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FIRE PREVENTION INSPECTION a EP~IRe'
A ARTM T
BAKERSFIELD FIRE DEPT. ~~-
Prevention Services ~ I'O
900 Truxtun Ave., Ste. 210 ~/~/
Bakersfield, CA 93301
Tel.: (661) 326-3979 ^ Fax: (661) 52-2171
DISTRICT BLOCK NO. DATE _~'7 ~~ ~
/ FEE ~ ~~ -~
FACILITY ADDRESS I ~ ~ / ~~ ,/~ /~ ~ ~ ~ f / ~
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FACILITY NAME
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~[~ r ~ ~,~~/ ~ MANAGER'S NAME FACILITY PHONE NO.
BUSINESS OWNER'S NAME AND ADDRESS CITY, STATE, ZIP OWNER'S PHONE NO.
BILL TO: (IF DIFFERENT FROM ABOVE) NAME, ADDRESS CITY, STATE, ZIP, BILLING PHONE NO.
OCC TYPE„ - -`
~ OCC LOFAD
~` NO. OF FLOORS
` HIGH RISE BLDG
l RISErR D-SAT-~E--
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CORRECT ALL VIOLATIONS viouriox REQUIREMENTS ~
CHECKED BELOW No.
COMBUSTIBLE WASTE I DRY 1 Remove and safely dispose of all hazardous refuse and dry vegetation on the above premises (U.F.C.)
VEGETATION 2 provide non-combustible containers with tight fitting lids for the storage of combustible waste and rubbish pending its
safe disposal. (U.F.C.)
COMBUSTIBLE STORAGE 3 Relocate combustible storage to provide at least 3 feet clearance around motor fuse box/fire door (N. E.C.) (U.F.C.)
4 Relocate fire extinguisher(s) so that they will be in a conspicuous location, hanging on brackets with the top to the
extinguisher not more than 5 feet above the floor. (N.F.P.A. No. 10)
EXTINGUISHERS 5 Provide and install (amount) _____ approved (type & size) __________________ portable fire extinguisher to be
_____ _______________________ (U.F.C.)
immediately accessible for use in (area)
g ~I{
Re-charge all fire extinguishers. Fx[mUu
by a person having a valid license ~-~~Fh ca e`.'"'° ~~s II e d at least once each year, and/or after each use,
( F. .)
7 Provide and maintain "EXIT" sign(s) with letters 5 or more inches in height over each required exit (door/window) to
SIGNS fire escape. (U.F.C.)
g Provide and maintain appropriate numbers on a contrasting background and visible from the street to indicate the
correct address of the building. (B. M.C.) (U. F. C.)
g Repair all (cracks%holes/openings) in plaster in (location) ______________________________________. Plastering
FIREDOORSI
FIRE SEPARATIONS shall return the surface to its original fire resistive condition. (U.B.C.)
10 Remove/repair (item 8 location) _________________________________________________________, Self-closing
doors shall be designed to close by gravity, or by the action of a mechanical device, or by an approved smoke and
heat sensitive device. Self-closing doors shall have no attachments capable of preventing the operation of the
closing device. (U.F.C.)
EXITS 11 Remove all obstruction from hallways. Maintain all means of egress free of any storage. (U.F.C.)
12 Provide a contrasting colored and permanently installed electric light over or near required exit (location)
______________________________ to clearly indicate it as an exit. (U.F.C.)
STORAGE 13 Remove all storage and/or other obstructions from fire escape landings and stairways stair shafts. (Fire
escapes/stair shafts are to be maintained free from obstructions at all times.) (U. F. C.)
14 Extension cords shall not be used in lieu of permanent approved wiring. Install additional approved electrical outlets
ELECTRICAL APPLIANCES where needed. (N.E.C.) (U.F.C.)
15 Remove multiple attachment cords from specific electrical convenience outlet (one plug per outlet) (N. E.C.) (U. F.C.)
OUTDOOR BURNING 16 Violation of Section 1102 dealin with recreational fires or o en burnin U.F.C.
FIREWORKS 17 Violations of Section 7802 U.F.C. or 8.49.040 of the Bakersfield Munici al Code B.M.C. re ardin fireworks.
