HomeMy WebLinkAboutFAI15-0067 Fire Annual Inspection Archiveire Prevention Bureau Butte County Fire Rescue White Copy - Business
76 Nelson Avenue California Department of Forestry Yellow Copy — Occupancy File
roville, CA 95965 and Fire Protection Pink Copy — Station File
elephone 530-538-7888 Facility Inspection Report Occ. Class.
ax 530-538-2105
Address: c • " cA Meoact; Business Name:
Ownerfflawger:Bus: ; Fax:
_�
Slstant Manager: Bus: Hm:
-t-1—fl—dine (honer Bus: Hm:
AN INPWRCTION OF VOITR FAC YLITV REVEALED THF, 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
IF
Knox Box keys
17.
Address posted and visible from road
9.
Fire Drill Witnessed Yes ❑ No ❑
18.
Other
DETAILED EXPLANATION AND CORRECTIONS: CORREUYED:
ate: r
Discussed ith-
Signed:
Cl_
- r
(print)�3Ao tk,,;✓
Inspecting Officer:
attalion 1 2 3 4 5' 6 7
Station: �"y FPB
,
FORR
PREVENTION SAVES LIVES, PROPERTY, AND BUSINESS. YOUR COOPERATION NyITH
ECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE:
'ire Prevention Bureau
76 Nelson Avenue
)roville, CA 95965
'elephone 530-538-7888
'ax 530-538-2105
Address: I I r -A,
anger: I0 e5
Manager:
Butte County Fire Rescue
California Department of Forestry
and Fire Protection
Facility Inspection Report
t
NUC Business Name:
a n Bus: .P - 1 Q
Bus:
Bus:
mm
F. M11
White Copy - Business
Yellow Copy — Occupancy File
Pink Copy - Station File
Occ. Class.
Gve�&
Fax:
AN TNCPF1'T1nN nF VnI1R FAC H.ITV RFVF.AI,FD 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
OF,TAILED EXPLANATION AND CORRECTIONS: COKKLUIVEIR
Date:
Discussed with:
Signed:, �+
(Print),
Ins ecting Officer:
Battalion 1 2 3 4 507
Station: G 3 FPB
V— c G;
FIRE PREVENTION SAVES LIVES, PROPERTY, AND BUSINESS. YOUR COOPERA110I yvri'll
CORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE:3 6
Ij
SF
Office of the State Fire Marshal -
Fire Safety Correction Notice
I I
CALIFORNIA STATE FIRE MARSHAL
File No: — — - —
_,
Name:
r l i
Address:
61� 40
The California Health and Safety Code and the State Fire Marshal's regulations require the following fire safety
deficiencies be corrected.
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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
- 7 .`
Fire Marshal at ( )
ISSUED BY (Pepuj�r State Fire Marshall 1 RECEIVED BY DATE
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EN -11 (Rev. 7/86) 89 88751/ DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field
-off
r
Cottage Guest Home
1059 Nevada Ave.
Oroville, CA 95965
533-1436
. .. - Ellen Anderson
Elaine Anderson
Owners
0
RAMP
1 Poo
r
'I
EXIT
,EXIT
J
J
a
Bedrooms
EXIT
PORCH Living Room
CD7ininRoom
Bathroom
Hallway
Closet
�� Exit
n I
y ( � pool Station
Family Room
EXIT
Kitchen
Ask,
BUTTE COUNTY FIRE DEPARTMENT/CDF FIRE
TITLE 19/24
FACILITY INSPECTION
INSPECTION NO. O 2 3
REINSPECT: � YES NO
Facility Occupancy
Address ! nJ/% _� I spector -�—.6c&J17
Phone — I U Station _5 6_3
Contact Station Phone Sid )S3� 711
Compliance: Yes =14t
ACC S --All inspections
Address correct/posted and visible from road (Butte Co. Code 32-9)
?Fire
Access to public street or 20 ft. wide lane (r19-3.05)
ates wide enough to admit fire apparatus (T19-3.16)
protection equipment visible/accessible (T19-3.14)
No = 0 Not applicable = N/A
PORTABLE FIRE EXTINGUISHERS --All Inspections
V Extinguishers have current annual service tag (r19-575.1A)
�K,'nguishers
ximum travel 75 ft. (T19-567)
ide clear access to fire extinguisher (T19-563.2)
mounted on wall/or in cabinet, visible and signed (r19-563.8)
EXITS --All Inspections
/Exits Exits not obstructed (r19-3.11)
Exit signs in place (CBC 1003.2.9.1)
Doors operate without key or special knowledge (CFC 1207.3)
Rooms with Occupant Load of 50 Persons or More
Exit illumination and signs in place (CBC 1003.2.8.2)
Maximum occupancy sign in place (r19-3.30)
Two exit doors/panic hardware swing in direction of travel (CFC 2501.8.2)
HOUSEKEEPING --All Inspections
�No waste or rubbish accumulation inside or outside T19-3.14)
_Reduce storage to at least Y" below ceiling/ sprinklers (T19-3.14)
Y Remove combus. storage from heater, mech., elect. room (r19 -3.19t)
O�FProvide approved metal container for oily rag storage (T-19-3.190)
4Flammable liquids stored properly (r-19-3.15)
ELECTRICAL --All inspections
✓ Extension cords do not replace permanent wiring (CEC-400-8(1))
✓ Extension cords do not pass through doors/walls (CEC-400-8 (2,3))
�3o inch clearance around all electrical panels (CEC-110-16A)
r� All panels and breakers are marked (CEC-110-17 C)
Repair holes in fire -resistive construction CEC (300-21,22)
✓ Multi -plug power strips have circuit breaker (CEC 400-13)
FIRE PROTECTION EQUIPMENT -- All Inspections
Hood system serviced/tagged every 6 mo. by cert. tech. (r19-904)
Clean filters, hood, and duct area over cooking appliances (CFC 1006.2.8)
_Maintain extinguishing systems (r19-3.24)
Provide spare sprinkler heads (6 min.) and/or sprinkler wrench (r19-904.5)
_y,Replace damaged, corroded, or painted sprinkler heads (T19-904.5)
_Identify sprinkler valves and secure in open position (T19-904.5)
✓ Replace missing caps on fire department connection (r19-904.3)
✓ Provide 5 -yr. certification test for sprinkler/standpipe (T19-904)
MECHANICAL EQUIPMENT --All Inspections
Vents and chimneys --No obvious hazards (CMC -Ch. 8)
SMOKE DETECTORS -- Day Care Sr. Res., Hospitals, Apts.
