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FAI15-0067 Fire Annual Inspection Archive (2)
,.effice of the State Fire Marshal Fire Safety Correction Notice File No: Name: Address 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 Marshal) RECEIVED BY DATE EN -11 (Rev. 7/86) 86 96708 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field t Page.—of—. File No.: 00 — 04 r. — 42 _ Dffice of the State fire Marsha REINSPECTION REPORT ..QOQ.2.. —Q00 035 - 1 Name of Facility: COTTAGE GUEST HOME Name of Building: MICE 4' STATE FIRE MA HAL Address: 1052 Nevada Ave., _ -- Oroville. Ca. 96965 -- • �Y•.. R�•, y� v ,t j - .N1 Yy:. ��� .. a'' + tr •S iY �. f`. ";?I t'�'•.. ••'1. �� ��t ), i.. .K �. :•.): •t' •fit - .. 1 J 1 /•\ ;��, • t . &'� w.r 7 • • � ,r•�• + i.... :� _• .a.�i`�!•. v �i1i., {i • •3• •I .w' •�. �!�' •:� F {j;fLrl .k � .••':J �i�l�. j•i�! S�S�`• �Y •`Y •4��; •=S .'.�.a'i{. •. �1,' Y " :i Y, ,� . •,• : �� S' ? -�"• t. -{'� �'. ,_�.. "5. -71Ce- ..3 A ,!, a .{i R ♦�r _�• �••', �.. x.3• ,�f..-v �"•' �• � ,+ -,1 y a`t �� v: a4. - �• is A I 4 z •! •,r�,I ':1' �j „r qi. w! I �. •.v a -.+� '•�-yti� .'e.- J. i ,.•. .t !• ,ice i::..r Maw. ,Y.. � ., !! i"•►. -A .t' .�''.. y •s X3 a. � •}' �� ;� 7 ;r- k< t "�:'! .. •„s. - •. , �. 7'J '�, - i•.. ,;; , 'a. ,Ery! :��" '•,2N:. K X :.w.'S'tj' j�,- 1!, .r r ;w - -ti.i ': t.h' •:� a f..7 ^w .t!":... a �•4..,� h� ••.. �,} i��� '�Y. °'y 'N .r K�•"'•. �y... .t �,•e".�a'. Pio•;.. 'f'Y�,�'.x�'r. �C� •, .s �,1 :.3;. � !. L • 1 w i s i as r r� Y - . i`' `.. v"' ��' d c , Y1.0„_ % . , - C : o•. s+ .i +'y � �. t i y” i ..i • �-. __�-X11..,.. t�� Vii. _ ~.•'�; .. �. .F .le� rr :'. ., .. . � + ^f .fi. ,.;a0i#.1 r�,. .. _ �►- r Fire Safety Deficiencies Numbered one Fire Safety Correction Notice (EN -11)] dated 17 April 89 have been corrected. Uncorrected Deficiencies Numbered none noted on the Letter 1:1 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, no 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 maintains a reasonable degree of f ire and lif a saf ety . Fire clearance is granted of one bedridden client in the sleeping room with " exit, three other nonambulatgry elderlylients and nine ambulator , y GO - 5 (REw. 7 /86) Page of Office of the State Fire Marshal REINSPECTION REPORT File No.: -002 — --�0n---.35_ — Name of Facility: Cottage Guest Home Name of Building: Address: 1059 Nevada Ave. Oroville, Ca. 95965 Discussed with: Eloise Anderson Title: Owner/Operator Accompanied by: Title: Fire Safety Deficiencies Numbered three noted on the Letter ❑ Fire Safety Correction Notice (EN -11) ® dated 3/2/89 have been corrected. Uncorrected Deficiencies Numbered two were re -issued as shown on the Fire Safety Correction. Notice dated 17 April 89 which is attached to and made a part of this Report. In addition, no 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: Fire clearance will not bp grant -Pd Int -i1 dirt -rt- nr gPmi–rli rPrt exiting is provided in patient room #2 a EIRE CLEARANCE GRANTED T -DATE STATUS F-8906 DEPUTY STATE FIRE MARSHAL - DATE OF REL'GPECTnON SLAUGHTER 17 April 89 :O - 5 (Rev. 7/86) Page of Vice of the State Fire Marsha! REINSPECTION REPORT File No.: Z' 013S Name of Facility: Name of Building: Address: �C� 5� �� `-7/'t��'�✓ �l/C Discussed with: Accompanied by: `� f�lc5 Title: '2%3�/ Title: Fire Safety Deficiencies Numbered noted on the Letter ❑ Fire Safety Correction Notice (EN -11);g dated %— Z —� have been corrected. Uncorrected Deficiencies Numbered 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, new deficiencies were identified at the time of this reinspection, and are shown as Items 3 on the attached Fire Safety Correction Notice. Fire Clearance Instructions: f DE Y_ STATE E a L" DATE OF REINSPECTION ^�] L✓ FRE CLEARANCE GRANTEDT -DATE _ /� STATUS f DE Y_ STATE E a L" DATE OF REINSPECTION ^�] L✓ GO - 5 (Rev. 7/86) l-8. FIRE Jack Piriski AUTHOR #4 Wi.11iamsberg Ln., Suite 3 NAME Chico, CA 95926 AND 'ADD L TO BE COMPLETED BY INSPECTING AUTHORITY J TO BE COMPLETED BY INSPECTING AUTHORITY 26. CLEARANCE CODE (- CODES 1. FIRE CLEAR, GRANTED 2. FIRE CLEAR, DENIED 3. FIRE CLEAR, WITHHELD 27. DENIAL CODE c.vutS • S NAME TELEPHONE NO. 22. CFIRS 23. T-19 OCC. ID NO. CLASS S41UGIffER 895-431235 I-2 1- EXITS 2. CONSTRUCTION W. INS � TE 25�. INSPECTOR'S SIGN 26 89 3. FIRE ALARM 8- E 1 ENIAL OR LIST SPECIAL CONDITION 4. SPRINKLERS Fire clearance is granted for one beddridden client i =5• HOUSEKEEPING �n the sleeping room sleeping room s. SPECIAL HAZARD prov ded with 44f1 exit, three other nonambulatory yelderl and nine 7. OTHER , ambu atory clients. STATE FIRE MARSHAL USE ONLY Dept. of Social Services OFFICE Community Care Licensin AND o g C hasset Rd.,#6 AODR 520 SS Chico, CA 95926 P •'� SATE FIRE MARSHAL 'IRE SAFETY INSPECTION REQUEST COPY DISTRIBUTION: 1 -3 --STATE SEE REVERSE. OF COPIES 2 AND' S FOR FIRE MARSHAL INSTRUCTIONS FOR COMPLETION ;TD 85 (REV. a/ Be) 2 --FIRE AUTHORITY I. REQUEST DATE 2. PROGRAM ' 4 -5 -LICENSING AGENCY b AGENY CONTACT 2 /14/89 DSS Community Care Licensing916 4. TELEPHONE NO. a. EVALUATOR 895-5033 0103/Bob Caldwell �. SFM REGION 7. SFM I.O. No. 330 8. REQUESTING AGENCY FACILITY NO. >i. REQUEST CODB 0) o5 41304641 7A REQUESTING FIRE CLEARANCE FOR ONE BEDRiD DEN CLIENT CODES 1.ORIGINAL A. FIRE CLEARANCE 2. RENEWAL 8. LIFE SAFETY Dept. of Social Services.. 9: CAPACITY CHANGE 10 -AGENCY Community Care Licensing a OWNERSHIP CHANGE NAM 520 C o h a s s e t R d.,# 6 S. ADDRESS CHANGE -AND Chico, C A 95926 6. NAME CHANGE ADD S PREVIOUS NAME L I _ 7. OTHER DATE OF ORIGINAL REQ. 11. AMB CAPACI TORY NONAMBULATORY AGE RANGE (YEARS) PREVIOUS TOTAL CAP. DATE OF LAST FIRE CLEARANCE ' CAPACITY TO 18 18 TO 6S AND CAPACITY AGE RANGE (YEARS) PREVIOUS CAPACITY 65 ed�R + 4 TO 18 18 TO 65 AND9 8;S `�'+ 19. FACILITY CODE 12. 13 • 7 4 O /RCF E FACT TY NAME COTTAGE GUEST -HOME 13. NO. BLDGS CODES 1 14. STRE ADDRESS (/�4CTUAL LOCATION) P.O. BOX I. GACH 7. OT ICF/ 105 Nevada Ave. 1S. RESTRAINT 2. GACH/R 8. ICF/DD CITY no 3. SH 9. ADHC o r 0 i l l e, CA 95965 ZIP CODE 95965 16. HOURS 24 4. APH 10. CLINIC 17. FACR TY CONTACT PERSON TELEPHONE NO. 5. P HF 11. JAIL Joh Anderson (916) 533-1436 18A. SPECIAL 6. SNF 12. ICF / DDN 13. OTHER l-8. FIRE Jack Piriski AUTHOR #4 Wi.11iamsberg Ln., Suite 3 NAME Chico, CA 95926 AND 'ADD L TO BE COMPLETED BY INSPECTING AUTHORITY J TO BE COMPLETED BY INSPECTING AUTHORITY 26. CLEARANCE CODE (- CODES 1. FIRE CLEAR, GRANTED 2. FIRE CLEAR, DENIED 3. FIRE CLEAR, WITHHELD 27. DENIAL CODE c.vutS • S NAME TELEPHONE NO. 22. CFIRS 23. T-19 OCC. ID NO. CLASS S41UGIffER 895-431235 I-2 1- EXITS 2. CONSTRUCTION W. INS � TE 25�. INSPECTOR'S SIGN 26 89 3. FIRE ALARM 8- E 1 ENIAL OR LIST SPECIAL CONDITION 4. SPRINKLERS Fire clearance is granted for one beddridden client i =5• HOUSEKEEPING �n the sleeping room sleeping room s. SPECIAL HAZARD prov ded with 44f1 exit, three other nonambulatory yelderl and nine 7. OTHER , ambu atory clients. STATE FIRE MARSHAL USE ONLY Dept. of Social Services OFFICE Community Care Licensin AND o g C hasset Rd.,#6 AODR 520 SS Chico, CA 95926 Page of File No.: 00 _— 04 — 42 Office of the State Fire Marshal REINSPECTION REPORT Name of Facility: COTTAGE GUEST HOME Name of Building: Address: 1059 Nevada Avenue Oroville Calif. 95965 Discussed with: Eloise Anderson Title: Owner /Opera or Accompanied by: Title: Fire Safety Deficiencies Numbered three Fire Safety Correction Notice (EN -11) ® dated 90 Dec 88 have been corrected. Uncorrected Deficiencies Numbered one & two noted on the Letter ❑ were re -issued as shown on the Fire Safety Correction. Notice dated 25 Jan. 89 , which is attached to and made a part of this Report. In addition no 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: The reinspection conducted at the above facility revealed two outstanding deficiencies An EN -11 was reissued FIRE CLEARANCE GRANTED T -DATE STATUS F -89(Z DEPUTY STATE FIRE MARSHAL DATE OF REINSPECTION SLAUGHTER 25 Jan. 89 10-5 (Rev. 7186) Office of the State Fire Mai _.dal Fire Safety Correction Notice File No: _------- Name: Address: The California Health and Safety Code and the State Fire Marshal's regulations rrequire the following tire 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 Marshal) RECEIVED BY DATE EN -I1 (Rev. 7/86) 86 96708 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field CA WEST ENGINEERED SYSTEIVOOO" 4680 PELL DRIVE, SUITE 8 AUTOMATIC SPRINKg�'-_-R •`' °• SYSTEM SACRAMENTO,1-1995 CAA 838 LIC.._. CALIFORNIA A MINM"TRATION CODE, TITLE 19, SUBCHAPTER 5 (916) 21-1995 G`P, LIC. NO 376930 ' •+•••• ADD ESS OF BUILDING PHONE NO. DATE 1 6clucQAI YFS NO - • A ------- -- E ALL SYSTEMS IN SERVICE?...................................................................... COUPLINGS FREE, CAPS IN PLACE, AND CHECK VALVES TIGHT? ❑-. ❑ ❑ • IS UILDING PARTIALLY SPRINKLERED?.............................................................. 