Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name Gascade Valley Senior Living

Address 8400 207th ,

City, State, Zip Arlington, WA 98223

Provider Number

Approval Status

Facility Type

2312

Approved

Residential Care

On 04/18/2019 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation ~3

1 Fire walls, fire barriers and fire partitions.

Required fire walls, fire barriers and fire partitions shall bemaintained to prevent the passage of fire. All openingsprotected with approved doors or fire dampers shall bemaintained in accordance with NFPA80.

(IFC 703.1.3 2015)

The facility provided documentation from Right On Heating &Sheet Metal, Inc., PO Box 758, Lake Stevens, WA 98258 andcontractor NO. RIGHTHM988CM.

Visual and witness/operation inspection of smoke fire damperson the 1st & 2nd floors completed on 3/17/19 and all operatingproperly. Letter was signed by Jeanle Graves, OfficeManager.

2 Smoke detector sensitivity.

Smoke detector sensitivity shall be checked within one yearafter installation and every alternate year thereafter. After thesecond calibration test, where sensitivity tests indicate that thedetector has remained within its listed and marked sensitivityrange (or 4-percent obscuration light grey smoke, if notmarked), the length of time between calibration tests shall bepermitted to be extended to a maximum of five years. Wherethe frequency is extended, records of detector-causednuisance alarms and subsequent trends of these alarms shallbe maintained. In zones or areas where nuisance alarms showany increase over the previous year, calibration tests shall beperformed.

(IFC 907.8.3 2012)

The facility provided the 3/29/19 testing/documentation andpurchase order from Commercial Alarm & Detection, 17199Bennett Road, Mount Vernon, WA 98273-9789, LicenseCOMMEA1948LO.

On 4/5 & 4/11/19 devices that had failed had been replaced.

1 of2 Initials of Authorized Facility Representative:_L^/

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Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name Cascade Valley Senior Living Provider Number 2312

Address 6WO 207th . Approval Status Approved

City. State, Zip Arlington, WA 98223 Facility Type Residential Care

On 04/18/2019 the Office of the State Fire Marshal conducted an inspection afyour facility.

Code Requirement I Statement of Violation

Next inspection scheduled on or after;

Right of appeal. Any person may appeal any decision made by the Fire Protection Bureau in accordance with WAC 212-12.

Owner or Authorize}) Repr^sen^tive

C^h±iA-A^U2-/c-^ixf nature

^-h-hc^ LaAl} .'-^x^od \1^.4:^Si^Print Name and Title ' ^^ ^^V~T^^ (1W •

)eputy State Fire Marshal Barbara McMullenPO BOX42600OlympiaWA 98504(360)596,^911

Signature

2 of 2 Initials of Authorized Facility Repiesentalivo _U^V_..

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•IWASHiSGTOM STATE PATROL11 In)

Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

March 19, 2019

Steve DetillionMaintenance DirectorCascade Valley Senior Living8400 207th

Arlington WA 98223

The Office of the State Fire Marshal conducted an annual fire and life safety inspection of Cascade Valley Senior Living.

Initial InspectionDuring the inspection, we identified a number of violations.We provided a copy of the inspection report to the facility.The mspection report outlined each violation and items to correct prior to a reinspection, scheduled on or after February 1 ,2019.

Required Reinspection• Today we conducted a reinspection of Cascade Valley Senior Living.• During the reinspection, one or more of the violations identified during the initial inspection remained uncon-ected.

These two inspections found this facility failed to gain and maintain compliance as required by state law. These violationsplace the residents, staff, and visitors at risk.

Required FoIlow-Up• "The facility administrator shall submit a letter to Deputy State Fire Marshal David Ridley, 2700, 116, ST, Marysville, WA

98271 within 30 days. The letter shall explain, in detail, how the code violations were con-ected and indicate the facility is

ready for a final reinspection.• Upon receipt of the letter, the Deputy State Fire Marshal will conduct a final reinspection.• If the letter is not received by the time specified, we shall notify the Department of Social and Health Services (DSHS)

Residential Care Services Division of the failure to correct violations. We will recommend enforcement action against thefacility. Enforcement actions available to DSHS under RCW 18.20.190 include civil fines, stop placements, and license

suspension or revocation.• If the option chosen by DSHS is a license revocation, a new fire and life safety inspection will be required prior to

recommending relicensure.t

If you have any questions regarding this process, please contact Deputy State Fire Marshal David Ridley at (360) 654-1189.