? Properly installed and tested (T19-749,754)
SCHOOLS, JAILS AND HOSPITALS
Decorations and curtains fire retardant (T19-3.08)
LPG tanks fenced with locked gates (r19-3.22)
FIRE DRILLS -- School and Day Care (Title 19-3.13)
All systems operable/hooked to office
Held monthly (elementary schools)
Held semi-annually (high schools)
Evacuation plans posted in all rooms
Emergency procedures posted in office
Teachers take roll books
Corrections and Comments E/(f-1 ( �D�, -5--2--00
The above deficiencies must be corrected within 31b days. Inspection Date: _6__-2_-00
AP #
BUTTE COUNTY FIRE DEPARTMENT/CDF FIRE
TITLE 19/24
FACILITY INSPECTION
INSPECTION NO. ij1 j 2 3
REINSPECT: '-vv] YES E] NO
Facility T�/ t_�S i`,Occupancy _ • rl
Address /O IC( nspector•�'c4.15,)S .�4, A:, �
Phone Station 6-3
Contact Station Phone3u S`3 ill/
Compliance: Yes =-If
ACCESS --All inspections
v Address correct/posted and visible from road (Butte Co. Code 32-9)
Access to public street or 20 ft. wide lane (r19-3.05)
Gates wide enough to admit fire apparatus (T19-3.16)
Fire protection equipment visible/accessible (r19-3.14)
PORTABLE FIRE EXTINGUISHERS --All Inspections
No = 0 Not applicable = N/A
Extinguishers have current annual service tag (r19 -575.1A)
Maximum travel 75 ft. (r19-567)
Provide clear access to fire extinguisher (r19-563.2)
Extinguishers mounted on wall/or in cabinet, visible and signed (r19-563.8)
EXITS --All Inspections
4. Exits not obstructed (r19-3.11)
:; Exit signs in place (CBC 1003.2.9.1)
Doors operate without key or special knowledge (CFC 1207.3)
Rooms with Occupant Load of 50 Persons or More
_Exit illumination and signs in place (CBC 1003.2.8.2)
Maximum occupancy sign in place (r19-3.30)
;ate
Two exit doors/panic hardware swing in direction of travel (CFC 2501.8.2)
HOUSEKEEPING — All Inspections
No waste or rubbish accumulation inside or outside T19-3.14)
Reduce storage to at least ' " " below ceiling/ sprinklers (r19-3.14)
Remove combus. storage from heater, mech., elect. room (r19 -3.19f)
,s Provide approved metal container for oily rag storage (-19-3.19c)
a
ELECTRICAL --All inspections
Extension cords do not replace permanent wiring (CEC-400-8(1))
y ° Extension cords do not pass through doors/walls (CEC-400-8 (2,3))
30 inch clearance around all electrical panels (CEC-110-16A)
All panels and breakers are marked (CEC-110-17 C)
Repair holes in fire -resistive construction CEC (300-21,22)
Multi -plug power strips have circuit breaker (CEC 400-13)
FIRE PROTECTION EQUIPMENT --All Inspections
Hood system serviced/tagged every 6 mo. by cert. tech. (r19-904)
Clean filters, hood, and duct area over cooking appliances (CFC 1006.2.8)
Maintain extinguishing systems (r19-3.24)
Provide spare sprinkler heads (6 min.) and/or sprinkler wrench (T19-904.5)
Replace damaged, corroded, or painted sprinkler heads (r19-904.5)
Identify sprinkler valves and secure in open position (T19-904.5)
Replace missing caps on fire department connection (r19-904.3)
Provide 5 -yr. certification test for sprinkler/standpipe (T19-904)
MECHANICAL EQUIPMENT -- All Inspections
,Vents and chimneys -- No obvious hazards (CMC -Ch. 8)
SMOKE DETECTORS -- Day Care Sr. Res., Hospitals, Apts.
Properly installed and tested (T19-749,754)
SCHOOLS, JAILS AND HOSPITALS
Decorations and curtains fire retardant (T19-3.08)
LPG tanks fenced with locked gates (r19-3.22)
FIRE DRILLS -- School and Day Care (Title 19-3.13)
�1 Flammable liquids stored properly (r-19-3.15) All systems operable/hooked to office
Held monthly (elementary schools)
Held semi-annually (high schools)
Evacuation plans posted in all rooms
Emergency procedures posted in office
Teachers take roll books
Corrections and Comments "4 — E if/— i ( "D �. 2- — 610
The above deficiencies must be corrected within days. Inspection Date: _,5-- 2--o ()
Owner/Manager AP #,
As -
Cottage Guest Home
1059 Nevada Ave.
Oroville, CA 95965
533-1436
Ellen Anderson
Elaine Anderson
Owners
RAMP EXIT
EXIT
EXI (`
t-�3
J
J
Q
I
EXIT
EXIT
EXIT
PORCH
�00ms
Li��in� Ruom
Dinins Room
Bathroom
Hallway
�lo:et
Pool station
Family Room
I�it�lli'[l
Office of the State Fire Marshal
Fire Safety Correction Notice
File No:
— — — — — — —
Name:
Address:
%r14}r) t t E �/�- . �S7- I C—
SF
I I
CALIFORNIA STATE FIRE MARSHAL
F2. I
The California Health and Safety Code and the State Fire Marshal's regulations require the following fire safety
deficiencies be corrected.
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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 Marshal) RECEIVED BY DATE
EN -11 (Rev. 7/86) 89 88751 tl DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field
i ��
D
BUTTE COUNTY FIRE DEPA�T�i[EN1 T/ ,DF FIRE
TITLE 19/24
FACILITY INSPECTION
INSPECTION NO. 2 3
R I�iSPE T: �� `S SIO
Facility 7~7 LI Occupancy . 1
•� �/%� I �' nsDec`n.
Addt .,ss 1 r -
Phone -- J s2��PAY_6_3
Contact Station Phonef'45-3e) )-
Compliance: Yes =,4f
ACC S -- All inspections
7 Address correct/posted and visible from road (Bate co. Code 32-9)
Access to public street or 20 ft. wide lane (719-3.05)
•1ates wide enough to admit fire apparatus (r19-3.16)
F7
ire protection equipment visible/accessible (T19-3.14)
PORTABLE FIRE EXTINGUISHERS -- All Inspections
. }
Extinguisners have current annus! service tag (T119 -575.1A)
., f/Maximum travel 75 ft. (r19 -60-T
No = 0 Not applicable = N/A
`/ ,Provide clear access to fire extinguisher (r19-563.2)
Extinguishers mounted on wail/or in cabinet, visible and signed (r19-563.8)
EXITS -- All Inspections
/Exits not obstructed (T1s -3.11)
Exit signs in place (CBC 1003.2.9.1)
Doors operate without key or special knowledge (CFC 1207.3)
Rooms with Occupant Load of 50 Persons or More
, A Exit illumination and signs in place (CBC 1003.2.8.2)
Maximum occupancy sign in place (T1 9-3.30)
Two exit doors/panic hardware swing in direction of travel (CFC 2501 8.2)
HOUSEKEEPING -- All Inspections
No waste or rubbish accumulation inside or outside T19-3.14)
_Reduce storage to at least 9"" below ceiling/ sprinklers (T19-3.14)
Remove combus. storage from heater, mech., elect. room (T19 -3.19f)
V;!� Provide approved metal container for oily rag storage (T -19-3.19c)
i
ELECTRICAL --All inspections
Extension cords do not replace permanent wiring (CEC-400-8(1))
Extension corns do not pass through doors/walls (CEC-400-8 (2,3))
�_30 inch clearance around all electrical panels (CEC-1 10-1 6A)
Q All panels and breakers are marked (CEC-110-17 C)
filih Repair holes in fire -resistive construction CLEC (300-21,22)
it Multi -plug power strips have circuit breaker (CEC 400-13)
FIRE PROTECTION EQUIPMENT -- All Inspections
x
,Hood system serviced/tagged ever/ 6 mo. by cert. tech. (T15-904)
Clean filters, hood, and duct area over cooking appliances (CFC 1006.2.8)
lMaintain extinguishing systems (T19-3.24)
Provide spare sprinkler heads (6 min.) and/or sprinkler wrench (719-904.5)
Replace damaged, corroded, or painted sprinkler heads (T19-904.5)
_Identify sprinkler valves and secure in open position (r19-904.5)
✓ Replace missing caps on fire department connection (T19-904.3)
Provide 5 -yr. certification test for sprinkler/standpipe (T19-904)
MECHANICAL EQUIPMENT --All Inspections
t,
Vents and chimneys -- No obvious hazards (CMC -Ch. a)
SMOKE DETECTORS -- Day Care Sr. Res., Hospitals, Apts.