19 SUBCHAPTER 5 AND THE TITLE 19 SUBCHAPTER 5 AND THE MUNICIPAL FIRE CODE. • A IE FIRE PUMPS, GRAVITY TANKS, RESERVOIRS AND PRESSURE TANKS IN ❑ ❑ • IS UILDING COMPLETELY SPRINKLERED?............................................................ ❑ ❑ 4. ALARMS ❑ ❑ • IE INSPECTORS TEST VALVE SATISFACTORY? LOCATION • A E ALL NEW ADDITIONS AND BUILDING CHANGES PROPERLY PROTECTED? .......................... • IE WATER MOTOR/GONG TEST SATISFACTORY? LOCATION �, ❑ ❑ ❑ ❑ • IS LL STOCK 18 INCHES BELOW SPRINKLER HEADS? ................................................ • IS SUPERVISORY ALARM TEST SATISFACTORY? LOCATION ❑ ❑ ❑ ❑ ❑ 2. ONTROL VALVES FIRE DEPT. USE ONLY RE DEPT PHONE NO. •RE ALL SPRINKLERS IN GOOD CONDITION, NOT QBSTRUCTED'AND FREE OF CORROSION OR LOADING? ❑ El • I CONDITION OF PIPING, DRAIN VALVES, HANGERS, PRESSURE GAUGES SATISFACTORY? • A E ALL SPRINKLER SYSTEM MAIN CONTROL VALVES SECURED OPEN? ............................... • RE ALL SPRINKLERS LESS THAN 50 YEARS OLD? El 1:1• ❑' ❑ ❑ • AF E ALL OTHER VALVES SECURED IN PROPER POSITION? ............................................. ❑ • AVE SPRINKLERS BEEN CHECKED FOR PROPER TEMPERATURE RATING? ❑ ❑ Q . ❑ ❑ • AF E ALL VALVES IDENTIFIED?........................................................................ r-' S ATIC PRESSURE BEFORE AFTER r �� RESIDUALS � WAS SYSTEM BACKFLOWED? EYES ❑ NO 81 REMARKS ❑ ❑ OPEN SECURED CLOSES SIGNS N/A 'TYPE YES NO YES NO YES NO YES NO CITY CONNECTION VALVE ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ T NK VALVES El 11 El ❑ 11 1] ElP MP VALVES El ❑ El El ❑- El 1:1S CTION VALVES ❑ ❑❑ ❑.. 1:1 ❑ I]❑ S STEM VALVES ❑ Rl ❑ ❑ ❑ ❑ Iq AIUK PI IMPC FIR1= nl=PAPTMFNT rnNNFC_TI0NS N/A YES NO • A IE FIRE DEPARTMENT CONNECTIONS IN SATISFACTORY CONDITION; CERTIFICATION COUPLINGS FREE, CAPS IN PLACE, AND CHECK VALVES TIGHT? ❑ 21 ❑ LOCATION ADMINISTRATIVE CODE TITLE 19 SUBCHAPTER 5 AND THE TITLE 19 SUBCHAPTER 5 AND THE MUNICIPAL FIRE CODE. • A IE FIRE PUMPS, GRAVITY TANKS, RESERVOIRS AND PRESSURE TANKS IN OOD CONDITION AND PROPERLY MAINTAINED? Pf ❑ ❑ 4. ALARMS • IE INSPECTORS TEST VALVE SATISFACTORY? LOCATION ❑ 15 ❑ • IE WATER MOTOR/GONG TEST SATISFACTORY? LOCATION �, ❑ ❑ • IS ALARM TEST SATISFACTORY? LOCATION ❑ El'. ❑ • IS SUPERVISORY ALARM TEST SATISFACTORY? LOCATION ❑ ❑ ❑ LTEF • RE ALARM VALVES/W JLLOW INDICATORS AND RETARDS IN SATISFACTORY CONDITION? ❑ ❑ 5. SPRINKLERS -PIPING FIRE DEPT. USE ONLY RE DEPT PHONE NO. •RE ALL SPRINKLERS IN GOOD CONDITION, NOT QBSTRUCTED'AND FREE OF CORROSION OR LOADING? ❑ El • I CONDITION OF PIPING, DRAIN VALVES, HANGERS, PRESSURE GAUGES SATISFACTORY? El ID • RE ALL SPRINKLERS LESS THAN 50 YEARS OLD? El 1:1• RE SPARE HEADS READILY AVAILABLE IN APPROPRIATE NUMBER AND TYPE? ❑„- ❑ • 1 SPRINKLER HEAD WRENCH AVAILABLE AND APPROPRIATE? ❑ • AVE SPRINKLERS BEEN CHECKED FOR PROPER TEMPERATURE RATING? ❑ ❑ • RE REQUIRED HAND HOSES ON SPRINKLER SYSTEMS IN SATISFACTORY CONDITION? ❑ ❑ 6. MAIN DRAIN TEST T SYSTEM r-' S ATIC PRESSURE BEFORE AFTER r �� RESIDUALS � WAS SYSTEM BACKFLOWED? EYES ❑ NO 81 REMARKS DATE LAST PERFORMED, L FIRE DEPT COPY CERTIFICATION I HEREBY CERTIFY THAT THE FIRE PROTECTION EQUIPMENT INDICATED ALL NECESSARY MAINTENANCE AND REPAIRS HAVE BEEN MADE ABOVE HAS BEEN TESTED IN ACCORDANCE WITH THE CALIFORNIA IN COMPLIANCE WITH THE CALIFORNIA ADMINISTRATIVE CODE ADMINISTRATIVE CODE TITLE 19 SUBCHAPTER 5 AND THE TITLE 19 SUBCHAPTER 5 AND THE MUNICIPAL FIRE CODE. MUNICIPAL FIRE CODE. 11TIAL TESTING DATE FINAL TESTING DATE SIGNATURE . - TITLE S1019ATURE TITLE STING AGENCY _ LICE,N$E ADDRESS PHONE FIRE DEPT. USE ONLY RE DEPT PHONE NO. INSPECTOR ASSIGNMENT FIRE DEPT COPY cc rrooeoer gpyairr iV4*0 /—/ ppm j 1p caws#44mr 04wa r oovawe /-/pos or Page.—Of +** Aim Office of the State Fire gars. _ _ File No.:D _ Name of Facility: Name of Building: Address: piLnJl'c(� Cg t59�S Tette. �� 17 � A'1/�".r9 !� Rn J '� .. 'ritln• � ()L .�A�/f'Yt .... � t:�'��'��^' f 19/i _ . 9,r o S 11-214 -S �' . � /1 SAT ,W CLEARANCE GRANTED 1"-DAg / STATUS DEPttfY STAT//E% 5 `DATE SOF IWECTION W GO - 6 (Rev. 7/86) 0 0.3 � - / Name of Facility: o Name of Building: Address: Y.: 1 .l .�'.. t 4 t - -. tia• �4f 1 } t y ,!v 4 � f 1. Y . • i .:32> 4. 1 .2 i Y- I •"1116A A ;t. �x z:= �2..: Zs 3 _.. t'•� s ar ,< s s' a. D. 4 '1M��h Y:.. N. .T ..:Y ...y Y+if. ... ...K ., � v ..�t ES. •.i r s ,�s� :?t. `:#. u'31..p .}>;>X• Li .r�2 �.+!` .3, $5 :..r. ``.')�! ;' .v F. S! .t ,h 1''.. �F, ll,„ J.;C :fi * . ik>n ' ., b •{" �,.;` Niimi o: �' 41, all, A. MAINTENANCE AND SERVICE (19 Cal Adm Code 904.5, 904.6) OK/NO/SR• 1. Maintenance inspections are conducted quarterly. Last inspection date 2. Service inspections are conducted every 5 years. Last inspection date By License # A- �- 3. Records of maintenance and service are retained for 5 years . . . . . . . . . . . . . . . . . . 4. Service label is in place . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R. CONTROL VALVES 5. Control Valve is secured in open position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. System, control valve(s) turns easily (1'/2 turns minimum) and are readily accessible . . . . . . . . . . . . . . . . . K 7. Control valve(s) are clean, lubricated and do not leak . . . . . . . . . . . . . . . . . . . . . . . . . C. RISER 8. Riser is free of leaks. Supports and bracing are secured and adequate • . . . . . . . . . . . . . . . . . . . . . . _ .--- D. SPRINKLERS 9. Extras sprinklers and a wrench are readily available. Extra sprinklers are the same as those in the system . . . . . . . . p 6 �- G 10. Sprinklers do not leak and are not painted, corroded or damaged. No sprinklers are missing . . . . . . . . . . . . . 11. Sprinklers are not obstructed. There is no storage closer than 18" to the deflectors . . . . . . . . . . . . . . . . 12. Sprinklers are the correct temperature rating and installed in the correct position (upright, pendant) . . . . . . . . . 13. New construction has not altered system needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E. ITE DEPARTMENT CONNECTIONS (FDC) 14. Protective plugs/caps are in place. Threads and swivels are operable . . . . . . . . . . . . . . . . . CAP - - 15. FDC is easily visible, accessible and labeled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . F. GAUGES 16. Gauges are in good condition . . . . . . . . . 17. System pressure is ,-2 PSI. Supply pressure is PSI (Some systems may not have a supply gauge) G. FLOW TEST 18. Alarm is activated within 90 seconds after inspector's test valve is opened . . . . . . . . . . l� 19. Residual pressure (Main drain open) PSI Static pressure (Main drain closed) PSI ^ A J z.:. :T 2. 1 22 •� •{ K 1 i • f/I�� r�C e T s Y: .i t . a 3. Y, y. , r y s c e a. t` f I r is .,� ,:♦ - - n t O PU'lY STAY FIDATE OF INSi "ON EN -1 (Rev. 7/86) erg dice of the State Fire Marshal *FIRE Fire Safety Correction Notice HAL File No: - — — — — ame: ddress: The California Health and Safety Code and the State Fire Marshal's regulations require the following fire safety deficiencies be corrected. & /71 ,J L c/ � z The above deficiencies are to, be corrected within days. When ALL deficiencies have been corrected, sign and return the certificatiorron 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) 86 96708 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field tTl Office of the State Fire Mar,..al Fire Safety Correction Notice File No:------ Name: Address: 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 (V ) ISSUED BY (Deputy State Fire Marshal) RECEIVED BY DATE EN -11 (Rev. 7/86) 86 96708 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field ..�. ., •y .... r_.�...�..._^...w.. .. .•-.-... •.•s._ - si_w_ ... ...... ...-.•r... . _. ... ._._ ... .......-_a �._. c. ...... ..:.:...;.._...w. ... ..._ . .. ... ..... ..... ... -.. _..:�•...:..:.•:.. .a•'_ a..:':.iv...a�.VU...:tiLili.C.•.•:et•..a•a•n.•.tiw.w:T:ilwi•Cir L... `.i'.Y-r�v.+liiw:lJ►.3rJ3•f .M ug, \. ►'l`• • .t .- REINSPECTION REPORT _-.-OFFICE OF FIRE MARSHAL -- FILE- N0. [oil li� FAI E QIZIQ.Qp =_ Date Reinspected Name of Facility � rQ ;-,e _ XS -r_ - UQ dd Ad d r e s s,-�_Q,�._____•_ww•__...«wr__.w___._.______.w Conditions Discussed With Com..ot S LE _ rr....r.+a.....w a.r._r,__•__r_ wr•. .r._a_... _-r_r•r_r.w.r.r. •....w.w. Accompanied By Title _» rrr. � w•.w.-r•arr_ __..r_+..r +• r. _ r• r r. +- •w+..r • w ».n ._. 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IL _ ;1.J r�a�•1Mn...j°;��..:✓.�•1'w'�i. i�a��71.�IR :..•�.... �.. v�� ..�..t• _. riLt'?witiLS�.Z•T'S�« 1r.'p.`�'C•-..'•:.�f'�:7k•.1��'tis�`--:. �... �����•a'..�. �"r':Y.�^.'7�:�... ����'�/'7r�„!