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1. Based on observation and interview it was determined the facility failed to provide a complete automatic sprinkler system, required for this type of construction and story height, in two of two smoke compartments in this component.

Findings include:

A. Observation on April 20, 2011, between 9:20 AM and 10:00 AM, revealed this component lacks complete automatic sprinkler coverage in two of two smoke compartments in this component.

Interview with maintenance representative #1 on April 20, 2011, at 10:01 AM, confirmed this component did not have complete automatic sprinkler coverage and identified the facility has an acceptable Fire Safety Evaluation System (FSES) revised on 4/20/2011 addressing this issue.

Based on observation and interview it was determined the facility failed to provide a complete automatic sprinkler system, required for this type of construction and story height, in two of two smoke compartments in this component.

Findings include:

A. Observation on April 20, 2011, between 10:05 AM and 10:30 AM, revealed this component lacks complete automatic sprinkler coverage in two of two smoke compartments in this component.

Interview with maintenance representative #1 on April 20, 2011, at 10:31 AM, confirmed this component did not have complete automatic sprinkler coverage and identified the facility has an acceptable Fire Safety Evaluation System (FSES) revised on 4/20/2011 addressing this issue.

Based on observation and interview it was determined the facility failed to provide a complete automatic sprinkler system, required for this type of construction and story height, in two of two smoke compartments in this component.

Findings include:

A. Observation on April 20, 2011, between 10:35 AM and 11:10 AM, revealed this component lacks complete automatic sprinkler coverage in two of two smoke compartments in this component.

Interview with maintenance representative #1 on April 20, 2011, at 11:11 AM, confirmed this component did not have complete automatic sprinkler coverage and identified the facility has an acceptable Fire Safety Evaluation System (FSES) revised on 4/20/2011 addressing this issue.

Based on observation and interview it was determined the facility failed to provide a complete automatic sprinkler system, required for this type of construction and story height, in two of two smoke compartments in this component.

Findings include:

A. Observation on April 20, 2011, between 11:15 AM and 11:58 AM, revealed this component lacks complete automatic sprinkler coverage in two of two smoke compartments in this component.

Interview with maintenance representative #1 on April 20, 2011, at 11:59 AM, confirmed this component did not have complete automatic sprinkler coverage and identified the facility has an acceptable Fire Safety Evaluation System (FSES) revised on 4/20/2011 addressing this issue.

Based on observation and interview it was determined the facility failed to provide a complete automatic sprinkler system, required for this type of construction and story height, in two of two smoke compartments in this component.

Findings include:

A. Observation on April 20, 2011, between 12:30 PM and 1:20 PM, revealed this component lacks complete automatic sprinkler coverage in two of two smoke compartments in this component.

Interview with maintenance representative #1 on April 20, 2011, at 1:21 PM, confirmed this component did not have complete automatic sprinkler coverage and identified the facility has an acceptable Fire Safety Evaluation System (FSES) revised on 4/20/2011 addressing this issue.

Based on observation and interview it was determined the facility failed to provide doors protecting corridor openings of substantial construction and/or to provide doors with no impediment to the closing of the door and/or to provide doors with a means suitable for keeping the door closed in its frame in one of five smoke zones in the component.

Findings include:

Observation of corridor doors on April 20, 2011, at 1:20 PM revealed a louvered door to the locker room which had combustible materials housed within.

Interview with facility representative #1 on April 20, 2011, at 1:21 PM confirmed the louvered door.

Based upon observation and interview, it was determined the facility failed to maintain vertical openings in one instance in one of two smoke zones in the component.

Findings include:

Observation of vertical openings on April 20, 2011, at 11:07 AM revealed the access panel located in the laundry room ceiling was damaged, leaving a penetration where the locking mechanism was originally installed.

Interview with the facility representative #1 on April 20, 2011, at 11:08 AM confirmed the access panel penetration.

Based on documentation review and interview it was determined the facility failed to properly configure the fire alarm system affecting two of two smoke compartments in this component.

Findings include:

A. Review of fire alarm documentation on April 20, 2011 at 8:32 AM revealed the facility did not have documentation available to verify the fire alarm monitoring vendor was immediately transmitting facility fire alarms to the designated emergency services dispatch center without delay.

Interview with maintenance representative #1 on April 20, 2011 at 8:33 AM, confirmed the fire alarm monitoring vendor was first contacting the facility, to verify the validity of the alarm, prior to transmitting facility fire alarms to the designated emergency services dispatch center.

Based on observation and interview it was determined the facility failed to provide electrical wiring and equipment in accordance with NFPA 101, and the National Electrical Code, NFPA 70 in one instance on one of two smoke zones in the component.

Findings include:

Observation of electrical wiring and equipment on April 20, 2011, at 11:05 AM revealed a 6x outlet multiplier was being used in the laundry room.

Interview with facility representative #1 on April 20, 2011, at 11:06 AM confirmed the multi outlet being used in the laundry room.

1. Based on observation and interview it was determined the facility failed to provide a complete automatic sprinkler system, required for this type of construction and story height, in two of two smoke compartments in this component.

Findings include:

A. Observation on April 20, 2011, between 9:20 AM and 10:00 AM, revealed this component lacks complete automatic sprinkler coverage in two of two smoke compartments in this component.