Properly installed and tested (719-7 49 754)
SCHOOLS, ,SAILS AND HOSPITALS
Decorations and curtains fire retardant (T19-3 08)
LPG tanks fenced with locked gates 719-3.22)
FIRE DRILLS -- School and Day Care (Title 19-3.13)
Flammable liquids stored properly (T-19-3.15) All systems operable/hooked to office
Held monthly (elementary schools)
Held semi-annually (high schools)
Evacuation plans posted in all rooms
Emergency procedures posted in office
Teachers take roil books
Z 0
Corrections and Comments
The above deficiencies must be corrected within .5� days. Inspection Date
Office of the State Fire Marshal
Fire Safety Correction Notice
File No: OD -
Name: _
Address:
SF
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I 1
CALIFORNIA STATE FIRE MARSHAL
The California Health and Safety Code and the State Fire Marshal's regulations require the following fire safety
deficiencies be corrected.
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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 (Depup Sate Fire Marshal) RECEIVED BY DATE
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Fire Safety Correction Notice
CALIFORNIA STATE FIRE MARSHAL
File No:
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Name: 0 1-kvwl�—
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Address: 0IVE,= VAb-4 A- u C. ?41u
California Health and
deficiencies be corrected.
Safety Code and the State Fire Marshal's regulations require the following fire safety
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The above deficiencies are to be corrected within — days. When ALL deficiencies have been corrected, sign
and return the certification on t , he opposite , side of this form. If you have any questions, contact the Office of the State
Fire Marshal at,(50)
ISSUED BY RECEIVED BY DATE
EN -11 (Rev. 7/86) 89 88751 DISTRIBUTION- GREEN—Facility WHITP—Raninn I r)\Al—f;.W
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Office of the State Fire Marshal
Fire Safety Correction Notice
File No: 00- f"11 -
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Name: 1....0(5�- (S7 �5(jc ss l4wc-
Address:
10-5q 1 /r, L/,fVb,4 ,`� �� C=A/u/
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SF
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CALIFORNIA STATE FIRE MARSHAL
The California Health and
deficiencies be corrected.
Safety Code and the State Fire Marshal's regulations requirethe following fire safety
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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
gym-
Fire Marshal at ( }
ISSUED BY (Deputy State Fire Marshall RECEIVED BY DATE
EN -11 (Rev. 7/86) 89 88751 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field
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File No: D- — —`- —f
Name:
Address
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Office of the State Fire Marshal
Fire Safety Correction Notice
SF
W�
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CALIFORNIA STATE FIRE MARSHAL
The California Health and Safety Code and the State Fire Marshal's regulations require the following fire safety
deficiencies be corrected.
Tp B10-914+—:Z04
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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 DATE
4. h?
EN -11 (Rev_ 7/86) 89 88751 DISTRIBUTION: GREEN—Facility WHITE—Reeion YFI I nW—Field
STATE F CALIFORNIA`
FIR SAFETY INSPECTION REQ:
See instructions on reverse.
STD. 85 (REV. 10.94)
AGENC CONTACTS NAME _0__",4 M TJJ Tif T T Y (1 A R T C 'P111 -T SO 1 TELEPHONE NUMBER REQUEST DATE PROGRAM
D-,13 E
EVA}L�U T/OgR'S.6,
.1 NAME REQUESJTI`NG A'jGENCY. FACILITY NUMBER REQUElfST CODE
2 ` 3 - -
3
CODES
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I.ORIGINAL ' A. FIRE CLEARANCE
2. RENEWAL B. LIFE SAFETY
3. CAPACITY CHANGE
4. OWNERSHIP CHANGE
5. ADDRESS CHANGE
6. NAME=CHANGE
7. OTHER
AMBULATORY
NONAMBULATORY
BEDRIDDEN
TOTAL CAPACITY
CAP CITY
PREVIOUS CAPACITY
CAPACITY
PREVIOUS CAPACITY
CAPACITY
PREVIOUS CAPACITY
I
B. CONSTRUCTION
13
D. SPRINKLERS
1
TELEPHONE NUMBER
FACT ITY NA(�ME
• OCCUPANCY CLASS
LICENSE CATEGORY'
ClIr N ;G1 F. r -l -'s S i - 4 !say
�- �
E. HOUSEKEEPING
HAZARD
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STR ET ADDRESS (Actual Location)
NUMBER OF BUILDINGS
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INSIDE R'S RE (Type or Pri ed
CI - - - - -
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RESTRAINT
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CONTACT PERSON'S NAME
,� ,,�F,.� "� 1' I�/
HOURS ..
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SP CIAL CONDITIONS
OfTAING-Ei TLI-0 A -IL -1-2 A VAL'!, - J A. -1.
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CLEARANCE IDE AL CODE
CODES
1. FIRE CLEARANCE GRANTED
TT
FIRE
UTHORITY . g L I A 34 S R �� 3 T: � "T E .,
AME AND 0 H T 0 3 (; A 9 5 926
FIRE CLEARANCE DENIED
ADDRESS
A. EXITS
I
B. CONSTRUCTION
C.-_ FIRE ALARM - -
D. SPRINKLERS
It ISPECTOR'S NAME (Typed or Printed)
TELEPHONE NUMBER
CFIRS NUMBER
• OCCUPANCY CLASS
��
94,5"
�- �
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HAZARD
F. SPECIAL
G. OTHER
ISP CTf DA
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STATI OF CALIFORNIA...
-
.-BEDRIDDEN
FIE
SAFETY INSPECTION REG.. --QST
PREVIOUS CAPACITY
-
PREVIOUS CAPACITY
-
See instructions on reverse.