�if�4L�tT-i -. ��y'.jw%�••:�.� .. _.. -- -72,7 - +... ._ _.. ..._r .•_�.r ... .. ... .. .. ._.`_.. ,...-• � .. • .. ..... _._ . . .. .. r,�.+... �-_»i.� mow..: - � . __ suo Lgoaa.Ao� ..4q.ajps a.1 LjaN _r � rr +.mss �•� rr r, • : suo L41puoO MaN pine S4uawwo3 EN -t (REV. 7/81) - YELLOW: REGION WHITE: FACILITY GREEN: FIELD 88701-355 3-84 12M TRIP OSP STATE FIRE MARSHAL ..Q- STATEAL FIRE SAFETY CORRECTION NO1j.CE *IREMAR OE FILE NUMBER 0E10o Elo❑ EloEl NA ADDRESS In accordance with the minimum standards of Title 19, CA nia Administrative Code, the following corrections are required: } The above deficiencies are to be corrected within days. Upon completion, please sign and return the certification on -the oppe side.�f thisform. If you have any questions, contact the State Fire Marshal's Office at ISSUED BY (DEPUTY: STATE FIRE-, MARSHAL) RECEIVED BY DATE EN -t (REV. 7/81) - YELLOW: REGION WHITE: FACILITY GREEN: FIELD 88701-355 3-84 12M TRIP OSP N *1RE „,,� STATE FIRE MARSHAL 10I a IRE SAFETY CORRECTION NOT�.,E AL VIE �a>�e l % FILE NUMBER ""9 c _. VAIII�i j L "M In accordance with the minimum standards of Title 19, California Administrative Code, the following corrections are required: T?'I-d /9 o. �0: U .3, 2- fl 4A &r,Ii) &e” 3,c .r /_ �,-L ! ' Lam./•/�/ _�/ /L_%i'/!�IIII!IIIIIIIF�.. I, V r i V Tlle 9, 41 4a-,,I3tIFAev�16 Vo4k- V,& A Mte?� 6V �3 III yc.2l 7iffea The above deficiencies are to be corrected within 47 days. Upon completion, please sign and return the certification on b� opp jside his form. If you have any questions, contact the State Fire Marshal's Office at O !Z�_=����. S 4B�Y( DEP TY TATE ARSHAL) R C' IVED BY DATE _ EN -11 REV. 7181) YELLOW: REGION WHITE: FACILITY GREEN: FIELD 88701-3533-8412M TRIP OSP / /d, CERTIFICATION OF CORRECTIONS BY OWNER I certify that all items listed on the reverse of this form have been corrected in accordance with the requirements of Title 19, California Administrative Code. SiGiVATi:RE , DATE Fold 'on .-this.linej_ - (Fold on this line) -- - - _ - _ - . t • • -ACE�� .. , � .. STAMF tiv,J��'- n'�'Yo2' G Y _f '� �`�a _ • = 1 :• , `t �.... t''V'�� t •'p; •` ti ` JRGip CHICO; CA"45926 a. 04 v -- EN -11 �(EV. 7/81) U YELLOW: REGION WHITE: FACILITY GREEN: FIELD 88701-3553-8412M TRIP OSP ^ STATE FIRE MARSHAL YRE SAFETY CORRECTION NOTt—E *1REAL 10 / FILE NUMBER NAME ADDRESS In accordance with the minimum standards of Title 19, California Administrative Code, the following corrections are required: 17 e l �ir. ax, c� , The above deficiencies are to be corrected within 7 days. Upon completion, please sign and return the certification onAh opp i �f this form. If you have any questions, contact the State Fire Marshal's Office at ISS D BY (DEPUTY TA FIRE M RSHAL) RBY DATE v -- EN -11 �(EV. 7/81) U YELLOW: REGION WHITE: FACILITY GREEN: FIELD 88701-3553-8412M TRIP OSP CERTIFICATION OF CORRECTIONS BY OWNER I certify that all items misted on the reverse of this form have been corrected in accordance with the requirements of Title 19, California AdministratiVe_Code. SIGNATURE DATE R e r " _ y . F i ... '• ... -mss � .. n (Fold on this tine). -----------------R.------,---- -------_ ------_._.— (Fold on this line) --------------------------------- PLAC£ STAMP HERE STATE FIRE MARSHAL WILLIAM U G LANE, SUITE 3 CHI O9 05 26 i 0 . :4- (Fold on this line) --------------------------------- PLAC£ STAMP HERE STATE FIRE MARSHAL WILLIAM U G LANE, SUITE 3 CHI O9 05 26 i 0 . N� N;: BUILDING SUWEZ REPORT Date:* AL File No: Clo - OL/ q2 - 000 1 - 000- 330--0 e. of Faci 1 i tyso Cqv i-) A 6 tEAT m ,ress: Jos &A er: Telephone No. /6 e of Bu i Idi ng: A DESCRIPTION. CaTm. 0=uj2an Class 1 2 Use PL I Capacity /.q 2,w --*Construction I --Type 5C Total Largest Floor &r. Year Built 15yo Is Basement 30 Area(Sq. Ft,, Stories No. High Rise Yes No 5a,, Exterior Wall Construction ZA-kno(O S 112ir.--il" 5 L4 05 v e 09 0 04 go 7M T- ofto s - -b a Opening. Protect lon -or T-1 r; er A L. C Irater l Wall Const -ruction IL/ va" A 7* Floor Construction ,0 04-J C C T4F A (014vJ, i. _T 1_ &4 r, t 3. Roof Construction, irezA W, Jr ot W -i woo 17) H ttic Draft Stops No. Ma. Occ. Sep. Wall Construction C. "j fgaa b.w Opening Protection No, 11a. Area Sep. Wall Cons tructiori b. Opening Protection No,, - 12a. S-moke Barrier I -Wall Construct -ion b, opening Protect ion ILIA Corridor Wall rMa. Construction 11-L 6i (3 tutc re t ij T14 OF ecau4w IUOV- AA T 0 b, opening Protection 3/ L(Xv V) 0 VL) a, 5 — V61'a %0 IL c0 5 1.4 1 14a. Corridor Ceiling Construction Dr 02" f V b. Opening Protection F, ie�r 15a, Shafts NwberzType b. Opening. - Protection Nor- nF:qrRT P`T'T C`N.. CCr. 16a. Stair Enclosure b. Opening .. Protection, 17,. Stairs Noo �= 13. R .s No. te k -. iFg i o tAl v2. w 19. interior Finish Class Room ET t Corridor Exit E cl . 20,v Exi is ..:iAii)YwMa)'R No. D Total Width ti .21w Exit HarcTware _.ape ,22a. Exit Signs/ Illumination ec ve & I le ozz' s i b.:Effergency M 1...a....w .,.. "' 1 t1 n t --VT tZ tr to r if -4- 23,o Auto- Sprink. Covera a _ Co04 !. c 1 L` 5 r f,� - W tli I: -ter - 2 = . Standpipes _ Class j�ation 25, Eire Alarm /Coverage ��+�� t �, --s�u�E���� �,-� ,� 1tN14K 2'�at i.ng •. ,c t r+�a Lr s Fuel. Lt t vent �/jf Oww.f' • Iwwwaw�A.w1 � fir• 1 .�w.wr wY w ��wi 27. Electrical Installation fuz G 1..28. Stage/ Platform 29. Hazardous _. Areas 30. O her ..- _ -•.- .... .. - - .. ...try ... �.c-.pv. - - - - _ .. cC3L��T`S . T t�` r't G r t r c. ►� ._ r u c-r;r 19 10 ' YL -sl P.4 Ao' L V t t- I LZ r'L log vL A c- _� _ a� +C' 2,�' W,' l3 ,� �, c t ire, w t T,Q V -- LI i 0 04 A C r�I tc r` P4-- T & C:c.J E V S T -q v� . f 7 ito V 110 e rL V U ( T I Z)O J `/ / AJ 7"P r IglaF Inspected By: t, v fiat `ty 5r&4-jc Firms WjAw i c. �'o. Attachments 'r' viewed By., Date: Updated: REINSPECTION REPORT OFFICE OF STATE FIRE MARSHAL FILE No. UiEol E2 f9f:21 Ed � � Da �112 oDate Reinspected � �, �-/1-e a N a a U rt Nagle of* Fa c i 1 i t y..w_Spi . 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AS F o l l Uw./ :_.r. ..�•w� .�w•w fii .ww.wy�rw`------------------------- Reinspection w.ww.www..w..+w----w-.w--.r_--- Reinspection Indicates That New Fire Safety Corrections Should be Issued. See keverse Side r6T-C&nments andTe-w Fire Safety Corrections. c o - sG _ - ---_-- _ - UF: - (3//U) H I V 'Del) 8 1 l�l t?1 Comments and New Conditions: r� lkl� New Fi re Safety Corrections: A 'ATE OF CALIFORNIA -STATE AND CONSUML MCES AGENCY TATE EIRE MARSHAL XRAMENTO REGION 33 FLORIN ROAD, SUITE 400 ►CRA -MENTO, CA. 93823 July 15, 1985 Eloise Anderson Cottage Guest Home 1059 Nevada Ave. Oroville, CA 95965 SUBJECT: FIRE ALARM - SFM # 00 -04 -42 -0002 -000 -330 -0' - Dear Ms. Anderson: I received your drawings for the proposed fire- alarm. Before they can be approved, we must have the manufacturero name, model number and State Fire Marshal listing number for each fire alarm component to be used on this project. Please have your contractor resubmit the plans with this information. Sincerely, NANCY RIVERS WOLFE Deputy State Fire Marshal Supervisor NRw:nal cc: Regional File Field File GEORGE DEUKMEJIAN, Govemor (916),427-432-5- AM 916).427•432s • rod ATE OF CALIFORNW.—STATE AND CONSU/ 4VICES AGENCY GEORGE DEU# MEJiAN, Govemor 916�)427-4323 E WTiFIRE MARSHAL ��- ` ►CRAMENTO REGION s 33 FLORIN ROAD, SUITE 400 ATSS 466-4325. CRAMENTO, CA 95823 — � at� P I� July 15, 1985 Eloise Anderson Cottage Guest Hone 1.059 Nevada Ave. Oroville, CA 95965 SUBJECT: FIRE ALARM - SFM # 00--04-42-0002-000--330-0 Dear Ms. Ander son I received your drawings for the proposed fire alarm. Before they cat be approved, we must have the manufacturers name, model number and State Fire Marshal listing number for each fire alarm component to be used on this project. Please have your contractor resubmit the plans with this inform-ation . Sincerely, 1 _V4+ NANCY RIVERS WOLFE Deputy State Fire Marshal Supervisor NRW:nal cc: Regional File Field File : OFFICE OF THE STATE FIRE MARS � INSPECTION LOG - f Tithe COTTAGE GUEST HOME 0 0 0 4 4 2 File 0 0 0 2 0 0 0 3 3 Address 1059 Nevada Ave Oroville CA 959.65pa-�g 03 18 85 Owner. Eloise Anderson ' Mrs Anderson telephoned this morning to state that a written response to SFM letter of 01-31-85 would be mailed as soon as possible. She had questions regarding the -type -of hard surface walkway required on item 5 and the type -of system, required in alternate -2. - A follow-up visit or recontact will be scheduled for April, 1985. • .tom • ; ... ��= Nancy Wolfe De ut State Fire Marshal (Supervisor) cc:. Chico field file GO -6* (Rev., 5/81.). Co`ctJr,<: Cr fir" O rav Lu -a- C)O--,,�- n� 6GXJcI-00o-3 —:S© --o L CfanG't.? Wit_ A FFICE OF THE STATE FIRE MARSV' INSPECTION LOG Title T E GUEST HOME 0 0 0 4 4 2 ■ File 0 0 0 2 0 0 0 El El Oa Address 1059 Nevada Ave Oroville CA 95965 Date 03 18 85 Owner Eloise Anderson Mrs Anderson telephoned this morning to state that a written response to SFM letter of 01-31-85 would be mailed as soon as po-ssible. She had questions regarding the type•of hard surface walkway required on item 5 and the typo -of system: required in alternate .2 . A follow-up visit or recontact will be scheduled for April, 1985. At --Nancy Wolfe De ut State Fire Marshal w (Supervisor) cc: Chico field file L._ �rrr. ■■ � ■ may- ■� r�.