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CUSTOMER: LEGEND:
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`(Signature) c I (Please Print Name Legibly, Title) C.F.C. CALIFORNIA FIRE CODE
U.B.C. UNIFORM BUILDING CODE
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INSPECTOR: ~~.' I~\ k !f~ JJ)~ ~~ ~. ~/(„------ AP NO.: ~ B.M.C. BAKERSFIELD MUNICIPAL CODE
N.F.P.A. NATIONAL FIRE PROTECTION
(Signature) V ASSOCIATION ,;.,
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N.E.C. NATIONAL ELECTRIC CODE
nnr-%~eu
White -Customer/Original Yellow -Station Copy Pink -Prevention Services FD 2022 (Rev. 09/05)
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~ STA~i~`U CALIFORNIA
FIRE SAFETY INSPECTION REQUEST
STD.850(REV.10-94)
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See instructions on reverse.
AGENCY CONTACT'S NAME TELEPHONENUMBER REQUEST DATE I PROGRAM
LATCC 66l 285-5242 7/17/2007 Group Home
EVALUATOR'S NAME REQUESTINGAGENCYFRCILITY NUMBER REQUEST CODE
Blnora Smith 157806036 1 A
CODES
1. ORIGINAL A. FIRE CLEARANCE
LICENSING LIFE SAFETY
2. RENEWAL B
AGENCY Department of Social Services .
NAME AND Los Angeles and Tri-Coastal Counties 3. CAPACITY CHANGE
ADDRESS Children's Residential Program 4. OWNERSHIP CHANGE
1000 Corporate Center Dr. Suite 200A
i Montery Park, CA 91754 ~
I~ 5. ADDRESS CHANGE
6. NAME CHANGE
' 7. OTHER
AMBULATORY NONAMBULATORY BEDRIDDEN TOTAL CAPACITY
CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY
4 4
FACILITY NAME LICENSE CATEGORY
Rimes Coronado GH-730
STREETADDRESS (ACfua/location) NUMBER OF BUILDINGS
4516 Coronado Ave. 1
CITY RESTRAINT
Bakersfield, CA 93306
FACILITY CONTACT PERSON'S NAME HOURS
Misty Varner 24/7
SPECIAL CONDITIONS
_,. „.
_~ ~ TO.BE COMPLETED BY INSPECTING AUTHORITY ~~
_ P
~~~~~ V ~~ ~ ~~~~ CLEARANCE/DEN LCODE
D
_ CO
ES
PIKE Bakersfield City Fire Department 1. IRE CLEARANCE GRANTED
AUTHORITY 900 Truxtun Ave.
Suite 210
NAME AND , FIRE CLEARANCE DENIED
Bakersfield, CA 93301
ADDRESS .A. EXITS
L ~ B. CONSTRUCTION
C. FIRE ALARM
D. SPRINKLERS
INSPECTOR'S NAME(Typed or Printed) TELEPHONE NUMBER CFIRS NUMBER OCCUPANCY CLASS
E. HOUSEKEEPING
~~ f'~_ ~ 3 F. SPECIAL HAZARD
I ECTIONDATE INSPECTO SI (Typed orPrin dJ ~ G. OTHER
a -~
EXPLAIN DENIAL ORL ST SP ECIALC DI I NS
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STATE OF CALIFORNIA
FIRE SAFETY INSPECTION REQUEST
STD.850 (REV.10-94) (REVERSE) INSTRUCTION S
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
NUMBER, 5. EVALUATOR. Enter the name and
telephone number of agency contact person.
1.0. FACILITY NAME. Insert the name of the facility as it
will appear on the license. List identifying sub name ifkno~vn
(i.e., Hacienda Corp/Medina Lodge).
3. PROGRAM. Licensing agency use.
4. REQUEST DATE. Enter date request vas prepared.
11. LICENSE CATEGORY. Insert the category of license
being sought as it will appear on the license certificate.
6. REQUESTING AGENCY FACILITY NUMBER. This 12. ADDRESS. Insert street address and city only. A post
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 number of
the appropriate number in the box following "Request Code". If buildings to be used for housing ofthe occupants covered by
the license. _
NAME CHANGE, please list previous name. Insert date 'of - -~` ~ - -- -
original request is other than an original. 14. RESTRAINT. Indicate if physical restraint (locked. in a
8. AGENCY NAME AND ADDRESS. Enter the name and room or the building) is to be used in the housing of the
address of the licensing facility requesting the inspection.. occupants.
