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21110 80TH PL W (2)FIRE'PREVENTION Serving Brier, ramonds, and 12425 Meridian Ave S INSPECTION REPORT SNO110r.11SWCO Mmintlake Terrace F1 Everett, WA 98208 0 EDMONDS 0 BRIER . - =22 DISTRIQ IET Phone (425) 551' - 1200 Fax 551-1272 0 MOUNTLAKE TERRACE 0 UNINCORPORATED www.FireDistrietl.org (425) 21110 80 th Place W 98026 FREQUENCY STAIIgTSHIFT"' Annual LOCATION: I Salish Apartments 4257754616 SCHEDULED Feb 2017 BUSINESS NAME: PHONE: D�TE DUE MAILING 320 Da yton,Edmonds, WA 98802 423206 LIFIR 0 ADDRESS: Aimie Litchfield BUSINESS OWNER: HOME PHONE: Chris Lyon 4254789189 EMERGENCY-1: HOME PHONE: CURRENT KEY ACCESS-2:. HOME PHONE: CITY YES NO BUSINESS F--j Fv-1 EMAIL: LICENSE nJ PERSON CONTACTED: INITIAL INSPECTION DATE NAME OF INSPECTOR: I Serving Bri r, �h AioLn e �2'�!h,5`Meridian Ave S FIRE PREVENTION INSPECTION REPORT ,and Mountlake Terrace. Everett, WA 98208 DEDMONDS 0 BRIER Phone (425) 551-1200 0 MOUNTLAKE TERRACE F1 T www.FireDistrictl.org Fax (425) 551-1272 [1 UNINCORPORATED LOCATION: 21110 80 th Place W 98026 BUSINESS%�NAME: Salish Apartments MAILING ADDRESS: WA 98802 BUSINESS OWNER: PHONE: HOME PHONE: EMERGENCY-1: HOME PHONE: KEY ACCESS-2: HOME PHONE: EMAIL: PERSON CONTACTED: Ao rorkr4 NAME OF INSPECTOR: t gc, rr%t 11) L Prod, FIRE SYSTEMS: AS 3/15 FA 3/15 FE 3/15 FD Lk Bp I F .1 ", FREQUENCY I STATION& SHIFT An 6-D SCHEDULED DATE DUE � Feb 2016 LIFIR 423 206 ',CURRENT CITy YES NO BUSINESS.' FUV LICENSE:'. LA INITIAL INSPECTION zz . DATE Ljl,� yr HAZARDS FOUND AND LOCATIONS COMMUNICATIONS 2 -2, --'AA/,v i A 0 1 o A) 3 3' k, 4 7, A 5 6 .. ............ 6. . . ... ......... . ..... . ..... 7 7 I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X 1 st RE -INSPECTION 12nd RE -INSPECTION �EXTENSION FINAL RE -INSPECTION VIOLATIONS DATE DUE: ITEDUE: GRANTEDTO: DATE DUE: CITED: PERSON PERSON PERSON .S.ONTACTED CONTACTED: CONTACTED, INSPECTOR: INSPE4'OR: INSPECTOR: 2. DATE: DATE: DATE: 3 VIOLATIONS VIOLATIOW, PRE -CITATION CITATION ISSUED 5 15 LETTER SENT NUMBER: 4 CODE 5 2 6 2 6 DATE: SECTION: RETURN RECEIPT 6 7 3 7 CEIVED C, DISPOSITION: 4 8' 4 8 DATE: 7 Lj: LETTER N - E . EDED _ff YES�,,,PAO LETTER NEEDED YES El NO 8 I T, E E,,merald Pir Fire Sprinkler Specialists 11021 Cramer Rd. KPN - Gig Harbor, WA 98329 Office (253) 857-2056 - Fax (253) 857-2312 - Local 699 Contractor AUTOMATIC SPRINKLER SYSTEMS (One System per Report) ks--,;L 2/110 YO-L6 rtw,.- L/V, Occupancy Address: tNa, Cj avg& Occupancy Nam Responsible Person: —Phone Number: Building Owner: Phone Number: Date of Inspection: 2-1 �to Type of Inspection: Quarterly 0 Annual W Other E] Testers Name (Please Print): F40 Pagem 14 WA State FSCC# 0633-1 U t DRY SYSTEM/PRE-ACTION SYSTEM: 1. Trio test (dry trip or full flow)- cond ucte'd: .................................................... Yes Fj Nb[ p System tripped in -seconds. 2. All flow switches,supervisory s . witches anclala'4 bells tested: ............. *..'...'..,,Yes E] No E] N/A E] 3. Alarm bell operates: ....................... . .......... ... Yes E] No [] N/A E] Flow tests conducted: .................. ..... V 4. ........... Yes [] No E] Flow pressure: psi -inch drain? ......... ............................ Yes F] No f_1 5. Systems inspected and lubricated: ................. ............... .. .................... Yes E] No E] N/A E] 6. Air compressor refills system in 30 min s: ..................... . ................... Yes Fj No E] A 7. System drained and restored to rmal operation: ..................................... Yes R No E] 8. Were the heat actuation vices tested on pre -action and deluge system? ..... Yes E] No E] N/A E] WET SYSTEM/ANTI-FREEZE SYSTEM: Tested at 1. Trip test c6nducted:........'....."-..'....*.'.,.'.'................. ...................... Yes JX No El Static pressur : .!C- -N ......... r2i: n No N/A e,- psiFl.ow-pr,essure: psi i ch drain? ....... Yes Flow I switches,'supervisory's'w'itches and alarm . bel Is tes t I ed . : ........................ Yesrp No E] N/A r-1 I Alarm bell operates: .............................................................................. Yes q No;A N/A E] 4. Systems inspected and lubricated: .......................................................... Yes RR No El Lr 5. Pressure regulating valves tested: ........................................................... Yes F-1 No E] N/A DQ 0 0 AUTOMATIC SPRINKLER SYSTEMS (continued) General: Central Station Monitoring? ........................................................................... Yes E] No [V Monitoring company name e44CCA� OW11 2. Location of Sprinklers 100% .......... W Parking ......... E] Basement ......... F] Hallways ......... Ej Other ......... E] 3. Pumper connections and clapper valves unobstructed ....................................... Yes No E] 4. Sprinkler heads less than 50 years old ............................................................. Yes No E] 5. Sprinkler coverage is acceptable .................................................................... Yes No E] 6. Spare sprinkler heads are available ................................................................. Yes No F� 7. Systems left in service .................................................................................. Yes No E) 8. Valves are sealed or supervised ...................................................................... Yes 1� No E] 9. Signs are provided on valves ......................................................................... Yes Dd No E] 10. City static water pressure -psi. Problems Found: ov&r y-ts - 00 ;2 - FDc, Dve fbc S' vr 1 -3. r-ICC4 uc_-� /'Vo� Corrections Made: Date Corrected: -/0 C orrected By: ;271:!:2 SIGNATURE OF TESTER: AGENCY: Emerald F.ire PHONE: 253-857-2056 MAILING ADDRESS: 11021 Cramer Road KPN, Gig Harbor, WA 98329 Westfall, John From: Westfall, John Sent: Monday, June 30, 2003 11:52 AM 'To: Smith, Mike Subject: NW Group Home Sprinkler Instal Auto Sprinkler Permit #03-312 Witnessed underground flush and connection. Witnessed 6 2-head bucket flow for 13R system at subject location. Project deficiencies identified prior to final: Construct doghouse to contain sprinkler riser and maintain above 40 degrees F. Install (visible) exterior bell and interior connection at constantly attended location. Place FIDC. Lock and secure valve to prevent inadvertant shutoff. John Westfall . Weitfall, Johin From: Westfall, John Sent: Monday, June 30, 2003 1:20 PM To: Fire Dept Group Subject: Edmonds Group Home 21110 80th PI W The Edmonds Group Home is a Licensed -Care (LC occupancy) operated by NW Family Homes that has been in operation since 1972 at this location. The home can house up to 15 mentally -disabled residents. The group home has an existing fire alarm system and has previously been non-sprinklered-until today. NW Family Homes has taken advantage of a State boarding home sprinkler retrofit grant from Y2001. The 13 R / UBC Standard 9-3 life safety sprinkler system will be active today separate from the FA system. The sprinkler system is not wholly approved -the exterior bell and interior notification are not yet connected and the exterior riser must be proivided a heated enclosure. This memo lets you know that the system is active until final approval. FM 0 0 MEMORANDUM DATE (" I - 1w I I, ) REPORTED BY SUBJECT ADDRESS: t 0 ej- CONCERNS/ HAZARDS: FOLLOW-UP: 9 Aj-40 _e�QLE� T-- , 1 6:5�, p rol— SIGNED 2- ��vg 5 F`6� f �- : 3�o I hL&f---') 5' : 2- t V -t,- F(, 0 57 t.