■■..��.ir�r.r..f.r■ i■r ..�..r+......w.�. � ■ - i • �r■ � r r �w�� r �r■■.rr ...r.■ r r.r • t 60--6 (Rev., 5/81.). v I .15_35 ?,i -yr 7.1 o t a l e � .� u e s t .r o e A]* ?emove existing dollble ��•jooI? } ��.5'_'1 windowand i'r.7.� calf_ si�l�;l�e pane 5 foot a t i o do c 1-1 s ��:� on ex t ri a. T w • .l o (n jr. f/1 r p i r. �-� n I T I c'� � ��r � 1�....... ' ~ , , Cr � , • � • r' � � 1 � � ^ • r f t1 1 l_ 1' ' C� { ; C �3 r T �1 la - t r t T �` .e. v„ :.�. e'.�� �. a d_t. ,�� r�_ v .�.�1 ;,, � 0 7-_l c__� �. ha t'r a„ F. a.�e • wind tex-1C,=1re. `o--":1eotii� ier to provide. -"finish -c- e%rt ire. Install interior ��ral�. partition T',JY+ :�e :• 'cathrac1 i. Ins tall I-ot --fop and r=i. n in floor. Install stall i.-tr�thout d�yp. _-Liste_ll coriimod.e and vanity. Install standard grade ceramic file on shot.7.rer and floor to extend giro rows up at base o f walls. Tape, textures paint, aint • be rTesta=l solid c -.gyre door tween rooyns using; closet as access. Instal. e ,st partition in closet • "Pniiove existing wood sash vrin.d.oyand intall solid core exterior door, nstall ramp on extefior. qj. TIN exterior steps and install ramp. Remove double sash window and xk1amkrQixk install sheetrock. Tape and exture. -- Install solid core door with jaiiibs, Sheetrock as necessary. Tape and ' e xt u_re . 'Pemove washer -and dryer from hallway and relocate in bathroom. Remove hovveer in bathroom. T?emove window and install sheetrock. Tape and texture. ns tall new underlayment and standard grade linoleum on floor. Remove existing dutch doors and install solid core doors :WM ME iC MECi■■■iii'�'io'�'=W�.iiiiiiiiiiiiiM�iiuiiiiiii�iiiii ■u iii■iiiin �Cii�i��miiiiiii�iiiiOMi�iiii�iiiii HORNE�Ni�i ■ �WOMEN GiREM iiiiiiiiuiiii'ii SEINE en Mumn MW on 0 KEPOPOW REMOVE= MEN NEEMSEI MMUMMMENIME Ml MEWAS'NERNM NOR BEESON MMEMOMMMIMM NAME NPNl7qMMNMR MUMEN soma ENMEM M Now ME M SEEN NOMMEMM1100 spa MARIMEMMUM MENNEN" son NEON a 11111 W-0 EW�0100019-- Wilmmus" Emil; ommommomogs ONE MREMMA�un MEMANNE M ME n' "MEN WE p�iuESE non MEMOS �i MEMOS Him., � �� iiiii%iiiii�i� i NEON ii���i i iiia i i' a EniM��'� ��ME==iMRSE mom �' W, Ell r. E Ej!%Ard r H.K.E.M.M. 58 P05M E SIR NAME Ion 0 MRSEMEMME 0 SAME I'M t;"' 0 MMMMI, ME mossmommmmoommmm oil M too In aid LM Imp ER NNE no momm�ommsonsIN MOMMENNERIMMOMMIMM 11INME Hunlin ONERNMERMANNO REAMMUSEN ■��in lAmm� IUMM N!nmmmmw MooKE Nmiowpl-inbd%r�; NMI I ism It a" 1�� r. M r. an mom INS iW. ��■GiNEON IT ME mom MENNEN Emma mannom� 4w�ww���iiiiii�iwi�iii�' —INONE In owans mum on N mum 111 WMAIR Iwo 011 .00 OE an SIMMIR in 0210�101 0 a MEEW," r man no �iN� u�n�no noun NI�ii =momMARIA OMEN �i r■OUR MMEMEMEN ■ iu� u r ■ LIS �iaa� STATE OF CALEEOP.NIA—STATE_AN3 CONST-,y�� r'ICES AGENCY _ 1 GEORGE DEUKIAFJIAN, Goemo_ r"A FIRE ,MARSHAL 427-4325 916)r •� .'' S CRAMrNTO REGION (s 3 FLORIN ROAD, SUITE 400 AT55466 4325 S CRAMEMO, CA 95823 a 4P j January. 3I1985 Dear Ms. Alnderson s } In--accordance -withthe rovi.sions of Sections 13145 and 13146 of-the � .1iealth and Safet Coae"�State of California ,an •an inspection . reZati_ve .'. to =ire and-life safety was recently made by representatives of this office. Comp 1,JJ it) Clic o1iiI ion, jt}'ovide _ and life safely substanti fly equivalentt.o mini:mum standards: 1 The construction of the building shall be.one-hour fire-resistive. :he building construction is currently not fire-resistive. Section 2-1002➢ T%tle 24; ^al.ifor i_= Code i..i Y C, L 0 1 through any intervening rooms. C'orridors.ourrently passthrough the `Section' 3304.,;. 1.979`' Unzfor-i Rui ldJ .tq Code. f.;.._. Window openings, a dutch door, zn` unprotected opening . i r : t'r.. u' living room provide an unacce Lat).e hazard to the corridor, Section 2-33C14 [gi ; t fP `c rrtia S ni t .'i ve Coc'e 4. The corridor shall be not less than 44 inches wide_ The corridor in this building is 32 36 inches wide at some points. Section 3304[b), Title 24, California administrative Code i - tj _ i ���-- ywv,ernafrs�'.x�nr ,mFxat �x...,..cy.m�.nse�ser January 31, 1985 , Eloise Anderson COTTAGE GUEST HOME 5. Exi.t4ng sha11 be by means of a ramp to grade. A hard -surface shall be pfo; ded to the Pur,l.icstt:eet 7�m all exit doors a n s� Sec 10n 2-3319, Title 24, California Administrative Code, „ Section 3301, 197� U �o� '`ode r' r "6. All exterior exit doorsshall swing in the direction of'egress �T Section 2-3319,1a], "Title 24, �:i_!1i,1 ril.tc Administrz .ive COGe '7- -'All -All exit corridors and 'oors shall be clear of all. ob wructior,s ;Furzsitand conbustis�).Fs -;ball." he removed Section 3s'll Title 19, California.Administrative Code 8. All 3oor hardware shall be -maintained as readily usable. Door knobs s_al1_ be , regi rec, or reFI ced; , 33 _ode The corridor sha '. not bc. u c_ilize .: as; an, air .pl3nul% for. veritilati.on. .t ec for r7� ; '19; 1 uniform. Meehan -,ca? CodE N� e abov Ytems are all deficiencies which must b 1 e corrected however, j.we would con icier •lternate means of protection for Items 1; 4, and The installation, of U`1` ect or semi -direct exiting frora each bedroom, and 2. The`in'sta>_1at'on of a complete products-of-combustion`(autb iT '-rP .alarm GyStem� client - eni, J �� ` s� "M Th s end 3., l( en a t t d . �v:iry a F t .. ` k 3 We mt . E : v�C� ., (30). days, If, ge e eV You. getter bef or(,, ai c_i, 20, �• � , c fire will be fo ced. oSot ay v Department: oF;'Social;s Senna ces that your a 3�. �` i .r '. �i "t' 'P'=3f' t. i_ -, `Q Por t, ` r�y,:��y^W+S�`� d ,�, t •, r ., ,;, ... -act ~1\1, f _ ,. .,. the If you have any coni T)eputy ncv Wol at addrF or- :phone number lis'. _v above, Sincerelyr I WALTER McDERMOTT Regi onal,;Director Sacramento • Regi.on; WM: NV;: nal` i cc: t_epartment or. C ,,,._.e,.,,..Y�,:,r.�.v�-.z s��-;c,�-�:,.=�s,s�rn.� ,�: r�T,er-"�'.»�-..c�-•-• ..a^ .. ^� ,a.,.R-=�,.,�,•�,;,�.,�;.r Cottage Guest Home 1059 Nevada Ave. Oroville, CA 95905 SFM #00-04-42-0002-000-330-0 Comments and Deficiencies Refer to GO --4 dated 10-18-84 1. CAPACITY: The Form 850 dated 9-27-84 requests a fire clearance for 14 aged clients - 4 of whom may be nonambulatory. 20 YEAR BUILT: The original building was built in the 1950's. However, several additions have been made since then which have created uneven floor levels. Exterior wall covering was not changed in some areas when they became interior walls. 13a. CORRIDOR WALL CONSTRUCTION: The corridor walls are not fire -rated. a. The corridor passes through a linen storage room (covered porch). b. The corridor passes through a utility room where it is exposed to a washer, dryer and water heater. C. Portions of the corridor are only 36" wide. .13b CORRIDOR WALL OPENING PROTECTION: a. No self-closing devices are provided for corridor doors. b. Plain glass transom type windows are provided in the corridor. c. A dutch door separates the kitchen from the corridor. d. The Living/dining area is not separated from the corridor. 1.4b. CORRIDOR CEILING OPENING PROTECTION.- No ROTECTION: No fire damper is provided for the return -air duct, 18 RAIV1P S Exits for nonambulatory clients are not provided with adequate ramps to grade. 4• 20. EXITS: a. Exit doors do not swing in the direction of egress. b. Exterior doors in Rooms 5 and 8 (nonambulatory bedrooms) are not readily openable. C. No hard surface walkway is provided from the rear of the house. d. The exterior door from the dining/living room is blocked with storage. 1/85 AM l Comments and Deficiei,cies Cottage Guest Home e. The front walkway is only 24" wide. f. The floor level in the corridor drops approximately 2 1/2" at the rear porch and 3" at the utility room. 21. EXIT HARDWARE:- Some ARDWARE:Some door knobs are unusable. 22a. EXIT SIGNS:. No exit signs are provided. 26. HEATING SYSTEM: The corridor appears to be used as a return air plenum for the air conditioning system. 30o HOUSEKEEPING: Combustibles, furniture and linens are stored in the corridor. SUPERVISION: Page 2 Two nonambulatory clients are housed in a bedroom located off the rear patio. Supervision for these clients --seems to be lacking. Manuela Moralez, Licensing Evaluator, was contacted about this potential problem. She will evaluate the supervision and take corrective action if necessary. of Faci li ty: BUILDING SURVEY RESORT Date: 10-18-84 • $E ess:Ave.. r:Eloise Ander Telephone Noe (916 } of Building: sae ag -sib DESCRIPTION CMllw • � GU -4 (KeV.S/234) Occu n Class �. .Use P S j dnt, 1 -.