HospitalInspections.org

Based on observation, the facility failed to maintain the walls of the building in a condition that would resist the passage of smoke and fire. This was evidenced by unsealed penetrations in the walls. This affected staff and patients on four of 32 floors at the Main Campus Buildings, and could potentially result in the spread of smoke and/or fire from one area to another.

Findings:

During a tour of the facility with the Engineering Staff from 9/24/2012 to 9/25/12, the wall construction was observed.

Main Campus Building K
1. At 9:40 a.m., there were two one-half inch unsealed penetrations in the wall opposite the door in the Fourth Floor West Wing Environmental Services Room. The escutcheon ring to the sprinkler head in this room was not flush to the ceiling, and created an approximately one-half inch penetration around the sprinkler pipe.

Main Campus Building C
2. At 11:02 a.m., there was an approximately two inch by three inch unsealed penetration in the east wall of Room 5C022. This penetration was approximately twelve inches up from the floor.



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Main Campus Building M

3. On 9/24/12, at 11:25 a.m., in the Medical Prep Room in the Fourth Floor Nursing Station, there was a 1/4 inch by 1 1 /2 inch penetration on the left side of a junction box below a monitor.

4. On 9/24/12. at 2:20 p.m., in Room BM034, a pull box cover was missing between two tape file cabinets leaving a 5 inch by 5 inch wall penetration. Maintenance Coordinator confirmed the missing pull box cover and penetration.



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Main Campus Building M
5. 9/24/12 At 2:07 p.m., in the closet located in Radiology Conference Room 1M095, there was an approximately 1/2 inch penetration around a conduit in the ceiling.

Main Campus Building K
6. 9/25/12 At 9:37 a.m., in Room 3K084, there was an unsealed 1/2 inch penetration in the ceiling where a sprinkler was removed.

Main Campus Building E
7. 9/25/12 At 2:55 p.m., in Room 4E052, there was an approximately 3 inch penetration below the trash chute door.

Based on observation, the facility failed to ensure that all corridor doors were maintained to prevent the passage of smoke or fire into the corridor. This was evidenced by corridor doors that failed to close and latch or were impeded from closing when tested. It is critical that corridor doors can be closed and latched to prevent the spread of smoke and/or fire into other areas of the facility. This affected 18 of 32 floors at the Main Campus Buildings, and the Valley Health Cinic Moorpark, Puentes, Bascom, and the Valley Specailty Clinic.

7.2.1.4.5 The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile.


Findings:

Main Campus Building M
During a tour of the facility with Engineering Staff from 9/24/2012 to 9/25.2012, the corridor doors were observed.

1. On 9/24/12, at 10:50 a.m., there was a trash can holding the door open in the Family Room 5M099.

2. On 9/24/12, at 2:30 p.m., the door to Equipment Room 2M029 was being held open by a cloth that was tied around the door knob and a shelf.

Main Campus Building C
3. On 9/25/12, at 11:33 a.m., the door to the room identified as 5C053 did not positive latch when tested by releasing the door from an open position.

Main Campus Building G
4. On 9/25/12, at 3:29 p.m., the door to Patient Room 1G254 did not positive latch when pulled closed.

5. On 9/25/12, at 3:45 p.m., the rolling fire doors at the Nurses' Station had a book placed on the ledge within the travel area of the door.



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Main Campus Building M
6. On 9/24/12, at 11:34 a.m., the door to the Fourth Floor Soiled Utility Room was equipped with a self-closing device. When fully opened and released, the door failed to positively latch.

7. On 9/24/12, at 2:46 p.m., the door to the south end Basement Mechanical Room was equipped with a self-closing device. When the door was fully opened and released, the door failed to positively latch.

Main Campus Building C
8. On 9/25/12, at 10:55 a.m., the door to Room 7CJ01 failed to positively latch when tested.

9. On 9/25/12, at 10:58 a.m., the door to Room 7C101 was equipped with a self-closing device. When the door was fully opened and released, the door failed to positively latch.

10. On 9/25/12, at 11:20 a.m., the door to Room 7C006 failed to positively latch when tested.

11. On 9/25/12, at 11:27 a.m., the door to Room 7C012 was equipped with a self-closing device. When the door was fully opened and released, the door failed to positively latch.

