HomeMy WebLinkAboutBUSINESS PLAN~ PROSPERITY SUCCESS HOME 2
4714 PEACOCK COURT
J,
?.r:..r .~--t..~ ~ h x"°-~ y~.:ru~~x-:::v ,r,.-w~;- :.~ ~ -.,. ~, - .~ , ~ , ~.,.k^..~t,~ati~;.., a•-'::~-'1..;,isc..~:.w:.v.+~a.;4':.-.~..wa.-cw:.ww~Yt~...vy ~. _ ..,. _ _ y ,. M., ~ _ . .. f.. . ;x ..
~, ~ ~ ' )
~~~~?573
~, ', a i, BAKERSFIELD FIRED
--`~ ~~ ~'` ~' Prevention Services ~ ~~~ ~~ ... ~'~~~~~- ~ ~~~~
RE PR:EVEN`TION INSPECTION B EFiRE I n 900 Truxtun Ave., ste. 2io ~ r;
-~~' ABTM T Bakersfield, CA 93301 ~,,i -~'~f .~j~ ~j
Tel.: (661) 326-3979 ^ Fax: (661) 852-2171
,,-' ,~`
-DISTRICT _..,,. BLOCK NO. DATE I „ '-7 ,,,,.. r~ /
I r<• (/ / ~EE~ ' ~- :.~
FACILITY ADDRESS ~'., `~->=''
,rte .. CITY, STATE, ZIP r
FACILITY NAME ~ MANAGER'S ME FACILITY PHONE NO.
4 ..~G/ ~
BUSINESS OWNER'S NAME AND ADDRESS ~ CITY, STATE, ZIP OWNER'S PHONE NOv
BILL TO: (IF DIFFERENT FROM ABOVE) NAME, ADDRESS CITY, STATE, ZIP, BILLING PHONE NO.
OCC TYPE OCC LOAD NO. OF FLOORS HIGH RIS BL G ISER TE
^ YES ~_ _ NO
CORRECT ALL VIOLATIONS VIOLATION REQUIREMENTS ~ ~ ~
CHECKED BELOW xo.
BUSTIB
STE /DRY
W 1 Remove and safely dispose-of-all_hazardous refuse and dry vegetation on the above premises (U.F.C.)
LE
A
COM
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.)
r
{ ~ Relocate fire extinguisher(s) so that they will be in a conspicuous location, hanging-on brackets with the top to the
t ~,. 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
.`
~---r. `immediately accessible for use in (area) ______________ U.F.C.)
~' Re-charge all fire extinguishers. Fire extinguishers shall be serviced a- I as o e ar, and/or after each use,
~ 6y.a-person having a valid license or certificate. (U.F.C.) ~'~-
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
-------------------
FIREDOORS/
FIRE SEPARATIONS shall return the surface to its original fire resistive condition. (U.B.C.)
~~ -
"
~ 10 Remove/repair (item & location) ____________________ ____ _______ ________
__ ___________ Self-closin
9
_
doors shall`bedesigned 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 93 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.)
oUTDOORBURNING 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, r ardin fir orks.
OTHER 1g A ~
x t. I ~ ~
I ~/I
' - i y
~ ~ ~' ~~~ ~"1 .-....-.-----'_""~ 'V
~ '~
CUSTOMER: ~ `. i' ~ ' . ., j ~ 1 -! . --.--- ... ___ LEGEND:
( Ignature~ (Please Print Name Legibly, Title)
`~
~ C.F.C. CALIFORNIA FIRE CODE
U.B.C. UNIFORM BUILDING CODE
B
M
C
BAKERSFIELD MUNICIPAL CODE
.~~, %{ ;~ j
~
INSPECTOR: ..
.~ ~ AP NO.: P ....,-'" .
.
.
N.F.P.A. NATIONAL FIRE PROTECTION
( __ ($IgnBtUre) ! """" ASSOCIATION
~._~. ., ~
N.E.C. NATIONAL ELECTRIC CODE
White -Customer/Original " Yellow -Station Copy Pink -Prevention Services FD 2022 (ReV. 09/05) _
~~
..-':
_ - - - ---. - - - -- - - - - ~ atv
1
~: ~„TE OF CA~I.IFORNIA ^.