�.tde.Y:,�. , Capacity ty 14 . Construction ..... SR TyjRe v -N --A one-hour required).'- approx. • Total. 5000 Lar �st Floor, sne a Na. one High- Rise Year Built 195Q's + .�� �r_��rrrrrf ._ _ _-_ Basement Yes No .: Area ( F t . ) Stories . Exterior Wall Construction wood siding - 4 wDgA -9same- lath/plaster) -_I be Opening Protection not re uired Interior Wall Construction. 112" GB'- 2 x 4 wood studs - 1 2" QB ome w Floor plaster) Construction concrete with asphalt the or carpeting- ar etinRoof Roof Construction GB - wood frame iblywood deck - com osition covering Attic Draft St22s No. 1 a. Occ. Sepe, Wall Construction not b. Opening -required Protection Noe not -required -i_-/i�'1_rlMr_rtl I�rr1r1.� _ ..M ■ ■ ■ \�� a. Area Sep. Wall. Construction not re uired b: Opening Protection No. not required 2a. Smoke Barrier Wall. Construction - not re uired -' be Opening Protection not required 1.3a, Corridor Wall Construction def 1/2" GB - 2 x 4 wood studs --j/2" GB some lath/plaster) ---DQnrat9 b ..Opening r t def un rotected and partially -protected openings. 4a: Corridor Ceiling t.Protection Construction def 1 2" GB - nonrated - be Opening . Protection def un rotected - no fire dampers on return air duct 5a. Shafts Nurrber/Type none be opening _ Protection none GU -4 (KeV.S/234) DESCRIPTION t Com • 1 a. Stair Enclosure none . Opening Protection none 1 Stairs NO.- none 1 EEPs No. def 19 Interior Finisb Class Rooms Class III+ Corridor Cla s II+ Exit Encl. ngne_,,,„„ ,. SR 200 Exits def No. Total Width 15, 2 Exit Hardware Type def self-releaging tyne -fLJ a. Exit Signs/ .. = I llumi nation def none rb. Emergency L1 tin not re wired X Io Auto Sprink. t,: .. Coverage com fete system 2 . Standpipes _ Class tion t e - 22 Fire Alarm ZM�=/Cover292_man al s sem -single-station gMoke deter or i ear bCdr.QgM 2 . Heatin def TYPe wall heaters Fuel natural gas Vent yes 270 Electrical Installation mul i reak r 2 . Stage/ Platform none 29. Hazardous Areas none 4. Other def housekeeping,supervision spected By No. Attachments : Daniel e 1 Na � e r.�•_�)_..._._ .�....._ .,�. .�... ■) .) ._.� viewed B Date • •'�� • Nanc Wolfe �•) .�•_�.�, ..,. , • dated: 1-14-85 Wolfe �. a er s -v e * A. �ixi •. • ZV f •L a ��„. r '. L.�zj st':• • - � 1 f y j ,+.yew � u� � •.��,J . T " �• 01 STAT If L COPY DISTRIBUTION; SEL REVERSE OF COPIES 2 AND 3 FOI IF Fl. ti 1NSFECTION REQUEST 1 - STATE FIDE MARSHAL INSTRUCTIONS FOR COMPLETION ST, By ��80) 2 - FIRE AUTHORITY 1. REQUEST DATE" 2. PROGRAM 3 - LI't*NSING AGENCY 9-27-84 k 3 ENI Y CONTACT DSS -Co * ty Care Licensing 4. TELEPHONE NO. S. SIGNATURE . (916) 8 95--5033 - 6. SFM REGION 7. SI=M I.D. NO. 000 cel• 00 04 42 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR 000 330 0 -.0413o��+1 _ 01+03 Manuela Noral.ez I& REQUEST •. - CODE, �](� �j t� ISI ONSE TED f, �n, F,�'` w,• - " CODES t�. 1. ORIGINAL A. FIRE CLEARANCE 1 AGENCY NAME DSS --CCTe 2. RENEWAL B. LIFE SAFETY ANDa a` , .. Bj ,�. 3t. -CAPACITY CHANGE Q ADDRESS 520*CohassetARoad- Su�Lte �.�, 4. OWNERSHIP CHANGE ,. Cbico 4A 95926 �,�a• S. ADDRESS CHANGE L, OTHER •a nnnnmbu1nLqm DATE OF ORIGINAL REI?. .11. AMBULATORY ,,. .. - NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE C PACiTY -AGE RANGE (YEARSY _ PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS ,.,..-.. .,., ._.,.: .- � a ;•� '.�:, ,.,�.. _ - .. CAPACITY To It..18 TO WAND 65 - OWE j CAPACITY i . TO 18 18 TO 65 AND 65 OVE 20_ FACILITY ,� `t 4 :� CODE 1} 745 12 ACILITY NAME .... 13. NO. BLDGS. CODES Cottage Guest Home.. 1. GACH One 7. ICFIoT 14. REET ADDRESS 15r RESTRAINT 2• GACHIR 8. ICF1DD 10 Nevada Avenue r - :... rT1l None 4. APH 14. CLINIC r 0rovillt.e CA - b l_._-------- DE 16. HOURS 5. PHF 11. JAIL -- •-�'' 6 8. SNF 12. OTHER 2 17. ACILITY CONY SON "�"'" TELEPHONE NO. 16A. SPECIAL John d Eloise Anderson (916�_533-1!L% "Res:Ldents l -Elderly ' TO BE COMPLETED BY �� ,fe ..............-.- INSPECTING AUTHORITY'"' ' = 1FIRE ' ;AUTHOR. 27. CLEARANCE CODE NAME CODES. AND.1-. _.:. FIRE. CLEAR. GRANTED ADDRESS. 2-' FIRE, CLEAR. DENIED- �j 3. FIRE CLEAR. WITHHELD 28. DENIAL . . .,.• -CODE • ;-TO BE COMPLETED BY INSPECTING AUTHORITY _ CODES 22: SPECTOR'S NAME. TELEPHONE NO. 23.. CFIRS 24: T-19 OCC. , .,� ID NO. -, CLASS A4 1..! ITS: .,- ° . ' • ♦.. • t:,. ...... . 2; CONSTRUCTION •2,5.1 SP. DATE 26. INSPECTOR'S SIGNATURE . ,. 3. FIRE ALARM 4. SPRINKLERS 29. PLAIN DENIAL OR LIST SP9CIAL CONDITIONS S. HOUSEKEEPING 6. SPECIAL HAZARD T. OTHER STATE FIRE MARSHAL USE ONLY . tyom^ .. -, , fs .r.'-�. jx- _ y -6_ •t w..- 1 •t. :. 1• • 21 REGION= � .. : State Fire Marsha�. - � - - .. - - • - - - 1 -l. .- - r -. -.- - .,.-. t - f _• r-. •J - !ted_ ).. 11,• .,`. W. - . : • • OFFICE tT-04 Florin Road Suite 400 A1�© S acaca meht o 9 CA �82' �J ADDRESS TIME MILES _ •-r"'r"•,t.r�r- rnrrr. NEXT INSP. (MSO. DA. YR.)t r i tr.rrr.r.rr_i ..t. W of Facility Fol E'�`31 LSI 0 FILE N0. ❑❑�� Fol no E] El Fol 0 iS4 REINSPECTION REPORT OFFICE OF CSTATE F /Y� t -A Address /\)Q VADA ,ASC . C)t`Uv)LL-e C PS Conditions Discussed With C Lj r a A()Q r 5 0 J A con ani ed By _ Title J;Qi�'% �_�__� I sP ecti on This Date Discloses That Fire Safety Correction Fire Safety Corrections ated Have Been Complied With. Fire Safety Corrections Were. Discussed Ili th and Disposition Will Be s Follows: • � New Fire Safety Corrections Should Be Reinspection Indicates That Issued. See Reverse Side for Comments and -New ire afety 1AA11A/ rrections. r 101,<-I-lAAA � ti GO -5 (3/70) REV 5/81 Deputy � T Comments and New Conditions,.,(* 1-1 i'vN is 44 AJ Clk; A I New Fire Safety Corrections: 'ICE OF STATE IRE MAR AL NA E AD. RESS 4r STATE FIRE MARSHAL txRE SAFETY CORRECTION N0Tx%_,E FILE NUMBER EJ ElEl 0 El El 'I 000❑ ❑o❑ o00 El In accordance with the minimum standards of Title 19, California Administrative Code., the following corrections are required: The above deficiencies are to be corrected within days. Upon completion, please sign and return the certification on the opposite side of this form. If you have any questions-,, contact the State Fire Marshal's Office at (� ��) II)SUED BY (DEPUTY STATE .FIRE MARSHAL) RECEIVED BY DATE EV -11 (REV. YELLOW : REGION WHITE -FACILITY* GREEN: FIELD 84013-355,7-81 2150.0 TRIP CAM 0T OSP �. _q.s... -:E'er � )!'2�, y •�- - �• tf Tt R ♦.mwZi -• 1Y r> 1- y-' 1. EXITS 2. CONSTRUCTION 25. INISP. DATE 26. INSPECTOR'S SIGNATURE 3. FIRE ALARM 4. SPRINKLERS 29. EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS 5. HOUSEKEEPING 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL COPY DISTRIBUTION; SEE REVERSE OF COPIES 2 AND 3 FOR TRE SAFETY INSPECTION REQUEST 1 - STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION STD 850A (NEW 6/80) 2 - FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM 3 - LICENSING AGENCY "/12./84 CCF109 3. AGE CY CONTACT 4. TELEPHONE NO. 5. SIGNATURE E PT SOCIAL SVCS* COM CARE LIC 4 916) 8 95--w50'336. ADDRESS SFM REGION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR J 00-- 40M loom --000-- 0413"641 0403 19. REQUEST CODE A CODES 1. ORIGINAL A. FIRE CLEARANCE F 2. RENEWAL B. LIFE SAFETY 10.GENCY DEPT SOCIAL S VCS s COM CARE LIC 3. CAPACITY CHANGE AM NDE 5 2 O . C HASSETT ROAD SW TE b 4. OWNERSHIP CHANGE %DDRESS C ICO .=CA 95926 5. ADDRESS CHANGE L 6. OTHER A SULATO Y/4 ON-mA BULATU Yo LICENS*EE AGES 62 OVER DATE OF ORIGINAL REQ. 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE 08/24/82 CA CITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS TO 18 18 TO 65 AND CAPACITY TO 18 18 TO 65 AND CAPACITY 65 OVER 65 OVER 20. FACILITY i IL 4 CODE 740 12. FA CILITY NAME 13. NO. BLDGS. CODES COTTAGE GUEST HOME 1. GACH. 7. ICF/OT 2- GACH/R 8. ICF/DD 14. ST IEET ADDRESS 15. RESTRAINT 3. SH 9. ADHC 1 59 NEVADA AVENUE 4. APH 10. CLINIC 5. PHF 11. JAIL C TY ZIP CODE 16. HOURS 6. SNF 12. OTHER � OVILLE 95965 24+ 17. F CILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL ELISE Lo ANDERSON 9L6-533-1436 RESIDENTIAL-�ELDERLY TO BE COMPLETED BY INSPECTING AUTHORITY 18. FIRE 27. CLEARANCE CODE ; AUTHOR. ' CODES NAME 1. FIRE CLEAR. GRANTED AND ADDRESS I LJ 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. INSPECTOR'S NAME TELEPHONE NO. 23. CFIRS 24. T-19 OCC. ID NO. CLASS 1. EXITS 2. CONSTRUCTION 25. INISP. DATE 26. INSPECTOR'S SIGNATURE 3. FIRE ALARM 4. SPRINKLERS 29. EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS 5. HOUSEKEEPING 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY TIME I MILES I NEXT INSP. (MO. DA. YR.) 21. REGION, OFFICE AND ADDRESS L J STATE FIRE MARSHAL USE ONLY TIME I MILES I NEXT INSP. (MO. DA. YR.) k Vih - .. _ ,. �� • _. 