12. On 9/25/12, at 11:46 a.m., the door to Room 2C053 was equipped with a self-closing device. When the door was fully opened and released, the door failed to positively latch.

Main Campus Building K
13. On 9/25/12 at 10:27 a.m., the door to Room 1K055 was equipped with a self-closing device. When the door was fully opened and released, the door failed to positively latch.

Main Campus Building E
14. On 9/25/12, at 2:51 p.m., the door to Room 4E035 was equipped with a self-closing device. When the door was fully opened and released, the door failed to positively latch.

15. On 9/25/12, at 2:53 p.m., the door to Room 4E043 was equipped with a self-closing device. When the door was fully opened and released, the door failed to positively latch.

16. On 9/25/12, at 3:50 p.m., the corridor door to Shower Room 1E024 failed to positively latch when tested.

17. On 9/25/12, at 3:55 p.m., the door to Room 1E028 was equipped with a self-closing device. When the door was fully opened and released, the door failed to positively latch.

18. On 9/25/12, at 4:00 p.m., the corridor door to Shower Room 1E042 failed to positively latch when tested.

19. On 9/25/12, at 4:38 p.m., the corridor door to Room 1E028 was equipped with a self-closing device. When the door was fully opened and released, the door failed to positively latch.

20. On 9/25/12, at 4:23 p.m., the door to Linen Chute Room BE042 was equipped with a self-closing device. When the door was fully opened and released, the door failed to positively latch.



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Main Campus Building M
21. On 9/24/12 at 11:17 a.m., in Room 3M063, the door failed to latch when tested.

Main Campus Building K
22. On 9/25/12 at 9:56 a.m., in Room 3K122, the self-closing device was disconnected from the door and the door frame.

23. On 9/25/12, at 10:00 a.m., in the Communications Closet 3KTD03, one of two leaf doors failed to latch when tested.

24. On 9/25/12, at 10:25 a.m., in Room 1K037, the self-closing device was disconnected from the door and the door frame.

Main Campus Building C
25. On 9/25/12, at 10:52 a.m., in Room 6C029, the door which was equipped with self-closing device failed to latch. The room contained approximately twelve dozen boxes and books.

26. On 9/25/12, at 11:13 a.m., in Room 6C061, the self-closing device on the door was missing the arm hinge that connected the door to the door frame.

27. On 9/25/12, at 11:27 a.m., the door to Room 3C021 failed to latch when tested.

Main Campus Building E
28. On 9/25/12, at 2:51 p.m., in Room 4E024, the door failed to latch when tested.

29. On 9/25/12, at 3:18 p.m., in Supply Closet 3E054, the door failed to latch when tested.

30. On 9/25/12, at 3:30 p.m., in Room 2E016, the southeast door was equipped with a self-closing device and failed to latch when tested.

Based on observation and interview, the facility failed to maintain all doors in exit passageways and horizontal exits to close automatically when the fire alarm system was activated. This was evidenced by doors that were held open by magnetic hold open devices, that failed to automatically close upon activation of the manual fire alarm system and automatic sprinkler system. This affected three of 32 floor at the Main Campus Buildings, and could result in the spread of smoke and/or fire.

Findings:

During fire alarm testing with Engineering Staff from 9/26/12 to 9/27/12, the cross corridor doors were observed.

Main Campus Building C
1. At 3:13 p.m., the cross corridors near smoke detector 71-25 released form their magnetic hold open devices when the smoke detector was activated. The doors failed to release when the manual pull station was activated.

Main Campus Building F
2. At 4:41 p.m., the corridor door to the Cafeteria failed to release from the magnetic hold open devices upon activation of the manual pull station. When smoke detector 33-28 was activated, the doors closed.


Main Campus Building G
3. At 9:41 a.m., the cross-corridor doors 1G196 did not automatically close upon activation of the manual pull station, or the sprinkler water flow.

When asked, Staff 6 stated that they thought that all of the automatic door closures in the two units were only activated to close by the smoke detector built into the door closure. Staff stated that the doors do not release when the corridor smoke detectors, sprinkler system, or the manual pulls are activated.

