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HomeMy WebLinkAboutFAI CF FA 4 2 2024 Roseleaf Fail oOTHILL FIRE flo PROTECTION INC. ji 170 Erma Court Chico CA 95928 (530)826-3013 C10#783132 SYSTEM RECORD OF INSPECTION AND TESTING This form is to be completed by the system inspection and testing contractor at the time of a system test. It shall be permitted to modify this form as needed to provide a more complete and/or clear record. Insert N/A in all unused lines. Attach additional sheets, data, or calculations as necessary to provide a complete record. Inspection/Test Start Date/Time: 4/02/2024@7:00AM Inspection/Test Completion Date/Time: 4/02/2024 @ 7:45AM Supplemental Form(s)Attached: Yes (yes/no) 1. PROPERTY INFORMATION Name of property: Roseleaf Oroville -Annual Fire Alarm Inspection Address: 1900 20th Street Description of property: Name of property representative: Address: Phone: (530) 444-8511 Fax: E-mail: 2. TESTING AND MONITORING INFORMATION Testing organization: Foothill Fire Protection, Inc. Address: 170 Erma Court Chico CA 95928 Phone: (530)826-3013 Fax: E-mail: Monitoring organization: Foothill Fire-Rapid Response Monitoring Services Address: 400 West Division Street,Syracuse, NY 13204 Phone: (800)932-3822 Fax: E-mail: Account number: Z571201 Phone line 1: Phone line 2: Means of transmission: On Board Built In Dialer To Cell Dialer Entity to which alarms are retransmitted: Rapid Response Phone: 1-800-932-3822 3. DOCUMENTATION On-site location of the required record documents and site-specific software: At FACP 4. DESCRIPTION OF SYSTEM OR SERVICE 4.1 Control Unit Ademco Model number: Vista 128 Manufacturer: 4.2 Software and Firmware Firmware revision number: N/A 4.3 System Power 4.3.1 Primary(Main)Power Nominal voltage: 120VAC Amps: N/A Location: Boiler Room Copyright©2012 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. SYSTEM RECORD OF INSPECTION AND TESTING (continued) Overcurrent protection type: Breaker Amps: 20 Disconnecting means location: Boiler Room Panel AC Ckt 2 4. DESCRIPTION OF SYSTEM OR SERVICE (continued) 4.3.2 Secondary Power Type: Battery Backup Location: FACP Battery type(if applicable): Sealed Lead Acid capacity of batteries to drive the system: In standby mode(hours): 24 In alarm mode(minutes): 5 5. NOTIFICATIONS MADE PRIOR TO TESTING Monitoring organization Contact: Rapid Response Time: Building management Contact: Time: Building occupants Contact: Staff Time: 7:00AM Authority having jurisdiction Contact: Time: Other,if Contact: Time: required 6. TESTING RESULTS 6.1 Control Unit and Related Equipment Visual Functional Description Inspection Test Comments Control unit 0 0 Lamps/LEDs/LCDs 0 0 Fuses ❑ ❑ N/A Trouble signals 0 0 Disconnect switches ❑ ❑ N/A Ground-fault monitoring 0 0 Supervision 0 0 Local annunciator ❑ ❑ N/A Remote annunciators 0 0 1 in front lobby. 1 in Activity Room. 1 on B side Remote power panels ❑ ❑ N/A ❑ ❑ 6.2 Secondary Power Visual Functional Description Inspection Test Comments Battery condition 0 ❑ (4) 12v8ah FACP Inst 6-17-22 Load voltage ❑ 0 Discharge test ❑ 0 Charger test ❑ 0 Remote panel batteries ❑ I ❑ N/A Copyright©2012 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. SYSTEM RECORD OF INSPECTION AND TESTING (continued) 6. TESTING RESULTS (continued) 6.3 Alarm and Supervisory Alarm Initiating Device Attach supplementary device test sheets for all initiating devices. 6.4 Notification Appliances Attach supplementary appliance test sheets for all notification appliances. 6.5 Interface Equipment Attach supplementary interface component test sheets for all interface components. Circuit Interface/Signaling Line Circuit Interface/Fire Alarm Control Interface 6.6 Supervising Station Monitoring Description Yes No Time Comments Alarm signal ❑ ❑ N/A Alarm restoration ❑ ❑ N/A Trouble signal ❑ ❑ N/A Trouble restoration ❑ ❑ N/A Supervisory signal ❑ ❑ N/A Supervisory restoration ❑ ❑ N/A 6.7 Public Emergency Alarm Reporting System Description Yes No Time Comments Alarm signal ❑ ❑ N/A Alarm restoration ❑ ❑ N/A Trouble signal ❑ ❑ N/A Trouble restoration ❑ ❑ N/A Supervisory signal ❑ ❑ N/A Supervisory restoration ❑ ❑ N/A Copyright©2012 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. SYSTEM RECORD OF INSPECTION