�Jif L"",j To d6f V67 7V 166 6010— 4ivV t4,eA�. SIGNED CityofEdmonds * Fire Prevention Division 0 0 Westfall, John From: Westfall, John Sent: Friday, May 23, 2003 3:20 PM To: Smith, Mike Subject: RE: NW Group Home Automatic Sprinkler 21110 80th PI W I'm not sure where you've found that every tamper on the main valve requires monitoring. The valve will be secured either by chain/lock at the valve or locked in the doghouse. The installation is a sprinkler system. The fire alarm will not require upgrade -they are not doing substantial work in the occupancy and no alarm or tamper devices will be tied in. You are correct the fire alarm company told him that the panel would not accept the sprinkler inputs without upgrade. ----- Original Message ----- From: Smith, Mike Sent: Friday, May 23, 2003 1:02 PM To: Westfall, John Subject: RE: NW Group Home Automatic Sprinkler 21110 80th Pl V It sounds to me like the alarm panel couldn't take the addition of a water flow alarm. What about the tamper on the main valve at the riser? Per code this also needs monitoring. The rational here was if the building already has an automatic fire alarm then any life safety devices added to the building that send alarms are tied into the existing alarm panel. ----- Original Message ----- From: Westfall, John Sent: Friday, May 23, 2003 10:47 AM To: Smith, Mike Cc: Bullis, Ann Subject: NW Group Home Automatic Sprinkler 21110 80th PI W The system has less than 100 heads. The Group Home is provided with a 24 hour caregiver on -site. I approved notification to be accomplished by exterior bell/horn AND interior bell/hornstrobe at the constantly attended location. Off -site system monitoring will not be required for acceptance. The monitored fire alarm is functional but antiquated and parts are out of production. There will be no connection between fire detection and suppression systems. Procedures for care were suggested for update: -Caregiver call 9-1 -1 during EVERY fire alarm. If phone is busy, the alarm system ' has captured the phone line and it is a detection -initiated alarm. If the phone is clear -the waterflow has activated. -If a sprinkler alarm is made, the caregiver should pull the fire alarm to initiate evacuation of the structure then assist evacuation. John 0 11 Wesffall, John From: Westfall, John Sent: Friday, October 25, 2002 10:47 AM To: Graf, Jeannine Subject: RE: Edmonds Group Home @ 21110 80th Place West Jeannine: The sprinkler system (UBC Standard 9-3) is being installed by a grant from the State Fire Marshal's Office. They are a nine -person (k-4/LC) boarding home that has a valid City BL since 1974 as well as state license for (approved by BO Whitcutt "subject to state licensing" on 2/26/74). 1 believe they currently have 9 residents. The last document of FID inspect is Feb 01, last FA system confidence test is Mar 02. John ----- Original Message ----- From: Graf, Jeannine Sent: Tuesday, October 15, 2002 11:19 AM To: Chave, Rob; Smith, Mike; Westfall, John Cc: DST Subject: Edmonds Group Home @ 21110 80th Place West Seeking your assistance and historical information. A fire sprinkler permit application was received today for the subject building. The application describes the building as a Group Home with 12 beds. In researching our permit files we found that in 1960 an existing single family dwelling was converted into apartment units at this site (total number of apartment units unknown but 6 parking spaces were required to be provided). We also found a permit for a new exterior stair and landing issued in 1994 to Northwest Group Homes. Please provide any historical or City approval information on this building. Also, Rob what Planning approvals would be required to convert from an apartment to a Group Home? I will be checking with the State to see what kind of approvals they have granted to this facility. Thanks JLGraf Jeannine L. Graf Building Official City of Edmonds Message Page I of 2 Westfall, John From: Highland, Scott Sent: Wednesday, October 16, 2002 7:34 AM To: Westfall, John Subject: RE: Edmonds Group Home Hello John, Yes we will do the tap and installation from main to property line from 3/4" to 2" sizes. Sizes larger than that are installed by contractor. Engineering will collect the fees depending on size requested. Hope this is what you wanted to know .... ? Thanks, Scott ----- Original Message ---- From: Westfall, John Sent: Tuesday, October 15, 2002 5:23 PM To: Highland, Scott Subject: FW: Edmonds Group Home Scott: Is this yes on a residential application? The project is 21110 80th Place, 9 resident grou.p home. John ----- Original Message ----- From: Harrison, Marie Sent: Tuesday, October 15, 2002 11:17 AM To: Westfall, John Cc: Graf, Jeannine Subject: Edmonds Group Home John: Jim Stuart f rom American Sprinkler called me saying he also needs to get a tap f or the f ire sprinkler system. I told him that was a separate f ire connection permit ($205.00). He said the f ire connection was �shown on the plans he submitted. He mentioned you were talking to PW regarding the tap. He asked if public works actually did the tap? JLG: I guess I need to route this to engineering as well to see if they need a street cut, ROW. E. Marie Harrison Development Services City of Edmonds 425.771.0220 x 1389 harrison@ci.edmonds.wa.us. 10/16/2002 Westfall, John From: Westfall, John Sent: Friday, October 25, 2002 10:47 AM To: Graf, Jeannine Subject: RE: Edmonds Group Home @ 21110 80th Place West Jeannine: The sprinkler system (UBC Standard 9-3) is being installed by a grant from the State Fire Marshal's Office. They are a nine -person (R-41C) boarding home that has a valid City BL since 1974 as well as state license for (approved by BO Whitcutt "subject to state licensing" on 2/26/74). 1 believe they currently have 9 residents. The last document of FID inspect is Feb 01, last FA system confidence test is Mar 02. John ----- Original Message ----- From: Graf, Jeannine Sent: Tuesday, October 15, 2002 11:19 AM To: Chave, Rob; Smith, Mike; Westfall, John Cc: DST Subject: Edmonds Group Home @ 21110 80th Place West Seeking your assistance and historical information. A fire sprinkler permit application was received today for the subject building. The application describes the building as a Group Home with 12 beds. In researching our permit files we found that in 1960 an existing single family dwelling was converted into apartment units at this site (total number of apartment units unknown but 6 parking spaces were required to be provided). We also found a permit for a new exterior stair and landing issued in 1994 to Northwest Group Homes. Please provide any historical or City approval information on this building. Also,* Rob what Planning approvals would be required to convert from an apartment to a Group Home? I will be checking with the State to see what kind of approvals they have granted to this facility. Thanks JILGraf . Jeannine L. Graf Building Official City of Edmonds Westfall, John 'From: Fiene, Don