Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name

Address

City, State, Zip

Champion House

1800 145THPLSE,

Bellevue, WA 98007

Provider Number

Approval Status

Facility Type

000698

Approved

Residential Care

On 6/4/2018 the Office of the State Fire Marshal conducted an inspection at your facility.

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

Ovyper or Owner's^e^^entative

^^^j^l/)-^icSignature /

K^Uf^ ^A4V ^ /-^'? / S%^^Print Name and Title

\)^^-

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

Signature

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

Washington State PatrolFire Protection Bureau

Phone: (360)596-3900 MAY 25 2018

FIRE PREVENTIONDIVISION

Aprill6,2018

Andrea GwynAdministratorChampion House

1800 145THPLSEBellevue WA 98007

The Office of the State Fire Marshal conducted an annual fire and life safety inspection of Champion House.

Initial InspectionDuring the inspection, we identified a number of violations.

We provided a copy of the inspection report to the facility.The inspection report outlined each violation and items to correct prior to a reinspection, scheduled on or after March 29,

2018.

Required Reinspection• Today we conducted a reinspection of Champion House.

• During the reinspection, one or more of the violations identified during the initial inspection remained uncorrected.

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 Follow-Up• The facility administrator shall submit a letter to Deputy State Fire Marshal Scott Campos, 2803, 156, AVE, Bellevue, WA

98007 within 30 days. The letter shall explain, in detail, how the code violations were corrected and indicate the facility isready 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 the

facility. 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 torecommending relicensure.

If you have any questions regarding this process, please contact Deputy State Fire Marshal Scott Campos at (425) 401-7735.

Letter Received By: Letter Issued By:

Deputy State Fire MarshalScott Campos

ec:

Enclosures

: ResidentialCareServiJeP^ ^\^0^\^

Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Provider Number 000698

Approval Status Disapproved

Facility Type Residential Care

On 04/16/2018 the Office of the State Fire Marshal conducted an inspection at your facility.

Business Name Champion House

Address 1800 145TH PLSE,

City, State, Zip Bellevue, WA 98007

Code Requirement Statement of Violation

1 Maintenance

Emergency and standby power systems shall be maintained inaccordance with NFPAHOand NFPA111 such that thesystem is capable of supplying service within the time specifiedfor the type and duration required.

(IFC 0604.4, 2015)

The following violation was observed.

The facility could not provide documentation of servicing andtesting of their generator.

2 Abatement of electrical hazards.

Identified electrical hazards shall be abated. Identifiedhazardous electrical conditions in permanent wiring shall bebrought to the attention of the responsible code official.Electrical wiring, devices, appliances and other equipment thatis modified or damaged and constitutes an electrical shock orfire hazard shall not be used.

(IFC 605.1 2012,2015)

The following violation was observed.

The facility was able to correct the deficiancy outside room #8,but did not correct the deficiancies outside room #4.

1 of 4 Initials of Authorized Facility Representative:

Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name Champion House

Address 1800 145TH PL SE,

City, State, Zip Bellevue, WA 98007

Provider Number

Approval Status

Facility Type

000698

Disapproved

Residential Care

On 04/16/2018 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation

3 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, ceiling 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 following violation was observed.

The facility failed to seal the penetration outside room #4.

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 violation was observed.

The facility could not provide documentation of the annualservicing and testing of their fire alarm system.

2 of 4 Initials of Authorized Facility Representative:

Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

\Business Name Champion House Provider Number

I Address 1800 145TH PLSE, Approval Status

State. Zio Bellevue, WA 98007 Facility Type

On 04/16/2018 the Office of the State Fire Marshal conducted an inspection at your facility.

000698

Disapproved

Residential Care

Code Requirement Statement of Violation

5 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 following violation was observed.

The facility could not provide documentation of the requiredfire alarm nuisance log for their zoned fire alarm system.

6 Buildings

In the event of power supply failure, in buildings that require twoor more means of egress, an emergency electrical system shallautomatically illuminate all of the following areas:

1. Exterior exit access stairways and ramps2. Interior and exterior exit stairways and ramps.3. Exit passageways4. vestibules and areas on the level of discharge used for exitdischarge in accordance with Section 1028.15. Exterior landings as required by Section 1010.1.6 for exitdoorways that lead directly to the exit discharge.

(IFC 1008.3.2 2015)

3 of 4 Initials of Authorized Facility Representative:

ifASHWGTONSTATTPATROLPl

Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name Champion House

Address 18°0 145THPLSE,

City, State, Zip Be"evue. WA 98007

Provider Number

Approval Status

Facility Type

000698

Disapproved

Residential Care

On 04/16/2018 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation

7 Fire Drills

In all Group I, Group E, and Group R2 Occupancies licensed bythe state, at least twelve planned and unannounced fire drillsshall be held every year. Drills shall be conducted quarterly oneach shift in Group I and Group R2, Occupancies and monthlyin Group E Occupancies to familiarize personnel with signalsand emergency action required under varied conditions. Adetailed written record of all fire drills shall be maintained andavailable for inspection at all times. When drills are conductedbetween 9:00 p.m. and 6:00 a.m., a coded announcement maybe used instead of audible alarms. Fire drills shall include thetransmission of a fire alarm signal and simulation of emergencyconditions. The fire alarm monitoring company shall be notifiedprior to the activation of the fire alarm system for drill purposesand again at the conclusion of the transmission and restorationof the fire alarm system to normal mode.