Letter Received By: Letter Issued By:Deputy State Fire MarshalDavid R|jeHey

-p^rr

ec: Residential Care ServicesEnclosures

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WAS HiliGfONSTOE PATROLIS-1 (CT|

Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name8400 207th

City, State, Zip Arlington, WA 98223^

Provider Number 2312

Approval Status Disapproved

Facility Type Residentia! Care

On 03/19/2019 the Office of the State Fire Marshal conducted a re-inspection at your facility. Listed below areviolations that have not been corrected.

Code Requirement Statement of Violation

1 Fire walls, fire barriers and fire partitions.

Required fire walls, fire barriers and fire partitionsshail be maintained to prevent the passage of fire.All openings protected with approved doors or firedampers shall be maintained in accordance withNFPA 80.

(IFC 703.1.3 2015)

The facility did not provide the four yearly fire/smoke damperreport

2 Smoke detector sensitivity.

[Smoke detector sensitivity shall be checked withinI one year after installation and every alternate year[thereafter. After the second calibration test, whereI sensitivity tests indicate that the detector has[remained within its listed and marked sensitivityI range (or 4-percent obscuration light grey smoke, if[not marked), the length of time between calibrationtests shall be permitted to be extended to amaximum of five years. Where the frequency isextended, records of detector-causecf nuisancealarms and subsequent trends of these alarms shallbe maintained. In zones or areas where nuisancealarms show any increase over the previous year,calibration tests shall be performed.

(IFC 907.8.3 2012^

here were several smoke detectors on the sensitivity testreport that failed. - please provide documentation these wererepaired or replaced.

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Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name

City, State, Zip

8400 207th ,

Arlington, WA 98223

Provider Number 2312

Approval Status Disapproved

Facility Type Residential Care

On 03/19/2019 the Office of the State Fire Marshal conducted a re-inspection at your facility. Listed below areviolations that have not been corrected.

Code Requirement Statement of Violation

Next inspection scheduled on or after: 04/18/2019

Right of appeal. Any person may appeal any decision made by the Fire Protection Bureau in accordance with WAG 212-12.

Si^fiature

Deputy State Fire Marshal David Ridley2700 116 ST NEMarysville WA^9627T(360) 654->re9,__^^4=E

Signature

2 of 2

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Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name

Address

City, State, Zip

Cascade Valley Senior Living

8400 207th ,

Arlington, WA 98223

Provider Number

Approval Status

Facility Type

2312

Disapproved

Residential Care

On 01/02/2019 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation

1 Means of egress.

Combustible materials shall not be stored in exits or enclosuresfor stairways and ramps.

(IFC 315.3.2 2015)

There was combustible storage in the memory care exitstair/passage that also blocked egress.

2 Equipment rooms.

Combustible material shall not be stored in boiler rooms,mechanical rooms or electrical equipment rooms.

(IFC 315.3,3 2015L

There was combustible storage in the memory caremechanical room that also blocked electrical panels.

3 Power test record.

Records of tests shall be maintained. The record shall includethe location of the emergency lighting tested, whether the unitpassed or failed, the date of the test, and the personcompleting the test.

(IFC 604.5.2.1 2015)

The facility failed to provide records showing annual 90 minuteexit sign power tests.

4 Unapproved Conditions

Open junction boxes and open-wiring splices shall beprohibited. Approved covers shall be provided for all switch andelectrical outlet boxes.

