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Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3.

Findings include:

1. On 1/25/10 between approximately 12:50 PM and 1:10 PM during an inspection with Facility Services staff, the following observations were made:

a. South Pavilion - 1st Floor; at approximately 12:50 PM, the corridor doors in assembly #GX22.02 leading to the Tunnel did not completely close upon activation of the fire alarm.

b. South Pavilion - Garden Level; at approximately 1:10 PM, the corridor doors leading to the rear hallway of the Pharmacy did not self-close to a positive latch.

Based on observation the facility failed to provide 1-hour fire resistive separation for the vertical openings in accordance with the LSC section 19.3.1.1.

Findings include:

1. On 1/25/10 at approximately 10:30 AM during an inspection with Facility Services staff, the following observation was made:

a. North Pavilion, 4th Floor room N-4403 was observed to have a linen chute door that did not self-close to a positive latch.

Based on observation the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6.

Findings include:

1. On 1/25/10 at approximately 1:14 PM during an inspection with Facility Services staff, the following observation was made:

a. South Pavilion - Garden Level; the cross-corridor smoke barrier doors by the East Entrance had a gap in excess of 1/8" when closed.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1.

Findings include:

1. On 1/25/10 between approximately 12:55 PM and 1:05 PM during an inspection with Facility Services staff, the following observations were made:

a. South Pavilion - Garden Level; at approximately 12:55 PM, the pump room off the dock area was observed to have a penetration above the spare sprinkler head cabinet that was not properly firestopped.

b. South Pavilion - Garden Level; at approximately 1:05 PM, the electrical sub-station room (G.V30.01) was observed to have a penetration above the fire alarm audio/visual device where the firestopping had become dislodged, therefore creating an open penetration.

Based on observation the facility failed to provide the required one-hour fire resistance rating for the exit component in accordance with the LSC section 8.2.5.2, 19.3.11.

Findings include:

1. On 1/25/10 between approximately 12:30 PM and 12:50 PM during an inspection with Facility Services staff, the following observations were made:

a. South Pavilion - 2nd Floor; at approximately 12:30, the exit stairwell door #2.N20.03 was observed not to self-close to a positive latch.

b. South Pavilion - 2nd Floor; at approximately 12:50 PM, the elevator lobby doors in assembly #2.W26.01 were observed not to self-close to a positive latch.

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.3.

Findings include:

1. On 1/25/10 at approximately 11:00 AM during an inspection with Facility Services staff, the following observation was made:

a. South Pavilion - 3rd Floor; the corridor next to room E-355 was observed to have 1-bed and 2-wheel chairs placed against the wall of the corridor and not in use.

Based on observation the facility failed to provide lighting in accordance with the LSC section 19.2.8.

Findings include:

1. On 1/25/10 between approximately 2:00 PM and 3:00 PM during a review of records with Facility Services staff, the following observation was made:

a. Several exit discharges were observed not to have either a dual light fixture or overlapping single light fixtures to provide illumination for a distance of 50 feet from the building or to a public way. The means of egress shall be illuminated to values of at least 1 ft-candle measured at the walking surface. Required illumination shall be arranged so that the failure of any single unit (bulb) does not result in an illumination of less than 0.2 ft-candle in any designated area.

Based on observation and/or review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1.

Findings include:

1. On 1/25/10 between approximately 2:00 PM and 3:00 PM during a review of records with Facility Services staff, the following observation was made:

a. The fire watch policy and procedure contained within the emergency plan does not address the requirements that persons assigned to fire watch duties not be assigned any other duties or that fire watch rounds shall be continuous. Fire watch shall be their "sole duty" and fire watch rounds shall be "continuous."

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4.

Findings include:

1. On 1/25/10 between approximately 2:00 PM and 3:00 PM during a review of records with Facility Services staff, the following observations were made:

a. The Quarterly fire alarm inspection & testing performed by the ACT 144 certified firm did not complete the inspection as required by the code for the year 2009. All four inspection reports indicated that the fire alarm audible devices were not sounded during the inspections at the request of the facility.

b. The Quarterly fire alarm inspection & testing performed by the ACT 144 certified firm did not complete the inspection as required by the code for the year 2009. Each quarterly inspection identified devices that were not tested due to access and other issues. The report indicated they would be tested in the next quarterly inspection. The reports do not indicate if the devices were ever tested at the next inspection.