Sent: Tuesday, October 08, 2002 10:05 AM To: Westfall, John Subject: RE: Hydrant flow extrapolatino The model shows 770 gpm @ 20psi with a peak hour demand. The 2002 Water Comp Plan states that the Fire Flow standard for that site is 3000 gpm. The plan recommends replacing the existing pipe with a 12" line in 2005, which will provide the proper fire flow. Don Fiene, P.E. Asst. City Engineer ----- Original Message ----- From: Westfall, John Sent: Thursday, October 03, 2002 2:54 PM To: Fiene, Don Subject: Hydrant flow extrapolatino Don: Could you give me an idea of worst case flow at 21110 80th Pl. It's a 4" Cl dead end stick. The folks at Northwest Group Home have received a state grant for a fire protection system. Thank you. John I bFf'20/5-9 X I - . PIR,INT 01'r2c 407-050e 172 0 ell 'FQ Page 2 of 3 ACW. I 1 11 ro. WN A AGING AND ADULT SERVICES ADMINISTRATION DIVISION OF RESIDENTIAL CARE SERVICES COMPLAINT INTAKE AND ROUTING FORM RESIDENTIAL CARE SERVICES ASSIGNMENT REFERRALS This intake form is being to the locati below Priority: 2 Significant Risk referred Control Number: 99-05-05367 as required by RCW 70.124. Each office should handle Facility Name: EDMONDS GROUP HOME this referral according to its own internal policies. Assigrunent Date: 05-19-1999 State Fire Marshall Initiate investigation within: 10 Working Days Assignment Comments: For questions about this referral, call 1-800-562-6078, or PRIORITY 2 FOR THE FIRE MARSHALL (360) 438-7910; FAX (360) 438-7903. FYI TO THE BH AREA MANAGER Confidenti'al.'*--IDENTIFYING INFORMATION- Facility.1 EbMONDS-GR I OUP District ID: BH -HOME Address-F 21110:80th�Pl W Federal Provider No: City.- -�-Edjjion& Telephone: (425) 778-6744 State: WA. County: Zip Code: 98020 Fax number: Comp Last name: PERSON Contact Telephone No: First name: ANONYMOUS Complainant Type/Title: Not Selected Mailing address: Remain Anonymous to Facility? Yes City: State: Zip Code: Follow-up Report Requested? No Alleged Victim Alleged Perpetrat Last name: Last name: First name: First Name: Gender:, Female DOB: Gender: Female DOB: Social �e'curity Number: Social Security Number: Victim Type: Perpetrator Type/Title: Incidents past 6 months: 0 Incidents past 6 months (3 years if staff): 0 Primary Medical DX UNKNOWN Primary Medical DX UNKNOWN Mental Status: UNKNOWN Mental Status: UNKNOWN Ambulatory Status: UNKNOWN Ambulatory Status: UNKNOWN OBRA Registry Status? Not in Registry Finding? No Crim Rx Check Date: Conviction? ntial . ..... % :Cohfidbi :.:':tWr--AKE INFORMATIONIALLEGA.TION DE.SCRiPTION..: ... Confidential Date, Time Reported by Callcr: 05-17-1999 14:50 CRUIntakeDate: 05-17-1999 Date and Time of Incident: CRU Intake Worker: JAMISRI CRU received the following anonymous phone call on 5/17/1999: I am calling in an issue that needs to referred to the Fire Marshall. I am a state employee that does inspections for BH's. May 1999 PAGE I 0 d-A- I 05/20/-9-9 01:36 407-050e r-" page -7 off 3 FACSW Control No. 99-05-05367 AGING AND ADULT SERVICES ADMINISTRATION DIVISION Or RESIDENTIAL CARE SERVICES COMPLAINT INTAKE AND ROUTING FORM There is a fire exit that is utilized on the second floor and the only way that the residents can access that is to go through a room in 122. Also within that room there are two windows that are higher than the required 40 inches from the floor. One measures 54 and one measures 64 in. Again these are fire safety issues and we ask that you would direct them to.the fire marshals. May 1999 PAGE 2 W 05/21/99 12: 31 F 360 679 3262 WSP OAIK HBR—FPA Q001 FAX..,: ask of.. From the d ROE119AT BERNEY Fax Deputy S e Region 3 Subj' ct: Gn, tain Fire Marshal PXG_ 940 . SE flth,�va Date-. .0akHotborWA98277 Tages: �tding.this sheet.*.. 360) 675r2636 Fa�: 1360) 679-3282 COMMENTS: V-1 Wy). A-10 AL aV. 6S Oki 61. aj Ae LL) .4 n&k FIRE PROTECTION BUREAU FIRE AND LIFE SAFETY INSPECTION: STATEMENT OF DEFICIENCY & CORRECTIVE ACTION FACJLITY,�:��Y,nV.r\ ADDRESS Mri!�U 5, ZIP CODE NAME ri-k x � 0 so",\ L Q jispEcTOR AGEWCEY DA��/ PROVIDER WSP - STATE FIRE MARSHAL 7 ITEM CODE OR WAC CORRECTION SEQUIRED 140. STATEN4kNj OF DEFICIENCY REFERENCE CORRECTIVE ACTION REQUIRED TEI RL vy\. ?AX L4 I�A� ;!)'0— Lq AL f)0. THE DEFICIENCIES DESCRIBED ABOVE HAVE BEEN EXPLAMED TO ME, SIGNA E OF FACILITY M GER BEINSPEC71ON DATE AND I AGREE TO MAKE CORRECTIONS NOT LATERTHAN THE DATES INDICATED. Z2, le� P RIGHT _OF AP�FAL PAGE —t— OF PAGES A facilitV aggiisved by the corrective orders of the State Fire Marshal or authorized representative maV appeal to the Slate Fire Marshal within five days or the order. It the State Fire Marshal oonflims the order, It 5hall remain In force. 3000-450470 12JS6 DISTRIBUTION: a White - State Fire Marshal a Yellow - Llcens;B Agency a Pink - Facility * Gold - Inspector Ica ITJ 10 IN 0 0 rl� MR WASHINGTON STATE PATROL uor. FIRE PROTECTION BUREAU FIRE AND LIFE SAFETY INSPECTION: STATEMENT OF DEFICIENCY & CORRECTIVE ACTION FACWT�P�'rC NAME Q461Ib _VeS+ Woakvlli =ajk+0() 7X I-"- CITY t_-- -nov� av ZIP CODE nADDRESS INSPECTOR Q-wr nL4 AGENCY WSP - STATE FIRE MARSHAL DATE IbO2 PROVIDER # 50 -5 2.3 ITEM NO. STATEMEN-I"OF DEFICIENCY CODE OR WAC REFERENCE CORRECTIVE ACTION REQUIRED uuKRECTION REQUIRED BY (DATE) Lox THE DEFICIENCIES DESCRIBED ABOVE HAVE BEEN EXPLAINED TO ME, SIGNATURE OF FACILITY REINSPECTION DATE AND I AGREE TO MAKE CORRECTIONS NOT LATER THAN THE DATES I INDICATED. I NP RIGHT OF APPEAL PAGE / OF PAGES A facility aggrieved by the corrective orders of the State Fire Marshal or authorized representative may appeal to the State Fire Marshal within five days of the order. If the State Fire Marshal confirms the order, it shall remain in force. I 0 3000-450-470 12/96 DISTRIBUTION: White - State Fire Marshal Yellow - License Agency e Pink - Facility Gold -Inspector DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED OMB NO. 0938-0390 HEALTH CARE FINANCING ADMINISTRATION POST -CERTIFICATION REVISIT REPORT Public reporting for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewin ' g the col I lection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to HCFA, Office of Financial Management, P.O. Box 26684, Baltimore, MD 21207; and to the office of Management and Budget, Paperwork Reduction Project (0938-0390), Washington, D.C. 20503. (Yl)PROVIDER/SUPPLIER/CLIA/IDENTIFICATION NUMBER (Y2) MULTIPLE CONSTRUCTION M) DATE OF REVISIT 505236 A. BUILDING 05/13/99 B. WING NAME OF FACILITY STREET ADDRESS, CITY, STATE, ZIP CODE ALDERCREST HEALTH & REHAB. CTR 21400 72ND. AVE. W EDMONDS, WA. 98020 This report is completed by a qualified State surveyor for the Medicare, Medicaid and/ I or Clinical Laboratory Improvement Amendments program, to show those deficiencies previously reported on the HCFA-2567, Statement of Deficiencies and Plan of Correction, that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC provision number and the identification prefix code previously shown on the HCFA-2567 (prefix codes shown to the left of each requirement.on the survey . report form). (YO ITEM (YS) DATE (Y4) (YO ITEM (YS) DATE ID Prefix — Reg. # LSC__10_027 'Correction Completed 05/13/99 ID Prefix Reg. # LSC K0076 Correction Completed 05/13/99 ID'Prefix Reg. # LSC Correction Completed ID Prefix Correction I ID Prefix Correction ID Prefix Correction # Completed Reg. # _ Completed Reg. # — Completed Reg. _ LSC_ LSC_ LSC_ ID Prefix Correction ID Prefix- Correction ID Prefix— Correction Completed Reg. # _ Completed Reg. # _ Completed Reg.'# _ LSC_ LSC_ LSC_ ID Prefix Correction ID Prefix Correction ID Prefix Correction # Completed Reg. # _ Completed Reg. # _ Completed Reg. _ LSC— LSC_ LSC_ ID Prefix Correction ID Prefix Correction ID Prefix Correction Reg. # Completed Reg. # _ Completed Reg. # _ Completed LSC_ LSC_ LSC_ REVIEWED BY STATE AGENCY IREVIEWED By J(INITIALb JDATE: f ISIATURE OF SURVEYOR: SI r -Z�! � � C, o (0 JDATE: q9 REVIEWED BY IREVIEWED BY JDATE: ITITLE: HCFA RO I(INITIALS) L 'AFICIENCIES. W A SUMMARY OF FOLLOWUP TO SURVEY COMPLETED ON: _CHECK FOR ANY UNCORRECTED 02/09/99 UNCORRECTED DEFICIENCIES (HCFA-2567) SENT TO THE FACILITY? YES NO FORM HCFA-2567B (9-92) FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB NO. 0938-0391 HEALTH CARE FINANCING ADMINISTRATION SURVEY TEAM COMPOSITION AND WORKLOAD REPORT Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Office of Financial Management, HCFA, P.O. Box 26684, Baltimore, MD 21207; or to the Office of Management and Budget, Paperwork Reduction Project(0838-0583), Washington, D.C...20503. Provider/Supplier Number I Provider/Supplier Name 505236 11 __ERCREST HEALTH & REHAB. CTR Type of Survey (select all that apply) A Complaint Investigation E Initial Certification I Recertification IIIHIKIDI I B Dumping Investigation F Inspection of Care J Sanctions/Hearing C Federal Monitoring G Validation K State License D Follow-up Visit H Life Safety Code L CHOW M Other Extent of Survey (select all that apply) A Routine/standard Survey (all providers/suppliers) JAI I I I B Extended Survey (HHA or Long Term Care Facility) C Partial Extended Survey (HHA) D Other Survey SURVEY TEAM AND WORKLOAD DATA . Please enter the workload information for each surveyor. Use the surveyor's identification number. I Isurveyor I First ID Number Date Arrived (A) (B) Last Date IDeparted (C) I Pre -Survey jPreparation I Hours (D) On -Site Hours 12am-8am- (E) on -Site Hours 8am-6pm (F) On -Site Hours 6pm-12am (G) Travel Hours (H) off -site Report Preparation Hours 11606 05/13/99 05/13/99 0.50 0.00 1.00 0.00 2.00 0.50 12. 13. I 14. 15. 16. I 17. I 19. I Total SA Supervisory Review Hours ...... 0.50 Total SA Clerical/Data Entry Hours ..... 0.50 Total RO Supervisory Review Hours ..... 0.00 Total RO Clerical/Data Entry Hours .... 0.00 Was Statement of Deficiencies given to the provider on -site at completion of the survey? ............ YES FORM HCFA-670 (12-91) k AV Request # 93-BM ROUTING AND ACTION CONTROL FORM FACILITIES AND SERVICES LICENSING DIVISION BOARDING H014E ACTIVITY ASSIGUMENT Initial Licensure/Certification eticensure/Recertification Survey Survey Follow-up Bed/unit Increase +_Bede/Units Complaint # change of ownership of Environment/Use Resurvey Life Safety ther Facili-E ji -ID-"� 6'61i6 BEDS/UNITS: 15 SURVEYOR(s):State Fire Marshal .0KNETA5505�,F OCCUPANTS: 0 SURVEYOR(s): EDMONDS Snohomish 98020 LAST FULL SURVEY:04/27/93 FIRE 14ARSHAL SURVEY: 02/01/93 ON -SITE SURVEY DUE: 02/28/.94 JEAN L BENNETT (206)778-6744 BH-453 LICENSE/CERT. EXPIRES: 03/31/94 Number of employees: 0 OWNER:NORTHWESTERN FAMILY HOMES INC DATE INITIAL Request sent to FPS Request sent to Deputy Survey date Due back to SFM Office Rec'd by DON 12/28193 Occ, y Type Construction _LState —11edicare Local Fire Department contacted? Yes 4 No Person contacted i�k 6(,n NA�Ks Reinspection required? Yes No Reinspection Date �a, L ,�b Number of stories Basement/Cel tar Yes No V Local AHJ Yes No Full Part Automatic No Full Part Manual Yes No Commercial Automatic Detection Fire Alarm Range Hood "I, System System Sprinklers System Surveyor Comments COMPLIANCE STATEMENT ACTION \4 Renewal New initial Licensure/certification Recommended Relicensure/Recertification Recommended The facitity/agency indentified above is in full State Medicare compliance with ticensure/certification Progress Report Required Date requirements. Disapproved The fciLity/agency indentified above is in compliance with licensure/certification requirements subject to implementation of approved plan of correction. (SFM 470) The facility/agency indentified above has not submitted an approved plan of correction. The faciLity/agency indentified above has failed or ref us 4ewd comply with Licensure/certification requi r, its or provide an approved plan of corr i I. Silrveyed B)F U Datl Reviewed By Date LICENSURE/CERTIFI TION DECISION: SFM Approval Full Licensure/Certification Short -Term License/Certificate to expire Prov. License/Certificate to expire License/Certificate Denial -Revocation Complaint Investigation Completed Certification Dates Certification Performed By: Fire Alarm System L��\ r-1 Sprinkler System Emergency Generator Fire Extinguishers FIRE AND LIFE SAFETY INSPECTION: STATEMENT OF DEFICIENCY & CORRECTIVE ACTION FACILITY NAME W kA�)�JM (N��)Up [-I()M, ADDRE IN I 21 T)Mcw Ds '40 .. INSPECTO AGENCY STATE FIRE MARSHAL DATE ITEM NO. STATEMENT OF DEFICIENCY CODE OR WAC REFERENCE CORRECTIVE ACTION REQUIRED CORRECTION RE - OUIRED BYWATE) L) 04- V, C) G VVUCI, w\.qo'bh r tom, WQ fe ()( k _� �0 '4�(j 0-V\A 'kA li's � YMY� �51k Nkk Atqo Cl) �t,A �� \n co V C ell pl��QAIV\Jtq)V (5)aL&/\Aq 'A tll\- -f6' �rtpUl.� Sv 2C Rb( cw-\6 w�� ww�(IL� (v a C\ V THE DEFICIENCIES DESCRIBED ABOVE HAVE BEEN EXPLAINEa�IGN.AJURE TO ME, AND I AGREE TO MAKE CORRECTIONS NOT LATER THAN HCFFP- I BY: NSPECTION DATE: THE DATES INDICATED. SF FORM 470 (Revised 9/89) OX A-259 OFFICE OF STATE FIRE MARHSAL VW 3 1 STATE FIRE MARSHAL NTRAL FILE CO PAGIt OF PAGES RIGHT OF APPEAL A facility aggrieved by the corrective orders of the State Fire Marshal or his authorized representative m y ap6 I (h-, S tu. F i r Marshal within five days of the order. 11 the Slate Fire Marshal confirms the order, it shall remain in force. 4 r) 277 p q5 -10 '115 890 . — 9 0 - 0 CITY OF EDMONDS 250 - 5TH AVE. N. - EDMONDS, WA 98020 - (206) 771-0220 - FAX (2061771-0221 COMMUNITY SERVICES DEPARTMENT Public Works a Planning * Parks and Recreation @ Engineering May 25, 1994 Jean L. Bennett - - Northwest Family Homes Post Oifice Box 839 Lynnwood, Washington 98046 RE: Edmonds Group Home @ 21110 80th Place West, Edmonds LAURA M. HALL MAYOR RECEIVED MAY � 6 1994 EDMONDS FIRE DEM The purpose of this letter is to follow-up the inspection made today by Myself and the City Fire Marshall on the subject residence. After being officially notified of a possible hazardous condition I have confirmed that the exterior, emergency stairs, at the above address, are structurally unsafe and present a danger by reason of dilapidation. Also, the stair configuration does not comply to the minimum code requirements of Uniform Building Code (UBC) Section 3306. for exiting. Unsafe structures and appendages are regulated under UBC Section 203 and, therefore, the following is required to resolve this matter: 1. Submit stair reconstruction plans and apply for a building permit by June 15, 1994. Note, the plans must fully comply to UBC Section 3306 (copy enclosed). Please be aware, as we discussed on -site, the second floor window must be changed out to a man - door to meet exiting requirements. Also, the new stair may not block egress ftom the lower floor window. 2. Complete the stair by no later than June 25, 1994 and obtain final approval by the State Fire Marshall and City Fire Marshall and Building Official. The dates hereby established are contingent upon your promise to immediately vacate the upper floor of the four tenants who currently reside there. It is hereby understood and agreed that these units shall remain ' vacant until the stair issue is resolved. If there are any questions or if you do not understand what is required of you, please feel free to contact me at 771-0220. Thank you, 01"—/06 Jeannine L. Graf Acting Building Official 0 Incorporated August 11, 1890 0 Sister Cities International — Hekinan, Japan CITY OF EDMONDS CIVIC CENTER -- EDMONDS, WA 98020 - (206) 771-0215 - FAX (206) 771-0208 FIRE DEPARTMENT 8 go . 199 Jean L. Bennett Northwest Family Homes, Inc. P-0 Box 839 Lynnwood, WA 98046 Dear Ms. Bennett, May 24, 1994 LAURA M. HALL - MAYOR SUBJECT: Edmonds Group Home, 21110-80th Place West, Edmonds, WA I was recently contacted by Mr. Bob Freedy, a parent of one of your tenants. He provided me with a copy of your most recent State Inspection and he questioned the requirement to correct the external emergency stairs from the second floor. In compliance with his request, I visited the site on the afternoon of May 24, 1994 to inspect the stairs in questions. Upon ascending the stairs, I found two stair treads that were so rotten that they nearly broke under my weight. After I reached the top landing I observed that the attachment to the building is not secure and the entire structure was shaky and unstable. In my opinion the emergency exit stairs are extremely dangerous and must be replaced as soon as possible. The new stairs should comply with the current code and plans must be submitted to the Edmonds Building Department for review and inspection. I am transmitting my finding to the Edmonds Building Official and the State for their information. I am currently reviewing the issue of safety for thetenants of the second floor now that the emergency exit is no longer useable. You will be advised of the,city's decision on this issue. If you have any questions, please feel free to call me at 771- 0213. 4,)�, Sincerely, SWAS 4 2q.,Gar McComas GLM:be 4 Fire Marshal 'elp v\ t��e, cc: Edmonds Building Official State Fire Marshal's Office 0 Incorporated August 11, 1890 0 Sister Cities International — Hekinan, Japan SECTIONS 3303-3304 UNIFORM BUILDING CODE Doors EXCEPTION: Approved revolving doors having leaves (Continued) which will collapse under opposing pressures may be used in exit situations provided: 1. Such doors have a minimum width of six feet six inches (6'6"). 2. Thev are not used in occupancies where exits are required to' be equipped with panic hard%vare. 3. At least one conforming exit door is located adjacent to each revolving door installe'd in a building. 4. The revolving door shall lot be consi(lee(l to provide any exit width. Corridors and Sec. 3304. (a) General. This Section shall apply to every Exterior Exit corridor serving as a required exit for ail occupant load of 10 Balconies or more persons. For the purposes of this. Section the term corridor' shall include "exterior exit balcony" and ariv cov- ered or enclosed exit passageway including ,v'alkways, tunnels and malls. Foyers, lobbies and reception rooms meeting the construe- tion requirements of corridors as specified in this Section may be classed as corridors. Partitions, rails, counters and similar space dividers not over 5 feet in height above the floor shall not be construed to form corridors. (b) Width. Every corridor shall be not less in width than 44 inches. For special requirements for Groups C and D Occu- pancies, see Sections 3317 and 3318. (c) Height. Corridors and exterior exit balconies shall have a clear height of not less than 7 feet rneaSUred to the lowest projection from the ceiling. (d) Projections. The required %vidth of corridoi-s shall be unobstructed. EXCEPTION: Trim handrails, ail(] cloors whell full\. opened, shall not reduce the required width by more than �1 inches. Doors in any position shall ]lot I-edLICC' the IWILlil-ed width by more than'one-hilf. (e) Access to Exits. When more than one exit is required. they shall be so arranged that it is possible to go in either direction from any point in a corridor to a separate exit, except for dead ends pei'mitted by this Section. (f) Dead Ends. Corridors Nvith dead ends are permitted when the dead end does not exceed 20 feet in length. (9) Construction. Walls and ceilings of corridors serving ail occupant load of 30 or more shall be of not less than one -hour fire -resistive construction. EXCEPTIONS: 1. One-story buildings housing croup c Occupancies. 2. Corridors more than 30 feet in width where occu- pancies served by such corridor have it least one exit inde- pendent from the corridor. 3. Exterior sides of exterior exit balconies. 446 1970 EDITION SECTIONS 3304-3305 Ceilings of noncombustible construction without a fire-resis- Corridors and tive rating may be suspended below the fire -resistive ceiling. Exterior Exit (h) Openings. Where corridor walls are required to be of Balconies one -hour fire -resistive construction by Subsection (g) above, (Continued) every door opening shall be rotected with a tight -fitting smoke or draft stop fire assembFNv having a fire- pro tee tion rat- ing of not less than 20 minutes w , hen tested in accordance with U.B.C. Standard No. 43-2 without the hose stream test. Clos- ing devices will not be required. Glazed openings of the size and construction permitted for three -fourths -hour fire door assemblies in Section 4306 (f) may be installed in such doors. Other interior openings shall be protected by approved 114- inch thick wired glass set in steel trames. The total area of all openings, other than doors, in any portion of an interior corri- dor shall not exceed 25 per cent of the area of the corridor wall of the room which it is separating from the corridor. Sec. 3305. (a) General. Every stairway serving any build- Stairways ing or portion thereof shall conform to the requirements of this Section. EXCEPTION: Stairs or ladders used only to attend equipment are exempt from the requirements of this See- tion. (b) Width. Stairways servin ri occupant load of more il a t than 50 shall be not less in wi th than 44 inches. Stairways serving ail occupant load of 50 or less may be 36 inches wide. Private stairways serving an occupant load of less than 10 may be 30 inches wide. Trim shall not reduce the required width by more than 3V'- inches, Handrails may project from each side of a stairway a distance of 3`/'2 inches into tile required width. (c) Rise and Run. The rise of every step in a stairway shall (- 1"-, ") -kill sliall not exceed seven and one -hull- inches I Mid tile t be not less than tell inches (10" ' ). Except as provided under SUbsection (d) the maximurn variations in the height of risers and the xvidth of' treads in any one flight shall be three -six- teenths inch ( . EXCErrio.N: I, private stairways serving M1 OCCUINInt loa(i of less than 10 tile rise nia\- be eight itiches (8") �lnd tile