ST-150D
REV. I -sa
~s 1. I IRE CLEARANCE GRANTED
JUTHORITY 4 %SIL IAMSB G LANE9, ST A
AGEIS CY CONTACTS NAME
TELEPHONE NUMBER
REQUEST DATE
PROGRAM
DS/COMMUNITY
CARE LICENSING
895--5033
04/22/99
J
EVA
ATOR'S NAME
REQUESTING AGENCY FACILITY NUMBER
REQUEST CODE
040t,07/GURRIERE
041304641
7A
C. FIRE ALARM
RESTRAINT
OROVILLEQ CA 95965
CODES
1. ORIGINAL A. FIRE CLEARANCE
FA ILITY CONTACT PERSON'S NAME =
LI
ENSING
ELOISE ANDERSON N 533-1436
2. RENEWAL B. LIFE SAFETY
24
GENCY
�` �
N
ME AND
E. HOUSEKEEPING
F. SPECIAL HAZARD
3. CAPACITY CHANGE
A
DRESS
4. OWNERSHIP CHANGE
5. ADDRESS CHANGE
L
6. NAME CHANGE
*PLEASE
ADVISE OF APPROPRIATE ROOMS Fc ORONMIBULA' ORY ®
. OTHER
AMBULATORY
NONAMBULATORY.
.-BEDRIDDEN
TOTAL CAPACITY
CA ACITY ;
PREVIOUS CAPACITY
CAPACITY :
PREVIOUS CAPACITY
CAPACITY
PREVIOUS CAPACITY
�- f r l
f
~s 1. I IRE CLEARANCE GRANTED
JUTHORITY 4 %SIL IAMSB G LANE9, ST A
44
2. FIRE CLEARANCE DENIED
AME AND CHIC - 95926-0 .: _ .
FACILITY NAME
LICENSE CATEGORY
COTTAGE GUEST HOME
J
7 4 0 / RC E
STF EET ADDRESS (Actual Location)
I
NUMBER OF BUILDINGS
1059 NEVADA AVE,
1
CITr
C. FIRE ALARM
RESTRAINT
OROVILLEQ CA 95965
NO
FA ILITY CONTACT PERSON'S NAME =
TELEPHONE NUMBER
HOURS
ELOISE ANDERSON N 533-1436
24
SP CIAL CONDITIONS
PLAIN DENIAL OR LIST SPECIAL CONDITIONS
001p4tr
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CLEARANCE /DENIAL CODE
F.z
CODES
FIRE STATE EIRE h��:SHALE
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JUTHORITY 4 %SIL IAMSB G LANE9, ST A
_ � �,. ;.,
2. FIRE CLEARANCE DENIED
AME AND CHIC - 95926-0 .: _ .
DDRESS -
J
A. EXITS
I
B. CONSTRUCTION
r
C. FIRE ALARM
D. SPRINKLERS
IN PECTOR'S NAME (Typed or Printed)
TELEPHONE NUMBER
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OCCUPANCY CLASS
...�
ef ?
�` �
f
E. HOUSEKEEPING
F. SPECIAL HAZARD
IN P CTION)DATE
INSPECTOR'S SIGN. ATURE (Typed or Pri ed)
G. OTHER
PLAIN DENIAL OR LIST SPECIAL CONDITIONS
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ia-
ma
ACCULARM SECURITY SYSTEMS
ALARM ACTIVITY REPORT FROM 04/10/97 TO 04/1$/97
> COTTAGE GUEST HOME; <CALL LOCATION FIRST!!!>
HU 04/10 9:44AM TEST ONLY: DAILY FIRE SYSTEM TEST
9:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
RI 04/11 9:44AM TEST ONLY: DAILY FIRE SYSTEM TEST
9:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
AT 04/12 9:44AM TEST ONLY: DAILY FIRE SYSTEM TEST
9:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
UN 04/13 9:44AM TEST ONLY: DAILY FIRE SYSTEM TEST
9:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
ON 04/14 9:44AM TEST ONLY: DAILY FIRE SYSTEM TEST
9:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
UE 04/15 9:44AM TEST ONLY: DAILY FIRE SYSTEM TEST
9:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
ED 04/16 9:44AM TEST ONLY: DAILY FIRE SYSTEM TEST
9:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
11:09AM FIRE: MANUAL PULL STATIONS
OPERATOR'S NOTES
CANCEL MR. ANDERSON HAVING FIRE DRILL.
11:14AM RESTORAL: ZONE 1 RESTORED,
11:14AM FIRE: MANUAL PULL STATIONS
OPERATOR'S NOTES
CANCEL MR. ANDERSON HAVING A FIRE DRILL
11:14AM RESTORAL: ZONE 1 RESTORED.
11:14AM FIRE: MANUAL PULL STATIONS
11:15AM RESTORAL: ZONE 1 RESTORED.
11:24AM FIRE: MANUAL PULL STATIONS
OPERATOR'S NOTES
CANCEL MR. ANDERSON IS HAVING A FIRE DRILL.
12:02PM RESTORAL: ZONE 1 RESTORED.
'HU 04/17 9:44AM TEST ONLY; DAILY FIRE SYSTEM TEST
9:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
7:33PM FIRE: MANUAL PULL STATIONS
OPERATOR'S NOTES
CANCEL PER GWEN, SHE IS TESTING SYSTEM.
7:41PM RESTORAL: ZONE 1 RESTORED.
CSID: 1063
99
99
99
99
99
99
99
99
99
99
99
99
99
99
11
E1
11
E1
11
E1
11
E1
99
99
11
E1
PAGE 1 PRINTED 8:29AM 04/18/97
ka
50
ACCULARM SECURITY SYSTEMS
Alarm Activity Report from 02/21/97 to 04/10/97
> COTTAGE GUEST HOME; <CALL LOCATION FIRST!!!>
CSID: 1063
RI 02/21 8:45AM
TEST ONLY: DAILY FIRE SYSTEM TEST
99
8:46AM
TEST ONLY: DAILY FIRE SYSTEM TEST
99
9:14AM
FIRE: MANUAL PULL STATIONS
11
Operator's Notes
DAN IS THERE WHILE THEY ARE TESTING THE SYSTEM.
9:14AM
RESTORAL: ZONE 1 RESTORED.
E1
9:14AM
FIRE: MANUAL PULL STATIONS
11
9:15AM
RESTORAL: ZONE 1 RESTORED.
E1
9:15AM
FIRE: MANUAL PULL STATIONS
11
9:15AM
RESTORAL; ZONE 1 RESTORED.
E1
9:15AM
FIRE: MANUAL PULL STATIONS
11
9:15AM
RESTORAL: ZONE 1 RESTORED.
E1
9:15AM
FIRE: MANUAL PULL STATIONS
11
9:15AM
RESTORAL, ZONE 1 RESTORED.
E1
9:15AM
FIRE: MANUAL PULL STATIONS
11
9:16AM
RESTORAL: ZONE 1 RESTORED.
E1
9:16AM
FIRE: MANUAL PULL STATIONS
11
9:18AM
RESTORAL: ZONE 1 RESTORED.
E1
9:18AM
FIRE: MANUAL PULL STATIONS
11
9:18AM
RESTORAL: ZONE 1 RESTORED.
E1
9:20AM
FIRE: MANUAL PULL STATIONS
11
9:20AM
RESTORAL: ZONE 1 RESTORED.
