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HomeMy WebLinkAbout069-450-020`-IRE SAFETY INSPECTION REPOr" Butte County Fire Department California Department of Forestry and Fire Protection Oroville, California 95965 * (5,30) 538-7888 PusinessAddress: H7 Z -A Aa",d Av�'� City - pusinessName: e_.-1 /Property Management: //- Inspection Date: g Z3 Business Phone::. AP#: No. CORRECTIONS REQUIRED NOL LOCATION I REMARKS CLENW F'-7 LOCATION I Provide addressnurnb� I.D. visiblee from street EXMNG 2 Remove obstructions at exits, doors, aisles, stanvays, etc. 3 Exit door to open without a key or any special know) d,* effort. 4 Repair exit door hardware. 5 Remove obstructions from door mquirW to be dosed 6 Remove locl&Wches from doors with panic harcWare. 7 Provide sign over main exit door - 'This door to remain unlocked during business hours". 8 Remove storage from under unprotected stairway. 9 Provdafmaintain wt s' em lighting. FIRE EXTINGUISHERS 10 Have fire estinguisher(s) serviced and tagged. RE -INSPECTION DATES INSPECTOR 11 Provide/mount fire extinguisher as indicated. 12 Post a sign inclicating fire edinguisher location. 1st 13 Provide clear access to fire ednguislw. FIRE PROTECTION EQUIPMENT 2nd 14 Maintain, repair, paint, inspect, and/or test sOnklerklancipi:)e system/hydranVFDC/PIV. Refer to FPB J 15 Maintain 3 feet minimum clearance for accessluse of fire appliances/equipment. District Attorney 16 Replace damaged/paintecilmissing sprinkler headstFW caps. Final Cleararxe 17 1 Provide 5 -year certification test for spriinklerklan*pe system. I Ocaqw1cycim El Check Pre -Fire Plan for accuracy. 18 Provide sonkler heads (min. 6) ardor compatible wrench. BY ORDER OF—THE FIRE CHIEF 19 Hood/duct adinguishing system to be serviced/ tagged every 6 mo. 20 Remove grease from hood, duct, and filters. (KEEP CLEAN) You are hereby notified to correct all violations immediately of show cause FIREALARMSYSTEMS why you should not be required to do so. A reinspection WII be conducted on . WillIful failure to comply with this notice is a 21 Maintain, repair, inspect, ardor test fire alarm system. misdemeanor. Violations that are notcorrectedimmediately and/or remain FIRE SEPARATIONS after the re -inspection may be processed as a criminal offense. Thank you 22 Repair holes in required fire resistive construction, for your assistance and cooperation in minimizing the fire and life loss in 23 Provide/ it self or automatic closing fire rated assemblies. your community: 24 Keep attic access and scuttle- openings closed. ELECTRICAL Signature of Recipient C, 25 Discontinue use of edension cords. 26 Install permanent wiring for fixed and stationary appliances. 0 Owner 0 Ma 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 30 iich clear space to and in front of electrical panel. FPR _ Engine Compa*. 30 Maintain wring in good condbon and protect from damage. Ld No vioi-AmNs NOTED THIS DAM FLAMMABLE L- COMPRESSED GASES VIDS THANK YOU FOR BEING FIRE SAFE] 31 Provide a flammable liquid storage cabinet or red" storage to 10 gallons or Addhonal Comments: less. 32 Remove all flammable liquids not used for maintenance purposes. 33 34 Store flammable liquids mvay from exits, stags, or corridors. Secure compressed gas cylinders. STORAGE - HOUSEKEEI)ING 35 Anunge storage in an orderly manner to provide access/egress. 36 Remove combustible storage from water heater and electrical mom. 37 Remove storage to 24 inches below ceiling or 18 inches below sonkler heads. 38 Remove linVdebrs from behind washers and dyars. 39 Remove wastakubbish mal -rials from the premises. 40 j j Kemp clumpsters 5 feet aff.)f from combustible walls, eaves, or Wings. MISCELLANEOUS 41 Other violations ardor comments. Page— of Address: ` Name: operty Management SIRE SAFETY INSPECTION REPO Butte County Fire Department California Department of Forestry and Fre Protection Orom'He, Califomia 95965 • {530 538-7888 Aa CAV.-- - - Inspection Date: Business Phone: �. Aft NO. CORRECTIONS REQU RED NOL LOCATION! REMAW CLEMW La�CAT�E�A1 PPW /'b 1 Provide address I.D. visible trap street. / 2 Remove obstructions at exits, doors, aisles, stairways, eta 3 Exit door to open without a key or any special kna wledgd efliort. 4 R eat door hardware. 5 Remove obshwfio rs from door regged Lobe dosed 1 I 6 Remove locIdUchess from doors with panic hardware. 7 Provide sign over main exit door - "The door to remain unlocked during business hours". 8 Remove storage from under u1nocled 9 PmvkMnaintain east s0Vem ti . 10 Have fie s servicedand tagged. RUNSPEC ION DATES INSPECTOR 11 Providelmount fire extinguisher as indicated. 1st / / 4 0% 12 Post a s fire ed i usher location. 13 Provide dear access to fire adinguishff. 2nd FIRE PWI.ECIKW 14 Illla}ritain, reps, paint, inspect, and % test sprin#clerlz1w &Vwe system hydranWDC/PIV. Refer to FPB I I 15 Maintain 3 feet minimum clearance fbr accessluse of fire appliar�equonent. District Attorney 16 Replace dainagedlpaintedl'missing sprinkler headslFDC caps. Flim Clearance l / 17 Provide ear certification test for 'nkler em. Clarss ❑ Check Pre -Fire Plan for 18 Provide spare Winkler heads min. and/or compatUe wrench. Y E R OF THE FIRE CHIEF YYehereby notified to correct all violations immediately or show cause why you t be required to do so. Are-inspecatlon wi[I be conducted � � � . � fa[�ure to comply w�h this notice is a m nor. Violations that are not corrected Immediately and/or remain after the re-im pection may be processed as a criminal offense. Thank you for your assistance and cmoperation in mmimb ft the fire and rife loss in your eommuri ty. 19 HoodJduct exiinguishigg soem to be senioedJ tagged every 6 mo. 20 Remove tease faun hood, duct, and filters. (KEEP C ;FMEALARMSYSTO5 21 Maintain, 'r, lisped, ardor test fire alarm tem. : F SEPARA't INS 22 Repek holes in required ftre resistive eonshction. 23 Provide! it self or automatic closing fire rated assemblies. 24 Keep attic access and wA& openingsclosed. E1ECrll1. Signature of Recipes 25 Discontinue use of a' demion dards. 26 Install permanent wiring for fixed and stationary iances. ❑ Owner ❑ MmW Wmployee Other 27 Provide cover plates for all 'unction boxes. Imgwfing Officer: OF 28 Remove egmsed wiring or protect in approved conduit 29 Provide a 304nch clear to and in front of electrical FPB: Erijine Co*w: =A2�4 Maintain ' ' in c�o�tion and tact from dam . ❑ NO VIOLATIONS NOTED THIS DATE THANK YOU FOR BEING FIRE SAFE RA LUM:C►O GtSE' _: Provide a flamable kluid storage cabinet or reduce storage to 10 gabs or less. Additional Comments: . Page of Remove all flammable liquids not used for maintenance es.OrA&X [33 Stage flammable i' from exits, stairs, or corridors. Secure compressed cylinders. wige sbWe in an marmer to aocessJty 36 Remove combustible stonc ge from water heater and electrical room. 37 Remove sbiNe to 24 inches below ceiling or 18 incus below' k{ef heads. 38 Remove linVddm from behind washers and chyers. 39 Remove wastefn ish mafarels from the premises. 40 Keep dumpsters 5 fleet away from combusWe wc*, eaves, or openings. .fiil�E#a�1t� 41 Other violations ardor comments. '"'SIRE SAFETY INSPECTION REPO'" Butte County Fre Department California Department of Forestry and Fre Protection Oroville, Califomia 95965 • (530) 538-7888 Address: I Ck-I LA V -k \ Q4�0t]4 CRY. Name: LA operty Management: ,/ Inspection Date. 111110 1l tb I o,�, Business Phone: - i't'& k API#: NO. CORRECTIONS REQUIRED NO. LOCATION / REMARKS CLEAR® LOCATION t=rt>� Y�(Z�^7. tin -Jam► / r 1 Provide address numbersbAding I.D. visible from sheet EXITING, , �l�5���cL is7�7CL�ZSS �\�N 1-1 �Z> >Zr0 50 .t ►'� / / 2 Remove obstructions at exits, doss, aisles, slairways, etc. 3 Exit door to open without a key or any special Im m6dgar effort. ` -Q V1' -O 4 Repair exit door hardware. 5 Remove cbstrucbom from door lecluired to be closed - 6 Remove b6s(latches from doors with panic hardware. 7 Provide sign over main exit door - "This door to remain unlocked during business hours'. ! / 8 Remove storage from under urprotected stairway - 9 ProvideJmaintain exit sign/emergency loting. FIRE t7XTURISHERS 10 Have fire s serviced and tagged. RE-MPECTION DATES INSPECTOR 11 Providelmount fire Extinguisher as indicated. 12 Past a sign inclicating fire ed usher location. 1st / 1 13 Provide clear access to fire adriguisher. FIRE PROTECTION EQUTiWM 2nd / / 14 Maintain, repair, paint, inspect, amd'or test sprinklerMancfpipe system/hydranVFDC/PIV. Refer to FPB / / 15 Maintain 3 feet minimum clearance for access/use of fire appliances/equipment. District Attorney / / 16 Replace damagedrpainted/mssing sprinkler headsA-M caps. Final Clearance / / 17 1 Provide 5 -year certification test for sprinklerfislandpipe s)dem- I Occupancyclass Z4 1 ❑ Check Pre -Fire Plan for accu 18 Provide spare sonkler treads min. ardorcompabble wrench. BY ORDER OF THE FIRE CHIEF 19 Hood/duct adinguishing system to be serviced/ tagged every 6 mo. 20 Remove grease from hood, dud, and filters. KEEP CLEAN) You are hereby notified to correct all violations immediately or show cause RREALARM SYSTENIS why you` houlli not be required to do so. A reinspection will be conducted on I4- t . Willful failure to comply with this notice is a 21 Maintain, repair, inspect ardor test fire alar system. misdemeanor. Violations that are not corrected immediately and/or remain FIRE SEPARATIONS after the re4rispection may be processed as a criminal offense. Thank you 22 Repair holes in required fire resisGre construction. for your assistance and cooperation in minimizing the fire and life loss in 23 Provide/ it self or automatic closing fire rated assemblies. your commun'� 24 Keep attic access and scuttle openings closed. ELECTRICAL Signature of Reciplert- 25 Discontinue use of extension cords. 26 Install permanent wiring for fixed and stationary appliances. ❑ Owner ❑ Nbriager ❑ Employee ❑ Other 27 Provide cover plates for all junction boxes. Inspecting Officer: _---- 28 Remove exposed wiring or protect in approved conduit. `- 29 Provide a 304 ch clear space to and in front of electrical panel. FPB: Engine Com 30 Maintain wiring in good condition and protect iron damage. ❑ NO VIOLATIONS NOTED THIS DATE FLAMNABI.E L1QLNDS • COMPRESSED GASES THANK YOU FOR BEING FIRE SAFE! 31 Provide a flammable liquid storage cabinet or reduce storage to 10 gallons or Additional Comments: less. 32 Remove all flammable liquids not used for maintenance purposes. 33 Store flammable liquids from exits, stairs, or corridors.` 34 Secure compressed gas cylinders. STORAGE * HOUSEKEEPING 35 Anange s in an orderly manner to povide access/egress.- 36 Remove combustible storage from water heater and electrical room. 37 Remove storage to 24 inches below ceiling or 18 inches below sprinkler heads. 38 Remove Iint1debrs from behind washers and dryers. 39 Remove waste/rubbish me' -rials from the premises. 