4. At 9:55 a.m., the right leaf facing west to door 1G192 did not close upon activation of the smoke detector.

5. At 9:51 a.m., both leaves of door 1G145 did not close when artificial smoke was sprayed into the door smoke detector/closure assembly.

Based on observation and staff interview, the facility failed to maintain the integrity of the construction of the smoke/fire barrier walls. This was evidenced by unsealed penetrations. This affected three of 32 floors at the Main Campus Buildings, and could result in smoke and/or fire spreading from one smoke compartment to another.

NFPA 101, 2000 Edition
8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

Main Campus Building G
During a tour of the facility with Engineering Staff on 9/28/12, smoke/fire barrier walls were observed.

1. At 11:00 a.m., the smoke barrier wall near Room 1G172 had three unsealed penetrations. These penetrations were located in the attic above the cross-corridor doors. One penetration was to the left of the inspection door, and was caused by a pipe traveling through the wall. This penetration was approximately one and one-half inches in size around the pipe. The other two penetrations were located opposite and to the right of the inspection door, and were caused by data cables traveling through the wall, and were approximately one-half inch in size.



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Main Campus Building K
2. At 9:15 a.m., the smoke barrier wall by Room 3K147 had an approximately 1 inch penetration around the cable wires.

3. At 9:20 a.m., the smoke barrier wall by Room 3K119 had an approximately 2 by 2 inch penetration on top of the cable wires.

4. At 9:30 a.m., the smoke barrier wall by Room 3K144 had an approximately 2 inch penetration around the cable wires that went through the smoke barrier wall near Room 3K145.

5. At 10:05 a.m., the smoke barrier wall by Room 2K095 had an approximately 4 by 8 inch penetration on top of a conduit.

Main Campus Building M
9/26/2012
11. At 10:18 a.m., the right leaf facing the Nurses' Station of the cross-corridor fire doors near Room 3M101did not close completely and latch.

12. At 10:33 a.m., the one and one half hour fire doors near Room 2M017 did not close completely due to one side of the door that was dragging the floor.

13. At 11:06 a.m., the right leaf facing south of the fire doors separating building K and M did not close when smoke detector 2-55 was activated.



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Based on document review, observation and interview, the facility failed to maintain their fire doors as evidenced by roll down fire doors that were past due for their annual inspection, by fire doors that did not fully close and latch, by fire doors that were obstructed, and by fire doors that did not latch after being opened. This affected 13 of 32 floors at the Main Campus Buildings, and the Valley Specialty Clinc, and could potentially result in the spread of smoke or fire.

Findings:
During document review from 09/24/12 to 09/27/12, the documents for the annual inspection of the drop down/roll down fire doors were requested. The documents provided indicated that the drop down doors had not been inspected since 04/22/11.

During a tour of the facility with a staff member between 09/24/12 and 09/27/12, the facility fire doors were observed during fire alarm testing.

Main Campus Building K
1. On 09/25/12, at 3:34 p.m., in the Basement Level in Room BK058, the drop down fire door was obstructed by a plastic bin.

2. On 09/26/12, at 11:45 a.m., on the 4th floor, the hour and a half fire-rated fire doors between Buildings K and C released and closed upon activation of the fire alarm system. The fire doors failed to latch when the door was re-opened and released. Upon leaving Building K and entering Building C, the right hand door failed to fully close and latch. The right hand door became stuck on the left hand door, and remained open approximately a half inch.

3. On 09/26/12, at 2:00 p.m., on the 2nd floor, the fire doors by Room 2K051 failed to release and close upon activation of the fire alarm system. The door was equipped with smoke detectors in the closing mechanism. When tested, the doors failed to close upon activation of the door smoke detector, the Inspector's Test Valve, and the manual pull station.

Main Campus Building M
4. On 09/26/12, at 10:15 a.m., on the 4th floor by Electrical Room# 4MME2, the fire doors released and closed upon activation of the fire alarm system. Both fire doors were difficult to open due to the emergency panic hardware that was sticking, and was required to be pushed forcefully to release and open.

5. On 09/26/12, at 10:22 a.m., on the 3rd floor by Staff Lounge Room 3M013, the fire doors released upon activation of the fire alarm system, but failed to fully close and latch. The latching edge on the right hand door was bent, and prevented the closure of both fire doors.

