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"`"~'SPECTION RECORD elr~'~e~p4.
1715 Chester Ave.
1.6%' _.
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Bakersf--i~el~~, C',E~A 93301 /
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DATE: ( FACILITY ADDRESS: ~"~ ~ ~ .~ ZIP: FE
FACILITY NAME: t/~ , 8
MANAGER NAME: ~"n A o~~ .PT ..?.u~, DD FACILITY PHONE X33' S 1 ~jC~
BUSINESS OWNER NAME, ADDRESS, ZIP CODE
BELL TO: (IF DIFFERENT FROM ABOVE}--NAME, ADDRESS, ZIP CODE, PHONE No.
OCC E OCC LOAD No. OF FLOORS HI RISE BLDG.
YES O NO RISER ATE
V10tATION NOTICE CORRECTION:
1. DATEbFREINSPECTION
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INSPECTOR: _ /` i~"~ ~`
-----~ AP No. ~ FIRE PREVENTION SERVICES
(661) 326-3979
WHITE ORIGINAL-OWNER YELLOW-INSPECTOR'S COPY PINK-FILE
FD1952
~K
;-~
STATe LIFORNIA
~E SSAFETY INSPECTION REQUEST
~STD.850(REV.10-94)
See instructions on reverse.
AGENCY CONTACT'S NAME TELEPHONE NUMBER REQUEST DATE PROGRAM
LATCC 323 981- 3324 11/16/05 Group Home
EVALUATOR'S NAME REOUESTINGAGENCYFACILITYNUMBER REQUEST CODE
Elnora Smith 197804725 ~ lA
CODES
r ~ 1. ORIGINAL A. FIRE CLEARAI
LICENSING
2. RENEWAL B. LIFE SAFETY
AGENCY Department Of SOClaI Serv1CCS
NAME AND 1,05 ArigeleS and Tri-Coastal COUnt1eS 3. CAPACITY CHANGE
ADDRESS Children's Residential Program 4. OWNERSHIP CHANGE
1000 Corporate Center Dr
Suite 200A
. 5. ADDRESS CHANGE
~Montery Park, CA 91754
_J
6. NAME CHANGE
7. OTHER
AMBULATORY NONAMBULATORY BEDRIDDEN TOTAL CAPACITY
CAPACITY PREVIOUS CAPACITY CApgCfTY PREVIOUSCPPACITY CAPACITY PREVIOUSCAP.4CiTY
6 6
FACILITY NAME ~ LICENSE CATEGORY
Miss Freise Youth Home for Girls GH-730
STREETADDRESS (Actual Location) NUMBER OF BUILDINGS
721 8th Street 1
CITY I RESTRAINT
Bakersfield, CA 93304
FACILITY CONTACT PERSON'S NAME ~ ~ HOURS
Administrator - (661) 633-5130 ~ ~ ~ 24/7
SPECIAL CONDITIONS
TO.BE COMPLETED BY INSPECTING AUTHORITY"
' LEARANC /DENIALCODE
CODES
FIRE $akersfleld Clty Flre Department 1. IRE CLEARANCE GRANTED
AUTHORITY prevention Services
NAME AND 2. FIRE CLEARANCE DENIED
900 Truxhin Ave., Suite 210
ADDRESS Bakersfield, CA 93301 A. ExITs
B. CONSTRUCTION
C. FIRE ALARM
D. SPRINKLERS
INSPECTOR'SNAME(TypedorPrinted) TELEPHONE NUMBER CFIRSNUMBER OCCUPANCY CLASS
t~r~ ~ J~ ~~_
'1~,f(, ~
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a, E. HOUSEKEEPING
F.. SPECIAL HAZARD
INSPECTION DATE INSPECTOR' G RE(TypedorPrinted) G.~OTHER
EXPLAI N GENIAL OR LIST SPECIAL CONDITIONS
-•~ '
;~ STATEQFCALIFORNIA ,
FIRE SAFETY INSPECTION REQUEST
^STD. 850 (REV. 10-94) (REVERSE) ~ N STR U CT lO N $
This form is designed for use with a window envelope
Licensing or Requesting Agencies--Complete the following 19 sections on this form
before submitting it to the fire authority having jurisdiction. .