E1
9:21AM
FIRE: MANUAL PULL STATIONS
11
9:22AM
RESTORAL: ZONE 1 RESTORED.
E1
9:42AM
FIRE: SMOKE SENSORS IN MAIN HOUSE
12
9:45AM
RESTORAL: MAIN HOUSE SMOKE SENSORS
RESET
EF
9:45AM
FIRE: SMOKE SENSORS IN MAIN HOUSE
12
9:48AM
RESTORAL: MAIN HOUSE SMOKE SENSORS
RESET
EF
9:48AM
FIRE: SMOKE SENSORS IN MAIN HOUSE
12
9:49AM
RESTORAL: MAIN HOUSE SMOKE SENSORS
RESET
EF
9:49AM
FIRE: SMOKE SENSORS IN MAIN HOUSE
12
9:49AM
RESTORAL: MAIN HOUSE SMOKE SENSORS
RESET
EF
9:49AM
FIRE: SMOKE SENSORS IN MAIN HOUSE
12
9:49AM
RESTORAL: MAIN HOUSE SMOKE SENSORS
RESET
EF
9:49AM
FIRE. SMOKE SENSORS IN MAIN HOUSE
12
9:51AM
ZONE BYPASSED: ZONE 2 BYPASSED
F2
9:51AM
RESTORAL: MAIN HOUSE SMOKE SENSORS
RESET
EF
9:51AM
RESTORAL; ZONE 2 RESTORED.
E2
9:52AM
FIRE: SMOKE SENSORS IN MAIN HOUSE
12
9:52AM
RESTORAL: MAIN HOUSE SMOKE SENSORS
RESET
EF
9:52AM
FIRE: SMOKE SENSORS IN MAIN HOUSE
12
9:52AM
RESTORAL: MAIN HOUSE SMOKE SENSORS
RESET
EF
9:53AM
FIRE: SMOKE SENSORS IN MAIN HOUSE
12
9:53AM
RESTORAL: MAIN HOUSE SMOKE SENSORS
RESET
EF
9:53AM
FIRE: SMOKE SENSORS IN MAIN HOUSE
12
9:54AM
RESTORAL: MAIN HOUSE SMOKE SENSORS
RESET
EF
9:54AM
FIRE: SMOKE SENSORS IN MAIN HOUSE
12
9:57AM
ZONE BYPASSED: ZONE 2 BYPASSED
F2
9:57AM
RESTORAL: MAIN HOUSE SMOKE SENSORS
RESET
EF
9:58AM
RESTORAL: ZONE 2 RESTORED.
E2
9:59AM
FIRE: SMOKE SENSORS IN MAIN HOUSE
12
Page 1 Printed 11:58AM 04/10/97
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ENO
ACCULARM SECURITY SYSTEMS
Alarm Activity Report from 02/21/97 to 04/10/97
E3
13
E3
99
99
99
99
99
99
99
99
99
Page 2 Printed 11:58AM 04/10/97
10:OOAM
RESTORAL: MAIN HOUSE SMOKE SENSORS RESET
10:OOAM
FIRE: SMOKE SENSORS IN MAIN HOUSE
10:01AM
RESTORAL: MAIN HOUSE SMOKE SENSORS RESET
10:01AM
ZONE BYPASSED: ZONE 2 BYPASSED
10i01AM
RESTORAL: ZONE 2 RESTORED.
10:02AM
FIRE: SMOKE SENSORS IN MAIN HOUSE
10:02AM
RESTORAL: MAIN HOUSE SMOKE SENSORS RESET
10:03AM
FIRE: SMOKE SENSORS IN MAIN HOUSE
10:03AM
RESTORAL: MAIN HOUSE SMOKE SENSORS RESET
10:04AM
FIRE: SMOKE SENSORS IN MAIN HOUSE
10:04AM
RESTORAL: MAIN HOUSE SMOKE SENSORS RESET
10:04AM
FIRE: SMOKE SENSORS IN MAIN HOUSE
10:04AM
RESTORAL: MAIN HOUSE SMOKE SENSORS RESET
10:04AM
FIRE: SMOKE SENSORS IN MAIN HOUSE
10:04AM
RESTORAL: MAIN HOUSE SMOKE SENSORS RESET
10:12AM
FIRE: WATER FLOWING TO MAIN SPRINKLERS
10:12AM
RESTORAL: ZONE 3 RESTORED.
10:17AM
FIRE: WATER FLOWING TO MAIN SPRINKLERS
10:17AM
RESTORAL: ZONE 3 RESTORED.
10:19AM
FIRE: WATER FLOWING TO MAIN SPRINKLERS
10:20AM
RESTORAL: ZONE 3 RESTORED,
.AT 02/22
8:45AM.TEST
ONLY; DAILY FIRE SYSTEM TEST
8:46AM
TEST ONLY: DAILY FIRE SYSTEM TEST
.UN 02/23
8:45AM
TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM
TEST ONLY: DAILY FIRE SYSTEM TEST
ION 02/24
8:45AM
TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM
TEST ONLY: DAILY FIRE SYSTEM TEST
'UE 02/25
8:45AM
TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM
TEST ONLY: DAILY FIRE SYSTEM TEST
IED 02/26
8:45AM
TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM
TEST ONLY: DAILY FIRE SYSTEM TEST
'HU 02/27
8:45AM
TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM
TEST ONLY: DAILY FIRE SYSTEM TEST
RI 02/28
8:45AM
TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM
TEST ONLY: DAILY FIRE SYSTEM TEST
2:40PM
FIRE: WATER FLOWING TO MAIN SPRINKLERS
Operator's Notes
DAN THERE TESTING W/ HUGHES FIRE EXTINGUISHER
2:40PM
RESTORAL: ZONE 3 RESTORED.
2:47PM
FIRE: WATER FLOWING TO MAIN SPRINKLERS
Operator's Notes
DAN THERE TESTING
2:47PM
RESTORAL; ZONE 3 RESTORED.