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3.

Findings include:

1. On 1/25/10 between approximately 10:30 AM and 1:30 PM during an inspection with Facility Services staff, the following observations were made:

a. South Pavilion - 4th Floor; at approximately 10:45 AM, room E-446 was observed to have a smoke detector located within 3' of an air diffuser.

b. South Pavilion - 3rd Floor; at approximately 10:30 AM, the cross-corridor smoke barrier doors next to room E-367 were observed to not have a smoke detector with in 5 feet of the doors.

c. South Pavilion - 1st Floor; at approximately 11:45 AM, the cross-corridor smoke barrier doors, next to room E-151, were observed to not have a smoke detector with in 5 feet of the doors.

d. North Pavilion - 3rd Floor; at approximately 1:00 PM, room 3841 was observed to have a smoke detector located within 3' of an air diffuser.

e. North Pavilion - 3rd Floor; at approximately 1:05 PM, room 3843 was observed to have a smoke detector located within 3' of an air diffuser.

f. North Pavilion - 3rd Floor; at approximately 1:10 PM, room 3845 was observed to have a smoke detector located within 3' of an air diffuser.

g. North Pavilion - 3rd Floor; at approximately 1:30 PM, room 3872 was observed to have a smoke detector located within 3' of an air diffuser.

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 19.3.5.

Findings include:

1. On 1/25/10 between approximately 10:00 AM and 10:10 AM during an inspection with Facility Services staff, the following observations were made:

a. South Pavilion - 3rd Floor; at approximately 10:00 AM, Room 340 was observed not to have fire sprinkler coverage in the wardrobe closet.

b. South Pavilion - 3rd Floor; at approximately 10:10 AM, Room 341 was observed not to have fire sprinkler coverage in the wardrobe closet.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3.

Findings include:

1. On 1/25/10 between approximately 12:50 PM and 1:10 PM during an inspection with Facility Services staff, the following observations were made:

a. South Pavilion - 1st Floor; at approximately 12:50 PM, the corridor doors in assembly #GX22.02 leading to the Tunnel did not completely close upon activation of the fire alarm.

b. South Pavilion - Garden Level; at approximately 1:10 PM, the corridor doors leading to the rear hallway of the Pharmacy did not self-close to a positive latch.

Based on observation the facility failed to provide 1-hour fire resistive separation for the vertical openings in accordance with the LSC section 19.3.1.1.

Findings include:

1. On 1/25/10 at approximately 10:30 AM during an inspection with Facility Services staff, the following observation was made:

a. North Pavilion, 4th Floor room N-4403 was observed to have a linen chute door that did not self-close to a positive latch.

Based on observation the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6.

Findings include:

1. On 1/25/10 at approximately 1:14 PM during an inspection with Facility Services staff, the following observation was made:

a. South Pavilion - Garden Level; the cross-corridor smoke barrier doors by the East Entrance had a gap in excess of 1/8" when closed.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1.

Findings include:

1. On 1/25/10 between approximately 12:55 PM and 1:05 PM during an inspection with Facility Services staff, the following observations were made:

a. South Pavilion - Garden Level; at approximately 12:55 PM, the pump room off the dock area was observed to have a penetration above the spare sprinkler head cabinet that was not properly firestopped.

b. South Pavilion - Garden Level; at approximately 1:05 PM, the electrical sub-station room (G.V30.01) was observed to have a penetration above the fire alarm audio/visual device where the firestopping had become dislodged, therefore creating an open penetration.

Based on observation the facility failed to provide the required one-hour fire resistance rating for the exit component in accordance with the LSC section 8.2.5.2, 19.3.11.