~~~1RE SAFETY INSPECTION REQUEST
~~'~~~~. 850 (REV. 10-4A)
~SENCY CONTACTS NAME
LATCC
EVALUATOR'S NAME
Esequiel Rodriguez
TELEPHONE NUMBER
323 981- 3324
REQUESTING AGENCY FACILITY NUMBER
157806025
LICENSING
AGENCY Department of Social Services
NAME AND Los Angeles and Tri-Coastal Counties
ADDRESS Children's Residential Program
1000 Corporate Center Dr. Suite 200A
Montery Park, CA 91754
REQUESTDATE PROGRAM
11/02/06 Group Home
AMBULATORY NONAMBULATORY BEDRIDDEN
CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY
_0006 ___-_------~------_-__------___---__-----------------..._.._______._~.---__~----...---------
FACILITY NAME
Prosperity Success Home 2 _
STREETADDRESS(Actua/LOCatronJ
4714 Peacock Court
CITY
Bakersfield, CA 93313
FACILITY CONTACT PERSON'S NAME
Patricia Hunn Tel: (661)301-8804
SPECIALCONDITIONS ~ ^
REQUESTCODE
lA
__ CODES __ u_____
1. ORIGINAL A. FIRE CLEARANCE
2. RENEWAL B. LIFE SAFETY
3. CAPACITY CHANGE
4. OWNERSHIP CHANGE
5. ADDRESS CHANGE
6. NAME CHANGE
7. OTHER
TOTAL CAPACITY
ouo6
LICENSE CATEGORY
GH-730
NUMBER OF BUILDINGS
RESTRAINT
HOURS
2417
TO BE COMPLETED BY INSPECTING AUTHORITY i""-'"-'""~.
L.~ -`
FIRE Bakersfield City Station # 13
AUTHORITY 4900 Poppyseed
NAME AND Bakersfield, CA 93313
ADDRESS
l-- ---~
INSPECTOR'S NAME (Typedor Printed)
,---.
INSPE~ATE INSPECTOR'S NATU E(Ty
11__:3- ~~
EXPLAIN DENIAL OR LISTSPECIAL CO DITI
LEARANCEIDE(t~IAL CODE
CODES ____
1. F E CLEARANCE GRANTED
2. FIRE CLEARANCE DENIED
A. EXITS
8. CONSTRUCTION
C. FIRE ALARM
0. SPRINKLERS
E. HOUSEKEEPING
F. SPECIAL HAZARD
G. OTHER
See instructions on reverse.
TELEPHONENUMBER CrIRS NUMBER OCCUPANC'lCLASS
~~ -
~_ ~r
' ~ -~
.x'
5.