9. AMBULATORY--NONAMBULATORY--BEDRID-
DEN.
Capacity: Insert in the appropriate section, the capacity
of licensed ambulatory or nonambulatory oc-
cupants covered by this request.
15. FACILITY CONTACT PERSON--TELEPHONE
NUMBER. Indicate the name and telephone number of the
responsible individual at the facility to be contacted by the
fire authority.
16. HOURS. Indicate the number of hours the occupants are
housed at the facility (less than 24 or 24+).
Previous If request is for renewal or capacity change, 17. SPECIAL CONDITIONS. Indicate any conditions
Capacity: insert capacity of previous clearance. unique to this request. As an example, if the inspection
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 AUTI-IORIT~' CONDUCTING THE INSPECTIOi~t--COMPLETE THE FOLLOWING:
18. FIRE AUTHORITY, NAME AND ADDRESS. Insert 22. OCCUPANCY CLASSIFICATION. Use California
the name and address of the fire authority where the facility is Building Code occupancy classifications and insert the
located. occupancy determined by the inspector.
1.9. CLEARANCE/DENIAL CODE. Use the two codes: 1
for clearance granted, and 2 for clearance denied. If denied,
also include the appropriate letter code. As an example, Denial
based upon exiting would be coded 2A.
23. INSPECTION DATE. Enter the actual date of the
inspection.
24. INSPECTOR'S SIGNATURE. To be signed by the
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-
ber assigned by California Fire Incident Reporting System.
25. EXPLAIN DENIAL OR SPECIAL
CONDITIONS. If clearance code #2 is used, briefly
explain reason. This space is also to be used to specify any
additional limitations placed by the file authority, such as the
use of certain floors or sleeping rooms approved for
nonambulatory clients.
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STATE OF CALIFORNU - F4EAlTH AND HUMAN-SERVICES AGENCY ~ CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNfTY CARE LICENSING
FACILITY SKETCH (Floor Plan)
\ Applicants are required to provide a sketch of the floor plan of the home or facility and outside yard. The floor sketch must label rooms
such as the kitchen, bath, living room, etc. Circle the names of the rooms that will be used by staff/residents/clients/children. Door and
window exits from the rooms must tie shown in case of an emergency (see Emergency Disaster Plan). Show room sizes (e.g. 8.5 x
12). Keep dose to scale. Use the space below. See bads for yard sketch.
FACILfTY NAME: - ADDRESS:
MMES Coronado. 4516 Coronado Ave. Bakersfield CA. 93306
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COAt1At11MYCRRE LiCE/~{SING
FACILITY SKETCH (Yard)
The yard sketch should show ail buildings in the yard including the home (with no detail}, garage and storage building.
Include walks, driveways, play area, fences, gates. Show any potential hazardous area such as pools, garbage storage,
animal pens, etc. Show the overall yard size. Try to keep the sizes close to scale. Use the space below.
FA,CILffY NAA1E: ADDRESS:
_AIMES Coronado 4516 Coronado Ave. Bakersfield CA. 93306 __
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1NSR~CTION RECORD
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Bakersfield Fire Dept.
1715 Chester Ave.
Bakersfield, CA 93301 ,
DA; E~ + ~ FACILI~ t DDRE~ ~~.~- J~ I~ ! FEE:
FACILITY NAME: ~ ~ !S `
MANAGER NAME: w
BUSINESS OWNER NAME, ADDRESS, ZIP CODE /
FACILITY PHONE Lol a ~~~~
BILL TO: (IF DIFFERENT FROM ABOVE-NAME, ADDRESS, ZIP CODE, PHONE No.
OCC TYP OCC LOAD No. OF FLOORS
I HI RISE BLDG. ~
YES O NO ~~ RISER DATE
/~.
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VIOLATION NOTICE CORRECTION:
1.
2. ~ ~ y i ~ c~- c :~->~--
~~~--t.~.~•r~.~ DATEbFREINSPECTION
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14. '
15.