414 =": {'. ' !C' ` G pte �f n ``P { L�� X11¢ `1. �js�Qj' {�_ .c•o.. �R =r - !f[f- - Ow as Qa '�,� '. - , 1 ; : i • c• � •: _ �i .. ,. i ) t! � ��y'jy]y � w� �!. �.•1 *+ .• ��, ry t - !, a � w.t �-' .r. �-, f ' .. • `_ ' .. - - - .�•- y -• is . ') ` •� , i. •` - '. . !' 0 O/ l ri.` V./ Y"i a! : . , r. 0 .1- �.L'. EE `pp ' '• ,`• r-'. t it • E. `: '+ A.P,' - _ _ _yt a _ _ _ . - . _ . `.tf - - •.•• � � - � �� >��_< _ `~ �.r 4,.� � RC1 sem.'.:.` .� a -. ^ • L. `S _ -. •»a4 II �.> ; R'�+ `. 4F i � � �' � � � .. , w► _ •r.•-� -.• __ -.�-.- «._._...__ �.� � • . ____ _ _ _... �'� �•. �;. �+,1�_ � }„ __ - __- , - .. - • .._ - __ •; �y P -Fx � j�sp'y t J. I • �� � ��� J��1 �� _ .. __�.�. _t� ..Y �wi .� �' _ �• d �_x\ eft ...--._...- -_.� r: 'DISTRIBUTION' TATE' FI§E MARSHAL '' COPY :.SEE REVERSE OF COPIES ZAND 3 FOR `SIRE S" ETY INSPECTION REQUEST .- 1 - s,TATE FIRE' MARSHAL T{ -'INSTRUCTIONS. FOR COMPLETION ST17- OA (NEW 6/80) 2 -FIRE AUTHORITY 1: REQUEST DATE 2. PROGRAM 3 - LICENSING, AGENCY', ` . � 'l� �. e�,� � � `� �" 04- � �. 3. AGE CY CONTACT' : ' •' ' 4 TELEPHONE :NO r S. SIGNATURE M+ r\ ASO 4,. /�'p J�j +A� E. jf,�� .,��`` Iii L� j$��y' �. S. L.►. .;y r.J•' J �.iJ ;. L.c �C Y A` = Tt ' V-0 - ,• '� ',' 1 • A � '` v: 'v , p f - 6. SFM REGION 7. SFM I.D. NO. 8, REOUE$TING AGENCY FACILITY NO. 9. EVALUATOR 464 U 19. REALEST - CODE t _ t CODES 1. ORIGINAL A,, FIRE CLEARANCE 17. 2: RENEWAL B- LIFE. SAFETY 10. GENCY' �� E 5 `�, :. . ' .:�• ��i . _. .� .� �. 4 ,. 3 C APACITY CHANGE' ' AME = '.� ..`► S " � .t 6 4. OWNERSHIP CHANGE DORESS: `'• '� ., ,' S: ADDRESS ..CHANGE' 6. OTHER '�} �,jj , J. a. « ; ;. ayd jJy�� , .P '>... y �.. a. # r�sf�y� fq'p ,'1 1j, �ppp� :� 'e _ .• J 1 i 6 1 " �.la `.`-"� �i LIT4i .w l� . . <: n. ''ca. �.;,• it . . t^S17 aw =-:r ' -.ri V P .,'DATE OF O�I:GINAL• REQ... 11. AMBULATORY NONAMBULATORY - ,. , TOTAL�CAP. DATE" OF LAST' -FIRE CLEARANCE CAP CITY.. .AGE R14�N C,E. (YEARS) PRE'V1(US , CAPACITY AGE RANG E (YEARS) PREVIOUS ' TO 18. 18' TO 65 AND CAPACITY TO 18 18 TO. .65 AND CAPACITY' � 65'.OVER 65 OVER : . 20. FACILITY. CODE47* '# 12.; FACILITY NAME 13. NO.'. BLDGS. CODES ' .F.n '1� 1..GACH, , 7.. :I,CF/OT 2.� GACH/R 8. ;ICF/DD 14. ST EET ADQRESS 15. RESTRAINT :3. SH.ADHC - 4. APH: 1-0. CLINIC 5.PHF 11. JAIL CI Y , ; ZIP CODE 16. HOURS 6. SNF 12 OTHER -,. k. �'�5 93 iy f ., It FA LLITY :•,CON'�ACT. PERSON.; '. _ --TELEPHONE NO. 46A. SPECIAL ' A . ♦'r..� -� . ' E', P '�, %�.:3`> .1 t � :;.. � .rt "'1 ,;' `�' 1 5 3 .ate � 3 +� pr ► ti!"+ ��,+ '� c ,�++a 7 � � �y'• ,n' 0 ., . � � . �,. tv ,.1: TO' BE COMPLETED BY INSPECTING AUTHORITY 27. 18. IRE CLEARANCE CODE UTH.M CODES AIME FIRE CLEAR. GRANTED AND DDR'ESS' 2: FIRE .CLEAR. DENIED J .36 FIRE 'CLEAR". ITHHELD 28. DENIAL' , COO ; - TO 'BE COMPLETED BY INSPECTING. AUTHORITY, CODES 22.. IN PECTOR'S NAME TELEPHONE NO.. 23. CFIRS 24.' T-19 :OCC. D NO. .,CLASS 1. EXITS 2. CONSTRUCTION 3. FIRE ALARM 25. IN P. DATE 26. INSPECTOR'S SIGNATURE C 'SPR�INKLERS 5. HOUSEKEEPING 20.' E PLAIN DENIAL - OR LIST SPECIAL CONDITIONS. • .6. SPECIAL. HAZARD. 7. OTHER :STATE FIRE MARSHAL USE ONLY, 21.' REGION, OFFICE .. AND ADDRESS L J TIME' MILES NEXT INSP. (MO. DA. YR.) INSTRUCTIONS This form is designed for use with a window envelope. To use, fold at marks indicated in the left margin. Licensing or Requesting Agencies - Complete the following'21 sections on this form before submitting it to the. State Fire Marshal Complete items marked with an asterisk only when Item 20 is not used. 1. REQUEST DATE. Enter the date request was prepared. 2. PROGRAM. Licensing agency use. 3. AGENCY CONTACT, 4. TELEPHONE NO., 5. SIGNATURE. Enter the .name, telephone number,' and signature of -agency contact person. 6. SFM REGION. Insert one of the following 3 numbers for the SFM Regional, Office in whose area the facility is located. 350 Coastal,- 330 Northern, 370 Southern. 7. SFNI ID NO. This is the SFM Identification Number and initially will be assigned. by the State Fire. Marshal '.-Licensing Agency -Insert this number on all clearance requests subsequent to'the -initial request. 8. REQUESTING AGENCY FACILITY NO. This is the file number assigned by the licensing agency. 9. EVALUATOR. For Iicensing, agency use. 10. AGENCY NAME. AND ADDRESS. Enter the name and address of the licensing facility requesting the inspection. *111. AMBULATORY - NON-AMBULATORY. Complete this section only when Item 20 does not apply. Capacity: Insert, in the appropriate section, the capacity, of licensed ambulatory or non-ambulatory oc- cupants covered by this request, Age Range: Indicate the age range of the licensed occupants. Previous If request is for renewal or capacity change, insert Capacity: capacity of previous clearance. Total Show total licensed capacity. If the Facility is Capacity: intended to house part ambulatory and part non- ambulatory, show the total of the two types of occupants. 12. FACILITY NAME. Insert the name of the facility -as it will appear on the license. 13. NO. SLOB: Insert the 'dotal number of buildings to be used for housing of the occupants covered by the license. 14. ADDRESS. Insert street address and city only. A post office box is not acceptable. 15. RESTRAINT. Indicate if physicial restraint (locked in a room or the building) is to be used in the housing of the. occupants. Y = yes., N = no. *16. HOURS. Indicate the at of hours the occupants are housed at the facility. (Less than 24 or 24+). 16a SPECIAL Use to designate persons who are determined to be non-ambulatory for reasons other than a physical handicap. 17. FACILITY CONTACT PERSON -TELEPHONE NOV Indicate the name and telephone- number of the re- sponsible, in'dividual at the facility to'be contacted by the fire authority. 18. FIRE AUTHOR. NAME AND ADDRESS. Inserl: the name and address of the fire authority in the vicinity where the facility is located.. 19. RE41UEST CODE. Use the six codes. shown and insert the appropriate number in the box following "Request Code". Insert date of original request when request is other than an original, 20. FACILITY. CODE. Mark this item only if the facility is a: (1) General Acute Care Hospital (GACH), (2) General Acute Care Hospital/Rehab (GACH/R), (3), Special Hospital (SH), (4) Acute Psychiatric Hospital (APH), (5) Psychiatric Health Facility (PHF), (6) Skilled Nursing Facility (SNF), (7) Intermediate Care Facility/Other (ICF/OT), (8) Intermediate C*are Facility/Developmentally Disabled (ICF/DD), (9) Adult Day Health Care (ADHC), (10) Clinic, (11) Jail or (12) Other. When Item 20 is used, Item 11 does not need to be completed (except total cap), 21. REGION, OFFICE AND ADDRESS.'Insert the nameand address of the State Fire Marshal Regional Office in whose area the facility is located. Fire Authority ' Conducting the Inspection - Complete the following: 22. INSPECTOR' , S NAME. Print the initial of the in- spector's first name and - full last name; insert the telephone nulm ber where the inspector may be contacted. 23. CFIRS ID.NO. Insert the fire department's number asigned by CFIRS. 24. TITLE 19 OCC. CLASS. Use Title 19 occupancy classifications and insert the occupancy deter- mined by the inspector. 25. INSP. DATE Enter the actual date of the in- spection. 26. INSPECTOR'S SIGNATURE. To be signed by inspector conducting the inspection. 27. CLEARANCE COD E.'Use the three codes shown and insert the appropriate number in the box following "Clearance Code". NOTE: If Code 2 (Denied) or Code 3 (Withheld) is used, explain. 28. DENIAL CODE. Use only the seven codes shown and insert rthe appropriate number in the box following "Denial Code". If No. 7 "Other" is used, explain at item 28. NOTE: Fire Clearance cannot be denied for other than lack of con- formance with the provisions of Title 19. 29., EXPLAIN DENIAL. If Clearance Code No. 2 or 3 is used, briefly explain reason. This space is also to be used to explain Denial Code item noted. ?"OkIN, /00011� .-,OFFICE OF THE STATE FIRE MARSHAL,_ I" a T -t Title %.__ --A(k UC -ST 410 Aq 6 INSPECTION LOG 1019 ON RD File 110111M oao Uoo E] Address (051 AIEV40 AVEA1 UC- OROVILLC CA , q S4 G150 Date 3_1 - �4 Owner /k)QVAI)A 1� L 10 f, v tj T L 4 A) i�c L i A GO -6 (Rev. 5/841 A 10/11 /k)QVAI)A 1� L 10 f, v tj T L 4 A) i�c L i A GO -6 (Rev. 5/841 ba OFFICE OF THE STATE FIRE MARSHAL INSPECTION LOG Title File P [11 B 0 Baa aQa a Address 10179 NeVAt?�§ AV E N U G oC0vtLLe cq. g5yt5Date I - II-��{ Owner i 19, c6i A 0 AtJfJuAL ��r �FP74 1 4 s eC i 10 tJ LAJ /V\ �. n 0 ;., uv rT T.,J GO -6 (Rev. 5/81) — - - — — iii•.. r...■�.__■.��._..�..�.■�� . r.n�._�n ■.��_ ��.