STATE OP CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
-. APPLICATION FOR A COMMUNITY CARE FACILITY OR RESIDENTIAL CARE FACILITY
FOR THE ELDERLY LICENSE (See Instructions on Back)
FOR DEPARTMENT USE ONLY I
DISTRICT: ~/
COUNTY: BERN _FACILITY NUMBER:
DATE: _ACTION TYPE:
REVIEWED BY: FACILITY TYPE:
REPLY TO:
1. APPLICANT(S) NAME(S) (PLEASE PRINT) 2. RE UESTEO ACTION (CHECK QNE):
^ D. CHANGE OF FACILITY TYPE
CIIUfJ.C <.,ICCK nUl11C,111G A. INITIAL APPLICATION ^ E. CHANGE OF AMBfNON-AMB STATUS
B. CHANGE OF CAPACITY ^ F. CHANGE WITHIN CORPORATION
^ C. CHANGE OF LOCATION ^ G. OTHER (Specify)
3. APPLICANT MAILING ADDRESS CITY ~ STATE ZIP CODE AREA CODElTELEPHONE
135 SO MILHAM DR BAKERSFIELD CA 93307 (661 ) 301-8804 _
4, APPLICATION A. INDIVIDUAL B. PARTNERSHIP / C. NON PROFIT CORP. G. LIMITED
LIABILITY
FILED BY: D. PROFIT CORP E. COUNTY F. OTHER PUBLIC AGENCY COMPANY
ILITY OR AGE
N
CY
NA
E
_
F
A
C
M
5
~
y
p~.~{~ q~ ,{-~~+-!~
~
p~~G
~
,
~
~
/
~
-- ". rRIJJ~~'t' -J~IJ I.~I.~CJ~IJIViGJ L__ ~ .. _.. -. ~ -- -.- -
6. FACILITY STREET ADDRESS CITY COUNTY ZIP CODE AREA CODERELEPHONE
4714 PEACOCK COURT BAKERSFIELD KERN 93313 ( 661 X301-8804
7. FACILITY MAILING ADDRESS CITY STATE ZIP CODE
5806 BRIDGE CREEK AVE _ __ BAKERSFIELD CALIF 93313
8. ADA4INISTRATOR OR PERSON IN CHARGE OF FAC ILITY TITLE
PATRICIA HUNN , , CEO
9. TYPE OF AGENCY OR FACILITY ~ 1 11. FOR CHILDREN'S FACILITIES
^ ADULT RESIDENTIAL
^
SOCIAL REHABILITATION 10. TOTAL REQUESTED CAPACITY ONLY:
_
^ RESIDENTIAL FACILITY-ELpERLY ^ FOSTER FAMILY AGENCY ~`
"
NUMBER OF:
^
RESIDENTIAL FACILITY-CHRONICALLY ILL ^ gDOPTfON AGENCY tOA.
~7
ADU
T
Y-CARE NUMBER OF NON-AMBULATORY O I
OA
~J
L
^
TRANSITIONAL HOUSING
(1F ANY) AGES 0
0 '
O
UGH 2)
THR
^
ADULT DAY SUPPORT CENTER PLACEMENT PROGRAM
I-~
^
OTHER (SPECIFY) NUMBER UNABLE TO INDEPENDENTLY TRANSFER
0
CHILDREN
NJ GROUP HOME ANDlOR BEDRIDDEN (IF ANYj
^ (AGES 3 6
THROUGH 17)
SMALL FAMILY HOME I
12. DAYS AND HOURS OF OPERATION: 13. PROPERTY OWNERSHIP:
24 HRS I ^ OWN ~ RENT ^ OTHER (SPECIFY)
13A. NAME, ADDRESS AND PHONE NUMBER OF PROPERTY OWNER, IF RENTING OR LEASING:
Henrietta Beavers 10111 Patterson Stree Bakersfield, Ca 93311
14. WAS FACILITY PREVIOUSLY LICENSED? IF YES, FACILITY NAME AND NUMBER:
^ YES ^ NO I
LICENSING AGENCY NAME'
15. IS MAJOR CONSTRUCTION REQUIRED? DATE CONSTRUCTION TO BEG4N~.
^ YES ^ NO DATE TO BE COMPLETED:
16. SOURCE OF WATER FOR HUMAN CONSUMPTION
® PUBLIC ^ PRIVATE __ __
17. ENTER THE INFORMATION BELOW FOR ANY COMMUNITY CORE FACILITY OR HEALTH FACILITY PREVIOUSLY OR CURRENTLY OWNED OR OPERATED BY APPLICANTS. REFER TO INSTRUCTIONS.
s.
#197605697
COMMUNITY CARE LICEN
18. APPLICANT(S)/LICENSEE(S) RESPONSIBILITIES:
A. fN ADDITION TO COMPLYING WITH THE HEALTH AND SAFETY CODES AND REGULATIONS APPLICABLE TO LICENSING AND FIRE SAFETY, 1/WE UNDERSTAND THAT THERE MAYBE
OTHER STATE, FEDERAL AND/OR LOCAL LAWS, WHICH ARE NOT ENFORCED BYTHIS AGENCY, THAT MAY NEED TO BE MET SUCH AS: ZONING, BUILDING, SANITATION AND LABOR
REQUIREMENTS. ___ .._
B. 1/WE HAVE READ AND UNDERSTAND THE STATUTES AND REGULATIONS WHICH PERTAIN TO MY/OUR LICENSING CATEGORY PRIOR TO THE ISSUANCE OR RENEWAL OF MY/DUR
LICENSE.