(IFC 605.6)

The outer cover was missing from the corridor heatercontroller

The power strip under the kitchen window pufcord was frayed

1 of 7 Initials of Authorized Facility Representative:.^^

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WASHTNC5TOH STATE PATHOL

Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name

Address

City, State, Zip

Cascade Valley Senior Living

8400 207th ,

Arlington, WA 98223

Provider Number

Approval Status

Facility Type

2312

Disapproved

Residential Care

On 01/02/2019 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation

5 Fire Resistance Rated Construction - Maintenance

The required fire-resistance rating of fire-resistance-ratedconstruction (including walls, firestops, shaft enclosures,partitions, smoke barriers , floors, fire-resistive coatings andsprayed fire-resistant materials applied to structural membersand fire-resistant joint systems) shall be maintained. Suchelements shall be visually inspected by the owner annually andproperly repaired, restored or replaced when damaged, altered,breached or penetrated. Records of inspection shall bemaitained Where concealed, such elements shall not berequired to be visually inspected by the owner unless theconcealed space is accessible by the removal or movement ofa panel, access door, celling tile or similar movable entry to thespace. Openings made therein for the passage of pipes,electrical conduit, wires, ducts, air transfer openings and holesmade for any reason shall be protected with approved methodscapable of resisting the passage of smoke and fire. Openingsthrough fire-resistance-rated assemblies shall be protected byself- or automatic-closing doors of approved constructionmeeting the fire protection requirements for the assembly.

(IFC 703.1 2015)

The memory care mechanical room has missing sheet rock

The memory care mechanical room was caulked with no firerated material

The sprinkler riser room was caulked with non fire ratedmaterial

6 Fire walls, fire barriers and fire partitions.

Required fire walls, fire barriers and fire partitions shall bemaintained to prevent the passage of fire. All openingsprotected with approved doors or fire dampers shall bemaintained in accordance with NFPA80.

(IFC 703.1.3 2015)

The facility did not provide the four yearly fire/smoke damperreport.

2 of 7 Initials of Authorized Facility Representative:^

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Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name

Address

City, State, Zip

Cascade Valley Senior Living

8400 207th ,

Arlington, WA 98223

Provider Number

Approval Status

Facility Type

2312

Disapproved

Residential Care

On 01/02/2019 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation

7 Opening protectives.

Opening protectives shall be maintained in an operativecondition in accordance with NFPA 80. Where allowed by thefire code official, the application of fleld-applied labelsassociated with the maintenance of opening protectives shallfollow the requirements of the approved third-party certificationorganization accredited for listing the opening protective. Firedoors and smoke barrier doors shali not be blocked orobstructed, or otherwise made inoperable. Fusible links shall bereplaced promptly whenever fused or damaged. Fire doorassemblies shall not be modified.

IFC 703.2

The following fire doors were wedged open"

1 #1192 #1203 Salon / Laundry room4 Mechanical room5 #2376 #234

The second floor exit stair fire door had an excessive gap(activities room)

8 Door Operation

Swinging fire doors shall close from the full-open position andlatch automatically. The door closer shall exert enough force toclose and latch the door from any partially open position.

(IFC 703.2.3)

The following fire doors would not close and latch:

123

CCFD#118CCFD#216Mechanical room

4 #203567

Report roomRestroomMemory care #109

9 Inspection, testing and maintenance.

Fire detection, alarm, and extinguishing systems, mechanicalsmoke exhaust systems, and smoke and heat vents shall bemaintained in an operative condition at all times, and shall bereplaced or repaired where defective. Nonrequired fireprotection systems and equipment shall be inspected, testedand maintained or removed.

(IFC 901.6 2012,2015)

The fire alarm annual report showed:

1 - Vault Tampers not secured or monitored

The exterior heads are dated 2003

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Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name

Address

City, State, Zip

Cascade Valley Senior Living

8400 207th ,

Arlington, WA 98223

Provider Number

Approval Status

Facility Type

2312

Disapproved

Residential Care

On 01/02/2019 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation

10 Smoke detector sensitivity.

Smoke detector sensitivity shall be checked within one yearafter installation and every alternate year thereafter. After thesecond calibration test, where sensitivity tests indicate that thedetector has remained within its listed and marked sensitivityrange (or 4-percent obscuration light grey smoke, if notmarked), the length of time between calibration tests shall bepermitted to be extended to a maximum of five years. Wherethe frequency is extended, records of detector-causednuisance alarms and subsequent trends of these alarms shallbe maintained. In zones or areas where nuisance alarms showany increase over the previous year, calibration tests shall beperformed.

(IFC 907.8.3 2012)

There were several smoke detectors on the sensitivity testreport that failed. - please provide documentation these wererepaired or replaced.