AND TESTING (continued) 7. NOTIFICATIONS THAT TESTING IS COMPLETE Monitoring organization Contact: Rapid Response Time: Building management Contact: Time: Building occupants Contact: Staff Time: 7:45AM Authority having jurisdiction Contact: Time: Other,if Contact: Time: required 8. SYSTEM RESTORED TO NORMAL OPERATION Date: 4/02/2024 Time: 7:45AM 9. CERTIFICATION This system as specified herein has been inspected and tested according to NFPA 72,2013 edition,Chapter 14. Signed: Printed name: Tyler Smedley Date: 4/02/2024 Organization: Foothill Fire Protection, Inc. Title: Inspector Phone: (530) 826-3013 Qualifications(refer to 10.5.3): C10 License(#783132) 10. DEFECTS OR MALFUNCTIONS NOT CORRECTED AT CONCLUSION OF SYSTEM INSPECTION, TESTING, OR MAINTENANCE Fail - Customer did not have key to open electrical room where the Fire panel is located 10.1 Acceptance by Owner or Owner's Representative: The undersigned accepted the test report for the system as specified herein: Signed: Printed name: Date: Organization: Title: Phone: Copyright©2012 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. (4a LO I I PROTECTION, INC 170 Erma Court Chico CA 95928 (530)826-3013 C10#783132 INITIATING DEVICE SUPPLEMENTARY RECORD OF INSPECTION AND TESTING This form is a supplement to the System Record of Inspection and Testing. It includes an initiating device test record. This form is to be completed by the system inspection and testing contractor at the time of the inspection and/or test. It shall be permitted to modify this form as needed to provide a more complete and/or clear record. Insert N/A in all unused lines. Inspection/Test Start Date/Time: 4/02/2024@7:00AM Inspection/Test Completion Date/Time: 4/02/2024@7:45AM Number of Supplemental Pages Attached: 5 1. PROPERTY INFORMATION Name of property: Roseleaf Orovilie Address: 1900 20th Street 2. INITIATING DEVICE TEST RESULTS Device Type Address Location Test Results Pull Stations 1 Side B West Area Pull Stations 2 Side B Middle Area Pull Stations 3 Side B East Area Smoke Detector I 10 Room 19 Smoke Detector 11 Side B Laundry Room Smoke Detector I 12 Side B Medication Room Smoke Detector 13 Room 21 Smoke Detector I 14 Room 23 Smoke Detector 15 Room 25 Smoke Detector I 16 Room 27 Smoke Detector 17 Room 29 Smoke Detector I 18 Room 31 Smoke Detector 19 Room 30 Smoke Detector I 20 Room 28 Smoke Detector 21 Room 26 Smoke Detector I 22 Room 24 Smoke Detector 23 Room 22 Smoke Detector I 24 Room 20 Smoke Detector 25 Side B East Rear Hallway Smoke Detector I 26 Side B East Hallway- Center Smoke Detector 27 Side B East Hallway- Front Area Copyright©2012 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. (4a LO I I PROTECTION, INC 170 Erma Court Chico CA 95928 (530)826-3013 C10#783132 INITIATING DEVICE SUPPLEMENTARY RECORD OF INSPECTION AND TESTING This form is a supplement to the System Record of Inspection and Testing. It includes an initiating device test record. This form is to be completed by the system inspection and testing contractor at the time of the inspection and/or test. It shall be permitted to modify this form as needed to provide a more complete and/or clear record. Insert N/A in all unused lines. Inspection/Test Start Date/Time: 4/02/2024@7:00AM Inspection/Test Completion Date/Time: 4/02/2024@7:45AM Number of Supplemental Pages Attached: 5 1. PROPERTY INFORMATION Name of property: Roseleaf Orovilie Address: 1900 20th Street 2. INITIATING DEVICE TEST RESULTS Device Type Address Location Test Results Smoke Detector I 28 Side B West Rear Area Smoke Detector 29 Side B West Middle Area Smoke Detector I 30 Side B Reception Area Smoke Detector 31 Side B West Front Area Smoke Detector I 32 Side B Lounge West Area Smoke Detector 33 Side B Lounge East Area Smoke Detecor 34 Side B Break Room CO Sensor 35 Side B Hot Water Room CO Sensor 36 Pantry Closet CO Sensor 37 Kitchen Water Flow I 1 Building Riser Smoke Detector 10 Side A Soda Shop Smoke Detector I 11 Room 2 Heat Detector 12 Side A Nelson Storage Room Heat Detector 13 Side A Water Heater Closet Smoke Detector I 14 Room 4 Smoke Detector 15 Nelson Wing Hallway Smoke Detector I 16 Room 6 Smoke Detector 17 Room 1 Smoke Detector I 18 Room 3 Smoke Detector 19 Room 5 Copyright©2012 