(WAC 212-12-044)

The following violation was observed.

The facility failed to provide documentation of requiredquarterly fire drills.

Next inspection scheduled on or after: 05/16/2018

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

Signature Print Name and Title

Deputy State Fire Marshal Brendan Magee2803 156AVESEBellevueWA 98007(425)401-7735

Signature

4of4 Initials of Authorized Facility Representative:

•U.JWASHINGTON STATE PATROL

Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name Champion House

Address 1800 145TH PLSE,

City, State, Zip Betlevue, WA 98007

Provider Number

Approval Status

Facility Type

000698

Disapproved

Residential Care

On 02/27/2018 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation

1 Maintenance

Emergency and standby power systems shall be maintained inaccordance with NFPA 110 and NFPA 111 such that thesystem is capable of supplying service within the time specifiedfor the type and duration required.

(IFC 0604.4, 2015)

The following violations were observed:

The facility failed to conduct the annual service and testing ofthe generator.

The generator battery is dated from 2009. Generator batteriesshall be replaced every 5 years.

2 Abatement of electrical hazards.

Identified electrical hazards shall be abated. Identifiedhazardous electrical conditions in permanent wiring shall bebrought to the attention of the responsible code official.Electrical wiring, devices, appliances and other equipment thatis modified or damaged and constitutes an electrical shock orfire hazard shall not be used.

(IFC 605.1 2012,2015)

The following violations were observed:

There was a power strip attached to the wall outside of room#4, the power cords are tucked behind the wood on the doorframe. Also the wires for the powered door opener/closer atthe top of the door were tucked into the door frame.

The wires for the powered door closer/opener for room #8were tucked behind the wooden door frame.

1 of4 Initials of Authorized Facility Representative:

•Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name

Address

City, State, Zip

Champion House

1800 145THPLSE,

Bellevue, WA 98007

Provider Number

Approval Status

Facility Type

000698

Disapproved

Residential Care

On 02/27/2018 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation

3 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, ceiling 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 703.12015)

The following violations were observed:

There was an open penetration from the corridor into room #4near the ceiling.

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:

The facility failed to provide documentation for the 2018 annualfire alarm test.

2 of 4 Initials of Authorized Facility Representative:

Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name

Address

City, State, Zip

Champion House

1800 145THPLSE,

Bellevue, WA 98007

Provider Number

Approval Status

Facility Type

000698

Disapproved

Residential Care

On 02/27/2018 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation

5 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 following violations were observed:

The facility failed to maintain a fire alarm nuisance log for thezoned fire alarm system.

6 Buildings

In the event of power supply failure, in buildings that require twoor more means of egress, an emergency electrical system shallautomatically illuminate all of the following areas:

1. Exterior exit access stairways and ramps2. Interior and exterior exit stairways and ramps.3. Exit passageways4. vestibules and areas on the level of discharge used for exitdischarge in accordance with Section 1028.15. Exterior landings as required by Section 1010.1.6 for exitdoorways that lead directly to the exit discharge.

(IFC 1008.3.2 2015)

The following violations were observed:

The emergency/exit light near the front door did not illuminatewhen tested.

3 of 4 Initials of Authorized Facility Representative:

Washington State PatrolFire Protection Bureau

Phone: (360)596-3900

Business Name

Address

City, State, Zip

Champion House

1800 145THPLSE,

Bellevue, WA 98007

Provider Number

Approval Status

Facility Type

000698

Disapproved

Residential Care

On 02/27/2018 the Office of the State Fire Marshal conducted an inspection at your facility.

Code Requirement Statement of Violation

7 Fire Drills

In all Group I, Group E, and Group R2 Occupancies licensed bythe state, at least twelve planned and unannounced fire drillsshall be held every year. Drills shall be conducted quarterly oneach shift in Group I and Group R2, Occupancies and monthlyin Group E Occupancies to familiarize personnel with signalsand emergency action required under varied conditions. Adetailed written record of all fire drills shall be maintained andavailable for inspection at all times. When drills are conductedbetween 9:00 p.m. and 6:00 a.m., a coded announcement maybe used instead of audible alarms. Fire drills shall include thetransmission of a fire alarm signal and simulation of emergencyconditions. The fire alarm monitoring company shall be notifiedprior to the activation of the fire alarm system for drill purposesand again at the conclusion of the transmission and restorationof the fire alarm system to normal mode.

(WAC 212-12-044)

The following violations were observed:

The facility failed to document fire drills for Dec 2017 and Jan2018.

The facility shall conduct one fire drill per shift before there-inspection.

Next inspection scheduled on or after: 03/29/2018

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

,(^i^Jl!L c- %aS£e.i.Signature Print Name and Title

Deputy State Fire Ma2803 156AVESEBellevue WA 980(;(425)401-7735

Brendan Magee

Signature

4of4 Initials of Authorized Facility Representative: