HomeMy WebLinkAboutroseleaf 2024 fire alarm 00THILL,
PROTECTION INC.
Chico
170 Erma Court Chico,CA 95928
(530) 826-3013
C10#783132
SYSTEM RECORD OF INSPECTION AND TESTING
This form is to be completed bythe system inspection and testing contractor at the time of a system test.
It shall be permitted to modfy 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: 08/21/23 12:00:00 AM Inspection/Test Completion Date/Time: 08/21/23 12:00:00 AM
Supplemental Form(s)Attached: Yes (yes/no)
Inspection Results:Fail
1. PROPERTY INFORMATION
Name of Property: Roseleaf Oroville
Address: 1900 20th St.Oroville,CA 95965
Description of Property: Roseleaf Oroville
Name of Property Representative: Diana Bingham
Address:
Phone: Fax: Email:
2.TESTING AND MONITORING INFORMATION
Testing organization: Foothill Fire Protection,Inc.
Address: 170 Erma Court I Chico,CA 95928
Phone: (530)826-3013 Fax: Email:
Monitoring Organization: Foothill Fire Protection-Rapid Response
Address:
Phone: (916)663-3582 Fax: Email:
Account Number: Z571201 Phone Line 1: N/A Phone Line 2: N/A
Means of Transmission: Digital
Entity to which alarms are restransmitted: Foothill Fire Protection-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
Manufacturer: Ademco Model Number: Vista 128
4.2 Software and Firmware
Firmware revision number: N/A
4.3 System power
4.3.1 Primary(Main)Power
Nominal Voltage: Ademco Amps: N/A Location: Boiler Room
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 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: Yes Time: 08:30:00
Building Management Contact: Yes Time: 08:30:00
Building Occupants Contact: Yes Time: 08:30:00
Authority Having Jurisdiction Contact: N/A Time:
Other Contact: Time:
6.TESTING RESULTS
6.1 Control Unit and Related Equipment
Description Visual Functional Comments
Inspection Test
Control Unit PASS PASS N/A
Lamps/LEDs/LCDs PASS PASS N/A
Fuses NA NA N/A
Trouble Signals PASS PASS N/A
Disconnect Switches NA NA N/A
Ground-Fault Monitoring PASS NA N/A
Supervision PASS PASS N/A
Local Annunciator NA NA N/A
Remote Annunciators PASS PASS N/A
Remote Power Panels NA NA N/A
6.2 Secondary Power
Description Visual Functional Comments
Inspection Test
Battery Condition PASS PASS (4)12v8ah FACP install 6-17-22
Load Voltage PASS PASS N/A
Discharge Test PASS PASS N/A
Charger Test PASS PASS N/A
Remote Panel Batteries NA NA N/A
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 devices.
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 Results Time Comments
Alarm Signal Yes 08:30:00 N/A
Alarm Restoration Yes 10:18:00 N/A
Trouble Signal Yes 08:30:00 N/A
Trouble Restoration Yes 10:18:00 N/A
Supervisory Signal Yes 08:30:00 N/A
Supervisory Restoration Yes 10:18:00 N/A
6.7 Public Emergency Alarm Reporting System
Description I Results I Time I 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
7.NOTIFICATIONS THAT TESTING IS COMPLETE
Monitoring Organization Contact: Yes Time: 10:17:00
Building Management Contact: Yes Time: 10:17:00
Building Occupants Contact: Yes Time: 10:17:00
Authority Having Jurisdiction Contact: N/A Time:
Other Contact: Time:
8.SYSTEM RESTORED TO NORMAL OPERATION
Date: 08/21/23 Time: 12:00:00 AM
9.CERTIFICATION
This system as specified herein has been inspected and tested according to NFPA 72,2013 edition,Chapter 14.