6. On 09/26/12, at 10:37 a.m., on the 2nd floor by the Linen Chute Room 2MJ03, the elevator lobby doors released upon activation of the fire alarm system, but failed to fully close and latch.

7. On 09/26/12, at 10:49 a.m., on the 1st floor, the fire doors to the back of Reception Area 1 released upon activation of the fire alarm system, but failed to fully close and latch.

8. On 09/26/12, at 11:01 a.m., on the Basement Level, the elevator lobby doors across from Room# BM006, released upon activation of the fire alarm system. The fire doors failed to fully close and latch.

Main Campus Building C
9. On 09/26/12, at 2:20 p.m., on the 3rd floor by Room 3C037, the fire doors released and closed upon activation of the fire alarm system. The right hand fire door failed to positively latch.

10. On 09/26/12, at 2:40 p.m., on the 6th floor by Room 6C041, the fire doors released and closed upon activation of the fire alarm system. The right hand door failed to positively latch when fully closed.




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Main Campus Building M
14. On 9/26/12, at 9:58 a.m., the smoke barrier doors located by the North Side Fifth Floor - M1 Elevator failed to release during testing.

15. On 9/26/12, at 10:16 a.m., the right leaf of the smoke barrier doors located by the North Side Fourth Floor - M1 Elevator by the waiting room failed to release upon activation of the fire alarm system.






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Main Campus Building E
9/26/2012
16. On 9/26/2012, a 4:15 p.m., the right leaf of the smoke barrier door near Room BE010 failed to positively latch during the fire alarm testing.

Rehabilitation Building - F Building
17. On 9/26/12, at 4:44 p.m., the left leaf of the smoke barrier door that led to the cafeteria failed to latch during the fire alarm testing.

Based on observation, the facility failed to protect its hazardous area enclosures. This was evidenced by rooms that contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building, and were not equipped with a self-closing mechanism on the door. This deficient practice affected three of 32 floors at the Main Campus Building, and the Valley Specialty Center, and could result in the spread of smoke and/or fire.

19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies
and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Findings:

During a tour of the facility with Engineering Staff on 9/25/12, hazardous area enclosures were observed.

1. At 9:35 a.m., Storage Room 4K092A in the Burn Unit did not have a self-closing device on the door. This room was greater that 50 square feet in size, and was used for paper type storage.




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2. At 11:07 a.m., in Room 6C094, the door had no self-closing device and the room contained papers, books, and approximately three dozen boxes. The room measured over 50 square feet in size.

3. At 11:33 a.m., in Room 3C037, the door was not equipped with a self-closing device. The room contained approximately six dozen boxes, and the room measured over 50 square feet in size.

Based on observation and interview, the facility failed to ensure that exits were readily accessible at all times as evidenced by smoke barrier doors that were locked and items that were stored in the exit access area of the corridors. This deficient practice affected staff and patients on three of 32 floors at the Main Campus Buildings as well as the Valley Specialty Center, and could potentially result in injury or a delayed egress in the event of an emergency.

19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

38.2.5 Arrangement of Means of Egress.

38.2.5.1 Means of egress shall be arranged in accordance with
Section 7.5.

7.5.1.1 Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times.
7.5.1.2* Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel. Exit access corridors shall provide access to not less than two approved exits without passing through any intervening rooms other than corridors, lobbies, and other spaces permitted to be open to the corridor.
Exception No. 1: This requirement shall not apply where a single exit

38.2.1.1 All means of egress shall be in accordance with Chapter 7 and this chapter.
38.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

3.3.121* Means of Egress. A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge.

7.2.1.5 Locks and Latches.
7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

7.1.10 Means of Egress Reliability.
7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.1.10.2 Furnishings and Decorations in Means of Egress.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

7.1.10.2.2 There shall be no obstructions by railings, barriers, or gates that divide the open space into sections appurtenant to individual rooms, apartments, or other occupied spaces. Where the authority having jurisdiction finds the required path of travel to be obstructed by furniture or other movable objects, the authority shall be permitted to require that such objects be secured out of the way or shall be permitted to require that railings or other permanent barriers be installed to protect the path of travel against encroachment.