40 Kee{ dumpsters 5 feet away firm combustible walls, eaves, or openings. MISCELLANEOUS - ' \ C. i7L- w �Z L \4- P \ 41 Other violations ardor comments. Page_ of V Fire Prevention Bureau 176 Nelson Avenue Oroville, CA 95965 Telephone 530-538-7888 Fax 530-538-2105 Address: Owner/Manager: Assistant Manager: Building Owner: Address: Butte County Fire Rescue California Department of Forestry and Fire Protection Facility Inspection Report ' White Copy - Business Yellow Copy — Occupancy File Pink Copy — Station File Occ. Class. Business Name: Bus:, Hm: Bus: Hm: Bus: Hm: Fax: 1 AN 1TTCPVCTION nF VnITR FAC H.ITV RF.VF.AI,F,D TAF 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: CORREUT-Ell: 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, WITH CORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE: ire Prevention Bureau 76 Nelson Avenue roville, CA 95965 elephone 530-538-7888 K 530-538-2105 Address: Manager: Owner: �3utte County Fire Rescue California Department of Forestry and Fire Protection Facility Inspection Report Business Name: Bus: Hm: Bus: Urn: Bus: Hm: White Copy - Business Yellow Copy — Occupancy File Pink Copy — Station File Occ. Class. Fax: AN INCPECTION OF VnITR FACH.1TY REVEALED THE FOLLOWING: 1. Fire Extinguishers: Required, service due 10. Exit(s) obstructed, inadequate 2. Extension cords: Excess use, defective 11. Exit sign(s) required, illumination 3. Excessive rubbish, trash, debris 12. Exit sign lights need replacing 4. Fire alarm system defective 13. Exit lighting: Required, defective 5. Sprinkler system: Service required, defective 14. Smoke detectors: Required, defective 6. Kitchen hood extinguishing system service due 15. Wiring: Exposed, damaged connectors, etc. 7. Fire walls, ceilings, fire doors, draft stops 16. Heating system: Defective appliance, flue combustibles 8. Knox Box keys 17. Address posted and visible from road 9. Fire Drill Witnessed Yes ❑ No ❑ 18. Other DETAILED EXPLANATION AND CORRECTIONS: CORRECTED: Date: Discussed with: Signed: ! 1 3leLl(Print) Inspecting Officer: alion 1 2 3 4 5 6 7 Station: FPB - PREVENTION SAVES LIVES, PROPERTY, AND BUSINESS. YOUR COOPERATION WITH ORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE ire Prevention Bureau 76 Nelson Avenue Iroville, CA 95965 Ielephone 530-538-7888 ax 530-538-2105 Address: I IA -7 Manager: Owner: MF ..ft. 3utte County Fire Rescue California Department of Forestry and Fire Protection Facility Inspection Report Business Name: Bus:. $9 _1'7 6 1 Bus: Bus: White Copy - Business Yellow Copy — Occupancy File Pink Copy — Station File Occ. Class. Z.. L- s­� ;Qs: Hm: j�q - Z Z S" `7 1 Fax: Yq 9 — Z Z. 7 -7' Hm: Hm: .,.T n►TQDUj-q`7nXT nTi X7njTD IRACYF.TTV RF.VFAIND 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 ❑: 18. Other ■i i 1 t11.'�!] w110KTA Y IaL`I_110111 1 Date: --� S _ 0 -3 Discussed with: Sign6d:, , � (print)�� d` D _,: _ Lj Inspecting fficer: Battalion 1 2 3 4 5 (0 7 Station: FPB ""r C FIRE PREVENTION SAVES LIVES, PROPER'I'Y, AND 13USnEJa. YVUl(C.VVYLL1ZAl1Vlr wrin CORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE: ire"Prevention Bureau 76 Nelson Avenue oville, CA 95965 elephone 530-538-7888 ax 530-538-2105 Address: 1Oil �ft�wger: sistant Manager: ii1ding Owner: Address: "'**'3utte County Fire Rescue California Department of Forestry and Fire Protection Facility Inspection Report usiness Name: 1.0k._40 to—A C. C!�a. Bus: r8ol — 1-78 Bus: Bus: White Copy - Business Yellow Copy — Occupancy File Pink Copy — Station File Occ. Class. Z,, Z C., 6 ok V1, Hm: -4;2;7 5771 Fax: 5-er, -a ��? , Hm: Hm: . ,.T r�►T���rrrT�11►T �1T V�1TT1? Ti S r'n .TTv uT VT. A T .F.11 Ti�F. FnT 1,0WT1 G! 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 14. Fire alarm system defective 13. Exit lighting: Required, defective 15. 16. Sprinkler system: Service required, defective Kitchen hood extinguishing system service due 14. Smoke detectors: Required, defective 15. Wiring: Exposed, damaged connectors, etc. 17. Fire walls, ceilings, fire doors, draft stops 16. Heating system: Defective appliance, flue combustibles 18. Knox Box keys 17. Address posted and visible from road 19. Fire Drill Witnessed Yes ❑ No4 1 18. Other ETAILED EXPLANATlUlV AND (:VKKL:l:11Vtvno: or Q). I k I C) �= C.. t�c0i -Cc S a� t tp U0 / CN,".r CU ; bs C-vr cx��; M %.Vi%XLMl., A ]NAP: �o 1r' Too i< Dom&1 �n \r -eq ker K Date: � _ 10_ 03 Discussed with: (Print)P\A k v c, � Si . ca, - Pf - ____ Y1 Battalion 1 2 3 4 5 6 7 Station: FPB Inspecting Offs (-,nqrrev� �ts,t FIRE PREVENTION SAVES LIVES, PROPERTY, AN 1) I3 U SJLN ESS. Y V U K U V VY.EKA 11VfW4 W 11 n CORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE: A01 t �" SF Office of the State Fire Marshal Fire Safety Correction Notice l 1 CALIFORNIA STATE FIRE MARSHAL File No: Name: ;Yi ! �1Q �%/ L - Address: The California Health and Safety Code and the State Fire Marshal's regulations require the deficiencies be corrected. following fire safety ct� %;+ 7- r���� fix, ,— lis 1 rfA) �771� i� �F- F1vs0.,.Mf 6 7r, !r/%—i l/1- WA -y. The above deficiencies are to be corrected within days. When ALL deficiencies have been corrected, sign and return the certification on the opposite side of this form. If you have any questions, contact the Office of the State Fire Marshal at ISSUED BY IDep* State. re Marshall RECEIVED BY DATE EN -11 (Rev. 7/86) 89 88751 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field Aft L K" _7-7 3 � �. T .y1.��c.� y.,i 4�"�'• Ste„ 777 ''•- as moo! AM WE - - y- ry 77 f 7- -77 r r. { � !e� __ .A-_� - __ _ _ ,y. �r �,; :Y. •- _ _• --mac. - - �q� - ,r'; :, - _ ��;R '3: sa Ry _ - � �#3�, •�!C•, !'JAgE1-1 ' _ S , rr trP'' X11` � t ltd• .c _ .ter. z SF Office of the State Fire Marshal Fire Safety Correction Notice I � CALIFORNIA STATE FIRE MARSHAL File No: -- —_ Name: _ J, '12-A t? Vt L 1`>' Address: The California Health and Safety Code and the State Fire Marshal's regulations require the following fire safety deficiencies be corrected. l J 1 :l n) moi` / t J llf i % UK„ Z f c .�. �4 6 /'j (_61 AL ---r 7-70 X16 Tr dwSc✓✓I E 'DtC-6 k�L 6F rr iC X,-rl,/, I—E r/'�-j �'i /1)Otj r3kL4 -ED /2-�e. The above deficiencies are to be corrected within days. When ALL deficiencies have been corrected, sign and return the certification on the opposite side of this form. If you have any questions, contact the Office of the State Fire Marshal at ISSUED BY (Deputy State Fire Marshall RECEIVED BY i m rE r ' lI :N-11 (Rev. 7/86) 89 88751 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field c V�. n Z50 4R, ........... o V, XII-Ij "--TA CALIFORNIA t`��} g -a. ,SAFETY INSPECTION R .:T 102!7/DONNA (REV. 10 9 See insfrucns on reverse. -CONTACTS NAME TELEPHONE NUMBER REQUEST DATE PROGRAM /COMITY CARE LICENSING 530 895-5023 10/15/9 TOR'S NAME REQUESTING AGENCY FACILITY NUMBER . REQUEST -CODE CURRIER 041370794 7A CODES,�• 1. ORIGINAL A. FIRE CLEARANCE LI ENSING � r of SOCIAL SE�.�� � '- A ENCY . � CA LIC�SI2. RENEWAL- B: LIFE SAFETY - N IIAE AND 520 COSSET ROAD, SU 6 3. CAPACITY CHANGE A DRESS . CHICO 9 CA 95926 4. OWNERSHIP CHANGE 5. ADDRESS CHANGE 6. NAME CHANGE 7. OTHER - AMBULATORY NONAMBULATORY. = BEDRIDDEN - TOTAL CAPACITY CAR � TTY : ' PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY.:' S .+ 6 Ri 14 Y,. . M4. I.�.. .yry6, • ;1 .� M1j %. •}: '•.Yf .•.1 •. ..\�' ••'.t•. •'.4 .E110 01 1 •• 'SAf•.Y� .h •. •{W.. 40, FACILITY NAME., - LICENSE CATEGORY LA. MIRADA VILLA 13RCF STRE ADDRESS, (Actual Location) . NUMBER' OF BUILDINGS 19 LA MROA AV= 1 CITY JACK ��RS71 RESTRAINT ,'I= CA' 95965 (530)-589-1781 0 s :. (076 �� FACI TY CONTACT PERSON'S NAME NIS.. � AND D HOURS ` RA .OR,-..- VERONICA ALMOCERA , � �L - � 24 • SPEC L CONDITIONS €T9 USTTIRE- INSP CTION WAS 1959 Ri Y,. . M4. I.�.. .yry6, • ;1 .� M1j %. •}: '•.Yf .•.1 •. ..\�' ••'.t•. •'.4 .E110 01 1 •• 'SAf•.Y� .h •. •{W.. �1 �{{�Y.: f. f:Y.KS:(`C{. . f�.•(••'... h.. • Y.• Y. .:\`.4•• .Y.iYf:. •. -•:.:. Y{ �` 4 . f. f h CLEARANCE /DENIAL --CODE CODES JACK ��RS71 j6,4, IRE AU HORITY STATE FI HAS #4 A�iSBURG LANE, SUS :. (076 �� GRANTED 1. FIRE CLEARANCED • 2. FIRE CLEARANCE DENIED NIS.. � AND D � ���CO CA 95926 s � �L - � A KESS . /" A. EXITS op B. CONSTRUCTION - D. SPRINKLERS .INSPE TO_ R'S NAME (Typed or Printed) TELEPHONE NUMBER CFIRS NUMBER OCCUPANCY CLASS �3 E. HOUSEKEEPING F. SPECIAL HAZARD G. OTHER INSPE TION DATE- INSPECTOR'S SIGMA E orP ' d) tvv_EXPLA N DENIAL OR UST SPECIALCONdPIfONS k4 -40 . - �� _ - -. •7; � i' •"' � ♦ � :�. -s_i.. �'.; o-•.' 1 -'moi- li • - . - - .' _ ,. `' � _ � _ � - � � _ .. � � <�' �r- - t -. - - - - _ __ - __ �. - -- .' i� = --- - -- -' = i - - .. ," ` - -- _.�.___; _ , _, . ___._ _�--�__-.T _�_•- -- . __.._ - - - -, ,� ^'T. � � .. - .r � -�. _-ter �r ^i � _ I -. — _ . � 1 . ,. • . _ �: �� - - - � - � tied. � 1. � � is �� - • - � j � � _ _ i � - _ _ ' _ 11 T _ .. � . ... _ . ... .r r � •. _ .� I• .. • .._ ._ .. - •. ... � r .- _____� •_ � !. •_ _ ._ .. __ _r-. � -.. _ � - . . - . - - r.. � N.. - - �.�+.� - _ ...Sr-.. -. ..� rn ..-. .w .�. _ a. - _ .-. .. ... _ _ �.._. - .. _ � _ . t. _ - - - _.� � . �� _ � r � ... _ � .. _� .� - . ., �� _��.�,i� _. .��_�.4_-_� � �.- .� �.. _ .�___. �_. .��. ._ �_�. _ __ __ � _ ��_ _ _ _. - .. _ _.._.� _ _ _ _ _ _..� _-..._._ _. �_. ��_ _� � _ .� _ .. �. _�_ _ ��._.�.� _ _tee-..._.,_. .._ _ . •..�-___. __ _ _�._ _ .�.�.��� _�.. _ ��. ...� -_ � i .. - � •t-.. _. _ - _. - � ..�_. . �_�.... ... .�..♦z1 ... ....___ .. _ - �.r.•... •.r--.'_ � �. _ _ -. _•-Y-_ __ _ � � a_. _ .� ... �+Z:• ..�1� ... .c.Ma.'-_ if! a ��. � .. .. _ __ � -ate __ �� +-..S�.c�. _ .... .. �_� .�, r • i- .. rh�.L�- ' � _. I _ - .1 . FK e of ;ice of the State Fire Marshal � E� REINSPECTION REPORT" STATE FIRE MA SHAL e No.: . — of Facility: ie of Building: re55: L wf 4, vim. I ..-n •L•!• I\.C':•>v• nl.i�'t,^,♦ { ..>> ¢1 L`..*: d •f, yi :f ✓ Jai'. ''f • ) !'� r is .-� nn:i.• v�. N �( , ;0{, w .+. .. '�^.. ... fn. ,r. .. x .5�.• .� .. {t•:. -)) :.d♦a+: •.. .G/1`yr' ...^: i. .; •..�l;, t'{ + ;:''� . �•. f Ar.� . `'2t'N• •�.; - v.lr, �{ J •r" ,( t;.. • � +y .t aI X .M ' i F T g `4 . J />n T. �. N ` ♦ ?..'4 .. t Y,.W !,^ 1'.1 r �1.. � �\.. � ! 1. ^' . n:An� �I . } •..iS , i .�c '�' ,��,y •I t•l'.. {i - A. • .; :.. .... ...... .. p w . .< t � .. .. .. ... :."�: �.n :..�'• :T,•.g, ,�. ..F. dt .� R'Di..V'. .x tr t r�.• r+. > ! 't ,CY r..q ,y,. `fy'`� �' � aR'.' {N,,��^��. -Y: F]W.' st Y.. ••r :� '�,itA'' �� t • S...t� �- t: - r:31�1�ll.... sed (y��y�.��■!!�.�"' r -i '\. mac?^ :1 .. v � 4.. '.�'�� Al } ..1P, it'µ<' �' � 2 ' i 4 .�L h 41 ,!3'tb-y�'•k:?C: -'t� 'a' y,y « t 1'1� �h�� p,./ .� S._s. .y.f... 3r': r.. r:.; w t.>, n{�Y.+ . .f,- -C •-4e,•.w. . •�`:. , Lf� rt `w'.` :Li •�., �' `'�::.�. -tt- ..� fr �'�• 1y Jcn X.I"t c�l"�L9 .�, - ? -'�•� 7-:`r""� - X^Z >: A.- T: .. "'::.<'. :•i 1 i1 f - t '� . ` ice"" ' ,�IIj�, } .-.:- :'Y if' d'fx�.a 7 Fire Safety Deficiencies Numbered _� noted on the Letter ❑ Fire SafetyCorrection Notice EN-11Eldated -�2, have been corrected. � ) Uncorrected Deficiencies Numbered were re -issued as shown on the Fire Safety Correction. Notice dated , which is attached to and made a part of this Report. In addition, Fire Clearance Instructions: new deficiencies were identified at the time of this reinspection, and are shown as Items on the attached Fire Safety Correction Notice. !�C �'�b A�f'�'1 :K .�+. ,: i:♦+ q:7r- r-. ♦ ••.1 tr\ ~:t.t, •N'.. a' �� ��.i�:Si� �� B? .I:.. �` :.�,, t �) •'i = B � ,Ci,.'�., r�Y'. .,.•... `iMf _ - R` Y Mf, f� �.� '• '>.>... 'x ...5.•,N. n,, 71,4r; '\. mac?^ :1 .. v � 4.. '.�'�� Y .Y{ ,kyr o t. -mss>..'�. �•rr . .'�J.,{ .. : A • ?'t .:� •.?:. STATE' -ri..' iv ",I ♦6+'1Fn� .' , f; v, ,y. .♦r• "•i. mow. .ilk .'>x':Y , n• . ft•' .�.: .: 'ZL'>LY� r ! [ T • '•.s ti;. 3.: < `iS.. _ .S!t .1'f ; .n. t < a; +ti: +i. �'.' ".. j v' '�. St:. f i >!.i ,t 'IT i• ,l uYi.. � tzv -�...IM >�.'. r:!•r' i, 2 t`� T:•• w7. ' >..• • " _ i.' �.f•' L�'��/?.,� Q �f,.. .W�+•a :K: f i 7ir.. / v ..YS . ,r. �. y"lv-rl�. may♦, A : y..- /+ ,N 7 Go - 5 (Rev. 7/86) age of office of the State Fire Marshal 0 � INSPECTION REPORT STATE FIRE MA AL File No.:.l:�.