HomeMy WebLinkAboutSydney CreekSTATE OF CALIFORNIA -FORESTRY AND FIRE PROTECTION
FIRE SAFETY INSPECTION REQUES
C(D 1 y
STD. 850 (REV. 4-2000) See instructions on reverse.
AGENCY CONTACT'S NAME TELEPHONE NUMBER REQUEST DATE PROGRAM
Department of Social Services (916) 653-5973 12/21/2017 Adult and Senior Care
EVALUATOR'S NAME REQUESTING AGENCY FACILITY NUMBER
REQUEST CODE
Dianne Ramos 405802294 IA
CODES
1. ORIGINAL A. FIRE CLEARANCE
LICENSING Community Care Licensing Division 2. RENEWAL B. LIFE SAFETY
AGENCY Centralized Application Unit
NAME AND 74415 Street MS 8-3-91 3. CAPACITY CHANGE
ADDRESSA 4. OWNERSHIP CHANGE
F 9 - 5. ADDRESS CHANGE
fflascpcau@dss.ca.gov 6. NAME CHANGE
7. OTHER
AMBULATORY NONAMBULATORY BEDRIDDEN TOTAL CAPACITY
CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY
0 1 12 1 0 12
FACILITY NAME
LICENSE CATEGORY
The Villages at Sydney Creek
ADP
STREET ADDRESS (Actual Location)
NUMBER OF BUILDINGS
1234 Laurel Lane
1
CITY
San Luis Obispo, CA 93401
RFSTRAINT
OCCUPANCY CLASS
N/A
FACILITY CONTACT PERSON'S NAME CONTACT PERSON'S TELEPHONE NUMBER
HOURS
[FACILITY
Kellie Gallegly 5) 543-2350
8 am- 4m
P
SPECIAL CONDITIONS
Please specify any special instructions; Please specify approval of delayed egress and/or locked perimeter
Please specify any rooms approved for non-ambulatory, and/or bedridden.
TO BE COMPLETED BY INSPECTING AUTHORITY
INSPECTOR'S NAME (Typed or Printed) TELEPHONE NUMBER CFIRS NUMBER
INSPECTION DATE INSPECTOR'S SIGNATURE (Typed or Printed)
I -4 - i
EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS
Pe
C� �, �iVvr � C� ✓b���i��l I�(�'�� p
CLEARANCE /DENIAL CODE
CODES
1. FIRE CLEARANCE GRANTED
FIRE
City of San Luis Obispo Fire Department
AUTHORITY
2160 Santa Barbara Avenue
NAME AND
San Luis Obispo, CA 93401
ADDRESS
C. FIRE ALARM
INSPECTOR'S NAME (Typed or Printed) TELEPHONE NUMBER CFIRS NUMBER
INSPECTION DATE INSPECTOR'S SIGNATURE (Typed or Printed)
I -4 - i
EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS
Pe
C� �, �iVvr � C� ✓b���i��l I�(�'�� p
CLEARANCE /DENIAL CODE
CODES
1. FIRE CLEARANCE GRANTED
2, FIRE CLEARANCE DENIED
A. EXITS
B. CONSTRUCTION
C. FIRE ALARM
OCCUPANCY CLASS
D. SPRINKLERS
E. HOUSEKEEPING
F. SPECIAL HAZARD
�—
G. OTHER