155 Modesto, CA 95351 .(209) 576-6122 DejUty State Fire Harshal . Q- Second Notice • EN* 12T i OFFICE OF THE STATE FIRE MARSHAL INSPECTION LOG T i t I e+- Fi { le 4 M�q- q!] Q1 V- 9 S Ad d res s� �- .�.,... � �� � � • t } ''� Date <, I(o Owner G a s .. .� LAI") CL L14 i ' Co . Al! Myx ov-�A' btf Ll2LA J. Ov tkA�- IN)5- cda-caLLL- S Pi'l: OF CALIFORNIA O -State Fire Marsha S r rxr,ento Reg i6n 44 3 Florin Raad, Suite 400 S car amen to,. CA 95823 • --9 (Rev. 7/83) (916) 427--4325 ATSS 466--4325 PLAN REVIEW APPROVAL ` FILE .•.. „'. �. �V a7 , a .r 3c� -b c' OSHPD NNWC'�tL.Q SIL � �� • S ECT: Rep oducible plans and specifications for the subject project covered by our Pian Review T a smittal dated , are now approved by the State F. ire Marshal and we r e. stamped and signed ons • The project is identified as the proposed 6bo g0o &&.1 2v S ec 7L401C v By ,opy of this transmittal to the Architect, we are advising that SFM stamped and approved pla s and specifications are to be available on this -job site. Nothing in this review shall be construed as encompassing structural integrity'. Final, approval of this project is, subject to field inspection,. - cc: Fire Department ~'1a" tre Cact tmerr+-. Pirch-i-tere t Fi.eic� . 0SHP S-o-trW44,-:2-r4Re-g ion Rei -ion• - B e�z-t.--,--af--Eorre c st i n s Signature. ST T , - IRO MARSHAL FIR SAFETY INSPECTION REQUEST COPY DISTRlBITION; �� SEE REVERSE OF COPIES 2 AND 5 FOR 1-3 - STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION STD 50 (REV. 7/80) 2 - FIRE AUTHORITY. 4-5 - LICENSING AGENCY35 1. REQUEST DATE 2. PROGRAM 3, AGENCY CONTACT 4. TELEPHONE NO. S. SIGNATURE anity ire yi (916)87�-483 .6. S M REGION 7. SFM I.D. NO. .22 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR 000484 334 4 0441"4M9 4143Aam-e .a ioralez zu 19. REQUEST A 3 CODE CODES 1. ORIGINAL A. FIRE CLEARANCE ' 10. GENCY � 2. RENEWAL B. LIFE SAFETY 11-0 1 34 AME I&C nx ND 520 t Road ftte D D R E S S Obi�,5 1 3. CAPACITY CHANGE 4. OWNERSHIP CHANGE 5. ADDRESS CHANGE L6. OTHER (NEW lr On) DATE OF ORIGINAL REQ. 11. AMBULATORY _ NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CAI A ITY AGE RANGE (YEARS) TO IS 1S TO 65 AND 6 OVER PREVIOUS CAPACITY CAPACITY AGE RANGE (YEARS) TO 18 1S TO 65 AND 65 OVER PREVIOUS CAPACITY 6 20. FACILITY � CODE 17 12. FACILITY NAME 13. NO. BLDGS CODES .. One 1. GACH 7. ICF/OT 2. GACH/R 8. ICF/DD 14. STREET ADDRESS 15. RESTRAINT IRI i Bm (Cherokee Road Ino 3. SH 9. ADHC 4. A P H 10. CLINIC 5. PH F I 1 . JAIL SNF 12. OTHER CI ry Mvviuleg CA 9596517. ZIP CODE 95965. 16. HOURS 24+6. FACILITY CONTACT PERSON TELEPHONE NO. 16A SPECIAL rr1eand Imla eman 010.5,30,10toww"30 Aftlt Residential TO BE COMPLETED BY INSPECTING AUTHORITY 18: F RE i 27. CLEARANCE A THOR. CODE ' NckME CODES A 14D 1. FIRE CLEAR. GRANTED ADDRESS L 2. FIRE CLEAR. DENIED JHHE L 3. FIRE CLEAR. WITHHELD ,28..'DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. N PECTOR S NAME TELEPHONE NO. 23. CFIRS 24. T-19 OCC. ID NO. CLASS 1. EXITS 2. CONSTRUCTION d 3. FIRE ALARM 25. INSP. DATE 26. INSPECTOR'S SIGNATURE 4. SPRINKLERS 5. HOUSEKEEPING 6. SPECIAL HAZARD 29. EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS 7. OTHER STATE FIRE MARSHAL USE ONLY 21. R GION. F- 0 F I C E State 71" a . 7 r1r." nerft- ft" ftite A DRESS 41 areata, CA 9%23 TIME MILES NEXT INS P. (MO.DA.YR.) �SIT sn0 +4iS iss,titsb. 951 IlubA ET mo rO (are) t� at F 000 8SOO4iB+1000 .V4 stiva bsoR *Ak smoo OR 6We AD ,00l:63 (MOR OT KalTIUc€A WE) 41 C bsofd seAozsrig) fl TOE x+ca P 4" tz%-up... (aro) -SSuI orplong ES" M -M WIn S* P ON 49*bmb ama,-li F.E. �:Sb�e AD olixemsoic SULT I PLE M I LD I iNGFA :.ITY RECORD FACILITY NAME ADDRESS:/ • t 3 Y FILE NO_ SERIAL • ' BUILDING IDENTIFICATION OCCUPANCY FILE_- { SUFFIX NO. CLASS ?tiJ� �ETt (Sep- Sec.Nc.3.) {`�� Am.. OFFICE OF THE STATE FIRE MARSHAL INSPECTION LOG Title %� .,, 45 0.-� t ,/ f/c RJ U [A 15] RR I e aaQQ aaa 2Q3 a Address f / �x �G� �r `�.�r cte�s- C� r- r �r •'//� � CAI. 5 S 5 G 5� Owner 7- A -z e_ c o.n L i h S9 �7'-fa c 7t" c- c G G� C`: c / ' /� "t � �'-P f t/''e C h � /rte 7- 7(— !1 C / fC' ✓ 4lor, C1 1iP -ct GD -6 (RAY. 5/81) .�� • .t,r``r '�^ ���� � .�M• __���s�,•,••�.�,tr'•j�,r: �•�"tt • �• .• � � .. `S'.''•• .+ -• .. -. ` • .- ' -• _ - t, w''•x.��. -Jv-�Yq~`f-f �i �' • -�• i�- •, - .• , J.. ' T N .. ` �J!i ori--:.a••'4�a.•t, r•'C'a'Y•� r. • _..r »-;r 1s,`. STATE FIRE` .. -'��'• .7...:1 -war - • _ , •� •-F�'�i••..4i.- _.` *A- ,•4•i L. M ..• • ♦ r - • • .�. ..• ' r, Y i wH! �• .I -t•' Tam r. 1 -~•'A• • . �.. _- y r.•....�i_ •-! _ i •u1„`i �7�4.a• +�•..s• �a2'- . V 1. _ . , •' -y .. - � t-;' •.,'•;�- ., S' � .^ - -Y• � C �; • •!r r y.+� �. ..+►: •7l�•wr��. ^iy�•.s� ` .. v_' - - ' .. _ .. •`' - lt.:.�•= 4. ... v • 1 •+rn. • . .t - - _ • �. •'�i, •�- • . - . t - ..� .. . • •,,.. I • ....,Jy r ).. - -�•�i1• -^� -/. I.• .•ju. .y��� ..• - +•" iii 'N �'�.'rY .'••' �.. . - + - .. �. �-'� .s•'"-'•�, �...c .. + � • ;.a, '• :�.'L.~'•.t • REGIO - • �..• � --�:..r. r.... - .••.r -- .•►+. ��•si•'�,✓r� �• ��'�M �Q..1'�y'.• _ ... '• •. , • •. FACT LLTY C Ag_ - . . - : .� ..-. _ .. •".: -. SL0zfR'V1 SOR dim- ammummuml •-. �� DATEMir.M.M. =1rRQL. CECT I OWCHA DEPUTY: _ :.. ' (4) A;Ss • - -� - _ • ECT IOWCH _ _ • _. • • ' :'!J •���`.'•.r•j♦iryy �yry.,-a. ��(f �••.rY•i. •,~j••.; "•� : ��., �r� - _�1 •.i..��•��S'� i•�, - Yof"jam �_.��f a 1 �.� �1- - ��+.•� �y-:r-{ �'a-(y .••Y•'.: .�•i�•+, '=�. - -I ,i _ �.-•f'-"►.f- - :/•.