Findings:

Main Campus Building M
During a tour of the facility with Maintenance Staff on 9/24/12, exit access was observed.

1. At 2:28 p.m., the second floor exit corridor leading to the stairwell between Operating Rooms 9 and 10, had a large cart stored against the wall approximately six feet from the exit door. Staff stated that it might be a HEPA cart

2. At 2:58 p.m., the corridor exit access from the Anesthesia Offices had anesthesia equipment that was stored along one side of the approximately 40 foot corridor. One location in the corridor had the width of the corridor reduced to 18 inches. Staff stated that the equipment was being stored there temporarily.

Main Campus Building E
3. At 4:13 p.m., there was a full-sized pallet stored in the exit corridor in the Building E Basement. The pallet was approximately five feet tall.



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Main Hospital - 1st Floor
4.On 9/24/12, at 2:51 p.m., in the Radiology Department -Angio Hallway, there were three carts stored along the corridor. The Medical Assistant stated on 9/24/12 at 2:53 p.m., that carts are parked in the corridor and are moved only once a day.

West Wing - 1st Floor
5. On 9/25/12, at 10:17 a.m., the Emergency Department corridor by Room 1K093, had a gurney and a wheelchair that obstructed the exit door.

Based on interview and record review, the facility failed to ensure the maintenance, inspection and testing of smoke detectors as evidenced by not conducting the required smoke detector sensitivity testing. This deficient practice affected Buildings M, K, F, E, G, E, Q, and F and could result in the failure of smoke detectors in the event of a fire.
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NFPA 72, National Fire Alarm Code, 1999 edition
7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following
methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

NFPA 72 National Fire Alarm Code, 1999 Edition
5-4.7 Record Keeping and Reporting.
5-4.7.1 A permanent record of the time, date, and location of all signals and restorations received and the action taken shall be maintained for at least 1 year and shall be able to be provided to the authority having jurisdiction. These records shall be permitted to be created by manual means.
5-4.7.2 Testing and maintenance records shall be retained as required in 7-5.3. These records shall be permitted to be created by manual means.

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.1 Records shall be retained until the next test and for 1 year thereafter.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following
information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business
address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15)Disposition of problems identified during test (for example, owner notified, problem corrected/successfully
retested, device abandoned in place)
7-5.3 For supervising station fire alarm systems, records pertaining to signals received at the supervising station that result from maintenance, inspection, and testing, shall be maintained for not less than 12 months. Upon request, a hard copy record shall be provided to the authority having jurisdiction. Paper or electronic media shall be permitted.

Findings:

Main Campus Buildings M, K, F, E, G, E, and F

1. During document review from 09/24/12 to 09/27/12, the documents for the smoke detector sensitivity testing were requested. No documents were provided to show that the facility had conducted the sensitivity testing of the smoke detectors. There was no report for testing, including a complete list of smoke detectors, results of the sensitivity testing, or the name of the person conducting the tests. Staff stated that the sensitivity testing had not been performed.

During fire alarm testing with Engineering Staff on 9/27/12, fire alarm devices were tested.

Valley Specialty Center
3. At 2:49 p.m., both supervised OS&Y valves supplying water to the automatic sprinkler system were closed. Both valves did not produce a local alarm or an alarm at a remote monitoring station. A vendor's inspection sticker on the valves indicated that they had been inspected and tested on 7/12.

Primary Care Clinic Bascom
During a tour of the facility on 9/27/12, the automatic sprinkler system riser was observed.

10. At 11:20 a.m., the sprinkler riser to the Bascom Clinic had an inspection date of 10/06. Documentation provided for the five year sprinkler certification at 3:57 p.m., was dated 10/4/06. Staff stated that the five year inspection was past due.



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Valley Health Center Bascom
1st Floor
11. On 9/26/12, at 10:13 a.m., in Room 130-02, there was a missing sprinkler escutcheon in the ceiling.

12. On 9/26/12, at 11:17 a.m., in Room 210-16, the sprinkler escutcheon was loose and had an approximately 3 by 3 inch gap from the ceiling.

Based on observation, the facility failed to maintain its portable fire extinguishers. This was evidenced by a fire extinguisher that was blocked from access and view and fire extinguishers that were past due for their annual inspection. This deficient practice affected staff and patients on three of 32 floors at the Main Campus Buildings and the Valley Health Center Bascom, and could potentially cause a delay in access to the fire extinguisher or the fire extinguisher not functioning properly during a fire.