.AT 03/01
8:46AM
TEST ONLY: DAILY FIRE SYSTEM TEST
8:47AM
TEST ONLY: DAILY FIRE SYSTEM TEST
.UN 03/02
8:45AM
TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM
TEST ONLY: DAILY FIRE SYSTEM TEST
ION 03/03
8:45AM
TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM
TEST ONLY: DAILY FIRE SYSTEM TEST
UE 03/04
8:45AM
TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM
TEST ONLY: DAILY FIRE SYSTEM TEST
QED 03/05
8:45AM
TEST ONLY: DAILY FIRE SYSTEM TEST
E3
13
E3
99
99
99
99
99
99
99
99
99
Page 2 Printed 11:58AM 04/10/97
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ENO
ACCULARM SECURITY SYSTEMS
Alarm Activity Report from 02/21/97 to 04/10/97
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
HU 03/06 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
RI 03/07 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
AT 03/08 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
UN 03/09 8:45AM TEST ONLY; DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
ON 03/10 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
UE 03/11 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
ED 03/12 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
HU 03/13 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY; DAILY FIRE SYSTEM TEST
RI 03/14 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
AT 03/15 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY; DAILY FIRE SYSTEM TEST
UN 03/16 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
ON 03/17 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
UE 03/18 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
ED 03/19 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
HU 03/20 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
RI 03/21 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
AT 03/22 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
UN 03/23 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
ON 03/24 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
UE 03/25 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
ED 03/26 8:45AM TEST ONLY: DAILY fIRE SYSTEM TEST
8:46AM TEST ONLY; DAILY FIRE SYSTEM TEST
HU 03/27 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
RI 03/28 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
AT 03/29 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
UN 03/30 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
8:46AM TEST ONLY: DAILY FIRE SYSTEM TEST
ON 03/31 8:45AM TEST ONLY: DAILY FIRE SYSTEM TEST
Page 3 Printed 11:59AM 04/10/97
7A
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Alarm Activity Report from 02/21/97 to 04/1.0/97
Page 4 Printed 12:OOPM 04/10/97
8:46AM
TEST
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99
UE
04/01
8:45AM
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99
8:46AM
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99
ED
04/02
8:45AM
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DAILY
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99
8:46AM
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DAILY
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99
HU
04/03
8:45AM
TEST
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DAILY
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99
8:46AM
TEST
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DAILY
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99
RI
04/04
8:45AM
TEST
ONLY:
DAILY
FIRE
SYSTEM
TEST
99
8:46AM
TEST
ONLY:
DAILY
FIRE
SYSTEM
TEST
99
AT
04/05
8:45AM
TEST
ONLY:
DAILY
FIRE
SYSTEM
TEST
99
8:46AM
TEST
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DAILY
FIRE
SYSTEM
TEST
99
UN
04/06
9:44AM
TEST
ONLY:
DAILY
FIRE
SYSTEM
TEST
99
9:45AM
TEST
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DAILY
FIRE
SYSTEM
TEST
99
10N
04/07
9:44AM
TEST
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DAILY
FIRE
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TEST
99
9:45AM
TEST
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DAILY
FIRE
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TEST
99
"UE
04/08
9:44AM
TEST
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DAILY
FIRE
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TEST
99
9:45AM
TEST
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DAILY
FIRE
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TEST
99
IED
04/09
9:44AM
TEST
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DAILY
FIRE
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TEST
99
9:45AM
TEST
ONLY:
DAILY
FIRE
SYSTEM
TEST
99
'NU
04/10
9:44AM
TEST
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DAILY
FIRE
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TEST
99
9:45AM
TEST
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DAILY
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99
Page 4 Printed 12:OOPM 04/10/97
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°'4"9ffice of the State Fire Marshar°
REINSPECTION REPORT
.�
0_a�o_-s-s9'
ame of Facility:
me of Building:
dress:� � �' � 1 Y � �%� l� F� � U GT .
Discussed with-
accompanied by. a ..... . , .Q
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STATE FIRE MA SHAL
Fire Safety Deficiencies Numbered � � 3 0,4A� -5 �0.� noted on the Letter El
Fire*Safety Correction Notice (EN -11) dated � a �� have been corrected.
Uncorrected Deficiencies Numbered 9' (2 � 7�- were re -issued as shown
on the Fire Safety Correction. Notice datedItolq7,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: AS ST&M:b oAt C—Al-11 i7 -Em --,z L- i s. 1r ---lb o�tT/-11-5
_._
R-C-P012;C- MUsT Se I �J WIMP.Li- CE eryruw-s/wtJ is 6t
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M CI. ARANCE C R P,= ,' TRATE '� = �
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00%M ss ATF FRE ..
DATE Of
1
GO - 5 (Rev 7 /e6)
SF
Office of the State Fire Marshal -
Fire Safety Correction Notice
I I
CALIFORNIA STATE FIRE MARSHAL
File No: I!Z)- 04 =f -
Name: 1 7TTA 6-5 C- : U t7 L 1 4)w
1o r'(t
Address: tCyr� 6P, AyE�
The California Health and Safety Code and the State Fire Marshal's regulations require the following fire safety
deficiencies be corrected.
lel �—�7 �t) 1U CU G� L'��� 30 l J t-� `7` J� i�l✓�? f i�
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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 DATE
FN -11 IR— 7/A61 89 88751' DNTRIRIITION- GRFFN—Facility WHITE—Reeion YELLOW—Field
SF
Office of the State Fire Marshal -
Fire Safety Correction Notice �° »
I I
CALIFORNIA STATE FIRE MARSHAL
File No:�'�—�-
Name: r-� CT7Jt t' W
Address:
The California Health and Safety Code and the .State Fire Marshal's regulations require the following fire safety
deficiencies be corrected.
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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 Marshal) RECEIVi D 8Y 1)ATF
EN -I1 (Rev. 7/86) 89 88751 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field
Office of the State Fire Marshal
Fire Safety Correction Notice
File No: — - — - ---<
%t�,�—
�4 OVA
Name:
Address: iJ
LT-
SF
1
CALIFORNIA STATE FIRE MARSHAL
The California Health and Safety Code and the State- Fire Marshal's regulations require
deficiencies be corrected.
the following fire safety
L 6?1- (,I)ITP DUG-
i -A -TY' Or
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A
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Jj i _j �_ — t i..✓�1 �: Y�( i � R ' a P. ti.l I
r 0 Tr+
11 IJ
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 Marshal) RECEIVED BY DATE �t
EN -11 (Rev. 7/86) 89 88751 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field
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Office of the State Fire Marshal
Fire Safety Correction Notice
File No:
00 —
t ! t`_� �- �7_��
Name:�x
Address: f{ �'- j /�I�UI Erg- A V C
OVI L LL , AL1 F,
SF
I �
CALIFORNIA STATE FIRE MARSHAL
The California. Health and Safety Code and the State Fire Marshal's regulations require the following fire safety
deficiencies be corrected.
L C-R_ =/.S- 0;'1Vi ,F -EQ � 1 if :a A 1 V t `}'fir ; Jt Cl< Vi L. u. .
L- T- I Sec Tt btJ 1-7v.1 J)
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AtUb %i(T G/ ,/I?LG 3MZi4-6-F - _SDCJC-�Cl7-Arli; PZ041 PC-1?A't�_,�
KI 7 C 14C _j 1A) EK IF /4( Al Pa c -S0 -"-X -
rbe-. CCS. T-11? c C T r �,u 90-f � q
- FIZE-kA 0-11'r i�6
The above deficiencies are to be corrected within days. When ALL deficiencies havebeencorrected, 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 ( IX)
ISSUED BY (Deputy State Fire Marshall RECEIVED BY DATE
EN -I I (Rev. 7/86) 89 88751 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field
Office of the State Fire Marshal
Fire Safety Correction Notice
�- t - L�.
File No: — _ _
Name: CV-1TAI 6-E U S>T WE
i
Address: �f IL Ul1i�� tJ� .