•ter -.4 �+ _•„•. �� 1._b.l'. ••+ • �.,�t t.••s au.�.•i ••►•. _ t� - -}. . "_' Cib I OCH - - ♦ r,.' = —.�. •. _ _.. (7) FACT LITY DISCONTt E r- • ' •- -- - 'N -E NLMEIM ► . _a , _ M ...... ••►: �r•r.+o! @1 s'�1tm':'s"'.. rev' �. w. ♦ . r ...• i • - ••1r �. - -,•Y .. •�. + .� I•. i•....Yi ►._• • �'� 'M �.' _ -•-.• :.►�': .M w' • ffjj�� 3` _ . qAr•'•= ..�..�Ml:i♦. =-�••i':� r••, +-' t A�� `, fir:.. •'A •-i• �•. t' -fir .. .`'_ •..A,:- Aw D' r ,� toe ADMR ESS .04 ow COUNTY: ; • : _ - (No. C. !) COUNTY. � - _ • . -' c I LE I DENT I F I CAT I O `h.� : F I LE. 1 DENT i F. I CAS' I ON NQ4 , . Z) 0 (12) OCCUPANCY- CLASS. -- � D F � OCCUPANCY CLASS � '-- �. - 1 � .•...„�, • - code. � pr-oc . • � � code roc- 44 INSPECTION AUTHOR I TY - i NSPECT I ON.. -A CR I r = 13) LCC e FAC I L I TY --LDC . I NSPECT' l ON (0) LOC. FAC I• L I TY- LOCMSPFC174 0� (D } : .74) LOCo FAC 1 L I TY --S FM I NSPECT I Did- (.1 - LOCe, FAC i L I TY S Fid f NSPECT I CN 0 ell { 15) S Fid FACILITY (0). S FM FACILITY (0). (16) ' COIN02MEN-TS-: 1 ? F -C tLITY CONTA C P _ le and L ► (916) 5 le. FIRE UTHOR. AME AND IaDRESS L Aftlt Re + ice. - TO BE COMPLETED BY INSPECTLNG AUTHORITY �-I '27. CLEARANCE ` CODE CODES t . FIRE CLEAR. GRANTED 2. FIRE CLEAR. DENIED J 3. FIRE CLEAR. WITHHELD 28.. DENIAL. CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES ZZ. 1 ;PECTOR S NAME TELEPHONE NO. 23. CFtRS 24. T-19 OCC. 10 NO. CLASS 1. EXITS 2. CONSTR-UCTIO.N 3. FIRE ALARM 25. INSP. DATE 26, INSPECTOrR S SIGNATURE S. SPRINKLERS 5. HOUSEKEEPING 2S. EXPLAIN. DENIAL OR LIST SPECIAL CONDITIONS 6. SPE`C'IAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY REGI.QN. F_ OFFICE state r maw A w r rl% - . - - - - - A Big sTA a RIR$ 1MARSMAL. COPY ©tsTRtBITtoN; SEE REVERSE OF COPIES 2 AND 5 FOR FIRE SAFETY INSPECTION REQUEST 1-3 - STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION STD 85 (REV. 7/80) 2 - FIRE AUTHORITY. - I. REQUEST DAT1S 2. P1ROQ.RJ1 4-»5 - LICEN'SI NG AGENCY AGENCY 3. CONTACT 4. TELEPHO-NU NO. 5. SIGNATURE D . t Cie 0" ' 8. SFIA REGION 7. SFM I.D. NO. ��.��.,. S. .REQUEST$ -NG AGENCY FACILITY NO. 9. EVALUATOR 00 a4 84 01901106, t 0 04,1304029. 0103. -Names - alez 19. REQUMST a CODS F -- - - - CODES 1. ORIGINAL A. FIRE CLEAR -A-1406 10 GENCY 2. RENEWAL. g. LIFE SAFETY JAML' ty Ca" I&C 3. CAPACITY CHAPtGE. NO 520 Cftad &dto 4. OWN)= R S H• W C t -I A N -G E.: DDR E S S A. Chico, 95926 5. ADDRESS. CHANG-€ L 6.. OTHER C'I-ATZ OF OR-IGIf*AL REO. TO m1m) -.--.l4IONAMBULATORY t1. AMBULATORY - TOTAL. CAP. DATE oaf LAST FIRE CLEARANCE CA A ITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS TO 18 18 TO 65 ANG CAPACITY TO 18 18 TO 6S AND CAPACITY 20. FACILITY* 65 OVER 65 OVER - G Q D E F 12. FACILITY NAME 13,. NO. BLOG•S CODES ..� 1. GACH 7. ICF/OT . One 16 S REET ADDRESS 2. G ACH jR 8. JC.F /DD. 15. RESTRAINT 3. SH 9_ ADHC Rt i G (Cherokoe. R 4. A P H S.-PHF It. JAIL.: C ITY ZIP CODE 16. HOURS • C�l.e CA 95965 9396-3 24+ 6. SKF t2. OTHE.R T ±eRSON TELEPHONE NO 165A SPECIAL 1 ? F -C tLITY CONTA C P _ le and L ► (916) 5 le. FIRE UTHOR. AME AND IaDRESS L Aftlt Re + ice. - TO BE COMPLETED BY INSPECTLNG AUTHORITY �-I '27. CLEARANCE ` CODE CODES t . FIRE CLEAR. GRANTED 2. FIRE CLEAR. DENIED J 3. FIRE CLEAR. WITHHELD 28.. DENIAL. CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES ZZ. 1 ;PECTOR S NAME TELEPHONE NO. 23. CFtRS 24. T-19 OCC. 10 NO. CLASS 1. EXITS 2. CONSTR-UCTIO.N 3. FIRE ALARM 25. INSP. DATE 26, INSPECTOrR S SIGNATURE S. SPRINKLERS 5. HOUSEKEEPING 2S. EXPLAIN. DENIAL OR LIST SPECIAL CONDITIONS 6. SPE`C'IAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY REGI.QN. F_ OFFICE state r maw A w r rl% - . - - - - - A [4ULTIPLE BUILDING FA%l JTY OFFICE OF THE STATE FIRE MARSHAL. INSPECTION LOG T i fi 1 e Rl File El 0 Q El Address t� :� •� fie-. -- -- - CJ r' c Nr // 5 s- - Owner 5-W rz. c to IN rib r 4 •�. � c-- or - 12 6:4 AP t� t -- _31N FEC E�� S:.". r;lam' ._ Ph.;i�5:-ir.L _-_ I:�%a +��'_ t I`. n ,- - LET:0N _ P z lR_, AUTHORITY ±_ R�OUM3T O.ATA r • � �. PQ JvRAm � � � 1 �•�� � � 1 sV±•f .,. Y f'r -•V ; Ii a. i , /' 1-......� .,.""__ _r.._� ^... � - - - ,-- ..5�....�r..�• L Z I > i� _ s 1 C .moi T . 5 . '•i . I . J �. `� G r +�- t � 8. R l. � a���i•iG a eNCY i~ ACILiT Y NO • 3. EVALUA r 0 R _ - •3 L/ ./ :� .r• V t .r L./ / • .1 -J L ...r .•� _ . •.."• 1 } �. ti ... a..� .1 ."Z = �'1 '" !'7 L -'L �•%� .i .3 �j•1 .sy 13_ i?MJUEST ' '.. J •• -I J fir' �► '. �.,; ,':' I r ka 4 AsU:,•A-0?Y- _ !`1C;`,^ttil�'.�L.:.TG?Y TOTAL DATE OPLAST z=rRaZ CtE,.Rktvr;� AGCz: RANGE YEARS; ;-,R V10US CA PA 17"r •JlO1�:. 1 !.0 STC .-3 ( td TQ 63 a�C=•�?ACITY 1 iTC t3 ` Id TO ; �r7 ,AND CAACIT'r • + FA CILITY + 65 i �R , .3 ! C P j ! :.. A :'Y NA`o4E G5 cc E 3 t ._.. n �a•.+w r+ .y � may... - ... ! ; !w ->, yt- ,y,,...... � � � w � ', G A C }"; � . 1 • '� ! � �' G A C H 'R $_ iCr itJrJ •act . A1]{3?. a5 15. RESTRAIN`!' La.i •w •'.•• L_.ti 3. SH 9_ ALJHC r 4�✓ t +.M�.%.A �� 1.! 1 .� .+. V .+_ r : \� rr Lr ... A P i I f ,J •- C, L i �� i �r C �. PH Ft i l A! L T' Z!P C a 0 E 16. HOUR S ., _. ?,„t .Z M ..:- �. ,., _ .•, r ,.. -, ► 6_ S N F t 2. O T N ER t • ;- - j _ _!rL C ;V -„rr- P 0N T'w;?Ft0NE NC7. 16A SPECIAL _ At J _ . _ i � �.rM ..r wr► �• _ . wJ ... � ��. �ti.r .: i i y i . • r • r ../ �� � �._ .i r 7 +� � `_.• � ''� Y'1 :�_► 1 .,� � -T .�� � ; i TO =E CQ N4 P L ET E.Q 3 Y t i'J5PE CT1NG A!JT3-4QR'..T Y f _ I_ t ! CLEC ' CO3 a: r { Y '- FIRE CLcAR. GF=A:ti* 55 ` i -7. F; R E CLEAR. G Es*41 E-0 �r F193E CL EAR Vi:T:4HE LG r ?