NFPA 10, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

4-4.4* Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

During a tour of the facility with Engineering Staff, fire extinguishers were observed.

Main Campus Building M
1. On 9/24/12 at 2:25 p.m., in the Electrical Room BMME6, the annual inspection for the Carbon Dioxide fire extinguisher had expired. The last inspection was done in April 2010.

Main Campus Building E
2. On 9/25/12 at 4:32 p.m., in Room BE090, the annual inspection for the fire extinguisher had expired. The last inspection was done in April 2011.



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Main Campus Building M
3. On 9/24/12 at 3:18 p.m., in the First Floor Gift Shop located in the Lobby, the fire extinguisher was blocked by a rolling cart and nine boxes.

Based on record review, the facility failed to maintain the kitchen hood, as evidenced by not providing the documents for the cleaning of the kitchen hood for the past 6 months. This deficient condition affected one of three floors in Building F, the Services Building, and could result in the ignition of a grease fire.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 editions
Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking Frequency Frequency
Systems serving solid fuel cooking operations monthly
Systems serving high-volume cooking operations quarterly
(such as 24-hr cooking, charbroiling or wok cooking)
Systems serving moderate-volume cooking semiannually
Systems serving low-volume cooking operations,
(such as churches, day camps, seasonal businesses,
or senior centers) annually
8-3.1.2 - When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the service company. It shall also indicate areas not cleaned.

Findings:

1. During document review between 09/24/12 through 09/27/12, the documents for the kitchen hood cleaning were requested. No documents were provided to indicate that the kitchen hood had been cleaned as required. Staff stated that the hood was cleaned by kitchen staff.

Based on observation and interview, the facility failed to comply with the regulations regarding portable space heating devices. This was evidenced by unapproved portable heaters in non-sleeping staff areas. This affected all staff and patients on four of 32 floors at the Main Campus Buildings and could potentially result in the ignition of fire.

1999 NFPA 99
2-1 Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.

9-2.1.8.1 Manuals. The manufacturer of the appliance shall furnish operator's, maintenance, and repair manuals with all units. These manuals shall include operating instructions, maintenance details, and testing procedures. The manuals shall include the following where applicable:
(d) Step-by-step procedures for proper use of the appliance
(e) Safety considerations in application and in servicing

1999 NFPA 70
110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Findings:

During a tour of the facility with the Engineering Staff, electrical equipment was observed.

1. On 9/24/12, at 2:45 p.m., there was a portable electric heater in Room 2M109 that did not have a facility's acceptance and testing tag on it. This heater was plugged in, had visible heating elements, and was tilted up on one edge under the front of the desk directing the heat upwards. Staff removed that heater at that time.

2. On 9/24/12, at 2:54 p.m., there was a portable electric heater in Room 2M118 that did not have a facility's acceptance and testing tag on it. This heater was plugged into a power strip.

3. On 9/25/12, at 11:24 a.m., there was an unapproved heater plugged into a power strip under a desk in Room 5C061. This heater had a high temperature warning requiring three feet of clearance from the front and sides.

4. On 9/25/12, at 11:29 a.m., there was a portable electric heater in Room 5C055 that did not have a facility's acceptance and testing tag on it. This heater had the heating element visible and was under a desk.



31203

Main Campus Building M
5. 9/24/12 At 2:17 p.m., in the First Floor Admitting Office, a portable heater was plugged into a surge protector with a computer monitor, computer, scanner, and an electric stapler.

6. 9/24/12 At 2:21 p.m., in the Admitting Office Room 1M148J, a portable heater was plugged into a surge protector with a fan, fax, and a desk task light.

Based on observation and interview, the facility failed to protect compressed gas cylinders in storage as evidenced by cylinders that were not segregated full from empty and cylinders that were not secured from falling. This affected two of 32 floors at the Main Campus Buildings and could potentially result in injury or damage to the cylinders if they were to fall. This could also result in confusion and delay in access time if the wrong cylinder were chosen.