� � —�-1 �7/ ol l/2�; 1 ame of Facility: ame of Building: ddress: Gu� v Discussed with: Title: Accompanied by. Tale: r� ` � w FRE CLEARANCE GRANTED T•DATE STATUS ot DEJVTY STATE FRE MARSfULL _ DATE OF , 7T<', 7 1, 1 ` 7:2 ====:d • 6 (Rev. 7/86) .ice of the State Fire Marshal REINSPECTION REPORT No.: -0 of Facility: `N. � \ V-& \�! � of Building: FRE CLEARANCE GRANTED Discussed with: Title: STATUS j Accompanied by: � �~i �( Title: DATE OF REINSPECTION % Fire Safety Deficiencies Numbered --71-noted on the Letter ❑ Fire Safety Correction Notice (EN -11) EX� dated - T5 `Piave been corrected. Uncorrected Deficiencies Numbered were reissued as shown on the Fire Safety Correction. Notice dated , which is attached to and made a part of this Report. In addition, new deficiencies were identified at the time of this reinspection, and are shown as Items on the attached Fire Safety Correction Notice. Fire Clearance Instructions: ✓�\�J�3{v �1 L-v\z u FRE CLEARANCE GRANTED T -DATE zm STATUS DE STATE FRE DATE OF REINSPECTION % GC • 5 (Rev. 7/86) Page---of--.� Office of the State Fire Marshal INSPECTION REPORT 4SI STATE FIRE MIAL He No • -- ... , ._ 04 .42 0027 000 555 9 ame of Facility: la Wrada Villa ame of Building: ddress: 197 LaMirada Ave. Oroville CA 95965 • ♦ � • � � .. Vr •' ll• � frt •i.. :j ::r � ..t •'•w ..,. l •.r +• t •r.' rw..�.�-�., r, tt + rL,. =j 1.. • •j . FI . ,L �.1� •• {'1 •�.�� �: 1 +� fV r. •1 !•i•r" 1 •'. _ . ��1 .• •. IT .1" /•r 7 ..i f �. 1 ,i l: r'r 4,• 4 .i• `� i .. �•'� •�� . 1 t+•• •�♦ 1 r r 1 l ':r a� :1 • l .fir•• • ' •,.. i rr`r �1 t .• .i . 1 1 • t' ►•� ' �'� t� �t' • �t � . t �• ff 1.7 Y� �r • \ t �1: � 1 r t�:.� �i:• \ j � t .�/ �{{ !' i .' �l: � ,1 '. rl •',t 'r• '1: ' ! �-1A r • .� t r •f t F . •' ° '33jj� • • 1' Jt.. .., • •. ' .1% j (, .. 111 /'• j r • , i , r . �.• • .�� rj `4 ., r•j: •1 ` % j,: �• '1 tr•t�,l `r;'. 'r�`S. r' • / • It»,f.. �1f 1.1 i•r It'• •� ; +,� jr 1. •• •�-. 1/ ,1♦+ y� ,�•% Discussed With, : a .. . , r r • _ ` ! `Titin' • `' . / s , ' , i j • ' !.1 .�,•F•� •�! jj1�'%r' . \ �;'( •i►r. 'i. et•�.,1µ11�"'+1f` f•�1�••. ..�•.r•�:�',,i 1R j r••�►�j. M. "L,�1� 1• '�� �; �`�i':11; • 'Y' ':.` , ,� •�,).,•,'� •,,r �.'• t i 'S •f•�1f',,,1�+.•��/•�.....rrr•r���r���+r.r • :1�1r;' 1 1 Ij.144�j ly �► i1� i.•► :t. �` 1: •t:Al •, �i. ► 4 .3 F•. / 1 • r''IFZ•i �E •'Y •4 t�t••��t�(, "•�fii7 tr:•1wi�''`• F.1 %. , •.rL. :i•.I{ � .r•i•!' t�.•i-.ia�.1.j:r•�i ,•;\j`it''�i(' . 'r. .1 �17�t '[�1.•..,� �l 1,.*�...1•,ri.'•/i�l•��v.,1��....t,F ''��fir, . �'••ttj1 f'��.j,��'Yf{�•�t1% : .+C��• •111l1}}}1't.r'fj;..i•i'.�.}itir.r•: . �l•j :I.j:.i�j..l':r•'••.+•�l{• •,;b�•�j•lj�.�'11�i1 •�ijlt• '•:'y7•.�1. r.}'•-••�t�. ra , ly)!•I':Y b.s ��:t.�1}. . yeG',. �. '.lL�t1,.��;\.,lf�•jr •t /1 11 r�• .��l.l:' '..�i•'Je'_•; �=. j 1, � 7 �� �' �1'.'•l••r/'� fi• S11•t!•.rj •�.:•1?{f��� 1►�"�1t�•, P1}; •��t 1 .• ',•.��.••1 t v�•yi, �it+ �•1 ' � �Y�:f''; it�,kpe��i.l �•j �a(.'.f•r• � _ •; «+t 1•: .•. ;.•• I � If. ••,. �.� 1 _ Nw11t r W. it Accompanied yz • .1th( t •�r• 1' ,•''i�•�• �I • 1 �• 1.� An annual inspection was conducted at the above f ' ty. ffiergemy lighting in rain house and beck fmm needs new batteries. An Fn -11- was i&%W, rm TM f aEARA cR^N , 1 1;./ - # MATE 1(_�4 �• 1 •.• 1 y�,j '."\ 1. t , .t•!• V + 'a.�i r'•.� _i _'ry .j r t•'t ), j• ',1 �' t • 1 '♦•t 1 91 1 ••�1 `1 ���•re' ���.�1.?1� _•���,'•� .71 •+ ..•�+•1. ;i. �' 1� .«.•�•` t♦i � 1•� '�'f+t�'iy ..(�j••� .f!_.!' �, .. �irr i,jf �' ♦ •i.'' 1 '�'{• �, •• r • ' r. ' Otpm STATE FRE MAM 14 ' • •`' r /•, i •,�. ' s?•r (t � ,+', ~ ( t i rl•:• 1• .•4. .Y - 1• r (• r��Z++�.l,,'jt•1�. • i.i ' • 1I, • .i,i ..,i- DATE of PMC1 T0•4 Vbe.929 A( 'r • • _' r _ Is1 23 / 1 • 6 (Rev. 7/86) a Y,'ixr•'``�'m.�ii iLi':«i`�"`.'rn':. �tll�it- tt — ....- i..,.,�".'LiE-ii'3'.asaiG�i:...a�,t:«.ar/:!•iss:in.•t&u�:.iYr:::- ..t�kef�ir.;,:��r .., .. ,. .:.+..t.. v_ ... lubiTr:_ ���p��� 1`•,,'' n..' ..... V• L. Li. Y IiLbWfr�Yi1•/Y.V'J:.'..►I.i.OwJticii.iw....fi2K .•�.ti�i.�FL�: R Office of the State Fire Marshal INSPECTION REPORT No.:. 00 = 04 = 42 _ 0027 _ = 000 = 035 _ _ 9 me of Facility: J aMi rada Villa of Building: 197 La Mirada Ave. Oroville, CA 95965 r t .Yr i � y 1. Y `} I 4 #h'{' $ "Sr i'•a a . :l t ' Y3 7� r y'� :f Discussed Withrr'�,� {F 3 ritle`�' ����" �,iy�� , k � ^� i'Y � �C "Jf } �y ✓} ��'` r 4 Jv�, Accompanied L`fc,. r;!+�x•.?` �ev1 "k`».tkx'i4 #� !#': :. :�i 00,�k5.ir b. An annual inspection was conducted at the above facility. No deficiencies were noted at this time. The facility maintians a reasonable degree of fire and life safety. Fire rlearance one maybe 65 or is granted for fourteen clients six older, he rest between 18 & 64 of which maybe nonambulatory, and years of age r DEPUTY STATE FitE MAItSFUI �i BATE OF:�SPECfION FRF CIEARAP1Ci GRANTED $ M+ t "� F ye& q 'd` r'r trf;' KATE i3i� a 4, d1 ; Y iu ) a3 y: '6 y STA". � ( •ply - �F7try, J' - 7CiJ t T,�r X' ii7' p a r DEPUTY STATE FitE MAItSFUI �i BATE OF:�SPECfION •6 (Rev. 7/86) r4 - Office of the State Fire Marshal INSPECTION REPORT No.:. Q - of Facility: L—iA of Building: Discussed with: Title Accompanied by: Tit e:: e9u) IN cl-I iJ FRE ARANCE T -DATE STATUS ba— DEPUTY STATE IIRV DATE OF INSPECTION IN cl-I iJ FRE ARANCE T -DATE STATUS DEPUTY STATE IIRV DATE OF INSPECTION -6 (Rev. 7/86) Page --of office of the State Fire Marshal REINSPECTION REPORT File No.: 00_-04_- 42 0027 _ _—_000 _---35 _—_L Name of Facility: LA MIRADA VILLA Name of Building: Address: 197 La Mirada -- Oroville Ca. 95965 Discussed with: Veronica Almocera Title: Owner/Operator Accompanied by: Title: Fire Safety Deficiencies Numbered one noted on the Letter ❑ Fire Safety Correction Notice (EN -11) ® dated 27 March RA have been corrected. Uncorrected Deficiencies Numbered nnnne were re -issued as shown on the Fire Safety Correction. Notice dated which is attached to and made a part of this Report. In addition, no new deficiencies were identified at the time of this reinspection, and are shown as Items on the attached Fire Safety Correction Notice. Fire Clearance Instructions: The owners rpt „rnPd a ci SDPd FN—1 1 1 i rPncr, request for clearance of one elderly client was granted with the understanding that the client be housed in a room with direct or semi -direct exit. FIRE CLEARANCE GttANTF]] STATUS Yes � FT-11AT1 I-9003 (change) DEPUTY STATE FERE MARSNAI DATE OF REINSPECTION SLAUGHTER 24 April 89 GO - 5 (Rev. 7id6) C�� ST TE FIRE MARSHAL COPY DISTRIBUTION: o �:l SEE REVERSE OF COPIES 2 AND 5 FOR INSTRUCTIONS FOR COMPLETION ri G apwr. i T morr-%o i iv1r nr-%duG7 i a- - v,...a......._ ...r...v,..�� 2 --FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM STE 1850 (REV. 8 / 86) 4 -5 -LICENSING AGENCY 4/19/891 �. GENNCY CQNTACT 4. TELEPHONE NO. & EVALUATOR Dss/Community Care Licensing (916)895-5033 0103/Robert Caldwell 6. SFM REGION 7. SFM I.D. NO. S. REQUESTING AGENCY FACILITY NO. P. REQUEST CODE 330 041370794 7A CODES REQUESTING CLEARANCE FOR ONE CLIENT OVER 65 TO RESIDE 1. ORIGINAL A. FIRE CLEARANCE IN ADULT RESIDENTIAL FACILITY. 2. RENEWAL B. LIFE SAFETY 3. CAPACITY CHANGE 4. OWNERSHIP CHANGE 10. GENCY Dept. of Social Services 5. ADDRESS CHANGE AME Community Care Licensing 6. NAME CHANGE ND 520 C o h a s s e t R d. ,# 6 PREVIOUS NAME ADEssChico, CA 95926 i 7. OTHER DATE OF ORIGINAL REG. 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE C ., ,ACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS 8 TO 16 16 TO 65 AND CAPACITY 1 TO 18 18 TO 65 AND CAPACITY 19. FACILITY es OVER 65 OVER 1 CODE I 18- 1 6 1 1&-59160+ 14 735/A R F 1;. AGILITY NAME 13. NO. BLDCPS CODES 15. RESTRAINT 1. GACH 7. ICF / OT 2. GACH / R 8. ICF / DD 14. PTREET ADDRESS (ACTUAL LOCATION) P.O. BOX 197 La Mirada Ave. no 16. HOURS 3. SH s. ADHC 4. APH 10. CLINIC CITY ZIP CODE Oroville CA 95965 24 16A. SPECIAL s. PHF 11. JAIL 6. SNF 12. ICF / DDN 17. FACILITY CONTACT PERSON " TELEPHONE NO. Ray Almocera 916 589-1781 1 13. OTHER TO BE COMPLETED BY INSPECTING AUTHORITY F 26. CLEARANCE CODE 1,0. FIRE 1 Jack Pirisk AUTHOR 4 Williamsburg Lane, Suite , 3 CODES NAME Chico, CA 95926 1. FIRE CLEAR, GRANTED AND 2. FIRE CLEAR, DENIED ADDRESS I L,_J 3. FIRE CLEAR, WITHHELD 27. DENIAL CGDE TO BE COMPLETED BY INSPECTING AUTHORITY CODES a!1..IN$PECTOR'S NAME TELEPHONE NO. 22. CFIRS 23. T-19 OCC. ID NO. CLASS L EXITS RodneySlaughter 895-4312 035 g I-42 INSP. DATE 2S. INSPECTOR'S SIGNATURE April 8 2. CONSTRUCTION 3 FIRE ALARM 24. 24 EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS 4. SPRINKLERS 5. HOUSEKEEPING 28. Fire clearance is granted for 8 ambulator 6 non-ambulatory, and 6. SPECIAL HAZARD 7. OTHER one elderly client to be housed in a room with direct or semi --direct exiting). STATE FIRE MARSHAL USE ONLY RETURN TO: Dent . of Social Servi. ces !i P 20 REGION. Community Care Lich- ng OFFICE 520 Cohasset Rd.,# AND ------- Chico. CA 95926 Page�,of__-- Office of the State Fire Marshal INSPECTION REPORT Fite No.:. DD-_ �4 �... 1 Q35�- Name of Facility Name of Building: 197 La Mirada Address: 96965 Orovi1le, Calif. _ - �� ti, c b -•x y,. - 4 -Zs `^•.� "ff c fiY -�"° of ? 'c' ) wk> :<>.: ° ;:}- { •'• V. 4 r'i :, S #< y Sv ±?[• i <. v:x. t -t'., [ 4T [ [ • e„a<.. `t?t7 ` T ��C y.. � Ey 4 f�R , x - [_'e?fe'.. .,;<y1. < ...s.i.o � t T �+. '.�N R' 3 ,-.^ •..� i.r r- <yN ; y`• TX T,t '� Yom' .� i'.>rt•-H��( (��.� k .�",Z Z,: A'� ���;-)* > [ 't �-� q t , 6lx ^!:fk i .:i y {-Q;:i> ” %T x : � � Y � ° � S �.-i T'4. .!'.. ro xb.-. Y,3f tT/ } TT -. .; nc t w x -'- < ♦. ro r ,� x h -,ax. e�''`3 "' • ` \ �- }i`t `:2 .." l `a Y W tis r,aT i e t qT�,w. 3 �eKeq� STATE FIRE MA AL T : ro .> # . J m x ileNo:_------- Jame: Office of the State Fire Marshal Fire Safety Correction Notice STATE FIRE MARSHAL Address: The California Health and deficiencies be corrected. Safety Code and the State Fire Marshal's regulations require the following fire safety 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 FireMarshal at ISSUED BY (Deputy State Fire Marshall RECEIVED BY DATE EN -11 (Rev. 7/86) 86 96708 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field ia FILE N0. (72i n3 n) E � REINSPECTION REPORT' OFFICE OF STATE FIRE MARSHAL Jame of Facility , Ylg . address 19 7li 4A i wt ��. c conditions Discussed With-,70S(F A .. � Accompanied By Title ,��' Inspection This Date Discloses That Fire Safety Correction— Fire Safety Corrections Gated 91-112 1 - YG Have Been Complied With. Fire Safety Corrections Were Discussed Wi th and Disposition Will Be As Fol 1 ows - Z J� 'c. t-100 _ C WA opt A 7 tr V-0 MA4 OA - - .� 6, lug pect.-i rA YLx --ALowtw,, c..., TQ _ fet • Indicates That � New Fire Safety Corrections Should Be Reinspection Indica afet Corrections. Issu ed. See Reverse Side for -Co . an New Fi re y GO -5 Deputy (3/70) REV 5/81--- Comments and New Conditions. New Fire Safety COrrecti ons: 'h . STATE FIRE MARSHAL FI F E SAFETY INSPECTION REQUEST COPY DISTRIBITION; ^� SEE REVERSE OF COPIES 2 AND 5 FOR 1 -3 - STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION STF 850..(REV. 7/80) 2 - FIRE AUTHORITY. REQUEST DATE 2. PROGRAM 4-5 - LICENSING AGENCY 11. 3, AGENCY CONTACT 4. TELEPHONE NO, S. SIGNATURE i; v 0-01,211 LAITY CAIZ 'LICE. SING{ 1 b ` 39'5-- J` 6. SFM REGION 7. SFM I.D. NO. S. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR !J 19. REQUEST CODE CODES 1.ORIGINAL A.FIRE CLEARANCE • 10 AGENCYF-DEPARTMENT 07 SOCIAL SERVICES 2.RENEWAL B. LIFE SAFETY NAME COMMUNITY- CARE LICENSING - 3.CAPACITY CHANGE AND Cohasset Road, Su1te 4.OWNERSHIP CHANGE ADDRESS 520 Chico, CA 95928e 5.ADDRESS CHANGE ei s> J6.OTH ER •Ok+:E: OF ORIGINAL RF VL ez Z-7 - 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LA CLEARANCE CAPACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS TO 16 18TO 85 AND CAPACITY TO 16ff 6S AND CAPACITY8 i`i 20. FACILITY 5 OVER OVER CODE Tz5 12. rACILITY NAME 13. NO. BLDGS CODES 1. GACH 7. ICF/OT 2. GACH/R 8. ICF/DD 14. iTREET ADDRESS 15. RESTRAINT / 97 le Mirada Ave. .+� 3. SH 9. ADHC 4. APH 10. CLINIC 5. PHF 11, JAIL ITYs{�ttnn ZIP COOE 16. HOURS Qville, CA 6. SNF 12. OTHER . 