�.i�i s GO -6 (Rev. 5/81) ;- - 'I - F 1 ICENSE CHANGE if i a+Lii0il a-, a s b i t yell 'W, x to: Cottca-ge Hia-me A, DD F! F --'q 0 F C I L I TY '1059 GFFY A.N[D' CU*DjjN-ry: 0 r 0 v I[ GA. 09 5 9-6' 5 1 r- im p- N; v 1 9 I E I- E- F—H U I L Z. 53-10-14-110 op C, 1-1 Lice i i -'s, 2 1 s i. Inca d #04130-431 F&Mmiily Home A-dL.-JLL"j Hid F T -Y IJ tii S0 1 C Fz 0 F A, if a -Y S E 0 ' EN 4v OR (I.."ONINEINTS ED C 1 1 T y -- Ccs M%"ESTIGATION N"1 1 -.- I %- 6 . EMS, F C Counlk"-v "ory Lb)v Vour p -a t S Ir f �j j-1 �J_ inic-rat:-1.'Llor, i -s pre,1.,ide.r s REECIJEEST FO;F-31 FIRE S-fkFIET"I" C L E C E t1--, - , 14, 1 '— A I a t c 1, 4—, ; -.*:$1 4, L; -,=i z7pprop�iatc fire ins,--lct: fri�ec!c a,I.J subit-i4 0 s f 7 L '1., 4-1 t �, r IiCerlSe vii-thdrav,-i-I of-' danied o -ick- reci---ipt of the appro--.Ir! C. GLENN COUNTY ITELFM� D RA PT lktE I P D C, r ENN S i C 0 U ffl" H 0 USJ IE AN N LE X CkMi I T W Ir L L 0'r 17 S CA 8 520 r 11 talS' k-)' i -T% FN (,-',A D S U - rL TE- 6 c H I C", 0 CA 95 2 6 ;- - 'I - F 1 ICENSE CHANGE if i a+Lii0il a-, a s b i t yell 'W, x to: Cottca-ge Hia-me A, DD F! F --'q 0 F C I L I TY '1059 GFFY A.N[D' CU*DjjN-ry: 0 r 0 v I[ GA. 09 5 9-6' 5 1 r- im p- N; v 1 9 I E I- E- F—H U I L Z. 53-10-14-110 op C, 1-1 Lice i i -'s, 2 1 s i. Inca d #04130-431 F&Mmiily Home A-dL.-JLL"j Hid F T -Y IJ tii S0 1 C Fz 0 F A, if a -Y S E 0 ' EN 4v OR (I.."ONINEINTS ED C 1 1 T y -- Ccs M%"ESTIGATION N"1 1 -.- I %- 6 . EMS, F C Counlk"-v "ory Lb)v Vour p -a t S Ir f �j j-1 �J_ inic-rat:-1.'Llor, i -s pre,1.,ide.r s REECIJEEST FO;F-31 FIRE S-fkFIET"I" C L E C E t1--, - , 14, 1 '— A I a t c 1, 4—, ; -.*:$1 4, L; -,=i z7pprop�iatc fire ins,--lct: fri�ec!c a,I.J subit-i4 0 s f 7 L '1., 4-1 t �, r IiCerlSe vii-thdrav,-i-I of-' danied o -ick- reci---ipt of the appro--.Ir! STATE (RE -MARSHAL FIRE SAFETY INSPECTION REQUEST ^Ak, 1 COPY DISTRIBUTION; 1 • STATE FIRE MARSHAL 3E REVERSE OF COPIES 2 AND 3 FOR rNSTRUCTIONS FOR COMPLETION STD 85 A (NEW 6180) 2 FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM 3 LICENSING AGENCY 3. AG NCY CONTACT 4. TELEPHONE NO LESS COI -i 71dTTY CPT', LICENSING ;SIGNATURE 6. SF REGION 7. SFM I.D. NO-jF 8. REQUESTING AGENCY FACILITY NO. 9. EVALUATOR 1 C�. J 1 C 1 G C " C� ` 19. REQUEST .� CODE CODES 1. ORIGINAL A. FIRE CLEARANCE - 2. RENEWAL B. LIFE SAFETY 10. GENCY AME DEPART! E11T OF SOCIAL SERVICES 3. CAPACITY CHANGE NO vomrnunity Care Licenisng 4. OWNERSHIP CHANGE DDRESS 2400 Glendale Lane, Suite C 5. ADDRESS CHANGE 112�--crarnento, CA 95J2'-- 6. OTHER DATE OF ORIGINAL REQ. - 11. AMBULATORY NONAMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE CA ACITY AGE RANGE (YEARS) PREVIOUS CAPACITY AGE RANGE (YEARS) PREVIOUS TO 18 18 TO 65 AND CAPACITY TO 18 18 TO 65 AND CAPACITY 65 OVER 65 OVER 20. FACILITY 1 1 CODE 12. F CILITY NAME 13. NO. BLDGS. CODES Co Aage Guest Horr!e 1. GACH 7. ICFIOT 2• GACHIR 8. ICF/DD 14. S rREET ADDRESS 15. RESTRAINT 3. SH 9. ADHC 10 `i iVe,Tada Avenue 4. APH 10. CLINIC 5. PHF 11. JAIL C TY ZIP CODE 16. HOUR$ 6. SNF 12. OTHER Or v7.?_ie, CA 17. F CILITY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL L1Xi -,iIy 1,I•31SC l7?(�P_Xti0?1 1 - TO BE COMPLETED BY INSPECTING AUTHORITY 18 FIRE F 27. CLEARANCE CODE AUTHOR. OFFrCE OF STATE FIRE MARSHAL CODES NAME 7800 Lincolnshire Drive. Suite 170 1. FIRE CLEAR. GRANTED AND Sacramento, CA 96823 ADDRESS 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE - TO BE COMPLETED BY INSPECTING AUTHORITY CODES 22. NSPECTOR'S NAME NO. 23. CFIRS 24. T•19 OCC. ID NO. CLASS -- =TELEPHONE 1. EXITS 2. CONSTRUCTION 3. FIRE ALARM 25. NSP. DATE 26. INSPECTOR'S SIGNATURE _ 4. SPRINKLERS 5. HOUSEKEEPING 29. XPLAIN DENIAL OR LIST SPECIAL CONDITIONS 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY 2 REGION, l . OFFICE OF STATE FIRE MARSHAL OFFICE 7300 V�nshire Drive. Shite 170 AND Sacramento, CA 96823 ADDRESS LTIME MILES NEXT INSP. (MO. DA. YR.) INSTRUCTIONS This form is designed for use with a window envelope. To use, fold at marks indicated in the left_ margin. Licensing or Requesting Agencies — Complete the following 29 sections on this form before submitting It to the state Fire marshal Complete items marked with an asterisk only -when Item 20 is. not used.. 1. REQUEST DATE. Enter the date request was 14. ADDRESS. Insert street address and city only. A prepared. post office box is not acceptable. 2. PROGRAM.- Licensing agency use. 15. RESTRAINT. Indicate if physicial restraint (locked S. AGENCY CONTACT4. TELEPHONE Rio. 5. in -a room or the building) is to be used in the SIGNATURE. Enter the name, telephone number, housing of the occupants. Y= yes N = no. and signature of agency contact person. 160 HOURS. Indicate- the - number. of hours the 6. SF REGO®N. Insert 9 one of the following 3 numbers occupants -are housed at the facility. (Less than •' for the SFM Regional office in whose area the 24 or 24 facility is located. 16a SPECIAL. Use to designate persons who are 3.50 Coastal, 330 Northern, 370 Southern, determined to be non-ambulatory for reasons other than a physical handicap. 7. SFM AD No. This is the SFM identification Number - and initially 'will be assigned by the State-. Fire .. 17: FACILITY CONTACT PERSON � TELEPHONE NO. larshai. Licensing Agency —Insert this ildrnber on :. Marshal. Indicate the name and -telephone number of the re - all clearance requests subsequent to the initial sponslble Indiv dual at the facility to be contacted request . by the fire authority. 8. REQUESTING AGENCY FACOLITY. NO. This is the 18. FORE AUTH.GR. -NAME AND ADDRESS.- Insert the file number -assigned. by the licensing agency. name and address of the fire authority in the vicinity . , , where the fac.i.lity. is located-. 9. EVALUATOR. For licensing. agency use. _ _ 19. REQUEST CODE. Use the six codes shown and 10. AGENCY NAME AND ADDRESS. Enter the name 'requesting insert the -appropriate number in the box following and addvess of `the licensing facility "Request Code". Insert date of original request g q . the inspection. when request is other than an original. i *11. AMBULATORY ® NONeAMOULATORY. Complete 0' . PACILOTY CODE. dark. this iters only, if the facility this section only when Item 20 does not apply. is a: 1 General Acute Care Hospital GACH 2 • Capacity: Insert, in the appropriate section, the capacity. General Acute Care l-iospitallRehab (GACHIR), (3) of licensed ambulatory or non-ambulatory oc- Special hospital (SH), (4) (Acute Psychiatric Hospital cupants, covered by this request. (APH)7 (5) Psychiatric Health Facility (PHF), (0) Age Range: IndiCate the age range of the licensed occupants. Skilled Nursing Facility (SMF), (7) intermediate Previous If request is for renewal or capacity change, insert Capacity: capacity of previous clearance. (aa Facilltyther:tlF/o`j, (�} intermediate Care . , Tota! Show to#al licensed capacity. If the Facility is Capacity: intended to house , FAc4 jjty_1D�q_veI.op pnta.1��y, -Disabled (ICF/DD), (9) Adult, -Dc' HiAhbHO), (� 0 Clinic, (11) Jai art ambulate and art non- P ambulatory PE - ambulatory, show the total of the two types of or (12) Other. w�Ien1fe�1'�1 �20 is used ,item 11 does occupants. not need to be completed (except total cap). 12. FACflUTY NAME. insert the name of the facility as 21. REDO®N., QFFOCE AND ADDRESS. Insert the name it will appear on the license. and address of the State Fire Marshal Regional 13. NO. SLUGS. Insert the total number of buildings Office'! hn whose -area the facility 'is located. to be used for housing of the occupants covered by the license..... Fire Authority Conducting the Inspection — Complete the following: 22. INSPECTORS- NAME. Print the initial of the in- - 27. CLEARANCE CODE. -Use the three -codes showrn spector's first name rand full last name; insert the and insert the appropriate number in the box telephone number where the inspector may be following "Clearance Code". - - - -contacted. NOTE: If Code 2 (Denied) or Code 3 (withheld) is used, explain. 23. CFIRS 1D.W0. Insert the fire department's 26. DENIAL CODE. Use only the seven codes shown y � number assigned by CFIRS. and Insert the appropriate number n the box i 24. TOTLE 19 OCC. CLASS. Use Title 19 occupancy following "Denial Code". If No. 7 "other" is used, classifications and insert the occupancy deter- explain.at_jtem.2$.. . ��_•° •. mined by the inspector. , . _ ran � Qt bei,dented for other than lack of con - 25. INSP. DATE Enter the actual date of the in- �,aane with the Provisions of Title 19. , ; prow � spectlon. .•.y, 29. EXPLAIN DENIAL. If Clearance Code No. 2 or 3 26:" INSPECTORIS SOGNATURE. , To be signed by is used, briefly explain reason. This space is also inspector conducting the inspection° to be used to explain Denial Code item noted. ,TEFIRE MARSHAL _ COPY DISTRIBUTION; SEE REVERSE . SAFETY INSPECTIO14 �_ _.4��c�,.: 1 - STATE FIRE MARSHAL ;� �` of Cpp //vS7RUGT /ES 2 AND 3 pt 18 A p�l�, N 6180) .