19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99 Health Care Facilities (1999 Edition) 21-1 Referenced Publications. The following documents or portions thereof are referenced within this standard and shall be considered part of the requirements of this document. The edition indicated for each reference is the current edition as of the date of the NFPA issuance of this document.
NFPA 99 Health Care Facilities (1999 Edition) 21-1.2.6 CGA Publications. Compressed Gas Association, Inc., 1725 Jefferson Davis Highway, Arlington, VA 22202.
Pamphlet G-4-1987, Oxygen. III. STORAGE OF COMPRESSED AND LIQUEFIED GAS, Storage Requirements. All gas cylinders: Shall be stored so that full cylinders remain separate from empty cylinders.

1999 NFPA 99 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

4-3.5.2.2 (b)2
If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

During a tour of the facility with Engineering Staff on 9/24/12, compressed gas cylinders were observed.

Main Campus Building M
1. At 11:15 a.m., in Room 3M065, there were 12 E-cylinder tanks in the rack. One empty E-cylinder was mixed with full E-cylinder tanks. This was confirmed by the respiratory therapy staff.

2. At 2:50 p.m., in Room 1M025 located in the Radiology Department, there were four helium compressed tanks lying flat on the floor unsecured. Each one had a content of 135 cubic ft.

Based on observation, the facility failed to maintain the shut-off valves outside of each anesthetizing location as evidenced by two shut off valves that were blocked by large carts. This condition affected one of five floors in Building K and could result in a delay to shut off medical gases in the event of an emergency.

NFPA 99, 1999 Edition
4-3.1.2.3 Gas Shutoff Valves. Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.
(m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.
All gas-delivery columns, hose reels, ceiling tracks, control panels, pendants, booms, alarm panels, or other special installations shall be located downstream of this valve.
(n) A shutoff valve shall be located outside each anesthetizing location in each medical gas line, so located as to be readily accessible at all times for use in an emergency. These valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others. Valves shall be of an approved type, mounted on a pedestal or otherwise properly safeguarded against physical damage, and marked in accordance with 4-3.5.4.2.

Findings:

Main Campus Building K
1. During a tour of the facility with a staff member on 09/27/12, at 10:32 a.m., the shut off valves for Operating Rooms 4 and 8 were both blocked by a cart that was stored in front of the gas shut-off valves.

Based on document review and staff interview, the facility failed to ensurre that their generator area was provided with battery backed task illumination and failed to provide documentation of weekly generator visual inspection. This was evidenced by the failure to provide battery back-up task lights at its generator set locations and to visually inspect generator weekly. This finding affected all staff and patients at six of seven buildings at the Main Campus Buildings and at the Valley Health Center Gilroy
This could potentially result in a loss of lighting near the generator in the event that one or more generators or related equipment failed to function. A weekly visual inspection of the emergency power supply (EPS) is required to insure that the EPS is ready to provide emergency power.

NFPA 110, 5-3 Lighting.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

5-3.2* The intensity of illumination in the separate building or room housing the EPS equipment for Level 1 shall be 30 ft candles (32.3 lux), unless otherwise specified by a requirement recognized by the authority having jurisdiction.

Exception: This requirement shall not apply to units housed outdoors.

Findings:

During a tour of the facility with Engineering Staff on 9/28/12, generator set locations were observed.

Main Campus Buildings M, K, B, C, E, and F
1. Between 1:43 and 1:58 p.m., this surveyor did not observe any battery back-up task lights at both generator set locations. Engineering Staff confirmed the observation and stated that they could be installed.

During a tour of the facility with Engineering Staff on 9/27/12, Electrical equipment and wiring were observed.

Valley Specialty Center Building Q
45. At 4:20 p.m., there were two power strips chained together in Room 4Q149

46. At 4:25 p.m., there was a power strip suspended above the floor transferring tension to it joints an terminals.

47. At 4:30 p.m., there were two power strips chained together in Room 4Q259-01

48. At 4:33 p.m., there was a power strip suspended above the floor transferring tension to its joints an terminals in Room 4Q256A.

49. At 4:34 p.m., there was a coffee pot plugged into a power strip in Room 4Q263.



31201

During a tour of the facility with Engineering Staff on 9/28/12, electrical wiring and equipment were observed.