NOTES
CUSTOMER: ~
INSPECTOR: ~. ~-~-~-~" /1-_..._
AP No. ~ FIRE PREVENTION SERVICES
(661) 326-3979
WHITE ORIGINAL-OWNER YELLOW-INSPECTOR'S COPY PINK-FILE
FD1952
°----'-_
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STATEOF CALIFORNIA
.~FiSAFETY INSPECTION REQUEST
.~
STD. 85i. (RE V. t 0.94)
See instructions on reverse.
AGENCY CONTACTS NAME TELEPHONENUMBER REOUESTDATE PROGRAM
LATCC 323 981- 3331 12/07/05 Group Home
EVALUATOR'S NAME REQUESTING AGENCY FACILITY NUMBER REQUEST CODE
Irene Yamamoto 157806004 lA
CODES
1. ORIGINAL A. FIRE CLEARANCE
LICENSING RENEWAL 8. LIFE SAFETY
2
AGENCY Department of Social Services .
NAME AND Los Angeles and Tri-Coastal Counties 3. CAPACITY CHANGE
ADDRESS Children's Residential Program 4. OWNERSHIP CHANGE
1000 Corporate Center Dr. Suite 200A
Montery Park, CA 91754 I
l- _l 5. ADDRESS CHANGE
6. NAME CHANGE
7. OTHER
AMBULATORY NONAMBULATORY BEDRIDDEN TOTAL CAPACITY
CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY
4 4
FACILITY NAME LICENSE CAT EGUKY
AIMES Coronado Group Home GH-730
STREETADDRESS (ActualLocatron) NUMBER OF BUILDINGS
4516 Coronado Ave 1
CITY RESTRAINT
Bakersfield, CA 93306
FACILITY CONTACT PERSON'S NAME HOURS
.Kevin Vaner Tel: (661)663-3332 24/7
SPECIAL CONDITIONS
TO BE COMPLETED BY INSPECTING AUTHORITY
BAKERSFIELD FIRE DEPT.
FIRE PREVENTION SERVICES
AUTHORITY
NAME AND 900 TRUXTUN AVENUE, STE 210
ADDRESS BAKERSFIELD, CA 93301
L- ~ ~
INSPECTOR'SNAME(TypedorPrinted) I TELEPHONE NUMBER CFIRSNUMBER OCCUPANCYCLASS
~~~ ~ra..>,` (lid ) 326 ~~ s~o~ ~~
INSPECTION DATE INSPECTO IG RE(Type r rioted)
~ /`/^~/1/G~7
PLAIN DENIAL OR LISTSPEC~I~LCO 1 10 S ,cY~'~--
CODES
1. FIRE CLEARANCE GRANTED
2:- FIRE CLEARANCE DENIED
A. EXITS
B. CONSTRUCTION
C. FIRE ALARM
D. SPRINKLERS
E. HOUSEKEEPING
F. SPECIAL HAZARD
G. OTHER
"
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STATE OF CF!~!FORNIA -HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
co-nMUNrrv CARE ucEN51NG
_- FACILITY SKETCH (Floor Plan)
Applicants are required to provide a sketch of the floor plan of the home or faality and outside yard. The floor sketch must label rooms
such as the kitchen, bath, living room, etc. Circle the names of the rooms that will be used by staff/residents/Gients/children. Door and
window exits from the rooms must be shown in case of an emergency (see Emergency Disaster Plan). Show room sizes (e.g. B.5 x
12). Keep close to scale. Use the space below. See back for yard sketch.
FACILm NAME: ~ ADDRESS:
AIMES Coronado 4516 Coronado Ave. Bakersfield CA. 93306
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STATE OF G~,IFORNUI • AEALTH AND HUMAN SERVICES AGENCY ~ CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
~,
FACILITY SKETCH (Yard)
The yard sketch should show all buildings in the yard including the home (with no detail), garage and storage building.
Include walks, driveways, play area, fences, gates. ~ Show any potential hazardous area such as pools, garbage storage,
animal pens, etc. Show the overall yard size. Try to keep the sizes close to scale. Use the space below.
FACILffY NAME: ADDRESS:
AIMES Coronado 4516 Coronado Ave. Bakersfield CA. 93306
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