Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name

Address

City, State, Zip

Evergreen Court

900 124TH NE,

Bellevue, WA 98005

Provider Number

Approval Status

Facility Type

001502

Approved

Residential Care

On 08/29/2018 the Office of the State Fire Marshal conducted an inspection at your facility.

All violations noted during previous related inspection(s) have been corrected.

Owner or Owner,'^ Represeptative

Sfitou^A^-~^fgnature

Deputy State Fire Marshal Scott Campos2803 156AVESEBellevueWA 98007(360)481-9360

^[n^Gu^/L^^l/4, ^rinfName and Title I ' ' " /

Signature

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

1 of 1 Initials of Authorized Facility Representative:

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BU.JWASHINGTON STATE PATROL

Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name Evergreen Court

Address 90° 124TH NE,

City, State, Zip Bellevue, WA 98005

Provider Number

Approval Status

Facility Type

001502

Disapproved

Residential Care

On 7/11/2018 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation

1 Emergency lighting equipment.

Emergency lighting shall be inspected and tested inaccordance with Sections 604.6.1 through 604.6.2.1.

(IFC 604.6 2015)

The following violation was observed.

The facility could not provide documentation of an annual testof their emergency battery backup lights and exit signs.

2 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 violation was observed.

The doors in the following locations did not self close andlatch.

1. Dinning room double doors from main lobby.

3 Required Fre Protection Systems

Fire protection systems required by this code or theInternational Building Code shall be installed, repaired,operated, tested and maintained in accordance with this code.A fire protection system for which a design option, exception orreduction to the provisions of this code or the InternationalBuilding Code has been granted shall be considered to berequired system.

(IFc 901.4,1)

The following violation was observed.

The sprinkler head was bent and damaged in the followinglocation.

1. Near room #122.

4 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 following violations were observed.

1. The facility could not provide documentation of their annualfire sprinkler back flow inspection.

2. The facility could not provide documentation of a quarterlyfire sprinkler inspection.

1 of 3 Initials of Authorized Facility Representative: 3^7

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B.B.JWASH JN&TON STATE PATROL

Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name Evergreen Court

Address 90° 124TH NE,

City, State, Zip Bellevue, WA 98005

Provider Number

Approval Status

Facility Type

001502

Disapproved

Residential Care

On 7/11/2018 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation

5 System Test

Systems shall be inspected and tested for proper operation at6-month intervals. Tests shall include a check of the detectionsystem, alarms and releasing devices, including manualstations and other associated equipment. Extinguishing systemunits shall be weighed and the required amount of agentverified. Stored pressure-type units shall be checked for therequired pressure. The cartridge of cartridge-operated unitsshall be weighed and replaced at intervals indicated by themanufacturer.

(IFC 904.5.1 (2009, 2012, 2015)

The following violation was observed.

The facility could not provide documentation of theirsemi-annual servicing of the kitchen hood suppression systemfor last year. (They are current and up to date for 2018.)

6 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 violation was observed.

The internally illuminated exit signs backup battery did notfunction in the following location.

1. Near room #1952. Near room #116

2 of 3 Initials of Authorized Facility Representative: 5?

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Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Ifius/'ness Name Evergreen Court Provider Number 001502

\Address 90° 124TH NE' Approval Status Disapproved

\City, State, Zip Bellevue, WA 98005 Facility Type Residential Care

On 7/11/2018 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation

Next inspection scheduled on or after: 8/10/2018

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

Owner or Authorized Representative

V ^U^UUASignature

Deputy State Fire Marshal Scott Campos2803 156AVESEBellevueWA 98007(360) 48^9360

Signature

^w^ 6^ i^//^^ ^/,Print Name and Title

3 of 3 Initials of Authorized Facility Representative:

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