OHA/DHS Shared Services Production Region



|[pic] |SHARED SERVICES | |

| |Human Resources | |

| |Safety, Health and Wellness | |

|Licensed Facilities Referral for Fire Safety Inspection |

|for Oregon Office of State Fire Marshal |

|Licensing agency information (all information must be completed for form to be processed) |

|Licensing contact name: |      | |Date: |  /  /     | |

|Licensing agency name: |      |Phone: |      | |

|Agency address: |      |City: |      |ZIP: |      | |

|Other occupancy type (refer to last pages for definitions of occupancy type) | |

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| |Adult foster home§ |(capacity) |   | |

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|Day care/child care facility* | |

| |Wants to increase number of occupants |(if yes, check the box and enter correct numbers below) |

|Original number of children: |     | |Number increased to: |     | |

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|Facility/site information | |

|Provider/agency name: |      | |

|Street address: |      |City: |      | |

|ZIP: |      |County: |      |Nea|

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|License expiration date: |  /  /     |Number of residents/children/capacity: |     | |

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|Reason for referral | |

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|Name of Deputy/inspector: |      | |

|Inspecting agency: |      |Inspection date: |  /  /     | |

|Phone number: |      | |Fire inspection number: |      | |

| |Approved for occupancy (no deficiencies noted) | |Approved with corrections listed on inspection notice |

| |Not approved until all deficiencies are corrected (refer to fire inspection notice) |

|Deputy/inspector signature: | | |

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DHS-OHA office use only:      

Occupancy definitions

* Day care center: Any building or portion thereof used for day-care purposes for more than six persons.

†Health care facility: Hospital, sanitarium, nursing home with non-ambulatory patients and similar buildings.

‡Children’s residential facility: Private residential school, residential care or day treatment facility, and another similar facility licensed by the Oregon Department of Human Services to Children, Adults and Families.

§Adult foster home: Family home or other facility in which residential care is provided for compensation to five or fewer elderly or disabled adults, or adults with a physical disability, mental illness or I/DD that are not related to the provider by blood or marriage.

SR Special residence: Personal care is administered in buildings or portions thereof, which are licensed under the authority of the Department of Human Services (DHS) under ORS Chapter 418, or 443, or any other state agency. SR Occupancies shall be:

Division 1. A building, or part thereof, used for the lodging, boarding and personal care of residents whose evacuation capability is classified as impractical. Division 1 has the following classifications:

SR1.1-Large, licensed to provide care for 17 or more residents.

SR1.2-Small, licensed to provide care for 6 to 16 residents.

SR1.3-Licensed to provide care for five or fewer residents in a home.

Evacuation capability

Impractical - A group, even with staff assistance, that cannot reliably move to a point of safety in a timely manner, determined by an evacuation capability score of 5 or greater with evacuation drill times in excess of 13 minutes.

Division 2. A building, or part thereof, used for the lodging, boarding, and personal care of residents whose evacuation capability is classified as Slow. Division 2 has the following classifications:

SR 2.1-Large, licensed to provide care for 17 or more residents.

SR 2.2-Small, licensed to provide care for 6 to 16 residents.

SR 2.3-Licensed to provide care for five or fewer residents in a home.

Evacuation capability

Slow - A group that can move to a point of safety in a timely manner, determined by an evacuation capability score greater than 1.5 and less than 5 or with evacuation drill times over three minutes but not in excess of 13 minutes.

Division 3. A building, or part thereof, used for the lodging, boarding, and personal care of residents whose evacuation capability is classified as Prompt. Division 3 has the following classifications:

SR 3.1-Large, licensed to provide care for 17 or more residents.

SR 3.2-Small, licensed to provide care for 6 to 16 residents.

SR 3.3-Licensed to provide care for five or fewer residents in a home.

Evacuation capability

Prompt - A group with an evacuation capability score of 1.5 or less or equivalent to that of the general population or with evacuation drill times of three minutes or less.

EXCEPTIONS:

1. Group SR Occupancies shall not include foster care homes as defined in ORS Chapter 418 and ORS 443.705. Foster care homes are considered dwellings constructed under the One and Two Family Specialty Code. Where the structure is more than three stories in height the provisions of Section 310

of this code apply.

2. Correction facilities including jails, prisons, halfway houses and juvenile detention and correctional education facilities where egress is limited and occupants are confined under the authority of the state.

A county or city shall comply with Section 308 provisions applying to Group 1 Division 3 and 3.1.

SR 1.1 or 1.2 and SR 2.1 or 2.2

Assisted living facility - For senior and disabled persons receiving personal care services in their own individual apartment.

Residential care facility - 6 and greater capacity for senior and disabled persons requiring personal

care services.

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