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Home My WebLink AboutFAI15-0062 030-462-009 CF FA 2023 0.3c, L�( Z maul y : • Chico 170 Erma Court Chico.CA 95928 (530)826-3013 C 10#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: Inspection/Test Completion Date/Time: 04/07/23 09:48:47 AM Supplemental Form(s)Attached: Yes (yes/no) 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: Other Voltage Specialists Address: Phone: (916)663-3582 Fax: Email: Account Number: 18-9513 Phone Line 1: N/A Phone Line 2: N/A Means of Transmission: Digital Entity to which alarms are restransmitted: Other Voltage Specialists Phone: Other 1-800-722-0364 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: 07:12:00 Building Management Contact: Yes Time: 07:00:00 Building Occupants Contact: Yes Time: 07:00:00 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/LEDsJLCDs PASS PASS N/A Fuses PASS NA Located on battery terminals Trouble Signals PASS PASS N/A Disconnect Switches PASS PASS Marked and Locked Ground-Fault Monitoring PASS NA N/A Supervision PASS PASS N/A Local.Annunciator NA NA N/A Remote Annunciators PASS PASS 3 on site, Reception Desk Activities Office Side B Kitchen Remote Power Panels PASS PASS Server Room PS is actual panel that is connected to side B's panel.It does not.Send signals to monitoring. 6.2 Secondary Power Description Visual Functional Comments Inspection Test Battery Condition PASS PASS I (2) 12v 12ah Load Voltage PASS PASS I N/A Discharge Test PASS PASS I N/A Charger Test PASS PASS N/A Remote Panel Batteries PASS PASS (2))2v 8ah install 6/7/22 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 I Comments Alarm Signal. Yes 07:15:(H.) I N/A Alarm Restoration Yes 11:48:00 I N/A Trouble Signal Yes 07:15:00 I N/A Trouble Restoration Yes 11:48:00 I N/A Supervisory Signal Yes 07:15:(10 N/A Supervisory Restoration Yes 11:48:00 N/A 6.7 Public Emergency Alarm Reporting System Description Results Time Comments Alarm Signal Alarm Restoration Trouble Signal Trouble Restoration Supervisory Signal Supervisory Restoration _ 7. NOTIFICATIONS THAT TESTING IS COMPLETE Monitoring Organization Contact: Yes Time: 12:01:00 Building Management Contact: Yes Time: 12:01:00 Building Occupants Contact: Yes Time: 12:01:00 Authority Authority Having Jurisdiction Contact: N/A Time: Other Contact: Time: 8. SYSTEM RESTORED TO NORMAL OPERATION Dale Time: 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: Organization: Foothill Fire Protection,Inc. Title: Inspector Phone: Qualifications(refer to 10.5.3): N/A 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 Fixed as of 5/30/23 12v Bin water flow bell did FACP Boiler Room not sound on alarm. Fixed as of 5/30/23 Horn strobe outside main FACP Boiler Room office sounded but did not flash. Fixed as of 5/30/23 Did not send signal to panel when tested Fixed as of 5/30/23 Device did not send signal to panel when tested. Fixed as of 5/30/23 Device did not send signal to panel when tested Fixed as of 5/30/23 Device did not send signal to ' panel when tested ,44 Fixed as of 5/30/23 Device did not send signal to panel when tested 10.1 Acceptance by Owner or Owner's Representative: All deficiencies have been fixed as of 5/30/23.System is a PASS. The undersigned accepted the test report for the system as specified herein: Signed: Printed Name: David Date: Organization: Rose Leaf Gardens Title: Phone: ,' • , / , " dA� "' sue;<c.� ,„,,,,<,,, :<...M.✓ ._� ,,.... na,,,�,<,..3 ,,,,, r..- ,..,..6:. �...,.�.a< �.o.,.F.,;- ,,.