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. (4a LO I I PROTECTION, INC 170 Erma Court Chico CA 95928 (530)826-3013 C10#783132 INITIATING DEVICE SUPPLEMENTARY RECORD OF INSPECTION AND TESTING This form is a supplement to the System Record of Inspection and Testing. It includes an initiating device test record. This form is to be completed by the system inspection and testing contractor at the time of the inspection and/or test. It shall be permitted to modify this form as needed to provide a more complete and/or clear record. Insert N/A in all unused lines. Inspection/Test Start Date/Time: 4/02/2024@7:00AM Inspection/Test Completion Date/Time: 4/02/2024@7:45AM Number of Supplemental Pages Attached: 5 1. PROPERTY INFORMATION Name of property: Roseleaf Orovilie Address: 1900 20th Street 2. INITIATING DEVICE TEST RESULTS Device Type Address Location Test Results Smoke Detector I 20 Room 7A Smoke Detector 21 Room 7B Smoke Detector I 22 Room 8B Smoke Detector 23 Room 8A Smoke Detector I 24 Activity Room Smoke Detector 25 Activity Office Smoke Detector I 26 Beauty Shop Smoke Detector 27 Room 9A Smoke Detector I 28 Room 9B Smoke Detector 29 Room 10B Smoke Detector I 30 Room 10A Smoke Detector 31 Sierra Hallway Smoke Detector I 32 Room 12 Smoke Detector 33 Room 14 Smoke Detector I 34 Room 16 Smoke Detector 35 Room 18 Smoke Detector I 36 Grand Wing Hallway Smoke Detector 37 Room 11 Smoke Detector I 38 Room 15 Smoke Detector 39 Room 17 Smoke Detector 40 Side A Janitorial Room Copyright©2012 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. (4a LO I I PROTECTION, INC 170 Erma Court Chico CA 95928 (530)826-3013 C10#783132 INITIATING DEVICE SUPPLEMENTARY RECORD OF INSPECTION AND TESTING This form is a supplement to the System Record of Inspection and Testing. It includes an initiating device test record. This form is to be completed by the system inspection and testing contractor at the time of the inspection and/or test. It shall be permitted to modify this form as needed to provide a more complete and/or clear record. Insert N/A in all unused lines. Inspection/Test Start Date/Time: 4/02/2024@7:00AM Inspection/Test Completion Date/Time: 4/02/2024@7:45AM Number of Supplemental Pages Attached: 5 1. PROPERTY INFORMATION Name of property: Roseleaf Orovilie Address: 1900 20th Street 2. INITIATING DEVICE TEST RESULTS Device Type Address Location Test Results Smoke Detector I 41 Side A Dining Hallway Smoke Detector 42 Side A Dining Room Smoke Detector I 43 Laundry/Riser Room Heat Detector 44 Kitchen Smoke Detector I 45 Side A Living Room Smoke Detector 46 Side A Front Entry Hall Smoke Detector I 47 Side A Conference Room Smoke Detector 48 Reception Area Smoke Detector I 49 Side A Front Entry Smoke Detector 50 Side A Electrical Room Pull Station I 51 Side A Front Entry Hallway Pull Station 52 Side A Soda Shop Pull Station I 53 Nelson Wing Pull Station 54 Activity Room Pull Station I 55 Sierra Wing Pull Station 56 Grand Hall Pull Station I 57 Side A Dining Room Smoke Detector 58 Cottage Great Room Smoke Detector I 59 Cottage East Room Smoke Detector 60 Cottage West Room Smoke Detector 61 Cottage Middle Room Copyright©2012 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. OOTHILL FIRE I I C PROTECTION, INC. 170 Erma Court Chico CA 95928 (530)826-3013 C10#783132 INITIATING DEVICE SUPPLEMENTARY RECORD OF INSPECTION AND TESTING This form is a supplement to the System Record of Inspection and Testing. It includes an initiating device test record. This form is to be completed by the system inspection and testing contractor at the time of the inspection and/or test. It shall be permitted to modify this form as needed to provide a more complete and/or clear record. Insert N/A in all unused lines. Inspection/Test Start Date/Time: 4/02/2024@7:00AM Inspection/Test Completion Date/Time: 4/02/2024@7:45AM Number of Supplemental Pages Attached: 5 1. PROPERTY INFORMATION Name of property: Roseleaf Orovilie Address: 1900 20th Street 2. INITIATING DEVICE TEST RESULTS Device Type Address Location Test Results Pull Station I 62 Cottage CO Sensor 67 Cottage Hot Water Heater Room Control Panel I N/A Side A Electrical Room Copyright©2012 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution.