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Based on observation it was determined that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with the LSC, sections 18.1.1.4.1, 18.1.1.4.2. This deficient practice could affect all occupants in the facility in the event of a fire where the products of combustion are allowed to transmit throughout from the adjacent non-conforming building due to improperly maintained separation.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 08:40 AM observed that the 2nd floor Conference Hall #2300 south leaf of the south 2 hr rated doors did not close to a positive latch.
- At approximately 09:40 AM observed that on the 1st floor above the 2 hr rated doors near the Janitor's Closet #1027 there was a 4" conduit that had created a penetration through the wall that was not sealed with a fire rated material.
- At approximately 10:25 AM observed that on the 1st floor there were 2 hr rated doors at the Lab/Xray Entrance that were equipped with a power-assist mechanism that did not cease to function upon activation of a smoke detection system.


During the Recheck LSC survey, the door latch and penetration deficiencies were found to have been corrected. The facility is making progress on the door power-assisted mechanism deactivation upon activation of a smoke detection system deficiency. System relays have been installed, and a certified fire alarm contractor has been contracted for the fire alarm system connection. The POC date submitted is 07/31/12.