17. ACILITY CONTACT PERSON- TELEPHONE NO. 16A SPECIAL kl-,oce- , Veronica and Ray (915) 589-1781 Adult res. TO BE COMPLETED BY INSPECTING AUTHORITY 18. FIRE 27. CLEARANCE CODE AUTHOR. i NAME CODES AND :'1~%FIRE CLEAR. GRANTED ADDRESS 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. INSPECTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T-19 OCC. ID NO. CLASS 1, EXITS 2. CONSTRUCTION 3. FIRE ALARM 25. INSP. DATE 26. INSPECTOR'S SIGNATURE 4. SPRINKLERS 5. HOUSEKEEPING 29. E XPLAIN DENIAL OR LIST SPECIAL CONDITIONS - 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY 21. REGION. FFICE State fire Marshal NO 4455 1!orin Road Suite 100 DDRESS p/+�yi�y�'.a�}� Sacrarllento, CA 9582/ TIME MILES NEXT INS P. (MO.DA.YR.) v ��J �-' _ 2r- �y � � �c•�n�..�c�gc�4 �..,y �t z �X+i: y _ e-� .. � _ �. IT 44 -✓� R�,� _ -;:. ,int '3rr K -- t-+�3'.:�� �ti� � 3 .?=� yll01 •'�-" -�-yfF { t-+r. �T -. �' - _ -'�, G-::-r: �`.i--,�T-'� 's� -a 'rte �� �"',--�- ;, - - * ' - ter-: +v�yJ � D ;t��a �` t� �� Alk�r Br k-%•prat R a - .� - A!t� - .3 i � � �' ¢. i• :GO -+E � t1' ,.T � :T kt�[1v0 +:�a%i `��,w� a 4 Cal - �:.. �... � � a Y ,��..� � � � x �; -` ssL' �' .mss; �.• �. -^�- 71 *01 cp Y � .i'� �._ 4� .rte ^$ .• •� � �� - ��- l _ � s` � w � jai 4 frr = r � •s�- � •� to Tr 'H' •R -- l- 52 z F Et'f#7k'il*`-'t' k0 .a ti - ` _ _ .. - s -.vy AOM _ 4 AP jwl 0 ZZ 1704 A B Aiarni, Inc. INVOICE NO. 924 Nl�ard Ave. 0385 clll�o, CA S5926 G93-4269 SMM Tp 5 H XPE D TO S FREET Q NO. STREET& NO t"A S" A T E 1 p (-If y STATE ZVI ot T i7_ 01 f, IxCu -I. r it A _ _ - DACE 0 Ilk. " STATE IRE MAR AL STATE FIRE MARSHAL FIRE SAFETY CORRECTION NOTICE N ME FILE NUMBER DRESS Fa a 21531 N �l tiL.A�ObA aaFol, o [0- F21 tg EM [51Ok o a oykwt CA A In accordance with the minimum standards of Title 19, California Administrative Code, the following corrections are required: Z0"k" fp .°Z t fi�tdc� c� K LC 7. o lrk� C9 The above deficiencies are to be corrected within -36 days. Upon completion, please sign and return the certification on the opposite side of this form. I f you have any questions, contact the State Fire Marshal's Office at (�) P-9-r--vlz ISSU D BY (DEPU Y STATE FIRE MARSHAL) RE IVSD BY DATE L/ EN -11 ( EV. 7/81) YELLOW: REGION! M ::TE: FACILITY GREEN: FIELD 99701-355 3-94 12M TRIP OSP Amok 1 CERTIFICATION OF CORRECTIONS BY OWNER I certify that all items listed on the reverse of this form have been corrected in accordance ;.with the requirements of Title 19, California Administrative Code. SIGNATURE DATE 00, (Fold on this line (Fold on this line) _ ---. M ROUTE TO: (1) SUPERVISOR Q RECORDS CONTROL CLERICAL DEPUTY initials Cmc STATE FIRE MARSHAL REGIONAL FACILITY CHANGE NOTICE (2) DATE: (3) a"NAME CORRECTION/ HANGS (4) ADDRESS CORRECTION/CHANGE (5) OCCUPANCY CORRECTION/CHANGE (6) INSPECTION AUTHORITY CORRECTION/CHANGE (7) FACILITY DISCONTINUED (8) Q ISSUE OR CHANGE IN FILE NUMBER (9) OTHER NAME: 1A m t nA+ OA 121Z6T h4-171+11 Z ADDRESS: jq-7 t,,•4 N sn, 4io,4 0ae>vaf i(' CA 9 G.s- COUNTY: rlZ (No. c,,-/ ) FILES IDENTIFICATION NO. D E 1 0- El DDE 11120,> E OCCUPANCY CLASS: (- _ -ate code proc. INSPECTION AUTHORITY (10) N E W NAME: LA m,KAoA V1C,tA ADDRESS: COUNTY: <;<;c - (No. ) 1) FILE IDENTIFICATION NO. [IaQa 00[1 0011 0 12) OCCUPANCY CLASS: code proc. INSPECTION AUTHORITY (13) LOC. FACILITY -LOC. INSPECTION (0) LOC. FACILITY -LOC. INSPECTION (0) (14) LOC. FACILITY-SFM INSPECTION (1) LOC. FACILITY -SN INSPECTION (1) (15) D -''S FM FACILITY (0) SFM FACILITY (0 ) (16) COMMENTS: Av-1.1 OwP4t.s-ilty (17) ORIGINATOR� E I —13(T) (12/80) 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 located. (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 section marked "Code" and occupancy number as determined by Regional File 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. 2. This form is to be filed in a separate fiZe by month, county, and facility name (aZphabeticaLZy) and retained for one year. EN 2A OFFICE OF STATE FIRE MARSHAL COPS ENTS: 511x' 60.,6 ANNUAL. INSPECTION REPORT FILE # . 00-04-83-0005-000-330-0 ! C I STD -850A FACILITY NAME LA iIRADA PHONE; _ ft, 0-)_�'�G'�1'•:1XL FACILITY ADDRESS: 197 LA MIRADA AVE OROVILLE CA 95965-0000 INTERVIEWED BY. _ _ �? ___________ ii�iiiiiii i4wi _rr__ i-00_4Wii_100 ACCOMPANIED BY: __�gi, • &AvcK5s)A4,(E =_w__ MWli allow woiir iiiiii qw am �.waiom rai _a•w C INSPw OF INDIVIDUAL BUILDING — OCCUPANCY CLASS. (T24) C I HIGH RISE C , INSP. OF ENTIRE FACILITY CONSISTING OF 2 BUILDINGS CLASSIFIED AS FOLLOWS: NO..LOGS. 10 OCC. CLASS 83 NO. BLDGSs tit OCC.CLASS 9y NO. BLDGS. 0 OCC. CLASS No. LDGS. 0 OCCsCLASS NO.BLDGS. 0 OCC.CLASS NO:BLDGS. 0 OCCmCLASS C I GO -4* UPDATE ON-BLDG(S) NO i_ l l a w w_! _ l i_ l_ i! l l _ i _ i l i_ l i i __ l i-_ i i__ _iii an i i i_ l i i i i i i i__ i___ as __ _l __ __ it r_ _lii _i _ ii__ _ii_i __ __ii r___ iii_ii 0000 ___l ilii!_ __ __ilii it on i _i l i iii_ii___ _llii Goli_iili _ ami _ _iii__ ilii _i wi _4m _ i l i_ i__ l_ a i l _iii _ no i i l i i a i _ l i i_ i/ i w i i_ l l i__ i i_ i_ _ i_ _0* AMi l __ i064m_ i__i __ wiii_i iiii_iii_i_i _f _mai _ _ria _l.w ONi!i __-i_li•i_i _amii _l iOman ii___ on _l il•rliii_ i_ _!_00___0011 _l_ _i_ilii __ w_ lii_i i i i_iii ___i_i••l/ail _i __ _ iii•4i_i_w_ 000000_100_00 __ __ ill_ � _ ___1i1__ii _-_ __ i_ �i __ _ _ drill _ i i_ _1__ lila _0000100_ i_ i •Ilam 00_ 00 00 00 00 l i l 00 00 00 l 00 i 00 i 00 l 1 00 00 00 1 00! i i 00 i i_ 00__ 00_ 00_ a_ _-M w 00 1_ _iii - 00 00_ 1 00 6000 a i m_ an 1 i i 00_ 0000 w w _ 1 iii _ ii R-3 ri1_ _i ami 0000001001 iil00 Slim _i w00lilii ii _lama _00 ii _i_i_ili NONRATED BLDG. ;-->#STORIES___/FLOOR PLAN: iii_ilmiir•ii ii 0000_ _ ATTACHEMENTS: COPS ENTS: 511x' 60.,6 ' E GO -6 C I GO -4* ! C I STD -850A r C I DIAGRAM C I PHOTOS C Clo'OTHER00-J-11 TOTAL##_—L__00_i ►"i a44o4sx4x f 1!4M- l00 00 a t• 7 • I l i _iii INSP TIME HRS LIST DISPOSITION: C I CLEARED REVIEWED BY !VATi.+r.+._____+.._+. � C 90or NOT CLEARED f INSP CTED BY:. " DATE S l _�..____= _`_____ 00___i__i_i ll_i ! T DATEii__i_ rust • 1_i_i__l__ili_ii • l A_ ♦ . - 5, r if A .• _ � y r. r r A• � r - •- - ••/ , w `• ..� O.• ... n cs. s a .r' .s w. ear o -.. + /or. �► w 1 . cI ... t, j . - w a i - - .- '.fit i! ♦- `� .r I • ... .. w .. , ..� rrr ..r .. -•_ .•.r d a. 0' rot. r 9 am swV at& a+ IW i.a ... a- o tw r .s rw• aw 4} ••de: .v, s r ar .� w �. •. • �► y� ... d ry •r. .., �.- S Oo ra a .irr r +w .•. r. ... r ..• r .r w .. s*• •� .r. ea •.. 4 •.. m +r rr a •► w o irr ..� a, •.•• •i• •r .► a+ vi ••r -••• •s w' 4r m. o ••• w. •v w .ur .•n •rrr wr -w r ••�. ... .. •... w +� w- .v •.. rr �. 10 a~ trM M �• .s r o .. a .e e -c• d ••o o. o. a •► tl•n .r•• r w•.. •r .� ... r• m ! ow amw - . w �.. a• -s. •t• rr e. ••r a s.. 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V w dw O +r ••►• e• qo e+. .:► ¢•• es.• •7r v .s .•: ... me "M w 4t31 dop .fA%w rr. r. r•r w r. rllir .. W. r.il •L•. t P w •tw A Ad w a .ir• ..- ... .- ,a d- %W w .r _. •i. Ni •I• p .w. ... •. w . r ... •a .w � ..• ,�. - _ •r M � A ! �• 1.4 iN• !s Wr � A ! •t � V9 M i'r• 4 •l9 O �f �/ t•• om i 1 .. c r o a w sr se• e•.. ..•. ... .s. - ' 1 •41 �y v. s• s e . • r° b Oa •i• s0 w •4• w+ v r •• �. N+ nr r for - n • • . oft Mo i OFFICE OF THE STATE FIRE MARSHAL INSPECTION LOG Title 1, 1 OA VILk-A File ofumIn Mm[n0 Address ' ' 4,A MI &Ao"Vocc.C9X90-' Date Owner Veaou,`a ALm(.)cXA-4,4 't ev"o ;,c c 4,pF 40 A k,.� 1 A,,J5 0 4c c "i to p--) A j*0 47W#V of v t, .9'&4-t #0 614A uJ(o- # C&cXX&I #SA&t<f AA# -4F P;ijZ.sZ- i C f C4.) 7uZ 6 0- q' OA Wt G,( C ar" + o #c * A' S' t 4 W iF o' t o-,tt oci&6C CCZ440SCX to aoO 000; t U KVc.+ C� �%.�+ ' (Ft✓ _ t / ' ri�- `c s ' g i �7 % �' " 'Ca w* ► L.6. 13X ehfoat!�� A tvo' rUf t-44.! I4--'sA 6x 0 3 7-0 Cts (ACTS` C b � ',. 0 , dc I ate"' tc--r-- MA& W; 0ge6 rR?+sc:+s�_o -� V-HRr�.R,� � s.�.��-�r.8- �•-L-cs.�:nz.caw.►its::ct�w:.+,�tiae:.Stt.G.�.aes�,sur�i'.. -a+r-r,-a��a r'�::aa�ias�r..:.�k�a!-:�+'-•-airmsscrs�cmr.^-•--z.,.�r..;,•,:�..�w-.�a»e..�..,o....,._ S ATE FIRE MARSHAL COPY DISTRIBITION; r.. SEE REVERSE OF COPIES 2 AND 5 FOR FIRE SAFETY INSPECTION REQUEST "6` 1 -3 - STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION S D 850 (REV. 7/80) 2 - FIRE AUTHORITY, 1. REQUEST DATE 2. PROGRAM 4-5 - LICENSING AGENCY 1 5 AGENCY CONTACT 4, TELEPHONE NO. SIGNATURE x:J.. Car : Licensing 15, :; 95-503-; 0 6 SFM REGION 7. SFM I.D. NO, 8. REQUESTING AGENCY FACILITY NO, 9. EVALUATOR NEW APPLICATION 0+1370794 0103-Planuela 14oralez ,.vii voO5 -cam-33DDC7 REQUEST W--(gy- 19. ? RESPONaE REQUIRE- CODE CODES I.ORIGINAL A.FIRE CLEARANCE 1(. AGENCY 2.RENEWAL B. LIFE SAFETY NAME 3.CAPACITY CHANGE AND ADDRESS 4.OWNERSHIP CHANGE S.ADDRESS CHANGE I I L .J 6.OTHER DATE OF ORIGINAL REO. 11. AMBULATORY - NO NA MBULA'TORV - - TOACCAP: T .DQATE OF.LAST-FIR-E -CLEARANCE CA ACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS TO 16 18 TO AND CAPACITY TO 18 18 TO 65 AND CAPACITY 20. FACILITY 165 65 OVER 65 OVER CODE 12. FACILITY NAME 13. NO, BLDGS CODES -. x-aea Villa - - 1. GACH 7. ICF/OT 2. GACH/R 8. ICF/DD 14. STREET ADDRESS 15. RESTRAINT 197 La Mirada Ave 3. SH 9- ADHC - 4. APH 10. CLINIC 5. PHF 11. JAIL CITY ZIP CODE 16, HOURS _ _ CA 6. SNF 12. OTHER Adults 17. FACILITY CONTACT PERSON - TELEPHONE NO. 16A SPECIAL Veronica and Ray Flmocera f,_eSidert.i.a�_-Kn TO BE COMPLETED BY INSPECTING AUTHORITY 18. FIRE 27. CLEARANCE AUTHOR. vroville fd CODE CODES NAME 2055 Lincoln Blvd. 1. FIRE CLEAR. GRANTED AND Oroville, ca 95965 - ADDRESS L -2.. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. INSPECTOR S NAME TELEPHONE NO. 23. CFIRS 24. T-19 OCC. ID NO. CLASS 1, EXITS m '' 'C'I'1l,) ,�';jct--o-5 pG 5 �916� 0%,�-�JI-L 2. CONSTRUCTION 3. FIRE ALARM 25. I SP. DATE 26, INSPECTOR'S SIGNATURE 1 4. SPRINKLERS �� -[I%'�C' I`�-� �. /2?iQ' K;VI�. SfA IYr, (�. ✓cF lMr�✓1 '(J( S. HOUSEKEEPING 29. SPECIAL CONDITIONS '" j:LAINDENIALORSLIT 6. SPECIAL HAZARD !� ,L l w t_.% STATE FIRE MARSHAL USE ONLY 21. EGION. FFICE `"talbb Fire. Marshal NO 443- 7WFlorin Road DDRESS Sacramento, CA 95823 L TIME MILES NEXT INSP. (MO.DA.YR.) spol INSTRUCTIONS _ This -form is designed for use with --a. window -envelope. To -use, fold -at marks indicated in the-- leff-mar- git.- Licensing or -Requesting Agencies - Complete the following 21 sections on this form before submitting it to the _State Fine Marshal Complete items marked.. with an asterisk on-ly`when Item 20 is' not used. 1. REQUEST DAVE. Enter the date request was 14. ADDRESS. Insert street address and city only. A prepared-, post office box is -not acceptable. 2 -PROGRAM.. Licensing agency use. * 15. RESTRAINT. Indicate if physical restraint (locked 3. AGENCY - CONT -ACT, 4. TELEPHONE NO., 5. in -a room or the building) is to be used _ in the SIGNATURE.=, ..Enter the name, telephone number, housing of the occupants. Y = yes N = no. and si.gnatu.re _,af agency contact person. * 16. HOURS. Indicate the number of hours the occuP ants 6. SF.M.,REGI.ON. Insert one of the following 3 numbers are housed at the fac-ility, (less than 24 or 24 +). for the SFM Regional Office in whose area the , facility is located. - - 16a SPECIAL. Use to designate persons who are.determined - 350' Coastal, 330 Northern, 370 Southern, to be non-ambulatory for reasons other than a physical ., _ ,. hand icap. 7. SFM iD'I NO. This is the SFM Identification Number and -initially_ �rui he_ a Sre: Fi.r�A+ '�,.v ��.4.�� :�- -r"�! .rw+..�.�k.�_a . • _ 17. FACILITY_ CONTACT_ PERSON_- ---1'ELEPFi0.11�E NO. � t T• ter. .-. - - �.,..- -_� -. +•::..i-� _`�.'�Ra-..