run inay be nine inclics (9"). (d) Winding Stairways. In Group I OCCLIPMICICS MId ill private stairways in Group H Occupwicies, winders may be used if the required Nvidth of ru-n is provided at a point not more than twelve inclies (12") from the side of' dic, stair -a\. \\,here the treads ire the narro-er, but ill no Case silitil ;ill%* width of run be less thall six iliches (6") ilt �111Y point- (e) Circular Stairways. Cil-CUL11- St�kil'S be Used �Is �111 exit providim, tilt, millinlilln width of riln is lwt 14.,��s thall tell 4-47 UNIFORM BU-ILDING CODE 1970 1�1�n ODIUM I AUTHORIZED EDITION. second Printing COPYRIGH'I', 1970 bx, INTERNATIONAL CONFERENCE OFBuILDI'NG OFFICIALS 50 SOUTH LOS ROBLES - PASADENA, CALIFORNIA - 91101 PRINTED IN THE U.S.A. I t7 CITY OF EDMONDS - LAURA M. HALL CIVIC CENTER - EDMONDS, WA 98020 - (206) 771-0215 - FAX (206) 771-0208 MAYOR FIRE DEPARTMENT 1/ 8 C� 9 0 19 Jean L. Bennett Northwest Family Homes, Inc. P-0 Box 839 Lynnwood, WA 98046 Dear Ms. Bennett, May 24, 1994 SUBJECT: Edmonds Group Home, 21110-80th Place West, Edmonds, WA I was recently contacted by Mr. Bob Freedy, a parent of one of your tenants. He provided me with a copy of your most recent State Inspection and he questioned the requirement to correct the external emergency stairs from the second floor. In compliance with his request, I visited the site on the afternoon.of May 24, 1994 to inspect the'stairs in questions. Upon ascending the stairs, I found two stair treads that were so rotten that they nearly broke under my weight. After I reached the top landing I observed that the attachment to the building is not secure and the entire structure was shaky and unstable. In my opinion the emergency exit stairs are extremely dangerous and must be replaced as soon as possible. The new stairs should comply with the current code and plans must be submitted to the Edmonds Building Department for review and inspection. I am transmitting my finding to the Edmonds Building Official. and the State for their information. I am currently reviewing the issue of safety for the tenants of the second floor now that - the emergency exit is no longer useable. You will be advised of the city's decision on this issue. If you have any questions, please feel free to call me at 771- 0213. Sincerely, Gar McComas Fire Marshal GLM: be cc: Edmonds Building Official State Fire Marshal's Office 0 Incorporated August 11, 1890 0 Sister Cities International —,Hekinan, Japan /_ r",Fv FIRE AND LIFE SAFETY INSPECTION: STATEMENT OF DEFICIENCY & CORRECTIVE ACTIO 7 ;- 5-/- -7 FACIL NAM AD CITY, - Z �PECT?,R AGENCY/ DAT�3 �Z CR ITEM NO. /STATEMENT OF DEFICIENCY CODE OR WAC REFERENCE CORRECTIVE ACTION REQUIRED CORRECTION RE - QUIRED BY (DATE) 0 el/ 1 & 6 o ir 4c :t a- CL� IJ r 79, A-172114.c� keb A 44,;- 412, x1l `7 4fl' -4� THE DEFICIENCIES DESCRIBED ABOVE HAVE BEEN EXPLAINED SIGNATURE REINSPECTION DATE TO ME, AND I AGREE TO MAKE CORRECTIONS NOT LATER THAN THE DATES INDICATED. 41 1 " SF FORM 470 (REVISED) OFFICE OF STATE FIRE MARSHAL INSPECTOR COPY PAGE If OF 12. PAGES i" -7 0 FIRE AND LIFE SAFETY INSPECTION: STATEMENT OF DEFICIENCY & CORRECTIVE -ACTION FACIL NA ADDRESS CA CITY;" INSPECTOR AGE"C�S t DATE ITEM NO. STATEMENT OF DEFICIENCY CODE OR WAC REFERENCE CORRECTIVE ACTION REQUIRED CORRECTION RE - QUIRED BY (DATE) Die I,- A- 0 ::24 41A 2- - 36;l �" I e. e? __Qlleth Ar� 7 0.6 t6 CL /� 3. -A-0 L---------- THE DEFICIENCIES DESCRIBED ABOVE HAVE BEEN EXPLAINED TO ME, AND I AGREE TO MAKE CORRECTIONS NOT LATER THAN SIGNATURE INSPECTION DATE I THE DATES INDICATED. / - . � 53' SF FORM 470 (REVISED) - OFFICE OF STATE FIRE MARSHAL -4e301 3 INSPECTOR COPY PAGE-aLOF 11,PAGES COMMERCIAL RESIDENTIAL EVERYTHING ELECTRICAL Office Phone 259-9175 3509 BROADWAY EVERETT, WASHINGTON 98201 July 22, 1981 To Whom It May Concern: Re.: Northwest Family Homes- Edmonds 40 ELECTRIC HEAT NEON — SIGNS SALES & SERVICE MOTOR REWINDING Res. Phone #74c, 659-5858 June 1981 one of our employees checked out fire alarm system and ordered needed replacement parts. July 1981 another employee installed parts and checked out system asrrequested. He checked bell adjustment --every bell is ringing'loud. Alignment marks are not in alignment because bell has been adjusted for maximum volume. We replaced fuses, I battery and 2 lights. Respectfully, Bobbi Costa-- President W A S H I N G T 0 N S T A T E F I R E M A R S H A L Pronertv to be inspectd Edmonds Group Home 21110 - 80th Place 1-1. Edmonds, WA 98020 t-� n n REQUEST FM INS['ECTION. Date 212OLZ5- Ins,)-ctioll requested b Paul Gallaqhcr, Pr.:�gram, Surac,-vilsor ';Ce sta�o Vive CW 0. V�?rv-ia, k�A July 31, 1975 SPECTIOL41. LICENSMG: MN1eW L�penewal (current license expirinit:10n ate) Licensed as- —Hospital ay Care State Institution Nursing Home . Ch i I d Ca re 'Transient Accommodation E1,36arding Home 'Maternity Home Othe H.B. —Psychiatric Hosp. �roup Home DTitle XVIII ETitle XIX INSPECTION, CONSTRUCTION: r7New Const.tlAddition ollemodeling E]Systems Installation MAssy. Elinst. CEducational r-Inesiden I tial .. I i- tate Bldg. F70ther L_Lli _IS M JN$PECTION. OTHER: describe 0 H Information Desired: PIEME REPLY BY e ///Assign d to Oil -by - - - - - - - - - - - - - Inspect;d b '2,z- T In�4)'ctioif U- Completed E]Incomplete k'_facility to request reinspectJon ri,-,, t peg c heduled for OCCUPANCY LBI B2jB31B4jCjDljD2jD.3jEj E2jEajE4jE51 torles _�v�fo� base. 1,e-f.jj area: —sq.ft. TYPE CO'NST.T2j3-lhr13.q1 =3N4—jhr14Nj5—lhrj�Nj A/S_ Auto Det Alarm _j Local V.U. DETAILS: W - - InIdditional details attached Approved for licenslmq,.,? & [2no ON/A LIMITATIONS, RESTRICTIONS: (return this completed form & attachments to State Fire NLarshal i-mless otherwise directed) - - - - - - - - - - - - - - W - - - - - - - - - - - - - - - - - - I - - - - - - - - - - - - - - - - Report reviewed b Approved b Findings fonniarded to requesting. agency on by Follww-up required: cc: SE�M A11, REQUESTS TO: Office of State Fire- Marshal Inspe�,ction Division Insura.nce Building Oiyap.1--a. 11,a. "1165,04 T. R N H A L V1 A S H I N P 0 N S T A 'I.' F i 1-d i "I g 14o I " I -, 1:'. e C t e � I b �'y I- i rr, Marshal CLassification 11' / Yie D Name Zip Code /11P Z-0 Address___ County Telephone 6"7 C t, Director/Operator W, Facility Fir�� N1 shal- rD OCCUPANCY A B�cj i�j 1j, I i 2-Stories —w-- w/o Basement. Area: —sq. ft. .L92J24,5 Automatic SPrinkler- Ful I Partial - TYPE CONST. V L Dry Chem.Systera Cop.system , —/---'--He at : F P HT, 1-hr, N JA Fire Alarm: Manual Smoke: F_ Local Fire Dept. Year bldg-. built & additionsi-ff's-VATa: Municipal rivate Nearest Hydrant..2e..:) o ft. NO. I T E M Me.ets Re�uirements N No Yes I /A 1 Does the bldg. meet construction requirements? ............................... 2 Are stairwells & vertical shafts enclosed or fire -stopped? ................... 3 Are hazardous areas separated fr ' om other portions of the bldg.? .............. 4 Are unoccupied attics sub -divided? ............................................. 5 Are corridors one -hour rated? ................................................ 6 Are corridors free of obstr'uctions? ........................ 