1. AGENCY CONTACT, 2. TELEPHONE 10. FACILITY NAME.• Insert the name of the facility a
NUMBER, 5. EVALUATOR. Enter the name and will appear onthe license. List identifying sub name ifkno
telephone number of agency contact person. (i.e., Hacienda Corp/Medina Lodge).
3. PROGRAM. Licensing agency use. 11. LICENSE CATEGORY. Insert the category of lice
4. REQUEST DATE. Enter date request was prepared. being sought as it will appear on the license certificate
G. REQUESTING AGENCY FACILITY NUMBER. This 12. ADDRESS. Insert street address and city only. A p
is the file number assigned by the licensing agency. office box is not acceptable as only location.
7. .REQUEST CODE. Use the seven codes shown and insert 13. NUMBER OF BUILDINGS. Insert the total munbe
the appropriate number in the box following "Request Code". If buildings to be used for housing ofthe occupants covered
._ the..license. _ _ _ _ _ - . _
- `-NANIE`CI=IANGE; please List previous name. Insert date of`Y- ~ '"
original request is other than an original. 14. RESTRAINT. Indicate if physical restraint (locked
8. AGENCY NAME AND ADDRESS. Enter the name and
address of the licensing facility requesting the inspection.
9. AMBULATORY--NONAMBULATORY--BEDRID-
DEN.
Capacity: Insert in the appropriate section, the capacity
of licensed ambulatory or nonambulator}~ oc-
cupants covered by this request.
room or the building) is to be used in the housing of
occupants.
1.5. FACILITY CONTACT PERSON--TELEPHO
NUMBER. Indicate the name and telephone number of
responsible individual at the facility to be contacted by
fire authority.
1.6. HOURS. Indicate the number ofhours the occupants
housed at the facility (less than 24 or 24+).
Previous If request is for renewal or capacity change, 17. SPECIAL CONDITIONS. Indicate any conditi
Capacity: insert capacity of previous clearance. unique to this request. As an example, if the inspec
Total Show total licensed capacity. If the facility is request is for one building in amulti-building facility.
Capacity: intended to house part ambulatory, nonambu-
latory, and part bedridden, show the total of
the three types of occupants.
FIRE AUTHORITY CONDUCTING THE INSPECTION--COMPLETE THE FOLLOWING:
18. FIRE AUTHORITY, NAME AND ADDRESS. Insert 22. OCCUPANCY CLASSIFICATION. Use Califon
the name and address of the fire authority where the facility is Building Code occupancy classifications and insert
located. occupancy determined by the inspector.
19. CLEARANCE/DENIAL CODE. Use the two codes: 1 23. INSPECTION DATE. Enter the actual date of
for clearance granted, and 2 for clearance denied. If denied, inspection.
also include the appropriate letters code. As an example, Denial 24. INSPECTOR'S SIGNATURE. To be signed by
based upori exiting would be coded 2A. inspector conducting the inspection.
20. INSPECTOR'S NAME. Print the initial of the inspector's
first name and full last name; insert the telephone number
where the inspector may be contacted.
21. CFIRS LD. NUMBER.. Insert the fire department's num-
benassigned by California. Fire Incident Reporting System.
25. EXPLAIN DENIAL OR SPECIA
CONDITIONS. If clearance code #2 is used, brie
explain reason. This space is also to be used to specify a
additional limitations placed by the fire authority, such as
use of certain floors or sleeping rooms approved
nonambulatory clients.
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Shut-Offs
O Gas
O Electrical
O Water
In case of an emergency evacuate building from North, South, and East exits. North
exit to the sidewalk or parking lot and remain until further instructions are given.
East exits to the parking lat and remain until further instructions are given. South
exits to the parking lot and remain until further instructions are given.
E
Measurements
13'5"x11'9"
2~ 10' 1"x
14'
.
22'x13'6"
Bedrooms
Occupants
2- Teens
1-Teen/1-Child
1-Teen/1-Child
725 Bth Street
Bakersfield, Cao 93304