�. GEMl�� ` t COoE ! --------- -- - - - --- -T'.� ? ... ^.� •� �'t .� ti '�' ` '.� '� \' i r`i 7 P C � ~ : -._s A 1 - l � 1 f 't' �- ! -+•_ SPRINKLERS it S3 C1.4L ::=.ZAP.0 1 t f 5 TA 'I c F I ;:; E Ni -A L L+ 5 _. 0 _ti 1_ Y M rl.%4E I MILES . I NEXT !►VS?. imo.oA_Yr'4_) OFFICE OF THE STATE FIRE MAR5HAL INSPECTION LOG Title.-JR06A-S-5�QIq !t E��� goo ooe v Address ,;x /} Onvo E Dare /. Owner. ;' -po"I CAC � � 414D � • d +J iii c3 N'l. ttJ 1'tJc7t.c,J � �At��.- ��C; .� e�: 0 -_9 6 iol ES rL —W- A E 14!Wll Cdb !� (Av I %i� �©t.� � a ��' l�t� � f►'L• � • 1LfrL. l �� - ' a � .> �v � i " � %` t�K � Y -f - -c MEC. 13 6P.Z¢ w ids i S�� m-w,L4-ejQ Al 4 U &A M AY Sew GO -6 (Rovo 5/81) � ' ti - • . � � .. • . . 1. � , • • - . . l ••. � • . • .. � . _ •-' • ►� "'-..�.-�.... w� -•• � - ST TE FIRE MARSHAL �� FI El*FETY INSPECTION REQUEST COPY DISTRIBITION; -moi 1-3 - STATE FIRE MARSHAL SEE REVERSE OF COPIES 2 AND 5 FOR INSTRUCTIONS FOR COMPLETION S-1 850 (REV. 7/80) 2 - FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM 4-5 - LICENSING AGENCY 1 1 3. CONTACT _ -------[ 4. TELEPHONE NO. 5. SIGNATURE - �GENCY ti Community Care Licensing r 6. REGION 7, SFM I.D. NO, rJ Z 8. REQUESTING AGENCY FACILITY NO, 9, EVALUATOR �F. 00 04 84 0029 000 330 0 04"1304029 0103 Manuela Moralez 19. REQUEST CODE CODES 1, ORIGINAL A. FIRE CLEARANCE 10. AGENCY F DSS Comunity Care Licensing 2. RENEWAL B. LIFE SAFETY NAME 520 Cohasset Road Suite 6 3. CAPACITY CHANGE AND ADDRESS Lhlco, California 95926 4. OWNERSHIP CHANGE 5. ADDRESS CHANGE I LI JJJ 6. OTHER DATE OF ORIGINAL REO. 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CAP CITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS TO 18 18 TO 65 AND CAPACITY TO IB 18 TO 61 AND CAPACITY 20. FACILITY 65 OVER 1 l 65 4 OVER CODE 12. NAME 1` 13, NO, BLOCS CODES �ACILITY ,;hY1;ils�xL+ tin Family Home 01101 1. G A C H 7. ICF /OT Z. GACH/R 8. ICF/DD 14. TR EET A DRESS 15. RESTRAINT 3. SH 9. ADHC - 1ea- Road none 4, APH 10. CLINIC 5. PHF 11. JAIL I T'Y ZIP CODEI6. HOURS 6. SNF 12. OTHER ':,4+ 17. A ILITY CONTACT PERSON - NO. 16A SPECIAL =NE 3Th n TO BE COMPLETED BY INSPECTING AUTHORITY E --I 27. CLEARANCE CODE THOR. AIME CODES ryD 1. FIRE CLEAR. GRANTED DDRESSL 2. FIRE CLEAR. DENIED ,3. FIRE CLEAR. WITHHELD 28. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. 1 SPECTOR S NAME TELEPHONE NO. 23. CFIRS 21. T-19 OCC. ID NO. CLASS 1. EXITS (c%I6) 1 C-) 2. CONSTRUCTION 3. FIRE ALARM 25. 1 Sd. DATE 26. INSPECTORS' SIGNATURE 4. SPRINKLERS '�21��'� 'Ty [r,/Gr �< C 5, HOUSEKEEPING 29. EKPI AIN DENIAL O VLIST SPECIAL CONDITIONS 6, SPECIAL HAZARD 7. OTHER O - wt a cO iQ d' 1¢ L STATE FIRE MARSHAL USE ONLY FIRE CLEARANCE GRANTED STATE FIRE MARSHAL 21. EGION.W 2 11985 FFICE U�� L State Fire Marshal SACRAMENTO REGION DDRNNOESS vk 4433 Florin Road Suite 400 L TIME MILES NEXT INSP. (MO.DA.YR.) Sacramento, �J Ca. qv$2-, - 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 submi ting if to.the.State Fire Marshal *Complete items marked with an asterisk onlywhen Item _20 is not used. e. 1. -REQUEST DATE. Enter the date request was - prepared. 2. -PROGRAM. Licensing agency use. 3. AGENCY CONTACT, 4. TELEPHONE NO., 5.- -SIGNATURE. . - SIGNATURE. Enter the name, telephone. number, and signature of agency contact person. 6. SFM REGION. Insert one. of the following 3 numbers for the- SFM Regional Office. in whose area the facility is located. 350 Coastal, 330 Northern, 370 Southern. - 7. SFM ID NO. This is the SFM Identification Number and initially will - be assigned by Lhe State Fire Marshal. Licensing Agency Insert this number ° on all clearance- requests subsequent to the initial request. 8._ REQUESTING AGENCY FACILITY NO. This is the file number assigned by, the licensing agency. , 9. EVALUATOR. For, licensing agency use. -10. AGENCY NAME AND ADDRESS. ,Enter the name and address of the .licensing facility requesting the inspection. * 11. AMBULATORY — NON-AMBULATORY. Complete this section only when Item 20 does not apply. Capacity: Insert, in the appropriate section, the capacity of.. licensed -am bulatory or non-ambulatory occupants covered by this request. Age Range: Indicate the age rpnge of the licensed occu- pants Previous If 'request is- for renewal or capacity change, Capacity: insert capacity of previous clearance. Total Show total _ licensed capacity. If the Facility Capacity: is intended --to house part ambulatory avid part non-ambulatory, show the total of the two types of occupants. 12: FACILITY NAME. Insert the name of the facility as as it will appear on the license. 13. NO. BLDGS. Insert the total number of buildings to be used for housing 'of the occupants covered by the license. _14. ADDRESS. Insert street address and city only. A post office box is not acceptable. * 15. RESTRAINT. Indicate if- physical 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 fac.'rlity, (lees-- 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 O:Indicate the name and .telephone . number of the re- sponsible. e- sponsible. individual at - the- facility, to - be contacted, by the fire authority. 18. FIRE AUTHOR. NAME AND ADDRESS. Insert the name and address of the fire authority in the vicinity where the facility is located-. 19. REQUEST CODE: _. Use - the -six codes: shown and insert the appropriate number in the box following Request Code . Insert date of original request when request is`other than an original. 