� 2 . FIRE AUTHORITY )n '' �° � IONS FOR COMP R L ETIOiV ., � 3 - LICENSING SING AGENCY ._ _ �- REQUEST DATE 2 .PROGRAM A ENCY CONTACT 4. TELEPHONE NO. �p3�, �� 5. SIGNA%URE .S-�C0101UNITY CAPE LICENSING 91_b--895-503 SFM REGION 7. SFM I.D. NO. 8. REQUESTING AGENCY FACILITY N0. 9. EVALUATOR 041"04641 JI1tDe .c M() 'ca .E' 19. REQUEST CODE 2 CODES �. ENC Department � 1. ORIGINAL A. FIRE CLEARANCE O� ME SOCi�1. SCg'v�C�� 2. RENEWAL B. LIFE SAFETY A D �• '.'�'); ��• tiI'Licensing s CCAS 3. CAPACITY CHANGE A DRESS rla"�set in 4. OWNERSHIP CHANGE 4.1.1 6.nC©����Ct . �C�18ai3°C � 5. ADDRESS CHANGE hi c o 9 CA 95920 6. OTHER DATE OF ORIGINAL REQ. 11. AMBULATORY LPAC ITY AGE RANGE (YEARS) PREVIOUS NONAMBULATORY TOTAL CAP. DATE OF LAST -FIRE CLEARANCE CAPACITY CAPACITY AGE RANGE (YEARS) PREVIOUS T018 18 TO 65 AND 65 OVER CAPACITY T018 18 TO 65 AND . L4/, XX Xyl ��;_ 65 OVER t_� t.•;- -.�r i� , .._ �.1. __ • 20. FACILITY CODE 'ACI ITY NAME 13. NO. BLDGS. CODES 30 0AGE GUEST HC*`�T" 1 TRE T ADDRESS 1. GACH 7. ICF/OT 15. RESTRAINT 2. GACH/R 8. ICF/DD L059 NEVADA 3. SH 9 ADHC . ,EVEN ITY ONE 4. APH 10. CLINIC ZIP CODE 16. HOURS 5. PHF 11. JAIL �� Ck� (Butte) 95 965 6. SNF 12. OTHER 241 ACIL TY CONTACT PERSON TELEPHONE NO. 16A. SPECIAL URI & ELOISE ANDERSON 91. T_ FAM. IR11'. - ADULTS j �6 TO BE COMPLETED BY FIR INSPECTING AUTHORITY AUI HOR. 27. CLEARANCE 1►r CODE NAME CODES AND 1. FIRE CLEAR. GRANTED ADORES s D RESS L 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 28. DENIAL CODE c TO* BE COMPLETED "BY INSPECTING AUTHORITY r SPEC OR'S NAME TELEPHONE NO. 23. CFIRS 24. T-19 OCC. CODES ID NO. CLASS 1. EXITS .. 2. CONSTRUCTION SP. DJ TE 26. INSPECTOR'S SIGNATURE 3. FIRE ALARM lo( .%''1:"�. �f �J 4. SPRINKLERS PLAM DENIAL OR LIST SPECIAL CONDITIONS 5. HOUSEKEEPING 6. SPECIAL HAZARD 7. OTHER STATE FIRE MARSHAL USE ONLY IEGIC N, )EPIC IND 1DDR SS L -I TIME I MILES NEXT INSP. (MO. DA. YR.) S I • - r'✓ , INSTRUCTIONS. `.•T for use with a window envelope. . ned �9- To use, fold at marks indicated in the left margin. 21 form This form Is : ues#ing Agency ,�. Complete the following sections on this i4rising ojr R�q . Ll before submitting. it to the state Fite Marshal o m late items-7marked with an. a.�terisk only when Item 20 is not used. Cp 1• REQUEST DATE. Enter the date request was 14. ADDRESS. Insert street address and city only. A Prep aced. post office box is not acceptable. AM Licehsiri agency use.15. 2' RROGR 9 RESTRAINT. Indicate if physicial restraint (lockecl in -a room or the building) is to be used in the -3. AGENCY, CONTACT9 4. TELEPHONE NO., 5. housing of the occupants. Y= yes N = no. SIGNATURE. Enter the name, telephone number, and 9 signature of agency contact person. 9 16. HOURS., Indicate the number of hours the occupants are housed at the facility. (Lessthan 6. SFM REGION. Insert one of the following 3 numbers 24 or 24+). for the SFM Regional .Office in whose area the facility is located. 16a SPECIAL. Use to designate persons who are -reasons determined. to be non-ambulatory for othE,r h 370 Southern. Sao Coastal, 330 Northern, than a physical handicap. 7. SFM ID NO. This is the SFM Identification Number 17. FACILITY CONTACT PERSON-® TELEPHONE NO. - and. initially, will- be assigned-. by the State Fire he name and telephone' number of the re - Indicate t p Marshal. Licensing Agency —Insert this number on - Ma 9 9 y . • - . sponsible individual -at the facility to be contacted 'all clearance -requests subsequent to the Initial by the fire authority. ,request. - o This is the 3• RE���ST1NG AGENCY FACILITY �® 16. FIRE AUTHOR. NAME AND ADDRESS. Insert the name and address of the fire authority in the vicinity file number -assigned by the licensing agency. where the facility is located. 9. EVALUATOR. For licensing agency use. 19. REOUEST CODE. Use the six codes shown and 10:: .AGENCY NAME AND ADDRESS. Enter the name insert the .appropriate number in: the box fallowing and address of the licensing facility re�.uesting "Request Code". Insert date of original request the inspection. when request is other than an original. *11. AMBULATORY ® NON-AMBULATORY. Complete 20. FACILITY CODE. Mark this item only if the facility this section only, when Item 20 does not apply. 47 4Capacity: is a: (1) General Acute Care Hospital (GACH), (2) Insert, in the appropriate section, the capacity of licensed ambulatory or non-ambulatory oc- General Acute Care HospitallRehab (GACHIR), (3) Special Hospital (SH), (4) Acute Psychiatric Hospital cupants covered by this request, (APH), (5) Psychiatric Health Facility (PHF'), (6) Age Range: Indicate the age range of the licensed occupants. Skilled Nursing Facility (SNF), (7) Intermeditate Previous If request is for renewal or capacity change, insert Care Facility/Other (ICF/OT), (8) Intermediate Care Capacity: capacity of previous clearance. FacilitylDevelopmentally Disabled (ICFIDD), (9) Total Show total * licensed capacity. If the Facility is Adult Day Health Care (ADHC), (10) Clinic, (11) ,.Jail Capacity: intended to house part ambulatory and part non- ambulatory, show the total of the two types of or (12) Other. when Item 20 is used ,Item 11 does occupants. not need to be completed (except total cap). 12. FACILITY NAME. Insert the name of the facility as 21• REGION, OFFICE AND ADDRESS, Insert the name it will appear on the license. and address of the State Fire Marshal Regional 13. No BLDGSo Insert the total number of buildings Offi:Ge in whose area the facility is located. - to 'be used for housing of the -occupants covered by the license. Fire Authority Conducting the inspection -- Complete the following: '1 22. INSPECTOR'S NAME. Print the initial of the in- sPector's first name and full last name; insert the 27. CLEARANCE CODE. Use -the three codes shown and insert the appropriate number in the box I � telephone number where the inspector may be _- fallowing "clearance Code". _ contabted. NOTE: If Code 2 (Denied) or Code 3 (Withheld) is used, explain, 23• CFIRS 1D.N0• Insert the fire department's 23• DENIAL, CODE. Use only the seven codes shown number assigned by CFIRS• and insert the appropriate number in the box 24. TITLE 19 ®CC. CLASS. Use Title 19 occupancy following "Denial Code". if No. 7 "Other" is used, classifications and insert the occupancy deter- explain at item 23. mined by the inspector. - NOTE: Fire Clearance cannot be denied for other than lack of con - 25. INSP. ®ATE Enter the actual dale Of the in- formance with the provisions of Title 19. spection. 29. EXPLAIN DENIAL. If Clearance Code No. 2 or 3 signed b .26. INSPECTORS SIGNATURE. TO be 9 y is used, briefly explain reason. This space is also to be used to explain Denial Code item noted. inspector conducting the Inspectiono - -t 0 �>, 04 -L REINSPECTION REPOR�. Fileaof& (209114 110 OFFICE OF STATE FIRE MARSHAL Date Reinspected Name of Facility--CATI A(t �o J 9 Q>'T V -k OM't — ---- - - ---- Address --- A2- --AJ-LM-Dh---Afi V ULL-c-____—CA—L— ``� r, e conditions Discussed With- L A- AD:& Accompanied,,* By. Af S /A (A 0.4r S 0 4 Title--- () V --NR Inspection This Date Discloses That Recommendations Number --- - -------- 10 C L v Fr 4 AA ----------- ------ )____�_-------------__ of 'Recommendations �� �__ � �____�____�_____�_ Dated----A-------Have Been Complied With. Recommendations Numbers — ------- -- - ---------- - ------ • -------------------------------------------------------- fjo de — -------- Were Discussed With— - - - — ---------- - ---------------------------- --------------- a -------- ----------and Disposition Will -Be AsFollows: ------ — -------- - ----------- - ------ --- - - -- - ---------- -- - --------------------- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 0 o ---------------------- C At `6 k A r A N-0 - ----------------------------------------------------------- I ----- ---- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - r - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - ------------------------------------------------------------------------------------------------------------------------- Reinspection Indicates That---,---AJLQ------New Recommendations Should Be Issued, See Reverse Side for Comments and New Recommendations, 26861-355 11-68 8700 O OSP Deputy --------------------------------------------------------- ------------------------------- ------------------------ -------------------------------------------- 0 s ----------------------------------------------------------------------------------------•----------------------------rr--...-----------------------•---------------- : suo 4vpu9wtuoaa}j (noN ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ :suozjzpuoo max puv slumucoo