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Facility llata Certificatc: <br />Facility Name: Providence Hospice and Home Care of Snohomish Co Licensee UBI#: 313007977 <br />Site Address: 1717 13th St Critical Access Facility: ❑ Yes ❑ No <br />Eve�•ett, WA 98201 <br />�stimated Date of Occupancy: <br />Occupancy I-2 Construction Applicable Code: 2000 Nrl'A 101 <br />Group: Type: 2012 IBC <br />� <br />W Number of Current: 0 Added: ] 6 Removed: Total: 16 <br />� Beds: <br />��,,, Automatic Fire Sprinkler System: � Yes ❑ No Type 13 <br />Fi <br />� Automatic Firc Alarm System: � Yes ❑ No <br />� <br />� Comparhnentation r�eq'd: �Ycs ❑No S�noke Control System Provided: ❑ Yes �No <br />w <br />� Special Delayed Egress Control: ❑ Yes �No Location: <br />� <br />Certificate of Need Required: ❑ Yes �No CON Approval Granted: ❑ Yes ONo <br />CON Number : <br />� <br />W <br />Fi <br />O <br />z <br />Number of units: Private occupancy: <br />Based on size of rooms used for sleeping Residents <br />Based on size of common rooms Residents <br />Maximum allowable licensable beds: <br />Qualifies for Assisted Living Funding Program ❑ Yes <br />Two person occupancy: <br />o Number af qualifying units: <br />Ac1d a 16 bed Hospice Care Cente�• on t11e 8th flooi• of tile old Providence hospital A-wing in Everett, WA <br />The data above is based on the information presented to CRS. Any change in the facility or facility program that <br />causes the above information to be incorrect is subject to review by CRS. Approval for construction is not <br />approval for liceiisure. A copy of the facility data certiiicate will be sent to the licensing agency. <br />Page 2 of 10 Plan Review Commcnts for Project # 60542870 � I <br />