SF
I I
CALIFORNIA STATE FIRE MARSHAL
The California Health and Safety Code and the State Fire Marshal's regulations require the following fire safety
deficiencies be corrected.
ll � iif(.0 (,.rJ1Qj tic�_ UST 13c= /�,'t�i�
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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 Stole Fire Marshal) RECEIVED BY DATE
EN -11 (Rev. 7/86) 89 88751 DISTRIBUTION: GREEN—facility WHITE—Region YELLOW—Field
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INSPECTION REPORT
No.:.00_04_4
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STA E OF CALIFORNIA SEE REVERSE OF COPIES 2 AND 5 FOR
CA�f=TV If►ICDC(`TI(1A1
,� COPY DISTRIBUTION: INSTRUCTIONS FOR COMPLETION
f=1 F Q��1, ` T
• -
STD
- -• -• - ...v. �v ...... ..��..v . 1-3-61AIL FIHt MAHSHAL
850 (REV. 3-93) 2 -FIRE AUTHORITY
4 -5 -LICENSING AGENCY
1. REQUEST DATE
1/17/97
2. PROGRAM
3. AGENCY
CONTACT
NO. 5.
----T-
EVALUATOR
SS/Community Care Licensing
F4.ELEPHONE
(916) 895-5033
0207/Bob Caldwell
6. 5
M REGION
7. SFM I.D. NO.
8. REQUESTING AGENCY FACILITY NO.
9. REQUEST CODE
041304641
7A
CODES
1. ORIGINAL A. FIRE CLEARANCE
2. RENEWAL B. LIFE SAFETY
1 O.
GENCY Community Care Licensing
3. CAPACITY CHANGE
4. OWNERSHIP CHANGE
AME 520 C o h as s e t R d. ,# 6
5. ADDRESS CHANGE
/
ND Chico, C A 95926
6. NAME CHANGE
PREVIOUS NAME
%DDRESS
L7.
OTHER
DATE OF ORIGINAL REQ.
11.
AMBULATORY NONAMBULATORY
TOTAL CAP.
DATE OF LAST FIRE CLEARANCE
CAF
ACITY
MEDICAL CARE
PREVIOUS CAPACITY
MEDICAL CARE
PREVIOUS
CAPACITY
CAPACITY
19. FACILITY
CODE # 13 R C F
YES ❑• NO
X
9 4
YES NO
f
4
13
12.
FACILITY NAME
13. NO. BLDGS.
CODES
Cottage Guest Home
1
1. GACH 9. ADHC
2. GACH/R 10. CLINIC
14.
STREET ADDRESS (ACTUAL LOCATION)
P.O. BOX
15. RESTRAINT
1059 Nevada Ave.
no
3. SH 11. JAIL
4. APH 12. ICF/DDN
CI
ZIP CODE
16. HOURS
Croville, Ca
95965
24
S. PHF 13. RCF
6. SNF 14. CCF
7, ICF/OT 15. DAF
.17.
FACILITY CONTACT PERSON
TELEPHONE NO.
16A. SPECIAL
Eloise Anderson
(916) 533-1436
8. ICF/DD 16. OTHER
TO BE COMPLETED BY
INSPECTING AUTHORITY
18.
FIRE /� � � •i�•�
26. CLEARANCE
CODE
AUTHOR 2r oy l 1 le Fire Dept,
NAME 205�Linco n
AND1.
0-r-5-V-1-TT--e--,--CT-979F6 6
ADDRESS L
CODES
FIRE CLEAR, GRANTED
2. FIRE CLEAR, DENIED
�
3. FIRE CLEAR WITHHELD
27. DENIAL
CODE
TO BE COMPLETED BY INSPECTING AUTHORITY
CODES
21. INSPECTOR'S NAME
TELEPHONE N=. ��/
(�
22.
ID No
ID NO.
23. T-19 OCC.
CLASS
1. EXITS
P
2. CONSTRUCTION
3. FIRE ALARM
4. SPRINKLERS
- AT
25. I ECTOR' NATURE
tqt 4hE �
4�
S. HOUSEKEEPING
6. SPECIAL HAZARD
-
28 EXPLAIN DENIAL OR LIST SPE IAL CONDITION
7. OTHER
STATE FIRE MARSHAL USE ONLY
2C REGION,
OFFICE Community CAre Licensing
AND 520 Cohasset Rd.,#6
ADDRESS L Chico, CA 95926
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INSPECTION
1
_ REPO --:1 SMI tinE MA IiAt
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- - - � � - friit ,I 5. f a� t. �• yL 'jti %'Jt`� 1t�-'.,tt�• > �'c - ,• '
, - . � - �'�'1V w!� •a�•� �Ir�/• r.+i!/ ,,.� rte•�._ � �rt•>ar� �•J�..���� �4.. Iiqdt t .t1 rr i t , �i � �, '.14� ' µ-t•' `1 �t�_r "f I,JI b' •r,�; r off• , >'
j.•.t �� +4 .� i- l�� 7 1�, t tr, tl. ..I b:. ..
r t tat ilit ` COTTAGE GUEST HOME
!/ Me � y #'
f !• I�i`: 1�� 1�1•nt�..'�p• - -?H', t 1 - - .. s7 v °^ii C ,1 -.dt - T,�� Y:, �,. . - �, ;'_•
59 Nevada
HeCA 965 ;.. i •_ • • j• f::. : �' � ��, � �. ' �, >z
Ol
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tic •� � 1 v�'i�l�: • • ; •" •,. . „ t • ..• ��.• • • .'� � �+ •�• ,• =�.q , .• / .�. � • • � ��� • �; � �j .� � ;.� •••.•:� �,• ,�� .
.,� • • •j•� � ;�`. I� t, �wr••� : ;,,��I���i'r••� •�••�! `•�•';f'••�•1•��•,+• '•�•�. •,.1.••:.•i.• J •• •t}, � ,•••00-4 �••'•' ••.•. .•�' ••.••'. � • , • •
• ' • ♦•� Ir i !•R `1.1 • �� !1�•.1�1•'� •�'1 ••t,N !1 l•�' .R, _._'�� ••r�M�+�y�.•�t+�•.r �,f ,•. '_•�••:'I.�j, •L �. •, 1 ,�•••;�: . ,. .I.•
�i�ie�1 !iy a nes t Owener/'�per�ato�r''' • +4
• - 't ilii - '
s e'c•tion was • .conducted at"the above' facility. Two `deficiencies have
_fie One d'efic*iency is outstanding , the servicing of her fireP ull
-The-electrical contractor has been sche-duled•the following week
�t 6(w,
�•».adi r � w, t ^ � ./ V • a:••• .. y•. . r. .sti 1. _ 1• _ t ,`1 •• •, a
... z sued as she i s sti.�ll under, the ,', a1 loted tune frame for repairs,
? t :. '. ,, .' ' '� •, ,, rf �''��' .. .cry r .,, •
'f .. - i" ,I t ` "'- 1 < 1 I • ' 1. •, ��' ,
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' Slauehter ~ •; l• ,: .• /, •:..' • • :� h . '. . • . •.. .. 1� .i r
SIAIUS
ilk
�~
DAR OF fl51'EC • --•-
1-7 'Feb 93 • =••
C.