C I/WE SHALL ENSURE THAT ALL-PERSONS SUBJECT TO FINGERPRINT REQUIREMENTS SHALL HAVE A DEPARTMENT OF JUSTICE CLEARANCE OR A CRIMINAL RECORD EXEMPTION
PRIOR TO EMPLOYMENT, RESIDENCE OR INITIAL PRESENCE IN THE FACILITY AS REQUIRED.
D. fF 1/lNE OPER,4TE A FACILITY WHICH PROVIDES CARE AND SUPERVISION TO CHILDREN. I/WE SHALL ENSURE THAT A CHILD ABUSE INDEX CHECK FORM FOR EACH PERSON SUBJECT
TO FINGERPRINT REQUIREMENTS IS SUBMITTED TO THE DEPARTMENT OF JUSTICE AS REQUIRED.
E. 1/WE SHALL NOTIFY THE LICENSING AGENCY IMMEDIATELY IF A PERSON, SUBJECT TO FINGERPRINTING REQUIREMENTS, IS CONVICTED OF A CRIME AFTER EMPLOYMENT
F. I/WE SHALL OBTAIN APPROVAL FROM THE LICENSING AGENCY PRIOR TO MAKING ANY CHANGE(S) THAT AFFECT THE TERMS OF THE LICENSE.
19. IANE UNDERSTAND THAT IANE NAVE THE RIGHT TO APPEAL ANY DECISION REGARDING THE DISPOSITION OF THIS APPLICATION.
20. I/WE DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS APPLICATION AND ON THE ACCOMPANYING ATTACHMENTS ARE CORRECT TO THE BEST OF MYlOUR
KNOW GE.
~t. L^JVE" ""„'A AL'THORiZED TO SIG;)TN FPLICAT(ON OPJ 6Eh'ALF OF THE NA1~1c'D APPLiCAiJT 1`~--~
i' '-
1~ ~~~+-_~"`+•'~~ ~ TITLE CEO COUNTY WHERE SIGNED KERN V`~ \~ D'A'f~E-~
y
SIGNED ..- ___ __ .__ _ . TITLE _ __ .. __ __ COUNTY WHERE SIGNED _ _ DATE
LIC 200 (8103) _ .. _. .~~ ..,:
f i ~~
~,? t < < `~
.. -<`i_ k
..
fl
_c. ~
SafetyForLifel
ce F-~e
t~
c
Pia
-~
i
~~ ~~~ ~~f~ -~a ~~
.-,
~Y1Gn~~ ~ , ,(~'~--~1~~
Courtl~sy Of
BAKERSFIELD FIRE DEPARTMENT
Helping To Make Our Community A Safer Place To Live!
` ~~ .I To reorder this publication call 800841-9532 and ask for product #PBFP83PAD
ISBN 1-56230.662a ®1998 Syndistar, Inc. 5801 River Road, New Orleans, LA 70123-5106
_-~
4T-.M1T~ D`PARTMENT OF soCiAt. seRV!cEs
r~munity Care Licensing Division
,._,a & Tri-Coastal Counties Children
Residential Program Office
1 OUO Corporate Center Dr., Suite 200A
Monterey Park, CA 81754
----
--
~,~~~\ -
'~~
niuiiiiiiiiiiiiiiiiiiiiiiiuiNii~ni
,002 2.~0 000 93.a 3~3~
'
~g g:E<sa ~.~
C A
E~~ ~'a~ ~~
.
i;~i~'s f5~ ~
F
_ '~ _ .; __° _:~.i+`: _ - _ _ i:~.:... _ ~1!~!!!!~~!!!~!!!!!~~?!1~???'tlIl?I?i?1~!!~!~!!~~d!ilt!!}!4ti?t~