Interview with maintenance representative #1 on April 20, 2011, at 10:01 AM, confirmed this component did not have complete automatic sprinkler coverage and identified the facility has an acceptable Fire Safety Evaluation System (FSES) revised on 4/20/2011 addressing this issue.

Based on observation and interview it was determined the facility failed to provide a complete automatic sprinkler system, required for this type of construction and story height, in two of two smoke compartments in this component.

Findings include:

A. Observation on April 20, 2011, between 10:05 AM and 10:30 AM, revealed this component lacks complete automatic sprinkler coverage in two of two smoke compartments in this component.

Interview with maintenance representative #1 on April 20, 2011, at 10:31 AM, confirmed this component did not have complete automatic sprinkler coverage and identified the facility has an acceptable Fire Safety Evaluation System (FSES) revised on 4/20/2011 addressing this issue.

Based on observation and interview it was determined the facility failed to provide a complete automatic sprinkler system, required for this type of construction and story height, in two of two smoke compartments in this component.

Findings include:

A. Observation on April 20, 2011, between 10:35 AM and 11:10 AM, revealed this component lacks complete automatic sprinkler coverage in two of two smoke compartments in this component.

Interview with maintenance representative #1 on April 20, 2011, at 11:11 AM, confirmed this component did not have complete automatic sprinkler coverage and identified the facility has an acceptable Fire Safety Evaluation System (FSES) revised on 4/20/2011 addressing this issue.

Based on observation and interview it was determined the facility failed to provide a complete automatic sprinkler system, required for this type of construction and story height, in two of two smoke compartments in this component.

Findings include:

A. Observation on April 20, 2011, between 11:15 AM and 11:58 AM, revealed this component lacks complete automatic sprinkler coverage in two of two smoke compartments in this component.

Interview with maintenance representative #1 on April 20, 2011, at 11:59 AM, confirmed this component did not have complete automatic sprinkler coverage and identified the facility has an acceptable Fire Safety Evaluation System (FSES) revised on 4/20/2011 addressing this issue.

Based on observation and interview it was determined the facility failed to provide a complete automatic sprinkler system, required for this type of construction and story height, in two of two smoke compartments in this component.

Findings include:

A. Observation on April 20, 2011, between 12:30 PM and 1:20 PM, revealed this component lacks complete automatic sprinkler coverage in two of two smoke compartments in this component.

Interview with maintenance representative #1 on April 20, 2011, at 1:21 PM, confirmed this component did not have complete automatic sprinkler coverage and identified the facility has an acceptable Fire Safety Evaluation System (FSES) revised on 4/20/2011 addressing this issue.

Based on observation and interview it was determined the facility failed to provide doors protecting corridor openings of substantial construction and/or to provide doors with no impediment to the closing of the door and/or to provide doors with a means suitable for keeping the door closed in its frame in one of five smoke zones in the component.

Findings include:

Observation of corridor doors on April 20, 2011, at 1:20 PM revealed a louvered door to the locker room which had combustible materials housed within.

Interview with facility representative #1 on April 20, 2011, at 1:21 PM confirmed the louvered door.

Based upon observation and interview, it was determined the facility failed to maintain vertical openings in one instance in one of two smoke zones in the component.

Findings include:

Observation of vertical openings on April 20, 2011, at 11:07 AM revealed the access panel located in the laundry room ceiling was damaged, leaving a penetration where the locking mechanism was originally installed.

Interview with the facility representative #1 on April 20, 2011, at 11:08 AM confirmed the access panel penetration.

Based on documentation review and interview it was determined the facility failed to properly configure the fire alarm system affecting two of two smoke compartments in this component.

Findings include:

A. Review of fire alarm documentation on April 20, 2011 at 8:32 AM revealed the facility did not have documentation available to verify the fire alarm monitoring vendor was immediately transmitting facility fire alarms to the designated emergency services dispatch center without delay.

Interview with maintenance representative #1 on April 20, 2011 at 8:33 AM, confirmed the fire alarm monitoring vendor was first contacting the facility, to verify the validity of the alarm, prior to transmitting facility fire alarms to the designated emergency services dispatch center.

Based on documentation review and interview it was determined the facility failed to properly maintain and inspect the automatic sprinkler system affecting two of two smoke compartments in this component.

Findings include:

A. Review of sprinkler system testing and inspection documentation on April 20, 2011 at 8:35 AM, revealed the facility did not have documentation available to support conducting a required 5-year inspection of the internal portion of the 60,000 gallon bulk water storage tank which supplies water for the sprinkler system in accordance with NFPA 25, 1998 edition, Chapter 6-2.4

Interview with maintenance representative #1 on April 20, 2011 at 8:35 AM, confirmed that documentation for the required internal 5-year inspection 60,000 gallon bulk water storage tank, that supplies water for the sprinkler system, was not available.

Based on observation and interview it was determined the facility failed to provide electrical wiring and equipment in accordance with NFPA 101, and the National Electrical Code, NFPA 70 in one instance on one of two smoke zones in the component.

Findings include:

Observation of electrical wiring and equipment on April 20, 2011, at 11:05 AM revealed a 6x outlet multiplier was being used in the laundry room.

Interview with facility representative #1 on April 20, 2011, at 11:06 AM confirmed the multi outlet being used in the laundry room.