�i�Ci6'ft�'•`Ift�f;Cnni•�.�'!�`�-. f r_ r�'� . 'th!��'.?L7"!f�°: 5"L ,1'i.. .d. >• L>5.��-�i�4i �ji'lrY;•!r. . . 'LitJ.1iti'k :i7Rts',�'t ,{•.�1�.;Li4�7>Sl;.td:. i:e i'. . .._ .
Office of the State Fire Marshal
Fire Safety Correction Notice
File No: —
----
Name: _
Address:
SF
I I
CALIFORNIA STATE FIRE MARSHAL
The California Health and Safety Code and the State Fire Marshal's regulations require the following fire safety
deficiencies be corrected:
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 DATE
EN -11 (Rev. 7/86) 89 88751 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field
Na e of I'acif;ly: o •
Him «e of nuimmig:
Ai c!t
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scussed Willi. . , j
t Ac
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to ompanied by18A
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:ii$i�;�i�."iif+tlNif65'�'1%�irsfY�iY'r���'�{�Ys.:F. lfi�r•7?t�RiOiCle�,faR • * •� �! .•�1 r ,,y� 1, .^r ty... ��►� Y�•y� ,,��• .L..' r
- - ___- _ �S' '.�:fabT��..i���aKBa�Y���.�.i...•7��:L-.��I2tiSi�£S+�'..:1'SL��rT.�it.'�[R:.{i: �h•�.��Kx♦,`�.1�`�. �Y.t'i �-.4.':...4.3.
SF
Office of the State Fire Marshal
at
Fire Safety Correction Noticefi'
I I
CALIFORNIA STATE FIRE MARSHAL
ile No: - — - -
Name:
Address:
The California Health and Safety
e ' iencies be corrected.
Code and
the State Fire Marshal's regulations require the followingfire safety
f.
_4� I, .
1 '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 DATE
EN -17 (Rev. 7/86) 89 88751 F DISTRIBUTION: GREEN—facility WHITE—Region YELLOW—Field
Office of the Slate fire Marshal
INSI'EC710N KL"1'OR7'
I i1e. Nn.k - —OD----04d..,---A2
5..
toiame 1)f radlity: COTTAGE GUEST HOME
Name f B01(filig:
IL
Addie s-1052 Nevada Street
Go—
OrovillLe. CA .95965
T
*1 :•$--
(A;Is'.' -: '� ...•i 1; 4 4. . � ,
.4
V ussed Willi:
_6 I
I Ifle,
48
s 01
d,
se"! Al2'd to,
Owiie'ro/0""''
Ac ompatiled by dr.9 6� I I I
--NOM 2pera
1
id go
R
STA1111t MAR I lAt
STALE
stations
sort in the
-odd iddd�
(MAXAMI MMIM :143AM
StAlts .�- -d
F•
I •f 1 '} �! • 1 •i
q . ? • i .
Ob 2
L -A
IV I Y sI/1 it P.F MI1RS1 !!1! t .-v it
%
MR C* R"CTIM
• StAWH-T&
6'Jan 93
- 6 lRev. 7/tVIII
a a.w F�d F KE,
_of i�;ice of the State fire Marshal
REINSPECTION REPORT
No.: 00 _ 04 _ 47
0002_ = 000 = 555 = 9
of Facility: COTTAGE GUEST HOME
of Building:
1059 Nevada Street
Oroville, CA 95965
Discussed with: _
Accompanied by
ELOISE ANDERSON
Fire Safety Deficiencies Numbered ONE—THREE
Title:
Title. OWNER/OPERATOR
Fire Safety Correction Notice (EN -11) ® dated ?TJ.a n. 9 9 have been corrected.
Uncorrected Deficiencies Numbered none
noted on the Letter ❑
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, n o 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: FACILITY AMINTAINS A REASONABLE DEGREE OF FIRE AND LIFE
SAFETY. FIRE CLEARANCE IS GRANTED FOR NINE AMBULATORY FOUR
NONAMBULATORY, ONE OF WHICH MAYBE BEDRIDDEN CLTENTS.
FIRE CLEARANCE GRANTED
T -DATE
STATUS
YES
I-9303
DEPUTY STATE FIRE MARSHAL
DATE OF REINSPECTION
SLAUGHTER
4 March 92
GO -5 (Rev. 7/86)
. a.
Office of the State Fire Marshal
Fire Safety Correction Notice
File No:
tet-. _
� l
Name:
Address:
1
SF
I I
CALIFORNIA STATE FIRE MARSHAL
The California Health and Safety Code and the State Fire
deficiencies be corrected.
Marshal's
regulations require the following fire safety
r
i / -
(R✓ /�•
a moi.! ,tr
- ,fit � ! '�f �y.rrr1 � f-r�,.�..
1, �,i'
,.,,� � . � .�:� -fir_ � T��-�••.._
7 L) -5,c
;tet //�,
i - /fir �c.� 3, s
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 Marshal) RECEIVED BY DATE
EN -11 (Rev. 7/86) 89 88751 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field
isge-o/
office of the State Fire Marshal
INSPECTION REPORT
File No.:. 00= 04 _42
0002 _ 000 _ 555 _ 9
Name of Facility: COTTAGE GUEST HOME
Name of Building:
Address:
1059 Nevada Street
Oroville, CA 95965
Discussed with: Tide:
Accompanied b : Lour ANde' rson : ' Title: Owner/Operator
An annual inspection was conducted at the above facility.' There was some confusion
when I asked the owner to test.the fire alarm system, she'did not know the number
to the central alarm company, did not have a key to reset fire alarm pull station.
rer
era fit
hedF-N I
FRE CLEARANCE CRAN1iD
TeATE . ,.. ;'
SUITUS .
Ft2203
DEPUTY STATE FRE Atil11!
DATE INSPECTION'
SLAUGHTER ,: �' - i �
29 Jan .92
Go - 6 (Rev. 7/86)
Office of lK�e State fire Marshal
INSPVC VION
REPORT
hl+ NO. - 00 04 4
--Q-004-
mir"""[7arUky COTTAGE GUFST HOME
RuUdhVg:--------- ----------
[)isru^sulrlwith:
Ac« t)y: Elosie Anderson I Title:: Owner/Overator
An anIlLia j.t-I.Pe-cLj.on was conducLed at the above facility, rhe faciliLy is
in Lhe munth QT March, however hecause of
No deficieTICies were aat-ed.~
__--L]ue.laciliL}�jua.juLo-ins._a._zz�asu
_ __..Ph'p c_1.enrnncc is grooLed for nine ambulaLory and three oonambulaLory, and
"nn
Yes T-DATF 1-9203 SYMIPS
DA I [ OF INSPECTION
21 Feb 91
Page of
File No.:. Q U— 0 �— y -Z
Office of the State Fire Marshal
INSPECTION REPORT
Name of Facility:
�o��C�G� CgG 'Orn
Name of Building:
Address: r C
Discussed with:
Accompanied by: _
—xs �11
c
yVr`N P
FIRE CLEARANCE GRANTED
Go -6 (Rev. 86J
Q CSA
,Cl r
*FIREMA
STATEHAL
TATE
STA T
77-
Dq 0�
= A
la