4 of 7 Initials of Authorized Facility Representative: __=_^

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WAS HINGTON STAT E PAT ROL[ffl

Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name

Address

City, State, Zip

Cascade Valley Senior Living

8400 207th ,

Arlington, WA 98223

Provider Number

Approval Status

Facility Type

2312

Disapproved

Residential Care

On 01/02/2019 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation

11 Locks and latches.

I Locks and latches shall be permitted to prevent operation ofI doors where any of the following exists:

1. Places of detention or restraint.

2, In buildings in occupancy Group A having an occupant loadI of 300 or less, Groups B, F, M and S, and in places of religious|worship, the main exterior door or doors are permitted to beI equipped with key-operated locking devices from the egressI side provided:

12.1. The locking device is readily distinguishable as locked;

|2.2. A readily visible sign is posted on the egress side on or[adjacent to the door stating: THIS DOOR TO REMAINIUNLOCKED WHEN BUILDING IS OCCUPIED. The sign shallI be in letters 1 inch (25 mm) high on a contrasting background;land

12.3. The use of the key-operated locking device is revocable byI the building official for due cause.

13. Where egress doors are used in pairs, approved automatic[flush bolts shall be permitted to be used, provided that the doorI leaf having the automatic flush bolts has no doorknob orsurface-mounted hardware.

4. Doors from individual dwelling or sleeping units of Group Roccupancies having an occupant load of 10 or less arepermitted to be equipped with a night latch, dead bolt, orsecurity chain, provided such devices are openable from theinside without the use of a key or a tool.

5. Fire doors after the minimum elevated temperature hasdisabled the unlatching mechanism in accordance with listedfire door test procedures.

6. Approved, listed locks without delayed egress shall bepermitted in Group 1-2 condition 2 assisted living facilitieslicensed by the State of Washington provided that:

6.1. The clinical needs of one or more patients require

There was no instructions for the keypads located within 6 feetof the memory care exit gates

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WASHINOTON STATE PATROL|pj]

Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name

Address

City, State, Zip

Cascade Valley Senior Living

8400 207th ,

Arlington, WA 98223

Provider Number

Approval Status

Facility Type

2312

Disapproved

Residential Care

On 01/02/2019 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation

specialized security measures for their safety.

6.2. The doors unlock upon actuation of the automatic sprinklersystem or automatic fire detection system.

6.3. The doors unlock upon loss of electrical power controllingthe lock or lock mechanism.

6.4. The lock shall be capable of being deactivated by a signalfrom a switch located in an approved location.

6.5. There is a system, such as a keypad and code, in placethat allows visitors, staff persons and appropriate residents toexit. Instructions for exiting shall be posted within six feet of thedoor

(IFC 1010.1.9.3 2015WAC51-54A)12 Internally illuminated exit signs.

Electrically powered, self-luminous and photoluminescent exitsigns shall be listed and labeled in accordance with UL 924 andshall be installed in accordance with the manufacturer'sinstructions and Chapter 27 of the International Building Code.Exit signs shall be illuminated at all times.

(IFC 1013.5 2015)

The following exit signs located near the following locationswould not activate when the test button was pressed:

1 East side stairs2 #2333 #238

6 of 7 Initials of Authorized Facility Representative:

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Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name

Address

City, State, Zip

Cascade Valley Senior Living

8400 207th ,

Arlington, WA 98223

Provider Number

Approval Status

Facility Type

2312

Disapproved

Residential Care

On 01/02/2019 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation

Next inspection scheduled on or after: 02/01/2019

Right of appeal. Any person may appeal any decision made by the Fire Protection Bureau in accordance with WAC 212-12.

Owner or ^yl^orizec^Repr^sentatjv^..-.-^' / ^^^^

^.^>y^^>- ^L^y^^^^/SFgnaTure

5 ^&<C^<^- lO^/r,Print Name and Title

r <-?-'7 /^A'^V7jy^^&- 'c^.

Deputy State Fire Marshal David Ridley2700 116 ST NEMarysyille-l(36Q)"654-j^9_

Signature

7 of 7 Initials of Authorized Facility Representative: ^.

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