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Based on observation, document review, and interview, the facility failed to maintain the kitchen cooking exhaust system as evidenced by a noncompliant cooking exhaust system. This affected the entire kitchen and had the potential for a fire in the exhaust system.

NFPA 101, Life Safety Code, 2000 Edition
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition
4.7 Authority Having Jurisdiction Notification. If required by the authority having jurisdiction, notification in writing shall be given of any alteration, replacement, or relocation of any exhaust or extinguishing system or part thereof or cooking equipment.

12.1.2 Installation.
12.1.2.1 All listed appliances shall be installed in accordance with the terms of their listings and the manufacturer's instructions.
12.1.2.2* Cooking appliances requiring protection shall not be moved, modified, or rearranged without prior reevaluation of the fire-extinguishing system by the system installer or servicing agent, unless otherwise allowed by the design of the fire-extinguishing system.

Findings:

During document review and tour with the Director of Plant Operations on 12/2/13 through 12/5/13, the facility kitchen exhaust system was examined, documents were reviewed, and a staff person was interviewed.

12/2/13

1. At 1:45 p.m., the construction advisory report dated 11/14/13 from the Office of Statewide Health Planning and Development (OSHPD) provided the following information:
a. It appears that the kitchen equipment for hood #1 has been relocated since the construction documents were approved. The current configuration does not allow proper coverage and protection by suppression system. Current design does not comply with the manufacturers installation instructions and CFC, Section 904.5. Direction from the EOR is required.

b. Manual pull station shall be located between 10 feet and 20 feet from the kitchen hood. The current location of the manual pull for the hood#1 is approximately 8 feet from the hood. NFPA 17A.

c. Discussed requirements for fire stopping of through penetrations
in fire-resistive rated roof/ceiling assembly. Fire stopping shall comply with CBC, Section 712.

c. One (1) hole was noted in kitchen hood #1 that requires a listed seal or repair in accordance to NFPA 17A.

2. At 2:55 p.m., OSHPD letter dated 10/29/13, stated in the subject line of the letter "Project closure without California Building Standards Code Compliance.

12/5/13

3. At 11:36 a.m., the manual pull station was observed to be approximately 9 feet from kitchen hood #1.

At 11:45 a.m., the Chief of Plant Operations said during an interview that the facility will need to open a new permit and resubmit a plan to get the items that OSHPD identified repaired. We will request a waiver to get this fixed.

At 12:05 p.m., during the exit a waiver was suggested for the facility to have time to correct the issues that OSHPD identified.

Based on observation, document review, and interview, the facility failed to maintain the kitchen cooking exhaust system as evidenced by a noncompliant cooking exhaust system. This affected the entire kitchen and had the potential for a fire in the exhaust system.

NFPA 101, Life Safety Code, 2000 Edition
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition
4.7 Authority Having Jurisdiction Notification. If required by the authority having jurisdiction, notification in writing shall be given of any alteration, replacement, or relocation of any exhaust or extinguishing system or part thereof or cooking equipment.

12.1.2 Installation.
12.1.2.1 All listed appliances shall be installed in accordance with the terms of their listings and the manufacturer's instructions.
12.1.2.2* Cooking appliances requiring protection shall not be moved, modified, or rearranged without prior reevaluation of the fire-extinguishing system by the system installer or servicing agent, unless otherwise allowed by the design of the fire-extinguishing system.

Findings:

During document review and tour with the Director of Plant Operations on 12/2/13 through 12/5/13, the facility kitchen exhaust system was examined, documents were reviewed, and a staff person was interviewed.

12/2/13

1. At 1:45 p.m., the construction advisory report dated 11/14/13 from the Office of Statewide Health Planning and Development (OSHPD) provided the following information:
a. It appears that the kitchen equipment for hood #1 has been relocated since the construction documents were approved. The current configuration does not allow proper coverage and protection by suppression system. Current design does not comply with the manufacturers installation instructions and CFC, Section 904.5. Direction from the EOR is required.

b. Manual pull station shall be located between 10 feet and 20 feet from the kitchen hood. The current location of the manual pull for the hood#1 is approximately 8 feet from the hood. NFPA 17A.

c. Discussed requirements for fire stopping of through penetrations
in fire-resistive rated roof/ceiling assembly. Fire stopping shall comply with CBC, Section 712.

c. One (1) hole was noted in kitchen hood #1 that requires a listed seal or repair in accordance to NFPA 17A.

2. At 2:55 p.m., OSHPD letter dated 10/29/13, stated in the subject line of the letter "Project closure without California Building Standards Code Compliance.

12/5/13

3. At 11:36 a.m., the manual pull station was observed to be approximately 9 feet from kitchen hood #1.

At 11:45 a.m., the Chief of Plant Operations said during an interview that the facility will need to open a new permit and resubmit a plan to get the items that OSHPD identified repaired. We will request a waiver to get this fixed.

At 12:05 p.m., during the exit a waiver was suggested for the facility to have time to correct the issues that OSHPD identified.