- .. - Marsh 1. LicensingTen - a A9 cy ! nsert this numbe on r--ssa _ � _- r - Indicate fie name `and-teaTepiione nur��er-7thre-�' - - . - - - , - - - - . _ _.._ "6e ° ,. , • all clearance- requests subsequent to, the initial sponsible-. _ n_&v_ idua.l_ -: a.t. the _ -facility- to- contacted: : _- request. - by the fire autfiorit` , = - Y N 8. REQUESTING A ENCY G FACILITY NO. This is the 18. FIRE AUTHOR. NAME AND ADDRESS. Insert the, - - _ - file number assigned by the -licensing agency. name and address of - the fire authority in the vicinity where the facility is located. 9, EVALUATOR. Far licensing1. use.. agen-1 __ -cy _ _ - _ - -1.9. REQUEST CODE.-- Use -the six- codes -, shown aqd.- 10. AGENCY NAME AND ADDRESS-. Enter the name and insert the appropriate number in the box following -address of the licen_s_ing facility requesting the _ _ "Request - Code".Lnsert_ _ date._ of s r�.gi.nal.- -request _ inspection. - when request is other than an ori.ginal. * 11. AMBULATORY - NON-AMBULATORY._ Complete 20. FACILITY CODE. Mark this item only if -the facilit-y is this section only when Item -20. does not apply. a: (1) General Acute Care Hospital (G-A+CH); (2) G�eneral Capacity: Insert, in the appropriate section, the capacity. Acute Care. Hospital/Rehab (GAC'H/R), (3) Special - - `of _ licensed- -ambulatory or non-ambulatory -"Hospital (SH), W Acute Psychiatric Hospital-(APH); (5) - occupants covered by this request. Psychiatric Health Facility (PHF), (6) Skillet Nursing Age" Range: Indicate the age range of the licensed occu- Facility (SNF), (7) Intermediate Care Facility/Other pants. _ :Previous If request is for renewal or capacity change, : (ICF/OT), (8) Intermediate Care Facility/Developmental- 'Capacity: insert capacity of previous clearance. ly Disabled ( ICF/DD), (9) Adult Day Health ` Care Total - Show total licensed capacity. If the Facility (AD HC), (10) Clinic, (11) Jai I or (12) Other. When- Item -Capacity: ; is - --intended to house part ambulatory and 20 is used., Item 11 does not need to be completed part non-ambulatory, show the total of the (except total cap). - two .types'of occupants. ; = - 1�2 FACILITY: NAME.,.:1•nsert the name of the -facility as 21. REGION, OFFICE AND ADDRESS. Insert -'the name as it will appear on the license. and address of the State Fire Marshal Regional 13. NO.. BLDG&: Insert the total number of buildings to Office in whose area the facility is located. - - - - be used_ for --housing- -of- -the- - accu-pants -.c a -real. bby-= � � � - : _ f- _ __- _ - - - _ : - - _ -• - ' the license. Fire Authority Conducting the Inspection - Complete the foilowilCd- ` ' 22. I N�SPEC.TOR'S NAME. Pr_i nt the i-nt'iai:-_of the- : inspec- 27. CLEARANCE _CODE. Use the three codes shown anid- tor's first name and full last. name; insert the tele- insert the appropriate number in the box following phone number where the inspector may be contacted. "Clearance Code s _ •F 23. CFLRS:_ tQ. NCI..--In.s�r_t _the fire_ -department's number NOTE: If Code 2 (Denied) or Code 3 (Withheld) is used, ex plain. assigned by CF I RS. 28. DENIAL CODE. Use only the seven codes shown . Y 24. TITLE 19 OCC. CLASS. Use Title 19 occupancy and insert the appropriate number in the box fol - classifications and insert the occupancy determined lowing "Denial Code". If No. 7 "Other" is used, ex - by the inspector. `-`- plain at Item 28. - 25. INSP. DATE. Enter the actual date of the inspection. NOTE: Fire Clearance cannot be denied for other than- Lack -'of conformance with the provisions of Title 19. - 26. INSPECTOR'S SIGNATURE. To be signed by inspec- 29. EXPLAIN DENIAL. If Clearance Code No, 2 or 3 is for conducting the inspection. used, briefly explain reason. This space is also to be used to explain Denial Code item noted. V 1 (REV. 7181) YELLOW: REGION WHITE: FACILITY GREEN: FIELD i 88701-355 3-84 12M TRIP OSP STATE FIREMARSHALFIRE SAFETY CORRECTION NOTICE *1REAL E FILE NUMBER RESS � ❑ ® 0 ® 9 No " ► R ,., 90 ®0 TI [N51[9 /� IL' (� ' 95--19S- NA AD In In accordance with the minimum standards of Title 19, California Administrative Code, the following corrections are required: ki A>-)4 'w ru A 1 N t47-C#e 'ix..) kkpatt Rwt-go K: w cs4viO )pAcv4(0X A Sc?L( ekax &cgt Lv! S Z - C c03-Ta(,Cw 4 (v- 0--;4 DILI dr,,OZ S u C+' it y The above deficiencies are to be corrected within days. Upon completion, please sign and return the certification on the opposite side of this form. If you have any questions, contact the State Fire Marshal's Office at ( c?16 ) _�9s-'i3i2 ISSUED BY (D rrUTY STATE FIRE MARSHAL) RECEIVED BY DATE V 1 (REV. 7181) YELLOW: REGION WHITE: FACILITY GREEN: FIELD i 88701-355 3-84 12M TRIP OSP AOMWN --- A00"k 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) -------------------------------------------- 1 (Fold on this line) ----------------_=-------------- — .� Sn X. STATE FIRE MARSHAL Sacramento Region 4433 Florin Road, Suite 400 Sacramento, CA 95823 P ME Y • :y• 1 �of r 01 $TAT£ IRE 'M; AC. l FILE N0. DO i� REINSPECTION REPORT OFFICE OF STATE FIRE MARSHAL Ed I � � Eol a I I i [ :o] U� lc LA Date Reinspected Nall-. of Fac i l i tyr--•wk& f Y. 5-' lfom.wwwr+.w.w.w.w.w.wwww.w.w+��w.w.w.w.w.www�•wrw•.www.w+�w•ww+�w.��.�+w•w+�•ww.w.w ����'�• Add res s_J a 2_ � ! ��?�v �� `..----------------------------------- Conditions _.._wwww--.wwww-------www.-www-www._-w-Conditions Discussed With f�4��-� rw.w__Uj .�wwwww.wr --w---w-.w -•------ww---www.w--ww.w •w +�w++w.i�•w.w -w.w .. Accompanied By,, AWC Title , -.w .ww.w.w.www.•wwwwwwwr+w ww.w .w w w.�. w.w .w ..w ..ice �.ww�� Inspection This Date Discloses That Fire Safety Corrections Number ww www+++w.w w.ww.w .w .w .w+w+++�.�.•+"•••'�• .ww w..ww.w.ra w.w w.wry.w r..w•w .w w.ww.w ++..+ww.w .w..w..wry.ww.w .w.w .www.w._.. w.w.��www.w.��.w.w ry.w-w w.w-----.w-------- -.w - -w.w w w.w--.w ww.w--+-+�+w of Fire Safety Correcti ons . ..w.rwr�ww.wwwww.w.ww+..wr...www.ww.w w_ww.wwwwwwwwww.ww.+�.wwwww.ww.w .w.w•w •w..w.wwww.www.ww w.w w.w Dated ��- c�- �S Have Been Complied With. ......wwww...ww.....wr.wwwwwwww.w.w.wwwwwww w.ww.www.•�+� Fire Safety Corrections Nui�lber --------------- _.....w r...www.w .w .www +r�w.w•wrrwww..i+.w.w.w.w.ww w.w .w Were Discussed .www... ww ww w.w wr_ww.w-w .wwww ww wwww w�.w.w..w..www_www....wwr.+�+�_w.wwr�•w.��.w..+.w.+�.��•w.w•www.��www.w w•w.��w www -w -.w• With and Disposition Will Be �w.wwwww.www.www.ww.www_._www..w..w.wwww.r�ww.wwwwwwwww.w_wwwwwwwwww.wwwwwwww..•..wwwwr. As Follows: Ic r nAt C (..4A �w ww�.w�C c s r s ww w 04 wW 141 C_ i-4_ At _... www.wwwwwww wwwww ---ALE.I_ � .l��iw-.ice I � �� � �.I�_/� � ���w_I�ww./�w.I�•I�.��w.��.��.A.��.IIYew-www--w- ------- Reinspection Indicates That ��w www��Po ww.+.w.w.w ww New Fire Safety Corrections Should Be Issued. See Reverse Side icor �c�m��lents and New Ff re Safety Corrections. k1 GO -5 - ( 1)E l� 3/ / U) K ! v �' 8 1 ?! Comments and New Conditions: , - ---- ----- -- -- New Fire Safety Corrections: NAME f FILE NUMBER ^ dWCE STATE FIRE MARSHAL FIRE SAFETY CORRECTION NOTICh STATE RE MAR AL FILE NUMBER Fo- 1 Ro F -4 1 R%? 9. 1 7 1,1,144 mi aAv,,.4 Fv-] nt--,) 9 R1 R] Fol Fil"51., R--� Rl9 NAIVE ADDRESS In accordance with the minimum standards of Title 19, California Administrative Code., the following corrections are required: in. jo;p,,Cer -pflzv,.)z awr-so The above deficiencies are to be corrected within days. Upon completion, please sign and return the certification on the opposite side of this form. If you have any questions., contact the State Fire Marshal's Office at( ISSUED 1 BY (D UTY STATE FIRE MARSHAL) CLO PUZ-94 7 RECEIVED BY ae,�,, DATE ^ OFFICE OF THE STATE FIRE 14ARSHAL INSPECTION LOG Title LA- 1MtAA-0A Im fm H H H Q File C MR I9 Address 161-1 LA YVkt UVN<) T nye ox u - (A- Date Owner DW r�1�.1 L-,� .[,F�-�J �1�1-u%K-S C:a;c.� `T:�- �5'PEU� o rJ t�19� �O ►�- �� GQ -6 (Rev. 5/81) i OFF I -CE OF THE STATE FIRE MARSHAL MSPECT ION LOG Title a Olin 010 r�Q� aaQ a Address 1Q"I C..� �Llrvt�-,oma C�vw�,u,� GA �r��i�c�— Date Owner -- ICh.� JL — �_.�cPi:sh ►.1 c-r� �n.�-i . i-1-� �, �-r.-�.��J c�-u c.,c� �r� f�� � �=� A� VW� UJAS 'F) TC l��t�' • .1- �XP�, ate. i 1� �J1 �..f o�� ��� ��vc�sz,i .�.��n,�� S)(�5YL"K min I%tW� wv�sil� GO -6 (Rev. 5/81) OL _C_ -,Ji i -D Am" - 0s u,�i rj VX,4/ `3u � 6 --vu u I S �C- A,--�O <�;l S)(�5YL"K min I%tW� wv�sil� GO -6 (Rev. 5/81) r 1 .....Ab a jr ~.do& � �L..►i. Via 1 � ,.. 3I'AT E I:IK Ec ?MSA AL 4 File NoeQ4 +' .► i . IJ of Facility,LA_. ..._._ .A . Address. l I G� e r;r__aIT., e 1 eph ansa No N of Bu ildi rig: 1UO1 DESCP-',D. T ' oN ' Carni. 2 Occupancy Class �. Use --. - .. ....-.....:apac�..tY ..... .. Construct 16 onCAE { � 1 Year Built vo 3 Area Fte Tota . 2.o Largest F1oor Basnt Stories• OWN" No. High Rise des too. k", Exterior Wall Cot"1StiuCtion ming Now Protection epu I D _ Interior Hall Construction 70 Floorf Construction 8 Roof _. 91, ConstructiontA�-_ LA30 - 4». Draft St22S No� �► i 10a. o Cc • Sep • Wall ll .._.`....-_..-.....,., Construction- LQD b.. Openinq Protection No 11a.,w Area Sep. Wall Construction - Opening �......w V tocyi Vn No. - 12 ►r.r..rrrr• Smokes Barrier l Wall Construction . Opening - ---- Protection 0 Ar - .3 Corridor Wail . Construction . j a Opening Protection � .. - s n Corridor Ceiling t Construction j . opening Protection Shafts. Nmrber/T eb . i . open -.ng protection Sa-4 a..: _ J��'�'t� (tieZINC MINIMUM I IN y 6a. - - , IA Stair - Enclosure . �r`I1L1ll♦ AK .10� b. Opening Protection 7 . Stairs No 4 f . 0. 8. Rates No, r • Inter for .�. _. Finish Class Rooms 1., . Q' Corridor E -- Encl., f 0 i • Exits is • o• Totai, Width 1. Exit H arclware mom�- 2a Signs/ - ........ _ IlAu'nation be Erar gene'..," Lighting-%a� ... e.j Nato Spri�, LIP o Standpipes . Class tion P...b tj 5 r e A farm -4 /Covera d Aq.ANU4Ab_ ;60 Feat i n`�`ue3, Vw" IQ Vent--_....�.... 27e • Electrical --�..�. - 8. Starve - -Platform �� ..... 4-9. H clz a .Y d ou•. - .- •�•�•.�M�iw.UArw.rr�r. r.�.N�r�.�.�� w..r..rw•.. Auras �. i •Other - a c.mE: tus : f Idspected By: - Slrn' . No. At'acbments. s •'" vi ewed1 0 Date: - UEdated: - ""'State of Ca orn#a State and Consumer Services Agency m or a ad u m DATE: t. hTQ Department of Social Services' .department of Social Services ---- Community Care Licensing --- Community Care Licensing 2400 Glendale Lane, Suite C 520_ Cohasset Road, Suite 6 A Sacramento,- CA. 95-825 Chico, CA 95926. Depai tment of Social Services Department of Health Services Community Care Licensing Licensing and Certification . 770 E. Shaw Ave. ,. Suite 330 2:422 Arden., way, Bldg B,, Ste:: 35 s Fre n4, CA '9371.0--7785 Sacramento; CA -9=58.25 - . #�• _. c5�--- � - File.-- w � may,-- Coo a:i vrvrr�,�� FROG STATE FIRE MARSHAL - SACRAMENTO REGION. 4433 Florin Road, Suite 400 Sacramento, CA 95823 .' SOB ECT FIRE CLEARANCE FOR L& V& - An inspection was recently conducted. on the above facility located at V vt.�r- . �' During the course of this inspec ' on it was A16termined 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 -r ---•-- at i • •- Olt• i tA __ _. _ __ .._ _-_... _.---,_-_.._._. _.. _- _-____._...... ..«_... .. .+._... .-.......+ ._ . •._�.._-._.. .. ... __._�_..,,w.+.._.w,. <.....-.•__. .,..-___... ...._ ..- ...-..._�_�_�.�_..-_.. _.•v«.. .. _++..._«,..__...._-. _._-��«..-«r+._.,.�•.....-,........w..._.•w.............._w...,.wn.«•.._.-«ww._.«.--.-..........�+,.a�...w..•►..r n.,.�r_. _.. _ _.. ......_.......-_ •_ _...__....-..- ..-. .-.._-•. .-._... .... _._.,.,.«_.,_._....+........+..•_........ .._....�_.....-r.r-«.....w..-_.._...«.-...._.�,.-.,......._w.r._.....«� ..-.-._..-.w•..«._«..,. ._ _-.__.._«-.w.. ..w ........-..,....• .. •.._...«..._..,.................._._,_.....+«r:.a..•.r....wr...._.._...r...__...«..-ww.....«,.+...w..vay.«.........�.•...w.rfw..►ww...�w . _ .... _ _ _...w,__,._._..._-«...._..�..__.._...._w.�.....-._....._«,..r+..