� .,.;,d � Chico 170 Errna 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 rest,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/Pest Start Date/Time: Inspection/Test Completion Date/Time: 04107/23 09:48:47 AM Supplemental Form(s)Attached: Yes (yes/no) 1.PROPERTY INFORMATION Name of Property: Roseleaf Oroville Address: 1900 20th St. Omville,CA 95965 2. INITIATING DEVICE RESULTS Device Type Address Location I Visual I Functional Pull Stations 1 Side B West Area I PASS I PASS Pull Stations 2 Side B Middle Area I PASS I PASS Pull Stations 3 Side B East Area PASS PASS Smoke Detector 10 Room 19 PASS PASS Smoke Detector 11 Side B Laundry Room PASS PASS Smoke Detector 12 Side B Medication Room PASS PASS Smoke Detector 13 Room 21 PASS PASS Smoke Detector 14 Room 23 PASS PASS Smoke Detector 15 Room 25 PASS PASS Smoke Detector 16 Room 27 PASS PASS Smoke Detector 17 Room 29 PASS PASS Smoke Detector 18 Room 31 PASS PASS Smoke Detector 19 Room 30 PASS PASS Smoke Detector 20 Room 28 PASS PASS Smoke Detector 21 Room 26 PASS PASS Smoke Detector 22 Room 24 PASS PASS Smoke Detector 23 Room 22 PASS PASS Smoke Detector 24 Room 20 PASS PASS Smoke Detector 25 Side B East Rear Hallway PASS PASS Smoke Detector 26 Side B East Hallway-Center PASS PASS Smoke Detector 27 Side B East Hallway-Front Area PASS PASS Smoke Detector 28 Side B West Rear Area PASS PASS Smoke Detector 29 Side B West Middle Area PASS PASS Smoke Detector 30 Side B Reception Area PASS PASS Smoke Detector 31 Side B West Front Area PASS PASS Smoke Detector 32 Side B Lounge West Area PASS PASS Smoke Detector 33 Side B Lounge East Area PASS PASS Smoke Detecor 34 Side B Break Room PASS PASS CO Sensor 35 Side B Hot Water Room PASS PASS CO Sensor 36 Pantry Closet PASS PASS CO Sensor 37 Kitchen PASS PASS Water Flow 1 Building Riser PASS PASS Smoke Detector 10 Side A Soda Shop PASS PASS _ Smoke Detector 11 Room 2 PASS PASS Heat Detector 12 Side A Nelson Storage Room PASS PASS Heat Detector 13 Side A Water Heater Closet PASS PASS Smoke Detector 14 Room 4 PASS PASS Smoke Detector 15 Nelson Wing Hallway PASS PASS Smoke Detector 16 Room 6 PASS PASS Smoke Detector 17 Room 1 PASS PASS Smoke Detector 18 Room 3 PASS PASS Smoke Detector 19 Room 5 PASS PASS Smoke Detector 20 Room 7A PASS PASS _ Smoke Detector 21 Room 7B PASS PASS _ Smoke Detector 22 Room 8B PASS PASS Smoke Detector 23 Room 8A PASS PASS Smoke Detector 24 Activity Room PASS PASS Smoke Detector 25 Activity Office PASS PASS Smoke Detector 26 Beauty Shop PASS PASS Smoke Detector 27 Room 9A PASS PASS Smoke Detector 28 Room 9B PASS PASS Smoke Detector 29 Room 10B PASS PASS Smoke Detector 30 Room 10A PASS PASS Smoke Detector 31 Sierra Hallway PASS PASS Smoke Detector 32 Room 12 PASS PASS Smoke Detector 33 Room 14 PASS PASS Smoke Detector 34 Room 16 PASS PASS Smoke Detector 35 Room 18 PASS PASS Smoke Detector 36 Grand Wing Hallway PASS PASS Smoke Detector 37 Room 11 PASS PASS Smoke Detector 38 Room 15 PASS PASS Smoke Detector 39 Room 17 PASS PASS Smoke Detector 40 Side A Janitorial Room PASS PASS Smoke Detector 41 Side A Dining Hallway PASS PASS Smoke Detector 42 Side A Dining Room PASS PASS Smoke Detector 43 Laundry/Riser Room PASS PASS Heat Detector 44 Kitchen PASS PASS Smoke Detector 45 Side A Living Room PASS PASS Smoke Detector 46 Side A Front Entry Hall PASS PASS Smoke Detector 47 Side A Conference Room PASS PASS Smoke Detector 48 Reception Area PASS PASS Smoke Detector 49 Side A Front Entry PASS PASS Smoke Detector 50 Side A Electrical Room PASS PASS Pull Station 51 Side A Front Entry Hallway PASS PASS Pull Station 52 Side A Soda Shop PASS PASS Pull Station 53 Nelson Wing PASS PASS Pull Station 54 Activity Room PASS PASS Pull Station 55 Sierra Wing PASS PASS Pull Station 56 Grand Hall PASS PASS Pull Station 57 Side A Dining Room PASS PASS Smoke Detector 58 Cottage Great Room PASS PASS Smoke Detector 59 Cottage East Room PASS PASS Smoke Detector 60 Cottage West Room PASS PASS Smoke Detector 61 Cottage Middle Room PASS PASS Pull Station 62 Cottage PASS PASS CO Sensor 67 Cottage Hot Water Heater Room PASS PASS S 3 - - 21 70