50. At 9:12 a.m., a coffee maker was plugged into a surge protector in Room BQ249.

Based on observation, the facility failed to install alcohol-based hand rub (ABHR) dispensers in locations not adjacent to or above sources of potential ignition. This was evidenced by ABHR dispensers located adjacent to or above electrical fixtures. These findings affected four of 32 floors at the Main Campus Buildings, as well as two of six offsite buildings at Valley Health Center Moorpark and Valley Health Clinic Bascom, and could potentially result in the ignition of fire.

Where Alcohol Based Hand Rub (ABHR) dispensers are installed:
The corridor is at least 6 feet wide
The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)
The dispensers shall have a minimum spacing of 4 ft from each other
Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.
Dispensers are not installed over or adjacent to an ignition source.
If the floor is carpeted, the building is fully sprinklered. 19.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623

Findings:

Main Campus Building M
During a tour of the facility with Engineering Staff on 9/24/12, ABHR dispensers were observed.
1. At 10:48 a.m., there was an ABHR dispenser above a light switch in Janitor's Closet 5MJ02.

2. At 1:58 p.m., there was an ABHR dispenser located 18 inches above a light switch in Room 2M084

3. At 2:38 p.m., there was an ABHR dispenser located approximately eight inches above a light switch in PACU Secondary Recovery.



31203

Main Hospital - 1st Floor
4. 9/24/12 At 3:04 p.m., in Room 1M065, the ABHR (Alcohol Based Hand Rub) was mounted approximately 1 inch adjacent to the light switch. The ABHR contained 70% Ethyl Alcohol.

Based on observation, the facility failed to install alcohol-based hand rub (ABHR) dispensers in locations not adjacent to or above sources of potential ignition. This was evidenced by ABHR dispensers located adjacent to or above electrical fixtures. These findings affected four of 32 floors at the Main Campus Buildings, as well as two of six offsite buildings at Valley Health Center Moorpark and Valley Health Clinic Bascom, and could potentially result in the ignition of fire.

Where Alcohol Based Hand Rub (ABHR) dispensers are installed:
The corridor is at least 6 feet wide
The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)
The dispensers shall have a minimum spacing of 4 ft from each other
Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.
Dispensers are not installed over or adjacent to an ignition source.
If the floor is carpeted, the building is fully sprinklered. 19.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623

Findings:

Main Campus Building M
During a tour of the facility with Engineering Staff on 9/24/12, ABHR dispensers were observed.
1. At 10:48 a.m., there was an ABHR dispenser above a light switch in Janitor's Closet 5MJ02.

2. At 1:58 p.m., there was an ABHR dispenser located 18 inches above a light switch in Room 2M084

3. At 2:38 p.m., there was an ABHR dispenser located approximately eight inches above a light switch in PACU Secondary Recovery.



31203

Main Hospital - 1st Floor
4. 9/24/12 At 3:04 p.m., in Room 1M065, the ABHR (Alcohol Based Hand Rub) was mounted approximately 1 inch adjacent to the light switch. The ABHR contained 70% Ethyl Alcohol.

Valley Health Center Moorpark
During a tour of a facility with Engineering Staff on 9/26/12, alcohol based hand rub dispensers were observed.

2nd Floor
5. At 1:46 p.m., the ABHR (Alcohol Base Hand Rub) was approximately 3/4 inch above the light switch in the following rooms: 212-27, 212-28, 212-23, 212-13, 212-11, 212-09, 212-15, 212-26, and 212-16. The ABHR contained 62% Ethyl Alcohol.

6. At 2:38 p.m., in Room 011, the ABHR (Alcohol Base Hand Rub) was mounted approximately 1 inch adjacent to the light switch. The ABHR contained 62% Ethyl Alcohol.

Valley Health Clinic Bascom - 3rd Floor

7. On 9/26/12, at 11:31 a.m., in Room 330-03, the ABHR (Alcohol Base Hand Rub) was approximately 1 inch adjacent to the light switch. The ABHR contained 62% Ethyl Alcohol.

8. On 9/26/12, at 11:32 a.m., in Room 330-15, the ABHR (Alcohol Base Hand Rub) was approximately 1 inch adjacent to the light switch. The ABHR contained 62% Ethyl Alcohol.