__......__..,...«�w_,..._._....._..«......VT�_ _ _rte._._-..,.._.«..«-.,_ .......-_. ,_�.,.,. ...._. _..�...� .. ... __.,__._+_r. -.._....__._.. ..._. ....-..__._.-+�.__«.....-.+w....-.._._.+.++.+.�w._.,+.�.++.►.-..�...•••. .mow.»+.•+........_ '.i.«_ «...�..... s, --� ..-+....-_..�._._..-._.a.w..�+,....r.r..w. n.,...-.-.r___�.+.+...,wi__.+.._......�.�.._..._....a-..._...-,w__.,..._ «..... ....-....-..._....,_r.��,-r_.._......_...w.....w_...w_.r...-.....rn�••►.w..•... r..�.«r....�w+..,...._,... ww..._....r..w..•-www.wn....:•n.......h�..r.+...w�«•.. _ _ .............t._._....._.�...____.._�_..-._+ .....__r.�_ _...�.__.._.� ._+.�... .rte_. �._ ._..-_.+....�.+...._......ti 1 • t . _. __. __-.._.__._-. ____„r.n ..�.---•_•_w__..r.w..__ __ ...__+..w ..,.«.r -r._' .-...«..+w«.�.._.,.-.-. _...+__.. �.rrti.._..._.__.w_...r �-.._..._.__._._.___«... .•_ - .. «.._,.��..�.._. _..•.w»_.... .__. __._.. y._��-.._.._. ._.,... .....+..«._-. _✓w ..- rw .�__.._r...r....._..__rr.__ _..+ Y • i PIA j � �._ `�= .+l. �'� may✓ _+�'� V��- �' y.� �•. Pm ES ...... o__._ Rig Mp 14,0 n _ 0�!NJ t VJ5.0ROOM i00 } .rr.4 Ta SS �Y sf�t U �•V� pE7'c�T�'s =I DIN/ &V v(_ All ;,Ott Ott OPE STAT FIRE MARSHAL COPY DISTRIBUTION; SEE REVERSE OF COPIES 2 AND 3 FOR FIR SAFETY INSPECTION REQUEST 1 - STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION STD 8 WA (NEW 6/80) 2 - FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM 3 - LICENSING AGENCY 04/11/85 CCF109 3. AGENCY CONTACT 4. TELEPHONE NO. S. SIGNATURE DEPT SOCIAL SVCSt CUM CARE LIC (916) 895-m5033 6. SFN REGION 7. SFM I.D. NO. cxw-p�s 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR 00--0 --83-#%-^ --000--3300 0413021.4.E 0103 19. REQUEST CODE 2A CODES 1. ORIGINAL A. FIRE CLEARANCE F 2. RENEWAL B. LIFE SAFETY 10. GENCY DEPT SOCIAL SVCS* CO CARE LIC 3. CAPACITY CHANGE AME 520 COH SS ETT RU A0 t SUITE 6 ND 4. OWNERSHIP CHANGE DDRESS C N I CO 9 CA 95926 5. ADDRESS CHANGE L 6. OTHER NOT APPROVED FOR ELDERLY* AMB/6 ON"A 8o COMBINATION HOUSED DATE OF ORIGINAL REQ. IN WEST OR SOUTHEAST. LICENSEE PREFERS AGES 18 THRU 61 YR SO - 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE �, CAP CITY 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 13 20. FACILITY CODE 735 12. FACILITY NAME 13. NO. SLDGS. CODES L4 MIRADA 'REST SOME 1. GACH. 7. ICF/OT 2. GACH/R 8. ICF/DD 3. SH 9. ADHC 14. ST EET ADDRESS 15. RESTRAINT 1 T LA N 1 RA DA 4. APH 10. CLINIC 5. PHF 11. JAIL 6. SNF 12. OTHER CI Y ZIP CODE 16. HOURS oll, DV ILLE 95965 24+ 17. FA ILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL COLLEEN BARKSDALE 916--.589--.1781 ADULT RESIDENTIAL TO BE COMPLETED BY INSPECTING AUTHORITY 18. F 1RE I 27. CLEARANCE � CODE ; AUTHOR. ' CODES AME 1. FIRE CLEAR. GRANTED AND ADDRESS L 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE - TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. INSPECTOR'S NAME TELEPHONE NO. 23. CFIRS ID NO. 24. T-19 OCC. CLASS 1. EXITS 2. CONSTRUCTION 3. FIRE ALARM 25. IN P. DATE 26. INSPECTOR'S SIGNATURE 4. SPRINKLERS 5. HOUSEKEEPING 29. EX LAIN DENIAL OR LIST SPECIAL CONDITIONS 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY 21.EGION tFFICE AND ADDRESS L TIME MILES I NEXT INSP. (MO. DA. YR.) .�2 Til _ �✓ Ci F. -' Q.�._ ♦t r 1 ' 2 yp�•.�a�j Y r.- I/. � :.. = C1 �ei . �. r gjp, � .c � .� w y -• �� F!.') Q �� ..h Fj �of� 4 «•.Tr.ysI' ,�'� i.' �ci S !' �/ T ! t ir ST 11 FIRE MARSHAL COPY DISTRIBlTION; SEE REVERSE OF COPIES 2 AND 5 FOR FI SAFETY INSPECTION REQUEST 1-3 - STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION ST 850 (REV. 7/80) 2 - FIRE AUTHORITY. 1. REQUEST DATE 2. PROGRAM 4-5 - LICENSING AGENCY 3. AGENCY CONTACT 4. TELEPHONE NO. 5. SIGNATURE t a L3.c 911"95 - 40110 .6. 5FM REGION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR 041 VI V 4.5 3 uel-a Moralez �1 19. REQUEST � CODE CODES 1. ORIGINAL A. FIRE CLEARANCE 10 AGENCY r-Departmint of Sooietl Sorvicass NAME i.r i:333 .a.,i� Care Y i aensin 2. RENEWAL B. LIFE SAFETY 3. CAPACITY CHANGE AND 1� ��� ADDRESS Cohassat RLiad Coballaot S ~ G r� �j Ku i t e 4. OWNERS -HIP CHANGE 5. ADDRESS CHANGE 6. OTHER 11. AMBULATORY _ NONAMBULATORY TOTAL CAP. DATE OF ORIGINAL REQ. DATE OF LAST FIRE CLEARANCE CA ACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS TO 18 18 TO 65 AND 65 OVER CAPACITY TO 18 18 TO 65 AND 65 OVER CAPACITY 20. FACILITY �rim r. CODE 1x x 6 x X 1.: 12. FACILITY NAME 13. NO. BLDGS CODES .. Do" a One 1. GACH 7. ICF/OT 2. GACH/R 8. ICF/DD 14. STREET ADDRESS 15. RESTRAINT 192 La ftAvmuo NO 3. SH 9. ADHC 4. APH 10. CLINIC 5. PH F 1 1 . JAIL 6. SNF 12. OTHER CITY ZIP CODE 16. HOURS e At Ran &g Rtd&rl3g TO BE COMPLETED BY 17. ACILITY CONTACT PERSON Colleen Barkadal e TELEPHONE NO. (916) 0%1781 16A SPECIAL INSPECTING AUTHORITY 18. FIRE --i 27. CLEARANCE '. I AUTHOR. CODE ' NAME CODES AND 1. FIRE CLEAR. GRANTED ADDRESS I L 2. FIRE CLEAR. DENIED J 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. INSPECTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T-19 OCC. ID NO. CLASS 1. EXITS 2. CONSTRUCTION . 3. FIRE ALARM 2S. INSP. DATE 26. INSPECTORS SIGNATURE 4. SPRINKLERS 5. HOUSEKEEPING 29. EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY 21. REGION. OFFICE AND �� ft" to ADDRESS 113-a ="$ CA "823 TIME MILES NEXT INSP. (MO.DA.YR.) se.Ls%oK z.Esv#mF,a0 Z SOCr+iO QM!M W00%&" a V. YS - a, fr e ON xl"bLa osa aga "$,Tr mw Gre) ounevA 00+1 ObA ehms ai=. U t. {QST 1RE,- MARSHAL t COPY DISTRIBUTION; ; SEE REVERSE OF 2 AND, 3 FOR .COPIES. I; - R "SAFETY cINSPECTION REQUEST: 1 - STATE. IFIRE MARSHAL '-� � INSTRUCTIONS FOR: COMPLETION STD 56A (NEW 6/80)'' 2 -. FIRE AUTHORITY. 1.. REQUEST- DATE 2. PROGRAM 3. - LICENSING AGENCY ,;, 112 / - 4i- :3.- '3. AG E NCY CONTACT . 4. -TELEPHONE ;NO. 5: SIGNATURE L S V C, S.:Q ) E L ., � �` • � �.� � ':.� �r ' f� : � ✓ .�.�e-, ,� � � ' 6. SFIA REGION 7.. SFM'LD. NO. B. REQUESTING AGENCY .FACILITY, NO. 9. EVALUATOR 19. REOUE8T � - CODE: CODES _ 1. ORIGINAL A;-.FIRE#CLEARAN`CE. �. 2. -RENEWAL:` B: LIF.E_SAFETY 10. GENCY 97 S w1 -A L S VC S 9 :C A C AR � L I lt.0 3. CAPACITY CHAN'Gf NAME- ; , ,_ , ... :C1314,� S -SET T R C ,�► �� � '� �:. � ; .. � , 4. OiAINERSHIP JC N'GE AND -�' .� _ _ DDRESS fid : C G?1 C A 5 Z;. 5, ADDRESS.. CHANGE " & OTHER' ,' t '� ; �' i� > . n .� s �'i ! 's i $ '� ' ! �4� �; { t .� "' f� ;'`tea a �,,,� "`� :- 1 -• 3 " a., �� !., .� i`s f?�. �� .: .� ®" 4 8,t.. 3 �3 i `$ , 4� •. ; ` ;.? -� 7'�i ..0 .. i Ib.'r7ry� c i Rl INAL . RE DATE OF O G Q. Q `r J,,��,, 's.` sj� •.�w .'�<,�'T (6 " yT�+�'!,'� �£j� �!'. -`- ]Y7"'. tire-jj-'y'q, '�! �.s'- ,�°p�.y .}:-{4►� 1 �.. (^� -i '�{}���'� J is !' ' �, Jd!' R ,T{ fy, !'�.$' :` �•.a. Via' y A' ' y. l .• �' w: t ► �} �^I ri y! - ' i' � y �' : , . 11..AMBULATORY �. NO.N;AAABULATORY •TOTAL CAP: DATE- OF LAST FIRE' CLEARANCE 1 �` 131181 ,-C#%F ACiTY AGE R'ANGE*(YEARS) 'PREVIOUS :' CAPACITY AGE RANGE: YEARS) :-'PREVIOUS 'CA►PACITY _ CAPACITY' ' TO 18 1& -TO : 65'AND.TO 18 f$ TO 65 AND 65 OVER'. 65 OVER 20.. FACILITY 13 CODE 14: F A CILITY NAME' 13: NO:. 6LDGS. ;. CODES HCl ill 1..GACK 7. ICF/ -OT. -2. GACH/R ..Oe ICF/DD 14. ST IEET ADDRESS :. '15. RESTRAINT vl L IM 4,k 4. APH.. ' 10: CL'iN `C S. PHF 11-. JAIL CITY,-' ZIP CODE 16. HOURS 6. SNF 1-2; .,'OTHER 11. FA QIL-1TY-` CONTACT PERSONTELEPHONE NO. .46A. SPECIAL, TO BE • COMPLETED BY -INSPECTING AUTHORITY 77777 18.: IRE 27. CLEARANCE CODE: UTHOR, CODES ` AME. CLEAR.; GRANTED • Np1::.FIRE� DDRESS. -2. AFIRE CLEAR. ' DENIED - •. 3. FIRE CLEAR:WITHHEL-.D ..28. DENIAL : ,.f.. ...... •- .: , . .. ♦ .. , CODE ; -- = TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. • IN PECTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T-19 'OCC. ID NO. CLASS 1. EXITS 2. CONSTRUCTION 3. FIRE ALARM 25. IN P. DATE 26. INSPECTOR'S SIGNATURE 4 'SPRINKLERS 5. HOUSEKEEPING 29. EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS 6. SPECIAL HAZARD 7. OTHER ` STATE FIRE MARSHAL USE`.O.NLY ` 21.. EGION ,j.FICE ND ,ADDRESS L 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. SF M 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. SF M ID NO. This is the SFM Identification Number and initially will be assigned by ,the State Fire Marshal . Licensing Agency - Insert this number oh 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 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 h the liponecs 14. ADDRESS. Insert street address and city only. A post office box is not acceptable. *15. RESTRAINT. Indicate if physicial restraint (locked in, a room or the building) is to be used in the housing of the occupants. Y = yes N = no. *16. HOURS. Indicate the number of hours the occupants are housed at the facility. (Less than 24 or 24+). 16a SPECIAL Use to designate persons who are determined to be non-ambulatory for reasons other than a physical handicap. 17. FACILITY CONTACT PERSON -TELEPHONE NO. Indicate the name and telephone number. of the re sponsible individual at the facility to be contacted by the fire autho rity. 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 (EACH), (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/Developmentally Disabled (ICF/DD),. (9) Adult Day Health Care (ADHC), (10) Clinic, (11) Jail or (12) Other. When Item 20 is used, Item 11 does not need to be completed (except total cap). 210 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 ID.NO. Insert the fire department's number aligned by CrFIRS. 24. TITLE 19 OCC. CLASS. Use Title 19 occupancy classifications and insert the occupancy deter- mined by the inspector. 25. INSP. DATE Enter the actual date of the in- spection. 26. INSPECTOR'S SIGNATURE. To - be signed by inspector conducting the inspection. 27. CLEARANCE CODE. Use the three codes shown and insert the appropriate number in the box following "Clearance Code". NOTE: If -Code 2 (Denied) or Code 3 (Withheld) is used, explain. 28. DENIAL CODE. Use only the seven codes shown and insert the appropriate number in the box 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. I I 1 FIRE MARSHAL COPY DISTRIBUTION; SEE REVERSE OF COPIES 2 AND 3 FOR SAFETY INSPECTION REQUEST - 1 - STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION JSTD 50A (NEW 6/80) 2 - FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM 3 - LICENSING AGENCY 04/12/84 CC 109 3. AGENCY CONTACT 4. TELEPHONE NO. 5. SIGNATURE EPT SOCIAL SVCSjv CON .SCARE LIC 4916) 8.95033 6. SF REGION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR O 0--04--w8 3-0 0 08 30 t}-- 041302145 0 403 19. REQUEST CODE 2A CODES 1. ORIGINAL A. FIRE CLEARANCE I 2. RENEWAL B. LIFE SAFETY 10. AGENCY DEPT SOCIAL S VCS ! CON CARE LIC 3. CAPACITY CHANGE NAME AND 520 COHASSETT RCIA03 SUITE 6 4. OWNERSHIP CHANGE ADDRESS C H I CD ICA 95926 5. ADDRESS CHANGE L 6. OTHER N FOR ELDERLY s AMB/ 6 ON -AM B e COMBINATIONHOUSED DATE OF ORIGINAL REQ. WEST :. OUT ST. LICENSEE PREFERS AGES 1 TH U 6 S O 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE 08/31/81 CA AC1TY 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 1 3 CODE 735 12. Fi CILITY NAME 13. NO. BLDGS. CODES L RADA RESTHOME1. GACH. 7. ICF/OT 2. GACH/R 8. ICF/DD 3. SH 9. ADHC 14. STEET ADDRESS 15. RESTRAINT 1 7 LA MI A D A 4. APH 10. CLINIC 5. PHF 11. JAIL 6. SNF 12. OTHER C Y 1,;, ZIP CODE 16. HOURS Go) I L L E 95965 24t 17. F CILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL COLLEEN BARKSD.ALE 916--589 --1781 ADULT RESIDENTIAL TO BE COMPLETED BY INSPECTING AUTHORITY 18. IRE 27. CLEARANCE � CODE UTHOR. CODES AME 1. FIRE CLEAR. GRANTED ND DDRESS L I 2. FIRE CLEAR. DENIED J 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. IN PECTOR'S NAME TELEPHONE NO. 23. CFIRS ID NO. 24. T-19 OCC. CLASS 1. EXITS 2. CONSTRUCTION 25. IN 3. FIRE ALARM P. DATE 26. INSPECTOR'S SIGNATURE 4. SPRINKLERS 29. EX 5. HOUSEKEEPING LAIN DENIAL OR LIST SPECIAL CONDITIONS 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY 21.EGION, FFICE ND ADDRESS L TIME MILES I NEXT INSP. (MO. DA. YR.) f X- d' If yy � +..r-• , rev[ �c• � ' � �, d (�• r• � � R j� fpr• �• w• def . 