20: FACILITY CODE. Mark this item -only -if The facility is a: (1) General Acute -Care Hospital (GACH), (2.) General Acute Care Hospital/Rehab (GACH/R), (3) ' Special- Hospi-tal (SH), (4) -Acute Psychiatric Hospitar'(APH), (5) Psychiatric Health Facility (PHF), (6) Skilled Nursing Facility (SNF), (7) Intermediate Care Facility/Other (ICF/OT), (8) Intermediate Care Facility/Developmental- ly Disabled ( ICF/DD), (9) Adult Day Health Care (AD HC), (10) Clinic, (11) Jail or (12) Other. When Item 20 is used, Item 11 does not need to be completed (except total cap). 21. REGION, OFFICE AND ADDRESS.' Insert. the name and address of the State Fire Marshal Regional Office in whose area -the facility is located. Fire Authority Conducting the Inspection — Complete the following 22. INSPECTOR'S NAME. Print the initial of the inspec- tor's first name and full last. name; insert the tele- phone number where the inspector may be contacted. 23. CFI RS ID. NO. Insert the fire department's number assigned by CF,I RS,,, 24. TITLE- 19 OCC. CLASS. ,Use 'Title 19 occupancy classifications and insert the occupancy determined by the inspector. . 25. I,NSP. DATE. Enter the actual date of the inspection. 26. RIUSPECoR'S :S1:N,AT• 4R E. To be signed by inspec- for coedUcti hg t inspect on,.. 27._ -CLEARANCE CODE. Use the three codes .shown and insert the appropriate number in the box following "Clearance Code". NOTE: If Code 2 (Denied) or Code 3 (Withheld) is used, explain. 28. DENIAL , CODE. Use only the seven codes shown and insert the appropriate number in the box fol- lowing "Denial Code". If No. 7 "Other" is used, ex- plain -at Item 28. NOTE: Fire Clearance cannot, be denied for other than lack of conformance -with the provisions of Title 19. 29. EXPLAIN DENIAL. "If Clearance Code No, 2 or 3 is used, -briefly explain reason.. This space is also to be used to explain Denial Code item noted. -CV C, r TATE OF CALIFORNIA-- CONSUMER v STATE AND CON E SERVICES AGENCY 'ATE FIRE MARSHAL :RAMENTO REGION 3 FLORIN ROAD, SUITE 400 :RAMENTO, CA 95823 November 22, 1985 Mr, and Mrs. Harley Thomasson Rt 1 Box 307-G Oroville CA 95965 SUBJECT: THOMASSON FAMILY HOME SFM FILE #00-04-84-0022-000-330-0 GEORGE. DEUKMEJiAN, Governor (916) 427-4325 _ ATSS 466-4325 -�; � w -_. In accordance with the prov i s ions of Sections 13145 and 131.46, Health and Safety Code, State of California, an inspection. was recently conducted at. your residential care facility. This inspection was based on a request for an increase in capacity to ten adult clients (to include a maximum of six nonambulatory clients) The building occupancy for this type of fan"lity is classified as a Group D, Division to - The deficiencies listed below are based on this occupancy classification and shall be corrected before the increase in capacity may be approved by this office. 1. The building shall be of minimum Type V. one-hour construct ion . In 1. i eu of one-hour rated construction, a complete automatic fire sprinkler system may be -installed. [Title 24, Cal ifor.nia Administrative Code, Section 2-1403; 1979 Uniform Building Code,#} Section 508] 2. An automatic fire alarm system shall be installed throughout the facility, This system shall utilize devices which respond to products of combustion. other than heat.. One manually operated initiating device shall be located on each floor level. (NOTE: A smoke detection system is not necessary if the building is protected by a complete automatic fire sprinkler system). [Title 24, California Administrative Code, Section 2-1409] 3. Ducts which penetrate the floor -ceiling assemb ly shall be provided with fire dampers complying with the requirements of State Fire Marshal Standard 43-2. [Title 19, California Admi n i stra.tive Code, Section 2-4306(i)] 4. The interior stairway shall be enclosed with construction raving a one- hour fire resistive rating. An acceptable method of satisfying this requirement would be the installation of a one-hour fire -rated wall and one-hour rated fire assembly ('door) at the bottom of the stairs. Ti t.1 e 24, California Administrative Code, Section 2-3308,(b, c)]' N .. ME Mr. and Mrs. Harley Thomas so•n November 22, 1985 Page Two The plans for your recent building addition were reviewed by a representative of this office based on information supplied by you that your building would house a total of six ambulatory or nonambulatory adult guests. This. type of facility is classified as a Group D, Division 2 occupancy... As you know, a. fire clearance was granted on October 21, 1985 for a capacity of six adult clients (maximum of four to be nonambu lstory) . This fire clearance is st ll valid and is not affected by the proposed increase in capacity, Please notify me- of your timetable for • correcting the above iters. To avoi-d any possible misunderstanding that may result in unnecessary expenditures: plans and specifications shall be submitted to this office for review prior to beginning c.on s t ru ct i on . Because the four items listed above take a considerable period of time, to correct, the request for fire inspection we have received from the Department of Social Sery ices is being returned to them marked "fire clearance withheld". A new request may be made when the corrections have been made If you have any questions please do not hesitate to contact me at. the address or telephone number. listed above o Sincerely, JAMES F. McMULLEN State Fire Marshal By r 1 NANCY RI VERS WOL FE10 j Deputy State Fire Marshal I If Field SuP ery i s•or NRW:vk cc: Manuel a Morales, DSS -CCL, Chico Regional File Field File . -.- - � _ ..- - �. S ..•�` � f �. ��.TZ"" ?� t, 4 .u�Y.►...•a of .i r�,' �4 �1,+ S- 5� � ..»r,•• :.•t. • - .. _.. •. - , _ .. - ... � - fti. ,I . �• •�••i. -. � •iHM :R+ i w f �Z1� l f� }•C. � .'.'fi _ •.� '-moi • F ' ) 7.L t tMi . - !if _ C. - .• - � f .. - .. � t ... ls...�. r«h•yR � �4 .•3 J � ♦ Vii'•. 1��i v' f "'" .,{\� aFF c� o �r�-c sr�-r t Re s a ♦ �� S• { INSPECTION LOU{ Title w «. Fide WN I ci 3 3 t� Address n. L� f� Date ! Owner tMINW. S T't At S4 ry Irl / t �J U w► /'�t t2 rt- S t • -_a. C1t:C' =20M 1 __ - 6 zay.." I---.,--- . aes mr. m OX •;pR'�rsnaa. . w�..W..�s••w....+ir++F�*�w..a•sY�a�.�y�H+.vis*�.•aw.,.r...,.o..iWq.nt�vuuR..p.ar. - i GO -6 (Rev,* 5/8 1 - tate of California i Memorandum TO : Department of Social Services --- Community Care Licensing 2400 Glendale Lane,'Suite C Sacramento, CA 95825 Department of Social Services - Community Care Licensing 770 E. Shaw Ave., Suite 330 F-resno,- CA'. -9371.0-7785 F OM STATE FIRE MARSHAL - SACRAMENTO REGION 4433 Florin Road, Suite 400 Sacramento, CA 95823 S BJECT : FIRE CLEARANCE FOR - D State and Consumer Services Agency DATE: Department of Social Services Community Care Licensing 520. Cohasset Road, Suite 6 Chico, CA 95926 rj Department of Health Services Licensing and Certification 2422 Arden Way, Bldg B, Ste 35 Sacramento; CA :.95825 File #: )a r An inspection was recently conduct d on the a ov faci�ty located at � �t. During the 1 course of this inspection it was determined that fire. clearance would be WITHHELD pending. correction of deficiencies. A reinspection will be conducted when the deficiencies have been corrected. Notification of fire clearance approval or denial will be sent to you after this reinspection has been completed. If you have any questions please contact Deputy (�iR�T CC5TfA at (cA XV. �c� °M�N EY RT BUILDING SURF REPO -� Date: STATE AL File No: N me of Faci 1 ty: Tho,n& AxIdress: L' ate sro lc.¢.e.. Q.'f_. $0 7a Q v,0g Lt.LP , Sq cv S OWL r: Telephone No. (Qlco ) S33 - to 830 Nz of Building: (e6( 0 04Z DESCRIPTION Ccrin. 1. Occupan Class -b- 1 Use � ,�,., .- rescan a� Capacity IC) Clo r�mb/4 2. Construction Type au,' N Year Built I q '} Q 6q8t5 c.e, Total !c d � Largest Floor Basements No. j ' High Rise Yes No 3. Area (Sq., Ft.) 410 Stories C 5a. Exterior Wall Construction C 4n LuncreL YA©el . opening Protection net, L" 41L --a- 6. Interior Wall . Construct i on Ut,,r„;$ -, L9�n& 449=n!��� 7. Floor lou - cAr`a -te., . Construction �' ti � ,�,�,. Ln• .Lm 8. Roof Construction Gt.Qa ,c.�t (-ao OwLr CO2le 9. Attic U U U Draft S t s No. nest, o . Occ. Sep,, Wall .Construction . opening Protection Noe np� fe% 1 . Area Sep, Wall Construction h OL . opening Protection Now r 2 0 Smoke Barrier Wall Construction ngL r _ . opening Protection n at .13a. Corridor Wall Construction no . opening Protection n (o 1.4a. Corridor Ceiling Construction . Opening Protection -5h. Shafts Number/'T LUCc . Opening Protection I�ovt,2, G 4 (Rev.5/84) XV. �c� YdlICE "CE OF M STATE(1RE MAR AL NAME -. - A fRESS STATE FIRE MARSHAL FIRE SAFETY CORRECTION NOTICE FILE NUMBER El El 0 El IJ El 0000 ❑oo ❑oo 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 y= have any questions,. contact the State Fire .Marshal's Office at (- ) ' MSUED. BY (DEPU'T'Y STATE FIRE MARSHAL) RECEIVED BY DATE 11TIEV. 7/81) YELLOW: REGION' WHOTE: FACILITY GREEN: FIELD 84013-3557-812,500 TRP CAM (DT' OSP- ............... ..... . . .... OFFICE OF THE STATE FIRE MAR&r,,L INSPECTION LOG Title 7ooMAS5va3 F'AMm Home, t= a 'l != l El LJ lJ File 127ElQ151 0P -1c a] aFLI E Address Oto VILLe- `Pt - V5165 Date Owner -TL, aNJ FRWRS 1"4 S 1)eCr1D PrJi) CL?AretD Fa(' R;,6uc (or� Aid Z It/On,1AM6ut4TorY 18to 6 �3 GO -6 (Rev. 5/81) STATFI .', r?404b� ' IE MA At COPY DISTRIBUTION; r�. SEE REVERSE OF COPIES 2 AND 3 FOR FIR D 8 AFETY INSPECTION REQUEST 1 •STATE FIRE MARSHAL `. , INSTRUCTIONS FOR COMPLETION 0 NEW 6180 2 - FIRE AUTHORhY 1. REQUEST DATE 2. PROGRAM f ( ) * :t.. 3 LICENSING AGENCY C).. 3. AGEP AGE CY CONTACT 4. TELEPHONE NO. 5. SIGNATURE ISS CtJFEUNITY GA,i%E LIGZNS INN8C)5.5033 6. S M EGION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR o•m 4-84 8-io- �u Moni3el or. 19. REQUEST CODE CODES 1. ORIGINAL A. 'FIRE CLEARANCE :• 10. ENCY .T-,- , ,, - , -. N ME � ARTFUZT U �UCIAL 4 �LRVIC E 5 2. RENEWAL B. LIFE SAFETY 3. CAPACITY CHANGE- AbD CQ tunny Care Licensing DRESS 520 COhasiset Rd., Cohasset Square 19 Suite 6 4. OWNERSHIP CHANGE 5. ADDRESS CHANGE Uhi CO i (;A. 9�926 6. OTHER DATE OF ORIGINAL REQ. 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CAF ACITY AGE RANGE (YEARS) TO 18 18 TO 65 AND 65 OVER PREVIOUS CAPACITY CAPACITY AGE RANGE (YEARS) TO 18 18 TO 65 AND 65 OVER PREVIOUS CAPACITY 20. FACILITY . 4 1 1 � � CODE 12. FACILITY ITY NAME 13. NO. BLDGS. CODES 14. SIRE R , „ = TFMvIlIX r 3. 1. GACH 7. ICF/OT 2. CACHIR 8. ICFlDD 3. SH 9. ADHC T ADDRESS 15. RESTRAINT �I w2cl No 4. APH 10. CLINIC Ci 5. PHF 11. JAIL 6. SNF 12. OTHER "Y ZIP CODE 16. HOURS 31 94 ITY CONTACT PERSON TELEPHONE NO. `' 16A. SPECIAL 17. FOCI_ �a r _eat and T-julm- Thoms-ssonTO mall Fam Home A f. BE COMPLETED BY INSPECTING AUTHORITY 18. FI E THOR. 27. CLEARANCE CODE CODES ME 1. FIRE CLEAR. GRANTED D A10 DRESS 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE -' TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22.- IN P CTOR'S NAME TELEPHONE NO. zz J 23. CFIRS ID NO. i� -- 24. T•19 OCC. CLASS 1. EXITS 2. CONSTRUCTION 25. IN . 29. EXPLAIN 3. FIRE ALARM 4. SPRINKLERS 5. HOUSEKEEPING P. _ DATE r 2- 26. INSPECTOR'S SIGNATURE ` , ; „ ' ,, , r f e DENIAL OR LIST SPECIAL CONDITIONS _�. 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY 21. IE ION, F ICE ' ND f D RESS • TIME MILES NEXT INSP. (AAO. DA. YR.) v I I NSTRUC®NS 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; uvhen 'ltern 20 is not used. 1. REQUEST DATE. Enter the date request was ..prepared. 2. PROGRAM. Licensing agency use. 3. AGENCY CONTACT, 4. TELEPHONE NO., 5. SIGNATURE. Enter the name, telephone number, and signature .of agency contact person. 6. SFM REGION. Insert 'one of the following 3 numbers for the SFM'- Regional Office in whose area the facility is located. 3%Coastal, 330 Northern, 370 Southern. 7. SFM OD NO. This is the SFM Identification Number acid-. initially will be assigned. by the State lyre Marshal. Licensing Agency - Insert this number on, all clearance requests subsequent to the initial request. 6. REQUESTING AGENCY FACILITY •.N®. This is • the -file number assigned by the licensing agency. 98 EVALUATOR.. For -licensing agency -use. 14. 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. . BLDGS. Insert the- total number of buildings to be used for housing of the occupants covered by the license. 14. ADDRESS. Insert street address and city only. A post office box is not acceptable. 15. RESTRAINT. Indicate if physicial restraint (locked in -a room or the building) is to be used in the housing of the occupants. Y = yes N = no. * 16. HOURS. I.ndicate 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 TEL.EP■ -IME NO. Indicate the name and telephone n.dmbar of the re- sponsible individual at the facility to be contacted by the fire authority. 16. FORE 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 f.ollQwing "Request Code". Insert date of original request when request is other than an original. 20. FACILITY CODE. Mark this item only 1 the facility is a: _(1) General Acute Care Hospital. (CACH), O General Acute Care Hospital/Rehab (GACH/R), (3) Special Hospital (SH), (4) Acute Psychiatric Hospital (APH), (5) Psychiatric Health Facility (PHF), ,(6). Skilled Nursing Facility (SNF), (7) Intermediate' Care Facility/Other (ICF/0T), (3) Intermediate Care Facility/Developmentally Disabled (ICFIDD), (9) Adult Day Health Care (ADHC), (10) Clinic, (11) Jail or (12) Other. When Item 20 is used , Item 1:1 does not need to be completed (except total cap). 21. REGION,, OFFICE AND ADDRESS. Insert the name and address of the State Fire Marshal Regional Office in whose area the facility is located. Fire Authority Conducting the Inspection - Complete the following: d 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 CFIRS. 24. TITLE 19 OCC. CLASS. Use Title 19 occupancy classifications and insert the occupancy deter- mined by the inspector. 25. INSP. DATE Enter the actual date of the in- spection. 26. INSPEQTOWS SIGNATURE. To be signed by Inspector conducting the inspection. 27. CLEARANCE CODE. Use the three codes shown and insert the appropriate number in the box following -"Clearance Code". NOTE: If Code 2 (Denied) or Code 3 (Withheld) is used, explain. 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 Clearance cannot be denied for other than lack of con- formance with the provisions of Title 19. 29. EXPLAIN DENIAL. If Clearance Code No. 2 or 3 is used, briefly explain reason. This space is also to -be used to explain Denial Code item noted. OFFICE OF THE STATE FIRE MARSHAL INSPECTION LOG Title t jrvjA A -.,vi k Lq AA El F El El El File ��m to El Address�L Q:1 Date 5 - Owner ove AA i Lk.Lj i, M c It (7 p li J� -e GO -6 (Reve' 5/81) EN -11 (REV. 7/81) YELLOW: REGION WHITE: FACILITY GREEN: FIELD 84013-3557-812,500 TRIP CAM OT OSP '� STATE FIRE MARSHAL FIRE SAFETY CORRECTION NOTIC STATEAL *IREMAR FILE NUMBER ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1:11:1 ❑ ❑ ❑ ❑ NAME ADDRESS In accordance with the minimum standards of Title 19, California Administrative Code, the following corrections are required: a I 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 i7ire Marshal's Office at ( ) ISS ED BY (DEPUTY STATE FIRE MARSHAL) RECEIVED BY DATE EN -11 (REV. 7/81) YELLOW: REGION WHITE: FACILITY GREEN: FIELD 84013-3557-812,500 TRIP CAM OT OSP CERTIFICATION OF CORRECTIONS BY OWNER I certify that all items listed on the reverse of this form have been corrected in accordance with the requirements of Title 19, California Administrative Code. SIGNATURE % DATE (Fold on this line) -------------------------- (Fold on this line) ---------------------------- -/'t • r �jD'/y2 �4SS0 0 7 OFFICE OF STATE FFIRE MARSHAL 2300 "Amir .ed Street San Loandro. C, 9"77 ------------------- ��c 0, C c, MAY. 4 '�---~ PQ r2' .---------- INSPECTION OF INDIVIDUAL BUILDING as OCCUPANCY CLASSIFICATION -(T-24) HIGH RISE 1: J. , INSPECTION OF ENTIRE FACILITY CONSISTING Or= THE FOLLOWING BUILDINGS: FILE I.D. FILE I.D. F -�=-- FILE logo t� LOGS. OCC. CLASS. � N0. BLDGS. --.__ OCC. CLASS. N0. BLDGS. OCC*CLASS., LASS .FILE I.D. FILE I.D. FILE I.D.- NC,, LDGS. OCC.CLASS. N0. BLDGS. OCC, CLASS. �' .NO. BLDGS. �..._.