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Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into the other areas. This facility has a capacity of 25 and a census of 4.

Findings Include:

During the tour starting on 09/21/2015 and ending on 09/22/2015, following is observed:

--1. On 09/21/2015 at 12:14 P.M., the administration area storage room door was found blocked open by a wedge.

The Facilities Director was present, and acknowledge the finding.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1. When the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting ceilings, partitions, and doors. The doors shall be self closing or automatic closing. 2000 NFPA 101

Based on record review and staff interview the facility failed to assure that fire drills are held at least quarterly on each shift. This deficient practice may prevent proper evacuation in a timely manner due to staff ' s inability to respond in the event of an emergency. This facility has a capacity of 25 and a census of 4.

Findings Include:

During record reviews starting on 09/21/2015 and ending on 09/22/2015, following is observed:

--1. On 09/22/2015 at 10:01 A.M., record reviews shows no documentation of fire drills for the Night shift during January through march of 2015, and April through June of 2015.

The Facilities Director was present, and acknowledge the finding.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on observation and staff interview the facility failed to ensure access to the sprinkler system control valves were limited and secured. This deficient practice could result in tampering and/or closing of the control valves. This facility has a capacity of 25 and a census of 4.

Findings Include:

During the tour starting on 09/21/2015 and ending on 09/22/2015, following is observed:

--1. On 09/22/2015 at 9:36 A.M., the main control valve to the sprinkler system located on the north wall does not have a tamper switch.

The Facilities Director was present, and acknowledge the finding.

NFPA Standard: Sprinkler control valves shall be electrically supervised so that at least a local alarm will sound at a constantly attended location when the valve is turned. 2000 NFPA 101, 18/19.3.5.1 and 9.7.2.1 and 1999 NFPA 13, 5-14.1.1.3, and 1999 NFPA 72, 2-9.1

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire. This facility has a capacity of 25 and a census of 4.

Findings Include:

During record reviews starting on 09/21/2015 and ending on 09/22/2015, following is observed:

--1. On 09/22/2015, record reviews shows no documentation of a flow test of the fire sprinkler systems since this building opened in January of 2015

The Facilities Director was present, and acknowledge the finding.

NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per NFPA 101, 9.7.5. Obstructions shall not prevent sprinkler discharge from reaching the protected area. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inches below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section. The requirements of this section shall also apply to obstructions 18 in. or less below the sprinkler for light and ordinary hazard occupancies per NFPA 13, 5-6.5.3. Water flow alarm devices including, but not limited to, mechanical water motor gongs, vane-type water flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly per 1998 NFPA 25, 2-3.3

Based on observation and staff interview the facility failed to ensure electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2., including the improper maintenance of and access to the electrical panel. This deficient practice fails to prevent the overheating of the panel and the facility's inability to access the panel in an emergency situation. This facility has a capacity of 25 and a census of 4.

Findings Include:

During the tour starting on 09/21/2015 and ending on 09/22/2015, following is observed:

--1. On 09/22/2015 at 9:18 A.M., electrical room #225B has storage in front of electrical panels.

The Facilities Director was present, and acknowledge the finding.

NFPA Standard: The width of the working space in front of the electrical equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of the equipment doors or hinged panels. Minimum clear distance required for the working space of an electrical panel is 3 to 4 feet. 1999 NFPA 70, 110-26 (a)(1)(2).

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into the other areas. This facility has a capacity of 25 and a census of 4.

Findings Include:

During the tour starting on 09/21/2015 and ending on 09/22/2015, following is observed:

--1. On 09/21/2015 at 12:14 P.M., the administration area storage room door was found blocked open by a wedge.

The Facilities Director was present, and acknowledge the finding.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1. When the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting ceilings, partitions, and doors. The doors shall be self closing or automatic closing. 2000 NFPA 101

Based on record review and staff interview the facility failed to assure that fire drills are held at least quarterly on each shift. This deficient practice may prevent proper evacuation in a timely manner due to staff ' s inability to respond in the event of an emergency. This facility has a capacity of 25 and a census of 4.

Findings Include:

During record reviews starting on 09/21/2015 and ending on 09/22/2015, following is observed:

--1. On 09/22/2015 at 10:01 A.M., record reviews shows no documentation of fire drills for the Night shift during January through march of 2015, and April through June of 2015.

The Facilities Director was present, and acknowledge the finding.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on observation and staff interview the facility failed to ensure access to the sprinkler system control valves were limited and secured. This deficient practice could result in tampering and/or closing of the control valves. This facility has a capacity of 25 and a census of 4.

Findings Include:

During the tour starting on 09/21/2015 and ending on 09/22/2015, following is observed:

--1. On 09/22/2015 at 9:36 A.M., the main control valve to the sprinkler system located on the north wall does not have a tamper switch.

The Facilities Director was present, and acknowledge the finding.

NFPA Standard: Sprinkler control valves shall be electrically supervised so that at least a local alarm will sound at a constantly attended location when the valve is turned. 2000 NFPA 101, 18/19.3.5.1 and 9.7.2.1 and 1999 NFPA 13, 5-14.1.1.3, and 1999 NFPA 72, 2-9.1

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire. This facility has a capacity of 25 and a census of 4.

Findings Include:

During record reviews starting on 09/21/2015 and ending on 09/22/2015, following is observed:

--1. On 09/22/2015, record reviews shows no documentation of a flow test of the fire sprinkler systems since this building opened in January of 2015

The Facilities Director was present, and acknowledge the finding.

NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per NFPA 101, 9.7.5. Obstructions shall not prevent sprinkler discharge from reaching the protected area. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inches below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section. The requirements of this section shall also apply to obstructions 18 in. or less below the sprinkler for light and ordinary hazard occupancies per NFPA 13, 5-6.5.3. Water flow alarm devices including, but not limited to, mechanical water motor gongs, vane-type water flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly per 1998 NFPA 25, 2-3.3

Based on observation and staff interview the facility failed to ensure electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2., including the improper maintenance of and access to the electrical panel. This deficient practice fails to prevent the overheating of the panel and the facility's inability to access the panel in an emergency situation. This facility has a capacity of 25 and a census of 4.

Findings Include:

During the tour starting on 09/21/2015 and ending on 09/22/2015, following is observed:

--1. On 09/22/2015 at 9:18 A.M., electrical room #225B has storage in front of electrical panels.

The Facilities Director was present, and acknowledge the finding.

NFPA Standard: The width of the working space in front of the electrical equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of the equipment doors or hinged panels. Minimum clear distance required for the working space of an electrical panel is 3 to 4 feet. 1999 NFPA 70, 110-26 (a)(1)(2).