Signed: Printed Name: Enrique Ramos Date: 08/21/23
Organization: Foothill Fire Protection,Inc. Title: Inspector Phone:
Qualifications(refer to 10.5.3): 783132
10. DEFECTS OR MALFUCTIONS NOT CORRECTED AT CONCLUSION OF SYSTEM INSPECTION,TESTING,OR MAINTENANCE
DEFICIENCIES AN)COMMENTS
Severity Device Location Description of the issue Take a picture of the issue
Side A Electrical Upon arrival panel was in -- - -
Deficient Control Panel Room trouble for bell 2.Panel still
in trouble upon departure
man
her- ---
10.1 Acceptance by Owner or Owner's Representative:
The undersigned accepted the test report for the system as specified herein:
Signed: Printed Name: Michelle Date:
Organization: Rose Leaf Gardens Title: Phone:
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Chico
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: 08/21/23 12:00:00 AM Inspection/Test Completion Date/Time: 08/21/23 12:00:00 AM
Supplemental Form(s)Attached: Yes (yes/no)
1. PROPERTY INFORMATION
Name of Property: Roseleaf Oroville
Address: 1900 20th St.Oroville,CA 95965
2. INITIATING DEVICE RESULTS
Device Type Address Location Visual Functional Comments
Pull Stations 1 Side B West Area N/A 2 devices on point
Pull Stations 2 Side B Middle Area N/A 2 devices on point
Pull Stations 3 Side B East Area N/A 2 devices on point
Smoke Detector 10 Room 19 N/A N/A
Smoke Detector 11 Side B Laundry Room N/A N/A
Smoke Detector 12 Side B Medication Room N/A N/A
Smoke Detector 13 Room 21 N/A N/A
Smoke Detector 14 Room 23 N/A N/A
Smoke Detector 15 Room 25 N/A N/A
Smoke Detector 16 Room 27 N/A N/A
Smoke Detector 17 Room 29 N/A N/A
Smoke Detector 18 Room 31 N/A N/A
Smoke Detector 19 Room 30 N/A N/A
Smoke Detector 20 Room 28 N/A N/A
Smoke Detector 21 Room 26 N/A N/A
Smoke Detector 22 Room 24 N/A N/A
Smoke Detector 23 Room 22 N/A N/A
Smoke Detector 24 Room 20 N/A N/A
Smoke Detector 25 Side B East Rear Hallway N/A N/A
Smoke Detector 26 Side B East Hallway-Center N/A N/A
Smoke Detector 27 Side B East Hallway-Front Area N/A N/A
Smoke Detector 28 Side B West Rear Area N/A N/A
Smoke Detector 29 Side B West Middle Area N/A N/A
Smoke Detector 30 Side B Reception Area N/A N/A
Smoke Detector 31 Side B West Front Area N/A N/A
Smoke Detector 32 Side B Lounge West Area N/A N/A
Smoke Detector 33 Side B Lounge East Area N/A N/A
Smoke Detecor 34 Side B Break Room N/A N/A
CO Sensor 35 Side B Hot Water Room N/A N/A
CO Sensor 36 Pantry Closet N/A N/A
CO Sensor 37 Kitchen N/A N/A
Water Flow 1 Building Riser PASS PASS N/A
Smoke Detector 10 Side A Soda Shop N/A N/A
Smoke Detector 11 Room 2 N/A N/A
Heat Detector 12 Side A Nelson Storage Room N/A Manual Test Performed.
Heat Detector 13 Side A Water Heater Closet N/A Manual Test Performed.
Smoke Detector 14 Room 4 N/A N/A
Smoke Detector 15 Nelson Wing Hallway N/A N/A
Smoke Detector 16 Room 6 N/A N/A
Smoke Detector 17 Room 1 N/A N/A
Smoke Detector 18 Room 3 N/A N/A
Smoke Detector 19 Room 5 N/A N/A
Smoke Detector 20 Room 7A N/A N/A
Smoke Detector 21 Room 7B N/A N/A
Smoke Detector 22 Room 8B N/A N/A
Smoke Detector 23 Room 8A N/A N/A
Smoke Detector 24 Activity Room N/A N/A
Smoke Detector 25 Activity Office N/A N/A
Smoke Detector 26 Beauty Shop N/A N/A
Smoke Detector 27 Room 9A N/A N/A
Smoke Detector 28 Room 9B N/A N/A
Smoke Detector 29 Room 10B N/A N/A
Smoke Detector 30 Room l0A N/A N/A
Smoke Detector 31 Sierra Hallway N/A N/A
Smoke Detector 32 Room 12 N/A N/A
Smoke Detector 33 Room 14 N/A N/A
Smoke Detector 34 Room 16 N/A N/A
Smoke Detector 35 Room 18 N/A N/A
Smoke Detector 36 Grand Wing Hallway N/A N/A
Smoke Detector 37 Room 11 N/A N/A
Smoke Detector 38 Room 15 N/A N/A
Smoke Detector 39 Room 17 N/A N/A
Smoke Detector 40 Side A Janitorial Room N/A N/A
Smoke Detector 41 Side A Dining Hallway N/A N/A
Smoke Detector 42 Side A Dining Room N/A N/A
Smoke Detector 43 Laundry/Riser Room N/A N/A
Heat Detector 44 Kitchen N/A Manual test performed
Smoke Detector 45 Side A Living Room N/A N/A
Smoke Detector 46 Side A Front Entry Hall N/A N/A
Smoke Detector 47 Side A Conference Room N/A N/A
Smoke Detector 48 Reception Area N/A N/A
Smoke Detector 49 Side A Front Entry N/A N/A
Smoke Detector 50 Side A Electrical Room N/A N/A
Pull Station 51 Side A Front Entry Hallway N/A N/A
Pull Station 52 Side A Soda Shop N/A N/A
Pull Station 53 Nelson Wing N/A N/A
Pull Station 54 Activity Room N/A N/A
Pull Station 55 Sierra Wing N/A N/A
Pull Station 56 Grand Hall N/A N/A
Pull Station 57 Side A Dining Room N/A N/A
Smoke Detector 58 Cottage Great Room N/A N/A
Smoke Detector 59 Cottage East Room N/A N/A
Smoke Detector 60 Cottage West Room N/A N/A
Smoke Detector 61 Cottage Middle Room N/A N/A
Pull Station 62 Cottage N/A N/A
CO Sensor 67 Cottage Hot Water Heater Room N/A N/A
Control Panel N/A Side A Electrical Room PASS FAIL