�. OCC, CLASS. OFFICE STATE FIRE MARSHAL For office Use Only ITEM FIRE & PANIC -SAF STANDARDS - _ - INSPECT ION REPORTANNUAL I n NEW DELETE - 16.. Housekeepi n 9 52 � . 3. -- FOLLOW-UP PREY. INSP. DATE: _._....._ 0 FIIjE. Pre- re Pan 53 0 r Supervision/Staffing 50 Correction oFi sL N to Noted FACILITY NAME: ikr\ al ., d m qw.._.. PHONE: � 19. Portable F i re Ex .. FACILITY ADDRESS. i - ' INsD.EC ED BY� I _ r G " "S RE (St�eet)_ INTERVIEWED �; �� � �-. eon-� �- L i �� .AA �i ACCOMPA�'1IED -BY gi P INSPECTION OF INDIVIDUAL BUILDING as OCCUPANCY CLASSIFICATION -(T-24) HIGH RISE 1: J. , INSPECTION OF ENTIRE FACILITY CONSISTING Or= THE FOLLOWING BUILDINGS: FILE I.D. FILE I.D. F -�=-- FILE logo t� LOGS. OCC. CLASS. � N0. BLDGS. --.__ OCC. CLASS. N0. BLDGS. OCC*CLASS., LASS .FILE I.D. FILE I.D. FILE I.D.- NC,, LDGS. OCC.CLASS. N0. BLDGS. OCC, CLASS. �' .NO. BLDGS. �..._.�. OCC, CLASS. ._ 2'-'�l TEM REF* N I C CFS 65 & Ove, ITEM RE F_ N i CN. CFN tJL'•d. , CT'ua apace y 9,58 - 16.. Housekeepi n 9 52 � . 3. Rosement re Protection Systems 2 23 pplicabl.e IC I . 18. Pre- re Pan 53 0 r Supervision/Staffing 50 Correction oFi sL N to Noted posures 4i CS 24 � • 19. Portable F i re Ex .. 57, , ✓ INsD.EC ED BY� 2$ " "S RE 20 . REVIEWED BY- b. I teri or onstructi on �, 29930,31 21. ....... , - • i rQ As S.el�b t e s ' 7 9 31 j �i 22_,m_ � _-3.oterar Finish32- - 23. �' zardous Areas 40 �- - 24. +L. ating 0,43 ✓ 2a. - 3.. _. ire Protective Sig. sys • 44 26. .. 12• V 45 270 3. ectri ca = 4 � 28. corative Materia s 5 290 5s Storage 51 ,, 30. :) 4 y UPDATE ON BLDGS NO. - :r v AM NTS: 71 14 c- DI P SITION: GO -6 Attached CLEAR -RE IN;SPE.CTION DATE CORRECTION NOTICE EN_I1 Attached ._ 2'-'�l CAPAC I T CUS g To AMBULATORY AGE RANGE(YEARS)CAPAC 1 18 to 6., 65 & Over' NONAMBULATORY I T AGE RANGE(YEARS _ To 1 18 to 65 65 & Ove, TOTAL CAPACITY ,r tJL'•d. , ED - �, ... ' I i T Y FC pplicabl.e IC I. Compl;ance CN = Cor rection Neaded Ci Correction oFi sL N to Noted -0-4 Item No. � • INsD.EC ED BY� � 6 3 DAA " "S RE ION TIME': REVIEWED BY- DAT� :air t 10th of Hoar) mizroll i CAr� ....... , - 1£em 20 - Stage/Platform area (REF* 42) Item 21 - Stage/Platform vents (REF* 42 Item 22 - Stage/P1 at fc rm sprinklers (REF* 42 Item 23 - Stage/Pl at form access roamsREF* 42 , { } Item 24 - Stage/Platform curtains (REF* 50) Item 2.5 - Seati ng/Ai sl es (REF* 43) INS T ITUT-IONS - ' Iters 23 - Nonflammable g ,r as st st ems (REF* 54 } • Item 24 - Surgery floor {REF* 40} ' . ' Item 25 - Sur gery air - change (REF* 40 ) Item '26 - Surgery equipment/Furnishings REF* 40 Item 27 - Surgery electrical system REF* 46 Iters 28 -- Restraint (REF* 9) • CAMP Item 26 Tent fabric., Item 27 - Tent heating. Item 29 - _ Teat electrical Item 29 - Tent 1 ocatl.on siP arati on :_ T / Itzm 30 - - Tent ground clearance 4r OFFICE OF THE STATE FIRE MARSht." li INSPECTION LOG Title F i le roe El F] E] 0 [31 Vj M Address Date Owner -2 Jq 90, 17 Z--- 4 -wee 0.4 GO-6 (Rev. 5/81) r COPY DISTRIBUTION; y w• PIE 2 AND 3 FOR �TA�TEE SHAL V: SEE REVERSE OF COPIES 1 - STATE FIRE MAS � F-= S FETY INSPECTION REQUEST �J INSTRUCTIONS FOR COMPLETION j D 850A ( EW 6180) 2 • FIRE.AUTHCFRITY 1. REQUEST DATE 2. PROGRAM l 3 - LICENSII�p AGEN, CY Q 3. AG ENCY CONTACT 4. TELEPHONE.NO. 5. SIGNATURE r-C:ONAUNITY CSAR LICENSING r �•�$ •• . 6. SF11 R GION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR 19. REQUEST �������� N C 11J..d�C'•�� E IN. CAPACITY ,. CODE CODES I� Department, of Social Services 1. ORIGINAL A. FIRE CLEARANCE 10. G NCY F C�omminity Care Licensing� .2. RENEWAL B. LIFE SAFETY . A E 520 Cohasset Road, Cohasaet Square I 3. CAPACITY CHANGE N D RESS Suite 4. OWNERSHIP CHANGE , Chico. , CA 95926 5. ADDRESS CHANGE 6. OTHER DATE OF ORIGINAL REQ. 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CAP, WITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS ' TO 18 18 TO 65 AND CAPACITY TO 18 18 TO 65-AND CAPACITY OVER 6516 65 OVER 20. FACILITY 1 xx 2 1 6 CODE 12 ' 12. F, I ITY NAME 13. NO. BLDGS. CODES UM�' C I:{'A I�,, Q UI1�, ; 1. GACH 7. ICF/OT 2• GACHIR 8. ICFIDD 14. STET ADDRESS 15. RESTRAINT 3. SH 9. ADHC I BOX G (GhERuAa. ROAD ,NONE 4.APH 10. CLINIC 5. PHF 11. JAIL CI Y ZIP CODE 16. HOURS t 6. SNF 12. OTHER UZOULLIE, CA (BUTTE COUNTY) 959 24 17. FAICII.ITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL TO BE COMPLETED BY INSPECTING AUTHORITY 18. FI OE 27. CLEARANCE AL THOR. CODE / CODES NiME 1. FIRE CLEAR. GRANTED t A6 D A DRESS 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD • 28. DENIAL CODE . _ TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22.1 SP CTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T•19 OCC. ID NO. CLASS 1. EXITS 2. CONSTRUCTION ' ' 25. M 3. FIRE ALARM SP DATE 26. INSPECT 0 S SIGNATURE �~- .. �'� ; •-��2�--*-�- ✓�' 4. SPRINKLERS 29. E 5. HOUSEKEEPING P IN DENIAL 0 IST SPECIAL ITIONS , 6. SPECIAL HAZARD 7.. OTHER ' STATE FIRE MARSHAL USE ONLY 21. R GION, I STATE FIRE MAiZSHAL O FICE Marina-Merced Office i.ce Compl A D 2500 Merced Street A DRESS San Leandro, CA 94577 TIME MILES NEXT INSP. (MO. DA. YR.) ' s INSTRUCTIONS This -.form is designed for -use with a window envelope. To use, fold at marks indicated in. the left margin. Licensing or Requesting Ageneles-CoMp161e ho fell®Wing 21 'sections on thris forte before submitting it to the State Fite Marshal Complete items ..'Marked with'an asterisk only When (tern 20 -is not used. 1. REQUEST DATE. Enter the date request was prepared. 