HomeMy WebLinkAboutFAI18-0006 CF 850 Inspection (2) Iraq I ss 06C6
STATE OF CALIFORNIA-FORESTRY AND FIRE PROTECTION O (J`ul Q s
FIRE SAFETY INSPECTION REQUEST V l
See instructions on reverse.
STD.850(REV.4-2000)
AGENCY CONTACTS NAME TELEPHONE NUMBER REQUEST DATE PROGRAM
CHRISTINA GARRISON (916)322-2911 05/24/2017 RESIDENTIAL
EVALUATORS NAME REQUESTING AGENCY FACILITY NUMBER REQUEST CODE
MATT DAMON , 040034AN 3-A
CODES
1. ORIGINAL A.FIRE CLEARANCE
LICENSING I DEPARTMENT OF HEALTH CARE SERVICES 2. RENEWAL B.LIFE SAFETY
AGENCY SUBSTANCE USE DISORDER DIVISION
NAME AND LICENSING AND CERTIFICATION BRANCH 3. CAPACITY CHANGE
ADDRESS PO BOX 997413,MS 2600 4. OWNERSHIP CHANGE
SACRAMENTO,CALIFORNIA 95899-7413 5. ADDRESS CHANGE
6. NAME CHANGE
7. OTHER
AMBULATORY ( NONAMBULATORY I BEDRIDDEN I TOTAL CAPACITY
CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY
13 13
FACILITY NAME LICENSE CATEGORY
Elijah House Restoration Center Alcohol and Drug Facility
STREET ADDRESS(Actual Location) NUMBER OF BUILDINGS
40 Coyote Moon Trail 2
CITY RESTRAINT
Bangor,California 95966 None
FACILITY CONTACT PERSONS NAME FACILITY CONTACT PERSON'S TELEPHONE NUMBER HOURS
Joe Henderson (530)868-7091 24+
SPECIAL CONDITIONS
6 treatment beds and 1 staff bed in the main house
6 treatment beds in the second house
TO BE COMPLETED BY INSPECTING AUTHORITY
CLEARANCE/DENIAL CODE
1
C• ODES
FIRE ( 1 FIRE CLEARANCE GRANTED
AUTHORITY
CalFireButte County Fire
NAME AND 116 Nelson Avenue,Oroville,CA 95965 2. FIRE CLEARANCE DENIED
ADDRESS Telephone 530-538-7888 Fax 530-538-2105 A. EXITS
B. CONSTRUCTION
C. FIRE ALARM
INSPECTORS NAME(Typed or Printed) TELEPHONE NUMBER CFIRS NUMBER OCCUPANCY CLASS D. SPRINKLERS
E. HOUSEKEEPING
CI 15 3010 (530)538-7888 F. SPECIAL HAZARD
INSPECTION DATE INSPECTOR' 1 NATURE(T orPrin G. OTHER
5-31-17 kw; Atli?,s 8ccy4)
EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS /r
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