7 8 Does interior finish of corridors & public areas meet current flamespreadrequirements? ................................................. Are floor coverings tested & certified as meeting DOC FF.1-70 for surface flemnapility? ............. ................................ 9 1.0 11 12 Are proper exits provided? ............................................... Are exits properly marked? ............................... Do all exit doors open outward? ............................................... Are all outside exit doors easily openable from the inside? .................... J�� 13 Are cooking units provided with hoods & filters? ............................. 1 4 15 Automatic fire protection? .... Type .......... Is automatic fire detection system tested, inspected & certifi*�'* i �'e at least annually? Date by whom .......... Is automatic fire detection system in . terconn_eE�,9e'_-1U`10_ - e-- -m- E-0 &u-Aa 1 f i r e alarmsystem? ......... Fire Dept. ...... ............. 16 Is automatic sprinkler system tested, inspected & certi d at least annually?. Date by whom ........ 17 Is the automatic sprinkler system electrically interconnected ta the 18 manual fire alarm system?.... Fire Dept. ...................... Is the automatic sprinkler main valve electrically sup—ervised? ............... 19 20 Is proper clearance maintained around sprinkler heads? ........................ Is sprinkler piping & valves free of obstructions? ............. .............. 21 Is a fire department connection provided? ... Accessible & not obstructed?...., 22 Is outside bell provided:.Electric water motor ..................... 23 24 Are operating instructions, spare heads & wrench located adjacemt to themain control valve? ................. ; ................................ i Is proper fire extinguisher coverage provided ...................... ........... 25 26 Have fire extin uishers been serviced within the past year? ... .............. Date 17 -by whom A - 19 Are all areas 'provided with manual-Tir—realarm boxes & wffrning demices? ....... 27 Is fire alarm system electrically supervised? ................... ............... 28 29 30 Connected directly to the fire dept.?_,7�1�__Ylow? .............. Is f ire alarm tested at regular intervals & records keq;.- .............. Is ai, emergency generator provided? KW 1 "u e I . .......... Has comprehens.i've Fire & Evacuation Plan been estab - lishe d --- Ll ............. I T E H Ye3_ t4/A No Ye copies of Fire & E%rac77,ion Plan ,.xva.ila1.)1,! tu aJ1 empj.17eles? ........ 32 re periodic training sessions held for al.] empi,)y(,es & r(,(:ords kept? ......... (Date,- time,'subject, those attending, ot.c.) 33 Is fire safety included as a part of new emploiec� in doctrin ? ..... ........ 34 Have all employees received training in the actual i.ise of fire extinguishersand hoses? .................................................. ?r, Are adequate fire exit drills held? ..................................... — I * ... * -6 Does the local fire dept. participate in drills & trai.ning sessions? ......... J7 Does the local fire dept. make at least annual inspections & furnish written copies of their findings? .......................................... 38 �re smoking regulations established.& enforced? .............................. 39 n areas where smoking is allowed,,are.sui-table,ash-ti-ays provided? ............ 40 re "No Smoking" signs provided in prohibited areas? ..................... 41 Are draperies, curtains & Other similar decorative effects of fire - resistive material or flame -proof treated? ............................... 42 Is rubbish stored & handled safely? ....... ; .................................... 43 is housekeeping in all areas satisfac tory .......................... ........ 44 rre storage methods satisfactory? ............................................. 45 1 s all equipment and fixtures in good repair? ................................. 46 re electrical cords in good repair and properly used! .......................... lk:_� 4--1 . 7 DETAILS: (Use foxm S.F. 470 for requirements) �_/Additional details attached Sketch or Plan Photos Other L—jumitations & Restrictions Location approved: es 7,Y By (name & title) Report reviewea by (name & title) ire Marshal Approval Granted: L-1yes L--Jno L___JCertificate Z_/Letter By (name & title) Date Findings.forwaroed to requesting agency: Date By �ollow-up required: Z_/yes L__/no — Within days. Copy to area deputy on (date) SEND ALL REQUESTS TO: 140 212 - J-0/73 Office of State Fire Marshal Inspection Division Insurance Bldg. 11A =3 VMB Ale b7 k0bdb MOO rO 7-W Count- Auly 4 ol S// T e 1. 729 �Q-ossa& Fire Marshal year Storles_.=Q, Area or Dimensions g4(pp� EQ, Construction Typeg Vl&&605:v�_ IXX Ix 2prlaftlor Protection Heat DetectIoq_A!Y_ Licensed Capacitv- Vare Protection byS—p-magavas FiPue t tlatoy: P�Inicipml Private Reare , at Hydrant'Aao �Xoar RGE I 2 3 6 5 6 ? 0 9 20 In8W 12 X0 the bldg. of at least 1-hr. con@�T (new, not over 2 storl eg)... o R@ the bldgo of firg-roolative cobotT (netv, over 2 stnrIe0.o,o...000-0-' X8 thQ bldg. provldo� wl AoS. protection? fisee enee'Ptionq)..000000000 Doeo the bldg,, meet conot. requirefitantsT (e2gisting)GO000000000900000 ArG 09811�aallo S vertical shafto enclosed or fire-stopped?oo. 0 0 0 0 0 0 Q 0c, Ago hazardous arae@ oup@rated frea other portions of the buildingT..o Are uRoccupled attic@ oub-dlvMod000.000000000000000,*O00040000000000. are corridon oj@G—hour ratedP, 'o 0 0 0 0 0 0 0 0 0 0 0 a 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 a 0 0 0 0 0 0.00 Aire corridors free of obgtructions?.00 ......... 000000000 . 0090000090000 D080 Interior fifilah of corridor@ & public areas meet curroat flamaspread 'raquAro=nts?000...00.00o ......... 000000000 coo proper exito provIdadV..o..00.00.c00000000400000b0000cocoocc000000 ZQ oach, floor sub -divided Into at least two smoke -free areas, VAth no undivided corridor o=eedlng 1501 in length?oo..00000000000 15 14 15 16 17 16 n9 Age exit@ properly m@rftecR0000000o000000oQ0000 000 go 011 otit doovo open outvjaraoo.oOo 0 0 0 0 0 * 0 0 0 0 0 * 0 0 0 0 0 a 0 0 0 0 0 0 0 0 0 0 . 0 0 0 t)w all outelde exit doors'oaally openable from th;o:ionosiod*eio00000,000000000 go laundry and rubblah chutes torm2nate in 0 fire -resistive rocwT0000 Are laundry 9, rubbloh chutes equipped with automatic spr1nftlersT.000, 8ge laundry S rubblah chute opouBiBage protected�at each floor level?.. ago cooking units provided with hoods & filteroLoo ........... o..o...o 20 21 autaffietic.fire protectionv Type 8re oxidising gaBoa properly storGao.o...�..o ... 0 0 0 0 0 0 . 0 0 0 0 0 0 0 0 8re piped oxygoa 9 nitrous anlde 0yotemsprovAded tvith 22 23 emergency shut -Off V81voo er twnlng devlco@V.00.000..000'00000;)O0000 Z9 automatic fire detection oyatem tested, �nspected S certified at least mnnually� (date) by whom B--zs Z&z4TA14_t EY912f= 10 automatic fire detection sjs__te� Interconnected to the manual fire alarm system? Fire DepartmentV A/0.00...o*000*0000Q*0000000000 24 Xs zutOmBtic SPTI-fiftler syoteffi tested, —inspected certified at leNt annu@lly'? (date) by whom 25 26 27 28 t4 Xs the automatic Sprinftlor sys'tem electrically Interconnected to the manu@lfire alarm system? Fire Department? 