2.. ,PROGRAM. Licensing agency use. .3. AGENCY CONTACT, 4. TELEPHONE No., 5. , SIGNATURE.' Enter the name, telephone number, and signature of agency contact person. S. SFM REGOONo Insert one of the following 3 numbers for the SFM Regional Office in whose area the facility is located. 350 Coastal; 330 Northern, 370 Southern. 7. SFM I® -NO. This is the. SFM Identification .Number and initially will be assigned by the' 'State. l=ire Marshal. Licensing Agency —'Insert this'n u-mber'on all clearance- requests subsequent to ' the initial request. 8. REQUESTING AGENCY FACILfTY No. This is the file number assigned by the licensing agency. 9. EVALUATOR. For licensing agency use. 10. AGENCY NAME. AND ADDRESS. Enter the name and address of the licensing facility requesting the inspection, *11. AMBULATORY — NON-ANSULATORY. 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. •OL®GS. Insert the total number of buildings to be used for housing of the ,occupants covered by the license. 14. ADDRESS. Insert street address and, city only. A post office box is not acceptable. 15. RESTI,,AINT. Indicate jf ph-ysiciai restraint (locked in= room,. or, tl"e buildf rigj' is to .be used in the housl0g; of tl�e,%ocd'upar'ts. Y=� yes N = no. r X16. • 6V & a' IMdicat;e 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. 16. 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 oforiginal request when request is. other than an original. 20. PACILITY CODE. Dark this item only if the facility is a: (1) General Acute Care Hospital. (GACH), (2) General Acute Care Hospital/Rehab (GACHIR), (3) Special Hospital (SH), (4) Acute Psychiatric Hospital (APH), (5) Psychiatric Health Facility (PHF), (6) Skilled Nursing Facility (SNF), (7) Intermediate Care Facility/Other (ICF/OT), (8) Intermediate Care Facility/Developmentally Disabled (ICP/DD), (9) Adult Day Health Care (ADHC), (10) Clinic, (11) Jail. or (12) Other. When Item 20 is used , Item 11 .does not need to be completed (except total cap). - 21. REGION., OFFICE AND ADDRESS. Insert the name and address of the State Fire Marshal Regional Office in. whose area the facility is located. Fire Authority Conducting the Inspection — Complete the following: 22. 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 i®oNO. Insert the fire department's number assigned by CFIRS. 24. TITLE 19 ®CCs 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. 2 1NSPECTORIS SIGNATURE., URE., - To be signed by Inspector conducting the inspection. d 27. CLEARANCE CODE. Use. the three codes shown and insert the appropriate number in the box -following "Clearance Code". NOTE: If Code 2 (Denied) or Code 3 (Withheld) is used, explain. 28. DENIAL CODE. Use only the seven codes shown and insert the appropriate number in the box following "Denial Code", If No. 7 "Other" is used, . explain at Item, 28. _NOTE: Fire Clearance, cannot be denied for other than lack of con- formance with the previsions of Title 1.9. 29. EXPLAIN. DENIALQ If Clearance : Code No. 2 or 3 is •used, briefly explain reason. This space is also to be used to explain Denial Code item noted. i i 2*,17- 81 -- 11. AMBULATORY NONAMBULATORY /STA IRE MARSHAL C PY DISTRIBUTION; CAP C TY SEE REVERSE OF COPIES 2 AND 3 FOR FIR 160) AFETY INSPECTION REQUEST 1 - STATE F' �3L' KWHAL INSTRUCTIONS FOR COMPLETION STD (NEW 6180) 2 - FIRE AUTHORITY 21 1. REQUEST DATE 2. PROGRAM 6 3 - LICENSING AGENCY 12. FA I�. TY NAME .11-1242 3. A VGZECY CONTACT '�` alp son Farm l Home 4. TELEPHONE NO. 5. SIGNATURE 15. RESTRAINT SCommunity Care Licensing none 916495w5033- CIT 6. S REGION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR 17. FA ILI ry CONTACT PERSON 00-- 04- 84-0028- 000.338H 0400 "1304029 r a - & Iola Thomasson. 0403 none Sma1 I Faso Hme for Adults TO BE COMPLETED BY . 19. REQUEST INSPECTING AUTHORITY 18.R 27. CLEARANCE CODE CODES CODE T OR. CODES JA 10 A ENCY [-Department o£ Social SeYvices N ME Community Care Licensing A DRESS 520 Cohassat Rand, Cohasset Square I -Suite 6 Lchico, GA, 95926 2. RENEWAL B. LIFE SAFETY 3. CAPACITY CHANGE 4.. OWNERSHIP CHANGE 5. ADDRESS CHANGE 6. OTHER DATE OF ORIGINAL REQ. 2*,17- 81 -- 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE '" '" 81 CAP C TY AGE RANGE (YEARS) TO 18 18 TO 65 AND OVER PREVIOUS CAPACITY CAPACITY AGE RANGE (YEARS) TO 18 18 TO 65 AND 65 OVER PREVIOUS CAPACITY • 20. FACILITY 6 l65 xMM 21 6 CODE715 12. FA I�. TY NAME 13. NO. BLDGS. CODES 1. GACH 7. ICF/OT 2. GACHIR 8. ICFlDD 3. SH 9. ADHC '�` alp son Farm l Home T ADDRESS 14. SST E:te-1 15. RESTRAINT Sox 307 G none 4. APH 10. CLINIC 5. PHF 11. JAIL 6. SNF 12. OTHER CIT ZIP CODE 16. HOURS 0 17. FA ILI ry CONTACT PERSON TELEPHONE NO. 16A. SPECIAL r a - & Iola Thomasson. 916-533-6830 none Sma1 I Faso Hme for Adults TO BE COMPLETED BY . INSPECTING AUTHORITY 18.R 27. CLEARANCE CODE T OR. CODES JA E 1. FIRE CLEAR. GRANTED ARESS 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. INS EC OR'S NAME TELEPHONE NO. 23. CFIRS ID NO. 24. T-19 OCC. CLASS 1. EXITS 2. CONSTRUCTION 25. INSP 3. FIRE ALARM D TE 26. INSPECTOR'S SIGNATURE 4. SPRINKLERS 29. EXPL 5. HOUSEKEEPING 16. ki DENIAL OR LIST SPECIAL CONDITIONS SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY 21. RE OF AD I ;I R N, E reed coTf ice COMP102K .V 140' A. id � � Street SS s Ltaladrqq CA 94577 TIME MILES NEXT INSP. (MO. DA. YR.) tet'.,_ , •' ,. _ .`'. .-. - - •• . _ , 0413 P. SWOCI. a .: �A o3ldD 1 1 • smoH mO pay.9 sP,r �.