1''1es.! C;i'ib/ 1r� �llfei�.;Qas�ro� �1 .. 1 r1 ti •�I .�rj ~ �,""+' 7 •� '�, iVim' i><�.? �t 1v.1 �• je I '4 qoa 5� .. - ..' . J, � � ,� '�' -! �4 ''nr � �yi 1pp. •�--'* •1{(�► �- -•; _ b i l� • - - - � E•.{� ! � � .� _ .'AIS /�� � •.-: P iT •r' '� { Olt 1 t � v r i t , 4 F,ct vF STATE. FIRE MARSHAL - .&RE SAFETY CORRECTION NOTICE STATE 1RE MAR AL NAME FILE NUMBER ADDRESS El El El El Ell ,. o Ell. aEl El El' El El El o. In accordance with the minimum standards :of Title 19, California Administrative . Code, the following corrections are required; ILI 1- V The- above deficiencies are to be corrected within dans. Upon completion, please sign and' f - return the certification on the opposite. side. of this .form. If you have any questions, contact the State _ .Fire` Marshal's Office at ( ) ISSI JED BY (DEPUTY STATE. FIRE MARSHAL) RECEIVED BY DATE � ;J Y N W �EN-�RV. zra ;) YELLOW; REGION: V. 1 TS��Qr Qsg :� 0 -E COPY DISTRIBUTION; STA FIRE MARSHAL SEE REVERSE OF COPIES 2 AND 3 FOR r FIF E SAFETY` INSPECTION REQUEST 1 - STATE FIRE MARSHAL `" �� INSTRUCTIONS FOR COMPLETION A _ STD 850A (h16l 6180) 2 - FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM �. 3 • LICENSING AGENCY I 3. ENCY CONTACT .4. TELEPHONE NO. 5. SIGNATURE DDRESS 6. FM REGION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR t•. � y i \.. IJV TIME 19. REQUEST NEXT INSP. (MO. DA. YR.) ' CODE ' CODES 1. ORIGINAL A. FIRE CLEARANCE 10. AGENCY - - .. 2. RENEWAL B. LIFE SAFETY _ ;_ NAME - 3. CAPACITY CHANGE AND -. ;- : ,; ,� �. �� T 4. OWNERSHIP CHANGE ADDRESS 5. ADDRESS CHANGE 6. OTHER DATE OF ORIGINAL REQ. -- 11. AMBULATORY NONAMBULATORY ' TOTAL CAP. DATE OF LAST FIRE CLEARANCE CA ACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS CAPACITY CAPACITY TO 18 18 TO 65 AND T018 18 TO 65 AND - 65 OVER 65 OVER 20. FACILITY c s CODE .J 12. FACILITY NAME 13. NO.BLDGS. CODES 1. GACH 7. ICF/OT 2. GACHIR .8. ICF/DD 14. STREET ADDRESS' 15. RESTRAINT _ r } �, r. % 3. SH 9. ADHC 4. APH 10. CLINIC 5. PHF 11. JAIL -ClY ZIP CODE 16. HOURS y 6. SNF 12. OTHER 17. FACILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL_ -1 J TO BE COMPLETED BY INSPECTING AUTHORITY 27. CLEARANCE CODE CODES 1. FIRE CLEAR. GRANTED 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. INSPECTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T-19 OCC. ID NO. CLASS 1. EXITS 3 2. CONSTRUCTION 25. IN P. DATE 26. INSPECTOR'S SIGNATUR J 3. FIRE ALARM Do 4. SPRINKLERS 29. EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS 5. HOUSEKEEPING i ; l r s l°i 4 .� �, ;Jf; ;., i :l1 ;l• 6. SPECIAL HAZARD r 7. OTHER STATE FIRE MARSHAL USE ONLY o 21. REGION, 18. FIRE AUTHOR. AME ND DDRESS -1 J TO BE COMPLETED BY INSPECTING AUTHORITY 27. CLEARANCE CODE CODES 1. FIRE CLEAR. GRANTED 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. INSPECTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T-19 OCC. ID NO. CLASS 1. EXITS 3 2. CONSTRUCTION 25. IN P. DATE 26. INSPECTOR'S SIGNATUR J 3. FIRE ALARM Do 4. SPRINKLERS 29. EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS 5. HOUSEKEEPING i ; l r s l°i 4 .� �, ;Jf; ;., i :l1 ;l• 6. SPECIAL HAZARD r 7. OTHER STATE FIRE MARSHAL USE ONLY o 21. REGION, FFICE ND DDRESS TIME MILES NEXT INSP. (MO. DA. YR.) ' 1 INSTRUCTIONS This form is designed for use with a window envelope. To use, fold at marks indicated in the left margin. Licensing or Requesting Agen @s Caplet the folldwing 2i sections on this form blare submitting It to the state Fire Marshal Complete items marked with an' asterisk only when Item 20As not used. _ 1. REQUEST DATE. Enter the date request was prepared. -2. PROGRAe. Licensing agency use. 3. AGENCY .CONTACT, 4. TELEPHONE N0., 5. SIG TURe._. -anter the name, telephone number, and signature of agency contact person. 5. SFM REGRON.-lnsert'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 Identificatton 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. 0: REQUESTQNG AGENCY .FACILITY NO.- This is the file. number assigned by the licensing agency. 9. EVALUATOR. For licensing agency use. 14; AGENCY NAME AND ADDRESS. Enter, the name and address of the licensing facility requesting the inspection. *11. AMBULATORY m NOW-ADULATOKY' Complete this section only when Iters 20 does not apply. Capacity: Insert, in the appropriate section, the capacity of licensed, ambulatory or non-ambulatory oc- cupants cavered 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. FACWTY NAME. Insert the name of the facility as it will appear on the license. 13. NO. SLOGS. Insert the total number of buildings to be used for housing of the 'occupants covered by the license. 14. ADDRESS. Insert street address and city only. A post office box is not acceptable. * 15. RESTRAINT. Indicate if physiciai restraint (locked in -a room or the building) is to be used in the housing of the occupants. Y= yes N = no. 15. HOURS. Indicate the number of hours the occupants are housed at the facility. (Less than, 24 or 24+). 1fia SPECIAL. Use to designate persons who are determined to be non-ambulatory for reasons other than a physical handicap. - 170 FACILITY CONTACT PERSON-.TELEPONE NO. Indicate the name and telephone number*'O'f the re- sponsible individual- at the. facility., to be.contacted by the fire authority. 18. FORE AUTHOR.- NAME AND ADDRESS. Insert the name and address of the fire authority in the vi`cin'ity - 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 it 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/01), (3) Intermediate Care FacilitytDevelopmentally Disabled (ICF/DD), (9) Adult Day LHealth Care (AD11% (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 Marsha! Regional ffiee� 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 10.N0. 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. DAVE Enter the actual date of the in- spection. - - 26, INSPECTOR'S SIGNATURE. To be signed by inspector conducting the inspections 2T.' -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 provisions of Title 19. 29. EXPLAIN DENIAL. If Clearance Code No. 2 or 3 is used, briefly explain reason. This space is also to be used to explain Denial Code item noted. STA E FIRE MARSHAL l' COPY DISTRIBUTION; SEE REVERSE OF COPIES 2 AND 3 FOR FI E7,SAFLTT'INSPECTION REQUEST - 1 - STATE FIRE MARSHAL ._ INSTRUCTIONS FOR COMPLETION STD 8vA (NEW 6180) 2 - FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM 3 - LICENSING AGENCY ; 3. , ENCY CONTACT 4. TELEPHONE NO. 5. SIGNATURE 6. FM REGION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR ' - 19. REQUEST - J CODE CODES 1. ORIGINAL A. FIRE CLEARANCE • 10. AGENCY I- _ 2. RENEWAL B. LIFE SAFETY NAME - 3. CAPACITY CHANGE AND ADDRESS 4. OWNERSHIP CHANGE ' S. ADDRESS CHANGE r 6. OTHER ' DATE OF ORIGINAL REQ. 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CA ACITY AGE RANGE (YEARS) T018 18 TO 65 AND PREVIOUS CAPACITY CAPACITY AGE RANGE (YEARS) T018 18 TO 65 AND PREVIOUS CAPACITY 65 OVER 65 OVER 20. FACILITY • CODE 12. FACILITY NAME 13. NO. BLDGS. CODES 1. GACH 7. ICF/OT 14. STREET 2• GACHlR 8. ICF/DD 3. SH 9. ADHC 4. APH 10. CLINIC ADDRESS �- 15. RESTRAINT CI 5. PH F 11. JAIL 6. SNF 12. OTHER ry ZIP CODE 16. HOURS 17. FACILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL TO BE COMPLETED BY INSPECTING AUTHORITY 18. IRE 27. CLEARANCE ; CODE. UTHOR. CODES AME 1. FIRE CLEAR. GRANTED AND ADDRESS 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. IN PECTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T-19 OCC. ID NO. CLASS 25. INS P. DATE 26. INSPECTOR'S SIGNATURE 29. EX LAIN DENIAL OR LIST SPECIAL CONDITIONS • A 21. R GION, FICE A D A DRESS J 1. EXITS 7. CONSTRUCTION 3. FIRE ALARM 4. SPRINKLERS 5. HOUSEKEEPING 6. SPECIAL HAZARD 7. OTHER STATE' FIRE MARSHAL USE ONLY TIME I MILES I NEXT INSP. (MO. DA: YR.) 1. This form is lestned fo.r .. T. ..... � _.. _use .with a .window e��etope. To..user.fol� at r�nsrks_sndicated-in_.the_ ie.#�t margin.. Licensing or,ReqWW1;1g Agencies - CaMol"tt the 161jawing 21 sections on this form b6,f0re Submitting it to the State, Fire Marshal Complete items m-arked-with an asterisk only when Item 20, is ­not "used. ' 1. REQUEST 'DATE. Enter the date requdst was 14. ADDRESS. Insert street address and cit onl ■ A Y Y prepared. -post office box i s n p of acceptable. 2. 'PROGRAM. Licensing agency use. 16. RESTRAINT. Indicate if physicial restraint locked 3. AGENCY CONTACT,4. TELEPHONE �4®a, 5. in -a room or the building) is to be used in. ,the 898M URE. Enter, the name, telephone 'number, l housing of the occupants. Y= yes N = no. and signature of agency contact person. 16. HOURS. Indicate the number of hours tho 6. SFM REGAGM.insert;one of the following 3 numbers occupants are housed at the facility. (Less -than for the SFM Reglanal Office in whose area the 24 or 24-x). facility is 10C.ated. ` Ga SPECIAL. Use to designate. persons Who are g 350 Coastal. 330 -Northern, 370 Southern. determined to be non-ambulatory for reasons other 7.F M NO. This is the SFM Identification. Number . than a physical handicap. -and=- iilitiaiiy v�iil b& assigned by the State -*dire _17. ��a��AT.������H� �o; Marshal. Licensing Agdncy �-- insert this number on � _ .._ Inditcate'the-name,and..t.el'e � • phdr�e number of 't�ie re. all -clearance requests subsequent ' to 'the initial. spcnsible indflva Ual -at ;the, facility to be contActed request . by the •tire authority. (� jg� nu ��yp �i�.� pyq��'��wa pg��(� �p�O p��o ip� [r{j This' REQUESTING 8. REQUESTIN AGENCY $ ACALWY NO. This' it the :- jp� AUTHOR. �- -.'- -1B.- FIRE/�w.� fp��� .Q rA7 (n! jg�� !��( ��py (�'®p (pj�� AND- C'6@A'TLLt O . �1Y�18 p11 E E"DND �1®OC ESSM Inseit t'he.J.• .. -,file n Aber assigned geed by the licensing agency. name and address of -the fire authority i n thevicinity' g.-EV.ALUAT0flo For licensing agency use: Where the' Wfliity-is located. 10. AtENC 11 HA E�:'A D ADDRESS. S. Enter th name e a e (� CODE. 19• REQUEST 'CJC9'D� E. lyse the six codes shown and aid address of the 1t��flsn�� ��f��iQi�y r�����ting ._ D ., _.. .•. insert -the appropriate number in the �� box following, . the inspection. "Request Code". Insert date of original request -when request is other than an -original. * 11. ANBUL&TO Y® NDNaA�BU TGny. Complete this section only when item 20 does not apply. _. 2®2 FACOLM CODE. Mark this item only if the facility Y is_ a: (1) .General -Acute Care Hospital (CACH), (2). . Capacity: Inset, in the, appropriate section, the capacity I�cepsed. ambulatory or 'non-ambulatory od- General Acute Care Hospital/Rehab(GACHIR),3of � o�. Q } Special Hospital (SH), (4) Acute PSychlatric.Hospital 'cuoatft covered by this request. Age Range: Lndicate. the age range of the. licensed occupants. (APH), (5) Psychiatric Health Facility (PHF), (6) ; Previous if request is for renewal or capacity change, insert Capaci.tc:. dapacity of previous clearance. . Skiiled Nursing1=actilf(SNF),• 7 lr1 r (} Intermediate Care Facility/Other (ICF/07), (8) Intermediate Care' - Total Show total licensed capacity. If the Facility is Capacity: Antended to house part ambulatory and part non- Facility/Developmentally Disabled (1C1mIDD), (9) Adult Day Health Care (ADHC), (10) Clinic, (11) Jail'' acbtlatary, show the total of the two ;types of or (12) Other. When Item 20 is used Item 11 does occupants. , not need to be completed (except total cap). 12. FACILITY NAME.Jrjsert the narne of the facility as it will appear on -the license. 