0000000000000 Is the automatic sprinkler main valve electrically supervised?o.00..o b proper clearance mointaimed around spriaftle* headsT000.00000000000 sprinkler piping free of obstruciAon@?000000r00000000000.00.0000000 =::'11/72 Meets Requiremato -29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 5Slo 55 56 57 Xs a V.D.Conn. providedV Accessible not obstructed?..........O.,00., Is outside bell provided? Electric 12ater Motor o... . .. .. . 0 ......... Are operating instructions,,spere heads & virench located adjacent to the main control valveT ....... o..Gd�'oo*ooc.*o6DooQ0000000 Are wet standpipes properly maintained?o.o ......... o..00..o ........ o..o Are fire extinguishers provided where special hazards exist?.o..,.c0000 Have fire extinguishers been serviced within the post year?o..o ....... Date By sih om Are all areas provided with manual fire alarm boxes and warning devices?o.o ................ oo...00..00000000000000f0000c0000 1@ fire alorm system electrically stwervised?.o ....... Q0000cooc0000000 Connected directly to Fire Dept? A1r19 How? Is fire alarm system zone coded?.o7_ 0 a 0 0 � 0.0 0 a 0 0 0 0 0.0 0 0 0 0 0 a a 0 0 0 0 0 0 0 a 0 0 0 0 0 Is fire alarm tested at regular intervals & records kept? ......... Is an emergency pn��rator provide& EM Fuel Has comprehensive Fire & Evacuation Plan been established?...O.O."..0 Are copies of fire-& evacuation plan available to all employees?....O. Are periodic training sessions held for all employees & records kept?. (Date, time, subject, those attending, etc.) la fire safety included as a part -of new employee indoctrinatioRoO000 Have all employees received training in the actual use of fire eninguishero and�hoses%o...00000009000 0 a 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Are fire drills hold at least 4 times per year, per shift?..o.00000000 Is at least one drill per year, per shift, held on a Sunday or holiday? (to test effectiveness of plan with limited stiff)..,.00 000 Does the local fire dept. participate in drills & training sessions?,, Doe@ the local fire dept. make at least annual inspections & furnish written copies of their findings?0000.o.o.000.o.co.o.000'00000 8re omoking,regulations establiihed & enforced?o ... o 0 0 0 0 0 0 0 a 0 0 0 0 0 0 0 0 0 0 In areas where smoking is allowed, are suitable ashtrays provided?o0*0 Are 'No Smolring' signs provided in prohibited areas?..o.00000000000000 nre draperies, curtains & other similar decorative effects of fire -resistive material or flame -proof treated? ........... 0 . 000000000 rubbish stored G handled safely?o..000000000000000..O000t, 00000000000 locatioddescription Is housekeeping in all areas 3etisfactory?...o..o..o'o..o ..... o ........ — location/description Are storage methods sa"tisfactory?.00.o .... 0 .... 000000000000600000000oo. location/descriptioO., Is all equipment & fixtures in good repair?o...o....0000000cocoocoocoo location/descriptiom,- C:_ 8re electrical cords In— good repair 9 properly used?. o o 0 0 9 0 0 0 0 0 0 0 0 J_QgQ %biVARso"A R& A a MEC', F1,Re Fx'T/.o& wtiog&5 ?a 5-r T:�V r&� ge=- AV / C, a Ftp,e DIPQL -7�. US-= bP_:E1r-1Og8CY coj%&S-L, P'�r8pproved C] Not Approved Revievied by: 'Datq Deputy StatQ Fire Marshal 0 (Based on compliance with Life Safety Code. Items marked O'noco,require attention @VJ/or correction unless specifically waived.). � BU.'311'"JESS LTCE.`,��E Ar'PLIC11.,;;j&GPj �CITY OIP ED�X)111)-dl �,A_"HII�'G T IC -,*,IS- JjO. r, PLEASE PRINT RECC t,OV,T 140 ')'�T77 OF uPLICATION .1 JANUARY 24,1974 OF BUSINESS .11 1Z1)WWW.W&; i";t4wil jj�o;qjj SlY APAVAME'NTS �'ATURE OF BUSINESS !,-0ARjvj,,jG IF APARTI-I,EINT HGU-----;' 7_11hysician, 111L dru7 store, etc.) =1.""EIR OF o�,PARTIIETS: ','01?M OF 13USINESS ENTITY CIA)S'SCI, (Sole proprietorshipq corporation__,_pa_rtncrship) 71P%v! OFFICFRS: DAN'JEL F, IUViAQ 1411 COl'-ITLETE ADDRESS OF BUSINESS LOCATION WITHIN THE CITY OF EDMONDS: 21110 80th, PLACEs F-DUUNDS- WASTITNGTON —TELEPHONE N0.7Z-8-6,44 ADDRESS WHERE LICENSE IS TO BE SENT: CL,)S�F I35_',� N`J*E OF APPLICANT DANIEL E, CL,,-)SS!,�k 1,Y)SWOOD, WASH. 98036 DATE OF BIRTH 9-!4-29 PLACE OF BIRTH KANSAS CITY, N_f9q()UnT Month Day Year BOME ADDRESS 13531 BEVLRLY PARK ROAD LYNVY)f), WASHTNGTON 98036 H0111E TELEPHONE 745-0330 SOCIAL SECURITY NO. 55-1-33-0925 APPLICATION INSTRUCTIONS: Please complete and return this application form to thr� City Clerk's Office, with the $5.00 fee. After Staff review, your license will be mailed to you, unless ther,� is need for revin-wing with you thr�, rt�quiremr_,nts of cany portion of City of EdIrrion0s Ordin;ince ffl.1319, or 'an,/ othr�r condition"s pr-rtaininq to Cii! of E�I`rrionrls orr1in,1nc,?F:, including zoning, con-struction, and Firc Prr,vnntion Cor.r, PRESDENT IIGIATURE OP APPj,1CATJT RELATTOTTS11IF TC) T=INE'S FOR CITY USE ONLY APPR&E DISAPPROVE REASON FOR DISAPPROVAL FIRE DEPT. DATE SIGNATURE APPRO D SAPPROVE REASON FOR DISkPPROVAL POLICE DEPT. � / - _ � -f (/ -t- - Z, , / /// .4/Z DATE APPROVE WILDING DEPT. __aT5WPP1T= L)Ltcr 120 51A-r6t' A DATE :2 cx,, — APPROVE DISAPPROXTE SIGNATURE i_1(9S1A4r SIGNATURE REASON FOR DISAPPROVAL REASON FOR DISAPPROVAL ?UBLIC WORKS I IF APPLICABLE DATE SIGNATURE ZPPR'V- DISAPPROVE REASOPI FOR DISAPPROYAL ME� I d/ i,ANNING DEPT. I DAq E r4'_160 I ' SIGNATURE ITY CLERK: LICENSE ISSUED: DATE- SI(,rJATURE 51 1 4 --Vw-mw CITY of EDMONDS Civic Center - Edmonds, Washington 98020 - Telephone (206) 775-2525 Fire Department December 13, 1973 Ted Curcio Chief Deputy Fire Marshal Insurance Building Olympiat Washington 98504 Re: Edmonds Group Home 21110-80th Place West Dear Ted: To confirm our conversation this date relating to a pre-aale inspection of the above captioned occupancy, the following are items found by Inspector Barnard on the premises: 1. Possible exit door nailed shut:,no exit doors were found in a secured condition. 2. Possible louvered door by Unit I -A: Door has been replaced, however all bedroom doors are hollow core type. 3. During the inspection this date the manager was in process of installing spacer blocks by all baseboard heaters to maintain proper clearance of 12 inches from combustable furniture. Additionally, as the premises had been scheduled for a routine inspection, both alarm systems were checked and the manager advised to have all fire extinguishers signed annually by a licensed serviceman. Please advise if further information will be desired. Sincerely, Ralph 11. Klein Assistant Fire Chief NN'r HINGTON STATE FIRE MA&HAL ONSURANCE BUILDING—OLYMPIA, WATIF,04 FIRE & LIFE SAFETY INSPECTION Date................ /.-Z.7 ......... Z3 .............. yo Property Inspected....'�:-.b/k.iC)/",I),5 P/ / �L , 3'k I C' f; �6 a 0 .................................... ...... ................................................................. . I ................................................... f ..................... Inspected ....................... Reinspection Date ... ............................ Item Description, Location Correction Required Date ��'Vw APT, / 'V�k Ild 7-em) /�T 4 Z /�-ST /�/Ub 0T&t,-JL_ 71-qF_ J_:::'LELTAjC ,b Xz The described deficiencies have been explained to m and 1 agree to correct by the dates indicated. Signed .............. 2—'-272.1.: .............. �..'O ....................... Owner, perator. S. F. 470-OS. 7,bSh-3 -7, yo�'Cfi 0 I'd W14