Findings include:

1. On 1/25/10 between approximately 12:30 PM and 12:50 PM during an inspection with Facility Services staff, the following observations were made:

a. South Pavilion - 2nd Floor; at approximately 12:30, the exit stairwell door #2.N20.03 was observed not to self-close to a positive latch.

b. South Pavilion - 2nd Floor; at approximately 12:50 PM, the elevator lobby doors in assembly #2.W26.01 were observed not to self-close to a positive latch.

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.3.

Findings include:

1. On 1/25/10 at approximately 11:00 AM during an inspection with Facility Services staff, the following observation was made:

a. South Pavilion - 3rd Floor; the corridor next to room E-355 was observed to have 1-bed and 2-wheel chairs placed against the wall of the corridor and not in use.

Based on observation the facility failed to provide lighting in accordance with the LSC section 19.2.8.

Findings include:

1. On 1/25/10 between approximately 2:00 PM and 3:00 PM during a review of records with Facility Services staff, the following observation was made:

a. Several exit discharges were observed not to have either a dual light fixture or overlapping single light fixtures to provide illumination for a distance of 50 feet from the building or to a public way. The means of egress shall be illuminated to values of at least 1 ft-candle measured at the walking surface. Required illumination shall be arranged so that the failure of any single unit (bulb) does not result in an illumination of less than 0.2 ft-candle in any designated area.

Based on observation and/or review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1.

Findings include:

1. On 1/25/10 between approximately 2:00 PM and 3:00 PM during a review of records with Facility Services staff, the following observation was made:

a. The fire watch policy and procedure contained within the emergency plan does not address the requirements that persons assigned to fire watch duties not be assigned any other duties or that fire watch rounds shall be continuous. Fire watch shall be their "sole duty" and fire watch rounds shall be "continuous."

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4.

Findings include:

1. On 1/25/10 between approximately 2:00 PM and 3:00 PM during a review of records with Facility Services staff, the following observations were made:

a. The Quarterly fire alarm inspection & testing performed by the ACT 144 certified firm did not complete the inspection as required by the code for the year 2009. All four inspection reports indicated that the fire alarm audible devices were not sounded during the inspections at the request of the facility.

b. The Quarterly fire alarm inspection & testing performed by the ACT 144 certified firm did not complete the inspection as required by the code for the year 2009. Each quarterly inspection identified devices that were not tested due to access and other issues. The report indicated they would be tested in the next quarterly inspection. The reports do not indicate if the devices were ever tested at the next inspection.

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3.

Findings include:

1. On 1/25/10 between approximately 10:30 AM and 1:30 PM during an inspection with Facility Services staff, the following observations were made:

a. South Pavilion - 4th Floor; at approximately 10:45 AM, room E-446 was observed to have a smoke detector located within 3' of an air diffuser.

b. South Pavilion - 3rd Floor; at approximately 10:30 AM, the cross-corridor smoke barrier doors next to room E-367 were observed to not have a smoke detector with in 5 feet of the doors.

c. South Pavilion - 1st Floor; at approximately 11:45 AM, the cross-corridor smoke barrier doors, next to room E-151, were observed to not have a smoke detector with in 5 feet of the doors.

d. North Pavilion - 3rd Floor; at approximately 1:00 PM, room 3841 was observed to have a smoke detector located within 3' of an air diffuser.

e. North Pavilion - 3rd Floor; at approximately 1:05 PM, room 3843 was observed to have a smoke detector located within 3' of an air diffuser.

f. North Pavilion - 3rd Floor; at approximately 1:10 PM, room 3845 was observed to have a smoke detector located within 3' of an air diffuser.

g. North Pavilion - 3rd Floor; at approximately 1:30 PM, room 3872 was observed to have a smoke detector located within 3' of an air diffuser.

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 19.3.5.

Findings include:

1. On 1/25/10 between approximately 10:00 AM and 10:10 AM during an inspection with Facility Services staff, the following observations were made:

a. South Pavilion - 3rd Floor; at approximately 10:00 AM, Room 340 was observed not to have fire sprinkler coverage in the wardrobe closet.

b. South Pavilion - 3rd Floor; at approximately 10:10 AM, Room 341 was observed not to have fire sprinkler coverage in the wardrobe closet.