21. C 9 E MB „ 9 ���io insert the name �Qp�p and address of. the State Fire Marshal Regional,, �3. NO. ,.ti..'.bQ 8 Insert the total number of'. bui-idings " Office rin '1�i�ose area the facility is Located.. to be u'sed for housing of the occupants covered _ ' by the license. ire Apt ®city Conducting the Inspootion - Complete the fomwinga 22. INSPECTORIS NAME. t r Iln't the' Initial of the in - 27. CLEARANCE CODE. Use the three codes shown n spector's first name and full last name; insert the tel�ph� � number where --the inspector may be and insert the appropriate number in the box _ _.folt•owing "Clearanco Code". contacted. 23. GF��� ��ti��. insert the fire department's (VOTE: if Code 2 (Denied) or Code 3 (Withheld) is used, explain. - nua�nberassigned by C�IRS. 2�. ®��1��. CODE . Use only the seven codes shown 24. TITLE 19 OCC. CLASS. Use Title 19 occupancy . and insert the appropriate number in the bob following "Denial Code". If No. 7 "Other" is used,,,, ciaSSIfleations and i Nert the occupancy doter- explain at Item 28. p miy inspector. U the ins ector. NOTE: Fire Clearance cannot be denied for other than lack of con - 26. INSP. DATE Enter the actual date of the in- formance with the provisions of Title 19. spection. _ 29. EXPLAIN DE AL. if Clearance Code No., 2 or 3 26• 1 SPTOR'5� � �� �o T® be signed by is used, briefly explain reason. This space is also inspector conducting the lnspection. to be used to explain Denial Code item noted. ICE OF THE STATE FIRE MARSHAL INSPECTION LOG Title od Fi le EIVID 0040 DIME] a Address Date Owner ' ;7 i. GO -6 (,Rev. 5/81-) BEDlzobm BEID90o� C4 CYSSAP 'a CH Sol/ "el XZ '04CA, ................ ?EST Home, ��SdO hlPPRAX. TA rin S- d4m 10c,tosar B�oR�M 7001AI Ouse RM 0 STAT Loce. -Flo P1,4 0 946t/,r OA)10Zr 7 Ozx so=%, 1pm**! PIG u $Ep Room O BEDROC, Op, cze Ossp pla g c 14 • � i� 0 0 . i Roo • _ N TRY o PEA PO c r, xf �I H V-0010-mosm - XO#V X57 nME ooTA6EAPPRAx• 9. Z500 •.e M »Ya�Nia[ �MaMM+•.�.�+.•.�yK�•.rr.�r�w�.l.www�yM••N`I�•«i.� •r•. �...r,ww•.rwwr+w.�rrsar..v.aw�www�s.M�I�_- fVl wiq .... ..w... ..r r. •'w �.,r...Mr•:7.: .�. .�.. +••.••..� .�Yr.•p.:wA..r•••.:M fix- i..w. w• . $aDRapM 7 o.. to:ar om CIOSST 15 r , -r1A I TO �M Val••s••��•�a•�a••yM\�•www•.ar•s..•.+.•+«ti•r�.arw•.••M•y ♦•w �.ala��r p.w....��NN..r+�ArArwM.�•�•�•�1/Mw•�I�•�••.•w.q•�•s•-..•..w.......A•w wwM.••w��••w �.M�w.rtiM•M��► . -+rb: waw --- ---- �_.. _�......... ,....�--........•- . +. �� '-%'�:i M 0 JTATS PAI)OZ 7Fe ww....r�•..a.r�•..w.+.r••.ww.wr..�..�M.�w.r M•w.• �.r. a+•w..y. - .. ` .- , •, ! -.. , ..... .. .._ - .. �. . ... • a•� ....... -tea• �-- .. r — • w.�.... •�t ;� • •. � max. CE OF THE STATE FIRE MARSHAL INSPECTION LOG Title; - EJ [1) El D . EJ File Q El El, El -E1 El El, El 0, 0 D t �-- �� Date Address -_ ■ r i Owner tz � � � �l �` f L 1 t ^r� {• r .� r•..r.■r���rtsr��a■■ GO -6 (Rev. 5/81) STA E FIRZ MARSHAL FI E SAFETY INSPECTION REQUEST COPY DISTRIBUTION; 1 - STATE FIRE MARSHAL SEE REVERSE OF COPIES 2 AND 3 FOR INSTRUCTIONS FOR COMPLETION STD 50A (NEW 6180) 2 - FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM 3 - LICENSING AGENCY 8_18_81 3. GENCY CONTACT DSS COMMUNITY CARE LICENSING 4. TELEPHONE NO. 920-6855 5. SIGNATURE 6. FM REGION 7. SFM I.D. NO. 0 (4 B 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR 040302145 Herb Cortez 19. REQUEST CODE 3 CODES 1. ORIGINAL A. FIRE CLEARANCE 10. AGENCY A f ...----� 2. RENEWAL B. LIFE SAFETY NAME DEPARTMENT OF SOCIAL SERVICES 3. CAPACITY CHANGE AND Community Licensing4. CO ADDRESS y C-� 2400 Glendale Lane, Suie C ( Sacramento, CA ' 95825 ; rATr s _ RW ��R�p{AL OWNERSHIP CHANGE 5. ADDRESS CHANGE 6. OTHER DATE OF ORIGINAL REQ. -j 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CA 1 ACITY AGE RANGE (YEARS) TO 18 1 18 TO 1 65 AND 65 OVER x x PREVIOUS CAPACITY CAPACITY 10 AGE RANGE( EARS) TO 18 18 TO 65 AND 65 OVER PREVIOUS CAPACITY 1 20 FACIELITY 12 12. F CILITY NAME 13. NO. BLDGS. CODES Mirada Rest Home 1 1. GACH 7. ICF/OT 2. GACHIR 8. ICFIDD 3. SH . ADHC 4. APH 100. CLINIC 5. PHF 11. JAIL 6. SNF 12. OTHER 14. S 197 REET ADDRESS La Mirada 15. RESTRAINT NO CI pro Y i.11e, CA ZIP CODE 95965 16. HOURS 24 17. F CILITY CONTACT PERSON NO. 16A. SPECIAL Col een Barksdale �EPHONE (' G 8 -1 81 Group Home Adults TO BE COMPLETED BY INSPECTING AUTHORITY 18. IRE F UTHOR. OFFICE OF STATE FIRE MARSHAL 27. CLEARANCE CODE CODES AME 7300 Lincolnshire Drive, Suite 170 1. FIRE CLEAR. GRANTED ND S8Cf81T1@fli0, CA 95823 DDRESS -�� 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. IN PECTOR'S NAME TELEPHONE NO. 23. CFIRS ID RS 24. T•19 OCC. CLASS 1. EXITS 2. CONSTRUCTION 3. FIRE ALARM 25. IN P. DATE INSPECTQR'S SIGNATURE 126. 4. SPRINKLERS 5. HOUSEKEEPING 29. EX LAIN DENIAL OR LIST SPECIAL CONDITIONS 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY 21. R GION, I OFFICE OFFICE OF STATE FIRE MARSHAL A D 7300 Lif100ifshire D&A. Suite 170 A DRESS SwfemeM. CA 9W23 L TIME MILES NEXT INSP. (MO. DA. YR.) O(W% JAH2AAM 3J;4ij j►AT2 10 X.)IM "'V . Dvw 'I'MIP A.3 s . J► STA E FIRr-MARSHAL FI E 94FETY INSPECTION REQUEST COPY DISTRIBUTION; SEE REVERSE OF COPIES 2 AND 3 FOR 1 • STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION STD 85JiA (NEW 6180) 2 FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM 3 LICENSING AGENCY 3. GENCY CONTACT 4. TELEPHONE NO. S. SIGNATURE I 6. REGION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO. 9. EVALUP.TOR �FM 19. REQUEST CODE CODES ry �y�• 1. ORIGINAL A. FIRE CLEARANCE 10. AGENCY, 2. RENEWAL B. LIFE SAFETY NAME DEPARTM-IT OF SOCIAL SERVICES 3. CAPACITY CHANGE AND ADDRESS CiUYi1 iunl t y Care Licensing 4. OWNERSHIP CHANGE 2400 Glendale Ixane, SUie C 5. ADDRESS CHANGE ARS4 /;� LSacranlento, CAAc-)5'3E M25 E ARS 6. OTHER DATE OF ORIGINAL REQ. - 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CAACITY 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 1 65 OVER 20. FACILITY z CODE 12. F`CILITY NAME 13. NO. BLDGS. CODES 1. GACH 7. ICF/OT 2. GACH/R 8. ICF/DD T .J a;; 14. S REET ADDRESS 15. RESTRAINT 3. SH 9. ADHC 1: (1 4. APH 10. CLINIC 5. PHF 11. JAIL GI Y ZIP CODE 16. HOURS II 6. SNF 12. OTHER 17. FA ILITY CO TACT PERSON TELEPHONE NO. 16A. SPECIAL TO BE COMPLETED BY INSPECTING AUTHORITY 18. IRE OFFICE OF STATE FIRE MARSHAL 27. CLEARANCE CODE UTHAME 7300 Lincolnshire Drive, Suite 170 AME CODES Sacramento, OA 55823 1. FIRE CLEAR. GRANTED ND DDRESS 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. INS ECTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T•19 OCC. ID NO. CLASS 1. EXITS 2. CONSTRUCTION 3. FIRE ALARM 25. INS DATE INSPECTOR'S SIGNATURE 126. I. 4. SPRINKLERS 5. HOUSEKEEPING 29. EXP AIN DENIAL OR LIST SPECIAL CONDITIONS 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY F 21. R GION, OFFICE OF STATE FIRE MARSHAL 0 FICE 7300 Lincolnshire Drive, Suite 170 A D Sacramento, CA 95823 ADDRESS LTIME MILES NEXT INSP. (MO. DA. YR.) INSTRUCTIONS- NSTRUCTIONS This This form is designed for use with a window envelope. To use,;told at marks indicated in the left margin. Licensing or Requesfang Agencies m 061601ete,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 -0 Enter the date request was 14. ADDRESS. Insert street address and city only. A prepared. - post office box is not acceptable, 2. PROGRAM. Licensing agency use. - ` `� M, .' ±' 15. RESTRAINT. Indicate if physicial restraint (locked tl _ `` � 3. -.AGENCY C�'NTACT9 4• TELEPHONE Y�q®'o9 5- ' :•• in -a room or the building) is to be used in the SIGNATURE:. Enter the name, telephone number, housing of the occupants. Y— yes N = no. and signature of agency contact person. 16. HOURS. .Indicate the number of hours -the 6. SFM RE8I0No lnser��one of the following 3 numbers_ occupants are housed at the facility. {Less than . for the Si=lo Regi' al office in whose .4 24 or 24+). facility is located. :ti: ;f�, F : 16a SPECIAL. Use to designate persons who are 350 Coastal, 33a Northern, 370 Soi�tfier.J'�'•;�4u determined to be non-ambulatory for reasons other - , , than a physical handicap. 7. SFM ID NO. This is the Identification :SFM. .Number and initisllyviie.:be. assigned by the State Else 17• FACILITY CONTACT PERSON'- TELEPHONE NO. • Marshal. Licensing Agency -- Insert -this number•on Indicate the name. and -tele one number of the. re-. ,_ , : , , all clearance requests subsequent 't© the initial , sponsible individual at `the faciltity,to be contacted request . by the fire authority. 6. REQUESTING AGENCY -.FA iL1TY NO. This is the 160 FIRE AUTHOR. NAME AND ADDRESS4 - I.nsert the -file number assigned by the licensing agency. name and address of the fire authority in the vicini#y -- i where the facility s located, 90 -EVALUATOR. For licensing agency use. - 19. REQUEST CODE. Use the six codes shown and 10. AGENCY NAME AND _ADDRESS. Enter the name insert the appropriate number in the box following and address of the licensing facility requesting "Request Code". Insert date of original request -'the inspection. when request is other than an original. *11. AMBULATORY ® NOW -AMBULATORY. Complete 20. FACILITY CODE. Mark this item only if the iacilitythis section only when Item 20 doenot apply. - .. _ is a. ('9) General_ Acute Care Hospital (GACH), (2) Capacity: Insert, in the appropriate section, the capacity Genera! Acute Care Hospital/Rehab (GACH/R), (3) of licensed ambulatory or non-ambulatory oc- Special Hospital (SH), (4) Acute Psychiatric Hospital cupants covered by this request. (APH), (5) Psychiatric Health Facility (PHF), (6) Age Range: Indicate the age range of the licensed occupants. • S)Cil(sd � t,Nural, g-- Fac! t .( i�F}, (7) intermediate Previous If request Is for renewal or capacity change, insert capacity of previous clearance. _ It tbet 19 �} lnterm�diate Care PCapacity: ,- �J'� � : �,,`Total Show iota! licensed ca acct If the Facilit is intended ambulatory non- city .eve16"pmenly Disabled (ICF/D®), (9) Ad1!'I.`�ay" HealflI�e+ (A®l-iC), (10) Clinic, (11) Jail Capacity: to house part and part :ambulatory, show the total of the two types of or (12) other. When !tern 20 is used , Item 1.1, does occupants. not need to be completed (except total cap). 12. FACILITY NAME. Insert the name of the facility as 21. REGION., OFFICE ARID ADDRESS. Insert the namE it will appear on the license. and address of the State Fire marshal Regional, 13. NO-o-BLDGS. Insert the- total number of buildings Office in w"hose:aiea.the'.facility is located. to be used for housing of the occupants -covered : « _ . _ by the license. Fire Authority Conducting the Inspection o Complete the following: ! 22. INSPECTOR'S NAME. Print the initial of the in- t• -27. CLEARANCE CODE. Use 'the three codes shown Spector's first name and full last name; insert the and insert the appropriate number in the bo:K telephone - number where the inspector may be following "Clearance* Code". - - obntacted. NOTE: If Code 2 Denied or Code 3 Withheld is used explain. 23. CFIRS 1D.N0. Insert the fire department's 28. DENIAL CODE. Use only the seven codes shown number assigned by CFIRS. and insert the appropriate number in the box 24. TITLE 19 OCC. CLASS. Use Title 19 occupancy following "Denial Code". If No. 7 "Other" is used, classifications and insert the occupancy deter- mined by the inspector. NOTE: ; Fire Cieat�ence�;aannotr be,=deniietl for other than lack ofi con- . 25. INSP. DATE Enter the actual date of the in- a formance with the.. provia�pns of Title 19. spection. 29. EXPLAIN DENIAL. If Clearance Code No. 2 or 3 • 26, INSPECTOR'S SI A` URE. -,To be signed by is used, briefly explain reason. This space is also inspector conducting the inspection. to be used to explain Denial Code item noted.